Bladder incontinence: What to know

Bladder leaks are common — but they are not something you just have to live with. In a recent BCH lecture Madeline Koerner, MD, MBA, a board-certified urologist withColorado Urology, shared expert insights on bladder incontinence, including common causes, treatment options and why patients should not feel embarrassed to seek help.

“Just because it’s very common doesn’t mean it has to be normal,” Dr. Koerner said.

Urinary incontinence affects millions of Americans and can significantly impact daily life, exercise, travel, work and mental health. Fortunately, many cases can be improved — and sometimes even cured — through lifestyle changes, physical therapy, medications or minimally invasive procedures.

What is urinary incontinence?

Urinary incontinence is the involuntary loss of urine, or leaking urine when someone does not want to.

There are four main types of incontinence:

• Stress incontinence, caused by pressure such as coughing, sneezing, laughing or exercise

• Urgency incontinence, involving sudden intense urges to urinate

• Overflow incontinence, caused by the bladder not emptying properly

• Mixed incontinence, which combines stress and urgency symptoms

The two most common forms are stress and urgency incontinence.

“Stress tends to be leaking when we cough, sneeze, laugh and jump,” Dr. Koerner said. “Urgency is sudden need — I better run — and I can’t get there in time.”

Bladder leaks are more common than people realize

Urinary incontinence is extremely common, especially as people age. About one in three people over age 60 experience incontinence, and roughly half of women experience stress incontinence at some point in their lives. Women are affected more often than men, though bladder symptoms can affect anyone at any age. Because many people feel uncomfortable discussing bladder leaks, incontinence is often underreported.

“You’re not alone,” Dr. Koerner said.

She emphasized that while bladder leaks are common, they should not simply be accepted as an unavoidable part of aging.

“It’s almost never caused by something that the individual did,” Dr. Koerner explained.

How the bladder works

The bladder has two important jobs: storing urine until it is socially appropriate to urinate and emptying completely when it is time to go. This process depends on coordination between the bladder muscle and the urinary sphincter. During storage, the bladder relaxes while the sphincter stays closed to prevent leakage. During urination, the bladder contracts and the sphincter relaxes to allow urine to pass. Problems with either system can contribute to incontinence symptoms.

“The bladder has to store urine until it’s socially appropriate to pee,” Dr. Koerner explained.

When patients visit a urologist, evaluation often includes a detailed symptom history, urine testing and sometimes additional studies such as bladder scans, voiding diaries or cystoscopy. Dr. Koerner noted that other medical conditions — including constipation, sleep apnea and neurologic disorders — can also contribute to bladder symptoms.

Understanding stress incontinence

Stress urinary incontinence happens when increased abdominal pressure overwhelms the body’s ability to keep the urethra closed. Common triggers include coughing, sneezing, laughing, running, lifting or standing up from a chair. Pregnancy, childbirth, aging and weakened pelvic floor muscles may all contribute.

“Anytime the pressure in the abdomen increases and overwhelms the ability of the sphincter to close,” leakage can occur, Dr. Koerner explained.

Treatment usually begins conservatively. Many patients improve with lifestyle adjustments such as fluid management or reducing caffeine intake before exercise. Pelvic floor physical therapy can also be highly effective. Physical therapists may help patients strengthen pelvic floor muscles, improve breathing patterns and address hip, back or core muscle dysfunction that contributes to leakage.

Learn more about pelvic floor care

Some women also benefit from vaginal support devices called pessaries or over-the-counter inserts that help support the bladder and urethra.

Procedures for stress incontinence

For patients seeking additional treatment, minimally invasive procedures may help significantly improve symptoms. One option is urethral bulking, in which a gel is injected into the wall of the urethra to help it seal more effectively and reduce leakage. Dr. Koerner compared the procedure to replacing weatherstripping on a door.

“The function of the door is the same,” she explained. “It just seals more tightly.”

The procedure takes only a few minutes, requires little recovery time and may provide relief for years.

“For five minutes of fussing, about seven years of relief seems like a pretty good option,” Dr. Koerner said.

The mid-urethral sling procedure is another common option, which places a narrow strip of mesh under the urethra for additional support. The outpatient surgery typically takes less than 30 minutes and has high long-term success rates.

Overactive bladder and urgency incontinence

Urgency incontinence is often part of a broader condition called overactive bladder. Symptoms may include frequent urination, sudden urges to urinate, leakage before reaching the bathroom and waking multiple times overnight to urinate. Certain bladder irritants can worsen symptoms, particularly caffeine and alcohol. Constipation, diabetes, obesity, enlarged prostate and poor sleep may also contribute.

Dr. Koerner noted that many patients experience “key-in-the-door syndrome,” where urgency suddenly worsens when arriving home or approaching the bathroom.

“The bladder hasn’t fundamentally changed in the 10 seconds since I parked the car,” she said. “But the sensation has dramatically changed.”

Behavioral techniques and bladder training may help patients better control urgency symptoms.

Menopause and bladder symptoms

Genitourinary syndrome of menopause is a condition related to declining estrogen levels during menopause. Symptoms can include urgency, frequent urination, recurrent urinary tract infections and discomfort with urination. Low-dose vaginal estrogen therapy may help restore tissue health and improve symptoms safely for many women.

“It's a really exciting and totally treatable area,” Dr. Koerner shared.

Medications and advanced therapies

Several medications can help relax the bladder and reduce urgency symptoms. Older medications called antimuscarinics may cause side effects such as dry mouth, constipation and blurry vision. Newer medications known as beta-3 agonists tend to have fewer side effects and work more specifically on bladder tissue.

For patients whose symptoms do not improve with medications or lifestyle changes, additional therapies may help.

Bladder Botox injections can reduce involuntary bladder contractions and often provide relief for several months at a time. Other options include tibial nerve stimulation, which uses gentle electrical stimulation near the ankle to improve bladder signaling, and sacral neuromodulation — which uses an implanted device to regulate nerves that control bladder function.

Dr. Koerner joked that her husband says she “puts in bladder pacemakers for fun.”

When to seek help

Patients should consider discussing bladder symptoms with a healthcare provider if incontinence interferes with daily activities, exercise, travel, sleep or emotional wellbeing.

Dr. Koerner encouraged patients not to let embarrassment prevent them from seeking care.

“If people are willing to get over the little bit of awkward about talking about peeing,” she said, “we can often make it better.”

For more information about bladder incontinence and available treatment options, watch the full BCH lecture recording below.