What is urinary incontinence ? What causes urinary incontinence ?

Urinary incontinence is the involuntary leakage of urine; in
simple terms, to wee when you don't intend to. It is the
inability to hold urine in the bladder because voluntary
control over the urinary sphincter is either lost or weakened.
Urinary incontinence is a much more common problem than
most people realize. In the United Kingdom it is estimated
that at any one time at least 3 million people - 5% of the
total population - suffer from urinary incontinence. The US
Department of Health and Human Services estimates that
approximately 13 million Americans suffer from urinary
incontinence.
Urinary incontinence is more common among women than
men. 10% to 30% of American women/girls aged 15-64
years are thought to suffer from it, compared to between
1.5% and 5% of men. Over half of all nursing home
residents are thought to be affected by urinary
incontinence. The Department of Health, UK, estimates that
20% of all women over the age of 40 are affected by urinary
incontinence.
The Latin word continentem (nom. continens) means "to hold
together", while incontinentem (nom. Incontinens) means "not
holding together". The English word incontinent meaning
unable to control bowels or bladder was probably first used in
1828.
Fecal incontinence means the inability to control one's
bowel movements. This article focuses just on urinary
incontinence.
What are the signs and symptoms of urinary
incontinence ?
The main symptom is the release (leakage) of urine when
you don't want to. When and how this occurs will depend
on the type of urinary incontinence.
Stress incontinence - this is the most common kind of
urinary incontinence, especially among women who have
given birth or have gone through the menopause . In this
case stress refers to physical pressure, rather than mental
stress . When the bladder and muscles involved in urinary
control are placed under sudden extra pressure the person
may urinate involuntarily.
The following actions may trigger stress incontinence:
A sudden cough
Sneezing
Laughing
Heavy lifting
Exercise.
The amount of urine that leaks out unwillingly depends on
how full the bladder is and how affected the muscles are.
Urge incontinence (effort incontinence) -, also known as
reflex incontinence. This is the second most common type
of urinary incontinence. The bladder is either unstable or
overactive. There is a sudden, involuntary contraction of
the muscular wall of the bladder (detrusor muscles) that
causes urinary urgency - an urge to urinate that cannot be
stopped. There is an involuntary loss of urine for no
apparent reason while suddenly feeling the need or urge to
urinate.
When the urge to urinate comes the person has a very short
time before the urine is released regardless of what they try
to do. The urge to urinate may be caused by:
A sudden change in position
The sound of running water (for some people)
Sex (especially during orgasm).
People with urge incontinence tend to have to pass urine
frequently; sometimes having to get up to go to the toilet
during the night.
Bladder muscles can activate involuntarily because of
damage to the nerves of the bladder, the nervous system, or
to the muscles themselves.
Overflow incontinence - this type of urinary incontinence is
more common in men with prostate gland problems, a
damaged bladder, or a blocked urethra. The enlarged
prostate gland obstructs the bladder; the person often only
manages to urinate in small trickles and has to go
frequently. He may feel that his bladder is never really
completely emptied, even after trying hard.
Put simply, overflow incontinence is an inability to empty
the bladder, the patient frequently dribbles urine. Some
patients constantly dribble urine (as opposed to frequently).
Mixed incontinence - if a patient experiences both stress
and urge incontinence he/she has mixed incontinence.
Functional incontinence - the person knows there is a need
to urinate, but cannot make it to the bathroom in time due
to a mobility problem. If a person has a disability they may
not be able to get their pants down in time; this would be an
example of functional incontinence. The amount of urine
lost may be large. Common causes of functional
incontinence include:
Confusion
Dementia
Poor eyesight
Poor mobility
Poor dexterity (cannot unbutton pants in time)
Depression, anxiety or anger (unwilling to go to the
toilet).
People with functional incontinence may have difficulties in
thinking, moving or communicating - these difficulties may
prevent them from reaching a toilet.
Functional incontinence is more prevalent among elderly
people, and is common in nursing homes.
Functional incontinence may occur when there is nothing
physically wrong with the person. If you are on a long trip
and dying to urinate but there are not toilets nearby.
Gross total incontinence - this either means the person
leaks urine continuously all day and night, or has periodic
uncontrollable leaking of large amounts of urine. The
bladder is unable to store urine. The patient may have a
congenital problem (was born with a defect), there may be
an injury to the spinal cord, and injury to the urinary system,
or there may be a fistula between the bladder and, for
example the vagina.
What are the risk factors of urinary
incontinence ?
A risk factor is something that increases your chances of
developing a condition or disease. For example, being
obese raises the risk of developing diabetes type 2;
therefore, obesity is a risk factor for diabetes type 2. Below
are some risk factors linked to urinary incontinence:
Being obese - obese people have increased pressure
on their bladder and surrounding muscles, compared
to people of normal weight. This weakens the muscles
and makes it more likely that a leak occurs when the
person sneezes or coughs.
Smoking - regular smokers are more likely to develop
a chronic cough, which may result in episodes of
incontinence. A chronic cough (coughing a lot over the
long term) places undue stress on the urinary
sphincter, leading to stress incontinence. A regular
smoker is also more susceptible to having an
overactive bladder.
Gender - women have a significantly higher chance of
experiencing stress incontinence than men. Certain
aspects of a female's life, such as childbirth and
menopause make incontinence more likely. A man's
risk is higher if he has prostate gland problems.
Old age - the muscles in the bladder and urethra
weaken during old age. This means the bladder cannot
hold as much liquid as before, raising the risk of
involuntary leakage. This does not mean that people
will necessarily become incontinent when they are old;
it just means the risk is higher.
Some diseases and conditions - people with diabetes
and some kidney diseases are more likely to suffer
from urinary incontinence.
Coffee (caffeine) - men who drink approximately two
cups of coffee each day are much more likely to suffer
from urinary incontinence than males of the same age
who drink less or no coffee at all, researchers from the
University of Alabama at Birmingham wrote in The
Journal of Urology (January 2nd, 2013 issue).
What are the causes of urinary incontinence ?
Causes of stress incontinence
When the pelvic floor muscles are weakened and cannot
keep the urethra completely closed, stress incontinence
occurs. Sudden pressure on the bladder may cause urine to
leak out of the urethra. A cough or sneeze can trigger it. The
following can cause the pelvic floor muscles to lose some of
their strength:
Pregnancy.
Childbirth (labor).
Menopause - when estrogen levels drop the muscles
may get weaker.
A hysterectomy - surgical removal of the uterus
(womb).
Some other surgical procedures.
Age.
Obesity.
Causes of urge incontinence
Urge incontinence happens when the person's bladder
contracts prematurely, usually before it is full. The sufferer
typically cannot get to a toilet in time. Experts believe it is
caused by something going wrong with the signaling
system between the brain and the bladder, but they are not
really sure.
Most cases of urge incontinence are diagnosed as
overactive bladder syndrome because no specific cause was
found. The following causes of urge incontinence have been
identified:
Cystitis - inflammation of the lining of the bladder. It
usually occurs when the normally sterile urethra and
bladder are infected by bacteria and become irritated
and inflamed. Cystitis is fairly common and can affect
both men and women of all ages - it is more common
in women.
CNS (central nervous system) problems - examples
are multiple sclerosis , stroke and Parkinson's disease.
An enlarged prostate - the bladder may drop and the
urethra could become irritated.
Causes of overflow incontinence
This happens when there is an obstruction or blockage to
the bladder. The patient may not be able to empty the
bladder completely after urination, pressure builds up
behind the obstruction, causing leakages. The following
may cause an obstruction:
An enlarged prostate gland.
A tumor pressing against the bladder.
Urinary stones.
Constipation .
Urinary incontinence surgery which went too far.
Causes of total incontinence
This occurs when the bladder cannot hold any urine and the
patient either leaks all the time or frequently. The following
can cause total incontinence:
An anatomical defect the person has had from birth.
A spinal cord injury which messes up the nerve signals
between the brain and the bladder.
A fistula - a tube (channel) develops between the
bladder and a nearby area, most typically the vagina.
The following may also sometimes cause urinary
incontinence:
Some medications - especially some diuretics,
antihypertensive drugs, sleeping tablets, sedatives,
and muscle relaxants.
Alcohol - if a person drinks a large quantity of alcohol
the bladder and the muscles around it will relax, plus
the individual may become less aware of when it is
time to urinate. Alcohol is also a diuretic and a bladder
stimulant. In general, any amount of alcohol will relax
the muscles linked to urinary control to a certain
extent.
Other drinks and foods - some sodas (carbonated
drinks), tea, coffee, artificial sweeteners, corn syrup
can aggravate the bladder and trigger episodes of
incontinence. For some people, incontinence may be
triggered by foods with certain spices, sugar, acid
(citrus and tomatoes). Caffeine is a diuretic and a
bladder stimulant.
Urinary tract infection - this can irritate the bladder,
triggering strong urges to urinate which may
sometimes result in episodes of incontinence.
Dehydration - if a person becomes dehydrated the
urine can become highly concentrated - the
concentrated salts can irritate the bladder and cause
incontinence.
How is urinary incontinence diagnosed?
A bladder diary - the GP (general practitioner, primary
care physician) or urologist (a doctor specialized in
diseases of female urinary organs and male urinary
tract and sex organs) may ask the patient to record
how much he/she drinks, when urination occurs, how
much urine is produced, whether there was an urge to
urinate, and the number of episodes of incontinence.
Physical exam - the doctor may examine a woman's
vagina and check the strength of her pelvic floor
muscles. If the patient is male the doctor may
examine his rectum to determine whether the prostate
gland is enlarged.
Urinalysis - this is a urine test. A sample of urine is
collected and sent to a laboratory where it is checked
for signs of infection and abnormalities.
Blood test - a blood test can reveal details about
substances linked to causes of incontinence.
PVR (postvoid residual) measurement - this measures
how much urine is left in the bladder after the person
has finished urinating. The patient urinates into a
container which measures how much urine was
expelled. Then, either with a catheter or ultrasound the
doctor measures how much urine remained in the
bladder. If a lot of urine remained in the bladder..
..there may be an obstruction in the urinary tract.
..there may be a problem with the bladder
nerves.
..there may be a muscle problem.
Pelvic ultrasound - the doctor may wish to look at
other parts of the urinary tract or genitals.
Stress test - the patient will be asked to apply sudden
pressure - he/she may be asked to cough - while the
doctor looks out for loss of urine.
Urodynamic testing - a catheter is inserted via the
urethra into the bladder, and the bladder is filled with
water. A monitor determines how much pressure the
bladder and urinary sphincter muscle can withstand.
Cystogram - this is an X-ray procedure to visualize the
bladder. A catheter is inserted into the bladder via the
urethra. A fluid containing a special dye goes through
the catheter into the bladder. As the patient urinates
the dye shows up in the X-ray images. The doctor can
track the dyed liquid which shows up on the X-ray
pictures and detect any problem within the urinary
tract.
Cystoscopy - a cystoscope (a thin tube with a lens at
the end) is inserted into the urethra. The doctor can
view abnormalities in the urinary tract.
What are the treatment options for urinary
incontinence ?
Treatment for urinary incontinence will depend on several
factors, such as the type of incontinence, the patient's age,
general health, as well as his/her mental state. Any
underlying condition that is causing the incontinence will
have to be treated first.
Changes in lifestyle - some lifestyle changes may help
reduce the severity of incontinence, regardless of the type.
These may include:
Cutting down on caffeine consumption.
Consuming more fluids if the doctor determines the
patient is not drinking enough.
Consuming less fluid if the doctor determines the
patient is drinking too much.
Losing weight.
Stress incontinence
As well as the lifestyle changes mentioned, the doctor may
recommend some pelvic floor exercises to strengthen the
muscles. Pelvic floor exercises, also known as Kegel
exercises, or just Kegels, help strengthen the urinary
sphincter and pelvic floor muscles - the muscles that help
control urination. The doctor, nurse or physical therapist
(UK: physiotherapist) will ask the patient to do the exercises
regularly. Kegel exercises are especially effective for stress
incontinence, but may also help those with urge
incontinence.
Pelvic floor exercises (Kegels)
To identify the muscle you need to squeeze in order to do
this exercise properly, imagine you want to stop urinating
mid-stream. Squeeze the muscle you would use in order to
interrupt urination. If you cannot find the muscle, try
urinating and stop midstream (only stop urination once to
identify the muscle, not many times).
Some physical therapists may ask the patient to squeeze
the muscle and hold for eight seconds, then relax it for
another eight seconds, and repeat the process eight times.
When the eight are done, squeeze the muscle for one last
time, but for longer. It is important to do what the health
care professional has decided is right for you. The number
of squeezes, how long to hold, etc., and how often you
should do the whole set of exercises varies from patient-to-
patient.
It is important that you start these exercises off with a
specialized health care professional, such as a physical
therapist (UK: physiotherapist), urinary nurse or a doctor,
because it is important to be sure that you are contracting
the right muscle, and in the right way. When you squeeze
the muscle you should have a pulling-up sensation. Males
will often notice that when they squeeze the muscle, that
action pulls their penises slightly towards their bodies. Do
not tighten other muscles while squeezing, such as the
buttocks, leg or stomach muscles. The doctor may suggest
vaginal cones - these are weights that help women
strengthen the pelvic floor.
Electrical stimulation - if you cannot contract the muscle
electrodes may be temporarily inserted into the rectum or
vagina to stimulate and strengthen the pelvic floor muscles.
Exercising the pelvic floor muscles has been shown to be
extremely effective in treating stress and urge incontinence.
However, the patient needs to have faith and persevere
because the benefits usually take at least a couple of
months before they become apparent.
Bladder training
Delaying the event - this may be done on its own or in
combination with other therapies, such as pelvic floor
exercises. The aim is to control urge. The patient
learns how to delay urination whenever there is an
urge to do so. Initially, this may involve trying to put
off urination by ten minutes whenever there is an urge
to go. Gradually the patient should be able to extend
the period of delay until there is an interval of at least
two hours between each visit to the toilet.
Double voiding - this involves urinating, then waiting
for a couple of minutes, then urinating again. By doing
this the patient learns to completely empty the bladder
each time he/she goes to the toilet; thus avoiding
overflow incontinence.
Toilet timetable (scheduled toilet trips) - this means
going to the toilet at set times during the day, rather
than whenever you feel like it. The patient learns to go,
for example, every two hours. Some people find that
this technique helps.
Bladder training helps the patient gradually gain back
control over his/her body and bladder. Relaxation and
breathing exercises can be learnt and effectively used when
an urge to urinate occurs, resulting in better bladder control
and longer intervals between each toilet visit.
Medications If medications are used, they are usually done
so in combination with other techniques or exercises. The
following medications are prescribed to treat urinary
incontinence:
Anticholinergics - these drugs calm down an
overactive bladder and may help patients with urge
incontinence. Examples include oxybutynin (Ditropan),
tolterodine (Detrol), darifenacin (Enablex) solifenacin
(Vesicare) and trospium (Sanctura).
Topical estrogen - topical means you apply it onto
your skin. Low-dose topical estrogen as a ring, patch
or vaginal cream may reinforce tissue in the urethra
and vaginal areas and lessen some of the symptoms
of incontinence.
Imipramine (Tofranil) - this tricyclic antidepressant can
sometimes help patients with a combination of urge
and stress (mixed) incontinence.
Medical devices
The following medical devices are designed just for
females.
Urethral inserts - this plug is inserted into the
woman's urethra (the tube from the bladder to the hole
in where urine exits from). It is a tampon-like
disposable device. Urethral inserts should not be used
daily, but when incontinence is expected to occur,
such as during a sporting activity. The woman inserts
the device before her activity and takes it out when
she wants to urinate.
Pessary - this is a rigid ring a woman inserts into her
vagina. It is worn all day. The device helps hold the
bladder up and prevents leakage of urine. If a woman
has a prolapsed bladder or uterus she may find this
device helps her incontinence. It is important to keep
the device clean.
Interventional therapies
Radiofrequency therapy - tissue in the lower urinary
tract is heated. When it heals it is usually firmer, often
resulting in better urinary control.
Botox (botulinum toxin type A) - Botox is injected into
the bladder muscle, which may help those with an
overactive bladder. This apparently effective therapy
has not been approved in several countries
(September 2009) for incontinence treatment. Botox
administered to the bladder was found to be as good
as targeted medications for tackling urinary urgency
and twice as effective in eliminating symptoms
completely, scientists from Loyola University Chicago
Stritch School of Medicine reported in October 2012.
Bulking agents - bulking agents are injected into tissue
around the urethra, which help keep it closed.
Examples of bulking agents include collagen or carbon
coated zirconium beads. The patient will need repeat
injections once or twice a year. This 5-minute
procedure can be done at a doctor's office and only
requires a mild local anesthetic.
Sacral nerve stimulator - the device is implanted under
the skin of the patient's buttock. It looks much like a
pacemaker. A wire connects it to a nerve that runs
from the spinal cord to the bladder (sacral nerve) and
is a key player in bladder control. The wire emits an
electrical pulse that stimulates the nerve, resulting in
better bladder control - the electrical pulses are
painless.
Surgery
Surgery is usually an option if other therapies have not
been effective. Women who plan to have children should
discuss surgical options thoroughly with their doctors.
Sling procedures - something is inserted into the neck
of the bladder to help support the urethra, this could be
a strip of tape made of polypropylene. It is inserted
into the bladder, under the urethra in order to support it
and stop urine from leaking out. Instead, the surgeon
may take tissue from another part of the body and use
that to support the urethra. The patient will undergo
either a local or general anesthetic for this procedure.
The operation usually requires a hospital stay of up to
three days.
Colposuspension - the bladder neck is lifted. The
procedure can help patients with stress incontinence.
An incision is made in the patient's lower abdomen
and stitches are placed through the walls of the
bladder neck. Hospitalization is generally about one
week long.
Artificial sphincter - an artificial sphincter (valve) may
be inserted to control the flow of urine from the
bladder into the urethra. As this procedure has a
serious risk of side effects it is only recommended if
nothing else has worked.
Patients who have undergone initial surgery for stress
incontinence that has not worked should have urodynamic
tests before being recommended for any other surgical
intervention. Urodynamic tests determine whether the
bladder and urethra are functioning correctly.
Urinary Catheter
If the patient is incontinent because their bladder does not
empty properly, they may have to learn how to insert a
catheter into their urethra several times a day to drain the
bladder.
Some patients who do not remember to go to the toilet,
such as those with dementia, may have to wear a urinary
catheter. It is a tube which goes from the bladder, through
the urethra, out of the body into a bag which collects urine.
There is a type of tap on the bag which can be turned to
empty it (some bags are disposable).
Some patients have to have a catheter after an operation,
such as a radical prostatectomy (surgical removal of the
prostate gland), for a specified period.
Absorbent pads
There is a vast range of absorbent pads patients can
purchase at pharmacies and supermarkets which help
manage urinary incontinence. Some are placed into normal
underwear, while others are items of underwear, like
diapers (nappies). Pads and absorbing devices are
generally designed for either males or females.
What are the complications of urinary
incontinence ?
Skin problems - a person with urinary incontinence is
more likely to have skin sores, rashes and infections.
This is because the skin is wet most of the time.
Urinary tract infections - people with incontinence are
more susceptible to urinary tract infections . Long-
term use of a urinary catheter significantly increases
the risk of infection.
Prolapse - part of the vagina, bladder and sometime
the urethra can fall into the entrance of the vagina.
This is usually cause by weakened pelvic floor
muscles. The problem generally requires surgery.
My personal experience with urinary
incontinence
After my radical prostatectomy (prostate gland surgically
removed) for prostate cancer in March 2009, I had a
catheter for ten days, after which I was totally incontinent
while standing and fairly incontinent while sitting or lying
down for several weeks.
I am grateful that within 3 months most of my bladder
control returned. Even today, 6 months after the operation, I
still have little 'moments' when I cough, laugh or go to the
toilet and come out realizing there were still a couple of
drops left which trickle down as I walk. These little
moments only occur when I am tired or not thinking. I
regularly do the Kegel (pelvic floor muscle) exercises and I
am convinced they have helped a lot.
If you have never suffered from incontinence you are lucky.
Incontinence, depending on its severity, can dictate many
aspects of your everyday life, including what you wear,
where you go, how you get there, who you go with, what
you eat and drink, how you sit, how you stand up, how you
lie down, how you turn over in bed, and what activities you
decide to become involved in.
Just deciding on going for a walk triggers a cascade of
thoughts, all related to urinary incontinence:
How long is the walk? (the longer the walk, the more I
will leak, or the more likely I am to leak)
Are there any hills and steps?
Will I have to climb over anything, such as fences?
Will I have to cross busy roads (suddenly changing
pace can trigger urination)?
If I am going with someone will they start speeding up
the pace? Will they remember what my ideal pace is?
Will I have to keep reminding them? Will having to
remind them annoy them or embarrass me?
Do I have enough pads for the walk?
Is there anywhere private along the way where I can
change my pads?
Do I have an empty plastic bag/container to carry the
dirty pad(s)?
Are there any toilets along the way?
Is there anywhere along the way where I can sit down?
(I found that sitting for a couple of minutes during the
walk helped extent my bladder control time)
Am I gassy? (Farting while walking for people with
incontinence frequently triggers a leak). If so, I must
make sure I get rid of as much gas as possible before I
start.
Have I put a spare pair of underpants in my bag? If it
is a long walk I must make sure I have a spare pair of
pants (trousers) too - just in case.
Do I have anything to cover myself with in case there
is a wet stain down there? Fortunately I was in
England during spring (wet season) at the time and
always wore a long raincoat. I would like to know what
people in hot/tropical countries do - perhaps wearing a
very long shirt that is not tucked in.
If you do not suffer from incontinence, remember that many
people do. For some people, parking near the entrance to a
supermarket can be the difference between a successful
shopping trip and having to go back home without buying
anything. For a few weeks I was able to get from my house
to my car, drive to the supermarket, then get down and
walk to the supermarket toilet only if I was within a one-
minute walk of it, without over-wetting myself. If I found no
parking spaces near the entrance I would sit in my car and
wait five minutes - if no nearby space became vacant I
would go back home. I had fairly good bladder control while
sitting, but less when standing, and much less when
walking. Later I learnt that I could have gotten a disabled
sticker. I did not park in the disabled spaces because I was
too embarrassed (worried people would give me
disapproving looks). If you ever see somebody park in a
disabled space, do not be hasty in judging them just
because they do not appear to be disabled.
My experience with serious incontinence lasted only a few
weeks. There are people who live like that all the time. With
good organization and planning it is possible to live a
productive and active life if you have severe incontinence.
Support and consideration from members of the public are
extremely important, as well as encouragement and a
positive attitude from close friends and relatives.