Causes of bladder incontinence

Treatment also requires addressing factors in the environment to improve accessibility.

If you suffer from functional incontinence, there are things you can do to reduce your risk of accidents. At home, make sure your bathroom is accessible and the route from your bathroom is uncluttered, which could help you avoid delays or falls. When out and about, know where the restrooms are, so you will not have to take time to ask directions or locate one when you need to go. Wear clothing that is easy to remove. For example, if arthritis in your fingers makes it difficult to work zippers, wear pants with elastic waists. If you have trouble transferring from a wheelchair to toilet, try to have someone with you who can help.

Sometimes simple behavioral treatments that help other forms of incontinence can be helpful in reducing accidents caused by functional incontinence. These treatments include:

Bladder training : This technique involves scheduling the amount of time between bathroom trips. You’ll initially start by going every two hours. If you feel the need to go between trips, you should stand or sit still, contract the pelvic muscles, and concentrate on making the urge to urinate go away. Once the urge is under control, you can go to the bathroom and urinate. After you have stayed dry for two days, you should slowly increase intervals until you are able to go three to four hours without using the bathroom.

Pelvic muscle exercises: Pelvic muscle exercises, also called Kegel exercises, strengthen the muscles that support the bladder and urethra to prevent leakage. To do Kegel exercises you should focus on isolating your pelvic muscles, so that contractions are in these muscles. 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. Once you identify the muscles, do not practice while urinating. Do the exercises for about five minutes at a time as you go about your day. After a few weeks to a month you should start to notice some improvement. Practicing Kegel exercises may be helpful in preventing accidents as you try to get to the bathroom.


Urge incontinence

Treatment depends on how bad your symptoms are and how they affect your life.

There are four main treatment approaches for urge incontinence:

  • Bladder and pelvic floor muscle training
  • Lifestyle changes
  • Medicines
  • Surgery


Managing urge incontinence most often begins with bladder retraining. This helps you become aware of when you lose urine because of bladder spasms. Then you relearn the skills you need to hold and release urine.

  • You set a schedule of times when you should try to urinate. You try to avoid urination between these times.
  • One method is to force yourself to wait 1 to 1 1/2 hours between trips to the bathroom, even if you have any leakage or an urge to urinate in between these times.
  • As you become better at waiting, gradually increase the time by 1/2 hour until you are urinating every 3 to 4 hours.


Sometimes, Kegel exercises, biofeedback, or electrical stimulation may be used with bladder retraining. These methods help strengthen the muscles of your pelvic floor:

Kegel exercises — These are mainly used to treat people with stress incontinence. However, these exercises may also help relieve the symptoms of urge incontinence.

  • You squeeze your pelvic floor muscles like you are trying to stop the flow of urine.
  • Do this for 10 seconds, and then relax for 10 seconds.
  • Repeat 10 times, 3 times a day.

Vaginal cones — This is a weighted cone that is inserted into the vagina to strengthen the pelvic floor muscles.

  • You place the cone into the vagina.
  • Then you try to squeeze your pelvic floor muscles to hold the cone in place.
  • You can wear the cone for up to 15 minutes at a time, 2 times a day.

Biofeedback — This method can help you learn to identify and control your pelvic floor muscles.

  • Some therapists place a sensor in the vagina (for women) or the anus (for men) so they can tell when they are squeezing the pelvic floor muscles.
  • A monitor will display a graph showing which muscles are squeezing and which are at rest.
  • The therapist can help you find the right muscles for performing Kegel exercises.

Electrical stimulation — This uses a gentle electrical current to contract your bladder muscles.

  • The current is delivered using an anal or vaginal probe.
  • This therapy may be done at the provider’s office or at home.
  • Treatment sessions usually last 20 minutes and may be done every 1 to 4 days.

Percutaneous tibial nerve stimulation (PTNS) — This treatment may help some people with overactive bladder.

  • An acupuncture needle is placed behind the ankle, and electrical stimulation is used for 30 minutes.
  • Most often, treatments will occur weekly for around 12 weeks, and perhaps monthly after that.


Pay attention to how much water you drink and when you drink.

  • Drinking enough water will help keep odors away.
  • Drink a little bit of fluid at a time throughout the day, so your bladder does not need to handle a large amount of urine at one time. Drink less than 8 ounces (240 milliliters) at one time.
  • Do not drink large amounts of fluids with meals.
  • Sip small amounts of fluids between meals.
  • Stop drinking fluids about 2 hours before bedtime.
  • Avoid carbonated drinks.

It also may help to stop eating foods that may irritate the bladder, such as:

  • Caffeine
  • Highly acidic foods, such as citrus fruits and juices
  • Spicy foods
  • Artificial sweeteners

Avoid activities that irritate the urethra and bladder. This includes taking bubble baths or using harsh soaps.


Medicines used to treat urge incontinence relax bladder contractions and help improve bladder function. There are several types of medicines that may be used alone or together:

  • Anticholinergic medicines help relax the muscles of the bladder. They include oxybutynin (Oxytrol, Ditropan), tolterodine (Detrol), darifenacin (Enablex), trospium (Sanctura), and solifenacin (VESIcare).
  • Beta agonist drugs can also help relax the muscles of the bladder. The only medicine of this type currently is mirabegron (Myrbetriq).
  • Flavoxate (Urispas) is a drug that calms muscle spasms. However, studies have shown that it is not always effective at controlling symptoms of urge incontinence.
  • Tricyclic antidepressants (imipramine, doxepin) help “paralyze” the smooth muscle of the bladder.
  • Botox injections are commonly used to treat overactive bladder. The medicine is injected into the bladder through a cystoscope. The procedure is most often done in the provider’s office.

These medicines may have side effects such as dizziness or dry mouth. Talk with your provider if you notice bothersome side effects.

If you have an infection, your provider will prescribe antibiotics. Be sure to take the entire amount as directed.


Surgery can help your bladder store more urine. It can also help relieve the pressure on your bladder. Surgery is only used for people who have too many spasms and are not able to store much urine.

Augmentation cystoplasty is the surgery most often performed for severe urge incontinence. In this surgery, a part of the bowel is added to the bladder. This increases the bladder size and allows it to store more urine.

Possible complications include:

  • Blood clots
  • Bowel blockage
  • Infection
  • Pneumonia
  • Slightly increased risk of tumors
  • Not being able to empty your bladder

There is a risk of forming tube-like passages from the bladder to other organs or your skin. These are called urinary fistulae. They can lead to:

  • Urine draining out in an unusual way, such as from your vagina
  • Urinary tract infection
  • Difficulty urinating

Sacral nerve stimulation — A small unit is implanted under your skin. This sends small electrical pulses to the sacral nerve (one of the nerves that comes out at the base of your spine). The electrical pulses can be adjusted to help relieve your symptoms.

Urinary incontinence is a long-term (chronic) problem. While treatments can cure your condition, you should still to see your provider to make sure you are doing well and check for possible problems.

What Is Urinary Incontinence?

Bladder control problems can be embarrassing, but understanding what causes incontinence can improve your chances of getting it under control.

Urinary incontinence occurs when the muscles in the bladder that control the flow of urine contract or relax involuntarily.

This results in either leaking or uncontrolled urination.

The condition affects nearly 1 in 10 people over age 65.

Urinary incontinence can range from mild, occasional leaking to chronic uncontrolled urination.

Incontinence itself is not a disease, but it can be a symptom of an underlying medical condition.

Causes of Urinary Incontinence

Incontinence may be a temporary problem caused by a vaginal or urinary tract infection (UTI), constipation, certain medications, or it can be a chronic condition.

The most common causes of chronic incontinence include:

  • Overactive bladder muscles
  • Weakened pelvic floor muscles
  • For some men, an enlarged prostate, or benign prostatic hyperplasia (BPH)
  • Nerve damage that affects bladder control
  • Interstitial cystitis (chronic bladder inflammation) or other bladder conditions
  • A disability or limitation that makes it difficult to get to the toilet quickly
  • Side effects from a prior surgery

Stress Incontinence

While there are many different types of urinary incontinence, the most common include stress incontinence and overactive bladder (also called urge incontinence).

Stress incontinence occurs when there is unexpected leakage of urine caused by pressure or sudden muscle contractions on the bladder.

This often occurs during exercise, heavy lifting, coughing, sneezing, or laughing.

Stress incontinence is the most common bladder control problem in young and middle-aged women.

In younger women, the condition may be due to an inherent weakness of the pelvic floor muscles or an effect from the stress of childbirth.

In middle-aged women, stress incontinence may begin to be a problem at menopause.

Urge Incontinence

Sometimes called overactive bladder, or OAB, urge incontinence occurs when a person feels the urge to urinate but is unable to hold back the urine long enough to get to a bathroom.

Urge incontinence sometimes occurs in people who’ve had a stroke or have chronic diseases such as diabetes, Alzheimer’s disease, Parkinson’s disease, or multiple sclerosis.

In some cases, urge incontinence may be an early sign of bladder cancer.

Other Types of Incontinence

Overflow incontinence: This occurs when a person is unable to empty their bladder completely and it overflows as new urine is produced.

Overflow incontinence sometimes occurs in men who have an enlarged prostate. It’s also found in people with diabetes or spinal cord injuries.

Functional incontinence: This type of incontinence has less to do with a bladder disorder and more to do with the logistics of getting to a bathroom in time.

It’s usually found in elderly or disabled people who have normal or near normal bladder control but cannot get to the toilet in time because of mobility limitations or confusion.

Gross total incontinence: This refers to the constant leaking of urine from a bladder that simply has no functioning storage capacity.

This condition may result from an anatomical defect, a spinal cord injury, an abnormal opening in the bladder (fistula), or as an aftereffect of urinary tract surgery.

Risk Factors for Urinary Incontinence

The most common risk factors for incontinence include:

Being female: Women experience stress incontinence twice as often as men. Men, on the other hand, are at greater risk for urge and overflow incontinence.

Advancing age: As we get older, our bladder and urinary sphincter muscles often weaken, which may result in frequent and unexpected urges to urinate.

Even though incontinence is more common in older people, it is not considered a normal part of aging.

Excess body fat: Extra body fat increases the pressure on the bladder and can lead to urine leakage during exercise or when coughing or sneezing.

Other chronic diseases: Vascular disease, kidney disease, diabetes, prostate cancer, Alzheimer’s disease, multiple sclerosis, Parkinson’s disease, and other conditions may increase the risk of urinary incontinence.

Smoking: A chronic smoker’s cough can trigger or aggravate stress incontinence by putting pressure on the urinary sphincter.

High-impact sports: While playing sports doesn’t cause incontinence, running, jumping, and other activities that create sudden pressure on the bladder can lead to occasional episodes of incontinence during sports activities.

How Is Incontinence Diagnosed?

Urinary incontinence is easy to recognize. The primary symptom most people experience is an involuntary release of urine.

However, determining the type and cause of incontinence can be more difficult and require a variety of exams and tests.

Most physicians will use the following:

A bladder diary: Your doctor may have you track your fluid intake and output over several days.

This may include any episodes of incontinence or urgency issues. To help you measure urine quantities, you may be asked to use a calibrated container that fits over your toilet to collect the urine.

Urinalysis: A urine sample can be checked for infections, traces of blood, or other abnormalities, such as the presence of cancer cells.

A urine culture checks for signs of infection; urine cytology looks for cancer cells.

Blood tests: Blood tests can look for chemicals and substances that may relate to conditions causing the incontinence.

Pelvic ultrasound: In this imaging test, an ultrasound device is used to create an image of the bladder or other parts of the urinary tract to check for problems.

Postvoid residual (PVR) measurement: In this procedure, the patient empties the bladder completely and the physician uses a device to measure how much urine, if any, remains in the bladder.

A large amount of residual urine in the bladder suggests overflow incontinence.

Stress test: In this test, the patient is asked to cough or vigorously tense her midsection as though exerting herself while the physician checks for loss of urine.

Urodynamic testing: This test measures the pressure that the bladder muscles and urinary sphincter can tolerate both at rest and during filling.

Cystogram: In this series of X-rays of the bladder, a dye is injected into the bladder and as the patient urinates, the dye shows up in the X-rays and can reveal abnormalities in the urinary tract.

Cystoscopy: This procedure uses a thin tube with a tiny lens and a light at one end called a cystoscope.

The cystoscope is inserted into the urethra and the physician visually checks the lining of the bladder and urethra.

Home Remedies for Urinary Incontinence

The treatment of urinary incontinence varies depending on the cause of the bladder control problem.

In most cases, a physician will try the simplest treatment approach before resorting to medication or surgery.

Bladder habit training: This is the first approach for treating most incontinence issues.

The goal is to establish a regular urination schedule with set intervals between urinations.

A doctor will usually recommend starting by urinating at one-hour intervals and gradually increasing the intervals between urination over time.

Pelvic muscle exercises: Also called Kegel exercises (named after the gynecologist, Dr. Arnold Kegel, who developed them), this exercise routine helps strengthen weak pelvic muscles and improve bladder control.

The person contracts the muscles used to keep in urine, holds the contraction for 4 to 10 seconds, then relaxes the muscles for the same amount of time.

It may take weeks or months of regular pelvic exercise to show improvement.

Another way to perform Kegel exercises is to interrupt the flow of urine for several seconds while urinating.

Incontinence Medications

The drugs prescribed to manage incontinence work by relaxing the bladder muscles to stop abnormal contractions and therefore are most effective for treating urge incontinence.

They include:

  • Bentyl (dicyclomine)
  • Cystospaz (hyoscyamine)
  • Detrol or Detrol LA (tolterodine)
  • Ditropan or Ditropan XL (oxybutynin)
  • Levbid (hyoscyamine)
  • Oxytrol (oxybutynin)
  • ProBanthine (propantheline)
  • Sanctura (trospium)
  • Urispas (flavoxate)
  • Urotrol (oxybutynin)

Other medications used for incontinence are:

M3 selective receptor antagonists: These anticholinergic medications target specific nerve receptors that cause involuntary bladder muscle spasms.

These two M3 selective receptor antagonists are approved for use with urge incontinence:

  • Enablex (darifenacin)
  • VESIcare (solifenacin)

Alpha-adrenergic antagonists or blockers: These drugs work by relaxing smooth muscles, which can improve urine flow.

This class of drugs is especially effective for men with BPH and urge incontinence.

Alpha-adrenergic antagonists include:

  • Cardura or Cardura XL (doxazosin)
  • Flomax (tamsulosin)
  • Hytrin (terazosin)
  • Uroxatral (alfuzosin)

Alpha-adrenergic agonists: These drugs, which include ephedrine and pseudoephedrine, may be helpful for patients with mild stress incontinence because they strengthen the muscle that opens and closes the urinary sphincter.

Side effects of these medications may include insomnia, agitation, and anxiety.

Alpha-adrenergic agonists should not be given to people with heart problems, hypertension, diabetes, glaucoma, or hyperthyroidism.

Tricyclic antidepressants: The neurotransmitters serotonin and noradrenaline are believed to play a role in urination and urge and stress incontinence.

Among the medications used to regulate the neurotransmitters are:

  • Janimine (imipramine)
  • Norpramin (desipramine)
  • Pamelor (nortriptyline)
  • Sinequan (doxepin)
  • Tofranil (imipramine)

Surgery or Implants for Incontinence

Surgery is sometimes performed to remove a blockage in the bladder or urethra that is causing overflow incontinence or to shift the position of the bladder to remove pressure on it that is causing stress incontinence.

The two most common surgical procedures used to treat stress incontinence include sling procedures and bladder neck suspension procedures.

Sacral nerve stimulation is sometimes used to treat overactive bladder. This treatment involves a surgical procedure to implant a small device below the skin of the buttock.

This device periodically generates a mild electrical stimulation to the sacral nerves, which results in increased tension in the bladder, sphincter, and pelvic floor muscles.

Products to Help Manage Incontinence

Many people find the following products useful for decreasing incontinence symptoms:

Adult diapers and undergarments: Absorbent, non-bulky pads and underwear that’s worn discreetly under clothing are available in different sizes for both men and women.

For those with mild or moderate leakage, panty liners are sometimes all that’s required.

Patches and plugs: Many women are able to manage light leakage from stress incontinence by using products that block the flow of urine, such as a small, disposable adhesive patch that fits over the urethral opening, a tampon-like urethral plug, or a vaginal insert called a pessary.

Catheters: For otherwise unmanageable incontinence, a physician can place a catheter in the urethra to continually drain the bladder.

Due to a higher risk of developing infections and kidney stones, catheters are usually a last resort and used only for severely ill patients.

Learn More About Urinary Incontinence Resources

Voiding Dysfunction in Children

What is voiding dysfunction in children?

Voiding dysfunction is a term that means your child’s bladder is not emptying — he or she is not urinating — normally or fully.

Are there different types of voiding dysfunction that occur in children?

Yes. Some of the more common types include:

  • Daytime wetting (also called diurnal enuresis): Daytime wetting can consist of either small urine leaks that spot or dampen underwear to their complete soaking. Wetting occurs more commonly in the afternoon, as most children are anxious about wetting in school and work hard to stay dry.
  • Giggle incontinence: This is the complete emptying of the bladder that occurs with vigorous laughter or giggling.
  • Urge syndrome: Frequent attacks of the need to void (at least seven times a day) countered by hold maneuvers, such as squatting. Urine loss is mild, represented by a slight wetting of underwear.
  • Bedwetting (also called nocturnal enuresis): This is when a sleeping child cannot control his/her urination at night. This problem begins to be considered abnormal after the age of five.

What is the difference between voiding dysfunction and overactive bladder?

Overactive bladder is a condition in which the large bladder muscle (detrusor) contracts involuntarily, causing symptoms including urinary frequency, urgency and or/or urge incontinence. Urinary incontinence is the involuntary leakage of urine. Urinary incontinence can range from the occasional leakage of urine to a complete inability to hold any urine and can be one symptom of overactive bladder.

What causes voiding dysfunction in children?

Voiding dysfunction can be caused by:

  • Behavioral problems or poor habits (infrequent urination, poor toileting habits, having too much fun or being too busy to break to go to the bathroom, being afraid of urinating due to a past painful urinary tract infection, attention deficit disorder, psychological or emotional stress)
  • Congenital (born with) urinary tract problems
  • Acquired problems of the urinary tract (such as those caused by tumors or trauma)
  • Central nervous system diseases and conditions that affect the urinary tract (such as cerebral palsy, epilepsy, multiple sclerosis, other abnormalities of the brain or spinal cord that affects the nerves that control bladder or urinary sphincter function)
  • Endocrine or kidney diseases that affect the urinary tract (diabetes, chronic kidney disease)
  • Genetic diseases that affect the urinary tract (Ochoa syndrome, Williams syndrome)
  • Infections or irritations that affect the urinary tract (such as urinary tract infections, urethritis, pinworms, foreign body)

Other causes can include stress incontinence (the involuntary loss of urine during actions such as coughing or sneezing), giggle incontinence (see next page for definition), and delayed nighttime bladder control.

What are the symptoms of voiding dysfunction in children?

Signs and symptoms of voiding dysfunction include:

  • Incontinence (urine leakage) during the day and/or night – often is the first sign noticed by parents that there is a problem
  • Increase in urinary frequency and/or urgency (the need to go immediately)
  • Urinary hesitancy, dribbling, intermittent urine flow and/or straining at urination
  • Pain in the back, lower side, or abdomen
  • Returning urinary tract infections
  • Blood in the urine
  • Infrequent urination or three or fewer voids in a 24-hour period
  • Constipation and fecal soiling

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Certain diseases. Multiple sclerosis is a disease that can damage the nerves that tell the bladder when to empty and can also lead to bladder spasms. Some other conditions that can damage your nerves and keep your bladder from sending or receiving the signals it needs to work correctly are:

  • Diabetes
  • Stroke
  • Alzheimer’s disease
  • Parkinson’s disease

Surgery. Major bowel surgery, lower back surgery, and prostate surgery can all cause problems with your bladder. This is usually because some of the nerves in your urinary tract have been damaged during surgery.

Old age. Just like other muscles in your body, your bladder loses some of its tone and strength as you age and this can cause leaks.

Obesity or lack of exercise. When you don’t get enough activity, you may start carrying extra weight. When you add pounds to your body, your bladder feels more pressure. This can make you go to the bathroom more often, because you have a harder time holding your urine for a long time.

Chronic coughing. If sickness, allergies, or other problems keep you in coughing fits, it can put stress on your bladder and pelvic floor muscles. If they’re weak, they may struggle to keep pee inside.

Urinary tract infection. Bacteria can sometimes infect part of your urinary tract. The infection can irritate your bladder and cause incontinence.

Constipation. When your stool is hard or backed up, it can press on the nerves to your urinary system. This can cause leaks.

Also good to know: drinking alcohol or taking certain medications like diuretics, antidepressants, sedatives, narcotics, or over-the-counter cold and diet medicines can make urinary incontinence worse. So, though they don’t cause the problem, they can worsen your symptoms.

Solutions for a Leaky Bladder

Regaining Bladder Control

No matter what’s causing your bladder leakage, Wright offers good news: “The vast majority of cases can either be cured or significantly improved.” Some strategies that can help:

Watch your diet

You may be able to cut down on bladder leaks by avoiding certain foods, drinks and ingredients, including:

  • Alcohol
  • Artificial sweeteners
  • Caffeine
  • Carbonated beverages
  • Chocolate
  • Citrus fruits and tomatoes
  • Corn syrup
  • Honey
  • Spicy foods

Shed extra pounds

Research has found that overweight and obese women who lose weight report fewer episodes of bladder leakage.

Train your bladder

Certain exercises can help you keep your bladder under better control:

  • Kegel exercises. During Kegels, you regularly tighten certain muscles in your pelvis to strengthen them, which helps you become more leak-proof.
  • The Knack. With this method, you do a Kegel just as you cough, sneeze or do another activity that tends to trigger a leak.

These require practice, Wright says. You may need a professional—your doctor or a physical therapist—to show you how to do them properly.

Know your options

Depending on the type of incontinence you have, your doctor may recommend one of the following treatments, Wright says:

  • Medications that can help your bladder hold more, reduce urgency and improve your ability to empty your bladder. (There is even a recently approved over-the-counter patch for women with overactive bladder that helps relax the bladder muscle; the patch is available for men by prescription.)
  • An injection of Botox into the lining of your bladder to block the release of a chemical that prompts muscle contractions.
  • An injection of a thick substance around your urethra (the tube that carries urine out of your body) to help it hold back urine.
  • Surgery to insert a strip of mesh to press against your urethra and prevent leaks.

“Many solutions are available, but you can only get help for what you’re willing to talk about and explain,” Wright says.

Types of urinary incontinence

Published: December, 2014

Many things can go wrong with the complex system that allows us to control urination. Incontinence is categorized by the type of problem and, to a lesser extent, by differences in symptoms.

Stress incontinence

If urine leaks out when you jump, cough, or laugh, you may have stress incontinence. Any physical exertion that increases abdominal pressure also puts pressure on the bladder. The word “stress” actually refers to the physical strain associated with leakage. Although it can be emotionally distressing, the condition has nothing to do with emotion. Often only a small amount of urine leaks out. In more severe cases, the pressure of a full bladder overcomes the body’s ability to hold in urine. The leakage occurs even though the bladder muscles are not contracting and you don’t feel the urge to urinate.

Stress incontinence occurs when the urethral sphincter, the pelvic floor muscles, or both these structures have been weakened or damaged and cannot dependably hold in urine. Stress incontinence is divided into two subtypes. In urethral hypermobility, the bladder and urethra shift downward when abdominal pressure rises, and there is no hammock-like support for the urethra to be compressed against to keep it closed. In intrinsic sphincter deficiency, problems in the urinary sphincter interfere with full closure or allow the sphincter to pop open under pressure. Many experts believe that women who have delivered vaginally are most likely to develop stress incontinence because giving birth has stretched and possibly damaged the pelvic floor muscles and nerves. Generally, the larger the baby, the longer the labor, the older the mother, and the greater the number of births, the more likely that incontinence will result.

Age is likewise a factor in stress incontinence. As a woman gets older, the muscles in her pelvic floor and urethra weaken, and it takes less pressure for the urethra to open and allow leakage. Estrogen can also play some role, although it is not clear how much. Many women do not experience symptoms until after menopause.

In men, the most frequent cause of stress incontinence is urinary sphincter damage sustained through prostate surgery or a pelvic fracture.

Lung conditions that cause frequent coughing, such as emphysema and cystic fibrosis, can also contribute to stress incontinence in both men and women.

Overactive bladder (urge incontinence)

If you feel a strong urge to urinate even when your bladder isn’t full, your incontinence might be related to overactive bladder, sometimes called urge incontinence. This condition occurs in both men and women and involves an overwhelming urge to urinate immediately, frequently followed by loss of urine before you can reach a bathroom. Even if you never have an accident, urgency and urinary frequency can interfere with work and a social life because of the need to keep running to the bathroom.

Urgency is caused when the bladder muscle, the detrusor, begins to contract and signals a need to urinate, even when the bladder is not full. Another name for this phenomenon is detrusor overactivity.

Overactive bladder can result from physical problems that keep your body from halting involuntary bladder muscle contractions. Such problems include damage to the brain, the spine, or the nerves extending from the spine to the bladder — for example, from an accident, diabetes, or neurological disease. Irritating substances within the bladder, such as those produced during an infection, might also cause the bladder muscle to contract.

Often there is no identifiable cause for overactive bladder, but people are more likely to develop the problem as they age. Postmenopausal women, in particular, tend to develop this condition, perhaps because of age-related changes in the bladder lining and muscle. African American women with incontinence are more likely to report symptoms of overactive bladder than stress incontinence, while the reverse is true in white women.

A condition called myofascial pelvic pain syndrome has been identified with symptoms that include overactive bladder accompanied by pain in the pelvic area or a sense of aching, heaviness, or burning.

In addition, infections of the urinary tract, bladder, or prostate can cause temporary urgency. Partial blockage of the urinary tract by a bladder stone, a tumor (rarely), or, in men, an enlarged prostate (a condition known as benign prostatic hyperplasia, or BPH) can cause urgency, frequency, and sometimes urge incontinence. Surgery for prostate cancer or BPH can trigger symptoms of overactive bladder, as can freezing (cryotherapy) and radiation seed treatment (brachytherapy) for prostate cancer.

Neurological diseases (such as Parkinson’s disease and multiple sclerosis) can also result in urge incontinence, as can a stroke. When hospitalized following a stroke, 40% to 60% of patients have incontinence; by the time they are discharged, 25% still have it, and one year later, 15% do.

Mixed incontinence

If you have symptoms of both overactive bladder and stress incontinence, you likely have mixed incontinence, a combination of both types. Most women with incontinence have both stress and urge symptoms — a challenging situation. Mixed incontinence also occurs in men who have had prostate removal or surgery for an enlarged prostate, and in frail older people of either gender.

Overflow incontinence

If your bladder never completely empties, you might experience urine leakage, with or without feeling a need to go. Overflow incontinence occurs when something blocks urine from flowing normally out of the bladder, as in the case of prostate enlargement that partially closes off the urethra. It can also occur in both men and women if the bladder muscle becomes underactive (the opposite of an overactive bladder) so you don’t feel an urge to urinate. Eventually the bladder becomes overfilled, or distended, pulling the urethra open and allowing urine to leak out. The bladder might also spasm at random times, causing leakage. This condition is sometimes related to diabetes or cardiovascular disease.

Men are much more frequently diagnosed with overflow incontinence than women because it is often caused by prostate-related conditions. In addition to enlarged prostate, other possible causes of urine blockage include tumors, bladder stones, or scar tissue. If a woman has severe prolapse of her uterus or bladder (meaning that the organ has dropped out of its proper position), her urethra can become kinked like a bent garden hose, interfering with the flow of urine.

Nerve damage (from injuries, childbirth, past surgeries, or diseases such as diabetes, multiple sclerosis, or shingles) and aging often prevent the bladder muscle from contracting normally. Medications that prevent bladder muscle contraction or that make you unaware of the urge to urinate can also result in overflow incontinence.

Functional incontinence

If your urinary tract is functioning properly but other illnesses or disabilities are preventing you from staying dry, you might have what is known as functional incontinence.

For example, if an illness rendered you unaware or unconcerned about the need to find a toilet, you would become incontinent. Medications, dementia, or mental illness can decrease awareness of the need to find a toilet.

Even if your urinary system is fine, it can be extremely difficult for you to avoid accidents if you have trouble getting to a toilet. This problem can affect anyone with a condition that makes it excessively difficult to move to the bathroom and undress in time. This includes problems as diverse as having arthritis, being hospitalized or restrained, or having a toilet located too far away.

If a medication (such as a diuretic used to treat high blood pressure or heart failure) causes you to produce abnormally large amounts of urine, you could develop incontinence that requires a change in treatment. If you make most of your urine at night, the result might be nocturnal incontinence, or bedwetting.

Reflex incontinence

Reflex incontinence occurs when the bladder muscle contracts and urine leaks (often in large amounts) without any warning or urge. This can happen as a result of damage to the nerves that normally warn the brain that the bladder is filling. Reflex incontinence usually appears in people with serious neurological impairment from multiple sclerosis, spinal cord injury, other injuries, or damage from surgery or radiation treatment

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What is Urinary Incontinence?

There are many devices and products that collect and hold urine. They help manage urinary retention and urinary incontinence. With urinary retention, your bladder does not completely empty. With urinary incontinence (UI), you have urine leakage that you cannot control.

Products and devices can help men and women of all ages. For some people, they are the only way to manage bladder problems. These devices can also give older and disabled persons more freedom.

Indwelling Catheters

Foley Catheter
Image: Blamb/.com

Suprapubic Catheter
Image: Blamb/.com

A catheter is a flexible tube placed in your bladder. An “indwelling” catheter stays in your bladder all day and night. There are two types of indwelling catheters. Indwelling “Foley” catheters are placed in your urethra. Indwelling “suprapubic” catheters go above your pubic bone through a small surgical cut in the belly. With both types, a balloon holds the tube in your bladder. They both also drain urine into a bag outside the body.

A health care provider will place the Foley catheter in your urethra. The catheter can be managed by home care nurses when used long term. A urologist places the suprapubic catheter with minor surgery.

A Foley catheter should only be used for less than 2 years. If you need an indwelling catheter for a longer period of time, you should consider a suprapubic catheter. Because the suprapubic catheter is only in the bladder, there is less risk of bacteria growing (because it is away from the vagina and rectum). That means less risk of urinary tract infections, especially in women.

Both Foley and suprapubic catheters need to be replaced with a new catheter at least once every month. This also lowers the risk of infection. Both catheters can cause complications if used for a long time. Bladder, testicle (males), and kidney infections, bladder stones and bladder cancer can occur. Foley catheters can cause permanent damage to the urethra.

Foley and suprapubic catheters should be taped or strapped to the upper thigh or lower belly. This lowers the chance of injury if the catheter is tugged accidentally.

Catheters are made from latex with Teflon coating or silicone. The choice depends on a person’s allergies and the health care provider’s preference. Some catheters are coated with antibiotics to prevent infection. There is debate about whether this works.

Indwelling catheters vary in shape, tube size and tip. They are sized using the French (Fr) scale. Size 14 Fr is the most common size. A balloon is inflated once the catheter is inserted. This keeps the catheter from falling out. The balloon is usually filled with about 2 teaspoons of sterile water.

External Collecting Systems

For men, there are external collecting systems called condom or Texas catheters. These special condoms are rolled over the penis. They are kept in place by adhesive or straps. The condoms have holes at the tip. A tube goes from the hole to a drainage bag. Urine from incontinence collects in the drainage bag. Newer condoms are usually silicone. They come in sizes, with a sizing guide.

This device may be hard to use if you have problems with finger dexterity. A caregiver or family member would need to apply the condom catheter. Adhesive pouches may be better for men whose penis has retracted (drawn back).

An external collection device for women funnels urine from a pouch through a tube to a collecting device. These must be stuck to the outside of the labia. They are rarely used as the labia do not form a good water tight seal, so urine leaks.

Urine Drainage Bags

Both indwelling and external collecting devices are connected to drainage bags. They collect urine coming out of the bladder. Drainage bags come in different sizes. Overnight bags hold 1500 to 2000 milliliters (1.5 to 2.0 liters) of urine. These are large and cannot be hidden.

A leg bag is a smaller drainage bag. It holds 500 to 800 milliliters. It allows more freedom of movement. It can be hidden under clothing. It can be strapped to the thigh or calf. A new type, called the Belly Bag, is strapped to the belly. Drainage bags work by gravity. So they should be strapped somewhere below the bladder.

When choosing a bag, make sure the strap is not too restrictive or tight. The valve that drains urine from the bag should be easy to open.

Drainage bags can be cleaned and deodorized. Soak 20 minutes in a solution of two parts vinegar and three parts water.

Catheters for Intermittent Catheterization (IC)

Catheter for Clean Intermittent Catheterization

Intermittent catheterization is also called “in and out” catheterization. It is also called “clean intermittent catheterization” (CIC). Because it is clean you don’t need gloves and sterile preparation.

A catheter is inserted in the urethra 3 to 5 times a day. After you empty your bladder, you remove the catheter and throw it away. You or a caretaker can insert the catheter. You don’t have to wear it all the time. This lowers the chance of infection. And these devices don’t have a balloon like the indwelling catheter.

Older men and women can perform CIC and should be on a routine schedule. The amount of urine in the bladder should be 15 ounces or less. Catheterization may be needed four to five times a day. Most healthcare insurances and Medicare will pay for 4 catheters a day (120 a month).

Most IC catheters are straight. Some (called Coudé catheters) have a curved tip. It may be easier for a man to advance a curved tip past the prostate gland. Catheter lengths are 6 inches for women and 12 inches for men.

You can get catheters and other supplies, such as lubricant, packaged together. These packages are helpful if you need to use the catheter at work. Catheter supply companies deliver catheters and other supplies by mail.

Absorbent Products

Absorbent products such as pads and adult diapers are available for incontinence. There are many designs. Some pads or panty liners have adhesive strips that attach to underwear. There are also undergarments, adult briefs and protective underwear. There are guards and drip collection pouches for men.

These products all absorb urine leakage and they help protect the skin from urine accordingly, they keep urine from wetting clothing. Pads can be disposable or reusable.

Absorbent incontinence products are designed to absorb and hold urine. Feminine hygiene pads are designed to absorb blood, not urine. The advantage of using incontinence products is that the surface area is closest to the urethral opening, which is above the vaginal opening. The pads are super absorbent and they cause less skin irritation and fewer rashes. Reusable pads are made of cloth with a rayon or polyester core and helps urine absorb.

When choosing a product, consider ease of use. Consider whether you need to remove outer clothing to change the device. Also consider absorbency, the liner, and the materials. For example, outside coverings made of plastic may irritate skin. Cost is also a concern for many people.

Toilet Substitutes

Portable devices can be very helpful if you cannot get to a regular toilet. These devices include commode seats or bedside commodes. There are also bedpans and urinals.

A bedside commode is placed close to the bed. It is easy to use at night or on a floor of the house with no bathroom. When choosing a commode you should consider its height and weight, how easy it is to empty, seat type, and cost. A soft surface may be more comfortable.

There are also raised seats (toilet raisers) that can help you get up and down from a regular toilet on your own.

Bedpans are usually not very effective or comfortable. Special fracture pans can help if you are recovering from surgery and can’t get out of bed.

Urinals (plastic jug-type devices) are useful if you cannot move easily. You urinate into these devices directly. They can help when restrooms are not accessible. They are also useful when traveling. And they are an option if you are confined to a bed or chair. Most urinals, such as the newer spill proof ones, are easier for men to use. Urinals for women are not as easy to use.

Skin Care Products

If you are using incontinence devices or products, you may need skin care. Over time, urine leakage can cause skin breakdown, rash and redness. Urine on your skin can lead to bacteria growth and infection.

Soaps, skin products, topical antimicrobials, cleansers and skin barrier products can all help if used properly. Frequent washing with soap and water can dry out your skin. Rinses or cleansers made to remove urine may be better for washing the skin around the urethra.

Disposable wipes or wash clothes rather than toilet tissue may help keep your skin healthy. Moisturizing creams, lotions or pastes keep the skin moist. They seal in or add moisture. Barrier products protect the skin from contact with moisture. They lower friction from absorbent incontinence products.

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.

Overactive Bladder vs. Stress Urinary Incontinence

“This information was made available with an “unrestricted educational grant from Pfizer Canada.”

Overactive bladder occurs when a muscle in the bladder known as the detrusor contracts more often than normal. This causes a person to feel a sudden and sometimes overwhelming urge to urinate even when the bladder isn’t full.

The symptoms of overactive bladder include:

  • Frequency — having to urinate more than 8 times over 24 hours, often including 2 or more times a night.
  • Urgency — frequent, sudden, strong urges to urinate with little or no chance to postpone urination.
  • Wetting accidents — (also called urge incontinence) : involuntary loss of or leaking urine following a sudden, strong desire to urinate.
  • It is estimated that most people with overactive bladder experience only the symptoms of urgency and frequency (63%). The remaining 37% have wetting accidents (urge incontinence) in addition to urgency and, often, frequency.

If you have these symptoms, don’t forget one important fact – overactive bladder can be treated regardless of the cause!

Who has Overactive Bladder?

It is estimated that nearly 1 in 5 Canadians over the age of 35 suffer from overactive bladder. Overactive bladder, with frequency and urgency only, affects men and women of all ages – most people with this condition are under age 65.

Types of Urinary Incontinence

Urinary incontinence is any involuntary loss of urine even if that is not considered a problem. There are different types of incontinence whose symptoms may appear to be similar. To help avoid confusion, the different types of urinary incontinence are described below.

Urge incontinence is a component of overactive bladder. Urge incontinence occurs when the bladder contracts involuntarily (detrusor overactivity). Symptoms include the sudden, uncontrollable need to urinate which can lead to wetting accidents. The urge to urinate can also be especially strong at night (nocturia) or may lead to accidental leakage while sleeping (enuresis).

Stress incontinence occurs when the muscles around your urethra become too weak to prevent the urine in your bladder from escaping when the bladder pressure rises with increased abdominal pressure. Even the small amount of stress created by coughing, sneezing, laughing, exercising or lifting can result in a bit of leaking. Many women experience this after vaginal childbirth and menopause and aging, and adjust their lives by wearing pads and diapers.

It’s important to remember that stress incontinence is NOT the same as overactive bladder. They have different symptoms, causes AND therefore, different treatments.

Mixed Symptoms (Overactive Bladder and Stress Incontinence)

Many people who have the symptoms of overactive bladder also suffer from stress incontinence. Unfortunately, there is no single treatment that works for both conditions. So if you have mixed symptoms, each will have to be treated separately.

To help you further differentiate between overactive bladder and Stress Urinary Incontinence

Mixed Urinary Incontinence (MUI) = Urge Urinary Incontinence (UUI) + Stress Urinary Incontinence (SUI). 3†

A combination of symptoms of overactive bladder and stress incontinence is common. The most bothersome symptom (overactive bladder or stress incontinence) should be treated first.4†

The Symptoms of overactive bladder (OAB) vs. Stress Incontinence (SI)

Working Diagnosis – Symptoms OB SI
Urgency (strong, sudden desire to void) Yes No
Frequency with urgency (> 8 times/24 hrs) Yes No
Leaking during physical activity No Yes
Amount of urinary leakage with each episode of incontinence Large
(if present)
Ability to reach toilet in time following an urge to void No Yes
Waking to pass urine at night Usually Seldom

References for the text:

  1. Abrams P. et al. The overactive bladder – A widespread and treatable condition. 1998; Erik Sparre Medical AB.
  2. Stewart WF, et al. Prevalence and burden of overactive bladder in the United States. World J Urol. 2003;20:327-336.
  3. Corcos J, et al. Prevalence of overactive bladder and incontinence in Canada. Can J Urol. 2004;77(3):2278-2284.
  4. Knapp PM. Identifying and treating urinary incontinence – the crucial role of the primary care physician. Postgraduate Med. 1998;103:279-294

Stress and Urge Urinary Incontinence in Women

Normal bladder function is represented by:

  • a frequency 4-6 per day (0-1 at night);
  • 1-2 cups of urine (250-500mls) are passed;
  • voiding can be deferred until convenient;
  • urine is passed in a steady continuous stream until bladder is empty
  • no leakage between visits to the toilet.

There are two main types of urinary incontinence: stress and urge incontinence. In some instances both types of incontinence can occur though the cause for each is different.

AMS Stress and Urge Urinary Incontinence in Women308.4 KB

Stress incontinence leads to leakage of urine when the pressure in the abdomen is higher than the sphincter (muscle closing the bladder outlet) pressure. Normally, contraction of the pelvic floor muscles compresses the urethra and prevents loss of urine when situations of raised intra-abdominal pressure occur thus preventing urine loss and stress incontinence (1). Urine loss from stress incontinence can happen with sneezing, coughing and during exercise such as lifting, jumping and walking.

Urge incontinence occurs when an uncontrollable need to void urine occurs due to overactivity of the bladder wall muscle. Typically this occurs as you put the key in the front door or when water is running. There is generally no weakness in the pelvic floor muscles or muscles controlling the bladder outlet. This is also known as overactive bladder syndrome.
Mixed incontinence occurs when there is muscle weakness and uncontrollable need to void.

There is a high incidence of stress and urge incontinence in the presence of chronic low back pain. This has been shown to be due to poor motor control in the local low back and pelvic floor muscles that work together to control continence as well as to support the spine. Both problems are often treated with transverses abdominus exercises otherwise known as core stabilising exercises.

Prevalence of incontinence

Incontinence is a problem to 35.3% of women. Stress Urinary Incontinence is a problem to 20.8%; urge2.9% and mixed 11.6%.
10.9%; of women who have not had babies find stress incontinence a problem and after their first baby 37.4% of women acquire the problem. 51.9% of women aged over 70 have some form of incontinence.

Management of Stress Incontinence:

Pelvic floor muscle exercises are the most effective method of treating stress incontinence (2). The efficiency of the pelvic floor muscle training can be improved with biofeedback (3) that assists in gaining a stronger contraction of the muscles through visual feedback from real time ultrasound imaging of the pelvic floor muscles or a dial or lights indicating increased pressure on a vaginal probe from pelvic floor muscle contraction. Physiotherapists can assist with achieving pelvic floor muscle contractions which many women find hard to localise. Control of continence is not achieved if all the muscles around the abdomen, pelvic floor and hips are contracted during the pelvic floor exercise so localised muscle training is needed to gain effect.

How to Contract the Pelvic Floor Muscles:

When lying on your back or sitting upright and not slumped; to contract the pelvic floor muscles you should gently draw up the muscles of your pelvic floor. The contraction should mainly be felt around the bladder opening. Placing the fingers over that area will allow you to feel the pelvic floor draw up and away from your fingers. During the slow gentle contraction keep breathing normally in and out. Once you can feel the contraction try holding the contraction with the pelvic floor drawn up away from your fingers. Keep breathing. Gradually increase the number of times as well as the duration of holding the contraction (where 10 second holds are recommended) when you practice the PFM contractions each day. Gradually you will be able to do these contractions at any time and when standing as the muscles strengthen. If you can’t get a contraction in this way in lying, try blowing a tissue held about 6 inches in front of your mouth so that it flutters a little. Feel the gentle tightening of the muscles with your other hand. Alternately when sitting very upright on a firm chair, lift your arms above your head. Feel the area around the bladder outlet pull up and away from the chair. See if you can hold that pelvic floor contraction when you lower your arms.

To prevent the stress episodes actively contract the pelvic floor before you do a movement that increases your abdominal pressure that leads to leakage. That is before you cough, sneeze, jump or pick up an object. Now you are using the ‘knack’ to control and prevent incontinence episodes.

By focusing on the anal area when contracting the pelvic floor muscles control of flatus and anal incontinence can be achieved.

Other approaches to treating stress incontinence

There are many types of surgery for stress incontinence and the cause of incontinence determines which surgery is undertaken so accurate diagnosis of cause of stress incontinence is vital. Around 80-90% of women will be cured by their operation. Unfortunately as time goes by a number of women will get a return of their urine leakage. This is most noticeable 5 to 10 years after surgery. Surgical intervention has been shown to be slightly better than medication management but has not been compared to exercise nor has the long term effect been investigated (4).
Medications have limited effect over placebo and have many adverse responses reported in these drug trials (5). Oestrogen used locally as a cream has been reported to provide some control of incontinence but the effect is not long lasting (6).

Management of Urge Incontinence:

  • Bladder retraining (7) – deferment to gradually increase bladder capacity
  • Urge control strategies (Pelvic Floor muscle contraction with a hold of the contraction, perineal pressure over the urethral outlet, toe pressure (grip floor with toes), distraction strategies)
  • Pelvic floor exercises
  • Remove irritants eg alcohol & tea & coffee
  • Anticholinergic medication to decrease detrusor over activity (vesicare, ditropan, oxytrol)
  • Neuromodulation S2,3,4 dermatome via Sacral Nerve stimulation implants

Prolapse – Pooling of urine in the bladder is often a problem where there is a cystocoele due to poor bladder support underneath. Leaning the trunk forwards at the hips and not straining to empty the bladder when urinating will help empty the bladder more completely and reduce leakage when standing up after going to the toilet. Success rates for prolapse surgery vary and up to 20-30% of women will require a second operation to treat prolapse in the future. This may be due to the recurrence of an old prolapse or development of a new prolapse.

Pelvic floor muscle exercises also help reduce prolapse in mild to moderate cases. Some adaptation of lifestyle to reduce problem of raised intra-abdominal pressure such as reducing lifting also helps.

Avoiding straining to defecate is also suggested.

Rare causes of incontinence are due to neurological disorders such as multiple sclerosis or spinal cord injury and management in these instances are tailored to the individual woman’s needs.

Where to seek further help/ information:

Australian Physiotherapy Association website:
Then go to Find a Physio and choose a Women’s Health & Continence physio close to you.
Urogynaecology clinic or Physiotherapy Department in a public hospital.

1. Sapsford R Hodges PW Contraction of the Pelvic Floor Muscles During Abdominal Maneuvers Arch Phys Med Rehabil Vol 82, August 2001
2. Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD005654. DOI:
3. Herderschee R, Hay-Smith EJC, Herbison GP, Roovers JP, HeinemanMJ. Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women. Cochrane Database of Systematic Reviews 2011, Issue 7. Art.No.: CD009252. DOI:10.1002/14651858.CD009252.
4. Rehman H, Bezerra CCB, Bruschini H, Cody JD. Traditional suburethral sling operations for urinary incontinence in women. Cochrane Database of Systematic Reviews 2011, Issue 1. Art. No.: CD001754. DOI: 10.1002/14651858.CD001754.pub3.
5. Alhasso A, Glazener CMA, Pickard R, N’Dow JMO. Adrenergic drugs for urinary incontinence in adults. Cochrane Databaseof Systematic Reviews 2005, Issue 3. Art. No.: CD001842. DOI: 10.1002/14651858.CD001842.pub2.
6. Cody JD, Richardson K, Moehrer B, Hextall A, Glazener CMA. Oestrogen therapy for urinary incontinence in post-menopausal women. Cochrane Database of Systematic Reviews2009, Issue 4. Art. No.: CD001405. DOI:10.1002/14651858.CD001405.pub2.
7. Wallace SA, Roe B, Williams K, Palmer M. Bladder training for urinary incontinence in adults. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD001308. DOI: 10.1002/14651858.CD001308.pub2

Content updated May 2013

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