What is incontinence?
Incontinence is a widespread condition that ranges in severity from ‘just a small leak’ to complete loss of bladder or bowel control. In fact, over 4.8 million Australians have bladder or bowel control problems for a variety of reasons. Incontinence can be treated and managed. In many cases it can also be cured.
If you’re leaking urine when you cough, laugh or sneeze, or you have sudden urges to go to the bathroom that are so intense you fear you won’t get there in time, you’re probably experiencing incontinence. The inability to control urination is frequently a treatable, and often curable, problem faced by millions of Americans, many of them women.
While at least half the elderly experience the condition, and it is a major cause of admission to nursing homes, it is often mistakenly thought of as a problem suffered only by older people. In fact, incontinence can occur at any age.
Although the majority of incontinence cases can be improved or cured, many of those afflicted never discuss their problem with a health care professional. Instead of recognizing incontinence as a treatable condition and pursuing treatment, many women view it as an embarrassing consequence of aging. They may wear absorbent products and do not seek treatment. Health care professionals may recommend using absorbent products during treatment or as part of treatment, but rarely as the only treatment for incontinence.
Left untreated, incontinence can lead to skin rashes and infections, loss of self-esteem, emotional distress and self-imposed isolation. You don’t have to suffer incontinence in silence, as there are several treatment options from which you and your health care professional can choose.
Incontinence is not a disease—it’s a symptom that can be caused by a wide range of conditions, such as weak pelvic floor muscles from prior childbirth or an overactive bladder muscle from aging. Less frequently, diabetes, stroke and nerve diseases, likemultiple sclerosis, may also cause leakage. Your urinary tract includes two kidneys, two ureters, the bladder and the urethra. Your kidneys remove waste and water from your blood to produce urine. Urine travels through muscular tubes called the ureters to the bladder. The bladder is a balloon-like organ composed of muscle, connective tissue and nerves that expands as it fills with urine. Urine is stored in the bladder until it is released from the body through a tube called the urethra.
Circular muscles, called the urinary sphincters, control the activity of the urethra. The sphincter muscles prevent the loss of urine. The sphincters close off the base of the bladder—like a rubber band at the base of a balloon—so you do not leak urine.
As the bladder fills with urine, you have an increasing urge to urinate. Sensory nerves in the bladder signal your brain when the bladder is full. Just before you urinate, the sphincter first relaxes and then, in reflex fashion the bladder muscle contracts, squeezing urine out through the urethra. When you stop urinating, the bladder muscle relaxes, and the sphincters contract.
Incontinence can worsen because of aging, illness or injury. A urinary tract infection, vaginal infection or irritation and constipation may result in temporary bouts of incontinence that are alleviated by treating the primary ailment. Additionally, some medications can cause incontinence, and changing or discontinuing a drug may bring relief. Women who are pregnant may also suffer from temporary bladder control problems, which are caused by hormonal changes and pressure exerted on the urinary tract by the growing fetus.
Most incontinence in women is triggered by problems with the bladder and sphincter muscles, which can weaken with age. A bladder muscle that is too active, weak pelvic muscles resulting from pregnancy and childbirth, hormonal imbalances in menopausal women, nerve disorders and immobility also can contribute to incontinence. Although these bladder control problems tend to be long-term, many women who seek treatment see an improvement or are cured.
To help you better understand your incontinence and better explain it to your health care professional, it’s helpful to recognize what kind of incontinence you may have. Health care professionals classify incontinence by the symptoms displayed or the circumstances occurring at the time urine is involuntarily released. The following are types of urinary incontinence:
Urinary incontinence
Urinary incontinence (or poor bladder control) is a common condition, that is commonly associated with pregnancy, childbirth, menopause or a range of chronic conditions such as asthma, diabetes or arthritis.
Poor bladder control can range from the occasional leak when you laugh, cough or exercise to the complete inability to control your bladder, which may cause you to completely wet yourself. Other symptoms you may experience include the constant need to urgently or frequently visit the toilet, associated with ‘accidents’.
There are different types of incontinence with a number of possible causes. The following are the most common:
- stress incontinence
- urge incontinence
- incontinence associated with chronic retention, and
- functional incontinence.
Urinary incontinence can be caused by many things, but can be treated, better managed and in many cases cured. For this reason, it is important to talk to your doctor or a continence advisor about your symptoms, in order to get on top of them.
Some different types of urinary incontinence:
- Stress incontinence is the most common form of incontinence in women. This occurs when any kind of pressure is put on the bladder, such as during sneezing, laughing, lifting, running, coughing, exercising, walking or even rising from a chair. Childbirth and weight gain are two common causes of incontinence because these conditions stretch the pelvic floor muscles. The pelvic floor muscles support the bladder, and when they are stretched, the neck of the bladder, or the place where the bladder and the urethra meet, drops and pushes against the vagina wall, preventing the sphincter muscles that force the urethra shut from tightening as well as they should. The result is urine leaks during physical stress. Stress incontinence also can occur when the sphincter muscles themselves weaken. Additionally, decreased estrogen levels may cause the lining of the urethra to thin, reducing bladder support.
- Urge incontinence is characterized by urgent needs to urinate, followed by sudden urine leakage. Occasionally, some women have no warning or urge sensation. You also may leak urine when you drink small amounts of liquid, or when you hear or touch running water. You may go to the bathroom as often as every two hours, and you may wet the bed at night or wake multiple times during the night to urinate. Involuntary bladder contractions are the most common cause of urge incontinenceand are described by health care professionals as “overactive,” “unstable” or “spastic” bladder. It is often difficult to assign a direct cause to the involuntary bladder muscle contractions. In rare instances, these can be caused by damage to the bladder muscle or nerves, or to the body’s nervous system, including the spinal cord and brain. Such damage may be caused by diseases such as multiple sclerosis, Parkinson’s, Alzheimer’s, stroke, brain tumors or injuries, including those that can occur in surgery, but in many cases the cause may not be known.
- Overflow incontinence occurs when your bladder remains full and leaks urine. You may feel as though you need to empty your bladder but cannot. Or you may urinate a small amount, but feel like your bladder is still full. Frequent or constant dribbling of urine also is a sign of this type of incontinence, which is rare in women. A damaged bladder or a blocked urethra can cause an inability to empty the bladder. Diabetes and other diseases can cause nerve damage that weakens the bladder muscle. Urinary stones or tumors also can block the urethra, which can force urine to remain in the bladder and even back up the urinary tract.
- Functional incontinence is untimely urination because of physical disability, external obstacles or problems in thinking or communicating that prevent a person from reaching a toilet. This may occur with severe arthritis, after joint replacement or with dementia such as seen in Alzheimer’s disease.
- Mixed incontinence is a combination of types of incontinence, usually stress and urge. In some studies, mixed incontinence is the predominant form of incontinence.
- OAB Incontinence — is the medical term denoting a group of symptoms resulting from involuntary bladder spasm that includes frequency of urination especially at night and urgency with or without involuntary leakage.
Some therapies for urinary incontinence:
- Kegel exercises or pelvic floor muscle training — Regular daily exercises of the pelvic floor muscles .May be done with or without Biofeedback equipment and electrical stimulation, which help identify the right muscles to contract.
- Bladder training — Teaches people to resist the urge to urinate and to gradually expand the interval between urinating.
- Diet — Helps people by avoiding foods and/or fluids which can irritate the bladder, like caffeine and excessive alcohol.
- Medications — One type can calm bladder spasms.
- Hormone replacement — Estrogen treatments to assist in improving stress incontinence in post-menopausal women
- Injections — These involve injections of a substance into the urinary passage (urethra) to improve its strength and resistance.
- Surgery — The most frequently performed one is a repositioning the neck of the bladder. There is also an artificial sphincter implant, which can be helpful for men who have incontinence after prostate cancer surgery. Sacral nerve stimulation device, an option for some adults, involves a device which can be implanted in the body to help stimulate nerves in the pelvis and improve bladder function.
Faecal incontinence
People with poor bowel control or faecal incontinence have difficulty controlling their bowels. This may mean you pass faeces or stools at the wrong time or in the wrong place. You may also find you pass wind when you don’t mean to or experience staining of your underwear.
About one in 20 people experience poor bowel control. It is more common as you get older, but a lot of young people also have poor bowel control. Many people with poor bowel control also have poor bladder control (wetting themselves).
Faecal incontinence can have a number of possible causes. The following are the most common:
- weak back passage muscles due to having babies, getting older, some types of surgery or radiation therapy
- constipation, or
- severe diarrhoea.
What is inflammatory bowel disease (IBD)?
Inflammatory bowel disease (IBD) is a medical term that describes a group of conditions in which the intestines become inflamed (red and swollen). Two major types of IBD are Crohn’s disease and ulcerative colitis. Ulcerative colitis affects the large intestine (colon) whereas Crohn’s disease can occur in any part of the intestines.
For more information please visit Crohn’s and Colitis Australia who provide support and information for people suffering from IBD.
Diagnosis
To diagnose the cause of your incontinence, your health care professional will first ask questions about your urinary habits and medical history. You should receive a thorough physical examination, including a pelvic exam, in which your health care professional will look for medical conditions that may be causing leakage, such as infections, tumors or impacted stool.
Constipation, or infrequent bowel movements that pass small amounts of hard, dry stool, can cause the stool to pack the intestine and rectum so tightly that the normal pushing action of the colon cannot move and discharge the stool. This condition, known as impacted stool or fecal impaction, occurs most often in the elderly or nursing home populations. It can produce urinary incontinence as the packed intestine and rectum swells and presses against the urinary tract, blocking flow of urine. Loosening and removing the impacted stool, usually by taking softening medication and having a health care professional break up and extract the stool with a finger inserted in the anus, relieves the urinary incontinence. Constipation should be avoided in any woman seeking to improve continence.
You may be asked to keep a diary of your urinary patterns for at least three days and up to a week. In the bladder diary, you record what, when and how much liquid you drink; how many times you urinate and how much; how many leaks you have; whether you felt an urgency to urinate; and what you were doing at the time you experienced a leak.
Your health care professional may also perform some tests, depending on the type and suspected causes of your incontinence, including:
- Urinalysis, in which you will provide a sample of your urine that will be analyzed for the evidence of blood, infection, urinary stones and other abnormalities that can cause leakage.
- Cough stress test, in which you first relax and then cough while your health care professional looks for urine leakage. This test checks for stress incontinence and may be performed either lying down or an upright position.
- Post-void residual (PVR) measurement test that is performed to see how much urine remains in your bladder after urination. In this test, you drink fluids and urinate into a measuring pan. Then, your health care professional drains the remaining urine in your bladder for measurement by inserting a small, pliable tube, called a catheter, through the urethra into the bladder. Alternatively, your health care professional measures the urine remaining in the bladder by using bladder ultrasound, in which a machine directs sound waves at the bladder and produces shadowy images from which the amount of urine in the bladder can be determined. Your health care professional can explain what your PVR readings mean.
- Blood tests to check levels of substances in the blood that might be related to disorders or diseases that may cause incontinence.
If the results of the basic evaluation and initial tests fail to point to a definitive diagnosis, your health care professional may refer you to a specialist, such as a urologist, who treats urinary tract disorders, or a urogynecologist, who treats urinary tract problems in women. Your health care professional also may recommend the following additional tests:
- Urodynamic testing assesses bladder and sphincter function, including the pressure and volume of urine in the bladder and the pressure and flow of urine from the bladder through the urethra. One test, called cystometry, measures contractions of the bladder muscle as it fills and empties by inserting a catheter through the urethra into the bladder and filling it with water. As part of the test, another tiny tube is inserted into the rectum or vagina to measure pressure on your bladder when you cough or exert pressure. Urodynamic testing also may include imaging, such as X-rays or ultrasound, to examine changes in the position of the bladder and urethra during urination, coughing or straining.
- Cystoscopy, a test that uses a tiny telescope-like instrument that allows your health care professional to see inside the bladder and urinary tract and examine them for problems. You may be given some local numbing jelly and medication to relax you before the test, which involves inserting a thin tube that contains a miniature camera through the urethra and into the bladder.
Your health care professional may also perform additional tests to rule out pelvic weakness as the cause of your incontinence, including one called the Q-tip test. The Q-tip test measures the difference in the angle of the urethra when it is at rest versus when it is straining. If the angle changes more than 30 degrees, there is most likely significant weakness in the pelvic floor muscles.
Be sure to discuss with your health care professional which tests are best for you, the exact procedures that will be followed when they are conducted and what the results mean in assessing your bladder control problem and developing an appropriate course of treatment.
Symptoms
Many people experience occasional, minor leaks of urine. Others may lose small to moderate amounts of urine more frequently.
Types of urinary incontinence include:
- Stress incontinence. Urine leaks when you exert pressure on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy.
- Urge incontinence. You have a sudden, intense urge to urinate followed by an involuntary loss of urine. You may need to urinate often, including throughout the night. Urge incontinence may be caused by a minor condition, such as infection, or a more-severe condition such as a neurologic disorder or diabetes.
- Overflow incontinence. You experience frequent or constant dribbling of urine due to a bladder that doesn’t empty completely.
- Functional incontinence. A physical or mental impairment keeps you from making it to the toilet in time. For example, if you have severe arthritis, you may not be able to unbutton your pants quickly enough.
- Mixed incontinence. You experience more than one type of urinary incontinence.
Causes
Female urinary system/ Male urinary system
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.
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.
Complications
Complications of chronic urinary incontinence include:
- Skin problems. Rashes, skin infections and sores can develop from constantly wet skin.
- Urinary tract infections. Incontinence increases your risk of repeated urinary tract infections.
- Impacts on your personal life. Urinary incontinence can affect your social, work and personal relationships
Think you might have a problem?
If you experience bladder or bowel problems, but are not sure if you should seek help, try the questionnaire below.
Bladder and bowel questionnaire
- Do you sometimes feel you have not completely emptied your bladder?
- Do you have to rush to use the toilet?
- Are you frequently nervous because you think you might lose control of your bladder or bowel?
- Do you wake up twice or more during the night to go to the toilet?
- Do you sometimes leak before you get to the toilet?
- Do you sometimes leak when you lift something heavy, sneeze, cough or laugh?
- Do you sometimes leak when you exercise or play sport?
- Do you sometimes leak when you change from a seated or lying position to a standing position?
- Do you strain to empty to bowel?
- Do you sometimes soil your underwear?
- Do you plan your daily routine around where the nearest toilet is?
Treatment
The majority of incontinence conditions can be improved or cured with treatment, once the condition is brought to the attention of a health care professional and accurately diagnosed. Many women are too ashamed or embarrassed to discuss their incontinence condition with their health care team or think that treatment isn’t available. In fact, a variety of treatment options are available for incontinence conditions, depending on which type of incontinence is diagnosed: stress incontinence, urge incontinence, overflow incontinence or mixed incontinence.
Incontinence is not a disease, though it can be a symptom of an underlying condition, such as diabetes. However, most incontinence in women is triggered by problems with the bladder and sphincter muscles, which can weaken with age and from childbirth.
Treatment options include:
- behavioral techniques
- pelvic muscle exercises
- medications
- Botox
- medical devices that block or capture urine
- electrical stimulation
- surgery
Your health care professional can teach you ways to control your bladder and sphincter muscles. Behavioral techniques generally are tried first because once you learn them, you usually can do them yourself at home; they have no side effects; and they don’t preclude other treatment options. Types of behavioral techniques are:
- Pelvic muscle exercises, such as Kegel exercises, strengthen the muscular components of the urethral closing mechanism and are often used in stress incontinence therapy. Kegel exercises involve squeezing the muscles, holding the squeeze for a few seconds, then relaxing, and repeating the process. The basic recommended regimen is to do three sets of eight to 12 contractions, holding each contraction for eight to 10 seconds, performed at least three to four times a week (preferably every day) for 15 to 20 weeks. The keys to success with pelvic muscle exercises are accuracy (making sure you exercise the correct muscles) and compliance (sticking with the exercise program). Your health care professional can help you learn to identify the muscles. Sometimes biofeedback and electrical stimulation are used to improve exercise results.
- Biofeedback is a training technique that teaches you how to control physical responses, such as breathing, muscle tension, heart rate and blood pressure that are not normally controlled voluntarily. Biofeedback techniques may help you to gain control over your bladder and pelvic muscles and to strengthen the sphincter muscle. A monitoring device is placed on the muscles that let you know when you have contracted them, and how strong the contraction was. In one study of 222 women with urge incontinence, behavioral training combined with biofeedback led to a 63 percent reduction in incontinence. Over the years, mainstream health care professionals and insurers have increasingly accepted biofeedback techniques.
- Electrical stimulation stimulation involves using brief doses of electrical stimulation to strengthen muscles in the lower pelvis in a way similar to exercising the muscles. It may include use of devices such as a radiofrequency treatment (Renessa) or pelvic floor biofeedback. Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles. This procedure will stabilize overactive muscles and stimulate contraction of urethral muscles. Electrical stimulation can be used to reduce both stress incontinence and urge incontinence, though it is rarely used for primary stress incontinence. Some insurers may not pay for this procedure, so be sure to check on your coverage.
- Bladder training is is used to treat urge incontinence, but may also be used for other types of incontinence. Your health care provider teaches different ways to control the urge to urinate, such as through distraction (thinking about things other than having to go to the bathroom), taking a deep breath, contracting the pelvic muscles, or visualizing the urge as a wave that rises and falls. You also follow a urination schedule that gradually lengthens the time between bathroom visits.
Several medications can be used to treat incontinence and are sometimes used in conjunction with behavioral techniques. Because many drugs can have side effects, can interact with other medications, or should not be used by people with certain medical conditions, only you and your health care professional can determine which medications are right for you.
Some of the medications are drugs that block production and use of a chemical that prompts bladder contractions. These medications are often used to treat urge incontinence, but they should not be taken by if you have urinary retention, certain types of stomach problems, or narrow-angle glaucoma. Here are some of the most common drugs for overactive bladder/urge incontinence.
- Oxybutynin blocks bladder muscle contractions and is recommended for treatment of urge incontinence. Oxybutynin is available in tablets (Ditropan), extended-release tablets (Ditropan XL), patch (Oxytrol) and gel form (Gelnique). The patch form recently was approved as the first over-the-counter treatment for overactive bladder in women (Oxytrol for Women). It became available OTC in fall 2013 for women but will remain available by prescription only for men. The patch is applied every four days. The prescription gel is applied daily. Common side effects of oxybutynin include mouth, nose and throat dryness; headache; constipation; nausea; dizziness and blurred vision. The patch and gel may also cause skin irritation.
- Tolterodine tablets (Detrol) is a drug for overactive bladder. Side effects include cause dry mouth, headaches, constipation, blurring of near vision, dizziness, upset stomach and abdominal pain.
- Trospium (Sanctura). This drug is approved for the treatment of overactive bladder. Side effects include dry mouth and constipation.
- Solifenacin (Vesicare) and darifenacin (Enablex). These drugs are also approved for the treatment of overactive bladder. Side effects include constipation and dry mouth.
- Imipramine (Tofranil). This is an antidepressant drug that may occasionally be prescribed together with other medications to treat incontinence. It works by causing the bladder muscle to relax while simultaneously causing the smooth muscles at the neck of the bladder to contract. Side effects include blurred vision, dizziness, dry mouth, fatigue, insomnia and nausea.
- Fesoterodine (Toviaz). This tablet is approved to treat overactive bladder with symptoms of urinary frequency, incontinence and urgency. It works by reducing spasms of the bladder muscles. Side effects may include allergic reactions, blurred vision, dizziness, constipation, upset stomach, insomnia and dry mouth, eyes or throat.
- Mirabegron (Myrbetriq). Mirabegron is the first beta-3 adrenergic agonist to be approved by the U.S. Food and Drug Administration (FDA) for incontinence caused by overactive bladder (OAB). It is a once-a-day pill that works by relaxing the bladder’s detrusor muscle to regulate the filling and storage of urine. This increases bladder capacity and helps control the frequent urge to urinate, as well as urine leakage. Mirabegron can cause some side effects, including headache, high blood pressure, urinary infection and upper respiratory infection.
If you have mild to moderate stress incontinence, your health care professional may prescribe one or more of the following medications, however, no drugs have been proven effective for treating stress incontinence:
- Anticholinergic drugs which may assist with mixed incontinence, such as oxybutynin (Ditropan, Oxytrol), tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura) or solifenacin (Vesicare)
- Alpha-adrenergic agonist drugs, such as phenylpropanolamine and pseudoephedrine, which can strengthen the sphincter and work to improve symptoms in many people. These drugs are rarely prescribed, however, because of their potential side effects on the heart.
- The tricyclic antidepressant imipramine (Imipramil, Tofranil), which works similarly to alpha-adrenergic drugs.
Absorbent products may be used while treatments are under way or as part of a treatment plan, in combination with behavioral training, exercises, medications or other treatment options.
Surgery
Surgical procedures also may help women with stress incontinence when less invasive therapies do not improve symptoms. Surgery is a serious step that needs to be discussed with your health care professional so you clearly understand all the risks, as well as the chances that the surgery will relieve your urine control and urinary tract support problems. Although the procedures do have high success rates, complications can occur, including recurrence of incontinence.
The most popular procedure in the United States and Europe today involves a mid-urethral polypropylene sling. A surgeon uses the synthetic material to make a sling that compresses the bottom of the bladder and the top of the urethra, preventing urine leaks. Alternatively, the surgeon may use a piece of pelvic connective tissue to create a sling.
Surgery may also involve bladder neck suspension. Done through an abdominal incision using general or spinal anesthesia, this surgical procedure provides support to the urethra and bladder neck, an area of thickened muscle where the bladder and urethra connect.
There are many additional surgical procedures for stress incontinence in women, and new techniques continue to emerge. Some techniques use several small incisions for insertion of instruments and a laparoscope, a telescope that lets the surgeon see inside the abdomen and perform the procedure to raise the bladder or bladder neck or to remove urinary obstructions. Recovery from laparoscopic procedures may be faster and less painful than from open abdominal surgery, but as with any surgery, there are risks.
In very rare instances of complex stress incontinence, an artificial sphincter may be surgically implanted. A hollow, ring-shaped device that encircles the urethra is placed and filled with fluid that squeezes the urethra shut. A valve is implanted under the skin that, when pressed, deflates the device, permitting urination. This procedure is particularly helpful for men who have weakened urinary sphincters as a result of treatment of prostate cancer; it is rarely used in women with stress incontinence.
Surgery to remove tissue-causing blockage in the urinary tract or to enlarge a small bladder may also treat overflow incontinence.
Other treatments for incontinence include:
- A pessary is a device inserted by a health care professional into the vagina to support pelvic organs. It either presses against or supports the vagina wall and the urethra, leading to less urine leakage in stress incontinence. It has to be removed, cleaned and reinserted regularly to prevent possible urinary tract infections and vaginal ulcers. There are different kinds of pessaries, and you may have to try several to obtain a good fit. Some patients may be able to remove and clean the pessary by themselves.
- Catheters may be used either constantly or occasionally for overflow incontinence not caused by a blockage, or in women who cannot empty their bladders because of muscle weakness, previous surgery or spinal cord injury. Your health care professional can teach you how to insert the catheter through the urethra into the bladder yourself so you can drain urine. If you use a catheter long-term, the tube will be connected to a urine collection bag that you can wear on your leg underneath clothing. You also need to be on the alert for urinary tract infections, which are possible with long-term catheter usage.
- Percutaneous tibial nerve stimulation (PTNS) is an option for women with urge incontinence who don’t respond to lifestyle changes or medications, as well as for those who don’t want to or cannot have surgery. The procedure involves delivering electrical stimulation to the sacral nerve that controls the bladder via the tibial nerve in the ankle that leads to nerves that control the pelvic floor.
- Sacral nerve stimulation is an electronic stimulation therapy that involves a surgically implanted sacral nerve stimulator resembling a pacemaker. More invasive than PTNS, it involves sending small, electrical impulses directly to the sacral nerve. The continuous electrical stimulation reduces or eliminates urgency, frequency and urge incontinence.
- Botulinum toxin type A (Botox) was recently approved by the FDA to treat women with incontinence from overactive bladder who have not responded to medications, as well incontinence in people with neurological conditions, such as multiple sclerosis or spinal cord injuries. Botox works to control incontinence by relaxing the bladder, increasing storage capacity and decreases leakage. Possible side effects may include urinary tract infections, painful or difficult urination and urinary retention.
- The use of radiofrequency energy to heat tissue in the lower urinary tract can also help improve symptoms of incontinence. When the tissue heals, it is usually stronger and firmer, which can reduce urinary leaks.
Prevention
Performing pelvic muscle, or Kegel, exercises, especially during and after pregnancy, and using topical forms of estrogen may play a role in possibly preventing or treating incontinence. Your health care professional can advise whether such therapies are appropriate for you.
Reducing caffeine and alcohol consumption can improve the body’s ability to retain urine. Both substances can inhibit production of a hormone that concentrates and decreases the volume of urine by increasing reabsorption of fluid by the kidneys.
Your health care provider may suggest you keep a chart to track your urinary frequency to help determine whether your fluid intake is reasonable. Emptying your bladder four to eight times in 24 hours is normal, as is urinating about every three to four hours during the day, as well as getting up once at night to go to the bathroom.
Although there is no specific diet to prevent incontinence, it is thought certain foods and drinks can irritate the bladder and should be avoided if consuming them appears to produce or increase symptoms:
- carbonated beverages
- coffee or tea, including decaffeinated forms
- yogurt
- citrus juice and fruits
- tomatoes and tomato-based products
- bananas
- artificial sweeteners
- chocolate
- spicy foods
- vinegar
- processed meats and fish
Some medications may contribute to incontinence. Talk with your health care professional if you experience urinary leakage while taking these drugs:
- diuretics, or “water pills,” that increase urine flow, including bumetanide (Bumex), forosemide (Lasix), and theophylline (Bronkodyl)
- sedatives and sleep aids, including diazepam (Valium), flurazepam (Dalmane) and lorazepam (Ativan)
- antihistamines and cold and allergy medications, such as benztropine (Cogentin)
- antidepressants and antipsychotics, including amitriptyline (Elavil), desipramine (Norpramin) and haloperidol (Haldol)
- angiotensin-converting enzyme (ACE) inhibitors, which are often prescribed for high blood pressure and congestive heart failure, including benazepril (Lotensin) and captopril (Capoten)
Facts to Know
- Millions of Americans suffer from urinary incontinence, and many of them are women.
- Although incontinence is most prevalent among older women, it can occur at any age and in both genders.
- Many women with incontinence never discuss it with their health care professionals. In most cases, treatment can improve or cure incontinence, once the condition is brought to the attention to a health care professional.
- Incontinence is a symptom, not a disease. It has a variety of causes. Urine leakage can be caused by problems that, when treated, stop the incontinence, including urinary tract infections, bladder irritations and constipation. Incontinence also can be the result of a serious illness or disease, such as diabetes, multiple sclerosis, Parkinson’s, Alzheimer’s, stroke or brain tumors. Long-term incontinence can be caused by weak pelvic, bladder, or urinary sphincter muscles or a bladder that contracts involuntarily and expels urine.
- Stress incontinence is the most common form of incontinence among younger women. It consists of urine leakage when any physical pressure is placed on the bladder, such as sneezing, coughing or exercising. Another common type of urine control problem in women is urge incontinence, characterized by a sudden, strong urge to urinate but an inability to make it to the toilet in time. It can be caused by a disorder known as “overactive bladder.” Women can have a combination of these problems, known as mixed incontinence.
- Overflow incontinence, which is the feeling that the bladder is always full, accompanied by dribbling of urine, is rare in women. It can be caused by diabetes, all neurologic diseases or an obstruction in the urinary tract that can lead to serious illness, so if you experience such symptoms, see your health care professional.
- With treatment, incontinence can be improved or cured in many cases. Treatment depends on the type of incontinence and its causes. Therapy options include simple behavior modification techniques women can learn to do themselves, medications, Botox injections, use of special devices and surgery. Talk with your health care professional about what treatments may help you.
- Behavior modification techniques are often the first-line treatment for incontinence, but their success depends on your ability to stick to with them. Pelvic muscle exercises, such as Kegel exercises, strengthen weak muscles that support the urinary system. Studies show that when done correctly, Kegel exercises can be effective in helping to prevent stress incontinence. Bladder training may also change urination habits.
- There are numerous surgical techniques for treating stress incontinence, and many of them have been highly successful. Some procedures are minimally invasive and can have quick recovery times. But surgery does carry risks and needs to be fully discussed with your health care professional before you choose it as a treatment option.
- Absorbent pads and adult diapers are generally recommended by health care professionals for use while undergoing other treatments or for long-term use in conjunction with other treatments—not as the only option available.
Key Q&A
- Isn’t incontinence just part of the aging process?No, incontinence, or the inability to control urination, can occur at any age. Because urinary incontinence is most common in the elderly, and it is a major cause of admission to nursing homes, it is often mistakenly thought of as a problem suffered only by older people.
- Why do I need to see a health care professional about urine leakage when I can just wear a pad?Incontinence is not normal. It is a symptom that can have many causes. Some of those causes can be problems that are easily treated to stop the incontinence, such as urinary tract infections, bladder irritations and constipation. Other causes can be more serious, such as an obstruction in the urinary tract, which can cause urine to back up and harm the kidneys. The most common causes are weak pelvic muscles that support the urinary tract and an overactive bladder, both of which can be treated or improved in most cases. If you don’t talk to your health care professional, your problem could persist and even worsen. Continual exposure to urine can result in skin rashes and infections. There’s no need to suffer with this problem when there are many treatment options that can improve it, or even cure it.
- What kinds of treatments are there for incontinence?There are many kinds of therapies for incontinence, depending on the type you have and the cause of your problem. Initial treatment may include pelvic muscle exercises or changing your urination patterns or habits. Several medications are available that may help and may be used in conjunction with pelvic muscle exercises and bladder training techniques. Insertable devices and bulking agent injections also may relieve urinary leakage. Additionally, there are several surgical techniques that can be highly successful. Ask your health care professional about the risks and benefits of each option, and what course of therapy might best help you.
- I hear a lot of talk about overactive bladder. What’s the difference between it and incontinence?An overactive bladder can cause urge incontinence. When your bladder muscles contract to expel urine when you don’t want them to do so, you have an overactive bladder. Frequent trips to the bathroom; sudden, overwhelming urges to urinate; and an inability to get to a toilet in time are characteristics of urge incontinence caused by an overactive bladder.
- Must I have surgery to stop my urine leakage?Not necessarily. Surgery can be highly successful in many cases of incontinence, especially those caused by weak pelvic muscles that allow the bladder to drop onto its neck and prevent the urinary sphincter muscles from staying tight under pressure, causing leaks. But having an operation is not the only treatment available. Talk to your health care professional about what treatments are best for you.
- Will I have incontinence when I reach menopause?There is no way to predict who will become incontinent. It is true, however, that many menopausal and postmenopausal women have stress incontinence. Weak pelvic muscles that support the bladder and urethra may cause stress incontinence. Decreases in levels of the hormone estrogen also have been associated with less muscular pressure around the urethra, reduced urinary sphincter strength, thinning of the lining of the urethra and reduced bladder support.
- What can I do to prevent incontinence?There is no scientifically proven regimen to prevent incontinence. However, maintaining good overall health, particularly with regards to weight, is always a good idea. And, since weak pelvic muscles are at the root of many urine control problems, exercising them may help maintain bladder control, especially during and after pregnancy. Your health care professional can tell you whether pelvic exercises are right for you and teach you how to do them correctly. Reducing caffeine and alcohol consumption can improve the body’s ability to retain urine. Also, some foods and beverages may irritate the bladder and should be avoided if you’re having urinary control problems. Some prescription and over-the-counter medications can cause incontinence, too. If you’re experiencing incontinence, talk with your health care professional about it.
- My doctor wants me to have an urodynamic test. What is it, and will it hurt?This type of testing assesses bladder and sphincter function, including the pressure and volume of urine in the bladder, and the pressure and flow of urine from the bladder through the urethra. One test, called cystometry, measures contractions of the bladder muscle as it fills and empties by inserting a catheter through the urethra into the bladder and filling it with water. Another tiny tube is inserted into the rectum or vagina to measure pressure on your bladder when you cough or exert pressure. Urodynamic testing also may include imaging, such as X-ray or ultrasound, to examine changes in the position of the bladder and urethra during urination, coughing or straining. The use of catheters can be uncomfortable but these tests are well-tolerated. Imaging tests are generally noninvasive and do not hurt.
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