A Quiet Epidemic of
Approximately 25 million Americans suffer from involuntary loss of urine (urinary incontinence) and that number is growing rapidly as the Baby Boomers age. Yet, even with those staggering numbers, it is also believed to be the most under-reported, under-diagnosed and under-treated health condition. Why?
One reason is that many people believe that bladder-related health conditions such as urinary incontinence are an inevitable result of aging, with no cure. It is true that the incidence of bladder troubles, especially urinary incontinence, increases with age for both men and women. However, depending on the cause, there may be treatment options that can help prevent, forestall or reduce these problems.
Another reason is that many people are too embarrassed to discuss bladder health issues. There is a huge stigma attached to loss of bladder control, and that gets in the way of seeking help. The unfortunate (and often unnecessary) outcome for many is a long, slow, steady and heartbreaking decline in quality of life.
But it doesn’t need to be this way. Let’s get bladder health out of the water closet! The first step in regaining bladder control—and control over quality of life—is education. Shall we begin?
The Urinary Tract
In very simple terms, the purpose of the urinary tract is to process, store and expel urine from the body. With a healthy urinary tract (and healthy, normal prostate in men) and normal bladder function, the process goes something like this. The kidneys filter blood to clean out waste and byproducts, producing urine, which travels through a pair of long tubes called the ureters into the bladder. As the bladder fills with urine, it stretches like a balloon. With a healthy nervous system, most adults will begin to sense the bladder filling when the urine accumulates to just under a cup (approximately 200 mL), which is only about one-third to one-half of the bladder’s average capacity. As the bladder continues to fill, the urge to urinate grows stronger.
When you intentionally urinate, the brain sends a series of nerve signals to simultaneously relax the pelvic floor muscles and contract other muscles surrounding the bladder to force the urine out through the urethra. Keeping urine in also requires the coordination of multiple bladder sphincter muscles to prevent leaking, while also allowing the bladder to expand as it continues to fill.
Controlling urination is more complex than one might imagine, requiring healthy muscles, a healthy nervous system, and a healthy urinary tract. So, it is no wonder that bladder control can sometimes be a problem.
Types of Bladder Trouble
Bladder-related health conditions such as urinary incontinence, overactive bladder, urinary tract infections and interstitial cystitis are the top healthcare problems today, affecting well over 200 million people worldwide. Often, urinary incontinence is the only symptom that a problem exists—and it is a big problem that can be life-changing. Fortunately, many bladder problems can be treated with an early and proper diagnosis.
Urinary incontinence can be caused by many factors, and it is often a symptom of another bladder-related health problem. One of the biggest risk factors is simply being born female; urinary incontinence affects women far more often than men, especially during or after pregnancy and during or after menopause. Documenting the circumstances under which incontinence happens will help narrow down the cause(s). The primary types of incontinence are:
- Stress incontinence refers to the involuntary urine leakage during physical activity such as coughing, sneezing, laughing, bending over, getting out of a chair, lifting something heavy, or other exercise. This is the most common type of urinary incontinence for women.
- Urge incontinence (also called overactive bladder or irritable bladder) refers to a sudden, strong need to urinate, typically due to bladder muscle spasms or involuntary contractions. With this type of incontinence, there is not enough time to get to the bathroom after feeling the need to urinate. It can be caused by a diet high in bladder irritants including alcohol, coffee, tea, colas, acidic beverages and chocolate.
- Overflow incontinence refers to a bladder that constantly dribbles, even with frequent urination. The bladder seems to constantly overflow (hence the name) because it does not empty properly, continually exceeding its capacity. This type of incontinence is more common in men than in women.
- Mixed incontinence refers to a combination of the other types of urinary incontinence, and it is quite common in the elderly population.
It is important to note that incontinence can also be transient or temporary due to some medications, an adrenal insufficiency or another hormone imbalance. Severe constipation can also affect bladder control by pushing against the bladder or obstructing flow.
Incontinence can also be caused by lifestyle factors including being overweight, consuming a lot of caffeine and/or alcohol, and smoking. For some people with incontinence, simply losing a few pounds, eliminating caffeine and alcohol, and stopping smoking resolves the issue.
One of the most common bladder problems is overactive bladder, also known as irritable bladder. It is a general term for a chronic medical condition that is characterized by a sudden and sometimes uncontrollable need to empty the bladder. The strong urge can strike at any time, day or night, with or without involuntary leakage (urge incontinence).
With an overactive bladder, various triggers can cause the bladder muscles to contract involuntarily, signaling the brain that it is time to urinate. However, sometimes that urge is purely sensory and they feel the need to go, even though the muscles are not contracting. In either case, the sense of urgency is so strong that it typically leads to more frequent trips to the bathroom, and sometimes results in accidents, either during the day or while sleeping.
Urinary Tract Infections
Urinary tract infections (UTIs) affect women far more often than men, due in part to the fact that the female urethra is much shorter than the male counterpart, making it easier for bacteria to reach the bladder. Health data indicates that nearly 90 % of US women experience at least one recurring urinary tract infection in their lifetime.
The incidence of both UTIs and bladder infections increases with aging, as tissues become weakened and hormones depleted. Incontinence, coupled with burning during urination and low back pain, are symptoms typically associated with an infection. The most common source of urinary infections is the E. coli bacteria.
Maintaining a healthy urinary tract is important to avoid developing chronic infections, especially for those who have had a UTI in the past. Contrary to popular belief, sweetened cranberry juice may actually contribute to conditions that promote an unhealthy urinary tract due to its high sugar content. However, cranberries do contain a carbohydrate called D-mannose (also now available as a supplement), which is believed to help by attaching to the E. coli organism such that it can be eliminated in the urine. Urine should be slightly acidic to inhibit bacterial growth and, surprisingly, prune juice seems to be the best juice for this.
Interstitial cystitis (IC) is a painful, chronic inflammation of the bladder that can be difficult to diagnose. Symptoms may be similar to a bladder infection, with lower back pain and a frequent urge to urinate, but bacteria are not involved.
It is more common for women to have IC, but men can also be affected. Women may experience pain in the vulva or vagina, while men may feel it in the penis, testicles or scrotum. For some people with IC, the pain gets worse as the bladder fills, or they may feel it in other areas such as the urethra, lower abdomen or pelvic area.
Relief may be achieved while urinating; but, as the bladder fills again, the pain builds again. This may feed an increasing sense of urgency and frequency of urination, making it difficult to travel or socialize. Physical or mental stress can make symptoms worse. Both men and women may also experience sexual dysfunction due to the pain.
Some people achieve relief by eliminating foods that trigger symptoms. Others simply live with the symptoms because they have been told that there is nothing physically wrong—that the problem is all in their head.
Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy or enlarged prostate, is a potential bladder problem unique to men. The prostate gland, which surrounds the urethra, tends to grow larger with age in nearly all men. Depending on the degree of enlargement, it can interfere with urinary function and lead to incontinence.
Much has been written about BPH as a condition on its own, independent of the bladder problems, and drug treatments are readily available. However, it is worth noting that the prostate gland is very sensitive to hormonal changes, especially estrogen. As men age, testosterone levels decline and estrogen levels rise. Excess estrogen stimulates tissue growth and can contribute to an enlarged prostate, which can then interfere with bladder function and control.
Lifestyle changes, behavior management and muscle training are typically recommended before other treatments, and can be effective in reducing incontinence. Addressing a hormone imbalance may also be required, even if drugs or surgery are recommended. Treatment options are further described below.
Simple changes to diet and daily habits can make a significant difference in regaining bladder control. Typically, these suggestions might include:
- Maintaining a healthy weight. Dropping even just a few pounds may reduce or eliminate urinary incontinence.
- Reducing fluid intake, or following a schedule. Consulting with a healthcare practitioner to determine an appropriate fluid consumption (both type of fluid and quantity) is advised. Some people drink more than the normal amount, others not enough or the wrong types of fluids.
- Avoiding caffeine, carbonated beverages, alcohol, acidic fruits and juices, spicy foods and other triggers to reduce irritation to the bladder.
- Taking dietary fiber to ensure regular bowel movements and avoid constipation, which can lead to incontinence or make it worse.
- Quitting smoking to reduce coughing and bladder irritation.
Behavior management uses a “mind over bladder” approach to retrain your bladder to be controlled by your brain. This approach includes:
- Keeping a journal to document fluid intake, trips to the bathroom, accidents or leaking, and level of activity.
- Timed voiding to re-establish a pattern for urination, with gradual increases in the interval between urinations.
- Deep breathing, visualization and other diversion techniques to suppress bladder contractions and stretch the intervals between voiding.
Pelvic floor muscles can be strengthened or retrained with Kegel exercises consisting of repeated contraction and relaxation of the pelvic floor muscles, which are responsible for holding in urine. Clenching and holding these muscles for 10 – 15 seconds, 20 to 30 times per day, should help with control over urine flow. These exercises can be beneficial in treating urinary incontinence in both men and women, although it may take several weeks before noticing a change in symptoms.
For women, testosterone therapy applied vaginally daily, can also help strengthen and rebuild the bladder and pelvic floor muscles to improve bladder control.
For both men and women with bladder problems, correcting age-related hormone imbalances can improve the overall health of the urinary tract and therefore control over urinary flow.
For men, incontinence due to an enlarged prostate may be alleviated by treating abnormal levels of estrogens and low testosterone. Natural treatments can help metabolize estrogen and pharmaceutical treatments can block estrogen conversion to avoid accumulation. Declining testosterone levels can be supplemented to help rebuild muscles that have atrophied.
For women, vaginal estrogens (but not oral estrogens) have been shown to improve bladder and urinary tract tissue. Vaginally applied estriol, which preferentially binds to estrogen receptors in both vaginal tissue and the urinary tract, has demonstrated effectiveness for treating chronic urinary tract infections.
Another hormone imbalance that may be a contributing factor in bladder problems involves adrenalin and its natural counterbalance, progesterone. An excess of adrenalin may trigger contractions in the bladder muscles, which in turn causes a rise in lactic acid, leading to the pain associated with interstitial cystitis.
Some practitioners think interstitial cystitis may also be caused by too much adrenalin, and that it may be the culprit in overactive bladder (urge incontinence) as well. Progesterone cream applied at bedtime may help reduce the need to urinate and allow for more uninterrupted sleep.
Drugs that relax the bladder muscles can be effective for alleviating symptoms of bladder problems and urinary incontinence. However, side effects such as dry mouth and increased thirst are common, and drinking more fluids can then further aggravate symptoms. Additional side effects include dizziness and blurred vision, which can contribute to falls and broken bones as people with bladder problems hurry to the bathroom, especially in the middle of the night.
Surgery is recommended only in severe cases when other treatment methods have been explored and failed. Various techniques can be used to reduce pressure on the bladder or increase the bladder’s storage capacity. However, these procedures generally don’t relieve any bladder pain, and incontinence may still occur post-surgery.
Biofeedback involves being connected to electrical sensors that teach a person how to make subtle changes in their body, such as contracting the pelvic muscles in response to a feeling of urgency, thus improving bladder control.
In another form of electrical muscle stimulation (EMS), an electrode attached to the skin passes an electrical current through the skin to the underlying pelvic floor muscles, causing them to contract and relax similar to Kegel exercises. Electrodes can also be attached directly to the vaginal or anal wall, and there are implantable EMS devices as well.
Acupuncture, herbal remedies such as uva ursi (also known as bearberry), and other holistic practices such as traditional Chinese medicine (TCM) have a history of over 2,000 years in treating urinary problems. While Western medicine views the bladder as primarily just a storage sack, TCM regards the bladder as an important and complex organ. Rather than looking at the body as a series of tissues, muscles and organs that need “fixing,” TCM views the body as a whole in which a symptom can result from an imbalance anywhere within the body. Correcting the imbalance with acupuncture or medicinal herbs allows the body to heal itself.
A Sense of Urgency
Regardless of the cause, urinary incontinence is not something to ignore—in yourself or others who are close to you—because it can quickly cascade into other health-related issues. In fact, urinary incontinence is one of the primary reasons for elderly people being moved into an institution or care facility.
Here’s how it starts. People with a bladder problem may stop socializing or participating in activities to avoid the embarrassment of an accident. They stop exercising, refuse to travel anywhere or, if they do go out, they map out the locations of the bathrooms ahead of time. They begin to feel isolated and lonely. They start using sanitary napkins or other feminine products, urinating again “just in case” and avoiding fluids, which can lead to dehydration or other serious side-effects. Soon, their sleep cycles become disrupted and erratic, and they may get emotionally unstable or depressed.
In short, if left untreated, a bladder problem can be debilitating, affecting both quality of life and overall well-being. But it doesn’t have to be that way! Be proactive at the first sign of bladder trouble. Make an appointment to discuss incontinence or other urinary issues with your healthcare practitioner, who may be reluctant to ask about it, not wanting to embarrass you. And, advocate for incontinent family members in care facilities to make sure that the appropriate treatment options have been explored.
- “Urinary Incontinence: Economic Burden and New Choices in Pharmaceutical Treatment” by Richard Levy, PhD, and Nancy Muller; Advances in Therapy, Vol. 23, No. 4; July/August 2006.
- “Pharmacists Talking Bladder Health Out of the Water Closet: OAB, Incontinence, UTI, and Interstitial Cystitis” by Diane K. Newman, DNP, FAAN, BCB-PMD; a presentation at The American Pharmacists Association Conference, 2012.
- “D-Mannose for Bladder and Kidney Infections” by Jonathan V. Wright, MD; published on Dr. Jonathan Wright’s Tahoma Clinic Blog at https://tahomaclinicblog.com/d-mannose-for-bladder-and-kidney-infections/ as of April 16, 2012.
- The Platt Protocol for Hormone Balancing: A Wellness Manual for Healthcare Practitioners, an unpublished manuscript by Michael Platt, MD.
- “A Controlled Trial of Intravaginal Estriol in Postmenopausal Women with Recurrent Urinary Tract Infections” by Raul Raz and Walter E. Stamm; New England Journal of Medicine; 1993; 329:753-756.