By Gretchen Quinn, MS, OTR/L, PRPC Occupational Therapist

It was a day just like any other. It was 3:00 pm and I was beginning my last evaluation of the day with Ms. S., a 76-year-old woman who lives alone. She greeted me at the door holding onto a rolling walker, a pleasant smile on her face. She invited me into her neatly kept home and we both walked over to her sofa and began to chat. I began my evaluation, asking how she would describe her daily routines and ability to perform basic ADLs and IADLS. When we touched on her ability to perform toileting tasks, she began to open up on what she described as “embarrassing habits.” She confessed the need to wear incontinence briefs and described constant trips to and from the bathroom, day and night. She added, with a frown, that she was often unable to make it to the toilet in time, resulting in the need to change her clothes constantly. At night she would often get up six or seven times to urinate or to change a soiled brief. With this confession, Ms. S looked down at her shoes and said, “my bladder rules my whole life.” It wasn't that I hadn't heard of these “embarrassing habits” before. Of course, I had. Isn't incontinence just part of getting old? If not, it sure felt that way as I filled my days with donning and doffing adult briefs or setting up bedside commodes. As an occupational therapist, asking patients their concerns regarding daily ADLs is a routine procedure at evaluation and subsequent treatment sessions. But what happens when you ask a patient about their bathroom habits and they tell you everything that is wrong with them? How do you fix incontinence? Can incontinence even be fixed?

Identifying Different Types of Urinary Incontinence

Incontinence is the loss of voluntary control over urination or defecation. However, there are various types of incontinence affecting older adult patients. Here are the 5 most common forms occupational therapists are likely to encounter:

• Stress incontinence: Leaking due to strain on the bladder from movement such as coughing, sneezing, jumping, or laughing. This is the most common type of incontinence
• Overactive bladder: Sudden and unstoppable urinary urgency even when the bladder is not full
• Mixed incontinence: Having more than one kind of incontinence (i.e., stress incontinence and overactive bladder)
• Overflow incontinence: An inability to fully empty the bladder leading to urine build-up (urinary retention) that may leak out unexpectedly
• Functional incontinence: Urinary leakage due to cognitive issues, including forms of dementia, delirium, and intellectual disabilities, and neurological or muscular limitations such as arthritis

How Occupational Therapists Can Treat Urinary Incontinence

Identifying what kind of incontinence a patient may be experiencing is the first step in treating any form of incontinence. But why treat it? Urinary and fecal incontinence may not be life-threatening conditions, but they can be life-altering. They negatively impact a person's independence and social interactions as well as increase financial burdens on individuals or their families. According to the National Association for Continence, there are more than 25 million adults impacted by urinary incontinence in the United States. Fifty percent of nursing home residents are impacted by urinary incontinence and it is estimated that $19.5 billion is spent annually on urinary incontinence treatments such as adult briefs, diapers, wipes, and medications. Routine care and nursing home admissions make up a significant portion of these cost estimates. This is a medical condition, especially in the older adult population, that is often overlooked or viewed as part of the normal aging process by healthcare professionals. It can be an embarrassing topic that is brushed over or not talked about at all. In a survey of 260 participants living with urinary incontinence conducted in 2020 (National Association for Continence), only 48% of participants reported having a conversation with their doctor, and only about half of these conversations led to a discussion of treatment options. Doctors who did offer treatment options mainly discussed the use of absorption products and medications to "manage" symptoms rather than offering all alternative treatments available. Alternative treatments are where we as therapists come into play! One treatment occupational therapists can offer is pelvic floor rehabilitation. This is a non-surgical approach to the rehabilitation of dysfunctions in the pelvis that contribute to bowel, bladder, sexual health, and pain complaints. These approaches may include behavioral strategies, manual therapies, modalities, therapeutic exercise, education, and functional retraining. Overall, pelvic rehab is no different than the rehabilitation techniques we perform each and every day as occupational and physical therapists, focused on weak or tight muscles, postural adjustments, body mechanics, and lifestyle modifications.

Good Bladder Health Education

Apart from specific treatment options, OTs can help educate older adult patients to encourage good bladder health:

• Go to the bathroom every 3-4 hours (5-7 times in 24 hours)
• Sit on the toilet, do not squat
• Do not strain to go to the bathroom. Do not perform "just in case" peeing before leaving the house or before bed
• Avoid constipation
• Avoid food and drinks that may irritate your bladder (i.e., alcohol, citrus, artificial sugars, carbonation, caffeine)
• Avoid bulky pads that trap in moisture and can lead to infections such as a UTI
• Maintain a healthy fluid intake (1/2 your body weight in oz. is optimal fluid intake per day. 2/3 of those fluids should be water)

Lifestyle Modifications for Incontinence

Along with good bladder health, other lifestyle modifications may be necessary:

• Use a bladder diary
• Assess diet and modify as appropriate
• Assess medication and timing of medication

Assessing a patient's body posture and breath-holding patterns with functional tasks can also be very effective in the treatment of urinary incontinence. A patient's body posture while sitting on the toilet can add pressure on the bladder and tighten pelvic floor muscles decreasing a person's ability to fully empty their bladder. Also, breath-holding can put an increased strain on pelvic floor muscles weakening them over time and leading to further incontinence. Perform pursed-lip breathing with all functional tasks, especially while urinating and having a bowel movement. Therapeutic exercise example: Have the patient perform sit to stand while counting out loud to decrease breath-holding and decrease the strain placed on the pelvic floor with movement Self-care example: When having a bowel movement, have the patient perform diaphragmatic breathing, however, allow the stomach to stay extended with exhaling. This will create intra-abdominal pressure to assist with evacuation without straining the pelvic floor muscles and reduce the tendency of breath-holding. Trial multiple positions when sitting on the toilet to fully empty the bladder. Example: Have a patient perform forward trunk flexion and trunk extension while sitting on the toilet after having a bowel movement or urinating to ensure the bladder is empty. You can also have a patient stand up and sit back down. Assess normal resting posture, is the trunk always flexed? This might be placing too much pressure on the urethra causing insufficient ability to fully empty their bladder. Educate the patient on limiting time on the toilet to a maximum of 10 minutes.

Bladder Retraining Techniques

• Lower body and core strengthening exercise program
  • Clamshells in supine: can progress with the use of a TheraBand
  • Bridges in supine: can progress with bridge holds or having patient balance ball between legs during exercise
  • Hip abduction and adduction: can progress with TheraBands or squeezing a ball between the knees
  • Kegel contractions: start out in supine (gravity eliminated plane) and progress to standing and then during functional tasks
• Behavioral techniques
  • Brace "knack" urge drills
  • Distraction techniques

Incontinence should never be a topic that is brushed over or ignored due to its negative impact on a person's ability to participate in a variety of basic ADLs, IADLs, and community integration. It can place high financial demands on individuals and family members and can be a contributing factor in the need for an individual to be relocated from their home to a senior living community or nursing home. No matter how many people we may see experiencing incontinence, it is important to remember that it is never part of the normal aging process and directly affects a person's quality of life and wellbeing. Speak up for your patients and offer alternative treatments rather than bulky briefs and medications. No one should suffer in silence!