Urinary Incontinence: Introduction & Behavior Modification
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC)
Many people suffer from urinary incontinence. Yet, because of embarrassment or the belief that it is a normal part of growing older, people do not seek help. It is estimated that 50% of women and 18% of men over the age of 65 experience some type of urinary incontinence. It is not a problem of old age. The onset of this embarrassing problem is very gradual, but never unnoticed. The important fact is - incontinence is curable.
The purpose of this document is to consider various types of incontinence and the role of behavior modification. Overactive bladder (OAB) / urge incontinence is a common condition that becomes even more prevalent as people age. It is associated with significant psychological and physical morbidity as well as increased healthcare costs. The prevalence of stress incontinence represents a spectrum, depending on how incontinence is defined. There is racial and ethnic variation in the prevalence of urinary incontinence in women.
Many people find it difficult to discuss their incontinence problems, even with a nurse or doctor. Urinary incontinence is common and very treatable. Fortunately, millions of men and women are being successfully treated and even cured. Leaking urine is neither normal nor acceptable, and your problem just may be the beginning of what becomes a downward spiral where loss of bladder control goes hand-in-hand with loss of self respect, as well as anxiety and depression. Here is some general information about urinary incontinence.
Causes of Urinary Incontinence:
Urinary incontinence can be caused by a number of physical conditions. About half of all cases of incontinence are temporary and can be reversed once the cause is identified and treated. You must consult with your healthcare provider for accurate diagnosis and treatment. Some of the most common conditions are:
- Urinary Tract Infections
- Vaginal Infections
- Fecal impaction
- Reaction to medications
Incontinence that is not a result of infection, impaction, or reaction to medication often has a more fixed cause. Some of the most common fixed causes to incontinence include:
- Pelvic muscle weakness
- Weakness of the urethral sphincter
- Bladder muscle over-activity
- Obstruction in urinary tract
- Bladder muscle weakness
- Nerve disorders
- Decrease in estrogen hormone in women
Once identified, these conditions can be successfully treated and incontinence cured. Your health care provider can help to identify the exact cause of your incontinence.
Types of Incontinence:
There are also many different types of incontinence, and often the type of incontinence is related to the cause. Some people have more than one type of incontinence. Three different types of incontinence are Urge Incontinence, Stress Incontinence and Overflow Incontinence. The symptoms are described below:
- Urge Incontinence:
- People with urge incontinence lose urine as soon as they feel a strong need to go to the bathroom. If you have urge incontinence, you may leak urine.
- Sometimes called an over- active bladder;
- When you cannot get to the bathroom quickly enough without losing urine; and/or
- When you have to urinate every time you drink even a small amount of liquid, or when you hear or touch running water.
- You may also go to the bathroom at least every two hours during the day and night, and pass only a small amount of urine and even wet the bed; and/or
- Have had a Stroke, Multiple Sclerosis, or in men prostrate problems.
- Stress Incontinence:
We all talk about "stress", it is important to understand that stress incontinence should not be confused with psychological stress of daily living. People with stress incontinence lose urine when they exercise or move in a certain way. If you have stress incontinence, you may leak urine:
- When you sneeze, cough, or laugh;
- When you exercise; and/or
- When you get up from a chair or get out of bed in the morning.
- Overflow Incontinence:
People with overflow incontinence may feel that they never completely empty their bladder. Overflow incontinence develops slowly over time and is more common in men than women. If you have overflow incontinence, you may:
- Dribble urine during the day and night;
- Get up often during the night to go to the bathroom;
- Often feel as if you do not completely empty your bladder;
- Pass only a small amount of urine but feel as if your bladder is still full; and/or
- Spend a long time on the toilet, but produce only a weak, dribbling stream of urine.
- Mixed Incontinence:
Mixed incontinence contains components of both Stress Urinary Incontinence (SUI) and Urge Incontinence (UI). When a patient has components of both SUI and UI, the incontinence that is bothersome should be treated first. If the second form of incontinence becomes apparent after the first is treated, the second should be treated as well.
Finding the Cause of Urinary Incontinence:
Once a patient tells her healthcare provider about the problem, finding the cause of the urinary incontinence is the next step. The patient's medical history and urinary voiding habits are discussed and noted in detail. Physical examination and urine tests are routinely done. There are other tests that can be done to find out how well you empty the bladder, to verify that there is a leakage, to test how well your bladder works (Urodynamic Tests) and to actually look into your bladder for abnormalities (cystoscopy). These tests will help the healthcare providers to find out the exact cause of patient's problem and choose the best treatment. Other chapters in this section will explain these tests, especially Urodynamic Tests (UDTs), in detail.
These tips for controlling the urge to urinate might be helpful. Behavior Modification is an essential part of the cure. These suggestions might be useful for patient education. The cornerstones of Behavior Modification are: control fluid intake, change voiding pattern, bowel care, weight loss and removal of transient causes. Make sure you consult your healthcare providers first, for accurate diagnosis and management.
- Never rush or run to the bathroom, try to walk slowly.
- Do not go to the bathroom before you get the urge to void, unless you are on a prescribed voiding schedule.
- Use deep breathing to relax when you have the urge to void before your scheduled voiding time or within 3-4 hours. For example, if you get the urge to void whenever you start to unlock your front door, stop, relax and take three slow, deep breaths until the urge lessens or passes. Then unlock the door and walk slowly to the bathroom.
- When you walk to the bathroom, do pelvic exercises (quick repetitions) to prevent the accident.
- If you are successful in lessening the urge, try to lengthen the time between voiding.
- At first, when you work on decreasing the frequency of voiding episodes, you may have a few accidents. If this happens, do not go back to voiding more frequently, but keep with your new schedule.
- Keep a check on yourself and do not revert to your old way of going to the bathroom frequently. By this time, you should be able to go without a pad confidently.
- Remember not to drink coffee, tea or sodas that have caffeine or beverages containing alcohol. Both may irritate your bladder and cause you to go to the bathroom more often.
- If you are waking up to urinate more than once during the night, do not drink liquids after 6 pm.
- Stop smoking if this is the cause of your cough. Every time you cough, the pressure is transmitted to your pelvic floor. Chronic chest complaints (e.g. asthma, bronchitis) will increase the chance of incontinence. Get the proper treatment for your ailment.
Take steps to change all those things which you are able to. Aim to follow a nutritional program that will ensure weight loss, if necessary, and a high fiber content to prevent constipation.
Foods of High Oxalate Acid Content should be avoided: These are: Beets, Beet tops, Black tea, Chocolate, Cocoa, Dried figs, Ground pepper, Lime peel, Nuts, Parsley, Poppy seeds, Rhubarb, Spinach, Swiss Chard.
Foods of Moderate Oxalate Acid Content should be eaten sparingly: These are: Beans (green and wax), Blackberries, Blueberries, Carrots, Celery, Coffee, Concord grapes, Currants (red), Dandelion Greens, Gooseberries, Okra, onion (green), Oranges, Orange peel, Peppers (green), Raspberries, Strawberries, Sweet potatoes.
- Pelvic Muscle Exercises: Also called Kegel exercises help strengthen weak muscles around the bladder.
- Biofeedback: Some patients find this is easier and more effective than Kegel exercises to strengthen the pelvic floor muscles. In some circumstances, it is used in postpartum period for stress incontinence prophylaxis.
- Medications: can influence bladder contraction and improve the tension of certain muscles and the urethra.
All these modalities will be discussed in detail in separate chapters.
Bladder neck suspension, slings, and radio-frequency are the most frequently used surgical procedures for the treatment of Stress Incontinence. These will be discussed in separate chapters in detail.
Behavioral therapy, including bladder training and prompted voiding, improves symptoms of urge and mixed incontinence and can be recommended as non-invasive treatment in many women. Pelvic floor training appears to be an effective treatment for adult women with stress and mixed incontinence and can be recommended as a non-invasive treatment for many women. Pelvic muscle exercise, also called Kegel and pelvic floor exercises, are performed to strengthen the voluntary periurethral and perivaginal muscles (voluntary urethral sphincter and levator ani). Bladder training is widely used with no reported side effects and does not limit future treatment options. Also known as bladder drills or timed voiding, it generally is used for the treatment of urge incontinence, but it also may improve symptoms of mixed and stress incontinence. Healthcare providers can teach patients the correct method of distinguishing and contracting the pelvic muscles.
World Health Organization
Women's Health: Western Pacific Region
U.S. Center for Disease Control and Prevention
Urologic Diseases in America
U.S. National Institutes of Health (NIH)
Urinary Incontinence in Women
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