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Urinary Incontinence

Urinary incontinence is the involuntary loss of urine that results from loss of bladder control. It often accompanies aging in women and can result from multiple causes. It is one of the most prevalent health concerns confronting women over 60, and is often under-reported and undertreated because of its embarrassing nature and the social stigma attached. Ten to twenty percent of women (and up to 77% of women residing in nursing homes) have urinary incontinence, yet fewer than half seek treatment. It can significantly decrease a woman’s quality of life; not knowing when and where an accident might occur can affect everything from work to exercise to one’s social life. However, urinary incontinence can be significantly improved with correct assessment, treatment, and management. Urinary incontinence is not a disease; it’s a sign of either weak pelvic floor muscles or another problem, such as a nerve problem, that’s causing bladder or urethral dysfunction.

Urine is produced in the kidney and travels down the tubular ureter to reach the bladder where it’s stored. When there’s the urge to urinate, the bladder muscles tighten and force urine out of the bladder and into the urethra (another tubular structure). The muscles surrounding the urethra then relax to let the urine out of the body. The muscles of the pelvic floor have a role in this process as they provide the physical and functional support for the bladder and urethra, as well as for the uterus and rectum.

Symptoms of urinary incontinence include an abrupt, strong urge to urinate, urinating more than eight times during the day or more than twice at night, loss of urine while sleeping, and loss of urine when coughing, laughing, or climbing stairs—essentially whenever “bearing down” occurs.

  1. Stress urinary incontinence is the loss of bladder control that occurs during physical activity that increases abdominal pressure by, as mentioned, “bearing down,” such as with coughing, laughing, sneezing, running, lifting, or climbing stairs. This type of incontinence can be experienced by women of all ages, but is the most common bladder control problem in younger women. It occurs because of weakness in the pelvic floor muscles that support the anatomical area where the urethra comes off the bladder. When a woman bears down, excess pressure is exerted on the bladder/urethral junction and that pressure overwhelms the urethra’s ability to stay closed, so urine leaks out. Pressure on the bladder/urethral junction from simply coughing or laughing may be all it takes for leakage to happen. There are several reasons why the supporting pelvic floor muscles can lose strength. They may have been stretched by weight gain, pregnancy, vaginal childbirth, or a sports injury.
  2. Urge incontinence (also known as overactive bladder, or OAB) involves the sudden strong urge to urinate, and this sensation may be very difficult to control. If a woman desperately needs to urinate and can’t get to the bathroom in time, that’s urge incontinence. With this type of incontinence, there may be leakage of a large volume of urine from a full bladder or small leakage from an almost empty bladder. The sudden, overwhelming urge to urinate is thought to be due to acute spasms of the bladder muscle. These spasms can result from nerve or muscle damage, a stroke, an infection, or inflammation of the bladder, but most cases of urge incontinence are of unknown causes and are due to an inability to stop these bladder muscle contractions.
  3. Finally, mixed urinary incontinence involves the combination of a strong, uncontrollable urge to urinate accompanied by the loss of urine during physical activity.

  • Menopause: the drop in estrogen levels during menopause causes the lining of the urethra to thin out and the muscles of the pelvic floor to weaken. These muscles are needed for bladder control.
  • Aging: as a woman ages, the muscles of the pelvic floor weaken. Aging of the bladder muscle itself can decrease the bladder’s capacity to store urine. Also, involuntary bladder muscle contractions become more frequent as a women ages.
  • Diabetes: women living with diabetes may have up to a 70% higher risk of urinary incontinence. This may be due, in part, to damage caused by diabetes to nerves around the bladder.
  • Obesity: obesity causes constant pressure to be exerted on the bladder, which may lead to pelvic muscles weakness over time.
  • Constipation: the rectum is anatomically near the bladder and shares many of the same nerves. Repeated straining to have a bowel movement can cause overactivity in these nerves, which can increase urinary frequency. If urinary frequency becomes severe enough, incontinence ensues.
  • Childbirth: vaginal delivery can weaken the muscles and tissues of the pelvic floor. This can lead to a dropped (prolapsed) pelvic floor. With prolapse, the bladder, uterus, rectum, or small intestine can get pushed down from their usual position and protrude into the vagina. Such protrusions can be associated with urinary incontinence and can be seen on gynecologic exam.
  • Neurologic disorders: multiple sclerosis, Parkinson’s disease, stroke, spinal cord injury, and brain tumors can interfere with the nerve signals involved in bladder control, which can lead to urinary incontinence. The problem in this setting may be that the bladder doesn’t completely empty each time the woman urinates, and eventual over-accumulation of urine and inevitable overflow leads to urinary spillage in the form of small amounts of urine dripping out over time.
  • Smoking: tobacco can increase a woman’s risk of urinary incontinence if she has a chronic cough that puts ongoing pressure on the bladder and pelvic floor muscles.
  • Family history: a woman has a higher risk of developing urinary incontinence, especially urge incontinence, if a close family member has urinary incontinence.

It is important that all women be screened for symptoms of urinary incontinence by their gynecologist. The screening process starts simply with the question of whether there is any loss of urine. If so, then a discussion follows about general medical and, specifically, bladder control issues, past pregnancies and pelvic surgeries, and current medications. Answers to questions on the frequency of urination, on how and when urinary loss occurs, etc. and, perhaps even better, information from a journal that a woman can keep for several days (in which she documents how often and under what circumstances urinary leakage occurs, etc.) can all start to help determine the pattern of urinary loss and type of incontinence that’s occurring. A pelvic exam exam is done to examine the pelvis, bladder, urethra, uterus, and vagina for findings that may add more information toward the diagnosis of the type of urinary incontinence (a “stress” test can be done here: the gynecologist can ask the woman to cough to see if any urine leaks out from the urethra). Urine samples are sent to test for urinary tract infection as a possible cause for the incontinence. A pelvic sonogram is ordered to look at the contents of the bladder and assess its emptying ability in a non-invasive way. A cystoscopy may be done to directly look inside the bladder and urethra to evaluate for any suspected pathology that may be at hand (this is typically done in the office setting by a urogynecologist or urologist). And finally, to complete the diagnostic process for the incontinence, specialized bladder and urethral testing known as urodynamic testing is performed in the office to determine how much urine the bladder can retain and how well the urethral sphincter is working.

Once the type of urinary incontinence is diagnosed, appropriate treatment can be given. The treatment should progress from less invasive to more invasive until the patient’s goals are met. An improvement in quality of life should be the end goal for both the patient and physician.

“Conservative” (non-surgical) treatment options are typically recommended before invasive interventions are proposed. These options include lifestyle changes such as bladder emptying on a regular schedule and before physical activity; avoiding the lifting of heavy objects; doing pelvic floor (Kegel) exercises to strengthen the pelvic muscles; modifying fluid intake; avoiding the lifting of heavy objects; and avoiding alcohol and caffeine, which can cause urge incontinence. Medications that reduce leakage may also be prescribed. Some medications stabilize the bladder muscle contractions that cause an overactive bladder and urge incontinence. Others do the opposite—they relax the bladder to allow complete emptying of the urine. Hormone therapy might also be used: often, with estrogen replacement, bladder function improves.

If conservative measures fail to treat the urinary incontinence, then more invasive interventions may have to be considered. Referral to a urogyneologist or urologist would be necessary for these interventions. Injections of Botox into the bladder can help relax the muscles and improve urge incontinence. This treatment is not permanent and may need to be repeated over time. A pacemaker that stimulates the nerves of the bladder can be implanted, also to improve urge incontinence. Finally, a sling surgical procedure can be performed in the operating room for stress urinary incontinence where either a strip (sling) of synthetic material or a woman’s own tissue is placed beneath the bladder/urethral junction to help support the urethral channel.

Prevention is always preferable, but isn’t always possible. However, risk can be decreased by the following:

  • Maintaining a healthy weight
  • Practicing pelvic floor (Kegel) exercises
  • Avoiding bladder irritants like caffeine, alcohol, and acidic foods
  • Eating more fiber to prevent constipation
  • Not smoking

We at (Adaptive) Gynecology recognize how challenging urinary incontinence can be for a woman and how much it can affect her quality of life. We can treat many women in our office, but have our urology and urogynecology colleagues available as part of the team often needed to definitively manage this common problem.

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