Incontinence

Urinary incontinence—the involuntary leakage of urine—is a common condition affecting millions of people, but it doesn’t have to disrupt your life. While it becomes more prevalent with age, it’s not an inevitable part of aging, and treatments are available to help you regain control.

Table of contents

• What is incontinence?
• Types of incontinence
• Symptoms
• Causes and risk factors
• Diagnosis
• Treatment options
• Lifestyle changes and self-care
• Living with incontinence

What is incontinence?

Urinary incontinence is the loss of bladder control, or being unable to control urination. The severity ranges from occasionally leaking urine when you cough or sneeze to having an urge to urinate that’s so sudden and strong you don’t get to a toilet in time^[1].

Your urinary system consists of many different organs. These organs work together to filter, store and remove waste from your body as urine. When your urinary system works as expected, you usually have time to get to a bathroom, and you don’t leak. Urinary incontinence occurs when these parts don’t operate as they should. This can happen for many different reasons throughout your life^[2].

The prevalence of urinary incontinence is likely underestimated, as many patients do not report their symptoms to healthcare providers for various reasons. About 62% of females age 20 and older have some type of urinary incontinence. In males, a little less than 14% have incontinence^[2]. The condition is particularly common among older adults, with up to 30 percent of older adults living in their communities experiencing urinary incontinence^[6].

Types of incontinence

There are several different types of urinary incontinence. They have different causes, characteristics and triggers. Knowing the type of incontinence is an important part of your diagnosis and treatment plan^[2].

Stress incontinence happens when you leak urine during physical activities that put pressure on your bladder, such as coughing, sneezing, laughing, exercising or lifting something heavy. This type is caused by weak pelvic floor muscles and the bladder being out of its normal position^[4]. Stress incontinence is most common in younger women, and can occur in those active in sports. Pregnant women and women who have experienced childbirth may be especially prone to stress incontinence^[3].

Urge incontinence, also called urgency incontinence or overactive bladder, happens when you have a sudden, intense urge to urinate, and some urine leaks out before you can make it to the toilet. You may need to urinate often, including throughout the night. Urge incontinence causes uncontrolled bladder contractions, creating an intense urge to urinate or leak^[5]. This type is most common in older people and can sometimes be a sign of a urinary tract infection. It can also happen in some neurological conditions, such as multiple sclerosis and spinal cord injuries^[1].

Overflow incontinence happens when your bladder doesn’t empty all the way. This causes too much urine to stay in your bladder. Your bladder gets too full, and you leak urine. You experience frequent or constant dribbling of urine due to a bladder that doesn’t empty completely^[1]. This form of incontinence is most common in men and can be caused by an enlarged prostate, tumors, kidney stones, diabetes, and certain medicines^[4].

Mixed incontinence means that you have more than one type of incontinence. It’s usually a combination of stress and urge incontinence^[4]. This is the overall most common type of incontinence^[12].

Functional incontinence happens when a physical or mental impairment keeps you from making it to the toilet in time. For example, if you have severe arthritis, you may not be able to unbutton your pants quickly enough, or a person with Alzheimer’s disease may not realize they need to plan to use the toilet^[4].

Transient incontinence is urine leakage that is caused by a temporary situation such as an infection or new medicine. Once the cause is removed, the incontinence goes away^[4].

Symptoms

Many people experience occasional, minor leaks of urine. Others may lose small to moderate amounts of urine more frequently^[1].

The primary symptom of incontinence is leaking urine before you can make it to the bathroom or during activities like sneezing, coughing, laughing or exercising. If you have incontinence, you might leak a lot of urine or a small amount. It could be a constant drip or an occasional leak. Your symptoms usually depend on the type of incontinence you have^[2].

Symptoms may include:

• Peeing more than eight times a day (frequent urination)
• Needing to use the bathroom but only a little amount comes out each time
• Waking up to pee more than twice (nocturia)
• Wetting the bed (enuresis)
• Leaking urine during activities like exercise, laughing, coughing, sneezing, bending over or having sexual intercourse^[2]

In cases of stress incontinence, urine leaks when you exert pressure on your bladder. With urge incontinence, you have a sudden, intense urge to urinate followed by an involuntary loss of urine. In overflow incontinence, you experience frequent or constant dribbling of urine^[1].

Causes and risk factors

Urinary incontinence can result from many different factors and conditions. Understanding what causes your bladder control problem is an important part of finding the right treatment^[2].

Stress urinary incontinence is the involuntary leakage of urine that occurs with increased pressure inside the abdomen during activities such as exertion, straining, sneezing, or coughing due to urethral sphincter weakness, pelvic floor weakness, or urethral hypermobility^[3].

Urge incontinence typically occurs when the bladder’s muscles weaken or its urine-holding capacity decreases. The muscles of the bladder spasm or contract, forcing urine past the sphincter muscles around the tube that urine flows out of^[5]. This may be caused by a minor condition, such as infection, or a more severe condition such as a neurological disorder or diabetes^[1].

Overflow incontinence can be caused by anatomic obstruction or impaired bladder muscle contractions from neurologic disorders, including diabetic neuropathy^[12].

You are at higher risk of developing urinary incontinence if you:

• Are female, especially after going through pregnancy, childbirth, and menopause
• Are older. As you age, your urinary tract muscles weaken, making it harder to hold in urine
• Are a man with prostate problems
• Have certain health problems, such as diabetes, obesity, or long-lasting constipation
• Are a smoker^[4]

Pregnancy, childbirth, weight gain, and menopause can all strain the pelvic floor muscles, which support the bladder and help stop the flow of urine. When extra pressure is put on the bladder, urine may leak out^[5]. Most women begin to experience symptoms in their 40s and 50s, after childbearing^[5].

Many people think incontinence is a normal part of getting older, and you can’t do anything to stop it. It’s true that your risk of incontinence increases as you get older. But it can happen to anyone, regardless of age. And treatments are available to help you manage it^[2].

Diagnosis

It’s important to determine the type of urinary incontinence that you have, and your symptoms often tell your doctor which type you have. That information will guide treatment decisions^[8].

Your health care provider may use many tools to make a diagnosis. A medical history, which includes asking about your symptoms, is an important first step. Your provider may ask you to keep a bladder diary for a few days before your appointment^[4].

Your doctor is likely to start with a thorough history and physical exam. You may then be asked to do a simple maneuver that can demonstrate incontinence, such as coughing^[8].

A comprehensive evaluation of urinary incontinence may involve several steps:

• A review of your symptoms and medical history
• A physical, pelvic, or urogynecological exam
• An ultrasonogram to evaluate the uterus, bladder, and rectum, their position and size, and to look for any unusual anatomical characteristics of the pelvic organs^[5]

After the initial assessment, your doctor will likely recommend additional tests:

Urinalysis. A sample of your urine is checked for signs of infection, traces of blood or other abnormalities^[8].

Bladder diary. For several days you record how much you drink, when you urinate, the amount of urine you produce, whether you had an urge to urinate and the number of incontinence episodes^[8].

Postvoid residual measurement. You’re asked to urinate into a container that measures urine output. Then your doctor checks the amount of leftover urine in your bladder using a catheter or ultrasound test. A large amount of leftover urine in your bladder may mean that you have an obstruction in your urinary tract or a problem with your bladder nerves or muscles^[8].

If further information is needed, your doctor may recommend more-involved tests, such as urodynamic testing and pelvic ultrasound. These tests are usually done if you’re considering surgery^[8].

Treatment options

Treatment for urinary incontinence depends on the type of incontinence, its severity and the underlying cause. A combination of treatments may be needed^[8]. A stepped-care approach that advances from least invasive (behavioral modification) to more invasive (surgery) interventions is recommended^[12].

About 80% of those who are affected by urinary incontinence can get better with treatment^[19].

Conservative treatments

Conservative treatments, which do not involve medicines or surgery, are tried first^[10].

Pelvic floor muscle training (Kegel exercises) is considered first-line treatment for both stress and urge incontinence^[12]. Your pelvic floor muscles surround the bladder and urethra and control the flow of urine as you urinate. Weak or damaged pelvic floor muscles can cause urinary incontinence, so exercising these muscles is often recommended^[10].

To do Kegel exercises, squeeze the muscles you would use to stop the flow of urine. Hold for 10 seconds, then release. Try to practice three or four sets of 10 each day^[11]. If you can contract your pelvic floor muscles, you’ll be given an exercise programme based on your assessment. Your programme should include a minimum of 8 muscle contractions at least 3 times a day and last for at least 3 months^[10].

Bladder training is often one of the first treatments offered for urge incontinence. It involves learning techniques to increase the length of time between feeling the need to urinate and passing urine^[10].

Electrical stimulation may be recommended if you’re unable to contract your pelvic floor muscles. A small probe is inserted into the vagina, or into the anus. An electrical current runs through the probe, which helps strengthen your pelvic floor muscles while you exercise them^[10].

Biofeedback is a way to monitor how well you do pelvic floor exercises by giving you feedback as you do them. This may help motivate some people to do their exercises^[10].

Vaginal cones may be used to assist with pelvic floor muscle training. These small weights are inserted into the vagina. You hold the weights in place using your pelvic floor muscles^[10].

Medications

Pharmacologic therapy with anticholinergic medications is another option for treating urge incontinence if behavioral therapy is unsuccessful. However, because of adverse effects, these agents are not recommended in older adults. Other medication options for urge incontinence include mirabegron and onabotulinumtoxinA^[12].

Limited or conflicting evidence exists for the use of medications for stress incontinence, and no medications are approved by the U.S. Food and Drug Administration for this condition^[12].

Medical devices and procedures

Alternatives for treating stress incontinence include vaginal inserts, such as pessaries, and urethral plugs^[12].

Neuromodulation devices, such as posterior tibial nerve stimulators, are an option for urge incontinence that does not respond to behavioral therapy^[12].

Sacral nerve stimulators, which are surgically implanted, have been shown to improve symptoms of urge incontinence^[12].

Minimally invasive procedures, including radiofrequency denaturation of the urethra and injection of periurethral bulking agents, can be used if stress incontinence does not respond to less invasive treatments^[12].

Surgery

Surgical interventions, such as sling and urethropexy procedures, should be reserved for stress incontinence that has not responded to other treatments^[12]. Surgery may include “sling surgery,” an operation designed to support the bladder or urethra and prevent leaks^[19].

Lifestyle changes and self-care

You may be able to reduce leaks by making lifestyle changes. Sometimes a simple dietary change, such as cutting back on fluids, is all that is needed^[19].

Manage your fluid intake

You should drink the right amount of liquid at the right time. Drink up to two litres (six to eight glasses) of fluid (preferably water) each day, unless advised otherwise by your doctor. To limit nighttime trips to the bathroom, you may want to stop drinking liquids a few hours before bedtime^[14].

Limiting foods and drinks with caffeine, such as chocolate, tea, coffee, and carbonated beverages, may help reduce leaks. You should also limit alcoholic drinks, which can increase how much urine your body makes^[14]. Certain types of foods and beverages may irritate the bladder, including alcohol, caffeine, spicy foods, high-acid foods such as citrus fruits and juices, and carbonated drinks^[11].

Maintain a healthy weight

Your chances of developing urinary incontinence and other diseases are higher if you’re overweight or have obesity. Losing weight can help you have fewer leaks, and avoiding weight gain may prevent incontinence^[14]. Being overweight can weaken your pelvic floor muscles and cause incontinence because of the pressure of fatty tissue on your bladder. Your symptoms may improve, and could go away completely, if you lose any excess weight^[16].

On average, losing 10% of body weight produces a 50% improvement in both stress and urgency urinary incontinence in women who are overweight or obese^[17].

Stay physically active

Although you may not feel like being physically active when you have urinary incontinence, regular physical activity is important for weight management and good overall health. Activities such as walking, swimming, biking, and dancing can improve your health^[14].

However, high-impact exercises (such as jumping jacks) or specific maneuvers (such as a golf swing) can elicit leakage if you have stress incontinence. Replace high-impact exercise, such as jogging and aerobics, with strengthening exercise, such as pilates. Pilates strengthens your core muscles, which is beneficial for stress incontinence^[16].

Avoid constipation

Constipation can make urinary tract health worse and can lead to urinary incontinence. Talk with your health care professional about drinking more liquids and eating enough fiber to avoid constipation^[14]. Straining to pass bowel movements weakens your pelvic floor muscles and makes urinary incontinence worse^[16].

Stop smoking

If you smoke, you put yourself at risk of incontinence, because coughing puts strain on your pelvic floor muscles^[16]. Smoking nearly doubles the likelihood that a woman will develop stress incontinence, perhaps because it can lead to frequent and vigorous coughing^[17].

Living with incontinence

Don’t wait to address your bladder control problem. With a little effort, you can overcome the challenges of a leaky bladder. It can be as easy as a few simple changes in your daily routine^[19].

If urinary incontinence affects your daily activities, don’t hesitate to see your doctor. For most people, simple lifestyle and dietary changes or medical care can treat symptoms of urinary incontinence^[1].

Plan ahead

Before you go out, think about the day ahead of you. A little foresight can make living with urinary incontinence less stressful. Know where the bathrooms are when you are out and about, and try to go as often as possible. If you know you always shop longer than you plan to, consider one of the many urinary incontinence products, such as panty liners or pads^[19].

Focus on solutions

Try not to let your condition bring you down. Some people get stressed or depressed, especially with urge incontinence because it’s so unpredictable. Know there are plenty of treatment options available for you to try on your own or with the support of a doctor^[19].

Reach out for support

Talk about what’s going on with your partner and others close to you. It could make your life easier if they know, and they will want to be there for you. If you and your friends and family focus on solutions, you’ll probably feel better^[19].

If you or someone you are caring for has urinary incontinence, talk with your healthcare provider about it. Getting treatment can improve quality of life and help prevent infections and falls^[6].

Treatment can improve quality of life. Getting treated may not require drugs, procedures, or surgery. Urinary incontinence becomes more common as people grow older, but it is not a normal part of aging^[6].