A Family Doctor's Tale - URINARY INCONTINENCE

DOC I CANNOT CONTROL MY URINATION

Urinary incontinence( A Simple Guide to Urinary Incontinence) is a symptom and means the the uncontrollable leakage of urine. 

This can cause a lot of discomfort to patients having this problem.
Elderly men are more prone to it than women.

Nowadays with a longer life span many elderly patients can be seen brought to the family doctor clinic wearing adult diapers.


Urinary Incontinence is a medical condition which may be temporary or permanent.


There are many causes of urinary incontinence:


1.Diet: 
too much tea, coffee or carbonated drinks can irritate the bladder and cause or contribute to incontinence.
Coffee and other drinks containing caffeine can be a particular problem as caffeine is a diuretic, i.e. it increases the urge to pass urine.


2.Excessive alcohol. 
Alcohol is also a diuretic. 
Because it has depressant effect on the the brain, it may affect the person's judgement temporarily, hence resulting in accidental leakage of urine.


3.medications 
diuretic pills, heart medications and antidepressants can cause or contribute to incontinence.


4.Urinary Tract Infection may cause sufficient irritation to the bladder to stimulate incontinence.


5.Constipation result in impaction of the stools in the rectum. This irritates the nerves to the bladder resulting in incontinence.


Permanent urinary incontinence

In both sexes there are many conditions which can cause or contribute to chronic or persistent urinary incontinence:


Men:
Enlarged prostate
BPH or benign prostate hypertrophy is associated with aging  and can obstruct the urethra and block urinary flow resulting in urge or overflow incontinence.


Prostate Cancer
Prostate cancer can cause incontinence if untreated. However the incontinence in prostate cancer patients may be a side effect of treatment e.g. surgery, radiation therapy.


Prostatitis
Inflammation of the prostate gland sometimes can cause constriction of the urinary flow and incontinence.


Women:

prolapsed uterus,
enlarged uterus due to fibroids,
ovarian cysts or tumors  can pull on the muscles of the perineum causing weakness of the muscles and poor constriction of the bladder opening


Aging
With age there is a decrease in the bladder capacity to store urine.


Surgery

Any operations involving organs such as the ovary, uterus, prostate, rectum can cause inadvertent damage to muscles or nerves of the urinary tract, resulting in incontinence.


Urinary tract obstruction
Any enlarged tumors along the urinary tract can obstruct the normal flow of urine and cause incontinence. 
Bladder stones can do the same.


Neurological conditions
Stroke, Parkinson's disease, tumors in the brain or spinal cord and injury to the nerves in pelvis or spinal cord can can affect the nerves to the bladder and weakening of the bladder opening muscles.



Urinary incontinence may be categorized into 4 main types. 
It is possible however to have more than one type of urinary incontinence


1.Stress incontinence
Leakage of urine occurs because of weakness of the pelvic floor muscles. When there is pressure exerted on the bladder - e.g. from laughing, sneezing, coughing, exercising or heavy lifting, pregnancy, the muscles at the opening of the bladder comes under stress and opens to allow leaking of urine. 

Recently one of my elderly female patient had to wear a menses pad because of her chronic  cough. Each time she coughs, the urine automatically leaks out.



2.Urge incontinence
There is an uncontrollable leakage of urine while suddenly feeling the urge to urinate.


3.Overflow incontinence
There is a constant dribbling of urine even after finishing urination. 
There is  an inability to completely empty the bladder.


4.Functional incontinence
There is physical or mental impairment resulting in the failure to realize the need to urinate.As a result the person fail to get to the toilet in time and pass out the urine. 
Examples are people who suffer from dementia, parkinson or is incapacitated by poor physical movement.


Other types of urinary incontinence include enuresis(bed wetting ) which is common in children,

Transient incontinence which is temporary and sometimes caused by medications.


A Family doctor will look for a history of:

1.Uncontrollable leakage of urine. 
This leakage may be frequent and heavy, or it may be small and rare.
2.Urgency - a strong desire to urinate even when the bladder is not full together with pelvic discomfort or pressure

3.Frequency - urinating more than once in a two-hour period or more than seven times a day
4.Nocturia - the need to wake up and urinate at least twice during sleep
5.Dysuria - painful urination
6.Enuresis - bed-wetting or urinating while sleeping


The Family Doctor will look for:
medical conditions causing incontinence, such as pelvic tumors, stool impaction, and poor reflexes or sensations.

He will send the patient for
1.measurement of bladder capacity and residual urine for signs of poor functioning bladder muscles.
2.Stress test - the patient coughs vigorously as the doctor watches for loss of urine.
3. urine is tested for infection, urinary stones.

4.Blood tests - for PSA( in case of Cancer of prostate) or alphafoetoprotein (in case of cancer of the ovaries)

5.Ultrasound -to visualize the kidneys, ureters, bladder, and urethra.

6.Cystoscopy - a thin lighted tube is used to see the inside of the urethra and bladder.

7.Urodynamics -  measurement of pressure in the bladder and the flow of urine.




Elderly patients tend to believe that the only way to prevent embarrassment is to wear absorbent pads or padded undergarments like adult Diapers. 
However the wetness may lead to rashes, sores, or infections. 

Treatment involves:
A. making certain lifestyle changes.

1.Timed Voiding
Timed voiding (urinating) means writing a chart of your urination and leakage patterns for several days. 
This will then tell you which times of day you normally need to empty your bladder before leakage may occur.


2.Bladder training
This involves training your bladder to control the urge to urinate. 


3.Changing Fluid Intake
Restricting your fluid intake, or changing the timing of fluid intake will help you to gain more control over the bladder. Restriction of alcohol, tea, coffee and other caffeinated beverages can reduce the amount of urine from your body


4.Exercises
Exercising the muscles of the pelvis (Kegel exercises) may strengthen the muscles of the affected area.


5.Vaginal cone therapy
This exercise for women involves the use of a set of five small vaginal cones of increasing weight. 
The patient simply places the smallest plastic cone within her vagina and hold it in by a mild reflex contraction of the pelvic floor muscles. This exercise is done twice a day for fifteen to twenty minutes. As the pelvic floor muscles becomes stronger, cones of increasing weight can be used, thereby strengthening the muscles gradually.


6.Electrical stimulation
Electrodes are temporarily placed in the vagina or rectum to stimulate nearby muscles and strengthen the pelvic muscles.
This can reduce stress and urge incontinence.


7.Biofeedback
Using electronic devices or diaries to track when the bladder and urethral muscles contract, the patient can slowly control movement of  these muscles.


B.Treating the cause of the incontinence:

1.Medications:
drugs may be given to treat urinary tract infections or inhibit contractions of an overactive bladder.


2.Pessaries
A pessary is a ring shaped medical device that is inserted into the vagina. It compresses the urethra against the pubic bone and elevates the bladder neck.


3.Surgery
Surgery to reduce the size of your prostate gland ( transurethral resection of the prostate or TURP) helps to reduce urinary incontinence in men.


Bladder repositioning
In older women incontinence results from the bladder dropping down toward the vagina.
Surgery involves pulling the bladder up to a more normal position. Using an incision in the vagina or abdomen, the surgeon raises the bladder and secures it with a string attached to muscle, ligament, or bone.


4.Catheterization
A catheter may be inserted to drain the urine if your bladder never empties completely  or if your bladder cannot empty because of poor muscle tone, post surgery or spinal cord injury. This can be done on a if required basis.


5. Botox injections
Botox injection has been tried to reduce the sensitivity of the nerves at the opening of the bladder. It appears more successful for women than in men.


Patients can prevent urinary incontinence by:

1.Maintain a healthy weight.
Obesity can lead to urinary incontinence.
2.Avoid constipation by drinking sufficient amounts of fibre and fluids in your diet.
3.Avoid drinks which can irritate your bladder such as coffee, tea, carbonated drinks and alcohol.


Urinary incontinence can also cause problems in the family.
I have a stroke patient who was promised a place to stay at his sibling's house after his mother passed away so that the mother's house can be sold and the proceeds divided by the siblings.
After 1 month staying at his brother's house he was sent to a nursing home because the sister-in-law could not deal with his leakage of urine on the bed and floors.