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Chelsey Poisson, BSN-RN, FP-C, MSN/MPH-C

LCDR Domenique Selby (ret.), BSN-RN, CEN, CRFN

HunterSeven Foundation

Urinary incontinence is one of the most underreported concerns amongst combat veterans returning from armed conflicts in Iraq and Afghanistan; despite being reported in low numbers, the rate of medical visits with accounts of subsequent side effects and secondary complaints is quite high, surpassing the diagnosis rate. The purpose of this review is to highlight potential treatment concerns, associated mechanisms and causation across the post-9/11 veteran cohort as supported by evidence-based statistical data and qualitative research.

Incontinence – clinically speaking is the loss of bladder control – an embarrassing concern for adults, especially those of the younger age. However, statistically speaking, very rarely in the younger population is incontinence or bladder control issues related to the organ functionality of the genitourinary system. Holistically speaking, the human body is interconnected and offers a cascading, domino-like effect, meaning if your brain is in recovery (post-injury) or your spinal cord is pressing on your sciatic nerve, the adverse effects can (and will) travel to supporting organ systems, such as the kidneys and bladder for example. Statistically speaking, men younger than 55-years who have deployed to Iraq/Afghanistan are “three-times” more likely to report urinary incontinence as compared to their non-military, civilian counterparts. Like males, approximately one-in-five recently deployed female veterans report “overactive bladder” symptoms, including those of incontinence. While both genders reported psychological conditions to include depression, anxiety and post-traumatic stress which seems to have a significant impact on urinary issues; it is not the only cause of this disconcerting condition. To fully examine this condition, physiological, psychological, and physical factors will be evaluated and approaches to treatments.

Physiologic function is how the bodies’ systems relates to each other. Physiologic incontinence can characterized by urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical stressors on the abdominal cavity and, thus, the bladder, this is most common in women who’ve given birth.

Psychological function is how the emotional state of mind impacts the bodies’ functioning. As it is understood, specifically in women with co-morbid conditions like depression and anxiety, as well as males with post-traumatic stress (n = 26 yrs. median), incontinence is more likely to occur despite not knowing the association mechanism. There are various potential relatives affecting the genitourinary system: adrenal fatigue, elevated “fight-or-flight” reaction and common medications prescribed for mental health concerns.

During a chart review of 381 Afghanistan and Iraq Veterans who’ve returned from combat within one year and suffered an injury reported an average of 61 outpatient medications and a large number of those medications have been proposed as possible causes of drug-induced urinary incontinence, to include alpha1-adrenoceptor antagonists, antipsychotics, benzodiazepines, antidepressants, and drugs used for hormone replacement therapy: specifically testosterone. Since most drugs are frequently metabolized in the kidneys and excreted in the urine, the lower urinary tract is particularly vulnerable to adverse effects.

Furthermore, carcinogens or inflammatory agents (from either medications or environmental toxins) in the urine are near the epithelium for prolonged periods when they are stored in the bladder. The drugs may cause stress or urge incontinence. In addition to medication-related incontinence, those who suffer from poorly managed or untreated chronic stress, anxiety or depression face the downslope of the military performance curve, leading to “adrenal fatigue”. Majority of individuals do not realize their chronic stress activates their brain’s HPA-axis, hypothalamus, releasing a corticotropin hormone throughout the bloodstream. The hormone cascade releases ACTH which binds to the “adrenal cortex” slightly above the kidneys bilaterally thus releasing the stress hormone cortisol. Normally, this system acts as a negative-feedback loop, but with prolonged, chronic stress, adrenal fatigue occurs, and the autonomic nervous system continues to release epinephrine causing increased activity in and around the kidneys and epinephrine impacting urinary production. Evidence has shown chronic stress is a direct impacting factor for nighttime urination.

Let’s talk physical. Your body is connected in functionality by your spine. Your spine runs from your brain (as we mentioned above can have an adverse effect on urinary symptoms) into your brain stem and into your spinal cord. Numerous sections of your spinal cord control every function of human life, to include breathing, purposeful movements, sensation, and bladder control. 

Between 2002 and 2015, over 625,290 post-9/11 veterans utilized the Department of Veterans Affairs with a chief complaint of musculoskeletal “back pain”. Back pain can stem from various events and numerous reasons, physical trauma being the most common. Many veterans are unaware that a lower back injury, whether a herniated/bulging disc or pinched sciatic nerve, can greatly impact your urinary system, specifically in controlling your bladder. It is an issue often not discussed because incontinence is not a commonly seen complaint in this young, veteran population, therefore it goes unnoticed and becomes a “taboo” for treatment. 

Veterans need to understand that this is a common area of concern and can be easily managed, controlled and treated if addressed by your healthcare provider. If you are enrolled in the VA, you may be eligible for expendable incontinence supplies at no cost to you. There are provisions in the Veterans Health Administration Medical Equipment and Supplies handbook that allow a beneficiary to receive medically necessary supplies at home such as male incontinence guards, protective underwear for men or women, or other various forms of effective personal care products, like ones made by Attends. These discreet products can help veterans regain confidence and a sense of independence in their day-to-day lives. 

Made possible with support by Attends, a leading provider of high performance bladder control products to millions of American Veterans.

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