Incontinence: A Fairly Common Problem

Millions of Americans suffer from chronic urinary incontinence, according to a study by the Agency for Healthcare Research and Quality. A large percentage of those with incontinence severely limit their interaction with other people to avoid embarrassment, and most do not even disclose their problem to their doctor.

Bowel (fecal) incontinence is not nearly as prevalent as urinary incontinence. Constipation, which can be part of the problem of bowel incontinence, can lead to urinary difficulties by creating pressure on the bladder that the brain misreads, causing an urge to empty a bladder that is not yet full.

Types of incontinence

Bladder and bowel control are complex processes that involve the brain, spinal cord and muscles of the bladder, bowel and pelvis. Loss of bladder or bowel control can be caused by problems with any of these components. Incontinence, or loss of the ability to control urination or defecation, is a symptom, not a disease. Some of the causes include normal changes in muscles because of aging, birth defects, pelvic surgery, injuries to the pelvic region or the spinal cord, neurological diseases, multiple sclerosis, infection, degenerative changes associated with aging, and pregnancy and childbirth.

There are four basic types of urinary incontinence:

  • Stress incontinence occurs when the internal sphincter muscle surrounding the urethra, the tube that drains urine from the bladder during urination, weakens. This allows the bladder to leak during exercise, coughing, sneezing, laughing or any body movement that puts pressure on the bladder. In women, the causes include vaginal childbirth, hysterectomy and lack of estrogen after menopause. In men, this can be caused by prostate surgery or radiation treatment for prostate cancer.

  • Urge incontinence is the urgent need to pass urine and the inability to get to a toilet in time. It also is called hyperactive or irritable bladder. It occurs when nerve passages along the pathway from the bladder to the brain give the wrong the signal to the brain or the brain is unable to inhibit the bladder muscle from contracting.

  • Overflow incontinence refers to leakage that occurs when the quantity of urine produced exceeds the bladder's holding capacity. This happens when the bladder is not able to empty completely. This can be caused by a blockage or by a weak bladder muscle that cannot contract enough to empty the bladder. Tumors or enlarged prostates can block the flow of urine out of the bladder. Some blood pressure medications can weaken the bladder muscle. Nerve damage to the spinal cord or pelvic nerves also can cause the bladder muscle to weaken.

  • Reflex incontinence is the loss of urine when the person is unaware of the need to urinate. It most often is caused by problems with the nerves or spinal cord.

Bowel elimination is controlled by three factors: the rectal sphincter muscle, which relaxes to allow defecation; the muscle capacity of the rectum to stretch to hold stool; and the nerves that send to the brain the message that the rectum is full. Damage to any of the muscles or nerves involved in defecation can cause fecal incontinence. The most frequent cause is muscle weakness. Damage to the muscle can occur in childbirth, prolonged straining to have a bowel movement, or in some diseases such as diabetes, multiple sclerosis and in spinal cord injuries. The ability of the muscles of the rectum to stretch can be decreased by surgery, radiation and inflammatory bowel disease.

Diagnosis and treatment

Because incontinence is a symptom, not a disease, treatment depends upon the results of diagnostic tests by your physician, which may include X-rays, blood work, and urine analysis, and examination of bladder capacity, the amount of urine left in the bladder after urination, urethral pressure, and sphincter condition.

Three major categories of treatment are behavior change, medications and surgery.

These are common behavioral approaches:

  • Scheduled toileting. A person with urinary incontinence is prompted to go to the bathroom every two to four hours. This puts the person on a regular schedule. The goal is simply to keep the person dry. This is frequently recommended as therapy for frail elderly, bedridden or Alzheimer's patients.

  • Bladder or bowel retraining. Bladder retraining involves scheduled toileting, but the length of time between bathroom trips is gradually increased. This therapy trains the bladder to wait for larger time intervals and has been proved effective in treating urge and mixed incontinence. In bowel retraining, elimination is stimulated by suppositories, at the same time each day. The muscles are trained to defecate on a regular schedule.

  • Pelvic muscle rehabilitation. This technique involves pelvic muscle exercises, which may be used alone or in conjunction with biofeedback therapy, vaginal weight training and pelvic floor stimulation to stimulate pelvic nerves.

Drinking less water is not a good way to avoid problems with urinary incontinence. Concentrated urine caused by dehydration can cause the lining of the bladder and urethra to become irritated and actually make incontinence worse. Drinking two to three quarts a day may help. Some fluids, like alcohol, may make incontinence worse. Stop drinking any fluids two to three hours before bedtime.

A high-fiber diet that prevents constipation helps with fecal and urinary incontinence. Constipation makes urinary incontinence worse.

Medications may be prescribed to help control incontinence. Medications relax the bladder and reduce spasms or instability. These drugs help prevent the bladder contracting spontaneously.

Sometimes a health care provider will take a person off a medication that is causing or contributing to incontinence. Of course, only your provider should tell you to stop using a drug that he or she has prescribed.

Topical estrogen applied to the vaginal area can help if the cause of urinary incontinence is related to menopause or an estrogen deficiency.

Surgery should be performed only after being thoroughly evaluated by a health care provider. All appropriate nonsurgical treatments should be tried before deciding on surgery.

Many different surgical procedures may be used to treat urinary incontinence. The type of operation recommended depends on the type and cause of your incontinence. Some of the more common procedures performed to treat urinary incontinence include "suspending" internal organs, injecting collagen around the urethra to ensure closure, and implanting an artificial urinary sphincter or sacral nerve stimulator.

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