Bladder control problems in women

Factors that contribute to bladder control problems include:

• pregnancy and childbirth
• constipation
• medications including prescribed medicines, over-the-counter medicines and herbal supplements (read more about how medicines can affect your bladder)
• chronic cough
• urinary infection
• diseases that affect your nervous system and muscular control
• diabetes(external link)(external link)
• obesity
• reduction in hormones after menopause (when your period stops).

The 2 types of incontinence most common in women are stress incontinence and urge incontinence. 

Stress incontinence is the spontaneous, uncontrolled leakage of small amounts of pee when you exert yourself, such as by coughing, sneezing, straining, lifting or playing sport (without any desire to go to the toilet).

Urge incontinence causes a sudden, overwhelming urge to pee. If you can't get to the toilet in time but pee a bit, you have urge incontinence. This is often referred to as an overactive bladder. 

Mixed incontinence is when you have both stress and urge incontinence.

Under-active bladder is when your bladder muscle is weak and does not squeeze strongly enough when you pee. This can lead to slow or incomplete bladder emptying. It can be associated with other symptoms such as urinary incontinence and bladder infections.

Bladder control problems don't have to hamper your lifestyle. Talk to your doctor, pelvic floor physiotherapist, continence nurse or midwife for advice.

Issues with bladder control can be annoying but there are a few simple measures that can help if you have mild-to-moderate bladder control problems. A surgical fix should always be a last resort.

• Reduce coffee, tea and alcohol intake.
• Reduce intake of bladder irritants such as fizzy drinks, fruit juices and artificial sweeteners.
• Have your medicines reviewed by your pharmacists as some can cause bladder problems or make them worse. This includes over-the-counter and herbal supplements.
• Learn the right way to do the correct pelvic floor exercises for you from a pelvic floor specialist. Note: Different exercises are used for different conditions and it is important to know which will help you.
• Once you know the correct pelvic floor exercises for you, do them often – these can strengthen the muscles that empty your bladder. About 7 out of 10 women with stress incontinence can become dry or significantly improve the problem by doing pelvic floor exercises.
• Train your bladder to hold more pee without leaks. Bladder training is sometimes combined with medicine (see below).
• Use continence products to help you manage leaks.

See the self-care section below for more detailed information on pelvic floor exercises and bladder training. 

Medicines

If you have ongoing problems with urinary incontinence that are not helped by the self-care measures above, your doctor may prescribe you an anticholinergic medicine, such as oxybutynin, solifenacin or tolterodine. These act on your bladder muscles to help improve bladder control.

Support

Continence NZ(external link)(external link) Information and education on continence topics. Also, a free helpline phone 0800 650 659.

The non-surgical and surgical treatment options on this page are available for stress incontinence (not urge incontinence). Talk to your GP, pelvic floor physio or continence nurse to find out the best treatment in your case. 

Non-surgical treatment options

Non-surgical treatment options are often tried before considering surgical treatment. Examples of non-surgical treatment options include:

• pelvic floor exercise 
• weight loss
• continence pessaries
• incontinence pants or pads
• lifestyle changes such as reducing high impact activities that cause incontinence
• other self-care for bladder control problems. 

Surgical treatment options

When non-surgical treatment options have been tried and been unsuccessful, surgical treatment options may be considered. It is important to ensure that you know what specific questions to ask of your surgeon. Finding a credentialed surgeon with experience in these procedures is essential. 

Not everyone will undergo the same procedure. Your doctor or surgeon may recommend one method over another for different clinical reasons. Discuss with your doctor or surgeon to find out which procedure is most suitable for you. Your doctor or surgeon will consider all relevant issues, including your previous surgical history and your wishes.  

Surgical treatment can be further divided into procedures that do not involve a mesh implant and procedures that do use surgical mesh. Procedures not involving mesh are summarised in the table below.

Procedures not involving mesh currently recommended by the Ministry of Health

Procedures involving surgical mesh implants

The term ‘surgical mesh’ refers to a permanent synthetic implant that is made from a non-absorbable polypropylene (plastic) material. It is known by multiple names including tape, sling, TVT, patch, ribbon, graft or hammock.

A mesh implant is used to support and hold your urethra, similar to the function of ligaments that are weakened in the case of incontinence. It will stay in your body permanently as it is non-absorbable.  

The most common procedure involving mesh is known as a mid-urethral sling (MUS) procedure. 

Two procedures can be used to place the sling:

• retropubic method – inserted from behind your pubic bone
• transobturater method – inserted via the top of your inner thigh on each side.

However, the Ministry of Health only recommends that surgeons use the retropubic approach, not the transobturator method. A diagram of this process can be found on page 7 of this MOH guide.(external link)

Complications and adverse events from surgical mesh implants

Unfortunately, all surgical procedures have complications and risks. The most common complications from mesh surgery include:

• pain, including pelvis, back, leg, groin, buttock and vaginal pain
• mesh erosion through your vagina (also called exposure, extrusion or protrusion)
• infection
• damage to your bladder
• urinary problems, including urinary tract infections (UTI)
• recurrent incontinence
• pain during sexual intercourse
• bleeding
• organ perforation (hole)
• neuromuscular problems, including acute pain and/or chronic pain in your groin, thigh, leg, pelvic and/or abdominal area
• vaginal scarring
• potentially the new onset of autoimmune conditions (research into this is ongoing as this link has not yet been fully established).

Read more about surgical mesh, including questions to ask your doctor before considering a surgical mesh implant.

Lifestyle changes

Just a few adjustments to your lifestyle may improve your bladder control.

• If rushing to the toilet and needing to go often are a problem, try reducing things drinks that can stimulate your bladder, eg, tea, coffee, blackcurrant, fizzy drinks and alcohol.
• Work out how much fluid (such as water, juice, coffee, tea, fizzy drinks) you drink each day. Usually, 5–6 drinks a day in total is enough. There is no right amount to drink – often people think they should drink a lot more than they need.
• Cut down on drinking fluid in the evening if going to the toilet at night is a problem.
• Try to break the habit of rushing to the toilet as soon as you arrive home and instead, go before you head home. Wait a few seconds until the urgency passes before moving to the toilet.
• Try to keep your bowel movements regular.
  • As your bladder and bowel are next to each other, a full bowel affects bladder function.
  • Many people find their bladder control problems are worse if they are constipated, which can happen if you don’t empty your bowel regularly or don’t eat enough fibre. 
  • Avoid straining while emptying your bowels as this can overstretch the muscles of your pelvic floor and may lead to weakness developing. 
• Try to maintain a healthy weight, as being overweight puts extra strain on your pelvic floor muscles.  
• If you smoke, get support to quit smoking. Research suggests that smokers are more likely to experience urinary incontinence and this is due to the excessive strain that repetitive coughing puts on your pelvic floor. 

Pelvic floor muscle exercises 

These exercise aim to strengthen the muscles that empty your bladder. Different exercises are used for different conditions and it is important to know which will help you. Speak to your doctor, pelvic floor physiotherapist, continence nurse or midwife for advice and to learn the right way to do the correct pelvic floor exercises for you. The following is a guide only:

• Stand, sit or lie down with your knees slightly apart. Relax.
• Find your pelvic muscle. Imagine that you are trying to hold back urine (pee) or a bowel movement (poo). Squeeze the muscles you would use to do that. DO NOT tighten your stomach or buttocks.
• Tighten the muscles for 5–10 seconds. Make sure you keep breathing normally.
• Now relax the muscles for about 10 seconds.
• Repeat 12–20 times, 3 to 5 times a day.
• Keep doing the exercises. You should begin to see results after a few weeks.
• Like any other muscle in your body, your pelvic muscles will only stay strong as long as you exercise them regularly.

 Read more about pelvic floor training for women.

Bladder training

As a guide, if you drink 5–8 cups of liquid per day you should be able to wait at least 2 hours between visits to the toilet. Bladder training may be helpful if you:

• are going to the toilet more often
• are getting up more than once or twice during the night
• can’t delay the urge to empty your bladder for at least 30 minutes.

Bladder training involves making changes to your toileting habits to help improve your bladder control. There are 2 main strategies:

1. Keeping a regular toilet schedule (this is called ‘timed voiding’), where you visit the toilet to pee at set times. You slowly increase the time between visits.
2. Learning to suppress the urge to pee by doing strong pelvic muscle contractions and distracting yourself with something else, like counting backwards.

Learn more about bladder training.

Clinical resources

Considering surgical mesh to treat stress urinary incontinence(external link) Ministry of Health, NZ, 2019
Continence screening form for residential care(external link) Deakin University, Continence NZ
Continence assessment and care plan(external link) Continence NZ
Urinary incontinence in women(external link) NICE Guidelines, UK

Continuing professional development

Video: Goodfellow Unit Webinar: Beyond mesh

Beyond mesh – I have a mesh, should I be worried? With Eva Fong

(Goodfellow Unit Webinar, NZ, 2020)