Urinary Incontinence

(Loss of Bladder Control, Bladder Control Problems, Incontinence)

The Facts

When someone is unable to control the ability to urinate and there's an involuntary loss of urine, this person is said to have urinary incontinence. This condition is also called "leaky bladder."

It's a very common problem, especially among older adults. Around 12% of seniors living in the community and more than 80% of seniors living in nursing homes experience this condition. It generally affects more women than men until the age of 80.

Many people believe that urinary incontinence is a normal part of aging when in fact it's not. Others may be embarrassed to talk about incontinence with a health care professional. For these reasons, many people don't seek medical help and never get properly diagnosed or treated. In many cases, urinary incontinence can be cured, or at least significantly relieved.

The Causes

Loss of urine can occur for a number of reasons that are related to the bladder (where urine is stored in the body) or the bladder sphincter (a thick muscle that controls the flow of urine out of the bladder).

Although aging itself doesn't cause incontinence, normal changes that occur in the urinary and genital systems as people age make this condition more common in the elderly.

For example, the bladder and the muscles that support it tend to sag with age, making it more difficult to store urine. Many medications taken by seniors for various medical conditions (e.g., high blood pressure, depression) can also increase bladder problems and lead to incontinence.

A common cause of temporary urinary incontinence is a urinary tract infection. Other causes of incontinence include severe constipation, delirium, depression, reduced mobility, and diabetes.

There are 4 main types of urinary incontinence:

**Stress incontinence: **Urine will leak out in sudden spurts when someone coughs, sneezes, strains, bends, lifts, or laughs. All these activities increase the pressure on the abdomen and bladder, causing urine to abruptly flow out. It's most commonly the result of weakened or stretched muscles that support the uterus and bladder. Childbirth via vaginal delivery, prolonged or difficult labour, previous pelvic surgery, being overweight or obese, and having a family history of stress incontinence can all increase the risk of stress incontinence. As well, the loss of estrogen associated with menopause can lead to weakness of the pelvic muscle support and cause stress incontinence. Stress incontinence typically does not occur in men and may be seen only after some type of prostate surgery.

Overflow incontinence: This occurs when the bladder stores more urine than it can handle. It often affects elderly men who have enlarged prostate glands (called benign prostatic hyperplasia), or people with a weak bladder muscle. In BPH, the large prostate squeezes or compresses the urethra (the tube that empties urine from the bladder) and prevents normal flow of urine. The urine then starts to collect in the bladder until there's so much excess that the bladder becomes distended (overstretched) and urine leaks out. Other conditions that can cause overflow incontinence include diabetic neuropathy and multiple sclerosis. Chronic untreated BPH can eventually lead to bladder muscle weakening.

**Urge incontinence: This occurs when moderate to large amounts of urine leak due to inability to delay voiding despite the urge. **Overactive bladder is a condition that can lead to urge incontinence. This condition causes people to feel an urgent need to urinate due to muscle spasms in the bladder. It is common to experience this at night. It is the most common type of incontinence in older people. Cues such as running water or unlocking the door when returning home can trigger the urge to urinate.

Functional incontinence: This type of incontinence occurs when people have urge incontinence but are unable to get to the toilet because of conditions such as dementia, stroke, or immobility.

Some people may have mixed incontinence, which is a combination of the 4 types. The most common combination is urge and stress incontinence. Incontinence can either be temporary (e.g., caused by infections or medications) or persistent.

Symptoms And Complications

A typical symptom is involuntary loss or leakage of urine. If you experience repeated episodes of urine leaks, it's important that you see your doctor as soon as possible.

Many people with incontinence may feel embarrassed due to unpleasant odours. They may avoid going out with friends or family. This can lead to isolation and depression.

Incontinence, when left untreated and inadequately managed, can lead to rashes and other skin disorders. If overflow incontinence is not treated, it can lead to urinary tract infection. If severe enough, urinary retention can be a medical emergency.

Making A Diagnosis

Assessment by a doctor is the first step in diagnosing urinary incontinence. Your doctor will review your history, perform a physical examination, and run laboratory tests. The doctor will also ask questions to determine whether the incontinence occurs only at night (nocturnal) or during both day and night, how much urine is lost, and what factors trigger it.

You may be asked to provide a list of medications you are taking and to keep a bladder diary (writing down the amount of fluid intake and urine output). This information will help your doctor figure out why you might be experiencing incontinence.

Tests for urine leakage with coughing and bending will help diagnose stress incontinence, while tests that measure the degree of bladder emptying will establish overflow incontinence.

In certain cases, more extensive bladder testing may be needed to determine the exact cause of the incontinence. Your doctor may also test your urine or blood to see if problems such as diabetes or infection are causing incontinence. A pelvic or rectal exam may also be performed.

Finding out the cause of the problem will help determine what treatments are given.

Treatment And Prevention

In most people, incontinence can be successfully treated. If medications (e.g., water pills, certain antidepressants) or medical conditions (e.g., diabetes, atrophic vaginitis) are the root of the problem, then the medications may be discontinued or changed, or the medical condition treated.

In people suffering from dementia or Alzheimer's disease, incontinence isn't always treatable. In these cases, wearing undergarments or using bedpans or urinary catheters (flexible tubes that allow for urination) can be helpful.

Treatment options depend on the type and cause of incontinence and include the following:

Kegel or pelvic floor exercises: These exercises are particularly helpful if you have stress incontinence, but may also provide some benefit for those with urge incontinence. They specifically target the muscles of the pelvic floor. By contracting the muscles that support the bladder, you strengthen and tighten the bladder outlet. Kegel exercises need to be done regularly and consistently to work. It may take up to 6 to 8 weeks to see results from Kegel exercises.

**Bladder or behaviour training: **This treatment may be useful if you have stress or urge incontinence – about 75% of people report some improvement. You learn to control urine output and toilet habits over a training period of weeks to months. Training depends on the type of incontinence, but it can consist of learning how to "hold on" for longer time periods before urinating, voiding at regular time intervals, and resisting the "urge to go."

Weight loss: being overweight or obese puts additional pressure on the abdomen, which can cause or worsen incontinence. Your health care provider may recommend you lose weight to help reduce urine leakage.

Combination of Kegel exercises and behaviour training: These two therapies are sometimes combined with biofeedback. Treatments like these require a high level of determination and commitment, but the result is often worth the effort.

Medications: When exercises and behaviour training don't work, doctors may offer medication treatment. Some medications prevent bladder contractions, while others help increase bladder capacity. It's not recommended that you self-medicate with over-the-counter medications – if you have symptoms of incontinence, it's best to see your doctor for appropriate medications.

There are several types of medications used to treat incontinence, including:

antispasmodics (e.g., oxybutynin*, tolterodine, solifenacin, trospium) help increase the bladder's storage ability and decrease bladder spasms – this delays the urge to urinate
**mirabegron **is another medication that is used in people with urge incontinence to help relax the bladder smooth muscles
**botox **can be also used in urge incontinence
alpha-blockers (e.g., terazosin, tamsulosin) can be used to help urine flow easier
**5-alpha-reductase inhibitors **(e.g., dutasteride, finasteride) can be used in men with BPH to reduce prostate size

Bladder surgery: surgery is the most effective treatment for those with stress incontinence. Overflow incontinence caused by an obstruction in the urinary tract or an enlarged prostate in men may also be treated with surgery. Different types of surgeries are available, and the doctor will determine which one is best for a specific case.

Other treatment options for urinary incontinence include pessaries, catheterization and electrical stimulation. Preventing constipation by eating a diet high in fiber can also help with symptoms.

Helpful tips for managing incontinence:

Reduce intake of foods or beverages that increase urination or may irritate the bladder (e.g., coffee, tea, alcohol).
Avoid or reduce smoking, as it can worsen existing urinary incontinence, or potentially increase your risk of developing urinary incontinence.
Avoid or reduce high impact activities, especially if you are experiencing stress incontinence, until symptoms improve.
Scheduled emptying of the bladder helps, in addition to emptying before you sleep.
Drink small amounts of fluids regularly throughout the day, but limit fluid intake 2 to 3 hours before going to sleep.
Empty the bladder completely when you urinate and try to give an extra push to get the last drops of urine out.
Before using absorbent pads or adult diapers, talk to your doctor to make sure you are getting proper medical treatment.