What reporters should know about bladder control in older adults

By Liz Seegert

We’ve all seen the commercials for adult diapers and have probably thought, “that will never happen to me.” However, bladder control problems, which include conditions like stress incontinence, urge incontinence and overactive bladder (OAB), affect about 30 million people in the U.S. The prevalence of incontinence and OAB increase with age, but they’re not inevitable. Effective treatments and therapies exist — from medications to exercise to surgery. Even so, misconceptions and stigma can lead to psychological or emotional barriers to getting treatment and living well with this condition.

Overactive bladder occurs when a muscle in the bladder known as the detrusor contracts more often than normal. This causes a person to feel a sudden and sometimes overwhelming urge to urinate even when the bladder isn’t full. Urinary incontinence is any involuntary loss of urine even if that is not considered a problem. There are different types of incontinence whose symptoms may appear to be similar. The severity ranges from occasionally leaking urine while coughing or sneezing to having an urge to urinate that’s so sudden and strong a person can’t get to a toilet in time.

According to a new report from the Global Coalition on Aging, the impact of bladder control issues on people over age 60 can be devastating. Data shows that three-quarters of people with OAB find it more difficult to complete daily activities, resulting in decreased physical activity and weight gain because of an inability to exercise. Nearly one-third report feelings of depression and high levels of stress. Millions of adults over age 60 have left the workforce early due to issues with incontinence. Older people with bladder control problems often become more socially isolated, which leads to other negative health effects.

There are several types of urinary incontinence (UI):

Stress incontinence. Urine leaks when pressure is exerted on the bladder by coughing, sneezing, laughing, exercising or lifting something heavy.
Urge incontinence. There is a sudden, intense urge to urinate followed by an involuntary loss of urine. The person may need to urinate often, including throughout the night. Urge incontinence may be caused by a minor condition, such as infection, or a more-severe condition such as a neurologic disorder or diabetes.
Overflow incontinence. The person experiences frequent or constant dribbling of urine due to a bladder that doesn’t empty completely.
Functional incontinence. A physical or mental impairment keeps someone from making it to the toilet in time. For example, severe arthritis may interfere with the ability to work buttons and zippers.
Transient incontinence. UI that lasts a short time. Transient incontinence is usually a side effect of certain medications, drugs, or temporary conditions.
Mixed incontinence. Some people experience more than one type of urinary incontinence.

Bladder control problems are not a disease, they’re symptoms. The Mayo Clinic points out that they can result from a variety of factors, such as:

Changes with age. The bladder’s capacity to store urine may decrease with age. Also, involuntary bladder contractions become more frequent as people get older.
Gender:
- Women are more likely to have stress incontinence.
- Menopause. Post-menopausal women produce less estrogen; this hormone helps keep the lining of the bladder and urethra healthy. Deterioration of these tissues can aggravate incontinence.
- Hysterectomy. Any surgery that involves a woman’s reproductive system, including removal of the uterus, may damage the supporting pelvic floor muscles, which can lead to incontinence.
- Men with prostate gland problems are at increased risk of urge and overflow incontinence.
- Enlarged prostate. Especially in older men, incontinence often stems from enlargement of the prostate gland, a condition known as benign prostatic hyperplasia.
- Prostate cancer. Stress incontinence or urge incontinence can be associated with untreated prostate cancer. But more often, incontinence is a side effect of prostate cancer treatments.
Obstruction. A tumor anywhere along the urinary tract can block the normal flow of urine, leading to overflow incontinence. Urinary stones — hard, stone-like masses that form in the bladder — sometimes cause urine leakage.
Neurological disorders. Multiple sclerosis, Parkinson’s disease, a stroke, a brain tumor or a spinal injury can interfere with nerve signals involved in bladder control, causing urinary incontinence.

The National Institutes of Health cites other risk factors, including:

Being overweight. Extra weight increases pressure on the bladder and surrounding muscles, which weakens them and allows urine to leak out during a cough or sneeze.
Smoking. Tobacco use may increase risk of urinary incontinence.
Family history. If a close family member has urinary incontinence, especially urge incontinence, the risk of developing the condition is higher.

UI can be slightly bothersome or totally debilitating. For some people, the chance of embarrassment keeps them from enjoying many activities, including exercising, and causes emotional distress. Decreased activity leads to increased risk of developing other health problems, like obesity and diabetes. Incontinence can result in loss of independence and quality of life. It is a major reason for nursing home placement. There is a strong association between urge incontinence and falls and injuries, which may be due in part to the rush to the toilet in the middle of the night according to Penn State Hershey Medical Center.

Gender differences

According to the National Institute of Diabetes and Digestive and Kidney Disease, urinary incontinence in men results when the brain does not properly signal the bladder, the sphincters do not squeeze strongly enough, or both. The bladder muscle may contract too much or not enough because of a problem with the muscle itself or the nerves controlling the bladder muscle. Damage to the sphincter muscles themselves or the nerves controlling these muscles can result in poor sphincter function.

Urinary incontinence occurs in 11 to 34 percent of older men. Two to 11 percent of older men report daily UI. Although more women than men develop UI, the chances of a man developing UI increase with age because he is more likely to develop prostate problems as he ages. Men are also less likely to speak with a health care professional about UI, so UI in men is probably far more common than statistics show. Having a discussion with a health care professional about UI is the first step to fixing this treatable problem.

Some 25 to 45 percent of women have some degree of UI. Nine to 39 percent of women older than 60 report daily UI. Women experience UI twice as often as men.

Treatment options

Treatment depends on the type of UI. Some types of treatment include behavioral and lifestyle changes, bladder training, pelvic floor exercises, and urgency suppression. Losing weight, engaging in more physical activity, and changes in diet may help.

Pharmacologic treatments range from anticholinergics to alpha-blockers to Botox. Each works differently, depending on the type of incontinence and cause. Some drugs relax bladder muscles to prevent spasms, others treat the prostate which relieves pressure. Botox is used to treat people with urinary problems due to neurological problems from multiple sclerosis or spinal cord injuries.

However, some medications can have serious side effects, including reduced cognitive function, according to the Global Coalition on Aging. The organization also reports that 92 percent of patients using anticholinergic drugs failed initial treatment within two years and 82 percent stopped taking drugs due to side effects or unmet expectations. Other research backs up the risks of anticholinergic drugs in older patients.

Electrical nerve stimulation may be offered as an option to prevent UI, frequency and other symptoms. Electrical nerve stimulation involves altering bladder reflexes using pulses of electricity. The results of ES treatment vary from center to center,

depending on treatment protocols and patient selection. A meta review found that electrical stimulation may work better than drug treatment but results were not conclusive.

Surgery may be performed as a last resort, most commonly it involves either a sling procedure or bladder neck suspension; prolapse surgery may also be performed in women, or an artificial urinary sphincter implanted in men. However, any type of surgery is risky for an older patient. Side effects from anesthesia can include delirium and cognitive dysfunction; surgery for stress incontience could lead to development of overactive bladder, which could include urge incontinence or urinary tract infection.

Story ideas

Check your local hospital’s urology clinic or urogynecology department: have they seen an uptick in cases as the population ages? Are there any formal or informal programs available to educate the public about this condition?
Look at various treatment options and side effects. No one option is right for everyone so what are the pros and cons?
What’s happening in the world of research to find new, less invasive treatments or drugs that have fewer side effects?