Urinary Incontinence

What is urinary incontinence?
Urinary incontinence is the inability to hold urine leading to involuntary loss of urine. The urine loss can range from slight leakage of urine to severe frequent wetting. This condition severely affects quality of life by interfering with work, travel, social recreation and sexual activities.

What is the incidence of urinary incontinence?
At least 10% of people over the age of 65 years have urinary incontinence. According to World Health Organisation estimates, there are 200 million patients worldwide with symptoms of male or female urinary incontinence. However, as this condition is associated with shame, embarrassment and silence, the exact figure is not known.

Is urinary incontinence an inevitable part of aging?
With aging, the urge to urinate may occur more frequently and be harder to control: however, incontinence can affect men and women of all ages and is not a normal response to aging.

Is the incidence of urinary incontinence similar in men and women?
No, women experience incontinence two times more often than men. Pregnancy and child-birth, menopause and the structure of the female urinary tract account for this difference. However, both women and men can become incontinent from stroke, multiple sclerosis and other physical problems associated with old age.

What are the risk factors for urinary incontinence?
Risk factors for urinary incontinence vary, but include:
  • Pregnancy
  • Childbirth
  • Obesity
  • Menopause
  • Cigarette smoking
  • Prostate enlargement and/or surgery
  • Hysterectomy
  • Radiation therapy to the pelvis
  • Diabetes
  • Parkinson's disease
  • Back injury
  • Cerebral vascular accident
  • Dementia
What are the consequences of urinary incontinence?
Urinary incontinence has far reaching consequences not only on a person's physical health but also on the mental condition. Embarrassment, stigmatization, isolation, demoralization and depression are common in these patients. Urinary incontinence is also associated with an increased number of falls, urinary tract infections and skin breakdown. The economic burden of the disease is also considerable as it often leads to premature admission of the patient to nursing home.

Are there different types of urinary incontinence?
There are three basic types of urinary incontinence:
  • Urge incontinence
  • Stress incontinence
  • Overflow bladder
What is urge incontinence?
Urge incontinence or detrusor overactivity is a common problem that increases in frequency and severity with advancing age. In this condition, the patient often loses urine for no apparent reasons while suddenly feeling the need or urge to urinate. In urge incontinence, the bladder involuntarily empties during sleep, after drinking a small amount of water, or while touching water or even when hearing it run (as when someone else is taking a shower or washing dishes).

What causes urge incontinence?
The most common cause of urge incontinence is inappropriate and involuntary bladder contractions. These involuntary contractions may occur because of inflammation or irritation within the bladder or when certain neurologic diseases impair control of bladder contractions.

  • Urinary tract infections
  • Cancer
  • Parkinson's disease
  • Alzheimer's disease
  • Certain drugs such as hypnotics or narcotics
  • Injury (such as those occurring during surgery)
  • Benign prostatic hyperplasia (BPH)
Urge incontinence can also occur when mobility is impaired (for example, in patients with arthritis), making it difficult for patients to get to the bathroom in time. This condition is sometimes referred to mass "functional" incontinence.

What is stress incontinence?
Stress incontinence is the most prevalent form of incontinence in elderly patients. It is caused by malfunction of the urethral sphincter that causes urine to leak from the bladder when intra-abdominal pressure increases, such as during laughing, coughing or sneezing.

What causes stress incontinence?
Physical changes resulting from pregnancy, childbirth and menopause are common causes of stress incontinence. It is the most common form of incontinence in women and is treatable. Certain muscles, known as the "pelvic floor muscles" support the bladder. If these muscles weaken, the bladder can move downward, pushing slightly out of the bottom of the pelvis toward 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 also occurs if the muscles that do the squeezing weaken. Stress incontinence can worsen during the week before menstrual period. At that time, lowered oestrogen levels might lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause. Stress incontinence can also occur as a result of drugs, Surgical trauma or radiation damage.

What is overflow incontinence?
Overflow bladder is more relatively uncommon. Urinary incontinence due to overflow bladder is more common in men because of the prevalence of obstructive prostate gland enlargement. In this condition urine accumulates in the bladder until maximum bladder capacity is reached. It then leaks through the urethra by "overflow", usually manifesting as dribbling. However, increased intra-abdominal pressure, which occurs during coughing and sneezing, may also cause loss of urine, so that overflow incontinence may be confused with stress incontinence.

What causes overflow incontinence?
Overflow bladder incontinence occurs because of:
  • Week bladder muscles caused by nerve damage from diabetes or other diseases (e.g., tumours, radiation, surgery)
  • Obstructed urinary outflow, such as those caused by prostate enlargement and urinary stones
  • Under active bladder contractions caused by certain medications. These medications lead to urinary retention with bladder distension.
Are there any other types of incontinence?
When stress and urge incontinence occur together, it is sometimes referred to as "mixed incontinence". This is common in women. "Transient" or temporary incontinence can be caused by medications, urinary tract infections, mental impairment, restricted mobility and severe constipation, which can push against the urinary tract and obstruct outflow.

Is there any treatment of urinary incontinence?
Most types of urinary incontinence can be effectively treated and the symptoms improved the type of incontinence present is determined. In some patients, incontinence is often improved by weight loss. Smokers who have a chronic cough have fewer problems when they stop smoking (and stop coughing). Some common drugs can also aggravate the situation.

What are the treatment options for urge incontinence?
These patients often respond to behavioural therapy consisting of bladder re-training provided they are motivated to do so and their mental faculties are all right. For example, such patients are instructed about a fluid intake schedule, voiding techniques and scheduled voiding. Institutionalised patients can also benefit from behavioural training using scheduled toileting or prompted voiding. Urge incontinence also responds to various drugs. Special care must be taken when using these medications, especially in patients who may have urinary outflow obstruction, as these drugs can precipitate urinary retention.

What are the treatment options for stress incontinence?
In these patients, pelvic floor exercises (e.g. Kegel exercises, vaginal cones) can be effective. These exercises strengthen both the periurethral and pelvic floor muscles. They are easy to perform, however must be performed frequently throughout the day and continued for long-term effect. Certain drugs are also available for the management of stress incontinence. Oestrogen replacement therapy can also be very helpful in this condition, particularly postmenopausal women. Topical, oral, or transdermal oestrogen preparations, all are effective. There are several surgical procedures, which may also prove helpful for stress incontinence.

How do pelvic floor exercises help?
The urinary sphincter, with the help of surrounding pelvic floor muscles, controls release of urine from the bladder. Pelvic floor exercises strengthen these muscles, which help to prevent or reduce incontinence.

Which are these exercises?
Exercises used to strengthen these muscles called "Kegels". To do them, imagine that you are trying to stop passing gas. Squeeze the muscles you would use to stop the gas and hold the squeeze as you count to 3. Relax, count to 3 again, and then repeat the squeezing exercise. Don't use stomach, leg, or buttock muscles. Do this for about 5 minutes three times a day. It may take 6-8 weeks before any beneficial effect is noted. Reported improvement/cure rates have been as high as 77%. These exercises can be done practically anywhere-while driving, watching television, or fixing a meal. But the important thing is to get into the habit of doing Kegels regularly. But remember to avoid pelvic floor exercises while you are urinating, because that may actually weaken the muscles.

What are the treatment options for overflow incontinence?
Patients with overflow incontinence have difficulty emptying their bladder. The goal of treatment is therefore to improve bladder drainage. This can be achieved by drugs, catheterisation and surgery. Intermittent self-catheterisation may also be used for chronic management in patients with overflow incontinence. Most of these patients can be taught to self-catheterise safely with clean catheters. Patients with overflow incontinence can also be instructed in assisted voiding techniques (e.g., abdominal strain, Crede manoeuvre).

What are the treatment options for functional incontinence?
Treatment of functional incontinence depends on the successful management of causative or contributing conditions. Mobility can be improved by relieving pain and providing equipment for patients suffering from arthritis, contractures, deconditioning and neurologic impairments. Environmental modifications (e.g., improved lighting, use of a bedside commode or reducing the distance to the toilet) can be useful in selected patients.

Should these patients use absorbent undergarments?
Although absorbent undergarments can help elderly patients regain freedom lost as a result of urinary incontinence, they may cause many patients to avoid medical evaluation and simply accept the incontinence. Absorbent undergarments are expensive and may cause skin irritation and breakdown with long-term use.

Are there any other treatment options?
Behavioural therapy has been recommended as the initial approach to urinary incontinence. Even when surgery is the treatment of choice, it is often complemented with some form of behavioural treatment. Behavioural interventions include pelvic muscle exercises, biofeedback, bladder training and fluid /dietary modifications.

What is biofeedback?
Biofeedback uses measuring devices to help the patient become aware of the body's functioning. By using electronic devices or diaries to track bladder and urethral muscle contractions, the patient can gain control over these muscles. Biofeedback can be used with pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.

What is electrical stimulation?
Electodes are temporarily placed in the vagina or rectum to stimulate nearby muscles. This will stabilize overactive muscles and stimulate contraction of urethral muscles. Brief doses of electrical can strengthen muscles in the lower pelvis in a way similar to exercising the muscles. Electrical stimulation can be used to reduce both stress incontinence and urge incontinence.

Disclaimer - Information for the Patients are as per current practice standard and wide experience of the author. Patients are advised to refer to respective international medical guidelines for contemporary management of specific issue.