Urinary incontinence is the loss of control over urination that affects more than 15 million Americans, particularly women and the elderly. The condition exacts a considerable toll on quality of life, interfering with work, social activities, and sex. Many people who suffer from urinary incontinence are too embarrassed to seek help or think that the condition is just part of the aging process. In the majority of cases, urinary incontinence can be cured or controlled.
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In urinary incontinence, the organs and muscles that govern urination fail to work properly. Your bladder relaxes as it fills with urine produced by your kidneys. The bladder stores urine until it is full. Messages are then relayed to your brain, which lets you know you need to urinate. At this point, you can decide to hold in the urine by tightening your urinary sphincter—the muscle that controls the opening from your bladder to the tube through which urine leaves your body (the urethra)—or let it out by relaxing your sphincter. Your bladder muscles will then contract to expel the urine But if you have developed incontinence, this process gets disrupted somewhere along the way. A variety of things could be responsible including, but not limited to:
- A urinary tract infection
- A side effect of medication, such as a diuretic for high blood pressure, a calcium channel blocker for heart disease, or a sedative for a sleep disorder
- Impaired nerve transmission resulting from diabetes, multiple sclerosis, or another illness
- Brain changes from a stroke, or confusion from dementia
- Hormonal changes during pregnancy, after childbirth, and during menopause are a frequent cause of incontinence in women
- In men, an enlarged prostate gland or surgery to remove a prostate gland
- Excess caffeine and alcohol intake
- Spinal cord injuries and pelvic trauma
The symptoms of incontinence vary according to the cause of the condition, and can range from minor leaks during a sneeze or physical activity to complete inability to hold in urine. Doctors generally classify urinary incontinence into four patterns: urge incontinence, stress incontinence, overflow incontinence, and total incontinence. Some people have a combination of types (mixed incontinence).
- Urge incontinence: People who suffer from urge incontinence experience an unpredictable overwhelming need to urinate that stems from a sudden, involuntary contraction of the bladder muscle. Typically, patients are unable to hold their urine until they can reach a bathroom, and experience modest amounts of urine loss. Older adults suffer most from this form of incontinence. An overactive bladder caused by a medication or an illness that interferes with the brain’s ability to control the bladder (for example, stroke or Parkinson’s disease) is often to blame. Obstruction to the flow of urine out of the bladder from an enlarged prostate gland also may affect the bladder and cause episodes of urge incontinence.
- Stress incontinence: People who suffer from stress incontinence experience predictable urinary leakage during activities that increase abdominal pressure, such as coughing, sneezing, exercise, laughing, and lifting heavy objects. This form of incontinence results when the urinary sphincter is weak and fails to stay closed during these activities. This form of incontinence is most common in postmenopausal women. Much less commonly, it can occur in men who have had some types of prostate surgery.
- Overflow incontinence: People who suffer from overflow incontinence experience periodic urine leakage. Urine leaks out of a bladder that is distended and overfilled. In men, prostate enlargement and prostate cancer can block the bladder outlet and make the bladder distended and leaky. Scar tissue from prostate surgery sometimes narrows the urethra or bladder neck and causes overflow incontinence. Nerve damage caused by a spinal cord injury, an illness, or a medication can also contribute to this form of urinary incontinence.
- Total incontinence: People who suffer from total incontinence experience constant unrelenting urine leakage. This type of incontinence is very severe and fortunately very uncommon. It may result from a number of causes including neurological problems, injuries, and various types of pelvic surgery.
- Mixed incontinence: People who suffer from mixed incontinence have a combination of the various forms of incontinence. Stress incontinence and urge incontinence frequently appear together.
Urinary incontinence can occur in anyone at any age, but is more common in women and in older adults. A third of older adults have some degree of incontinence. This does not mean that losing urinary control is a normal part of the aging process; however, it can be a consequence of illnesses that are more prevalent in older age groups, such as dementia, diabetes, Parkinson’s disease, and stroke. Likewise, medications taken by many older adults and procedures that are more common in this group (such as hysterectomy and prostatectomy) can predispose a person to incontinence.
Women are twice as likely as men to suffer from incontinence. Pregnancy, and injury to the structures that govern continence during childbirth may be to blame. A number of menopausal and postmenopausal women experience stress incontinence due to declining estrogen levels. Tissues in the urethra and vaginal area in particular may become dry and less elastic when estrogen levels decline, which may contribute to incontinence.
Table 1. Medications That Affect Continence
Methyldopa (Aldomet, Amodopa)
Doxazosin Hcl (Cardura)
Terazosin Hcl (Hytrin)
Irritable bowel syndrome, chronic obstructive pulmonary disease
Calcium channel blockers
Amlodipine besylate (Norvasc)
Verapamil Hcl (Covera-HS)
Ethacrynic acid (Edecrin)
Severe, chronic pain, particularly that associated with terminal cancer
To determine what is causing your symptoms, your doctor will start with a medical history and physical exam. Your doctor will want to know if you are using any medications, or have any illnesses that are associated with incontinence. He or she also will want to know if you have sustained an injury or undergone a medical procedure that may underlie the problem. If you have had children, your doctor will ask you about your experiences during childbirth. Your doctor will ask you how often you lose continence, and to describe what happens. For example, do you lose small amounts of urine when laughing or sneezing (a sign of stress incontinence)? Or do you experience a strong urge to urinate followed by significant urine loss (a sign of bladder overactivity)? Is your urine flow weak, or do you feel that you have not completely emptied your bladder after you have urinated (a sign of obstruction)?
Physical exams are useful in diagnosing incontinence. Your doctor will feel your abdomen for signs of distention. He or she may ask you to lie down and cough to assess the strength of your urinary sphincter. In women, a pelvic exam can reveal evidence of pelvic relaxation such as uterine prolapse--a condition that occurs when the uterus is inadequately supported, and protrudes out of the vagina--or another anatomic problem that makes the urethra more vulnerable to increased abdominal pressure or degeneration of local tissues. In men, a urologic exam can reveal an enlarged prostate gland that is obstructing the bladder.
Your doctor may order diagnostic tests to help determine the precise nature of your problem. Urine analysis can show if a urinary tract infection is the cause of your continence problem. For this, your doctor will ask you to provide a urine sample. Your doctor may wish to investigate how much urine stays in your bladder after you urinate to see if an obstruction or nerve problem is at work. This can be done with ultrasound imaging, which uses sound waves to show how much urine is in the bladder, or by placing a small thin tube called a catheter into your bladder to drain it. Cystoscopy, which uses a thin viewing instrument inserted into your bladder, can allow your physician to thoroughly inspect your bladder.
Sometimes, tests that are done while you are urinating are helpful. The object is to measure the pressure in your bladder as it is filling. To do this, you will have a catheter inserted into your bladder, which will then be filled with water. Normally, pressure increases at a slow, even imperceptible rate. However, in people with urge incontinence, pressure may build quickly before the bladder is filled due to involuntary contractions of the bladder muscle.. Finally, tests that measure the rate of urine flow can unearth an obstruction or bladder muscles that are unable to expel urine.
Prevention and Screening
- Steer clear of coffee, soda, and other drinks that have caffeine, as it can irritate the bladder.
- Try to drink a moderate amount of water every day to keep your urine from becoming too concentrated.
- Do special exercises to strengthen your pelvic floor muscles. Kegel exercises can help strengthen your pelvic floor muscles. Named after the physician who developed them, Kegels are especially beneficial if you are suffering from stress incontinence. To do a Kegel, tighten the muscle that you use to stop the flow of urine, hold for about 5-10 seconds, and then release. Try doing this on the toilet while you are urinating to feel which muscles control the stop and start of urination. If you can stop your urine flow, you are using the right muscles. Eventually you won’t need to use the toilet to practice these.
If you have a complete blockage of urine, seek emergency room help right away. Blockage is a sign that something is obstructing your urine output, and may indicate a serious disease. It is important to seek medical help immediately. Prolonged retention of urine may damage the bladder, leading to further urinary problems. A doctor can drain the bladder with a catheter and determine the cause of the blockage.
Go to the bathroom frequently, and make sure a bathroom is close by to prevent accidents. If you suffer from stress incontinence or urge incontinence, bladder training may help. Make it a point to urinate every hour for a week. Then see if you can extend the stretch to 2 hours, and then to 3 hours, and see how you do. This should help keep your bladder empty enough to sustain continence. As many as 15 percent of people with stress or urge incontinence stay dry this way. When you are out in public, be sure to locate and be near a bathroom so you are not caught short.
Wear loose-fitting clothing to facilitate bathroom trips, and use protective undergarments as a safeguard. Be sure to wear clothes that are easy to slip in and out of so you don’t waste time when the urge to urinate strikes. In situations where you fear you may lose control, wear a disposable pad or another type of absorbent undergarment to protect your skin and keep you dry in an emergency.
Drugs that relax the bladder may be helpful if you have urge incontinence. Anticholinergic and antispasmodic drugs inhibit the nerve impulses that trigger the involuntary bladder contractions of urge incontinence. These drugs can cut down on the number of bathroom trips and wetting accidents for people with urge incontinence, but their drawbacks can sometimes outweigh their benefits. Dry mouth, constipation, vision problems, and a host of other unwanted effects can occur. A newer drug called tolterodine (Detrol) is less likely to cause unwanted side effects. An antidepressant called imipramine (Tofranil) also has a relaxing effect on the bladder, but may cause dry mouth and drowsiness.
If you are suffering from stress incontinence due to menopausal changes, replacing estrogen may help. Applying estrogen cream directly to the vagina relieves continence problems in some postmenopausal women. However, these drugs should be used cautiously in people with high blood pressure, breast cancer, uterine cancer, ovarian cancer, liver disease, abnormal blood clotting, or a history of heartbeat abnormalities.
- Biofeedback can help teach you muscle control continence. If you lose control when you sneeze, cough, laugh, or do anything that increases abdominal pressure, and have a hard time sensing which muscles you use to hold urine in, you may benefit from biofeedback. During biofeedback, you will have electrodes placed on your bladder muscles, urinary sphincter, and abdominal muscles. An instructor will tell you to tense and relax the muscles and auditory or visual feedback will let you know when you are doing it right. After training, you should be able to control your muscles automatically to prevent leakage in situations that increase abdominal pressure. Techniques learned through biofeedback may also help you hold your urine until you can reach a bathroom when you get a strong urge to go. More than half of people with stress incontinence and urge incontinence are cured or helped by biofeedback.
- Collagen injections can help the sphincter to close more tightly. If you experience episodes of stress incontinence and have good pelvic muscles and a functioning bladder, you may benefit from collagen injections to bulk up your sphincter. During this procedure, your physician will inject collagen into the tissue surrounding your urethra. It takes about a half an hour and you should be able to go home afterwards.
- Transvaginal electrical stimulation helps some women remain dry. Some women with urge or stress incontinence benefit from electrical stimulation with a transvaginal probe. This device is used at home once or twice daily for 15 to 20 minutes per session. After 6 to 12 weeks 50 to 60 percent of women see an improvement in their symptoms. After symptoms improve, it is often possible to reduce treatments to three times per week. Women with pacemakers should avoid this treatment.
When the outflow of urine is obstructed, a procedure to clear the blockage may be needed. Prostate cancer can obstruct the outflow of urine, and cause the bladder to become too full, and leak. Surgery to remove all or part of the prostate can resolve some cases of overflow incontinence. Surgery to repair or replace faulty structures can be helpful.
The main surgical procedures include sling procedures, anterior repairs, and artificial urinary sphincter placement. Bladder neck suspensions and sling procedures can be very effective, curing up to 80 to 95 percent of carefully selected patients. Each surgery carries risks you should discuss with your surgeon.
- Sling procedure: For this procedure, a piece of tissue or synthetic material is attached under the urethra and bladder neck, and is secured like a sling or hammock to the abdominal wall and pelvic bone to put the structures back into the proper position.
- Anterior repair: This procedure relocates the connective tissue located under the bladder and neck to restore support of the bladder.
- Artificial Urinary Sphincter placement: For this procedure, an artificial sphincter constructed out of silicone is implanted around the urethra preventing urinary leakage
With the right treatment, your chances of solving your continence problem are very high. The percentage of patients cured varies by cause, treatment, and type of incontinence, but more than half of those suffering from stress or urge incontinence are helped by behavioral therapy or Kegel exercises alone. However, in order for such noninvasive treatments to work, patients must learn the correct way of practicing them and continue follow-up visits with a physician. Cure rates for surgery are very high, with as many as 95 percent of patients remaining dry 5 years after the operation.
What are Kegel exercises, and how can they help with incontinence?
Kegel exercises, named after the doctor who invented them, can help restore continence by strengthening the muscles of the pelvic floor. The exercises were intended to assist women before and after childbirth, but they are useful for men and women with stress and urge incontinence and other wetting problems. Kegels involve tightening and relaxing the muscles that control urine flow. Because they can be difficult to feel, doctors recommend trying this on the toilet at first. Doing 15 or 20 of these a few times a day helps many people stay dry.
I am taking a medication for my overactive bladder and it has been helpful. But I occasionally lose control, which is really embarrassing. What do you recommend I do?
Start with a program of timed voiding. If you can consistently empty your bladder on a schedule then it will not fill up to the point where the bladder will have involuntary contractions. Another option would be doing Kegel exercises. A properly performed Kegel exercise right at the time of the urgency will prevent urine leakage.
I sometimes leak urine when I sneeze. This started around the time I hit menopause. Do I need to be on medication?
Declining estrogen levels during menopause can contribute to urinary incontinence. Applying estrogen as a vaginal cream may help to restore your urethral lining, which could be the source of your problem. You may notice results in as little as 6 weeks or as long as 6 months.