All About Urinary Incontinence

Dateline: 01/15/99

Some men there are love not a gaping pig;
Some, that are mad if they behold a cat;
And others, when the bagpipe sings i' the nose,
Cannot contain their urine.

William Shakespeare, The Merchant of Venice (c. 1595)

Thanks to all those bladder control commercials (and maybe the freedom gained from public discussion of Viagra and erectile dysfunction), urinary incontinence is getting more attention. Because urinary incontinence creates embarrassment in its victims, good statistics have been hard to come by. Low estimates suggest that only 1 in 10 seniors are affected by incontinence. More realistic estimates indicate that one-third of seniors suffer from urinary incontinence, with women affected twice as often as men. Upwards of half of all women experience urinary incontinence at some time during their lives.

A problem that affects as many as 25 million Americans deserves better understanding. Out of embarrassment or resignation, most people with urinary incontinence never mention the problem to their doctors. The aim of this article is to describe urinary incontinence and its treatments, in the hope that seniors and others will be encouraged to seek medical evaluation and treatment of their incontinence. As at least one commercial says, pads aren't the only treatment. Urinary incontinence often responds remarkably to medical or surgical treatment. Depending on its cause, urinary incontinence might even be reversible.

What Is Urinary Incontinence?

Put simply, urinary incontinence is the uncontrollable loss of urine. There are several kinds of urinary incontinence, and each has its own causes and treatments. In this article, we will consider four types: urge incontinence, stress incontinence, functional incontinence, and overflow incontinence. In real life, of course, it often is not quite so simple to put a person's incontinence neatly into one category -- sometimes urinary incontinence has mixed causes.

Urge incontinence. With urge incontinence, you lose the ability to hold your urine when you get the urge to urinate. It's usually caused by abnormal spasms of the bladder once the bladder starts to fill. Urge incontinence may be brought on by stroke, multiple sclerosis, Parkinson's disease, brain and spinal cord abnormalities, or infections, but most often, a specific cause is not identifiable. This is the most common type of urinary incontinence in seniors.

Stress incontinence. As it sounds, stress incontinence is brought on by activities that suddenly put added pressure on the bladder, causing urine to leak. Coughing, sneezing, and laughing are common precipitants. Stress incontinence predominantly affects women, whose bladders undergo changes because of pregnancy, childbirth, and menopause. This is the most common type of urinary incontinence among women.

Functional incontinence. Functional incontinence means the problem lies somewhere other than the bladder. Folks with functional incontinence may have trouble reaching a toilet in time because of problems of mobility or communication or thinking. This may account for a significant proportion of urinary incontinence cases among institutionalized elderly people.

Overflow incontinence. Overflow incontinence occurs when the bladder is so full that the urine has no place to go but out. The two main causes of overflow incontinence are weak bladder muscles (due to nerve damage from diabetes and other conditions) and blockage of the urethra (by an enlarged prostate gland or "kidney" stones or tumors). This affects mainly elderly men who have prostate disease.

How is Urinary Incontinence Evaluated?

If you have any type of urinary incontinence, you need to have a frank discussion with your physician. Your doctor will begin by trying to understand exactly how your incontinence occurs. As you might guess from having read the types above, a medical history is often sufficient to categorize your urinary incontinence. Certain drugs can worsen or cause urinary incontinence, so she/he will certainly ask about your medications. The doctor will also perform a physical exam to determine whether there is an obvious cause of your incontinence.

The next step may be a complete urinalysis. Many forms of urinary incontinence are worsened by bladder infections, so she/he will want to identify and treat any urinary tract infection that complicates the picture.

Finally, your doctor may do some combination of the following tests of your bladder anatomy, capacity, and function:

• Bladder capacity: a test that determines how much urine your bladder holds when it's full. You drink water until you feel full, then urinate into a container that measures volume.
• Residual volume: a test that determines how much urine remains in your bladder after you have urinated as completely as possible. After you urinate, the doctor will insert a catheter to collect and measure any remaining urine.
• Stress test: a test of stress incontinence. Your doctor will observe for signs of urine loss while you cough vigorously or simply strain as you would to have a bowel movement.
• Urodynamics: tests that measure pressures within your bladder and the rate your urine flows out. For these, your doctor may refer you to a specialist (e.g., a urologist or urogynecologist).
• Cystoscopy: a look at the inside of your bladder. The doctor inserts a small tube through your urethra into your bladder to look for possible causes of your incontinence.
• Ultrasound: a view of your urinary tract from the outside using sound waves. Your doctor or a radiologist moves a metal probe across your skin and "takes pictures" of your kidneys, bladder, urethra, and ureters.

After your doctor has conducted or ordered all the tests necessary to understand why you have urinary incontinence, she/he will discuss with you the different ways of managing your specific situation.

How is Urinary Incontinence Treated?

Different types of urinary incontinence lend themselves to different sorts of treatment. It is especially important to undergo the detailed diagnostic scheme above so that your doctor can recommend the treatment that's best for your particular type of urinary incontinence.

The first thing your doctor may do is treat any urinary tract infection she/he may have identified. This will involve taking prescription antibiotics for anywhere from one day to two weeks, depending upon the severity of the infection and the identity of the culprit infecting your urinary tract.

Beyond treating any infection, the doctor has a host of therapeutic options:

• Kegel exercises. For patients with stress incontinence, exercises to strengthen the pelvic and sphincter muscles are often quite effective in improving symptoms. You can learn Kegel exercises online or through your healthcare professional.
• Electrostimulation. To supplement pelvic muscle exercises, electrical stimulation can be used to strengthen muscles that can help maintain bladder control. Electrostimulation helps people with either stress or urge incontinence.
• Bladder training. Urinating on schedule and combining that with biofeedback (below) may be especially helpful for people with urge and overflow incontinence. Caregivers may also employ a schedule for people under their care who have functional incontinence.
• Biofeedback. Stress and urge incontinence often respond to biofeedback. Electronic sensors help you to understand your body physiology so that you can control the muscles you've been exercising.
• Medications. Several medicines are available to improve urinary incontinence. Drugs like oxybutynin (now available in a once-a-day formulation), propantheline, and hyoscyamine may reduce the contractions that result in urge incontinence. Pseudoephedrine may help a weak urinary sphincter to contract, thus improving stress incontinence. Hormone replacement therapy may improve the urge incontinence that sometimes accompanies menopause.
• Pessaries. A pessary, a donut-shaped ring inserted into your vagina, helps reposition your urethra and improve stress incontinence.
• Implants. Different rubbery substances have been injected around the urethra of stress incontinence victims in an effort to improve symptoms. Sometimes it works, sometimes it doesn't.
• Urethral plugs and patches. The plug is like a tiny tampon that you insert into your urethra and inflate to prevent urine leakage. The patch is a foam pad that adheres to your skin around your urethra to keep urine from leaking. These devices are effective in some women sufferers of mild incontinence.
• Surgery. For patients with obstructions causing overflow incontinence, surgery may be necessary to relieve the obstruction. In addition, surgery is sometimes used to treat stress incontinence when Kegel exercises and electrostimulation fail to strengthen the muscles supporting the bladder.
• Catheterization. For sufferers of overflow incontinence due to obstruction, especially those not amenable to surgery, periodic insertion of a catheter through the urethra to drain the urine may be employed.
• Pads. There are now several brands of disposable pads which may be used along with any of the foregoing treatments. While they offer good protection, they should not prevent you from seeking treatment for your urinary incontinence.

As you can see, there are many effective treatments for urinary incontinence. Do yourself a big favor: make an appointment with your doctor to discuss your problem and ask for a real solution. You'll be glad you did.

What Other Resources are Available?

For all sorts of information, advice, and support, try this organization: National Bladder Foundation

And for a wealth of information about bladder control, be sure to visit the website of NIDDK. You'll find pamphlets, instructions, and the latest research results.

You may not know everything about urinary incontinence that you want to know, but you certainly know enough now not to be too embarrassed to ask your doctor about the best treatments. Call him today and improve or overcome your urinary incontinence soon.

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