What is incontinence?
- Incontinence is a common condition that means the involuntary loss of urine.
- This condition can occur for a number of reasons but is most commonly associated with the loss of urine when coughing, sneezing, or exercising or by the inability to hold urine when the urge to urinate occurs.
- Both men and women are affected by incontinence, most typically as they get older.
- Several types and causes of incontinence exist, and many can be treated to either eliminate or significantly reduce the problem.
Who is affected by incontinence?
Incontinence is sometimes called a silent epidemic because people struggling with the condition often do not talk about it to others or their physicians. Researchers estimate that 13 million or more people in the United States alone are affected by incontinence.
- One out of 10 people age 65 or older are estimated to experience bladder control problems.
- A significant percentage of elderly people living in their own homes have some type of incontinence.
- Almost half of nursing home residents have incontinence.
- More women than men are affected by incontinence.
When untreated, people with incontinence may limit their activities outside of the home for fear of embarrassment. Subsequently, the condition can contribute to loneliness and depression caused by social isolation. When treated, symptoms of incontinence can be reduced or eliminated altogether:
- Most people with stress incontinence either improve significantly or are cured.
- Less than half of people with urge incontinence are cured.
Are there different kinds of incontinence?
Several different types of incontinence have been identified. Stress and urge incontinence are the most common types.
- Stress incontinence: Also known as exertional incontinence, stress incontinence typically is associated with activities such as laughing, coughing, and sneezing can cause urine to leak unexpectedly. This is most common in women and is often caused by physical changes occurring with and after pregnancy.
- Urge incontinence: The bladder feels like it needs to be relieved immediately, regardless of how much urine is in the bladder. Symptoms include needing to urinate immediately (urgency), needing to urinate often (frequency), and having to get up at night to urinate (nocturia). When one cannot get to the bathroom in time and leaks, this is urge incontinence. Most people now refer to this condition as overactive bladder (OAB). Occurring in men and women, this condition is believed to be caused by bladder muscles contracting
(bladder spasms) at the wrong times. This may be due to a disruption of signals between the bladder and the brain.
- Mixed incontinence: When one person has both stress and urge incontinence, the condition is called mixed incontinence.
- Overflow incontinence: Characterized by the retention of urine in the bladder after urinating, overflow incontinence is most common in men. Symptoms include dribbling of urine, urgency, hesitancy (waiting for the urine stream to begin), weak urine stream, straining to urinate, and urinating small amounts of urine at a time.
- Dribbling incontinence: Dribbling urine immediately after urination is completed is called dribbling incontinence. This can occur in men and women.
- Functional incontinence: When people are physically unable to make it to the bathroom in time due to a physical or mental condition, they are said to have functional incontinence.
- Congenital incontinence: A child born with the bladder or ureter(s) out of place is said to have congenital incontinence.
- Neuropathic incontinence: Problems affecting one or more nerves related to the bladder can cause different symptoms of incontinence. Abnormalities in the brain such as a stroke or a neurological disease can affect bladder function.
- Traumatic incontinence: An injury to the pelvis, such as a fracture, or a complication of surgery can cause traumatic incontinence.
What causes incontinence?
Several factors contribute to incontinence. Many causes can be treated, thus eliminating symptoms of incontinence. Some causes are gender-specific, meaning that they occur in males or females exclusively. Among the known causes and contributing factors for incontinence are the following:
Difficulties with toilet training in childhood have nothing to do with incontinence occurring later in life. Having an incontinent parent does not automatically mean a person will suffer with incontinence later in life.
What lifestyle and health factors reduce the likelihood of incontinence?
The following lifestyle habits can help you maintain bladder and urinary health:
- Urinate regularly, and do not delay having bowel movements.
- Drink adequate fluids, 6-8 cups a day, to maintain a urinary output of 50 ounces per day, more if you are exercising or sweating due to hot weather.
- Limit alcohol and caffeinated drinks.
- If you smoke, quit.
- Maintain a healthy weight (body mass index < 25).
- Eat a healthy diet low in fat, sugar, and salt.
- Limit consumption of spicy foods, chocolate, and citrus or acidic fruits.
- Exercise regularly. Kegel exercises (exercises that strengthen the muscles of the pelvic floor) also help women strengthen muscles used during urination.
Urinary Incontinence: Keeping a Daily Record
In order to diagnose the root cause of and determine the proper treatment for urinary incontinence, doctors often ask patients to keep a "voiding log," that is, a record of all fluids consumed as well as all urine released, both voluntary and involuntary.
What are the symptoms of incontinence?
The uncontrollable leakage of urine from the bladder is the most common symptom of incontinence. Several terms are used to describe other symptoms of incontinence:
- Urgency: Feeling the need to urinate immediately or very soon
- Hesitancy: Difficulty starting the urine stream when trying to urinate
- Frequency: Urinating more often than usual
- Dysuria: Pain or burning with urination (often associated with infection)
- Hematuria: Blood in the urine, which causes a pink or reddish color
- Nocturia: Getting up during sleeping hours to urinate
- Dribbling: Dripping or dribbling urine after urination is completed
- Straining: Bearing down to start the urine stream
When should I seek medical attention?
Make an appointment to see your doctor if you
- leak urine,
- get up more than twice a night to urinate,
- feel the urgent need to urinate often,
- have difficulty starting the urine stream,
- feel the bladder is still full after urinating,
- dribble urine after going to the bathroom.
See a doctor if you
- have blood in your urine (pink or reddish urine)
- have pain or burning with urination.
What will my doctor do?
Your doctor will ask you about your symptoms, health history, and personal habits.
Your doctor will do a physical exam, possibly including a vaginal and pelvic exam in women and a genital and rectal exam in men.
Your doctor will ask for a urine sample to test for infection and other abnormalities. Your doctor may also take a blood sample to rule out other medical conditions.
Your doctor may ask you to keep a urination or voiding diary.
Your doctor may refer you to a specialist such as a urologist for further management of your situation.
What tests are used to diagnose incontinence?
A wide variety of diagnostic tests are used, depending on the type or symptoms of incontinence. Some examples of diagnostic tests include the following:
- Measurement of the post void residual. For overflow incontinence, this test checks how much urine remains in the bladder after urination. The test can be done by inserting a catheter into the bladder after urination to see how much urine remained in the bladder or by using an ultrasound image to calculate how much urine remained in the bladder.
- Cotton swab test. This test detects hypermobility of the urethra, which is common in women with stress incontinence. The test is performed by inserting a well-lubricated, sterile, cotton-tipped applicator into the urethra and bladder neck.
- Cystoscopy. This diagnostic tool allows your doctor to view the inside of your bladder by inserting a small tube with a camera into the urethra and into the bladder.
- Urodynamic tests. Sometimes called an ECG of the bladder, these tests are used to determine how well the bladder and sphincter muscles work. These tests are typically done in a series and can determine if your bladder fills and empties completely. They can also show if the sensation of fullness corresponds to the bladder actually being full.
What is the treatment for incontinence?
Many people think incontinence cannot be treated at all or that surgery is the only way to treat incontinence. This is not true. Treatment options include behavioral, medical, and surgical therapies. Which treatment is best depends on the type and cause of the urinary incontinence. For urge incontinence, the emphasis is on finding and treating the underlying cause. For stress incontinence, surgery may be the most effective way to eliminate symptoms of incontinence. Medications may also improve symptoms of some types of incontinence.
Behavioral techniques are often the first treatment of choice because they are noninvasive and have no side effects.
- Biofeedback: This involves retraining the bladder through pelvic muscle tightening and relaxing that is guided by a trained technologist.
- Behavioral therapy: You may be able to change your habits to reduce or eliminate episodes of incontinence.
- Timed voiding and bladder training: Keeping to a schedule for urinating may minimize your symptoms.
- Pelvic-floor exercises: Kegel exercises help women strengthen muscles used during urination.
- Pelvic-floor stimulation: Women can increase the tone of pelvic-floor muscles by having a small probe inserted into the vagina or rectum that delivers painless electrical pulses.
- Weighted vaginal cone: For women, a cone-shaped weight is inserted into the vagina and exercises are performed to strengthen pelvic floor muscles.
- Pessary: This device is inserted into a woman's vagina to support the bladder and improve bladder control.
- Urethral plug: To block urine flow, a small tampon-like plug is inserted into the urethra.
In some cases, catheterization may be used to drain urine from the bladder. In this medical procedure, a thin tube is inserted into the urethra and bladder to drain urine. Several medications are also used to medically treat incontinence.
- Anticholinergic or spasm-relieving drugs suppress bladder contraction and relax bladder muscles for those with urge incontinence or overactive bladder. These medications include darifenacin (Enablex), solifenacin (VESIcare), trospium (Sanctura, Sanctura XR), fesoterodine (Toviaz), topical oxybutynin (Gelnique), oral oxybutynin (Ditropan, Ditropan XL, Urotrol), tolterodine (Detrol, Detrol LA), and others.
- Tricyclic antidepressants such as imipramine (Tofranil, Tofranil-PM) also have the above anticholinergic effects but are not approved for the use in patients with OAB.
- Adrenergic agonists such as midodrine (ProAmatine) and pseudoephedrine (Sudafed) may increase internal sphincter tone in people with stress incontinence. These medications may have serious side effects, such as high blood pressure, and are therefore not commonly prescribed for stress incontinence. Mirabegron
(Myrbetriq) is a beta-3 adrenergic agonist indicated for the treatment of overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and urinary frequency.
- Topical estrogen cream is sometimes prescribed to menopausal women to strengthen pelvic muscles and improve the health of vaginal tissues.
Surgery can correct an anatomical defect or alter bladder muscle function. All surgeries need to be carefully discussed with your physician because of potential complications and varying success rates and indications. Surgical techniques can
- alter bladder neck position;
- repair or support weakened pelvic floor muscles and improve leakage in a patient with stress incontinence;
- remove a blockage;
- implant a "sling" around the urethra (now done as an outpatient procedure in almost all cases);
- implant a nerve stimulation device to increase awareness of need to urinate in patients with overactive bladder refractory to medications and behavioral treatments;
- inject a bulking agent (Contigen or Macroplastique) around the urethra to add bulk to the area and compress the urethra, thus increasing resistance to urine flow;
- enlarge the bladder by injecting an antispasmodic medication such as botulinum toxin type A (Botox, Botox Cosmetic) into the bladder muscle (used as an off-label approach to OAB that does not respond to other treatments).
What is a urination diary?
Your doctor may ask you to keep a urination diary to determine factors contributing to your condition. Things you will be asked to record include
- types and amount of liquids consumed;
- times of urge to urinate;
- strength of urge to urinate or pain;
- time of urination;
- volume of urine;
- and amount, if any, of leakage
What are Kegel exercises?
Women are often instructed to do Kegel exercises to strengthen their pelvic-floor muscles. Kegel exercises are most often taught at childbirth classes. While Kegel exercises assist in vaginal childbirth, they can also strengthen the muscles that help you hold back urine. Kegel exercises are believed to reduce the incidence of stress and urge incontinence. Unfortunately, Kegel exercises are often done incorrectly, thus offering no benefit. The following instructions describe the correct way to do a Kegel exercise:
- Find the correct muscles by inserting your first two fingers into the vagina. Squeeze your pelvic muscles as if you are holding urine. The muscles you feel tighten around your fingers are the muscles you need to use when performing Kegel exercises.
- Squeeze and hold these muscles tight for three to 10 seconds, then relax the same muscles for three to 10 seconds. Do this for 10 to 20 repetitions, three times each day.