The Prevalence and Scope of Urinary Incontinence

Female urinary stress incontinence

Urinary incontinence (UI) is more common than any other chronic disease, such as hypertension, depression or diabetes, with the prevalence estimated between 9 and 74%. Among the various forms of urinary incontinence, stress incontinence (SUI) is the most prevalent (50%), with urgency incontinence (UUI) representing 11% and mixed type (MUI) 36% (3% not classified). Nowadays, the restoration of urinary continence is one of the greatest challenges for the well-being and quality of life of women. The introduction of minimally invasive surgical procedures changed the anti-incontinence surgery, leading to similar, or even better results as traditional, invasive techniques. The development of the mid-urethral slings offers a viable alternative to surgical correction of SUI. These further developments of mini-sling procedures are appropriate for local anesthesia, less traumatic, 'tension-free' (to ensure continence without obstruction), simple, rapid and repeatable. The latest minimally invasive approaches can be performed in day surgery, with clear advantages compared to traditional procedures. A novel approach through the use of vaginal laser techniques could represent an additional opportunity, as a non-invasive, outpatient method to treat SUI.

Influence of ovariohysterectomy and deslorelin acetate on the spontaneous activity of the rabbit urinary bladder in vitro

Lower urinary tract symptoms are not only a serious health problem but also a substantial sociologic issue affecting human beings and companion animals. Estrogen deficiency is considered an etiologic factor of urinary incontinence in postmenopausal women and spayed female dogs. However, insufficient effectiveness of hormonal therapy has caused an intensive search for new therapeutic options. GnRH analogs have positive clinical effects in neutered female dogs suffering from incontinence, but the mechanism of action is not known. The aim of our study was to determine the effect of long-acting deslorelin acetate on the spontaneous activity of urinary bladder sections from a rabbit model of long-term estrogen deprivation. The study was conducted on 21 female New Zealand White rabbits divided into the following groups: control group, ovariohysterectomized (OHX) group, and ovariohysterectomized group given a deslorelin acetate implant. Urinary bladders were excised immediately after sacrifice, and the spontaneous activity of dorsal and ventral strips of the bladder body was examined in organ bath chambers. The amplitude and frequency of the spontaneous contractions were evaluated. Most of the sections developed spontaneous activity. Ovariohysterectomy caused a decrease in the amplitude of spontaneous contractions of the tissues obtained only from the dorsal part of the bladder body. After OHX, the frequency was higher compared with the control group in both parts of the bladder. Deslorelin acetate did not significantly affect the spontaneous contraction amplitude but caused a decrease in the frequency in the dorsal and ventral parts of the bladder. In conclusion, long-term changes in the levels of hormones and other regulatory substances associated with the reproductive system are related to altered spontaneous activity of the urinary bladder, which may impact the symptoms of urgency and incontinence appearing in women after menopause and in female animals after gonadectomy. However, long-acting deslorelin acetate partially reverses the effect of OHX on the spontaneous activity of the bladder. This process might underlie the positive effects of GnRH analogs in incontinent spayed female dogs.

Predictors and Incidence of Urinary Incontinence in Elderly Canadians With and Without Dementia — A Five-Year Follow Up: The Canadian Study of Health and Aging

Based on the national Canadian Study of Health and Aging, the objective of this study was to determine the importance of socio-demographic and medical factors, cognitive and functional status as predictors of the development of urinary incontinence, and to estimate five-year incidence by sex and age group. Participants from the Canadian Study of Health and Aging who underwent a clinical examination in 1992 and were continent for urine at the time were followed up and their continence status was again determined in 1997. Multivariate logistic regression models with daily incontinence and daily or less than daily incontinence as the outcomes were developed separately for male (n = 306) and female (n = 520) survivors. Predictor variables were introduced in the following chunks: socio-demographic factors; cognitive status; functional status, diabetes and stroke. Five-year cumulative incidence of daily and less than daily incontinence by sex and age group was also estimated. Results indicated that the incidence of urinary incontinence was higher in women than in men, and increased by age in both men and women. Especially among men, those in institutions were much more likely to develop urinary incontinence than those in the community. Incontinence increased dramatically with severity of dementia, less so with physical immobility. Diabetes mellitus was related to the development incontinence in men but not in women, prior stroke was related to development of incontinence in both sexes. It is concluded that urinary incontinence is common in older persons, and enquiries about its presence should be part of routine medical and nursing assessment of older persons. Those who develop incontinence commonly have dementia and are physically impaired. The extent of assessment and management should be carefully tailored to each individual patient.

Introducing a new incontinence management system for nursing home residents

OBJECTIVES

To describe current practices of incontinence care in nursing homes (NHs) provided by certified nurse assistants (CNAs), and to evaluate the feasibility and acceptability of an integrated incontinence care product, the One Step Incontinence System (OSIS) in the NH setting. While the ultimate purpose of OSIS is to encourage more consistent skin cleansing and thus reduce perineal dermatitis and risk of pressure ulcers, this study reports an initial feasibility test of OSIS.

DESIGN

Controlled trial at two NH sites, with one ward at each site assigned to intervention with OSIS and one ward at each site assigned to a control condition with a box of wipes placed at the bedside (BW).

SETTING

Two NHs (one community and one Veterans Administration) in the Los Angeles area.

PARTICIPANTS

24 incontinent NH residents and 61 CNAs.

INTERVENTION

OSIS integrates an adult brief and two cleansing/protective wipes into a single item by way of a waterproof pouch that is removed at the time of incontinence care. The OSIS briefs were placed on the intervention wards in the same location(s) and adjacent to regular adult briefs.

MEASUREMENTS

Structured observations of incontinence care episodes were performed by trained research staff at baseline on all wards, and at follow-up with either the intervention (OSIS) or control condition (BW) in place. Observations included resident location, thoroughness and duration of incontinence care, and materials used. In addition, CNAs' opinions of their preferred incontinence care materials and their experience using OSIS were obtained by self-administered survey.

RESULTS

Use of OSIS resulted in significantly greater frequency of use of cleansing wipes (97% of episodes) compared to the baseline (77% of episodes) and BW conditions (41% of episodes). In 59% of the observed episodes in the BW condition, the box of wipes was actually missing from the bedside, or completely absent from the patient's room and had to be replaced. The two wipes that were incorporated with OSIS were used for perineal skin cleansing immediately when providing incontinence care. There was a significant reduction in the percentage use of and number of cloth towels used during incontinence care with OSIS (53% of episodes, 0.8 towels) compared to baseline (67%, 1.1 towels) and BW conditions (82%, 1.2 towels; p=.002 and p=.012, respectively). CNAs were significantly less often interrupted by the need to find supplies during OSIS condition (13%) compared to baseline (23%) and BW (36%; p= .005). There were no significant differences between conditions in the thoroughness of observed cleansing. The average observed time for incontinence care from putting on gloves to fastening the clean adult brief (T1) and between uncovering the resident to fastening a clean adult brief (T2) decreased significantly within both groups (OSIS and BW) at follow-up (all p-values <.05), but there were no significant differences in T1 and T2 between groups at follow-up. CNAs were more likely to report that they felt that OSIS facilitated skin cleansing compared to the BW.

CONCLUSION

We successfully implemented a trial of an innovative adult brief that encouraged skin cleansing during incontinence care. The system was easily and effectively incorporated into the nursing home, was used by CNAs whenever available (97% of the time), and was favored by CNAs. Patterns of incontinence care differed at follow-up with OSIS compared to BW, with fewer linens used, fewer wipes used, and less CNA interruption during care, which may result in greater privacy and comfort for residents.

Management of overactive bladder and urge urinary incontinence in the elderly patient

The symptoms of overactive bladder (OAB) and urge urinary incontinence may occur at any age but are particularly common among the elderly. These symptoms are associated with significant morbidity and often have a profound impact on patient quality of life. Urinary incontinence is an important contributor to the complications and economic cost of OAB for both community-dwelling and institutionalized elderly individuals. Many patients with OAB do not seek treatment because of embarrassment, fear of surgery, or the misperceptions that the problem is untreatable or is a normal and inevitable consequence of aging. Nonpharmacologic therapies improve bladder control by modifying lifestyle and behavior to prevent urine loss. This requires patient and caregiver motivation and can be time consuming. Improved results may be obtained by combining these strategies with pharmacotherapy or by means of pharmacotherapy alone. The most commonly used pharmacologic agents are the muscarinic receptor antagonists. These include oxybutynin, tolterodine, and three agents that have recently been approved for use in the United States: trospium, darifenacin, and solifenacin. In general, these therapies are well tolerated and safe; however, the selection of an optimal agent merits careful consideration. For elderly patients, important considerations include tolerability, absence of drug interactions, and the availability of a range of dosages to tailor treatment to individual patients. Primary care practitioners and geriatricians can have a key role in successful diagnosis and treatment of OAB. It is important for these physicians to realize that satisfactory outcomes may be achieved within the scope of a busy outpatient practice.

Multicenter randomized clinical trial comparing surgery and collagen injections for treatment of female stress urinary incontinence

OBJECTIVES

To compare, in a multicenter, randomized clinical trial, collagen injections versus surgery with regard to efficacy, quality of life, satisfaction, and complications.

METHODS

Of 133 women with stress urinary incontinence, 66 were randomized to collagen injection and 67 to surgery (6 needle bladder neck suspensions, 19 Burch, and 29 slings). After randomization, 15 women refused their allocated treatment. "Intent-to-treat" and "per protocol" analyses were applied. Women assigned to collagen injection could receive up to three injections before it was considered a failure. A "top-up" injection was allowed within 3 months after cure. Success as the primary outcome at 12 months was defined as a dry 24-hour pad test (2.5 g or less of urine) after having received only the allocated intervention.

RESULTS

The per protocol analysis showed that the success rate 12 months after collagen injections (53.1%) was much lower than that after surgery (72.2%). The difference was 19.1% (95% confidence interval -36.2% to -2%). The general and disease-specific quality-of-life scores measured by the Rand Medical Outcomes Study 36-item Health Survey and Incontinence Impact Questionnaire were similar in the two groups (P = 0.306). Women treated by surgery were, on average, more satisfied (79.6%) than those treated by collagen injection (67.2%), but the difference was not significant (P = 0.228). Finally, complications were less frequent and severe with collagen injection: 36 events in 23 subjects for collagen injection versus 84 events in 34 subjects for surgery (P = 0.03).

CONCLUSIONS

One year after intervention, the success rate of collagen injection as a treatment for stress urinary incontinence was about 19% lower than that after surgery. This has to be tempered by the similar changes in quality of life and satisfaction in both groups and that the number and severity of complications were much greater after surgery than after collagen injection. The results of this study indicate that collagen injections might be a worthwhile alternative to surgery for the treatment of stress urinary incontinence.

[Five-year follow-up of urinary incontinence in older people in a Spanish rural population]

OBJECTIVE

To determine prevalence, incidence and remission rates and change patterns of urinary incontinence (UI) over a 5-year time span.

DESIGN

Longitudinal study.

LOCATION

Basic Health Zone of Cabra (Cordoba).

PATIENTS

A random age-stratified sample of 827 subjects selected from a total of 5139 persons > or = 65 years of age and followed up between 1996 and 2001.

INTERVENTIONS

Home interview.

MEASUREMENTS

Questions about detection and level of severity of UI, sociodemographic data, and level of functioning. Two logistic regression models were created to identify risk factors for the probability to be alive and to develop UI, respectively.

RESULTS

UI prevalence reached 36% at baseline and 46% five years later. Mortality rates were similar in continent and incontinent subjects. 54.5% of continent subjects in 1996 remained so in 2001. Five-year incidence and remission rates were 29% and 15%, respectively. In both sexes, slight and moderate incontinence mainly progressed to moderate and severe degrees, whereas severe UI remained unchanged in 40.1%. The main risk factors for increased survival and for UI incidence were self-rated health and level of functioning.

CONCLUSIONS

Prevalence of UI is high, incidence is moderate and remission is low. Urinary incontinence is a dynamic problem and does not affect mortality. Impaired mobility has a strong influence on UI incidence.

Urinary incontinence as a predictor of death and institutionalization in a general aged population

The prognostic significance of urinary incontinence (UI) was evaluated using the Helsinki (Finland) Aging Study Database, in which a random sample of persons of three age cohorts (75, 80 and 85 years, n=649) was followed for 5 years. The prevalence rates of UI in the three age groups were 10.5%, 20.4% and 28.6%, respectively. UI was also frequent in healthy aged subjects (15.6%), but most common in hospitalized patients (35.3%), in those with severe depression (51.8%), previous stroke (37.6%) or dementia (48.8%). UI had age- and gender-adjusted risk ratios (95% C.I.) for mortality of 1.75 (1.33-2.30) and for long-term institutional care of 2.37 (1.30-3.84). However, after controlling for the presence of dementia, the risk ratios were no longer significant. Thus, UI predicts both death and long-term institutionalization in the general aged population. However, this observation is mainly explained by the close association of UI with dementia.

Urinary incontinence and psychological distress in community-dwelling older African Americans and whites

OBJECTIVES

To compare the association between urinary incontinence (UI) and psychological distress in older African Americans and whites.

DESIGN

A population-based longitudinal survey.

SETTING

Continuing participants in a study of community-dwelling adults who were initially living in East Baltimore in 1981.

PARTICIPANTS

African Americans and whites aged 50 and older at follow-up interviews performed between 1993 and 1996 for whom complete data were available (n=747).

MEASUREMENTS

Participants were classified as incontinent if any uncontrolled urine loss within the 12 months before the interview was reported. Psychological distress was assessed using the General Health Questionnaire (GHQ).

RESULTS

African Americans with UI were more likely to experience psychological distress as measured using the GHQ than were African Americans without UI (unadjusted odds ratio=4.22, 95% confidence interval=1.72-10.39). In multivariate models that controlled for age, sex, education, functional status, cognitive status, and chronic medical conditions, this association remained statistically significant. The association between UI and psychological distress did not achieve statistical significance in whites.

CONCLUSION

The effect of UI on emotional well-being may be greater for African Americans than for whites.

Neurological evaluation of urinary incontinence in the female patient

BACKGROUND

Urinary incontinence is one of the most common medical complaints of women older than 50 years of age. Understanding the anatomy and physiology is important in the diagnosis and management of these patients.

REVIEW SUMMARY

Evaluation of the incontinent patient is complicated by the frequent vagueness of the patient's complaints, complexity of anatomic pathways involved in maintaining continence, and the poor availability of specific diagnostic tests for evaluating incontinence. Close attention to specific aspects of the patient's history including type of leakage, precipitating factors, and associated symptoms can dramatically increase diagnostic yield. In addition to the routine neurologic examination, certain additional clinical testing sheds light on the site of lesion causing incontinence. Examination of tone and voluntary contraction of the anal sphincter, bulbocavernosus reflex, and the anal reflex are valuable but underused methods that can be cost-effective as a means of achieving a specific diagnosis. Electrophysiological testing may be needed as an adjunct to physical examination and includes electromyography of the anal sphincter and urodynamic testing.

CONCLUSIONS

Urinary incontinence is a problem that needs a systematic approach to the patient both in terms of specific questions and physical examination. This allows categorization of type of urinary incontinence and identification of the anatomic process. During treatment the underlying neurologic problem causing incontinence needs to be addressed. Mild incontinence may be treated by conservative measures that reduce social inconvenience. In patients for whom the problem is more severe, various pharmacologic and surgical options are available.

Effects of a controlled exercise trial on pain in nursing home residents

OBJECTIVES

To report preliminary data relevant to the effects of an exercise and toileting intervention on pain among incontinent nursing home (NH) residents.

DESIGN

A randomized controlled intervention trial.

SETTING AND PARTICIPANTS

Fifty-one incontinent residents in one skilled NH.

INTERVENTION

The intervention was implemented by research staff for a total of 4 times a day (every 2 hours), 5 days a week, for 32 weeks. Residents were provided with incontinence care and assistance to either walk or, if nonambulatory, wheel their chairs, and to repeat sit-to-stand movements.

MEASUREMENTS

Pain was measured in two ways at baseline and again at 32 weeks: (1) a count of the number of verbal expressions and pain behaviors during a standardized physical performance assessment; and (2) a modified Geriatric Pain Measure administered in a one-on-one interview format.

RESULTS

There were significant differences between intervention and control groups on all physical performance measures over time, with the intervention group remaining stable and the control group showing a significant decline in sit-to-stand, walking, and wheelchair propulsion endurance. Both groups showed mild to moderate pain at baseline according to each of the two pain measures, while there were no significant changes in pain reports between groups over time based on either measure. There was, however, a trend for pain to increase in the intervention group.

CONCLUSIONS

No significant changes in pain reports were attributable to exercise despite significant improvements in physical performance. In fact, there was a tendency for pain reports to increase with exercise. These preliminary findings suggest that exercise alone may be ineffective for pain management among incontinent NH residents. Care providers should consider that exercise to improve physical function may increase pain symptoms, requiring preemptive analgesia, other pain control strategies, or modified exercise techniques for this frail segment of the NH population.

Overactive bladder patients and role of the pharmacist

OBJECTIVES

To summarize the prevalence, quality of life (QOL) implications, cost of illness, and pharmacotherapy of overactive bladder (OAB), and to describe the pharmacist's role in the management of patients with OAB.

DATA SOURCES

Articles published between 1990 and 2001 identified through a MEDLINE search using the terms overactive bladder, unstable bladder, urinary incontinence, prevalence, cost of illness, quality of life, drug therapy, pharmacist, and pharmacy in various combinations.

STUDY SELECTION

All studies providing information on OAB or urinary incontinence were retrieved.

DATA EXTRACTION

By the authors.

DATA SYNTHESIS

Published prevalence and cost studies focus primarily on urinary incontinence, which is only one possible symptom of OAB. Reported prevalence rates of urge and mixed incontinence in the United States range from 3% to 8% and 5% to 37%, respectively, and the highest prevalence has been found in geriatric and psychogeriatric populations. Associated costs are substantial. Total costs of OAB in the United States were estimated to be $12.6 billion in 2000. Patients with OAB score lower than the general population in QOL assessments. All aspects of QOL can be compromised by OAB, as physical, social, occupational, domestic, and sexual activities are often limited in OAB patients. The pharmacist is instrumental in improving an individual's QOL through ensuring safe and effective treatment for OAB. Oxybutynin and tolterodine (Detrol-Pharmacia) have been the mainstays of pharmacotherapy for OAB, but frequent adverse effects (including dry mouth) often prevent patients from adhering to treatment. Tolterodine, now available in a new long-acting formulation, has been proven safe and efficacious in the treatment of OAB, with fewer adverse effects and better tolerability than existing agents.

CONCLUSION

Pharmacists can play an active role in helping identify and recommending interventions for OAB that can ultimately improve an individual's QOL.

Informal caregiving time and costs for urinary incontinence in older individuals in the United States

OBJECTIVES

To obtain nationally representative estimates of the additional time, and related cost, of informal caregiving associated with urinary incontinence in older individuals.

DESIGN

Multivariate regression models using data from the 1993 Asset and Health Dynamics Study, a nationally representative survey of people aged 70 and older (N = 7,443).

SETTING

Community-dwelling older people.

PARTICIPANTS

National population-based sample of community-dwelling older people.

MEASUREMENTS

Weekly hours of informal caregiving, and imputed cost of caregiver time, for community-dwelling older people who reported (1) no unintended urine loss, (2) incontinence that did not require the use of absorbent pads, and (3) incontinence that required the use of absorbent pads.

RESULTS

Thirteen percent of men and 24% of women reported incontinence. After adjusting for sociodemographics, living situation, and comorbidities, continent men received 7.4 hours per week of care, incontinent men who did not use pads received 11.3 hours, and incontinent men who used pads received 16.6 hours (P <.001). Women in these groups received 5.9, 7.6, and 10.7 hours (P <.001), respectively. The additional yearly cost of informal care associated with incontinence was $1,700 and $4,000 for incontinent men who did not and did use pads, respectively, whereas, for women in these groups, the additional yearly cost was $700 and $2,000. Overall, this represents a national annual cost of more than $6 billion for incontinence-related informal care.

CONCLUSIONS

The quantity of informal caregiving for older people with incontinence and its associated economic cost are substantial. Future analyses of the costs of incontinence, and the cost-effectiveness of interventions to prevent or treat incontinence, should consider the significant informal caregiving costs associated with this condition.

Urinary incontinence and psychological distress in community-dwelling older adults

OBJECTIVES

To examine the relationship between urinary incontinence (UI) and psychological distress in older adults. We hypothesized that persons with UI associated with condition-specific functional loss would be most likely to report psychological distress.

DESIGN

A population-based longitudinal survey.

SETTING

Continuing participants in a study of community-dwelling adults who were initially living in East Baltimore in 1981.

PARTICIPANTS

Persons aged 50 and older (n=781) at follow-up interviews conducted between 1993 and 1996 for whom complete data were available.

MEASUREMENTS

Participants were classified as incontinent if they reported any uncontrolled urine loss within the 12 months preceding the 13-year follow-up interview. Condition-specific functional loss secondary to UI was further assessed based on a series of questions relating directly to participants' inability to engage in certain activities due to their UI. Psychological distress was assessed using the General Health Questionnaire (GHQ) at interviews in 1981 and at the 13-year follow-up.

RESULTS

Persons with UI were more likely to experience psychological distress as measured by the GHQ than were persons without UI (unadjusted odds ratio (OR)=1.74, 95% confidence interval (CI)=1.13-2.68). Persons with condition-specific functional loss secondary to UI were substantially more likely to have psychological distress as measured by the GHQ than were persons without UI (unadjusted OR=4.02, 95% CI=1.86-8.70). In multivariate models that controlled for potentially influential characteristics such as age, gender, ethnicity, and chronic medical conditions the association between condition-specific functional loss secondary to UI and psychological distress remained statistically significant. Among people with UI, persons with persistently elevated GHQ scores were much more likely to report condition-specific functional impairment from UI (adjusted OR=6.55, 95% CI=1.94-22.12).

CONCLUSION

Individuals with UI, especially when incontinence was associated with condition-specific functional loss, were more likely to have psychological distress than were other older adults. Our findings support a general conceptual model that condition-specific functional impairment mediates the relationship between a chronic medical condition and psychological distress.

Anxiety disorders and disability secondary to urinary incontinence among adults over age 50

OBJECTIVE

No previous research has investigated whether there is an association between anxiety disorders and urinary incontinence. We hypothesized that anxiety disorders would be associated with increased urinary incontinence related disability.

METHOD

Continuing participants who were aged 50 years and older in a longitudinal study of community-dwelling adults who were initially living in East Baltimore in 1981 (n = 787). Participants were classified as incontinent if any uncontrolled urine loss within the 12 months prior to the interview was reported. Urinary incontinence related functional loss was further assessed based on a series of questions relating directly to participants' inability to engage in certain activities due to their urinary incontinence. Anxiety disorders were assessed with standardized interviews.

RESULTS

Persons meeting criteria for an anxiety disorder were no more likely to have urinary incontinence than were persons without anxiety disorders (unadjusted odds ratio (OR) = 1.36,95 percent confidence interval (CI) [0.96, 1.93]). Among people with urinary incontinence (n = 159), persons meeting criteria for anxiety disorders in 1981 and in 1994 were much more likely to report urinary incontinence relatedfunctional impairment in 1994(adjusted OR = 6.51, 95 percent CI [1.42, 29.86]).

CONCLUSIONS

Individuals with changes in day-to-day routines or activities secondary to urinary incontinence were more likely to meet criteria for an anxiety disorder than were other older adults. Further studies must tease out the temporal relationship and whether early detection of urinary incontinence and associated anxiety improves quality of life and functioning.

The identification of residents capable of accurately describing daily care: implications for evaluating nursing home care quality

PURPOSE

The goal of this study was to develop a method of identifying incontinent nursing home (NH) residents capable of providing accurate interview information about daily NH care.

DESIGN AND METHODS

In 177 incontinent NH residents from four facilities, selected Minimum Data Set (MDS) ratings were compared with two standardized, performance-based, cognitive screening instruments to predict which residents could accurately answer questions concerning receipt of daily incontinence and mobility care practices.

RESULTS

MDS ratings of activity of daily living performance and cognition significantly predicted residents' ability to accurately describe daily care practices. Performance-based measures of cognitive functioning did not outperform the MDS ratings. Selecting residents who scored two or more on four orientation items composing the MDS Recall subscale identified residents capable of accurately describing daily care practices with a sensitivity of 64% and a specificity of 75%.

IMPLICATIONS

The MDS-based criteria identified are a promising, objective method for selecting incontinent NH residents for interview to verify the occurrence of specific daily care practices.

An intervention to increase fluid intake in nursing home residents: prompting and preference compliance

OBJECTIVE

To evaluate a three-phase, behavioral intervention to improve fluid intake in nursing home (NH) residents.

DESIGN

Controlled clinical intervention trial.

SETTING

Two community NHs.

PARTICIPANTS

Sixty-three incontinent NH residents.

INTERVENTION

Participants were randomized into intervention and control groups. The intervention consisted of three phases for a total of 32 weeks: (1) 16 weeks of four verbal prompts to drink per day, in between meals; (2) 8 weeks of eight verbal prompts per day, in between meals; and (3) 8 weeks of eight verbal prompts per day, in between meals, plus compliance with participant beverage preferences.

MEASUREMENTS

Between-meal fluid intake was measured in ounces by research staff during all three phases of the intervention. Percentage of fluids consumed during meals was also estimated by research staff for a total of nine meals per participant (3 consecutive days) at baseline and at 8 and 32 weeks into the intervention. Serum osmolality, blood urea nitrogen, and creatinine values were obtained for all participants in one of the two sites at the same three time points.

RESULTS

The majority (78%) of participants increased their fluid intake between meals in response to the increase in verbal prompts (phase 1 to 2). A subset of residents (21%), however, only increased their fluid intake in response to beverage preference compliance (phase 3). There was a significant reduction in the proportion of intervention participants who had laboratory values indicative of dehydration compared with the control participants. Cognitive and nutritional status were predictive of residents' responsiveness to the intervention.

CONCLUSIONS

A behavioral intervention that consists of verbal prompts and beverage preference compliance was effective in increasing fluid intake among most of a sample of incontinent NH residents. Verbal prompting alone was effective in improving fluid intake in the more cognitively impaired residents, whereas preference compliance was needed to increase fluid intake among less cognitively impaired NH residents.

[Communication, diagnosis and treatment of urinary incontinence in the elderly in a basic health area]

OBJECTIVE

To investigate the frequency in which aged people who suffers on urinary incontinence (UI) talk about this problem with primary care professionals, variables related to no healthcare-seeking as well as diagnostic and therapeutic habits of these professionals.

DESIGN

Cross-sectional study.Location. Basic Health Zone of Cabra (Córdoba, Spain).

PATIENTS

A random age-stratified sample of 869 patients selected from a total of 5139 persons >= 65 years of age.Interventions. Home interview.

MEASUREMENTS

Proper questionnaire with questions about reporting of incontinence to health professionals and the procedures used for routine screening as well as diagnostic and therapeutic assessment of incontinence. A logistic regression model was elaborated to identify explanatory factors for reporting incontinence to healthcare professionals.

RESULTS

Of 330 incontinents, only 32% reported their problem to healthcare professionals. The remaining 68% did not report their incontinence because most thought it was a minor problem and/or part of the ageing process. The explanatory factors for seeking medical help were the frequency, duration and impact of incontinence, and dependence in self-care. Physicians performed routine screening for incontinence in 10% of 827 inquired aged. In 1 out of 5 incontinents, the physician did not take any diagnostic or therapeutic measures.

CONCLUSIONS

Seeking of UI medical help was very limited and depends on variables related to perception in symptom's changes. Diagnosis and treatment done by professionals was suboptimal. Severity of UI conditions diagnosis and treatment.

Prevalence of stress urinary incontinence in both sexes at or after age 15 years: a cross-sectional study

PURPOSE

We determine the prevalence of stress urinary incontinence among males and females at or after age 15 years in an education and research health district.

MATERIALS AND METHODS

During a personal interview questionnaires were given to a total of 2,053 people at or after age 15 years in an education and research health district near Ankara, Turkey. In addition to the particular questions about stress incontinence, the medical history, including congenital or acquired diseases of clinical significance, operations and details relevant to positive findings were obtained. Groups with or without stress incontinence were compared in regard to age and sex, and parity in women. Subgroups that emerged as to the presence of nocturia and/or urgency incontinence were examined in regard to systemic diseases, operations, congenital anomalies and regular medications.

RESULTS

A total of 229 people (11.1%) had stress incontinence, with a female predominance of 20.8% versus 1.0% (p <0.05). People 65 years old or older experienced stress incontinence 6.24 times more than those in the 15 to 24-year age group. In contrast, females had increasing stress incontinence prevalence by age as noted by relevant odds ratios. Stress incontinence prevalences among women in the 35 to 44 and 45 to 54-year age groups were about 39 and 35 times higher than those of men in the corresponding age groups. As expected the incontinence prevalences increased with the number of births in women. Nocturia was absent in 50.2% of all subjects, whereas 26.7% reported nocturia at all times and 23.0% had nocturia sometimes. Persistent nocturia was present in 21.1% of males and 32.1% of females. Persistent nocturia and urgency were apparently greater in patients with systemic diseases and/or those who had undergone surgery. Urgency incontinence was present in 9.7% of the entire population with a distinct female predominance of 16.3% versus 2.7%.

CONCLUSIONS

Stress incontinence occurred in both sexes at or after age 15 years with a female predominance. The prevalence of stress incontinence increases with age and parity in women. Urgency and nocturia are more prevalent in people with systemic diseases and those who have undergone previous pelvic or neurosurgical operations.

Prevalence and psychosocial impact of urinary incontinence in older people of a Spanish rural population

BACKGROUND

The prevalence and the psychosocial impact of urinary incontinence in older people of a rural population were investigated.

METHODS

A cross-sectional study was made by means of a home health interview in a representative sample of people aged 65 years and older in the Basic Health Zone of Cabra (Córdoba). A questionnaire was used with two questions to detect urinary incontinence and further questions regarding its duration, frequency, volume, severity and psychosocial impact. Data were analyzed with basic statistics. A logistic regression model was created to identify which factors affect people's lifestyles.

RESULTS

Among the 827 respondents the prevalence of incontinence reached 36% [95% confidence interval (CI): 34%-38%] and was higher (p < .001) in women (42%; 95% CI: 39%-45%) than in men (29%; 95% CI: 25%-38%). The most frequent duration of incontinence was from 1 to 5 years (16.8%). Fifteen percent had daily episodes and 10.6% estimated the volume of urine loss as high. Incontinence was severe in 9% of the affected subjects. Half the incontinent subjects expressed social limitations and negative feelings related to incontinence, and 21% admitted that incontinence negatively affected their lives. In the logistic regression model, both volume of urine loss [odds ratio (OR) = 5.61; 95% CI: 2.76-11.42] and being married (OR = 2.34; 95% CI: 1.03-5.33) were the factors statistically associated with a negative influence of incontinence on lifestyle.

CONCLUSIONS

Urinary incontinence is a very frequent symptom in our population. Half the incontinent subjects suffer from some degree of psychosocial limitation. The volume of urine loss and being married are the most important factors with psychosocial impact.

Surgical treatment of stress urinary incontinence

The treatment of stress urinary incontinence (SUI) is one of more controversial aspects of pelvic floor surgery. The indications for the surgical approach are related to the international classification as: Type 1 and Type 2 (Anatomical Incontinence), and Type 3 urinary incontinence (Intrinsic Sphincteric Dysfunction). The procedure of choice for Type 1 and Type 2 is Bladder Neck Suspension (BNS) that create a strong hammock against which the urethra can be compressed with sudden changes of abdominal pressure. Type 3 has to be treated by coaptation or compression of the deficient sphinteric unit (slings or injections). The mean cure rate after Marshall-Marchetti-Krantz is 77%, that of the Burch is 81%, and that of the Needle Suspension is 79%. Laparoscopy, Bone Anchors BNS and Tension-Free Vaginal Tape represent a promising option to the traditional techniques. The contribution of minimal invasive surgery consisting in: short recovery or possibility of day surgery, reduced trauma and pain, and success rate similar to the conventional techniques, is changing the SUI treatment.

Conservative treatment of stress urinary incontinence in women: a systematic review of randomized clinical trials

OBJECTIVE

To assess the efficacy of physical therapies for first-line use in the treatment and prevention of stress urinary incontinence (SUI) in women, using a systematic review of randomized clinical trials (RCTs).

MATERIALS AND METHODS

A computer-aided and manual search for published RCTs investigating treatment and prevention of SUI using physical therapies, e.g. pelvic floor muscle (PFM) exercises, with or without other treatment modalities, were carried out. The methodological quality of the included trials was assessed using criteria based on generally accepted principles of interventional research.

RESULTS

Twenty-four RCTs (22 treatment and two prevention) were identified; the methodological quality of the studies included was moderate and 11 RCTs were of sufficient quality to be included in further analysis. Based on levels-of-evidence criteria, there is strong evidence to suggest that PFM exercises are effective in reducing the symptoms of SUI. There is limited evidence for the efficacy of high-intensity vs a low-intensity regimen of PFM exercises. Despite significant effects of biofeedback after testing as an adjunct to PFM exercises, there is no evidence that PFM exercises with biofeedback are more effective than PFM exercises alone. There is little consistency (of stimulation types and parameters) in the studies of electrical stimulation, but when the results are combined there is strong evidence to suggest that electrostimulation is superior to sham electrostimulation, and limited evidence that there is no difference between electrostimulation and other physical therapies. In the prevention of SUI the efficacy of PFM exercises, with or without other adjuncts, is uncertain.

Variation in estimates of urinary incontinence prevalence in the community: effects of differences in definition, population characteristics, and study type

OBJECTIVES

Prevalence estimates for urinary incontinence among community-dwelling adults vary from 2 to 55%. A review of the literature was undertaken to investigate the degree to which differences in definitions of incontinence, age, and gender of the populations studied, response rates, measurement techniques, or location could explain differences in reported prevalences.

DESIGN

A literature search was conducted to locate all studies published in English reporting the prevalence of urinary incontinence in a population-based sample of adults.

MEASUREMENT

Information was abstracted for study size, response rate, type of survey, definition of urinary incontinence, and prevalence of incontinence by age group and gender. Prevalence by type of incontinence was also abstracted where available. Stratification was used to obtain prevalence estimates specific for age, gender, and frequency of incontinence. Data were examined for associations between prevalence and survey type, response rate, year, and location of survey.

RESULTS

A total of 21 studies met inclusion criteria. Stratification of reported prevalence by frequency, gender, and age substantially reduced the variation in prevalence estimates. For older women, the estimated prevalence of urinary incontinence ranged from 17 to 55% (median = 35%, pooled mean = 34%), and for daily incontinence it ranged from 3 to 17% (median = 14%, pooled mean = 12%). For older men, incontinence prevalence was estimated to be 11 to 34% (median = 17%, pooled mean = 22%), and 2 to 11% reported daily incontinence (median = 4%, pooled mean = 5%). Within studies, the prevalence of any incontinence was 1.3 to 2.0 times greater for older women than for older men. Among middle-aged and younger adults, prevalence of incontinence ranged from 12 to 42% (median = 28%, pooled mean = 25%) for women and from 3 to 5% (median = 4%, pooled mean = 5%) for men. The ratio of prevalence of any incontinence for women to men in this age group ranged from 4.1 to 4.5. Stress incontinence predominated in younger women, whereas urge and mixed incontinence predominated in older women. There was a tendency for studies using in-person interviews to report higher prevalences.

CONCLUSIONS

An accurate estimate of the prevalence of urinary incontinence depends on specifying the definition of incontinence and the age and gender groups of interest.

A study of European womens' experience of the problems of urogenital ageing and its management

OBJECTIVES

A six country Pan-European study of aspects of urogenital ageing (UGA).

METHODS

The study was carried out using a stratified random sample of 3000 women between the ages of 55 and 75 years.

RESULTS

A total of 30% suffered from UGA symptoms, of whom 60% made efforts to alleviate their UGA problems, most commonly using HRT. There were some international differences regarding womens' perceptions of HRT, sexual relationships, prevalence and treatment of UGA problems and their attitudes to them across the six European States.

CONCLUSIONS

Despite some international differences there was a generally similar experience of UGA problems across the six European populations studied, with a minority of women suffering significantly, however the distress of that subgroup highlighted the need for health professionals to appreciate the impact of UGA on those affected and to understand that many of these older women may be reticent in seeking help.

The cost-effectiveness of laparoscopic versus abdominal Burch procedures in women with urinary stress incontinence

STUDY OBJECTIVE

To evaluate the cost-effectiveness of laparoscopic versus abdominal Burch procedures in women with urinary stress incontinence (USI).

DESIGN

A historical cohort with a minimum follow-up of 1 year.

SETTING

Two tertiary, university-affiliated referral centers.

PATIENTS

Women with USI who had either a laparoscopic Burch (31 women) or an abdominal Burch procedure (31). They were matched for the type of procedure as well as any concurrent procedures.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was cure, defined as the absence of USI subjectively as described by the patient, and objectively as confirmed by urodynamic and stress tests. Cost data were extracted from hospital charts and office records. To calculate costs we assessed professional fees (physicians, nurses, nursing assistants), investigations (laboratory tests, radiology, urodynamics), drugs, capital equipment, disposable equipment, and length of stay. The cure rates were 97% and 90%, respectively. The mean duration of follow-up was 1.2 years (range 1-2.5 yrs) for a laparoscopic Burch and 2.7 years (range 1-9 yrs) for an abdominal Burch. Preliminary results showed a significant difference in cost effectiveness between the procedures. The average cost for a laparoscopic Burch was $2938.35 and for an abdominal Burch $5692.30. The higher costs for abdominal Burch were due to increased hospital stay. The cost-effectiveness ratios (cost/cure) were $3029.23 and $6324.78, respectively. Sensitivity analysis was performed to assess for robustness.

CONCLUSIONS

The preliminary results show that a laparoscopic Burch is more cost-effective than the abdominal Burch in treating women with USI.

Mobility in older patients with hip fractures: examining prefracture status, complications, and outcomes at discharge from the acute-care hospital

The purpose of this study was to examine the relationships among prefracture status, development of complications, mobility outcomes at discharge, and disposition at discharge. We singled out a case series of consecutive noninstitutionalized elderly persons hospitalized for hip fracture (ICD 820.0-820.9) at two Baltimore hospitals during 1992-1993. Data were abstracted from the medical records for the following variables: sociodemographic information, prefracture status, selected medical conditions, injury and surgical treatment, complications, functional mobility and assistance needed at discharge, and disposition. Factors associated with four complications were identified from multiple logistic regression analyses. (a) Prefracture needs for assistance with activities of daily living (ADL), and age > or = 80, were associated with the development of pressure ulcers. (b) Male gender and prefracture urinary incontinence (UI) were associated with pneumonia. (c) Prefracture UI and weight-bearing status were associated with UI after removal of an indwelling catheter. (d) Age > or = 80 was associated with urinary retention. The amount of assistance needed for mobility tasks at discharge was associated with prefracture need for assistance with ADLs, gender, weight-bearing status, and hospitals with shorter lengths of stay and fewer physical therapy sessions. Patients who were older and had shorter lengths of stay and less physical therapy were more likely to go to another health facility than directly home. Prefracture status (ADL, prefracture UI) was significantly associated with the development of complications. Prefracture needs for assistance with ADL and complications were associated with mobility outcomes at discharge. These prefracture factors have an effect on outcomes and need to be addressed in the development of critical pathways for case treatment. Specific protocols for subgroups of patients may need to be designed and evaluated.

Epidemiology of urinary symptoms in the geriatric population

As the US population ages, there is a growing need for information about the urologic health problems facing older adults. In conjunction with findings from clinical studies and basic research on biological mechanisms, the epidemiologic approach offers insights on the prevalence, etiology, and impact of these geriatric conditions. This information can provide the basis for planning health care services and intervention programs. The authors discuss trends associated with population aging and the challenges posed by the epidemiologic study of older adults. Also reviewed are current findings on the prevalence, incidence, and correlates of urinary incontinence and other common urologic symptoms.

Functional Incidental Training, mobility performance, and incontinence care with nursing home residents

OBJECTIVE

To determine if an exercise intervention, Functional Incidental Training (FIT), results in improvements in mobility endurance and physical activity when compared with prompted voiding (PV) among cognitively and mobility impaired nursing home residents.

DESIGN

Residents from four nursing homes were randomized into either a PV only (PV) or a PV plus FIT (FIT) intervention group for 8 weeks. Research staff implemented all intervention and measurement protocols.

PARTICIPANTS

Seventy-six incontinent nursing home residents completed all phases of the trial.

MEASURES

The standing, walking, and wheelchair endurance, physical activity, and frequency of agitation of all residents were assessed before, during, and after the 8-week intervention.

RESULTS

The average length of time that subjects could walk or wheel was 2.6 and 4.6 minutes, respectively, at baseline. There was a significant group x time interaction after intervention, with only the FIT group showing improvements in walking, wheelchair, and standing endurance (Manova F = 4.56, 2.62, and 5.98, respectively; P < .05 in all cases). The frequency with which agitation was observed showed a significant drop over time in both groups (F = 14.3, P < .001), with no significant group x time interaction.

CONCLUSION

The FIT intervention, which requires 6 minutes more nurses' aide time than does PV, increases both physical activity and mobility endurance in extremely frail and deconditioned nursing home residents. The increased cost of this intervention must be evaluated both in terms of clinical outcomes and by the reality that the target group for this intervention is very frail and will continue to require nursing home care, even assuming an excellent response to the intervention.

A cost and value analysis of two interventions with incontinent nursing home residents

OBJECTIVE

More than half of nursing home residents suffer from urinary incontinence. These residents typically have long stays and, because of comorbid cognitive and physical impairments, have little hope of living again in a noninstitutional environment The value of interventions to change functional status of this chronically institutionalized population is often questioned. This paper explores this value issue in the context of two incontinence management interventions that have been shown to improve functional status: (1) Functional Incidental Training (FIT), and (2) Prompted Voiding (PV). The relative value of the different interventions for the nursing home population was estimated using paired preferences.

DESIGN

The cost of two interventions (FIT and PV) that target incontinent nursing home residents was related to the value of these interventions as perceived by consumers of nursing home services. Both interventions decrease incontinence frequency, and one intervention also improves mobility endurance.

PARTICIPANTS

Ninety incontinent nursing home residents received the intervention; 37 older nondemented board and care residents and 31 family members of the nursing home residents provided estimates of the intervention's value.

MEASUREMENT

The staff-time allocations involved in implementing both interventions were documented in more than 85 resident care episodes. These time data were converted to labor cost based on the cost of nursing aides who would actually implement the intervention. The value of each intervention was assessed by asking consumers to make choices between the intervention and its associated outcomes (such as increased dryness) and other nursing home services of known cost (e.g., moving to a private room).

RESULTS

Both interventions had labor costs that were greater than "usual care" costs. The additional cost was estimated to be $4.31 per resident per day for PV and $6.42 per resident per day for FIT if these programs were implemented from 7 AM to 7 AM. Consumer preference data indicated that consumers preferred the FIT and PV outcomes to more expensive alternative services, calculated to cost $10.00 per day, often marketed to consumers,

CONCLUSION

Consumers may prefer the FIT and PV interventions relative to the typical services often marketed to the nursing home consumer. The analysis completed in this paper suggests that both interventions have value for frail residents likely to live out their lives in a nursing home.

Controlled trial evaluation of a General Practitioner education package on incontinence: use of a mailed questionnaire

OBJECTIVE

To evaluate whether an education package will significantly improve General Practitioners' knowledge of the aetiology, diagnosis and treatment of incontinence.

SUBJECTS AND METHODS

Of the 510 General Practitioners contacted 124 returned a 27 item questionnaire (q1). The doctors were randomized into a test group (n = 80) who received an education package and a control group (n = 44) who did not. Follow-up questionnaires (q2) were sent to those in the test group at 6 weeks and to those in the control group at 4 weeks post-randomization. The answers to 18 of the 27 questions were found in the education package and the remaining nine were not. The test group was asked to rate the usefulness of the package.

RESULTS

There was a mean increase in scores for the two questionnaires of 5.2 in the test group compared with 0.4 in the control group. The average increase in scores in the test group was highly significant compared with that in the control group (P < 0.001). The results remained significant when the non-responders were included. The change in scores in the test group was significant only for those 18 questions with answers contained in the education package. There was no significant improvement between the two groups for the change in scores for the nine questions not answered in the education package (P = 0.74). General Practitioners gave the package a mean rating of 4.2/5 and it was still being used more than 6 weeks after delivery by at least 31 of 49 General Practitioners.

CONCLUSIONS

For the General Practitioners who expressed an interest in receiving an education package on incontinence, and who answered the questionnaires, there was an improvement in the knowledge of incontinence directly attributable to the package.

Association between urinary incontinence in women and a previous history of surgery

In a cross-sectional study, 85% of 3114 women responded to a questionnaire on urinary incontinence and a history of abdominal, gynaecological and urological surgery. In 1987 the prevalence of urinary incontinence was 17%; 63% had undergone surgery, mainly gynaecological, and almost one-third of the respondents had had more than one operation. Bivariate and multivariate analysis showed stress urinary incontinence to be associated with previous exposure to surgery.

Parity as a correlate of adult female urinary incontinence prevalence

STUDY OBJECTIVE

The aim was to investigate the possible association between parity, as indicated by the number of childbirths, and prevalence of urinary incontinence in an adult female population sample.

DESIGN AND SETTING

A sample of 3114 women aged 30-59 years was selected at random from the population of Aarhus, Denmark, and mailed a self administered questionnaire on urinary incontinence and, among other things, parity.

PARTICIPANTS

A total of 2631 questionnaires was returned (85%) with a slight but significant decrease in respondency by age.

MAIN RESULTS

The 1987 urinary incontinence period prevalence was 17%. Seventy eight percent were parous, and 24% had had three or more childbirths. In women aged 30-44 years, the prevalence of urinary incontinence was found to be associated with parity and, in women aged 45 years and more, with three or more childbirths. In parous women 30-44 years of age, the prevalence of urinary incontinence increased with age at least childbirth and, in women aged 45 years and over, it increased with increasing parity but decreased with increasing age at first childbirth. In parous women, no association was found with time since last childbirth. Among clinical types of urinary incontinence, stress incontinence consistently showed the strongest associations with indicators of parity. In women aged 30-44 years, nearly two thirds of the 1987 prevalence of stress incontinence could be attributed to parity.

CONCLUSIONS

These findings support the hypothesis that pregnancy and childbirth are potent causes of female urinary incontinence, so that they exert considerable impact on the level of population urinary incontinence prevalence. In the individual woman, the effect seems to be cumulative and long lasting but fades with age.

Urinary incontinence: correlates among cognitively impaired elderly veterans

1. Although a range of factors can contribute to urinary incontinence in long-term care residents, it is more closely associated with a decline in both cognitive and functional status. 2. Although all subjects had to be cognitively impaired to participate in the study, the incontinent group had a significantly lower mean score on the mental status examination than did the continent group. 3. Incontinent subjects were more dependent in activities of daily living and took significantly longer to carry out functional tasks specifically related to toileting. 4. Urinary incontinence was strongly associated with a history of urinary tract infections, positive urine cultures, epididymitis, hematuria, and fecal incontinence. Medical diagnosis, medications, and affective status were not associated with the problem.

Risk factors for urinary incontinence one year after nursing home admission

Secondary data analysis was conducted from a longitudinal nursing home study to identify nonurologic risk factors for continence outcomes at 1 year after admission. Of 434 nursing home admissions, 196 subjects (45%) remained. At 1 year prevalence of incontinence was 43.8%. Age was not associated with prevalence or incidence. Risk factors identified were of male gender, urinary incontinence and poor behavioral adjustment at 2 weeks, presence of dementia and impaired mobility at 2 months. Once established, incontinence tended to persist. The data suggest types of residents who might be targeted for early preventive intervention.

Incontinence among elderly community-dwelling dementia patients. Characteristics, management, and impact on caregivers

Incontinence was identified by 36% of 184 caregivers as a problem in their care of older community-dwelling patients with dementia. Incontinent dementia patients had greater impairment of cognitive function and more frequent behavioral problems than did patients without incontinence. Burden scores were higher among caregivers of incontinent patients, but multiple regression analyses indicated that factors other than incontinence contributed more to perceived burden. Follow-up interviews revealed that incontinence had played an important role in most decisions to institutionalize among caregivers of patients who were placed in a nursing home between interviews; it rarely, however, was the primary reason. The majority of incontinent patients still residing in the community were being managed by nonspecific techniques such as diapers and toileting schedules. These data emphasize the need to educate community caregivers of dementia patients in the appropriate management of incontinence and the need for further research on methods of effectively targeting assessment and treatment strategies to this patient population.

Assessing urinary incontinence

Nursing assistants are often responsible for the difficult task of accurately observing and recording the incontinence patterns of nursing home residents. Use of the Incontinence Monitoring Record may provide nursing assistants with an easier and more comprehensive method of recording incontinence patterns. Education is an essential component in expecting nursing assistants to consistently and accurately document time, amount, and frequency of incontinence. Satisfactory inter-rater reliability can be attained through use of the Incontinence Monitoring Record with nursing assistants.

Urinary incontinence in the elderly

Urinary incontinence is a prevalent problem among the elderly and has a significant clinical, social, psychological, and economical impact. In spite of these consequences, often very little is done to evaluate the problem. Furthermore, patients may be reluctant to bring their complaint to the attention of their health care provider. This broad review will discuss the anatomy, physiology, and pathophysiology of urinary incontinence. The initial evaluation and treatment options will also be outlined. As the aged population continues to grow, physicians can expect to see this problem with greater frequency. It is hoped that this discussion will facilitate the evaluation and management of this common but frequently neglected problem.

Urinary incontinence: medical and psychosocial aspects

Recognition has been growing over the past two decades that urinary incontinence is a rather widespread condition among older adults. Prevalence rates of about 30% for any incontinence and about 5% for severe incontinence among older adults were suggested by several European studies and have recently been confirmed by American studies. The rates are typically higher among women than men. Despite these findings, much about the true distribution of urinary incontinence remains to be firmly established. The proportion of different types and the differences between sexes, ages, and races need to be confirmed using representative population samples and valid measures of incontinence. These distributions cannot be accurately described using clinical populations. Perhaps because urinary incontinence is viewed as highly embarrassing, it has not been a focus of media coverage or public discussion. More attention by the media and by health-care professionals would build public awareness of the condition. Older adults and their caregivers need to know that urinary incontinence is common and treatable, so that they will identify it promptly and bring it to their physicians' attention. Health-care providers and social workers must also be alert to the possibility of incontinence among their clients. They should be prepared to ask older patients directly, because many patients may disregard urine loss or be too embarrassed to mention it. Currently, much of the management of urinary incontinence appears to be self-devised. Many incontinent persons have not talked to a physician about their problem. The largest proportion of those who attempt to control their urine loss use absorbent products or try to avoid loss by awareness of toilet locations and frequent toileting. Reliance on these methods is unfortunate because much progress has been made in developing diagnostic and treatment procedures for urinary incontinence. For example, surgical procedures to rectify an incompetent sphincter have been shown to be effective and are generally accepted. There are a number of medications effective for controlling detrusor instability. Further, various behavioral techniques appear to be promising as noninvasive initial interventions for many patients. We are on weaker ground regarding the prevention of and early intervention in urinary incontinence. The existing epidemiological data on the development of incontinence are poor. We do not know the proportion of urinary incontinence that is transient and the proportion that is chronic or established. Nor do we know the risk factors for onset and progression of the condition.(ABSTRACT TRUNCATED AT 400 WORDS)

Practical management of urinary incontinence

A comprehensive evaluation of incontinence using office-based techniques may discover reversible problems such as delirium, urinary infections, vaginitis, depression, drug effects, endocrinologic causes, immobility, or impaction. Treatment of these causes may alleviate incontinence. Bedside urodynamics are a sensitive, specific, and useful office-based technique that can identify detrusor instability, overflow incontinence, or stress incontinence. Low urinary flow rate, difficulty with catheterization, slow bladder filling or severe urgency, bladder capacity over 600 ml, and post-void residual over 150 ml need referral. Patients with hematuria, recurrent infections, recent surgery or pelvic irradiation, and pelvic or prostatic masses also need further evaluation. A number of medical and behavioral therapies are available for stress incontinence and detrusor instability that can substantially reduce incontinence, but most patients with overflow have more complicated problems requiring further evaluation, surgery, or long-term bladder drainage.