Urinary Incontinence

Urinary incontinence, or the loss of bladder control, is a common problem that affects most women at some time or another.  It can range from occasionally leaking a small amount of urine during a cough or sneeze to having sudden and uncontrollable urges to urinate.

Although urinary incontinence affects millions of people, it is a medical problem that can almost always either be stopped, controlled or successfully managed.  There are many possible causes and many possible treatments.  Your healthcare provider is the best person to help you determine the best course of treatment.

How and Why We Urinate

Urinating, or voiding, is the result of a complex process.  The body uses nutrients from food to maintain the bodily functions.  Once the body has taken the nutrients needed from the food, waste products are left in the blood and the bowels.  The urinary system works with the lungs, skin, and intestines to keep the chemicals and water in a balanced state.  The amount urinated depends on things such as how much fluid a person takes in, and how much is lost through sweating and breathing, but the average adult eliminates about one and one-half quarts of urine per day.

The urinary system removes a type of waste called urea from your blood. Urea is produced from foods containing protein, and is carried by the bloodstream to the kidneys, which are bean-shaped organs about the size of a fist.  The kidneys remove the urea through tiny filtering units, and it, together with water and other waste substances, forms the urine.

After leaving the kidneys, the urine travels down two thin tubes called ureters to the bladder. Muscles in the ureter walls constantly tighten and relax to force urine downward away from the kidneys.  Small amounts of urine are emptied into the bladder from the ureters about every 10 to 15 seconds.The bladder is a hollow muscular organ shaped like a balloon. It is located in the pelvis and is held in place by ligaments attached to other organs and the pelvic bones. The bladder is the storage place for urine.  It swells into a round shape when it is full and gets smaller when empty.  A healthy adult’s bladder can hold up to 2 cups of urine without discomfort for 2 to 5 hours.

Circular muscles called sphincters help keep urine from leaking. The sphincter muscles close tightly around the opening of the bladder into the urethra, the tube that allows urine to pass outside the body.Nerves in the bladder indicate when the bladder is full, and the urge to empty the bladder becomes strong.  Once a person is ready to urinate, the brain sends a signal to the bladder muscles to squeeze urine out of the bladder, while also signaling the sphincter muscles to relax.  Relaxing these muscles allows the urine to exit the bladder. 

Types of Urinary Incontinence

There are six types of urinary incontinence.  They are:

• Stress incontinence, in which urine leakage occurs when physical pressure or stress is exerted on the bladder.  The stress is usually caused by coughing, sneezing, laughing, or exercising. Stress incontinence is one of the most common types of incontinence in women and usually occurs because the sphincter muscle at the bladder is weakened.  The problem is worsened when the bladder is full.  Pregnancy, childbirth and menopause can all cause stress incontinence.
• Urge incontinence is characterized by a sudden, intense urge to urinate, followed by an involuntary loss of urine. The bladder muscle contracts sharply and may often release the urine within a few seconds.  People suffering from this type may need to urinate often, including several times in the middle of the night.  Sometimes simply standing up may cause a urine leak.  It may be caused by something as simple as a urinary tract infection, or by a much more serious disease.  Because the bladder is contracting even when it’s not necessarily full, urge incontinence is often called an “overactive” bladder.
• Overflow incontinence is diagnosed with a person frequently dribbles urine.  It is the inability to empty the bladder completely, leading to overflow. A person with overflow incontinence may feel as if her bladder is never completely empty. This type of incontinence is common in people with a damaged bladder or blocked urethra, and can also be caused by nerve damage from diabetes.
• Mixed incontinence is the presence of symptoms of one or more types of urinary incontinence, most often stress and urge.  One is usually more severe than the other.
• Functional incontinence is more common in older adults, and occurs because some kind of impairment keeps them from getting to the bathroom on time.  Someone with severe arthritis may have trouble undoing his or her pants quickly enough, or a person suffering from dementia may not realize what the pressure in the bladder means.
• Gross total incontinence is a term is sometimes used to describe continuous leaking of urine, day and night, or daily large volumes of urine and uncontrollable leaking. This usually occurs when the bladder has no storage capacity. Often a birth defect is the reason for this type; or it can be caused by a spinal cord or urinary system injury.

Diagnosis

When a patient reports a problem with urinating, the healthcare provider usually begins with a physical examination, including a pelvic exam.  He or she is looking for signs of blockages and for weakness in the pelvic floor.  In addition, since the pattern of leaking may suggest the type of incontinence present, the physician often has the patient keep a diary over several days that tracks fluid intake and times of urination or leakage.  Sometimes the diary alone helps the physician to diagnose the problem.  If not, it will at least help to indicate which tests are needed.

Based on this information, any or all of the following tests may be offered:

• Bladder stress test.  This test consists of coughing vigorously while the physician examines the urinary opening for signs of loss of urine.
•  Urinalysis and urine culture.  A urine sample is tested in the lab for evidence of urinary stones, infections or other abnormalities.
•  Ultrasound.  An ultrasound test uses sound waves to create an image of the organs involved, including the kidneys, ureters, bladder, and urethra.
•  Cystoscopy.  The physician looks inside the urethra and bladder using a thin tube with a small camera inside.
•  Urodynamics.  Measuring the urinary systems functions such as pressure in the bladder and the flow rate as it empties.

Treatment for Urinary Incontinence

Behavioral Remedies

• Lifestyle Changes
  Sometimes the treatment is only a matter of making changes to the daily diet and routine.  These include maintaining a healthy weight, avoiding caffeine, quitting smoking, and eating lots of fiber to avoid being constipated.  Women who routinely lift heavy weights may want to reconsider if the heavy lifting causes leakage.
•  Bladder Retraining
  With bladder retraining, the physician will recommend making it a point to use the bathroom at regular timed intervals, a habit called “timed voiding.”  As control improves, the time between trips to the bathroom can be extended.
   

Medical Remedies
Many women manage urinary incontinence with menstrual pads that catch slight leakage during activities such as exercising.

There are also several remedies that the physician might prescribe or provide, based on the specific diagnosis.  These include:

Physical therapy, such as Kegel exercises, which are used to strengthen the pelvic muscles.  Following is the procedure for Kegel exercises, which must be done consistently for at least several weeks to show an improvement:

1. First, find the right muscles. Squeeze the muscles that you normally use to stop the urine flow.   Do not squeeze other muscles such as stomach, legs or buttocks.  Don’t hold your breath.
2.  Find a quiet spot to practice.  Some people begin the exercises lying down.  Squeeze the pelvic muscles and hold for a count of five, then relax for a count of five.
3.  Do 10 repeats at least three times per day.  Once your muscles get stronger, begin doing the exercises sitting or standing.

Medical devices.  Several medical devices are available.  Those designed for women include:

1. Urethral inserts – Small, tampon-like disposable devices that a woman can insert into her urethra to prevent urine from leaking out. These work best for women who have predictable incontinence during certain activities, such as playing sports. The device is inserted before the activity, and when the woman needs to urinate, she simply removes the device. Urethral inserts are available by prescription.
2. Pessary (PES-uh-re) – A firm ring that is inserted into the vagina and worn all day.  The device helps hold up the bladder, which is near the vagina, to prevent urine leakage. The device needs to be removed and cleaned regularly.

Medications-There are several different drugs that are prescribed for different reasons, from calming an overactive bladder, to actually stimulating the bladder, to treating a urinary tract infection that may be the cause of the incontinence.

Surgery-If other treatments aren't working, several surgical procedures have been developed to fix problems that cause urinary incontinence. For example, if the bladder or uterus has slipped out of position, a surgeon can put it back in place with a variety of techniques.  Sometimes surgery is used to strengthen a weakened sphincter muscle.  And, rarely, surgery to treat urinary incontinence may involve enlarging the bladder or correcting a birth defect.

Remember

Urinary incontinence is very common in women, but the great majority of cases are either treatable or manageable.  Your healthcare provider can recommend the best treatment for your specific case.