Women and Urinary Incontinence
It is generally thought that between 10-12% of women regularly experience urinary incontinence, with the incidence being far higher in some groups. The most common form of urinary incontinence among women is stress urinary incontinence. This is followed by urge incontinence, and many women experience both forms of incontinence with a mixture of symptoms.
When a woman presents with reported symptoms of urinary incontinence, it is most important to rule out other pathology before making a diagnosis of stress urinary incontinence (SUI), urge incontinence (UUI), or mixed incontinence. This should involve a medical history including any head, neck or back injury, relevant conditions, e.g. diabetes, sports activity, parity, family history and both urinary symptom analysis and physical examination.
Symptom analysis includes reported episodes and nature of incontinence. Urinary analysis to test for bladder or urinary tract infection and to exclude hematuria should always be undertaken. If feasible, direct her to fill out a urinary diary to document both time and amount of voiding, and the volume and nature of her fluid intake.
Physical examination should rule out constipation, prolapse, masses or tumors, fistulae and damage from pregnancy, childbirth or previous surgery or injury. Neurological symptoms and mental state should be assessed in case of head trauma, multiple sclerosis, Parkinson's disease, Alzheimer's, etc.
Finally, an assessment of quality of life, mobility and bathroom access may be applied to determine need for treatment.
STRESS URINARY INCONTINENCE
Stress urinary incontinence describes the complaint of involuntary leakage of urine upon effort or exertion, or upon sneezing or coughing. This may be a small amount, but it can sometimes be significant.
Review lifestyle for food and fluid intake, weight reduction and smoking. Overweight people have a greater tendency for stress incontinence because of increased abdominal pressure. Smokers cough more, which can result in an increased incidence of leakage.
- Do not drink too much or too little. Reducing fluid intake to decrease urine may produce further irritation of the bladder and promote infection.
- Avoid caffeine and fizzy drinks, which may irritate the bladder, as may alcohol.
- Review current medication for interaction or iatrogenic effects.
Pelvic Floor Muscle Exercise
The generally accepted first treatment for stress incontinence is pelvic floor muscle exercise, to improve bladder support and closure pressure of the urethra. Referral to a physiotherapist is the most effective way of ensuring that the exercises are being done correctly, and so give the best chance for success. Physical examination will help determine the status of the pelvic floor muscles and so allow the physiotherapist to advise on a personalized exercise regime.
Biofeedback and electrical stimulation aid in the execution of pelvic floor muscle exercise for both men and women and ideally should be recommended by a physiotherapist or continence professional.
Absorbent Continence Management products designed specifically for urinary incontinence are the most popular products among Residents for protection against urine leakage. There are both disposable and reusable products, and although all products are not alike, many are developed to a high technological standard and provide the user with flexibility and ease of use. Residents may use several different types of products or underwear depending on their daily needs. There are products and underwear developed for specific purposes, which can be slim and unobtrusive for day use or substantial enough to contain heavy leakage. Continence advisers can give the best guidance on what to use, and local continence organizations can help with consumer issues.
Other products for urine collection and inhibiting urine flow may also be used to contain leakage in certain circumstances. Catheters may be used as a temporary measure after surgery, or as a long-term solution. Catheters may be intermittent or indwelling, and are connected either to a drainage bag held on the person, or to a valve that allows the catheter to be emptied in a vessel on a regular basis. Indwelling suprapubertal catheters may be surgically introduced through the abdomen rather than via the urethra. Patients or caregivers may be trained to change and clean these.
Pharmacological and surgical interventions (under certain conditions)
New agents are available that aid in stress incontinence. These are called dual noradrenaline/serotonin reuptake inhibitors, and are available in certain European markets. Studies have suggested that the best results are achieved if these are used in association with pelvic floor muscle exercises.
A urologist or gynecologist can advise on all the available surgical procedures for stress urinary incontinence. There are both open procedures and day procedures, as well as the use of bulking agents. For most patients, surgery for stress incontinence should be considered as tertiary care after conservative and pharmacological interventions have not produced the desired result.
Urge incontinence, or overactive bladder, refers to the overactivity of the detrusor muscle of the bladder that creates an increased urgency with little or no warning, and it is often accompanied by urine leakage. In severe cases, the volume of leakage can be large. Urinary frequency (more than eight times per day) and nocturia (one or more per night) may also occur.
Make getting to the bathroom as easy as possible. This may involve special adaptations to the Resident's living area. A raised toilet seat, handrails, commodes in the bedroom, all may aid in helping the Resident, as may clothes that can be opened easily if manual dexterity is a problem.
Bladder retraining is a behavioral technique designed to increase the capacity of the bladder and decrease the frequency of urination. Over time, the bladder becomes less irritable and able to cope with larger volumes of urine. A urinary diary is the first step in assessing urge incontinence and setting up a course of bladder retraining.
Pelvic Foor Muscle Exercise
Pelvic floor muscle exercise is most successful with stress incontinence and mixed incontinence, but may be of value to those with urge incontinence, to strengthen the musculature and minimize or eliminate leakage. Biofeedback and electrical stimulation aid in the execution of pelvic floor muscle exercise and ideally should be recommended by a physiotherapist or continence professional.
Some women experience sudden involuntary urine loss and choose to wear an absorbent continence management product when they are in at-risk situations. There are several styles and shapes of products and underwear that suit varying amounts of leakage. There are both disposable and reusable products available, and an experienced continence advisor who can direct the patient to the most appropriate form of protection that is designed to absorb urine rather than a sanitary product, which is designed to absorb blood.
Other products for urine collection and inhibiting urine flow may also be used to contain leakage under certain circumstances. Catheters may be used as a temporary measure, after surgery, or as a long-term solution. Catheters may be intermittent or indwelling, and are connected either to a drainage bag connected to the person or to a valve that allows the catheter to be emptied into a vessel on a regular basis. Indwelling suprapubertal catheters may be surgically introduced through the abdomen rather than via the urethra. Patients or caregivers may be trained to change and clean these catheters.
Pharmacological and surgical interventions (under certain conditions)
Anitmuscarinics and anticholinergics may be prescribed for detrusor muscle overactivity. Surgical intervention for urge incontinence without stress incontinence symptoms is rare.
With mixed incontinence, the symptoms of stress urinary incontinence co-exist with those of urge incontinence. According to the most recent guidelines of the International Committee on Incontinence, it is recommended to treat the predominant symptom first.
OTHER FORMS OF INCONTINENCE
There are other forms of incontinence that may not fall into the above categories.
- Giggle incontinence: A form of incontinence generally experienced in youth, but may continue into adulthood. Urination triggered by laughter, the result of instable detrusor muscles, which may be hereditary.
- Functional incontinence: The inability to reach the bathroom to urinate either due to disability (physical or mental) or infirmity.