Types Of Urinary Incontinence - Urinary Incontinence: Bladder Conditions
Content provided by the Faculty of the Harvard Medical School
Types of urinary incontinence
Many things can go wrong with the complex system that allows us to control urination. Incontinence is categorized by the type of problem and, to a lesser extent, by differences in symptoms.
Stress incontinence
If urine leaks out when you jump, cough, or laugh, you may have stress incontinence. Any physical exertion that increases abdominal pressure also puts pressure on the bladder. The word "stress" actually refers to the physical strain associated with leakage. Although it can be emotionally distressing, the condition has nothing to do with emotion. Often only a small amount of urine leaks out. In more severe cases, just the pressure of a full bladder sometimes overwhelms the body's ability to hold in urine. The leakage occurs even though the bladder muscles are not contracting and you may feel no urge to urinate.
Stress incontinence occurs when the urethral sphincter or pelvic floor muscles have been weakened or damaged and cannot hold in urine all the time. Stress incontinence is divided into two subtypes. In urethral hypermobility, the bladder and urethra shift downward when abdominal pressure rises, and there is no hammock-like support for the urethra to be compressed against to keep it closed. In intrinsic sphincter deficiency, problems in the sphincter interfere with full closure or allow the sphincter to pop open under pressure. Many experts believe that women who have delivered vaginally are most likely to develop stress incontinence because giving birth has stretched and possibly damaged their pelvic floor muscles and nerves (see "The childbirth connection"). Generally, the larger the baby, the longer the labor, the older the mother, and the greater the number of births, the more likely that incontinence will result.
Not all studies support this notion. When researchers surveyed 149 nuns who had never given birth, they found that the nuns were just as likely to develop urinary incontinence as women who had borne children.
Age is likewise a factor in stress incontinence. As a woman gets older, the muscles in her pelvic floor and urethra weaken, and it takes less pressure for the urethra to open and allow leakage. Estrogen may also play some role, although it is not clear how much. Many women do not experience symptoms until after menopause.
In men, the most frequent cause of stress incontinence is sphincter damage sustained through prostate surgery or a pelvic fracture. Both men and women with lung conditions that result in frequent coughing (such as cystic fibrosis or emphysema) often develop stress incontinence.
The childbirth connectionIt's a little-known fact that many childbirth classes fail to adequately cover: An estimated 40% of women who give birth vaginally go on to develop one or more of the problems collectively known as pelvic floor disorders. These include stress incontinence, overactive bladder, uterine prolapse, cystocele, rectocele, and anal incontinence. These disorders often grow worse over time, resulting in a need for surgical repair in at least 11% of women over all. It may seem obvious how childbirth leads to pelvic floor damage: a baby stretches the pelvic floor muscles and other tissues on its way through the birth canal, sometimes causing tearing or other damage. But doctors are trying to sort out the specifics. What exactly is it about vaginal birth that causes these problems? Are there steps that can be taken or changes that can be made in delivery procedures that would help reduce this common but often ignored problem that affects so many women's lives for so many years? Research results show that a number of factors raise the risk of damage for women who deliver vaginally, including these:
What are the solutions? Delivery by cesarean section is one option. The rate of cesarean section continues to rise (about 30% of babies were delivered by cesarean section in 2004), and many women and health professionals are concerned that too many unwarranted cesarean deliveries are performed. But research to help determine when a cesarean is the best choice is ongoing. Women with some of the above risk factors should consider their birth options based on their risk factors. Researchers who published a study in the journal Obstetrics and Gynecology in 2006 suggested that health professionals inform their patients that cesarean delivery would reduce the risk of pelvic floor injury by 85%. This study of 4,458 women found that stress incontinence was 86% more likely in women who delivered vaginally compared with those who had cesarean section. Anal incontinence was 72% more common, and overactive bladder was 53% more common. However, because cesarean delivery comes with its own set of risks, the issue of when to opt for cesarean birth is controversial. Each woman should discuss her situation thoroughly with her obstetrician while making plans for childbirth. The still-common use of episiotomy during childbirth is another concern. Millions of women have had episiotomy, an incision made during vaginal delivery from the vagina toward the anus. It was previously believed that episiotomy helped prevent tearing of the vagina and damage to the pelvic floor. However, evidence has failed to confirm any benefit. And episiotomy may cause more damage than it prevents. For example, a 2006 study in Obstetrics and Gynecology found that women who had episiotomy were the most likely to experience tears in the anal sphincter. Sphincter tears can result in fecal incontinence, a condition common to 3% of women who deliver vaginally, and gas incontinence, a complaint of 37% of such women. Other major factors contributing to sphincter tears were heavier babies, a prolonged second stage of labor, and forceps delivery. Vacuum delivery did not result in sphincter tear. The rate of episiotomy has declined, from 60% in 1995 to 45% in 2000, but it remains high among physicians in private practice compared with physicians employed by hospitals, according to the American Academy of Obstetrics and Gynecology. Pregnant women can talk with their health care providers in advance about their specific risk factors for pelvic damage and consider their childbirth choices in the context of these risk factors. Women who already have symptoms of pelvic floor damage can learn more about treatment options elsewhere in this report. |
Urge incontinence
If you feel a strong urge to urinate even when your bladder isn't full, you may have urge incontinence. This condition occurs in both men and women and involves an overwhelming urge to urinate immediately, frequently followed by loss of urine before you can reach a bathroom (see "Key-in-the-door syndrome"). Even if you never have an accident, urgency and urinary frequency can interfere with work and a social life because you need to keep running to the bathroom.
Key-in-the-door syndromeDo you get an overwhelming urge to urinate just when you arrive home and start to open the door? Also called "latchkey incontinence," this phenomenon is a good demonstration of the bladder-brain connection. When you feel the urge to urinate as you're going home, you probably suppress it until you arrive. Eventually, the bladder becomes conditioned to associate arriving home with urinating, and the urge comes on whether or not your bladder is full. This is not a "psychological" problem, but a reflex-conditioning problem, much as when you salivate upon smelling something good to eat. |
Urgency is caused when the bladder muscle, the detrusor, begins to contract and signals the brain that you must go, even when the bladder is not full. Other names for this phenomenon are overactive bladder and detrusor instability.
Urge incontinence results from physical problems that keep your body from halting involuntary bladder muscle contractions. Such problems include damage to the brain, the spine, or the nerves extending from spine to bladder — for example, as a result of an accident, diabetes, or neurological disease. Irritating substances within the bladder, such as those produced during an infection, may also cause the bladder muscle to contract.
Often there is no identifiable cause for urge incontinence, but people are more likely to develop the problem as they age. Postmenopausal women, in particular, tend to develop this condition, which may be due to changes in the bladder lining and muscle associated with aging.
Infections of the urinary tract, bladder, or prostate can cause temporary urgency. Partial blockage of the urinary tract by a bladder stone, a tumor (rarely), or an enlarged prostate — a condition also known as benign prostatic hyperplasia (BPH) — can cause urgency, frequency, and sometimes urge incontinence.
In addition, prostate surgery for cancer or BPH can trigger symptoms of urge incontinence, as can freezing (cryotherapy) and radiation seed treatment (brachytherapy) for prostate cancer. Neurological diseases (such as Parkinson's disease and multiple sclerosis) can also result in urge incontinence, as can a stroke. When hospitalized following a stroke, 40% to 60% of patients have incontinence; by the time they are discharged, 25% still have it, and one year later, 15% do.
Mixed incontinence
If you have symptoms of both urge and stress incontinence, you may have mixed incontinence, a combination of both types. Most women with incontinence have both stress and urge symptoms; those with "the worst of both worlds" can be the most challenging to deal with. Mixed incontinence also occurs in men who have had prostate removal or surgery for an enlarged prostate, and in frail older people of either sex.
Overflow incontinence
If your bladder never completely empties, you may experience urine leakage, with or without a sense of needing to go. Overflow incontinence occurs when urine is blocked from flowing normally out of the bladder, as in the case of prostate enlargement that partially closes off the urethra. It may also occur if the bladder muscle becomes underactive (the opposite of urge incontinence) so you don't feel an urge to urinate. Eventually the bladder becomes overfilled, or distended, pulling the urethra open and allowing urine to leak out. The bladder may also spasm at random times.
Overflow incontinence may result if a tumor, enlarged prostate, bladder stone, or scar tissue blocks urine from leaving the bladder. If a woman has severe prolapse of her uterus or bladder (meaning that the organ has dropped out of its proper position), her urethra can become kinked like a garden hose that is bent on itself, interfering with the flow of urine.
Nerve damage (from injuries, childbirth, past surgeries, or diseases such as diabetes, multiple sclerosis, or shingles) and aging may prevent the bladder muscle from contracting normally. Medications that prevent your bladder muscle from contracting or that make you unaware of the urge to urinate can also result in overflow incontinence. Men are much more frequently diagnosed with overflow incontinence than women because it is commonly caused by prostate-related conditions.
Functional incontinence
If your urinary tract is functioning properly but other illnesses or disabilities are preventing you from staying dry, you may have what is known as functional incontinence.
For example, if an illness rendered you unaware or unconcerned about the need to find a toilet, you would become incontinent. Medications, dementia, or mental illness can decrease awareness of the need to find a toilet.
Even if your urinary system is fine, it may be extremely difficult for you to avoid accidents if you have trouble getting to a toilet. This problem can affect anyone with a condition that makes it excessively difficult to move to the bathroom and undress in time. This includes problems as diverse as having arthritis, being hospitalized or restrained, or having a toilet located too far away.
If a medication (such as a diuretic used to treat high blood pressure or congestive heart failure) causes you to produce abnormally large amounts of urine, you may develop incontinence that requires a change in treatment. If you make most of your urine at night, it can result in functional nocturnal incontinence, or bedwetting.
Reflex incontinence
This condition results when your bladder muscle contracts and you urinate (often in large amounts) without having had any warning or urge to go. This can occur as a result of damage to the nerves that usually warn the brain that the bladder is filling. Reflex incontinence usually appears in people with serious neurological impairment from multiple sclerosis, spinal cord injury or other injuries, or damage from surgery or radiation treatment.
Is it cancer?Incontinence can be a symptom of bladder cancer, but it is rarely the first or only sign of this disease. If you have other symptoms, such as blood in your urine, your physician may suggest specific tests to rule out bladder cancer. Bladder cancer is much less common than cancers of the colon, lungs, breast, or prostate. |
| Last updated: | September 05, 2008 |
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Medical content reviewed by the Faculty of the Harvard Medical School. Harvard Health Publications, Copyright © 2007 by President and Fellows of Harvard College. All rights reserved. Used with permission of StayWell.
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