Urinary Incontinence

Urinary incontinence (UI) is defined as the “involuntary release of urine so severe as to have social and/or hygiene consequences”. It may be caused by physiologic, pharmacologic, pathologic, or psychological factors.

The problem is divided into two broad categories, each of which is further divided into subcategories. The two broad categories are acute UI and chronic UI.

Acute UI is brief period of incontinence associated with a disease such as a urinary tract infection, bladder stones, or as a side effect of some medications. It is sometimes called transient incontinence.

Chronic or long-term urinary incontinence is often related to changes in the patient’s urinary anatomy, musculature or the nerves controlling those muscles. Chronic incontinence is categorized according to the circumstances of voiding.

Stress incontinence
Loss of urine during contractions of the abdomen caused by sneezing, laughing, coughing, exercising and other such actions. It is often caused by movement of the bladder neck lower into the pelvis.

Overactive Bladder
The urge to urinate is sudden and extreme, and urine is often expelled before a bathroom is reached. This occurs even when there is a minimal amount of urine in the bladder.

Specifically, the symptoms of overactive bladder include :

• urinary frequency—bothersome urination eight or more times a day or two or more times at night.
• urinary urgency—the sudden, strong need to urinate immediately.
• urge incontinence—leakage or gushing of urine that follows a sudden, strong urge.
• nocturia—awaking at night to urinate.

Urge Incontinence
If you lose urine for no apparent reason after suddenly feeling the need or urge to urinate, you may have urge incontinence. A common cause of urge incontinence is inappropriate bladder contractions. Abnormal nerve signals might be the cause of these bladder spasms.

Urge incontinence can mean that your bladder empties during sleep, after drinking a small amount of water, or when you touch water or hear it running (as when washing dishes or hearing someone else taking a shower). Certain fluids and medications such as diuretics or emotional states such as anxiety can worsen this condition. Some medical conditions, such as hyperthyroidism and uncontrolled diabetes, can also lead to or worsen urge incontinence.

Involuntary actions of bladder muscles can occur because of damage to the nerves of the bladder, to the nervous system (spinal cord and brain), or to the muscles themselves. Multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, stroke, and injury—including injury that occurs during surgery—all can harm bladder nerves or muscles.

Functional Incontinence
People with medical problems that interfere with thinking, moving, or communicating may have trouble reaching a toilet. A person with Alzheimer’s disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may have a hard time getting to a toilet in time. Functional incontinence is the result of these physical and medical conditions. Conditions such as arthritis often develop with age and account for some of the incontinence of elderly women in nursing homes.

Overflow Incontinence
Overflow incontinence happens when the bladder doesn’t empty properly, causing it to spill over. Your doctor can check for this problem. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Overflow incontinence is rare in women.

Other Types of Incontinence

Stress and Urge incontinence often occur together in women.

Combinations of incontinence—and this combination in particular—are sometimes referred to as mixed incontinence. Most women don’t have pure stress or urge incontinence, and many studies show that mixed incontinence is the most common type of urine loss in women.

Transient incontinence is a temporary version of incontinence. Medications, urinary tract infections, mental impairment, and restricted mobility can all trigger transient incontinence. Severe constipation can cause transient incontinence when the impacted stool pushes against the urinary tract and obstructs outflow. A cold can trigger incontinence, which resolves once the coughing spells cease.

The problem is twice as common in women as in men and although it is perceived to be common among the elderly people, bladder problems are not natural consequence of aging and they are not exclusively a problem of the elderly.

Older men can become incontinent as the result of prostate surgery. For women, pregnancy and childbirth, menopause, and the structure of the female urinary tract account for this difference. This type of incontinence is a constant dripping of urine, they may experience these while running or coughing, others may feel a strong, sudden urge to urinate just before losing a large amount of urine. Many women experience both symptoms. Urinary incontinence is not associated with increased mortality. UI can be slightly bothersome or totally debilitating. For some women, the risk of public embarrassment keeps them from enjoying many activities with their family and friends. Urine loss can also occur during sexual activity and cause tremendous emotional distress.

HOW IS INCONTINENCE DIAGNOSED?

The presentation of the problem is sufficient for a general diagnosis of UI. The challenge is identifying the origins of the problem. Diagnosis begins with a careful medical history that leads to a description of the character of the problem. The pattern and nature of the leakage will help determine the type of incontinence. A physical examination that includes reflex testing and palpation of areas around the urinary tract will offer additional information suggesting the cause of the incontinence.

Bladder scanning represents a simple, painless, noninvasive way to visualize the bladder contents. Urine and blood samples may be taken to be analyzed for evidence of infection, kidney stone or metabolic imbalances.

Urodynamic study may be conducted in which bladder pressure and flow rates are determined. Ultrasound is a technology which bounces sound waves off interior structures. The resultant echoes are translated to images of the kidneys, bladder, ureters, urethra and adjacent structures.

Cystoscopy involves inserting a thin hollow tube into the urethra and advancing it into the bladder. Miniature lights and lenses at the tip of the tube allow the walls of the urethra and interior of the bladder to be examined.

Not all of these tests are utilized in every patient. Testing stops as soon as the origin of the incontinence is reliably determined.


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TREATMENT OPTIONS

Acute urinary incontinence associated with infections, kidney stones or medication side effects often resolves when the primary problem is successfully treated.

As noted, chronic incontinence can originate from a variety of circumstances. The nature and mix of therapeutic measures are tailored to the individual patient.

Conservative management

A simple exercise routine involving Kegel exercises can strengthen pelvic floor and sphincter muscles to reduce or eliminate leakage.

Biofeedback involves what might be called electronic training wheels. Electronic sensing devices are placed to record nerve impulses and muscle contractions. These offer the patient more information concerning voiding impulses than she would normally be aware of. By monitoring these impulses and learning to control them, additional control over urination can be gained.
MEDICATIONS

There are a number of medications that can reduce leakage. Some of these drugs inhibit an overactive bladder’s activities by stabilizing muscle contractions and others have the opposite effect of relaxing muscles to permit more complete bladder emptying. Hormone replacement therapies, usually involving estrogen, may help restore normal bladder function.

Continence Devices
Several devices and procedures help reposition and stabilize the bladder and urethra. A pessary is a semi-rigid ring placed in the vagina to reposition the urethra and reduce stress incontinence leakage.

Bulking substances such as collagen (fat) or specially formulated artificial substances may be injected to provide support and bulk around the urethra. These substances compress the urethra near the bladder outlet to reduce the effects of stress incontinence. The substances are not permanent and the procedure may need to be repeated at annually or more frequent intervals.

Surgical treatment
Several other surgical procedures have been shown to have high success rates. Stress incontinence often results from the bladder losing support and gradually dropping toward the vagina.

The bladder can be returned to a more normal position with sutures that stabilize it by attaching it to nearby structures such as muscle, stable tissue or bone. Another procedure that provides bladder support involves placing a pubo-vaginal sling, a sort of hammock, beneath the bladder.

The sling is sutured to adjacent structures. Excellent results with the pubo-vaginal sling have been achieved in women with stress urinary incontinence.

An artificial sphincter is a novel device that mimics the musculature of the sphincter. It is a surgically implanted ring that encircles the urethra. It can be manually inflated to close around the urethra and prevent urine leakage.

Sphincter implantation is not a common procedure but one that can be successfully employed in carefully selected patients.

A Foley catheter has a balloon attachment at one end. After the Foley catheter is inserted, the balloon is filled with sterile water. The filled balloon prevents the catheter from leaving the bladder.

Other Helpful Hints
Many women manage urinary incontinence with menstrual pads that catch slight leakage during activities such as exercising. Also, many people find they can reduce incontinence by restricting certain liquids, such as coffee, tea, and alcohol.

Finally, many women are afraid to mention their problem. They may have urinary incontinence that can improve with treatment but remain silent sufferers and resort to wearing absorbent undergarments, or diapers. This practice is unfortunate, because diapering can lead to diminished self-esteem, as well as skin irritation and sores.

If you are relying on diapers to manage your urinary incontinence, you and your family should discuss with your doctor the possible effectiveness of treatments such as timed voiding and pelvic muscle exercises.

Points to Remember

• Urinary incontinence is common in women.
• All types of urinary incontinence are treatable.
• Incontinence is treatable at all ages.
• You need not be embarrassed by incontinence.

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