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Urinary incontinence

Urinary incontinence is an inability to hold your urine until you get to a toilet. More than 13 million people in the United States--male and female, young and old--experience incontinence. It is often temporary, and it always results from an underlying medical condition.

In this article, the term "incontinence" will be used to mean urinary incontinence. See also fecal incontinence.

Table of contents

Urinary incontinence in women

Women experience incontinence twice as often as men. Pregnancy and childbirth, menopause, and the structure of the female urinary tract[?] account for this difference. But both women and men can become incontinent from neurologic injury, birth defects, strokes, multiple sclerosis, and physical problems associated with aging.

Older women, more often than younger women, experience incontinence. But incontinence is not inevitable with age. Incontinence is treatable and often curable at all ages. If you experience incontinence, you may feel embarrassed. It may help you to remember that loss of bladder control can be treated. You will need to overcome your embarrassment and see a doctor to learn if you need treatment for an underlying medical condition.

Incontinence in women 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 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 (see figure 1). Incontinence will occur if your bladder muscles suddenly contract or muscles surrounding the urethra suddenly relax. Image of bladder with different parts labeled Figure 1.--Front view of bladder and sphincter muscles.

What Are the Types of Incontinence?

Stress Incontinence

If coughing, laughing, sneezing, or other movements that put pressure on the bladder cause you to leak urine, you may have stress incontinence. Physical changes resulting from pregnancy, childbirth, and menopause often cause stress incontinence. It is the most common form of incontinence in women and is treatable.

Pelvic floor muscles support your bladder (see figure 2). If these muscles weaken, your bladder can move downward, pushing slightly out of the bottom of the pelvis toward the vagina. This prevents muscles that ordinarily force the urethra shut from squeezing as tightly as they should. As a result, urine can leak into the urethra during moments of physical stress. Stress incontinence also occurs if the muscles that do the squeezing weaken.

Stress incontinence can worsen during the week before your menstrual period. At that time, lowered estrogen levels might lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause. Side view of female pelvis with organs labeled. Figure 2.--Side view of female pelvic muscles.

Urge Incontinence

If you lose urine for no apparent reason while suddenly feeling the need or urge to urinate, you may have urge incontinence. The most common cause of urge incontinence is inappropriate bladder contractions.

Medical professionals describe such a bladder as "unstable," "spastic," or "overactive." Your doctor might call your condition "reflex incontinence" if it results from overactive nerves controlling the bladder.

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).

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 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 in nursing homes.

Overflow Incontinence

If your bladder is always full so that it frequently leaks urine, you have overflow incontinence. 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."

"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. The Types of Urinary Incontinence Stress Leakage of small amounts of urine during physical movement (coughing, sneezing, exercising). Urge Leakage of large amounts of urine at unexpected times, including during sleep. Functional Untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet. Overflow Unexpected leakage of small amounts of urine because of a full bladder. Mixed Usually the occurrence of stress and urge incontinence together. Transient Leakage that occurs temporarily because of a condition that will pass (infection, medication).

How Is Incontinence Evaluated?

The first step toward relief is to see a doctor who is well acquainted with incontinence to learn the type you have. A urologist specializes in the urinary tract, and some urologists further specialize in the female urinary tract. Gynecologists and obstetricians specialize in the female reproductive tract and childbirth. A urogynecologist focuses on urological problems in women. Family practitioners and internists see patients for all kinds of complaints. Any of these doctors may be able to help you.

To diagnose the problem, your doctor will first ask about symptoms and medical history. Your pattern of voiding and urine leakage may suggest the type of incontinence. Other obvious factors that can help define the problem include straining and discomfort, use of drugs, recent surgery, and illness. If your medical history does not define the problem, it will at least suggest which tests are needed.

Your doctor will physically examine you 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.

Your doctor will measure your bladder capacity and residual urine for evidence of poorly functioning bladder muscles. To do this, you will drink plenty of fluids and urinate into a measuring pan, after which the doctor will measure any urine remaining in the bladder. Your doctor may also recommend

  • Stress test--You relax, then cough 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 "see" 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.

Your doctor may ask you to keep a diary for a day or more, up to a week, to record when you void. This diary should note the times you urinate and the amounts of urine you produce. To measure your urine, you can use a special pan that fits over the toilet rim.

How Is Incontinence Treated?

Exercises

Kegel exercises[?] to strengthen or retrain pelvic floor muscles[?] and sphincter muscles can reduce or cure stress leakage. Women of all ages can learn and practice these exercises, which are taught by a health care professional.

Most Kegel exercises do not require equipment. However, one technique involves the use of weighted cones. For this exercise, you stand and hold a cone-shaped object within your vagina. You then substitute cones of increasing weight to strengthen the muscles that help keep the urethra closed.

Electrical Stimulation

Brief doses of electrical stimulation can strengthen muscles in the lower pelvis in a way similar to exercising the muscles. Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles. This will 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 you become aware of your body's functioning. By using electronic devices or diaries to track when your bladder and urethral muscles contract, you can gain control over these muscles. Biofeedback can be used with pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.

Timed Voiding or Bladder Training

Timed voiding (urinating) and bladder training are techniques that use biofeedback. In timed voiding, you fill in a chart of voiding and leaking. From the patterns that appear in your chart, you can plan to empty your bladder before you 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. Some drugs tighten muscles at the bladder neck and urethra, preventing leakage. And some, especially hormones such as estrogen, are believed to cause muscles involved in urination to function normally.

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 for cancers of the breast and endometrium (lining of the uterus). Talk to your doctor about the risks and benefits of long-term use of medications.

Pessaries

A pessary is a stiff ring that is inserted by a doctor or nurse into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less stress leakage. If you use a pessary, you should watch for possible vaginal and urinary tract infections and see your doctor regularly.

Implants

Implants are substances injected into tissues around the urethra. The implant adds bulk and helps to close the urethra to reduce stress incontinence. Collagen (a fibrous natural tissue from cows) and fat from the patient's body have been used. Implants can be injected by a doctor in about half an hour using local anesthesia.

Implants have a partial success rate. Injections must be repeated after a time because the body slowly eliminates the substances. Before you receive collagen, a doctor must perform a skin test to determine whether you would have an allergic reaction to the material.

Surgery

Doctors usually suggest surgery to alleviate incontinence only after other treatments have been tried. Many surgical options have high rates of success.

Most stress incontinence results from the bladder dropping down toward the vagina. Therefore, common surgery for stress incontinence involves pulling the bladder up to a more normal position. Working through an incision in the vagina or abdomen, the surgeon raises the bladder and secures it with a string attached to muscle, ligament, or bone.

For severe cases of stress incontinence, the surgeon may secure the bladder 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.

In rare cases, a surgeon implants an artificial 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, you can cause the artificial sphincter to deflate. This removes pressure from the urethra, allowing urine from the bladder to pass.

Catheterization

If you are incontinent because your bladder never empties completely (overflow incontinence) or your bladder cannot empty because of poor muscle tone, past surgery, or spinal cord injury, you might use a catheter to empty your bladder. A catheter is a tube that you can learn to insert 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 you can attach to your leg. If you use a long-term (or indwelling) catheter, you should watch for possible urinary tract infections.

Other Procedures

Many women manage urinary incontinence with pads that catch slight leakage during activities such as exercising. Also, you often can reduce incontinence by restricting certain liquids, such as coffee, tea, and alcohol.

Finally, many women who could be treated resort instead to wearing absorbent undergarments, or diapers--especially elderly women in nursing homes. This is unfortunate, because diapering can lead to diminished self-esteem, as well as skin irritation and sores. If you are an elderly woman, you and your family should discuss with your doctor the possible effectiveness of treatments such as timed voiding, pelvic muscle exercises, and electrical stimulation before resorting to absorbent pads or undergarments.


Urinary incontinence in children

In the United States, at least 13 million people have problems holding urine until they can get to a toilet. This loss of urinary control is called "urinary incontinence" or just "incontinence." Although it affects many young people, it usually disappears naturally over time, which suggests that incontinence, for some people, may be a normal part of growing up. No matter when it happens or how often it happens, incontinence causes great distress. It may get in the way of a good night's sleep and is embarrassing when it happens during the day. That's why it is important to understand that occasional incontinence is a normal part of growing up and that treatment is available for most children who have difficulty controlling their bladders.

How Does the Urinary System Work?

Urination, or voiding, is a complex activity. The bladder is a balloonlike muscle that lies in the lowest part of the abdomen. The bladder stores urine, then releases it through the urethra, the canal that carries urine to the outside of the body. Controlling this activity involves nerves, muscles, the spinal cord, and the brain.

The bladder is made of two types of muscles: the detrusor, a muscular sac that stores urine and squeezes to empty, and the sphincter, a circular group of muscles at the bottom or neck of the bladder that automatically stay contracted to hold the urine in and automatically relax when the detrusor contracts to let the urine into the urethra. A third group of muscles below the bladder (pelvic floor muscles) can contract to keep urine back.

A baby's bladder fills to a set point, then automatically contracts and empties. As the child gets older, the nervous system develops. The child's brain begins to get messages from the filling bladder and begins to send messages to the bladder to keep it from automatically emptying until the child decides it is the time and place to void.

Failures in this control mechanism result in incontinence. Reasons for this failure range from the simple to the complex.

Incontinence happens less often after age 5: About 10 percent of 5-year-olds, 5 percent of 10-year-olds, and 1 percent of 18-year-olds experience episodes of incontinence. It is twice as common in boys as in girls.

What Causes Nighttime Incontinence?

After age 5, wetting at night--often called bedwetting or sleepwetting--is more common than daytime wetting in boys. Experts do not know what causes nighttime incontinence. Young people who experience nighttime wetting tend to be physically and emotionally normal. Most cases probably result from a mix of factors including slower physical development, an overproduction of urine at night, a lack of ability to recognize bladder filling when asleep, and, in some cases, anxiety. For many, there is a strong family history of bedwetting, suggesting an inherited factor.

Slower Physical Development

Between the ages of 5 and 10, incontinence may be the result of a small bladder capacity, long sleeping periods, and underdevelopment of the body's alarms that signal a full or emptying bladder. This form of incontinence will fade away as the bladder grows and the natural alarms become operational.

Excessive Output of Urine During Sleep

Normally, the body produces a hormone that can slow the making of urine. This hormone is called antidiuretic hormone, or ADH. The body normally produces more ADH at night so that the need to urinate is lower. If the body doesn't produce enough ADH at night, the making of urine may not be slowed down, leading to bladder overfilling. If a child does not sense the bladder filling and awaken to urinate, then wetting will occur.

Anxiety

Experts suggest that anxiety-causing events occurring in the lives of children ages 2 to 4 might lead to incontinence before the child achieves total bladder control. Anxiety experienced after age 4 might lead to wetting after the child has been dry for a period of 6 months or more. Such events include angry parents, unfamiliar social situations, and overwhelming family events such as the birth of a brother or sister.

Incontinence itself is an anxiety-causing event. Strong bladder contractions leading to leakage in the daytime can cause embarrassment and anxiety that lead to wetting at night.

Genetics

Certain inherited genes appear to contribute to incontinence. In 1995, Danish researchers announced they had found a site on human chromosome 13 that is responsible, at least in part, for nighttime wetting. If both parents were bedwetters, a child has an 80 percent chance of being a bedwetter also. Experts believe that other, undetermined genes also may be involved in incontinence.

Obstructive Sleep Apnea

Nighttime incontinence may be one sign of another condition called obstructive sleep apnea, in which the child's breathing is interrupted during sleep, often because of inflamed or enlarged tonsils or adenoids. Other symptoms of this condition include snoring, mouth breathing, frequent ear and sinus infections, sore throat, choking, and daytime drowsiness. In some cases, successful treatment of this breathing disorder may also resolve the associated nighttime incontinence.

Structural Problems

Finally, a small number of cases of incontinence are caused by physical problems in the urinary system in children. Rarely, a blocked bladder or urethra may cause the bladder to overfill and leak. Nerve damage associated with the birth defect spina bifida can cause incontinence. In these cases, the incontinence can appear as a constant dribbling of urine. What Causes Daytime Incontinence?

Daytime incontinence that is not associated with urinary infection or anatomic abnormalities is less common than nighttime incontinence and tends to disappear much earlier than the nighttime versions. One possible cause of daytime incontinence is an overactive bladder. Many children with daytime incontinence have abnormal voiding habits, the most common being infrequent voiding.

An Overactive Bladder

Muscles surrounding the urethra (the tube that takes urine away from the bladder) have the job of keeping the passage closed, preventing urine from passing out of the body. If the bladder contracts strongly and without warning, the muscles surrounding the urethra may not be able to keep urine from passing. This often happens as a consequence of urinary tract infection and is more common in girls.

Infrequent Voiding

Infrequent voiding refers to a child's voluntarily holding urine for prolonged intervals. For example, a child may not want to use the toilets at school or may not want to interrupt enjoyable activities, so he or she ignores the body's signal of a full bladder. In these cases, the bladder can overfill and leak urine. Additionally, these children often develop urinary tract infections (UTIs), leading to an irritable or overactive bladder.

Other Causes

Some of the same factors that contribute to nighttime incontinence may act together with infrequent voiding to produce daytime incontinence. These factors include

  • a small bladder capacity
  • structural problems
  • anxiety-causing events
  • pressure from a hard bowel movement (constipation)
  • drinks or foods that contain caffeine, which increases urine output and may also cause spasms of the bladder muscle, or other ingredients to which the child may have an allergic reaction, such as chocolate or artificial coloring

Sometimes overly strenuous toilet training may make the child unable to relax the sphincter and the pelvic floor to completely empty the bladder. Retaining urine (incomplete emptying) sets the stage for urinary tract infections. What Treats or Cures Incontinence?

Growth and Development

Most urinary incontinence fades away naturally. Here are examples of what can happen over time:

  • Bladder capacity increases.
  • Natural body alarms become activated.
  • An overactive bladder settles down.
  • Production of ADH becomes normal.
  • The child learns to respond to the body's signal that it is time to void.
  • Stressful events or periods pass.

Many children overcome incontinence naturally (without treatment) as they grow older. The number of cases of incontinence goes down by 15 percent for each year after the age of 5.

Medications

Nighttime incontinence may be treated by increasing ADH levels. The hormone can be boosted by a synthetic version known as desmopressin, or DDAVP, which recently became available in pill form. Patients can also spray a mist containing desmopressin into their nostrils. Desmopressin is approved for use by children.

Another medication, called imipramine, is also used to treat sleepwetting. It acts on both the brain and the urinary bladder. Unfortunately, total dryness with either of the medications available is achieved in only about 20 percent of patients.

If a young person experiences incontinence resulting from an overactive bladder, a doctor might prescribe a medicine that helps to calm the bladder muscle. This medicine controls muscle spasms and belongs to a class of medications called anticholinergics.

Bladder Training and Related Strategies

Bladder training consists of exercises for strengthening and coordinating muscles of the bladder and urethra, and may help the control of urination. These techniques teach the child to anticipate the need to urinate and prevent urination when away from a toilet. Techniques that may help nighttime incontinence include

  • determining bladder capacity
  • stretching the bladder (delaying urinating)
  • drinking less fluid before sleeping
  • developing routines for waking up

Unfortunately, none of the above has demonstrated proven success.

Techniques that may help daytime incontinence include

  • urinating on a schedule, such as every 2 hours (this is called timed voiding)
  • avoiding caffeine or other foods or drinks that you suspect may contribute to your child's incontinence
  • following suggestions for healthy urination, such as relaxing muscles and taking your time

Moisture Alarms

At night, moisture alarms can awaken a person when he or she begins to urinate. These devices include a water-sensitive pad worn in pajamas, a wire connecting to a battery-driven control, and an alarm that sounds when moisture is first detected. For the alarm to be effective, the child must awaken or be awakened as soon as the alarm goes off. This may require having another person sleep in the same room to awaken the bedwetter.

Incontinence is also called enuresis

  • Primary enuresis refers to wetting in a person who has never been dry for at least 6 months.
  • Secondary enuresis refers to wetting that begins after at least 6 months of dryness.
  • Nocturnal enuresis refers to wetting that usually occurs during sleep (nighttime incontinence).
  • Diurnal enuresis refers to wetting when awake (daytime incontinence).

Points to Remember

  • Urinary incontinence in children is common.
  • Nighttime wetting occurs more commonly in boys.
  • Daytime wetting is more common in girls.
  • After age 5, incontinence disappears naturally at a rate of 15 percent of cases per year.
  • Treatments include waiting, dietary modification, moisture alarms, medications, and bladder training.



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