Female Urinary Incontinence

Millions of women experience involuntary loss of urine called urinary incontinence. Women experience incontinence twice as often as men. Pregnancy and childbirth, menopause, and the structure of the female urinary tract account for this difference.

Some women may lose a few drops of urine while running or coughing. Others may feel a strong, sudden urge to urinate just before losing a large amount of urine. Many women experience both symptoms.

Urinary incontinence can be slightly bothersome or totally debilitating. For some women, the risk of public embarrassment keeps them from enjoying many activities with their family and friends. Urine loss can also occur during sexual activity and cause tremendous emotional distress.

Older women, more often than younger women, experience incontinence. But incontinence is not inevitable with age. Incontinence is treatable and often curable at all ages.

Risk Factors

Factors that increase your risk of developing urinary incontinence include:

• Gender — Women are more likely to have stress incontinence. Pregnancy, childbirth, menopause and normal female anatomy account for this difference. However, men with prostate gland problems are at increased risk of urge and overflow incontinence.
• Age — As you get older, the muscles in your bladder and urethra lose some of their strength. Changes with age reduce how much your bladder can hold and increase the chances of involuntary urine release.
• Being overweight — Extra weight increases pressure on your bladder and surrounding muscles, which weakens them and allows urine to leak out when you cough or sneeze.
• Smoking — Tobacco use may increase your risk of urinary incontinence.
• Family history — If a close family member has urinary incontinence, especially urge incontinence, your risk of developing the condition is higher.
• Pregnancy — Hormonal changes and the increased weight of the fetus can lead to stress incontinence.
• Childbirth — Vaginal delivery can weaken muscles needed for bladder control and also damage bladder nerves and supportive tissue, leading to a dropped (prolapsed) pelvic floor. With prolapse, the bladder, uterus, rectum or small intestine can get pushed down from the usual position and protrude into the vagina. Such protrusions can be associated with incontinence.
• Menopause — After menopause women produce less estrogen, a hormone that helps keep the lining of the bladder and urethra healthy. Deterioration of these tissues can aggravate incontinence.
• Hysterectomy — In women, the bladder and uterus are supported by many of the same muscles and ligaments. Any surgery that involves a woman’s reproductive system, including removal of the uterus, may damage the supporting pelvic floor muscles, which can lead to incontinence.
• Neurological disorders — Multiple sclerosis, Parkinson’s disease, a stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control, causing urinary incontinence.

Symptoms

The main types of urinary incontinence are stress, urgency, and overflow incontinence. Many women have features of more than one type. Identifying the classification of incontinence helps guide therapy.

Types of urinary incontinence include:

Stress incontinence — Individuals with stress incontinence have involuntary leakage of urine that occurs with increases in intraabdominal pressure (e.g., with exertion, sneezing, coughing, laughing) in the absence of a bladder contraction. Stress incontinence is the most common type in younger women, with the highest incidence in women ages 45 to 49 years.

Urgency incontinence — Women with urgency incontinence experience the urge to void immediately preceding or accompanied by involuntary leakage of urine. The amount of leakage ranges from a few drops to completely soaked undergarments. Overactive bladder (OAB) is a term that describes a syndrome of urinary urgency with or without incontinence, which is often accompanied by urinary frequency. The terms “urgency incontinence” and “overactive bladder with incontinence” are often used interchangeably.

Urgency incontinence is more common in older women and may be associated with comorbid conditions that occur with age. It is believed to result from detrusor overactivity, leading to uninhibited (involuntary) bladder muscle contractions during bladder filling. This may be secondary to neurologic disorders (e.g., spinal cord injury), bladder abnormalities, increased or altered bladder microbiome, or may be idiopathic.

Mixed incontinence — Women with symptoms of both stress and urgency incontinence are described as having mixed incontinence.

Overflow incontinence — Overflow incontinence typically presents with continuous urinary leakage or dribbling in the setting of incomplete bladder emptying. Associated symptoms can include weak or intermittent urinary stream, hesitancy, frequency, and nocturia. When the bladder is very full, stress leakage can occur, or low-amplitude bladder contractions can be triggered resulting in symptoms similar to stress or urgency incontinence.

Functional incontinence – Functional incontinence occurs when a patient has intact urinary storage and emptying functions but is physically unable to toilet herself in a timely fashion. This appears to be a common contributor to urinary incontinence for older women. Such functional incontinence may be reversible in the setting of modifiable factors (e.g., decreased mobility post-surgery, decreased manual dexterity, and change in cognitive or mental status from sedation from medications).

Evaluation and Diagnosis

The initial evaluation of urinary incontinence includes characterizing and classifying the type of incontinence, identifying underlying conditions (e.g., neurologic disorder or malignancy) that may manifest as urinary incontinence, and identifying potentially reversible causes of incontinence.

The evaluation should start with a thorough history, physical examination, and urinalysis. Additional evaluation is warranted in the presence of complex medical conditions or concerning findings on history and/or physical examination.

Additional testing may include:

• Urinalysis — A sample of your urine is checked for signs of infection, traces of blood or other abnormalities.
• Bladder diary — For several days you record how much you drink, when you urinate, the amount of urine you produce, whether you had an urge to urinate and the number of incontinence episodes.
• Post-void residual measurement — You’re asked to urinate (void) into a container that measures urine output. Then your doctor checks the amount of leftover urine in your bladder using a catheter or ultrasound test. A large amount of leftover urine in your bladder may mean that you have an obstruction in your urinary tract or a problem with your bladder nerves or muscles.
• Bladder stress test — You cough vigorously as the doctor watches for loss of urine from the urinary opening.

If further information is needed, your doctor may recommend more-involved tests, such as:

• Ultrasound —This test uses sound waves to create an image of the kidneys, ureters, bladder, and urethra.
• Urodynamics studies (UDS) — Various techniques measure volume and pressure in the bladder and the flow of urine.
• Cystoscopy — The doctor inserts a thin tube with a tiny camera in the urethra to see inside the urethra and bladder.

These tests are usually done if you’re considering surgery.

Treatment

Lifestyle Changes and Bladder Training

Fluid control — You will likely be asked to track what you drink, when and how much. You may learn that you should limit caffeine, alcohol, some fruit juices, and fizzy colas. These beverages bother the bladder. You may also be asked to drink more water. Six to eight glasses of water per day are ideal. And, you may be asked not to drink for a few hours before bed. This will help reduce your need to get up and go to the bathroom at night.

Dietary changes — There are a few foods that are known to irritate the bladder. For example, spicy foods, coffee, tea, and colas are often bothersome. Some patients also find that their problems are relieved with weight loss.

Bladder training or retraining — A bladder diary is the starting point for bladder training. For 3 days you write down what you drink and how often you go to the bathroom. You note when you leak urine. This diary can help you and your provider find things that may make your symptoms worse. It will also help your provider make a training schedule with you. This is when you empty your bladder in a controlled way at set times. With regular bladder emptying, you should have fewer leaks. Timed urination, scheduled voiding or double voiding are methods that help with both overactive bladder and stress incontinence.

If you go to the bathroom too often, retraining your bladder can help. The goal is to hold urine in for longer and longer amounts of time. This takes small steps. Start with 5-10-15 minutes. The goal is to retrain your bladder to hold urine for 2 to 4 hours with less urgency and leaking.

Pelvic floor exercises — Kegel exercises can strengthen the sphincter and pelvic floor muscles. If you can learn to tighten and relax these muscles, and then learn to control these muscles, you can often improve bladder control. Kegels can prevent bladder spasms that trigger the urge to go. This can stop or pause leaks. A health care provider can teach you how to do this exercise with success. Kegels can help with stress incontinence or overactive bladder symptoms. Like any fitness program, you must often practice the exercise to keep its benefits.

Drug Treatment

Pseudoephedrine (decongestant) can tighten the bladder neck — This can help to control leaks from stress urinary incontinence. It may not be an option if you have a history of high blood pressure.

Anticholinergic drugs can treat OAB — They allow the bladder muscles to relax. These drugs work but may have side effects. For example dry mouth, confusion, constipation, blurred vision, and preventing urination. Be sure to mention any other bladder relaxing drugs you’ve tried when you talk with your urologist.

Hormone treatment can help if you have incontinence after menopause — Hormone replacement may improve the health of the bladder neck and urethral tissues. This may relieve symptoms. There are some medical reasons not to use hormones. Speak to your provider about what’s best for you.

Botox Injections for Overactive Bladder

A urologist may offer botulinum toxin (Botox) injections to stop bladder spasms. Botox relaxes the bladder muscle to relieve bladder spasms. Over time, this relaxing effect can wear off. Most patients say the effect lasts for about 6 months. After that, the injections can be repeated. Your urologist should make sure your bladder can empty fully after injections.

Neuromodulation Therapy for Overactive Bladder

Neuromodulation involves the placement of a lead wire to stimulate the nerves that control the bladder. For this treatment, a small electrode is placed near the nerves that control your bladder. It sends electrical pulses to the bladder to stop the spasms which cause leaks. There are two types:

Percutaneous tibial nerve stimulation (PTNS). This therapy stimulates the tibial nerve. For this type of neuromodulation, you will not have to have surgery. PTNS is performed during an office visit that takes about 30 minutes. Your health care provider places a needle electrode near your ankle. It sends electrical pulses to the tibial nerve which runs along your knee to the sacral nerves. The electrical pulses help block the nerve signals that aren’t working correctly. Often, patients receive 12 weekly treatments, depending on how well they are doing.

Sacral neuromodulation (SNS). This therapy works by stimulating the sacral nerve (near the base of the spine). This nerve carries signals between the spinal cord and the bladder. In OAB, these nerve signals don’t work the right way. SNS uses a “bladder pacemaker” to interrupt these signals, which can improve OAB symptoms. During the placement of a “bladder pacemaker,” a surgeon makes a small cut and places a thin wire close to the sacral nerves. The device is then tested to see how well it works for you. In a second procedure, the surgeon connects the wire to a small battery-operated device placed under the skin. This device delivers electrical impulses to the bladder to stop the signals that can cause OAB.

Surgical Treatment for Stress Incontinence

Bulking agent injections — A variety of bulking agents, such as collagen and carbon spheres, are available for injection near the urinary sphincter. Bulking agent are injected into the tissues around the bladder neck and urethra to make the tissues thicker and close the bladder opening to reduce stress incontinence. Often, the injections are done under local anesthesia in your healthcare provider’s office. The injections can be repeated if needed. This method may not be as effective as other surgeries, but the recovery time is short. Bulking agents are a temporary treatment for stress incontinence.

Female sling — The most common surgical treatment for female stress incontinence is sling surgery. For this, a strip of tissue or soft mesh is placed under the urethra to support urethral closure. The tissue used to make the sling can be from the patient’s abdominal wall donated tissue or made from mesh. If using donated tissue or mesh, women often recover quickly because only a small cut is made. Many women find that they feel almost 100% better after this surgery.

Bladder neck suspension — Burch, colposuspension or bladder neck suspension is surgery for female stress incontinence that attaches the bladder neck to the pubic bone with permanent sutures. This is a major surgery with a cut through the abdominal wall. It may take a long time to recover from this, but it can also prevent leaks for a long time.

Products and Devices

For some people, products and devices are the only way to manage bladder problems. They can give older and disabled persons more freedom. Examples:

• Indwelling catheter (stays in your body day and night, connected to a drainage bag)
• Intermittent catheters that are used several times each day
• Absorbent products (pads, adult diapers, tampons)
• Pessaries
• Toilet substitutes (like portable commodes)