Urinary incontinence in women is usually divided into several types; stress incontinence, emergency incontinence, mixed incontinence, overactive bladder and overflow incontinence. Stress and emergency incontinence account for 90% of all incontinence cases in women. The most important risk factors for incontinence are advanced age and pregnancies with vaginal delivery. Obesity and a family history of incontinence also increase the likelihood of developing incontinence.
Types of Urinary Incontinence in Women
Stress incontinence is defined as leakage associated with increased intra-abdominal pressure or physical activity such as coughing, sneezing, or getting up from a chair. It occurs in 25-45% of women over the age of 30. It is caused by atrophy or damage to the pelvic floor muscles, ligaments, or fascia. This is often associated with childbirth and menopause.
Urgent (sudden) incontinence is leakage associated with or immediately after the sudden need to void (called urgency). The volume of urine lost is variable and complete emptying of the bladder, known as complete incontinence, may occur. Immediate incontinence occurs due to overactivity of the detrusor muscle. This overactivity may be neurogenic or idiopathic secondary to an underlying pathology. Neurogenic overactivity of the bladder can result from any condition that causes a loss of neurological control, most commonly stroke, multiple sclerosis, spinal cord injury or spina bifida.
UTI- Urinary Tract Infections
Secondary causes of urinary incontinence include urinary tract infection (UTI), sexually transmitted infections (STI), interstitial cystitis, atrophic vaginitis, bladder diverticulum, or previous pelvic radiation or surgical treatment. Idiopathic overactivity is poorly understood, but it occurs with aging and is closely linked to overactive bladder syndrome.
Overactive Bladder Syndrome
Overactive bladder syndrome is a largely idiopathic urological condition involving urgency, frequency, and often nocturia. Urgent incontinence with no known cause is often referred to as overactive bladder. However, in people with overactive bladder, urgency and frequency may occur without resulting in any incontinence. Frequency of urination is usually defined as more than eight times a day. The cause of overactive bladder is not fully understood, but loss of neurological control of detrusor muscle activity is thought to contribute to the condition. Overactive bladder is managed in the same way as emergency incontinence.
Mixed incontinence is defined as a combination of stress and urgency incontinence and occurs in approximately one-third of women with incontinence. Mixed incontinence becomes more common with age as multiple disease states begin to emerge, for example, idiopathic urgency incontinence begins to develop in a woman with a weak pelvic floor causing stress incontinence. Management should follow the individual management of each type of incontinence, but focus on the dominant type.
Overflow incontinence occurs when there is an obstruction in the bladder neck or when there is a disruption in detrusor contractility so that leakage occurs from an overfilled bladder, often without urgency. It is more common in men. Urethral obstruction, sagging of the pelvic organs, neurological damage, and conditions that can reduce sensation in the bladder, such as stroke, multiple sclerosis, and diabetes, can cause overflow incontinence.
Other Types of Incontinence
Other types/causes of incontinence include:
1. Functional incontinence: Occurs when cognitive or physical impairments prevent the patient from voiding independently and appropriately.
2. Leakage after urination: It is the leakage that occurs after urination due to residual urine in the urinary tract.
3. Urogenital fistula: It is the place where a passage is opened between the bladder / urethra and the vagina by passing through the urethral sphincter. Urogenital fistula can cause complete incontinence. Among women in the developed world, this is most often due to complications from gynecological surgery, eg hysterectomy.
How Does the Bladder Work?
The bladder is a muscular urinary reservoir that sits behind the inguinal symphysis. A normal bladder in an adult holds 300 – 600 mL of urine. When healthy, bladder function is controlled by coordination between musculoskeletal and neurological inputs. The neurological control of the bladder is biphasic and works like a switch: alternating between storage or voiding. The neural pathways that control urination are complex and include the brain, spine, and peripheral ganglia. These pathways include autonomic (sympathetic and parasympathetic) and somatic nerves (via the pudendal nerve). NB Acetylcholine is one of the neurotransmitters of the parasympathetic pathways that mediate detrusor contraction, so anticholinergic drugs are used to stabilize the bladder.
Damage to any of these structures or nerve pathways can cause incontinence. Afferent and efferent nerve fibers involving bladder control are mainly located at the S2 – S4 spinal nerve levels (but also include T11 – L2 spinal segments), so spinal cord injuries at the sacral level often affect continence. The anterior lobe of the brain provides preventive entry, suppressing inappropriate bladder voiding. Therefore, for the incontinent, it may result from damage to the frontal lobe, among those people who have had a stroke or dementia. In men, surgical procedures involving the urogenital system, such as prostatectomy, can cause incontinence by damaging the adjacent external urethral sphincter or the urethra itself.
In healthy people, urination is under conscious control and is based on learned behaviors developed during childhood. Mechanical control of continence involves the muscles and connective tissue surrounding the bladder. The bladder neck and pelvic floor musculature work together to increase output resistance to a point where it is greater than the output pressure created by the resting bladder. Acute pressure increases also occur with daily activities such as coughing, standing up, and laughing. If the pelvic floor muscles have sufficient tone, the protective reflex increases the urethral pressure as the outlet pressure increases, allowing urine to continue. Leakage occurs if the outflow resistance is less than these pressure increases, such as loss of pelvic floor support. When the detrusor muscles contract, the outflow pressure also increases. This occurs consciously during normal urination, but can also occur unconsciously with excessive activity in the bladder, causing incontinence.
Diagnosis and Diagnosis of Urine Leakage in Women
The diagnosis of urinary incontinence should initially be based on the patient’s symptom report, the history of the incontinence, and the focus of the examination to determine the type, underlying factors, severity, and impact of the patient’s incontinence. While taking the symptoms, the following should be considered;
Leak frequency (how many times per day, how many days in a typical week) and volume of urine leaked
Triggers associated with leakage, i.e. does leakage occur when the patient laughs? Lying flat in bed?
Use of pads or other protective devices
Diet and fluid intake, including caffeine and alcohol intake
Lower urinary tract symptoms such as UTI symptoms, leakage after urination, needing to urinate again immediately after urination,
Other genitourinary symptoms, such as urogenital or abdominal pain, discomfort, hematuria, other discharge
Whether there is constipation and fecal incontinence / contamination,
Sexual function (ie psychosocial effects of incontinence)
Past history: bladder surgery, hysterectomy, delivery (including number and mode of delivery), previous UTI, previous STI
Cigarette smoking is associated with bladder overactivity, is thought to be a bladder irritant and causes chronic coughing, which over time can weaken the pelvic floor and directly affect the severity of stress incontinence. At this point in the assessment in women, the type of incontinence will likely be evident. The following types of incontinence are more likely depending on when urine leakage occurs:
Stress urinary incontinence; when coughing, sneezing, laughing, lifting or exercising,
Immediate incontinence with or without overactive bladder syndrome, with sudden urgency, frequency, and nocturia, especially if the patient is lying in bed and motionless (ie without stress)
mixed incontinence; both types of symptoms are present
If incontinence is not related to the above causes (which is rare), the following factors should be considered:
o Chronic urinary retention associated with bladder overflow incontinence or bladder outlet obstruction – difficulty voiding (hesitancy, straining to void, weak or intermittent urine flow, and post-void dripping)
o Fistula (vesicovaginal, urethrovaginal or ureterovaginal – continuous passive urine leakage and often complete incontinence
o Urethral diverticulum; postvoid drip, frequency, dyspareunia, and dysuria, especially in a woman with recurrent UTI
A urethral diverticulum is an outward incision of the urethra of unclear etiology. It is most common in women aged 30-60 years. Urine stays in this sac and may predispose the patient to recurrent infections. If the diverticulum is large, it may obstruct the bladder outlet. Over time, chronic inflammation can lead to malignant transformation of the cells lining the urethral diverticulum.
Writer: Ozlem Guvenc Agaoglu