Incontinence (Overactive Bladder)

Urinary incontinence is loss of bladder control. Symptoms can range from mild leaking to uncontrollable wetting. It can happen to anyone but, it becomes more common with age. Most bladder control problems happen when muscles are too weak or too active. If the muscles that keep your bladder closed are weak, you may have accidents when you sneeze, laugh or lift a heavy object. This is stress incontinence. If bladder muscles become too active, you may feel a strong urge to go to the bathroom when you have little urine in your bladder. This is urge incontinence or overactive bladder. There are other causes of incontinence such as nerve damage. Treatment depends on the type of problem you have and what best fits your lifestyle. It may include simple exercises, medicines, special devices or treatments or surgery.

Symptoms

The problem has varying degrees of severity. Some people experience only occasional, minor leaks — or dribbles — of urine. Others wet their clothes frequently.

Types of urinary incontinence include:

  • Stress incontinence. Loss of urine when you exert pressure on your bladder by coughing, sneezing, laughing, exercising or lifting something heavy. It has nothing to do with psychological stress. Stress incontinence occurs when the sphincter muscle at the bladder is weakened. The problem is especially noticeable when you let your bladder get too full. Stress incontinence is one of the most common types of incontinence, often affecting women. Physical changes resulting from pregnancy, childbirth and menopause can cause stress incontinence.
  • Urge incontinence. This is a sudden, intense urge to urinate, followed by an involuntary loss of urine. Your bladder muscle contracts and may give you a warning of only a few seconds to a minute to reach a restroom. With urge incontinence, you may also need to urinate often. The need to urinate may even wake you up several times a night. Some people with urge incontinence have a strong desire to urinate when they hear water running or after they drink only a small amount of liquid. Simply going from sitting to standing may even cause you to leak urine. Urge incontinence may be caused by a urinary tract infection or by anything that irritates the bladder. It can also be caused by bowel problems or damage to the nervous system associated with multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke or injury. In urge incontinence, the bladder is said to be “overactive” — it’s contracting even when your bladder isn’t full. In fact, urge incontinence is often called an overactive bladder.
  • Overflow incontinence. If you frequently or constantly dribble urine, you may have overflow incontinence. This is an inability to empty your bladder, leading to overflow. With overflow incontinence, sometimes you may feel as if you never completely empty your bladder. When you try to urinate, you may produce only a weak stream of urine. This type of incontinence is common in people with a damaged bladder or blocked urethra and in men with prostate gland problems. Nerve damage from diabetes also can lead to overflow incontinence. Some medications can cause or increase the risk of developing overflow incontinence.
  • Mixed incontinence. If you experience symptoms of more than one type of urinary incontinence, such as stress incontinence and urge incontinence, you have mixed incontinence. Usually one type is more bothersome than the other is.
  • Functional incontinence. Many older adults, especially people in nursing homes, experience incontinence simply because a physical or mental impairment keeps them from making it to the toilet in time. For example, a person with severe arthritis may not be able to unbutton his or her pants quickly enough. Someone with Alzheimer’s disease may not plan well enough to make a timely trip to the toilet. This type of incontinence is called functional incontinence.
  • Gross total incontinence. This term is sometimes used to describe continuous leaking of urine, day and night, or periodic large volumes of urine and uncontrollable leaking. The bladder has no storage capacity. Some people have this type of incontinence because they were born with an anatomical defect. It can be caused by a spinal cord injury or by injury to the urinary system from surgery. An abnormal opening (fistula) between the bladder and an adjacent structure, such as the vagina, also may cause this type of high-grade urinary incontinence.

Causes

Urinary incontinence isn’t a disease, it’s a symptom. It indicates some underlying problem or condition that likely can and should be treated. A thorough evaluation by your doctor can help determine what’s behind your incontinence.

How bladder control works

Except when you’re urinating, your bladder muscle stays relaxed so that it can expand to store urine. The relaxed bladder gets support from increasing contractions of your pelvic floor muscles. Your bladder and pelvic floor muscles communicate with each other to help hold urine in the bladder without leaking.

When your bladder is full, it sends nerve signals to your brain. In response, and at an appropriate time and place, you relax your pelvic floor muscles and your bladder contracts, allowing urine to pass through the urethra and out of your body.

Causes of temporary urinary incontinence

Certain foods, drinks, and medications and cause temporary urinary incontinence. A simple change in habits can bring relief.

  • Alcohol. Beer, wine and spirits are all diuretics. They cause your bladder to fill quickly, triggering an urgent and sometimes uncontrollable need to urinate. In addition, alcohol can temporarily impair your ability to recognize the need to urinate and act on that need in a timely manner.
  • Over-hydration. Drinking a lot of water or other beverages, particularly in a short period of time, increases the amount of urine your bladder has to deal with and may result in an occasional accident.
  • Dehydration. If you have urge incontinence, you may try to limit your fluids to reduce the number of trips to the toilet. However, if you don’t consume enough liquid to stay hydrated, your urine can occasionally become very concentrated. This collection of concentrated salts can irritate your bladder and worsen your urge incontinence.
  • Caffeine. Caffeine also is a diuretic. It causes your bladder to fill more quickly and hold less than usual so that you suddenly and perhaps uncontrollably need to urinate.
  • Bladder irritation. Carbonated drinks, tea and coffee — with or without caffeine — may irritate your bladder and cause episodes of urge incontinence. Citrus fruits and juices and artificial sweeteners also can be sources of aggravation.
  • Medications. Sedatives, such as sleeping pills, can sometimes interfere with your ability to control bladder function. Other medications — including water pills (diuretics), muscle relaxants and antidepressants — can cause or increase incontinence. Some high blood pressure drugs, heart medications and cold medicines also can affect bladder function. After surgery, some people experience temporary incontinence from the lingering effects of anesthesia.

Easily treatable medical conditions also may be responsible for urinary incontinence.

  • Urinary tract infection. Infectious agents — usually bacteria — can enter your urethra and bladder and start to multiply. The resulting infection irritates your bladder, causing you to have strong urges to urinate. These urges may result in episodes of incontinence, which may be your only warning sign of a urinary tract infection. Other possible signs and symptoms include a burning sensation when you urinate and foul-smelling urine.
  • Constipation. The rectum is located near the bladder and shares many of the same nerves. Hard, compacted stool in your rectum causes these nerves to be overactive and trigger urine frequency.

Causes of persistent urinary incontinence

Urinary incontinence can also be a persistent condition caused by some underlying physical problem — weakened pelvic floor or bladder muscles, neurological diseases, or an obstruction in your urinary tract. Factors that can lead to chronic incontinence include:

  • Pregnancy and childbirth (*women only). Pregnant women may experience stress incontinence because of hormonal changes and the increased weight of an enlarging uterus. In addition, the stress of a vaginal delivery can weaken the pelvic floor muscles resulting in stress incontinence — urine escapes past the weakened muscles whenever pressure is placed on your bladder. The changes that occur during childbirth can also damage bladder nerves and supportive tissue and can lead to a dropped (prolapsed) pelvic floor, producing a vaginal bulge. With prolapse, your bladder, uterus, rectum or small bowel can get pushed down from the usual position and protrude into your vagina. Such protrusions can be associated with incontinence. Incontinence related to childbirth may develop right after delivery or, more likely, may not develop until years later.
  • Changes with aging. Aging of the bladder muscle affects both men and women, leading to a decrease in the bladder’s capacity to store urine and an increase in overactive bladder symptoms. Women produce less of the hormone estrogen after menopause, a decrease that can contribute to incontinence. Estrogen helps keep the lining of the bladder and urethra healthy. With less estrogen, these tissues lose some of their ability to close — meaning that your urethra can’t hold back urine as easily as before.
  • Hysterectomy (*women only). In women, the bladder and uterus (womb) lie close to one another and are supported by the same muscles and ligaments. Any surgery that involves a woman’s reproductive system — for example, removal of the uterus (hysterectomy) — runs the risk of damaging the supporting pelvic floor muscles, which can lead to incontinence.
  • Painful bladder syndrome (interstitial cystitis). This rare, chronic condition can be associated with an inflammation of the bladder wall. It occasionally causes urinary incontinence, as well as painful and frequent urination. Interstitial cystitis affects women more often than men, and it does not have a definite cause
  • Prostatitis (*men only). Loss of bladder control isn’t a typical sign of prostatitis, or inflammation of the prostate gland. Even so, urinary incontinence sometimes occurs with this extremely common condition. The prostate actually surrounds the urethra, so inflammation of the prostate occasionally swells and constricts the urethra, blocking normal urine flow and leading to urinary urgency and frequency.
  • Enlarged prostate (*men only). In older men, incontinence often stems from enlargement of the prostate gland, a condition also known as benign prostatic hyperplasia (BPH). The prostate begins to enlarge in many men after about age 40. As the gland enlarges, it can constrict the urethra and block the flow of urine. For some men, this problem results in urge or overflow incontinence.
  • Prostate cancer (*men only). In men, stress incontinence or urge incontinence can be associated with untreated prostate cancer. However, more often, incontinence is a side effect of treatments such as surgery or radiation.
  • Bladder cancer or bladder stones. Incontinence, urinary urgency and burning with urination can be signs and symptoms of bladder cancer and also of bladder stones. Other signs and symptoms include blood in the urine and pelvic pain.
  • Neurological disorders. Multiple sclerosis, Parkinson’s disease, stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control, causing urinary incontinence.
  • Obstruction. A tumor anywhere along your urinary tract can obstruct the normal flow of urine and cause incontinence, usually overflow incontinence. Urinary stones — hard, stone-like masses that can form in the bladder — may be to blame for urine leakage. Urinary obstruction can also occur after overcorrection during a surgical procedure to correct urinary incontinence, leading to more urine leakage.

Treatment

Treatment for urinary incontinence depends on the type of incontinence, the severity of your problem and the underlying cause. Your doctor will recommend the approaches best suited to your condition. Often a combination of treatments is used. Most people treated for urinary incontinence see a dramatic improvement in their symptoms.

Treatment options for urinary incontinence fall into four broad categories — behavioral techniques, medications, devices and surgery. In most cases, your doctor will suggest the least invasive treatments first.

The success of your treatment depends most of all on the right diagnosis. Talk to your doctor about the specifics and possible complications of any treatment. Ask questions and express concerns to help find out which treatment is right for you.

Behavioral techniques

Behavioral techniques and lifestyle changes work well for certain types of urinary incontinence. They may be the only treatment you need.

Kegel Exercises

  • Pelvic floor muscle exercises. These exercises strengthen your urinary sphincter and pelvic floor muscles — the muscles that help control urination. Your doctor may recommend that you do these exercises frequently to treat your incontinence. They are especially effective for stress incontinence, but may also help urge incontinence.To do pelvic floor muscle exercises (Kegels), imagine that you’re trying to stop your urine flow. Squeeze the muscles you would use and hold for a count of three. Relax, count to three again, then repeat. You can do these exercises almost anywhere — while you’re driving, watching television or sitting at your desk at work.For more information about how to do Kegel exercises, go to: http://www.mayoclinic.com/health/kegel-exercises/WO00119
  • With Kegels it can be difficult to know whether you’re contracting the right muscles and in the right manner. In general, if you sense a pulling-up feeling when you squeeze, you’re using the right muscles. Men may feel their penises pull in slightly toward their bodies. To double-check that you’re contracting the right muscles, try the exercises in front of a mirror. Your abdominal, buttock or leg muscles shouldn’t tighten if you’re isolating the muscles of the pelvic floor. Another way to be sure you’re doing Kegels correctly is a simple finger test. Place a finger in your anus or vagina. Then squeeze around your finger. The muscles you contract are your pelvic floor muscles.If you’re still not sure whether you’re contracting the right muscles, ask your doctor for help. Your doctor can refer you to a physical therapist for biofeedback techniques that will help you identify and contract the right muscles.After several months of doing pelvic floor muscle exercises correctly, you should notice improvement in your urinary control. Contract your pelvic muscles to control leakage when you have an urge to urinate or when you cough or sneeze.
  • Bladder training. Your doctor may recommend bladder training — alone or in combination with other therapies — to control urge and other types of incontinence. Bladder training involves learning to delay urination after you get the urge to go. You may start by trying to hold off for 10 minutes every time you feel an urge to urinate. Then try increasing the waiting period to 20 minutes. The goal is to lengthen the time between trips to the toilet until you’re urinating every two to four hours. This exercise can help you learn to empty your bladder more completely to avoid overflow incontinence.
  • Scheduled toilet trips. This means timed urination — going to the toilet according to the clock rather than waiting for the need to go. Following this technique, you go to the toilet on a routine, planned basis — usually every two to four hours.
  • Fluid and diet management. In some cases, you can simply modify your daily habits to regain control of your bladder. You may need to cut back on or avoid alcohol or caffeine, if either causes you incontinence. If acidic foods irritate your bladder, cutting back on such triggers may rid you of your problem.

Medications

Many times, urinary incontinence can be corrected with the help of medication. Often, medications are used in conjunction with behavioral techniques. Drugs commonly used to treat incontinence include:

  • Anticholinergic (antispasmodic) drugs. These prescription medications calm an overactive bladder, so they may be helpful for urge incontinence. Examples include tolterodine (Detrol), oxybutynin (Ditropan), solifenacin (Vesicare) and darifenacin (Enablex). These drugs can be effective at controlling incontinence, but a side effect is dry mouth. Or you may want to try an extended-release form of oxybutynin (Ditropan XL) or tolterodine (Detrol LA) or an oxybutynin skin patch (Oxytrol). These forms of medication may have fewer side effects than the standard forms do.
  • Imipramine (Tofranil). This antidepressant may occasionally be used in combination with other medications to treat incontinence. It causes the bladder muscle to relax, while causing the smooth muscles at the bladder neck to contract.
  • Antibiotics. If your incontinence is due to a urinary tract infection or an inflamed prostate gland (prostatitis), your doctor can successfully treat the problem with antibiotics.

Surgery

If other treatments aren’t working, several surgical procedures have been developed to fix problems that cause urinary incontinence. (*MEN ONLY): In men, surgery may be necessary to remove the obstructive part of an enlarged prostate gland.

If your bladder or uterus has slipped out of position, a surgeon can put it back in place with a variety of techniques.

Some of the more common surgical procedures include:

  • Artificial urinary sphincter (*men only). This small device is particularly helpful for men who have weakened urinary sphincters from treatment of prostate cancer or an enlarged prostate gland, and it’s used rarely in women with stress incontinence. Shaped like a doughnut, the device is implanted around the neck of your bladder. The fluid-filled ring keeps your urinary sphincter shut tight until you’re ready to urinate. This surgery is the most effective procedure for male incontinence. Complications include malfunction of the device — which means the surgery will need to be repeated — and infection, but both are uncommon.
  • Trans-Opturator Tape Sling procedure. The most popular and common surgery for women with stress incontinence is the sling procedure. During this procedure, a surgeon removes a strip of abdominal tissue and places it under the urethra. Or the surgeon may use a strip of synthetic mesh material or a strip of tissue from a donor (xenograft) or cadaver. Sling procedures improve or cure incontinence in most cases.
  • Bladder neck suspension. In this procedure, your surgeon makes a 3- to 5-inch incision in your lower abdomen. Through this incision, he or she places stitches (sutures) in the tissue near the bladder neck and secures the stitches to a ligament near your pubic bone (Burch procedure) or in the cartilage of the pubic bone itself (Marshall-Marchetti-Krantz, or MMK, procedure). This has the effect of bolstering your urethra and bladder neck so that they don’t sag. The downside of this procedure is that it involves major abdominal surgery. It’s done under general anesthesia and usually takes about an hour. Recovery takes about six weeks, and you’ll likely need to use a catheter until you can urinate normally.

Absorbent pads and catheters

If medical treatments can’t completely eliminate your incontinence — or you need help until a treatment starts to take effect — you can try products that help ease the discomfort and inconvenience of leaking urine. These products should be a last resort, because most people benefit from other treatments.

  • Pads and protective garments. Various absorbent pads are available to help you manage urine loss. Most products are no more bulky than normal underwear, and you can wear them easily under everyday clothing. (*Men only: Men who have problems with dribbles of urine can use a drip collector — a small pocket of absorbent padding that’s worn over the penis and held in place by closefitting underwear.) Men and women can wear panty liners or pads in their underwear to collect urine. Adult diapers are available in both disposable and reusable forms and come in a variety of sizes. Others opt for washable underwear and briefs with waterproof panels. Incontinence products can be purchased at drugstores, supermarkets and medical supply stores.
  • Catheter. If you’re incontinent because your bladder doesn’t empty properly, your doctor may recommend that you learn to insert a soft tube (catheter) into your urethra several times a day to drain your bladder (self-intermittent catheterization). This should give you more control of your leakage, especially if you have overflow incontinence. You will be instructed on how to clean these catheters for safe re-use.

From: Mayo Clinic