Urinary Incontinence
in Women
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
twice as often as 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 neurologic
injury, birth defects, strokes, multiple sclerosis, and physical
problems associated with aging.
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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Figure 1.--Front view of bladder and
sphincter
muscles
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What are the types of incontinence?
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 often
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.
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Figure 2.--Side view of female pelvic
muscles
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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 washing dishes or hearing someone else taking a shower).
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 the muscles themselves. Multiple sclerosis, Parkinson's disease,
Alzheimer's disease, stroke, 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 frequently 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.
The Types of Urinary Incontinence
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Stress
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Leakage
of small amounts of urine during physical movement
(coughing, sneezing, exercising).
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Urge
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Leakage
of large amounts of urine at unexpected times, including
during sleep.
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Functional
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Untimely
urination because of physical disability, external
obstacles, or problems in thinking or communicating
that prevent a person from reaching a toilet.
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Overflow
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Unexpected
leakage of small amounts of urine because of a full
bladder.
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Mixed
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Usually
the occurrence of stress and urge incontinence together.
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Transient
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Leakage
that occurs temporarily because of a condition that
will pass (infection, medication).
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How is incontinence evaluated?
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, and some urologists further specialize in the female urinary
tract. Gynecologists and obstetricians specialize in the female
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 inside of 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 for a day or more, up to a week, to record
when you void. 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.
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How is incontinence treated?
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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