Urinary incontinence

INTRODUCTION — Urinary incontinence is the involuntary leakage of urine. Although it becomes more common as people get older, incontinence is not normal at any age. Many types of therapy are available for urinary incontinence. A brief review of the normal process of urination in adults will help in understanding both the causes and treatment of urinary incontinence.

NORMAL URINATION — Urine is produced by the kidneys and passes into a muscular sac called the urinary bladder. The urethra is the tube that leads from the bladder to the outside of the body (show figure 1).

A ring of muscles, called the urinary sphincter, surrounds the urethra. As the bladder fills with urine, complex nerve signals ensure that the sphincter muscles are contracted and the bladder muscle stays relaxed. This allows the bladder to fill with urine and prevents urine from leaking out.

When the bladder is nearing full, nerve signals are sent to the brain, letting the person know that the bladder is getting full. Additional nerve signals must be sent to begin urination. Some of these signals cause the bladder muscles to contract, which pushes urine into the urethra. At the same time, other signals cause the sphincter muscles to relax, which allows the urine to pass out of the body. Most individuals empty their bladder every three to five hours during the day and zero to one times during the night.

Simply put, four things can go wrong with this process: The bladder contracts when the person is not ready to urinate, called urge incontinence. This is the most common reason people have incontinence. The sphincter does not close properly or does not stay closed when there is increased pressure (as with a cough or sneeze), allowing urine to leak. This is called stress incontinence, and is a common reason for incontinence in women, especially women who have had children. The bladder is too weak to empty completely, causing leakage when the bladder is overly full. This is called overflow incontinence, and is uncommon. The urethra is obstructed, preventing urine from draining completely, which can also lead to overflow incontinence. This is common in men with an enlarged prostate.

Urine leakage also can occur when persons are unable to make it to the toilet on time when medical conditions, medications, and/or difficulty with thinking and immobility interfere with normal bladder and sphincter function and getting to a bathroom.

RISK FACTORS — The frequency of urinary incontinence increases with age, and it affects more women than men. About 10 to 30 percent of women and 1.5 to 5 percent of men up to age 64 have urinary incontinence. In those age 65 and older, 15 to 30 percent of individuals have incontinence. At least 50 percent of persons older than 65 who live in long-term care facilities (eg, nursing homes) have incontinence [1].

Urinary incontinence also has been associated with a number of conditions, including obesity (in women), high impact physical activities, heart failure, lung problems, smoking, chronic cough, depression, constipation, pregnancy, vaginal delivery, and problems with mobility.

TYPES OF URINARY INCONTINENCE

Urge incontinence — Urge incontinence occurs when the bladder contracts suddenly, so that a normal "urge" becomes more forceful "urgency", the strong, uncomfortable need to urinate. A person with urge incontinence will generally have an abrupt, overwhelming urge to urinate, followed by urine leakage that can range from a few drops to soaking. The urgency and leakage may occur in response to a stimulus, such as unlocking the door when returning home, going out in the cold, turning on the faucet, or washing hands.

There are many names that have been used for urge incontinence and the associated symptoms of urgency and frequency, including overactive bladder, detrusor instability or overactivity, and irritable or spastic bladder.

Some patients with overactive bladder have symptoms of urinary urgency and frequency during the daytime only, while other patients also have to urinate frequently during the night (called nocturia). Frequency is the complaint of needing to urinate more often than other people (normal is considered to be 8 times in 24 hours).

Factors that can lead to urge incontinence include age-related changes in the anatomy of the urinary tract and the physiology of urination, nervous system problems related to conditions such as stroke, or bladder irritation caused by inflammation.

Stress incontinence — Stress incontinence occurs when the urinary sphincter does not stay closed during an increase in pressure in the abdomen, leading to urine leakage. As an example, the increased pressure in the abdomen with coughing, sneezing, laughing, or running can cause episodes of stress incontinence in susceptible patients. Stress incontinence is the most common cause of urinary incontinence in younger women, the second most common cause in older women, and may occur in older men after certain types of prostate surgery.

Stress incontinence in women is most commonly caused by weakness in the muscles and other tissues that support the urethra. Less commonly, stress incontinence is caused by complete failure of the sphincter to close, a condition known as intrinsic sphincter deficiency (ISD). This can occur due to scarring from surgery or radiation therapy used for cancer treatment.

Mixed incontinence — Mixed incontinence is the combination of both urge and stress incontinence, and is most common in younger to middle aged women.

Incontinence associated with medical factors — Urinary incontinence can occur due to treatable factors and medical conditions (show table 1A-1B). As examples, medical conditions such as urinary tract infection or poorly-controlled diabetes may temporarily cause urinary leakage. Certain medications, excess fluid intake, fluid retention, and arthritis or other problems that cause difficulty in getting to the toilet are potentially treatable causes of incontinence.

Overflow incontinence — Overflow incontinence refers to leakage that occurs when the bladder fails to empty properly, either because of obstruction of the urethra or weak bladder muscle contractions. When the person tries to urinate, abnormally large amounts of urine remain in the bladder. There may be a weak stream, dribbling, and frequent urination. An element of stress incontinence may occur at the same time.

Overflow incontinence is relatively uncommon, but can occur in some older men in whom either benign or cancerous enlargement of the prostate (a gland that surrounds the urethra) causes marked narrowing of the urethra. It is uncommon in women.

DIAGNOSIS — One of the most important first steps in the diagnosis and treatment of urinary incontinence is for the patient to openly and honestly discuss their problem with a healthcare provider. Studies have shown that up to one-half of persons with incontinence do not discuss their problem with a healthcare professional. However, disclosing the problem to a clinician can lead to an accurate diagnosis and effective treatment.

A number of tools are available to help determine the cause of urinary incontinence.

History and physical examination — The history and physical examination are among the most important steps in the investigation and treatment of urinary incontinence. Patients should discuss the type of leakage (associated with urgency, increases in abdominal pressure, or without warning), when their leakage began, if it has worsened or improved over time, and if they have tried any self-management techniques or prescribed treatments. Patients should also mention if they have a problem with leakage of stool (fecal incontinence). A full physical examination includes a review of mental status (alert versus confused), nerve and heart function, genital or pelvic exam, and a rectal examination, all of which can provide clues about the cause(s) of incontinence.

Bladder diary — Patients may be asked to keep a bladder diary to measure the timing and amount of urine voided, frequency and amount of leakage, and any associated factors, such as coughing or sneezing (show figure 2A-2B). This provides useful information about the cause(s) and potential treatment of incontinence.

Office tests — Simple tests may be done during an office visit to determine the type of leakage a patient has, which can help to guide treatment decisions. The provider may ask the patient to cough vigorously to determine if leakage occurs (usually as a result of stress incontinence). They may measure the amount of urine left in the bladder after normal urination to determine how well the bladder empties; this is called the post void residual, and should be less than 50 cc (approximately 2 ounces). This can be done by inserting a catheter into the bladder after the patient voids, or by using a type of ultrasound (called a bladder scanner).

Laboratory tests — The clinician will request a urine test (urinalysis) to look for evidence of infection or blood in the urine. Blood tests may be ordered to measure the kidney function.

Urodynamic testing — Urodynamic testing examines the bladder, urethra, and urethral sphincter as the bladder is filled with water, when the bladder is full, and when the person coughs or bears down. Testing includes measurement of the bladder capacity (how much the bladder can hold), the pressures in the bladder and urethra, and how fast urine flows during urination. Urodynamic testing is not needed for all persons with incontinence, but may be recommended in certain situations, such as to confirm stress incontinence if surgery is planned.

TREATMENT — The treatment of urinary incontinence will depend, in part, upon the type and cause of the incontinence. In most cases, treatment begins with conservative therapies, such as changes in lifestyle and potentially reversible factors, behavioral treatments, or a pessary. If these therapies are inadequate, medication or surgery may be considered.

Before embarking on a treatment plan, the patient and clinician should discuss the goals of treatment in detail, as these will not be the same for every patient.

Treatments for stress and urge incontinence — The following treatments may be helpful for persons with stress, urge, or mixed incontinence.

Fluid management — Persons who drink large amounts of fluids (especially those containing caffeine) may find that cutting back decreases the frequency of their leakage. The body requires a certain amount of fluids to function; for most people, thirst is a good indicator of when fluids are needed. Persons who are older may need to make a special effort to drink enough as they may not become thirsty in the initial stages of dehydration.

Drinking excessive amounts of fluid is of little benefit despite the popular misconceptions that drinking water can "flush out toxins," improve skin health, or assist with weight loss. Between 32 and 64 ounces of fluid per day (from food and fluids) is sufficient for most people; more fluids may be needed for persons who are active and perspiring or when outdoor temperatures are high. Decreasing evening fluid intake (eg, no fluids after 6 to 7 P.M.) is advised for persons with frequent nighttime voids or overnight leakage.

Potentially reversible factors — Patients who take certain medications (such as diuretics ("water pills")), have swollen ankles or feet (edema), are diabetic and have elevated blood glucose levels, and those who have difficulty walking may be at increased risk for urinary incontinence. A variety of techniques can be used to reduce symptoms. Persons who take diuretics should take them at a time when there is easy access to a bathroom. Persons with edema should elevate their feet for several hours in the afternoon or evening, and may consider wearing graduated pressure stockings, or in some cases can take a diuretic in the afternoon. Some prescription drugs and over-the-counter medications (e.g., ibruprofen and other nonsteroidal anti-inflammatory agents) can worsen edema; check with your healthcare provider. these measures may help to reduce overnight frequency, urgency, and leakage. Persons with diabetes who have elevated blood glucose levels should work with their healthcare provider to reduce blood glucose. Elevated blood glucose levels cause the kidneys to produce more urine, which can increase frequency, urgency, and leakage. Persons who have difficulty walking should be evaluated for interventions such as physical therapy, which could improve mobility. These persons may benefit from a portable toilet that can be placed close to their bed or living area. Potential obstacles such as electrical cords, throw rugs, or furniture should be moved out of hallways and walkways.

Pelvic muscle exercises — Pelvic muscle exercises, also known as Kegel exercises, strengthen the muscles involved in closing the urethral sphincter. These are used primarily for stress incontinence but can also be used to control sudden urges in persons with urge incontinence (show figure 4). (See "Patient information: Pelvic muscle exercises").

Studies have shown that, when done correctly, pelvic muscle exercises can be effective in people with stress incontinence. Patients may benefit from a visit to a physical therapist, or a urology, gynecology, or geriatric nurse specialist for detailed instructions. Biofeedback may also help teach correct exercise technique.

Treatments for urge incontinence

Bladder irritants — Some foods and beverages are thought to contribute to frequency and urgency. This includes caffeinated beverages and alcohol, spicy foods, and acidic foods or beverages. While this has not been proven, it may be reasonable to see if eliminating one or all of these items helps.

Bladder retraining — Normally, a person should urinate approximately every three to four hours during the day; getting up once during the night to void is normal for older persons. Bladder retraining can help persons with urge incontinence by slowly increasing the amount of urine the bladder hold, and therefore the time interval between voids (show figure 5). This regimen retrains the nerves and pelvic muscles, which can improve control of bladder contractions. Patients are instructed to urinate at specific intervals through the day, starting with a small time interval. For example, a person who must currently void every 30 to 45 minutes would start by voiding every 45 minutes, whether there is an urge or not.

If the patient feels the need to urge sooner, they should not to run to the bathroom, but should stand still or sit down and concentrate on decreasing the urge, usually while doing several pelvic muscle contractions (see "Pelvic muscle exercises" above). Once the urge has decreased or passed, the patient can walk slowly to the bathroom to urinate. After one to two weeks, the time interval can be increased by 30 to 60 minute increments. The goal is to increase the voiding interval to a more normal pattern, approximately every 3 to 5 hours.

For patients with dementia or memory impairment, treatment focuses on encouraging the patient to use the toilet at regular intervals (usually every two to three hours) and providing positive feedback for successful toileting.

Constipation — Constipation can lead to fecal impaction (when stool collects and is difficult to pass from the rectum), which can increase symptoms of frequency and urgency. Patients can prevent constipation by increasing the amount of fiber in their diet to between 20 and 30 grams per day (show table 3A-3C). (See "Patient information: Constipation in adults").

Medications — When bladder retraining and fluid management alone are not successful in treating urge incontinence, medications can be added. Medicines that are available are called bladder relaxants or antimuscarinic agents. Medications work best when combined with behavioral therapy. In general, these drugs have similar effectiveness, but may differ somewhat on the type and severity of side effects, such as dry mouth, constipation, and heartburn.

Patients and their clinicians should wait at least 4 weeks to determine the response to a medication. A patient who does not respond to one drug may respond to another. Patients who take these medications for long periods of time need to practice good dental care because dry mouth can increase the risk of cavities. There is a small risk of urinary retention (causing the bladder to incompletely empty) with these medications, especially in older patients. Oxybutynin comes in three forms: immediate release (generic oxybutynin, taken two to three times daily), extended release (Ditropan XL®, taken once daily), and a patch (Oxytrol®, which is worn on the skin and changed twice weekly). The immediate release form is particularly useful for people who require protection at specific times (eg, when going out to dinner) since it begins to work quickly and wears off after about six hours. Side effects occur less frequently with Ditropan XL® and Oxytrol®. Tolterodine is available in an immediate release form (Detrol® 1 or 2 mg, taken twice daily) and extended release (Detrol LA®, 2 or 4 mg taken once daily). Side effects occur less frequently with Detrol LA®. Trospium (Sanctura®) is taken one or two times daily on an empty stomach, and is available in 20 mg. Solifenacin (Vesicare®) is taken once a day, and is available in 5 mg or 10 mg. Darifenacin (Enablex®) is taken once a day, and is available in 7.5 mg and 15 mg.

Treatments for stress incontinence

Weight reduction — Obesity can contribute to symptoms of stress or mixed incontinence. In persons who are obese, weight loss can significantly reduce episodes of leakage due to stress incontinence.

Medication — There is currently no medication available for treatment of stress incontinence. Use of oral estrogen in women was found to worsen stress incontinence. Whether topical estrogen cream can improve incontinence is controversial.

Vaginal pessaries — A vaginal pessary is a flexible device made of silicone that can be worn in the vagina (show figure 6). It is traditionally used for women with pelvic organ prolapse (when the bladder, vagina, uterus, or rectum bulge from the vagina), but specially designed stress incontinence pessaries are also available. These help to support the urethra during a cough or sneeze, and may reduce or eliminate stress or overflow incontinence (show figure 7). A pessary is a reasonable treatment for women who want to delay surgery and for those who prefer a non-surgical treatment. When fit properly, the woman will not feel the pessary.

The pessary must be removed and cleaned with soap and water periodically. In addition, there is a small risk that the pessary can cause irritation of the vaginal tissues. Most women who use a pessary see their healthcare provider every three to six months for an examination. Some women are able to learn how to insert and remove the pessary on their own; this is especially helpful for women who are sexually active.

Periurethral bulking injections — In selected women, stress urinary incontinence is caused by complete failure of the urethral sphincter muscles; this is called intrinsic sphincter deficiency (ISD). This may occur in women who have had previous pelvic surgery or radiation treatment and later developed scarring, but it can also occur in postmenopausal women who have severely thinned (atrophic) vaginal tissues. ISD leakage is typically continuous and can occur while sitting or standing quietly.

Women with ISD may gain some short term benefit from injection of material into the wall of the urethra to help keep the urethra closed. These are called periurethral bulking injections. Materials injected include collagen, Teflon®, silicone, and carbon-coated beads.

Surgical treatments for women — Surgery offers the highest cure rate of any treatment for stress urinary incontinence, even in elderly women. Cure rates vary by procedure and by length of time since surgery, although most procedures result in 85 to 95 percent of women being cured at six weeks after surgery; cure rates tend to decrease over time. Ideally, surgery should be reserved for women who have completed childbearing because pregnancy and childbirth can cause damage to the urethral supports, potentially causing incontinence to recur.

There are several surgical procedures for the treatment of SUI in women. The best procedure depends upon several factors. Each procedure has its own risks, benefits, complications, and chance of failure. Long-term outcomes are not always known because some procedures have not been used long enough to measure the incidence of incontinence 10 to 20 years after surgery; the risk of incontinence recurring at a later time is difficult to know in these situations. All of these issues should be discussed in detail with the surgeon.

Other measures

Pads — While pads are not a recommended treatment for incontinence, they are necessary for some persons who are unable or unwilling to use behavioral treatments, medications, or more invasive treatments, or who have incomplete relief of leakage despite treatment.

Pads and protective undergarments are available for both men and women in a large variety of sizes and absorbencies. The choice of garment depends upon the type, frequency, and volume of urinary incontinence leakage. Pads designed for menstrual bleeding may be insufficient for persons with sudden, large volume leakage. In addition, menstrual pads typically do not manage urine odor as well as incontinence products. Men may prefer a penile sheath to a pad; the sheath covers the penis like a condom, and is connected to a tube and bag that collects the urine.

These items are expensive and are usually not covered by insurance; in some states within the United States, Medicaid may cover pads for people of very limited income, while in other countries pads may be obtained for no or little cost through continence advisor nurses. Information on pad varieties and other urinary incontinence supplies is available from medical supply companies and urinary incontinence patient advocacy groups (see "Where to get more information" below). The U.S. National Association for Continence has an online tool that can help a patient to choose a protective garment based upon individual characteristics (www.nafc.org/productdiagnostic.asp).

For all protective products, it is important that the skin is kept dry and that odor is managed. Skin that is exposed to urine for long periods can cause skin irritation, and can potentially cause skin burns or infection. In addition to protecting the skin, patients may need protective products for their bed or other furniture.

Catheters — A catheter may be necessary in some patients who cannot empty their bladder completely or at all. Because catheters (especially those left in place for long periods) can cause urinary tract infections and other serious complications, they are usually a treatment of last resort.

A catheter may be inserted and left in the bladder, or may be inserted as needed to drain the bladder, and then removed. A healthcare provider can teach the patient or a family member how to perform catheterization at home.

WHEN TO SEEK HELP — Patients should seek help from their healthcare provider if they are bothered by urinary frequency or urgency or leakage, if they are awakened more than twice during the night to urinate, if urinary leakage occurs, if there is pain with urination, or if they notice blood in the urine.

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute on Aging

(www.nia.nih.gov/)
National Association for Continence

1-800-BLADDER
(www.nafc.org)
Simon Foundation

(www.simonfoundation.org)
National Institute of Diabetes & Digestive & Kidney Diseases

(www.niddk.nih.gov/)
American Foundation for Urologic Disease

(www.afud.org)
For continence resources in other countries, go to Continence Worldwide

(www.continenceworldwide.com)


[1-5]


Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. Herzog, AR, Fultz, NH. Prevalence and incidence of urinary incontinence in community-dwelling populations. J Am Geriatr Soc 1990; 38:273.
2. DuBeau, CE, Levy, B, Mangione, CM, Resnick, NM. The impact of urge urinary incontinence on quality of life: importance of patients' perspective and explanatory style. J Am Geriatr Soc 1998; 46:683.
3. Fantl, JA, Newman, DK, Colling, J, et al. Urinary Incontinence in Adults: Acute and Chronic Management. Clinical Practice Guideline, No. 2, 1996 Update, AHCPR Publication No. 96-0682. Public Health Service, Agency for Health Care Policy and Research, Rockville, MD. (Available at www.ahrq.gov/clinic/uiovervw.htm, accessed 9/7/2006).
4. Brown, JS, Bradley, CS, Subak, LL, et al. The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med 2006; 144:715.
5. Wyman, JF, Choi, SC, Harkins, SW, et al. The urinary diary in evaluation of incontinent women: A test-retest analysis. Obstet Gynecol 1988; 71:812.