Photo by Chung Chow
It’s big business in Canada and the main reason for placing an elder in a care facility.
But no one wants to talk about, much less deal with it.
That’s the bad news.
The good news is there is much that can be done about incontinence and associated problems on the road to good bladder health.
“What we don’t want is that your bladder starts to dictate your life because it can be very isolating for people,” says Corey Knott, the nurse continence advisor (NCA) and the clinical resource nurse for the Department of Urology at Richmond Hospital where she helps people with a variety of challenges.
“We treat symptoms like stress incontinence. That’s when you laugh, cough, or sneeze, you leak urine. We also look at urgency and urge incontinence. You have to go suddenly or else you have an accident.”
Surgery can be an option but Knott, an RN with post-graduate training as a continence advisor, has tricks up her sleeve to teach people, men and women, so they sometimes avoid surgery all together.
“We can advise on how to conservatively manage those symptoms. If we can’t, we’ll send them back to the urologist,” Knott says.
Knott describes others the clinic helps.
“People who have difficulty initiating urine, who can’t go. Sometimes it can be prostate related for men. For some people who have voiding dysfunction, the muscles are too engaged. We make sure they have been seen by the urologist first. It can be physically worse for you than leaking. It’s hard on the kidneys,” she says.
She offers options: “For the conservative management, I do teaching or, if they have been advised by their urologist, I teach them how to intermittently put in a catheter.”
People’s anxiety will also impact their bladder, according to Knott.
“This is what we’re seeing a lot of in children. Having difficulty urinating often has to do with anxiety.”
So, what can be done if you are leaking or coming close to having accidents?
“They can do pelvic floor muscle strengthening, also known as Kegel exercises. They are not just for women. They can also be used for men. They are good not only for stress incontinence, but also for urinary urgency—for urge suppression.
“When you are rushing off to bathroom and just can’t make it, there are techniques to suppress the urge to go,” Knott says.
For Kegels, Knott says, you need to do a committed three times a day for a minimum of three months to have any benefit. Kegels strengthen the sling of muscles that hold up the pelvic organs.
“Most people do them incorrectly. It’s a definite commitment to get the pelvic floor (stronger),” she says.
According to a manager at a gynecologist’s office, two thirds of the women scheduled to have their significant incontinence or prolapse corrected surgically called to cancel their surgery when they had strengthened their pelvic floor muscles enough with Kegels.
Prolapse is when the bladder, uterus, vagina or rectum are looping down, out of their proper place.
A lower back ache that gets worse with standing and better through lying flat with your lower legs up on pillows, is a common indicator of prolapse.
“Heaviness, heavy sort of feeling vaginally or a feeling like things are falling out, or you can physically feel things falling out,” Knott says are other symptoms.
Knott says prolapse, which often causes bladder or bowel problems, needs to be assessed by the urologist first who will then refer the patient to see her.
“(Prolapse) needs to be addressed. It’s not going to get better as time goes on. It is progressive, so get it fixed when you’re younger, because you may not be a surgical candidate when you’re 85,” she says.
While prolapse and incontinence can be addressed at any age, they
become problematic in the very elderly. “The number one reason to place a family member in a facility is due to urinary or bowl incontinence. People can take a lot but as soon as they start losing control of their bowel or bladder, it’s very limiting,” Knott says.
In addition to doing Kegels, some women may benefit from a pessary.
“It’s a round plastic ring inserted into the vagina that can push up a prolapse,” says Knott. Either a pelvic floor physiotherapist, or two of the Richmond urologists, can find the right pessary that will work for each patient. It often helps with incontinence of bladder and sometimes of bowel.
Whether it’s to learn proper Kegel technique or to also have a pessary fitted, time with the pelvic floor physiotherapist is covered by some private insurance but not under MSP.
But, says Knott, “If you are leaking and paying for pads and laundry—it’s a good investment, because you can minimize or get rid of pads completely.”
Pads are expensive over time.
“Incontinence is a $1.5 billion industry in Canada,” says Knott.
There are pelvic floor physiotherapists who help patients do their Kegel exercises properly. A patient’s time with Knott is covered by MSP, the time spent learning proper Kegels at a physiotherapist’s is not. Knott warns that you should never do Kegels while urinating because stopping the flow of urine can lead to problems as the bladder may not empty properly.
She also points out that if other techniques don’t work well enough, there is medication for an over active bladder. “And now we can use Botox for overactive bladder and our urologists do that.”
Botox, a toxin that stops nerve messages getting through, can calm an overactive muscle.
During her time with each patient, she also points out the dietary modifications that usually help.
“Coffee, tea and alcohol can increase leakage,” Knott says. She also suggests people take out a measuring cup to see how much their typical mug holds.
She describes a young patient who complained of being quite jittery: “His bladder was not responding well. It turns out he was having 17 cups of coffee a day.”
She also says diabetics have to watch their sugar intake because that can affect bladder function.
Knott also looks at behavioural modifications that may help. For instance, some people postpone urination for too long.
“This is the normal pattern: you go every three to four hours in a typical day. And once at night is perfectly normal,” according to Knott.
If you are getting up more than once in the night, “Is it your bladder waking you or something else?” she asks.
According to Knott, a lot of times it is a sleep disturbance more than a bladder issue so she sends the client to a sleep clinic, or their spouse to a sleep clinic. When we wake, for whatever reason, it’s normal for our bladder to fill and tell us it is time to urinate.
One elderly woman had a variety of unsuccessful treatments for her frequent trips to the bathroom throughout the night. Nothing helped. It turns out, her husband had sleep apnea. Every time he would start breathing again with a loud snore, he would wake his wife; her bladder would then fill and cause yet another trip to the bathroom.
If you notice you are truly being awakened by your bladder, Knott offers hope.
“For some people, they just have to cut the caffeine before bed, just not have any caffeine within three or four hours of going to bed.” She says even better is to cut the caffeine off by 2 pm.
When it comes to caffeine, “A lot of people are drinking way too much,” says Knott.
She says eight to 10 cups should be the absolute maximum. And, she says with a smile, “Measuring cups not Starbucks mugs.” Knott says in that daily amount of liquid you have to count fluid from all sources like juice, soup or fruit.
“If you have a bowl of soup at lunch and supper, and have milk on your cereal for breakfast, you don’t have to drink 10 cups of water on top of all that fluid you’re having,” she explains.
Knott suggests you stop drinking water after supper and while you should limit fluid after supper, if you are thirsty drink, but not too much.
Some people with urine leakage try to control it by not drinking much of anything but that can backfire.
“If your fluid is too restricted, urine then becomes too concentrated in the bladder and that (irritation) causes frequency,” Knott says. Fluid restriction can lead to dehydration which, in the elderly, can make confusion worse.
In addition to the urinary issues, she sees patients for problems passing stool. Sometimes, the solution is easy. For instance, Knott says, people can use too much stool softener, like Metamucil.
“That can lead to constipation. Constipation and bladder issues have a strong correlation,
If your bowels are not going every day, that can exacerbate (bladder problems),” she says.
Knott says she tries to exhaust all conservative management options before looking to surgery. Even then, patients sometimes see Knott before surgery.
“For example men with prostate cancer: the urologist will send them to me first so when their catheter comes out they have a really strong pelvic floor. One symptom of having your prostate out is that you can have incontinence after surgery.”
Just as women can sometimes find a pessary helps with incontinence, there are devices, Knott says, that can help men with incontinence as well as an external condom catheter.
When seeking out a nurse continence advisor, you find hope and often, practical solutions to an embarrassing and all too common problem.
“People want to sit down. I give them the time they need to talk to me and it’s much better because you have to listen to people. I try to give people my very best,” Knott says.
This skilled, personal care takes time. Sometimes the wait after a urologist’s referral can be long but for many who’ve been through her clinic, it has been worth the wait.