Incontinence

URINARY INCONTINENCE OR URINARY LEAKAGE

Urinary incontinence is a bladder control problem that causes the involuntary loss of urine. Urine leakage is experienced by more than 30 million Americans, both men and women, although it is most prevalent in women. While there may be many different causes and degrees of severity, one thing is certain: bladder control problems are not normal in adults of any age. Unfortunately, urinary Incontinence can be both frustrating and embarrassing, and it can prevent those affected from participating in life's activities, and can lead to social isolation. The good news is that there are several treatment options available for urinary incontinence. Ironically, statistics reveal that over 50% of those experiencing incontinence fail to seek treatment.

WHAT IS YOUR BLADDER AND HOW DOES IT WORK?

Three sets of muscles control urine. One set is the bladder muscle itself. The second set is sphincter muscles that open and close the urethra and the third set is the pelvic floor muscles. They support the uterus, rectum and the bladder. The bladder is the muscle that sits just under your pubic bone and is connected to the kidneys. The two tubes (ureters) bring urine made by the kidneys down to the bladder. The bladder has two main jobs:

1) To store urine. Every time you eat or drink, your body absorbs liquids. The kidneys filter out waste products from the blood and make urine.
2) To empty the urine out that it has stored or "to void".

HOW DOES YOUR BLADDER KNOW WHAT TO DO?

The slight need to urinate is sensed when urine volume reaches about one half of the bladder's capacity. When your bladder is full, nerves in your bladder signal the brain that it is full and you get the urge to go to the bathroom. Your brain sends signals through nerves in your spinal cord that tell the large bladder muscle called the detrusor (layered smooth muscle that surround the bladder) when to relax and when to contract. Once stimulated, the detrusor contracts into a funnel shape ready to expel the urine. The brain also helps to co-ordinate the bladder, the sphincters and pelvic floor muscles so that they are working together to relax and to let the urine through. So, conditions that affect brain function and spinal cord function often affect a person's ability to control urination.

WHAT IS INCONTINENCE?
 

  • Long-term (chronic) incontinence usually starts gradually and slowly becomes worse. Incontinence is the involuntary loss of urine. It is not a disease but a symptom of a problem with the urinary tract.
  • Acute Incontinence is a temporary loss of urine control that ends when the problem causing it is successfully treated. It may be caused by childbirth, urinary tract infection, drug side effect, constipation or bladder stones.
  • Chronic incontinence is a long-term loss of urine control. It may be caused by muscle weakness in the urinary tract or by damage or malfunction in the urinary tract or the nerves that control urination. It is common for a person to have more than one cause of incontinence. Chronic incontinence is more common in women than in men. Chronic can be classified into several types, the most common being:

    1) Urge incontinence - a sudden need or urge to urinate that results in the loss of urine before a bathroom is reached. (See our overactive bladder discussion for more details).
    2) Stress incontinence - any activity that causes the abdominal muscles to contract (laughing, straining, coughing, sneezing, or lifting) may result in involuntary loss of urine.
    3) Overflow incontinence - constant dribbling of urine due to bladder overfilling, spilling excess and never emptying completely.

Other types of incontinence:

1. Reflex incontinence occurs when the bladder contracts involuntarily and you are unable to stop it. This can be caused by spinal card injuries, multiple sclerosis and other disorders that affect nerve function.
2. Functional incontinence occurs when something makes it hard to reach a bathroom in a timely manner.
3. Anatomical incontinence results when there are problems with the urinary tract that affect the urine flow. They may be present from birth.
4. De-estrogenization of the urethra occurs with the loss of estrogen after menopause. Estrogen makes the urethra spongy, and this imparts increased resistance to the flow of urine.

WHAT CAUSES URGE INCONTINENCE?

Some people leak urine because they have bladder contractions when they are not able to go to the bathroom. Many experience this kind of incontinence when they hear water running or are in the car and know there is no bathroom nearby. Sometimes uninhibited bladder contractions occur when a person changes positions, for example upon standing up from a sitting position. Urge incontinence is characterized by a sudden uncontrollable urge to urinate. With urge the bladder contracts and squeezes out urine involuntarily.

Urge incontinence can be caused by:

  • Irritability of the bladder without an identifiable cause
  • Brain injury
  • Damage to the spinal cord
  • Infection of the bladder
  • An enlarged prostate
  • A stone
  • A bladder outlet (sphincter) that doesn't open properly during urination
  • Cancer

If you think you have urge incontinence you should contact a urologist. A urologist will investigate the cause and initiate treatment.

HOW CAN MY UROLOGIST DETERMINE THE CAUSE OF URGE INCONTINENCE?

Your urologist can determine the cause of your urge incontinence with a few simple tests which may include:

  • A health history and physical exam
  • Review of a voiding diary from the patient
  • Urine analysis - looking for blood, stone crystals, bacteria
  • Urine culture - looking for an infection
  • Urine cytology - looking for cancer cells in the urine
  • IVP - an x-ray looking at the kidneys, the urine tubes that connect the kidney to the bladder (ureters), and the bladder
  • Kidney ultrasound - looking at the kidneys
  • Bladder ultrasound - looking at the bladder
  • Cystoscopy - looking into the bladder with a small scope that has a miniature camera on the tip
  • Urodynamics - a test that involves putting a small tube into the rectum and a small tube into the bladder and taking measurements during bladder filling and emptying

Your urologist often needs to only do a select few of these tests to determine the cause of your urge incontinence.

HOW WILL MY UROLOGIST TREAT MY URGE INCONTINENCE?

The treatment of urge incontinence varies greatly because it depends on what is determined to be the cause. If there is no identifiable cause and it is determined that the over-activity is due to a primary bladder dysfunction your urologist may treat it with:

1) Medications to make the bladder less irritable
2) Exercises of the pelvic floor muscles that often can stop an urge episode once sensed, i.e., biofeedback and electrical stimulation
3) Bladder training with timed voiding
4) Sacral nerve stimulation- the surgical implantation of a device that interacts with the nerves going into and out of the bladder making the bladder less irritable. InterStim® Therapy for urinary control is a reversible treatment for people with urge incontinence caused by overactive bladder who do not respond to behavioral treatments or medications.

WHAT CAUSES STRESS INCONTINENCE?

In women, Stress Incontinence often results from weakening of the pelvic floor musculature related to childbearing and the aging process. The bladder may move down and bulge into the vagina. It is said to be hypermobile. This herniation or cystocele changes the angle of the urethra, which causes it to remain open and allow urine to leak out. It is not, however a normal part of aging and can be effectively evaluated and treated. Incontinence that occurs with coughing, laughing or straining is caused by an abnormal rotation downward of the bladder and urethra. It can be caused by:

  • lack of function of the sphincter that normally helps to hold back urination
  • weakness of the muscles that support the urethra and bladder

Risk factors include childbirth, menopause and pelvic surgery (e.g. prostatectomy, hysterectomy), and weight gain.

HOW CAN MY UROLOGIST DETERMINE THE CAUSE OF STRESS INCONTINENCE?

Your urologist can determine the cause of you stress incontinence with a few tests including:

  • Health history and physical exam
  • Urodynamics - a test that involves putting a small tube into the rectum and a small tube into the bladder and taking measurements during bladder filling and emptying

HOW WILL MY UROLOGIST TREAT MY STRESS INCONTINENCE?

Treatment and management of stress incontinence is tailored to correcting the cause of the stress incontinence. Treatments and management can include

Medical Therapies

  • Vaginal estrogen cream can improve the integrity of the vaginal mucosa and underlying urethral tissue.
  • Imipramine
  • Ephedrine

Internal Devices

  • Pessary (a device worn in the vagina to support the bladder and urethra and prevent involuntary leakage). They are silicone or latex devices inserted into the vagina to compress the urethra and support the bladder neck to prevent leakage during strenuous activity. They are available in different sizes and shapes.
  • Femsoft insert is a disposable, single use device inserted into the urethra, creating a seal at the neck of the bladder that prevents urine leakage.

External Devices

  • Single use foam pad is a small patch with adhesive held over the urethral opening causing pressure to prevent leakage.
  • Silicone caps use suction to support the urethral sphincter. An ointment is applied to the inner surface to create a vacuum seal that holds the cap in place.
  • A penile clamp is a v-shaped casing with a foam cushion that fits over the penis. When closed, the clamp stops the flow of urine. Compression rings fit around the penis and are inflated to pinch off urine flow.
  • Absorbent pads

Injection Therapy

Injecting material to increase the bulk around the urethra can improve the function of the urethral sphincter and compress the urethra near the bladder outlet. Injectable materials include collagen, fat from the patient's body and synthetic compounds.

Non-surgical treatments

  • Pelvic floor muscle rehabilitation:
  • Kegel exercises strengthen the pelvic floor muscles (puboccygeus muscle) to improve bladder control for people suffering from stress incontinence. Exercises should be performed several times per day and must be done over a period of 6-12 weeks to be effective.
  • Biofeedback may be used with Kegel Exercises to reinforce proper technique. A simple instrument records small electrical signals that are produced when the muscle contracts. The signals help the patient gain greater control over urinary muscle activity.
  • Neuromuscular Electrical Stimulation (NMES) treatments retrain and strengthen urinary muscles and improve bladder control used with men and women. Electrical stimulation to the nerve in the pelvic floor is performed causing the urethral sphincter muscles to contract.
  • NeoControl therapy is beneficial for women with stress, urge or mixed urinary incontinence caused by weak pelvic floor muscles. The treatment is delivered through pulsating magnetic fields in a chair.

Surgical treatments

  • Stress incontinence is the most common form of incontinence that is treated surgically. Surgical treatment is done to lift and support the connection between the bladder and the urethra. Surgery can be done through the vagina, through the abdomen, or a combination of the two and includes:
  • Bladder suspensions or pulling the bladder up to a more normal position and securing it to muscle, ligament or bone.
  • Sling procedures are often performed on patients with severe stress incontinence and intrinsic sphincter deficiencies. The goal is to create sufficient urethral compression to achieve bladder control.
  • Artificial sphincters may help patients who are incontinent after surgery for prostate cancer or stress incontinence, trauma victims and patients with birth defects in the urinary tract

WHAT IS OVERFLOW INCONTINENCE?

Overflow incontinence is the constant dribbling of urine that occurs in a bladder that never completely empties. So, as urine arrives in an already full bladder, the excess spills out like water flowing over a dam. Overflow incontinence is more common in older men with benign prostate hyperplasia (BPH) and in people with damage to their spinal cord that has resulted in a bladder that cannot contract effectively. Neurogenic bladder associated with overflow incontinence is caused by the loss of sensation of bladder fullness due to damage or obstruction of sacral nerves. Bladder weakness can develop in both men and women, but it happens most often in people with diabetes, heavy alcohol users, and others with decreased nerve function (multiple sclerosis, stroke, Parkinson Disease).

HOW CAN MY UROLOGIST DETERMINE THE CAUSE OF OVERFLOW INCONTINENCE?

Your urologist can determine the cause of overflow incontinence with a few tests including:

  • Health history and physical exam
  • Urodynamics - a test that involves putting a small tube into the rectum and a small tube into the bladder and taking measurements during bladder filling and emptying

HOW WILL MY UROLOGIST TREAT MY OVERFLOW INCONTINENCE?

Overflow incontinence is treated differently depending on the cause. For patients with overflow incontinence due to blockage of their urinary flow from a large prostate treatment includes:

  • Medications to relax or shrink the size of the prostate
  • Intermittent self-catherization for patients with neurogenic bladder
  • Microwave therapy to shrink the size of the prostate
  • For men, minimally invasive surgery using laser or electrocautery to remove the prostate tissue that is blocking the flow of urine
  • For men, open surgery to remove the prostate tissue that is blocking the flow of urine

ARE THERE ANY ALTERNATIVE OR HOMEOPATHIC MEDICINES THAT CAN BE USED TO TREAT INCONTINENCE?

Alternative and homeopathic medicines have been used for centuries to treat incontinence. Although there have been few scientific studies providing information on the success rates and side effects of these treatments many individuals believe that they have achieved improved continence using these methods. In general, alternative and homeopathic treatments are most successful in patients whose incontinence is caused by hormonal deficiencies or bladder inflammation from food sensitivities. Such therapies include:

  • Phytoestrogens - these are plant estrogens found in soy products and have been used in women with menopause related tissue atrophy as the cause of their incontinence
  • Eliminating foods that trigger bladder irritability
  • Avoiding foods/beverages containing caffeine
  • Drinking 1/2 of your body weight in ounces of water daily (e.g., if you weigh 150 lbs, drink 75 oz of water daily).
  • Vitamin supplements such as bromelain, flaxseed oil, vitamin C, and vitamin E may help to reduce inflammation within the bladder

The Urology Team does not recommend, endorse, or take responsibility for patient use of alternative or homeopathic treatments included in this web page.

Unfortunately most people suffer from a combination of the above types of urinary incontinence. The urologist must use a combination of tools in the evaluation of this problem.

The nature of the leakage must be determined by a careful history, and physical exam. Pelvic examination for women will demonstrate the degree of anatomic relaxation. A digital exam may be done for men to assess the prostate. Special testing for men and women is done (Urodynamics) that can determine the presence of uninhibited bladder contractions. Bladder x-rays demonstrate the anatomy during bladder filling and emptying. All this information will assist the urologist in determining the best treatment.

Unfortunately, many men and women who could be successfully treated resort instead to wearing absorbent undergarments or diapers.

No woman or man should have to live with urinary control problems. And no man or woman should be embarrassed to discuss this with their doctor. It's not a normal part of getting older. If you suffer from urinary incontinence or overactive bladder seek help because you deserve to be dry.

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