The Impact Of Incontinence
It is estimated that at least 25 million Americans suffer from urinary incontinence
or overactive bladder. Urinary incontinence (UI) is the unwanted and involuntary
leakage of urine. Stress urinary incontinence (SUI) is the most common form
of lost bladder control. SUI is involuntary loss of urine which often accompanies
coughing, sneezing or physical activity without warning. Although this condition
is more common among older women, one third of women with this problem develop
it before age 35. People with urge incontinence or overactive bladder (OAB),
have a sudden urge to void and may just not get to the rest room on time. Good
news for these patients is that there are now new medications available to treat
this condition. Ironically, most people who suffer from incontinence do not
even discuss it with their physicians for years after having this problem.
The inability to control urine is one of the most unpleasant and distressing
problems a person can suffer--both psychologically and socially. In most cases,
incontinence starts gradually over time and increases, often to the point of
causing people to stop doing many of their normal activities. Not only does
UI cause wetness, odor, discomfort, and skin irritation, it can also damage
self-esteem as a result of shame and embarrassment. Women report that incontinence
has affected sexual relationships with their partners because of the fear of
urine leakage during sexual activity. Those afflicted with UI or OAB may become
depressed and socially isolated. OAB negatively impacts quality of life more
severely than persons suffering from diabetes and rheumatoid arthritis.
Individuals suffering from
OAB often limit social interaction and excursions as a consequence of their
condition. Planning ahead to locate accessible public toilets, a behavior called
"toilet mapping," becomes a source of major anxiety. UI and OAB may
also increase the risk of falls in elderly persons.
In the United States, UI causes a significant economic burden. In 1995, the
direct cost of caring for incontinent persons over the age of 65 years in the
community and in nursing homes was estimated to be $28 billion annually. This cost is greater than the combined Medicare costs for open-heart
surgery and end-stage renal disease. The costs are predominantly for palliative
rather than rehabilitative services. It is expected that overall costs for managing
UI will increase as the aging population increases.
Identification of Those Persons At Risk
Even though ambulatory and
primary care settings are ideal for screening, basic evaluation, and initial
management of UI and OAB, most clinicians do not ask patients about the problem
and, if UI is detected, are unaware of interventions that can be successful.
Documented risk factors that
are associated with UI and OAB are wide-ranging:
Treatment of Urinary Incontinence
- Age: It is
believed that stress incontinence usually occurs in women ages 45 to 54 years,
while UI usually occurs in women ages 35 to 64 years, increasing with age.
- Race: It has been suggested that Caucasian women have
a shorter urethra, weaker pelvic floor muscles, and a lower bladder neck than
African American women, thus making them more likely to have incontinence.
However, parity and socioeconomic factors may also contribute to the difference.
There are no data on the relation between race and UI or OAB in men.
- Pregnancy and childbirth: Pregnancy and vaginal childbirth
increase the risk of UI in women. Vaginal delivery involves significant relaxation
and lengthening of the pelvic floor muscle to permit the passage of an infant.
The pelvic floor must contract again after childbirth to functionally normally.
UI that occurs post-childbirth has been associated with several risk factors
occurring during delivery: use of forceps, episiotomy, and pudendal anesthesia. Women
report a reduced ability to voluntarily contract the pelvic muscle 3 months
- Menopause and depletion
of estrogen: Pelvic muscle relaxation accelerates rapidly after menopause
and may progress with aging in general. This causes prolapse of pelvic organs
in women. Estrogen depletion is associated with diminished urethral mucosa
vascularity and thickness. Estrogen receptors are present in a woman's urethra
and bladder tissue and in the musculature of the pelvic floor. This deterioration
and a decline in mucus production within the urethra weaken the urethra's
ability to maintain a tight seal, especially when intra-abdominal pressure
increases with the Valsalva maneuver. Sensitivity and responsiveness to estrogen
have been found in epithelial, connective, muscle, and vascular tissue. While
these findings may suggest that replacing estrogen could cure or lessen incontinence,
studies have not always supported this hypothesis. However, the
use of estrogen in the form of a topical cream or vaginal ring often helps
older women with vaginal atrophy and symptoms of OAB.
- Pelvic surgery: A 40% increased risk of UI has been seen
in community-dwelling women who had a hysterectomy. This may be due to the
loss of structural support to the bladder, scarring of the urethra, or disruption
of the pelvic nerve plexus.
- Smoking: There appears to be a relationship between smoking
and UI. There is a potential contractile effect of the bladder from nicotine
as well as significant pressure exerted on the bladder and urethra during
coughing. Chronic and frequent coughing may lead to damage of urethral and
vaginal supports and cause perineal nerve damage.
- Obesity: Weight gain and morbid obesity may increase the
susceptibility for UI and, consequently, weight loss may reduce the risk.
The UI seen in obesity may be secondary to increased pressure on the bladder
and greater urethral mobility. Obesity may impair blood flow or nerve innervation
to the bladder. Despite this association, no studies have evaluated the effect
of moderate weight loss on UI. However, research has shown that UI symptoms
decrease in morbidly obese women who undergo extreme weight loss.
- High-impact physical activities: It is known that young,
highly fit women who have never been pregnant can still have symptoms of UI
when exercising. Up to one third of women experience urine loss during physical
activities. Causes of incontinence may include inadequate abdominal pressure
transmission, pelvic floor muscle fatigue, and changes in connective tissue
or collagen of the pelvic floor muscle. Sports most likely to provoke UI include
those that create a sudden increase in intra-abdominal pressure (e.g., jumping,
landings, and dismounts). That may explain why 26% of women parachutests in the Air Force reported experiencing urine leakage and 18% reportedly experienced urine leakage while flying.
- Medications: Several medications can cause bladder over-activity.
Diuretics can adversely affect bladder filling and emptying; anticholinergic
agents cause urinary retention and impaction; antidepressants cause anticholinergic
actions and sedation; sedatives/hypnotics/central nervous system depressants
cause sedation, delirium, immobility, and muscle relaxation; and narcotic
analgesics cause urinary retention, fecal impaction, sedation, and delirium.
- Chronic diseases: Diseases such as multiple sclerosis,
spinal cord injury, diabetes, Parkinson's disease, and stroke may cause nerve
and bladder neuropathy, increasing a person's risk for UI or OAB.
Caffeine is a bladder irritant and may cause increased bladder and urethral
contractivity. It is also a diuretic.
Treatment success depends
on the patient's compliance to the treatment plan and the ability to follow
the plan physically, emotionally, and financially. If motivated, most people
treated with behavioral techniques show improvement ranging from complete dryness
to decreased incontinence episodes.
- Diet counseling: Patients with urinary symptoms of urgency
and frequency should limit caffeine intake. Caffeine is found in cola beverages,
coffee, tea, milk chocolate, and certain nonprescription medications (e.g.,
Anacin, Excedrin, Midol). With caffeine's diuretic effect, it can
increase urine overload of the bladder and contribute to both stress and urge
incontinence. Patients with UI may decrease urine leakage through modification
of certain diet habits, specifically, fluid intake. Ironically, adequate fluid
intake is necessary to prevent UI. Dehydration can cause constipation, concentrate
the urine, and increase the irritating effects of dietary substances. When
nocturia or nighttime UI is a problem, suggest that the patient limit fluid
intake after dinner.
- Pelvic floor muscle rehabilitation: Pelvic floor muscle
rehabilitation?Kegel exercises-- is used in the treatment of mixed UI and
OAB. These should be performed daily until continence is restored or significantly
improved. Kegels are most effective with persons who have stress incontinence
but can also be effective in persons with UI. Weighted vaginal cones provide
biofeedback. Vaginal cone therapy can be used alone as a method to increase
pelvic muscle strength or in conjunction with Kegels. Electromyogram (EMG)
or pressure probes (vaginal or rectal), or perianal EMG surface electrodes,
are also used to display the patient's strength, duration, relaxation, and
pelvic floor muscle isolation onto a patient-viewing monitor.
- Bladder retraining: In patients with OAB and urge UI,
the addition of bladder retraining, in conjunction with other methods, can
alleviate symptoms of urinary urgency and frequency. The basis of a bladder
training regimen includes education followed by a strict schedule of voluntary
voiding with specific instructions to avoid responding prematurely to urinary
- Prescription medicines:
Several medicines are now available to treat OAB. You should discuss this
with your physician.
Click here for more information on incontinence.
Created: 5/24/2001  - Donnica Moore, M.D.