Individuals with urinary incontinence can impact their quality of life socially and hygienically. This condition is most prevalent in the elderly but can affect younger adults. Individuals are reluctant to seek medical care due to embarrassment and assume urinary incontinence is just a normal part of aging. There are many types of urinary incontinence and treatment options. Medications should be reviewed for medications causing bladder contractions and consideration of discontinuing to control the incontinence. The first line of treatment is conservative and behavior lifestyle changes. This blog will review the different types of urinary incontinence and treatment care for these conditions.
Stress incontinence is involuntary leakage of urine with activities causing abdominal pressure. Individuals can predict when leakage can occur due to certain activities that apply pressure to a full bladder. These activities include laughing, lifting, coughing, sneezing, and high-impact exercises. However, if the bladder pressure is relieved and leakage continues, it is more likely to be caused by urge incontinence.
Causes for Women
Stress incontinence risks are higher in women than men. Pregnancy causes stress to the bladder and supporting muscles. Estrogen stimulates blood flow to the lining of the bladder, the urethra, and pelvic muscles. When estrogen levels drop, the lining to the bladder and urethra become dry and irritated. In addition, the sphincter muscles may lose their tone, causing the urethra to not close properly.
- Urethral hypermobility. Due to the weakening of the pelvic floor muscles, the urethra is out of its normal position, becomes too mobile, and causes failure of the urethral sphincter. The sphincter is unable to close completely. There are two types of urethral hypermobility. Type I is an incomplete closure of the bladder neck and urethra. With type II, a bladder prolapse may develop. The prolapse is caused by a shift of position of the bladder neck.
- Intrinsic sphincteric deficiency. The urethral sphincter can not maintain adequate resistance due to weakened muscles around the bladder neck.
- Denervation. Denervation is a loss of nerve supply caused by trauma from childbirth, chronic cough, or lifting.
Causes for Men
Prostatectomy can cause external sphincter damage that results in stress incontinence. However, with advances in surgical techniques, the nerves can be preserved.
- Kegel exercises strengthen the pelvic floor muscles.
- Biofeedback is an electrical stimulation for pelvic floor muscles.
- Behavior therapy includes prompted urination, constipation management, and controlling fluid intake.
- Mechanical devices: Pessaries are prosthetic devices for treating pelvic organ prolapse in women. A pelvic exam is required for individualized fit for comfort and support.
- Weight management may help to relieve pressure on the pelvic floor muscles.
Alpha-adrenergic agonists\s. For men, serotonin and noradrenaline reuptake inhibitors.
- Hormone replacement therapy. Literature supports it does not provide the same benefit as natural estrogen and can increase the risks of incontinence.
- Intravesical balloon. Treatment for women who failed conservative management and either failed surgery or were not candidates for surgery. The balloon is placed inside the bladder to decrease the increasing bladder pressure, causing stress incontinence.
- Trans or periurethral bulking agents. Injection of bulking agents is a minimally invasive treatment for stress incontinence.
- Sling procedures. Slings are placed around the urethra and attached to the abdominal wall to lift it back to a normal position.
- Urethropexy: The urethra and bladder neck are stitched to the lining of the pelvic bone to reposition the bladder and urethra.
Urge (Overactive Bladder)
Urge incontinence is caused by leakage following the urgency to urinate due to abnormal overactive bladder contractions while the bladder is filling. In addition, bladder irritation or loss of neurological control can result from contractions.
The cause may be related to neuromuscular diseases (Stroke, Parkinson’s, multiple sclerosis, and spinal cord tumors). Less frequent causes are urinary tract infections and bladder irritants.
- Detrusor hyperactivity with hyperreflexia: Involuntary bladder contractions during the storage phase, causing the sensation of urgency and forcing urine past the sphincters.
- Detrusor hyperactivity with impaired contractile function: This is an involuntary bladder contraction during the storage phase that empties the bladder during urination.
Conservative management includes bladder training (behavior therapy), biofeedback, and prompt voiding for individuals with dementia. Fluid management maintains adequate fluid and reducing bladder irritants (caffeine and artificial sweeteners).
- Medication management: Medications for incontinence management are given if bladder training is unsuccessful. The medications include anticholinergics, antimuscarinics, bladder relaxants, and topical vaginal estrogen (not FDA approved).
- Surgical Management: Sacral neuromodulation. Botulinum toxin type A injections paralyze the bladder and sphincter muscles. Botox relaxes the bladder muscle, reduces bladder sensation, and controls inflammation.
Overflow incontinence is caused by frequent small amounts of urine leakage from an overfilled bladder. The bladder fills normally but is unable to empty properly.
- Detrusor underactivity: There are many causes for under activity of the bladder. Nerve damage results from diabetes, spine disc disorders, and spine tumors. Neurological disorders (Parkinson’s disease) and medications (anticholinergics and opioids).
- Bladder outlet obstruction: The causes of obstruction are a prolapsed bladder, urethral stricture, trauma from a sling procedure, and fecal impaction.
- Detrusor-sphincter dyssynergia: Spinal cord lesions can interrupt the neurological pathways causing a loss of coordination with the sphincter and bladder muscle contractions.
Clean intermittent catheterization or indwelling urethral catheter to relieve the obstruction.
- Medication management: alpha-adrenergic antagonists
- Surgical management: Suprapubic catheter
Reflex incontinence is a type of urge incontinence related to an impaired neurological system. It is common with individuals who have a history of stroke, brain tumors, spinal cord injuries, advanced dementia, Parkinson’s disease, and multiple sclerosis.
- Detrusor hyperreflexia: Abnormal bladder contractions without the sensation to urinate.
- Dyssynergic contractions of the urethral sphincter cause obstruction and a distended bladder with a large residual urine volume.
- Behavior therapy: Scheduled urination with double voiding and applying pressure to the pelvic area (Crede maneuver) to prevent bladder distention.
- Body-worn absorptive products
- External catheters
- Intermittent clean or long-term catheterization
- Medications are used to treat overactive bladder.
- Implantable electrical stimulation of the sacral nerves
Mixed Urinary Incontinence
Mixed incontinence is a combination of both stress and urge incontinence. Treatment deals with both problems; however, it primarily focuses on the most prominent symptoms of the type of incontinence.
Functional incontinence is the inability of an individual to be independent of toileting needs due to a disability. Management is based on the causes to maintain continence.
- Pain: Pain assessment and management. Chronic pain may affect mobility and interfere with toileting needs.
- Decreased mobility: The treatment of the disability is required to make toileting easier, such as assistive devices or clothing that is easy to remove. Restraints in facilities or lack of assistance from caregivers can lead to the inability to use a toilet when needed.
- Dementia: Individuals with dementia may need a voiding scheduling program and prompted voiding.
- Inaccessibility to toilet facilities: Modify the bathroom to accommodate a wheelchair or assistive devices. For visually impaired individuals, poor lighting may be a factor. A bedside commode or urinals may be needed. For outside the home, advance identification of accessible toilet facilities.
Although urinary incontinence is more prevalent in adults, it is not a normal part of aging. Urinary incontinence is treatable, and some causes are reversible. Management options are available to conservative, pharmacological, and surgical. Care providers should assess the type of incontinence and see a collaborative approach for treatment options.
The views and opinions stated in this blog are exclusively those of the author and do not reflect those of iWound, its affiliates, or partner companies.
Further Reading and References
Aoki, Y., Brown, H. W., Brubaker, L., Cornu, J. N., Daly, J. O., & Cartwright, R. (2017). Urinary incontinence in women. Nature reviews. Disease primers, 3, 17042. https://doi.org/10.1038/nrdp.2017.42
Börgermann, C., Kaufmann, A., Sperling, H., Stöhrer, M., & Rübben, H. (2010). The treatment of stress incontinence in men: part 2 of a series of articles on incontinence. Deutsches Arzteblatt international, 107(27), 484–491. https://doi.org/10.3238/arztebl.2010.0484
Chen JL, Kuo HC. Clinical application of intravesical botulinum toxin type A for overactive bladder and interstitial cystitis. Investig Clin Urol. 2020 Feb;61(Suppl 1):S33-S42. doi: 10.4111/icu.2020.61.S1.S33. Epub 2019 Nov 13. PMID: 32055752; PMCID: PMC7004832.
DeLancey, J. O., Miller, J. M., Kearney, R., Howard, D., Reddy, P., Umek, W., Guire, K. E., Margulies, R. U., & Ashton-Miller, J. A. (2007). Vaginal birth and de novo stress incontinence: relative contributions of urethral dysfunction and mobility. Obstetrics and gynecology, 110(2 Pt 1), 354–362. https://doi.org/10.1097/01.AOG.0000270120.60522.55
Deng M, Ding J, Ai F, Zhu L. Clinical use of ring with support pessary for advanced pelvic organ prolapse and predictors of its short-term successful use. Menopause. 2017 Aug;24(8):954-958. doi: 10.1097/GME.0000000000000859. PMID: 28419067.
Ghaderi, F., & Oskouei, A. E. (2014). Physiotherapy for women with stress urinary incontinence: a review article. Journal of physical therapy science, 26(9), 1493–1499. https://doi.org/10.1589/jpts.26.1493
Kopańska, M., Torices, S., Czech, J., Koziara, W., Toborek, M., & Dobrek, Ł. (2020). Urinary incontinence in women: biofeedback as an innovative treatment method. Therapeutic advances in urology, 12, 1756287220934359. https://doi.org/10.1177/1756287220934359
Lee, A., Phillips, A. A., Squair, J. W., Barak, O. F., Coombs, G. B., Ainslie, P. N., Sarafis, Z. K., Mijacika, T., Vucina, D., Dujic, Z., & Krassioukov, A. V. (2017). Alarming blood pressure changes during routine bladder emptying in a woman with cervical spinal cord injury. Spinal cord series and cases, 3, 17101. https://doi.org/10.1038/s41394-017-0022-y
Li N, Cui C, Cheng Y, Wu Y, Yin J, Shen W. Association between Magnetic Resonance Imaging Findings of the Pelvic Floor and de novo Stress Urinary Incontinence after Vaginal Delivery. Korean J Radiol. 2018 Jul-Aug;19(4):715-723. doi: 10.3348/kjr.2018.19.4.715. Epub 2018 Jun 14. PMID: 29962877; PMCID: PMC6005944.
Luo DY, Wang KJ, Zhang HC, Dai Y, Yang TX, Shen H. Different sling procedures for stress urinary incontinence: a lesson from 453 patients. Kaohsiung J Med Sci. 2014 Mar;30(3):139-45. doi: 10.1016/j.kjms.2013.09.004. Epub 2013 Oct 15. PMID: 24581214.
Okunola, Temitope Omoladun MB, BS∗; Yakubu, Emmanuel MB, BS†; Daniyan, Babafemi MB, BS†; Ekwedigwe, Kenneth MB, BS†; Eliboh, Monday MB, BS†; Sunday-Adeoye, Ileogben MB, BS† Transvaginal Retropubic Urethropexy Versus Pubovaginal Sling for Treatment of Postrepair Urinary Incontinence, Female Pelvic Medicine & Reconstructive Surgery: October 2020 – Volume 26 – Issue 10 – p 603-606
Patel, P. D., Amrute, K. V., & Badlani, G. H. (2007). Pelvic organ prolapse and stress urinary incontinence: A review of etiological factors. Indian journal of urology : IJU : journal of the Urological Society of India, 23(2), 135–141. https://doi.org/10.4103/0970-1591.32064
Pipitone F, Sadeghi Z, DeLancey JOL. Urethral function and failure: A review of current knowledge of urethral closure mechanisms, how they vary, and how they are affected by life events. Neurourol Urodyn. 2021 Nov;40(8):1869-1879. doi: 10.1002/nau.24760. Epub 2021 Sep 6. PMID: 34488242; PMCID: PMC8556259.
Rahnama’i, M. S., Marcelissen, T., Geavlete, B., Tutolo, M., & Hüsch, T. (2021). Current Management of Post-radical Prostatectomy Urinary Incontinence. Frontiers in surgery, 8, 647656. https://doi.org/10.3389/fsurg.2021.647656
Sukhu, T., Kennelly, M. J., & Kurpad, R. (2016). Sacral neuromodulation in overactive bladder: a review and current perspectives. Research and reports in urology, 8, 193–199. https://doi.org/10.2147/RRU.S89544
Winkler, H., Jacoby, K., Kalota, S., Snyder, J., Cline, K., Robertson, K., Kahan, R., Green, L., McCammon, K., Rovner, E., & Rardin, C. (2018). Twelve-Month Efficacy and Safety Data for the “Stress Incontinence Control, Efficacy and Safety Study”: A Phase III, Multicenter, Prospective, Randomized, Controlled Study Treating Female Stress Urinary Incontinence Using the Vesair Intravesical Balloon. Female pelvic medicine & reconstructive surgery, 24(3), 222–231. https://doi.org/10.1097/SPV.0000000000000488