Urinary incontinence

Urinary incontinence

Definition:

Urinary incontinence — the loss of bladder control — is a common and often embarrassing problem. The severity of urinary incontinence ranges from occasionally leaking urine when you cough or sneeze to having an urge to urinate that's so sudden and strong you don't get to a toilet in time.
If urinary incontinence affects your day-to-day activities, don't hesitate to see your doctor. In most cases, simple lifestyle changes or medical treatment can ease your discomfort or stop urinary incontinence.

Symptoms:

Urinary incontinence is the inability to control the release of urine from your bladder. Some people experience occasional, minor leaks — or dribbles — of urine. Others wet their clothes frequently.
Types of urinary incontinence include:

• Stress incontinence. This is loss of urine when you exert pressure — stress — on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy. Stress incontinence occurs when the sphincter muscle of the bladder is weakened. In women, physical changes resulting from pregnancy, childbirth and menopause can cause stress incontinence. In men, removal of the prostate gland can lead to stress incontinence.
  
• Urge incontinence. This is a sudden, intense urge to urinate, followed by an involuntary loss of urine. Your bladder muscle contracts and may give you a warning of only a few seconds to a minute to reach a toilet. With urge incontinence, you may need to urinate often, including throughout the night. Urge incontinence may be caused by urinary tract infections, bladder irritants, bowel problems, Parkinson's disease, Alzheimer's disease, stroke, injury or nervous system damage associated with multiple sclerosis. If there's no known cause, urge incontinence is also called overactive bladder.
  
• Overflow incontinence. If you frequently or constantly dribble urine, you may have overflow incontinence, which is an inability to empty your bladder. Sometimes you may feel as if you never completely empty your bladder. When you try to urinate, you may produce only a weak stream of urine. This type of incontinence may occur in people with a damaged bladder, blocked urethra or nerve damage from diabetes, multiple sclerosis or spinal cord injury. In men, overflow incontinence can also be associated with prostate gland problems.
  
• Mixed incontinence. If you experience symptoms of more than one type of urinary incontinence, such as stress incontinence and urge incontinence, you have mixed incontinence.
  
• Functional incontinence. Many older adults, especially people in nursing homes, experience incontinence simply because a physical or mental impairment keeps them from making it to the toilet in time. For example, a person with severe arthritis may not be able to unbutton his or her pants quickly enough. This is called functional incontinence.
  
• Total incontinence. This term is sometimes used to describe continuous leaking of urine, day and night, or the periodic uncontrollable leaking of large volumes of urine.

When to see a doctor
You may feel uncomfortable discussing incontinence with your doctor. But if incontinence is frequent or is affecting your quality of life, seeking medical advice is important for several reasons:

• Urinary incontinence may indicate a more serious underlying condition, especially if it's associated with blood in your urine.
• Urinary incontinence may be causing you to restrict your activities and limit your social interactions to avoid embarrassment.
• Urinary incontinence may increase the risk of falls in older adults as they rush to make it to the toilet.

Causes:

Urinary incontinence isn't a disease, it's a symptom. It can be caused by everyday habits, underlying medical conditions or physical problems. A thorough evaluation by your doctor can help determine what's behind your incontinence.

Causes of temporary urinary incontinence
Certain foods, drinks and medications can cause temporary urinary incontinence. A simple change in habits can bring relief.

• Alcohol. Alcohol acts as a bladder stimulant and a diuretic, which can cause an urgent need to urinate.
  
• Overhydration. Drinking a lot of fluids, especially in a short period of time, increases the amount of urine your bladder has to deal with.
  
• Caffeine. Caffeine is a diuretic and a bladder stimulant that can cause a sudden need to urinate.
  
• Bladder irritation. Carbonated drinks, tea and coffee — with or without caffeine — artificial sweeteners, corn syrup, and foods and beverages that are high in spice, sugar and acid, such as citrus and tomatoes, can aggravate your bladder.
  
• Medications. Heart medications, blood pressure drugs, sedatives, muscle relaxants and other medications may contribute to bladder control problems.

Easily treatable medical conditions also may be responsible for urinary incontinence.

• Urinary tract infection. Infections can irritate your bladder, causing you to have strong urges to urinate. These urges may result in episodes of incontinence, which may be your only warning sign of a urinary tract infection. Other possible signs and symptoms include a burning sensation when you urinate and foul-smelling urine.
  
• 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. In addition, compacted stool can sometimes interfere with the emptying of the bladder, which may cause overflow incontinence.

Causes of persistent urinary incontinence
Urinary incontinence can also be a persistent condition caused by underlying physical problems or changes, including:

• Pregnancy and childbirth. Pregnant women may experience stress incontinence because of hormonal changes and the increased weight of an enlarging uterus. In addition, the stress of a vaginal delivery can weaken muscles needed for bladder control. The changes that occur during childbirth can also damage bladder nerves and supportive tissue, leading to a dropped (prolapsed) pelvic floor. With prolapse, your bladder, uterus, rectum or small bowel can get pushed down from the usual position and protrude into your vagina. Such protrusions can be associated with incontinence.
  
• Changes with aging. Aging of the bladder muscle leads to a decrease in the bladder's capacity to store urine and an increase in overactive bladder symptoms. Risk of overactive bladder increases if you have blood vessel disease, so maintaining good overall health — including stopping smoking, treating high blood pressure and keeping your weight within a healthy range — can help curb symptoms of overactive bladder.
  
  After menopause women produce less estrogen, a hormone that helps keep the lining of the bladder and urethra healthy. With less estrogen, these tissues may deteriorate, which can aggravate incontinence.
  
  
• Hysterectomy. In women, the bladder and uterus lie close to one another and are supported by many of the same muscles and ligaments. Any surgery that involves a woman's reproductive system — for example, removal of the uterus (hysterectomy) — may damage the supporting pelvic floor muscles, which can lead to incontinence.
  
• Painful bladder syndrome (interstitial cystitis). This chronic condition causes painful and frequent urination, and rarely, urinary incontinence.
  
• Prostatitis. Loss of bladder control isn't a typical sign of prostatitis, which is inflammation of the prostate gland — a walnut-sized organ located just below the male bladder. Even so, urinary incontinence sometimes occurs with this common condition.
  
• Enlarged prostate. In older men, incontinence often stems from enlargement of the prostate gland, a condition also known as benign prostatic hyperplasia (BPH).
  
• Prostate cancer. In men, stress incontinence or urge incontinence can be associated with untreated prostate cancer. However, more often, incontinence is a side effect of treatments — surgery or radiation — for prostate cancer.
  
• Bladder cancer or bladder stones. Incontinence, urinary urgency and burning with urination can be signs and symptoms of bladder cancer or bladder stones. Other signs and symptoms include blood in the urine and pelvic pain.
  
• Neurological disorders. Multiple sclerosis, Parkinson's disease, stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control, causing urinary incontinence.
  
• Obstruction. A tumor anywhere along your urinary tract can block the normal flow of urine and cause incontinence, usually overflow incontinence. Urinary stones — hard, stone-like masses that can form in the bladder — may be to blame for urine leakage. Stones can be present in your kidneys, bladder or ureters.

Complications:

Complications of chronic urinary incontinence include:

• Skin problems. Urinary incontinence can lead to rashes, skin infections and sores (skin ulcers) from constantly wet skin.
  
• Urinary tract infections. Incontinence increases your risk of repeated urinary tract infections.
• Changes in your activities. Urinary incontinence may keep you from participating in normal activities. You may stop exercising, quit attending social gatherings or even stop venturing away from familiar areas where you know the locations of toilets.
  
• Changes in your work life. Urinary incontinence may negatively affect your work life. Your urge to urinate may cause you to have to get up often during meetings. The problem may disrupt your concentration at work or keep you awake at night, causing fatigue.
  
• Changes in your personal life. Perhaps most distressing is the impact incontinence can have on your personal life. Your family may not understand your behavior or may grow frustrated at your many trips to the toilet. You may avoid sexual intimacy because of embarrassment caused by urine leakage. It's not uncommon to experience anxiety and depression along with incontinence.

Treatments and drugs  :

Treatment for urinary incontinence depends on the type of incontinence, the severity of your problem and the underlying cause. Your doctor will recommend the approaches best suited to your condition. A combination of treatments may be needed.

In most cases, your doctor will suggest the least invasive treatments first, so you'll try behavioral techniques and physical therapy first and move on to other options only if these techniques fail.

Behavioral techniques
Behavioral techniques and lifestyle changes work well for certain types of urinary incontinence. They may be the only treatment you need.

• Bladder training. Your doctor may recommend bladder training — alone or in combination with other therapies — to control urge and other types of incontinence. Bladder training involves learning to delay urination after you get the urge to go. You may start by trying to hold off for 10 minutes every time you feel an urge to urinate. The goal is to lengthen the time between trips to the toilet until you're urinating every two to four hours.
  
  Bladder training may also involve double voiding — urinating, then waiting a few minutes and trying again. This exercise can help you learn to empty your bladder more completely to avoid overflow incontinence. In addition, bladder training may involve learning to control urges to urinate. When you feel the urge to urinate, you're instructed to relax — breathe slowly and deeply — or to distract yourself with an activity.
  
  
• Scheduled toilet trips. This means timed urination — going to the toilet according to the clock rather than waiting for the need to go. Following this technique, you go to the toilet on a routine, planned basis — usually every two to four hours.
  
• Fluid and diet management. In some cases, you can simply modify your daily habits to regain control of your bladder. You may need to cut back on or avoid alcohol, caffeine or acidic foods. Reducing liquid consumption, losing weight or increasing physical activity are other lifestyle changes that can eliminate the problem.

Physical therapy

• Pelvic floor muscle exercises. These exercises strengthen your urinary sphincter and pelvic floor muscles — the muscles that help control urination. Your doctor may recommend that you do these exercises frequently. They are especially effective for stress incontinence, but may also help urge incontinence.
  To do pelvic floor muscle exercises (Kegel exercises), imagine that you're trying to stop your urine flow. Squeeze the muscles you would use to stop urinating and hold for a count of three and repeat.
  
  With Kegel exercises, it can be difficult to know whether you're contracting the right muscles and in the right manner. In general, if you sense a pulling-up feeling when you squeeze, you're using the right muscles. Men may feel their penises pull in slightly toward their bodies. To double-check that you're contracting the right muscles, try the exercises in front of a mirror. Your abdominal, buttock or leg muscles shouldn't tighten if you're isolating the muscles of the pelvic floor.
  
  If you're still not sure whether you're contracting the right muscles, ask your doctor for help. Your doctor may suggest you work with a physical therapist or try biofeedback techniques to help you identify and contract the right muscles. Your doctor may also suggest vaginal cones, which are weights that help women strengthen the pelvic floor.
  
  
• Electrical stimulation. In this procedure, electrodes are temporarily inserted into your rectum or vagina to stimulate and strengthen pelvic floor muscles. Gentle electrical stimulation can be effective for stress incontinence and urge incontinence, but it takes several months and multiple treatments to work.

Medications
Often, medications are used in conjunction with behavioral techniques. Drugs commonly used to treat incontinence include:

• Anticholinergics. These prescription medications calm an overactive bladder, so they may be helpful for urge incontinence. Several drugs fall under this category, including oxybutynin (Ditropan), tolterodine (Detrol), darifenacin (Enablex), fesoterodine (Toviaz), solifenacin (Vesicare) and trospium (Sanctura). Possible side effects of these medications include dry mouth, constipation, blurred vision and flushing.
  
• Topical estrogen. Applying low-dose, topical estrogen in the form of a vaginal cream, ring or patch may help tone and rejuvenate tissues in the urethra and vaginal areas. This may reduce some of the symptoms of incontinence.
  
• Imipramine. Imipramine (Tofranil) is a tricyclic antidepressant that may be used to treat mixed — urge and stress — incontinence.
• Duloxetine. The antidepressant medication duloxetine (Cymbalta) is sometimes used to treat stress incontinence.

Medical devices
Several medical devices are available to help treat incontinence. They're designed specifically for women and include:

• Urethral insert. This small tampon-like disposable device inserted into the urethra acts as a plug to prevent leakage. It's usually used to prevent incontinence during a specific activity, but it may be worn throughout the day. Urethral inserts aren't meant to be worn 24 hours a day. They are available by prescription and may work best for women who have predictable incontinence during certain activities, such as playing tennis. The device is inserted before the activity and removed before urination.
  
• Pessary (PES-uh-re). Your doctor may prescribe a pessary — a stiff ring that you insert into your vagina and wear all day. The device helps hold up your bladder, which lies near the vagina, to prevent urine leakage. You need to regularly remove the device to clean it. You may benefit from a pessary if you have incontinence due to a dropped (prolapsed) bladder or uterus.

Interventional therapies

• Bulking material injections. Bulking agents are materials, such as carbon-coated zirconium beads (Durasphere), calcium hydroxylapatite (Coaptite) or polydimethylsiloxane (Macroplastique), that are injected into tissue surrounding the urethra. This helps keep the urethra closed and reduce urine leakage. The procedure — usually done in a doctor's office — requires minimal anesthesia and takes about five minutes. The downside is that repeat injections are usually needed.
  
• Botulinum toxin type A. Injections of onabotulinumtoxinA (Botox) into the bladder muscle may benefit people who have an overactive bladder. Researchers have found this to be a promising therapy, but the Food and Drug Administration (FDA) has not yet approved this drug for incontinence. These injections may cause urinary retention that's severe enough to require self-catheterization. In addition, repeat injections are needed every six to nine months.
  
• Nerve stimulators. Sacral nerve stimulators can help control your bladder function. The device,which resembles a pacemaker, is implanted under the skin in your buttock. A wire from the device is connected to a sacral nerve — an important nerve in bladder control that runs from your lower spinal cord to your bladder. Through the wire, the device emits painless electrical pulses that stimulate the nerve and help control the bladder. Another device, the tibial nerve stimulator, is approved for treating overactive bladder symptoms. Instead of directly stimulating the sacral nerve, this device uses an electrode placed underneath the skin to deliver electrical pulses to the tibial nerve in the ankle. These pulses then travel along the tibial nerve to the sacral nerve, where they help control overactive bladder symptoms.

Surgery
If other treatments aren't working, several surgical procedures have been developed to fix problems that cause urinary incontinence.
Some of the commonly used procedures include:

• Sling procedures. A sling procedure uses strips of your body's tissue, synthetic material or mesh to create a pelvic sling or hammock around your bladder neck and urethra. The sling helps keep the urethra closed, especially when you cough or sneeze. There are many types of slings, including tension-free, adjustable and conventional.
  
• Bladder neck suspension. This procedure is designed to provide support to your urethra and bladder neck — an area of thickened muscle where the bladder connects to the urethra. It involves an abdominal incision, so it's done using general or spinal anesthesia.
  
• Artificial urinary sphincter. This small device is particularly helpful for men who have weakened urinary sphincters from treatment of prostate cancer or an enlarged prostate gland. Shaped like a doughnut, the device is implanted around the neck of your bladder. The fluid-filled ring keeps your urinary sphincter shut tight until you're ready to urinate. To urinate, you press a valve implanted under your skin that causes the ring to deflate and allows urine from your bladder to flow.

Absorbent pads and catheters
If medical treatments can't completely eliminate your incontinence — or you need help until a treatment starts to take effect — you can try products that help ease the discomfort and inconvenience of leaking urine.

• Pads and protective garments. Various absorbent pads are available to help you manage urine loss. Most products are no more bulky than normal underwear, and you can wear them easily under everyday clothing. Men who have problems with dribbles of urine can use a drip collector — a small pocket of absorbent padding that's worn over the penis and held in place by closefitting underwear. Men and women can wear adult diapers, pads or panty liners, which can be purchased at drugstores, supermarkets and medical supply stores.
  
• Catheter. If you're incontinent because your bladder doesn't empty properly, your doctor may recommend that you learn to insert a soft tube (catheter) into your urethra several times a day to drain your bladder (self-intermittent catheterization). This should give you more control of your leakage, especially if you have overflow incontinence. You'll be instructed on how to clean these catheters for safe reuse.