Urinary Incontinence: Causes and Treatment

Symptoms

Urinary incontinence manifests as involuntary leakage of urine. The common problem poses a psychosocial challenge for those affected, which can lead to changes in personal activities and a loss of quality of life. Risk factors include female gender, age, obesity, and numerous medical conditions.

Causes

Urinary incontinence can occur as a result of pathologic, anatomic, physiologic, and psychological causes. The main types are urge incontinence and stress incontinence: 1. Urge incontinence:

• Urge incontinence manifests itself in a frequent and strong urge to urinate. Affected individuals must repeatedly visit the toilet because emptying of the bladder can no longer be voluntarily restrained. A common cause is a hyperactive bladder. In addition, urge incontinence can also be caused by cystitis, urethritis, stones and tumors. In older people, it often develops as a result of a degenerative disease such as Parkinson’s disease or dementia.

2. stress incontinence:

• In stress incontinence (= stress incontinence), small amounts of urine are lost when coughing, sneezing, laughing or during physical activity. Women in particular are affected. The sphincter and the pelvic floor are no longer able to hold the urine during an increase in pressure in the lower abdomen. In a severe course, the urine already goes when walking, standing up or even without load.

Mixed incontinence is a simultaneously existing stress and urge incontinence. Overflow incontinence (overflow bladder) is associated with overstretching of the urinary bladder. Causes include prostate enlargement and nerve disorders such as those associated with diabetes mellitus, multiple sclerosis and spinal cord injuries. In so-called functional incontinence, the patient is no longer able to go to the bathroom in time or to open his or her clothes in time. The causes are cognitive or physical limitations.

Nonpharmacologic treatment

Treatment depends on the type, severity, and underlying causes. Nonmedication treatment should precede medication.

• Bladder retraining involves trying to postpone urination a little at first and then more and more, so that eventually urinary frequency can be reduced. It is considered the 1st choice method for urge incontinence.
• Pelvic floor training strengthens the pelvic floor muscles and the urethral muscle. It is also performed in combination with vaginal weights, biofeedback or electrical stimulation. Pelvic floor training is considered the 1st choice method for stress incontinence.
• Incontinence items such as incontinence pads, pants and diapers absorb urine and trap it outside the body.
• Keeping a micturition diary for diagnosis and control.
• Surgical intervention, for example, snare surgery for stress incontinence.
• Incontinence pessary and urethral plug for stress incontinence.
• Self-catheterization for overflow incontinence with chronic urinary retention.
• Weight loss may have a positive effect in overweight patients.
• Treatment of concomitant constipation.

Drug treatment

Parasympatholytics:

• They competitively abolish the effects of acetylcholine at muscarinic receptors on bladder wall muscles, preventing involuntary contraction of the muscles and bladder. Because of the potential anticholinergic adverse effects, they are not without controversy. They are used primarily to treat hyperactive bladder:

• Clidinium bromide (Librax).
• Darifenacin (Emselex)
• Fesoterodine (Toviaz)
• Oxybutynin (Ditropan)
• Solifenacin (Vesicare)
• Tolterodine (Detrusitol)
• Trospium chloride (Spasmo-Urgenin Neo)

Botulinum toxin:

• Reduces the release of acetylcholine from nerve endings, inhibiting contraction of the bladder wall muscles. It causes a type of “chemical denervation” and inhibits conduction along the nerve fibers. Botulinum toxin is administered parenterally into the detrusor muscle to treat hyperactive bladder and has a long duration of action of several months.

Duloxetine:

• Is approved in the EU for the treatment of women with moderate to severe stress incontinence (Yentreve). It is commercially available in many countries as Cymbalta/generics and has been registered exclusively for depression, diabetic neuropathy, and anxiety disorder. The effects are based on combined serotonin and norepinephrine reuptake inhibition.

Estrogens:

• Are used for treatment in postmenopausal women. Used mostly topical drugs such as ovules or creams. They act primarily on the atrophic mucosa and are used for both urge and stress incontinence.

Alpha blockers:

• Such as alfuzosin (Xatral, generic), tamsulosin (Pradif T, generic), and terazosin (Hytrin BPH) have been approved for the treatment of functional symptoms of benign prostatic hyperplasia. The effect is based on competitive and selective inhibition of the α₁-adrenoreceptors and smooth muscle relaxation in the prostate and urethra. This increases urine flow, improves urination and filling symptoms.

Other active ingredients:

• Calcium channel blockers such as nifedipine and verapamil, phosphodiesterase-5 inhibitors, e.g., taladafil, beta antagonists such as terbutaline, salbutamol, clenbuterol, and baclofen, desmopressin, and capsaicin.