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Efficient, high-quality disposble absorbent products are of great importance to the patient. They can relieve the worst effects and make incontinence more tolerable not only for the patient, but also for relatives and nursing staff. Modern disposable products absorb urine reliably without allowing any offensive smell to develop. There is no uniform solution when using absorbent disposable products - the patient's individual needs should be met in terms of the respective form and severity of the incontinence. Besides considering the quality of the product, ideally also the patient's environment and lifestyle, treatment options as well as the patient's age, gender and skin condition should be taken into account.
Experience has shown that the degree of severity can be graded according to the amount of urine passed within a 4-hour period.
Degree of Severity
Volume of urine passed within 4 hours
Severe Urinary Incontinence
Very Severe Urinary Incontinence
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Understanding urinary incontinence
Urinary incontinence is primarily a symptom of an underlying condition. It is characterised by the involuntary excretion of urine in quantities which are socially or hygienically unacceptable for the person concerned. Urinary incontinence occurs in all age groups and can be caused by a wide variety of pathological conditions. It manifests itself as a functional disorder of the lower urinary tract and requires exact diagnosis and appropriate treatment.
This also applies to urinary incontinence in the elderly, which is often regarded as untreatable. Although factors associated with the patient's advanced age may impede diagnosis and therapy, the underlying causes are essentially the same as in young people. The correct therapy can thus be of help even in elderly patients and it is possible, as an absolute minimum, to alleviate their problem by achieving "social continence".
Anatomy and function of the lower urinary tract
The urinary bladder (vesica urinaria) is a spherical musculomembranous sac into which the ureters leading from each kidney transport urine. At the lower end, the muscle fibres of the bladder form spirals merging into the urethra which leads through the pelvic floor to the external orifice. The muscles at the neck of the bladder form the internal sphincter, whilst the fascicles of muscle fibres in the region of the pelvic floor, which can normally be controlled voluntarily, form the external sphincter. These two sphincters function in concert to ensure that the urinary bladder remains closed until micturition becomes necessary.
The urge to urinate arises from the expansion of the bladder muscles as the bladder tills with urine. Information on the amount of urine in the bladder is transmitted via a special nerve centre in the lower region of the spinal cord (the sacral micturition centre) to the relevant centres in the brain. These make the person aware that a certain volume of urine has accumulated in the bladder and enable him or her to take a conscious decision to urinate.
The storage capacity of a healthy person's bladder can also be affected by emotional factors. The impulse triggering voluntary micturition is then transmitted from the brain down the spinal cord, causing the bladder muscles to contract and the sphincter to relax.
Causes of urinary incontinence
Urinary incontinence can be classified simply into passive incontinence involving a dysfunction of the sphincter mechanism and active incontinence involving a dysfunction of the bladder muscles. In cases where the functioning of the nerves controlling the lower urinary tract is impaired, the resulting incontinence can be either active, passive or a mixture of both.
Passive incontinence is usually caused by weakness in the pelvic floor which leads to a loss of tone in the sphincter. Bladder function may be completely intact. The weakness is generally the result of fatigue caused, for example, by repeated pregnancies, heavy physical work or obesity and can in women often be exacerbated by postmenopausal oestrogen deficiency. This is the most common form of incontinence.
In active incontinence, the bladder's ability to store and retain urine is impaired by premature involuntary contractions of the bladder muscles. This is termed detrusor instability and often results in the voiding of the entire bladder contents.
This type of hyperactivity of the bladder muscles can, for example, be caused by chronic cystitis, accompanied in some cases by partial obstruction. Cerebral or spinal cord dysfunction can also lead to loss of control of the micturition reflex.
Urinary incontinence will generally occur if the functioning of the nerve pathways between the brain, the spinal cord and the bladder is impaired or completely eliminated. This is frequently the case in patients with cerebral ischaemia, after strokes, in diabetes, multiple sclerosis or spina bifida, and can also happen as a result of injuries to the spinal cord or after radical rectectomy or hysterectomy.
As the bladder distends, sensory impulses (broken lines) are transmitted from the mucous membrane and bladder muscle to the sacral micturition centre where they are processed and relayed back in a reflex arc to the bladder muscles in the form of motor impulses (continuous line).
At the same time, the higher centres in the brain register these impulses either consciously or unconsciously and can increase or decrease the bladder's storage function and inhibit or stimulate its emptying.
Types of Urinary Incontinence
The causes of urinary incontinence serve to classify urinary incontinence into the various types, the most common of them you find listed below. Mixed types may also occur, especially in elderly patients or when neurogenic disorders are present.
• Stress incontinence
• Urge incontinence
• Paralytic incontinence
• Overflow incontinence
• Extraurethral/extravesical incontinence
• Other types
In this case, the closing and retaining mechanisms at the neck of the bladder and in the pelvic floor are not strong enough to resist an increase in intraabdominal pressure (stress). For anatomical reasons this condition occurs almost exclusively in women.
The female urethra is much shorter than the male and generally has a length of 3 - 4 cm. This alone makes it less capable of resisting increases in pressure. However, the neck of the bladder and the urethra are supported by the muscles in the pelvic floor and held in position intra-abdominally in such a way that no urine is normally passed during sudden strain, fits of coughing, sneezing or laughing or as a result of physical exertion.
When the pelvic floor is subjected to chronic strain, the urinary bladder and the urethra can shift into an unfavourable position. The length of the urethra decreases even further, with a consequent reduction in "urethral resistance". The functioning of the sphincter system is impaired. If a sudden increase in intra-abdominal pressure now occurs, the sphincter may be unable to resist it and urine is passed involuntarily. Three degrees of severity (I - III) are defined. In the most extreme degree there is loss of urine even when the patient is lying down.
The main aim in the treatment of female stress incontinence is to return the bladder and the urethra to their correct positions. In the milder forms, exercises can help to strengthen the muscles of the abdominal wall and the pelvic floor. Medication may be indicated in some cases to restore the tone and elasticity of the periurethral tissues. In most cases, however, corrective surgery is necessary.
In contrast to stress incontinence, the sphincter muscle system remains intact in urge incontinence, which is caused by increased sensory or motor impulses in the region of the bladder or lack of central inhibition. This leads to involuntary passage of urine when the urge to urinate can no longer be controlled.
In mild forms of urge incontinence the only symptom at the start is very often increased frequency of micturition (pollakiuria) with the patient remaining continent. If the symptoms become more severe, the patient is no longer able to control the urge consciously and incontinence ensues.
Urinary tract infections, urethral strictures, inflammation and hypertrophy of the prostate gland, tumours of the bladder and also metabolic disorders such as diabetes or degenerative diseases of the central nervous system are the main causes of urge incontinence.
Management of the condition is aimed at treating the underlying disorder. In the case of urinary tract infections and subvesical obstructions this is achieved by removing the primary cause, whilst metabolic and central nervous disorders are treated symptomatically.
Paralytic incontinence (also referred to as reflex bladder) is a symptom of neurogenic disorders involving damage to the brain or the spinal cord. Voluntary control over the sacral micturition centre is lost and the bladder function reverts to the type of reflex seen in babies.
Unlike the baby, the incontinent adult patient may experience a further complication in the form of detrusor sphincter dyssynergia which means that his or her bladder muscles and sphincter are no longer properly coordinated. Whereas the contraction of the detrusor and the relaxation of the external sphincter are more or less synchronous in normal physiological micturition, they both contract simultaneously in dyssynergia. This means that the bladder is only emptied when the external sphincter can no longer resist the pressure exerted by the accumulated urine.
A certain degree of social continence can be achieved in reflex bladder patients with bladder percussion training combined, where necessary, with medication. In the more severe cases, however, the accumulation of residual urine is followed by urinary stasis and vesico-renal reflux with a risk of serious damage to renal function. It is therefore often necessary to make a surgical incision in the external sphincter. This eliminates the detrusor sphincter dyssynergia and the risk of kidney damage, but only at the expense of social continence.
In overflow incontinence there is an acquired underlying weakness of the detrusor which initially is characterized by incomplete bladder emptying with the development of residual urine. With a gradual increase in residual urine the bladder muscles become overdistended with a consequent decrease in contractility. Bladder emptying is then only possible when the intravesical pressure is increased so sharply, for example, by pressing on the abdomen that it overcomes the resistance below the level of the bladder. The initial symptom is pollakiuria followed later by the passage in dribbles.
The majority of cases of overflow incontinence are caused by a purely mechanical obstruction below the level of the bladder. This type of incontinence can occur even after one single episode of acute overdistension of the bladder during or after surgery.
Neurogenic or psychogenic forms of overflow incontinence also exist but these are very rare. Examples of neurogenic forms are types of overflow incontinence following operations in the region of the true pelvis such as radical hysterectomy or rectectomy, after intervertebral disc prolapse, in peripheral diabetic and neuropathy and in multiple sclerosis and other degenerative disorders of the central nervous system.
Overflow incontinence is a urological emergency which like acute urinary retention must be treated immediately by transurethral or suprapubic catheterization. Mechanical obstructions can then be removed by surgery.
Extraurethral / extravesical incontinence
This rare type is actually a "Pseudo-Incontinence", as neither bladder nor sphincter function is impaired and the urine can be voided without difficulty at normal intervals and in normal quantities. The occurring in these cases continuous loss of urine is due to the fact that urine is bypassing the bladder, urethra or sphincter. This can be caused by congenital malformations of the upper urinary tract e.g. ectopic ureter from a double kidney or by a fistula, e.g. a ureterovaginal fistula. Extraurethral/extravesical incontinence is usually treated by surgery.
Certain psychotropic agents and drugs affecting the autonomous nervous system can induce incontinence. Diuretics increase the volume of urine excreted and this can also cause incontinence in some patients.
Psychological factors very often play an important role in incontinence. It is well known that emotional stress can lead to incontinence especially in elderly persons. Causative factors can be a change of domicile or admission to an old people's home or hospital. In many elderly persons urinary incontinence manifests itself only after admission to hospital.
General principles for diagnosis and treatment
The causes of urinary incontinence must always be clarified before any treatment is started. Careful study of the patient's case history and his or her micturition pattern will often provide valuable clues:
• Under what circumstances does loss of urine occur?
• How frequently and in what quantities is urine passed?
• Is the urge to urinate very strong?
• Are there times when urine can be passed voluntarily and, if so, in what quantities?
• Does the patient feel that the bladder has been completely emptied?
• Is the patient suffering from a urinary tract infection?
• Does the patient have a history of urological or gynaecological problems? Has he or she undergone surgery?
• Are there reasons to suspect a neurogenic or a metabolic disorder?
A phased diagnosis involving specific urological tests can be carried out. This will start with noninvasive procedures like measurement of the urinary stream, sonographic examination for residual urine or an electromyogram of the pelvic floor. These can be supplemented, where necessary, by gynaecological, neurological or other internal examinations. A complete urodynamic examination may be desirable in cases where there are difficulties in establishing a differential diagnosis. Before undertaking this, the urologist must consider what it will achieve either diagnostically or therapeutically and whether it is reasonable to ask the patient to submit to it.
Urinary incontinence is a symptom of an underlying condition and therapy should, where possible, concentrate primarily on dealing with this condition. Causal therapy is, however, often impossible, especially when the central or peripheral nervous systems are involved, e.g. spinal cord injuries, spina bifida, cerebral ischaemia, multiple sclerosis or sequelae of diabetes mellitus. The only available option in such cases is symptomatic treatment.
If conservative medication has failed to produce a lasting improvement, e.g. in cases of moderate or severe stress incontinence, surgical procedures aimed at restoring the anatomical requirements for continence may have good prospects of success in patients where surgery is not contraindicated. These include the Marshall-Marchetti-Krantz operation, Burch's modification and vaginal reconstruction. These are frequently combined with a radical hysterectomy. Sling procedures, e.g. Gobel-Stockel, or bladder neck suspension, e.g. the Stamey-Pereyra method, can also yield good results.
In men, bladder emptying problems tend to be caused mainly by mechanical obstructions which result in urge or overflow incontinence. This can generally be eliminated by causal therapy, e.g. transurethral resection of the bladder neck, removal of a pros-tatic adenoma or by urethrotomy in cases of urethral stenosis.
Artificial sphincters, e.g. Brantley-Scott sphincters, can be implanted in cases where prostatic resection or enuclea-tion is followed by incontinence. These can also be indicated in certain cases of paraplegia and in spina bifida or other neurogenic disorders of micturition.
In cases where artifical sphincters with mechanical automatic emptying devices are not feasible, the possibility of permanent urinary catheterisation should be considered. Urinary diversion either by ileal conduit to a stoma or into the colon with reservoirs in the small intestine is another alternative, but all three of these measures should be regarded as a last resort.
Even the most up-to-date diagnostic methods and therapy are incapable of helping a considerable number of patients in whom surgery is contra-indicated, who fail to respond to medication or who are suffering from a type of incontinence for which no adequate therapy at present exists. Such cases can only be treated symptomatically and conservative management methods can at least offer the patient a limited degree of social continence.
Modern disposable products absorb urine reliably without allowing any offensive smell to develop. They make the patient "socially continent" for a certain period. He or she is able to sursue normal everyday activities without fear of embarrassment.
The "social continence" aspect is especially important in the care of the sick and the elderly. It helps them to maintain or regain mobility or, at least, partial mobility. Elderly people often tend to withdraw completely from social contacts when faced with the problem of incontinence. This means that the stimulating influences of a normal active life are lost.
Attempts should be made in discussions with the patient to restore his or her confidence and self-assurance and to convince him or her that, with proper management, an almost normal life can be led despite the incontinence problem. Wherever possible, the patient should be encouraged to become selfsufficient, with measures like toilet training accompanying therapy and the recommendation or prescription of disposable absorbent products.
It should be remembered that, when patients are temporarily confined to bed through an illness which causes incontinence, the degree of incontinence can be diminished and the patient's mental anguish reduced if he or she regains mobility as soon as possible. Conversely, timely toilet training and the provision of disposable absorbent products help to make the patient mobile again and counteract any tendency for him or her to become bedridden.
In completely immobilised, chronically ill and bedridden patients, the management of incontinence is primarily a question of keeping the skin healthy. Modern products made of non-irritant, highly absorbent materials are indispensable in such cases. This is the reason why they can be prescribed in many cases, e.g. for the treatment and/or prophylaxis of skin diseases caused by incontinence in patients being cared for at home, especially when other severe functional disorders are present, e.g. hemiplegia with loss of speech.
In addition to protecting the skin, disposable absorbent products greatly improve general hygienic conditions in immobilised patients, thereby helping to reduce the tendency towards indiscriminate use of indwelling catheters.
This kind of product also simplifies general nursing care by helping to reduce the physical and mental burden on relatives and nursing staff and by saving time which can be used to give more active attention to the patient.
Selection of the right incontinence product
There are two main criteria for the selection of the correct incontinence product: The absorbent capacity must be adequate for the degree of severity of incontinence, and the product must meet the needs of the individual patient. Experience has shown that the degree of severity can be graded according to the amount of urine passed within a 4-hour period.
Loss of between 100 and 200 ml of urine in four hours, e.g. in grade II stress incontinence, in mild cases of urge and reflex incontinence.
Severe Urinary Incontinence
Loss of between 200 and 300 ml of urine in four hours, e.g. in grade III stress incontinence, in severe cases of urge and reflex incontinence.
Very Severe Urinary Incontinence
Loss of more than 300 ml of urine in four hours. Often with accompanying faecal incontinence, mostly elderly patients and highly dependent, bedridden patients are affected.