urinary incontinence

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Urinary Incontinence

 

Definition

Urinary incontinence is unintentional loss of urine that is sufficient enough in frequency and amount to cause physical and/or emotional distress in the person experiencing it.

Description

Approximately 13 million Americans suffer from urinary incontinence. Women are affected by the disorder more frequently than are men; one in 10 women under age 65 suffers from urinary incontinence. A study published in late 2002 found that between 21% and 29% of adult women in the workforce reported at least one episode of urinary incontinence each month. Older Americans, too, are more prone to the condition. Twenty percent of Americans over age 65 are incontinent. In general, the condition is underrecognized and undertreated.
There are five major categories of urinary incontinence: overflow, stress, urge, functional, and reflex.
  • Overflow incontinence. Overflow incontinence is caused by bladder dysfunction. Individuals with this type of incontinence have an obstruction to the bladder or urethra, or a bladder that doesn't contract properly. As a result, their bladders do not empty completely, and they have problems with frequent urine leakage.
  • Stress incontinence. Stress incontinence occurs when an individual involuntarily loses urine after pressure is placed on the abdomen (i.e., during exercise, sexual activity, sneezing, coughing, laughing, or hugging).
  • Urge incontinence. Urge incontinence occurs when an individual feels a sudden need to urinate, and cannot control the urge to do so. As a consequence, urine is involuntarily lost before the individual can get to the toilet.
  • Functional incontinence. Individuals who have control over their own urination and have a fully functioning urinary tract, but cannot make it to the bathroom in time due to a physical or cognitive disability, are functionally incontinent. These individuals may suffer from arthritis, Parkinson's disease, multiple sclerosis, or Alzheimer's disease.
  • Reflex incontinence. Individuals with reflex incontinence lose control of their bladder without warning. They typically suffer from neurological impairment.
In some cases, an individual may develop short-term or acute incontinence. Acute incontinence may occur as a symptom or by-product of illness, as a side effect of medication, or as a result of dietary intake. The condition is typically easily resolved once the cause is determined and addressed.

Causes and symptoms

Urinary incontinence can be caused by a wide variety of physical conditions, including:
  • Childbirth. Childbirth can weaken the pelvic muscles and cause the bladder to lose some support from surrounding muscles, resulting in stress incontinence.
  • Dysfunction of the bladder and/or the urinary sphincter. In a continent individual, as the bladder contracts, the outlet that releases urine into the urethra (bladder sphincter) opens and urine exits the body. In individuals with overflow incontinence, bladder contractions and dilation of the sphincter do not occur at the same time.
  • Enlarged prostate. In men, an enlarged prostate gland can obstruct the bladder, causing overflow incontinence.
  • Hysterectomy or other gynecological surgery. Any surgery involving the urogenital tract runs the risk of damaging or weakening the pelvic muscles and causing incontinence.
  • Menopause. The absence of estrogen in the postmenopausal woman can cause the bladder to drop, or prolapse.
  • Neurological conditions. The nervous system sends signals to the bladder telling it when to start and stop emptying. When the nervous system is impaired, incontinence may result. Neurological conditions such as multiple sclerosis, stroke, spinal cord injuries, or a brain tumor may cause the bladder to contract involuntarily, expelling urine without warning, or to cease contractions completely, causing urinary retention.
  • Obesity. Individuals who are overweight have undue pressure placed on their bladder and surrounding muscles.
  • Obstruction. A blockage at the bladder outlet may permit only small amounts of urine to pass, resulting in urine retention and subsequent overflow incontinence. Tumors, calculi, and scar tissue can all block the flow of urine. A urethral stricture, or narrow urethra caused by scarring or inflammation, may also result in urine retention.
Acute incontinence is a temporary condition caused by a number of factors, including:
  • Bladder irritants. Substances in the urine that irritate the bladder may cause the bladder muscle to malfunction. The presence of a urinary tract infection and the ingestion of excess caffeine can act as irritants. Highly concentrated urine resulting from low fluid intake may also irritate the bladder.
  • Constipation. Constipation can cause incontinence in some individuals. Stool that isn't passed presses against the bladder and urethra, triggering urine leakage.
  • Illness or disease. Diabetes can greatly increase urine volume, making some individuals prone to incontinence. Other illnesses may temporarily impair the ability to recognize and control the urge to urinate, or to reach the toilet in time to do so.
  • Medications and alcohol. Medications that sedate, such as tranquilizers and sleeping pills, can interfere with the proper functioning of the urethral nerves and bladder. Both sedatives and alcohol can also impair an individual's ability to recognize the need to urinate, and act on that need in a timely manner. Other medications such as diuretics, muscle
    Strengthening the pelvic floor muscles by performing Kegel exercises helps to alleviate stress incontinence in women. Contract the pelvic floor muscles as if stopping an imaginery flow of urine. Hold for 10 seconds and repeat.
    Strengthening the pelvic floor muscles by performing Kegel exercises helps to alleviate stress incontinence in women. Contract the pelvic floor muscles as if stopping an imaginery flow of urine. Hold for 10 seconds and repeat.
    (Illustration by Electronic Illustrators Group.)
    relaxants, and blood pressure medication can also affect bladder function.
  • Surgery. Men who undergo prostate surgery can suffer from temporary stress incontinence as a result of damage to the urethral outlet.

Diagnosis

Urinary incontinence may be diagnosed by a general practitioner, urologist, or gynecologist. If the patient is over age 65, a geriatrician may diagnose and treat the condition. A thorough medical history and physical examination is typically performed, along with specific diagnostic testing to determine the cause of the incontinence. Diagnostic testing may include x rays, ultrasound, urine tests, and a physical examination of the pelvis. It may also include a series of exams that measure bladder pressure and capacity and the urinary flow (urodynamic testing). The patient may also be asked to keep a diary to record urine output, frequency, and any episodes of incontinence over a period of several days or a week.

Treatment

There are numerous invasive and noninvasive treatment options for urinary incontinence:
  • Behavior modification therapy. Behavior modification is a psychological approach to the treatment of urinary incontinence in which patients gradually increase the length of the time interval between voidings and "retrain" the bladder in other ways. It is reported to be highly effective in treating urge incontinence.
  • Biofeedback. The use of sensors to monitor temperature and muscle contractions in the vagina to help incontinent patients learn to control their pelvic muscles.
  • Collagen injections. Collagen injected in the tissue surrounding the urethra can provide urethral support for women suffering from stress incontinence.
  • External occlusive devices. A new single-use disposable urethral cap is available without a prescription as of late 2002 for women suffering from stress urinary incontinence. The cap is noninvasive and appears to be quite effective in managing incontinence.
  • Inflatable urethral insert. Sold under the trade name Reliance, this disposable incontinence balloon for women is inserted into the urethra and inflated to prevent urine leakage.
  • Intermittent urinary catheterization. The periodic insertion of a catheter into a patient's bladder to drain urine from the bladder into an attached bag or container.
  • Medication. Estrogen hormone replacement therapy can help improve pelvic muscle tone in postmenopausal women. Other medications, including flurbiprofen, capsaicin and botulinum toxin, are sometimes prescribed to relax the bladder muscles or to tighten the urethral sphincter. As of late 2002, newer medications for the treatment of urinary incontinence were undergoing clinical trials. One of these drugs, duloxetine, differs from present medications in targeting the central nervous system's control of the urge to urinate rather than the smooth muscle of the bladder itself.
  • Pelvic toning exercises. Exercises to tone the pelvic muscle can help alleviate stress incontinence in both men and women. These exercises involve tightening the muscles of the pelvic floor, and are also known as Kegel or PC muscle exercises.
  • Perineal stimulation. Perineal stimulation is used to treat stress incontinence. The treatment uses a probe to deliver a painless electrical current to the perineal area muscles. The current tones the muscle by contracting it.
  • Permanent catheterization. A permanent, or indwelling, catheter may be prescribed for chronic incontinence that doesn't respond to other treatments. A Foley catheter is usually used for urinary catheterization. One end is inserted through the urethra and into the bladder, and the external end is attached to a plastic reservoir bag that the patient may wear on the leg. A second alternative is a permanent catheter, called a suprapubic tube, surgically inserted into the bladder. The tube exits the body through the abdomen near the pubic bone, where it is attached to a drainage bag. As infection may result, this treatment should be reevaluated periodically, and the possibility of alternative treatment addressed.
  • Sacral nerve stimulation (SNS). Also known as sacral neuromodulation, SNS is a procedure in which a surgeon implants a device that sends continuous stimulation to the sacral nerves that control the urinary sphincter. The FDA approved sacral nerve stimulation for the treatment of urinary urge incontinence in 1997 and for urinary frequency in 1999.
  • Surgery. Bladder neck suspension surgery is used to correct female urinary stress incontinence. Surgical techniques such as the Marshall-Marchetti-Krantz and Burch procedures use sutures to raise and support the bladder neck and urethra. A sling procedure, which uses a strip of biocompatible material or the patient's own muscle or tissue as a supportive sling under the urethra and bladder neck, may also be used to treat stress incontinence. Bladder enlargement surgery may be recommended to treat incontinent men and women with unusually small bladders.
  • Urinary sphincter implant. An artificial urinary sphincter may be used to treat incontinence in men and women with urinary sphincter impairment.
  • Vaginal inserts. Devices constructed of silicone or other pliable materials that can be inserted into a woman's vagina to support the urethra.

Prognosis

Left untreated, incontinence can cause physical and emotional upheaval. Individuals with long-term incontinence suffer from urinary tract infections, and skin rashes and sores. Incontinence can also affect their self-esteem and cause depression and social withdrawal. They frequently stop participating in physical activities they once enjoyed because of the risk of embarrassing "accidents." However, with the wide variety of treatment options for incontinence available today, the prognosis for incontinent patients is promising. If incontinence cannot be stopped, it can be improved in the majority of cases.

Key terms

Bladder neck — The place where the urethra and bladder join.
Bladder sphincter — The outlet that releases urine into the urethra.
Calculi (singular, calculus) — Mineral deposits that can form a blockage in the urinary system.
Occlusive — Closing off. One of the newest treatments for stress urinary incontinence in women is an external occlusive single-use cap that covers the urethral opening.
Perineal area — The genital area between the vulva and anus in a woman, and between the scrotum and anus in a man.
Sacral nerves — The five pairs of nerves that arise from the lowermost segments of the spinal cord and control bladder, bowel, and pelvic functions. Stimulation of the sacral nerves by an implanted device is a newer treatment for urinary incontinence.

Prevention

Women who are pregnant or who have gone through childbirth can reduce their risk for stress incontinence by strengthening their perineal area muscles with Kegel exercises. Men who have undergone prostate surgery may also benefit from pelvic muscle exercises. Men and women should consult with their doctor before initiating any type of exercise program.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Urinary Incontinence." Section 17, Chapter 215 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Periodicals

Amundsen, C. L., and G. D. Webster. "Sacral Neuromodulation in an Older, Urge-Incontinent Population." American Journal of Obstetrics and Gynecology 187 (December 2002): 1462-1465.
Bachmann, G., and B. Wiita. "External Occlusive Devices for Management of Female Urinary Incontinence." Journal of Women's Health (Larchmont) 11 (November 2002): 793-800.
Burgio, K. L. "Influence of Behavior Modification on Overactive Bladder." Urology 60, no.5, Supplement 1 (November 2002): 72-76.
Burgio, K. L., P. S. Goode, J. L. Locher, et al. "Behavioral Training With and Without Biofeedback in the Treatment of Urge Incontinence in Older Women: A Randomized Controlled Trial." Journal of the American Medical Association 288 (November 13, 2002): 2293-2299.
Haeusler, G., H. Leitich, M. van Trotsenburg, et al. "Drug Therapy of Urinary Urge Incontinence: A Systematic Review." Obstetrics and Gynecology 100, no. 5, Part 1 (November 2002): 1003-1016.
Palmer, M. H., and S. Fitzgerald. "Urinary Incontinence in Working Women: A Comparison Study." Journal of Women's Health (Larchmont) 11 (December 2002): 879-888.
Viktrup, L. "Female Stress and Urge Incontinence in Family Practice: Insight Into the Lower Urinary Tract." International Journal of Clinical Practice 56 (November 2002): 694-700.
Yoshimura, N., and M. B. Chancellor. "Current and Future Pharmacological Treatment for Overactive Bladder." Journal of Urology 168 (November 2002): 1897-1913.

Organizations

American Foundation for Urologic Disease. 1128 North Charles St., Baltimore, MD 21201. (800) 242-2383. http://www.afud.org.
American Urological Association (AUA). 1120 North Charles Street, Baltimore, MD 21201. (410) 727-1100. www.auanet.org.
Center for Biologics Evaluation and Research (CBER), U. S. Food and Drug Administration (FDA). 1401 Rockville Pike, Rockville, MD 20852-1448. (800) 835-4709 or (301) 827-1800. www.fda.gov/cber.
National Association for Continence. P.O. Box 8310, Spartanburg, SC 29305-8310. (800) 252-3337. http://www.nafc.org.
National Kidney and Urologic Diseases Information Clearinghouse. 3 Information Way, Bethesda, MD 20892-3580. (800) 891-5390.

incontinence

 [in-kon´tĭ-nens]
1. inability to control excretory functions.
2. immoderation or excess. adj., adj incon´tinent.
bowel incontinence
2. a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as a state in which an individual has a change in normal bowel habits, with involuntary bowel movements.
continuous incontinence continuous urinary leakage from a source other than the urethra, such as a fistula.
fecal incontinence (incontinence of the feces) inability to control defecation; both physiologic and psychological conditions can be contributing factors. Called also encopresis and bowel incontinence. See also bowel elimination, altered. Physiologic causes include neurologic sensory and motor defects such as those occurring in stroke and spinal cord injury; pathologic conditions that impair the integrity of the sphincters, such as tumors, lacerations, fistulas, and loss of sensory innervation; altered levels of consciousness; and severe diarrhea. Psychological factors include anxiety, confusion, disorientation, depression, and despair.

There is potential for physical and psychological stress when a person is unable to control his or her bowel movements. Damage to the integrity of the skin and its breakdown into pressure ulcers is always a possibility no matter how hard caregivers might try to keep the patient clean and dry. Psychologically the person is likely to suffer from loss of self-esteem and is certain to experience some alteration in self-image. From the time of toilet training a person is expected to be able to handle the tasks of bowel elimination. An adult who for some reason is no longer able to do this is often embarrassed by and ashamed of the inability to perform this most basic of self-care activities.
Patient Care. Assessment of the problem of fecal incontinence should be extensive and thorough so that a realistic and effective plan of care can be implemented. Sometimes all that is needed is a regularly scheduled time to offer the patient a bedpan or help using a bedside commode or going to the bathroom. If diarrhea is a problem it may be that dietary intake needs changing or tube feedings are not being administered correctly. Dietary changes may also help the patient who has a stoma leading from the intestine. In cases of neurologic or neuromuscular deficit, retraining for bowel elimination is a major part of rehabilitation of the patient. Frequently, it is possible to help a patient achieve control by means of a well-planned and executed bowel training program.

Biofeedback techniques can be helpful in many cases. The person learns to maintain higher tone in the anal sphincter through use of a balloon device that provides feedback information about pressures in the rectum. With practice the person can learn better control and develop a more acute awareness of the need to defecate.
functional incontinence incontinence due to impairment of physical or cognitive functioning.
functional urinary incontinence a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as an inability of a usually continent person to reach the toilet in time to avoid the unintentional loss of urine. See also urinary incontinence.
overflow incontinence (paradoxical incontinence) urinary incontinence due to pressure of retained urine in the bladder after the bladder has contracted to its limits; there may be a variety of presentations, including frequent or constant dribbling or symptoms similar to those of stress or urge incontinence.
reflex incontinence the urinary incontinence that accompanies detrusor hyperreflexia.
reflex urinary incontinence a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as an involuntary loss of urine at somewhat predictable intervals, whenever a specific bladder volume is reached. See also reflex incontinence.
risk for urge urinary incontinence a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as the state of being at risk for involuntary loss of urine associated with a sudden strong sensation of urinary urgency. See also urge urinary incontinence.
severe stress urinary incontinence severe stress incontinence as a result of incompetence of the sphincter mechanism.
stress incontinence urinary incontinence due to strain on the orifice of the bladder, as in coughing or sneezing.
stress urinary incontinence a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as loss of urine of less than 50 ml when there is increased abdominal pressure. See also stress incontinence.
total urinary incontinence a nursing diagnosis accepted by the Seventh National Conference on the Classification of Nursing Diagnoses, defined as a state in which an individual has continuous and unpredictable loss of urine; see also urinary incontinence.
urge incontinence (urgency incontinence) urinary or fecal incontinence preceded by a sudden, uncontrollable impulse to evacuate (see also urgency). Urge incontinence of urine is a major complaint of patients with urinary tract infections and is also present in some women two or three days before onset of the menstrual period.
urge urinary incontinence a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as the involuntary passage of urine soon after feeling a strong sense of urgency to urinate; see also urge incontinence.
urinary incontinence (incontinence of urine) loss of control of the passage of urine from the bladder; see also enuresis. It can be caused by pathologic, anatomic, or physiologic factors affecting the urinary tract, as well as by factors entirely outside it. See also urinary elimination, altered.
Patient Care. The Agency for Health Care Policy and Research (AHCPR) convened an interdisciplinary, non-Federal panel of physicians, nurses, allied health care professionals, and health care consumers that has identified and published Clinical Practice Guidelines for Urinary Incontinence in Adults. Identification and documentation of urinary incontinence can be improved with more thorough medical history taking, physical examination, and record keeping. Routine tests of lower urinary tract function should be performed for initial identification of incontinence. There are also situations that require further evaluation by qualified specialists.

The guidelines provide an informed framework for selecting appropriate behavioral, pharmacologic, and surgical treatment and supportive services that can be used to treat urinary incontinence. The panel concluded that behavioral techniques such as bladder training and pelvic muscle exercises are effective, low cost interventions that can reduce incontinence significantly in varied populations. Surgery, except in very specific cases, should be considered only after behavioral and pharmacologic interventions have been tried. The panel found evidence in the literature that treatment can improve or cure urinary incontinence in most patients. The address of the AHCPR is Agency for Health Care Policy and Research, P.O. Box 8547, Silver Spring, MD 20907. They can also be called toll free at (800) 358-9295.

urinary incontinence

inability to control urination, caused by acute or chronic factors. Five classes of chronic incontinence are recognized. Functional incontinence is the result of cerebral clouding and/or physical factors that make it difficult to get to bathroom facilities in time. Overflow incontinence occurs when the urinary tract is obstructed or when the detrusor muscle fails to contract as bladder capacity is reached; spinal cord injury or benign prostatic hypertrophy may be the cause. Stress incontinence is precipitated by coughing, sneezing, or straining; it occurs more often in women and is commonly related to anatomic changes. Urge incontinence is the inability to delay voiding after a sensation of bladder fullness is perceived. Reflex incontinence occurs when there is detrusor hyperreflexia and/or urethral relaxation due to neurological causes, such as spinal cord injury. Urinary incontinence can have mixed etiologies. Treatment depends on the underlying cause and may include anticipatory toileting, bladder retraining, exercise of perineal muscles, anticholinergic medications, and surgery. See also incontinence, retention with overflow.

uri·nar·y in·con·ti·nence

(yūr'i-nar-ē in-kon'ti-nĕns)
Involuntary leakage of urine.

urinary incontinence,

n failure to restrain urination. Functional incontinence is due to cognitive or physical aspects that increase the difficulty of reaching a facility in time. Overflow incontinence is due to an obstruction in the urinary tract or the failure of the detrusor muscle to contract when the bladder reaches capacity. Stress incontinence is brought on by a cough, sneeze or strain, most often after childbirth in women. The therapeutic approach depends on the source of the condition; retraining the bladder, anticipatory toileting, biofeedback, medication, surgery, and exercising perineal muscles may be prescribed. See also
incontinence.

urinary

pertaining to the urine; containing or secreting urine.

urinary bile pigment
bilirubin and urobilinogen are found in the urine of normal animals.
urinary calculi
urinary diversion
various surgical procedures involving the ureters, bladder or urethra may be used to alter the usual route of urine flow, thereby bypassing portions of the urinary tract, usually the bladder and/or urethra. Ureters, bladder or urethra are transplanted or anastomosed to the bowel or placed so urine exits at an orifice created through the skin. See also ureteroileostomy, trigonal-colonic anastomosis, ureterocolostomy, transureteroureterostomy.
urinary flow monitor
periodic measurement of the amount of urine secreted. In an anesthetized animal a catheter draining into a calibrated container is used. In a conscious animal a clamped-off, self-retaining catheter is inserted and drained at intervals. A metabolism cage is an alternative.
urinary flowmetry
the measure of urinary flow rates.
urinary incontinence
an inability to control urination with the involuntary passage of urine. Most commonly occurs in dogs due to congenital abnormalities of the ureters or urethra. Other causes include congenital or acquired defects in nervous control of micturition, neoplastic or inflammatory disease of the lower urinary tract, and prostate gland and endocrine abnormalities.
urinary obstruction
urethral or ureteral obstruction often caused by lodgement of a urinary calculus in the narrow lumen. Constriction of urethra due to hyperplastic prostate in male dogs.
urinary pole
the point on the glomerulus where the proximal convoluted tubule exits.
urinary pooling
urinary system, urinary tract
the system formed in the body by the kidneys, the urinary bladder (2), the ureters and the urethra, the organs concerned in the production and excretion of urine.
urinary territorial marking
urinary tract
see urinary system.

Patient discussion about urinary incontinence

Q. Can you treat urinary incontinence by only making exercise of circular muscles? I heard the exercise help but dont know if it is enough by itself.

A. This technique you have mentioned is called "bio-feedback" and it helps many people with urinary incontinence, by raising your awareness to muscles in your body you don't usually pay attention to, thus making you able to control them better. I do not think this is an only way to treat incontinence, however with the addition of the proper medications you can find this very helpful.

More discussions about urinary incontinence
References in periodicals archive ?
Shoulder subluxation and bladder incontinence were found to be inversely correlated with efficiency and effectiveness.
By the systems ability to immediately alert caregivers, the residents prolonged exposure to bowel and bladder incontinence is greatly reduced, helping decrease the chance for skin breakdown and minimizing barriers that impede normal tissue healing.
Treatment is often invasive and can produce permanent complications, such as impotence and bladder incontinence.
Inactivity due to fatigue, weakness or spasticity; inadequate fluid intake to counteract bladder incontinence problems or reaction to medication taken to relieve other MS symptoms can all cause distress," Dr.