What causes urinary incontinence?
Continence is a complex behavior that integrates many systems including the lower urinary tract (bladder and urethra), the central nervous system (brain and spinal cord), and the peripheral nerves that supply the bladder and urethra. Therefore, urinary incontinence (the involuntary loss of urine) should not be considered a disease, but rather a symptom or sign of an underlying problem that affects one or more of these symptoms.
A higher incidence of incontinence in the elderly reflects not only age-related changes in the lower urinary tract, but also an increased likelihood for additional medical-related illnesses of the systems that maintain urinary continence. As a result, the causes of urinary incontinence in the elderly are generally caused by many factors, often outside of the lower urinary tract.
What are the types of urinary incontinence?
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Stress incontinence
— involuntary loss of urine during activities such a laughing, coughing, or sneezing that increase pressure on the bladder in the presence of a poorly functioning bladder sphincter. This condition is the most common type of incontinence in women of all ages except for the elderly, where symptoms of urge incontinence become predominant.
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Urge incontinence
— involuntary loss of urine due to an abnormal bladder contraction that is generally, but not always, preceded by a strong, sudden need to void (urgency). This type of incontinence affects the elderly more than any other age groups.
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Mixed incontinence
— involuntarily loss of urine from a combination of stress and urge incontinence. This condition is more common in women than in men.
How serious is the problem?
Urinary incontinence has serious economic, physical, social, and psychological consequences for those it affects.
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Economic impacts
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Effects on health
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Social stigma
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Impact on mental health
How is urinary incontinence evaluated?
The general evaluation of all patients with urinary incontinence should include:
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History and quality of life assessment
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Physical examination (abdominal, neurologic, pelvic, and rectal examinations)
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Urinalysis and urine culture
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Postvoid residual (the amount of urine left in the bladder after voiding)
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Blood test (kidney function)
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Fluid intake and voiding diary
For certain patients, the evaluation may include:
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Urodynamic testing (physiologic "stress test" of the bladder)
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Cystoscopy (examination of the lower urinary tract with fiber optics)
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Imaging studies (kidney, bladder, and urethral evaluations)
How is urinary incontinence treated?
The three major treatment categories for urinary incontinence management include: behavioral, pharmacologic and surgical.
Behavioral:
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Bladder and habit training
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Pelvic muscle exercises
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Biofeedback
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Vaginal weights
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Pelvic muscle electrical stimulation
Pharmacologic:
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To promote urine storage:
- Drugs that reduce excessive bladder muscle contractions
- Drugs that increase sphincteric tone
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To promote urine expulsion:
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Drugs that increase bladder muscle contractions
- Drugs that decrease sphincteric tone
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Hormones
Surgical:
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Office-based procedures
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Percutaneous procedures
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Laparoscopic procedures
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Open abdominal procedures
What are the outcomes of urinary incontinence treatment?
Patients should be informed of all the treatment options and should receive information on the expected outcomes, risks, and benefits of each. The treatments should be staged, with the least invasive or least dangerous techniques introduced first.
What are the prospects for the future?
A successful management program for urinary incontinence in the elderly relies on the combination of a comprehensive assessment and a selection of available treatment options. Recent advances in behavioral, pharmacologic, and surgical procedures have expanded the list of options for elderly patients who require an individualized management program for urinary incontinence.
Explanation of treatments:
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 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 (afibrous 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, the 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 occasionally or on a regular basis, in which case the tube connects to a bag that you can attach to you leg. If you use a long-term (indwelling) catheter, you should watch for possible urinary tract infections.
Other procedures
Many people manage urinary incontinence with pads that catch slight leakage during activities such as exercising. Also, you can often can reduce incontinence by restricting certain liquids, such as coffee, tea, and alcohol.
Finally, many women whose incontinence is treatable 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 elderly, 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.
© Copyright 1995-2008 The Cleveland Clinic Foundation. All rights reserved.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 12/29/2005
