Eldercare at Home: Incontinence
Caregiving How Tos
Understanding the Problem
Urinary incontinence, or involuntary leaking of urine, is a problem for at least 30% of people over age 60. It is more common in women than in men and can range from occasional dribbling to total loss of bladder control. What can you do?
You should start by sensitively discussing the problem with the older person. Many people who have incontinence do not tell their health care provider because they are embarrassed or they feel it is not a major problem. The first step to help them accept that they have a problem is by discussing it with tact and sensitivity. Whether the incontinence is mild or severe, everyone with incontinence should be seen by a healthcare professional. A medical condition might be causing the incontinence and, if so, this should be treated. Incontinence is almost always treatable with bladder training, pelvic muscle exercises, medications, and surgery. Sometimes it can even be cured .
There are 4 common types of incontinence:
- Stress incontinence is when urine leaks out involuntarily during coughing, laughing, bending, or other activities that apply pressure to the abdomen. It is most common in women but can also occur in men. Common causes are weak muscles around the bladder opening as a result of surgery, childbirth, or lack of estrogen after menopause. "Stress" incontinence has nothing to do with emotional stress.
- Urge incontinence is when urine leaks while having the sudden urge to go to the bathroom, but not being able to reach the toilet, commode or urinal. People with urge incontinence often have an overactive bladder muscle. Bladder overactivity can also cause frequent urination and awakening at night to urinate (nocturia). When urge incontinence occurs, the bladder contracts with little or no warning and urine leaks as a result. It can be caused by illnesses such as stroke, Parkinson's disease, bladder infection, and disorders that affect the spinal cord.
- Overflow incontinence is when urine leaks from a full bladder that does not fully empty during voiding, leading to chronic retention of urine. This condition can be due to damage to the nerves that control the bladder-from diseases such as diabetes mellitus or injuries to the spinal cord-that make the bladder too weak to empty. It can also result from conditions that block the bladder opening and prevent the bladder from emptying, such as an enlarged prostate in men.
- Functional incontinence occurs when the bladder and the urethra are functioning normally, but the person either cannot physically get to the toilet, or has impaired mental function that interferes with recognizing the need to urinate and getting to the toilet on time. This condition is common in patients with Alzheimer's and other types of dementias.
Your goals are to:
- Have the older person evaluated by a health care provider no matter how small the problem appears.
- Schedule bathroom trips or, if necessary, provide a urinal or commode to make reaching the toilet easier.
- Encourage bladder training and Kegel exercises.
- Encourage changes in diet and fluid intake.
- Take care of constipation - pressure from hard stool in the rectum can make urinary incontinence worse.
Any new or persistent incontinence should be reported to your doctor or healthcare professional. This problem cannot be solved by visiting your local drugstore and buying pads - it needs to be evaluated by a doctor or other healthcare professional.
Incontinence is not usually life-threatening, although it can cause significant problems. But you should seek medical help soon - within a day - if any the following symptoms happen suddenly:
- sudden loss of ability to pass urine
- great difficulty urinating well enough to empty your bladder
- uncontrolled dribbling
- pain with urination
- blood in the urine
Symptoms could be caused by a urinary tract infection or urinary retention. Either condition can become life threatening if untreated.
Know the answers to the following questions before calling the doctor:
- What are the symptoms?
- When did the problem start?
- Has it ever happened before?
- Does the older person have other health problems?
- What medications are being taken by the older person? (Be sure to include non-prescription medications, and herbal and other remedies.)
Here is an example of what you might say when calling:
"Hello, this is Betty Jones. My mother, Sandra Jones, has been having problems with her bladder. She doesn't make it to the toilet on time and loses urine. We're concerned about it and would like to know what can be done."
- Keep a bladder record or diary. This is a daily record of the all the times when a person urinates, whether into the toilet or involuntary. It includes accidents such as urinating on his or her underwear or clothing. If there is leakage, write down what seemed to cause it (coughing, laughing, urge to urinate on the way to the toilet) or happened at the same time. This information helps the health care provider decide how to treat the problem. A two day record is usually enough.
- Ask the doctor about exercise and medications. A combination of exercise programs and medicine can strengthen the bladder opening or can be used to stop bladder contractions (very helpful for urge and stress incontinence). In some women, local estrogen creams may be helpful. However, certain medicines can make incontinence worse. Diuretics (water pills) make a person urinate a lot. Some over-the-counter medicines and herbal remedies can interfere with bladder function. Many other drugs can contribute to incontinence. The doctor might stop these medicines, change the time of day they are taken, or prescribe smaller doses.
- Set up a schedule. It is often helpful for people with stress incontinence or urge incontinence to urinate about every 2 hours to avoid having too full a bladder. They should keep a record of when they urinate for about 2 days, and then make a schedule of trips to the toilet just before they would normally feel the urge to go.
- Remind people with functional incontinence. People who are unable to remember to go to the toilet in time can be helped by reminding them when to go to the toilet, assisting them in getting to the toilet and helping with their clothing and hygiene. It may be useful to provide a urinal or portable toilet by the bedside at night.
- Control the diet. Limit caffeine (coffee, tea, cola) and alcohol, but do not decrease fluid intake. Older people should drink 4-6 glasses of water or other clear fluids a day. Too little fluid reduces cues to urinate regularly. Concentrated urine can cause bladder irritation and a sense of needing to void. If there is an incontinence problem at night, consider reducing drinking 2-3 hours before bedtime.
- Encourage doing Kegel or pelvic muscle exercises. These can be useful in treating stress and urge incontinence. Kegel exercises are explained at the end of this section.
- Ask about biofeedback.This can be used in combination with exercises. Biofeedback uses a computer to help a person learn how well he or she is contracting and relaxing the muscles involved in bladder control. Biofeedback can be used with exercises to gradually gain better control over those muscles and might be available locally through a medical office.
- Ask about surgery. This is usually a last resort after other treatment. Surgery can reposition the bladder or clear an obstruction such as an enlarged prostate in men. Sometimes minor surgery can cure the problem.
- Use pads, absorbent garments, and urinary catheters as a stopgap measure.. These may be needed for social and mobility reasons while waiting to receive diagnosis and treatment. Do not use them instead of a medical evaluation. Incontinence could be a result of an underlying medical condition that should be treated. Diapers and pads can be helpful for extra protection in situations where there is limited access to toilet facilities, such as on long trips or in unfamiliar settings. However, diapers and pads can worsen incontinence if the older person relies only on them and does not practice bladder exercises. If pads or diapers are necessary, change them often to avoid odor, leakage, and skin rashes. It is important to regularly clean the skin after each episode to prevent skin irritation. Petroleum or aloe based creams may also help protect the skin from chemical irritation and breakdown. Catheters should only be used if absolutely necessary because they can increase the risk of serious urinary tract infections.
What are pelvic muscle exercises?
They are exercises used to strengthen the pelvic muscles that help to control the outlet from the bladder and urination.
How do you learn to do the exercises?
A common way to learn to control urination is to stop the flow or urine in the middle of urinating. Others practice using the same muscles which hold back the passage of gas. This helps you get an idea of the muscles being used to control urine flow.
It is very important that only the pelvic muscles are used and not the muscles of the stomach. The stomach should stay relaxed during these exercises.
Breathing in and out while doing the exercise will help keep the stomach relaxed.
Many people benefit from biofeedback to help learn the exercises (see the What You Can Do To Help section). Biofeedback helps people gain control of their muscles.
How are the exercises practiced?
Once you get the feel of using the right muscles, you should do the exercises as follows:
- Squeeze the muscles and hold for 10 seconds It is likely that you will have to practice to build up to this long.
- Relax for 10 seconds.
- Repeat, gradually building up to 15 squeezes and 15 relaxations 3 times per day.
You should do no more than 50 per day, divided into 3-4 sessions. After 1-2 weeks of these exercises, you should start to be able to use these muscles to prevent accidents (both urge and stress).
When should the exercises be done?
You can practice anytime, while you are sitting, standing or lying down. But to prevent accidents, the exercise must be done at times that normally cause you to leak such as: coughing, laughing, straining or when a very strong urge to urinate begins. For example, when putting a key in the door, or when you hear running water.
How long do the exercises take to work?
If they are practiced properly, you should begin to notice a difference within 4-6 weeks.
Can the exercises be harmful?
No. If you get any stomach or back pain with the exercises, you are not doing them correctly. You should only contract your pelvic muscles. Do not use your stomach or abdominal muscles to do this. The exercises do not require great effort and should not cause discomfort or fatigue. Hold contractions only as long as comfortable, usually 8-10 seconds.
Remember: Like any other exercise, pelvic muscle exercises must be practiced regularly in order to work.
Problems You Might Have Carrying Out Your Plan
"Incontinence is something that just normally happens to you as you get older."
Urinary incontinence is common, but it is not caused by, nor is it a normal part of growing older. There are actions that can be taken that can be done to help. In almost all cases the symptoms can be treated, and in some cases, incontinence can be cured.
"All I need are pads. I don't need to see a doctor."
You do need to see a health care provider. Your incontinence could be caused by a medical condition that needs to be corrected. If after an evaluation, you and your provider decide that pads are the only treatment needed, then that is fine.
"I'm embarrassed to talk about incontinence with my doctor."
Many people feel this way, but health care providers are trained to talk to people with this problem and actually hear about it quite often. Would you prefer to talk to a doctor of the same sex as yourself? Would it be easier to talk to a nurse? Would it help if a family member brought up the topic with the doctor? Remember, incontinence can be a medical condition much like diabetes or high blood pressure, which can and should be treated.
Think of other obstacles that could interfere with carrying out your plan
What additional roadblocks could get in the way of doing the things suggested in this section? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out this plan?
Incontinence can be emotionally upsetting to both caregivers and the older person with the problem. It should be discussed with tact and sensitivity - but it should not be ignored. Incontinence is one of the common reasons for placing people in nursing homes. Therefore, it should be addressed early. The first step is to have an evaluation by a doctor or other healthcare professional, and then develop a plan based on the recommendations. Progress might be slow and might require setting up new routines and exercises.
If your plan does not work
If incontinence is becoming more of a problem, or if the person is becoming more and more bothered by it, ask the doctor or nurse for help. Tell what you have done and what the results have been. The doctor may refer you to a nurse or therapist who is specially trained to deal with incontinence problems and in therapies such as pelvic muscle exercises and bladder training. These specialists will also be knowledgeable in using biofeedback or other aids in helping to strengthen the pelvic muscles and to use them correctly to prevent urinary accidents. The doctor may also recommend seeing a geriatrician, urologist, or gynecologist.