URINARY INCONTINENCE: IT’S EMBARRASSING

Leaking urine is a very embarrassing problem for both men and women. It always happens at an inconvenient time or place and leads to a great deal of social anxiety. You do anything you can to keep it from happening, but despite your best efforts, accidents do occur.

Women are far more prone to have urinary incontinence than men. The anatomy of the female urinary system plays a large role because the female urethra is very short (average 1.5 inches in length) and control of urine flow is easily disrupted. The urethra is the tube that begins at the base of the bladder and through it, urine flows to exit the body. For comparison, men’s urethras average 7-8” long and pass through the center of the prostate gland and the length of the penis, giving rise to numerous chances for obstruction of urine flow. Incontinence can still happen, but less frequently than obstruction. 

Incontinence is the loss of control of the flow of urine from the body. If you cough, sneeze, or laugh too vigorously, you leak. If you try to delay going for too long, you leak. If you don’t get to the bathroom when the urge occurs, you leak. If you’re disabled and mobility is limited, you leak. If you drink too much tea or take a diuretic (water pill), you leak. It’s an unpleasant nuisance.

The previous descriptions are examples of the four categories of incontinence. They are:

     Stress Incontinence—a cough, sneeze, laugh causes a leak

     Overflow Incontinence—if your bladder gets too full, you leak urine

     Urge Incontinence—when you have to go, you have to go, or you leak

     Functional Incontinence—if you can’t get to the toilet quickly, control is lost 

The urinary bladder is a sac-like organ that holds urine until it’s ready for elimination. The walls of the bladder are largely made up of muscles that stretch as urine collects in the bladder, and contract when it’s time to release urine out of the body. Outflow is also controlled by very small muscles (sphincter muscles) that surround the urethra and function to stop and start urine flow, like a purse string. If those muscles are stretched or don’t work properly, control of the bladder and urine flow are lost. The patient then leaks. 

Sphincter muscles contain two types of muscle fibers. The first is skeletal, or striated muscle, over which we have conscious control. The second type is smooth muscle fibers which are controlled automatically by our sympathetic nervous system. Skeletal muscles are like the muscles of our arms and legs we can consciously control, and smooth muscle fibers are like those in our blood vessel walls that contract and relax automatically controlled by the autonomic nervous system. Complicated? Yes, but important because these fibers become a target for drugs used to treat incontinence.

Incontinence is a condition of the elderly and is uncommon before age 50. Men have incontinence much less frequently than women, and most often have the urge type. Women may be temporarily incontinent during pregnancy or during a urinary tract infection because the urethra is distorted out of normal position and shape, is swollen, or affected by downward pressure from the baby. Caffeine, alcohol, chocolate, artificial sweeteners, chili peppers, constipation, and certain blood pressure drugs also cause temporary incontinence. 

Permanent incontinence occurs in older women because of aging changes and decreasing estrogen stimulation from menopause, but also by alterations to the female urinary anatomy as a result of one or more vaginal births. Multiple pregnancies can cause stretching of the sphincter, bladder wall, and pelvic floor muscles and can cause prolapse, or a downward falling of the cervix, body of the uterus, and the bladder. This type of problem is rarely helped by anything but an operation to put things back in their normal place to the extent that can be. 

The following is a list of treatment options for urinary incontinence. The doctor never knows which treatment will work and which ones will not. Trial and error is the only way to find out. 

The starting point is to avoid caffeine, chocolate, alcohol, and medications known to cause problems. 

Next are Pelvic Floor and bladder sphincter exercises to strengthen the muscles that keep urine from leaking. One such exercise is to hold your urine for as long as possible unless, of course, the patient has overflow incontinence. Holding theoretically strengthens the urethral sphincter muscle and improves continence. Double voiding helps, too. The patient empties his/her bladder, waits a few minutes, then voids again. Scheduling urinations is another helpful technique. Voiding at scheduled intervals keeps the volume of urine in the bladder at a controllable level. 

Next are devices that physically block the urethra or act as a urine conduit. Devices such as a pessary or a urinary catheter are examples. They must be put in place by the patient and can be very bothersome. Repeated urinary catheterizations very often lead to a bladder infection. 

Drug therapy is often effective in women in particular. There are several classes of drugs designed to re-establish bladder control by influencing one particular part of the urinary system. These drugs have side effects that many people find unpleasant. In fact, it is the side effects that help patients gain bladder control. Ditropan, Detrol, Vesicare, Enablex, and Toviaz are examples. A consumer health reference guide lists 25 drugs of various classes that can be used to treat incontinence. With that kind of availability, trial and error is the only way to determine what works. 

The “gold standard” for treatment, when drug therapy fails, is some form of bladder suspension surgery. These procedures use different techniques that would take too long to explain, but essentially they “tighten” the urethra so it won’t leak. These procedures report an 85% to 90% success rate. My experience is not that rosy, but the surgeon must evaluate the patient  thoroughly to determine what procedure is best. Sometimes poor patient selection or the selection of the wrong procedure determine the success of surgery. 

Dr. G’s Opinion: No one should suffer with urinary incontinence! If you have it, see your doctor and do something about it. Try exercises, medications, or anything that might work before having surgery. That is, of course, unless your situation is obviously a surgical problem. For men, prostate problems or a urinary tract infection are the source of most male urinary woes. After prostate surgery, incontinence can be a troublesome problem and continence drugs are of limited benefit. Fortunately, new drugs are emerging that provide some hope for incontinence sufferers. Let’s hope they are significantly more effective. 

References: Vij M, Robinson D, Cardozo L. Emerging drugs for treatment of urinary incontinence. Expert Opinion Emerg Drugs 2010 June;15(2):299-308.

Nitti V. The Prevalence of Urinary Incontinence Reviews in Urology 2001;3(suppl1):S2-S6.