Understanding Urinary Incontinence: A Comprehensive Guide

Understanding Urinary Incontinence  

Urinary incontinence is a loss of bladder control. It can mean that you occasionally leak urine when you cough or sneeze, or that the urge to urinate is so strong that you don’t make it to the bathroom on time.

Incontinence is more common in older people and twice as common in women than men. Experts estimate that 1 in 4 women over the age of 35 have urine leaks. 

Common causes include overactive bladder, pelvic muscle weakness in women after childbirth, bladder outlet obstruction in middle-aged and older men due to prostate enlargement, and functional conditions such as dementia and stroke in older adults.

Effects on Quality of Life: What Does Being Incontinent Feel Like?  

Urine leakage is a common and embarrassing problem that can greatly affect daily life. According to the National Association for Continence, urinary incontinence affects both physical and mental health as well as a person’s lifestyle and quality of life. Some of the negative impacts of incontinence include:

• Risk of skin infections and sores

• Risk of falls and fractures, especially in seniors, when rushing to make it to the bathroom on time

• Needing to change clothes and bed linen frequently

• Limiting social engagements and activities due to embarrassment

• Avoiding exercise such as running and other high-impact exercises

• Embarrassment and shame leading to anxiety and depression

• Financial impact on patients and caregivers

Types of Urinary Incontinence  

Stress Incontinence  

Stress incontinence is urine leakage that happens when there is stress (pressure) on the bladder. This can occur during laughing, coughing, sneezing, heavy lifting, running, and other physical activity. 

Urge Incontinence  

Urge incontinence or urinary urgency is urine leaks that happen because of a sudden strong urge (need) to urinate. It results in urine leaking because you can’t make it to the bathroom on time. 

Overflow Incontinence  

Overflow incontinence occurs due to incomplete emptying of your bladder during micturition (urination). This results in too much urine remaining in the bladder and leaking (overflow) when the bladder gets too full.

Functional Incontinence  

Functional incontinence is urine leakage that occurs due to a physical or mental disability. For example, mobility problems, speech problems, or other functional issues. For example, a person with arthritis in their hands may have trouble unbuttoning their pants; someone who is confined to bed may not be able to walk to the toilet; a person with dementia may not know how to find a toilet or realize that they need to use one. 

Mixed Incontinence  

Mixed incontinence is the co-occurrence of more than one type of incontinence. The most common combination is stress incontinence and urge incontinence occurring together. 

Temporary Incontinence  

Temporary or transient incontinence is leakage of urine caused by certain foods and beverages, certain medicines, or a health problem such as urinary tract infections or constipation. Unlike chronic urinary incontinence, temporary incontinence goes away once the cause is treated or discontinued.

Bedwetting

Urine leakage during sleep is called bedwetting. It is more common in children under 5, especially boys. It can also occur in adults due to dietary choices and certain medical conditions such as urinary tract infections, kidney stones, sleep apnea, benign prostatic hyperplasia (BPH or enlarged prostate), and diabetes insipidus.

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What Causes Urinary Incontinence?

Common Risk Factors  

• Age: Urinary incontinence is more common in older adults due to age-related weakening of the bladder and urethra muscles. 

• Gender: Incontinence is more common in women than men. Women have a higher risk of developing stress incontinence due to female anatomy as well as changes related to pregnancy, childbirth, and menopause. Men with an enlarged prostate gland are at a higher risk of developing urge incontinence and overflow incontinence.

• Obesity: Extra body weight puts pressure on the urinary bladder and supporting muscles and can weaken them, causing urine to leak (stress incontinence). 

• Smoking: Chemicals in tobacco can irritate the bladder. Smokers can develop a chronic cough that can weaken pelvic floor muscles. 

• Family history: People who have a close family member with urinary incontinence, especially urge incontinence, are at an increased risk of developing it themselves.

• Certain health conditions: Diabetes and some neurological diseases can affect the ability to control urination.

Age-Related Changes

Doctors say urinary incontinence is not a normal part of aging. However, it is more common in older adults because of:

• Weakening of the pelvic floor muscles, ligaments, and connective tissues with age.

• Decrease in bladder capacity and inability to delay urination.

• More frequent involuntary bladder contractions.

• Weaker bladder contractions, leading to incomplete emptying of the bladder and overflow incontinence.

• Atrophy (thinning and wasting of the tissues) of the urethra and vagina due to decreased estrogen levels in postmenopausal women, leading to decreased strength of the urethral sphincter (the muscle that controls the flow of urine). 

• Bladder outlet obstruction in middle-aged and older men with an enlarged prostate gland leading to incomplete bladder emptying and pressure on the bladder muscle. 

Dietary and Lifestyle Factors

Bladder irritants such as caffeinated drinks, carbonated drinks, alcohol, chocolate, chili peppers, artificial sweeteners, spicy food, sugary foods, and citrus fruits can cause temporary urinary incontinence by increasing the volume of urine or irritating the bladder. 

Medications

Sedatives, muscle relaxants, heart medicines, blood pressure medications, and high doses of vitamin C can cause incontinence as a side effect. A diuretic (water pill) may cause incontinence by increasing urine volume.

Health Conditions Contributing to Incontinence  

Medical conditions that can cause short-term or long-term incontinence include:

• Urinary tract infections can cause irritation of the bladder, frequency, and urgency.

• Constipation (hard, impacted stool in the rectum) can irritate nerves near the urinary bladder and cause overactive bladder or urinary frequency.

• Overactive bladder, a condition in which the detrusor (bladder) muscles have involuntary contractions even when there is a small amount of urine in the bladder. Risk factors for OAB include older age, female gender, diabetes, and enlarged prostate.

• Pregnancy-related hormonal changes and the growing baby can put pressure on the bladder and cause stress incontinence. 

• Vaginal birth can weaken the mother’s pelvic muscles and connective tissues that support the bladder; damage nerves in the bladder; and lead to prolapse (dropped pelvic organs) where the bladder, uterus, and rectum get pushed down from their usual position, which can cause incontinence. 

• Low estrogen levels in menopause can affect the health of the bladder, urethra, and surrounding muscles.

• Prostate gland problems (BPH) in older men can cause incontinence by obstructing the flow of urine.

• Prostate cancer can cause symptoms such as stress incontinence or urge incontinence. Incontinence can also occur as a side effect of prostate cancer treatments.

• Obstruction in the urinary tract, for example, from kidney stones or a tumor, can prevent the normal flow of urine and cause overflow incontinence.

• Certain neurological disorders, such as stroke, Parkinson's disease, multiple sclerosis, brain tumors, and spinal cord injuries can interrupt nerve signals necessary for bladder control and lead to urinary incontinence.

Symptoms of Urinary Incontinence  

Symptoms of bladder control problems include:

• Urine leakage with coughing, sneezing, laughing, lifting something heavy, or exercising.

• Sudden intense need to urinate and involuntary loss of bladder control. 

• Needing to urinate frequently, including at night. 

• Dribbling of urine due to overflow. 

• Inability to make it to the bathroom on time due to a functional impairment, such as mobility problems or arthritis. 

When To See a Doctor

Urinary incontinence is not a life-threatening condition. However, many people don’t seek treatment for incontinence, believing it is a normal part of aging and something they have to live with. But you don’t have to live with embarrassing urine leaks. Lifestyle changes and medications are available to treat urinary incontinence. Having urinary incontinence diagnosed properly by a healthcare provider can help in identifying the type of incontinence and the appropriate treatment options. The treatment options vary depending on the type of incontinence.

Note: Seek emergency medical care for incontinence accompanied by symptoms such as weakness in the legs or loss of sensation in the genital area - these can be signs of spinal cord injury.

The Diagnostic Process  

Your healthcare provider will ask questions about your symptoms and obtain a medical history to find out what might be causing urinary incontinence. They will also perform a physical exam, including a pelvic exam in women (to look for menopause-related changes) and a rectal exam in men and women (to check for constipation, nerve damage, and enlarged prostate). Your provider may ask you to cough with a full bladder during the exam.

It may help to note down the following information in a voiding diary or bladder diary before your appointment:

• When does urine loss occur (time of day)?

• What makes it worse (such as laughing, coughing, sneezing, straining; certain activities; or certain foods and drinks)?

• Does the need to urinate come on suddenly? 

• How much urine leakage occurs?

• Is there any pain or burning with urination, frequency (needing to use the bathroom often), or voiding dysfunction (difficulty starting the urine stream or a weak urine stream)?

• Do you have a history of urinary tract infections, kidney stones, prostate problems, stroke, dementia, or spinal cord injury?

• Have you had pelvic or abdominal surgery in the past?

• What medications are you taking?

Tests and Examinations Used  

Doctors can make a diagnosis of urinary incontinence based on your symptoms, medical history, and physical examination. However, they may order some tests to make a confirmed diagnosis, such as: 

• Urinalysis (analysis of urine samples in the laboratory to check color, clarity, odor, volume, pH, specific gravity, and the presence of blood cells, proteins, and other substances).

• Urine culture to look for a urinary tract infection.

• Postvoid residual volume to check how much urine remains in the bladder after urinating. It is done using a catheter or ultrasound. More urine left over can indicate an obstruction in the urinary system or muscle and nerve problems.

• Urodynamic testing if the above tests do not reveal the cause of urinary incontinence.

  • Cystometry involves placing a catheter (thin tube) in the bladder through the urethra and injecting water into the bladder to see at what point a person develops bladder contractions and urgency incontinence. This can tell healthcare providers if the incontinence is due to an overactive bladder. 

  • Peak urinary flow rate involves the use of a special device called the uroflowmeter to measure at the volume and speed of urine flow. This test is done in men to find out if incontinence is caused by bladder neck obstruction due to prostate problems. 

  • Cystometrography involves measuring bladder pressure when the bladder is filled with different volumes of water. This test is done if other tests do not reveal the cause of a person’s incontinence. It can be done in combination with electromyography to assess sphincter function. 

Treatment and Management Options: How Do You Fix Incontinence?  

Lifestyle Changes

• Dietary changes and fluid intake: You can achieve better bladder control by cutting back on trigger foods and drinks and limiting how much fluid you drink. Losing weight and getting regular physical activity can help prevent urinary incontinence.

• Scheduled trips to the toilet: Using the toilet on schedule every 2-4 hours can help avoid embarrassing accidents if you have a weak bladder. 

• Bladder training: Delaying urination when you get an urge to urinate can retrain your bladder and help to manage bladder control issues. Start by waiting 10 minutes when you feel the urge to urinate and gradually work your way up to 2-4 hours between trips to the bathroom. 

• Double voiding: Overflow incontinence can be managed by waiting a few minutes after you urinate and then urinating again to completely empty your bladder.

Kegel Exercises or Pelvic Floor Muscle Training

Pelvic floor exercises or Kegel exercises are exercises you can do at home to strengthen your pelvic floor. Strong pelvic floor muscles can help to control urination. A pelvic floor specialist or urogynecologist can teach you how to do Kegel exercises. It involves contracting (tightening) the muscles you use to stop the flow of urine, holding for 5 seconds, and then relaxing for 5 seconds. You can start at 2-3 seconds and work your way up to 10 seconds. Doing these exercises to strengthen your pelvic floor muscles 3 times a day (10 repetitions each) can help to reduce stress incontinence. 

Medications 

Some of the medications used to treat urinary incontinence include:

• Anticholinergics such as tolterodine (Detrol), oxybutynin (Ditropan XL), solifenacin (Vesicare), darifenacin (Enablex), fesoterodine (Toviaz), and trospium chloride for overactive bladder and urge incontinence. 

• Mirabegron (Myrbetriq), a medicine that works by relaxing the bladder muscle, increasing the amount of urine the bladder can hold, and more completely emptying the bladder. 

• Alpha blockers, such as tamsulosin (Flomax), silodosin (Rapaflo), alfuzosin (Uroxatral), and doxazosin (Cardura), for men with urge incontinence or overflow incontinence due to prostate enlargement. 

• Topical estrogen (cream, ring, patch) to support urethral and vaginal tissues in postmenopausal women. 

Other Treatments for Urinary Incontinence

Electrical Nerve Stimulation

Electrical nerve stimulation involves the placement of electrodes (wires) in the rectum or vagina to cause involuntary contractions of the pelvic floor muscles. This gentle electrical nerve stimulation can strengthen the bladder muscles and help with stress and urge incontinence. Several treatments are needed over a period of months.

Medical Devices

Women with urinary incontinence may benefit from devices such as:

• Vaginal pessary (flexible silicone ring inserted in the vagina for all-day use). The ring helps prevent urine leaks by supporting the urethra in women with vaginal prolapse. 

• Urethral insert (a small, disposable, tampon-like device inserted into the urethra). It can be used before high-impact activities to prevent urine leakage. It must be removed before urinating.

Interventional Therapies

• Injections of urethral bulking material: Synthetic bulking agents are injected around the urethra to help keep it closed and reduce urine leakage in men and women with stress incontinence. More than one treatment may be necessary. It is less invasive but also less effective than surgical treatments.

• Botox injections (onabotulinumtoxinA): Botox injections into the bladder muscle are recommended for people with overactive bladder and urge incontinence who have not responded to other treatments. 

• Implantable nerve stimulators: These devices are implanted either under the skin of the buttocks or inserted into the vagina. They provide a gentle electrical current to stimulate the bladder nerves (sacral nerves). They are used to manage overactive bladder and urge incontinence that have not responded to other therapies.

Surgical Interventions  

Your healthcare provider may recommend one of the following surgical procedures to treat incontinence if you continue to have symptoms after conservative treatments: 

• Bladder neck suspension: This surgery is done to support the urethra and bladder neck. It is done through an abdominal incision (cut) using spinal or general anesthesia.

• Sling procedures: This involves placing a synthetic mesh under the urethra to create a supportive sling at the bladder opening. The sling keeps the urethra closed during straining in people with stress incontinence.

• Prolapse surgery: Women with pelvic organ prolapse and mixed incontinence may benefit from a surgical procedure to repair and reposition organs that have moved away from their natural position. 

• Artificial urinary sphincter: This procedure involves the implantation of a small, fluid-filled ring around the bladder neck to act as an artificial sphincter and keep the bladder opening closed until you need to urinate. Before urinating, you need to press a valve implanted under your skin to open the artificial sphincter. 

• Prostate surgery: Men with an enlarged prostate gland may get relief from urinary incontinence symptoms after procedures such as transurethral resection of the prostate (TURP).

Living with Urinary Incontinence  

Home Remedies and Hygiene 

In addition to medical treatments, you can manage your incontinence by:

• Using absorbent pads, protective garments, and drip collectors (in men). 

• Self-catheterization to empty your bladder completely. 

In addition, you should take the following precautions to prevent skin irritation from urine leakage: 

• Clean your genital area with a washcloth and allow it to air-dry.

• Avoid douching or frequent washing. This can increase your risk of bladder infections.

• Ask your healthcare provider about using less-drying cleansing products and barrier creams, such as cocoa butter or petroleum jelly. 

Managing Daily Activities  

If you have urge incontinence and nocturia (frequent urination at night):

• Ensure adequate lighting to prevent falls. 

• Move trip-hazards like rugs or furniture out of the way to the bathroom. 

If you have functional incontinence:

• Use a bedpan or bedside commode.

• Get an elevated toilet seat.

• Clear the path to the bathroom.

Support and Resources  

• National Association for Continence (NAFC)

• The Simon Foundation for Continence

• Urology Care Foundation

• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Can You Live A Normal Life With Incontinence?

Bladder control problems can be embarrassing, but they are manageable. You don’t have to live in shame or avoid doing the things you love because of your bladder control problem. Effective treatments for urinary incontinence can help you live a normal, confident life with incontinence.