Incontinence Can Be Treated
By Dr. Robert M. Wild Jr. and Linda Lochbaum
Health Break, Centre Daily Times
Monday, November 29, 1999

Don't be embarrassed to seek medical attention for urinary incontinence. It is very common. More than 15 million Americans have difficulty controlling their bladders.

The urinary bladder functions to store urine and then to expel its contents through the urethra (the tube that runs from the bladder to the outside). When the bladder is unable to store urine effectively, urinary leakage or incontinence ensues. Both bladder and urethral problems can cause incontinence.

Conditions that can contribute to bladder or urethral dysfunction include congenital necrologic problems, strokes, multiple sclerosis, bladder infections, confusion, medications, diabetes, bladder stones, prostate problems, low levels of female hormones, plus many others.

Several common types of urinary incontinence are:

Nocturnal enuresis or bed-wetting is generally seen in children. Many will outgrow the problem. Others require treatment.

Urgency incontinence results from the sudden uncontrolled desire to urinate. The "overactive bladder" along with infections, neurologic problems, bladder tumors and stones, even irritants such as spicy foods and caffeine, can lead to urge incontinence. Occasionally the cause is unknown.

Stress incontinence results from the inability of the urethra to remain closed due to injury or weak or damaged pelvic support. It can occur after coughing, sneezing, running, dancing, straining or just getting up from a chair. It is more common in women than in men.

Overflow incontinence is a consequence of the bladder failing to empty as designed. As the bladder becomes overfilled, small increases in urine volume overflow through the urethra. This is often the result of an obstructed urethra by the prostate gland in men.

Functional incontinence is an inability to get to the toilet fast enough. This can accompany mental impairment, poor manual dexterity, medical factors or environmental barriers.

In most cases, incontinence can be successfully treated.

The first step is to consult a physician for a thorough evaluation. Billions of dollars are spent on pads and catheters yearly. In many cases, they may be helpful, but they should not be considered the only remedy.

Incontinence is not a natural part of aging but is present in up to 50 percent of those in nursing homes. Children and adults of all ages and both sexes are affected.

Various treatments include:

Behavior methods can help some children with enuresis. Pelvic muscle strengthening exercises (Kegel exercises) may stop some stress incontinence and prevent the need for surgery. Timed urination may help some with incontinence.

Medical therapy is helpful to many with urgency incontinence or enuresis. Drugs such as Detrol and Ditropan are now seen in public advertisements. Other drugs are used to relax the bladder muscles or to strengthen the urethra.

Surgery of various types may be needed for the more severe forms of stress incontinence to repair holes in the bladder, remove obstructing prostate tissue, correct obstructions and other problems with the urethra or enlarge a bladder.

Incontinence is common. Do not hesitate to see medical attention. Most people with incontinence can be helped.

Dr. Robert M. Wild, Jr. is a urologist on the staff at Centre Community Hospital. Linda Lochbaum is a clinical nurse specialist at Centre Community Hospital. This article is reprinted with permission from Centre Daily Times.

Cancer of the prostate is the most common malignancy in males and the second most common cause of cancer deaths in men. Similarities exist between cancer of the prostate in men and cancer of the breast in women. It is estimated that there will be approximately 179,000 new cases of cancer of the prostate for 1999. Approximately 37,000 deaths will occur from cancer of the prostate in l999. These numbers are quite similar to those of cancer of the breast in women. Many cancers of the breast are stimulated to grow under the influence of the female hormone estrogen. Similarly, cancers of the prostate are generally influenced to grow under the stimulation of the male hormone testosterone.

The discovery of the effect of testosterone on cancer of the prostate in 1945 allowed for the first advance in the treatment of cancer of the prostate. Medical treatment to reduce the amount of testosterone or surgical removal of the source of testosterone was shown to slow the growth of cancer of the prostate in most cases.

The next significant advance in the evaluation and treatment of cancer of the prostate occurred with the development of the nerve sparring radical prostatectomy in 1982 by Dr. Walsh at Johns Hopkins University. This anatomical advance in the surgical removal of the entire prostate enabled men to have the possibility of being cured of their prostate cancer while at the same time having the possibility of retaining their erections in a significant percentage of cases. This new procedure also allowed for significant improvement in retaining urinary control or continence. Other improvements in various forms of radiation therapy are employed in the treatment options of this cancer that is unique to men.

With the discovery and eventual use of prostatic specific antigen (PSA) in the late 1980's, in combination with ultrasound evaluation and biopsy of the prostate, cancer of the prostate is now able to be diagnosed at its earliest stage. PSA is a protein that circulates in the blood of all men with a prostate. It is secreted by the prostate primarily into the ejaculate but small levels of it do get into the blood. It is specific to the prostate but it is not specific to cancer of the prostate. That means that PSA is manufactured by prostate glands that are both malignant (cancerous) and benign (non-cancerous).

Approximately 30 percent of patients with early elevations of PSA are found to have a clinically significant cancer of the prostate on transrectal ultrasonic guided needle biopsy of the prostate. However, PSA levels can be normal in approximately 30 percent of patients who do have cancer of the prostate. Standard normal levels of PSA range between 0 and 3.9. Early or mild elevations of PSA range between 4 and 9.9. As the PSA increases, the percentage of patients who are discovered to have prostatic cancer increases. Above the level of 20, roughly 75 percent of patients will be found to have cancer of the prostate.

Other methods to increase the usefulness of PSA have been developed. Age specific PSA defines PSA levels to each age group. Those men who are forty to forty-nine years of age should have PSA's less than 2.5. Levels to 3.5 have been defined as normal in men that are fifty to fifty-nine years of age. For men between sixty and sixty-nine years of age a PSA of 4.5 has been proposed as being normal. Those men of seventy to seventy-nine years of age may have a PSA of 6.5.

For the last several years, free and total PSA levels have been used to increase the chance that an elevated PSA level reflects an increased incidence of cancer. The majority of circulating PSA is bound to another protein in the blood. That portion that is unbound or free PSA, is produced more commonly in higher quantities by non-cancerous prostate glands. If the patient has a free PSA above 25 percent then the chance that the patient has cancer of the prostate is significantly diminished. Variations in the percentage of free PSA are dependent on the type of equipment used for testing.

The change in PSA level over time, called PSA velocity, can also be used as an indicator of the potential evidence of cancer of the prostate.

By using total PSA, free and total PSA, age adjusted PSA levels, and PSA velocity, in combination with the physical findings of a digital rectal examination of the prostate, physicians are able to help define those patients who need to undergo biopsy of the prostate. Those with positive biopsies can then be directed towards appropriate therapeutic options. Following appropriate treatment of cancer of the prostate, PSA is also used to check for possible recurrences. An elevated PSA represents disease that is still present and growing.

Other methods to detect other proteins that are specific to cancer of the prostate are being developed. At present, the standard levels of PSA remain the overall most useful method of detecting medically significant cancer of the prostate.

It is the recommendation of The American Cancer Society and The American Urologic Association that men over 50 years of age have a digital rectal exam and PSA yearly. Men of black African heritage and those with a family history of cancer of the prostate in either a brother or a father should have a yearly digital rectal examination and a PSA beginning approximately ten years younger. Almost 90 percent of cancers detected by PSA screenings have a disease that is confined to the prostate without evidence of spread beyond the prostatic borders.

There is little question that these examinations have led to a much earlier diagnosis of cancer of the prostate in thousands of men. Because of the often slower growing nature of prostatic cancer it takes fifteen to twenty years to accumulate totally meaningful data regarding improvement in cure. With the earlier diagnosis and employment of curative treatments, whether surgery or radiation therapy, the evidence is now accumulating that there is a real decline in the number of yearly deaths from cancer of the prostate. Without question those of us who treat this disease find far fewer patients today with advanced cancer and find the majority of patients to have a disease that can be cured. This is in contrast to twenty years ago when only 10 to 30 percent of men had lesions found on rectal examination that could be defined as small and hopefully curative.

It is only through patient awareness and the diligent screening by the patients' physicians that the urologic surgeon is able to make the early diagnosis of cancer of the prostate using the modern techniques available to us. Programs such as National Prostate Cancer Awareness Week, in which Centre Community Hospital and many volunteers, physicians, and nurses have participated since 1991, have significantly improved the awareness and interest of American men about this disease that claims roughly forty thousand lives yearly. We are now seeing the fruits of this labor as we have witnessed the early decline in death from cancer of the prostate. Much has been accomplished but much more is yet to be done.