Urinary Incontinence

A quick look at urinary incontinence

• The definition of urinary incontinence is when urine leaks out of a woman’s bladder involuntarily or when she experiences a sudden urge to urinate and a large amount of urine accidentally escapes.
• Incontinence is caused by a weakening of, or damage to, the muscles that keep the urinary tract in place, usually due to aging or pressure placed on the bladder from a fetus in the womb.
• At CU Medicine OB-GYN East Denver (Rocky Mountain), we understand that urinary incontinence can be an embarrassing issue for a woman, and our physicians are sensitive to both the physical and emotional needs of patients who seek our care.
• Diagnosing incontinence includes a urine test, medical history and physical exam, and possible further testing using ultrasound, cystography or urodynamics.
• Treatment for incontinence includes nonsurgical therapies, such as Kegel exercises, physical therapy, biofeedback, injections or nerve stimulation, and surgical treatments such as slings and bladder neck suspension.

What is urinary incontinence?

Urinary incontinence in women is the loss of bladder control, which causes urine to leak out of the bladder. Urinary incontinence is more common than many women think, affecting an estimate 10% of women in the United States.

Urinary incontinence is more prevalent in older aged women, with the U.S. Department of Health and Human Services saying that about 40% of women over 65 have urinary incontinence. Even so, it is not a condition that women should accept as an unavoidable consequence of aging.

Even though urinary incontinence issues do not affect the female reproduction organs, it is common for women to consult a gynecologist with this concern. In fact, more than 75% of women prefer that an OB-GYN, more so than any other provider, take care of their incontinence issues.

While urinary incontinence is a physical concern, it can also cause emotional problems as well. We know that women with incontinence can shy away from social situations due to embarrassment of having a potential accident. Some women avoid sexual intimacy as well. Avoiding being as active with her partner, family or friends may lead to depression or low self-esteem. Our doctors are attuned to these issues and take a comforting and caring approach when addressing incontinence with our patients.

Types: urge incontinence (overactive bladder), stress incontinence & others

The two most common types of urinary incontinence are stress incontinence and urge incontinence. Stress incontinence is when urine comes out while laughing, sneezing, lifting, straining or exercising. Urge incontinence is when a sudden urge to urinate accompanies an accidental leak. Overactive bladder is another term for urge incontinence.

Stress incontinence

This is when urine leaks due to pressure or stress on the bladder. Weakened pelvic floor muscles can exert pressure on the bladder and the urethra, the tube that carries urine out of the body. Normal actions like laughing or coughing stress the bladder and urethra, causing uncontrolled urine leakages. Stress incontinence is the most common type, and it also affects younger women more often than urge incontinence.

Urge incontinence (overactive bladder)

When a woman has an urge to urinate and leaks urine before she can get to the bathroom, that is urge incontinence. Having the urge to urinate more than eight times a day, even if the woman makes it to the bathroom without leaking, is also an aspect of urge incontinence.

Urge incontinence is often called overactive bladder, though some people think they are different conditions. Faulty bladder contractions can cause urge incontinence due to abnormal nerve signaling.

The sudden urges and leakage can occur during sleep, or be caused when a woman touches running water or hears it. Anxiety, medications and certain fluids can trigger overactive bladder/urge incontinence. Medical conditions that can damage bladder nerves or muscles, such as stroke, multiple sclerosis or Parkinson’s disease, can also lead to urge incontinence.

Other types of incontinence

There are other kinds of urinary incontinence as well. These include functional (due to inability to get to a bathroom), mixed (stress and urge together), overflow (when the bladder spills over rather than properly emptying), and total urinary incontinence (the bladder cannot hold urine). Fecal incontinence is another form of incontinence that can affect women.

Causes of urinary incontinence

For women, natural physiological events such as pregnancy, childbirth and menopause can bring on a weakening of the pelvic floor muscles that support the urinary tract, including the bladder and urethra.

As women age and approach menopause, the pelvic floor muscles that hold up the uterus, bowels and urinary tract can grow weak or become damaged over time. When that happens, the muscles surrounding the bladder and urethra must work overtime to hold in urine, often triggering urge incontinence. Damaged nerves can send signals to the bladder to release at the wrong time (or not at all). Health conditions like diabetes and multiple sclerosis can also affect these nerves, making women with these conditions more vulnerable to incontinence.

Hormonal changes during menopause can also contribute to urinary incontinence. This is why women over the age of 65 experience more incontinence than younger women.

Symptoms of incontinence

• Accidental leaking of urine escaping from the bladder.
• Feeling pressure or spasms in the pelvic area that trigger a strong urge to urinate.
• Having to urinate more than normal, meaning more than eight times a day and/or more than two times during sleep.
• Bedwetting.

How is incontinence diagnosed?

If a woman experiences any symptom such as a leaky bladder, spasms or pain with urination, or strong urges to urinate, she should call her OB-GYN. The first thing our provider will do is get a urine sample and culture to test for a urinary tract infection (UTI). If there is not a UTI, our provider would then talk with the woman about what the leaking symptoms feel like, when the leaks happen, how much urine comes out, pregnancy history, and what might aggravate the symptoms. We will also discuss any medications the patient takes and any other medical conditions she has.

A physical assessment may help identify causes. This exam will likely include an external assessment of the vulva, where any atrophy or dermatitis may contribute to the incontinence.

Pelvic exam

During a pelvic exam, the provider will look for any inflammation in the vagina (vaginitis), which may trigger vaginal discharge, pain, or the feelings of urgency or frequency. Our OB-GYN will also look for signs of bladder, uterine or other pelvic floor prolapse. The pelvic exam may include a bladder stress test, where the patient coughs or pushes as the provider looks for bladder leakage.

Ultrasound

A provider may suggest a sonogram, or ultrasound, test. It involves a technician rolling a wand over the skin covering the abdominal area. The wand emits sound waves that reflect the images of the bladder, urethra and other pelvic organs. These images can show the doctor if there are any unusual masses or other disruptions in the urinary tract.

Cystoscopy

A cystoscopy is a more precise way to look for damaged tissue in the urethra and bladder. The doctor inserts a thin tube attached to a tiny camera into the urethra to look at the inside of the bladder. This procedure may be performed while the patient is awake or as part of an outpatient surgery.

Urodynamics

Urodynamic testing examines how well the urethra and bladder are functioning. The doctor inserts a thin tube into the bladder and fills it with water. This test measures the pressure in the bladder and the volume of liquid it can hold.

Treatment for urinary incontinence

Female incontinence can be treated with medicine, diet, exercises, biofeedback or surgery.

Nonsurgical treatment for incontinence

• Dietary changes. If the incontinence is mild, avoiding certain alcoholic, caffeinated and acidic foods and beverages may help improve symptoms.
• Kegel exercises. These are pelvic floor muscle-strengthening exercises. To try it, squeeze the muscles used to stop urine flow and hold for 10 seconds, then release. Do three-to-four sets of 10 Kegels daily. Please do not perform your Kegel exercises by literally starting and stopping your urine stream. This starting and stopping could actually exacerbate urinary issues and could even cause a urinary tract infection.
• Biofeedback. With this method a provider places an electrical patch on the skin on the abdomen. The sensor in the patch transmits a signal to a computer monitor that shows the amount of force the muscles exert, so a patient can learn to control them.
• Bladder training. This involves journaling the intake of liquids, recording urges and sensations, and setting a schedule for urination, gradually working up to an increased amount of time between bathroom visits.
• Lifestyle changes. Smoking, constipation or above-average weight can put additional stress on the pelvic floor muscles.
• Injections. Collagen or Botox injected into the bladder, or around the urethra, may help when other treatments do not. These treatments would usually be performed by a specialist, called a urogynecologist.
• Nerve stimulation. This treatment uses mild electrical pulses to stimulate the nerves in the bladder to increase blood flow and improve the strength of the muscles that support it.
• Pessary. This small device can be inserted into the vagina to help hold the bladder in place.
• Urethral insert. This device can help alleviate leakage during specific activities that can predictably cause leakage. It needs to be removed before urination.

Surgical treatment for incontinence

Surgery may be an option when other treatments are not successful. However, it is not recommended if a woman plans to get pregnant in the future.

The two most common procedures include:

• Sling procedures. There are three types: tension-free, adjustable and conventional. For stress incontinence, a doctor may insert a sling (a narrow piece of mesh or a section of the patient’s own tissue) under the urethra. The sling serves as a hammock to hold the urethra and bladder in place.
• Burch procedure. Also called bladder neck suspension or colposuspension, this surgery involves putting stitches in place on either side of the urethra where it meets the neck of the bladder to hold the bladder in place.

Practicing Kegel exercises starting in the teenage years and continuing through life, even through pregnancy, can help increase the strength of pelvic floor muscles. Staying at a healthy weight and eating foods rich in fiber can also help.