Urinary Incontinence

Urinary incontinence is not a disease. It is a symptom of a wide range of health issues such as the short-term and long-term issues listed below.

Short-term health issues:

• Urinary tract infection (UTI)
• Constipation (hard, dry stool)
• Medicine (such as diuretics, antidepressants, antihistamines, others)

Long-term health issues:

• Diabetes
• Stroke
• Multiple sclerosis
• Enlarged prostate or prostate surgery for men
• Childbirth or menopause for women

What are the Types of Urinary Incontinence?

Stress Urinary Incontinence (SUI)

Stress Urinary Incontinence (SUI) is a common type of urinary leakage. With SUI, the pelvic floor muscles (which hold the pelvic organs in place) have become weak and can no longer support the bladder and urethra the way they should. Coughing, sneezing, bending, lifting, straining or even laughing could put enough pressure on the bladder to cause it to leak.

Overactive Bladder (OAB) / Urgency Urinary Incontinence (UUI)

Overactive Bladder (OAB) is a syndrome that often includes frequent urination and is associated with a sudden strong urge to void. This “gotta go” feeling makes you feel that you will leak if you do not use the bathroom now. If you indeed do not make it, this urge-related urine leakage is known as urgency urinary incontinence (UUI). If you live with OAB, you may feel like you need to pass urine many times during the day. You may even wake from sleep many times a night to void. It is a very common health issue for many people and may increase with age. It is also common for people with diabetes, multiple sclerosis or stroke.

Overflow Urinary Incontinence

This type of incontinence is when the bladder stays full. It cannot empty and so it overflows and leaks. Signs include many, small urinations each day, or ongoing dribbling. This is rather rare in women, but can be seen in people with diabetes, neurological disorders and/or a non-functional, underactive bladder. Most often overflow incontinence is seen in men who have prostate problems.

Mixed Urinary Incontinence

Mixed incontinence is a blend of these different types above. Some people have more than one type of urinary incontinence. Some people leak urine both with strong physical activity (SUI) and have a strong uncontrollable sense of urgency (OAB.) This is mixed urinary incontinence. In these cases, it helps to know what is occurring and what is causing leaks to learn how to manage problems.

A urologist or your health care team will start by asking questions. They will want to know about your symptoms and your medical history. They may ask about your health habits and fluid intake. They may also want to know how much your incontinence has changed your quality of life.

A good medical history, physical exam and a few simple tests are most often all that is needed to diagnose the cause of incontinence. A complete review of the medications you are taking may reveal one that alters normal bladder or urethral function. Your health care team may test your urine for bacteria or blood (urinalysis) to look for a urinary tract infection or other source of irritation to the bladder.

A cough stress test may be performed to check for SUI. A simple bladder ultrasound test to see how well you empty your bladder is often performed. Or a more involved “stress test” for the bladder (urodynamic test) can be done in more complicated cases to better see just how your bladder and urethra work. Other conditions to look for include vaginal hernias or pelvic organ prolapse (POP), and major bowel problems, such as constipation or fecal incontinence.

There are many ways to help you take control over your bladder. Some problems are short-term and may be easily relieved. Others take more time to treat. Treatments range from lifestyle changes to bladder training to medications to simple procedural therapies to surgery.

Lifestyle Changes

Lifestyle changes, such as changing your diet, should be tried first. With lifestyle changes, you change the way you live day-to-day. This may include what you eat or drink, or practicing other methods that may control symptoms. You may not get rid of all symptoms with lifestyle changes, but your symptoms may feel better after changing a few habits. For some, weight loss has been linked to helping urinary symptoms.

Fluid Control

You will likely be asked to track what you drink, when and how much. You may learn you should limit certain things such as caffeine and alcohol. These drinks may bother the bladder. You may also be asked to drink more water. Six to eight glasses of water per day is ideal. Also, you may be asked not to drink for a few hours before bed. This may help reduce your need to get up to pass urine at night.

Limit Certain Foods and Drinks

Some foods and drinks have been found to irritate the bladder of some people. For example, some people have found spicy foods, coffee, tea and colas to be bothersome. However, studies have not proven these are “bladder irritants” in all patients. A good plan is to try to notice on your own how different food and drinks affect you and your symptoms.

Bladder Training

A bladder diary may be the starting point for bladder training. For three days, you write down what and how much you drink, and how often you go to the bathroom. Noting when you leak urine may also be helpful. This diary may help you and your health care team find things that may make your symptoms worse. It may also help to build a bladder training plan for you. This is when you empty your bladder in a controlled way at set times. When you empty your bladder as a routine, you should have fewer leaks. Timed urination, scheduled voiding or double voiding are methods that can help with both OAB and SUI.

If you pass urine too often, retraining your bladder may help. The goal is to hold your urine in the bladder for longer and longer amounts of time. This takes small steps. Start with adding five to ten minutes. The goal is to retrain your bladder to hold urine for three to four hours, with less urgency and leaking.

Pelvic Floor Exercises

Kegel exercises can strengthen the urethral sphincter and pelvic floor muscles. This works for all genders. Learning to tighten and relax these muscles may help your bladder control.

Kegels may also help control the bladder spasms that trigger the urge to go. Squeezing the pelvic floor muscles triggers a reflex to the bladder to get the bladder to quiet down and may help suppress the urge feeling. This can pause or even stop uncontrollable UUI leaks. A health care provider can teach you how to do these exercises with success.

Kegels can help with both SUI (by making the muscles strong) and OAB/UUI (by suppressing the urge feeling). Like any fitness program, you must practice the exercises often to keep helping your body.

Prescriptions to Treat Incontinence

When lifestyle changes do not help enough, your health care team may ask you to try prescription medications. A short talk with your team about the risks, side effects and benefits of each medication will help you decide which might be the right one for you.

Anticholinergic Drugs

Anticholinergic drugs treat OAB/UUI by helping the bladder muscle to relax. Common medications include oxybutynin, tolterodine and solifenacin. They work well for the bladder but are also linked to many bothersome side effects such as dry mouth, constipation, blurred vision, and lately, some concern for causing confusion or dementia with longer-term use. Trospium chloride does not diffuse into the brain so is not thought to have a risk of confusion or dementia.

Another medication for OAB is mirabegron. It is not an anticholinergic medication, so it is not linked to any of the side effects described above. It is an alpha-agonist, so works a little differently on the bladder, but in the end has the same effect of getting the bladder to relax. It can cause increases in blood pressure so should be used with caution in patients with hypertension. A newer medication for OAB is vibegron. It works much like mirabegron but will not affect blood pressure, so it may be a good option for patients with OAB and high blood pressure.

Be sure to talk about any bladder relaxing drugs you have tried when you talk with your health care team.

Hormone Treatment

For women, local vaginal/urethral estrogen therapy may help if you are having urinary incontinence after menopause. Vaginal estrogen replacement may help the health of the walls of the vagina, the bladder neck and the urethra. This may ease irritative bladder symptoms and incontinence. There are some special medical reasons not to use local hormones, so be sure to speak with your provider about what is best for you.

Stress Urinary Incontinence (SUI) Treatments

Choosing to have surgery is very personal. If surgery is suggested, there are many choices. It helps to learn as much as you can before you decide. You should work with a doctor who has experience in SUI surgery. Learn the risks and benefits of all your surgical choices, as well as what to expect during and after surgery, to make an informed choice that will be best for you.

Slings

Female Sling

The most common surgical treatment and the current standard of care for the surgical treatment of female SUI is the midurethral sling surgery. For this, a strip of soft permanent mesh is placed under the urethra to support urethral closure during actions that involve physical pelvic stress (coughing, sneezing, bending, lifting, jumping and running). It is a simple 10 to 20-minute, outpatient procedure with a small single cut in the vagina. This is done under limited anesthesia and is linked to a quick return to normal day-to-day activities.

Another type of female sling surgery, the pubovaginal sling, is a bladder neck sling. Here the tissue used to make the sling comes from the patient’s abdominal wall or leg (fascia), or donated tissue (bovine or cadaver).

Male Sling

A sling procedure may be offered to treat SUI in some men. The male sling is for urethral sphincter muscle support. For this, a soft mesh tape is placed under the urethra through a cut between the scrotum and rectum. It supports the urethra and sphincter muscle by pushing up on the urethra and causing some coaptation (closure) of the urethra to prevent leaks.

Bladder Neck Suspension / Colposuspension

The Burch Colposuspension, or bladder neck suspension, is surgery for female SUI that lifts the bladder neck up towards the pubic bone with permanent stitches. This is a bigger surgery with a cut through the abdominal wall (muscles and skin) to reach the deeper pelvic areas. Because of the cut into the belly, it takes a longer time to heal from this surgery compared to the more minimally invasive midurethral sling. In some cases, it can be performed laparoscopically, which lessens the recovery time after surgery.

Bulking Agents (Injections)

This option is used to treat female SUI by “bulking up” the inner urethral lining and making the opening of the urethra smaller. Modern bulking agents are permanent materials that are placed into the tissues around the urethra and sphincter muscle up towards the bladder neck. This may help the natural urethral closure function to stop leaks. Note that bulking agents are not FDA-approved for male SUI.

Artificial Urinary Sphincter

Implanting a device around the urethra, called an artificial urinary sphincter (AUS), may be an option for men and women. This is the most common treatment for males with SUI. In some cases, women may also be helped from this surgery, but due to other surgical options mentioned earlier, this is rarely needed in women. The AUS is a device with three parts:

1. An artificial urinary sphincter, which is a fluid-filled cuff placed around the urethra.
2. A fluid-filled, pressure-sensing balloon that joins to the cuff and regulates the pressure within the cuff. This balloon is placed in the lower abdomen.
3. A pump placed in the scrotum for men (and labia for women) that transfers the fluid between the cuff and the balloon to open and close the cuff (artificial urinary sphincter). The pump is easily controlled by the patient.

At rest, the AUS cuff is closed (full of fluid) to prevent leaks. When you decide to empty your bladder, you activate the pump to push fluid from the cuff to the balloon. This allows the urethra to open so that the urine can flow through and empty the bladder. If you have had radiation, scar tissue in the urethra, or other bladder problems, then this option may not be the best option for you.

Overactive Bladder (OAB) Treatments

If lifestyle changes and medicine are not working for your OAB, there are other options. In appropriate patients, a trained urologist or urogynecology and reconstructive pelvic surgery (URPS) specialist may help.

Bladder Botox® Treatment

Botox® (onabotulinumtoxin) may help to relax the muscle of the bladder wall to reduce urinary urgency and urge incontinence. The effects of Botox® last about six to nine months, so repeat treatments will be needed when OAB symptoms return. A small instrument called a cystoscope is used to put Botox® into the bladder. A tiny needle attached to the cystoscope is used to inject the Botox® in small amounts straight into the bladder wall, spreading it evenly throughout the bladder. This procedure is most often performed in the office with local anesthesia (numbing mixture in the bladder). A small number of people have trouble emptying their bladder for a short time after this treatment and may need to use a catheter (small tube) to get the urine out of the bladder until their voiding improves.

Nerve Stimulation

Nerve stimulation, also called neuromodulation therapy, sends electrical pulses to nerves that share the same path for the bladder (pelvic nerves). In OAB, the nerve signals between your bladder and brain do not always communicate the right way. Treatment with electrical pulses may help to modulate the neurological signaling so the brain and the pelvic nerves can communicate better to help the bladder function to “calm down” and help OAB symptoms.

There are two main types available today:

• Percutaneous Tibial Nerve Stimulation (PTNS) stimulates peripheral nerves to your bladder. PTNS is performed in the office, with each session taking about 30 minutes. PTNS is done by placing a small needle electrode in your lower leg near your ankle. It sends stimulation pulses up the leg, by way of the tibial nerve, to the pelvic nerves that modulate the bladder function to calm the bladder down. The therapy is approved as a program of weekly 30-minute sessions for 12 treatments, followed by on-going monthly care treatment sessions to keep the benefits.

Percutaneous Tibial Nerve Stimulation (PTNS)

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• Implantable tibial nerve stimulator works like PTNS but is a small device implanted into the ankle so that stimulation can be done at home instead of coming into the doctor's office.
• Sacral Nerve Stimulation (SNS) stimulates the pelvic nerve root coming right off the spinal cord. Stimulation here again serves to modulate the neurological signaling between the bladder and the brain to help bladder function. SNS involves an implantable bladder pacemaker to control these signals to stop OAB symptoms. SNS is a two-step surgical process, which gives patients the chance to try the therapy first before making choices about final surgical implantation of the pacemaker.

Sacral Nerve Stimulation (SNS)

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The first step is to place a small wire through the skin in your lower back that goes deep towards the sacral nerves. This wire is linked to an external, handheld pacemaker for the test. If it helps sufficiently for your OAB symptoms, the second step is to join the wire to an implantable permanent pacemaker. The stimulation is then continuous as it regulates the pelvic nerve activity to control the OAB symptoms.

Bladder Reconstruction / Urinary Diversion Surgery

These types of major abdominal surgeries are only used in very rare and complicated cases. The main types of major abdominal surgery for OAB are:

• Augmentation cystoplasty, which may be used to make the bladder bigger to increase how much urine it can hold at any one time.
• Urinary diversion, which may be used to re-route the flow of urine away from the bladder and often requires a stoma and external appliance to catch the urine.

There are many risks to these surgeries, so they are offered only when no other option can help. In most cases, managing or treating symptoms leads to great improvements and even a cure. To avoid a setback after surgery, try to:

• Keep a healthy weight
• Practice Kegel exercises
• Avoid foods or drinks known to bother the bladder
• Eat more fiber and drink plenty of fluids to prevent constipation
• Avoid smoking

After treatment and lifestyle changes, most people feel a lot better. Still, be careful about how much fluid you drink and when. You may also need to plan regular bathroom breaks as part of your everyday life.

Taking care of yourself in these ways may help the benefits from surgery last. It helps to stay in touch with your health care team about your follow-up care.

Overflow Urinary Incontinence Treatments

Overflow urinary incontinence happens when the bladder cannot empty well and dribbles as bladder pressure grows. Treatment often requires some type of procedural or surgical action to fix the block of the bladder neck and/or urethra. Common problems in men that can lead to overflow incontinence include benign prostatic hyperplasia (BPH) and urethral strictures.

You should speak with your health care team to learn what therapy might be right for you.

Products and Devices to Help with Incontinence

For some people, incontinence products and devices may help to manage bladder problems. Some include:

• Indwelling catheters which stay in your body day and night and are joined to a drainage bag
• Intermittent catheters which are used many times each day
• External collecting systems, which are a condom style for men and a funnel with a pouch for women
• Absorbent products, such as pads, adult diapers or tampons
• Pessaries for women, mostly those designed for SUI
• Toilet substitutes, like portable commodes

Whatever your urinary problem is, there are likely good choices for you. It is vital to find a provider who specializes in bladder and incontinence problems, such as a urologist.

Preventing Future Problems

In most cases, managing or treating urinary symptoms can greatly help your quality of life, letting you return to activities you enjoy without being bothered by urinary symptoms or leakage. Lifestyle and food changes are the first steps. These changes need to be continued at all times for them to keep helping. Again, some of these recommendations include:

• Keep a healthy weight.
• Drink plenty of fluids - about two liters per day – spread out evenly throughout the day. It is of great value to stay well hydrated, but there is no added benefit to drinking more than your body needs.
• Avoid foods or drinks that are known to bother YOUR bladder.
• Eat more daily fiber to prevent constipation.
• Practice Pelvic Floor “Kegel” exercises, and work to make your core stronger.
• Stick with bladder re-training programs.

After lifestyle and food changes, most people feel a lot better. But if there is still room to make things better, medications or simple surgical options may be the right next step for you. Finding the best treatment plan is a step-by-step process of trying simple things first before advancing to other choices. It is of great value to stay in touch with your health care team during this process to make sure you are benefiting from the treatment options available and to find the right plan for you.

Questions to Ask Your Health Care Team

• What type of incontinence do I have?
• What tests will tell us the type and severity of my incontinence?
• Can you help me or should I see a different doctor?
• If I need a different doctor, how can I find the right one for me?
• What do you think is causing my incontinence?
• Should I keep a bladder diary?
• Without treatment, what will happen to me?
• Will diet and lifestyle changes help my condition?
• Should I try Kegel exercises? If so, how do I do these exercises the right way?
• What else do you suggest for me and why?
• Are there problems that can come from treatment?
• What are the potential side effects or risks of treatment?
• If leaking is linked to menopause, could hormone replacement therapy (HRT) help?
• Do you suggest surgery?
• What are the pros and cons of surgery?
• What does healing look like after surgery?
• If I keep having problems, what other options are available?
• What follow-up care do I need?
• What is my long-term plan?

Updated October 2024.