Managing Urinary Incontinence
While the prevalence of urinary incontinence (UI) increases with age, UI itself isn’t a normal part of aging. It’s only a symptom of other, often age-related changes – to the kidneys or the bladder or the urethra (the tube through which urine flows out of the body). UI may also be a sign of estrogen deficiency in postmenopausal women, or of health conditions like Parkinson’s disease, stroke, diabetes and prostate problems.
That’s why it’s not a good idea to keep a leakage problem to yourself: Incontinence could be the first sign of a more serious issue requiring immediate attention. But there’s another good reason for mentioning UI to a health professional: Incontinence is often treatable, in some cases curable.
Start by talking to your family doctor, who may be able to determine the source of the problem or, failing that, refer you to a specialist – a urologist, gynecologist or urogynecologist. Some women are helped simply by taking estrogen replacement therapy to reverse changes to the bladder or the lining of the urethra after menopause. Some men’s UI is caused by an enlarged prostate exerting pressure on their urethra; there are several possible interventions to rectifyhe problem, including medications and surgery.
There are in fact medications and surgical interventions that can be used to treat most forms of UI, but many problems are resolved or significantly improved simply by making a few lifestyle changes, such as diet modifications (reducing caffeine and other diuretics), reducing alcohol intake, losing weight – even quitting smoking may help.
Behavioral adaptations can have a big impact, starting with education to teach people to monitor and modify symptoms of UI using a diary, charts, Kegel exercises (see below) and bladder training with urge suppression.
Autumn Trumble, a nurse who created and operated the former incontinence clinic at St. Joseph’s Health Centre in Toronto, describes bladder training – or retraining – as a way of "relearning control over the bladder so you’re going to the bathroom on your schedule instead of jumping every time your bladder says so. This is done through regular, timed trips to the bathroom, along with measures to put off going called urge suppression exercises – things like doing a pelvic muscle contraction or using distraction [techniques]."
Kegel exercises were designed to treat incontinence in women, particularly stress incontinence, but they’re also useful for men who develop UI after prostate surgery. They work by strengthening the hammock of pelvic muscles that support the bladder and help close the urethra (they’re often taught pre- and postnatally, because pelvic muscles can be weakened by childbirth).
Kegel exercises are simple and effective, but they require instruction – they can be counter-productive if they’re not done right. Many physiotherapists, doctors and nurses teach them, often using biofeedback or electrical stimulation equipment to help their students identify the right muscles, because they’re not muscles we consciously use.
Kegel exercises can be done standing, sitting, lying, while you’re doing the dishes, waiting at a bus stop or driving in the car, says nurse Anita Saltmarche, a founding member of the Canadian Continence Foundation. "The idea is to incorporate them into your normal lifestyle with activities that you do every day, so it becomes spontaneous."
When most people think of UI, they think of pads, pantyliners, and absorbent undergarments (disparagingly known as "adult diapers"). Indeed, there’s a wide range of absorbent products available for people who experience slight leakage, including the aforementioned pads and pantyliners, as well as heavier products designed for loss of bladder control. Some people have no patience for any of it. Despite the inconvenience and cost, Saltmarche says, there are women who literally change clothes rather than wear a pad: "Women have told me they carry changes of underwear, and if they have to, they dispose of the underwear they have on and put on a new one." Others find absorbent products and other devices lifesavers, "and they’re able to continue with their normal day-to-day activities. They prefer to do that than constantly worry."
As Cheryle B. Gartley notes in her book, Managing Incontinence, there’s no perfect product that works for every consumer. In fact, she writes, "many people find that one product alone isn’t completely suitable for all situations… A bulky, highly absorbent product may be very good for nighttime use or for around the house. For work, or social events, an inconspicuous pad and pant system may be more appropriate. For long confinement periods or long periods of vibration (i.e., travelling for more than two hours on an airplane), an extended collection device may be the appropriate coping mechanism."
The best approach is to identify your chief concerns, then compile a checklist to compare various products and devices. For some people, the most important feature of a panty liner is absorbency – how much it absorbs before it needs changing. Others are more concerned with whether it’s bulky and obvious under clothing, whether it’s comfortable or causes skin irritation.
Other considerations: cost, availability, ease of use, and disposability. Does it rustle disturbingly when you move; require special fitting; contain a deodorant? Is the product equally effective whether you’re sitting, standing or moving about? Is it only appropriate for nighttime use?
For men, there are pouches, drip collectors, and collection devices that consist of a condom-like device that fits over the penis and drains through a tube into a bag strapped to the leg. Many men find such devices effective and convenient, but they aren’t without problems, including the possibility of parts coming undone, causing a spill. And drip collectors can’t help empty the bladder; they simply handle leakage. "If somebody’s really not emptying, they need to be able to use a catheter," Saltmarche says.
An idea to make men cringe: penile clamps, some of which are effective drip-stoppers. Old-style clamps look like padded clothes pins; new models are more discreet: Instead of two flat pieces joined together, they’re circular, with a cuff that inflates for comfort and to prevent leakage.
There are urethral devices for men and women "that go into the urethra and occlude it, or close it off," Saltmarche says. "Then you unclamp it. It’s removable, so you throw it out each time and reinsert [another] after you go to the washroom. Some of them look like small indwelling catheters [see below] that have a little bulb at the end that’s inflated. That rests at the bladder neck and has a piece that protrudes outside the urethra. It’s sort of anchored on both ends but occludes or closes the urethra."
There are new devices coming out that sound promising, Saltmarche says.
"There are little patches, not for large incontinent episodes, that are put over the urethra. They use natural suction in the area as well as a light adhesive. It’s just enough to prevent leakage in some women who don’t have large amounts of leakage. They’re working on a similar device for men."
Pessaries are devices for women that are placed in the vagina to provide support for the pelvic floor, the bladder neck or a prolapsed (fallen) urethra. Some physicians use them to determine whether surgery will be successful, Saltmarche says, "because if a pessary keeps things in place, and the woman finds it effective, chances are a surgical procedure that mimics that effect – without implanting a device in the vagina – would be successful too."
Pessaries have to be sized individually, fitted and inserted by a doctor (though women have been managing pessaries themselves for centuries).
Unfortunately there are fewer and fewer doctors, including urologists, who have much experience with them, and there’s a real art to selecting and inserting them, Saltmarche says.
Nor are pessaries without complications. They can irritate and erode vaginal tissue, and they need to be removed and cleaned regularly to prevent infection. Women who don’t have the manual dexterity or physical flexibility to do it have to visit a doctor’s office or health clinic every four to six weeks to have it done. And, because a pessary has to be removed before intercourse, Saltmarche says, "women who are sexually active need to be taught how to take it out and put it back in."
Catheterization is a technique that can be used to manage overflow incontinence and urinary retention. With intermittent catheterization, the catheter – a slender tube – is periodically (every three to six hours) inserted into the bladder through the urethra to drain it of urine. The catheter is then removed, rinsed and washed. The technique is so simple, Saltmarche says, "little kids with spina bifida or other congenital disorders are taught to do this as early as age four. They have little catheters they literally shove in their pocket – it’s a clean technique as opposed to sterile. They insert it, empty their bladder, and, as one little tyke told me, ‘You sort of just shake it really hard, and that’s it. And you throw it back in your pocket, and away you go’."
That’s not exactly "clean technique," but if the bladder is emptied efficiently and frequently enough during the day, so that it only fills to a normal amount (about two cups), there shouldn’t be a problem, Saltmarche says. "The normal immune system in the body will prevent infection from occurring. You’re emptying the bladder hopefully well enough there’s never a pool of urine left behind so that [bacteria in the bladder] can multiply."
For most men, the idea of inserting a tube up their urethra is beyond the pale (an enlarged prostate can make it uncomfortable), but it’s mostly a matter of adjusting to it as against overcoming pain. A lot of women feel the same way, Saltmarche says, "partly because they don’t know anything about what goes on ‘down there.’ They feel it would be uncomfortable or painful. In fact, if done properly, and if initially they use lubricant, they become accustomed to it. They really don’t have any pain associated with it."
The other type of catheter is an indwelling, or Foley, catheter, which is inserted and left in place; a balloon is inflated at the end to keep it secured at the bladder neck until the balloon’s deflated and removed.
Indwelling catheters aren’t used as much as they once were, Saltmarche says, because of potential side effects, including discomfort and bladder infections, but they can be useful for some people in specific circumstances.
Keep in mind that no treatment approach for UI has to be used in isolation. Dr. Gordon Brock, a family physician in Temiscaming, Ont., who lectures at McGill University in Montreal, advises colleagues to use as many treatment modalities as they can in treating anyone with UI: "Hit them with three, four, five methods of treatment if you can, all at the same time. Everything may work just a little bit, but the sum total can often be substantial."
Above all, people need to recognize that UI isn’t an inevitable part of aging, Brock says. "It is not normal at any age, at least any age above three or four. There is a public gap here, in that so often people are reluctant to walk in to physicians and say, ‘I’m incontinent’." Perhaps they wouldn’t be so reluctant if they realized, Brock says, "that treatment is often surprisingly simple and effective. Treatment is available for it."
To find out more, ask a health professional, your local hospital or contact the Canadian Continence Foundation (toll-free at 1-800-265-9575).