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Types of Urinary Incontinence
Urinary incontinence is generally categorized into the following types:
Treatment of Urinary Incontinence
Treatment options for urinary incontinence depend on the type of incontinence and the severity of the condition. Treatments include:
The American Urological Association’s 2012 guidelines for managing overactive bladder emphasize that behavioral therapies and lifestyle changes should be the first treatment approaches. According to a recent study, drugs for urge urinary incontinence only help about 20% of the women who take them and often have significant side effects.
Urinary incontinence is the inability to control urination. It may be temporary or permanent, and can result from a variety of problems in the urinary tract. Urinary incontinence is generally divided into four types:
Often, more than one type of incontinence is present. When this occurs, it is called mixed incontinence. Because incontinence is a symptom, rather than a disease, it is often hard to determine the cause. In addition, a variety of conditions may be the cause.
The urinary system helps to maintain proper water and salt balance throughout the body:
The Process of Urination
The process of urination depends on a combination of automatic and voluntary muscle actions. There are two phases: the emptying phase and the filling and storage phase.
The Filling and Storage Phase. When a person has completed urination, the bladder is empty. This triggers the filling and storage phase, which includes both automatic and voluntary actions.
When the need to urinate becomes greater than one's ability to control it, urination (the emptying phase) begins.
The Emptying Phase. This phase also involves automatic and conscious actions.
The primary symptom of stress incontinence is leakage due to activities that apply pressure to a full bladder. High-impact exercise poses the greatest risk for leaking. But stress incontinence can occur with even minor activities, such as:
Leakage stops when the stress ends. If the leakage persists, it is more likely to be urge incontinence.
Stress incontinence occurs because the internal sphincter does not close completely. In both men and women, the aging process causes a general weakening of the sphincter muscles and a decrease in bladder capacity. However, the causes of stress incontinence may be different in men and women.
In women, stress incontinence is nearly always due to one or more of the following:
Prostate treatments can impair the sphincter muscles and are major causes of stress incontinence in men.
Surgery or radiation for prostate cancer. Some degree of incontinence occurs in nearly all male patients for the first 3 - 6 months after radical prostatectomy. Within a year after the procedure, most men regain continence, although some leakage may still occur.
Surgery for benign prostatic hyperplasia. Stress incontinence can occur in some men after transurethral resection of the prostate (TURP), the standard treatment for severe benign prostatic hyperplasia (BPH).
Incontinence after prostate procedures is often a combination of urge and stress. Because studies often combine the two types of incontinence, it is not always clear which predominates.
Urge incontinence (also called hyperactive, irritable, or overactive bladder) is the need to urinate frequently. People with overactive bladder may go to the bathroom more than 8 times over 24 hours, including two or more times a night, and have subsequent leakage. In some cases, urge incontinence occurs only at night. This is called nocturnal enuresis.
All cases of urge incontinence involve an overactive bladder. This occurs when the detrusor muscle, which surrounds the bladder, contracts inappropriately during the filling stage. When this happens, the urge to urinate cannot be voluntarily suppressed, even temporarily.
Conditions that can cause urge incontinence include:
Benign prostatic hypertrophy (BPH) is a non-cancerous enlargement of the prostate gland, commonly found in men over the age of 50.
Overflow incontinence happens when the normal flow of urine is blocked and the bladder cannot empty completely. Overflow incontinence can be due to a number of conditions:
Causes of overflow incontinence include:
Patients with functional incontinence have mental or physical disabilities that keep them from urinating normally, although the urinary system itself is structurally intact. Conditions that can lead to functional incontinence include:
About 20 million American women and 6 million men have urinary incontinence or have experienced it at some time in their lives. The number, however, may actually be higher because many patients are often reluctant to discuss incontinence with their doctors.
Some of the main risk factors for urinary incontinence include:
Urinary incontinence is far more common among women than men. This is because pregnancy and childbirth, menopause, and the anatomical shape of the female urinary tract all increase the risk for incontinence. For men, enlarged prostate and surgery to correct prostate problems are the main risk factors for urinary incontinence.
As people age, the muscles in the bladder and urethrea weaken. For women, the loss of estrogen that occurs with menopause can also cause weakening of the pelvic and urinary tissues.
Pregnancy and childbirth increase the risk for stress incontinence. Vaginal birth can cause pelvic prolapse, a condition in which pelvic muscles weaken and the pelvic organs (bladder, uterus) slip into the vaginal canal. Pelvic prolapse, and the surgery used to correct it, can cause incontinence.
It is not clear if cesarean delivery helps prevent urinary incontinence. It’s also not clear if episiotomy prevents urinary incontinence. (Episiotomy is a surgical incision that is made during childbirth to the perineum, the muscle between the vagina and the rectum. Doctors perform this procedure to help widen the vaginal opening and prevent tearing.)
Being overweight is a major risk factor for all types of incontinence. The more you weigh, the greater the risk.
Diet. Acidic foods (citrus fruits, tomatoes, chocolate) and beverages (alcohol, caffeine) that irritate or overstimulate the bladder can increase the risk for incontinence. Spicy foods are also a problem. Excessive consumption of any type of fluid can create problems with incontinence but it’s also important not to cut back too much. Drinking insufficient amounts of healthy fluids (water) can lead to dehydration, which in turn causes bladder irritation and worsening of urinary incontinence.
Smoking. Smoking increases the risk for incontinence, especially in heavy smokers (more than a pack a day).
Exercise. High-impact exercise can trigger urinary leakage, particularly for women with a low foot arch. Shock to the pelvic area increases as the foot makes impact with hard surfaces. However, lack of physical exercise and movement can also increase the risk for incontinence.
Medical conditions associated with increased risk for urinary incontinence include:
Drugs are often a cause of temporary incontinence.
Urinary incontinence can have severe emotional effects. Patients may feel humiliated, isolated, and helpless about their condition. Incontinence can interfere with social and work activities. Depression is very common in women with incontinence. Incontinence also has emotional effects on men. A number of studies of patients with prostate cancer suggest that incontinence can be much more distressing side effect for men than erectile dysfunction (also a side effect of prostate cancer treatment).
To prevent wetness or odors, people with incontinence may alter their way of life. Running errands can become difficult and require advance planning for locating public bathrooms. This problem is particularly noticeable for those with urge incontinence who may need to quickly reach a bathroom in order to avoid large-volume spills.
Incontinence is particularly serious in older adults:
To diagnose urinary incontinence, your doctor will first ask about your medical history and lifestyle habits (including fluid intake). The doctor will conduct a physical examination to check for possible conditions that may be contributing to the problem. The doctor may collect a urine sample for analysis to check for infection.
If further evaluation is required, more specialized tests (urodynamic studies) may be performed. Urodynamic studies are used to test how well the bladder and urethra are performing. These tests include postvoid residual urine volume, cystometry, uroflowmetry, cystoscopy, and electromyography. Imaging tests (video urodynamic tests) may also be used.
The first step in the diagnosis of urinary incontinence is a detailed medical history. The doctor will ask questions about your present and past medical conditions and patterns of urination. Be sure to let your doctor know:
Another method of diagnosing incontinence uses a test that asks 3 questions, which helps a doctor distinguish between urge and stress urinary incontinence:
Voiding Diary. You may find it helpful to keep a diary for 3 - 4 days before the office visit. This diary, sometimes referred to as a voiding diary or log, should be a detailed record of:
For each incident of incontinence, the log should also detail:
Your doctor will do a thorough physical examination, checking for abnormalities or enlargements in the rectal, genital, and abdominal areas that may cause or contribute to the problem.
The postvoid residual (PVR) urine volume test measures the amount of urine left after urination. Normally, about 50 mL or less of urine is left. More than 200 mL is abnormal. Amounts between 50 - 200 ml may require additional tests for interpretation. The most common method for measuring PVR is with a catheter, a soft tube that is inserted into the urethra within a few minutes of urination. Ultrasound, which is non-invasive, may also be used.
Cystometry, also called filling cystometry, measures how much urine the bladder can hold and the amount of pressure that builds up inside the bladder as it fills. Cystometry can be performed at the same time as the PVR test. The procedure uses several small catheters:
The detrusor muscle of a normal bladder will not contract during bladder filling. Severe contractions at low amounts of administered fluid indicate urge incontinence. Stress incontinence is suspected when there is no significant increase in bladder pressure or detrusor muscle contractions during filling, but the patient experiences leakage if abdominal pressure increases.
To determine whether the bladder is obstructed, an electronic test called uroflowmetry measures the speed of urine flow. To perform this test, the patient urinates into a special measuring device.
Cystoscopy, also called urethrocystoscopy, is performed to check for problems in the lower urinary tract, including the urethra and bladder. The doctor can determine the presence of structural problems including enlargement of the prostate, obstruction of the urethra or neck of the bladder, anatomical abnormalities, or bladder stones. The test may also identify bladder cancer, and causes of blood in the urine and infection.
In this procedure, a thin tube with a light at the end (cytoscope) is inserted into the bladder through the urethra. The doctor may insert tiny instruments through the cytoscope to take small tissue samples (biopsies). Cytoscopy is typically performed as an outpatient procedure. The patient may be given local, spinal, or general anesthesia.
Electromyography, also called electrophysiologic sphincter testing, is performed if the doctor suspects that nerve or muscle problems may be causing urinary incontinence. The test uses special sensors to measure electrical activity in the nerves and muscles around the sphincter. The test evaluates the function of the nerves serving the sphincter and pelvic floor muscles as well as the patient’s ability to control these muscles.
Video urodynamic testing combines urodynamic tests with imaging tests like ultrasound or a special type of x-ray procedure called fluoroscopy. Fluoroscopy involves filling the bladder with a contrast dye so that the doctor can examine what happens when the bladder is filled and emptied.
Ultrasound is a painless test that uses sound waves to produce images. With ultrasound, the bladder is filled with warm water and a sensor is placed on the abdomen or inside the vagina to look for structural problems or other abnormalities.
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:
Lifestyle techniques to improve quality of life and improve hygiene are part of all treatments.
Lifestyle measures, including dietary recommendations, bladder training, and continent aids, are useful for anyone with incontinence. Other treatments vary depending on whether the patient has stress or urge incontinence. In people who have both (mixed incontinence), the treatment usually is aimed at the predominant form.
Treating Stress Incontinence. The general goal for patients with stress incontinence is to strengthen the pelvic muscles. Typical steps for treating women with stress incontinence are:
Treating Urge Incontinence. The goal of most treatments for urge incontinence is to reduce the hyperactivity of the bladder. The following methods may be helpful:
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 or retraining the bladder. These exercises are very effective for women, and also for men recovering from surgery for prostate cancer.
Pelvic floor (Kegel) exercises and bladder training are often recommended as the first-line approach for treating all forms of urinary incontinence. They can help to substantially improve symptoms in many patients, including elderly people who have had the problem for years.
Pelvic Floor Muscle (Kegel) Exercises. Kegel exercises are designed to strengthen the muscles of the pelvic floor that support the bladder and close the sphincters.
Dr. Kegel first developed these exercises to assist women before and after childbirth, but they are very useful in helping to improve continence for both men and women.
The general approach for learning and practicing Kegel exercises is as follows:
Bladder Training. Bladder training involves a specific and graduated schedule for increasing the time between urinations:
This system uses a set of weights to improve pelvic floor muscle control:
As with standard Kegel exercises, frequent repetition is required, but most women will eventually be able to use the heavier weights and build up the ability to prevent stress and urge incontinence.
Women who are unable to learn Kegel muscle contraction and release with verbal instructions may be helped with the use of biofeedback:
As with any Kegel exercise regimen, biofeedback must be used for several months before it is effective. Biofeedback that teaches control of pelvic muscles may also be helpful for children who have daytime wetting, frequent urinary tract infections, or both.
Medications for treating urinary incontinence increase sphincter or pelvic muscle strength or relax the bladder, improving the ability to hold more urine. Medications may be prescribed for both urge and stress incontinence, but they are generally most helpful for urge incontinence (overactive bladder). Because these drugs can cause side effects, it’s important to first try Kegel exercises, bladder training, and lifestyle modification methods.
Anticholinergics work by relaxing the bladder muscle and preventing bladder spasms that signal the urge to urinate. They also increase the amount of urine the bladder can hold.
These drugs can produce small but significant improvements in overactive bladder symptoms. Dry mouth and constipation are the most common side effects. Anticholinergics in pill form include:
Oxybutynin is also available as a skin patch (Oxytrol). In 2013, the FDA approved an over-the-counter (OTC) version of the skin patch for women. Men will continue to need a prescription for the oxybutynin skin patch. Oxytrol is approved only for adults.
Side effects of anticholinergic drugs include:
Alpha-blockers are drugs that relax smooth muscles and improve urine flow. They are useful for men with benign prostatic hyperplasia (BPH), also called enlarged prostate, who also have urge incontinence. The older alpha-blockers terazosin (Hytrin, generic) and doxazosin (Cardura, generic) are now prescribed less often than the newer selective alpha-blockers tamsulosin (Flomax, generic), alfuzosin (Uroxatral), and silodosin (Rapaflo). Alpha-blockers are sometimes combined with anticholinergics to treat men with moderate-to-severe lower urinary tract symptoms, including overactive bladder.
Both urge and stress incontinence are affected in part by chemical messengers in the brain (neurotransmitters) that affect pathways involved with urination. Antidepressants that target serotonin, norepinephrine, or noradrenaline neurotransmitters are sometimes used for urge incontinence and may also be helpful for some people with stress incontinence.
Mirabegron (Myrbetriq). Mirabegron is a new, first-in-class drug that was approved in 2012 for treatment of overactive bladder. It works in a different way than anticholinergics and other drugs used for urinary incontinence. This drug can increase blood pressure and may cause urinary retention in some patients especially those with bladder outlet obstruction.
Botox. In 2013, the FDA approved onabotulinumtoxinA (Botox) injections to treat overactive bladder in people who have not been helped by anticholinergic drugs. The FDA previously approved Botox injections for urinary incontinence that results from nerve damage associated with neurological conditions such as spinal cord injury and multiple sclerosis. Botox is injected into the bladder using a cystoscopy procedure. Increased risk for urinary tract infections is the most common side effect.
Topical Estrogen. For some women whose urinary incontinence is associated with menopause, topical estrogen may help improve urinary incontinence and overactive bladder symptoms. The estrogen is administered vaginally using a cream, tablet, or ring. Oral estrogen replacement should not be used to treat urinary incontinence because it can worsen the condition.
Alpha-Adrenergic Agonists. Alpha-adrenergic agonists, such as clonidine (Catapres, generic), may be helpful for select patients with mild stress incontinence but these drugs can have significant side effects and are only rarely prescribed.
There are nearly 200 surgical procedures for incontinence. Most are designed to restore the bladder neck and urethra to their anatomically correct positions in patients with stress incontinence. Injections of bulking materials are another option for women and men.
The choice of surgical procedure depends on a number of factors, including the presence of bladder or uterine prolapse, the severity of incontinence, and the surgeon’s experience in performing specific types of surgery.
In general, patients should weigh all options carefully. They should discuss the situation with their doctor, and ask about their surgeon's experience. They should also be completely informed about the benefits and risks of the procedures and the materials used. Patients will need to have a complete diagnostic evaluation with urodynamic testing before any surgical procedure.
A sling procedure is usually the first-line surgical approach for stress incontinence in women. It may also be useful for managing female urge incontinence. Sling procedures are also used for men who experience incontinence after prostatectomy.
The purpose of a sling procedure is to create a sling or hammock around the neck of the bladder to help keep the urethra closed. There are different types of sling procedures. They include:
Suburethral Sling Procedure. The suburethral, also called pubovaginal, sling is the traditional sling procedure. It uses a sling made from the patient’s own tissue (fascia), animal tissue, or a synthetic material. Suburethral means “beneath the urethra.” The procedure may be performed with laparoscopic or conventional “open” surgery. The procedure generally works as follows:
Complications can include infection, bleeding, and the formation of fistulas (holes that form and are usually infected).
Midurethral Sling Procedures. Midurethral sling procedures use slings made from synthetic mesh materials that are placed midway along the urethra. This newer type of sling procedure has largely replaced the conventional suburethral procedure because it can be performed on an outpatient basis using minimally invasive surgical techniques and no abdominal incisions. Midurethral sling procedures have high success rates and patient satisfaction.
There are two types of midurethral slings:
Sling Procedures in Men. For some men who have prostatectomy-induced incontinence, sling procedures may be a good option. Researchers have reported success rates similar to those of the artificial urinary sphincter, which is the standard surgical treatment for such patients. The sling procedure may be less effective for men who have undergone radiation therapy for prostate cancer. Minimally invasive procedures are also being tested.
Effectiveness and Complications. The sling procedure and the Burch colposuspension seem to have similar success rates for treating stress incontinence. Post-operative urinary problems, such as voiding problems, common urinary tract infections, and urge incontinence may occur. The FDA has reported complications associated with some synthetic mesh slings.
Retropubic colposuspension aims to correct the position of the bladder and urethra by sewing the bladder neck and urethra directly to the surrounding pelvic bone or nearby structures. Colposuspension is a common surgical treatment for stress incontinence.
Burch colposuspension is the standard approach. [Marshall-Marchetti Krantz (MMK) is an alternative approach.] It is often performed during abdominal surgeries such as hysterectomy or hernia operations. It is also performed along with sacrocolpopexy, a surgical procedure used to repair pelvic organ prolapse. (Pelvic organ prolapse occurs when the uterus or bladder slips from the pelvic cavity into the vagina. It is often due to pelvic muscle weakness that develops after childbirth.) Prolapse can lead to stress incontinence. However, prolapse surgery itself sometimes causes incontinence.
The Burch colposuspension procedure may be performed using open surgery or laparoscopy using spinal or general anesthesia. The surgeon makes an abdominal incision and secures the urethra and bladder neck with lateral (sideways) sutures that pass through thick bands of muscle tissue running along the pubic bones.
Effectiveness and Complications. Patients may stay in the hospital for a few days and usually need to use a urinary catheter for about 10 days after surgery. Because colposuspension surgery involves an abdominal incision, it can take up to 6 weeks for full recovery. (Laparoscopic procedures have a faster recovery time than open surgery.)
Complications can include problems with wound healing and postoperative voiding function. Convalescence time is longer with retropubic colposuspension than with sling procedures.
In cases of sphincter incompetence, or complete lack of sphincter function, an artificial internal sphincter may be implanted. This procedure is generally used for men, such as those who have experienced incontinence following radical prostatectomy.
This device uses a balloon reservoir and a cuff around the urethra that is controlled with a pump. The patient opens the cuff manually by activating the pump. The urethra opens and the bladder empties. The cuff closes automatically several minutes later. The two major drawbacks of the internal sphincter implant are malfunction of the implant and risk of infection.
Injections of materials, such as collagen, that provide bulk to help support the urethra may help the following patients:
Postoperative Care. People may experience immediate improvement followed by a temporary relapse after a week or so. Patients must be taught to use a catheter tube for withdrawing urine for a few days following the procedure. In general, it takes about a month for the full benefits to be apparent.
Complications. Bulking material injections pose a risk for infection and urinary retention, but these complications are usually temporary. This procedure may not be appropriate for patients with certain heart conditions.
Duration of Effectiveness. Collagen is absorbed over time, so injections generally need to be repeated every 6 - 18 months.
The sacral nerves, located near the sacrum (“tail bone”), appear to play an important role in regulating bladder control. A sacral nerve stimulation system (InterStim) may help some patients with urge incontinence. The system uses an implanted device to send electrical pulses to the sacral nerves to help retrain them. InterStim is reserved for the treatment of urinary retention and the symptoms of overactive bladder in patients who have failed or cannot tolerate less invasive treatments.
Complications include infection, lower back pain, and pain at the implant site. The system, however, does not cause nerve damage and can be removed at any time.
Patients have reported improvement in the frequency and volume of urination, as well as the intensity of urgency and their quality of life.
Keeping Skin Clean. Proper hygiene is essential for patients with incontinence.
To avoid skin irritation and infection associated with incontinence, keep the area around the urethra clean. The following tips may be helpful:
Preventing or Reducing Odor. Certain methods may help reduce odor from accidents. They include:
Diet and Weight Control. 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.
Fluid Intake. A common misconception among people with incontinence is that drinking less water will prevent accidents. In reality, limiting fluid intake has the following effects:
People with incontinence should, however, stop drinking beverages 2 - 4 hours before going to bed, particularly those who experience leakage or accidents during the night.
Fluid and Food Restrictions. 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.
Sometimes otherwise healthy adults stop exercising because of leakage. There are a number of methods for preventing or stopping leakage during exercise. The following are some tips:
Many products are available to help patients avoid embarrassment and prevent leakage.
A variety of absorbent pads and undergarments are quite effective in catching spills and leaks. Newer types of pads are thin enough to be worn undetected, and a spare can be hidden in a purse or pocket. Many undergarments developed for incontinence are almost indistinguishable from regular briefs and underpants.
For men, drip collectors are available which can be worn under briefs and are not noticeable under normal clothing. Lined with absorbent material, the pouch-like collector surrounds the penis or scrotum and is fastened with a belt or pins.
All absorbent undergarments should be changed when wet to limit problems of chafing or infection.
Self-Adhesive Foam Pads. Foam pads with an adhesive coating are available for women with stress incontinence. They work as follows:
Adhesive pads should not be used by women with the following conditions:
Urethral Caps. Small silicone caps that use suction to adhere to the urethral opening are also an option for women. These caps may be uncomfortable for some women, and side effects can include irritation and urinary tract infections.
Penile Clamps. The penile clamp is a hinged V-shaped external device that has two foam rubber pads which fit over the penis. When it is locked in place, it helps prevent dribbling. To urinate, the man releases the clamp.
Vaginal Pessaries. Vaginal pessaries are devices inserted into the vagina that support the inside of the vaginal walls. Pessaries are usually made of silicon and come in various forms, including donut or cube-shapes. They must be fitted by a health professional and are effective for vaginal prolapse or other vaginal structural problems. Serious complications are rare but can occur if the pessary is not replaced periodically.
Urethral Inserts. Urethral inserts are tampon-like silicone tubes or sleeves that fit into the urethral opening. When the tube is inserted into the urethra, the sleeve conforms to its shape and creates a seal at the bladder neck, preventing leakage. The insert is intended for one-time use and is replaced after voiding.
A catheter is a slim flexible tube inserted into the urethra. They are mainly used for cases of severe urge incontinence.
Temporary Catheterization. For people who are still active, catheterization is often problematic. When appropriate, temporary (also called intermittent) catheterization is usually best. Patients insert the catheter tube into their urethras, generally every 3 - 4 hours. This type of catheterization carries few risks and empties the bladder completely. Some patients report that they can maintain an active life with no significantly increased risk for infection with some simple precautions:
Permanent Catheterization. People who are mentally or physically incapable of self-catheterization may need permanent catheterization.
Nonsurgical catheterization procedures are generally not painful, but there is a substantial increased risk for urinary tract infections. Many doctors feel that the catheter is overused, especially in the elderly.
External Collection Devices. External catheter and collection devices include:
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