Urinary Incontinence

Urinary incontinence is the involuntary leakage of urine. Although it becomes more common as people get older, incontinence is not normal at any age. Many types of effective therapies are available for all types of urinary incontinence. A brief review of the normal process of urination in adults will help in understanding both the causes and treatment of urinary incontinence.

Most individuals empty the bladder approximately every three to four hours during the day, and getting up once during the night to void is not abnormal for older people. Urine is produced by the kidneys and passes into a muscular sac called the urinary bladder. A tube called the urethra leads from the bladder to the outside of the body.

A special ring of muscles called the urinary sphincter surrounds the urethra. As the bladder fills with urine, complex nerve signals ensure that the muscles of the sphincter stay contracted, and that the muscles of the bladder stay relaxed. This allows the bladder to fill with urine without urine leaking out of the body.

When the bladder fills to a certain level, nerve signals are sent to the brain, letting the person know that the bladder is getting full. Additional nerve signals must be sent in a coordinated fashion to initiate urination. Some of these signals cause the bladder muscles to contract, which pushes urine into the urethra. At the same time, other signals cause the sphincter muscles to relax, which allows the urine to pass out of the body.

However, four things can go wrong with this process:

  • The bladder contracts when it shouldn't (when the person is not ready to urinate). This is the most common reason people have incontinence.
     

  • The bladder fails to contract properly when it should (leading to a buildup of urine in the bladder and subsequent leakage). This problem is uncommon.
     

  • The sphincter doesn't close properly or doesn't stay closed when subjected to pressure (as with a cough or sneeze), allowing urine to leak. This is a common reason for incontinence in women.
     

  • The urethra is obstructed, preventing the proper drainage of urine, which can lead to leakage around the obstruction. This is most common in men with an enlarged prostate.
     

Risk Factors

The incidence of urinary incontinence increases with age and affects more women than men. About 10 to 30 percent of women have urinary incontinence. Urinary incontinence also has been associated with a number of conditions, including obesity, high-impact physical activities, heart failure, lung problems, smoking, chronic cough, depression, constipation, pregnancy, vaginal delivery and problems with mobility.


Types

Incontinence Associated With Medical Factors
Urinary incontinence can occur due to a number of treatable factors and medical problems. Conditions such as urinary tract infection, pregnancy or excess fluid intake may temporarily cause a problem with normal urination. Other potentially treatable factors are the use of certain medications, fluid retention, diabetes and arthritis and other problems causing difficulty walking.

Urge Incontinence
Urge incontinence occurs when the bladder contracts when it shouldn't. A person with urge incontinence is bothered by an abrupt, overwhelming urge to urinate, followed by urine leakage that can range from drops to soaking. The urge and leakage may occur in response to a stimulus, such as anticipation of urination, going out in the cold, turning on the faucet or washing hands. It is particularly common in older women.

Factors that can lead to urge incontinence include age-related changes in the anatomy of the urinary tract and the physiology of urination, nervous system problems related to conditions such as stroke, or bladder irritation caused by factors such as inflammation or cancer. In some elderly patients, urge incontinence is associated with bladder contractions that are both involuntary and weak, leading to leakage of urine due to the involuntary contractions but also a buildup of urine in the bladder from inefficient emptying.


Stress Incontinence
Stress incontinence occurs when the urinary sphincter does not stay closed when there is an increase in pressure in the abdomen, leading to urine leakage. As an example, the pressure in the abdomen caused by coughing, sneezing, laughing or running can cause episodes of stress incontinence in susceptible patients. Stress incontinence is the most common cause of urinary incontinence in younger women and the second most common cause in older women.

Stress incontinence in women is most commonly caused by weakness in the muscles and other tissues that support the lower urinary tract. That is, the muscles that help close the sphincter are weak and ineffective. Less commonly, stress incontinence is caused by complete failure of the sphincter to close, a condition known as intrinsic sphincter deficiency. This can occur with scarring from surgery.


Mixed Incontinence
Mixed incontinence is the combination of both urge and stress incontinence, and is most common in younger to middle-aged women.

Overflow Incontinence
Overflow incontinence refers to leakage that occurs when the bladder fails to empty properly, either because of obstruction of the urethra or weak bladder muscle contractions. When the person tries to urinate, abnormally large amounts of urine remain in the bladder. There may be a weak stream, dribbling and frequent urination. An element of stress incontinence may occur at the same time, and is usually related to the failure of the sphincter to remain closed under stress because of the large bladder volume. Overflow incontinence is relatively uncommon in women.
 

Diagnosis

One of the most important first steps in the diagnosis (and subsequent treatment) of urinary incontinence is for the patient and clinician to have a frank discussion about the problem. Many with incontinence do not report the problem to a health care professional, even though, in most cases, it will lead to an accurate diagnosis and effective treatment.

A number of tools are available to help determine the cause of urinary incontinence.


Medical History and Physical Exam
A careful history of the timing and characteristics of the leakage episodes, as well as an overall history of the patient's health, will give important clues as to the cause of incontinence. The patient may be asked to keep a "bladder diary" for a period of time to keep track of the timing and amount of urination and note possible associated factors. A physical exam will provide valuable information, such as whether there is evidence of fluid retention and whether nerve function is intact.

Clinical Tests
The doctor may perform some simple tests, such as asking the patient to cough vigorously and noting whether leakage occurs. The clinician also may check whether the bladder is emptying efficiently by measuring the amount of urine left in the bladder after normal urination.

Laboratory Tests
The clinician will want routine blood and urine tests in order to get an idea of the overall function of the kidneys. A urine culture will be done if infection is suspected.

Urodynamic Testing
Urodynamics refers to a series of tests that examine the bladder, urethra and sphincter under various conditions. Examples include measuring the bladder capacity and how fast urine flows during urination. Other tests may be done depending on the patient's symptoms. Urodynamic testing is not recommended as a routine in all cases of incontinence, but is advisable in certain situations, such as to confirm stress incontinence or urinary obstruction if surgery is planned.


Treatment

Treatment of urinary incontinence will depend on its type and cause. In all cases, treatment should start with the least invasive therapy, such as changes in lifestyle, before moving to more invasive methods such as drugs and surgery. Before embarking on a treatment plan, the patient and clinician should discuss the goals of treatment in detail, as these will not be the same for every patient.

Lifestyle Changes
The clinician may suggest changes in the amount, type and timing of beverages. For women, weight loss and stopping smoking may decrease incontinence. It is important to relax and not strain when voiding or moving the bowels. Keeping bowel movements regular is important for healthy urinary voiding. Fluid management also is important, especially decreasing the evening intake in older people who have incontinence and frequent voiding at night. Some foods and beverages are thought to contribute to bladder leakage. While this has not been proven definitively, it may be reasonable to see if eliminating one or all of these items helps:

  • Alcoholic beverages

  • Carbonated beverages

  • Coffee or tea

  • Citrus juice and fruits

  • Tomatoes and tomato-based products

  • Spicy foods

  • Artificial sweetener

  • Chocolate

  • Corn syrup

  • Sugar or honey
     

Potentially Reversible Factors
Some examples are changes in medications, treatment of swollen ankles, improving blood sugar control in diabetics and physical therapy for people with trouble walking.

Behavioral Treatment
Behavioral treatment includes strategies to control urgency and exercises to strengthen muscles in the pelvis that support the urethra.

Bladder Retraining
Bladder retraining may help with urge and stress incontinence. These regimens help keep the bladder volume low, and retrain the nervous system and pelvic muscles to better control bladder contractions. This involves urinating at specific intervals through the day whether there is an urge or not. In addition, the patient is instructed not to run to the bathroom when an overwhelming urge to urinate occurs, but to stand still or sit down and concentrate on making the urge decrease. Once in control of the urge, the patient walks slowly to the bathroom to urinate. If a decrease in incontinence is seen on this regimen, the interval between the timed urinations is gradually increased. For patients with cognitive impairment, behavioral treatment focuses on encouraging the patient to use the toilet at regular intervals and by providing positive feedback for successful toileting.

Pelvic Muscle Exercises
Pelvic muscle exercises, also known as Kegel exercises, strengthen the muscles involved in closing the urethral sphincter. These are used primarily for stress incontinence. The additional use of weighted cones in the vagina or electrical stimulation devices have not been shown to facilitate pelvic muscle exercises or improve stress incontinence.

Drug Therapy
When behavioral treatment alone is not successful in treating urge or mixed incontinence, medication can be used to suppress bladder muscle activity. Medicines that are available include Oxybutynin, Tolterodine, Trospium, Solifenacin and Darifenacin. In general, all of these drugs have similar effectiveness. People who do not respond to one drug may respond to another. Taking these drugs for long periods of time can cause dry mouth, which increases the risk of cavities.

Pessary
A pessary is a device placed in the vagina to support tissues that have become weak. It may benefit women with stress urinary incontinence whose problem is made worse by prolapse, or sagging, of the bladder or uterus. The specially fitted pessary provides internal support to the pelvic area, which may help reduce incontinence. Pessaries are used in older women who are not good candidates for or do not want surgery to correct prolapse, or as a temporary measure before surgery.

Surgery
Surgery offers the highest cure rates for stress urinary incontinence, even in elderly women. However, it is invasive and can be associated with complications. The surgical method depends on the underlying defect. Techniques that support parts of the bladder and/or the urethra may be used. In some cases, especially when the patient has very poor sphincter function, so-called "bulking agents" (such as collagen) are injected around the urethra to provide additional support.

Catheters
Catheters may be necessary for patients with overflow incontinence or who cannot empty their bladders at all. Because catheters have a high risk of causing urinary tract infections, they should be a last resort. Catheters may be left in the bladder or used intermittently to drain the bladder.

Other Measures
In patients with overflow, other maneuvers that can be effective are massage to the bladder area during urination, "double voiding," and increasing pressure in the abdomen by "bearing down" on the pelvic area to help encourage drainage of urine from the bladder. These techniques, though they seem simple, should only be done with instruction from your doctor.

Pads and protective garments should be used only as a last resort. The choice of garment depends upon gender and the type and volume of urinary incontinence leakage.

 

Learn More

A clinician is the best resource for important information related to your particular case. Not all patients with urinary incontinence

are alike, and it is important that your situation is evaluated by someone who knows you as a whole person.
 

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