Have you been facing recurring situations where you could not control the urgent need to urinate or leaked urine unconsciously? Chances are you might be experiencing a disorder known as urinary incontinence.
Urinary incontinence or unwanted and uncontrolled leaking of urine is not typically classified as a disease. While many people think of it as a part of aging, it is not considered normal. It is a disorder or symptom that can precipitate from an underlying medical condition or pathology.
Usually, people who suffer from urinary incontinence are embarrassed to go out in public and might hesitate if nearby access to toilets is not easily available. Because of the stigma that surrounds this topic, such bladder issues cause the affected individual to shy away from their normal daily activities and they may be embarassed to seek medical help. All in all, it affects the person’s physical, psychological and emotional health, delimits their social life, as well as impacts personal hygiene.
This detailed article compiles all the essential information about urinary incontinence, from its types to causes, symptoms, and medical treatments. If you or someone you know suffers from urinary incontinence, consult a healthcare professional to receive an accurate diagnosis and optimal treatment.
What Is Urinary Incontinence: An Overview
Urinary incontinence is defined as the process of micturition or urination occurring involuntarily. This means a person experiences involuntary leaking of urine when they do not intend to urinate. A person suffering from urine incontinence usually has a weakened bladder or sphincter or has a loss of control over them. Hence, it reduces the strength to hold in the urine fluid, which in turn, leads to uncontrolled leakage at unwanted times. If not managed at an early stage, this problem can adversely impact the affected individual’s quality of life and health.
As discussed in detail in the upcoming section, various classification types of urinary incontinence exist. Even though the chances of developing this problem increase with age, it is not always an age-specific condition and can even occur in young males and females.
Urinary incontinence can develop as a result of different underlying pathologies or physical changes. In any case, the affected individual is advised to get themselves assessed by a urologist or gynecologist to rule out an underlying reversible cause. Depending upon the type of incontinence present and the severity of the adverse symptoms, management is provided accordingly, either through a pharmacological route, surgical treatment, or physiotherapy.
Epidemiology Of Urinary Incontinence
The exact epidemiological information for urinary incontinence cannot be obtained primarily due to its cases being underreported. However, according to the results of various statistical kinds of research, an estimated amount of 423 million people suffer from this condition on a global scale.
This urinary condition is reported to be more prevalent in women than in men. This is because, anatomically, women have a shorter urethra than their male counterparts, and any disease, pressure strain, or injury leading to its weakness more rapidly causes urinary incontinence.
Physiology Of Normal Urination
Knowing the basic normal physiology or what normally happens during micturition or urination is important to understand what can be the possible causes of urinary incontinence.
Parts of the lower urinary tract, such as the renal pelvis, the two ureters, the urinary bladder, and the urethra, all work in unison for the process of micturition or urination. The filtered urine from the kidney is collected in the funnel-shaped renal pelvis and then flows through the ureters into the bladder. Here, the urine is stored temporarily until an emptying signal is received. After this, it exits the body through the urethral opening, which is direct in females and runs along the penis in males.
Your bladder is able to expand and store copious amounts of urine because of its unique morphological composition. It is wrapped externally by a muscle layer called the detrusor muscle, while internally, it consists of a layer of transitional epithelium called the urothelium.
This specialized epithelium is composed of five to six interlinked layers of abundant flattened cells known as the umbrella cells. When the urine fluid fills the bladder, these umbrella cells stretch out along with the detrusor muscle, allowing more urine to flow inside and store temporarily.
In general, the adult bladder is able to store about 750 ml of urine. This storing quantity is slightly less in women compared to in men since the position of their uterus restricts the bladder’s expansion by a bit.
Before exiting from the urethral opening, two sphincter muscles hold the urine inside the bladder. The first sphincter, the internal sphincter muscle, composed of smooth muscle and hence under involuntary control, opens when the bladder is half full. The second sphincter, the external sphincter muscle, consists of skeletal muscles and is under voluntary control, allowing you to urinate whenever you want to.
So how does this entire mechanism of micturition take place in an orderly manner? It all happens by the route of the peripheral and central nervous systems.
Stretch receptors, which are specialized nerves, are embedded within the bladder wall. When the bladder becomes half full, these stretch receptors sense the volume and then transmit impulses to the spinal cord and brain. The spinal cord receives these impulses in the sacral region, mainly S2 and S3, which collectively comprise the micturition center. On the other hand, the impulses are also sent to the brain in the pons region, primarily to the pontine storage center and the pontine micturition center.
The micturition center in the spinal cord is largely involved in producing the micturition reflex. As a response to the stretch receptor impulses, this micturition center increases parasympathetic and decreases sympathetic stimulation. This, in turn, causes the bladder’s detrusor muscle to contract and the internal sphincter muscle to relax. The response also reduces the external sphincter’s motor nerve stimulation, relaxing its tone.
But how do we keep our urination in control? This is where the two centers situated in the pons come into play. The pontine storage and micturition center are trained with age to control the process of micturition voluntarily. So, whenever you want to urinate voluntarily, the pontine micturition center further relaxes the tone of the external sphincter, allowing the urine to pass through. However, if you want to hold in or delay urination, the impulses from the pontine storage center override the micturition reflex, keeping the internal sphincter contracted.
Types Of Urinary Incontinence
Depending on the main underlying cause, the condition of urinary incontinence is loosely classified into the following types:
Stress Urinary Incontinence
Stress urinary incontinence, as the name suggests, occurs due to increased intra-abdominal pressure. This type of urinary condition is one of the most prevalent ones reported in women, both young and middle-aged, than in men. According to statistical analysis, an estimated 24% to 45% of women over 30 suffer from SUI.
Mostly young women who are active in sports or have become pregnant, or have undergone childbirth are prone to developing stress urinary incontinence. On the other hand, women in their middle age primarily suffer from this urinary incontinence as a result of menopause since a low level of estrogen weakens the urethra.
In this type of urinary incontinence, an unexpected leakage of urine occurs when stress or pressure is applied by the weakened pelvic floor muscles on the bladder and urethra, causing them to work more. This pressure on the pelvic floor can be generated by any daily normal activity or response such as sneezing, coughing, laughing, jumping, running, heavy lifting, etc.
Urge Urinary Incontinence
An individual suffers from urge urinary incontinence or an overactive bladder (OAB) if they feel the urgent need to go to the toilet but the urine almost immediately. The involuntary leakage of urine in urge incontinence is accompanied by or comes before a feeling of urinary urgency. However, it can sometimes be asymptomatic as well.
A primary reason behind urge incontinence is the overstimulation of the micturition centers that keep telling you to urinate. It is accompanied by the overactivity of the detrusor muscle, leading to intense contractions. This bladder covering muscle can become overstimulated because of various pathologies such as bladder irritation due to infections, diabetes, and neurological disorders like Alzheimer’s, Parkinson’s disease, stroke, multiple sclerosis, etc. In rare cases, persistent urge urinary incontinence may be a sign of developing bladder cancer.
Urge urinary incontinence affects both men and women and is estimated at 9% in women aged 40 to 45 years and 31% in women, and 42% in men over 75 years.
Individuals with urge incontinence feel the frequent need to go to the toilet during the day and night but urinate in minute amounts only. The involuntary leakage can also occur through external triggers, such as after drinking or when running water is heard or touched.
Overflow Urinary Incontinence
This type of urinary condition is characterized by constant dribbling of urine from an overdistended bladder that fails to empty adequately. Contrary to urge urinary incontinence, in overflow urinary incontinence, the contracting ability of the detrusor muscle becomes impaired, or an obstruction presents in the bladder outlet, restricting the normal urine outflow.
Pathologies that can contribute to the precipitation of overflow urinary incontinence include neurological disorders like spinal cord injuries and multiple sclerosis. Chronic diseases like diabetes can also impair the contractility of the detrusor muscle leading to overflow incontinence. Outlet obstructions contributing to this bladder disorder may include the growth of tumor or tumor-like lesions, the presence of obstructive masses in the abdomen or pelvis, and pelvic organ prolapse.
Functional Urinary Incontinence
Also known as toileting difficulty, the functional type of urinary incontinence is not typically a bladder disorder but instead involves being unable to reach the toilet in time. An environmental, physical, or mental barrier may cause this delay. Usually, people who have arthritis or any movement-limiting physical disorder experience functional incontinence since it is difficult for them to rush to the bathroom.
Older individuals with mental confusion or an impaired mental state can also find it difficult to locate the toilet and urinate when needed. It is to be noted that the affected individual with functional urinary incontinence has normal or near normal bladder function and control.
Total Urinary Incontinence
Total urinary incontinence is one of the severe forms of urinary incontinence. The affected individual has an impaired bladder that is not able to store urine at all. This incapability of storing urine causes constant involuntary leakage in copious amounts. Total urinary incontinence can most likely develop from a bladder anomaly present since birth. Other causative reasons could be a spinal cord injury or the presence of a fistula (tunnel-like hole) between the bladder and another anatomical region.
Nocturia
Nocturia is the medical term used for nocturnal urination. An individual suffering from nocturia does not always experience involuntary leakage of urine. Still, the person can have such episodes if they do not wake up on time to go to the toilet.
In nocturnal polyuria, the frequency of urination increases during nighttime, causing the affected individual to wake up and urinate twice or more. This bladder disorder affects both men and women aged 60 and above. Nocturia in men can be an indication of an underlying problem of a possible enlarged prostate.
Mixed Urinary Incontinence
Mixed urinary incontinence, as its name suggests, is a combination of different urinary incontinence types. One of the most common mixed urinary incontinence cases is a combination of stress and urge urinary incontinence. However, the affected individual can show symptoms of any of the types. According to statistical analysis, mixed urinary incontinence is present in 20% to 30% of those individuals with persistent chronic urinary incontinence.
Causes Of Urinary Incontinence
As mentioned above in the description of the different types, various etiologies or sets of causes can give rise to urinary incontinence. In order to make it easy to understand, this section will break down the causes according to the types of this urinary condition and how long they last.
Causes According To Types Of Urinary Incontinence
Stress Incontinence
Some of the causes underlying stress incontinence can include:
- Pregnancy and previous childbirths
- Age
- Menopause- low estrogen levels weaken the muscles
- Hysterectomy or other pelvic floor surgeries
- Obesity
Urge Urinary Incontinence
A few common causes that can lead to urge urinary incontinence include:
- Interstitial cystitis- a condition where the lining of the bladder is inflamed and bones irritated
- Prostate hyperplasia or enlarged prostate
- Neurological disorders like Alzheimer’s, Parkinson’s disease, stroke, and multiple sclerosis
Overflow Urinary Incontinence
Some underlying causes contributing to overflow urinary incontinence include:
- Neurological conditions such as multiple sclerosis and spinal cord injuries
- Diabetes
- Tumorous lesions obstructing the bladder
- Enlarged prostate gland
- Pelvic organ prolapse
- Severe constipation
- Presence of renal and bladder calculi
- Surgical complications that damage the detrusor muscle or underlying nerves
Total Urinary Incontinence
A case of total urinary incontinence can result from:
- A genetic anatomical malformation of the bladder or other structures present from birth
- The presence of a fistula, a tube-like channel, between the urinary bladder and another nearby area, which commonly can be the vagina
- A spinal cord injury and damage to impulse transmitting nerves
Causes According To Duration Of Urinary Incontinence
Temporary Urinary Incontinence
Various dietary and medicinal consumption and underlying physical and medical conditions can cause urinary incontinence that lasts for a short time. A few of these common causes include:
- Consumption of drinks like alcohol, carbonated beverages, and drinks containing caffeine
- Use of artificial sweeteners
- Ingesting foods that are extremely spicy, sweet, or acidic
- Citrus fruits and vitamin C ingested in large portions can cause urinary incontinence.
- Taking diuretics or medicines that have a diuretic effect, like water pills for treating renal diseases, heart failure, and liver cirrhosis. Other medicines can include antihypertensives, sedatives, sleeping tablets, and muscle relaxants.
- Urinary tract infections
- Severe constipation that over activates the bladder nerves and weakens the pelvic floor muscle
Persistent Urinary Incontinence
Urinary incontinence can become persistent and last for a longer time due to underlying physical and medical changes like:
- Vaginal delivery weakens the pelvic floor and can lead to its prolapse, causing urinary incontinence
- Hormonal changes and the increasing weight of the fetus during pregnancy
- Production of less estrogen after menopause
- Increase in involuntary bladder contractions and weakening of muscles with aging
- Prostatitis- inflammation of the prostate gland
- Prostate cancer
- Benign prostatic hyperplasia
- Obstruction by a tumor growing along the urinary tract
- Unmanaged obesity
- Surgical complications
- Long-standing diabetes
- Neurological disorders like spinal injuries, brain tumors, multiple sclerosis, stroke, Parkinson’s disease, Alzheimer’s, etc.
Signs And Symptoms Of Urinary Incontinence
As mentioned previously, urinary incontinence is not a disease but is more of a symptom or disorder that can arise from an underlying condition. While different types of urinary incontinence can present in different ways, the general signs and symptoms are somewhat the same among them all. You should consult a healthcare specialist if you observe the following findings:
- Leakage of urine when intra-abdominal pressure increases due to normal activities like coughing, sneezing, laughing, exercising, bending, and lifting.
- Spasms or pressure in the pelvic area creating a strong urge to micturate or urinate.
- Frequent and sudden trips to the bathroom in a single day.
- Unconscious dribbling or leakage of urine without any apparent sign and bed-wetting.
- History of cognitive impairment or spinal cord injury.
- A sudden urge to urinate while hearing running water sounds and during sexual intercourse, especially at the time of orgasm.
- Passing copious amounts of urine frequently or urinating in minute amounts after sudden strong urges to urinate.
- Cloudy or blood tint urine.
- Experience pain while urinating.
Risk Factors Of Urinary Incontinence
Certain factors can place an individual at a higher risk of developing this urinary condition. Some of the most crucial risk factors include:
Gender
Women have a twice higher chance of developing stress urinary incontinence compared to men since their pelvic floor becomes weaker with age, pregnancy, childbirth, and menopause. While on the other hand, men are at an increased risk of developing overflow and urge continence if they have pre-existing prostate-related problems and have undergone surgery or radiation therapy.
Age
With advancing age, the muscles in our body start to lose their strength and tone. The same is the case with bladder and sphincter muscles. These muscles that hold the urine become weak as you age, resulting in unexpected and frequent urges to urinate.
Overweight
Being overweight or having obesity can be a significant risk factor for urinary incontinence. The extra body fat exerts high amounts of pressure on the bladder, causing strong urges to urinate and accidental leakage while performing daily activities. Furthermore, the extra weight also weakens the pelvic floor muscles, worsening the existing urinary incontinence.
Pre-existing Diseases Or Injuries
Renal disease, vascular disease, chronic diseases like diabetes, and neurological disorders like Alzheimer’s. Multiple sclerosis, Parkinson’s disease, etc., are high-risk factors that can cause long-term urinary incontinence. Injuries to the pelvic floor and spinal cord can also develop persistent urinary incontinence that can take a long time to manage.
Family History
If an immediate family member also suffers from urinary incontinence, it can put you at high risk of developing the condition. The resulting urinary incontinence can become evident at a young age or any stage in life.
Smoking
Chronically inhaling tobacco or nicotine is another risk factor that can develop urinary incontinence. When burned and inhaled, the chemical irritants can trigger strong repeated bouts of cough, which strain the abdomen and pelvic floor muscles, aggravating stress incontinence.
Complications Of Urinary Incontinence
If the problem of urinary incontinence is not assessed and managed at an early stage, it can become chronic and lead to several complications such as:
Skin Problems
Since urinary incontinence involves recurrent involuntary leakage of urine, the fluid’s frequent contact with the skin can disturb its normal barrier. Individuals may develop skin rashes, infections, and sores due to the constantly damp skin. Such skin problems and reduced hygiene can promote the growth of severe fungal infections while slowing down wound healing.
Urinary Tract Infections
Without adequate management, the risk of developing different urinary tract infections increases. The frequency of UTIs can also slightly increase if the patient has a urinary catheter inserted for a long time.
Impact On Personal Life
Suffering from urinary incontinence can lead to unwanted embarrassing situations, causing the affected individual to withdraw from socializing and doing their daily activities. This, in turn, can impact their mental health, leading to the risk of developing depression.
Treating Urinary Incontinence
With the constant advancement in the healthcare industry, many treatment options are available for urinary incontinence. The optimal treatment your healthcare specialist will provide depends mainly on the type of urinary incontinence diagnosed, its severity, the condition of your bladder, and overall health. According to the diagnosis and assessment, your doctor or physician might recommend the following treatments:
Bladder Control Training
Bladder control or habit training is a physiotherapy treatment to manage urinary incontinence by improving your voluntary control. It is usually the initial approach recommended for treating any type of urinary incontinence. Depending upon the severity of the condition and regular therapy, improvement may be observed within weeks or months. The bladder control training regime typically comprises three collective therapies that are:
Timed Voiding
This therapy aims to create a set schedule of urination with fixed intervals. It is done by initially setting a one-hour interval for urinating, and with time, this interval is gradually extended to ensure better control over frequent urination.
Pelvic Muscle Exercises
Pelvic muscle exercises or Kegel exercises are specific training routines to strengthen the bladder-supporting muscles and improve urination control. The affected individual is instructed to contract the muscles involved in holding in the urine for about 4 to 5 seconds and then relax them for the same time duration. Besides this routine, the individual can also practice interrupting the flow for a few seconds while urinating.
Urgency Suppression
This therapy involves distracting yourself from strong urination urges to be able to make it to the toilet on time. It could be achieved by focusing on deep breathing, contracting the pelvic floor muscles, and keeping still.
Medications
Various medications are available for treating this urinary condition, and your doctor may prescribe one of these depending upon the severity of your condition in combination with exercises:
Alpha Blockers
These pharmacological agents relax bladder and prostate muscles, allowing easy outflow of urine in men with overflow or urge incontinence. Some commonly prescribed alpha-blockers include doxazosin, terazosin, tamsulosin, alfuzosin, and silodosin.
Anticholinergics
Bladder-selective anticholinergics like oxybutynin, fesoterodine, trospium, solifenacin, darifenacin, and tolterodine are usually prescribed for overactive bladders and urge incontinence. The chemical composition of these drugs helps calm the overactivity of the bladder and suppress strong urges.
Tricyclic Antidepressant
Imipramine is a tricyclic antidepressant commonly prescribed to children for nighttime bed-wetting and adults for treating depression, panic disorders, and anxiety. This drug is also prescribed for mixed urinary incontinence. Imipramine effectively relaxes the bladder muscles and contracts the smooth muscles of the sphincter, helping to strengthen the bladder’s urine-holding capacity.
Beta-3 Adrenoceptor Agonist
When taken orally, Mirabegron, a beta-3 adrenoceptor agonist, relaxes the detrusor muscle and increases the bladder’s urine storage capacity. This pharmacological drug is prescribed to patients with urge incontinence, helping them void their bladder completely.
Topical Estrogen
Vaginal estrogen creams, rings, or patches are prescribed to women with a low estrogen level in their system. These topical formulations contain a low dose of the estrogen hormone and are applied directly to the urethral tissue or vaginal wall. The composition of topical estrogen reinforces the vaginal area and the urethral tissue, preventing involuntary leakage of urine.
Surgery
In severe cases when therapies and medication do not work, urinary incontinence is treated by the surgical route. Some common surgical procedures used as treatment include:
Burch Colposuspension
This procedure involves lifting and suspending the bladder neck. It helps relieve the pressure exerted on the bladder and works best in treating stress urinary incontinence.
Artificial Sphincter
If the two sphincters fail to function optimally, an artificial valve or sphincter is inserted that helps to control the urine flow between the bladder and the urethra.
Sling Procedures
In order to stop the involuntary leakage of urine, a mesh is surgically placed under the bladder’s neck so that the urethra remains supported. The sling design is different for men and women but works the same way to prevent urine from leaking.
Medical Devices And Implants
A variety of medical devices and implants are available to manage urinary incontinence effectively. For females, urethral inserts and pessary are devices inserted in the vagina and can be worn all day to support the bladder and prevent urine from leaking. A sacral nerve stimulator implant provides a pathway between the spinal cord and the bladder and emits nerve-stimulating electrical impulses that help to keep the bladder’s tone in control.
Some specialists may inject botox into the bladder muscle of individuals with an overactive bladder. Additionally, bulking agents may also be injected into the tissue surrounding the urethra to keep it closed, preventing unwanted leakage due to stress incontinence.
Other Options
- Radiofrequency therapy involves heating the lower urinary tract tissues, and upon healing, firmness is achieved, which aids in controlling urine flow.
- Urinary catheters can be inserted to create a pathway between the bladder and urethral opening in cases of unmanageable incontinence. Since the risk of developing stones and infections is high, a catheter is used as a last resort.
- Absorbent pads or panty liners are ideal for managing mild to moderate involuntary urine leakage and help to maintain the patient’s hygiene.
- Incontinence Underwear is certainly not the first product for this issue on the market, but they are becoming increasingly popular. Their success can be attributed to certain advantages that make them superior to other incontinence hygiene products.
Bottom Line
Bladder control issues like urinary incontinence can be embarrassing and cause the affected individual to avoid living their life to the fullest. This problem can occur at any age, and even though it is not a disease, it can be indicative of an underlying serious health issue. However, with early diagnosis and religiously following the prescribed therapy, urinary incontinence can be managed and treated effectively.