Chapter One: Defining Incontinence
WHAT IS INCONTINENCE?
Incontinence is the uncontrollable loss of enough urine to cause social or sanitary difficulties. When we study the body and look at how we control urination, we know that an infant does not have the proper connections between its brain and bladder to be able to control the bladder. We also know that as the brain develops, young children can be taught to control when and where they empty their bladders. This learned control is then maintained, usually without much thought, throughout adulthood. To a child or an adult, any loss of bladder control feels like a return to infancy and can be an embarrassment and a source of terrible discomfort.
Incontinence can be a significant problem for young, middle-aged, and older women. Life with incontinence, even mild incontinence, can become very stressful as it threatens self-image, body image, and self-esteem. Concerns about having to deal with incontinence may hinder career opportunities for women in the workforce. The embarrassing loss of self-control makes a woman feel old and helpless. Outings for shopping and recreation may be planned around the availability of bathrooms. Travel to new places becomes difficult. Having a change of clothes handy and worrying about odor are constant concerns. Worst of all, women suffering from incontinence may stop some of the activities they enjoy altogether; they may avoid getting together with friends or family and having sexual contact altogether. Understandably, they may feel depressed.
Many people consider adult incontinence a natural part of aging. It is not! The vast majority of older women do not have incontinence. Most people are not aware that young women can also have incontinence. Since incontinence is so frequently associated with aging, younger women are even less likely to talk about it or seek treatment. The good news is that there are now many ways to treat women of all ages who have incontinence.
IS ALL INCONTINENCE THE SAME?
Incontinence is a symptom -- the loss of urine. The two most common types of incontinence are loss of urine with laughing, coughing, or sneezing, called stress incontinence, and loss of urine preceded by a strong urge to go, called urge incontinence or overactive bladder. Sometimes a woman has both types of incontinence at the same time. This combination of types of incontinence is called mixed incontinence. Different types of incontinence have different causes, and different treatments solve each type. The first step toward ending incontinence is for your doctor to determine which type of incontinence you have. This begins with your answering questions about your symptoms. Following that, a number of simple tests are performed to help pinpoint the nature of the problem, which we will discuss in Chapter 3. But first, it will be helpful to understand what the possible types of incontinence are. The chart below gives brief definitions of the types of incontinence. More detailed explanations follow.
TYPES OF INCONTINENCE
STRESS incontinence: Urine loss with some type of physical stress to the body such as with a cough, sneeze, physical activity, or laughing.
URGE incontinence: Urine loss preceded by a sense of needing to urinate before reaching the bathroom.
MIXED incontinence: Urine loss with features of both stress and urge.
OVERFLOW incontinence: Urine loss occurring when the bladder is full but the bladder does not contract properly to push the urine out. The urine then trickles out of the overfull bladder.
TOTAL incontinence: The constant loss of urine.
WHAT HAPPENS WHEN A LAUGH, COUGH, OR SNEEZE CAUSES LEAKING?
You may have noticed that sometimes a loss of urine occurs as a result of a cough, sneeze, laugh, or vigorous exercise. Many women with this problem, known as stress incontinence, may begin limiting their own activities for just this reason. However, coughing, sneezing, and even laughing are often unavoidable. We need to laugh and exercise (and cough and sneeze) to live life to its fullest. Understanding stress incontinence is the first step toward finding a solution.
Stress incontinence got its name because the pressure or strain from a laugh or cough results in a loss of urine. The bladder and urethra are normally held firmly in place by muscles and connecting tissue in the pelvis (Figure 1-1). When you cough, the pressure inside your abdomen increases, and the pressure pushes on your bladder and urethra. If the supporting pelvic muscles or connecting tissues have been damaged or weakened, they may not be able to withstand the force of the cough. The pressure then forces the urethra to open, and urine leaks out (Figure 1-2). Many activities that you ordinarily wouldn't even think about can cause increased pressure in the abdomen and the bladder. Coughing, straining to lift a heavy piece of luggage, aerobic exercise, or even a hiccup can challenge a woman with this problem.
WHAT CAUSES STRESS INCONTINENCE?
As we discuss in Chapter 4, pregnancy and childbirth can damage the pelvic ligaments that anchor the uterus and bladder to the bones of the pelvis. The muscles that support the bladder work differently from most other muscles. Other muscles in your body usually relax until you ask them to do something for you, such as lifting a fork or bending at the waist. However, the pelvic muscles are always contracted so that they can continually hold up the bladder, uterus, and intestines. If these muscles, and the connecting tissue that attaches the muscles to the pelvic bones, are stretched or damaged, as may happen during childbirth, they become less effective at holding things up. The urethra may then be pushed out of position by a cough, sneeze, or strenuous activity because the muscle support cannot withstand the extra pressure.
The nerves sending messages from the brain to the pelvic muscles may also be altered due to childbirth. In the birth canal, the baby's head puts pressure on these nerves. Prolonged pressure, or undue pressure because of the size of the baby's head, may damage these nerves so they cannot send proper signals to the supporting muscles. As a result, the muscles may not be able to hold the bladder up.
Other factors may also cause increased pressure on the pelvic organs that probably contributes to incontinence. A family history of incontinence may be an important factor since the amount and strength of the collagen that makes up the supporting tissue is inherited. Smoking can decrease the amount of oxygen the muscles and ligaments get and thereby lead to weakened tissues. In addition, smokers often cough, and every cough pushes against the bladder and pelvic ligaments and, over time, may weaken them. If a woman is overweight, extra pressure is added to an already weakened system and may aggravate the problem of leakage. Chronic constipation, which causes straining to pass a bowel movement, also increases the abdominal pressure and can weaken the support of the bladder and pelvic organs.
In some women, the hormonal changes that occur with menopause can cause thinning of the tissues and blood vessels of the urethra. Try to visualize the urethra as a tube -- if you were to cut across it, the cross section would look like a doughnut. With declining estrogen levels, the walls of this tube shrink, resulting in a larger hole. The larger the opening, the more difficult it is for the muscles to seal. If the urethra is not closed, urine can leak out (Figure 1-3).
Any one or more of these factors -- stretched pelvic muscles, excess body weight, damaged nerves, or thinning of the urethra -- may lead to stress incontinence. As you will see in later chapters, treatment for this type of incontinence involves strengthening the pelvic muscles or repairing the supporting tissues to the bladder and urethra.
WHAT IF YOU HAVE THE URGE TO URINATE FREQUENTLY?
Urgency is the sense that you have to urinate right now. When you gotta go, you gotta go. The constant urge to empty the bladder and all those trips to the bathroom can be disabling to many women. They do not necessarily leak urine, but their lives are nevertheless taken over by their bladder problems. Urgency is basically the result of the bladder misbehaving, of the bladder being overactive. In fact, the term overactive bladder is now frequently used instead of urgency. Instead of quietly collecting urine, the bladder is constantly making a nuisance of itself. This is perceived as ever-present bladder pressure. The bladder feels as if it is always full, but in fact most trips to the toilet produce no more than a few ounces of urine. Some women may note urgency during the night that wakes them repeatedly.
Urgency and frequency are frustrating problems. Many women suffer in silence because they do not realize that, thankfully, there are many solutions to their problem. These include taking prescription medication, learning to urinate on a schedule, and doing muscle exercises that can help reduce spasms. Simple dietary changes may also help reduce frequency and urgency. These nonsurgical treatments and others are fully discussed in Chapter 5.
HOW COMMON IS URGENCY?
Urgency is one area where age does seem to make a difference. About 6 percent of women under forty have symptoms of urgency, and about 10 percent of women have this symptom prior to menopause. By the time women reach their late fifties and early sixties, about 40 percent will have urgency. And by the time women reach their eighties, nearly 80 percent have this problem. About 40 percent of women who develop urgency also have urge incontinence, meaning urgency to the degree that they may actually lose urine.
WHAT CAUSES A STRONG URGE TO URINATE?
The most common temporary cause of having a strong urge to urinate is a bladder infection. The infection causes an irritation of the bladder lining that leads to spasms of the bladder muscle. However, the bladder irritation and urgency go away once the infection is treated with antibiotics. Only rarely does a bladder infection lead to such severe urgency that incontinence results. If treated, these infections have no permanent effect on your bladder.
Unlike with stress incontinence, childbirth does not appear to play any role in the development of urgency. Most women's urgency problems are not easily explained. A number of theories suggest what the causes might be, but none have been proven. Some researchers focus on the nerve signals to the bladder. They suggest that some women may have a mild, probably age-related, change in the nerves or the chemical signals between the nerves that leads to overactivity of the bladder. Some propose that the problem is rooted in the muscle cells of the bladder itself, which may be overactive. This theory is supported by the fact that about 50 percent of women with urge incontinence also have a similar problem with their intestines called irritable bowel syndrome. The overactivity of the muscle cells in the intestines that occurs with irritable bowel syndrome leads to abdominal cramping.
Some women have overactivity of the bladder from causes that are easier to establish. Women who have had multiple surgeries to correct incontinence are at a slightly higher risk of developing urgency and urge incontinence. In these women, the bladder nerves may be injured after being pulled, stretched, or even cut at the time of surgery. In others, previous surgery may have caused scar tissue to block the flow of urine out of the bladder. The bladder then needs to work harder to get the urine out past the scar tissue, and the overworked bladder muscle may function poorly.
Another condition associated with bothersome frequency and urgency is called interstitial cystitis, or IC. IC may also be associated with recurrent discomfort or pain in both the bladder and the nearby pelvic area. Interstitial cystitis is fully discussed in Chapter 7.
Conditions affecting the nervous system, such as Parkinson's disease, multiple sclerosis, Alzheimer's disease, or stroke, may also cause urge incontinence. Other rare conditions such as benign polyps or stone formation in the bladder can also lead to urgency and incontinence. These problems can easily be evaluated with a cystoscope, a small telescope that allows the doctor to look into the bladder. This office procedure, called a cystoscopy, takes only a few minutes. Prior to insertion of the cystoscope, a topical anesthetic in a gel form is inserted into the urethra in order to relieve discomfort. With the cystoscope, we can see irritation from interstitial cystitis or the presence of a bladder stone, bladder cancer, or overgrown bladder lining cells that form polyps.
WHAT IF THERE'S A STRONG URGE TO URINATE AND THEN YOU LOSE CONTROL?
Normally you make a conscious decision about when to empty your bladder. When you get the feeling that your bladder is full, you control the urge to urinate and make it to the bathroom in time. However, some women have an overactive bladder that tries to empty on its own, often without much warning. If you feel a bladder contraction that causes such a strong sense of urgency that you cannot control it, you may lose urine before you can get to the bathroom. This is called urge incontinence. The causes of this problem are similar to those described for urgency.
Some women may have urge incontinence when they put their hands in running water or hear water running. Some note urge incontinence when they change position rapidly, such as when they get up quickly from a chair. Others get urge incontinence when they return home with a full bladder, park the car, rush to the front door, and put the key in the door. The anticipation of relief triggers a bladder spasm. This is so common it has a name, "key-in-the-door incontinence." Women with urge incontinence report that it affects the quality of their lives more than do women who have stress incontinence, depression, or even diabetes. Urge incontinence often results in a larger amount of lost urine than stress incontinence and is often unpredictable. While you may be able to brace yourself when you are about to laugh or cough and prevent loss of urine from stress incontinence, there is little warning with urge incontinence. By the time you realize what is happening, it is too late. Hence, women with this problem are often subject to embarrassing accidents.
This is no small problem. The unpredictability often causes women to stay at home near a bathroom or to limit their activities to places where a bathroom will immediately be available. They may dress in dark colors that hide wetness. Fear of odor or loss of urine during intercourse may lead to avoidance of intimacy. This often leads to isolation and depression. Urge incontinence may occur at night, resulting in a wet bed that needs to be changed. Disturbed sleep and the resulting fatigue are common in women with this problem. Women with urge incontinence feel terrible about their condition but often delay seeing a doctor because they are depressed and feel helpless. These women are not aware of the available treatments, all nonsurgical, that are now used to help women with urge incontinence. A discussion of these treatments can be found in Chapter 5.
WHAT CAN CAUSE LEAKAGE WITH EVEN MINOR ACTIVITY?
Some women have very frequent leakage. They often leak when their bladders are full, but they may also leak when their bladders are nearly empty. They may leak when they cough or sneeze, but sometimes they also note leakage even when they are lying down. These symptoms may result from a condition called intrinsic sphincter deficiency, or ISD. Women with this problem are often understandably miserable.
Although this is a relatively rare problem, it has a number of possible causes. The problem exists in the urethral sphincter, the muscles and soft tissue that surround the urethra and hold the urine in the bladder (Figure 1-4). The muscles are normally squeezed closed, continuously shutting off the flow of urine. The urethra, which is shaped like a tube, is lined with soft, cushioning tissue that helps to form a watertight seal. When you laugh or sneeze, the muscles around the urethra resist the added pressure. The muscles are supposed to relax only when you are ready to urinate.
However, prior injury to the muscles or soft tissues can weaken the watertight seal and may allow urine to leak out (Figure 1-5). This type of incontinence is called intrinsic sphincter deficiency because it is the watertight seal (the sphincter) that is not functioning properly (is deficient). One cause of this problem, ironically enough, is the result of previous surgery for incontinence. The healing process following surgery around the bladder and urethra may sometimes lead to scar tissue, which is much less supple than normal tissue. In rare cases, excessive scar tissue may be formed. This can pull on the urethra and actually hold it open, allowing urine to leak out. In addition, the small nerves that carry signals to the urethra are not visible and may be inadvertently stretched or cut during surgery. Formation of scar tissue is not the result of poor surgical skills on the part of your doctor, but rather an unusual and unfortunate consequence of the body's healing process.
Another cause of this type of incontinence is radiation treatment for cancer. Radiation applied to the pelvic area can damage small blood vessels in the area, reducing the blood flow. Over time, often many years later, the radiation damage to the urethra can lead to thinning of the cushioning tissue that forms the watertight seal. As a result, the urethra does not close entirely, and incontinence is the result.
Age also appears to play a role in the development of ISD. As you age, the elasticity of the tissues decreases, and the watertight seal may not close off entirely. This type of very troubling incontinence probably results from a combination of aging, previous surgery, and radiation that eventually is significant enough to cause incontinence. The good news is that there are now a number of ways to help correct ISD (see Chapter 6).
f0 Alice's Story
Tiny, quiet Alice came in to our office accompanied by her dutiful but frustrated son Dennis. At ninety-seven years of age, Alice was blessed with a relatively sound body and a sound mind. Her bladder, however, was no blessing to her.
Ordinarily, Alice spent half the year in Los Angeles with Dennis and his family. For the other half of the year, she always traveled up to Oregon and stayed with her daughter Diane and her family. Winter and spring in Los Angeles, summer and fall in Oregon had been her routine for almost twenty years. This year, however, Alice would not leave her son's house for even an hour due to severe, constant loss of urine.
In her quiet way she made it clear that she had no intention of going to Oregon in this condition. Being wet all the time was naturally making her unhappy. The entire family was in an uproar, alternately worried about "this deterioration" and frustrated about her stubbornness. The seasonal routine was comfortable, and everyone was upset and fearful that it was over forever. This year had an extra significance since Alice's great-granddaughter Laurel was planning to be married in a great big June wedding, wearing lace from the bridal veil Alice herself had been married in seventy-six years before. During the months of planning, everyone was keeping their fingers crossed that great-grandma Alice would be there for the big day. As Dennis said, "It doesn't seem fair that after all she's been through in ninety-seven years, it comes down to wetting her pants." The big question in everyone's mind was "What can you do for a ninety-seven-year-old?"
Surgery as a solution to her incontinence seemed risky at her age. Nor did she want to put up with any recovery period, no matter how short. With a tremble in her chin, Alice said she knew that nothing could be done and she would just have to miss the wedding. But, as Dennis pointed out, the wedding was only a small part of the problem. Alice was now no longer willing to leave the house, and she was irritable and unhappy all the time. She had come today partly to get Dennis off her back, but now that she was in the office, she plaintively asked, "Is there any hope for me, doctor?"
We fully evaluated Alice with a complete history and physical. She was in remarkably good physical condition for her age. Her examination showed that there was some mild bulging of the bladder into the vagina. A complete evaluation, called urodynamic testing, showed that as we filled her bladder with fluid, it began to have spasms (overactivity) that led to urine leakage. The test also found that she had a very weak bladder sphincter. In thinking about the whole situation, we decided that collagen injections into the urethra would be the best bet for her. This procedure would help close off the urethral sphincter and could be performed under mild sedation in the hospital. She could get back home the same day, and the recovery would be painless and would last only a day. This solution would do nothing for the bulging bladder or its overactivity, but it would afford her extended periods of dryness each day. Alice and Dennis eagerly leapt at this "good enough" solution, and we proceeded with the collagen. Between her good physical health and her positive attitude, Alice recuperated quickly and was thrilled with the results. She still had some problems with the overactive bladder, but they were manageable. Within a few days she was taking an outing every day and was busy planning for the summer. She wore a pad for insurance and would need to have another collagen injection in a few months, but at her age she wasn't going to concern herself with that. In early June, Alice happily went off to Oregon, eagerly anticipating Laurel's wedding day.
WHAT IF YOU LEAK URINE ALL THE TIME?
In rare cases, women will note that they lose small amounts of urine all the time. Many of these women have no sensation that they are losing urine. Some note that when they try to urinate, the stream is weak or they only dribble. Pressing on the bladder or straining may be necessary in order to pass urine. This type of incontinence, called overflow incontinence, can be caused by a partial blockage of the flow of urine out of the bladder.
How can a blockage lead to the loss of urine? The blockage prevents you from fully emptying your bladder. As your kidneys make more urine, the bladder fills to capacity. Since the extra urine has nowhere to go, it pushes the watertight seal in the urethra open and urine trickles out, like water going over a dam. Women with this problem may also have frequent bladder infections because the trapped urine becomes a reservoir for bacteria that can multiply and cause an infection. Though a rare condition in women, overflow incontinence is much more common in older men. As men age, they often suffer from enlargement of the prostate gland. The prostate blocks the flow of urine out of the bladder, and the result is a constant trickle of urine.
WHAT CAN CAUSE YOU TO LEAK ALL THE TIME?
This is a rare condition, but there are a number of possible causes. Anything that blocks the urethra can lead to this condition. If the bladder drops (called cystocele or prolapse) and kinks the urethra, the kinking can prevent you from fully emptying your bladder. You may feel that your bladder is quite full, but as you attempt to urinate, only a small amount of urine is passed, and you do not feel empty. When your bladder fills to capacity, any additional urine leaks out, resulting in overflow incontinence. If kinking of the urethra is the problem, straightening out the bladder with a pessary or surgery will allow the bladder to empty properly and the problem will resolve.
In younger women, a contraceptive diaphragm can press on the urethra, making it difficult to empty the bladder with the diaphragm in place. Of course, if you remove the diaphragm, the blockage will be relieved and the problem will be fixed. Women who use a pessary may rarely notice a similar problem. On very rare occasions, a bladder infection makes urination so painful that you may hold urine in to avoid the pain. A herpes infection that occurs near the urethra can cause swelling and block the flow of urine. Over time the urine builds up until it dribbles out. These are just temporary situations that fade when the infections resolve.
Overflow incontinence is sometimes caused by an injury to the nerves that go to the bladder. This might be a temporary but severe injury to your back that puts pressure on the spinal cord or a permanent injury that might be the result of a serious accident that results in paralysis. Diseases that can affect the bladder nerves, such as multiple sclerosis, diabetes, or alcoholism, can interfere with the nerve signals to the bladder. If the proper messages cannot get from the brain to the bladder, the bladder cannot contract properly, and urine fills the bladder to the point of overflow.
Some medications can affect the nerve signals to the bladder. Though uncommon, medications such as anticonvulsants, antidepressants, or drugs for heart conditions, allergic conditions, or chemotherapy may sometimes lead to this type of incontinence. For this reason, it is a good idea to bring a list of your medications to the doctor when you are being treated for incontinence.
Another type of constant leaking occurs when the urethral muscle, the sphincter, doesn't ever close completely. This type of incontinence is called total incontinence. This is a very rare problem, sometimes related to an injury to the sphincter during childbirth or from previous surgery near the bladder. One more very rare cause of total incontinence is a fistula, a hole in the bladder that drains into the vagina. This problem can result from a difficult childbirth in which the vagina and bladder are torn, or it may result from an operation near the bladder, vagina, or uterus.
Although this sounds as though total incontinence may be caused by any number of things, it is actually very rare. Treatment for this condition is available using medications and, in some cases, surgery.
Copyright © 2002 by William H. Parker, M.D., and Rachel Parker