URINARY INCONTINENCE

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INTRODUCTION-

Urinary incontinence happens when you lose control of your bladder. In some cases, you may empty your bladder’s contents completely. In other cases, you may experience only minor leakage. The condition may be temporary or chronic, depending on its cause.

According to the Urology Care Foundation, millions of adults in the United States experience urinary incontinence. According to Johns Hopkins Medicine, it’s more common among women age 50 and over. However, this condition can affect anyone.

As you age, the muscles supporting your bladder tend to weaken, which can lead to urinary incontinence.

Many different health problems can also cause the condition. Symptoms can range from mild to severe and can be a sign of cancer, kidney stones, infection, or an enlarged prostate.

If you experience urinary incontinence, make an appointment with your healthcare provider. Urinary incontinence can interfere with your daily life and lead to potential accidents. Your healthcare provider can also determine if a more serious medical condition is the cause.

Urinary incontinence — the loss of bladder control — is a common and often embarrassing problem. The severity 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.

Though it occurs more often as people get older, urinary incontinence isn’t an inevitable consequence of aging. If urinary incontinence affects your daily activities, don’t hesitate to see your doctor. For most people, simple lifestyle changes or medical treatment can ease discomfort or stop urinary incontinence.

TYPES-

Urinary incontinence is divided into three general types. You can potentially experience more than one type at the same time.

Stress incontinence

Stress incontinence is triggered by certain types of physical activity.

For example, you might lose control of your bladder when you’re:

• exercising
• coughing
• sneezing
• laughing

Such activities put stress on the sphincter muscle that holds urine in your bladder. The added stress can cause the muscle to release urine.

Urge incontinence

Urge incontinence occurs when you lose control of your bladder after experiencing a sudden and strong urge to urinate. Once that urge hits, you may not be able to make it to the bathroom in.

Overflow incontinence

Overflow incontinence can occur if you don’t completely empty your bladder when you urinate. Later, some of the remaining urine may leak from your bladder. This type of incontinence is sometimes called “dribbling.”

Mixed Incontinence

Some people have more than one type of urinary incontinence. Some people leak urine both with strong physical activity (SUI) AND have a strong uncontrollable sense of urgency (OAB.) This is mixed urinary incontinence. This person has both SUI and OAB. In this case, it helps to know what is occurring and what is causing leaks to learn how to manage problems.

CAUSES-

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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.

Temporary urinary incontinence

Certain drinks, foods and medications may act as diuretics — stimulating your bladder and increasing your volume of urine. They include:

• Alcohol
• Caffeine
• Carbonated drinks and sparkling water
• Artificial sweeteners
• Chocolate
• Chili peppers
• Foods that are high in spice, sugar or acid, especially citrus fruits
• Heart and blood pressure medications, sedatives, and muscle relaxants
• Large doses of vitamin C

Urinary incontinence may also be caused by an easily treatable medical condition, such as:

• Urinary tract infection. Infections can irritate your bladder, causing you to have strong urges to urinate, and sometimes incontinence.
• 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.

Persistent urinary incontinence

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

• Pregnancy. Hormonal changes and the increased weight of the fetus can lead to stress incontinence.
• Childbirth. Vaginal delivery can weaken muscles needed for bladder control and also damage bladder nerves and supportive tissue, leading to a dropped (prolapsed) pelvic floor. With prolapse, the bladder, uterus, rectum or small intestine can get pushed down from the usual position and protrude into the vagina. Such protrusions can be associated with incontinence.
• Changes with age. Aging of the bladder muscle can decrease the bladder’s capacity to store urine. Also, involuntary bladder contractions become more frequent as you get older.
• Menopause. After menopause women produce less estrogen, a hormone that helps keep the lining of the bladder and urethra healthy. Deterioration of these tissues can aggravate incontinence.
• Hysterectomy. In women, the bladder and uterus are supported by many of the same muscles and ligaments. Any surgery that involves a woman’s reproductive system, including removal of the uterus, may damage the supporting pelvic floor muscles, which can lead to incontinence.
• Enlarged prostate. Especially in older men, incontinence often stems from enlargement of the prostate gland, a condition known as benign prostatic hyperplasia.
• Prostate cancer. In men, stress incontinence or urge incontinence can be associated with untreated prostate cancer. But more often, incontinence is a side effect of treatments for prostate cancer.
• Obstruction. A tumor anywhere along your urinary tract can block the normal flow of urine, leading to overflow incontinence. Urinary stones — hard, stone-like masses that form in the bladder — sometimes cause urine leakage.
• Neurological disorders. Multiple sclerosis, Parkinson’s disease, a stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control, causing urinary incontinence.

There are many potential causes of urinary incontinence.

Examples include:

• weakened bladder muscles, resulting from aging
• physical damage to your pelvic floor muscles
• enlarged prostate
• cancer

Some of these conditions are easily treatable and only cause temporary urinary problems. Others are more serious and persistent.

Aging

As you get older, the muscles supporting your bladder typically become weaker, which raises your risk for incontinence.

To maintain strong muscles and a healthy bladder, it’s important to practice healthy lifestyle habits. The healthier you are, the better your chances of avoiding incontinence as you age.

Damage

Your pelvic floor muscles support your bladder. Damage to these muscles can cause incontinence. It can be caused by certain types of surgery, such as a hysterectomy. It’s also a common result of pregnancy and childbirth.

Enlarged prostate

If you’re male, your prostate gland surrounds the neck of your bladder. This gland releases fluid that protects and nourishes your sperm. It tends to enlarge with age. It’s common for males to experience some incontinence as a result.

Cancer

Prostate or bladder cancer can cause incontinence. In some cases, treatments for cancer can also make it harder for you to control your bladder. Even benign tumors can cause incontinence by blocking your flow of urine.

Other potential causes

Other potential causes of incontinence include:

• constipation
• urinary tract infections (UTIs)
• kidney or bladder stones
• prostatitis, or inflammation of your prostate
• interstitial cystitis, or a chronic condition that causes inflammation within your bladder
• side effects from certain medications, such as blood pressure drugs, muscle relaxants, sedatives, and some heart medications

Some lifestyle factors can also cause temporary bouts of incontinence. For example, drinking too much alcohol, caffeinated beverages, or other fluids can cause you to temporarily lose control of your bladder.

DIAGNOSIS-

A urologist or primary care doctor will start by asking questions. They will want to know about your symptoms and your medical history. They will ask about your health habits and fluid intake. They will also want to know how much your incontinence has changed your quality of life.

A good medical history, physical exam and a few simple tests are most often all that is needed to diagnose the cause of incontinence. A complete review of the medications you are taking may reveal one that alters normal bladder or urethral function. Your doctor may test your urine for bacteria or blood (urinalysis) to look for a urinary tract infection or other source of irritation to the bladder.

A cough stress test may be performed to check for SUI. A simple bladder ultrasound test to see how well you empty your bladder is often performed. Or a more involved “stress test” for the bladder can be done in more complicated cases (urodynamic test) to better see just how your bladder and urethra work. Other conditions to look for include vaginal hernias or pelvic organ prolapse (POP), and major bowel problems, such as constipation or fecal incontinence.

A urologist or primary care doctor will start by asking questions. They will want to know about your symptoms and your medical history. They will ask about your health habits and fluid intake. They will also want to know how much your incontinence has changed your quality of life.

A good medical history, physical exam and a few simple tests are most often all that is needed to diagnose the cause of incontinence. A complete review of the medications you are taking may reveal one that alters normal bladder or urethral function. Your doctor may test your urine for bacteria or blood (urinalysis) to look for a urinary tract infection or other source of irritation to the bladder.

A cough stress test may be performed to check for SUI. A simple bladder ultrasound test to see how well you empty your bladder is often performed. Or a more involved “stress test” for the bladder can be done in more complicated cases (urodynamic test) to better see just how your bladder and urethra work. Other conditions to look for include vaginal hernias or pelvic organ prolapse (POP), and major bowel problems, such as constipation or fecal incontinence.

A cough stress test may be performed to check for SUI. A simple bladder ultrasound test to see how well you empty your bladder is often performed. Or a more involved “stress test” for the bladder can be done in more complicated cases (urodynamic test) to better see just how your bladder and urethra work. Other conditions to look for include vaginal hernias or pelvic organ prolapse (POP), and major bowel problems, such as constipation or fecal incontinence.

Risk factors

Factors that increase your risk of developing urinary incontinence include:

• Gender. Women are more likely to have stress incontinence. Pregnancy, childbirth, menopause and normal female anatomy account for this difference. However, men with prostate gland problems are at increased risk of urge and overflow incontinence.
• Age. As you get older, the muscles in your bladder and urethra lose some of their strength. Changes with age reduce how much your bladder can hold and increase the chances of involuntary urine release.
• Being overweight. Extra weight increases pressure on your bladder and surrounding muscles, which weakens them and allows urine to leak out when you cough or sneeze.
• Smoking. Tobacco use may increase your risk of urinary incontinence.
• Family history. If a close family member has urinary incontinence, especially urge incontinence, your risk of developing the condition is higher.
• Other diseases. Neurological disease or diabetes may increase your risk of incontinence.

Complications

Complications of chronic urinary incontinence include:

• Skin problems. Rashes, skin infections and sores can develop from constantly wet skin.
• Urinary tract infections. Incontinence increases your risk of repeated urinary tract infections.
• Impacts on your personal life. Urinary incontinence can affect your social, work and personal relationships.

Prevention

Urinary incontinence isn’t always preventable. However, to help decrease your risk:

• Maintain a healthy weight
• Practice pelvic floor exercises
• Avoid bladder irritants, such as caffeine, alcohol and acidic foods
• Eat more fiber, which can prevent constipation, a cause of urinary incontinence
• Don’t smoke, or seek help to quit smoking

TREATMENT-

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There are many ways to help you take control over your bladder. You may not need to wear pads or diapers. Some problems are short-term and can be easily relieved. Others take more time to treat. Treatments range from lifestyle changes to bladder training to medications to simple procedural therapies to surgery.

Lifestyle Changes

Lifestyle changes, such as changing your diet, should be tried first. With lifestyle changes, you change the way you live day-to-day. This may include what you eat or drink, or practicing other methods that may control symptoms. You may not get rid of all symptoms with lifestyle changes, but your symptoms may feel better after changing a few habits. For some, weight loss has been linked to helping urinary symptoms.

Fluid Control

You will likely be asked to track what you drink, when and how much. You may learn that you should limit certain things such as caffeine and alcohol. These drinks may bother the bladder. You may also be asked to drink more water. Six to eight glasses of water per day is ideal. Also, you may be asked not to drink for a few hours before bed. This will help reduce your need to get up and go to the bathroom at night.

Limit Certain Foods and Drinks

Some foods and drinks have been found, anecdotally, as irritants to the bladder. Some people have found spicy foods, coffee, tea and colas to be bothersome. However, studies have not proven that these are really “bladder irritants” in all patients. A good plan is for you to try to notice on your own how different food and drinks effect you and your symptoms.

Bladder Training

A bladder diary is the starting point for bladder training. For 3 days, you write down what and how much you drink, and how often you go to the bathroom. Noting when you leak urine can also be helpful. This diary can help you and your provider find things that may make your symptoms worse. It can also help your provider build a bladder training plan for you. This is when you empty your bladder in a controlled way at set times. When you empty your bladder as a routine, you should have less leaks. Timed urination, scheduled voiding or double voiding are methods that can help with both OAB and SUI.

If you go to the bathroom too often, retraining your bladder can help. The goal is to hold your urine in the bladder for longer and longer amounts of time. This takes small steps. Start with adding 5 to 10 minutes. The goal is to retrain your bladder to hold urine for 3 to 4 hours, with less urgency and leaking.

Pelvic Floor Exercises

Kegel exercises can strengthen the urethral sphincter and pelvic floor muscles. This works for both men and women. If you can learn to tighten and relax these muscles, this can often help your bladder control.

Kegels can also help control the bladder spasms that trigger the urge to go. Squeezing the pelvic floor muscles inspires a reflex to the bladder to get the bladder to quiet down, to help suppress the urge feeling. This can pause or even stop the uncontrollable UUI leaks. A health care provider can teach you how to do these exercises with success.

Kegels can help with both SUI (by making the muscles strong) and OAB/UUI (by suppressing the urge feeling). Like any fitness program, you must practice the exercises often to keep helping your body.

Medical Treatments

When lifestyle changes do not help enough, your health care provider may ask you to try prescription medications. A frank talk with your provider about the risks, side effects and benefits of each medication will help you decide which might be the right one for you.

Anticholinergic Drugs

Anticholinergic drugs treat OAB/UUI by helping the bladder muscle to relax. Common medications include oxybutynin, tolterodine and solifenacin. They work well for the bladder, but are also linked to many bothersome side effects such as dry mouth, constipation, blurred vision, and lately, some concern for causing confusion or dementia with longer-term use. Trospium chloride does not diffuse into the brain so is not thought to have a risk of confusion or dementia.

A newer medication for OAB is merbegron. It is not an anticholinergic medication, so it is not linked to any of the side effects described above. It is an alpha-agonist, so works a little differently on the bladder, but in the end has the same effect of getting the bladder to relax. It can cause increases in blood pressure so needs to be used with caution in patients with hypertension.

Be sure to talk about any bladder relaxing drugs you have tried when you talk with your urologist.

Hormone Treatment

For women, local vaginal/urethral estrogen therapy can help if you are having urinary incontinence after menopause. Estrogen replacement helps the health of the walls of the vagina, the bladder neck and the urethra. This may ease irritative bladder symptoms and incontinence. There are some special medical reasons not to use local hormones, so be sure to speak to your provider about what is best for you.

Surgical Treatments for SUI

Choosing to have surgery is very personal. If surgery is suggested, there are many choices. It helps to learn as much as you can before you decide. You should work with a doctor who has experience in SUI surgery. Learn the risks and benefits of all your surgical choices, as well as what to expect during and after surgery, to make the most informed choice that will be best for you.

Slings

• Female Sling

The most common surgical treatment and the current standard of care for the surgical treatment of female SUI is the midurethral sling surgery. For this, a strip of soft permanent mesh is placed under the urethra to support urethral closure during actions that involve “physical pelvic stress” (coughing, sneezing, bending, lifting, jumping and running). It is a simple 10-20 minute, outpatient procedure with a small single-cut in the vagina. This is easily done under limited anesthesia and linked to a very quick return to normal day-to-day activities. Long-term success rates are in the 90%.

Another type of female sling surgery, the pubovaginal sling, is a bladder neck sling. Here the tissue used to make the sling comes from the patient’s abdominal wall (fascia), or donated tissue (bovine or cadaver).

• Male Sling

A sling procedure may be offered to treat SUI in some men. The male sling is for urethral sphincter muscle support. For this, a soft mesh tape is placed under the urethra through a cut between the scrotum and rectum. It supports the urethra and sphincter muscle by pushing up on the urethra and causing some coaptation (closure) of the urethra to prevent leaks. Ask your healthcare provider if this is an option for you.

Bladder Neck Suspension / Colposuspension

The Burch Colposuspension, or bladder neck suspension, is surgery for female SUI that lifts the bladder neck up towards the pubic bone with permanent stitches. This is a bigger surgery with a cut through the abdominal wall (muscles and skin), to reach the deeper pelvic areas. Because of the cut into the belly, it takes a longer time to heal from this surgery compared to the more minimally invasive midurethral sling, but it can be the right choice for some patients. In some cases it can be performed laparoscopically, which lessens the recovery time after surgery.

Bulking Agents (Injections)

This option is used to treat female SUI by “bulking up” the inner urethral lining and making the opening of the urethra smaller. Modern bulking agents are permanent materials that are placed into the tissues around the urethra and sphincter muscle up towards the bladder neck. This helps how well the natural urethral closure function can work to stop leaks.

Note that bulking agents are not FDA-approved for male SUI.

Artificial Urinary Sphincter

The most common treatment for male SUI is to implant a device around the urethra called an artificial urinary sphincter (AUS). In some cases, women may also be helped from this surgery, but due to other surgical options mentioned earlier, this is rarely needed in women. The AUS is a device with three parts:

1. An artificial urinary sphincter, which is a fluid filled cuff placed around the urethra.
2. A fluid-filled, pressure-sensing balloon that joins to the cuff and regulates the pressure within the cuff. This balloon is placed in the lower abdomen.
3. A pump placed in the scrotum for men (and labia for women), that transfers the fluid between the cuff and the balloon to open and close the cuff (artificial urinary sphincter). The pump is easily controlled by the patient.

At rest, the AUS cuff is closed (full of fluid) to prevent leaks. When you decide to empty your bladder, you activate the pump to push fluid from the cuff to the balloon that holds your urine. This allows the urethra to open so that the urine can flow through and empty the bladder. This surgery can cure or greatly help urinary control in about 70-80% of men. If you have had radiation, scar tissue in the urethra, or other bladder problems then this option may not be the best option for you.

Surgical Treatments for OAB

If lifestyle changes and medicine are not working for your OAB, there are other options. A trained urologist or female pelvic medicine & reconstructive surgery (FPMRS) specialist can help.

Bladder Botox® Treatment

Your doctor may offer bladder Botox® (onabotulinumtoxin). Botox works for the bladder to relax the muscle of the bladder wall to reduce urinary urgency and urge incontinence. To put Botox into the bladder your doctor will use a small camera, a cystoscope, through the urethra and into the bladder. With a tiny needle attached to the cystoscope, the Botox is injected in small amounts straight into the wall of the bladder, spreading it out evenly throughout the bladder. This procedure is most often performed in the office with local anesthesia (numbing mixture in the bladder). The effects of Botox last about 6-9 months, so repeat treatments will be needed when OAB symptoms return.

Within a few weeks of the treatment, your health care provider will want to check to see how well it is working for you, and to make sure you are still able to empty your bladder well. A small amount (<10%) of patients have trouble emptying their bladder for a short time after the treatment and may need to use a catheter (small tube) until their voiding improves.

Nerve Stimulation

Another treatment for people who need extra help for their OAB is nerve stimulation, also called neuromodulation therapy. This type of treatment sends electrical pulses to nerves that share the same path for the bladder (pelvic nerves). In OAB, the nerve signals between your bladder and brain do not always communicate the right way. Treatment with electrical pulses help to modulate the neurological signaling so the brain and the pelvic nerves can communicate better to help the bladder function – to “calm down” — and help OAB symptoms.

There are two main types available today:

• Percutaneous Tibial Nerve Stimulation (PTNS)

Percutaneous Tibial Nerve Stimulation, or PTNS, (peripheral) is an easy way to modulate the nerves to your bladder. PTNS is performed in the office, with each session taking about 30 minutes. PTNS is done by placing a small needle electrode in your lower leg near your ankle. It sends stimulation pulses up the leg, by way of the tibial nerve, to the pelvic nerves that modulate the bladder function to “calm the bladder down.” The therapy is approved as a program of weekly 30 minute sessions for 12 treatments, followed by on-going monthly care treatment sessions to keep the benefits.

• Sacral Nerve Stimulation (SNS)

SNS (central) stimulates the pelvic nerves by way of direct sacral nerve stimulation – the nerve root coming right off the spinal cord. Stimulation here again serves to modulate the neurological signaling between the bladder and the brain to help bladder function. SNS involves an implantable bladder pacemaker to control these signals to stop OAB symptoms. SNS is a two-step surgical process, which gives patients the chance to try the therapy first before making choices about final surgical implantation of the pacemaker. The first step is to implant an electrical wire through the skin in your lower back that goes deep towards the sacral nerves. This wire is linked to an external, handheld pacemaker for the test. If it helps sufficiently for your OAB symptoms, the second step is to join the wire to an implantable permanent pacemaker. The stimulation is then continuous as it regulates the pelvic nerve activity to control the OAB symptoms.

Bladder Reconstruction / Urinary Diversion Surgery

These type of major abdominal surgeries are only used in very rare and complicated cases. There are two main categories of major abdominal surgery. The goal of augmentation cystoplasty is to make the bladder bigger to increase how much urine it can hold at any one time. The goal of urinary diversion is to re-route the flow of urine away from the bladder and often results in a stoma and external appliance to catch the urine. There are many risks to these surgeries, so it is offered only when no other option can help.

Surgical Treatments for Overflow Incontinence

Overflow urinary incontinence happens when the bladder cannot empty well and dribbles as the bladder pressure grows. Most often, it is linked to some type of block of the bladder neck and/or urethra, and requires some type of procedural or surgical action to fix the block. Common problems in men that can lead to holding urine in and overflow incontinence include an enlarged prostate (benign prostatic hyperplasia, BPH) and urethral strictures. It is quite rare for urethral strictures to happen in women. Other medical problems can change how the bladder contracts to empty, which can also lead to overflow incontinence.

You should speak with your urologist to learn what therapy might be right for you.

Products and Devices

For some people, incontinence products and devices are the only way to manage bladder problems to give you more freedom to do the things you want to do.

Some include:

• Indwelling catheter (stays in your body day and night, joined to a drainage bag)
• Intermittent catheters that are used many times each day
• External collecting systems (condom style for men, funnel and pouch for women)
• Absorbent products (pads, adult diapers, tampons)
• Pessaries for women, mostly those designed for SUI
• Toilet substitutes (like portable commodes)

Whatever your urinary problem is, there are likely good choices for you. It is vital to find a provider that specializes in bladder and incontinence problems, such as a urologist.

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