Urinary bladder

The urinary bladder is a hollow, collapsible muscular sac that stores and expels urine situated in the pelvic cavity posterior to the pubic symphysis. In males, it is
directly anterior to the rectum; in females, it is anterior to the vagina and inferior to the uterus (see Figure 1). Folds of the peritoneum hold the urinary bladder in position. When slightly distended due to the accumulation of urine, the urinary bladder is spherical. When it is empty, it collapses. As urine volume increases, it becomes pear shaped and rises into the abdominal cavity.

Urinary bladder capacity averages 700–800 mL. It is smaller in females because the uterus occupies the space just superior to the urinary bladder.

Anatomy of the Urinary Bladder

In the floor of the urinary bladder is a small triangular area called the trigone. The two posterior corners of the trigone contain the two ureteral openings; the opening into the urethra, the internal urethral orifice, lies in the anterior corner (see Figure 2). Because its mucosa is firmly bound to the muscularis, the trigone has a smooth appearance. Three coats make up the wall of the urinary bladder. The deepest is the mucosa, a mucous membrane composed of transitional epithelium and an underlying lamina propria similar to that of the ureters. The transitional epithelium permits stretching. Rugae (the folds in the mucosa) are also present to permit expansion of the urinary bladder. Surrounding the mucosa is the intermediate muscularis, also called the detrusor muscle (to push down),
which consists of three layers of smooth muscle fibers: the inner longitudinal, middle circular, and outer longitudinal layers. Around the opening to the urethra the circular fibers form an internal urethral sphincter; inferior to it is the external urethral sphincter, which is composed of skeletal muscle and is a modification of the deep muscles of the perineum. The most superficial coat of the urinary bladder on the posterior and inferior surfaces is the adventitia, a layer of areolar connective tissue that is continuous with that of the ureters. Over the superior surface of the urinary bladder is the serosa, a layer of visceral peritoneum.

Figure 1. Urinary bladder location

Figure 2. Urinary bladder anatomy

Voiding Urine

Discharge of urine from the urinary bladder, called micturition, is also known as urination or voiding. Micturition occurs via a combination of involuntary and voluntary muscle contractions. When the volume of urine in the urinary bladder exceeds 200–400 mL, pressure within the bladder increases considerably, and stretch receptors in its wall transmit nerve impulses into the spinal cord. These impulses propagate to the micturition center in sacral spinal cord segments S2 and S3 and trigger a spinal reflex called the micturition reflex. In this reflex arc, parasympathetic impulses from the micturition center propagate to the urinary bladder wall and internal urethral sphincter.

The nerve impulses cause contraction of the detrusor muscle and relaxation of the internal urethral sphincter muscle. Simultaneously, the micturition center inhibits somatic motor neurons that innervate skeletal muscle in the external urethral sphincter. On contraction of the urinary bladder wall and relaxation of the sphincters, urination takes place. Urinary bladder filling causes a sensation of fullness that initiates a conscious desire to urinate before the micturition reflex actually occurs. Although emptying of the urinary bladder is a reflex, in early childhood we learn to initiate it and stop it voluntarily.

Through learned control of the external urethral sphincter muscle and certain muscles of the pelvic floor, the cerebral cortex can initiate micturition or delay its occurrence for a limited period.

Figure 3. Bladder control

Bladder Control Problems in Men (Urinary Incontinence)

Urinary incontinence is the loss of bladder control, resulting in the accidental leakage of urine from the body ¹. For example, a man may feel a strong, sudden need, or urgency, to urinate just before losing a large amount of urine, called urgency incontinence.

Urinary incontinence can be slightly bothersome or totally debilitating. For some men, the chance of embarrassment keeps them from enjoying many activities, including exercising, and causes emotional distress. When people are inactive, they increase their chances of developing other health problems, such as obesity and diabetes.

How common is urinary incontinence in men ?

Urinary incontinence occurs in 11 to 34 percent of older men. Two to 11 percent of older men report daily urinary incontinence ². Although more women than men develop urinary incontinence, the chances of a man developing urinary incontinence increase with age because he is more likely to develop prostate problems as he ages. Men are also less likely to speak with a health care professional about urinary incontinence, so urinary incontinence in men is probably far more common than statistics show. Having a discussion with a health care professional about urinary incontinence is the first step to fixing this treatable problem.

What causes urinary incontinence in men ?

Urinary incontinence in men results when the brain does not properly signal the bladder, the sphincters do not squeeze strongly enough, or both. The bladder muscle may contract too much or not enough because of a problem with the muscle itself or the nerves controlling the bladder muscle. Damage to the sphincter muscles themselves or the nerves controlling these muscles can result in poor sphincter function. These problems can range from simple to complex.

A man may have factors that increase his chances of developing urinary incontinence, including:

• birth defects—problems with development of the urinary tract
• a history of prostate cancer—surgery or radiation treatment for prostate cancer can lead to temporary or permanent urinary incontinence in men

Urinary incontinence is not a disease. Instead, it can be a symptom of certain conditions or the result of particular events during a man’s life. Conditions or events that may increase a man’s chance of developing urinary incontinence include:

• Benign prostatic hyperplasia—a condition in which the prostate is enlarged yet not cancerous. In men with benign prostatic hyperplasia, the enlarged prostate presses against and pinches the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty, leaving some urine in the bladder. The narrowing of the urethra and incomplete emptying of the bladder can lead to urinary incontinence.
• Chronic coughing—long-lasting coughing increases pressure on the bladder and pelvic floor muscles.
• Neurological problems—men with diseases or conditions that affect the brain and spine may have trouble controlling urination.
• Physical inactivity—decreased activity can increase a man’s weight and contribute to muscle weakness.
• Obesity—extra weight can put pressure on the bladder, causing a need to urinate before the bladder is full.
• Older age—bladder muscles can weaken over time, leading to a decrease in the bladder’s capacity to store urine.

What are the types of urinary incontinence in men ?

The types of urinary incontinence in men include:

• Urgency incontinence
• Stress incontinence
• Functional incontinence
• Overflow incontinence
• Transient incontinence

Urgency Incontinence

Urgency incontinence happens when a man urinates involuntarily after he has a strong desire, or urgency, to urinate. Involuntary bladder contractions are a common cause of urgency incontinence. Abnormal nerve signals might cause these bladder contractions.

Triggers for men with urgency incontinence include drinking a small amount of water, touching water, hearing running water, or being in a cold environment—even if for just a short while—such as reaching into the freezer at the grocery store. Anxiety or certain liquids, medications, or medical conditions can make urgency incontinence worse.

The following conditions can damage the spinal cord, brain, bladder nerves, or sphincter nerves, or can cause involuntary bladder contractions leading to urgency incontinence:

• Alzheimer’s disease—a disorder that affects the parts of the brain that control thought, memory, and language
• Injury to the brain or spinal cord that interrupts nerve signals to and from the bladder
• Multiple sclerosis—a disease that damages the material that surrounds and protects nerve cells, which slows down or blocks messages between the brain and the body
• Parkinson’s disease—a disease in which the cells that make a chemical that controls muscle movement are damaged or destroyed
• Stroke—a condition in which a blocked or ruptured artery in the brain or neck cuts off blood flow to part of the brain and leads to weakness, paralysis, or problems with speech, vision, or brain function

Urgency incontinence is a key sign of overactive bladder. Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without enough warning time to get to the toilet.

Stress Incontinence

Stress incontinence results from movements that put pressure on the bladder and cause urine leakage, such as coughing, sneezing, laughing, or physical activity. In men, stress incontinence may also occur:

• after prostate surgery
• after neurologic injury to the brain or spinal cord
• after trauma, such as injury to the urinary tract
• during older age

Functional Incontinence

Functional incontinence occurs when physical disability, external obstacles, or problems in thinking or communicating keep a person from reaching a place to urinate in time. For example, a man with Alzheimer’s disease may not plan ahead for a timely trip to a toilet. A man in a wheelchair may have difficulty getting to a toilet in time. Arthritis—pain and swelling of the joints—can make it hard for a man to walk to the restroom quickly or open his pants in time.

Overflow Incontinence

When the bladder doesn’t empty properly, urine spills over, causing overflow incontinence. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Men with overflow incontinence may have to urinate often, yet they release only small amounts of urine or constantly dribble urine.

Transient Incontinence

Transient incontinence is urinary incontinence that lasts a short time. Transient incontinence is usually a side effect of certain medications, drugs, or temporary conditions, such as:

• Urinary tract infection, which can irritate the bladder and cause strong urges to urinate
• Caffeine or alcohol consumption, which can cause rapid filling of the bladder
• Chronic coughing, which can put pressure on the bladder
• Constipation—hard stool in the rectum can put pressure on the bladder
• Blood pressure medications that can cause increased urine production
• Short-term mental impairment that reduces a man’s ability to care for himself
• Short-term restricted mobility

How is urinary incontinence in men diagnosed ?

Men should tell a health care professional, such as a family practice physician, a nurse, an internist, or a urologist—a doctor who specializes in urinary problems—they have urinary incontinence, even if they feel embarrassed. To diagnose urinary incontinence, the health care professional will:

• take a medical history
• conduct a physical exam
• order diagnostic tests

Medical History

Taking a medical history can help a health care professional diagnose urinary incontinence. He or she will ask the patient or caretaker to provide a medical history, a review of symptoms, a description of eating habits, and a list of prescription and over-the-counter medications the patient is taking. The health care professional will ask about current and past medical conditions.

The health care professional also will ask about the man’s pattern of urination and urine leakage. To prepare for the visit with the health care professional, a man may want to keep a bladder diary for several days beforehand. Information that a man should record in a bladder diary includes:

• the amount and type of liquid he drinks
• how many times he urinates each day and how much urine is released
• how often he has accidental leaks
• whether he felt a strong urge to go before leaking
• what he was doing when the leak occurred, for example, coughing or lifting
• how long the symptoms have been occurring

The health care professional also may ask about other lower urinary tract symptoms that may indicate a prostate problem, such as:

• problems starting a urine stream
• problems emptying the bladder completely
• spraying urine
• dribbling urine
• weak stream
• recurrent urinary tract infections
• painful urination

Physical Exam

A physical exam may help diagnose urinary incontinence. The health care professional will perform a physical exam to look for signs of medical conditions that may cause urinary incontinence. The health care professional may order further neurologic testing if necessary.

Digital rectal exam. The health care professional also may perform a digital rectal exam. A digital rectal exam is a physical exam of the prostate and rectum. To perform the exam, the health care professional has the man bend over a table or lie on his side while holding his knees close to his chest. The health care professional slides a gloved, lubricated finger into the patient’s rectum and feels the part of the prostate that lies in front of the rectum. The digital rectal exam is used to check for stool or masses in the rectum and to assess whether the prostate is enlarged or tender, or has other abnormalities. The health care professional may perform a prostate massage during a digital rectal exam to collect a sample of prostate fluid that he or she can test for signs of infection.

The health care professional may diagnose the type of urinary incontinence based on the medical history and physical exam, or he or she may use the findings to determine if a man needs further diagnostic testing.

Diagnostic Tests

The health care professional may order one or more of the following diagnostic tests based on the results of the medical history and physical exam:

• Urinalysis. Urinalysis involves testing a urine sample. The patient collects a urine sample in a special container at home, at a health care professional’s office, or at a commercial facility. A health care professional tests the sample during an office visit or sends it to a lab for analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color to indicate signs of infection in urine.
• Urine culture. A health care professional performs a urine culture by placing part of a urine sample in a tube or dish with a substance that encourages any bacteria present to grow. A man collects the urine sample in a special container in a health care professional’s office or a commercial facility. The office or facility tests the sample onsite or sends it to a lab for culture. A health care professional can identify bacteria that multiply, usually in 1 to 3 days. A health care professional performs a urine culture to determine the best treatment when urinalysis indicates the man has a urinary tract infection.
• Blood test. A blood test involves drawing blood at a health care professional’s office or a commercial facility and sending the sample to a lab for analysis. The blood test can show kidney function problems or a chemical imbalance in the body. The lab also will test the blood to assess the level of prostate-specific antigen, a protein produced by prostate cells that may be higher in men with prostate cancer.
• Urodynamic testing. Urodynamic testing includes a variety of procedures that look at how well the bladder and urethra store and release urine. A health care professional performs urodynamic tests during an office visit or in an outpatient center or a hospital. Some urodynamic tests do not require anesthesia; others may require local anesthesia. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely; they may include the following:
  + uroflowmetry, which measures how rapidly the bladder releases urine
  + postvoid residual measurement, which evaluates how much urine remains in the bladder after urination
  + reduced urine flow or residual urine in the bladder, which often suggests urine blockage due to benign prostatic hyperplasia

How is urinary incontinence in men treated ?

Treatment depends on the type of urinary incontinence.

Urgency Incontinence

As a first line of therapy for urgency incontinence, a health care professional may recommend the following techniques to treat a man’s problem:

• behavioral and lifestyle changes
• bladder training
• pelvic floor exercises
• urgency suppression

If those treatments are not successful, the following additional measures may help urgency incontinence:

• medications
• electrical nerve stimulation
• bulking agents
• surgery

A health care professional may recommend other treatments for men with urgency incontinence caused by Benign Prostatic Hyperplasia.

Behavioral and lifestyle changes. Men with urgency incontinence may be able to reduce leaks by making behavioral and lifestyle changes:

• Eating, diet, and nutrition. Men with urgency incontinence can change the amount and type of liquid they drink. A man can try limiting bladder irritants—including caffeinated drinks such as tea or coffee and carbonated beverages—to decrease leaks. Men also should limit alcoholic drinks, which can increase urine production. A health care professional can help a man determine how much he should drink based on his health, how active he is, and where he lives. To decrease nighttime trips to the restroom, men may want to stop drinking liquids several hours before bed.
• Engaging in physical activity. Although a man may be reluctant to engage in physical activity when he has urgency incontinence, regular exercise is important for good overall health and for preventing and treating urinary incontinence.
• Losing weight. Men who are overweight should talk with a health care professional about strategies for losing weight, which can help improve urinary incontinence.
• Preventing constipation. Gastrointestinal (GI) problems, especially constipation, can make urinary tract health worse and can lead to urinary incontinence. The opposite is also true: Urinary problems, such as urinary incontinence, can make gastrointestinal problems worse.

To Help Prevent Bladder Problems, Stop Smoking

People who smoke should stop. Quitting smoking at any age promotes bladder health and overall health. Smoking increases a person’s chance of developing stress incontinence, as it increases coughing. Some people say smoking worsens their bladder irritation. Smoking causes most cases of bladder cancer. People who smoke for many years have a higher risk of bladder cancer than nonsmokers or those who smoke for a short time ³.

Bladder training. Bladder training is changing urination habits to decrease incidents of urinary incontinence. The health care professional may suggest a man use the restroom at regular timed intervals, called timed voiding, based on the man’s bladder diary. A man can gradually lengthen the time between trips to the restroom to help stretch the bladder so it can hold more urine.

Pelvic floor muscle exercises. Pelvic floor muscle, or Kegel, exercises involve strengthening pelvic floor muscles. Strong pelvic floor muscles hold in urine more effectively than weak muscles. A man does not need special equipment for Kegel exercises. The exercises involve tightening and relaxing the muscles that control urine flow. Pelvic floor exercises should not be performed during urination.

Men also may learn how to perform Kegel exercises properly by using biofeedback. Biofeedback uses special sensors to measure bodily functions, such as muscle contractions that control urination. A video monitor displays the measurements as graphs, and sounds indicate when the man is using the correct muscles. The health care professional uses the information to help the man change abnormal function of the pelvic floor muscles. At home, the man practices to improve muscle function. The man can perform the exercises while lying down, sitting at a desk, or standing up. Success with pelvic floor exercises depends on the cause of urinary incontinence, its severity, and the man’s ability to perform the exercises.

Urgency suppression. By using certain techniques, a man can suppress the urge to urinate, called urgency suppression. Urgency suppression is a way for a man to train his bladder to maintain control so he does not have to panic about finding a restroom. Some men use distraction techniques to take their mind off the urge to urinate. Other men find taking long, relaxing breaths and being still can help. Doing pelvic floor exercises also can help suppress the urge to urinate.

Medications. Health care professionals may prescribe medications that relax the bladder, decrease bladder spasms, or treat prostate enlargement to treat urgency incontinence in men.

Antimuscarinics. Antimuscarinics can help relax bladder muscles and prevent bladder spasms. These medications include oxybutynin (Oxytrol), tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), fesoterodine (Toviaz), and solifenacin (VESIcare). They are available in pill, liquid, and patch form.

Tricyclic antidepressants. Tricyclic antidepressants such as imipramine (Tofranil) can calm nerve signals, decreasing spasms in bladder muscles.

Alpha-blockers. Terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo) are used to treat problems caused by prostate enlargement and bladder outlet obstruction. These medications relax the smooth muscle of the prostate and bladder neck, which lets urine flow normally and prevents abnormal bladder contractions that can lead to urgency incontinence.

5-alpha reductase inhibitors. Finasteride (Proscar) and dutasteride (Avodart) block the production of the male hormone dihydrotestosterone, which accumulates in the prostate and may cause prostate growth. These medications may help to relieve urgency incontinence problems by shrinking an enlarged prostate.

Beta-3 agonists. Mirabegron (Myrbetriq) is a beta-3 agonist a person takes by mouth to help prevent symptoms of urgency incontinence. Mirabegron suppresses involuntary bladder contractions.

Botox. A health care professional may use onabotulinumtoxinA (Botox), also called botulinum toxin type A, to treat urinary incontinence in men with neurological conditions such as spinal cord injury or multiple sclerosis. Injecting Botox into the bladder relaxes the bladder, increasing storage capacity and decreasing urinary incontinence. A health care professional performs the procedure during an office visit. A man receives local anesthesia. The health care professional uses a cystoscope to guide the needle for injecting the Botox. Botox is effective for up to 10 months.

Electrical nerve stimulation. If behavioral and lifestyle changes and medications do not improve symptoms, a urologist may suggest electrical nerve stimulation as an option to prevent urinary incontinence, urinary frequency—urination more often than normal—and other symptoms. Electrical nerve stimulation involves altering bladder reflexes using pulses of electricity. The two most common types of electrical nerve stimulation are percutaneous tibial nerve stimulation and sacral nerve stimulation ⁴.

Percutaneous tibial nerve stimulation uses electrical stimulation of the tibial nerve, which is located in the ankle, on a weekly basis. The patient receives local anesthesia for the procedure. In an outpatient center, a urologist inserts a battery-operated stimulator beneath the skin near the tibial nerve. Electrical stimulation of the tibial nerve prevents bladder activity by interfering with the pathway between the bladder and the spinal cord or brain. Although researchers consider percutaneous tibial nerve stimulation safe, they continue to study the exact ways that it prevents symptoms and how long the treatment can last.

Sacral nerve stimulation involves implanting a battery-operated stimulator beneath the skin in the lower back near the sacral nerve. The procedure takes place in an outpatient center using local anesthesia. Based on the patient’s feedback, the health care professional can adjust the amount of stimulation so it works best for that individual. The electrical pulses enter the body for minutes to hours, two or more times a day, either through wires placed on the lower back or just above the pubic area—between the navel and the pubic hair. Sacral nerve stimulation may increase blood flow to the bladder, strengthen pelvic muscles that help control the bladder, and trigger the release of natural substances that block pain. The patient can turn the stimulator on or off at any time.

A patient may consider getting an implanted device that delivers regular impulses to the bladder. A urologist places a wire next to the tailbone and attaches it to a permanent stimulator under the skin.

Bulking agents. A urologist injects bulking agents, such as collagen and carbon spheres, near the urinary sphincter to treat incontinence. The bulking agent makes the tissues thicker and helps close the bladder opening. Before the procedure, the health care professional may perform a skin test to make sure the man doesn’t have an allergic reaction to the bulking agent. A urologist performs the procedure during an office visit. The man receives local anesthesia. The urologist uses a cystoscope—a tubelike instrument used to look inside the urethra and bladder—to guide the needle for injection of the bulking agent. Over time, the body may slowly eliminate certain bulking agents, so a man may need to have injections again.

Surgery. As a last resort, surgery to treat urgency incontinence in men includes the artificial urinary sphincter (AUS) and the male sling. A health care professional performs the surgery in a hospital with regional or general anesthesia. Most men can leave the hospital the same day, although some may need to stay overnight.

Artificial urinary sphincter. An artificial urinary sphincter is an implanted device that keeps the urethra closed until the man is ready to urinate. The device has three parts: a cuff that fits around the urethra, a small balloon reservoir placed in the abdomen, and a pump placed in the scrotum—the sac that holds the testicles. The cuff contains a liquid that makes it fit tightly around the urethra to prevent urine from leaking. When it is time to urinate, the man squeezes the pump with his fingers to deflate the cuff. The liquid moves to the balloon reservoir and lets urine flow through the urethra. When the bladder is empty, the cuff automatically refills in the next 2 to 5 minutes to keep the urethra tightly closed.

Male sling. A health care professional performs a sling procedure, also called urethral compression procedure, to add support to the urethra, which can sometimes better control urination. Through an incision in the tissue between the scrotum and the rectum, also called the perineum, the health care professional uses a piece of human tissue or mesh to compress the urethra against the pubic bone. The surgeon secures the ends of the tissue or mesh around the pelvic bones. The lifting and compression of the urethra sometimes provides better control over urination.

Stress Incontinence

Men who have stress incontinence can use the same techniques for treating urgency incontinence.

Functional Incontinence

Men with functional incontinence may wear protective undergarments if they worry about reaching a restroom in time. These products include adult diapers or pads and are available from drugstores, grocery stores, and medical supply stores. Men who have functional incontinence should talk to a health care professional about its cause and how to prevent or treat functional incontinence.

Overflow Incontinence

A health care professional treats overflow incontinence caused by a blockage in the urinary tract with surgery to remove the obstruction. Men with overflow incontinence that is not caused by a blockage may need to use a catheter to empty the bladder. A catheter is a thin, flexible tube that is inserted through the urethra into the bladder to drain urine. A health care professional can teach a man how to use a catheter. A man may need to use a catheter once in a while, a few times a day, or all the time. Catheters that are used continuously drain urine from the bladder into a bag that is attached to the man’s thigh with a strap. Men using a continuous catheter should watch for symptoms of an infection.

Transient Incontinence

A health care professional treats transient incontinence by addressing the underlying cause. For example, if a medication is causing increased urine production leading to urinary incontinence, a health care professional may try lowering the dose or prescribing a different medication. A health care professional may prescribe bacteria-fighting medications called antibiotics to treat urinary tract infections.

Bladder Control Problems in Women (Urinary Incontinence)

Urinary incontinence in women results when the brain does not properly signal the bladder, the sphincters do not squeeze strongly enough, or both ⁵. The bladder muscle may contract too much or not enough because of a problem with the muscle itself or the nerves controlling the bladder muscle. Damage to the sphincter muscles themselves or the nerves controlling these muscles can result in poor sphincter function. These problems can range from simple to complex.

A woman may be born with factors that increase her chances of developing urinary incontinence, which include:

• birth defects—problems with development of the urinary tract
• genetics—a woman is more likely to have urinary incontinence if other females in her family have urinary incontinence
• race—Caucasian women are more likely to be affected than Hispanic/Latina, African American, or Asian American women

Urinary incontinence is not a disease. Urinary incontinence can be a symptom of certain conditions or the result of certain events during a woman’s life. Conditions or events that may increase a woman’s chance of developing urinary incontinence include:

• Childbirth—the childbirth process can damage the muscles and nerves that control urination
• Chronic coughing—long-lasting coughing increases pressure on the bladder and pelvic floor muscles
• Menopause—reduces production of the hormone that keeps the lining of the bladder and urethra healthy
• Neurological problems—women with diseases or conditions that affect the brain and spine may have trouble controlling urination
• Physical inactivity—decreased activity can increase a woman’s weight and contribute to muscle weakness
• Obesity—extra weight can put pressure on the bladder, causing a need to urinate before the bladder is full
• Older age—bladder muscles can weaken over time, leading to a decrease in the bladder’s capacity to store urine
• Pelvic organ prolapse—causes sagging of the bladder, bowel, or uterus out of their normal positions
• Pregnancy—the fetus can put pressure on the bladder during pregnancy.

How common is urinary incontinence in women ?

Research shows that 25 to 45 percent of women have some degree of urinary incontinence. In women ages 20 to 39, 7 to 37 percent report some degree of urinary incontinence. Nine to 39 percent of women older than 60 report daily urinary incontinence. Women experience urinary incontinence twice as often as men ². Pregnancy, childbirth, menopause, and the structure of the female urinary tract account for this difference.

What are the types of urinary incontinence in women ?

The types of urinary incontinence in women include:

• Stress incontinence
• Urgency incontinence
• Mixed incontinence
• Other types of incontinence

Stress Incontinence

Stress incontinence results from movements that put pressure on the bladder and cause urine leakage, such as coughing, sneezing, laughing, or physical activity. Physical changes from pregnancy and childbirth often cause stress incontinence. Weakening of pelvic floor muscles can cause the bladder to move downward, pushing the bladder slightly out of the bottom of the pelvis and making it difficult for the sphincters to squeeze tightly enough. As a result, urine can leak during moments of physical stress. Stress incontinence can also occur without the bladder moving downward if the urethra wall is weak. This type of incontinence is common in women, and a health care professional can treat the condition.

Urgency Incontinence

Urgency incontinence is the loss of urine when a woman has a strong desire, or urgency, to urinate. Involuntary bladder contractions are a common cause of urgency incontinence. Abnormal nerve signals might cause these bladder contractions.

Triggers for women with urgency incontinence include drinking a small amount of water, touching water, hearing running water, or being in a cold environment—even if for just a short while—such as reaching into the freezer at the grocery store. Anxiety or certain liquids, medications, or medical conditions can make urgency incontinence worse.

Damage to the spinal cord or brain, the bladder nerves, or the bladder muscles may cause involuntary bladder contractions. Bladder nerves and muscles can be affected by:

• Alzheimer’s disease—a brain disorder that affects the parts of the brain that control thought, memory, and language
  injury
• Multiple sclerosis—a disease that damages the material that surrounds and protects nerve cells, which slows down or blocks messages between the brain and body
• Parkinson’s disease—a disease in which cells that make a chemical that controls muscle movement are damaged or destroyed
• Stroke—a condition in which the blood supply to the brain is suddenly cut off, caused by a blockage or the bursting of a blood vessel in the brain or neck

Urgency incontinence is a key sign of overactive bladder. Overactive bladder occurs when abnormal nerves send signals to the bladder at the wrong time, causing its muscles to squeeze without enough warning time to get to the toilet.

Mixed Incontinence

Mixed incontinence is when stress and urgency incontinence occur together.

Other Types of Incontinence

Functional incontinence occurs when physical disability, external obstacles, or problems in thinking or communicating keep a person from reaching a toilet in time. For example, a woman with Alzheimer’s disease may not plan ahead for a timely trip to a toilet. A woman in a wheelchair may have difficulty getting to a toilet in time. Arthritis—pain and swelling of the joints—can make it hard for a woman to walk to the toilet quickly or unbutton her pants in time.

Transient incontinence is urinary incontinence that lasts a short time. Transient incontinence is usually caused by medications or a temporary condition, such as:

• a urinary tract infection (UTI)—a UTI can irritate the bladder, causing strong urges to urinate
• caffeine or alcohol consumption—consumption of caffeine or alcohol can cause rapid filling of the bladder
• chronic coughing—chronic coughing can put pressure on the bladder
• constipation—hard stool in the rectum can put pressure on the bladder
• medication—blood pressure medications can cause increased production of urine
• short-term mental impairment
• short-term restricted mobility

Overflow incontinence happens when the bladder doesn’t empty properly, causing it to spill over. A health care professional can check for this problem. Weak bladder muscles or a blocked urethra can cause this type of incontinence. Nerve damage from diabetes or other diseases can lead to weak bladder muscles; tumors and urinary stones can block the urethra. Overflow incontinence is rare in women.

How is urinary incontinence in women diagnosed ?

Women should let their health care provider, such as a family practice physician, a nurse, an internist, a gynecologist, urologist, or a urogynecologist—a gynecology doctor who has extra training in bladder problems and pelvic problems in women—know they have urinary incontinence, even if they feel embarrassed. To diagnose urinary incontinence, a health care professional will take a medical history and conduct a physical exam. The health care professional may order diagnostic tests, such as a urinalysis.

Medical History

The health care professional will take a medical history and ask about symptoms, patterns of urination and urine leakage, bowel function, medications, history of childbirth, and past pelvic operations. To prepare for the visit with the health care professional, a woman may want to keep a bladder diary for several days beforehand. Information that a woman should record in a bladder diary includes:

• what and how much she drinks
• how many times she urinates and how much urine is released
• how often she has accidental leaks
• whether she feels a strong urge to go before leaking
• what she was doing when leaks occurred, for example, coughing or lifting

Physical Exam

The health care professional will also perform a limited physical exam to look for signs of medical conditions that may cause urinary incontinence. The health care professional may order further neurologic testing if necessary. The health care professional may also perform pelvic and rectal exams.

Pelvic exam. A pelvic exam is a visual and physical exam of the pelvic organs. The health care professional has the woman come to the exam with a full bladder. The woman will sit upright with her legs spread and asks her to cough. This test is called a cough stress test. Leakage of urine indicates stress incontinence. The health care professional then has the woman lie on her back on an exam table and place her feet on the corners of the table or in supports. The health care professional looks at the pelvic organs and slides a gloved, lubricated finger into the vagina to check for prolapse or other physical problems that may be causing urinary incontinence. The health care professional will determine the woman’s pelvic muscle strength by asking her to squeeze her pelvic floor muscles.

Digital rectal exam. A digital rectal exam is a physical exam of the rectum. The health care professional slides a gloved, lubricated finger into the rectum, usually during a pelvic exam. A health care professional uses the digital rectal exam to check for stool or masses in the rectum that may be causing urinary incontinence.

The health care professional may diagnose the type of urinary incontinence based on the medical history and physical exam or use this information to determine if a woman needs further diagnostic testing.

Diagnostic Tests

The health care professional may order one or both of the following diagnostic tests, based on the results of the medical history and physical exam:

Urinalysis. Urinalysis is testing of a urine sample. The patient collects the urine sample in a special container in a health care professional’s office or a commercial facility for testing and analysis. For the test, a nurse or technician places a strip of chemically treated paper, called a dipstick, into the urine. Patches on the dipstick change color when blood or protein is present in urine. A person does not need anesthesia for this test. The test can show if the woman has a urinary tract infection, a kidney problem, or diabetes.

Urine culture. A health care professional performs a urine culture by placing part of a urine sample in a tube or dish with a substance that encourages any bacteria present to grow. A woman collects the urine sample in a special container in a health care professional’s office or a commercial facility. The office or facility tests the sample onsite or sends it to a lab for culture. A health care professional can identify bacteria that multiply, usually in 1 to 3 days. A health care professional performs a urine culture to determine the best treatment when urinalysis indicates the woman has a urinary tract infection.

Blood test. A blood test involves drawing blood at a health care professional’s office or a commercial facility and sending the sample to a lab for analysis. The blood test can show problems with kidney function or a chemical imbalance in the body.

Urodynamic testing. Urodynamic testing is any procedure that looks at how well the bladder, urethra, and sphincters store and release urine. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely.

How is urinary incontinence in women treated ?

Treatment depends on the type of urinary incontinence. Health care professionals may recommend behavioral and lifestyle changes, stopping smoking, bladder training, pelvic floor exercises, and urgency suppression as a first-line therapy for most types of urinary incontinence.

Stress Incontinence

Behavioral and lifestyle changes. Women with urinary incontinence may be able to reduce leaks by making behavioral and lifestyle changes. For example, the amount and type of liquid women drink can affect urinary incontinence. Women should talk with their health care professional about whether to drink less liquid during the day; however, women should not limit liquids to the point of becoming dehydrated.

Signs of dehydration in women include:

• constipation
• dark-colored urine
• dizziness
• dry skin
• fatigue, or feeling tired
• less frequent urination than usual
• light-headedness
• thirst

A health care professional can help a woman determine how much she should drink to prevent dehydration based on her health, how active she is, and where she lives.

To decrease nighttime trips to the bathroom, women may want to stop drinking liquids several hours before bedtime if suggested by a health care professional.

Limiting bladder irritants—including caffeinated drinks such as tea or coffee and carbonated beverages—may decrease leaks. Women should also limit alcoholic drinks, which can increase urine production.

Although a woman may be reluctant to engage in physical activity when she has urinary incontinence, regular exercise is important for weight management and good overall health. Losing weight may improve urinary incontinence and not gaining weight may prevent urinary incontinence. If a woman is concerned about not having easy access to a bathroom during physical activity, she can walk indoors, like in a mall, for example. Women who are overweight should talk with their health care professional about strategies for losing weight. Being obese increases a person’s chances of developing urinary incontinence and other diseases, such as diabetes. According to one study, decreasing obesity and diabetes may lessen the burden of urinary incontinence, especially in women ⁶.

Gastrointestinal (GI) problems, especially constipation, can make urinary tract health worse and can lead to urinary incontinence. The opposite is also true: Urinary problems such as urinary incontinence can make GI problems worse. For example, medications such as antimuscarinics, which health care professionals use to treat urinary incontinence, have side effects such as constipation.

Health care professionals can offer several options for treating constipation.

Although a woman may be reluctant to engage in physical activity when she has urinary incontinence, regular exercise is important for weight management and good overall health.

Stopping Smoking. People who smoke should stop. Quitting smoking at any age promotes bladder health and overall health. Smoking increases a person’s chances of developing stress incontinence, as it increases coughing. Some people say smoking worsens their bladder irritation. Smoking causes most cases of bladder cancer. People who smoke for many years have a higher risk of bladder cancer than nonsmokers or those who smoke for a short time ⁷.

Bladder training. Bladder training is changing urination habits to decrease incidents of urinary incontinence. Based on a woman’s bladder diary, the health care professional may suggest using the bathroom at regular timed intervals, called timed voiding. Gradually lengthening the time between trips to the bathroom can help by stretching the bladder so it can hold more urine. Recording daily bathroom habits may be helpful.

Pelvic floor muscle exercises. Pelvic floor muscle, or Kegel, exercises involve strengthening pelvic floor muscles. Strong pelvic floor muscles more effectively hold in urine than weak muscles. A woman does not need special equipment for Kegel exercises. The exercises involve tightening and relaxing the muscles that control urine flow. Pelvic floor exercises should not be performed during urination. A health care professional can help a woman learn proper technique.

Women may also learn how to perform Kegel exercises properly by using biofeedback. Biofeedback uses special sensors to measure bodily functions, such as muscle contractions that control urination. A video screen displays the measurements as graphs, and sounds indicate when the woman is using the correct muscles. The health care professional uses the information to help the woman change abnormal function of the pelvic floor muscles. At home, the woman practices to improve muscle function. The woman can perform the exercises while lying down, sitting at a desk, or standing up. Success with pelvic floor exercises depends on the cause of urinary incontinence, its severity, and the woman’s ability to perform the exercises on a regular basis.

If behavioral and lifestyle changes, stopping smoking, bladder training, and pelvic floor muscle exercises are not successful, additional measures for stress incontinence, including medical devices, bulking agents, and—as a last resort—surgery, may help.

Medical devices. A health care professional may prescribe a urethral insert or pessary to treat stress incontinence. A urethral insert is a small, tamponlike, disposable device inserted into the urethra to prevent leakage. A woman may use the insert to prevent urinary incontinence during a specific activity or wear it throughout the day. The woman removes the insert to urinate. A pessary is a stiff ring inserted into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pressure helps reposition the urethra, leading to less leakage. The woman should remove the pessary regularly for cleaning.

Bulking agents. A doctor injects bulking agents, such as collagen and carbon beads, near the urinary sphincter to treat urgency and stress incontinence. The bulking agent makes the tissues thicker and helps close the bladder opening. Before the procedure, a health care professional may perform a skin test to make sure the woman doesn’t have an allergic reaction to the bulking agent. A doctor performs the procedure during an office visit. The woman receives local anesthesia. The doctor uses a cystoscope—a tubelike instrument used to look inside the urethra and bladder—to guide the needle for injection of the bulking agent. Over time, the body may slowly eliminate certain bulking agents, so a woman may need to have injections again. The treatment is effective in about 40 percent of cases ⁸.

Surgery. The bladder neck dropping toward the vagina can cause incontinence problems. Surgery to treat stress incontinence includes retropubic suspension and sling procedures. A doctor performs the operations in a hospital. The patient receives general anesthesia. Most women can leave the hospital the same day, though some may need to stay overnight. Full recovery takes 2 to 3 weeks; women who also have surgery for pelvic organ prolapse at the same time may have a longer recovery time.

Retropubic suspension. With retropubic suspension, the doctor raises the bladder neck or urethra and supports it using surgical threads called sutures. The doctor makes an incision in the area between the chest and the hips—also called the abdomen—a few inches below the navel and secures the sutures to strong ligaments within the pelvis to support the urethral sphincter.

Sling. The doctor performs sling procedures through a vaginal incision and uses natural tissue, man-made sling material, or synthetic mesh tape to cradle the bladder neck or urethra, depending on the type of sling procedure being performed. The doctor attaches the sling to the pubic bone or pulls the sling through an incision behind the pubic bone or beside the vaginal opening and secures it with stitches.

The Urinary Incontinence Treatment Network compared the suspension and sling procedures and found that according to women’s bladder diaries, about 31 percent with a sling and 24 percent with a suspension were still continent, or able to hold urine, all of the time 5 years after surgery. However, 73 percent of women in the suspension group and 83 percent of women in the sling group said they were satisfied with their results. Rates of adverse events such as urinary tract infections and urinary incontinence were similar for the two groups, at 10 percent for the suspension group and 9 percent for the sling group ⁹.

Serious complications are associated with the use of surgical mesh to repair incontinence. Possible complications include erosion through the lining of the vagina, infection, pain, urinary problems, and recurrence of incontinence.

Each woman should speak to her health care professional to help decide which surgery, if any, is right for her.

Urgency Incontinence

Women who have urgency incontinence can use the same techniques as for stress incontinence, including bladder training, urgency suppression, pelvic floor exercises, and behavioral and lifestyle changes. A woman can also try urgency suppression techniques, medications, Botox injections, and electrical nerve stimulation if necessary.

Urgency suppression. By using certain techniques, a woman can suppress the strong urge to urinate, called urgency suppression. Urgency suppression is a way to train the bladder to maintain control so a woman does not have to panic about finding a bathroom in the meantime. Some women use distraction techniques to take their mind off the urge to urinate. Other women find taking long, relaxing breaths and being still can help. Doing pelvic floor exercises also can help suppress the urgency to urinate.

Medications. Health care professionals may prescribe medications that relax the bladder or decrease bladder spasms to treat urgency incontinence in women.

Antimuscarinics. Antimuscarinics can help relax bladder muscles and prevent bladder spasms. These medications include oxybutynin (Oxytrol), which a person can buy over the counter, tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), fesoterodine (Toviaz), and solifenacin (VESIcare). They are available in pill, liquid, and patch form.

Tricyclic antidepressants. Tricyclic antidepressants such as imipramine (Tofranil) can calm nerve signals, decreasing spasms in bladder muscles.

Beta-3 agonists. Mirabegron (Myrbetriq) is a beta-3 agonist a person takes by mouth to help prevent symptoms of incontinence. Mirabegron suppresses involuntary bladder contractions.

Botox. A doctor may use onabotulinumtoxinA (Botox), also called botulinum toxin type A, to treat urgency incontinence in women including those with neurological conditions such as spinal cord injury or multiple sclerosis. Injecting Botox into the bladder relaxes the bladder, increasing storage capacity and decreasing urinary incontinence. A doctor often performs the procedure during an office visit. A woman receives local anesthesia. The doctor uses a cystoscope to guide the needle for injecting the Botox. Botox is effective for up to 10 months.

Electrical nerve stimulation. If behavioral and lifestyle changes and medications do not improve symptoms, the health care professional may suggest electrical nerve stimulation as an option to prevent urinary incontinence, urinary frequency—urinating more than normal—and other symptoms. Electrical nerve stimulation involves altering bladder reflexes using pulses of electricity. The two most common types of electrical nerve stimulation are percutaneous tibial nerve stimulation and sacral nerve stimulation ⁴.

Percutaneous tibial nerve stimulation uses electrical stimulation of the tibial nerve, which is located in the ankle, on a weekly basis. Anesthesia is not normally needed for the procedure. In an outpatient center, a health care professional inserts a battery-operated stimulator beneath the skin near the tibial nerve. Electrical stimulation of the tibial nerve prevents bladder activity by interfering with the pathway between the bladder and the spinal cord or brain. Although percutaneous tibial nerve stimulation is considered safe, researchers continue to study the exact ways it prevents symptoms and how long the treatment can last.

Sacral nerve stimulation involves a health care professional implanting a battery-operated stimulator beneath the skin in the lower back near the sacral nerve. The procedure takes place in an outpatient center often with local anesthesia. Based on the person’s feedback, the health care professional can adjust the amount of stimulation so it works best for that individual. The electrical pulses enter the body for minutes to hours, two or more times a day, either through wires placed on the lower back or just above the pubic area—between the navel and the pubic hair—or through special devices inserted into the vagina. Sacral nerve stimulation may increase blood flow to the bladder, strengthen pelvic muscles that help control the bladder, and trigger the release of natural substances that block pain. The person can turn the stimulator on or off at any time. If a period of test stimulation is successful, a health care professional will implant a device that delivers regular impulses to the bladder. A health care professional places a wire next to the tailbone and attaches it to a permanent stimulator under the skin of the lower abdomen.

If behavioral and lifestyle changes and medications do not improve symptoms, the health care professional may suggest electrical nerve stimulation as an option to prevent urinary incontinence, urinary frequency, and other symptoms.

Mixed Incontinence

Depending on the type of symptoms a woman has, she may successfully treat her mixed incontinence with techniques, medications, devices, or surgery. A health care professional can help decide what kind of treatments may work for each symptom.

Functional Incontinence

Women with functional incontinence may wear protective undergarments if they worry about reaching a toilet in time. Women who have functional incontinence should talk to their health care professional about its causes and how to prevent or treat functional incontinence.

Overflow Incontinence

A health care professional treats overflow incontinence caused by a blockage in the urinary tract with surgery to remove the obstruction. Women with overflow incontinence that is not caused by a blockage may need to use a catheter to empty the bladder. A catheter is a thin, flexible tube that is inserted through the urethra into the bladder to drain urine. A health care professional can teach a woman how to use a catheter. A woman may need to use a catheter once in a while, a few times a day, or all the time. Catheters that are used continuously drain urine from the bladder into a bag that is attached to the woman’s thigh with a strap. Women using a continuous, often called indwelling, catheter should watch for symptoms of a urinary tract infection.

Transient Incontinence

A health care professional treats transient incontinence by addressing the underlying cause. For example, if a medication is causing increased urine production leading to urinary incontinence, a health care professional may try lowering the dose or prescribing a different medication. A health care professional may prescribe bacteria-fighting medications called antibiotics to treat urinary tract infections.

How can someone cope with leaking urine ?

Even after treatment, some women still leak urine from time to time. Certain products can help women cope with leaking urine:

• Pads. Women can wear disposable pads in their underwear to absorb leaking urine.
• Adult diapers. A woman can wear an adult diaper to keep her clothes dry.
• Waterproof underwear. Waterproof underwear can protect clothes from getting wet.
• Disposable pads. Disposable pads can be used to protect chairs and beds from urine.
• Special skin cleaners and creams. Special skin cleaners and creams may help the skin around the urethra from becoming irritated. Creams can help block urine from skin.
• Urine deodorizing tablets. A woman should talk with a health care professional about whether urine deodorizing tablets can make her urine smell less strongly.

Eating, Diet, and Nutrition

No direct scientific evidence links eating, diet, and nutrition to either improving or worsening urinary incontinence. However, many people find that alcohol, tomatoes, spices, chocolate, caffeinated and citrus beverages, and high-acid foods may contribute to bladder irritation and inflammation, which can sometimes lead to urinary incontinence ¹⁰. Moreover, good eating, diet, and nutrition are directly related to preventing factors that increase the chances of developing urinary incontinence, such as obesity and diabetes.

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