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This page is dedicated to the retraining of continence in patients who have suffered a stroke, trauma, or some other condition which causes them to be incontinent of urine. First, incontinence is not a natural process of aging. Nor is it limited to women only. There are several different types of incontinence. Your doctor may send you for one of these tests to determine to what extent your incontinence extends. There are several different organizations that exist for the help of people with incontinence.

To learn best, first bookmark this page, then either view an online power point presentation about The Pathophysiology and Management of Urinary Incontinence, or scroll down and follow the blue links for more detailed information about this condition which plagues 13 million americans.

1. Causes of Incontinence:
Neurological conditions (stroke, Multiple Sclerosis, etc.)
Trauma
Urinary tract infection
Certain medications
Increased dietary intake of caffeine, alcohol, artificial sweeteners and carbonated beverages.

2. Review of Anatomy:

Female Urinary Tract Male Urinary Tract

3. How normal urination occurs:

Most people empty the bladder about every 3-4 hours during the day (4-8 times in 24 hours). “Continence is maintained by a balance between pressure within the bladder (expulsive forces) and the bladder outlet (retentive forces)” (Eisenberg, 1998, p. 2290).

Several different muscles are involved in bladder control. First, there is the external sphincter (urethrae), a muscular ring in the urethra which is made up of skeletal muscle, and therefore is under voluntary control. Next, the internal sphincter, or sphincter vesicae, is a circular muscle at the base of the bladder which is made up of smooth muscle tissue, and remains contracted until directed to relax by the micturation reflex. Next is the trigone, an area near the base of the bladder where the ureters enter and the urethra exits. The trigone plays an important part during filling and emptying. While the bladder fills, the trigone assists the internal sphincter to remain closed, and while emptying, the trigone prevents urine from backing up into the ureters. Finally, the bladder is a muscular organ, which serves as a storage reservoir for urine. The detrusor muscle of the bladder expands in all directions like a balloon (Chance, 1994).

As the bladder fills, baroreceptors in the bladder wall are stimulated and send a message to the sacral spinal cord: “I’m filling up, let’s go find a bathroom.” This message is sent up the spinal cord to the brain where the conscious mind becomes aware of the urge to void. If a toilet is not available, or if the conscious mind suppresses this urge, a message is sent to the bladder to: “calm down.” This causes the bladder to relax and enables it to nearly double its volume (350-500 ml). When increasing numbers of baroreceptors are stimulated with bladder distension, new messages are sent to the sacral spinal cord and brain regarding bladder fullness. It is at this time that an individual will experience discomfort and will be unable to ignore the urge to void. When an appropriate place is located, the external sphincter relaxes and simultaneously the detrusor muscle contracts and voiding occurs (Chance, 1994).

4. How aging affects incontinence

5. Types of urinary incontinence

Voiding difficulties are among the most common medical problems, but since patients are embarrassed to talk about urinary incontinence, often they do not report it until it becomes impossible to live with. Five major types of urinary incontinence exist: stress incontinence, urgency incontinence, overflow incontinence, functional incontinence, and mixed incontinence (Eisenberg, 1994).

6. Behavior methods of bladder control

In 1948 Kegel described an exercise to improve the tone of the muscles of the pelvic floor, thus improving urinary control (Jackson, Emerson, Johnston, Wilson, & Morales, 1996). At first, Kegel’s exercise was thought to only help stress incontinence, but recent studies show that it may also improve urgency incontinence (Eisenberg, 1998).

Since 1948, other non-surgical and non-pharmacologic treatments have been developed. These “behavioral” methods include: habit training, prompted voiding, bladder retraining, and pelvic muscle exercises with biofeedback (Colling, 1996). Habit training is timed toileting on a schedule unique to the individual. Prompted voiding involves determining whether the patient is wet or dry and to prompt the patient when to urinate. Kegel, pelvic exercises with biofeedback, and bladder retraining require active participation of the patient. Contraction of the pubococcygeal muscle, a maneuver which requires practice to master. By exercising this muscle 35-80 times daily, urethral resistance can be increased, thereby decreasing the incidence of stress incontinence. In bladder retraining, patients keep track of when they void, then increase the intervals between voidings by 30 minutes each week, until there is two and a half to four hours between each voiding (Colling, 1996).

Each of these methods has merits, and a thorough assessment will determine which method is right for the patient. Research suggests that behavior approaches report success rates from 50-80% (Messick & Powe, 1997). Furthermore, by incorporating bladder scan devices, nursing staff can perform noninvasive assessment for post-void residual urine volume. By combining intermittent straight catheterizations with bladder scans, patients can be allowed to fill their bladder to a proper amount, about 300-500 ml, without the danger of over-distention (Lewis, 1995).

7. Pharmacological Interventions

Several medications are available to improve continence. These drugs come in three basic categories: anti-histamines, antispasmodics, and hormones. These drugs may be given alone or in combination to augment a bladder-training program.

The first category, antihistamines, assists the neck of the bladder to tighten, thereby inhibiting bladder contraction. Antihistamines are most often used to treat stress incontinence. The second category, antispasmodics, promotes muscle relaxation when the “hold on” message is sent to the bladder. Unfortunately, besides dryness of the mouth, constipation, and sun sensitivity, these drugs can add to sphincter incompetency and actually cause the exact condition that is being treated. The third category is hormone replacement therapy for women. Estrogen softens the urethra and improves its ability to close. As with any drug, side effects should be monitored closely, and if possible treated separately.

As a general rule, people with continence problems should avoid drinking alcohol and beverages with caffeine or aspartame (an artificial sweetener produced by Nutrasweet®). Caffeine has a mild stimulating effect on the detrusor muscle, acting similar to a diuretic. Alcohol should be avoided because it has a strong diuretic effect. Alcohol also has strong sedative properties, which may contribute to functional incontinence. Beverages that contain Nutrasweet® can irritate the bladder, causing urgency. Finally, adequate fluid intake will prevent urinary tract infections, and dilutes the urine. Extremely concentrated urine has been known to irritate the bladder, the same as beverages with Nutrasweet®. Generally speaking, adequate fluid intake equals 25 ml multiplied by body weight in kilograms (Colling, 1996).

8. Surgical Management

Surgery is occasionally needed to correct a physical condition that prevents continence. Surgical interventions to treat urinary incontinence include: returning the bladder to its proper position, remove a blockage which is preventing outflow, support weakened pelvic muscles, or enlarge a small bladder in order to hold more urine. (Eisenberg, 1998). Surgery is indicated when more conservative methods of treatment have failed.

9. Nursing Implications

The focus of gerontologic nursing has long been on the elimination needs of patients. But only within the last twenty years has nursing taken an active role in treatment of incontinence. Up until then, pharmacological and surgical management were the mainstay of long-term bladder control (Colling, 1996).

Today, nurses are acting as continence-specialists and are actively involved in the retraining of patients who have lost the ability to void in an appropriate place at a convenient time. Nurses are key in the education of patients when incontinence occurs. It must be stressed to the public that incontinence is not a normal part of the aging process, and it can be treated medically, surgically, and through behavior programs. Only through public education can a change in attitude, improved management, and prevention of incontinence occur (Muller, 1997).

The challenge for gerontologic nurses is to gather a complete health history and perform a thorough assessment. With these, a clear, clinical picture can be painted, and an accurate diagnosis of the type of urinary incontinence can be made. If these puzzle pieces fall in the right place, the right combination of pharmacological, surgical, and bladder retraining can be implemented to help the older patient "regain confidence" with his or her continence and live life to the fullest extent.

This page is always under construction.
Last updated 4/28/99
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