Learn about urinary incontinence in women, its causes, symptoms, and effective management options at Meri Sehat. Empowering women's health.

Urinary Incontinence In Women

Humza Khizer

Overview

Urinary incontinence is defined as the involuntary loss of urine. 
Urinary incontinence is a common and often embarrassing issue. There are several types of urinary incontinence, each with its own set of symptoms. 
&nbsp;

According to the American Urological Association, a quarter to one-third of people in the United States suffer from urinary incontinence<a href="#accordion">[6]</a>. The condition affects women more than men, with an estimated 30% of females aged 30 to 60 years experiencing urinary incontinence<a href="#accordion">[6]</a>. It is believed that events such as pregnancy, childbirth, and menopause weaken the pelvic floor muscles in women, contributing to the involuntary loss of bladder control. Moreover, females have shorter urethra than men. Thus, any damage or weakness to the urethra is more likely to result in urinary incontinence. 
&nbsp;

In Pakistan, the exact prevalence of urinary incontinence remains unknown. A study on women attending gynecology clinics reported the frequency of urinary incontinence as 44.4%<a href="#">[8]</a>. Parity and age were most commonly associated with causing urinary incontinence in the women<a href="#accordion">[8]</a>. An observational study conducted at outpatient departments of various hospitals found mixed incontinence (64.5%) to be the most common type affecting women<a href="#accordion">[7]</a>. This was followed by stress (29.6%) and urge incontinence (6.0%)<a href="#accordion">[7]</a>.

The severity of urinary incontinence can range from leaking urine when coughing or sneezing to severe wetting. 
&nbsp;

Although urinary incontinence is more common in older adults, it is not an inevitable result of aging. Certain medications and infections can lead to urinary incontinence. In women, urinary tract infections, pregnancy, childbirth, and menopause are common causes.

Urinary incontinence affects both the emotional and psychosocial aspects of a woman&rsquo;s life. They become afraid to engage in normal daily activities and avoid social gatherings, scared of being too far from a toilet. Urinary incontinence can also lead to a loss of interest in sex and activities that once brought the person joy, leading to depression. Moreover, the stigma surrounding urinary incontinence makes it difficult for women to seek help. Thus, most women continue to suffer in silence. However, most underlying causes of urinary incontinence can be fixed with various medical or alternative treatments.&nbsp; 
&nbsp;

Urinary incontinence can be divided into the following types: 
&nbsp;

<ul>
	<li>Stress Incontinence - This is the most common type of urinary incontinence and is more common in young women. Weak pelvic floor muscles cause physical activity to put extra pressure on the bladder. Thus, activities, such as sneezing, coughing, laughing, lifting heavy objects, and exercising lead to a leakage of urine.&nbsp;&nbsp; 
	&nbsp;</li>
	<li>Urge Incontinence - Also called overactive bladder, urge incontinence is characterized by an intense need to pass urine. The individual is unable to postpone going to the toilet, and the time between the need to urinate and the release of urine is frequently only a few seconds. Urge incontinence commonly affects menopausal women. They may feel the need to urinate more than 8 times a day. A sudden change in position, or even the sound of running water, may cause an urge to pass urine. People may also pass urine during sexual intercourse, especially during an orgasm. 
	&nbsp;</li>
	<li>Mixed Incontinence - Many women suffer from both stress and urge incontinence. This is called mixed incontinence. For example, coughing or sneezing may cause a leak of urine and an intense urge to urinate. 
	&nbsp;</li>
	<li>Overflow Incontinence - Also known as chronic urinary retention, it occurs when the bladder is unable to empty completely when passing urine. It is more common in men than women. 
	&nbsp;</li>
	<li>Functional Incontinence - Mental impairment or physical conditions, such as arthritis or other disabilities makes it difficult for an individual to reach the toilet in time. Thus, resulting in the leakage of urine. 
	&nbsp;</li>
</ul>

Signs and Symptoms

Urinary incontinence is not a disease but rather a symptom of other health conditions. The severity of the sign can vary, depending on the cause. 
&nbsp;

The following are common symptoms associated with urinary incontinence.&nbsp;

<ul>
	<li>Leakage of urine with physical activity</li>
	<li>Leakage of urine with coughing, sneezing or laughing</li>
	<li>Frequent need to pass urine (frequency)</li>
	<li>Pelvic spasms or pressure in the pelvic area causing an intense need to urinate (urgency)</li>
	<li>Frequent trips to the toilet at night (nocturia)</li>
	<li>Bedwetting</li>
	<li>Constant wet feeling without the sensation of urine leakage</li>
	<li>A feeling of incomplete bladder emptying</li>
	<li>Rushing to the toilet because of fear or leaking of urine 
	&nbsp;</li>
</ul>

Note: If urinary incontinence is affecting your daily activities and causing distress, contact a healthcare professional immediately. 
&nbsp;

Causes

The urinary bladder has muscles that contract to force the urine out through the urethra. The sphincter muscles around the urethra typically relax to allow urine to exit the body. A sudden contraction of the bladder muscles and weakening of the sphincter muscles can lead to urinary incontinence. Moreover, dysfunction of the nerves controlling the bladder muscles and urethra can also lead to incontinence. Some common causes of urinary incontinence in women are: 
&nbsp;

<ul>
	<li>Pregnancy - Approximately 4 in 10 women experience urinary incontinence during pregnancy 9 . The weight of the fetus pushes against the pelvic floor muscles, bladder, and urethra, exerting pressure and causing the leakage of urine. Moreover, this increasing pressure may also weaken the pelvic floor muscles. Urinary incontinence typically resolves after childbirth as the muscles regain strength. However, if bladder problems persist 6 weeks post-childbirth, a healthcare professional should be contacted. 
	&nbsp;</li>
	<li>Childbirth - Vaginal delivery can weaken bladder control muscles and damage bladder nerves and supportive tissue, resulting in a prolapsed pelvic floor. When prolapse occurs, the bladder, uterus, rectum, or small intestine are pushed down from their normal position and protrude into the vagina. Incontinence may be associated with such protrusions. 
	&nbsp;</li>
	<li><a href="https://merisehat.pk/disease/menopause">Menopause </a>- The hormone, estrogen aids in the health of the bladder and urethra linings. Low levels of estrogen after menopause can cause a weakening of the urethra. Thus, resulting in incontinence. Moreover, the bladder&#39;s capacity to store urine reduces with age and involuntary bladder contractions become more common. 
	&nbsp;</li>
	<li>Infections - Urinary tract and bladder infections can also result in incontinence. 
	&nbsp;</li>
	<li><a href="https://merisehat.pk/disease/constipation">Constipation </a>- The rectum is located near the bladder and shares many nerves with it. The presence of hard, impacted stool in your rectum causes these nerves to become overactive, increasing urinary frequency. Moreover, constant straining can put pressure on the bladder and pelvic floor muscles, resulting in leakage of urine. 
	&nbsp;</li>
	<li>Overweight - Being overweight or obese exerts pressure on the bladder and weakens the muscles. A weak bladder is unable to hold too much urine, resulting in incontinence. 
	&nbsp;</li>
	<li>Obstruction - A tumor anywhere along the urinary tract can prevent urine from flowing normally, resulting in overflow incontinence. Urinary stones, which are hard, stonelike masses that develop in the bladder, can occasionally cause urine leakage. 
	&nbsp;</li>
	<li>Nerve Damage - <a href="https://merisehat.pk/disease/multiple-sclerosis">Multiple sclerosis</a>, <a href="https://merisehat.pk/disease/parkinsons-disease">Parkinson&#39;s disease</a>, a <a href="https://merisehat.pk/disease/stroke">stroke</a>, a brain tumor, or a spinal injury can all cause urinary incontinence by interfering with nerve signals involved in bladder control. 
	&nbsp;</li>
	<li>Surgery - Pelvic surgeries in women, such as hysterectomies, can damage the pelvic floor muscles and result in incontinence. 
	&nbsp;</li>
</ul>

Moreover, certain beverages, foods, and medications can act as diuretics, stimulating the bladder and increasing the volume of urine one produces. They are as follows:

<ul>
	<li>Alcohol</li>
	<li>Caffeine</li>
	<li>Sparkling water and carbonated beverages</li>
	<li>Artificial sweeteners</li>
	<li>Chocolate</li>
	<li>Chili peppers</li>
	<li>Foods high in spice, sugar, or acid, particularly citrus fruits</li>
	<li>Medication for heart and blood pressure, sedatives, and muscle relaxants</li>
	<li>Vitamin C in high concentrations 
	&nbsp;</li>
</ul>

Note: If your urinary incontinence does not resolve 6 weeks post-childbirth, contact a healthcare professional immediately. 
&nbsp;

The Women&#39;s Preventive Services Initiative (WPSI) recommends annually screening women for urinary incontinence<a href="#accordion">[10]</a>. Clinician- or self-administered questionnaires are typically used to identify women with the condition. However, there is a lack of evidence supporting the benefit of screening. 
&nbsp;

Diagnosis

The diagnosis of urinary incontinence is based on the patient&rsquo;s history, physical exam findings, and several tests. 
&nbsp;

<h5>Medical History</h5>

During a medical history, the doctor will question the patient on the duration, and severity of their symptoms. They may ask the following:

<ul>
	<li>Whether the individual experiences urinary incontinence after coughing or laughing</li>
	<li>Whether they regularly require a trip to the bathroom during the daytime or at night</li>
	<li>Whether they have any trouble passing urine while using the toilet</li>
	<li>Whether they are currently consuming any medications</li>
	<li>History of any pelvic surgeries</li>
	<li>The amount of liquid, alcohol, and/or caffeine they consume 
	&nbsp;</li>
</ul>

Moreover, the doctor will also ask about a history of pregnancy and whether they faced any complications during childbirth. 
&nbsp;

<h5>Physical Examination</h5>

During a physical exam, the doctor will examine the pelvic organs, such as the vagina, uterus, and rectum, and assess the strength of the pelvic floor muscles. 
&nbsp;

<h5>Bladder Diary</h5>

The doctor may ask the patient to keep a bladder diary for 2-3 days to provide details on the pattern of urinary incontinence. For several days, the patient will record their daily fluid intake, when they urinate, the amount of urine they produced, their urge to urinate, and the number of episodes of incontinence.

To identify or rule out potential causes of incontinence, the doctor may also recommend additional examinations and tests. These include: 
&nbsp;

<ul>
	<li>Urinalysis - Samples of the urine are checked for infections, presence of protein, and traces of blood. In case of infection, doctors may also send for a urine culture.</li>
	<li>Postvoidal Residual (PVR) Measurement - This involves checking the bladder for residual urine after the patient has completely emptied their bladder. The presence of a large amount of residual urine points to overflow incontinence.</li>
	<li>Pelvic Ultrasound - The imaging scan provides doctors with an image of the bladder and other parts of the urinary tract.</li>
	<li>Stress Test - The doctor tests for urine leakage while the patient coughs or strains.</li>
	<li>Cystoscopy - In a cystoscopy, the bladder and urinary tract are viewed through a little tube with a camera on it (endoscope). It can help detect abnormalities in the urinary tract.</li>
	<li>Urodynamic Tests - These tests are used to determine how well the bladder muscles and urinary sphincters can withstand pressure at rest and when filled.&nbsp;</li>
	<li>Cystogram - A dye is injected into the bladder and as the patient urinates, a series of X-rays help doctors detect any urinary tract abnormalities.</li>
	<li>Blood Tests - Doctors may order blood tests to assess kidney function. 
	&nbsp;</li>
</ul>

Treatment

Treatment typically depends on the underlying cause, the patient&rsquo;s age, the patient&rsquo;s general health, and the severity of urinary incontinence. 
&nbsp;

<h5>Conservative Therapy</h5>

Priority is given to conservative therapies that don&#39;t include drugs or surgery. These consist of the following: 
&nbsp;

<ul>
	<li>Lifestyle Changes - Quitting smoking &amp; alcohol, and avoiding caffeine and spicy food can improve urinary incontinence. Patients are also advised to reduce their fluid consumption. Moreover, losing weight relieves the pressure on the bladder and surrounding muscles, improving problems with bladder control.&nbsp;&nbsp; 
	&nbsp;</li>
	<li>Pelvic Floor Exercises (Kegel Exercises) - Kegel exercises help strengthen the pelvic floor muscles. It involves contracting and relaxing the pelvic muscles one normally uses to start and stop urinating. 10 sets of 10 contractions per day are typically recommended. However, all exercises should be started after a doctor&rsquo;s advice. 
	&nbsp;</li>
	<li>Bladder Exercises - A regular bathroom schedule can help train the bladder into recognizing when it&#39;s time to urinate. Thus, reducing urine leakage. Moreover, the bladder is slowly trained into increasing the time between trips to the toilet. Double voiding (urinating, then waiting for a few minutes and urinating again) is also practiced for bladder training. 
	&nbsp;</li>
	<li>Vaginal Weight Training - Small weights are inserted within the vagina. Tightening of the vaginal muscles helps hold the weights in place. Although it is beneficial in stress or mixed incontinence, some women may find the process difficult or uncomfortable. 
	&nbsp;</li>
</ul>

<h5>Electrical Stimulation</h5>

The vagina is fitted with electrodes that provide gentle electrical stimulation. This helps stimulate and strengthen the pelvic floor muscles. It can be beneficial for stress and urge incontinence. However, multiple treatments over a course of several months are required. 
&nbsp;

<h5>Incontinence Products</h5>

Even though incontinence products are not a cure for urine incontinence, they can be helpful for controlling symptoms while one waits for a diagnosis or for the treatment to start working. Moreover, these products can help ease the feeling of leaking urine. 
&nbsp;

<ul>
	<li>Catheter - A urinary catheter is a tiny tube that is placed in the urethra and continually drains the bladder. It is often reserved for severe cases.</li>
	<li>Pads And Protective Garments - Absorbent pads can be worn discreetly under clothes. Oftentimes, women may use panty liners. 
	&nbsp;</li>
</ul>

<h5>Medications</h5>

The following medications are used to treat urinary incontinence. 
&nbsp;

<ul>
	<li>Anticholinergics - In patients with urge incontinence, these can help calm overactive bladders. Examples include oxybutynin, tolterodine, fesoterodine, darifenacin, trospium, and solifenacin. These medications are commonly associated with side effects, such as constipation and dry mouth.</li>
	<li>Mirabegron - This medication is commonly used to treat urge incontinence. It helps relax the bladder muscles and increases the amount of urine the bladder can hold. Moreover, it can increase the amount of urine one empties out of the bladder at one time.</li>
	<li>Topical Estrogen - This can be applied in the form of a vaginal cream, patch, or ring. It helps strengthen vaginal and urethral tissues. 
	&nbsp;</li>
</ul>

<h5>Medical Devices</h5>

<ul>
	<li>Vaginal Pessary - This is a silicone ring that can be inserted into the vagina to help prevent urine leakage with activity. It is typically used in stress incontinence and can also be used in women with vaginal prolapse. The pessary should be removed and cleaned once every one or two weeks.</li>
	<li>Urethral Insert - This small, tampon-like device is inserted into the urethra before certain physical activities. The disposable device acts as a plug and prevents the leakage of urine. It is removed before urinating. 
	&nbsp;</li>
</ul>

<h5>Interventional Therapies</h5>

<ul>
	<li>Botox - Injections of botox into the bladder can be used to treat urge incontinence. It helps relax the bladder in cases of overactive bladder. Botox is only reserved for cases that don&rsquo;t respond to other treatments. However, it can cause UTIs or problems with emptying the bladder.</li>
	<li>Urethral Bulking Injections - This is an outpatient procedure and is performed under local anesthesia. A filler material is injected into the urethra to help keep it closed and reduce urine leakage. However, this procedure is less effective than surgical procedures for stress urinary incontinence.</li>
	<li>Sacral Nerve Stimulation - A sacral nerve stimulator is surgically implanted under the skin of the buttock. Wires connect it to the sacral nerve in the lower back. Painless electrical impulses stimulate the nerve which is involved in bladder control. It can be used to treat urge incontinence. 
	&nbsp;</li>
</ul>

<h5>Surgical Procedure</h5>

In women, surgical procedures are not performed if they intend to become pregnant in the future as pregnancy and childbirth can cause leakage again. The following surgical procedures are most commonly used for treating urinary incontinence in women. 
&nbsp;

Colposuspension - Colposuspension entails cutting a slit in the lower abdomen, elevating the bladder neck, and then sewing it in place. It can aid in preventing stress incontinence-related involuntary leaks. 
&nbsp;

Two varieties of colposuspension exist:

<ul>
	<li>Open Colposuspension, where a major cut is made during surgery</li>
	<li>Laparoscopic (Keyhole) Colposuspension, where surgery is performed through a laparoscope 
	&nbsp;</li>
</ul>

Although laparoscopic colposuspension must be performed by a skilled laparoscopic surgeon, both methods of colposuspension are effective long-term treatments for stress incontinence.

Recurrent urinary tract infections (UTIs), trouble emptying the bladder when urinating, and discomfort during sex are all potential complications that might arise following colposuspension. 
&nbsp;

Sling Surgery - An incision is made in the lower abdomen and vagina so that a sling can be inserted around the neck of the bladder. The sling keeps the urethra closed, stabilizing it and stopping urine leakage, especially when coughing or sneezing. A variety of materials can be used to create the sling. 
&nbsp;

<ul>
	<li>Autologous Sling - tissue from a different area of the body</li>
	<li>Allograft Sling - tissue provided by another individual</li>
	<li>Xenograft Sling - tissue harvested from an animal, such as cow or pig tissue 
	&nbsp;</li>
</ul>

An autologous sling is frequently employed. It is created from a portion of the tissue covering the abdominal muscles (rectus fascia). These slings are typically preferred since more information regarding their long-term performance and safety is available.

The procedure is most commonly associated with an inability to completely evacuate the bladder when urinating. Moreover, a tiny percentage of patients experience urge incontinence. 
&nbsp;

Prolapse Surgery - In women with pelvic organ prolapse and mixed incontinence, surgeons may opt for a combination of prolapse surgery and sling procedure.

Vaginal Mesh Surgery (Tape Surgery) - A strip of synthetic mesh is inserted behind the urethra to provide support. It is commonly used for the treatment of stress incontinence. Some common complications of the procedure are pain, nerve damage, constipation, incontinence, sexual problems, and mesh exposure through vaginal tissues. 
&nbsp;

Depending on the cause, duration, and severity, urinary incontinence can lead to the following complications:

<ul>
	<li>Urinary Tract Infections (UTIs) - Skin contact with moist underwear can cause UTIs to develop due to the favorable environment for the growth of bacteria. 
	&nbsp;</li>
	<li>Kidney Injury - If urine flow is obstructed, renal problems or kidney failure can develop. 
	&nbsp;</li>
	<li>Skin Problems - Skin infections, sores, and rashes can develop due to chronic urinary incontinence. 
	&nbsp;</li>
	<li>Prolapse - Weakened pelvic floor muscles can lead to part of the vagina, bladder, and sometimes urethra protruding through the vagina. 
	&nbsp;</li>
	<li>Negative Consequences On Mental Health - Urinary incontinence may result in reduced self-esteem, <a href="https://merisehat.pk/disease/anxiety">anxiety</a>, or stress. 
	&nbsp;</li>
</ul>

The following factors can increase one&rsquo;s risk of urinary incontinence: 
&nbsp;

<ul>
	<li>Gender - Stress incontinence is more common in women.</li>
	<li>Age - The bladder and urethra muscles deteriorate in strength with age. Moreover, the bladder&#39;s capacity also decreases, increasing the likelihood of accidental urine leakage.</li>
	<li>Being Overweight - Obesity or being overweight increases the pressure on the bladder and urethra. This excess pressure weakens the muscles. Thus, allowing urine to leak when one sneezes or coughs.</li>
	<li>Smoking - Tobacco increases the risk of urinary incontinence.</li>
	<li>Family History - The chance of acquiring urine incontinence increases if a close relative also has it, particularly urge incontinence.</li>
	<li>Some Diseases - Certain neurological conditions and diabetes can increase the risk of urinary incontinence. 
	&nbsp;</li>
</ul>

Sometimes urine incontinence cannot be avoided. However, the following measures can help lessen the risk:

<ul>
	<li>A healthy weight</li>
	<li>Pelvic floor exercises</li>
	<li>Avoiding alcohol, coffee, and foods high in acid.</li>
	<li>Consuming a high-fiber diet to avoid constipation</li>
	<li>Quitting smoking 
	&nbsp;</li>
</ul>

Urine analysis is a common clinical method for disease identification, which typically calls for trained professionals and expensive, heavy equipment. Moreover, it is difficult to collect urine from people suffering from urinary incontinence.

Now, researchers have come up with a cost-effective and convenient device that can detect urine in-situ<a href="#accordion">[5]</a>. The wearable sensing device is based on a smartphone and diaper.

It involves a built-in electrochemical biosensor, a portable detection tool, and an application (App) for data processing on a smartphone. A biosensor with a self-locking valve free from urine scouring is present between the diversion and absorption layer of a regular diaper to measure the amount of urine passed by the patient. Once the detection device is applied to the biosensor signal, it wirelessly transmits the data to a smartphone. The App can then draw curves of the urinary biomarkers based on the data.

According to the study, the wearable sensor reminded nurses to change a patient&rsquo;s diaper in time. Furthermore, it gave doctors real-time access to measured data of urine biomarkers to assess patients&#39; health. This demonstrated excellent application prospects for effectively caring for elderly people with disabilities in nursing homes. 
&nbsp;

Key Points

<ul>
	<li>Urinary incontinence is the involuntary loss of urine.</li>
	<li>Although this illness can strike at any age, women over the age of 50 are more likely to experience it.</li>
	<li>Pregnancy, childbirth, and menopause are the most common causes of urinary incontinence in women.</li>
	<li>Urinary incontinence exists in four different types: overflow, stress, functional, and urgency.</li>
	<li>Among the treatments for treating urine incontinence are behavioral therapies, drugs, nerve stimulation, and surgery</li>
</ul>

[1]  C JO, Luz ST Da, Brandão S, Da Luz CM, Jorge RN, Da Roza T. Urinary Incontinence in Physically Active Young Women: Prevalence and Related Factors. Int J Sports Med. 2017 Nov;38(12):937–41.

[2] Managing acute and chronic urinary incontinence. AHCPR Urinary Incontinence in  Adults Guideline Update Panel. Am Fam Physician. 1996 Oct;54(5):1661–72.

[3] Khandelwal C, Kistler C. Diagnosis of urinary incontinence. Am Fam Physician. 2013;87(8):543–50.

[4]=Hu JS, Pierre EF. Urinary incontinence in women: evaluation and management. Am Fam Physician. 2019;100(6):339–48.

[5] Su H, Sun F, Lu Z, Zhang J, Zhang W, Liu J. A wearable sensing system based on smartphone and diaper to detect urine in-situ for patients with urinary incontinence. Sensors Actuators B Chem. 2022;357:131459.

[6] Urinary incontinence: Treatment, causes, types, and symptoms. Medical News Today.

[7] Hassan S, Malik KK, Khursheed MA, Seikh AH, Ali A, Siddiqui AA. Frequency of different types of urinary incontinence and their impact on quality of life of Pakistani women. Pakistan BioMedical Journal. 2022:291-295. doi:10.54393/pbmj.v5i6.190

[8] Rizvi RM, Nazim MH. The frequency of urinary symptoms in women attending gynaecology clinics at the Aga Khan University Hospital Karachi, Pakistan. J Pak Med Assoc. 2005;55(11):489-492.