Urinary incontinence

urinary incontinence, antonini urologyUrinary incontinence is the inability to control and hold urine. It can manifest with varying severity, from minimal losses (one or a few drops) to the complete loss of bladder content. Urinary leaking, however slight, constitutes a hygienic problem and a cause of social discomfort that may significantly compromise quality of life.
Urinary incontinence most frequently affects females, but it is estimated that a percentage of 2-10% of the male population presents urinary leaking. Fortunately, solutions exist, which differ in accordance with the causes underlying the incontinence itself. Urinary incontinence is not a health hazard, except in the most severe cases, when it is associated with immobility and poor personal hygiene or when accompanied by serious urinary retention problems as in overflow incontinence or neurological diseases. Urinary incontinence can contribute to the aggravation of skin lesions, so-called bedsores, which increasingly compromise the health of the subject with reduced mobility. In most cases, however, urinary incontinence is a problem that “merely” diminishes the quality of everyday life. The inability to control urine leakage, in addition to hygiene problems, causes physical and psychological discomfort, eliciting feelings of embarrassment and shame.
Those affected by urinary incontinence increasingly tend to avoid embarrassing situations, new places (where it is difficult to find a bathroom in a hurry!), and social contact. All of this may also create discomfort at work and in their sex lives. This constitutes a vicious circle, in which the difficulty of communicating their disorder can aggravate the sense of frustration. Roughly speaking, the severity of urinary incontinence can be framed as being of four degrees:
Minimal, when the incontinent person does not make use of diapers and social activities are not compromised. Modest, when the use of various absorbent aids is occasional, but social and work relationships are not substantially compromised.
Moderate, when the use of absorbent aids is practically constant and meeting with other people starts to become problematic. Severe, when diapers or condoms (an external container connected to a bag) are a constant companion, social activities and work suffer heavy restrictions, and it necessary to enlist the help of other people.

What are the causes of incontinence?

The bladder is the sac-shaped organ designated to contain urine. The urethra is the tube connected to the bladder that leads outside of the body. This channel is kept closed by a sphincter mechanism. The functioning of the bladder and urethra when one wants or does not want to urinate is illustrated in the last two pages of this booklet.

Incontinence may be caused by a malfunctioning of the bladder, urethra, or both.
The bladder may contract and push out the urine when it should be at rest, or may not expand from the urine that it stores.

The urethra, however, may not have close sufficiently to ensure the sealing of the urine when the pressure in the bladder increases, for example when standing up, coughing, walking, exerting effort, squatting or, in more severe cases, even at rest, or the closing of the urethra may be too strong due to an obstruction, so much so that it fails when emptying of the bladder, with consequent overdistension and loss of urine.

But why might the bladder and/or urethra malfunction in this way?
Here is a list of some possible causes:
• Surgical operations

Operations on the prostate, especially total prostatic removal (radical prostatectomy) in the case of a tumor, may make the sphincter unable to perform its sealing function.
Certain operations performed on the urethra or bladder neck can compromise the sealing mechanisms as well.

  • Overactive bladder syndrome

There are some situations in which the filling of the bladder does not take place in a gradual manner, but is interrupted by capricious contractions with muscular spasms of the bladder (overactive bladder). Sometimes this situation is correlated with difficulty urinating due to an obstruction (for example from hypertrophy of the prostate), and sometimes there is an underlying neurological problem, but there is often a true identifiable cause of the dysfunction. Overactive bladder syndrome is characterized by an urgent need to urinate, often with an increase in the frequency of the urge, and inconsistently with incontinence.

  • Chronic urinary retention

A chronic obstruction in emptying (the most frequent non-neurological cause is benign prostatic obstructive hypertrophy), which results in abundant residual urine in the bladder (almost correspondent to its capacity) after completion of urination, which may cause distension of the reservoir and urinary leakage due to an inability of the bladder to fill up further.

  • Aging

The bladder and urethra age and may function less effectively. The presence of other health problems reducing ability of movement, manual dexterity, attention, and memory may contribute additional damage to the bladder-sphincter system.

  • Urinary infections can irritate the bladder and cause involuntary contractions.
  • Incidental trauma to the urethra involving the pelvis and causing a rupture of the sphincteral urethra, even if properly treated, may also compromise the mechanisms of continence.
  • Acquired and congenital neurological causes

Many neurological diseases, of both the central and peripheral nervous system, may result in an alteration of the regulatory mechanisms of vesicoureteral function.

  • Congenital conditions

Certain severe congenital malformations (epispadias, exstrophy) can cause incontinence due to alterations of the structure, and consequently the function, of the bladder and urethra.

How does incontinence manifest?

Urinary incontinence in men may manifest with a diversity of characteristics. The following situations or types of incontinence may occur:

  • loss of urine associated with exertion of effort, or stress, such as coughing, sneezing, and lifting objects from the ground, but also when changing posture: for example, standing up from a sitting or lying position

or even walking or squatting. In this case we refer to stress urinary incontinence;

  • loss of urine associated with a very strong, compelling, and uncontrollable (urgent) urinary urge, not allowing one to make it to the bathroom. In this case we are referring to urge incontinence;
  • loss of urine in both of the above circumstances, defined as mixed urinary incontinence;
  • continuous loss of urine, drop by drop, defined as continuous urinary incontinence;
  • loss of urine in drops that appears after having finished urinating, called post-void dribbling;
  • involuntary loss of urine during sleep, called nocturnal enuresis.

In certain cases, incontinence arises as a red flag for situations where the bladder does not empty completely during voluntary urination: the residual urine that accumulates in the bladder can lead to losses, caused by an overfilled bladder. In this case it is referred to as overflow incontinence, which is particularly important to differentiate from other forms of incontinence. In fact, in this case therapy consists of helping the person to more completely empty the bladder and does not involve the direct treatment of the incontinence. Moreover, this situation, if left untreated, has the potential to cause renal complications.

Urinary incontinence in men, besides being of different types, may be of varying severity. It is possible to have urinary leakage with characteristics ranging from the loss of only a few drops, to a more significant stream or quantity, to the entire loss of the contents of the bladder.

The frequency of loss can also be highly variable: some people are affected by a rare incontinence, of a frequency of less than once a week or month, while others lose urine many times a day or even continuously.