Female Urinary Incontinence
What is Urinary Incontinence?
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.
The Causes of Urinary Incontinence
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 Bladder 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 Urinary 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 of the above problems, leading to what is referred to as "mixed" incontinence.
Typical 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.
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 ounces per day depending on the individual.
Symptoms of Urinary Incontinence
- 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 frequently.
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 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.
Diagnosing Urinary Incontinence
When you go in to see your doctor, you'll 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 ask you to 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 0-60 cc. 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 100 cc.
- Urinalysis: This test is done to determine if you have an infection or other substances found in the urine. It's 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 250 cc (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.
Do You Have Incontinence?
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