Incontinence, the loss of bladder control can be an embarrassing issue, but it is also an extremely common problem among elderly people. At least 1 in 10 people age 65 or older deals with incontinence. Symptoms range from mild leaking of urine to chronic uncontrollable wetting.
What is Bladder Control?
The body stores urine in the bladder. During urination, muscles in the bladder contract or tighten forcing urine out of the bladder and into a tube called the urethra that carries urine out of the body. At the same time, muscles surrounding the urethra relax and let the urine pass through. Spinal nerves control how these muscles move. Incontinence occurs if the bladder muscles contract or the muscles surrounding the urethra relax without warning or control.
What Causes Incontinence?
Although aging does not cause incontinence, it is more likely to occur in older people. Incontinence can occur for many reasons. Some of those reasons cause bladder control problems that are reversible. Other, more progressive conditions like Parkinson's and Alzheimer's cause chronic incontinece. Although not directly responsible for loss of bladder control, arthritis and age-related conditions that impact mobility cause functional incontinence. In this instance, loss of bladder control occurs because of confusion or painful, slow walking which interferes with the ability to get to the bathroom in time.
Reasons for loss of bladder control:
- Vaginal infections
- Urinary Tract Infections
- Weak bladder muscles
- Overactive bladder muscles
- Blockage from an enlarged prostate
- Medication interactions
- Damage to nerves that control the bladder from diseases such as multiple sclerosis or Parkinson's disease
- Diseases such as arthritis that make walking to the bathroom painful or slow
- Confusion regarding the toileting process because of cognitive decline
- Loss of awareness of the need to urinate due to dementia or Alzheimer's
Many people with bladder control problems hide the problem from everyone, even from their doctor. The social consequences of incontinence can be devastating, leading to embarrassment, isolation and depression. In most cases, incontinence can be treated and controlled, if not cured. If your parent is having bladder control problems, they don't have to suffer in silence. Talk to your doctor about diagnosing incontinence.
The doctor will give your parent a physical exam and take their medical history including any major illnesses or surgeries. You should talk about the medications, both prescription and nonprescription, because they might be part of the problem. You should talk about how much fluid an elder drinks a day and whether they use alcohol or caffeine.
Your doctor also may do a number of continence tests. These might include urine and blood tests and tests that measure how well your mom or dad empties the bladder. In addition, your doctor may ask you to keep a daily diary of when your parent urinates and when they leak urine. Their pattern of urinating and urine leakage may suggest which type of incontinence your elderly parent has. These tests may be as simple as urinating behind a curtain while a doctor or nurse listens or more complicated, involving imaging equipment that films urination and pressure monitors that record the pressures of the bladder and urethra.
Record a Voiding Diary
When visiting a doctor about incontinence, provide as many details as possible about the problem and when it started. Oftentimes, patients are asked to keep a 24 hour voiding diary, which is simply a record of fluid intake and trips to the bathroom, plus any episodes of leakage.
Incontinence Pad Test
If leakage is the problem, the doctor or nurse may do a pad test. This test is a simple way to measure how much urine leaks out. Patients are given a number of absorbent pads and plastic bags of a standard weight. After wearing the pad for 1 or 2 hours while in the clinic or wearing a series of pads at home during a specific period of time, the pads are collected and sealed in a plastic bag. The doctor then weighs the bags to see how much urine has been caught in the pad. A simpler but less precise method is to change pads as often as you need to and keep track of how many pads used in a day.
A physical exam will also be performed to rule out other causes of urinary problems. This exam usually includes an assessment of the nerves in the lower part of the body. It will also include a pelvic exam in women to assess the pelvic muscles and the other pelvic organs. In men, a rectal exam is given to assess the prostate. The doctor will also want to check the urine for evidence of infection or blood.
Tests Doctors Use to Diagnose Incontinence
Any procedure designed to provide information about a bladder problem can be called a urodynamic test. Most urodynamic testing focuses on the bladder's ability to empty steadily and completely. It can also show whether the bladder is having abnormal contractions that cause leakage. The doctor will want to know whether their is difficulty starting a urine stream, how hard of a strain it is to maintain it, whether the stream is interrupted, and whether any urine is left in the bladder when done. The remaining urine is called the postvoid residual. Urodynamic tests can range from simple observation to precise measurement using sophisticated instruments.
Uroflowmetry (Measurement of Urine Speed and Volume)
A uroflowmeter automatically measures the amount of urine and the flow rate—that is, how fast the urine comes out. The patient may be asked to urinate privately into a toilet that contains a collection device and scale. This equipment creates a graph that shows changes in flow rate from second to second so the doctor or nurse can see the peak flow rate and how many seconds it took to get there. Results of this test will be abnormal if the bladder muscle is weak or urine flow is obstructed.
A doctor or nurse can also get some idea of bladder function by using a stopwatch to time urination into a graduated container. The volume of urine is divided by the time to see what your average flow rate is. For example, 330 milliliters (mL) of urine in 30 seconds means that your average flow rate is 11 mL per second.
Measurement of Postvoid Residual
To measure this postvoid residual, the doctor or nurse may use a catheter, a thin tube that can be gently glided into the urethra. He or she can also measure the postvoid residual with ultrasound equipment that uses harmless sound waves to create a picture of the bladder. A postvoid residual of more than 200 mL, about half a pint, is a clear sign of a problem. Even 100 mL, about half a cup, requires further evaluation. However, the amount of postvoid residual can be different each time you urinate.
Cystometry (Measurement of Bladder Pressure)
A cystometrogram (CMG) measures how much the bladder can hold, how much pressure builds up inside the bladder as it stores urine, and how full it is when you feel the urge to urinate. The doctor or nurse will use a catheter to empty the bladder completely. Then a special, smaller catheter will be placed in the bladder. This catheter has a pressure-measuring device called a manometer. Another catheter may be placed in the rectum to record pressure there as well. The bladder will be filled slowly with warm water. During this time your parent will be asked how the bladder feels and when they feel the need to urinate. The volume of water and the bladder pressure will be recorded. Involuntary bladder contractions can be identified.
Measurement of Leak Point Pressure
While the bladder is being filled for the CMG, it may suddenly contract and squeeze some water out without warning. The manometer will record the pressure at the point when the leakage occurred. This reading may provide information about the kind of bladder problem your parent has. Your elderly parent may also be asked to apply abdominal pressure to the bladder by coughing, shifting position, or trying to exhale while holding their nose and mouth. These actions help the doctor or nurse evaluate the sphincter muscles.
Pressure Flow Study
After the CMG, your parent will be asked to empty their bladder. The catheter can measure the bladder pressures required to urinate and the flow rate a given pressure generates. This pressure flow study helps to identify bladder outlet obstruction that men may experience with prostate enlargement. Bladder outlet obstruction is less common in women but can occur with a fallen bladder or rarely after a surgical procedure for urinary incontinence. Most catheters can be used for both CMG and pressure flow studies.
Electromyography (Measurement of Nerve Impulses)
This test measures the muscle activity in and around the urethral sphincter by using special sensors. The sensors are placed on the skin near the urethra and rectum or they are located on the urethral or rectal catheter. Muscle activity is recorded on a machine. The patterns of the impulses will show whether the messages sent to the bladder and urethra are coordinated correctly.
To overcome reluctance, help your elderly parent educate themselves on incontinence, know that it's common as people grow older -- and assure them that doctors have seen it all before! Discussing incontinence with caregivers and medical professions is the first step toward managing the problem.
Sources:National Association for Continence, https://www.nafc.org/bhealth-blog/patient-perspective-the-shame-of-incontinence-is-real