What Is Urinary Incontinence?
Urinary incontinence, or the inability to control the release of urine from the bladder, affects nearly one in 10 people over age 65. Incontinence occurs when the muscles in the bladder that control the flow of urine contract or relax involuntarily. This results in either leaking or uncontrolled urination.
Urinary incontinence can range from mild occasional leaking to chronic uncontrolled urination. Incontinence itself is not a disease, but a symptom of an underlying medical condition. Incontinence may be a temporary problem caused by a urinary tract or vaginal infection, constipation and certain medications, or it can be a chronic condition. The most common causes of chronic incontinence include:
- Overactive bladder muscles
- Weakened pelvic floor muscles
- For some men, an enlarged prostate, or benign prostatic hyperplasia (BPH)
- Nerve damage that affects bladder control.
- Interstitial cystitis (chronic bladder inflammation) or other bladder conditions
- A disability or limitation that makes it difficult to get to the toilet quickly
- Surgical side effects
Are There Different Types of Urinary Incontinence?
While there are many different types of urinary incontinence, the most common include stress incontinence and overactive bladder, also called urge incontinence.
Stress incontinence occurs when there is unexpected leakage of urine caused by pressure or sudden muscle contractions on the bladder. This often occurs during exercise, heavy lifting, coughing, sneezing and even laughing. Stress incontinence is the most common bladder control problem in young and middle-aged women. In younger women, the condition may be due to an inherent weakness of the pelvic floor muscles or an effect of the stress of childbirth. In middle-aged women, stress incontinence may begin to be a problem at menopause.
Urge incontinence, or overactive bladder (OAB), occurs when a person feels the urge to urinate but is unable to hold back the urine long enough to get to a bathroom. Urge incontinence sometimes occurs in people who’ve had a stroke or have chronic diseases such as diabetes, Alzheimer’s disease, Parkinson’s diseas, or multiple sclerosis. In some cases, urge incontinence may be an early sign of cancer of the bladder.
Less common types of incontinence include:
- Overflow incontinence: This type results when a person is unable to empty their bladder completely, and it overflows as new urine is produced. Overflow incontinence sometimes occurs in men who have an enlarged prostate. It is also found in people with diabetes or spinal cord injuries.
- Functional incontinence: This type of incontinence has less to do with a bladder disorder and more to do with the logistics of getting to a bathroom in time. It is usually found in elderly or disabled people who have normal or near normal bladder control but cannot get to the toilet in time because of mobility limitations or confusion.
- Gross total incontinence: This refers to the constant leaking of urine from a bladder that simply has no storage capacity or functioning. This condition may result from an anatomical defect, a spinal cord injury, an abnormal opening in the bladder (fistula) or as an after-effect of urinary tract surgery.
What Are the Risk Factors for Urinary Incontinence?
The most common risk factors for incontinence include:
- Being Female: Women experience stress incontinence twice as often as men. Men, on the other hand, are at greater risk for urge and overflow incontinence.
- Advancing age: As we get older, our bladder and urinary sphincter muscles often weaken, which may result in frequent and unexpected urges to urinate. Even though incontinence is more common in older people, it is not considered a normal part of aging.
- Excess body fat: Extra body fat increases the pressure on the bladder and can lead to urine leakage during exercise, or when coughing or even sneezing.
- Other chronic diseases: Vascular disease, kidney disease, diabetes, prostate cancer, Alzheimer’s disease, multiple sclerosis, Parkinson’s disease and other conditions may increase the risk of urinary incontinence.
- Smoking: A chronic smoker’s cough can trigger or aggravate stress incontinence by putting pressure on the urinary sphincter.
- High-impact sports: While playing sports doesn’t cause incontinence, running, jumping and other activities that create sudden pressure on the bladder can lead to occasional episodes of incontinence during sport activities.
How Is Incontinence Diagnosed?
Urinary incontinence is easy to recognize. The primary symptom most people experience is an involuntary release of urine. However, determining the type and cause of incontinence can be more difficult and require a variety of exams and tests. Most physicians will use the following:
- A bladder diary: Your doctor may have you track your fluid intake and output over several days. This may include any episodes of incontinence or urgency issues. To help you measure urine quantities, you may be asked to use a calibrated container that fits over your toilet to collect the urine.
- Urinalysis: A urine sample can be checked for infections, traces of blood or other abnormalities, such as the presence of cancer cells. A urine culture checks for signs of infection; urine cytology looks for cancer cells.
- Blood test: Blood tests can look for chemicals and substances that may relate to conditions causing the incontinence.
- Pelvic ultrasound: In this imaging test, an ultrasound device is used to create an image of the bladder or other parts of the urinary tract to check for problems.
- Postvoid residual (PVR) measurement: In this procedure, the patient empties the bladder completely and the physician uses a device to measure how much urine, if any, remains in the bladder. A large amount of residual urine in the bladder suggests overflow incontinence.
- Stress test: In this test, the patient is asked to cough or vigorously tense her midsection as though exerting herself while the physician checks for loss of urine.
- Urodynamic testing: This test measures the pressure that the bladder muscle and urinary sphincter can tolerate both at rest and during filling.
- Cystogram: In this series of X-rays of the bladder, a dye is injected into the bladder and as the patient urinates, the dye shows up in the X-rays and can reveal abnormalities in the urinary tract.
- Cystoscopy: This procedure uses a thin tube with a tiny lens and a light at one end called a cystoscope. The cystoscope is inserted into the urethra and the physician visually checks the lining of the bladder and urethra.
How Does Incontinence Progress?
Different forms of incontinence can appear at different stages of life. Incontinence may be a lifelong condition, it may appear gradually after menopause, or it may appear suddenly as a side effect of another condition or an after-effect of surgery. However, there are some common ways in which various types of incontinence progress.
- Urge incontinence, or overactive bladder (OAB): This type of incontinence usually appears gradually in older individuals as the result of increasing overactivity of the bladder muscles that causes involuntary bladder contractions. OAB can worsen over time unless ameliorated with exercises and/or treated with drugs.
- Stress incontinence: This is the most common form of incontinence in young women and the second most common in elderly women. Men also can develop stress incontinence later in life as their urinary sphincter weakens or if the urethra is weakened as an after-effect of surgery.
- Overflow incontinence: This type of incontinence is rare in women but common in men as they age and the prostate gland enlarges, a condition called benign prostatic hyperplasia (BPH). Over time, the enlarging prostate obstructs the flow of urine in the urethra and results in urinary hesitancy or an intermittent urinary stream. The condition can worsen as the prostate continues to enlarge.
- Functional incontinence: The problem of immobility or confusion that prevents a person from getting to the toilet in time often worsens over time as mobility decreases or dementia develops.
- Gross total incontinence: This may be a lifelong problem if it is the result of a congenital anatomical defect or a spinal cord injury.
How Can I Manage My Incontinence?
The treatment of urinary incontinence varies depending on the cause of the bladder control problem. In most cases, a physician will try the simplest treatment approach before resorting to medications or surgery.
Bladder habit training: This is the first approach for treating most incontinence issues. The goal is to establish a regular urination schedule with set intervals between urinations. A doctor will usually recommend starting by urinating at one hour intervals and gradually increasing the intervals between urination over time.
Pelvic muscle exercises: Also called ''Kegel'' exercises (named after the gynecologist, Dr. Arnold Kegel, who developed them), this exercise routine helps strengthen weak pelvic muscles and improve bladder control. The patient contracts the muscles used to keep in urine, holds the contraction for four to 10 seconds, then relaxes the muscles for the same amount of time. It may take weeks or months of regular pelvic exercise to show improvement. Another way to perform Kegel exercises is to interrupt the flow of urine for several seconds while urinating.
Which Medications Are Used to Treat Incontinence?
The drugs prescribed to manage incontinence work by relaxing the bladder muscles to stop abnormal contractions and therefore are most effective for treating urge incontinence. They include:
- Bentyl (dicyclomine)
- Cystospaz (hyoscyamine)
- Detrol, Detrol LA (tolterodine)
- Ditropan, Ditropan XL (oxybutynin)
- Levbid (hyoscyamine)
- Oxytrol (oxybutynin)
- ProBanthine (propantheline)
- Sanctura (trospium)
- Urispas (flavoxate)
- Urotrol (oxybutynin)
The side effects of these drugs may include:
- Dry eyes and mouth
- Accelerated heart rate
- Confusion, forgetfulness and possibly impaired mental function
- Glaucoma, in rare cases
Other medications used for incontinence are:
- M3 selective receptor antagonists: These anti-cholinergic medications target specific nerve receptors that cause involuntary bladder muscle spasms. These two M3 selective receptor antagonists are approved for use with urge incontinence:
- Enablex (darifenacin)
- VESIcare (solifenacen)
- Alpha-adrenergic antagonists or blockers: These drugs work by relaxing smooth muscles, which can improve urine flow. This class of drug is especially effective for men with BPH and urge incontinence. Alpha-adrenergic antagonists include:
- Cardura, Cardura XL (doxazosin)
- Flomax (tamsulosin)
- Hytrin (terazosin)
- Uroxatral (alfuzosin)
- Alpha-adrenergic agonists: These drugs, which include ephedrine and pseudoephedrine, may be helpful for patients with mild stress incontinence because they strengthen the muscle that opens and closes the urinary sphincter. Side effects of these medications may include insomnia, agitation and anxiety. Alpha adrenergic agonists should not be given to people with heart problems, hypertension, diabetes, glaucoma or hyperthyroidism.
- Tricyclic anti-depressants: Central nervous system processes and the neurotransmitters serotonin and noradrenaline are believed to play a role in urination and urge and stress incontinence. Among the medications used to regulate the neurotransmitters are:
- Janimine (imipramine)
- Norpramin (desipramine)
- Pamelor (nortriptyline)
- Sinequan (doxepin)
- Tofranil (imipramine)
What About Surgery or Implants for Incontinence?
Surgery is sometimes performed to remove a blockage in the bladder or urethra that is causing overflow incontinence or to shift the position of the bladder to remove pressure on it that is causing stress incontinence. The two most common surgical procedures used to treat stress incontinence include sling procedures and bladder neck suspension procedures.
Sacral nerve stimulation is sometimes used to treat overactive bladder (OAB). This treatment involves a surgical procedure to implant a small device below the skin of the buttock. This device periodically generates a mild electrical stimulation to the sacral nerves, which results in increased tension in the bladder, sphincter and pelvic floor muscles.
Are There Products Available to Help Manage Incontinence?
Many people find the following products useful for decreasing incontinence symptoms:
Adult diapers and undergarments
Absorbent, non-bulky pads and underclothing that are worn discretely under clothing are available in different sizes for both men and women. For those with mild or moderate leakage, panty liners are sometimes all that is required.
Patches and plugs
Many women are able to manage light leakage from stress incontinence by using products that block the flow of urine, such as a small, disposable adhesive patch that fits over the urethral opening, a tampon-like urethral plug or a vaginal insert called a pessary.
For otherwise unmanageable incontinence, a physician can place a catheter in the urethra to continually drain the bladder. Due to a higher risk of developing infections and kidney stones, catheters are usually a last resort and used only for severely ill patients.
More Information About Incontinence
You can find information about national and local support services and resources for all forms of incontinence and bladder retraining at the following Web sites:
AUGS is a professional organization for doctors and others who treat and research women’s urological conditions.
This nonprofit advocacy organization educates the public about the causes, diagnosis, treatment and management of incontinence.
This government agency provides information on incontinence and other urologic disorders and supports research on many diseases and conditions.
The NIA has information on incontinence for both patients and clinicians, including downloadable booklets.
The Simon Foundation is a non-profit organization that carries out innovative educational projects, such as the book “Managing Incontinence: A Guide to Living with the Loss of Bladder Control” and the television movie “I Will Manage.”
No More Leakage – Video Resource
A laugh, a sneeze or a cough used to make Colleen cringe, but a surgical procedure stopped her incontinence.