AAPB White Paper
Urinary Incontinence in Adults in Baltimore, MD
Joan A. Coxe, R.N. Andrea J. Sime, A.C.S.W. Carol J. Schneider, Ph.D.

Urinary incontinence, the involuntary loss of urine so severe as to have social and/or hygienic consequences, is a major clinical problem and a significant cause of disability and dependency. Urinary incontinence affects all age groups and is particularly common in the elderly. At least 10 million adult Americans suffer from urinary incontinence, including approximately 15 to 30 percent of community-dwelling older people and at least one-half of all nursing home residents.

The most common treatments include pelvic muscle exercises and other behavioral treatments, local and systemic drug therapies, and a variety of surgical approaches.

The number of patients with urinary incontinence who are not successfully treated remains surprisingly high. This is due to several factors, including underreporting by patients; underrecognition as a significant clinical problem by health providers; lack of education of health providers regarding new research findings; inadequate staffing in the long-term care setting; and the persistent major gaps in our understanding of the natural history, pathophysiology, and most effective treatments of the common forms of urinary incontinence. Current research shows that most cases of adult urinary incontinence can be improved or cured with a comprehensive approach involving health professionals from multiple disciplines.

Behavioral techniques increase the patient's awareness of the lower urinary tract and environment and can enhance control of bladder and pelvic muscular function. Such techniques require the client's active participation. The techniques do not have side effects and do not limit future treatment options. They do require time, effort, and continued practice. Some patients become dry, while a larger number experience important reduction of wetness, and others receive no benefit. Those who appear to benefit most are highly motivated individuals without cognitive deficits. Men and women with stress and urge incontinence have benefitted, whereas patients with severe sphincter damage (such as in postradical prostatectomy with constant leakage) generally do not benefit. Those unwilling to have surgery or medications for urinary incontinence find a combination of biofeedback and other behavioral strategies such as bladder training helpful. Containment products such as adult diapers should be the last resort after a diagnosis and full treatment trial.

The AHCPR recommends "the least invasive and least dangerous procedure that is appropriate for the patient should be the first choice (of treatment). For many forms of urinary incontinence, behavioral techniques meet these criteria" (Urinary Incontinence Guideline Panel, 1992, p. 27). Commonly employed techniques include:

Pelvic muscle exercises strengthen the voluntary periurethral and pelvic floor muscles, the contraction of which exerts a closing force on the urethra. These techniques have been emphasized for women with stress incontinence but appear to be useful in men as well. Benefit has been reported in up to 90 percent of women, but criteria for improvement differ among studies. Patients with mild symptoms may improve most. Continued exercise is required for continued benefit. Pelvic muscle exercises have been demonstrated to be helpful for improving urge incontinence also, although the exact mechanism is still unknown.

Biofeedback is a learning technique to exert better voluntary control over urine storage and elimination. Biofeedback uses visual or auditory instrumentation to give patients moment-to-moment information on how well they are controlling the sphincter, detrusor, and abdominal muscles. After such training, successful patients typically learn to perform the correct responses relatively automatically. Patients with urinary incontinence are trained to relax the detrusor and abdominal muscles and/or contract the sphincter, depending upon the form of incontinence. When used in patients with stress and/or urge incontinence, biofeedback has been shown to result in complete control of incontinence in approximately 20-25 percent of patients and to provide important improvement in another 30 percent. There are two caveats: the degree of improvement is variable, and long-term follow up data are not available. The sophisticated equipment and training used in biofeedback therapy enhance learning. About half the women given verbal instruction for pelvic muscle exercises (Kegels) practice incorrectly and could benefit from biofeedback. See Wheeler and Burgio references.

Bladder training instructs patients to void at regular short intervals, usually hourly during the day, and then at progressively longer intervals of up to 3 hours over a training period of a few to a dozen weeks. Bladder training appears to be effective in reducing the frequency of stress and urge incontinence. Studies have indicated cure rates of 10-15 percent and improvement in 75% of patients (Urinary Incontinence Guideline Panel, 1992, p. 57). Bladder training is the only non-drug treatment for urge incontinence. There is no surgical treatment for urge incontinence.

Behavioral techniques in the nursing home. For institutionalized elderly, almost any consistent attention to the problem, including bladder training and frequent scheduled checks for dryness appears to reduce incontinence in at least some patients. Another technique applicable in the nursing home is prompted voiding, in which frequent (1 to 2 hourly) checks for dryness are made, reminding the patient to void and praising success.

When behavioral techniques do not achieve the desired result, pharmacologic treatment can be initiated. Surgical treatment is an option for certain types of stress incontinence and can follow an extensive diagnostic work-up including urodynamic studies. Overflow incontinence due to prostatism and urge incontinence due to carcinoma of the bladder or prostate must be recognized and treated promptly. In patients with mixed incontinence, a combination of behavioral techniques, pharmacotherapy, and surgery may be helpful.

Conclusions:

Urinary incontinence is very common among older Americans and is epidemic in nursing homes.

• Direct costs reported January, 1994, at the Multispecialty Nursing Conference on Urinary Incontinence by Dr. Teh-wei Hue (of the AHCPR) are $19 billion yearly, based upon the 1992 dollar.

• Urinary incontinence is not part of normal aging, but age-related changes predispose to its occurrence.

• Urinary incontinence is embarrassing and leads to social isolation.

• Of the 10 million Americans with urinary incontinence, more than half have had no evaluation or treatment.

• Contrary to public opinion, most cases of urinary incontinence can be cured or improved.

• Many health care professionals are unfamiliar with evaluation, diagnosis and treatment of urinary incontinence. Curriculum development is needed to correct this deficit.

• A major research initiative is required to improve assessment and treatment for Americans with urinary incontinence.

• Acknowledgment to NIH/NIA should observe pioneering work by Burgio; acknowledgment is extended to AHCPR (Dept. of Health and Human Services) whose 1992 guidelines recommend behavioral therapy as treatment of first choice for urinary incontinence.