Don’t Make Me Laugh — Please!
Millions of American women suffer from female urinary incontinence. Nurses should familiarize themselves with its types and treatment modalities
By Bonnie P. Ward, RN, BSN
January 10, 2005
Laughter may be the best medicine in some situations, but for the estimated 12 million Americans who suffer from urinary incontinence (UI),1 the last thing they need is to double over with mirth: For many UI sufferers, that simple reflex can cause a leakage episode. UI itself is no laughing matter for women especially, since they’re twice as likely as men to experience it — along with the almost inevitable stigma.
Urinary incontinence can significantly affect a person’s quality of life by causing profound embarrassment. It limits daily activities and sexual functioning, and it leads to social withdrawal and depression. What’s more, increased urinary tract infections (UTIs) among incontinent women plus injury from falls incurred while hurrying to the toilet put these individuals at additional risk for negative health consequences.2
Beyond the tremendous psychosocial impact, UI also imposes an exceptional financial burden on affected individuals, society, hospitals, and insurers. In 1995, $26 billion was spent directly and indirectly on care for those with UI older than 65.3 This is up from $8 billion in 1984 and $16 billion in 1993.4
Sadly, while 80% of UI cases can be cured or significantly improved, women still suffer in silence.3 They fear not being taken seriously. Or they’ve been led to believe that incontinence is just part of growing older, so they just have to come to terms with it. Mean while, lives have been quietly rearranged and relationships lost as women avoid having to admit that
there’s a problem.5
What can nurses do to help this segment of the population? The first step is having a general understanding of the problem and knowledge of available treatment options.
Female Genitourinary System 
This schematic of the normal female genitourinary system points out the pelvic floor muscles, whose healthy functioning has been shown to enhance the urethral closure mechanism. Kegel exercises, which strengthen pelvic floor tissue, can help reverse urinary incontinence.
Types of UI
Urinary incontinence is the involuntary loss of bladder control, which in turn leads to involuntary loss of urine. Typically, UI is categorized four ways, each with different underlying causes.
Stress urinary incontinence (SUI) is the most common form, caused by weakness of the pelvic floor muscles, most often associated with the effects of pregnancy or childbirth. Other possible causes include urethral hypermobility, intrinsic urethral sphincter deficiency, and estrogen deficiency.2 Symptoms of SUI involve the loss of urine caused by an increase in abdominal pressure that generally occurs with laughing, sneezing, or coughing or during exercise.
Overactive bladder (OAB), also called urge incontinence or detrusor instability, is another form of UI that stems from a premature bladder contraction. Although the mechanism is poorly understood, the neurological message that normally transmits to the brain the need to void (the micturition reflex) is somehow short-circuited. The detrusor muscle surrounding the bladder contracts, regardless of accumulated bladder volume and without conscious control. This results in an extreme sense of urgency to void, accompanied by the loss of urine present in the bladder. Frequent nocturnal urination is also a common complaint with those affected by OAB. And although the condition is most often of an idiopathic nature, Parkin son’s disease, dementia, and cortical damage (resulting from stroke, for example) have been known to contribute to it.2
Overflow incontinence is associated with overdistension of the bladder and subsequent difficulty in emptying its contents. The condition is not as common as the previous two types of incontinence. The kidneys are constantly passing urine through the ureters to the bladder. The bladder fills, but it has a finite capacity. Beyond this level, excess urine will need to pass, resulting in symptoms of constant dribbling or leakage.
A combination of stress and OAB is referred to as mixed incontinence, the fourth category of UI. Although one type is usually more predominant with mixed incontinence, the expressed symptoms may be a mixture of loss of urine with increased abdominal pressure and frequency that appear without warning.
A thorough physical examination is necessary to determine the underlying cause or causes of UI. In some cases, more specialized urodynamic testing may be indicated. Once the full nature of the problem is understood, it’s important to review and discuss all possible treatments, taking into consideration each patient’s unique needs.
Treatment options
Treatment of UI falls into three general categories: behavioral techniques, pharmacological intervention, and surgical correction.
Stress incontinence is most often treated through behavioral techniques. Initial treatment usually starts with efforts at strengthening the pelvic floor muscles. This can be achieved by teaching the patient to perform Kegel exercises daily (see sidebar). It’s important to teach the correct technique and have the patient demonstrate understanding of how to isolate the perivaginal muscles.
Vaginal cones or weights can be used as adjunct therapy. These devices are inserted into the vaginal canal twice a day for 15 minutes each session. By trying to retain the cone or weight, the patient must tighten the perivaginal muscles, as if she were performing a Kegel exercise. This in turn will strengthen the pelvic floor muscles. The items, which come in a kit, are graduated in weight, with a predetermined amount of time spent at each level.
Biofeedback also can augment pelvic floor strengthening. This is usually done with the help of a specially trained continence nurse or physical therapist, since the equipment is rarely available in primary care offices.3 The instruments relay information or sensory feedback to the patient, assisting her in correctly performing Kegel exercises.
Mechanical devices like continence rings or pessaries (see photo on opposite page) can be used to lessen urinary leakage by stabilizing the urethrovesical junction to allow proper pressure transmission when intraabdominal pressure increases, as during sneezing or coughing.6
Pharmaceutical treatment is not often the first choice of therapy for stress incontinence; phenylpropanola mine, pseudoephedrine, and estrogen have been shown to be useful.7 In cases of sphincter insufficiency, phenyl pro panol amine and pseudoephedrine have been beneficial in causing muscle contractions in the alpha-adrenergic receptors around the bladder, thereby increasing bladder outlet resistance. Estrogen has been useful in treating vaginal atrophy.7 Improving the overall health of pelvic floor tissue has been shown to enhance the urethral closure mechanism.
Pharmaceutical management can be helpful in trying to stop the uninhibited bladder contraction of OAB. Oxybutynin, an anticholinergic agent, is usually the first-line drug of choice. This pharmaceutical agent, however, is not without potential adverse effects or contraindications. These must be taken into consideration and thoroughly discussed with the patient when considering this treatment. The principle behind this therapy is an attempt to allow a greater volume of urine to be stored in the bladder and achieve fewer uninhibited bladder contractions.3 Pharmaceutical therapy works best when combined with the behavioral measures previously mentioned.
Because surgical correction is more invasive, it might be preferable to try behavioral therapy or pharmacological intervention first. But for some, surgery becomes a first-line treatment option; it is actually commonly prescribed for women with SUI.
Retropubic or needle suspensions are recommended with urethral hypermobility, while sling procedures or periurethral bulking agents are used to treat intrinsic sphincter deficiency.8
A major goal in treating OAB is to reduce the intake of bladder irritants, such as caffeine, alcohol, spicy foods, and nicotine. Sudden bladder distention, overly concentrated urine, and constipation also should be avoided. Along with potentially lessening urgency by reducing the causative stimuli, bladder retraining also is indicated. This form of therapy, however, works best for highly motivated women who can keep a bladder record and demonstrate the ability to suppress urgency episodes through bladder relaxation and sensory distraction. These women must also have supportive education to help them understand that any movement at the time OAB is experienced — such as running for the bathroom — may merely stimulate the bladder further. Avoiding movement, making an effort to relax, and performing a pelvic muscle contraction (Kegel) exercise is a three-step process for helping overcome the immediate urgency.3
Functional electrical stimulation, similar to biofeedback, has been used with some success. A probe is inserted in the vaginal canal that will emit an electrical impulse stimulating pelvic floor muscles to contract. The goal is once again to improve the strength of the pelvic floor and additionally override uninhibited blad der contraction.
Because a physiological cause — such as diabetes, spinal cord injury, or an obstruction — most often precipitates overflow incontinence, individuals experiencing this type of UI should be thoroughly evaluated, with a focus on underlying factors.
What nurses can do
By understanding more about the causes and treatments of UI, nurses can open the door to a more comfortable dialogue with female patients over the sensitive issues surrounding urinary leakage. Helping women understand that they are not alone and need not suffer the indignities of UI can help overcome the stigma that may have caused them to restrict their daily activities or abandon pursuits that gave them pleasure.
Though the incidence of UI is still greater in those older than 50, nurses should not forget that women can be at risk for UI anywhere in the life cycle. Active screening and careful listening are important skills for the nurse to practice. They may ultimately spare a patient the embarrassment and humiliation of untreated urinary incontinence.
Kegel exercises
Pelvic floor muscle exercises are not a new concept in the treatment of urinary incontinence - they've been in use since the early 1930s. But it was the work of gynecologist Arnold Kegel, MD, that popularized the subject of pelvic muscle rehabilitation. In the late 1940s, Kegel invented the Kegel perineometer, basically a biofeedback device enabling a woman to observe the strength and duration of her pelvic floor muscle contractions to determine the effectiveness of the exercises.
Located in the bottom portion of the pelvis, pelvic floor muscles support internal organs and surround the urethra, vagina, and rectum. Loss of support of these muscles can lead to pelvic organ prolapse or incontinence of bladder and bowel.
To locate the pelvic floor muscles, pull in on your rectal muscles as if you were trying to retain gas. Try to keep the abdominal, thigh, and buttock muscles relaxed when tightening the muscles of the pelvic floor. At first, it may be difficult to tell if the muscles are getting stronger. Be patient and keep practicing, though - it can take two to eight weeks before you notice any significant change in muscle strength.
Attaching Kegel exercises to activities performed every day can help make them a healthful habit - try doing them whenever you stop at a red light, for example, or talk on the phone or perform household tasks. The exercises should take only about 10 minutes a day.
To perform pelvic muscle exercises -
Step 1: Slowly tighten the pelvic muscles and initially hold the contraction for three to five seconds, then relax the muscles for 10 seconds. Repeat 10 times. Work gradually up to a 10-second hold.
Step 2: Tighten the pelvic muscles in a quick, strong contraction. Relax the pelvic muscles. Repeat 10 times.
Then do Steps 1 and 2 above as a set.
Start by performing one to two sets each day, gradually building up to five a day. If your muscles become too tired to contract, stop and try again an hour or two later.
Do not hold your breath while performing these exercises. Instead, breathe out while tightening your pelvic muscles.
Remember, even when the muscles are stronger and leakage is no longer a problem, continuing Kegel exercises routinely will help maintain a healthy pelvic floor.
Bonnie P. Ward, RN, BSN, is a nurse educator in the Patient & Health Education Department at Southern California Kaiser Permanente, San Diego.
References
1. Urinary Incontinence. American Foundation for Urologic Disease Website. Available at: www.afud.org/conditions/ui.asp. Accessed December 8, 2004.
2. Loughrey L. Taking a sensitive approach to urinary incontinence. Nurs 99. May 1999;29(5):60-61.
3. Krissovich M, Safran R. Differential diagnosis: urinary incontinence in adults. Lippincott’s Primary Care Pract. 1997;1(4):361-381.
4. Telford C. Understanding the problem of urinary incontinence. J Am Acad Physician Assistants. 2002;15(1):45-50.
5. McCallig Bates P. Helping women manage urinary incontinence. Advance Skin Wound Care. 2000;13(6):85-89.
6. Weinberger MJ. Conservative treatment of urinary incontinence. Clin Obstet Gynecol. 1995;38(1):175-188.
7. Urinary Incontinence: Embarrassing but Treatable. American Academy of Family Physicians Website. Available at: http://familydoctor.org/189.xml. Accessed December 8, 2004.
8. Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline No. 2. Publication No. 96-0682. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research; 1996.
Bibliography
KFCnemann KP. The management of female urinary stress incontinence: II. the use of devices. Br J Urol Int. 2001;87:449-455.