The Good Life

Urinary Incontinence: Honesty, Acceptance, and Control

Despite popular belief, urinary incontinence (UI) is not a normal part of aging. Unfortunately, UI is a poorly understood problem in the elderly population. The prevalence of the condition may be significantly underestimated, due in part to miscommunication between physicians and patients. Physicians rarely ask questions about UI, and patients seldom initiate discussion on the issue, either because they fear embarrassment or because they believe that their UI, as a function of aging, is unavoidable and untreatable.

What is Urinary Incontinence?
Urinary incontinence is defined as a loss of control over urinary function; possible causes of UI include weakening of pelvic muscles that support the bladder, medical problems that affect the bladder’s ability to hold and empty urine, urinary tract infections, constipation, dehydration, immobility, and certain prescription and nonprescription medications. Some of the medications that can affect urinary incontinence are:

• Diuretics: most commonly taken for high- or low-blood pressure
• Anticholinergics: taken for pain relief of muscle spasms or cramps
• Sedatives or Hypnotics: taken to induce sleepiness
• Narcotics: taken to reduce pain, alter mood and behavior, and promote sleep
• Alpha-adrenergic agonists: found in some oral decongestants
• Alpha-adrenergic antagonists: used in high blood pressure treatment
• Calcium Channel Blockers: treatment for heart disease

There are four main types of urinary incontinence: urge incontinence, stress incontinence, overflow or obstructive incontinence, and functional or environmental incontinence.

1. Urge Incontinence
Urge incontinence, or overactive bladder, is the most common type of incontinence, observed in 40% to 70% of elderly patients (over the age of 65 years). Urge incontinence is characterized by a sudden urge to urinate, often appearing so rapidly that affected patients are unable to reach the bathroom in time. Patients have muscle contractions well before the bladder is full, creating this state of urgency, as well as leading to more frequent urination. Slight to moderate involuntary loss of urine is likely to occur.

Symptoms of urge incontinence are similar to those of a urinary tract infection. Sudden compelling urges to urinate, coupled with discomfort in the bladder, urinating more often than normal when fluid intake is not increased or decreased, abdominal swelling or distress, and involuntary loss of urine, are all signs of urge incontinence.

2. Stress Incontinence
Stress incontinence is caused by a sudden increase in pressure (stress) on the bladder. This can be caused by laughing, coughing, sneezing, exercising, or lifting heavy weights. Stress incontinence is more common among females; women’s bladders are normally high enough in the pelvis so the bladder neck is squeezed shut when there is increased pressure around the area. When pressure increases, the abdominal cavity squeezes the bladder neck shut, keeping urine within. As women bear children and age, the bladder drops closer to the pelvic floor, causing the bladder neck to drop as well. The bladder neck is no longer squeezed when there is increased pressure, resulting in loss of urine. High-impact exercisers, especially those with low foot arches, are especially susceptible to this problem, due to the impact of hard floor surfaces and the shock such impact produces on the pelvic area.

Feelings of bladder fullness, involuntarily urinating when laughing, coughing, or sneezing, involuntary leakage while actively exercising, uncomfortable sexual intercourse, and having trouble completely emptying the bladder are all signs and symptoms of stress incontinence.

3. Obstructive/Overflow Incontinence
Reduced urine flow and frequent and/or continuous urine dribbling are symptoms of overflow or obstructive incontinence. This usually occurs due to a dysfunction in the contraction of the bladder, or obstructed urinary outflow. Obstruction usually occurs from urethral or kidney stones. When the bladder is blocked, it causes the urine to be backed up in the kidney(s), and causes distention throughout the system.

Symptoms of obstructive incontinence depend on the time course of the obstruction and where it occurs in the system. A list of symptoms include strong and more frequent urges to urinate, difficulty initiating urinary flow, urinary dribbling, decrease in output of urine, decrease in the force of the urinary stream, frequent nighttime urination, burning or stinging while urinating, feeling of incomplete emptying of the bladder, alternating episodes of increased urine output and decreased urine output, and possible fever and chills.

4. Functional/Environmental Incontinence
Patients who suffer from functional or environmental incontinence generally have functioning urinary systems where incontinence is caused by an external factor. External factors may include physical or cognitive problems, or various medications (previously listed). A person suffering from functional incontinence does not recognize the urge to urinate, recognize where the bathroom is, or does not get there in time. This can be caused by confusion, dementia, poor eyesight, or poor mobility. Environmental factors include poor lighting, low chairs that are difficult to get out of, or bathrooms that are difficult to access.

Considering patients who suffer from functional incontinence generally have urinary systems that function normally, there are no standard symptoms to identify, per se. A few signs of functional incontinence include failure to recognize the urge to urinate, and inability to reach the bathroom in time to urinate for reasons external to the person him- or herself.

Risk Factors
There are some common risk factors with urinary incontinence associated with the elderly; different factors are relevant to males and females.

Women
Being female means that you are at greater risk for urinary incontinence, due to your anatomy. Pregnancy and childbirth change the formation and strength of the urinary system. Stretching and compression during childbirth puts a strain on the pelvic muscles and bladder, and can often cause damage to the pelvic floor and nerves. Pregnancy and childbirth also cause the bladder to drop closer to the pelvic floor, resulting in stress incontinence.

Obesity creates stress on the abdominal, pelvic, and bladder areas. This extra stress can lead to stress incontinence.

Decreasing estrogen levels from menopause can cause weakness in the muscles of the bladder and pelvic areas. Weakness in these areas will prevent a “tight seal” from forming around the bladder neck, resulting in possible stress in continence.

Having a hysterectomy can put women at greater risk for UI. The reason for this is as yet unknown, but may involve nerve damage in the pelvic area, and consequent loss of support to the bladder.

Men
Men who have been diagnosed with prostate cancer are at greater risk for UI. Prostate tumors can press onto the surrounding area, causing urination difficulties and possible urinary incontinence. Having a stroke can cause damage to the neurologic system, including major sensory deficits and even brain damage; in such as case, messages relaying a full bladder may be delayed, or may not even be received.

Lifestyle
Smoking increases the risk for all forms of urinary incontinence, and depends on the number of cigarettes smoked. Smokers cough more frequently then nonsmokers, resulting in extra stress on the bladder and surrounding areas. Chronic cough, along with extra stress on the bladder, can also weaken the muscles in the same vicinity. Increased bladder contractions may, too, be associated with nicotine.

Alcohol, caffeine, and other bladder irritants will increase the risk of UI. Milk, dairy products, citrus juice and fruit, tomato-based products, spicy foods, sugar, honey, corn syrup, artificial sweeteners, and carbonated beverages will make urine more concentrated; this, in turn, invites infection and other forms of bacteria into the bladder. The irritation wrought by such infection can cause more frequent urination.
Despite popular belief, dehydration can cause urinary incontinence, as well. Most people believe that lowering fluid intake will lessen trips to the bathroom, and cause less leakage. Drinking fewer fluids causes the body to produce less urine, but the urine it does produce is more concentrated. Concentrated urine irritates the bladder and will cause more frequent urination, while increasing the risk of urinary tract infections.

Age-Related Diseases
Some diseases associated with the geriatric population are risk factors for urinary incontinence. Alzheimer’s disease, stroke, diabetes, rheumatoid arthritis, Parkinson’s disease, and multiple sclerosis are all neurologic diseases that can lead to UI by affecting the nerve pathways to the lower urinary tract and pelvic muscles.

Treatment Options
Various treatment options have been successful in improving or curing urinary incontinence. Behavioral techniques, medications, and surgery are three options.

Medications
Medications that help in treating infection, halting bladder contractions, or increasing the amount of urine the bladder can hold all can assist in the management of UI. How well any given medication works depends on the type of incontinence and its severity level. Several follow-up visits will be needed to determine your correct dosage. Medications are commonly used with behavioral techniques in order to maximize improvement rate.

Behavioral Techniques
Behavioral techniques for the management of UI include bladder training, pelvic muscle (Kegel) exercises, dietary changes, and constipation management. Bladder training (http://healthinaging.org/public_education/tools/UItool09.pdf) consists of setting allotted times to urinate, and using the bathroom only during those periods.
Kegel exercises (http://healthinaging.org/public_education/tools/UItool10.pdf) are exercises that help build strength in the muscles around the bladder. The exercises involving squeezing and relaxing the muscles in the pelvic or genital area. Your doctor will explain how to do these exercises, which you will be asked to do several times each day.
Dietary and behavioral changes (http://healthinaging.org/public_education/tools/UItool08.pdf) can also help increase successful incontinence treatment. Drinking proper amounts of fluids will keep you hydrated, and exercise the bladder. Maintaining proper weight will keep excess stress of the bladder area, and not smoking will keep coughing to a minimum, and decrease the amount of bladder contractions.

Surgery
Surgery can also be used to treat some forms of UI, usually stress incontinence. Different surgeries are performed for men and women.

Women
Your doctor will use several tools to determine if surgery is the best treatment option for your problem. These tools include: your history and physical examination, bladder diary, urine tests, and other tests. You will be checked into a hospital for three days. A catheter will be inserted in your bladder for those three days to ensure an empty bladder. Once the catheter is taken out and urination is voluntary, you will be allowed to return home.

Once you are home, you have to take a few precautionary measures to avoid complications. They include no heavy lifting (no heavier than a telephone book) for four weeks, following those four weeks nothing heavier than five pounds for three months, no excessive stair climbing for four weeks, pelvic rest (no douching or intercourse) for four weeks, and no driving for two to four weeks. For more information on urinary incontinence surgery, visit http://healthinaging.org/public_education/tools/UItool16.pdf.

Men
Blood tests, physical examination, chest x-ray, and EKG will be used to determine if surgery is the most appropriate treatment for your specific UI problem. Once these tests have been completed and the diagnosis is surgery, you will be given a laxative to clean out your bowels. After surgery, a catheter is placed in your bladder to drain urine until you are healed. You will be given an intravenous (IV) drip for feeding until you can properly eat and drink, with a possible nosepiece for oxygen. Most hospital stays are between three and seven days. To be sure no complications arise, you are sent home with a catheter, and shown how to properly use and care for it. After three weeks, the catheter is removed. No heavy (no more than five pounds) lifting for six weeks. Visit http://healthinaging.org/public_education/tools/UItool17.pdf to learn more about surgery for urinary incontinence.

Visiting the Doctor
If you, or someone you know, have urinary incontinence, there are several things you can do to prepare for a doctor visit. First, consider keeping a diary of your trips to the bathroom; this allows your doctor to assess your urination pattern as normal or abnormal. You will also want to bring a list of any medications, prescription or nonprescription, so your physician can determine if medication is part of the problem.

Be familiar with your medical history, especially of any bladder, urinary, or kidney infections you have had in the past. This information will help your physician be able to determine the best treatment for you. Writing down any questions or concerns to ask your doctor will also help, not only to better understand the problem, but also to make you more comfortable with the situation.