Urinary incontinence (UI) has long been associated with respiratory symptoms and, in the main, a chronic cough. A chronic cough has been defined as a cough presenting as the only or predominant symptom and lasting for more than eight weeks with no obvious abnormalities on chest imaging (Yang et al, 2022). Chronic cough accounts for up to 10–38% of patients attending respiratory clinics (Yang et al, 2022) and has several complications associated with it, e.g. sleep disruption, headaches, and dizziness. Furthermore, the effects of a chronic cough can also lead to UI. Urinary incontinence is defined by the International Continence Society as the involuntary loss of urine (Abrams et al, 2010).  

The main type of UI associated with chronic coughing is stress urinary incontinence (SUI), which is the involuntary leakage of urine from the urethra associated with effort, physical exertion, sneezing or coughing (Haylen et al, 2010). The incidence of UI in females with chronic cough is higher than in males (Yang et al, 2022). This is mainly due to females having a higher risk of UI due to pregnancy, childbirth and the menopause (Haukeland-Parker et al, 2021). However Burge et al (2017) and Salman et al (2022) recognised in both studies of men with chronic cough/respiratory illness that prevalence of SUI and UI in this group is higher than men without respiratory/chronic cough symptoms.  

Complications of urinary incontinence can have a severe negative impact on quality of life. It is common for individuals to have higher levels of depression, anxiety and stress, and poor sleep quality (Haukeland-Parker et al, 2021). UI may also contribute to absences from work, avoidance of social activities and isolation, as well as financial implications including increased health costs (Haukeland-Parker et al, 2021). 

Thus, UI associated with chronic cough has been demonstrated as a significant clinical problem that professionals should have the knowledge to be able to identify and address.  

CAUSES OF CHRONIC COUGH  


To understand the impact of a chronic cough on UI, individual risk factors and the most common and less common causes responsible for chronic cough should be considered.  

Individual risk factors for a chronic cough are varied according to a study undertaken by Colak et al (2017). In this study of 14,669 individuals, prevalence of chronic cough in the general population was:  
  • 4% overall  
  • 3% in never smokers  
  • 4% in smokers  
  • 8% in current smokers.  
These figures identify smoking as a risk for respiratory conditions and a factor in chronic coughing. Other associated risks were being female, abdominal obesity, low income, environmental factors, allergies and increased age (Colak et al, 2017).  

The most common and less common causes contributing to a chronic cough are identified in Table 1. Some of the most common causes are now described in further detail.  

Table 1: Causes of chronic cough (adapted from NHS Inform Scotland, 2023a; Mayo Clinic, 2019).
Asthma is a chronic respiratory disease that affects the airways by causing inflammation of the inside walls which become sore and swollen causing constriction of the passage of the lungs and making it difficult to breath (Barrie, 2023). There are numerous triggers for asthma, including: 
  • Animal/pet hair  
  • Dust mites  
  • Certain medication including aspirin/non-steroidal anti-inflammatory drugs (NSAIDS)  
  • Changes in weather  
  • Chemicals in air/food  
  • Exercise  
  • Mould  
  • Pollen (Barrie, 2018). 
Postnasal drip is when more mucus than normal gathers and drips down the back of your throat. You may feel like you have a tickle in the back of your throat. Postnasal drip can be a bothersome condition that can lead to a chronic cough. The usual cause of postnasal drip is allergies (Mayo Clinic, 2019; NHS Inform Scotland, 2023a).  

Chronic obstructive pulmonary disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. Symptoms include difficulties breathing, mainly due to narrowing of airways (NHS inform Scotland, 2023b). The main cause is smoking, and the likelihood of developing COPD increases the more you smoke and the longer you have been smoking (NHS Inform Scotland, 2023b). This is because smoking irritates and inflames the lungs, which results in scarring. This inflammation leads to permanent changes in the lungs wall. Damage to the delicate walls of the air sacs in the lungs causes emphysema and the lungs lose their normal elasticity (NHS Inform Scotland, 2023b). The smaller airways also become scarred and narrowed. These changes cause the symptoms of breathlessness, cough and phlegm associated with COPD.  

Medications used for both the treatment of respiratory conditions and other conditions, i.e. oral medication, can cause chronic coughing leading to SUI. These can include:  
  • Angiotensin-converting enzyme inhibitors (ACE inhibitors)  
  • Opioids, which can account for an incidence rate of between 28–66% causing a chronic cough  
  • Statins  
  • Other drugs, e.g. omeprazole, interferon and ribavirin (Hongmei et al, 2020).  
However, a study by Battaglia et al (2019) on inhaled drugs for treatment of respiratory conditions concluded that the probability of these drugs causing or having an effect on urinary problems was very low. 

EFFECTS OF A CHRONIC COUGH ON THE PELVIC FLOOR  


There are many reasons for pelvic floor weakness (Table 2), however this article will concentrate on the effects of chronic coughing.  

It is commonly accepted that chronic coughing is a contributory cause for SUI, and this has been supported by a plethora of scientific evidence (Battaglia et al, 2019). Studies have shown the presence of symptomatic cough were statistically significantly higher in both men and women with UI, thus the chronic cough is suggested as being the main cause of SUI in this cohort of individuals (Battaglia et al, 2019).  

The question is why does a chronic cough have such a devastating effect on the pelvic floor? To understand this, an understanding of the anatomy and pathophysiology of the pelvic floor is needed.  

The pelvic floor is made up of muscles and connective tissue that form a ‘sling’ or ‘hammock’ across the base of the pelvis. It is designed to keep all pelvic organs in place, namely bladder, bowel and in female’s uterus, and support spinal and pelvic stability (Yates, 2019a). These muscles control the opening of the bladder and maintain sphincter pressure. When working correctly and intra-abdominal pressure is increased, i.e. coughing, they react by contracting around the urethra to prevent leakage. However, anything that repeatedly or continuously raises abdominal pressure will put added strain on the pelvic floor muscles and risks damaging them, i.e. chronic cough (Yates, 2019a). 

Table 2: Pelvic floor weakness — risk factors (Abrams et al, 2017; Yates, 2019a). 

ASSESSING CONTINENCE FOR AN INDIVIDUAL WITH CHRONIC COUGH  


It has been identified that healthcare professionals are not familiar with UI in men or women who suffer with respiratory conditions and exacerbation of chronic cough (Battaglia et al, 2019). Individuals who have UI due to chronic cough may also not mention the condition to a professional due to shame, embarrassment or low perception of the importance and consequences of the condition compared to presenting respiratory symptoms. Professionals should identify at-risk individuals and urinary assessment should be included within clinical assessment (Battaglia et al, 2019; Hennessey, 2023).  

A continence assessment should include (Colley, 2020; Yates 2019b):  
  • Complete medical, surgical, obstetric, neurological and mental health history, details of any allergies, mobility, dexterity, and cognitive or social issues  
  • Body mass index (BMI)  
  • Information about the onset, duration and current presentation of the symptoms and whether related to a specific event (i.e. coughing/condition), effect on current quality of life and current management 
  • Details of all medication, including over-the-counter medication, herbal remedies and recreational drug use  
  • A completed bladder diary (usually three days) 
  • Details of fluid intake (including amount and type of fluids)  
  • Dipstick urinalysis – which is used on an initial continence assessment only as a screening rather than a diagnostic test. This helps to rule out dehydration and other medical issues including renal problems, diabetes and potential urinary tract infections (UTIs)  
  • Bladder scans – if presenting with symptoms of poor flow, feelings of incomplete emptying and recurrent UTIs, or have an underlying neuropathy  
  • Examinations (vaginal/rectal/abdominal/neurological), if required, but only performed by a competent professional. 
It is vitally important to assess the individual before initiating any form of treatment or management plan. 

TREATMENTS AND MANAGEMENT  


Prevention is the primary aim of treating UI associated with chronic cough (Figure 1). 

This can include reviewing and possibly removing medication aggravating the chronic cough which has an impact on UI. For example:  
  • Treating asthma-related coughing with appropriate inhaled steroids (as these have a low impact on UI) 
  • Allergies can be treated by avoiding allergens and taking antihistamines to dampen down allergic reactions  
  • Treating bacterial infections with antibiotics (when clinically required)  
  • GORD can be treated with antacids to neutralise stomach acid and medication to reduce the amount of acid the stomach produces (but be aware that omeprazole may have an impact on coughing)  
  • COPD can be treated with bronchodilators to widen airways (NHS inform Scotland, 2023a).  
One of the best ways to improve SUI is the instruction of pelvic floor exercises and pelvic floor rehabilitation. Pelvic floor exercise is well evidenced and documented for reducing SUI in other populations but there is a sparsity of evidence with regards to its implementation within individuals who suffer SUI from chronic cough (Haukeland-Parker et al, 2021).  

Figure 1. Sample flow chart to indicate pathway for individuals with chronic cough presenting with UI. 
A study by Button et al (2019) explored if pelvic floor exercises would benefit to women with respiratory disease compared to women without respiratory disease. All participants underwent a three-month treatment programme, had assessments at baseline, treatment completion (three months) and three months following treatment by a specialist pelvic floor physiotherapist. Treatment comprised pelvic floor muscle training, including the knack, contraction of pelvic floor on exertion, sneezing, coughing etc and a daily pelvic floor exercise regimen (Button et al, 2019). The study indicated that the initiation of pelvic floor exercises did improve SUI outcomes for this group of individuals and should be promoted as a treatment.  

An example of a pelvic floor rehabilitation programme is identified in Box 2. Initial assessment and instruction should always be undertaken by a professional competent in pelvic floor assessment and rehabilitation.  

Box 1. Patient story.


Violet (name changed for confidentiality), a 30-year-old, was a self-referral into the author’s bladder and bowel service (BABS) with symptoms of urinary leakage on coughing, sneezing and exertion.

She had suffered with asthma since childhood, had no other relevant previous history and was nulliparous, non-smoker, with a BMI of 24. Previously, her medication had included a reliever inhaler (salbutamol, a preventative inhaler) and budesonide, and she stated that she had been prescribed steroids on numerous occasions. However, over the past five years symptoms of coughing and urinary leakage have got significantly worse. She has discussed her respiratory symptoms with her consultant and her medication was being reviewed. But Violet felt too embarrassed to bring up her urinary problem, as she thought that she was the only one suffering with this even though the symptoms were affecting her quality of life greatly. She finally heard of BABS through a friend and eventually plucked up the courage (after two months) to contact the service.

All of this information was taken during her initial assessment, when her presenting symptoms were also assessed. These included frequency of urination seven times in 24 hours, no urgency, hesitancy or straining to void, but urinary leakage five to six times daily, usually no night time leakage (apart from when having an exacerbation of her asthma, usually a small–moderate amount and always associated with coughing, sneezing or exertion). She currently purchases her own pad products to manage the situation. She found the whole situation extremely humiliating and degrading, especially for a young working lady — it has affected her working and social life, her emotional wellbeing, as well as her finances.

Continuing the assessment her bowel pattern was checked which was usually daily, type 3–4 on the Bristol Stool Chart (BSC), no straining or bleeding noted.

She consented to a pelvic floor examination, which identified that she had a very weak pelvic floor, grade 1 on the Oxford grading (flicker only). She could only hold for three seconds and only repeat twice, and only achieved two fast muscle contractions. There was also some descent and slight urinary leakage noted on coughing. She thus had a differential diagnosis of stress urinary incontinence.

A treatment plan was discussed in depth, which included lifestyle advice and referral to a pelvic floor physiotherapist, as this would be the gold standard for improving outcomes. She was advised that she would not see any improvement for up to three months.

Violet was happy that she had contacted the service and realised that she was not alone, and something could be done, her only regret was that she had not come forward sooner.

CONCLUSION  


Many individuals suffer with UI due to a chronic cough. However, healthcare professionals who treat respiratory conditions are unaware of the bearing that a chronic cough can have on UI and the negative impact this causes on quality of life. Individuals who are at risk, or already suffer with UI due to their condition, should be identified and treated. Review of their current treatments should be undertaken, and advice given to see if minimising the cough would have an impact. If they already have SUI, referral to an appropriate professional for pelvic floor instruction should be considered. At present, these individuals are having a raw deal when it comes to UI presentation, which, in the author’s clinical opinion, needs to be addressed. 

Box 2. Example of a pelvic floor rehabilitation programme


Rehabilitation comprises exercises in three positions — lying down, sitting and standing.

Slow muscle contractions

Lying down: lie down on your back on your bed with your knees bent and feet slightly apart. Tighten your pelvic floor as if trying to stop wind escaping. Hold contraction for ____ seconds. Relax for four seconds. Avoid holding your breath or tensing buttock muscles.

Sitting: sit on the edge of a chair or bed with your knees apart and feet facing forward. Tighten your pelvic floor and hold contraction for ____ seconds. Relax for four seconds. Avoid holding your breath or tensing buttock muscles.

Standing: stand with weight evenly distributed, and feet apart and facing forward. Tighten your pelvic floor and hold contraction for ____ seconds. Relax for four seconds. Avoid holding your breath or tensing buttock muscles. Perform three contractions to maximum strength three times daily in each position, building up to 10 three times daily.

Fast muscle contractions

In the same three positions as above, tighten pelvic floor as if trying to stop wind escaping but do not hold. Relax and repeat. Perform three contractions to maximum strength twice daily in each position, building up to 10 three times daily.

Other activities

50% lift: contract your pelvic floor to 50% of the maximum strength only while walking, climbing stairs and so on. This will increase endurance.

The knack: tighten your pelvic floor strongly and quickly before coughing, sneezing, getting up from a chair, lifting, and so on. This will help prevent leakage.

After urinating: tighten your pelvic floor strongly to ‘squeeze out’ the last few drops before leaving the toilet.

After defecating: tighten your pelvic floor to ‘push back’ any faecal matter left in the anal canal into the bowel.
During sexual activity: tighten the pelvic floor, as this will help enhance sexual intercourse. (Adapted from Pelvic Obstetric and Gynaecological Physiotherapy, 2018; Yates, 2019c; Dorey, 2003)

KEY POINTS

  • ● Chronic cough can have a significant impact on an individual’s bladder control

    ● The causes of chronic coughing should be reviewed regularly to prevent UI complications

    ● At risk individuals should be identified and advice/treatment/ preventative measures initiated
    ● Professionals treating respiratory conditions associated with chronic cough should be able to access relevant pelvic floor experts to treat patients.

Ann Yates is director of continence services, Cardiff and Vale University Health Board
This piece was first published in the Journal of Community Nursing. To cite this article use: Yates A (2023) Effects of chronic cough on urinary incontinence. J Community Nurs 37(4): 34–38

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