Cause of incontinence of urine
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Causes of Urinary Incontinence
Urinary incontinence (UI) is defined as the involuntary leakage of urine sufficient to be a health or social problem. Causes are broadly divided into transient and established (chronic) causes.
Types of Incontinence
| Type | Description |
|---|---|
| Stress UI | Leakage with increased intra-abdominal pressure (coughing, sneezing, exercise) |
| Urge UI | Involuntary leakage associated with a strong urge to void (overactive bladder) |
| Mixed UI | Combination of both stress and urge incontinence |
| Overflow UI | Bladder overfills and dribbles due to obstruction or detrusor underactivity |
| Functional UI | Normal lower urinary tract but patient cannot reach the toilet in time |
| Total/Continuous UI | Constant leakage (e.g., fistula) |
A. Transient (Reversible) Causes
Incontinence is transient in up to one third of community-dwelling elderly and up to half of acutely hospitalized patients. Most transient causes lie outside the lower urinary tract.
The classic mnemonic is DIAPPERS (from Goldman-Cecil Medicine):
| Letter | Cause | Mechanism |
|---|---|---|
| D | Delirium / Confusional states | Impaired recognition of the urge to void |
| I | Infection (UTI, urethritis, vaginitis) | Local irritation → urgency |
| A | Atrophic urethritis/vaginitis | Low estrogen → urethral mucosal fragility |
| P | Pharmaceuticals (see below) | Multiple mechanisms |
| P | Psychologic (depression, anxiety) | Functional impairment, apathy |
| E | Excess urine output (hyperglycemia, hypercalcemia, diuretics, heart failure, excess fluid intake) | Overwhelms bladder capacity |
| R | Restricted mobility / Retention (fecal impaction, urinary retention) | Can't reach toilet; fecal impaction exerts pressure |
| S | Stool impaction | Rectal mass stimulates detrusor |
Another mnemonic for reversible causes is DRIP:
- D – Delirium
- R – Restricted mobility, Retention
- I – Infection, Inflammation (urethritis / atrophic vaginitis), Impaction (fecal)
- P – Polyuria, Pharmaceuticals
Drugs Causing Incontinence
| Drug Class | Effect |
|---|---|
| Diuretics | Increase urine volume → urgency |
| Sedatives / hypnotics (especially long-acting benzodiazepines) | Sedation, immobility |
| Anticholinergics | Urinary retention → overflow incontinence |
| α-Adrenergic agonists (decongestants) | Increased urethral tone → retention (men) |
| α-Adrenergic blockers | Decreased urethral tone → stress incontinence (women) |
| Calcium channel blockers | Urinary retention, reduced detrusor contractility |
| Opioids | Urinary retention, constipation, sedation |
| ACE inhibitors | Cough → stress incontinence |
| Alcohol | Diuresis, sedation, impaired mobility |
B. Established (Chronic) Causes — Related to the Lower Urinary Tract
1. Detrusor Overactivity (Urge Incontinence)
The most common lower urinary tract cause in the elderly (accounts for ~2/3 of cases). The detrusor muscle contracts involuntarily during filling.
Causes include:
- Idiopathic (most common at any age)
- Neurological: cerebrovascular disease (stroke), Parkinson's disease, multiple sclerosis, spinal cord injury (upper motor neuron lesions)
- Bladder calculus or carcinoma
- Bladder outlet obstruction (secondary detrusor overactivity)
- Bladder ischemia and inflammation
2. Stress Urinary Incontinence (SUI)
Second most common in older women; dominant cause in middle-aged women. Caused by failure of the urethral sphincteric mechanism.
Causes include:
- Pelvic floor laxity — pregnancy, vaginal childbirth (trauma to levator ani and pudendal nerve), multiparity
- Post-menopausal estrogen deficiency — atrophy of urethral mucosa and submucosa
- Urethral hypermobility — loss of normal anatomical support
- Intrinsic sphincter deficiency (ISD) — weak internal urethral sphincter (post-radiation, prior surgery, aging)
- Prior pelvic surgery (e.g., hysterectomy)
- Post-radical prostatectomy in men — sphincteric damage
3. Overflow Incontinence
Continuous or intermittent dribbling from an overdistended bladder.
Causes:
- Bladder outlet obstruction:
- Benign prostatic hyperplasia (BPH) — most common cause in men
- Urethral stricture
- Pelvic organ prolapse (women)
- Large cystocele
- Detrusor underactivity / acontractile detrusor:
- Diabetes mellitus (autonomic neuropathy)
- Vitamin B12 deficiency
- Lumbar disc herniation / pelvic surgery disrupting sacral nerves (S2–S4)
- Multiple sclerosis
- Medications (anticholinergics, opioids)
4. Neurogenic Incontinence
Disruption of the neural control of micturition at any level:
| Level | Lesion | Result |
|---|---|---|
| Suprapontine (cerebral cortex, basal ganglia) | Stroke, dementia, Parkinson's | Detrusor overactivity (urge incontinence) |
| Suprasacral spinal cord | Spinal cord injury, MS, myelopathy | Detrusor-sphincter dyssynergia |
| Sacral spinal cord / cauda equina | Disc prolapse, tumors, sacral agenesis | Acontractile detrusor (overflow) |
| Peripheral nerve | Diabetic neuropathy, pelvic surgery | Sensory/motor deficit → overflow |
5. Genuine (Total) Incontinence
- Vesicovaginal fistula — obstetric trauma (prolonged obstructed labor), pelvic surgery, radiation, malignancy
- Ureterovaginal fistula
- Urethral fistula or ectopic ureter
C. Functional / Systemic Causes (Can Cause or Worsen Any Type)
- Immobility (arthritis, stroke, hip fracture) — patient cannot reach the toilet in time
- Severe cognitive impairment / dementia — loss of social awareness
- Obesity — increases intra-abdominal pressure (worsens stress UI)
- Constipation — fecal loading exerts mechanical pressure
- Nocturnal polyuria — heart failure, venous insufficiency, OSA, excessive fluid intake
Summary Table
| Category | Key Causes |
|---|---|
| Detrusor overactivity | Idiopathic, neurological disease, bladder irritation |
| Sphincter/pelvic floor weakness | Childbirth, menopause, prostatectomy, aging |
| Outlet obstruction | BPH, urethral stricture, prolapse |
| Neurological | Stroke, MS, spinal cord injury, diabetic neuropathy |
| Fistula | Vesicovaginal (obstetric trauma, surgery) |
| Drugs | Diuretics, anticholinergics, α-blockers, opioids, ACE inhibitors |
| Infections | UTI, atrophic vaginitis/urethritis |
| Functional/systemic | Immobility, dementia, obesity, constipation |
Sources:
- Goldman-Cecil Medicine, Chapter 115 (Resnick & DuBeau) — Urinary Incontinence
- Smith and Tanagho's General Urology, 19th ed., Chapter 30 — Types of Incontinence
- Campbell-Walsh-Wein Urology — Evaluation and Management of Incontinence
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