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Home , Overactive bladder, Overflow incontinence, Stress incontinence, Urinary incontinence, Urinary urgency

in Women

National Kidney and Urologic Diseases Information Clearinghouse

Millions of women experience involuntary , , and physical loss of called urinary incontinence problems associated with aging. (UI). Some women may lose a few drops of urine while running or coughing. Others Older women experience UI more often National than younger women. But incontinence Institute of may feel a strong, sudden urge to urinate and just before losing a large amount of urine. is not inevitable with age. UI is a medical Digestive problem. Your doctor or nurse can help and Kidney Many women experience both symptoms. Diseases UI can be slightly bothersome or totally you find a solution. No single treatment debilitating. For some women, the risk of works for everyone, but many women can NATIONAL find improvement without . INSTITUTES public embarrassment keeps them from OF HEALTH enjoying many activities with their family Incontinence occurs because of problems and friends. Urine loss can also occur dur­ with muscles and nerves that help to hold ing sexual activity and cause tremendous or release urine. The body stores urine— emotional distress. water and wastes removed by the kidneys— Women experience UI twice as often as in the bladder, a balloon-like organ. The men. and , meno­ bladder connects to the , the tube pause, and the structure of the female uri­ through which urine leaves the body. nary tract account for this difference. But During , muscles in the wall of both women and men can become inconti­ the bladder contract, forcing urine out of nent from neurologic injury, birth defects, the bladder and into the urethra. At the

Kidneys Muscular bladder wall

Ureters

Pelvic Sphincter bones muscles Urethra

Bladder Bladder and sphincter muscles U.S. Department of Health and Human Services Figure 1. Front view of female urinary tract. same time, sphincter muscles surrounding the urethra relax, letting urine pass out of Enlargement of muscles the body. Incontinence will occur if your bladder muscles suddenly contract or the sphincter muscles are not strong enough to hold back urine. Urine may escape with less pressure than usual if the muscles are damaged, causing a change in the position of the bladder. , which is associated Uterus with increased abdominal pressure, can worsen incontinence. Fortunately, weight Bladder loss can reduce its severity.

What are the types of incontinence? If coughing, laughing, sneezing, or other Pelvic floor movements that put pressure on the blad­ muscle der cause you to leak urine, you may have Urethra stress incontinence. Physical changes resulting from pregnancy, childbirth, and often cause stress incontinence. Figure 2. Side view of female pelvic muscles. This type of incontinence is common in women and, in many cases, can be treated. a result, urine can leak into the urethra during moments of physical stress. Stress Childbirth and other events can injure the incontinence also occurs if the squeezing scaffolding that helps support the blad­ muscles weaken. der in women. Pelvic floor muscles, the vagina, and ligaments support your bladder Stress incontinence can worsen during the (see figure 2). If these structures weaken, week before your menstrual period. At your bladder can move downward, push­ that time, lowered levels might ing slightly out of the bottom of the pelvis lead to lower muscular pressure around toward the vagina. This prevents muscles the urethra, increasing chances of leak­ that ordinarily force the urethra shut from age. The incidence of stress incontinence squeezing as tightly as they should. As increases following menopause.

2 Urinary Incontinence in Women Urge Incontinence Specifically, the symptoms of overactive If you lose urine for no apparent reason bladder include after suddenly feeling the need or urge to • urinary frequency—bothersome urina­ urinate, you may have urge incontinence. tion eight or more times a day or two A common cause of urge incontinence or more times at night is inappropriate bladder contractions. Abnormal nerve signals might be the cause • —the sudden, strong of these bladder spasms. need to urinate immediately Urge incontinence can mean that your blad­ • urge incontinence—leakage or gushing der empties during sleep, after drinking a of urine that follows a sudden, strong small amount of water, or when you touch urge water or hear it running (as when wash­ ing dishes or hearing someone else taking • —awaking at night to urinate a shower). Certain fluids and medications such as diuretics or emotional states such Functional Incontinence as anxiety can worsen this condition. Some People with medical problems that inter­ medical conditions, such as hyperthyroidism fere with thinking, moving, or communicat­ and uncontrolled diabetes, can also lead to ing may have trouble reaching a toilet. A or worsen urge incontinence. person with Alzheimer’s disease, for exam­ ple, may not think well enough to plan a Involuntary actions of bladder muscles can timely trip to a restroom. A person in a occur because of damage to the nerves of wheelchair may have a hard time getting to the bladder, to the nervous system (spinal a toilet in time. Functional incontinence cord and brain), or to the muscles them­ is the result of these physical and medical selves. Multiple sclerosis, Parkinson’s conditions. Conditions such as arthritis disease, Alzheimer’s disease, stroke, and often develop with age and account for injury—including injury that occurs during some of the incontinence of elderly women surgery—all can harm bladder nerves or in nursing homes. muscles. Overflow incontinence happens when the Overactive bladder occurs when abnormal bladder doesn’t empty properly, causing nerves send signals to the bladder at the it to spill over. Your doctor can check for wrong time, causing its muscles to squeeze this problem. Weak bladder muscles or without warning. Voiding up to seven a blocked urethra can cause this type of times a day is normal for many women, incontinence. Nerve damage from diabetes but women with overactive bladder may or other diseases can lead to weak bladder find that they must urinate even more muscles; tumors and urinary stones can frequently. block the urethra. Overflow incontinence is rare in women.

3 Urinary Incontinence in Women Other Types of Incontinence The Types of Urinary Stress and urge incontinence often occur together in women. Combinations of Incontinence incontinence—and this combination in Stress Leakage of small amounts particular—are sometimes referred to as of urine during physi­ mixed incontinence. Most women don’t cal movement (coughing, have pure stress or urge incontinence, and sneezing, exercising). many studies show that mixed incontinence is the most common type of urine loss in Urge Leakage of large amounts women. of urine at unexpected times, including during Transient incontinence is a temporary ver­ sleep. sion of incontinence. Medications, urinary tract , mental impairment, and Overactive Urinary frequency and restricted mobility can all trigger transient Bladder urgency, with or without incontinence. Severe can urge incontinence. cause transient incontinence when the Functional Untimely urination because impacted stool pushes against the urinary of physical disability, exter­ tract and obstructs outflow. A cold can nal obstacles, or problems trigger incontinence, which resolves once in thinking or communicat­ the coughing spells cease. ing that prevent a person from reaching a toilet. How is incontinence Overflow Unexpected leakage of evaluated? small amounts of urine The first step toward relief is to see a doc­ because of a full bladder. tor who has experience treating incon­ Mixed Usually the occurrence of tinence to learn what type you have. A stress and urge incontinence urologist specializes in the urinary tract, together. and some urologists further specialize in the female urinary tract. Gynecologists Transient Leakage that occurs tempo­ and obstetricians specialize in the female rarily because of a situation reproductive tract and childbirth. A uro­ that will pass (, tak­ gynecologist focuses on urinary and associ­ ing a new medication, colds ated pelvic problems in women. Family with coughing). practitioners and internists see patients for all kinds of health conditions. Any of these doctors may be able to help you. In addition, some nurses and other health care providers often provide rehabilitation services and teach behavioral therapies such as fluid management and pelvic floor strengthening.

4 Urinary Incontinence in Women To diagnose the problem, your doctor will functioning bladder muscles. To do this, first ask about symptoms and medical his­ you will urinate into a measuring pan, after tory. Your pattern of voiding and urine which the nurse or doctor will measure leakage may suggest the type of inconti­ any urine remaining in the bladder. Your nence you have. Thus, many specialists doctor may also recommend other tests: begin with having you fill out a bladder diary over several days. These diaries can • Bladder stress test—You vigor­ reveal obvious factors that can help define ously as the doctor watches for loss of the problem—including straining and dis­ urine from the urinary opening. comfort, fluid intake, use of drugs, recent • Urinalysis and urine culture—Labo­ surgery, and illness. Often you can begin ratory technicians test your urine for treatment at the first medical visit. evidence of infection, urinary stones, Your doctor may instruct you to keep a or other contributing causes. diary for a day or more—sometimes up to a • Ultrasound—This test uses sound week—to record when you void. This diary waves to create an image of the kid­ should note the times you urinate and the neys, , bladder, and urethra. amounts of urine you produce. To mea­ sure your urine, you can use a special pan • —The doctor inserts a thin that fits over the toilet rim. You can also tube with a tiny camera in the urethra use the bladder diary to record your fluid to see inside the urethra and bladder. intake, episodes of urine leakage, and esti­ mated amounts of leakage. • Urodynamics—Various techniques measure pressure in the bladder and If your diary and medical history do not the flow of urine. define the problem, they will at least sug­ gest which tests you need. How is incontinence Your doctor will physically examine you treated? for signs of medical conditions causing incontinence, including treatable blockages Behavioral Remedies: Bladder from bowel or pelvic growths. In addition, Retraining and Kegel Exercises weakness of the pelvic floor leading to By looking at your bladder diary, the doc­ incontinence may cause a condition called tor may see a pattern and suggest making prolapse, where the vagina or bladder it a point to use the bathroom at regular begins to protrude out of your body. This timed intervals, a habit called timed void­ condition is also important to diagnose at ing. As you gain control, you can extend the time of an evaluation. the time between scheduled trips to the bathroom. Behavioral treatment also Your doctor may measure your bladder includes Kegel exercises to strengthen the capacity. The doctor may also measure muscles that help hold in urine. the residual urine for evidence of poorly

5 Urinary Incontinence in Women How do you do Kegel exercises? down. This is the easiest position to do The first step is to find the right muscles. them in because the muscles do not need to One way to find them is to imagine that work against gravity. When your muscles you are sitting on a marble and want to get stronger, do your exercises sitting or pick up the marble with your vagina. Imag­ standing. Working against gravity is like ine sucking or drawing the marble into adding more weight. your vagina. Be patient. Don’t give up. It takes just Try not to squeeze other muscles at the 5 minutes a day. You may not feel your same time. Be careful not to tighten your bladder control improve for 3 to 6 weeks. stomach, legs, or buttocks. Squeezing the Still, most people do notice an improve­ wrong muscles can put more pressure on ment after a few weeks. your bladder control muscles. Just squeeze the pelvic muscles. Don’t hold your breath. Some people with nerve damage cannot Do not practice while urinating. tell whether they are doing Kegel exercises correctly. If you are not sure, ask your doc­ Repeat, but don’t overdo it. At first, find tor or nurse to examine you while you try a quiet spot to practice—your bathroom to do them. If it turns out that you are not or bedroom—so you can concentrate. Pull squeezing the right muscles, you may still in the pelvic muscles and hold for a count be able to learn proper Kegel exercises by of three. Then relax for a count of three. doing special training with , Work up to three sets of 10 repeats. Start electrical stimulation, or both. doing your pelvic muscle exercises lying

Bladder neck Bladder neck

Weak pelvic muscles Strong pelvic muscles

Urethral sphincter Urethral sphincter Urethra Urethra

Figure 3. Front view of bladder. Weak pelvic muscles allow urine leakage (left). Strong pelvic muscles keep the urethra closed (right).

6 Urinary Incontinence in Women Medicines for Overactive Scientists are studying other drugs and Bladder injections that have not yet received U.S. Food and Drug Administration If you have an overactive bladder, your (FDA) approval for incontinence to see doctor may prescribe a medicine to block if they are effective treatments for people the nerve signals that cause frequent urina­ who were unsuccessful with behavioral tion and urgency. therapy or pills. Several medicines from a class of drugs called can help relax Biofeedback bladder muscles and prevent bladder Biofeedback uses measuring devices to spasms. Their most common side effect help you become aware of your body’s is dry mouth, although larger doses may functioning. By using electronic devices cause blurred vision, constipation, a faster or diaries to track when your bladder and heartbeat, and flushing. Other side effects urethral muscles contract, you can gain include drowsiness, confusion, or memory control over these muscles. Biofeedback loss. If you have glaucoma, ask your oph­ can supplement pelvic muscle exercises thalmologist if these drugs are safe for you. and electrical stimulation to relieve stress and urge incontinence. Some medicines can affect the nerves and muscles of the urinary tract in differ­ ent ways. Pills to treat swelling (edema) or high blood pressure may increase your urine output and contribute to bladder control problems. Talk with your doc­ tor; you may find that taking an alterna­ tive to a medicine you already take may solve the problem without adding another prescription.

7 Urinary Incontinence in Women Neuromodulation Injections for Stress For urge incontinence not responding to Incontinence behavioral treatments or drugs, stimula­ A variety of bulking agents, such as col­ tion of nerves to the bladder leaving the lagen and carbon spheres, are available for spine can be effective in some patients. injection near the urinary sphincter. The Neuromodulation is the name of this doctor injects the bulking agent into tissues therapy. The FDA has approved a device around the bladder neck and urethra to called InterStim for this purpose. Your make the tissues thicker and close the blad­ doctor will need to test to determine if this der opening to reduce stress incontinence. device would be helpful to you. The doctor After using local anesthesia or sedation, a applies an external stimulator to determine doctor can inject the material in about half if neuromodulation works in you. If you an hour. Over time, the body may slowly have a 50 percent reduction in symptoms, a eliminate certain bulking agents, so you surgeon will the device. Although will need repeat injections. Before you neuromodulation can be effective, it is not receive an injection, a doctor may perform for everyone. The therapy is expensive, a skin test to determine whether you could involving surgery with possible surgical have an allergic reaction to the material. revisions and replacement. Scientists are testing newer agents, includ­ ing your own muscle cells, to see if they are Vaginal Devices for Stress effective in treating stress incontinence. Incontinence Your doctor will discuss which bulking One of the reasons for stress incontinence agent may be best for you. may be weak pelvic muscles, the muscles that hold the bladder in place and hold urine inside. A is a stiff ring that a doctor or nurse inserts into the vagina, where it presses against the wall of the vagina and the nearby urethra. The pres­ sure helps reposition the urethra, leading to less stress leakage. If you use a pessary, you should watch for possible vaginal and urinary tract infections and see your doctor regularly.

8 Urinary Incontinence in Women Surgery for Stress Incontinence man-made material. The surgeon attaches In some women, the bladder can move out both ends of the sling to the pubic bone of its normal position, especially following or ties them in front of the just childbirth. Surgeons have developed dif­ above the pubic bone. ferent techniques for supporting the blad­ Midurethral slings are newer procedures der back to its normal position. The three that you can have on an outpatient basis. main types of surgery are retropubic sus­ These procedures use synthetic mesh pension and two types of sling procedures. materials that the surgeon places midway Retropubic suspension uses surgical along the urethra. The two general types threads called sutures to support the blad­ of midurethral slings are retropubic slings, der neck. The most common retropubic such as the transvaginal tapes (TVT), suspension procedure is called the Burch and transobturator slings (TOT). The procedure. In this operation, the surgeon surgeon makes small incisions behind makes an incision in the abdomen a few the pubic bone or just by the sides of the inches below the navel and then secures vaginal opening as well as a small incision the threads to strong ligaments within the in the vagina. The surgeon uses specially pelvis to support the urethral sphincter. designed needles to position a synthetic This common procedure is often done at tape under the urethra. The surgeon pulls the time of an abdominal procedure such the ends of the tape through the incisions as a hysterectomy. and adjusts them to provide the right amount of support to the urethra. Sling procedures are performed through a vaginal incision. The traditional sling If you have pelvic prolapse, your surgeon procedure uses a strip of your own tissue may recommend an anti-incontinence pro­ called to cradle the bladder neck. cedure with a prolapse repair and possibly Some slings may consist of natural tissue or a hysterectomy.

Bladder Bladder Bladder

Bladder Bladder Bladder neck neck neck

Tape ends Pubic Pubic Pubic bone bone bone Sutures Sling Transobturator material tape Urethra Urethra Urethra

Figure 4. Side view. Supporting sutures in place following retropubic or transvaginal suspension (left). Sling in place, secured to the pubic bone (center). The ends of the transobturator tape supporting the urethra are pulled through incisions in the groin to achieve the right amount of support (right). The tape ends are removed when the incisions are closed.

9 Urinary Incontinence in Women Recent women’s health studies performed Catheterization with the Urinary Incontinence Treatment If you are incontinent because your blad­ Network (UITN) compared the suspen­ der never empties completely—overflow sion and sling procedures and found that, incontinence—or your bladder cannot 2 years after surgery, about two-thirds empty because of poor muscle tone, past of women with a sling and about half of surgery, or , you might women with a suspension were cured of use a to empty your bladder. A stress incontinence. Women with a sling, catheter is a tube that you can learn to however, had more urinary tract infections, insert through the urethra into the blad­ voiding problems, and urge incontinence der to drain urine. You may use a catheter than women with a suspension. Overall, once in a while or on a constant basis, in 86 percent of women with a sling and which case the tube connects to a bag that 78 percent of women with a suspension you can attach to your leg. If you use an said they were satisfied with their results. indwelling—long-term—catheter, you For more information, please visit should watch for possible urinary tract www.uitn.net. Women who are interested infections. in joining a study for urinary incontinence can go to www.ClinicalTrials.gov for a list of current studies recruiting patients. Talk with your doctor about whether sur­ Points to Remember gery will help your condition and what type • Urinary incontinence is common in of surgery is best for you. The procedure women. you choose may depend on your own pref­ erences or on your surgeon’s experience. • All types of urinary incontinence are Ask what you should expect after the pro­ treatable. cedure. You may also wish to talk with • Incontinence is treatable at all ages. someone who has recently had the proce­ dure. Surgeons have described more than • You need not be embarrassed by 200 procedures for stress incontinence, so incontinence. no single surgery stands out as best.

10 Urinary Incontinence in Women Other Helpful Hints Hope Through Research Many women manage urinary incontinence The National Institute of Diabetes and with menstrual pads that catch slight leak- Digestive and Kidney Diseases (NIDDK) age during activities such as exercising. has many research programs aimed at Also, many people find they can reduce finding treatments for urinary disorders, incontinence by restricting certain liquids, including urinary incontinence. The such as coffee, tea, and alcohol. NIDDK is sponsoring the Urinary Incon- tinence Treatment Network (UITN), a Finally, many women are afraid to men- consortium of urologists and urogynecolo- tion their problem. They may have urinary gists who are evaluating and comparing incontinence that can improve with treat- treatment methods for stress and mixed ment but remain silent sufferers and resort incontinence in women. The goal of the to wearing absorbent undergarments, first study, completed in 2007, was to learn or . This practice is unfortunate, which treatment methods have the best because diapering can lead to diminished short- and long-term outcomes for treat- self-esteem, as well as skin irritation and ing stress urinary incontinence in women. sores. If you are relying on diapers to Ongoing studies focus on treatments for manage your incontinence, you and your urge incontinence and minimally invasive family should discuss with your doctor the treatments for stress incontinence. possible effectiveness of treatments such as timed voiding and pelvic muscle exercises. The National Institute of Child Health and Human Development also supports research in the area of pelvic health. The The U.S. Government does not endorse or favor any Pelvic Floor Disorders Network (PFDN) specific commercial product or company. Trade, proprietary, or company names appearing in this was formed in 2001 to do research to document are used only because they are considered improve the care and daily lives of women necessary in the context of the information provided. with and bladder and If a product is not mentioned, the omission does not mean or imply that the product is unsatisfactory. bowel control problems. For more infor- mation about the PFDN, please visit www.pfdn.org.

11 Urinary Incontinence in Women For More Information National Kidney and American Urogynecologic Society Urologic Diseases 2025 M Street, NW, Suite 800 Information Clearinghouse Washington, DC 20036 3 Information Way Phone: 202–367–1167 Bethesda, MD 20892–3580 Email: [email protected] Phone: 1–800–891–5390 Internet: www.augs.org Fax: 703–738–4929 Email: [email protected] American Urological Association Internet: www.kidney.niddk.nih.gov 1000 Corporate Boulevard Linthicum, MD 21090 The National Kidney and Urologic Diseases Phone: 1–866–RING–AUA (746–4282) Information Clearinghouse (NKUDIC) is a ser- or 410–689–3700 vice of the National Institute of Diabetes and Email: [email protected] Digestive and Kidney Diseases (NIDDK). The Internet: www.UrologyHealth.org NIDDK is part of the National Institutes of Health of the U.S. Department of Health and National Association for Continence Human Services. Established in 1987, the Clear- P.O. Box 1019 inghouse provides information about diseases of Charleston, SC 29402–1019 the kidneys and urologic system to people with kidney and urologic disorders and to their fami- Phone: 1–800–BLADDER (252–3337) lies, health care professionals, and the public. or 843–377–0900 The NKUDIC answers inquiries, develops and Email: [email protected] distributes publications, and works closely with Internet: www.nafc.org professional and patient organizations and Gov- ernment agencies to coordinate resources about The Simon Foundation for Continence kidney and urologic diseases. P.O. Box 815 Wilmette, IL 60091 Publications produced by the Clearinghouse are Phone: 1–800–23–SIMON (237–4666) carefully reviewed by both NIDDK scientists or 847–864–3913 and outside experts. This publication was Email: [email protected] reviewed by Linda Brubaker, M.D., Loyola Internet: www.simonfoundation.org University Medical Center, Maywood, IL; Susan Meikle, M.D., M.S.P.H., Agency for Healthcare Research and Quality; and William Steers, M.D., University of Virginia, Charlottesville, VA. You may also find additional information about this topic by visiting MedlinePlus at www..gov. This publication may contain information about medications used to treat a health condition. When This publication is not copyrighted. The Clearing- this publication was prepared, the NIDDK included house encourages users of this fact sheet to duplicate the most current information available. Occasion- and distribute as many copies as desired. ally, new information about medication is released. This fact sheet is also available at For updates or for questions about any medications, www.kidney.niddk.nih.gov. please contact the U.S. Food and Drug Administra- tion at 1–888–INFO–FDA (463–6332), a toll-free call, or visit their website at www.fda.gov. Consult your doctor for more information.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health

NIH Publication No. 08–4132 October 2007