By Jeanette S. Brown, MD, and Janis Luft, NP, MSN
“I wake up four or five times a night to use the bathroom. I’m exhausted!” “I must know every public restroom in the city.” “I had to cancel the trip I was planning because I didn’t think my bladder could handle it.” “I’ve stopped going to my exercise class because I leak.”
Do these comments sound familiar? Current estimates suggest that roughly 15 million Americans experience urinary incontinence — the involuntary loss of urine — and that up to 85% of those affected are women. Like many other health problems, the risk of developing incontinence increases as a person ages. By the year 2030, 20% of the U.S. population will be older than 65, meaning the number of Americans affected by urinary incontinence will almost certainly grow.
Incontinence can have an enormous effect on a woman’s quality of life, including her emotional well-being and ability to carry out ordinary, daily activities. As one woman put it, “Incontinence doesn’t kill you; it just takes your life away.” It is also a costly problem. An estimated $25 to $36 billion is spent every year on medical and personal care costs associated with incontinence, from evaluations and treatments to extra loads of laundry. But the human toll in embarrassment, shame, social isolation, and depression is inestimable.
Women with diabetes have up to a 70% greater risk of developing urinary incontinence. Diabetes is also associated with an earlier onset and increased severity of incontinence. Classically, it was thought that the most common problem for women with diabetes was bladder cystopathy (also known as neurogenic bladder), a disorder characterized by diminished bladder sensation and impaired ability of the bladder muscle to contract, resulting in an inability to empty the bladder. However, bladder cystopathy most likely represents end-stage bladder failure. It is now thought that urinary incontinence in women with diabetes is a progressive condition, encompassing a broad spectrum of symptoms including urinary urgency (or a strong pressure to void), frequent daytime and nighttime voiding, and incontinence.
The exact mechanism by which diabetes causes incontinence is not yet known. However, it is known that high blood sugar can cause an increase in the amount of urine produced, resulting in urgency, frequent urination, and possibly incontinence. Similarly, complications associated with diabetes, such as autonomic neuropathy, may damage the nerves of the bladder to varying extents, possibly causing incontinence. Whether or not improved blood glucose control can improve bladder control in women with urinary incontinence and diabetes is currently under investigation.
Of course, diabetes is not the only cause of urinary incontinence. Some commonly used substances and drugs can also trigger incontinence or exacerbate existing incontinence as a side effect. For example, alcohol can contribute to urinary frequency, while diuretics (water pills) and caffeine can contribute to both frequency and urgency. People who take antidepressants in the class called SSRIs are also at an elevated risk of developing urinary incontinence. (Alternatively, a variety of drugs can lead to urinary retention.)
Common types of incontinence are urge incontinence or overactive bladder, stress incontinence, and mixed incontinence. A relatively uncommon type of incontinence is called overflow incontinence.
Urge incontinence or overactive bladder. Urge incontinence is a loss of urine that is associated with a sudden, strong desire to urinate. A person with urge incontinence or overactive bladder may describe a mounting need to urinate or sudden urine loss while approaching the bathroom or front door of her home, when she hears the sound of running water, or when she is suddenly exposed to cold. Other symptoms include a need to urinate frequently and waking often during the night to urinate. Some people with overactive bladder manage to avoid wetting accidents by urinating very often and restricting fluids excessively. These strategies may work early on, but they fail as symptoms increase.
Overactive bladder is caused by sudden, involuntary bladder contractions. Normally, the bladder expands with urine, much like a balloon. Though the stretching of the bladder wall sends increasingly stronger signals of fullness to the brain as its capacity is being reached, a healthy bladder contracts to expel urine only when given permission by its owner. An overactive bladder may contract at socially awkward times, even when the amount of urine in the bladder is small.
Stress incontinence. Urine loss that results from an increase in pressure on the bladder is called stress incontinence. Coughing, sneezing, laughing, exercising, lifting an object, and even just standing up can cause urine loss in people with this type of incontinence. Stress incontinence is not caused by emotional stress.
Stress incontinence can occur if the muscles supporting the urethra (the tube through which urine exits the bladder and body) are weakened and the urethra loses its ability to remain tightly closed when pressure hits the bladder.
Mixed incontinence. It is possible to have a combination of urge and stress incontinence symptoms. This condition is called mixed incontinence. Often one or another of the types will predominate.
Overflow incontinence. The bladder has two functions: storing and emptying urine. Most incontinence results from defects in ability of the bladder to store urine. Overflow incontinence, however, results from faulty emptying. In women — especially women with diabetes, who may have some nerve damage to the bladder — the bladder can lose its ability to contract well, causing emptying to become compromised. An overfull bladder tends to spill over, causing leaking accidents.
Functional incontinence. Some people lose bladder control because of factors not related to the urinary tract. If one is unable to walk to the bathroom, if arthritis makes removal of clothing difficult, or if cognitive impairment (from Alzheimer disease, for example) interferes with recognizing the signs of bladder fullness, loss of urine may result. People with these sorts of problems are said to have functional incontinence.
The first step toward treating incontinence is to educate yourself about incontinence and bladder function, even before you see a doctor. Many resources are available (click here for some continence resources), and there are many simple approaches you can take toward better bladder control. Being well-informed will also be helpful when you seek treatment from a medical professional.
Next, discuss your incontinence with your primary physician or health-care provider. Ask about the treatments that he can offer for incontinence, and ask whether you should see a specialist. Keeping a diary that includes how often you urinate during the day, a record of the times and events surrounding leakage, and what you drink during the day can be helpful as both a management tool and a document of patterns and changes for you and your health-care provider.
The initial evaluation may be as simple as answering some questions about incontinence and having a urine test to check for a bladder infection. Many doctors will want to perform a pelvic exam to check for pelvic muscle strength and signs of pelvic organ prolapse, the dropping of the pelvic organs out of place, which can contribute to stress incontinence.
Some of the options for treating incontinence include behavioral treatments, drug therapy, devices, and, as a last resort, surgery. Losing excess weight can also help restore continence, although other methods are often prescribed simultaneously since a weight-loss program can take some time to show results.
Behavioral treatments. Because behavioral treatments are effective for most types of incontinence, and because they have no harmful side effects, learning pelvic muscle exercises, urge suppression techniques, and/or bladder retraining is a good first step toward regaining continence.
Pelvic muscle exercises, commonly called Kegel exercises, have been shown to improve urethral sphincter function and to inhibit unwanted bladder contractions. Such exercises can be useful in the management of both stress and urge incontinence. Exercises can be enhanced by the use of weighted vaginal cones (tampon-shaped devices that can help a woman identify which muscles to contract when practicing Kegel exercises) or biofeedback.
In biofeedback therapy, special sensors are attached to the abdomen, and a small probe is placed in the vagina or rectum to measure the muscles’ electrical activity while pelvic muscle exercises are performed. This activity is then translated into colored lines on a computer screen, which show a person if she is using the correct muscles. Biofeedback therapy takes place in a doctor’s office, and the person is also given exercises to practice daily at home.
Biofeedback therapy can also incorporate Pelvic Floor Stimulation (PFS), a technique in which the pelvic floor muscles are strengthened via painless electrical stimulation through a vaginal or rectal probe. If the technique is found to reduce urinary urgency or frequency, a PFS unit can be purchased for home use, where it is usually used twice daily for 15 minutes for several weeks, and then tapered off as symptoms decrease.
Urge suppression is a technique for managing sudden urgency and regaining control when the need to urinate is mounting. It involves remaining still, tightening and relaxing the pelvic floor muscles rapidly several times, breathing deeply, and distracting yourself with a mental activity (such as making lists or reading) until the strong urge to urinate wanes.
Bladder retraining uses scheduled visits to the toilet to help relearn normal bladder function. For instance, a person might wait 1 to 1 1/2 hours between trips to the bathroom, ignoring any urge to urinate or any leakage that occurs in the interim. As her body becomes used to waiting, she increases these intervals by half-hour blocks until she is urinating at a comfortable interval. As the interval between trips to the bathroom is gradually increased using this method, bladder capacity improves and leaking accidents are reduced.
It is reasonable to try behavioral treatments on your own. Further information on these techniques can be obtained from these resources. If you don’t have adequate improvement, or if you think you might benefit from biofeedback therapy or PFS, working with a physical therapist or nurse specialist trained in pelvic floor rehabilitation can be very helpful.
Drug therapy. There are several different drugs approved for the treatment of overactive bladder, such as anticholinergics, beta-3 adrenergic agonists, neuromuscular blockers, and tricyclic antideppresants. Anticholinergics can block the chemicals that act on bladder nerves, decreasing unwanted bladder contractions, while beta-3 adrenergic agonists relax the muscles of the bladder, increasing its capacity. Drugs can offer significant relief and are safe, but they have side effects, some of the most common of which are dry mouth and constipation. It’s often necessary to go through a process of trial and error to determine which drug at what dose offers the best improvement in continence with the fewest or least bothersome side effects.
Inserted devices. A pessary is a device that is placed into a woman’s vagina to support the uterus and/or bladder and rectum. When used to treat stress incontinence, a properly fitted pessary prevents urine loss by acting as a “backstop” and maintaining pressure within the urethra when it is challenged by coughing, sneezing, or exercise. A well-fitted pessary should not cause discomfort. The user is generally unaware of the presence of the device in the vagina.
FemSoft is a flexible, soft, fluid-filled device that is inserted into the urethra and acts as a temporary plug against urine leakage. The user must learn the insertion technique and change the device with each urination or every four to six hours. Many users reserve FemSoft for high-impact activities such as running or aerobics. It is available by prescription only.
Other treatments. There are other treatments available, including injections and surgery for stress incontinence, but they should only be considered once simpler treatments have failed. Women who have longstanding or complicated problems, who are interested in surgery, or who fail to improve after initial treatment should be referred to a continence center, urogynecologist, or urologist, who can perform more extensive testing and offer further treatment options.
Urinary incontinence can steal sleep, make social events difficult, and get in the way of physical activity. It is common, chronic, and costly, but it is not a normal part of aging. A wide variety of treatment options are now available, and they can help improve quality of life considerably. If you believe that you are affected by incontinence, learn all you can about it and talk to your health-care provider about which treatments may be right for you. Don’t let urinary incontinence continue to keep you from the activities you enjoy.
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