   |  | | A surprisingly common problem | By Mike Magee, MD
Incontinence– the loss of bladder control – affects about 25 million Americans, but you don't hear much about it.1 While 55% of women in their 80s have the problem, nearly 30% of women in their 30s experience some loss of bladder control at least once a month. Altogether approximately 50% of American women have experienced incontinence. That adds up to $26 billion a year in direct costs and lost productivity.1,2,3
There are several different types of incontinence with the most common being stress incontinence. This is urine leakage when any physical pressure is placed on the bladder, such as sneezing, coughing, or exercising. The majority of incontinence conditions can be improved or cured with treatment.4 But in order to get treatment, you have to take that first step – talk openly and honestly with your health care professional.
Why is incontinence so common in women? Well let’s first take a step back and talk about the bladder. As with the heart, the bladder is a hollow organ, constructed of muscles, designed to propel fluid outward. This fluid, urine, is brought from the kidneys to the bladder via two tubes, called ureters. The amount of urine carried depends on fluid intake.
The bladder is a sophisticated organ. It’s expected, on the one hand, to be able to relax enough to serve as an adequate reservoir for urine collection. While, on the other hand, it also must be able to contract in order to efficiently empty when it’s supposed to.5,6 If it does not relax completely, it can only hold small amounts of urine, and frequent urination is the result. If it does not contract completely, the bladder fails to release all the urine it holds. This is a problem because with less emptying there is less room for more urine that arrives from above and, once again, frequent urination is the result. To make matters worse, when the bladder does not empty completely, the stagnant urine is more likely to become infected. Infection makes the bladder wall irritable and less likely to relax and be able to hold an adequate amount of urine.
All of this relaxing and contracting must be in conjunction with the voluntarily controlled sphincter muscle that surrounds the urethra, the tube that empties the bladder. The sphincter muscle must relax as the bladder muscles contract in order for urine to flow easily outward. When the sphincter muscle contracts, it squeezes the urethral tube and prevents urine flow.4
Basically, women are more susceptible to incontinence because of their anatomy. A woman’s urethra is much shorter than a man’s, so it offers less resistance to outflow when the bladder muscle contracts. Also in women, the urethra sits on the upper wall of the vagina, and it is relatively easy for bacteria in the vagina to find their way up the urethra and into the bladder to cause a urinary tract infection.5
The bladder, urethra, and sphincter muscle are all directly connected with the woman’s uterus, vagina, and pelvic musculature. So women who deliver babies vaginally have an increased risk of incontinence – around 17%, compared to non-childbearing women.1 How does this happen? Vaginal delivery can stretch pelvic muscles, allowing abdominal organs and the bladder to push downward. This causes the already short urethra to telescope on itself and become shorter still, offering even less resistance to urine flow. In addition, in some births, the urinary sphincter muscle and urethra can be traumatized.5 In the same way, weight can have a similar effect on the urinary system as childbirth. In one study, women with a body mass index (BMI) of greater than 30 were 139% more likely to be incontinent than those within a normal weight range.1 Also, any metabolic conditions, like diabetes or depression, or neurological degenerative diseases, like multiple sclerosis, can injure the nerves of the bladder and urethra and increase the risk of incontinence.1,6,7
As you might expect, problems with incontinence increase as a woman ages.1 In the late years, it can become a serious enough management problem that it can trip a woman from independence to dependence. In fact, half of all nursing home patients are incontinent.8 And dependency doesn’t come cheap. Adding a single month of independence and health to America’s senior population would save $5 billion. With a 10% decrease in hospitalization and institutionalization, $50 billion in savings per year would accrue.9
In her lifetime, a woman’s bladder will be asked to relax and contract with perfection 300,000 to 400,000 times. What to do? First, as a woman, understand that bladder care is essential. If you have pain, frequency, or leakage, don’t suffer in silence. Be evaluated thoroughly. Second, for caregivers, routine questioning and screening for incontinence in women is crucial – especially among those who have had children or hysterectomies, are depressed or overweight, or are diabetic or have neurological problems.
References
1. Melville JL, Katon W, Delany K, Newton K. Urinary incontinence in U.S. women. Arch Intern Med. 2005; 165,537-542.
2. Fantl JA et al. Urinary Incontinence in Adults: Acute and Chronic Management. US Dept. of Health and Human Services. Agency for Health Care Policy and Research 1996. Clinical Practice Guideline 2. Cited in Melville JL, Katon W, Delany K, Newton K.
3. Wagner TH, Hu TW. Economic costs of urinary incontinence in 1995. Urology. 1998; 51, 355-361. Cited in Melville JL, Katon W, Delany K, Newton K.
4. American Academy of Family Physicians. Urinary Incontinence. August 2005.
5. Patrick DL, et al. Quality of life of women with urinary incontinence: Further development of the Incontinence Quality of Life Instrument. Urology. 1999; 53:71-76. Cited in Melville JL, Katon W, Delany K, Newton K.
6. National Association for Continence. What is Incontinence? 2008.
7. Grodstein F, et al. Association of age, race and obstetric history with urinary symptoms among women in the Nurses’ Health Study. Am J Obstet Gynecol. 2003;189:423-434. Cited in Melville JL, Katon W, Delany K, Newton K.
8. Freiman, M.P. Special care units in nursing homes: selected characteristics. 1996. Rockville, MD: U.S. Agency for Health Care Policy and Research, 1999.
9. Alliance for Aging Research. Ten Reasons Why America is not ready for the Aging Boom. 2002.
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