Urinary incontinence in women and men: causes, symptoms, treatment

1. General information about urinary incontinence
2. Causes
3. Types and symptoms
4. Diagnosis and necessary tests
5. Treatment
6. Urinary incontinence during pregnancy
7. Urinary incontinence at menopause

General information about urinary incontinence

Urinary incontinence is the loss of bladder control. The two most common types of urinary incontinence affecting women are stress incontinence and urge urinary incontinence, also called overactive bladder. Incontinence affects twice as many women as men. This may be due to the fact that pregnancy, childbirth and menopause can make urinary incontinence more likely. Urinary incontinence is not a normal part of aging and can be treated.

Incontinence can occur when the bladder muscles suddenly tighten and the sphincter muscles are not strong enough to close off the urethra. This causes a sudden, strong urge to urinate that you cannot control. Pressure caused by laughing, sneezing or exercising can cause urine leakage. Urinary incontinence can also happen if there is a problem with the nerves that control the bladder muscles and the urethra.

Causes

Urinary incontinence is usually caused by problems with the muscles and nerves that help the bladder hold or release urine. Certain health events unique to women, such as pregnancy, childbirth and menopause, can cause problems with these muscles and nerves.

Other causes of urinary incontinence include:

• Excess weight. High body weight puts pressure on the bladder, which can weaken the muscles over time. A weak bladder cannot hold much urine.
• Constipation. Bladder control problems can occur in people with long-term (chronic) constipation. Constipation, or straining to have a bowel movement, can put stress or pressure on the bladder and pelvic floor muscles. This weakens the muscles and can cause urinary incontinence or leakage.
• Nerve damage. Damaged nerves can send signals to the bladder at the wrong time, or not at all. Childbirth and health problems, such as diabetes and multiple sclerosis, can cause nerve damage to the bladder, urethra, or pelvic floor muscles.
• Surgery. Any surgery involving a woman's reproductive organs, such as a hysterectomy, can damage the supporting muscles of the pelvic floor, especially if the uterus is removed. This can cause urinary incontinence.

Sometimes urinary incontinence is temporary and happens for other reasons, including:

• Certain medications. Urinary incontinence can be a side effect of medications, such as diuretics, used to treat heart failure, liver cirrhosis, high blood pressure and certain kidney diseases. Incontinence often goes away when you stop taking the medication.
• Caffeine. Caffeinated beverages can cause the bladder to fill up quickly, which can cause you to leak urine. Studies suggest that women who drink more than two cups of caffeinated beverages a day may have more problems with incontinence. Limiting caffeine can help with incontinence, since there is less stress on the bladder.
• Infection. Urinary tract and bladder infections can cause incontinence for a short period of time. Bladder control often returns once the infection clears up.

Types and symptoms

Urinary incontinence is not a disease in itself. Urinary incontinence is a symptom of another health problem, usually weak pelvic floor muscles. In addition to urinary incontinence, some women also have other urinary symptoms:

• Pressure or spasms in the pelvic area that cause a strong urge to urinate
• Going to the bathroom more than usual (more than eight times a day or more than twice a night)
• Urinating during sleep

Stress urinary incontinence (with exertion)

This is the most common type of incontinence. It is also the most common type of incontinence affecting younger women. Stress incontinence occurs when there is stress or pressure on the bladder. Stress incontinence can happen when weak pelvic floor muscles put pressure on the bladder and urethra, making them work harder. With stress urinary incontinence, everyday actions that use the pelvic floor muscles, such as coughing, sneezing or laughing, can cause urine leakage. Sudden movements and physical activity can also cause urine leakage.

Urge urinary incontinence

With urge urinary incontinence, urine leakage usually happens after a strong, sudden urge to urinate and before you can reach a bathroom. Some women with urge urinary incontinence can make it to the bathroom in time, but feel the need to urinate more than eight times a day. They also don't urinate much after reaching the bathroom. Urge urinary incontinence is sometimes called "overactive bladder." Urge urinary incontinence is more common in older women. It can occur at any time, such as during sleep, after drinking water, or when hearing running water.

Mixed urinary incontinence

Many women with urinary incontinence have both stress incontinence and urge incontinence. This is called mixed urinary incontinence.

Overflow urinary incontinence

In overflow urinary incontinence, the body produces more urine than the bladder can hold, or the bladder is full and cannot empty, thus causing urine leakage. In addition, there may be something blocking the flow, or the bladder muscle might not contract as it should. One symptom is frequent urination of a small amount. Another symptom is a constant dribble. This type of urinary incontinence is rarely seen in women. It is more common in men who have prostate problems or have had prostate surgery.

Diagnosis and necessary tests

Your doctor will ask you questions about your symptoms and medical history, including:

• How often you empty your bladder
• How and when you leak urine
• How much urine leaks
• When your symptoms started
• What medications you take
• Whether you have ever been pregnant and what your childbirth experience was like

Your doctor will perform a physical exam to look for signs of health problems that can cause incontinence. Your doctor or nurse may also perform other tests, such as:

• Urine test. After you urinate into a container, the doctor or nurse will send the urine to a laboratory. At the laboratory, your urine will be checked to see if there are infections or other causes of incontinence.
• Ultrasound. The doctor will perform imaging to see the kidneys, bladder and urethra. They will look for anything unusual that could cause urinary incontinence.
• Cystoscopy. Your doctor inserts a thin tube with a small camera into the urethra and bladder to look for damaged tissue. Depending on the type of cystoscopy you need, your doctor may use medication to numb the skin and urinary organs while you are still awake, or you may be fully sedated.
• Urodynamic testing. Your doctor inserts a thin tube into the bladder and fills the bladder with water. This allows your doctor to measure the pressure in the bladder to see how much fluid the bladder can hold.

Your doctor may ask you to keep a diary for 2 to 3 days to track when you empty your bladder or when urine leaks. The diary can help the doctor see patterns of incontinence that give clues about the possible cause, and the treatments that might work for you.

Treatment

You and your doctor will work together to create a treatment plan. You can start with steps you can take at home. If these steps don't improve your symptoms, your doctor may recommend other treatments, depending on the type of urinary incontinence you have. It may take a month or more for different treatments to start working.

Non-invasive treatment

If an underlying condition is causing your symptoms, your doctor will first treat that condition. Your doctor may suggest the least invasive treatments first, and move on to other options only if these techniques fail.

• Bladder training, to delay urinating after you feel an urgent need. You can start by trying to hold it for 10 minutes each time you feel a desire to urinate. The goal is to extend the time between bathroom trips until you urinate only every 2.5 - 3.5 hours.
• Scheduled bathroom trips, to urinate every two to four hours, rather than waiting until you feel the need to go.
• Fluid and diet management, to regain bladder control. You may need to reduce or avoid alcohol, caffeine or acidic foods. Reducing fluid intake, losing weight, or increasing physical activity can also help ease symptoms.

Kinetotherapy

There are special exercises for strengthening the pelvic muscles. The exercises can be done alone or with vaginal cones, biofeedback therapy, or electrical stimulation. In general, exercise is a safe and effective treatment, which should be performed to treat urge urinary incontinence and mixed incontinence. These exercises must be performed correctly to be effective; if the patient uses the abdominal muscles or contracts the buttocks, these exercises are being performed improperly.

For some people, electrical stimulation improves pelvic muscle rehabilitation therapy. Electrical stimulation is a more sophisticated form of biofeedback used for rehabilitating the pelvic floor muscles. When the pelvic muscles are stimulated by small electrical currents, the muscles and urinary sphincter contract, and bladder contraction is inhibited. Research indicates that electrical stimulation of the pelvic floor can significantly reduce urinary incontinence in women with stress incontinence, and can be effective in men and women with mixed incontinence.

Physiotherapy

One of the physiotherapy treatments for urinary incontinence involves the use of vaginal cones. These are small-sized objects, which can have different weights, and are inserted into the vagina for therapeutic purposes. The exercise consists of holding the cone in the vagina through contraction. As part of a progressive exercise program, a single cone is inserted into the vagina and held in place by squeezing the muscles for 15 minutes. As the muscles become stronger, the duration of the exercise can be increased to 30 minutes.

Kegel exercises

If you have stress incontinence, Kegel exercises to strengthen your pelvic floor muscles can help you. Some women have urinary symptoms because the pelvic floor muscles are always tight. In this situation, Kegel exercises will not help your urinary symptoms and could cause more problems. Talk to your doctor about your urinary symptoms before doing Kegel exercises.

To do pelvic floor muscle exercises, imagine that you are trying to stop the flow of urine. Squeeze (contract) the muscles you would use to stop urinating and hold for five seconds, then relax for five seconds. (If this is too difficult, start by holding for two seconds and relaxing for three seconds.) Work up to holding the contractions for 10 seconds at a time, and relaxing for 15 seconds. Do at least three sets of 10 repetitions every day.

Urinating at certain times

Bladder training generally consists of self-education, using the bathroom according to a schedule, and consciously delaying bathroom trips. Although bladder training is mainly used for the symptoms of urge urinary incontinence, this program can also be used for stress incontinence and mixed incontinence. For bladder training to work, a person must resist or inhibit the sensation of urgency and wait to go to the bathroom. The individual must urinate at certain times, rather than every time they feel the need to urinate. This plan includes dietary changes, such as adjusting fluid intake and avoiding dietary stimulants.

Invasive treatment

If you have severe symptoms of stress urinary incontinence or overactive bladder, invasive treatment can offer a permanent solution to your problems. Urethral occlusive devices are different for men and women. Devices for women are artificial instruments that can be inserted into the urethra or placed over the urethral opening to prevent urine leakage.

Inserting devices into the vagina

These inserts for the urethra - the tube through which urine travels from the bladder - can help with stress incontinence:

• Intravaginal device. Similar to a tampon, this disposable device can serve as a barrier against leaks during special activities.
• Pessary. If the bladder has prolapsed (dropped), this ring-shaped device can act as support. It will be inserted and fitted at the doctor's office. It will need to be removed and cleaned, and can help avoid surgery.

Collagen injections

Collagen injections appear to be a good option for women suffering from severe stress incontinence, but who do not want to have corrective surgery. Collagen injections into the lining of the urethra or the neck of the bladder act as a bulking agent, either by bringing the walls of the urethra closer together, or by sealing the base of the bladder. Collagen allows the urethra to close well enough to prevent urine leakage. The result is similar to how the body naturally functions, and in most cases, urinary control will be improved and restored. If a patient is allergic to collagen, other bulking agents are available.

Retropubic colposuspension

Retropubic colposuspension is a surgical procedure that helps control stress incontinence. This is the leakage of urine that happens when you laugh, cough, sneeze, or lift objects, or exercise. The surgery helps close off the urethra and the neck of the bladder. The urethra is the tube that carries urine from the bladder to the outside. The neck of the bladder is the part of the bladder that connects to the urethra. During the laparoscopic procedure, the doctor makes a small cut in the belly. A tube-like device that allows the doctor to see your organs (the laparoscope) is inserted into the belly through this cut. The doctor sutures the neck of the bladder, part of the vaginal wall and the urethra, as well as the ligaments in the pelvic area, in order to bring them back to their original anatomical position.

Placement of a sling (support mesh)

The sling is meant to eliminate stress urinary incontinence, by providing support beneath the urethra. The minimally invasive procedure involves inserting a support mesh under the urethra through three small incisions in the groin area. Studies have shown that this support procedure is the safest and most effective, and reduces the risks of bowel, bladder injury and major bleeding, and has an excellent cure rate.

Placement of an artificial urinary sphincter (in men)

An artificial sphincter is a device made of silicone rubber that is used to treat urinary incontinence in men. An artificial sphincter has an inflatable cuff that fits around the urethra near the point where it joins the bladder, and is controlled by the patient. The cuff is inflated to prevent urine leakage. When urination is desired, the cuff is deflated, allowing urine to flow.

Medication treatment

Medication therapy may be prescribed to relax the bladder. Bladder control can also be negatively affected by certain medications you may be taking for other conditions. Medications that help tone the urethra are sometimes used, and can help with stress incontinence. Medication therapy for stress incontinence and urge urinary incontinence may be most effective when combined with a pelvic exercise regimen. Medications commonly used to treat incontinence include:

• Anticholinergics. These medications can calm an overactive bladder and can be helpful for incontinence.
• Alpha-blockers. In men with urge urinary incontinence, these medications relax the muscles of the bladder neck and the muscle fibers of the prostate, and facilitate bladder emptying.
  
• Topical estrogen. For women, applying low-dose topical estrogen, in the form of a vaginal cream, ring, or patch, can help tone and rejuvenate the tissues in the urethra and vaginal areas. Systemic estrogen - the hormone in pill form - is not recommended for urinary incontinence and may even worsen it.

Urinary incontinence during pregnancy

During pregnancy, many women experience some degree of urinary incontinence, which is the involuntary loss of urine. Incontinence can be mild for some pregnant women, but quite severe for others. Age and body mass index are risk factors for urinary incontinence during pregnancy. Incontinence can continue after pregnancy and may not be present immediately after childbirth. The type of incontinence experienced during pregnancy is usually stress incontinence.

After pregnancy, incontinence problems can continue, since childbirth weakens the pelvic floor muscles, which can cause an overactive bladder. Pregnancy and childbirth can also contribute to bladder control problems, due to the following conditions:

• Damage to the nerves that control the bladder
• The fact that the urethra and bladder shifted during pregnancy
• Episiotomy, a cut made in the pelvic floor muscle during childbirth, to allow the fetus to come out more easily

Behavioral methods such as scheduled urination and bladder training can be helpful in treating urinary incontinence during and after pregnancy. In certain cases, women can use pessary devices, to block the urethra or to strengthen the pelvic muscles. In addition, medications can be helpful in controlling muscle spasms in the bladder or strengthening the muscles in the urethra. Some medications can help relax the overactive bladder.

Urinary incontinence at menopause

When you are in menopause, it may be harder to control your bladder. This is a common problem. Changes in your body can lead to urinary incontinence. The ovaries no longer produce estrogen during this period of your life. This hormone is essential for women, since it controls the menstrual cycle. Vaginal estrogen cream can help you if you have urinary incontinence. A low dose applied inside the vagina or urethra can help ease the symptoms. Antispasmodic medications can block the signals that cause spasms in the bladder muscles.

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