Urinary Incontinence in Adults

In people with urinary incontinence, certain symptoms and characteristics are cause for concern. They include

People with warning signs should go to an emergency department at once. People without warning signs should call their doctor. The doctor will decide how quickly they need to be seen based on their other symptoms and other known conditions. In general, if incontinence is the only symptom, a delay of a week or so is not harmful.

Most people are embarrassed to mention incontinence to their doctors. Some people believe that incontinence is a normal part of aging. However, incontinence, even incontinence that has been present for some time or that occurs in an older person, may be helped by treatment. If symptoms of urinary incontinence are bothersome, interfere with activities of daily living, or cause people to curtail their social activities, people should see a doctor.

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the incontinence and the tests that may need to be done.

Doctors ask questions about the circumstances of urine loss, including amount, time of day, and any precipitating factors (such as coughing, sneezing, or straining). People are asked whether they can sense the need to urinate and, if so, whether the sensation is normal or comes with sudden urgency. Doctors may also ask the person to estimate the amount of urine leakage. Doctors will also ask whether the person has any additional problems with urination, such as pain or burning during urination, a frequent need to urinate, difficulty starting urination, or a weak urine stream.

Sometimes doctors may ask people to keep a record of their urination habits over a day or two. This record is called a voiding diary. Each time the person urinates, the volume and time are recorded. After an episode of incontinence, the person also records any related activities, especially eating, drinking, drug use, or sleep.

Doctors ask about whether the person has other disorders that are known to cause incontinence, such as dementia Dementia Dementia is a slow, progressive decline in mental function including memory, thinking, judgment, and the ability to learn. Typically, symptoms include memory loss, problems using language and... read more , stroke Overview of Stroke A stroke occurs when an artery to the brain becomes blocked or ruptures, resulting in death of an area of brain tissue due to loss of its blood supply (cerebral infarction) and symptoms that... read more , urinary tract stones Stones in the Urinary Tract Stones (calculi) are hard masses that form in the urinary tract and may cause pain, bleeding, or an infection or block of the flow of urine. Tiny stones may cause no symptoms, but larger stones... read more , spinal cord Overview of Spinal Cord Disorders Spinal cord disorders can cause permanent severe problems, such as paralysis or impaired bladder and bowel control ( urinary incontinence and fecal incontinence). Sometimes these problems can... read more or other neurologic disorders, and prostate disorders Benign Prostate Disorders . Doctors need to know what drugs a person is taking because some drugs cause or contribute to incontinence. Women are asked about number and types of deliveries and any complications. All are asked about previous pelvic and abdominal surgery, particularly prostate surgery in men.

The physical examination can help doctors narrow possible causes. Doctors test strength, sensation and reflexes in the legs, and sensation around the genitals and anus to detect nerve and muscle problems that may make it difficult for the person to remain continent.

In women, doctors do a pelvic examination to detect abnormalities that could cause incontinence, such as vaginal atrophy Symptoms after menopause Menopause is the permanent end of menstrual periods and thus of fertility. For up to several years before and just after menopause, estrogen levels fluctuate widely, periods become irregular... read more (menopausal changes in which the lining of the vagina becomes thinner, drier, and less elastic and may be accompanied by urinary tract changes) or weakness of pelvic muscles Pelvic Organ Prolapse (POP) Pelvic organ prolapse involves relaxation or weakening of the ligaments, connective tissue, and muscles of the pelvis, causing the bladder, urethra, small intestine, rectum, or uterus to bulge... read more . In men and women, doctors do a rectal examination to look for signs of constipation or damage to the nerves supplying the rectum. In men, the rectal examination allows doctors to check the prostate because an enlarged prostate Benign Prostatic Hyperplasia (BPH) Benign prostatic hyperplasia (BPH) is a noncancerous (benign) enlargement of the prostate gland that can make urination difficult. The prostate gland enlarges as men age. Men may have difficulty... read more or occasionally prostate cancer Prostate Cancer Prostate cancer begins in a small area of the prostate gland, an organ found only in males. The risk of prostate cancer increases as men age. Symptoms, such as difficulty urinating, a need to... read more can contribute to incontinence. The person may be asked to cough with a full bladder to detect whether stress incontinence Stress incontinence Urinary incontinence is involuntary loss of urine. Incontinence can occur in both men and women at any age, but it is more common among women and older people, affecting about 30% of older women... read more is present. Women may be asked to repeat this procedure during a pelvic examination, to see whether supporting some pelvic structures (with the doctor's fingers) eliminates the leak of urine.

Often findings during the physical examination can help doctors determine the cause or identify factors that contribute to incontinence. However, some tests are often needed so doctors can make a firm diagnosis. Routinely obtained tests include

Urodynamic testing includes cystometry, urinary flow rate testing, and cystometrography and is done when clinical evaluation and the above tests do not reveal the cause of incontinence.

Although urodynamic testing is important, results do not always predict response to drug treatment or assess the relative importance of multiple causes.

Regardless of the type and cause of incontinence, some general measures are usually helpful.

Fluid intake can be limited at certain times (for example, before going out or 3 to 4 hours before bedtime). Doctors may suggest that people avoid fluids that irritate the bladder (such as caffeine-containing fluids). However, people should drink 48 to 64 oz (1500 to 2000 mL) of fluid a day because concentrated urine irritates the bladder.

Bladder training is a technique that involves having the person follow a fixed schedule for urination while awake. The doctor works with the person to establish a schedule of urinating every 2 to 3 hours and suppressing the urge to urinate at other times (for example, by relaxing and breathing deeply). As the person becomes better able to suppress the urge to urinate, the interval is gradually lengthened. A similar technique, called prompted voiding, can be used by people who care for a person with dementia or other cognitive problems. In this, the person is asked whether they need to urinate and whether they are wet or dry at specific intervals.

Pelvic muscle exercises (Kegel exercises Exercises Pelvic organ prolapse involves relaxation or weakening of the ligaments, connective tissue, and muscles of the pelvis, causing the bladder, urethra, small intestine, rectum, or uterus to bulge... read more ) are often effective, especially for stress incontinence. People must be certain to exercise the correct muscles, the muscles around the urethra and rectum that stop the flow of urine. The muscles are tightly squeezed for 1 to 2 seconds and then relaxed for about 10 seconds. The exercises are repeated about 10 times three times each day. People are gradually able to increase the time the muscles are tightly squeezed until the contraction is held for about 10 seconds each time. Because it can be difficult to learn to control the correct muscles, doctors may need to provide instruction or recommend the use of biofeedback or electrical stimulation (an electronic version of pelvic floor exercises in which an electric current is used to stimulate the correct muscles).

The goal is to relax the bladder wall muscles. Bladder training, Kegel exercises, and relaxation techniques are tried first. Biofeedback also can be tried. With the urge to urinate, the person can try relaxing, standing in place or sitting down, or tightening the pelvic muscles. The most commonly used drugs are oxybutynin and tolterodine. Oxybutynin is available as a skin patch or skin gel as well as a pill. Newer drugs include mirabegron, fesoterodine, solifenacin, darifenacin, and trospium.

If other treatments are ineffective for urge incontinence, further treatments can be tried, such as gentle electrical stimulation of the sacral nerves by a device similar to a pacemaker, instillation of chemicals into the bladder (when the cause is a spinal cord or brain disorder), or, rarely, surgery.

Treatment usually begins with bladder training and Kegel exercises. Avoiding physical stresses that cause loss of urine (for example, heavy lifting) and losing weight may help control incontinence. Pseudoephedrine may be useful in women with bladder outlet incompetence. Imipramine may be used for mixed stress and urge incontinence Urge incontinence Urinary incontinence is involuntary loss of urine. Incontinence can occur in both men and women at any age, but it is more common among women and older people, affecting about 30% of older women... read more or for either separately. Duloxetine is also used for stress incontinence. If stress incontinence is caused by atrophic urethritis or vaginitis, estrogen cream is often effective. For people with stress incontinence, urinating frequently to avoid a full bladder is often helpful.

For stress incontinence that is not relieved with drugs and behavioral measures, surgery or devices such as pessaries may be helpful. The vaginal sling procedure creates a hammock of support to help prevent the urethra from opening during coughing, sneezing, or laughing. Most commonly, a sling is created from synthetic mesh. Mesh implants are effective, but a few people with mesh implants have serious complications. Alternatively, doctors can create a sling using tissue from the abdominal wall or leg. In men with stress incontinence, a mesh sling or an artificial urinary sphincter implant may be placed around the urethra to prevent leakage of urine.

Treatment depends on whether the cause is bladder outlet obstruction, weak bladder wall muscles, or both. For overflow incontinence caused by bladder outlet obstruction, specific treatments may help relieve obstruction (for example, surgery or drugs for prostate disease, surgery for cystocele, and dilation or stenting for urethral narrowing).

For overflow incontinence caused by weak bladder wall muscles, treatments can include reducing the amount of urine in the bladder by intermittent insertion of a bladder catheter or, rarely, insertion of a catheter that remains in the bladder. The goal is to reduce the bladder's size, allowing its walls to regain some capacity to prevent it from overflowing. Other measures can help empty the bladder after urinating. These can include trying to urinate again after urination has ended (called double voiding), bearing down at the end of urination, and/or pressing over the lower abdomen at the end of urination. Occasionally, electrical stimulation can be used to help empty the bladder more completely.