Bowel continence, a skill acquired by most toddler children, is often considered essential to psychological well-being and social functioning. Patients who suffer from bowel incontinence may be reluctant to share their symptoms with anyone, including their family doctor. This fact makes accurate estimates of the prevalence of bowel incontinence in the general population rather difficult. The number of people afflicted with bowel incontinence in Europe is thought to be around 53 million.

When assessing the situation it is important to understand the mechanisms behind bowel continence. Bowel continence is maintained essentially through the action of the anal sphincters, the internal and external anal sphincters. The anal sphincters are muscles which are normally contracted at rest, a property referred to as myogenic tone, and whenever defecation is to occur, these muscles relax allowing the faeces to pass. The internal anal sphincter (IAS) is sometimes considered the key to bowel continence. The natural resting tone which prevents soiling is attributed primarily to the properties of the internal anal sphincter. When the internal anal sphincter is damaged, patients often complain of passive faecal incontinence, where the faecal soiling occurs without the patient being aware of the leak. This passive soiling occurs most readily with soft stools or small pellets of faeces. This type of soiling may occur after the bowel has been emptied, or during physical exertion.

Bowel incontinence is also a function of the integrity of the external anal sphincter. The external anal sphincter (EAS) is formed of skeletal muscles, i.e. muscles which are under voluntary control. Whenever there is an urge to defecate or pass wind, one can voluntarily contract the external anal sphincter to “hold on”. Damage involving the external anal sphincter commonly results in what is known as faecal urge incontinence, which is a condition where patients find themselves unable to suppress the urge to defecate. They complain of soiling especially in cases of diarrhoea.

It is worth noting that the external anal sphincter is part of the pelvic floor muscles, which also play an essential role in preventing bladder leaks. And because of that, in many instances, urinary incontinence may co-exist with faecal incontinence. Obstetric, or child-birth related injuries are the most common forms of damage to the pelvic floor muscles, which could result in loss of both bladder and bowel continence.

Assessment of the proper functioning of both the internal and external anal sphincters is possible through a simple procedure, which is Endorectal Ultrasound (ERUS). The Endorectal ultrasound is inserted into the rectum to allow visualization of the rectal wall and anal sphincters. Any defects or tears in the anal sphincters are detected, which allows the physician to determine whether the patient is an appropriate candidate for surgery to restore bowel continence.

Surgery is not the only option available for patients with bowel incontinence. There are many other conservative methods available, including rehabilitation and medications. After careful assessment and identification of the underlying causes, the physician will be able to decide on the action plan geared towards restoration of bowel continence.

Patients who suffer from an overactive bladder and stress incontinence are said to have mixed urinary incontinence. They experience loss of urine whenever they get a sudden strong urge to urinate, and urinary leakage upon coughing, sneezing or physical activity. Mixed urinary incontinence is more common in women, with symptoms of stress incontinence typically being more pronounced than symptoms of an overactive bladder.

Treatment strategies for mixed urinary incontinence include treatment modalities aimed at both of its components. The first prescribed line of treatment is pelvic floor exercises, known as Kegel exercises, combined with bladder training. Keeping a urinary diary helps to ascertain that the cause of urinary incontinence is diagnosed correctly. Pelvic floor muscle exercises are a series of contractions and relaxations preformed by the patient in order to strengthen the muscles responsible for opening and closing the bladder on demand. Strong pelvic floor muscles keep urine from leaking when the intra-abdominal pressure rises. Normally, a rise in intra-abdominal pressure is naturally and momentarily brought upon by sneezing, laughing or coughing. Weakened pelvic floor muscles ‘give way’ when the pressure rises, which is the main contributor to the development of stress incontinence. Pelvic floor muscle training also helps the patient learn to use urge suppression in order to combat the sudden, seemingly uncontrollable, urge to urinate. Pelvic floor exercises are aimed at improving both components of mixed urinary incontinence. They are very effective, but they are only effective if preformed using correct technique.

Most patients are also instructed to use a bladder training schedule as a line of behavioural modification. The patient is instructed to void the bladder at regular intervals, not when the urge hits. The intervals are determined using the bladder diary and are increased gradually first by fifteen minute increments, then by half an hour, until the bladder gets accustomed to comfortably holding urine for three to four hour intervals.

When these treatment modalities fail, physicians often resort to more invasive interventions and pharmacological measures. Some medications may be used in cases of mixed urinary incontinence to appease the hyper excitable bladder and relax the involuntary bladder muscle so as to allow the urinary bladder to hold more urine and improve its function. The most common drug class that is prescribed for mixed urinary incontinence is the anti cholinergic drug. Anti cholinergics are drugs that block the action of a chemical transmitter known as Acetyl Choline responsible for the contraction of bladder muscles. The resultant effect is that of muscle relaxation. These anti spasmodic preparations are available as formulas to be conveniently consumed once a day.

When the above measures, usually referred to as the conservative measures by the medical community, fail the physician may discuss interventional therapies or minimally invasive surgical procedures to mixed urinary incontinence patients. Most of these procedures are aimed at alleviating the stress incontinence component. The surgery used when urge incontinence is the main complaint is a bladder enlarging surgery known as augmentation cystoplasty.

Many people experience the phenomenon of urine leak after voiding. The typical patient is a male, and the typical scenario is that as the patient has just finished urinating and is putting on his underwear, a few drops of urine escape. Although post-micturition dribble occurs also in females, it is more common in males and occurs predominantly in older patients. It has been identified as the most common type of male urinary incontinence.

Post-micturition dribble, also referred to as the after-dribble, is a notoriously embarrassing occurrence that can wet the patient’s pants after every trip to the bathroom. In the beginning, the patient erroneously assumes that he can avoid the embarrassing urine leak if he shakes the penis so as to “empty” it. He may even try straining at the end of micturition in order to squeeze out those last few drops, but all to no avail. These efforts fail because the urine that is leaked after urination is over is not actually present in the penis at the patient evacuates his bladder. It is located higher up in the urethra, at the U-shaped junction between the penile urethra and the bladder. The part of the urethra known as the bulbar urethra, named after the adjacent bulbospongiosus muscle. Normally, the bulbospongiosus muscle, part of the pelvic floor muscles, contracts at the end of micturition to expel the urine which has pooled in this part of the urethra. When this muscle has been weakened, it does not contract properly and the urine is later expelled while redressing or some time later. This muscle can be weakened by excess weight, operation for removal of the prostate, chronic cough, and chronic constipation because of the associated excessive straining.

As a part of the pelvic floor muscles, the bulbospongiosus muscle can be strengthened through Kegel exercises. While performing Kegel exercises, it may be challenging to correctly identify the right muscles at first. Some patients cannot correctly identify which muscles to contract except with the help of a continence expert. It usually helps to try to imagine passing a stream of urine and then interrupting it in the middle without contracting the abdominal or leg muscles. The muscles identified during this exercise are the pelvic floor muscles. Performing several squeezes of the pelvic floor muscles four to five times per day is an excellent rehabilitative measure for the bulbospongiosus muscle. It may take six to nine months, however, for an improvement to be noted.

Another technique taught to patients seeking relief from the post-micturition urine leak is the urethral milking, also known as the bulbar urethral massage. The patient is instructed to place two or three fingers behind his scrotum after urination and massage in a forward and upward direction. This empties the bulbar urethra and allows the patient to squeeze out and pass the last few drops of urine left. Squeezing the pelvic floor muscles immediately before massaging the bulbar urethra has been proven to significantly help in eliminating the post-micturition urine leak.

Disclaimer: All material published on the web site is for informational purposes only. Readers are encouraged to confirm the information contained herein with other sources. The information is not intended to replace medical advice offered by your doctor or health professional. Readers should always discuss health matters and review the information carefully with their doctor or health care professional. Extended Disclaimer
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