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Urinary Incontinence
Managing an embarrassing problem

If you have urinary incontinence (UI), you are probably all too familiar with this unintentional loss of bladder control. Urinary incontinence often occurs when the nerves that control the bladder have been damaged.

Poor control of the muscles that support the bladder can also cause incontinence. The bladder may leak, or alternatively be unable to empty. Nerve damage can be caused by diabetes, a stroke, spinal cord injury or other conditions that interfere with normal bladder function. Some evidence shows those with diabetes may experience incontinence at an earlier age than those without it.

Although incontinence is a problem for many adults in Canada, it is not a disease. Help is available and can often improve or completely cure the condition. It is a mistake to think that urinary incontinence is a normal part of aging. Many do not talk to a doctor about this embarrassing problem, even though it may greatly affect quality of life. For instance, someone may avoid going out for fear of having a humiliating accident. If this becomes a habit, social isolation can follow. For the elderly, untreated UI might lead to entering a care facility sooner than necessary.

Incontinence has many possible complications. If not managed properly, it can contribute to bladder and kidney infections and may even damage the kidneys. If you have diabetes, you need to be especially aware of possible problems. Symptoms of undiagnosed or poorly controlled diabetes can affect your urinary habits. Such signs include abnormal thirst and a frequent urge to empty the bladder as blood glucose levels rise. The kidneys then seek more water to dilute the glucose in the urine. Nerve damage in those with diabetes can often lead to difficulty passing urine and failure to empty the bladder.

Normal bladder function

After the kidneys process liquid, it passes to the bladder to be stored. Two sphincters (valves) control the flow in the urethra, a tube that empties the bladder. As the bladder fills, it reaches a point where it signals the brain that it needs to empty. The first sphincter opens involuntarily. Normally the bladder continues to fill for a time before pressure on the second sphincter reminds the brain of the need to urinate. Usually, we are able to control this sphincter until it is socially acceptable to go to the bathroom.

Normal bladder capacity is 14 to 20 ounces (about 400 to 600 millilitres). Everyone needs at least two litres (eight to nine eight-ounce glasses) of fluid per day. The amount of fluid you drink determines how often you need to urinate. It is considered normal to go to the bathroom (urinate) five to seven times a day. If there is heavy fluid intake late in the day, you may also go once or twice at night.

Types and causes of urinary incontinence

Stress incontinence occurs when an action such as laughing, sneezing, exercising or position change result in urine loss. It is caused by poor pelvic floor support and muscle weakness. It may happen following childbirth or menopause in women, and after prostate surgery in men.

Urge incontinence is a sudden, uncontrollable urge to empty the bladder. Frequent trips to the bathroom become necessary day and night. This urge to urinate during the night is called nocturia. Frequent passing of urine should be mentioned to your doctor since it can signal diabetes.

Overflow incontinence is the uncontrollable loss of urine when pressure in the bladder builds up until the valves give way. It can be caused by blockage or by weakened bladder muscles resulting in an overfilled and enlarged bladder. Nerve damage in those with diabetes can result in a larger bladder. Others may develop the problem following surgery. Since the bladder does not empty completely, infections of the urinary system can develop.

Functional incontinence happens when people are unable to get to the toilet. It may happen with loss of ability to move from one spot to another. It can be related to physical problems caused by diabetes, stroke or arthritis, including poor circulation or loss of sensation in lower limbs. Functional incontinence can also emerge as an unwillingness to go to the bathroom at appropriate times. Conditions affecting memory can result in passing urine at the wrong place or time. Depressed or emotionally disturbed people may also stop going to the bathroom when necessary.

Mixed incontinence occurs when people have more than one type of incontinence. The most common type is stress and urge incontinence in women. A man with an enlarged prostate may have overflow incontinence due to the enlarged prostate and urge incontinence from a stroke. Still others may experience functional along with stress, urge or overflow incontinence.

Assessment

The best way to get help is to ask for advice. Many doctors, nurses, physical and occupational therapists are specially trained to help with incontinence. This problem can be managed, and the sooner it is checked, the easier it is to treat. Be prepared to answer questions about when incontinence began, how long it has lasted, how and when it happens, and ability to reach the toilet.

A record of passing urine (voiding) is very helpful. Record how much urine is passed, how often you go, the number and type of pads you use, and all medications you take. Medications used to treat other health problems can interfere with the normal function of the bladder, so it is important to list all of them.

Your doctor may send you to a urologist or urogynecologist. This specialist will examine your nervous system to see how the brain and the nerves are working with the bladder. Special tests may also be done and X-rays taken to investigate how your bladder works. Once the specific cause is clearly understood, treatment is available.

Treatment may be
as simple as
eliminating these temporary causes:
• Good nutrition and physical activity can help prevent urinary problems.
• Use less caffeine and alcohol, which irritate the bladder.
• Quitting smoking not only lowers your risk of developing incontinence due to nerve damage, but can help prevent heart attack and stroke.
• Constipation puts extra pressure on the bladder and urethra and can cause leaking of urine. Drinking plenty of non-caffeinated fluids, especially water, helps prevent constipation and irritation to the bladder. Discuss a bowel routine with your health care provider. Getting enough fibre and at least six to eight cups of liquid per day may also help.
• Plan to take in more fluid during the day and avoid excess drinking during the evening. Note that in some cases it can be harmful to reduce fluid intake in order to avoid making trips to the bathroom. Urine concentrates in the bladder, causing irritation and increasing the urge to void.

Treatment

Keep in mind that treatment can help. In some incontinence can be cured, while others will feel a whole lot better. Your doctor can assess the condition and recommend a treatment right for you.

Urge incontinence may be the result of drinking beverages that contain caffeine – coffee, colas and so on. Simply giving these up may solve the problem. Certain techniques may also help. For instance, you might try to put off the urge to void for a minute or two before going to the bathroom. The time period is gradually increased from minutes to hours.

If simple causes have been ruled out and further investigations are done, medications such as Ditropan™, Urispas™, and Detrol™ may be prescribed. However, some may cause side effects such as dry mouth and thirst.

The two most common treatments for stress incontinence are weight loss and pelvic muscle (Kegel) exercises. To do Kegels, identify the pelvic floor muscles by stopping the flow while urinating. Once you are aware of which muscles to use, exercise by contracting them for one to two seconds each. Try to do this five to ten times a day, gradually working up to ten seconds per contraction. Men who have had prostate surgery can also benefit from this routine.

Sometimes biofeedback, using vaginal weights, or muscle stimulation may be necessary. A specialist might also recommend pelvic organ support devices called pessaries, medications, or surgery if less invasive treatments do not work.

Making regular trips to the bathroom to better empty the bladder can help manage overflow incontinence. To empty the bladder more efficiently, try passing urine a second time (double voiding). Scheduling more frequent bathroom breaks may also help. Recognizing the need to regularly empty the bladder is important so that the bladder doesn’t stretch resulting in loss of sensation. Another treatment involves inserting a thin tube, called a catheter, through the urethra and into the bladder to drain urine.

Scheduling a visit to the toilet every two to three hours can help treat functional incontinence. Adjusting the environment - perhaps by raising the toilet seat, adding lighting, or using a commode beside the bed at night - can make going to the toilet easier. Older adults may risk falling when rushing to use the toilet. Physical and occupational therapists can help improve mobility and regain bladder control.

Until the cause of the problem is treated, continence products may be necessary. These products, specially designed for both men and women, are used to collect urine. They are made of a special polymer material that draws fluid away from the skin. When buying protective garments, take care to select the right ones. Urine irritates the skin, increasing the risk for skin rashes and pressure sores. To choose the right one, first decide if incontinence is light, moderate or heavy. Use the most absorbent and skin-friendly products you can find.

Urinary incontinence is a common problem for older adults, especially for those with diabetes. Rest assured that treatment is available and many health care professionals can help with managing this condition.