TYPES OF URINARY INCONTINENCE

In simplest terms, urinary continence means to stay dry and that there is no leakage of urine regardless of the activity the person is engaged in. Continence means that even with a full bladder and a “need” to go, the person can take the necessary steps to void without rushing and without urine leakage.

The normal pattern for urination is 6 to 8 times per 24 hours. Those under the age of 65 years can expect to void perhaps once during the night. For those over 65 years, the pattern is one to two voids during the night. When the bladder starts filling, the first signal to void usually occurs when there is 150–200 cc of urine present; at this stage the detrusor muscle of the bladder begins to stretch. It is possible to ignore this first signal to void if the time and place are not convenient. When the bladder capacity reaches 400–600 cc of urine, it is time to void (Haag, 2019).

It is important for clinicians to remember that urinary incontinence is not a disease itself; it is a symptom of some other malfunctioning in the human body. Early diagnosis is essential to determine whether there is an underlying serious medical condition causing urinary incontinence. Some of those conditions include multiple sclerosis (MS), Parkinson’s disease, and tumor. Approximately 80% of individuals with MS develop some form of urinary incontinence (WOCN, 2016).

Urinary incontinence can be divided into several different types, with different underlying factors associated with each type.

Acute or Transient Urinary Incontinence

Acute or transient urinary incontinence occurs in individuals with no previous history of urinary incontinence. It usually comes on suddenly and lasts less than six months (WOCN, 2016). This type of urinary incontinence is caused by reversible factors such as:

• Urinary tract infection
• Medications
• Stool impaction
• Atrophic urethritis and vaginitis
  (WOCN, 2016)

URINARY TRACT INFECTION (UTI)

Urinary tract infections are a major cause of transient incontinence. They can occur in any age group and gender, but they are more common in females. Evidence shows that by the age of 35 years, 50% of women have experienced at least one UTI. Urinary tract infections can develop in the kidneys, bladder, or urethra, and the most common causative organism is E. coli (NAFC, 2019c). The offending organism causes inflammation of the bladder wall and urethra.

The symptoms of a UTI include:

• Urgency to void
• Increased frequency of urination
• Pain with urination
• Cloudy-colored urine, often with a malodor
• Fever
  (NAFC, 2019c)

A change in mental status, such as sudden confusion in elderly patients, along with a new onset of urinary incontinence is a primary symptom of a UTI (WOCN, 2016).

Diagnosis of a UTI can be made by a urine culture and is treated by antibiotic therapy. Patients are advised to stay well hydrated, and female patients are advised against using any female hygiene products that could irritate the urethra (NAFC, 2019c).

MEDICATIONS

Medications can frequently result in urinary incontinence. The medications most commonly associated with urinary incontinence are diuretics. Diuretics can be responsible for the rapid production of large amounts of urine, which can result in incontinent episodes, especially in patients with compromised mobility. This can be of particular concern for older adults.

Other categories of medications that can cause urinary incontinence include:

• Alpha-blockers used to treat high blood pressure can cause the muscles surrounding the bladder neck to relax, resulting in urine leakage.
• Antipsychotics, antihistamines, and tricyclic antidepressants can lead to urinary retention and overflow incontinence (involuntary leakage of a small amount of urine from an over-distended bladder).
• Calcium–channel blockers used for the treatment of high blood pressure can cause urinary retention and overflow incontinence.

Since each patient will have an individualized response to medications, it is important for clinicians to be aware of the patient’s medications and to discuss the possibility of urinary incontinence. If incontinence does occur, the healthcare provider may be able to make medication adjustments (Simon Foundation, 2019d).

STOOL IMPACTION

Constipation can result in urinary incontinence. The bladder and rectum are in close proximity in the restricted space in the bony pelvis, and fecal impaction causes the bowel to become distended, leading to obstruction of the bladder neck. Obstruction of the bladder neck can make it difficult for the patient to urinate, causing a build-up of urine in the bladder that results in overflow incontinence. There is also a possibility that straining during bowel movements, which is common with chronic constipation, may result in weakening of the pelvic floor muscles. Clinicians should always inquire about bowel health in conjunction with bladder health, especially when there is an issue with urinary incontinence (WOCN, 2016).

ATROPHIC URETHRITIS

In women, urinary continence is in part dependent on coaptation of the walls of the urethra (when the urethral walls collapse together). The urethra in females is about 4 cm in length and made up of four layers, which supports urethral closure or coaptation. Diminished estrogen supplies, especially in older females, leads to dryness and thinning of the urethral tissue (atrophic urethritis), lessening coaptation and causing urinary leakage. Treatment with estrogen vaginal suppositories or creams can help to counteract this problem (WOCN, 2016).

Urge Urinary Incontinence

Urge urinary incontinence is the most frequently occurring type of urinary incontinence and the result of an overactive detrusor muscle (a smooth muscle that forms part of the bladder wall). When the detrusor muscle contracts, the bladder empties.

Urge incontinence is caused by an abnormal sensitivity and contractibility of the bladder wall, but the exact mechanism is not known. Possible causes include changes in the levels of neurotransmitters, with heightened stimulation of sensory fibers indicating early bladder fullness. In adults over 65, the bladder is more susceptible to untimely contractions. The amount of urine lost can vary from small to considerable (Haag, 2019; WOCN, 2016).

The most significant finding in urge incontinence is an overpowering urge to void together with the involuntary loss of urine. Urge incontinence is sometimes referred to as the “key-in-lock” syndrome, in which the bladder may begin to contract when the individual knows they will soon be able to reach the toilet and they will be overcome by a sudden urge to void (Haag, 2019). Triggers for urge incontinence also include the sound of running water or making a position change (WOCN, 2016).

Other symptoms of urge incontinence are needing to void frequently and voiding during the night (nocturia). Nighttime voiding is particularly problematic for older adults, causing disruption in sleep and increasing the risk for falls.

Urge urinary incontinence can be found in women of any age group but is more common in older women. Statistically, about 9% of women under the age of 45 have problems with urge incontinence, while in women over the age of 75, the rate increases to 31% (Stoppler, 2017). Urge incontinence is the most common type of urinary incontinence in the male population, with 40% to 80% of men with incontinence estimated to have urge incontinence (Simon Foundation, 2019c).

Stress Urinary Incontinence

With stress urinary incontinence, the patient typically complains of involuntary urine leakage with exertion (e.g., sneezing, coughing, laughing, running, or lifting). This type of incontinence is also known as activity-associated incontinence.

Stress incontinence is primarily caused by the inability of the sphincter muscle to sustain closure when the patient is performing activities that increase abdominal and bladder pressure, referred to as sphincter insufficiency. This, in turn, leads to a partially open urethra, which allows urine to escape (WOCN, 2016; Shah, 2019).

Weak pelvic floor muscles are a secondary contributor to stress urinary incontinence. In particular, the levator ani muscle (which lends support to the bladder from below) in females is susceptible to damage during childbirth, with around 5% to 10% of females with a first-time vaginal delivery found to have some degree of laceration of this muscle. The greatest risk of levator ani damage is among those who undergo forceps-assisted deliveries (Schuiling & Likis, 2017).

Stress urinary incontinence can have a debilitating impact on women’s lives and activities. Women with stress urinary incontinence are acutely aware that their control over urination has been greatly diminished, and a simple act such as walking across a room could result in urine leakage.

Stress urinary incontinence is less common in males, affecting less than10% of men with urinary incontinence. Men most often experience stress urinary incontinence after surgery for prostate cancer or for an enlarged prostate.

Mixed Urinary Incontinence

Patients with mixed urinary incontinence have symptoms of both stress incontinence and urge incontinence. It combines bladder muscle dysfunction resulting in bladder over-activity with sphincter dysfunction resulting in urine leakage associated with urgency (WOCN, 2016). Usually, the symptoms of one type of incontinence (stress or urge) are more severe than the other.

Mixed urinary incontinence is a common problem, and the majority of women with incontinence have mixed incontinence. It is usually more prevalent among older women. Mixed urinary incontinence is also found in men who have had their prostate gland removed or undergone surgery for an enlarged prostate. As with women, mixed urinary incontinence occurs in older men (Underwood, 2017).

Functional Incontinence

In most instances of functional incontinence, the bladder, urethra, and sphincter mechanism is functioning correctly, and the incontinence results from problems outside the urinary tract. These external problems impede the person’s ability to respond appropriately to the need to void. The most frequent types of impairments resulting in functional incontinence are:

• Impaired mobility
• Impaired cognitive function
  (WOCN, 2016)

Impaired mobility can pose several difficulties for individuals, including an inability to reach the restroom in time to void and a hampered ability to prepare for voiding. In some cases, the person may be dependent on others for assistance with toileting, and if assistance is not readily available, incontinence may occur.

Impaired cognition can have several causes, such as advanced dementia. In cases of cognitive impairment, the person does not recognize the urge to void or is unable to recall the stages of voiding (WOCN, 2016).

Medications can also lead to functional incontinence, for example, a person with some degree of impaired mobility who also takes a diuretic medication to treat hypertension or congestive heart failure. The diuretic medication will increase the volume of urine, and the urgency to void along with the extra time needed to reach the restroom may result in episodes of incontinence (Underwood, 2017).

Neurogenic Bladder

Neurogenic bladder is caused by a lack of neuron regulation of the lower urinary tract mechanism. The most common finding in neurogenic bladder is a lesion located between the sacral cord and the brain. These lesions occur most frequently in persons with spinal cord injury and conditions such as multiple sclerosis (WOCN, 2016).

Patients with neurogenic bladder have no sensory awareness of bladder filling. They are unable to instigate voiding and have lost control over the urinary sphincter. This inability to maintain continence is due to a loss of communication between the cerebral cortex, the brain stem, the bladder, and the sphincter muscle. Since the patient has lost voluntary control over voiding, bladder emptying happens due to reflex arc responding to bladder filling.

Patients with neurogenic bladder are at risk for developing a severe problem called detrusor sphincter dysynergia, which is characterized by failure of the sphincter to relax in response to contraction of the detrusor muscle (WOCN, 2016).

Peyronie’s Disease

The name of this condition is somewhat misleading, since it is not an actual disease but a condition that results from injury or damage to the penile tissue. The consequence of this injury is the development of an irregular twist or curvature of the penis (NAFC, 2018b). Peyronie’s disease is caused by a problem with wound healing, leading to an accumulation of collagen tissue on the shaft of the penis. This can occur after a single traumatic event or due to frequent minute injuries during sexual intercourse. Other causes include:

• Vigorous sport activities
• Autoimmune conditions, such as scleroderma
• Diabetes
• Heredity
  (NIDDK, 2020)

Scar tissue builds up on the surface of the penis and leads to a change in the shape of the penis over a period of time. The condition usually stabilizes after a period of 3–12 months (Mayo Clinic, 2020b). This gradual change distinguishes Peyonie’s disease from a hereditary curvature of the penis, which remains constant.

Apart from urinary incontinence, the other symptoms of Peryonie’s disease include:

• Firm lumps on the shaft of the penis
• Shortening of the penis
• Erectile dysfunction
• Pain with or without an erection
  (NAFC, 2018b)

Peyronie’s disease has been estimated to affect about 1 in every 100 men in this country but based on investigation of those who describe having symptoms of Peyronie’s disease, a more accurate prevalence has been predicted as 1 in 10 men. It can occur in men of all ages, but it is not a common condition in men in their 20s and 30s, with the rates increasing with age (NIDDK, 2020).

Incontinence in Children

Urine leakage is the most frequently occurring urine symptom in children and teenagers. Problems with urinary incontinence can result in emotional and mental health issues that may be revealed as behavioral disorders in children. Teenagers who had problems with urinary incontinence during their childhood can develop pervasive concerns about continence and bladder control (Shah, 2019).

Children usually become continent between the ages of 2–4 years, although it is highly individualized. Research has demonstrated an incidence of urinary incontinence in children who are 7-1/2 years old as 7.8%, with the possible consideration that urinary incontinence could have a genetic link.

Urinary incontinence or enuresis has two types. Primary enuresis in children occurs when the child never gains continence. Secondary enuresis refers to the onset of urinary incontinence in children who have achieved continence for at least 6 months. For most children, problems with bladder control resolves as they get older. Parents and caregivers, although frustrated with the problem, can be educated that incontinence in children is not due to laziness, heedlessness on the part of the child, or problems with toilet training. The majority of children who experience incontinence are emotionally and physically normal (NIDDK, 2017).

Conditions that can lead to incontinence in children include:

• Urinary tract infection
• Vesicouretal reflux (VUR) retrograde flow of urine from the bladder to the kidneys
• Constipation
• Diabetes
• Structural malformation of the urinary tract, such as narrowing of the urethra
• Arousal disorder (unable to respond to physical signals that urination is needed)
• Sexual abuse

Depending on the symptoms and severity of the problem, a child may be referred to a pediatric urologist. Treatment options include:

• Bedwetting alarm
• Nighttime waking and toileting by parents
• Bladder therapy
• Psychotherapy
• Medications such as desmopressin (DDAVP, Nocdurna)
  (WOCN, 2016; NAFC, 2018a)

Incontinence in Adults During Sleep

Bedwetting is an atypical condition related to urinary continence, and it occurs in both children and adults. Adult bedwetting, also known as sleep enuresis, can happen for many reasons, including depression and anxiety. Approximately 1% to 2% of adults have problems with bedwetting. There are several factors that can be related to sleep enuresis, including:

• Heredity. There is a strong possibility of a genetic component in the development of sleep enuresis. An individual is at greater risk if one or both parents experienced bedwetting as children.
• Imbalance in the production of antidiuretic hormone (ADH). This hormone, released by the pituitary gland, decreases the amount of urine produced in the kidneys. Usually there is an increase in ADH production at night to maintain continence. If there is a decrease in the amount of ADH produced or the kidneys do not respond appropriately to the hormone, there is an increased production of urine that can result in sleep enuresis.
• Small bladder capacity. Individuals with decreased bladder capacity (which can be caused by bladder obstruction, pressure on the bladder caused by an enlarged prostate gland in males, and inflammation) are at greater risk for sleep enuresis. This is not due to a decrease in the actual size of the bladder but to a decrease in the functional capacity of the bladder.
• Overactive detrusor muscle. Studies have found that overactive detrusor muscle occurs in 70% to 80% of people with sleep enuresis (NAFC, 2019a).
• Urinary tract infection. UTI can increase the risk of bedwetting in some individuals.
• Medications. The side effects from certain medications can increase the risk of sleep enuresis. These medications include sleep medications, hypnotics, and medications used to treat psychiatric conditions, such as thioridazine and clozapine.
• Underlying health conditions. Examples include pelvic organ prolapse in females, prostate enlargement in males due to either benign or malignant causes, bladder cancer, diabetes, and sleep apnea.

Treatment for adult bedwetting focuses on determining the underlying cause and requires a thorough assessment of the patient by the clinician. Behavioral interventions can include decreasing fluid intake in the evenings, using bedwetting alarms, and using absorbent products (NAFC, 2019a).