Urinary incontinence (inability to control urination or the involuntary loss of urine from the bladder) afflicts more than 13 million people in the United States of both sexes and all age groups. Incidence is higher in the elderly and twofold greater in women. Exercise and behavioral therapies have a high degree of success; medication and surgery are effective in a select group over the short-term. Many drugs have unwanted and/or serious side effects. Surgery should be considered only when other treatment options fail. Diagnostic categories are:

• Stress incontinence (SUI): Most common form among women primarily due to pregnancy, childbirth, menopause. Weakened pelvic floor muscles fail to support bladder and resultant pressure interferes with muscles that close the urethra. Leakage occurs with physical stress (e.g., coughing, sneezing).
• Urge (or reflex) incontinence (UI): Leakage accompanied by sudden unexplained need to urinate (e.g., when touching water). May be due to nerve damage (e.g., from Alzheimer's disease, stroke, brain tumor, injury, surgery).
• Overflow incontinence (OI): Rare in women. Bladder overextension due to blocked urethra or inability of bladder muscles to expel urine. Caused by neurological damage (e.g., from diabetes), tumors, urinary stones, enlarged prostate.
• Mixed incontinence (MI): SUI/UI in combination.
• Functional incontinence (FI): Impaired cognitive abilities and/or restricted movement (e.g., confined to a wheelchair) prevents timely access to toilet.
• Transient incontinence (TI): Triggered by medication, UTIs, restricted mobility, stool impaction.

• Neurological damage/disorders (dementia, spinal cord injury, multiple sclerosis, stroke)
• Low estrogen levels in women
• Physical changes (from pregnancy or enlarged prostate, stool impaction, tumor)
• Medications
• Urinary tract infections (UTIs)
• Weak urethral sphincter
• Weak pelvic floor muscle

• Overweight
• Hysterectomy before age 45
• At least one live birth
• Labor exceeding 24 hours
• Prostate disease or hypertrophy in males
• Physical problems associated with age/debility
• Neurologic damage or disorders

• Involuntary urination Perineal irritation
• Frequent and unusual urinary urge

• Vaginal discharge in women UTIs
• Urethral discharge in men Medication effects (diuretics)

• Urine leakage
• Findings specific to risk factors

Urinalysis to determine urinary tract/bladder infection, urinary stones, diabetes, glomerular disease, tumor.

• Urethral sphincter incompetence Prostatic hypertrophy
• Bladder tumor UTI

• Pelvic ultrasound Renal ultrasound
• Transrectal ultrasound (prostate)

• Physical examination
• Neurological assessment
• Medical history
• Interview for pattern of voiding/leakage, straining/discomfort associated with urination
• Test for stress incontinence (e.g., vigorous coughing to detect urine loss)
• Urodynamics
• Voidin cystourethrogram

Along with the drug therapies and surgical procedures listed below, the following may be necessary.

• Catheters Urethral plugs
• Condom catheters Absorbent pads, undergarments, diapers

• Antibiotics: For UTIs or sexually transmitted diseases
• Anticholinergics: For UI, reduce detrusor muscle contractions/increase urethral resistance (imipramine [Tofranil] 10 to 25 mg up to tid; oxybutinin [Ditropan] 2.5 to 5 mg up to tid; hyoscyamine [Cystospaz], hyoscyamine sulfate [Levsin/Levsinex, Cystospaz-M], and flavoxate [Urispas] all 100 to 200 mg tid or qid). High instance of undesirable/intolerable side effects
• Antimuscarinic/ganglionic-blockers: Propantheline (Pro-Banthine) 15 to 30 mg every four to six hours. High incidence of side effects including confusion, agitation, coronary artery disease, especially in the elderly.
• Cholinergics: For underactive detrusor, bethanechol (Duvoid, Myotonachol, Urecholine); contraindicated with asthma, bradycardia, Parkinson's disease. Can produce intolerable sweating/excessive salivation.
• Sympathomimetics: For SUI, phenylpropanolamine (found in Ornade) 25 to 100 mg bid; or pseudoephedrine (found in Sudafed) 15 to 30 mg tid; caution with hypertension, angina, hyperthyroidism, diabetes
• Hormones: SUI in women, increase urethral resistance (conjugated estrogens [Premarin] 1.25 to 2.5 mg/day in cream; 0.3 to 0.625 mg/day orally with estradiol [Estrace]); increased risk of endometrial cancer, particularly with unopposed estrogen

Success rate higher in younger patients; effectiveness deteriorates over time; long-term success rate estimated at 75% to 90% for five years.

• Artificial sphincter: Inflatable cuff surrounding bladder neck activated by mechanism implanted in scrotum or labia.
• Supportive devices: String secured to the bladder and attached to muscle, bone, or ligament; in severe SUI, a wide sling elevates bladder.

The main thrust of alternative therapies is Kegel exercises, biofeedback, and preventing any exacerbating conditions. Underlying conditions (e.g., malnutrition, dementia, prostatitis, and UTIs) need to be addressed. Yoga may be beneficial. Habit training (establishing toilet times to increase regularity of voiding) may also help treat this condition.

• Eliminate caffeine, alcohol, sweetener substitutes, simple sugars.
• Cranberries and blueberries contain substances which inhibit the adhesion of bacteria to bladder tissue. This may be useful in preventing infections which can exacerbate incontinence. Also helps to deodorize urine.
• Vitamin C (1,000 mg tid) acidifies urine, which inhibits bacterial growth.
• Beta-carotene (25,000t to 50,000 IU/day) is necessary for immune function and mucous membrane integrity.
• Zinc (30 mg/day) supports immune function, often deficient in the elderly.
• Calcium (1,000 mg/day) and magnesium (500 mg/day) together may help to improve sphincter control.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

Urinary astringents have been used historically for sphincter tone and connective tissue integrity. Demulcents soothe irritated tissue and may decrease spasm of the bladder.

These urinary astringents tone and heal the urinary tract and can be taken long term at 1 cup/day or 30 drops tincture/day.

• Horsetail (Equisetum arvense) also helps with connective tissue integrity.
• Plantain (Plantago major) is an astringent and demulcent.

Marshmallow root (Althaea officinalis) is a urinary demulcent, best used alone in a cold infusion. Soak 1 heaping tbsp. of marshmallow root in 1 quart of cold water overnight. Strain and drink during the day in addition to other teas.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Causticum for SUI, especially with retention from holding the urine and frequent urges to urinate
• Natrum muriaticum for SUI, vaginal dryness, painful coitus, especially with a history of grief
• Pareira for retention of urine from an enlarged prostate
• Sepia for SUI with sudden urging, especially with prolapsed uterus and vaginitis
• Zincum for SUI, urinary retention from prostate problems, unable to urinate standing, must sit

May be of help, depending on cause.

Compliance with behavioral techniques is essential and may require close monitoring and reinforcement. Physician must be alert to and monitor side effects of medications, or for infections following implants/surgery.

Early treatment is most beneficial; embarrassment often causes delay in seeking help.

• Pelvic muscle strengthening (Kegel) exercises during and after pregnancy
• Maintenance of healthy prostate in men; maintenance of healthy pelvis in women
• Maintenance of optimal body weight for height/age

• Drugs: Considerable risk of unwanted, intolerable and/or serious side effects; contraindication with other medications
• Surgery: Possible complications
• Catheters: UTIs

Most cases can be vastly improved with appropriate management; effectiveness may deteriorate with age.

Pregnancy increases risk of incontinence; effect of drugs upon fetus must be determined before being administered during pregnancy.

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