What is Mixed Incontinence?
Urinary incontinence is a condition where a person is not able to control his/her urination resulting in leakage of urine. There are millions of Americans who suffer from this problem. There are different types of incontinence such as: Stress incontinence is where there is leakage of urine caused by sneezing, coughing and other such movements that exert pressure on the bladder. In urge incontinence, patient has a sudden and strong need to urinate and experiences leakage of urine after that feeling.
Many individuals can have both stress incontinence as well as urge incontinence; and this combination of having more than one type of incontinence is known as mixed incontinence. According to research, older women more often suffer from mixed incontinence.
Causes of Mixed Incontinence
The causes of mixed incontinence include causes of both stress incontinence as well as urge incontinence.
- Urge incontinence occurs as a result of involuntary muscle action of the bladder. The common causes behind this are bladder nerve damage, damage to the muscles or nervous system. This damage can be due to surgeries or certain diseases, such as Parkinson's disease, multiple sclerosis, stroke, diabetes or any trauma or injury.
- Stress incontinence commonly is experienced after pregnancy, childbirth, coughing, sneezing, and other such factors, which result in weakened muscles which support and control the bladder leading to increase in pressure on the bladder after any activity and causing urine to leak.
- There are some medical conditions, which worsen the symptoms of urinary incontinence, such as uncontrolled diabetes, thyroid problems and taking diuretics.
Signs & Symptoms of Mixed Incontinence
In Mixed Incontinence, Patient experiences symptoms of both stress, as well as urge incontinence and they include:
- Patient with mixed incontinence has urine leakage when he/she sneezes, laughs, coughs, lifts heavy objects or does high impact exercises.
- There is urine leakage after the patient experiences an abrupt urge to urinate. This urge can occur when the patient is sleeping, after drinking some water, after touching water or after hearing the water run.
Investigations to Diagnose Mixed Incontinence
If the incontinence is severe and is affecting the patient's daily activities of life, then it is important to seek consultation with the doctor, who will diagnose the type of incontinence, its cause and form a treatment plan accordingly. The doctor may advise the patient to keep a diary to record the number of times the patient urinates. The patient is also advised to note down his/her fluid intake. The doctor will conduct a physical examination and ask the patient's medical history and questions such as:
- How many times in the day and night do you use the bathroom?
- Is there any leakage of urine before you have had reached the bathroom?
- Is there any problem starting or stopping the urine flow?
- Is there constant urine leakage or only during specific activities?
- Has there been any injury or trauma to the back?
- Do you experience frequent urinary tract infections?
- Do you experience burning or pain upon urination?
- Do you suffer from any medical conditions, which can interfere with function of the bladder such as multiple sclerosis or Parkinson's?
After physical examination, the doctor will perform certain tests and depending on the result, will refer you to a neurologist or an urologist. These tests include:
- Catheterization is done where after the patient has emptied the bladder, the doctor will insert a catheter to see if there is urine left. If more urine comes out, then it means that the patient is not able to completely empty the bladder.
- Bladder stress test where the doctor will check whether the patient is leaking urine upon coughing. If he/she does, then this indicates stress incontinence.
- Urinalysis and urine culture is done to look for urine infection, other abnormalities or presence of kidney stones.
- Ultrasound is an imaging test which is done to visualize the inner organs like kidneys, bladder, and ureters.
- Urodynamic testing is done to further confirm the diagnosis and it can give more information regarding bladder pressure and contractions, nerve signals, urine flow and urine leakage.
- Cystoscopy is another test which is performed using a narrow tube known as cytoscope. This helps in examining the internal side of the bladder and urethra.
Treatment for Mixed Incontinence
A combination of different approaches is needed for treating mixed incontinence. Treatment comprises of treating both urge and stress incontinence. Everyone requires a different type of treatment and no single treatment works for everyone. Treatment is tailored depending on the severity of the incontinence and the patient's lifestyle and preferences.
- Behavior modification is recommended if the patient is using bathroom at regular intervals.
- Kegel exercises should be done on a daily basis. These help in strengthening the pelvic floor muscles, which help in controlling the urine leakage. The muscles of the pelvic floor need to be contracted and held for 5 seconds and then relaxed for 5 seconds. This should be repeated multiple times daily.
- Biofeedback helps in regaining the control over bladder muscles, which are involved in urination.
- Medications, such as anticholinergics, are prescribed to control the urge incontinence part of the mixed incontinence. These medications help in relaxing the bladder muscles to prevent spasms. Sometimes, the doctor will change certain medications, such as anti-hypertensives, which can increase the urine output and cause incontinence.
- Vaginal Devices are helpful in stress incontinence in women, where a pessary is inserted into the vagina, which helps in supporting and repositioning the urethra thus decreasing leakage. If the stress incontinence is mild, then inserting a diaphragm or tampon before doing any exercise or specific physical activities help in reducing the leakage.
- Neuromodulation helps in urge incontinence, which does not get better with behavioral modification or medications. This is a therapy where a device is used to stimulate the bladder nerves.
- If this device is beneficial, then it can be implanted surgically.
- Compression clamps and rings can be used for men. These are fitted over the penis to shut off the urethra. However, they need to be removed before using the bathroom.
- Botox injections or injections which introduce bulking agents into the tissues surrounding the bladder neck are given to minimize leaking due to stress. This procedure is done using local anesthesia and takes about 30 minutes. Injections need to be repeated over the time.
- Surgery is needed if there is prolapse of the bladder because of childbirth or other causes. The two commonly done surgical procedures which help in returning the bladder back to its normal position are: Retropubic Suspension and Sling Procedures. These are done if required.
- There is no definitive treatment which can cure mixed incontinence; however, a combination of different treatments brings a great amount of relief in many patients.