Diagnosis & Treatment
Diagnosis Overview
Diagnosis
The first step is to see your doctor for a complete exam. Through a series of questions he or she will be able to determine what your bladder problems may be, for example:
How many times a day do you urinate?
Are you having problems holding your urine?
How often do you get up at night to urinate?
Do you lose urine when you don’t want to?
Do you leak urine when you cough, sneeze, laugh or lift heavy objects?
Do you have to strain to urinate?
Do you often experience urinary tract infections?
Do you find it difficult to start urinating or have a slow, weak urinary stream?
Do you feel that you are not completely emptying when you urinate?
Do you have constant dribbling of urine?
Pharmaceutical Treatments
Medications are often used in combination with the behavioural techniques described earlier to treat urinary incontinence. Again, your doctor will help you decide which is best for you based on the type of incontinence you have, as well as the severity of your symptoms.
Medications for overactive bladder
Drugs used to treat OAB block the abnormal contractions of the bladder muscle and can therefore also help ease the symptoms of urge urinary incontinence in both men and women. You’ll find a list of OAB medications available in Canada on page 20. Generally speaking, these drugs fall into three categories:
Anticholinergics
Anticholinergic medications block the action of acetylcholine, a chemical messenger that tells the muscles of the bladder wall to contract. Unfortunately, acetylcholine acts in other parts of the body as well, so medications that block it can cause unwanted side effects like dry mouth, blurred vision, impaired cognition and constipation. New “extended” or “prolonged” release versions of anticholinergic medications reduce the incidence of side effects and improve compliance because they only need to be taken once a day to produce a steady absorption rate and constant blood levels of the drug.
The two most commonly prescribed anticholinergic drugs are oxy- butynin (Ditropan®, Ditropan XL®, Oxytrol®) and tolterodine (Detrol®), both of which are available in extended-release formulations.
Seek help.
Find an interested and knowledgeable healthcare professional.
It is important to know that your regular healthcare professional may not be the best choice for of your incontinence. Ask your healthcare professional if he/she has an interest and expertise in assessing and treating incontinence. If the answer is no, ask for a referral to one who has an expertise.
Many consumers feel they are disturbing their doctor with a minor issue as they think their doctor has more serious issues to deal with. Your quality - of - life and psychological well-being is extremely important.
Are you aware that incontinence is one of the main reasons seniors are placed in institutions, as family caregivers can no longer cope? We all know the consequences of falls among the elderly. Is it due to rushing to the washroom to avoid an accident or that they slipped in urine leakage.
Wearable Pads and Guards
A number of pads and guards are designed especially for women whose stress incontinence causes them to experience the loss of small to moderate amounts of urine during physical activities such as coughing, sneezing, lifting, or working out at the gym. These pads generally have a waterproof back, a pad containing a gel-forming polymer to absorb fluid more effectively, and an adhesive strip that is designed to hold the product securely inside your panties. Most are contoured to fit comfortably between your legs and have elasticized sides to provide a cupping form. They come in several sizes and levels of absorbency. These products resemble sanitary napkins that are designed for use during menstruation, but the padding and absorbent gel are different in the two kinds of products. The padding and gel in sanitary napkins is designed to absorb blood, while those in the incontinence products are designed to absorb urine. The chemistry of blood and urine is different enough to require different products for best performance.
Pads and guards especially designed for men with mild incontinence are also available. Like the pads designed for women, the products for men have an adhesive strip to anchor the product inside snug knitted underwear, a waterproof backing to prevent leakage, and a pad containing gel-forming polymer.
Disposable Briefs (Adult Diapers)
These products which are designed for moderate to heavy urinary and/or bowel incontinence closely resemble baby diapers, except that they have two or three tape closures on each side instead of just one. The current products have either a plastic or fibrous “cloth-like” waterproof padding and absorbent padding that contains gel-forming polymer. Disposable briefs differ in quality in many ways; and the adage “you get what you pay for” is especially appropriate with these products. Cheap briefs often have a noisy, fragile plastic backing that tears easily and unreliable tape closures that may come loose if you are active and that cannot be adjusted without damaging the plastic backing. Better briefs have a less noisy and more robust plastic or a noiseless “cloth-like” covering and tapes that hold reliably and can be fastened and unfastened repeatedly to facilitate using the toilet. Inexpensive briefs also absorb less urine than their more expensive competitors and thus must be changed more often. The capacity difference between products is often great enough to make a higher-priced brief less expensive to use because you don’t use as many of them. Disposable briefs work equally well for men and women and have the advantage of not requiring you to remove your trousers or slacks when changing in a public washroom.
Many people have a strong psychological resistance about wearing diapers; and this fact is a reason why these products are called “disposable briefs” instead of “diapers.” That resistance is also the reason why belted undergarments and disposable underwear, which look less like a diaper, were invented. However, if your incontinence is great enough to require something more than a pad or shield worn inside your regular underwear, a high-quality disposable brief will provide more reliable protection for a longer period of time and during a greater range of activity than any other kind of product. If you want to get out into the community and lead a normal life, you will find that it’s better to have more protection than you need than to need more protection than you have; and a disposable brief is the most reliable way to get that protection.
Internal Catheters
People who are unable to empty their bladders may need to use an internal catheter. These come in two major varieties. Intermittent catheters are essentially rubber or latex tubes that one inserts into the bladder and then removes after the bladder has drained. An indwelling catheter is a latex or silicon tube with a small balloon that can be inflated once the catheter has been inserted in order to hold it in place. Both kinds of catheters have the potential to cause dangerous urinary tract infections. They should be used only upon the advice of a physician and only if you are able to take the precautions needed to reduce the danger of infection.
Your Role
Treatment
Once you understand the reason for your incontinence, the choice of what to do about, and how to treat your incontinence it is up to you. Most professionals suggest that their patients first try a form of treatment other than the use of medication or surgery. Here's a list of some healthy bladder habits:
Avoid bladder irritants (e.g. caffeinated beverages and alcohol)
Eat more fibre to avoid constipation
Maintain a healthy weight
Stay active and mobile
Don’t smoke
Empty your bladder every three to four hours during the day and before going to sleep
Drink moderate amounts of fluid (six to eight glasses per day)
Talk to your doctor about urine loss or other bladder symptoms. There’s no reason to wait!
As you can see, there are many different types of, and possible causes for your incontinence. The first step is to see your doctor for a complete exam. He or she will ask you a series of questions (see the list of sample questions on the right).
Before your appointment, take some time to look them over and write down any information you think may be useful. Answer the questionnaire on page 11 and bring a copy to your doctor — the more information he/she has about your symptoms, the better equipped he/she will be to help.
Keeping a bladder diary (also called a voiding record) for a couple of days is another great way to help your doctor understand your symptoms. Use it to record what you drink, how often and how much you urinate over the course of two days. You’ll find an example of a bladder diary on page 12.
During the visit, your doctor will perform a thorough physical exam of your abdomen and genitals. He/she will look for things like a urinary tract infection or bladder infection, a mass or compacted stool. He/she may also do or order the following simple tests:
Stress test: You’ll be asked to cough or bear down while the doctor checks for urine loss.
Urinalysis: A sample of your urine is sent to the lab to check for signs of infection, blood or other abnormalities.
Most often, these simple tests will be enough for your doctor to identify the type of incontinence you have and recommend some form of treatment. In some cases however, he or she may refer you to a specialist (see “Meet the experts” on page 28) for additional tests. These can include:
Flow test and postvoid residual measurement (PVR) — This test is done to see if you have problems emptying your bladder. You will be asked to urinate into a special measuring container (so the doctor can check how fast you empty your bladder and how much you urinate). He or she will then measure the amount of urine left in your bladder, either by ultrasound or by placing a small tube (catheter) into the bladder.
Urodynamic testing — Using a catheter, this test measures the pressure in your bladder when it’s empty and as it fills, giving information about how the bladder and urethra are working. Some people find these tests embarrassing and uncomfortable, but they may help determine the best course of treatment for your symptoms.
Cystocopy — A tube with a tiny lens at the end of it is inserted through the urethra and into the bladder, so your doctor can check for and possibly remove abnormalities in your urinary tract.
Pelvic ultrasound — Like the ultrasounds done on pregnant women, this test lets the doctor get a better look at your urinary tract.
Voiding cystogram (rare) — During this test, a special dye is injected into the urethra and bladder. You will then be asked to urinate. Because of the dye, the flow of urine through the lower urinary tract can be seen by x-ray, allowing your doctor to look for problems with your urethra.
Diagnosis
Options for Treatment, Remedies or Management of Incontinence
Once you understand the reason for your incontinence, the choice of what to do about it, and if and how to treat it, is up to you. Most professionals suggest that their patients first try a form of treatment other than the use of medication or surgery.
Depending upon the type and cause of your incontinence, lifestyle changes, or exercises, with or without equipment to help identify and strengthen the pelvic floor muscles, may help. For some, medications that affect the bladder or the sphincter can be effective. Surgery, an artificial sphincter, or an injection of a substance into the sphincter muscle may be recommended. Absorbent products or collection devices may help. Whichever you choose, be sure to discuss the latest information available with your healthcare professional. You may find that something new has been developed which may be appropriate for you.
Incontinence Treatments
Behavioural Treatments
Pelvic floor muscle Kegel exercises
Developed by Dr. Arnold Kegel, these exercises are designed to strengthen the muscles of the pelvic floor so that the bladder is kept in place and the urethra stays shut tight. Kegel exercises work best for people who have stress or mixed incontinence, but anyone can try them, even as a preventive measure to keep your pelvic floor muscles strong.
How to do them
Stand, sit or lie down with your knees slightly apart. Relax.
Find your pelvic muscle. Imagine that you are trying to hold back urine or a bowel movement. Squeeze the muscles you would use to do that. DO NOT tighten your stomach or buttocks.
Women: to make sure you’ve got the right muscle, insert your finger into your vagina while you do the exercise. You should feel a tightening around your finger.
Men: when you tighten the pelvic floor muscle, your penis will twitch and contract in towards your body.
Tighten the muscles for 5 to 10 seconds. Make sure you keep breathing normally
Now relax the muscles for about 10 seconds
Repeat 12–20 times, three to five times a day
Stick to it! You should begin to see results after a few weeks. Like any other muscle in your body, your pelvic muscles will only stay strong as long as you exercise them regularly.
If you’re having a hard time doing Kegel exercises, your healthcare professional can teach you how to do them correctly. He/she may even suggest a tool or device to help make sure you’re using the right muscles (see “Behavioural training aids” in the sidebar).
Pelvic floor retraining with vaginal cones (i.e. LadySystem) is a non-surgical method to help women strengthen their pelvic floor muscles by doing their exercise once or twice daily, at home. Using a set of small cones identical in shape and size but of differing weights, the exercise consists of inserting a cone in the vagina, starting with the lightest one that can comfortably be retained and moving up to increasingly heavier cones as the pelvic floor muscles become stronger.
Your doctor may also suggest biofeedback, a training technique that’s used to monitor the contraction of the pelvic floor muscles as you do your Kegel exercises. Biofeedback uses a machine that records the contractions of your muscles and translates the movement into a visual signal that you can watch on a monitor. Some people find this helpful in learning how to do Kegel exercises correctly.
Biofeedback training is usually given in a hospital or private clinic by a physiotherapist, doctor, nurse or trained technician, but you can also buy or rent a machine to use at home.
Bladder retraining
Some people, especially those with urge incontinence, find that modifying their bathroom habits helps ease the symptoms of urinary incontinence and helps improve healthy bladder control. There are two basic strategies involved in bladder retraining:
Keeping a regular bathroom schedule (this is called “timed voiding”), gradually increasing the time between visits
Learning to suppress the urge to urinate by doing strong pelvic muscle contractions and distracting yourself with something else, like counting backwards to delay urination (this is called bladder drill)
A person who drinks five to eight cups of liquid per day should be able to wait at least two hours between bathroom visits. If you’re going to the bathroom more often, are getting up more than once or twice during the night, or can’t delay the urge to empty your bladder for at least 30 minutes, bladder retraining may be helpful. To get started, keep a voiding diary for two days (page 12) and bring it to your doctor for advice on a training program that will work for you.
OAB or incontinence medications used in Canada
| DRUG NAME | DRUG TYPE | DOSING |
|---|---|---|
| Oxybutynin, sold as: Ditropan® (generics also available) Ditropan XL®, Uromax® (both controlled release) Oxytrol® (skin patch) | Anticholinergic | Once daily Twice daily Twice weekly |
| Oxybutynin chloride gel, sold as: Gelnique® (rubbed into arm, thigh or stomach area) | Anticholinergic | Once daily |
| Tolterodine, sold as: Detrol LA® (extended release) Detrol® | Anticholinergic | Once daily Twice daily |
| Trospium chloride, sold as: Trosec® | Anticholinergic | Twice daily |
| Solifenacin, sold as: Vesicare® | Anticholinergic | Once daily |
| Darifenacin, sold as: Enablex® (extended release) | Anticholinergic (selective for bladder) | Once daily |
| OnabotulinumtoxinA, sold as: Botox® (injection) | Neurotoxin | Every 36 to 42 weeks |
| Fesoterodine, sold as: Toviaz® | Toviaz® Anticholinergic | Once daily |
| Mirabegron, sold as: Myrbetriq® | Beta 3 receptor agonist | Once daily | SIDE EFFECTS |
| The most common adverse events found with anticholinergic medications include (but aren’t limited to): dry mouth, constipation, impaired cognition and blurred vision. Talk to your doctor about limiting these side effects and which medication may be right for you. | ||
Recently, medications have been developed that also limit unwanted side effects. These medications include darifenacin (Enablex®), solifenacin (Vesicare®), trospium (Trosec®), fesotoredine (Toviaz®), Myrbetriq® (mirabegron) and oxybutynin chloride gel (Gelnique®). Gelnique, is rubbed into the skin, making side effects like dry mouth milder because of constant absorption rates. Myrbetig is a new drug that works by a different mechanism to relax the bladder muscle without blocking the action of acetyl choline and therefore produces lesser side effects. The other drugs are anti-cholinergics but are more specific to the bladder muscle.
There is much you can do to help your healthcare professional determine the type and cause of your incontinence. Before your visit, prepare a list of all prescription and non-prescription medications which you are taking, or bring them with you. Also briefly describe your medical history, including information on any surgeries you may have had. In addition, your healthcare professional will ask you questions about how much fluid you drink, and how and when you lose urine.
Once a complete history has been taken, you may find that special diagnostic studies, including urodynamic tests, are in order. The type and the cause of your incontinence will determine the appropriate options.
Questions your doctor may ask:
How many times a day do you urinate?
Are you having problems holding your urine?
How often do you get up at night to urinate?
Do you lose urine when you don’t want to?
Do you leak urine when you cough, sneeze, laugh or lift heavy objects?
Do you have to strain to urinate?
Do you find it difficult to start urinating or have a slow, weak urinary stream?
Do you feel that you are not completely emptying when you urinate?
Do you have constant dribbling of urine?
Before Your Doctor’s Visit
Help your doctor to understand your symptoms by keeping a bladder diary.
Become an informed partner with your healthcare professional.
Stop and think about your incontinence experience. How often does it occur? How much urine is lost? Are there any contributing factors, such as lifting, laughing, etc? Then think about how the loss of bladder control has affected your daily activities. Has it affected your participation in physical, social, sexual, or work activities?
Click here to read more about the Types of Urinary Incontinence.
Once you are able to describe your symptoms and how they affect your everyday life, you can confidently speak with your healthcare professional, and work together to find the best treatment options for you incontinence. Keeping a daily record of your fluid intake, well as your voiding history plus all medications you are taking is a way to open discussion with your healthcare professional. This can save everyone a great deal of time.
Managing Urinary Incontinence
Methods of Managing Urinary Incontinence
Anyone who is experiencing involuntary loss or leaking of urine should consult a physician. Although not in itself a disease, urinary incontinence is never normal and is sometimes a symptom of a serious problem that requires attention. In addition, your doctor will be able to recommend treatments that may eliminate or reduce the severity of your incontinence.
However, even for those whose incontinence will ultimately be cured, there is likely to be a period of time before the cure is attained when management with products is an important interim strategy. For some people, lack of proper management can cause them to hide at home in fear of an embarrassing accident. Some people quit their jobs, give up their volunteer work, shy away from social engagements and even give up necessary routine activities such as grocery shopping. Fortunately, none of these restrictions is necessary. With the proper use of the right products, you can live a full and active life despite urinary incontinence.
This section will help you learn about the kinds of products that are out there, make wise choices about which products are most likely to help manage incontinence effectively for you. To some extent, the kind of product you need will depend on the kind of incontinence you are experiencing and the amount of leakage that you have. Other important considerations are the cost of the products and their appearance and whether you are a woman or a man. Most people want to find the least expensive and most discrete product that will handle their problem effectively.
Lifestyle Changes
Once you understand the reason for your incontinence, the choice of what to do about it is up to you. Most professionals suggest that their patients first try a form of treatment other than the use of medication or surgery.
Depending upon the type and cause of your incontinence, lifestyle changes, or exercises, with or without equipment to help identify and strengthen the pelvic floor muscles, may help manage incontinence effectively. For some, medications that affect the bladder or the sphincter can be effective. Surgery, an artificial sphincter, or an injection of a substance into the sphincter muscle may be recommended. Absorbent products or collection devices may help. Whichever you choose, be sure to discuss the latest information available with your health care professional. You may find that something new has been developed which may be appropriate for you.
Incontinence Products
Belted Undergarments
Designed to be worn instead of ordinary underpants, this category of product consists of a belt worn around the waist with buttons or Velcro attachments in the front and back to which a pad that fits between the legs is attached. The pads have a plastic or fibrous waterproof backing and contain gel-forming polymer.
Some manufacturers produce pads with different levels of absorbency. These products are useful for both women and men whose incontinence results in the loss of small to moderate amounts of urine. Because the belt to which the pad is attached is elastic, the product can be pulled up and down easily to facilitate using the toilet; and the pads can be changed easily without needing to remove your trousers or slacks.
Disposable Underwear
These are one-piece, absorbent underpants that have a fibrous “cloth-like” waterproof backing and a built-in absorbent pad containing gel-forming polymer. They resemble ordinary underwear more than any other incontinence product. Some manufacturers produce products with different levels of absorbency, but all these products are designed mild to moderate levels of incontinence. The distribution of the padding in most of these products makes them more appropriate for women than for men. A characteristic of these products is that you have to take off your trousers or slacks in order to put on a new pair of these underpants. This is a major disadvantage if you ever need to change in a public washroom.
Reusable Products
Although most people prefer to use disposable products, reusable washable products are available in almost every category for which disposable products are made. Factors which make these products less popular are the need to do extra laundry and the difficulty of temporarily storing and transporting wet products when you are away from home. One major reason why some people prefer to use a reusable product is the belief that disposable products place a heavier burden on the environment. Conclusive data are not available about whether this belief is correct when all factors are considered. Disposable products certainly produce more waste that has to be handled in some way; and recycling of disposable incontinent products is not available in most communities. However, reusable products also stress the environment by requiring additional detergent and additional power for laundering and drying. Another reason why some people use reusable products is that they believe that reusable products produce fewer skin irritations than disposables. Other people believe the opposite.
External Catheters
Another option available to men is an external catheter consisting of an adhesive sheath that is attached to the penis and connected to a collection bag via a tube. Adhesive sheaths made of either latex or silicon are available. Collection bags are worn either attached to the leg or around the waist. Judging from what one reads in internet discussion forums, these systems are preferred by men who feel that they offer more dignity than wearing a “diaper” or who believe that they produce less skin irritation than an absorbent product. Some physicians also feel that these appliances are more appropriate than absorbent products and thus recommend them to their male patients.
Nevertheless, using an external catheter is associated with its own problems. The fact that the sheath is attached to the penis means that it isn’t practical to urinate in the toilet. Thus, the system is impractical for anyone who is partially continent and wants to use the toilet when he can. Second, there is the potential for the tube to come loose from either the sheath or the bag and cause a leak; and this is likely to happen when a man is doing something that requires a substantial amount of movement. Finally, a full collection bag may rupture and cause a major mess if it is bumped roughly. These considerations make the system most appropriate for men who lead sedentary lives.