Symptoms of both stress and urge
Mixed Incontinence occurs when there is a combination of both stress urinary incontinence and urge urinary incontinence (overactive bladder).
There are many possible causes of incontinence in men and women, sometimes with multiple causes occurring at the same time. When multiple causes occur, it can make diagnosis difficult.
Life events are often the cause of urinary incontinence, whether it’s aging or bearing children. Urinary incontinence may also appear as a side effect of a medication prescribed for a non-urinary problem or caused by bladder or urinary tract infections.
Since mixed incontinence is a combination of stress and urge incontinence, it shares the symptoms of both:
Risk Factors & Complications
Mixed incontinence is more common among older women, but gender and age are not the only factors. According to the Urology Care Foundation, risk factors of getting urinary incontinence include:
- Pregnancy and childbirth
- Chronic coughing
- Nerve injuries to the lower back
- Pelvic surgery
- Caucasian or Hispanic race
- Overweight or obesity
If urinary incontinence goes untreated, it can lead to infections and other problems. While physical discomfort affects your daily life, the emotional stress of dealing with urinary incontinence is an important factor to consider. The Urology Care Foundation, official foundation of the American Urological Association, says many people who have urinary incontinence don’t tell anyone about their symptoms; they’re embarrassed and believe nothing can be done, and so suffer in silence. Dealing with urinary incontinence without treatment can affect the emotional, psychological and social life – those who suffer are not able to live their full lives, afraid to stray too far from a toilet.
Many people think urinary incontinence is just part of getting older. It’s not. And it can be treated, or even cured.
The Urinary Care Foundation says a quarter to a third of men and women in the U.S. suffer from urinary incontinence. The exact number is unknown because it’s not a problem easily talked about; those affected may be embarrassed or think nothing can be done.
Urinary incontinence can affect a person’s emotional, psychological and social life – it is not just a medical issue. Those who have urinary incontinence are hesitant to do daily activities, not wanting to stray too far from a toilet.
Below are the best ways to treat mixed incontinence.
Depending on the severity, type or underlying cause of incontinence, your doctor may recommend these treatments first to help strengthen and train your pelvic floor and bladder.
- Bladder Training: It is possible to train the bladder to hold out for longer and longer periods between bathroom visits. You may begin bladder training by holding off for 10 minutes once you have the urge to urinate and then slowly increase the amount of time until you are going every two to four hours.
- Fluid Management: Having a reasonable fluid intake, drinking less, avoiding coffee, tea, caffeinated sodas and alcohol.
- Double Voiding: Urinating twice – once you urinate you wait a few minutes and urinate again to release any residual urine.
- Scheduled Trips to the Restroom: Urinating every two to four hours instead of waiting for the urge to go to the bathroom.
Absorbent Pads & Catheters
Absorbent products may be used to manage any form of incontinence. However, incontinence products are NOT a TREATMENT for incontinence; for some individuals, urinary incontinence products are a temporary strategy until they address and resolve the underlying cause of their incontinence. Most people find the use of pads, diapers and bladder supports to be extremely inconvenient, expensive and impacts their quality of life.
According to WebMD, absorbent products, such as adult diapers, plastic-coated underwear, pads or panty liners that attach to underwear can be used if:
- Your incontinence is not a significant disruption in your life
- You are waiting for another treatment for incontinence to take effect
- Your incontinence cannot be treated by other means
- You prefer to use absorbent products rather than medicines or surgery
Risks when using absorbent products include irritation around the groin area and an increased risk of urinary tract infections.
Product options include:
- Depends® Adult Underwear
- Tena Serenity®
- Poise® Pads
- Always Discreet®
Treatment of the pelvic floor is a specialized aspect of physical and occupational therapy. There are a wide range of issues that can arise from weakness in the muscles of the pelvic floor or around the organs inside the pelvis such as urinary frequency, urgency or problems with incontinence and interstitial cystitis.
Patients typically attend in-office appointments 2-3 times per week for a duration of 12 weeks. Treatment requires manual digital manipulation of the external and internal tissues of the pelvis, vagina and/or rectum. This type of therapy is fairly intimate and can be uncomfortable for some patients.
Therapists will often utilize bladder training, biofeedback, pelvic floor muscle exercises and electrical muscle stimulation. With mixed incontinence, your doctor will need to recommend the best treatment for your situation.
Pelvic Floor Muscle Exercises (Kegel Exercises)
Many physicians recommend Pelvic Floor Exercises as a first line treatment for Stress and Urge bladder leakage. The goal of pelvic floor muscle training is to strengthen weak urinary sphincter and pelvic floor muscles – the muscles that control urination and defecation.
Pelvic floor muscle exercises are often referred to as “Kegel” exercises; named after the physician, Dr. Arnold Kegel, who popularized this technique.
How to Perform Kegel Exercises
Imagine attempting to stop the flow of urine or passing gas. When you perform this action you are contracting the muscles of the pelvic floor. It is extremely important that you are contracting these muscles in isolation and NOT using your abdominal, buttock or leg muscles.
The Problem with Kegel Exercises
Research has shown that over half of women who attempt Kegel exercises do them incorrectly by overusing their abdominal, buttock or leg muscles resulting in no improvement in pelvic floor muscle strength—remember, you have to contract these muscles in isolation in order to be effective! In addition, if you already have very weak pelvic floor muscles, you may not be able to contract them effectively.
Finally, according to Dr. Arnold Kegel, “Muscles that have lost tone, texture and function can be restored to use by active exercise against progressive resistance since muscles increase in strength in direct proportion to the demands placed upon them.” Simply put, you need to perform your exercises with active resistance—something to squeeze against.
There are devices available, including over-the-counter devices (no prescription required) to assist you in identifying the correct muscles and providing active resistance.
Biofeedback is a technique that provides you with real-time information about activity in the bladder and pelvic muscles to help you learn to contract these muscles properly. Sensors are placed internally and/or externally within or around the vagina or rectum. Many trained specialists, such as physical therapists, occupational therapists, and nurses provide these services. Patients typically require 2-3 in-office visits per week to learn how to isolate and contract the pelvic floor muscles while using biofeedback to guide performance. In addition, there are biofeedback products available for home use.
Medical devices can be used to help build and strengthen pelvic floor muscles, treating incontinence at the issue instead of just managing the result. According to the Mayo Clinic, “gentle electrical stimulation can be effective for stress incontinence and urge incontinence, but you may need multiple treatments over several months.”
Electrical Muscle Stimulation
The use of electrical muscle stimulation for urinary and fecal incontinence spans a 30 year period and has gained popularity as it is an effective, safe, non-invasive treatment for treating stress, urge, mixed urinary incontinence and fecal incontinence.
Electrical stimulation resolves incontinence by treating the underlying problem – it strengthens weak pelvic floor muscles and can calm an over-active detrusor muscle without the use of medications or surgery. Muscle stimulation is a first-line treatment option that should be used prior to more invasive options.
Muscle stimulation causes a contraction of the pelvic floor muscles to strengthen them (resolving stress incontinence) and can also calm an overactive detrusor muscle (resolving urge incontinence). This therapy is very valuable when a person is too weak to contract their muscles on their own and also helps you to isolate the pelvic floor muscles.
Electrical muscle stimulation can be done in your doctor or therapist’s office or in the privacy of your home with an over-the-counter (no prescription necessary) muscle stimulation device.
InControl Medical ApexM
A recent clinical study shows a 90% improvement in daily incontinence occurrences over a 12-week period. ApexM treats the underlying causes of incontinence – weak pelvic floor muscles and an overactive detrusor muscle through gentle muscle stimulation surrounding the muscles that allow you to squeeze your urethra, stopping any unwanted leakage. The device is used intravaginally and can be done in the privacy of your own home. Learn more about InControl Medical ApexM here.
InterStim was developed by Medtronic and has been FDA-approved since 1997 for urge incontinence and since 1999 for urinary retention and urgency-frequency. According to a clinical study sponsored by Medtronic, 59% of patients with urge incontinence who received and completed follow-up with their physicians had at least 50% fewer leaks per day compared to the number of leaks before therapy. Learn more about Medtronic InterStim here.
As mixed incontinence is a combination of urge and stress incontinence, your doctor may recommend medication options.
For urge incontinence, drug treatment has a strong ACP recommendation if bladder training is unsuccessful. Medications are available to treat your bladder leakage. As with any medication, there are side effects. Be sure to discuss with your care provider all potential side effects of the medication and be sure to share with your provider a list of all medications that you are currently taking.
Physicians often prescribe anticholinergic/antimuscarinics medications to help with urge incontinence. These pills or patches block the nerves that trigger contraction in the bladder muscle and prevent bladder spasms. The most common side effects include dry mouth and constipation.
Mirabegron (Myrbetriq®) is another medication used to treat incontinence by relaxing the bladder muscle and increasing the amount of urine the bladder may hold. Most common side effects include increased blood pressure, common cold symptoms, headache and urinary tract infection.
In men with urge or overflow incontinence, alpha blockers help to relax bladder beck muscles and muscle fibers found in the prostate to make it easier to empty the bladder.
As with all medications, please discuss potential side effects with your physician and be sure to let them know your complete list of medications that you are currently taking.
Note: Medications do nothing to strengthen the pelvic floor muscles.
Neurotoxin Injection (Botox)
Also, Botox injected into the bladder muscle causes the bladder to relax, increasing its storage capacity and reducing episodes of urinary incontinence. It can be used for adults who do not respond to or can’t use the medications listed above.
Neurotoxin (Botox®) is used for urge incontinence. Toxin is injected into the detrusor muscle (the muscle that surrounds the bladder) to limit the muscle’s ability to contract, thus diminishing the symptoms of urgency for a period of time. Injections must be completed with regularity, as the effects of the injection diminish.
Common side effects:
- Urinary retention (not being able to empty the bladder completely) which may require catheterization
- Urinary tract infection
- Hematuria (blood in the urine)
- Fatigue (extreme tiredness)
- Insomnia (difficulty getting to sleep and or staying asleep)
Note: Does not strengthen of the pelvic floor muscles.
According to the Cleveland Clinic, approximately 11 percent of patients seeking treatment for urinary incontinence will undergo surgery.
Sling surgery for stress urinary incontinence is often done as an outpatient procedure. One option for stress incontinence is to place the bladder in a “sling” – a piece of tissue or synthetic material is used to create a sling around the bladder neck and urethra in order to provide support to keep the urethra closed in order to prevent leaks. As with any surgical procedure, please discuss thoroughly with your physician the benefits and possible complications that may exist.
The Cleveland Clinic describes different types of sling procedures:
- Tension-Free Transvaginal Tape (TVT): When a woman has finished having children, a minimally invasive treatment can fix stress urinary incontinence (SUI), allowing her to return to a full and active life. TVT can stop urine leakage by supporting the urethra with a tape-like strip of mesh. Used in an approximately 30-minute outpatient procedure, it has shown proven results for the treatment of SUI. A mesh-like tape is inserted under the urethra to create a supportive sling. This provides support and allows the urethra to remain closed when appropriate, preventing urine loss during sudden movements or exercise. Patients may be able to go home as early as a few hours after the procedure and patients can expect a short recovery period. The best way to determine if you are a candidate for this treatment is to ask your doctor.
- Transobturator Tape (TOT) Sling: First developed in Europe, the transobturator tape (TOT) sling procedure is meant to eliminate stress urinary incontinence by providing support under the urethra. The minimally invasive procedure involves inserting a mesh tape under the urethra through three small incisions in the groin area. Studies have shown that the safer, more efficient tot sling procedure decreases the risks of bowel and bladder injury and major bleeding and has an excellent cure rate.
- Mini-Sling: The Mini Sling procedure is the latest and least invasive treatment for stress urinary incontinence. The five to 10-minute procedure utilizes the same concepts of the tension-free tape mid-urethral slings, but involves a single incision. This procedure has displayed a high cure rate and reduces the risk of bowel injury, bladder injury, and major bleeding because it bypasses retropubic needle passage altogether.
Note: Does nothing to strengthen the pelvic floor muscles.
Bladder neck suspension
This procedure will support your bladder neck and urethra. The bladder neck is an area of muscle where the bladder connects to the urethra. The surgery involves an abdominal incision, so it can be done during general or spinal anesthesia.
If a woman has mixed incontinence as well as a pelvic organ prolapse, surgery may include a combination of sling and prolapse surgery.
Artificial urinary sphincter
For men, a small, fluid-filled right is implanted around the bladder neck to keep the urinary sphincter shut until you’re ready to urinate. When you do urinate, you press a valve implanted under your skin that causes the ring to deflate and allows urine to flow.