Learn about: Stress incontinence, Urge incontinence (over-active bladder), Over-flow, Mixed incontinence. Causes, symptoms, diagnosis, treatment.
Imagine yourself going for a walk or a run and each time you take a step you feel urine or stool leak. This is what women with incontinence experience and often find it embarrassing and debilitating. It is often the result of pelvic floor damage. Women with urinary incontinence problems may have one or more of the following:
- Stress incontinence: This happens when something you do — such as coughing, laughing, sneezing jumping, lifting, exercise — increases the pressure in your abdomen enough that it pushes urine past the urethra. In other words, some external force pushes on the bladder and urine squirts out.
- Urge incontinence (over-active bladder): Women with this are not able to wait until it is convenient to empty their bladder. They find that "When I have to go, I have to go." This occurs because the normal ability to tell the bladder to wait until it is the right time is weakened. When a woman feels the need to empty her bladder telling the bladder to wait simply doesn't work anymore. Some women have to get up frequently during the night to urinate, they may wet the bed and go to the bathroom at least every two hours to avoid wetting themselves. This is sometimes referred to as "latch key" incontinence.
- Over-flow: This is a rare condition where women leak small amounts of urine frequently because their bladder is constantly full. With this condition the bladder does not empty completely and as a result the bladder becomes progressively swollen. The bladder is unable to do its job properly and urine leaks due to overflow.
- Mixed incontinence: Women with urinary incontinence generally have stress, urge, and often times mixed incontinence, which is a combination of both stress and urge. Sometimes women experience problems with urination due to other conditions such as frequency or fluid intake.
As you read this paragraph, your bladder is filling with urine. Urine produced by the kidneys travels through the ureters into the bladder and the bladder expands to accept the arriving urine. Normally, the bladder can go from empty to holding between 8 and 15 ounces (about 1-2 cups) of urine before it needs to empty. The urethra is the tube that connects the bladder with the outside and is the tube which urine passes through during urination. While the bladder is filling, muscles in the urethra tighten so that urine stays in the bladder and does not dribble out.
How the process works
Imagine a balloon as it is filled with water. If you squeezed the balloon, or contracted it, the water would leak out. The balloon needs to be flexible (or relaxed) as the water enters. And to further ensure that the water would not escape you would pinch closed the opening of the balloon. In other words, in order to keep the water from leaking you would allow the balloon to remain flexible and pinch close the opening. Similarly, urinary control happens when these two elements are present: a bladder that relaxes while it fills and a urethra that stays closed.
So, what happens when you want to go to the bathroom? The situation reverses itself. In order to empty your bladder, the muscles of the urethra and pelvic floor relax and the bladder begins to contract. Like squeezing the balloon, the detrusor muscles (a smooth muscle of the bladder) contracts causing the bladder to push the urine out through the relaxed urethra until the bladder is empty.
How does the bladder know when to relax and when to contract? Our ability to decide when it is right or wrong to empty the bladder is something that is established during toilet training. When we are born, our bladder fills to a certain point and automatically empties itself no matter where we are. During toilet training, you learn to control your bladder and allow it to empty only when it is an appropriate time. This control over the bladder is not direct. It is not like moving your hand to scratch your nose. Rather, it is a state of mind that you can establish. This is similar to breathing, it happens on its own but you can control it when necessary. This state of mind allows the bladder to contract even though you cannot directly control it.
When the system breaks down
What happens when certain aspects of the system break down? If the bladder contracts, pressure is put upon it, or the urethra does not stay closed, the result is some form of leakage, known as incontinence. Because the system to hold urine in place is made up of several parts, there are various forms of incontinence caused by different factors.
- Stress incontinence: Stress incontinence usually is a result of damage to the urethra or the bladder neck. When the urethra and the urethral sphincters are damaged, a condition called intrinsic sphincter deficiency (ISD) can result. This condition usually results in severe stress incontinence. Stress incontinence can also be caused by damage to the supportive structures of the UVJ. If these structures fail, then the urethra is "hypermobile" or moves too much leading to incontinence.
- Urge incontinence: Urge incontinence is usually the result of problems with the bladder muscle. The bladder muscle can tighten or contract involuntarily when it should be relaxed. This leads to urge incontinence.
Mixed incontinence: Women can have a combination of two the above
problems leading to what is referred to as "mixed" incontinence.
Other causes of urinary incontinence:
The cause of urinary incontinence is varied. It can ranges from childbirth, aging, medications, various medical conditions, to behavioral causes.
Recent childbirth: " I just had a baby and now I leak urine. Will it go away?" This is one of the most common causes of urinary incontinence among women. The exact reason why women leak urine after having a baby is unclear, yet there does seem to be a direct cause. Even some women who underwent caesarean instead of vaginal delivery report increased leakage after delivery. When this happens, your care provider will usually encourage you to watch and wait for up to 6 months after delivery as there is a natural recovery process where the majority of women who leak urine after pregnancy do recover.
Aging/Menopause: As women age, more of them develop urinary incontinence. Some women have worsening symptoms around the time of menopause but the relation between hormones and incontinence is not known.
Medical conditions that can cause urinary incontinence:
Urinary Tract Infection: (UTI): Acute or chronic Urinary Tract Infection (UTI) can result in symptoms of urge and frequency incontinence. This is something your doctor may test you for to make sure it is not a cause. Chronic UTIs can result in symptoms of urge and frequency incontinence.
- Congestive heart failure
- Excessive fluid intake
- Neurological - strokes, multiple sclerosis, Alzheimer’s disease
Medications that can cause urinary incontinence:
- Calcium channel blockers
There are many common habits or behaviors that can lead to or significantly worsen incontinence. Your doctors may ask you to keep track of a "Bladder Diary" so that they can see if you can treat the incontinence by modifying behaviors.
- Bladder irritants: The most common are caffeine, decaffeinated coffee, carbonated beverages such as soda, juices, and spicy foods.
- Excessive fluid intake: Women often drink too many fluids for general health which results in incontinence. A recommended amount of fluid for bladder health can be anywhere from 30-60 oz/ day depending on the individual.
- Stress Incontinence: loss of urine with coughing, sneezing, laughing, or exercise.
Urge incontinence: loss of urine that happens because you can’t
make it to the bathroom in time, you have to an urge to go very
Women with pelvic urinary incontinence often feel alone, isolated, and depressed. They may feel embarrassed by this condition. Because urine leakage is often associated with children they may try to hide their condition and feel embarrassed by their body. Women may also feel that it is an inevitable part of growing older or that’s it’s just the natural course of life. This belief leads women to think that incontinence is caused by age and thus irreversible.
While it is true that older women more commonly have involuntary loss of urine than younger women, age alone is not usually the cause of severe incontinence. Often times this condition can lead to reduced intimate contact and social isolation. However, incontinence is a medical condition and should be treated as such. Many forms of incontinence are treatable once a doctor is consulted.
When you go in to see your doctor you will have a health history taken. Some of the questions you may be asked include:
- What types of symptoms you are having?
- Do you have any type of chronic disease such as asthma, bronchitis, etc?
- Did you have any vaginal births?
- Do you smoke?
Do you do heavy lifting or stand on your feet for long periods of time?
To find out what treatment will be most useful in treating your symptoms of urine loss, your doctor will do a pelvic exam. This is usually done while you lie on an exam table, or sometimes while sitting or standing. The doctor may ask you to push down or cough to see how much urine you leak. The doctor will exam you for pelvic prolapse by having you push down or cough to see the full extent of the prolapse. A pelvic exam may be performed where a speculum in inserted into your vagina. A rectal exam might also be performed to check the strength of these muscles which can weaken with age or childbirth. The doctor will also likely as you do a Kegel (pelvic floor contraction- these are the muscles that you use to stop the flow of urine).
Are there other tests I can expect as part of my evaluation?
- Post-void Residual (PVR): A post-void residual (PVR) is done to determine how much urine is left behind after you urinate. It is normal for the bladder to not completely empty itself of a small amount of urine. Even though you may have voided ten minutes earlier urine may still be collected from your bladder. The post-void residual test consists of you first emptying your bladder and then within 15 minutes a catheter is placed in your bladder to determine the amount of urine left behind. Most women have a post-void residual between 0-60cc. A PVR is done to determine if you have any urinary retention which can be a sign of an underlying condition. Most doctors will conduct follow up studies if the PVR is over 100cc.
- Urinalysis: This test is done to determine if you have an infection or other substances found in the urine. It is usually performed at the beginning of any type of bladder test. A clean catch of urine is obtained and then a test strip is dipped into the urine. Results are usually obtained within minutes. If you have a high white blood cells count it could indicate a bladder infection. For follow-up doctors may also send your urine out to be cultured which is a more sensitive test.
- Bladder testing (Urodynamics): Urodynamic testing is a series of
bladder tests that are done in order to see how your bladder reacts
under certain conditions. It is usually done to see if you have
problems with loss of urine (urinary incontinence) or to figure out
what type of incontinence you may have.
Cystometry, sometimes also referred to by the general term urodynamics,
consists of filling your bladder with sterile water, observing the
pressure and how your bladder reacts under these conditions. When the
test begins the physician places a small soft catheter in your bladder
and a tube is hooked up to a bag of sterile water. Your bladder is then
filled to around 250cc (approx. 1 cup) which most women can hold
without needing to urinate. A second catheter which is connected to a
machine or computer is also inserted. This catheter measures the
pressures within your bladder.
Once the bladder is filled you will be asked to cough and strain in order to see how much urine you leak. Also, many women will leak if their bladder is full and they cannot get to the bathroom in time.
- Voiding (Bladder) Diary: An important tool in guiding treatment for urine loss is to keep records over a 3 day period of your bladder function. The diary will ask you to measure the volume voided with every void. In the clinic you will be given a special container to put on the toilet to help measure urine volumes. You will also record the times in which you voided, time when you loss urine, and type of urine loss (urge versus stress incontinence). You will also keep track of your fluid intake- what type, when and how much. At your follow-up visit your doctor will review your diary with you and make recommendations about treatments that might improve or cure you symptoms of urine loss.
UVA's Women's Center for Continence and Pelvic Surgery offers a number of treatment options.
- Decreasing intake of fluids- women with bothersome urine loss are likely to benefit from limiting their fluid intake to a total of 50-60 ounces, per day provided they do not have a medical condition that prohibits limiting fluids.
Avoiding or decreasing certain types of fluids- caffeinated
beverages (example: colas, teas, and coffee), alcohol, or acidic juices
(example: grapefruit juice, orange juice).
There are different types of bladder training to improve symptoms of stress and urge incontinence. The type of training recommended by the nurse or doctor will have to do with your ability to move without any difficulty.
- Classic bladder training (Habit training): Typically this type of training is used for women with symptoms of an overactive bladder- urgency, frequency or urge incontinence. This type of training includes first keeping a bladder diary and then setting up a voiding schedule to slowly increase the interval between voids (time between void). At weekly intervals, the voiding interval is increased by 15 minutes. The goal is to eventually void every 2 to 3 hours. Important in this training is learning to suppress the urge to void before the scheduled time. Performing pelvic floor contractions (Kegels) is one way to suppress the urge. This therapy trains the bladder to delay voiding for larger time intervals and has been proven effective in treating urge and mixed incontinence.
- Timed voiding: this type of training, unlike habit training fixes intervals for patients to empty their bladder. This type of bladder training in commonly used when the doctor prescribes medication for overactive bladder.
- Prompted voiding: The care giver prompts the incontinent patient to go to the bathroom every 2-4 hours. This puts the patient on a regular voiding schedule. The goal is simply to keep the patient dry and is a frequently recommended therapy for frail elderly, bedridden or Alzheimer's patients. Note: There are multiple pads commercially available specifically for incontinence.
- Pelvic muscle rehabilitation (Kegel Exercises): This technique involves pelvic muscle exercises (PME). PME may be used alone or in conjunction with biofeedback therapy, vaginal weight training, pelvic floor stimulation
- Pessaries: A pessary is a device worn in the vagina to help support the prolapsed organ. Pessaries come in many different shapes and sizes and must be fitted by a doctor. While a pessary may ease your symptoms it does not repair the prolapse. A pessary can be taken in and out either on a daily, weekly or monthly basis. This will depend on you and your doctor. It does, however, need to come out periodically for cleaning.
- Urge incontinence (overactive bladder): Medications to treat undesired bladder contractions include tolterodine (Detrol), oxybutynin (Ditropan), solifenacin (Vesicare), and darifenacin (Enablex). These medications block the receptors on the bladder responsible for contraction. This allows more urine storage before undesired contractions occurs.
Stress incontinence: Symptoms can be improved with medications such
duloxetine (Cymbalta) and imipramine (Tofranil). These medications can
increase the activity of the muscle surrounding the urethra (the tube
that carries urine from the bladder to the outside).
Vaginal surgery for stress incontinence:
Sling procedures are surgeries used to treat stress urinary incontinence symptoms. A piece of tissue or artificial mesh is placed underneath the urethra. It acts as a layer of support so that the urethra is closed off when there is increased pressure in the abdomen (for example, laughing, coughing, sneezing, and exercising). Materials commonly used include a patient’s own fascia (the tough covering around muscles), a piece of animal tissue specially treated for human use, or polypropylene mesh. The following are common sling procedures:
- Pubovaginal sling uses a piece of a patient’s own fascia (autologous) or piece of animal tissue. It requires a small abdominal incision ranging from 5-10 centimeters (2-4 inches) on the lower abdomen.
- Tension free Vaginal Tape (TVT, Gynecare) uses a mesh which is place The mesh is directed behind the pubic bone and exits on the lower abdomen within the hair-bearing area of the mons in two 1cm (1/2 inch) incisions.
Transobturator Tension free Vaginal Tape (TVT-O, Gynecare) also
uses a mesh. It differs slightly from the TVT. The mesh is directed
around the pubic bones to exit at about the crease of the inner thigh
from a one-centimeter (1/2 inch) incision.
Urethral bulking agents for stress incontinence symptoms:
There are multiple agents that can be injected into or around the urethra. These agents narrow the width of the urethra and can help to control stress incontinence symptoms. Examples include biodegradable agents such as collagen (Contigen), and non biodegradable agents include carbon-coated zirconium beads (Durasphere), silicone (Macroplastique Implantation System), calcium hydroxylapatite (Coaptite) and ethylene vinyl alcohol (Uryx).