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Resource Description: 
American Urological Association is an online patient information resource.
Kidney and Urology Foundation of America focuses on kidney and urologic research.
National Association for Continence is a source for public education and advocacy about the causes, prevention, diagnosis, treatments, and management alternatives for incontinence.
National Institute of Diabetes and Digestive and Kidney Diseases of the National Institute of Health conducts and supports biomedical research and disseminates research findings to the public.
Simon Foundation for Continence provides assistance and support to those suffering from urinary incontinence.
Episode number: 
106

Urinary incontinence means the bladder is unable to hold urine for as long as needed, that is, until it can be released voluntarily.  Incontinence is not a disease in itself, but a symptom of some other problem. In this episode of Second Opinion, you'll learn about different types of incontinence, their causes, how they're diagnosed and how they're treated.

The urinary tract consists of the organs that produce and eliminate urine (liquid waste) from the body: the kidneys, ureters, bladder, and urethra (links to glossary).

Urine is made by the kidneys (a pair of bean shaped organs in the back of the abdomen) when they filter excess water, salt and waste products from the blood.  Urine flows from the kidneys through the ureters (a pair of thin tubes) to the bladder, where it is stored until a person urinates.  The bladder is a hollow, muscular, balloon-shaped organ located in the pelvis. Urine leaves the body by passing from the bladder through another tube, the urethra, which is open at one end.  In men, the opening is at the tip of the penis; in women, it's just above the vagina.

During urination, sphincter muscles that surround the urethra relax, while muscles in the wall of the bladder contract.  This muscular action forces urine into the urethra. The pelvic floor muscles, located below the bladder, aid the sphincter muscles by supporting the bladder and helping it release or hold urine.

The process of urination is controlled by communication between the urinary tract and the brain. The bladder sends messages along nerves to the brain, telling the brain that the bladder is full.  The brain responds with messages sent along the same nerves, telling the muscles of the bladder to relax and retain the urine, or contract and let it go.

Clearly, the urinary system is complex.  A problem anywhere in the system - a blockage in one of the tubes, a problem with the message carrying nerves - can cause incontinence.  That is why there are several types of incontinence, with a variety of causes - and why it is important to take incontinence seriously.

Despite what many people think, aging alone is not one of those causes. Incontinence is not a normal result of aging.

 

Quick Facts

Urinary Incontinence Quick Facts

  • Incontinence means the bladder is unable to hold urine for as long as needed until it can be released voluntarily. 
  • Incontinence is not a disease in itself, but a symptom of some other problem.  Some of those problems can be serious.  That is why it is important to take incontinence seriously and talk to your doctor about it.
  • Embarrassment often keeps people from telling their doctor about their incontinence problems.  Embarrassment is not good for your health.
  • $15 billion are spent on incontinence products each year. Only 1% of that money is spent on medical evaluation and treatment.
  • About 30% of American women have incontinence problems.
  • Although incontinence is more common in older people, it is not a normal part of aging and it can be improved or cured.
  • Kegel exercises to strengthen the pelvic floor muscles may be an effective treatment for incontinence when done correctly.

Ask Your Doctor

Provided by Amy Rosenman, M.D.
Director, Pacific Continence Center
Assistant Clinical Professor, UCLA
Author, The Incontinence Solution: Answers for Women of All Ages

This list of questions is a good starting point for discussion with your doctor; however, it is not a comprehensive list.

  1. Since I have learned that it is not normal to leak urine, can you help me determine why this happens and how it can be treated?
  2. Is my urinary leakage related to menopause and aging, or childbirth?
  3. What are the exams and tests needed to evaluate my bladder problems?
  4. What are the available treatments for my situation?
  5. What are the non-surgical options?
  6. What are the medicines available and what side effects should I anticipate?
  7. Is surgery appropriate for this condition?
  8. Who can do the surgery laparoscopically or minimally invasively without indwelling catheters?
  9. Can a pessary be used for prolapse in place of surgery?
  10. Is there a biofeedback program available which can help with all types of incontinence, voiding and defecatory (bowel movement) problems?
  11. Is there a urogynecologist or urologist in town who specializes in these problems?

Key Point 1

Urinary incontinence is not just embarrassing or a nuisance.  It is a real medical problem that should not be ignored. It requires a medical workup.

The urinary system is complex, and the process of urination involves a series of interactions between the brain and a number of organs and muscles.  A problem anywhere within this system can lead to incontinence.  That is why there are several types of incontinence, with a variety of causes - and why it is important to take incontinence seriously.

The types of incontinence include:

  • Stress incontinence: small amounts of urine leak during any movement that puts pressure ("stress") on the bladder, such as exercise (including dancing), bending over, laughing, coughing, sneezing, lifting, etc.
    • Occurs more often in women
    • May be caused by weakened pelvic floor muscles 
  • Urge incontinence (also called "overactive bladder" or "spastic bladder"): urine is released after a sudden, uncontrollable urge to urinate is felt
    • Caused by sudden, uncontrollable, inappropriate bladder contraction
    • Overactive bladder can cause urgency and frequency without leakage (dry overactive bladder)
    • In this category, interstitial cystitis is sometimes included.  This is a disorder of the bladder wall muscle where it is intolerant of even small amounts of urine.  In this Second Opinion episode, Golf Pro Terri-Jo Myers shares her battle with Interstitial Cystitis.
  • Mixed incontinence: a combination of stress and urge incontinence
  • Overflow incontinence: small amounts of urine leak or dribble out often and unexpectedly because the bladder does not empty completely during normal urination, and then gets too full. This is often caused by:
    • Blockages in the urine flow 
    • Bladder muscles that do not contract completely

Those are the most common types of incontinence.  Other types appear less frequently, such as: 

  • Functional incontinence: the inability of someone to get to the bathroom before urinating because of physical disabilities, external obstacles, or problems in thinking or communicating.  It is not caused by a specific bladder or urinary tract pathology.
  • Reflex incontinence (also called unconscious incontinence): being unaware of the need to urinate
  • Transient incontinence: urine leakage or inability to control urination because of a temporary condition, such as infection (such as a bladder infection or cystitis), medications or irritants (such as blood in the urine)

From this you might infer correctly that incontinence is not a disease or disorder in itself, but a symptom of some other problem.  That is why an accurate diagnosis is so important.

The process of diagnosing the problem usually begins with a physical exam and a frank discussion of the person's complaints or symptoms and urinating habits. At least, the discussion should be frank.  Unfortunately, as this episode of Second Opinion makes clear, too often people don't talk to their doctor about difficulties controlling urination. They don't take the issue seriously or, more commonly, they are embarrassed about it.

But the fact is, when it is a question of health, you cannot afford to be embarrassed.  The doctor's office is the one place where, for your own good, it is best to "tell all."

If you do have an incontinence problem, you may be asked to keep a "voiding diary," a record of how often you urinate, what times of day, how much each time, how soon after drinking, etc.  You may think you already know the answers and do not need to write them down, but you - and your doctor -may discover some surprises, or make some connections you were not aware of.  At any rate, the doctor needs the details to understand the problem.

    

Key Point 2

Urinary incontinence is a symptom, not a disease. A number of medical problems can give you this symptom. Identifying the problem is the first step in treating it.

The process of diagnosing the problem usually begins with a physical exam, including a pelvic exam, and a frank discussion of your complaints or symptoms and urinating habits. You may be asked to keep a "voiding diary," a record of how often you urinate, what times of day, how much each time, how soon after drinking, etc.  Your doctor needs these details to understand the problem.

Then one or more diagnostic tests may be ordered.  Some common tests are:

  • Postvoid residual (PVR) measurement: measures the bladder's capacity and its ability to empty itself completely
  • Stress test: as its name implies, this tests for the presence of stress incontinence; for example, you will be checked for urine leakage while you cough
  • Urinalysis: laboratory analysis of a urine sample can uncover evidence of urinary tract infection (UTI), urinary tract stones (blockages in the urinary tract), and other causes of incontinence
  • Blood test: similarly, laboratory analysis of a blood sample can find various chemicals, substances and other possible causes of incontinence
  • Imaging tests: images of the urinary tract can show abnormalities or problems; a number of different imaging techniques are available, including:
    • Ultrasound: sound waves are bounced off the organs of the urinary tract to produce images of them (similar to ultrasound imaging used with pregnant women to produce images of fetuses)
    • Cystoscopy: looking directly into the bladder by inserting a cystoscope (a thin, telescope-like instrument with a fiber-optic lighting system and a special lens) up the urethra and into the bladder
  • Urodynamic studies: a general term for a group of techniques (ranging from simple observation to using sophisticated measuring equipment) to examine various functional aspects of the urinary system, including
    • Pressure on the bladder
    • Strength and functionality of bladder muscles
    • Bladder contractions
    • Bladder's ability to empty steadily and completely
    • Urine flow

You can find detailed descriptions of most of these tests at the National Institute of Diabetes and Digestive and Kidney Diseases web site.

When the specific problem has been diagnosed, its causes can be understood, and a plan of treatment designed.   Some of  the conditions, disorders and diseases that can cause incontinence are specific to women, others are specific to men, and still others can affect both.

Causes of incontinence specific to women include:

  • Pregnancy, childbirth and menopause: these can all weaken the pelvic floor muscles that support the bladder; weakened muscles can lead to stress incontinence
  • Prolapsed bladder: also known as a dropped bladder or cystocele, it happens when the wall between the bladder and the vagina weakens and stretches and lets the bladder droop into the vagina; this can cause stress incontinence, problems fully emptying the bladder and urge incontinence / overactive bladder
  • Interstitial cystitis (IC): this is a chronic inflammation of the bladder wall; although both men and women can have the condition, 90% of people with IC are women
    • IC is not the same as common cystitis, a bacterial infection that most often causes urinary tract infections.  IC is chronic or persistent.
    • IC is not caused by bacteria and is not treated with antibiotics
  • Hysterectomy: this surgery to remove the uterus can weaken or damage urinary tract nerves and muscles which can cause incontinence

Causes of incontinence specific to men include:

  • Prostate gland problems, such as
    • Benign prostatic hyperplasia (BPH): fairly common in older men, this is a benign (non-cancerous) enlargement of the prostate that can cause blockages in the urinary tract, leading to incontinence
    • Prostatitis: inflammation of the prostate gland
    • Prostate cancer
    • Side effects of prostate cancer treatment
  • Prostatectomy: this surgery to remove the prostate can weaken or damage urinary tract nerves and muscles which can cause incontinence

Causes of incontinence that affect women and men include:

  • Blockages in the urinary tract; these can result from several conditions, such as
    • Benign tumors or masses
    • Cancerous tumors
  • Urinary tract infections (UTIs): bacterial infections in the urinary tract can cause urge incontinence
    • Both men and women can get UTIs, though they affect women more frequently
  • Interstitial cystitis, mentioned above, can affect men as well as women
  • Neurogenic bladder: a condition in which the nerves that carry messages between the bladder and brain that control urination are damaged, something related to diseases such as diabetes, spinal stenosis and multiple sclerosis.

There are also a number of risk factors that may increase the likelihood of developing incontinence. They include:

  • Gender: twice as many women as men are affected with incontinence
  • Age: although incontinence is not inevitable with aging, it does occur more often in older adults
  • Diet: 
    • A number of common foods can irritate the bladder, leading to incontinence; these foods include
      • Products with caffeine, such as coffee, tea, colas, and chocolate
      • Acidic fruit juices
      • Alcoholic beverages
    • Not drinking enough fluid can cause urine to become concentrated which can irritate the bladder
    • Drinking a lot of fluid in a short time can cause temporary urinary frequency
  • Medicines: some medications have side effects that lead to incontinence, such as
    • Diuretics (water pills)
    • Some sedatives, muscle relaxants and antidepressants
    • High blood pressure and heart medicines
    • Cold pills
    • Diet pills
  • Damaged nerves or nerve pathways: as mentioned above, this can cause neurogenic bladder
  • Neurological injury or disease, such as multiple sclerosis and strokes
  • Congenital physical abnormalities in the urinary tract
    

Key Point 3

There are treatments for incontinence.  They include behavioral, medical, and surgical interventions.

Because incontinence is a symptom rather than a disorder, treatment naturally depends on the type, cause, and severity of the situation. Of course, various treatment approaches can be combined.

The most commonly prescribed behavioral treatment is the one discussed in this episode of Second Opinion: Kegel exercises .  They consist of alternately squeezing and relaxing the pelvic floor muscles to strengthen them.  Strengthening those muscles can reduce or cure both urge and stress incontinence.  

However, for these exercises to be effective, you must work the correct muscles, in the correct way. In fact, doing them incorrectly can be harmful.  The National Kidney and Urologic Diseases Information Clearinghouse offers detailed instructions, with diagrams.  But written and verbal instructions are not always enough; the best way to learn to do them correctly is to have your doctor show you. This should be done during a physical exam, when your doctor can give you direct feedback about whether you're exercising the right muscles.  Your doctor can also use biofeedback techniques.

In addition to doing Kegels, you might also be asked to do some "bladder retraining," which means becoming aware of your urinary habits and gradually increasing the time between urinating, or urinating at specific intervals or times of day.  As with any form of behavioral therapy, both Kegels and bladder retraining require your full participation.  In other words, if you do not do them, they cannot work.  Doing them may seem inconvenient, or annoying, or unpleasant.  But remaining incontinent is worse.

There are many behavioral therapies that may be an option-you should talk to your doctor about all of your treatment options.

A non-behavioral form of physical therapy involves applying mild electrical pulses to the nerves that control the bladder and sphincter muscles. Known as "neuromodulation" or "Transcutaneous Electrical Nerve Stimulation" (TENS), this treatment can reduce both stress and urge incontinence.  Normally it is done in a doctor's office.  But there is a new version of this treatment that uses a "sacral nerve stimulator," a sort of pacemaker for the bladder. Like a pacemaker, it is implanted under the skin during a minor surgical procedure.

Another approach is to inject a bulking agent into the tissues around the urethra. The added bulk expands these tissues so they press on the urethra and help close it, which reduces stress incontinence. Collagen, mentioned in this episode of Second Opinion, is a bulking agent.

There are also a number of medical devices that can treat incontinence in women, such as a pessary (a stiff ring you insert in your vagina that supports the bladder and helps reduce stress incontinence) and urethral inserts (tiny devices inserted into the urethra to stop urine leakage during specific activities that cause you to leak or lose urinary control).

But the fact is, we often want to reject any form of treatment other than "a pill," because taking a pill seems like the easiest, quickest answer.  However, medication may not be appropriate for your specific problem, and virtually all drugs have some side effects. 

Nevertheless, there are a number of medicines that can treat certain types of incontinence, and your doctor may prescribe one or more.  Some are bladder relaxants, drugs that relax the muscles in the bladder and prevent bladder spasms, which helps the bladder empty completely during urination.  Others stop muscular contractions in an overactive bladder, or tighten bladder and urethra muscles to prevent leaking.  Of course, if your incontinence is caused by a specific disease or disorder, the drugs that treat it should stop the incontinence.

Finally, there are surgical interventions to treat incontinence. These include surgeries to implant an artificial sphincter to control urination, to implant a sacral nerve stimulator, as described above, to correct an enlarged prostate in men, and to correct a prolapsed bladder in women.

Medline Plus

Medline Description: 

Conduct an off-site search for Incontinence and Urine Leakage information from MedlinePlus.  These up-to-date search results are based on search terms specific to Second Opinion Key Points.

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