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Urinary incontinence: Its causes and treatments

Incontinence, or the involuntary loss of urine, is a very common condition that affects at least 50 percent of women and between 10 and 15 percent of men over the course of their lifetimes.

There are many types of incontinence, but two major categories are stress and urge incontinence. Stress incontinence is the involuntary loss of urine with physical effort or exertion, such as coughing, sneezing, lifting, etc. Urge incontinence is the involuntary loss of urine with an urge component, which is a sudden, compelling desire to pass urine which is difficult to defer. Often patients have a combination of both types of incontinence. However, the treatments for them are different, so it is important to get an accurate diagnosis.

To diagnose incontinence, a thorough medical history and exam is performed. Typically a pelvic exam will be performed as well, especially if you are seeing a specialist.  Additionally, your urine will be checked to rule out infection or other potentially complicating factors, such as blood in the urine, which may be from an underlying source contributing to the incontinence. It is also important to make sure that you are emptying your bladder well, so a bladder ultrasound may also be performed. 

Typically, your primary care physician can make the initial diagnosis just by taking a medical history. Initial treatments can be started right away. If those treatments aren’t helping the symptoms, then you will likely be referred to a urologist for further evaluation.

Stress urinary incontinence typically arises from a loss of pelvic floor support. The risk factors for stress incontinence are:

  • Childbirth, in particular with vaginal deliveries;
  • Family history of incontinence;
  • Race, in particular among Caucasian and Hispanic patients;
  • Anything that puts pressure on the pelvic floor such as smoker’s cough or being overweight.

Treatments for stress incontinence start with behavioral and lifestyle modifications such as monitoring fluid intake and timed voiding to try to minimize the amount of urine in the bladder. Kegel exercises are also recommended, which can help strengthen the pelvic floor muscles. Often referral to a pelvic floor physical therapist is made to help with training the pelvic floor muscles. Some medical devices can help minimize leakage.

If these options aren’t helping, your urologist may recommend a surgical procedure called a “mid-urethral sling,” in which a piece of synthetic mesh is used to create a “sling” under the urethra to recreate the pelvic floor support.   

Urinary urgency incontinence is part of the general condition of overactive bladder. The underlying cause typically involves many factors.  Risk factors for overactive bladder can include the following:

  • Older age;
  • Outlet obstruction: enlarged prostates in men or symptomatic prolapse in women;
  • Neurologic disease – dementia, multiple sclerosis, Diabetes mellitus, stroke;
  • Pelvic radiation;
  • Stool impaction or constipation; and
  • Obesity.

The treatments for overactive bladder also start with behavioral therapies such as fluid management, timed voiding, and controlling constipation. Kegel exercises are also encouraged because they can help with urge suppression and bladder re-training.  Doctors often refer overactive bladder patients to pelvic floor physical therapists to help with training the pelvic floor muscles to maximize function.

If behavioral techniques do not adequately control symptoms, medications may be recommended. There are two classes of medication that can help with overactive bladder. A combination of physical therapy and medications often work best. Many patients are able to control their symptoms using these relatively conservative interventions.

If the condition persists, you would likely be referred to a specialist who may utilize advanced therapies. Three advanced therapies are available for refractory overactive bladder and urinary urgency incontinence symptoms: percutaneous neuromodulation (PTNM), sacral neuromodulation (SNM), and Botox of the bladder. Both PTNM and SNM provide neuromodulation, which means they deliver harmless electrical impulses to nerves to modulate/change how they work. PTNM is office-based, and SNM is an outpatient surgical procedure. With Botox, the medicine is injected into the bladder to partially paralyze the bladder muscle. The risks and benefits of each treatment would be discussed in detail to determine the best option for you.

If you find that you are experiencing symptoms of incontinence, talk to your doctor. There are medications and behavioral therapies that may improve your symptoms.

Another option is to seek the care of a urologist, which is a doctor specially trained to handle these types of conditions.

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