Urinary Incontinence

Introduction

Does your bladder feel full even after you have urinated? Do you avoid social situations or wear protective garments because you fear having an accident? When you cough or sneeze, does urine leak?

If you answered yes to any of these questions, you may have a condition known as urinary incontinence. Urinary incontinence, or the loss of bladder control, is an embarrassing condition that affects millions of people emotionally, psychologically, and even socially. Ultimately, it can decrease an individual?s overall quality of life.

What is it?

Urinary incontinence is the involuntary leakage, or loss, of urine due to the inability to control urine release from the bladder. It results from an underlying cause that can be permanent (such as a stroke) or temporary (such as a urinary tract infection). Individuals with urinary incontinence may experience leakage to different extents ¯ from occasional slight dribbles to frequent complete wetting of clothing with urine. Incontinence affects almost 50 % of individuals who live in institutions, such as nursing homes, and 20 % of individuals who are not institutionalized.

There are five types of urinary incontinence.

Stress Incontinence - Stress incontinence occurs when pressure or stress is placed on the bladder, mainly during activities that require exertion, such as exercising, running, coughing, laughing, and sneezing. The most common type of incontinence that occurs in women, stress incontinence is often due to damage to the urinary sphincter (the muscle that controls urine exiting the bladder) or urethra (the tube that carries urine from the bladder).

Urge Incontinence (Overactive Bladder) - Urge incontinence begins with a sudden, strong need to urinate, followed by bladder contraction, and ultimately by involuntary loss of urine. Individuals who have urge incontinence have to urinate frequently. Urge incontinence is most common in the elderly. Some individuals who experience urge incontinence may even have to wake up several times during the night to urinate (known as nocturia).

Overflow Incontinence - Often, the amount of urine that is produced is more than the bladder can hold. Overflow incontinence occurs when the bladder is full to capacity, but is unable to empty completely, thus causing urine to spill out. Individuals who urinate frequently but only produce a weak, dribble of urine may have overflow incontinence. Also, overflow incontinence occurs mostly in men, particularly those who have an enlarged prostate or other abnormality that may prevent normal emptying of the bladder.

Functional Incontinence (Environmental Incontinence) - Functional incontinence occurs mostly in elderly individuals who are in a hospital or long-term care facility. Patients with functional incontinence often have normal bladder control, but they cannot always get to the toilet in time due to physical or mental conditions that interfere with normal toilet use.

Mixed Incontinence - Mixed incontinence is a combination of different types ¯ usually stress incontinence and urge incontinence.

What causes it?

The ability to urinate properly depends mainly on a normally functioning urinary tract and nervous system. Many muscles, tubes, and nerves located in the urinary system work together to achieve good bladder control.

The process of urination involves two main phases:

  1. Filling of the bladder and storing of urine

  2. Emptying of the bladder

During the filling and storing phase, the bladder fills with urine from the kidneys, the organs responsible for removing waste from the blood and turning it into urine. From the kidneys, urine travels through a pair of tubes known as the ureters, which empty into the urinary bladder - the storage compartment for urine. An average urinary bladder stretches to hold up to 20 ounces of urine. When the bladder is full, a healthy nervous system would signal an urge to urinate.

During the emptying phase, the bladder?s detrusor muscle contracts to force out urine. At the same time, the urinary sphincter muscle at the bottom of the bladder relaxes, allowing urine to pass out of the body through another tube known as the urethra. Incontinence occurs if the muscles do not function properly.

Temporary causes of urinary incontinence include the following:

  • Constipation
  • Excessive fluid intake
  • Heavy alcohol consumption
  • Medications such as diuretics (water pills), muscle relaxants, sedatives, antidepressants, pain medications, and blood pressure medications known as calcium channel blockers
  • Menopause
  • Poorly controlled diabetes
  • Pregnancy and childbirth
  • Urinary tract or vaginal infections

Permanent or long-term urinary incontinence may result from conditions such as:

  • Birth defects
  • Blockage from an enlarged prostate or prostate cancer
  • Diabetes
  • Kidney disease
  • Neurological disorders such as Alzheimer?s disease, Parkinson?s disease, multiple sclerosis, and stroke
  • Nerve or muscle damage following pelvic radiation
  • Spinal cord injuries
  • Weakened bladder muscles or sphincter muscles surrounding the urethra

Who has it?

Urinary incontinence can affect both men and women, at any age. However, the incidence of urinary incontinence increases in individuals who are 65 years or older, occurring in one of every 10 elderly individuals. Additionally, it is more predominant in patients who are in long-term care facilities, particularly women - whose first symptoms often appear at the start of menopause.

What are the risk factors?

Risk Factors for stress incontinence include:

  • Coughs due to smoking
  • Damage or changes to pelvic muscles from pregnancy and childbirth
  • Diabetes
  • High-impact sports
  • Illnesses that impair cognition (Alzheimer?s disease, dementia) or neurological illnesses (stroke, multiple sclerosis, spinal cord injury, Parkinson?s disease)
  • Obesity
  • Severe trauma

Risk Factors for urge incontinence include:

  • Damaged or obstructed bladder
  • High consumption of beverages or foods that can irritate the bladder such as coffee, cola, tea, and chocolate
  • Illnesses that impair cognition (Alzheimer?s disease, dementia)
  • Neurological illnesses (stroke, multiple sclerosis, spinal cord injury, Parkinson?s disease)

Risk Factors for overflow incontinence include:

  • Medications such as diuretics (water pills), muscle relaxants, sedatives, antidepressants, pain medications, and blood pressure medications known as calcium channel blockers
  • Prostate cancer or enlarged prostate

Risk Factors for functional incontinence include:

  • Diabetes
  • Illnesses that impair cognition (Alzheimer?s disease, dementia)
  • Kidney disease
  • Urinary tract infections

What are the symptoms?

  • Dribbling of urine
  • Feeling of bladder fullness even after urination
  • Leaking of urine when coughing or sneezing
  • Nocturia (urinating more than twice during the night)
  • Sudden, strong desires to urinate
  • Urinating more than eight times a day
  • Weak urine stream

How is it treated?

Even though urinary incontinence has no complete cure, it can often be managed adequately with behavioral techniques, medications, surgery, or a combination of therapies. The main goal of treatment is to control bladder problems so that they do not interfere with daily activities. The correct assessment of the type of urinary incontinence by an urologist (a physician who specializes in the urinary system) is very important. A health care professional will then decide which of the following treatment options is best for the individual and the type of incontinence.

Behavioral Techniques

  1. Bladder training/retraining: A diary can be used to record the volume of fluid intake, the number of urinations, and urinary accidents on a daily basis. The diary then helps a physician set ?timed intervals? for urination, so the individual establishes regular bladder emptying times. The goal is urination only every 3 to 4 hours while the individual is awake.

  2. Pelvic floor exercises (also known as Kegel exercises): Exercising focuses primarily on strengthening the pelvic floor muscles that support the urethra and bladder. The assistance of a health care professional may be required to locate the correct muscles prior to beginning exercises. Generally, pelvic floor muscles are tightened (contracted) for 10 seconds, then relaxed for 10 seconds. This procedure is repeated 10 times, at least three times a day. When performed properly, these exercises significantly improve urinary incontinence, by about 50% to 80%. Patients with stress incontinence or urge incontinence benefit the most from pelvic floor exercises.

  3. Fluid and diet management: Reducing the consumption of bladder irritants such as acidic fruits and vegetables, alcohol, carbonated beverages, chocolate, coffee, and tea may relieve urinary incontinence for some individuals. However, water intake may need to be increased, so that urine is less concentrated, which helps reduce bladder irritation.

Devices

The most common external devices used by individuals with any type of incontinence are absorbent pads and disposable undergarments that soak up any urine leakage. For men, small disposable pads of absorbent material enclosed in waterproof coverings are available. Called drip collectors or penis caps, these pads are worn on the penis to collect small urine leaks. For larger amounts of urine, men may also use a condom catheter - a sheath that is attached to the penis. A tube at the end of the sheath leads to a urine storage bag, which can be emptied several times a day. Some men may wear padded clamps or inflatable rings that fit over the penis and compress the urethra. When closed, these compression devices stop urine from leaking. They must be opened for urination.

Internal devices are also used to control incontinence. Particularly for individuals with functional incontinence, internal catheters are common. The catheter is a narrow tube inserted into the bladder to drain urine directly into a collection pouch. The pouch is then emptied. For women, a pessary may be inserted into the vagina to help support the bladder. Usually used to stabilize the uterus, a pessary is a small, soft device similar to a contraceptive diaphragm or sponge.

Surgery

When other therapy fails, or when incontinence symptoms become severe, surgical treatment may be necessary.

For men with stress incontinence, several different types of minimally invasive surgery are used to insert collagen or another bulking agent, graft tissue, or implant an artificial sphincter. The most common surgical option for women with stress incontinence is called a sling procedure, in which donor or synthetic tissue is attached to the urethra. A more invasive technique involves supporting the bladder by attaching the vagina to the pubic bone.

For urge incontinence, both men and women may benefit from a bladder pacemaker. Similar to a heart pacemaker, the bladder pacemaker uses a small, implanted electrical stimulator that can be used to regulate bladder function. For severe urge incontinence, a procedure called augmentation cystoplasty uses a piece of the patient?s intestine to enlarge the bladder.

Surgery for overflow incontinence consists mainly of removing an obstruction of the urethra. This type of surgery is common for men with enlarged prostates.

What is on the horizon?

Clinical studies have shown that duloxetine (Cymbalta) may be an alternative agent for the treatment of stress incontinence. Currently approved for the treatment of depression and diabetic neuropathy (a complication of diabetes), duloxetine has reduced the frequency and the number of urinations per day for participants in clinical trials. However, the increased incidence of side effects associated with duloxetine may limit its use for urinary incontinence. The most common are nausea, headache, and difficulty sleeping. An increase in blood pressure is also possible with duloxetine use.

Two other drugs that are already approved for other conditions are also being studied for incontinence. Tramadol, a drug approved for pain control, has been tested for individuals with urge incontinence. In general, study participants taking tramadol had to urinate fewer times a day and they had less involuntary urination than patients taking a placebo. A drug used to treat nerve pain and seizures, gabapentin, has also shown some promise for treating incontinence.

Although it is not yet approved for treating incontinence, botulinum toxin type A has been effective for patients whose detrusor muscles contract too much or too often. Inserted into the bladder through a catheter or injected into the detrusor muscle, botulinum toxin type A relaxes the detrusor, allowing the bladder to fill more completely and preventing involuntary urination due to constant detrusor contraction. The effects of one treatment with botulinum toxin type A have lasted as long as 9 months for some patients. A different type of toxin, resiniferatoxin, has shown similar effects when a solution of it is inserted into the bladder through a catheter. Derived from a cactus-like plant, resiniferatoxin is believed to desensitize some of the nerves involved in urination. Some patients who received resiniferatoxin in a clinical study experienced an increase in bladder capacity for at least 3 months after each treatment.

In Europe, researchers have been able to use stem cells taken from an individual with incontinence to grow new muscle cells. The new cells are then injected into weakened sphincter muscles. As the new cells grow, the sphincter regains some of its ability to regulate urination. This technique is not approved and it has not been studied in the United States.

References

  1. About Incontinence. National Association for Continence. 2005. Available at: http://www.nafc.org/about_incontinence/. Accessed Dec 2007.

  2. Andersson KE. New pharmacologic targets for the treatment of the overactive bladder: an update. Urology. 2004;63(3 Suppl 1):32-41.

  3. Appell RA, Sand P, et al. Prospective randomized controlled trial of extended release oxybutynin chloride and tolterodine tartrate in the treatment of overactive bladder: Results of the OBJECT study. Mayo Clin Proc 2001; 76:358-363.

  4. Giannantoni A, Di Stasi SM, Stephen RL, Bini V, Costantini E, Porena M. Intravesical resiniferatoxin versus botulinum-A toxin injections for neurogenic detrusor overactivity: a prospective randomized study. J Urol. 2004;172(1):240-243.

  5. Gottwald MD. Urinary Incontinence. In: Koda-Kimble MA, Young LY, Kradjan WA, Guglielmo BJ, eds. Applied Therapeutics: The Clinical Use of Drugs-8th ed. Philadelphia: Lippincott Williams & Wilkins; 2005: 101-21 to 101-29.

  6. Grise P, Daoudi Y, Tanneau Y, Sibert L. Use and mechanism of botulinum toxin in overactive bladder treatment. [Article in French] Ann Urol (Paris). 2005;39(3-4):105-115.

  7. Kegel exercises. MedlinePlus. Medline Encyclopedia. Updated August 17, 2007. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003975.htm. Accessed Dec 2007.

  8. Minimally invasive management of urinary incontinence. American Urological Association. No date given. Available at: http://www.urologyhealth.org/search/index.cfm?topic=106&search=urinary%20AND%20incontinence&searchtype=and. Accessed March 2006.

  9. Newman DK, Dzurinko MK. The Urinary Incontinence Sourcebook. Los Angeles. Lowell-House Publishing Group, 1999.

  10. Payne CK. Urinary Incontinence: Nonsurgical Treatment. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Cambell?s Urology 8th ed. Philadelphia. Saunders Publishers. 2002; pages 1069-1091.

  11. Rovner ES, Wyman J, Lackner T, Guay D. Urinary Incontinence. In: Dipiro JT, Albert RL, Yee G, Matzke G, Wells B, Posey L,. Pharmacotherapy. A Pathophysiologic Approach. 6th ed. New York: Appleton & Lange; 2005:1547-1561.

  12. Sahai A, Khan MS, Arya M, John J, Singh R, Patel HR. The overactive bladder: review of current pharmacotherapy in adults. Part 2: treatment options in cases refractory to anticholinergics. Expert Opin Pharmacother. 2006;7(5):529-538.

  13. Strasser H, Marksteiner R, Margreiter E, et al. Transurethral ultrasound guided stem cell therapy of urinary incontinence. Presented at the American Urological Association 101st Annual Meeting. Atlanta Georgia. May 21, 2006.

  14. Surgical Management of Urinary Incontinence. American Urological Association. No date given. Available at: http://www.urologyhealth.org/search/index.cfm?topic=133&search=incontinence&searchtype=and. Accessed May 26, 2006.

  15. Urinary Incontinence. Mayoclinic.com. June 27, 2007. Available at: http://mayoclinic.com/health/urinary-incontinence/DS00404. Accessed Dec 2007.

  16. Urinary incontinence devices. MedlinePlus-Medline Encyclopedia. Updated November 1, 2007. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/003973.htm. Accessed Dec 2007.

Urinary Incontinence Health Condition Last Updated: December 2007

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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