Incontinence

by Adriane Fugh-Berman, MD

Urinary incontinence (passing urine involuntarily) affects more than 13 million adults, the majority of them older women. Half of the elderly female population suffers from this problem, and incontinence is one of the main contributing reasons that people enter longterm care facilities. The United States spends at least 16 billion dollars annually to care for people with incontinence.

There are several different kinds of incontinence. "Stress" incontinence refers to a loss of urine while laughing, coughing, sneezing, or lifting heavy things (all things that increase pressure inside the abdomen and "stress" the bladder). In its most severe form it results in urine loss in any upright position.  "Urge" incontinence (or "spastic bladder") is the inability to suppress the urge to urinate; when the bladder is full the person has a sudden uncontrollable need to urinate, and if she's not right next to a toilet... "Overflow" incontinence happens when someone can't feel that their bladder is full, usually because of a nerve problem. The bladder stretches and stretches, then overflows.  

Why is incontinence more common in women? Some theorize that obstetric practices such as episiotomy may contribute, but not all women with incontinence have had episiotomies or even given birth. Another theory is that the seated position in which women in developed countries urinate (as opposed to a squatting position) makes the pelvic floor muscles "lazy." Neither of these theories has been proven.
Urinary tract infection, fecal impaction, and side effects of a number of drugs are easily reversible causes of incontinence. It's a good idea to have an evaluation with a clinician.

 Sometimes a simple change is all that's needed to manage incontinence.  Urge incontinence, for instance, may respond well to a schedule of going to the toilet every two hours while awake.  Drugs, especially diuretics, sedatives, and antipsychotic drugs, may contribute to incontinence; changing a prescription may solve the problem.

A recent "advance" in managing incontinence, the intraurethral insert, may work for some people but sure sounds like an expensive and uncomfortable idea. The Reliance Urinary Control Insert is inserted into the urethra (the tube leading from the outside of the body to the bladder) and then a little attached balloon is inflated inside the bladder to hold it in place. The balloon is deflated and the device removed for urination. It's not reusable, so one uses a number of these during a day.  The device can cause irritation, increase the chances of a urinary tract infection, and in a few cases has migrated into the bladder, where it had to be removed by a urologist.

There are drugs used to treat incontinence, including imipramine and oxybutynin, but they have many side effects.  Some women find a topically applied estrogen cream helpful. An even more drastic treatment is bladder suspension surgery (usually done for severe stress incontinence), but sometimes that results in difficulty urinating.

Kegel exercises (contracting the pelvic floor muscles, which are the ones we use to interrupt urinating) can be used instead of surgery. A study of fifty female patients compared surgery to Kegel exercises and found that although surgery as superior, fifteen out of 24, or 42%, of the Kegeling patients were so much improved that they didn't want the surgery. Another study of 36 women with stress incontinence found that twenty, or 56%, women who were taught Kegel exercises considered their stress incontinence substantially improved (seven) or cured (thirteen); sixteen women considered their problem unchanged.

It's fine to learn where the pelvic floor muscles are by interrupting urination but once you know which muscles to contract the exercises shouldn't be one with a full ladder. A few dozen ontractions (do some quick ones and some slow, extended ones) several times a day should do the trick. No one can tell you're Kegeling, so it's a good thing to do during boring meetings.

Not everyone can learn to Kegel with verbal instruction alone, so Kegeling aids exist. Various forms of vaginal balloons are used, or weighted vaginal cones (a patient starts by retaining the lightest cone for a set amount of time, then gradually increases the weights).

Biofeedback can be very helpful in learning Kegel exercises. A pressure-sensitive balloon I inserted and sends out audio or visual signals to let a woman know if she is Kegeling correctly.

One study of 27 women found that eight one hour biofeedback sessions was enough to improve 81% of the women. Another controlled study of 135 women compared pelvic Kegel exercises and biofeedback to untreated controls and found that urine losses were reduced by 54% in the Kegel group and 61% in the biofeedback group, while the controls increased their urine loss by 9%. Of the 40 patients in the biofeedback group, nine (23%) were completely cured. Of the 43 patients in the Kegel group, seven women (16%) were cured. Only one out of 38 women 3%) in the control group was cured.

Fecal incontinence also responds to biofeedback. In seven uncontrolled studies, biofeedback training (utilizing rectal balloons to train the patient to contract the anal sphincter in response to rectal distension) has resulted in continence or markedly reduced frequency of incontinence in 70-83% of patients. One to five treatments were required, and the beneficial effect was maintained at 1-2 years follow-up. Although these studies were uncontrolled, many patients had been deemed incurable by conventional medical treatments, so the results are still impressive. Patients who are incontinent due to anorectal surgery seem to respond best to biofeedback training, but there is some evidence that diabetics with fecal incontinence also benefit.

Adriane Fugh-Berman is chair of the NWHN Board of Directors.

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