What is urinary incontinence?

Urinary incontinence is any involuntary or unwanted loss of urine and is considered a medical condition. The risk of developing incontinence increases with age, but younger people may also develop it. Women are more likely to suffer from this condition than men.

Incontinence is common and causes distress and embarrassment. Many people go without treatment because they feel uncomfortable discussing incontinence with their doctor. If incontinence affects your quality of life, it is important to seek medical advice. In most cases, incontinence can be treated or cured with various treatment options. These include pelvic floor exercises, drug treatment, or surgery. Together with your doctor you can discuss which treatment is best for you.

Fig. 1a: The male lower urinary tract.

Fig. 1a: The male lower urinary tract.

Fig. 1b: The female lower urinary tract.

Fig. 1b: The female lower urinary tract.

Diagnosis of urinary incontinence

Urinary incontinence is a problem that needs to be diagnosed correctly so that you get the appropriate treatment.

This section lists the different tests your doctor may need to assess your situation. It offers general information about diagnosis and assessment of urinary incontinence. Keep in mind that situations can vary in different countries and hospitals.

Medical history

Your doctor might take a medical history to understand what type of urinary incontinence you have. As part of the medical history your doctor might ask about any other conditions you may have, or medication you take. This can be related to the incontinence or have an effect on your symptoms.

Your doctor may ask you:

If you take any medication

If you smoke

When and how much you drink

If you drink much coffee or alcohol

If you ever had surgery

To describe your bowel habits

If you have ever been pregnant

If you have entered menopause

Your doctor might also ask you about the impact of incontinence on your daily life, for example:

How often you go to the toilet

How often you have urine leakage

If you leak urine when you laugh, cough, or sneeze

If you wake up at night to urinate

If you need to hurry to reach the toilet in time when you feel the urge to urinate

If your bladder does not feel empty after urinating

The doctor may also ask you about your sex life and your treatment wishes.

Physical examination

The doctor may perform a physical examination of your abdomen to detect an enlarged bladder. He or she may ask you to cough with a full bladder, in order to see if you suffer from stress urinary incontinence (SUI). The doctor also needs to test how well the pelvic floor muscles work. For men, this is done through a digital examination of the rectum and the prostate (Fig. 2). Women may get a gynaecological examination.

Fig. 2: Digital rectal examination male.

Fig. 2: Digital rectal examination male.

Patient questionnaires

The doctor may ask you to fill out a questionnaire to better understand your symptoms and how they affect your everyday life. Questionnaires can also be used to monitor your symptoms over time, so you may need to fill them out more than once.

Urine test

You may need to give some of your urine for testing. The test will show if you have a urinary tract infection.

Bladder diary

Your doctor may ask you to keep a bladder diary for a few days. Here you will note down how much you drink, how often you urinate, and how much urine you produce. The bladder diary is important because it helps your doctor to understand your symptoms better.

Assessment of residual urine

Residual urine is the amount of urine that is left in the bladder after urinating. It is also known as post-void residual urine (PVR). It is usually measured with the help of an ultrasound.

Residual urine can worsen incontinence and may point to other urological conditions, such as a urinary tract infection. It can also help your doctor to better understand the causes of your incontinence.

Pad test

Your doctor may also need to know the weight of the pads that you wear during a period of time, which is called the pad test. Your doctor will explain in detail how to perform the test. A pad test is not always easy to do, and your doctor will need your full cooperation.

Urodynamic evaluation

A urodynamic evaluation might be necessary to get more information about your urination cycle and how your bladder muscles and urinary sphincter work. Urodynamic evaluation may consist of uroflowmetry or invasive urodynamic tests.

Uroflowmetry

Uroflowmetry consists of electronically recording the rate of your urine flow. It is easily done in privacy at the hospital or clinic. You will urinate into a container, called a uroflowmeter. This test helps your doctor to check whether there is any obstruction to the flow of urine out of the bladder.

Invasive urodynamic tests

If you are scheduled to undergo surgery for urinary incontinence, an invasive urodynamic test may be done. The test may also be needed when your diagnosis is uncertain.

During an invasive urodynamic test, your doctor or nurse inserts catheters in your urethra and rectum to measure the pressure in your bladder and abdomen. The bladder is slowly filled with sterile water through the catheter in the urethra. This is done to simulate the filling of the bladder with urine. When your bladder is full, you will urinate into a uroflowmeter.

The test results are shown on a screen which is connected to the catheters.

Cystoscopy

With a cystoscopy, the doctor can look inside the urethra and the bladder with the help of a small camera. Cystoscopy is not a common test during initial assessment for urinary incontinence. It may be needed when you suffer from other symptoms, such as blood in the urine or if your diagnosis is unclear.

Imaging

The doctor or nurse may scan your urinary tract with ultrasonography or magnetic resonance imaging. However, imaging is not a common test during the initial assessment for incontinence.

Treatment options urinary incontinence

There are many different ways of coping with urinary incontinence. Seek help if your symptoms bother you: consult your family doctor, general practitioner, or a urologist. It may be uncomfortable to discuss your condition with a doctor, but it is the most effective way to deal with your concerns.

Treatment for urinary incontinence depends on the type of incontinence, how severe it is, and what may cause it. There is no single solution to incontinence that works for everyone. Discuss with your doctor or specialist nurse which measures can help you. It is common to try different options to figure out which one works best for you.

Sometimes, conservative measures can significantly improve your condition and lead to a better quality of life. These measures include lifestyle changes, bladder training and pelvic floor muscle exercises. Other treatment options, such as medication and surgery, should be considered if conservative management is not effective.

The most used drugs to treat urinary incontinence are the antimuscarinic (or anticholinergic) drugs and mirabegron. Both intent to ameliorate urgency urinary incontinence.  In some cases, other drugs like desmopressin, duloxetin or vaginal oestrogens could be appropriate. Discuss with your doctor if some of these drugs can help you and which benefits and adverse effects you can expect with any of them.

Surgical treatment for urinary incontinence

Sometimes conservative or pharmacological treatment  do not improve your urinary incontinence. In these cases, other treatment options are available. Together with your doctor you can decide which approach is best for you and which are the expected benefits and side effects that you can expect with every one of the different options.

 Surgical treatment options for urgency urinary incontinence are:

Botulinumtoxin bladder injection: injection in your bladder wall a substance that avoid involuntary contraction of your bladder.

Nerve stimulation (neuromodulation): electrical pulses to stimulate the sacral nerves, which control the bladder behaviour.

Surgery to increase bladder volume. This represents the last choice, only when all other treatments have failed, and it is rarely performed nowadays. If this surgery is recommended, you will need to discuss its implications and side effects with your doctor, because they can be significant.

Surgical treatment options for stress urinary incontinence:

Suburethral slings: sling placed under your urethra.

Bulking agents: a substance injected into your urethra to increase its resistence.

External compression devices: devices that compress your urethra to avoid leakage.

Second-line treatment for urgency urinary incontinence

Sometimes self-management or the drugs your doctor prescribed do not improve your urgency urinary incontinence (UUI). In these cases, other treatment options are available. Together with your doctor you can decide which approach is best for you.

Common second-line treatment options for UUI are:

Botulinumtoxin bladder injection

Nerve stimulation, also known as neuromodulation

Surgerytoincrease bladder volume

Bladder surgery

In case your symptoms have not improved with drug or other treatments, you may need surgery on your bladder. The goal of the procedure is to increase the capacity of the bladder. This will reduce the pressure in the bladder as it fills so that it can hold more urine.

The doctor makes an incision in your lower abdomen and uses a piece of your bowel to increase the size of the bladder. This procedure is called bladder augmentation or cystoplasty, and is rarely performed nowadays (Fig. 3). If this surgery is recommended, you will need to discuss its implications and side effects with your doctor because they can be significant.

Fig. 3: Bladder surgery to increase the size of the bladder.

Fig. 3: Bladder surgery to increase the size of the bladder.

Conservative treatment (self-management) for urinary incontinence

Drug treatment for urinary incontinence

Surgical treatment for women with stress urinary incontinence (SUI)

Surgical treatment for men with stress urinary incontinence (SUI)

Causes of urinary incontinence

Some of the causes of urinary incontinence are:

Hormone deficiencies

Weak pelvic floor muscles

Childbirth

Pelvic surgery

Urinary tract infections

Neurological diseases

Benign prostatic enlargement

Prostate surgery

Urinary incontinence becomes more common with increasing age. However, it should not be seen as a normal part of ageing.

Types of incontinence

There are different types of urinary incontinence, depending on how and when you lose urine.

Stress urinary incontinence

Stress urinary incontinence (SUI) means that you lose urine during certain activities, like:

Coughing, sneezing, or laughing

Exercise like running or jumping

Lifting heavy things such as groceries

This happens because during these kinds of activities the pressure on your bladder increases. If your urethra or urinary sphincter are weak, they cannot resist the pressure of a full bladder, and will leak urine.

Urgency urinary incontinence

Urgency urinary incontinence (UUI) happens when you get a sudden need to urinate which you cannot postpone. The bladder muscle involuntarily contracts and you urinate when you do not want to.

Mixed incontinence

Your doctor may diagnose you with mixed urinary incontinence if you suffer from both SUI and UUI symptoms.