Types of Urinary Incontinence
Urinary incontinence is generally categorized into the following types:
- Stress incontinence is caused by activities (coughing, sneezing, laughing, running, or lifting) that apply pressure to a full bladder. Stress incontinence is very common among women, with childbirth and menopause increasing the risk for it. It can also affect men who have had surgical procedures for prostate disease, especially cancer.
- Urge incontinence, also called overactive bladder, is marked by a need to urinate frequently. There are many causes of urge incontinence, including medical conditions (benign prostatic hyperplasia, Parkinson’s disease, multiple sclerosis, stroke, and spinal cord injuries), surgeries (hysterectomy, radical prostatectomy), and infections.
- Overflow incontinence occurs when the bladder cannot empty completely, which leads to dribbling. Bladder obstruction and inactive bladder muscle can cause overflow incontinence. Risk factors include certain types of medications, benign prostatic hyperplasia, and nerve damage.
- Functional incontinence is incontinence due to mental or physical disabilities that impair a person’s ability to use or get to the toilet, despite a healthy urinary system.
- Mixed incontinence. Many people have more than one type of urinary incontinence.
Treatment of Urinary Incontinence
Treatment options for urinary incontinence depend on the type of incontinence and the severity of the condition. Treatments include:
- Lifestyle Changes. Significant weight gain can weaken pelvic floor muscle tone, leading to urinary incontinence. Losing weight through healthy diet and exercise is important. Regulating the time you drink fluids and avoiding alcohol and caffeine are also helpful.
- Behavioral Techniques. Pelvic floor exercises (Kegel exercises) can help strengthen the muscles of the pelvic floor that support the bladder and close the sphincter. Bladder training can help patients learn to delay urination.
- Medications. Drugs, such as oxybutynin (Ditropan, generic) and tolterodine (Detrol), are mainly used to treat urge incontinence.
- Surgery. Many types of surgical procedures are used to correct anatomical problems that contribute to severe urinary incontinence.
Urinary incontinence is the inability to control urination. It may be temporary or permanent, and can result from a variety of problems in the urinary tract. Urinary incontinence is generally divided into four types:
- Stress incontinence
- Urge incontinence
- Overflow incontinence
- Functional incontinence
Often, more than one type of incontinence is present. When this occurs, it is called mixed incontinence. Because incontinence is a symptom, rather than a disease, it is often hard to determine the cause. In addition, a variety of conditions may be the cause.
The urinary system helps to maintain proper water and salt balance throughout the body:
- The process of urination begins in the two kidneys, which process fluids and eliminate water and waste products to produce urine.
- Urine flows out of the kidneys into the bladder through two long tubes called ureters.
- The bladder is a sac that acts as a reservoir for urine. It is lined with a tissue membrane and enclosed in a powerful muscle called the detrusor. The bladder rests on top of the pelvic floor. This is a muscular structure similar to a sling running between the pubic bone in front to the base of the spine.
- The bladder stores the urine until it is eliminated from the body via a tube called the urethra, which is the lowest part of the urinary tract. (In men it is enclosed in the penis. In women it leads directly out.)
- The connection between the bladder and the urethra is called the bladder neck. Strong muscles called sphincter muscles encircle the bladder neck (the smooth internal sphincter muscles) and urethra (the fibrous external sphincter muscles).
Click the icon to see an animation about urination.
The Process of Urination
The process of urination depends on a combination of automatic and voluntary muscle actions. There are two phases: the emptying phase and the filling and storage phase.
The Filling and Storage Phase. When a person has completed urination, the bladder is empty. This triggers the filling and storage phase, which includes both automatic and voluntary actions.
- Automatic Actions. The automatic signaling process in the brain relies on a pathway of nerve cells and chemical messengers (neurotransmitters) called the cholinergic and adrenergic systems. Important neurotransmitters include serotonin and noradrenaline. This pathway signals the detrusor muscle surrounding the bladder to relax. As the muscles relax, the bladder expands and allows urine to flow into it from the kidney. As the bladder fills to its capacity (about 8 - 16 oz of fluid) the nerves in the bladder send back signals of fullness to the spinal cord and the brain.
- Voluntary Actions. As the bladder swells, the person becomes conscious of a sensation of fullness. In response, the individual holds the urine back by voluntarily contracting the external sphincter muscles, the muscle group surrounding the urethra. These are the muscles that children learn to control during the toilet training process.
When the need to urinate becomes greater than one's ability to control it, urination (the emptying phase) begins.
The Emptying Phase. This phase also involves automatic and conscious actions.
- Automatic Actions. When a person is ready to urinate, the nervous system initiates the voiding reflex. The nerves in the spinal cord (not the brain) signal the detrusor muscle to contract. At the same time, nerves are also telling the involuntary internal sphincter (a strong muscle encircling the bladder neck) to relax. With the bladder neck now open, the urine flows out of the bladder into the urethra.
- Voluntary Actions. Once the urine enters the urethra, a person consciously relaxes the external sphincter muscles, which allows urine to completely drain from the bladder.
The female and male urinary tracts are relatively the same except for the length of the urethra.
The primary symptom of stress incontinence is leakage due to activities that apply pressure to a full bladder. High-impact exercise poses the greatest risk for leaking. But stress incontinence can occur with even minor activities, such as:
- Running (sometimes even standing can produce leakage)
Leakage stops when the stress ends. If the leakage persists, it is more likely to be urge incontinence.
Causes of Stress Incontinence in Women
Stress incontinence occurs because the internal sphincter does not close completely. In both men and women, the aging process causes a general weakening of the sphincter muscles and a decrease in bladder capacity. However, the causes of stress incontinence may be different in men and women.
In women, stress incontinence is nearly always due to one or both of the following:
- Urethral hypermobility
- Intrinsic sphincteric deficiency
Many women are prone to one or both of these problems, which can occur under the following circumstances:
- Having had many children through vaginal deliveries. In such cases, pregnancy and childbirth strain the muscles of the pelvic floor. Prolapsed uterus, in which the uterus protrudes into the vagina, occurs in about half of all women who have given birth. This condition can often cause incontinence.
- Menopause. Estrogen deficiencies after menopause can cause the urethra to thin out so that it may not close properly.
- Injury from surgery or radiation
Urethral Hypermobility. In urethral hypermobility the urethra does not close properly, allowing it to move too much (hypermobile). This condition typically occurs when the pelvic floor muscles in women become weak, and the following events occur:
- The weakened pelvic floor muscles stretch.
- This allows the bladder to sag downward within the abdomen.
- The sagging bladder pulls on the muscles surrounding the bladder neck (internal sphincter), which are connected to the urethra.
Intrinsic sphincteric deficiency (ISD). Intrinsic sphincter deficiency is the other major cause of stress incontinence in women. It occurs when the bladder neck muscles are damaged or weakened. The result is twofold:
- The bladder neck is open during filling.
- The closing pressure around the urethra is low.
This is the most severe stress incontinence in women and usually occurs after previous surgeries for incontinence.
Causes of Stress Incontinence in Men
Prostate treatments can impair the sphincter muscles. Such treatments are the major causes of stress incontinence in men. They include the following:
Surgery or radiation for prostate cancer. Some degree of incontinence occurs in nearly all male patients for the first 3 - 6 months after radical prostatectomy. Within a year after the procedure, most men regain continence, although some leakage may still occur.
Surgery for benign prostatic hyperplasia. Stress incontinence occurs in 1 - 5% of men after transurethral resection of the prostate (TURP), the standard treatment for severe benign prostatic hyperplasia.
Click the icon to see an illustrated series detailing TURP surgery.
Incontinence after prostate procedures is often a combination of urge and stress. Because studies often combine the two types of incontinence, it is not always clear which predominates.
The main symptom of urge incontinence (also called hyperactive, irritable, or overactive bladder) is the need to urinate frequently. Patients may go to the bathroom more than 8 times over 24 hours, including two or more times a night, and have subsequent leakage. In some cases, urge incontinence occurs only at night. This is called nocturnal enuresis.
All cases of urge incontinence involve an overactive bladder. This occurs when the detrusor muscle, which surrounds the bladder, contracts inappropriately during the filling stage. When this occurs, the urge to urinate cannot be voluntarily suppressed, even temporarily. There is usually one of two types:
- Idiopathic Detrusor Overactivity (formerly called Detrusor Instability). In this type, the nerves serving the bladder have signaled the brain appropriately that the bladder is full, but the detrusor muscle cannot be suppressed.
- Neurogenic Detrusor Overactivity (formerly called Detrusor Hyperreflexia). With this type, a known neurologic problem impairs the signaling systems between the bladder and the central nervous system, and the brain is unable to inhibit the detrusor muscle controlling urination.
Conditions that can produce the disorders leading to urge incontinence include:
- Benign prostatic hyperplasia (BPH). Detrusor instability occurs in about 75% of men with BPH and causes frequency, urgency, and urination during the night (although incontinence itself occurs only in very severe cases). Urge incontinence only at night can be a sign of severe obstruction in the urinary tract.
Benign prostatic hypertrophy (BPH) is a non-cancerous enlargement of the prostate gland, commonly found in men over the age of 50.
- Prostate surgical procedures. Either prostatectomy for prostate cancer or transurethral resection of the prostate (TURP) for BPH can cause detrusor overactivity. As with stress incontinence, radical prostatectomy poses a much higher risk than TURP, which carries a very low risk.
- Hysterectomy. Complications of this operation, which removes the uterus, are associated with up to double the risk for eventually needing surgery for incontinence.
Click the icon to see an image about hysterectomy.
- Radiation to the pelvis that involves the bladder.
- Damage to the central nervous system. Certain neurologic disorders or injuries can disrupt the passage of nerve messages between the urinary tract and central nervous system. These neurological conditions include stroke, multiple sclerosis, spinal cord or disk injury, and Parkinson's disease.
- The aging process.
- Emotional disorders. Anxiety is associated with urge incontinence.
- Medications, including some sleeping pills.
- Genetic factors may play a role in some cases.
Overflow incontinence happens when the normal flow of urine is blocked and the bladder cannot empty completely. Overflow incontinence can be due to a number of conditions:
- A partial obstruction. In this case the urine cannot flow completely out of the bladder, so it never fully empties.
- An inactive bladder muscle. In contrast to urge incontinence, the bladder is less active than normal, not more. It cannot empty properly and so becomes distended, or swells. Eventually this distention stretches the internal sphincter until it opens partially and leakage occurs.
The causes of the conditions leading to overflow incontinence include:
- Certain medications (anticholinergics, antidepressants, antipsychotics, sedatives, narcotics, and alpha-adrenergic blockers)
- Benign prostatic hyperplasia (enlarged prostate)
- Scar tissue
- Nerve damage. In such cases, nerves in the bladder are damaged so that the body cannot feel when the bladder is full, and the bladder does not contract. Such damage can be caused by spinal cord injuries, previous surgery in the colon or rectum, and pelvic fractures. Diabetes, multiple sclerosis, and shingles also can cause this problem.
Patients with functional incontinence have mental or physical disabilities that keep them from urinating normally, although the urinary system itself is intact. Conditions that can lead to functional incontinence include:
- Parkinson's disease
- Alzheimer's disease and other forms of dementia. Mental confusion may prevent both recognition of the need to void and locating a bathroom.
- Severe depression. In such cases, people may become incontinent because they have difficulty with self-control.
About 20 million American women and 6 million men have urinary incontinence or have experienced it at some time in their lives. The number, however, may actually be higher because patients are often reluctant to discuss incontinence with their doctors.
In general, the main risk factors for urinary incontinence are:
- Female sex
- Older age
- Neurological disorder (such as stroke)
Higher body mass index, inactivity, depression, and diabetes can also increase risk.
Incontinence in Women
Urinary incontinence is far more common among women than men. Between 15 - 50% of women experience urinary incontinence during their lifetimes, with the highest rates occurring in women who have had children. Severe urinary continence affects 7 - 10% of women. About 10% of women undergo surgery for urinary incontinence or pelvic organ prolapse. In women, stress incontinence decreases with age while urge incontinence increases as women get older.
Pregnancy and Childbirth. Pregnancy and childbirth can increase the later risk for urinary incontinence. The risk is highest with the first child, and there is an increased risk in women who have their first child over age 30. Vaginal birth can cause pelvic prolapse, a condition in which pelvic muscles weaken and the pelvic organs (bladder, uterus) slip into the vaginal canal. Pelvic prolapse, and the surgery used to correct it, can cause incontinence.
It is not clear if cesarean delivery helps prevent urinary incontinence. Similarly, evidence is inconclusive as to whether episiotomy prevents urinary incontinence. (Episiotomy is a surgical incision that is made during childbirth to the perineum, the muscle between the vagina and the rectum. Doctors may perform this procedure to help widen the vaginal opening and prevent tearing.)
High-Impact Exercise. Women who engage in high-impact exercise are susceptible to urinary leakage, particularly women with a low foot arch. Shock to the pelvic area is increased as the foot makes impact with hard surfaces.
Smoking. Studies have reported a higher risk for incontinence, notably mixed incontinence, in women who are current or former heavy smokers (more than a pack a day).
Obesity. Being overweight is a major risk factor for all types of incontinence. The more a woman weighs, the greater her risk.
Medical Factors in Older Women. Urge incontinence is more common among postmenopausal women who have a history of:
- Two or more urinary tract infections within the past year
Incontinence in Men
The rate of incontinence in men (about 5 - 15%) is much lower than in women. The risk for urinary incontinence increases with age. In the United States, about 21% of men over age 65 have urinary incontinence, mostly urge incontinence and mixed urinary incontinence. In older men, prostate problems and their treatments are the most common factors that affect the urinary tract. Up to 30% of men who have had surgery to remove their prostate gland experience some degree of urinary incontinence.
Incontinence in the Elderly
All older adults are susceptible to incontinence. About one in 10 people over age 65, and 3 in 10 over age 80, have some type of bladder control loss. About half of the elderly who are housebound or in nursing homes experience incontinence.
Incontinence in Children and Young People
Incontinence is relatively uncommon in children 5 years and older. When incontinence does occur before puberty, it is twice as common in boys as in girls. It is often difficult to diagnose incontinence in children. Many cases result from a combination of factors, including:
- Birth defects or inborn conditions that cause problems in the urinary tract
- Slower physical development
- An overproduction of urine at night
- A lack of ability to recognize bladder filling when asleep
- Inherited factors (indicated by a strong family history of bedwetting)
Bedwetting in children is not considered incontinence.
Factors in Temporary Incontinence
A number of conditions can cause temporary incontinence in anyone:
- Urinary tract infections
- Excess fluid intake
- Severe depression
- Restricted mobility
Drugs. Drugs are often a cause of temporary incontinence.
- Drugs that affect the adrenergic system (a nerve-cell and hormonal pathway that regulates the sphincter muscle) are common causes of incontinence. For example, alpha-adrenergic blockers, such as tamsulosin (Flomax), used for benign prostatic hyperplasia, can cause incontinence by over-relaxing the muscles. On the other hand, men with enlarged prostates who suffer from urinary problems may be helped by the increase of urine flow after using alpha blockers.
- Alpha-adrenergic agonists, such as pseudoephedrine (found in some oral decongestants) tighten the muscles and may cause overflow incontinence in susceptible people.
- Diuretics, used for high blood pressure, often rapidly introduce high urine volumes into the bladder.
- Colchicine, a drug used for gout, can cause urge incontinence.
- Other medications and substances that increase the risk for incontinence are caffeine, sedatives, antidepressants, antipsychotics, and antihistamines.
Urinary incontinence can have severe emotional effects. Patients may feel humiliated, isolated, and helpless about their condition. Incontinence can interfere with social and work activities. Depression is very common in women with incontinence. Incontinence also has emotional effects on men. A number of studies of patients with prostate cancer suggest that incontinence can be much more distressing side effect for men than erectile dysfunction (also a side effect of prostate cancer treatment).
Disruption of Daily Life
To prevent wetness or odors, people with incontinence may alter their way of life.
- Errands become very difficult and need advanced planning.
- Public bathrooms may be difficult to locate or unavailable. The problem is particularly severe for those with urge incontinence who have little time to reach a bathroom and have large volume spills.
Specific Effects of Incontinence in Seniors
Incontinence is particularly serious in older adults:
- Older adults who are otherwise healthy may stop exercising because of leakage, which can increase their impairment.
- Incontinence can result in loss of independence and quality of life.
- It is a major reason for nursing home placement.
- Severe incontinence may require catheterization. This is the insertion of a tube that allows urine to continually pass into an external collecting bag. In such cases, complications are common, particularly infections.
- There is a strong association between urge incontinence and falls and injuries, which may be due in part to the rush to the toilet in the middle of the night. Keeping a pan or portable commode near the bed may prevent injuries as well as improve sleep and general convenience.
Fewer than half of the patients who have urinary incontinence tell their doctor about the problem. In many cases, patients simply feel that incontinence is part of aging. And, in spite of the commonness of this problem, two-thirds of doctors never ask their older patients if they experience incontinence.
It is important, however, for both the doctor and the patient to raise the issue. Although a third of American men and women age 30 - 70 have had at least some loss of bladder control, most have not been diagnosed by a doctor.
The first step in the diagnosis of incontinence is a detailed medical history. The doctor should ask questions about the patient's present and past medical conditions and patterns of urination. Patients should tell the doctor the following information:
- When the problem began
- Frequency of urination
- Amount of daily fluid intake
- Use of caffeine or alcohol
- Frequency and description of leakage or urine loss, including activity at the time, sensation of urge to urinate, and approximate volume of urine lost
- Frequency of urination during the night
- Whether the bladder feels empty after urinating
- Pain or burning during urination
- Problems starting or stopping the flow of urine
- Forcefulness of the urine stream
- Presence of blood, unusual odor or color in the urine
- A list of major surgeries with their dates, including pregnancies and deliveries, and other medical conditions
- Any medications being taken
Another method of diagnosing incontinence uses a test that asks 3 questions, which help a doctor distinguish between urge and stress urinary incontinence:
- During the last 3 months, have you leaked urine (even a small amount)?
- When did you leak urine? (During physical activity; when you could not reach the bathroom quickly enough; without physical activity or bladder urge.)
- When did you leak urine most often? (Physical activity; bladder urge; without or about equally with physical activity or bladder urge.)
Voiding Diary. The patient might find it helpful to keep a diary for 3 - 4 days before the office visit. This diary, sometimes referred to as a voiding diary or log, should be a detailed record of:
- Daily eating and drinking habits
- The times and amounts of normal urination
For each incident of incontinence, the log should also detail:
- The amount of urine lost (the patient may be asked to catch and measure urine in a measuring cup during a 24-hour period)
- Whether the urge to urinate was present
- Whether the patient was involved in physical activity at the time
The office visit should consist of a thorough physical examination, checking for abnormalities or enlargements in the rectal, genital, and abdominal areas that may cause or contribute to the problem.
Measuring Postvoid Residual Urine Volume
The postvoid residual urine volume (PVR) measures the amount of urine left in the bladder after urination:
- Normally, about 50 mL or less of urine is left
- More than 100 mL suggests an abnormality and requires further tests
- More than 200 mL is a definite sign of abnormalities
Use of a Catheter. The most common method for measuring PVR uses a catheter, which is inserted into the urethra after a few minutes of urination. The advantage of the catheter is that it can also collect urine for analysis, but it can be uncomfortable and lead to urinary tract infections.
Ultrasound. Ultrasound may also be used to measure the volume of remaining urine.
Cystometry measures the bladder's ability to retain urine at different capacities and pressures. It uses a catheter and can be performed at the same time as the PVR test.
Subtraction Cystometry. Although procedures vary, the basic steps for the technique are as follows:
- The patient empties the bladder as much as possible.
- A double-channel catheter is inserted through the urethra and into the bladder. It is used to fill the bladder with water and to measure pressure. Another catheter is inserted into the rectum or vagina, which is used to measure abdominal pressure.
- While water is instilled through the tube into the bladder, the pressure in the bladder and abdomen are measured and the results are recorded in a computing device.
- During the process, the patient informs the doctor about any changes in the need to urinate, including the initial need to urinate, a normal desire to urinate, and a strong need to urinate.
- Often during this process, the patient is asked to cough, bounce up and down, or even walk in place. The patient may also be asked to strain as if he or she is having a bowel movement. This is called the Valsalva maneuver. The point at which leakage occurs during this action is called the Valsalva leak point pressure, which might be a useful measurement for determining treatment.
- When the urge to urinate is strong, the doctor stops this portion of the test.
- A calculation is then made using bladder and abdominal pressure measurements as well as volume and flow rate of the urine. The result provides the doctor with an assessment of detrusor contractions.
The detrusor muscle of a normal bladder will not contract during bladder filling. Severe contractions at low amounts of administered fluid (less than 200 mL) indicate urge incontinence. Stress incontinence is suspected when there is no significant increase in bladder pressure or detrusor muscle contractions during filling, but the patient experiences leakage if abdominal pressure increases.
To determine whether the bladder is obstructed, the speed of urine flow is measured electronically using a test called uroflowmetry. The test involves the following steps:
- Patients are instructed not to urinate for several hours before the test and to drink plenty of fluids so they have a full bladder and a strong urge to urinate.
- To perform this test, a patient urinates into a special toilet equipped with a uroflowmeter.
- It is important that patients remain still while urinating to help ensure accuracy, and that they urinate normally and do not exert strain to empty their bladder or attempt to retard their urine flow.
Many factors can affect urine flow (such as straining or holding back because of self-consciousness) so doctors recommend that the test be performed at least twice.
Cystoscopy, also called urethrocystoscopy or cystourethroscopy, detects structural abnormalities, inflammation of the bladder wall, or masses that might not show up on x-ray.
- The patient is given a light anesthetic, and the bladder is filled with water.
- Next, a thin flexible tube called a cystoscope is inserted through the urethra into the bladder.
- The end of the cystoscope contains a tiny microscope-like instrument.
- The doctor uses the cystoscope to look for abnormalities in the interior of the bladder.
Cystoscopy is a procedure that uses a flexible fiber optic scope, which is inserted through the urethra into the urinary bladder. The doctor fills the bladder with water and inspects the interior of the bladder. The image seen through the cystoscope may also be viewed on a color monitor and recorded on videotape for later evaluation.
Intravenous Pyelogram. Intravenous pyelogram (IVP) may be used to diagnose urge incontinence. It is performed as follows:
- A dye is injected into the patient's vein and is processed by the kidneys.
- A series of x-ray pictures are taken of the kidneys, ureter, and bladder as the dye passes through them. This provides a dynamic picture of the relationship between the patient's urinary system and urinary functioning.
Click the icon to see an image of an intravenous pyelogram.
IVPs can detect structural abnormalities, urethral narrowing, or incomplete emptying of the bladder. This test should not be used on pregnant women, those allergic to the dye, or patients with kidney failure.
Ultrasound. Ultrasound is another diagnostic tool. Because it does not expose the patient to radiation or require an injection of dye, it has replaced many IVPs. Ultrasound is helpful in measuring urine volume in the bladder. It may also be useful in identifying abnormalities in the bladder neck, and in assessing the urinary tract before and after surgery.
Electrophysiologic Sphincter Testing
Electrophysiologic sphincter testing, also referred to as electromyography (EMG), evaluates two important factors:
- The function of the nerves serving the sphincter and pelvic floor muscles
- The patient's ability to control these muscles
Using a technique similar to that of an electrocardiogram, the doctor places electrodes on the affected areas to observe electrical activity in the muscles.
Urethral Pressure Profile
Urethral pressure profile is used to investigate urethral blockage. A probe is placed in the urethra to determine pressure at different points along this pathway during urination and the exact location of any obstruction in the urethra.
Treatment for temporary incontinence can be rapid, simple, and effective. If urinary tract infections are the cause, they can be treated with antibiotics. Any related incontinence will often clear up in a short time. Medications that cause incontinence can be discontinued or changed to halt episodes.
Chronic incontinence may require a variety of treatments, depending on the cause. Treatment options are listed below in the order in which they are usually tried, from least-to-most invasive:
- Behavioral techniques, which include pelvic floor (Kegel) exercises and bladder training, are sometimes all a person needs for achieving continence. A number of devices can also be used to strengthen muscles and prevent urine leakage. Bladder training is useful for urge incontinence.
- Medications are tried next. Often, these involve anticholinergics. Estrogen or estrogen plus progesterone used to be recommended, but recent research has shown that these hormone treatments can actually make urinary incontinence worse.
- Surgery. Surgery is the last resort. There are many effective procedures available for stress incontinence.
Lifestyle techniques to improve quality of life and improve hygiene are part of all treatments.
General Approach for Treating Specific Forms of Incontinence
Lifestyle measures, including dietary recommendations, bladder training, and continent aids, are useful for anyone with incontinence. Other treatments vary depending on whether the patient has stress or urge incontinence. In people who have both, the treatment usually is aimed at the predominant form.
Treating Stress Incontinence. The general goal for women with stress incontinence is to strengthen the pelvic muscles. Typical steps for treating women with stress incontinence are:
- Devices and continent aids for blocking urine in the urethra (vaginal pessaries, adhesive pads, and others).
- Behavioral techniques and noninvasive devices, including Kegel exercises, weighted vaginal cones, and biofeedback.
- Medications. Alpha-adrenergic agonists and possibly anticholinergics.
- Surgery is a reasonable option if symptoms do not improve with noninvasive methods. There are many surgical techniques. Most are designed to restore the bladder neck and urethra to their anatomically correct positions.
Treating Urge Incontinence. The goal of most treatments for urge incontinence is to reduce the hyperactivity of the bladder. The following methods may be helpful:
- Behavioral methods
- Medications (anticholinergics and alpha blockers)
- Procedures that stimulate the pelvic floor or nerves in the tailbone (the sacral nerves), which help retrain the bladder
With the exception of functional incontinence, most cases of incontinence will almost always improve with behavioral techniques. There are a variety of methods, but the focus is usually on strengthening or retraining the bladder. Studies indicate that such exercises are very effective, even for men recovering from surgery for prostate cancer.
To enhance bladder training for incontinent patients who are in nursing rooms, nurses may need to check patients for dryness and regularly remind them to urinate. As an extra tip for older people with severe incontinence, keeping a pan or portable commode near the bed may prevent injuries from falling as well as improve general convenience.
Combination of Kegel Exercises and Bladder Training
Pelvic floor (Kegel) exercises and bladder training are often recommended as the first-line approach for treating all forms of urinary incontinence. They can help to substantially improve symptoms in many patients, including elderly people who have had the problem for years. Kegel exercises may be especially helpful for women in their 40s and 50s who suffer from stress incontinence.
Pelvic Floor Muscle (Kegel) Exercises. Kegel exercises are designed to strengthen the muscles of the pelvic floor that support the bladder and close the sphincters.
Stress incontinence is an involuntary loss of control of urine that occurs at the same time abdominal pressure is increased as in coughing or sneezing. It develops when the muscles of the pelvic floor have become weak.
Dr. Kegel first developed these exercises to assist women before and after childbirth, but they are very useful in helping to improve continence for both men and women.
The general approach for learning and practicing Kegel exercises is as follows:
- Since the muscles are sometimes difficult to isolate, the best method is to first learn while urinating. The patient begins to urinate and then contracts the muscle in the pelvic area with intention of slowing or stopping the flow of urine. Women should contract the vaginal muscles as well. They can detect this by inserting a finger inside the vagina. When the vaginal walls tighten, the pelvic muscles are being correctly contracted. Patients should place their hands on their abdomen, thighs, and buttocks to make sure there is no movement in these areas while exercising.
- An alternate approach is to isolate the muscles used in Kegel contractions by sensing then squeezing and lifting the muscles in the rectum that are used in passing gas. (Again, women should contract the vaginal muscles as well.)
- The first method is used for strengthening the pelvic floor muscles. The patient slowly contracts and lifts the muscles and holds for 5 seconds, then releases them. There is a rest of 10 seconds between contractions.
- The second method is simply a quick contraction and release. The object of this exercise is to learn to shut off the urine flow rapidly.
- In general, patients should perform 5 - 15 contractions, three to five times daily.
Some notes of caution:
- Once learned, Kegel exercises should not be performed while urinating more than about twice a month, since this practice may eventually weaken the muscles.
- In women, incorrect or overly vigorous exercises may cause vaginal muscles to tighten excessively, resulting in pain during sexual intercourse.
- Overexercise can tire muscles and cause more leakage.
- Incontinence will return to its original severity if these exercises are discontinued.
- It may be several months before the patient sees significant improvement.
Bladder Training. Bladder training involves a specific and graduated schedule for increasing the time between urinations:
- Patients start by planning short intervals between urinations, then gradually progressing with a goal of voiding every 3 - 4 hours.
- If the urge to urinate arises between scheduled voidings, patients should remain in place until the urge subsides. At the time, the patient moves slowly to a bathroom.
This system uses a set of weights to improve pelvic floor muscle control:
- The typical set includes five cones of graduated weights ranging from 20 grams (less than 1 ounce) to 65 grams (slightly over 2 ounces).
- Starting with the lightest, the woman places the cone in her vagina while standing and attempts to prevent the cone from falling out. The muscles used to hold the cone are the same ones needed to improve continence.
As with standard Kegel exercises, frequent repetition is required, but most women will eventually be able to use the heavier weights and build up the ability to prevent stress and urge incontinence.
Women who are unable to learn Kegel muscle contraction and release with verbal instructions may be helped with the use of biofeedback:
- Biofeedback uses a vaginal or rectal probe inserted by the patient that relays information to monitoring equipment.
- The patient isolates the pelvic floor and bladder muscles and performs Kegel exercises.
- The monitor emits auditory or visual signals that indicate how strongly the patient is contracting the proper pelvic floor muscles and how effectively the bladder muscles are being released.
- The apparatus is designed for home use.
As with any Kegel exercise regimen, biofeedback must be used for several months before it is effective. Biofeedback that teaches control of pelvic muscles may also be helpful for children who have daytime wetting, frequent urinary tract infections, or both.
Electrical Stimulation of the Pelvic Floor
Electrical stimulation of the pelvic floor muscles has been a common treatment for years. The procedure uses a probe inserted into the anus or vagina, which produces a contraction in the pelvic floor muscles. Studies evaluating this procedure’s effectiveness have been mixed. Many insurance companies consider this procedure investigational and will not pay for it.
Medications for treating urinary incontinence increase sphincter or pelvic muscle strength or relax the bladder, improving the ability to hold more urine. Medications are prescribed for all kinds of incontinence, but they are generally most helpful for urge incontinence.
Medications Used for Urge Incontinence
Anticholinergics. Anticholinergics work in the following ways:
- Inhibit the involuntary contractions of the bladder
- Increase capacity of the bladder
- Delay the initial urge to void
These drugs can produce small but significant improvements. However, the medications have not been rigorously compared with behavioral methods, such as bladder training and Kegel exercises, which are very effective for most cases of urge incontinence. Anticholinergics can have distressing side effects, notably dry mouth.
- Propantheline (ProBanthine, generic). This drug used to be the most commonly prescribed anticholinergic, but has been largely replaced by newer anticholinergics with fewer side effects.
- Oxybutynin (Ditropan, Oxytrol, generic)
- Tolterodine (Detrol)
- Hyoscyamine (Levbid, Hyomax, generic)
- Trospium (Sanctura, generic)
- Darifenacin (Enablex)
- Solifenacin (Vesicare)
- Fesoterodine (Toviaz)
Extended-release forms of oxybutynin (Ditropan XL) and tolterodine (Detrol LA) are available. They improve continence and have fewer adverse effects than short-acting forms. A skin patch form of oxybutynin (Oxytrol) is another option. It may have fewer side effects, such as dry mouth and constipation, than the pill form. Oxybutynin is also approved for pediatric use in children ages 6 and older.
Side effects of anticholinergic drugs include:
- Dry eyes (a particular problem for people who wear contact lenses; patients who wear contacts may wish to start with low doses of medication and gradually build up)
- Dry mouth
- Rapid heart rate
- Confusion, forgetfulness, and possible worsening of mental function, particularly in older people with dementia, such as those with Alzheimer's disease
- Hallucinations, possibly, especially for children and older adults; doctors should monitor patients for this symptom
Alpha-Blockers. Alpha-blockers are drugs that relax smooth muscles and improve urine flow. They are useful for men with benign prostatic hyperplasia who also have urge incontinence. The older alpha-blockers terazosin (Hytrin, generic) and doxazosin (Cardura, generic) are now prescribed less often than the newer selective alpha-blockers tamsulosin (Flomax, generic), alfuzosin (Uroxatral), and silodosin (Rapaflo). Alpha-blockers are sometimes combined with anticholinergics to treat men with moderate-to-severe lower urinary tract symptoms, including overactive bladder.
Medications Used for Stress Incontinence
Alpha-Adrenergic Agonists. Alpha-adrenergic agonists, such as clonidine (Catapres, generic), are used to strengthen the smooth muscle that opens and closes the internal sphincter. These drugs include ephedrine and pseudoephedrine, which have been common ingredients in numerous over-the-counter decongestants and appetite suppressants.
Such drugs may be helpful for select patients with mild stress incontinence not caused by nerve damage, but evidence on their benefits is weak. They also can have significant side effects, including agitation, insomnia, and anxiety. Alpha-adrenergic agonists may have adverse effects on the heart in people with existing heart problems. People with glaucoma, diabetes, hyperthyroidism, heart disease, or high blood pressure should not take these drugs.
Both urge and stress incontinence are affected, in part, by central nervous system processes. Serotonin, norepinephrine, and noradrenaline are chemical messengers (neurotransmitters) that affect pathways involved with urination. (These neurotransmitters are also important for many other emotional and physical functions.) Antidepressants targeting one or both of these neurotransmitters are sometimes used for urge incontinence and may also be helpful for some people with stress incontinence.
- Tricyclic Antidepressants. Tricyclic antidepressants, such as imipramine (Tofranil, generic), may help both urge and stress incontinence. They act as anticholinergic drugs and relax the bladder. They also strengthen the internal sphincter. These drugs should be used carefully. They pose some risk for adverse effects on the heart and possibly the lungs, and they have other severe side effects in older adults. These antidepressants produce side effects similar to anticholinergic drugs, and may cause drowsiness. They may also cause overflow incontinence in some people.
- Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs). SNRIs are specially designed antidepressants that are similar to tricyclics but do not have the same side effects. They target the neurotransmitters serotonin and norepinephrine, which are thought to play key roles in the normal action of bladder muscles and nerves. Increased neurotransmitter activity stimulates the nerve that controls the urethral sphincter. The SNRI duloxetine (Cymbalta) is approved in Europe for treatment of stress urinary incontinence. It is approved in the U.S. for other conditions, but not for stress urinary incontinence. Nevertheless, it is sometimes prescribed off-label for stress urinary incontinence. The FDA is investigating whether duloxetine can increase the risk for suicidal behavior.
Botulinum (Botox). Botulinum, the deadly toxin that sometimes contaminates improperly cooked foods, is also a powerful muscle-relaxant. Researchers are investigating whether tiny injected amounts of a purified form (Botox) can relax the muscles and help control overactive bladder that causes urge incontinence.
There are nearly 200 surgical procedures for incontinence. Most are designed to restore the bladder neck and urethra to their anatomically correct positions in patients with stress incontinence. Injections of bulking materials are another option for women and men.
The choice of surgical procedure depends on a number of factors, including the presence of bladder or uterine prolapse, the severity of incontinence, and the surgeon’s experience in performing specific types of surgery.
In general, patients should weigh all options carefully. They should discuss the situation with their doctor, and ask about their surgeon's experience. They should also be completely informed about the benefits and risks of the procedures. Patients will need to have a complete diagnostic evaluation before any surgical procedure, including assessment of post-void residual urine volume.
A sling procedure is usually the first-line surgical approach for stress incontinence in women who have either intrinsic sphincter deficiency or urethral hypermobility. It may also be useful for managing female urge incontinence. Sling procedures are also available for men who experience incontinence after prostatectomy.
The purpose of a sling procedure is to create a sling or hammock around the neck of the bladder to help keep the urethra closed. There are different types of sling procedures. They include:
- Suburethral, which is the traditional type
- Midurethral, which includes retropublic transvaginal tape (TVT) and transobturator tape (TOT)
Suburethral Sling Procedure. The suburethral, also called pubovaginal, sling is the traditional sling procedure. It uses a sling made from the patient’s own tissue (fascia), animal tissue, or a synthetic material. Suburethral means “beneath the urethra.” The procedure may be performed with laparoscopic or conventional “open” surgery. The procedure generally works as follows:
- The surgeon makes an incision above the pubic bone and removes a layer of abdominal fasci (tissue that covers muscle fibers). This muscle strip is set aside and later serves as the sling.
- The surgeon makes an incision in the vaginal wall. The piece of muscle fiber or material is attached under the urethra and bladder neck, somewhat like a hammock, and secured to the abdominal wall and pelvic bone.
- This sling then compresses the urethra back to its original position. The sling must be supportive without being too tense, which can cause urinary obstruction.
Complications can include infection, bleeding, and the formation of fistulas (holes that form and are usually infected).
Midurethral Sling Procedures. Midurethral sling procedures use slings made from synthetic mesh materials that are placed midway along the urethra. This newer type of sling procedure has become more commonly used than the conventional suburethral procedure because it can be performed on an outpatient basis using minimally invasive surgical techniques and no abdominal incisions.
There are two types of midurethral slings:
- In the retropublic procedure, the surgeon makes a small vaginal incision under the urethra and then two small incisions above the pubic bone.
- The transobturator procedure uses only a vaginal incision.
Sling Procedures in Men. For some men who have prostatectomy-induced incontinence, sling procedures may be a good option. Researchers have reported an 80% success rate, the same as an artificial urinary sphincter, which is the standard surgical treatment for such patients. The sling procedure has been less effective in men who have had radiation therapy, although improved techniques are making this approach useful even for these patients. Minimally invasive procedures are also being tested.
Effectiveness and Complications. The sling procedure and the Burch colpsuspension seem to have similar success rates. Post-operative urinary problems, such as voiding problems, common urinary tract infections, and urge incontinence may occur. The FDA has reported complications associated with some synthetic mesh slings.
Retropubic Colposuspension (Burch Colposuspension)
Retropubic colposuspension aims to correct the position of the bladder and urethra by sewing the bladder neck and urethra directly to the surrounding pelvic bone or nearby structures. There are many variants, but, in general, they are effective only for women with urethral hypermobility. Most procedures require a general or spinal anesthetic and a 2-day hospital stay.
Burch colposuspension is the standard approach. (Marshall-Marchetti Krantz [MMK] is an alternative approach.) It is often performed during abdominal surgeries such as hysterectomy or hernia operations. It is also performed along with sacrocolpopexy, a surgical procedure used to repair pelvic organ prolapse. (Pelvic organ prolapse occurs when the uterus or bladder slips from the pelvic cavity into the vagina. It is often due to pelvic muscle weakness that develops after childbirth.) Prolapse can lead to stress incontinence. However, prolapse surgery itself sometimes causes incontinence.
The Burch colposuspension procedure may be performed using open surgery or laparoscopy. The surgeon makes an abdominal incision and secures the urethra and bladder neck with lateral (sideways) sutures that pass through thick bands of muscle tissue running along the pubic bones.
Click the icon to see an illustrated series detailing bladder neck surgery.
Effectiveness and Complications. Patients usually need to use a urinary catheter for about 10 days after surgery. Because colposuspension surgery involves an abdominal incision, it can take up to 6 weeks for full recovery. (Laparoscopic procedures have a faster recovery time than open surgery.)
Complications can include problems with wound healing and postoperative voiding function. Convalescence time is longer with retropubic colposuspension than with sling procedures.
In cases of sphincter incompetence, or complete lack of sphincter function, an artificial internal sphincter may be implanted. This procedure is generally used for men, such as those who have experienced incontinence following radical prostatectomy.
Click the icon to see an illustrated series detailing artificial sphincter surgery.
This device uses a balloon reservoir and a cuff around the urethra that is controlled with a pump. The patient opens the cuff manually by activating the pump. The urethra opens and the bladder empties. The cuff closes automatically several minutes later. The two major drawbacks of the internal sphincter implant are malfunction of the implant and risk of infection.
Bulking Material Injections
Injections of materials, such as collagen, that provide bulk to help support the urethra may help the following patients:
- Women with severe stress incontinence who cannot or do not wish to have surgery that involves anesthesia.
- Men who have slight incontinence caused by prostate surgery. Men who have bulking injections after TURP (transurethral resection of the prostate) have a continence rate that is equal to the rate in women. After radical prostatectomy (removal of the prostate gland in prostate cancer), collagen injections can achieve some level of continence in up to nearly half of men. (Collagen injections are not beneficial after radiation therapy for prostate cancer.)
- The basic procedure involves injecting bulking material into the tissue surrounding the urethra.
- The material used is usually animal or human collagen. (Collagen is the basic protein in bones, muscles, and all connective tissue.) Synthetic bulking materials, such as carbon-coated beads, are also being used.
- The doctor passes the collagen-containing needle through a cystoscope, a tube that has been inserted into the urethra. The collagen can also be injected into the skin next to the sphincter.
- The injected collagen tightens the seal of the sphincter by adding bulk to the surrounding tissue.
- The procedure takes about 20 - 40 minutes, and most people can go home immediately afterward.
- Two or three additional injections may be needed to achieve satisfactory results.
Postoperative Care. People may experience immediate improvement followed by a temporary relapse after a week or so. Patients must be taught to use a catheter tube for withdrawing urine for a few days following the procedure. In general, it takes about a month for the full benefits to be apparent.
- There is a risk for infection and urinary retention, although these conditions are temporary.
- The procedure may not be appropriate for patients with certain heart conditions.
Duration of Effectiveness. Collagen is absorbed over time, so injections generally need to be repeated every 6 - 18 months.
The sacral nerves, located near the sacrum (“tail bone”), appear to play an important role in regulating bladder control. A sacral nerve stimulation system (InterStim) may help some patients with urge incontinence. The system uses an implanted device to send electrical pulses to the sacral nerves to help retrain them. InterStim is reserved for the treatment of urinary retention and the symptoms of overactive bladder in patients who have failed or cannot tolerate less invasive treatments.
Complications include infection, lower back pain, and pain at the implant site. The system, however, does not cause nerve damage and can be removed at any time.
Patients have reported improvement in the frequency and volume of urination, as well as the intensity of urgency and their quality of life.
Keeping Skin Clean. Proper hygiene is essential for patients with incontinence.
To avoid skin irritation and infection associated with incontinence, keep the area around the urethra clean. The following tips may be helpful:
- After a urinary accident, clean any affected areas right away.
- When bathing, use warm water and don't scrub forcefully; hot water and scrubbing can injure the skin.
- A number of cleansers are available that are specially created for incontinence and allow frequent cleansing without over-drying or causing irritation to the skin. Most do not have to be rinsed off; the area is simply wiped with a cloth.
- After bathing, apply a moisturizer plus a barrier cream. Barrier creams include petroleum jelly, zinc oxide, cocoa butter, kaolin, lanolin, or paraffin. These products are water repellent and protect the skin from urine.
- Anti-fungal creams that contain miconazole nitrate are used for yeast infections.
Preventing or Reducing Odor. Certain methods may help reduce odor from accidents. They include:
- Deodorizing tablets can be taken by mouth or used in appliances.
- Drinking more water, not less, will also reduce odors. Drinking more water may actually help reduce leakage, too.
- To remove odors from mattresses, use a solution of equal parts vinegar to water. Once the mattress has dried, apply baking soda on the stain, rub it in, and then vacuum it off.
Diet and Weight Control. In women, pelvic floor muscle tone weakens with significant weight gain. Weight loss can help reduce the frequency of urinary incontinence episodes in overweight women. Women should eat healthy foods in moderation and exercise regularly. Constipation can worsen urinary incontinence, so diets should be high in fiber, fruits, and vegetables.
Fluid Intake. A common misconception among people with incontinence is that drinking less water will prevent accidents. In reality, limiting fluid intake has the following effects:
- The lining of the urethra and bladder becomes irritated, which may actually increase leakage.
- Concentrated urine also has a stronger pungency, so drinking plenty of fluids can help reduce odor.
People with incontinence, however, should stop drinking beverages 2 - 4 hours before going to bed, particularly those who experience leakage or accidents during the night.
Fluid and Food Restrictions. A number of foods and beverages may increase incontinence. People who drink caffeinated or alcoholic beverages should try eliminating them to see if incontinence improves.
Considerations for Exercising
Sometimes otherwise healthy adults stop exercising because of leakage. There are a number of methods for preventing or stopping leakage during exercise. The following are some tips:
- Limit fluid intake before exercising (but be sure not to become dehydrated)
- Urinate frequently, including right before exercise
- Women can try wearing pads or urethral inserts
Urinary Incontinence Products
Many products are available to help patients avoid embarrassment and prevent leakage.
Absorbent Pads and Protective Undergarments
A variety of absorbent pads and undergarments are quite effective in catching spills and leaks. Newer types of pads are thin enough to be worn undetected, and a spare can be hidden in a purse or pocket. Many undergarments developed for incontinence are almost indistinguishable from regular briefs and underpants.
For men, drip collectors are available which can be worn under briefs and are not noticeable under normal clothing. Lined with absorbent material, the pouch-like collector surrounds the penis or scrotum and is fastened with a belt or pins.
All absorbent undergarments should be changed when wet to limit problems of chafing or infection.
Self-Adhesive Foam Pads. Foam pads with an adhesive coating are available for women with stress incontinence. They work as follows:
- The pad is placed over the opening of the urethra where it creates a seal, preventing leakage.
- It is removed before urinating and replaced with a new one afterwards.
- The pad can be worn up to 5 hours a day and through the night.
- It can be used during physical activity, although it may change position during vigorous exercise.
- It should not be worn during sexual intercourse.
Adhesive pads should not be used by women with the following conditions:
- Urinary tract or vaginal infections
- Urge or other forms of nonstress incontinence
- A history of surgery for incontinence
Urethral Caps. Small silicone caps that use suction to adhere to the urethral opening are also an option for women. These caps may be uncomfortable for some women, and side effects can include irritation and urinary tract infections.
Penile Clamps. The penile clamp is a hinged V-shaped external device that has two foam rubber pads which fit over the penis. When it is locked in place, it helps prevent dribbling. To urinate, the man releases the clamp.
Vaginal Pessaries. Vaginal pessaries are devices inserted into the vagina that support the inside of the vaginal walls. Pessaries are usually made of silicon and come in various forms, including donut or cube-shapes. They must be fitted by a health professional and are effective for vaginal prolapse or other vaginal structural problems. Serious complications are rare but can occur if the pessary is not replaced periodically.
Urethral Tubes. Silicone tubes or sleeves that fit into the urethral opening are also available, although they are rarely recommended. When the tube is inserted into the urethra, the sleeve conforms to its shape and creates a seal at the bladder neck, preventing leakage. It is intended for one-time use and is replaced after voiding.
Catheters and Collection Devices
A catheter is a slim flexible tube inserted into the urethra. They are mainly used for cases of severe urge incontinence.
A catheter (a hollow tube) may be inserted into the urinary bladder when there is a urinary obstruction, following surgical procedures to the urethra, in unconscious patients (due to surgical anesthesia or coma), or for any other problem in which the bladder needs to be kept empty (decompressed) and urinary flow assured.
Click the icon to see an image of male bladder catheterization.
Temporary Catheterization. For people who are still active, catheterization is often very distressing. If possible, temporary, also called intermittent, catheterization is usually the best choice. Patients insert the catheter tube into their urethras, generally every 3 - 4 hours. This type of catheterization carries few risks and empties the bladder completely. Some patients report that they can maintain an active life with no significantly increased risk for infection with some simple precautions:
- Sterilize catheters at home.
- Use a zip lock plastic bag for carrying them when leaving home.
- Use another plastic bag for antiseptic cleansing solution.
- When using public bathrooms, wash before and after catheterization. Touch as few places in the bathroom as possible.
Permanent Catheterization. People who are mentally or physically incapable of self-catheterization may need permanent catheterization.
- The permanent catheter is inserted by a doctor or nurse into the opening of the bladder and a cuff is inflated to hold the tube in place. (A suprapubic tube may be recommended for long-term use. It is an indwelling catheter that is surgically placed directly into the bladder through the abdomen. The catheter is inserted above the pubic bone.)
- Urine drains to an external collection device, which is generally strapped to the leg and must be emptied periodically.
Nonsurgical catheterization procedures are generally not painful, but there is a substantial increased risk of infection. Many doctors feel that the catheter is overused, especially in the elderly.
External Collection Devices. External catheter and collection devices include:
- Condom catheters. Condom catheters are much more satisfactory than standard catheters for many male patients, although there is more spillage. The condom is worn all day and at night it is removed and washed for reuse the next day.
- Collection devices attached to the leg. For chronic or severe incontinence, collective devices drain urine into a bag that is attached to the lower leg and emptied periodically. These are generally more successful for men than women. Urine can be funneled into the tube by a pouch surrounding the penis. The positioning of the collecting device is difficult for women, and more accidents occur. For both men and women, irritation of the area around the urethral opening is a problem, since urine is in contact with the area for long periods.
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Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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