Incontinence: Learning to deal with it

By Smriti Daniel

A Consultant Urologist, Dr. Anura Wijewardane knows that often enough it is simply embarrassment that makes patients hesitate. For those who are unable to control the flow of their urine, incontinence is as much a social problem as it is a hygienic one. While there are no studies in Sri Lanka Dr. Wijewardane says that incontinence is nevertheless a common enough complaint, especially among elderly women.

Fortunately, in recent years, medical advances have led to a greater understanding not only of the mechanisms responsible for incontinence but the development of a number of non-invasive treatment options. This week, MediScene speaks to Dr. Wijewardane about the importance of identifying the cause of incontinence and the benefits of adopting behavioural therapies to treat it.

Why it happens

As children, we learn continence. Our brains control our bladders, and we are able to wait for an appropriate time and place. To find that effortless control unexpectedly challenged can be deeply humiliating, yet many people assume it is a natural part of growing old. This need not be the case, according to Dr. Wijewardane.

There are different kinds of incontinence, each of which has a different root cause. Traditionally, doctors speak of these categories of incontinence. Among these stress and urge incontinence are the most common, though some patients also exhibit mixed incontinence, which borrows symptoms from the different types.

Stress Incontinence:

Coughing, sneezing, laughing or even lifting something heavy can trigger a bout of stress incontinence, says Dr. Wijewardane. These are all activities associated with a rise in intra-abdominal pressure. In some cases, there is a weakening of the urethral sphincters. The latter has been associated with obesity and in the case of women, with childbirth. In men sphincter weakness may follow pelvic fractures and urethral injuries.

Urge Incontinence:

This condition can also be called as Over active Bladder [OAB]. As the name suggests, urge incontinence is characterised by an overpowering desire to urinate that undermines one’s control. Detrusor contractions or the uninhibited contraction of the bladder muscle and irritation of the bladder associated with diseases like severe urinary infection, bladder stones and even bladder tumours are known causes.

In such cases, incontinence is a symptom of a disease, and treatment of this disease will cure incontinence. In men, over the age of 40, an enlarged prostate with bladder out flow obstruction is the most common cause of urge incontinence. When it involves an enlarged prostate the condition is known as benign prostatic hyperplasia that causes an obstruction in the channel.

Overflow Incontinence:

This occurs from an over distended bladder, when pressure in the bladder due to over distension exceeds Urethral closure pressure says Dr. Wijewardane. However, a heavily distended bladder applies pressure on the urethral opening and also can put great strain on the kidneys. In addition, chronic retention of urine brings with it its own complications.

In men, the flow of urine might be obstructed by benign prostatic hyperplasia, which as mentioned before is essentially the enlargement of the prostate gland. In elderly women, the common cause is urethral stenosis –[ the narrowing of the urethral channel].

Insensible Incontinence:

Neurological disorders that damage the sensory nerve pathways can cause sudden incontinence. Particularly in the elderly, diseases that cause cerebral degeneration such as a stroke or cerebral atrophy can mean that they are not only unaware of having a full bladder but are also not in control of their excretory functions.

Diagnosing Incontinence:

A doctor faced with a case of incontinence must first take a thorough medical history of his patient. This helps determine the pattern of incontinence, says Dr. Wijewardane. Pain on passing urine suggests urinary infection while blood in the urine means that a doctor must also rule out the possibility of bladder stones or tumours. You should inform your doctor if you have undergone surgery previously or if you have any other illnesses such as diabetes.

Constipation in the elderly has sometimes been known to cause incontinence and so keeping a record of the patient’s bowel movements may be important.

Treating Incontinence:

Depending on the type of incontinence, its underlying cause and its severity, your doctor will decide how to approach your treatment. In some cases, it is as simple as making sure a patient visits the restroom at regular intervals throughout the day. The time between each visit can be gradually increased. Dr. Wijewardane says he recommends at least once every three hours, he also suggests that the patient continue to consume 2 to 2 ½ litres of water a day, as it is essential in this climate.

Crucial to treating stress incontinence is weight management. Significant weight reduction has been known to eliminate the occurrence of urinary incontinence altogether. This should be accomplished in consultation with a dietician. Practising pelvic floor exercises are another simple way of strengthening the muscles concerned. These are particularly effective after weight reduction and many doctors recommend that new mothers do these regularly post birth.

Drug therapy

Systemic drug therapy is of little use in stress incontinence. It’s well recognised that in post menopausal women, oestrogen deficiency may be a contributory factor for sphincter weakness, and local oestrogen therapy has been shown to be helpful. In urge incontinence, systemic drug therapy is widely used with notable response.

These drugs calm an overactive bladder Surgery, as in most cases, is the last resort, such as in men with severe sphincter weakness or in those with enlarged prostates. Though over a 100 different operative procedures exist, patients and doctors must be careful to undertake these only when the patient has reached his or her optimal weight. Obesity can cause complications and impair healing, warns Dr. Wijewardane.

For those with stress incontinence, your doctor might suggest you undergo a ‘sling’ procedure. Here a strip of your body’s own tissue or a synthetic mesh is used to fashion a hammock like pelvic sling around your bladder neck and urethra. It helps keep the urethra closed, even when you cough or sneeze. The procedure is routinely undergone by patients in Sri Lanka, says Dr. Wijewardane.

Behavioural Techniques and Lifestyle Changes:

A little fore planning will do wonders. Begin by exploring some of the situations which could be particularly embarrassing – for instance sexual intimacy, exercise and travel can really cause those with incontinence a great deal of stress. Plan for these by making sure you have hygiene products and a change of clothes with you in case of an accident. Identify the location of the nearest toilet and test any new strategies at home before you go into a social situation. Pads and other protective garments can be worn discreetly and allow you to move around freely and are available for both men and women.

Dr. Wijewardane says he particularly believes in the efficacy of bladder training. Here a patient is encouraged to practise holding off until the time between trips to the toilet stretches to at least two to four hours. “This is called void urine by the clock,” says Dr. Wijewardane. While practising this, it helps to concentrate on relaxing. Breathe deeply and distract yourself with another activity.

You may also be introduced to the concept of ‘double voiding’ where after you urinate, you wait a few minutes and then try again. This can help patients cope with overflow incontinence.

Causes of urinary incontinence

  • Thinning and drying of the skin in the vagina or urethra, especially after meno pause
  • Enlarged prostate gland or prostate surgery for men
  • As a side effect from certain medicines
  • Weakened pelvic muscles post-childbirth/ Post Pelvic or Urethral Injury
  • Diseases such as diabetes, Alzheimer's disease, vascular disease and multiple sclerosis
  • Obesity is associated with increased pressure on the bladder and the weakness of muscles that control it.
  • Urinary tract infections.

associated with Neurological [Spinal cord or brain] disease

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