Helping women manage urinary incontinence

Advances in Skin & Wound Care,  Nov/Dec 2000  by Bates, patricia McCallig

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For some women, maintaining bladder control is a daily struggle. Unfortunately, embarrassment, denial, and misinformation keep many of them from seeking the help they need. Some may believe urinary leakage is a natural part of life, a consequence of having children or growing old. Others may attribute it to "weak kidneys."

Whatever the reason, most women are unwilling to talk openly about urinary incontinence. Instead, they quietly rearrange their lives and relationships, preferring to endure in silence rather than to admit they have a problem.

If they would only share their secret, they would learn that they are not alone. Urinary incontinence is so common that half of all women in the United States will experience it at some point in their lifetime. It affects women of all ages, socioeconomic backgrounds, and ethnicities.

The good news for these women is that urinary incontinence is treatable, often with simple behavioral modifications. The key is to create an atmosphere in which women will feel safe admitting that they are incontinent so that they can finally find some relief from the leakage episodes that adversely affect their lives (see Sharing the Secret).

Anatomy of a Problem

Urination is a complex process, involving a coordinated effort by the urinary structures, the brain, and the spinal cord. Although only a simplified explanation is given here, it provides a basic understanding of how these structures work together to maintain bladder control.

Detrusor muscles give tone to the bladder. They relax as the bladder fills with urine and contract during urination. The bladder neck, which joins the bladder and the urethra, is surrounded by smooth muscle that acts like a switch to either hold urine in the bladder or let it flow into the urethra. The urethra, surrounded by both smooth and striated muscle, allows urine to leave the body.

When the bladder fills, a signal is sent from the bladder to the brain via the spinal cord to initiate the urge to urinate. If urinating is not convenient, a message is sent back to the bladder to diminish the urge to urinate by increasing contraction of the sphincter and relaxing the bladder. The sphincter is a unit that combines smooth muscles from the bladder neck and urethra and striated muscles from around the urethra. When it becomes convenient to urinate, another message is sent for the sphincter to open and the bladder to contract. These actions must coordinate for successful urination.

Women are more likely to have bladder control problems than men because of their anatomy. In women, the bladder, bladder neck, and urethra are partially supported by the vagina and the striated muscles of the pelvic floor. Muscle tone weakens with childbirth, age, and significant weight gain. Changes in muscle support will allow the bladder and urethra to shift and can affect continence.

In addition, a woman's urethra is shorter, approximately 3 to 5 cm, compared with about 23 cm for a man's urethra. Therefore, men have a longer area of urethral compression to resist bladder pressure when the bladder wants to contract.

A woman's urethra is not normally a rigid, pipelike tunnel; it has suppleness. The walls of the urethra normally cushion together (coapt), adding to the urethra's ability to compress. This is directly related to estrogen's effects. As estrogen levels decrease, the urethra loses its ability to compress. Urethral blood supply, tone, and suppleness are decreased and the urethra then becomes more rigid and pipelike.

Types of Incontinence

Urinary incontinence can be transient or chronic. Transient incontinence is generally related to an acute illness or an infection; it will disappear when the trigger resolves. Chronic incontinence is ongoing.

The type of incontinence a patient has will determine the most appropriate treatment option. There are 5 primary types of incontinence:

* stress incontinence. The result of weak sphincter or pelvic muscles, stress incontinence involves urine leakage with physical activity, laughing, or coughing.

* urge incontinence. Also called instability incontinence or overactive bladder, urge incontinence occurs when the detrusor muscles of the bladder contract involuntarily. There is little time between feeling the need to urinate and leakage of urine.

* mixed incontinence. Features of stress and urge incontinence can occur together. This is the most common type of urinary incontinence.

* overflow incontinence. Leakage of urine between trips to the bathroom may occur if the bladder does not completely empty. This may be the result of neurologic changes, such as those caused by diabetes, or when the urethra is narrowed or blocked (ie, scar tissue).

* functional incontinence. If cognition, mobility, or dexterity is impaired, the woman may be unable to get to the bathroom in time.

Evaluating Incontinence

Subjective descriptions of a woman's incontinence problem and her symptoms are a valuable part of the patient evaluation. The patient can be her own detective by completing a questionnaire and a 2- or 3-day voiding diary. She should observe for incidents that relate to the occurrence of urinary leakage. Ask her to make a list of the prescription and over-the-counter medications she takes and to write down medical conditions or previous treatments that could directly affect urinary continence, especially childbirth, surgeries, or radiation therapy. If she uses absorbency products, have her note what kind of pads she uses, how many she uses each day, and the amount of wetness. Pad use can be marked down on the voiding diary.