Forty years ago, Woody Allen directed the zeitgeist comedy "Everything You Always Wanted to Know about Sex *But Were Afraid to Ask." Today, fewer people are reluctant to talk about sex, but that misplaced sense of delicacy has moved to a different bodily function: urinary incontinence, or the involuntary release of urine. What most people might call having "accidents."
Whether it's leaking urine during exercise, sneezing or laughing, or a sudden uncontrollable need to go that results in wet pads or pants, urinary incontinence is a problem that plagues many older people, most often women. They may resort to adult diapers, plan their day around access to bathrooms, or give up activities they love, or work they need, as a result. Some 13 million people -- as many as one in three older adults -- live with this distress. Among nursing home residents, the numbers soar as high as seven out of ten.
"Urinary incontinence not only causes great unhappiness but can also increase disability, social isolation, and health care costs," says Catherine DuBeau, M.D., Clinical Chief of the Division of Geriatric Medicine at University of Massachusetts Medical School and a researcher specializing in incontinence. DuBeau received an American Federation for Aging Research Award for her work, which focuses on quality of life impact and patient-centered outcomes. "Not only that, it is associated with loss of independence, falls and fractures and increases the risk of admission to long-term care facilities."
Despite serious consequences, urinary incontinence gets seriously overlooked and under treated. But it does not have to be this way. Very few older people need to be wearing adult diapers, because urinary incontinence is highly treatable. It is not ever a part of normal aging or a foregone conclusion.
So, as a geriatrician and medical officer for the American Federation for Aging Research, I strongly believe that, even if it may be a bit uncomfortable, we need to talk about urinary incontinence.
I say that equally to patients and health care professionals. Doctors and nurses, it is your responsibility to know this subject and to ask your patients, particularly if there are any clues. If someone comes into the office in Depends, you must have this conversation. Get specific. Is the problem urgency? Dribbling? Pain? Then please follow up. It is simply unacceptable that half of all people with urinary incontinence never get any help, or that 40 percent of those who do summon up the courage to ask still don't get any care.
Ladies and gentlemen, for your part, please overcome your embarrassment and bring the subject up. Half of all sufferers won't, but you owe it to yourself. You can be cured! Or, at a minimum, greatly improved.
What you need to know
Not only can nearly 90 percent of women get great results from treatment for urinary incontinence, but it usually will not require surgery or drugs. This is because urinary incontinence isn't a disease in its own right. It is caused by a combination of problems, habits and sometimes medications.
The bladder has two main functions. It stores urine when you don't want to urinate. Then, when you do want to go, it should empty on demand.
The major problem facing most older people is generally known as overactive bladder or urgency incontinence. Overactive bladder -- which includes conditions known as "detrusor (bladder) instability" or "overactive detrusor" -- happens when the detrusor (the main contractile muscle of the bladder) cannot properly control whether it is storing or releasing urine. It can feel like a sudden urge to go, a leak that comes on without warning, or a leak that happens before a person can make it to the bathroom.
Also common, particularly in women, is stress incontinence -- a leak that happens while coughing, sneezing, laughing, lifting or even just climbing stairs. The problem may be traceable to weakening of the support muscles of the pelvic floor following childbirth decades earlier, but even women who never were pregnant can have it. (Men may also develop stress incontinence after surgery for prostate cancer.)
Another condition known as "intrinsic sphincter deficiency" -- referring to failure of the sphincter "valve" to close completely -- has the same unfortunate result: accidents.
The two conditions -- stress incontinence and urge incontinence -- often occur together, so the bladder is overactive and the pelvic supports of the bladder are weak.
Less common is an emptying problem -- sometimes erroneously called "overflow incontinence" -- which makes it necessary to go more often, less efficiently and in some cases can lead to an inability to pass urine at all, a condition called urinary retention. Causes of a weak bladder can include medications, advanced diabetes or problems with the central nervous system that may have been caused by a spinal injury or diseases like multiple sclerosis.
Men may have a mechanical obstruction to urine passage (usually due to an enlarged prostate). Obstruction is less common in women but may occur as a complication of pelvic floor weakness or bladder surgery.
The simplest therapy is the best place to start, and often all that is needed. This is something we've learned just in the last 25 years -- before then, most doctors believed that most stress incontinence required surgery.
Most incontinence can be diagnosed simply with the patient's report of symptoms, review of medical conditions and medications, a basic physical exam and a urine test for infection.
Your doctor may also ask you to keep a "bladder diary," in which you record two days and nights of activity. You can use a "hat" -- a collection container placed under the seat of your toilet -- to help you measure how much urine you release. You also take note of any accidents and how big they were. A drop? Completely soaked?
Finally, were there events that triggered it? Laughing? Drinking coffee? This can help with diagnosis and treatment, especially for people who have to go frequently during the day or have to get up several times a night to urinate (a problem called nocturia).
- For otherwise healthy people, the next step is lifestyle therapy. If you are very heavy, losing some weight will help. Stop smoking (for this and many other reasons). Limit your caffeine. If you have trouble with trouble with nocturia, avoid drinking liquids after 7 p.m. If constipation is a problem, treat it.
- Next comes behavioral therapy, which means a combination of two techniques, bladder and pelvic muscle exercises and bladder training. Practice contracting -- and thus strengthening -- the muscles on your pelvic floor (these are called Kegel exercises, often recommended to pregnant women).
- For those with urge problems, the strategy is slightly different. Bladder training involves going on a regular schedule and learning how to retrain the central nervous system to control strong urges ("mind over bladder").
- Instead of running to the bathroom as quickly as possible, be still. Do pelvic muscle contractions and focus on feeling the urgency recede (like a decreasing wave). The urgency will lessen, then you can get to the bathroom in time.
And be patient with yourself -- this doesn't happen overnight.
Some people may need to move on to medication, but you should be aware that most drugs have only modest effect at best. Also, some medications can cause incontinence in the first place.
Don't make things worse!
Many drugs have been found to make incontinence worse, including:
- some blood pressure medications
- alpha blockers (also used to treat blood pressure; causes incontinence in women)
- anticholinergic drugs (including Benadryl and other antihistimines)
- ACE inhibitors (for heart disease)
- loop diuretics (for congestive heart failure)
- cholinesterase inhibitors (such as Aricept, given for Alzheimer's Disease)
Surgery should be the last resort. While there are a number of options, the most important and helpful type of surgery is for women with stress incontinence. A less permanent approach to stress incontinence is injection of material (collagen or carbon spheres) into the tissues surrounding the urethra to help close the bladder opening.
Menopause and incontinence
Some women first become incontinent during menopause, because of the drop in estrogen. For them, short-term topical estrogen (usually a cream or gel) may be helpful, but many do not benefit and need the other approaches mentioned above. It's also important to note that oral estrogen (pill form) causes incontinence, or can make it worse.
New research indicates that Botox, normally used to remove the appearance of wrinkles, may be helpful for urgency incontinence that doesn't respond to first-line treatment and was recently approved for that use by the Food and Drug Administration.
When urinary incontinence means trouble
Sometimes incontinence can be a sign of a larger or more urgent problem. It is even more important to discuss the situation with a medical professional, which can include:
- Blood in urine (called hematuria)
- Pelvic pain
- Symptoms that come on very fast or very dramatically. For instance, frequent uncontrollable urination can be an early sign of diabetes. Sudden pelvic pain with incontinence can be a sign of cancer in the pelvis.
- Complex neurological disease other than dementia
- Pelvic floor prolapse (a weakening of the pelvic muscles that permits organs such as the bladder or uterus to slip and sometimes even protrude from the vagina)
- Painful urination (dysuria) or frequent small voids (a sign of possible interstitial cystitis)
Finally, there is a crying need for more knowledge, particularly in the area of medications. As the Agency for Healthcare Research and Quality in a 2009 report, "We find a concerning lack of high-quality evidence to inform clinical decision-making for millions of women in the United States. [...] a priority on promoting high-quality research in the United States is imperative. Women and their care providers deserve better information to guide their choices."
We at AFAR agree, and are proud to support some of the leading researchers in the field, including Catherine DuBeau, M.D., mentioned above, and Alison Huang, M.D., M.A.S. Huang is an internist at the University of California, San Francisco, whose work includes studying a streamlined algorithm for diagnosing and treating incontinence in primary care and testing new complementary behavioral treatments for urinary symptoms (such as a slow-breathing intervention, that reduces anxiety and stress to help manage urgency incontinence episodes and a yoga therapy intervention to improve pelvic floor muscle control and reduce stress incontinence episodes. Huang, who received a Paul Beeson Career Development Award, is reaching out to urologists, internists, geriatricians and women's health researchers who together can seek new cures and better quality of life for people with urinary incontinence.
For now, good old fashioned conversation still holds the key. Older adults and their health care providers must to get past embarrassment and start talking about urinary incontinence.
For more by Richard W. Besdine, M.D., click here.
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