There are many different treatments available for those suffering from bladder and/or bowel incontinence. Grouped here into conservative therapies, non-surgical medical treatments and surgical treatments.
Working with your GP you can agree a programme of several treatments, to give you a lasting solution. The treatment programme will aim to resolve the issues that are bothering you most first. For example, if you are struggling to get enough sleep as your bladder is waking you up multiple times a night (Nocturia), you may wish to treat that first before concentrating on an issue you may have with leaking when you laugh (giggle incontinence). The programme will aim to improve your quality of life by reducing the impact of your symptoms. Alongside resolving the original cause of the incontinence to reduce the risk of it recurring and repairing any damage that has been done.
If you are suffering with depression, associated with your incontinence, speak to your doctor about what support is available during your treatment.
There are surgical treatments available for incontinence, but they are only offered when other treatments have been unsuccessful, and you are still severely suffering. Pelvic surgeries lose their effectiveness over time; therefore they are usually reserved for adults which are finished having children. Surgeries cannot be considered as a one-time solution to incontinence, and should always be accompanied with permanent lifestyle changes, and pelvic floor exercises, to prevent the incontinence from returning.
As incontinence can be a symptom of another condition, seek formal diagnosis from your doctor before proceeding with treatment. Not all treatments are appropriate for all conditions, and can even result in your incontinence getting worse.
Conservative Therapy's to Treat Incontinence
Conservative therapy's are considered as the first course of treatment for incontinence. They are able to significantly improve 25% of minor and moderate bowel incontinence cases, and even more urinary incontinence cases. Your GP will look to treat the reversible (transient) causes of your incontinence first, often by reviewing your lifestyle and existing prescriptions:
- Lifestyle changes -
- Maintain a weight of BMI 30 or less. Reducing your weight by just 8% can decrease the frequency of your incontinence episodes by half.
- Cut down on diuretic food and drinks such as caffeine and alcohol, to reduce the amount of urine you produce.
- Avoid constipation which puts added strain on your pelvic floor and can even put pressure on your bladder.
- Stop smoking and treat any chronic cough, to stop weakening your pelvic floor.
- Amend your diet to reduce the occurrence of diarrhoea (low fibre) or constipation (high fibre).
- Wear clothes which can be easily removed if you urgently need the toilet.
- Empty your bladder before exercise, sex and going to sleep.
- Review existing prescriptions - Do not stop any prescribed medications without first consulting your GP. Medicines which can lead to incontinence include; diuretics, opiods (e.g. morphine), blood pressure medicines, antidepressants, sedatives, hormone replacement therapy drugs, and ketamine (used in anaesthesia and as a pain killer). These can affect the effectiveness of your muscles, and increase the volume of urine your kidneys produce.
- Manual pelvic floor muscle (Kegel) exercises - Strong pelvic floor muscles are essential for having voluntary control over your bladder and bowel. The muscles support the bladder and bowel as they gradually fill, you then voluntarily contract the sphincter muscles to prevent leaks whilst you make your way to a toilet. When you are ready, your muscles help you empty your bladder and bowel. You lose control over these functions as your muscles weaken or experience damaged. Luckily this can be quickly reversed, it takes just a 12 week course of daily exercises to bring your pelvic floor muscles back to full strength. Pelvic floor exercises are proven to provide; a 70% improvement in the symptoms associated with stress urinary incontinence; reduce the frequency of incontinence episodes by half after just 6 weeks; and can fully resolve most cases of incontinence that occur as a result of a newly weakened pelvic floor following childbirth. Pelvic floor exercises should be continued even after you have treated your incontinence, on a weekly 'maintenance' schedule to prevent the incontinence from returning.
- Pelvic floor (Kegel) exercises using electrical stimulation - When you first begin to exercise your pelvic floor, you may struggle to contract the correct muscles or not be contracting them correctly. As a result you will not see much improvement in your incontinence. If this is the case, or you wish to see an improvement even quicker, electronic pelvic toners are available to contract your pelvic floor muscles for you. Some toners even have specialised, medically approved, programmes that look to resolve the specific form of incontinence you are suffering from. Through a proven series of timed artificial muscle contractions and relaxations. The toners can use a vaginal probe, anal probe or skin electrodes, to send electrical pulses to your muscles. These devices do not need to be prescribed and are beneficial for everyone, even if they do not suffer from a pelvic floor disorder. However, avoid using electrical stimulation if you are pregnant or suffer from an overactive bladder, unless otherwise specified by your GP.
- Anal sphincter exercises (for bowel incontinence) - To improve the control you have over your bowel, you can specifically exercise your internal and external sphincter muscles to increase their strength. Sit with you knees slightly apart. Squeeze your anus as if you are trying to stop yourself passing wind, then lift the muscle as tightly as you can, away from the chair - as if you can feel a leak is about to occur. Your buttocks, abdomen and thighs should not tense - check this is the case and relax everything and start again if they are. Breath normally as you should be able to hold a conversation as you do these exercises. There are different routines available to train the strength of the sphincter muscles, their endurance, and reflex to sudden urges. Each routine involves holding the contraction for different amounts of time, always followed with an equal relax period to avoid the muscles getting too tight. These exercises can be done alongside your pelvic floor exercises, and should be continued even after you have treated your incontinence.
- Bowel and/or bladder behaviour therapy - Usually a six week, partly supervised, programme. The purpose of this therapy is to teach you how to contract your muscles correctly in order to urinate and/or defecate most effectively. Resulting in fewer trips to the bathroom, which are more successful. Biofeedback techniques can be used to inform you when you are incorrectly contracting or relaxing your muscles. This uses a small electronic probe, inserted into the vagina or anus, to capture information about the muscles and how they are working. This can be used by a specialist to advise on which exercises you need to do to improve the function of your bladder and/or bowel. For bowel retraining, you should see an improvement in stool consistency. For bladder therapy, you will also be trained on how to relax your muscles to hold urine for longer.
- Alarm therapy - If you suffer from bed wetting as you sleep, an electronic sensor can be placed in your underwear, on a pad which is put in your underwear, or on a mat which you sleep on which triggers an alarm when it senses moisture. This can be used at night to wake you up when you begin to leak. This therapy is commonly used for children which will otherwise consistently wet the bed as they sleep. The alarm should be used until you have at least 14 consecutive dry nights.
- Ask for support - If you suffer from functional incontinence, you may experience the sensation to go to the bathroom, but cannot go for physical or psychological reasons. Ask for help in improving the environment around the bathroom to make it more accessible, and for someone to be regularly available when you need to go. If you need help communicating your need to go to the bathroom, speak to a friend, relative or carer about implementing a system to express this need. It may help to plan a regular schedule of using the bathroom, when someone can be available.
Non-Surgical Medical Treatments for Incontinence
If your incontinence has occurred because of a reversible (transient) cause, you may be prescribed medical treatment alongside undergoing some of the conservative therapy's listed above. These can ease and treat your symptoms, or prevent the abnormal functions which are leading to your incontinence:
- Treat any underlying condition - If you have developed a form of incontinence as a result of suffering from another condition, such as recurring UTI's or constipation, treat these alongside treating your incontinence to prevent it from returning.
- Duloxetine - This oral medicine helps keep the urethra closed when you are not urinating, by increasing the muscle tone of the urethral sphincters. Often favoured over surgery with the same aim.
- Bethanechol chloride - This orally administered drug increases the tone of your bladder muscle and its ability to contract. It works within an hour of administration and therefore its benefits are often seen within just a few days.
- Antimuscarinics - Specifically for an overactive bladder, this group of medicines are usually taken orally several times a day, or though a skin patch. They reduce involuntary contractions of the detrusor muscle which can lead to an overactive bladder.
- Mirabegron - This oral medicine causes the bladder muscles to relax to allow it to fill and store urine, increasing the amount of urine you are able to hold.
- Desmopressin - Specifically for nocturia, this medicine reduces the amount of urine produced by the kidneys and is taken a few hours before going to sleep.
- Loperamide - To treat diarrhoea, this medicine slows the movement of stools through the digestive system to allow more water to be absorbed into the bloodstream.
- Laxatives - Laxatives treat constipation by loosening your stools and increasing the volume of your bowel movements.
- Suppositories and enemas - Where you suffer from faecal impaction blocking the rectum, these deliver medication straight to the issue.
- Rectal irrigation - Also used for faecal impaction, a small tube injects liquid medicine into the rectum to flush out faeces.
- Catheter - You can have a catheter fitted intermittently, to empty your bladder into a toilet in a procedure called clean intermittent catheterisation. This is repeated at multiple points during the day to reduce overflow incontinence. You can fit the catheter into your bladder yourself or a professional can do so. An indwelling catheter is a more permanent solution, it is left in place to continually collect urine in a bag which you will carry with you.
- Posterior tibial nerve stimulation - Through a series of 12 sessions (30 minutes each week), you will have a needle inserted into your ankle, through which a mild electric current is sent. This stimulates the posterior tibial nerve, which runs from your ankle to your pelvis. It can relieve symptoms of your overactive bladder, urge incontinence, and bowel incontinence. Potential complications: 15% of patients will suffer one of the following; temporary swelling, headaches, cramps, blood in the urine and occasionally a worsening of the incontinence. No long term negative effects have been reported.
- Botox injections - Botox (botulinum toxin A) can be injected into your bladder to relax it. The effects last several months, after which the injections can be repeated. Potential complications: the injections are unable to resolve overflow incontinence and studies into its long-term effects are incomplete.
- Bulking agents - Bulking agents are injected into the walls of the urethra or anal sphincter muscles to increase their size, encouraging them to stay closed with greater strength. This procedure has a 53% success rate - but this does differ depending on the bulking agents used. Potential complications: this procedure is often not as effective as other options. For a short time after the procedure you may suffer from a burning sensation, an abscess, or bleeding.
Surgical Treatments for Incontinence
Incontinence is considered chronic if the original cause of the incontinence cannot be reversed or resolved through conservative therapy's alone i.e. spinal injury. The lasting damage may be treated with a course of medicine. If this is not sufficient, you may be considered as a suitable candidate for surgery.
If you opt for surgery, your doctor will speak to you about the risks, and likelihood for the success of the surgery to fall as time goes on. Surgery is usually reserved for adults that have finished having children as pelvic surgery can cause issues with conception, and falling pregnant can reverse the benefits of previous pelvic surgeries. If you suffer from several different types of incontinence, you may require multiple surgeries. The risk of fatality is present for all surgeries.
- To remove uterine fibroids (in women) - If you suffer with fibroids that are irritating your bladder, there are three popular procedures:
- Myomectomy - Surgical removal of the fibroids from the uterus. Potential complications: inability to conceive.
- Hysterectomy - Surgical removal of the entire womb. Potential complications: unable to have children and increased vulnerability to developing pelvic organ prolapses.
- Non-surgical uterine fibroid embolisation (UFE) - Deprives the fibroids of their blood supply so they shrink in size.
- Bladder enlargement (augmentation cystoplasty) - This procedure increases the size of your bladder by adding a piece of intestinal tissue. It also aims to reduce the effects of muscle contractions.
- Potential complications: you may require a permanent catheter following this surgery, and can suffer from recurrent UTI's as a result.
- Sacral nerve stimulation (sacral neuromodulation (SNM)) - You can have a device fitted near your sacral nerves (at the bottom of your back) which is stimulated to tell the muscles of the bladder to relax. Reducing the impact of an overactive bladder caused by detrusor muscle over activity. The device can also be used to increase the strength of the sphincter and pelvic floor muscles, for them to work together more effectively. SNM can be used to resolve pelvic pain, reduce incontinence episodes, treat an overactive bladder, constipation and many other pelvic conditions. It influences the muscles, nerve endings and reflexes in the pelvis.
- Potential complications: no long term negative effects have been reported, however, you may suffer temporary discomfort or infection.
- Urinary diversion - If your bladder or urethra is blocked or severely damaged, a urinary diversion redirects the urine straight from the kidney into either; an artificial pouch inside the body (continent diversion); or a plastic pouch worn outside the body (urostomy). It can be done temporarily whilst a blockage is resolved, or permanently.
- Potential complications: this is a major surgery and can lead to bladder infections and needing further surgery.
Procedures to treat stress incontinence include:
- Tension-free Vaginal Tape (TVT) procedure - A tape procedure reduces the pressure on the bladder. It involves a piece of plastic tape being permanently inserted behind the urethra to support it. 2/3 women experience normal bladder function after the surgery.
- Potential complications: some women develop urge incontinence following the surgery; increasing how often they need to go to the bathroom, and cannot always empty their bladder when they do go. Artificial mesh and tape can erode into the surrounding tissue, causing lasting pain. From 2017, the National Institute for Health and Care Excellence recommend that artificial mesh and tape is only used in pelvic surgeries within the context of research - whilst further evidence into its long-term safety is carried out.
- Sling procedure - A sling (made of your or a donors tissue, or a synthetic material) is placed around the neck of your bladder to support it and prevent accidental leaks.
- Potential complications: some individuals develop overflow incontinence. From 2017, the National Institute for Health and Care Excellence raise serious concerns about using synthetic mesh in such procedures. Serious complications are possible, which include lasting pain and the surgery failing. If the mesh needs to be removed, as it begins to erode into your tissue, it can be difficult and occasionally impossible to do so.
- Colposuspension - This surgery lifts the neck of your bladder to prevent involuntary leaks in women suffering from stress incontinence.
- Potential complications: issues with this surgery include developing overflow incontinence, sexual discomfort and frequent urinary tract infections.
- Artificial urinary sphincter - When you are holding in urine, you are unconsciously contracting your urinary sphincter. An artificial urinary sphincter can replace yours, and can be activated and deactivated as needed, depending on the type of item fitted. This procedure is mostly used for men suffering from stress incontinence.
- Potential complications: it is not uncommon for the artificial sphincter to fail and need to be removed after many years of use.
Procedures to treat bowel incontinence include:
- Artificial anal sphincter - If the muscles of the sphincter are irreparably damaged, an artificial circular cuff is placed under the skin around the anus. This keeps the anus closed until a button under the skin is pressed, at which point the cuff opens and stool can be passed. The cuff then slowly refills with fluid, closing it again.
- Potential complications: 86% of patients suffer from complications. These range from infection and pain, to erosion of the cuff and increased faecal incontinence and constipation.
- Sphincteroplasty - To give extra support and strength to the anal sphincter, some of the tissue in the muscle is removed, and then the muscles are overlapped.
- Potential complications: infection, no improvement in the incontinence and leaks around the surgical stitches.
- Endoscopic heat therapy - A new treatment for bowel incontinence, heat is applied to the anal sphincter through a thin probe. It encourages tissue scarring to tighten the muscles.
- Potential complications: the most common issue is anal ulcers forming, leading to anal pain. Other reported risks include increased constipation, diarrhoea and severe bleeding.
- Colostomy - If other treatments have been unsuccessful, the colon (lower bowel) is shortened and given an artificial opening which leads to an external colostomy bag, which then collects the stool.
- Potential complications: the development of granulomas (a mass of cells caused by inflammation), infection, pain, leaks and skin conditions around the opening.
- Sacral nerve stimulation (sacral neuromodulation (SNM)) - You can have a device fitted near your sacral nerves (at the bottom of your back) which is stimulated to increase the strength of the sphincter and pelvic floor muscles, for them to work together more effectively. SNM can be used to resolve pelvic pain, reduce incontinence episodes, treat an overactive bladder, constipation and many other pelvic conditions. It influences the muscles, nerve endings and reflexes in the pelvis.
- Potential complications: no long term negative effects have been reported. You may suffer from temporary discomfort or infection.
- Implanted magnetic bead band - If you have weak or damaged sphincters, you may be offered this relatively new procedure. A tunnel is made around the anus, into which a ring of magnetic beads is placed. The magnets keep the sphincter closed, until stool presses against it to interfere and open the ring. The National Institute for Health and Care Excellence recommend this procedure due to the significant improvement in quality of life that it can provide.
- Potential complications: more research into the procedures effectiveness and safety needs to be done. Current known risks include temporary infection, swelling, pain and bleeding. Long term risks include difficulty passing stool, developing abscesses and the band breaking.
- Muscle transposition - A segment of the gracilis muscle, from the patients thigh, is added to the anus as extra bulk. An electric pulse generator is implanted into the abdomen which continuously stimulates the muscle, turning it into a slow twitch endurance muscle.
- Potential complications: infection, electrical/technical problems and issues emptying your bowel.
Other treatments to resolve incontinence are being studied all the time to ensure they are safe and effective. Visit the National Institute for Health and Care Excellence for advice into procedures you are offered which are not mentioned above.
Living With Incontinence
Whilst you treat your incontinence, there are many techniques and products you can use to reduce the impact of incontinence on your life. Read more in Living with Incontinence.
Al-Shaikh, G. Syed, S. Osman, S. Bogis, A. Al-Badr, A. (2018). International Journal of Women's Health. Pessary use in stress urinary incontinence: a review of advantages, complications, patient satisfaction, and quality of life. [online] 10(1), p195-201. [viewed 23/04/18]. Available from: https://www.dovepress.com/pessary-use-in-stress-urinary-incontinence-a-review-of-advantages-comp-peer-reviewed-article-IJWH
Bladder and Bowel Support Company (2014). Factsheet: Faecal Incontinence. [online] Bladder and Bowel Community. [viewed 25/04/18]. Available from: https://www.bladderandbowel.org/wp-content/uploads/2017/05/BBC017_Faecal-Incontinence.pdf
Carter, D. (2014). Gastroenterology. Conservative treatment for anal incontinence. [online] 2(2), p85-91. [viewed 26/04/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4020129/#__ffn_sectitle
Chang-Bum, K. Seong-Hi, P. (2014). Advances in Nursing. Review Article: Effect of Kegel Exercises on the Management of Female Stress Urinary Incontinence: A Systematic Review of Randomized Controlled Trials. [online] 640262, p 1-10. [viewed 03/04/2018] Available from: https://www.hindawi.com/journals/anurs/2014/640262/
Chughtai, B. Laor, L. Dunphy, C. Lee, R. Te, A. Kaplan, S. (2015). Reviews in Urology. Diagnosis, Evaluation, and Treatment of Mixed Urinary Incontinence in Women. [online] 17(2), p78-83 [viewed 18/04/18] Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4857898/#__ffn_sectitle
Dwyer, N. T. (2006). Urology Board Review Manual. Stress Urinary Incontinence in Women. 13(1), p 1-12.
Heymen, S. Scarlett, Y. Jones, K. Ringel, Y. Drossman, D. Whitehead, W. E. (2009). Diseases of the colon and rectum. Randomized Controlled Trial Shows Biofeedback to be Superior to Alternative Treatments for Patients with Pelvic Floor Dyssynergia-type Constipation. [online] 52(10), doi: 10.1007/DCR.0b013e3181b55455. [viewed 26/04/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3855426/#__ffn_sectitle
NHS Trust. (2016). Urinary incontinence: Non-surgical treatment. [online] NHS Trust, 2016. [viewed 20/04/18] Available from: https://www.nhs.uk/conditions/urinary-incontinence/treatment/
Kegel, A. H. (1952). Ciba Clinical Symposia. Stress incontinence and genital relaxation; a nonsurgical method of increasing the tone of sphincters and their supporting structures. [online] 4(2), p 35-51 [viewed 03/04/2018]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14905555
Khandelwal, C. Kistler, C. (2013). American Family Physician. Diagnosis of Urinary Incontinence. [online] 87(8), p543-550. [viewed 23/04/18] Available from: https://www.aafp.org/afp/2013/0415/p543.html
Maternik, M. Krzeminska, K. Zurowska, A. (2015). Pediatric Nephrology (Berlin, Germany). The management of childhood urinary incontinence. [online] 30(1), p41-50. [viewed 24/04/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4240910/#!po=59.3750
Mid Cheshire Hospitals NHS Foundation Trust. (2008). Sphincter exercises for people with bowel control problems. [online] The Association of Coloproctology of Great Britain and Ireland, 2008. [viewed 30/04/18]. Available from: http://colorectalassociates.com/wp-content/uploads/2017/10/MCH_CU_Sphincter-ExercisesA5_V1.pdf
NHS Trust. (2016a). Urinary incontinence: Overview. [online] NHS Trust, 2016. [viewed 20/04/18] Available from: https://www.nhs.uk/conditions/urinary-incontinence/
NHS Trust. (2016b). Urinary incontinence: Surgery and procedures. [online] NHS Trust, 2016. [viewed 20/04/18] Available from: https://www.nhs.uk/conditions/urinary-incontinence/surgery/
NICE. (2004a). Sacral nerve stimulation for urge incontinence and urgency-frequency. [online] National Institute for Health and Care Excellence, 2004. [viewed 01/05/18] Available from: https://www.nice.org.uk/guidance/ipg64/resources/sacral-nerve-stimulation-for-urge-incontinence-and-urgencyfrequency-pdf-257123773
NICE. (2004b). Sacral nerve stimulation for faecal incontinence. [online] National Institute for Health and Care Excellence, 2004. [viewed 01/05/18] Available from: https://www.nice.org.uk/guidance/ipg99/resources/sacral-nerve-stimulation-for-faecal-incontinence-pdf-302618557
NICE. (2004c). Artificial anal sphincter implantation. [online] National Institute for Health and Care Excellence, 2004. [viewed 01/05/18] Available from: https://www.nice.org.uk/guidance/ipg66/resources/artificial-anal-sphincter-implantation-pdf-257170429
NICE. (2005). Intramural urethral bulking procedures for stress urinary incontinence is women. [online] National Institute for Health and Care Excellence, 2005. [viewed 01/05/18] Available from: https://www.nice.org.uk/guidance/ipg138/resources/intramural-urethral-bulking-procedures-for-stress-urinary-incontinence-in-women-pdf-304250221
NICE. (2006a). Percutaneous endoscopic colostomy. [online] National Institute for Health and Care Excellence, 2006. [viewed 01/05/18] Available from: https://www.nice.org.uk/guidance/ipg161/resources/percutaneous-endoscopic-colostomy-pdf-304436845
NICE. (2006b). Stimulated graciloplasty for faecal incontinence. [online] National Institute for Health and Care Excellence, 2006. [viewed 01/05/18] Available from: https://www.nice.org.uk/guidance/ipg159/resources/stimulated-graciloplasty-for-faecal-incontinence-pdf-304431661
NICE. (2010). Treating an overactive bladder by stimulating a nerve near the ankle. [online] National Institute for Health and Care Excellence, 2010. [viewed 01/05/18] Available from: https://www.nice.org.uk/guidance/ipg362/resources/treating-an-overactive-bladder-by-stimulating-a-nerve-near-the-ankle-pdf-315919405
NICE. (2011). Treating faecal incontinence using endoscopic radiofrequency (heat) therapy. [online] National Institute for Health and Care Excellence, 2011. [viewed 01/05/18] Available from: https://www.nice.org.uk/guidance/ipg393/resources/treating-faecal-incontinence-using-endoscopic-radiofrequency-heat-therapy-pdf-317683261
NICE. (2013). Urinary incontinence in women: management. [online] National Institute for Health and Care Excellence, 2015. [viewed 18/04/18] Available from: https://www.nice.org.uk/guidance/cg171/resources/urinary-incontinence-in-women-management-pdf-35109747194821
NICE. (2014). Inserting a magnetic bead band for faecal incontinence. [online] National Institute for Health and Care Excellence, 2014. [viewed 01/05/18] Available from: https://www.nice.org.uk/guidance/ipg483/resources/inserting-a-magnetic-bead-band-for-faecal-incontinence-pdf-474842514373
NICE. (2015). Urinary incontinence in women: management, 1 Recommendations [online] National Institute for Health and Care Excellence, 2015 [viewed 03/04/2018]. Available from: https://www.nice.org.uk/guidance/cg171/chapter/1-Recommendations#physical-therapies
NICE. (2017a). Single-incision short sling mesh insertion for stress urinary incontinence in women. [online] National Institute for Health and Care Excellence, 2017. [viewed 01/05/18] Available from: https://www.nice.org.uk/guidance/ipg566/ifp/chapter/What-has-NICE-said
NICE. (2017b). Mesh for vaginal wall prolapse should only be used in the context of research, says NICE. [online] National Institute for Health and Care Excellence, 2017. [viewed 01/05/18] Available from: https://www.nice.org.uk/news/article/mesh-for-vaginal-wall-prolapse-should-only-be-used-in-the-context-of-research-says-nice
NICE. (2018). Find guidance. [online] National Institute for Health and Care Excellence, 2018. [viewed 01/05/18] Available from: https://www.nice.org.uk/guidance
Olson, C. H. (2014). Clinics in Colon and Rectal Surgery. Diagnostic Testing for Fecal Incontinence. [online] 27(3), p85-90. [viewed 23/04/18]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174193/
Price, N. Dawood, R. Jackson, S. R. (2010). Maturitas. Pelvic floor exercise for urinary incontinence: A systematic literature review. [online] 67(4), p309-315. [viewed 16/04/18]. Available from: https://pdfs.semanticscholar.org/bd40/19fc898987cfb343c6652205837f92029039.pdf
Rahule, A. Sagdeo, V. Soni, N. (2014). Journal of Contemporary Medicine and Dentistry. Evaluation of Effect of Kegel Exercise for the Management of Stress Incontinence in Women of Gujrat, India.[online] 2(3), p 20-23. [viewed 27/04/2018]. Available from: https://pdfs.semanticscholar.org/20e2/6c8d8375900d97ab45d416870746afc85307.pdf
Roche, B. (2018). Sphincteroplasty : Technique and Results. [online] University Hospital of Geneva, 2018 [viewed 30/04/18]. Available from: http://www.proctology.ch/proctology/images/doc_pdf/Reconstruction_sphincter.pdf
Rosen, A. Taragano, L. Condrea, A. Sidi, A. Ron, Y. Ginath, S. (2015). The Israel Medical Association Journal. Effects of Sacral Neuromodulation on Urinary and Fecal Incontinence. [online] 17(6), p 351-355. [viewed 30/04/18]. Available from: https://www.ima.org.il/FilesUpload/IMAJ/0/152/76420.pdf
Royal College of Nursing. (2016a). Causes of incontinence. [online] Royal College of Nursing, 2016. [viewed 23/04/18]. Available from: https://rcni.com/hosted-content/rcn/continence/causes-of-incontinence
Royal College of Nursing. (2016b). Interventions/treatment. [online] Royal College of Nursing, 2016. [viewed 23/04/18]. Available from: https://rcni.com/hosted-content/rcn/continence/interventionstreatment
Sangsawang, B. Serisathien, Y. (2012). Journal of Advanced Nursing. Effect of pelvic floor muscle exercise programme on stress urinary incontinence among pregnant women. [online] 68(9), p1997- 2007. [viewed 27/04/2018]. Available from: http://dx.doi.org/10.1111/j.1365-2648.2011.05890.x