Urinary incontinence is called one of the giants of elderly care and is quite prevalent in old age. The other giants in the care of elderly (geriatric medicine) are: immobility or difficulty in walking, instability or unpredictable behavioural problems and impairment of memory or dementia.
These were called giants of elderly care by a physician named Issacs who practised medicine in England. When these giants were present, it was found to be very difficult to keep the elderly person at home and continue to look after him/her by the relatives. So, most of them had to be managed in the nursing homes.
Urine incontinence is common in children under the age of five years and in the elderly over 65 years. The incidence of urine incontinence is about 7% in men and 12% in women over 65 years
What is incontinence of urine?
Inappropriate urination at the wrong place at the wrong time with lack of control is called incontinence of urine. The associated stigma makes it difficult for the patients and carers to complain about it. This problem makes the patient feel embarrassed and isolated and reluctant to engage in activities, affecting their quality of life. This is of course the case only when the patient is aware that there is a problem.
How does the urinary
bladder work?
The bladder is the receptacle where urine is stored till it is evacuated. When the urine is filtered by the kidneys, it comes down the two tubes (one from each kidney) called the ureters, and is stored in the urinary bladder to be evacuated by the person at the appropriate time. Under normal conditions, passing urine is a voluntary act and is done with the help of the nerves which innervate the urinary bladder, and the intact brain and spinal cord.
The bladder is supplied with two sets of nerves. One set activates when the bladder fills up and informs the brain about the condition of the bladder. At the same time the bladder’s urinary outlet sphincter or the valve is kept closed. When the brain is functioning well it sends messages through the main nervous system to the other nervous system (which activates the urinary bladder contraction while urinary bladder outlet sphincter is relaxed) to pass the urine when an appropriate place is found. Here the other set of nerves helps to evacuate the bladder by contracting the bladder muscles while the urine outlet is open.
What are causes of urinary incontinence?
In children, continence is learned gradually when the brain becomes aware that the urinary bladder is full and stops reflex emptying. This takes a few years. Most children are dry by the age of five years.
In old age urinary incontinence is due mainly to non-neurological causes or neurological causes.
The non-neurological causes include:
- Faecal impaction
- Impaired mobility-not being able to get to the toilet in time
- Urinary tract infections
- Hormonal changes in women
- Enlarged prostate in men
- Psychiatric problems.
Neurological problems
These are problems associated with nerve supply to the bladder, brain and the spinal cord.
- Loss of memory and behavioural problems (dementia)
- Damage to the spinal cord will result in incontinence of urine, in trauma
- Brain injury- by tumours and strokes
What should be done for urinary incontinence?
The most important thing is to have a consultation with your family doctor. He will ask a detailed history which includes duration of the problem, difficulty of passing urine, any injury to your back, or problems with patient’s memory, and difficulties with bowel opening.
He may want to examine the patient and perform a few basic tests. If he needs you to be referred to a specialist, he will refer to him/her with a referral letter.
Therapeutic intervention obviously depends on the cause of incontinence.
- If there is an infection appropriate antibiotics is the answer.
- If there is fecal impaction, treatment must be taken to relieve this problems which maybe with oral medication or suppositories
- Incontinence caused by anatomical problems such as for instance prolapsed uterus etc may be treated initially by pelvic floor exercises to strengthen the muscle or by referral for surgical intervention.
- Prostate enlargement, causing incontinence should be referred to the appropriate specialist for management
- If the cause is a neurological injury such as spinal cord injury, the patient needs to be reviewed for long term management and advice given regarding self care and catheterization.
- If due to a stroke advice must be given to the patient and the family if the patient is unaware of the incontinence. In this instance the use of intermittent catheterization maybe considered. Long term catheters are available on the market.
If urinary incontinence is a problem don’t be embarrassed to seek help. Your family doctor can help you understand the problem and how to best manage the problem.
There is help available and guidance on how to best manage the problem, preserving dignity and enabling you to carry on with a good quality of life.
(The writer is a family doctor)
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