Mixed Incontinence: A little of this, a little of that. What do you do for treatment?
You are doing your research on incontinence… so many types, and it looks like you have some of “this” and some of “that” type. Which treatment should you try then? And why are symptoms changing as you age? With all the information out there, there can still be confusion about what urinary incontinence, and its various forms, actually are. By having a clear understanding, you will be better prepared to understand treatment options and improve your quality of life.
WHAT DOES URINARY INCONTINENCE ENCOMPASS?
Urinary incontinence is a common problem that leads to loss of bladder control (as opposed to fecal incontinence which is less common). People who suffer from this are unable to control urinary leaks from occurring. It not only affects people physically but also emotionally and psychologically. Urinary incontinence is an umbrella term that can actually manifest in a few different ways, but the most common are outlined below.
HOW DO I KNOW WHICH TYPE OF INCONTINENCE I HAVE?
As you read the descriptions below, one or more may resonate with your symptoms. There are validated standard questions from King’s Health Questionnaire that give good clues. Do you answer “yes” to:
“Is it very difficult to control when you have a strong urge to urinate?” If yes, you likely have urge incontinence.
“Do you lose urine with physical activities such as coughing, sneezing running?” If yes, you likely have stress incontinence.
STRESS URINARY INCONTINENCE (SUI)
Stress Urinary Incontinence (SUI) is caused by weakened pelvic floor muscles, which includes the urethral sphincter (valve to hold urine in the bladder). When external stimuli like laughing or coughing or jumping put pressure on the bladder, it involuntarily releases urine. The urinary leaks will commonly occur after sneezing, laughing, or exercising. SUI is common after giving birth or reaching menopause. Additionally, while there are many stereotypes around age and urinary incontinence, SUI affects people of all ages, even those young in their teens and 20s, due to high-impact sports and giving birth.
URGE URINARY INCONTINENCE (UUI)
Urge Urinary Incontinence (UUI), leads to an involuntary loss of urine after having an intense and sudden urge to use the bathroom even when the bladder is not full. This urgency, aka bladder spasms, is caused by nerves overstimulating the muscles surrounding the bladder to squeeze (not the pelvic floor muscles underneath the bladder closing the urethra.) This is also known as overactive bladder. If you can make it to the toilet on time, it is just urgency and increased frequency of toilet trips. If it leads to an accident, it becomes UUI. UUI can also manifest at night, called Nocturia. Waking up multiple times throughout the night can cause sleep deprivation, which can negatively impact both physical and mental health. Unlike SUI, UUI typically starts later, often for those in their 50s or above.
WHAT IS MIXED INCONTINENCE?
Commonly, women have mixed incontinence which includes symptoms of both stress and urge incontinence. Data from the National Health and Nutrition Survey shows that 50% of women have pure (only) stress incontinence. Pure urge incontinence makes up only 16% of those with incontinence. It is not incontinence if one can make it to the toilet. If one cannot make it to the toilet without an accident that is an indication of a weakened urethral sphincter which is why mixed incontinence makes up the second largest group.
However, many women have symptoms of one type of incontinence that are more severe and bothersome than the other, and symptoms may start with either type. Symptoms of mixed incontinence can include classic SUI symptoms such as leaking urine after laughing, sneezing, exercising, or heavy lifting. But often, since those external stimuli can be “managed” or “prepared for” the leaks don’t happen as often as the unprepared at-the-most-inconvenient-time symptoms of intense urgency. The urgency can even be triggered by something as simple as hearing or seeing running water. Many women report that it is urge incontinence that is more bothersome because of the perceived lack of control.
An additional note is that the term “mixed incontinence” may also be used to define both urinary and fecal incontinence. This is often due to weakened pelvic floor muscles since those muscles span from the pubic bone to the tail bone encompassing the urethra and anal sphincters. Typically, treatments for SUI can also treat fecal incontinence.
WHAT CAUSES MIXED INCONTINENCE?
The same things that contribute to SUI and UUI also cause mixed incontinence. Pregnancy and delivery can put immense strain on the pelvic floor muscles and other tissues that surround the bladder, which contributes to SUI. The hormonal changes and fluctuations from pregnancy and going through menopause later in life can increase elasticity in your pelvic floor, which also makes it easier for leaks to occur.
Drinking alcohol and other diuretics such as coffee can irritate the bladder and exacerbate leaks of UUI. UUI symptoms can be caused by nerve damage from injuries, surgeries, and diseases such as Parkinson’s, Diabetes, and multiple sclerosis.
Other factors, such as having a thyroid issue or taking different medications, can also lead to sudden urinary leaks. Mixed incontinence can also affect people in a wide age range, as it can begin with symptoms after childbirth, and become intensified over time by aging and menopause.
HOW CAN MIXED INCONTINENCE BE TREATED?
Although living with mixed incontinence can feel overwhelming, there are treatment options available. Unfortunately, this often includes multiple treatments since the underlying cause of SUI and UUI differ. Since many women will find that one type of incontinence is more severe than the other, addressing the more serious condition may be the best way to start. The recommended treatments may also depend on the severity of your incontinence. Finally, there is a treatment that combats both. First, let’s start with the other common treatments.
Bladder training can be helpful for minimizing leaks of UUI by adhering to a set bathroom schedule. The main goal of implementing a bladder training routine is to increase the time span between bathroom trips. Over time, the intense urge to run to the bathroom will lessen and leaks should gradually become less frequent. During the process of bladder training, there is still the potential for leaking as the bladder becomes more accustomed to a less frequent bathroom schedule, so it is recommended that patients have some kind of protection against leaking during this process.
Kegel exercises are essential for strengthening the pelvic floor muscles in order to regain bladder control over SUI but often can help UUI as well. Kegel exercises tone the weakened pelvic floor muscles that provide support for the bladder and other important organs such as the uterus and rectum. These exercises treat incontinence symptoms that are already present and prevent them from getting worse, and they may also make it easier to control the outlet when there is urgency.
Kegel exercises are performed by contracting and relaxing the pelvic floor muscles many times in a row, and throughout the day. Unfortunately, a quarter of women do them incorrectly because it is hard to visualize. For Kegel exercises to be effective, they need to be performed consistently and correctly. And like a personal trainer, a Kegel device can help with this.
Biofeedback helps with performing pelvic floor exercises correctly and learning how to control the bladder. It uses computerized graphs or other visuals, with a corresponding vaginal probe, to show if you are exercising the pelvic floor muscles correctly and may provide feedback on muscle strength.
If you have been doing Kegel exercises regularly but aren’t sure if you’re doing them correctly, this option might be an excellent way to ensure that your form and technique are correct. There are often less expensive forms of these “trainers”, but they are not FDA-approved for incontinence.
While there are no medications available that have been approved to treat stress incontinence, there are some available for treating urge incontinence. An anticholinergic will not cure urinary incontinence completely but can help diminish the symptoms by relaxing the bladder and preventing spasms. Your physician may also recommend changing different medications that you’re already taking for other things, such as high blood pressure, as they can increase urine output. Unfortunately, many medications interfere with other medications, become ineffective after a while, or have notable side effects.
Surgery is also an option for incontinence, but unfortunately, different surgeries are applicable for SUI or UUI, and all have many risks and should be considered a last resort. For SUI physical manipulation of the urethra via a sling (often mesh) surgery is performed. Mesh surgery was initially a popular intervention, but due to the many negative side effects, painful permanent damage, and subsequent malpractice lawsuits, its use has been largely discontinued. As with any surgery, make sure that you are aware of exactly what the process entails, what the recovery looks like, and what your potential success rate might be. Most importantly, make sure that you are comfortable with any risks or potential side effects that could occur.
ELECTRICAL STIMULATION – A REAL SOLUTION FOR MIXED INCONTINENCE
Electrical stimulation uses gentle electrical pulses to stimulate the pelvic floor muscles to contract, essentially doing Kegel exercises for you. There are numerous FDA-cleared options available for prescription and over-the-counter use. The biggest benefit to these devices is that they take the guesswork out of Kegel exercises by performing them for you through the electrical pulses they emit.
There are internal vaginal devices available as well as external devices. Internal devices involve a probe that is inserted into the vagina and is connected to a handheld controller, which may look similar to vaginal biofeedback devices.
Many women who may want a more comfortable, convenient, and discrete option may benefit from an external device placed around the perineal area instead. Some external devices are worn under clothes while doing other activities so it doesn’t take up time to use the device.
There are a few electrical stimulation devices that can emit both signals to strengthen weak pelvic floor muscles and calm overactive bladders by alternating the signals using different frequencies. This is a great option for women seeking relief from mixed incontinence as it treats both types of incontinence at once.
Incontrol Medical’s ApexM is a vaginal device that sends out both signals, and Elidah’s ELITONE device is an easy-to-use, external wearable device that sends out both signals. These are incredibly helpful ways to treat mixed incontinence and minimize the impact it can have on your life.
This post was contributed by Elidah, the makers of ELITONE®.
ABOUT ELITONE®: ELITONE® tones weakened pelvic floor muscles for the 1 in 3 women with bladder leaks. The externally-placed GelPad is discreet, comfortable, and worn under clothing for 20 minutes, making treatment EASY. She receives Kegel contractions, longer and stronger than she could herself, without the work. ELITONE® is FDA-cleared and clinically proven to reduce incontinence. The device is sold directly to consumers without a prescription on https://elitone.com, and CVS.com.