Incontinence is the involuntary release of urine from the bladder (referred to as urinary incontinence) or stool from rectum (referred to as faecal incontinence). Incontinence is frequently linked to ageing, childbirth, and menopause. Although it is more common among older people, it is by no means a normal component of the ageing process. Incontinence can have a significant impact on a patient’s quality of life. Depression, feelings of humiliation, loss of self-confidence, lower perceived sense of wellness, social isolation, sexual dysfunction, and financial issues are all psychosocial repercussions of incontinence (due to the cost of pads, bedding, laundry, and reduced ability to work). Sleep loss is common, as are falls and fractures in elderly patients (due to rushing to the bathroom).

Depression, feelings of humiliation, loss of self-confidence, lower perceived sense of wellness, social isolation, sexual dysfunction, and financial issues are all psychosocial repercussions of incontinence [Image: Shutterstock].

Incontinence can develop because of heart failure, stroke, multiple sclerosis, diabetes, trauma, surgery, or as a side effect of some medications, such as loop diuretics. Urinary incontinence affects around 10% of adults at some time in their lives, and the incidence increases with age. Females are six times as likely than males to have incontinence, although it is more frequent in the elderly, affecting roughly 30% of older women and 15% of older men.

As a result, incontinence is frequently thought to be a female-only problem. Nonetheless, incontinence is also common in certain groups of men, such as those who have undergone prostate surgery. Since incontinence is a symptom of a multitude of different conditions, it is important to understand these conditions first.

  • Pregnancy and childbirth: Hormonal changes and increased strain on the bladder from the uterus during pregnancy can cause incontinence. The problem can be further amplified by pregnancy’s interference with the way the urethra relaxes and contracts. Incontinence issues may persist after pregnancy because childbirth weakens the pelvic floor muscles, which can lead to an overactive bladder.
  • Menopause: Menopause weakens the pelvic floor weakens and can even contribute to the development of prolapse. The bladder also becomes more elastic, causing the bladder muscles to become irritated and leading to overactive urinary or faecal release.
  • Prostate problems: In men over the age of 45, benign prostatic hyperplasia could lead to incontinence. Stress incontinence and urge incontinence could both be associated with the onset of prostate cancer but is most often caused by medications used to treat treatment of this
  • Obesity: Urinary incontinence is closely linked to obesity and being overweight. Obesity is the most important risk factor for daily urinary incontinence and is an independent risk factor for stress and mixed urinary incontinence. It has also been shown that weight loss reduces the frequency of incontinence episodes.

 

TYPES OF INCONTINENCE

It is also useful to understand the subcategories of incontinence. The involuntary leakage of urine caused by an increase in intra-abdominal pressure caused by activities such as coughing, laughing, or exercising is known as stress incontinence. Urge incontinence is characterised by involuntary urine leakage preceded by a strong urge to void, regardless of whether the bladder is full or not.

Urine loss induced by bladder overdistension is known as overflow incontinence. Patients may experience dribbling on a regular basis. An underactive detrusor muscle and/or outlet obstruction are the most common causes of bladder overdistension.

Functional incontinence is defined as urinary incontinence induced by a prolonged impairment of physical or cognitive function, or both. These patients typically have trouble getting to the bathroom in time. Mixed incontinence is a combination of urge and stress incontinence, which is due to a weakened pelvic floor or other health issues.

 

MAKING A DIAGNOSIS

A history, physical examination, and a few simple laboratory tests can be used to make a preliminary diagnosis of incontinence. These results may be used to guide initial treatment. If there are comorbidities present, or if initial therapies have failed, further testing is called for. To determine the possible causes of incontinence, it is essential to conduct a thorough patient history. The focus of the patient’s history and examination should be on determining the type, underlying causes, severity, and impact of their incontinence.

Because certain drugs cause or contribute to incontinence, it’s critical to know what medications a person is taking. Female patients should be asked how many and what kinds of births they have had. Previous pelvic and abdominal surgery, particularly prostate surgery in males, should be askedinquired about. The physical examination can assist doctors in determining the root of the problem.

Doctors must assess leg strength, sensation, and reflexes, as well as sensation around the genitals and anus, to look for nerve and muscle abnormalities that might make it difficult for the patient to stay seated. It is also important to perform a pelvic examination on women to look for abnormalities that might lead to incontinence, such as vaginal atrophy prompted by menopause.

It’s also a good idea to have patients keep track of their incontinence episodes, either through a ‘voiding diary’ or by other means. These records are a semi-objective way of measuring characteristics like incontinence frequency. They also assist clinicians in quantifying urodynamic variables such as voided volume and total urine volume throughout a 24-hour or nocturnal timeframe.

 

TREATMENT OPTIONS

Most cases of incontinence can be significantly improved. Treatment initially focuses on behavioural therapies such as pelvic floor muscle exercises and bladder training, as well as lifestyle changes. These should be considered the go-to treatments in mild cases. Depending on the type of incontinence, pharmaceutical treatments can be used if behavioural therapies are ineffective.

If conservative treatments fail, surgical options are available for some types of urinary incontinence, notably stress incontinence. The prognosis for persons suffering from urine incontinence is determined by the type of incontinence, its severity, the underlying cause(s), any contributing variables, and the patient’s motivation for seeking treatment.

Non-pharmacological interventions

Exercises to strengthen the pelvic floor muscles are an effective therapy for stress incontinence. Females who participate in these activities are more likely to report a cure or improvement, a higher quality of life, fewer daily leakage episodes, and less urine leakage. A pelvic floor strengthening programme should last at least three months, be tailored to the patient, and include instruction on proper technique as well as a home exercise regimen.

The patient’s pelvic floor muscle tone and the regimen’s impact on incontinence should be reviewed after twelve weeks of exercises. Any patient who benefits from the exercises should be encouraged to do them two to four times per week. Patients can also be urged to work on bladder control. Bladder training is a technique in which a person is forced to adhere to a strict urination schedule while awake.

In bladder training, patients must establish a urination routine of every 2 to 3 hours and control the need to urinate at other times (for example, by relaxing and breathing deeply). The interval is gradually prolonged as the person’s ability to suppress the need to urinate improves. People who care for someone with dementia or other cognitive issues might utilise a similar procedure called prompted voiding. At regular intervals, the person is questioned if they need to urinate and if they are wet or dry.

Surgical interventions

Surgical procedures performed by a urologist, urogynaecologist or gynaecologist are an extreme intervention but are justified in some cases. Surgery is risky, and complications such as damage to the bladder or other pelvic organs, problems caused by the mesh tape used in surgery, infection, and problems related to anaesthesia are all dangers associated with surgical intervention.

To increase bladder outlet resistance, surgical methods of treating urinary incontinence often aim to lift and support the urethro-vesical junction between the urethra and the bladder.  However, there is dispute over the exact mechanism by which continence is acquired following surgery. Co-existing conditions, a surgeon’s specialty and preference, and the physical characteristics of the patient impacted all influence the choice of surgical procedure.

Every surgical and medical procedure has various side effects, such as increased voiding frequency and urge incontinence. Mid-urethral slings, in which a mesh tape is put beneath the urethra by two to three tiny incisions to support the urethra and augment the patient’s pelvic floor muscles, is a surgical procedure for females with stress incontinence.

The tape helps to artificially reconstruct the pubo-urethral ligaments by increasing sub-urethral support. Intramural urethral bulking agents are another surgical option. Bulking materials are injected into the urethra and bladder neck, restricting the urethral lumen and increasing outflow resistance. However, there is little evidence that this therapy is effective or long-lasting.

Pharmacological interventions

Antimuscarinic and beta-3-agonist medications are currently used in the treatment of urinary incontinence. Botulinum toxin A detrusor injections represent an effective but more invasive alternative. Antimuscarinics are the most prescribed pharmaceutical treatment for overactive bladder and/or urge incontinence. Unfortunately, they are linked to several unpleasant side effects, including dry mouth, constipation, somnolence, drowsiness, and impaired vision, all of which have an influence on long-term treatment compliance and persistence.

Beta-3 adrenergic receptor agonists cause relaxation of the detrusor smooth muscle of the urinary bladder and increases bladder capacity. In the human bladder, Beta-3 AR is the most prevalent subtype of -ARs, and it causes noradrenaline-induced detrusor relaxation. Traditionally, phosphodiesterase 5 inhibitors (PDE5i) have been used to treat erectile dysfunction. Through suppression of cGMP breakdown, a key modulator of smooth muscle tone, PDE-5i prolongs the physiological effects of nitric oxide (NO)/cyclic guanosine monophosphate (cGMP) signalling in tissues.

A recent study to evaluate the effects of PDE5i on urinary continence recovery after bilateral nerve-sparing radical prostatectomy found that PDE5i improves final continence status. However, administration of PDE5i immediately after surgery causes a distinct temporary deterioration in urinary incontinence.

Incontinence products

It might be prudent to point patients who have chronic incontinence in the direction of the plethora of many incontinence products that are available, especially since few interventions are 100% effective. The aim of absorbent products is to keep urine or faeces contained so that it does not leak onto clothing, bedding, or furniture, reducing unpleasant consequences and improving quality of life.

There are a host of body-worn products to take care of light to heavy bladder weakness. Working with families to establish which type of products are the most comfortable and inconspicuous while still offering the most coverage for the kind and amount of incontinence is essential.

These products feature a surface area that is against the perineum and collects and transports urine to a super absorbent polymer inner core when worn on the body. This absorbent inner core allows urine and faeces to travel throughout the pad, allowing for maximum absorption while preventing leaks and odour.

Both unisex and gender-specific products are commonly available. They can range from an incontinence liner that can absorb a few drops for those experiencing mild incontinence, to pads when more absorbency is required. There are also incontinence pants for those who are mobile, all-in-one adult diapers for those who are bedridden, and more ergonomic belted brief options that reduce back strain and changing time.

Skin care in incontinent patients

Regardless of the products chosen, it is extremely important that they offer some form of protection to the skin. When skin is exposed to moisture from urine combined with faeces, skin trauma occurs. The skin over the buttocks and sacrum macerates, abrades, and blisters because of prolonged contact with urine and faeces, moisture, and friction. Long-term perineal contact with moisture and heat can encourage the growth of microorganisms like Candida albicans, resulting in candidiasis or yeast dermatitis.

All of these factors combine to produce skin irritation, breakdown, and other skin problems. Abrasion of the skin can be caused by friction. Moving wet skin against an object, such as cloth and plastic in leg gathers and tape fasteners on adult briefs, is more likely to abrade it. Obese elderly patients who are wearing a tight-fitting adult brief are also prone to tape cuts.

Some incontinent patients with conditions such as dry skin, contact dermatitis, and eczema may find that their skins are harmed further by washing with regular soap and water. Because regular washing with soap and water dehydrates the skin, a perineal rinse may be recommended in some older people.

Specially designed no-rinse perineal cleansers can help to cleanse, moisturise and protect the skin. These skin cleansers have a pH that is adjusted for the skin, whereas bar soaps are almost always alkaline can irritate the skin even more when patients are affected by incontinence. Non-rinse cleansers have also proven to make a significant difference in preventing incontinence related moisture lesions.

CONCLUSION

Incontinence is an embarrassing, negative experience for patients who typically come from vulnerable groups like the elderly, post-menopausal women and men who have undergone prostate surgery. However, the amount of available treatments means that patients who suffer from incontinence can mitigate nearly all the negative aspects of this experience. From simple first-line therapies such as pelvic floor exercises to surgical and pharmacological interventions, a variety of methods exist to alleviate the burden of incontinence. There are also numerous products available to ease the burden of incontinence and related skin damage.

 

REFERENCES

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  • World Health Organization, 2017. Evidence profile: urinary incontinence. Integrated care for older people (ICOPE) Guidelines on community-level interventions to manage declines in intrinsic capacity. Published by World Health Organization, Geneva.