Does Nicotine Use Affect Urinary Incontinence?
Yes, nicotine use significantly increases the risk of urinary incontinence in women, with both current and former smokers showing approximately 2-3 times higher odds of developing both stress and motor (urge) incontinence compared to never-smokers.
Evidence for Nicotine's Impact on Incontinence
Epidemiological Evidence
The relationship between smoking and urinary incontinence is well-established through case-control studies:
Current smokers have 2.48 times the odds of developing genuine stress incontinence (95% CI: 1.60-3.84) and 1.89 times the odds of motor incontinence (95% CI: 1.19-3.02) compared to never-smokers 1
Former smokers remain at elevated risk with 2.20 times the odds for stress incontinence (95% CI: 1.18-4.11) and 2.92 times the odds for motor incontinence (95% CI: 1.58-5.39), indicating lasting effects even after cessation 1
Dose-response relationship exists for stress incontinence: increasing daily and lifetime cigarette consumption correlates with progressively higher odds ratios for genuine stress incontinence, though not for motor incontinence 1
Among women with incontinence, 60% were current or former smokers versus only 32% in continent controls (p = 0.000009), representing a highly significant difference 1
Type-Specific Effects
The impact varies by incontinence subtype:
Motor (urge) incontinence appears more strongly associated with smoking than stress incontinence, with heavy current smokers developing motor incontinence more frequently, though this difference did not reach statistical significance 2
Stress incontinence is more common in non-smokers among those who develop incontinence (21/32 in non-smokers vs 19/48 in smokers, p < 0.0025), suggesting nicotine preferentially promotes motor incontinence 2
Surgical Outcomes
Nicotine use affects treatment success:
Tobacco use increases the risk of requiring reoperation for stress urinary incontinence by 43% (OR = 1.43, p < 0.001) within 2 years of initial surgery 3
This increased failure rate occurs alongside other risk factors including obesity (OR = 2.97), anti-muscarinic use (OR = 1.68), and diabetes (OR = 1.21) 3
Mechanisms of Nicotine-Induced Incontinence
Direct Bladder Effects
Animal studies reveal nicotine's direct actions on bladder function:
Nicotine increases intravesicular pressure and triggers bladder contractions through mechanisms that are atropine-resistant and not mediated by adrenergic or cholinergic pathways 4
Purinergic mechanisms via P2-receptor activation in the urinary bladder appear responsible for nicotine-induced contractions 4
Nicotine elevates pelvic afferent nerve activity, which can trigger reflex bladder contractions, particularly with sustained exposure 5
Continuous nicotine infusion produces maintained elevation of afferent discharge that persists after withdrawal, leading to repetitive bladder contractions 5
Systemic Cardiovascular Effects
Broader vascular impacts contribute to incontinence risk:
Nicotine causes significant cardiovascular effects including increased blood pressure, heart rate, arterial narrowing, and arterial wall hardening that may compromise pelvic blood flow 6
These vascular changes may affect the structural integrity of pelvic floor tissues and urethral support mechanisms 6
Clinical Implications
Screening and Counseling
When evaluating women for urinary incontinence:
Inquire specifically about current and past tobacco use, including duration, daily consumption, and tar/nicotine content to calculate total exposure 2
Classify smoking status precisely: current smokers, former smokers (with time since cessation), and never-smokers, as risk persists even after quitting 1
Document smoking history before surgical intervention for stress incontinence, as tobacco use predicts higher reoperation rates 3
Treatment Recommendations
Strongly counsel all women with incontinence to quit smoking, as this represents a modifiable risk factor that affects both disease development and treatment outcomes 7, 1
Implement evidence-based cessation strategies:
Nicotine replacement therapy (patches, gum, lozenges, nasal spray, or inhalers) substantially improves quit rates, particularly when started before the cessation date 7
Combination nicotine replacement therapy outperforms single formulations for achieving abstinence 7
Pharmacologic adjuncts including bupropion and varenicline improve cessation success 7
Brief physician advice alone increases quit rates, making even minimal counseling worthwhile 7
Surgical Planning
For women requiring surgical treatment:
Consider tobacco use as a significant predictor of surgical failure when counseling patients about expected outcomes 3
Strongly encourage smoking cessation before elective incontinence surgery to optimize surgical success rates 3
Weight loss should be emphasized in obese smokers, as this combination represents the highest risk for reoperation (OR = 2.97 for obesity alone) 3
Important Caveats
The increased incontinence risk from smoking cannot be explained by confounding factors such as age, parity, weight, or hypoestrogenic status, indicating a direct causal relationship 1
Even former smokers maintain elevated risk, suggesting permanent structural or functional changes from past nicotine exposure 1
While nicotine has some documented anti-inflammatory effects in animal models, any potential benefits are vastly outweighed by harmful effects, particularly addiction potential and the specific detrimental impact on bladder function 6
Recreational nicotine use should be strongly discouraged in all women, especially those with or at risk for urinary incontinence 6