Incontinence

What is Incontinence?

Incontinence is the involuntary loss of urine or stool. Urinary incontinence is common in older adults, especially those in nursing homes, but it also affects younger adults of both sexes, and many people never mention it to a clinician.^[1] Fecal incontinence ranges from leaking gas to losing liquid or solid stool and can seriously affect quality of life.^[2]

Common symptoms

Symptoms depend on the type. Stress incontinence is leakage during effort such as coughing, sneezing, laughing, lifting or exercise. Urge incontinence is a sudden, strong need to urinate followed by leakage.^{[3, 4]} Mixed incontinence combines both.

• Overflow incontinence, with dribbling because the bladder does not empty well
• Functional incontinence, when mobility or thinking problems make it hard to reach a toilet in time^[1]
• Leakage of liquid or solid stool, or an urge to pass stool that cannot be controlled^[2]
• Getting up at night to urinate, which can disturb sleep^[4]

Causes and risk factors

Urinary incontinence has several distinct causes. In women, pregnancy, vaginal delivery, menopause, obesity, smoking, chronic constipation and pelvic surgery raise the risk of stress incontinence. Pelvic organ prolapse is often linked to it. In men, stress incontinence usually follows prostate surgery.^[3] Medicines, nerve conditions and reversible problems such as infection should be looked for first.^[1]

Fecal incontinence can result from damage to the anal sphincter, hemorrhoids, rectal prolapse, laxative use, inflammatory bowel disease and infections.^[2]

How it is diagnosed and treated conventionally

A careful history usually identifies the type of urinary incontinence. A urine test, a check of how well the bladder empties and, in women, a pelvic examination help clarify the cause.^[4]

Treatment usually starts with conservative steps: bladder training, pelvic floor muscle training, cutting back on caffeine, weight loss and vaginal estrogen for some women.^{[4, 5]} Medicines for overactive bladder, nerve stimulation, injections and surgery are used when these are not enough.^[5] A Cochrane overview found high-certainty evidence that pelvic floor muscle training is more beneficial than control for all types of urinary incontinence in women.^[6]

Why Incontinence calls for a whole-person approach

Incontinence rarely has a single cause. Muscles, nerves, hormones, weight, bowel habits, medicines and mood all play a part, and the type of leakage decides which of these matter most.^{[1, 3]}

Care that looks at these factors together can help alongside targeted treatment of the bladder or bowel. It cannot replace finding out which type of incontinence you have.

Pelvic floor and nerve control

Stress incontinence arises when the structures that keep the urethra closed no longer cope with pressure from the abdomen.^[3] Weak or damaged pelvic floor muscles and nerves are also a recognized cause of urine and stool leakage.^{[1, 2]}

Weight, bowel habits and lifestyle

Obesity, smoking and chronic constipation are modifiable risk factors for stress incontinence.^[3] A Cochrane overview found high-certainty evidence that weight loss led to more improvement than control in women with urinary incontinence.^[6]

Hormones and life stage

Pregnancy, childbirth and menopause are linked to stress incontinence in women.^[3] In men, prostate surgery is the usual trigger.^[3]

Mood, sleep and daily life

Incontinence is associated with depression, anxiety, social isolation and lost sleep from nighttime urination. It also raises the risk of falls from extra trips to the bathroom.^[4]

Acupuncture for Incontinence

What the research shows

The research is strongest for electroacupuncture in women with stress urinary incontinence. In a trial at 12 hospitals in China, 504 women received 18 sessions over 6 weeks of electroacupuncture or sham electroacupuncture without skin penetration. Urine leakage on a 1-hour pad test fell by 9.9 g with electroacupuncture and 2.6 g with sham. Fewer incontinence episodes were still reported at later follow-up, and side effects were mild in both groups.^[7] A meta-analysis found electroacupuncture improved leakage and symptom scores compared with sham, and combined with pelvic floor training did better than training alone, though results varied a lot between trials.^[8]

Results are less certain for other types. A Cochrane review of 15 studies of overactive bladder found the evidence very uncertain against sham acupuncture and low-certainty for a slight benefit over medication. All studies had some concern about bias.^[9] A review of 30 studies found acupuncture better than sham for overactive bladder symptom scores and similar to drugs, with mostly low or very low certainty.^[10]

Other groups have fewer studies. A review of 15 trials of electroacupuncture after stroke found fewer 24-hour leakage episodes than with sham electroacupuncture or with basic treatment alone, but no improvement in responder rate against active treatments, and the evidence was mostly low or very low certainty.^[11] A single-center trial of 110 men after prostate removal found more men regained continence at 6 weeks with electroacupuncture than with sham (43.6% versus 21.8%).^[12] In an 85-patient trial of fecal incontinence, acupuncture was compared with biofeedback rather than sham, and the acupuncture group had fewer episodes at week 15, though longer follow-up is needed.^[13]

How acupuncture may work

How acupuncture helps incontinence is not established. The authors of the large stress incontinence trial said that long-term benefit and the mechanism still need research.^[7] Electroacupuncture in these trials was applied to the lower back and sacral region, where nerves supply the bladder and pelvic floor, but this is a description of the method, not proof of how it works.^{[7, 12]}

What treatment involves

Treatment uses fine, sterile, single-use needles, with sessions of about 20 to 40 minutes, and some points are connected to a mild electrical stimulator. Trials of electroacupuncture used 3 sessions a week for 6 weeks, and one prostatectomy trial used 30-minute sessions.^{[7, 12]} We reassess after a short course of visits.

In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[14] Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker or other implanted device, which matters for electroacupuncture.

Ayurvedic medicine for Incontinence

The Ayurvedic view

Ayurveda does not have one condition that matches incontinence. Loss of bladder control is traditionally described as a disturbance of Vata, the principle said to govern downward movement and elimination. These are traditional categories, not biomedical diagnoses.

Therapies that may be used

Ayurvedic care is chosen for the individual and traditionally includes:

• Diet and routines meant to calm Vata, such as warm, regular meals, steady sleep and avoiding long constipation
• Gentle warm-oil massage of the lower back and legs
• Individually prescribed herbs

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty. Because many people with incontinence are older or have other illnesses, they should only be considered after medical review and with your physician's knowledge.

What the research shows

We found no clinical trials of Ayurvedic medicine, Ayurvedic herbs or Panchakarma for incontinence in PubMed, so the evidence is none. The closest studied practice is yoga, which comes from the same Indian tradition. A Cochrane review found only two small trials, 49 women in total, and was uncertain whether yoga helps incontinence.^[15] A later trial of 240 women found a pelvic floor yoga program was not better than a general stretching and strengthening program.^[16]

Herbal medicine for Incontinence

Herbs and formulas that have been studied

Research on herbs for incontinence is thin. Traditional Chinese medicine therapies have been studied for female stress incontinence, and a Japanese herbal formula, gosha-jinki-gan, has been tried in women with overactive bladder.^{[17, 18]} Herbs are prescribed individually and not as a standard remedy.

What the research shows

The evidence is very limited. A meta-analysis of 8 studies with 744 women reported that traditional Chinese medicine therapy improved clinical outcomes, symptom scores and urodynamic measures in stress incontinence. Its abstract does not separate herbs from other methods or rate study quality, so it cannot be read as proof for herbs.^[17] The gosha-jinki-gan report was a single-group study of 44 women with no placebo group. About half reported better quality of life, and about 9% had side effects.^[18]

Safety and herb-drug interactions

Herbs can interact with medicines. Case reports describe bleeding when warfarin was combined with herbs including dan shen, dang gui, ginseng, ginger and Boswellia.^[19] Tell us every medicine and supplement you take so that herbs can be checked against them.

About one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine often describes incontinence as weakness or deficiency of kidney and spleen qi, with the bladder failing to hold. Researchers instead study the pelvic floor muscles, the nerves to the bladder, urethral closing pressure and bladder sensation.^{[3, 17]}

Ayurveda's Vata imbalance describes downward-moving functions that are not well controlled. No study has shown that a dosha corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for incontinence is complementary. Keep seeing your physician, urologist, urogynecologist or pelvic floor therapist, and do not stop or change prescribed medicines without your prescriber. We do not diagnose the type or cause of incontinence, so new or changing leakage should be evaluated first.^[1]

Please bring your diagnosis, any urodynamic or imaging reports, a full list of medicines and supplements, and details of past surgery, including prostate or pelvic surgery.

When to seek urgent medical care

Some symptoms suggest a serious cause that needs prompt assessment.

• Sudden loss of bladder or bowel control with new back pain, leg weakness or numbness in the groin or inner thighs
• Being unable to pass urine, or a painfully full bladder
• Blood in the urine, or fever, flank pain or burning with urination
• Blood in the stool or black stools with bowel leakage
• Incontinence that starts suddenly after a stroke, head injury or with confusion

If any of these occur, call 911 or go to the nearest emergency department.