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What is Urinary Incontinence?

Urinary incontinence is a problem with bladder and sphincter control. It is the uncontrolled leaking of urine. Millions of Americans, about 1 out of 2 women   and 1 out of 4 men  , suffer from urinary incontinence symptoms. If the fear of leaking urine stops you from doing things you enjoy, then it is time to think about treatment. Do not be embarrassed to talk to your doctor about this medical condition. There are treatment options waiting for you!

How Does the Urinary Tract Work?

When it is not full of urine, the bladder is relaxed. Nerve signals in your brain let you know when your bladder is getting full  . When full, you feel the need to go to the bathroom. If your bladder is normal, you can hold urine for some time. Once you are ready, the brain sends a signal to the urethral sphincter muscle (located towards the top of the urethra) and the bladder.

The urethral sphincter muscle relaxes and opens the urethra, and the bladder muscle squeezes (or contracts) forcing urine out through the urethra to empty the bladder. After going to the bathroom, the sphincter muscle closes again (or contracts) to keep urine in the bladder. It only opens again when your brain says you are ready to go to the bathroom.

With urinary incontinence, some parts of this system do not work the way they should.

What are the types of urinary incontinence?

Stress Urinary Incontinence (SUI)

Stress Urinary Incontinence (SUI) is a common type of urinary leakage. With SUI, the pelvic floor muscles (which hold the pelvic organs in place) have become weak, and can no longer support the bladder and urethra the way they should. Coughing, sneezing, bending, lifting, straining or even laughing, could put enough pressure on the bladder causing it to leak.

To learn more about SUI risk factors, diagnosis and treatments visit our SUI article page.

Overactive Bladder (OAB)/Urgency Urinary Incontinence (UUI)

Overactive Bladder (OAB)   is a syndrome that often includes frequent urination, associated with a sudden strong urge to void. This "gotta go" feeling makes you feel that you will leak if you do not use the bathroom NOW. If you indeed do not make it, this urge-related urine leakage is known as urgency urinary incontinence (UUI). If you live with OAB, you may feel like you need to go to the bathroom many times during the day. You may even wake from sleep many times a night to void. It is a very common health issue for many people, and it increases with aging. It is also common for people with diabetes, multiple sclerosis or stroke.

To learn more about OAB risk factors, causes and treatments visit our OAB page.

Overflow Incontinence

This type of incontinence is when the bladder stays full. It cannot empty and so it overflows and leaks. Signs include multiple, small urinations each day, or ongoing dribbling. This is rather rare in women, but can be seen in people with diabetes, neurological disorders and/or a non-functional, underactive bladder. Most often overflow incontinence is seen in men who have prostate problems.

Mixed Incontinence

Some people have more than one type of urinary incontinence. Some people leak urine both with strong physical activity (SUI) AND have a strong uncontrollable sense of urgency (OAB.) This is mixed urinary incontinence. This person has both SUI and OAB. In this case, it helps to know what is occurring and what is causing leaks to learn how to manage problems.

Symptoms

The symptoms tell you what kind of urinary incontinence you have.

Not all incontinence is long term. Some causes are temporary so that the incontinence ends when the cause goes away. Vaginal infections can cause temporary incontinence. Irritation, medications, constipation and restricted mobility can cause it.  Urinary tract infections (UTIs) are a common cause of temporary incontinence and should be addressed.

It remains important that if the cause isn't temporary or easily treated, the leakage is probably one of the four types described above. With SUI, the pelvis or sphincter muscles (or both) aren't strong enough to hold the urine by closing the bladder and urethra. With OAB, the bladder muscles contract too much, pushing urine out even when you are not ready to release it. Mixed incontinence is usually both SUI and OAB. With overflow incontinence, the bladder gets too full without releasing.

These are the symptoms for each:

SUI

The key symptom of SUI is leaking when you are active. The activity and amount of leaking depends on how severe the SUI is. To learn more about SUI, visit our SUI article page and www.UrologyHealth.org/SUI.

OAB

The main symptom of OAB is a sudden, strong urge to urinate that you can't control. The urge may or may not cause your bladder to leak urine. To learn more about OAB, visit our OAB article page and www.UrologyHealth.org/OAB.

You can also take this quiz "Think You Have an Overactive Bladder?" Print the questions and answer them. Use your answers talk to your doctor about your symptoms. The quiz will help you and your doctor know which OAB symptoms you have. It will help your doctor figure out how best to treat you.

Mixed incontinence (SUI and OAB)

The symptoms of mixed incontinence include leaking and a sudden, strong urge to urinate. Mixed incontinence is when you have more than one type of incontinence. Most often, people with mixed incontinence have SUI and OAB.

To find out more about SUI, visit our SUI article page and www.UrologyHealth.org/SUI.
To find out more about OAB, visit our OAB article page and www.UrologyHealth.org/OAB.

Overflow Incontinence

Frequent small urinations and constant dribbling are the main symptoms of overflow incontinence. The bladder is unable to empty. Symptoms happen when the bladder is full. This type is less often in women however, dropped bladders, prior bladder surgeries or diabetes may affect this. It is more common in men with a history of prostate problems or surgery.

Causes

Urinary incontinence is not a disease. It is a symptom of a wide range of health issues such as the short-term and long-term issues listed below.

Short-term health issues:

  • Urinary tract infections (UTI)
  • Constipation (hard, dry stool)
  • Medicine (such as diuretics, antidepressants, antihistamines, others)

Long-term health issues:

  • Diabetes
  • Stroke
  • Multiple sclerosis
  • Enlarged prostate or prostate surgery for men
  • Childbirth or menopause for women

Diagnosis

A urologist or primary care doctor will start by asking questions. They will want to know about your symptoms and your medical history. They will ask about your health habits and fluid intake. They will also want to know how much your incontinence has changed your quality of life.

A good medical history, physical exam and a few simple tests are most often all that is needed to diagnose the cause of incontinence. A complete review of the medications you are taking may reveal one that alters normal bladder or urethral function. Your doctor may test your urine for bacteria or blood (urinalysis) to look for a urinary tract infection or other source of irritation to the bladder.

A cough stress test may be performed to check for SUI. A simple bladder ultrasound test to see how well you empty your bladder is often performed. Or a more involved "stress test" for the bladder can be done in more complicated cases (urodynamic test) to better see just how your bladder and urethra work. Other conditions to look for include vaginal hernias or pelvic organ prolapse (POP), and major bowel problems, such as constipation or fecal incontinence.

Treatment

There are many ways to help you take control over your bladder. You may not need to wear pads or diapers. Some problems are short-term and can be easily relieved. Others take more time to treat. Treatments range from lifestyle changes to bladder training to medications to simple procedural therapies to surgery.

Lifestyle Changes

Lifestyle changes, such as changing your diet, should be tried first. With lifestyle changes, you change the way you live day-to-day. This may include what you eat or drink, or practicing other methods that may control symptoms. You may not get rid of all symptoms with lifestyle changes, but your symptoms may feel better after changing a few habits. For some, weight loss has been linked to helping urinary symptoms.

Fluid Control

You will likely be asked to track what you drink, when and how much. You may learn that you should limit certain things such as caffeine and alcohol. These drinks may bother the bladder. You may also be asked to drink more water. Six to eight glasses of water per day is ideal. Also, you may be asked not to drink for a few hours before bed. This will help reduce your need to get up and go to the bathroom at night.

Limit Certain Foods and Drinks

Some foods and drinks have been found, anecdotally, as irritants to the bladder. Some people have found spicy foods, coffee, tea and colas to be bothersome. However, studies have not proven that these are really "bladder irritants" in all patients. A good plan is for you to try to notice on your own how different food and drinks effect you and your symptoms.

Bladder Training

A bladder diary is the starting point for bladder training. For 3 days, you write down what and how much you drink, and how often you go to the bathroom. Noting when you leak urine can also be helpful. This diary can help you and your provider find things that may make your symptoms worse. It can also help your provider build a bladder training plan for you. This is when you empty your bladder in a controlled way at set times. When you empty your bladder as a routine, you should have less leaks. Timed urination, scheduled voiding or double voiding are methods that can help with both OAB and SUI.

If you go to the bathroom too often, retraining your bladder can help. The goal is to hold your urine in the bladder for longer and longer amounts of time. This takes small steps. Start with adding 5 to 10 minutes. The goal is to retrain your bladder to hold urine for 3 to 4 hours, with less urgency and leaking.

Pelvic Floor Exercises

Kegel exercises can strengthen the urethral sphincter and pelvic floor muscles. This works for both men and women. If you can learn to tighten and relax these muscles, this can often help your bladder control.

Kegels can also help control the bladder spasms that trigger the urge to go. Squeezing the pelvic floor muscles inspires a reflex to the bladder to get the bladder to quiet down, to help suppress the urge feeling. This can pause or even stop the uncontrollable UUI leaks. A health care provider can teach you how to do these exercises with success.

Kegels can help with both SUI (by making the muscles strong) and OAB/UUI (by suppressing the urge feeling). Like any fitness program, you must practice the exercises often to keep helping your body.

Medical Treatments

When lifestyle changes do not help enough, your health care provider may ask you to try prescription medications. A frank talk with your provider about the risks, side effects and benefits of each medication will help you decide which might be the right one for you.

Anticholinergic Drugs

Anticholinergic drugs treat OAB/UUI by helping the bladder muscle to relax. Common medications include oxybutynin, tolterodine and solifenacin. They work well for the bladder, but are also linked to many bothersome side effects such as dry mouth, constipation, blurred vision, and lately, some concern for causing confusion or dementia with longer-term use. Trospium chloride does not diffuse into the brain so is not thought to have a risk of confusion or dementia.

A newer medication for OAB is merbegron. It is not an anticholinergic medication, so it is not linked to any of the side effects described above. It is an alpha-agonist, so works a little differently on the bladder, but in the end has the same effect of getting the bladder to relax. It can cause increases in blood pressure so needs to be used with caution in patients with hypertension.

Be sure to talk about any bladder relaxing drugs you have tried when you talk with your urologist.

Hormone Treatment

For women, local vaginal/urethral estrogen therapy can help if you are having urinary incontinence after menopause. Estrogen replacement helps the health of the walls of the vagina, the bladder neck and the urethra. This may ease irritative bladder symptoms and incontinence. There are some special medical reasons not to use local hormones, so be sure to speak to your provider about what is best for you.

Surgical Treatments for SUI

Choosing to have surgery is very personal. If surgery is suggested, there are many choices. It helps to learn as much as you can before you decide. You should work with a doctor who has experience in SUI surgery. Learn the risks and benefits of all your surgical choices, as well as what to expect during and after surgery, to make the most informed choice that will be best for you.

Slings

  • Female Sling

The most common surgical treatment and the current standard of care for the surgical treatment of female SUI is the midurethral sling surgery. For this, a strip of soft permanent mesh is placed under the urethra to support urethral closure during actions that involve "physical pelvic stress" (coughing, sneezing, bending, lifting, jumping and running). It is a simple 10-20 minute, outpatient procedure with a small single-cut in the vagina. This is easily done under limited anesthesia and linked to a very quick return to normal day-to-day activities. Long-term success rates are in the 90%.

Another type of female sling surgery, the pubovaginal sling, is a bladder neck sling. Here the tissue used to make the sling comes from the patient's abdominal wall (fascia), or donated tissue (bovine or cadaver).

  • Male Sling

A sling procedure may be offered to treat SUI in some men. The male sling is for urethral sphincter muscle support. For this, a soft mesh tape is placed under the urethra through a cut between the scrotum and rectum. It supports the urethra and sphincter muscle by pushing up on the urethra and causing some coaptation (closure) of the urethra to prevent leaks. Ask your healthcare provider if this is an option for you.

Bladder Neck Suspension / Colposuspension

The Burch Colposuspension, or bladder neck suspension, is surgery for female SUI that lifts the bladder neck up towards the pubic bone with permanent stitches. This is a bigger surgery with a cut through the abdominal wall (muscles and skin), to reach the deeper pelvic areas. Because of the cut into the belly, it takes a longer time to heal from this surgery compared to the more minimally invasive midurethral sling, but it can be the right choice for some patients. In some cases it can be performed laparoscopically, which lessens the recovery time after surgery.

Bulking Agents (Injections)

This option is used to treat female SUI by "bulking up" the inner urethral lining and making the opening of the urethra smaller. Modern bulking agents are permanent materials that are placed into the tissues around the urethra and sphincter muscle up towards the bladder neck. This helps how well the natural urethral closure function can work to stop leaks.

Note that bulking agents are not FDA-approved for male SUI.

Artificial Urinary Sphincter

The most common treatment for male SUI is to implant a device around the urethra called an artificial urinary sphincter (AUS). In some cases, women may also be helped from this surgery, but due to other surgical options mentioned earlier, this is rarely needed in women. The AUS is a device with three parts:

  1. An artificial urinary sphincter, which is a fluid filled cuff placed around the urethra.
  2. A fluid-filled, pressure-sensing balloon that joins to the cuff and regulates the pressure within the cuff. This balloon is placed in the lower abdomen.
  3. A pump placed in the scrotum for men (and labia for women), that transfers the fluid between the cuff and the balloon to open and close the cuff (artificial urinary sphincter). The pump is easily controlled by the patient.

At rest, the AUS cuff is closed (full of fluid) to prevent leaks. When you decide to empty your bladder, you activate the pump to push fluid from the cuff to the balloon that holds your urine. This allows the urethra to open so that the urine can flow through and empty the bladder. This surgery can cure or greatly help urinary control in about 70-80% of men. If you have had radiation, scar tissue in the urethra, or other bladder problems then this option may not be the best option for you.

Surgical Treatments for OAB

If lifestyle changes and medicine are not working for your OAB, there are other options. A trained urologist or female pelvic medicine & reconstructive surgery (FPMRS) specialist can help.

Bladder Botox® Treatment

Your doctor may offer bladder Botox® (onabotulinumtoxin). Botox works for the bladder to relax the muscle of the bladder wall to reduce urinary urgency and urge incontinence. To put Botox into the bladder your doctor will use a small camera, a cystoscope, through the urethra and into the bladder. With a tiny needle attached to the cystoscope, the Botox is injected in small amounts straight into the wall of the bladder, spreading it out evenly throughout the bladder. This procedure is most often performed in the office with local anesthesia (numbing mixture in the bladder). The effects of Botox last about 6-9 months, so repeat treatments will be needed when OAB symptoms return.

Within a few weeks of the treatment, your health care provider will want to check to see how well it is working for you, and to make sure you are still able to empty your bladder well. A small amount (<10%) of patients have trouble emptying their bladder for a short time after the treatment and may need to use a catheter (small tube) until their voiding improves.

Nerve Stimulation

Another treatment for people who need extra help for their OAB is nerve stimulation, also called neuromodulation therapy. This type of treatment sends electrical pulses to nerves that share the same path for the bladder (pelvic nerves). In OAB, the nerve signals between your bladder and brain do not always communicate the right way. Treatment with electrical pulses help to modulate the neurological signaling so the brain and the pelvic nerves can communicate better to help the bladder function - to "calm down" -- and help OAB symptoms.

There are two main types available today:

  • Percutaneous Tibial Nerve Stimulation (PTNS)

Percutaneous Tibial Nerve Stimulation, or PTNS, (peripheral) is an easy way to modulate the nerves to your bladder. PTNS is performed in the office, with each session taking about 30 minutes. PTNS is done by placing a small needle electrode in your lower leg near your ankle. It sends stimulation pulses up the leg, by way of the tibial nerve, to the pelvic nerves that modulate the bladder function to "calm the bladder down." The therapy is approved as a program of weekly 30 minute sessions for 12 treatments, followed by on-going monthly care treatment sessions to keep the benefits.

  • Sacral Nerve Stimulation (SNS)

SNS (central) stimulates the pelvic nerves by way of direct sacral nerve stimulation - the nerve root coming right off the spinal cord. Stimulation here again serves to modulate the neurological signaling between the bladder and the brain to help bladder function. SNS involves an implantable bladder pacemaker to control these signals to stop OAB symptoms. SNS is a two-step surgical process, which gives patients the chance to try the therapy first before making choices about final surgical implantation of the pacemaker. The first step is to implant an electrical wire through the skin in your lower back that goes deep towards the sacral nerves. This wire is linked to an external, handheld pacemaker for the test. If it helps sufficiently for your OAB symptoms, the second step is to join the wire to an implantable permanent pacemaker. The stimulation is then continuous as it regulates the pelvic nerve activity to control the OAB symptoms.

Bladder Reconstruction / Urinary Diversion Surgery

These type of major abdominal surgeries are only used in very rare and complicated cases. There are two main categories of major abdominal surgery. The goal of augmentation cystoplasty is to make the bladder bigger to increase how much urine it can hold at any one time. The goal of urinary diversion is to re-route the flow of urine away from the bladder and often results in a stoma and external appliance to catch the urine. There are many risks to these surgeries, so it is offered only when no other option can help.

Surgical Treatments for Overflow Incontinence

Overflow urinary incontinence happens when the bladder cannot empty well and dribbles as the bladder pressure grows. Most often, it is linked to some type of block of the bladder neck and/or urethra, and requires some type of procedural or surgical action to fix the block. Common problems in men that can lead to holding urine in and overflow incontinence include an enlarged prostate (benign prostatic hyperplasia, BPH) and urethral strictures. It is quite rare for urethral strictures to happen in women. Other medical problems can change how the bladder contracts to empty, which can also lead to overflow incontinence.

You should speak with your urologist to learn what therapy might be right for you.

Products and Devices

For some people, incontinence products and devices are the only way to manage bladder problems to give you more freedom to do the things you want to do.

Some include:

  • Indwelling catheter (stays in your body day and night, joined to a drainage bag)
  • Intermittent catheters that are used many times each day
  • External collecting systems (condom style for men, funnel and pouch for women)
  • Absorbent products (pads, adult diapers, tampons)
  • Pessaries for women, mostly those designed for SUI
  • Toilet substitutes (like portable commodes)

Whatever your urinary problem is, there are likely good choices for you. It is vital to find a provider that specializes in bladder and incontinence problems, such as a urologist.

More Information

Preventing Future Problems

In most cases, managing or treating urinary symptoms can greatly help your quality of life, letting you return to activities you enjoy without being bothered by urinary symptoms or leakage. Lifestyle and food changes are the first steps. These changes need to be continued at all times for them to keep helping. Again, some of these recommendations include:

  • Keep a healthy weight.
  • Drink plenty of fluids -- about two liters per day - spread out evenly throughout the day. It is of great value to stay well hydrated, but there is not added benefit to drinking even more than your body needs.
  • Avoid foods or drinks that are known to bother YOUR bladder.
  • Eat more daily fiber to prevent constipation.
  • Practice Pelvic Floor "Kegel" exercises, and work to make your core stronger.
  • Stick with bladder re-training programs.

After lifestyle and food changes, most people feel a lot better. But if there is still room to make things better, then medications or simple surgical options may be the right next step for you. Finding the best treatment plan is a step-wise process of trying simple things first, before advancing to other choices. It is of great value to stay in touch with your health care provider during this process to make sure you are benefiting from the treatment options available and finding the right plan for you.

Questions to Ask Your Doctor

  • What type of incontinence do I have?
  • What tests will tell us the type and severity of my incontinence?
  • Can you help me or should I see a different doctor?
  • If I need a different doctor, how can I find the right one for me?
  • What do you think is causing my type(s) of incontinence?
  • Can I use the Urology Care Foundation's OAB Assessment Tool to help learn the type of incontinence I have?
  • Should I keep a bladder diary?
  • Without treatment, what will happen to me?
  • Will diet and lifestyle changes help me with my condition?
  • Should I try Kegel exercises? If so, how do I do these exercises the right way?
  • What other treatment(s) do you suggest for me and why?
  • Are there problems that can come from treatment?
  • What are the potential side effects or risks of treatment?
  • If leaking is linked to menopause, could hormone replacement therapy (HRT) help?
  • Do you suggest surgery?
  • What are the pros and cons of surgery?
  • What does healing look like after surgery?
  • If I keep having problems, what other options are available?
  • What follow-up care do I need?
  • What is my long-term plan?

Web Article Updated - April 2020