Urinary incontinence

Symptoms Of Urinary Incontinence

Urinary incontinence is not a disease, rather it is usually a symptom of underlying health problems. The symptoms of urinary  incontinence include: 

• Leaking urine during normal day to day activities such as lifting weights, coughing, sneezing, laughing, exercising without any urge to urinate

• Leaking urine during sexual activity

• Bedwetting (leaking urine during sleeping)

• Being unable to hold urine

• Being unable to react toilet in time

• Frequent urination (more than 8 times a day)

• Feeling of wetness

• Feeling of incomplete emptying of bladder

Causes Of Urinary Incontinence

The urinary system consists of detrusor muscles, the internal and external sphincters, and their neurological components. 

In infants, the fullness of the bladder causes contraction of the detrusor muscles that leads to emptying of the bladder. As we grow, our bladder is trained to respond to the sensation of urge at volumes 200-300 ml. At this stage, a voluntary decision can be made for passing the urine depending upon the location and availability. 

The emptying of the bladder upto 7 times in waking hours in a day is considered normal. The normal tolerance capacity of a healthy bladder is approximately 500 ml which the bladder can accommodate without increasing bladder pressure even during physical activities, coughing, lifting weights etc. 

Any disturbance in the whole mechanism can lead to urinary incontinence. The possible causes are:

• Detrusor overactivity: This is the most common cause of urinary incontinence in which there are consistent contractions of the detrusor muscles. This leads to relaxation of the sphincters and involuntary leakage of urine. It is commonly seen after spinal injuries, multiple sclerosis or other lesions of the central nervous system.

• Impaired bladder contractility: An inadequately contractile bladder can also cause urinary incontinence. This can be due to aging and several pelvic floor diseases. 

• Decreased pressure in urethra closure: The sphincteric unit helps in the closure of the bladder which expresses the urethral pressure during the resting state (where the abdominal pressure is at its resting value where no voiding and no pelvic floor contraction occurs). The decreased pressure in urethra closure can also leakage of urine. 

• Atrophy of urethral areas: It is a medical condition in which urethra and its surrounding structures lose its strength and elasticity. It also causes urinary incontinence due to dysfunctioning of the urinary system. The atrophy is commonly seen in postmenopausal women due to estrogen deficiency. 

• Prostatic hypertrophy: The enlarged prostate in men also puts pressure on the bladder which can cause UI. 

• Urethral hypermobility: It is a condition in which there is an excess movement of urethra that can cause UI. It can be due to pregnancy, vaginal delivery, obesity, smoking, chronic cough, and chronic constipation

• Weakness of urinary sphincter: Some conditions such as advanced age, menopause, enlarged prostate weaken the sphincter and pelvic floor muscles which can lead to UI. 

• Poor detrusor compliance: Sometimes, the bladder fails to stretch, which causes increased pressure, discomfort during filling and reduces urine holding capacity of the bladder. This pattern is typical after pelvic radiotherapy, or can result from prolonged periods of catheterization. 

Reversible causes of Urinary incontinence

Reversible causes of UI, often described by the mnemonic DIAPPERS includes: 

D- Delirium (confusion)

I - Infection (urinary tract infection)

A- Atrophic (urethral atropy due to menopause)

P- Pharmacological (medications)

P- Psychological (disorders such as stress and anxiety)

E- Endocrine (excess urine production)

R- Restricted mobility (not able to reach washroom on due to conditions such as arthritis)

S- Stool impaction (hardened stool that's stuck in the rectum or lower colon due to chronic constipation)

Types Of Urinary Incontinence

Urge incontinence

• It is characterized with a feeling of sudden and strong urge to urinate, usually more than 8 times a day.

• In this, the patient is not able to hold urine long enough to get the toilet.  

• This can be due to certain medical conditions such as diabetes, Alzheimer’s disease, stroke, and multiple sclerosis or can be a separate condition. 

• It is more common in elderly women.

Stress incontinence

• It refers to the leakage of urine due to pressure exerted by urethra and bladder on weak pelvic floor muscle.

• It involves leakage of urine during exercise, coughing, sneezing, laughing, lifting heavy objects. 

• Any form of physical activity and sudden bodily movements also increases the chances of leakage of urine.

• Being overweight and prostate surgery also increases the chances of stress incontinence. 

• It mostly affects people who are active in sports. 

Functional incontinence

• In this type, the patient leaks urine due to his/her inability to reach the washroom on time.

• This can happen due to some physical disability such as arthritis, a barrier in the environment or memory problem. 

• This type of incontinence is also known as toileting difficulty. 

• It mostly occurs in older people who have a normal bladder normal control but having other disabilities make it hard to reach the washroom on time. 

Overflow incontinence

• In this, leakage occurs when the bladder is overfilled than its capacity. 

• This can happen due to blocked urethra which leads to the incomplete emptying of the bladder. 

• The increased urine production in some conditions such as diabetes can also cause overflow incontinence. 

Mixed urinary incontinence

• It is the involuntary leakage of urine caused by a combination of stress and urge urinary incontinence. 

Risk Factors For Urinary Incontinence

Various risk factors that can increase the risk of UI include:  

1. Medical conditions

Urinary tract infection: An infection of the urinary tract (urethra, ureters, bladder and kidneys) can cause urinary incontinence. This is temporary and goes away once the condition is treated. 

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Pelvic floor disease: The weak pelvic floor muscles in women during certain conditions can also make it hard for the bladder to hold urine and can be a cause of urinary incontinence. 

Stroke: Stroke can affect various muscles of the body including the one that controls the urinary bladder. This can also cause urinary incontinence. 

Diabetes: The increase in the amount of urine in diabetes can also cause urinary incontinence. 

Menopause: During menopause, there are changes in the hormones that can impact the bladder and cause urinary incontinence. 

Pregnancy: Urinary incontinence is very commonly seen during pregnancy as the expanding uterus puts pressure on the bladder. This usually subsides within a few weeks after delivery. 

Multiple sclerosis:This condition disrupts the nerve signals that direct the movement of urine in your body and can cause urinary incontinence. 

Enlarged prostate: The enlargement of the prostate gland puts pressure on the bladder and causes leakage of urine. 

Constipation: Constipation for a long period of time can also cause urinary incontinence. 

Obesity/overweight: Being obese or overweight puts more pressure on the bladder which is not able to hold urine can also be a reason for urinary incontinence. 

Birth defects: There are certain birth defects that can also cause urinary incontinence such as bladder exstrophy in which the bladder develops outside the fetus.

Chronic cough: The persistent cough also puts pressure on the abdomen and that can also cause leakage of urine.  

Genitourinary fistulas:  It is an abnormal connection or passageway between the urinary and genital structures. This condition is also associated with urinary incontinence and is often treated with surgery. 

Surgery: Some surgical procedures such as surgery of prostate gland can also cause urinary incontinence. 

2. Nerve damage

It is the most common cause of functional incontinence. Nerve carries signals from brain to bladder and muscles of urinary bladder. The brain decides when to urinate. Any damage in the nerve can cause involuntary release of urine. The nerve damage can occur in various conditions such as: 

• Diabetes

• Vaginal childbirth

• Parkinson’s disease

• Multiple sclerosis

• Alzheimer’s disease

• Brain or spinal cord injury

• Anxiety 

• Heavy metal poisoning

3. Lifestyle factors

There are certain lifestyle factors that can cause urinary incontinence. These include:

• Consuming food that cause constipation

• Drinking excessive caffeinated beverages and alcohol

• Physical inactivity

• Smoking

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4. Medications

Urinary incontinence can also result as a side effect of certain medications such as antipsychotics, benzodiazepines, antidepressants and hormone replacement therapy in postmenopausal women.

Diagnosis Of Urinary Incontinence

1. Medical history

The complete medical history is asked to determine the type, severity, and duration of urinary incontinence. The type can be determined by the history:

• Urge urinary incontinence: It can be determined through the symptoms such as increase in frequency, urgency, and nocturia (frequent night time urination).
• Mixed urinary incontinence: This is represented by characteristics of both stress and urge urinary incontinence. 
• Overflow urinary incontinence: This condition is associated with straining due to incomplete bladder emptying.
• Stress urinary incontinence:  It can be predicted through the trigger activity that is causing urine leakage.
• Functional urinary incontinence: The history of the patient may suggest physical disabilities or some memory related issues. 

Patients are also asked about the history of medical conditions and surgery that could be the reason for urinary incontinence. For females, a complete gynecological history is obtained to determine the number of births including the type of delivery (c section or normal). 

2. Physical examination

The various ailments are assessed through physical examination such as pedal edema, cough, surgical scars, range of motion, enlargement of prostate gland, and pelvic exam  to determine any cardiovascular, pulmonary, abdominal or musculoskeletal issue. 

3. Urine test

The urine is tested for the presence of: 

• Urinary tract infections

• Glycosuria (glucose in urine)

• Proteinuria (protein in urine)

• Hematuria ((blood in urine)

In various cases, blood urea nitrogen (BUN) and creatinine tests are also performed to assess kidney function. 

4. Urodynamic testing

This includes several tests that are performed to check the urine holding capacity of the bladder. The tests also help in determining the functioning of urethral sphincter muscles – the muscles that control the involuntary flow of urine. 

One such test includes the insertion of a tube into the bladder and filling it with fluid. This checks the holding capacity of the bladder. 

5. Pad test

The patient is given a pad to wear which will help in checking any leaked urine. 

6. Stress test

The patient is asked to cough to demonstrate involuntary leakage of urine. The test is more sensitive when done in a standing position.

7. Imaging

• Ultrasound: This includes imaging of the bladder and assessing the urine emptying capacity of the bladder. 

• Cystoscopy: This technique uses a thin flexible tube with a camera at its end. The urethra and urinary bladder is examined through it for any anomalies that could be a cause of urinary incontinence. 

8. Maintaining a journal 

The doctor also recommend the patient to maintain a journal for a few days to record the following activities:

• Any leakage of the urine

• Frequency of urination

• Ability to reach washroom on time

• Conditions that trigger leakage of urine

The above information helps in identifying a pattern of urinary incontinence which will aid in the diagnosis process.

Specialist To Visit

It is believed that urinary incontinence is a normal process that goes along with aging. However, it is somewhat true but it can be treated and managed through several ways. The problem of urinary incontinence  should not be ignored, if it is impacting your daily activities.

Some of the specialists that can help detect and treat urinary incontinence include:

• General physician

• Urologist

• Gynecologist

• Urogynecologist

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Prevention Of Urinary Incontinence

There is no sure shot way to prevent urinary incontinence. However, several factors that act as a trigger for urinary incontinence can be minimized by some lifestyle modifications. These include: 

1. Modify your eating habits

The healthy eating habits helps in the prevention of obesity and diabetes that acts as a trigger for developing urinary incontinence. The follow eating habits should be followed to prevent UI:

• Limit alcohol, spicy foods, chocolate, artificial sweeteners, caffeinated beverages as they may cause irritation and inflammation of the bladder.

• Include high fiber foods such as wholegrain cereals (such as porridge, brown rice, wholemeal pasta, wholemeal bread or pulses such as lentils and beans) to avoid constipation. Aim for at least 25-30 gms of fiber each day. 

• Eat fruits and vegetables to keep the process of defecation easy.

2. Keep yourself hydrated

The lesser intake of water is also associated with constipation and bladder irritation. This can act as a risk factor for developing UI. To prevent dehydration:

• Drink at least 6 to 8 glasses of water every day

• Drink more water in hot weather and after strenuous exercise

• Make a habit of frequently sipping water even when you are not feeling thirsty

The color of the urine helps in identifying whether the person is taking an adequate amount of water or not. The pale yellow color of the urine indicates that the person is adequately hydrated. Dehydration is characterized by the dark yellow color of the urine. 

Note: Some medications, vitamins and foods can also affect the color of urine.

3. Indulge in some physical activity

It is always advised to indulge in some kind of exercise as it helps to maintain a healthy weight which reduces pressure on the pelvic floor muscles. This helps in reducing the chances of UI. 

Physical activity also helps in preventing constipation which acts as a trigger for UI. Suggestions for physical activity include:

• Include a brisk 30 minute walk every day

• Pick any physical activity that you enjoy as it helps you to stick to a regular regimen

• Include pelvic floor exercises to strengthen the muscles

4. Follow good toilet habits

Urinary incontinence can be prevented by adopting some good toilet habits which includes:

• Avoid holding urine for a long period of time 

• Take as much as you need and empty the bladder fully

• Sit in the full crouching squat position while urinating 

• Go to the toilet when the bladder is full

• Avoid pushing your pelvic floor muscles to push the urine

• Avoid straining during passing stools as it may weaken the pelvic floor muscles

• Use correct posture while passing urine which involves an upright sitting with elevated feet

5. Quit smoking

Smoking affects the health of the bladder and it increases the chances of urinary incontinence. Avoiding smoking is known to be associated with decreasing the risk of UI.

Treatment Of Urinary Incontinence

The treatment plan is created according to the type of incontinence. 

A. Medications

There are various medications that are used to reduce leakage. The medications are selected according to the needs of the patient. Some medications stabilize the muscle contractions of the bladder while some work by relaxing muscles of the bladder. This allows the complete emptying of the bladder. Some common examples of medications include: 

• Antimuscarinics ( darifenacin, solifenacin, oxybutynin, tolterodine, fesoterodine, and trospium)

• Alpha-adrenergic agonist (phenylpropanolamine)

• Antidepressants (duloxetine)

• Alpha-adrenergic antagonists (terazosin and tamsulosin)

• Beta-adrenergic agonist (mirabegron)

B. Vaginal estrogen creams

As the name suggests, these creams are directly applied to the vaginal walls and urethral tissue that helps in relieving urge or stress incontinence.  

C. Hormone replacement therapies

It is most commonly used in women to restore normal bladder function. One such example includes estrogen replacement therapy during menopause. 

D. Other procedures and surgeries

If lifestyle, behavioral and pharmacological (medications) therapy fails to treat the conditions, then some invasive techniques are used. These techniques can range from the use of simple injections to complicated surgeries that are selected as per the cause and symptoms of incontinence. 

Bulking agents: This involves injecting a permanent substance into the lining of the urethra which helps in increasing its lining. It is mostly used in women with stress incontinence. 

Botulinum toxin injections: This involves injecting botulinum toxin into the bladder which relaxes its muscles. It is used to treat urge incontinence. 

Medical devices: This involves the implantation of several devices such as: 

• Neuromodulation devices: There are various devices that can modulate the nerve control to the bladder such as pacemakers. In some cases, nerves near the ankle are stimulated to achieve bladder control. 

• Artificial urethral sphincter: It is a device that is placed closed to the urethra to control urination. These types of devices are typically used in men with stress incontinence usually after prostate cancer surgery. 

• Vaginal insert: There are devices that can be placed in the vagina to compress the urethra. It helps in reducing stress incontinence in women.

Biofeedback sensor: This technique uses sensors to make the patient aware of the urine signals. It may help to regain control on the muscles of the bladder and urethra.

Electrical nerve stimulation: This technique sends electrical signals to the nerves present around the bladder that helps in controlling urine. 

Catheterization: This involves the use of a catheter to drain the urine. A catheter is a tube that is inserted through the urethra into the bladder. It can be used occasionally or on a constant basis.

Surgery: It may be required in some cases such as when incontinence is caused by an enlarged prostate.

Home-care For Urinary Incontinence

Home remedies

Magnesium: It plays an important role in the proper functioning of muscles and nerves. It reduces spasms of the bladder and allows its complete emptying.  It is found to reduce the symptoms of urinary incontinence, especially nocturia. 

The people having incontinence issues should take magnesium-rich foods in their diet which include corn, potatoes, and bananas. 

Vitamin D: The low levels of Vitamin D is associated with weak pelvic floor disorders including urinary incontinence. Patients of UI are advised to take sufficient amounts of Vitamin D as it has shown to reduce its symptoms. 

Here’s the right way to take Vitamin D. 

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Complications Of Urinary Incontinence

• Urinary tract infections (UTIS)

• Skin sores and rashes due to wet skin

• Cellulitis (bacterial skin infection characterized by inflammation)

• Pressure ulcers (injuries to the skin due to constant pressure on it)

• Trauma and infection due to catheterization

• Sexual dsyfunction

• Prolapse (slipping of a part of body from its usual position)

Medication side effects

There are several physical symptoms that are the side effect of medications used in urinary incontinence. These include:

• Dry mouth

• Restlessness

• Hypertension

• Insomnia

• Dizziness

• Tiredness
  
  
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Living With Urinary Incontinence

Urinary continence can be a cause of embarrassment for many and a hindrance to many daily activities. Here are a few tips that can help in living with urinary incontinence:

1. Timed voiding

Practice going to the bathroom on a regular time interval instead of waiting for the urge to go. This will prevent the overfilling of the bladder and thus reduces the chances of incontinence.

2. Emptying before physical activities 

The patients of urinary incontinence are advised to empty their bladder before doing any physical activities such as running, jumping, or doing any form of exercise. This will reduce the chances of leakage. 

3. Avoid heavy lifting

Most people tend to leak urine while lifting heavy objects. People suffering from urinary incontinence should avoid lifting heavy objects. If any heavy object is needed to move, take help. 

4. Regulate the intake of caffeinated beverages

Caffeinated beverages such as tea and coffee trigger the leakage of urine. It is advised to limit their intake especially before starting an activity. If you are frequently waking up in the night to urinate, avoid these drinks right before going to bed. 

5. Wear pads 

There are various pads and products available in the market that are specially designed to absorb leaked urine. It can be worn to avoid the leakage of urine through the clothes. 

6. Maintain a healthy weight

Being overweight can also be the cause of incontinence. It is advised to maintain a healthy weight through diet and exercise. 

7. Keep yourself hydrated 

Inadequate fluid intake can also cause urinary incontinence. Keep yourself hydrated throughout the day by drinking at least 8 glasses of water in a day. 

8. Prevent constipation

Long term constipation can also stimulate the leakage of urine. It is advised to have a diet rich in fiber such as wholegrains, cereals, fruits, and vegetables to prevent constipation. 

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9. Quit smoking

Smoking can make many health problems, including urinary incontinence, worse.