Urinary Incontinence

Urinary incontinence is a common embarrassing condition in which there is loss of bladder control.

The severity of the problem ranges from a occasional mild leaking of urine when you cough or sneeze to uncontrollable wetting or a strong urge to urinate that occurs so suddenly that you do not get to a toilet in time.

It can appear at any age, but is more common in the elderly people. Urinary incontinence is twice more common in women than men. Loss of bladder control occurs when the muscles of your bladder sphincter become either too weak or too active.

If the muscles are too weak, you may leak urine when you

• cough,
• sneeze,
• laugh
• lift heavy objects,

and this is called stress incontinence. If your bladder muscles are very active, you may have a strong urge to urinate even when your bladder is not full. This is called urge incontinence or overactive bladder.

Prostate problems in men and nerve damage may be other causes of incontinence. If your urinary incontinence affects your daily routine, consult your doctor. Treatment depends on the type of your incontinence and your lifestyle.

In most people, simple lifestyle changes, exercises, and medicines can relieve the discomfort, but some conditions may require special devices or surgical procedures.

Signs and symptoms of urinary incontinence vary depending on its type.

Some people may have occasional, minor leaks of urine, while others wet their clothes frequently.

Types of urinary incontinence include:

Stress incontinence

Urine leaks as pressure is exerted on your bladder during exercise, coughing, sneezing, laughing or lifting some heavy object. This is most common in young or middle-aged women, and it begins around menopause.

Urge incontinence

You will have a sudden, intense urge to urinate followed by an involuntary loss of urine. You may need to urinate more often, including throughout the night. This may be caused by a minor condition, such as an urinary tract infection, or a more severe condition such as neurologic disorder or diabetes.

Overflow incontinence

You may experience frequent or constant dribbling of urine due to a bladder that does not empty completely. An enlarged prostate may block the urethra causing trouble in emptying the bladder. Diabetes and injury to the spinal cord may also cause this type of urinary incontinence.

Functional incontinence

This occurs in older people with a physical or mental impairment that keeps them from making it to the toilet in time. For example, severe arthritis may make it hard to move quickly enough.

Mixed incontinence

There may be a mix of stress and urge urinary incontinence, which means, you may leak urine when you laugh or sneeze at one time, and then you may leak urine as a result of a sudden urge to urinate that cannot be controlled.

When to see a doctor

You may hesitate to discuss your problem of incontinence with your doctor. But if incontinence is so frequent that it affects the quality of your life, it is necessary to seek medical advice because urinary incontinence may:

• Indicate a more serious underlying condition
• Restrict your social activities and interactions
• Increase the risk of falls in older adults when they rush to the toilet

Several causes exist for urinary incontinence.

Urinary incontinence is a symptom that may arise due to your daily habits, underlying medical disorders or physical damage.

Your doctor will perform a thorough evaluation to determine what is the cause of your incontinence.

Temporary urinary incontinence

Certain drinks, foods, and medications may act as diuretics and increase the amount of urine stimulating your bladder.

These include:

• Alcohol
• Caffeinated beverages
• Decaffeinated tea and coffee
• Carbonated drinks
• Artificial sweeteners
• Corn syrup
• Foods that are high in spice, sugar or acid, especially citrus fruits
• Heart and blood pressure medications, sedatives, and muscle relaxants
• Large doses of vitamins B or C

Certain conditions may also cause a short spell of incontinence. Constipation increases the need to urinate because the hard, compacted stool can cause the nerves that control your bladder to be overactive.

A urinary tract infection can irritate your bladder, and lead to temporary incontinence with a strong urge to urinate.

Persistent urinary incontinence

Urinary incontinence may persist for a long time due to underlying physical problems or changes such as:

Pregnancy

Changes in the hormone levels and an increasing weight of the uterus can lead to stress incontinence.

Childbirth

Vaginal delivery, sometimes, can cause weakening of the muscles needed for bladder control and also damage the nerves of the bladder and supportive tissue, leading to a dropped pelvic floor (prolapse). With this prolapse, the bladder, uterus, rectum or small intestine get displaced down from the normal position to protrude into the vagina. Such protrusions can lead to incontinence.

Changes with age

As you become older, aging of the bladder muscle makes it weaker, decreasing the bladder's capacity to hold urine. Incontinence becomes more likely with advancing age.

Damage to pelvic floor muscles

As pelvic floor muscles support your bladder, a damaged or weakened muscle – usually during the removal of the uterus or childbirth can lead to incontinence.

Menopause

Post-menopausal women produce less estrogen, a hormone that maintains the lining of the bladder and urethra healthy. Decreased estrogen levels cause deterioration of these tissues which aggravates incontinence.

Enlarged prostate

As a result of enlarged prostate gland, older men experience some incontinence.

Prostate cancer or bladder cancer

Untreated prostate cancer in men and bladder cancer in women can cause stress incontinence or urge incontinence. But in some cases, incontinence may occur as a side effect of prostate cancer treatment.

Obstruction

A tumor or a stone formed at any site along your urinary tract may cause block in the normal flow of urine, leading to overflow incontinence.

Neurological disorders

Parkinson's disease, multiple sclerosis, stroke, a brain tumor or a spinal injury interferes with the nerve signals involved in bladder control, causing urinary incontinence.

Making a diagnosis of urinary incontinence is done by performing several tests.

If you have urinary incontinence, you may consult seeing family doctor or a general practitioner initially. After evaluation, you may be referred to a doctor who specializes in urinary tract disorders (urologist), or if you are a woman, a gynecologist with specialized training in female bladder problems and urinary function (urogynecologist).

What you can do?

Getting ready for your appointment:

• Be aware of any pre-appointment restrictions, such as any diet restrictions.
• List your symptoms, including how often you urinate, nighttime bladder activity, and episodes of incontinence.
• Make a list of all your medications, vitamins and supplements, including their doses and regimen.
• Your key medical information along with other conditions you have.
• Ask a relative or friend to come along, this helps you remember what the doctor says. A notebook or an electronic device may be carried along to note important information during your visit.

Write down questions to ask your doctor.

For urinary incontinence, some basic questions you may ask your doctor include:

• What is the most likely cause of my symptoms?
• What kind of tests will I need?
• Do these tests require any specific preparations?
• Is my condition temporary?
• What treatment options are available?
• Will there be any side effects of the treatment?
• Is there a generic alternative to the medicine you have prescribed?
• How can I best manage urinary incontinence with my other conditions?

What to expect from your doctor?

Your doctor may ask you a number of questions, such as:

• When did you first experience your symptoms, and how severe were they?
• Do your symptoms appear continuously or occasionally?
• Is there anything that seems to improve or worsen your symptoms?
• How often do you need to urinate?
• When do you leak urine?
• Do you feel difficulty in emptying your bladder?
• Have you noticed blood in your urine?
• Do you smoke?
• How often do you drink alcohol and caffeinated beverages?
• How often do you eat spicy, sugary or acidic foods?

It is very important to determine the cause and type of your urinary incontinence, which will guide the treatment decisions. Your doctor will take a thorough history and perform a careful physical examination.

You may be asked to do a simple maneuver that demonstrates incontinence:

• close your mouth,
• pinch your nose shut and exhale forcefully.

After that, your doctor will recommend some tests:

Urinalysis

Your urine sample is checked for signs of infection, traces of blood or other abnormalities.

Bladder diary

You will be asked to maintain a dairy in which you can record how much fluids you drink, when you urinate, the amount of urine expelled, whether you had an urge to urinate and the number of episodes of incontinence you have had.

Post-void residual measurement

You are asked to urinate into a container that measures urine output. Then, your doctor measures the amount of urine left in your bladder using a catheter or ultrasound test. A large amount of residual urine in your bladder indicates an obstruction in your urinary tract or a problem with your bladder nerves or muscles.

Special testing

Your doctor may order the following tests if any further information is needed.

Urodynamic testing

This test helps to distinguish the type of urinary incontinence you have. It measures your bladder strength and the health of your urinary sphincter. A catheter is inserted into your urethra and bladder in order to fill your bladder with water. Meanwhile, a pressure monitor is used to measure and record the pressure inside your bladder.

Cystoscopy

Your doctor inserts a thin tube with a tiny lens attached to its end into your urethra. Your doctor can visualize and possibly remove abnormalities in your urinary tract.

Cystogram

Your doctor will insert a catheter into your urethra and bladder through which a special dye is injected. As you urinate and expel this fluid, X-ray images of your bladder are taken to reveal problems with your urinary tract.

Pelvic ultrasound

This is done to check for abnormalities in the urinary tract or genitals.

Treatment options for urinary incontinence depends on the type of incontinence, its severity, and the underlying cause. A combination of treatments may be needed. Your doctor may suggest the conservative treatment methods first and move on to other options only if these techniques fail.

Behavioral techniques

Your doctor may advise the following mesures:

• Bladder training: Helps to delay urination after you get the urge to go the toilet. You may at first start by trying to hold urine for 10 minutes each time you feel an urge to urinate. The ultimate goal is to extend the time between trips to the toilet until you start urinating once in every two to four hours.
• Double voiding: Double voiding means passing urine, and then waiting for a few minutes and then urinating again. This helps you to empty your bladder more completely and avoid overflow incontinence.
• Maintain a schedule of toilet trips: Urinate every two to four hours instead of waiting for the need to go.
• Fluid and diet management, to regain control of your bladder:You may need to limit or avoid alcohol, caffeine or acidic foods. Reducing liquid consumption, losing weight or increasing physical activity also can relieve your problem.
• Pelvic floor muscle exercises: Your doctor may advise you to perform these exercises often in order to improve the strength of the muscles that control urination. Also called Kegel exercises, these are very effective for stress incontinence but may also help urge incontinence. To perform pelvic floor muscle exercises, imagine as if you are trying to stop the flow of your urine. Then:

Tighten or contract the muscles you would use to stop urinating and hold them for five seconds, and then relax for five seconds. (If this is too difficult, start by holding for two seconds and relaxing for three seconds). Slowly increase the time of holding the muscle tight for 10 seconds at a time.

Target for at least three sets of 10 repetitions each day. To help you identify and contract the appropriate muscles, your doctor may advise you to try biofeedback techniques or refer you to a physical therapist.

• Electrical stimulation: Electrodes may be temporarily inserted into your rectum or vagina to stimulate and strengthen the pelvic floor muscles. Gentle electrical stimulation can be effective in treating stress incontinence and urge incontinence, but multiple treatments may be required over a period of several months.

Medications

Medications commonly prescribed to treat incontinence include:

• Anticholinergics: These medications are useful in urge incontinence as these calm an overactive bladder. Examples include oxybutynin (Ditropan XL), tolterodine (Detrol), darifenacin (Enablex), fesoterodine (Toviaz), solifenacin (Vesicare) and trospium (Sanctura).
• Mirabegron (Myrbetriq): This medication helps in relaxing the bladder muscles and increases the quantity of urine your bladder can hold. It is used to treat urge incontinence. It may also increase the amount of urine expelled at one time, thus helping to empty your bladder more completely.
• Alpha blockers: In men with urge or overflow incontinence, these medications can relax bladder neck muscles and muscle fibers in the prostate gland making it easier to empty the bladder. Examples include tamsulosin (Flomax), alfuzosin (Uroxatral), silodosin (Rapaflo), terazosin (Hytrin) and doxazosin (Cardura).
• Topical estrogen: Application of a low-dose, topical estrogen in the form of a vaginal cream, ring or patch helps in toning and rejuvenating the tissues in the urethra and vaginal areas. This reduces some symptoms of incontinence.

Medical devices

Devices that are designed to treat urinary incontinence in women include:

• Urethral insert: It a small, tampon-like disposable device inserted into the urethra. It can be used during a physical activity such as tennis, that can trigger incontinence. This insert acts as a plug that prevents urine leakage, and can be removed before urination.
• Pessary: This is a stiff ring that is inserted into your vagina and worn all day. The device holds up your bladder, which lies near the vagina, to prevent urine leakage. Incontinence due to a prolapsed bladder or uterus may benefit from a pessary.

Interventional therapies

Interventional therapies that helps in urinary incontinence include:

• Bulking material injections: A synthetic material is injected into the tissues surrounding the urethra. This bulking material helps in keeping the urethra closed and thus decreases the leakage of urine. This procedure should be repeated regularly, and is much less effective than more-invasive treatments such as surgery for stress incontinence. Botulinum toxin type A (Botox) injections into the bladder muscle may be helpful in people with an overactive bladder. Botox is usually prescribed only if other first line medications have been unsuccessful.
• Nerve stimulators: A device similar to a pacemaker is implanted beneath your skin. It delivers painless electrical pulses to the nerves involved in bladder control (sacral nerves). Sacral nerve stimulation can control urge incontinence if other treatments have been unsuccessful . The device is implanted under the skin in your buttock and is connected directly to the sacral nerves or may deliver pulses to the sacral nerve via a nerve in the ankle.

Surgery

There are several surgical procedures to treat the problems that cause urinary incontinence:

• Sling procedures: Strips of your body tissue, synthetic material or mesh are used to create a pelvic sling around your urethra and the area of thickened muscle where the bladder connects to the urethra (bladder neck). This sling keeps the urethra closed when you cough or sneeze. This procedure treats stress incontinence.
• Bladder neck suspension: It involves an abdominal incision, so it is done under general or spinal anesthesia. This procedure provides support to your urethra and bladder neck — an area of thickened muscle where the bladder connects to the urethra.
• Prolapse surgery: In women with mixed incontinence and pelvic organ prolapse, surgery includes a combination of a sling procedure and prolapse surgery.
• Artificial urinary sphincter: In men, a small, fluid-filled ring is implanted around the bladder neck, which keeps the urinary sphincter closed until you are ready to urinate. These are useful in men with incontinence associated with treatment of prostate cancer or an enlarged prostate gland.

Absorbent pads and catheters

There are certain products available to ease the discomfort and inconvenience of urine leakage:

• Pads and protective garments: Most products are similar to a normal underwear and can be easily worn everyday. Men who have problems with dribbles of urine can use a drip collector — a small pocket of absorbent padding that is worn over the penis, and held in place by a tightly fitting underwear.
• Catheter: If your incontinence is because of incomplete bladder emptying, your doctor may advise you to learn insertion of a soft tube (catheter) into your urethra many times a day to drain your bladder. You will also be taught how to clean these catheters for safe reuse.

Urinary incontinence is not a preventable condition. However, you can follow certain measures to decrease your risk:

• Maintain a healthy body weight
• Practice pelvic floor exercises, especially during pregnancy
• Avoid intake of bladder irritants such as caffeinated beverages and acidic foods
• Eat foods high in fiber, which can prevent constipation, a cause of urinary incontinence

No alternative remedies have been proved to cure urinary incontinence yet.

Although, initial pilot studies on acupuncture have shown that it can provide some short-term benefit, but more research is needed.

Lifestyle modifications are necessary in order to cope with urinary incontinence.

Even after completing the treatment, you may still experience incontinence from time to time.

You need not bother as there are some products that can help you cope with your problem. The products include:

Absorbent pads

You may place disposable pads in your underwear to absorb leaked urine and avoid your clothes from getting wet.

Adult diapers

You can make use of an adult diaper if you leak large amounts of urine. You can either choose disposable adult diapers, which you wear once and throw away or washable adult diapers that can be reused after washing.

Protective underwear

There are special kinds of underwear, which can prevent clothes from getting wet. These underwears have a waterproof crotch with room for a pad or liner. Some underwears may be made from a waterproof fabric to keep your skin dry.

Furniture pads

These pads are designed to protect chairs and beds from leaking urine. Some pads are disposable, whereas cloth pads can be washed and reused.

Special skin cleansers and creams

Urine irritates your skin if it stays there for a long time. Special skin cleansers and creams are available for people who leak urine. These products may prevent the skin around your urethra from getting irritated. Creams may act as a barrier and protect your skin from urine.

Deodorizing pills

Deodorizing pills can help you smell less strongly. This way, even if you leak urine, it may be less noticeable. Ask your doctor about deodorizing pills.
Avoid constipation to prevent pressure on your bladder.

• Drink sufficient water,
• eat plenty of fiber rich foods such as whole grains, vegetables, and fruits,
• be physically active to prevent constipation.

You need to take good care of your skin to prevent skin related problems with urine leakage.

• Use a washcloth to clean yourself
• Let your skin air-dry
• Do not perform frequent douching and washing as it can interfere with your body's natural defenses against bladder infections
• Apply a barrier cream such as petroleum jelly or cocoa butter, to protect your skin from urine

If you have urge incontinence or nighttime incontinence, make your toilet more convenient:

• Remove any rugs or furnitures that you might trip over or collide with on the way to the toilet
• Let your path to the toilet be well-lit to reduce your risk of falling
• If you have functional incontinence, you might need to:
• Keep a bedpan in your bedroom
• Make an elevated toilet seat
• Widen an existing bathroom doorway

If you are embarrassed about a bladder control problem, you may try to cope on your own by wearing absorbent pads, carrying extra clothes or even avoiding going out.