Unveiling the Burdens of Urinary Incontinence - Diane Newman

July 21, 2023

Diane Newman delivers an in-depth talk on urinary incontinence, detailing its nature, symptoms, and considerable impact on individuals' lives. She defines the condition as involuntary urine leakage, often triggered by social norms and activities causing physical pressure on the bladder. Symptoms like urinary urgency, frequency, nocturia, and bedwetting are more common in women due to factors such as pregnancy, childbirth, menopause, and aging. Dr. Newman presents data showing the increasing prevalence of this global health issue, particularly among women, and underscores the medical, social, psychological, and financial burdens it imposes. She differentiates between two primary types, stress and urgency incontinence, and highlights risk factors, including prostate cancer treatments, obesity, and certain medications. Asserting that urinary incontinence isn't an inevitable part of aging nor a normal occurrence, Dr. Newman urges sufferers to seek help, ending her presentation by offering further resources via her website, Awaken Pelvic Health.


Diane K. Newman, DNP, ANP-BC, BCB-PMD, FAAN, Adjunct Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania, and Former Co-Director of the Penn Center for Continence and Pelvic Health, Philadelphia, PA

Read the Full Video Transcript

Diane Newman: Welcome. I'm Diane Newman. I'm a continence nurse specialist and advanced practice nurse practitioner. I specialize in pelvic floor dysfunction including urinary incontinence, and I'm going to present to you an overview of what is urinary incontinence. Let's talk about urinary incontinence. What is urinary incontinence? A lot of patients will say it's a bladder problem, but there's a lot of terms that are being used such as, "My bladder leaks. I'm having an accident. I peed on myself. I wet myself. I had an accent. I have a leaky weak bladder." Or, "I just don't have bladder control." There's many, many terms. Basically, it's the involuntary leakage of urine. It's when a person leaks urine in a socially unacceptable place. It's also culture driven. In the United States and Western countries, women go into a stall, hopefully sit down and urinate privacy. Men stand around urinals or next to each other and void.

There is a cultural component to being continent, to having bladder control. Incontinence is the opposite, is when you lose that control of the bladder. There are other bladder related symptoms and the first one is urgency. Urinary urgency is not the urge to urinate, which all of us get. It's the sudden intense desire to pee. A lot of times people say, I don't know what's coming. It comes on suddenly and what they do is they develop urinary frequency. What that means is they go to the bathroom just in case. I don't want to be caught unaware, so I'm going to go to the bathroom every time I see one, which is called actually toilet mapping. Going to the bathroom more than eight times in a 24 hour period is abnormal. With urgency, individuals develop these types of what I call bad habits.

We also see nocturia. Nocturia is when you get up in night to urinate. That's a difficult symptom because it's not always related to the bladder. Nocturia may be that, well, I'm awake and if you're awake I'll go to the bathroom and then I'll go back to sleep. Or one of the biggest causes of nocturia is actually sleep apnea. Actually a C pap machine can help that. Sometimes it's because you may have edema in your legs and when you lie flat at night, you diurese, which means the kidneys push out more urine into your bladder and that causes you to get up.

Then the last one is nocturnal enuresis or bedwetting. That's really when you have urine leakage while you're asleep or incontinence while you're asleep. That can be very devastating for individuals. Now, urinary incontinence is much more prevalent in women than men. I practice in urology. I've been a urologic nurse now for many years and I do see a lot of men because my practice is in a more of a male-based specialty. Really urinary incontinence is much more common in women. I'll show you why in a few minutes. Why should we care about it? Well, in women, it occurs across a lifespan. In men you tend to see problems with the bladder if they have some type of prostate problem such as an enlarged prostate, which is called BPH or prostate cancer and they need to have some kind of intervention.

Really for women it occurs. What we know is that it's prevalent worldwide, incontinence is all over the world. It's not just here in the United States. Its incidence is high, which means it can occur maybe after pregnancy and childbirth or actually when you go through menopause, it's a chronic condition. We know there are risk factors and we'll talk about those in a few minutes. Its severity can be greater, which means it can be just, oh, I leak urine when I cough, laugh, and sneeze, which is stress incontinence. It only occurs once in a while or it can be quite severe. It can be mild, moderate or severe and it really can affect us.

It can affect us emotionally. We see depression with it. Socially, people do not go out. It really can make us very much dependent on knowing where that bathroom is and it's very costly. One of the first things that individuals will go to is buy absorbent products, which are really helpful. In retail, any kind of drugstore has them or pharmacy. The problem is, it contains the urine. It's not treating the urine. It's a major problem for women across the lifespan. What we know though is it's not normal. It's common, affects men and women of all ages. It's a medical condition and we should not be ashamed of it if we have it. It should always be investigated and it can be managed and really that we have certain habits that might be able to prevent the problems. I discuss healthy bladder habits and one of the other presentations on this website.

Now about one in eight younger women will have urinary incontinence. We're just not talking about older women. Younger women also have this. About half of women by menopause, so when they start menopause, about half of women will develop incontinence. You can see that as we age, us women are more prone to it and it can be quite prevalent. This is a slide that goes over the prevalence and is actually was done in about 28,000 women in Norway. This is a very strong population based study and what it shows is that starting at the age of 20 is that women can start with urinary problems and it may be incontinence, urgency or frequency. Basically, what you see is it increases as we go through the childbearing years, you can see it spike in the menopausal years and then it increases with aging. It's just a trajectory of going up as we get older.

You when you look at LUTS, lower urinary tract symptoms, as far as incontinence plus urgency, frequency, again, you can see the fact that overall it's about 14%, but it does increase as we age. It's also in men. This is a study that actually I think was done in the United States about 22,000 men. Again, you don't see those higher numbers in the younger years. Where you start to see it is when that prostate gets larger in the fifties, sixties and the prostate is actually squeezing the urethra, which is where the urine comes out and men have urgency, frequency, and that's when we start to see men.

Now it is a public health issue and this is actually a great picture to show you the projected increase in lower urinary tract symptoms, which includes incontinence and urgency frequency up to the year of 2025. Basically it's estimated that 25 million women will have this problem. It's only going to get worse. That means it really is a public health importance that we address it now. Now there are other studies that have looked at different races as far as the prevalence of nocturia, incontinence, and interstitial cystitis or painful bladder syndrome, which is also one of the lower urinary tract symptoms that we see.

Bladder symptoms can be very embarrassing and they're hidden. As I said, women will become depressed. They don't want to tell anyone. I'm always surprised by the fact that women who have it don't tell their husbands, but they will not have any type of sexual intimacy with their husband because they're worried about urine leakage, which really can be a downer when you're having sex. They don't tell anybody. I find older mothers hide it from their children, even their girls because they're afraid that they'll move them into a nursing home, so it's hidden. So it's can be a really embarrassing problem. It also has a big stigma. We become toilet trained as we're toddlers. Then to feel that as you get older you're going to develop urine leakage again and not be able to control it is very demeaning, especially I think for women.

What if it goes untreated? I tell patients a lot the time. I say, "It's so great that you came to see me because if it goes untreated, what we've learned is that it's really increases your chance of going to the hospital if you have it." It's the second leading cause of admissions to nursing homes. By the way, the first cause is dementia. It can lead to bladder infections, urinary tract infections, skin problems, urine always against the skin in that area can cause it to blister and break down. It can cause a person to fall and break a bone. There's data that shows that women who break their hip or break a knee, it happens at night when they're rushing to the bathroom. Really, like I said, they can develop depression.

What can be done? Well, there's a lot of things that can be done, but I want to stress to you that there's a big burden as far as incontinence. I think this shows you that it can affect work if you always have to run to the bathroom or if you're in a job where the bathroom is not accessible. I always when I'm checking out my groceries think, and I see a woman, I think, "Wow, I wonder if she has any problems." Because really one out of three women have these symptoms. What happens when she has urgency and she's checking me out at the counter? She's not going to stop and run to the bathroom. That's always of concern. It can cause work issues. It can cause older people to be isolated because they don't want to go out and embarrass themselves. We talked about skin rash. It can be expensive. The number one fear that older individuals will say is that they fear that they smell, so the odor issues around the urine leakage.

It can impact quality of life. This shows you something called the SF36, which is a general questionnaire, has a lot of domains as far as role physical, bodily pain, general health. You can see where the normal line is where a normal person kind of rates your quality of life and the bars here show you where a person with incontinence rates their quality of life. Look how below normal it is, especially when there's physical functioning as far as role emotional role. It really is very abnormal as far as it can impact the quality of life. I talked to you a little about background about the prevalence, how debilitating and embarrassing this problem can be. I want to give you a little bit of information about the types of incontinence. There's two main types, stress incontinence, which means when there's added stress from above, you leak urine and urgency incontinence, which usually accompanies bladder urgency.

A lot of individuals, especially as they age, have mixed urinary incontinence. They have a combination of both. Let's talk about stress incontinence. I hate that term because when I do a history on a patient and I'll say, "Well, it seems like you have something called stress incontinence." I've had women say to me, "Oh, I knew it. I knew it. My kids drive me nuts. I knew it was stress related." It's not related to mental stress. It means stress on the bladder. Pressure on the bladder. Sometimes people call it activity incontinence or effort incontinence, which means when you laugh, cough, or sneeze, you leak urine. Okay? Pressure from above. Doesn't matter how much you leak urine. If you have a full bladder, very little in the bladder, you'll drip couple drops, episodic. It only happens, people tell me when I play tennis. Men will tell me It only happens when I do a golf swing, Diane. The pressure of doing that golf swing actually causes the bladder to leak.

Small amounts, okay? It's not a large amount, it's not the whole bladder contents. Basically it's episodic. What happens is a lot of times it occurs with activity or exercise and you'll hear men and women say, "Well, I don't run anymore because I was leaking urine. I can't do that anymore." Or, "I don't play basketball anymore because I leak urine." "I don't play tennis." That's one of the worst things because it really takes away something that they should be doing exercising. Actually that's stress incontinence. This is also the incontinence that you see with pregnant women especially during the last trimester is that as that baby gets heavier on the pelvic floor and on the bladder they may leak and in about a third of women it may not get better. Urgency incontinence is the next type. Urgency is bladder dysfunction. Stress incontinence is when that sphincter is not tight. We talked about that in the session I did on anatomy and physiology. When the sphincter is not tight, it's not compressing the urethra so that you don't leak urine, that stress incontinence. Urgency incontinence is bladder dysfunction.

That means at some volume the bladder becomes overactive. We used to say bladder spasms. Basically the whole contents of the bladder come out. Patients will say, "Oh my goodness, I rush to the bathroom, I leak on the way to the bathroom, I can't hold it. It just comes out. I wet all my clothes." These are large volumes and they usually accompany the symptom of bladder urgency. What are risk factors? Well as we get older, we see childbirth and menopause can cause bladder and pelvic problems. Pelvic muscle gets weak. Urine leakage can start after prostate cancer treatments, surgery. We also see it with people who smoke If you're overweight, some medications can cause this. If you're really a physical athlete, there's a recent publication in Brazil where women who did CrossFit exercise very active, really leaked urine. That's again the pressure on the bladder and the pelvic floor.

Now why are we more prone to this as we get older? Now, incontinence is not an aging issue so you shouldn't accept it. It's just not norm normal because you get older. There are changes in the bladder that occur that might put an older person at risk for having incontinence and urgency frequency. One is that at night you produce most urine. As we age, the blood vessels are not as effective. The heart doesn't pump as well. We may have a little bit of extra fluids in our ankles. When you're flat, you diurese, which means the heart is pumping better, dumping more blood into the kidneys that make more urine. Pure volume, you are going to get up at night to urinate. Okay? That's a normal aging change. The bladder holds less. The bladder is a muscle as I discussed in the session on an anatomy and physiology and can not hold as much.

Where you would go, I don't know, hours when you're younger, you're going to go more frequently. The amount of urine left in the bladder called residual urine volume is higher as we age. Again the bladder muscle's not as effective so it doesn't clamp down and get rid of as much urine as we like. It becomes overactive the more spasms. We start having issues with dietary irritants such as caffeine, which would cause that bladder to kind of contract and maybe we lose urine and that's more common as we get older. The last thing is functionally we're not as quick, we're not as fast as we were when the younger. It may take us longer to get to the bathroom. That actually is some of the reason why we see urgency incontinence in an older adult.

Now I talk a little bit about childbirth and childbirth and vaginal delivery can put a person, a woman at risk because the pelvic floor muscles, which we discussed in another type of presentation I have here on the website actually provides support to the bladder, the uterus, and the rectum. Okay? Those pelvic nerves keep that area really healthy. What happens is that when we have a baby vaginally, we can stretch that muscle and we may damage the nerves, especially if someone's had an episiotomy, they've used forceps, a very large child really can cause pelvic floor dysfunction and can put that person at risk for incontinence.

The data is showing that over 30% of women develop incontinence within five years after having a vaginal delivery. About 5% may have incontinence prior to delivery. If you are a woman who's pregnant, make sure if you have any urine leakage, you tell your doctor before you deliver that baby because that may say you're at increased risk for developing problems with the delivery. Really future urinary incontinence, so developing future incontinence is fourfold higher in women who have developing urinary incontinence during pregnancy or in the post-op period. I think this is an area where we can maybe make a change.

Some drugs will cause or worsen than urinary problems. I have a list here of different medications, definitely water pills, diuretics. Patients tell me all the time, "Oh when I take my water pill, that's when I have to go. That's when I lose it, Diane. Sometimes I don't take my water pill." Which is not good for that individual who needs it. Water pills can do it. A lot of other drugs including over the counter drugs that we can buy off the shelf the for colds and that can cause issues with the bladder. You need to know that. Now what happens is, as I said previously, is that less than 50% of women report this problem because it's so embarrassing and most of them think nothing can be done.

They self-manage their incontinence and they do things like go buy a pad. You now will go in stores where the menstrual pads are one isle. The incontinence products are another. It's really big business. They won't go on trips or travel. One of the stories I tell is a patient who said to me, "My husband's so upset with me, he sold his software company, we did very well. He now wants to travel around the world. Diane, I won't do it. I can't bring enough pads. I don't want to be caught unaware. Okay? I carry those on and I don't want them opening up my bag and embarrass me when I go through TSA, through security." So they don't travel. That can be really terrible for someone in their healthy years as far as going and enjoying life. They stop drinking water or other liquids.

People think that if I don't drink I'm not going to have bladder problems. That's a fallacy. They won't exercise. They wear only dark clothing. Another story I tell happened to me with a teacher, and this happened about four years ago, the Philadelphia school district went bankrupt and they cut out certain positions. One of the positions they cut out was teacher's assistant. I had four teachers come to me asking would I write them off for disability the Summer after the school year that happened. Three of them had been teaching for 35 years. Three of them were in their fifties, early sixties. One of them was younger.

What they basically told me is that what would happen before is that they had old buildings in Philadelphia County for the public schools. The bathrooms sometimes were in other buildings, they could not leave their room between class. There wasn't enough time because the faculty bathroom was maybe down the hall or in another building. They didn't have time to go and they were so worried about incontinence, they did not want to teach anymore. You can see that impact. One of the teachers told me a story that she would have problems sometimes with urgency incontinence. She would always wear black or navy pants. She would keep another pair in her drawer so if she had an accident, if sometimes she couldn't get there and she had some leakage, she would change her clothes.

No one would be the wiser. Right? No one noticed. Well she said it was spring and she decided wear nice tan pants. It was warm out, the birds were singing and she had an incontinent episode, so she had the black pants in the drawer. She went to the bathroom, she changed them and she came back and she said, "I teach fourth grade, and one of the little boys who's always is causing problems said to me, 'oh Mrs. So-and-so you changed your pants. Did you wet them? Did you wet yourself'?" She said she was so embarrassed she was immobile. I said, "Well, you could have said, 'yeah, I spilled coffee on them'." She said, "Diane, you don't understand. I was so embarrassed by that. I don't want to go back anymore. I can't deal with it." You hear these stories and you think, "Wow, what an impact bladder control issues can have on someone."

What I find, it's not just the 80 year old, the 70 year old woman, it's the 40, it's the 30 year old. The issue is it can have really quite a problem. You can see why people self-manage. Then the other thing is they toilet map, which means they only go to places where they know where the toilet is or the first thing they say when they go to the mall, they go the entrance with the toilet because they use it. They urinate before they leave the house. Then when they hit maybe the church and their whole day is mapped around the location of the toilet. I hope this was helpful to give you an overview of incontinence. There's many ways to regain bladder control and I have another presentation on different ways. Please look through the website, Awaken Pelvic Health. I think this can really educate you about what a significant problem the bladder can cause men and women. Thank you.