Urinary Incontinence (UI) Treatment
What is urinary incontinence?
A person who is affected by urinary incontinence (UI) loses control of their urinary sphincter — made up of the two muscles, which control the passage of urine into the bladder — causing 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 often associated with conditions which affect older people, such as prostate problems in males and menopause in females.
Normal urinary function is controlled by the brain, which sends signals to the muscles in the bladder to hold or release urine, in particular the pelvic floor muscles. Urine is produced by the kidneys. It contains waste products from the body — including toxins, salts and water — that are filtered from the blood. It is transported from the kidneys and excreted (expelled) from the body via the urinary system. Urine travels from the kidneys via the ureters - connecting tubes between the kidneys and the bladder - to the bladder, where it is stored until urination.
There are two principal circumstances which lead to a person developing UI:
- The brain’s process of sending a signal to the bladder to release the urine can become compromised. This results in a person having limited control over the muscles in their urinary system.
- Alternatively, a local muscle fragility can cause UI. If the functionality of all, or part(s), of the muscles in the urinary system is compromised, the bladder may become unable to contract and relax as needed in order to store and release urine effectively, resulting in UI.
For more information about the symptoms, causes, risk factors and diagnosis of UI, see this resource on urinary incontinence.
In most cases, UI can be treated effectively. Treatment options for UI are chosen based on the type of incontinence affecting the person and might range from exercises for strengthening the pelvic floor muscles to surgery, if necessary.
Types of urinary incontinence
There are six main types of urinary incontinence:
Transient urinary incontinence
Temporary and directly related to a short-term condition being experienced by a person, such as an infection or stool impaction. Transient UI often clears up on its own when the causal condition is treated.
Stress urinary incontinence
Due to pressure on the bladder from physical activity like sneezing or coughing, when the bladder and/or sphincter are weakened. People with stress incontinence usually experience small scale 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
A sudden and intense need to urinate due to an overactive bladder. 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 a doctor to identify a specific cause of urge incontinence, but it primarily affects women and the elderly.
Chronic urinary retention
Feelings of having failed to fully empty the bladder after urination. This is also called overflow incontinence. Chronic urinary retention can be the result of a mechanical obstruction — for example a urethral stricture, e.g. narrowing of the urethra — the tube by which urine exits the body — caused by injury, infection or disturbance to the area from devices such as a catheter or a dynamic obstruction, such as a loss of muscle tone or by a combination of these factors.
Functional urinary incontinence
An inability to urinate due to physical and mental obstacles. 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.
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. It is possible to manage and/or treat mixed incontinence with a treatment plan that addresses the triggers of all the types of UI present.
Treatment for urinary incontinence
UI can be treated or managed successfully through a variety of treatment options, including:
- Non-surgical options, including using absorbent products, undertaking exercise programmes such as Kegel exercises, behavioral treatments and non-surgical procedures, such as botox injections or electrical nerve stimulation.
The type of treatment and management guidelines for treating UI will depend on factors such as the type of UI a person has and whether they are biologically male or female.
Often, successful treatment of UI will involve a combination of treatment options. For example, treatment for stress incontinence may require medication, Kegel exercises and/or behavioral change therapy. In the event that these methods are not sufficient to treat the UI, surgery may be considered.
Non-surgical treatments for UI include:
Absorbent products may be used in the treatment of all types of UI. During the period when appropriate treatment for UI is being planned and before it has had a chance to work, many people use them to manage involuntary leakages of urine.
Most absorbent products for UI are single-use, disposable items. Environmentally-friendly items such as cotton pads that can be laundered and reused are also available. The doctor will recommend suitable products for an individual, depending on the frequency and quantity of their urinary leakage.
Absorbent products for UI include:
- Adult diapers
- Plastic-coated underwear
- Drip-collectors that fit over the penis
Absorbent products alone are not sufficient to manage UI, and most people stop needing to use them as their treatment plan becomes effective. However, in cases where UI persists despite treatment or returns after surgery, the use of absorbent products may form part of a long-term strategy for the management of UI.
Physical exercise programs (such as Kegel exercises)
Kegel exercises are a commonly prescribed physical exercise program for treating urinary incontinence in women in particular and are recommended in the treatment of stress incontinence, urge incontinence and mixed incontinence.
The three primary areas which are strengthened by Kegel exercises are:
- The bladder, which holds the urine
- The pubococcygeus which supports the bladder and rectum
- The sphincter, which helps open and close the urethra
Kegel exercises should be practiced as directed by a doctor in order to keep the pelvic floor muscles, which control the bladder and urine flow, operational. The movements generally involve tightening and relaxing the vaginal and rectal muscles.
It can take three to six weeks to feel the benefits of starting a program of Kegel exercises, with daily practice. After starting a program, it is advisable to demonstrate how one performs one’s exercises to a doctor or nurse during a check-up to ensure that the proper forms of the Kegel movements are being practiced.
Other forms of exercise which may be helpful in the treatment and prevention of UI include:
Pilates is a form of exercise which can target specific areas of the body in order to improve physical strength and flexibility. Apparatus, like resistance bands and balls are often used in order to help ensure that the correct area of the body is being targeted during the routine.
When performing pilates to improve the pelvic floor muscles, a small pilates ball is often placed between the knees or thighs to ensure the attention is focused on the muscles in this area. Some people find it helpful to join a specialized pilates class, but it is also possible to practice the routines that help lessen UI using equipment at home.
Exercises that are designed to prevent an excessive curve of the lumbar region or mid-back, also called kyphosis or a dowager’s hump, have proven beneficial for alleviating the symptoms of UI in both women and men. These exercises improve posture, which can relieve pressure on the urinary system and also strengthen the pelvic floor muscles. Exercises which involve squatting or stretching the mid-back over a foam roller are particularly helpful.
Behavioral treatment can be particularly helpful in treating urge and/or stress incontinence, and can be prescribed on its own or in combination with other options, such as medication and/or surgery. Behavioral treatment involves learning psychological techniques which can help prevent involuntary urinary leakage. It has been found to be significantly more effective than oral medication alone in overcoming UI.
Behavioral techniques which can be helpful in the management of UI principally involve bladder training. The affected person will learn techniques aimed at emptying their bladder completely and lengthening the intervals between toilet trips. The training also involves scheduling toilet trips, rather than waiting until one feels a sense of urgency.
Other behavioral techniques include:
- Relaxation exercises
- Breathing exercises
- Limiting liquid intake before bed to avoid wetting the bed or waking up recurrently during the night. This needs to be discussed in detail with a doctor to ensure that dehydration does not occur.
- Avoiding alcohol
- Avoiding caffeine
- Avoiding acidic foods
- Increasing exercise
There are several non-surgical treatments, such as stimulating the muscles in the bladder with electricity using a probe inserted into the vagina, or inserting bulking agents into the urethral wall, which are minimally invasive. This means they are considered preferable to surgical treatments by some patients.
These techniques have a lower long-term efficacy rate than surgical methods. However, for people who are unable or unwilling to undergo surgery and for whom medications and/or behavioral therapies have not successfully treated UI, these options can provide a helpful alternative.
- Bulking agents: Substances designed to provide structural reinforcement will be injected into the urethral wall in order to strengthen the urethra. This can help a person regain control of the operation of their urinary sphincter and their ability to hold urine in the bladder. Bulking agents are usually composed of synthetic materials, silicone particles or collagen.
- Electrical nerve stimulation (ES): This treatment involves inserting a probe into the vagina and/or anus to deliver electrical stimulation to the muscles in the urinary system in order to strengthen them. ES is mostly prescribed for women with UI and has not been found to be as effective for men.
- Laser treatment: This is a fairly new treatment for UI. It makes use of an erbium‐doped yttrium‐aluminum‐garnet (Er:YAG) laser, which has previously been used successfully in the field of plastic skin reconstruction. This technique has principally been used to treat UI in women. The Er:YAG laser is applied to the supportive tissues in the pelvic area to tighten them. This has been found to effectively treat stress urinary incontinence, with effects lasting up to one year. Laser treatment for UI has not been found effective for other types of urinary incontinence, however.
- Botox: It is possible to strengthen and rejuvenate the muscles in the urinary system with the use of botox injections (intradetrusor botulinum toxin). Although this is not a first-line treatment for UI, it may be prescribed as an alternative if a person with urge incontinence does not find relief using oral medication.
This list includes the principal medications which are used in the treatment of UI:
- Alpha blockers: These medications are usually prescribed specifically for men who are affected by overflow incontinence. They function to relax the muscles in the neck of the bladder and the muscle fibers in the prostate. This makes it easier to empty the bladder.
- Anticholinergic drugs (muscarinic antagonists): These medications target neurotransmitters, which send signals from the brain to the body, and function to block involuntary muscle movements. In people with UI, this can serve to calm an overactive bladder. Anticholinergics may be especially helpful in treating urge incontinence.
- Topical estrogen: Women who are affected by urge incontinence may benefit from toning the tissues in the vaginal and urethral areas. Vaginal creams, rings or patches containing low-dose, topical estrogen can be helpful for this purpose. Taking the hormone orally, however, can worsen UI and is not recommended.
- Beta-3 adrenergic agonists: These medications are primarily prescribed to treat urge incontinence. They work by relaxing the muscles in the bladder, which increases its capacity. In some cases, they can also help a person to empty their bladder increasingly effectively during urination.
Surgical treatment options
Surgery is very rarely considered as a first-line treatment for UI. It is typically only considered in cases where non-invasive methods such as Kegel exercises, behavioral therapies and/or medications and interventional therapies have been prescribed and have not been effective, or when other therapies would not be useful in targeting the underlying cause of UI.
Most surgery for UI is designed to treat stress incontinence. Most of the surgical procedures for UI have the same goal, which is bringing the bladder back to its original position.
For this reason, surgery for UI is mainly performed on women. Women are most often affected by UI that results from factors like hormonal changes, pregnancy and the anatomy of the pelvis changing with age. All of these factors are likely to damage the pelvic floor in a way which causes the bladder to sink and leave its original position.
There are several types of surgical procedure that can be performed to treat UI, most of which are carried out under general or local anesthetic as in-patient procedures by surgeons called urologists and who specialize in problems related to the urinary system. In cases when surgery for UI is to be performed on a woman, the urologist will work closely with a gynecologist. 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.
This procedure is primarily carried out on women as a treatment for stress incontinence.
Its purpose is to insert a mesh product called a urinary sling into the pelvic area to restore the urethra to its correct position and full functionality. One advantage of the sling procedure is that it can be performed under local or local anesthetic, although general anaesthetic will be required in some cases, depending on the extent to which the urethra has moved from its correct position.
During the procedure, a small incision will be made in the pelvic area, usually in the abdomen, where the pelvic area meets the top of the thigh or the vagina. The urinary sling will be inserted. It works by providing support to the urethra, which it restores to its correct position. In the recovery period, the body’s tissues will begin to grow around the mesh, reinforcing the corrective effects of the procedure.
Men can also undergo the sling procedure. A variety of urinary sling products are specifically designed for men; these are called male urinary slings. Men often choose the sling procedure for UI where possible to avoid surgical options that involve the insertion of a mechanical device, like an artificial urinary sphincter. (See the section titled “Artificial urinary sphincter”).
A further advantage of the sling procedure is that correct urinary function is generally restored to the affected person within hours. Additionally, recovery times are usually short, minimizing the need to refrain from normal daily activities.
Bladder neck suspension
Bladder neck suspension surgery is solely used to relieve stress incontinence in men and women. The procedure involves restoring a deteriorated bladder to its previous position within the pelvis.
Bladder suspension surgery is used to treat UI arising from:
- Muscle deterioration
- Changes to the body caused by pregnancy and related internal damage
- Menopause and associated complications
Bladder neck suspension surgery is highly successful at relieving UI for a prolonged period of time in most cases, but the effects of the surgery are not always permanent, and UI eventually returns in a small number of cases.
Artificial urinary sphincter
This is primarily used to relieve stress incontinence in men and is rarely recommended for women.
The procedure involves the insertion of a device called an artificial urinary sphincter which consists of a reservoir which holds the urine securely in the abdomen, and a circular cuff which releases a flow of urine when the device is activated.
This is not a popular type of surgery for UI. In addition to experiencing pain and bleeding in the postoperative period, many people find that artificial urinary sphincters have a tendency to stop working. Further surgery is then needed to remove the device.
In some women, a vaginal prolapse can put pressure on the bladder, causing UI. Prolapses occur when weakness in the vaginal walls causes the formation of a bulge which protrudes beyond the pelvic area. They can be triggered by activities and physical states which place exertion on the pelvic area, such as heavy lifting, pregnancy or straining repeatedly to pass a bowel movement. The protruding lump will usually come out of the vagina, and can contain the bladder, bowel, uterus or all three of these body parts.
Surgery to correct a vaginal prolapse can restore the prolapsed parts to their correct anatomical position, and can thereby relieve pressure on the bladder and restore normal urinary function.
However, vaginal prolapse surgery alone cannot treat any case of UI which is triggered by any additional or alternative causes to a vaginal prolapse. Furthermore, complications from the surgery, such as an infection at the surgery site where the wound is healing, can also trigger UI or cause it to return.
It is very common for UI to co-occur with obesity. The risk of developing UI among those affected by obesity is greatly increased, the higher a person’s body mass index (BMI) is: each 5-unit increase in a person’s BMI correlates to an increased risk of developing UI, which can range from 20 to 70 percent. The link between UI and obesity is believed to relate to excess weight contributing to increased abdominal pressure, which can disrupt normal urinary function.
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 total body weight can have a similar effect to other non-surgical treatments for alleviating UI in obese people.
Eating healthily and increasing the amount of physical activity can help a person to lose weight, which can reduce the symptoms of UI. Stopping smoking, staying hydrated, consuming increased quantities of fresh fruits and vegetables and reducing consumption of sugary foods can increase a person’s metabolic rate and also contribute to weight loss, which can help to treat UI.
Liquid-diet weight reduction program
A low-calorie liquid diet (of around 800 calories per day or less) with increased exercise has been found to be effective at inducing weight loss and reducing symptoms in women with UI. However, major changes to a person’s diet, especially a significantly reduced calorie intake, should only be carried out under the supervision of a nutritionist, in order to ensure that they are suitable and safe for the affected person.
Weight reduction surgery
Also called bariatric or metabolic surgery, weight loss surgery is a major surgical procedure which can help very overweight people to lose weight rapidly. It may involve having a gastric band, gastric bypass or sleeve gastrectomy: each of these options aims to shrink the capacity to of the stomach so that the affected person feels full sooner, reducing their food intake and ultimately losing weight. In UI caused by obesity, weight reduction surgery may help a person lose weight to the point where they are no longer affected by UI more quickly than is usually possible by means of diet or exercise alone.
Although UI is a symptom of other conditions and/or physical states that exert pressure on the bladder (such as pregnancy) which it may not be possible to avoid, it is possible to minimize the risk of experiencing UI by taking measures to reduce the frequency and acidity of your urination and to exercise the pelvic floor muscles.
Methods which may contribute to the prevention of UI include:
- Regular exercise
- Avoiding spicy and acidic foods
- Avoiding caffeine and alcohol
- Eating high-fiber foods to avoid constipation
- Maintaining a healthy body weight
- Kegel exercises to strengthen the pelvic floor muscles
Urinary incontinence treatment FAQs
Q: Are there any effective natural remedies for UI?
A: There is a growing interest in the use of alternative remedies for all manner of health conditions, including UI. In particular, increasing numbers of people are exploring treatments derived from homeopathy, a branch of alternative medicine involving the consumption of special natural tinctures, and Ayurvedic medicine,an alternative system of medicine with historical Indian roots. However, the FDA (Food and Drug Administration) does not currently recognize the efficacy of any homeopathic, Ayurvedic or any other natural remedies for UI. For the best treatment of UI, anyone who is or may be affected should seek a regular medical appointment in a clinical setting from a licensed healthcare provider, in order to access treatment options (medications and/or procedures) that have been found to be effective in clinical trials.
If a person wishes to experiment with any alternative remedies for UI, such as the use of particular herbs, spice or essential oils, they should always consult their healthcare provider before starting these treatments. There is insufficient medical understanding of the mechanisms of action or the efficacy of alternative remedies and practices for treating UI, for these treatments to be FDA-recommended. Furthermore, some alternative products may be unsuitable for people with certain medical conditions or be unsuitable for use with certain pharmaceutical medications.
Q: What treatment options are recommended for people with UI caused by spina bifida?
A: Spina bifida is a congenital condition (a condition which is present from birth) in which the spine and spinal cord do not develop properly, causing a gap in the spine. Urinary incontinence is one of the principal symptoms of spina bifida and is caused by the neural connections between the brain and the bladder being broken in most people with the condition, leading to loss of sensation and/or poor bladder control.
UI related to spina bifida may improve on its own if the condition is treated or managed successfully. Overflow or mixed incontinence are the types of UI most commonly experienced, and a variety of treatment options may be effective; doctors will advise on the treatment that is right for each person. In particular, people with spina bifida may be prescribed anticholinergic medications, which help to prevent involuntary bladder spasms.
Q: What treatment options are recommended for people with UI caused by a stroke?
A: It is common for people to have continence problems after a stroke. Frequency, urgency, functional stress and nocturnal incontinence are types of UI which are commonly experienced in the short-term. For many people, UI caused by a stroke goes away on its own, although this may take months, depending on the extent of the damage caused by the stroke. For the majority of people affected by continence problems after a stroke, these resolve within a year. In the meantime, absorbent pads and other products are an effective means of managing any urinary leakage.
If continence does not return as expected, any underlying causes for the UI beyond the stroke will need to be diagnosed. The affected person can then begin suitable treatments. In this situation, medications, behavioral therapies and exercises to strengthen the pelvic floor muscles are considered as first-line treatments for persistent UI. If these methods prove ineffective, bladder stimulation or surgery may be considered.
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