What is Urinary Incontinence?
Urinary incontinence, or unintentional leakage of urine, often affects older people, particularly those living in care homes. However, it can also occur in younger adults of any gender. This health condition can greatly alter a person’s wellbeing and lifestyle quality. It’s probably more common than we think, because many patients don’t share their symptoms with their doctors for different reasons.
Urinary incontinence can be categorized into five types: stress, urge, functional, mixed, and overflow incontinence. An initial checkup usually doesn’t involve an examination by a urologist or a gynecologist, but it is important to rule out any causes that can be treated. The ways to manage the incontinence depend on what type it is, how severe it is, and how much discomfort and trouble the patient is experiencing.
What Causes Urinary Incontinence?
Urinary incontinence is when you can’t control your bladder and you unintentionally leak urine. There are five main types:
1. Stress Urinary Incontinence: This happens when you have sudden pressure in your belly due to activities like exercising, sneezing, or coughing, and it causes a leak of urine. This is sometimes due to weak muscles in the pelvis, or the tube that carries urine out of your body moving around too easily. Young women who play a lot of sports and women who are pregnant or have given birth might experience this kind of leakage. In men, it’s often a side effect of prostate surgery.
2. Urge Incontinence: This is when you feel an intense urge to urinate and can’t hold it in. This might be due to abnormal bladder contractions or brain signals not working properly. The condition may be caused by an overactive bladder, or by neurological conditions such as stroke, Parkinson’s disease, or multiple sclerosis.
3. Mixed Urinary Incontinence: This type results from a combination of stress and urge incontinence. Usually, either urge or stress incontinence is the main problem.
4. Overflow Urinary Incontinence: This happens when urine leaks out because your bladder is too full, which might be due to your bladder not contracting properly or an obstruction blocking the flow of urine. Various neurological diseases such as spinal cord injuries, multiple sclerosis, and diabetes can weaken the function of the detrusor muscle in your bladder, resulting in a weak bladder. Something blocking the bladder could be due to things like pelvic area growths, narrow urethra, and bladder prolapse. In men, an enlarged prostate is a common cause. This condition can be quite serious as it can lead to kidney failure and permanent bladder damage.
5. Functional Urinary Incontinence: This type happens when physical or environmental barriers make it difficult for a person to get to the toilet in time. It’s sometimes referred to as toileting difficulty.
Risk Factors and Frequency for Urinary Incontinence
It’s hard to get accurate data on how common urinary incontinence is because it’s often underreported, different studies define it in various ways, and research methods differ. However, it’s estimated that around 423 million people aged 20 and up worldwide have some form of urinary incontinence.
In the United States, around 13 million people are affected by urinary incontinence. More than half of nursing home residents have it, and this increases to over 75% among long-term residents. About 53% of elderly people needing home care have this condition. A sample of older hospital patients showed 11% had persistent urinary incontinence when they were admitted and 23% had it at discharge.
Between 24% and 45% of women report having urinary incontinence. Among women aged 20 to 39, it’s between 7% and 37%. Among those over 60, between 9% and 39% say they have it every day. Pregnancy, giving birth, diabetes, and being overweight can increase the risk of urinary incontinence.
Meanwhile, the overall prevalence of urinary incontinence in men is about half of that in women. It’s reported in 11% to 34% of older men, with 2% to 11% reporting daily occurrences. Prostate surgery can increase the risk.
- Stress urinary incontinence: Reported by 24% to 45% of women over 30.
- Urge urinary incontinence: Affects 9% of women aged 40 to 44, 31% of women over 75, and 42% of men over 75.
- Mixed urinary incontinence: Affects 20% to 30% of those with long-term urinary incontinence.
- Overflow urinary incontinence: Affects 5% of those with long-term urinary incontinence
- Functional urinary incontinence: Data is uncertain.
In the United States, over 60% of adult women (about 80 million people) report some degree of urinary incontinence, with a third experiencing leakage at least once a month. The most common type reported is stress incontinence (37.5%), followed by mixed (31.3%) and urge incontinence (22%).
Signs and Symptoms of Urinary Incontinence
When dealing with urinary incontinence, a thorough patient history and physical examination are crucial. These help identify what’s causing the problem, the different types of incontinence, and then help to create a suitable treatment plan.
The patient’s history should lay out the type, severity, impact, and length of urinary incontinence. Lists or diaries kept about incontinence events could help with this. It’s important to look for signs of emergency conditions, like cauda equina syndrome, and reversible causes.
Incontinence comes in several types, often distinguished by their symptoms:
- Stress urinary incontinence: This is usually caused by physical activities like coughing, laughing, sneezing, or straining.
- Urge urinary incontinence: Symptoms include feeling a need to urinate often, even at night, and any volume of urine loss. Often there is not much urine left in the bladder after peeing.
- Mixed urinary incontinence: Both urge and stress incontinence symptoms are present.
- Overflow urinary incontinence: This type is related to trouble emptying the bladder fully or retaining urine. The patient may feel the need to strain. High amounts of urine left after peeing is typical.
- Functional urinary incontinence: The patient’s history might suggest some physical or cognitive difficulties.
The patient’s past medical and surgical histories are also important, as are any current conditions or lifestyle choices that might be contributing to incontinence. This includes things like chronic illnesses, previous surgeries, and use of substances like alcohol, caffeine, and certain medications.
The severity of the symptoms, the patient’s preferences for treatment, and their ability to tolerate potential surgical intervention are all taken into account when planning their treatment.
Where the physical examination is concerned, the doctor will review any relevant emergency conditions and reversible causes based on the patient’s history.
Typical components to look at are:
- Cardiovascular: Swelling in the feet and distended jugular veins.
- Pulmonary: Hearing crackling sounds in the lungs and coughing.
- Abdominal: Lumps and surgical scars.
- Genitourinary/rectal: Bladder swelling, thinning of the vagina, a prolapse, an enlarged prostate, impacted feces, and rectal tone.
- Musculoskeletal: Strength, flexibility, and overall function of the limbs.
- Neurologic: The patient’s cognitive function, feeling, and reflexes.
There are also optional tests available to help diagnose stress incontinence, such as having the patient cough to see if urine leaks involuntarily, or using a lubricated cotton swab inserted into the bladder through the urethra to see if there’s excessive movement in the urethra.
Testing for Urinary Incontinence
To evaluate urinary incontinence (the inability to control urination), your doctor will consider your medical history, current habits, and perform a physical exam. They’ll also investigate any factors that could be causing the problem. These could include irregular sleeping patterns, having too much fluid in the body, misuse of water tablets (diuretics), among others. They’ll look at any other health conditions you may have and review your medication.
Normally, there’s little need for lab tests or imaging scans. These are usually used to rule out other serious conditions. However, one common test is to look at a sample of your urine. This can reveal if you have a urinary tract infection, excess sugar or protein in your urine, or if there’s blood present. A further test might be done if an infection is suspected to find out what type of bacteria is involved. If there’s a risk that urine is backing up into your kidneys (which could damage them), a blood test might be done to check how well your kidneys are working.
If your doctor thinks that you might be having trouble emptying your bladder completely, they may want to check the amount of urine left in your bladder after you’ve been to the toilet. This is done using a bladder ultrasound. If more than 200 mL of urine is detected, this could indicate an issue with your bladder’s muscle tone and a type of incontinence where your bladder is too full. However, if you’ve been able to empty your bladder adequately, and only a small amount is leftover, this might indicate a different type of incontinence tied to an overactive bladder.
In some cases, your doctor might ask you to keep a diary over 24 hours or longer where you note how frequently you urinate and how much each time. Patients who frequently pass small amounts of urine might have an overactive bladder. Those who regularly pass large amounts may potentially have polyuria, a condition where the body produces too much urine. Typically, the average person will produce about 1300 mL (just over 2 pints) of urine in 24 hours. If you’re producing more than 3000 mL (about 5 pints), this could be a sign of polyuria.
In specific cases, a “pad test” might be used to assess the severity of incontinence. Pads are changed either when they’re wet or after six hours. The difference in weight before and after use can indicate how much urine has been released unintentionally, which can help measure the severity of your urinary incontinence.
In situations where it’s suspected that urine might be backing up into the kidneys or in folks with kidney disease, a renal ultrasound might be taken. If your urinary incontinence has become severe or surgery is being contemplated, a more complex test known as urodynamic testing might be conducted.
Treatment Options for Urinary Incontinence
The treatment plan for urinary incontinence, which is when you can’t completely control your bladder, really depends on what type of incontinence you have. There are plenty of options, including medication and surgery, so it’s best to start with least invasive methods, like lifestyle changes, and take further action if necessary.
One common lifestyle change is avoiding alcohol and caffeine if you find they make your incontinence worse.
For stress urinary incontinence, which happens when coughing, laughing or doing activities causes leaks, there are different options:
– Behavioural therapy: This could mean controlling fluid intake, planning bathroom visits, training your bladder, and managing constipation.
– Electrical stimulation or the use of devices that strengthen muscles in the pelvic area.
– Physical therapy: Exercises for strengthening the pelvic floor muscles like Kegel exercises can help manage the symptoms.
– Weight loss: Sometimes, excess weight causes extra pressure on the bladder resulting in leakage. It might be beneficial to lose weight to manage the condition.
– Dietary adjustments: Some foods and drinks can irritate your bladder and worsen the symptoms so removing them from your diet can help.
If these methods don’t work, you might need medications that are designed to strengthen the muscles and nerves around the bladder.
In instances where medication doesn’t help, then surgery might be the next step, including procedures involving injections to bolster the area around the urethra (the tube that carries urine out of your body).
Urge urinary incontinence is another type of incontinence where you feel a sudden need to urinate. It can also be managed with behavioral therapy, medication, and possibly surgery. One possible surgical intervention in such cases might involve neuromodulation, where mild electrical pulses are used to influence nerve activity.
For mixed urinary incontinence, which is a combination of stress and urge incontinence, treatment will focus on the most dominant symptoms.
Overflow urinary incontinence happens when you can’t completely empty your bladder, causing leaks. Some options for treatment include using a catheter to empty the bladder or medications to stimulate bladder activity. If those methods don’t work, surgery may be an option.
Lastly, if your urinary incontinence is caused by physical or mental impairment that prevents you from reaching the bathroom in time (functional urinary incontinence), the most effective method is to treat the underlying causes if possible.
What else can Urinary Incontinence be?
Identifying the exact type and cause of urinary incontinence calls for a careful process of ruling out various possibilities. This helps to separate and identify the different types of incontinence such as stress, urge, overflow, and functional incontinence from other potential medical conditions. By doing this, doctors can ensure that each patient gets the specific treatment they need.
The mnemonic ‘DIAPPERS’ can make it easier to identify potential reversible causes of urinary incontinence:
- Delirium, dementia, or other cognitive impairments
- Infection (normally a urinary tract infection)
- Atrophic vaginitis or urethritis
- Pharmaceuticals or substances such as diuretics, caffeine, and alcohol
- Psychological disorders
- Excessive urine output seen with conditions such as diabetes and diabetes insipidus
- Reduced mobility or reversible urinary retention
- Stool impaction
But, there are also some less common but still possible conditions that doctors need to consider:
- Anatomical abnormalities like urogenital fistulas, diverticula, duplicated kidneys, and misplaced ureters
- Swelling of the kidney (hydronephrosis)
- Tumors in the abdomen or pelvis
- Painful bladder syndrome (interstitial cystitis)
- Neurological conditions like spinal cord injuries, cauda equina syndrome, multiple sclerosis, strokes, normal-pressure hydrocephalus, spinal stenosis, Parkinson’s disease, and diabetic neuropathy
- Falling or dropping of the pelvic organs (pelvic organ prolapse)
- Excess urination (polyuria)
- Urinary tract infections
- Kidney stones, especially in the lower part of the ureter (distal ureteral calculi)
- Backflow of urine from the bladder to the kidneys (vesicoureteral reflux)
What to expect with Urinary Incontinence
Patients respond differently to treatment and management of urinary incontinence depending on their specific situation. For those who continue to experience symptoms, managing these symptoms as much as possible through the use of multiple treatments is recommended. In regards to different treatment methods, here are some notable success rates:
For stress urinary incontinence, some common treatments and their success rates are:
- For women who underwent supervised pelvic floor muscle training, about 58.8% were cured after 12 months.
- For men that used pelvic floor muscle training, the cure rate was 78% after 6 months.
- For women who received surgical treatment, the cure rate was 84.4% after 12 months.
- For patients who received an artificial urinary sphincter, about 50% were completely cured after 5 years, and another 40% needed only 1 pad per day to manage.
- 55% of patients who used a dual-balloon adjustable continence device reported being cured or having significantly less leakage in the long term.
- 75% of properly selected men who received a sling treatment experienced a cure or major improvement in their urinary incontinence.
- For men who received slings, the cure rate was 53% after 3 years.
For urge urinary incontinence, some common treatments and their success rates are:
- For women who used antimuscarinics, the cure rate was 49% at 12 months.
- For women who used onabotulinum toxin A, the cure rates ranged between 15.9% to 50.9% after 3 months.
- For women who used sacral neuromodulation, the cure rate was 17% after 10 years.
- For men who underwent supervised pelvic floor muscle training, the cure rate ranged between 24% to 35% after a year.
For mixed urinary incontinence, some common treatments and their success rates are:
- 28% at 6 months for women who underwent supervised pelvic floor muscle training.
- 47% cure rate for men who underwent supervised pelvic floor muscle training.
- For women who received surgical treatment, the cure rate was 82.3%.
To help evaluate the severity of the symptoms and the effectiveness of the treatments, there are several questionnaires and tests. These include the Michigan incontinence symptom index (M-ISI), the international consultation on incontinence questionnaire form (ICIQ-UI short form), and the Sandvik questionnaire (incontinence severity index), which all assess the frequency and severity of urinary incontinence. Another helpful tool is the 24-hour pad test, which measures the amount of leakage in a specific time period.
Possible Complications When Diagnosed with Urinary Incontinence
Urinary incontinence, or inability to control urination, can cause a number of complications that seriously affect a person’s health and everyday life. These problems can be physical, like skin and urinary tract infections, and psychological, like anxiety and depression. Moreover, urinary incontinence can lead to social isolation and decreased mobility. Having a complete understanding of these complications is important to provide the best care for patients.
Complications that can come with urinary incontinence include:
- Cellulitis (a bacterial skin infection)
- Reduced physical activity and libido (sexual desire)
- Depression
- Heavier burden on caregivers
- Increased risk of falls and the fractures that can come with them
- Failure of a device to stop leaks
- Negative side effects from medications
Different medications have different side effects:
- Alpha-adrenergic agonists can cause dry mouth, restlessness, high blood pressure, and insomnia.
- Alpha-adrenergic antagonists can cause low blood pressure, dizziness, fatigue, and sleepiness.
- Antimuscarinics can cause dry mouth, constipation, blurred vision, dry eyes, fatigue, difficulty urinating, and fast heart rate.
- Duloxetine can cause dry mouth, nausea, fatigue, constipation, and excessive sweating.
- Mirabegron and vibegron can cause urinary tract infections and high blood pressure.
- Onabotulinumtoxin A injection can cause urinary tract infections and urinary retention (inability to completely empty the bladder).
Other complications related to urinary incontinence include:
- Pressure ulcers (sores caused by pressure on the skin)
- Kidney problems due to obstructive uropathy (blockage of urine flow)
- Sexual dysfunction
- Social isolation
- Injury and infection due to the use of a catheter (a tube inserted into the bladder to drain urine)
- Failure of treatment
- Urethral erosion (damage to the tube that carries urine out of the body)
- Urinary tract infections
- Worse urinary incontinence after surgical intervention
Preventing Urinary Incontinence
Preventing and effectively addressing urine leakage or urinary incontinence starts with education for both the patient and their families. It’s essential to know that urinary incontinence, though common among older adults, is not simply a ‘normal’ part of getting older. You should also know that many of its causes can be reversed and all cases can be improved to some degree.
When patients learn about risk factors such as being overweight, having a chronic cough, or weak pelvic floor muscles, they can take proactive steps to prevent urinary incontinence. These steps could include managing their weight and doing regular exercises to strengthen the pelvic floor. Being educated also means understanding the different types and causes of incontinence, knowing how to manage fluid intake properly, and recognizing symptoms early. It’s important to learn about all the treatment and management options available, including non-surgical treatments, medications, and surgical procedures.
Encouraging open conversations about urinary incontinence can help reduce any stigma associated with this condition. It also enables patients to seek timely medical advice and adopt proactive management strategies. By emphasizing the importance of education and prevention, healthcare professionals greatly help patients to understand and manage urinary incontinence better.
