Urinary Incontinence (UI)

A person who is affected by urinary incontinence (UI), loses control of their urinary sphincter, the two muscles which control the passage of urine into the bladder, resulting in an involuntary leakage of urine.

UI is a symptom of other conditions, rather than a medical condition in its own right. People develop UI for a variety of reasons. It is generally associated with conditions which affect people in later life, such as prostate problems in men and the menopause in women.

Normal urinary function is controlled by the brain, which sends signals to the muscles that control the urine flow, in particular the pelvic floor muscles. Urine is produced by the kidneys. It contains the waste products from the body — including toxins, salts and water — that collect in the blood. Urine travels from the kidneys via the ureters (these are the connecting tubes between the kidneys and the bladder) to the bladder where it is stored until urination. In people with UI, the brain’s process of sending a signal to the bladder to release the urine can become compromised.

This causes a person to be mentally unprepared for a sudden leakage of urine. The muscles in the bladder may also lose their functionality. This renders the bladder physically unprepared to contract and relax as needed in order to store urine effectively.

People affected by UI often experience a poorer quality of life than continent people. This is because the condition usually impacts significantly upon an individual’s daily routine. In severe cases, UI can necessitate taking time off work and may cause physical sexual dysfunction due to an inability to control the timing of urination — as well as inspiring feelings of embarrassment and distress. 1

However, in most cases, UI can be alleviated with correct management and/or treatment methods. Treatments include learning behavioral techniques and following an exercise program to strengthen the pelvic floor muscles, called Kegel exercises. In cases where an initial treatment plan does not alleviate UI, supplementary surgery may be considered. Alternatively, a long-term strategy for minimising the day-to-day impact of UI can be devised.

People affected by urinary incontinence (UI), experience loss of control over their urinary system. This can result in many different kinds of difficulties related to urinating, ranging from involuntary leakage to becoming unable to fully empty the bladder during urination.

UI can be transient: 2 a short-term or temporary problem which clears up on its own after the underlying cause, for example, a urinary tract infection, is resolved. However, UI can persist indefinitely.

Ongoing cases of UI are described as chronic 2 and can be the result of long-term conditions which affect the production of urine and/or the urinary system, such as diabetes. Chronic UI can last indefinitely if left untreated, so it is important for anyone affected by UI to seek medical guidance.

The most common types of UI are stress incontinence, i.e.placing stress on the bladder during involuntary physical activities, such as sneezing or laughing causes an involuntary release of urine, and urge incontinence, which is a sudden and uncontrollable need to urinate. If you think that you or a loved one may be affected by urinary incontinence, you can get a free symptom assessment by downloading the Ada app.

There are six types of urinary incontinence:

• Transient urinary incontinence. This is temporary, and directly related to a short-term condition being experienced by the affected person.
• Stress urinary incontinence. This type of UI is due to pressure on the bladder from physical activity, such as sneezing or coughing.
• Urge urinary incontinence. This involves a sudden and intense need to urinate due to an overactive bladder.
• Chronic urinary retention. This results in feelings of having failed to fully empty the bladder after urination. This is also called overflow incontinence.
• Functional urinary incontinence. This relates to an inability to urinate due to physical and mental obstacles.
• Mixed urinary incontinence. This is when a person experiences two or more types of incontinence in combination. Stress and urge incontinence are the kinds of UI which are most commonly experienced together.

Transient, short-term urinary incontinence can be caused by easily treatable factors, such as an adverse reaction to medication, and will clear up when the causal problem is remedied. In the first instance, when a person presents with UI, the doctor will determine whether the individual is affected by short-term UI and will then seek to treat the cause or causes.

In a case where UI is caused by an adverse reaction to medication, for example, this would involve stopping using the medication in question and prescribing a replacement option which is not associated with causing UI. Doctors often use a mnemonic — DIAPERS 3 — to explore the possible causes of transient UI and rule out a diagnosis.

Transient UI may be triggered by:

• Delirium
• Infection
• Atrophy (when the pelvic floor muscles weaken due to underuse)
• Pharmaceuticals
• Excess urine output
• Restricted mobility
• Stool impaction

A person can be affected by several causes of transient UI simultaneously. In cases where UI may be caused by multiple factors, treating all the causes will maximise the chances of alleviating the UI. Pharmaceuticals which can cause UI principally do so by relaxing the bladder, increasing fluid retention, or inhibiting bladder contractions. 4 Medications which are often associated with the condition include anti-hypersensitives, pain relievers, psychotherapeutics (muscle relaxants) and others, such as antihistamine.

If none of the causes specified in the DIAPERS mnemonic are present, the doctor will begin to investigate other causes of UI, dependent on the specific symptoms of the individual. 2

Stress urinary incontinence is one of the two most common types of UI — the other being urge urinary incontinence. Stress incontinence is not related to feeling stressed. It occurs when the urethral sphincter, the pelvic muscles that support the bladder and control the progress of urine into the urethra, weakens. The urethral sphincter ceases to function to prevent the flow of urine into the bladder and when the bladder is put under sudden pressure, this results in involuntary leakages of urine.

Activities which may cause leakage of urine with stress incontinence include:

• Coughing
• Sneezing
• Laughing
• Exercise
• Heavy lifting

People with stress incontinence usually experience small amounts of urinary leakage at intervals over the course of the day. More rarely, the condition can cause a person to involuntarily empty their bladder entirely.

Urge urinary incontinence (overactive bladder syndrome) is one of the two most common types of UI — the other being stress urinary incontinence. Urge incontinence is also sometimes called urgency incontinence because it involves a sudden need to relieve the bladder, causing the affected person to release urine a few seconds after they feel the need to do so. Urge incontinence can be triggered by both physical and psychological factors.

Activities and actions which cause leakage of urine with urge incontinence include:

• Sexual intercourse
• Reaching orgasm
• A rapid or sudden change of position
• Hearing the sound of running water.

People affected by urge incontinence may experience urinary leakage very frequently, and typically wake up several times during the course of the night to pass urine. It is not often possible for the doctor to identify a specific cause of urge incontinence, but it primarily affects women and the elderly.

People affected by chronic urinary retention (overflow incontinence) cannot empty the bladder completely when they pass urine.

Chronic urinary retention can be the result of:

• A mechanical obstruction, for example a urethral stricture (narrowing of the urethra caused by injury, infection or disturbance to the area from devices such as a catheter).
• A dynamic obstruction, such as a loss of muscle tone, or by a combination of these factors. The condition can also be caused by the failure of the nervous system to transmit signals to the bladder.

People with chronic urinary retention are usually unaware that they are affected, until they develop a further symptom, such as a urinary tract infection (UTI) or lose their bladder control, resulting in an involuntary leakage of urine.

Good to know: Rather than experiencing chronic, long-term urinary retention, a person can experience acute urinary retention, a short-term form of UI in which it becomes impossible to empty their bladder at all, even when it is full. 5 Acute urinary retention can be painful and potentially life-threatening, so it is vital to seek urgent medical attention.

People experiencing functional urinary incontinence usually become aware that they need to urinate in advance of voiding their bladder. Their involuntary leakage of urine is caused by a range of possible physical and mental factors which prevent them from accessing the appropriate facilities in time.

Factors which contribute to functional urinary incontinence can include:

• Dementia
• Impaired dexterity
• Confusion
• Alzheimer’s disease
• Parkinson’s disease
• Depression
• Anxiety
• Poor eyesight (this may reduce a person’s ability to find their way to the restroom)

Functional urinary incontinence primarily affects the elderly, and people suffering from impaired mobility. It can involve either emptying the bladder fully or passing small amounts of involuntary urinary leakage.

It is possible for a person to experience several types of UI simultaneously; this is called mixed incontinence. The most commonly experienced form of mixed incontinence involves being affected by both stress incontinence (leaking urine with activity) and urge incontinence (the sudden, uncontrollable urge to pass urine).

It is possible to manage and/or treat mixed incontinence with a treatment plan which addresses the triggers of all the types of UI present.

UI is a common problem which affects more females than males. UI most commonly affects elderly people because it is associated with many conditions that typically develop in later life, such as Parkinson’s disease and dementia.

UI may develop as a result of any of the following factors:

• Another condition affecting the individual, for example, benign prostate hyperplasia
• A number of different biological processes, for example pregnancy and the ageing of a person’s connective tissue, which can be influenced by their genetics and gender
• A side-effect of medication
• A complication relating to a surgical procedure

Conditions and procedures which are commonly associated with urinary incontinence include:

• Urinary tract infections, which may be intermittent or chronic
• Congenital or birth defects — problems with development of the urinary tract
• Benign prostatic hyperplasia (BPH) — an enlarged prostate gland
• Kidney failure
• Vaginal prolapse
• Injuries to the spinal and nervous system
• Injuries to the pelvic area
• Stroke
• Diabetes
• High blood pressure
• Smoking tobacco
• Alcohol abuse
• Obesity
• Interstitial cystitis (bladder pain syndrome)
• Pregnancy: risk of UI increases with each pregnancy a person experiences
• Prostatectomy (prostate surgery)
• Menopause and postmenopausal complications

Because of the differences between the sexes in terms of pelvic and genital structure and the way the genitalia are connected to the urinary system, UI generally affects females and males differently in terms of the type of UI experienced, and for different reasons. Females are often affected by UI in relation to their reproductive processes, whereas males commonly experience UI in relation to problems affecting the prostate gland and associated surgery.

Women are more likely to experience UI than men because they are, physiologically, more likely to undergo bodily changes which compromise the normal function of the urinary system. Women can be affected by all types of UI and at any age. However, UI in women is primarily associated with ageing and with natural biological processes.For example, UI often accompanies pregnancy and also commonly affects women during or after they experience the stages of menopause.

The principal types of UI experienced by women are:

• Stress incontinence
• Urgency incontinence
• Mixed incontinence

People who have experienced pregnancy are more likely to experience UI. This is because being pregnant always involves changes to a person’s hormonal levels and an increase of pressure on their pelvic floor muscles as the developing fetus grows, which is likely to disrupt urinary function during the pregnancy as well as afterwards.

Giving birth itself, particularly vaginally, can alter the position of the pelvic floor muscles that control the flow of urine from the bladder, further increasing the chances of developing UI after being pregnant. However, the hormonal changes and stress to the pelvic floor involved in pregnancy, are the primary causes of UI in women, rather than the actions involved in birth itself. Therefore, opting for a c-section will not significantly reduce a person’s likelihood of developing UI. If you are concerned that you or a loved one may be developing UI, get a free symptom assessment with the Ada app.

The risk of UI increases with the number of times a person experiences pregnancy and childbirth. Both cesarean (c-section) and vaginal birthing methods can give rise to UI. Many people experience UI whilst going through the menopause, which involves a reduction in their accustomed estrogen levels. However, it is not thought possible to alleviate UI with any significant success by taking oral estrogen supplements; these can in fact worsen the condition. 6

Men can experience any of the types of UI. UI primarily occurs in males because of developing problems with nerve function, such that the brain no longer sends signals to the bladder effectively. This can include suffering from a stroke or a spinal cord injury (SCI), both of which affect the nervous system, interrupting the transmission of the nerve signals required for control of the urinary sphincter. Those who are affected by problems related to the prostate gland are also at risk of experiencing UI.

The prostate gland is located beneath the bladder, inside the male body, between the bladder and the penis and produces about 30% of the body’s ejaculation fluid. Problems which affect the prostate and may be associated with UI, include:

• Benign prostatic hyperplasia
• Prostate cancer
• Prostatitis (swelling of the prostate gland)

All of these conditions can change the position of the urinary sphincter and/or exert pressure on the bladder, causing UI.

Prostate problems and associated cases of UI most commonly develop in later life. People who have undergone treatment, such as radiation therapy for prostate cancer, or who have undergone a prostatectomy (prostate surgery) will experience urinary incontinence initially. This usually occurs after the urinary catheter, which facilitates urinary function in the initial postoperative period, is removed. UI associated with prostate surgery generally goes away with correct management and/or treatment, as the recovery period progresses.

For more information about the prostate and conditions that affect it, see this resource on enlarged prostate.

Several cross-sectional and/or population-based studies 7 8 9 have been undertaken to investigate a tendency for people, and females in particular, to refrain from seeking medical attention for UI until such point as the urinary leakage poses a serious imposition to their daily routine.

A reason which is commonly given for avoiding consulting a healthcare professional, is the perception that UI is a minor problem which one can tolerate. 10 However, it is important to seek medical attention, as UI develops into a long-term condition which does not alleviate without medical management or treatment in most cases.

Good to know: Many people are first diagnosed with UI after visiting a gynecologist, a doctor who specialises in the female reproductive system. Gynecologists are trained to look out for all potential cases of UI and understand that women may not mention or know that they could be affected by UI. Due to the fact that UI is often diagnosed by gynecologists first, there is a significant overlap between doctors who specialise in gynecology and urology (treating problems with the urinary system).

To diagnose UI, a doctor will review a person’s medical history, carry out urinalysis; an analysis of the composition of the person’s urine; and urodynamic testing; tests which ascertain the function of the individual’s urinary system. Doctors who specialise in problems related to the urinary system are called urologists.

Urodynamic testing involves filling and then emptying the bladder. Pressure readings are taken from the stomach and bladder throughout the process. The aim of urodynamic testing is to replicate the person’s urination process, allowing the doctor to assess any problems and determine their possible causes.

To establish which type or types of UI a person may be experiencing, a doctor will ask about:

• The timeframe in which difficulties urinating have been experienced
• Any triggering factors, such as sexual activity, coughing and sneezing, exercise, hearing running water
• The typical length of time between feelings of urgency, the sudden need to urinate, and actual urination
• Whether the urine loss is intermittent or constant
• The volume of urinary leakage
• Whether the person has experienced urinary tract infections (UTIs)

There are many factors which may trigger or worsen UI in a person. Knowledge of a person’s full medical history will help a doctor to determine the type or types of UI which are affecting an individual and the best treatment plan. The doctor will also establish whether a person is using any prescription and/or over-the-counter medications, as these can cause or aggravate UI.

UI can be treated or managed successfully with a variety of methods, including:

• Absorbent products
• Physical exercise programs, such as kegel exercises
• Behavioral treatment
• Medications
• Non-surgical procedures, such as electrical nerve stimulation
• Weight loss (for the obese)
• Surgery, i.e. procedures to restore the correct function of the urinary system

The type of treatment and management techniques required to treat UI will depend on the type and its severity. Often, successful treatment of UI will involve a combination of methods. For example, treatment for stress incontinence may require medication, Kegel exercises and/or behavioural change therapy. In the event that these methods are not sufficient to alleviate the UI, surgery may be considered.

There is a great variety of absorbent products for people with UI, including pads, panty-liners and adult diapers. These are mostly used to soak up involuntary leakages of urine on a temporary basis while planning further treatment for UI. Doctors will be able to recommend appropriate products for each person.

Kegel exercises, which target the main muscles involved in the urinary system are particularly helpful for strengthening the pelvic floor muscles. Doctors will advise on an exercise program. Other techniques which may be recommended to manage or prevent UI include pilates and kyphosis exercises.

Making various changes to a person’s diet and lifestyle and teaching them specific psychological coping techniques related to managing UI, has been found to reduce instances of involuntary urine leakage. Relaxation and breathing techniques, increasing exercise and avoiding drinking excess caffeine and alcohol are particularly helpful.

There are several different types of medication which may be used to treat UI, including:

• Hormonal medications for females which help tone the vaginal and urethral muscle tissue
• Medications which work by relaxing the muscles in the bladder to increase its capacity
• Medications to target the neurotransmitters in the brain to help block involuntary muscle movements that lead to urinary incontinence

The type of medication which a person is prescribed will depend on factors like their gender and the type and severity of their condition.

There are several procedures which can strengthen, rejuvenate and reposition some of the muscles in the urinary system, with the goal of improving bladder control and alleviating the symptoms of UI. This includes injecting bulking agents into the urethral wall to strengthen the urethra or electrically stimulating the muscles. These methods have a lower long-term efficacy rate than surgical treatments, but may be preferable for those unwilling to undergo surgery.

In obese people, losing weight can be an effective way to reduce the impact of UI and should be considered before surgery as part of an initial treatment plan. Losing five to ten percent of one’s body weight can have a similar effect to other non-surgical treatments for alleviating UI in obese people. 11

Surgery is very rarely considered as a first line treatment for UI. It is considered in cases where non-invasive methods such as Kegel exercises, behavioral therapies and/or medications and interventional therapies have been prescribed with negligible results.

Most surgery for UI is designed to treat stress incontinence. Most of the surgical procedures for UI have the same goal, bringing the bladder back to its original position. For this reason, surgery for UI is especially performed for treating the condition in women, who are most often affected by UI resulting from factors like hormonal changes, pregnancy and the anatomy of the pelvis changing with age. All of these can cause UI by damaging the pelvic floor in a way which causes the bladder to sink and leave its original position.

There are several types of surgical procedure for UI, most of which are carried out under general or regional anesthetic as in-patient procedures by surgeons called urologists,who specialise in problems related to the urinary system. The appropriate kind of surgery will be decided by the doctor on a case-by-case basis. The types of surgery with the best success rates are the sling procedure and bladder neck suspension surgery.

Although UI is a symptom of other conditions and/or physical states which exert pressure on the bladder, such as pregnancy, which it may not be possible to avoid, it is possible to minimise the risk of experiencing UI by taking measures to reduce the frequency and acidity of your urination and to exercise your pelvic floor muscles.

Methods which contribute to the prevention of UI include:

• Regular exercise
• Avoiding spicy and acidic foods
• Avoiding caffeine and alcohol
• Eating high-fibre foods to avoid constipation
• Maintaining a healthy body weight
• Kegel exercises to strengthen the pelvic floor muscles

Q: Does urinary incontinence affect children?</br>A: Cases of UI in children are rare. UI most commonly develops in later life, as a result of physical states, such as pregnancy, and conditions, such as dementia, which affect elderly people. In childhood, boys are more prone to nocturnal enuresis (bedwetting) than girls, as they develop bladder control at a later age. Most children develop bladder control by the age of three. 12

UI in children above the age of three is usually the symptom of another condition such as kidney problems or a UTI. An isolated instance of UI is not a cause for concern. However, if a child has UI regularly or for a prolonged period of time, it is important to seek a medical opinion and to diagnose and treat any related conditions the UI may pertain to.

Q: How does constipation / fecal incontinence affect UI?</br>A: Fecal impaction is caused by constipation. When feces builds up in the rectum, it can become packed in so tightly that it is impossible to pass the stool. The blockage puts pressure on the surrounding tissues, including the pelvic muscles related to the bladder and urinary system. This pressure can impede the bladder’s normal function, causing UI. Treating the constipation and removing the blockage will allow the urinary system to resume normal function.