Urinary incontinence is involuntary urination (ie, wetting oneself). It can lead to hygiene problems as well as considerable social embarrassment. Incontinence has a negative effect on quality of life, emotional well-being, social function, and general health. Left untreated, urinary incontinence can lead to skin inflammation, pressure ulcers, urinary tract infections, falls (and fractures), sleep deprivation, social withdrawal, depression, and sexual dysfunction. People who suffer from incontinence may manage to maintain some social activities, but usually with more and more embarrassment. The burden to caregivers is also increased, which can contribute to decisions to place an older adult in a nursing home.

If you suffer from incontinence, you can take comfort that it is a common problem shared by many other older people and that it can generally be cured or at least greatly improved.

Background

Incontinence is a problem for up to one third of older adults living in the community and about half of those living in nursing homes. Women are usually affected twice as often as men until age 80, after which men and women are equally affected. The degree of incontinence may change over time. Over the course of one year, incontinence may affect perhaps 1 out of every 5 older women, and 1 out of every 10 older men. However, incontinence may disappear spontaneously in 10%-30% of older adults. Urinary incontinence can be a temporary problem when caused by medications, urinary infections, constipation, psychiatric problems, and episodes of delirium (acute confusion).

It is not completely known why some older adults develop urinary continence, while others do not. However, risk factors include the following:

Fewer than half of older adults affected by urinary incontinence consult a health professional or even mention this problem during an office visit. This is unfortunate, because in most people, incontinence can be cured or greatly improved with treatment. Don’t let embarrassment stand in the way of dealing with this problem.

How the Urinary System Works

The kidneys filter out body wastes (byproducts of metabolism) from the blood into the urine. The urine moves through a tube called the ureter to the bladder, where it is stored until urination. During urination, the urine passes from the bladder through a tube called the urethra to outside the body (see Figure: Urinary Anatomy, Male (left) and Female (right).

The bladder is located in the lower abdomen. As it fills with urine, it stretches until sensors in the bladder wall tell the brain that the bladder is full. Normally, muscles that form a ring around the urethra keep it closed. When you voluntarily urinate, these muscles relax, while other muscles in the walls of the bladder contract. This forces the urine to pass from the bladder through the urethra, until the bladder is empty.

Normal urination is under voluntary control from the brain, ie, the individual can decide when to urinate. However, as the bladder fills, the muscles in the bladder wall try to contract. These contractions are weak at first, but become stronger and stronger as the bladder stretches bigger and bigger to hold more urine. These contractions are what give you the urge to urinate. After you urinate, the bladder shrinks, and the contractions and urge pass.

If you wait too long and the bladder becomes too full, you’ll eventually urinate whether you want to or not. This is normal. However, there are many disorders in which you cannot control urination and end up wetting yourself. This is urinary incontinence.

Causes of Urinary Incontinence

Many medical terms are used to describe the various types of urinary incontinence. However, these can be grouped into four basic types:

Urge incontinence is the most common type of incontinence in older adults. It is seen when involuntary bladder contractions overcome the muscles that form a ring around the urethra to keep it closed. Other names for urge incontinence are unstable bladder, spastic bladder, or uninhibited bladder. The following list briefly describes the basic causes:

Symptoms and signs: Urge incontinence is associated with frequent, sudden, sometimes intense urges to urinate. It is also often associated with nighttime bed wetting. The amount of urinary leakage may vary from a few drops to a large amount.

Stress incontinence

This is the second most common type of incontinence in older women. It generally occurs from weakening of the muscles that normally keep the urethra closed. This weakening allows urine to flow more easily and results in urine leaking out. The muscles around the urethra can be damaged by bladder infections, vaginal scarring in women, or prostate removal in men. Other common causes in women are weakened pelvic muscles from childbearing and changes in the urethra after menopause.

Symptoms and signs: Unlike the name suggests, stress incontinence is not associated with emotional stress. It is actually caused by conditions that suddenly increase pressure in the abdomen, which results in losing urine. This could be as simple as coughing, laughing, straining, sneezing, or even pushing on the abdomen. People with stress incontinence usually stay dry at night. In women, a pelvic examination by a physician may reveal signs of decreased estrogen.

Overflow incontinence

Overflow incontinence is seen when the bladder cannot empty properly. It is the second most common cause of incontinence in older men. Overflow incontinence is generally caused by either very weak bladder contractions or an obstruction to urine outflow. Weak bladder contractions are usually associated with nerve damage from conditions like severe diabetes or damage to the spinal cord. Obstruction to urine outflow is a fairly common cause, especially in older men with an enlarged prostate or prostate cancer. In these conditions, the enlarged prostate presses on the urethra, which blocks the urine flow. Bladder stones can cause the same type of blockage. A less common third problem is a decreased sense that the bladder is full and requires emptying.

Symptoms and signs: Generally, people with overflow incontinence have the feeling that their bladder has not emptied completely, and there is frequent (sometimes constant) small volume loss of urine They may also have difficulty starting to urinate. Symptoms may include dribbling, a weak urine stream, a urine stream that starts and stops, urinating more often than usual, and nighttime bed wetting. Examination by a physician may show an enlarged bladder. Large amounts of urine can be collected if the bladder is drained with a catheter, confirming that the bladder did not empty normally.

Functional Incontinence

In functional incontinence, the urinary system is normal, but the person cannot reach the toilet in time. This is most often because the person has trouble getting around because of arthritis, back problems, or another problem with the muscles, bones, or nerves. Sometimes, the bathroom facilities are not easy to get to, or are not set up for use by people with disabilities. People who have dementia or delirium may not recognize that they need to urinate, or they may not be able to find the bathroom facilities.

Certain medication can also affect the urinary system. For example, the use of diuretics can also result in functional incontinence. Strong sedatives can make someone groggy, so that he or she can’t recognize the need to urinate until it is too late.

Symptoms and signs: Functional incontinence can be intermittent. It usually does not occur at night. It is usually associated with medical (eg, dementia, disability) or environmental conditions that need to be recognized.

Assessment of Urinary Incontinence

Urinary incontinence can be caused by multiple factors working together. Evaluating urinary incontinence focuses on the following:

If you have urinary incontinence, the information you give your healthcare provider is extremely important for him or her to be able to evaluate your condition. Your healthcare provider is likely to ask you many questions, including the following:

Try to answer these questions as completely as possible. Your healthcare provider may even ask you to keep a "bladder diary" for a few days, which is a record of the timing and duration of all accidents, fluid intake, and trips to the bathroom. Observations made by nursing home staff can also be helpful.

Your healthcare provider will do a physical examination to check for any medical problems, especially in the nervous system or the genital, pelvic, or rectal areas. Blood work will be done to look for problems such as diabetes, kidney disease, or abnormal blood chemistries (eg, calcium and vitamin B12 levels). A urine sample is checked for infections and other problems in the bladder. Sometimes a catheter is run into the bladder to determine the amount of urine that is left in the bladder after urination; in other cases, an ultrasound examination may be performed.

Other diagnostic procedures may be helpful. These could include ultrasound, X-rays, imaging studies (eg, MRI, CAT scan, or dye study), or specific urologic tests. The decision to do a particular diagnostic procedure usually depends on whether the result could change the way the problem is managed and on whether there is a chance of missing a particular condition without it. For example, there is evidence that behavioral treatments can be effective for both stress incontinence and urge incontinence, so behavioral therapies can often be started without complex testing to determine the specific type of incontinence. On the other hand, using an imaging study to look within the bladder may be critically important if bladder cancer is suspected.

Treatment of Urinary Incontinence

The most important thing to know about treating urinary incontinence is that most people can be substantially improved or cured. The type of treatment depends on the cause of the incontinence and the medical condition of the affected person. If the affected person has physical or mental limitations, family members or other caregivers are often needed for support and assistance. Relieving the most bothersome aspects of incontinence is the immediate goal.

In most cases, a few general suggestions for management are useful, including the following:

Addressing other medical illnesses, side effects of medications, problems in the environment, and other triggers often improves continence without any other treatment. As a general rule, behavioral treatments should be started before medications, and both tried before surgery. Cure often requires multiple visits to the health care provider.

Behavioral treatments

Many time, simple behavioral treatments can help, as long as a person has the mental capacity to understand and follow the procedure. These are typically the first treatments for both urge and stress incontinence. The most commonly used techniques include bladder retraining, pelvic muscle exercises, and scheduled/prompted voiding. These methods are described briefly below and in more detail at www.healthinaging.org/public_education/bladder_control.php. Special biofeedback techniques can also be used to help a person become aware of muscle contraction, eg, by doing pelvic muscle exercises. All of these behavioral techniques require a motivated person and a series of sessions with a skilled and enthusiastic trainer.

Bladder retraining: Bladder retraining can be very helpful for urge or stress incontinence, especially among older women living in the community. In bladder training, the amount of time between voidings is scheduled. Bathroom trips are initially planned at time intervals necessary to stay dry, usually every 2 hours. If you have an urge during the time interval, you should stand still or stay sitting, contract the pelvic muscles, and concentrate on making the urge decrease and pass. You can do this by taking a deep breath and letting it out slowly, or by thinking of the urge as a wave that peaks and then falls. Once you have the urge under control, you should walk slowly to a bathroom and urinate. After 2 days without leakage, the time between scheduled bathroom trips can be increased by 30-60 minutes until you can urinate every 3-4 hours without leakage. Successful bladder retraining usually takes several weeks, so if you aren’t successful initially, keep trying and don’t be discouraged. Bladder training during the day will also train the brain to reduce or eliminate voiding at night.

Pelvic muscle exercises: Pelvic muscle exercises strengthen the muscles around the urethra and are the cornerstone of behavioral treatment for stress incontinence. Pelvic muscle exercises (Kegel’s exercises) are very similar to the isometric exercises used in strength training. You should focus on isolating your pelvic muscles, so that contractions are in these muscles, and not the butt, abdomen, or thigh muscles. A good way to be sure you are contracting the right muscles is by contracting the muscles to stop urine passing during voiding. Strong, slow contractions should be held for 6-8 seconds. Try and perform these contractions in sets of 8-12 at a time, three or four times a day, for at least 15-20 weeks. Often, people who are not having success with pelvic muscle exercises have simply either not performed the exercises correctly or for a long enough time. Special incontinence clinics or trained physical therapists can help people who have trouble doing the Kegel’s exercises on their own.

In addition to doing specific exercises to strengthen the pelvic floor muscles, walking more is also helpful. Walking improves a person’s ability to sense that the bladder is filling.

Schedule, timed, or prompted voiding: Scheduled voiding involves setting a schedule for bathroom trips to avoid accidents. This is a part of bladder retraining. When a person can’t keep track of the time for voiding, asking the person if he or she will go to the bathroom when it is time, and praising them if they are dry–and also if they void when asked to–may work well for certain individuals (eg, people in nursing homes) who have urinary incontinence.

Variations on this process can also help those with functional incontinence, including people with dementia. For example, a toileting program can be established based on an evaluation of the person’s urination pattern. To accomplish this, the person is checked every 2 hours for 2 days, and a record is kept of whether the person is wet or dry. The best toileting schedule can then be established to allow toilet use at a time when the bladder is most likely to be full. Successful toileting should be positively reinforced.

"Prompted voiding" involves monitoring toilet habits, prompting to toilet (ie, asking if you need to go to the bathroom) on a set schedule, and praise and positive feedback when the person is continent and attempts to toilet. People most likely to respond to prompted voiding are those who urinate four or fewer times during the daytime (approximately 12 hours) and do not have an accident over 75% of the time.

The above methods require training, motivation, and continued effort by older adults and their caregivers. Special attention and staff reinforcement is needed in nursing homes for treatment success to continue.

Drug treatment

Certain drugs may be useful along with behavioral treatment, or when behavioral methods do not fully restore continence. Combining behavioral and drug therapy sometimes works better than either treatment alone. The type of drug used depends on the type of incontinence and the person’s medical condition. Drug treatment is most commonly used for urge or stress incontinence.

Urge incontinence: In general, medications used to treat urge incontinence work by decreasing bladder contractions. The drugs most commonly used are oxybutynin, tolterodine, and trospium. All are available as tablets taken once or twice daily, and oxybutynin is also available as a patch that is applied to the abdomen, thighs, or buttocks twice a week. Sometimes, if one of these drugs doesn’t work, one of the others still might.

The dosages of all medications must be monitored carefully, because they can result in incomplete urination or possibly even the inability to urinate. Other possible side effects include confusion, agitation, a drop in blood pressure on standing, dry mouth, and an irregular heart rhythm.

Stress incontinence: The goal of treatment for stress incontinence is to increase resistance in the urethra, so that urine doesn’t leak out. Estrogens have been commonly used, and they may have beneficial effects on the tissues around the urethra. However, how much they help is not clear. In numerous research studies, oral estrogen was not effective in treating stress or mixed (eg, stress and urge) incontinence. Further studies are needed to evaluate topical estrogen formulations (eg, cream, vaginal tablet, or slow-release ring). Pseudoephedrine is an old drug for stress incontinence that should not be used in people with high blood pressure because its main side effects are high blood pressure, fast heart rate, and headache.

Duloxetine is a new drug that increases contraction of the muscles lining the urethra. Research data are limited, but early results suggest that this drug may be helpful in treating stress or mixed incontinence. One of its main side effects is nausea.

Surgery and other medical treatments

If other treatments are not successful, surgery may be necessary. Surgery is an effective treatment for stress incontinence.

Overflow incontinence: The goal of treatment for overflow incontinence is to drain the bladder. This involves placing a catheter in the urethra to empty the bladder and keep it emptied. If the reason for the overflow is that the bladder contracts poorly, then keeping it empty for about 2 weeks may allow the bladder to strengthen and return to normal function. However, the more common reason for the overflow in older adults is that the bladder is obstructed. This is often the case in older men who have an enlarged prostate or prostate cancer, and surgery to remove the obstruction is often necessary. There are also some drugs that can be used to shrink the prostate or to relax the prostate tissue surrounding the urethra.

Stress incontinence: Surgery may be needed for stress incontinence that has not responded well to behavioral or drug treatment. Surgery provides the highest cure rates for stress incontinence in women. Although surgical procedures vary, they all generally try to tighten up a sagging bladder or urethra so that urine outflow can be controlled. However, these surgeries can result in complications in about 10% of cases.

Another possible treatment involves injecting a substance (eg, collagen, Teflon®, or fat) around the urethra to stiffen the area. In many cases, this is only a short-term (less than a year) solution, and usually a series of injections is required.

Adult diapers

Many products that are not excessively bulky under clothing are available to keep incontinent people dry and free of odor. These items include rubber or plastic pants with absorbent pads, and they are generally needed only while the problem is being improved or corrected. Long-term use is generally a last resort after careful evaluation and treatment have not fully restored continence.

If pads and protective garments are needed, the correct ones should be chosen based on sex, type of incontinence, and volume of leakage. Medical supply companies and patient advocacy groups publish illustrated catalogs of various products. Pads and protective garments should be changed as often as necessary to avoid skin irritation from urine.

A warning about urinary catheters and collection devices

A urinary catheter is a rubber tube that is passed through the urethra into the bladder, to drain and collect the urine. Catheter use can result in bacteria getting into the bladder, which is normally sterile. Indwelling catheters (those left in place for days, weeks, or months) can cause significant problems, including bladder and kidney infections, fever, and bladder stones. Antibiotics can be used to treat infection, but can cause other problems with long-term use. Sleeves, condoms, and other external collection devices can also cause infection, inflammation of the penis, and tissue damage.

Indwelling catheters are generally reserved for use only in the following situations:

The potential for misuse of indwelling catheters is probably greatest in nursing homes. However, federal laws enacted in 1990 (ie, the Omnibus Budget Reconciliation Act) protect people from inappropriate catheter use and have resulted in decreased catheter use in long-term care facilities.