Types of Urinary Incontinence in Men: Urge, Stress and Overflow

Urinary incontinence, defined as the involuntary leakage of urine, is a complaint that also affects men. Because it is more commonly associated with women, men often delay mentioning it; some patients spend years managing the situation by using pads or restricting their daily lives. Incontinence, however, is not a single condition but a group of complaints resting on different mechanisms, and treatment varies according to that mechanism.

Correct treatment therefore begins with correctly identifying the type. An approach used for urge incontinence may not provide the expected benefit in stress incontinence; and in overflow incontinence, interventions carried out without addressing the underlying obstruction will not produce results. This article covers the types of urinary incontinence seen in men, how they are distinguished from one another and which investigations guide that distinction.

What is urge incontinence?

Urge incontinence is leakage that occurs alongside a sudden and hard-to-suppress need to pass urine, before the patient can reach the toilet. The underlying problem here is the bladder itself: the bladder muscle contracts involuntarily before it is full, and the patient cannot control this contraction.

Its typical features are:

• A sudden, undeferrable need to pass urine
• Frequent urination during the day and waking at night
• Leakage while approaching the toilet or turning a key in the door
• Triggering by stimuli such as the sound of running water or cold air

Urge incontinence may be part of an overactive bladder picture, but it can also relate to changes in the bladder caused by long-standing obstruction from prostate enlargement, to neurological conditions, or to irritative conditions within the bladder.

What is stress incontinence?

Stress incontinence is leakage occurring at moments when intra-abdominal pressure rises, without any sensation of needing to pass urine. It appears during coughing, sneezing, laughing, lifting a weight or standing up. The problem here is not in the bladder but in the closure mechanism that holds urine.

The most common cause of stress incontinence in men is an effect on the continence mechanism after prostate surgery; this picture may be seen particularly after radical prostatectomy performed for prostate cancer. Less frequently, trauma involving the pelvic area, neurological causes and some surgical procedures may be responsible.

The severity of stress incontinence varies widely: some patients experience only a few drops during heavy exercise, while others may need pads throughout the day. This difference in severity directly affects the treatment plan.

What is overflow incontinence?

Overflow incontinence is leakage from a bladder that fills because it cannot empty adequately. The patient generally reports being unable to empty fully, passing urine in an interrupted stream and dribbling afterwards.

The most common cause of this type in men is obstruction of urine outflow due to prostate enlargement; urethral stricture and conditions affecting the contractile power of the bladder muscle may also be responsible. Diseases affecting the bladder muscle, such as nerve involvement due to diabetes, can produce a similar picture when the patient cannot empty the bladder even without obstruction.

Overflow incontinence is not merely a complaint affecting quality of life; urine constantly remaining in the bladder can create the conditions for recurrent urinary tract infections, stone formation and, over time, problems that may affect kidney function. It therefore requires particular attention.

Mixed type and other situations

In some patients more than one mechanism is present rather than a single type. The most common example is mixed incontinence, where urge and stress types occur together. In a patient who has had prostate surgery, for instance, both leakage related to the closure mechanism and urgency arising from the bladder may be present.

Beyond these, there are situations where the bladder and closure mechanism work normally but the patient cannot reach the toilet in time; restricted mobility, advanced age and some neurological conditions can lead to this picture. In addition, certain medications such as diuretics can contribute to the existing situation by increasing urinary symptoms.

How are the types distinguished?

The first and most important step in making the distinction is a detailed history. The moments at which leakage occurs, whether it is preceded by a sensation of urgency, how many pads are needed daily and any previous operations are all asked about. In most patients this information largely establishes the type.

Investigations supporting the history include:

• Bladder diary: Recording fluid intake, urine volumes and episodes of leakage over several days; this guides the distinction between urge and stress types.
• Pad test: Provides an objective assessment of the volume of urine leaked.
• Urinalysis: Performed to exclude additional conditions such as infection or blood in the urine.
• Uroflowmetry and residual volume measurement: Shows urine flow rate and the urine remaining in the bladder after voiding; important in identifying overflow incontinence.
• Ultrasound: Allows assessment of the bladder, prostate and kidneys.
• Urodynamic study: Shows in detail how the bladder and closure mechanism function, in patients where the picture is unclear, where more than one mechanism is suspected or where surgery is planned.
• Cystoscopy: Where considered necessary, the urethra and the inside of the bladder are assessed directly.

Not all of these investigations are performed in every patient; which tests are needed is determined by the history and examination findings.

Which type calls for which treatment?

Treatment is planned according to the mechanism identified. In general terms:

• In urge incontinence: Bladder training, adjusting fluid intake and drinks that irritate the bladder, pelvic floor exercises and, where needed, medication directed at the bladder muscle come to the fore. In cases that do not respond, advanced options such as intravesical treatments or sacral neuromodulation may be considered.
• In stress incontinence: Pelvic floor rehabilitation is the first step; if the complaint persists, surgical options are assessed according to the severity of leakage. In patients with severe leakage, an artificial urinary sphincter may be considered.
• In overflow incontinence: The priority is addressing the cause preventing the bladder from emptying; obstruction from the prostate, urethral stricture or bladder muscle dysfunction is treated accordingly.
• In mixed incontinence: The component affecting the patient most is prioritised and treatment is planned in stages.

The starting step common to every type is lifestyle adjustment and correct activation of the pelvic floor muscles. Where these steps alone are not sufficient, more advanced options are assessed.

When should a doctor be consulted?

Urinary incontinence is not an inevitable consequence of ageing, and in most cases it has a cause that can be assessed. Prompt review is advised in the following situations:

• Leakage severe enough to require pads
• Difficulty passing urine, an interrupted stream or a sense of incomplete emptying
• Blood in the urine
• Recurrent urinary tract infections
• Leakage of sudden onset or rapidly increasing
• Accompanying neurological symptoms such as weakness or numbness in the legs

Urinary incontinence in men is a complaint that can largely be managed once the type is correctly identified. Urge, stress and overflow types rest on different mechanisms, so the treatment plan is formed after a detailed history, examination and any investigations considered necessary. Assoc. Prof. Dr. Zülfü Sertkaya practises in urology and andrology in Istanbul; assessment of urinary incontinence is carried out with individual planning and confidentiality.

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