Bladder Control Problems

People who have bladder control problems have trouble stopping the flow of urine from the bladder. They are said to have urinary incontinence. Incontinence is the uncontrollable leaking of urine from the bladder. Although urinary incontinence is a common problem, it is never normal.

Incontinence is both a health problem and a social problem.

• Most people with incontinence suffer social embarrassment. Many become depressed and limit their activities away from home, often becoming socially isolated and lonely.

Why can I not hold my pee?

• Physical conditions linked to incontinence include infection, skin irritations, infections, falls, fractures, and sleep disturbances.
• Many people with incontinence are too embarrassed to talk to their physician about it. They "cope" or "just learn to live with it." This is changing gradually as people realize that help is available.
• A significant percentage of elderly people who live at home and in nursing homes are affected by urinary incontinence. Incontinence is a major reason for people going into nursing homes. However, it is not an inevitable consequence of aging.

Here is a brief description of the urinary system and the process of urination (micturition):

• The urinary system is composed of the kidneys, ureters, bladder, and urethra.
• The kidneys filter water and waste from the blood. They excrete urine, which passes via the ureters to the bladder. The bladder stores urine until you urinate.
• The kidneys typically excrete about 1-1½ quarts (1,000-1,500 mL) of urine in 24 hours.
• The bladder is a hollow, muscular organ. The bladder wall includes a smooth muscle known as the detrusor muscle. The bladder's size, shape, position, and relation to other organs vary with age and the amount of urine stored.
• The urethra is a narrow tube connecting the bladder with the opening when urine comes out of the body. Surrounding the urethra are sphincter muscles, which partly control the release of urine from the bladder and from the body.
• Although the bladder is able to hold about 600 mL of urine, the urge to urinate develops once the bladder contains 300 mL. As the bladder starts to stretch, nerves in the bladder and surrounding area send messages to the brain, via the spinal cord, telling it that the bladder is filling. The brain sends back the urge to urinate.
• Although you normally make the choice when to urinate, once you decide to do so the nervous system takes over and the process becomes automatic. The detrusor contracts and the sphincters relax to allow urine to flow. When the bladder is empty, the sphincters contract and the detrusor relaxes.
• You can stop or hold off urination by contracting (squeezing) the external sphincter, which causes relaxation of the detrusor. Urine is stored, and the urge to urinate is temporarily stopped.
• As you continue to produce urine, however, the messages to and from the brain get more urgent, and the urge to urinate becomes even stronger.

Urinary incontinence is believed to affect at least 13 million people in the United States.

• That number may even be higher, and it is expected to increase sharply with the aging of the baby boomers.
• Incontinence affects both sexes and all ages but is most common in older people.
• Incontinence is much more common in women than in men. Most men with incontinence are older and suffer from some type of prostate disease.

How can I regain bladder control?

The good news about urinary incontinence is that it is treatable. A great majority of people with bladder control problems can be helped by treatments that are available now. If incontinence cannot be cured, it can at least be controlled.

Incontinence is a symptom with a wide variety of causes. The most common causes include the following:

• Urinary tract infection (UTI)
• The side effects of medication: Examples include alpha-blockers, calcium channel blockers, antidepressants, antihistamines, sedatives, sleeping pills, narcotics, caffeine-containing preparations, and water pills (diuretics). Occasionally, the medicines used to treat some forms of incontinence can also worsen the incontinence if not prescribed correctly.
• Impacted stool: Stool becomes so tightly packed in the lower intestine and rectum that a bowel movement becomes very difficult or impossible.
• Weakness of muscles in the bladder and surrounding area: This can have a variety of causes.
• Overactive bladder
• Bladder irritation
• The blocked urethra is usually due to an enlarged prostate (in men)
• Prior prostate, bladder, or pelvic surgery
• Nerve damage or neurological diseases (spinal cord injury, stroke, etc.)

Many of the causes are temporary, such as urinary tract infections. The incontinence improves or goes away completely when the underlying condition is treated. Others are longer lasting, but incontinence can usually be treated.

Risk factors: Underlying causes or contributors to urinary incontinence include the following:

• Smoking: The connection with incontinence is not completely clear, but smoking is known to irritate the bladder in many people.
• Obesity: Excess body fat can reduce muscle tone, including the muscles used to control urination.
• Chronic constipation: Regular straining to have a bowel movement can weaken the muscles that control urination.
• Diabetes: Diabetes can damage nerves and interfere with sensation.
• Spinal cord injury: Signals between the bladder and the brain travel via the spinal cord. Damage to the cord can interrupt those signals, disrupting bladder function.
• Disability or impaired mobility: People who have diseases such as arthritis, which make walking painful or slow, may have "accidents" before they can reach a toilet. Similarly, people who are permanently or temporarily confined to a bed or a wheelchair often have problems because of their inability to get to a toilet easily.
• Neurologic disease: Conditions such as stroke, multiple sclerosis, Alzheimer's disease, or Parkinson's disease can cause incontinence. The problem can be a direct result of a disrupted nervous system or an indirect result of restricted movement.
• Surgery or radiation therapy to the pelvis: Incontinence can result from certain surgeries or medical therapies.
• Pregnancy: One-third to one-half of pregnant women have problems controlling their bladder. In most of these women, incontinence stops after delivery. However, 4%-8% of pregnant women experience renewed incontinence after delivery (postpartum). Risk factors for postpartum incontinence include vaginal delivery, the long second stage of labor (the time after the cervix is fully dilated), and having large babies.
• Menopause: Studies have not demonstrated a consistent increase in the risk of incontinence following menopause. The relationship between postmenopausal hormone replacement therapy and incontinence is unclear.
• Hysterectomy: Women who have had a hysterectomy may have incontinence later in life.
• Enlarged prostate: In men with an enlarged prostate, the prostate can block the urethra, causing urine leakage. However, less than 1% of men treated for benign (noncancerous) enlargement of the prostate report incontinence.
• Prostate surgery: Up to 87% of men whose prostate has been removed report problems with incontinence.
• Bladder disease: Certain disorders of the bladder, including bladder cancer, can sometimes cause incontinence.

There are several types of urinary incontinence. Many people have more than one type. A combination of stress and urge incontinence is especially common. Stress and urge incontinence are the most common types.

• Stress incontinence: This occurs when you do anything that strains the muscles around the bladder, such as laughing, coughing, sneezing, bending, or even walking in people. It is caused by weakness or injury to the muscles of the pelvis or the sphincters. The underlying causes include physical changes due to pregnancy, childbirth, or menopause. It is a frequent type of incontinence in women.
• Urge incontinence: This is a sudden uncontrollable desire to urinate regardless of how much urine is in the bladder. It is believed to be caused by inappropriate contractions of the bladder. The term "overactive bladder" has been adopted to describe urge incontinence, detrusor instability, and hypersensitive detrusor. Urgency, frequency, and urination at night (nocturia) are common in people with this condition. This is due to the disruption of signals between the bladder and the brain. Environmental cues, such as running water or putting the key in the front door, may prompt urgency or leakage. It is a frequent type of incontinence in both men and women.
• Mixed incontinence: This is a mixture of stress and urges incontinence.
• Overflow incontinence: This results when you retain urine in your bladder either because your muscle tone is weak or you have some sort of blockage below your bladder. Symptoms include dribbling, urgency, hesitancy, low-force urine stream, straining, and urinating only a small amount despite a sense of urgency. It is a frequent type of incontinence in men.
• Neuropathic incontinence: This results from a problem affecting one or more nerves. Either the detrusor muscle over contracts or the interior sphincter lacks the tension to hold urine in.
• Fistula: This is an abnormal internal connection between organs or structures such as the bladder, ureters, or urethra. This can cause incontinence.
• Traumatic incontinence: This is incontinence that occurs after injury to your pelvis (such as a fracture) or as a complication of surgery.
• Congenital incontinence: This may occur in people born with their bladder or one or both ureters.
• Obstruction to urine flow: This may cause incontinence.

The following seem to have little or nothing to do with causing bladder control problems:

• Problems or delays in toilet training in childhood (However, some evidence links childhood voiding dysfunction with adult voiding dysfunction, that is, incontinence.)
• Having a parent with a bladder control problem

Incontinence is a symptom itself. It is uncontrollable leakage of urine from the bladder. Words used to describe bladder control problems include the following:

• Urgency: The feeling of having to urinate very soon
• Hesitancy: When trying to urinate, difficulty getting a urine stream going
• Frequency: Having to urinate often
• Dysuria: Pain or burning with urination (This is usually associated with a bladder infection.)
• Hematuria: Blood in the urine (red or pinkish urine)
• Nocturia: Urination at night (having to wake up to urinate)
• Dribbling: Continuing to drip or dribble urine after finishing urination
• Straining: Having to squeeze or bear down on the external sphincter to urinate

Some people with incontinence experience the following problems:

• Bedwetting (nocturnal enuresis) can stem from a blockage, nerve problem, or some unknown cause. It is most common in children younger than 3 years of age, but it occurs in 15% of children 3-5 years of age and in 1% of school-aged children. The percentages decrease as children get older.
• Dribbling incontinence occurs immediately after urination. In men, it may result from retained urine in the urethra in front of the sphincter. In women, it may result from retained urine in a urethral diverticulum (a saclike outpouching of the urethral wall).
• Functional incontinence occurs if you are unable to reach the bathroom. You may physically "not make it" or not know you need to urinate because of some mental disability.

If you have a problem with urine leakage or have to get up more than twice in the night to urinate, make an appointment with your healthcare provider. The problem may be caused by a medical condition that can be treated. You owe it to yourself to find out. Most likely you do not have to resign yourself to living with incontinence for the rest of your life.

If you have kept records of urination ("urination diary"), take a copy with you to the appointment. Be prepared to provide a complete list of your medications, including nonprescription drugs, herbs, and supplements.

Your health-care provider will ask questions about your symptoms and the situations in which you experience urine leakage. He or she will also ask you about your medical and surgical history, medications, and habits. A thorough physical exam will include your abdomen, pelvis (women), rectum (men), and nervous system.

You may be referred to a specialist. Physicians who specialize in diagnosing and treating disorders of the urinary tract include urogynecologists and urologists.

A physical exam should be performed. In women, a thorough vaginal and pelvic exam along with a rectal exam should be performed. The quality of the tissue, the degree of prolapse (bladder descent), and the evaluation of masses or tissue support are documented.

In men, an exam of the genitalia with attention to the urethral meatus (opening) and a rectal exam is performed. The character and size of the prostate are evaluated.

Which tests are performed depends on which type(s) of incontinence your healthcare provider suspects. A urine sample will be collected.

• The amount and appearance of the urine will be recorded.
• The chemistry of the urine will be analyzed (urinalysis).
• The urine will be looked at under a microscope to check for infection and other abnormalities.
• The urine will be cultured. A smear of urine is put in a small sterile dish and allowed to sit for a few days. If any bacteria grow on the dish, you probably have a urinary tract infection.

Postvoid residual measurement: This measures how well you are able to empty your bladder when you urinate. This is done for people whose symptoms suggest overflow incontinence. The measurement can be done in either of two ways.

• You will first be asked to urinate normally. In men, a uroflow test is usually obtained to measure the velocity and character of the urinary stream. This can also be done in some women.
• The first technique involves tapping your bladder after urination to see how much urine remains. The tap is done with a thin, soft plastic tube called a catheter. The catheter is inserted into your urethra and up into your bladder, and the urine flows out.
• The second technique uses an ultrasound device to "take a picture" of the bladder. From this picture, the operator can calculate how much urine remains in the bladder.

Blood tests are not usually helpful, but your healthcare provider may perform certain tests to rule out specific medical conditions.

A cotton swab test may be done. This evaluates the urethra for hypermobility. (Many women with stress incontinence have hypermobility.) A well-lubricated, sterile, cotton-tipped applicator is inserted through the urethra into the bladder neck. This is done in a lying-down position.

Urodynamic tests are used to discover how well the muscles of the bladder and sphincter are working. A series of these tests can measure your bladder capacity and how well your sensation reflects that. They can also tell whether your bladder fills and empties in a normal way. This test is often described as an "EKG of the bladder."

Cystoscopy is a technique that allows the doctor to view the inside of the bladder. A thin tube is inserted into your urethra and up into your bladder. This is a very important test for those people who have blood in their urine (hematuria) and for those with significant irritative voiding symptoms, especially in people who smoke.

Many people who have incontinence do not seek treatment because they believe the only treatment available to them is surgery. This is a misconception; treatments for incontinence include behavioral, medical, and surgical approaches.

Generally, behavioral therapies are the first choice; because they are non-invasive and have no side effects, they are the safest. A variety of medical treatments are available. Surgery is usually reserved for people whose problem does not improve with behavioral and medical therapy.

Your overall medical condition, the type of bladder control problem you have, and your lifestyle will all determine which treatments are right for you. Talk to your healthcare provider; together you can come up with a treatment plan that works for you.

Incontinence is never normal. If you have a problem with urine leakage, you should see a medical professional.

While waiting for your appointment, make yourself more comfortable.

• Avoid foods and drinks that may irritate the bladder. These include alcohol, caffeine, carbonated drinks, chocolate, citrus fruits, and acidic fruits and juices.
• Do not drink too much fluid; 6-8 cups a day is adequate, but you may need more if you are exercising, sweating a lot, or the weather is hot. In people with kidney stone disease, voiding at least 2 liters of fluid per day is important. Fluid restriction may lead to stone growth or formation.
• Urinate regularly.
• Do not ignore the urge to urinate or to have a bowel movement.
• If you are overweight, try to lose weight and reach a healthier weight.
• If necessary, wear absorbent pads to catch urine.
• Maintain proper hygiene. This will help you feel more confident and will prevent odors and skin irritation.

Kegel exercises: Exercising the muscles of your pelvic floor may benefit women with either stress or urge incontinence.

• The exercises involve strongly contracting the pelvic muscles that you use to hold back urine.
• Many women are familiar with these exercises from childbirth classes.
• To find the muscles, place the first and second fingers of one of your hands into your vagina. Squeeze as if holding urine in until you feel a tightening around your fingers.
• Tightening these muscles is the exercise. Squeeze and hold for at least 10 seconds, then relax for 10 seconds. Repeat these exercises at least 10-20 times, three times per day. The more often you do the exercises, the more likely that they will work.

Create a urination diary. Take notes every day on your urination patterns. This will help your healthcare provider in diagnosing your problem:

• Time of urge to urinate (or if there was no urge)
• Strength of pain or urge
• The time you actually urinated
• Volume of urine
• Amount of leakage
• Type and amount of fluids you drink and when you drink them

A relatively new but promising new treatment is biofeedback. It has been shown to make a significant difference in the pediatric population. Because many people with incontinence have pelvic floor dysfunction from unidentifiable causes, it is felt that bladder retraining may improve many people with incontinence. Biofeedback consists of pelvic muscle tightening and relaxation with a trained technologist facilitating the sessions. This treatment does require a dedicated person but may eliminate the need for medications and/or surgery.

Treatment depends on the type and severity of the incontinence. Many of these treatments require a commitment on your part to master the technique and practice it daily. Discuss all of the treatment options with your healthcare provider before making a decision together.

Some medications that you may take for other medical conditions can cause incontinence. Review your medications with your healthcare provider. If a medication is causing the problem, an alternative may be available.

Urge incontinence: Treatment is focused on eradicating the underlying cause. If your healthcare provider is unable to identify a reversible cause, the focus of treatment becomes on reducing symptoms. Treatment may include the following:

• Providing a commode or urinal for urination "emergencies"
• Limiting fluid intake
• Behavioral therapy: Changing your habits to try to reduce incontinence
• Timed voiding and bladder training regimens: Gradually prolonging the time between urination
• Pelvic floor exercises: To strengthen the sphincter muscles
• Pelvic floor electrical stimulation: Painless electrical pulses are applied via a small probe in the vagina or rectum to increase the tone of the pelvic floor muscles
• Medications: To relax the bladder or tighten the sphincter muscles

Stress incontinence: In general, surgical treatment is far more successful than nonsurgical treatment. Medications generally do not work well in stress incontinence. Nonsurgical methods cure very few people, although symptoms may improve for up to 88%.

• If overweight, work toward weight loss. Weight loss can cure incontinence in as many as half of the cases.
• Kegel exercises
• Weighted vaginal cones: Strengthen pelvic muscles to prevent the involuntary flow of urine
• Urethral plug: A small tampon-like insert placed into the urethra to block urine flow
• Topical estrogen cream: Applied in the vagina, for use only after menopause (Many people are reluctant to use estrogen cream because of its potential association with female malignancies. Topical estrogen, however, is a very good treatment for those who need replacement and the risk is negligible.)
• Pessary: A device worn by women in the vagina to help support the bladder and improve control
• Barrier devices: Work like pads but are much smaller and less bulky
• Pelvic floor electrical stimulation
• Medication: To increase the tone of the internal sphincter, not always effective

Overflow incontinence: No effective medication is available for this condition, which usually occurs in people with longstanding diabetes, bladder outlet obstruction, or lumbar spine injury/disease. The cornerstone of treatment is catheterization.

• A catheter is a thin tube that goes through your urethra to your bladder to drain urine. There are two different kinds of catheters.
  • One is an intermittent catheter. You insert this yourself whenever needed, drain your bladder, and remove the catheter. You are taught how to do this by a specially trained nurse.
  • The other, called a Foley catheter, is worn all the time. Urine drains into a bag, usually taped to your leg. You simply replace the bag as necessary. Your healthcare provider will make arrangements for you to have the catheter changed regularly. This type of catheter is used for incontinence only as a last resort.

No matter what type of incontinence you have, medical treatment can take some time to take effect. During treatment, or if medical treatment does not work for you, you have the following alternatives:

• Wear an absorbent product
• Use a catheter to remove urine
• Surgery

Anticholinergic and spasm-relieving drugs are used in urge incontinence to suppress bladder contraction and relax bladder smooth muscle. This class of drugs includes

• darifenacin (Enablex),
• dicyclomine (Antispas, Bentyl),
• flavoxate (Urispas),
• hyoscyamine (Anaspaz, Levbid, Levsin),
• methantheline (Banthine, Pro-Banthine),
• oxybutynin (Ditropan,
• Ditropan XL, Oxytrol),
• solifenacin (VESIcare),
• tolterodine (Detrol, Detrol LA), and
• trospium (Sanctura).

Anticholinergic agents may help relieve urge incontinence. (Anticholinergic means to oppose or counteract the activity of certain nerve fibers that cause the bladder to contract.)

Myrbetriq (mirabegron) is a beta-3 adrenergic agonist indicated for the treatment of overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and urinary frequency.

Some tricyclic antidepressants (TCAs), such as imipramine (Tofranil, Tofranil PM), have strong anticholinergic effects and may be prescribed to treat incontinence. Because the effects of newer, long-acting agents (for example, Detrol LA, Ditropan XL, Enablex, or VESIcare) last throughout the day, they need to be taken only once daily, which makes them very convenient. Additionally, the effects of Detrol and Detrol LA are mostly limited to the bladder, thus lessening the prevalence of side effects typically caused by anticholinergic medications.

Medications are sometimes used in stress incontinence. These medications can have serious side effects, such as high blood pressure. They are not for everyone. These medications include adrenergic agonists, such as midodrine (ProAmatine) and pseudoephedrine (Sudafed), which increase internal sphincter tone.

No medications are effective in treating overflow incontinence. A drug called Urecholine has been FDA approved for overflow incontinence but has not met with a lot of success in clinical practice.

See Understanding Bladder Control Medications for more information on medications used to treat incontinence.

Surgery for urinary incontinence either corrects an anatomical problem or implants a device to alter bladder muscle function.

• Most people do not need surgery, but most of those who have surgery become dry.
• Like any surgery, these procedures do not work on everyone. A small number of people are not completely dry after surgery.
• Like all surgery, these operations can have complications.
• Each of these procedures is appropriate only for a certain type or type of incontinence.
• A urogynecologist or urologist can advise you about which, if any, might work for you.

Types of operations used in people with incontinence include the following:

• Altering the position of the bladder neck can change how urine is released from the bladder
• Repairing or supporting severely weakened pelvic floor muscles
• Removal of a blockage
• Implantation of a "sling" around the urethra
• Implantation of a device that stimulates the nerves to increase awareness of the need to urinate
• Injection of a naturally occurring material called collagen around the urethra (This is an option for women with stress incontinence. This adds bulk to the area, which compresses the urethra. This increases resistance to urine flow. Since collagen is slowly absorbed into the body, this may have to be repeated.)
• Injection of Botox into the bladder muscle using a cystoscope
• Surgical placement of an artificial urinary sphincter
• Enlargement of the bladder (considered the last resort)

Follow the recommendations of your physician.

Make and keep regular follow-up appointments. You can discuss your progress with your physician, and he or she can tailor your treatment accordingly.

The following measures can help maintain good bladder and urinary health:

• Drink plenty of fluids.
• Avoid alcohol and caffeine.
• Urinate regularly.
• Avoid foods that irritate your bladder.
• Maintain good health: Eat a healthy diet, maintain a healthy weight, and engage in some physical activity daily.
• Follow up with your doctor regularly.

Although treatment may not result in a cure, in most cases, your symptoms will be reduced. For people with stress incontinence, most experience either improvement or cure. For people with urge incontinence, some experience cure, and must improve.

American Urogynecologic Society
2025 M Street NW, Suite 800
Washington, DC 20036

National Association for Continence (formerly Help for Incontinent People)
PO Box 1019
Charleston, SC 29402-1019
1-800-BLADDER (252-3337)

American Foundation for Urologic Disease, Inc.
1000 Corporate Boulevard, Suite 410
Linthicum, MD 21090
1-800-828-7866

American Urological Association
1000 Corporate Boulevard
Linthicum, MD 21090
1-866-RING AUA (746-4282)

The Simon Foundation for Continence
PO Box 815
Wilmette, IL 60091
1-800-23-SIMON (237-4666)