Urinary Incontinence is simply the loss of control over urination. There may be actual loss of urine, as in "Stress Urinary Incontinence", or merely the threatened loss, as in some forms of "Urge Incontinence".
The severity of the problem varies greatly, as do people's reaction to having the problem; some are extremely embarrassed by even the slightest leak, while others are merely inconvenienced and irritated by it.
1. Acute versus Chronic Incontinence. First of all, if the "incontinence" is relatively new, it may not be (chronic) incontinence at all, but simply a temporary by-product of another condition, such as an infection, an injury, constipation, or even a side-effect of a prescription drug taken for another problem. Click here to see a detailed list of the common causes of what is called "acute", "transient", or "temporary" incontinence.
2. Most Common forms of Chronic Incontinence. In the old days (pre-1988), when surgery or drugs were the only remedies, it was important to differentiate between "Stress" incontinence and "Urge" incontinence. That's because surgical procedures were the "accepted medical practice" for "Stress", but pharmaceutical products were used to treat "Urge". In reality, however, the distinction was more important to insurance companies than actual patients, because many people have both Stress and Urge, which is usually called "Mixed Incontinence". Many people with Mixed Incontinence were often classified (and sent to either surgery or drugs) on the basis of which of these two symptoms bothered them the most.
Now that there are harmless alternatives to surgery and drugs, the distinction between Stress and Urge incontinence isn't so important anymore. In fact, research has shown that BOTH Stress and Urge patients tend to have a common problem - weak pelvic floor muscles! Back when nothing could be done about that, it wasn't important to know. Now it is.
3. Stress Incontinence (also called "Urinary Stress Incontinence", or "Stress Urinary Incontinence", depending on which medical school the doctor attended.) SUI has nothing to do with emotional or psychological stress; it refers entirely to physical stressors which put physical pressure on the bladder. Since the valve or sphincter muscles are weak, they are unable to hold back the increased internal pressure, and a leak occurs. Typical examples of SUI occur when (1) bending over to pick up a heavy object, (2) getting up from low furniture, (3) during aerobic exercise or jogging, (4) when coughing or sneezing, or (5) when laughing hard. In the old days, surgery was usually the only hope for treating serious SUI.
4. Urge Incontinence. The term "Urge" covers several conditions which have in common the absence of apparent physical defect and, usually, little or no leakage, but share a sense of urgency about toileting. Common symptoms are (1) Can't get to be bathroom quickly enough, (2) Always need to know how many steps to the nearest bathroom, (3) sometimes uncontrollable urge to urinate when hearing or touching running water (as in washing the dishes). A variety of drugs have been used to treat Urge Incontinence. Unfortunately, they have serious side effects and many people stop using them. The several kind of "urge" are quite different:
5. Enuresis (nighttime wetting, bedwetting).
Enuresis is a form of incontinence that is very common among preschool children, and often
persists into adulthood. It is quite unlike the preceding types in both origin and
treatment. Fortunately it can be effectively and inexpensively treated with wet-bed alarm
systems which are readily available and easy to use. Information about alarms (and many
other aspects of incontinence) can be found on the web pages of the Tri-State Incontinence Support Group. They also
have several very interesting and informative "fact sheets" available. There is
also a "National Enuresis Society"
that you might want to check out. However, be forewarned that this is a
physician-sponsored group that promotes the use of Desmopressin acetate (synthetic ADH), a
nasal spray. If you read the NES site, please also check out the warnings about DDAVP on
Tri-States' homepage, above, before you start spraying! For an interesting bio-behavioral
approach to enuresis, check out our own experience in the essay "Enuresis: Another Perspective".
6. Conditions with an Organic Basis. The preceding conditions, which account for over 90 percent of chronic incontinence cases, all share a lack of any organic basis. But sometimes incontinence is secondary to an organic condition which, when appropriate, needs to be treated.
Overflow Incontinence. This describes the condition in which the bladder does not empty but remains full, and small amounts of urine continually "overflow". It is most commonly caused by an obstructed urethra caused by an enlarged prostate gland. It is often accompanied by or preceded by a diminished urinary stream, and is a serious condition requiring immediate medical attention. Overflow was previously detected by inserting a catheter and measuring how much urine was drained out. This sometimes caused infection or irritation. Now it is detected with a "Bladder Scan" instrument (Sonar, sort of like a depth finder in a boat) that is harmless and non-invasive.
Post-Prostate Incontinence. As more and more men are tested for and receive life-saving treatment for prostate cancer, many are left with a combination of incontinence and impotence after the surgery. This can be psychologically devastating. Fortunately, the same computerized EMG biofeedback instruments that treat Stress and Urge incontinence can also treat Post-Prostate Incontinence. Unfortunately, this form usually takes longer to treat, and is somewhat difficult to project how long, because of the surgical removal of tissue. In treating stress and urge incontinence, most otherwise healthy patients recover complete control in 4 to 5 weeks; they only need to strengthen the muscles. But in post-prostate it may also be necessary to build up the muscle bulk (just like a weight-lifter does) and that can take longer. Note: If you are planning to schedule prostate surgery, you should first have your pelvic muscles checked for strength (by the same clinics that treat incontinence). If you ensure that your muscles are strong before surgery, your recovery will probably be a lot quicker.
Other medical problems. Sometimes incontinence is secondary to bladder tumors which may or may not be cancerous. Fortunately, these can readily be detected by a cystoscopic examination, in which a physician inserts a kind of "periscope" into the bladder through the urethra and a visual inspection is made of the inside wall of the bladder. It isn't fun, but it doesn't hurt for long and it can save your life. It is usually done only after a urine analysis has detected red blood cells in the urine. (Of course, if you have actual blood in your urine, like I did, you won't bother waiting for the urine analysis!)
Spina Bifida and other Birth Defects. Certain birth defects which involve the final development of the lower spinal cord often result in urinary or fecal incontinence or both. There is considerable research that shows almost all such patients can be greatly improved or even cured with biofeedback methods. These cases are more difficult to treat and require a more experienced therapist. Children as young as 6 or 7 have been successfully treated.
7. The Brief Therapy Model. The EMG biofeedback treatment
of incontinence grew out of the "brief therapy" model of behavioral sciences. It
states that it is more economical to treat a presenting problem as a simple one, and, if
it goes away, you know you were right. If it doesn't, you bring out the heavier guns. This
therapy is of no help in, for example, detecting bladder cancer. But the average
uncomplicated patient can be cured in less than a month, a lot sooner than you can get an
appointment with a busy, popular urologist these days. If the incontinence is gone by the
time your appointment comes up, you might decide not to keep it. Being cured of
incontinence doesn't mean that you DON'T have bladder cancer; it simply means that it
wasn't the cause of your incontinence. If in doubt (or if you have reason to fear) consult
your urologist.
Important Exception: a male over age 50 with diminished flow should always RUN, not
walk, to the nearest urologist for a definitive examination. Back in 1955, when my dear
grandfather died of prostate cancer, no one was urging screening examinations. Today there
is no excuse; even Bob Dole talks about it.
8. What about the Kegel Exercises? Won't they help without spending any money? Many well-meaning professionals advocate what they mistakenly call "Kegel Exercises" on the grounds that "they can't hurt and they might help". But in fact, the "do-it-yourself" exercises which they advocate, and which you may have read in one of the "women's magazines", are seldom effective and sometimes actually harmful. And they are NOT correctly called "Kegel" exercises. Lets examine the facts:
Exercises to strengthen the pelvic floor muscles were actually first proposed by a Dr. Davies in the 1930s. A decade later, California gynecologist Arnold Kegel developed a simple air-pressure "biofeedback" device which, together with guidance from a physician, enabled a woman to learn how to strengthen her own pelvic muscles. Kegel never ever advocated doing these exercises without first learning to do them correctly with his device and professional guidance. (If you are interested in this fascinating man and his contributions to medicine, there are several interesting articles on his work in our technical section on Urinary Incontinence.)
When Dr. Kegel reported a "93%" cure rate, he was describing some 2,000 patients who used his biofeedback device on a thrice-daily basis under weekly physician supervision. Although there is considerable variation in programs, non-biofeedback Pelvic Muscle Exercises typically achieve significantly less success. Even with weekly professional supervision and "manual" biofeedback (from a nurse's educated finger) the results are typically only a 50-60% reduction in symptoms (accidents), with very few people actually cured. When the weekly professional supervision is not provided, the improvements in symptoms are even less.
To make matters worse, one recent study of older persons doing PME totally on their own found that a quarter of these people actually got worse, not better, as a result of doing the exercises without professional supervision. The authors recommended against the use of unsupervised PMEs.
Unsupervised exercise was often promoted by public health types as a cost-saving technique, which made some sense when the alternative was expensive surgery or expensive drugs. But the marginal benefits and inherent dangers no longer justify this policy. Thanks to the on-going educational efforts of continence advocate groups, most insurance companies now provide coverage for this serious, albeit not life threatening condition. This expanded coverage was enhanced by the considerable cost savings inherent in the new EMG biofeedback methods, compared with surgery or drugs.
Anyone interested in learning more about the issues discussed here is invited to visit
our technical sections, listed under the "Professional Needs" banner on our home page.
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© 1996 by John D. Perry
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