Incontinence Diagnosis

  • Diagnosis

    Urinary incontinence is the loss of control over urination Figure 01. Urinary incontinence affects more than 15 million Americans, particularly women and the elderly. The condition exacts a considerable toll on quality of life, interfering with work, social activities, and sex. Many people who suffer from urinary incontinence are too embarrassed to seek help, or think that the condition is just part of the aging process.

    Click to enlarge: The urinary system

    Figure 01. The urinary system

    In the majority of cases, urinary incontinence can be cured or controlled.

    In urinary incontinence, the organs and muscles that govern urination fail to work properly. Your bladder relaxes as it fills with urine produced by your kidneys. The bladder stores urine until it is full. Messages are then relayed to your brain, which lets you know you need to urinate. At this point, you can decide to hold in the urine by tightening your urinary sphincter (the muscle that controls the opening from your bladder) to the tube through which urine leaves your body (the urethra) or let it out by relaxing your sphincter. Your bladder muscles will then contract to expel the urine. However, if you have developed incontinence, this process gets disrupted somewhere along the way. A variety of things could be responsible:

    • A urinary tract infection.
    • A side effect of medication, such as a diuretic for high blood pressure, a calcium channel blocker for heart disease, or a sedative for a sleep disorder.
    • Impaired nerve transmission resulting from diabetes, multiple sclerosis, or another illness.
    • Brain changes from a stroke, or confusion from dementia.
    • Hormonal changes during pregnancy, after childbirth, and during menopause are a frequent cause of incontinence in women.
    • In men, an enlarged prostate gland or surgery to remove a prostate gland.
    • Excess caffeine and alcohol intake.
    • Spinal cord injuries and pelvic trauma.

    The symptoms of incontinence vary according to the cause of the condition, and can range from minor leaks during a sneeze or physical activity to complete inability to hold in urine. Doctors generally classify urinary incontinence into four patterns: urge incontinence, stress incontinence, overflow incontinence, and total incontinence. Some people have a combination of types (mixed incontinence).

    • Urge incontinence. People who suffer from urge incontinence experience an unpredictable overwhelming need to urinate that stems from a sudden, involuntary contraction of the bladder muscle. Typically, patients are unable to hold their urine until they can reach a bathroom, and experience modest amounts of urine loss. Older adults suffer most from this form of incontinence. An overactive bladder caused by a medication or an illness that interferes with the brain’s ability to control the bladder (for example, stroke or Parkinson’s disease) is often to blame. Obstruction to the flow of urine out of the bladder from an enlarged prostate gland also may affect the bladder and cause episodes of urge incontinence.
    • Stress incontinence. People who suffer from stress incontinence experience predictable urinary leakage during activities that increase abdominal pressure, such as coughing, sneezing, exercise, laughing, and lifting heavy objects. This form of incontinence results when the urinary sphincter is weak and fails to stay closed during these activities. This form of incontinence is most common in postmenopausal women. Much less commonly, it can occur in men who have had some types of prostate surgery.
    • Overflow incontinence. People who suffer from overflow incontinence experience periodic urine leakage, in which urine leaks out of a bladder that is distended and overfilled. In men, prostate enlargement and prostate cancer can block the bladder outlet and make the bladder distended and leaky. Scar tissue from prostate surgery sometimes narrows the urethra or bladder neck and causes overflow incontinence. Nerve damage caused by a spinal cord injury, an illness, or a medication can also contribute to this form of urinary incontinence.
    • Total incontinence. People who suffer from total incontinence experience constant unrelenting urine leakage. This type of incontinence is very severe, and fortunately very uncommon. It may result from a number of causes including neurological problems, injuries, and various types of pelvic surgery.
    • Mixed incontinence. People who suffer from mixed incontinence have a combination of the various forms of incontinence. Stress incontinence and urge incontinence frequently appear together.

    Urinary incontinence can occur in anyone at any age, but is more common in women and in older adults Table 01. A third of older adults have some degree of incontinence. This does not mean that losing urinary control is a normal part of the aging process; however, it can be a consequence of illnesses that are more prevalent in older age groups, such as dementia, diabetes, Parkinson’s disease, and stroke. Likewise, medications taken by many older adults and procedures that are more common in this group (such as hysterectomy and prostatectomy) can predispose a person to incontinence.

    Women are twice as likely as men to suffer from incontinence. Pregnancy and injury to the structures that govern continence during childbirth may be to blame. A number of menopausal and postmenopausal women experience stress incontinence due to declining estrogen levels. Tissues in the urethra and vaginal area in particular may become dry and less elastic when estrogen levels decline, which may contribute to incontinence.

    Table 1.  Medications That Affect Continence

    Drug name Associated condition
    Alpha-adrenergic agonists
    Clonidine Guanfacine Methyldopa Hypertension
    Alpha-adrenergic antagonists
    Doxazosin HCl Terazosin HCl Hypertension, benign prostatic hyperplasia
    Anticholinergics
    PropanthelineTolterodine Oxybutynin Dicyclomine Overactive bladder, urinary incontinence, irritable bowel syndrome (Dicyclomine)
    Calcium channel blockers
    Amlodipine besylateFelodipineNifedipineNisoldipineVerapamil HCl Angina, hypertension
    Diuretics
    Ethacrynic acid Furosemide Edema
    Narcotics
    MorphineOpiumCodeine Relief of moderate to severe pain
    Sedatives
    Pentobarbital Phenobarbital Insomnia, convulsions

    To determine what is causing your symptoms, your doctor will start with a medical history and physical exam. Your doctor will want to know if you are using any medications, or have any illnesses that are associated with incontinence. He or she also will want to know if you have sustained an injury or undergone a medical procedure that may underlie the problem. If you have had children, your doctor will ask you about your experiences during childbirth. Your doctor will ask you how often you lose continence, and to describe what happens. For example, do you lose small amounts of urine when laughing or sneezing (a sign of stress incontinence)? Or do you experience a strong urge to urinate followed by significant urine loss (a sign of bladder overactivity)? Is your urine flow weak, or do you feel that you have not completely emptied your bladder after you have urinated (a sign of obstruction)?

    Physical exams are useful in diagnosing incontinence. Your doctor will feel your abdomen for signs of distention. He or she may ask you to lie down and cough to assess the strength of your urinary sphincter. In women, a pelvic exam can reveal evidence of pelvic relaxation such as uterine prolapse—a condition that occurs when the uterus is inadequately supported, and protrudes out of the vagina—or another anatomic problem that makes the urethra more vulnerable to increased abdominal pressure or degeneration of local tissues. In men, a urologic exam can reveal an enlarged prostate gland that is obstructing the bladder.

    Your doctor may order diagnostic tests to help determine the precise nature of your problem. Urine analysis can show if a urinary tract infection is the cause of your continence problem. For this, your doctor will ask you to provide a urine sample. Your doctor may wish to investigate how much urine stays in your bladder after you urinate to see if an obstruction or a nerve problem is at work. This can be done with ultrasound imaging, which uses sound waves to show how much urine is in the bladder, or by placing a small thin tube called a catheter into your bladder to drain it. Cystoscopy, which uses a thin viewing instrument inserted into your bladder, can allow your physician to thoroughly inspect your bladder.

    Sometimes, tests that are done while you are urinating are helpful. The object is to measure the pressure in your bladder as it is filling. To do this, you will have a catheter inserted into your bladder, which will then be filled with water. Normally, pressure increases at a slow, even imperceptible rate. However, in people with urge incontinence, pressure may build quickly before the bladder is filled due to involuntary contractions of the bladder muscle. Finally, tests that measure the rate of urine flow can unearth an obstruction or bladder muscles that are unable to expel urine.

    Drink water and avoid beverages that contain caffeine. Avoid gaining weight. Excess weight can contribute to incontinence problems. Steer clear of coffee, soda, and other drinks that have caffeine, as it can irritate the bladder. Try to drink a moderate amount of water every day to keep your urine from becoming too concentrated.

    Do special exercises to strengthen your pelvic floor muscles. Doing Kegel exercises can help strengthen your pelvic floor muscles. Named after the physician who developed them, Kegels are especially beneficial if you are suffering from stress incontinence. To do a Kegel, tighten the muscle that you use to stop the flow of urine, hold for about 5-10 seconds, and then release. Try doing this on the toilet while you are urinating to feel which muscles control the stop and start of urination. If you can stop your urine flow, you are using the right muscles. Eventually you won’t need to use the toilet to practice these.

  • Prevention and Screening

    Drink water and avoid beverages that contain caffeine. Avoid gaining weight. Excess weight can contribute to incontinence problems. Steer clear of coffee, soda, and other drinks that have caffeine, as it can irritate the bladder. Try to drink a moderate amount of water every day to keep your urine from becoming too concentrated.

    Do special exercises to strengthen your pelvic floor muscles. Doing Kegel exercises can help strengthen your pelvic floor muscles. Named after the physician who developed them, Kegels are especially beneficial if you are suffering from stress incontinence. To do a Kegel, tighten the muscle that you use to stop the flow of urine, hold for about 5-10 seconds, and then release. Try doing this on the toilet while you are urinating to feel which muscles control the stop and start of urination. If you can stop your urine flow, you are using the right muscles. Eventually you won’t need to use the toilet to practice these.

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