Neurological Disorders: Incontinence

Urinary or bladder incontinence is nothing but the involuntary leaking of urine that occurs when somebody loses his/her control over the urinary bladder. In addition to being a health condition, it may also be associated with social embarrassment.

The urine produced in the kidneys reaches the urinary bladder through ureters, a pair of tubular structures. From the bladder the urine is emptied through another tube like structure called urethra. There are two muscular sphincters (gates) where the bladder joins the urethra; an outer voluntary & inner involuntary and they both regulate the emptying of bladder. In men the pelvic portion of urethra passes through prostate, a glandular structure seen only in them.

The major types are;

• Stress type
• Urge type
• Mixed incontinence (stress & urge types together)
• Overflow type

Stress type:

This occurs whenever there is increased stress or pressure in the pelvic and/or abdominal cavities forcing urine to leak out, examples – during bending, coughing, sneezing, weight lifting etc.

Urge type:

This happens when the bladder becomes over sensitive to its filling and creates an abnormal urge to void urine, however urine leaks out generally before the patient reaches the bathroom.

Overflow type:

This type occurs when urine first fills to its capacity; however for certain reason patient cannot empty the bladder immediately. Since the bladder has filled to its maximal capacity leakage is the only way to make room for additional urine filling the bladder.

Stress type:

Normal people while executing above mentioned strenuous activities do not experience incontinence. Imagine how much weight a world champion has to lift, if incontinence results then such events like weight lifting would have been excluded from such athletic meets.

Good news is our pelvic cavity is endowed with a very effective mechanism in the form of powerful muscles and connective tissues that withstand an enormous pressure and prevent any unexpected bladder leakage. If damage occurs to these structures due to any prior infections, surgeries, child birth injuries, other kinds of traumas etc they can precipitate stress type urine leak.

Urge type:

The phenomenon of urge to empty the bladder is a normal one to start with. As the bladder starts filling this urge gradually builds up and progresses in parallel to the amount of urine filled. A normal person has a lot of voluntary control on, when to initiate the urination e.g. if you are with other people you can delay the voiding.

However for patients with this type of urine leak there is an exaggerated urge to empty the bladder and many times the urge is so strong that the patient cannot inhibit this impulse. So the person has to rush to the bathroom immediately or urine leakage can precipitate wherever they are.

Urge type is generally seen in the following settings including;

• Idiopathic overactive bladder (cause is not found)
• A small & spastic bladder (due to stroke, spinal cord injuries etc)
• Bladder infections
• Bladder stones etc

Overflow type:

Normally people should be able to void their bladder before it overfills and begins leaking, so any situation or health condition where people cannot accomplish their bladder emptying on time will experience this type of urine leak.

The following types of patients usually experience this type of incontinence;

• Non ambulatory ones, due to any reason, and cannot reach the bathroom in time
• Confused/demented patients who cannot respond to their body’s demands and urges
• BPH (benign prostate hypertrophy)
• Those not able to feel their bladder filling etc.

There are some neurological conditions where the patients are not aware of the filling of their urinary bladder. The bladder filling sensation is carried to the awareness centers in the brain through nerves in the pelvis and then through ascending tracts in the spinal cord and brain. If there is discontinuity anywhere along this awareness pathway then the patient may not self-initiate emptying of urine, so eventually when urine overfills it forces open the sphincters of urethra and results in incontinence but thank God, it is a safety measure and if this doesn’t happen bladder might burst open.

In the early stages there may be occasional and very small amount of urine leakage (just drops of urine). As the condition advances however there could be more volume of urine inadvertently coming out. This can cause lot of social embarrassment too. The urine can cause irritation of the skin in the genital region resulting in itching. Infections of the skin in the peri urethral region and/or urinary tract are common. Foul smelling happens if the wet under garments are not frequently changed.

A myriad number of investigations may be required since there are so many causes for this condition. The following are the generally accomplished tests and are ordered on case to case basis;

• Urine analysis
• Ultrasound of bladder
• Urodynamic studies
• CT, MRI or X-Ray of abdomen & pelvis as required etc

The specific treatment would depend upon what caused the incontinence and some of the usual treatment approaches include;

• Antibiotics if urinary tract infection is found
• Gynaecological causes like uterine prolapse may require surgical intervention
• If neurological diseases like stroke, multiple sclerosis etc is the cause then they are treated appropriately
• Anticholinergic medications for urge incontinence and overactive bladder
• Prostate treatment if that is the cause
• Bladder exercises etc