Urinary incontinence

Q:I would be grateful for any help and advice you could offer with regard to an unstable bladder. The hospital doctor I saw for diagnosis many years ago prescribed imipramine. Although it cured the symptoms, it also caused unacceptable side effects,

I am 52 now and stopped taking the imipramine about 12 years ago (after a month's treatment). The symptoms (urgency to urinate, getting up several times in the night) returned a week or so after I stopped taking the drug, and I have lived with the problem ever since. A T, Pontefract, West Yorkshire......

A:It may be some comfort to know that you are not alone. Urinary incontinence, as it is formally referred to, affects some three million adults and a half million children in the UK, , or up to nearly a third of elderly people and one adult in 15, at some point in their lives. In the US in 1987, over $10 billion was spent attempting to manage incontinence, more than the amount spent on dialysis and bypass surgery combined (The Lancet, July 8, 1995)! Nevertheless, so many adults are embarrassed and ashamed of the problem that they live with it for many years in secret dispair.

To understand the problem fully, it's necessary to understand how the lower plumbing works. The bladder sends urine to the urethra, the tube leading out of you, via two rings of muscles, called sphincters. The first of these, which prevents leakage, is controlled involuntarily, but the second sphincter is under our control and the muscle you relax when you urinate. As the water begins to pass, the muscles of the bladder (called the detrusor muscles) contract, sending the urine out.

From what you describe, you may have one of the most common type of established incontinence, which is referred to as "detrusor overactivity", in which the bladder muscle contracts involuntarily. The usual hallmark of this type of incontinence is a sudden, overwhelming need to urinate, often in the night. It may simply be instability of the muscle (as you appear to have) or be due to a central nervous system disease. As people get older, the bladder capacity, its ability to contract and your ability to postpone urination or control bladder contractions declines; in women the length of the urethra and its ability to close also decrease. In men, it may often be caused by an enlarged prostate, causing retention of urine on top of the other symptoms.

A enormous laundry list of drugs cause incontinence. These include: potent diuretics, antipsychotics, anti-parkinsonian drugs, sedatives and sleeping pills, such as diazepam (Valium) and the other benzodiazepines, certain narcotic analgesics, calcium channel blockers, ACE inhibitors and nasal decongestants (The Lancet, July 8, 1995). Because older adults are often taking one or more of those drugs, they may be behind the frequency of incontinence among the the elderly.

Another largely unrecognized cause of incontinence in adults and children can be food or chemical allergy or intolerance. Allergies cause swelling throughout the body. Oftentimes in the middle of the night, this swelling goes down, and water accumulated in the tissues

is sent to the kidneys and onto the bladder. Any difficulty in controlling the bladder muscles would then be exacerbated.

Usually, patients with incontinence get hopelessly mismanaged. Ironically, two of the mainstays of drug treatment for the problem anticholinergic drugs and antidepressant drugs like imipramine can themselves cause incontinence!

Anticholinergics work (and only in some 60 per cent of cases) by blocking the nerves that control the bladder, and theoretically reduce the leakage of urine. Antidepressant drugs like imipramine one of the favoured drugs for bedwetting in children may work with essentially the same effect. We don't blame you for quitting the drugs you were taking, which only relieve the symptoms, rather than the underlying cause, but with a host of other problems thrown into the bargain. These include memory problems, disturbed attention span, delirum, dry mouth, confusion, blurred vision, sexual dysfunction, worsening of glaucoma, fatigue and sleepiness, dangerous lowering of blood pressure or rapid heart beat, and even heart attacks or stroke.

If you haven't been thoroughly investigated, it may be worth undergoing a few tests to determine the cause of incontinence, but avoid x-rays using dye. You should also have your doctor rule out a urinary infection or diabetes or any disease of the nervous system which can cause an unstable bladder. A simple rectal exam will also determine whether an enlarged prostate is a contributing factor. (If it is, try to investigate non-surgical solutions, since having your prostate removed often causes the very problem you're trying to solve (see WDDTY vol 4 no 1 for some suggestions).

There are many other successful non-medical solutions. The first is to working with a trained practitioner to determine whether you have any

allergies, which add to your bladder's burden.

The Incontinence Information Bureau says that simple pelvic floor exercises in which you periodically tighten the pelvic muscles can help both men and women control both urine and bowel leakage. However, you have to be prepared to do between 30-200 of them a day (The Lancet, 8 July 1995).

A safe and highly effective solution for incontinence stemming from an uncontrollable bladder muscle is a bladder "retraining" programme. In the programme, you are often first asked to keep a diary recording how much you drink, how often you pass water and how much urine results. The object is now to extend the time between urination. If you are incontinent every three hours, you are told to urinate every two hours and to suppress any urgency in between. Once you remain dry, you attempt to extend this interval by half an hour by repeating the process, until you have achieved satisfactory control. According to Dr Neil M Resnick, of the Gerontology Division of Brigham and Women's Hospital in Boston, you don't need to work on retraining at night because success in the daytime will be mirrored at night (The Lancet, July 8, 1995).

Another possibility which also has good success is adding biofeedback to the process, in which you are taught how to use a number of techniques to stop or reduce your feelings of having to go to the toilet. Both techniques must be faithfully practised to avoid relapse. Another possibility which claims some success is acupuncture.

For more information, you can contact the Incontinence Information

Bureau, PO Box 29, Green Lane, Tewkesbury, Gloucester GL20 8YB, which can provide you with a full information pack about bladder retraining programmes.