incontinence — inability to contain oneself — may apply to many contexts of human function and behaviour. When applied literally to the body it means the uncontrolled leakage of excreta — or sometimes to unbridled sexual activity.

Urinary and faecal (‘double’) incontinence is of course universal in infants, common in debilitated or demented old people, and occasional between these extremes of age in some nervous system disorders. In all these instances the conscious brain has no dominion over the reflex emptying of bladder and bowel. Yet even with a normal nervous system and the best will in the world, other persons can suffer this ignominy for a variety of reasons. Faecal incontinence can happen to anyone if the ‘call to stool’ is precipitate in severe diarrhoea. Urinary incontinence in men may accompany abnormality of the penis or problems with the prostate. But incontinence, especially of urine, is most commonly a female affliction.

Incontinence of urine in women

Incontinence of urine in women is certainly common, although due to embarrassment, and the fact that some women regard it as the inevitable consequence of childbearing and ageing, the exact prevalence is uncertain: estimates suggest that at least 14% of women over 30, up to 50% of the elderly and infirm, and hence at least 2–3 million women in the UK are affected.

Incontinence impairs quality of life in a number of ways. Embarrassment may lead to withdrawal from normal social activities, may cause difficulties with childcare or employment, and may interfere with relationships; nocturnal incontinence leads to disturbed sleep; caring for an elderly relative with incontinence can become intolerable, leading to institutional care. Embarrassment and isolation may lead to feelings of worthlessness and depression. In some cultures women suffering from incontinence are completely ostracized and forced to leave their community.

Continence of urine

Continence of urine is normally maintained by the bladder and urethra acting as a single unit with a dual role: holding urine until it is convenient to void, and then, at a suitable time, completely emptying the bladder under voluntary control. As a storage organ the bladder must relax to accommodate large volumes of fluid without any rise in pressure. This requires that the muscle of the bladder wall (the detrusor) remains relaxed and compliant and able to stretch. To prevent urine leaking during this storage phase there is a sphincter mechanism acting to close the neck of the bladder and prevent urine entering the urethra. This sphincter has a number of components, all of which contribute to continence and which may be disrupted in a variety of ways. The bladder and urethra are maintained in position by the muscles of the pelvic floor and by fibrous supporting ligaments; when held in its correct position within the pelvis any rise in the pressure within the abdomen, during physical activity or coughing, is also transmitted to the urethra, preventing urine leakage.

In a baby voiding of urine is via a spinal reflex, but brain control of this reflex is gained during ‘potty-training’ and the ability is developed to suppress bladder contraction until a convenient time. During normal voiding the detrusor muscle contracts and the muscles of the urethral sphincter and pelvic floor relax in a co-ordinated fashion to allow the bladder to empty.

Causes of incontinence

Incontinence of urine results from a number of underlying causes:(i) genuine stress incontinence (urethral sphincter incompetence);(ii) detrusor instability/detrusor hyperreflexia;(iii) overflow incontinence, retention, voiding difficulties;(iv) fistulae (abnormal openings into the vagina from the urethra, bladder, or ureter);(v) congenital (abnormal development of the urinary tract);(vi) temporary causes (urine infection, constipation, drugs);(vii) functional (immobility, dementia).

Stress incontinence is a term coined in 1928 by Sir Eardley Holland and refers to the loss of urine on coughing or straining. Genuine stress incontinence (GSI) is incontinence believed to be due to weakness of the urethral sphincter after other causes have been excluded. Childbirth has a major influence: during pregnancy hormonal changes and the increase in pressure on the pelvic floor cause softening and stretching of the supporting structures of the bladder and damage may occur during delivery. Ageing results in a loss of muscle strength; also, after the menopause the reduction in oestrogen levels causes loss of elasticity of the tissues of the urethra, bladder, and pelvic floor. There are racial and hereditary differences related to variations in posture, pelvic muscle strength, and collagen. Obesity, constipation, and chronic cough also increase pressure on the bladder.

These factors lead to weakness of the tissues supporting the bladder in its correct anatomical position and allow it to descend during straining. This, together with damage to the sphincter mechanism, prevents the normal transmission of intra abdominal pressure to the urethra and allows the leakage of urine during physical effort.

Treatment of GSI

Pelvic floor exercises were first described and used by Kegel in 1948 and remain the first line of therapy: their aim is to improve the muscle strength and tone of the pelvic floor. Continence surgery is warranted when conservative measures fail or when incontinence is severe, but the fact that over 150 operations have been described suggests that no one single procedure is best. Most operations aim to restore the bladder to its normal anatomical position. Colposuspension has been shown to be one of the most effective of these with success rates in excess of 90%. Other procedures utilizing synthetic or natural slings or laparoscopically placed sutures also have a place in certain circumstances. Surgically implanted artificial sphincters have also been tried, with varying success.

Detrusor instability

is the second commonest cause of female incontinence; uninhibited contractions of the detrusor muscle lead to the need to void frequently and urgently and in severe cases to ‘urge incontinence’. The cause is unclear, but may be due to the bladder ‘learning’ to empty frequently. It may be aggravated by tea, coffee, alcohol, and stress. Loss of the normal bladder control may also occur in neurological conditions such as multiple sclerosis and after spinal injury, leading to uncontrolled detrusor contractions, known as detrusor hyper-reflexia.

Detrusor instability tends to be a chronic condition and its management aims to alleviate, rather than cure, the symptoms. Bladder retraining is useful — increasing the times between bladder emptying by the clock — and there are drugs which can be employed to assist this process. As a last resort, for those with severe and intractable incontinence, surgery may be necessary, to make a new bladder or to divert the urine to an artificial reservoir.

Overflow incontinence

implies incomplete bladder emptying, overflow, and constant dribbling. This can occur if the bladder has been overstretched, if there is obstruction to normal emptying in pregnancy or by an enlarged fibroid uterus, or in neurological conditions which interfere with the emptying reflex.

Fistulae

The tissues of the lower urinary tract may be so damaged that a direct channel forms from the bladder to the vagina and urine can leak continuously. Historically this form of incontinence was the most important as fistulae formed after prolonged obstructed childbirth: such fistulae have been identified in Egyptian mummies. This is still the commonest cause of incontinence where modern obstetric facilities are not available; specialist ‘fistula hospitals’ have been set up in parts of Africa. Fistulae are unusual in developed countries but may occur following surgery or radiation therapy or in advanced cancer.

Many other conditions may lead to incontinence. Infection of the urine causes symptoms of urgency and sometimes leakage of urine. Fibrous scarring of the bladder wall after radiation therapy can lead to a shrunken bladder unable to hold sufficient urine. Lastly, anything which limits an older person's independence can precipitate incontinence, which will be transient if the circumstances are reversed.

To investigate the cause of incontinence, infection of the urine is first excluded by microbiological examination of a sample. For further study, more complex tests of bladder function are necessary. The bladder has been described as ‘an unreliable witness’ as symptoms alone do not always reveal the underlying cause. ‘Urodynamic’ studies can be employed, to measure urine flow and the pressures within the bladder during filling and emptying. Imaging techniques (X-ray, ultrasound, and magnetic resonance imaging) can reveal the anatomy of the pelvic floor and lower urinary tract, and the inside of the bladder can be visualized directly with a cystoscope.

In some women incontinence is intractable and the aim is to improve quality of life. Absorbent pads, indwelling catheters, hand-held urinals, commodes, and toilet adaptations can be supplied; continence may be improved by promoting mobility and making toilets more accessible. Changes in lifestyle and coping strategies may also help. Devices worn internally may help some women to remain dry without the use of surgery. Support is essential to help women cope with their problems, and Continence Advisors, usually specially trained nurses, are being increasingly employed. The outlook for sufferers has improved dramatically. Modern investigation and treatment seems likely to restore continence and relieve the misery of increasing numbers of women.

John Bidmead,, Kelvin Boos,, and Linda Cardozo

Incontinence

Description

Incontinence is the loss of normal control of the bowel or bladder. Incontinence can involve the involuntary voiding of urine (urinary incontinence) or of stool and gas (fecal or bowel incontinence). There are several types of urinary incontinence. Those most frequently seen as side effects of cancer include overflow incontinence, urge incontinence, and stress incontinence. In rare cases incontinence occurs as the result of cancer, but more commonly it is a side effect of treatment. Because the subjects of bowel and bladder control are perceived as socially unacceptable, those affected with incontinence often feel ashamed or embarrassed by the problem. Instead of seeking medical attention, these individuals try to hide the problem or manage it themselves. For this reason, incontinence is sometimes referred to as "the silent affliction." Impacts of incontinence include low self-esteem, social withdrawal and isolation, and depression . In most cases incontinence can be successfully treated, so affected individuals should discuss the problem with a doctor.

Causes

Incontinence can result from damage to the muscle, nerves, or the structure of the body parts involved in the control of voiding. Complex systems of hollow organs (such as the bladder) and tube-shaped structures (such as the rectum and urethra) work together to store and release waste. Special muscles, including sphincters, are especially important in maintaining the tight seals that hold in waste. When physical damage to muscle or organ structure occurs, the system can no longer maintain these tight seals, and waste can leak out.

Nerves carry messages between the brain and the bowel and bladder systems. Injury to these nerves, or the related part of the brain, interferes with the delivery of these messages, which can prevent the body from recognizing the signals telling it when to void. Without these signals and messages, an individual cannot coordinate the brain with the bowel and bladder systems, and incontinence results.

Several types of cancer and its treatments are associated with incontinence. Usually, it is the treatment of cancer that causes incontinence, rather than the cancer itself.

Prostate cancer

The treatment of prostate cancer is one of the most common causes of cancer-related urinary incontinence, largely because the prostate is located so closely to the nerves, muscles, and structures involved in urine control. Surgical removal of the prostate, or prostatectomy , carries the highest risk of urinary incontinence as a side effect; the risk from radiation therapy is somewhat lower. The incontinence (typically stress or urge incontinence) is often temporary, but in a small percentage of men it may be long lasting.

Prostate cancer itself seldom causes incontinence. However, this depends on the location and size of the cancer; a large cancerous prostate can interfere with the flow of urine and result in overflow incontinence.

Bladder cancer

Incontinence is only occasionally the direct result of bladder cancer , but it is a common side effect of some treatments. For early-stage cancer where treatment does not require the bladder to be removed, incontinence almost never occurs. But removal of the bladder and surrounding structures is often necessary to treat more advanced cancer. This requires creation of an artificial system for storing and releasing urine and carries a risk of long-term incontinence.

Colon cancer and rectal cancer

Muscles in the anal and rectal region largely control bowel evacuation, with the colon storing stool and gas. When these regions are removed or damaged during cancer treatment, or if injury to the related nerves occurs, fecal incontinence can result. Fecal incontinence is most commonly a side effect of surgery. Weakening of bowel muscles or damaging of nerves by radiation therapy can also cause incontinence, but this type is more likely to be mild and temporary, and will often improve as these areas heal. However, in some patients, radiation causes permanent and severe fecal incontinence.

Other causes

Loss of voluntary bowel and bladder control is less commonly associated with other cancers of the genital and urinary systems, mainly as a side effect of treatment. Incontinence can also result from cancer or treatment damage in the brain and spinal cord. Other cancers indirectly cause incontinence; for example, constant coughing from lung cancer can lead to stress incontinence. Very rarely, incontinence can be a side effect of certain medications.

Treatments and complementary therapies

The method of treatment depends on the cause and type of incontinence. Surgical treatment is usually reserved for severe or long-lasting incontinence. An artificial pouch for storing urine or stool can be placed inside the body as a substitute for a removed bladder, colon, or rectum. Placement of an artificial sphincter successfully treats other cases. For mild or temporary incontinence, treatment may include medications, dietary changes, muscle-strengthening exercises, or behavioral training, such as establishing a time pattern for voiding. A small group of patients, however, requires a permanent colostomy or urostomy .

Electrical stimulation therapy, which targets involved muscles with low-current electricity, can be used to treat either urinary or fecal incontinence. Biofeedback uses electronic or mechanical devices to improve bladder or bowel control by teaching an individual how to recognize and respond to certain body signals.

Embarrassment may lead some people to manage the symptoms of incontinence themselves by wearing absorbent pads to prevent the soiling of their clothes. However, many treatments exist to successfully restore or improve control of bowel and bladder function, so individuals experiencing incontinence should speak to a doctor or nurse.

Resources

BOOKS

Walsh, Patrick C., and Alan B. Retik. Campbell's Urology Seventh edition. Philadelphia: W. B. Saunders Co., 1998.

PERIODICALS

Jackson, Susan L., Tracy L. Hull. "Fecal Incontinence in Women." Obstetrical and Gynecological Survey Vol. 53, no. 12 (December, 1998): pp. 741-747.

Kamm, Michael. "Fortnightly Review:Faecal Incontinence."British Medical Journal Vol. 316, no. 7130: pp. 528-532.

Kunkel, Elisabeth J. S., M.D., Jennifer R. Bakker, Ronald E. Meyers, Ph.D., Olo Oyesanmi, M.D., and Leonard Gomella, M.D. "Biopsychosocial Aspects of Prostate Cancer." Psychosomatics Vol. 42, no. 2 (March/April 2000): pp.85-94.

Scientific Committee of the First International Consultation on Incontinence. "Assessment and treatment of urinary incontinence." The Lancet Vol. 355, no. 9221 (June 17, 2000): pp. 2153-2158.

Smith, Dorothy B., RN, MS, CETN, FAAN. "Urinary Continence Issues in Oncology." Clinical Journal of Oncology Nursing Vol. 3, No. 4: 161-167.

Stefanie B. N. Dugan, M.S.

KEY TERMS

Evacuation

—Release of stool or gas from the bowel system.

Overflow incontinence

—Slow leaking or dripping of urine from an overfilled bladder that may be unable to empty completely.

Sphincter

—A circular muscle that relaxes and tightens to control the storage and release of bodily waste.

Stress incontinence

—Involuntary loss of waste resulting from sudden pressure or force, such as by coughing, sneezing, laughing, or lifting an object.

Urethra

—A tube-like structure allowing the passage of urine between the bladder and the outside of the body.

Urge incontinence

—Involuntary loss of waste after feeling a strong, sudden need to void, without enough time to get to a toilet.

Voiding

—Release of urine from the bladder system.

incontinence (in-kon-ti-nĕns) n.
1. (urinary incontinence) the inappropriate involuntary passage of urine. stress i. the loss of urine on exertion (e.g. coughing or straining), which is common in women in whom the muscles of the pelvic floor are weakened after childbirth. overflow i. leakage from a full bladder, which occurs most commonly in elderly men with bladder outflow obstruction. urge i. leakage of urine that accompanies an intense desire to pass water with failure of restraint, frequently caused by overactivity of the detrusor muscle. See also enuresis.

2. (faecal or anal incontinence) inability to control bowel movements, causing involuntary loss of faeces or flatus.
www.continence-foundation.org.uk Website of the Continence Foundation

Incontinence

What Is Incontinence?

What Causes Incontinence?

How Is Incontinence Treated?

Incontinence is a person’s inability to control when he or she passes urine or feces.

KEYWORDS

for searching the Internet and other reference sources

Defecation

Urination

What Is Incontinence?

Older men and women, as well as some young children, find they cannot wait when they have to go to the bathroom. Usually, incontinence (in-KON-ti-nens) involves urinating at the wrong time, or it can mean having a bowel movement before reaching a bathroom. Although incontinence

occurs mostly in older men and women and younger children, it can occur in people of all ages.

Sometimes it is simply a small amount of urine that is released when a person strains, such as with coughing or laughing too hard. For others, it occurs only when the bladder is too full.

What Causes Incontinence?

There are many causes for incontinence. Urinary tract infections, cancer, diabetes, stroke, Parkinson’s disease, and Alzheimer’s disease are some of the illnesses that can cause incontinence. Several problems in the brain or spinal cord can lead to urine and bowel incontinence. Surprisingly, severe constipation can cause bowel incontinence. Withholding stool can cause a hardened plug of stool to block the rectum. This plug irritates the lining of the rectum and causes watery stool to leak out from around the hardened plug.

Urinary incontinence affects more older women than men. One reason is that changes in a woman’s hormone levels later in life can weaken muscles that control urination. Woman who have had children also may experience more incontinence because the muscles that are stretched during pregnancy and childbirth may become weakened.

Some over-the-counter cold medicines as well as some prescription drugs for conditions such as high-blood pressure can cause incontinence.

How Is Incontinence Treated?

Treatments for urinary incontinence involve avoiding liquids and caffeinated drinks such as coffee near bedtime and going to the bathroom at regular intervals. Also, a woman can do certain exercises to strengthen weakened muscles and help her control her urine. Some adults wear pads to absorb small amounts of urine that leak. Medications and surgery are helpful for some people.

The treatment for bowel incontinence depends on the cause. If the cause is chronic constipation, treatment involves adding fiber to the diet and correcting the constipation. Other causes may require surgery.

See also

in·con·ti·nent / inˈkäntənənt; -ˈkäntn-ənt/ • adj. 1. having no or insufficient voluntary control over urination or defecation. 2. lacking self-restraint; uncontrolled: the incontinent hysteria of the fans. DERIVATIVES: in·con·ti·nence n. in·con·ti·nent·ly adv.

incontinence, incontinent XIV. — (O)F. or L.; see IN-2, CONTINENCE.