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	Incontinence - Urinary and Fecal Ernest H. Rosenbaum MD and Cigall Kadoch, BA Incontinence Risk Factors and Causes Potential Treatments and Solutions for Incontinence

Incontinence Back to the Table of Contents About 25% of adults experience urinary or fecal incontinence during their lifetime. Over half will go untreated, despite some of the available resources and interventions. 1,2 Both fecal and/or urinary incontinence can have a devastating psychological and physical effect, as well as a huge economic impact. This may also force people to limit their activities and often withdraw from social life, family and friends. The embarrassment is a major problem, as some patients are anxious about their incontinence and the stigma of these conditions rather than seek treatment and retreat into isolation with the feeling of hopelessness. Urinary incontinence affects 15-50% of women and is, thus, a medical, social and economic burden estimated at $20 billion in the year 2000. Urinary incontinence at 45 occurs in about over twenty million women (20-40%). Stress incontinence decreases with age, and urge incontinence increases with age. Fecal incontinence occurs starting at about age 40 in 19% and by 80, 29%, increasing with age. 50% of those with fecal incontinence also have urinary incontinence. For those who take care of elderly patients or at nursing homes, there is a cost and time element due to the need for extra care and also problems with living conditions and more hours needed for care-giving. This also involves economic loss due to expensive costs of caregivers, as well as drugs and supplies (pads) for incontinence. An estimated cost for the institutional population is increasing, and an estimated cost of $20 billion for urinary incontinence similar to the costs of treating arthritis. Patients should consult with their physicians, and together they can make a decision on whether and type of treatment should be initiated. With proper assessment and consultation, they realize that many people have this problem, and it can be treated, is a part of aging for many people, and lifestyle changes, behavioral modifications, medical and possibly surgical treatments can relieve incontinence problem. Despite the fact that these problems are more common with aging, often they are also multifactoral, involving the bladder and/or sphincter, peripheral nerves, neurologic problems, and other problems, which include problems with cognitive function, mood, problems with physical mobility and debility, as well as various comorbid conditions. There are three types of urinary incontinence: 1. Urge incontinence is a sudden urge and loss of urine when one cannot get to the bathroom in time. 2. Stress incontinence when urine is leaked, such as after coughing, sneezing, laughing or lifting. 3. Mixed incontinence when a person has a combination or urge and stress incontinence - urinary leakage, occasionally constant. It is important to identify which type of incontinence is present. Risk Factors and Causes Back to the Table of Contents The type of risk factors,3 in part, determines the treatment. 1. Physical risk factors involve obesity, sex and physical activity. 2. There are genetic risk factors; for example, a positive family history. 3. There are psychiatric problems of depression and dementia and other problems such as multiple sclerosis, spinal injury, diabetes, stroke, and various neuropathies. 4. Trauma is very important - such as after childbirth, post-prostatectomy, radiation. 5. Associated comorbid conditions, such as inflammatory bowel, irritable bowel syndrome, smoking, constipation and menopause. 6. Peak prevalence around menopause and after age 65. 7. Obesity and multiparity are risk factors, although also seen in young athletes with increased physical activity. Women adjust their lives, in part, because of leakage and its affect on QOL measures. Physical problems following prostate surgery and radiation or anorectal surgery, which may have adverse physical defects, require compensatory supportive treatments. For example, a routine episiotomy at childbirth has been associated with bladder or rectal sphincter injury and sometimes fecal incontinence occurs requiring preventive interventions. The effects of incontinence are embarrassment, physical discomfort and destruction. There is anxiety about possible accidents, as well as social isolation, depression, and even social exclusion. There are also management problems. For example, after childbirth or after prostate surgery, there may be nerve or muscle damage in the pelvis, leading to incontinence. A history and physical examination helps determine which of the risk factors and potential neurological disorders is involved, leading to urge incontinence and/or stress incontinence. Potential Treatments and Solutions for Incontinence Back to the Table of Contents The clinical assessment helps determine what can be achieved to relieve the symptoms of incontinence. Lifestyle changes which may help reduce the risks. 1. Obesity- weight control. 2. Increased physical activity and exercise (Kegels). 3. Improved diet. 4. Smoking cessation (Less coughing). It is important to encourage these lifestyle changes through: 1. Education. 2. Support groups. 3. Self-management strategies. Fecal (stool) incontinence It's important to ask the questions Do you leak stool or have diarrhea? Do you use of pads or protective garments, how often? Fecal incontinence occurs starting at age 40 in ~6-15% and increases with age. Fifty percent of those with fecal incontinence also have urinary incontinence. It involves the unintentional loss of solid or liquid stool, as often seen more commonly in nursing homes and in older persons, who are affected or caused by: 1. Loss of rectal sphincture sensation. 2. Loss of rectal storage capacity. 3. Anal sphincter pressure loss. 4. Poor bowel habits After determining the severity, frequency, and related symptoms consequences of possible comorbidities, a plan can be given for a systemic treatment approach,. Preventive interventions, such as weight reduction, increased physical activity and pelvic floor exercises, have been found to be helpful. Simple Interventions 1. Many people are overweight, and losing weight and exercising have been shown to reduce symptoms for both urinary and fecal incontinence. 2. Added abdominal weight increases pressure on the bladder and bowels along with inactivity, which is associated with weakened muscles of the pelvis. Excess weight also decreases mobility, which is often necessary to get to the bathroom on time. 3. Obese people are at a 60-70% higher risk for developing incontinence, and often bariatric surgery has improved symptoms. Even less dramatic weight loss can have an effect. 4. Women are at higher risk for both fecal and urinary incontinence. This could be because of pelvic injuries from childbirth and episiotomies during delivery. One million women have episiotomies each year, and 1,000 of them will develop incontinence. 5. Pelvic core muscle training can be very helpful, and structured training on how to contract muscles of the pelvic floor during and after pregnancy, with exercises done regularly, may reduce urinary incontinence, at least for the short term. 6. Advising patients to do Kegel exercises and that by contracting muscles used to stop the flow of urine can also be of help. A structured training program was recommended by the Consensus Committee for pelvic floor exercises. It is not just using the gluteal muscles, but properly isolating the pelvic floor muscles is the effective way, and position and self training in these areas should be initiated.4,5 Surgery - pubovaginal sling procedure and the Burch procedure have helped up to 80-90% of patients. 4-10% of women in the U.S. undergo surgery to restore continence, a rate that's increased over the past twenty years - an estimated 70-85% successful. The Importance of Managing Comorbid Conditions Survivors with diabetes, irritable bowel syndrome, inflammatory bowel disease, frailty with impaired mobility, urologic conditions, psychological problems with depression, as well as diarrhea, constipation and urinary urgency, need to be dealt with to reduce risks and symptoms. By effectively treating depression, incontinence has been relieved in some patients. Often, embarrassment is a major problem, as some patients are anxious about their incontinence and retreat into isolation with the feeling of hopelessness. With proper assessment and consultation, they realize that many people have this problem, and it can be treated, is a part of aging for many people, and lifestyle changes, behavioral modifications, medical and possibly surgical treatments can relieve incontinence problems. Despite the fact that these problems are more common with aging, often they are also multifactoral, involving the sphincter, peripheral nerves, neurologic problems, and other problems, which include problems with cognitive function, mood, problems with mobility and debility, as well as various comorbid conditions. Using coping skills and control of comorbid problems can improve quality of life and often help reduce some of the symptoms and problems of urinary incontinence. Unfortunately, the natural history of these problems is not fully known. It is sort of a trial and error with hope that there will be an improvement and reduction of symptoms. Often, there are major financial costs for repeated medical treatments and visits, and, insurance companies may not always cover this. Through physical activity and pelvic floor exercises, one can reduce the risk of poor muscle training, and biofeedback has proven effective in preventing and reversing some of the problems of fecal and urinary incontinence in older women and men, especially after prostate surgery, and with medical supportive treatment and lifestyle changes, some of the symptoms can be reduced. Withdrawal of medication may cause symptoms or even a possible rebound effect. References 1 C. Seth Landefeld, Barbara J. Bowers, PhD, RN; Andrew D. Feld, MD, JD; Katherine E. Hartmann, MD, PhD; Eileen Hoffman, MD; Melvin J. Ingber, PhD; Joseph T. King, Jr., MD, MSCE; W. Scott McDougal, MD; Heidi Nelson, MD; Endel John Orav, PhD; Michael Pignone, MD, MPH; Lisa H. Richardson; Robert M. Rohrbaugh, MD; Hilary C. Siebens, MD; and Bruce J. Trock, PhD, National Institutes of Health State-of-the-Science Conference Statement: Prevention of Fecal and Urinary Incontinence in Adults, An Intern Med, 2008; 18 March 2008 | Volume 148 Issue 6 | Pages 449-458 2 Bridget M. Kuehn, Consensus Report Highlights Incontinence, JAMA,2008;299(3):278. 3 Kris Strohbehn, MD, Shades of Dry -- Curing Urinary Stress Incontinence, N Eng J Med, 356; 21: 2198. 4 Manassero F, Traversi C, Ales V, Pistolesi D, Panicucci E, Valent F, Selli C.M. Contribution of early intensive prolonged pelvic floor exercises on urinary continence recovery after bladder neck-sparing radical prostatectomy: results of a prospective controlled randomized trial. Neurourol Urodyn. 2007;26(7):985-9. 5 M. Overgard, A. Angelsen, S. Lydersen, S. Morkved, Does Physiotherapist-Guided Pelvic Floor Muscle Training Reduce Urinary Incontinence After Radical Prostatectomy? A Randomised Controlled Trial, European Urology, Volume 54, Issue 2, Pages 438-448

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