Excerpts from The Incontinence Solution: Answers for Women of All Ages

DEFINING INCONTINENCE

WHAT IS INCONTINENCE? 
Incontinence is the uncontrollable loss of enough urine to cause social or sanitary difficulties. When we study the body and look at how we are able to control urination, we know that an infant does not have the proper connections between their brain and their bladder to be able to control the bladder. We also know that as the brain develops, young children can be taught to have control of when and where they empty their bladders. This learned control is then maintained, usually without much thought, throughout adulthood. To a child or an adult, any loss of bladder control feels like a return to infancy and can be an embarrassment and a source of terrible discomfort.  

Incontinence can be a significant problem for young, middle age and older women. Life with incontinence, even mild incontinence, can become very stressful. Incontinence threatens self-image, body image and self-esteem. Concerns about having to deal with incontinence may hinder career opportunities for women in the workforce. The embarrassing loss of self-control makes a woman feel old and helpless. Outings for shopping and recreation may be planned around the availability of a bathroom. Travel to new places becomes difficult. The need to always have a change of clothes or to worry about odor is a constant concern. Or, women suffering from incontinence may stop some of the activities they enjoy altogether; they may avoid getting together with friends or family; they may avoid sexual contact; they may feel depressed. 

Many people consider adult incontinence a natural part of aging. It is not! The vast majority of older women do not have incontinence. Most people are not aware that young women also can have incontinence. Since incontinence is so frequently associated with aging, those younger women are even less likely to talk about it or seek treatment. The good news is that there are now many ways to treat women of all ages who have incontinence. 

IS ALL INCONTINENCE THE SAME?
Incontinence is a symptom- the loss of urine. The two most common types of incontinence are loss of urine with laughing, coughing or sneezing, called stress incontinence, and loss of urine proceeded by a strong urge to go, called urge incontinence or overactive bladder. Sometimes a woman has both types of incontinence at the same time. This combination of incontinence is called mixed incontinence. Different types of incontinence have different causes, and different treatments solve each type of incontinence. The first step to end the incontinence is for the doctor to determine which type of incontinence you have. This starts by having you answer questions about your symptoms. Following that, there are a number of simple tests performed to help pinpoint the nature of the problem, which we will discuss in chapter 3. But first, it will be helpful to understand what the possible types of incontinence are. The chart gives brief definitions of the types of incontinence, and more detailed explanations follow.

TYPES OF INCONTINENCE (CHART)

• STRESS incontinence.... urine loss with some type of physical stress to the body such as with a cough, sneeze, physical activity or laughing.
• URGE incontinence.... urine loss proceeded by a sense of needing to urinate before reaching the bathroom.
• MIXED incontinence.... urine loss with features of both stress and urge.
• OVERFLOW incontinence.... urine loss occurring when the bladder is full, but the bladder does not contract properly to push the urine out. The urine then trickles out of the over-full bladder.
• TOTAL INCONTINENCE.... the constant loss of urine. 

WHAT HAPPENS WHEN A LAUGH, COUGH OR SNEEZE CAUSES LEAKING?
You may have noticed that sometimes a loss of urine occurs as a result of a cough, sneeze, laugh or vigorous exercise. Many women with this problem, known as stress incontinence, may begin limiting their own activities for just this reason. However, coughing, sneezing and even laughing are often unavoidable. We need to laugh and exercise (and cough and sneeze) to live life to it fullest. Understanding stress incontinence is the first step to finding a solution.

Stress incontinence got its name because the pressure or strain from a laugh or cough results in a loss of urine. The bladder and urethra are normally held firmly in place by muscles and connecting tissue in the pelvis (see figure 1-1). When you cough, pressure increases inside your abdomen, and the pressure pushes on your bladder and urethra. If the supporting pelvic muscles or connecting tissues have been damaged or weakened, they may not be able to withstand the force of the cough. The pressure then forces the urethra to open, and urine leaks out. (fig 1-2) Many activities that you ordinarily wouldn't even think about can cause increased pressure in the abdomen and the bladder. A cough, a strain to lift a heavy piece of luggage, aerobic exercise, or even a hiccup can challenge a woman with this problem.

WHAT CAUSES STRESS INCONTINENCE?
As we discuss in chapter 4, pregnancy and childbirth can damage the pelvic ligaments that anchor the uterus and bladder to the bones of the pelvis. The muscles that support the bladder work differently than most other muscles. Other muscles in your body usually relax until you ask them to do something for you, like lift a fork or bend at the waist. However, the pelvic muscles are always contracted, so they can continually hold up the bladder, uterus and the intestines. If these muscles, and the connecting tissue that attaches the muscles to the pelvic bones, get stretched or damaged, as may happen during childbirth, they become less effective at holding things up. As a consequence, the urethra may be pushed out of position as a result of a cough, sneeze or strenuous activity because the muscle support cannot withstand the extra pressure. 

The nerves sending messages from the brain to the pelvic muscles may also be altered due to childbirth. In the birth canal, the baby's head puts pressure on these nerves. Prolonged pressure, or undue pressure because of the size of the baby's head, may damage these nerves so they cannot send signals properly to the supporting muscles. As a result, the muscles may not be able to hold the bladder up. 

Other factors also cause an increased pressure on the pelvic organs that probably contributes to incontinence. A family history of incontinence may be an important factor since the amount and strength of the collagen that makes up the supporting tissue is inherited. Smoking can decrease the amount of oxygen the muscles and ligaments get and thereby lead to weakened tissues. In addition, smokers often cough, and every cough pushes against the bladder and pelvic ligaments and, over time, may weaken them. If a woman is overweight, extra pressure is added to an already weakened system and may aggravate the problem of leakage. Chronic constipation that causes straining to pass a bowel movement also increases abdominal pressure and can weaken the support of the bladder and pelvic organs. 

In some women, hormonal changes that occur with menopause can cause thinning of the tissues and blood vessels of the urethra. Try to visualize the urethra as a tube - if you were to cut across it, the cross section would look like a donut. With declining estrogen levels, the walls of this tube shrink, which results in a larger hole. The larger the opening, the more difficult it is for the muscles to seal. If the urethra is not closed, urine can leak out. (see fig 1-3)

Any one or more of these factors- stretched pelvic muscles, excess body weight, damaged nerves, or thinning of the urethra - may lead to stress incontinence. As you will see in later chapters, treatment for this type of incontinence involves strengthening the pelvic muscles or repairing the supporting tissues to the bladder and urethra.

WHAT IF YOU HAVE THE URGE TO URINATE FREQUENTLY?
Urgency is the sense that you have to urinate right now. When you gotta go, you gotta go. A constant urge to empty the bladder and all the necessary trips to the bathroom can be disabling to many women. They do not necessarily leak urine, but their lives are nevertheless taken over by their bladder problems. Urgency is basically the result of the bladder misbehaving, of the bladder being over-active. In fact, the term overactive bladder is now frequently used instead of urgency. Instead of quietly collecting urine, the bladder is constantly making a nuisance of itself. This is perceived as ever-present bladder pressure. The bladder feels as if it is always full, but, in fact, most trips to the toilet produce no more than a few ounces of urine. Some women may note urgency during the night that repeatedly wakes them. 

Urgency and frequency are frustrating problems. Many women suffer in silence because they do not realize that, thankfully, there are many solutions to their problem. These include taking prescription medication, learning to urinate on a schedule or doing muscle exercises that can help reduce spasms. Simple dietary changes may also help reduce frequency and urgency. These non-surgical treatments and others are fully discussed in chapter 5. 

HOW COMMON IS URGENCY?
Urgency is one area where age does seem to make a difference. About 6% of women under 40 have symptoms of urgency, and about 10% of women have this symptom prior to menopause. By the time women reach their late 50s and early 60s, about 40% will have urgency. And, by the time women reach their eighties, nearly 80% have this problem. About 40% of women who develop urgency also have urge incontinence, meaning urgency to the degree that they may actually lose urine.

WHAT CAUSES A STRONG URGE TO URINATE?
The most common temporary cause of having a strong urge to urinate is a bladder infection. The infection causes irritation of the bladder lining that leads to spasms of the bladder muscle. However, the bladder irritation and urgency goes away once the infection is treated with antibiotics. Only rarely will a bladder infection lead to such severe urgency that incontinence results. If treated, these infections have no permanent effect on your bladder. 

Unlike stress incontinence, childbirth does not appear to play any role in the development of urgency. Most women who have urgency have no easily explainable reason for their problem. A number of theories suggest what the causes might be, but none have been proven. Some researchers focus on the nerve signals to the bladder. They suggest that some women may have a mild, probably age-related, change in the nerves or the chemical signals between the nerves, which leads to over-activity of the bladder. Some propose that the problem is rooted in the muscle cells of the bladder itself, which may be over-active. This theory is supported by the fact that about 50% of women with urge incontinence also have a similar problem with their intestines called irritable bowel syndrome. The over-activity of the muscle cells in the intestines that occurs with irritable bowel syndrome leads to abdominal cramping.

Some women have over-activity of the bladder from causes that are easier to establish. Women who have had multiple surgeries to correct incontinence are at a slightly higher risk to developing urgency and urge incontinence. In these women, the bladder nerves may be injured after being pulled, stretched or even cut at the time of surgery. In others, previous surgery may have caused scar tissue to block the flow of urine out of the bladder. The bladder then needs to work harder to get the urine out past the scar tissue, and the over-worked bladder muscle may function poorly.

Another condition associated with bothersome frequency and urgency is called interstitial cystitis, abbreviated IC. IC may also be associated with recurrent discomfort or pain, both in the bladder and the nearby pelvic area. Interstitial cystitis is fully discussed in chapter 7.

Conditions affecting the nervous system such as Parkinson's disease, multiple sclerosis, Alzheimer's disease or stroke may also cause urge incontinence. Other rare conditions such as benign polyps in the bladder or stone formation in the bladder can also lead to urgency and incontinence. These problems can easily be evaluated with a cystoscope, a small telescope that allows the doctor to look into the bladder. This office procedure is called cystoscopy and only takes a few minutes. Prior to insertion of the cystoscope, a topical anesthetic in a gel form is inserted into the urethra in order to relieve discomfort. With the cystoscope, we can see irritation from interstitial cystitis, or the presence of a bladder stone, bladder cancer or the over-grown bladder lining cells that form polyps. 

WHAT IF THERE'S A STRONG URGE TO URINATE AND THEN YOU LOSE CONTROL? 
Normally you make a conscious decision about when to empty your bladder. When you get the feeling that your bladder is full, you control the urge to urinate and make it to the bathroom in time. However, some women have an over-active bladder that tries to empty on its own, often without much warning. If you get a contraction of the bladder that causes such a strong sense of urgency that you cannot control it, you may lose urine before you can get to the bathroom. This is called urge incontinence. The causes of this problem are similar to those described for urgency.

Some women may have urge incontinence when they put their hands in running water or just hear water running. Some note urge incontinence when they change position rapidly, such as getting up quickly from a chair. Others get urge incontinence when they return home with a full bladder, park the car, rush to the front door, and put the key in the door. The anticipation of relief triggers a bladder spasm. This is so common it has a name, "key in door incontinence". Women with urge incontinence report that it affects the quality of their lives more than do women who have stress incontinence, depression, or even diabetes. Urge incontinence often will result in a larger amount of lost urine than stress incontinence, and it is often unpredictable. While you may be able to brace yourself when you are about to laugh or cough and prevent loss of urine from stress incontinence, there is little warning with urge incontinence. By the time you realize what is happening, it is too late. Hence, women with this problem are often subject to embarrassing accidents. 

This is no small problem. The unpredictability often causes women to stay at home near a bathroom or to limit activities to places where a bathroom is immediately available. Clothes may be limited to dark colors that hide wetness. Fear of odor or loss of urine during intercourse may lead to avoidance of intimacy. This often leads to isolation and depression. Urge incontinence may occur at night, resulting in a wet bed that needs to be changed. Disturbed sleep and resulting fatigue are common in women with this problem. Women with urge incontinence feel terrible about their condition, but often delay seeing a doctor because they are depressed and feel helpless. These women are not aware of the available treatments, all non-surgical, that are now used to help women with urge incontinence. A discussion of these treatments can be found in chapter 5.

WHAT CAN CAUSE LEAKAGE WITH EVEN MINOR ACTIVITY?
Some women have very frequent leakage. They often leak when their bladders are full but may also leak when their bladders are nearly empty. They might leak when they cough or sneeze, but sometimes also note leakage even when they are lying down. These symptoms may result from a condition called intrinsic sphincter deficiency or ISD. Women with this problem are often understandably miserable.

Although this is a relatively rare problem, there are a number of possible causes for this type of incontinence. The problem exists in the urethral sphincter, the muscles and soft tissue that surround the urethra and hold the urine in the bladder (see figure 1-4). The muscles are normally squeezed closed, continuously shutting off the flow of urine. The urethra, which is shaped like a tube, is lined with soft, cushioning tissue that helps to form a watertight seal. When you laugh or sneeze, the muscles around the urethra resist the added pressure. The muscles are only supposed to relax when you are ready to urinate.

However, prior injury to the muscles or soft tissue can weaken the watertight seal and may allow urine to leak out. This type of incontinence is called intrinsic sphincter deficiency (ISD) because it is the watertight seal (the sphincter) that is not functioning properly (deficient). One cause for this problem, ironically enough, is the result of previous surgery for incontinence. The healing process following a surgery around the bladder and urethra may sometimes lead to scar tissue, which is much less supple than normal tissue. In rarely cases, you may form too much scar tissue, and it may pull on the urethra and actually hold it open, allowing urine to leak out. In addition, small nerves to the urethra are not visible and may be inadvertently stretched or cut during surgery. This is not the result of poor surgical skills on the part of your doctor, but rather an unusual and unfortunate consequence of the body's healing process. 

Another cause of this type of incontinence is radiation treatment for cancer. Radiation applied to the pelvic area can damage small blood vessels in the area, thus reducing the blood flow. Over time, often many years later, the radiation damage to the urethra can lead to thinning of the cushioning tissue that forms the water-tight seal. As a result, the urethra does not close entirely, and incontinence is the result. 

Age also appears to play a role in the development of ISD (intrinsic sphincter deficiency). As you age, the elasticity of the tissues decreases, and the watertight seal may not close off entirely. This type of very troubling incontinence probably results from a combination of aging, previous surgery or radiation that eventually are significant enough to cause incontinence. The good news is that there are now a number of ways to help correct ISD (see chapter 6).

References:

REFERENCES

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Diokno A. Diagnostic categories of incontinence and the role of urodynamic testing. 1990 Journal of the American Geriatric Society 38:300.

Elving L, Foldspang A, Lam G, Mommsen S. Descriptive Epidemiology of urinary incontinence in 3,100 women age 30-59. 1989 Scandinavia Journal of Urology and Nephrology Supplement 125:37.

Herzog A, Fultz N. Prevalence and incidence of urinary incontinence in community-dwelling populations. 1990 Journal of the American Geriatric Society 38:273.

Kelleher C, Cardozo L, Toozs-Hobson P. Quality of life and urinary incontinence. Current Opinion in Obstetrics and Gynecology 1995 7;404.

Klutke C, Golomb J, Babaric Z, et al. The anatomy of stress incontinence: magnetic resonance imaging of the female bladder neck and urethra. 1990 Journal of Urology 143:563.

Nygaard I, Thompson F, Svengalis S, et al. Urinary incontinence in elite Nulliparous athletes. 1994 Obstetrics and Gynecology 84:183.

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