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Urinary Incontinence

Basic Information

Urinary incontinence (UI) is an involuntary or uncontrollable loss of urine -- in other words, losing urine when it is unwanted. The International Continence Society has defined the problem as "An involuntary loss of urine that is objective, demonstrable and a social or hygiene problem." Many feel too embarrassed to discuss or bring up the problem to their health care providers. Or they don't believe help is available anyway, assuming that UI is an inevitable consequence of aging -- it isn't. Although advancing age does cause decreased bladder capacity. It is believed that only 50% of persons with UI seek help because of this. It is unfortunate that more help is not sought because both social restrictions and practical inconveniences result from the lack of treatment. For instance, daily routines are often interrupted, limiting the time an adult suffering from UI feels comfortable enough to leave the home for fear of soiling clothes if unable to reach a bathroom in time. Depression may result from an unwelcome and baffling loss of independence as well as from battling physical problems ranging from urinary tract infections to skin disorders and sleep disruptions. This is why it is recommended that all elderly patients undergo screening for UI. Help is available and most symptoms (UI is a symptom, not a disease) can be reduced or even eliminated.

It is estimated that UI affects ten million Americans, accounting for 3% of all health care expenditures in the U.S. at an estimated 15 billion dollars per year. While it can affect all ages and both sexes, twice as many women are affected as men, possibly because of decreasing levels of estrogen, among other causes listed below. IU affects 30% of the community-dwelling elderly and more than 50% of nursing home residents. In fact, UI itself may be responsible for needless institutionalization of scores of elderly Americans.

Causes of UI can include:

Temporary Or Transient Ui

  • side effects from medication
  • constipation
  • vaginal infection
  • urinary tract infection

Chronic Or More Permanent Ui

  • bladder weakness
  • weakness in muscles that hold the bladder in place
  • weakness in the urinary sphincter muscles
  • hormone imbalance (women)
  • enlarged prostate (men)

UI is divided into five different categories -- stress, urge, overflow, functional and mixed.

STRESS INCONTINENCE This is the most common form of UI -- accounting for up to 70--75% of cases and predominantly affecting women. Persons commonly lose urine when they cough or sneeze or laugh or when they suddenly get up from bed or up out of a sitting position. Stress UI also occurs when persons engage in physical exercise or activities during the lifting of heavy objects. Then intra abdominal pressure is increased. Going to the bathroom often in order to avoid an accident is common. Main causes include sphincter incompetence and hypermobility of the urethra.

URGE INCONTINENCE Persons lose urine when they feel the need to go to the bathroom and often begin to leak urine when they can't get to the bathroom quickly enough. Even hearing running water or drinking a small amount can precipitate an abrupt desire to void. Causes include involuntary bladder contractions and bladder hypersensitivity. Consumption of too much caffeine and alcohol can play a part as well.

OVERFLOW INCONTINENCE Persons feel they do not empty their bladder well enough. They often wake up int he middle of the night only to urinate a little while spending an inordinate amount of time at the toilet -- and still feel as if they have not voided enough, that there is still urine in the bladder. Constant dribbling may occur day and night. Usually an anatomic obstruction such as an enlarged prostate or urethral stricture is the cause or an atonic bladder due to stroke or neurologic disease. This kind of UI is seen regularly in men with BPH (benign prostatic hypertrophy).

FUNCTIONAL INCONTINENCE Persons do not get to the bathroom in time when the urge to urinate is felt. This kind of UI is not caused by organic problems of the lower urinary tract but by a decrease in cognitive function or status, depression, obstinacy or adverse environmental conditions.

MIXED INCONTINENCE This is a mixture of more than one kind of UI and can be a challenge to diagnose correctly. Mixed incontinence is common and most usually is a combination of both stress and urge incontinence with one symptom usually more prevalent than the other.

Diagnosis/Treatment

History taking is a key to diagnosis. It can differentiate between transient or acute UI and chronic UI. Acute UI is usually reversible within several weeks and can be caused by constipation, urinary tract infection, vaginitis, fecal impaction, dehydration and urinary retention. A patient history should include eliciting such information as:

  • history of estrogen deficiency
  • diabetes
  • stroke
  • urinary tract infections
  • neurologic history
  • diuretic, sedative, antidepressant use
  • genitourinary and gynecological history
  • amount of liquid intake, most notably coffee, tea and alcohol

Additionally your health care provider may ask you to keep a diary of urinary frequency and volume while going about your daily activities over a 24--72 hour period. This will help your health care provider in evaluating the severity of your UI.

The Urinary Incontinence Guideline Panel (UIGP) recommends a physical exam as well. This includes:

  • abdominal pain
  • rectal exam
  • vaginal exam
  • sitting and standing blood pressure
  • urinalysis
  • blood test (to check for diseases that can precipitate UI)

Stress and pad tests are routinely done by your health care provider. During a stress test a woman patient with a full bladder coughs and the health care provider looks for urine as well as mobility of the urethra. Pad tests can be done at home during regular activities during a 24--48 hour period or in the clinic as a one hour test. Pads are weighed before they are fitted and after they are removed to calculate leakage. Home tests are generally preferred because of a higher sensitivity rate.

Ultrasound can also be utilized, most often as a diagnostic tool for presurgical evaluation.

There are a number of management options for treating UI but the UIGP recommends an initial stepwise approach that is noninvasive and conservative. Treatment modalities can include:

  • Monitoring your fluid intake -- Avoid drinking excessive amounts of liquid during the day and especially large amounts at once -- Space liquid intake evenly over the course of the day and limit consumption of caffeine and alcohol -- Try to avoid drinking liquids after 8 P.M. if you get up regularly during the night to urinate.
  • Bladder drills or training -- Increase gradually the intervals between urinating. A common goal is to be able to go three hours before urinating (in the daytime) without leaking.
  • Pelvic muscle strengthening -- Women can be taught how to insert cone devices two times a day into their vaginas leaving them in place for fifteen minutes.
  • Kegel exercises -- These exercises are intended to strengthen or tighten your pelvic floor muscles and improve overall functioning of the urethra. Your health care provider, urologist or gynecologist should make certain you know how to do these exercises properly. You try to stop your urine flow midstream -- hold ten seconds -- then relax and urinate. Generally, fifty Kegels are recommended daily, especially when you laugh, cough, or sneeze.

If these behavior modifications do not prove effective over time you may benefit from or need medication or surgery and your health care provider will refer you to a UI specialist.

If you have UI please see your health care provider promptly. And do not be embarrassed -- this is a common problem affecting ten million Americans whose quality of life will improve with treatment.