Urinary Incontinence in Men, Women and Children

Urinary incontinence is the involuntary passing of urine, which is also known as enuresis. Problems within one of the two stages of the micturition cycle (storage or voiding) may result in incontinence. It is possible for leaking to occur from an overly filled bladder where a person has both normal storage and voiding stages of the micturition cycle. The pathology leading to incontinence may affect the ureter (rare), bladder (most common) and urethra (less common).

Causes of Different Types of Urinary Incontinence

The two most common types of incontinence are stress and urge incontinence. Sometime both types of incontinence are present, more often in women, and this is known as mixed incontinence.

Stress Incontinence

This type of incontinence is where the pelvic floor does not offer sufficient support or the urethral sphincter is weak and cannot cope with any increase in intra-abdominal pressure. Diagnosis is often made by asking the patient to cough and checking if there is any urine leakage. This is commonly seen in women but can also occur in men.

Common triggers include :

  • coughing
  • laughing
  • sneezing
  • bending over
  • lifting a heavy weight
  • sudden pressure on the abdomen

Some of the causes/risks include :

  • Pregnancy
  • Childbirth (intra-partum injury) or even much later in life due to the weakening of the pelvic floor after multiple vaginal deliveries. Larger babies and an episiotomy may also increase the weakening.
  • Post-menopause
  • Pelvic surgery
  • Age related changes
  • Obesity

Urge Incontinence

This is a result of an overactivity of the detrusor (bladder wall) muscle (instability or hyperrflexia) which increases bladder pressure to the point that it can overcome the urethral sphincter. It is often referred to as an “overactive bladder” or patients admit to having poor bladder control. The urging may be intense even though the bladder is not completely full.

Common triggers include :

  • Arriving home (“latch-key incontinence”). This is not psychological but rather a reflex conditioning phenomenon.
  • Cold
  • Sound of running water
  • Drinks that have a diuretic effect like tea, coffee or cola (caffeine) or alcohol.

Some causes/risks include :

  • Urinary tract infections (UTIs) will cause temporary urge incontinence
  • Bladder stone (calculus)
  • Cystitis
  • Prostate disorders :
  • Tumors of the bladder or uterus
  • Neurological diseases/nerve damage :
    • Parkinson’s disease
    • Multiple sclerosis
    • Alzheimer’s disease
    • Stroke
    • Damage to the spinal cord (upper) or pons
  • Surgical procedures :
    • Cesarean section
    • Hysterectomy
    • Prostatectomy
    • Surgery to the colon or rectum
  • Fecal impaction
  • Cystocele

Overflow Incontinence

This is a result of incomplete emptying of the bladder and there is chronic over-filling. The detrusor muscle may be damaged, the nerve supply to the muscle may be compromised or there may be an obstruction preventing the urine from emptying. All of this hampers complete emptying

Some causes/risks include :

  • Congenital anatomical defect (birth)
  • Renal calculus (kidney stone) lodged in the urethra
  • Benign prostatic hyperplasia
  • Prostatitis
  • Pelvic nerve damage :
    • Diabetic neuropathy
    • Disc prolapse (lower column)
    • Infection
    • Tumor
    • Trauma including surgical damage

Functional Incontinence

In this type of incontinence, there is an inability to recognize the urge or to reach the toilet or both. This may be seen in :

  • Bed-ridden patients
  • Dementia (elderly)
  • Depression
  • Drugs, psychoactive
  • Limited mobility – arthritis, Parkinson’s disease and other neurological or musculoskeletal conditions that affect mobility.
  • Stroke

Severe Urinary Incontinence

Severe incontinence is very frequent leakage of urine, sometimes to point where it is almost constant (continual). Any cause of urinary incontinence, especially stress incontinence, may progress till it becomes severe enough to cause constant incontinence. However, there are some uncommon causes of incontinence where leakage is constant or persists for a period of time after passing urine.

Constant or Continuous Incontinence

In both males and females there may be total failure of the urethral sphincter. This allows urine to constantly leak out rather than flow like is the case in urination. This may be due to :

  • Surgery to the penis or vulva.
  • Radiation therapy
  • Lower motor neuron disease

Women

Continual incontinence is more often seen in women where the urine is entering the vagina from where it constantly leaks into the environment or soils the clothing. This usually indicates the presence of a fistula – an abnormal passageway or canal that forms between two organs or between an organ and the environment.

In the case of continual incontinence, a fistula between the ureter and vagina (ureterovaginal) or bladder and vagina (vesicovaginal) causes urine to enter the vagina. Since the vagina has no sphincter control like the urethra, the urine will not flow as is the case with urination but rather there is a constant drip or wetness.

Some of the causes of urogenital fistulas include :

  • Cancer
  • Radiation therapy
  • Prolonged obstructed labor

Men

Apart from total urethral sphincter failure (mentioned above), most cases of apparent continual leakage in men is a result of post-micturition dribble. Here urine is trapped within the urethra and may dribble slowly over a period of time.

Some of the causes include :

  • Benign prostatic hypertrophy, prostatitis or prostate cancer
  • Phimosis is the inability to retract the foreskin thereby causing an outlet obstruction or some urine is trapped between the foreskin and penis.
  • Paraphimosis is when the foreskin is trapped behind the ‘head’ of the penis (glans penis) and this can constrict the distal parts of the male urethra. Urine is trapped within the urethra and gradually leaks after urination.

Infants

In babies, the cause of constant incontinence may be related to congenital anatomical defects. This includes :

  • Ectopic ureters
  • Bladder exstrophy
  • Epispadias
  • Spinal bifida occulta