Urinary Incontinence 101

Top things to know

• Urinary incontinence among women is very common—a quarter of women over 20 years old and half of women over 40 are estimated to suffer from urinary incontinence
• Rates of incontinence increase with age, obesity, pregnancy, and birth (especially vaginal birth)
• Just because incontinence is common, does not make it normal

What is urinary incontinence?

Urinary incontinence (UI) a condition where a person involuntarily leaks urine. This could be just a few drops or a complete emptying of your bladder. Urinary incontinence affects many people, particularly adult and older women. Incontinence is often considered taboo, and for reasons of embarrassment, fear, or thinking that it’s normal, incontinence is often not discussed.

Aside from the inconvenience of having to wear panty liners or frequently changing your underwear, urinary incontinence can have negative impacts on health and quality of life.

People often experience anxiety and depression related to their urinary incontinence, which can affect work performance and social experiences (1). This can also have an impact on intimate relationships—up to a quarter of women aged 40 to 80 who have urinary incontinence may also suffer from coital incontinence (involuntary leaking urine during sex) (2). This can impact a woman’s experience of sexual activity and can cause women to choose to restrict sexual activity (2).

Urinary incontinence is also associated with other illnesses and repercussions. Continually having a moist environment around the pelvic area can lead to irritations and increased rates of rashes and Urinary Tract Infections (UTIs) (3).

Within older population groups, urinary incontinence has been associated with increased rates of nursing home admissions, fractures (especially with urgency incontinence), and a decreased ability to perform activities of daily life (3,4).

How common is urinary incontinence?

A quarter of women over 20 years of age are estimated to suffer from urinary incontinence. This trend increases with age, with up to half of women over 40 experiencing incontinence (3,5,6). This could be having incontinence every time you need to urinate, to only involuntarily passing urine once per month, and can range in volume from just a few drops to a complete emptying of the bladder. Even though incontinence is very common, only a quarter of these women will seek help from their medical provider (3). For reference of what is considered “normal”, an average woman urinates eight times or less per day (3).

What causes incontinence?

Let’s break down the most common types of incontinence:

1) Stress urinary incontinence (SUI)

Stress urinary incontinence is the involuntary loss of urine when intra-abdominal pressure is increased. This can happen under any type of bodily effort or exertion — sneezing, coughing, laughing, or performing strenuous exercise (7). Stress incontinence is the most common type of incontinence, accounting for up to half of cases of incontinence in women, and the predominant type affecting younger women with incontinence (6).

Women who experience SUI often have either weaker urethral sphincters or weaker pelvic floors, or a combination of both (3). The urethra is the tube which connects your bladder to the outside, where urine exits through. The sphincters are circular muscles that when constricted, prevent any urine from leaving the bladder. When these muscles relax, urine can leave the bladder. The bladder and urethra are located within the abdominal cavity, in the lower pelvis. As intra-abdominal pressure increases, the urethra may not be strong enough to maintain closure under the increase in pressure, and urine can involuntarily be passed (3).

Reasons for urethral injury and weakness of the urethral sphincter include pelvic surgeries, childbirth, and diabetic neuropathy (3). During pregnancy, when the growing baby takes up additional space within the pelvis, more pressure is put on the bladder and on the urethral sphincters.

Having a weak pelvic floor also contributes to stress incontinence by not providing the urethra with enough support, and hindering its ability to be fully sealed (3).

It has also been suggested that postmenopausal women who have low estrogen (hypoestrogenic) can develop a thinning of the vaginal tissue around the urethra (9). This could make it more difficult to achieve and maintain urethral closure under pressure. The postmenopausal stage is full of changes, and it is difficult to determine a clear relationship between low estrogen and incontinence (8). There have been conflicting results using estrogen therapy to treat incontinence in menopausal women, and more research is still needed (8,9,10). In general, vaginal estrogen creams appear to have some benefit, while estrogen oral medications seem to worsen incontinence (10).

2) Urgency urinary incontinence (UUI)

Urgency urinary incontinence is experienced as a dramatic sense of urgency to empty the bladder before or during leakage (3,7). When a person who suffers from UUI notices a sense of urgency, they will often need to empty their bladder promptly, or it might empty accidentally.

Urine does not just leave the body through gravity. There is a large round muscle that surrounds the bladder called the detrusor muscle. When the detrusor muscle contracts, it causes the bladder to shrink in size. With UUI, the detrusor muscle is most likely overactive and may contract at random, especially at night (3). In these situations the detrusor muscle contraction is stronger that the urethral sphincter seal, and it forces urine out.

3) Mixed type incontinence

Mixed type incontinence is a combination of both a sense of urgency to empty your bladder and incontinence brought on by increases in intra-abdominal pressure (3,7).

5) Other forms of incontinence

There are many other reasons why a person can experience incontinence, including urinary tract infections, neurologic disease (like MS or Parkinson’s), spinal cord/nerve injury, cognitive impairment, cancers, or physical limitations that prevent them from getting to the bathroom on time (3).

Obstetric fistulas

A fistula is an abnormal passageway between two hollow organs. A common cause of urinary incontinence within Sub-Saharan Africa and other under-served communities are obstetric fistulas, which can form during labor, especially in a labor that is unattended by a trained birth professional, like a midwife or a doctor. An estimated 2 million people suffer from fistulas in places where gynecological care is inaccessible (11).

Obstetric fistulas often occur because of blocked labor, when the baby cannot pass through the birth canal. This can be due to the baby being of larger size, or the mother’s pelvis being too small, especially if the mother is young. In these situations, as the baby descends down the birth canal being pushed by uterine contractions, the baby can become stuck. If the baby’s body is being forcibly pressed against the mother’s pelvic organs for a long time, this can cut off the blood supply to the vagina, bladder, urethra, or rectum. Without a source of oxygenated blood to that area, the tissue dies, leaving a hole between affected organs. This can lead to lifelong urinary and fecal incontinence.

People with obstetric fistulas are at increased risk of infections and are often stigmatized and shamed by their community, and perceived as unclean, malodorous, and unable to bear children. There are organizations working to eliminate fistulas and the effects they have on womens’ lives (12).

Within the developed world, obstetric fistulas are extremely rare because they are both preventable and treatable. Obstructed or difficult labors are supervised by trained medical professionals and any obstacles are treated with medical techniques, medications, and caesarean sections (11,12).

Who is at risk for urinary incontinence?

Pregnant people, and people who’ve recently given birth (especially vaginally)

Increased pressure on the bladder makes urinary incontinence considerably more common during pregnancy. Incontinence during pregnancy can affect 1 out of 2 people at some point throughout their pregnancy (13). People are also more likely to experience urinary incontinence after childbirth. This is often due to stress and injury to the pelvic floor from vaginal birth. Especially within the first three months post-partum, research suggests that a third of women who give birth vaginally experience incontinence. Less than 1 in 6 women who had caesarean sections experience incontinence (14,15).

Hormonal changes during pregnancy may also affect continence. Relaxin is a hormone produced during pregnancy which helps to regulates the blood volume changes that occur. Relaxin concentration peaks around 10–14 weeks gestation, and promotes blood flow and increased tissue growth in the genitourinary area. After 14 weeks, relaxin begins to decline, causing urethral tissue to also decrease, along with a decrease in urethral closure pressure. Women with lower relaxin levels were also found to have more incidences of SUI in later pregnancy (16,17). Thus far, studies on relaxin have been small and preliminary, indicating that more research is needed.

Obesity

People who are obese are more likely to have disorders of the pelvic floor including incontinence, due to additional physical stress (weight) that the pelvic floor has to support (14,18–20).

Increasing age

The incidence of incontinence increases with age, even for women who have never been pregnant (3,15,19). The low estrogen state of menopause can lead to decreases in the tissue and blood supply which offer support to the urethra, so it may not be able to close as effectively as before menopause (3).

A new study suggests that postmenopausal women might have weaker involuntary pelvic floor contractions — like what happens during sneezing, laughing, or coughing — compared to premenopausal women. But it’s still unclear whether this is related to estrogen levels, increasing age, or some other factor, and more research is needed.

It is important to remember that although incontinence is very common with increased age, it is not a normal part of aging, and should be discussed with your healthcare provider.

Family history

Your family history can also play a role, with increased risk if your mother or sister has incontinence (22).

Other reasons

There is some evidence to suggest that smoking cigarettes may also have an effect on urinary health, particularly by impacting the urgency and frequency that people need to empty their bladder (20,23).

How is urinary incontinence usually treated?

For immediate leak prevention, disposable absorbent products or reusable leak-proof underwear are good temporary solutions, but will not treat the cause. If you are experiencing incontinence, be mindful of how many absorbent products you use per day and the amount you soak them (just a few drops or completely soaked through?). Also take note of when the leaks occur (during sneezing or mostly random?), and note if there is any sense of urgency. This information is important to tell to your healthcare provider.

To treat stress incontinence, the first step is to improve the muscle tone of your pelvic floor, by doing pelvic floor exercises or Kegel exercises (3). Kegel exercises are quick, easy, free, inconspicuous, and (usually) require no equipment. When compared to people with stress incontinence receiving no treatment, those doing Kegel exercises were 17 times more likely to report improvement or cure of their incontinence (24).

Lifestyle changes like decreasing alcohol or caffeine intake may also help. Behavioural therapy such as bladder training—where urinations are planned and timed out—is also one way to approach incontinence.

Therapeutic pessaries (a medical device inserted into the vagina—in this case to provide structural support) can be used to also help treat stress incontinence (3). Surgical treatments are also an option.

For some people, especially with older populations, people with dementia, or people who have restricted mobility, catheterization is used to prevent involuntary urine loss and maintain a healthier and dry pelvic area.

What can I do to prevent urinary incontinence?

• Maintain a healthy pelvic floor and core strength. You can do this by performing Kegel exercises, core and balance exercises, or by practicing using your pelvic floor muscles to stop your urine stream mid-flow.
• Decrease alcohol and caffeine intake, as these will increase the need to pee (3)
• Don’t stop drinking water or fluids, but try to consume small amounts of fluids throughout the day. Avoid drinking too much before bed.
• Treat all urinary tract infections (UTIs), as they can further disrupt incontinence by increasing urgency signals
• Maintain a healthy weight

Let’s have more open conversations about urinary health. Up to half of women struggle with incontinence—by removing the stigma, we can continue to promote education, prevention, and treatment.

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