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Don’t Ask…Don’t Tell – The Untold Story of Urinary and Fecal Incontinence
“You are not alone.” This is what the National Institutes of Health has recently said to consumers about incontinence. I had the honor of participating in a State of the Science Panel charged with reviewing what is currently known about both fecal and urinary incontinence…and what needs to be known going forward, especially with the aging of the baby boomers. We found lots of data about how common and disturbing incontinence is and how poorly addressed it is both clinically and scientifically. Incontinence may not be life-threatening, but it can be life-limiting, leading to social isolation, avoidance of intimacy, and depression. It may also be life-transforming—the tipping point where family caregivers can no longer manage their elders at home and resort to nursing home placement. Interestingly, people entering nursing homes without incontinence soon become so because there is not enough staff to actually bring them to the bathroom on a regular basis!
"What is incontinence?” Urinary incontinence can affect persons of all ages but is most common in child-bearing women and older women and men. There are several forms: “urge” incontinence, when a person has the sudden urge to urinate and cannot get to the bathroom in time; “stress” incontinence, when a person leaks urine after strains such as laughing, coughing, sneezing, lifting or exercising; “mixed” incontinence, when a person has both urge and stress incontinence; and “other” incontinence, when there is constant leakage. There is also fecal incontinence, the unintentional loss of solid or liquid stool. There is scant data on this issue as it is less often addressed (personally or professionally). It is more common in women and older persons.
“Incontinence does not have to be a part of aging.” While it is true that the risk of incontinence for both women and men increases with age, a significantly effected population is younger women, especially those who had vaginal deliveries…and even more so if they had an elective episiotomy (cutting of the muscle between the vagina and rectum) before delivery. There is no data about vaginal intercourse as a risk factor but there is some awareness that gay men who engage in rectal intercourse can have fecal incontinence. Prostate problems and their surgical treatments may contribute to the increased incidence seen in older men. Incontinence has also been associated with childhood abuse and adult sexual abuse, but this requires more study.
Some simple life style measures and pelvic muscle strengthening can be very helpful in both preventing and treating these problems, however, many people are uninformed about them (many doctors too!). It is also difficult to separate the effects of aging in women from the effects of menopause. While vaginal estrogen may help stress incontinence, oral hormone replacement has, surprisingly, shown negative effects. Most of the studies looking at the effect of HRT on incontinence evaluated postmenopausal women as one uniform group instead of distinguishing them by years since menopause and may not be reliable.
There are risk factors that are found more commonly in those who are incontinent.
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Female sex |
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Number of births |
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Episiotomy (cutting the opening of the vagina for childbirth delivery) |
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Caucasian |
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Family history |
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Older age |
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Overweight |
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Limited physical exercise |
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Surgery that damages the sphincter muscles of bladder and anus. |
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Neuropsychiatric conditions such as multiple sclerosis, spinal cord injury, dementia, depression, stroke, diabetic neuropathy |
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Inflammatory bowel disease |
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Irritable bowel syndrome |
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Diarrhea and constipation Risk factors that currently have inadequate data but need further study are |
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Menopause |
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Smoking |
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Childhood abuse and adult sexual abuse |
What can be done to decrease the risk of incontinence? There are no long-term studies describing the “natural history” of incontinence so it is hard to identify strategies that work over time. Unnecessary episiotomy is clearly one risk factor that is avoidable. Risks that are changeable through behavior modification are worth doing, such as maintaining a healthy weight and exercising.
There are also some simple strategies to decrease urinary urgency such as
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avoiding bladder irritants - tea, coffee, alcohol, chocolate, caffeinated soft drinks, tomato based products, spicy and acidic foods and drinks and artificial sweeteners.
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Avoiding over-the-counter medications such as Excedrin, Midol, Anacin, Dristan, Sinarest and prescription drugs such as diuretics may also be of help.
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Drink lots of nonirritating fluids (concentrated urine is irritating to the bladder).
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Keep healthy bowel habits: increase fiber intake found in foods such as beans, unprocessed oatmeal, bran, whole grain breads, fresh fruits and vegetables. A simple remedy for bowel regularity is taking 2 tablespoons of this mixture: 1 cup apple sauce, I cup unprocessed wheat bran, and ¾ cup prune juice.
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While data on smoking and incontinence is limited, it is a known bladder irritant and a smoker’s cough can cause leakage.
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There is good data about the value of pelvic floor muscle training as a part of prenatal care to prevent incontinence after delivery.
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Interestingly enough, continence can be achieved in nursing home patients just by having aids bring them to the bathroom every few hours! |
What can be done to treat incontinence? Once again, pelvic floor muscle training and bladder training have both been shown to improve incontinence in women. Sometimes inserting a pessary (a rubber cup) into the vagina can decrease incontinence caused by a fallen bladder. Oral hormone replacement therapy showed mixed results, worsening it in some studies, but topical or transdermal estrogens may be helpful. Some antispasmodic medications showed some improvement in incontinence but did not resolve it.
“You should tell your health care provider.” “Don’t ask, don’t tell” is what happens between patients and doctors around this issue. Results of programs to enhance physician screening have been unimpressive…and once again, it is up to consumer activism to raise this as an important issue. So tell your doctor…and tell your friends that incontinence is an important issue to address.
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