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Bladder Control

 
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Anatomy of the Urinary System | Causes of Incontinence | Diagnosis | Screening questionnaire | Treatment
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About Bladder Control Disorders


  Incontinence: A common problem in the elderly, but not a normal part of the aging process...Incontinence, or involuntary urine leakage, affects 17 million Americans and occurs twice as often in women as in men.  Although incontinence occurs more often in older people than in younger adults, it is not considered a normal part of the aging process.  Changes with age do occur increasing the potential for problems, but usually with treatment the symptoms can be controlled or cured.  The key is to ask your doctor or health care provider for help. Take the bladder assessment tool to see if you should seek further medical evaluation. 


Anatomy of the Urinary System:

Urinary tractThe urinary bladder is composed of smooth muscle which is normally relaxed at rest.  Urine flows from the kidneys, through the ureters, and empties into the bladder.   The urethral sphinctor (a valve that seals off the bladder outlet through the urethra)  remains closed, allowing the bladder to fill.  The bladder first signals an urge to empty when it is about half full.  Urination normally begins voluntarily, by muscle contraction, pushing the urine out of the bladder, causing the sphinctor to open. Once urination begins, the urine flows from the bladder, past the now open urethral spinctor, and out of the body through the urethra. 

Urinary dysfunction in general can be caused or aggravated by any one of the following:

    • In women weakened pelvic muscles from childbirth, menopausal thinning and drying of the skin in the vagina or urethra,
    • In men, enlarged prostate gland or prostate surgery
    • Constipation with a build-up of stool in the bowel that is pushing on the bladder.
    • Urinary tract infection
    • Bladder irritants such as caffeinated drinks, alcohol, aspartame, fruit juices, chocolate, spicy foods, tomato-based products
    • Smoking
    • Obesity
    • Certain medications (Anacin, Dristan, Sinarest, Midol, Excedrin)
    • Poor mobility with difficulty getting to the bathroom; poor dexterity with inability to manage buckles, buttons or zippers
    • Diabetes

      Illustration courtesy of the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health

Causes and types of urinary incontinence:

1) Overactive bladder and urge incontinence:   This condition is characterized by involuntary contractions (muscle spasms) of the detrusor muscle in the bladder at low volumes during the bladder's filling phase.  These spasms give rise to frequent sensations of urgency.  When these contractions cannot be suppressed, urinary leakage may occur.  Patients have a sudden, intense urge to go to the bathroom, with no warning.  Frequently they don't have enough time to get there and may have urine leakage on the way (urge incontinence).  Usually the quantity of urine loss is in large amounts, actually saturating through to their outer clothing.    With this condition, patients feel the need to urinate more than 8 times in a 24-hr period (urinary frequency), and awaken more than 2 times at night to urinate.  Patients report these symptoms as being very bothersome and anxiety producing. Frequent urination, as often as every hour usually results in an attempt to avoid incontinent episodes. Constant trips to the bathroom are not only exhausting and a burden for caregivers, but can actually further aggravate the condition and weaken the bladder muscle.

2) Stress incontinence is the most common type of urinary incontinence in women.  About half of all women suffer from this problem at some point, and it becomes more prevalent with age.   Stress incontinence is characterized by an involuntary loss of small amounts of urine in response to increased pressure on the bladder. This occurs during coughing, sneezing, lifting, bending or exercise.    It is often caused by damage to the pelvic floor muscles and support system of the bladder as a result of pregnancy and childbirth, or possibly the effects of aging. Kegal exercises can help, if not completely relieve these symptoms.

3) Mixed incontinence is very common and occurs when a patient has a mixture of both types of incontinence (stress and urge).  Roughly one-third of all patients with urinary incontinence have mixed incontinence.(1)  Often times symptoms of one type may be more severe than the other. Treatment will depend on which symptoms are more bothersome to the patient

4) Overflow incontinence
This type of incontinence often causes a constant dribbling of urine because of an overfilled bladder. You may feel like you can't empty your bladder all the way and you may strain when urinating. This often occurs in men and can be caused by something blocking the urinary outflow tract (urethra), such as an enlarged prostate gland or tumor. Diabetes or certain medicines may also cause the problem.  For more information on this, click here.

5) Neurogenic incontinence can occur from a spinal cord injury, stroke, Parkinson's Disease, Multiple Sclerosis, etc. 

6) Functional incontinence This type occurs when you have normal urine control but have trouble getting to the bathroom in time because of either physical impediments such as arthritis or cognitive problems such as dementia.
In patients with dementia, a prompted and timed voiding schedule is used to treat functional incontinence. It trains a caregiver to prompt the incontinent person to urinate on a predetermined schedule. The intention is to decrease the chance of accidents by making the incontinent person aware of the need to urinate periodically. This can be successfully used in any patient who is insufficiently aware of their bodily functions, such as people who have dementia.

Diagnosis

Take the bladder assessment tool to see if you should seek further medical evaluation.  Print out the form, complete it and take it to your doctor or health care provider for help.

Treatment

People are often reluctant to seek help for this troubling problem partly because it is an awkward and embarrassing subject, but also because there is a prevailing misconception that nothing can be done.  Ask your doctor or health care provider for help.  In most cases,  the symptoms can be controlled or cured.

1) Kegel exercises strengthen the pelvic floor muscles which treats stress incontinence.  These exercises help strengthen the muscles that control the bladder. They can be done anywhere, any time. Although designed for women, the Kegel exercises can also help men. First of all, locate the pelvic muscles: while urinating try stopping and starting your urine flow without using your stomach, leg or buttock muscles. When you're able to stop and restart the stream of urine without contracting your stomach, leg or buttock muscles, you've located the right muscles. Now that you know which muscle to contract, you're ready to start your Kegal exercises:

Contract the pelvic floor muscles without urinating, (remembering what it felt like to control these muscles during urination) If your stomach or buttocks muscles tighten, your pelvic muscles are not being exercised correctly.
  • Tighten your pelvic muscles for 3 seconds and then relax them for 3 seconds.
  • Repeat for 10 to 15 times per session and do at least 3 sessions per day

    Note: Some physical therapists are specialists in this area & will teach biofeedback with exercise.  
    It's very important that your remember to do the exercises, otherwise the symptoms will return.  Pick a specific time of the day and get into a routine of doing them regularly.  Do them while you're driving a car, sitting at a desk, watching TV, or cooking a meal.  Just about any time works. Roughly 80% of stress incontinence can be successfully treated with Kegal exercises alone, but the exercises cannot be stopped.

2) Bladder retraining is used for treating urge incontinence   Bladder retraining attempts to increase how long you can wait before having to urinate. Keep a log of schedule bathroom visits.  If you are currently emptying your bladder every hour, stretch out the time to 1 hour and 15 minutes.  Resist the first urge to urinate and refrain from urinating until the scheduled time. You can practice relaxation techniques when you feel the urge to urinate before your time is up. 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.
Keep to that schedule for two to three days, then stretch it out by 15-30 minutes more every two to three days.  Continue with this pattern until you're urinating every 3 to 4 hours. Bladder training does not work well for everyone, but some people benefit significantly. Many people who use bladder training have fewer symptoms of incontinence and for some, the incontinence completely disappears.

3) Avoid bladder irritants listed below. 

Bladder irritants: Some foods and beverages can be irritating to your bladder, especially in large amounts. Why these foods sometimes cause irritation isn't exactly understood, and bladder irritants differ from person to person. A food that might be a bladder irritant to one woman may not bother another woman at all. try eliminating it from your diet for about a week to see if your symptoms improve. Avoid foods that might be bladder irritants for about a week. Then gradually — every one to two days — add one food back into your diet, making note of any changes in urinary urgency, frequency or incontinence. You might not even have to eliminate your favorite foods entirely. Simply cutting down on the amount you consume might help, too. The following is a list of common bladder irritants:

  • Caffeine
  • Alcohol
  • Acidic fruits and and fruit juices from oranges, grapefruits, lemons and limes
  • Spicy foods
  • Tomato-based products
  • Carbonated drinks
  • Artificial sweeteners

4) Quit smoking if you smoke,

5) Maintain a healthy weight

6) Avoid constipation When the colon is full of stool, it can press on the bladder and cause problems.

7) Avoid dehydration Concentated urine can be irritating to the bladder

8) Drink most of your fluids in the morning and afternoon if you're having to get up several times a night to urinate.

9) Medications can help the symptoms of overactive bladder, if all else fails. Talk to your doctor about the following prescription medication:

  • Enablex decreases the muscle spasms of overactive bladder.
  • Detrol LA decreases the muscle spasms of overactive bladder.  It can be taken once daily at bedtime and greatly decreases the number of trips to the bathroom during the night. During the day it decreases the symptoms of urgency, frequency, and episodes of incontinence.  The most common side effect is dry mouth; this is often avoided by taking the pill at bedtime.  Detrol LA is not recommended for patients with urinary retention, gastric retention, uncontrolled narrow-angle glaucoma, or patients who are allergic to the drug or its ingredients.
  • Ditropan XL decreases the muscle spasms of overactive bladder.
    • Ditropan XL has been widely used in the treatment for symptoms of overactive bladder for many years. Urinary dysfunction such as urge urinary incontinence, urgency and frequency can be diminished by Ditropan. Recent data from a clinical study (2006) looking at the effects of two prescription medications (Enablex and Ditropan) used to treat overactive bladder showed that treatment with Enablex did not result in impaired memory function in healthy adults age 60 and older. In contrast, treatment with Ditropan XL®(i) (oxybutynin extended-release or ER) caused significant memory deterioration. Furthermore, the individuals receiving Ditropan XL failed to notice the change in their memory function. These clinical findings were presented during the 2006 Annual Meeting of the American Urological Association.
  • Sanctura decreases the muscle spasms of overactive bladder
  • Oxytrol a patch to be applied to the skin and changed twice weekly

5) Surgical Treatment, in certain situations is helpful but is only recommended as a last resort when all other attempts at treatment have failed.

Local Physical Therapists who treat incontinence:

  • Foundation Physical Therapy (offices in Largo and Palm Harbor:)
  • 29605 U.S. 19 N. Suite # 360, Clearwater, FL 33761
    Phone: 727-784-6088; Fax: 727-784-3034
  • 2310 West Bay Dr., Largo, FL 33770
    Phone: 727-518-8115; Fax:  72
    7-784-3034


References:
1) "Patient characteristics that are associated with urodynamically diagnosed detrusor instability and genuine stress incontinence"  Am J Obstet Gynecol 2002;186:866-868.  Klingele CJ, Carley ME, Hill RF.
2) Urinary Incontinence from Medline Plus, A Service of the National Library of Medicine and the National Institute of Health.

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