Emotional Factors in StressIncontinence

P. ABOULKER and L. CHERTOK

Diurnal orthostatic incontinence is considered to be an organic disorder and is mostfrequently treated surgically. There is in the literature not a single instance in whichany lefeience is made to the role of emotional factors in this disturbance.

The case presented is a classic case of stress incontinence. Since childhood thepatient had always been incontinent when coughing, exeiting herself, or running Afterseveral operations her symptoms worsened, the incontinence being almost completeand activity entirely precluded Nocturnal enuiesis also appeared

Psychological investigation revealed emotional immaturity after an unhappy child-hood with many fiustrations. There was no oppoitunity for deeper psychological treat-ment and supportive psychotherapy aided by hypnosis for symptom removal was used.

The symptoms disappeared, the patient was able to return to social life and was stillactive 3 years latei.

J-N THE VAST literature on enuresis thereis almost universal agreement that it is es-sentially a psychogenic disorder. Diurnalorthostatic incontinence, on the otherhand, is considered to be an organic dis-order, and is most frequently treated sur-gically. We have not found a single ref-erence to the role of emotional factors inorthostatic incontinence.* We have there-fore felt it of value to report the followingcase, in which the possible importance ofemotional factors in orthostatic inconti-nence is clearly indicated.

From the Department of Urology, HopitalCochin, Paris, "France

Translated by D. Graham and revised by theauthors.

Received for publication December 4, 1961.*Even O. Schwartz, urologist and psycho-

therapist, in Psychogenese mid Psychotherapie,Korperlicher Symptome, his epoch-making workwhich was the first "psychosomatic" book (1925),does not list stre;>s incontinence among the psy-chogenic disorders.

Case Report

Mme. B., aged 24, entered the departmentof urology on Apr. 15, 1958, for urinary in-continence. Since childhood, she had been in-continent when coughing, exeiting herself, oirunning, but had been quite continent whenstanding and when lying still. Her symptomswere aggravated after a delivery in 1953. Shehad had several operations which failed andher symptoms worsened. Aftei a bilateraloophorectomy in 1955, incontinence began tooccur during rapid walking, and even some-times while she was standing. In 1957, a sub-total hysteiectomy was followed by almostcontinuous incontinence, total in the standingposition and partial in the recumbent position.In November 1957, the patient underwent ab-dominal hysteropexy of the uterine stump andnarrowing of the neck of the bladder by thevaginal route, and in January 1958, abdominalcervicocystopexy. After these four operations,all by the same suigeon, urinary incontinencewas almost complete, and activity entirely pre-cluded. Nocturnal enuresis also appeared.

507

STRESS INCONTINENCE

The clinical examination showed that a stressincontinency existed, characterized by slightprolapse of the uretra with slight bulging ofthe bladder neck, and by the urinary emissionwhen the patient was straining, coughing, orsneezing. A cystoscopic examination showednothing abnormal. Urinalysis was normal. AnX-ray examination showed the bladder neckto have a funnel-like shape (Fig. 1). Therewas no sign of neurological diseases.

As soon as she entered the hospital, the noc-turnal enuresis disappeared and incontinenceduring 'the day improved. An interview withthe patient revealed emotional immaturity.Mme. B. had had an unhappy childhood andhad been subject to many frustrations. Al-though she was married and the mother of achild, she was completely frigid. In 1956, shewent to a psychiatric hospital, complaining of"nerves," but this was not followed up. Herfather had died of delirium tremens, her grand-mother had been certified, and a brother of28 and a female cousin of 26 were entireties.

There was no opportunity for a psychologi-cal investigation at a deeper level. Treatmentby suggestion was decided upon, the patientbeing a good subject for hypnosis. Posthypnoticsuggestions of symptom removal were given.

Apart from suggestion, a supporting and in-vigorating attitude was adopted. This gratify-ing measure, in a patient who had a multitudeof frustrations in her childhood, had a particu-

FIG. 1. Intravenous urugrum made with pa-tient supine. Note funnel-like shape of bladderneck.

larly beneficial effect. On the evening of thefirst hypnotic session, she wet her bed, but wascontinent during the day. She left the hospitalon April 26 and was followed up by the hos-pital psychosomatic clinic. During the weekfollowing her release from hospital, she wasstill enuretic on several nights, but had nofurther diurnal incontinence. When seen sev-eral weeks later, she no longer had any trouble.Surgical treatment for the stress incontinencewas then abandoned.

The patient was seen again on July 22. Shehad had no trouble, diurnal or nocturnal, for6 weeks. Her habitual irritability, however,had increased, without yet reaching a disturb-ing level, and she said that she sometimes feltlike "breaking everything." She added that sofar she preferred these "rages" to her urinarytrouble.

After this, she attended clinics irregularly,and was under no pressure in this respect (psy-chotherapy "on demand"). The patient hadseveral hypnotic sessions during her stay in thehospital (from April 15-26). From her dis-charge until October 6 she was seen 5 times; 2times hypnosis was used and then only suppor-tive psychotherapy. On October 6, she nolonger had any urinary trouble, and her "rages"had disappeared. She therefore broke off treat-ment and resumed her professional duties,which had been interrupted for several years.

She was asked to return Feb. 9, 1959, butdid not appear, writing to say that she washaving a radiological examination of the gall-bladder. She was seen on April 14. She hadhad no more urinary trouble, the results of thegall-bladder examination had been negative,and she was still working. Those who knewher, and in particular her husband, have grad-ually been getting used to her recovery, whichthey regard as miraculous.

The patient was seen again on Mar. 18,1960, that is, about 2 years after she first en-tered the hospital. She was still free fromurinary trouble, and her life had undergone atransformation. After resuming work, she hadfound an employer who had helped her to findan apartment, and she had been able to leavea railway coach in which she had been livingwith her family.

The patient was visited on May 31, 1961,when she was free of incontinence symptoms.Results of the clinical examination were-nor-mal. There was no stress incontinence when

PSYCHOSOMATIC MEDICINE

ABOULKER & CHERTOK 509the patient strained or coughed, and theie wasno bulging of the urethra. At X-ray examina-tion, the funnel-like shape of the bladdei neckwas still seen.

Discussion

Several lessons may be learned fromthis case. From the point of view of urol-ogy, the use of psychotherapy enabledmore precise diagnosis. The patient hadtwo complaints, diurnal incontinence andnocturnal enuresis. Diurnal or so-calledorthostatic incontinence is attributed toinadequate functioning of the sphincter,induced by the traumata of childbirth orpostmenopausal involution, or in excep-tional cases, to a congenital partial sphinc-teral aplasia. Its characteristic is that itappears with effort, and disappears whenthe patient is lying down. It consists ofinvoluntary loss of urine without micturi-tion. This is an organic disorder, the sur-gical treatment of which consists of mus-cular restoration or the re-establishmentof normal anatomical connections. Ourpatient's diurnal incontinence showed allthe features of this organic disorder. Thefailure of the plastic operations (and suchfailures are not exceptional) cannot beconsidered as evidence against organicorigin.

Nocturnal enuresis is a matter of activemicturition which is nevertheless involun-tary and unconscious, and is generally re-garded as psychogenic.

It is well known that the features ofany organic illness may be modified byemotional factors. This was the case withour patient, since the diurnal inconti-nence was overcome by psychotherapy.Even if the incontinence were to return,it remains true that this symptom, whichhad been present since childhood, wasremoved for 3 years by psychotherapy.

From the point of view of surgerv. thiscase reminds us of the importance of clini-

cal analysis of the symptoms, and of thepotential advantage of a psychological in-vestigation for patients who have under-gone several unsuccessful operations.

From the point of view of psychother-apy, the treatment had two kinds of effect.In the first place, as has already been said,it enabled an exact diagnosis to be made.Second, it had a psychotherapeutic effect.At this point we come up against themuch-debated question of the treatmentof symptoms in a way which causes thesymptom to disappear but runs the riskof inducing substitute symptoms. This isa complex question which cannot be dis-cussed in detail. It is enough to say thatour patient was not available for depththerapy aimed at "restructuring" the per-sonality. Substitute symptoms do seem tohave appeared; the patient's rages maybe interpreted as signs of "psychologicalaggression" replacing "urethral aggres-sion." Her preoccupation with her gall-bladder may also be interpreted as a sub-stitution mechanism, the gallbladder re-placing the bladder. Although psycho-logical equilibrium before and after treat-ment cannot be measured, the resultsachieved in this case may surely be re-garded as positive. The psychotherapywhich the patient received cannot be re-garded as having brought about a perma-nent cure, since the deep .conflicts havenot been resolved, and there has been nofundamental restructuring of the person-ality; but the gratification of deep uncon-scious needs may sometimes activate ina beneficial way certain psychodynamicprocesses (regression in the service of theego), even though we cannot explain thedetails of the mechanism.1

In this case the patient abandoned asymptom which provoked invalidism. and"contented herself" with certain substi-tute symptoms which presented a lesserhandicap and allowed her to return tosocial life, with the emotional gratifica-tions which it provides.

VOL XXIV, NO. 5, 1962

510Summary

A case is reported of a 24-year-oldwoman suffering from diurnal orthostaticincontinence. In spite of several repara-tive operations, there was no improve-ment, and professional activity was com-pletely impossible. Psychotherapy re-moved the urinary symptoms, and the pa-tient was able to return to social life. Shewas still active 3 years later. The case is

STRESS INCONTINENCE

a good example of the importance of emo-tional factors in stress incontinence.

L.C.22 Rue LegendreParis 17e, France

Reference1. GILL, M., and BRENMAN, M. Hypnosis

and Related States: Psychoanayltic Studiesin Regression. Internal.. Univ. Press, NewYoik, 1959.

Society for the Scientific Study of SexThe Fifth Annual Meeting of the Society for the Scientific Study of Sex will be

held at 9:30 A.M. on Saturday, Oct. 20, 1962, in the Barbizon Plaza Hotel, 106 Cen-tral Park South, New York, N. Y.

PSYCHOSOMATIC MEDICINE