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Urinary incontinence

Definition:
Urinary incontinence is the loss of bladder control. This means that you can’t always control when you urinate. Urinary incontinence can range from leaking a small amount of urine (such as when coughing or laughing) to having very strong urges to urinate that are difficult to control.
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It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners. There is also a related condition for defecation known as fecal incontinence.

Incontinence affects up to 20 per cent of the older female population. One factor is declining oestrogen levels after the menopause.

Urinary incontinence is less common in men but still occurs, especially if the man has any sort of prostate disease or is frail and weak.

It’s more frequent in people with reduced mobility and other medical problems, as they’re less able to get to the toilet when necessary.

It’s a common problem among people living in residential or nursing homes.

If you leak a small amount of urine when you cough, laugh or move (or without any obvious trigger), it’s worth talking to your doctor. Incontinence isn’t an inevitable part of growing older and you don’t have to accept it.

Faecal incontinence is even more abnormal and usually requires investigation.

Physiology of continence:
Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure factors: urethral pressure falls and bladder pressure rises.

Causes:–
*Polyuria (excessive urine production) of which, in turn, the most frequent causes are: uncontrolled diabetes mellitus, primary polydipsia (excessive fluid drinking), central diabetes insipidus and nephrogenic diabetes insipidus.  Polyuria generally causes urinary urgency and frequency, but doesn’t necessarily lead to incontinence.

*Caffeine or cola beverages also stimulate the bladder.

*Enlarged prostate is the most common cause of incontinence in men after the age of 40; sometimes prostate cancer may also be associated with urinary incontinence. Moreover drugs or radiation used to treat prostate cancer can also cause incontinence.

*Brain disorders like multiple sclerosis, Parkinson’s disease, strokes and spinal cord injury can all interfere with nerve function of the bladder.

Types:–
*TypesStress incontinence, also known as effort incontinence, is due essentially to insufficient strength of the pelvic floor muscles.

*Urge incontinence is involuntary loss of urine occurring for no apparent reason while suddenly feeling the need or urge to urinate.

*Overflow incontinence: Sometimes people find that they cannot stop their bladders from constantly dribbling, or continuing to dribble for some time after they have passed urine. It is as if their bladders were like a constantly overflowing pan, hence the general name overflow incontinence.

*Mixed incontinence is not uncommon in the elderly female population and can sometimes be complicated by urinary retention, which makes it a treatment challenge requiring staged multimodal treatment.

*Structural incontinence: Rarely, structural problems can cause incontinence, usually diagnosed in childhood, for example an ectopic ureter. Fistulas caused by obstetric and gynecologic trauma or injury can also lead to incontinence. These types of vaginal fistulas include most commonly, vesicovaginal fistula, but more rarely ureterovaginal fistula. These may be difficult to diagnose. The use of standard techniques along with a vaginogram or radiologically viewing the vaginal vault with instillation of contrast media.

*Functional incontinence occurs when a person recognizes the need to urinate, but cannot physically make it to the bathroom in time due to limited mobility. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity, unwillingness to toilet because of depression, anxiety or anger, drunkenness, or being in a situation in which it is impossible to reach a toilet.  People with functional incontinence may have problems thinking, moving, or communicating that prevent them from reaching a toilet. A person with Alzheimer’s Disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may be blocked from getting to a toilet in time. Conditions such as these are often associated with age and account for some of the incontinence of elderly women and men in nursing homes.  Disease or biology is not necessarily the cause of functional incontinence. For example, someone on a road trip may be between rest stops and on the highway; also, there may be problems with the restrooms in the vicinity of a person.

*Bedwetting is episodic UI while asleep. It is normal in young children.
Transient incontinence is a temporary version of incontinence. It can be triggered by medications, adrenal insufficiency, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow.

*Giggle incontinence is an involuntary response to laughter. It usually affects children.

Diagnosis:–
Patients with incontinence should be referred to a medical practitioner specializing in this field. Urologists specialize in the urinary tract, and some urologists further specialize in the female urinary tract. A urogynecologist is a gynecologist who has special training in urological problems in women. Gynecologists and obstetricians specialize in the female reproductive tract and childbirth and some also treat urinary incontinence in women. Family practitioners and internists see patients for all kinds of complaints and can refer patients on to the relevant specialists.

A careful history taking is essential especially in the pattern of voiding and urine leakage as it suggests the type of incontinence faced. Other important points include straining and discomfort, use of drugs, recent surgery, and illness.

The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.

A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.

Other tests include:
*Stress test – the patient relaxes, then coughs vigorously as the doctor watches for loss of urine.

*Urinalysis – urine is tested for evidence of infection, urinary stones, or other contributing causes.

*Blood tests – blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.

*Ultrasound – sound waves are used to visualize the kidneys, ureters, bladder, and urethra.

*Cystoscopy – a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.

*Urodynamics – various techniques measure pressure in the bladder and the flow of urine.

Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced

Treatment:
The treatment options range from conservative treatment, behavior management, medications and surgery. In all cases, the least invasive treatment is started first. The success of treatment depends on the correct diagnoses in the first place.

Most treatment options are most appropriate for a specific underlying cause of the incontinence (though these can overlap if there is a mixed component to the incontinence.) However, some approaches (such as use of absorbent products) address the problem symptomatically, and can be applicable to more than one type. It is also sometimes possible to use a treatment for the pathophysiology of one type of incontinence to provide relief for an unrelated type of incontinence.

The Doctor may also suggest self-help techniques you can try before resorting to medication.

For example :-
Kegel exercises:
•To locate the right muscles, try stopping or slowing your urine flow without using your stomach, leg or buttock muscles. When you’re able to slow or stop the stream of urine, you’ve located the right muscles.
•Squeeze your muscles. Hold for a count of 10. Relax for a count of 10.
•Repeat this 10 to 20 times, 3 times a day.
•You may need to start slower, perhaps squeezing and relaxing your muscles for 4 seconds each and doing this 10 times, 2 times a day. Work your way up from there.

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Bladder training:..….CLICK & SEE
Some people who have urge incontinence can learn to lengthen the time between urges to go to the bathroom. You start by urinating at set intervals, such as every 30 minutes to 2 hours (whether you feel the need to go or not). Then gradually lengthen the time between when you urinate (for example, by 30 minutes) until you’re urinating every 3 to 4 hours.

You can practice relaxation techniques when you feel the urge to urinate before it is time to go to the bathroom. Breathe slowly and deeply. Think about your breathing until the urge goes away. You can also do Kegel exercises if they help control your urge.

After the urge passes, wait 5 minutes and then go to the bathroom even if you don’t feel you need to go. If you don’t go, you might not be able to control your next urge. When it’s easy to wait 5 minutes after an urge, begin waiting 10 minutes. Bladder training may take 3 to 12 weeks.

•Retraining the bladder with regular trips to the toilet can help, especially when the bladder has been overstretched by ‘holding on’ or failing to empty it completely.

•Bowel retraining can help some forms of faecal incontinence. It’s also important to make motions as formed and regular as possible, using dietary changes and medication as necessary.

•Exercises can help women to strengthen pelvic floor muscles that have been damaged or stretched during childbirth.

•Some women find it hard to become aware of, and so exercise, their pelvic floor muscles. There are a number of devices that doctors, incontinence nurses or physiotherapists can recommend which can help. These are put in the vagina where they either mechanically or electrically trigger the muscles to contract automatically. They are fairly simple to use, very discreet and have been shown to improve continence.

•It can be helpful to treat any problems that increase pressure on the bladder, such as constipation and fibroids. Losing excess weight may also help.

•Drugs are available to treat urinary incontinence, depending on the cause. Most improve the muscle tone of the bladder. These may have to be taken for at least several months.

Urinary incontinence isn’t a serious disease or life-threatening, but it can seriously disrupt quality of life. With the appropriate treatment it may be cured or improved dramatically. There’s no need for anyone to suffer in silence.

Faecal incontinence may require surgery.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose

Resources:
http://www.bbc.co.uk/health/physical_health/conditions/incontinence.shtml
http://familydoctor.org/online/famdocen/home/women/gen-health/189.html
http://en.wikipedia.org/wiki/Urinary_incontinence
http://www.lifespan.org/adam/indepthreports/10/000050.html

http://www.doh.state.fl.us/Family/wh/lifespan/Middleage/urinary.html

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