Weight loss. Obesity is strongly associated with metabolic syndrome, defined as the clustering of risks that predispose the patient to diabetes mellitus type 2 and cardiovascular disease and to the concurrence of glucose intolerance, central obesity, hypertriglyceridemia, hypertension, and low high-density lipoprotein (HDL).2
Metabolic syndrome and obesity also are strongly correlated to bladder dysfunction — specifically, problems of bladder storage. Overactive bladder (OAB) symptoms (often associated with urge incontinence) are more common in men and women who are overweight or have metabolic syndrome. Body mass index >25 is correlated to all forms of incontinence; even a 5% to 10% weight reduction can lessen the severity of stress, urge, or mixed UI symptoms, especially in women.3-7 Excess weight places pressure and stress on the internal organs, particularly the muscles of the pelvic floor. Over time, if people do not manage their weight, the extra pounds will increasingly damage their pelvic floor muscles, leading to UI or a worsening of UI symptoms.
Additionally, adipose tissue must be considered more than fat occupying space. Adipose tissue is an endocrine organ; when it exceeds a certain threshold, it can promote oxidative stress and set in motion a deleterious cascade of chemical damage to all tissues in the body,2 including the nerves and muscles governing bladder and bowel function. This condition can lead to diabetes mellitus type 2, which can provoke further neurovascular injury and worsen bowel and urinary symptoms.
Patients may require consultation with a registered dietitian or nutritionist. The prescribed diet should consider the patient’s age, gender, and all other health factors to promote a safe, effective weight loss program. Because everyone is unique and has different health challenges, a diet must be designed that may include family members and counseling and take into account the 4 pillars of obesity medicine (dietary therapy, behavior therapy, physical activity, and supplement/drug therapy; available at www.ObesityMedicine.org).
Moderate exercise. Exercise can help prevent or lessen UI symptoms. Studies show moderate physical activity can improve muscle tone and reduce UI.8-12 Recent research13 has demonstrated a correlation between a sedentary lifestyle and increased risk of UI in women. Walking is usually one of the easiest ways for an able-bodied person to add some moderate physical activity into a daily routine.
Patients who have been sedentary or have other medical conditions may need to have a general cardiovascular screening before embarking on a new exercise program. A common-sense approach to exercise includes starting out slowly and gently, gradually progressing to include weight training.
As encouraged by Crowley and Lodge in Younger Next Year,14 engaging with groups or partners for physical activities and exercise greatly enhances motivation, satisfaction and compliance.
Strengthening the pelvic floor.
Exercise. Kegel exercise (the most common pelvic floor muscle exercise) involves contracting and relaxing the pubococcygeus muscles, which are used to stop the flow of urine. To learn to do the exercise properly and to use only the correct muscles, the exercise should be taught by a nurse or physiotherapist. In addition, small sensors (or probes) or vaginal cones may be used to provide the patient with immediate feedback to ensure proper muscles are being engaged. Kegel exercise is particularly important for young women as they prepare for pregnancy and childbirth.15,16 Keeping the pelvic floor muscles strong throughout a woman’s lifetime may prevent or lessen stress UI symptoms.17 Men who are facing prostatectomy also may benefit from pelvic floor muscle training (especially with biofeedback) both before and after surgery.18,19
Electric stimulation (E-stim). E-stim uses small, very safe electrical impulses to assist weak muscles to contract, thus helping strengthen the pelvic muscles over time. E-stim may be used alone or in combination with biofeedback.
Biofeedback. For many, the use of biofeedback (with and without exercise and/or e-stim) or e-stim alone can decrease the severity of UI symptoms.20-23
If successful, these therapies must be continued indefinitely to keep the muscles strong. Unfortunately, if the exercise is stopped, symptoms will recur or worsen. This technique requires a doctor’s order, and not all insurance companies will cover this service. However, because it is a conservative, noninvasive management tool, it is well worth discussing with your patients.
Bladder retraining. Bladder retraining is most useful for people with urinary urge and mixed incontinence.24 After adequate instruction, bladder retraining is performed at home, usually without equipment. Patients who are able to comply with strict a toileting schedule are the best candidates for this intervention. Patience, likewise, is a prerequisite, given the amount of time required and the gradual improvements expected.
Bladder retraining should not be undertaken during an active urinary tract infection. The week before starting bladder retraining, patients should keep a Bladder Diary (see Figure 1), noting all urges, leaks, and voids. This will help determine an appropriate time interval between voids for Week 1 of bladder retraining. If a patient needs to void every hour, he/she should start with a 60-minute interval. Patients should keep updating their Bladder Diary throughout a bladder retraining program so the diary can be reviewed and discussed for progress with the patient. Table 1 provides guidance on bladder retraining.
Diet modifications. Diet changes or modifications are aimed at those foods and beverages that may (or may not) aggravate the bladder and worsen symptoms of UI in some patients25 (see Table 2).
One way to determine if foods are contributing to a patient’s symptoms is by asking them to completely eliminate the items listed in Table 2 from their diet for 2 weeks. If after that time the patient is improved, he/she may add an item back into the diet each week and observe its potential effect. Further additions or deletions from the diet can proceed accordingly. However, always be certain patients have not eliminated sources of essential nutrients from their diets. A nutritionist or registered dietitian may be helpful when dealing with complicated dietary choices in the setting of bowel and bladder sensitivity.
Liquid intake. It is important to discuss liquid intake. Eliminating the intake of certain beverages is fine during an elimination diet, but it is not acceptable for patients to severely cut total fluid intake, thinking this will decrease the need to run to the bathroom as often. Patients need to understand that getting dehydrated in an attempt to reduce incontinence symptoms is dangerous, and that drinking a healthy quantity of fluids each day is beneficial to their urinary system.
Not surprisingly, patients with UI are at higher risk for kidney stone formation because of their conscious or unconscious avoidance of water. This state of chronic dehydration leads to more bladder irritation due to concentrated urine; more constipation, which exacerbates symptoms of OAB; and incontinence and may increase risk of urinary tract infection.
An adult should consume 6 8-oz glasses of nonalcoholic fluids in a 24-hour period (urine should be light or nearly clear in color versus yellow or dark in color). Patients may be advised to decrease fluid intake after 6:00 pm (or about 3 to 4 hours before going to bed) to lessen the need to void during the night.26
Smoking. Nicotine in smoking materials irritates the bladder. Smoking also can cause chronic coughing, which will increase pressure on the bladder and, subsequently, incontinence episodes.27 Smoking cessation can prevent or improve incontinence symptoms. Some patients may require formal smoking cessation programs. These programs are sometimes provided for free through insurance carriers, hospitals, or clinics.
Smoking is the leading cause of bladder cancer. Patients usually present with painless or asymptomatic hematuria (either macro- or microscopic blood in the urine).
Medications. It is advisable to review all current medications at each patient visit and no less often than annually. Some medications (prescribed, nutritional supplements, and over-the-counter) contain caffeine (a diuretic and bladder irritant) and some are, in fact, diuretics. Some antihypertensive medications can cause coughing, which greatly exacerbates stress UI. Women should be queried about any effects of hormone replacement therapy on UI.28 Medications in the elderly may alter cognition or mental status. These changes, even subtle ones, can manifest as new onset incontinence. Health care providers must be especially vigilant of polypharmacy in this patient population.