Causes, Symptoms, and Treatment Options

Urinary incontinence (UI), or the loss of bladder control, is a condition that affects roughly 25 million people living in the United States. Though females are twice as likely to experience UI than males—particularly females over 50—certain types are known to affect males more than females.

Managing UI can be frustrating because there is no “one-size-fits-all” solution for every type of incontinence. This includes the five major types: stress incontinence, urge incontinence, mixed incontinence, overflow incontinence, and functional continence.

The first step in finding the right treatment is to obtain a correct diagnosis, either from a urologist trained in disorders of the urinary tract or a specially trained obstetrician-gynecologist known as a urogynecologist.

This article describes the five types of urinary incontinence, including how each is diagnosed and treated.

Stress Incontinence

Stress incontinence, also known as stress urinary incontinence (SUI), is the most common type of incontinence, particularly among younger women. It is not caused by emotional stress but rather by physical activities that place stress or pressure on the bladder, causing accidental leakage.

These include physical actions like:

• Sneezing
• Laughing
• Coughing
• Lifting heavy objects
• Changing positions
• Exercising
• Having sex

SUI happens when the muscles at the bladder neck (called the urethral sphincters) and the muscles of the pelvic floor are weak. This allows urine to seep into the urethra (the tube through which urine exits the body), typically in smaller amounts.

The diagnosis of SUI involves a review of your medical history and a physical exam. As part of the evaluation, you may undergo a urinary stress test in which you are asked to cough or “bear down” to see if there is any bladder leakage.

Other specialized tests, like post-residual urine volume (PRUV), may be ordered, but these are less commonly used for uncomplicated cases.

SUI is usually treated conservatively with pelvic floor exercises, fluid management, weight loss, vaginal pessaries, and other devices. Severe cases may benefit from injectable urethra bulking agents or surgery. These treatments are described in detail later in this article.

Urge Incontinence

Urge incontinence, also known as urge urinary incontinence (UUI), is the sudden, uncontrollable urge to pee that causes bladder leakage before you can get to the bathroom. UUI is more common in older females and the most common form of urinary incontinence in males.

Urinary urgency is often accompanied by urinary frequency, in which some people may need to rush to the bathroom more than eight times a day. Unlike SUI, UUI typically involves larger volumes of urine.

UUI is caused by the hyperactivity of the muscle that contracts the bladder walls, called the detrusor muscle. It may be due to a prior bladder injury, irritants, infections, or conditions that damage the nerves that regulate the detrusor muscle.

Common risk factors for UUI include:

UUI may require extensive testing, including:

• Blood tests
• Urinalysis
• Imaging studies
• Cystoscopy (views the bladder using an instrument inserted through the urethra)
• Electromyography (tests electrical signals between nerves and muscles)
• Urodynamic studies (which measure the volume, speed, and retention of urine during and after urination).

In addition to pelvic floor exercises and fluid management, the treatment may involve medications to ease bladder spasms and bladder training to teach you how to “hold it in.” Surgery is a less common option reserved for severe cases.

Mixed Incontinence

Mixed incontinence, also known as mixed urinary incontinence (MUI), is when you have both stress incontinence and urge incontinence. MUI affects roughly 30% of females and 50% of males with urinary incontinence.

MUI is harder to diagnose and treat because the underlying cause is multifactorial. It is also more disruptive, with 1 in 3 affected women reporting signs of chronic depression.

MUI is usually suspected when a person answers “yes” to the following two questions:

• Do you lose urine during sudden physical exertion, lifting, coughing, or sneezing?
• Do you experience such a strong, sudden urge to pee that you leak before reaching the toilet?

A urodynamic study is central to the diagnosis of MUI. This is a battery of tests that includes a urinary stress test, uroflowmetry (which measures how fast you urinate), cytometry (which measures the pressure inside the bladder), and post-void residual volume (which measures how much urine is left in the bladder after peeing).

While useful in differentiating MUI from SUI or UUI, a urodynamic study cannot diagnose MUI on its own. Additional tests and clinical expertise are required to render an accurate diagnosis.

The treatment plan varies based on the severity of symptoms. With that said, the antidepressant Cymbalta (duloxetine) has proven effective in people with MUI, easing both the frequency of bladder leakage and the severity of depression symptoms.

Overflow Incontinence

Overflow incontinence, also known as overflow urinary incontinence (OUI), is leakage that occurs because the bladder is overfull. People with OUI experience leakage without the urge to urinate and tend to be unable to fully empty their bladder.

Unlike other forms of incontinence, OUI is more common in males than in females.

OUI occurs when the bladder is overfilled due to an obstruction, a weak detrusor muscle, or a neurologic condition that blocks signals to the brain telling it that the bladder is full.

Common causes of OUI include:

The diagnosis of OUI is similar to other types of incontinence. However, a type of X-ray called a voiding cystourethrogram (VCUG) is especially important as it can visualize the bladder as it fills and empties. This can help confirm the diagnosis of OUI.

The treatment of MUI involves bladder training, pelvic floor exercises, and catheterization to help empty the bladder. Medications can help shrink an enlarged prostate, while surgery can help treat blockages caused by tumors, fibroids, or vaginal prolapse.

Functional Incontinence

Functional incontinence is the loss of bladder control arising from the inability to get to the toilet in time due to a physical or cognitive problem. It may be because a person has a physical disability or does not realize that they need to pee.

Functional incontinence is largely associated with older people who may be frail and experiencing cognitive decline, but it can also affect younger people for different reasons.

Causes of functional incontinence include:

Functional incontinence can be diagnosed based on physical or mental impediments that prevent you from getting to the toilet on time.

Even so, additional tests may be ordered to check for other forms of incontinence, such as SUI, UUI, or OUI. This is especially important for people who are bed-bound, are non-communicative, or have dementia or intellectual disability.

The treatment of functional incontinence varies by the cause. Some people may benefit from assistive mobility devices, occupational therapy, assisted living, or simply moving closer to the bathroom.

Treatment for Different Types of Urinary Incontinence

Many treatments are available for urinary incontinence. Some are useful for all forms of incontinence, while others are specific to certain types.

Lifestyle and Behavioral Therapies

Studies suggest that up to 70% of incontinence cases can be relieved with changes in certain behaviors and lifestyle habits. Even if complete relief is not achieved, these changes can improve your overall response to treatment compared to doing nothing at all.

These include:

• Bladder training: This method, useful for people with UUI and MUI, involves going to the bathroom at regularly spaced times rather than rushing to the bathroom whenever the urge strikes. The goal is to gradually lengthen the time between urinations to three to four hours.
• Pelvic floor exercises: These primarily involve Kegel exercises in which you consciously tighten and relax the muscles between the anus and genital to strengthen them. Most experts recommend doing four sets of 10 repetitions daily to achieve better urinary control.
• Fluid management: Managing your fluid intake is an essential strategy for all forms of incontinence. This may involve restricting fluids before bedtime or outings or taking smaller sips of water throughout the day rather than drinking large quantities all at once.
• Dietary interventions: Certain foods can irritate the bladder and trigger UUI and MUI. Avoid fizzy drinks, spicy or acidic foods, artificial sweeteners, and drinks made with high-fructose corn syrup. Caffeine should be avoided as it is a diuretic and can complicate all forms of incontinence.

Pads and Vaginal Inserts

A number of products are available over-the-counter (OTC) and through medical retailers to help control bladder leakage. These don’t actively treat incontinence but can help you avoid the embarrassment of an accident while at work, at school, or in social situations.

These include:

• Incontinence underwear: If you have relatively light leakage, an incontinence pad placed in your underwear may provide ample relief. Washable, leak-proof underwear like Knix are also useful. For heavier leakage, disposable adult diapers like Depends are highly effective.
• Vaginal pessaries: These are silicone devices inserted into the vagina to support the bladder and urethra. They come in different sizes and shapes depending on the severity of vaginal prolapse.
• Vaginal inserts: These are disposable devices that are inserted into the vagina like a tampon. They put pressure on the urethra to prevent bladder leakage. After use, they are thrown away.
• Urethral inserts: A soft plastic balloon is inserted into the urethra to block urine from coming out during exercise and other physical activities. It is ideal for people of any sex with SUI.
• Cunningham clamp: This is a plastic device that clamps over the shaft of the penis to keep the urethra shut. Ideal for people with a penis who have OUI. It is removed whenever you need to pee.
• Condom catheter: This is a type of urinary catheter worn over the penis like a condom. It has a tube connected to a bag strapped to your leg to catch any overflow.

Electrical Stimulation

Transcutaneous electrical stimulation (TENS) is a non-surgical treatment commonly used to treat incontinence. It involves placing electrodes on the muscles that control urination. The gentle electrical pulses are thought to strengthen the muscles.

The electrodes can be placed on the vagina, penis, rectum, or sacrum (the triangular bone at the base of the spine). Studies have shown that stimulating the tibial nerve at the outer ankle and foot may also help.

Despite showing promise in studies, TENS’s effectiveness varies significantly, and its benefits remain unclear. Even so, TENS is considered safe and noninvasive and can be self-administered in the comfort of your home.

Medications and Injections

Many different medications can be used to treat urinary incontinence. These are generally prescribed when bladder leakage cannot be controlled with lifestyle changes or your quality of life and well-being are being compromised.

Some of the drugs are taken orally (by mouth), while others are delivered by injection or transdermally (through the skin).

Currently, no medications are approved for the treatment of SUI in the United States. However, people with MUI or pure UUI often respond well to drugs like:

• Anticholinergics: These are oral drugs that block a chemical called acetylcholine that signals bladder contractions. They include Ditropan XL (oxybutynin), Toviaz (fesoterodine), and Vesicare (solifenacin). An oxybutynin patch is also available OTC for women only.
• Beta-3 adrenergic receptor agonists: Oral drugs like Myrbetriq (mirabegron) and Gemteza (vibegron) are a newer class of medications for the treatment of overactive bladder. They work by relaxing the detrusor muscle and improving bladder clearance. These medications have fewer side effects than anticholinergics.
• Tofranil (imipramine): This tricyclic antidepressant can relax smooth muscles, including those of the bladder wall. It is taken by mouth before bedtime (as it can cause drowsiness); doing so also helps reduce the risk of bedwetting.
• Cymbalta (duloxetine): This antidepressant and nerve pain medication has proven effective in easing symptoms of UUI and MUI. It also helps ease symptoms of anxiety and depression common in people with severe incontinence.
• Topical estrogen replacement therapy (ERT): The loss of estrogen during menopause can weaken the tissue around the urethra and pelvic floors. Using intravaginal topical ERT can help improve urinary control, particularly when combined with pelvic floor exercises.
• Botox (onabotulinum toxin type A): This is an option for people who fail to respond to other medications. It is delivered by injection into the bladder during cystoscopy. The drug helps block acetylcholine and can reduce bladder spasms.

There is no specific drug treatment for OUI, but people with an enlarged prostate may benefit from alpha-blockers that relax the bladder neck and improve urinary flow. These include oral medications like Flomax (tamsulosin), Uroxatral (alfuzosin), Rapaflo (silodosin), and Cardura (doxazosin).

Another treatment sometimes is a product called a urethral bulking agent. Used mainly for SUI, this involves the injection of a substance around the opening of the urethra to narrow it. The narrowing helps prevent urine from escaping.

Different bulking agents a urologist can use include:

• Bovine collagen (obtained from cow hides)
• Calcium hydroxyapatite (a common dermal filler)
• Carbon bead particles (made from petroleum)
• Polydimethylsiloxane (a silicone polymer)a
• Bulkamid (soft water-based gel)

Of the four, polydimethylsiloxane is often preferred because it is permanent, while the others require additional injections after the first year.

Surgery

Surgery is generally the last resort for treating urinary incontinence. There are different types of surgery for different conditions. Some procedures may be combined.

Many procedures can be performed laparoscopically, using small “keyhole” incisions, narrow surgical tools, and a lighted, fiber-optic scope. Other procedures are transurethral, meaning the surgeon accesses the bladder through the urethra. Others still are open surgeries involving a large incision.

Surgeries used to treat SUI include:

• Urethral sling: The surgeon creates a “sling” with either mesh fabric or tissue harvested from your body to lift and support the urethra and urethral sphincters.
• Colposuspension: This involves placing stitches on either side of the urethra, which are tied to nearby ligaments to hoist the vagina and urethra.
• Artificial urethral sphincter: This implanted device fits around the bladder neck like a cuff. It is attached to a hand pump (implanted in the scrotum or lower abdomen), which can inflate or deflate the cuff.

Surgeries used to treat UUI include:

• Sacral neuromodulation (SNM): This implanted device delivers mild electrical impulses to the nerves of the sacrum. Sold under the brand names Interstim and Axonics, it works like a pacemaker to better regulate bladder contractions. It is approved by the Food and Drug Administration (FDA).
• Augmentation cystoplasty: This is a major surgery to enlarge the bladder. It involves taking a piece of tissue from your intestine and grafting it into the bladder wall.

No specific surgeries are used to treat OUI, but different types can be used to clear blockages or reduce external pressure on the bladder. Examples include:

• Transurethral resection of the prostate (TURP): This procedure reduces the size of the prostate. The prostate is accessed through the urethra and reduced with an electrical loop.
• Transurethral cystolitholapaxy: This surgery is used to treat bladder stones. After accessing the bladder through the urethra, the stone is broken with lasers, ultrasound, or a crushing device.
• Myomectomy: This surgery removes uterine fibroids. It can be done as an open or laparoscopic procedure or performed transvaginally (through the vagina) for milder cases.

Summary

The five major types of urinary incontinence are stress incontinence, urge incontinence, mixed incontinence, overflow incontinence, and functional incontinence. Each has different causes, diagnosis methods, and treatments.

While some treatments (like pelvic floor exercises and fluid management) are useful for all types of incontinence, others, like medications and surgery, are specific to each type. It is important to seek a diagnosis from a urologist or urogynecologist. A treatment for one type of incontinence may not work for another.