Incontinence is the inability to control the passage of urine (urinary incontinence) or feces (fecal incontinence). Both are symptoms of an underlying medical condition, not a disease in themselves. The term “incontinence” alone is most commonly used in reference to urinary incontinence.

Urinary incontinence affects many Americans. More than 20 million women and 6 million men have or have had episodes of incontinence according to the National Institutes of Health. Although it is more common in older adults, incontinence is not considered a normal part of the aging process. It occurs during a malfunction of the urinary system, which is composed of two kidneys, two ureters, a bladder and a urethra. The kidneys are two bean-shaped organs that produce urine, which is moved to the bladder by the tube-like ureters. Urine is stored in the bladder until it is passed from the body through the urethra.

There are several types of urinary incontinence that are classified according to the symptoms and circumstances of urine leakage. For instance, stress incontinence occurs when an increase in pressure in the abdomen forces the urinary sphincter (ring of muscles that surrounds the urethra) to open inappropriately causing urine to leak. Stress incontinence may occur from activities such as coughing or exercising.

Urge incontinence is another type of urinary incontinence. This form occurs when the bladder unnecessarily contracts and can cause an abrupt, overwhelming urge to urinate followed by urine leakage. Urge incontinence is often associated with a condition called overactive bladder (OAB).

A third type of urinary incontinence, known as mixed incontinence, occurs when the patient has more than one type of incontinence, usually stress and urge incontinence

There are many possible causes for urinary incontinence. Some are temporary and easily addressed, such as drinking too much alcohol or caffeine, taking certain types of medications or having a urinary tract infection. More often, however, incontinence is a persistent condition caused by a physical problem. Among conditions that can lead to chronic incontinence are pregnancy and childbirth, hormonal changes following menopause, changes in a man's prostate gland and neurological disorders.

In addition to a physical examination, several medical tests may be performed to diagnose the cause of urinary incontinence. Examples include a post-void residual measurement (determines whether urine remains after a patient has attempted to empty the bladder) and a urinalysis (detects abnormalities in the urine).

The treatment of incontinence depends on the severity of the problem and its underlying cause. Treatment can be divided into four categories – behavioral techniques, medications, medical devices and surgery.

In some individuals, incontinence cannot be prevented because its cause is out of the patient’s control. However, other cases can be prevented with lifestyle changes including losing weight and avoiding beverages that increase the rate of urine production (e.g., caffeine, alcohol). Pelvic muscle exercises and bladder training programs also may help reduce or prevent urinary incontinence.

Urinary incontinence is loss of control of the bladder, a balloon-like organ that stores urine. It is a symptom, not a disease in itself, and can indicate some underlying medical condition.

Incontinence is a problem of the urinary system, which involves the kidneys, ureters, bladder and urethra. The kidneys are two bean-shaped organs that remove waste and water from the blood to produce urine. The muscular, tube-like ureters move urine from the kidneys to the bladder. Urine is stored in the bladder until it flows out of the body through a tube connected to the bottom of the bladder called the urethra.

A ring of muscles called the urinary sphincter surrounds the urethra. As the bladder fills with urine, a complex system of coordinating nerve signals make the sphincter muscles contract, which close off the opening to the bladder while at the same time, the bladder muscles relax. This action prevents urine from leaking out of the body.

When the bladder fills to a certain level, nerve signals are sent to the brain, giving it the sensation that the bladder is getting full. Additional nerve signals must be sent in a coordinated fashion to initiate urination. Some of these signals make the bladder muscles contract, pushing urine into the urethra. Other signals make the sphincter muscles relax, allowing urine to exit the body.

Urinary incontinence occurs when:

• The bladder contracts when it should not
  
  
• The bladder fails to contract properly, leading to a buildup of urine in the bladder and subsequent leakage
  
  
• The sphincter does not close properly or does not remain closed when subjected to pressure, allowing urine to leak
  
  
• The urethra is obstructed, preventing proper drainage of urine

According to the National Institutes of Health, 20 million women and 6 million men are currently living with or deal with incontinence at some point in their lives. Approximately 20 percent of women younger than 45 years have problems with bladder control. This increases to almost 30 percent of women aged 80 years or older. Incontinence rates among men rise from 5 percent of those younger than 45 years to more than 20 percent of the 65 years and older age group. It is important to note that, although it is more common in older adults, incontinence is not considered a normal part of the aging process.

Urinary incontinence can be caused by a number of factors, but is best known for its association with a condition called overactive bladder (OAB). OAB is caused by involuntary bladder contractions that occur as the bladder fills. Only one type of incontinence is associated with OAB – urge incontinence (an urgent need to pass urine).

There are several types of urinary incontinence, which are classified according to the symptoms experienced and circumstances at the time of the urine leakage. They are:

• Stress incontinence. Occurs when an increase in pressure in the abdomen from activities such as exercising, coughing, sneezing and laughing forces the urinary sphincter (the ring of muscles that surrounds the urethra) to open, causing urine to leak. It is the most common form of incontinence. This opening of the muscle can be the result of an actual problem with the muscle or it can be caused by the muscle becoming displaced from abdominal pressure (e.g., coughing, sneezing).
  
  
• Urge incontinence. Occurs when the bladder contracts when it should not, causing an abrupt, overwhelming urge to urinate followed by urine leakage. The urge and leakage often occur in response to a stimulus, such as going out in the cold, turning on the faucet or washing hands. Urge incontinence is a symptom of overactive bladder (OAB), a condition characterized by involuntary bladder contractions during the time the bladder is filling.
  
  
• Mixed incontinence. Occurs when the patient has more than one type of incontinence, usually stress and urge incontinence. One of the types is usually more bothersome than the other.
  
  
• Overflow incontinence. Occurs when the bladder fails to empty properly, either because of obstruction or weak bladder muscle contractions. When the patient tries to urinate, abnormally large amounts of urine remain in the bladder. A weak urine stream, dribbling or frequent urination are symptoms of this condition.
  
  
• Reflex incontinence. Occurs when people with a neurological injury (such as paralysis) experience urinary incontinence without any warning signals.
  
  
• Functional incontinence. Occurs when physical or mental disabilities prevent patients from getting to the toilet in time. This is common in older adults, especially those in nursing facilities.
  
  
• Transient incontinence. Leakage resulting from a temporary condition, such as a urinary tract infection. The incontinence is short-term and typically ends when the condition passes.
  
  
• Nocturnal enuresis (or nighttime incontinence). Some toilet-trained children, mostly boys, experience nighttime incontinence for a variety of reasons. Adults can also experience nighttime incontinence due to drinking excessive alcohol or taking certain types of medications. Older adults sometimes experience nighttime incontinence because aging bladders can have difficulty storing urine.

Urinary incontinence has many possible causes. Some problems are temporary and can be easily managed, including:

• Consuming excessive alcohol. Alcohol is a diuretic, meaning it increases the rate of urine production. Drinking too much alcohol causes the bladder to fill quickly with urine. In addition, alcohol can interfere with a person’s ability to recognize the need to urinate.
  
  
• Drinking excessive fluids. Drinking a large amount of water or other fluids in a short period of time causes an increased rate of urine production and large amounts of urine in the bladder. In addition, beverages that contain caffeine may also increase an urgency to urinate. Caffeine is a diuretic and consuming many caffeinated beverages causes the bladder to fill quickly with urine.
  
  
• Not drinking enough fluids. If the amount of liquids consumed is not adequate to keep a person hydrated, urine can become over-concentrated. The concentrated salts in the urine can irritate the bladder and cause incontinence.
  
  
• Consuming foods or beverages that irritate the bladder. Carbonated drinks, tea and coffee (with or without caffeine), citrus fruits, juices and artificial sweeteners can all irritate the bladder, causing incontinence.
  
  
• Taking certain medications. Bladder function is affected by many different types of medications. For instance, sedatives, diuretics, muscle relaxants and antidepressants can cause or increase incontinence. Side effects from anesthesia used during surgery can also cause temporary incontinence.
  
  
• Having a urinary tract infection (UTI). This infection develops along the urinary tract, which includes the kidneys, ureters (tubes from the kidneys to the bladder), bladder and urethra. Bacterial infection irritates the bladder, causing a strong urge to urinate. These urges may result in episodes of incontinence.
  
  
• Having constipation. The rectum and bladder are near one another and share many of the same nerves. When feces (stool) remain in the rectum, it can cause the nerves to become overactive, resulting in urine leakage.

Chronic incontinence is often caused by an underlying medical issue or condition. For instance, pregnancy and childbirth can cause stress incontinence in women due to the hormonal changes that occur and the increased weight of the uterus. Childbirth can weaken the muscles in the pelvic floor and the urinary sphincter (the muscles that surround the urethra). Some studies have shown that women who suffer from incontinence in their pregnancies may have a higher risk of developing incontinence later in life.

For men, chronic urinary incontinence is often associated with health conditions involving the prostate, a gland that surrounds the urethra. For many men, the prostate enlarges with age. The larger prostate squeezes the urethra and interferes with normal urination. Treatments for prostate cancer can also cause incontinence as a side effect.

Other potential causes of chronic incontinence include:

• Reduced hormone levels after menopause. The hormone estrogen helps keep a woman’s bladder lining and urethra healthy. As estrogen levels fall, the tissues can lose some ability to hold back urine. As the bladder ages, its capacity to hold urine declines as well.
  
  
• Hysterectomy (surgical removal of the uterus). The bladder and uterus are located near one another and are supported by the same muscles and ligaments. Surgeries that involve a woman’s reproductive system, such as a hysterectomy, may damage muscles or nerves of the urinary tract, which can lead to incontinence. The body also produces less estrogen if the ovaries and uterus are removed at the same time. Among its other functions, estrogen helps maintain the health of the bladder and the urethra. Therefore, lower levels of the hormone after a hysterectomy may result in bladder control problems.
  
  
• Interstitial cystitis (chronic inflammation of the bladder). This can cause painful and frequent urination, and possibly incontinence.
  
  
• Cystocele (fallen bladder). Occurs when the bladder drops into the vagina due to the weakening of the wall between the bladder and vagina. This can cause discomfort and urine leakage. This condition can occur alone or may be associated with uterine and/or rectal prolapse.These are all types of pelvic floor dysfunctions.
  
  
• Bladder cancer. Incontinence, urinary urgency and burning during urination can be signs and symptoms of bladder cancer.
  
  
• Neurologic disorders. Damage to the nerves and muscles of the bladder can cause incontinence. Stroke, spinal cord injuries, brain tumors, multiple sclerosis (an autoimmune disease that affects the central nervous system) and Parkinson’s disease (a brain disorder)  are examples of neurologic disorders. Nerve damage can also be associated with diabetes.
  
  
• Obstruction. Urinary stones (small, hard masses) that form in the bladder can also cause urine leakage. A benign or cancerous tumor in the urinary tract can obstruct the normal flow of urine and cause incontinence.
  
  
• Arthritis (inflammation of the joints) or other conditions that limit movement. This can cause functional incontinence by limiting the ability to get to the toilet in time.

There are a number of risk factors associated with incontinence, including:

• Gender. Women are more likely to experience incontinence than men. Pregnancy and childbirth, menopause and the structure of the female anatomy account for the difference.
  
  
• Age. The prevalence of incontinence increases with age because the muscles of the bladder and the urinary sphincter weaken as individuals get older.
  
  
• Obesity. Extra weight puts constant pressure on the bladder and surrounding muscles, weakening them and allowing urine to leak.
  
  
• Participating in high-impact activities. Running, sports and other weight-bearing exercises can cause sudden episodes of incontinence in healthy women. These activities place sudden, strong pressure on the bladder, allowing urine to leak past the urinary sphincter.
  
  
• Smoking cigarettes. Some studies have shown that smokers have a higher incidence of incontinence than nonsmokers. The chronic cough associated with smoking puts pressure on the urinary sphincter.

The first step for a physician to diagnose the cause of incontinence is to conduct a physical examination. Patients may be treated by a urologist (a physician specializing in the urinary tract) or a urogynecologist (a physician specializing in urological problems in women).

The physician will ask about the type of symptoms being experienced and review the patient’s medical history, including a list of current medications, past surgeries, pregnancy history and past illnesses. During a physical exam, the physician will look for signs of medical diseases or conditions that can cause incontinence. The examination can include looking for signs of pelvic floor abnormalities (e.g., types of prolapse or urethral abnormalities).

Patients may be asked to keep a bladder diary to record the times of urination and measure the amounts of urine produced. To measure urine, special containers that fit over the toilet rim are used. They can be purchased at drug stores or surgical supply stores.

Depending on the type and suspected cause of the incontinence, a physician may perform tests to determine the appropriate treatment. Some tests that may be performed include:

• Post-void residual measurement. Determines whether urine remains in the bladder after a patient has urinated. Measurements may be made by inserting a catheter (a small, soft tube) into the bladder to drain remaining urine or with an ultrasound, which uses sound waves to produce images of the body’s organs.
  
  
• Urinalysis. Laboratory analysis of a urine sample to determine the presence of infection, blood or other abnormalities in the urine.
  
  
• Ultrasound. An ultrasound may be performed to determine the size and shape of the kidneys and bladder and detect whether there are abnormalities that may cause incontinence.
  
  
• Cystoscopy. The physician places a cystoscope (a thin, tube with a tiny camera) inside the urethra to view the inside of the urethra and bladder.
  
  
• Urodynamic tests. Examine muscle function of the bladder and sphincter (the ring of muscles that surrounds the urethra). Urodynamics is a term to describe the study of how the body stores and releases urine. Using several urodynamic tests, the physician can determine whether bladder sensations and capacity are normal and whether the bladder fills and empties in a normal manner. An x-ray may be used to establish the degree of change in the position of the bladder and urethra during normal urination, coughing or sneezing.
  
  
• EEG (electroencephalogram) or EMG (electromyogram). Measuring nerve activity in the brain and lower abdomen may indicate a nervous condition contributing to incontinence.
  
  
• Blood test. Laboratory analysis of a sample of blood to test for the presence of various chemicals and substances related to the causes of incontinence.

Treatment for incontinence depends on the type of incontinence, the severity of the problem and the underlying cause. Often, a combination of treatments is used and most people treated for incontinence experience improvement.

Treatment options can be divided into four categories – behavioral techniques, medications, medical devices and surgery. Some behavioral techniques include:

• Dietary changes. Certain foods and beverages, such as chocolate, coffee, tea, alcohol and carbonated beverages (e.g., soda), can cause incontinence by irritating the bladder. They may also contain caffeine, which is a diuretic (increases the rate of production of urine).
  
  
• Weight loss. Extra weight places pressure on the bladder and surrounding muscles, weakening them and allowing urine to leak.
  
  
• Pelvic muscle exercises. Also called Kegel exercises, they are simple exercises to strengthen the muscles that help control urination, the urinary sphincter and pelvic floor muscles. Multiple studies have demonstrated the effectiveness of Kegels for women with urinary incontinence. However, the usefulness of Kegel exercises for men has not been scientifically proven.
  
  
• Timed urination or bladder training. These are two techniques to help train the bladder to hold urine better. Timed urination involves using the toilet on a routine, planned basis rather than waiting for the urge to urinate. Bladder training involves learning to delay urination after the urge occurs. This technique is often used in the geriatric population. 

When behavioral techniques alone are not successful in treating incontinence, medications may be used to suppress bladder muscle activity. They include:

• Antispasmodic drugs. Prescription medications that decrease muscle spasms and calm an overactive bladder (OAB). They can be effective in controlling incontinence. However, one side effect of this medication is dry mouth, which may cause a patient to drink more water thereby producing more urine and eventually worsening incontinence.
  
  
• Prostate medications. Drugs used to treat male urinary incontinence due to enlarged prostate. Two classes of medications are used. The first are alpha blockers, which relax the muscle of the prostate and allow for smooth urine flow. The second are 5-alpha reductase inhibitors, a class of drugs that help reduce the size of an enlarged prostate.
  
  
• Antibiotics. Medications that kill bacteria. Incontinence caused by a urinary tract infection (UTI) can be successfully treated with antibiotics.
  
  
• Hormone replacement therapy (HRT). Medications that replace female hormones that are no longer produced in adequate quantities after menopause. These medications are primarily used to relieve menopause-related symptoms. After menopause, a woman’s body produces less of the hormone estrogen, which can cause changes in the skin lining the urethra and vagina and contribute to the development of incontinence. Therefore, HRT is sometimes prescribed to reverse these changes and treat incontinence in postmenopausal women. However, several studies have found that HRT may increase the incidence of incontinence in postmenopausal women. Most experts no longer recommend it for the treatment of urinary incontinence.

If behavioral techniques and medications are ineffective in treating incontinence, some medical devices and procedures may help the condition. These include:

• Urethral insert. A small device available by prescription that a patient inserts into the urethra to prevent urine from leaking. It works best with women who experience predictable incontinence during certain activities, such as playing tennis. The insert is removed before urination and reinserted afterwards.
  
  
• Pessary. A stiff ring inserted into the vagina by a physician where it presses against the wall of the vagina and nearby urethra. The pressure helps to hold up the bladder and reduce leakage. It must be removed periodically for cleaning. A pessary is usually worn during the day and removed at night.
  
  
• Catheterization. A procedure for releasing urine from the bladder. A urinary catheter is a small tube inserted by a physician or patient through the urethra into the bladder to drain urine. Catheters can be used periodically or at all times. If it is continually used, the tube is connected to a bag that can be attached to the leg.
  
  
• Injection of bulking materials. Bulking materials, such as animal or human collagen, are injected through a needle into tissues around the urethra. Collagen is the fibrous protein found in skin, cartilage, bone and other connective tissue. The injection adds bulk and helps the urethra to remain closed, reducing incontinence. The procedure is done with minimal anesthesia and typically lasts about two to three minutes. It must be repeated every six to 18 months because the bulking agents do not remain effective over time. There are several new types of bulking agents being studied that may be more effective for longer periods. Also, they do not present the same problem with allergies or sensitivity to collagen that can exist with other products.
  
  
• Urine seal. A small foam pad that is placed by a patient over the opening of the urethra. The pad seals itself against the body, preventing leakage. It is removed and discarded after urination and a new seal is inserted.
  
  
• Dryness aids. Pads or adult incontinence briefs designed to absorb urine. Though they do not cure incontinence, they can be useful in managing episodes until the underlying condition causing incontinence can be resolved. They can be purchased at drug stores and medical supply stores.

If medical and behavioral treatments do not work, surgical procedures may be used to treat incontinence. These may include:

• Sacral nerve stimulation. A small device called a sacral nerve stimulator is implanted under the skin in the abdomen. A wire from the device is connected to a sacral nerve, a nerve involved in bladder control that runs from the lower spinal cord to the bladder. Through the wire, the device emits electrical pulses that control bladder and pelvic floor contractions.
  
  
• Sling procedure. A strip of tissue or synthetic material is surgically attached below the urethra to act like a hammock, compressing the urethra to prevent leaks. Following sling procedures, patients are able to control when urine is released. Sling procedures are the most popular surgery for women experiencing incontinence and are also available for men.
  
  
• Artificial sphincter. An implanted device used to control urethra opening in men with urinary incontinence. The patient triggers release of urine using a pump implanted into his scrotum.

In addition, there are other more invasive surgeries that can be done abdominally or laparoscopically to correct urinary incontinence. In conditions of prolapse, other surgeries may be used along with pelvic floor reconstruction to correct the problem.

In many cases, the cause of incontinence is out of the patient’s control and cannot be prevented. However, some types of incontinence may be prevented by:

• Losing weight. Helps reduce the pressure exerted on the bladder from excess weight.
  
  
• Performing Kegel exercises. Pregnancy and childbirth can weaken the urinary sphincter (the ring of muscles that surrounds the urethra) and pelvic floor muscles. For this reason, physicians often suggest women perform Kegel exercises (pelvic muscle exercises) during and after pregnancy to prevent incontinence during pregnancy and after childbirth. Continuing Kegel exercises through life may help women maintain muscle strength for better urinary control. 
  
  
• Avoiding certain types of beverages. Caffeine and alcohol are diuretics, which increase the rate of urine production. Limiting their intake can help prevent incontinence.
  
  
• Avoiding activities that may contribute to stress incontinence. If individuals develop incontinence as the result of high-impact activities, such as running, they may choose another form of exercise. Also, incontinence may be prevented if the individual does not drink large amounts of liquids before exercising.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions about urinary incontinence:

1. What may be causing my incontinence?
2. What type of urinary incontinence do I have?
3. What diagnostic tests can be used to determine the possible cause of my incontinence?
4. Are there lifestyle changes I can make to help with my condition?
5. Are any of my medications contributing to the incontinence?
6. Do I have any structural problems with my urinary system?
7. What are my treatment options?
8. What are the risks of these treatments?
9. Should I consider a pessary, seal or other device?
10. Will these devices interfere with sexual intercourse?
11. Am I a candidate for a surgical procedure to relieve my incontinence?
12. When should I expect to see results from the chosen treatment plan?
13. How can I prevent developing incontinence problems as I age?
14. If I have incontinence, will the condition progressively worsen?