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| '''For patient information, click [[Urinary incontinence (patient information)|here]] | | '''For patient information, click [[Urinary incontinence (patient information)|here]] |
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| {{Infobox_Disease | | | {{CMG}}; '''Howard B. Goldman M.D.''' [mailto:GOLDMAH@ccf.org], Center for Female Pelvic Medicine and Reconstructive Surgery |
| Name = Urinary incontinence |
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| Image = |
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| Caption = |
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| DiseasesDB = 6764 |
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| ICD10 = {{ICD10|R|32||r|30}} |
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| ICD9 = {{ICD9|788.3}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 003142 |
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| }}
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| {{Search infobox}}
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| '''Editor(s)-in-Chief:''' [[C. Michael Gibson]], M.S.,M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; '''Howard B. Goldman M.D.''' [mailto:GOLDMAH@ccf.org], Center for Female Pelvic Medicine and Reconstructive Surgery
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| Glickman Urologic and Kidney Institute, The Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, Cleveland, OH | | Glickman Urologic and Kidney Institute, The Cleveland Clinic, Lerner College of Medicine, Case Western Reserve University, Cleveland, OH |
| | {{Urinary incontinence}} |
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| ==Overview==
| | {{SK}} Incontinence, urine; loss of bladder control; uncontrollable urination; urination - uncontrollable; incontinence - urinary; bladder incontinence |
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| '''Urinary incontinence''': unintentional loss of urine. Inability to hold urine in the [[bladder]] due to loss of voluntary control over the bladder (detrusor) muscle and/or urinary sphincters resulting in the involuntary passage of urine.
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| In this article, the term "incontinence" will be used to mean urinary incontinence. See also [[fecal incontinence]].
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| ==Physiology of continence==
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| Continence and [[micturition]] involve a balance between outlet (urethra) and bladder [[detrusor]] muscle activity. Lower urinary tract function is often divided into filling and voiding phases. Normally as the bladder fills the detrusor is compliant - stretching and increasing the volume it holds - without any unpleasant sensation and the outlet is closed. At a socially acceptable time and place to void the bladder (detrusor) contracts and the outlet relaxes and flow ensues. Any perturbation in that balance can lead to voiding dysfunction or incontinence. Abnormal detrusor muscle activity or hypersensitivity of the bladder can lead to urge incontinence. An incompetent outlet can lead to stress incontinence. A bladder that cannot contract may lead to overflow incontinence.
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| ==Types==
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| === Stress incontinence ===
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| Stress urinary incontinence (SUI) occurs when the intraabdominal pressure on the bladder exceeds the resistance provided by the urethra. The symptoms include loss of urine with coughing, laughing, sneezing, exercising or other movements that increase intraabdominal pressure and thus increase pressure on the bladder. The pathophysiology is related to pelvic floor muscle and tissue weakness and changes in the intrinsic "water seal" function of the urethra. Physical changes resulting from pregnancy, childbirth, prior pelvic surgery and menopause may lead to stress incontinence in women while in men it may occur following a [[prostatectomy]].
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| The urethra is supported by [[fascia]] of the pelvic floor. If the fascial support is weakened, as it can be in pregnancy and childbirth, the urethra can move downward at times of increased abdominal pressure, resulting in stress incontinence. There are many different theories as to why SUI actually occurs. Two of the classic concepts are changes in abdominal pressure transmission and loss of the normal suburethral support
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| Stress incontinence can worsen during the week before the menstrual period. At that time, lowered estrogen levels may lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause, similarly because of lowered estrogen levels resulting in changes in urethral function. '''LABS''' Urine analysis, cystometry and postvoid residual volume are normal.
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| === Urge incontinence ===
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| Urge incontinence describes incontinence associated with a sudden urge to void. This urge is not the typical sense that one has of a need to void but is a pathologic sense of an extreme need to void which is difficult to ignore. Typically patients describe a sudden urge to urinate but before they can get to the toilet urine starts to leak out. Often the entire bladder may empty leading to a large volume of urine loss. Classically urge incontinence was thought to be due to abnormal sudden bladder contractions which the patient could not control. However, when observing these patients during urodynamics, some of them do not have these abnormal bladder contractions (detrusor overactivity) but instead seem to have an early sensation of the need to void (detrusor hypersensitivity).
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| Patients with urinary tract infections or other inflammatory conditions of the bladder may develop urge incontinence. In some cases when the underlying cause is treated, for example with a UTI, the urge incontinence will resolve.
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| Urge incontinence may also coexist with other symptoms of the overactive bladder syndrome - urinary frequency, urgency and nocturia.
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| ''Idiopathic Detrusor Overactivity'' - describes urge incontinence with no clear etiology
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| ''Neurogenic Detrusor Overactivity'' - describes urge incontinence in a patient with neurologic disease. In many neurologic diseases loss of normal bladder inhibition may occur which can lead to urge incontinence
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| Medical professionals describe such a bladder as "unstable," "spastic," or "overactive." Urge incontinence may also be called "reflex incontinence" if it results from overactive nerves controlling the bladder.
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| Some patients with urge incontinence may have triggers that lead to it. Many will complain of urge incontinence after washing their hands or hearing running water (as when washing dishes or hearing someone else taking a shower), after feeling a chill, or when they get close to their home and are fumbling for the keys to get in the house.
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| Involuntary bladder contractions can occur because of damage to the nerves of the bladder, to the nervous system (spinal cord and brain), or to the muscles themselves. Multiple sclerosis, Parkinson's disease, Alzheimer's Disease, stroke, and injury--including injury that occurs during surgery--can all harm bladder nerves or muscles.
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| ===Functional incontinence ===
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| Functional incontinence occurs when a person does not recognize the need to go to the toilet, recognize where the toilet is, or because of disability is unable to get to the toilet in time. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity, unwillingness to toilet because of depression, anxiety or anger, or being in a situation in which one is unable to reach a toilet. <ref name=au>{{cite web | title =Functional incontinence | publisher=Australian Government Department of Health and Ageing | work = | url=http://www.health.gov.au/internet/wcms/publishing.nsf/Content/continence-what-functional.htm | year = 2004 | accessdate=2006-12-20}}</ref>
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| People with functional incontinence may have problems thinking, moving, or communicating that prevent them from reaching a toilet. A person with Alzheimer's Disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may be blocked from getting to a toilet in time. Conditions such as these are often associated with age and account for some of the incontinence of elderly women and men in nursing homes.
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| ===Overflow incontinence or Hypotonic===
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| Sometimes people find that they cannot stop their bladders from constantly dribbling, or continuing to dribble for some time after they have passed urine. It is as if their bladders were like a constantly overflowing pan - hence the general name overflow incontinence. Overflow incontinence occurs when the patient's bladder is always full so that it frequently leaks urine. Weak bladder muscles, resulting in incomplete emptying of the bladder, or a blocked urethra can cause this type of incontinence. [[Autonomic neuropathy]] from diabetes or other diseases (e.g [[Multiple sclerosis]]) can decrease neural signals from the bladder (allowing for overfilling) and may also decrease the expulsion of urine by the [[detrusor]] muscle (allowing for urinary retention). Additionally, tumors and [[kidney stone]]s can block the urethra. In men, [[benign prostatic hypertrophy]] (BPH) may also restrict the flow of urine. Overflow incontinence is rare in women, although sometimes it is caused by fibroid or ovarian tumors. Spinal cord injuries or nervous system disorders are additional causes of overflow incontinence. Also overflow incontinence in women can be from increased outlet resistance from advanced vaginal prolapse causing a "kink" in the urethra or after an anti-incontinence procedure which has overcorrected the problem.<ref name=AMN>{{cite web | Christopher M. Tarnay, MD, & Narender N. Bhatia, MD | title =Overflow Incontinence | publisher=Armenian Medical Network | work =Urinary Incontinence - Overview | url=http://www.health.am/gyneco/overflow-incontinence/ | year = 2006 | accessdate=2006-12-20}}</ref>
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| Early symptoms include a hesitant or slow stream of urine during voluntary urination.
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| [[Anticholinergic]] medications may worsen overflow incontinence.
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| ===Other types of incontinence===
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| Stress and urge incontinence often occur together in women. Combinations of incontinence - and this combination in particular - are sometimes referred to as "mixed incontinence."
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| "Transient incontinence" is a temporary version of incontinence. It can be triggered by medications, urinary tract infections, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow. Incontinence can often occur while trying to concentrate on a task and avoiding using the toilet.
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| | ==[[Urinary incontinence overview|Overview]]== |
| | ==[[Urinary incontinence classification|Classification]]== |
| | ==[[Urinary incontinence pathophysiology |Pathophysiology]]== |
| | ==[[Urinary incontinence causes|Causes]]== |
| | ==[[Urinary incontinence differential diagnosis|Differentiating Urinary incontinence from other Diseases]]== |
| | ==[[Urinary incontinence epidemiology and demographics|Epidemiology and Demographics]]== |
| | ==[[Urinary incontinence natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
| ==Diagnosis== | | ==Diagnosis== |
| Patients with incontinence should be referred to a medical practitioner specializing in this field. [[urology|Urologist]]s specialize in the urinary tract, and some urologists further specialize in the female urinary tract. A '''urogynecologist''' is a gynecologist who has special training in urological problems in women. [[gynecology|Gynecologists]] and obstetricians specialize in the female reproductive tract and childbirth and some also treat urinary incontinece in women. Family practitioners and internists see patients for all kinds of complaints and can refer patients on to the relevant specialists.
| | [[Urinary incontinence history and symptoms|History and Symptoms]] | [[Urinary incontinence physical examination|Physical Examination]] | [[Urinary incontinence laboratory findings|Laboratory Findings]] | [[Urinary incontinence MRI|MRI]] | [[Urinary incontinence echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Urinary incontinence other diagnostic studies|Other Diagnostic Studies]] |
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| A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Other important points include straining and discomfort, use of drugs, recent surgery, and illness.
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| The [[physical examination]] will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.
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| A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.
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| Other tests include:
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| * [[Stress test]] - the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.
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| * [[Urinalysis]] - urine is tested for evidence of infection, urinary stones, or other contributing causes.
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| * [[Blood test]]s - blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
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| * [[Ultrasound]] - sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
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| * [[Cystoscopy]] - a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
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| * [[Urodynamics]] - various techniques measure pressure in the bladder and the flow of urine.
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| Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced.
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| === Urinary incontinence in men ===
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| Men experience incontinence twice as often as women, and the structure of the male [[urinary tract]] accounts for this difference. But both women and men can become incontinent from neurologic injury, [[congenital defect]]s, [[stroke]]s, [[multiple sclerosis]], and physical problems associated with [[Senescence|aging]].
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| While urinary incontinence affects older men more often than younger men, the onset of incontinence is not inevitable with age. Incontinence is treatable and often curable at all ages.
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| Incontinence in men usually occurs because of problems with muscles that help to hold or release urine. The body stores urine - water and wastes removed by the kidneys - in the [[urinary bladder]], a balloon-like organ. The bladder connects to the [[urethra]], the tube through which urine leaves the body. <!--
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| --><ref name="AA1-Stats">{{cite web |year = 2006 | url = http://www.stayfree.com/moms_bladder_control.jsp | title = Stayfree - Bladder Control
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| | accessdate = 2006-10-12}}</ref>
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| During [[urination]], muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, [[sphincter]] muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if the bladder muscles suddenly contract or muscles surrounding the urethra suddenly relax.
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| == Differential Diagnosis ==
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| In alphabetical order. <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016</ref> <ref>Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X</ref>
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| *[[Bladder Cancer]]
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| *[[Delerium]]
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| *[[Drugs]]
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| *[[Infection]]
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| *[[Inflammation]]
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| *Multiparity
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| *Neuropathic bladder dysfunction
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| *[[Neurologic]]
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| *[[Obesity]]
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| *Obstetric/gynecologic surgery
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| *Outlet obstruction
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| *Pelvic surgery
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| *[[Polyuria]]
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| *[[Postpartum]]
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| *[[Pregnancy]]
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| *Prostate surgery
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| *Restricted mobility
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| *Sphincteric atony
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| *Stool impaction
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| *[[Tumor]]
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| *[[Vaginitis]]
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| *[[Vesicovaginal fistula]]
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| ==Treatment== | | ==Treatment== |
| ===Exercises===
| | [[Urinary incontinence non pharmacological treatment|Non pharmacological treatment]] | [[Urinary incontinence medical therapy|Medical Therapy]] | [[Urinary incontinence surgery|Surgery]] | [[Urinary incontinence cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Urinary incontinence future or investigational therapies|Future or Investigational Therapies]] |
| [[Kegel exercise]]s to strengthen or retrain [[pelvic floor muscles]] and sphincter muscles can reduce stress leakage.<ref name="pmid17625461">{{cite journal |author=Choi H, Palmer MH, Park J |title=Meta-analysis of pelvic floor muscle training: randomized controlled trials in incontinent women |journal=Nursing research |volume=56 |issue=4 |pages=226-34 |year=2007 |pmid=17625461 |doi=10.1097/01.NNR.0000280610.93373.e1}}</ref> Patients younger than 60 years old benefit the most.<ref name="pmid17625461"/> The patient should do at least 24 daily contractions for at least 6 weeks. | | ==Case Studies== |
| <ref name="pmid17625461"/>
| | :[[Urinary incontinence case study one|Case #1]] |
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| ===Vaginal cone therapy===
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| A more recently developed exercise technique suitable only for women involves the use of a set of five small vaginal cones of increasing weight. For this exercise, the patient simply places the small plastic cone within her vagina, where it is held in by a mild reflex contraction of the pelvic floor muscles. Because it is a reflex contraction, little effort is required on the part of the patient. This exercise is done twice a day for fifteen to twenty minutes, while standing or walking around, for example doing daily household tasks. As the pelvic floor muscles get stronger, cones of increasing weight can be used, thereby strengthening the muscles gradually.
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| The advantage of this method is that the correct muscles are automatically exercised by holding in the cone, and the method is effective after a much shorter time. Clinical trials with vaginal cones have shown that the pelvic floor muscles start to become stronger within two to three weeks, and light to medium stress incontinence can resolve after eight to twelve weeks of use.
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| ===Electrical stimulation===
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| Brief doses of electrical stimulation can strengthen muscles in the lower pelvis in a way similar to exercising the muscles. Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles. This can stabilize overactive muscles and stimulate contraction of urethral muscles. Electrical stimulation can be used to reduce both stress incontinence and urge incontinence.
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| ===Biofeedback===
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| [[Biofeedback]] uses measuring devices to help the patient become aware of his or her body's functioning. By using electronic devices or diaries to track when the bladder and urethral muscles contract, the patient can gain control over these muscles. Biofeedback can be used with pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence. | |
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| ===Timed voiding or bladder training===
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| Timed voiding (urinating) and bladder training are techniques that use biofeedback. In timed voiding, the patient fills in a chart of voiding and leaking. From the patterns that appear in the chart, the patient can plan to empty his or her bladder before he or she would otherwise leak. Biofeedback and muscle conditioning--known as bladder training--can alter the bladder's schedule for storing and emptying urine. These techniques are effective for urge and overflow incontinence.
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| ===Medications===
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| Medications can reduce many types of leakage. Some drugs inhibit contractions of an overactive bladder. Others relax muscles, leading to more complete bladder emptying during urination. Some drugs tighten muscles at the bladder neck and urethra, preventing leakage. And some, especially hormones such as estrogen, are believed to cause muscles involved in urination to function normally.
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| Pharmacological treatments of urinary incontinence:
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| <br>in vaginal atrophy - topical or vaginal [[estrogen]]s; [[tolterodine]], [[oxybutynin]], [[propantheline]], [[darifenacin]], [[solifenacin]], trospium in urge incontinence,
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| [[imipramine]] in mixed and stress urinary incontinence, [[pseudoephedrine]] and [[duloxetine]] in stress urinary incontinence.
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| Some of these medications can produce harmful side effects if used for long periods. In particular, estrogen therapy has been associated with an increased risk for cancers of the breast and endometrium (lining of the uterus). A patient should talk to a doctor about the risks and benefits of long-term use of medications.
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| ===Pessaries===
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| A pessary is a medical device that is inserted into the vagina. The most common kind is ring shaped, and is typically recommended to correct vaginal prolapse. The pessary compresses the urethra against the symphysis pubis and elevates the bladder neck. For some women this may reduce stress leakage. If a pessary is used, vaginal and urinary tract infections may occur and regular monitoring by a doctor is recommended.
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| ===Surgery===
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| Doctors usually suggest surgery to alleviate incontinence only after other treatments have been tried. Many surgical options have high rates of success.
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| ===Bladder repositioning===
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| Most stress incontinence in women results from the bladder dropping down toward the vagina. Therefore, common surgery for stress incontinence involves pulling the bladder up to a more normal position. Working through an incision in the vagina or abdomen, the surgeon raises the bladder and secures it with a string attached to muscle, ligament, or bone. For severe cases of stress incontinence, the surgeon may secure the bladder with a wide sling. This not only holds up the bladder but also compresses the bottom of the bladder and the top of the urethra, further preventing leakage.
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| ===Marshall-Marchetti-Krantz===
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| The Marshall-Marchetti-Krantz (MMK) procedure, also known as retropubic suspension or bladder neck suspension surgery, is performed by a surgeon in a hospital setting. Developed in 1949 by doctors Victor F. Marshall (urologist), Andrew A. Marchetti (OB/GYN), and [[Kermit E Krantz|Kermit E. Krantz]] (OB/GYN) is the standard which new procedures are measures. In 1961 Dr. Burch reported a modification of the MMK operation (the Burch modification.)
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| The patient is placed under general anesthesia, and a long, thin, flexible tube (catheter) is inserted into the bladder through the narrow tube (urethra) that drains the body's urine. An incision is made across the abdomen, and the bladder is exposed. The bladder is separated from surrounding tissues. Stitches (sutures) are placed in these tissues near the bladder neck and urethra. The urethra is then lifted, and the sutures are attached to the pubic bone itself, or to tissue (fascia) behind the pubic bone. The sutures support the bladder neck, helping the patient gain control over urine flow. The Burch modifications involved placing the surgical sutures at the bladder neck and tying them to the Cooper ligament.
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| Approximately 85% of women who undergo the Marshall-Marchetti-Krantz procedure are cured of their stress incontinence.
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| ===Slings===
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| The procedure of choice for stress urinary incontinence in females is what is called a sling procedure. A sling usually consists of a synthetic mesh material in the shape of a narrow ribbon but sometimes a biomaterial (bovine, porcine) or the patients' own tissue that is placed under the [[urethra]] through one vaginal incision and two small abdominal incisions. The idea is to replace the deficient pelvic floor muscles and provide a "backboard" or "hammock" of support under the [[urethra]]. According to published peer-reviewed studies, these slings are approximately 85% effective.
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| ===Adjustable sling===
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| Slings employ a "one size fits all" philosophy as the body's reaction to the sling is to scar it into place. There is an adjustable sling which consists of a standard synthetic mesh sling combined with sutures that attach to an implatable tensioning device that resides as a permanent implant under the skin in the abdominal wall. Once implanted, this device can be re-accessed under local anesthesia to fine tune the sling should incontinence reappear months or years after the initial surgery.
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| ===Bladder augmentation===
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| ===Artificial urinary sphincter===
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| In rare cases, a surgeon implants an artificial urinary sphincter<ref>[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool=abstractplus&db=pubmed&cmd=Retrieve&dopt=abstractplus&list_uids=16945659 ''14 years of experience with the artificial urinary sphincter in children and adolescents without spina bifida'' Ruiz et al. J Urol. 2006 Oct;176(4 Pt 2):1821-5]</ref>, a doughnut-shaped sac that circles the urethra. A fluid fills and expands the sac, which squeezes the urethra closed. By pressing a valve implanted under the skin, the artificial sphincter can be deflated. This removes pressure from the urethra, allowing urine from the bladder to pass.
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| ===Catheterization===
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| If an incontinence is due to overflow incontinence, in which the bladder never empties completely, or if the bladder cannot empty because of poor muscle tone, past surgery, or spinal cord injury, a [[catheter]] may be used to empty the bladder. A catheter is a tube that can be inserted through the urethra into the bladder to drain urine. Catheters may be used once in a while or on a constant basis, in which case the tube connects to a bag that is attached to the leg. If a long-term (or indwelling) catheter is used, urinary tract infections may occur.
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| ===Other procedures===
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| Many people manage urinary incontinence with pads that catch slight leakage during activities such as exercising. Also, incontinence may be managed by restricting certain liquids, such as coffee, tea, and alcohol.
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| Finally, many people who could be treated resort instead to wearing absorbent, reusable undergarments which can hold 6 oz. or disposable diapers which can hold more. The reusable undergarments may be positive from a self-esteem perspective though depending on the amount of fluid being passed, disposable diapers can also be positive as they can hold more liquid and may eliminate leakage. Either can lead to skin irritation and sores if the urine is left in contact with the skin. The possible effectiveness of treatments such as timed voiding, pelvic muscle exercises, and electrical stimulation should be discussed with a doctor.
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| Kneading the perineum immediately after urination can help expel unvoided urine retained by a urethral stricture, a urethral sphincter that is slow to close, or overdeveloped abdominal floor muscles and connective tissue (as may be developed by the stresses of bicycle seats.)
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| [[Hospital]]s often use some type of [[incontinence pad]], a small but highly absobant sheet placed beneath the patient, to deal with incontinence or other unexpected discharges of [[bodily fluid]]. These pads are especially useful when it is not practical for the patient to wear a diaper.
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| There are also trials taking place in the UK at the moment using Botox. It has been tested with some success under general anaesthetic conditions, and is currently (February 2006) being tried under local anaesthetic. While it originally appears that it may be quite successful for women, it does not appear to be as successful for men. Botox works for around 6-9 months when the treatment has to be redone.
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| == Urinary incontinence in children ==
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| In the United States, at least 13 million people have problems holding urine until they can get to a toilet. This loss of urinary control is called "urinary incontinence" or just "incontinence." Although it affects many young people, it usually disappears naturally over time, which suggests that incontinence, for some people, may be a normal part of growing up. Recent studies in Japan show that an increasing number of children are wetting their beds and even wearing diapers full time, well into elementary school.[http://mdn.mainichi-msn.co.jp/waiwai/archive/news/2005/04/20050402p2g00m0dm999000c.html][http://mdn.mainichi-msn.co.jp/waiwai/archive/news/2002/07/20020726p2g00m0dm999000c.html]
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| No matter when it happens or how often it happens, incontinence causes great distress. It may get in the way of a good night's sleep and is embarrassing when it happens during the day. That's why it is important to understand that occasional incontinence is a normal part of growing up and that treatment is available for most children who have difficulty controlling their bladders.
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| Babies are never considered incontinent, as they cannot physically attain bowel and bladder control and incontinence is a loss of pre-existing control.
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| ===Urinary system===
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| Urination, or voiding, is a complex activity. The bladder is a balloonlike muscle that lies in the lowest part of the abdomen. The bladder stores urine, then releases it through the urethra, the canal that carries urine to the outside of the body. Controlling this activity involves nerves, muscles, the spinal cord, and the brain.
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| The bladder is made of two types of muscles: the detrusor, a muscular sac that stores urine and squeezes to empty, and the sphincter, a circular group of muscles at the bottom or neck of the bladder that automatically stay contracted to hold the urine in and automatically relax when the detrusor contracts to let the urine into the urethra. A third group of muscles below the bladder (pelvic floor muscles) can contract to keep urine back.
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| A baby's bladder fills to a set point, then automatically contracts and empties. As the child gets older, the nervous system develops. The child's brain begins to get messages from the filling bladder and begins to send messages to the bladder to keep it from automatically emptying until the child decides it is the time and place to void.
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| Failures in this control mechanism result in incontinence. Reasons for this failure range from the simple to the complex.
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| Incontinence happens less often after age 5: About 10 percent of 5-year-olds, 5 percent of 10-year-olds, and 1 percent of 18-year-olds experience episodes of incontinence. It is twice as common in girls as in boys.
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| ===Causes of nighttime incontinence===
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| After age 5, wetting at night--often called [[bedwetting]] or sleepwetting--is more common than daytime wetting in boys. Experts do not know what causes nighttime incontinence. Young people who experience nighttime wetting tend to be physically and emotionally normal. Most cases probably result from a mix of factors including slower physical development, an overproduction of urine at night, a lack of ability to recognize bladder filling when asleep, and, in some cases, anxiety. For many, there is a strong family history of bedwetting, suggesting an inherited factor.
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| ===Slower physical development===
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| Between the ages of 5 and 10, incontinence may be the result of a small bladder capacity, long sleeping periods, and underdevelopment of the body's alarms that signal a full or emptying bladder. This form of incontinence will fade away as the bladder grows and the natural alarms become operational.
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| ===Excessive output of urine during sleep===
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| Normally, the body produces a hormone that can slow the making of urine. This hormone is called antidiuretic hormone, or ADH. The body normally produces more ADH during sleep so that the need to urinate is lower. If the body does not produce enough ADH at night, the making of urine may not be slowed down, leading to bladder overfilling. If a child does not sense the bladder filling and awaken to urinate, then wetting will occur.
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| ===Anxiety===
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| Experts suggest that anxiety-causing events occurring in the lives of children ages 2 to 4 might lead to incontinence before the child achieves total bladder control. Anxiety experienced after age 4 might lead to wetting after the child has been dry for a period of 6 months or more. Such events include angry parents, unfamiliar social situations, and overwhelming family events such as the birth of a brother or sister.
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| Incontinence itself is an anxiety-causing event. Strong bladder contractions leading to leakage in the daytime can cause embarrassment and anxiety that lead to wetting at night.
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| ===Genetics===
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| Certain inherited genes appear to contribute to incontinence. In 1995, Danish researchers announced they had found a site on human chromosome 13 that is responsible, at least in part, for nighttime wetting. If both parents were bedwetters, a child has an 80 percent chance of being a bedwetter also. Experts believe that other, undetermined genes also may be involved in incontinence.
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| ===Obstructive sleep apnea===
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| Nighttime incontinence may be one sign of another condition called obstructive sleep apnea, in which the child's breathing is interrupted during sleep, often because of inflamed or enlarged tonsils or adenoids. Other symptoms of this condition include snoring, mouth breathing, frequent ear and sinus infections, sore throat, choking, and daytime drowsiness. In some cases, successful treatment of this breathing disorder may also resolve the associated nighttime incontinence.
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| ===Structural problems===
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| Finally, a small number of cases of incontinence are caused by physical problems in the urinary system in children. A condition known as urinary reflux or vesicoureteral reflux, in which urine backs up into one or both ureters, can cause urinary tract infections and incontinence. Rarely, a blocked bladder or urethra may cause the bladder to overfill and leak. Nerve damage associated with the birth defect spina bifida can cause incontinence. In these cases, the incontinence can appear as a constant dribbling of urine.
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| ===Causes of daytime incontinence===
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| [[Daytime Wetting|Daytime incontinence]] that is not associated with urinary infection or anatomic abnormalities is less common than nighttime incontinence and tends to disappear much earlier than the nighttime versions. One possible cause of daytime incontinence is an overactive bladder. Many children with daytime incontinence have abnormal voiding habits, the most common being infrequent voiding. | |
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| ===An overactive bladder===
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| Muscles surrounding the urethra (the tube that takes urine away from the bladder) have the job of keeping the passage closed, preventing urine from passing out of the body. If the bladder contracts strongly and without warning, the muscles surrounding the urethra may not be able to keep urine from passing. This often happens as a consequence of urinary tract infection and is more common in girls.
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| ===Infrequent voiding===
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| Infrequent voiding refers to a child's voluntarily holding urine for prolonged intervals. For example, a child may not want to use the toilets at school or may not want to interrupt enjoyable activities, so he or she ignores the body's signal of a full bladder. In these cases, the bladder can overfill and leak urine. Additionally, these children often develop urinary tract infections (UTIs), leading to an irritable or overactive bladder.
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| ===Other causes===
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| Some of the same factors that contribute to nighttime incontinence may act together with infrequent voiding to produce daytime incontinence. These factors include
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| * a small bladder capacity
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| * structural problems
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| * anxiety-causing events
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| * pressure from a hard bowel movement (constipation)
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| * drinks or foods that contain caffeine, which increases urine output and may also cause spasms of the bladder muscle, or other ingredients to which the child may have an allergic reaction, such as chocolate or artificial coloring
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| Sometimes overly strenuous toilet training may make the child unable to relax the sphincter and the pelvic floor to completely empty the bladder. Retaining urine (incomplete emptying) sets the stage for urinary tract infections.
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| ===Treatment===
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| ====Growth and development====
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| Most urinary incontinence fades away naturally. Here are examples of what can happen over time:
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| * Bladder capacity increases.
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| * Natural body alarms become activated.
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| * An overactive bladder settles down.
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| * Production of ADH becomes normal.
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| * The child learns to respond to the body's signal that it is time to void.
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| * Stressful events or periods pass.
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| Many children overcome incontinence naturally (without treatment) as they grow older. The number of cases of incontinence goes down by 15 percent for each year after the age of 5.
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| ====Medications====
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| Nighttime incontinence may be treated by increasing ADH levels. The hormone can be boosted by a synthetic version known as [[desmopressin]], or DDAVP, which recently became available in pill form. Patients can also spray a mist containing desmopressin into their nostrils. Desmopressin is approved for use by children.
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| Another medication, called [[imipramine]], is also used to treat sleepwetting. It acts on both the brain and the urinary bladder. Unfortunately, total dryness with either of the medications available is achieved in only about 20 percent of patients.
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| If a young person experiences incontinence resulting from an overactive bladder, a doctor might prescribe a medicine that helps to calm the bladder muscle. This medicine controls muscle spasms and belongs to a class of medications called anticholinergics.
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| ====Bladder training and related strategies====
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| Bladder training consists of exercises for strengthening and coordinating muscles of the bladder and urethra, and may help the control of urination. These techniques teach the child to anticipate the need to urinate and prevent urination when away from a toilet. Techniques that may help nighttime incontinence include
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| * determining bladder capacity
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| * stretching the bladder (delaying urinating)
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| * drinking less fluid before sleeping
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| * developing routines for waking up
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| Unfortunately, none of the above has demonstrated proven success.
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| Techniques that may help [[Daytime Wetting|daytime incontinence]] include
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| * urinating on a schedule, such as every 2 hours (this is called timed voiding)
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| * avoiding caffeine or other foods or drinks that may contribute to a child's incontinence
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| * following suggestions for healthy urination, such as relaxing muscles and taking your time
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| ====Moisture alarms====
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| At night, [[bedwetting alarm|moisture alarms]] can awaken a person when he or she begins to urinate. These devices include a water-sensitive pad worn in pajamas, a wire connecting to a battery-driven control, and an alarm that sounds when moisture is first detected. For the alarm to be effective, the child must awaken or be awakened as soon as the alarm goes off. This may require having another person sleep in the same room to awaken the bedwetter.
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| ===Incontinence is also called enuresis=== | |
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| * Primary enuresis refers to wetting in a person who has never been dry for at least 6 months.
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| * Secondary enuresis refers to wetting that begins after at least 6 months of dryness.
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| * [[Nocturnal enuresis]] refers to wetting that usually occurs during sleep (nighttime incontinence).
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| * [[Daytime Wetting|Diurnal enuresis]] refers to wetting when awake (daytime incontinence).
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| ====Points to remember====
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| * Urinary incontinence in children is common.
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| * Nighttime wetting occurs more commonly in boys.
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| * [[Daytime Wetting]] is more common in girls.
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| * After age 5, incontinence disappears naturally at a rate of 15 percent of cases per year.
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| * Treatments include waiting, dietary modification, [[bedwetting alarm|moisture alarms]], medications, and bladder training.
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| ==References==
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| {{reflist|2}}
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| {{Symptoms and signs}}
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| {{SIB}}
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| [[cs:Močová inkontinence]]
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| [[de:Harninkontinenz]]
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| [[fr:Incontinence urinaire]]
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| [[hr:Inkontinencija mokraće]]
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| [[hu:Vizeletinkontinencia]]
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| [[nl:Urine-incontinentie]]
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| [[ja:尿失禁]]
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| [[pl:Inkontynencja]]
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| [[pt:Incontinência urinária]]
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| [[sk:Močová inkontinencia]]
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| [[fi:Inkontinenssi]]
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| [[tr:Üriner inkontinans]]
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| [[Category:Overview complete]]
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| [[Category:Urology]]
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| [[Category:Signs and symptoms]]
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