Understanding Urinary Incontinence for Today's Caregiver

By Jacek L. Mostwin, MD,DPhil
& Rene Genadry, MD

 

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 future.

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 of life.

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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