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.

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:

• 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 post-childbirth.
  
  
• 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: 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 urgency.
  
  
• Prescription medicines: Several medicines are now available to treat OAB. You should discuss this with your physician.

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Created: 5/24/2001  -  Donnica Moore, M.D.