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 millions of 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.

HOW DOES THE BLADDER 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:

  • 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.
  • To empty the urine out that it has stored or "to void".

WHAT IS INCONTINENCE?

Urinary incontinence is the involuntary loss of urine which can be chronic or acute. Chronic incontinence means that it starts gradually and slowly becomes worse over time. It may be caused by muscle weakness in the urinary tract, damage, or a malfunction in the urinary tract or the nerves that control urination. Chronic incontinence is most common in women, although it does occur in men. Acute incontinence is a temporary loss of urine control that ends when the underlying issue is successfully treated or addressed. Examples could be a urinary tract infection, a medication side effect, constipation, bladder stones, or even childbirth. Acute incontinence is categorized among the following types:

  • Urge incontinence - a sudden need or urge to urinate that results in the loss of urine before a bathroom is reached. It's that "gotta go, gotta go" feeling.
  • Stress incontinence - any activity that causes the abdominal muscles to contract (laughing, straining, coughing, sneezing, exercise or lifting) may result in involuntary loss of urine.
  • Overflow incontinence - constant dribbling of urine due to bladder overfilling, spilling excess and never emptying completely.

Other types of incontinence:

  • 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.
  • Functional incontinence occurs when something makes it hard to reach a bathroom in a timely manner.
  • Anatomical incontinence results when there are problems with the urinary tract that affect the urine flow. They may be present from birth.
  • 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?

Urge incontinence is characterized by a sudden uncontrollable urge to urinate. With urge incontinence, the bladder contracts and squeezes out urine involuntarily. It's that "gotta go, gotta go" feeling that can be triggered by something as simple as hearing running water, or being in a car and knowing there is no bathroom nearby. However, it can also be caused by an underlying physical condition. Leakage from urge incontinence occurs with urgency, frequency, nocturia (making several trips to the bathroom at night), and sometimes sexual intercourse. Urine loss is unpredictable, in large amounts, and requires the increased use and number of feminine pads to protect clothing. Underlying physical conditions could include:

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

HOW DOES A UROLOGIST DIAGNOSE URGE INCONTINENCE?

  • A health history and physical exam
  • Voiding diary
  • 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

TREATMENT OPTIONS FOR URGE INCONTINENCE

The treatment of urge incontinence varies greatly based on the cause. Options may include:

  • Medications to make the bladder less irritable
  • Exercises of the pelvic floor muscles
  • Biofeedback and electrical stimulation
  • Bladder training with timed voiding
  • 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 the weakening of pelvic floor muscles related to childbearing and/or the aging process. It can also occur with menopause, as a result of pelvic surgery (prostatectomy for men; hysterectomy for women), obesity, family history/race, smoking, and chronic cough. Stress incontinence that occurs with coughing, sneezing, exercise, laughing or straining is caused by an abnormal rotation downward of the bladder and urethra. Urine loss is predictable, in small amounts (such as a dribble), and requires fewer feminine pads to protect clothing.

HOW DOES A UROLOGIST DIAGNOSE STRESS INCONTINENCE?

  • A health history and physical exam
  • Pelvic exam
  • Urethral assessment
  • Other tests: urinalysis, bladder diary, Urodynamics

TREATMENT OPTIONS FOR STRESS INCONTINENCE

  • Vaginal estrogen cream can improve the integrity of the vaginal mucosa and underlying urethral tissue.
  • Medications
  • Pessary (a device worn in the vagina to support the bladder and urethra and prevent involuntary leakage). 
  • Surgical options such as bulking agents, or a midurethral sling
  • Pelvic floor muscle rehabilitation
  • Kegel exercises
  • Biofeedback

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 DOES A UROLOGIST DIAGNOSE OVERFLOW INCONTINENCE?

  • Health history and physical exam
  • Urodynamics

TREATMENT OPTIONS FOR OVERFLOW INCONTINENCE

  • 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

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