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Health Information
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Saturday, May 17, 2008
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Urinary
incontinence is an inability to hold your urine until you get to a toilet.
More than 13 million people in the United States--male and female, young
and old--experience incontinence. It is often temporary, and it always results
from an underlying medical condition.
(In this fact sheet, the term
"incontinence" will be used to mean urinary incontinence.)
Women experience incontinence
two times more often than men. Pregnancy and childbirth, menopause, and
the structure of the female urinary tract account for this difference.
But both women and men can become incontinent from strokes, multiple sclerosis,
and physical problems associated with old age.
Figure
1.--Front
view of bladder and sphincter
muscles. |
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Older women, more often than younger
women, experience incontinence. But incontinence is not inevitable with
age. Incontinence is treatable and often curable at all ages. If you experience
incontinence, you may feel embarrassed. It may help you to remember that
loss of bladder control can be treated. You will need to overcome your embarrassment
and see a doctor to learn if you need treatment for an underlying medical
condition.
Incontinence in women usually
occurs because of problems with muscles that help to hold or release urine.
The body stores urine--water and wastes removed by the kidneys--in the
bladder, a balloon-like organ. The bladder connects to the urethra, the
tube through which urine leaves the body.
During urination, muscles in
the wall of the bladder contract, forcing urine out of the bladder and
into the urethra. At the same time, sphincter muscles surrounding the
urethra relax, letting urine pass out of the body (see figure 1). Incontinence
will occur if your bladder muscles suddenly contract or muscles surrounding
the urethra suddenly relax.
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Stress
Incontinence
If coughing, laughing, sneezing,
or other movements that put pressure on the bladder cause you to leak
urine, you may have stress incontinence. Physical changes resulting from
pregnancy, childbirth, and menopause are common events that cause stress
incontinence. It is the most common form of incontinence in women and
is treatable.
Pelvic floor muscles support
your bladder (see figure 2). If these muscles weaken, your bladder can
move downward, pushing slightly out of the bottom of the pelvis toward
the vagina. This prevents muscles that ordinarily force the urethra shut
from squeezing as tightly as they should. As a result, urine can leak
into the urethra during moments of physical stress. Stress incontinence
also occurs if the muscles that do the squeezing weaken.
Stress incontinence can worsen
during the week before your menstrual period. At that time, lowered estrogen
levels might lead to lower muscular pressure around the urethra, increasing
chances of leakage. The incidence of stress incontinence increases following
menopause.
Urge Incontinence
If you lose urine for no apparent
reason while suddenly feeling the need or urge to urinate, you may have
urge incontinence. The most common cause of urge incontinence is inappropriate
bladder contractions.
Medical professionals describe
such a bladder as "unstable," "spastic," or "overactive." Your doctor
might call your condition "reflex incontinence" if it results from overactive
nerves controlling the bladder.
Urge incontinence can mean
that your bladder empties during sleep, after drinking a small amount
of water, or when you touch water or hear it running (as when someone
else is taking a shower or washing dishes).
Figure
2.--Side
view of female pelvis.
muscles. |
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Involuntary actions of bladder
muscles can occur because of damage to the nerves of the bladder, to the
nervous system (spinal cord and brain), or to muscles themselves. Multiple
sclerosis, Parkinson's disease, Alzheimer's disease, stroke, brain tumors,
and injury--including injury that occurs during surgery--all can harm
bladder nerves or muscles.
Functional Incontinence
People with functional incontinence
may have problems thinking, moving, or communicating that prevent them
from reaching a toilet. A person with Alzheimer's disease, for example,
may not think well enough to plan a timely trip to a restroom. A person
in a wheelchair may be blocked from getting to a toilet in time. Conditions
such as these are often associated with age and account for some of the
incontinence of elderly women in nursing homes.
Overflow Incontinence
If your bladder is always full
so that it continually leaks urine, you have overflow incontinence. Weak
bladder muscles or a blocked urethra can cause this type of incontinence.
Nerve damage from diabetes or other diseases can lead to weak bladder
muscles; tumors and urinary stones can block the urethra. Overflow incontinence
is rare in women.
Other Types of
Incontinence
Stress and urge incontinence
often occur together in women. Combinations of incontinence--and this
combination in particular--are sometimes referred to as "mixed incontinence."
"Transient incontinence" is
a temporary version of incontinence. It can be triggered by medications,
urinary tract infections, mental impairment, restricted mobility, and
stool impaction (severe constipation), which can push against the urinary
tract and obstruct outflow.
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The first
step toward relief is to see a doctor who is well acquainted with incontinence
to learn the type you have. A urologist specializes in the urinary tract.
Gynecologists and obstetricians specialize in the woman's reproductive tract
and childbirth. A urogynecologist focuses on urological problems in women.
Family practitioners and internists see patients for all kinds of complaints.
Any of these doctors may be able to help you.
To diagnose the problem, your
doctor will first ask about symptoms and medical history. Your pattern
of voiding and urine leakage may suggest the type of incontinence. Other
obvious factors that can help define the problem include straining and
discomfort, use of drugs, recent surgery, and illness. If your medical
history does not define the problem, it will at least suggest which tests
are needed.
Your doctor will physically
examine you for signs of medical conditions causing incontinence, such
as tumors that block the urinary tract, stool impaction, and poor reflexes
or sensations, which may be evidence of a nerve-related cause.
Your doctor will measure your
bladder capacity and residual urine for evidence of poorly functioning
bladder muscles. To do this, you will drink plenty of fluids and urinate
into a measuring pan, after which the doctor will measure any urine remaining
in the bladder. Your doctor may also recommend
- Stress test--You relax,
then cough vigorously as the doctor watches for loss of urine.
- Urinalysis--Urine is tested
for evidence of infection, urinary stones, or other contributing causes.
- Blood tests--Blood is taken,
sent to a laboratory, and examined for substances related to causes
of incontinence.
- Ultrasound--Sound waves
are used to "see" the kidneys, ureters, bladder, and urethra.
- Cystoscopy--A thin tube
with a tiny camera is inserted in the urethra and used to see the urethra
and bladder.
- Urodynamics--Various techniques
measure pressure in the bladder and the flow of urine.
Your doctor may ask you to keep
a diary to record when you void for a day or more, up to a week. This diary
should note the times you urinate and the amounts of urine you produce.
To measure your urine, you can use a special pan that fits over the toilet
rim.
The Types of Urinary Incontinence
Stress |
Leakage
of small amounts of urine during physical movement (coughing,
sneezing, exercising) |
| Urge |
Leakage
of large amounts of urine at unexpected times, including during
sleep |
| Functional |
Untimely
urination because of physical disability, external obstacles,
or problems in thinking or communicating that prevent a person
from reaching a toilet |
| Overflow |
Unexpected
leakage of small amounts of urine because of a full bladder |
| Mixed |
Usually
the occurrence of stress and urge incontinence together |
| Transient |
Leakage
that occurs temporarily because of a condition that will pass
(infection, medication) |
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Exercises
Kegel exercises to strengthen
or retrain pelvic floor muscles and sphincter muscles can reduce or cure
stress leakage. Women of all ages can learn and practice these exercises,
which are taught by a health care professional.
Most Kegel exercises do not
require equipment. However, one technique involves the use of weighted
cones. For this exercise, you stand and hold a cone-shaped object within
your vagina. You then substitute cones of increasing weight to strengthen
the muscles that help keep the urethra closed.
Electrical Stimulation
Brief doses of electrical stimulation
can strengthen muscles in the lower pelvis in a way similar to exercising
the muscles. Electrodes are temporarily placed in the vagina or rectum
to stimulate nearby muscles. This will stabilize overactive muscles and
stimulate contraction of urethral muscles. Electrical stimulation can
be used to reduce both stress incontinence and urge incontinence.
Biofeedback
Biofeedback uses measuring
devices to help you become aware of your body's functioning. By using
electronic devices or diaries to track when your bladder and urethral
muscles contract, you can gain control over these muscles. Biofeedback
can be used with pelvic muscle exercises and electrical stimulation to
relieve stress and urge incontinence.
Timed Voiding
or Bladder Training
Timed voiding (urinating) and
bladder training are techniques that use biofeedback. In timed voiding,
you fill in a chart of voiding and leaking. From the patterns that appear
in your chart, you can plan to empty your bladder before you would otherwise
leak. Biofeedback and muscle conditioning--known as bladder training--can
alter the bladder's schedule for storing and emptying urine. These techniques
are effective for urge and overflow incontinence.
Medications
Medications can reduce many
types of leakage. Some drugs inhibit contractions of an overactive bladder.
Others relax muscles, leading to more complete bladder emptying during
urination. Some drugs tighten muscles at the bladder neck and urethra,
preventing leakage. And some, especially hormones such as estrogen, are
believed to cause muscles involved in urination to function normally.
Some of these medications can
produce harmful side effects if used for long periods. In particular,
estrogen therapy has been associated with an increased risk for cancers
of the breast and endometrium (lining of the uterus). Talk to your doctor
about the risks and benefits of long-term use of medications.
Pessaries
A pessary is a stiff ring that
is inserted by a doctor or nurse into the vagina, where it presses against
the wall of the vagina and the nearby urethra. The pressure helps reposition
the urethra, leading to less stress leakage. If you use a pessary, you
should watch for possible vaginal and urinary tract infections and see
your doctor regularly.
Implants
Implants are substances injected
into tissues around the urethra. The implant adds bulk and helps to close
the urethra to reduce stress incontinence. Collagen (a fibrous natural
tissue from cows) and fat from the patient's body have been used. Implants
can be injected by a doctor in about half an hour using local anesthesia.
Implants have a partial success
rate. Injections must be repeated after a time because the body slowly
eliminates the substances. Before you receive collagen, a doctor must
perform a skin test to determine whether you would have an allergic reaction
to the material.
Surgery
Doctors usually suggest surgery
to alleviate incontinence only after other treatments have been tried.
Many surgical options have high rates of success.
Most stress incontinence results
from the bladder dropping down toward the vagina. Therefore, common surgery
for stress incontinence involves pulling the bladder up to a more normal
position. Working through an incision in the vagina or abdomen, the surgeon
raises the bladder and secures it with a string attached to muscle, ligament,
or bone.
For severe cases of stress
incontinence, the surgeon may secure the bladder with a wide sling. This
not only holds up the bladder but also compresses the bottom of the bladder
and the top of the urethra, further preventing leakage.
In rare cases, a surgeon implants
an artificial sphincter, a doughnut-shaped sac that circles the urethra.
A fluid fills and expands the sac, which squeezes the urethra closed.
By pressing a valve implanted under the skin, you can cause the artificial
sphincter to deflate. This removes pressure from the urethra, allowing
urine from the bladder to pass.
Catheterization
If you are incontinent because
your bladder never empties completely (overflow incontinence) or your
bladder cannot empty because of poor muscle tone, past surgery, or spinal
cord injury, you might use a catheter to empty your bladder. A catheter
is a tube that you can learn to insert through the urethra into the bladder
to drain urine. Catheters may be used once in a while or on a constant
basis, in which case the tube connects to a bag that you can attach to
your leg. If you use a long-term (or indwelling) catheter, you should
watch for possible urinary tract infections.
Other Procedures
Many women manage urinary incontinence
with pads that catch slight leakage during activities such as exercising.
Also, you often can reduce incontinence by restricting certain liquids,
such as coffee, tea, and alcohol.
Finally, many women who could
be treated resort instead to wearing absorbent undergarments, or diapers--especially
elderly women in nursing homes. This is unfortunate, because diapering
can lead to diminished self-esteem, as well as skin irritation and sores.
If you are an elderly woman, you and your family should discuss with your
doctor the possible effectiveness of treatments such as timed voiding,
pelvic muscle exercises, and electrical stimulation before resorting to
absorbent pads or undergarments.
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Points
To Remember
- Urinary incontinence
is common in women.
- All types of urinary
incontinence can be treated.
- Incontinence can
be treated at all ages.
- You need not be
embarrassed by incontinence.
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American
Foundation for Urologic Disease
The Bladder Health Council
1128 North Charles Street
Baltimore, MD 21201
(800) 242-2383 or (410) 468-1800
American Uro-Gynecologic Society
401 North Michigan Avenue
Chicago, IL 60611-4267
(312) 644-6610
Continence Restored, Inc.
407 Strawberry Hill Avenue
Stamford, CT 06902
(203) 348-0601 or (914) 285-1470
National Association for Continence
(formerly Help for Incontinent People, Inc.)
P.O. Box 8310
Spartanburg, SC 29305
(800) BLADDER or (803) 579-7900
The Simon Foundation for Continence
P.O. Box 835
Wilmette, IL 60091
(800) 23-SIMON
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National Kidney and
Urologic Diseases Information Clearinghouse
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NIH Publication
No. 97-4132
July 1997
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