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Urinary Incontinence in Women

What are the types of incontinence?
The Types of Urinary Incontinence
How is incontinence evaluated?

Millions of women experience involuntary loss of urine 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. Many women experience both symptoms. 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. Urine loss can also occur during sexual activity and cause tremendous emotional distress.

Women experience UI 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, stroke, multiple sclerosis, and physical problems associated with aging.

Older women experience UI more often than younger women. But incontinence is not inevitable with age. UI is a medical problem. Your doctor or nurse can help you find a solution. No single treatment works for everyone, but many women can find improvement without surgery.

Incontinence occurs because of problems with muscles and nerves 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.

Figure 1.—Front view of bladder and sphincter muscles

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. Incontinence will occur if your bladder muscles suddenly contract or the sphincter muscles are not strong enough to hold back urine. Urine may escape with less pressure than usual if the muscles are damaged, causing a change in the position of the bladder. Obesity, which is associated with increased abdominal pressure, can worsen incontinence. Fortunately, weight loss can reduce its severity.

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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. This type of incontinence is common in women and, in many cases, can be treated.

Childbirth and other events can injure the scaffolding that helps support the bladder in women. Pelvic floor muscles, the vagina, and ligaments support your bladder (see figure 2). If these structures 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 squeezing muscles weaken.

Figure 2. Side view of female pelvic muscles.

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.

Urge Incontinence
If you lose urine for no apparent reason after suddenly feeling the need or urge to urinate, you may have urge incontinence. A common cause of urge incontinence is inappropriate bladder contractions. Abnormal nerve signals might be the cause of these bladder spasms.

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). Certain fluids and medications such as diuretics or emotional states such as anxiety can worsen this condition. Some medical conditions, such as hyperthyroidism and uncontrolled diabetes, can also lead to or worsen urge incontinence.

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.

Overactive Bladder
Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without warning. Voiding up to seven times a day is normal for many women, but women with overactive bladder may find that they must urinate even more frequently.

Specifically, the symptoms of overactive bladder include

urinary frequency—bothersome 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—leakage or gushing of urine that follows a sudden, strong urge
nocturia—awaking at night to urinate
Functional Incontinence
People with medical problems that interfere with thinking, moving, or communicating may have trouble 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 have a hard time getting to a toilet in time. Functional incontinence is the result of these physical and medical conditions. Conditions such as arthritis often develop with age and account for some of the incontinence of elderly women in nursing homes.

Overflow Incontinence
Overflow incontinence happens when the bladder doesn’t empty properly, causing it to spill over. Your doctor can check for this problem. 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. Most women don’t have pure stress or urge incontinence, and many studies show that mixed incontinence is the most common type of urine loss in women.

Transient incontinence is a temporary version of incontinence. Medications, urinary tract infections, mental impairment, and restricted mobility can all trigger transient incontinence. Severe constipation can cause transient incontinence when the impacted stool pushes against the urinary tract and obstructs outflow. A cold can trigger incontinence, which resolves once the coughing spells cease.

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.
Overactive Bladder Urinary frequency and urgency, with or without urge incontinence.
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 situation that will pass (infection, taking a new medication, colds with coughing).

How is incontinence evaluated?
The first step toward relief is to see a doctor who has experience treating incontinence to learn what 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 urinary and associated pelvic problems in women. Family practitioners and internists see patients for all kinds of health conditions. Any of these doctors may be able to help you. In addition, some nurses and other health care providers often provide rehabilitation services and teach behavioral therapies such as fluid management and pelvic floor strengthening.

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 you have. Thus, many specialists begin with having you fill out a bladder diary over several days. These diaries can reveal obvious factors that can help define the problem—including straining and discomfort, fluid intake, use of drugs, recent surgery, and illness. Often you can begin treatment at the first medical visit.

Your doctor may instruct you to keep a diary for a day or more—sometimes 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. You can also use the bladder diary to record your fluid intake, episodes of urine leakage, and estimated amounts of leakage.

If your diary and medical history do not define the problem, they will at least suggest which tests you need.

Your doctor will physically examine you for signs of medical conditions causing incontinence, including treatable blockages from bowel or pelvic growths. In addition, weakness of the pelvic floor leading to incontinence may cause a condition called prolapse, where the vagina or bladder begins to protrude out of your body. This condition is also important to diagnose at the time of an evaluation.

Your doctor may measure your bladder capacity. The doctor may also measure the residual urine for evidence of poorly functioning bladder muscles. To do this, you will urinate into a measuring pan, after which the nurse or doctor will measure any urine remaining in the bladder. Your doctor may also recommend other tests:

Bladder stress test—You cough vigorously as the doctor watches for loss of urine from the urinary opening.
Urinalysis and urine culture—Laboratory technicians test your urine for evidence of infection, urinary stones, or other contributing causes.
Ultrasound—This test uses sound waves to create an image of the kidneys, ureters, bladder, and urethra.
Cystoscopy—The doctor inserts a thin tube with a tiny camera in the urethra to see inside the urethra and bladder.
Urodynamics—Various techniques measure pressure in the bladder and the flow of urine.