by Michel A. Boileau, M.D. and
Dorothy B. Smith, R.N., M.S., FAAN
 THE SECRET
ARE YOU ONE OF MILLIONS KEEPING A
SECRET ABOUT YOUR HEALTH? OVER 25
MILLION AMERICAN MEN AND WOMEN HAVE
bladder control problems. Most will go to
great lengths to conceal their problem.
Symptoms may vary among individuals but
include the following:
- quickly rushing to the bathroom every 30¨C45 minutes because of an urgent need to "go"
- making several trips to the bathroom during the night
- having urinary leakage with a laugh, sneeze or cough
- losing bladder control when lifting a heavy object or exercise
- having bladder control problems during sexual intercourse
- urinary leakage when standing from a sitting position or on the way to the bathroom
- never recovering from bladder control problems while being pregnant.
Bladder control is the most personal of personal
problems. Many associate it with
being childlike. Historically those with
uncontrolled urine loss were shunned and
made to feel ashamed. Today only one in
four seek help for this condition. Most
choose to remain silent, resorting to diapers,
pads and secrecy. Embarrassment and social
isolation still surround this issue even
though most men and women can be
helped. Up to 85 percent of those suffering
from bladder control problems can find
relief without drugs or surgery.1
Bladder control problems are not only
found in the elderly. One third of young
female soldiers have urinary leakage during
field exercises.2 In a report from the
University of Iowa, one third of the elite
athletes studied leaked urine during their
sport.3 Many women have symptoms of
urgency, frequency and leakage during pregnancy
and after childbirth. A common side
effect for men after treatment for prostate
cancer is loss of bladder control. Both men
and women may feel urgency to go to the
bathroom after a cup of coffee or tea.
The involuntary loss of urine is also
known as a bladder control problem, overactive
bladder, urinary incontinence, urinary
leakage or simply "an accident." There
are several types. Briefly, "stress incontinence"
is a loss of bladder control after a
cough, laugh, sneeze, lift or impact exercise.
"Urge incontinence" refers to a sudden and
urgent need to get to the bathroom. This
can happen after a cup of coffee, tea, glass of
water or as soon as one sees the "fasten your
seat belt" sign on an airplane. It is not
uncommon to have symptoms of both stress
and urge, or "mixed incontinence." For
example, a young mother may leak urine
when she picks up her toddler as well as having
to search out every bathroom in the shopping
mall due to urgency and frequency.
You are not alone with this problem.
There are many risk factors for loss of bladder
control. Common risk factors are:
- Gender (female)
- Pregnancy
- Childbirth
- Menopause
- Hysterectomy
- Obesity, smoking
- Prostate enlargement
- Prostate treatment
- Pelvic surgery
- Diabetes
- Lifting
- Impact exercise.
Healthy behaviors such as those discussed
in this article can lower risks and
improve symptoms of stress, urge and mixed
incontinence.
WHAT YOU CAN DO WITHOUT DRUGS OR SURGERY
Fluid/diet management
Some fluids and foods act as irritants to the
lining of the bladder, causing the bladder to
be overactive. This leads to having the
urgent and frequent need to empty the bladder
even though there is only a small
amount of urine in the bladder.
Not everyone reacts to these items the
same way. The best way to determine if
something is making the bladder more
active is to drink only water for three or four
days. Then, one at a time, reintroduce other
items, observing if any are causing you to
have an urgent need to go to the bathroom.
Adjust your behaviors accordingly. For
example, if you identify coffee as a bladder
irritant, perhaps you would choose to omit
coffee before travel or a long meeting.
Water is the best fluid for your body.
Drink eight to 10 glasses a day. Sometimes,
in an effort to reduce the need to go to the
bathroom, a person cuts back on fluid
intake. This makes the urine more concentrated
and the bladder more active, causing
the opposite effect of what was intended.
Drinking water in small amounts throughout
the day is the best method. The current
practice of carrying a "sports" bottle is actually
very healthy.
Urge suppression
What is urge suppression? Children learn to
suppress an urge by necessity. For example,
after a movie you take your child to the rest
room and there is a line waiting. You tell
your child to "hold it" for a minute. Your
child may then do the "pee-pee dance" as
s/he tries to hold back the leakage. You may
have had to do the same thing on an airplane,
at the mall, at a sports event or at work. To suppress an urge or need to go to the
bathroom, take a deep breath and focus on
relaxing. Do a quick pelvic muscle contraction.
Distract yourself by making a phone call,
starting a grocery list or putting away the
dishes. Allow the urge to pass. It will. Wait a
few minutes and then slowly move to the
bathroom. Rushing only makes the bladder
more likely to contract, making the urge
worse. This increases the risk of an “accident,”
either leaking urine or a fall. Urge suppression
becomes easier as you practice. Begin by waiting
five minutes before going to the bathroom.
Gradually build up to where you are
only going to the bathroom every three to
four hours. Urge suppression or inhibition is a
process requiring practice and time to succeed.
Do not make the mistake of thinking
you are safe if you have been successful one
time. Practice urge suppression in a comfortable
environment with a bathroom nearby
until you have control.
Bladder training
This goes along with urge suppression.
Suppress the urge to go to the bathroom initially,
letting your bladder fill more. Gradually
your bladder gets used to a greater volume of
urine. Instead of sending a message of a full
bladder every 45 minutes, the bladder “learns”
to wait up to three hours. There will be times
when you get the message with a shorter interval,
depending on what and how much fluid
you have had. For example, drinking two cups
of tea may normally send you to the bathroom
in 30 minutes.
Pelvic muscle re-education/biofeedback
Pelvic muscle re-education refers to an exercise
program of correctly contracting and
relaxing the pelvic floor muscles. Biofeedback
is simply a tool that tells you how your body
is responding. For example, a blood pressure
device or a thermometer provides biofeedback.
The pelvic floor muscles surround the
urethra, which is the tube that empties urine
from the bladder. Because the urethra has to
close tightly to keep urine from leaking, the
muscles around the urethra, when contracted,
can help the urethra close tightly. Pelvic muscle
re-education with biofeedback is very
effective for stress, urge and mixed bladder
control symptoms. Biofeedback is important
because 50 percent of women cannot correctly
do a pelvic muscle contraction with just
verbal instructions.4 That is why so many
women have said “I tried that and it didn’t
help.” Pelvic muscle re-education is actually a
muscle exercise program. It can be used to
tighten the closure of the urethra as well as to
inhibit the nerve that causes the bladder to
contract. By correctly squeezing or contracting
the pelvic floor muscle, the bladder is
given a message to relax. This is helpful for
urge incontinence and in performing urge
suppression. Pelvic muscle re-education also
serves to strengthen the muscles that surround
the urethra. As these muscles get stronger and
larger, they can help the urethra close and prevent
the leakage of urine after a cough, laugh,
sneeze, lift or exercise. For the man who has
had prostate surgery resulting in loss of bladder
control, these muscles can actually take
over as a mechanism for bladder control in
some instances.
Successful muscle exercise programs
require specificity (correct muscle), overload
(against resistance) and consistency.5 Because
pelvic floor muscles are not easy to identify,
biofeedback is recommended. An easy to use,
affordable, over-the-counter biofeedback system
such as *fria™ can be used in the privacy
of home.
Start with where you are—do not be discouraged.
You will improve with practice. Do
one or two sessions a day. Do not overdo your
exercises as these muscles fatigue easily. Men
seem to want to start with 100 contractions
the first day. This effort can actually make
symptoms worse initially because of muscle
fatigue. Plan a program and build muscle
strength gradually as you would with any
muscle-strengthening program. Then stick
with it.
Double void
This term means just what it says—empty the
bladder twice. After first trying to empty the
bladder, relax for a few seconds and try to
empty it a second time. It may be helpful to
change positions, lean forward or press above
the bladder with your hand. This can be very
useful for people who are not emptying their
bladder completely with the first attempt.
Interestingly enough, this is something many
pregnant women do without even thinking
about it—changing positions while on the
toilet and straining a second time.
Avoid constipation
Constipation can lead to straining for elimination.
Constipation, or hard-formed stool in
the rectum, can affect urinary function.
Before working on bladder training, pelvic
muscle re-education or urge suppression, first
reduce constipation. To minimize constipation,
drink plenty of fluids, eat grains, fruits
and vegetables for fiber. Bran or fiber can be
added to muffins, jam or cereal. Exercise daily,
have a routine for bowel elimination, respond
to the urge for a bowel movement and allow
plenty of time for evacuation.
Lifestyle changes
There are some lifestyle changes that can
improve bladder control symptoms. Smoking
cessation is one. Nicotine can be a bladder
irritant, causing the bladder to be overactive.
Also, many smokers have a chronic cough,
which contributes to stress incontinence.
Weight control is another. Being overweight
increases the gravity forces on the pelvic muscles
that support the bladder and urethra.
Without good support the bladder and urethra
may “fall” out of position, losing some
ability to close tightly. A third is type of exercise.
High impact exercises (aerobics, jumping,
jogging, lifting) create forceful stresses on
the pelvic muscles and support ligaments for
the bladder. If you are participating in these
activities, it is recommended that you
strengthen your pelvic floor muscles to counter
these exercise forces.
SUMMARY
By gaining knowledge about bladder health,
recognizing factors that contribute to bladder
control symptoms and adopting healthy
behaviors mentioned in this article, you can
take control and provide a better quality of
health for your future.
*fria™ is a home biofeedback unit cleared by
the FDA for bladder control. It is available
from DesChutes Medical Products, Inc.
Tel: 800-383-2588.
Michel A. Boileau, M.D., is a clinical professor
of urology, Oregon Health Sciences University.
Dorothy B. Smith, R.N., M.S., FAAN, is vice
president, Clinical Affairs, DesChutes Medical
Products, Inc., Bend, Oregon.
References:
1. Fantl, J. A., Newman, D. K., Colling, J., et al. “Urinary Incontinence in Adults: Acute and Chronic Management.” Clinical Practice Guideline, No. 2, 1996. Rockville, MD. U.S. Dept. of Health and Human Services. AHCPR Publication No. 96-0682. March 1996.
2. Sherman, R. A., Davis, G. D. “Behavioral treatment of exercise-induced urinary incontinence among female soldiers.” Military Medicine (1997). Vol. 162(10) pp. 690–4.
3. Nygaard, I. E., Thompson, F. L., Svengalis, S. L., Albright, J. P. “Urinary incontinence in elite nulliparous athletes,” Obstet Gynecol (1994). Vol. 84 pp. 183–7.
4. Bump, R. C., Hurt, W. G., Fantl, J. A., Wyman, J. F. “Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction,” Am J Obstet Gynecol (1991). Vol. 165 pp. 322–9.
5. DiNubile, N. S. “Strength training,” Clin Sports Med (1991). Vol. 10(1) pp. 33–62.
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