Continence

Urinary incontinence affects about four million Australians of all ages and is most common in older people. It may be caused by brain or nerve damage, by other physical changes (e.g. prostate enlargement or infections) or the environment may contribute (e.g. difficulty finding public toilets). There are several different types of urinary incontinence: 

• Stress incontinence
• Urge incontinence
• Overflow incontinence
• Reflex incontinence
• Functional (Age and disability-related) incontinence
  
  

Stress incontinence

Stress incontinence is when small amounts of urine leak while coughing, sneezing, laughing, straining or lifting. It is usually related to changes in the pelvic floor muscles as a result of childbirth, being overweight, chronic constipation, chronic coughing, menopause or prostate surgery.

Urge incontinence

This type occurs when a bladder contracts without warning and the person gets a sudden, strong urge to urinate. This may result in some loss of urine. People with urge incontinence visit the toilet very often. It's common in people with stroke, Parkinson's disease and other conditions. Alcohol, caffeine, cold weather and anxiety make it worse.

Overflow incontinence

Overflow occurs where the bladder does not empty properly and urine spills out without warning. The cause is usually something obstructing the flow of urine. It is common in men with an enlarged prostate but constipation can also contribute. Sometimes a neurological problem can make the person unable to feel a full bladder, causing overflow incontinence.

Reflex incontinence

When certain nerves in the spinal cord are damaged, the messages they send from the bladder to the brain are disrupted. When full, the bladder takes action and empties itself. Reflex incontinence is particularly distressing because it results in flooding, rather than leaking, without warning.

Functional incontinence

Older people or people with a physical disability cannot always reach the toilet in time. They may have difficulty in moving fast or in undoing clothing. The problem may be complicated by dementia, poor vision, or a toilet that is difficult to reach in time.

Bowel Incontinence

Bowel control problems are less common than bladder problems but still affect many people of all ages. Poor diet, not enough to drink and lack of exercise are key contributors to bowel incontinence. A well balanced diet, good fluid intake, and regular exercise can help prevent it.

There are many causes of urinary and faecal incontinence. It might be a neurological problem, a urinary tract infection, prostate problems, diabetes, constipation, or even a chronic cough, but most causes can be treated.

Medications are sometimes the culprit. For instance, some sedatives reduce a person's awareness of body signals, while blood pressure pills can occasionally cause stress incontinence. Other drugs may cause constipation, which can lead to bladder or bowel incontinence. Talk to your doctor about any problems you are experiencing.

In the case of bowel incontinence, severe constipation is often the problem. This causes the back passage to become stretched and weakened over time and the person loses control over it. Loose stools can also be difficult to control, especially if your pelvic floor muscles are weak or the sphincter muscle has been damaged. Loose stools may be caused by eating too much fibre, highly spiced foods or other food intolerance, some medications or bowel surgery.

Your doctor might order tests, such as a urinalysis to check for a urinary infection. A bladder ultrasound may be required to check if the bladder is emptying fully. Sometimes an X-ray may be required to detect severe constipation.

Treatments can range from losing weight and bladder retraining to curing chronic constipation, physiotherapy and for a few, surgery.

Where medication is contributing to incontinence, your doctor may be able to reduce the dose, spread the pills out over the day or change the medication. For urge incontinence, medicines are available to slow down the bladder, which doesn’t cure the problem, but it can improve things significantly. There may be side effects however.

Physiotherapists can help with stress and urge incontinence by providing simple exercises to strengthen the pelvic floor muscles that need to be done regularly. 

Your doctor might need to refer you to a continence advisor – a nurse, physiotherapist or medical specialist working in continence management. Sometimes a referral to a urologist (a specialist in urinary problems), a urogynacologist (for bladder problems related to gynaecological issues) or a geriatrician (a specialist in aged-care) is appropriate. 

Incontinence often results when a toilet is not easy to find or use. An occupational therapist or advisors at the Independent Living Centre can help you assess your environment for practical purposes and set it up to help prevent accidents. Are any of the following issues in your home?

Getting to the toilet

Can the person readily walk the distance to the toilet? Is the lighting good enough? Are there mats to trip on? Would it help to leave a night light on? A label on the toilet door may remind someone with memory problems where it is.

Setting up the toilet

Do steps create access issues? Is the doorway and room big enough for a wheelchair or walking frame? Can the person balance at the toilet? Grip rails may help. If access can’t be improved, a urinal or commode chair may be the best solution. Is the toilet too low? Devices are available to raise the toilet seat. Can the person reach the toilet paper? Does poor balance or restricted movement in shoulders, elbows or hands make it difficult to use the toilet paper? 

Clothing

Is clothing easy to get on and off? Lots of layers can be a problem. Use stretch fabrics, elastic waist bands and Velcro rather than zips or buttons. For easy laundering, buy non-iron clothes or consider using a linen service if constant washing of sheets is an issue.

Public facilities

When out, look for places with disabled toilets as these have space for a wheelchair and two people. See the Melbourne Central Business District Mobility Map, published in the Melway Street Directory or available free from the City of Melbourne Hotline: (03) 9658 9658. Also check the National Public Toilet Map website at www.toiletmap.gov.au to locate toilets by town, suburb or postcode.

When memory is a problem

Establish a routine and remind the person to use the toilet at regular intervals (every two or three hours) or at the times you know they usually go.

Diet, fluid intake and exercise are all key elements for managing incontinence well. 

Diet

Constipation can make bladder problems worse and sometimes leads to faecal incontinence. A regular bowel pattern depends on a healthy, high- fibre diet, which means lots of fruits (fresh, stewed, dried), vegetables, wholegrain and wholemeal cereals and breads (oatmeal, rice, rye, wheat, barley) and nuts and lentils. 

Fluid intake

We need about 1.5 to 2 litres of fluid a day – six to eight glasses. Fluid intake includes foods with high fluid content, such as jellies, soups and yoghurt. In the case of faecal incontinence, adequate fluid helps to soften constipated stools or thicken loose stools. 

Often people with bladder problems try to drink less for fear of becoming wet, but this only makes matters worse. Firstly, it can cause constipation. Secondly, urine becomes concentrated, which can irritate the bladder, leading to infection. Thirdly, the bladder learns to hold less fluid, resulting in more frequent trips to the toilet. It’s important to drink enough, but sensible to refrain from lots of fluid before bedtime or social outings.

Exercise

Regular exercise is important because it improves blood flow throughout the body, including the gut, which helps to prevent constipation. If walking isn’t possible, arm, leg and body exercises will help. 

Weak pelvic floor muscles can often also contribute to both bladder and bowel incontinence. Continence Physiotherapists can assist with pelvic floor exercises.

Absorbent pads and special pants are available that are designed to absorb urine or contain faeces. These come in a range of sizes and levels of absorbency. Some pads are disposable, some are reusable and they are held in place by special pants. 

For mild incontinence, some women can use thin continence pads or even panty liners. Menstrual pads are not effective because they are not designed to hold urine and they do not eliminate odour. 

Urinary incontinence in men can be managed through condom drainage – a sheath over the penis, with a tube attached that leads to a leg bag or overnight bag. Some people use condom drainage as a back-up on outings, for example. 

For men or women, urine can also be collected via a catheter – a tube inserted into the bladder. Long- term catheters need careful management however to minimise infections and other complications. A bag to collect the urine is strapped to the leg under the clothing. A larger bag can hang on the bed at night. Ask your doctor about this method. 

Other continence aids include absorbent bed sheets and chair covers (reusable or disposable), bed pans, commodes and non-spill urinals for use in bed or on car journeys.

Most people must pay for their continence aids. Some assistance is available in some states and territories through government-funded schemes, such as the Aids and Equipment Scheme in Victoria. Some people on a disability pension may be eligible for the Continence Aids Payment Scheme. Ask your doctor, the National Continence Helpline or another health professional about this. 

Other sources of help include continence services and clinics, general practitioners, local community health centres or community nursing services. Your doctor can refer you to a nursing service.