My wife Becky is my local expert on child care and development. She has academic credentials, but more importantly she has experience teaching preschoolers and raising children. Our granddaughter just turned two years old and understandably is still in diapers. As I was changing Josie’s britches, I became curious and asked my expert, “When do we start toilet training?”
I’m an internist and a geriatrician, and I try to avoid topics beyond my expertise. Therefore, I’ll follow the lead of my daughter and my wife regarding potty training of my granddaughter. However, because I have some experience, I taught my grandson the nuanced skill of relieving himself in the woods, which every man should know. Perhaps the confusion we see in big city folks like New Yorkers stems from their lack of common sense and potty training in the wild.
I once read that urinary incontinence is one of the reasons older people are put in institutions. It appears that urinating on your clothes or on the floor is not acceptable in our culture. Years ago I received a frantic call from a seventy-six year old patient. She said, “Dr. Ferguson, you’ve got to do something. Moma is killing me!” No, Moma had not become violent. My patient wanted a urinary catheter for her elderly mother who was bed confined and incontinent.
“Men Are from Mars, Women Are from Venus” is the title of a book describing the differences between men and women – as if we needed such a book. Actually, the book written by a PhD described the psychological differences between men and women. I passed anatomy in Medical School and I’ve stayed in a Holiday Inn, so I have better than working knowledge of human anatomy; and the anatomy of women predisposes to incontinence, especially after repeated pregnancies and aging. On the other hand, an older man’s enlarging prostate, through which the bladder empties, predisposes to difficulty urinating. From a urinary standpoint, it may seem that aging “guys and dolls” are like ships passing in the night, but it’s no laughing matter.
Mark Twain once observed that humor is the highest art form. Many of us have told what we thought was a humorous story that fell on deaf ears when told in the wrong situation, but I’ll take a chance: If you’re an American going into a bathroom, and an American coming out, what are you while you’re in the bathroom? (Don’t worry, this is not an LGBTQ…whatever anecdote.) The answer? While in the bathroom, “Eur-a-pee’n” of course!
Imagine a balloon filled with water. Now, invert the filled balloon, with the neck at the bottom. Hopefully, your fingers are pinching the imaginary neck or you’ll soon have imaginary wet shoes. This picture is analogous to a full bladder sitting behind the pubic bone, with the bladder neck pinched closed by constricting sphincter muscles maintaining urinary continence.
I once saw a patient in consultation before incontinence surgery. I discovered that she was taking a blood pressure medicine whose side effects included relaxation of her bladder sphincter muscles. This class of medicine might be helpful for a man with high blood pressure and an enlarged prostate, but was not a good choice for this poor woman. I changed her medicine, the incontinence resolved and we cancelled her surgery.
There are other medications which irritate the bladder muscles and produce urinary urgency. An example is caffeine which stimulates the bladder (not the sphincter) musculature. And we’ve all experienced the “key in the door knob” syndrome!
In women, aging is associated with loss of estrogen production, and can contribute to bladder muscle irritability and sphincter dysfunction. Estrogen deficiency causes thinning of tissues in the pelvic floor. Continence issues may develop if prolapse of the bladder and uterus occur and alter bladder sphincter function.
The tube leading from the bladder (urethra) is short in a woman and obviously longer in a man. This anatomical difference is an important consideration in the evaluation of incontinence. Doctors try to identify whether a patient is having stress incontinence related more to sphincter problems or urgency issues from bladder muscle irritability and dysfunction. Often patients have a mixed disorder where both problems are present. Patients may also have what’s called overflow incontinence due to urinary flow obstruction. Like water overflowing the swollen reservoir of the dam in California, an enlarged uterus or prostate may press on the bladder. Even fecal impaction can obstruct flow and result in overflow incontinence. A thorough history and examination, supplemented by various tests of the urinary bladder and sphincter muscles are necessary to arrive at a proper diagnosis and appropriate treatment.
You might be surprised to read that the writer of Proverbs alluded to incontinence. Proverbs 21:23 doesn’t speak of urinary difficulties, but advises people that they’ll stay out of trouble if they control their tongue. Most of us wish President Trump would do so. However, who has the courage or a forum to defend him against the unrelenting attacks of the media and the Democrats? Certainly not the establishment Republicans like Mitch McConnell. Certainly not the “never-Trumpers like George Will who seems to have dropped off the face of the earth. At least 50% of the American people support the President, but most of us have no voice. So, Trump uses the bully pulpit of the Presidency and he uses social media, the new outlet of discourse to defend himself.
After all the hoopla regarding the Russians, the drive-by media have suddenly gone silent with those attacks and have moved on to the “leaking” government and intelligence agencies. Three months of Russian “connections” abruptly stopped when Trump accused Obama of wiretapping. Whether it’s true or not, someone seems alarmed by the accusation, given that Obama wiretapped German Prime Minister Angela Merkel, the Associated Press and Fox News’ James Rosen to name a few. Perhaps the philosophy of former House Speaker Tom Foley (D) and George Mitchell (D) former Senate Majority Leader is being reconsidered. It was Foley in 1980 who coined the infamous phrase, “We have no evidence of wrongdoing, but the seriousness of the allegations…compel an effort to establish the facts.” The target of the Democrats in 1980 was Ronald Reagan and Iran. The target today is Trump and the Russians via government officials leaking state secrets to the politicized corrupt media. Little has changed in the Democrat playbook except the truth may be too close to the Obama Administration for comfort.