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- The prevalence of urinary incontinence in the general
population is high, and the problem carries a number of adverse physical, psychosocial,
and economic implications. Primary health care professionals and specialists will be key
in initiating the basic evaluation of urinary incontinence and in planning intervention.
Although those with urinary incontinence may hesitate to seek medical attention, research
indicates many are eager for treatments that reduce symptoms.
Definition
The inability to control urination (passage of urine).
Urinary incontinence can range from an occasional leakage of urine to a complete inability
to hold any urine.
Alternative names
loss of bladder control; uncontrollable urination; urination,
uncontrollable.
Considerations
Incontinence is fairly rare in children. Infants and children
up to the time of toilet training are not considered incontinent but merely untrained.
Occasional accidents in children up to age 6 years, especially with urine, are not
unusual. Nighttime incontinence is usually referred to as bedwetting or enuresis in
children. In young girls, and occasionally adolescent females, slight leakage of urine may
be associated with laughing.
Incontinence in children may be associated with severe urinary tract infections, spinal
injuries and neurological abnormalities that result in abnormal bladder control.
Incontinence is seen more frequently among the elderly. Almost 20% of older people living
at home, one-third of those in hospitals and one-half of all nursing home residents suffer
from urinary incontinence. Women are more likely than men to be affected by urinary
incontinence.
Incontinence is not a hopeless situation. Although incontinence is usually not an
emergency, problems with incontinence should be reported to the doctor. The gynecologist
and the urologist are the specialists who are most familiar with incontinence and can
evaluate the causes of incontinence and recommend several treatment approaches.
NORMAL URINATION:
The ability to hold urine and maintain continence is dependent on normal anatomy and
function of the lower urinary tract and the nervous system. Additionally, the person must
possess the physical and psychological ability to recognize and appropriately respond to
the urge to urinate.
The process of urination involves two phases: 1) the filling and storage phase, and 2)the
emptying phase. Normally during the filling and storage phase, the bladder begins to fill
with urine from the kidneys. The bladder stretches to accommodate the increasing amounts
of urine. The first sensation of the urge to urinate occurs when approximately 200 ml of
urine is stored. The healthy nervous system will respond to this stretching sensation by
alerting you to the urge to urinate while also allowing the bladder to continue to fill.
The average person can hold approximately 350 to 550 ml of urine. The ability to fill and
store urine properly requires a functional sphincter (the circular muscles around the
opening of the bladder) and a stable bladder wall muscle (detrusor).
The emptying phase requires the ability of the detrusor muscle to appropriately contract
to force urine out of the bladder. Additionally, the body must also be able to
simultaneously relax the sphincter to allow the urine to pass out of the body.
TYPES OF INCONTINENCE:
Incontinence can be classified as acute (sudden onset) or persistent. Acute incontinence
is usually caused by sudden changes in the urinary tract (such as infection, increased
urine amounts) or changes in the ability to urinate. Persistent incontinence is usually
caused by chronic (long-term) conditions and can be further classified based on the type
of symptoms the person exhibits. The common types of incontinence are:
Proper treatment can help the majority of people, and often
the problems can be eliminated altogether. Sometimes surgery is required. However,
incontinence can often be greatly improved and sometimes even cured without surgery.
What are the causes and risks of the condition?
ACUTE INCONTINENCE:
- mental confusion (delirium)
- restricted mobility
- urinary tract infection
- prostate infection
- inflammation of the urinary tract
- stool impaction
- side effects of medications (such as diuretics, tranquilizers,
anticholinergics, and antidepressants)
- polyuria (increased urine amounts)
- psychological factors
PERSISTENT INCONTINENCE:
- sphincter weakness (following prostate surgery in men, or
vaginal surgery in women)
- pelvic prolapse (in women)
- nervous system impairment (Multiple sclerosis, Parkinson's
disease, strokes, spinal cord injury)
- mental or psychological changes (Alzheimer's disease, acute
confusion, depression)
- bladder cancer
- pelvic muscle weakness, especially in women who have had
multiple pregnancies
- enlarged prostate in middle-aged or older men
- nerve or muscle damage after pelvic radiation
- developmental problems of the bladder
- pelvic, prostate, or rectal surgery
- bladder spasms
Home care
There are many things you can do to manage incontinence, but
they should not be done at the exclusion of a visit to your health care provider.
Treatment usually focuses on identifying the cause and type of the incontinence, treating
or managing the incontinence appropriately, and preventing complications (skin breakdown,
injury, social embarrassment).
The various treatment options may be appropriate for several types of incontinence.
Treatment options may involve use of various medications to enhance bladder function,
bladder training to enhance continence, and various surgical treatments based on
eliminating the cause of the incontinence.
Medications that may be prescribed include drugs that relax the bladder, increase bladder
muscle tone, or strengthen the sphincter.
Treatment usually includes performing Kegel exercises, bladder retraining, biofeedback and
electrical stimulation.
Surgery may be required in specific instances of urinary incontinence, such as to relieve
an obstruction or deformity of the bladder neck and urethra. Uterine or pelvic suspension
operations are sometimes needed in women. Men may require prostatectomy (removal of the
prostate gland). Incontinence can sometimes be managed by artificial sphincters which are
synthetic cuffs that are surgically placed around the urethra to help retain urine.
People with overflow incontinence and those who cannot empty their bladder completely may
use catheters to manage the incontinence (either long term indwelling catheters or
intermittent short term catheterization), but this procedure exposes the person to
potential infection.
Most incontinent people are able to manage minor incontinent episodes through the use of
various urinary incontinence products (undergarments and pads).
Additional preventative measures include avoiding bladder or urethral irritants such as:
- too much alcohol or coffee
- cigarettes (if they make you cough)
- diuretics (water pills)
- beta-blockers
- various anti-spasmodic medications
- antidepressants
- antihistamines
- cough/cold medications
- Ventolin (albuterol) or other beta agonists
What to expect at your health care
provider's office
The medical history will be obtained and a physical
examination performed.
Medical history questions documenting incontinence may include:
CHARACTERISTICS:
- Describe your problem.
- When does this occur?
- How long has incontinence been a problem?
- How much of a problem has this condition become?
- How many times does this happen each day?
- Are you aware of the need to urinate before you leak?
- Are you immediately aware that you have passed urine?
- Are you wet most of the day?
- Do you wear diapers in case of accidents? Occasionally? All
the time?
- Do you avoid social situations in case of accidents?
AGGRAVATING FACTORS:
- Do you have a urinary tract infection now? In the past?
- Is it more difficult to control your urine when you cough,
sneeze, strain, or laugh?
- Is it more difficult to control your urine when running,
jumping or walking?
- Is the incontinence worse when sitting up or standing?
- Do you suffer from constipation?
RELIEVING FACTORS:
- Is there anything you can do to reduce or prevent accidents?
- Have you ever been treated for this condition before? Did it
help?
- Have you tried pelvic floor exercises (Kegel)? Did it help?
ASSOCIATED FACTORS:
- What surgeries have you had?
- What injuries have you had?
- What medications do you take?
- Do you drink coffee? How much?
- Do you drink alcohol? How much? How often?
- Do you smoke? How much each day?
OTHER:
- Are there any other symptoms present?
The physical exam will include abdominal examination, genital
examination of the male, pelvic exam in the female, rectal exam, and neurological exam.
Diagnostic tests that may be performed include:
- urinalysis
- urine culture to check for infection if indicated
- cystoscopy (inspection of the inside of the bladder)
- urodynamic studies (tests to measure pressure and urine flow)
- uroflow (to measure pattern of urine flow)
- post void residual (PVR) to measure amount of urine left after
urination
Other tests may be performed to rule out pelvic weakness as
the cause of the incontinence. One such test is called the Q-tip test. This test involves
measurement of the change in the angle of the urethra when it is at rest and when it is
straining. An angle change of greater than 30 degrees often indicates significant weakness
of the muscles and tendons that support the bladder.
After seeing your health care provider:
You may want to add a diagnosis related to urinary incontinence to your personal medical
record.
Preventative
If you have a bladder control problem, there are some
additional measures that may help to prevent accidental urination. For example:
- Do Kegel exercises daily
- Double void (that is, after urinating, wait a few seconds,
then try again)
- Avoid constipation by eating many fruits, vegetables and whole
grains each day
- Retrain your bladder (try not to urinate more frequently than
every 3 to 6 hours)
- Avoid over consumption of bladder and urethral irritants such
as alcohol and coffee
- Avoid overuse of drugs such as diuretics (water pills),
antidepressants, antihistamines and cough/cold preparations
- Don't smoke (the nicotine in smoke is a bladder irritant)
- If you are a woman with stress incontinence, cross your legs
when sneezing or coughing (this simple action may stop leakage).
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