Incontinence - Urine

Introduction

Urinary incontinence is as concerning as it can be inconvenient and embarrassing.  Urinary incontinence is the involuntary loss of urine, affects some 25 million adults, 75-80% of them women. Estimates of the annual cost of managing and treating incontinence in the U.S range from $16 billion to $26 billion.  It is not a disease, but rather a symptom.  

There are three principal types of incontinence:

• Stress urinary incontinence or SUI
• Overactive bladder (also called urge incontinence)
• Mixed incontinence

There are many causes of incontinence; some are more serious than others are.  Incontinence is not a normal part of the aging process, although older adults may experience more disorders or diseases that contribute to urine loss.  You should talk to your doctor about your concerns, because in many cases the underlying cause can be treated.

Anatomy

Your urinary system consists of your kidneys, bladder, and urethra.  Your kidneys are a pair of bean shaped organs located in the lower back area.  The kidneys filter waste products and extra fluid from your blood which creates urine.  Urine is composed of mainly water and metabolic waste products.  From the kidneys, urine travels through two tubes (ureters), to the bladder.

Your bladder holds and collects the urine that arrives from the kidneys.  When a certain level of urine has accumulated in the bladder, your bladder sends signals to your brain so you know that it is time to urinate.  Urination is a voluntary action.  When you are ready, the bladder walls (detrusor muscle) contract and the pelvic floor muscles relax.  A valve-like muscle in the bladder (urinary sphincter) opens and allows urine to empty from the bladder.  Urine is carried from the bladder to the outside of your body through a tube called the urethra.  The female urethra is short and ends above the vaginal opening.  The male urethra is longer and ends at the tip of the penis.  When you have finished urinating, the urinary sphincter closes.

Causes

There are different types and causes of urinary incontinence.  In some cases, the cause is unknown. It may result because of a very simple reason, such as too much caffeine intake, and thus only be a temporary concern.  However, urinary incontinence may be persistent and caused by more complex reasons, such as cancer or a neurological disorder.  Below are some common types of incontinence and their causes.

STRESS URINARY INCONTINENCE
Stress urinary incontinence or SUI is the most common type of incontinence, characterized by leakage of urine during coughing, sneezing or laughing. SUI is caused by weakening of the pelvic muscles that support the bladder and urethra. As a result, the urethra is not held in its correct position and/or loses its seal. Then, when a sudden movement of the diaphragm puts pressure on the bladder, the sphincter muscle on the urethra is not able to control the leakage of urine. SUI may be a symptom of pelvic organ prolapse, but it is also a health condition on its own. Unlike other forms of incontinence, SUI is not accompanied by an urge to urinate.

Prevalence
Studies suggest that SUI may affect more than 30 million American women. Although SUI can occur in women of all ages, it becomes more prevalent with age. One review of published studies estimates that severe symptoms of SUI are experienced by:

• 29% of women aged 25 to 44 years
• 33% of women aged 45 to 60 years
• 86% of women aged 60 or older

Risk factors
The single biggest risk factor is vaginal childbirth.  The risk of SUI increases proportionately with the number of vaginal deliveries a woman has had.  Previous gynecologic surgery, especially a hysterectomy, is another factor:  women who have had pelvic surgery have a 40% higher risk of developing SUI.  Other risk factors include high-impact physical activity, smoking, and chronic conditions such as obesity, respiratory ailments, coughing and constipation.

Under-diagnosis
SUI is not well known or understood by most women.  According to the National Association for Continence, most women with SUI suffer from the condition for 3 to10 years before talking to their doctor about it.  As many as two-thirds of women with SUI never talk about it with their doctors at all.  This is a serious concern, because SUI has a negative impact on a woman’s quality of life, self-esteem and activity level.  In one survey, nearly 60% of women with SUI said they changed their lifestyle to accommodate their condition instead of seeking medical help.

Treatment options
It is important for women to know that incontinence is not a normal consequence of aging. In addition to non-surgical approaches, minimally invasive surgical approaches are now available to treat SUI, so women do not have to accept a compromised lifestyle. These include retropubic suspension and sling procedures performed vaginally such asTVT.

OVERACTIVE BLADDER/URGE INCONTINENCE
Overactive bladder (OAB) and urge incontinence (UI) are overlapping conditions characterized by the sudden, uncontrollable urge to urinate about every two hours, including through the night. UI occurs when nerve passages along the pathway from the bladder to the brain are damaged, causing a sudden bladder contraction that cannot be consciously inhibited. Many factors can cause overactive bladder, including certain types of foods, beverages and medications. However, some cases of OAB have no known cause.

Overactive Bladder- “Irritable Bladder”
Overactive bladder causes an extreme sudden urgent need to urinate, frequent urination, and the need to wake and urinate at night (nocturia).  It may be accompanied by urge incontinence, known as “overactive bladder, wet.”  About two thirds of people with overactive bladder do not experience urge incontinence, which is termed “overactive bladder, dry.” 

Overactive bladder occurs when the bladder wall muscles contract before the bladder is completely full.  The muscle wall contraction signals the brain that it is “time to go to the bathroom,” although the bladder is only partially full.  In many cases, the cause of overactive bladder is not known.  It may develop in people with Parkinson’s disease, strokes, or other neurological disorders.  Urinary tract infections, structural abnormalities, inflammation, bladder stones, enlarged prostate in men, diabetes, excess alcohol or caffeine intake, and certain medications can contribute to overactive bladder, as well.

Prevalence
According to the National Association for Continence, about 17% of women and 16% men over 18 years old have overactive bladder and an estimated 12.2 million adults have urge incontinence. Like SUI, OAB and UI occur more frequently in women than in men and become more prevalent with age.Overactive bladder occurs most frequently in men over the age of 65 or women in their mid-40s.  It is fairly common in the United States, affecting about one in six people.  Women with OAB are significantly more likely to suffer from other health disorders, such as hypertension, obesity and arthritis, than women without OAB. 

OAB has a negative impact on a woman’s quality of life. In a national survey, sufferers of OAB reported they are two to three times more likely to regularly experience disturbed sleep, overeating and poor self-esteem, compared with non-OAB sufferers.

Treatment options
At least 80% of people with urinary incontinence can be cured or improved.Treatment of OAB/UI normally involves lifestyle changes and techniques for bladder retraining, strengthening of pelvic floor muscles, and frequently medications.

MIXED INCONTINENCE
Mixed Incontinence is the coexistence of both stress urinary incontinence and overactive bladder/urge incontinence. It affects approximately one-third of all women with SUI. Treatment options are likely to include approaches for both conditions and will depend on which symptoms are most troublesome to the patient.

OVERFLOW INCONTINENCE
With overflow incontinence, the bladder has difficulty emptying completely. This leads to persistent urine dribbling and a weak stream of urine when you go to the bathroom. Overflow incontinence can be caused by a blocked urethra, injured bladder, prostate gland conditions in men, certain medications, and nerve damage associated with diabetes.

FUNCTIONAL INCONTINENCE
Functional incontinence occurs because of a physical or thought processing problem that prevents a person from getting to the bathroom in time.  For example, people with Alzheimer’s disease may fail to plan to go to the bathroom, or people with physical limitations may not allow enough time to get to the bathroom.

GROSS TOTAL INCONTINENCE
Gross total incontinence is the inability to hold any urine at all in the bladder at any time.  This can happen to people that sustain a spinal cord injury or urinary tract injury.  Some people are born with a structural abnormality such as an abnormal opening (fistula) near the urethra which can contribute to gross total incontinence.

Symptoms

Urine incontinence is the unintentional leakage or loss of urine.  The amount of urine loss varies.  As described in the “Causes” section of this article, the type of symptoms you develop may depend on the type of urine incontinence that you experience.   You may feel the sudden urgent need to go to the bathroom.  You may leak  urine before you reach the bathroom.  You may only produce a weak stream of urine.  You may leak urine when you cough, sneeze, lift, or exercise.  Some people with urine incontinence also have overactive bladder, which causes them to urinate frequently. 

Diagnosis

Before considering a treatment for urinary incontinence, a doctor must first determine its cause.  Your doctor will conduct a physical evaluation, review your medical history, conduct lab tests, and in some cases, consult with another specialist.  Make sure to bring a list  of your medications to your appointment.  It is helpful to write down your symptoms before your appointment and bring them to discuss with your doctor.  Some people may feel embarrassed about discussing “private” matters, but rest assured that your doctor respects and appreciates the information that you provide, as it helps in diagnosing your problem.

Each case of urinary incontinence is evaluated individually.  Specific evaluations will differ from person to person, depending on what the doctor determines is most appropriate.  Common tests include blood tests and urine sample tests.  Your doctor may ask you to keep a record of how much you drink and urinate and episodes of incontinence over several days.  A stress test may be used to evaluate urine leakage while you stand and cough with a full bladder.

An urologist or urogynecologist (for women) can conduct specialized tests.  A post void residual (PVR) measurement helps to find out if you have a problem with emptying your bladder.  After you have urinated, your doctor will use a catheter or ultrasound to assess how much urine is left in your bladder.  A catheter is a soft thin tube that is carefully inserted into your urethra to your bladder to remove remaining urine for measurement.  An ultrasound is a painless imaging test that uses sound waves to create a picture of the bladder and remaining urine.  With either test, a large amount of remaining urine indicates a blockage in the urinary tract or a bladder problem.

Urodynamic testing is another test to learn more about bladder function.  Urodynamic testing evaluates the muscle strength in the bladder walls and sphincter.  For this procedure, a catheter is inserted into the bladder and then the bladder is filled with water via the catheter.  A pressure monitor records the pressure within the full bladder.  Pressure in a healthy bladder increases slightly while filling.

Bladder pressure can also be measured with cystometry.  For this procedure a catheter is inserted into the bladder and the bladder is filled with water.  A small pressure monitor is inserted through the anus and into the rectum.  The device measures pressure changes in the bladder and surrounding areas while the bladder is filled to various capacities. 

Video urodynamic testing is frequently performed at the same time as cystometry.  Video urodynamic testing uses X-rays or ultrasound to show what the bladder looks like while it is filling and emptying.  A special dye may be used to enhance the images.

Your doctor may use a cystoscope to view the inside of your lower urinary tract.  A cystoscope is a thin tube with a viewing instrument.  It is carefully inserted through your urethra.  The bladder is expanded with air or water to open the bladder folds and provide a better view.  A cystoscopy allows your doctor to check for problems inside of the bladder and urethra.  Narrow instruments can be inserted through the cystoscope to allow your doctor to remove tissue if necessary.

Treatment

The type of treatment that you receive depends on the cause of your urine incontinence.  In some cases, treating the cause stops incontinence.  For example, treating a urinary tract infection or eliminating excessive alcohol intake may solve the problem.  For ongoing incontinence, there are many different types of treatment including behavior strategies, medications, devices, surgery, or a combination of treatments.

Your doctor may recommend behavioral changes, such as limiting fluids, avoiding alcohol and caffeine, losing weight, and quitting smoking. It can be helpful to go to the bathroom more often or do so on a regular schedule.  Bladder training involves holding urination for increasing minutes after feeling the urge to go to the bathroom to help lengthen the time between urinating.

It is common for people with incontinence to be instructed in Kegel exercises to help strengthen the muscles that control urination.  Your doctor may instruct you or refer you to a physical therapist that specializes in pelvic floor strengthening.  Under select circumstances, clinical electrical stimulation is used to promote muscle strengthening.  Electrical stimulation can be helpful for treating stress and urge incontinence.

In many cases, behavioral interventions are paired with prescription medications.  There are several different types of medications that may be used depending on the type of incontinence.  Medications may calm an overactive bladder, relax the bladder wall muscles, or contract the muscles at the bladder neck.  For men with an enlarged prostate gland, medications may help decrease the size of the gland or relax the muscles around the urethra.

There are a variety of disposable or washable protective pads and briefs on the market today that can be worn to protect clothing. There are insertion devices designed especially for women, including plug-like urethral inserts or a ring-like device (pessary) to help support the bladder.

For men with chronic incontinence, a condom catheter can be worn over the penis to collect urine into a collection bag.  The bag can be strapped to the ankle or a wheelchair.  The collection bag is emptied into the toilet when it becomes full.  Indwelling catheters may be placed in men or women, usually those with serious illness, and the bag is emptied in the same manner.  Men and women with bladder emptying issues can learn to use a soft catheter to drain their bladder throughout the day (self-intermittent catheterization).

Surgery may be recommended when other methods are not working.  There are specific surgeries for women and men. There is more than one type of surgery, and the type that you receive will depend on your individual circumstances.  For men, surgically removing part of an enlarged prostate gland can be helpful. Also for men, an inflatable artificial sphincter implant is considered a very effective treatment.  An inflatable ring is surgically place around the neck of the bladder to hold urine in.  When an implanted valve is pressed, the urine is released.

For women, injectable bulking agents, such as collagen, synthetic gels, or synthetic sugars, are used to build up the tissues surrounding the urethra or urinary sphincter.  This is a short noninvasive procedure that is sometimes tried before other types of surgery. Open retropubic colposuspension is a surgery for a woman that uses sutures to help lift and support tissues near the bladder neck and upper urethra.  A sling procedure is another type of surgery for a woman that uses tissue or synthetic material to create a sling to support the urethra.

Prevention

Depending on the cause, urine incontinence can be eliminated or managed if treatment is received early.  If you have urine incontinence, it is important to follow your doctor’s treatment directions carefully.  Maintaining a healthy weight, performing Kegel exercises, not smoking, and avoiding alcohol and caffeine can all be helpful.

Am I at Risk

Risk factors may increase your likelihood of developing urinary incontinence.  It is important to note that urinary incontinence is not a normal part of aging.  Older adults may be at higher risk for urinary incontinence because they are more likely to develop conditions that contribute to it.  Additionally, women experience urinary incontinence more frequently than men do.

Risk factors for urinary incontinence:
___ Diabetes
___ Inflamed vaginal tissues in women
___ Enlarged prostate in men
___ Bladder inflammation or infections
___ Bladder stones or obstruction
___ Smoking
___ Weight gain or obesity
___ Chronic coughing
___ Constipation and straining during bowel movements
___ Pregnancy or Childbirth
___ Excess alcohol consumption
___ Excess caffeine consumption
___ Excess beverage or water consumption
___ Certain medications
___ Pelvic prolapse in women
___ Hysterectomy in women
___ Interstitial cystitis- a painful bladder condition
___ Neurological disorders, such as traumatic brain injury, spinal cord injury, multiple sclerosis or stroke
___ Prostate cancer
___ Bladder cancer
___ Colon and rectal cancer
___ Certain types of cancer treatment

Complications

The experience of urinary incontinence may be embarrassing or even humiliating for some people.  Others may feel depression, anxiety, or a loss of dignity.  In some cases, this leads to reduced social interaction and social isolation.  Make sure to discuss your concerns with your doctor.  Your doctor is happy to offer suggestions or recommendations for assistance and support.

With ongoing urine incontinence, the risk of skin infections or sores (ulcers) increases.  Additionally, chronic urine incontinence increases the risk for repeated urinary tract infections.  Ask your doctor to recommend preventive measures that are appropriate for you.

References

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