Urinary incontinence

Answer 1

Definition

Urinary (or bladder) incontinence is when you are not able to keep urine from leaking from your urethra, the tube that carries urine out of your body from your bladder. It can range from an occasional leakage of urine, to a complete inability to hold any urine.

The three main types of urinary incontinence are:

• Stress incontinence -- occurs during certain activities like coughing, sneezing, laughing, or exercise.
• Urge incontinence -- involves a strong, sudden need to urinate followed by instant bladder contraction and involuntary loss of urine. You don't have enough time between when you recognize the need to urinate and when you actually do urinate.
• Overflow incontinence -- occurs when the bladder cannot empty completely, which leads to dribbling.
• Mixed incontinence -- involves more than one type of urinary incontinence.

Bowel incontinence, a separate topic, is the inability to control the passage of stool.

Alternative Names

Loss of bladder control; Uncontrollable urination; Urination - uncontrollable; Incontinence - urinary

Considerations

Incontinence is most common among the elderly. Women are more likely than men to have urinary incontinence.

Infants and children are not considered incontinent, but merely untrained, up to the time of toilet training. Occasional accidents are not unusual in children up to age 6 years. Young (and sometimes teenage) girls may have slight leakage of urine when laughing.

Nighttime urination in children is normal until the age of 5 or 6.

NORMAL URINATION

Normally, the bladder begins to fill with urine from the kidneys. The bladder stretches to allow increasing amounts of urine.

The first urge to urinate occurs when around 200 mL (just under 1 cup) of urine is stored in the bladder. A healthy nervous system will respond to this stretching sensation by alerting you to the urge to urinate, while also allowing the bladder to continue to fill.

The average person can hold around 350 to 550 mL (more than 2 cups) of urine. Two muscles help control the flow of urine:

• The sphincter (the circular muscles around the opening of the bladder) must be able to squeeze to prevent urine from leaking.
• The bladder wall muscle (detrusor) must stay relaxed so the bladder can expand.

When it is time to empty the bladder, the bladder wall (detrusor) muscle contracts or squeezes to force urine out of the bladder. Before this muscle squeezes, your body must be able to relax the sphincter to allow the urine to pass out of the body.

The ability to control urination depends on having normal anatomy, a normally functioning nervous system, and the ability to recognize and respond to the urge to urinate.

Common Causes

Causes include:

• Problems with the anatomy
• Blockage
• Brain or nerve problems
• Nerve and muscle disorders (neuromuscular disorders)
• Dementia or other psychological problems that affect the ability to recognize and respond to the urge to urinate

Incontinence may be sudden and temporary, or ongoing and long-term. Causes of sudden or temporary incontinence include:

• Bedrest -- for example, when recovering from surgery
• Certain medications (such as diuretics, antidepressants, tranquilizers, some cough and cold remedies, and antihistamines for Allergies)
• Mental confusion
• Pregnancy
• Prostate infection or inflammation
• Stool impactionfrom severe constipation, causing pressure on the bladder
• Urinary tract infection or inflammation
• Weight gain

Causes that may be more long-term:

• Alzheimer's disease
• Bladder cancer
• Bladder spasms
• Depression
• Large prostate in men
• Neurological conditions such as multiple sclerosis or stroke
• Nerve or muscle damage after pelvic radiation
• Pelvic prolapse in women -- falling or sliding of the bladder, urethra, or rectum into the vaginal space, often related to having had multiple pregnancies and deliveries
• Problems with the structure of the urinary tract
• Spinal injuries
• Weakness of the sphincter, the circular muscles of the bladder responsible for opening and closing it; this can happen following prostate surgery in men, or vaginal surgery in women

Home Care

See your doctor for an initial evaluation and to come up with a treatment plan. Treatment options vary, depending on the cause and type of incontinence you have. Fortunately, there are many things you can do to help manage incontinence.

The following methods are used to strengthen the muscles of your pelvic floor:

• Bladder retraining -- this involves urinating on a schedule, whether you feel a need to go or not. In between those times, you try to wait to the next scheduled time. At first, you may need to schedule 1-hour intervals. Gradually, you can increase by 1/2-hour intervals until you are only urinating every 3 - 4 hours without leakage.
• Kegel exercises -- contract the pelvic floor muscles for 10 seconds, then relax them for 10 seconds. Repeat 10 times. Do these exercises three times per day. You can do Kegel exercises any time, any place.

To find the pelvic muscles when you first start Kegel exercises, stop your urine flow midstream. The muscles needed to do this are your pelvic floor muscles. Do NOT contract your abdominal, thigh, or buttocks muscles. And Do NOT overdo the exercises. This may tire the muscles out and actually worsen incontinence.

Two methods called biofeedback and electrical stimulation can help you learn how to perform Kegel exercises. Biofeedback uses electrodes placed on the pelvic floor muscles, giving you feedback about when they are contracted and when they are not. Electrical stimulation uses low-voltage electric current to stimulate the pelvic floor muscles. It can be done at home or at a clinic for 20 minutes every 1 - 4 days.

Biofeedback and electrical stimulation will no longer be necessary once you have identified the pelvic floor muscles and mastered the exercises on your own.

Vaginal cones enhance the performance of Kegel exercises for women. Other devices for incontinence are also available.

For leakage, wear absorbent pads or undergarments. There are many well designed products that go completely unnoticed by anyone but you.

See also: Urinary incontinence products

Other measures include:

• Regulate your bowels to avoid constipation. Try increasing fiber in your diet.
• Quit smoking to reduce coughing and bladder irritation. Smoking also increases your risk of bladder cancer.
• Avoid alcohol and caffeinated beverages, particularly coffee, which can overstimulate your bladder.
• Lose weight if you need to.
• Avoid foods and drinks that may irritate your bladder, like spicy foods, Carbonated Beverages, and citrus fruits and juices.
• Keep blood sugar under good control if you have diabetes.

Your doctor may recommend medication or surgery, especially if home care measures are not helping or if your symptoms are getting worse.

Medications that may be prescribed include drugs that relax the bladder, increase bladder muscle tone, or strengthen the sphincter.

Surgery may be required to relieve an obstruction or deformity of the bladder neck and urethra.

See also:

• Urge incontinence
• Stress incontinence

If you have overflow incontinence or cannot empty your bladder completely, a catheter may be recommended. But using a catheter exposes you to potential infection.

PREVENTION

Performing Kegel exercises while you are pregnant and soon after delivery may help prevent incontinence related to childbirth.

Call your health care provider if

Discuss incontinence with your doctor. Gynecologists and urologists are the specialists most familiar with this condition. They can evaluate the causes and recommend treatment approaches.

Call your local emergency number (such as 911) or go to an emergency room if any of the following accompany a sudden loss of urine control:

• Difficulty talking, walking, or speaking
• Sudden weakness, numbness, or tingling in an arm or leg
• Loss of vision
• Loss of consciousness or confusion
• Loss of bowel control

Call your doctor if:

• You have been constipated for more than 1 week
• You have difficulty starting your urine flow, dribbling, nighttime urination, pain or burning with urination, increased frequency or urgency, or cloudy or bloody urine
• You are taking medications that may be causing incontinence -- do NOT adjust or stop any medications without talking to your doctor.
• You are over 60 years old and your incontinence is new, especially if you are also having trouble with your memory or caring for yourself
• You have the urge to go often, but are only passing small amounts of urine
• Your bladder feels full even after you have just urinated
• Incontinence persists for more than 2 weeks even with exercises to strengthen your pelvic muscles

What to expect at your health care provider's office

Your doctor will take your medical history and perform a physical examination, with a focus on your abdomen, genitals, pelvis, rectum, and neurologic system.

Medical history questions may include:

• How long has incontinence been a problem for you?
• How many times does this happen each day?
• Are you aware of the need to urinate before you leak?
• Are you immediately aware that you have passed urine?
• Are you wet most of the day?
• Do you wear protective garments in case of accidents? How often?
• Do you avoid social situations in case of accidents?
• Have you had urinary tract infections in the past? Do you think that you may have one now?
• Is it more difficult to control your urine when you cough, sneeze, strain, or laugh?
• Is it more difficult to control your urine when running, jumping, or walking?
• Is your incontinence worse when sitting up or standing?
• Are you constipated? For how long?
• Is there anything you do to reduce or prevent accidents?
• Have you ever been treated for this condition before? Did it help?
• Have you tried pelvic floor exercises (Kegel)? Do they help?
• What procedures, surgeries, or injuries have you had?
• What medications do you take?
• Do you drink coffee? How much?
• Do you drink alcohol? How much?
• Do you smoke? How much each day?
• Do you have diabetes or a family history of diabetes?
• Do you have any other symptoms?

Diagnostic tests that may be performed include:

• Urinalysis
• Urine cultureto check for infection, if indicated
• Cystoscopy(inspection of the inside of the bladder)
• Urodynamic studies (tests to measure pressure and urine flow)
• Uroflow (to measure pattern of urine flow)
• Post void residual (PVR) to measure amount of urine left after urination

Other tests may be performed to rule out pelvic weakness as the cause of the incontinence. One such test is called the Q-tip test. This test involves measurement of the change in the angle of the urethra when it is at rest and when it is straining. An angle change of greater than 30 degrees often indicates significant weakness of the muscles that support the bladder.

References

Gerber GS, Brendler CB. Evaluation of the urologic patient: History, physical examination, and urinalysis. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 3.

Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE. What type of urinary incontinence does this woman have? JAMA. 2008;299:1446-1456.

Rogers RG. Clinical practice: urinary stress incontinence in women. N Engl J Med. 2008;358:1029-1036.

Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008;148:459-473.

Answer 2

Definition

Urinary (or bladder) incontinence is when you are not able to keep urine from leaking out of your urethra, the tube that carries urine out of your body from your bladder. You may leak urine from time to time. Or, you may not be able to hold any urine.

The three main types of urinary incontinence are:

• Stress incontinence -- occurs during certain activities like coughing, sneezing, laughing, or exercise.
• Urge incontinence -- involves a strong, sudden need to urinate. Then the bladder squeezes and you lose urine. You don't have enough time after you feel the need to urinate to get to the bathroom before you do urinate.
• Overflow incontinence -- occurs when the bladder cannot empty. This leads to dribbling.
• Mixed incontinence -- involves more than one type of urinary incontinence.

Bowel incontinence is when you are unable to control the passage of stool. It is not covered in this article.

Alternative Names

Loss of bladder control; Uncontrollable urination; Urination - uncontrollable; Incontinence - urinary

Considerations

NORMAL URINATION

Normally, the bladder begins to fill with urine from the kidneys. The bladder stretches to allow more and more urine.

You should feel the first urge to urinate when there is around 200 mL (just under 1 cup) of urine stored in your bladder. A healthy nervous system will respond to this stretching sensation by letting you know that you have to urinate. At the same time, the bladder should keep filling.

The average person can hold around 350 to 550 mL (more than 2 cups) of urine in the bladder. Two muscles help control the flow of urine:

• The sphincter (the circular muscles around the opening of the bladder) must be able to squeeze to prevent urine from leaking.
• The bladder wall muscle (detrusor) must stay relaxed so the bladder can expand.

When it is time to empty the bladder, the bladder wall (detrusor) muscle contracts or squeezes to force urine out of the bladder. Before this muscle squeezes, your body must be able to relax the sphincter to allow the urine to pass out of your body.

To control urination, you must have:

• A working urinary system
• A working nervous system
• The ability to feel and respond to the urge to urinate

Incontinence is most common among the elderly. Women are more likely than men to have urinary incontinence.

Infants and children are not incontinent before they have been toilet trained. Children up to age 6 may still have accidents sometimes. Young (and sometimes teenage) girls may leak a little bit of urine when they laugh.

It is normal for children to wet the bed until age 5 or 6.

Common Causes

Causes of urinary incontinence include:

• Blockage in the urinary system
• Brain or nerve problems
• Dementia or other mental health problems that make it hard to feel and respond to the urge to urinate
• Problems with the urinary system
• Nerve and muscle problems

Incontinence may be sudden and go away after a short period of time. Or, it may continue long-term. Causes of sudden or temporary incontinence include:

• Bedrest -- for example, when recovering from surgery
• Certain medications (such as diuretics, antidepressants, tranquilizers, some cough and cold remedies, and antihistamines for allergies)
• Mental confusion
• Pregnancy
• Prostate infection or inflammation
• Stool impactionfrom severe constipation, which causes pressure on the bladder
• Urinary tract infection or inflammation
• Weight gain

Causes that may be more long-term:

• Alzheimer's disease
• Bladder cancer
• Bladder spasms
• Depression
• Large prostate in men
• Nervous system conditions, such as multiple sclerosis or stroke
• Nerve or muscle damage after radiation treatment to the pelvis
• Pelvic prolapse in women -- falling or sliding of the bladder, urethra, or rectum into the vagina, which may be caused by pregnancy and delivery
• Problems with the urinary tract
• Spinal cord injuries
• Weakness of the sphincter, the circle-shaped muscles that open and close the bladder (this can be caused by prostate surgery in men, or surgery to the vagina in women)

Home Care

See your health care provider for tests and a treatment plan. What type of treatment you get depends on what caused your incontinence and what type you have.

The following methods are used to strengthen the muscles of your pelvic floor:

• Bladder retraining -- You urinate on a schedule, whether or not you feel a need to go. In between bathroom visits, you try to wait until the next scheduled time. At first, you may need to schedule urination every hour. Gradually, you can increase by 1/2 hour at a time until you only urinate once every 3 - 4 hours without leaking.
• Kegel exercises -- squeeze the pelvic floor muscles for 10 seconds, then relax them for 10 seconds. Repeat 10 times. Do these exercises three times a day. You can do Kegel exercises any time, in any place.

For urine leaks, wear absorbent pads or undergarments. There are many well-designed products that no one else will notice. See also: Urinary incontinence products

Other treatments include:

• Keep your bowel movements regular to avoid constipation. Try increasing the fiber in your diet.
• Quit smoking to reduce coughing and bladder irritation. Smoking also increases your risk for bladder cancer.
• Avoid alcohol and caffeinated drinks such as coffee, which can stimulate your bladder.
• Lose weight if you need to.
• Avoid foods and drinks that may irritate your bladder, like spicy foods, carbonated drinks, and citrus fruits and juices.
• If you have Diabetes, keep your blood sugar under good control.

See also: When you have urinary incontinence

For more information about treating urinary incontinence, see also:

• Stress incontinence
• Urge incontinence

If you have overflow incontinence or cannot empty your bladder completely, you may need to use a catheter. For more information on catheter use, see also:

• Indwelling catheter care
• Self-catheterization - female
• Self-catheterization - male

Call your health care provider if

Talk to your health care provider about incontinence. Health care providers who treat incontinence are called gynecologists and urologists. They can find the cause and recommend treatments.

Call your local emergency number (such as 911) or go to an emergency room if you suddenly lose control over urine and you have:

• Difficulty talking, walking, or speaking
• Sudden weakness, numbness, or tingling in an arm or leg
• Loss of vision
• Loss of consciousness or confusion
• Loss of bowel control

Call your health care provider if:

• You have been constipated for more than 1 week
• You have:
  • Cloudy or bloody urine
  • Dribbling
  • Frequent or urgent need to urinate
  • Pain or burning when you urinate
  • Trouble starting your urine flow
• You are taking medicines that may cause incontinence -- but do NOT change or stop taking any medicines without talking to your doctor.
• You are over 60 years old and your incontinence is new, especially if you are also having trouble with your memory or caring for yourself
• You have the urge to go often, but are only passing small amounts of urine
• Your bladder feels full even after you have just urinated
• Incontinence lasts for more than 2 weeks, even though you are doing exercises to strengthen your pelvic muscles

What to expect at your health care provider's office

Your health care provider will ask about your medical history. You will have a physical exam focusing on your abdomen, genitals, pelvis, rectum, and nervous system.

Your health care provider may ask questions such as:

• How long have you had a problem with incontinence?
• How many times do you leak urine each day?
• Do you know that you need to urinate before you leak?
• Do you know right away that you have passed urine?
• Are you wet most of the day?
• Do you wear protective garments in case of accidents? How often do you wear them?
• Do you avoid social situations in case of accidents?
• Have you had urinary tract infections in the past? Do you think that you may have one now?
• Is it harder to control your urine when you cough, sneeze, strain, or laugh?
• Is it harder to control your urine when you run, jump, or walk?
• Is your incontinence worse when you sit up or stand?
• Are you constipated? For how long have you been constipated?
• Is there anything you do to reduce or prevent accidents?
• Have you ever been treated for this condition before? Did treatment help?
• Have you tried pelvic floor exercises (Kegels)? Do they help?
• What procedures, surgeries, or injuries have you had?
• What medications do you take?
• Do you drink coffee? How much?
• Do you drink alcohol? How much?
• Do you smoke? How much each day?
• Do you have diabetes or a family history of diabetes?
• Do you have any other symptoms?

Tests that may be performed include:

• Cystoscopy(viewing the inside of the bladder)
• Post void residual (PVR) to measure the amount of urine left after you urinate
• Urinalysis
• Urine cultureto check for infection
• Urodynamic studies (to measure pressure and urine flow)
• Uroflow (to measure the pattern of urine flow)

References

Gerber GS, Brendler CB. Evaluation of the urologic patient: History, physical examination, and urinalysis. In: Wein AJ, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 3.

Resnick NM. Incontinence. In: Goldman L, Ausiello D, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 25.

Deng DY. Urinary incontinence in women. Med Clin North Am. 2011;95:101-109.

Reviewed By

Review Date: 09/19/2011

Linda J. Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington, School of Medicine; and Louis S. Liou, MD, PhD, Assistant Professor of Urology, Department of Surgery, Boston University School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.