My mum (97 and proud of it) and my sister-in-law – both ageing with grace and beautiful smiles
As sure as the sun rises and sets every day our bodies are going to continually change as the years click over. Today I am going to remind us about the changes that affect the pelvic health region as we age. We can have some influence over some of these factors – such as supplementing our hormonal levels and general exercise adherance – but some others are beyond our control.
By the end of this blog you will realise that throughout our life we should always do what we can control (‘Control the Controllables’ as my pelvic health colleague Michelle Lyons from Ireland always says) because there are plenty of ageing effects that we cannot control and it can get pretty ugly in the pelvic health region.
As we age there are obvious changes that occur to muscles, collagen and the nervous system which can significantly affect bladder, bowel and pelvic floor function. Significantly though, we can hasten or exaggerate these changes, not only through bad habits, but also through inactivity and weight gain and sometimes from excessive weight loss. Older people should try to do some form of physical exercise (even if it’s dancing to some music while sitting) regardless of age, weight, health problems or abilities and be encouraged to develop habitual physical activity behaviours. (1)
Hiking is such a thing all through Europe in the Alps – and who wouldn’t develop good habits when the scenery is so magnificent and the air is pleasantly cool
“If you don’t use it, you will lose it”.
While there are substantial physiological changes that do occur with ageing, one of the critical things to remember is the old saying: “If you don’t use it, you will lose it”. We have already seen that if you do not maintain regular training of your pelvic floor throughout your life there will be a 5% to 10% loss of muscle strength per week which is worse in older age groups compared to younger age groups.(2) The more sedentary you are, the more likely you are to hasten the problems that come after the age of 60 – when the ageing process really kicks in.
If you are suffering incontinence (leakage of urine or faeces), it is also important to use proper incontinence pads especially when exercising as they have material in them to ensure good absorption of the urine compared with less adequate menstruation pads. Research has shown that women see urinary incontinence as a barrier to exercise (38% of women with moderate leakage and 85% with severe incontinence stop exercising due to UI).(3) Therefore it is better to exercise with an appropriate pad (as long as you have had your exercise regime assessed by a pelvic health physiotherapist), than to stop exercising because you are leaking.
Some pessaries that can be used to help urinary incontinence
Pessaries are devices that can not only help support prolapse, but can also be used for urinary incontinence. If you try a device to help reduce leakage such as a pessary or Contiform®, remember to ask your doctor about using supplemental local oestrogen. If you cannot use an oestrogen-based product (due to previous oestrogen-dependent breast cancer), try a vaginal moisturizer twice a week or a medical lubricant to help insert the devices.
As we age, fat is often deposited around the middle waist area. This increases intra-abdominal pressure, especially when exercising. Evidence tells us that if you are overweight, losing 5% to 10% of body weight can significantly help to reduce incontinence episodes and decrease risk of worsening prolapse.(4) Another research paper suggested that if you can lose one level BMI you can get a 23%improvement in your stress urinary incontinence – which could be as little weight loss as 2.5-3kg.
Movement is the key
Finding a variety of exercises to do such as walking, dancing, cycling, swimming, Tai Chi, bowls, golf, resistance training plus many more is a prescription for a healthy life. But if you lose too much weight, there is a certain amount of fat that is important in the pelvic region and if the weight loss is sudden, women can often experience worsening incontinence. Oestrogen is also stored in your fat so if you are too underweight this also can cause deterioration in control. (You can also be more at risk of fractures if you have a fall and there is very little fat protecting the hip joint particularly.)
Dementia is another serious disease process which comes with ageing and has a detrimental effect on continence. There are many types of brain impairment that come under the broad category of dementia but almost all of them result in loss of continence control for both bladder and bowel. This may result in nursing home admission.
Research into continence and nursing home admission has demonstrated the staggering statistics that at 6 months after admission, 28% of nursing home residents developed urinary and faecal incontinence (dual incontinence); at 1 year 42% did so; and at 2 years, 61% had dual incontinence. Significant predictors for the length of time to developing dual incontinence were already having urinary incontinence, greater functional or cognitive deficits, more comorbidities, older age and lesser quality of nursing home care.(5)
An important management strategy for the patient with dementia can be to institute timed voiding – either nursing staff prompting the client 2 hourly to use the toilet or by the client using a watch that vibrates to alert them to go to the toilet every two hours to help stay dry. Other neurological conditions such as Parkinson’s Disease or stroke can mean the woman (or man) can suffer with slowness of their gait, leading to functional incontinence – where they are just too slow to get to the toilet in time. The impact of this will be exacerbated by any urinary or faecal urgency.
As we age we can also suffer with more bowel emptying difficulties. Patients (and sometimes their health care professionals) say to us that they are constipated, but often there may be more a functional defaecatory problem. Co-ordinating the abdominal and pelvic floor muscles is important to understand with defaecation because if you do not get release of the muscles (puborectalis and the external anal sphincter) you won’t get complete evacuation.
The important ano-rectal angle showing release of pubo-rectalis with the correct dynamics of defaecation.
Some of the changes that occur with the ageing process
- A decline in muscle mass, although continuing to exercise regularly throughout your whole life can help this.
- Less elastin in the collagen which results in less strength, plasticity and elasticity of the fascia.
- Average loss of 2% per year from age 15 to 80 years in the total number of striated muscle fibres in the wall of the urethra leading to decrease in urethral closing pressure.(6)
- Stiffer smooth muscle which is found in the bladder, urethra and internal anal sphincter.
- Urodynamic studies show advancing age is associated with a reduced bladder capacity, an increase in uninhibited contractions, decreased urinary flow rate, reduced urethral closing pressure (particularly in women), and increased post-void residual urine volume.(7)
- Decreased number of motor neurones.
- Decreased conduction velocity of the nerves.
- Higher excitability threshold of the nerve therefore making it harder for the muscle to get going
So the message is – keep moving,keep extending your brain and learning new things and revising old things (like Don’t go just in case to the toilet), manage your bowels well, specifically strengthen your pelvic floor muscles (it is better if you do this in combination with a programme such as Pilates, Yoga or just some general hip, lower limb or abdominal exercises) and brace the pelvic floor with increased intra-abdominal pressure (called The Knack).
I would definitely recommend seeing a pelvic health physio near you to check you are doing things correctly, that you are up-to-date with all the latest practises and to just support you in these later years to allow you to not feel so alone when dealing with any bladder or bowel problems.
Ash and The Dance Ladies <insert heart emoji>
References:
1. Taylor D (2014). Physical activity is medicine for older adults. Postgraduate Medical Journal, 90
(1059), 26–32. http://doi.org/10.1136/postgradmedj-2012-131366
2. Morkved S, & Bo K(2014). Effect of pelvic floor muscle training during pregnancy and after
childbirth on prevention and treatment of urinary incontinence: A systematic review. British
Journal of Sports Medicine, 48(4), 299-310. 10.1136/bjsports-2012-091758.
3. Nygaard I, Girts T, Fultz N, Kinchen K, Pohl G, Sternfeld B. (2005)Is urinary incontinence a
barrier to exercise in women? Obstetrics & Gynaecology Vol 106 (Issue 2)
4. Wing RR, Creasman JM, West DS, et al. (2010) Improving urinary incontinence in overweight
and obese women through modest weight loss. Obstet Gynecol; 116(2 Pt 1):284–92 .
5. Bliss D, Gurvich O, Eberly L, Harms S. (2018)Time to and predictors of dual incontinence in
older nursing home admissions. Neurourology and Urodynamics. 37:229–236. https://
doi.org/10.1002/nau.23279 .
6. Bo K, Berghmans B, Van Kampen M, Morkved S. (2007) Evidence-Based Physical Therapy for
the Pelvic Floor. Bridging Science and Clinical Practice. Churchill Livingstone Elsevier
7. Siroky, M. B. (2004). The aging bladder. Reviews in Urology, 6 Suppl 1(Suppl 1), S3-S7.
