What Is Urinary Incontinence? What Causes Urinary Incontinence?

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Main Category: Urology / Nephrology
Article Date: 27 Sep 2009 - 14:00 PDT

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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.

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.


• 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 weak a urinary catheter. It is a tube which goes from the bladders, 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.

Written by Christian Nordqvist


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