Urinary Incontinence

Urinary incontinence is the loss of bladder control.

Urine is a waste product made as the kidneys filter the blood. Each kidney (one kidney on each side of the abdomen) sends newly made urine to the bladder through a tube called a ureter. The bladder acts as a storage site for urine. It expands to hold the urine until a person decides to urinate. Incontinence is the involuntary loss of urine or feces (stool); this article will be limited to discussing urinary incontinence and will not address fecal incontinence.

Holding urine and maintaining bladder control (continence) requires normal function of the renal system as well as the nervous system. Also, a person must be able to sense, understand, and respond to the urge to urinate. The process of urination involves two phases: (1) the filling and storage phase and (2) the emptying phase. During the filling and storage phase, the bladder fills with urine from the kidneys. The bladder stretches as it fills with increasing amounts of urine. A healthy nervous system responds to the stretching of the bladder by signaling the need to urinate, while also allowing the bladder to continue to fill.

Upon urination, the muscle holding the stored urine in the bladder (the sphincter muscle) relaxes, the bladder wall muscle (the detrusor) contracts, and urine passes from the bladder to the outside of the body through another tube called the urethra. The ability to fill and store urine properly requires a functional sphincter muscle to control the output of urine from the bladder and a stable detrusor muscle. To empty the bladder completely, the detrusor muscle must contract appropriately to force urine out of the bladder and the sphincter must relax to allow the urine to pass out of the body.

Urinary incontinence is defined by the International Continence Society as involuntary loss of urine that is a hygienic or social problem to the individual. Some define urinary incontinence to include any involuntary loss of urine. According to the Clinical Practice Guideline issued by the Agency for Health Care Policy and Research, there are four different types of incontinence: stress, urge, mixed, and overflow. Some doctors also include functional incontinence as a fifth potential type. The treatment of urinary incontinence varies depending on the specific cause of incontinence.

There are many possible causes for being incontinent of urine, and sometimes several causes are occurring at the same time. Diagnosis and therapy are more difficult when more than one cause is present, but the cause or causes of incontinence must be identified to provide effective treatment.

Stress Incontinence

Stress incontinence occurs during physical activity; urine leaks out of the body when the abdominal muscles contract, leading to an increase in intra-abdominal pressure (for example, when sneezing, laughing, or even standing up from a seated position). Stress incontinence is most commonly caused when the urethra (the tube from the bladder to the outside of the body) is hypermobile because of problems with the muscles of the pelvis. A less common cause of stress incontinence is a muscle defect in the urethra known as intrinsic sphincter deficiency. The sphincter is a muscle that closes off the urethra and prevents urine from leaving the bladder and passing through the urethra to the outside of the body. If this muscle is damaged or deficient, urine can leak out of the bladder. Some people may have both.

Stress incontinence is the most common type of bladder control problem in younger and middle-aged women. In some cases, it is related to pregnancy and childbirth. It may also begin around the time of menopause. Stress incontinence affects 15% to 60% of women and can affect young and older people. It is especially common in young female athletes who have never given birth, and it occurs while they are participating in sports.

Urge Incontinence

People with urge incontinence cannot hold their urine long enough to get to the toilet in time; it is also called an overactive bladder. Healthy people can have urge incontinence, but it is often found in elderly people or in those who have diabetes, stroke, Alzheimer's disease, Parkinson's disease, or multiple sclerosis.

Urge incontinence occurs due to overactivity of the bladder wall muscle (the detrusor). Urge incontinence may be caused by a problem with the muscle, with the nerves that control the muscle, or both. If the cause is unknown, it is called idiopathic urge incontinence. Overactive bladder, or urge incontinence, without neurologic causes is called detrusor instability, meaning the muscle itself contracts inappropriately.

Risk factors for urge incontinence include aging, obstructions to urine flow (such as an enlarged prostate), and consumption of so-called bladder irritants (such as coffee, tea, colas, chocolate, and acidic fruit juices).

Mixed Incontinence

Mixed incontinence is caused by a combination of stress and urges incontinence. In mixed incontinence, the muscle controlling the outflow of the bladder (the sphincter) is weak, and the detrusor muscle is overactive. Common combinations involve hypermobile urethra and detrusor instability.

Overflow Incontinence

Overflow incontinence occurs because the bladder is too full and urine passively leaks or overflows through the urinary sphincter. This can occur if the flow of urine out of the bladder is constricted or blocked (bladder outlet obstruction), if the bladder muscle has no strength (detrusor atony), or if there are neurologic problems. Common causes of bladder outlet obstruction in men include benign prostatic hyperplasia (BPH or nonmalignant enlargement of the prostate gland), prostate cancer, bladder (vesical) neck contracture (narrowing of the outlet from the bladder due to scarring or excess muscle tissue), and urethral narrowing (strictures). Bladder outlet obstruction can occur in women with significant pelvic organ prolapse (such as a prolapsed uterus). It may even occur after surgery to correct incontinence (such as the sling or bladder neck suspension procedures); this is called iatrogenic-induced overflow incontinence.

Some common neurologic causes of overflow incontinence include herniated lumbar disc, diabetes-related bladder problems, and other nerve problems (peripheral neuropathy). Less common causes of overflow incontinence include AIDS, neurosyphilis, and genital herpes affecting the perineal area (perineal neurosyphilis).

Functional Incontinence

This type of incontinence occurs when a person is unable to reach the toilet in time due to a physical or mental impairment. For example, a person with severe arthritis may not be able to unbutton his or her pants quickly; also someone with Alzheimer's disease or another type of brain dysfunction may not be able to plan a trip to the bathroom.

Conditions that can worsen or contribute to the different types of incontinence include constipation or stool impaction, diabetes, hypertension, tobacco use, and obesity. Further, taking certain medications (such as some antidepressants, estrogens, diuretics, and sleep medications) may worsen incontinence.

An infrequent cause of bladder incontinence (usually acute) is a condition termed cauda equina syndrome. It is caused by significant narrowing of the spinal canal that may be caused by trauma, disc herniation, spinal tumors, inflammation, infections, or after spinal surgery. The incontinence often occurs acutely and may be accompanied by bowel incontinence, groin numbness, and loss of strength and/or sensation in the lower extremities. This condition is a medical emergency; if pressure on the nerves is not removed quickly (within about 48 hours of initial symptoms), permanent nerve damage with function loss may occur. Most clinicians suggest that the earliest interventions have the best outcomes.

Stress Incontinence

In stress incontinence, a variable amount of urine escapes suddenly with an increase in intra-abdominal pressure (for example, when the abdomen tenses). Not much urine is lost unless the condition is severe. This type of urinary loss is predictable. People with stress incontinence do not usually have urinary frequency or urgency (a gradual or sudden compelling need to urinate) or need to wake up at night to go to the bathroom (nocturia).

Urge Incontinence

With urge incontinence or overactive bladder, there is uncontrolled urine loss associated with a strong need to go to the bathroom. While the urge to urinate may be gradual, it is often sudden and rapid and occurs without any warning. Urge incontinence cannot be prevented. In this situation, the entire contents of the bladder are lost rather than a few drops of urine. People with overactive bladder feel the intense need to urinate and are unable to hold back the urine. Other symptoms include frequent urination, urgency, and nocturia. Some situations trigger urge incontinence, including turning a key in the door, washing dishes, or hearing running water. Urge incontinence also may be triggered by drinking too much water or drinking coffee, tea, or alcohol.

Mixed Incontinence

This type of incontinence includes the symptoms of stress incontinence and urge incontinence together. With mixed incontinence, the problem is that the bladder is overactive (the urge to urinate is strong and frequent) and the urethra may be underactive (the urine cannot be held back even without the urge to urinate). Those with mixed incontinence experience mild to moderate urine loss with physical activities (stress incontinence). At other times, they experience sudden urine loss without any warning (urge incontinence). Urinary frequency, urgency, and nocturia also occur. Most of the time, the symptoms blend together, and the first goal of treatment is to address the part of the symptom complex that is most distressing.

Overflow Incontinence

In overflow incontinence, the urine overflows from the bladder because the pressure inside the bladder is higher than the urethral sphincter closure pressure. In this condition, there may be no strong urge to urinate, the bladder never empties, and small amounts of urine leak continuously. Overflow incontinence is prevalent in older men with an enlarged prostate and is less common in women. Because the bladder is too full, the bladder empties even though the bladder muscle may not contract.

Overfilling of the bladder can occur if the outlet from the bladder is obstructed so urine backs up in the bladder or if the bladder muscle does not work so urine is not completely expelled from the bladder during urination. People with overflow incontinence may feel like the bladder does not empty completely, their urine flows out slowly, and/or that urine dribbles out after voiding. Symptoms of overflow incontinence may be similar to those of mixed incontinence. A small amount of urine may be lost when intra-abdominal pressure is increased. There may be symptoms of frequency and urgency as the detrusor muscle attempts to expel urine.

Functional Incontinence

People with functional incontinence have relatively normal bladder function and control. Other conditions separate from the bladder affect their ability to reach the toilet in time.

A complete medical history, which includes a voiding diary and incontinence questionnaire, physical examination, and one or more diagnostic procedures, helps the physician determine the type of urinary incontinence and an appropriate treatment plan.

Medical History

By asking questions, a physician can better understand a patient's particular situation and type of incontinence. Questions focus on bowel habits, patterns of urination and leakage (for example, when, how often, and how severe), and whether there is pain, discomfort, or straining when voiding. The doctor will also want to know whether or not the patient has had any illnesses, pelvic surgeries, and pregnancies, as well as what medications he or she is currently taking. In certain situations (such as an elderly person with dementia), a mental status evaluation and assessment of social and environmental factors may be performed.

Physical Examination

A physical examination includes tests of the nervous system and examination of the abdomen, rectum, genitals, and pelvis. The cough stress test, in which the patient coughs forcefully while the physician observes the urethra, allows observation of urine loss. Instantaneous leakage with coughing suggests a diagnosis of stress incontinence. Leakage that is delayed or persistent after the cough suggests urge incontinence. The physical examination also helps the physician identify medical conditions that may be the cause of incontinence. For instance, poor reflexes or sensory responses may indicate a neurological disorder.

Voiding Diary

The physician may ask the patient to keep a bladder diary (or record) of his or her bladder activity. In the voiding diary, the patient records fluid intake, fluid output, and any episodes of incontinence. This contributes valuable information to help the physician understand the patient's situation.

Pad Test

The pad test is an objective test that determines whether the fluid loss is in fact urine. The patient may be asked to take a medication that colors the urine. As fluid leaks onto the pad, it changes color indicating that the fluid lost is urine. The pad test may be performed during one hour or a 24-hour period. The pads may be weighed before and after use to assess the severity of urine loss (1 gram of increased weight = 1 mL of urine lost).

Urine Studies

• Because bladder infection, or urinary tract infection, can cause symptoms similar to urge incontinence, the doctor may obtain a sample of urine for urinalysis and urine culture to see if any bacteria are present.
• Bladder cancer such as carcinoma in situ of the urinary bladder (cancer that is confined to the bladder lining cells in which it originated and has not spread to other tissues) can cause symptoms of urinary frequency and urgency, so a urine sample may be examined for cancer cells (cytology).
• A study of the urine called a chemistry 7 profile may be performed to test for poor kidney (renal) function.

Post-Void Residual Volume

The measurement of post-void residual (PVR) volume is a part of the basic evaluation for urinary incontinence. The PVR volume is the amount of fluid left in the bladder after urination. If the PVR volume is high, the bladder may not be contracting correctly or the outlet (bladder neck or urethra) may be obstructed. To determine the PVR urine volume, either a bladder ultrasound or a urethral catheter may be used. With ultrasound, a wand-like device is placed over the abdomen. The device sends sound waves through the pelvic area. A computer transforms the waves into an image so the doctor can see how full or empty it is. A catheter is a thin tube inserted through the urethra. It is used to empty any remaining urine from the bladder.

The initial attempt to urinate should be evaluated for hesitancy, straining, or interrupted flow. A PVR volume of less than 50 mL indicates adequate bladder emptying. Measurements of 100 mL to 200 mL or higher, on more than one occasion, represent inadequate bladder emptying.

Cough Stress Test

A critical part of the pelvic examination is direct observation of urine loss using the cough stress test. The bladder is filled through a catheter with sterile fluid until it is at least half full (250 mL). The patient is instructed to bear down and tense the abdominal muscles while holding his or her breath (known as a Valsalva maneuver) or simply cough. Leakage of fluid during the Valsalva maneuver or cough indicates a positive test result.

Q-tip Test

This test is performed by inserting a sterile lubricated cotton swab (Q-tip) into the female urethra. The cotton swab is gently passed into the bladder and then slowly pulled back until the neck of the cotton swab is fit snugly against the outflow tract of the bladder (the bladder neck). The patient is then asked to bear down (Valsalva maneuver) or simply contract the abdominal muscles. Excessive motion of the urethra and bladder neck (hypermobility) with straining is noted as the movement of the Q-tip and may correlate with stress incontinence.

Urodynamic Studies

Urodynamics uses physical measurements such as urine pressure and flow rate as well as clinical assessment. These studies measure the pressure in the bladder at rest and while filling. These studies range from simple observation to precise measurements using specialized equipment.

• Uroflowmetry
  • Uroflowmetry, or uroflow, is used to identify abnormal voiding patterns. This is a noninvasive test to measure the volume of urine voided (urinated), the velocity or speed of the urination, and its duration.
  • This is used as a screening test to evaluate bladder outlet obstruction. Consistently low flow rates generally indicate a bladder outlet obstruction but also may indicate decreased contraction of the bladder wall muscle. To properly diagnose bladder outlet obstruction, pressure-flow studies are performed.
• Cystometry
  • Cystometry is a procedure that measures the capacity and pressure changes of the bladder as it fills and empties. The evaluation determines the presence or absence of detrusor overactivity (or instability).
  • Simple cystometry detects abnormal detrusor compliance (a bladder that does not expand enough).
  • The multichannel, or subtracted, cystometrogram simultaneously measures intra-abdominal, total bladder, and true detrusor (muscle) pressures. With this technique, the doctor can distinguish between involuntary detrusor (bladder) contractions and increased intra-abdominal pressure.
  • The voiding cystometrogram, or pressure-flow study, detects outlet obstruction in patients who can urinate at will. The voiding cystometrogram is the only test able to provide information about bladder contractility and the extent of a bladder outlet obstruction.
  • A filling cystometrogram assesses the amount the bladder can hold (bladder capacity), how much the bladder can expand (bladder compliance) and the presence of contractions. This test may be performed using either gas or liquid to fill the bladder through a catheter (a small tube inserted into the bladder through the urethra).

Assessment of Urethral Function

• Urethral pressure profilometry is a test that measures the resting and dynamic pressures in the urethra.
• Abdominal leak point pressure (ALPP)
  • Determining the ALPP, which is also known as Valsalva leak point pressure, is important. First, the bladder is filled with fluid by a catheter. Then, the patient is instructed to bear down (Valsalva maneuver) in gradients (mild, moderate, severe) to demonstrate leakage. The lowest amount of pressure required to generate leakage is recorded as ALPP.
  • By determining ALPP, the doctor can determine whether stress urinary incontinence is due to urethral hypermobility, intrinsic sphincter deficiency, or both in combination.
  • Cough leak point pressure (CLPP) is determined similarly.

Cystogram

A cystogram is a radiograph (X-ray image) of the bladder. In this procedure, a solution containing a radioisotope (contrast media) is instilled into the bladder via a catheter until the bladder is full (or the patient indicates that the bladder feels full). X-ray images are then taken of the bladder while full and during or after urination.

A cystogram helps to confirm a diagnosis of stress incontinence, the degree of mobility of the urethra, and the presence of cystocele (a condition occurring in women in which the wall between the bladder and vagina weakens and allows the bladder to droop into the vagina, which may cause discomfort and problems with emptying the bladder). These radiographs (X-rays) also may demonstrate problems with the sphincter muscle (intrinsic sphincter deficiency). The presence of an abnormal connection between the bladder and the vagina (vesicovaginal fistula) also may be documented in this fashion.

Ultrasound

Ultrasound is a noninvasive method that can show bladder volumes of urine to help determine bladder urinary retention and/or bladder residual volumes after urination.

Electromyography

Electromyography is a test to evaluate potential nerve damage. This test measures the muscle activity in the urethral sphincter using sensors placed on the skin near the urethra and rectum. Sometimes the sensors are on the urethral or rectal catheter. Muscle activity is recorded on a machine. The patterns of the impulses will show whether the messages sent to the bladder and urethra are coordinated correctly.

Cystoscopy

Cystoscopy, an examination of the inside of the bladder, also is indicated for patients experiencing persistent urinary symptoms or blood in the urine (hematuria). The cystoscope has lenses like a telescope or microscope which allow the doctor to focus on the inner surfaces of the urinary tract. Bladder abnormalities, such as a tumor, stones, and cancer (carcinoma in situ) can be diagnosed with cystoscopy. Biopsies (small tissue samplings) can be done via cystoscopy for diagnosis of areas that may appear abnormal. Urethroscopy can be performed to assess the structure and function of the urethral sphincter mechanism.

Urinary incontinence is an underdiagnosed and underreported medical problem that is estimated to affect up to 13 million people in the United States, predominantly women. This includes 10%-35% of adults and 50%-84% of residents in nursing homes. It has also been estimated that most (50%-70%) women with urinary incontinence fail to seek appropriate treatment for the condition because of the social stigma. People with incontinence often live with this condition for six to nine years before seeking medical therapy. Living with urinary incontinence puts people at risk for rashes, sores, and skin and urinary tract infections. Effective treatments for this common problem are available in many cases.

Dietary Measures

Some foods can worsen symptoms of urinary frequency and urge incontinence. Changes in diet can help improve some people's symptoms. Monitoring the diet often requires reading food labels and avoiding foods and drinks that contain stimulants. Stimulants worsen the symptoms of urinary urgency and frequency.

Foods

• Foods that contain heavy or hot spices can contribute to urge incontinence by irritating the bladder. Some examples of hot spices include curry, chili pepper, cayenne pepper, and dry mustard.
• A second food group that may worsen symptoms is citrus fruit. Fruits and juices that are acidic can aggravate urge incontinence. Examples of fruits that have significant acidity include grapefruits, oranges, limes, and lemons.
• A third food group that may worsen urinary bladder incontinence is chocolate-containing sweets. Chocolate snacks and treats contain caffeine, which is a bladder-irritating agent. Excessive intake of chocolate may worsen pre-existing bladder symptoms.

Drinks

• The quantity and type of drinks consumed can affect urinary symptoms.
• Drinking too much water can worsen pre-existing bladder symptoms. The exact amount of fluid needed depends on a person's lean body mass and so varies from person to person.
• Many drinks contain caffeine. Caffeine-containing products produce excessive urine and worsen symptoms of urinary frequency and urgency. Caffeine-containing products include coffee, tea, hot chocolate, and colas. Chocolate milk and many over-the-counter medications also contain caffeine. Even decaffeinated coffee contains a small amount of caffeine. If an affected person consumes a large amount of caffeine, he or she should slowly decrease the amount of caffeine to avoid withdrawal symptoms such as headaches and depression.
• Drinking carbonated beverages, citrus fruit drinks, and acidic juices may worsen pre-existing voiding or urge symptoms.
• Artificial sweeteners may contribute to urge incontinence.

Anti-incontinence exercises are designed to strengthen the pelvic floor muscles (the muscles that hold the bladder in place). These muscles are also called the levator ani muscles. They are named levator muscles because they hold (elevate) the pelvic organs in their proper place. When the levator muscles weaken, the pelvic organs move out of their normal place (prolapse), and stress incontinence results. Physical therapy is usually the first step to treating stress incontinence caused by weakened pelvic muscles. If aggressive physical therapy does not work, surgery may be necessary.

There are special exercises to strengthen the pelvic muscles. Exercises can be done alone or with vaginal cones, biofeedback therapy, or electrical stimulation. In general, exercise is a safe and effective treatment that should be used first to treat urge and mixed incontinence. These exercises must be performed correctly to be effective; if the patient is using abdominal muscles or contracting the buttocks, these exercises are being performed improperly. If individuals have difficulty identifying the levator muscles, biofeedback therapy can help. For some people, electrical stimulation further enhances pelvic muscle rehabilitation therapy.

Pelvic Floor Exercises

The first step in pelvic muscle rehabilitation is to establish a better awareness of the levator muscle function. Pelvic floor exercises, sometimes called Kegel exercises, are a rehabilitation technique used to tighten and tone the pelvic floor muscles that have become weak over time. These exercises strengthen the sphincter muscle to prevent urine from leaking out due to stress incontinence. These exercises can also strengthen the pelvic floor muscles to prevent pelvic prolapse (improper movement of pelvic organs). Kegel exercises can also eliminate urge incontinence. Contracting the urinary sphincter muscle makes the bladder muscle relax. Pelvic floor muscle rehabilitation may be used to reprogram the urinary bladder to decrease the frequency of incontinence episodes.

• People who tend to benefit most from pelvic floor exercises alone are younger women who can identify the levator muscles accurately. Older adults who may have difficulty recognizing the right muscles need biofeedback or electrical stimulation in addition. Pelvic floor exercises work best in mild cases of stress incontinence with urethral hypermobility but not intrinsic sphincter deficiency. These rehabilitation exercises may be used for urge incontinence as well as mixed incontinence. They also benefit men who develop urinary incontinence following prostate surgery.
• Pelvic floor muscle exercises are performed by drawing in or lifting the levator ani muscles. This movement is done normally to control urination or defecation. Individuals should avoid contracting the abdominal, buttock, or inner thigh muscles. The following techniques can be used to learn how to squeeze these muscles: (1) trying to stop the flow of urine while in the middle of going to the bathroom; (2) squeezing the anal sphincter as if to prevent passing gas; and (3) tightening the muscles around the vagina (for example, as during sexual intercourse).
• For the treatment of stress incontinence, beginners should perform the squeezing exercise five times, holding each squeeze for a count of five (a person may have to start with a count of two or three). This should be done one time every hour while awake. These exercises can be performed while driving, reading, or watching television. After practice, a person may be able to hold each contraction for at least 10 seconds, and then relax for 10 seconds. The pelvic floor exercises must be performed every day for at least three to four months to be effective. If an individual does not notice an improvement after four to six months, he or she may need additional help, such as electrical stimulation.
• For urge incontinence, pelvic floor muscle exercises are used to retrain the bladder. When one contracts the urethral sphincter, the bladder automatically relaxes, so the urge to urinate eventually goes away. Strong contractions of the pelvic floor muscles suppress bladder contractions. Whenever an individual feels urinary urgency, they can try to stop the feeling by strongly contracting the pelvic floor muscles. These steps may give the person more time to walk slowly to the bathroom with urinary control.
• This technique may be used for stress and urge symptoms (mixed incontinence).
• A person should be sure that he or she is not contracting their abdominal muscles when performing these drills. This can worsen urinary incontinence.

• An individual should practice contracting the levator ani muscles immediately before and during situations when leakage may occur. This is known as the guarding reflex. Involuntary urine loss is stopped by tightening the urinary sphincter at the appropriate time (for example just as one is about to sneeze). By making this muscle squeeze a habit, one can develop a protective mechanism against stress and urge incontinence.
• Success in reducing urinary incontinence has been reported to range from 56%-95%. Pelvic floor exercises are effective, even after multiple anti-incontinence surgeries.

Vaginal Weights

Vaginal weight training can be used to strengthen the pelvic floor muscles and treat stress incontinence in women. Vaginal weights look like tampons and are used to enhance pelvic floor muscle exercises. Shaped like a small cone, vaginal weights are available in a set of five, with increasing weights (for example, 20 g, 32.5 g, 45 g, 60 g, and 75 g). As part of a progressive resistive exercise program, a single weight is inserted into the vagina and held in place by tightening the muscles around the vagina for as long as 15 minutes. As the levator ani muscles become stronger, the exercise duration may be increased to 30 minutes.

• This exercise is performed twice daily. With the weight in place, a woman can feel the appropriate muscles working so she knows that she is contracting the pelvic floor muscles. The contraction needed to keep the weight in place within the vagina increases the strength of the pelvic floor muscles.
• The best results are achieved when standard pelvic muscle exercises (Kegel exercises) are performed with intravaginal weights. In premenopausal women with stress incontinence, the rate of cure or improvement is approximately 70%-80% after four to six weeks of treatment. Vaginal weight training also may be useful for postmenopausal women with stress incontinence; however, vaginal weights are not effective in the treatment of pelvic organ prolapse.

Biofeedback

Biofeedback therapy uses an electronic device to help individuals having difficulty identifying the levator ani muscles. Biofeedback therapy is recommended for the treatment of stress incontinence, urge incontinence, and mixed incontinence. Biofeedback therapy uses a computer and electronic instruments to let an individual know when the pelvic muscles are contracting.

• Biofeedback is intensive therapy, with weekly sessions performed in an office or a hospital by a trained professional, and it often is followed by pelvic floor muscle exercises at home. During biofeedback therapy, a special tampon-shaped sensor is inserted in the vagina or rectum and a second sensor is placed on the abdomen. These sensors detect electrical signals from the pelvic floor muscles. The patient will contract and relax the pelvic floor muscles when the specialist tells him or her to do so. The electric signals from the pelvic floor muscles are displayed on a computer screen.
• With biofeedback, the patient knows that he or she is strengthening the pelvic muscles that need rehabilitation. The benefit of biofeedback therapy is that it provides minute-by-minute feedback on the quality and intensity of one's pelvic floor contraction.
• Studies on biofeedback combined with pelvic floor exercises show a 54%-87% improvement with incontinence. Biofeedback also has been used successfully in the treatment of men with urge incontinence and intermittent stress incontinence after prostate surgery.
• Medical studies have demonstrated significant improvement in urinary incontinence in women with neurologic disease and in the older population when a combination of biofeedback and bladder training is used.
• Female urinary incontinence is reduced more with biofeedback than with pelvic muscle exercises alone.

Electrical Stimulation

Electrical stimulation is a more sophisticated form of biofeedback used for pelvic floor muscle rehabilitation. This treatment involves stimulation of levator ani muscles using painless electric currents. When the pelvic floor muscles are stimulated with these small electrical currents, the levator ani muscles, and urinary sphincter contract, and bladder contraction is inhibited. Similar to biofeedback, electrical stimulation can be performed at the office or at home. Electrical stimulation can be used with biofeedback or pelvic floor muscle exercises.

• Electrical stimulation therapy requires similar types of tampon-like probes and equipment as those used for biofeedback. This form of muscle rehabilitation is similar to biofeedback therapy, except small electric currents are used to directly stimulate the pelvic floor muscles.
• As in biofeedback, pelvic floor muscle electrical stimulation has been shown to be effective in treating female stress incontinence, as well as urge and mixed incontinence. Electrical stimulation may be the most beneficial in women with stress incontinence and very weak or damaged pelvic floor muscles. A program of electrical stimulation helps these weakened pelvic muscles contract so they can become stronger. For women with urge incontinence, electrical stimulation may help the bladder relax and prevent it from contracting involuntarily.
• Research indicates that pelvic floor electrical stimulation can reduce urinary incontinence significantly in women with stress incontinence and may be effective in men and women with urge and mixed incontinence. Urge incontinence that is caused by neurologic diseases may be decreased with this therapy. Electrical stimulation appears to be the most effective when combined with pelvic floor exercises. The rate of cure or improvement with electrical stimulation ranges from 54%-77%; however, significant benefit occurs after a minimum of four weeks, and the individual must continue pelvic floor exercises after the treatment.

Bladder Training

Bladder training involves relearning how to urinate. This method of rehabilitation is usually used for active women with urge incontinence and sensory urge symptoms known as urgency. Many people who have urge incontinence sense that they have to urinate, but their bladder is not full and they do not urinate much when they return to the bathroom frequently. This means that, although their bladder is not full, it is signaling for them to void.

• Bladder training generally consists of self-education, using the bathroom according to a schedule, consciously delaying going to the bathroom, and positive reinforcement. Although bladder training is used primarily for symptoms of urgency and findings of urge incontinence, this program may be used for simple stress incontinence and mixed incontinence. For bladder training to work, a person must resist or inhibit the feeling of urgency and wait to go to the bathroom. An individual must urinate according to a scheduled timetable rather than every time he or she has the feeling that they need to urinate.
• This plan incorporates dietary changes such as adjusting how much one drinks and avoiding dietary stimulants. In addition, there are distraction and relaxation techniques to delay voiding to help expand the urinary bladder. By using these strategies, an individual can train the bladder to accommodate more stored urine.
  • The initial goal is set according to a person's current voiding habits and is not followed at night. Whatever a person's voiding pattern is, the first goal for the time between trips to the bathroom (voiding interval) may be increased by 15 to 30 minutes. As the bladder becomes accustomed to this delay in voiding, the interval between voids is increased. The ultimate goal is usually two to three hours between voids, and it may be set further apart if desired.
  • Another method of bladder training is to maintain the prearranged schedule and ignore the unscheduled voids. In this method, regardless of whether an individual makes an unscheduled trip to the bathroom, he or she still has to maintain the prearranged voiding times and go to the bathroom as scheduled. This program must be continued for several months.
• Another method of bladder training uses ultrasound to prove to that the bladder is not full even though one feels the need to urinate. A bladder scanner is a portable ultrasound machine that measures the amount of urine present in the bladder. With this method, a person can void when their bladder fills to a certain volume visible on ultrasound rather than when he or she feels the need to go to the bathroom. Each time the person feels the need to void, he or she checks their bladder using the scanner to see how much urine is being stored. If the bladder is shown to be empty, then the person should ignore that sensation.
• Bladder training has been used primarily to manage symptoms of urgency and the findings of urge incontinence; however, it also may be used for stress and mixed incontinence. With bladder training, the cure rate for mixed incontinence is reported to be 12%, while the improvement rate was 75% after six months.

Anti-Incontinence Products

Anti-incontinence products, such as pads, are not a cure for urinary incontinence; however, using these pads and other devices to contain urine loss and maintain skin integrity is extremely useful in selected cases. Available in both disposable and reusable forms, absorbent products are a temporary way to stay dry until a more permanent solution becomes available.

• One should not use absorbent products instead of treating the underlying cause of incontinence. It is important to work with the doctor to decrease or eliminate urinary incontinence. Also, improper use of absorbent products may lead to skin injury (breakdown) and UTI.
• Absorbent products used include underpads, pant liners (shields and guards), adult diapers (briefs), a variety of washable pants, and disposable pad systems, or combinations of these products.
• Unlike sanitary napkins, these absorbent products are specially designed to trap urine, minimize odor, and keep an individual dry. There are different types of products with varying degrees of absorbency.
• For occasional minimal urine loss, panty shields (small absorbent inserts) may be used. For light incontinence, guards (close-fitting pads) may be more appropriate. Absorbent guards are attached to the underwear and can be worn under usual clothing. Adult undergarments (full-length pads) are bulkier and more absorbent than guards. They may be held in place by waist straps or snug underwear. Adult briefs are the bulkiest type of protection, they offer the highest level of absorbency, and they are secured in place with self-adhesive tape. Absorbent bed pads also are available to protect the bed sheets and mattresses at night. They are available in different sizes and absorbencies.
• A pessary is a plastic device that is inserted into the vagina. It may help prevent urine leakage by supporting the neck of the bladder in cases of stress incontinence.

Urethral Occlusive Devices

Urethral occlusive devices are different for males and females. Female devices are artificial implements that may be inserted into the urethra or placed over the urethral opening to prevent urine from leaking out. Inserts include the Reliance Urinary Control Insert device, while patches include the CapSure and Impress Softpatch devices. Urethral occlusive devices tend to keep people drier; however, they may be more difficult and expensive to use than pads, and those who use them need to understand their potential problems if not used correctly. Urethral occlusive devices must be removed after several hours or after each voiding. Unlike pads, these devices may be more difficult to change and insert correctly.

Male devices are usually clamps that constrict the penis and decrease the amount of urine leakage. They are usually used in severe incontinence that is resistant to other treatments and is variably effective. Males using these devices should not have mental disabilities that would allow them to "forget" and leave a clamp on for extended times as this may cause penile damage.

Urinary Incontinence Catheters

A catheter is a long, thin tube inserted up the urethra or through a hole in the abdominal wall into the bladder to drain urine (suprapubic catheter). Draining the bladder this way has been used to treat incontinence for many years. Bladder catheterization may be a temporary or a permanent solution for urinary incontinence.

In cases of overflow incontinence resulting from obstruction, some people respond well to temporary continuous Foley catheter drainage. Their bladder capacity returns to normal, and the strength of their bladder (detrusor) muscle improves. This treatment is more likely to benefit people without neurologic injury. It usually takes at least one week of catheter drainage depending on the degree of bladder muscle injury to see the benefits. If the incontinence has not resolved after four weeks, then the bladder is unlikely to recover using catheter drainage alone.

If the underlying cause of the overflow problem is bladder outlet obstruction, normal voiding may return after the obstruction is relieved. If the obstruction cannot be relieved, periodic catheterization is usually the best long-term treatment, although surgery may be required. Sometimes, a permanent catheter may need to be considered.

Different types of bladder catheterization include indwelling (left inside the bladder) urethral catheters, suprapubic tubes, and intermittent self-catheterization.

Indwelling Urethral Catheterization (Foley Catheterization)

Indwelling urethral catheters are commonly known as Foley catheters. Urethral catheters used for extended treatment need to be changed every month. These catheters may be changed at an office, a clinic, or at home by a visiting nurse. All indwelling catheters that stay in the urinary bladder for more than two weeks begin to have bacterial growth. This does not mean that a person will have a bladder infection, but infection is a risk, especially if the catheter is not changed regularly. Foley catheters should not be used for prolonged periods (months or years) because of the risks of UTI, and a suprapubic tube may be recommended. Urethral catheters are not used to treat urge incontinence. Other complications associated with indwelling urethral catheters include encrustation of the catheter, bladder spasms resulting in urinary leakage, blood in the urine (hematuria), and inflammation of the urethra (urethritis). More severe complications include the formation of bladder stones, the development of a severe skin infection around the urethra (periurethral abscess), kidney (renal) damage, and damage to the urethra (urethral erosion).

Most doctors use a suprapubic catheter for long-term catheterization and only use Foley catheters in the following situations:

• As comfort measures for terminally ill patients
• To avoid contamination or to promote the healing of severe pressure sores
• In case of urethral obstruction that prevents bladder emptying and cannot be operated on
• In individuals who are severely impaired for whom alternative interventions are not an option
• When an individual lives alone and a caregiver is unavailable to provide other supportive measures
• For acutely ill people in whom accurate fluid balance must be monitored
• For severely impaired people for whom bed and clothing changes are painful or disruptive

Suprapubic Catheterization

A suprapubic catheter is a tube surgically inserted into the bladder through an incision made in the abdomen (above the pubic bone). This type of catheter is used for long-term catheterization, and when the tube is removed, the hole in the abdomen seals up within one to two days. The most common use of a suprapubic catheter is in people with spinal cord injuries and a malfunctioning bladder. As in the urethral catheter, a doctor or nurse must change the suprapubic tube at least once a month on a regular basis.

The suprapubic catheter has advantages compared to the urethral catheter: The risk of urethral damage is eliminated, a suprapubic tube is more patient-friendly, bladder spasms occur less often because the suprapubic catheter does not irritate the outflow area of the bladder, and suprapubic tubes are more sanitary because the tube is away from the urethra/anal area (perineum). Suprapubic tubes may cause fewer urinary tract infections than standard urethral catheters.

Suprapubic catheters are not used in people with chronically unstable bladders or intrinsic sphincter deficiency because involuntary urine loss is not prevented. A suprapubic tube does not prevent bladder spasms from occurring in unstable bladders nor does it improve the urethral closure mechanism in an incompetent urethra. Potential problems with long-term suprapubic catheterization are similar to those associated with indwelling urethral catheters, including leakage around the catheter, bladder stone formation, UTI, and catheter obstruction. Other potential complications include skin infections (cellulitis) around the tube site.

Intermittent Catheterization

With intermittent catheterization or self-catheterization, the bladder is drained at timed intervals rather than continuously. In order to do intermittent catheterization, a person has to be able to use their hands and arms; however, a caregiver or health professional can perform intermittent catheterization for a person who is physically or mentally impaired. Intermittent catheterization works best for people who are motivated and have intact physical and cognitive abilities. Of all three possible options (urethral catheter, suprapubic tube, and intermittent catheterization), intermittent catheterization is the best way to empty the bladder for motivated individuals who are not physically handicapped or mentally impaired.

The bladder must be drained on a regular basis, either based on a timed interval (for example, on awakening, every three to six hours during the day, and before bed) or based on bladder volume. Advantages of intermittent catheterization include independence and freedom from an indwelling catheter and bags. Also, sexual relations are uncomplicated by intermittent catheterization. Potential complications of intermittent catheterization include bladder infection, urethral trauma, urethral inflammation, and stricture formation. However, studies have demonstrated that long-term use of intermittent catheterization appears to have fewer complications compared to indwelling catheterization (urethral catheter or suprapubic tube), with respect to urinary tract infections, renal failure, and the development of stones within the bladder or kidneys.

Stress incontinence results from a weak urinary sphincter. Medications that strengthen urethral contraction include sympathomimetic drugs (such as pseudoephedrine hydrochloride, known as Sudafed), estrogen, and midodrine.

Medical conditions that cause urge incontinence may be neurologic or non-neurologic. The urethra is healthy, but the bladder is hyperactive or overactive. Pharmacologic therapy for stress incontinence and an overactive bladder may be most effective when combined with a pelvic exercise regimen.

The four main categories of drugs used to treat urge incontinence include the following:

Antispasmodic Drugs

• Oxybutynin chloride (Ditropan)
• Lavoxate (Urispas)

Tricyclic Antidepressant Agents

• Imipramine
• Amitriptyline

Anticholinergic Drugs

• Dicyclomine hydrochloride (Bentyl)
• Hyoscyamine sulfate (Levsin, Cystospaz)
• Propantheline (Pro-Banthine)
• Darifenacin (Enablex)
• Solifenacin succinate (VESIcare)
• Tolterodine (Detrol)
• Trospium (Sanctura)
• Fesoteridine (Toviaz)

Anticholinergic Drugs

• Mirabegron (Myrbetriq)

Patients should not use anticholinergic drugs if they have narrow-angle glaucoma, urinary retention, bowel obstruction, ulcerative colitis, myasthenia gravis, or severe heart diseases. These medications can cause drowsiness. Anticholinergic drugs should not be taken with alcohol, sedatives, or hypnotic drugs.

When a single drug treatment does not work, a combination therapy such as oxybutynin (Ditropan) and imipramine may be used, but the risk of side effects should be reviewed with the physician.

In some cases, a medication called desmopressin (DDAVP) can be used to decrease nighttime urine production and help reduce nocturia.

Urinary Incontinence Surgical Treatment

Anterior Vaginal Repair

This procedure's primary purpose is to repair a cystocele in women (bladder descended into the vagina). A vaginal incision is used for vaginal repair; a vaginal or abdominal incision is used for the variation called paravaginal repair. The purpose of the procedure is to do two things: reduce the cystocele and reinforce the tissues that support the bladder and urethra.

This procedure was first described in 1913 and today is most commonly used when cystocele is an issue in addition to incontinence. Other procedures (see the following) have had better success rates at curing stress incontinence.

Bladder Neck Suspension

First described in 1959, this type of surgery stabilizes the bladder and urethra. Several different techniques are used and may be referred to as retropubic suspension, transvaginal suspension, and Marshall-Marchetti-Krantz (MMK) and Burch procedures, for example. These techniques elevate the bladder and urethra and are used for stress incontinence.

Generally, the surgeon stitches into the ligaments and tendons that provide support to the pelvic organs, and these stitches are tied to the pelvic bone, for example, to provide support to the bladder and urethra. This can be done either through the vagina with a long needle or with an incision into the abdomen.

The laparoscopic Burch procedure is a newer approach that accomplishes the suspension laparoscopically. Using an endoscope, which goes through the belly button, the abdomen is inflated and the tissue next to the bladder is lifted to reduce the pressure the bladder places on the urethra. The three to four small incisions require just a couple of stitches or surgical tape. The laparoscopic Burch procedure also offers a short hospital stay (one or two days), reduced recovery time and pain, lower cost, and smaller scars.

Sling Procedure

This procedure is most often performed for women with stress incontinence and is rarely used for men. The purpose of the procedure is to repair weakened urethral sphincter muscles by using a sling to compress the sphincter. This prevents urine from leaking when laughing, coughing, or doing other activities that can cause stress incontinence.

The sling is made out of abdominal tissue or synthetic tissue. The tissue is formed into a sort of hammock for the sphincter and is attached to the pubic bone or the front of the abdomen (just above the pubic bone). The technique requires a small abdominal incision and (in women) a vaginal incision.

A more recent advance is the Tension-Free Vaginal Tape Procedure. Also called TVT surgery for short, this variation on the sling procedure uses mesh-like tape under the urethra, which acts like a hammock to provide compression to the urethra sphincter. The TVT procedure requires no sutures and takes just 30 minutes under local or sedation anesthesia. The tape is inserted through small incisions in the abdomen and vaginal wall. The patient may be released the same day as surgery or stay overnight. People undergoing TVT typically have minimal pain and discomfort during and immediately after the procedure but are instructed to avoid sex and strenuous activity for several weeks. Long-term success rates are very good and range from 80%-90%.

Bulking Agent/Collagen Injection

This minor outpatient procedure is used for stress incontinence in men and women when the sphincter controlling the outflow of urine is weakened or incompetent. Done under local anesthesia, collagen or another substance is injected into the area around the urethra. This adds bulk, which better compresses the sphincter. A skin test is required before the procedure to determine if any allergic reaction might occur to the collagen.

The cure rate of this procedure is reported to be somewhat higher for women than men. The collagen used can be absorbed by the body over time, so the procedure may need to be repeated. In addition, other materials exist that work as effectively as collagen and may last longer (silicone-coated beads and Coaptite, or Macroplastique).

Artificial Urinary Sphincter

Performed most often for men and only rarely for women, this procedure creates a functioning artificial urinary sphincter using a cuff, tubing, and a pump. The cuff goes around the sphincter and is connected to a pump, which is placed in the scrotum for men and the labia for women. Squeezing the pump causes the pressure to be released in the cuff, thus allowing urination to begin.

This procedure is generally considered only after other treatments have failed, and it is most commonly done for men after prostate surgery. Because of where the pump is placed, activities such as bike riding may not be recommended.

Expectations

Each procedure has published cure rates that can range between 75%-95%. If one is considering surgery for stress incontinence, one should ask the surgeon what his or her success rates have been for the proposed surgery. If surgery does not cure incontinence, it often does improve symptoms significantly.

Several factors can influence the success of any surgical procedure, such as medical conditions like diabetes, other genital or urinary problems, or previous surgical failures. The patient should be prepared to undergo a thorough physical examination and another test to determine not only the cause of urinary incontinence but also to discover other factors that may influence the success of a procedure.

Urinary incontinence is a treatable condition with an excellent prognosis. Medical and surgical treatments for urinary incontinence can have very high cure rates. The choice of treatment depends upon the underlying cause for the incontinence and in some cases depends upon the willingness of the patient to participate in the treatment process (for options such as pelvic floor exercises and biofeedback).

It is not always possible to prevent urinary incontinence, and it is generally only preventable to the extent that its underlying causes are preventable. It can be possible for some people to reduce the degree of incontinence by dietary modifications, as discussed previously. Control of underlying diseases such as hypertension or diabetes that may predispose to incontinence can also help prevent its development. Maintaining a healthy weight and avoidance of tobacco can also help prevent some cases of incontinence.