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Female Incontinence

The bladder is the name for a structure in the body that stores urine, which is made by the kidneys. Simply speaking, the bladder is a bag that expands as it fills with urine and contracts when it is full to empty. The middle part of the wall of the bladder is a muscle that can contract urine out from the bladder - this muscle is called the detrusor muscle. The bladder has an inner lining known as 'urothelium'. In women, urine is passed from the bladder to the outside world through the urethra. In men, the prostate sits between the bladder and the urethra, and the urethra is much longer in men than in women.

 

The bladder is behind the pubic bone, which is the firm structure that can be felt in the lower abdomen, and in front of the vagina in women or the rectum in men. As it fills, there is a sensation for the need to pass urine felt in the lower belly/abdomen. In women, the bladder and urethra are supported by muscles and the pelvic floor. These muscles help women stay dry and. In men, there are additional muscles present at the junction of the bladder and prostate, and the prostate and urethra.

 

Women can have problems relating to staying dry either because the bladder muscle (detrusor) contracts and squeezes urine out of the bladder ('detrusor over activity') or because the support for the bladder and urethra is not sufficient to withstand pressure from coughing and lifting ('stress urinary incontinence'). Women may suffer from recurrent cystitis (urinary tract infections) or bladder discomfort and frequent urination with infection ('interstitial cystitis a.k.a. chronic pelvic pain syndrome).

 

What is urinary incontinence?

 

This means that urine leaks out at times when it shouldn't. It is a common problem affecting many women sometimes several or more times a week. It can be so bad that underwear needs to be changed during the, pads have to be worn to keep dry and daily activities like lifting, dancing or going on long journeys have to be restricted.

 

Women, and some men, have bladder control problems. it is a very common problem affecting women of all ages. In young women, urine leakage can occur after giving birth to a child. 

 

Sometimes it occurs after periods stop (menopause) or in older women in their 70s.

Incontinence is not something to be ashamed and affects many women. Urine leakage is not normal and can be successfully treated in the majority of women.

 

Why do I leak when I cough, exercise, laugh or sneeze?

 

Activities such as these increase the pressure on the bladder literally forcing urine out of the bladder. Usually, the muscles in the pelvis support the bladder and urethra (water pipe) prevent urine from coming out. These muscles can be weakened by pregnancy, obesity, menopause or an inherited tissue weakness. This is usually known as 'genuine stress incontinence'.

 

Sometimes, the problem is due to a weakness in the wall of the urethra (water pipe) rather than the bladder or urethral support.

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Less commonly, coughing, exercise, laughing or sneezing can stimulate the bladder muscle to contract and that causes urine to leak. This is known as Valsalva induced detrusor overactivity.

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Why do I need to rush to the toilet when I feel the need to pass urine? 

 

Normally, the bladder muscle should contract only when you pass urine. Sometimes, the bladder muscle contracts before it is full and when you would rather not go to the toilet. If you don't reach the toilet on time, you might leak. 

 

During the day and night, the urge to pass urine may be overwhelming and so you go to the toilet more than other people. If you don't make it to the toilet on time, incontinence may occur. If the bladder muscle itself is contracting inappropriately, this condition is often known as 'detrusor overactivity'. Sometimes, there are important causes for this problem, but often no specific cause is found.

 

How does bladder control normally occur?

 

The bladder is like an expandable bag that holds urine as it fills. When the bladder is full, the pelvic floor relaxes, the bladder muscle ('detrusor') contracts and urine is passed. Urine passes from the bladder through a tube called the urethra (water pipe) to the outside world. Usually, the desire to pass urine occurs when the bladder is almost completely full, but in some people, the bladder muscle (detrusor) contracts far too early. This gives rise to an urgent desire to pass urine that can sometimes be too strong to stop resulting in a leak. This is often called detrusor overactivity. Thus, normal bladder filling occurs with the detrusor (bladder muscle) remaining relaxed and not overactive.

 

As the bladder becomes full, coughing, lifting and other activities do not usually cause urine leakage because the urethra (water pipe) is supported. The support comes from the pelvic floor, which is a layer of muscle under the bladder. Lack of urethral support results in urine leakage with stressful activities. Urethral support can be improved by pelvic floor exercises, losing weight, drugs and new procedures that can be performed as day cases or with an overnight stay.

 

For bladder control to be effective, the nervous system has to be working normally.

How do you work out why bladder control is poor and urine leakage occurs.

 

In the majority of women, the cause is principally either of the two problems listed above ie stress incontinence or detrusor overactivity. It can be difficult to distinguish between the two from symptoms alone, as they can often overlap in 3 in 10 cases.

 

Symptoms that suggest that detrusor overactivity is present include the sudden urge to pass urine (urgency) that occurs day and night, together with urine leakage that occurs with urgency ('urge incontinence'). Urine is passed frequently and often in large amounts when the strong urge is present.

 

Stress incontinence usually occurs with activity and the leakage is usually only a few drops only. Urine leakage rarely occurs at night except in the worst cases.

Symptoms and the findings on physical examination can help sometimes. The 'cough test' determines whether leakage occurs on coughing or not. However, often it is difficult to reliably rule out one or other condition. If the symptoms do not resolve after simple help, additional tests are required.

 

These include

  • Urodynamics (pressure/flow studies): This is a test in which a narrow tube is placed in the bladder and rectum ('backpassage') so that the pressure in each can be recorded.

  • Ultrasound of the bladder

  • Frequency/volume chart (voiding diary/log)
     

What can I do myself to reduce urine leakage?

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There are simple things one can do: pelvic floor exercise and lose weight.

 

Can pelvic floor exercises and physiotherapy help?

 

Providing the exercises are done, they will help, and they will need to be done for the rest of one's life. They can be performed by oneself or taught with the aid of a physiotherapist. Please see Pelvic Floor Exercises.

 

They help urinary leakage that occurs due to stress incontinence as well as due to detrusor overactivity (urge incontinence).

 

There are additional aids that one can use to improve the efficacy of pelvic floor exercises. These include biofeedback machines. Again, these have to be performed regularly like any exercise programme.

 

Can drugs or medicines help? 

 

For women with stress incontinence, Yentreve or duloxetine is a new drug that helps women by reducing the number of times incontinence occurs. It is not a complete cure, but does make some women better and maybe usefully combined with pelvic floor exercises. The feeling of nausea may occur, but usually ameliorates after the first few weeks. This drug should only be taken on the advice of a doctor who knows your medical history well.

 

For women with urge incontinence or detrusor overactivity, drugs such as Detrusitol (tolterodine), Lyrinel (oxybutynin), Regurin (Trospium), Mirabegron ( Betmega ), Propiverine or Solifenacin may help. To some extent these can give rise to a dry mouth or constipation. These medications should be combined with changes in drinking habits such as reducing caffeine and alcohol consumption.

 

Aren't there procedures or operations that can help?

 

It is possible to improve the urethral support that has become weak resulting in stress incontinence. There are three ways that this can be done:

 

  • Placing a mid urethral tape under the urethra to support the urethra when there is stress - Tension Free Vaginal Tape or Transobturator Tape

  • Fixing the bladder in a higher position by stitches placed at an operation (eg Burch colposuspension) - this is the traditional way to treat stress incontinence.

  • Autologous Pubovaginal Sling  - similar in principle to the mid urethral tape but using your own tissue but more invasive ( need bul

  • Injecting agents to increase the bulk of the urethral wall

 

Of all these, many prefer the first option nowadays. However since mid 2018 these have not been available due to concerns over long term safety  In some cases, these can improve symptoms of urgency or urge incontinence, but you need to have a careful discussion with your doctor.

 

​What about the new transobturator tapes?

 

Urinary leakage occurs in part because the support of the urethra is inadequate. A tape or hammock can be placed under the urethra to provide additional support. The number of times urinary leakage occurs is reduced and it is possible to enjoy a better quality of life as a result. You have to come in to hospital for up to 24 hours and normal activities can be resumed after a month or so. More details are on the MONARC page.

 

To some extent, this problem can also be ameliorated by placing a tape to support the urethra, but a specific operation may be needed to correct this itself. This is usually assessed at the time of investigation of incontinence.

Urinary incontinence is the inability to control urination. This can occur temporarily if there is a short-term problem such as a urinary infection and this can usually be resolved promptly. Longer term (more than 3 months) often indicate an underlying problem.

 

Stress urinary incontinence is the name for incontinence most commonly due to lack of support for the bladder structures. People who suffer from overactive bladder, or urinary incontinence, can't hold their urine -- they wet themselves. (Leaking urine is normal only in infants; it is not a normal result of aging). If you have this problem, you may be too embarrassed or upset to ask for help. Don't be.

 

Symptoms aren't reliable in making a diagnosis for the absolute cause for urinary leakage, but can give an indication. If you leak most often with physical activity (e.g. coughing, sneezing, lifting or exercise), then stress incontinence is likely to be present. If you leak when you have a strong desire to empty your bladder, but can't reach the toilet fast enough, then urge incontinence is present. Urge incontinence may be due to the bladder muscle contracting when you don't want it to do so ('detrusor instability'). Sometimes, both stress and urge incontinence can exist together, and this is known as mixed incontinence.

 

Please read the frequently asked questions on incontinence. 

 

Available now are simple approaches that help the majority of women and new minimally invasive procedures (eg transobturator tapes) that can keep women dry.

 

It is helpful if you can complete a questionnaire on the severity of urinary incontinence as this helps doctors to make decisions on the need for investigations or treatment.

The following Adobe PDFs can be downloaded and printed:

  • ICIQ (questionnaire on severity of incontinence)

  • UDI-6 and IIQ-7 (questionnaire on severity of incontinence)

  • Bladder diary (frequency/chart: a record of the time and amount of urine passed)

 

Instructions on pelvic floor exercises can be found on this website and downloaded also: pelvic floor exercises

 

Why exercise pelvic muscles?

 

Life's events can weaken pelvic muscles. Pregnancy, childbirth, and being overweight can do it. Luckily, when these muscles get weak, you can help make them strong again.

 

Pelvic floor muscles are just like other muscles. Exercise can make them stronger. Women with bladder control problems can regain control through pelvic muscle exercises, also called Kegel exercises.

 

Pelvic Fitness in Minutes a Day

 

Exercising your pelvic floor muscles for just 5 minutes, three times a day can make a big difference to your bladder control. Exercise strengthens muscles that hold the bladder and many other organs in place.

 

The part of your body including your hip bones is the pelvic area. At the bottom of the pelvis, several layers of muscle stretch between your legs. The muscles attach to the front, back, and sides of the pelvis bone.

 

Two pelvic muscles do most of the work. The biggest one stretches like a hammock. The other is shaped like a triangle. These muscles prevent leaking of urine and stool.

 

How do you exercise your pelvic muscles?

 

Find the right muscles. 

 

This is very important. Your doctor, nurse, or physical therapist will help make sure you are doing the exercises the right way.

 

Female Pelvic Anatomy 

 

You should tighten the two major muscles that stretch across your pelvic floor. They are the "hammock" muscle and the "triangle" muscle. Here are three methods to check for the correct muscles.

 

Try to stop the flow of urine when you are sitting on the toilet. If you can do it, you are using the right muscles.

 

Imagine that you are trying to stop passing gas. Squeeze the muscles you would use. If you sense a "pulling" feeling, those are the right muscles for pelvic exercises.

 

Lie down and put your finger inside your vagina. Squeeze as if you were trying to stop urine from coming out. If you feel tightness on your finger, you are squeezing the right pelvic muscle.

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Don't squeeze other muscles at the same time.

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Be careful not to tighten your stomach, legs, or other muscles. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscle. Don't hold your breath.

 

Repeat, but don't overdo it.

 

At first, find a quiet spot to practice—your bathroom or bedroom—so you can concentrate.

Lie on the floor.

Pull in the pelvic muscles and hold for a count of 3.

Then relax for a count of 3.

Work up to 10 to 15 repeats each time you exercise.

 

Do your pelvic exercises at least three times a day.

 

Every day, use three positions: lying down, sitting, and standing. You can exercise while lying on the floor, sitting at a desk, or standing in the kitchen. Using all three positions makes the muscles strongest. Image of the bladder, and the related muscles used in the urination process.

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Be patient. Don't give up. It's just 5 minutes, three times a day. You may not feel your bladder control improve until after 3 to 6 weeks. Still, most women do notice an improvement after a few weeks.

 

Exercise aids. You can also exercise by using special weights or biofeedback. Ask your health care team about these exercise aids.

 

Female Bladder 


Hold the Squeeze 'til After the Sneeze.

You can protect your pelvic muscles from more damage by bracing yourself.

 

Think ahead, just before sneezing, lifting, or jumping. Sudden pressure from such actions can hurt those pelvic muscles. Squeeze your pelvic muscles tightly and hold on until after you sneeze, lift, or jump.

 

After you train yourself to tighten the pelvic muscles for these moments, you will have fewer accidents.

 

Points to Remember

 

  • Weak pelvic muscles often cause bladder control problems.

  • Daily exercises can strengthen pelvic muscles.

  • These exercises often improve bladder control.

  • Ask your doctor of nurse if you are squeezing the right muscles.

  • Tighten your pelvic muscles before sneezing, lifting, or jumping. This can prevent pelvic muscle damage.

 

Pelvic Floor Exercise Diary - print out this chart and use it to record your exercises

 

What is a urodynamic test?

 

This is the name for a test performed as an outpatient to determine how the bladder works. It takes about one hour to do. The aim is to understand the activity of the bladder whilst it is filling with urine and during activity. To do this, a very narrow tube has to be passed into the bladder through the urethra.

 

The procedure is usually well tolerated. Sometimes, it is combined with x-rays and is known as videourodynamics. Local anaesthesia may be used, but not general anaesthesia. Pressures are measured in the rectum (the 'back passage') at the same time through a separate tube.

 

This test is also known as videourodynamics, pressure flow studies or cystometrogram.

 

Why am I having this test?

 

Female Urodynamic Testing 


The test can determine the cause of urinary symptoms such as:

  • Urine leakage (incontinence) that occurs on activity (e.g. coughing, lifting, sneezing, laughing) or without activity but associated with an urgent desire to pass urine

  • Increased frequency of passing urine during the day and night

  • Slow flow, stopping and starting, and the need to dribble to finish passing urine

 

It can also help predict whether drugs or surgery are likely to have a good result for;

  •  Stress incontinence in women

  • Overactivity of the bladder (also known as detrusor instability or overactivity)

 

What should I do before this test?

 

It is not necessary to fast the night before or take laxatives. As long as the urine test is normal, the study is very safe and can be performed with minimal discomfort. It is important to arrive with a full bladder since it may be necessary to pass urine into a special machine ("urinary flow rate test") before the formal urodynamic test and for a test by the nurse to determine if an infection is present. Usually, a nurse and an x-ray technician will be in the room during the test.

 

If you are having a period (menstruating), it is still possible to perform the test, but it may be more comfortable to delay the test to a day when you are not.

 

If you are taking medication such as Detrusitol (tolterodine), Lyrinel (oxybutynin), Regurin (trospium), propiverine, or solifenacin (Vesicare), please stop these about 1 week before the test. Continue taking other medication including aspirin, clopidogrel (Plavix) and warfarin unless you are told otherwise. You can restart them after the test. If you are not sure whether you should stop these drugs, please ask your doctor first. This is especially important if you are taking Yentreve (duloxetine) and you should not stop this drug without discussing with your doctor how to do it.

 

What will happen during the test?

 

You will need to undress and put on a gown. Local anaesthetic jelly will be placed in the urethra (the water-pipe from the bladder). A narrow tube (catheter) will be placed by a doctor or nurse through the urethra ('water pipe') into the urinary bladder. In addition, another narrow tube will be placed in the rectum (the 'back passage'). The study can be performed standing or sitting. A computer will record all of the measurements and produce a record of the events during the test.

 

Your doctor may be present during the study or later when the results are available for analysis. He will evaluate and interpret the study based on the recordings and x-ray tests if they have been performed.

 

What happens after the test?

 

Half an hour after the test, you will be able to go home. You may experience some burning when passing urine for a few days and this is normal. There may be some blood in the urine, but as long as large clots are not formed, the bleeding will settle if you drink plenty of fluid. You can resume regular diet, medications, and normal activity levels after you leave.

 

Antibiotics are often prescribed for three days afterwards.

 

Your results and their analysis will be discussed in a clinic in outpatients.

 

What is a transobturator tape?

 

This is a narrow strip of synthetic material placed in your body to support the urethra. The 'Monarc subfascial hammock' is a brand name for such a tape made by a company called American Medical Systems (AMS). The hammock cradles your urethra and gives it a solid point to rest on and press against. This helps the urethra close more tightly at times of stress.

 

You can download documents from NICE 

(National Institute for Clinical Excellence) and the companies that make the product from here.

 

  • NICE advice to patients on the transobturator tape for incontinence

  • AMS (American Medical Systems) Monarc patient information 1

  • AMS (American Medical Systems) Monarc patient information 2

 

How likely is it that a transobturator tape will cure incontinence?

 

In women who have incontinence due to weakness in the pelvic floor and poor support of the urethra (i.e. "genuine stress incontinence"), 8 or 9 out of 10 women should be completely dry or much better after surgery than before. Nine out of every 10 women are able to be as active as they like after placement of a transobturator tape e.g. lift children, dance or exercise. As a result, 19 out of every 20 women are satisfied by the results of the procedure.

 

No-one can guarantee that everyone will be cured and about 1 in 20 women are not satisfied by the operation. If the bladder is overactive as well, then the success rate is less and fewer women are satisfied. In addition, side-effects are always possible and it is important to think carefully about the advantages, alternatives and risks of any procedure before going ahead.

 

How long does it take for a transobturator tape to work?

 

In general, you will be dryer once the catheter is removed. The full improvement may take several weeks to be noticed.

 

How is a transobturator tape placed in the body?

 

You have either a general anaesthetic so you are asleep or the lower half of the body is made to feel numb by a spinal anaesthetic. A small incision (about 1 to 1.5 inches, 3 cm) is made in the vagina just below the opening of the urethra (water pipe), and two 1/4 inch (0.5 cm) incisions in the inner thigh. The tape (e.g. Monarc) is positioned under the urethra and the incisions are the closed with stitches. These stitches will dissolve spontaneously. During the procedure, a telescope may also be passed through the urethra (water pipe) to examine the inside of the bladder (cystoscopy). The whole operation takes about 30 minutes

 

Are there alternatives to a transobturator tape?

 

In general, it is wise to try simple remedies as these may be successful and make surgery unlikely. Pelvic floor exercises can help in many cases. When taught by a physiotherapist, these can work very well. Like any exercise programme, it is necessary to keep doing them for them to work.

 

In addition, it is possible to try a drug called duloxetine. The trade name for this drug is "Yentreve". It needs to be taken twice a day indefinitely. It may be used in combination with physiotherapy. It is not as effective as a surgical procedure, needs to be taken twice a day and has side-effects. In some situations, it may be preferable in some cases.

 

Another operation was used in the past. This was called the Burch colposuspension and to many is still the gold standard by which all other procedures are judged. As it involves an incision made in the lower belly and requires several days in hospital, many people have chosen not to have this procedure because newer procedures require less time in hospital and are equal effective.

 

More recently, the TVT has been introduced as an innovative procedure for incontinence. The original TVT was placed behind a bone (pubis) in front of the bladder felt in the lower abdomen. As the approach required the passage of needles behind this bone, injuries that occurred from time to time to the bladder or bowel. 

 

The newer transobturator approach is much less likely to cause such problems and is preferable.

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There are different forms of the transobturator tape. I prefer to use the Monarc, because it appears to be safer (click here).

 

What happens after the transobturator tape has been placed?

 

When you return to the ward, there may be a catheter present. This is a tube draining the bladder. If there is a catheter, this is usually removed after a few hours. If your bladder does not empty properly, it may be necessary to have a catheter for a longer period of time, but this is unusual. After you have passed urine, you can leave the ward and go home. This may be the same day, or sometimes the day after the operation. If the operation has been combined with a procedure for prolapse, you will probably be in hospital for a longer period of time.

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You may need to take antibiotics for a while to prevent infection, and apply oestrogen cream (e.g. Vagifem tablets) to the vagina to promote healing.

 

The stitches present in the vagina and thigh dissolve spontaneously over a few weeks.

After 4 to 6 weeks, you should be reviewed by your doctor who may want to test the rate at which you pass urine and how effectively you empty your bladder. These tests are simple and are not invasive. After that you will probably be reviewed between 6 and 12 months after the operation.

 

When can I have sex after a transobturator tape and will it be different?

 

You should not have sex for four to six weeks after the operation. Some women may experience discomfort with sexual intercourse after the procedure.

 

When can I start dancing, heavy lifting or rigorous exercise?

 

Again, you should avoid such activities for about 4 to 6 weeks.

 

Every operation has risks and these need to be weighed against the advantages.

 

Fortunately, the side-effects are relatively uncommon:

  • Of every 10 women, about one may experience difficulty passing urine, the urinary flow is slower and it takes longer to empty the bladder - this is usually transient and gets better over several weeks. Rarely, this requires temporary use of a catheter or another operation

  • Of every 10 women, two may experience bleeding. Usually, this can be controlled relatively easily, but rarely this may need additional treatment

  • Of every 10 women, two might have a urine infection that would require antibiotics

  • Of every 10 women, one could develop new symptoms such the need to pass urine more frequently during the day and night, or have to rush to the toilet to pass urine when they feel the need to empty their bladder

  • Of every 100 women, one or two may have damage to the urethra (water pipe) or bladder. This may need a specific repair by further surgery

  • Of every 100 women, about 2 may have damage to the vagina ("erosion"). The chance of this is less if antibiotics are taken. After the menopause, oestrogen cream in the vagina before and after surgery can also make this less likely. If damage to the vagina is substantial, the tape may have to be removed either partially or completely by another operation.

  • Of every 100 women, about 2 might have severe pain felt in the vagina or thigh that might last one week

  • Of every 100 women, a severe infection is possible - this is avoided and treated by giving antibiotics. If it is extremely severe, a further operation may be necessary.

 

In general, these risks are greater in women who are obese, diabetic or with lung disease.

 

Can I become incontinent again after a transobturator tape?

 

If you become pregnant, it is possible that incontinence can return. Therefore, it is preferable to wait until your family has been completed before undergoing the procedure.

 

Incontinence can also occur later in life after such procedures. About 7 out 10 women will still be dry 5 to 10 years after surgical procedures. Failure is more likely if the bladder is overactive. This can often be treated successfully by medication.

 

Over what period of time will the benefits of a transobturator tape last?

 

Transobturator tapes have been in existence for about 3 years. The materials used for the procedure have been in existence for considerably longer. What is relatively new, is the technique for inserting the tapes beneath the urethra. It is thought that continence will be preserved for many years after insertion of the tape. Until there are people who have had transobturator tapes for that long, this will not be known.

 

For people who suffer with a strong urge to pass urine that does not respond to simple drugs and medication, BOTOX injections can significantly relax the bladder easing such symptoms. It is a well tolerated procedure, but needs to be repeated every 4 to 9 months.

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What is Botox?

 

Botox is the brand name for botulinum toxin. Botox is used to relax muscular tissue and is commonly used for wrinkles on the face. In the bladder, it can relax the bladder muscle. This results in a reduction in the need to visit the toilet as frequently as one did before.

 

Who is suitable for treatment with Botox?

 

Men or women who have to pass urine too frequently or rush to the toilet to pass urine, especially during the day and night may be suitable for Botox. A test called urodynamics is performed first to determine whether the bladder muscle ('detrusor') contracts inappropriately i.e. when the bladder is meant to be storing urine. If the bladder is proven to be contracting inappropriately, drugs are tried first to calm the bladder muscle. These drugs are known as anticholinergic drugs and include tolterodine (Detrusitol), solifenacin (Vesicare) and oxybutynin (Lyrinel). 

 

If the medications do not work, then it is necessary to know whether the bladder has a reduced physical size. This is determined by filling the bladder up under a short general anaesthetic and seeing how much it can hold. There are no cuts or incisions when this is done. If the bladder is of normal size, then Botox can be performed. If not, it may be better to have an operation to enlarge the size of the bladder.

As Botox weakens the bladder muscle, I usually recommend that people learn how to pass a specially designed catheter themselves before Botox is given. This is because the bladder may temporarily be unable to completely empty and this occurs in about 1 in 10 to 1 in 20 people. may be the easiest way to empty the bladder. 

 

A catheter will not be needed forever, as Botox wears off after 4 to 9 months anyway. The technique is known as intermittent self catheterisation (ISC or CISC) and is tolerated very well by the majority of people who do this. If ISC is not possible for whatever reason, it may not be sensible to perform Botox for the bladder.

Typically, people with an overactive bladder due to detrusor instability or a neurological problem such as multiple sclerosis or a stroke are suitable providing the conditions described above are met.

 

How is Botox given?

 

The procedure is a day case procedure, so patients are admitted onto the ward on the day that Botox is administered. No drinking or eating is allowed 5 hours before the procedure. No other special preparation is necessary.

 

Botox can be given either when asleep ('general anaestheisa') or with the bladder made numb ('local anaesthesia') Under a general anaesthetic, a telescope examination of the bladder is performed ('cystoscopy'). The telescope is passed through natural passage ways in the bladder, so there are no incisions. The bladder is examined carefully. Botox is injected into the bladder wall through a special needle passed through the telescope directly. The bladder is emptied afterwards. Sometimes, a catheter is placed to empty the bladder - this is a small tube to drain the bladder that is removed on the ward.

 

It is possible to eat and drink shortly after the Botox has been given, and you should be able to go home the same day.

 

You should notice a reduction in the urgency and frequency of going to the toilet to pass urine about 5 days after it has been given. If leakage occurred before Botox, there should be no leakage afterwards. The maximum benefit is obtained about two weeks after the administration of Botox and the total effect lasts for between four and nine months.

 

What are the side-effects of Botox?

 

There are few reported side-effects.

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Blood may be seen in the urine after injections of Botox, as a needle penetrates the bladder wall. The blood may appear for a few days, but always wears off after a while. An infection may develop in the urine, but antibiotics are given to avoid this.

 

About 1 in 10 to 1 in 20 people describe a difficult in completely emptying the bladder. In some of these people, it may be necessary to pass a catheter intermittently (ISC). This is well tolerated by most and is not necessary for more than a few weeks in the vast majority.

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Allergic reactions are reported, but again these are very rare.

 

Very rarely, if Botox is injected directly into a blood vessel, breathing might stop. This would not occur immediately, but be noticed slowly over the next few weeks usually within time to act. Appropriate treatment would be administered.

 

What are the alternatives to Botox?

 

The alternatives include:

 

  •  Cystoscopy and hydrodistension: this means stretching the bladder under general anaesthetic by trying to overfill it with water. This is well tolerated in the majority and rarely causes problems. This can be tried a few times, but does not last very long.

  • Bladder augmentation: this means that the bladder is physically made larger. To do this, a segment of intestine is reshaped and fitted onto the bladder to increase its size. This is a fairly big operation, although it can be performed using key-hole techniques.

  • Take no action: as this is not a life-threatening problem, treatment is not necessary to prolong life, although it may improve the quality of life.

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Patient Information Sheet

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