Urinary Incontinence – Causes, Symptoms, Diagnosis, Treatment

Urinary incontinence is the involuntary leakage of urine; in simple terms, it means a person urinates when they do not want to. Control over the urinary sphincter is either lost or weakened. Urinary incontinence is a much more common problem than most people realize.

According to the American Urological Association, one-quarter to one-third of men and women in the United States experience urinary incontinence.Urinary incontinence is more common among women than men. An estimated 30 percent of females aged 30-60 are thought to suffer from it, compared to 1.5-5 percent of men.

Types of Urinary Incontinence

 

Urinary incontinence may be caused by alcohol intoxication.

• Stress incontinence – also known as effort incontinence, is due essentially to insufficient strength of the pelvic floor muscles to prevent the passage of urine, especially during activities that increase intra-abdominal pressure, such as coughing, sneezing, or bearing down.
• Urge incontinence  – is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate.
• Overflow incontinence – Sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine. It is as if their bladders were constantly overflowing, hence the general name overflow incontinence.
• Mixed incontinence – is not uncommon in the elderly female population and can sometimes be complicated by urinary retention, which makes it a treatment challenge requiring staged multimodal treatment.
• Structural incontinence – rarely, structural problems can cause incontinence, usually diagnosed in childhood (for example, an ectopic ureter). Fistulas caused by obstetric and gynecologic trauma or injury are commonly known as obstetric fistulas and can lead to incontinence. These types of vaginal fistulas include, most commonly, vesicovaginal fistula and, more rarely, ureterovaginal fistula. These may be difficult to diagnose. The use of standard techniques along with a vaginogram or radiologically viewing the vaginal vault with instillation of contrast media.
• Functional incontinence – occurs when a person recognizes the need to urinate but cannot make it to the bathroom. The loss of urine may be large. There are several causes of functional incontinence including confusion, dementia, poor eyesight, mobility or dexterity, unwillingness to toilet because of depression or anxiety or inebriation due to alcohol.Functional incontinence can also occur in certain circumstances where no biological or medical problem is present. For example, a person may recognise the need to urinate but may be in a situation where there is no toilet nearby or access to a toilet is restricted.
• Nocturnal enuresis – is episodic UI while asleep. It is normal in young children.
• Transient incontinence – is a temporary incontinence most often seen in pregnant women when it subsequently resolves after the birth of the child.
• Giggle incontinence  – is an involuntary response to laughter. It usually affects children.
• Double incontinence -there is also a related condition for defecation known as fecal incontinence. Due to involvement of the same muscle group (levator ani) in bladder and bowel continence, patients with urinary incontinence are more likely to have fecal incontinence in addition. This is sometimes termed “double incontinence”.
• Post-void dribbling – is the phenomenon where urine remaining in the urethra after voiding the bladder slowly leaks out after urination.
• Coital incontinence (CI) – is urinary leakage that occurs during either penetration or orgasm and can occur with a sexual partner or with masturbation. It has been reported to occur in 10% to 24% of sexually active women with pelvic floor disorders.

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Causes of Urinary Incontinence

Urinary incontinence isn’t a disease, it’s a symptom. It can be caused by everyday habits, underlying medical conditions or physical problems. A thorough evaluation by your doctor can help determine what’s behind your incontinence.

Temporary urinary incontinence

Certain drinks, foods and medications may act as diuretics — stimulating your bladder and increasing your volume of urine. They include:

• Alcohol
• Caffeine
• Carbonated drinks and sparkling water
• Artificial sweeteners
• Chocolate
• Chili peppers
• Foods that are high in spice, sugar or acid, especially citrus fruits
• Heart and blood pressure medications, sedatives, and muscle relaxants
• Large doses of vitamin C

Urinary incontinence may also be caused by an easily treatable medical condition, such as:

• Urinary tract infection. Infections can irritate your bladder, causing you to have strong urges to urinate, and sometimes incontinence.
• Constipation. The rectum is located near the bladder and shares many of the same nerves. Hard, compacted stool in your rectum causes these nerves to be overactive and increase urinary frequency.

Persistent urinary incontinence

Urinary incontinence can also be a persistent condition caused by underlying physical problems or changes, including:

• Pregnancy – Hormonal changes and the increased weight of the fetus can lead to stress incontinence.
• Childbirth – Vaginal delivery can weaken muscles needed for bladder control and also damage bladder nerves and supportive tissue, leading to a dropped (prolapsed) pelvic floor. With prolapse, the bladder, uterus, rectum or small intestine can get pushed down from the usual position and protrude into the vagina. Such protrusions can be associated with incontinence.
• Changes with age – Aging of the bladder muscle can decrease the bladder’s capacity to store urine. Also, involuntary bladder contractions become more frequent as you get older.
• Menopause – After menopause women produce less estrogen, a hormone that helps keep the lining of the bladder and urethra healthy. Deterioration of these tissues can aggravate incontinence.
• Hysterectomy – In women, the bladder and uterus are supported by many of the same muscles and ligaments. Any surgery that involves a woman’s reproductive system, including removal of the uterus, may damage the supporting pelvic floor muscles, which can lead to incontinence.
• Enlarged prostate – Especially in older men, incontinence often stems from enlargement of the prostate gland, a condition known as benign prostatic hyperplasia.
• Prostate cancer – In men, stress incontinence or urge incontinence can be associated with untreated prostate cancer. But more often, incontinence is a side effect of treatments for prostate cancer.
• Obstruction – A tumor anywhere along your urinary tract can block the normal flow of urine, leading to overflow incontinence. Urinary stones — hard, stone-like masses that form in the bladder — sometimes cause urine leakage.
• Neurological disorders – Multiple sclerosis, Parkinson’s disease, a stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control, causing urinary incontinence.

The following points regarding the clinical presentation should be sought when obtaining the history

• Severity and quantity of urine lost and frequency of incontinence episodes
• Duration of the complaint and whether problems have been worsening
• Triggering factors or events (eg, cough, sneeze, lifting, bending, feeling of urgency, the sound of running water, sexual activity/orgasm)
• Constant versus intermittent urine loss
• Associated frequency, urgency, dysuria, pain with a full bladder
• History of urinary tract infections (UTIs)
• Concomitant fecal incontinence or pelvic organ prolapse
• Coexistent complicating or exacerbating medical problems
• Obstetrical history, including difficult deliveries, grand multiparity, forceps use, obstetrical lacerations, and large babies
• History of pelvic surgery, especially prior incontinence procedures, hysterectomy, or pelvic floor reconstructive procedures
• Other urologic procedures
• Spinal and central nervous system surgery
• Lifestyle issues, such as smoking, alcohol or caffeine abuse, and occupational and recreational factors causing severe or repetitive increases in intra-abdominal pressure
• Medications

Relevant complicating or exacerbating medical problems may include the following

• Chronic cough
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure
• Diabetes mellitus
• Obesity
• Connective tissue disorders
• Postmenopausal hypoestrogenism
• CNS or spinal cord disorders
• Chronic UTIs
• Urinary tract stones
• Benign prostatic hyperplasia
• Cancer of pelvic organs

Medications that may be associated with urinary incontinence include the following

• Cholinergic or anticholinergic drugs
• Alpha-blockers
• Over-the-counter allergy medications
• Estrogen replacement
• Beta-mimetics
• Sedatives
• Muscle relaxants
• Diuretics
• Angiotensin-converting enzyme (ACE) inhibitors

Risk factors

Factors that increase your risk of developing urinary incontinence include:

• Gender – Women are more likely to have stress incontinence. Pregnancy, childbirth, menopause and normal female anatomy account for this difference. However, men with prostate gland problems are at increased risk of urge and overflow incontinence.
• Age – As you get older, the muscles in your bladder and urethra lose some of their strength. Changes with age reduce how much your bladder can hold and increase the chances of involuntary urine release.
• Being overweight – Extra weight increases pressure on your bladder and surrounding muscles, which weakens them and allows urine to leak out when you cough or sneeze.
• Smoking –Tobacco use may increase your risk of urinary incontinence.
• Family history – If a close family member has urinary incontinence, especially urge incontinence, your risk of developing the condition is higher.
• Other diseases – Neurological disease or diabetes may increase your risk of incontinence.

Symptoms of Urinary Incontinence

The main symptom is the unintentional release (leakage) of urine. When and how this occurs will depend on the type of urinary incontinence.

Stress incontinence

This is the most common kind of urinary incontinence, especially among women who have given birth or gone through the menopause.

In this case, stress refers to physical pressure, rather than mental stress. When the bladder and muscles involved in urinary control are placed under sudden extra pressure, the person may urinate involuntarily.

The following actions may trigger stress incontinence:

• A sudden cough
• Sneezing
• Laughing
• Heavy lifting
• Exercise

Urge incontinence (effort incontinence)

Also known as reflex incontinence or “overactive bladder,” this is the second most common type of urinary incontinence. There is a sudden, involuntary contraction of the muscular wall of the bladder that causes an urge to urinate that cannot be stopped.

When the urge to urinate comes, the person has a very short time before the urine is released, regardless of what they try to do. The urge to urinate may be caused by:

• A sudden change in position
• The sound of running water (for some people)
• Sex (especially during orgasm)

Bladder muscles can activate involuntarily because of damage to the nerves of the bladder, the nervous system, or to the muscles themselves.

Overflow incontinence

This is more common in men with prostate gland problems, a damaged bladder, or a blocked urethra. An enlarged prostate gland can obstruct the bladder.

The bladder cannot hold as much urine as the body is making and/or the bladder cannot empty completely, causing small amounts of urinary leakage. Often, patients will need to urinate frequently, and they may experience “dribbling” or a constant dripping of urine from the urethra.

Mixed incontinence

This is where a patient experiences both stress and urge incontinence at the same time.

Functional incontinence

With functional incontinence, the person knows there is a need to urinate, but cannot make it to the bathroom in time due to a mobility problem.

Common causes of functional incontinence include:

• Confusion
• Dementia
• Poor eyesight
• Poor mobility
• Poor dexterity (cannot unbutton pants in time)
• Depression, anxiety, or anger (unwilling to go to the toilet)

Functional incontinence is more prevalent among elderly people and is common in nursing homes.

Gross total incontinence

This either means that the person leaks urine continuously, or has periodic uncontrollable leaking of large amounts of urine.

The patient may have a congenital problem (born with a defect), there may be an injury to the spinal cord or urinary system, or there may be a hole (fistula) between the bladder and, for example, the vagina.

Diagnosis

A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Other important points include straining and discomfort, use of drugs, recent surgery, and illness. The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.

A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.

Other tests include:

• A bladder diary – the doctor may ask the patient to record how much they drink, when urination occurs, how much urine is produced, and the number of episodes of incontinence.
• Physical exam – the doctor may examine the vagina and check the strength of her pelvic floor muscles. If the patient is male, the doctor may examine his rectum to determine whether the prostate gland is enlarged.

• Stress test – the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
• Urinalysis – urine is tested for evidence of infection, urinary stones, or other contributing causes.
• Blood tests – blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
• Ultrasound – sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
• Cystoscopy – a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
• Urodynamic testing – determines how much pressure the bladder and urinary sphincter muscle can withstand.
• Cystogram – X-ray procedure to visualize the bladder.
• Cystoscopy – a cystoscope (a thin tube with a lens at the end) is inserted into the urethra. The doctor can view abnormalities in the urinary tract.

Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced.

Treatment

Your physician may suggest one or more options to treat an overactive bladder:

• Bladder training, or urinating according to a timetable (instead of according to urge)
• Kegel exercises to strengthen pelvic muscles
• Dietary changes to avoid foods that trigger your symptoms
• Medications, including hormone replacement therapy and anticholinergics (which prevent bladder spasms)
• A pessary, a ring inserted into the vagina that helps support the bladder and uterus
• Sacral nerve stimulation therapy, an electrical device to stimulate nerves, affecting signals to the bladder
• Acupuncture, yoga and other alternative treatments

Medical devices for treatment

The following medical devices are designed for females.

• Urethral inserts – the woman inserts the device before activity and takes it out when she wants to urinate.
• Pessary – a rigid ring inserted into the vagina. It is worn all day. The device helps hold the bladder up and prevent leakage.
• Radiofrequency therapy – tissue in the lower urinary tract is heated. When it heals it is usually firmer, often resulting in better urinary control.
• Botox (botulinum toxin type A) – injected into the bladder muscle, to help those with an overactive bladder.
• Bulking agents – injected into tissue around the urethra, to help keep it closed.

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• This is a non-surgical, low-risk treatment to consider if Kegel exercises and medication have failed to relieve urinary symptoms. PTNS works by indirectly providing electrical stimulation to the nerves responsible for bladder and pelvic floor function. During this office procedure, the patient’s foot will be elevated and supported, and a slim needle electrode will be placed near the tibial nerve at the ankle.
• A device is then connected to the electrode that sends mild electrical pulses to the tibial nerve. These impulses then travel to the group of nerves at the base of the spine—the sacral nerve plexus—that are responsible for bladder function.

Promo block

• This treatment stimulates the nerves through gentle electrical impulses, and this can lead to gradual changes in bladder activity over time.
• Typically, patients will undergo a series of 12 weekly, half-hour sessions. Improvements with PTNS are typically noted five to six weeks later. Studies have reported that upwards of 80 percent of patients benefit from the procedure.

Sacral neuromodulation

• InterStim therapy is a proven neuromodulation therapy that targets the communication problem between the brain and the nerves that control the bladder.
• Bladder function is regulated by a group of nerves at the base of the spine called the sacral nerve plexus. When those nerves are stimulated through gentle electrical impulses similar to that in a heart pacemaker, bladder overactivity can be calmed or eliminated.
• The implantation of the InterStim device sends continuous impulses to the sacral nerve plexus, which inhibits urgency and spontaneous uncontrolled bladder activity.

Autonomic dysreflexia

• Autonomic dysreflexia associated with intradetrusor injections of BOTOX^® could occur in patients treated for detrusor overactivity associated with a neurologic condition and may require prompt medical therapy. In clinical trials, the incidence of autonomic dysreflexia was greater in patients treated.

Antimuscarinic (antispasmodic) medications 

These medications reduce the number of involuntary bladder contractions by preventing spasm of the detrusor muscle that causes them and increase bladder capacity. In general, these medications can reduce leakage of urine caused by OAB by 60% to 75%. Examples of antimuscarinic medications include:

• darifenacin
• oxybutynin
• solifenacin
• tolterodine
• trospium

The most common side effects of antimuscarinic medications are dry mouth, dry eyes, increased pressure inside the eye, and constipation. Be sure to tell your doctor about all of the medications you are taking and all of your medical conditions, as there are some people who should not take antimuscarinic medications. These side effects can be minimized bv starting with a low dose of medication and gradually increasing the dose.

Beta3-agonist

• This is a new type of medication for the treatment of OAB. It helps relax the detrusor muscle (in the bladder wall) to prevent unwanted spasms that may cause symptoms of OAB. Currently, there is only one drug in this category called “mirabegron”. An uncommon side effect of mirabegron is an increase in blood pressure. Be sure to tell your doctor about all of the medications you are taking and all of your medical conditions, as there are some people who should not take this medication.

Other Medications

• Medications are known as tricyclic antidepressants (e.g., amitriptyline, imipramine) and calcium channel blockers (e.g., nifedipine, diltiazem) have been used with mixed results in the treatment of OAB. They may be prescribed for urinary incontinence, but this is an “off-label” or unapproved use and is not recommended.

The Complete Nighttime Guide to an Overactive Bladder

Physiotherapy

Pelvic floor muscle exercise

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References