by Glynn B. Wittber, M.D.
Urinary incontinence is the involuntary leakage of urine. It is more common in women than in men, occurring in up to 30 percent of women. Effective therapies are available for all types of incontinence. However, less than half of incontinent women seek medical care due to the false belief that nothing can be done to correct their problem. Instead they rely on absorbent pads and restrict their social interactions, leading to isolation and depression.
Normally, a woman empties her bladder every 3 or 4 hours during the day and possibly once during the night. The kidneys produce urine which travels to the urinary bladder. The bladder stores urine until it passes to the outside of the body through the urethra. A ring of muscles called the urinary sphincter surrounds the urethra. When the bladder is storing urine, nerve signals cause the sphincter muscle to contract and stay closed and the bladder to stay relaxed. This prevents urine from leaking out of the body. When the bladder is full, it signals the brain, and the individual becomes aware of the need to urinate. When the person is ready the brain then sends a message to initiate urination. It tells the bladder to contract and the urethra to relax, allowing the urine to be expelled.
Two main things can go wrong with normal urination: 1) The bladder contracts when it shouldn’t (when the person is not ready to urinate). This condition is called urge incontinence. 2) The sphincter does not stay closed when subjected to pressure, allowing urine to leak. This condition is known as stress incontinence.
Urge incontinence occurs when the bladder contracts when it shouldn't. It is due to over-activity of the bladder muscle and is also called overactive bladder. A person with urge incontinence experiences a sudden and strong urge to urinate, followed by urine leakage. The leakage may occur in response to a stimulus, such as anticipation of urination (for example, unlocking the door when returning home), or hearing running water. Factors that can lead to urge incontinence include bladder inflammation or cancer, stroke, or Parkinson’s disease. Stress incontinence occurs when urine leakage happens during physical activity. Activity such as coughing or sneezing increases pressure in the abdomen forcing open the urinary sphincter, causing leakage of urine.
Stress incontinence is due to weakness in the tissues that support the urinary sphincter. Factors associated with stress incontinence include vaginal delivery and postmenopausal estrogen deficiency. Stress incontinence is the most common form of urinary incontinence in younger women.
A person who is bothered by symptoms of urinary incontinence should contact her physician. The physician will first ask questions to characterize the incontinent episodes. The patient may be asked to keep a "bladder diary" for 24-72 hours. During that time the patient will record all fluid intake, incontinence episodes, and normal urination. A physical examination will be performed along with urinalysis, blood-work, and possibly urodynamic testing. Urodynamic testing involves inserting a special catheter into the bladder to measure things such as bladder capacity, bladder pressure, and urethral sphincter strength.
Incontinence treatment depends on its cause. Therapy for urinary incontinence consists of behavioral treatment, medications, and surgery. Generally, surgery will be reserved for those who don't respond to conservative measures. All incontinent women should limit their fluid intake to approximately 1/2 gallon per day. Consumption of caffeine-containing beverages should be reduced to no more than 8 oz. daily.
Treatment for urge incontinence involves behavioral therapy and/ or medications. Surgery is not helpful. Behavioral therapy involves retraining the nervous system and pelvic muscles to better control unwanted bladder contractions. The patient urinates at specific intervals through the day and learns to suppress inappropriate urinary urges. The number of incontinence episodes decreases, and eventually a normal urination frequency is achieved.
In addition to behavioral therapy, medications can be used to suppress bladder activity. The two most common medications used are oxybutinin or Ditropan and tolterodine or Detrol. Side effects include dry mouth and constipation. Some people respond better to one medication than the other.
Therapy for stress incontinence involves pelvic muscle exercise, surgery and possibly medications. Pelvic muscle exercises are also known as Kegel exercises. They improve urinary control in 40-75% of patients. To learn how to perform Kegel exercises properly a person needs to be taught by a doctor or by a therapist using biofeedback equipment. Once learned, the exercises need to be continued in order to have a lasting effect, just like any other form of exercise.
Surgery offers the highest cure rates for stress incontinence. However, it is invasive and can be associated with complications. There are many different surgical procedures for stress incontinence, and a patient should have a detailed discussion with her doctor prior to undergoing surgery.
Currently, there are no FDA approved medications available for the treatment of stress incontinence. The Jackson Clinic is involved in a study investigating a new medication for use in the treatment of stress incontinence. Patients interested in enrolling in the study may contact The Jackson Clinic for more information. Incontinence pads should only be used when a person has exhausted all treatment options. They may cause skin irritation and breakdown. Most people who are using pads have never talked to a doctor about their problem. Remember that in most cases urinary incontinence can be treated with success.
Dr. Glynn M. Wittber is a physician specializing in Obstetrics and Gynecology with The Jackson Clinic. She is Board Certified by the American Board of Obstetrics and Gynecology. After graduating from Vanderbilt University with a degree in Molecular Biology, she received her medical degree from the University of Tennessee College of Medicine, Memphis and completed her internship and residency at The Ohio State University Hospitals in Columbus, Ohio.