Incontinence is defined as the inability to control excretory functions, generally the inability to control urine and fecal excretion. Incontinence is a common medical problem in both children and adults, generally affecting the earliest and latest years of life. Urinary incontinence alone, for example, affects an estimated five to 15 percent of community-dwelling older adults.
Normal urination and defecation are controlled by the autonomic nervous system of the body, which is composed of the parasympathetic and sympathetic nervous system. In general, the sympathetic nervous system promotes retention of feces and urine, while the parasympathetic nervous system promotes elimination. The balance of these systems occurs in the levels of the organs involved, spinal cord, brainstem, and cerebral cortex. Voluntary control over elimination occurs in the cerebral cortex.
More than 50 percent of adult residents in long-term care facilities are estimated to have either urinary or fecal incontinence. Incontinence can dramatically influence quality-of-life issues, often leading to social isolation, depression, and institutionalization (in the case of older adults). Nevertheless, it is largely unrecognized and underaddressed in the healthcare setting. Neurologic impairment, immobility, and gender—females are more likely to suffer urinary incontinence than males—are major independent risk factors in adults.
Urinary incontinence in adults can be originate from wide range of medical and psychological causes. In many cases, incontinence is only transient. Common causes of transient incontinence include medication side effects, delirium, fecal impaction (often from constipation), urinary tract infections or other infections, irritation of the vagina or urethra, psychological factors such as depression, or physical mobility limitations. There are several forms of more chronic incontinence commonly experienced by individuals.
Urge Incontinence—This form of incontinence results from overactivity of the detrusor muscle, a muscle in the bladder wall that promotes elimination. Urge incontinence is generally believed to be the most common form of chronic incontinence. Individuals with this form of incontinence commonly describe a sudden feeling of needing to void before involuntary voiding. Treatments include behavioral management, such as timed voiding schedules and visualization techniques, as well as pharmacologic treatment through medications that decrease contractions of the detrusor muscle.
Stress Incontinence—This form of incontinence results from impaired urethral closure. Individuals with this type of incontinence often describe involuntary loss of urine associated with sneezing, coughing, laughing, or lifting objects. Treatment options include pelvic muscle exercises, weight loss in obese patients, use of estrogen, pharmacologic treatments, and surgical procedures, which are generally used for those who fail medical management.
Overflow Incontinence—This form of incontinence results from incomplete emptying of the bladder and abnormally high bladder volumes. This often results from mechanical obstruction of outflow, such as by an enlarged prostate, or from decreased contraction of the detrusor muscle. Individuals generally complain of frequent dribbling of urine, which can be constant, and a feeling of incomplete emptying of the bladder. They often also complain of a decreased force of urinary stream. Treatment options include intermittent catheterization, pharmacologic therapy, and surgery.
Functional Incontinence—This form of incontinence results from the inability of an individual to transport in a timely manner to a location to void. Examples include individuals with severe mobility limitations or with dementia.
Mixed Incontinence—Many individuals with incontinence often have a combination of the various above types.
Fecal incontinence is common, affecting three to 21 percent of community-dwelling elderly individuals over age 65. Fecal incontinence is also referred to as encopresis, although this term is more commonly used in children. Like urinary incontinence, fecal incontinence can have enormous impact on the lifestyle of an individual. Fecal incontinence can occur transiently in healthy adults in cases such as diarrhea. Fecal incontinence, similar to urinary incontinence, can result from functional difficulties, such as arthritis or other gait difficulties, or poor access to toileting facilities. It can also result from neurological disease, such as spinal cord damage, or damage to the nerves in the intestinal tract or rectum. Other causes include dementia, severe depression, fecal impaction (constipation), neoplasm, and cerebral vascular disease.
Girls typically gain bladder control before boys. Toilet training usually begins between ages 2–4. By the age of 5, 90 to 95 percent of children are nearly completely continent during the day, and 80 to 85 percent are continent at night.
Diurnal (Daytime) Incontinence—The most common pediatric cause of this form of incontinence is unstable (overactive) bladder. This form is associated with a smaller-than-normal bladder, which has strong, uninhibited contractions. Other causes can include urinary tract infections, neurological disease, infrequent voiding, giggle incontinence, sphincter abnormalities, anatomical abnormalities of the urinary tract, overflow incontinence, sexual abuse, and behavioral causes. Treatment of daytime incontinence varies depending on the etiology. Most children outgrow this problem; however, pelvic floor exercises, behavioral training, and pharmacologic therapy may be helpful.
Nocturnal Enuresis—Children often deal with nocturnal enuresis, the occurrence of involuntary voiding at night at 5 years old and older. This problem is more common in boys and it seems to occur more often in children with a family history of the problem. Nocturnal enuresis without overt daytime symptoms affects up to 20 percent of children at the age of 5. Causes may include sleep disorders, psychological factors, urinary tract infections, urinary tract obstruction, sleep apnea, genetic factors, and delayed neurological development allowing voluntary control of voiding.
In the majority of cases, the problem ceases spontaneously. Treatment depends on the cause but may include nighttime fluid restriction, motivational measures (reward systems), conditioning therapy (such as use of alarms), psychological therapy, and pharmacologic therapy.
In children, more than 90 percent of fecal incontinence, or encopresis, is associated with constipation. Other problems include neurological disease, poor toilet training, psychosocial problems, and other digestive tract disease. Treatment generally involves treating the constipation. More than half of cases resolve spontaneously in two years.
Constipation; Urinary Tract Infection.
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