Incontinence describes the involuntary loss of urine from the bladder (urinary incontinence) or bowel motion, including faeces expulsion (faecal or bowel incontinence) (Continence Foundation of Australia, 2018). Its severity can range from mild to severe, from a small leak to a complete loss of bladder/bowel control, depending on the causes and the individual circumstances. Evidently, this disrupts normal life for patients, causing a variety of physical and psychological impacts.
More specifically, urinary incontinence, otherwise referred to as poor bladder control, is common and is usually associated with pregnancy, childbirth, menopause and a range of chronic conditions including asthma, arthritis and diabetes, yet may be prevalent in those that otherwise seem ‘healthy’ (Continence Foundation of Australia, 2018). There are four major types of urinary incontinence including; stress incontinence, urge incontinence, incontinence associated with chronic retention and functional incontinence (Continence Foundation of Australia, 2018). These are classified based on varying causes and symptoms, yet worldwide, urinary incontinence as an umbrella term affects 200 million people. It is estimated that approximately 17% of women and 16% of men over the age of 18 have an overactive bladder, with an approximately 12.2 million having urge incontinence (Urinary Incontinence in Women Statistics, 2018). Alongside this, it has been documented that women specifically, on average, wait 6.5 years from the first time they experience symptoms until they obtain a diagnosis (Urinary Incontinence in Women Statistics, 2018). This suggests that a large proportion of the world’s population are suffering from incontinence in silence and are not seeking medical advice. This may be due to embarrassment, lack of knowledge of the symptoms or misunderstanding of the condition. Regardless, it is important to provide education and advice to reduce this statistic.
Less common but still significant is bowel incontinence, with a prevalence of up to 12% (Wang, J.Y., Abbas, M.A., 2013) affecting men and women of all ages, with studies such as Whitehead, W.E et al 2013 suggesting the condition is more prevalent with increasing age, however. As with urinary incontinence, understanding the mechanisms of normal bowel movements is helpful in understanding the alterations that lead to incontinence. Urgency usually occurs when the faeces arrives in the rectum, causing strong contractions and anal relaxation (The IBS Network, n.d). The mechanisms behind this incontinence shall be discussed in further detail throughout the guide.
This guide aims to provide a comprehensive view into urge incontinence, the symptoms, medical advice and treatment and management plans in hope of providing an educational aid to assist in informing potential incontinence sufferers.
What Is Urge Incontinence?
Urge incontinence is described as the inability to sufficiently control your bladder or bowels, usually requiring a rush to the toilet. This condition can occur for the bladder, for the bowels, or for both, causing single or double incontinence. The condition usually has a range of causes, some of which are poorly understood or unknown, yet there are sufficient treatment and management plans that can assist with the prohibition of incontinence.
Urinary Urge Incontinence
According to the International Urogynecological Association (IUGA) and the International Continence Society (ICS) standard definition, urgency incontinence, otherwise commonly known as an overactive bladder, is the complaint of urine leakage associated with a sudden persuasive desire to void that is difficult to defer (Haylen, B.T et al, 2013). Chronic incontinence usually involves the bladder more directly, whereby the detrusor muscle malfunctions (Vogel, S.L., 2001). Thereby, urge urinary incontinence is the depletion of the normal functioning of the bladder, whereby it contracts prematurely, or fails to contract at all which causes bladder enlargement. Hence, this causes the premature release of urine, or the release when not expected. As a result, the person may leak urine in a small amount, or show signs of complete incontinence whereby the entire bladder empties.
The causes of urinary urge incontinence are poorly understood, but urgency can be worsened by bladder irritation from cystitis, atrophic tissue due to hormone depletion, or bladder tumors or stones (Vogel, S.L., 2001). Further, disturbances in nerves, smooth muscle, and urothelium have been described to cause this condition (Steers, W.D., 2002).
Bowel Urge Incontinence
For bowel incontinence, the situation is similar, yet described for faeces. In normal patients, urgency usually occurs when the faeces arrives in the rectum, causing strong contractions and anal relaxation (The IBS Network, n.d). In that situation specifically, continence can only be maintained by conscious contraction of the external anal sphincter (The IBS Network, n.d). In those susceptible to incontinence, this muscular contraction and relaxation process is absent or damaged. Thereby, this urgency is most common in patients with irritable bowels (IBS), as the rectum is more sensitive to distension and in those with a weak sphincter.
In more mechanistic detail, the anal sphincter complex involves two muscles; the internal and external sphincter (Wang, J.Y., Abbas, M.A., 2013). The internal sphincter consists of circular muscles of the rectal wall and is under autonomic nervous system control, meaning this system is not consciously controlled (Wang, J.Y., Abbas, M.A., 2013). The external sphincter muscle is a continuation of the pelvic floor and is under the control of the voluntary nervous system, meaning we can consciously control this (Wang, J.Y., Abbas, M.A., 2013). During normal defecation, the stool enters the rectum and the internal sphincter is relaxed as a result. As the stool enters the anal canal, the external sphincter is voluntarily contracted. The stool can be stored in the rectum until the stretching of the rectum allows the passing of the stool. However, this normal function is diminished in those suffering from incontinence and as a result, stools are passed prematurely, or without warning.
Once again, the causes are less well known, yet majorly the weakening of the sphincter which leads to bowel urge incontinence is due to damage of to the pelvic floor sustained during childbirth. Faecal incontinence may also occur after spinal injury, stroke, in Multiple Sclerosis and in long-term diabetes. Sometimes, it may be as simple as your diet that requires changing to prevent incontinence (The IBS Network, n.d).
What Are the Symptoms of Urge Incontinence?
As with the causes of urge incontinence, symptoms offer differ from person to person. Some may experience small leakages with minor problems, yet others may display full incontinence with complete loss of control of their bladder or bowels (Age UK, 2017).
Symptoms of urge urinary incontinence
The symptoms vary in degree and type between individuals. However, the following symptoms are generally the most common:
- Sudden urge to urinate followed by an involuntary loss of urine.
- Need to urinate often, including throughout the night.
- Feeling that the bladder doesn’t empty completely.
Symptoms of urge bowel incontinence
The symptoms vary in degree and type between individuals. However, the following symptoms are generally the most common:
- Leaking from the bowel.
- Urgent need to open bowels followed by an involuntary loss of faeces.
When Should You Seek Medical Advice?
Incontinence is usually a challenging condition to cope with, but treatment is highly effective, and a cure is often possible. Identifying incontinence is the most important step in the treatment and management programme, therefore any individual displaying any symptoms of urge incontinence should seek medical guidance. This is especially important if the condition is impeding on your daily life or suggests the prevalence of another disease.
Clinicians are able to investigate the cause of incontinence on an individual basis, as there are usually many possible reasons why people become incontinent. It is important to remember that primary care physicians are proficient in conducting medical histories, examinations and providing treatment advice (Vogel, S.L., 2001). These steps can improve the quality of life of incontinent adults. Further, they are able to refer complex cases to specialists, which allows the reconfirmation of the medical history, further examinations, urinalysis and a treatment decision. They are able to recommend medications or dosages, and with consistent reassessment, they are able to change dosages over time. This specialised and tailored treatment plan can aid in the management of the condition, hence improving the quality of life of the patients. Usually treatments are varied and depend on your unique symptoms and condition, meaning each person has a slightly different treatment plan.
Further to this, if you have a serious case of urge incontinence, seeking medical guidance is extremely important as your symptoms could be signalling secondary diseases such as:
- Bladder infections
- Kidney or bladder stones
These diseases may be coupled with other symptoms including burning or pain with urination, pain in the pelvic region and prolonged symptoms (Healthline, 2005).
How to Treat/Manage Urge Incontinence?
There are varied treatment and management options, usually varying on a case-by-case basis. Although there is a plethora of treatment options, conservative management techniques are usually the first-line option for most patients. This is because urge incontinence is usually not a progressive or chronic condition, and therefore conservative therapies can be effective and safe and are usually preferred by patients as an initial approach (Faiena, I., et al, 2005). If these conservative therapies are not effective, surgical intervention can take place. One of the recommendations of the 1992 Agency for Health Care Policy and Research guideline states that “surgery, except in very specific cases, should be considered only after behavioural and pharmacologic interventions have been tried.” (Faiena, I., et al, 2005).
Conservative Behavioural Treatment
Behavioural treatment can be practised on your own without the requirement of medical assistance, however guidance can be provided from medical professionals. It usually involves some lifestyle changes and learning when your bladder is overactive and contracting abnormally so that you are able to act to avoid leakage (WebMD, 2005). The ultimate goal is to have comfortable intervals between voids with continence.
Biofeedback is a type of conservative behavioural treatment and is the practise that helps individuals learn how the body behaves and such can work out when it isn’t functioning properly. It can help recognise when it the bladder or bowels is overactive. Two techniques include timed voiding and bladder training. Timed voiding involves using a chart to record the times that you pass urine/faeces and also when you leak involuntarily. This technique works by understanding your leakage patterns, therefore avoiding leakage in future by visiting the bathroom at those times. With bladder training, the intervals which you go to the bathroom are elongated, waiting a little longer before each time. You follow a certain pattern, for example, every hour for a prolonged period of time. This interval is then increased, such that the interval is increased by up to four hours in the long term. This can aid in training the bladder and ‘teaching’ it when to pass urine, restoring normal bladder activity (Faiena, I., et al, 2005).
Pelvic floor exercises can help strengthen the muscles that support the bladder, uterus and bowels. Strengthening these muscles can aid in reducing or preventing problems such as urine or faeces incontinence. To practice these exercises, you pretend you are trying to stop the flow of urine or preventing the release of gas, causing the contraction of the pelvic floor muscles. Usually it is recommended that these should be done every day, roughly five times each day. These exercises can improve your ability to hold urine until you get to a bathroom, avoiding accidental leakage (NHS, 2017).
If behavioural therapies are not an effective treatment for urge incontinence, your medical professional may prescribe medication called antimuscarinics. They are often used in primary care in combination with behavioural and lifestyle changes (McDonnell, B. and Birder, L.A., 2017). There are many subtypes of this medication, but common types include oxybutynin, tolterodine and darifenacin. Usually, patients are prescribed at a low dose to avoid any possible side effects, and doses can be increased until the medication proves effective. Reassessment occurs after approximately 4 weeks, and then every 6 to 12 months thereafter if the medication continues to help (NHS, 2017).
Mirabegron is an alternative medication if antimuscarinics are unsuitable, ineffective or if they cause unpleasant side effects. This treatment usually causes the bladder muscle to relax, which helps with the filling up of the bladder and storage of urine. Studies have shown that this drug causes improved bladder compliance, increased bladder capacity, reduced urinary frequency, and reduced incontinence (McDonnell, B. and Birder, L.A., 2017).
Whilst incontinence products are not a treatment for urge incontinence, they can offer useful management for the condition. They can aid with the continuation of normal life and products may include:
- Absorbent products such as incontinence pads or pants.
- Handheld urinals.
- Catheter which can be inserted into your bladder to drain urine.
Specialised products can be purchased and used to mitigate the negative effects of incontinence. Absorbent products often come in a wide range of shapes, designs and styles, suiting those with mild to severe incontinence. Further to this, wash lotion, cleansing foam, cleansing tissues and other skin care products can be used to keep the skin sanitary and protected. Private specialists, such as HARTMANN Direct provide a personal, discreet service, supplying high quality incontinence products
Occasionally, usually in more severe cases, behavioural therapies and medications do not directly work in preventing urge incontinence. Therefore, more invasive treatments are required to prevent the condition. These treatments should be discussed in detail with a specialist, providing an outline of the benefits and risks associated with the treatment. Other options include (NHS, 2017 and WebMD 2005):
- Botulinum toxin A (Botox) injection into the bladder, increasing its storage capacity and reducing leakage episodes.
- Hormone therapies for women, using oestrogen alone or in combination with progesterone
- Sacral nerve stimulation which delivers an electrical signal which controls the amount of abnormal contractions.
- Surgical procedures:
- Augmentation cytoplasty involves making your bladder bigger by adding a section of intestinal tissue to the bladder wall. This is usually accompanied by the use of a catheter.
- Urinary diversion involves redirecting the ureters (from the kidney to the bladder) to outside of your body, bypassing the bladder.
How to Avoid Urge Incontinence?
Incontinence isn’t always preventable, however in cases of acute incontinence your risk can be decreased by (WebMD, 2005 and MayoClinic, n.d):
- Maintaining a healthy weight.
- Dietary changes such as avoiding irritants like caffeine, alcohol and acidic foods.
- Changing when you eat as timing of meals may help reduce the possibility of anal leakage.
- Strengthening pelvic and sphincter muscles through practicing pelvic floor exercises.
- Do not smoke or seek advice for stopping.
- Bladder and bowel training – emptying at a specific time every day.
- Not drinking fluids right before you go to bed.
- Go to the bathroom on a regular basis, especially before physical activity.
Urge incontinence affects between 12-17% of individuals worldwide incontinence (Urinary Incontinence in Women Statistics, 2018), showing that this condition requires combatting. As an easily treatable and manageable condition, it is suggested that individuals suffering from any symptoms presented within this guide should seek specialist medical guidance. From there, the medical professionals will be able to offer personalised treatment programmes and solutions for management of the condition. As such, this will improve the quality of life of many of those suffering from incontinence.
Treatment varying from behavioural therapies, medication and surgical intervention can aid in curing urge incontinence, yet there are products that can aid with the management of the condition before it is cured. These products include personal pads and pants, specialist bedsheets and skincare products provided by https://www.hartmanndirect.co.uk/. These products are highly effective in aiding the restoration to normal life and they can mitigate any negative effects of incontinence.
Overall, although the condition is sensitive and therefore may be embarrassing to discuss, as an increasing problem that can affect all age groups and can have a severe impact on both the healthcare system and a patients’ quality of life, its important to seek medical guidance to mitigate any negative effects of the condition.
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