10-11-2004This is part of the Brejcha Personal and Disability Resource Site, and after reading this page you can Click here for a Menu . But for now, Welcome to my:
Note: Information provided at this web site is of a general nature and is not intended to take the place of a physician's advice. It is vital that persons diagnosed with, or suspected of having, any disability or medical condition consult with their physician or with the appropriate division at a major teaching hospital, to assure proper evaluation, treatment, and interpretation of information contained on this site.
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Those who have read the preceeding article ("For Men: Incontinence and Impotence") will find some necessary duplication of material here, but my focus this time is on a woman's perspective, and I have added some additional information (and deleted that which is irrelevant).
The first of the issues I want to address is incontinence. This is one of those embarrassing problems that people just don't want to talk about. Regrettably, this attitude often translates into neglect and unnecessary, self-imposed isolation. Granted, a woman's anatomy makes this a more difficult condition for her to deal with than it is for a man, but there are still a lot of options available that I want to discuss.
A common companion problem that also needs to be considered is the urinary tract infection (UTI). Statistics show that one out of five women will have a bladder infection within any given year. Such infections are caused by rectal bacteria that can easily cross the perineum, the area between the rectal and vaginal areas. Since women have a very short urethra, bacterial access to the bladder from the vaginal area is simple. If a woman is incontinent, this substantially compounds the risk of infection because of the increased contact between the areas.
Finally, I also want to talk about the effects of the above problems on a woman's sexuality.
I do want to stress that consultation with an urologist is essential for either problem. Through urodynamic studies, cultures, and physical examinations, your doctor will be able to determine the best possible ways to manage both incontinence and bladder infections. In addition, if you want more detailed information on bladder problems, I want to highly recommend Overcoming Bladder Disorders, by Rebecca Chalker and Kristine E. Whitmore, M.D. (HarperPerennial, New York: 1991). This guide to understanding and managing a wide range of bladder-related problems is easy to understand and comprehensive. My own article is only meant as an introduction and an assurance that options are available.
Incontinence
To begin on a reassuring note, let me say that this is a common problem. It affects millions of people to varying degrees -- probably more than statistics alone would show, since it is an embarrassing condition few people want to acknowledge. But according to Chalker and Whitmore, if all incontinent individuals would seek treatment, "...more than one half could be cured, another third could be helped significantly, and most of the rest made more comfortable.". Granted, if considering only individuals with disabilities, the cure-rate would not be as high, but most can certainly be helped significantly in managing their problems.
In general, there are several types and degrees of incontinence, and an understanding of the type or types you have is the first step to controlling it.
One of the most common among women is stress incontinence, which refers to physical, not emotional stress. This occurs when sudden activities like coughing, sneezing, laughing, or physical exertion cause a leakage of urine. It is most common in women who have had pelvic surgery, or whose pelvic muscles may have been damaged by a difficult delivery. Such conditions can allow the bladder and/or the urethra (the tube leading from the bladder) to slip out of position, putting more pressure on the bladder. It is also possible for the uterus to descend, causing further problems.
Another type is urge incontinence, where an over-active bladder causes an involuntary contraction that results in moderate to significant leakage. A bladder infection can also cause this, as it makes the bladder lining more sensitive. In older women, urge incontinence can also be due to nerve irritation, which can be mitigated by hormone therapy, and/or with a bladder anesthetic or analgesic. A variation of urge incontinence is reflex incontinence, where the bladder empties involuntarily, without sending a sensation of a need to urinate. This condition often results from spinal injuries or from some neurological disorders which interfere with spinal transmission of signals to and from the bladder and sphincter.
Overflow incontinence is another problem that can result from the lack of sensation from the bladder, causing the bladder to fill beyond its capacity and leaks the excess. This can also happen because of a tumor that blocks the urethra or interferes with the sphincter (the natural valve between the bladder and the urethra).
An additional problem resulting from some spinal injuries or conditions is bladder-sphincter dyssynergia, where the bladder contractions, voluntary or involuntary, do not coordinate with the relaxation of the sphincter. The bladder is constantly pushing, but the sphincter will not relax. If untreated, the bladder loses its ability to expand and contract normally and gets very high-pressured and small, holding only two to four ounces.
For the sake of simplicity, most reasons for incontinence boil down to a combination of four factors: an over-active or an under-active bladder, and an over-active or an under-active sphincter. The causes for these problems can be wide-ranging and fall into two classes: temporary and transient, or longstanding and chronic. For persons with disabilities, the latter category is likely to be the applicable one, and the question is how to deal with it most effectively. The important thing is to be sure to preserve the kidneys by not letting back pressure build up in the bladder.
There are many solutions for incontinence problems, but the first step is obviously to contact a doctor with experience of treating the condition. Call around to local hospitals to see if they have an incontinence center. Such a center should be equipped to do urodynamic testing. Ask about the availability of bladder-training and biofeedback programs, drug treatments and surgical intervention. Ideally, there should also be a nurse or trained office person available to discuss these options.
The next step is to put together a good picture of your relevant medical history so that when you have your first appointment, your urologist will know what he or she is dealing with. I would advise coming to your appointment with a voiding chart (Chalker & Whitmore, 1991 - copy soon to be posted). Fill it out for about a week prior to your appointment. This will enable your urologist to get a better understanding of your problem, and it will make it easier to diagnose you and establish treatment. A food diary of what you ate can also be useful.
Once your doctor has your history, a physical examination and various diagnostic tests will be the next step before deciding on how to manage your incontinence. The purpose of the testing is to determine the capacity of your bladder and your ability to retain urine. Your doctor may also look into your bladder with a cystoscope.
After a proper diagnostic work-up, treatment and management can be worked out, clinical as well as comfort and hygiene. There is a whole range of options for both, but I'll begin with clinical options.
Bladder training for urge, reflex and overflow incontinence:
Using the voiding chart as a basis, a pattern of urination catn often be determined. By taking a look at the amount of time between fluid intake and voluntary and involuntary voiding, an average interval can often be discerned. If there is a pattern of voiding about every two hours, do so whether it is needed or not. If you do not feel an urge, stimulate one with a Credét maneuver. Place your thumbs over your hip bones and spread your hands over your lower abdomen. Now, lean forward, and using your fingertips, press over your bladder area with rapid and rhythmic presses, digging in a bit. This will often work to bring on an urge to enable you to urinate. After voiding, pause briefly to fully relax, and then try to void again, repeating the pressing. Doing this will make sure that you empty your bladder as much as possible. Over time, gradually work to increase the interval between voiding by setting up a pattern of emptying as much as possible and trying to hold out. By establishing and sticking to a routine like this, you should be able to gradually increase the time span between urges, and also to reduce the number of incontinent episodes.
For individuals with overflow incontinence, a variation of timed toileting is also effective. Once a pattern of uncontrolled voiding has been determined, use a small alarm as a reminder to always go at regular intervals, timed to fall within the "safe" time periods. Be sure to maintain consistence in the timing of what you drink.
Pelvic muscle exercises for stress incontinence:
Exercises are also useful as a supplemental tool for persons with urge or reflex incontinence. Combine timed toileting with pelvic muscle exercises to strengthen the muscles needed to control your bladder. Very often, the combination can dramatically increase the length of time between voiding urges. For women with stress incontinence, these exercises can also be very useful as they strengthen the very muscles weakened by surgery or childbirth. To learn more about these exercises, the Pelvic Training Manual, and a tape with detailed information on pelvic muscle exercises, can be obtained from The National Association for Continence (see Organizations at the end of this article).
Drug Treatment:
There are two categories of drugs for incontinence problems. One slows down a hyperactive bladder, and the other either tightens or relaxes the bladder outlet, or sphincter area.
The first class, called anticholinergic, acts to damp the involuntary bladder spasms that lead to urge or reflex incontinence. Some also target certain receptors in the urethra to relax it. These drugs help reduce involuntary voiding and allow the bladder to fill more.
The second, adrenergic class is split into two types. Alpha blockers relax the muscles of the sphincter, which is useful in persons with overflow incontinence. In contrast, alpha agonists, on the other hand, tighten the sphincter muscles, which can help those with stress incontinence.
Another type of drug therapy being tried with women is hormone replacement, since the urethra and bladder require estrogen. As this type of treatment is still under investigation, discussion with your doctor is recommended.
However, because of potential side effects and interactions, drug treatment is ultimately not the best long-term treatment for incontinence. It is used primarily for urge incontinence and, on a long-term basis, mainly with individuals with neurological deficits causing urge incontinence -- commonly an interruption in spinal transmission, between the sacrum and the thoracic spine.
Intermittent catheterization:
For individuals who have no bladder contractions at all, or who have sphincter dysfunction and/or overflow incontinence, an alternative to alpha-blockers is to regularly self-catheterize. Once you get to know your body and your voiding schedule, simply set up a regular schedule to self-catheterize. A kit for this can be discretely carried with you if you have to be out. Sometimes, the bladder is paralyzed (surgically or medically), and regular self-catheterization becomes the standard way of managing a problem bladder.
Surgical Intervention:
Surgery is a last-resort option, but in certain cases, it is a useful one. For stress incontinence in women due to displacement of bladder, urethra and/or uterus, a fairly common procedure is a bladder-neck suspension. There are various ways to accomplish this, but all have the goal of lifting the urethra and bladder neck (where the two join) back up as close as possible to their original positions. In this way, sudden straining or motion will not stress them.
In cases where the bladder has become too small because of dyssynergia, another type of surgery used is urinary diversion. With this procedure, the bladder is augmented by using a piece of bowel, or a new reservoir is created to replace it, and in some cases a new drainage system is created. For more information on these procedures, see Chalker and Whitmore's book, or discuss it with your urologist.
Living with incontinence
The above gives a brief overview of incontinence and treatment, but what about living with incontinence? As anatomy makes external collection devices impractical, women are primarily forced to rely on sanitary pads. The only external collection system for women that I am aware of is made by the Hollister Corporation (for information, contact the Hollister Corporation Note: they have changed numbers and address. I'll post the new info soon). This system consists of a cup held in place by the labia and panties, and which connects with a line leading to a collection bag. The problem with this system is that activity may displace it, which leads to leakage. However, with proper cleaning and maintenance, it can be a good option for occasional use where activity is not an issue, such as long flights, where access to a bathroom may be difficult or delayed. It is recommended mainly for women with good self-maintenance skills, who have enough perineal sensation to be able to feel when the cup is dislodged. It is also important to remove the cup for a few hours every day and, at the same time, to clean and disinfect the whole system.
The most common option for incontinent women is the use of sanitary pads. There are a number of these available, and the way they work is that within the pad, there is a gel which soaks up the urine in five to fifteen minutes. However, due to the time-lag, the wearer sits in the urine for up to ten minutes, which may cause skin breakdown. The best one of these pads is probably the widely available Serenity. This has a polyethylene outer coating and very thick pad layers that the urine passes through to reach an absorbent gel which traps the urine so that it doesn't irritate the skin. In nursing homes, residents with Serenity pads seem to do better than most. Nevertheless, a skin care regimen is critical with any of these products. It is best to also use a good skin barrier (such as Bard's) to protect areas of skin that will be exposed to urine.
Ideally, the use of pads should be combined with a bladder training regimen and, if necessary, intermittent catheterization. By combining techniques like this, it may be possible to keep almost totally dry.
Urinary Tract Infections
Women with incontinence problems run a chronic risk of UTI's, as does anyone with an indwelling catheter. The best way of preventing such infections is naturally to protect the bladder from exposure to bacteria. While the above techniques aim to do that, incontinent women are still at greater risk than most people. And as I mentioned before, statistics show that one out of five women will have a bladder infection within any given year, and since such infections are caused by rectal bacteria that can easily cross the perineum, the area between the rectal and vaginal areas, this is a greater risk for incontinent women since women have a very short urethra, and bacterial access to the bladder from the vaginal area is simple.
In the case of indwelling catheters, the unavoidable slime that always forms around the catheter where it enters the urethra is a natural highway for bacteria straight into the bladder. Unfortunately, these catheters are overused. Ninety percent of individuals who get indwelling catheters could probably be managed with timed toileting, bladder training, drug therapy and intermittent catheterization, so be sure to explore the alternative options before going this route.
Assuming you have normal sensation, the symptoms of a bladder infection include frequent urination with small amounts, burning on urination, constant urge to go, some blood in the urine, and cloudy, odorous urine. It is important to be aware of this problem because if you have a history of frequent or long-standing UTI's, there is a 40% chance of getting a kidney infection at some point. With such an infection, you feel very tired and nauseous, get fevers and chills, have pain over kidney area, and have a positive urine culture.
In terms of general infection prevention, the best defense is a regular wash-out. Bacteria stick to the bladder walls, and if the bladder has a regular flow of liquid through it, it minimizes the chance of infection. Also, use the Credét maneuver regularly to make sure that the bladder is emptied as completely as possible whenever voiding. Residual, stagnant urine trapped in the bladder can be a breeding ground for bacteria. Also, as sperm can harbor bacteria, cleaning after unprotected sex is a good preventive measure.
Treatment for infections utilizes antibiotics. It is important to get a culture so that a sensitivity test can be done to determine what antibiotic will work for the particular bacteria involved. A note: if you have an indwelling catheter, it is not practical to treat every occurrence of bacteria in urine, because overuse of antibiotics can lead to resistance.
However, if you are prone to infections, once your doctor knows your condition, he or she can often direct you to do a self-start antibiotic regimen. When you start having symptoms, clean your perineal area thoroughly, get a clean catch specimen and refrigerate it, so that you can get it to your doctor for a culture. Immediately drink sixteen ounces of water and then four ounces of water with a teaspoon of baking soda, take your first dose of antibiotics, and, if your doctor recommends, take one of the bladder analgesics with it. Then take a warm bath, as it is soothing. If you do all that and keep well hydrated, the infection will probably not last too long. Then get a follow-up culture a week or two after your three to five day course of antibiotics is over. An important note: a common failure is that people get a prescription for antibiotics, take part of the prescription, and then stop when the symptoms seem to be gone. Then, when the symptoms come back, they just start taking the antibiotics again, without getting a culture done. Sometimes, especially for women with neurological problems or who are at high risk for complicated UTI's, their doctor will never know what is being treated. Whenever you are on antibiotics for any kind of infection, it is important to finish out the prescription as directed. And as antibiotics can kill the good bacteria in the bowels and cause diarrhea, it is a good idea to take to take an over-the-counter supplement such as Acidophilus or to eat yogurt.
Usually, most simple bladder infections can be cured by a single high dose of Bactrim or a sulfa drug like Amoxicillin, or by a more common three to five day course of an antibiotic such as Bactrim or Noroxin. More complex infections may require a five to ten day treatment with a stronger antibiotic such as Fluoroquinolone. But, again, treatments depend on the organism and your history.
It is important to realize that incontinence and bladder infections are manageable, especially with some foresight. Learn to pay attention to your body and to think preventively. There are no valid excuses to hide at home in embarrassment over potential "accidents" if you understand and manage your incontinence properly.
Sexuality
Sexuality poses delicate problems for women with incontinence problems. As I will discuss further in a separate chapter on sexuality and disability, you have to learn to reorient your thinking and find new ways of expressing and experiencing your sexuality, but there is no reason to shut yourself off from it.
Granted, if you are female and have a bladder problem, there will be some problems with sexuality. Most common is painful intercourse, because as penis hits upper part of vagina, the bladder, which is already sore and inflamed, gets traumatized and bruised, causing pain. If you are incontinent and experience this bruising, bacteria may stick to the urethra and get into the bladder. And if you have stress incontinence or a neurological incontinence, you may experience incontinence during sex.
There are some precautions that can help with these problems. First of all, be sure to drink plenty of fluid before sex, and try to void as fully as possible with the Credét maneuver or catheterization. This will help prevent any leakage. If you have painful bladder problems, you may want to take a mild analgesic for the pain. It is also useful to learn some relaxation exercises to avoid tensing during sex. After sex, it is important to urinate again if you have had enough to drink, and it is also a good idea to clean out thoroughly with hand-held shower or a baking soda bath. Good hygiene is important because of the increased infection risk for anyone with incontinence problems. In some cases (discuss this with your doctor) it may be a good idea to take an antibiotic prior to sex, because sex-related UTI's are the most common kind among adult women who are sexually active.
A note on actual intercourse: if you get pain over the bladder, or if the bladder is irritated and you leak every time penis hits it, find a way to aim the penis so that when it is in the vagina it is aimed more towards the back. Due to penile differences, this may take some experimenting, but that can be good fun with an understanding partner.
All this brings me back to my first point about alternate ways of enjoying sex. Focus on fondling, caressing, foreplay and oral sex as supplemental expression. Perhaps that might even be preferable to straight intercourse for most of the session. Whatever you work out together with your partner, the important thing is to concentrate on the pleasuring you are sharing with your partner -- whatever form it may take. Do not let this, or any disability, make you feel that you are any less of a woman!
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Recommended Reading (more resources coming, including a voiding chart)
Overcoming Bladder Disorders by Rebecca Chalker and Kristine E. Whitmore, M.D., New York: HarperPerennial, 1991.
Staying Dry: A Practical Guide to Bladder Control, Kathryn L. Burgio, K. Lynette Pearce, and Angelo J. Lucco, M.D., Baltimore: The Johns Hopkins University Press, 1989.
Urinary Incontinence In Adults. This free 32-page pamphlet is available from The Office of Medical Applications of Research, Building 1, Room 260, Bethesda, MS 20892.
Organizations
10-11-2004
'Dry Life' website, provided by the American Urological Association,The site is designed as a step-by-step guide to treating incontinence and is entitled "You are not alone". This guide provides an overview of the different types of incontinence, their causes, symptoms, and treatments.
National Association For Continence. P.O. Box 8310, Spartanburg, SC 29305-8310. Phone: 800-BLADDER and 864-579-7900, FAX: 864-579-7902. Web Site: http://www.nafc.org. This organization offers a range of reasources including a quarterly newsletter Quality Care.
The Simon Foundation for Continence. P.O. Box 835, Wilmette, IL 60091. 1-800-23-SIMON and 708-864-3913. This organization distributes Managing Incontinence: A Guide to Living with the Loss of Bladder Control, edited by Cheryle B. Gartley; and a quarterly newsletter called The Informer.
Continence Restored, Inc. Contact co-directors Anne Smith-Young, C.U.T., and E. Douglas Whitehead, M.D., at the Association forUrinary Continence Control, 785 Park Ave., New York, NY 10021. This organization was formed to provide support for incontinent individuals, and to provide information on how to form local support groups.
Acknowledgement: I would like the thank Dr. Kristene E. Whitmore, Director of the Incontinence Center at Philadelphia's Graduate hospital for proofing this manuscript to assure no errors or false advice slipped in.
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