Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life.[1] It has been identified as an important issue in geriatric health care.[2] The term enuresis is often used to refer to urinary incontinence primarily in children, such as nocturnal enuresis (bed wetting).[3] UI is an example of a stigmatized medical condition, which creates barriers to successful management and makes the problem worse.[4] People may be too embarrassed to seek medical help, and attempt to self-manage the symptom in secrecy from others.
Pelvic surgery, pregnancy, childbirth, and menopause are major risk factors.[5] Urinary incontinence is often a result of an underlying medical condition but is under-reported to medical practitioners.[6] There are four main types of incontinence:[7]
Treatments include pelvic floor muscle training, bladder training, surgery, and electrical stimulation.[9] Behavioral therapy generally works better than medication for stress and urge incontinence.[10] The benefit of medications is small and long term safety is unclear.[9] Urinary incontinence is more common in older women.[11]
Age is a risk factor that increases both the severity and prevalence of UI
The body stores urine — water and wastes removed by the kidneys — in the urinary bladder, a balloon-like organ. The bladder connects to the urethra, the tube through which urine leaves the body.[21]
Continence and micturition involve a balance between urethral closure and detrusor muscle activity (the muscle of the bladder). During urination, detrusor muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. The urethral sphincter is the muscular ring that closes the outlet of the urinary bladder preventing urine to pass outside the body. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder, and maintaining continence.[22] The urethra is supported by pelvic floor muscles and tissue, allowing it to close firmly. Any damage to this balance between the detrusor muscle, urethral sphincter, supportive tissue and nerves can lead to some type of incontinence .
For example, stress urinary incontinence is usually a result of the incompetent closure of the urethral sphincter. This can be caused by damage to the sphincter itself, the muscles that support it, or nerves that supply it. In men, the damage usually happens after prostate surgery or radiation,[17] and in women, it's usually caused by childbirth and pregnancy.[23] The pressure inside the abdomen (from coughing and sneezing) is normally transmitted to both urethra and bladder equally, leaving the pressure difference unchanged, resulting in continence. When the sphincter is incompetent, this increase in pressure will push the urine against it, leading to incontinence.
Another example is urge incontinence. This incontinence is associated with sudden forceful contractions of the detrusor muscle (bladder muscle), leading to an intense feeling of urination, and incontinence if the person does not reach the bathroom on time. The syndrome is known as overactive bladder syndrome, and it's related to dysfunction of the detrusor muscle.[24]
– the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
Stress test
– urine is tested for evidence of infection, urinary stones, or other contributing causes.
Urinalysis
– blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
Blood tests
– sound waves are used to visualize the kidneys and urinary bladder, assess the capacity of the bladder before voiding, and the remaining amount of urine after voiding. This helps know if there's a problem in emptying.
Ultrasound
– a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
Cystoscopy
– various techniques measure pressure in the bladder and the flow of urine.
Urodynamics
(for men) – consists of a sheath worn over the penis funneling the urine into a urine bag worn on the leg. These products come in a variety of materials and sizes for individual fit. Studies[55] show that urisheaths and urine bags are preferred over absorbent products – in particular when it comes to 'limitations to daily activities'. Solutions exist for all levels of incontinence. Advantages with collecting systems are that they are discreet, the skin stays dry all the time, and they are convenient to use both day and night. Disadvantages are that it is necessary to get measured to ensure proper fit, and in some countries, a prescription is needed.
Collecting systems
Absorbent products (include , incontinence pads, undergarments, protective underwear, briefs, diapers, adult diapers and underpants) are the best-known product types to manage incontinence. They are widely available in pharmacies and supermarkets. The advantages of using these are that they barely need any fitting or introduction by a healthcare specialist. The disadvantages with absorbent products are that they can be bulky, leak, have odors and can cause skin breakdown due to the constant dampness.
shields
are single-use catheters that are inserted into the bladder to empty it, and once the bladder is empty they are removed and discarded. Intermittent catheters are primarily used for urinary retention (inability to empty the bladder), but for some people they can be used to reduce or avoid incontinence. These are prescription-only medical devices.
Intermittent catheters
Different types of pessaries. These are inserted inside the vagina for support.Indwelling catheters (also known as foleys) are often used in hospital settings, or if the user is not able to handle any of the above solutions himself/herself (e.g. severe neurologic injury or neurodegenerative disease). These are also prescription-only medical devices. The indwelling catheter is typically connected to a urine bag that can be worn on the leg or hung on the side of the bed. Indwelling catheters need to be monitored and changed on a regular basis by a healthcare professional. The advantage of indwelling catheters is that because the urine is funneled away from the body, the skin remains dry. However, the disadvantage is that it is very common to incur urinary tract infections when using indwelling catheters. Bladder spasms and other problems can also occur with long-term use of indwelling catheters.[56]
(or penis compression device), which is applied to compress the urethra to compensate for the malfunctioning of the natural urinary sphincter, preventing leakage from the bladder.[57] This management solution is only suitable for light or moderate incontinence.
Penis clamp
for women are devices inserted into the vagina. This device provides support to the urethra which passes right in front of it, allowing it to close more firmly.
The management of urinary incontinence with pads is mentioned in the earliest medical book known, the Ebers Papyrus (1500 BC).[83]
Incontinence has historically been a taboo subject in Western culture. However, this situation changed some when Kimberly-Clark aggressively marketed adult diapers in the 1980s with actor June Allyson as spokeswoman. Allyson was initially reticent to participate, but her mother, who had incontinence, convinced her that it was her duty in light of her successful career. The product proved a success.[84]
The effectiveness of different therapeutic approaches to treating urinary incontinence is not well studied for some medical conditions. For example, for people who experience urinary incontinence due to stroke, treatment approaches such as physical therapy, cognitive therapy, complementary medicine, and specialized interventions with experienced medical professionals are sometimes suggested, however it is not clear how effective these are at improving incontinence and there is no strong medical evidence to guide clinical practice.[20]
