The Secret of Great Health Care
Involuntary loss of urine at a time when it is undesirable, affecting about 30% of older adults, is an embarrassing problem for approximately 13 million Americans and costs the United States health care system billions of dollars each year (1). Women are more commonly affected than men until the age of 85 when both sexes are equally affected. Even though it is common; it is not normal. Many individuals with incontinence are too embarrassed to tell their doctor about the condition and the disease remains an under diagnosed and under treated entity. Causes
Three broad categories are responsible for urinary incontinence.
As individuals age, there are a number of changes to the urinary system that contribute to urinary incontinence. The maximum amount of urine that the bladder holds decreases as one ages – meaning the older person needs to urinate more frequently. There is an increased amount of urine in the bladder after voiding – which predisposes the older individual to infections.
In postmenopausal women, the lack of estrogen results in a decreased ability of the urinary system to hold back urine. Prostate enlargement, which is common in older men, also contributes to urinary incontinence. Hormonal changes of aging and weakened pelvic muscles are another common cause of incontinence.
Diseases of urinary system result in urinary incontinence. Urinary tract infection, which is more common in older adults, can result in temporary urinary incontinence. Trauma to the urinary systems such as childbirth or previous gynecological conditions increases the risk of incontinence in women.
Medical problems are a common contributor to incontinence. Certain disease processes result or exacerbate urinary incontinence. Individuals afflicted with diabetes mellitus, arthritis, heart failure, Parkinson’s disease, stroke, chronic lung disease and chronic constipation are at increased risk for incontinence.
Diseases such as diabetes and congestive heart failure have systemic affects on the body – including the urinary system – and contribute to incontinence. Arthritis limits mobility, making it harder for the patient to get to the bathroom increasing the risk for incontinence. Arthritic fingers can decrease the speed a patient can remove their pants and contributes to incontinence. Coughing, which is very common in those with chronic lung disease, increase the risk of stress incontinence.
Men who have surgery on their prostate are at risk for incontinence. History of pelvic trauma or damage to the spinal cord also puts a patient at risk. Other conditions that are related to incontinence include constipation, bladder tumors or kidney disease.
Bladder irritation leads to incontinence. Irritation in the form of urinary tract infections, radiation, chemotherapy, bladder tumors or fecal impaction all contributes to incontinence.
Medications are a common cause of urinary incontinence. Drugs, such as diuretics, also known as water pills, increase the amount of urine production and are a major contributor. Medicines to treat cold symptoms such as antihistamines (Benadryl) and pseudoephedrine (Sudafed) can add to incontinence. Caffeine and alcohol increase urine production and are common causes of incontinence. Treatment for cancer with radiation or chemotherapy are associated with incontinence. Types of incontinence
There are five main types of urinary incontinence: urge, stress, overflow, mixed and functional incontinence. Urge incontinence is the inability to hold the urine once the urge to urinate occurs. This is often described as the "I gotta go know" incontinence. This is a potentially dangerous type of incontinence, because of the urgency the patient needs to rush to get to the bathroom and is at high risk for falls. While no cause is found in many cases, contributing factors to urge incontinence include infections, stroke and dementia. These conditions affect the ability of the nervous system to inhibit voiding.
Stress incontinence is leaking urine when coughing, laughing or sneezing. The sudden increase of pressure in the abdomen overcomes the bladder outlet and incontinence results. Damage, like what happens in pregnancy, to the urinary valves or urethra can lead to stress incontinence. Lack of estrogen can also contribute to stress incontinence. Urge and stress incontinence contribute to the women being more affected than men.
Overflow incontinence involves small amounts of urine that leaks from a bladder that never completely empties and is typically partially full. Blockage of the urinary system or weak muscle contractions of the bladder contributes to urine being retained in the bladder. When the bladder reaches maximal capacity it has two choices; empty or explode. The bladder will not explode; so, a small amount of urine will leak out, resulting in overflow incontinence. The causes of overflow incontinence include: prostate enlargement, severe constipation, nerve damage, stroke ad diabetes.
Functional incontinence occurs when the individual has normal bladder control, but the person may have a condition that makes it hard to reach the toilet in time. Individuals afflicted with severe arthritis do not have the ability to get to the toilet and remove their pants in time. Those with dementia may not remember how to go to the bathroom.
Mixed incontinence occurs when two or more of the above types of incontinence are mixed. This is the most common type of incontinence.
Table 21: Reversible Causes of Incontinence
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Table 22: Risk factors for urinary incontinence
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Complications
Complications can be broken down into social, medical and economic. Urinary incontinence can cause social isolation resulting in older adults fearing to leave the house for fear of embarrassment. Fear of not getting to the toilet in time and having an accident in public contributes to social isolation. Fearing one will smell of urine often cripples the individual to a point where they do not want to leave the home.
Economic consequences of incontinence come in from a variety of sources. Medications to treat incontinence have significant cost associated with them. Adult diapers are another economic strain on people afflicted with incontinence.
Medical complications of urinary incontinence can be life threatening. Those who are bed bound and afflicted with urinary incontinence are at increased risk for skin breakdown and bed sores. When urinary incontinence results from an obstruction there is a risk of renal failure.
Urinary incontinence increases the risk of infections. Urine that lies stagnant in the bladder in those with decreased ability to empty the bladder are at increased risk for infection as bacteria grows in stagnant urine.
Catheters can lead to many complications. Long-term catheters increase the risk of infection, bladder stones, and breakdown of the urinary system. Signs and symptoms
The most obvious symptoms of incontinence is leakage of urine at an undesirable time. The circumstances surrounding the urinary leakage is important. Incontinence after a strong urge is consistent with urge inconstancy. Leaking urine after coughing or sneezing defines stress incontinence. Dribbling after voiding can occur in overflow incontinence. Urinating frequently and having many bouts of urination at night are other symptoms of urinary incontinence. There can also be changes in the vaginal system such vaginal thinning, dryness and itching all of which result from a lack of estrogen, which is common after menopause. Diagnosis
Diagnosis of urinary incontinence is simple, either you have it or you do not. Determining the type of incontinence, the cause and how best to treat it is much more challenging.
The first step is a history and physical by the health care provider. A history can be best taken if there is written documentation of the events surrounding the incontinent episodes. The voiding diary will facilitate the patient reporting an accurate history that assures the clinician will formulate an accurate diagnosis and treatment plan.
Basic tests for the treatment of urinary incontinency include a physical exam and a urine analysis. Blood tests are sometimes done to rule out diseases processes that contribute to or complicate incontinence. This may include looking for kidney problems, diabetes or an enlarged prostate. Second-line testing for urinary incontinence is a bladder stress test and post void residual. A post void residual determines how much urine is in the bladder immediately after voiding and it can be done by ultrasound or putting a catheter in the bladder after urination. A urinary stress test is done by evaluating if there is any leaking of urine after the patient forcefully coughs. Renal ultrasound is sometimes done to rule out obstruction. Bladder stones or tumors can cause an abrupt onset of urinary incontinence usually accompanied by lower abdominal pain or pain in the groin. This situation requires an evaluation of the urine by a culture and a consultation with a bladder specialist or urologist for a cystoscopy. Cystoscopy is a special exam where a camera is put into the bladder to look inside. Treatment Treatment for urinary incontinence includes education and behavioral therapy, devices and drug therapy. Surgery can be used but should be reserved for difficult cases that cannot be managed with medicines and behavioral approaches. The first line – and safest – treatment for urinary incontinency is education and behavioral changes. Learning about the disease and how diet and fluid intake affects your bladder function is vital to managing urinary incontinence. Keeping a diary can help the doctor make an accurate diagnosis and, more importantly, can help you understand how certain foods and drinks or activities affect incontinence. Using the voiding diary in the Appendix involves recording your pattern of urination including the amount voided, amount leaked, what you were doing when you leaked and reporting if there was an urge. It also allows you to record fluid intake including the type and amount. Utilize this form and study it. It often reveals patterns that will educate you as to how specific fluids affect bladder incontinence.
Behavioral Therapy/EducationBehavioral therapy includes planned toileting, exercises, and controlling fluid intake. Going to bathroom at scheduled times keeps the bladder empty and helps avoid leaking. This method is extremely efficacious for urge incontinence. Scheduled voiding prevents the bladder from filling to a critical level. In those with urge incontinence this critical level is associated with a sudden, strong urge to void. There are other lifestyle changes that can help prevent incontinence. Maintaining good bladder health by assuring good hydration and avoiding certain foods such as caffeine and alcohol. Maintaining a healthy body weight, stopping smoking and preventing constipation can decrease the amount of incontinence. Eating a diet high in fiber and assuring adequate fluid intake can help prevent constipation. Appropriate fluid intake is essential to normal bowel and bladder function. Concentrated urine (which happens when fluid intake is inadequate) irritates the bladder and increases incontinence. People decrease the amount of fluid intake in fear that more fluid intake will increase incontinence, when in fact, concentrated urine increases the amount of incontinence. Consuming 1500 ml of fluid a day and limiting or eliminating caffeine and alcohol is recommended for ideal bladder hygiene. Consuming most of your fluid before dinner limits the amount of urine production at night. Older females are often afflicted with thin vaginal walls, which is a predisposing factor to incontinence. These women can benefit from local estrogen therapy to decrease the incidence of incontinence. Bladder hygiene, wiping from front to back and maintaining bowel regularity, are important and can help prevent incontinence. In those who are diabetic – controlling blood sugars can have a profound affect on controlling incontinence. If certain disease states are contributing to incontinence than treatment of those diseases will help treat the incontinence. Assuring that medical conditions such as heart failure, arthritis and diabetes are well controlled reduces the incidence of incontinence. For individuals with some degree of functional incontinence improving the physical environment by using bright bathroom lights, raising the toilet seats and using nonskid surfaces can help prevent or treat incontinence. Education can promote bladder health. Not being ashamed of this common malady and reporting signs and symptoms to your health care provider is a critical step in treating this major health problem. Exercise An exercise program is a key component to the behavioral approach to treating incontinence; not a regular exercise program – including walking or running – but exercises for the urinary muscles called Kegel exercises (Table 23). Exercises for the pelvic muscles are used to help strengthen the pelvic floor to treat both stress and urge incontinence. Urge inhibition is another exercise that is used to help delay voiding, resist the sudden need to void, and prevent incontinence. When an urge to urinate occurs, the person waits for the urge to pass before going to the bathroom. It is done by stopping all activity and standing still or sitting down when the urge is first noticed. The next step is to contract the pelvic muscles five to six times or until the urge subsides. The key component to this exercise is to avoid going to the bathroom too often or during a strong urge. Table 23: How to do Kegal Exercises
Scheduled voiding involves the patient voiding at a specific time interval (every two hours for example) and gradually increasing this amount of time over a period of weeks to months. This will help train the bladder to improve its ability to hold urine.
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Devices
Devices are used to manage incontinence and reduce the social impact of incontinence. Products used to treat incontinence include: absorbent products, pessaries and Foley catheters.
Absorbent Products
Absorbent products absorb or contain urine. They come in a variety of throwaway and reusable undergarments. The products include: adult diapers, plastic underwear and feminine hygiene products. The severity of the incontinence helps the patient choose which product to use. Those who are frequently incontinent need to change absorbent products often.
Skin irritation may be a recurring problem if soiled or wet absorbent products have extended contact with the skin. Do not apply occlusive dressings too tightly as this will trap heat, increase skin temperature, promote friction and increase bacterial growth and infection risk. A protective barrier ointment repels irritants and moisture by providing a water-repellant coating to the skin and can be applied several times a day.Products
Pessaries – They are rubber rings worn in the vagina. They push up the bladder neck against the pelvic bone, and hold it in place, so your urinary system can work properly. They are used for those with pelvic organ prolapse. It is a simple device, which is used in patients who don’t want surgery or are poor candidates for surgery.
Foley catheters are typically used to manage long-term incontinence. Individuals who are unable to empty his or her bladder are candidates for catheters but the risks of maintaining a long-term Foley catheter are many including infection, erosion of the urinary system and self-esteem issues associated with catheters. Medications
Medicines to help with incontinence are among the most popular ways to treat it. It is important to get an accurate diagnosis so treatment can be focused on the right system.
Incontinence is often related to shrinking of the vaginal wall, which can be treated with estrogen. Local estrogen therapy can be used in those post-menopausal women who have evidence of estrogen deficiency. Treatment with estrogen therapy can decrease burning, improve urogenital comfort, and help prevent skin rashes and vaginal infection. Typically the health care provider prescribes an estrogen cream.
Drugs for stress incontinence work by preventing urine leakage with increased intra-abdominal pressure. A common drug used for this purpose is pseudoephedrine (Sudafed) in its short or long-acting form. Caution must be used with this drug because of the many side effects including high blood pressure, fast heart rate, shortness of breath, nervousness, and dizziness.
Other drugs sometimes used to treat stress incontinence include: Midodrine (Pro-Amatine), imipramine and duloxetine (Cymbalta)
Treatments for overflow incontinence involve eliminating or reducing the cause of urine being retained. Treating an enlarged prostate with medicines to relax the urinary sphincter or shrink the prostate can be effective. Surgery on the prostate is required in some men to treat the incontinence. Some individuals with severe urinary retention are unable to be treated due to the nerve damage and need to be treated with catheterization. Catheterization can either be intermittent or permanent.
Drug therapies are used for urge incontinence. Urge incontinence can be treated with trospium (Sanctura), solifenacin (VESIcare), fesoterodine (Toviaz), darifenacine (Enblex), oxybutyin (Ditropan or Oxytrol transdermal patch) and tolterodine (Detrol). These drugs increase volume at which the first sensation of bladder filling is felt, volume at which the normal desire to void occurs, and maximum bladder pressure during voiding, thus decreasing contractility. These drugs can lead to dry mouth, constipation and dry eyes.
Imipramine (Tofranil®) can be used in women who have mixed incontinence. This drug is often used for depression and has more side effects than oxybutyin or tolterodine. Side effects include low blood pressure, slow heart rate, dizziness, abnormal heart rhythms, weakness and fatigue. This drug is usually given at bedtime and can reduce nocturia and urge incontinence during the night and its sedating effects may help with sleep and reduce daytime sedation. Caution must be used in those who have urinary retention or narrow-angle glaucoma.
The medications used to treat urinary incontinence are symptom control medications. If the medications are not significantly impacting incontinence, then they should not be continued. If you are on the highest dose of a given medication and there is no significant improvement in continence then the medication should be switched or discontinued. No drug for incontinence treats the natural course of the disease and if side effects are worse than the positive effect of the medicine then stopping the medicine is the reasonable thing to do. Always discuss any decision to stop medications with your health care provider. Voiding Diary
The voiding diary listed in the appendix will help you manage the condition. The diary should be filled out before going to the doctor to be evaluated for incontinence. Fill out the voiding diary for thee days. Not only will this help your doctor make the diagnosis but it will help you understand your incontinence. The diary includes an hour-by-hour listing of the food and fluids that you consume. It also includes when you go to the bathroom.
When you are being re-evaluated fill out this form again to compare the results against the results before your treatment began. This aids you and your doctor in determining if continuing the mediation is worthwhile. Table 24: Lifestyle changes for improving incontinence
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Your Responsibility
Questions
References
