Estee* was a long time beloved patient of ours. Age 46, she had been a widow since her early 20's and raised a son all on her own. He was now in the armed services and you couldn't find a prouder mother. For years I had teased her that she might meet a new "Mr. Right" and would come in here sporting a big diamond. She'd laugh and say "Girl I am trying"! A devout Christian, her biggest enjoyment in life besides her son, was her church. She told me that if the Lord was going to bring a new man into her life, she would find him at church.
Not long ago she came to see me. Usually she was so upbeat and jovial, with a grin that lit up her whole face. But that day she was barely smiling. I asked her what was wrong and sadly shaking her head, she told me that she couldn't "get happy" at church no more.
"Get happy?" I asked her.
She explained that in her church they would sing as their praise band played and "You just opened yourself up to let that Spirit in and you would raise your hands and dance and shake". Filled with the Spirit -- you were "getting happy"! But lately she found to her terrible embarrassment, that when she danced and shook, she would wet. In her church everybody dressed to the nines in their Sunday best and she had actually ruined a nice dry clean only suit! As a consequence she got less and less active, dancing became swaying. She would use the bathroom right before services started and then pray that the preacher didn't get too wound up and prolong the service. It wasn't just church either. She couldn't lift her little niece without feeling that trickle and had taken to buying pads to wear every day. The last straw came when one of the deacons from her church came to visit her and inquire if everything was OK because he noticed that she wasn't participating as enthusiastically in church as she usually had. She was mortified and mumbled something about being worried about her son even though he wasn't deployed and they prayed together, but silently she prayed that she would just stop leaking. She said she always told her son that you had to "put your feets to your prayers" so she was doing that and it was her fervent prayer that I could help her.
Fortunately, I had a pretty good idea from talking to Estee what her problem was. After the doctor examined her, he referred her to me for testing.
Carolyn* was a retired school teacher and mother of five grown children. She complained of random leaking all day long and even sometimes at night! She couldn't really relate it to any specific activity. She never really felt like she emptied out her bladder when she went to the bathroom because she went frequently and good volumes. She was overweight by about 25 pounds, but upon exam it looked like she had pretty good support from the muscles and ligaments that hold the bladder in place. She was a long time type II diabetic. The first part of my testing, I have the patient urinate on a special commode into a beaker that holds 1000 ml or roughly 64 ounces -- 8+ cups. The average total bladder capacity in a person is between 400-600 ml -- around 4 cups. Most of us would be climbing the walls to find the bathroom if we let ourselves get that full. When I brought Carolyn back to the testing room, she walked and talked normally. She sat down and we spent a few minutes reviewing her questionnaire and 24 hour voiding diary. After I left the room, she used the commode to void and when I came back in I was amazed to see that she had overflowed the beaker! I had a pretty good idea what was going on with Carolyn too.
Jan* was just 37 years old and the mother of two young boys. Both of her boys weighed over 9 pounds at birth. A former smoker, she found herself sneaking a cigarette or two now and then "to help her lose weight" as she was still carrying around about 60 extra pounds after the birth of her last child. She came to me because she felt like her life was ruled by the bathroom. She had to go constantly, and at least once a day she would experience such urgency without warning that she couldn't get to the bathroom fast enough and she would find that urine escaped before she even got her pants pulled down. "It's silly", she told me, "I can just see a sign saying bathroom and I've got to go". The worst was when she'd pick up the boys from after school child care and as soon as she got home she couldn't get her key in the door fast enough to get to the bathroom in time to prevent leaking. She had taken to leaving her back door unlocked - a practice that her husband highly disapproved of. It didn't matter if she used the bathroom right before leaving work. She tried restricting her intake of fluids, having no water all afternoon. Her husband wanted to get a sitter and take her to the movies. Just the two of them like when they were dating, but she feared going because even if she emptied her bladder right before the show started and she drank no soda during the show, she knew she'd have to go at least once during the movie and again right after it ended. It was much easier to watch a movie at home where she could hit the pause button anytime she needed to go. Hmm... I think I know what her issue may be too.
Three women, three different scenarios, but each suffering a decrease in quality of life because of urinary incontinence issues. As I said, I had a fairly good idea from the outset what was causing each woman's symptoms but it isn't just a matter of being able to diagnose from simply interviewing a patient. To me, it's like putting together a big puzzle and when all the pieces fit together and you can treat the patient successfully, it's very gratifying to see an improvement in their lives.
We have a saying in my line of work that "nobody has ever died from urine incontinence". However, occasionally a patient will come close. Like the 70 year old patient that was hurrying to the bathroom when she fell and broke her hip. Surgery was required and two days after surgery she developed a blood clot in her lung which then required an extended hospital stay and she couldn't participate in physical therapy until the clot was dissolved with blood thinners. She ended up leaving the hospital and entering into a skilled care facility. She ultimately ended up in a nursing home, giving up the beloved home she had lived in for over 40 years. She used a walker at first, but eventually had to use a wheelchair. She became depressed and because of medical issues, she was a poor risk for any more surgery and couldn't use medication to suppress her incontinence. She just wore adult incontinence pants -- or diapers as she sadly referred to them.
So you can see that incontinence is not just a "embarrassing little problem" that every female eventually has to endure.
Quite a process takes place when we have to urinate. When you are a kid, you run in the bathroom, pull down your pants, go, jump up and run out and never give it another thought. When you become an adult and start to have "issues", the bathroom takes on a greater precedence. Everywhere you go you scout out the bathrooms in advance -- just in case.
Picture your bladder like a balloon. Like filling a balloon with air, the bladder fills with urine from the kidneys as we eat and drink. As it starts to become full, the pressure inside the bladder increases and that pressure increase sends a signal to the brain that you are going to need a bathroom. So the brain tells you to find the toilet and once you do it sends signals to the nerves that supply the pelvic region (lower abdomen) and control the coordinated process.
A balloon is made entirely of latex. Your bladder is made almost entirely of a muscle called a detrusor muscle. It is designed to contract once you are sitting on the toilet so that there is a force to expel the urine.
The urethra -- the tube that leads from the bladder to the outside of the body is like the tied off part of the balloon. It is designed to be shut tight. Watertight like a frogs behind I always tell my patients. However, when you are on the toilet, and the detrusor muscle that makes up the bladder kicks in and starts to contract, this urethral "sphincter" relaxes and lets the urine flow out.
You can see right now that any number of things can and frequently does go wrong:
First that detrusor muscle can get a mind of it's own and start to contract when you are nowhere near a bathroom. If it's mild and you can distract yourself you may be able to suppress the developing urge, but sometimes it reaches an intensity that you can't and you do what one patient described as "the pee-pee dance" all the way to the bathroom. Many people just can't overcome the urge. This is referred to as urge incontinence or DOA -- detrusor overactivity.
Some people have just the opposite problem. Their detrusor muscle has become lazy for many different reasons. Sometimes it's related to getting poor messages from the brain. People with spinal cord injuries, herniated disks in the back compressing nerves, diabetics with chronic neuropathy (poor nerve conduction) all can suffer from this. When the muscle doesn't contract properly, there is no force to expel the urine. Patients try to push with their abdominal muscles but they never really empty out their bladders appropriately. They walk around as if they were carrying an over full bucket that sloshes over the edge. This is known as overflow incontinence. The risk here is that the muscle will eventually get enlarged and floppy. Big bladders hold big volumes and that increases the pressure in the bladder which can lead to damaged kidneys over time.
The sphincter known as the urethra can have issues of it's own. When a woman's bladder starts to sag, it pulls down the bladder "neck" or the urethra. Normally it is fixed snug like up against the vagina, but when it become unhinged, it becomes mobile. It moves when you cough, sneeze, dance, or lift heavy things. Sometimes just walking will cause it to move. The trouble is that when it moves, it opens a little and urine escapes. This is known as stress urinary incontinence (SUI). Not because it causes you stress, even though it does, but because it takes a "stress maneuver" to make it move and cause subsequent leaking. Sometimes the sphincter itself is compromised and never really is shut tight like that frog's rear. It's like a door that isn't shut all the way, leaving a crack for urine to escape. If the sphincter gets weakened overtime it can lose it's tone and when you sit to urinate, it doesn't gradually relax timed with the detrusor contractions. It flops open and urine runs out. This may happen when you aren't even on the toilet. This has the fancy term "instrinsic sphincter deficiency" or ISD.
That old urethral sphincter may have the opposite problem of being jammed shut tight whether from an obstruction like a polyp, or it's kinked off from a severe prolapse, or there is a stricture from scarring from chronic inflammation or infection. It may not relax appropriately and those folks end up urinating in spurts and trickles. It may also contract rhythmically while trying to empty and that can cause urine to reflux or travel back up into the bladder and they never quite empty out.
The three most common forms of incontinence in order are mixed ( a combination of one or more of the following) stress, urge, ISD, and overflow.
Whatever the cause, all whom are incontinent start to develop some common patterns. They go to the bathroom frequently whether or not they have an urge to go. They want to get the jump on it and feel like if they empty their bladder continually, somehow there won't be enough urine in there to leak. This doesn't work because the kidneys are constantly making urine and there is always going to be a residual left whether large or small that has the potential to leak.
Because a person heads to the bathroom before they have the proper urge, they tend to want to assist the detrusor muscle by pushing out the urine with their abdominal muscles. Even those with strong urges will often push as a method of trying to squeeze out every last drop. What this does over time is contribute to prolapse or worsen an existing prolapse. The bladder might not contract as much as needed over time. Hey if you are willing to do half the work, why shouldn't it just wait on your abdominal assistance? However, abdominal voiding is a very poor way to urinate. If you push hard enough for long enough, you may just push that bladder neck down to where it kinks and then you have to try and lean forward, stretch back, stand, insert your fingers in your vagina JUST TO PEE. So, don't do it -- it's a trick!
People then think if they don't drink much, they won't make much urine and they won't have to go as much. We all know the dangers of dehydration. It's not healthy and besides that it backfires too. The more concentrated your urine is, the more irritating it is to the lining of the bladder and the detrusor muscle will tune up in defense giving you even more urgency.
Because incontinence can be caused by so many different factors and often be a combination of factors, patients come to me to unravel their symptoms and put the puzzle pieces back together. I measure and trace their urine flow pattern. I test the integrity of their urethral sphincter. I fill them with sterile saline and check to see that their nerves are working well and they are feeling proper sensations to go. I see how well they empty and how much they leave behind in the bladder. I check for prolapse and have them perform stress maneuvers so I can see if that urethra is moving. I use electrodes to sense if they are pushing with their abdominal muscles while they urinate. I monitor their detrusor pressures to see if its contracting when it shouldn't be but contracting enough when it should be.
Once I put all the pieces together, I submit my report to the physician who will then prescribe a treatment. Treatments vary according to just what's going on. It might be physical therapy to strengthen the pelvic floor muscles to prevent further prolapse or strengthen the urethral sphincter. It might be surgery to snug everything back up into place tight. It might be behavior modification to relearn poor toileting habits. It might be medication to calm an overactive detrusor muscle. It might be a referral to a urologist. It might even be teaching
them to catheterize themselves if they aren't able to empty due to poor nerve conduction.
It's important to test before treating because when there is a mix of symptoms, you have to sort it out. A patient who urinates frequently because she is sloshing over the edges of her over full bucket due to her poor detrusor contractions wouldn't be a good candidate to snug that urethra up too tight with surgery or give her medication to calm down an already underactive detrusor muscle -- even though she is in the bathroom a lot. She is there because she has trained herself to be there not because her body is telling her it's time to go.
Now you know everything you never wanted to know about urinary incontinence, you may be asking what causes all this? Number one cause in females is childbearing. (Prostate in men) Pregnancy and vaginal delivery wreck havoc on the pelvic floor muscles that hold everything in place. My theory is that you don't pass something the size of a bowling ball through something the size of a golf ball and come out unscathed!
Number two cause is smoking. Yes, smoking. I know smokers feel picked on but the carcinogens in cigarettes that affect the lining of the lungs affect the lining of the bladder the same way. Smokers have a higher incidence of bladder cancer. It also weakens the muscles --The bladder muscles as well as the muscles and ligaments that support the bladder. PLUS - smokers cough more. Plain and simple.
Third leading cause is obesity. Think about it. Put a pound of fat like the kind Oprah famously wheeled out on her show down on something that weighs ounces like a marshmallow. Is it squashed? Uh-huh....
Take an obese smoker that has given birth several times, worked an occupation that doesn't allow for regular bathroom breaks (think nurses, teachers, assembly line workers, telephone operators...) and you have TROUBLE that starts with a capital T that rhymes with P that stands for PEE. (Give me a break -- I'm from Iowa!)
So there you have it -- Urinary Incontinence 101. Now that you've taken the class, see if you can guess the primary causes of the three patients at the beginning. They all ended up revealing mixed patterns, but each one had a primary cause. Come on -- it ought to be easy by now!
If YOU have any of these symptoms, see your physician. Some problems caught early can benefit from the least invasive treatments like physical therapy or behavior modification techniques.
stop you from seeking treatment and improving the quality of your life!
Whew! After reading this back I realize that It's kinda long.
If you've made it this far -- thanks for staying the course!!