Coping with urinary incontinence

For older adults, increased urinary frequency is fairly common.

“As people age, in general, the bladder does lose some of its capacity,” says Jonathan M. Vapnek, MD, associate clinical professor of urology at Mount Sinai School of Medicine, according to Mt. Sinai's Focus on Healthy Aging. “The bladder gets a bit stiffer and therefore, it does not hold as much. You can certainly expand it to the same amount, but you can get urgency earlier and that's one of the reasons why people, as they get older, will urinate more frequently.”

However, while increased urinary frequency is a normal consequence of aging, urinary incontinence (UI) is not. The Journal of the American Medical Association reports that the condition affects about 200 million people worldwide. At least one out of every 10 people over the age of 65 experiences UI. Despite its prevalence, the stigma surrounding UI causes many people to hide the fact that they have the problem, even though it can significantly affect their quality of life.

In order to control incontinence, you must understand the basics of urination. The bladder muscle stores urine, and the urethra is the tube through which the urine passes as it exits the body. When urination occurs, the bladder muscle contracts, pushing the fluid out, and the pelvic muscles that keep the urine from leaving the urethra relax, allowing the urethra to open and the urine to flow out of the body. The major types of urinary incontinence occur when there is a problem with either the way the bladder muscle contracts or the ability of the urethra to open fully or stay closed.

To determine which treatment is best for you, talk to your doctor about which of the four types of UI you are experiencing:
Stress incontinence. Stress incontinence refers to urinary leakage that occurs with increased abdominal pressure caused by activities such as exercising, laughing, or sneezing. Women who have given birth vaginally may experience structural damage that affects the ability to “hold in” urine. In addition, postmenopausal women produce less estrogen, and according to Dr. Vapnek, “That's a big thing. When women hit menopause there is not as much estrogen, and there is an atrophy that occurs causing weakness not only of the vagina, but also the bladder and the urethra.”

Although it's more common in women, stress incontinence also can occur in men who have undergone radical prostatectomy (removal of the prostate due to cancer). The prostate is a gland that surrounds the urethra, and removal of the gland can affect urination.

Pelvic floor exercises (shown on page 7) can help prevent stress incontinence. An antidepressant called imipramine (Tofranil) is sometimes used to treat stress incontinence. It works by relaxing the bladder muscle and contracting the muscles in the bladder neck, making it easier to control the release of urine. Success rates with this drug are not extremely high and therefore researchers are exploring alternative treatment methods for stress incontinence.

Some women find relief from stress incontinence by using a device known as a pessary. This plastic device, which is inserted into the vagina, compresses the urethra and elevates the bladder neck, making it less likely that increased abdominal pressure will cause urine to leak. Use of a pessary is generally safe, but sometimes can lead to vaginal and urinary tract infections.

Urethral sling surgery also can be performed to control stress incontinence. This procedure helps to “lift” a drooping bladder neck or urethra back into its normal position, which helps relieve pressure. Sling surgery is generally effective at relieving incontinence. In the past, urethral sling surgery required hospitalization, but due to recent medical advances, the procedure is now minimally invasive and can be completed in about 20 minutes. Possible risks include infection, reaction to anesthesia, and rarely, sexual dysfunction.

Urge incontinence. As the name suggests, urge incontinence refers to incontinence that occurs right after the urge to urinate is felt. People with this form of incontinence are not able to make it to the restroom in time. There are several conditions that may cause urge incontinence including stroke, diabetes, and Alzheimer's disease. However, the most common cause of urge incontinence is uninhibited bladder contractions, which increase in frequency as we age.

Medications that prevent unwanted bladder contractions are sometimes used to treat urge incontinence. These include tolterodine (Detrol) and oxybutynin (Ditropan). They are generally effective, but can cause side effects such as dry mouth and constipation.

Kegel or pelvic floor exercises and bladder training are as effective as medications in treating urge incontinence. Although they take a month or so to work, studies have found that these methods produce less incontinence than medications over the long term.

Surgery is not recommended for the treatment of urge incontinence.

Overflow incontinence. This form of UI occurs when the amount of urine in the bladder exceeds capacity. It can affect people with diabetes, as well as men with benign prostatic hyperplasia (BPH), which is an enlarged prostate that can “squeeze” the urethra, making urination difficult. “In males, it's almost inevitable that they'll have prostate enlargement at some point in their lives,” says Dr. Vapnek.

Overflow incontinence caused by BPH can be improved by drugs called alpha blockers that relax muscles, enabling the bladder to empty more effectively during urination. Some examples include tamsulosin (Flomax) and alfuzosin (Uroxatral).

Surgery can be performed to treat BPH, but it's generally only appropriate for men who have not had success with medication. The most commonly performed surgery is transurethral resection of the prostate (TURP). This requires a device to be inserted through the urethra in order to remove part of the prostate. TURP carries the risk of several side effects, including sexual side effects, and in rare cases can actually make incontinence worse. Medications like dutasteride (Avodart) and finasteride (Proscar) may help to reduce prostate size without surgery, but they generally take several months to work.

Functional incontinence. Functional incontinence is not typically a bladder-related problem, but rather something that occurs when conditions, such as arthritis, affect mobility and make it difficult to get to the bathroom in time. Pain-relieving drugs that improve mobility, such as acetaminophen (Tylenol), can help prevent functional incontinence from occurring.

Getting out of bed at night to urinate (nocturia) is a fairly common problem in older adults. “In addition to age-related structural changes, the kidneys do not concentrate urine as well (the less concentrated your urine is, the more often you will have to urinate) and therefore, the amount of urine coming out at night is larger,” says Dr. Vapnek.

However, if you have nocturia but are unable to make it to the bathroom in time, that's considered incontinence and you should work with your doctor to determine the cause. For example, BPH can cause nocturia; therefore, treating this condition with medication or surgery may improve your symptoms.

WHAT YOU CAN DO
Don't stop drinking water. Some people with incontinence may limit their fluid intake to avoid accidents, but not drinking enough water can cause dehydration, which is particularly harmful for older adults.

Limit alcohol, caffeine, and tea. These beverages can aggravate urinary symptoms, particularly incontinence, and tea is a natural diuretic.

Avoid foods that cause bladder irritation. These include acidic foods like citrus fruits and tomatoes, sugary foods like honey, and foods that contain caffeine like chocolate.

Perform pelvic floor exercises. These simple exercises can help strengthen the muscles that control the bladder and therefore reduce urinary incontinence.

Train Your Bladder through Exercise

Pelvic floor exercises can help both men and women with stress or urge incontinence. These exercises, also known as Kegel exercises, can help you strengthen the muscles that control the urethra.

A study published online June 13 in the Journal of Urology revealed that being able to contract certain muscle groups in a particular sequence (superficial muscle contractions, which means muscles that are closer to the outer surface of the body, followed by deep muscle contractions, or muscles that are deep within the body) may optimize urinary control.

For example, try lying on your back with your knees bent and feet flat on the floor. Tighten the superficial muscle group known as the pelvic floor muscles (these are the muscles you use to hold in urine) and then raise your hips off of the floor in order to contract the deep muscles within your abdomen. Hold this position for 10 seconds and then lower your hips back to the floor. Finally, relax your pelvic floor muscles. Repeat this process five to 10 times two to three times a day.

Other things that you can do on your own to control urinary incontinence include scheduled toileting, which means visiting the restroom every two to four hours, using absorbent underclothing to prevent leakage, or bladder training. For more information, visit The National Association for Continence at http://www.nafc.org