Thanks to a growing awareness of the physical
problems and social repercussions of urinary incontinence, more and
more people—including doctors—are taking incontinence seriously.
This is good news for women dealing with this condition: there are
health professionals available who understand what incontinence is,
what causes it, and how to successfully treat and manage it.
It is also good news for children caring for
parents who are seniors, and those in the health profession who work
with and care for elderly patients. Urinary incontinence becomes
more common as women age. In fact, this condition can be responsible
for as many as 50 percent of nursing home admissions, so learning
what you can do now to help may lessen or prevent problems in the
Childbirth, menopause and aging of the nervous
system all contribute to the development of incontinence over the
many stages of a woman’s life. When younger women bear children,
labor and delivery may stretch and tear muscles and nerves of the
bladder and urethra and can injure the structures providing vaginal
support. Although some women will develop symptoms of stress
incontinence (leakage with coughing, laughing or exertion) during
their pregnancy or shortly after delivery, these problems often
disappear, only to return 10-20 years later. Stress incontinence can
be improved with pelvic muscle exercises, weight loss, and, if
necessary, will usually respond well to surgical treatment.
As a woman passes through menopause, the muscle
mass surrounding the urethra becomes thinner and resistance to
leakage decreases. So even if there is good vaginal support, or very
little sign of a “dropped bladder,” an older woman may start
developing the same symptoms she had as a younger woman: leakage
with coughing, sneezing or laughing.
Increasingly strong urges to urinate may begin
to develop later in life, making it difficult to reach a toilet in
time. This is called urge incontinence, and may become serious
enough that a woman has to wear one or more pads a day to manage the
leakage. These problems may respond well to treatments such as
medications or injections of bulking agents like collagen (Contigen),
although surgical repairs may still be required.
With advanced age, older nervous systems
sometimes develop problems that can result in overflow incontinence.
Sensation of the bladder filling up may begin to diminish so that a
woman doesn’t feel the desire to urinate until the bladder reaches
its full capacity. At that point, if the urethra is very weak, she
may already experience leaking. In some cases, she may feel urine
escaping from the bladder or running down her leg. It might be
assumed that she has an overactive bladder and is experiencing urge
incontinence, but the leaking may actually be occurring before she
feels any urgency at all.
Even if a woman has a normal amount of urgency,
if she moves slowly with her advanced age, it may take her a long
time to get to a toilet. More commonly, the urgency comes late in
the filling cycle of the bladder, which means even less time to
reach a toilet.
In advanced aging situations, in which a woman
is affected by Alzheimer’s or another form of cognitive loss, the
bladder may appear to the patient to empty completely on its own.
Patients with neurological conditions can have varying degrees of
awareness of their own problems. Sometimes it is the family or the
caregiver that will bring the patient to a doctor, because the
laundry or diaper bill has become too much, or because the patient
has developed severe diaper rash.
It can be difficult to distinguish one cause of
incontinence from another. Sometimes there are co-existing or
overlapping causes. An experienced and sympathetic practitioner can
sort out the various problems and help the patient and her family
find the best treatment that is appropriate for her particular stage
To help today’s caregiver, we have written A
Woman’s Guide to Urinary Incontinence (Johns Hopkins Press, December
2007) – the first book about incontinence in 20 years. In it, we
combine our urological and gynecological expertise into a practical
and readable guide for patients and their families and caregivers.
We explain the nature and causes of incontinence in reader-friendly
terms. We also share our patients’ experiences, to help readers get
their problems into perspective. Our hope is to prepare patients to
become partners in their own health care decisions by becoming
informed about their conditions and the available options. In the
treatment of incontinence, one size does not fit all. It is tempting
for physicians to group patients together into categories because
“after all, leakage is leakage.” But this is not the best approach
to use, especially if the patient is faced with choosing an invasive
or irreversible treatment.
Today’s caregiver must be educated about a
patient’s condition, and proactive in helping her find the right
doctor. The physician best able to help her manage and treat her
incontinence should be both experienced in the field, and someone
with whom the patient feels comfortable. Proper medical evaluation
(what medical tests to expect during an exam is covered in the book)
will enable a urologist to discover the causes of the incontinence
and suggest one or more treatment options appropriate to the
condition and the patient’s personal needs. A caregiver can assist a
patient or loved one by helping her prepare a list of questions to
ask the specialist before each visit. It is important for the
patient to clearly understand the benefits and risks of possible
treatments before determining which one is right for her.
Jacek L. Mostwin, MD, DPhil is a Professor of
Urology in the Brady Urological Institute at Johns Hopkins where he
is also Director of the Division of Reconstructive and Neurological
Urology. Rene Genadry, MD is an Associate Professor in the
Department of Gynecology and Obstetrics at Johns Hopkins Medical
School. A Women’s Guide to Urinary Incontinence is an outgrowth of
many years of collaboration and compatibility between these two
colleagues. A Women’s Guide to Urinary Incontinence is available in
bookstores and online through Amazon.com
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