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Encourage others to start talking and gain control of their bladder health!  We've made it simple for you to share National Bladder Health Week news, resources, tips and tools with your friends, family and healthcare providers.  We have a variety of  simple activities you can choose from to promote awareness of bladder health.  They are cut and paste one of the sample newsletter or emails below.

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NAFC is a non-profit offering resources for people struggling with incontinence, adult bedwetting, OAB, SUI, nocturia, neurogenic bladder, and pelvic floor disorders like prolapse. 

The Continence Connection Blog

Enuresis or “Bedwetting” Urinary Incontinence in Adults Young and Old

Holly Kupetis

Enuresis, or bed-wetting, is commonly associated with children but night time incontinence also affects adults, both young and old. 

Night time incontinence or “bedwetting” requires medical attention starting with primary care providers.  When asking about urinary history, providers may consider inquiring about any recent incontinent episodes along with any history during childhood.  This would help uncover a problem and save the patient the embarrassment of bringing it up.  Simply asking if there is “any problem with bowel or bladder” may not uncover an issue a patient is uncomfortable talking about.  In young adults, bedwetting is uncommon and can be indicative of something more serious.  In the elderly it is not as unusual, but is not considered a normal part of aging.  Incontinence can be managed in a variety of ways.

Causes of bedwetting in younger adults might be:

·      Diabetes – new or undiagnosed

·      Medication side effects

·      Sleep apnea, or not awakening to the sensation of a full bladder

·      Manufacturing large amount of urine at night

·      Underdeveloped bladder

·      Urinary tract infection or kidney/bladder stones

·      Chronic constipation

·      Weak pelvic floor muscles (mostly females)

·      Neurological disorder or injury

In older adults, causes might also include:

·      Bladder cancer or tumor

·      Prostate cancer or enlargement

·      Overactive bladder

·      Weak pelvic floor muscles

·      Dementia

PCPs should start with a complete physical examination that includes lab analysis of urine and blood.  A referral to a specialist might be needed where additional tests would be ordered such as an abdominal ultrasound, neurological exam and other urological procedures.

Treatment of bedwetting in adults centers on the root cause.  Many times the incontinence is reversible once the underlying cause is indentified.  Determining the origin is often the biggest challenge but definitely worth pursuing.  Until there is a diagnosis and treatment regimen, it is important to keep patients dry and comfortable during the night.  Here are ways to achieve this.

Absorbent products: Adult protective underwear (or adult pull ups) works wonders in protecting skin, bedding and clothing from urine when the need is moderate.  For the best performance of these products, make sure they are the correct size and worn comfortably snug.  If protective underwear is not enough protection, a “brief” product can also be worn for heavier need.  They are comfortable to wear and are available at drug stores, medical equipment providers and on line.   Go to prevail.com for more information.

Kegels exercises:  Pelvic floor strengthening has proven to help adults of all ages with urge incontinence and bedwetting.  A stronger pelvic floor could reduce the number of bedwetting episodes and allow a person to get to the bathroom in time to void.  A physical therapist trained in incontinence care can be very helpful with these exercises.

Here are some other ideas, but patients should speak to their doctor before trying:

Set an alarm to awaken during the night to toilet.  If the patient is wet before the time of the alarm, set the alarm to an earlier time until finding the ideal hour of the night to toilet.

Watch fluid intake:  Limiting after-dinner fluids will likely reduce urine production at night.  But PLEASE NOTE: if someone is very physically active into the evening hours, or could become dehydrated for any reason, this would not be recommended.

Prescription Drugs:  Medications to control incontinence is directed at treating the underlying cause.   In cases where there is urge incontinence, some medications may help to relax the detrusor muscle contractions of the bladder.  This type of incontinence is more common in older adults, but can certainly effect younger and middle-age patients.  For those suffering from a lack of vasopressin (a chemical that keeps the body from eliminating too much fluid), Desmopressin is a drug that replaces vasopressin in the body.  This is often associated with diabetes insipidus, brain tumor or head injury.  Careful assessment by a specialist would be in order in this case.

Night time incontinence may differ with younger and older adults but can be treated and managed in most cases.  Perseverance and motivation on the part of both patients and providers are key to managing night time incontinence.  Providers should stress that this is not the patient’s fault and it happens to others as well.  A provider should also emphasize that incontinence can be managed and assure patients they will search for the underlying cause and proper treatment.

About The Author

Christine Pruneau RN, BSN, RAC-CT

Christine has 25 years of experience in clinical education for a long term care and home health. She is a frequent speaker on the subject of continence management and has a special interest in restorative health in both adults and children.  Christine is the Clinical Director for Home Care Division at First Quality Healthcare.

 

 

CAREGIVERS IN AN AGING POPULATION

Holly Kupetis

Sally was 56 when she first decided to invite her Dad to live with her. He, then 80, had been suffering with slight forms of dementia for a few years, but his episodes had increased greatly and she decided that the time had come where he simply could not live on his own.  Being an only child, most of the burden of care for her father fell on her.  And while she was happy to do it, it brought with it many challenges.  The extra time needed to help him with his daily activities, accompanying him to doctor’s appointments, researching medical needs and performing tasks that were new to her were just a few of the issues. A bigger challenge was balancing the demands of her father with her full time job. And while her boss was understanding, she found she was forced to reduce her hours at work in order to be available to her father when he needed her, creating a greater financial strain on her family.

Sally’s issues are ones faced by many who find themselves in a caregiver role to a parent or loved one.  And with a population that is aging quickly these issues are likely to be felt by far more of us in the future.  The AARP estimates that by 2050 there will be only 3 potential caregivers for every person aged 80 and above. That’s a drastic difference from today’s 7-to-1 ratio.

Why the sharp decline?  In just 10 years, the oldest of the Baby Boomer generation will be slipping into their 80’s, and with them, the need for additional care. Unfortunately, with the population expected to grow at just a 1% pace over the next several years, the caregiver ratio simply won’t be able to keep up. The AARP estimates that over the next several years we’ll see a steady decline in the ration of caregivers to older adults, with the sharpest decline happening as the Baby Boomers reach their 80’s.

What are the implications here? In the coming years, caregivers will need more support than ever before.  The greater number of caregivers will create an increased need for nationwide Long Term Services and Support.  And workplace policies will need to accommodate flexible work schedules to allow caregivers the extra time they so desperately need. And, care for the caregivers themselves will need to be addressed to ensure that they have the tools to take care of themselves, as well as their loved ones.  Things such as providing extra funding or tax credits to caregivers, creating more resources for caregivers to ensure they have the tools and skills needed to care for their loved ones, adjusting FMLA laws to allow for greater workplace flexibility and time off, and making adjustments to medicare and medicaid to cover caregiver coordination services are just a few of the things that can be done to avert this growing crisis.  Putting these types of resources and policies in place is crucial in the coming years if we want to support the caregiving community and our growing, older population

Surgical Treatment of SUI and/or Prolapse

Holly Kupetis

Dr. Donna Deng is the Director of Female Reconstructive Urology and Neuro-Urology for Kaiser Permanente Northern California

There are two main types of incontinence—stress and urgency. Treatment for them is very different.  Before operating on a patient I try to remind them that this is their quality of life, if it doesn’t bother them, it doesn’t bother me.  The patient guides treatment, and my job is to explain the treatment options, surgical and non-surgical.

Surgical treatments for stress incontinence can be divided into two categories—urethral bulking agent injection or some type of suspension (sling). The urethral injections are in the form of collagen or Durasphere. Suspension surgery is when a sling is used. There are three main ways to perform suspension surgery. The first is Burch suspension, where tissue around the urethra/vagina is lifted up. This can be done by making a cut in the abdomen or laparoscopically. The other two are the pubovaginal sling and the mid-urethral sling, which are implanted through the vagina. These use different types of material, and most commonly now is synthetic mesh.  The surgeon and patient will decide what material is best for the patient.

Like any surgery, continence surgery has risks. It is common that the surgery may have fixed the stress incontinence, but symptoms of frequency, urgency or urge incontinence may persist or appear. Other risks are not being able to fully release all urine, vaginal mesh erosion, vascular and bowel problems, and significant bleeding. A patient needs to think about the risks before going into surgery because there are different ways to perform anti-incontinence or sling surgery. The risks vary.

Surgical treatments for urgency incontinence include using Botox and nerve stimulation implants (InterStim). They are used to calm the bladder. Botox lasts about six months and will need to be reinjected. The InterStim is safe and reversible and can last from three to five and up to ten years (depending on the size of the battery), but it requires a little more surgery than injecting Botox into the bladder. Patients who receive neurostimulator need to be aware that they cannot have an MRI and will set off alarms in airports.

Prolapse is usually not detrimental to health. Often there is a little bit of falling, but if it is not affecting the patient’s quality of life, my advice would be to not undergo any extensive reconstructive surgery. Surgery for prolapse is not a cure all. The outcome of this type of surgery varies with every patient. Lifting through the vagina or abdomen needs to be tailor made for each person.

Surgical treatments are the same for the old as for the not so old, and results are similar. There is no reason not to proceed with surgery based on chronological age. Each person is different, and chronologic age is not a good indicator of how healthy someone is.

Dr. Deng has disclosed that she has no financial interests related to this topic.

About The Author:

Dr. Donna Deng is the Director of Female Reconstructive Urology and Neuro-Urology for Kaiser Permanente Northern California, caring for nearly 4 million people. Prior to this recent move, she was Associate Professor of Urology at the University of California San Francisco. During this decade long tenure, she helped develop the use of stem cells in the treatment of urinary incontinence and bladder function, as well as teach and mentor countless medical students and residents in the art and science of Urology.  She continues to lecture at national meetings and publish in peer-reviewed journals and major textbooks.

OAB Study Methodology

Holly Kupetis

Methodology:

Patients were screened and those that qualified replied to an online questionnaire about bladder health and OAB symptoms, implications and treatment options.  Of the 356 that completed the survey, 153 reported a physician had diagnosed them with OAB. The remaining 203 respondents all had reported symptoms of OAB, but have not been diagnosed by physician. Respondents ages ranged from 18-65+, with 60% of the respondents age 35-54 and 30% age 55+.

 

The non-diagnosed patients self identified through the use of a series of questions regarding the frequency of need to void urgently, the number of times per day, and the days per week the urgency occurred and the degree to which the problem was considered bothersome. Questions follow the standard diagnosed questions published by the American Urological Association and others.

Ask The Expert: Hear from our 2016 Continence Care Champion Award Winner – Dr. Christian Winters.

Holly Kupetis

QUESTION: Since you have been in practice, what changes have you observed in patient expectations of clinical outcomes?

DR. WINTERS: "In my view, patients have always wanted the same thing - safe and effective treatment of their conditions. What I have always found most appealing about my practice is that I need to do the best I can to select the best treatment for each individual. That’s what I view as the “art of our science”. Patients with very similar conditions may do best with different treatments based on a variety of factors, including their goals and expectations. To me, that hasn’t really changed. What is a bit different is that patients come with more information – some good and some bad – and we have to do our best job to help them make the most informed decisions. At some level, it’s the same process but the conversations continue to evolve. Another difference is that patients are expecting our treatments to not only be effective, but as minimally invasive as possible. Many of our patients are now wanting quicker recovery and faster return to work / or other activities. So, it’s a more comprehensive and encompassing discussion – I think that’s been a great development over time. "

QUESTION: So many patients with incontinence issues never seem to see the right physicians.  They seem to approach either primary care or gynecologist.  The data suggests that this initial consultation does little to address issues of incontinence.  What we can do to help patients find the physicians that are more knowledgeable and able to address their health concerns?

DR WINTERS:  "I view this as great opportunity for clinicians involved in the care of women with pelvic floor disorders. In my view, we need to “raise all boats”. What I mean is that we need a multi-faceted approach to improve access to pelvic health for all of our patients – men, women and children. I think part of this is enhancing efforts to collaborate with our primary care clinicians to improve the comfort level in having the conversation with our patients regarding pelvic floor disorders and in their basic evaluation and treatment. I’m always afraid of our patients in rural areas who may not have easy access to specialty care never seeking any treatment because it’s harder to access it. If we can increase the dialogue at the primary care level, I’m hopeful that these patients will have improved access to care. At the specialty level, we need to improve our access as well. We need to lead efforts in clinical and patient education – “how to start these conversations” – and we need to be cognizant of our accessibility. These issues can be improved by “outreach clinics” as well as more accessibility to our primary care clinicians who are treating these patients. Hopefully this “networking” can lead to integration of pelvic floor treatments – even across health systems. So, I think we as specialists need to support our patients and primary care clinicians on the “front end” by education them to initiate conversations and treatment. And, we need to be accessible on the “back end” to our patients and clinicians where more complex treatments are needed."

QUESTION: We hear that patients wait upwards of 7 years before seeking treatment for conditions like OAB. What can be done to to decrease the time to treatment?

DR WINTERS:  "Much of what I mentioned above would hopefully decrease this interval of time. Also, we need more research and development as our treatments for OAB have much room for improvement. We have very different patients with different symptom complexes entering the same “treatment algorithms”. Can we do better refining selection of therapies? Can we improve our therapies? Can we learn more about how these conditions are affecting our patients and what prompts them to treatment? We can. I believe if we are able to improve and refine our treatment approaches, this too will have a positive impact in decreasing the time to treatment. But at the end of the day, I think its about getting the conversation started."

Physical Therapy Care for the Pregnant & Postpartum Mama

Holly Kupetis

Physical Therapy Care for the Pregnant & Postpartum Mama

Lizanne Pastore PT, MA, COMT

            Pregnant and postpartum mothers comprise a significant segment of our population that is too often underserved by our medical community.  As we all know, a woman’s body goes through profound changes during pregnancy.  Bodily systems are taxed to the max.  The vascular, respiratory, endocrine, and certainly the neuro-musculo-skeletal systems are overloaded with extra stressors.   They say pregnancy is like training for a marathon, but when the marathon ends with the birth of baby, that’s only the first finish line, because mom has to lace up her running shoes again and continue running.  She must take care of her newborn, plus any other youngsters already at home; maybe she has to get back to her former job soon too.  The finish line is ethereal.

                  And as Mom is lugging those heavy, awkward car seats and strollers and lifting loads of laundry and bending deeply and often to maneuver ever-heavier infants into and out of cribs, she is doing so with less-than-optimal muscular and skeletal strength and form, not to mention her sleep deprivation!  Her ligaments are still lax; she probably has a bit of rectus abdominis diastasis making her core even weaker; her tendons and nerves are still mushy making her more at risk for things like carpal tunnel syndrome, tendonitis, and sciatica.  (All that extra fluid from pregnancy takes a toll on connective tissue.)  

                  And let’s not forget her pelvic girdle.  Pubic symphysis, sacroiliac joint (SIJ) or coccyx pain, pelvic girdle and hip movement dysfunctions, pelvic muscle or pudendal nerve pain, incontinence of bladder and/or bowel, pelvic organ prolapse (POP) are just some of the maladies that can affect the pelvic floor and pelvic girdle during or after pregnancy.

                  These pelvic issues are common, but they are not “normal,” as many women are led to believe.  “Oh, leaking?  That’s normal.  All my friends have leaked, it should get better.”  Stress urinary incontinence (SUI), for example, is extremely treatable, especially if addressed quickly.  But if a busy mom ignores her leaking and begins preemptively voiding or gripping her pelvic muscles to avoid leaks, she could actually turn her “straight forward” SUI into an urge scenario, creating muscle tightness or bladder dysfunction and making her case harder to treat.  

                  Similarly, intermittent SIJ pain or pubic pain can become more severe the longer left untreated.   POP, again, while common, is not normal, and is highly distressing to new moms, who hadn’t expected to experience such blatant anatomical changes.  Pelvic concerns are huge, both physically and emotionally for a new mom struggling to care for a new baby.  She hadn’t factored in the care she might need following birth; rarely is she forewarned that she might need help adjusting to her new “body-after-baby.”    

                  But the great news is that pelvic floor physical therapists are experts in treating the pregnant and postpartum mom.  We help many of these women return to fully functioning, active, healthy lives.  In a perfect world, every pregnant woman and new mom would be able to see a pelvic PT, but our world isn’t perfect.   So remember to include a physical therapy referral when your next pregnant or postpartum mama enters your office.  Assure her that her complaints, while common, are not normal but that there is help out there.  Let’s support our moms!

                  Get to know the pelvic specialists in your area; here are 3 great links to help:

http://www.nafc.org/find-a-doctor

http://www.womenshealthapta.org/pt-locator/

https://hermanwallace.com/practitioner-directory