Urinary Incontinence

Many women leak small amounts of urine at times. This can occur with certain movements; during pregnancy; or during other stress, such as coughing. Some women lose urine when they hear the sound of running water or when their hands are in water. Others find that they feel the urge to urinate and are not able to control it. When leakage of urine becomes frequent or severe enough to become a problem, it is called urinary incontinence.

This page will explain:

• Symptoms of urinary incontinence
• What causes it
• How it is diagnosed and treated

If you have symptoms of urinary incontinence, tell your doctor. In most cases, urinary incontinence can be treated with success.

About Urinary Incontinence

Urinary incontinence is more common in women than in men. It affects 10 percent to 25 percent of women under age 65 and 15 percent to 30 percent of women older than 60 who do not live in nursing homes. Incontinence is even more common in nursing home residents - more than half may be affected.

Incontinence does not always mean that a woman leaks often. For an active woman or a woman who loses a large amount of urine each time, even one time a week or less may be too much.

Women sometimes do not tell their doctor about their symptoms of urinary incontinence. Less than one half of women seek medical care. Instead, they rely on absorbent pads or changes in lifestyle to deal with this condition. They may feel ashamed. They may even avoid certain social or work events.

Some women have the false belief that urinary incontinence is a normal part of aging and that nothing can be done to correct it. Urinary incontinence often can be treated. Tell your doctor if you have any leakage of urine. Proper diagnosis and treatment may correct your problem and ease your symptoms.

Normal Voiding

The urinary tract is made up of:

• Kidneys, which produce urine
• Bladder
• Tubes called ureters that carry urine to the bladder
• Urethra

Normal urination (also called voiding) occurs when a woman is able to empty her bladder when she has a natural desire to do so. In normal voiding, the muscles around the urethra relax, the bladder contracts, and urine flows from the bladder to the urethra and out of the body. When the bladder is almost empty, the muscles around the urethra contract, the bladder relaxes, and the stream of urine stops flowing.

Types of Incontinence

There are three types of incontinence:

• Urge
• Stress
• Overflow

The most common type is urge incontinence. It occurs if the detrusor muscle - the muscle wall of the bladder - is overactive. This leads to loss or leakage of urine.

Stress incontinence occurs when the pressure inside the bladder (which moves urine out) is greater than the pressure in the urethra (which keeps urine in). It causes loss of urine during coughing, laughing, sneezing or physical activity. Its main cause is when the tissues that surround and support the urethra and bladder are weakened.

In overflow incontinence, the bladder does not empty during voiding. This results in a steady leakage of small amounts of urine. Overflow incontinence is less common than urge incontinence. It occurs when the detrusor muscle is underactive.

Symptoms

Women who have urinary incontinence may leak urine often. They may have to wear a pad to keep from wetting their clothes. Some women with incontinence feel such a strong desire to urinate that they cannot control it. This results in a loss of urine. Awoman with urinary incontinence also may have other symptoms:

• Urgency - A strong desire to urinate, whether or not the bladder is full. This often occurs along with pelvic discomfort or pressure. The fear of leakage or pain also occurs.
• Frequency - Urinating more than every two hours or more than seven times a day.
• Nocturia - The need to urinate two or more times during hours of sleep.
• Dysuria - Painful urination.
• Enuresis - Bed-wetting or wetting while sleeping.

Causes

Urinary incontinence may be caused by pelvic support problems (cystourethrocele and cystocele) or urinary tract abnormalities (fistula and diverticulum). There are many possible causes of urinary incontinence. These include infection, damage to organs and muscular disorders.

Urinary Tract Infection

Urinary incontinence may occur because of an infection of the urinary tract. Often such an infection occurs along with pain, frequency and blood in the urine. Infections of the bladder (cystitis) and of the urethra (urethritis) are common in women.

Pelvic Support Problems

Pelvic support problems occur when the tissues that support the pelvic organs are stretched and damaged. This allows the organs that they support to sag out of place. If the tissues that support the urethra, bladder, uterus and rectum are weakened, these organs may drop. This may lead to urinary incontinence or difficulty passing urine.

Two types of pelvic support problems are the cystocele and the cystourethrocele. When the bladder drops from its normal place into the vagina, it is called a cystocele. The place where the bladder joins the urethra is called the bladder neck. When tissues that support the bladder neck are damaged, it may drop and push against the vaginal wall. A dropped bladder neck is called a cystourethrocele.

The main causes of pelvic support problems are childbirth and aging. As the baby passes through the vagina during childbirth, the vaginal wall and ligaments may be damaged. They may become weak. In later years, when a woman goes through menopause, the loss of the female hormone estrogen may make these problems worse.

Urinary Tract Abnormalities

Fistulas are abnormal openings between the urinary tract (urethra, bladder or ureters) and the vagina. These openings can allow urine to leak out through the vagina. Fistulas may result from:

• Pelvic surgery
• Childbirth
• Radiation treatment
• Advanced cancer of the pelvis

Urinary incontinence also can be caused by a urethral diverticulum - a small pocket that bulges out of the wall of the urethra. Urine can collect in this pocket and then spill out later.
Abnormal growths in the urinary tract also can cause incontinence. Sometimes, a small bladder size may cause problems as well.

Neuromuscular Disorders

Neuromuscular disorders are problems with the nerves that control the function of the bladder and urethra. Bladder spasms - uncontrolled contractions - may occur. If the nerves do not control the contractions of the bladder muscle, the bladder may expel urine.
The bladder also may become too full, and urine may leak. Most of the time it is not known why the nerves lose control of the bladder muscle. It could be linked to other conditions, such as diabetes.

Drug Therapy

Urinary incontinence may be a side effect of medications taken for some other condition. For instance, diuretics, sedatives, tranquilizers or antihistamines may cause some women to leak urine. To ease your symptoms, your doctor may only need to change the dosage or type of medication.

Physical Limitations

Some women have nothing wrong with their bladder or urethra. They have conditions, such as arthritis, that prevent them from moving quickly. They may lose urine before they can get to the bathroom. Such limits are a real problem for many older women.

Diagnosis

Your doctor may ask you to keep a voiding diary to record the time and amount of urine leakage.

A number of steps may be needed to find the cause of urinary incontinence. These steps may vary. It depends on the nature of the problem.

The first step often is a detailed medical history. You will be asked questions about factors that may affect your voiding habits. The voiding diary is one of the most useful methods to diagnose incontinence. The doctor may ask you to record the time and amount of urine leakage over 24 to 72 hours. You also may be asked to record how much water or other fluids you drank and any activity that might have caused the leakage.

A pelvic exam also may be done. It can detect physical conditions that might be linked to incontinence. Other exams and tests used may include:

• Lab tests - patient provides a sample of urine, which is analyzed to detect urinary tract infection.
• Stress test - patient must cough a few times with a full bladder. Any loss of urine is recorded.
• Pad test - patient wears a preweighed pad for one hour while doing a series of movements. If the pad weighs more at end of the hour, there was a loss of urine.
• Dye test - patient wears a pad while a nontoxic dye is put into the bladder. If the pad is stained with the dye, there was a loss of urine.
• Cystometry - the pressure and volume of the bladder as it is filled with fluid is measured.

These tests can help detect the cause of the problem. Some patients may have more than one cause. Knowing the cause helps your doctor select the best treatment for you.

Treatment

Many women delay seeking medical care until their symptoms are so severe that they need surgery. In the meantime, they use pads to soak up the urine. Pads or adult diapers may offer security, but they have drawbacks. For instance, they can bother the skin. These products should not be the first - or only - treatment tried for incontinence. They should only be used to make other treatments work better or when other treatments have failed.
There are many options for treatment. It depends on the cause of your problem. Treatments include behavioral changes, medication, special devices or surgery.

Behavioral Treatments

The goal of behavioral treatment is to help a woman know why leakage occurs and how to avoid it. It may include bladder retraining and pelvic muscle exercises.

With bladder retraining, you will be taught about normal and abnormal voiding patterns. You will be told to void at set times - whether or not you have the urge. You will be told about ways to help you ignore any urges to pass urine. One is distraction - thinking about other things. After a few weeks you should have fewer instances of leaking urine. This method can be a success in many cases.

Pelvic muscle exercises, such as Kegel exercises (see box), improve urine control in 40 percent to 75 percent of women who use them. Biofeedback might be used with this or other treatments to improve your response. Biofeedback is a process that tells you about your body functions. This helps you to gain control of these same functions.

Kegel Exercises

Kegel exercises tone your pelvic muscles. They strengthen the muscles that surround the openings of the urethra, vagina and rectum. Just like doing sit-ups to flatten your abdomen, these exercises work only if the right muscles are used, the "squeeze" is held long enough, and enough repetitions are done. This is how they are done:

• Squeeze the muscles that you use to stop the flow of urine.
• Hold for up to 10 seconds, then release.
• Do this 10 to 20 times in a row at least three times a day.

After doing these exercises on a regular basis for at least six weeks, you should be able to better hold your urine.

Medication

Medications that help control muscle spasms can help prevent leakage. Other drugs strengthen the smooth muscle of the urethra and improve symptoms. These medications may cause:

• Dry mouth
• Constipation
• Nausea
• Blurred vision
• Sleeplessness

If you have gone through menopause, your doctor may prescribe estrogen replacement therapy. This improves the elasticity of the muscles and the tissues that surround them. Treatment can be with a cream that is placed in the vagina, pills or a patch applied to the skin. Although it may take a while for the medications to take effect, they must be continued. Symptoms improve in many patients with this therapy.

If you have a urinary tract infection, you will be given antibiotics. Leakage may stop once the infection is cured.

Special Devices

Sometimes devices can be used to strengthen the pelvic muscles. Weighted cones are devices like a tampon that a woman places in her vagina twice a day. When she contracts her pelvic muscles to keep the cone in place, the muscles are strengthened.

Another device used is called a pessary. It supports the pelvic organs. It also helps prevent leakage by pressing against the urethra.

The pelvic muscles also can be made to contract by using electrical stimulation. This may help women who were not helped by other treatments.

Surgical Treatment

Surgery has different risks than drug or behavioral therapy. If you are thinking about surgery, you should know the chances of success as well as the complications that could occur.
Factors that put extra pressure on the pelvic muscles add to the problem of urinary incontinence. Make the following changes in your lifestyle, before and after your surgery, if they apply to you. It can increase your chances for solving the problem:

• Stop smoking
• Get treatment for lung diseases
• Lose weight
• Avoid constipation
• Avoid heavy lifting

There are many types of operations used to correct urinary incontinence. Your doctor's evaluation will help decide if your incontinence occurs from lack of support at the bladder neck or from weakness of the bladder neck itself.

The most common cause of incontinence in women is lack of support at the bladder neck. This type of incontinence can be treated with three basic procedures:

• Abdominal incision
• Vaginal surgery
• Needle suspension (a more minor procedure)

The abdominal incision has the highest long-term success rates. It is also more serious surgery. You and your doctor will need to think about many factors before choosing the surgery that is right for you. They include:

• Your age
• Your lifestyle
• Need for hysterectomy or treatment of pelvic prolapse
• Whether you've had radiation or prior surgery for incontinence
• Your general health

Some of the complications that may occur after surgery include:

• Difficulty emptying your bladder
• Bladder spasms
• Bladder infection
• Injury to the bladder during surgery
• Recurrence of incontinence

Bladder spasms are short-term in most cases. They last while the bladder is going through the healing process and can be controlled with medication. Not being able to empty your bladder after surgery may occur, but it also is short-term. You may need to wear a catheter for a few weeks. Or, you may be taught to empty your own bladder with a small catheter that can be thrown away.

Finally...

Urinary incontinence is a common problem. If you have symptoms of urinary incontinence, or if they affect your daily living, tell your doctor. A complete and thorough exam is needed to find the cause of the problem. In most cases, urinary incontinence can be treated with success.

Glossary

Bladder: A muscular organ in which urine is stored.

Diuretics: Drugs given to increase the production of urine.

Diverticulum: An abnormal pouch or sac in an internal organ or structure.

Estrogen: A female hormone produced in the ovaries, which stimulates the growth of the lining of the uterus.

Fistula: An abnormal opening or passage between two internal organs.

Ureters: A pair of tubes, each leading from one of the kidneys to the bladder.

Urethra: A short, narrow tube that carries urine from the bladder out of the body.

This excerpt from ACOG's Patient Education Pamphlet is provided for your information. It is not medical advice and should not be relied upon as a substitute for visiting your doctor. If you need medical care, or have any questions, please contact your obstetrician-gynecologist. Copyright (c) 2000 The American College of Obstetricians and Gynecologists.

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