Incontinence is a very common problem, particularly during middle age and beyond. A wide range of treatments are available, which can be very effective, however many people remain reluctant to seek help due to embarrassment or a mistaken belief that incontinence is simply 'part of getting older'.

There are two main types of incontinence - stress incontinence and urge incontinence, sometimes known as an overactive bladder.

Stress incontinence is characterised by the leaking of urine when there is sudden extra pressure on the bladder, typically when you cough, laugh, jump or run. This is because the pelvic floor muscles which support the bladder have weakened and cannot cope with extra pressure. Stress incontinence is rare in men and is usually the result of an injury or the symptoms of an enlarged prostate or Benign Prostatic Hyperplasia (BPH). Approximately 40 per cent of women have some degree of stress incontinence at one stage in their lifetime.

Urge incontinence is a different bladder condition, which causes the bladder to contract suddenly in an uncontrolled way. Contractions often occur when the bladder is not full. About one in six people experience some symptoms of an overactive bladder, according to two large studies. However symptoms vary in their severity.

Although 40 per cent of women experience incontinence, only five per cent will have such a severe problem that surgery is required. Treatment should always start with the most conservative, non-invasive approaches and if the patient does not respond, treatment moves step-by-step towards more intense interventions.

Step One: Behavioural Therapy

Behavioural therapy should be the first step in any treatment. Many people find their problems improve when they change the amount of fluid they drink, when they drink and reduce certain drinks such as those containing caffeine.

This is often combined with pelvic floor exercises, to strengthen the muscles needed to prevent the flow of urine. Pelvic floor exercises are particularly important after pregnancy and childbirth, but are often neglected or done ineffectively.

Step Two: Pelvic Floor Exercises and Rehabilitation

Pelvic floor rehabilitation is another step and is often used after behavioural therapy and pelvic floor exercises. It involves using a small probe to measure muscle movement and the results are projected onto a computer screen. Patients can see how their muscles work and exactly how much harder they need to work in order to gain full control. Muscles are re-trained, initially using the computer guidance and then without guidance.

Bladder retraining is normally undertaken at the same time. This is a method of gradually increasing the time between your visits to the toilet, so that your bladder is able to hold larger quantities of urine comfortably.

Step Three: Medication

Medication can be effective in the treatment of incontinence and is sometimes used to support changes made in steps one and two. Urgency and overactive bladder are treated using anticholinegic medications such as oxybutynin (Lyrinel), tolterodine (Detrusitol) and slifenacin (Vesicare). There are some common but usually mild side-effects, which can include dry mouth, constipation, blurred vision and drowsiness. Mild or modest stress incontinence has been treated using duloxetine (Yentreve).

Duloxetine, originally developed for depression, has been found to interfere with the chemicals used in transmitting impulses from the nerves to the bladder muscles, helping these muscles to contract more effectively.

Step Four: Acupuncture

Studies show acupuncture can be effective in terms of increasing bladder capacity and reducing discomfort. Acupuncture is now recognised as an effective treatment, offered in specialist teaching hospitals as part of a wider service for patients with bladder problems. Percutaneous nerve stimulation is a more constant and intense form of acupuncture and can be effective in terms of strengthening the muscles required to achieve better bladder control and inhibiting the nerve impulses that cause unwanted bladder contraction, resulting in urgency.

Step Five: Minimally Invasive Techniques

For patients with more severe urgency, urge incontinence and overactive bladder, there are two minimally invasive techniques. Botox has been used for over five years to treat the overactive bladder and is now an established treatment. It works by inhibiting the nerves, which send signals to the bladder, telling the muscle to contract. Botox is effective on average for 6 to 9 months, but does risk the need for catheterisation in up to 20% of patients to assist bladder emptying.

Sacral Nerve Stimulation is a new technique is based on the stimulation of the nerves that control the bladder in the sacral part of the lower spine. A test stimulation is performed for a 3 week period, to which two thirds of patients respond. If a patient successfully responds to the temporary stimulator, a permanent bladder pacemaker is implanted, with battery life up to 7 years. This new technique has minimal risk of requiring catheters.

Step Six: Surgery

Surgery is normally only considered for women with significant stress incontinence. Women with an overactive bladder are likely to have found a solution in the first five steps of treatment. Women who continue to experience problems with stress incontinence following the first five steps of treatment may have structural problems which need to be addressed by surgery. Bladder surgery has rapidly developed during the past ten years and while surgical options need to be very carefully considered, success rates are over 80%.

The main types of surgery for stress incontinence are:

-Urethral bulking agents or implants

-Tension-free vaginal tape (TVT)

-Vaginal sling

-Bladder neck suspension by colposuspension

-Artificial urinary sphincter

For those patients with the most severe urge incontinence, surgery known as a clam cystoplasty involves using a small segment of your bowel is used to augment the bladder and prevent spasm. Success rates are fairly high, but this is a major, complex procedure which is only suitable for patients who have not responded to previous treatments.