In 1992, the Agency for Health Care Policy and Research
(AHCPR) released its first guideline on urinary incontinence. Since then
the guideline has become the standard of care for incontinence in many
settings across the country.
This update of the guideline reflects new findings in
the rapidly changing field of treatment for urinary incontinence. To
develop the update, AHCPR convened a multidisciplinary private-sector
panel of physicians, nurses, allied health professionals, and health care
consumers to study the effectiveness of diagnostic and treatment
procedures for urinary incontinence, their costs, and how they affect
patient outcomes.
The results of this research show that incontinence can
be improved, and in some cases, even cured. Anecdotal evidence shows that
long-term care facilities that have adopted the guideline have improved
the quality of life of their patients and saved money at the same time.
What Is Urinary Incontinence?
Urinary incontinence (UI), or the unintentional loss of
urine, is a problem for more than 13 million Americans—85 percent of
them women. Although about half of the elderly have episodes of
incontinence, bladder problems are not a natural consequence of aging, and
they are not exclusively a problem of the elderly.
Incontinence has several causes. Women are most likely
to develop incontinence either during pregnancy and childbirth, or after
the hormonal changes of menopause, because of weakened pelvic muscles.
Older men can become incontinent as the result of prostate surgery. Pelvic
trauma, spinal cord damage, caffeine, or medications including cold or
over-the-counter diet tablets also can cause episodes of incontinence.
But even though urinary incontinence can be improved in
8 out of 10 cases, fewer than half of those with bladder problems ever
discuss the condition with their health care professional. The condition
often goes untreated.
Facts About Incontinence
13 million Americans are incontinent; 11 million
are women.
1 in 4 women ages 30-59 have experienced an episode
of UI.
50% or more of the elderly persons living at home
or in long-term care facilities are incontinent.
$16.4 billion is spent every year on
incontinence-related care: $11.2 billion for community-based programs
and at home, and $5.2 billion in long-term care facilities.
$1.1 billion is spent every year on disposable
products for adults.
Types and Causes of UI
There are four common types of incontinence:
1. Stress incontinence happens when the bladder
can't handle the increased compression during exercise, coughing, or
sneezing. This kind of incontinence happens mostly to women under 60 and
in men who have had prostate surgery.
2. Urge incontinence is caused by a sudden,
involuntary bladder contraction. It is more common in older adults.
3. Mixed incontinence is a combination of both
stress and urge incontinence, and is most common in older women.
4. Overflow incontinence, in which the bladder
becomes too full because it can't be fully emptied, is rarer and is the
result of bladder obstruction or injury. In men, it can be the result of
an enlarged prostate.
5. Other factors can cause incontinence such as
decreased mobility, cognitive impairment or medications.
Treatment Recommendations
Treatment for UI depends on the type of incontinence,
its causes, and the capabilities of the patient. The guideline update
recommends the following treatments:
Pelvic Muscle Rehabilitation—to improve pelvic
muscle tone and prevent leakage.
Kegel exercises. Regular, daily exercising
of pelvic muscles can improve, and even prevent, urinary incontinence.
This is particularly helpful for younger women. Should be performed
30-80 times daily for at least 8 weeks.
Biofeedback. Used in conjunction with Kegel
exercises, biofeedback helps people gain awareness and control of
their pelvic muscles.
Vaginal weight training. Small weights are
held within the vagina by tightening the vaginal muscles. Should be
performed for 15 minutes, twice daily, for 4 to 6 weeks.
Pelvic floor electrical stimulation. Mild
electrical pulses stimulate muscle contractions. Should be performed
in conjunction with Kegel exercises.
Behavioral Therapies—to help people regain
control of their bladder.
Bladder training teaches people to resist
the urge to void and gradually expand the intervals between voiding.
Toileting assistance uses routine or
scheduled toileting, habit training schedules, and prompted voiding to
empty the bladder regularly to prevent leaking.
Pharmacologic Therapies—to improve
incontinence medically.
Oxybutynin (brand name Ditropan) prevents
urge incontinence by relaxing sphincter muscles.
Estrogen, either oral or vaginal, may
be helpful in conjunction with other treatments for postmenopausal
women with UI.
Surgical Therapies—to treat specific
anatomical problems.
Sling procedures, bulking injections (such
as collagen) and other surgical procedures support or move the bladder
to improve continence.
Treatment Recommendations for the Chronically
Incontinent
Although many people will improve their continence
through treatment, some will never become completely dry. They may need to
take medications that cause incontinent episodes or have cognitive or
physical impairments that keep them from being able to perform pelvic
muscle exercises or retrain their bladders. Many will be cared for in
long-term care facilities or at home. The guideline update makes the
following recommendations to help caregivers keep the chronically
incontinent drier and reduce their cost of care:
Scheduled toileting—take people to the
toilet every 2 to 4 hours or according to their toilet habits.
Prompted voiding—check for dryness
and encourage use of the toilet.
Improved access to toilets—use
equipment such as canes, walkers, wheelchairs, and devices that raise
the seating level of toilets to make toileting easier.
Managing fluids and diet—eliminate
dietary caffeine (for those with urge incontinence) and encourage
adequate fiber in the diet.
Disposable absorbent garments—use to
keep people dry.
Education
The guideline recommends that patients and
professionals learn about the different treatment options for
incontinence.
Patients and their families should know that
incontinence is not inevitable or shameful but is treatable or at
least manageable. All management alternatives should be explained.
Professional education about UI evaluation
and treatment should be included in the basic curricula of
undergraduate and graduate training programs of all health care
providers, as well as continuing education programs.
For Further Information
Alliance for Aging Research
2021 K Street, N.W., Suite 305
Washington, DC 20006
(202) 293-2856
Bladder Health Council
c/o American Foundation for Urologic Disease
300 West Pratt Street, Suite 401
Baltimore, MD 21201
(410) 727-2908
National Association For Continence
(formerly Help for Incontinent People)
P.O. Box 8310
Spartanburg, SC 29305
(800) BLADDER or
(800) 252-3337
Simon Foundation for Continence
Box 835
Wilmette, IL 60091
(800) 23-SIMON
(800) 237-4666
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