Caregiver Guide: Incontinence

Understanding the Problem

Incontinence is when someone has leakage of urine.  You may also hear it referred to as having accidents or problems with bladder control.
 
Urinary incontinence, or leaking urine, is a problem for at least 30% of people over age 60. It is more common in women than in men and can range from occasional dribbling to total loss of bladder control. 
 
You should start by sensitively discussing the problem with the older person. Many people who have incontinence do not tell their healthcare provider because they are embarrassed or they feel it is not a major problem. The first step to help them accept that they have a problem is by discussing it with tact and sensitivity.
 
Whether the incontinence is mild or severe, everyone with incontinence should be seen by a healthcare professional. A medical condition might be causing the incontinence and, if so, this should be treated. Incontinence is almost always treatable with bladder training, pelvic muscle exercises, medications, and/or surgery. Sometimes it can be cured.

There are 4 types of incontinence

Urge incontinence

Urge incontinence is the sudden urge to go to the bathroom but not having enough time to reach the toilet. People with urge incontinence often have an overactive bladder muscle. Bladder over-activity can also cause frequent urination and awakening at night to urinate (this is known as nocturia.). When urge incontinence occurs, the bladder contracts with little or no warning and urine leaks as a result. This can be caused by stroke, Parkinson's disease, bladder infection, and disorders that affect the spinal cord.

Stress incontinence

Stress incontinence is most common in women. It happens during coughing, laughing, bending, or other activities that apply pressure to the abdomen. Common causes are weak muscles around the urethra and bladder opening as a result of childbirth, surgery, or lack of estrogen after menopause. Stress incontinence has nothing to do with emotional stress. 

Mixed incontinence

Mixed incontinence is a combination of urge and stress incontinence.

Other incontinence

Other incontinence is incontinence that does not fall into the categories of urge, stress, or mixed incontinence. Sometimes this occurs when the bladder and the urethra are functioning normally, but the person either cannot physically get to the toilet, or has impaired mental function that interferes with recognizing the need to urinate and getting to the toilet on time. This latter condition is common in patients with Alzheimer’s and other types of dementia. However, sometimes people with physical or cognitive conditions can have the above types of incontinence or abnormal bladder function as well.  Even if it is assumed that the person is incontinent because of physical or cognitive reasons, they should be evaluated for other types of incontinence and contributing factors that should be addressed.

Your goals are to:

  • Have the older person evaluated by a healthcare provider no matter how small the problem appears.
  • Schedule bathroom trips or, if necessary, provide a urinal or commode to make reaching the toilet easier.
  • Encourage bladder training and Kegel exercises.
  • Encourage changes in diet and fluid intake.
  • Take care of constipation - pressure from hard stool in the rectum can make urinary incontinence worse.
Click on each of the topics below to read more. 

When To Get Professional Help

Call the healthcare provider immediately if any of these symptoms occur

  • sudden loss of ability to pass urine
  • great difficulty urinating
  • blood in the urine

Call the healthcare provider during office hours to discuss the following problems

Any incontinence or leakage should be reported to the healthcare provider.  This problem cannot be solved by buying pads at the drugstore. It needs to be evaluated by a healthcare provider.

Although incontinence by itself is not a life-threatening problem, medical help should be sought within a day if any of the following symptoms happen suddenly. Please note that these symptoms are not unique to people with incontinence. These symptoms could be caused by a urinary tract infection or urinary retention (inability to urinate). Either condition can become life-threatening if left untreated.

  • uncontrolled dribbling
  • pain with urination
However, if the person has had recurrent urinary tract infections, diabetes, or a history of sepsis, the healthcare provider should be contacted immediately.

Know the answers to the following questions before calling the doctor

  • What are the symptoms?
  • When did the problem start?
  • Has it ever happened before?
  • Does the older person have other health problems?
  • What medicines does the older person take? (Be sure to include over-the-counter medicines, and herbal and other remedies)

What You Can Do To Help

Keep a bladder record or diary

The healthcare provider might ask you to keep a bladder record or diary. This is a daily record of the times when a person urinates into the toilet or has accidents urinating on underwear or clothing. The record should also include how much urine is passed each time. 

If there is leakage, write down what caused it (coughing, laughing, urge to urinate on the way to the toilet). This information helps the healthcare provider decide how to treat the problem. A two-day record is usually enough.

Ask the healthcare provider about treatments for incontinence, including exercises and possibly medicines

Talk to the healthcare provider about approaches to treating incontinence.  The provider can take a stepwise approach.  That means that the first step to take would be behavioral interventions and/or exercises. A program of exercises can strengthen the resistance of the urethra (the hole urine passes through). If exercises are not enough, then some medicines can be added to the treatment plan along with exercises  if necessary or possible (for example, there are no approved medicines for stress incontinence.) However, certain medicines can make incontinence worse. Some over-the-counter medicines and herbal remedies can interfere with bladder function. Many other drugs can contribute to incontinence. The healthcare provider may choose to stop these medicines or prescribe smaller doses. 

Set up a schedule

It is important for people with stress incontinence or urge incontinence to urinate about every two hours while awake to avoid having too full a bladder. They should keep a record for about two days of when they go to the toilet and then schedule trips to the toilet just before the person would normally feel the urge to go. The healthcare provider may also teach strategies for controlling strong urges. 

Remind people with cognitive problems

People who are unable to remember to go to the toilet in time can be helped by reminding them when to go to the toilet, assisting them in getting to the toilet, and helping with their clothing and hygiene. If necessary, provide a urinal or portable toilet by the bedside at night.

Control the diet

Limit caffeinated drinks (coffee, tea, cola) and alcohol, but do not decrease fluid intake. Older people should drink four to six glasses of water or other non-caffeinated liquids a day. Too little fluid reduces cues to urinate regularly. Concentrated urine can cause bladder irritation. If there is an incontinence problem at night, restrict drinking for two to three hours before bedtime.

Ask about biofeedback

Biofeedback uses a computer to help a person learn how well they are contracting and relaxing the muscles involved in bladder control. Biofeedback can be used in combination with exercises to gradually gain better control over these muscles.

Ask about surgery

Surgery is usually a last resort, although it can help support the urethra so it can stay closed properly.  Other surgery can clear an obstruction such as an enlarged prostate in men. Sometimes minor surgery can cure the problem.

Do not rely solely on pads and absorbent garments

Pads and absorbent garments should not be used in place of a healthcare provider’s evaluation. Incontinence could be a result of an underlying medical condition that should be treated. Absorbent garments and pads can be helpful for extra protection on long trips. However, incontinence can worsen if the older person relies on them instead of getting medical evaluation or treatment. If the older person’s incontinence is not totally controlled by treatment, sometimes pads or absorbent garments are necessary. They should be changed often to avoid odor, leakage, and skin rashes.

There are many styles of garments and pads.  Pick the style that best meets the needs of the older person.

Urinary catheters are a last resort

Catheters are only used in very particular circumstances in managing urinary incontinence and should be used only if absolutely necessary because they have significant risks, including increasing the risk of serious urinary tract infections. 

Encourage doing Kegel or pelvic muscle exercises

These can be useful in treating stress, urge, and mixed incontinence. Kegel exercises are explained in the next section.

Pelvic Muscle Exercises

What are pelvic muscle exercises?

These exercises are sometimes called Kegel exercises. These exercises can be useful in treating stress, urge, and mixed incontinence. They are used to strengthen the muscles that help to control the bladder and urination. 

How do you learn to do the exercises?

To teach the older person to do the exercises, explain that the best way to learn to control urination is to stop the flow of urine in the middle of urinating. If they can stop the urine flow, that means they have successfully found the right muscles.  However, when the older person is practicing the exercises, they should not be done during urination. Stopping the flow of urine is only used to identify the correct muscles.

It is very important that only the pelvic muscles are contracted (or squeezed) and not the muscles of the stomach. The stomach should stay relaxed during these exercises. 

Breathing in and out while doing the exercise will help keep the stomach relaxed.

How are the exercises practiced?

  1. Squeeze the pelvic muscles and hold for 10 seconds. The older person should gradually build up to 10 seconds per hold. (Again, the correct muscles to squeeze are the ones that are used to stop the flow of urine. The exercises are only effective if the older person is squeezing the correct muscles.  They should not be squeezing the abdominal (stomach) or thigh muscles.)
  2. Relax for 10 seconds.
  3. The older person should gradually build up to 15 squeezes and 15 relaxations 3 times per day.

The older person should do no more than 50 muscle squeezes (or exercises) per day, divided into 3-4 sessions. After 1-2 weeks of these exercises, they should start to be able to use these muscles to prevent accidents (both urge and stress).

When should the exercises be done?

They can be practiced anytime, while sitting, standing or lying down. But to prevent accidents, the exercises must be done at times that normally cause leakage, such as coughing, laughing, straining or when a very strong urge to urinate begins. For example, when putting a key in the door, or when hearing running water. 

How long do the exercises take to work?

If they are practiced properly, the older person should begin to notice a difference within  4-6 weeks. 

Can the exercises be harmful?

No. If there is any stomach or back pain with the exercises, they are not being performed correctly. Only the pelvic muscles should be contracted. Do not use the stomach or abdominal muscle to do this. The exercises do not require great effort and should not cause discomfort or fatigue. Contractions should only be held as long as comfortable, starting with 3 to 5 seconds and building up to 10 seconds. 

Remember, like any other exercise, pelvic muscle exercises must be practiced regularly in order to be effective.  If the older person stops doing the exercises, they will probably lose muscle strength.

Carrying Out Your Plan

Problems you might have carrying out your plan

The person you are caring for may have beliefs that might get in the way of carrying out your plan.  Here are examples of those beliefs and how you can respond.

"Incontinence is something that just normally happens to you as you get older."

 

Urinary incontinence is common, but it is not a normal condition of aging. There are things that can be done to help. In almost all cases the symptoms are treatable, and in some cases, incontinence can be cured.
 

"All I need are pads. I don't need to see a doctor."

You do need to see a doctor or other healthcare provider.  Your incontinence could be caused by a medical condition that needs to be corrected. If the healthcare provider decides that pads are the only treatment needed, then that is fine.  

"I'm embarrassed to talk about incontinence with my doctor."

Even if you feel embarrassed, remember that incontinence is a common problem.  Even if your healthcare provider doesn’t ask about incontinence, bring it up to them.  Think about what would make it easier to talk about it. Would you prefer to talk to a provider of the same gender? Would it be easier to talk to a nurse instead of a doctor? Would it help if a family member brought up the topic with the provider? Remember, incontinence is a medical condition much like diabetes or high blood pressure, which can and should be treated. 

Think of other obstacles that could interfere with carrying out your plan

What additional problems could get in the way of doing the things suggested in this presentation? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out this plan? 

Checking on Progress

Incontinence can be emotionally upsetting to both caregivers and the older person with the problem. 
It should be discussed with tact and sensitivity, but it should not be ignored. If you feel the older person’s healthcare provider is ignoring or not taking the incontinence seriously, consider getting a second opinion, perhaps from a specialist, or reaching out to patient advocacy groups for advice.

If your plan does not work

If incontinence is becoming more of a problem, or if the person is becoming more and more bothered by it, ask the healthcare provider for help. Explain what you have done and what the results have been. You may be referred to a provider who is specially trained to deal with incontinence problems and in therapies such as pelvic muscle exercises and bladder training. These specialists will also be knowledgeable in using biofeedback or other aids in helping to strengthen the pelvic muscles and to use them correctly to prevent urinary accidents. The healthcare provider may also recommend seeing a geriatrician, urologist, or gynecologist.