Urinary incontinence refers to the loss of urinary control which causes a patient’s physical or social harm. It is a common urological condition that can have a significant impact on the quality of life for those who suffer from the condition, but also potentially for friends and family members of the patient. Incontinence is a treatable condition that begins with an evaluation by a urologist. It can be due to a variety of causes and effects both men and women. Once the evaluation is complete and the underlying problem identified, then treatment may be considered. Therapy for urinary leakage may include, lifestyle changes, specific exercises, medications, surgery or a combination of these depending on the type of incontinence There are three major classifications of incontinence and some patients may have more than one type.
- Urge Incontinence (Overactive Bladder) — Leakage that is accompanied by a strong need (urge) to urinate that does not allow time to reach the bathroom.
- Stress Incontinence — This is leakage which occurs with coughing, sneezing, exercising or straining. It is most common among middle aged and older women and some men after prostate removal.
- Incontinence Without Sensation (Overflow Incontinence) — This leakage occurs when the bladder empties poorly and often without good sensation. Urine may overflow through a relatively weak urinary sphincter.
Urge Incontinence (Overactive Bladder)
- A sudden, strong urge to urinate
- Inability to get to the bathroom in time
- Frequent need to urinate, including at night
- Feeling the urge to urinate when you hear water running
- Most commonly this disorder is due to changes in the bladder muscle and pelvic nerves.
- A diet high in bladder irritants such as coffee, tea, chocolate or acidic fruit juices can worsen the symptoms
- Recurrent urinary tract or vaginal infections
- Bowel problems including chronic constipation or irritable bowel disease
- Some medications
- Damage to the nervous system caused by Multiple Sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke, diabetes and other causes.
- Urine leaks when lifting heavy objects, exercising, coughing, sneezing, etc.
- Symptoms worsen when your bladder is full or you are more active.
- Most commonly this disorder is due to weakness in the pelvic floor muscle or external sphincter. This weakness may be is worsened by:
- previous pelvic surgery (i.e. hysterectomy).
- Prostate surgery in men
Incontinence Without Awareness or with Overflow
- Usually patients are unaware when the leakage occurs. It may happen when they first rise from sitting or at night when the bladder silently fills. Some patients note a constant, slow leaking through the day that worsens with cough, sneeze, and other physical activities. At times however the only indication is a damp pad or underwear.
- Aging can cause a gradual loss of sensation in the bladder and sphincter area.
- Neurological conditions from injury or with diseases such as diabetes.
- Obesity Side effects from medication that cause the bladder to be over relaxed.
The first step is a thorough history and physical by your doctor, who will examine your abdomen, urethra, and genital area carefully. Additional tests may include:
- Bladder diary — your doctor may ask you to keep a record of times and volume of urination, and intake of fluids.
- Measurement of the angle of the urethra
More specialized tests that your urologist may perform include:
- Postvoid residual test (PVR) — your doctor can determine how well you empty your bladder by using an ultrasound that detects the amount of leftover (residual) urine. A large amount may indicate a blockage, or a nerve or bladder muscle problem.
- Urodynamic test — More specific measurement of bladder function using a catheter inserted into your bladder, slow flow of fluid into the bladder and measurements of pressure, flow and sphincter relaxation or overactivity.
- Cystogram — a special X-ray of your bladder.
- Cystoscopy — An office procedure where a small scope is inserted gently into the bladder through the urethra.
Treatment will depend on your type of incontinence and its cause. With an accurate diagnosis most people can be treated successfully, allowing them to enjoy a normal life again. The first step to treating urinary leakage is to understand the cause. If leakage is caused by poorly controlled diabetes, then better diabetic management should be considered first. If obesity is the primary cause for leaking, then an aggressive weight loss program should be the first recommendation. If poor bladder emptying is causing overflow leakage, then treating the obstruction, if present, would be first. If it is due to a neurological problem, then clean intermittent self-cath would be best. Once the underlying problem has been addressed, treatment may begin with noninvasive therapy, such as behavioral changes or medication Other patients may benefit from a procedure, particularly when a weak or ineffective sphincter is the main cause of leaking. Some treatment options are listed below.
Lifestyle Changes (improvement may take time)
- Fluid and diet management — avoid caffeinated or acidic foods and drinks like tomatoes and citrus fruits and drink adequate water
- Bladder retraining — for a small capacity bladder one might increase the length of time between urinations to improve bladder size and hopefully control
- Bowel management — avoiding constipation with the help of fiber, stool softeners, or sometimes laxatives.
- Pelvic floor (Kegel) exercises — learn techniques to strengthen your pelvic muscles
- Biofeedback — can help you determine when you’re exercising the right muscles
- Special absorbent pads and underwear — these have improved in recent years and may be all that is needed, particularly in the elderly or infirmed.
- If you have urge incontinence, your doctor may prescribe medicine to relax your bladder muscles.
- If you urinate frequently at night, there are medications that cause your body to make less urine at night.
Surgery and Implanted Devices
- Bulking agent — for certain types of stress incontinence a thick substance called a bulking agent can be injected into the area around the bladder to support it. This procedure is best for mild leakage in patients at higher risk for more invasive surgery.
- Electrical device — this outpatient procedure entails placement of a small electrode that delivers a mild electrical signal to the pelvic nerves to calm the bladder and reduce leakage.
- Sling surgery — A small strip of tissue or mesh is implanted under the bladder to support the bladder neck and urethra. This is usually a very effective outpatient surgery for selected patients.
- Artificial Urinary Sphincter — this implanted device replaces the natural muscle that controls the urine flow at the outlet of the bladder. This works best for men who suffer from significant stress incontinence due to failure of their native urinary sphincter muscles, most commonly from prostate removal.