The Ultimate Guide to Female Urinary Incontinence in Singapore (2021)

Urinary incontinence is an issue commonly faced by women, especially those undergoing pregnancy, childbirth or menopause. According to local research [a], 1 in 2 healthy midlife women in Singapore are affected by urinary incontinence, making this a highly common condition. It’s nothing to be ashamed of; many of these cases are due to a myriad of factors that are not within our control. 

If you’ve noticed that you leak urine sometimes, you may want to read on about the different types of urinary incontinence, what lifestyle changes can help with your urinary incontinence, and understand your treatment options. That said, always check with your doctor about your diagnosis and treatment plan, which may be different for different individuals.

What is female urinary incontinence? 

Urinary incontinence happens when there is a loss of control over the bladder, which means you may leak urine accidentally, perhaps when sneezing or coughing. Otherwise, you may have a very strong urge to urinate and may not be able to reach the toilet in time. 

Urinary incontinence may increase with age, but it doesn’t happen to all the elderly. It is also more common in women, due to things like pregnancy, childbirth and menopause. 

What causes female urinary incontinence? 

Urinary incontinence is caused by problems with the pelvic floor muscles and nerves supplying the bladder that controls the holding or passing of urine. It may be a result of underlying medical conditions or the use of medication. In women, pregnancy, childbirth and menopause can affect the muscles controlling urination, causing urinary incontinence. The causes of urinary incontinence include: 

Being overweight 

Being overweight will put additional pressure on the bladder, causing weakening of the pelvic floor muscles over time and hence leads to an increased risk of having urinary incontinence.

Constipation

Chronic or long-term constipation may cause urinary incontinence, due to the strain during bowel movements that can put pressure on the bladder or pelvic floor muscles. This weakens the muscles, causing leakage of urine. 

Nerve damage 

Childbirth or nerve problems from diabetes or multiple sclerosis may affect nerves supplying the bladder, urethra or pelvic floor muscles. These damaged nerves may send wrong signals or not fire when they’re supposed to, causing urinary incontinence. 

Surgery

Surgery involving a woman’s reproductive organs, such as a hysterectomy where the uterus is removed, can affect the support and nerve supply of the pelvic floor muscles. When this occurs, there is a higher risk of pelvic organ prolapse e.g. sagging bladder, and may also lead to urinary incontinence. 

Certain medicines

Some medicines like diuretics (medicines that make you urinate more) may cause side effects like urinary incontinence. Diuretics are used in the treatment of heart failure, high blood pressure, liver cirrhosis and some kidney diseases. Adjusting the medication in conjunction with your physician can help with urinary incontinence. 

Caffeine

Caffeine is a diuretic, which means if you take too much of it, your bladder could fill more quickly. Those who are used to taking multiple cups of caffeinated drinks (e.g. tea, coffee) a day are more likely to have incontinence problems. Limiting caffeine intake would help to reduce incontinence in such cases. 

Infection

Urinary tract infections or infections in the bladder may cause temporary bladder irritation and urinary incontinence. When the infection is cured, the incontinence goes away as well. 

Why does urinary incontinence affect more women than men? 

Women have life events such as pregnancy, childbirth and menopause that may affect their urinary tract and the muscles around it. The pelvic floor muscles supporting the bladder, urethra, uterus and bowels may be weakened or damaged during these events. When the muscles of the urinary tract are weakened, they are not able to effectively hold or control the flow of urine. This can cause the symptoms of urinary incontinence or involuntary leakage of urine. 

What are the symptoms of female urinary incontinence? 

Urinary incontinence is not actually a disease but a symptom signalling another health problem, usually weak pelvic floor muscles, pelvic floor dysfunction or pelvic organ prolapse. Some women may have additional urinary symptoms on top of urinary incontinence, such as: 

  • Pressure or spasms in bladder muscle, causing strong urges to urinate (a strong feeling of needing to go to the toilet that is difficult to defer)
  • Urinating more frequently than usual (more than 8 times a day)
  • Needing to wake up at night frequently to pass urine, or nocturia (more than 2 times at night) 
  • Urinating while sleeping (bedwetting, or enuresis) 

What are the types of female urinary incontinence? 

Stress incontinence 

This happens when pressure is exerted on the bladder as a result of other actions that increase intra-abdominal pressures, such as coughing, sneezing, laughing, exercising or lifting heavy objects. 

Urge incontinence 

This occurs when you experience sudden and intense urges to urinate regardless of whether the bladder is full, followed by involuntary leakage of urine (i.e. you are not able to make it to the toilet in time before urine comes out). Your frequency of urination may be high, including at night. This may be caused by a minor condition like an infection, or a more serious condition like a neurological disorder or diabetes. 

Mixed incontinence 

This is when there is a combination of more than 1 type of urinary incontinence. Urge incontinence and stress incontinence can often happen together in the same person. 

Overflow incontinence 

This occurs when the bladder is unable to signal when it is full or cannot empty completely, causing frequent or constant dribbling of overflowing urine.

Functional incontinence

Chronic physical or cognitive impairment may prevent the functionally impaired person from getting to the toilet quickly enough to relieve themselves. 

What happens if incontinence is left untreated? 

Long-term or chronic urinary incontinence may cause complications such as: 

Skin problems 

You may develop rashes, skin infections and sores because of skin that is constantly wet. 

Urinary tract infections

Urinary incontinence increases the chances of repeatedly getting urinary tract infections. 

Chronic urinary incontinence also affects the quality of life in many women. Some effects of urinary incontinence on the quality of life include:

  • Social isolation and loneliness
  • Reduced sexual satisfaction
  • Lack of sleep 
  • Higher incidences of mental conditions such as depression and anxiety 
  • Problems with employment

What are the risk factors for urinary incontinence? 

Gender 

Women are more likely to experience stress incontinence, due to factors like pregnancy, childbirth, menopause and normal female anatomy. However, men with prostate gland problems are also more likely to have urge and overflow incontinence. 

Age

With age, the muscles and nerves in the pelvic floor, bladder and urethra may weaken and degenerate. 

Being overweight 

The extra weight puts additional chronic pressure on the bladder and the surrounding muscles, weakening them. This makes it easier to get both stress and urge incontinence. 

Smoking

The use of tobacco may increase the chances of urinary incontinence. 

Family history 

Your risk of urinary incontinence is higher when your family member also has it. 

Certain medical conditions

Certain medical conditions such as neurological disease or diabetes may put you at higher risk of urinary incontinence. 

How is female urinary incontinence diagnosed?

Your doctor will determine which type of urinary continence you have through your history and a physical examination. You may be asked to carry out a simple action such as coughing with a full bladder to see whether you leak urine. After which, your doctor may recommend:

Urinalysis

A sample of your urine will be taken to analyse for signs of infection, traces of blood or other problems. 

Bladder diary 

For a bladder diary, you will keep track of what fluids you drink, how much you drink and how often and how much you urinate, as well as whether you had a strong urge to urinate and the number of times incontinence occurred in a day. This will allow your doctor to have a better insight of your bladder habits throughout the day.

Post-void residual measurement

For this test, you will be asked to empty your bladder first. Then, using an ultrasound test or a catheter, your doctor will check the amount of urine remaining in the bladder. 

If the amount of leftover urine in the bladder is large, it might signify an obstruction in the urinary tract or a problem with your bladder nerves and muscles causing an inability of the bladder to empty satisfactorarily. 

When should I see a doctor for female urinary incontinence? 

You should see a doctor for urinary incontinence if it: 

  • Is causing you to avoid social activities 
  • Negatively impacting your quality of life
  • Increases your risk of falling while rushing to the toilet 
  • Indicates a more serious underlying medical condition

What are the treatments for female urinary incontinence in Singapore? 

Treatments for female urinary incontinence in Singapore depends on the type of incontinence, the severity of it and its underlying cause. Different cases require different types of treatment, and some may need a combination of more than one. If an underlying medical condition is found to be causing urinary incontinence, that needs to be treated first. 

The doctor will usually start with less invasive options before moving on to other treatments should they not achieve satisfactory improvement. Some of these methods include:

Behavioural techniques

  • Fluid and diet management 

These are methods such as cutting back on alcohol, caffeine (coffee/tea). Avoiding foods with high salt, sugar and preservatives also helps. These help to reduce bladder irritants that result in urinary urgency and frequency. Increasing one’s intake of fibre also helps avoid constipation. 

  • Weight optimisation

Maintaining a healthy weight and exercising more frequently help to reduce pressures on the pelvic floor and hence improves urinary incontinence.  

  • Kegel exercises 

This refers to pelvic floor exercises, where you aim to strengthen and tone the muscles supporting your bladder and urethra so that they are able to control and hold your urine better. Kegel exercises is a fancy term for pelvic floor muscle training, designed specifically to strengthen pelvic floor muscles. These muscles help to support your bladder, uterus and bowel. Doing these exercises can help in urinary or faecal incontinence in both males and females. 

To find the right muscles, imagine trying to stop passing gas and squeeze the muscles. The pulling feeling is caused by the pelvic floor muscles. Another method for women is to put a finger inside the vagina and squeeze as if trying to stop peeing. The tightness around the finger will be from squeezing the pelvic floor muscles.  

There are several things to note when doing the Kegel exercise:

  1. Ensure your bladder is empty. Sit or lie down. 
  2. Tighten your pelvic floor muscles, hold tight and count 3 to 5 seconds. 
  3. Relax the pelvic floor muscles and count 3 to 5 seconds. 
  4. Repeat these steps about 10 to 15 times, 3 times a day. 
  5. Breathe in deep and relax. Make sure you do not tighten the stomach, thigh, buttock or chest muscles. 
  6. Avoid doing Kegel exercises while urinating, because it might result in bad bladder habits. 
  • Bladder training

This is used to delay urination every time you feel the urge to go. You will need to do a bladder diary first to help your doctor ascertain your bladder capacity. If you are found to be voiding low volumes of urine each time but frequently, your doctor may advise you to start off by delaying your trip to the toilet for about 10 minutes. The goal is to progressively lengthen the time between trips to the toilet until you urinate only about every 2.5 to 3.5 hours. 

  • Scheduled toilet trips 

This is planning toilet trips such that you urinate every 2 to 4 hours instead of holding your bladder excessively. 

  • Stop smoking 

Smoking cessation will help in the symptoms of urinary incontinence.

  • Double voiding 

Double voiding means emptying the bladder twice in close succession. After urinating, wait a few minutes before trying to void again. This helps with overflow incontinence. 

Medications

  • Anticholinergics 

These help to calm an overactive bladder by inhibiting unprovoked bladder muscle contractions when the bladder is not yet full, and may help feelings of urgency as well as reduce the episodes of urge incontinence.

  • Mirabegron 

This is also for urge incontinence. It acts on the receptors of bladder muscles and works by promoting the relaxation of the bladder muscle, thereby reducing your feelings of urgency and urge incontinence. 

  • Alpha-blockers 

These are mainly used in men to relax bladder neck muscles and muscles in the prostate to make it easier to empty the bladder. 

  • Topical oestrogen 

As menopausal skin changes in the genital and urinary tract can affect urinary symptoms, low-dose, topical oestrogen can be applied as vaginal creams or tablets to help rejuvenate the tissues in the urethra and vaginal areas. 

Electrical stimulation

In electrical stimulation, electrodes may be inserted into the vagina or rectum to gently stimulate and strengthen pelvic floor muscles. This can be coupled with biofeedback and may be useful for stress or urge incontinence, but the treatment may require multiple sessions for several months. 

Interventional therapies

  • Bulking agent injections 

A synthetic, bulking agent may be injected into the tissue surrounding the urethra. This bulking agent helps to keep the urethra closed, thus reducing urine leakage. This is mainly for stress incontinence and is known to be less effective than other invasive methods like surgery, and may require repeated treatments as their efficacy will wane over time. 

  • Botulinum Toxin Type A (Botox) 

Botox injections into the bladder muscles using a cystoscopy may help an overactive bladder and urge incontinence. Botox is usually only recommended when other treatments have failed, and may require repeated treatments as their efficacy will wane over time. 

  • Nerve stimulation

This utilizes painless electrical pulses to stimulate the nerves involved in bladder control. The first type involves a permanent device implanted near your spine to stimulate the nerve roots there (sacral nerve stimulation), and the other type is a temporary electrode inserted into a nerve that runs near to your ankle which also supplies your bladder muscles (posterior tibial nerve stimulation). If other therapies didn’t work, this could be a potential treatment for overactive bladders and urge incontinence. 

Surgery

Last of all, your doctors may recommend invasive treatments if other therapies have not worked. 

  • Sling procedures 

Synthetic mesh or strips of your body’s tissues are used to create a pelvic sling that goes underneath the middle portion of your urethra, creating a hammock effect that keeps the urethra closed, especially during episodes of raised intra-abdominal pressures, such as when coughing, sneezing or exercising. This is performed under anaesthesia via a vaginal approach and is an effective treatment for those with stress incontinence. 

  • Bladder neck suspension 

This procedure, otherwise known as Burch colposuspension, helps to support your urethra and bladder neck by using sutures to attach your paravaginal fascia to nearby pelvic ligaments (Cooper’s ligaments). An abdominal incision is required, so there will be general or spinal anaesthesia. This surgery is longer than sling procedures, and involves a longer post-operative recovery period. 

  • Prolapse surgery 

If women have mixed incontinence along with pelvic organ prolapse, which is when one of their pelvic organs slip and bulge into the vagina, this could be a treatment option. A sling procedure paired with prolapse surgery may help because prolapse surgery alone does not help with urinary incontinence. 

At the Advanced Centre for Reproduction Medication (ACRM), we offer a Urogynae Package for just $350 that covers a consultation with our urogynaecology specialist Dr Ng Kai Lyn, comprehensive tests, scans and a tailored treatment plan plus education to help you understand and manage your urinary incontinence.

What foods should I avoid or take for urinary incontinence? 

Foods you should take:

Choose foods that are high in vitamins and non-acidic. Some bladder-friendly foods that could help with urinary incontinence are:

  • Pears 
  • Bananas 
  • Green beans 
  • Winter squash 
  • Potatoes 
  • Sweet potatoes 
  • Whole grains such as quinoa and oats 
  • Bread 
  • Nuts like almonds, cashews and peanuts 
  • Eggs 

Foods you should avoid:

  • Alcohol 
  • Caffeine 
  • Carbonated drinks and sparkling water 
  • Artificial sweeteners 
  • Chocolate 
  • Chilli peppers 
  • Fruits high in spice, sugar or acid, such as citrus fruits 

Should I avoid fluids if I have urinary incontinence?

Many of those with urinary incontinence have the wrong impression that they are supposed to drink less to reduce leakage of urine. This is not true. Water is a fluid that plays an especially important role in your health. However, it is true that alcohol or caffeine may irritate or stress the bladder, aggravating urinary incontinence. 

Drinking enough water helps to keep the kidneys and bladder healthy, prevents urinary tract infections and prevents constipation, all of which are beneficial towards urinary incontinence. Therefore, make sure to get enough water each day. The average woman needs about 1.5 to 2L of fluids a day from food and drinks. 

Conclusion

Urinary incontinence is an extremely stressful problem that may be due to an underlying medical condition. If you are facing problems with urinary incontinence, speak to your doctor and they will discuss the possible options with you and find a way to overcome it. You may find it embarrassing or difficult to talk about, but know that your doctors will handle your situation with professionalism and confidentiality while helping you to find the right solution. A combination of lifestyle or behavioural changes along with medical treatments may go a long way in treating urinary incontinence, so be sure to stick to the advice of your doctors.

References

  1. Ng KL, Ng KWR, Thu WPP, Kramer MS, Logan S, Yong EL. Risk factors and prevalence of urinary incontinence in mid-life Singaporean women: the Integrated Women’s Health Program. Int Urogynecol J. 2020 Sep;31(9):1829-1837. doi: 10.1007/s00192-019-04132-3. Epub 2019 Nov 28. PMID: 31781824.
  2. Aoki, Y., Brown, H. W., Brubaker, L., Cornu, J. N., Daly, J. O., & Cartwright, R. (2017). Urinary incontinence in women. Nature reviews. Disease primers, 3, 17042. https://doi.org/10.1038/nrdp.2017.42
  3. Culligan, P. J., & Heit, M. (2000). Urinary incontinence in women: evaluation and management. American Family Physician, 62(11), 2433-2444.