Leading an active life Tips on how to live with incontinence

Transcription

1 Leading an active life Tips on how to live with incontinence Incontinence Management

2 Dear readers! Occasional or constant loss of urine is referred to as urinary incontinence. As a result of this condition, the affected people not only have to cope with hygienic aspects but also frequently suffer from extreme emotional stress. Many people suffer from urinary incontinence, as much as one third of the people in older age groups. Despite this prevalence, incontinence is a problem that most people are reluctant to talk about openly. Therefore, we want to help you address the issues surrounding incontinence. In this brochure, we will provide you with extensive information about the clinical syndrome, about how to prevent urinary incontinence, how it is correctly diagnosed, and which therapeutic and secondary measures are available. In addition, we will present proven practical tips for helping deal with incontinence. In total, this brochure will provide suggestions on how to cope with your problem in the best possible way so that it does not interfere with a healthy and active lifestyle. Yours sincerely, PAUL HARTMANN AG 1

3 Urinary incontinence what is it exactly? Involuntary loss of urine is connected with functional disorders of the bladder and the pelvic floor musculature. In this chapter you will find out more about the processes involved. 2

4 The term incontinence is derived from the Latin word incontinens. Translated into English this term means not retaining. The involuntary passage of urine out of the bladder is referred to as urinary incontinence. The people affected can no longer consciously control when and where urination takes place. Urinary incontinence is not an independent disease. Different causes and underlying conditions can be responsible for it. Therefore it is important to search for the underlying factors. Such factors can be, for example, previous childbirths, bladder stones, cystitis or other conditions. Urinary incontinence is a common problem Women are more frequently affected by urinary incontinence then men. Almost every second of all women between the age of 20 and 50 have experienced the loss of urine during physical strain or exertion. Incontinence is a frequent problem that can affect people of all ages. It is estimated that approximately five per cent of the total population suffer from incontinence of varying degrees of severity. Incontinence in the elderly is much more common than in younger people. Approximately every third of all persons over the age of 65 who live at home suffer from incontinence. 3

5 Urinary incontinence what is it exactly? The emptying of the urinary bladder is a vital function of the body Bladder and pelvic floor In order to understand incontinence, it is required to know how a healthy bladder functions. In the following we will explain the anatomical structure and function of the urinary bladder and the pelvic floor musculature. That s necessary because the bladder and the pelvic floor musculature play a significant role in the natural process of urination. Your kidneys form urine continuously for a variety of reasons, such as enabling the excretion of toxic substances. The urine flows out of the kidneys through the two ureters into the urinary bladder. The bladder is a very expandable hollow organ that stores urine. The urinary bladder can normally hold about a half a litre, and can stretch to hold over one litre at full capacity. It consists of several layers of muscle and is lined inside with a mucous membrane. The urethra leads out of the bladder at the neck of the bladder. At the exit of the ureter from the bladder several muscle fibres are arranged in a spiral form, they form a sling and close the bladder. The muscle system at the neck of the bladder are called the inner sphincter and function automatically (reflex controlled). 4

6 In its further course the urethra passes through the pelvic floor musculature. Shaped like an upside down umbrella and situated between the pelvic bones, this musculature supports the bladder and other organs of the lower abdominal cavity. Comprised of several muscle bundles, the pelvic floor musculature forms the outer sphincter of the bladder which can be controlled consciously. Together, the inner muscle at the bladder neck and the outer sphincter of the bladder are responsible for the closure of the urinary bladder: During urination they must be relaxed, and then urine can flow out. Correct functioning of the bladder does not depend solely on intact bladder muscles and closure systems. The nerve network in this area also plays an important role, as nerve impulses control muscle activity. Now you will find out more about these mechanisms that activate and control the bladder. The urinary paths 5

7 What causes urinary incontinence? In this chapter we present the different types of urinary incontinence and describe the characteristics that distinguish them from one another. 6

8 Incontinence can be caused by a poorly functioning sphincter (passive incontinence) or by a disorder of the bladder musculature (active incontinence). Disorders of the nerve supply in this area can result in both active and passive urinary incontinence, as well as in mixed types of urinary incontinence. Passive incontinence When the sphincter of the urinary bladder does not function properly, the most common cause is a weakened musculature of the pelvic floor, especially in women. Instances that can lead to a weakened pelvic floor could be repeated childbirth, as a result of hard manual work or as a result of severe overweight. Passive incontinence is the most frequent type of urinary incontinence. Active incontinence Premature, uncontrollable contraction of the bladder musculature leads to involuntary loss of urine, frequently until the bladder is completely emptied. This over-activity of the bladder musculature is often caused by recurrent inflammation of the bladder (cystitis) or a disorder of the nervous system due to changes in the brain or in the spinal cord, for example in paraplegia or multiple sclerosis. 7

9 What causes urinary incontinence? Urinary incontinence is a complex disorder with many possible causes There are five different types of urinary incontinence. Urge incontinence As in the other types of urinary incontinence, urge incontinence involves the involuntary loss of urine. In milder forms of urge incontinence, this is experienced in the early stages as a constant need to urinate. Urge incontinence as a result of an infection of the bladder. The micturition urge arises because the mucous membranes are being irritated by the existing illness. If the symptoms are fully pronounced, the people affected usually feel a sudden, extremely strong urge to urinate which they can suppress for a short time at best. But it is usually very hard to keep up this strenuous squeezing for very long, and after a few moments, urine is passed. Frequently the bladder is not even very full and could still store more urine. The cause of this premature and uncontrollable urge can be found in the control of the bladder; expansion sensors in the bladder wall send faulty signals to the control centres in the brain and spinal cord indicating that the bladder is full. The musculature of the bladder wall starts contracting. The pressure inside the bladder increases. Despite great efforts, the urge to urinate can no longer be controlled voluntarily. 8 There are many causes of urge incontinence: For instance inflammation of the bladder (cystitis), bladder stones or urethral constriction in enlarged prostate or also disorders of the nervous system may bring about this situation.

10 For treatment it is therefore necessary to diagnose the underlying disease and include its treatment in the therapy. As a rule, excellent results can be expected with this approach. Urge incontinence is especially common in men. Stress incontinence Stress incontinence is the most frequent type of urinary incontinence happening when involuntary loss of urine is caused by a quick and sudden pressure increase in the abdominal cavity. The abdominal muscles contract during strenuous activities, laughing, sneezing, pressing or coughing. Effective closure of the bladder is not a problem for a healthy sphincter. Predominantly women are affected by this type of urinary incontinence. About 50 percent of women who lose urine involuntarily suffer from stress incontinence. However when the pelvic floor musculature is weakened, for instance after repeated childbirth, as a result of weak connective tissue or overweight, it cannot adequately balance this pressure increase. Overflow incontinence In overflow incontinence small amounts of urine are lost constantly, even if the person feels no urge or is not in a particularly stressful situation. The bladder cannot be completely emptied. Generally, this condition is caused by an obstruction, for example, urethral constriction due to enlarged prostate gland with advancing age or bladder stones. When the pressure inside the bladder becomes too great, a constant dribbling of urine starts flowing through the urethra. Bladder with stress incontinence. The sphincter does not operate as effectively as it should, involuntary loss of urine is caused by a pressure increase in the abdominal cavity and in the bladder. 9

11 What causes urinary incontinence? Reflex incontinence In reflex incontinence, the people affected do not feel the urge to urinate. The bladder empties itself automatically, but often not completely. Residual urine remains in the bladder. Emptying the bladder is not a conscious act, and it cannot be stopped. In some cases the cause of the loss of urine can be recognized, for example, through changes in position such as standing up or walking. Reflex incontinence occurs often in persons with nervous lesions, particularly following transverse lesions of the spinal cord or in multiple sclerosis. Extra-urethral incontinence A typical symptom of this rare type of incontinence is constant loss of urine. Urine is lost through unusual openings. Frequently connecting canals (fistulas) extend from the bladder outwards or into the vagina. In addition to congenital anomalies, this condition can be caused by chronically inflammatory intestinal diseases, accidents or operations. Risk factors and diseases which can trigger incontinence Descent of female pelvic organs The organs in the female pelvis can descend, or drop down. For instance in women with weak connective tissue, the uterus can change its normal position, having adverse effects on the bladder as well as the urethra. This frequently leads to problems during urination. Women who have had multiple pregnancies are particularly affected by this condition. 10

12 Enlarged prostate gland The male prostatic gland (prostate) encircles the urethra directly below the bladder like a ring. This gland can enlarge with advancing age and constrict the urethra. This can impede urination. As a result, the individual can experience an increasing urge to urinate, incomplete emptying, and recurrent bladder inflammations (cystitis) accompanied by irritation of the bladder and incontinence. Chronic constipation A constantly constipated intestine presses on the bladder and promotes incontinence through nervous stimulations. Furthermore, constant, intense pressing while trying to empty the intestines can damage the pelvic floor musculature and thus the closure mechanism of the bladder. Once regular intestine movements are restored, the symptoms caused by urinary incontinence usually disappear. Strain on the pelvic floor Extreme overweight makes the pelvic floor more susceptible to incontinence. In this case, appropriate weight loss frequently results in the improvement of bladder symptoms. Incontinence can also arise in women who carry heavy objects frequently or for long periods of time. Therefore avoid lifting or carrying heavy objects (not heavier than ten kilograms). Chronic respiratory disorders such as asthma or chronic bronchitis lead to prolonged and intense coughing episodes, exerting recurrent pressure on the musculature of the pelvic floor and weakening the sphincter of the urinary bladder. Treatment of the underlying disorder as well as consistent pelvic floor training can help to improve this condition. 11

13 What causes urinary incontinence? Inflammation of the Bladder (Cystitis) Due to the short urethra and its orifice located very close to the vagina, women are more susceptible to diseases such as cystitis and urethritis. Bacteria can easily enter and ascend the urinary tract. In many cases, cystitis can be the cause of an exaggerated urge to urinate. Drugs Certain drugs can cause or worsen incontinence. These include, for example, diuretics which lead to increased urination. Also, various hypotensive agents (for example betablockers) and anti-depressants can affect the musculature of the bladder. Consult your physician about medication and incontinence. 12

14 Old age With advancing age, the mucous membranes of the bladder, urethra and vagina become thinner and more susceptible to infections and injuries. The bladder wall musculature also becomes weaker. To complicate matters, elderly people with little social contact often suffer from reduced mental awareness. Together, these factors can also increase the likelihood of incontinence. Bladder stones or tumours of the urogenital system In very rare cases, a bladder stone or a tumour in the urinary system can cause incontinence. These symptoms become noticeable very suddenly. In such cases, one may notice blood mixed with the urine. Please consult your physician immediately in this case. Acute diseases Incontinence frequently occurs after operations, accidents or illnesses. However it usually does not last very long. Emotional stress Various kinds of psychological factors can contribute to or cause the emergence of incontinence. Examples of this could be the uncertainty resulting from sudden changes in life, loneliness or depression. 13

15 What can be the effects of urinary incontinence? What can happen if urinary incontinence is not treated correctly or in time? How does inadequate skin care diminish the protective function of the skin? These questions will be answered in the following chapter. 14

16 In our society, it is considered important to always be in control of oneself. For this reason, fear of the loss of urine in public often leads to extreme limitation of social contact. A stressful condition with resulting health risks Incontinence leads to recurrent urinary tract infections, especially when it is accompanied by disturbed urination: Due to incomplete emptying, bacteria and other pathogenic germs multiply in the bladder and migrate further through the ureters to the kidneys. This can result in severe renal disorders and damages. Besides, a serious disease can be the underlying cause of incontinence. Its treatment is very essential for maintaining the affected person s health and quality of life. Impairment of the protective functions of the skin due to exterior influences In addition to the emotional stress, untreated or incorrectly treated incontinence can lead to skin problems: Skin irritation, chronic eczema or even open pressure sores (decubitus) can arise when wetness and urine act upon the skin for a long time. We would like to encourage you: Do not try to cope with disturbed bladder function on your own. Seek competent medical advice from an understanding and supportive professional as early as possible. 15

17 What effects can urinary incontinence have? The skin is irritated by constant contact with urine and/or faeces and thus can no longer defend itself sufficiently against pathogenic germs. The skin is additionally weakened by necessary frequent washing which can impair the skin s protective acid mantle. Use soap-free cleansing products to clean your skin. They are safer than soaps that tend to dry the skin. The risk of inflammations and infections is especially high in the elderly because their skin is less resistant due to normal ageing processes: Elderly skin produces fewer lipids and less sebum than younger skin. Use suitable care products which effectively support the protective functions of the skin. If associated diseases such as circulatory disorders or diabetes mellitus exist, the protective ability of the skin is further impaired. To keep your skin healthy and prevent inflammations, mycotic infections or pressure sores effectively, you should therefore pay special attention to skin care: 16

18 Use highly absorbent briefs and pads that provide proven protection against inflammations and infections; depriving bacteria and yeasts of their culture medium is very important. Care for and cleanse your skin regularly with suitable products which replenish lipids and condition your skin sufficiently. This is very important in order to prevent further irritation of the skin and to maintain or rebuild the protective function of the skin. Ideal cleansing and care products are those which have been specifically developed to meet these requirements. 17

19 How does your physician make a diagnosis? A correct diagnosis must be made before the right treatment can be initiated. In this chapter How does your physician make a diagnosis? you will find detailed information on the individual examination steps that may be required. We will explain the various methods that are commonly carried out by general practitioners. 18

20 As a rule, it is not very difficult for the physician to find the cause of incontinence. The diagnostic measures are usually limited to a few examination steps which are neither painful nor especially unpleasant. A private conversation about a sensitive topic The first and most important step for you is to confide in your physician. Bear in mind: Your physician is familiar with this sensitive topic through his daily work. If you find the thought of a conversation embarrassing, write down what you want to tell the physician at home. This way you can prepare yourself at home and will be able to speak more freely. Exact information is very important for the physician to make a diagnosis. In most cases, this information will enable him to deduce the type and cause of incontinence. For example, he would ask you under what circumstances incontinence occurs, how much urine you lose and whether or not you feel an urge to urinate. Another important piece of information is whether diseases of the urinary tract and genital organs have been diagnosed and treated earlier. Please remember to tell your physician what drugs you take and whether you suffer from a chronic disease. Your physician will give you a diary where you can enter your drinking habits and trips to the toilet (urination diary). 19

21 How does your physician make a diagnosis? Physical and laboratory diagnostic examinations as a basis for treatment Physical examination Your physician examines the genital region and the intestine for externally visible causes of incontinence. Additionally in women an examination by a gynaecologist is usually recommended. Urinalysis A urine specimen is analysed for bacteria, pus, blood and other substances. This can indicate an inflammation or renal disorder. Blood test The physician can determine elevated blood sugar values or renal disorders through a blood test. Ultrasonic examination An ultrasonic examination is a method in which a transducer is guided over your stomach, painlessly and without side-effects. The transducer sends signals which are reflected by the organ surfaces and displayed on a screen. Through this procedure it is possible to determine whether kidney stones, tumours or urinary obstruction are present. A prolapsed uterus or enlarged prostate can be determined as well. 20

22 Examinations by specialists for more diagnostic certainty If your general practitioner cannot clarify the cause of incontinence completely, further examinations may be necessary. Urologists and some gynaecologists specialize in these kinds of examinations. A simple diagnostic procedure involves an examination of the urinary flow (Uroflow). This procedure involves urinating into a special funnel. This examination can be used to determine whether the outflow of the bladder is disturbed by an obstruction and whether the bladder can summon up enough strength to discharge the urine. During a cystoscopic examination, a thin optical instrument is inserted into the urethra and the bladder and the ureteral orifice. When performed correctly, this examination is virtually painless. It can be used to assess the constitution of the urethra, bladder and ureteral orifices into the bladder. Additional examinations by a specialist are possibly required to check nerve, spinal cord and brain functions. Based on the results of the preceding examinations, your attending physician will suggest further examinations by a specialist. These functional tests are normally carried out by orthopaedic surgeons, neurologists or psychiatrists. X-ray tests can be performed to examine ureters, urinary bladder and urethra. This type of procedure can be used for functional tests as well, both with and without a contrast medium. 21

23 How can you prevent incontinence? If you have been diagnosed with risk factors for incontinence, you can do a lot yourself to eliminate them or lessen their effect. This will not entail a drastic change in lifestyle. The following section provides simple but effective advice for the prevention of incontinence. 22

24 A healthy lifestyle supports the natural functions of the bladder Following these simple tips can help regulate bladder functions in cases of slight incontinence. Regulated digestion Extended intestinal inactivity can lead to excessive exertion during defecation, which can in turn, weaken the connective tissue of the pelvic floor. Therefore take enough time during defecation and avoid excessive pressing: Instead, contract the anal sphincter several times in succession, each time holding for about 3 seconds. This encourages the increased movement of the intestine, thus inducing natural defecation. Wholesome diet A healthy, easily digestible diet has a high fibre content. Examples of high fibre foods include wholemeal products such as wholemeal bread, wholemeal rolled oats and wheat bran as well as raw fruit and vegetables. However you should avoid high fibre foods that can lead to flatulence for example pulses, cabbage, onions, leeks and plums. Flatulence can occasionally worsen incontinence through the pressure increase in the abdominal cavity. It is therefore advisable that changes in your diet be made very slowly. Foster a healthy intestinal flora that digests fibre, thus preventing flatulence. Yoghurt and kefir in your daily diet support the natural intestinal flora. 23

25 How can you prevent incontinence? Adults need to drink litres a day to ensure a sufficient intake of fluid. Sufficient intake of fluid It is very important that you drink enough fluids. This can prevent constipation and help a high fibre diet take its full effect. Herbal and fruit teas as well as slightly carbonated mineral water are recommendable. Fruit juices and some vegetable juices have a diuretic effect and are therefore not suitable. Avoid drinking black tea, coffee and alcoholic beverages too often, as they can lead to increased urination and irritate the bladder. Regular relaxation If you experience anxiety because of your incontinence, mental relaxation can be a very valuable aid. Avoid worrying about problems excessively. Deliberately include activities in your daily life that bring you pleasure for example meeting friends, going to the cinema or taking a walk. In addition, it may be helpful to learn relaxation techniques. One easy-to-learn method uses progressive muscular relaxation according to Jacobson. However many other methods are also well-suited for this purpose including for example, autogenic training, yoga and meditation. The method you choose is not what is important, but rather practicing this on a regular basis, preferably daily. 24

26 Healthy Exercise Regular exercise is very important for incontinent people with constipation, and can lead to an improvement in the symptoms. Suitable activities are those which do not exert great pressure on the abdominal cavity and pelvic floor: walking, swimming, dancing and cycling are examples of appropriate exercises. We perform many of our daily activities without consciously thinking about our movements. Especially for incontinent people, it is important to practice good posture and pay more attention to proper movement, relieving the strain on the pelvic floor. Therefore, try to keep your back as straight as possible when lifting or carrying objects. As a rule, women should avoid lifting objects which weight more than 10 kilograms. Additionally, when you are carrying something, hold it as close to your body as possible and above your navel. If you have to stoop while working, keep your back as straight as possible. Always work on an area that is directly in front of you. This is especially important when doing housework such as vacuuming, sweeping or mopping. As a general rule of thumb: every movement that protects the back also protects the musculature of the pelvic floor. 25

27 How can you prevent incontinence? Easy exercises and specific training for strengthening the pelvic floor musculature Strengthening the pelvic floor with specific training With regular, daily exercise you can do a lot to strengthen your pelvic floor and attain lasting relief of your incontinence symptoms. 1. Start of exercise Relax the pelvic floor for about 5 minutes by simply reversing the pressure conditions in the pelvis. Kneel on the floor and lean the upper body forward. Support yourself on your lower arms and rest your head on your hands. A further variation: Lie on your back and rest your lower legs on a stool or chair. Raise the position of your pelvis by placing a pillow under the buttocks. 2. Pelvic floor training You can feel your pelvic floor by interrupting the urinary stream during urination. The muscle which you use to do this is your pelvic floor and can be trained with the following exercises. Repeat each exercise as often as you like. 26

28 Make sure you breathe correctly during the exercises: Inhale your pelvic floor is relaxed. Exhale tense your pelvic floor at the same time. A. Sitting on a firm object will make it easier to feel the muscles affected and tense them. For example, a rolled up towel is well suited for this. Exercise A B. Cross your legs while standing, sitting or lying down. While exhaling press the outer edges of your feet against each other. C. Sit with a hollow back so that you can contract the musculature around the urethra and vagina better. Now concentrate on the pelvic floor and squeeze the muscles together while exhaling. Exercise B D. Sit on the floor and bend your legs up. The lower legs are spread apart. Press your knees together with your hands. Now while exhaling, try to open the upper thighs by pulling apart against the hands. Tip for emergencies, for example, when you are not at home. When a sudden pressure in the bladder occurs, bend over deeply at the waist, as you would when tying your shoes. The pressure in the abdominal cavity is thereby shifted in the opposite direction and the bladder is relieved. Exercise C Exercise D 27

29 How is incontinence treated? Incontinence can be successfully treated. In fact 80-90% of the people affected experience significant improvement after treatment. Therefore we would like to advise you again to consult a physician, who can determine the type of incontinence and initiate a treatment that is exactly right for you. In the following section, we will explain what you can do in addition to the physician s measures to make your treatment as effective as possible. 28

30 Recognized therapeutic measures for: Urge incontinence In urge incontinence, the bladder musculature contracts at the wrong time. An urge to urinate arises resulting in the involuntary loss of urine. Accordingly, the goal of the therapy is to induce the bladder musculature to wait until urination is really necessary and desired. Two therapeutic measures are commonly used together and have a success rate of over 80%. 1. Medication 2. Urination exercises and a diary Medication Different, very effective medications are available which are used to treat a constant urge to urinate. They have a soothing and relaxing effect on the bladder, suppressing premature contraction and the resulting pressure increase in the bladder. With small doses and modern active agents, sideeffects are rarely experienced (for example, dryness of the mouth, constipation, tiredness). 29

31 How is incontinence treated? Urination exercises You can accustom the bladder to certain voiding times. By voiding your bladder at fixed times, with specific intervals, it adapts itself exactly to this rhythm and forgets" the urge between these times. In the side column you see a page from a urination diary that is essential for planning this behavioural training. After discussing this with your physician, you can begin your bladder training by going to the toilet during the day exactly every two hours for two weeks. Plan additional trips to the toilet depending on your individual drinking and other usual habits for example, a half an hour after breakfast but do not exceed a total of ten trips to the toilet per day. Try to observe the fixed times as well as you can, despite the wish to urinate. Gradually you can increase the intervals between the planned trips to the toilet. You should always go to the toilet at these fixed times even if you do not feel the urge. Tips on how to control the urge micturition In the battle against the urge to urinate, it is important to keep in mind that an urge never lasts longer than 5 minutes: If you can get through these 5 minutes, you will have won! Do not get up to go to the toilet under any circumstances during the strongest urge because vibrations while walking and heavy breathing while running increase the pressure on the bladder. It is better to sit or stand still. 30

32 If possible, bend forwards as if you wanted to tie your shoelaces. This frequently helps to ease the urge to urinate immediately. Tense your pelvic floor to avoid a loss of urine. Once the urge to urinate has passed, go to the toilet slowly and keep the pelvic floor closed by constant tensing. The measures described above, in conjunction with medication, are sufficient for the vast majority of the people affected. If these measures are not successful, an electro-stimulation treatment may be helpful. In this procedure, electrodes are used to selectively stimulate certain nerves, preventing the bladder musculature from contracting prematurely. Your urge to urinate is completely suppressed. A more invasive procedure is necessary only in extremely rare cases. Stress incontinence Emergency posture If you suffer from stress incontinence, it is essential that you strengthen the musculature of your pelvic floor and sphincter with specific exercises. Usually this pelvic floor training leads to noticeable improvement or complete elimination of the symptoms. In some cases it is required to use medication and behaviour training as well. Treatment is successful in 90% of the cases. 31

33 How is incontinence treated? Appropriate exercises are presented in chapter How can you prevent incontinence?. Strengthening the pelvic floor The supporting musculature in the pelvis is an important element of the closure mechanism of the bladder. Pelvic floor training serves to strengthen these muscles and to rebuild damaged muscle tissue. By doing the exercises properly, you will begin to feel the muscles in the pelvic floor after a short period of time. It is advisable for you to do your exercises under professional guidance at first. Vaginal cones and exercise instruments Vaginal cones can be used to support effective training of the musculature. These small weights shaped like a suppository are inserted into the vagina and held there for a few minutes by contracting the pelvic floor. So-called perineometers are also a suitable aid. These are exercise instruments that measure the pressure you produce when you tense your pelvic floor, providing you with reliable feedback on your progress. Biofeedback This method helps you to perceive your body functions better. A small probe in the vagina or rectum measures the muscle strength of the pelvic floor electronically and transmits this measurement to a computer. This way you can find out if you are exercising the right muscles of the pelvic floor and can see how great the tension is. It is possible to do these specific exercises at home, the necessary instruments are covered by health insurance when they are prescribed by a physician. 32

34 Behaviour training for coping with stress situations Make a list of all the situations when you pass urine involuntarily. These situations are often connected with certain movements or activities, such as coughing or sneezing. The next time you get into a stress situation, tense your pelvic floor before the triggering movement or the triggering pressure. Exhale during tensing and try to keep your back as straight as possible, which will help you control your pelvic floor. If you practise this frequently, your pelvic floor will soon contract automatically in these situations. Medication If necessary, your physician will prescribe oestrogens or alpha-sympathomimetics which stimulate the musculature of the sphincter. Operations In some cases incontinence can only be remedied with the aid of surgery for example, when the uterus is prolapsed. Specific pelvic floor training can still be used to ensure the long-term success of the operation and should be started beforehand in preparation. Pads and incontinence pants Aids such as pads (for example MoliMed) or incontinence all-in-one briefs (for example MoliCare Mobile light) make treatment much easier. They provide excellent protection until successes in the treatment are noticed, as well as in the event when treatment is not successful. 33

35 How is incontinence treated? Incontinence pads and all-in-one incontinence briefs have proven to be excellent for meeting the various needs of individuals with incontinence. Overflow incontinence We will inform you about products from HARTMANN in the chapter How can you choose the right incontinence product?. In case of overflow incontinence, first of all it is very important to determine the cause. If the passage is obstructed by an enlarged prostrate or a tumour an operation or procedure in the urethra will be required. Medication has proven to be an effective therapy for disorders in the closure system. They ensure that the smooth muscles of the sphincter relax and allow urine to pass freely. Reflex incontinence Bladder tapping training is a method used to stimulate the bladder by tapping or stroking the lower abdominal region at regular, three-hour intervals. This causes the bladder to contract and empty, and helps avoid uncontrolled losses of urine between these periods. Spasmodic contraction of the sphincter during bladder tapping training can be reduced by medication or by a small operative procedure on the sphincter. It is very difficult to restore the function of a reflex bladder. Paraplegic people are particularly affected by this problem. Currently the best method for dealing with emptying problems is intermittent auto-catheterism. This involves inserting a catheter (thin, flexible plastic tube) into the urethra every three to four hours to empty the bladder completely. 34

36 Keeping a supply of absorbent incontinence products is always helpful, regardless of the type of incontinence (see chapter How can you choose the right incontinence product? ). Extra-urethral incontinence For this form of incontinence, in which urine attempts to find another passageway through a fistula, the only reliable treatment is an operation. Alternative methods as accompanying and supportive measures Reflex zone therapy is regarded as a very successful treatment method. Particularly elderly people seem to respond very positively and quickly to these natural therapeutic stimulants. Reflex zone therapy on the feet is considered to be especially helpful. Individual studies document the efficacy of hypnosis, acupuncture and homoeopathy as well. Important: Consult your physician before you try these alternative therapies to ensure that all the necessary treatment methods used in conventional medicine are included in your treatment plan as well. Modern aids for improving the quality of life To support the therapeutic measures, various modern aids are available which help you continue to take part in a normal social life. In the following section, we present aids which enable you to continue to lead a normal life, without worrying excessively about incontinence. 35

37 How is incontinence treated? Condom urinals Condom urinals can be a suitable option for men. They are made of soft latex and must be fitted appropriately by a nursing staff. The condom may be self-adhesive or fastened with special adhesive strips to the skin. On the lower end of the urinal tube there is an extension for attaching a urine drainage bag. These drainage bags are offered as leg-bags for mobile people and as bed-bags for the night or for bedridden people. The leg-bags can be fastened to the inside of the calf or the thigh securely and unobtrusively with non-irritating Velcro fasteners or cuffs. Draining aids Draining aids are intended for people with severe and very severe incontinence. The physician or trained assistant inserts a thin plastic tube into the bladder through the urethra. This indwelling catheter drains urine continuously from the bladder into a drainage bag that is fastened to the leg of mobile people or to the bed. This indwelling catheter should, however, be used as seldom as possible because infections will set in after one month at the latest. The suprapubic catheter, a thin plastic tube that is directly inserted into the bladder through a puncture in the abdominal wall above the pubic bone (suprapubically), poses a lower risk of infection. 36

38 Absorbent aids Despite effective incontinence treatment methods, the use of absorbent incontinence pads and alll-in-one incontinence briefs or pants is indispensable in many cases. The acceptance of incontinence pads is especially high among women. Product improvements, such as thinner, lighter materials have been developed, so that pads can be worn very unobtrusively. Suitably shaped incontinence pads that can be worn comfortably and inconspicuously are also available for men. These products provide excellent security primarily because of the special absorbent material. This material is able to safely retain even large amounts of fluid, even under pressure. In addition the skin stays almost completely dry, preventing skin problems and unpleasant odours. Bladder problems, which are caused by the cooling effect of wetness and which can further aggravate incontinence, can also be avoided by using pads. Tip: Do not wear your pad too long despite its high wearing comfort. If you change your pads at regular intervals, you can prevent the occurrence of mycotic and other skin infections. All-in-one incontinence briefs are available for bedridden people and people with severe incontinence. They are also very suitable if faecal and urinary incontinence exist at the same time. By choosing high-quality products and changing them regularly, your skin will stay virtually dry. This way you can prevent damage to the skin which can occur as a result of long periods of contact with the aggressive elements in urine. The improved hygiene and easy use of pads make the situation much easier for the people affected as well as for the relatives caring for them. 37

39 How can you make your situation easier? Changes around the house and suitable clothing can help optimize the therapeutic measures for incontinent people who suffer from additional physical impairments. In this section you will also learn about the conditions that need to be met so that the prescription of the required incontinence products is covered by the compulsory health insurance funds. 38

40 Appropriate changes in the home Simple changes around the house can also help to reduce the problems associated with incontinence. The toilet must be designed so that you can go to it and use it as easily as possible. This applies particularly if you have problems moving or finding your way. Have handles attached to the toilet. Under certain conditions, the costs for this will be reimbursed by your insurance. Adapt the height of the toilet seat to your requirements. Check whether the height of the toilet seat is suitable for you and have it lowered or raised if required. Toilet paper should be easy to reach, and the toilet room should provide enough space for a walker or a wheelchair if possible. Of course you should have any objects that you might trip or stumble over on the way to the toilet removed. 39

41 How can you make your situation easier? Suitable clothing Whenever possible, wear skirts, trousers and dresses with zip or Velcro fastenings that can be opened quickly. There are ready-made clothing manufacturers that make fashionable and very functional clothing, especially designed for the needs of incontinent people. Please visit your medical supplies store for more information. Choose clothing that is permeable to air and absorbent and can be frequently washed or boiled. Cotton fabrics are a very suitable choice. Make sure your clothing fits loosely, as loose-fitting articles can be removed quickly. Take special measures if you wear draining incontinence care products. Widely cut trouser legs hide urine bags and allow easy emptying. Trousers can be adapted for this by opening a trouser seam and fitting it with a Velcro fastening. Trousers and skirts with an elastic waistband are very suitable for people who are restricted in their movement. They can be pulled up and down easily in the toilet. 40

42 Incontinence Products on prescription In Germany issuing a prescription for payment by statutory sickness insurance, incontinence products will be considered when the use of incontinence products is medically indicated and is necessary in individual cases and permits the person to carry out the basic necessities of their daily life. Over and above there are recognised types of cases where incontinence products can be prescribed 1. If incontinence aids enable you to take part in a normal social life again, 2. If your symptoms cause skin alterations and their treatment is supported by a suitable product, 3. If severe functional disorders exist, for example, stroke on one side with loss of speech. Because the person cannot say anything about the loss of faeces or urine, this condition could result in the risk of decubitus (open pressure sores) or skin inflammations if absorbent incontinence products are not used. 41

43 How can you protect your skin from damaging influences? So far we have informed you about the topic of urinary incontinence : How urinary incontinence arises, how it is diagnosed and treated. An important aspect is also the protection, the cleansing and care of the sensitive or irritated skin in the genital area. In this section you will learn the importance of using suitable medical care products and what characteristics they should have. 42

44 The structure and functions of the skin The skin serves as the border between an individual and the environment. It plays a critical role in the external appearance of a person and in communication, by taking in and relaying important information from our environment. Pain and itching are perceived by free nerve endings. Various receptors that perceive pressure, temperature and vibration are also located in the skin. Skin cells receive information from the outer world and relay impulses to the central nervous system. More than one million sensory fibres extend from the skin to the spinal cord. The perception of temperature and pain is one of the most important protective mechanisms of the body. The body is immediately removed from danger zones by unconscious and conscious reflexes. In addition, the skin performs other vital tasks. For example, it is involved in the regulation of the water and temperature balance. It also performs other protective functions, for example, if the body is exposed to potentially harmful foreign substances, rays or micro-organisms. If the acid ph value of the skin is disturbed by a longer lasting disorder, pathogenic germs can multiply easily resulting in infections. 43

45 How can you protect your skin from damaging influences? The balanced Menalind professional range for cleansing as well as protecting irritated and sensitive skin Urinary incontinence irritates the skin for many reasons. It can macerate (soften and damage) the skin through moisture and the aggressive degradation substances in urine. The natural skin flora, which constitutes the skin s most important defence system against pathogenic germs, is impaired as well. However washing too frequently with damaging cleansers and soaps can result in lasting damage to this natural protective acid layer. The skin in elderly people is generally less resistant due to the normal ageing processes. After a disorder the regeneration of the skin s natural protective acid layer happens only slowly because fewer lipids and less sebum are produced. If the skin is to remain healthy, it requires thorough care and protection. In addition to the use of suitable absorbent incontinence products that keep the skin dry, Menalind professional cleansing, care and skin protection products provide this reliable nurture. It is very important that all urine residues are removed completely from the skin. Menalind professional wash lotion cleanses very gently and can be used daily. Panthenol which moisturises the skin and supports the natural skin functions offers a valuable support to the maintenance of the health of ageing skin. 44

46 If some parts of the skin in the genital area are very soiled because for example, faecal incontinence is also present, this sensitive area can be cleansed gently with Menalind professional cleansing foam. The foam gently dissolves the soiling, which can then be removed without problem using a tissue. At the same time the natural skin protection mechanism is supported by creatine. For an effective skin protection there is now a new Menalind professional skin protection foam, the innovative solution from HARTMANN especially for ageing skin irritated by incontinence. The light foam is simple to apply and does not leave a film of grease. A protective film is formed on the skin. The new formula contains panthenol and the completely new ingredient creatine. Creatine stimulates the reduced skin energy household thereby supporting the natural skin function mechanisms. However creatine can do even more: it forms itself around the skin cells and protects them from exterior attack. To protect the skin, in case of incontinence, the foam is thinly applied to the genital area after thorough but mild skin cleansing. The skin tolerance is dermatologically tested on affected skin. The product may be obtained from chemists (pharmacists) and medical suppliers. Menalind professional body lotion containing creatine and panthenol cares intensively for affected ageing skin. 45

47 How can you choose the right incontinence product? An important aspect of the comprehensive treatment of incontinent people is the use of appropriate, absorbent incontinence products. They are needed to accompany the therapy so that the person affected can be spared embarrassing accidents until he or she is free of symptoms. High-quality incontinence products, such as the HARTMANN products described in the following chapter, ensure a reliable and unnoticeable disposal of urine. Incontinence products are worn discreetly in the undergarments, protecting sensitive skin and preventing unpleasant odours. 46

48 Use of modern absorbent incontinence products, with consideration of the condition and personal situation The HARTMANN Inco System Selecting the right absorbent incontinence product depends above all on how much urine is actually excreted as well as on the usual or required changing rhythms. To determine the excreted amount it is helpful to weigh the absorbent product before and after use. The difference in weight will indicate the amount which was excreted. To obtain the average of the excreted amount, it is advisable to weigh all absorbent products over a period of 48 hours and then calculate the average loss of urine per hour. Once the average amount has been established, the HART- MANN Inco System makes it easy to select the most suitable product. HARTMANN absorbent incontinence products feature a special colour code corresponding to the four degrees of severity of incontinence and thus to the different amounts of urine excreted per hour. The colour code is used both on all of the packaging, as well as on the backing foil of the product itself. 47

49 How can you choose the right incontinence product? MoliMed: Pads for slight incontinence A discreet, easy-to-use and anatomically shaped pad, such as MoliMed, is recommendable for slight incontinence. Thanks to their perfect physical fit and the breathable textile backsheet, MoliMed pads ensure maximum wearing comfort. In addition, MoliMed is highly absorbent and very gentle on the skin. Fluid is guided quickly through the white Dry Plus non-woven fluid distribution layer, into the core of the absorbent pad and is retained there securely by the innovative super absorber HighDry SAP. Odours are also tightly sealed in by the unique odour-binding molecules. The fluid cannot flow back to the surface, and the skin stays dry. This excellent skin compatibility has even been confirmed by dermatological tests. MoliMed is available in six types of absorption capacities: ultra micro, micro light, micro, mini, midi and maxi to exactly meet your individual needs. MoliMed can be affixed securely and discreetly in the undergarments with an adhesive strip. MoliMed Slips are underwear specially designed to attach to absorbent pads. The specially designed gusset provides a perfect fit even for the larger sizes midi and maxi and even better than conventional undergarments. MoliMed Slip has a high cotton content and can be washed at 95 C. 48