June 18, 2022

When Urine Leaks – A Quick Guide To Urinary Incontinence

Written by: Marina Peric, M.D.

Does every sneeze mean wet underwear for you? Can’t make it to the toilet in time?

Urinary incontinence, or involuntary urine leakage, is a problem that is estimated to affect around 30% of the population, while 50% of women will experience associated symptoms at least once during their lifetime. It is more frequently seen in women, and the prevalence increases with age, with the peak incidence of the condition in the fifth decade. Risk factors also include obesity, number of vaginal deliveries, pelvic surgeries, suffering from other diseases (diabetes for example), etc. With humankind growing older and the obesity pandemic, it is estimated that the number of patients with urinary incontinence will rise by around 50% by 2050 compared to 2010.

But although common, urinary incontinence is not a hot topic in medicine. You’ll rarely hear about it in the media; researches in this field are not very popular and profitable. Due to embarrassment and fear of being stigmatized, sufferers often don’t speak about this problem. Even worse, many consider it to be a normal part of aging that one simply has to learn to live with, with all the limitations that this entails.

But is there nothing to be done?

 

Why does urinary incontinence develop?

Normally, the urine produced by the kidneys travels down the ureters to be stored in the bladder until the circumstances for urination are convenient. The bladder wall has a specific structure, with detrusor muscle and a unique lining that allows widening, which allows it to store up to 500ml of urine without any or with only a slight rise of the pressure within it. The urine from the bladder is eliminated through the urethra, which closes thanks to the activity of a circular, outer sphincter muscle, which is voluntarily controlled, and nearby muscles and fasciae of the pelvic floor aid in keeping the urethra shut. Usually, when a person wants to urinate, they voluntarily relax the outer urethral sphincter, and the muscle in the bladder wall contracts, leading to a rise in the pressure within the bladder, with nothing blocking the way; this causes the urine to flow out.

When this fine mechanism is compromised in some way, urine can leak involuntarily between voluntary urinations – in other words; urinary incontinence may develop.

Although the exact mechanisms are controversial and possibly yet to be discovered, potential reasons for urine leakage include:

 

 

  • Weakness of the urinary sphincter, which may develop as a consequence of trauma, surgery, neurological and muscle diseases, ageing, etc;
  • Loss of support to the urethra from the pelvic floor muscles and fasciae, associated with, for example, obesity, vaginal deliveries, surgery, or chronic constipation;
  • Excessive activity of the detrusor muscle, which may come as a consequence of a spinal injury, but is of unknown cause in most cases;
  • Inability of the bladder wall to spread, after radiotherapy, or after having a urinary catheter for a long time;
  • Overactive bladder syndrome, sometimes associated with urinary tract infections;
  • Urine retention, due to an obstruction in the bladder or urethra, neural damage, weak detrusor muscle contractions, or an increase in urine volume.

The 3 major types of urinary incontinence

  1. Stress incontinence

Stress urinary incontinence is characterized by losing a small amount of urine when abdominal pressure suddenly rises, for example when coughing or sneezing. The mechanism behind this predictable type of incontinence is the weakness of the urinary sphincter or the weakening of the pelvic floor muscles that support the urethra. This is the most common type of incontinence in women, affecting 25-45% of those over the age of 30.

 

  1. Urgency incontinence

In case of urgency incontinence, the culprit is the overly active detrusor muscle. Patients can’t control this muscle’s contractions, which presents with a sudden, uncontrollable urge to void and a loss of urine, usually on the way to the bathroom. Urination is more frequent, and nocturia (urination during the night) is associated too. Around 30% of women in their 7th decade suffer from this type of incontinence.

 

  1. Mixed incontinence

Mixed incontinence is a combination of the previous two, with both the sudden urge to void and a loss of small amount of urine during coughing, sneezing, or laughing. It is estimated that 20-30% of the population has this type of incontinence.

 

Functional incontinence

Functional incontinence is a specific category in which wetting exists, but it is not caused by any previously described mechanisms concerning the urinary system. Instead, the loss of urine here happens because of patients’ other diseases, such as arthritis, or Alzheimer’s, making it difficult for them to reach the toilet in time.

 

Transient incontinence: what lies behind?

The incontinence sometimes develops all of a sudden and is caused by a temporary circumstance or a treatable condition. When the underlying problem is solved, this incontinence completely disappears within 6 months – which is why it is called transient or temporary incontinence.

Transient incontinence usually develops due to short-termed overproduction of urine, for example, after drinking large amounts of coffee or alcohol, eating too much spicy or sweet food, or taking some medications, but it can also be associated with urinary tract infections or constipation.

 

Incontinence in men: a taboo issue

Incontinence is usually addressed as a female problem, and for a reason – it is overall more common in women, and women seek medical help in this regard more often. However, it is estimated that 1 in 4 men over the age of 70 suffers from some form of urinary incontinence, and the prevalence of urinary incontinence in men and women over the age of 80 is similar.

Apart from already mentioned typical forms of urinary incontinence, men are likely to suffer from a specific type of incontinence called overflow incontinence. The underlying mechanism is as follows: the urethra is obstructed, usually by an enlarged prostate, and urine is retained within the bladder until the pressure within it gets high, and the urine starts to leak. Apart from wetting, the patients also complain about a constant feeling of bladder fullness/inability to completely empty the bladder, and about difficulties and straining during urination.

 

Things to be done

Despite popular belief, urinary incontinence should not be concerned a normal part of aging, and every patient should receive proper treatment. However, studies report that it is usually not the case, and most patients have either inadequate or no treatment at all.

The treatment mode depends primarily on the type of incontinence but also on associated factors such as age, comorbidities, etc. Possible treatment strategies include:

  • Lifestyle changes and other non-surgical interventions, although with limited results, are the first step to take in the treatment process, and there are several things to be done in this regard. Fluid intake should be moderately limited if the general state and associated diseases allow it, but this is unfortunately not always the case, especially in elderly patients. Weight loss is recommended for obese patients, which is beneficial not only regarding urinary incontinence but regarding general health and condition too. Kegel exercises and toilet training aim to strengthen pelvic floor muscles and provide better control of urination and are particularly advised in case of stress incontinence. Patients with severe stress incontinence can also benefit from using pessaries and other intravaginal devices.
  • Pharmacological treatment, using drugs such as anticholinergics, estrogens, β3-adrenergic agonists, serotonin-noradrenaline reuptake inhibitors, or oxybutynin, is recommended in those who do not show improvement with previously described strategies. The particular drug to be used is chosen depending on the symptoms, patient age, general state, and comorbidities. The first results can be seen in several weeks, so it is important to be persistent and carefully follow the doctor’s instructions. Using some of these drugs can, unfortunately, be followed with an array of unpleasant side effects, and they are only reserved for those with urgency incontinence – to date, there are no drugs registered for stress incontinence therapy.
  • Surgical treatment is the final and most successful strategy for urinary incontinence management. Depending on the type of incontinence and severity of symptoms, several procedures can be performed, usually the urethral sling procedure and implantation of sacral neuromodulating stimulators. Less invasive procedures, such as injections of bulking agents into the urethra or onabotulinumtoxinA bladder injections, are a possible solution for those with severe symptoms who are not good candidates for surgery. 

 

When to seek help

Urinary incontinence has a strong negative impact on life quality: it is associated with depression, poor sexual function, sleeping disorders, and dependence on caregivers, as well as limited social activities, low self-confidence, and low productivity in daily activities. Sometimes, it is also a manifestation of a more serious underlying condition.

Do not wait for all that to happen - if you have any symptoms of urinary incontinence, seek medical help without hesitation. Even if the symptoms are mild and/or occasional, a doctor must be consulted to timely diagnose and treat the condition.

 

References

  1. Aoki Y, Brown HW, Brubaker L, et al. Urinary incontinence in women. Nat Rev Dis Primers. 2017;3:17042.
  2. Hu JS, Pierre EF. Urinary Incontinence in Women: Evaluation and Management.Am Fam Physician. 2019;100(6):339-348.
  3. Goforth J, LangakerM. Urinary Incontinence in Women.N C Med. 2016;77(6):423-425.
  4. Chung E, Love C, Katz DJ. Adult male stress and urge urinary incontinence – A review of pathophysiology and treatment strategies for voiding dysfunction in men.AustFam Physician. 2017;46(9):662-666.
  5. Minassian VA, Drutz HP, Al-Badr A. Urinary incontinence as a worldwide problem. Int J Gynaecol Obstet. 2003;82(3):327-38.
  6. Khandelwal C, Kistler C. Diagnosis of Urinary Incontinence.Am Fam Physician. 2013;87(8):543-550.
Article written by Marina Peric, M.D.
Marina is a medical doctor from Belgrade, Serbia. She graduated with high honors in 2020 and is aspiring to become a pathologist. During her studies, she took part in several scientific researches, mostly in the pharmacology niche. She was also an assisting teacher at the Department of Histology and Embryology for 5 years (2015-2020). Marina has years of experience as a writer on health-related topics. Apart from English, she fluently speaks several languages, including Spanish, Russian, and Czech.

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