What is Mixed Urinary Incontinence?
Urinary incontinence refers to the unwanted leakage of urine, causing symptoms of varying intensity that can significantly impact a person’s quality of life. Leading medical associations like the International Urogynecological Association (IUGA), the International Incontinence Society (ICS), and the American Urological Association (AUA) have divided urinary incontinence into three main types.
Stress incontinence refers to the unintentional leakage of urine during activities that put pressure on your bladder, like coughing, sneezing, jumping, lifting, laughing, or exercising. Urge incontinence, on the other hand, is an intense, sudden need to urinate followed by involuntary loss of urine. Mixed urinary incontinence (MUI) is a mix of both stress and urge incontinence symptoms.
MUI is especially common in women over 65, affecting more than 37% of older female patients, and often requires major lifestyle adjustments because of its impact on both physical and emotional health.
Although urinary incontinence is not a life-threatening condition, it can contribute to overall mortality, especially in nursing home residents, where it has been found to increase the death rate by 20%. More commonly, it impacts other aspects of the patient’s health and quality of life. Conditions related to MUI include skin, perineal, and vaginal infections, as well as an increased risk of falls and fractures due to frequent bathroom trips. The likelihood of falls in postmenopausal women with urinary urgency and urge incontinence is twice as high as their counterparts without such urinary issues.
Incontinence can significantly affect quality of life by causing depression, anxiety, embarrassment, withdrawal from social interactions, insomnia due to frequent urination at night, and loss of self-confidence. It can also cause sexual dysfunction, with up to 33% of incontinence patients experiencing leakage during sexual activity. The fear of leakage during sex can also greatly impact their sexual enjoyment. MUI also significantly burdens family caregivers and nursing facilities. As many as 10% of all nursing home admissions in the United States are due solely to urinary incontinence.
A careful evaluation of the patient’s medical history and noninvasive diagnostic tests like urinalysis, measurement of leftover urine after urinating, and for women, a pelvic exam can help identify the type and cause of urinary incontinence. Multiple behavioural, medical, and surgical solutions can help improve the quality of life for people suffering from incontinence. The initial treatment usually begins with simple lifestyle changes and various nonsurgical treatments like Kegel exercises, avoiding caffeine, vaginal estrogen for women, physical therapy, and oral medications. For conditions that don’t respond to these conservative therapies, more invasive treatments may be considered.
What Causes Mixed Urinary Incontinence?
Mixed urinary incontinence (MUI) is often linked to severe cases of female pelvic organ prolapse. Pelvic organ prolapse happens when organs like the bladder, uterus or rectum drop from their normal place and push against the walls of the vagina. Studies have shown that more than half of patients with MUI saw improvement after undergoing surgery to correct the prolapse.
Pelvic organ prolapse can block the bladder outlet, causing issues in the bladder’s detrusor muscle (the muscle that helps push out urine). This can lead to the muscle being overstretched, making it more responsive to signals that stimulate urine release, while reducing the ability of the muscle fibers to contract properly. This loss of coordination in the muscle fibers of the bladder causes it to become overly active, and can result in bladder irritation.
When the supportive fascia tissue in the lower pelvic region weakens, it could distort and displace the urethra (the tube that permits urine to leave the body). This displacement can lead to a loss of normal bladder positioning and results in unintended leakage of urine. There are several subtypes of incontinence (unintended leakage of urine), including ones caused by urinary conditions (fistula, infection, in-born conditions, overflow) and ones that aren’t directly related to urinary conditions (functional, environmental, drug-induced, metabolic).
The most significant types of incontinence include overflow and functional incontinence. Overflow incontinence occurs when urine involuntarily leaks due to a bladder that is excessively full, usually due to a blockage in the bladder outlet, or a decrease in the ability of the bladder to contract. Functional incontinence happens when someone can’t get to the bathroom in time, perhaps due to physical barriers or environmental factors.
Risk Factors for Mixed Urinary Incontinence
There are several factors that could increase the chance of developing MUI. These include:
– Getting older
– Having other medical conditions (depression, diabetes, stroke, fecal incontinence, atrophic vaginitis, cognitive impairment, history of recurrent urinary tract infections (UTIs), multiple sclerosis, hydrocephalus, and childhood wetting)
– Having ureters that are not in the correct position
– Exercise, especially activities with high impact, such as running and jumping
– A family history of incontinence
– A bladder condition known as interstitial cystitis
– Having given birth multiple times
– Neuropathy (a nerve condition that can affect bladder control)
– Being a resident in a nursing home
– Being overweight or obese
– Having undergone pelvic radiation treatment
– Having had pelvic surgery in the past (such as removal of the prostate or uterus)
– Smoking.
Risk Factors and Frequency for Mixed Urinary Incontinence
Urinary incontinence, or losing control of the bladder, affects many people, but it’s often underreported due to embarrassment. This condition affects a large portion of American women and even young female athletes, with many not disclosing their symptoms to doctors. Older homebound individuals and nursing home residents are significantly impacted, with a high number of admissions due to urinary incontinence. Females experiencing this issue are double that of males, and it’s common with significant pelvic organ prolapse. Treating urinary incontinence costs over $10 billion each year and affects people worldwide. There are various types of long-lasting urinary incontinence, each with its prevalence.
- Urinary incontinence affects 25% to 45% of all adult American women.
- Over 25% of female athletes in their teens and college years report having incontinence, but 90% do not disclose this to their physicians.
- Among older individuals who are homebound, 53% experience incontinence.
- Approximately 6% of admissions to nursing homes are due to urinary incontinence, with estimated urinary leakage of 50% or more among residents.
- Urinary incontinence is twice as common in women as in men. Over 33% of women with significant pelvic organ prolapse will also have mixed urinary incontinence (MUI).
- The annual cost to treat urinary incontinence, either medically or surgically, exceeds $10 billion.
- The types of chronic urinary incontinence and their prevalence are:
- Functional incontinence: Data uncertain
- MUI affects 20% to 30% of people.
- Overflow incontinence: 5% of those with chronic incontinence.
- Stress-related incontinence: 24% to 45% of females older than 30 years.
- Urge incontinence:
- Women between 40 to 44 years: 9%
- Men older than 75 years: 42%
- Women older than 75 years: 31%
Signs and Symptoms of Mixed Urinary Incontinence
Mixed Urinary Incontinence (MUI) is a condition that needs careful diagnosis, which starts by gathering a thorough history from the patient. Some patients might feel too shy about discussing symptoms like frequent urination, urgency, or painful urination, so it’s crucial for doctors to initiate this conversation. Symptoms of MUI also include hesitation before urinating, a weak urine stream, straining to urinate, not fully emptying the bladder, or wetting pads or clothes. A patient’s surgical and obstetric history can be important for determining the type of incontinence. To help diagnose MUI, doctors also need information about the nature, onset, duration, trigger events of the incontinence symptoms, along with frequency of urination, volume of leakage, use of pads, nighttime urination, and fluid intake. Caffeine can worsen urgency, so intake should also be documented.
- Frequent urination
- Urgency
- Painful urination
- Hesitation before urinating
- Weak urine stream
- Straining to urinate
- Not fully emptying the bladder
- Wetting pads or clothes
There are many questionnaires available to help measure the impact of these symptoms on daily life. It is also important to discuss comorbidities and confounding factors. A review of medications that affect urinary incontinence, especially cholinergic drugs and diuretics should be done. In women, the impact of decreased estrogen levels during perimenopause or postmenopause and the potential benefits of vaginal estrogen cream should be discussed. Keeping a 24-hour diary of urination by the patient helps in objectively quantifying incontiness and assessing the condition. Ideally, a diary comprising 3 days is preferred, but even a 1-day diary can be helpful.
The physical examination of a patient with MUI should particularly focus on the abdominal and pelvic areas. Observations to be made include the presence of a large panniculus (abdominal fat), previous surgical scars, and suprapubic muscle tone. The examination should be done with both full and empty bladder, and in both standing and lying down positions. In women, the degree of uterine and vaginal prolapse, and any obvious stress urinary incontinence when coughing should be assessed. A rectal examination should also be done to evaluate rectal sphincter tone and, in men, the size of the prostate.
A cough stress test is often used to assess stress incontinence. For this test, 250 to 300 mL of fluid is inserted into the bladder using a catheter. The patient is then asked to cough – if there’s no urine leakage when the patient is lying down, the patient is asked to stand and the test is repeated. While this test is fairly definitive for diagnosing stress incontinence, a negative test could be unreliable as the bladder may not have had enough volume, or the patient may have inhibited urine leakage because of anxiety or embarrassment.
Testing for Mixed Urinary Incontinence
If you’re experiencing urinary incontinence, your doctor will likely start with some simple tests in the clinic. These tests aim to diagnose the type of urinary incontinence you have.
The first test is a urinalysis and culture. This is a simple procedure where a sample of your urine is tested for infections. Infections can cause symptoms like those of acute cystitis, a bladder infection, and need to be ruled out.
The next test is checking your postvoid residual urine volume. This involves measuring the amount of urine left in your bladder after you’ve emptied it. This test is important because it checks for overflow incontinence and whether you’re completely emptying your bladder. Around 20% of women with symptoms of an overactive bladder have more urine left in their bladder than usual after voiding. Risk factors for this can include being over 55, having had previous incontinence surgery, multiple severe urinary symptoms, multiple sclerosis, vaginal prolapse, and more than two previous vaginal deliveries.
Your doctor may ask you to keep a 24-hour voiding diary. This involves noting down the frequency and amount of incontinence episodes. This test helps your doctor understand how serious and what type the urinary leakage is.
Next, you may undergo a cough stress test. This test is very useful in diagnosing stress incontinence. In this test, any urinary leakage when you cough (both while sitting and lying down) suggests stress incontinence.
A pelvic examination may be performed to check for vaginal prolapse – a condition where the structures supporting the vagina lose their strength and the vagina falls down. Vaginal prolapse can either hide or decrease incontinence symptoms, so if it’s detected, it should be treated. A cough stress test will be performed after this treatment. Your doctor will also check the strength of the levator ani muscle, a muscle that supports the vagina.
The Q-tip test another simple test where a cotton-tipped swab is gently inserted into the urethra (the tube that carries urine out of your body) to check for its mobility. If the direction of the urethra changes more than 30 degrees when you bear down, it indicates that your urethra is overly mobile.
All patients with urinary incontinence should also have a neurological examination to rule out any nerve-related causes of their symptoms.
You might also have an ultrasound, a imaging test using sound waves. This test can be useful, especially in women with MUI (mixed urinary incontinence) with significant stress component. Ultrasound helps view the angles of your urethra and how far the bladder neck descends. For example, it’s observed that female patients with MUI, who have more urge symptoms, tend to have thicker bladder walls. Those with equally severe urge and stress symptoms demonstrate greater bladder neck descent. Ultrasounds are quicker and easier to tolerate for patients than more complex tests called urodynamics.
In some cases, if initial tests don’t give a clear diagnosis, or if your symptoms are complex, you may be referred to a urology specialist for further tests. These might include urodynamic testing, which looks at how well your urinary system is functioning, as well as cystoscopy – a test which uses a thin tube with a camera to view inside the bladder. Video-urodynamic testing, a combination of urodynamic testing and imaging, might also be recommended.
Treatment Options for Mixed Urinary Incontinence
The starting approach to managing incontinence tends to be comprised of non-surgical methods. These might include bladder training, biofeedback, Kegel exercises, specific dietary adjustments like limiting caffeine, acupuncture, use of vaginal estrogen for postmenopausal women, weight loss, and physical therapy. Typically, the least invasive treatment is used initially to see if it reduces patients’ symptoms. Patients often prefer improvement in their symptoms rather than achieving complete continence, particularly if they have a high risk for surgery.
Bladder retraining is usually the first step. This includes training yourself to wait before voiding and gradually increasing the waiting time. This is usually done in conjunction with Kegel exercises and reducing caffeine intake and takes about 6 to 12 weeks to become effective. There are basic instructions for bladder retraining like voiding first thing in the morning, then trying to wait a minimum amount of time before voiding again, then gradually increasing this time.
A tool known as the Knack tutorial helps patients identify situations where they’re likely to have urine leakage. By learning to contract their pelvic floor muscles at the right time, leakage can be minimized or eliminated. In fact, a clinical study demonstrated that 71% of patients using this simple technique reported marked improvement in their incontinence compared to only 21% using diet and exercise alone.
Several non-surgical treatments have been developed to aid in muscle and bladder training. These include vaginal cones, intravaginal biofeedback, percutaneous tibial nerve stimulation, and pelvic floor muscle training through electrical vaginal activation or magnetic innervation therapy. These treatments can help some, although they often don’t prove more effective than properly done bladder training programs and Kegel exercises. Combined treatments typically provide better results than separate single treatments.
Behavior changes to lessen MUI can include biofeedback, bladder retraining, diet changes like avoiding alcohol or caffeine products, electrostimulation, extracorporeal magnetic innervation therapy, and pelvic floor physical therapy.
If symptoms do not improve after these nonmedical treatments, medications may be used. These might include alpha-adrenergics, anticholinergics, calcium channel blockers, estrogen (for women), selective serotonin and norepinephrine reuptake inhibitors, and tricyclic antidepressants. Note that some of these medications have substantial side effects, so their use should be carefully considered.
Doctors might refer patients to a specialist if noninvasive therapies don’t work, if surgery might be needed, or if there are complications like abdominal or pelvic pain, recurrent urinary tract infections, or other more atypical symptoms.
Surgery aims to provide the best overall cure for the condition when significant prolapse with bothersome incontinency and pelvic pressure symptoms are present. However, surgery only addresses stress incontinence, whilst the urgency portion of MUI must be treated separately.
The specific surgical procedure chosen depends on the individual patient, but may include the use of mid-urethral slings, perineal bulking agents, adjustable continence therapy devices, or artificial urinary sphincters. Adjustments to these interventions can be made in the office or clinic and have generally proven effective.
Artificial urinary sphincters are an option when lesser invasive treatments have failed. In most cases, these sphincters provide satisfactory outcomes, even in older women.
Intrinsic sphincter deficiency is caused by a loss of muscle tone in the urethra due to neuromuscular damage from repeated incontinence or pelvic surgeries. Treatment for the condition is more difficult than with the standard stress incontinence, and surgical outcomes are generally not as successful.
What else can Mixed Urinary Incontinence be?
When consulting with a doctor about specific symptoms, there are several different conditions they might consider. These include:
- Acute or chronic cystitis (inflammation of the bladder)
- Benign prostatic hyperplasia (enlargement of the prostate)
- Cough-induced detrusor overactivity (bladder control issues related to coughing)
- Cystocele, rectocele (types of pelvic organ prolapse)
- Interstitial cystitis (also known as painful bladder syndrome)
- Multiple sclerosis (a disease that affects the central nervous system)
- Neurogenic bladder (a condition affecting bladder control)
- Prostatitis (inflammation or infection of the prostate)
- Radiation cystitis (bladder inflammation caused by radiation therapy)
- Spinal cord abscess (an infection in the spinal cord)
- Spinal cord neoplasms (tumors in the spinal cord)
- Spinal cord trauma (injury to the spinal cord)
- Urethral strictures (narrowing of the urethra)
- Urge incontinence (a strong, sudden need to urinate)
- Urinary obstruction (blockage of urine flow)
- Urinary tract infections in males
- Uterine prolapse (when the uterus sags or slips from its normal position)
- Vaginitis (inflammation of the vagina)
What to expect with Mixed Urinary Incontinence
If someone chooses to have surgery for stress urinary incontinence—a condition that causes urine leakage due to pressure or stress on the bladder—they must be fully informed about what the treatment involves. Discussions about the success rates of the procedure should be included.
There are various surgical approaches available, including abdominal and vaginal procedures, and these have a similar overall success rate of about 86%. This means in 86% of cases, the person will be cured, with no leakage. However, in about 7% of cases, there will be some improvement but not a complete cure, and in another 7% of cases, the surgery might fail.
If a person is completely cured, with no more incontinence, they will not need any more treatment or bladder health tests (urodynamic testing). However, if there is occasional leakage or if the procedure hasn’t worked properly, bladder health tests might be necessary. This is because these tests can help doctors find out whether the person still has stress incontinence or whether they have a different kind of incontinence.
In cases where the treatment isn’t successful, behavioural or medical therapy might be necessary. Sometimes, a second surgery might be needed. There are also newer surgical treatments available that can relieve the symptoms of stress incontinence. These include periurethral bulking agents (that bulk up the area around the urethra to help control leakage), adjustable continence device therapy, and artificial sphincters. These treatments work to successfully treat both men and women who haven’t improved with other treatments.
There are also treatments that are effective for other bladder control problems (like overactive bladder symptoms) which can’t be treated with standard medicine. These include treatments like sacral neuromodulation (treatment to stimulate the sacral nerve in your lower back), botulinum A toxin detrusor injections (a treatment where a small amount of Botox is injected into a muscle in your bladder), and tibial nerve stimulation (a treatment to stimulate the nerves in your lower back that control bladder function).
Possible Complications When Diagnosed with Mixed Urinary Incontinence
When it comes to surgery for stress urinary incontinence, there are some risks that patients should be aware of. These dangers include:
- Bleeding
- Infection
- Injury to the urinary or intestinal tract
- Continued or repeated urinary incontinence or prolapse
- Painful sexual intercourse after the operation
- Breakdown of the urethra (the tube which carries urine out of the body)
These risks should be carefully explained to the patient before opting for surgery.
Recovery from Mixed Urinary Incontinence
After surgery, some patients may need a catheter (a tube to help drain urine from the body) for a longer period of time. This could be a tube inserted through the urinary passage or above the pubic area. Ideally, the amount of urine left in the bladder after going to the restroom should be less than 100 mL.
Sometimes, it’s hard for patients to pass urine normally after the catheter is removed. But not to worry, this usually gets better on its own within a few days or weeks.
It’s important for patients to avoid sexual activity for at least 6 weeks after surgery. This helps prevent damaging the surgical area before it has fully healed. Moreover, patients are also advised not to lift heavy objects more than 25 lbs. Lifting heavy things can potentially cause too much pressure in the abdomen, which might lead to failure of the treatment, the recurrence of the prolapsed organ, and urinary incontinence (inability to control urine flow).
Preventing Mixed Urinary Incontinence
It’s crucial for patients, the public, and healthcare providers to be well-informed to ensure the best outcomes when treating conditions like incontinence. Incontinence is a condition in which you can’t control your urination or bowel movements. ‘Evidence-based medicine’ means that the treatment your doctor is recommending is based on well-established scientific evidence.
There are many reliable websites that offer free education and helpful resources about incontinence:
1. The American College of Obstetrics and Gynecology (ACOG) provides information here.
2. The American Urological Association and the Urology Care Foundation also have helpful resources, which can be accessed here.
3. The National Association for Continence (NAFC) website is another useful resource and can be found here.
4. The Simon Foundation for Continence also shares valuable information regarding incontinence, their website can be found here.
5. The European Association of Urology provides patient education on incontinence here.
6. For those outside the United States, the Continence Worldwide website has resources available here.
7. The International Urogynecological Association (IUGA) also provides resources on urinary health with their website available here.
8. United Kingdom’s National Health Services has information here.
9. The Continence Foundation of Australia also offers resources, which you can access here.
These websites are great resources to understand incontinence better and get advice on how to manage it.
