A Chat with the Doctor: Incontinence

By Guest Contributor December 15, 2012 12:00

By Dr. Eric Freedman

Suzanne’s mother, Jane, is 84 and was recently placed in a care home because of progressive dementia. She was referred to me for incontinence.

“So how long has your mom had problems with bladder control?” I ask.

Though Jane does not feel she has a problem, Suzanne says her mother has been wearing adult diapers for more than a year and is now losing bowel control.  “I think this must be an inevitable part of aging,” she says.

This misconception is prevalent among patients, families, caregivers and doctors alike. It can result in complacency and medical neglect.

Aging is associated with many bodily changes, such as reduced mobility and shortened warning time, which can predispose the elderly to incontinence. But many of these conditions are treatable, preventable or reversible.

I call such conditions the M-Factors – reduced Mobility, less Manual dexterity, diminished Mental capacity, lack of Motivation, Muscle weakness, Medical conditions and side effects of Medicine.

Some of the more common medical problems affecting urinary incontinence are stroke, dementia, Parkinson’s, and multiple sclerosis. Arthritis, hip fractures and balance conditions also can severely affect one’s ability to get to the bathroom in time.

Bladder infections, urinary tract infections, constipation, overactive bladder, benign prostate enlargement in men, dropped bladder (prolapse) in women, obesity,  diabetes, sleep apnea, chronic pain syndromes and coughs – most of these common and treatable – can also cause incontinence.

Asking the right questions can lead to a treatment plan.

“Do you see this sort of thing very often?” asks Suzanne.

The answer is yes: The burden of urinary and fecal incontinence on patients, their families and society is huge.  Incontinence affects half the residents of long-term care facilities and, with dementia, is one of the two main

reasons patients are placed in long-term care in the first place.

Dealing with incontinence is also the major annual cost of providing long-term care (more so even than medication). The problem is also worsening, as people over 80 become the fastest growing segment of our population.

The good news is that more than half those over age 65 have no significant incontinence. Women are two to three times more likely than men to have urinary leakage, but only a quarter of females with incontinence ever discuss it with their doctors, because many think it is normal and inevitable.

“What can be done?” asks Suzanne.

I tell her we first must determine what type of incontinence her mother is experiencing, and if there are any factors we can modify.

There are three main types of incontinence, each with different treatments.

  • Stress incontinence is leakage of urine with exertion, such as coughing, sneezing, laughing or running.
  • Urge incontinence is when the bladder starts emptying before a person can reach the toilet, and in some cases, even before realizing it is happening.
  • Overflow incontinence is when bladder emptying is incomplete and urine overflows.

Elderly patients often show a combination of these factors. Evaluation requires a complete review of the patient’s history and medications, a physical exam and testing. Non-surgical treatment options include reducing the types or amounts of beverages consumed, dieting, cutting caffeine, increasing fiber, regular bathroom schedules, bedside commodes and catheters. Weight reduction is key to controlling stress incontinence, and treating constipation and infections is crucial to managing urge incontinence.

Pelvic exercises (Kegels) can help, as can the assistance of specially trained physical therapists who can perform biofeedback. Other options include acupuncture, hypnosis, herbs and medications. All treatments must be used cautiously, especially in the elderly, due to potential side effects and drug interactions.

Surgical options may include new minimally invasive urethral slings, bladder lifts, artificial sphincters, bladder injection of Botox, and urethral bulking agents. In males with significant prostate obstruction, outpatient laser treatments are available with excellent outcomes.

Another option is pelvic nerve electrical stimulation with implantable pacemakers, which has been successful in patients who have not responded to other treatments. Muscle cell harvesting, an offshoot of stem cell research, may be available in the future to help weak sphincters.

“How does one choose?” asks Suzanne.

This is where the partnership between patients, families, caregivers and healthcare providers can determine realistic goals and achievable outcomes.

Jane was found to have severe constipation and a bladder infection. When these conditions were treated and her mobility improved through physical therapy, her incontinence was significantly diminished. A major problem became minor and acceptable.

Dr. Freedman is a urologist and urologic surgeon practicing in Sonora, California.

© 2013 Friends and Neighbors Magazine

By Guest Contributor December 15, 2012 12:00
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