Urinary incontinence is the accidental leakage of urine from the bladder. It is also commonly referred to as the loss of bladder control. The leakage can occur very frequently (daily) or less often (once or twice in a week). The leakage can be small volumes (drops or a teaspoon), large volumes that can soak or overwhelm a pad, or it can be continuous. Many women consider urinary incontinence to be a normal part of aging; however, it is not a normal condition, especially when it interferes with one’s ability to be social or maintain satisfactory hygiene. There are many different causes for loss of bladder control and a comparable array of treatments.
Urinary Incontinence: Types & Symptoms
There are various types of urinary incontinence, and more than one cause for the incontinence may exist. The most common forms of incontinence are: stress, urge, and mixed.
Most Common Forms
With stress incontinence, leakage occurs immediately after coughing, sneezing, laughing, lifting, exercising, or other similar activities that place stress on the bladder. Normally, the muscle that holds the bladder closed, the urethral sphincter, is strong enough to prevent leakage during these activities. When this sphincter muscle weakens, it may no longer be able to prevent urine from leaking out of the bladder during periods of extra stress or strain. Most women with stress incontinence leak only small amounts of urine with the activities listed above.
Stress incontinence is more common in women than in men. Pregnancy, vaginal delivery, obesity and loss of estrogen after menopause are believed to contribute to the development of incontinence. All of these factors can cause weakening of the muscles in the pelvic floor, which supports and holds the bladder in place.
The sudden feeling that the bladder needs to be emptied – often resulting in urine leakage before a person can make it to the bathroom – is known as urge incontinence. Usually the cause of urge incontinence is a strong bladder contraction that can’t be controlled. Often, women complain that they lose large amounts of urine when this happens. Urge incontinence becomes more common with age.
Mixed incontinence is a combination of stress and urge incontinence. Most women who have incontinence have mixed incontinence.
Other Forms of Urinary Incontinence
Overflow incontinence occurs when the bladder does not empty well at the time of voiding. This may occur if something is blocking the urethra (prolapse can kink the urethra, a prior incontinence surgery can be too tight) or if something is preventing the bladder from effectively contracting (nerve damage, neurologic diseases, medication side-effects). Women with overflow incontinence may feel as if their bladder is still full after they have gone to the bathroom and may dribble small amounts of urine all day, not necessarily with activity. Women with diseases that affect nerve function such as multiple sclerosis, Parkinson’s disease, diabetes and stroke may experience this type of incontinence. This diagnosis is made by checking how much urine is left in the bladder after urinating.
Functional incontinence occurs when women do not empty their full bladders either because they cannot access a bathroom or because they do not know their bladder is very full. This often occurs in women who are institutionalized, bedridden, or have a decreased mental awareness that they need to empty their bladder. Some drugs may also affect awareness or mobility, which may lead to incontinence situations. Generally, the bladder can function normally when regular access to the bathroom is possible.
This form of incontinence often occurs in women with birth defects such as spina bifida, spinal cord injuries, or other chronic medical conditions that damage the spinal cord. Damage to the spinal cord may cause a loss of bladder sensation, the inability to empty the bladder, or unpredictable bladder contractions.
Bladder fistulas are holes or openings between the ureter (the tube that drains the kidney) or the bladder and the vagina, uterus, bowel or abdominal wall. These openings often result in continuous leakage.
Urinary Incontinence: Evaluation
Any regular loss of urine – no matter how infrequent or small in amount – should be addressed. Expect that an initial assessment will take at least 1-2 hours. Information may be collected over 1-3 visits dependent upon how complicated the symptoms. A thorough evaluation of urinary incontinence may include:
- Medical history and interview
- Bladder diaries and pad tests
- Physical examination
- Simple cystometrics
- Urodynamic studies
Medical History and Interview
A thorough medical history is vital in discovering the patterns and timing of the incontinence. This interview may include questions regarding:
- Past surgeries and medical problems
- Current medications
- Past pregnancies and deliveries
- Fluid intake
- Detailed information of the incontinence
Bladder Diaries and Pad Tests
These evaluations provide additional and important information about the patterns and timing of the incontinence. Some women may be asked to keep a bladder diary for 1-7 days in which they will be asked to record the times they voided and any times that they leaked urine accidentally. Information on fluid intake may also be recorded. This information is helpful in counseling patients about lifestyle and dietary changes. In addition, some women may be asked to wear a pre-weighed pad and return it to their provider so that the actual weight of any leaked urine can be determined.
A general physical examination (from head to toe) will be conducted and will include a pelvic exam to evaluate how well the pelvic muscles and supportive tissues are holding the pelvic organs. It may also include a rectal exam. Women may be asked to bear down at different times during the exam as well as to squeeze their pelvic muscles.
Also called bladder filling or stress test, this medical procedure is conducted when the physician is unable to diagnose the bladder control problem through a general history and physical examination. It assists the physician in deciding which treatment is best for the patient. The procedure is generally painless and is conducted in the physician’s office. It does not require sedatives.
These tests are performed by a specially trained technician to evaluate how the bladder fills and empties in order to help determine the cause of the bladder dysfunction. The test measures pressure changes in the urinary bladder in response to changes in the volume of fluid contained. It is generally painless. Women can have this test done standing or sitting on a special table. Small tubes or catheters are placed in the bladder and rectum. The catheters take pressure measurements while the bladder is filled with sterile water. The patient will be asked to cough and bear down several times to see if any urine leaks. She will also be asked to empty her bladder in a special toilet that measures how much and how fast her bladder empties.
This is a visual inspection of the bladder and urethra. It’s done using a thin, lighted tube called a cystoscope that is inserted into your numbed urethra and bladder. Cystoscopy is often done to look for causes of bladder spasms, pain or blood in the urine such as stones, sutures, mesh or cancer.
Urinary Incontinence: Treatment
The type of treatment depends upon the type and severity of the incontinence. Some circumstances may require a combination of treatments; there is usually not one single solution and different types may be tried until the best treatment is reached. Usually, less complicated treatments – behavioral or medical – are tried first. If these treatments do not work, more complicated and invasive treatments, such as surgery, may be necessary.
Behavioral treatments rely on two important factors:
- A knowledgeable health professional who can provide the educational training and positive reinforcement to the patient
- A patient who is motivated and able to perform the treatment(s)
In other words, a woman must be taught to follow the treatments correctly and on a regular basis in order to obtain the best chance for success. Behavioral treatments include:
- Dietary changes
- Bladder training
- Pelvic muscle exercises
- Vaginal cones or weights
- Vaginal pessaries
Women with urinary incontinence may want to avoid some foods and liquids that may cause bladder problems. These include alcoholic beverages, carbonated beverages, citrus juice and fruits, tomatoes and tomato-based products, highly spiced foods, and artificial sweeteners. Urinary incontinence sufferers, however, should not restrict fluid intake. Restricting fluids often worsens the problem because the urine becomes too concentrated and irritates the bladder. Ideally, 6-8 eight-ounce glasses of fluid should be consumed each day. Some women are helped if they restrict evening fluids only, especially if they have problems with frequent nighttime urination.
Also known as bladder retraining, this treatment is based upon the assumption that people learn bad habits associated with voiding such as urinating too frequently or not frequently enough, which may contribute to urinary incontinence. The goal of bladder training is to relearn good bladder and voiding habits and to ultimately return to normal bladder and voiding function. Bladder training consists of educational instruction in distraction and/or relaxation techniques. These techniques can be used to delay voiding according to a schedule that is designed by the patient and her educator, who is trained in incontinence behavioral therapy.
Pelvic Muscle Exercises
When done correctly and regularly, these exercises, also known as Kegel exercises, can strengthen the muscles that support the pelvic organs. The exercises should be taught correctly by a professional with proper training and must be practiced regularly. They are not difficult to perform and can be done anywhere and at any time once properly learned. Biofeedback can be used in conjunction with pelvic muscle exercises. It uses manual, electronic or mechanical instruments to relay information to patients about whether they are contracting the proper muscles and the intensity and length of the muscle contraction. Biofeedback requires the presence of a trained professional and offers immediate reinforcement to the patient.
Vaginal Cones or Weights
These cones or weights are inserted into the vagina, and the patient attempts to retain them by contracting the pelvic muscles. They may be used to help some women achieve a sustained pelvic muscle contraction. Similar to biofeedback, the use of vaginal cones and weights provides immediate reinforcement.
These supportive devices come in many shapes and sizes. They are fitted to comfortably sit in the vagina and support prolapsing internal organs such as the bladder, uterus and rectal wall. Some incontinence pessaries have special shapes, which help support the urethra in an effort to prevent incontinence.
Medical or Pharmacologic Therapy
Medications are often used in combination with behavioral treatments to treat urinary incontinence. Some medications affect the bladder muscle itself and are used to weaken the involuntary bladder spasms that occur with urge incontinence. Other drugs affect the nerves that affect the bladder, which also decreases bladder muscle contractions.
This treatment is often compared to a heart pacemaker. It is a reversible treatment that uses mild electrical pulses to stimulate nerves going to the bladder that influence bladder emptying (urinary retention) and storage (urgency urinary incontinence) function. The stimulation is delivered by battery power and is directed to the sacral spinal nerves or to peripheral nerves near the ankle. For more details on this and other treatments, please visit our suggested links to other websites.
Onabotulinum toxinA (Botox®) Injections
BOTOX® helps to treat urgency , frequency and urgency urinary incontinence symptoms by making the bladder muscle relax better. It is injected into the bladder wall through a cystoscope (a thin telescope passed into the bladder through the urethra or urinary tube). Repeat injections may be necessary when the therapy wears off.
If behavioral and/or medical therapies are not successful, surgery is another alternative. The goal of surgery is to correct any prolapse (falling down of pelvic organs) and restore the bladder and its supports to their original positions in the pelvis. There are several different surgical procedures, and each patient will have a different surgical plan developed for her dependent upon the type and/or cause of incontinence.
The most common surgical procedure for stress urinary incontinence in women is the midurethral sling. Another procedure is an injection of bulking agents into the urethral sphincter. There are investigations underway of muscle cell injections into the urethra. These muscle cells are harvested from each patient (thigh) and reinjected into the urethra.