Incontinence

Urinary incontinence (popularly known as bladder weakness) is the failure to learn or the loss of the ability to safely store urine in the bladder and to determine when to void. It is a fairly common condition, estimated by research to affect between 5 and 25% of people - exact figures are difficult to determine as many sufferers do not see a doctor out of shame. Basically, it can be said that women suffer from incontinence more often than men and that the number of cases increases with age.

Many of those affected suffer not only physically, but also emotionally from the unwanted loss of urine. Out of shame and fear that their condition could be discovered, they withdraw more and more from social life. Especially for young people who have grown up believing that incontinence only affects older people, the pressure of suffering is immense. Those affected often try to hide their condition for several years before seeking professional help. The great psychological stress manifests itself in frustration, nervousness and sleep disturbances.

Involuntary leakage of urine can be prevented in some cases simply by strengthening the pelvic floor muscles (through intensive pelvic floor training). Medication is also used to treat certain forms of bladder weakness - and surgery is an option of last resort. There is also a wide range of professional aids available in drugstores and pharmacies, such as insoles, which allow sufferers to go about their normal lives without restrictions.

The following four variants are the most common manifestations of incontinence. They are each based on different causes:

• Stress incontinence
• Urge incontinence
• Overflow incontinence
• Reflex incontinence

Stress incontinence

This type of incontinence has nothing to do with stressful, psychological factors - the reason for the loss of urine is that the muscles which close off the bladder to the urinary tract are too weak. If the pressure in the abdominal cavity and, as a consequence, the pressure on the bladder is increased in special stress situations, this results in the involuntary leakage of urine. A distinction is made between three degrees of stress incontinence depending on the degree of muscle weakness:

• Grade I: Incontinence only when coughing, sneezing or laughing.
• Grade II: incontinence during abrupt movements or when sitting down or standing up
• Grade III: Incontinence when lying down or during effortless movements.

There are various reasons why the sphincter muscles of the urinary bladder can no longer fulfil their function. Usually, pelvic floor weakness occurs, for example, after operations in the lower abdominal area or after several births.

Another reason in women would be the lowering of the bladder, uterus and vagina in the pelvis. Normally, these organs are held in their original position by ligaments and muscles - but if these are too weak, the organs and the urethra slip a little deeper into the pelvis, impairing the function of the closing muscles of the urinary bladder.

In rare cases, the muscles of the urethra itself are not strong enough, resulting in incontinence. Normally, however, the urethral muscles are strengthened by the other muscles of the pelvic floor.

In men, stress incontinence can occur after prostate surgery if the muscles of the urethra have been damaged by the surgery.

Urge incontinence

This form is also known as overactive bladder syndrome, urge incontinence or irritable bladder. Urge incontinence is characterized by a sudden, unsuppressible urge to urinate that forces the person to go to the toilet immediately. The sudden urge to urinate is caused by the following two mechanisms:

• motor urge incontinence: in this case, the nerve impulses that activate the detrusor muscle (the muscle that empties the urinary bladder) are overactive, resulting in sudden and premature urination. Normally, the detrusor muscle is regulated by the central nervous system - over-activation can occur in brain diseases such as tumours, strokes, dementia and inflammation.

• Sensory urge incontinence: In this case, the perception of bladder filling is disturbed and there is an early signal that the bladder is full. This disorder can be triggered by inflammation, bladder stones, bladder tumours or remodelling processes of the bladder mucosa (as a result of an oestrogen deficiency during the menopause).

Overflow incontinence

Overflow incontinence is caused by a constantly overfull bladder that is difficult to empty naturally due to drainage problems. If the pressure in the bladder rises above the resistance in the urethra, the bladder "overflows" and a constant dribbling of urine is the result.

There are several causes of overflow incontinence:

• The most common cause is an enlarged prostate (prostate gland), which often occurs in men over the age of 60. Since the prostate completely surrounds the urethra just below the bladder, enlargement can cause the urethra to become constricted.

• Diabetes mellitus can cause damage to the nerves that should activate the detrusor muscle (the muscle that empties the bladder). Urine can no longer be forced out of the bladder and overflow incontinence occurs.

• The nerve to the detrusor muscle can also be damaged during the surgical removal of, for example, uterine or ovarian tumours and during injuries to the lower spinal cord.

• During pregnancy, overflow incontinence can also develop temporarily due to increased pressure on the bladder.

Reflex incontinence

Reflex incontinence is caused by damage to the nerve pathways between the brain and the bladder centre in the spinal cord, such as occurs in paraplegics. The damage results in reflex-like contractions of the bladder muscles due to the predominance of activity impulses, causing the bladder to empty.

Fistulas

Fistulas are newly formed pathological connecting ducts between an internal hollow organ and another organ or the surface of the skin. Fistulas can develop as a result of a chronic inflammatory process (for example Crohn's disease), after abdominal surgery or complicated childbirth.

If the urinary bladder is connected to the intestine, vagina or skin surface via a fistula, urine can pass through this channel without resistance.

Each manifestation of incontinence manifests itself in different symptoms and conditions.

Stress incontinence

Stress incontinence is caused by light or heavy exertion (e.g. lifting heavy weights, sneezing, laughing, coughing) leading to involuntary leakage of urine. If stress incontinence is severe, urine can be passed even when lying down or during unstrained movements. Women are often affected (even at a young age), whereas men are rarely affected.

Urge incontinence

Urge incontinence manifests itself in such a sudden and uncontrollably strong urge to urinate that it is almost impossible for those affected to visit the nearest toilet in time. Older people in particular (preferably women) suffer from this form of incontinence.

Overflow incontinence

Overflow incontinence mainly affects older men with prostate problems. The bladder can no longer empty normally due to increased resistance (e.g. due to an enlarged prostate) - the pressure rises, the bladder "overflows" and urine is lost drop by drop.

Reflex incontinence

This form of incontinence affects people with damage or disorders of the nerve tracts or spinal cord. The closing muscles of the bladder can no longer be controlled and there is involuntary, active emptying of the bladder.

Fistulae

Incontinence as a result of fistula formation is very rare. In this form, there is constant leakage of urine through the fistula.

For the right choice of therapy, the cause of the incontinence must first be determined. This can be found out primarily through a precise anamnesis (patient interview) and the assessment of the symptoms.

To confirm the diagnosis, other diseases such as cystitis, tumours or bladder stones must be excluded as causes. By means of sonography (ultrasound examination), it is possible to detect any bladder stones or tumours and to measure the amount of residual urine.

Urodynamic diagnostics can be used to determine the pressure in the abdomen and in the bladder during filling and emptying of the bladder (for example, to differentiate between urge and overflow incontinence).

In some cases, a cystoscopy (for internal examination of the bladder if tissue changes are suspected) or X-ray and laboratory tests are also necessary to confirm the diagnosis.

The type of therapy varies between the forms of incontinence:

Stress Incontinence

Since pelvic floor weakness is the most common cause of stress incontinence, targeted training of the pelvic floor muscles often leads to recovery. The daily strengthening exercises are initially carried out under expert guidance, and later on alone at home.

In overweight people, weight reduction often leads to an improvement in incontinence. Women after the menopause can sometimes be helped by treatment with oestrogens.

If the symptoms do not improve despite therapy, incontinence can usually be treated by surgery (for example, by inserting an artificial sphincter).

Urge incontinence

This type of incontinence is caused by a hypersensitivity of the bladder receptors to stimuli. Therefore, bladder teas, hot water bottles or herbal medicines such as pumpkin or goldenrod extract help with mild symptoms.

Targeted bladder training (in which the patient learns to empty the bladder at specific times - description under"Prognosis") helps the patient to avoid the uncontrollable urge to urinate and thus prevents involuntary urination.

In the case of severe urge incontinence, the use of antispasmodic medication can also be helpful. These prevent the bladder muscle from contracting, which weakens the strong urge to urinate. Drug treatment should be maintained for a few weeks.

Overflow incontinence

Since the cause in this form is usually an enlarged prostate, surgery must be considered in severe cases. However, mild forms can sometimes be treated with herbal medicines such as pumpkin, nettle or saw palmetto extract.

As an alternative to surgery, drug therapy with alpha receptor blockers is also possible. These have the effect of reducing bladder closure and therefore outlet resistance, reducing the amount of residual urine in the bladder.

Another option would be to take 5-alpha-reductase inhibitors, which have the effect of reducing the size of the prostate.

If surgery is not possible and other therapeutic approaches fail, the insertion of a catheter is sometimes necessary. The urine is drained through this catheter via the urethra or the abdominal wall.

Reflex incontinence

The cause of this incontinence is damage to the nerve connection from the brain to the bladder, which means that the bladder can no longer be consciously controlled. Various medications (for example parasympatholytics) inhibit the spontaneous activation of the urinary bladder muscles and thus effectively prevent sudden urination.

However, a catheter must now be inserted for the deliberate emptying of the bladder. A thin plastic tube is inserted through the urethra into the bladder.

If the respective therapy is carried out well and consistently, incontinence can be greatly improved or completely eliminated in most cases.

There are a number of recommendations that can alleviate the extent of incontinence:

Pelvic floor training

This is a form of physiotherapy that can be learned under the guidance of a physiotherapist. If the training is only learned by means of written instructions, the exercises are often performed incorrectly and there is no success.

During pelvic floor training, those affected learn various strengthening exercises for the pelvic floor muscles as well as methods that reduce everyday stress on the pelvic floor - for example, by learning special lifting techniques or how to get out of bed correctly with reduced pressure.

For support, bio-feedback devices can be very helpful in the initial phase of training. These show the user the degree of tension in the pelvic floor muscles, so that the feedback can be used to determine whether the exercises are being performed correctly. For this purpose, a sensor is inserted into the vagina for women and into the rectum for men. When the pelvic floor muscles are tensed, the pressure is transmitted to the sensor. Without these devices, the degree of tension of the muscles cannot be sensed.

Another option would be electrotherapy. In this case, the pelvic floor muscles are stimulated by electronic impulses, whereupon they tense up at rhythmic intervals and are thus strengthened. Electrotherapy is particularly suitable as preparation for active pelvic floor training, for example after operations in the pelvic area.

Pelvic floor training can only be successful if it is continued consistently at home.

Fluid intake

In many cases, those affected try to control their incontinence by drinking less. However, this usually has the opposite effect, as concentrated urine in the bladder tends to increase the urge to urinate. Emptying the bladder less often also increases the risk of infection. Bladder infections themselves can in turn increase incontinence.

Health also suffers from reduced fluid intake, as the body needs an average of two litres per day. Otherwise, this has negative consequences for the kidneys, skin, digestive tract and brain.

Bladder training

By emptying the bladder regularly at certain times, the intense urge to urinate can be prevented in the case of urge incontinence.

This is best achieved by keeping a so-called micturition diary (bladder emptying diary). In this diary, all voluntary bladder emptying and involuntary urination as well as the amount and type of drinks consumed are recorded over several days. With the help of the diary, regularities in the bladder emptying rhythm can now be determined. Then, over time, you can train yourself to always go to the bathroom about half an hour before you expect to empty your bladder, which will help prevent uncontrollable urination.

In many cases, a well-trained pelvic floor and the avoidance of the following factors can reduce or even completely prevent existing incontinence:

• In cases of severe overweight, a reduction in body weight exerts a positive influence due to the reduced pressure on the pelvic area.

• Treatment of chronic constipation reduces the pressure on the urinary bladder.

• Frequent coughing in chronic bronchitis increases the discomfort of stress incontinence. Treating lung disease and quitting smoking for smoker's bronchitis can improve the situation.