This pamphlet will explain:

Symptoms of urinary incontinence What causes this condition How it is diagnosed and treated

Loss of bladder control is a common problem and there are many treatment options available.

About Urinary Incontinence

Urinary incontinence is more common in women than in men. Mild leakage affects most women at some time in their lives. Severe leakage is less common and affects about one in ten women.

Incontinence does not always mean that a woman leaks often. But, for an active woman or a woman who loses a lot of urine each time, even one time a week or less often may be too much.

Women sometimes do not tell their doctors about their symptoms. More than one half of women who have symptoms do not seek medical care. These women may not consider leakage to be a problem or rely on absorbent pads or changes in lifestyle to deal with the problem. Others may feel ashamed or depressed or may avoid social or work events.

Some women have the false belief that loss of bladder control is a normal part of aging. They think that nothing can be done to correct it, but often it can be treated.

Tell your doctor if you have any leakage of urine. Proper diagnosis and treatment often can ease your symptoms.

Normal Voiding

The urinary tract is made up of four parts:

1. Kidneys, which produce urine
2. Ureters, which take urine to the bladder
3. The bladder, where urine is stored
4. The urethra, which carries urine out of the body

Normal urination (also called voiding) occurs when a woman is able to empty her bladder when she has a natural need to do so. In normal voiding, the muscles around the urethra relax. The bladder then contracts, and urine flows to the urethra and out of the body. When the bladder is almost empty, the muscles around the urethra contract. The bladder relaxes, and the stream of urine stops flowing.

Types

There are five types of urinary incontinence:

1. Stress
2. Urge
3. Mixed
4. Overflow
5. Functional

Stress incontinence, which is the most common type of urinary incontinence in younger women, occurs when the pressure in the bladder is greater than the pressure in the urethra. This causes a loss of urine when a woman coughs, laughs, or sneezes. Leaks also can happen when a woman walks, runs, or does aerobics. It is caused when the tissues that support the bladder or the muscles of the urethra get weak.

With urge incontinence, a woman has a sudden strong urge to void and leaks urine before she can get to the bathroom. It is sometimes called overactive bladder. It occurs if the muscles of the bladder are too active and contract too often. This leads to leakage of urine. It also can be caused by problems with the nerves that send signals to the bladder.

Mixed incontinence occurs when a woman has both stress and urge symptoms. This combination may cause more urine to leak than either type alone would.

Overflow incontinence occurs when the bladder does not empty all the way during voiding. It happens when the bladder muscle is not active enough or when the urethra is blocked. This allows steady leaks of small amounts of urine.

Functional incontinence causes leaks to happen because other health problems keep a woman from getting to the toilet in time. Conditions that cause it include:

• Arthritis
• Stroke
• Nervous system disorders
• Mobility problems (for example, trouble walking)

Symptoms

In addition to leaking urine often, a woman with incontinence also may have other symptoms:

• Urgency: A strong urge to urinate whether or not the bladder is full, often with pelvic pressure.
• Frequency: Voiding more often than she considers usual.
• Nocturia: The need to void during hours of sleep.
• Dysuria: Painful voiding.
• Enuresis: Bed-wetting or leaking while sleeping.

Urge incontinence (top) can occur if the muscles of the bladder are too active and contract too often. Stress incontinence (bottom) occurs when the pressure inside the bladder is greater than that inside the urethra.

Causes

There are many likely causes of urinary incontinence. Some are short-term and easier to treat than others.

Urinary Tract Infection

Loss of bladder control may be caused by an infection of the urinary tract. Signs of an infection include pain, frequency, and possible blood in the urine. Infections of the bladder (cystitis) and of the urethra (urethritis) often occur in women and are easily treated.

Pelvic Support Problems

The pelvic organs are held in place by supportive tissues and muscles. Support problems occur when these tissues are stretched or weakened by pregnancy, childbirth, and aging. This lets the organs that they support sag out of place. If the tissues that support the urethra, bladder, uterus, and rectum become weak, these organs may drop down and press against the vagina. That may lead to leaks or may make it hard to pass urine. However, many of these pelvic support problems are mild and cause no symptoms.

Urinary Tract Abnormalities

A fistula is an abnormal opening from the urinary tract into the vagina. It can allow urine to leak out through the vagina. A fistula may result from:

• Pelvic surgery
• Childbirth
• Radiation treatment
• Advanced cancer of the pelvis

Abnormal growths in the urinary tract also can cause incontinence.

Neuromuscular Disorders

Neuromuscular disorders (disorders that affect muscle control) can cause a woman to leak or retain urine. This may happen because the signals from brain and spinal cord do not connect properly with the bladder and urethra. This problem can be linked to other conditions, such as diabetes, stroke, or multiple sclerosis.

Medications

Loss of bladder control may be a side effect of medications, such as diuretics. Your doctor may need to change the dosage or type of medication to relieve symptoms.

Your doctor may ask you to keep a voiding diary to record the time and amount of urine leakage.

Diagnosis

A number of steps may be needed to find the cause of urinary incontinence. During a detailed medical history, you will be asked about factors that may affect your voiding habits. A voiding diary is a useful tool your doctor may suggest. He or she may ask you to record the time and amount of urine leakage, often for 3 days. You also should note how much liquid you drank and what you were doing when a leak occurred.

A pelvic exam will be done to detect physical conditions that might be linked to the problem. Lab tests also may be done to detect a urinary tract infection. Other tests measure how well your bladder empties:

• Stress test—coughing a few times with a full bladder. Any loss of urine is recorded.
• Dye test—wearing a pad after a nontoxic dye is put in the bladder. If the pad gets stained with the dye, there was a loss of urine.
• Urodynamics—measuring the pressure and volume of the bladder as it fills and the flow rate as it empties.
• Cystoscopy—looking inside the bladder and urethra through a thin, lighted tube with a lens at the end.

Treatment

There are many options for treatment. Often treatments are more effective when used in combination. Talk to your doctor as soon as your leakage is at a point that it bothers you. Some treatments work best when the trouble is found early.

Behavioral Treatments

The goal of behavioral treatment is to help a woman know why leaks occur and how to avoid them. Actions that put extra pressure on the pelvic muscles, such as coughing and straining, make some women leak more. Making the following changes in your lifestyle, if they apply to you, may help the problem:

• Lose weight.
• Avoid constipation.
• Avoid very heavy lifting (that causes urine leaks).
• Drink less caffeine (coffee, tea, some soda).
• Get treatment for lung diseases that make you cough.
• Stop smoking.

Physical Therapy

There are many types of physical therapy that can be done to treat urinary incontinence. One type, Kegel exercises, can help strengthen the pelvic muscles (see box). They improve urine control in 40–75% of women who use them. Like any exercise, they work only as long as you keep doing them.

Other types of physical therapy include biofeedback. This process teaches you how to strengthen pelvic muscles. It might be used with physical therapy or bladder training.

Devices

Sometimes devices can be used to make the pelvic muscles stronger or to block urine. The most common ones are:

• A weighted cone shaped like a tampon is placed in the vagina for a few minutes twice a day. When a woman contracts her pelvic muscles to keep the cone in place, the muscles get stronger.
• A pessary is a firm ring with a knob that is placed in the vagina. The knob supports the pelvic organs. It also may help prevent leaks by pressing on the urethra.

Medications

Kegel Exercises Kegel exercises tone your pelvic muscles. They strengthen the muscles around the openings of the urethra, vagina, and rectum. Just like doing sit-ups, these exercises work only if you use the right muscles, hold the "squeeze" long enough, and do enough of them. Here is how to do them: Squeeze the muscles that you use to stop the flow of urine (but don't do these exercises while you are urinating). Hold for up to 10 seconds, then release. Do this 10–20 times in a row at least 3 times a day. Be careful not to squeeze the muscles of the leg, buttock, or abdomen. Do these exercises on a regular basis. After 6–12 weeks, you should be able to hold your urine better.

Drugs that help control muscle spasms can help prevent leaks. Others can strengthen the muscle of the urethra. Some help relax a bladder that is too active. Your doctor will decide which is most likely to work best for you. Some drugs may have side effects, such as:

• Dry mouth
• Constipation
• Nausea
• Blurred vision
• Change in sleeping patterns

Surgery

Surgery can be done to treat stress urinary incontinence. You and your doctor will discuss many factors before choosing the surgery that is right for you:

• Your age
• Your lifestyle
• Any other condition that may be present
• Your medical history (if you have had surgery for loss of bladder control or radiation therapy)
• Your general health

Finally...

Loss of bladder control is a common problem and there are many treatment options available. However, it is important to seek professional help. If you have symptoms that affect your daily life, tell your doctor. A complete and thorough exam is needed to find the cause of the problem. In most cases, urinary incontinence can be greatly improved with treatment.

Glossary

Bladder: A muscular organ in which urine is stored.

Diuretics: Drugs given to increase the production of urine.

Fistula: An abnormal opening or passage between two internal organs.

Kidneys: Two organs that cleanse the blood, removing liquid wastes.

Pelvic Exam: A manual examination of a woman's reproductive organs.

Ureters: A pair of tubes, each leading from one of the kidneys to the bladder.

Urethra: A short, narrow tube that carries urine from the bladder out of the body.

Vagina: A tube-like structure surrounded by muscles leading from the uterus to the outside of the body.

This Patient Education Pamphlet was developed under the direction of the Committee on Patient Education of the American College of Obstetricians and Gynecologists. Designed as an aid to patients, it sets forth current information and opinions on subjects related to women's health. The average readability level of the series, based on the Fry formula, is grade 6–8. The Suitability Assessment of Materials (SAM) instrument rates the pamphlets as "superior." To ensure the information is current and accurate, the pamphlets are reviewed every 18 months. The information in this pamphlet does not dictate an exclusive course of treatment or procedure to be followed and should not be construed as excluding other acceptable methods of practice. Variations taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate.

Copyright © November 2005 by the American College of Obstetricians and Gynecologists. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

ISSN 1074-8601

Requests for authorization to make photocopies should be directed to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923.

To reorder Patient Education Pamphlets in packs of 50, please call 800-762-2264 or order online at sales.acog.org.

The American College of Obstetricians and Gynecologists
409 12th Street, SW
PO Box 96920
Washington, DC 20090-6920

12345/98765