Urinary Incontinence

Urinary incontinence simply means leaking urine. Incontinence can range from leaking just a few drops of urine to complete emptying of the bladder.

Millions of women experience it each year. Some women may lose a few drops of urine while coughing, sneezing, laughing, during exercise and even during sexual activity. Others may feel a strong, sudden urge to urinate but may leak a large amount of urine before reaching the bathroom. Some women experience a combination of both of these. There are also other types of incontinence, which you can learn more about below.

There are three main types of urinary incontinence:

Stress Incontinence

When pressure on the bladder increases, and the muscles around it are weak, some urine can come out. This weakness can happen as a result of pregnancy, childbirth and hormonal changes during menopause. You may have a leak when you’re coughing, laughing, sneezing, walking, running, exercising or having sex.

Urgency Incontinence or Overactive Bladder

A sudden strong urge to urinate that is hard to stop. Women with this type of urinary incontinence may leak urine on the way to the bathroom. If you have an overactive bladder, it means that you have symptoms of urgency and frequency that may or may not include incontinence.

Mixed Incontinence

Many women have symptoms of both stress and urgency incontinence. This is the most commonly seen incontinence pattern in women.

In addition to these three types, there are also several, less common types:

Functional Incontinence

Functional incontinence happens as a result of mental or physical disabilities keep a person from getting to the toilet, despite a healthy urinary system. For instance, individuals with Alzheimer’s disease may simply forget to urinate. People with injuries, or those that are wheelchair bound, may not be able to make it to the bathroom on time. This can lead to urinary leakage.

Overflow Incontinence

Overflow incontinence occurs when the bladder can’t empty completely. As it continues to fill, it reaches the point where it can hold no more urine. This leads to an eventual leak. Bladder obstruction, an inactive or weak bladder muscle, spinal injuries or diabetes can cause overflow incontinence.

Sensory Irritative Incontinence

Sensory irritative incontinence occurs due to chronic or acute bladder irritation. This can be cause by urinary tract infections or vaginal atrophy, as seen in women who have gone through menopause.

Bypass Incontinence

Bypass incontinence occurs in individuals with urinary tract fistulae. Urine can freely flow from the bladder through a hole leading directly into the bladder. The result is chronic, continuous urinary leakage.

It is common for several symptoms to occur along with urinary incontinence:

• Urgency — Having a strong urge to urinate
• Frequency — Urinating more often than what is usual for you
• Nocturia — Waking from sleep to urinate
• Dysuria — Painful urination
• Nocturnal enuresis — Leaking urine while sleeping

Many of our physicians offer testing for urinary incontinence right in the office, called urodynamics. This refers to a group of tests that are performed to assess function of the urinary tract by measuring urine storage and evacuation. The purpose of urodynamic testing is to make a diagnosis so a treatment can be designed for you.

Many things can cause urinary incontinence. These can include:

• Urinary tract infection — Urinary tract infections can cause leakage, which usually goes away when they’re treated with antibiotics.
• Diuretic medications, caffeine, or alcohol — Incontinence may be a side effect of substances that cause your body to make more urine.
• Pelvic floor disorders — These disorders are caused by weakening of the muscles and tissues of the pelvic floor and accidental bowel leakage, and pelvic organ prolapse.
• Constipation — Long-term constipation often is present in women with urinary incontinence, especially in older women.
• Neuromuscular problems — When something disrupts the nerve signals from the brain to the bladder, the muscles that control those organs can malfunction, allowing urine to leak.
• Anatomical problems — The outlet of the bladder into the urethra can become blocked by bladder stones or other growths

Due to the risk of public embarrassment, many women alter their lifestyles, choosing not to participate in the things they normally enjoy. Many women also choose to ignore their symptoms and refuse to discuss incontinence with their providers. Regardless of your type of incontinence, our doctors can quickly investigate, diagnose and treat it with care and compassion.

No single treatment is available to treat all types of incontinence. While surgery is warranted in some patients, many patients never require surgery. Doctors also prescribe many conservative therapies. These include pelvic floor physical therapy (Kegel exercises), control of medical conditions, weight loss, medications and pessaries (a device you put in the vagina to support the pelvic organs).

Treatment for temporary incontinence can be rapid, simple and effective. If urinary tract infections are the cause, they can be treated with antibiotics. Any related incontinence will often clear up in a short time. Medications that cause incontinence can be discontinued or changed to halt episodes.

Chronic incontinence may require a variety of treatments, depending on the cause. Treatment options are listed below in the order in which they are usually tried, from least-to-most invasive:

• Behavioral techniques, which include pelvic floor (Kegel) exercises and bladder training, are sometimes all a person needs for achieving continence. A number of devices can also be used to strengthen muscles and prevent urine leakage. Bladder training is useful for urge incontinence With the exception of functional incontinence, most cases of incontinence will almost always improve with behavioral techniques. There are a variety of methods, but the focus is usually on strengthening the pelvic floor muscles or retraining the bladder. Studies indicate that such exercises are very effective.
• Medications are tried next. Often, these involve anticholinergics. Estrogen therapy (particularly vaginal estrogen cream) has been shown effective in treating some forms of urinary incontinence.
• Pessaries may also improve incontinence symptoms is some patients, negating the need for surgical repair.
• Surgery is the last resort. There are many effective procedures available for both stress incontinence and for urge urinary incontinence that do not respond to more conservative measures.

In women, pelvic floor muscle tone weakens with significant weight gain. Weight loss can help reduce the frequency of urinary incontinence episodes in overweight women. Women should eat healthy foods in moderation and exercise regularly. Constipation can worsen urinary incontinence, so diets should be high in fiber, fruits and vegetables.

 A common misconception among people with incontinence is that drinking less water will prevent accidents. In reality, limiting fluid intake has the following effects:

• The lining of the urethra and bladder becomes irritated, which may actually increase leakage.
• Concentrated urine also has a stronger pungency, so drinking plenty of fluids can help reduce odor.

People with incontinence, however, should stop drinking beverages 2-4 hours before going to bed, particularly those who experience leakage or accidents during the night.

A number of foods and beverages may increase incontinence. People who drink caffeinated or alcoholic beverages should try eliminating them to see if incontinence improves.

Medications for treating urinary incontinence increase sphincter or pelvic muscle strength or relax the bladder, improving the ability to hold more urine. Medications are prescribed for all kinds of incontinence, but they are generally most helpful for urge incontinence.

Medications Used For Urge Incontinence

Anticholinergics work in the following ways:

• Inhibit the involuntary contractions of the bladder
• Increase capacity of the bladder
• Delay the initial urge to void

These drugs can produce small but significant improvements.  Anticholinergic medications carry certain side effects, most notably dry mouth and constipation.

Anticholinergics include:

• Oxybutynin (Ditropan, Oxytrol)
• Tolterodine (Detrol)
• Hyoscyamine (Levbid, Hyomax)
• Trospium (Sanctura, generic)
• Darifenacin (Enablex)
• Solifenacin (Vesicare)
• Fesoterodine (Toviaz)

Extended-release forms of oxybutynin (Ditropan XL) and tolterodine (Detrol LA) are available. They improve continence and have fewer adverse effects than short-acting forms. A skin patch form of oxybutynin (Oxytrol) is another option. It may have fewer side effects, such as dry mouth and constipation, than the pill form. Oxybutynin is also approved for pediatric use in children ages 6 and older.

Side effects of anticholinergic drugs include:

• Dry eyes (a particular problem for people who wear contact lenses; patients who wear contacts may wish to start with low doses of medication and gradually build up)
• Dry mouth
• Headache
• Constipation
• Rapid heart rate
• Confusion, forgetfulness, and possible worsening of mental function, particularly in older people with dementia, such as those with Alzheimer’s disease
• Hallucinations, possibly, especially for children and older adults; doctors should monitor patients for this symptom

Tricyclic Antidepressants

Tricyclic antidepressants, such as imipramine (Tofranil, generic), may help both urge and stress incontinence. They act as anticholinergic drugs and relax the bladder. They also strengthen the internal sphincter. These drugs should be used carefully. They pose some risk for adverse effects on the heart and possibly the lungs, and they have other severe side effects in older adults. These antidepressants produce side effects similar to anticholinergic drugs, and may cause drowsiness. They may also cause overflow incontinence in some people.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

SNRIs are specially designed antidepressants that are similar to tricyclics but do not have the same side effects. They target the neurotransmitters serotonin and norepinephrine, which are thought to play key roles in the normal action of bladder muscles and nerves. Increased neurotransmitter activity stimulates the nerve that controls the urethral sphincter. The SNRI duloxetine (Cymbalta) is approved in Europe for treatment of stress urinary incontinence. It is approved in the U.S. for other conditions, but not for stress urinary incontinence. Nevertheless, it is sometimes prescribed off-label for stress urinary incontinence. The FDA is investigating whether duloxetine can increase the risk for suicidal behavior.

Drugs For Refractory Urge Incontinence

Individuals who have failed conventional, conservative therapy are diagnosed as having Refractory Urge Incontinence. Botulinum (Botox), the deadly toxin that sometimes contaminates improperly cooked foods, is also a powerful muscle relaxant. Botox can be injected directly into the muscular wall of the bladder, relaxing the muscles and helping to control overactive bladder that causes urge incontinence. Its limitations lie in its side effects (voiding dysfunction–up to 25-30%) and in its short-term effect, meaning repeat injections are necessary.