Volume 11 Number 4, 1998, Pages 241-247
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Urinary Incontinence in Individuals With Diabetes Mellitus
Adeline M.Yerkes, BSN, MPH
Dysfunctions of urination have long been known as a problem associated with diabetes, although the literature on the subject is limited. The neurogenic bladder is more commonly discussed in the literature as an issue related to such chronic conditions and diseases as spinal cord lesions, muscular dystrophy, and multiple sclerosis.
Also called cystopathy, the neurogenic bladder is considered a form of autonomic neuropathy. It begins with selective damage to autonomic afferent nerves, leaving motor function intact but impairing the sensation of bladder fullness and, therefore, resulting in decreased urinary frequency. As this neuropathy progresses, autonomic efferent nerves become involved, leading to incomplete bladder emptying, urinary dribbling, and overflow incontinence. This article will focus on the diagnosis and management of urinary incontinence.
Although less than 1% of all neuropathies are related to the neurogenic bladder,1 due to the prevalence of diabetes, the prevalence of obesity (a risk factor for urinary incontinence) among patients with type 2 diabetes, and the overall prevalence of urinary incontinence (especially among women), most health care practitioners are likely to encounter patients with urinary incontinence.
URINARY CONTINENCE AND MICTURITION
The storage and periodic elimination of urine depends on a complex neural control system that coordinates autonomic and somatic nerve activity to various distal sites, including the detrusor muscle, regions of the bladder, the urethra and urethral sphincter, and the striated muscles of the pelvic floor. The detrusor muscle is innervated primarily by the parasympathetic nervous system,5 which increases the contractility of the muscle and responses to cholinergic activity. The bladder and the urethra are innervated by the sympathetic nervous system, which causes the local receptors to stimulate contractions at the bladder base and proximal urethra.5,6 The urethral sphincter is controlled by the somatic nervous system.
There are four nervous-system loops for control of micturition, including the cerebral hemispheres, the spinal cord, and the local nervous system.5 Disruption at any of the loops can cause urinary dysfunction.
If one wishes to urinate, one relaxes these muscles. This learned behavior allows an increase in intra-abdominal pressure and voluntary relaxation of the pelvic floor and perineal muscles. The result is a decrease in the urethral closure pressure, descent of the pelvic floor and bladder base, and initiation of a reflex detrusor muscle contraction, which allow the urine to flow through the urethral outlet.
Changes With Aging
Not only a physical problem, urinary incontinence also affects an individuals psychological state and quality of life. It is a major factor underlying the placement of individuals in personal care institutions. More than 50% of all nursing home residents are incontinent.10
Urge incontinence. Urge incontinence is due to detrusor muscle over-activity. Here, the bladder empties completely and is of normal size, but the person cannot voluntarily retain urine, because the detrusor muscle contracts when it should not.
The primary symptom associated with urge incontinence is involuntary loss of urine associated with a strong desire to void (i.e., urgency).11 Although urge incontinence may be associated with neurological disorders, it is also found in individuals with normal neurological systems. A common neurological disorder associated with urge incontinence is stroke. People with urge incontinence and neurological deficits may have increased PVR volumes, symptoms of obstruction, and stress or overflow incontinence.9
Stress incontinence. Stress incontinence is incontinence due to inability of the urethral sphincter to generate enough resistance to retain urine (i.e., it is open when it should be closed). This urethral incompetence can be caused by displacement of the urethra and/or bladder neck or by hypermobility of the urethra.11 As with urge incontinence, the bladder empties completely and is of normal size.
The primary symptom of stress incontinence is involuntary loss of urine during coughing, sneezing, laughing, or other physical activities that cause increased intra-abdominal pressure. Stress incontinence can be caused by trauma, congenital anomalies, or sacral spinal cord lesions.12 People with stress incontinence tend to have continuous leakage.
Overflow incontinence. Overflow incontinence is due to over-distention of the bladder.11 This over-distention is related to the retention of urine secondary to an underactive or noncontracting detrusor muscle or to obstruction of the urethra or bladder outlet. These abnormalities can be caused by drug therapy, neurological conditions (such as diabetic neuropathy), low spinal cord injuries, or radical pelvic surgeries. In men, overflow incontinence is generally associated with prostatic hyperplasia obstruction. In women, outlet obstruction is rare but can occur with severe uterine or other pelvic organ prolapse, multiple sclerosis, or spinal cord injuries.
The symptoms of overflow incontinence appear in a variety of manifestations: frequent dribbling, constant dribbling, and symptoms of urge or stress incontinence.
Overflow incontinence is associated with the neurogenic bladder.
Mixed incontinence. The fourth type of incontinence is mixed incontinence. This is a combination of one or more of the above types.
NEUROGENIC BLADDER AND URINARY INCONTINENCE IN INDIVIDUALS WITH
The basic evaluation should include a history, physical examination, measurement of PVR volume, and urinalysis.11,19,20 This basic evaluation performed by the primary care physician can provide an accurate diagnosis of either transient or chronic urinary incontinence. Patients with urge, stress, or mixed stress and urge incontinence, normal PVR volumes, and no other complicating features should not be referred for further urodynamic testing. Patients with overflow incontinence should be referred for further urodynamic testing.
Health history. To aid in the diagnosis of urinary incontinence, the health history should contain questions to identify risk factors and symptoms.11 For patients with known urinary incontinence, the health history should contain a 7-day voiding schedule that identifies time of voidings, time of incontinent accidents, changing of pads/barrier protection, and activity at time of accident.
A careful health history must be taken to determine whether the incontinence is transient or chronic. Table 3 includes critical factors for inclusion in the health history.
The examination should include:11
Urological testing. Urological testing for overflow incontinence associated with diabetes should include conducting an estimate of PVR volume and urinalysis, as well as performing urodynamic tests such as multichannel or voiding cystometrogram with electromyography, uroflowmetry, and cystourethroscopy.11,19,20 Patients should be referred to a urologist for urodynamic tests.
PVR volume. The PVR volume can be determined by catheterization or pelvic ultrasound. The person should void just a few minutes before either the catheterization or the ultrasound. Amounts of 50 ml or less of urine retained are considered normal. The PVR volume should be determined a minimum of two times in order to adequately estimate PVR volumes.
Urinalysis. Increases in PVR volume, or incomplete bladder emptying, places the patient at increased risk for bladder infections. Urinalysis is utilized to detect hematuria, pyuria, and bacteuria.
Multichannel cystometrogram. The multichannel cystometrogram measures intra-abdominal, total bladder, and true detrusor pressures simultaneously and can determine involuntary detrusor contractions and bladder incompetence. This test is utilized primarily to determine detrusor muscle integrity. When conducted with electromyography of the striated muscle of the urethral sphincter, this test measures the integrity and function of the nerves and evaluates the detrusor muscle innervation. For people with diabetes and cystopathy, the tests generally reflect impaired sensation of the nerves that innervate the bladder and may show hyperreflexia of the detrusor muscle.
Voiding cystometrogram. The voiding cystometrogram, or pressure flow study, rules out urodynamic obstruction and measures detrusor contractions.
Uroflowmetry. Uroflowmetry measures urine flow visually and is useful in identifying abnormal voiding patterns or difficulty in emptying the bladder. People with diabetes and cystopathy generally have a low peak and long duration flow associated with residual urine. Voiding entails straining marked with short, interrupted spurts of urine.
MANAGEMENT OF URINARY INCONTINENCE AND CYSTOPATHY
The goals of management are to lessen the episodes of incontinence, use the least invasive treatment with the fewest adverse effects, and meet the goals and expectations of the person with the condition.11 Behavioral techniques will be discussed first, followed by pharmacological approaches and then surgical techniques. First, however, educational strategies for health care professionals will be addressed.
Educational Strategies for Health Care Professionals
Education regarding normal voiding schedule. One educational strategy is to teach these individuals about the normal voiding schedule.11,21,22 Most adults urinate about every 23 hours. The average person urinates 68 times a day. People over the age of 50 years frequently have at least one episode of nocturia, which is normal with the aging process.
People with urinary incontinence will often urinate every 1530 minutes to compensate for and manage incontinence during the waking hours. This frequent urination lessens bladder capacity and detrusor tone. By using a toileting schedule, health care professionals can assist patients with timing of voids, better design their medication regimens, and help them to increase fluid intake.
Instruction in the use of a voiding/fluid diary. Another strategy to teach patients with urinary incontinence is the use of a voiding/fluid diary. In this tool, the patient records (by time of day) how much fluid was drunk, when urine was passed, whether it was passed purposefully or by accident, what caused any accidents, and when bladder training exercises were performed. This should be kept for 18 weeks, depending on the other treatment modalities. The diary can increase a persons knowledge about urinary incontinence and the causes and frequency of incontinent episodes.11,21,23
The diary is a learning tool for both people with urinary incontinence and for the health care professionals who coach them. Health care professionals and people with urinary incontinence can identify critical points in behavioral management, such as timing of medications, fluid intake, and anticipated continence and incontinence. With the diary, anticipatory guidance can be given to reinforce positive behaviors. The diary can graphically show people with incontinence their personal progress over time. Individuals must keep the diary for at least 6 weeks to show some type of sustained progress.
Education regarding fluid intake. A third educational strategy is instructing the person about fluid intake.11,21,24 Frequently, people with incontinence will limit their fluid intake. This results in concentrated urine, which can cause irritation and detrusor or sphincter irritability.
Discuss the benefits of drinking water, the amount of water our bodies need in the day, and the stimulating effects of caffeine and artificial sweeteners. Caffeine and artificial sweeteners act as natural stimulants and cause fluid flushes within 1520 minutes after consumption. For some people, acidic beverages or foods will have the same stimulating effect. Counsel individuals to decrease their intake of caffeine products and increase water consumption.
Instruction regarding the urge wave. A fourth educational strategy is to counsel people with urinary incontinence on the urge wave.24 The urge wave is the normal urge feelings that come in waves. First, a person feels a little urge, which grows and peaks, and then finally subsides.
People with urge incontinence have trained themselves to urinate at the height of the urge. Assisting people with understanding the urge wave, focal point relaxation, or breathing relaxation techniques can promote conscious activity used to deter urination at the most urgent moment.
The behavioral techniques discussed in this paper require active participation and education of patients with the problem. Successful management rests with well-taught, motivated patients. Unfortunately, there are usually other physical or functional impairments that make compliance and self-care management difficult.
Bladder retraining (including relaxation techniques), pelvic muscle exercises, biofeedback, and intermittent catheterization will be discussed as the behavioral techniques.
Bladder training. Although varying levels of bladder inactivity or sensation may be present, bladder training may be helpful in some people. It is strongly recommended for the treatment of both men and women with urge and mixed incontinence.11,21,23-26 Bladder training also assists with managing stress incontinence. Bladder training has three components: education, scheduled voiding with gradual systematic delay of voiding, and breathing or focal point relaxation skills.
The educational aspect of bladder training combines written, visual, and verbal coaching. Individuals are taught about the physiology and pathophysiology related to the lower urinary tract and the urge wave. Using simple drawings of the body, pelvic sling, and urinary system can help individuals visualize what occurs with the bladder, detrusor muscle, and the urethral sphincter. Graphic display of the urge wave is also helpful.24-26
In bladder training, individuals must resist or inhibit the sensation of urgency, postpone voiding, and urinate according to a timetable. Professionals and patients use two tools: a voiding diary to review previous voiding habits and accidents, and a toileting schedule to record progress in delayed voiding.
The initial goal for delayed voiding is a time interval of 15 minutes. The delay time should be gradually increased so that intervals between voiding reach 23 hours. Starting with only a few minutes of delay gives individuals control. Positive reinforcement comes from being able to delay or postpone voiding.
Establish with patients the times during the day when they can manage the voiding schedule and delay voiding. The literature reflects that 75% of cognitive participants will decrease incontinence episodes by 50% and that this behavior can be sustained for 6 months or more.27
Breathing relaxation techniques or focal point visioning (distraction technique) are used to help inhibit the urge wave. A relaxation and distraction technique to teach patients can be as follows:
In some people, a "triggering methodology" may be helpful for initiating bladder contractions. For example, a person may tap the suprapubic abdominal wall until voiding starts. Others use the Valsalva or Credé maneuvers to assist in voiding. The Credé maneuver is the most common and is performed by applying pressure suprapubically and directly over the bladder until it empties.
Pelvic muscle exercises. Pelvic muscle exercises are strongly recommended to prevent or decrease the incidence of urinary incontinence. These exercises are strongly recommended as a management strategy for stress incontinence, are recommended as treatment for urge incontinence, and may benefit men who develop urinary incontinence following prostatectomy.
Pelvic muscle exercises are also called Kegel exercises.11,24-26,28 Individuals are taught to "draw in" or "lift up" the perivaginal muscles and the anal sphincter as if to control urination or defecation with minimal contraction of abdominal, buttock, or inner thigh muscles. Individuals should attempt to hold the "draw in" for at least 5 seconds (preferably 10 seconds) with an equal time of relaxation.
The exercises, a total of 7580 repetitions, should be conducted as 1520 repetitions at different intervals several times daily for a minimum of 8 weeks. Ideally, they should be maintained for a lifetime. A minimum of 8 weeks should show progress in controlling the stream of urine. Studies reflect that pelvic muscle exercises, as a behavioral management strategy, can reduce incontinent episodes by 5060%.27-31
Biofeedback. For individuals who continue to have difficulty controlling urination, biofeedback can be tried.26 The aim of biofeedback is to improve bladder dysfunction. Biofeedback therapy uses electronic or mechanical instruments to relay information to a person about his or her physiological activity, the responses that mediate bladder control. The use of biofeedback for urinary incontinence involves simultaneous measurement of the pelvis and detrusor muscle activity. Biofeedback must be taught by a trained professional. Biofeedback verifies accurate muscle use, gives immediate feedback, and provides a visual cue for patients.
Intermittent catheterization. Incomplete bladder emptying may lead to urinary tract infections, which can be compounded with vaginal infections in women. Persistent residual urines of 400 ml or greater may lead to renal damage. If a person has a residual urine of 400 ml, and the bladder normally holds 500 ml, this leaves room for only 100 ml of new urine to enter the bladder, causing a storage problem and prompting frequent voiding. This same person may suffer from uninhibited detrusor contractions, causing incontinence after voiding.
Intermittent catheterization stimulates normal physiology by allowing for periodic filling and emptying of the bladder. It also prevents bladder over-stretching or shrinkage and minimizes the risk of infection.
Individuals should be taught to perform the procedure utilizing a clean (not sterile) technique while seated on the toilet. Sitting on the toilet allows the lowering of the pelvic floor, a normal process that precedes voiding. This position is better than lying down, but patients may first have to learn the technique while lying down so that they can view the procedure through a mirror.
With the introduction of a catheter, the sphincter may undergo spasms that may only allow small amounts of urine to be expelled, or urine may be discharged as dribbles or spurts. In this case, use of an anticholinergic drug may be necessary.
Minimizing urinary tract infections is key to successful intermittent catheterization. Individuals should be taught to seek medical assistance whenever they suspect an infection.
Intermittent catheterization is recommended for overflow incontinence caused by spinal cord lesions or chronic urinary retention secondary to underactive bladder or cystopathy.11,20,25
In the pharmacological treatment of urge incontinence, the best candidates are those patients with demonstrated detrusor overactivity who do not have reduced bladder capacity and impaired emptying.11,32
For urge incontinence, anticholinergic agents such as oxbutynin, dicyclomine hydrochloride, and propantheline are recommended as first-line therapy. These drugs block the contraction of normal and overactive bladders. Use of these drugs is contraindicated in people who are diagnosed with narrow-angle glaucoma.
For stress incontinence, the first-line therapy is phenylpropanolamine or pseudoephedrine. These drugs can be administered with the co-morbidity of hypertension. To manage stress incontinence, drugs that increase bladder outlet resistance are the choice. In the treatment of stress incontinence or mixed incontinence in postmenopausal women, estrogen therapy can be an adjunct. Estrogen therapy has been shown to result in continence in at least 10% of patients, while 50% experience fewer episodes of incontinence.33 Estrogen therapy can be administered either orally or vaginally.
The goal of surgical management is to correct, compensate, or circumvent the underlying pathology causing urine loss.11 Surgical intervention to improve stress incontinence is aimed at increasing sphincter outlet resistance. Techniques include retropubic suspension, needle bladder neck suspension, or anterior vaginal repair. Surgeries that manage sphincter deficiency include sling procedures or placement of an artificial sphincter. Overflow incontinence due to bladder neck obstruction can be addressed by surgical procedures to relieve the obstruction.
Urinary incontinence overall is a very common and costly problem. As society ages, the prevalence of both diabetes and urinary incontinence increase. As medical technology provides for the extension of life for people with diabetes, co-morbidities increase.
Careful and thorough health histories and physical examinations should be conducted periodically to assess for urinary incontinence and the neurogenic bladder. If a person is diagnosed with urinary incontinence, an individualized management program should be developed to decrease incontinent episodes.
Clean-technique intermittent catheterization is the current choice for treating the atonic bladder and should be carefully taught and monitored by a health care professional. Reducing the risk for urinary tract infections would be the cornerstone of management.
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33Fantl JA, Cardozo L, McClish DK, Hormones and Urogenital Therapy Committee: Estrogen therapy in the management of urinary incontinence in postmenopausal women: a meta-analysis: first report of the Hormones and Urogenital Therapy Committee. Obstet Gynecol 83:8-12, 1994.
Adeline M. Yerkes, BSN, MPH, is chief of the Chronic Disease Service and Womens Health coordinator at the Oklahoma State Health Department in Oklahoma City.
Copyright © 1998 American Diabetes Association
Last updated: 9/98