Before I get down to describing incontinence, let me start by explaining the physiology of urinary continence. Bladder control means more than just telling yourself to wait to urinate until you get to the bathroom.

So what causes Urinary Incontinence?

Urinary incontinence has many etiologies. Some can be transient while others are permanent in nature.The leading culprits of incontinence have been neurologic disease, prostatic disease and obstetric factors.

Below is a list of some of the causes:

Anatomical problems- these are problems with the structure of the urinary tracti.e birth defects (congenital) like people born with duplex kidney with 2 ureters, Ectopic ureter or abnormal bladder, duplicated renal collecting system.

Blockage – obstruction to urine flow

Brain or nerve problems- (neuromuscular disorders) problems affecting one or more nerves. Either the detrusor muscle over-contracts or the interior sphincter lacks the tension to hold urine in. Neurological conditions such as multiple sclerosis or stroke.; Spinal injuries; Nerve or muscle damage after pelvic radiation

Psychological disorders- Dementia, Mental confusion and Depression or other psychological problems that affect the ability to recognize and respond to the urge to urinate

Post-Surgery complications -Weakness of the sphincter, the circular muscles of the bladder responsible for opening and closing it; this can happen following prostate surgery in men (side-effect of transurethral resection of the prostate (TURP) , or vaginal surgery in women

Pharmaceutical agents- Certain medications (such as diuretics, antidepressants, tranquilizers, some cough and cold remedies, and antihistamines for allergies)

Pregnancy and childbirth - Studies show that pregnancy, mode of delivery and parity (the number of children a woman has had) are all factors that can increase the risk of incontinence

Prostate infection or inflammation

Stool impaction- from severe constipation, causing pressure on the bladder

Urinary tract infection or inflammation

Poor overall general health - diabetes, stroke, high blood pressure, smoking history, Parkinson's, back problems, obesity (Weight gain), Alzheimer's, and pulmonary disease

Bladder cancer

Bladder spasms - overactive bladder

Large prostate in men

Pelvic prolapse in women -- falling or sliding of the bladder, urethra, or rectum into the vaginal space, often related to having had multiple pregnancies and deliveries

Who can suffer from incontinence?

The condition of urinary incontinence is far more prevalent in women than men with a significant progress in incidence with the increase of age (as the human body ages, muscle loss and weakness occur and the urinary tract is not spared).

This does not necessarily mean when you grow old you’ll, definitely suffer from urinary incontinence nor does it mean young people don’t suffer from incontinence.

TYPES

“Urinary incontinence” is a general term. There are, in fact 5 types of urinary incontinence.

Stress incontinence

Also known as effort incontinence. Stress incontinence is when urine leaks because of sudden pressure on your lower stomach muscles, such as when you cough, laugh, lift something or exercise. Stress incontinence usually occurs when the pelvic muscles are weakened, for example by childbirth or surgery. Stress incontinence is common in women.

Urge incontinence

Also referred to as "overactive bladder" . Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate. Your body may only give you a warning of a few seconds to minutes before you urinate. Risk factors for urge incontinence include aging, obstruction of urine flow, inconsistent emptying of the bladder and a diet high in bladder irritants (such as coffee, tea, colas, chocolate and acidic fruit juices).

Overflow incontinence

This type of incontinence is the uncontrollable leakage of small amounts of urine. It's caused by an overfilled bladder. It is characterized by frequent urination and dribbling (they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine). You may feel like you can't empty your bladder all the way and you may strain when urinating. This often occurs in men and can be caused by something blocking the urinary flow, such as an enlarged prostate gland or tumor. Diabetes or certain medicines may also cause the problem.

Functional incontinence

This type occurs when you have normal urine control (a person recognizes the need to urinate) but have trouble getting to the bathroom in time. You may not be able to get to the bathroom because of arthritis or other diseases that make it hard to move around (confusion, dementia, poor eyesight, poor mobility, poor dexterity, unwillingness to toilet because of depression, anxiety or anger, drunkenness).

Mixed incontinence

Involves more than one type of urinary incontinence.

Others

Coital incontinence (voiding during sex or orgasm), nocturnal incontinence (Bedwetting- Enuresis),

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The clinical presentation of urinary incontinence, based on severity, frequency, and amount of debilitation varies from patient to patient. And since many patients may be reluctant to initiate discussions about incontinence, all patients, especially in the risk group, should be asked focused questions about voiding problems.

Depending on the etiology, clinical signs can include, Fecal incontinence, Pelvic organ prolapse, vaginal splinting for bowel movements, Urinary hesitancy, frequency, urgency, dysuria (painful urination), Incomplete emptying, poor stream, Pelvic pressure/pain, Chronic constipation, Sacral backache.

The patient may also have some drug side effects or certain medical conditions (diabetes, stroke, high blood pressure, smoking history, Parkinson's, back problems, obesity (Weight gain), Alzheimer's, and pulmonary disease)

Diagnostics

A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Therefore the following should be included in history taking’

Duration of complaint

Conditions at onset - use of drugs, recent surgery, and illness, pregnancy, postpartum, trauma

Patterns - nocturnal vs diurnal

Precipitants- cough, sneeze, position change, sound of running water

Frequency/severity/quantity, patients voiding diary (to request that the patient fill out a diary of her voiding habits over 1-7 days)

bowel function, pelvic pain, and sexual function

Physical Exam: The examination is targeted at those systems which help support the bladder and maintain continence. In particular, sensation of the perineal area, reflexes that involve the pelvic nerves, the muscles of the pelvic floor, the skin as an estimation of the overall strength of connective tissue, and of course the supports of the bladder, urethra and bladder neck will be evaluated.

Lab diagnostics and tests

Obtain a urinalysis and urine culture.

urodynamic tests- The bladder is filled through a catheter, a narrow tube that is inserted into the urethra, and the function of the bladder and urethra are checked. If the bladder is overactive, the pressure will rise, and this pressure change can be measured. With the bladder filled to a specified volume, coughing and straining are performed to allow measurement of the pressures on the bladder that will cause an individual to leak urine.

Postvoid residual volume test—The amount of urine that is left in the bladder after urinating is measured with an ultrasound device or by placing a catheter in the bladder.

Stress test—During a stress test, you are asked to cough a few times with a full bladder. Any loss of urine is recorded.

Cystoscopy— A thin, lighted tube with a camera lens at the end is used to look inside the bladder and urethra. It is usually performed after placing an anesthetic gel in the urethra. The patient is placed in a special examining chair, and the cystoscope, which is only a few milimeters in diameter, is passed into the urethra while sterile water is running into the bladder. The physician can observe the health of the urethra, and can observe the response of the urethra and bladder neck to the patient's attempts to squeezing to hold urine, or to coughing or straining. Any holes into the vagina (fistula) or pockets (diverticula) can be seen as well. After the urethra is examined, the physician will then advance the cystoscope into the bladder and systematically examine the entire bladder wall for evidence of anything that may account for the symptoms

Dye test—A pad is worn after a nontoxic dye is put in the bladder. If the pad gets stained with the dye, there was a loss of urine.

Treatment

Treatment depends on what's causing the problem and what type of incontinence you have, your lifestyle, and your preferences, starting with the simpler treatment options. The treatment options range from conservative treatment, behavior management, medications and surgery.

Behavioral therapies include bladder retraining, timed voiding, prompted voiding, decreasing fluid intake, and decreasing caffeinated beverages.

Pelvic muscle rehabilitation includes

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.

Squeeze the muscles that you use to stop the flow of urine.

Hold for up to 10 seconds, then release.

Repeat 10–20 times 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. It may take 4–6 weeks to notice an improvement in urinary incontinence symptoms.

Performing Kegel exercises while you are pregnant and soon after delivery may help prevent incontinence related to childbirth.

Biofeedback

In biofeedback, sensors are placed inside or outside the vagina. These sensors measure the force of pelvic muscle contraction. When you contract the right muscles, you will see the measurement on a monitor. This feedback lets you know that you are doing Kegel exercises in the right way.

Others include, vaginal weight training, and pelvic floor electrical stimulation(the pelvic muscles are made to contract with special electrodes.). It increases urethral resistance by strengthening the pubococcygeus, periurethral, and pelvic muscles.

Anti-incontinent devices include pessaries(a device that is inserted into the vagina to treat pelvic support problems and urinary incontinence. Pessaries support the pelvic structures, and some compress the urethra.), urethral occlusion devices, absorbent pads

surgical therapies. This includes retropubic slings(slings to lift or provide support for the urethra.), suspensions(Colposuspension—Stitches are suspended across the neck of the bladder and the first part of the urethra and attached to tissue on either side. These stitches lift up the bladder and urethra and hold them in place.), and bulking injections(A substance is injected into the tissues around the urethra to add bulk. The urethra becomes narrowed, decreasing leakage). High success rates but higher complication rates

electrostimulation and magnetic therapy- are used in patients with spinal cord dysfunction. (Pelvic floor muscle stimulation, Intravaginal electrical stimulation, Sacral neuromodulation - Implanted devices for nerve stimulation). The effectiveness of these methods is questionable because there are insufficient studies. These modalities

Intravesical botulinum injections- i.eBotox to treat patients with overactive bladder problems caused by multiple sclerosis and spinal cord injury.

Medicines can affect bladder control in different ways. Some medicines help prevent incontinence by blocking abnormal nerve signals that make the bladder contract at the wrong time, while others slow the production of urine. Still others relax the bladder or shrink the prostate. Therefore, your doctor may consider changing a prescription you already take or prescribe the following:

• Alpha-blockers are used to treat problems caused by prostate enlargement and bladder outlet obstruction. They act by relaxing the smooth muscle of the prostate and bladder neck, allowing normal urine flow and preventing abnormal bladder contractions that can lead to urge incontinence.

• 5-alpha reductase inhibitors: work by inhibiting the production of the male hormone DHT, which is thought to be responsible for prostate enlargement.
• Imipramine: Marketed as Tofranil, this drug belongs to a class of drugs called tricyclic antidepressants. It relaxes muscles and blocks nerve signals that might cause bladder spasms.

• Antispasmodics: Propantheline (Pro-Banthine), tolterodine (Detrol LA), oxybutynin (Ditropan XL), darifenacin (Enablex), trospium chloride (Sanctura), and solifenacin succinate (VESIcare) belong to a class of drugs that work by relaxing the bladder muscle and relieving spasms.

What else can you do? Self-help

Other measures include:

• Regulate your bowels to avoid constipation. Try increasing fiber in your diet.

• Quit smoking to reduce coughing and bladder irritation. Smoking also increases your risk of bladder cancer.

• Avoid alcohol and caffeinated beverages, particularly coffee, which can overstimulate your bladder.

• Lose weight if you need to.

• Avoid foods and drinks that may irritate your bladder, like spicy foods, carbonated beverages, and citrus fruits and juices.

• Keep blood sugar under good control if you have diabetes.

• Bladder retraining -- this involves urinating on a schedule, whether you feel a need to go or not. In between those times, you try to wait to the next scheduled time. At first, you may need to schedule 1-hour intervals. Gradually, you can increase by 1/2-hour intervals until you are only urinating every 3 - 4 hours without leakage.