CHAPTER 26—URINARY INCONTINENCE
THE PATHOPHYSIOLOGY OF INCONTINENCE
Urinary incontinence (UI) is a multifactorial syndrome produced by a combination of genitourinary pathology, age-related changes, and comorbid conditions that impair normal micturition or the functional ability to toilet oneself, or both.
The prevalence of UI increases with age and affects women more than men (2:1) until age 80, after which men and women are equally affected. Of persons aged 65 years and over, 15% to 30% in the community and at least 50% in long-term care are incontinent. UI may cause morbidity, including cellulitis, pressure ulcers, urinary tract infections, falls with fractures, sleep deprivation, social withdrawal, depression, and sexual dysfunction. UI is not associated with increased mortality. UI impairs quality of life, affecting the older person’s emotional well-being, social function, and general health. Incontinent persons often manage to maintain their activities, but with an increased burden of coping, embarrassment, and poor self-perception. Caregiver burden is higher with incontinent older persons, which can contribute to decisions to institutionalize. Estimated annual UI-related costs total more than $26 billion.
The detrusor contracts via parasympathetic nerves from spinal cord levels S2 to S4 (sacral micturition center). Urethral sphincter mechanisms include proximal urethral smooth muscle (which contracts by sympathetic stimulation from spinal levels T11 to L2), distal urethral striated muscle (which contracts via cholinergic somatic stimulation from the sacral micturition center), and musculofascial urethral supports. In women, these tissues form a two-layered “hammock” that supports and compresses the urethra when abdominal pressure increases. Micturition is coordinated by the central nervous system: parietal lobes and thalamus receive and coordinate detrusor afferent stimuli; frontal lobes and basal ganglia provide signals to inhibit voiding; and the pontine micturition center integrates these inputs into socially appropriate voiding with coordinated urethral relaxation and detrusor contraction until the bladder is empty. Urine storage is under sympathetic control (inhibiting detrusor contraction and increasing sphincter tone), and voiding is parasympathetic (detrusor contraction and relaxation of sphincter tone).
Especially in older persons, incontinence may not reflect abnormal micturition physiology. Continence also depends on the ability to toilet oneself—requiring physical function, cognition, motivation, and toilet availability—and the absence of medical conditions, medications, or other factors that affect lower urinary tract function, volume status, and urine excretion. Table 26.1 and Table 26.2 list the mechanisms by which these conditions may impair continence. Evaluation and correction of these factors are crucial in the care of older persons with UI.
Age-related changes in the lower urinary tract (Table 26.3) are found in both continent and incontinent older persons. Why some older persons develop UI and others do not remains unclear; differences in lower urinary tract and other compensatory mechanisms may play a role.
Risk factors in community-dwelling older persons include advanced age, parity, depression, transient ischemic attacks and stroke, heart failure, fecal incontinence and constipation, obesity, chronic obstructive lung disease, chronic cough, diabetes mellitus, impaired mobility, and impaired activities of daily living. Among institutionalized older persons, UI is associated with impaired mobility, depression, stroke, diabetes mellitus, and Parkinson’s disease; at least one third have multiple conditions. Although moderate to severe dementia is associated with UI, even severely demented persons remain continent if they have mobility for transfers. Thus, UI in demented persons may not be caused by dementia but may be a multifactorial epiphenomenon with treatable causes.
Urge UI is the most common type in older persons. It is characterized by abrupt urgency, frequency, and nocturia; the volume of leakage may be small or large. Urge UI is associated with uninhibited bladder contractions—detrusor overactivity (DO)—that may be age related, idiopathic, secondary to lesions in central inhibitory pathways (eg, stroke, cervical stenosis), or due to local bladder irritation (infection, bladder stones, inflammation, tumors). Because DO is found in healthy, continent older persons, failure of lower urinary tract and functional compensatory mechanisms may play an important role in urge UI. Distinctions between neurogenic DO (due to central nervous system lesions) and idiopathic DO are commonly blurred in the older person with comorbidity. Less common causes of urge UI are interstitial cystitis (urge UI with otherwise unexplained pelvic pain) and spinal cord injury, which results in impaired detrusor compliance (excessive pressure response to filling), detrusor-sphincter dyssynergia, or both. Stress maneuvers may trigger DO; with such stress-related urge UI, leakage occurs after a several-second delay following the stress maneuver.
DO may coexist with impaired detrusor contractility (detrusor hyperactivity with impaired contractility, or DHIC), characterized by urge UI with an elevated postvoid residual (PVR) volume in the absence of outlet obstruction. DHIC accounts for most established UI in frail older persons. Women with DHIC can be misdiagnosed with stress UI if weak DHIC contractions are not detected, and men misdiagnosed with outlet obstruction because of the similarity of the symptoms (urgency, frequency, weak flow rate, and elevated PVR).
Stress UI, the second most common type of UI in older women, results from failure of the sphincter mechanisms to preserve outlet closure during bladder filling. Leakage is due to impaired pelvic supports or, less commonly, failure of urethral closure. The latter occurs with trauma, scarring from anti-incontinence surgery, severe urethral atrophy in women, and post-prostatectomy in men. Unlike the episodic leakage of “genuine” stress UI, this leakage is typically continual and can occur while the person is sitting or standing quietly. Many women may have mixed UI, with both stress and urge symptoms.
So-called “overflow” UI results from detrusor underactivity (impaired contractility), bladder outlet obstruction, or both. Leakage is typically small in volume but continual. The PVR volume is high, and symptoms may include dribbling, weak urinary stream, intermittency, hesitancy, frequency, and nocturia. Associated urge and stress UI may occur. Rarely, continual leakage is due to extraurethral incontinence (eg, vesicovaginal fistula).
Outlet obstruction is the second most common cause of UI in older men; most obstructed men, however, are not incontinent. Causes include benign prostatic hyperplasia, prostate cancer, and urethral stricture. In women, obstruction is uncommon and usually due to previous anti-incontinence surgery or a large cystocele that kinks the urethra.
Detrusor underactivity causing urinary retention and UI occurs in only 5% to 10% of older persons. Intrinsic causes are replacement of detrusor smooth muscle by fibrosis and connective tissue (eg, from chronic outlet obstruction). Neurologic causes include peripheral neuropathy (diabetes mellitus, vitamin B12 deficiency, alcoholism) or damage to the spinal detrusor afferents by disc herniation, spinal stenosis, tumor, or degenerative neurologic disease.
UI is like many geriatric syndromes, in that its multifactorial nature requires a comprehensive diagnostic evaluation, with a careful search for all possible causes and precipitants beyond the genitourinary tract. UI management is similar to that for other chronic conditions, using a stepped approach over time. Table 26.4 provides a framework for evaluating and managing common types of UI over several visits. The sections below describe techniques.
The clinician must ask the patient about UI symptoms because 50% of affected persons do not volunteer UI symptoms. Sudden, compelling urgency suggests DO, and leakage with cough, for example, is sensitive for stress UI. Leakage with minimal maneuvers or continual urine dripping suggests intrinsic sphincter damage. Frequency, nocturia, slow urine stream, hesitancy, interrupted voiding, straining, and terminal dribbling are common with DO, DHIC, bladder outlet obstruction, detrusor underactivity, many medical conditions, and volume overload. Symptom scores (eg, the American Urological Association symptom score for benign prostatic hyperplasia) are useful as severity measures but lack specificity. Assess UI characteristics such as frequency, volume, timing, and precipitants (eg, medications, caffeine, alcohol, physical activity, cough), and associated factors (bowel and sexual function, medical conditions and medications with temporal relation to UI). Inquire how patient and caregiver quality of life are affected with respect to activities of daily living, social role, emotional and interpersonal (eg, sexual) relations, self-concept, general health perception, and the most bothersome aspect.
The general examination must include cognition and functional status. Cardiovascular examination focuses on volume status (peripheral edema, heart failure). Abdominal palpation for bladder distension is insensitive. Neurologic evaluation should include cervical signs (limited lateral rotation and lateral flexion, interossei wasting, and Hoffman’s or Babinski’s sign). Assess rectum for masses, prostate nodules or firmness, and tone (at rest and volitional, tightening around examiner’s finger). Prostate sizing by digital examination is inaccurate (see Prostate Disease). Check sacral root integrity by perineal sensation, anal “wink” (lightly scratch the perianal area and look for anal sphincter contraction), and bulbocavernosus reflex (lightly touch the clitoris or glans and look for rectal contraction). Assess vaginal mucosa and pelvic support (see Gynecologic Diseases and Disorders). Check uncircumcised men for phimosis, paraphimosis, and balanitis.
Laboratory tests include renal function and urinalysis. Pyuria and bacteriuria on urinalysis may represent asymptomatic bacteriuria (see the section on urinary tract infection in Infectious Diseases). Urine cytology and cystoscopy are indicated if hematuria or pelvic pain is present. Tests for glucose, calcium, and vitamin B12 levels are optional.
A bladder diary provides baseline UI severity, the timing and circumstances of UI and typical voided volume, voiding frequency, and the total day and nocturnal urine output (for a sample diary see http://www.healthinaging.org/public_education/bladder_control.php). In institutions, have staff record the patient’s continence status (dry, damp, soaked) every 2 hours. If nocturnal diuresis occurs, seek causes (eg, pedal edema, heart failure, or use of an alcohol “nightcap”). UI occurrence at a typical time of day suggests an association with medication, beverages, or activity.
Postvoiding residual volume (PVR) measurement is recommended. Men with a PVR volume > 200 should be screened for hydronephrosis.
A clinical stress test is best done with the bladder full, the patient relaxed, and using a single vigorous cough. It is specific for stress UI if leakage is instantaneous but insensitive if the patient cannot cooperate, is inhibited, or if bladder volume is low. If results are negative, consider repeating the test with the patient standing. On urine flow rate testing (if available), a peak flow ≥ 12 mL/sec with voided volume ≥ 150 mL excludes bladder outlet obstruction. Routine urodynamic testing is usually not needed. Precise diagnosis is most important when surgical treatment is being considered for stress UI or outlet obstruction, because surgery is ineffective for DO, DHIC, and detrusor weakness that present with similar symptoms. Geriatric UI is multifactorial, and lower urinary tract pathology is rarely the only cause. A focus on urodynamic diagnosis detracts from more relevant precipitants. Moreover, some treatments are effective for several types of UI (see the section, below, on specific treatment strategies). Urodynamics also should be considered if the diagnosis is unclear or if empiric therapy has failed. Cystometry measures bladder proprioception, capacity, detrusor stability, and contractility; carbon dioxide cystometry may be unreliable. Simultaneous measurement of abdominal pressure is necessary to exclude abdominal straining and detect DHIC. Fluoroscopic monitoring, abdominal leak-point pressure, or profilometry tests detect and quantify stress UI. Pressure-flow studies are the criterion standard for obstruction.
Correction of medical illnesses, medications, and other precipitating factors alone often improves continence. Relieving the most bothersome aspects of UI for the patient is key. A stepped strategy moving from the least to more invasive treatments should be used, with behavioral methods tried before medication, and both tried before surgery. Treatment that simply decreases the number of UI episodes may not be sufficient for persons most bothered by the timing of UI, nocturia, or leakage with exercise. Cure often requires multiple visits. Evidence for the efficacy of UI treatment is summarized in Table 26.5, Table 26.6, and Table 26.7.
General management suggestions include avoiding high fluid intake (> 2L/day), caffeinated beverages, and alcohol, and minimizing evening intake if nocturnal UI is bothersome. Constipation should be reduced. If pads and protective garments are used, they should be chosen on the basis of the patient’s gender and the type and volume of UI. Because these products are expensive, some patients may not change pads frequently enough. Medical supply companies and patient advocacy groups publish illustrated catalogs for product selection.
Behavioral treatment for urge UI employs two principles: frequent voluntary voiding to keep bladder volume low, and retraining of central nervous system and pelvic mechanisms to inhibit detrusor contractions and leakage. Cognitively intact persons can use bladder retraining, with timed voiding while awake and suppression of urgency by relaxation techniques (for patient handouts see http://www.healthinaging.org/public_education/bladder_control.php). The initial toileting frequency can be every 2 hours or based on a bladder diary (using the shortest interval between voids). When the urgency occurs, the patient is instructed to stand still or sit down, contract the pelvic muscles, and concentrate on making the urgency decrease and pass: to take a deep breath and let it out slowly, or to visualize the urgency as a wave that peaks and then falls. Once in control of the urgency, the patient should walk slowly to a bathroom and void. After 2 days without leakage, the time between scheduled voids is increased by 30 to 60 minutes until the person voids every 3 to 4 hours without leakage. Although marginal benefit is unproven, many experts believe biofeedback can improve teaching and outcomes. Successful bladder retraining usually takes several weeks; patients need reassurance to proceed despite any initial failure.
For cognitively impaired patients, behavioral methods include habit training (timed voiding, with the interval based on a person’s usual voiding schedule), scheduled voiding (timed voiding usually every 2 to 3 hours), and prompted voiding. Prompted voiding has three components: regular monitoring with encouragement to report continence status, prompting to toilet on a scheduled basis, and praise and positive feedback when the person is continent and attempts to toilet. Persons most likely to respond to prompted voiding are those with who void four or fewer times in 12 daytime hours and who toilet correctly over 75% of the time in an initial trial. These methods require training, motivation, and continued effort by patients and caregivers; special attention and staff reinforcement are needed in institutionalized settings to ensure continued treatment success.
When behavioral methods alone are not sufficient, bladder-suppressant medications can be added. The combination of behavioral and drug therapy has higher efficacy than either alone. There are now five available antimuscarinic agents. The oxybutynin (immediate-release 2.5 to 5mg mg two to four times daily; extended-release 5 to 20 mg once daily; topical patch 3.9 mg applied to abdomen, thighs, or buttocks twice weekly); tolterodine (immediate-release 1 to 2 mg twice daily, extended-release 2 to 4 mg once daily); trospium 20 mg twice daily; darifenacin 7.5 to 15 mg once daily; and solifenacin 10 to 20 mg once daily. Overall, they have similar efficacy, with some variation in adverse events (See Table 26.5). Lack of response to one agent does not preclude response to another.
Anticholinergic side effects can be bothersome (eg, constipation and compensatory fluid intake for xerostomia may exacerbate UI) but also potentially dangerous. Chronic xerostomia predisposes the patient to caries and tooth loss. Visual changes and cognitive impairment present safety issues. Although there are a growing number of case reports regarding cognitive effects, outcome studies of cognitive impairment from these agents are still under way. The PVR should be monitored if UI worsens; if high, then UI may improve when the dose is lowered. Patients with DHIC may tolerate bladder-suppressant medications if initial dose is low and titration is slow and based on symptom response; the PVR should be monitored.
These agents also differ in metabolism, drug interactions, and ease of use. Trospium should be given once daily in persons with renal insufficiency, and it needs to be taken on an empty stomach. Tolterodine is metabolized by the cytochrome P-450 pathways and interacts with drugs that induce 2D6 (eg, fluoxetine) or are metabolized by 3A4 (eg, erythromycin, ketoconazole). There are case reports of interactions between bladder relaxants and cholinesterase inhibitors, and caution should be used if drugs in the two classes are to be used together.
Other agents (propantheline, dicyclomine, imipramine, hyoscyamine, calcium channel blockers, and nonsteroidal anti-inflammatories) have scant efficacy data. Flavoxate is ineffective. Vasopressin was found to decrease nocturnal voids in a small randomized trial in healthy older persons, yet its expense and risk of heart failure and hyponatremia argue against routine use.
Sacral nerve neuromodulation by an implanted S3 electrode may decrease severe refractory DO, but reimplantation is required in one third of patients. Augmentation cystoplasty surgery has high morbidity and is reserved for patients with profound DO (usually younger persons with poorly compliant bladders from neurologic disease).
Pelvic muscle exercises (PME) strengthen the muscular components of urethral support and are the cornerstone of noninvasive treatment for stress UI. PME, like strength training, employ a small number of isometric repetitions at maximal exertion. Unfortunately, professional and lay misinformation about PME abounds; persons who report failing PME trials may have used inadequate methods. PME requires motivated patients and instruction and monitoring by health professionals, although simple instruction booklets alone have been shown to have moderate benefit. PME instruction should focus on isolation of pelvic muscles; avoidance of buttock, abdomen, or thigh muscle contraction; moderate repetitions of a strong, slow-velocity contraction sustained for 6 to 8 seconds, performed in sets of 8 to 12 contractions three or four times a week and continued for at least 15 to 20 weeks (the patient handout at http://www.healthinaging.org/public_education/bladder_control.php should be amended to decrease initial contraction frequency). The marginal benefit of adding biofeedback or weighted vaginal cones is uncertain, yet many experts feel that biofeedback helps instruction. Adjunctive electrical stimulation does not increase efficacy.
Pessaries may benefit women with stress UI exacerbated by bladder or uterine prolapse. (See Gynecologic Diseases and Disorders.)
In numerous epidemiologic and intervention studies, oral estrogen was not found to be effective for the treatment of stress or mixed UI, especially when combined with progestins. Further studies are needed to evaluate topical estrogen (cream, vaginal tablet, or slow-release ring). α-Adrenergic agonists stimulate urethral smooth muscle contraction, but no pure α-agonists are currently available. The α-agonist and anticholinergic actions of imipramineOL have been used for mixed UI, yet efficacy data are scant and anticholinergic effects are marked. DuloxetineOL is a novel norepinephrine- and serotonin-reuptake inhibitor that increases sphincter contraction; early short-term data suggest efficacy for both stress and mixed UI. However, the dose for incontinence is twice the dose used to treat depression and neuropathic pain, with concomitant higher rates of adverse effects such as nausea. (The manufacturer has put the application for this indication in the United States on hold. The drug does have approval for this indication in Europe and is approved in the United States for depression and pain.)
Surgery provides the highest cure rates for stress UI in women, yet there are few data to assist in procedure and patient selection for older women, especially if they have mixed UI, poor detrusor contractility, prior failed anti-incontinence surgery, and comorbidity. The standard procedure has been bladder neck suspension (eg, transvaginal colposuspension). Suburethral slings and tension-free vaginal tape (synthetic sling inserted at midurethra without tension) are increasingly used; complication rates can exceed 10%. Periurethral injection of collagen, Teflon, or autologous fat is a short-term (≤ 1 year) alternative, usually requiring a series of injections. Anterior colporrhaphy and needle suspensions are less effective and not recommended. Artificial sphincters are used for severe sphincter damage (eg, from surgical scarring).
Postprostatectomy stress UI is more common in older men. Overall, UI rates decline over 6 to 12 months, regardless of PME therapy. Although preoperative PME improves early postoperative UI rates, there is no difference from controls at 1 year. No drugs are known to be effective. Artificial sphincter replacement can be effective but requires manual dexterity and cognition, and it has high revision rates (up to 40%); urodynamics should assist patient selection, as outcomes are worse with severe DO and poor detrusor compliance. Early short-term reports suggest that suburethral sling placement may offer benefit.
A range of medical and surgical alternatives are available for prostatic obstruction (see Prostate Disease). Obstruction should be considered as a diagnosis in women with previous vaginal or urethral surgery; treatment by unilateral suture removal or urethrolysis (remobilization of adhesions) may restore continence. Pessaries may improve urethral kinking due to pelvic organ prolapse; otherwise, prolapse repair surgery can be considered.
Treatment is supportive. Drugs that impair detrusor contractility and increase urethral tone should be decreased or stopped, and constipation should be treated. Bethanechol chloride is ineffective except possibly for patients with overflow UI who must remain on anticholinergic agents (eg, antidepressant or antipsychotic medications). Intermittent clean catheterization is effective for willing and able patients. Sterile intermittent catheterization is preferred for frailer patients and those in institutionalized settings. In some cases bladder emptying may improve with double voiding or simply unhurried voiding.
Indwelling catheters cause significant morbidity, including polymicrobial bacteriuria (universal by 30 days), febrile episodes (1 per 100 patient days), nephrolithiasis, bladder stones, epididymitis, chronic renal inflammation and pyelonephritis, and meatal damage. External collection devices also cause bacteriuria, infection, penile cellulitis and necrosis, and urinary retention and hydronephrosis if the condom twists or its external band is too tight.
Indwelling catheters should be reserved for the following situations: short-term decompression of acute retention; chronic retention that cannot be managed surgically or medically; wounds that need protection from urine; a terminally ill or severely impaired patient who cannot tolerate garment changes, or when there is persistent patient preference for catheter management despite risks. The passage of the 1990 Omnibus Budget Reconciliation Act has resulted in more appropriate and decreased catheter use in long-term care but with an increased prevalence of UI.
Several general principles guide safe and effective catheter care. Bacteriuria and infection are reduced by closed drainage systems. Topical meatal antimicrobials, catheters with antimicrobial coating, collection bag disinfectants, and antimicrobial irrigation are not effective. Although antibiotics decrease bacteriuria and infection, routine use induces resistant organisms and secondary infections such as Clostridium difficile colitis. Bacteriuria is universal in catheterized patients and should not be treated unless there are clear symptoms. Routine cultures should not be done because of the changing flora and failure to predict infection. In symptomatic patients, cultures should be done after the old catheter is removed and a new catheter is placed. Institutionalized patients with catheters should be kept in separate rooms to decrease cross-infection.
With acute urinary retention, decompression should continue at least 7 days, followed by a voiding trial after catheter removal (never clamping). Prophylactic antibiotics are recommended only with short-term catheterization in high-risk patients (eg, those with prosthetic heart valves). For men with chronic obstruction, suprapubic catheters can avoid meatal and penile trauma, and intraurethral stents, if available, may be another alternative (but sometimes at a cost of increased urgency and frequency).
Risk factors for catheter blockage include alkaline urine, female gender, poor mobility, calciuria, proteinuria, copious mucin, Proteus colonization, and preexistent bladder stones. Changing the catheter every 7 to 10 days may decrease blockage in such patients. In the absence of risk factors, catheters need not be changed routinely as long as monitoring is adequate. If patients cannot be monitored, changing catheters every 30 days is reasonable. Persistent leakage around the catheter can be caused by irritation by a large Foley balloon, catheter diameter that is too large, bacteriuria, constipation or impaction, improper catheter positioning, or catheter materials.
Clean intermittent catheterization is an alternative for willing patients with sufficient dexterity. Strict sterility is not necessary, although good handwashing and regular decontamination of the catheters is needed. Bacteriuria can be minimized by a frequency of catheterization that keeps bladder volume < 400 mL. Stiffer catheters are easier to insert.
Resources, including Web site addresses, of use to clinicians treating patients with UI are listed in the Appendix.
■ Carlson KV, Nitti VW. Prevention and management of incontinence following radical prostatectomy. Urol Clin North Am. 2001;28(3):595–612.
This review covers behavioral treatment, injection therapy, and the use of artificial sphincters for post-prostatectomy incontinence, which is predominantly stress urinary incontinence with intrinsic sphincter deficiency. Case series are now emerging about the potential use of urethral “sling” operations for this condition (analogous to sling or tension-free transvaginal tape procedures for women with stress incontinence).
■ Diokno A, Appell RA, Sand PK, et al. Prospective, randomized, double-blind study of the efficacy and tolerability of the extended-release formulations of oxybutynin and tolterodine for overactive bladder: results of the OPERA trail. Mayo Clin Proc. 2003;78(6):687–695.
This is the first prospective randomized, controlled, double-blind multicenter trial comparing extended-release oxybutynin 10 mg per day versus extended-release tolterodine 4 mg per day in women. Subjects were 790 women (mean age 60, 39% at least 65 years, 15% at least 75 years) who had moderate to severe overactive bladder with at least 21 urge urinary incontinence episodes weekly and a mean frequency of 10 voids per day; 47% had previously taken antimuscarinic medication for incontinence. At 12 weeks, reduction in weekly urge incontinence episodes was similar. Cure rate with oxybutynin was 23%, versus 17% with tolterodine (P = .03). Dry mouth was more common with oxybutynin (30% versus 22%, P = .02), though study withdrawal rates were similar. These results may aid clinicians in making initial drug choices for similar patients, balancing efficacy and tolerability on the basis of the individual patient’s needs.
■ Goode PS, Burgio KL, Locher JL, et al. Effect of behavioral training with or without pelvic floor electrical stimulation on stress incontinence in women. JAMA. 2003; 290(3):345–352.
This prospective, randomized, controlled, double-blind trial compared behavioral training (BT) with and without adjunctive home pelvic floor electrical stimulation (PFES) with a self-administered behavioral therapy instruction booklet in treating 200 healthy, community-based women (mean age 56.2 [9.8]) with stress or stress-predominant mixed urinary incontinence (UI). Total UI frequency was reduced 69% with BT alone, 72% with BT plus PFES, and 53% with the instruction booklet (P = .60 BT versus BT plus PFES, P = .002 active therapy versus instruction book). Rates of patient-defined “much better” outcome was highest with BT plus PFES (77%, versus 57% BT alone [P = .048] and 30% with booklet [P < .001]). Quality-of-life improvement, determined by using the Incontinence Impact Questionnaire, did not differ between the groups. These results emphasize the discordance between objective and patient-based outcomes of UI interventions. PFES would be cost-effective by subjective but not objective or quality-of-life outcomesan interesting dilemma for providers and payers. The results with the self-instruction booklet show that modest but real improvement is possible without intense intervention.
■ Schnelle JF, Kapur K, Alessi C, et al. Does an exercise and incontinence intervention save healthcare costs in a nursing home population? J Am Geriatr Soc. 2003, 51(2):161–168.
■ Wagner TH. Subak LL. Evaluating an incontinence intervention in nursing home residents [editorial]. J Amer Geriatr Soc. 2003, 51(2):275–276.
This randomized controlled trial examined the effect of low-intensity, functionally oriented exercise program on physical inactivity, urinary incontinence, immobility, and costs in 190 incontinent residents in four nursing homes. The program, based on federal and clinical practice guidelines, was provided every 2 hours during 8 daytime hours, 5 days a week for 8 months. The program group had significantly better functional outcomes (strength, mobility endurance, urinary and fecal incontinence), but there was no difference in prevalence or cost of acute health conditions. The authors conclude that the cost of implementing such labor-intensive interventions in nursing homes will have to be justified on the basis of functional and quality-of-life outcomes, as they are unlikely to be offset by savings in medical care costs. In the accompanying editorial, Wagner and Subak emphasize the importance of and need for cost-effectiveness analysis to support the use of such interventions in nursing homes.
■ Schnelle JF, Smith RL. Quality indicators for the management of urinary incontinence in vulnerable community-dwelling elders. Ann Intern Med. 2001;135(8 Pt 2):752–758.
Quality indicators based on evidence and expert opinion were developed as part of the Assessing Care of the Vulnerable Elderly project (see Ann Intern Med. 2001;135[8], Part 2). The target population is community-based frail elderly persons. The ten indicators are in the domains of evaluation, documentation, patient education, and treatment.
■ Walters MD, Daneshgari F. Surgical management of stress urinary incontinence. Clin Obstet Gynecol. 2004;47(1):93–103.
Stress urinary incontinence is the most common form of incontinence in women and surgery is held as the mainstay of therapy. This is a review of the various surgical approaches for the management of stress urinary incontinence. The authors recommend specific surgical approaches for patients with various characteristics, on the bassis of evidence.
Catherine E. DuBeau, MD