Urine Incontinence Diagnosis and Treatment

What are the different types of incontinence?

Incontinence can present in several distinct forms, each characterised by unique causes, symptoms, and triggers. Identifying the specific type of incontinence is often critical for diagnosing the issue and devising an appropriate treatment plan.

Urge Incontinence

Urge incontinence is marked by a sudden, overwhelming need to urinate, often resulting in leakage before reaching a toilet. This condition is commonly linked to overactive bladder (OAB), which can occur due to various factors, including weakened pelvic muscles, nerve damage, infections, hormonal changes such as low oestrogen levels after menopause, or excess body weight. Additionally, certain medications and beverages, such as alcohol or caffeine, can trigger overactive bladder symptoms.

Stress Incontinence

Stress incontinence is caused by physical activity and causes urine leakage due to weakened pelvic floor muscles. These muscles provide essential support for pelvic organs, and their weakness increases the likelihood of accidental leakage during activities that put pressure on the bladder, such as coughing, laughing, jumping, sneezing, running, or lifting objects. Women, particularly those who have given birth, are at greater risk for stress incontinence, as are men who have undergone prostate surgery.

Overflow Incontinence

This type of incontinence arises when the bladder does not fully empty during urination, leading to a risk of spillage. The bladder can be likened to a jug that is only partially emptied, leaving residual urine prone to leaking out, often in small, continuous dribbles rather than in one large gush. Overflow incontinence is more commonly observed in individuals with chronic medical conditions such as multiple sclerosis (MS), stroke, or diabetes, as well as in men with an enlarged prostate.

Mixed Incontinence

Mixed incontinence is a combination of various forms of incontinence that collectively contribute to urinary leakage. For example, an individual might simultaneously experience stress incontinence and urge incontinence due to an overactive bladder. Understanding the specific triggers and scenarios leading to leakage is essential for managing mixed incontinence effectively.

Who gets incontinence?

Incontinence can affect anyone, but certain groups are more predisposed to this condition. Women are particularly susceptible due to factors such as pregnancy, childbirth, and menopause, which can weaken pelvic support muscles over time. Age is another significant factor, as the risk of incontinence increases with the natural weakening of muscles as one grows older.

Am I at a higher risk of incontinence at an older age?

As the body undergoes changes over a lifetime, ageing can lead to a decline in the strength of the muscles supporting the pelvic organs. This loss of support can contribute to urine leakage. Older age increases the likelihood of incontinence, particularly in individuals with chronic health conditions, those who have experienced childbirth, gone through menopause or had medical interventions like prostate cancer surgery. Consulting with a doctor is crucial to understanding the risks and exploring management strategies to maintain quality of life despite incontinence.

Is incontinence more common in women?

Yes, women are significantly more likely to experience incontinence compared to men. This disparity is largely due to biological and life events such as pregnancy, childbirth, and menopause. During pregnancy, temporary bladder control issues may arise, which typically improve after delivery. However, the strain childbirth places on the pelvic floor muscles can lead to long-term weakness and subsequent leakage problems.

Menopause also plays a critical role in the onset of incontinence for women. Hormonal shifts, particularly a decrease in oestrogen, can alter bladder control mechanisms, increasing the likelihood of leakage issues.

Although incontinence is less prevalent among men, they can still develop the condition, particularly as a result of specific factors such as prostate surgery or enlarged prostates.

What causes incontinence?

Incontinence can result from a variety of causes, which may differ based on whether you are male or female. Some causes are temporary and resolve once the underlying issue is treated, leading to the cessation of incontinence. Other causes are associated with long-term (chronic) medical conditions, which may require ongoing management as incontinence often persists as a symptom of these conditions. Chronic conditions are generally not curable, so incontinence management becomes an integral part of long-term care.

Temporary or Short-Term Causes of Incontinence

Several temporary health issues can lead to incontinence, including:

• Urinary Tract Infections (UTIs): Infections affecting the urinary system — including the urethra, bladder, ureters, and kidneys — can result in pain and an increased urge to urinate. Following treatment, the frequent need to urinate typically subsides.
• Pregnancy: The expanding uterus during pregnancy places additional pressure on the bladder, which often leads to temporary incontinence. Many women find that this resolves within a few weeks after giving birth.
• Medications: Certain medications, such as diuretics and antidepressants, may have incontinence as a side effect.
• Beverages: Drinks like coffee and alcohol can act as diuretics, leading to a more frequent need to urinate. Reducing or avoiding these beverages usually alleviates the issue.
• Constipation: Persistent constipation involving hard and dry stools can contribute to bladder control problems.

Chronic or Long-Term Causes of Incontinence

In contrast to short-term causes, chronic conditions may necessitate ongoing incontinence management. These include:

• Pelvic Floor Disorders: Dysfunction in the pelvic floor muscles can affect organ function, including the bladder, leading to incontinence.
• Stroke: A stroke can impair muscle control, including the muscles that regulate bladder function.
• Diabetes: Diabetes can cause increased urine production, leading to leakage. Additionally, peripheral neuropathy associated with diabetes can disrupt bladder control.
• Menopause: Hormonal changes during menopause, particularly the decline in oestrogen, can weaken pelvic floor muscles, contributing to incontinence.
• Multiple Sclerosis (MS): Individuals with MS may experience a loss of bladder control due to neurological damage, resulting in urine leakage.
• Enlarged Prostate: A condition known as benign prostatic hyperplasia (BPH), or an enlarged prostate, can cause various bladder control issues.
• Prostate Cancer Surgery: During surgery to treat prostate cancer, the sphincter muscle may sustain damage, leading to stress incontinence.

Why does pregnancy cause incontinence?

Pregnancy brings significant physical changes, many of which can contribute to incontinence. As the uterus expands to accommodate the growing baby, the bladder is compressed, reducing its capacity and increasing the frequency of urination. This is especially noticeable during the later stages of pregnancy when the baby is the largest, making bladder control more challenging.

Additionally, the pelvic floor muscles — which provide support for the pelvic organs — can stretch and weaken during pregnancy due to the increasing weight and size of the uterus. This weakening can lead to urinary leakage.

What are the symptoms of incontinence?

The primary symptom of incontinence is urine leakage. This may present as:

• Constant Dripping: A persistent small trickle of urine.
• Occasional Leakage: Periodic instances of urine loss, which may occur under certain conditions or activities.
• Variable Quantities: Leakage may range from small amounts of urine to larger, more significant losses.

Symptoms of Incontinence

You might experience urine leakage under specific circumstances or during certain activities. Common triggers for urinary incontinence include:

• Exercise: Physical activities may strain the pelvic floor muscles, resulting in leakage.
• Coughing: A sudden burst of pressure from coughing can cause urine to leak.
• Laughing: Intense laughter may lead to unintentional urine leakage.
• Sneezing: Similar to coughing, sneezing can apply extra pressure to the bladder.
• Having a strong urge to urinate but not reaching the toilet in time can lead to accidents.
• Getting up to urinate during the night (nocturia): Frequent urination at night may be associated with leakage.

How is incontinence diagnosed?

Diagnosing incontinence often begins with a detailed conversation between you and your medical professional about your medical history and bladder control difficulties. The doctor will likely ask you questions to understand your symptoms and identify potential patterns. Typical questions might include:

• How often do you need to urinate?
• Do you experience urine leakage between trips to the toilet? If so, how frequently, and how much urine do you lose each time?
• How long have you been dealing with incontinence?

These discussions help establish patterns of leakage, which may indicate a particular type of incontinence. During this review, it's crucial to share details about all medications you're taking, as certain drugs can contribute to incontinence. Additionally, the doctor may ask about your history of pregnancies and details of each delivery.

To confirm a diagnosis, the doctor might perform one or more of the following tests:

• Physical examination: This helps identify any physical issues causing your incontinence. For women, this may include a pelvic exam, while for men, the size of the prostate may be assessed.
• Urine samples: Urinalysis involves testing a urine sample to detect infections or blood, both of which could contribute to incontinence.
• Bladder ultrasound: This painless imaging test uses sound waves to create a visual of your bladder. It allows the doctor to assess how well your bladder empties and examine its contents.
• Stress test: To identify stress incontinence, you may be asked to perform actions like coughing, running, or jumping to see if these cause urine leakage.
• Cystoscopy: Using a thin, flexible tube with a camera (cystoscope), the doctor can examine the inside of your urethra and bladder to check for abnormalities in the urinary tract.
• Urodynamic testing: This comprehensive set of tests evaluates bladder capacity and the function of the urethral sphincter muscle. During the procedure, fluid may be introduced into your bladder via a tube to measure its holding capacity.
• Pad test: You may be given a pad to wear, which will collect any leaked urine. At the end of the test period, the pad is checked to measure how much urine was lost.

Additionally, your doctor may recommend maintaining a journal of your incontinence episodes at home over a few days. This diary should include details like:

• The frequency of urination.
• The amount of urine passed during each trip.
• Instances of leakage between bathroom visits.
• Activities performed when leakage occurred.

Bring this journal to your appointment for review, as it can provide valuable insight and aid in diagnosis.

When should I see a doctor about incontinence?

It is important to understand that incontinence can often be treated. Many people mistakenly believe that urinary incontinence is an inevitable part of ageing. However, if your symptoms disrupt your daily life or prevent you from participating in activities you enjoy, you should consult a medical professional. There are various treatment options available to help manage and improve symptoms.

Management and Treatment of Incontinence

How is incontinence treated?

Treatment for incontinence is tailored to each individual based on the type of incontinence, its impact on daily life, and personal preferences. Healthcare professionals usually focus on three primary treatment categories:

• Medications
• Lifestyle changes
• Surgical procedures

Each treatment option has specific benefits and drawbacks, which your doctor will discuss with you to ensure the best outcome.

Medications to Treat Incontinence

Several medications are available to reduce urinary leakage. These may work in different ways, such as:

• Stabilising bladder muscle contractions (useful for overactive bladder).
• Relaxing bladder muscles to allow complete emptying.
• Hormone replacement therapy (HRT): In menopausal women, oestrogen replacement can sometimes help restore normal bladder function.

Doctors typically prescribe medications cautiously, starting with low doses and gradually adjusting as needed to minimise side effects while assessing effectiveness.

Common medications for incontinence include:

• Oxybutynin (Ditropan®, Ditropan XL®, Oxytrol®)
• Tolterodine (Detrol®)
• Solifenacin (Vesicare®)
• Fesoterodine (Toviaz®)
• Darifenacin (Enablex®)
• Trospium (Sanctura XR®)
• Imipramine (an antidepressant also used for bladder control)
• Mirabegron (Myrbetriq®): Helps relax the bladder muscles to increase capacity

Lifestyle Changes to Manage Incontinence

Lifestyle adjustments can often be effective in managing incontinence, particularly for mild to moderate cases. These changes may include specific exercises, habit modifications, and dietary adjustments. They can sometimes reduce or even eliminate symptoms without the need for additional treatments.

Always discuss lifestyle changes with a medical professional before starting, as these strategies may not address all types of incontinence.

Common lifestyle modifications include:

• Scheduled urination (timed voiding): Using a regular bathroom schedule instead of waiting for urgency.
• Bladder training: Gradually increasing the time between urination to improve bladder control and capacity.
• Emptying the bladder before physical activities: Prevent leakage during exercise or strenuous tasks.
• Avoiding heavy lifting: Heavy lifting can strain the pelvic floor muscles; seek help if needed.
• Kegel exercises: Regular pelvic floor exercises strengthen the muscles that support bladder control.
• Fluid management: Reducing caffeine and fluid intake before bedtime or physical activity.
• Wearing protective products: Pads and other products can catch leaked urine discreetly and provide reassurance.
• Maintaining a healthy weight: Excess weight places pressure on the bladder and pelvic muscles, increasing leakage risk. A healthy diet and exercise can mitigate this.

Devices for incontinence management include:

• Vaginal inserts (for women): These devices compress the urethra to reduce stress incontinence during activities. Over-the-counter versions are available for home use.

Procedures and Surgeries to Treat Incontinence

For individuals whose symptoms are not relieved through medication or lifestyle modifications, medical professionals may recommend procedural or surgical treatments. These treatments can vary from non-invasive injections to more complex surgeries, depending on the type and severity of the incontinence.

Key factors influencing the choice of procedure include:

• The type of incontinence.
• How severe the symptoms are.
• The individual's overall health and treatment goals.

Examples of potential surgical and procedural options include:

• Injections (e.g., bulking agents): Injected near the urethra to improve muscle support.
• Bladder neck suspensions: Surgical techniques that provide additional support to the bladder neck.
• Sling procedures: The insertion of a supportive sling beneath the urethra to reduce stress incontinence.
• Artificial urinary sphincters: Devices surgically implanted to control urine flow.

Discussing these options thoroughly with a healthcare professional can help determine the most suitable approach.

Procedures to Treat Incontinence

In some cases, non-invasive treatments may not sufficiently address incontinence, and procedural options become necessary. These treatments vary in terms of complexity and permanence, and the most appropriate option depends on the type and severity of incontinence.

Common procedures include:

• Bulking agents: This treatment typically targets women with stress incontinence. A permanent substance is injected into the lining of the urethra to increase its size, providing better support and reducing leakage.
• Botulinum toxin injections (Botox®): Known for its cosmetic uses, Botox® can also relax the bladder muscles to help treat urge incontinence. The treatment is not permanent, requiring repeated injections over time to maintain its effectiveness.
• Neuromodulation devices: Pacemaker-like devices are implanted to stimulate the nerves that control the bladder. This treatment improves bladder function and control. Another form of neuromodulation stimulates a nerve near the ankle to enhance bladder control.
• Sling procedures: These surgical procedures can be performed for both men and women. For women, a synthetic material or a strip of their own tissue is typically used to support the urethral channel. This technique is effective for addressing stress incontinence.
• Artificial urethral sphincter: Used in men with stress incontinence, particularly following prostate cancer surgery, this device is implanted to close the urethra when urination is not occurring, preventing leakage.

How to Perform Kegel Exercises

Kegel exercises help strengthen the pelvic floor muscles, which support the bladder and other pelvic organs. These exercises involve lifting, holding, and relaxing the pelvic floor muscles and can be done discreetly throughout the day.

To perform Kegel exercises:

• Identify your pelvic floor muscles: One way to find them is by stopping the flow of urine mid-stream. Once you know where the muscles are, avoid doing this regularly, as stopping urine flow too often can be harmful.
• Start small: Initially, hold the contraction for just a few seconds. As you get used to the exercise, work your way up to holding for longer periods of time.
• Consistency is key: Perform Kegel exercises in sets of 10, aiming for two sets per day. Over time, aim to increase the number of repetitions per set.

Since Kegel exercises can be performed anytime and anywhere, they offer a simple yet effective way to manage and prevent incontinence. No one will be able to tell when you're doing them, making them a convenient treatment option for strengthening your pelvic floor.

Prevention of Incontinence

While certain life events and conditions can increase the likelihood of developing incontinence, there are steps you can take to strengthen your pelvic floor muscles, which may help prevent or manage the condition. The muscles that support your pelvic organs (bladder, rectum, ovaries, uterus and prostate gland) can weaken over time due to factors such as ageing or significant events like pregnancy and childbirth.

Strengthening Pelvic Floor Muscles

The same way you work out your legs or arms to build strength, you can strengthen your pelvic floor muscles. While exercising your pelvic floor may not entirely prevent incontinence, it can assist in regaining control of the bladder and significantly improve bladder function.

Maintaining a healthy body weight can also be beneficial for better bladder control. Carrying excess weight can put additional pressure on the bladder, contributing to leakage.

Discuss with your healthcare professional the best strategies for maintaining pelvic floor strength as you age. They can suggest appropriate exercises and lifestyle adjustments.

Outlook / Prognosis: Will Incontinence Last a Lifetime?

Incontinence is sometimes a temporary issue, which will be resolved once the underlying cause is treated. For instance, if the cause is a urinary tract infection (UTI), the associated frequent urination and leakage should also resolve once the infection is cleared. The same can apply to some women experiencing bladder control problems during pregnancy, which often resolves within a few weeks after childbirth.

However, in many cases, the causes of incontinence are long-term, particularly when linked to chronic conditions like diabetes, multiple sclerosis, or other ongoing health issues. In these situations, while incontinence may not go away, it can often be managed effectively with the right treatment and lifestyle adjustments. Managing these conditions in collaboration with your healthcare professional is essential to keeping the impact of incontinence minimal and ensuring it does not interfere with daily life.

Note

It's completely understandable to feel embarrassed about discussing incontinence with your healthcare professional, but this should never deter you from seeking help. A conversation with your professional can lead to a clear diagnosis and help create a tailored plan for managing incontinence. By addressing the issue early, you can enhance your quality of life and regain confidence in your everyday activities, free from worries of leakage. Remember, you're not alone, and support is available.

Reach out to us today for more information.