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An Overview of Incontinence Prevention

Special to OWM

An Overview of Incontinence Prevention

Index: Ostomy Wound Manage. 2017;63(12):16-20.

Introduction

The words incontinence and prevention are rarely seen together. However, more than 33 million persons in the United States and more than 200 million worldwide live with some form of urinary incontinence (UI). Millions more have fecal incontinence (FI) or both types of incontinence. Thus, it is imperative for health care professionals not only to screen for this condition, but also to educate patients about preventive measures. Incontinence is not an inevitable part of aging — steps can be taken throughout a person’s lifetime to minimize risks and to intervene early when incontinence occurs.1

In the realm of public health, prevention comes in 3 forms. Primary prevention involves taking steps to ensure a disease never occurs or that the risks are greatly reduced. Secondary prevention includes screening tests for early detection of an asymptomatic disease so it can be cured. Tertiary prevention comprises activities that prevent deterioration, slow progression, or reduce complications after a disease is evident. This article emphasizes primary and secondary forms of incontinence prevention. 

UI

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. 

FI

Weight loss. A recent study showed women who were overweight and obese reported a higher monthly incidence of FI; these women also had a diet low in fiber.29 Therefore, it is a good idea to discuss a weight-loss program to help reduce the stress any extra pounds are putting on the pelvic floor. Remind patients that weight loss requires an overall change in lifestyle. Gradual weight loss, along with other healthy habits, will enhance long-term benefits, which include improvement of FI.30 As mentioned, weight loss can prevent or treat diabetes, which is associated with constipation and diarrhea, both of which can exacerbate symptoms of FI.31 

Bowel retraining. Bowel retraining is useful for anyone experiencing constipation, which can be the cause of FI and UI. Having regular bowel movements is crucial to preventing FI and restoring bowel control. Both constipation and loose stools can lead to or worsen FI. It is easy to imagine how a watery stool can provoke leakage. Conversely, in the setting of constipation or impaction, the evacuation system becomes blocked. However, the normally softer and watery stool, which travels to the colon, seeps around the hard stool and can easily provoke leakage as well. It is important to rule out constipation and impaction before concluding the patient is incontinent because of watery stool.

Harnessing a person’s natural gastrocolic reflex is the most practical way to initiate bowel training. The gastrocolic reflex can be stimulated by a meal, usually breakfast. Sometimes, even just the smell of coffee can provoke this reflex in some persons. After identifying the optimal timing for bowel movement (eg, 20 to 40 minutes after breakfast), patients should be counseled about using this time consistently to defecate. Additional stimulants can be added, such as a glass of warm water or tea and/or mineral or olive oil a few hours before toileting. It is extremely important to make patients aware it will take a minimum of 2 weeks to establish this pattern and much longer if there is no consistency in their regimen. 

Sometimes it may be necessary to provoke a bowel movement using digital stimulation — that is, using one’s finger, gently inserted into the anus, to initiate a reflex. Suppositories can be used for this purpose as well. 

A more rigorous bowel retraining program may employ physiotherapy and/or biofeedback therapy, patient education, and/or other behavioral therapies. Successful biofeedback programs for FI can vary slightly, but the overall technique involves visual and auditory feedback linked to pelvic floor and external anal sphincter muscle strengthening. Unfortunately, some insurances do not cover this service. 

Dietary changes. Americans have a difficult time including enough dietary fiber in their diets. Our lifestyles may tempt us to choose fast and easy foods that often lack the level of fiber and nutrients needed to keep us healthy. However, recent attention and focus on the health consequences of poor food choices have led many food companies to offer healthier options. The best options are always nonpackaged, unprocessed foods, such as fresh fruits and vegetables, beans, lentils, and whole grains (see Table 3). 

Fiber supplementation is helpful both for constipation and loose stools, which are more prone to leak. Additional fiber should be introduced gradually to prevent bloating and increased gas. Certain supplements are tolerated better than others; patients should be encouraged to try different types or brands. 

Along with added fiber, patients also need to increase their fluid intake. Fiber (both soluble and insoluble) absorbs liquid in the intestine and may cause undesired bulk or hardness of the stool. Having a formed stool, which is easy to pass volitionally, will allow a person to have better sphincter control and decrease leakage of more watery stool. 

Fiber supplements such as psyllium should be used with caution. Added fiber may worsen diarrhea in some patients. Supplementation should be stopped in patients who either experience no benefit or have worsening symptoms. Also, if a patient already has well-formed stools, adding more fiber into the diet may have a laxative effect and contribute to FI episodes.

Keeping a food diary also may help a patient pinpoint other dietary changes that might help prevent a worsening of symptoms or episodes of incontinence. Patients may find that caffeine, chocolate, spicy foods, and milk products adversely affect their bowel and therefore increase incontinence episodes. Eliminating these foods from their diet could be beneficial. Other food culprits may include smoked or cured foods (eg, bacon or ham), alcohol, fruits, foods high in saturated fats, and sugar substitutes. However, make sure that if the patient is eliminating a food that provides essential nutrients (such as calcium from dairy products), a supplement or an appropriate food substitution is made. A registered dietitian can help with those choices.

In addition to dietary modifications, patients may find eating smaller meals more often throughout the day to be helpful. Large meals may trigger contractions in the bowel that can lead to diarrhea. 

Medications. All supplements and prescribed medications should be reviewed with patients with bowel symptoms annually at the minimum; some medications and supplements can aggravate FI. For instance, metformin (a drug used for diabetes) and antibiotics can cause diarrhea or constipation in some people. Alternative drugs may be available with fewer side effects. The timing of dosages should also be reviewed.

Smoking. Anecdotal evidence suggests smoking cessation may be helpful in decreasing the urgency to defecate.32 Because smoking is a known risk factor for UI and UI and FI often occur together, it would be a healthy decision to stop smoking if a patient has any form of incontinence. Also, smoking has been directly linked to colon cancer, and reducing risk factors for this disease is in a patient’s best interest.

Stool classification. Using a Bristol Stool Chart in the office to classify patient’s stools can be very illuminating to patients (see Figure 2). Patients should be encouraged to produce Type 3 or 4 stools.

Considerations for Both UI and FI

Initial evaluation and follow-up. The topic of incontinence should be introduced at all patient visits in conjunction with general bowel and bladder health discussions. Patients should be screened regularly in a natural and empathic manner regarding their urinary and bowel habits. Concerns must be addressed via a very detailed history using visual aids such as the Bristol Chart. Whether male or female, with FI or UI or both, all patients require inspection, palpation of the abdomen and pelvis/saddle region, and careful and thorough digital evaluation of the rectum. A neurological assessment should be performed as well. Follow-up appointments should be scheduled every 3 to 6 months to assess progress. Lack of improvement or worsening symptoms requires repeat evaluation, including pelvic and rectal examinations. Patients must be made aware that cause(s) of incontinence may change over time, and patients should be encouraged to communicate regularly. Underlying health conditions must be monitored as well. In this way, important testing and/or modifications in management can be performed in a timely fashion. 

The knowledgeable patient. Educating patients while destigmatizing incontinence can lead to empowerment and a renewed sense of well-being. As patients become better educated health care consumers, clinicians must be better prepared to address their needs. More importantly, we need to foster open dialogue about incontinence with all patients. Similar to the topic of sex, patients may be uncomfortable initiating a discussion and report disappointment in their health care providers for not asking them about these issues. Health care providers first must ask themselves if they avoid having such discussions because they are personally uncomfortable with these topics and subsequently presume patients would prefer not to discuss them as well. We must promote and nurture open, stigma-free conversations about incontinence as well as urinary and bowel dysfunction. 

Conclusion

This article explored strategies for the primary prevention of UI and FI as well as secondary prevention by means of screening and prescribing early interventions. Preventing further deterioration of patients’ continence requires a multifaceted approach in order to improve diet, hydration, weight loss, exercise, and toileting habits. We must encourage a comfortable demeanor and environment to open and facilitate sensitive conversations about their urinary and bowel symptom during office visits.33