Urinary Incontinence

 

 

Urinary incontinence is the involuntary loss of urine from the body. It is a far more common than generally appreciated and often takes a significant toll on the affected individual. Approximately 15 million women in the United States cope with urinary incontinence.  Incontinence can also affect men, most often as a result of prostate problems or after prostate surgery.

 

Types of Urinary Incontinence

There are several types of urinary incontinence, but many individuals experience a combination of symptoms from more than one category of incontinence. Because each type of incontinence is treated differently, accurate diagnosis is essential to successful treatment.

  • Stress Incontinence - urine leaks during activities that increases pressure in the abdomen, such as exercising, sneezing, laughing, or getting out of a chair.   In women, stress urinary incontinence (SUI) results from hypermobility of the urethra and/or weakness of the urethral sphincter mechanism, known as intrinsic sphincter deficiency. Hypermobility results from pelvic floor muscle weakness, which is often due to pregnancy and childbirth.  In men, SUI is generally due to sphincter weakness.
  • Urge Incontinence - the abrupt, overwhelming need to urinate is called urgency and is the hallmark of "overactive bladder." If it results in urine loss before the intended time, the condition is termed urge incontinence.
  • Mixed Incontinence - combination of stress incontinence and urge incontinence.
  • Overflow Incontinence - in patients with obstruction of the bladder outlet, the bladder fills to capacity and is unable to empty normally. The end result can be slow continuous leakage of urine. This type of incontinence is most common in men with an an enlarged prostate. It may also occur when the bladder loses its ability to contract, such as late in the course of diabetes.
  • Functional Incontinence - factors outside the lower urinary tract, such as weaknesses in physical and/or cognitive function, cause this form of urinary incontinence. Common examples are dementia and stroke.

Causes of Urinary Incontinence

Urinary incontinence in women can be caused by a single condition or a combination of conditions.

  • Pregnancy, Childbirth, Pelvic Surgery- Weakened or damaged pelvic floor muscles and associated tissue can be the result of pregnancy and childbirth, causing the bladder and urethra to relax and descend from their normal positions. Pelvic surgery, hysterectomy in particular, can weaken the normal pelvic organ structural supports. The bladder and urethra must be well supported by the pelvic muscles and tissue to allow them to work properly.
  • Pelvic Organ Prolapse - prolapse of the bladder, rectum, or small intestines into the vagina can contribute to incontinence by altering the normal anatomic relationships between these structures and the urethra. It can also interfere with normal bowel and sexual function. Often, prolapse develops, or progresses years after hysterectomy or multiple vaginal deliveries.
  • Aging and Genetic Factors - Muscular strength wanes with aging and the pelvic muscles are no different. Over time, pelvic muscle loss often contributes to urinary incontinence.
  • Medical Conditions - some medical and neurological conditions, such as spinal cord problems (e.g., spina bifida, spinal cord injury, malformation of the lower spine), multiple sclerosis, Parkinson's disease, stroke and diabetes can make incontinence worse.
  • Infections and Medications - urinary tract infections can cause temporary incontinence, and certain medications may increase the likelihood of temporary incontinence.
  • Obesity - while obesity does not cause incontinence, it can exacerbate leakage due to the increased abdominal pressure on the bladder.
  • Smoking - While not a direct cause, smoking may aggravate incontinence through progressive tissue injury.

 

Evaluation of Urinary Incontinence

  • History and Physical Exam - Your urologist will take a detailed history related to your urine leakage and pelvic health, including number of pregnancies, vaginal deliveries, cesarian sections, and pelvic surgery. A pelvic exam is part of the standard evaluation of incontinence and pelvic organ prolapse.
  • Voiding Diary - A standard component of the evaluation, a voiding diary provides objective information about fluid intake, frequency of urination and incontinent episodes, as well as severity of leakage, and bladder volume.
  • Urodynamics - This is the most objective study of bladder function and urinary incontinence. It can be thought of as an "EKG for the bladder." Small catheters are placed for monitoring bladder and abdominal pressures. The bladder is filled and emptied while pressures are measured and leakage episodes observed. Urodynamics provides useful information that can not be obtained by other means and often directs treatment decisions.

 

 Treatment Options for Urinary Incontinence 

Depending on severity, a variety of options are available for managing urinary incontinence.

  • Behavioral Therapies
    • Decreasing fluid intake in the late afternoon and evening
    • Prompted or timed voiding (for example, if urge incontinent episodes happen around 3 hours after the last void, prompt the individual to go to the bathroom every 2-2.5 hours)
  • Pelvic muscle exercises - These exercises are commonly called Kegel exercises and are used to strengthen the pelvic floor muscles.
  • Protective Undergarments - Products such as pads, undergarment liners and absorbent underwear are worn to absorb urine that has leaked from the bladder.
  • Catheter - Some women require an indwelling catheter, which is left in place 24 hours a day to continually collect urine in an external drainage bag.
  • Pessary - Some women with urinary incontinence and/or vaginal prolapse may benefit from use of a pessary. The passive compression device is inserted into the vagina where it presses against the wall of the vagina and the urethra. The pressure helps reposition the urethra, preventing leakage.
  • Bulking Injections - collagen or similar agents can be injected into the urethral lining to narrow the passageway and improve closure, thereby decreasing leakage. These types of procedures often lack durability, however, and may need to be repeated.
  • Medication - Several medications are FDA approved to help bladder control problems due to overactivity. There are, however, no medicines currently available to treat stress incontinence, which remains primarily treatable with surgery. Patients with mixed (stress and urge) incontinence may find drug therapy helpful in addressing the urge component of their incontinence.

  • Surgery - A variety of surgical options are available to treat urinary incontinence and pelvic orgran prolapse. The appropriate procedure depends on the evaluation and resulting diagnosis.
    • Stress incontinence in women is most often treated with a sub-urethral sling, a very easy and quick operation.
    • Mild-Moderate stress incontinence in men after prostate surgery can also be treated by placement of a mesh sling below the urethra. 
    • Severe post-prostatectomy incontinence, fortunately a rare outcome in skillled hands, is best treated by placing an artificial urinary sphincter.
    • Urge incontinence that has failed to respond to medications may be improved by either botulinum toxin (BoTox) injections into the bladder wall or by implanting a device that regulates nerve control of the bladder.  This is known as neuromodulation and the device is known as InterStim.