Contributing Causes of Incontinence

There are several conditions that can contribute to the development and progression of incontinence.

These can include medical conditions, medications, environmental and clothing obstacles, loss of mobility, and even dehydration, which can lead to concentrated urine and bladder irritation. There may also be a combination of these conditions along with cognitive decline that will require treatment and maintenance strategies.

A physician may determine if the cause of incontinence is medical in nature and treatable. These may include urinary tract infections, constipation, or prostate issues, each of which can be treated with medication and other strategies.

Diabetes-related neurologic complications are associated with a higher risk for incontinence, especially in women. Nerve damage that happens with diabetes can affect the nerves that control the bowel and bladder. Compromised immune function with diabetes can lead to infections, such as urinary tract infections that can cause urinary incontinence. And, diabetes medications may cause diarrhea, leading to fecal incontinence. Patients with diabetes and high blood sugar may drink more fluids to satisfy their thirst and urinate (more often). 

Additional medical conditions associated with incontinence include neurologic problems caused by trauma affecting nerves, stroke, or other conditions, certain diseases, such as Parkinson’s disease, multiple sclerosis, and prostate cancer, enlargement, and/or surgery. Menopause with changes that affect bladder function can play a role. Even previous pregnancy may have affected pelvic floor function and bladder muscle.

Medications that relax muscles of the bladder and/or reduce awareness include sleeping pills and anxiety medications. Patients with mobility limitations may find it difficult to reach the toilet in time to properly use the facilities.

Toileting includes the ability to get to the toilet in time, use it properly, and clean oneself after use. Environmental obstacles may include clothing that is difficult to remove or put on, hard to reach locations and/or the inability to visually identify bathroom facilities, and pathways to the toilet that are cluttered or difficult to navigate. This can lead to the struggle to get to the toilet, get clothes off in time, and lead to urinating and/or defecating in places other than the toilet.

Cognitive decline can add challenges to accomplishing this ADL, such as confusion with the multi-step process of toileting, even in familiar settings. For instance, Alzheimer’s patients can forget where the toilet is in their home, what it is used for, and how to use it. Some forms of dementia may include communication deficits, which can include the inability to express the need to use the toilet and result in an incontinence accident. These issues may occur as early as a middle stage of dementia and eventually lead to dependence on others for personal care of incontinence issues.

Recognizing Incontinence

Recognizing the symptoms of incontinence and seeking early medical attention are important starting points. Some very general signs of incontinence may include noticing soiled underwear and bedsheets, seeing or smelling leaked urine or feces, and any overly apparent problems with going to the toilet.

Symptoms may exhibit a range in severity. For instance, urinary incontinence can range from mild leaking to unintentional emptying of the bladder. Urinary incontinence is most common in patients with dementia. Fecal incontinence is less common and may range from an occasional leakage of stool before defecation to total loss of bowel control.

Several features may be explored during visits to diagnose and build a plan to manage incontinence. In patients with middle to late-stage dementia, this may require caregivers to note toileting and hygiene cues as they observe the patient from day to day.

Building a bladder journal can help to identify incontinence issues. This may include a record of when and how often the patient goes to the bathroom, when incontinence occurs, how frequently incontinence occurs, and if there are any triggers, such as coughing or laughing, or any foods or beverages associated with incontinence incidences.

Caregivers can provide more detailed information, such as how long the patient has been experiencing incontinence, and if there were other episodes of incontinence in the past, which types of incontinence are being experienced (urinary, fecal, or both), how much (trickle or flood), any differences between daytime and nighttime, any physical or mental barriers noted, and an estimate of diet and fluid typically consumed.

If possible, it’s ideal if the patient can be asked about their awareness of bladder fullness, passive wetting, and general motivation to maintain continence.