There is nothing unusual when you find yourself in a situation where an elderly person in the family needs help because she cannot get to the toilet in time and passes urine without her knowledge. She is facing an issue of urinary incontinence, seen in around 30 percent of people aged over 60 years and more common in women. Many elders feel embarrassed or awkward when they have this condition, but as a loved one, you need to discuss this issue with them very sensitively, assuring them that incontinence is almost always treatable especially with behavioral techniques like bladder training.
About Urinary Incontinence
Urinary incontinence occurs when there is loss of urinary bladder control, and urine leaks, drips or rushes out depending on the type of incontinence. In elderly people, this condition arises due to aging of the bladder muscle with a reduction in its capacity to store the urine, and an increase in overactive bladder symptoms.
Once women attain menopause, lower levels of the estrogen hormone may lead to urinary incontinence. Other factors that cause long-term incontinence include:
- Nerve damage (multiple sclerosis or Parkinson’s disease)
- Brain and spinal cord disorders (stroke)
- Diabetes
With aging, the ability to postpone urination after feeling the need to urinate decreases and the amount of residual urine (urine left in the bladder post urination) increases. In men, the rate of urine flow through the bladder and urethra decreases, especially when there is an enlarged prostate gland, seen commonly with age.
Types of Urinary Incontinence
Different types of urinary incontinence are seen:
Stress incontinence happens when some pressure comes on the bladder (during exercise, laughing, sneezing or lifting heavy objects) causing urine to leak. This is common in menopausal and younger women.
Urge incontinence happens when there is a sudden need to urinate but cannot hold the urine to get to the toilet in time. This is common in people with diabetes, multiple sclerosis, stroke, Alzheimer’s or Parkinson’s disease.
Overflow incontinence happens when the bladder is always full, small amounts of urine may leak out. This may be seen in individuals with conditions like enlarged prostate, diabetes or spinal cord injury.
Functional incontinence is seen when aged people having normal bladder control cannot get to the toilet in time, due to inability or unwillingness (arthritis, dementia).
Mixed incontinence involves more than one type of incontinence, commonly seen in older women (mixture of stress and urge incontinence). Aged people also tend to develop a mixture of urge and functional incontinence.
Diagnosis
A physical examination with detailed history and symptoms will be carried out. The doctor might ask to keep a bladder diary, for recording fluid intake, time of urination, quantity of urine produced and the number of incontinence episodes for at least 3 days. A sample of urine for analysis might be taken to detect any infection, and a blood test to determine other factors causing incontinence is done. Other specialized tests for diagnosis include postvoid residual measurement (PVR) to check the amount of residual urine, pelvic ultrasound, stress test, urodynamic testing (to measure bladder and sphincter strength), cystogram (X-ray of the bladder) and cystoscopy.
Management and treatment
Urinary incontinence can be best treated by using behavioral methods, which are safe, easy, effective and at the same time inexpensive. These include:
- Bladder training (or bladder retraining) – mainly used to treat urge incontinence
- Timed voiding (or habit training) – mainly used to treat functional incontinence
- Prompted voiding – mainly used to treat functional incontinence
Timed voiding sets a schedule for urinating, determined by personal habits. Prompted voiding is done with the help of a caregiver by reminding the individual to urinate periodically.
In most cases these behavioral methods, along with a few lifestyle changes are successful in treating or decreasing urinary incontinence.
Along with behavioral therapy, certain changes need to be implemented on a daily basis. Manage fluid and diet intake by drinking as per the body’s thirst requirements. Avoid drinking large amounts of fluid at one time and cut down on acidic food. Reduce the intake of caffeine, artificial sweeteners and citrus juices as they contain chemicals that act as bladder irritants. Losing weight might also help by relieving some pressure off the bladder. Pelvic floor muscles that weaken with increasing age can be strengthened with Kegel exercises. This will improve bladder control and prevent urine leakage.
Bladder Training
Bladder training or retraining is one such technique that restores the normal functioning of an otherwise overactive bladder. The goal here is to:
- Reduce the frequency of visits to the toilet
- Increase the quantity of urine passed out each time
- Postpone emptying the bladder or hold on for longer
The following basic steps must be practiced:
- Find out the pattern of urination with the help of a bladder diary
- Extend the interval between each bathroom visit by 15 minutes; if a bathroom visit is required every one hour, extend the subsequent visit to one hour and 15 minutes.
- Once a schedule has been made, stick to it for best results.
- Try to lengthen the intervals between every bathroom visit slowly, till the desired goal is reached.
A typical day for bladder training is as follows:
Empty the bladder first thing in the morning, then visit the bathroom only at the next scheduled time. The bladder must be voided even if there is no urge to urinate. This pattern must be followed throughout the day, while at night, visit the bathroom if awake and required. If there is any urge to urinate before the stipulated time, then ‘urge suppression’ techniques or ‘relaxation’ techniques should be used such as:
- Breathing slowly and evenly
- Do not rush to the toilet
- Apply perineal or vaginal pressure (cross legs or sit on a rolled towel)
- Curl the toes or hold them firmly
- Stretch the calf muscles and hold the stretch
- If walking, slow down and try heel-toe walking
- Press or rub the trigger point on the inside of the leg, above ankle
- Press or rub the trigger point at the base of the nose
- Exercise the pelvic floor muscles by squeezing and lifting, hold tight
- Distract oneself by not thinking about the toilet or leaking (try a mental task like counting backwards or a physical task)
Once a particular technique has been applied, visit the toilet in a slow and controlled manner. Do remember that a person’s bladder cannot see or sense how far away the toilet is, and it is one’s own anxiety that one may leak. So, stay calm and relaxed, and with practice it can be determined which bladder-training techniques are most suitable. Never be disheartened by setbacks, as there will be good days and bad days. Around 6 to 12 weeks might be required to achieve this goal.
Outlook
Bladder training and other behavioral methods are often more effective and safer than medication, surgery, or using devices to manage incontinence. To help our loved ones overcome this condition have a dedicated caregiver or family member who is motivated and committed. It’s crucial to let elderly individuals know that incontinence is a common issue that can be resolved with the right guidance and support.
