Urinary Incontinence

Jumping jacks, coughing, laughing...they all seem a little wetter lately. Or perhaps when you need to go, you really need to go. And I mean now. Right now. Whatever the reason for your urine leakage, it can be frustrating and embarrassing. Many women might feel as though they are alone in their experience, but rest assured, urine leakage, or urinary incontinence, is a common issue affecting 25% of young women, up to 57% of middle aged women, and 75% of older women.

Incontinence even comes in four different types: stress incontinence, urge incontinence, mixed incontinence, and overflow incontinence. This week, we’ll discuss all about the different types of incontinence, their treatments, and what you can do at home to help prevent incontinence.

Urinary incontinence, or urine leakage, can occur in different amounts and for different reasons. In small amounts, this issue is little more than a bother, but in large amounts it can become a serious issue that interferes with sleep, social outings, exercise, and other everyday activities. Despite the fact that this issue is very common, less than half of women who experience incontinence seek care for their symptoms. I’d like to urge all women to not feel ashamed of their symptoms and seek treatment for you are not alone and there is treatment and potentially ways to try and prevent incontinence in early stages.

Types of Urinary Incontinence

Stress Incontinence

Stress incontinence is the loss of urine when stress is placed in the bladder via cough, laugh, sneeze, and/or exercise.

Cause: Weakened support of the tissues that support the bladder and weakening of the muscles of the urethra. Structures that help hold up the bladder include your pelvic floor muscles, vagina, and support ligaments. The pelvic floor muscles are especially important because they help the urethra close tightly shut. When the urethra cannot close shut, urine may leak out during certain activities like those mentioned above. The process of childbirth often weakens and stretches these supports for the bladder, especially if it is a large baby. Menopause also contributes to the weakening of these structures due to the loss of estrogen. Estrogen helps contribute to your pelvic floor muscle strength. Before your menstrual period, there is also a drop in estrogen, thus some women may be more likely to experience incontinence before their period.

Symptoms

• Urine loss with cough, laugh, sneeze, exercise

Urge Incontinence

Urge incontinence is also known as overactive bladder and causes an increased urge to go to the bathroom with increased frequency. Coffee, alcohol, other diuretics, and some medications can worsen urge incontinence. Conditions such as anxiety, hyperthyroidism, and uncontrolled diabetes can also worsen this type of incontinence.
Cause: Overactive bladder muscles or uncontrolled bladder muscle contractions cause this.  Sometimes problems with your nerves communicating to the bladder can be a cause of urge incontinence. Thus, conditions that affect the brain such as Parkinson’s, Alzheimer’s, stroke, or brain trauma can affect nerves that communicate with the bladder and cause urge incontinence. Estrogen also play a large role in this type of incontinence. Loss of estrogen due to menopause or other reasons causes the bladder to become easily irritated. Certain behaviors like consuming alcohol, caffeine, soda, aspartame, cigarette smoking, tomato, and citrus all contribute to urge incontinence. Additionally, there may be a genetic component in urge incontinence that needs more research. Lastly, being overweight or obese contributes to this incontinence.

Symptoms

• Urine loss for no reason
• Increased urge to urinate
• Hearing or touching water triggers the need to urinate
• Drinking small amounts of water causes you to urinate
• Interrupting sleep to use the bathroom
• Emptying the bladder during sleep

Mixed Incontinence

Mixed incontinence is a combination of stress and urge incontinence.

Overflow Incontinence

Overflow incontinence is slowly and steadily losing urine in small amounts when the bladder is not completely emptied or is too full and thus overflows. This type of incontinence is rare in women and is usually due to a neurologic condition.
Cause: Underactive bladder muscles as well as failure to completely empty the bladder can cause overflow incontinence. If the urethra is blocked, this type of incontinence can also occur. Conditions that may cause this are MS, spinal cord injuries, and age due to weak bladder muscle.

Symptoms

• Urine leakage for no reason
• Recurrent urinary tract infection

Treatment

Treatment for urinary incontinence is dependent on the type of incontinence and the severity of the issue. There are medical, surgical, physical, and several holistic/at home methods to treat and improve incontinence.

Holistic

At home, there are several methods you can try to help improve urinary incontinence and these should always be done first before trying medication or surgical remedies. These methods will not treat or get rid of urinary incontinence completely, especially when it is already severe, however it may improve your symptoms.

Kegel Exercises

Kegel exercises aren’t just something you read in Cosmopolitan magazine to help improve your sex life. They are exercises that strengthen your pelvic floor muscles and help improve urinary incontinence. By strengthening your pelvic muscles, you are helping your urethra be able to close more tightly and strengthening bladder supports. Kegel exercises improve stress, urge, and mixed incontinence and is an effective first line treatment. Studies show that of women who started kegel exercises, half were satisfied with the improvement in urinary incontinence after 1 year.

To do kegel exercises, squeeze the muscles in your pelvic floor that help stop the flow or urine, however, it is important not to practice these exercises while urinating. This can form bad habits.  Some women have difficulty finding these muscles and tend to push rather than squeeze. To help you locate the proper muscles, try inserting a finger into your vagina and squeezing. If you can feel a squeezing/tightening around your finger, you are doing the exercise correctly. You should not feel any sort of pushing but rather a tightening. Imagine yourself trying to grab something up with your vagina. This imaginative exercise can also help locate the pelvic floor muscles. If you are still unsure if you are finding the pelvic floor muscles, a nurse or gynecologist can help you locate the muscles in an office visit. Women with damage to their nerves may have more difficulty locating the muscles.

Squeeze the muscles and hold for 10 seconds. Repeat 10-20 times, 3 times per day. While you practice these exercises, try to relax. Relax all other muscles in your body and remember to breathe through the exercises. Do not strain or tighten your abs, butt, thighs, or any other muscle aside from the pelvic floor muscles. With consistent practice, most women will find improvement in incontinence within a few weeks, however some may not feel results for 6 weeks. If you do not feel results right away, do not give up! Simply practice little by little every day until you can feel your strength increasing. Just like any muscle you are trying to strengthen -- biceps, quads, glutes, etc. -- it takes time.

Bladder Training

The goal of bladder training is to literally train your bladder to need to empty at longer and specific intervals by making a timed schedule for yourself to urinate. This method was first thought to be effective only for urge incontinence, but is now known to be useful for stress and mixed incontinence. You can empty your bladder at timed intervals such as every 3-4 hours during the day and every 4-8 hours at night. These intervals may be extended.

Biofeedback

Biofeedback is a method that helps you become aware of your body’s functions. The hope is that by simply becoming aware of your bladder and when its muscles contract, you may gain better control over these muscles and involuntary contractions.

Weight Loss

Obesity is a large risk factor for urinary incontinence and obese women are over 4 times as likely to develop urinary incontinence than women with average body mass index (BMI) measurements. Many studies have shown that losing weight, even under 10% of your body weight is enough to reduce incontinence episodes. Healthy weight loss can be achieved in several methods. For tips, I recommend visiting the American Heart Association’s Dietary and Lifestyle Recommendations.

Other

• Avoid constipation (chronic constipation and the straining that goes with it puts pressure on the bladder and damages the pelvic floor muscles).
• Avoid diuretics such as coffee, tea, and alcohol
• Stop smoking
• Treat causes of cough and sneeze

Medical Treatments

Medical treatments for urinary incontinence include medications, pessaries, and surgery. Below we’ll review these options in more detail.

Medications

There are two different types of medication that help urinary incontinence. The first is best for urge incontinence and reduces muscular contractions of the bladder. The second type of medication helps reduce the frequency of urination.

Estrogen

As discussed above, estrogen plays a large role in urinary incontinence. Thus, one possible medical therapy that helps improve urinary incontinence is topical estrogen. Topical Estrogen is a method of applying the hormone directly to the area where it’s most needed and doesn’t allow much Estrogen to circulate in the blood stream. Topical estrogen comes in several forms including Estrogen creams and Estrogen rings.

Pessary

Pessaries act as a physical device to help hoist the bladder up into place. This method is effective, but is only for women who no longer wish to be sexually active or who are already sexually inactive. At an office visit, we fit women with a pessary that is the correct size and shape for you, personally. Studies have shown that, though pessaries are effective in improving the symptoms of stress and mixed incontinence, physical therapy exercises are 12% more effective than pessaries. Therefore, if you are capable and willing to adhere to a physical therapy regimen to strengthen the pelvic floor muscles, it is beneficial to try that method first.

Surgery

When stress incontinence is severe enough to interfere with everyday activities and even health, surgery may be needed. Sometimes severe urinary incontinence can cause urinary tract infections to frequently occur. At my office, I perform a procedure that requires only one small 1 inch incision in the vagina. This procedure uses a sling across the middle of the urethra to elevate the urethra and help lift it back into place so that less accidental urine loss will occur with cough, laugh, sneeze, etc. This procedure is highly effective with 85% effectiveness depending on the route of surgery. It is important to know, however, that surgical correction may not endure the woman’s lifetime and there is a chance that years later, a second procedure may be needed again if the pelvic floor continues to gradually weaken. Surgical treatment for urinary incontinence is known to be more effective than the holistic methods above, however the choice of surgery is an important one and women should consider the severity of their symptoms and overall health when making the decision for surgery. ​

Pelvic organ prolapse is also a problem many women with incontinence also have with about 80% of women with pelvic floor weakness also having stress incontinence. Thus, oftentimes if surgery is desired, both problems can be repaired while undergoing surgery for one problem or the other. Thus, women with both issues should highly consider both surgeries if already doing one.

Conclusion

Urinary incontinence is a problem that affects many women. 1 in 4 young women, about 1 in 2 middle aged women, and 3 in 4 older women are affected by urinary incontinence. Incontinence comes in several types: stress incontinence, urge incontinence, mixed incontinence, and overflow incontinence. Stress incontinence is the the loss of urine with cough, laugh, sneeze, etc and it caused by weakened bladder support, often due to childbirth. Urge incontinence is when the urge to urinate becomes fiercely strong and causes urine loss to occur. Mixed incontinence is a combination of the first two and overflow incontinence is when urine loss occurs when the bladder isn’t emptied completely or when the bladder is too full and overflows. Holistic treatments include kegel exercises, bladder training, weight loss, and other behavioral modifications. Medical treatments include medications, topical estrogen, pessaries, and surgery. Overall, this common problem is not one to be ignored and women should be comforted that they are not alone in their issue and that they can feel safe explaining their concerns to a medical professional.

References
Self
ACOG. Urinary Incontinence in Women. ACOG Practice Bulletin 155. 2015.
ACOG. Urinary Incontinence. ACOG FAQ081. 2011.
NIDDK. Urinary Incontinence in Women. NIH Pub: 08-4132. 2013.