BPH

Regaining Control Of Your Bladder

A weakened bladder or urinary incontinence is a common problem as we age.

It is underdiagnosed because many patients do not report their symptoms.

They feel embarrassed and do not talk to their doctor about it. Still, this problem affects up to 84% of patients in long-term healthcare facilities.

What causes a weakened bladder in men?

There are three types of urinary incontinence, and each one is triggered by different causes (1):

  • Stress incontinence: This type of incontinence is triggered by abdominal pressure. For example, when the patient is coughing, laughing, or climbing stairs. The abdominal muscles press against the weakened bladder resulting in bladder leakage.

  • Urge incontinence: It is a type of urinary incontinence preceded by sudden urgency. Out of nothing, the patient feels an urgent impulse to urinate. It is usually due to pressure problems or irritation problems in the bladder.

  • Functional incontinence: When none of the above is the trigger of incontinence, it is usually functional incontinence. There is no urinary tract dysfunction or neurologic-urologic problem. Instead, the patient has psychiatric issues, mobility issues, or any other cause.

  • Mixed incontinence: It is a combination of urge incontinence and stress incontinence. The patient feels urgency and has urinary leakages with exertion.

In most cases, patients do not have only one but multiple causes at the same time. Most of them are either functional or structural problems in the bladder, ureters, or urethra. The problem is sometimes in the surrounding connective tissue, the spinal cord, or another structure. That’s why it is essential to recollect medical issues that may cause or aggravate this condition.

In women, the most likely cause is poor pelvic support, which causes urethral hypermobility. They have a descended and highly mobile bladder and urethra. In males and females, stress incontinence may also be caused by sphincter muscle deficiency. These ring-like muscles prevent urine leakages. They can become weaker after surgery, trauma to pelvic organs, or as a result of aging.

Neurologic dysfunction also makes the sphincter fail, causing stress incontinence. In men, the most common cause is radical prostatectomy or transurethral resection of the prostate. Prostate cancer may also invade the tissue and cause significant problems.

However, as we age, our connective tissue becomes weaker. In some cases, there is an atrophy of genitourinary structures. In other cases, nutritional deficiencies such as low vitamin D levels contribute to increasing the risk. Moreover, obesity and smoking contribute to the problem and worsen the situation.

As you can see, there are many causes, and each patient has their own. But in some patients, there is detrusor overactivity with no traceable reason.

To summarize and list possible causes, we can separate them into three categories:

  • Transient causes: As the name implies, these causes are temporary. It is the typical case of urinary incontinence in hospitalized or critical patients. After they recover from their condition, the problem improves significantly. Urinary tract infections are a likely transient cause, especially in women. It can also be the case in men, especially when bladder stones are irritating the urinary tract. Psychological or psychiatric disorders are also important to note. That includes behavioral disturbances, depression, acute confusion, and delirium. Patients with restricted mobility may also suffer from incontinence, regardless of their psychological status. Some pharmaceutical agents can be included as transient causes, as well as atrophic urethritis. Moreover, we can have too many alcoholic beverages or coffee and increase the urine output, causing a transient case of urinary incontinence (2).

  • Neurological causes: The most severe neurological cause of urinary incontinence is a cortical lesion. For example, after a stroke, cranial hemorrhage, tumor, or aneurysm. They can cause voiding problems or sphincter relaxation issues. In some cases, they trigger a depression of social awareness that contributes to the problem. Spinal cord lesions may also cause urinary incontinence, especially when they alter the parasympathetic tone. This is what happens in diabetic patients with peripheral neuropathy. As a result, the bladder has contractile dysfunction and starts leaking urine. Cancer and other tumors may also compress the spinal cord and cause alterations. The most common spinal cord alterations are found in the S2-S5 nerves. It is also essential to rule out multiple sclerosis as another likely cause of incontinence. This diagnosis should be considered in case of a rapid onset of symptoms without urinary tract infections (3).

  • Pharmacologic causes: Medications can be a transient cause. But it is sometimes difficult to change medications in elderly patients with multiple health problems. Thus, we should know that different types of drugs increase the risk of incontinence. For example, antidepressants and calcium-channel blockers can lead to urinary retention and overflow incontinence. The same happens with alpha-adrenergic agonists. On the other hand, alpha antagonists cause urethral relaxation and let urine escape. Diuretics overwhelm the capacity of the bladder in older adults (3).

Symptoms

As noted above, incontinence is felt differently in each type. Urge incontinence is sudden and very violent. Sometimes patients experience urine leakages as they try to find an available bathroom.

Stress incontinence starts when abdominal pressure increases. It is the typical patient who experiences urine leakages when making physical efforts or laughing. In many cases, patients experience a combination of stress and urge incontinence. This is known as mixed incontinence.

Let us take a look at each type of incontinence, but this time focusing on their symptoms:

  • Stress incontinence: This is one of the most predictable types of incontinence. It only appears then the patient makes an abdominal effort. The most common are laughing, coughing, or sneezing. But it can also be sporting activities such as tennis and lifting the stairs. They usually experience leakages when standing and not when lying down. The leakage is usually significantly reduced and usually handled with thin pads. These patients typically don’t need more than 1 to 3 pads every day. They usually don’t have urgency, increased frequency, or repeated urination at night (4).

  • Urge incontinence: This type of incontinence is the most difficult to predict or control. Patients report a sudden and uncontrollable urge to urinate. They do not have any previous warning and cannot prevent the loss of urine. Thus, they can have a significant leakage if they don’t reach the bathroom on time. In these cases, patients have an increased frequency of urination. They also have continuous episodes of waking up at night to urinate (nocturia). Undoubtedly, drinking alcohol, tea, coffee, or too much water can trigger the symptoms, too. But in most cases, it is difficult to trace the triggers (5).

  • Mixed incontinence: In these patients, there’s a combination of urge and stress incontinence. Physical activities and other situations that create abdominal pressure cause urine loss. This urine loss is more considerable compared to stress incontinence. It is often accompanied by urgency, nocturia, and increased frequency (6). 

  • Overflow incontinence: It is also essential to evaluate overflow incontinence. This will allow us to make a distinction. This type of incontinence happens when the bladder is full and overdistended. The organ cannot physically hold more urine. The symptoms are similar to those of mixed incontinence. However, this type is common in patients that do not void their bladder completely. For example, in benign prostatic hyperplasia and prostate cancer (7).

It is useful to record these symptoms in a voiding diary to help your doctor make an accurate diagnosis. Your doctor will ask about different aspects of your symptoms, including when the symptoms appeared and their frequency.

Be sure to tell him about your triggering factor, that is, what triggers the episodes. He may also need to evaluate your urine and bladder capacity with urodynamic studies, cotton swab tests, and others.

Complications

There are not many complications of urinary incontinence. However, most of them can severely impair the patient’s quality of life. So, one of the worst complications is the impact on the patient’s personal life.

Urinary incontinence can affect your personal relationship, your social circles, and work. Some patients decide to stay home, avoiding all types of social interaction. Others do not talk about their problems, not even with close family members, and always feel anxious and ashamed (8).

Other complications include skin problems and urinary tract infections. Skin problems are caused by the contact of the skin with wet clothes. The patient would typically exhibit a rash or a sore area near the genitals. Bacteria or fungi sometimes infect this area, and the problem gets worse. These patients also have an increased risk of urinary tract infections.

Treatment

There’s much we can do to regain control of the bladder. Depending on the type of incontinence, doctors would recommend different treatments (9):

  • Stress incontinence: Some medications can be helpful for this type of incontinence. Doctors would also recommend physiotherapy of the pelvic floor. In some cases, anti-incontinence devices or surgery are recommended.

  • Urge incontinence: These patients usually improve after a few modifications in their lifestyle. Dietary changes and pelvic floor strengthening exercises are also important. Some medications and surgical interventions may also be recommended.

  • Mixed incontinence: In most cases, these patients improve with anticholinergic drugs. In some cases, surgery is also recommended.

  • Overflow incontinence: Lifestyle recommendations are important in these cases. In others, catheterization is required to prevent overflow incontinence.

Besides medical treatment, patients can take control of the situation by using a combination of these recommendations (9,10):

  • Absorbent products: These are special garments or pads designed to absorb urine leakages. Some of them are reusable; others are disposable. They are designed to be very comfortable and reduce the odor, too. They do not cure urinary incontinence but are useful in social circumstances. It is an appropriate measure for persistent cases of incontinence. It is also valuable for patients who cannot participate in rehabilitation and behavioral programs. The problem with this type of intervention is the early dependence on these pads. Some patients finally accept incontinence and do not have the motivation to seek treatment. Additionally, inadequate use of these pads could contribute to urinary tract infections.

  • Pelvic floor exercises: Strengthening the pelvic floor is a crucial rehabilitation program for these patients. It is usually more effective in women, but men may also benefit from it. It is actually a general recommendation after prostate surgery. The most important type of exercise is known as Kegels or Kegel exercises. They improve the sphincter function. They also enhance the tone and strength of the pelvic floor muscles. They are useful to hold back urine when the abdominal pressure increases (stress urinary incontinence).

  • Weight loss: Obesity worsens incontinence, especially stress incontinence. This condition increases the abdominal pressure and precipitates more leakage episodes. Thus, weight loss is a useful intervention in overweight patients. In some cases, it is considered a first-line treatment before any other invasive measure is taken.

  • Behavioral changes: Bladder training is recommended to improve urinary incontinence symptoms. It is a self-education process consisting of resisting the urgency and postponing bladder voiding. Patients follow a schedule and try to stick to it while at home. In time, they extend the voiding intervals with 15-minute increments as they achieve their goals. This bladder retraining should be performed at home or in controlled settings. Bladder training is not appropriate if you’re at a social event.

  • Dietary changes: It is also important to contribute to your symptoms with nutritional modifications. Certain foods and drinks increase urine output or have irritative effects on the bladder. For example, spicy foods trigger urge incontinence. Citrus fruit and their acidic pH worsen the symptoms of urge incontinence. Chocolate often contains traces of caffeine, which irritates your bladder. These patients are recommended to take 6-8 glasses of fluids to prevent dehydration. But they should not drink in excess and avoid natural diuretics such as caffeine, tea, and alcohol. Hot chocolate and cola drinks are not recommended, either.

  • Control constipation: In many cases, constipation is associated with worsened urinary symptoms. Thus, it is important to have a high-fiber diet and adequate hydration. This is the first step before considering laxative agents. Talk to your doctor before using these drugs. 

Conclusion

Urinary incontinence is triggered by weakened bladder muscles, sphincter dysfunction, neurological problems, and others. For example, overactive bladder and neurogenic bladder. These are all bladder control problems, but some are caused by a pelvic floor disorder that causes bladder leaks.

In women, pelvic organ prolapse is a likely cause of these symptoms. In men, a weak bladder is usually a result of prostate surgery in cases of an enlarged prostate. This organ is located in the bladder neck, and certain types of surgery lead to nerve damage in this area. When anything compromises bladder muscles or urine flow, it can cause incontinence in the long run.

Incontinence does not have many consequences, but they impair the patient’s quality of life significantly. However, patients can feel better by following the advice of their doctors. It is important to lose weight and avoid eating or drinking bladder irritants. Pelvic floor exercises can also improve this symptom.

Sources

  1. Abrams P, Cardozo L, Khoury S, et al (2009). Incontinence. 4th ed. Paris, France: Health Publication Ltd.
  2. Patel, A. K., & Chapple, C. R. (2008). Urodynamics in the management of female stress incontinence-which test and when?. Current Opinion in Urology, 18(4), 359-364.
  3. Wyndaele, J. J., Kovindha, A., Madersbacher, H., Radziszewski, P., Ruffion, A., Schurch, B., … & Wein, A. (2010). Neurologic urinary incontinence. Neurourology and Urodynamics: Official Journal of the International Continence Society, 29(1), 159-164.
  4. Nygaard, I. E., & Heit, M. (2004). Stress urinary incontinence. Obstetrics & Gynecology, 104(3), 607-620.
  5. Steers, W. D. (2002). Pathophysiology of overactive bladder and urge urinary incontinence. Reviews in urology, 4(Suppl 4), S7.
  6. Chaliha, C., & Khullar, V. (2004). Mixed incontinence. Urology, 63(3), 51-57.
  7. Schröder, A., Abrams, P., Andersson, K. E., Artibani, W., Chapple, C. R., Drake, M. J., … & Thüroff, J. W. (2009). Guidelines on urinary incontinence. European association of Urology, 15.
  8. Coyne, K. S., Zhou, Z., Thompson, C., & Versi, E. (2003). The impact on health‐related quality of life of stress, urge and mixed urinary incontinence. BJU international, 92(7), 731-735.
  9. Lucas, M. G., Bosch, R. J., Burkhard, F. C., Cruz, F., Madden, T. B., Nambiar, A. K., … & Pickard, R. S. (2012). EAU guidelines on assessment and nonsurgical management of urinary incontinence. European urology, 62(6), 1130-1142.
  10. Imamura, M., Williams, K., Wells, M., & McGrother, C. (2015). Lifestyle interventions for the treatment of urinary incontinence in adults. Cochrane Database of Systematic Reviews, (12).

 

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