Urinary Incontinence; Urgency, Retention and Voiding Problems

This page focuses on two of the more common disorders related to the urinary tract health of women:

  1. Urinary Incontinence; accidental leakage
  2. Urinary Retention and other Voiding Problems; urgency or difficulty emptying

What is Urinary Incontinence (UI)?
UI is the loss of bladder control, or being unable to control urination (accidental leakage).  It can affect men, women, and children, but women are twice as likely as men to experience UI.  This is due to the structure of the female urinary tract as well as the effects of pregnancy, childbirth, and menopause. UI is also more common among older women, although it is not a normal part of the aging process.

Types of Urinary Incontinence

  • Stress incontinence is usually related to a structural issue, such as when the bladder is out of its normal position. Urine leaks can occur during physical movement such as laughing, coughing, exercising, or lifting, or when no movement is occurring.
  • Urge incontinence or overactive bladder is usually related to the muscles around the bladder. It occurs when urine leaks at unexpected times, including during sleep. Urge incontinence is most common in older people and may or may not be a sign of a Urinary Tract Infection. It is also associated with certain neurological conditions, such as multiple sclerosis.
  • Overflow incontinence happens when an overfilled bladder causes uncontrollable leaking of urine. A person with overflow incontinence may feel unable to completely empty the bladder. Causes include tumors, kidney stones, diabetes, and medications. Overflow incontinence is most common in men.
  • Functional incontinence is the inability to get to the bathroom in time because of a physical or other type of disability.
  • Mixed incontinence occurs when a person experiences more than one type of incontinence. Generally, mixed incontinence refers to a combination of stress and urge incontinence.
  • Transient incontinence occurs when urine leakage is caused by a temporary situation such as an infection or new medication. Once the cause is removed, the incontinence goes away.

What are the symptoms and signs of Urinary Incontinence?

  • Leaking urine because of sudden pressure on the lower stomach from physical activity such as laughing, coughing, running, or lifting
  • Sudden, strong, and frequent urges to urinate
  • Unexpected and uncontrollable leaking of urine

What causes Urinary Incontinence in women?
UI is caused by problems with the muscles and nerves that hold or release urine. These muscles include bladder muscles, which contract to force urine into the urethra, and sphincter muscles that surround the urethra, which relax to allow urine to pass from the body. Incontinence occurs if bladder muscles suddenly contract or sphincter muscles are not strong enough to hold back urine.

These muscles also help to hold the urinary tract in place, so if the muscles are weakened, they may not be able to keep the bladder or other structures in the right position in the body. These types of structural problems, such as when the bladder is out of position, can also cause UI.

UTIs, vaginal infections or irritation, and medications can temporarily cause or aggravate UI. Constipation and being overweight or obese put pressure on the bladder and its controlling muscles and can also cause or aggravate UI. Other features and conditions that can contribute to UI in women include:

  • Weakened and stretched pelvic muscles after childbirth, with aging, or from genetic causes
  • Thinning and drying of the skin in the vagina or urethra after menopause
  • Weak bladder muscles or muscle spasms
  • Damage to nerves that control the bladder because of Parkinson's disease, multiple sclerosis, or physical injury
  • Age-related or behavioral changes
  • Diabetes
  • Obesity
  • Any injury, disability, or disease that makes it difficult to get to the bathroom promptly

How is Urinary Incontinence Diagnosed?
Healthcare providers begin by taking a medical history and asking about symptoms. They often ask patients to keep a bladder diary to track patterns of voiding (urinating) and leaking episodes. The diary can help a health care provider understand the cause of the problem and how best to treat it.

Information collected in a bladder diary typically includes times and amounts a patient urinates, straining or discomfort, fluid intake, and when and about how much urine leaks. Health care providers may give patients a special pan that fits over the toilet rim to measure how much they urinate. If the diary, symptoms, and medical history are not enough to diagnose UI, health care providers may recommend other tests. In addition to urodynamics and cystoscopy tests and an ultrasound of the urinary tract, the tests may include:

  • Bladder stress test -  This test requires a patient to cough vigorously while the health care provider watches for leakage from the urethra opening.
  • Urinalysis and urine culture - A laboratory test of urine is conducted to detect infection, urinary stones, and other possible UI causes.

What are the treatments for Urinary Incontinence?
Health care providers select treatments for UI based on the woman's age, the specific type of bladder control problem, and lifestyle.

Bladder Control Training - This method may involve the following strategies:

  • "Timed voiding," or using the bathroom at planned times; health care providers may use a bladder diary to help set a schedule
  • Kegel (pronounced KEY-guhl) exercises to strengthen the pelvic muscles that help hold in urine
  • Lifestyle changes, including losing weight, quitting smoking, avoiding alcohol and caffeine, avoiding lifting heavy objects, and preventing constipation

Medications - Medications can be used to block nerve signals that cause urinary frequency and urgency.  They can help prevent bladder spasms by relaxing bladder muscles. Medications that prevent swelling and high blood pressure may increase urine output and aggravate UI. Switching to an alternative medication may solve the UI problem.

Biofeedback - Tracking the contractions of the bladder and urethra muscles with an electronic device or diary may help patients gain control over these muscles.

Neuromodulation - Implanting a device to stimulate the nerves leading from the spine to the bladder can be effective when urge incontinence does not respond to bladder training or medication.

Absorbent Underclothing - Absorbent products worn under clothes may help patients feel more assured and confident.

Vaginal Devices, Injections, and Surgery for Stress Incontinence - Options include:

  • A stiff ring inserted into the vagina to reposition the urethra
  • Collagen injected into the bladder neck and urethra tissues to thicken them
  • Surgery to support the bladder in its normal position, which may be done with a sling that is attached to the pubic bone

Catheterization - Inserting a catheter tube through the urethra into the bladder can assist people whose bladders do not empty completely because of overflow incontinence, poor muscle tone, surgery, or spinal cord injury.

What is Urinary Retention? 
Urinary retention is the inability to empty the bladder completely. Urinary retention can be acute or chronic. Acute urinary retention happens suddenly and lasts only a short time. People with acute urinary retention cannot urinate at all, even though they have a full bladder. Acute urinary retention, a potentially life-threatening medical condition, requires immediate emergency treatment. Acute urinary retention can cause great discomfort or pain.

Chronic urinary retention can be a long-lasting medical condition. People with chronic urinary retention can urinate. However, they do not completely empty all of the urine from their bladders. Often people are not even aware they have this condition until they develop another problem, such as urinary incontinence—loss of bladder control, resulting in the accidental loss of urine—or a urinary tract infection (UTI), an illness caused by harmful bacteria growing in the urinary tract.

What causes Urinary Retention? 

Obstruction of the Urethra.  Obstruction of the urethra causes urinary retention by blocking the normal urine flow out of the body. Conditions such as urethral stricture, urinary tract stones, cystocele, rectocele, constipation, and certain tumors and cancers can cause an obstruction.

  • Urethral stricture. A urethral stricture is a narrowing or closure of the urethra. Causes of urethral stricture include inflammation and scar tissue from surgery, disease, recurring UTIs, or injury.  Since men have a longer urethra than women, urethral stricture is more common in men than women. Urethral stricture and acute or chronic urinary retention may occur when the muscles surrounding the urethra do not relax. This condition happens mostly in women.
  • Surgery to correct pelvic organ prolapse, such as cystocele and rectocele, and urinary incontinence can also cause urethral stricture. The urethral stricture often gets better a few weeks after surgery.
  • Urinary tract stones. Urinary tract stones develop from crystals that form in the urine and build up on the inner surfaces of the kidneys, ureters, or bladder. The stones formed or lodged in the bladder may block the opening to the urethra.
  • Cystocele. A cystocele is a bulging of the bladder into the vagina. A cystocele occurs when the muscles and supportive tissues between a woman’s bladder and vagina weaken and stretch, letting the bladder sag from its normal position and bulge into the vagina. The abnormal position of the bladder may cause it to press against and pinch the urethra.
  • Rectocele. A rectocele is a bulging of the rectum into the vagina. A rectocele occurs when the muscles and supportive tissues between a woman’s rectum and vagina weaken and stretch, letting the rectum sag from its normal position and bulge into the vagina. The abnormal position of the rectum may cause it to press against and pinch the urethra.
  • Constipation. Constipation is a condition in which a person has fewer than three bowel movements a week or has bowel movements with stools that are hard, dry, and small, making them painful or difficult to pass. A person with constipation may feel bloated or have pain in the abdomen— the area between the chest and hips. Some people with constipation often have to strain to have a bowel movement. Hard stools in the rectum may push against the bladder and urethra, causing the urethra to be pinched, especially if a rectocele is present.
  • Tumors and cancers. Tumors and cancerous tissues in the bladder or urethra can gradually expand and obstruct urine flow by pressing against and pinching the urethra or by blocking the bladder outlet. Tumors may be cancerous or noncancerous.

Nerve problems - Urinnary retention can result from problems with the nerves that control the bladder and sphincters. Many events or conditions can interfere with nerve signals between the brain and the bladder and sphincters. If the nerves are damaged, the brain may not get the signal that the bladder is full. Even when a person has a full bladder, the bladder muscles that squeeze urine out may not get the signal to push, or the sphincters may not get the signal to relax. People of all ages can have nerve problems that interfere with bladder function. Some of the most common causes of nerve problems include

  • vaginal childbirth
  • brain or spinal cord infections or injuries
  • diabetes
  • stroke
  • multiple sclerosis
  • pelvic injury or trauma
  • heavy metal poisoning
  • In addition, some children are born with defects that affect the coordination of nerve signals among the bladder, spinal cord, and brain. Spina bifida and other birth defects that affect the spinal cord can lead to urinary retention in newborns.
  • Many patients have urinary retention right after surgery. During surgery, anesthesia is often used to block pain signals in the nerves, and fluid is given intravenously to compensate for possible blood loss. The combination of anesthesia and intravenous (IV) fluid may result in a full bladder with impaired nerve function, causing urinary retention. Normal bladder nerve function usually returns once anesthesia wears off. The patient will then be able to empty the bladder completely.

Medications - Various classes of medications can cause urinary retention by interfering with nerve signals to the bladder.

Weakened bladder muscles - Aging is a common cause of weakened bladder muscles. Weakened bladder muscles may not contract strongly enough or long enough to empty the bladder completely, resulting in urinary retention.

What are the symptoms of Urinary Retention?
The symptoms of acute urinary retention may include the following and require immediate medical attention:

  • inability to urinate
  • painful, urgent need to urinate
  • pain or discomfort in the lower abdomen
  • bloating of the lower abdomen

The symptoms of chronic urinary retention may include

  • urinary frequency—urination eight or more times a day
  • trouble beginning a urine stream
  • a weak or an interrupted urine stream
  • an urgent need to urinate with little success when trying to urinate
  • feeling the need to urinate after finishing urination
  • mild and constant discomfort in the lower abdomen and urinary tract

How is Urinary Retention Diagnosed?

A physical exam - A health care provider may suspect urinary retention because of a patient’s symptoms and, therefore, perform a physical exam of the lower abdomen. The health care provider may be able to feel a distended bladder by lightly tapping on the lower belly.

Postvoid residual measurement - This test measures the amount of urine left in the bladder after urination. The remaining urine is called the postvoid residual. A specially trained technician performs an ultrasound, which uses harmless sound waves to create a picture of the bladder, to measure the postvoid residual. The technician performs the bladder ultrasound in a health care provider’s office, a radiology center, or a hospital, and a radiologist—a doctor who specializes in medical imaging—interprets the images. The patient does not need anesthesia.

A catheter—a thin, flexible tube—may be used to measure postvoid residual. The health care provider inserts the catheter through the urethra into the bladder, a procedure called catheterization, to drain and measure the amount of remaining urine. A postvoid residual of 100 mL or more indicates the bladder does not empty completely. A health care provider performs this test during an office visit. The patient often receives local anesthesia.

Medical Tests - The following medical tests may be used to help determine the cause of urinary retention:

  • Cystoscopy - a procedure that requires a tubelike instrument, called a cystoscope, to look inside the urethra and bladder. A health care provider performs cystoscopy during an office visit or in an outpatient center or a hospital. The patient will receive local anesthesia. However, in some cases, the patient may receive sedation and regional or general anesthesia. A health care provider may use cystoscopy to diagnose urethral stricture or look for a bladder stone blocking the opening of the urethra.
  • Computerized tomography (CT) scans - CT scans use a combination of x rays and computer technology to create images. For a CT scan, a health care provider may give the patient a solution to drink and an injection of a special dye, called contrast medium. CT scans require the patient to lie on a table that slides into a tunnel-shaped device where a technician takes the x rays. An x-ray technician performs the procedure in an outpatient center or a hospital, and a radiologist interprets the images. The patient does not need anesthesia. A health care provider may give infants and children a sedative to help them fall asleep for the test. CT scans can show:
    • urinary tract stones
    • UTIs
    • tumors
    • traumatic injuries
    • abnormal, fluid-containing sacs called cysts
  • Urodynamic tests - These tests include a variety of procedures that look at how well the bladder and urethra store and release urine. A health care provider may use one or more urodynamic tests to diagnose urinary retention. The health care provider will perform these tests during an office visit. For tests that use a catheter, the patient often receives local anesthesia.
  • Uroflowmetry -  Measures urine speed and volume. Special equipment automatically measures the amount of urine and the flow rate—how fast urine comes out. Uroflowmetry equipment includes a device for catching and measuring urine and a computer to record the data. The equipment creates a graph that shows changes in flow rate from second to second so the health care provider can see the highest flow rate and how many seconds it takes to get there. A weak bladder muscle or blocked urine flow will yield an abnormal test result.
  • Pressure flow study. A pressure flow study measures the bladder pressure required to urinate and the flow rate a given pressure generates. A health care provider places a catheter with a manometer into the bladder. The manometer measures bladder pressure and flow rate as the bladder empties. A pressure flow study helps diagnose bladder outlet obstruction.
  • Video urodynamics. This test uses x rays or ultrasound to create real-time images of the bladder and urethra during the filling or emptying of the bladder. For x rays, a health care provider passes a catheter through the urethra into the bladder. He or she fills the bladder with contrast medium, which is visible on the video images. Video urodynamic images can show the size and shape of the urinary tract, the flow of urine, and causes of urinary retention, such as bladder neck obstruction.
  • Electromyography - Uses special sensors to measure the electrical activity of the muscles and nerves in and around the bladder and sphincters. A specially trained technician places sensors on the skin near the urethra and rectum or on a urethral or rectal catheter. The sensors record, on a machine, muscle and nerve activity. The patterns of the nerve impulses show whether the messages sent to the bladder and sphincters coordinate correctly. A technician performs electromyography in a health care provider’s office, an outpatient center, or a hospital. The patient does not need anesthesia if the technician uses sensors placed on the skin. The patient will receive local anesthesia if the technician uses sensors placed on a urethral or rectal catheter.

How is Urinary Retention Treated? 

Bladder drainage - This involves catheterization to drain urine. Treatment of acute urinary retention begins with catheterization to relieve the immediate distress of a full bladder and prevent bladder damage. A health care provider performs catheterization during an office visit or in an outpatient center or a hospital. The patient often receives local anesthesia. The health care provider can pass a catheter through the urethra into the bladder. In cases of a blocked urethra, he or she can pass a catheter directly through the lower abdomen, just above the pubic bone, directly into the bladder. In these cases, the health care provider will use anesthesia. For chronic urinary retention, the patient may require intermittent—occasional, or not continuous—or long-term catheterization if other treatments do not work. Patients who need to continue intermittent catheterization will receive instruction regarding how to self catheterize to drain urine as necessary.

Urethral dilation - Treats urethral stricture by inserting increasingly wider tubes into the urethra to widen the stricture. An alternative dilation method involves inflating a small balloon at the end of a catheter inside the urethra. A health care provider performs a urethral dilation during an office visit or in an outpatient center or a hospital. The patient will receive local anesthesia. In some cases, the patient will receive sedation and regional anesthesia.

Urethral stents - Another treatment for urethral stricture involves inserting an artificial tube, called a stent, into the urethra to the area of the stricture. Once in place, the stent expands like a spring and pushes back the surrounding tissue, widening the urethra. Stents may be temporary or permanent. A health care provider performs stent placement during an office visit or in an outpatient center or a hospital. The patient will receive local anesthesia. In some cases, the patient will receive sedation and regional anesthesia.

Are there Surgical Treatments?

Internal urethrotomy. A urologist can repair a urethral stricture by performing an internal urethrotomy. For this procedure, the urologist inserts a special catheter into the urethra until it reaches the stricture. The urologist then uses a knife or laser to make an incision that opens the stricture. The urologist performs an internal urethrotomy in an outpatient center or a hospital. The patient will receive general anesthesia.

Cystocele or rectocele repair. Women may need surgery to lift a fallen bladder or rectum into its normal position. The most common procedure for cystocele and rectocele repair involves a urologist, who also specializes in the female reproductive system, making an incision in the wall of the vagina. Through the incision, the urologist looks for a defect or hole in the tissue that normally separates the vagina from the other pelvic organs. The urologist places stitches in the tissue to close up the defect and then closes the incision in the vaginal wall with more stitches, removing any extra tissue. These stitches tighten the layers of tissue that separate the organs, creating more support for the pelvic organs. A urologist or gynecologist––a doctor who specializes in the female reproductive system––performs the surgery to repair a cystocele or rectocele in a hospital. Women will receive anesthesia.

Tumor and cancer surgery. Removal of tumors and cancerous tissues in the bladder or urethra may reduce urethral obstruction and urinary retention.