TECHNIQUES FOR IMPROVING URGENCY INCONTINENCE
The passage of urine is caused by the bladder muscle squeezing coordinated with the sphincter muscles relaxing. Under normal circumstances, the bladder muscle does not squeeze until it becomes convenient to do so, because the brain is able to inhibit and control the bladder reflex. When the ability of the brain to control the bladder reflex is lost or diminished, the bladder can squeeze at any time without warning, giving rise to the symptoms of urgency, frequency, precipitancy, urgency incontinence, and sometimes incontinence without any associated urge.
Adult urgency incontinence is a very similar situation to the normal urinary pattern of infants before they are toilet trained. Infants urinate in reflex fashion. Reflex refers to contraction of muscles without involvement of the central nervous system. For example, the knee-jerk reflex occurs when the knee tendon is tapped, sensory nerves convey sensory input to the spinal cord, and motor nerves convey motor input to the thigh muscle resulting in extension of the knee. Similarly, pre-toilet training reflex voiding occurs in the following fashion: as the bladder fills, the sensory nerves convey filling information to the spinal cord and the motor nerves from the spinal cord initiate a bladder contraction. As the neurological system develops, this spinal cord reflex is controlled and modulated by the central nervous system, resulting in the achievement of urinary continence. Urgency incontinence is essentially a return to this infantile state of voiding. In most people, it occurs in the absence of any underlying neurological problem and is referred to as bladder over-activity. When due to a neurological problem such as a spinal cord injury, multiple sclerosis, stroke, etc., it is referred to as neurogenic bladder over-activity.
Urgency incontinence (the sudden urge to urinate with an inability to get to the toilet in time to prevent leakage) is the most common type of incontinence in the elderly population. However, it can occur at any age, even in childhood where it is referred to as pediatric bladder over-activity. Urgency incontinence can be defined as a "bladder that squeezes without its owner’s permission". It can be triggered by hand-washing, rising from sitting, running water, entering the shower, cold or rainy weather, and getting closer and closer to a bathroom, particularly when one places the key in the door to their home.
Behavioral treatments are based on the idea that the patient can be educated about the condition and develop strategies to minimize or eliminate the problem. The goal of the following behavioral techniques is to re-establish control of the bladder. Providing that the following recommendations are carried out with diligence and determination, the results can be extremely satisfactory with improvement—if not cure—of the incontinence. Having a positive attitude is a prerequisite for this form of treatment.
1. FLUID MODERATION
Bladder over-activity often will not occur until a "critical" urinary volume is reached, and by moderating fluid intake, it will take a longer time to achieve this critical volume. Try to sensibly restrict your fluid intake. This will not always be possible, but a moderate fluid intake will always decrease the volume of urinary output. By the same token, overdoing fluid restriction can result in super-concentrated urine that can be an irritant to the urinary tract. Caffeine and alcohol increase urinary output and are urinary irritants, so it is best to limit intake of these beverages. Caffeine is present in relatively high concentrations in tea, coffee, cola and chocolate. Additionally, many foods—pparticularly fruits and vegetables—have hidden water content, so moderation applies best here as well. It is important to try to consume most of your fluid intake before 7:00 PM to improve nocturnal frequency.
Taking a diuretic medication (water pill) may be contributing to your symptoms. It may be worthwhile checking with your medical doctor to see if it is conceivable to change to an alternative, non-diuretic medication. This will not always be possible, but if so, may substantially improve your symptoms.
2. TIMED VOIDING
Urinating by the "clock" and not by your own sense of urgency will keep your bladder as empty as possible. By emptying the bladder before the critical volume (at which urgency incontinence occurs) is reached, the incontinence can be controlled. Voiding on a two-hour basis is usually effective, although the specific timetable has to be tailored to the individual. Such "preemptive" or "defensive" voiding has been proven a very useful technique since purposeful urinary frequency is more desirable than incontinence. Eventually, a gradual increase in fixed interval voiding to a socially acceptable 3-4 hours is possible.
3. BOWEL MANAGEMENT
Avoidance of constipation is an important means of helping control bladder over-activity. Because of the anatomical proximity of the rectum and the bladder, a rectum that is full of stool can put unwanted pressure on the urinary bladder resulting in worsening of urgency, frequency and incontinence.
4. PELVIC FLOOR MUSCLE EXERCISE
The pelvic floor muscle (PFM), present in both men and women, is a muscle that provides support to the bladder, vagina, and rectum. Increasing PFM strength and tone is one of the most effective and natural remedies of combating urgency and incontinence, both urgency and stress types.
You must first become aware of the presence, location, and nature of this muscle and then exercise it to increase its strength and tone. This is not the muscle of the abdominal wall, thighs or buttocks. A simple means of recognizing the PFM for a woman is to insert a finger inside your vagina and squeeze the PFM until the vagina tightens around your finger. A simple means of identifying the PFM for either gender is to start urinating and when about half completed, to abruptly stop the stream. Once you are fully aware of the location and nature of this muscle, you can then exercise it anywhere and at any time. These exercises can be done in various positions such as lying down, sitting, or standing and can be integrated into your daily activities. "Down times", such as sitting in your car at a red light or waiting in line at the market checkout are convenient times to exercise your PFM.
For maximum benefit, three sets of these exercises should be done over the course of the day. During each set, 25 repetitions should be performed. For several seconds this muscle should be squeezed, and then for several seconds relaxed. After completion of 25 repetitions of alternating "squeeze, relax" etc., the set is completed. Gradually, the strength and tone of the PFM will increase. Given the potential success of these exercises, they are well worth your effort. You may notice some soreness in the pelvic floor muscles once you start exercising regularly. Do not worry about this—it is only soreness associated with increased muscle activity. The benefits of these exercises will continue only as long as you do them. "Use it or lose it" applies here. As in any muscle-conditioning program, it may take 6 to 12 weeks of exercising before you notice an improvement in urinary control.
It is important to recognize the specific triggers that induce your urgency or incontinence: hand washing, key in the door, rising from sitting, running water, entering the shower, cold or rainy weather, etc. Please pay careful attention to these and other activities and events that previously have resulted in incontinence. Defensive urge control methods need to be employed prior to exposure to a trigger or at the time of the perceived urgency—specifically, rhythmic PFM exercises—"snapping" the pelvic floor muscles several times to try to preempt the bladder contraction before it may occur or diminishing or aborting the bladder contraction after it begins. Thus, by actively squeezing the PFM just before and during these activities, the urgency can be diminished and the urgency incontinence can often be avoided. At the initial sensation of urgency, instead of running to find a toilet, several vigorous and rhythmic snaps of the PFM should be performed. Such vigorous squeezes can often preemptively abolish an unwanted bladder contraction and thus eliminate or decrease the sense of urgency and the ensuing incontinence.
Desensitization exercises can be very useful—after emptying the bladder, expose yourself to the trigger, and use the aforementioned tactics to try to "blunt" your typical conditioned response to the specific trigger.
5. BLADDER RELAXANT MEDICATION
There are a variety of medications that are useful to suppress bladder overactivity. It may take several trials of different medications or combinations of medications to achieve optimal results. The newest medications include the following: Tolterodine (Detrol LA), Oxybutynin (Ditropan XL), Transdermal Oxybutynin (Oxytrol patch), Trospium (Sanctura), Solifenacin (Vesicare), and Darifenacin (Enablex). The most common side effects are dry mouth and constipation. These medications cannot be used in the presence of urinary or gastric retention or uncontrolled narrow-angle glaucoma.
6. WEIGHTED VAGINAL CONES
Weighted vaginal cones are an adjunct to PFM exercise for women using a set of cones that are of identical shape and volume but of increasing weight. You insert the weighted cone into the vagina like a tampon and attempt to retain it for 15 minutes twice daily while walking. As the PFM becomes stronger, the heavier cones can be used.
Biofeedback is an adjunct to PFM exercise in which electronic instrumentation is used to relay auditory and visual feedback information about your PFM contractions. This can enhance your awareness and strength of the PFM. Biofeedback can be obtained at the physical therapy department under the guidance of a physical therapist.
8. INTERSTIM THERAPY -–SACRAL NERVE STIMULATION
Neuromodulation is a novel technique used when bladder over-activity does not respond to conservative therapy. It uses mild electrical pulses to stimulate and modulate your sacral nerves. Stimulating the nerves may relieve the symptoms of urgency incontinence as well as urgency/frequency. A neurostimulator provides the mild electrical pulses, very similar to a pacemaker for the heart. A small lead, or thin wire, carries the pulses to stimulate the selected sacral nerves.
9. BOTOX TREATMENT
As of the time of this writing, this is considered to be an investigational technique that is not approved by the FDA. This formulation, when injected directly into the bladder of patients with overactive bladder, can help reduce symptoms by "paralyzing" those areas of the bladder into which it is injected. Because of the investigational status, insurance companies do currently not reimburse this, and the formulation is very costly.
Andrew L. Siegel, M.D.
255 W. Spring Valley Ave.