Urinary Incontinence: Causes

Pathogenesis (development of disease)

Stress incontinence (formerly stress incontinence) is an involuntary leakage of urine as a result of an increase in pressure in the abdomen, as occurs under stress (e.g., coughing, sneezing, jumping, walking). The cause is failure of the closure mechanism of the urinary bladder due to muscle weakness often associated with pelvic floor insufficiency (weakness of the pelvic floor), as can occur in women after several births. In men, pure stress incontinence is mostly iatrogenic (“caused by a doctor”) (the main cause is considered to be radical prostatectomy/surgical removal of the prostate with capsule, the end pieces of the vas deferens, the seminal vesicles and the regional lymph nodes); for other operations, see below). In urge incontinence (urine leakage during an imperative urge to urinate; synonym: overactive bladder wet), the sphincter muscle is intact. The cause is a dysregulation of the bladder muscles. We speak of sensory urge incontinence when a more or less strong urge to urinate develops even when the bladder is only slightly full. This is a false signal to the brain, which then gives the command to empty the bladder. Motor urge incontinence is when the correct filling state of the bladder is reported to the brain, but the nerve impulses of the brain inhibiting bladder emptying are too weak to prevent contraction of the bladder muscles. The term unstable bladder is used when both mechanisms are impaired. This classification is medically useful for the person affected, but it is irrelevant, because the symptoms are the same in each case. In milder forms, urine can usually be retained until the toilet is reached. In severe forms, however, there is an involuntary loss of urine. Often psychological and emotional problems such as excitement, fear, anger but also depression play a triggering role. Reflex incontinence occurs in patients with damage to the central nervous system (e.g., apoplexy (stroke), multiple sclerosis (MS)) or the peripheral nervous system (e.g., transverse paralysis or other traumatic spinal cord damage, polyneuropathy, diabetes mellitus) can result in faulty bladder and or sphincter function. It can occur at any age. However, it may be associated not only with urinary leakage, but also with urinary bladder emptying dysfunction, because the affected person does not feel the need to urinate. Emptying of the urinary bladder can neither be started nor interrupted or stopped voluntarily. Overflow incontinence is characterized by involuntary leakage of urine in dribs and drabs when the bladder is overly full without the bladder muscles contracting. The bladder virtually overflows due to the excessive filling. Large amounts of residual urine therefore always remain in the bladder. The cause is primarily drainage obstructions in the area of the bladder outlet or the urethra. Causes include traumatic or inflammatory narrowing of the urethra, urinary bladder stones or urinary bladder tumors. These cases are referred to as obstructive overflow incontinence. Alternatively, there is also functional overflow incontinence. This is when the urinary bladder can no longer contract sufficiently. This is often the result of the obstructive cause, when overstretching causes the bladder wall to lose its ability to contract. Extraurethral urinary incontinence often occurs due to bladder fistulas or an ectopic – ureter opening outside of the proper location. In children, this is usually congenital. In adults, such fistulas often occur after surgery, childbirth, radiotherapy (radiation therapy), or injury.

Etiology (causes)

Biographic causes

• Multiple births; women who have already lost urine during their first pregnancy are particularly at risk for long-term urinary incontinence
• Hormonal factors – menopause (menopause in women; due to the lack of estrogen).

Behavioral causes

• Consumption of stimulants
  • Alcohol
  • Tobacco (smoking) – nicotine abuse is associated with urge incontinence
• Physical activity
  • Physical stress
    • Z. E.g. after sports (stress incontinence).
    • Performance and high-performance athletes (insb.Sports disciplines such as long jump, triple jump, high jump; runners, esp. long distance; team sports such as basketball, handball, volleyball).
• Psycho-social situation
  • Psychological stress
• Overweight (BMI ≥ 25; obesity) – dependence broken down by incontinence type:
  • Mixed urinary incontinence to be recorded (+52%),
  • Pure stress or urge incontinence (+33% and +26%, respectively; each per 5 BMI points).

Disease-related causes.

Congenital malformations, deformities and chromosomal abnormalities (Q00-Q99).

• Epispadias (urethral cleft formation).
• Urethra (urethra), short or long – mildest form of bladder exstrophy-epispadias complex; rarely occurs in isolation
• Ureteral ectopia (mis-orifice of the ureter distal (“remote”) to the bladder neck into the urethra, prostate, vagina/vagina or uterus/uterine).

Respiratory System (J00-J99)

• Bronchitis, chronic (permanent inflammation of the respiratory tract with chronic cough).

Endocrine, nutritional and metabolic diseases (E00-E90).

• Diabetes mellitus (→ sensory neuropathy/peripheral nerve disease).
• Hyperglycemia (high blood sugar)

Cardiovascular system (I00-I99)

• Heart failure (cardiac insufficiency)

Infectious and parasitic diseases (A00-B99).

• Syphilis (→ sensory neuropathy).

Mouth, esophagus (esophagus), stomach, and intestines (K00-K67; K90-K93).

• Constipation (constipation)

Neoplasms – tumor diseases (C00-D48)

• Urinary bladder tumor

Psyche – nervous system (F00-F99; G00-G99)

• Delirium (states of confusion)
• Depression
• Diabetic neuropathy
• Enuresis – involuntary wetting of the child.
• Kauda syndrome – cross-sectional syndrome at the level of the cauda equina (anatomical structure located inside the spine in a sac of hard meninges (dura mater) and the arachnoid mater adjacent to it inside); this leads to damage to the nerve fibers below the conus medullaris (name for the conical, caudal end of the spinal cord), which is accompanied by flaccid paresis (paralysis) of the legs, often with urinary bladder and rectal dysfunction.
• Multiple Sclerosis (MS)
• Paraplegia – paralysis of all extremities.

Genitourinary system (kidneys, urinary tract – reproductive organs) (N00-N99).

• Atrophic urethritis – inflammation of the urethra in older women due to receding mucosa.
• Atrophic vaginitis – vaginitis in older women due to receded mucosa.
• Pelvic floor insufficiency (pelvic arch weakness).
• Bladder neck stenosis (narrowing of the bladder neck).
• Benign prostatic hypertrophy (BPH; benign enlargement of the prostate).
• Descensus genitalis (deepening of the uterus or vagina).
• Detrusor instability (unstable bladder, uninhibited bladder contractions), idiopathic or secondary (e.g., apoplexy/stroke, dementia, Parkinson’s disease, etc.).
• Interstitial cystitis (IC; chronic abacterial cystitis).
• Neurogenic bladder – dysfunction of the urinary bladder due to a disorder in the nervous system.
• Overflow bladder
• Urethrastenosis (narrowing of the urethra)
• Urolithiasis (urinary stone disease)
• Cystitis (cystitis), infectious.

Digestive system (K00-K93)

• Constipation (constipation) (demonstrated in women only: Incontinence risk for women with constipation (odds ratio, OR 2.46)).

Injuries, poisonings, and other consequences of external causes (S00-T98).

• Trauma (injury), unspecified (e.g., pelvic fracture/fracture with sphincter injury/sphincter injury)

Medications (which may cause temporary urinary incontinence).

• Alpha blockers (stress incontinence as a direct side effect).
• Analgesics of the COX inhibitor group (celecoxib).
• Anticholinergics (e.g., disopyramide).
• Antidepressants (e.g., amitriptyline, fluoxetine).
• Antihypertensives (eg, captopril, dihydropyridine, prazosin).
• Anti-Parkinsonian drugs (e.g., trihexyphenidyl).
• Antipsychotics (e.g., haloperidol).
• Diuretics (e.g., furosemide)
• Opiate analgesics
• Oral antidiabetic agents (e.g., rosiglitazone)
• Cytostatic drugs (vincristine* )

* Reversibility possible

Surgeries

• Male (male-only stress incontinence is mostly iatrogenic/due to medical intervention):
  • State n. radical prostatectomy (surgical removal of prostate gland with capsule, the end pieces of the vas deferens, the seminal vesicles, and the regional lymph nodes); usually temporary (transient).
  • Zust. n. transurethral resection of the prostate (TUR-P; surgical removal of the prostate through the urethra).
  • Zust. n. Laser treatment of the prostate
  • Zust. n. Adenomenukleation (surgical peeling of an adenoma (enucleation = peeling from the well-defined tissue without entrainment of surrounding tissue).
  • Zust. n. transurethral urethral surgery for urethral stenosis.
• Woman:
  • Zust. n. operations with fistula formation (e.g., vesicovaginal fistula (bladder-vaginal fistula)).
  • Zus. n. vacuum extraction (“suction cup delivery”).

Environmental pollution – intoxications (poisoning).

• Alcohol

Further

• Birth(s) – In a study of nearly 8,000 mothers was found by survey:
  • After twelve years: 52.7% cases with urinary incontinence, 37.9% of cases with persistent incontinence.
  • Stress incontinence in 54.2% of cases, a mixture of stress and urge incontinence in 32.8%; pure urge incontinence 9.8% of women.
• After radiatio (radiotherapy).
• Menopause (menopause in women)

Possible triggers of transient urinary incontinence in the elderly in a nursing home (modified from).

• Excessive urine production
• Limited mobility
• Psyche
• Atrophic urethritis/colpitis
• Delirium
• Infections
• Fecal problems/obstipation
• Pharmaceuticals