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September 11, 2014

Aging: When you've got to go

Reuel S. Amdur

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Incontinence was recently addressed in an on-line seminar given by Champlain Rehab Solutions. The presenter was Susan Watson, RN, Regional Manager of the Chatham-Kent, Sarnia-Lambton Branch of VHA Home Health Care. What follows is a summary of her remarks, both condensed and enhanced.

Watson is credentialed as a nurse continence advisor, having completed the appropriate distance education program.  Urinary incontinence is defined as the involuntary loss of urine.  It is not a natural result of aging and may be able to be resolved or improved in many cases.

In order to avoid incontinence, we need to know when we need to go, where to go, to hold it till we get there, and then be able to pass urine. 

If we are not able to complete these steps and suffer incontinence, we run the risk of skin breakdown caused by the urine, and there is also danger of urinary tract infection.  With incontinence, there is a reduction of fluid intake.  It also has social consequences, tending to isolate the person and impede intimacy.

There are medical, social, and psychological problems that can affect continence.  Some, such as Parkinson’s, multiple sclerosis, and strokes, can leave the bladder not totally empty after voiding.  Diabetes results in decreased sensation and decreased bladder muscle contraction.  An enlarged prostate makes a person want to go frequently, with the bladder not completely emptied.  That person may also have difficulty urinating and may dribble after.

Mobility can also be an issue. Older people may not be aware to the need to go till it is too late to get to the bathroom, especially if they have limited mobility.  Cognitive impairment can create a series of problems.  Does the person know he needs to go?  Does he know where the bathroom is and that it is the appropriate place to go?  Alcohol and drugs, both prescribed and illicit, can be factors. 

Watson spoke of four kinds of incontinence: urge incontinence, stress incontinence, overflow incontinence, and functional incontinence.

Urge incontinence follows a strong and sudden desire to void.  It is characterized by urgency, frequency, night time need to go, and loss of large amounts of urine.  Causes include infection, concentration of urine, aging, alcohol use, some medications, caffeine, too much or too little fluid intake, and muscle atrophy.

In addressing this kind of incontinence, a person can perform Kegel exercises, tightening the muscles of the pelvis. 

The person can also go to the toilet on a regular basis, every two to two-and-a-half hours.  It is important to have an appropriate intake of liquids, not too much or too little.  And alcohol and caffeine beverages do not count in considering liquid intake.  Decreasing caffeine may help.  If the distance to the toilet is a problem, then a commode or urinal may be indicated.  Medicines may need to be properly timed.  For example, a water pill should be taken in the morning.  If the prescription is for two a day, the second should be taken at lunch.  A person may also be trained to self-catheterize. 

Stress incontinence is loss of small to moderate amounts of urine due to increased abdominal pressure even without bladder contraction.  Coughing, sneezing, laughing, or jumping may be implicated.  The loss occurs with physical activity and is not due to urgency.  Possible causes include weakened sphincter muscle, obesity, prolapsed uterus, too much caffeine intake, excessive or inadequate quantity of liquid intake, and activities which increase pressures in the abdomen.  Treatments include many already discussed with urge incontinence. 

Overflow incontinence is loss of urine due to distension of the bladder.  The bladder is too full.  Symptoms are difficulty getting going, straining to go, poor flow, dribbling before and after, and loss of urine with stress.  The person voids small amounts frequently and urgently.  A large amount is left in the bladder and the bladder is prone to infection.  The person has to go frequently at night.  Often, there is a lack of awareness that it is necessary to urinate.

This kind of incontinence may be due to an obstruction which may require surgery.  It may also be due to nerve damage resulting from diabetes, Parkinson’s, or multiple sclerosis.  Medicines may also be implicated.  Or quite simply the person may not have been going to the bathroom often enough.  The solution may simply be to go more often and do Kegel exercises.  It may be necessary to use a catheter.

Finally, functional incontinence. In this situation, there is nothing wrong with the plumbing.  Instead we are dealing with mental impairment, problems with mobility and dexterity, and conditions of the physical environment.  The path to the bathroom needs to be cleared of obstructions.  If that does not resolve the issue, then a commode or urinal should be close at hand.  If dexterity is the issue, the person may need to wear modified clothing.  Toileting on schedule can also be tried. 

We have spoken of Kegel exercises.  Squeeze the pelvic muscle and hold it for three to five seconds.  Relax for the same period of time.  Watson suggests repeating this exercise over the time it takes to watch a television commercial.  Do this once or a few times a day.  She says that you may see improvements over a month or six weeks, especially for stress incontinence.

The urge suppression exercise is similar to the Kegel.  Before getting up from a chair or out of bed, squeeze and relax the pelvic muscle rapidly ten times. 

Some people try to counter incontinency by interrupting the flow of urine and then resuming the flow.  That may be a good way to find the pelvic muscle, but continuing with the technique is counterproductive, as it tends to leave urine in the bladder.

There are products for managing incontinence, but “they are not cheap,” she noted.  Do not use sanitary napkins, as these do not hold enough urine.  There are many types on the market, and the packaging is ordinarily marked with a symbol of little drips, indicating how much flow the product will hold.  Men need to be aware that boxer shorts do not work with these products.

Incontinence can increase the risk of falling, due to rushing to the toilet or to mobility problems.  And if you leak on the way, on a hard surface, the surface may become slippery.  To avoid problems of these sorts, there are things that you can do.  Go to the toilet on schedule.  In getting up from bed, sit on the bed before rushing to the bathroom. Sit when urinating.  Drink enough liquids.  Have a commode or urinal next to the bed.  Use an incontinence product.  Clear the path to the bathroom of any obstructions.  Use a night light or flashlight at night.

If you need help in sorting out what the problem is and what to do about it, have an assessment.  Your doctor can make a referral to a urologist or a nurse continence advisor.

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