Incontinence – Types, Causes, and Treatments

Incontinence:

Loss of voluntary control over the bladder, leading to accidental peeing.

5 Types of Incontinence

1. Enuresis (Bedwetting):

• Involuntary urination in children older than four.
• In children under four, it’s considered normal due to immature nervous system development. The nervous system continues to mature into early adulthood (up to ~30 years).
• Causes of enuresis:
  • Delayed neural maturation.
  • Psychosocial stressors or disturbances.
  • Usually outgrown with age.

2. Stress Incontinence:

• Caused by increased intra-abdominal pressure (coughing, sneezing, heavy lifting, laughing).   This pressure forces urine out through weakened sphincters or pelvic muscles.
• Pelvic Floor Muscle weakness: Often due to multiple pregnancies, aging, or hormonal changes. More common in women.
• Treatment Strategies:

• • Pelvic Floor Exercises: Kegel exercises strengthen pelvic floor muscles and urethral sphincters.
    • Improves urinary control by enhancing muscle tone around the bladder outlet.
  • Alpha-adrenergic agonists: Mimic norepinephrine/epinephrine.
    • Bind to alpha-adrenergic receptors on internal sphincter smooth muscles.

• • • Stimulate internal sphincters to contract and close, reducing leakage.

3. Urge Incontinence: 

• Characterized by an abrupt, strong urge to urinate.
• Most common with aging.
• The person must rush to the bathroom and can’t hold it for long, leading to frequent urination.
• Cause:
  • Overactivity of the detrusor muscle (the bladder muscle), leading to involuntary contractions.
• Treatment:
  • Bladder training (timed bathroom trips), lifestyle adjustments (adopting healthy diet with fiber, fewer caffeinated beverages), stop smoking, building up pelvic floor muscles. 

4. Overflow Incontinence and Retention: 

• Occurs when the bladder becomes overfilled.
• Results from weakened bladder muscles failing to empty properly, leading to dribbling and frequent urination.
• The detrusor muscle becomes weak or insufficiently contractile.  The bladder gradually distends and overfills.
• The increase in stretch weakens the detrusor muscle further, creating a vicious cycle.
• When the muscle cannot fully contract, urine remains in the bladder (residual urine).  The residual volume causes the bladder to fill up again faster, leading to frequency of urination.
• As the bladder overflows, the pressure pushes urine through the urethral sphincters, leading to dribbling or involuntary leakage.
• Risk factors include urethral blockages (e.g., prostate enlargement, renal calculi), in which case treatment should address the cause. Urethral strictures or scarring due to frequent infections or Trauma can also lead to Retention and then Overflow Incontinence.  As can nerve damage (eg. spinal cord injury below T12), or medications (e.g., anesthesia) that impair nerve signalling.
• Treatments:
  • Catheters, possibly adult absorption underwear, bladder training, surgical removal of obstruction, or nerve repair. Retention needs immediate treatment to prevent bladder damage.
• Note:  Both Urge and Overflow Incontinence have common risk factors that include: aging, or nerve/muscle dysfunction. 

5. Spinal Cord Injury & Neurogenic Bladder Types:

Above T12 and brain injuries/disease:

• • Bladder contracts involuntarily — spastic bladder (spastic, overactive, or hyperreflexic bladder).
  • Causes frequent, involuntary urination (incontinence).
  • Treatment:
    • Usually treated with anticholinergic drugs to relax the detrusor muscle.
  • Risk factors include:
    • Brain damage (e.g., stroke), Neurological diseases (Multiple Sclerosis, Parkinson’s Disease, Cerebral Palsy, Alzheimer’s Disease, Encephalitis (viral or bacterial brain infection), Syphilis, Diabetes, Alcoholism (can cause neural damage).

Below T12:

• • Muscle is inappropriately relaxed—flaccid bladder (flaccid, underactive, or hyporeflexic bladder).
  • The bladder overfills because it fails to contract properly.
  • Leads to overflow incontinence, urinary retention and dribbling.
  • Treatment:
    • Relax the sphincters by blocking norepinephrine/epinephrine receptors, allowing the sphincter to relax when appropriate and enable voiding.  Use alpha-adrenergic blockers.

• • • Bladder management involves controlling urination timing to prevent bladder distention and detrusor muscle weakening.  Catheter use may be required.