Urinary incontinence is a condition that occurs when there is involuntary loss of urine from the bladder. It is estimated that more than 17 million Americans are affected, women more commonly than men (38% versus 19%). Costs related to medical care, sanitary products, and pharmaceutical agents top $28 billion per year.
Urinary incontinence occurs across the life span; it encompasses bedwetting in older children, urine loss after childbirth, postmenopausal leakage, middle-aged prostate complications, and a variety of situations in the elderly.
There has been considerable medical research relating to the management of urinary incontinence. Newly developed medications (with few side effects), behavioral interventions (such as muscle training, electrical stimulation, and biofeedback exercises), vaginal pessary use, and surgery to lift and reposition the bladder can successfully help 8 out of 10 people suffering with urinary incontinence.
Urinary incontinence occurs when the lower urinary tract, composed of the bladder, prostate gland in men, urethra, internal and external sphincters, and uretheral meatus malfunction. Normally the bladder, a hollow organ that expands to store urine from the kidneys, receives sensory signals that direct its detrussor muscle to fill and empty. Although the usual capacity of the bladder is about the size of a large orange, when the bladder is half full the first sensation to urinate should occur. The desire to void is voluntary. This allows the bladder to contract while the urethral sphincters relax, so that urine passes freely. When standing, men voluntarily contract abdominal muscles to aid in emptying. Women sit or squat to empty, thus compressing their abdomens by positioning.
Urinary incontinence can be acute or chronic. Different causes create these conditions. Acute (transient) urinary incontinence is usually associated with illness or a specific medical problem. Dehydration, restricted mobility, vaginitis, bladder infection, severe constipation, and side effects of high blood pressure medications are common examples. For those people taking multiple medications on a daily basis, urinary incontinence can occur because of drug interactions. Urinary incontinence is usually transient in those with high fever or delirium.
Chronic conditions affect the majority of people experiencing urinary incontinence. Dysfunction in the bladder can cause overactivity and hypersensitivity or distention. Obstruction from an enlarged prostate or narrowing and poor urethral tone can lead to urethral or sphincter dysfunction, resulting in incontinence.
Stress urinary incontinence commonly occurs when the urethra or sphincter are weakened. Activities that change the interabdominal pressure, such as coughing, sneezing, laughing, lifting heavy objects, performing aerobic exercise, and changing positions from supine to upright, are associated with urine leakage when the urethra and/or sphincter are weakened. Amounts of leakage can range from a few drops to complete soaking of clothing. Obesity, recent childbearing, birth trauma, having multiple pregnancies, and experiencing menopause can increase urinary incontinence in women. In men, prostate surgery and radiation to the bladder or prostate can contribute to stress urinary incontinence. Pelvic muscle strengthening exercises, called Kegels, have been shown to be 75% effective in reducing symptoms by half for mild to moderate cases. Vaginal weights and pessaries (a mechanical device to hold muscles in place) can be used for mild to severe cases. If fitted correctly, pessaries can be 100% successful in maintaining continence. In women, estrogen supplementation by mouth, patch, or direct application has demonstrated improvement in. In men, Kegel exercises (75%), biofeedback techniques (66%), and electric muscle stimulators (62%) can offer relief. For moderate to severe leakage, gynecologic surgery to resuspend the bladder is successful in most cases.
Urge urinary incontinence (also called overactive bladder) is caused by confused neurological pathway signals. Urge incontinence occurs while the bladder is filling when the detrussor muscle involuntarily contracts and pushes the urine out the urethra. Once the bladder starts emptying, it cannot be voluntarily stopped. Often large amounts of urine are leaked. Symptoms of urge incontinence include sudden urge to void, greater than eight voids per day, and three to four nocturnal voidings. People report common triggers such as running water, dish washing, cold exposure, anxiety, caffeine consumption, and immersion of an extremity in water. Conditions that commonly occur with urge incontinence are stroke, spinal problems, multiple sclerosis, diabetes, and bladder tumors. Most elderly people suffering from incontinence have this type. People with urge incontinence frequently perform “toilet mapping.” “Toilet mapping” involves identifying areas with toilets at malls, or locations with toilets when traveling. Behavioral therapies to assist with urge incontinence focus on timed bladder emptying. Toileting training has been successful with 25% to 40% of elderly people with incontinence. Anticholinergic medications (Detrol and Ditropan are most commonly prescribed) are very effective in decreasing urgency and frequency and stabilizing signals to the bladder. Studies have shown that 43% to 67% of people taking anticholinergic medications became continent and another 50% had reduced symptoms in 61% to 86% of cases. These medications can be used long-term. Electrical stimulation can improve symptoms in 50% to 60% of cases. Penile clamps, placed half way down the shaft of the penis, can be 100% effective in controlling urge incontinence following cancer surgery in men. Care must be used to avoid injury to the penis. Combination anticholinergic medications with behavioral treatments have demonstrated an 88% continence rate. Surgery cannot help remedy this type of incontinence.
- Boone, T., & Spann, S. (2004). Overactive bladder: Antimuscarinic therapy in primary care. Patient Care for the Nurse Practitioner, May (Special edition).
- Culligan, P. J., & Heit, M. (2000). Urinary incontinence in women: Evaluation and management. American Family Physician, 62, 2433–2444, 2447,
- Fantl, A., Newman, D. K., Colling, J., DeLancey, J. O. L., Keeys, C., Loughery, R., et al. (1996). Urinary incontinence in adults: Acute and chronic management. Clinical Practice Guideline, No. 2, 1996 Update (AHCPR Publication No. 96-0682). Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research.
- Miller, B. (2000). Urinary incontinence: A classification system and treatment protocols for the primary care provider. Journal of the American Academy of Nurse Practitioners,12(9), 374–379.
- National Kidney and Urologic Diseases InformationClearinghouse, http://kidney.niddk.nih.gov
- National Women’s Health Information Center, http://www.4wgov
- Newman, K. (2002). Managing and treating urinary incontinence. Baltimore: Health Professions Press.
- Palmer, M. H. (2004). Urinary stress incontinence: Prevalence, etiology and risk factors in women at 3 life stages. American Journal for Nurse Practitioners, May(suppl.), 5–14.
- The Simon Foundation for Continence, http://www.simon.org
- Van Kampen, , De Weerdt, W., Van Poppel, H., De Ridder, D., Feys, H., & Baert, L. (2000). Effect of pelvic floor re-education on duration and degree of incontinence after radical prostatectomy: A randomized controlled trial. Lancet, 355(8), 98–102.
- Wagner, T. , & Hu, T. W. (1998). Economic costs of urinary incontinence in 1995. Urology, 51(3), 355–361.
- Youngkin, Q., & Davis, M. S. (2004). Women’s health: A primary care clinical guide (3rd ed.). Upper Saddle River, NJ: Pearson/Prentice Hall.