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 It's time to put aside the misconception that urinary incontinence is inevitable and irreversible. Most women who are correctly diagnosed and receive appropriate treatment can put this condition behind them and engage in daily life.
An estimated 75 percent of the 25 million people in the United States affected by urinary incontinence are women. The most common type of incontinence, particularly among older women, is mixed incontinence. A diagnosis can be challenging because mixed incontinence is a combination of symptoms that each require individual assessment.
Aging itself doesn't cause incontinence, but the lower urinary tract changes with age. These changes, in addition to comorbid conditions and pharmacologic interventions, predispose older adults to urinary problems. Age-related changes result in diminished muscle tone, bladder capacity, flow rate, void volume, bladder compliance (stretchability), bladder capacity and urethral pressure profile.1 At the same time, uninhibited bladder contractions and postvoid residual volumes increase. This appears to be due to the deterioration of detrusor muscle function, vascular insufficiency, bladder wall fibrosis and increased sensitivity to neurotransmitters.
Although more than half of women with incontinence would welcome treatment, most are reluctant to seek help. Approximately 50 percent of women never mention their incontinence to a health care provider.2
Untreated incontinence can have detrimental effects on quality of life and promote embarrassment, depression, decreased sexual activity, sleep deprivation and social isolation. Many women restrict physical exercise and avoid settings where access to toilets might be difficult.
In the Right Position
Health care providers should understand lower urinary tract function in order to correctly diagnose incontinence and recommend appropriate treatments. The bladder and urethra form a functioning unit that constitutes the lower urinary tract system. Their function is to store urine in the bladder as it fills and empty the bladder through the urethra. Urine that filters through the kidneys travels through the ureters to fill the bladder.
The bladder is free floating, attached to the pelvic area by strings of ligaments that act as guide wires to stabilize it. This flexibility allows for constant size and shape changes. The ureters are attached to the lower portion (base) of the bladder and fill the bladder from the bottom up. Like a hot air balloon, the normal bladder lies in folds when empty and stretches and rises above the pubic bone as it fills.
The bladder and urethra are supported by a flat group of muscles known as the levator ani, or pelvic floor muscles. This group of muscles acts like a hammock to cradle the bladder. Some of these muscles form a u-shaped sling that attaches to the pubic bone in front and extend to the coccyx in back.
How securely the bladder rests in this sling depends on the tone and strength of the muscles that hold it.
The pelvic floor muscles also stabilize the urethra and help keep it closed when the muscles contract to prevent leaking. When the bladder is properly positioned in the abdominal cavity, both it and the bladder neck are above the pelvic floor muscles. As the sling stretches due to conditions such as pregnancy, bladder support decreases, and the base of the bladder and the bladder neck fall below the pelvic floor. This changes the relationship of the bladder and urethra to their surrounding structures, which can result in incontinence.
Continence depends on several active and passive properties of the detrusor urinae and urethra. During bladder filling, the detrusor forms a watertight seal, assisted by two muscle groups. The pelvic floor muscles also contract around the middle of the urethra to close it off to prevent leaking. The urethral tube is surrounded by rings of a different group of muscles that contract to form a water-tight seal.
Continence requires coordination between the detrusor muscle of the bladder and the urethral sphincteric mechanism. When any part of this sophisticated continence mechanism fails, the other parts are affected, and incontinence occurs. The most common bladder problems are the result of a failure to store or retain urine (incontinence), failure to empty (retention) or a combination of both.
Making a Diagnosis
Incontinence is categorized as stress, urge or mixed incontinence. Stress incontinence is the involuntary or accidental leaking of urine.3 It's associated with activities that exert a sudden increase in abdominal pressure, such as coughing, laughing, tripping, sneezing, heavy lifting or strenuous physical activity.
Any increase in abdominal pressure is transmitted directly to the bladder. Leakage may occur with something as simple as position changes to get out of bed in the morning or rising from a sofa.
Overactive bladder is a symptom complex consisting of urgency, frequency and urge incontinence.3 It's characterized by sudden, strong feelings of urgency that's caused by uncontrolled (overactive) contractions of the detrusor urinae during filling. The urgency may be strong or subtle and can frequently send a patient running to find the nearest toilet-only to void a miniscule amount of urine.
Incontinence that occurs following a strong urge is called urge incontinence. Urge incontinence is defined as the involuntary leakage of urine that's often accompanied by an urge to urinate. It occurs in the absence of physical activity. The amount of urine lost may be a few drops, but it more often occurs as a "gush" that completely empties the bladder contents.
Mixed incontinence is often described as being "stress dominant" or "urge dominant," depending on which group of symptoms is more prevalent.
Incontinence classification can be confirmed through physical examination, urinalysis and simple diagnostic techniques. Once the diagnosis is established, formulate a personalized plan of care that takes into account the patient's unique needs, symptomatology and quality of life.
Patient assessment begins with a medical history and detailed physical exam, which may reveal abnormalities within the lower abdomen or pelvis that are contributing to lower urinary tract symptoms.
Since most women with incontinence don't volunteer information about their condition, health care providers should incorporate leading questions into the health history questionnaire. Inquire about the presence of dysuria, frequency, urgency, hematuria and the severity and duration of incontinence. Ask whether pelvic pain increases just before menstruation or with intercourse; this timing is suggestive of interstitial cystitis.
Inquire about medications that may adversely affect bladder function (diuretics), prior pelvic surgeries, number of vaginal deliveries, patient mobility, mental status, pad use and history of urinary tract infections. Address the impact that incontinence has on the patient's life, self-esteem, activities of daily living and coping mechanisms.
Collectively, this information helps characterize the pattern of incontinence as urge, stress, mixed or interstitial cystitis.
The presence of stress and urge incontinence symptoms is required for a diagnosis of mixed incontinence.4 Symptoms can be misleading because they are based on subjective interpretation, so objective evaluation is necessary.
Putting Together a Plan
Therapeutic options for mixed incontinence encompass conservative and pharmacologic measures, with maximal therapy directed at the most bothersome symptom. Craft a comprehensive, conservative and multifaceted plan that includes bladder retraining that re-educates the bladder, along with dietary changes to exclude foods and fluids that irritate the bladder.
Implement pelvic floor muscle rehab using biofeedback to strengthen pelvic floor muscles for better control and introduce support devices, such as pessaries, that realign the pelvic anatomy. Medicines can calm overactive bladder muscles, increase bladder capacity and strengthen the urethral sphincter. And vaginal estrogen replacement therapy can revascularize the mucosa.
Four categories of treatment are recommended: behavioral, mechanical, pharmacologic and surgical. Research suggests that combining these methods is the best approach.5
Behavioral techniques are considered first-line options because they are low-risk interventions.6 But women should understand that conservative therapies aren't a quick fix and it takes weeks or months to notice improvement. But pelvic floor muscles respond to an exercise plan.
- Bladder retraining. Bladder retraining can break frequent voiding habits and decrease urinary urgency. This form of behavior modification helps women "relearn" how to urinate and regain cortical control over the detrusor muscle. It also serves as a form of bladder "stretching" by voluntarily prolonging the time between voids, increasing the volume of urine the bladder holds.
A toileting schedule works best when it's based on the woman's own pattern, as documented in her bladder diary. Instruct the patient to void only on a predetermined schedule.
For this technique to be successful, the patient must keep to the voiding schedule. Instruct her to follow this schedule for three days, voiding at the appointed times regardless of her desire to urinate. If she can't maintain this prescribed schedule for three days, increase the voiding intervals by 15 minutes. Once she has been successful with the new schedule for three to seven days, gradually increase the voiding intervals by 15 to 30 minutes until she reaches a maximum of 2.5- to 4-hour intervals and decreased urgency. Timed voiding can be best accomplished during the day; it's unrealistic to expect women to time patterns at night.
The goal is that at the end of this training period, voluntary, repetitive efforts to suppress and induce bladder activity may improve cortical voluntary control and improve symptoms. Recent research suggests that a timed voiding interval schedule can also be helpful in treating stress incontinence.7
- Biofeedback training. Biofeedback can be a valuable adjunct to pelvic floor muscle exercises, especially when a woman has difficulty isolating her pelvic floor. Biofeedback uses computerized technology to isolate the pelvic floor muscles. The technique monitors the electrical activity of these muscles through a vaginal or anal sensor and records any unwanted contraction of accessory muscles (buttocks, inner thigh, lower abdomen) using a sensor.
Electromyography records the electrical potentials generated by the depolarization of muscle fibers. Data from the sensors is recorded on a computer screen, where the woman can view the tracings and use them to alter her responses. Biofeedback also provides an objective assessment of patient progress, via the electromyography data.
Pelvic floor muscle exercises using biofeedback can cure 30 percent to 70 percent of motivated patients over a series of six visits.8 Other research shows that 50 percent of women who use biofeedback training can avoid surgery.9
- Pelvic floor strengthening. When performed correctly, pelvic floor exercises strengthen the muscles of the bladder outlet and the sling that supports the bladder and holds pelvic organs in place. Through regular pelvic muscle exercise, a woman can build strength and endurance to help improve, regain or maintain bladder and bowel control.10
It only takes a few minutes a day to make a difference in bladder control. Instruct the patient to squeeze the pelvic floor for five seconds and relax 10 seconds. She should perform these contractions threetimes a day. After she incorporates this schedule into her daily routine, instruct her to lengthen the contraction to 10 seconds. With this schedule, symptoms can improve in two to eight weeks.
Pelvic floor muscle exercises are the mainstay of conservative therapy for urinary incontinence, whether it's the stress, urge or mixed form. The goal is to decrease incontinence episodes by increasing the efficiency and magnitude of pelvic floor muscle contraction. This improves the tone of the voluntary external urethral musculature, increasing urethral resistance and pelvic support.
Kegel exercises should be performed by squeezing the anal sphincter. Most of the pelvic muscles form a triangle around the perineum, with the base below the anal sphincter.
Women tend to compensate for weak pelvic muscles by inappropriately recruiting their abdominal muscles, buttocks and thighs to control continence. This further weakens the pelvic floor.
Vaginal weights are an effective tool for strengthening the muscles of the pelvic floor, especially when used in conjunction with pelvic floor exercises. Vaginal weights are designed to help women identify, strengthen and tone the muscles in the lower pelvis. The smooth, slippery nature of the cone-shaped weights forces women to automatically tighten the pelvic muscles.
Women can slowly strengthen their pelvic muscles by increasing the amount of weight. In most vaginal weight sets, the weights range from 20 g to 70 g. After a woman is able to retain 1 weight for a period of time, she progresses to the next size. Like all other muscle exercises, "workouts" using the cones and vaginal weights must be done a few times a week for continued success.
- The vaginal pessary. A vaginal pessary helps restore continence by elevating and stabilizing the bladder neck and increasing urethral resistance. In addition to reducing stress incontinence, the pessary may also improve urge incontinence and an overactive bladder by elevating the bladder, allowing it to empty more completely. This decreases the contractions that work continuously to empty the bladder.11
A properly fitting pessary should take up redundant vaginal tissue, forming a sling that supports and elevates the uterus, and flattens and supports a cystocele. For women who aren't interested in surgery or who aren't good surgical candidates, pessaries offer a viable long-term treatment option.12 Start with a pessary known as the incontinence ring. It's available as a simple ring or as a ring with a knob-similar to a diaphragm.
- Pharmacologic therapy. Behavioral therapies alone aren't always effective for the long-term treatment of incontinence. The addition of pharmacotherapy can enhance patient compliance and improve outcomes. Anticholinergics are recommended as first-line therapy for an overactive bladder and may also help treat stress incontinence.13 These agents inhibit binding of acetylcholine to cholinergic receptors and interrupt the overactive reflex circuit, reducing contractions in the overactive bladder. The most common side effects are reduced salivary gland secretion and altered bowel function.
- Vaginal estrogen. Most women experience urogenital atrophy after menopause, and it often presents as vulvovaginal irritation and vaginal dryness. Without treatment, atrophic vaginitis persists for life. Estrogen thickens the layers of the vaginal wall, enhancing support of the bladder and rectum. It also affects continence via receptors in the urethra and pelvic floor musculature. Estrogen deficiency can reduce the effectiveness of the sphincters and pelvic muscles and may exacerbate stress incontinence.14
In addition, proper hydration is important for women with incontinence. Many women erroneously decrease their fluid intake in an attempt to decrease trips to the bathroom. This places them at risk for the harmful effects of dehydration and can actually make incontinence worse, particularly in the presence of an overactive bladder. The concentrated urine that results from inadequate hydration can cause irritative symptoms and increase feelings of urgency.
Urinary incontinence has a significant impact on quality of life. A diagnosis of mixed incontinence is especially challenging, and the treatment plan should include components that treat both urge and stress incontinence. With proper treatment and self-motivation, most women with mixed incontinence can experience dramatic symptom improvement.
For a list of references, go to www.advanceweb.com/rehab and click on the references toolbar.
Helen Carcio, NP, is a women's health nurse practitioner who owns the Health and Continence Institute in South Deerfield, MA.
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