Urinary incontinence

Urinary incontinence is not a disease; rather, it is usually a symptom of underlying health problems. The symptoms of urinary incontinence include:

• Leaking urine during normal daily activities such as lifting weights, coughing, sneezing, laughing, or exercising without any urge to urinate
• Leaking urine during sexual activity
• Bedwetting (leaking urine during sleep)
• Inability to hold urine
• Inability to reach the toilet in time
• Frequent urination (more than 8 times a day)
• Feeling of wetness
• Feeling of incomplete emptying of the bladder

The urinary system consists of detrusor muscles, the internal and external sphincters, and their neurological components.

In infants, the fullness of the bladder causes contraction of the detrusor muscles, leading to emptying of the bladder. As we grow, our bladder is trained to respond to the sensation of urge at volumes of 200-300 ml. At this stage, a voluntary decision can be made regarding passing urine, depending on location and availability.

The emptying of the bladder up to 7 times during waking hours is considered normal. The normal tolerance capacity of a healthy bladder is approximately 500 ml, which the bladder can accommodate without increasing pressure, even during physical activities, coughing, or lifting weights.

Any disturbance in this mechanism can lead to urinary incontinence. The possible causes are:

• Detrusor overactivity: This is the most common cause of urinary incontinence, characterized by consistent contractions of the detrusor muscles. This leads to relaxation of the sphincters and involuntary leakage of urine. It is commonly seen after spinal injuries, multiple sclerosis, or other lesions of the central nervous system.
• Impaired bladder contractility: An inadequately contractile bladder can also cause urinary incontinence, which can be due to aging and several pelvic floor diseases.
• Decreased pressure in urethra closure: The sphincteric unit helps in the closure of the bladder, which maintains urethral pressure during the resting state (where abdominal pressure is at its resting value, with no voiding or pelvic floor contraction). Decreased pressure in urethra closure can lead to leakage of urine.
• Atrophy of urethral areas: This medical condition occurs when the urethra and its surrounding structures lose strength and elasticity, causing urinary incontinence due to dysfunction of the urinary system. Atrophy is commonly seen in postmenopausal women due to estrogen deficiency.
• Prostatic hypertrophy: An enlarged prostate in men can put pressure on the bladder, potentially causing urinary incontinence.
• Urethral hypermobility: This condition involves excess movement of the urethra, which can lead to urinary incontinence. It can be due to pregnancy, vaginal delivery, obesity, smoking, chronic cough, and chronic constipation.
• Weakness of urinary sphincter: Conditions such as advanced age, menopause, and enlarged prostate can weaken the sphincter and pelvic floor muscles, leading to urinary incontinence.
• Poor detrusor compliance: Sometimes, the bladder fails to stretch, causing increased pressure, discomfort during filling, and reduced urine-holding capacity. This pattern is typical after pelvic radiotherapy or can result from prolonged periods of catheterization.

Reversible causes of urinary incontinence:

Reversible causes of urinary incontinence, often described by the mnemonic DIAPPERS, include:

• D: Delirium (confusion)
• I: Infection (urinary tract infection)
• A: Atrophic (urethral atrophy due to menopause)
• P: Pharmacological (medications)
• P: Psychological (disorders such as stress and anxiety)
• E: Endocrine (excess urine production)
• R: Restricted mobility (inability to reach the washroom due to conditions such as arthritis)
• S: Stool impaction (hardened stool stuck in the rectum or lower colon due to chronic constipation)

Various risk factors that can increase the risk of urinary incontinence (UI) include:

1. Medical Conditions

• Urinary Tract Infection: An infection of the urinary tract (urethra, ureters, bladder, and kidneys) can cause urinary incontinence. This is temporary and resolves once the condition is treated. UTIs are very common in women.
• Pelvic Floor Disease: Weak pelvic floor muscles in women during certain conditions can hinder the bladder's ability to hold urine, leading to urinary incontinence.
• Stroke: Stroke can affect various muscles of the body, including the one that controls the urinary bladder, potentially causing urinary incontinence.
• Diabetes: Increased urine production in diabetes can contribute to urinary incontinence.
• Menopause: Hormonal changes during menopause can impact the bladder and lead to urinary incontinence.
• Pregnancy: Urinary incontinence is commonly observed during pregnancy due to the expanding uterus putting pressure on the bladder. This usually subsides within a few weeks after delivery.
• Multiple Sclerosis: This condition disrupts nerve signals that direct urine movement in the body, potentially causing urinary incontinence.
• Enlarged Prostate: Enlargement of the prostate gland can exert pressure on the bladder, resulting in urine leakage.
• Constipation: Prolonged constipation can also lead to urinary incontinence.
• Obesity/Overweight: Being obese or overweight increases pressure on the bladder, which may lead to urinary incontinence.
• Birth Defects: Certain birth defects, such as bladder exstrophy, where the bladder develops outside the fetus, can cause urinary incontinence.
• Chronic Cough: A persistent cough can exert pressure on the abdomen, potentially causing urine leakage.
• Genitourinary Fistulas: An abnormal connection between urinary and genital structures, this condition is associated with urinary incontinence and is often treated surgically.
• Surgery: Some surgical procedures, such as prostate gland surgery, can lead to urinary incontinence.

2. Nerve Damage

Nerve damage is a common cause of functional incontinence. Nerves carry signals from the brain to the bladder and urinary muscles. Damage to these nerves can result in involuntary urine release. Nerve damage may occur due to:

• Diabetes
• Vaginal childbirth
• Parkinson’s disease
• Multiple sclerosis
• Alzheimer’s disease
• Brain or spinal cord injury
• Anxiety
• Heavy metal poisoning

3. Lifestyle Factors

Certain lifestyle factors can contribute to urinary incontinence, including:

• Consuming foods that cause constipation
• Drinking excessive caffeinated beverages and alcohol
• Physical inactivity
• Smoking

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4. Medications

Urinary incontinence can also result as a side effect of certain medications, including antipsychotics, benzodiazepines, antidepressants, and hormone replacement therapy in postmenopausal women.

1. Medical history

   The complete medical history is obtained to determine the type, severity, and duration of urinary incontinence. The type can be determined by the history:

   • Urge urinary incontinence: Characterized by increased frequency, urgency, and nocturia (frequent nighttime urination).
   • Mixed urinary incontinence: Exhibits characteristics of both stress and urge urinary incontinence.
   • Overflow urinary incontinence: Associated with straining due to incomplete bladder emptying.
   • Stress urinary incontinence: Predicted through activities that trigger urine leakage.
   • Functional urinary incontinence: History may suggest physical disabilities or memory-related issues.

   Patients are also questioned about any medical conditions and surgeries that could contribute to urinary incontinence. For females, a complete gynecological history is obtained, including the number of births and type of delivery (C-section or normal).

2. Physical examination

   A variety of ailments are assessed through physical examination, including:

   • Pedal edema
   • Cough
   • Surgical scars
   • Range of motion
   • Enlargement of the prostate gland
   • Pelvic exam

   This examination helps determine any cardiovascular, pulmonary, abdominal, or musculoskeletal issues.

3. Urine test

   The urine is tested for the presence of:

   • Urinary tract infections
   • Glycosuria (glucose in urine)
   • Proteinuria (protein in urine)
   • Hematuria (blood in urine)

   In various cases, blood urea nitrogen (BUN) and creatinine tests are also performed to assess kidney function.

4. Urodynamic testing

   This includes several tests to evaluate the urine holding capacity of the bladder and the functioning of urethral sphincter muscles, which control involuntary urine flow. One such test involves inserting a tube into the bladder and filling it with fluid to check the bladder's holding capacity.

5. Pad test

   The patient is given a pad to wear, which helps check for any leaked urine.

6. Stress test

   The patient is asked to cough to demonstrate involuntary leakage of urine, with increased sensitivity when performed in a standing position.

7. Imaging

   Imaging techniques include:

   • Ultrasound: Imaging of the bladder to assess urine emptying capacity.
   • Cystoscopy: A thin flexible tube with a camera is used to examine the urethra and urinary bladder for anomalies that could cause urinary incontinence.
8. Maintaining a journal

   The doctor may recommend that the patient maintain a journal for a few days to record:

   • Any leakage of urine
   • Frequency of urination
   • Ability to reach the restroom on time
   • Conditions that trigger leakage of urine

   This information helps identify a pattern of urinary incontinence, aiding in the diagnosis process.

There is no sure way to prevent urinary incontinence. However, several factors that trigger urinary incontinence can be minimized through lifestyle modifications. These include:

1. Modify your eating habits

   Healthy eating habits help prevent obesity and diabetes, which can trigger urinary incontinence. The following eating habits should be adopted to prevent UI:

   • Limit alcohol, spicy foods, chocolate, artificial sweeteners, and caffeinated beverages, as they may irritate and inflame the bladder.
   • Include high-fiber foods such as whole grain cereals (e.g., porridge, brown rice, wholemeal pasta, wholemeal bread) and pulses (e.g., lentils and beans) to avoid constipation. Aim for at least 25-30 grams of fiber each day.
   • Eat fruits and vegetables to facilitate easy defecation.
2. Keep yourself hydrated

   A lower intake of water is associated with constipation and bladder irritation, which can increase the risk of developing UI. To prevent dehydration:

   • Drink at least 6 to 8 glasses of water every day.
   • Drink more water in hot weather and after strenuous exercise.
   • Make a habit of frequently sipping water, even when not feeling thirsty.

   The color of urine can help identify whether a person is adequately hydrated. Pale yellow urine indicates proper hydration, while dark yellow urine suggests dehydration. Note: Some medications, vitamins, and foods can also affect urine color.

3. Indulge in some physical activity

   Engaging in regular exercise helps maintain a healthy weight, reducing pressure on the pelvic floor muscles and lowering the chances of UI. Physical activity also helps prevent constipation, which can trigger UI. Suggestions for physical activity include:

   • Incorporate a brisk 30-minute walk every day.
   • Choose any physical activity you enjoy to help maintain a regular regimen.
   • Include pelvic floor exercises to strengthen the muscles.
4. Follow good toilet habits

   Adopting good toilet habits can prevent urinary incontinence, including:

   • Avoid holding urine for extended periods.
   • Take your time and ensure the bladder is fully emptied.
   • Adopt a full crouching squat position while urinating.
   • Go to the toilet when the bladder is full.
   • Avoid straining during bowel movements, as this may weaken the pelvic floor muscles.
   • Use correct posture while urinating, which involves sitting upright with elevated feet.
5. Quit smoking

   Smoking negatively affects bladder health and increases the chances of urinary incontinence. Quitting smoking is associated with a decreased risk of UI.

The treatment plan is created according to the type of incontinence.

A. Medications

Various medications are used to reduce leakage, selected according to the patient's needs. Some medications stabilize the muscle contractions of the bladder, while others relax the bladder muscles, allowing complete emptying. Common examples of medications include:

• Antimuscarinics (darifenacin, solifenacin, oxybutynin, tolterodine, fesoterodine, and trospium)
• Alpha-adrenergic agonist (phenylpropanolamine)
• Antidepressants (duloxetine)
• Alpha-adrenergic antagonists (terazosin and tamsulosin)
• Beta-adrenergic agonist (mirabegron)

B. Vaginal estrogen creams

These creams are directly applied to the vaginal walls and urethral tissue, helping to relieve urge or stress incontinence.

C. Hormone replacement therapies

Commonly used in women to restore normal bladder function, an example includes estrogen replacement therapy during menopause.

D. Other procedures and surgeries

If lifestyle, behavioral, and pharmacological therapies fail to treat the conditions, invasive techniques may be used. These techniques can range from simple injections to complex surgeries, selected based on the cause and symptoms of incontinence.

• Bulking agents: Involves injecting a permanent substance into the lining of the urethra to increase its lining, mostly used in women with stress incontinence.
• Botulinum toxin injections: Involves injecting botulinum toxin into the bladder to relax its muscles, used to treat urge incontinence.
• Medical devices: Involves the implantation of several devices such as:
• Neuromodulation devices: Various devices that can modulate nerve control to the bladder, such as pacemakers. In some cases, nerves near the ankle are stimulated to achieve bladder control.
• Artificial urethral sphincter: A device placed close to the urethra to control urination, typically used in men with stress incontinence after prostate cancer surgery.
• Vaginal insert: Devices placed in the vagina to compress the urethra, helping to reduce stress incontinence in women.
• Biofeedback sensor: Uses sensors to make the patient aware of urine signals, which may help regain control over the muscles of the bladder and urethra.
• Electrical nerve stimulation: Sends electrical signals to the nerves around the bladder to help control urine.
• Catheterization: Involves using a catheter to drain urine; a catheter is a tube inserted through the urethra into the bladder, used occasionally or continuously.
• Surgery: May be required in cases where incontinence is caused by an enlarged prostate.

Home remedies

• Magnesium: It plays an important role in the proper functioning of muscles and nerves. It reduces bladder spasms and facilitates complete emptying. Magnesium has been found to alleviate symptoms of urinary incontinence, particularly nocturia. Individuals experiencing incontinence should include magnesium-rich foods in their diet, such as corn, potatoes, and bananas.
• Vitamin D: Low levels of Vitamin D are associated with weak pelvic floor disorders, including urinary incontinence. Patients with urinary incontinence are advised to ensure adequate intake of Vitamin D, as it has been shown to reduce symptoms. Here’s the right way to take Vitamin D.

The urine leakage can lead to discomfort and embarrassment, along with various physical problems. This can cause individuals to avoid social gatherings and may eventually lead to depression. The physical complications related to urinary incontinence include:

• Urinary tract infections (UTIs)
• Skin sores and rashes due to wet skin
• Cellulitis (bacterial skin infection characterized by inflammation)
• Pressure ulcers (injuries to the skin due to constant pressure)
• Trauma and infection due to catheterization
• Sexual dysfunction
• Prolapse (slipping of a part of the body from its usual position)

Medication side effects

There are several physical symptoms that can be side effects of medications used for urinary incontinence. These include:

• Dry mouth
• Restlessness
• Hypertension
• Insomnia
• Dizziness
• Tiredness

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Urinary continence can be a cause of embarrassment for many and a hindrance to daily activities. Here are a few tips that can help in living with urinary incontinence:

• Timed voiding: Practice going to the bathroom at regular time intervals instead of waiting for the urge. This helps prevent overfilling of the bladder and reduces the chances of incontinence.
• Emptying before physical activities: Patients with urinary incontinence are advised to empty their bladder before engaging in physical activities such as running, jumping, or exercising. This reduces the chances of leakage.
• Avoid heavy lifting: Many individuals tend to leak urine when lifting heavy objects. Those suffering from urinary incontinence should avoid heavy lifting and seek assistance when necessary.
• Regulate the intake of caffeinated beverages: Caffeinated drinks like tea and coffee can trigger urine leakage. It is advisable to limit their consumption, especially before activities. If you frequently wake up at night to urinate, avoid these beverages before bedtime.
• Wear pads: Various pads and products are available that are specially designed to absorb leaked urine. These can be worn to prevent leakage through clothing.
• Maintain a healthy weight: Being overweight can contribute to incontinence. It is recommended to maintain a healthy weight through a balanced diet and regular exercise.
• Keep yourself hydrated: Inadequate fluid intake can also lead to urinary incontinence. Stay hydrated by drinking at least eight glasses of water daily.
• Prevent constipation: Long-term constipation can stimulate urine leakage. A diet rich in fiber, including whole grains, cereals, fruits, and vegetables, can help prevent constipation.
• Quit smoking: Smoking can exacerbate many health issues, including urinary incontinence.