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What is Urinary Incontinence?

Urinary incontinence is a common problem that almost everybody has experienced at some point in their life. Unfortunately, as we get older, changes in our bodies can make controlling our bladder a lot more challenging.
 
A “weak bladder” can be an embarrassing and inconvenient source of anxiety. An estimated 30% of the world’s population has some form of urinary incontinence. If you’re feeling under pressure, you are certainly not the only one!

Right up top, if you have developed a sudden urge to pee all the time or stress incontinence, you should pay a visit to your doctor to be on the safe side. Put aside any embarrassment, abrupt bladder problems can be a symptom of ovarian cancer or an enlarged prostate. And if this isn’t the cause, your GP will be able to offer some smart solutions to your bladder bugbear. 

What’s The Problem?

Firstly, urinary incontinence can take different forms and can have varying underlying causes. Some people might have total loss of bladder control and an ongoing leak, others might be fine one minute and bursting the next. Many people are quite happy until a sudden sneeze or a belly laugh.

Different causes of incontinence will need different treatments, so let’s start off by figuring out what’s going on.

Why Do I Pee When I sneeze? Stress Incontinence

Urinating when pressure is applied to your lower stomach area is an everday experience for many. Laughing, sneezing, coughing, straining, intense exercise, bending or twisting among other activities can all put pressure on your pelvic area—squeezing your bladder. This is “stress incontinence”. 

What’s happening in my body?

Normally, your pelvic muscles pinch your urethra closed to prevent urine from passing through. Damaging or weakening the pelvic floor muscles can make it difficult for the muscles to squeeze tightly enough to keep the tube sealed. 

Pelvic floor damage

Pregnancy and childbirth: Pregnancy can cause body changes that make the connective tissue around the pelvis a little stretchier to allow movement of the organs as the uterus grows and to improve the elasticity of the vagina. As the collagen that holds everything together loosens up to make space, it has the unintended consequence of making the pelvic floor area weaker.

During childbirth, intense vaginal pressure pushes out the baby, but can also strain the pelvic floor. This intense pressure can also crush nerves required to control the “gates”.

Menopause: Reductions in estrogen levels during menopause can cause muscle weakness. Loss of pelvic floor strength is one example of this.


Injuries to pelvic region: Physical trauma, for example, injuries caused by a car crash can damage the pelvic floor.


Surgery: Any procedure that requires cutting through the pelvic floor will weaken it.

Obesity: High BMI adds more weight for the pelvic floor to support. This can cause strain over time.


Old age: Regardless of sex, the hormonal changes found in old age result in general muscle weakening-including the pelvic floor.

Neuromuscular damage

Surgeries or injuries around the bladder can damage surrounding nerves that control the bladder muscles. In layman’s terms, the nerves “malfunction” and don’t relay the messages to your muscles when they should.

I Haven’t Drunk Any More Than Usual,
Why Do I suddenly Need to Pee? Urge Incontinence

Another type of urinary incontinence is urge incontinence. This is when you feel the sudden, unpredictable need to urinate.

What’s triggering the urge?

Urge incontinence is most often traced to issues with the detrusor muscles around the bladder that squeeze it to force the urine out. There are three main forms of urge incontinence.

Detrusor Overactivity: Detrusor muscles will “squeeze” the bladder even at low volumes. The cause is unknown, but urologists believe that “malfunctioning” nerves might be sending the wrong signals to the bladder.

Poor Detrusor Compliance: The bladder loses its ability to “stretch” reducing the volume of urine it can hold. Effectively your bladder is smaller and gets full faster. Extended periods of catheter use and pelvic radiotherapy can cause this.

Bladder Hypersensitivity: An irritated inner protective layer of the bladder can disrupt its ability to sense bladder fullness. This can result in the brain thinking the “gates” should be open when it is not necessary. Some theorize that changes of bacteria populations in the bladder could be responsible for the inflammation.

Why can’t I urinate when I need to? Overflow Incontinence


Overflow incontinence first starts when you can feel the urge to urinate, but when attempting to go, you can’t. Eventually, your bladder will be so full that the built-up pressure will force the opening of the urethra open. Overflow incontinence is usually caused by either blockage of the urethra or poor detrusor function.

Am I Really Blocked?

Blockage: A physical barrier blocks the urethral “tube” causing it to build up in the bladder. Male-sexed urinary systems can develop a blockage through an enlarged prostate. Urinary blockage is rare in female-sexed urinary systems but can occur because of cystitis/urinary tract infection (UTI). In this case, the urethra is so inflammed that it becomes too swollen to open when you need it to.

Poor Detrusor Function: The detrusor muscles are unable to contract well limiting your ability to “squeeze” your bladder. Spinal cord or lower-urinary nerve damage can interrupt the signal that tells the muscles to squeeze.

Why Do I Feel I’ve Lost All Control of My Bladder? Total Incontinence

Total incontinence is when your bladder is not storing any urine. As your kidney feeds liquid into your bladder, there is nothing to stop it from flowing straight through and out. The problem here is damage to the ability to close your urethra.

What’s happening in my body?

Neuromuscular causes: In some cases, a spinal or nerve injury might prevent the messages between your bladder and the muscles that control the urethra from being sent or received.

Damage to connective tissue: In other situations, a fistula, or hole, in the urethra above the sphincter muscles that open and close the tube could be responsible.

The fistula forms a small tunnel between the urethra and the surrounding area, for example, the vagina. The leak will allow urine to drain continuously.

Fistula is an unfortunately common complication of childbirth, but it’s not something you have to put up with. Visit your doctor ASAP if you are experiencing this, modern treatments are available.


Why do I pee when I sleep? Nocturnal enuresis

Nighttime accidents are a part of life and can be caused by 1) excessive urine production at night, 2) urgency incontinence, and 3) Inability to wake upon needing to urinate.

While some people assume bed wetting is due to incomplete potty training, in reality, any or all of delayed brain/bladder control, a smaller than average bladder, sleep disorders and decreased hormone production of arginine vasopressin (AVP), and increased atrial natriuretic peptide (ANP) at night are the real culprits.

AVP and ANP hormones cause increased urine production. You can use a drug to correct the hormonal imbalance and normalize your ability to sleep uninterrupted. If bed wetting is an ongoing problem for you, or your child, have a chat with your doctor.

Why do I sometimes pee during sex?

If you are concerned about releasing urine during sex, it’s not abnormal if you are having pressure applied to your bladder area, but it is trickier for it to happen with an erection.

Female reproductive system

While potentially embarrassing, leaks during sex are common for 10–27% of women. Often this form of incontinence is just stress or urgency incontinence. Sex is a strenuous affair, and the pressure near your urinary system can cause issues. What you need to ask yourself is when it happens:

During Penetration: This part of sex puts a lot of pressure on your lower body. That along with the high amounts of movement can cause stress incontinence to occur.
During Orgasm: An overactive detrusor muscle or a weakened urethral wall might cause a little urine to escape.  

Male reproductive system

To be upfront it is true that most males cannot urinate while erect. To prevent your semen from flowing back into the bladder, your muscles will naturally close the urinary tract.

That said, if you’ve had a prostatectomy or radiation treatments, they might have damaged your urinary sphincters. This can, assuming sexual function remains, allow urine to leak out during your ejaculation.

Why Can’t I Reach the Bathroom In Time? Functional Incontinence

Functional incontinence is when you can’t reach the bathroom in time despite having a normally functioning bladder.

What’s happening in my body?

There are two main categories of functional incontinence: mobility and neurological issues.

Mobility disorder: This refers to individuals who, while capable of sensing the need to urinate, are unable to reach the bathroom in time. This covers many older adults and those with mobility disorders.

Neurological causes: Individuals lose the ability to feel the need to urinate. This is common for patients with dementia and neurological disorders that affect sensation.


Strategies to Avoid Accidents

In the case of Mobility functional incontinence, the aim is to make it easier to reach the bathroom. Installation of disabled access toilets, having bathrooms in easily accessible locations, and adding mobility assistive devices can improve access. Scheduled bathroom use can also help prevent urination at inopportune moments. Functional incontinence with neurological causes might be better addressed by the use of incontinence briefs or pads.

What Treatments Are Available For Incontinence?

If you are struggling with your weak bladder, all is not lost. There are behavioral changes that you can adopt that will make life a little more predictable. If tweaking your lifestyle doesn’t help, your GP can offer a solution.

What Can I Do?

Pelvic Floor Exercises: A set of exercises meant to strengthen the pelvic floor. The most popular of these is the Kegel exercise. These exercises have you lie on the floor (with an empty bladder) and practice contractions of the pelvic floor.

As it is possible to injure yourself with these exercises, it is recommended that a licensed physiotherapist assist you with your first attempts. Pilates has also been shown to help strengthen the pelvic floor.

Like any muscle, your pelvic floor will weaken if not regularly exercised.

Timed voiding: set yourself a regular schedule for bathroom breaks. This should keep your bladder relatively empty limiting potential accidents.

Avoid Bladder Irritants: Certain substances like alcohol, caffeine, carbonated beverages, and smoking can worsen incontinence. Avoid these whenever possible.

Don’t drink immediately before bed: Strike a balance between drinking during the day to stay hydrated, and minimizing the amount you drink within two hours of bedtime. More than two hours is unnecessary and makes you dehydrated.

Avoid Constipation: Constipation can cause stress incontinence.

What Can My Doctor Do?

These days incontinence care is more than just catheters and incontinence supplies. Physiotherapy, drugs, medical devices, and surgeries are available with a referral to a urologist/gynaecologist. If you have bladder problems, don’t shy away from your doctor.

Drugs

There are a number of medications that can help if changing behavior and physiotherapy isn’t sufficient.

Stress incontinence

Oxybutynin: Reduces signals to detrusor muscles that cause bladder “squeezing.”

Tricyclic antidepressants and/or estrogen: Strengthens contraction of the urethra helping to prevent urine leakage.

Urge Incontinence

Anti-muscarinic drugs (oybutynin, tolterodine, fesoterodine, trospium, darifenacin, and solifenacin): Reduces signals to detrusor muscles that cause bladder “squeezing”.

Beta-3 adrenoreceptor agonists: Block the nerve signals that would cause detrusor “squeezing” in detrusor overactivity.

Nighttime Polyuria/eneuresis

Desmopressin acetate (DDAVP): This synthetic hormone can prevent you from making excessive urine while you sleep.

Oxybutynin and Tolterodine: These drugs can prevent muscle spasms in the bladder that can cause nighttime stress incontinence.

Medical Devices

Pessaries: Put bluntly, you place structural support inside your vagina to hold the bladder in the correct position. This can help where incontinence is caused by pelvic organ prolapse. Your doctor can advise you on what will work for you.

Catheter systems: For people with an enlarged prostate that is causing urge incontinence, there are a growing number of non-surgical solutions. A small catheter can be fitted in the urethera that can hold the tube open where the prostate is pressing on it.

Surgical Approaches

Sometimes surgery might be considered as a last resort, for example, where the issue is caused by a late-stage pelvic organ prolapse.

Retropubic Suspension/Abdominal Suspension: A surgical method meant to provide support to the urethra. There are two main variants:

Marshall-Marchetti-Krantz Procedure Uses sutures to attach the urethra and bladder to pelvic cartilage.

Burch Procedure: Uses sutures to attach urethra and bladder to pelvic muscles.

Pubovaginal Sling: Uses muscle tissues to form a “hammock” on which the bladder and urethra can rest.

An enlarged prostate can be shaved down to a more manageable size.

References

Aoki Y, Brown HW, Brubaker L, Cornu JN, Daly JO, Cartwright R. Urinary incontinence in women. Nat Rev Dis Primer. 2017;3:17042. doi:10.1038/nrdp.2017.42

Lugo T, Riggs J. Stress Incontinence. In: StatPearls. StatPearls Publishing; 2023. Accessed October 22, 2023. http://www.ncbi.nlm.nih.gov/books/NBK539769/

Memon HU, Handa VL. Vaginal childbirth and pelvic floor disorders. Womens Health Lond Engl. 2013;9(3):10.2217/whe.13.17. doi:10.2217/whe.13.17

Kołodyńska G, Zalewski M, Rożek-Piechura K. Urinary incontinence in postmenopausal women – causes, symptoms, treatment. Przegla̜d Menopauzalny Menopause Rev. 2019;18(1):46-50. doi:10.5114/pm.2019.84157

Nandy S, Ranganathan S. Urge Incontinence. In: StatPearls. StatPearls Publishing; 2023. Accessed October 22, 2023. http://www.ncbi.nlm.nih.gov/books/NBK563172/

Leron E, Weintraub AY, Mastrolia SA, Schwarzman P. Overactive Bladder Syndrome: Evaluation and Management. Curr Urol. 2018;11(3):117-125. doi:10.1159/000447205

Ferrara P, Franceschini G, Bianchi Di Castelbianco F, Bombace R, Villani A, Corsello G. Epidemiology of enuresis: a large number of children at risk of low regard. Ital J Pediatr. 2020;46(1):128. doi:10.1186/s13052-020-00896-3

Kiddoo DA. Nocturnal enuresis. CMAJ Can Med Assoc J. 2012;184(8):908-911. doi:10.1503/cmaj.111652

Lau HH, Huang WC, Su TH. Urinary leakage during sexual intercourse among women with incontinence: Incidence and risk factors. PLoS ONE. 2017;12(5):e0177075. doi:10.1371/journal.pone.0177075

El-Azab AS, Yousef HA, Seifeldein GS. Coital incontinence: relation to detrusor overactivity and stress incontinence. Neurourol Urodyn. 2011;30(4):520-524. doi:10.1002/nau.21041

Pastor Z. Female ejaculation orgasm vs. coital incontinence: a systematic review. J Sex Med. 2013;10(7):1682-1691. doi:10.1111/jsm.12166

Moutounaïck M, Miget G, Teng M, et al. L’incontinence coïtale. Prog En Urol. 2018;28(11):515-522. doi:10.1016/j.purol.2018.05.00113.

Kannady C, Clavell-Hernández J. Orgasm-associated urinary incontinence (climacturia) following radical prostatectomy: a review of pathophysiology and current treatment options. Asian J Androl. 2020;22(6):549-554. doi:10.4103/aja.aja_145_19

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