Urinary incontinence is the inability to hold urine even till reaching the toilet. 1 in 10 women experience urinary incontinence. It is often temporary, and it always results from an underlying medical condition.
(In this fact sheet, the term "incontinence" will be used to mean urinary incontinence.)
Women experience incontinence twice as often as men. Pregnancy and childbirth, menopause, and the structure of the female urinary tract account for this difference. But, both women and men can become incontinent from neurologic injury, birth defects, strokes, multiple sclerosis, and physical problems associated with aging.
Older women experience incontinence more often than younger women. But, incontinence is not inevitable with age. Incontinence is treatable and often curable at all ages. If you experience incontinence, you may feel embarrassed. It may help you to remember that loss of bladder control can be treated. You will need to overcome your embarrassment and see a doctor to learn if you need treatment for an underlying medical condition.
Incontinence in women usually occurs because of problems with muscles that help to hold or release urine. The body stores urinein the bladder, which is a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.
During urination, muscles of the bladder wall contract and force urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax and let urine pass out of the body (see figure 1). Incontinence occurs if the bladder muscles contract suddenly or when the muscles surrounding the urethra relax suddenly.
Stress Incontinence
If coughing, laughing, sneezing, or other movements that put pressure on the bladder cause you to leak urine, you may have Stress Incontinence. Physical changes resulting from pregnancy, childbirth and menopause often cause stress incontinence. It is the most common form of incontinence in women and is treatable.
Pelvic floor muscles support the bladder. If these muscles weaken, the bladder can move downwards, pushing slightly out of the bottom of the pelvis towards the vagina. This prevents muscles that ordinarily force the urethra shut from squeezing as tightly as they should. As a result, urine can leak into the urethra during moments of physical stress. Stress incontinence can also occur if the muscles that do the squeezing weaken.
Stress incontinence can worsen during the week before your menstrual period. At that time, lowered estrogen levels might lead to lower muscular pressure around the urethra, thereby increasing the chances of leakage. The incidence of stress incontinence increases after menopause.
Types of Urinary Incontinence
- Stress
Leakage of small amounts of urine during physical movement (coughing, sneezing, exercising).
- Urge
Leakage of large amounts of urine at unexpected times, including sleep.
- Functional
Untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching the toilet.
- Mixed
Unexpected leakage of small amounts of urine because of a full bladder.
- Overflow
Usually the occurrence of stress and urge incontinence together.
- Transient
Leakage that occurs temporarily because of a condition that will pass (infection, medication).
How is incontinence evaluated?
The first step towards relief is to see a doctor who is well acquainted with incontinence to learn what type you have. A urologist specializes in the urinary tract, and some urologists further specialize in the female urinary tract. Gynecologists and obstetricians specialize in the female reproductive tract and childbirth. A urogynecologist focuses on urological problems in women. Family practitioners and internists see patients for all kinds of complaints. Any of these doctors may be able to help you.
To diagnose the problem, your doctor will first ask about symptoms and medical history. Your pattern of voiding and urine leakage may suggest the type of incontinence. Other obvious factors that can help define the problem include straining and discomfort, use of drugs, recent surgery, and illness. If your medical history does not define the problem, it will at least suggest which tests are needed.
Your doctor will physically examine you 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 an evidence of a nerve-related cause.
Your doctor will measure your bladder capacity and residual urine for evidence of poor functioning of the bladder muscles. To do this, you will have to drink plenty of fluids and urinate into a measuring pan, after which the doctor will measure the urine still remaining in the bladder. Your doctor may also recommend:
- Stress test- You relax, then cough 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 examined for substances related to causes of incontinence
- Ultrasound- Sound waves are used to "see" 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.
- Urodynamics- Various techniques measure pressure in the bladder and the flow of urine.
Your doctor may ask you to keep a diary for a day or more, up to a week, to record when you void. This diary should note the times you urinate and the amounts of urine you produce. To measure your urine, you can use a special pan that fits over the toilet rim.
How is incontinence treated?
Exercises
Kegel exercises to strengthen or retrain pelvic floor muscles and sphincter muscles can reduce or cure stress leakage. Women of all ages can learn and practice these exercises, which are taught by a health care professional.
Most Kegel exercises do not require equipment. However, one technique involves the use of weighted cones. For this exercise, you stand and hold a cone-shaped object within your vagina. You then substitute cones of increasing weight to strengthen the muscles that help keep the urethra closed.
Electrical Stimulation
Brief doses of electrical stimulation can strengthen muscles in the lower pelvis in a way similar to exercising the muscles. Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles. This will stabilize overactive muscles and stimulate contraction of urethral muscles. Electrical stimulation can be used to reduce both stress incontinence and urge incontinence.
Biofeedback
Biofeedback uses measuring devices to help you become aware of your body's functioning. By using electronic devices or diaries to track when your bladder and urethral muscles contract, you can gain control over these muscles. Biofeedback can be used along with pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.
Timed Voiding or Bladder Training
Timed voiding (urinating) and bladder training are the techniques that use biofeedback. In timed voiding, you fill a chart of voiding and leaking. From the patterns that appear in your chart, you can plan to empty your bladder before you would otherwise leak. Biofeedback and muscle conditioning(known as bladder training)can alter the bladder's schedule for storing and emptying urine. These techniques are effective for urge and overflow incontinence.
Medications
Medications can reduce many types of leakage. Some drugs inhibit contractions of an overactive bladder. Others relax muscles, leading to more complete bladder emptying during urination. Some drugs tighten muscles at the bladder neck and urethra, preventing leakage. And some, especially hormones such as estrogen, are believed to cause muscles involved in urination to function normally.
Some of these medications can produce harmful side effects if used for long periods. In particular, estrogen therapy has been associated with an increased risk for cancer of the breast and endometrium (lining of the uterus). Talk to your doctor about the risks and benefits of long-term use of such medications.
Pessaries
A pessary is a stiff ring that is inserted by a doctor or nurse into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less stress leakage. If you use a pessary, you should watch for possible vaginal and urinary tract infections and see your doctor regularly.
Implants
Implants are substances injected into tissues around the urethra. The implant adds bulk and helps to close the urethra to reduce stress incontinence. Collagen (a fibrous natural tissue from cows) and fat from the patient's body are used. Implants can be injected by a doctor in about half an hour using local anaesthesia.
Implants have a partial success rate. Injections must be repeated after a time because the body slowly eliminates these substances. Before you receive collagen, a doctor must perform a skin test to determine whether you have an allergic reaction to the material or not.
Surgery
Doctors usually suggest surgery to reduce incontinence only after other treatments have been tried. Many surgical options have high rates of success.
Most stress incontinence results due to dropping down of the bladder towards the vagina. Therefore, common surgery for stress incontinence involves pulling the bladder up to a more normal position. Working through an incision in the vagina or abdomen, the surgeon raises the bladder and secures it with a string attached to muscle, ligament or bone.
For severe cases of stress incontinence, the surgeon may secure the bladder with a wide sling. This not only holds up the bladder, but also compresses the bottom of the bladder and the top of the urethra, further preventing leakage.
In rare cases, a surgeon implants an artificial sphincter, a doughnut-shaped sac that circles the urethra. A fluid fills and expands the sac, which squeezes and closes the urethra. By pressing a valve implanted under the skin, you can cause the artificial sphincter to deflate. This removes pressure from the urethra, allowing urine from the bladder to pass.
Catheterization
If you are incontinent because your bladder never empties completely (overflow incontinence) or your bladder cannot empty because of poor muscle tone, past surgery, or spinal cord injury, you might use a catheter to empty your bladder. A catheter is a tube that you can learn to insert through the urethra into the bladder to drain urine. Catheters may be used once in a while or on a constant basis, in which case the tube connects to a bag that you can attach to your leg. If you use a long-term (or indwelling) catheter, you should watch for possible urinary tract infections
Other Procedures
Many women manage urinary incontinence with pads that catch slight leakage during activities such as exercising. Also, you often can reduce incontinence by restricting certain liquids, such as coffee, tea, and alcohol.
Many women, especially elderly women in nursing homes, who can be treated, resort to wearing absorbent undergarments or diapers.. This is unfortunate because diapering can lead to diminished self-esteem as well as skin irritation and sores. If you are an elderly woman, you and your family should discuss with your doctor the possible effectiveness of treatments such as timed voiding, pelvic muscle exercises, and electrical stimulation before resorting to absorbent pads or undergarments.
