Causes of Incontinence

Causes of Incontinence

According to the Simon Foundation for Continence, there are several contributing factors that encourage adult incontinence. Below are some, but not all, of these factors:

Chronic Cough or Asthma - In some cases, asthma or coughing all the time for many years can stretch the muscles of the pelvic floor and may make tiny tears in the muscles. These tears may cause stress urinary incontinence.

Constipation - Constipation may cause you to strain. Straining while trying to pass stool may weaken your sphincter muscles, which can in turn increases the risk of bowel incontinence.

Diabetes - Diabetes is often related to obesity, and obesity can cause incontinence due to the increased weight placed on the muscles of the pelvic floor. Studies have shown that weight loss may reduce incontinence.

  • Diabetes can affect nerve function, which can also affect the nerves in the bladder and bowel. Nerve damage may lead to several changes in bladder function:
    • The most common occurrence is “bladder over activity,” which can lead to urgency and urgeincontinence.
    • Decreased bladder sensation, leading to little to no warning before feeling the urge to urinate, which can lead to episodes of incontinence.
    • In persons with severe and/or longstanding diabetes, the bladder muscle may become weak so that you don't completely empty the bladder with each urination. Residual (or leftover) urine in the bladder may lead to urinary tract infection. In severe cases, the bladder does not contract, causing "overflow incontinence.”
  • When diabetes is not well controlled and blood sugars run very high, your body tries to get rid of the extra glucose by excreting it in the urine. This causes a large increase in the amount of urine produced.
  • Constipation, which affects nearly 60% of persons with diabetes, can make it difficult to empty your bladder.
  • Congestive heart failure (CHF) from diabetes-related coronary artery disease can cause your legs and feet to retain water, and can cause your body to create too much urine at night. This can lead to getting up many times at night to urinate, and can also lead to experiencing incontinence at night.
  • Stroke from diabetes can affect bladder sensation and your ability to hold back from urinating. Additionally, mental impairment can make it difficult for the individual to toilet themselves (and when severely advanced, even toileting with assistance becomes difficult).
  • Mobility challenges due to diabetic neuropathy, peripheral vascular disease, and amputation can prevent you from reaching a toilet, removing clothing, etc. “in time”, which leads to episodes of leakage. This is called "functional incontinence."
  • Some medications for the treatment of diabetes, or for the treatment of the complications of diabetes, can impair continence or complicate its treatment:
    • Some medications may cause fluid retention in the legs and feet and congestive heart failure (CHF), thereby leading to an increased production of urine at night, and nighttime urinary incontinence.
    • Some individuals may experience a cough from ACE inhibitors, which are frequently used in to treat high blood pressure in persons with diabetes. Such coughing can trigger stress urinary incontinence, or make it worse.
    • Calcium channel blockers (CCBs) used for hypertension can make it difficult for the bladder to contract and empty completely, potentially leading to overflow incontinence. Some CCBs can cause swelling in the feet and constipation, also worsening incontinence.

Hormonal Changes in Women - Women have the hormone "estrogen" in their body. Estrogen helps develop female characteristics, and is also responsible for your monthly period by causing the lining of your uterus to build up before being released every 28 days or so. Estrogen also helps your pelvic floor to be strong, supple and stretchy, which gives you greater control over your bladder and bowel function. Stress urinary incontinence is the most common type of incontinence experienced as a result of a loss of tissue strength from declining estrogen levels in the peri (before) and post (after) menopausal stage of life. Prior pelvic floor injury from multiple or traumatic vaginal deliveries tends to contribute to a higher incidence of stress urinary incontinence in menopause. Estrogen depletion can contribute to more urgency, frequency of urination and sometimes urge urinary incontinence.

As mentioned above, the following can all cause changes to your estrogen levels, and thus cause incontinence:

  • Menopause: During menopause your estrogen levels naturally decline, which can lead to increased incontinence. Additionally, during the time leading up to menopause, called “premenopause” or “perimenopause”, a woman’s estrogen levels begin to gradually decline.
  • Changes during your monthly menstrual cycle: Estrogen levels change throughout your monthly cycle. Estrogen is highest while ovulating. Right before, during, and right after your period is generally when your estrogen levels are at their lowest, making you more likely to experience leakage during that time in your cycle.
  • Hormone Replacement Therapy: There is conflicting evidence regarding whether or not hormone replacement therapy can affect urinary incontinence, although some women claim to notice a difference in bladder control when either starting or stopping HRT. In some cases, women feel that the HRT helps them gain more bladder control, and in other cases women feel that it causes further incontinence.
  • Hysterectomy: A hysterectomy can cause incontinence for a couple reasons: 1) Removing the womb (uterus) changes the pelvic floor and can cause the muscles to weaken and sag, which can cause incontinence; 2) Your ovaries are responsible for creating most of the estrogen in your body. Sometimes the ovaries are removed during a hysterectomy, which can lead to a significant drop in estrogen levels.

Medications - Medications affect many areas of our body - not just the area they are intended to help. This is what we call "side effects". Some ways in which medication side effects can cause or worsen incontinence include:

  • causing the body to produce additional urine, making it more difficult to control the increased amount
  • weakening the bladder’s ability to empty
  • causing swelling of the feet
  • affecting how well the sphincter (the muscle that closes the urethra and keeps urine in the bladder) closes
  • causing constipation
  • causing confusion

Neurological Conditions - Conditions affecting the nerves of the body, such as spina bifida, multiple sclerosis, diabetes, and spinal cord injury, can cause a neurogenic bladder. In some cases, incontinence may be one of the first signs or symptoms of a neurological condition. The body senses bladder fullness, and then empties the bladder, based on messages the brain receives from nerves. When there is nerve damage, or a condition blocking the messages sent or received by the nerves, the messages between the brain and the bladder may not be sent and received correctly. Conditions affecting the nerves can cause the brain not to receive the message when the bladder is full, or could block the message sent by the brain: to hold urine, or when it is appropriate to relax the sphincter muscle and empty the bladder.

Obesity - The extra weight around the abdomen adds stress and pressure to the muscles of the pelvic floor. Every breath, every cough, every giggle may tear a few threads in the muscle. With time, this adds up. For more information, read about stress urinary incontinence. Obesity can also cause diabetes. This can cause damage to the nerves that control the muscles of the bladder.

Pregnancy and Childbirth - There are several reasons why pregnancy and childbirth can cause incontinence. While a vaginal delivery can cause incontinence (straining on the pelvic floor during labor, complications due to episiotomies, and damage and tearing due to forceps or a large baby), some studies also find that simply carrying the weight of pregnancy can cause incontinence. There is also a hormonal shift during pregnancy and during and after childbirth that may contribute to incontinence.

Prostate Problems in Men - One of the major contributing causes to incontinence in men is prostate problems. According to the National Institutes of Health, “The prostate is a male gland about the size and shape of a walnut. It surrounds the urethra just below the bladder, where it adds fluid to semen before ejaculation.” There are three major prostate problems that can lead to incontinence:

  • Prostatitis: Prostatitis, or inflammation of the prostate, is the most common prostate problem in men under the age of fifty.
  • Benign Prostatic Hyperplasia (BPH): As men age, their prostate gland grows. In some cases the enlargement can become troublesome - a condition called benign prostatic hyperplasia (BPH). BPH is a common condition, affecting more than 50% of men in their sixties. As the prostate grows, it closes off the urethra (the tube leading the urine out of the body from the bladder), and the bladder needs to contract harder to get the urine out. After struggling to push urine out, the bladder can become weakened and end up holding urine in, causing overflow incontinence. BPH has many symptoms that vary from person to person, and it can be treated in many different ways. Depending on the severity of symptoms, BPH can be managed with lifestyle changes, medication, or surgery, and some of these treatments, especially surgery, can lead to incidences of incontinence. The illustration below shows an enlarged prostate.
  • Prostate Cancer Treatments: An abnormal growth of cells in the prostate gland is prostate cancer. Prostate cancer is the second most common cause of cancer-related deaths among men, but when discovered and treated early-on, prostate cancer is often very treatable. As with BPH, many of the treatment options for prostate cancer can lead to varying degrees of incontinence, because the prostate itself is very closely entwined with the sphincter (the small muscle that clamps the urethra closed), so treatment of BPH and prostate cancer can cause damage to the sphincter, which can result in stress urinary incontinence.

Smoking - Cigarette smoking causes chronic coughing. This can damage the muscles of the pelvic floor causing a loss of stability of the pelvic floor muscles. Smoking is also known to be a bladder irritant.

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