INCONTINENCE

There are five types of incontinence and each one has different mechanisms and treatment.

Stress Incontinence

Urine leaks when there is increased abdominal pressure, such as coughing, sneezing, laughing, exercising, or lifting. This is due to weakened pelvic floor muscles and tissues.

Stress incontinence is the most common type in younger and middle-aged women. It may be associated with pregnancy, childbirth, and menopause. It may also be associated with female athletes who have never given birth, and occurs while they are participating in sports. Other factors may also increase the risk for stress incontinence, such as being overweight or obese, having had prostate surgery, and taking certain medications.

Urge Incontinence

Urge incontinence is often referred to as overactive bladder: People who have this cannot hold their urine long enough to get to the toilet in time. This is caused by damage to the bladder’s nerves and/or muscles.

Conditions such as multiple sclerosis, Parkinson’s disease, diabetes, and stroke can affect nerves, leading to urge incontinence. Other conditions such as bladder infections, bladder stones, and use of certain medications can also contribute to symptoms. Risk factors for urge incontinence include aging, obstructions to urine flow (such as an enlarged prostate), and consumption of so-called bladder irritants (such as coffee, tea, colas, chocolate, and acidic fruit juices).

Symptoms of urge incontinence:

• Frequent and sudden uncontrollable need to urinate
• May leak a moderate to large amount of urine, although a small amount is possible

Mixed Incontinence

Mixed incontinence is caused by a combination of stress and urge incontinence.

Symptoms of mixed incontinence:

• mild to moderate urine loss with physical activities (stress incontinence)
• sudden urine loss without any warning (urge incontinence)
• Urinary frequency (needing to urinate more often than usual)
• Urgency (increased feeling of need to urinate)
• nocturia (increased amount of urination at night)

Overflow Incontinence

You may have overflow incontinence if you are not able to empty your bladder appropriately. As a result, you may have leakage once the bladder is already full. This is more common in men with symptoms of frequent dribbling of urine.

Causes of overflow incontinence include:

• benign prostatic hyperplasia
• bladder neck contracture
• urethral narrowing
• pelvic organ prolapse
• herniated lumbar disc
• diabetes-related bladder problems
• other nerve problems (peripheral neuropathy)

Symptoms of overflow incontinence:

• Feel like the bladder does not empty completely
• urine flows out slowly
• urine dribbles out after voiding
• Small amount of urine may be lost when intra-abdominal pressure is increased
• Frequency
• urgency

Functional Incontinence

This type of incontinence occurs when a person is unable to reach the toilet in time due to a physical or mental impairment. The main symptom of urinary incontinence is a problem controlling urination.

DIAGNOSIS

It’s important to determine the type of urinary incontinence that you have. That information will guide treatment decisions.

Medical History

By asking questions, a physician can better understand a patient’s particular situation and type of incontinence. Questions focus on:

• bowel habits,
• patterns of urination and leakage,
• pain, discomfort, or straining when voiding
• Medical and Surgical History: illnesses, pelvic surgeries, and pregnancies
• medications he or she is currently taking

Physical Examination

The cough stress test, in which the patient coughs forcefully while the physician observes the urethra, allows observation of urine loss. Instantaneous leakage with coughing suggests a diagnosis of stress incontinence. Leakage that is delayed or persistent after the cough suggests urge incontinence. The physical examination also helps the physician identify medical conditions that may be the cause of incontinence. For instance, poor reflexes or sensory responses may indicate a neurological disorder.

Voiding Diary

The physician may ask the patient to keep a record of his or her bladder activity. In the voiding diary, the patient records fluid intake, fluid output, and any episodes of incontinence. This contributes valuable information to help the physician understand the patient’s situation.

Pad Test

The pad test is an objective test that determines whether the fluid loss is in fact urine. The patient may be asked to take a medication that colors the urine. As fluid leaks onto the pad, it changes color indicating that the fluid lost is urine. The pad test may be performed during a one-hour period or a 24-hour period. The pads may be weighed before and after use to assess the severity of urine loss (1 gram of increased weight = 1 mL of urine lost).

Urine Studies

Because bladder infection, or urinary tract infection, can cause symptoms similar to urge incontinence, the doctor may obtain a sample of urine for urinalysis and urine culture to see if any bacteria are present.

Bladder cancer such as carcinoma in situ of the urinary bladder (cancer that is confined to the bladder lining cells in which it originated and has not spread to other tissues) can cause symptoms of urinary frequency and urgency, so a urine sample may be examined for cancer cells (cytology).

• A study of the urine called a chemistry 7 profile may be performed to test for poor kidney (renal) function.

Post-Void Residual Volume

The measurement of post-void residual (PVR) volume is a part of the basic evaluation for urinary incontinence.

To determine the PVR urine volume, either a bladder ultrasound or a urethral catheter may be used. The initial attempt to urinate should be evaluated for hesitancy, straining, or interrupted flow. A PVR volume less than 50 mL indicates adequate bladder emptying. Measurements of 100 mL to 200 mL or higher, on more than one occasion, represent inadequate bladder emptying.

Q-tip Test

This test is performed by inserting a sterile lubricated cotton swab (Q-tip) into the female urethra.

The cotton swab is gently passed into the bladder and then slowly pulled back until the neck of the cotton swab is fit snugly against the outflow tract of the bladder (the bladder neck). The patient is then asked to bear down (Valsalva maneuver) or to simply contract the abdominal muscles. Excessive motion of the urethra and bladder neck (hypermobility) with straining is noted as movement of the Q-tip and may correlate with stress incontinence.

RECOMMENDED MEDICATIONS

Treatment for urinary incontinence depends on the type of incontinence, its severity and the underlying cause. A combination of treatments may be needed.

Behavioral techniques

Your doctor may recommend:

• Bladder training
• Double voiding
• Scheduled toilet trips
• Fluid and diet management
• Pelvic floor muscle exercises or Kegel exercises

Electrical stimulation

Electrodes are temporarily inserted into your rectum or vagina to stimulate and strengthen pelvic floor muscles. Gentle electrical stimulation can be effective for stress incontinence and urge incontinence, but you may need multiple treatments over several months.

Medications

Medications commonly used to treat incontinence include:

• Anticholinergics. These medications can calm an overactive bladder and may be helpful for urge incontinence. Examples include oxybutynin (Ditropan XL), tolterodine (Detrol), darifenacin (Enablex), fesoterodine (Toviaz), solifenacin (Vesicare) and trospium (Sanctura).
• Mirabegron (Myrbetriq). Used to treat urge incontinence, this medication relaxes the bladder muscle and can increase the amount of urine your bladder can hold. It may also increase the amount you are able to urinate at one time, helping to empty your bladder more completely.
• Alpha blockers. In men with urge or overflow incontinence, these medications relax bladder neck muscles and muscle fibers in the prostate and make it easier to empty the bladder. Examples include tamsulosin (Flomax), alfuzosin (Uroxatral), silodosin (Rapaflo), terazosin (Hytrin) and doxazosin (Cardura).
• Topical estrogen. Applying low-dose, topical estrogen in the form of a vaginal cream, ring or patch may help tone and rejuvenate tissues in the urethra and vaginal areas. This may reduce some of the symptoms of incontinence.

Medical devices

Devices designed to treat women with incontinence include:

• Urethral insert
• Pessary

Interventional therapies

Interventional therapies that may help with incontinence include:

• Bulking material injections.
• Botulinum toxin type A (Botox)
• Nerve stimulators

Surgery

If other treatments aren’t working, several surgical procedures can treat the problems that cause urinary incontinence:

• Sling procedures
• Bladder neck suspension
• Prolapse surgery
• Artificial urinary sphincter

Absorbent pads and catheters

If medical treatments can’t completely eliminate your incontinence, you can try products that help ease the discomfort and inconvenience of leaking urine:

• Pads and protective garments
• Catheter