Sunday, January 15, 2006


(see Table 27) There are two types of incontinence-urinary and fecal. Urinary incontinence is the inability to control urinary function. This is a distressing symptom for many older people. There are many causes for incontinence. Mental impairment, brain damage associated with dementia, urinary tract infection, irritable bladder. prostate hyperatrophy (enlargement), and pelvic relaxation all can be responsible for incontinence.
Treatment for incontinence is varied. If the incontinence is intermittent the contributing cause should be treated. If there is a significant degree of pelvic relaxation, as in stress-related incontinence, when a person's urination is associated with coughing, sneezing, or running, a trial of Kegel exercises may be tried. These are relatively simple and involve contracting muscles to the point of stopping the urine stream up to 100 times a day. If this is not effective, surgery may be necessary.
Drug therapy may be useful, especially if bladder spasms are a problem. Anticholingerie drugs are used for this purpose. There are frequent side effects to these drugs including dry mouth, blurred vision, and constipation. These drugs should not be used in people with congestive heart failure, urinary obstruction, and narrow-angle glaucoma. Often, a program of bladder retraining can be useful. People who are unable to feel the need to urinate may benefit from this program.
The program includes regularly scheduled toileting and limiting the amount of fluid intake after the evening hours. It is important not to limit overall fluid intake, however. Adequate hydration alone may correct incontinence, by preventing fecal impaction, constipation, and urinary tract infection.
The Brantley Scott artificial urinary sphincter is a sophisticated device to control incontinence. This does, however, require a rather extensive surgical procedure but is about 90 percent successful in carefully selected candidates. If none of these treatments are successful, a catheter may be necessary. This is regarded as a last resort because of the serious risks of urinary infection. Those with an indwelling Foley catheter must be careful to maintain proper drainage, remove encrustation, and apply antibiotic ointment in the urethral area daily. Periodic replacement of the catheter, irrigation of the catheter, maintaining good fluid intake, and sometimes antibiotic therapy are necessary to prevent infection. External catheters may be the best choice for males with at least partial emptying function. Intermittent catheterization may be suitable, especially if the older person or a family member can be taught this relatively simple procedure.
Fecal incontinence is the inability to control bowel function. There are several causes for fecal incontinence. The external anal sphincter may be relaxed, the voluntary control of defecation may be interrupted in the central nervous system or messages may not be transmitted to the brain because of a lesion within the spinal cord or external pressure on the cord. The most common cause in the elderly is relaxation caused by general loss of muscle tone.
Treatment for fecal incontinence should involve a bowel training program. Ordinarily, the bowel is trained to empty at regular intervals. Once a day or every other day after breakfast is common. Foods and fluids increase peristalsis. Glycerin suppositories help stimulate evacuation of the bowel; they should be inserted about two hours before the usual time of defecation. Occasionally, it is necessary to use a laxative suppository, such as Dulcolax, to provide additional stimulus. Routine enemas and laxatives should be avoided because they can caused dependence.
If incontinence cannot be managed, it can be made easier to live with by using plastic incontinence pants, penile clamps, condom drainage systems, and incontinence pads. Generally, these are available at medical equipment stores or large drug stores. The psychological factors of incontinence are very important. Incontinence contributes to physical and social isolation and frequently leads to admission to extended-care facilities. It is important to maintain the older person's quality of life by managing incontinence with all available methods.
Brocklehurst, J. C. Geriatric Medicine and Gerontology, 3rd ed. New York: Churchill Livingstone, 1985.
Calkins, E. et al. The Practice of Geriatrics. Philadelphia: W. B. Saunders Co., 1986.


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