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Overview |
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Definition |
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Urinary incontinence (inability to control urination or the involuntary loss
of urine from the bladder) afflicts more than 13 million people in the United
States of both sexes and all age groups. Incidence is higher in the elderly and
twofold greater in women. Exercise and behavioral therapies have a high degree
of success; medication and surgery are effective in a select group over the
short-term. Many drugs have unwanted and/or serious side effects. Surgery should
be considered only when other treatment options fail. Diagnostic categories
are:
- Stress incontinence (SUI): Most common form among women primarily due
to pregnancy, childbirth, menopause. Weakened pelvic floor muscles fail to
support bladder and resultant pressure interferes with muscles that close the
urethra. Leakage occurs with physical stress (e.g., coughing,
sneezing).
- Urge (or reflex) incontinence (UI): Leakage accompanied by sudden
unexplained need to urinate (e.g., when touching water). May be due to nerve
damage (e.g., from Alzheimer's disease, stroke, brain tumor, injury,
surgery).
- Overflow incontinence (OI): Rare in women. Bladder overextension due
to blocked urethra or inability of bladder muscles to expel urine. Caused by
neurological damage (e.g., from diabetes), tumors, urinary stones, enlarged
prostate.
- Mixed incontinence (MI): SUI/UI in combination.
- Functional incontinence (FI): Impaired cognitive abilities and/or
restricted movement (e.g., confined to a wheelchair) prevents timely access to
toilet.
- Transient incontinence (TI): Triggered by medication, UTIs,
restricted mobility, stool impaction.
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Etiology |
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- Neurological damage/disorders (dementia, spinal cord injury, multiple
sclerosis, stroke)
- Low estrogen levels in women
- Physical changes (from pregnancy or enlarged prostate, stool
impaction, tumor)
- Medications
- Urinary tract infections (UTIs)
- Weak urethral sphincter
- Weak pelvic floor muscle
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Risk Factors |
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- Overweight
- Hysterectomy before age 45
- At least one live birth
- Labor exceeding 24 hours
- Prostate disease or hypertrophy in males
- Physical problems associated with age/debility
- Neurologic damage or disorders
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Signs and Symptoms |
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- Involuntary urination Perineal irritation
- Frequent and unusual urinary
urge
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Differential
Diagnosis |
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- Vaginal discharge in women UTIs
- Urethral discharge in men Medication effects
(diuretics)
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Diagnosis |
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Physical Examination |
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- Urine leakage
- Findings specific to risk
factors
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Laboratory Tests |
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Urinalysis to determine urinary tract/bladder infection, urinary stones,
diabetes, glomerular disease, tumor. |
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Pathology/Pathophysiology |
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- Urethral sphincter incompetence Prostatic hypertrophy
- Bladder tumor UTI
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Imaging |
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- Pelvic ultrasound Renal ultrasound
- Transrectal ultrasound
(prostate)
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Other Diagnostic
Procedures |
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- Physical examination
- Neurological assessment
- Medical history
- Interview for pattern of voiding/leakage, straining/discomfort
associated with urination
- Test for stress incontinence (e.g., vigorous coughing to detect urine
loss)
- Urodynamics
- Voidin
cystourethrogram
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Treatment Options |
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Treatment Strategy |
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Along with the drug therapies and surgical procedures listed below, the
following may be necessary.
- Catheters Urethral plugs
- Condom catheters Absorbent pads, undergarments, diapers
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Drug Therapies |
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- Antibiotics: For UTIs or sexually transmitted diseases
- Anticholinergics: For UI, reduce detrusor muscle
contractions/increase urethral resistance (imipramine [Tofranil] 10 to 25 mg up
to tid; oxybutinin [Ditropan] 2.5 to 5 mg up to tid; hyoscyamine [Cystospaz],
hyoscyamine sulfate [Levsin/Levsinex, Cystospaz-M], and flavoxate [Urispas] all
100 to 200 mg tid or qid). High instance of undesirable/intolerable side
effects
- Antimuscarinic/ganglionic-blockers: Propantheline (Pro-Banthine) 15
to 30 mg every four to six hours. High incidence of side effects including
confusion, agitation, coronary artery disease, especially in the
elderly.
- Cholinergics: For underactive detrusor, bethanechol (Duvoid,
Myotonachol, Urecholine); contraindicated with asthma, bradycardia, Parkinson's
disease. Can produce intolerable sweating/excessive salivation.
- Sympathomimetics: For SUI, phenylpropanolamine (found in Ornade) 25
to 100 mg bid; or pseudoephedrine (found in Sudafed) 15 to 30 mg tid; caution
with hypertension, angina, hyperthyroidism, diabetes
- Hormones: SUI in women, increase urethral resistance (conjugated
estrogens [Premarin] 1.25 to 2.5 mg/day in cream; 0.3 to 0.625 mg/day orally
with estradiol [Estrace]); increased risk of endometrial cancer, particularly
with unopposed estrogen
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Surgical Procedures |
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Success rate higher in younger patients; effectiveness deteriorates over
time; long-term success rate estimated at 75% to 90% for five
years.
- Artificial sphincter: Inflatable cuff surrounding bladder neck
activated by mechanism implanted in scrotum or labia.
- Supportive devices: String secured to the bladder and attached to
muscle, bone, or ligament; in severe SUI, a wide sling elevates
bladder.
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Complementary and Alternative
Therapies |
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The main thrust of alternative therapies is Kegel exercises, biofeedback, and
preventing any exacerbating conditions. Underlying conditions (e.g.,
malnutrition, dementia, prostatitis, and UTIs) need to be addressed. Yoga may be
beneficial. Habit training (establishing toilet times to increase regularity of
voiding) may also help treat this condition. |
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Nutrition |
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- Eliminate caffeine, alcohol, sweetener substitutes, simple
sugars.
- Cranberries and blueberries contain substances which inhibit the
adhesion of bacteria to bladder tissue. This may be useful in preventing
infections which can exacerbate incontinence. Also helps to deodorize urine.
- Vitamin C (1,000 mg tid) acidifies urine, which inhibits bacterial
growth.
- Beta-carotene (25,000t to 50,000 IU/day) is necessary for immune
function and mucous membrane integrity.
- Zinc (30 mg/day) supports immune function, often deficient in the
elderly.
- Calcium (1,000 mg/day) and magnesium (500 mg/day) together may help
to improve sphincter control.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
Urinary astringents have been used historically for sphincter tone and
connective tissue integrity. Demulcents soothe irritated tissue and may decrease
spasm of the bladder.
These urinary astringents tone and heal the urinary tract and can be taken
long term at 1 cup/day or 30 drops tincture/day.
- Horsetail (Equisetum arvense) also helps with connective
tissue integrity.
- Plantain (Plantago major) is an astringent and
demulcent.
Marshmallow root (Althaea officinalis) is a urinary demulcent, best
used alone in a cold infusion. Soak 1 heaping tbsp. of marshmallow root in 1
quart of cold water overnight. Strain and drink during the day in addition to
other teas. |
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Causticum for SUI, especially with retention from holding the
urine and frequent urges to urinate
- Natrum muriaticum for SUI, vaginal dryness, painful coitus,
especially with a history of grief
- Pareira for retention of urine from an enlarged
prostate
- Sepia for SUI with sudden urging, especially with prolapsed
uterus and vaginitis
- Zincum for SUI, urinary retention from prostate problems,
unable to urinate standing, must sit
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Acupuncture |
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May be of help, depending on cause. |
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Patient Monitoring |
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Compliance with behavioral techniques is essential and may require close
monitoring and reinforcement. Physician must be alert to and monitor side
effects of medications, or for infections following
implants/surgery. |
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Other
Considerations |
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Early treatment is most beneficial; embarrassment often causes delay in
seeking help. |
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Prevention |
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- Pelvic muscle strengthening (Kegel) exercises during and after
pregnancy
- Maintenance of healthy prostate in men; maintenance of healthy pelvis
in women
- Maintenance of optimal body weight for
height/age
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Complications/Sequelae |
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- Drugs: Considerable risk of unwanted, intolerable and/or serious side
effects; contraindication with other medications
- Surgery: Possible complications
- Catheters: UTIs
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Prognosis |
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Most cases can be vastly improved with appropriate management; effectiveness
may deteriorate with age. |
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Pregnancy |
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Pregnancy increases risk of incontinence; effect of drugs upon fetus must be
determined before being administered during
pregnancy. |
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References |
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Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace
Publishers; 1995:247.
Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:432.
Dambro MR, ed. Griffith's 5 Minute Clinical Consult. Baltimore, Md:
Williams & Wilkins; 1998.
Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill;
1998:1466-1468.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:111-113, 258-261, 286,
402.
Olshevsky M, Noy S, Zwang M, et al. Manual of Natural Therapy. New
York, NY: Facts on File Inc; 1989.
Thom DH, Van den Eeden SK, Brown JS. Evaluation of parturition and other
reproductive variable as risk factors for urinary incontinence. Obstet
Gynecol. 1997;90:983-989.
Ullman D. The Consumer's Guide to Homeopathy. New York, NY: The Putnam
Publishing Group; 1995. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |