Urinary incontinence

2 Pathophysiology

Urinary incontinence (UI), involuntary urination, is

any leakage of urine. It can be a common and distressing
problem, which may have a profound impact on quality
of life. Urinary incontinence almost always results from
an underlying treatable medical condition but is underreported to medical practitioners.[1] Enuresis is often used
to refer to urinary incontinence primarily in children, such
as nocturnal enuresis (bed wetting) [2]

Continence and micturition involve a balance between

urethral closure and detrusor muscle activity. Urethral
pressure normally exceeds bladder pressure, resulting in
urine remaining in the bladder. The proximal urethra and
bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the
pressure dierential unchanged, resulting in continence.
Normal voiding is the result of changes in both of these
pressure factors: urethral pressure falls and bladder pressure rises.

Causes

The body stores urine water and wastes removed by the

kidneys in the urinary bladder, a balloon-like organ.
The bladder connects to the urethra, the tube through
which urine leaves the body.

The most common types of urinary incontinence in

women are stress urinary incontinence and urge urinary incontinence. Women with both problems have
mixed urinary incontinence. Stress urinary incontinence
is caused by loss of support of the urethra which is usually a consequence of damage to pelvic support structures
as a result of childbirth. It is characterized by leaking of
small amounts of urine with activities which increase abdominal pressure such as coughing, sneezing and lifting.
Additionally, frequent exercise in high-impact activities
can cause athletic incontinence to develop. Urge urinary
incontinence is caused by uninhibited contractions of the
detrusor muscle. It is characterized by leaking of large
amounts of urine in association with insucient warning
to get to the bathroom in time.

During urination, detrusor muscles in the wall of the bladder contract, forcing urine out of the bladder and into
the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the
body. Incontinence will occur if the bladder muscles suddenly contract (detrusor muscle) or muscles surrounding
the urethra suddenly relax (sphincter muscles).

2.1 Children
Main article: Enuresis

Polyuria (excessive urine production) of which,

in turn, the most frequent causes are: uncontrolled diabetes mellitus, primary polydipsia (excessive uid drinking), central diabetes insipidus and
nephrogenic diabetes insipidus.[3] Polyuria generally
causes urinary urgency and frequency, but doesn't
necessarily lead to incontinence.

Urination, or voiding, is a complex activity. The bladder is a balloonlike muscle that lies in the lowest part of
the abdomen. The bladder stores urine, then releases it
through the urethra, the canal that carries urine to the outside of the body. Controlling this activity involves nerves,
muscles, the spinal cord and the brain.

The bladder is made of two types of muscles: the detrusor, a muscular sac that stores urine and squeezes to
empty, and the sphincter, a circular group of muscles at
Enlarged prostate is the most common cause of inthe bottom or neck of the bladder that automatically stay
continence in men after the age of 40; sometimes
contracted to hold the urine in and automatically relax
prostate cancer may also be associated with urinary
when the detrusor contracts to let the urine into the ureincontinence. Moreover drugs or radiation used to
thra. A third group of muscles below the bladder (pelvic
[4]
treat prostate cancer can also cause incontinence.
oor muscles) can contract to keep urine back.
A babys bladder lls to a set point, then automatically
Disorders like multiple sclerosis, spina bida, contracts and empties. As the child gets older, the nerParkinsons disease, strokes and spinal cord injury vous system develops. The childs brain begins to get
can all interfere with nerve function of the bladder. messages from the lling bladder and begins to send mes1

3 DIAGNOSIS

sages to the bladder to keep it from automatically empty- Research projects that assess the ecacy of antiing until the child decides it is the time and place to void. incontinence therapies often quantify the extent of uriFailures in this control mechanism result in incontinence. nary incontinence. The methods include the 1-h pad
Reasons for this failure range from the simple to the com- test, measuring leakage volume; using a voiding diary,
counting the number of incontinence episodes (leakage
plex.
episodes) per day; and assessing of the strength of pelvic
oor muscles, measuring the maximum vaginal squeeze
pressure.

Diagnosis

Patients with incontinence should be referred to a medi- 3.1

cal practitioner specializing in this eld. Urologists specialize in the urinary tract, and some urologists further
specialize in the female urinary tract. A urogynecologist
is a gynecologist who has special training in urological
problems in women. Family physicians and internists see
patients for all kinds of complaints, and are well trained to
diagnose and treat this common problem. These primary
care specialists can refer patients to urology specialists if
needed.

Types

A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type
of incontinence faced. Other important points include
straining and discomfort, use of drugs, recent surgery,
and illness.
The physical examination will focus on looking for signs
of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and
poor reexes or sensations, which may be evidence of a
nerve-related cause.
A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.
Other tests include:
Stress test the patient relaxes, then coughs vigor- Urinary incontinence may be caused by alcohol intoxication.
ously as the doctor watches for loss of urine.
Stress incontinence, also known as eort inconti Urinalysis urine is tested for evidence of infection,
nence, is due essentially to insucient strength of
urinary stones, or other contributing causes.
the pelvic oor muscles to prevent the passage of
urine, especially during activities that increase intra Blood tests blood is taken, sent to a laboratory, and
abdominal pressure, such as coughing, sneezing, or
examined for substances related to causes of inconbearing down.
tinence.
Ultrasound sound waves are used to visualize the
kidneys, ureters, bladder, and urethra.
Cystoscopy a thin tube with a tiny camera is inserted in the urethra and used to see the inside of
the urethra and bladder.
Urodynamics various techniques measure pressure
in the bladder and the ow of urine.
Patients are often asked to keep a diary for a day or more,
up to a week, to record the pattern of voiding, noting
times and the amounts of urine produced.

Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling
the need or urge to urinate.
Overow incontinence: Sometimes people nd that
they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after
they have passed urine. It is as if their bladders
were constantly overowing, hence the general name
overow incontinence.
Mixed incontinence is not uncommon in the elderly female population and can sometimes be complicated by urinary retention, which makes it a

3
treatment challenge requiring staged multimodal
treatment.[5]
Structural incontinence: Rarely, structural problems
can cause incontinence, usually diagnosed in childhood (for example, an ectopic ureter). Fistulas
caused by obstetric and gynecologic trauma or injury are commonly known as obstetric stulas and
can lead to incontinence. These types of vaginal
stulas include, most commonly, vesicovaginal stula and, more rarely, ureterovaginal stula. These
may be dicult to diagnose. The use of standard
techniques along with a vaginogram or radiologically viewing the vaginal vault with instillation of
contrast media.[6]

4 Treatment
Treatment options range from conservative treatment,
behavior management, bladder retraining,[10] pelvic oor
therapy, collecting devices (for men), xer-occluder
devices for incontinence (in men), medications and
surgery.[11] The success of treatment depends on the correct diagnoses.[12] Weight loss is recommended in those
who are obese.[13]

4.1 Exercises

Exercising the muscles of the pelvis such as with Kegel

exercises are a rst line treatment for women with stress
incontinence.[13] Eorts to increase the time between uri Functional incontinence occurs when a person recnation, known as bladder training, is recommended in
ognizes the need to urinate but cannot make it to the
those with urge incontinence.[13] Both these may be used
bathroom. The loss of urine may be large. There
in those with mixed incontinence.[13]
are several causes of functional incontinence including confusion, dementia, poor eyesight, mobility or Small vaginal cones of increasing weight may be used to
dexterity, unwillingness to toilet because of depres- help with exercise.[14]
sion or anxiety or inebriation due to alcohol.[7] Func- Biofeedback uses measuring devices to help the patient
tional incontinence can also occur in certain circum- become aware of his or her bodys functioning. By using
stances where no biological or medical problem is electronic devices or diaries to track when the bladder
present. For example a person may recognise the and urethral muscles contract, the patient can gain conneed to urinate but may be in a situation where there trol over these muscles. Biofeedback can be used with
is no toilet nearby or access to a toilet is restricted. pelvic muscle exercises and electrical stimulation to relieve stress and urge incontinence.
Nocturnal enuresis is episodic UI while asleep. It is
Time voiding while urinating and bladder training are
normal in young children.
techniques that use biofeedback. In time voiding, the
Transient incontinence is a temporary version of patient lls in a chart of voiding and leaking. From the
incontinence. It can be triggered by medications, patterns that appear in the chart, the patient can plan to
adrenal insuciency, mental impairment, restricted empty his or her bladder before he or she would othermobility, and stool impaction (severe constipation), wise leak. Biofeedback and muscle conditioning, known
which can push against the urinary tract and obstruct as bladder training, can alter the bladders schedule for
storing and emptying urine. These techniques are eecoutow.
tive for urge and overow incontinence
Giggle incontinence is an involuntary response to A 2013 randomized controlled trial found no benet of
laughter. It usually aects children.
adding biofeedback to pelvic oor muscle exercise in
Double incontinence. There is also a related condition for defecation known as fecal incontinence.
Due to involvement of the same muscle group
(levator ani) in bladder and bowel continence, patients with urinary incontinence are more likely to
have fecal incontinence in addition.[8] This is sometimes termed double incontinence.

stress urinary incontinence, but observing improvements

in both groups.[15] In another randomized controlled trial
the addition of biofeedback to the training of pelvic oor
muscles for the treatment of stress urinary incontinence,
improved pelvic oor muscle function, reduced urinary
symptoms, and improved of the quality of life.[16]

4.2 Medications

Post-void dribbling is the phenomenon where urine

remaining in the urethra after voiding the bladder
A number of medications exist to treat incontinence
slowly leaks out after urination.
including: fesoterodine, tolterodine and oxybutynin.[17]
have a small benet, the risk of
Coital incontinence (CI) is urinary leakage that oc- While a number appear to [17]
For every ten or so people
side
eects
are
a
concern.
curs during either penetration or orgasm and can octreated
only
one
will
become
able to control their urine
cur with a sexual partner or with masturbation. It has
and
all
medication
are
of
similar
benet.[18]
been reported to occur in 10% to 24% of sexually
active women with pelvic oor disorders.[9]

Medications are not recommended for those with stress

TREATMENT

incontinence and are only recommended in those who Readjustable sling The re-adjustable sling consists of
have urge incontinence who do not improve with bladder a standard synthetic mesh sling combined with sutures
training.[13]
that attach to an implantable tensioning device that resides permanently under the skin in the abdominal wall.
Once implanted, this Readjustable Mechanical External
4.3 Surgery
(REMEEX) device can be re-accessed under local anesthesia to ne tune the sling should incontinence reappear
Surgery may be used to alleviate incontinence after other months or years after the initial surgery.[20]
treatments have been tried and found not to be eective. Urodynamic testing seems to conrm that surgical
restoration of vault prolapse can cure motor urge inconti- 4.3.2 Bladder repositioning
nence. In those with problems following prostate surgery
Most stress incontinence in women results from the bladthere is little evidence regarding the use of surgery.[19]
der dropping down toward the vagina. Therefore, common surgery for stress incontinence involves pulling the
4.3.1 Slings
bladder up to a more normal position. Working through
an incision in the vagina or abdomen, the surgeon raises
The procedure of choice for stress urinary incontinence the bladder and secures it with a string attached to musin females is what is called a sling procedure. A sling cle, ligament or bone. For severe cases of stress inconusually consists of a synthetic mesh material in the shape tinence, the surgeon may secure the bladder with a wide
of a narrow ribbon but sometimes a biomaterial (bovine sling. This not only holds up the bladder but also comor porcine) or the patients own tissue that is placed under presses the bottom if the bladder and the top of the urethe urethra through one vaginal incision and two small thra, further preventing leakage.
abdominal incisions. The idea is to replace the decient
pelvic oor muscles and provide a backboard of support
under the urethra.
4.3.3 Marshall-Marchetti-Krantz
Tension-free transvaginal tape The tension-free
transvaginal tape(TVT) sling procedure treats urinary
stress incontinence by positioning a polypropylene mesh
tape underneath the urethra. The 20-minute outpatient
procedure involves two miniature incisions and has
an 86-95% cure rate. Complications, such as bladder
perforation, can occur in the retropubic space if the
procedure is not done correctly. This minimally invasive
procedure is a common treatment for stress urinary
incontinence.
Transobturator tape The transobturator tape (TOT)
sling procedure aims to eliminate stress urinary incontinence by providing support under the urethra. This minimally invasive procedure eliminates retropubic needle
passage and involves inserting a mesh tape under the urethra through three small incisions in the groin area. While
the procedure has shown risks during its infancy, recent
developments have increased the cure rate to 90%.

The Marshall-Marchetti-Krantz (MMK) procedure, also

known as retropubic suspension or bladder neck suspension surgery, is performed by a surgeon in a hospital setting. Developed in 1949 by doctors Victor F.
Marshall (19132001), a urologist, Andrew Anthony
Marchetti (19011970), an OB/GYN, and Kermit E.
Krantz (OB/GYN) is the standard by which new procedures are measured. The patient is placed under general
anesthesia, and long, thin, exible tube (catheter) is inserted into the bladder through the narrow tube (urethra)
that drains the bodys urine. An incision is made across
the abdomen, and the bladder is exposed. The bladder is
separated from surrounding tissues. Stitches (sutures) are
placed in these tissues near the bladder neck and urethra.
The urethra is then lifted, and the sutures are attached to
the pubic bone itself, or to tissue (fascia) behind the pubic
bone. The sutures support the bladder neck, helping the
patient gain control over urine ow. Approximately 85%
of women who undergo the Marshall-Marchetti-Krantz
procedure are cured of their stress incontinence.

Mini-sling The mini-sling procedure has reported 4.4 Devices

short term cure rates of 67% to 83%.
Individuals who continue to experience urinary incontiNeedleless sling The needleless sling is a single inci- nence need to nd a management solution that matches
devices has not been
sion TOT. It is implanted via one unique incision. The their individual situation. The use of
[21]
well
studied
in
women
as
of
2014.
needleless has approximately 136% more surface area
than the mini sling, which may better support the pelvic
oor and urethra, and no sharp instruments are required
to implant the sling besides the scalpel used to make the
incision, which may enhance patient comfort.

Collecting systems (for men) consists of a sheath worn

over the penis funneling the urine into a urine bag worn on
the leg. These products come in a variety of materials and
sizes for individual t. Studies[22] show that urisheaths

5.1

Children

and urine bags are preferred over absorbent products in

particular when it comes to limitations to daily activities.
Solutions exist for all levels of incontinence. Advantages
with collecting systems are that they are discreet, the skin
stays dry all the time, and they are convenient to use both
day and night. Disadvantages are that it is necessary to
get measured to ensure proper t and you need a health
care professional to write a prescription for them.
Absorbent products (include shields, undergarments,
protective underwear, briefs, diapers, adult diapers and
underpants) are the most well know product types to manage incontinence. They are generally easy to get hold of in
pharmacies or supermarkets and thus very popular. The
advantages of using these are that they barely need any
tting or introduction by a health care specialist. The disadvantages with absorbent products are that they can be
bulky, leak, have odors and can cause skin breakdown.

5
of bladder control products and to the health care system and nursing home industry. Injury related to incontinence is a leading cause of admission to assisted living
and nursing care facilities. More than 50% of nursing
facility admissions are related to incontinence.[27]

5.1 Children
Incontinence happens less often after age 5: About 10
percent of 5-year-olds, 5 percent of 10-year-olds, and 1
percent of 18-year-olds experience episodes of incontinence. It is twice as common in girls as in boys.

5.2 Women

Bladder symptoms aect women of all ages. However, bladder problems are most prevalent among older
women.[28] Women over the age of 60 years are twice
as likely as men to experience incontinence; one in three
women over the age of 60 years are estimated to have
[24]
Indwelling catheters (also known as foleys) are very of- bladder control problems. One reason why women are
ten used in hospital settings or if the user is not able to more aected is the weakening of pelvic oor muscles by
[29]
handle any of the above solutions himself. The indwelling childbirth.
catheter is typically connected to a urine bag that can be
worn on the leg or hang on the side of the bed. Indwelling
catheters need to be changed on a regular basis by a health 5.3 Men
care professional. The advantage of indwelling catheters
are, that the urine gets funneled away from the body keep- Men tend to experience incontinence less often than
ing the skin dry. The disadvantage, however, is that it is women, and the structure of the male urinary tract acvery common to get urinary tract infections when using counts for this dierence. It is common with prostate
cancer treatments. Both women and men can become
indwelling catheters.[23]
incontinent from neurologic injury, congenital defects,
Intermittent catheters are single use catheters that are strokes, multiple sclerosis, and physical problems assoinserted into the bladder to empty it, and once the blad- ciated with aging.
der is empty they are removed and discarded. Intermittent catheters are primarily used for retention (inability While urinary incontinence aects older men more often
to empty the bladder) but for some people can be used to than younger men, the onset of incontinence can happen
at any age. Estimates in the mid-2000s suggested that 17
reduce / avoid incontinence.
percent of men over age 60, an estimated 600,000 men,
experienced urinary incontinence, with this percentage
increasing with age.[30]
Fixer-occluder devices (for men) are strapped around
the penis, softly pressing the urethra and stopping the ow
of urine. This management solution is only suitable for
light or moderate incontinence.

Epidemiology

Globally, up to 35% of the population over the age of 60 6 History

years is estimated to be incontinent.[24] In 2014, urinary
leakage aected between 30% and 40% of people over
The management of urinary incontinence with pads is
65 years of age living in their own homes or apartments
mentioned in the earliest medical book known, the Ebers
in the U.S.[25] Twenty-four percent of older adults in the
Papyrus (1500 BC).[31]
U.S. have moderate or severe urinary incontinence that
should be treated medically.[25]
Bladder control problems have been found to be associated with higher incidence of many other health problems
such as obesity and diabetes. Diculty with bladder control results in higher rates of depression and limited activity levels.[26]
Incontinence is expensive both to individuals in the form

7 References
[1] Managing Urinary Incontinence. National Prescribing
Service, available at http://www.nps.org.au/health_
professionals/publications/nps_news/current/nps_news_
66_managing_urinary_incontinence_in_primary_care

[2] see
[www.medicaldictionaryweb.com/
Enuresis-definition/]
[3] merck.com > Polyuria: A Merck Manual of Patient
Symptoms podcast. Last full review/revision September
2009 by Seyed-Ali Sadjadi, MD
[4] What is urinary incontinence? Family Doctor. Retrieved
on 2010-03-02
[5] Walid MS, Heaton RL (2009).
Stepwise Multimodal Treatment of Mixed Urinary Incontinence
with Voiding Problems in a Patient with Prolapse.
Journal of Gynecologic Surgery 25 (3): 121127.
doi:10.1089/gyn.2009.0014.
[6] Macaluso JN, Appell RA, Sullivan JW: Ureterovaginal
stula detected by vaginogram. JAMA. 246:1339-1340,
1981
[7] Functional incontinence. Australian Government Department of Health and Ageing. 2008. Archived from the
original on 2008-07-23. Retrieved 2008-08-29.
[8] Shamliyan, T; Wyman, J; Bliss, DZ; Kane, RL; Wilt, TJ
(December 2007). Prevention of urinary and fecal incontinence in adults.. Evidence report/technology assessment (161): 1379. PMID 18457475.
[9] Karlovsky, Matthew E. MD, Female Urinary Incontinence
During Sexual Intercourse (Coital Incontinence): A Review, The Female Patient (retrieved 22 August 2010)
[10] Bladder retraining ichelp.org Interstitial Cystitis Association Accessed July 13, 2012
[11] Clinical audit of the use of tension-free vaginal tape
as a surgical treatment for urinary stress incontinence,
set against NICE guidelines. Price N and Jackson
SR. J Obstet Gynaecol, Aug 2004; 24(5): 534538http://www.oxfordgynaecology.com/Conditions/
Urinary-Incontinence.aspx
[12] What is Male Urinary Incontinence? Retrieved on 201003-02
[13] Qaseem, A; Dallas, P; Forciea, MA; Starkey, M; Denberg, TD; Shekelle, P; for the Clinical Guidelines Committee of the American College of, Physicians (Sep 16,
2014). Nonsurgical Management of Urinary Incontinence in Women: A Clinical Practice Guideline From
the American College of Physicians.. Annals of internal medicine 161 (6): 429440. doi:10.7326/m13-2410.
PMID 25222388.
[14] How to Use Vaginal Weights. National Incontinence.
Retrieved 10 October 2012.
[15] Hirakawa, T; Suzuki, S; Kato, K; Gotoh, M; Yoshikawa,
Y (2013-01-11).
Randomized controlled trial of
pelvic oor muscle training with or without biofeedback for urinary incontinence.
Int Urogynecol J.
doi:10.1007/s00192-012-2012-8. PMID 23306768.
[16] Fitz, Ftima Fan; Resende, Ana Paula Magalhes; Stpp,
Liliana; Costa, Thas Fonseca; Sartori, Marair Gracio Ferreira; Giro, Manoel Joo Batista Castello; Castro, Rodrigo Aquino (November 2012). Efeito da

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[31] ed, Horst-Dieter Becker ... (2005). Urinary and fecal incontinence : an interdisciplinary approach ; with 89 tables.
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External links
Urinary incontinence at DMOZ
Urinary Incontinence Information
Continence Coach from Ostomy Wound Management

9 TEXT AND IMAGE SOURCES, CONTRIBUTORS, AND LICENSES

Text and image sources, contributors, and licenses

9.1

Text

Urinary incontinence Source: http://en.wikipedia.org/wiki/Urinary%20incontinence?oldid=645485545 Contributors: Kpjas, Alex.tan,

Fubar Obfusco, SimonP, Patrick, Fred Bauder, Karada, Ahoerstemeier, Ronz, Darkwind, DropDeadGorgias, Tristanb, Emperorbma,
Charles Matthews, Timwi, Bemoeial, Auric, Geeoharee, Zigger, Jfdwol, TonyW, Kevin Rector, Mwanner, Spearhead, Circeus, Arcadian, Zetawoof, Espoo, Nr10232, Arthena, Wouterstomp, Bigjarom, Wdfarmer, NTK, Gpvos, Drbreznjev, Markaci, Oleg Alexandrov, TigerShark, LOL, Benbest, Bluesixer, Tabletop, Zpb52, Matilda, Graham87, Wachholder0, FreplySpang, Rjwilmsi, Omodaka,
Gurch, Srleer, King of Hearts, YurikBot, Wavelength, Mushin, Midgley, Big Brother 1984, Royalbroil, NawlinWiki, Aaron Brenneman, DailyDiapers, TakingUpSpace, Shultz, Samir, Bota47, Badgettrg, John Broughton, GrinBot, SmackBot, DOC DS, Ohnoitsjamie,
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Alan Flynn, Kegels, Neelix, Drshefa, Jac16888, Gogo Dodo, Anthonyhcole, Hughierua, Roberta F., CTHG, The1anton, NorthernThunder, Thijs!bot, Rex maverick, Kathie DeVoe, Horologium, Autocracy, MER-C, Kfrohlinger, JamesBWatson, Dr.Gangino, Michele123,
WhatamIdoing, Quinn callahan, Sue34uk, Wshallwshall, Scottalter, Flowanda, CliC, J.delanoy, Deedeedum, Katalaveno, Dskluz, Naniwako, Mikael Hggstrm, HealthiNation LLC, Hugo999, Almazi, Philip Trueman, Garrondo, Una Smith, Ricland, Jackfork, Alborz Fallah,
Plutonium27, Papte, Synthebot, Fsecret, Doc James, Logan, Gb2house, SieBot, Jonmwang, Moonriddengirl, Rmindick, Sbarne3, Mseliw,
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Jeni HB, Mr.whitesh, Tnxman307, Computer97, DumZiBoT, Estemi, Ariconte, Tisrach, Addbot, Jackpickard1985, Chimeric Glider, DOI
bot, Yoenit, Ronhjones, MrOllie, 1archie99, OlEnglish, KatH73, 55, Jarble, Touro3591, Chaldor, Yobot, Fraggle81, Wikipedian Penguin, Dennisrosenberg, AnomieBOT, Hystomagna, Law, Jmarchn, ArthurBot, Obersachsebot, Xqbot, Zad68, Aris riyanto, Qwerty2829,
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of Reading, Eekerz, Tommy2010, Dcirovic, Vrebztrew48, Awilfong, IncontinenceForum, H3llBot, Mjgreene27, Donner60, Philtercom,
ClueBot NG, Kegeladvocate, Sahnsey, KlappCK, Creck01, Satellizer, O.Koslowski, 85doris, Rezabot, InvaderAkemi, Crazymonkey1123,
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montez, Monkbot, Lincopeland, Smartwear, Sabregoddess87, Esyda, Leakybladder and Anonymous: 229

9.2

Images

File:Intoxicated_men.jpg
Source:
http://upload.wikimedia.org/wikipedia/commons/6/61/Intoxicated_
men.jpg
License:
CC
BY
2.0
Contributors:
https://www.flickr.com/photos/lostseouls/495724599/in/
photolist-7ykux-2BvvmW-8QuVEz-efFgyM-KNHDR-7vYLKn-bwF5bk-6CmwuJ-7i2koi-7imSA1-62vg3D-4zBJWi-6nT4PZ-5tX1VV-6Uc8rz-7Ksj1D-6Dz
Original artist: James Creegan

9.3

Content license

Creative Commons Attribution-Share Alike 3.0