Mixed Incontinence

Millions of Americans suffer from symptoms of urinary incontinence, the inability to control urination.

There are several types of incontinence: Stress incontinence is leakage of urine caused by coughing, sneezing, or other movements that put pressure on the bladder; urge incontinence is the loss of urine after feeling a sudden need to urinate.

Many people have symptoms of both stress incontinence and urge incontinence. This combination is often referred to as mixed incontinence. Many studies show that mixed incontinence is a more common type of incontinence in older women.

Symptoms of Mixed Incontinence

Because mixed incontinence is typically a combination of stress and urge incontinence, it shares symptoms of both. You may have mixed incontinence if you experience the following symptoms:

• Urine leakage when you sneeze, cough, laugh, do jarring exercise, or lift something heavy
• Urine leakage after a sudden urge to urinate, while you sleep, after drinking a small amount of water, or touching water or hearing it run

Causes of Mixed Incontinence

Mixed incontinence also shares the causes of both stress incontinence and urge incontinence.

Stress incontinence often results when childbirth, pregnancy, sneezing, coughing, or other factors lead to weakened muscles that support and control the bladder or increase pressure on the bladder, causing urine to leak.

Urge incontinence is caused by involuntary actions of the bladder muscles. These may occur because of damage to nerves of the bladder, the nervous system, or muscles themselves. Such damage may be caused by certain surgeries or diseases such as multiple sclerosis, Parkinson's disease, diabetes, stroke, or an injury.

Other medical conditions, such as thyroid problems and uncontrolled diabetes, can worsen symptoms of incontinence, as can certain medications such as diuretics.

Diagnosis of Mixed Incontinence

If you have problems with incontinence, it's important to speak with your doctor, who can diagnose the type of incontinence you have and devise a treatment plan. Your doctor may have you keep a diary for a day or more as a record of when you urinate -- purposely or not. You should note the times you use the toilet and the amount of urine (your doctor may have you use a special measuring pan that fits in the toilet seat) and when you leak. You may also record fluid intake.

Your diary entries along with answers to your doctor's questions will help make the diagnosis. These questions may include:

• How often do you go to the bathroom?
• When you get to the bathroom, do you have trouble starting or stopping the flow of urine?
• Do you leak urine constantly or only during certain activities?
• Do you leak urine before you get to the bathroom?
• Do you experience pain or burning when you urinate?
• Do you get frequent urinary tract infections?
• Have you had a back injury?
• Do you have a medical condition such as Parkinson's or multiple sclerosis that could interfere with bladder function?

Your doctor may also perform a physical examination and look for signs of damage to the nerves that supply the bladder and rectum. Depending on the findings of the examination your doctor may refer you to a neurologist (a doctor who specializes in diagnosing and treating diseases of the nervous system) or perform tests.

These may include:

• Bladder stress test. Your doctor checks to see if you lose urine when coughing. This could indicate stress incontinence.
• Catheterization. After having you empty your bladder, the doctor inserts a catheter to see if more urine comes out, meaning you are unable to empty your bladder completely.
• Urinalysis and urine culture. Lab technicians check your urine for infection, other abnormalities, or evidence of kidney stones.
• Ultrasound. An imaging test is performed to visualize inner organs such as the bladder, kidneys, and ureters.

If the diagnosis is still not clear, your doctor may order urodynamic testing. This can help provide information on bladder contractions, bladder pressure, urine flow, nerve signals, and leakage.

Another test used to confirm a diagnosis is cystoscopy, which examines the inside of the bladder and urethra with a small scope called a cystoscope.

Treatment for Mixed Incontinence

Treatment for mixed incontinence will require a combination of approaches used to relieve both stress incontinence and urge incontinence. There is no single treatment that works for everyone. The treatments you and your doctor choose will depend on the severity of your incontinence as well as your lifestyle and preferences.

These treatments may include:

Behavior Modification: If your diary shows a pattern of urination, your doctor may recommend that you use the bathroom at regular intervals to minimize leaking. Doing Kegel exercises regularly can help strengthen muscles that are involved in urine control. To learn how to do Kegel exercises, go to the bathroom and urinate. Halfway through, try to stop the stream of urine. This will help you identify the muscles you need to contract for Kegel exercises. Once you identify the muscles, do not practice while urinating. Do the exercises for about five minutes a day as you go about your day. After a few weeks to a month you should start to notice some improvement.

Medications: For the urge incontinence component of mixed incontinence, doctors may prescribe a medication called an anticholinergic to help relax bladder muscles to prevent spasms. Alternatively, your doctor may change a medication you are taking, such as high blood pressure medications that increase urine output and can contribute to incontinence.

Biofeedback: This technique can help you regain control over muscles that contract when you urinate by helping you better become aware of your body's functioning.

Neuromodulation: For urge incontinence that does not respond to behavioral modification or medications, your doctor may recommend neuromodulation, a therapy that involves using a device to stimulate nerves to the bladder. If a trial of the device shows it is helpful, the device is surgically implanted.

Vaginal Devices: For stress incontinence in women, doctors may prescribe a device called a pessary that is inserted into the vagina to reposition the urethra and reduce leakage. For mild stress incontinence, inserting a tampon or a contraceptive diaphragm -- prior to exercise or activities that are likely to lead to leakage -- may offer a similar benefit.

Compression Rings and Clamps: For men, these devices fit over the penis to close off the urethra. They must be removed before going to the bathroom.

Injections: To minimize leaking from stress, doctors may inject bulking agents into tissues around the bladder neck and urethra. The procedure takes about a half hour and is done with local anesthesia. Because the body may eliminate certain bulking agents over time, repeat injections may be necessary.

Surgery: If your bladder has dropped because of childbirth or other reasons, your doctor may recommend one of several different surgeries to support the bladder and return it to its normal position. Two commonly used types of surgical procedures are:

• Retropubic suspension, which involves placing sutures to support the bladder neck
• Sling procedures, which are performed through a vaginal incision and involve using a strip of your own tissue or other materials to create a hammock to support the neck of the bladder

Although no treatment can completely cure mixed incontinence, for most people who seek treatment, a combination of measures can bring relief.

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