A few years ago I did a research paper on urinary incontinence for my Human Body class (a combination of biology and anatomy). Here it is.
Urinary incontinence is defined by an involuntary loss of urine from the body. This condition, along with fecal incontinence, is present in infants, and typically disappears between ages 3 and 5. There are many causes for incontinence after the age of 5, usually stemming from an underlying medical or psychological condition. Most cases of incontinence are temporary, and disappear with time, treatment, or a change in living habits. (Wikipedia, Urinary Inc)
Urine is produced in the kidneys and transported to the bladder, a balloon-like organ. When the bladder collects enough urine, the detrusor, a muscle that lines the bladder, contracts and squeezes the urine out of the bladder through the urethra. The perineal muscle, which lines the urethral opening, and the external sphincter, a ring of muscles surrounding the urethra, receive impulses from a somatic nerve to relax and allow urine to pass out of the body. This process is called urination, and happens several times a day. The sphincter and perineal muscle are controllable, allowing for older children and adults to delay urination until a proper time. If any one step of the urination process fails, incontinence may occur. This fact is apparent in the many forms that the disorder takes. (Wikipedia, Urination)
Stress incontinence is caused by a sudden pressure on the abdominal area with such actions as coughing, sneezing and laughing. The squeezing action of the sphincter on the urethra does not withstand the sudden increase in urinary pressure, and a small amount of urine is expelled from the body. The abdominal pressure may also displace the urethra and bladder structure, resulting in a cystocele, or hernia. This pressure, combined with weakened or damaged pelvic muscles, causes the structures to bulge down into the muscles and reduce their ability to close the urethra. Stress incontinence is most commonly found in women who have given birth, or women around their menopause. (Urology Channel, Stress Incontinence) For many women, stress incontinence is handled by wearing small pads such as those used during menstruation.
Urge incontinence is caused by unexpected contractions of the detrusor muscle, triggered for no apparent reason, often so suddenly that the person does not contract the sphincter in time. Those with urge incontinence may urinate in their sleep, or after touching, drinking or hearing water. Involuntary bladder action also occurs due to damage to the bladder muscles (as in inflammation or infection) or the nervous system (as in multiple sclerosis or spinal injury). Overactive Bladder syndrome (OAB) and consumption of diuretics, which stimulate production of urine, increase the frequency and magnitude of the urges. (Urology Channel, Urge)
A continuous leaking of urine is generally referred to as overflow incontinence. Symptoms may include an inability to void, a feeling that the bladder is never empty, and dribbling even after voiding. People with overflow incontinence may not feel an urge to urinate, or are unable to, and so the urine collects in the bladder and leaks out in small amounts. This form of incontinence commonly occurs when the prostate gland in males becomes enlarged, and obstructs the passage of urine through the urethra. Other causes include tumors or urinary stones that block the urethra, or damaged sacral nerves that no longer sense bladder fullness. Medical treatment for overflow incontinence is limited, and may require the patient to use self-catheterization every 3 to 8 hours to keep the urine level low. (Urology Channel, Overflow)
Some people have normally healthy urinary systems, but have other problems that prevent them from reaching a bathroom in time. For example, people with osteoarthritis have difficulty moving to the bathroom, and people with Alzheimer’s disease may forget to use the toilet at a more convenient time. Others with delirium or major depression may not be aware of their need to urinate. These and many other potential problems that interfere with toilet access are collectively known as functional incontinence. (Wikipedia, Urinary Inc)
There are other types of urinary incontinence proposed in medical world beyond the four listed here. “Reflex incontinence”, the automatic emptying of the bladder without an urge or awareness of voiding, is listed in the 10th edition of the International Statistical Classification (ICD) database, along with stress, urge, and overflow incontinence. (ICD-10, N39.4) “Mixed incontinence” is classified as having symptoms of both urge and stress incontinence, and treatment is given by what symptoms are the most bothersome in the patient. (Urology Channel, Inc) “Transient incontinence” is temporary and “can be triggered by medications, urinary tract infections, mental impairment, restricted mobility, and stool impaction (severe constipation), which can push against the urinary tract and obstruct outflow.” (Wikipedia, Urinary Inc)
Traumatic events, anxiety, stress, genetics, low production of antidiuretic hormone (ADH), and underdeveloped bladders can also cause incontinence, usually in the form of enuresis, or bedwetting. These are found mostly in children up to the age of 10, and are usually not a cause for alarm. Bladder stretching, drinking less fluid before sleeping, and developing routines for waking up are helpful solutions. Most children overcome incontinence or enuresis as they grow. (Wikipedia, Urinary Inc)
There are some people who become incontinent simply from not using the related muscles on a regular basis. Recreational diaper wearers, or “infantilists”, may wear diapers out of desire and not need. When these people wear and wet diapers often enough, they may possibly lose their muscle tone and, over time, be unable to control their urination. This is not to say that infantilists are all incontinent, but some are able to and choose that path. Sometimes the only way to remove this form of functional incontinence is through conventional toilet training, as in a growing child, or to use Kegel exercises. (Wikipedia, Inf)
Kegel exercises prove helpful in strengthening the muscles that contract around the urethra, and tend to improve stress incontinence in particular. Targeting the pubococcygeus muscle group on the pelvic floor, the exercise begins by urinating, then attempting to stop the flow without tensing the legs. After identifying the correct muscles, the person suddenly contracts and then relaxes the muscles, or contracts and holds for a few seconds at a time. The exercise should be performed for 5 minutes, three times a day. Strengthening these muscles increases the pressure that can be applied on the urethra, helping to prevent accidents. (NKUDIC)
There is a special emphasis on finding the correct muscle group when practicing pelvic muscle therapy. Squeezing the legs, abdomen, or other muscles may put more pressure on the bladder. In biofeedback, electrodes are placed on the abdomen and along the anal area, and occasionally in the vagina in women or anus in men, to monitor contraction of the pelvic floor muscles. A monitor shows which muscles are contracting and which are at rest, and the therapist helps the patient identify which muscles are correct for Kegel exercises. “Of the people who used biofeedback, about 75% have reported improvement of their symptoms, and 15% were cured.” The muscles can also be stimulated and contracted by running a low electric current through an anal or vaginal probe. These treatments can be done in a clinic or in the home, and usually last around 20 minutes. (Medline Plus, Medical Encyclopedia: Stress)
Stress incontinence can also be treated through medications that strengthen the urinary sphincter. These treatments are more effective in mild or moderate cases of stress incontinence. “Alpha-adrenergic agonist drugs, such as phenylpropanolamine and pseudoephedrine (common components of over-the-counter cold medications) may be used to treat stress incontinence. They work by increasing the strength of the urethral sphincter, and improve symptoms in about 50% of patients. Additionally, the tricyclic antidepressant imipramine has similar properties, and so it may also be used to treat stress incontinence. Estrogen therapy can be used to improve symptoms of urinary frequency, urgency and burning in postmenopausal women, and it has also been shown to increase the tone and blood supply of the urethral sphincter muscles. However, whether estrogen treatment improves stress incontinence is controversial.” (Medline Plus, Medical Encyclopedia: Stress)
Other treatments use surgery to strengthen the fascial support or compress the sphincter muscles. In anterior vaginal or paravaginal repair, fascial tissue is folded and stitched to other tissue, to support the bladder and urethral structures more properly. These procedures have a relatively low cure rate, so they are typically performed along with another procedure, such as retropubic suspension. This is a group of surgeries that use an abdominal incision to elevate the bladder and urethra within the pelvic area. Sling procedure uses fascial or synthetic tissue to compress the sphincter muscle, preventing leakage. Finally, an artificial urinary sphincter may be implanted in the body; this is generally considered a last-resort treatment, performed mostly on males who have undergone prostate surgery. (Medline Plus, Medical Encyclopedia: Stress)
Urge incontinence, being neurological in nature, is more difficult to cure without changes in behavior. The most effective treatment, bladder retraining, “involves becoming aware of patterns of incontinence episodes and relearning skills necessary for storage and proper emptying of the bladder. Bladder retraining alone is successful in 75% of people treated for urge incontinence.” A schedule is made of times to urinate, and a person tries to consciously delay urination between intervals. As they become skilled at waiting, they may increase the time by half-hour intervals, until they reach a level of control they are comfortable with. (Medline Plus, Medical Encyclopedia: Urge)
Kegel exercises are mostly used in those with stress incontinence, but may be beneficial to those with urge incontinence as well. “The success of Kegel exercises depends on proper technique and adherence to a regular exercise program.” The exercises are similar to bladder retraining in its emphasis on maintaining a regular schedule, in order to bring control back to the person. Biofeedback and electrical stimulation can be used to augment the Kegel exercises. (Medline Plus, Medical Encyclopedia: Urge)
Some experts also suggest changes in a person’s diet, such as distributing fluid consumption throughout the day, so the bladder does not need to handle a large amount at one time. It is helpful to eliminate foods that irritate the bladder, such as spicy food, caffeine, and carbonated or acidic drinks, and to stop drinking fluids shortly before bedtime. (Medline Plus, Medical Encyclopedia: Urge)
Augmentation cytoplasty, a surgical procedure, may be undertaken to increase the holding capacity of the bladder, by removing a segment of the bowel and using it to replace part of the bladder. This surgery has many possible complications however, and should only be performed on people with an unstable bladder and poor urine storing ability. (Medline Plus, Medical Encyclopedia: Urge)
“Medications used to treat urge incontinence are aimed at relaxing the involuntary contraction of the bladder and improving bladder function.” Oxybutynin (Ditropan) and tolterodine (Detrol) relax the smooth muscle of the bladder and reduce spasmodic contractions. Dicyclomine (Bentyl) carries the same benefits but also has a wider range of side effects. Another antispasmodic drug is flavoxate (Urispas), but studies have shown inconsistent benefit in controlling symptoms of urge incontinence. “Tricyclic antidepressants have also been used to treat urge incontinence because of their ability to inhibit or ‘paralyze’ the bladder smooth muscle. Possible side effects include fatigue, dry mouth, dizziness, blurred vision, nausea and insomnia.” (Medline Plus, Medical Encyclopedia: Urge)
Unfortunately, many cases of incontinence are long-term, permanent, or severe, despite the treatment methods listed above. People with spinal injuries or damage to the nervous tissue that regulates urine flow often do not regain their control at any time in their life. Sphincter muscles and fascial support can usually be corrected with surgery, but not if the damage is quite extensive. People with mental disorders that prevent them from learning or retaining bladder control skills will be incontinent for the duration of their disorder, whether temporary or lifelong. In many cases, changes to lifestyle must be made.
A number of products are available on the market for incontinent people, such as adult diapers, liners or soakers, moisture pads, etc. Depend, a popular brand of adult diaper owned by the Kimberly-Clark Corporation, has a wide variety of products to support different needs for mild to heavy (or fecal) incontinence, while remaining low-cost and discreet. Attend, Tena, Molicare, Abena, store brands, and many other diapers offer an even greater range for selection, focusing on other aspects such as absorption, capacity, tape quality, thickness, comfort, noise, cost, and so forth. These factors make incontinence less of an inconvenience, and generally allow people to live normal, healthy lives outside of this disorder.
“Diseases of the genitourinary system (N00-N99).” ICD-10. May 4, 2006. World Health Organization. June 13, 2006.
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