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Urinary Incontinence

Urinary Incontinence in Men

Urinary Incontinence in Women

Treatments for Urinary Incontinence in Women


Urinary Incontinence in Men

Urinary incontinence (UI) is the accidental leakage of urine. Over a lifespan, there are gender differences in the frequency of UI. In childhood, girls usually develop bladder control at an earlier age than boys, and bedwetting (nocturnal enuresis) is less common in girls than in boys. However, adult women are far more likely to experience UI because of the anatomy of their urinary tract and the stresses caused by pregnancy and childbirth. Nevertheless, men may experience UI as a result of prostate problems, and both men and women can experience nerve damage that leads to UI. Its prevalence increases with age, but it is not an inevitable part of aging.

UI is a medical problem. To find a treatment that addresses the root of the problem, you need to talk to your health care provider. The four forms of UI are

  • temporary or reversible incontinence related to urinary tract infection, constipation, or delirium
  • stress incontinence caused by weak pelvic and sphincter muscles
  • urge incontinence caused by damaged or irritable nerves
  • overflow incontinence that results when an individual is unable to empty the bladder
Male urinary tract, front and side views, including kidney, ureter, bladder, prostate, pelvic floor muscle, and urethra
Male urinary tract, front and side views

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  Nerves carry signals from the brain through the central nervous system (brain and spinal cord), then down the spinal cord to both the bladder and the sphincter.
 

Nerves carry signals from the brain to the bladder and sphincter. Any disease, condition, or injury that damages nerves can lead to urination problems.

What causes UI in men?

For the urinary system to do its job, muscles and nerves must work together to hold urine in the bladder and then release it at the right time. Babies are not born with the ability to control urination. As children grow, they learn to interpret nerve signals and develop the muscle control required to stay dry. In children between the ages of 5 and 10, some incontinence may result from limited bladder capacity or delayed development of the nerve pathways that signal a full or emptying bladder. This form of incontinence fades away as the bladder grows and nerves become mature. Other types of nerve problems, however, can cause urination problems that are more difficult to overcome.

Nerve Problems

Any disease, condition, or injury that damages nerves can lead to urination problems. Nerve problems can occur at any age.

  • Men who have had diabetes for many years may develop nerve damage that affects their bladder control as well as their sexual function.

  • Stroke, Parkinson's disease, and multiple sclerosis all affect the brain and nervous system, so they can also cause incontinence.

  • Overactive bladder is a condition in which the bladder squeezes at the wrong time. The condition may be caused by nerve problems, or it may occur without any clear cause. A person with overactive bladder may have any two or all three of the following symptoms:
    • urinary frequency--urination eight or more times a day or two or more times at night
    • urinary urgency--the sudden, strong need to urinate immediately
    • urge incontinence--urine leakage that follows a sudden, strong urge

  • Spinal cord injury can cause incontinence by interrupting the nerve signals required for bladder control.

  • In neural birth defects such as spina bifida or myelomeningocele, the backbone and spinal canal do not close before birth. In severe cases, nerve damage can result in many problems, including lack of control over urination.

Prostate Problems

The prostate is a male gland about the size and shape of a walnut. It surrounds the urethra just below the bladder, where it adds fluid to semen before ejaculation.

  • BPH: The prostate gland commonly becomes enlarged as a man ages. This condition is called benign prostatic hyperplasia (BPH) or benign prostatic hypertrophy. As the prostate enlarges, it may squeeze the urethra. The bladder wall thickens and becomes irritable, and the bladder begins to contract even when it contains only small amounts of urine. This results in more frequent urination. BPH rarely causes symptoms before age 40, but more than half of men in their sixties and up to 90 percent in their seventies and eighties have some symptoms of BPH. The symptoms vary, but the most common ones involve changes or problems with urination, such as a hesitant, interrupted, weak stream; urgency and leaking or dribbling; more frequent urination, especially at night; and urge incontinence. Problems with urination do not necessarily signal blockage caused by an enlarged prostate. Other changes associated with aging can cause urination problems experienced by both men and women.

  • Radical prostatectomy: The surgical removal of the entire prostate gland--called radical prostatectomy--may be recommended to treat prostate cancer. The surgeon may approach the prostate through the abdomen or through the perineal area (between the scrotum and the anus). The surgery may lead to erection problems and UI, although nerve-sparing procedures in the abdominal approach may make these side effects less likely.

  • External beam radiation: This therapy uses an x-ray machine to deliver radiation to the prostate gland. The treatment is not painful but can cause loss of bladder control as well as fatigue, skin redness and irritation, rectal burning or injury, diarrhea, inflammation of the bladder wall (cystitis), blood in the urine, loss of sexual function, and loss of appetite.
Before and after illustrations show the urinary system before prostate cancer is treated and after the entire prostate is removed.

Radical prostatectomy


Prostate Symptom Scores

If your prostate could be involved in your incontinence, you may be asked a series of standardized questions, either the International Prostate Symptom Score or the American Urological Association (AUA) Symptom Scale. Some of the questions you will be asked for the AUA Symptom Scale will be the following:

  • Over the past month or so, how often have you had to urinate again in less than 2 hours?

  • Over the past month or so, from the time you went to bed at night until the time you got up in the morning, how many times did you typically get up to urinate?

  • Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating?

  • Over the past month or so, how often have you had a weak urinary stream?

  • Over the past month or so, how often have you had to push or strain to begin urinating?

Your answers to these questions may help identify the problem or determine which tests are needed. Your symptom score evaluation can be used as a baseline to see how effective later treatments are at relieving those symptoms.

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How is UI diagnosed?

Medical History

The first step in solving a urinary problem is talking to your health care provider. Your general medical history, including any major illnesses or surgeries, and details about your continence problem and when it started will help your doctor determine the cause. You should talk about how much fluid you drink a day and whether you use alcohol or caffeine. You should also talk about the medicines you take, both prescription and nonprescription, because they might be part of the problem.

Voiding Diary

You may be asked to keep a voiding diary, which is a record of fluid intake and trips to the bathroom, plus any episodes of leakage. Studying the diary will give your health care provider a better idea of your problem and help direct additional tests.

Physical Examination

A physical exam will check for prostate enlargement or nerve damage. In a digital rectal exam, the doctor inserts a gloved finger into the rectum and feels the part of the prostate next to it. This exam gives the doctor a general idea of the size and condition of the gland. To check for nerve damage, the doctor may ask about tingling sensations or feelings of numbness and may check for changes in sensation, muscle tone, and reflexes.

EEG and EMG

An electroencephalogram (EEG), a test where wires are taped to the forehead, can sense dysfunction in the brain. An electromyogram (EMG) measures nerve activity in muscles and muscular activity that may be related to loss of bladder control.

Ultrasound

For an ultrasound, or sonography, a technician holds a device, called a transducer, that sends harmless sound waves into the body and catches them as they bounce back off the organs inside to create a picture on a monitor. In abdominal ultrasound, the technician slides the transducer over the surface of your abdomen for images of the bladder and kidneys. In transrectal ultrasound, the technician uses a wand inserted in the rectum for images of the prostate. Depending on your symptoms, your doctor may recommend one of these tests.

Urodynamics

Urodynamic testing focuses on the bladder's ability to store urine and empty steadily and completely, and on your sphincter control mechanism. It can also show whether the bladder is having abnormal contractions that cause leakage. The testing involves measuring pressure in the bladder as it is filled with fluid through a small catheter. This test can help identify limited bladder capacity, bladder overactivity or underactivity, weak sphincter muscles, or urinary obstruction. If the test is performed with EMG surface pads, it can also detect abnormal nerve signals and uncontrolled bladder contractions.

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How is UI treated?

No single treatment works for everyone. Your treatment will depend on the type and severity of your problem, your lifestyle, and your preferences, starting with the simpler treatment options. Many men regain urinary control by changing a few habits and doing exercises to strengthen the muscles that hold urine in the bladder. If these behavioral treatments do not work, you may choose to try medicines or a continence device--either an artificial sphincter or a catheter. Finally, for some men, surgery is the best choice.

Behavioral Treatments

For some men, avoiding incontinence is as simple as limiting fluids at certain times of the day or planning regular trips to the bathroom--a therapy called timed voiding or bladder training. As you gain control, you can extend the time between trips. Bladder training also includes Kegel exercises to strengthen the pelvic muscles, which help hold urine in the bladder. Extensive studies have not yet shown that Kegel exercises are effective in reducing incontinence in men, but many clinicians find them to be an important element in therapy for men.

Some people with nerve damage cannot tell whether they are doing Kegel exercises correctly or not. If you are not sure, you may still be able to learn proper Kegel exercises by doing special training with biofeedback, electrical stimulation, or both. Biofeedback uses sensors to detect muscle activity and create a visual or audio signal when the appropriate muscles are being used. A small probe, about the size of a pen, is inserted in the anus to record muscle contractions during the exercises. If you squeeze the right muscle, you will see a change on a television screen or hear a tone from a speaker.

Mild electrical pulses delivered to the pelvic muscles cause them to contract and grow stronger. This technique can also help you locate the right muscles to use during Kegel exercises.


How do you do Kegel exercises?

The first step is to find the right muscles. Imagine that you are trying to stop yourself from passing gas. Squeeze the muscles you would use. If you sense a "pulling" feeling, those are the right muscles for pelvic exercises.

It is important not to squeeze other muscles at the same time and not to hold your breath. Also, be careful not to tighten your stomach, leg, or buttock muscles. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Squeeze just the pelvic muscles.

Repeat, but do not overdo it. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of 3. Work up to 3 sets of 10 repeats. Start doing your pelvic muscle exercises lying down. This is the easiest because the muscles then do not need to work against gravity. When your muscles get stronger, do your exercises sitting or standing. Working against gravity is like adding more weight.

Be patient. Do not give up. It takes just 5 minutes, three times a day. Your bladder control may not improve for 3 to 6 weeks, although most people notice an improvement after a few weeks.

Medications

Medicines can affect bladder control in different ways. Some medicines help prevent incontinence by blocking abnormal nerve signals that make the bladder contract at the wrong time, while others slow the production of urine. Still others relax the bladder or shrink the prostate. Before prescribing a medicine to treat incontinence, your doctor may consider changing a prescription you already take. For example, diuretics are often prescribed to treat high blood pressure because they reduce fluid in the body by increasing urine production. Some men may find that switching from a diuretic to another kind of blood pressure medicine takes care of their incontinence.

If changing medicines is not an option, your doctor may choose from the following types of drugs for incontinence:

  • Alpha-blockers: Terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), and alfzosin (Uroxatral) are used to treat problems caused by prostate enlargement and bladder outlet obstruction. They act by relaxing the smooth muscle of the prostate and bladder neck, allowing normal urine flow and preventing abnormal bladder contractions that can lead to urge incontinence.

  • 5-alpha reductase inhibitors: Finasteride (Proscar) and dutasteride (Avodart) work by inhibiting the production of the male hormone DHT, which is thought to be responsible for prostate enlargement. These 5-alpha reductase inhibitors relieve voiding problems by shrinking an enlarged prostate. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) sponsored the Medical Therapy of Prostate Symptoms (MTOPS) trial, a multicenter study that found that doxazosin and finasteride taken together reduced the risk of BPH progression by 67 percent compared with placebo. The risk of progression was reduced by 39 percent with doxazosin alone and by 34 percent with finasteride alone.

  • Imipramine: Marketed as Tofranil, this drug belongs to a class of drugs called tricyclic antidepressants. It relaxes muscles and blocks nerve signals that might cause bladder spasms. Imipramine is also used to treat bedwetting in children.

  • Antispasmodics: Propantheline (Pro-Banthine), tolterodine (Detrol LA), and oxybutynin (Ditropan XL) belong to a class of drugs that work by relaxing the bladder muscle and relieving spasms. Their most common side effect is dry mouth, although larger doses may cause blurred vision, constipation, a faster heartbeat, headache, and flushing.

Catheters

A catheter is inserted through the urethra into the bladder.

Clean intermittent catheterization

If all other methods fail or are found unacceptable, you may consider controlling incontinence by using a catheter, a thin tube inserted through the urethra to drain the bladder. Catheters must be managed with great care to avoid infection and stone formation.

  • Clean intermittent catheterization: If you have problems emptying your bladder because of an enlarged prostate or because of nerve damage, you may use a catheter at regular times, or as needed, to drain urine and prevent overflow incontinence. Depending on your situation, the catheterization may be done for you, or you may learn to do it yourself. You will need to learn sterile technique to avoid urinary tract infections.

  • Condom catheter: Some men may prefer a drainage system that fits over the penis like a condom. You must take the same care to avoid infection as you do with other catheters. Condom catheters can also carry a risk of skin breakdown.
  An injection needle and a probe to guide needle placement are inserted in the urethra as collagen is injected into the area that surrounds the opening of the bladder.
 

Urethral injections. Adding bulk to the tissue around the bladder opening helps keep the urethra closed.

Urethral Injections

Another method to help keep the urethra closed is to inject a fat-like substance into the area that surrounds the opening of the bladder into the urethra. A variety of bulking agents are available for injection. Your doctor will discuss which one may be best for you. Collagen, for example, is a natural tissue from cows. After using local anesthesia or sedation, a doctor can inject the material in about half an hour. Over time, the body slowly eliminates the collagen, so you may need repeat injections. Before you receive collagen, a doctor will perform a skin test to determine whether you could have an allergic reaction to the material.

Artificial Sphincter

Some men may eliminate urine leakage with an artificial sphincter, an implanted device that keeps the urethra closed until you are ready to urinate. This device can help people who have incontinence because of weak sphincter muscles or because of nerve damage that interferes with sphincter muscle function. It does not solve incontinence caused by uncontrolled bladder contractions.

An artificial sphincter keeps the urethra closed with three parts: a cuff that fits around the urethra, a pump that is placed in the scrotum, and a pressure-regulating balloon that is placed in the abdomen.

Artificial sphincter

Surgery to place the artificial sphincter requires general or spinal anesthesia. The device has three parts: a cuff that fits around the urethra, a small balloon reservoir placed in the abdomen, and a pump placed in the scrotum. The cuff is filled with liquid that makes it fit tightly around the urethra to prevent urine from leaking. When it is time to urinate, you squeeze the pump with your fingers to deflate the cuff so that the liquid moves to the balloon reservoir and urine can flow through the urethra. When your bladder is empty, the cuff automatically refills in the next 2 to 5 minutes to keep the urethra tightly closed.

Male Sling

Surgery can improve some types of urinary incontinence in men. In a sling procedure, the surgeon creates a support for the urethra by wrapping a strip of material around the urethra and attaching the ends of the strip to the pelvic bone. The sling keeps constant pressure on the urethra so that it does not open until the patient consciously releases the urine.

Urinary Diversion

  A male figure with the kidneys, ureters, reservoir, and stoma labeled.
 

Urinary diversion

If the bladder must be removed or all bladder function is lost because of nerve damage, you may consider surgery to create a urinary diversion. In this procedure, the surgeon creates a reservoir by removing a piece of the small intestine and directing the ureters to the reservoir. The surgeon also creates a stoma, an opening on the lower abdomen where the urine can be drained through a catheter or into a bag.

Social Support

UI should not cause embarrassment. It is a medical problem like arthritis or diabetes. Your health care provider can help you find a solution. You may also find it helpful to join a support group. In many areas, men dealing with the aftereffects of prostate cancer treatment have organized support groups. Other organizations to help people with incontinence exist as well.

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Urinary Incontinence in Women

Urinary incontinence is an inability to hold your urine until you get to a toilet. More than 13 million people in the United States--male and female, young and old--experience incontinence. It is often temporary, and it always results from an underlying medical condition.

(In this fact sheet, the term "incontinence" will be used to mean urinary incontinence.)

Women experience incontinence twice as often as men. Pregnancy and childbirth, menopause, and the structure of the female urinary tract account for this difference. But both women and men can become incontinent from neurologic injury, birth defects, strokes, multiple sclerosis, and physical problems associated with aging.

Older women, more often than younger women, experience incontinence. But incontinence is not inevitable with age. Incontinence is treatable and often curable at all ages. If you experience incontinence, you may feel embarrassed. It may help you to remember that loss of bladder control can be treated. You will need to overcome your embarrassment and see a doctor to learn if you need treatment for an underlying medical condition.

Incontinence in women usually occurs because of problems with muscles that help to hold or release urine. The body stores urine--water and wastes removed by the kidneys--in the bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.

During urination, muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body (see figure 1). Incontinence will occur if your bladder muscles suddenly contract or muscles surrounding the urethra suddenly relax.

Image of bladder with different parts labeled

Figure 1.--Front view of bladder and sphincter muscles

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What are the types of incontinence?

Stress Incontinence

If coughing, laughing, sneezing, or other movements that put pressure on the bladder cause you to leak urine, you may have stress incontinence. Physical changes resulting from pregnancy, childbirth, and menopause often cause stress incontinence. It is the most common form of incontinence in women and is treatable.

Pelvic floor muscles support your bladder (see figure 2). If these muscles weaken, your bladder can move downward, pushing slightly out of the bottom of the pelvis toward the vagina. This prevents muscles that ordinarily force the urethra shut from squeezing as tightly as they should. As a result, urine can leak into the urethra during moments of physical stress. Stress incontinence also occurs if the muscles that do the squeezing weaken.

Stress incontinence can worsen during the week before your menstrual period. At that time, lowered estrogen levels might lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause.

Side view of female pelvis with organs labeled.

Figure 2.--Side view of female pelvic muscles

Urge Incontinence

If you lose urine for no apparent reason while suddenly feeling the need or urge to urinate, you may have urge incontinence. The most common cause of urge incontinence is inappropriate bladder contractions.

Medical professionals describe such a bladder as "unstable," "spastic," or "overactive." Your doctor might call your condition "reflex incontinence" if it results from overactive nerves controlling the bladder.

Urge incontinence can mean that your bladder empties during sleep, after drinking a small amount of water, or when you touch water or hear it running (as when washing dishes or hearing someone else taking a shower).

Involuntary actions of bladder muscles can occur because of damage to the nerves of the bladder, to the nervous system (spinal cord and brain), or to the muscles themselves. Multiple sclerosis, Parkinson's disease, Alzheimer's disease, stroke, and injury--including injury that occurs during surgery--all can harm bladder nerves or muscles.

Functional Incontinence

People with functional incontinence may have problems thinking, moving, or communicating that prevent them from reaching a toilet. A person with Alzheimer's disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may be blocked from getting to a toilet in time. Conditions such as these are often associated with age and account for some of the incontinence of elderly women in nursing homes.

Overflow Incontinence

If your bladder is always full so that it frequently leaks urine, you have overflow incontinence. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Overflow incontinence is rare in women.

Other Types of Incontinence

Stress and urge incontinence often occur together in women. Combinations of incontinence--and this combination in
particular--are sometimes referred to as "mixed incontinence."

"Transient incontinence" is a temporary version of incontinence. It can be triggered by medications, urinary tract infections, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow.

The Types of Urinary Incontinence

Stress   Leakage of small amounts of urine during physical movement (coughing, sneezing, exercising).
Urge   Leakage of large amounts of urine at unexpected times, including during sleep.
Functional   Untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet.
Overflow   Unexpected leakage of small amounts of urine because of a full bladder.
Mixed   Usually the occurrence of stress and urge incontinence together.
Transient   Leakage that occurs temporarily because of a condition that will pass (infection, medication).

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How is incontinence evaluated?

The first step toward relief is to see a doctor who is well acquainted with incontinence to learn the type you have. A urologist specializes in the urinary tract, and some urologists further specialize in the female urinary tract. Gynecologists and obstetricians specialize in the female reproductive tract and childbirth. A urogynecologist focuses on urological problems in women. Family practitioners and internists see patients for all kinds of complaints. Any of these doctors may be able to help you.

To diagnose the problem, your doctor will first ask about symptoms and medical history. Your pattern of voiding and urine leakage may suggest the type of incontinence. Other obvious factors that can help define the problem include straining and discomfort, use of drugs, recent surgery, and illness. If your medical history does not define the problem, it will at least suggest which tests are needed.

Your doctor will physically examine you for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.

Your doctor will measure your bladder capacity and residual urine for evidence of poorly functioning bladder muscles. To do this, you will drink plenty of fluids and urinate into a measuring pan, after which the doctor will measure any urine remaining in the bladder. Your doctor may also recommend

  • Stress test--You relax, then cough vigorously as the doctor watches for loss of urine.

  • Urinalysis--Urine is tested for evidence of infection, urinary stones, or other contributing causes.

  • Blood tests--Blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.

  • Ultrasound--Sound waves are used to "see" the kidneys, ureters, bladder, and urethra.

  • Cystoscopy--A thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.

  • Urodynamics--Various techniques measure pressure in the bladder and the flow of urine.

Your doctor may ask you to keep a diary for a day or more, up to a week, to record when you void. This diary should note the times you urinate and the amounts of urine you produce. To measure your urine, you can use a special pan that fits over the toilet rim.

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How is incontinence treated?

Exercises

Kegel exercises to strengthen or retrain pelvic floor muscles and sphincter muscles can reduce or cure stress leakage. Women of all ages can learn and practice these exercises, which are taught by a health care professional.

Most Kegel exercises do not require equipment. However, one technique involves the use of weighted cones. For this exercise, you stand and hold a cone-shaped object within your vagina. You then substitute cones of increasing weight to strengthen the muscles that help keep the urethra closed.

Electrical Stimulation

Brief doses of electrical stimulation can strengthen muscles in the lower pelvis in a way similar to exercising the muscles. Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles. This will stabilize overactive muscles and stimulate contraction of urethral muscles. Electrical stimulation can be used to reduce both stress incontinence and urge incontinence.

Biofeedback

Biofeedback uses measuring devices to help you become aware of your body's functioning. By using electronic devices or diaries to track when your bladder and urethral muscles contract, you can gain control over these muscles. Biofeedback can be used with pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.

Timed Voiding or Bladder Training

Timed voiding (urinating) and bladder training are techniques that use biofeedback. In timed voiding, you fill in a chart of voiding and leaking. From the patterns that appear in your chart, you can plan to empty your bladder before you would otherwise leak. Biofeedback and muscle conditioning--known as bladder training--can alter the bladder's schedule for storing and emptying urine. These techniques are effective for urge and overflow incontinence.

Medications

Medications can reduce many types of leakage. Some drugs inhibit contractions of an overactive bladder. Others relax muscles, leading to more complete bladder emptying during urination. Some drugs tighten muscles at the bladder neck and urethra, preventing leakage. And some, especially hormones such as estrogen, are believed to cause muscles involved in urination to function normally.

Some of these medications can produce harmful side effects if used for long periods. In particular, estrogen therapy has been associated with an increased risk for cancers of the breast and endometrium (lining of the uterus). Talk to your doctor about the risks and benefits of long-term use of medications.

Pessaries

A pessary is a stiff ring that is inserted by a doctor or nurse into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less stress leakage. If you use a pessary, you should watch for possible vaginal and urinary tract infections and see your doctor regularly.

Implants

Implants are substances injected into tissues around the urethra. The implant adds bulk and helps to close the urethra to reduce stress incontinence. Collagen (a fibrous natural tissue from cows) and fat from the patient's body have been used. Implants can be injected by a doctor in about half an hour using local anesthesia.

Implants have a partial success rate. Injections must be repeated after a time because the body slowly eliminates the substances. Before you receive collagen, a doctor must perform a skin test to determine whether you would have an allergic reaction to the material.

Surgery

Doctors usually suggest surgery to alleviate incontinence only after other treatments have been tried. Many surgical options have high rates of success.

Most stress incontinence results from the bladder dropping down toward the vagina. Therefore, common surgery for stress incontinence involves pulling the bladder up to a more normal position. Working through an incision in the vagina or abdomen, the surgeon raises the bladder and secures it with a string attached to muscle, ligament, or bone.

For severe cases of stress incontinence, the surgeon may secure the bladder with a wide sling. This not only holds up the bladder but also compresses the bottom of the bladder and the top of the urethra, further preventing leakage.

In rare cases, a surgeon implants an artificial sphincter, a doughnut-shaped sac that circles the urethra. A fluid fills and expands the sac, which squeezes the urethra closed. By pressing a valve implanted under the skin, you can cause the artificial sphincter to deflate. This removes pressure from the urethra, allowing urine from the bladder to pass.

Catheterization

If you are incontinent because your bladder never empties completely (overflow incontinence) or your bladder cannot empty because of poor muscle tone, past surgery, or spinal cord injury, you might use a catheter to empty your bladder. A catheter is a tube that you can learn to insert through the urethra into the bladder to drain urine. Catheters may be used once in a while or on a constant basis, in which case the tube connects to a bag that you can attach to your leg. If you use a long-term (or indwelling) catheter, you should watch for possible urinary tract infections.

Other Procedures

Many women manage urinary incontinence with pads that catch slight leakage during activities such as exercising. Also, you often can reduce incontinence by restricting certain liquids, such as coffee, tea, and alcohol.

Finally, many women who could be treated resort instead to wearing absorbent undergarments, or diapers--especially elderly women in nursing homes. This is unfortunate, because diapering can lead to diminished self-esteem, as well as skin irritation and sores. If you are an elderly woman, you and your family should discuss with your doctor the possible effectiveness of treatments such as timed voiding, pelvic muscle exercises, and electrical stimulation before resorting to absorbent pads or undergarments.

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Points to Remember

  • Urinary incontinence is common in women.
  • All types of urinary incontinence can be treated.
  • Incontinence can be treated at all ages.
  • You need not be embarrassed by incontinence.

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Treatments for Urinary Incontinence in Women
Image of front view of female urinary tract.

Front view of female urinary tract.

Millions of women experience loss of bladder control, also called urinary incontinence (UI). Some women may lose a few drops of urine while running or coughing. Others may feel a strong, sudden urge to urinate just before losing a large amount of urine. UI can be slightly bothersome or totally debilitating. For some women, the risk of public embarrassment keeps them from enjoying many activities with their family and friends.

UI is a medical problem. Your doctor or nurse can help you find a solution. No single treatment works for everyone, but most women can be treated without surgery. The treatment you select depends on your lifestyle and your preferences. Many women try the simpler treatment options first, such as changing a few habits and doing exercises to strengthen the muscles that hold urine in the bladder. If these behavioral treatments do not work, you may choose to try medicines or vaginal devices. Sometimes mild electrical stimulation to the pelvic nerves may help. And for some women, surgery is the best solution.

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Behavioral Remedies: Bladder Retraining and Kegel Exercises

Your doctor or nurse may ask you to keep a bladder diary--a record of your fluid intake, trips to the bathroom, episodes of urine leakage, and an estimate of the amount of leakage. By looking at this record, the doctor may see a pattern and suggest making it a point to use the bathroom at regular timed intervals, a habit called timed voiding. As you gain control, you can extend the time between scheduled trips to the bathroom. Behavioral treatment also includes Kegel exercises to strengthen the muscles that help hold in urine.

How do you do Kegel exercises?

The first step is to find the right muscles. Imagine that you are sitting on a marble and want to pick up the marble with your vagina. Imagine "sucking" the marble into your vagina.

Try not to squeeze other muscles at the same time. Be careful not to tighten your stomach, legs, or buttocks. Squeezing the wrong muscles can put more pressure on your bladder control muscles. Just squeeze the pelvic muscles. Don't hold your breath. Do not practice while urinating.

Repeat, but don't overdo it. At first, find a quiet spot to practice--your bathroom or bedroom--so you can concentrate. Pull in the pelvic muscles and hold for a count of 3. Then relax for a count of 3. Work up to 3 sets of 10 repeats. Start doing your pelvic muscle exercises lying down. This is the easiest position to do them because the muscles do not need to work against gravity. When your muscles get stronger, do your exercises sitting or standing. Working against gravity is like adding more weight.

Be patient. Don't give up. It takes just 5 minutes a day. You may not feel your bladder control improve for 3 to 6 weeks. Still, most people do notice an improvement after a few weeks.

Some people with nerve damage cannot tell whether they are doing Kegel exercises correctly or not. If you are not sure, ask your doctor or nurse to examine you while you try to do them. If it turns out that you are not squeezing the right muscles, you may still be able to learn proper Kegel exercises by doing special training with biofeedback, electrical stimulation, or both.

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Medicines for Overactive Bladder

Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without warning. Normal women may void up to 12 times a day, but women with overactive bladder may find that they must urinate more frequently. Specifically, the symptoms of overactive bladder include

  • urinary frequency--urination 13 or more times a day or 2 or more times at night
  • urinary urgency--the sudden, strong need to urinate immediately
  • urge incontinence--leakage or gushing of urine that follows a sudden, strong urge

If you have an overactive bladder, your doctor may prescribe a medicine to block the nerve signals that cause frequent urination and urgency.

Drugs that relax muscles and prevent bladder spasms include oxybutynin chloride (Ditropan) and tolterodine tartrate (Detrol), which belong to the class of drugs called bladder relaxants. Their most common side effect is dry mouth, although larger doses may cause blurred vision, constipation, a faster heartbeat, and flushing. Ditropan XL and Detrol LA are long-acting drugs that can be taken once a day.

Imipramine hydrochloride (Tofranil), a tricyclic antidepressant that relaxes bladder muscles and tightens urethral muscles, may be used instead of or in combination with Ditropan XL or Detrol LA. Side effects may include fatigue, dry mouth, dizziness, blurred vision, nausea, and insomnia.

If you take medicine to treat an overactive bladder, you should take several precautions.

  • Wear sunglasses if your eyes become more sensitive to light.
  • Take care not to become overheated.
  • Chew gum or suck on sugarless hard candy to avoid dry mouth.

Different medicines can affect the nerves and muscles of the urinary tract in different ways. Pills to treat swelling (edema) or high blood pressure may increase your urine output and contribute to bladder control problems. Talk with your doctor; you may find that taking an alternative to a medicine you already take may solve the problem without adding another prescription.

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Electrical Stimulation for Nerve Problems

Mild electrical pulses can be used to stimulate the nerves that control the bladder and sphincter muscles. Depending on which nerves the doctor plans to treat, these pulses can be given through the vagina or by using patches on the skin. Other forms of electrical stimulation or neuromodulation are also available.

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Front view of bladder. Weak pelvic muscles allow urine leakage.

Front view of bladder. Weak pelvic muscles allow urine leakage.

Strong pelvic muscles keep the urethra closed.

Strong pelvic muscles keep the urethra closed.

Vaginal Devices for Stress Incontinence

Stress incontinence is urine leakage that occurs when an action puts pressure on the bladder. Laughing, sneezing, coughing, rising from a chair, lifting an object, and running can all cause the stomach muscles to press down on the bladder and force urine out. Stress incontinence usually results from weak pelvic muscles, the muscles that hold the bladder in place and keep urine inside.

A pessary is a stiff ring that is inserted by a doctor or nurse into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less stress leakage. If you use a pessary, you should watch for possible vaginal and urinary tract infections and see your doctor regularly.

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Injections for Stress Incontinence

Collagen, one of the bulking agents used for injections, is a natural tissue from cows. It is injected into tissues around the bladder neck and urethra to add bulk and close the bladder opening to reduce stress incontinence. After using local anesthesia or sedation, a doctor can inject the material in about half an hour. Over time, the body slowly eliminates the collagen, so you may need repeat injections. Before you receive collagen, a doctor will perform a skin test to determine whether you could have an allergic reaction to the material. A variety of bulking agents are available for injection. Your doctor will discuss which one may be best for you.

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Surgery for Stress Incontinence

In some women, the bladder can move out of its normal position, especially following childbirth. Surgeons have developed different techniques for supporting the bladder in its normal position. The two main types of surgery are retropubic suspension and the sling procedure.

Retropubic suspension uses sutures (surgical threads) to support the bladder neck. The threads are secured to the pubic bone and other structures within the pelvis to form a cradle for the bladder. To place the sutures, the surgeon makes an incision in the abdomen a few inches below the navel.

Sling procedures are performed through a vaginal incision. The conventional sling procedure uses a strip of material to support the bladder neck. The sling may be made of natural tissue or synthetic (man-made) material. Both ends of the sling are attached to the pubic bone or tied in front of the abdomen just above the pubic bone. Another sling method uses a synthetic tape, but the ends are not tied but rather pulled up above the pubic bone.

Surgeons report that the retropubic suspension and sling procedures cure stress incontinence for at least 4 years in more than 80 percent of their cases. Possible side effects include persistent stress incontinence, bladder overactivity, and voiding changes.

Talk with your doctor about whether surgery will help your condition and what type of surgery is best for you. The procedure you choose may depend on your own preferences or on your surgeon's experience. Ask what you should expect after the procedure. You may also wish to talk to someone who has recently had the procedure.

Side view. Supporting sutures in place following retropubic or transvaginal suspension.

Side view. Supporting sutures in place following retropubic or transvaginal suspension.

Sling in place, secured to the pubic bone.

Sling in place, secured to the pubic bone.

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Urinary Incontinence