Incontinence, Urinary

Urinary incontinence (UI) is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners. There is also a related condition for defecation known as fecal incontinence.

Physiology of continence

Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure factors:urethral pressure falls and bladder pressure rises.

Causes

• Excess consumption of alcohol, which acts like a diuretic.
• Drinking lots of fluid in a short time period also results in excess urine production.
• Caffeine or cola beverages also act like diuretics and stimulate the bladder.
• Medications which control blood pressure, sedative or decongestant.
• Enlarged prostate is the most common case of incontinence in men after the age of 40; sometimes prostate cancer may also be associated with urinary incontinence. Moreover drugs or radiation used to treat prostate cancer can also cause incontinence.
• Kidney stones can cause urinary urgency and loss of bladder control.
• Brain disorders like multiple sclerosis, Parkinson's disease, strokes and spinal cord injury can all interfere with nerve function of the bladder.

Types

Stress incontinence

Stress urinary incontinence (SUI), also known as effort incontinence, is due essentially to insufficient strength of the pelvic floor muscles. It is the loss of small amounts of urine associated with coughing, laughing, sneezing, exercising or other movements that increase intra-abdominal pressure and thus increase pressure on the bladder. The urethra is supported by fascia of the pelvic floor. If this support is insufficient, the urethra can move downward at times of increased abdominal pressure, allowing urine to pass.

In men, stress incontinence is common following a prostatectomy. It is the most common form of incontinence in men.

In women, physical changes resulting from pregnancy, childbirth, and menopause often contribute to stress incontinence. Stress incontinence can worsen during the week before the menstrual period. At that time, lowered estrogen levels may lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause, similarly because of lowered estrogen levels. In female high-level athletes, effort incontinence occurs in all sports involving abrupt repeated increases in intra-abdominal pressure that may exceed perineal floor resistance.

Most lab results such as urine analysis, cystometry and postvoid residual volume are normal.

Stress incontinence is treatable.

Urge incontinence

Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate. The most common cause of urge incontinence is involuntary and inappropriate detrusor muscle contractions.

Idiopathic Detrusor Overactivity – Local or surrounding infection, inflammation or irritation of the bladder.

Neurogenic Detrusor Overactivity – Defective CNS inhibitory response.

Medical professionals describe such a bladder as "unstable", "spastic", or "overactive". Urge incontinence may also be called "reflex incontinence" if it results from overactive nerves controlling the bladder.

Patients with urge incontinence can suffer incontinence during sleep, after drinking a small amount of water, or when they touch water or hear it running (as when washing dishes or hearing someone else taking a shower).

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, spina bifida and injury—including injury that occurs during surgery—can all harm bladder nerves or muscles.

Functional incontinence

Functional incontinence occurs when a person recognizes the need to urinate, but cannot physically make it to the bathroom in time due to limited mobility. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity, unwillingness to toilet because of depression, anxiety or anger, drunkenness, or being in a situation in which it is impossible to reach a toilet.

People with functional incontinence may have problems thinking, moving, or communicating that prevent them from 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 be blocked from getting to a toilet in time. Conditions such as these are often associated with age and account for some of the incontinence of elderly women and men in nursing homes. Disease or biology is not necessarily the cause of functional incontinence. For example, someone on a road trip may be between rest stops and on the highway; also, there may be problems with the restrooms in the vicinity of a person.

Overflow incontinence

Sometimes people find that they cannot stop their bladders from constantly dribbling, or continuing to dribble for some time after they have passed urine. It is as if their bladders were like a constantly overflowing pan, hence the general name overflow incontinence. Overflow incontinence occurs when the patient's bladder is always full so that it frequently leaks urine. Weak bladder muscles, resulting in incomplete emptying of the bladder, or a blocked urethra can cause this type of incontinence. Autonomic neuropathy from diabetes or other diseases (e.g. Multiple sclerosis) can decrease neural signals from the bladder (allowing for overfilling) and may also decrease the expulsion of urine by the detrusor muscle (allowing for urinary retention). Additionally, tumors and kidney stones can block the urethra. Spinal cord injuries or nervous system disorders are additional causes of overflow incontinence. In men, benign prostatic hyperplasia (BPH) may also restrict the flow of urine. Overflow incontinence is rare in women, although sometimes it is caused by fibroid or ovarian tumors. Also overflow incontinence can be from increased outlet resistance from advanced vaginal prolapse causing a "kink" in the urethra or after an anti-incontinence procedure which has overcorrected the problem. Early symptoms include a hesitant or slow stream of urine during voluntary urination. Anticholinergic medications may worsen overflow incontinence.

Structural incontinence

Rarely, structural problems can cause incontinence, usually diagnosed in childhood, for example an ectopic ureter. Fistulas caused by obstetric and gynecologic trauma or injury can also lead to incontinence. These types of vaginal fistulas include most commonly, vesicovaginal fistula, but more rarely ureterovaginal fistula. These may be difficult to diagnose. The use of standard techniques along with a vaginogram or radiologically viewing the vaginal vault with instillation of contrast media.

Bedwetting (enuresis)

Bedwetting is episodic UI while asleep. It is normal in young children.

Other types of incontinence

Mixed urinary incontinence disorder is not uncommon in the elderly female population and can sometimes be complicated by urinary retention, which makes it a treatment challenge requiring staged multimodal treatment. "Transient incontinence" is a temporary version of incontinence. It can be triggered by medications, urinary tract infections, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow.

Diagnosis

Patients with incontinence should be referred to a medical practitioner specializing in this field. Urologists specialize in the urinary tract, and some urologists further specialize in the female urinary tract. A urogynecologist is a gynecologist who has special training in urological problems in women. Gynecologists and obstetricians specialize in the female reproductive tract and childbirth and some also treat urinary incontinence in women. Family practitioners and internists see patients for all kinds of complaints and can refer patients on to the relevant specialists.

A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Other important points include straining and discomfort, use of drugs, recent surgery, and illness.

The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.

A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.

Other tests include:

• Stress test – the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
• Urinalysis – urine is tested for evidence of infection, urinary stones, or other contributing causes.
• Blood tests – blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
• Ultrasound – sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
• Cystoscopy – a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
• Urodynamics – various techniques measure pressure in the bladder and the flow of urine.

Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced.

Urinary incontinence in women

Bladder symptoms affect women of all ages. However, bladder problems are most prevalent among older women. Up to 35% of the total population over the age of 60 years is estimated to be incontinent, with women twice as likely as men to experience incontinence. One in three women over the age of 60 years are estimated to have bladder control problems.

Bladder control problems have been found to be associated with higher incidence of many other health problems such as obesity and diabetes. Difficulty with bladder control results in higher rates of depression and limited activity levels.

Incontinence is expensive both to individuals in the form of bladder control products and to the health care system and nursing home industry. Injury related to incontinence is a leading cause of admission to assisted living and nursing care facilities. More than 50% of nursing facility admissions are related to incontinence.

Urinary incontinence in men

Men tend to experience incontinence less often than women, and the structure of the male urinary tract accounts for this difference. But both women and men can become incontinent from neurologic injury, congenital defects, strokes, multiple sclerosis, and physical problems associated with aging.

While urinary incontinence affects older men more often than younger men, the onset of incontinence can happen at any age. Incontinence is treatable and often curable at all ages.

Incontinence in men usually occurs because of problems with muscles that help to hold or release urine. The body stores urine—water and wastes removed by the kidneys—in the urinary bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.

During urination, muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if the bladder muscles suddenly contract or muscles surrounding the urethra suddenly relax.

Treatment

The treatment options range from conservative treatment, behavior management, medications and surgery. In all cases, the least invasive treatment is started first. The success of treatment depends on the correct diagnoses in the first place.

Behavior techniques for incontinence include retraining the bladder to hold more urine. The goal is to lengthen the time between periods of urination. This includes relaxation techniques and learning how to cope with urges to urinate. Fluid management is the cornerstone of all urinary incontinence. One must not drink lots of fluids and avoid beverages which stimulate the bladder. Alcohol, caffeine or acidic foods should be avoided.

Weight loss

A study published in The New England Journal of Medicine on January 29, 2009, demonstrated that weight loss in overweight women reduced stress incontinence. The study included women with a Body Mass Index (BMI) over 25 and at least 10 episodes of urinary incontinence per week. The results demonstrated that with exercise and restricted diet they had a 70% or greater reduction in overall incontinence episodes.

Absorbent products

Absorbent pads and urinary catheters may help those individuals who continue to have incontinence. The absorbent pads are not bulky like in the old days but are close fitting underwear with liners. Men also can use a small urine collector that is worn around the penis.

Absorbent products include shields, undergarments, protective underwear, briefs, diapers and underpads.

Exercises

One of the most common treatment recommendations includes exercising the muscles of the pelvis. Kegel exercises to strengthen or retrain pelvic floor muscles and sphincter muscles can reduce stress leakage. Patients younger than 60 years old benefit the most. The patient should do at least 24 daily contractions for at least 6 weeks. It is possible to assess pelvic floor muscle strength using a Kegel perineometer.

Increasingly there is evidence of the effectiveness of pelvic floor muscle exercise (PFME) to improve bladder control. For example, urinary incontinence following childbirth can be improved by performing PFME.

Electrical stimulation

Brief doses of electrical stimulation can strengthen muscles in the lower pelvis in a way similar to exercising the muscles[citation needed]. Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles. This can stabilize overactive muscles and stimulate contraction of urethral muscles. Electrical stimulation can be used to reduce both stress incontinence and urge incontinence.

Biofeedback

Biofeedback uses measuring devices to help the patient become aware of his or her body's functioning. By using electronic devices or diaries to track when the bladder and urethral muscles contract, the patient can gain control over these muscles. Biofeedback can be used with pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence[citation needed].

Timed voiding or bladder training

Timed voiding (urinating) and bladder training are techniques that use biofeedback. In timed voiding, the patient fills in a chart of voiding and leaking. From the patterns that appear in the chart, the patient can plan to empty his or her bladder before he or she would otherwise leak. Biofeedback and muscle conditioning—known as bladder training—can alter the bladder's schedule for storing and emptying urine. These techniques are effective for urge and overflow incontinence.

Medications

Medications can reduce many types of leakage. Some drugs inhibit contractions of an overactive bladder, others relax muscles, leading to more complete bladder emptying during urination, and yet others tighten muscles at the bladder neck and urethra, preventing leakage. Some hormones, such as estrogen, are believed to cause muscles involved in urination to function normally.

Pharmacological treatments of urinary incontinence include:

• Topical or vaginal estrogens – used in cases of vaginal atrophy
• Tolterodine (Detrol)
• Oxybutynin (Ditropan, Oxytrol)
• Propantheline
• Darifenacin (Enablex)
• Solifenacin (Vesicare)
• Trospium (Sanctura) – used in urge incontinence
• Imipramine – used in mixed and stress urinary incontinence
• Pseudoephedrine
• Duloxetine (Cymbalta) – used in stress urinary incontinence

Some of these medications can produce harmful side effects if used for long periods. In particular, estrogen therapy has been associated with an increased risk of cancers of the breast and endometrium (lining of the uterus). A patient should talk to a doctor about the risks and benefits of long-term use of medications.

Pessaries

A pessary is a medical device that is inserted into the vagina. The most common kind is ring shaped, and is typically recommended to correct vaginal prolapse. The pessary compresses the urethra against the symphysis pubis and elevates the bladder neck. For some women this may reduce stress leakage. If a pessary is used, vaginal and urinary tract infections may occur and regular monitoring by a doctor is recommended.

Peri/Trans Urethral Injections

A variety of materials have been historically used to add bulk to the urethra and thereby increase outlet resistance. This is most effective in patients with a relatively fixed urethra. Blood and fat have been used with limited success. The most widely used substance, gluteraldehyde crosslinked collagen (GAX collagen) proved to be of value in many patients. The main downfall was the need to repeat the procedure over time.

Surgery

Doctors usually suggest surgery to alleviate incontinence only after other treatments have been tried. Many surgical options have high rates of success. Urodynamic testing seems to confirm that surgical restoration of vault prolapse can cure motor urge incontinence.

Bladder repositioning

Most stress incontinence in women results from the urethra dropping down toward the vagina. Therefore, common surgery for stress incontinence involves pulling the urethra up to a more normal position. Working through an incision in the vagina or abdomen, the surgeon raises the urethra and secures it with a string attached to muscle, ligament, or bone. For severe cases of stress incontinence, the surgeon may secure the urethra with a wide sling. This not only holds up the bladder but also compresses the bottom of the bladder and the top of the urethra, further preventing leakage.

Marshall-Marchetti-Krantz

The Marshall-Marchetti-Krantz (MMK) procedure, also known as retropubic suspension or bladder neck suspension surgery, is performed by a surgeon in a hospital setting. Developed in 1949 by doctors Victor F. Marshall (urologist), Andrew A. Marchetti (OB/GYN), and Kermit E. Krantz (OB/GYN) is the standard by which new procedures are measured. In 1961 Dr. Burch reported a modification of the MMK operation (the Burch modification.)

The patient is placed under general anesthesia, and a long, thin, flexible tube (catheter) is inserted into the bladder through the narrow tube (urethra) that drains the body's urine. An incision is made across the abdomen, and the bladder is exposed. The bladder is separated from surrounding tissues. Stitches (sutures) are placed in these tissues near the bladder neck and urethra. The urethra is then lifted, and the sutures are attached to the pubic bone itself, or to tissue (fascia) behind the pubic bone. The sutures support the bladder neck, helping the patient gain control over urine flow. The Burch modifications involved placing the surgical sutures at the bladder neck and tying them to the Cooper ligament.

Approximately 85% of women who undergo the Marshall-Marchetti-Krantz procedure are cured of their stress incontinence.

Slings

The procedure of choice for stress urinary incontinence in females is what is called a sling procedure. A sling usually consists of a synthetic mesh material in the shape of a narrow ribbon but sometimes a biomaterial (bovine, porcine) or the patients' own tissue that is placed under the urethra through one vaginal incision and two small abdominal incisions. The idea is to replace the deficient pelvic floor muscles and provide a "backboard" or "hammock" of support under the urethra. According to published peer-reviewed studies, these slings are approximately 85% effective. There is a great variety of slings that have been marketed in the U.S. Three of the most common are the Tension-free Transvaginal Tape, The Trans-obturator Tape, and the Minislings. Currently there is minimal long term data to show better success with one variety of sling over the others. The decision in regards to what brand or type of sling to utilize is based primarily with an individual surgeons experience, patient preference and comorbidities such as prior abdominal surgery or previous anti-incontinence surgery.

Tension-free transvaginal (TVT) sling

The tension-free transvaginal (TVT) sling procedure treats urinary stress incontinence by positioning a polypropylene mesh tape underneath the urethra. The 20-minute outpatient procedure involves two miniature incisions and has an 86–95% cure rate. Complications, such as bladder perforation, can occur in the retropubic space if the procedure is not done correctly. However, recent advancements have proven that the minimally invasive tvt sling procedure is regarded as a common treatment for SUI.

Transobturator tape (TOT) sling

First developed in Europe and later introduced to the U.S. by urogynecologist Dr. John R. Miklos, the transobturator tape (TOT) sling procedure is meant to eliminate stress urinary incontinence by providing support under the urethra. The minimally-invasive procedure eliminates retropubic needle passage and involves inserting a mesh tape under the urethra through three small incisions in the groin area.

Mini-sling procedure

The mini-sling procedure was released in the United States in late 2006 by Gynecare/Johnson and Johnson under the name of TVT-Secure. AMS have released a similar version called MiniArc. The TVT-SECUR was designed to overcome two of the perioperative complications reported with use of TVT-Obturator: thigh pain and bladder outlet obstruction. The TVT-SECUR was designed to minimize the operative procedure as much as possible in order to reduce those undesired complications. This new device is composed of an 8 cm long laser cut polypropylene mesh and is introduced to the internal obturator muscle (Hammock position) by a metallic inserter, while no exit skin cuts are needed.The MiniArc is also quite simple and again eliminates the need for skin incisions other than the vaginal incision.

Bladder augmentation

Artificial urinary sphincter

In rare cases, a surgeon implants an artificial urinary sphincter, a doughnut-shaped sac that circles the urethra. A fluid fills and expands the sac, which squeezes the urethra closed. By pressing a valve implanted under the skin, the artificial sphincter can be deflated. This removes pressure from the urethra, allowing urine from the bladder to pass.

Catheterization

If an incontinence is due to overflow incontinence, in which the bladder never empties completely, or if the bladder cannot empty because of poor muscle tone, past surgery, or spinal cord injury, a catheter may be used to empty the bladder. A catheter is a tube that can be inserted through the urethra into the bladder to drain urine. Catheters may be used once in a while or on a constant basis, in which case the tube connects to a bag that is attached to the leg. If a long-term(or indwelling)catheter is used, urinary tract infections may occur.

Other procedures

Kneading the perineum immediately after urination can help expel unvoided urine retained by a urethral stricture, a urethral sphincter that is slow to close, or overdeveloped abdominal floor muscles and connective tissue (as may be developed by the stresses of bicycle seats.)

Hospitals often use some type of incontinence pad, a small but highly absorbent sheet placed beneath the patient, to deal with incontinence or other unexpected discharges of bodily fluid. These pads are especially useful when it is not practical for the patient to wear a diaper.