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washromWhen It Gets Wet Down There

Urinary incontinence is the uncontrollable and involuntary loss of urine that affects more than 13 million Americans. Incontinence can be very embarrassing as it can interfere with a normal, full life. Fortunately, today something can be done about it and in most instances it can be cured completely.

In an age when people talk about sex and Viagra as if they were discussing golf scores, it seems ironic that many of the millions adults who suffer from urinary incontinence are too embar­rassed to broach the subject with their doctor.  But if they did, they would learn that there are treatments that can eliminate or improve the problem in 9 out of 10 people who experience urine leakage.

Although urinary incontinence affects both women and men, it is more common in women, and it is not, as many people believe, a problem mainly in older people.  In fact, many women develop diffi­culties with urine leakage in their 40s and 50s.  The problem is believed to affect 10%-20% of men and 20%-40% of women over 60.  However, inconti­nence is not considered normal at any age, and it should not be seen as an inevitable part of growing older.  But because many people are too embar­rassed to discuss the problem with a doctor, they re­sign themselves to wearing adult diapers or pads.

Fortunately, incontinence can be treated or even cured in most people by strengthening the pelvic muscles, taking medication, or both.

Urine is produced in the kidneys and flows through two tubes called the ureters to the bladder, where it is stored until it leaves the body through the urethra, another tube.  The process of urination is largely controlled by the detrusor muscle, the smooth muscle in the wall of the bladder, and sphincter mus­cles, which are located in the wall of the urethra, at the base of the bladder. When the bladder is filling, the detrusor relaxes and the sphincter muscles contract, preventing urine from flowing through the urethra.  A sheet of pelvic-floor muscles support the base of the bladder and close the urethra, further blocking the flow of urine.  During urination, the detrusor muscle con­tracts and the sphincter muscles relax, opening the way for the passage of urine.

Incontinence may be due to weakened pelvic or sphincter muscles due to childbirth, prostate en­largement or surgery, nerve damage, an overactive bladder, or infections.  Because, in rare instances, it may signal a spinal tumor, prostate cancer, or a slipped disc, it is important to seek medical attention.

Incontinence is divided into three types: stress, urge, and overflow.  Stress incontinence occurs when involuntary pressure is placed on the bladder by cough­ing, laughing, sneezing, lifting, or straining.  It devel­ops most frequently in women in between the ages 40 to 50.

Urge incontinence, which is generally due to in­voluntary contractions of the bladder muscle, is more common in people over 60.  Those who suffer from it report an urgent need to urinate, accompa­nied by a sudden loss of urine.  Women often expe­rience a combination of stress and urge inconti­nence.  Overflow incontinence, which is much less common, occurs when the bladder is so full that it continually leaks urine.  It is often due to weak blad­der muscles, a blocked urethra due to prostate en­largement, or nerve damage.

A primary care doctor will often refer a patient with incontinence to a urol­ogist, who specializes in both the male and female urinary tract, a urogynecolo­gist, who focuses on urologi­cal problems in women, or a geriatrician, who concen­trates on the medical prob­lems of older people.

Individuals may be asked to keep a diary during the week prior to the doctor’s visit to keep track of how much and how often they urinated or leaked urine.  Tests performed in the of­fice may include a pelvic and/or rectal exam, a uri­nalysis to test for infection, and a non-invasive imag­ing scan to check for residual urine in the bladder.

Strengthening pelvic floor muscles with Kegel ex­ercises has been shown to reduce urine leakage in 50%-75% of women and cure it in 20% with stress incontinence.  The easiest way to identify these mus­cles is to start to urinate and then stop the flow mid­stream; Kegel exercises are performed by contracting and relaxing these muscles.  To reap the greatest benefit, tighten the pelvic floor muscles and hold for a count of 10 seconds, then relax the mus­cles completely for a count of 10.  Do the exercises 3-5 times a day in sets of 5-15 contractions.  It may take 4-6 weeks for any improvement to become no­ticeable, and the exercises may have to be continued indefinitely to keep the pelvic floor muscles strong.  Fortunately, they take only a few minutes and, of course, can be performed anywhere.

Sometimes the exercises are more effective when weighted cones are inserted into the vagina.  Another treatment involves inserting a stiff ring known as a pes­sary, which puts pressure on the urethra and results in less leakage.  Some women substitute a tampon for the pessary.  People are sometimes helped by collagen injections near the sphincter; this bulks up tissue and helps strengthen muscles.

Timed urination, also called bladder retrain­ing, is used to increase the bladder’s storage ca­pacity in people with urge incontinence.  If a person normally has an incontinent episode every 3 hours, he or she may be asked to urinate every 2 hours and then focus on suppressing the urgency.  Once there is improvement, the person then extends the time between bathroom visits.

Kegel exercises and bladder retraining are often done in combination with biofeedback.  In this technique, electrodes are placed around the abdomen and in the rectum; in women they may be inserted into the vagina.  The electrodes are hooked to a monitoring device.  When the pa­tient is asked to contract certain muscles, the monitor will display a graph showing the con­tractions, letting him or her know when the ex­ercises are being performed correctly.

A study led by researchers from the University of Alabama at Birmingham in the December 16, 1998, Journal of the American Medical Association indicates that Kegel exercises coupled with biofeedback may be more effective in treating urge incontinence than oxybutynin (Ditropan), a commonly used medication that relaxes the smooth muscle in the bladder.  Participants included 197 women age 55-92 with either urge or mixed urge and stress incontinence who were divided into three groups: a “behavioral” group, which did biofeedback and Kegel exercises, a drug treatment group, and a control group, which received no ther­apy.  All participants kept a diary of urinary habits.

After eight weeks, the behavioral therapy group reported an 81% reduction in episodes of inconti­nence compared to a 68.5% decrease in the drug treatment group and a 39% reduction in the control group.  Although biofeedback and exercise were shown to be superior to medication in this study, finding a physician with expertise in biofeedback may be difficult.

Anti cholinergic drugs are available for treating urge incontinence.  The most commonly used drugs are Ditropan, Detrol, Enablex, Vesicare, Sanctura, and Myrbetriq.

Men with overflow incontinence are often helped by a class of drugs called alpha-blockers, which in­clude Flomax, Uroxatrol, and Rapaflo.   They work by relaxing the smooth muscle in the capsule that sur­rounds the prostate.  This relieves constriction of the urethra and allows urine to flow more easily.

Surgery is generally considered a last resort, and is mainly used to strengthen pelvic muscles or lift the bladder and the urethra to alleviate stress incontinence.  Fortu­nately, most cases of incontinence can be cured or improved with less drastic measures.  In addition to pelvic exercises and medication, it’s a good idea to cut down on alcohol and caffeine, which can irritate the bladder and trigger urinary frequency.

Bottom Line: Urinary incontinence shouldn’t take over your life. It is almost always treatable, and often completely curable. Working as a team, we can put you back in control of your bladder and your life. That means you’ll be free-free to get a night of uninterrupted sleep, to travel comfortably, to be as active as you want to be. Instead of worrying about embarrassing accidents, you’ll be able to do the things you most enjoy.

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