Table of Contents
- Introduction to Urinary Incontinence
- Types of Urinary Incontinence
- Cause of Urinary Incontinence
Introduction to Urinary Incontinence
Urinary incontinence, simply known as loss of control over the bladder, is a medical problem in which there is a sudden involuntary leakage of urine. The basic pathology is the loss of control over the urinary sphincter or bladder that leads to unconscious and involuntary urine leakage. This could be due to multiple reasons.
Incontinence: Key Statistics
The incidence of urinary incontinence is fairly high in the senile population. It is estimated that approximately five million adults suffer from overactive bladder. 1 It is seen twice as commonly in women than men. The percentage is about 3 to 17% in women while that in men is 3 to 11%.2
Urinary incontinence is not only a medical problem that affects the bladder but is also a cause of social stigma. It adversely affects one’s quality of life, often keeping the sufferer from activities that they enjoy. Therefore, it is vital to seek medical attention and get a proper treatment instead of managing it by using incontinence aids only.
Types of Urinary Incontinence
Depending on the cause, urinary incontinence can be classified as:
- Stress incontinence: As the name indicates, it occurs in stressful conditions in which there is a rise in intraabdominal pressure, like coughing, sneezing, laughing, or during exercise. This condition is more common in young women. The likely cause is urethral sphincter weakness secondary to labor and childbirth, or gynecological procedures like hysterectomy and pelvic surgery.
- Urge incontinence: In this condition, there is a desire to urinate, but before the patient is able to reach the toilet, the urine leaks out. This is due to detrusor overactivity. The detrusor is a muscle of bladder that holds the urine, and its contraction leads to urine outflow. This condition is often accompanied by symptoms like urgency (a sudden desire to void), frequency, nocturia (frequently waking up at night to void), and low volume of urine voided.
- Overflow incontinence: In this condition, the bladder remains full due to a disorder affecting its ability to void completely. It is characterized by frequent, small urinations throughout the day or constant dribbling. It is usually seen in men with prostate problems.
- Functional incontinence: This is actually not incontinence. The patient may have some other medical problems like arthritis due to which they are not able to reach the toilet in time resulting in urine leakage.
- Mixed incontinence: This is urinary incontinence occurring with bowel incontinence. Bowel incontinence is a sudden involuntary leakage of stools.
Causes of Urinary Incontinence
Urinary incontinence is not a disease itself but rather a symptom of underlying pathology. The primary cause varies in patients, which explains different types of urinary incontinence. It is, however, essential to note that there are certain conditions that may transiently produce the symptoms of urinary incontinence, and it is essential to differentiate them from true incontinence. These include:
- Foods, drinks, and medications: There are certain products that act as a diuretic and increase urine production causing bladder fullness and urine leakage. These include caffeine, alcohol, carbonated drinks, artificial sweeteners, chocolate, chili pepper, blood pressure-lowering drugs, and large doses of vitamin C.
- Urinary tract infection (UTI): UTIs cause bladder irritation and, thus, often urine leakages.
- Constipation: The rectum lies posterior to the bladder. Hard stools in the rectum irritate the nerves of the bladder. Also, a heavy and full rectum applies pressure on the bladder causing it to leak easily.
Some common primary causes of urinary incontinence are:
- Pregnancy: It is a condition that causes many physiological changes in the female body. The weight of a growing fetus raises the pressure in the abdomen and may cause incontinence when even a little more stress is added to it (e.g. while coughing or sneezing).
- Labor and Childbirth: A complicated and prolonged labor may cause lifelong damage to pelvic floor muscles, permanently weakening them. This may result in incontinence as the patient is not able to hold the urine for a long time because of damaged pelvic floor muscles.3
- Menopause: Menopause refers to the cessation of menstruation. Women no longer produce a sex hormone (estrogen) important for many normal bodily functions. This results in thinning of urethral tissue, further adding to incontinence.4
- Enlarged prostate: Prostate enlargement with advancing age is seen in a large proportion of men. This enlarged prostate, because of its close anatomical relation to the urinary system, interferes with its function.5
- Prostate cancer: Stress and urge incontinence are seen in this setting. More often, incontinence occurs secondary to the damage caused by the treatment of the prostate cancer.6
- Senile changes: The bladder tone decreases with age; it cannot hold a large amount of urine for a long time without causing involuntary urine leakage. There is also an increased sudden bladder contraction in the older population.
- Obstruction: The blockage of urine outflow due to a tumor or stone may result in incomplete bladder emptying producing symptoms of continuous dribbling and incontinence.
- Neurological disorders: Certain neurological diseases like multiple sclerosis, stroke, brain or spinal cord injury may interfere with the signaling mechanism that is necessary for voiding.7
Since urinary incontinence is a medical symptom for an underlying disease, your healthcare provider will be more focused on looking for the primary cause. For this purpose, several tests are ordered. These include:
- Urinalysis and urine culture: These tests help your doctor find out if there is an infection in your urinary tract. These tests also help in ruling out a prostate infection.
- Bladder stress test: This test is done to check stress incontinence. The doctor checks if there is urine leakage while coughing or any other stressful event.
- Bonney test: This test is similar to the bladder stress test. It is performed in women. The tip of the bladder is lifted by inserting a finger or tool through the vagina. Leakage is then checked after applying stress (asking the patient to cough).
- Pad test: This test is done to measure how much urine is leaking. A weighted pad is given to the patient, which is worn until soiled. It is then weighed to see how much urine the patient is leaking, which helps to determine the severity.
- Imaging: Imaging techniques like X-ray and ultrasound are used to see the internal anatomy of the bladder and urinary tract, especially if there is any noticeable change occurring while voiding and coughing.
- Urodynamic studies: These tests are done to assess the functioning of the urinary tract- how well it is performing the function of storing and voiding the urine. These include:
- Uroflowmetry: This test helps determine the rate of flow of urine. When there is a low peak flow rate, it means either there is an obstruction somewhere in the urinary system or the bladder muscles are weak.
- Pressure flow studies: When urine flows out of the bladder, pressure changes occur inside it. This test records the changes that occur while voiding. Your doctors suggest this test to look for any blockage, or muscle or nerve damage.
- Post void residual volume: This test is used to measure the amount of urine that is left behind after voiding.
- Cystometry: This test measures the pressure inside the bladder at different levels of fullness.
- Electromyogram: This test is used by your doctor to see the electrical activity of your bladder muscles.
- Cystoscopic exam: In this test, your doctor uses a thin and lighted tube to see the urinary tract from inside.
- Cystourethrogram: This is an X-ray of your bladder and urethra, which is taken while you are urinating.
The treatment strategy is devised according to the age and gender of the patient and the type and severity of incontinence. The treatment options include:
- Lifestyle and dietary changes: Lifestyle changes can have profound effects on the prognosis of any disease. Weight loss is an essential aspect of any lifestyle modification strategy. In addition, quitting smoking is also very important. Dietary changes include adding more fiber, consuming more healthy vegetables, and removing processed and fast food from the diet. It is also essential to decrease caffeine intake, consume water instead of carbonated drinks, and reduce fluid intake at night. Avoiding heavy weight lifting is also necessary to minimize damage to pelvic floor muscles.
- Bladder training: Also known as timely voiding, this is a type of behavioral strategy to reduce the symptom of urinary incontinence. In this technique, your doctor advises you to make a schedule for urination, like every hour or every two hours, for example, and then gradually increase the duration between two voids. This is often added with pelvic floor exercises.
- Pelvic floor exercises: These are a group of exercises that target pelvic floor muscles. These are often suggested by the doctor to strengthen the pelvic muscles, especially to new mothers. Dramatic changes were noted in incontinence symptoms of women who performed pelvic exercises after childbirth.8
- Medical devices: These are available in the form of pessaries for women and specialized catheters for men. Pessaries are medical devices that are inserted in the vagina to hold the bladder and other pelvic organs at their place. For men, there are specialized catheters that are thin, flexible, and enter the bladder through the urethra to prevent leaks. It is important to note pessaries can be self-inserted, while for catheter insertion, the specialized staff is required. This is often done in hospital admitted patients.
- Pharmacologic therapy: Our body muscles have different types of receptors that receive signals from the brain, such as when to contract and when to relax. One way to control autonomous (that are not voluntarily controlled, usually internal organs muscles) muscle contraction is to provide exogenous chemicals that control their movement. These exogenous chemicals act on bladder receptors and cause it to contract in order to resist sudden urine outflow.9, 10
- Surgery: When all the above therapies have been attempted and no significant outcome is obtained, surgery becomes inevitable. The surgical options vary for men and women. For females, mostly urinary surgery is combined with gynecological surgical procedures, as the majority of issues stem from there. Your doctor will decide with you all the procedures and outcomes, giving you different options according to the severity of your condition.
- Milsom, I., Abrams, P., Cardozo, L., Roberts, R. G., Thüroff, J., & Wein, A. J. (2001). How widespread are the symptoms of an overactive bladder, and how are they managed? A population-based prevalence study. BJU international, 87(9), 760–766.
- Nitti V. W. (2001). The prevalence of urinary incontinence. Reviews in urology, 3 Suppl 1(Suppl 1), S2–S6
- Farrell, S. A., Allen, V. M., & Baskett, T. F. (2001). Parturition and urinary incontinence in primiparas. Obstetrics and gynecology, 97(3), 350–356.
- Kołodyńska, G., Zalewski, M., & Rożek-Piechura, K. (2019). Urinary incontinence in postmenopausal women – causes, symptoms, treatment. Przeglad menopauzalny = Menopause review, 18(1), 46–50
- Roehrborn C. G. (2005). Benign prostatic hyperplasia: an overview. Reviews in urology, 7 Suppl 9(Suppl 9), S3–S14.
- Singla, N., & Singla, A. K. (2014). Post-prostatectomy incontinence: Etiology, evaluation, and management. Turkish journal of urology, 40(1), 1–8.
- National Clinical Guideline Centre (UK). Urinary Incontinence in Neurological Disease: Management of Lower Urinary Tract Dysfunction in Neurological Disease. London: Royal College of Physicians (UK); 2012 Aug. (NICE Clinical Guidelines, No. 148.) 2, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK132842/
- Haddow G, Watts R, Robertson J. Effectiveness of a pelvic floor muscle exercise program on urinary incontinence following childbirth. JBI Libr Syst Rev. 2005;3(5):1-62.
- Lin, H. H., Sheu, B. C., Lo, M. C., & Huang, S. C. (1999). Comparison of treatment outcomes for imipramine for female genuine stress incontinence. British journal of obstetrics and gynaecology, 106(10), 1089–1092.
- Wein A. J. (1995). Pharmacology of incontinence. The Urologic clinics of North America, 22(3), 557–577.