Urinary Incontinence

Overview

The involuntary flow of urine is known as urinary incontinence. This disorder is more common in the elderly, affecting both health and quality of life, although it can also afflict younger persons. Urinary incontinence is frequent and can range from a minor leak when you laugh, cough, sneeze, or exercise to an inability to control your bladder completely.

Urinary incontinence can be treated, controlled, and even cured in many situations. It is critical to discuss your symptoms with your doctor or a continence professional. Many people are too embarrassed to seek treatment because of the stigma that surrounds it. However, most illnesses that cause UI may be treated medically or by alternative methods.

What is Urinary Incontinence?

Urinary incontinence (UI) is defined as the unintentional loss of urine. Urinary incontinence can have a negative influence on both patient health and quality of life. The prevalence may be underestimated because some people may not disclose their health care providers that they have urine incontinence for a variety of reasons.

Urinary incontinence may be classified into several categories, including stress urinary incontinence, urge urinary incontinence, functional incontinence, mixed incontinence, and overflow incontinence. Most urologic or gynecologic evaluations are not required at the first exam, but reversible reasons should be checked out. The treatment of urine incontinence is determined by the kind of incontinence and the severity of the symptoms.

Is Urine Incontinence Common?

Over 25 million adult Americans suffer with either transient or chronic urine incontinence, according to the National Association for Continence. UI may happen at any age but it is more frequent in women over the age of 50. Urinary incontinence may be a transient symptom caused by another medical problem. It can range from the discomfort of minor pee losses to severe, regular wetness.

What Causes Urinary Incontinence?

In most cases, urinary incontinence is caused by issues with the muscles and nerves that enable the bladder hold or pass pee. Certain women's health events, such as pregnancy, delivery, and menopause, might create issues with these muscles and nerves.

Other causes of urinary incontinence include:

Overweight. Obesity increases strain on the bladder, which can weaken the muscles over time. A weak bladder is unable to store as much pee.
Constipation. People suffering from long-term (chronic) constipation may experience bladder control issues. Constipation, or straining for a bowel movement, can place strain on the bladder and pelvic floor muscles. This causes muscular weakness and might result in urine incontinence or leakage.
Damage to the nerves. When nerves are damaged, they may deliver signals to the bladder at the wrong time or not at all. Diabetes and multiple sclerosis, as well as childbirth, can cause nerve loss in the bladder, urethra, and pelvic floor muscles.
Surgery. Any operation involving a woman's reproductive organs, such as a hysterectomy, can harm the muscles that support the pelvic floor, especially if the uterus is removed. If a woman's pelvic floor muscles are injured, her bladder muscles may not function properly. Urinary incontinence can result from this.

Sometimes urinary incontinence lasts only for a short time and happens because of other reasons, including:

Specific medications. Diuretics (used to treat heart failure, liver cirrhosis, hypertension, and some renal illnesses) may cause urinary incontinence as a side effect. When you stop using the medication, the incontinence usually goes away.
Caffeine. Caffeine-containing beverages can cause the bladder to fill fast, causing you to leak pee. According to research, women who consume more than two cups of caffeine-containing beverages each day are more prone to experience incontinence issues. Caffeine restriction may assist with incontinence since it puts less strain on your bladder.
• Infection. Urinary tract and bladder infections can induce incontinence for a short period of time. When the illness is gone, bladder control usually recovers.

Types of Urinary Incontinence

There are different types of urinary incontinence. The following are the most common:

Stress incontinence. The most prevalent sort of incontinence is this. It's also the most prevalent kind of incontinence among young women. When there is tension or strain on the bladder, stress incontinence occurs. Stress incontinence occurs when weak pelvic floor muscles exert strain on the bladder and urethra, causing them to work harder. Everyday acts that activate the pelvic floor muscles, such as coughing, sneezing, or laughing, might cause you to leak urine if you have stress incontinence. Urine leakage can also be caused by sudden movements and physical exercise.
Urge incontinence. Urine leaking with urge incontinence generally occurs after a strong, sudden desire to urinate and before you can get to a restroom. Some women with urge incontinence can use the restroom but need to urinate more than eight times per day. They also do not urinate frequently after using the restroom. Urge incontinence is sometimes known as "overactive bladder." Urge incontinence is more frequent in women over the age of 50. It might happen unexpectedly, such as when sleeping, after drinking water, or when you hear or touch rushing water.
Overflow incontinence. This happens when a person is unable to completely empty their bladder and it overflows when additional pee is generated. It is frequently observed in patients who have diabetes or spinal cord injury.
Mixed incontinence. You show evidence of more than one type.
Functional incontinence. This sort of incontinence is caused by the practicalities of getting to a restroom on time rather than a bladder disease. It is most common in elderly or handicapped persons who have normal or near-normal bladder control but are unable to use the restroom on time due to mobility difficulties or disorientation.
Nocturia: Urge to urinate twice or more throughout the night, which generally affects men and women over the age of 60. Nocturia in males might be a sign of an enlarged prostate.

Pathophysiology of Urinary Incontinence

Incontinence can occur when the bladder muscles tense unexpectedly and the sphincter muscles are unable to clamp the urethra shut. This generates an intense need to urinate that you may be unable to control. Urine leakage can be induced by the pressure created by laughing, sneezing, or exercising. Urinary incontinence can also occur if the nerves that regulate the bladder muscles and urethra are damaged. Urinary incontinence can occur when you leak a tiny bit of pee or when you release a large volume of urine all at once.

Why does Urinary Incontinence affect more women than men?

Pregnancy, delivery, and menopause are all unique health experiences for women that can alter the urinary tract and associated muscles. The pelvic floor muscles, which support the bladder, urethra, uterus (womb), and intestines, may weaken or become injured. When the muscles that support the urinary system are weak, the urinary tract muscles must work harder to retain pee until you are ready to urinate. This additional strain or pressure on the bladder and urethra might result in urine incontinence or leaking.

In addition, the female urethra is shorter than the male. Any weakening or injury to a woman's urethra increases her risk of urine incontinence. This is due to less muscle holding the urine in until you're ready to urinate.

What are the Symptoms of Urinary Incontinence?

To assess the type, severity, burden, and duration of urine incontinence, the history should be considered. Voiding diaries might assist offer specifics regarding incontinence events. Signs and symptoms of life-threatening illnesses (such as cauda equina syndrome) and reversible causes should be investigated.

The type of urinary incontinence can often be determined by the history:

Stress urinary incontinence – Patients can predict the inciting activity.
Urge urinary incontinence – There may be frequency, urgency, and nocturia. Volume loss is vary, ranging from none to inundation.
Mixed urinary incontinence – Both stress and urge incontinence have symptoms. Determine which component is the most frequent and bothersome.
Overflow urinary incontinence – This syndrome is related with inefficient bladder emptying. The patient may agree to the stretching.
Functional urinary incontinence – The history may suggest physical or cognitive impairment.

Patients should be asked about medical conditions such as:

Chronic obstructive pulmonary disease and asthma (which can cause cough),
Heart failure (with related fluid overload and diuresis),
Neurologic conditions (which may suggest dysregulated bladder innervation),
Musculoskeletal conditions (which may contribute to toileting barriers)

The surgical history should be reviewed as well, as the relevant anatomy and innervation may have been affected.

A gynecologic history should be collected for females to determine the number of births, whether they were vaginal or by c-section, and whether they are presently pregnant. Furthermore, estrogen level should be assessed since atrophic vaginitis and urethritis can cause reversible urine incontinence during perimenopause.

Patients should be asked about their medication and drug usage (e.g., diuretics, alcohol, caffeine), as they might contribute to incontinence either directly or indirectly. Potential side effects include cognitive impairment, changes in bladder tone or sphincter function, cough induction, diuresis promotion, and so on.

Symptom severity is asked about to determine the aggressiveness of treatment.

Physical exam

If necessary, the following physical exam components and results should be evaluated:

Cardiovascular - pedal edema, jugular venous distension
Pulmonary - pulmonary crackles, cough
Abdominal - Masses, surgical scars
Musculoskeletal - extremity strength, range of motion, and overall function
Genitourinary/rectal - bladder distension, vaginal atrophy, pelvic organ prolapse, prostatic hypertrophy, fecal impaction, rectal tone
Neurologic - cognitive function, sensory, reflexes

Tests and maneuvers to consider, but are not necessary, are:

Cough stress test - To show involuntary pee leakage, the patient is instructed to cough. When performed while standing, the test is more sensitive.
Cotton swab test - The patient is asked to Valsalva after a swab is inserted into the bladder through the urethra to indicate urethral hypermobility (associated with stress urine incontinence), with a good result being an angle change of more than 30 degrees. When the angle ranges from 21 to 49 degrees, the test results may not agree.

How is Urinary Incontinence Diagnosed?

Your doctor or nurse will inquire about your symptoms and medical history, such as:

How often you empty your bladder?
How and when you leak urine?
How much urine you leak?
When your symptoms started?
What medicines you take?
If you have ever been pregnant and what your labor and delivery experience was like.

A physical exam will be performed by your doctor or nurse to search for indicators of health conditions that may cause incontinence.

Your doctor or nurse also may do other tests such as:

Urine analysis. The doctor or nurse will send your urine to a lab after you urinate into a cup. Your urine will be tested in the lab for infection or other reasons of incontinence.
Ultrasound. Your doctor will use an ultrasound wand to capture photographs of your kidneys, bladder, and urethra on the exterior of your abdomen. Your doctor will search for anything out of the ordinary that might be causing urine incontinence.
Stress test for the bladder. During this test, you will cough or bear down as if pushing during childbirth, while your doctor looks for urine loss.
Cystoscopy. To search for damaged tissue, your doctor inserts a small tube with a tiny camera into your urethra and bladder. Depending on the sort of cystoscopy you require, your doctor may numb your skin and urinary organs while you are awake, or you may be completely sedated.
Urodynamics. Your doctor will place a tiny tube into your bladder and fill it with water. This lets your doctor to determine how much fluid your bladder can contain by measuring the pressure in your bladder.

Your doctor or nurse may instruct you to keep a journal for two to three days to record when you empty your bladder or leak pee. The diary may assist your doctor or nurse in identifying trends in your incontinence that may provide information about the likely cause and therapies that may be effective for you.

How is Urinary Incontinence Treated?

The kind of urine incontinence determines treatment and management. There are conservative, pharmaceutical, and surgical treatment options. Treatment and care should begin with the least intrusive treatments and progress as needed:

Stress urinary incontinence

Conservative management - behavioral therapy (controlling fluid intake, prompted voiding, constipation management, etc.), electrical stimulation, mechanical devices (cones, pessaries, urethral plugs), pelvic floor muscle strengthening (Kegel and floor muscle exercises), weight loss
Pharmacologic management - alpha-adrenergic agonists (e.g., phenylpropolamine), duloxetine
Surgical management - intravesical balloons, trans- or periurethral injections of bulking agents, sling procedures, urethropexy

Urge urinary incontinence

Conservative management - similar to the treatment for stress urinary incontinence with the exception of mechanical devices
Pharmacologic management - antimuscarinics (e.g., darifenacin, solifenacin, oxybutynin, tolterodine, fesoterodine, trospium), topical vaginal estrogen (not FDA approved), mirabegron
Surgical management - neuromodulation, onabotulinumtoxinA injection

Mixed urinary incontinence

Treatment and management as above, focusing on dominant symptoms

Overflow urinary incontinence

Conservative management - clean intermittent catheterization, indwelling urethral catheter, relief of obstruction
Pharmacologic management - alpha-adrenergic antagonists (e.g. terazosin, tamsulosin)
Surgical management - suprapubic catheter

Functional urinary incontinence

Underlying causes should be addressed or alleviated if possible

Medications should be balanced, and coffee and alcohol should be avoided if they are leading to incontinence. Urinary incontinence can be challenging to control in end-of-life care and should be treated on a case-by-case basis. In rare cases, an indwelling catheter or condom catheter may be required to provide maximum comfort to the patient in their latter stages of life.

Prognosis

Patients' responses to therapy and management differ. Multiple therapy modalities should be used to achieve best symptom management in people whose symptoms cannot be fully removed. The following are the median cure rates for stress, urge, and mixed urine incontinence by selected modalities:

Stress urinary incontinence

- 1. 84.4% at 12 months for women that received surgical interventions
  2. 53% after 3 years for males that received slings
  3. 58.8% at 12 months for women that used supervised pelvic floor muscle training (PFMT)
  4. 78% at 6 months for men that used PFMT

Urge urinary incontinence

49% at 12 months for women that used antimuscarinics
17% at 10 years for women that used sacral neuromodulation
15.9% to 50.9% at 3 months in women that used onabotulinumtoxinA

Mixed urinary incontinence

82.3% for women that received surgical interventions
47% for men that used supervised PFMT
28% at 6 months for women with supervised PFMT

Complications

Complications related to urinary incontinence include:

Urinary tract infections
Renal dysfunction secondary to obstructive uropathy
Cellulitis
Pressure ulcers
Medication side effects:

Alpha-adrenergic agonists side effects: dry mouth, restlessness, hypertension, insomnia
Duloxetine: dry mouth, nausea, fatigue, constipation, hyperhidrosis
Antimuscarinic side effects: dry mouth, constipation, blurred vision, dry eyes, fatigue, difficulty in micturition, palpitations
Mirabegron: urinary tract infections, hypertension, dry mouth
OnabotulinumtoxinA injection: urinary tract infections, urinary retention
Alpha-adrenergic antagonists: hypotension, dizziness, fatigue, sedation

Trauma and infection due to catheterization
Worsening of urinary incontinence after surgical intervention
Social isolation
Decreased physical activity
Sexual dysfunction
Increased caregiver burden
Increased risk of falls and subsequent fractures
Depression

Conclusion

Urinary incontinence is simply the leakage of urine. Incontinence can range from a few drops of pee seeping to total bladder emptying. If you have this condition, see your doctor. You run the danger of developing rashes, blisters, skin infections, and urinary tract infections if you conceal your incontinence. You may also shun friends and family members out of fear and humiliation.