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Dr. Andre A. Kulisz
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Urinary Incontinence -- US Government Wiew
Urinary Incontinence (*)
(*)Urinary Incontinence in Adults: Acute and Chronic Management, U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research
UI is a voiding dysfunction that affects approximately 13 million Americans, with the highest prevalence in the elderly in both community and institutional settings (National Kidney and Urologic Diseases Advisory Board, 1994). The high prevalence of UI and its significant adverse physical, psychological, and financial effects clearly justify more aggressive efforts to identify, evaluate, and treat UI in all settings. Growing evidence indicates that appropriate management can reduce the morbidity and cost of UI, particularly in institutionalized populations (Ouslander, Palmer, Rovner, et al., 1993).
Although the prevalence of UI increases with age, UI should not be considered a normal part of the aging process. Reported prevalence rates of UI vary considerably, depending on the population studied, the definition of UI, and how the information is obtained (Diokno, Brock, Herzog, et al., 1990). Among the population between 15 and 64 years of age, the prevalence of UI in men ranges from 1.5 to 5 percent and in women from 10 to 30 percent (Burgio, Matthews, and Engel, 1991; Harrison and Memel, 1994). Although UI is usually regarded as a condition affecting older multiparous women, it is also common in young, nulliparous women, particularly during physical activity (Bo, Maehlum, Oseid, et al., 1989; Nygaard, Thompson, Svengalis, et al., 1994).
For noninstitutionalized persons older than 60 years of age, the prevalence of UI ranges from 15 to 35 percent, with women having twice the prevalence of men. Between 25 and 30 percent of those identified as incontinent have frequent incontinence episodes, usually daily or weekly (Burgio, Matthews, and Engel, 1991; Diokno, Brock, Brown, et al., 1986).
Survey data from caregivers of the elderly show that approximately 53 percent of the homebound elderly are incontinent (Noelker, 1987). A random sampling of hospitalized elderly patients identified 11 percent as having persistent UI at admission and 23 percent at discharge (Palmer, McCormick, Langford, et al., 1992).
UI is generally recognized as one of the major causes of institutionalization of the elderly. Among the more than 1.5 million nursing facility residents, the prevalence of UI is 50 percent or greater, with the majority of nursing home residents having frequent UI (Ouslander, Kane, and Abrass, 1982; Palmer, German, and Ouslander, 1991). The annual incidence of UI in nursing home residents who are admitted continent was recently reported to be 27 percent and is higher in males; it is strongly associated with dementia, fecal incontinence, and inability to walk and transfer independently (Ouslander, Kane, and Abrass, 1982; Palmer, German, and Ouslander, 1991).
UI imposes a significant psychosocial impact on individuals, their families, and caregivers. UI results in a loss of self-esteem and a decrease in ability to maintain an independent lifestyle. Dependence on caregivers for activities of daily life increases as incontinence worsens. Consequently, excursions outside the home, social interaction with friends and family, and sexual activity may be restricted or avoided entirely (Grimby, Milsom, Molander, et al., 1993; Harris, 1986; Noelker, 1987). Quality-of-life and symptom distress questionnaires for women with UI have been validated for use (Shumaker, Wyman, Uebersax, et al., 1994; Uebersax, Wyman, Shumaker, et al., 1995).
Fewer than half of individuals with UI living in the community consult health care providers about the problem (Burgio, Ives, Locher, et al., 1994). The reasons for this could be the availability of absorbent products, low expectations of benefit from reporting the condition to health care providers, and lack of information regarding management options. There is a lack of understanding about UI, especially among men, those age 85 or older, and those with lower levels of education (Branch, Walker, Wetle, et al., 1994).
Studies show significant variation in performance of adequate examination, assessment, and management of UI. UI is often undetected and underreported by hospital and nursing home personnel, masking its true extent and clinical impact and reducing the opportunity for effective management. Assessment tools with cue words for continence status significantly improve identification of UI in nursing homes and increase the opportunity for effective management (Palmer, McCormick, Langford, et al., 1992).
The incidence of incontinence is sufficiently high that the development of an effective prevention program would reduce new cases of incontinence in community-dwelling women alone approximately 50,000 cases annually (Siu, Beers, and Morgenstern, 1993). There is good evidence that specific risk factors for incontinence can be both identified and remedied with targeted interventions. However, no controlled clinical trial data exist showing that these interventions reduce incontinence incidence, severity, or prevalence. Table 1 provides a summary of risk factors associated with incontinence that have been documented in the literature. Only one reference has been listed for each risk factor, although in most cases multiple studies have described the same factor. Several of the studies described interventions that have modified these risk factors successfully.
Risk factors associated with incontinence
| Risk Factor | Reference |
| Immobility/chronic degenerative disease | Ouslander, Palmer, Rovner, et al., 1993; Adams, Lorish, Cushing, et al., 1994 |
| Impaired cognition | Morris, Browne, and Saltmarche, 1992; Skelly and Flint, 1995 |
| Medications | Dwyer and Teele, 1992 |
| Morbid obesity | Bump and McClish, 1994 |
| Diuretics | Diokno, Brock, Herzog, el al., 1990 |
| Smoking | Bump and McClish, 1994 |
| Fecal impaction | Resnick and Yalla, 1985 |
| Delirium | Resnick, 1988 |
| Low fluid intake | Colling, Owen, and McCreedy, 1994 |
| Environmental barriers | Wyman, Elswick, Ory, et al., 1993 |
| High-impact physical activities | Nygaard, Thompson, Svengalis, et al., 1994 |
| Diabetes | Appell and Baum, 1990 |
| Stroke | Benbow, Sangster, and Barer, 1991 |
| Estrogen depletion | Burns, Nochajski, and Pranifoff, 1993 |
| Pelvic muscle weakness | Burns, Nochajski, and Pranifoff, 1993 |
| Childhood nocturnal enuresis | Moore, Richmond, and Parys, 1991 |
| Race | Burgio, Matthews, and Engel, 1991 |
| Pregnancy/vaginal delivery/ episiotomy | Foldspang, Mommsen, Lam, et al., 1992; Klein, Gauthier, Robbins, et al., 1994 |
A recent estimate of the direct costs of caring for persons of all ages with incontinence is $11.2 billion annually in the community and $5.2 billion in nursing homes (based on 1994 dollars) (Hu, 1994). This cost estimate is more than 60 percent greater than that for the cost of services in the medical care sector. Data show that costs of providing care for UI vary widely (Baker and Bice, 1995; Hu, Gabelko, Weiss, et al., 1994).
The guideline does not address specific reimbursement issues, which are being evaluated by other groups (National Kidney and Urologic Diseases Advisory Board, 1994).
Urinary Incontinence: Types, Definitions, Pathophysiology and Symptoms (**)
(**)Managing Acute and Chronic Urinary Incontinence, U.S. Department of Health and Human Services Public Health Service, Agency for Health Care Policy and Research, AHCPR Publication No. 96-0686
| Type of Urinary Incontinence | Definition | Pathophysiology | Symptoms and signs |
| Urge Incontinence | Involuntary loss of urine associated with a strong sensation of urinary urgency | Involuntary
detrusor (bladder) contractions (detrusor instability (DI). Detrusor hyperactivity with impaired bladder contractility (DHIC). Involuntary sphincter relaxation. |
Loss of
urine with an abrupt and strong desire to void; usually loss of urine on way to bathroom. DHIC-elevated post-void residual (PVR) volume. Involuntary loss of urine (without symptoms). |
| Stress Incontinence
|
Urethral sphincter failure usually associated with increased intra-abdominal pressure. | Urethral
hypermobility due to anatomic changes or defects such as fascial detachments
(hypermobility) Intrinsic urethral sphincter deficiency (ISD), failure of the sphincter at rest. |
Small
amount of urine loss during coughing, sneezing, laughing, or other physical activities. Continuous leak at rest or with minimal exertion (postural changes). |
| Mixed Incontinence | Combination of urge and stress UI. | Combination
of urge and stress features as above. Common in women, especially older women. |
Combinations of urge and stress UI symptoms as above. One symptom (urge or stress) often more bothersome to the patient than the other. |
| Overflow Incontinence | Bladder overdistention. | Acontractile
detrusor. Hypotonic or underactive detrusor secondary to drugs, fecal impaction, diabetes, lower spinal cord injury, or disruption of motor innervation of the detrusor muscle. In men -- secondary obstruction due to prostatic hyperplasia, prostatic carcinoma, or urethral stricture. In women -- obstruction due to severe genital prolapse or surgical overcorrection of urethral detachment. |
Variety of symptoms, including frequent or constant dribbling or urge or stress incontinence symptoms, as well as urgency and frequent urination. |
| Functional Incontinence | Chronic impairments of physical and/or cognitive functioning. | Chronic functional and mental disabilities. | Urge incontinence or functional limitations. |
| Unconscious or reflex Incontinence | Neurologic dysfunction | Decreased
bladder compliance with risk of vesicoureteral reflux and hydronephrosis. Secondary to radiation cystitis, inflammatory bladder conditions, radical pelvic surgery, or myelomenigocele. In many nonneurogenic cases, no demonstrable DI. |
Postmicturitional or continual incontinence. Severe urgency with bladder hypersensitivity (sensory urgency). |
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