Although the incidence of strokes in the U.S. has declined over the past 50 years, our population still experiences over 750,000 new strokes a year. It is the third leading cause of death behind heart disease and cancer in this country and the leading neurologic cause of long-term disability. What is most alarming is that the severity of strokes has not declined over the decades. This is, in part, due to the gender gap in how men differ from women in experiencing strokes. Men tend to experience strokes at a younger age than women. And while the number of men experiencing strokes is greater overall than women, outcomes for women are often worse. This is believed to be largely due to the fact women are older and thus more vulnerable to lasting disabilities and even death. In fact, because public health measures have improved our control of risk factors, the 30-day mortality rates have declined only in men (Carandang et al., 2006).
All strokes represent an interruption of blood flow to the brain. In situations where the blockage of flow results in a burst of blood vessels followed by bleeding, the event is referred to as a cerebrovascular accident (CVA). The aftermath of a stroke for survivors is a function of both where the stroke occurs in the body and its severity. Degree of severity is assessed by doctors and depends on the size of the area of coagulated necrosis (death) in tissue, referred to as an infarct, resulting from the blockage and the extent of brain hemorrhage. Urinary and fecal incontinence are considered good markers of severity, as researchers have found that 52% of stroke patients experiencing the onset of urinary incontinence and 59% of stroke patients experiencing the onset of fecal incontinence are dead within six months (Brittain, Peet, & Castleden, 1998).
Every stroke is different, and so is the recovery for survivors. For many, symptoms of incontinence lessen over time or disappear altogether in the rehabilitation process. Review of published studies indicates that as many as 79% of stroke victims have urinary incontinence and 40% have fecal incontinence upon hospital admission, whereas at six months these percentages fall to 19% and 9%, respectively (Ibid). Yet given the evidence that incontinence occurs in cases of greatest severity and thus is directly correlated with mortality, it is imperative that greater attention be paid to understanding and addressing the symptoms. Otherwise, we are not likely to be successful lowering deaths occurring shortly after the event.
Because the neurophysiologic damage often triggers symptoms of overactive bladder (OAB), OAB medications can be helpful. In some patients, urine retention occurs because of weakness of the bladder muscle, preventing contraction of the bladder for emptying. Intermittent catheterization may therefore be necessary for a time in the case of retention to prevent damage to the bladder or even kidneys and reduce symptoms of frequency. Biofeedback therapy can help stroke survivors identify the pelvic floor muscles to exercise and use to relax unwanted or ill-timed spasms of the bladder otherwise resulting in urgency. Bladder retraining, guided by a skilled nurse or therapist, is often the most helpful to stroke survivors and includes timed toileting aimed at preventing toileting accidents. Physical therapy aimed at restoring balance, gait, and muscle strength for improved mobility are critically important to protect against daytime and nighttime falls, especially if nocturia becomes troublesome following a stroke. Diet and daily habits continue to be the first-line defense against symptoms of OAB. Click for more information on all of these helpful suggestions and more.
Bowel management can be a problem for stroke survivors as well, as both fecal incontinence and constipation are often present. Lifestyle modifications, medications, exercise, biofeedback, and stimulated defecation programs are part of any comprehensive treatment plan. There is research underway to assess success for addressing fecal incontinence specifically from phenylephrine gel, sacral nerve stimulation, and bulking agents.
To lower the risk of depression and isolation in the stroke survivor, tackling the incontinence in the aftermath is a key pathway to full recovery and restoration of quality of life. And life itself.
Executive Director, NAFC
Published On: December 02, 2009