Living with urinary incontinence: a longitudinal study of older women

Association of overweight, obesity and risk of urinary incontinence in middle-aged and older women: a meta epidemiology study

Aims

The aim of this meta-analysis is to evaluate the potential correlation between obesity and overweight, and the vulnerability to urinary incontinence (UI) in women aged middle-aged and above.

Methods

We searched PubMed, Cochrane Library, and Embase for observational studies published between the inception of the databases and April 25, 2023. A fixed-effects model was used when the P>0.1 and the I2 ≤ 50%. In cases where I2 ≥ 50% (indicating significant heterogeneity), a random-effects model was applied. For the purpose of evaluating publication bias, a funnel plot and Egger's test were used. Stata 14.0 was used for all statistical analyses.

Findings

This meta-analysis includes 16 observational studies, covering29,618 individuals. The pooled analysis shows that being overweight(25 kg/m2≤BMI<30kg/m2) in middle-aged and elderly women is more likely to develop UI (OR=1.27; 95% CI: 1.17-1.37; I2 = 51.8%, P=0.013). Middle-aged and elderly women with obesity(30 kg/m2≤BMI<35 kg/m2) are significantly more likely to develop UI (OR=1.60; 95% CI: 1.42-1.81; I2 = 71.8%, P=0.000). In addition, the results indicated a higher probability of UI in middle-aged and older women with obesity class II (BMI≥35 kg/m2) (OR=1.85; 95% CI: 1.59-2.16; I2 = 48.1%, P=0.103). In subgroup analysis, there is no direct relationship between the obesity in middle-aged and elderly women and an increased risk of stress urinary incontinence (SUI) (OR=1.31; 95% CI: 0.99-1.74; I2 = 63.7%, P=0.011). In middle-aged and elderly women with obesity are more likely to develop urgent urinary incontinence (UUI) (OR=2.11; 95% CI: 1.54-2.89; I2 = 80.2%, P=0.000).

Conclusion

In this meta-analysis, overweight and obesity are associated with an increased risk of UI in middle-aged and elderly women. Obesity and overweight are independent risk factors for UI, as demonstrated by this study.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023421986.

Association between Loneliness and Depression among Community-Dwelling Older Women Living Alone in South Korea: The Mediating Effects of Subjective Physical Health, Resilience, and Social Support

Social isolation and loneliness are the key risk factors for depression in late life. Older adults living alone and socially isolated are at greater risk for physical and mental health. This study aims to examine the mediating effects of subjective physical health, resilience, and social support on the association between loneliness and depression among the elderly female population living alone in South Korea. We included a total of 308 older women aged 60 years or older who live alone in a medium-sized city in South Korea. The survey data was collected using the validated survey instruments between November 2015 and April 2016. A parallel mediation model was performed to investigate whether physical health, resilience, and social support had mediating effects on the association of loneliness with depression. The findings of this study showed that loneliness was directly and indirectly associated with depression through its association with the subjective physical health, resilience, and social support among the older female population living alone. Our results suggest the importance of supporting community-based programs to improve physical and mental health of the elderly people as a way to minimize the level of loneliness and prevent depression.

A Review of Aging and the Lower Urinary Tract: The Future of Urology

Lower urinary tract symptoms (LUTS) are common among elderly people, with significant effects on individuals, caregivers, and the wider health care system. As the elderly population with multiple comorbidities is increasing, the burden of LUTS will increase. This review describes the demographic trends in the aging society, changes in lower urinary tract function with aging, and deterioration of physical and cognitive function in aging, as well as what has been done regarding geriatric urology and what urologists should do to meet the health care needs of the aging population. Frailty and dementia are unmissable factors in the evaluation of elderly patients. Numerous reports have described associations between LUTS and frailty and between LUTS and dementia. Urologists must be aware of the multiplex physical, cognitive, and social characteristics of elderly people. Maintaining a geriatric viewpoint in the diagnosis, treatment, and management of elderly individuals with LUTS will fulfill the unmet needs of elderly people. It is also essential to discuss the treatment and management goals of LUTS with patients and caregivers. Active case identification, appropriate evaluations of LUTS and comorbidities, and a multidisciplinary approach with other health-care professionals are recommended for better treatment and management.

Factors Associated With Urgency Urinary Incontinence Among Older Mexican American Women Aged 65 years and Older

The purpose of this study was to determine which socio-demographic, clinical, or functional factors are associated with urgency urinary incontinence (UUI) over 20-years of follow-up in a community-dwelling sample of Mexican American women aged 65 years and older without UUI at baseline. We included 1,358 women participants from the Hispanic Established Population for the Epidemiologic Study of the Elderly study conducted in the southwestern of US (Arizona, California, Colorado, New Mexico, and Texas). Measures included self-reported UUI, socio-demographics, smoking status, body mass index, medical conditions, depressive symptoms, physical and cognitive function, and handgrip strength. We used generalized estimating equation models to estimate the odds ratio (OR) and 95% Confidence Interval (CI) of UUI as a function of socioeconomic, clinical, and functional factors. Self-reported UUI increased from 3.1% to 21.9% from baseline (1993/1994) to follow-up (2012/2013). Current smokers, obesity, arthritis, previous heart attacks, and depressive symptoms were factors associated with greater odds of UUI over time. Identification of these factors can help clinicians determine those at high risk of developing UUI. Preventing and/or treating the risk factors early may delay UUI and increase quality of life in this underserved population.

Urinary urgency acts as a source of divided attention leading to changes in gait in older adults with overactive bladder

AIMS

There is a well-recognised but unexplained association between lower urinary tract symptoms including urgency and urgency incontinence and falls in older people. It has been hypothesised that urinary urgency acts as a source of divided attention, leading to gait changes which increase falls risk. This study aimed to assess whether urinary urgency acts as a source of divided attention in older adults with overactive bladder (OAB).

METHODS

27 community-dwelling adults aged 65 years and over with a clinical diagnosis of OAB underwent 3-Dimensional Instrumented Gait Analysis under three conditions; bladder empty, when experiencing urgency, and when being distracted by the n-back test. Temporal-spatial gait and kinematic gait data were compared between each condition using repeated measures ANOVA.

RESULTS

Gait velocity decreased from 1.1ms-1 in the bladder empty condition to 1.0ms-1 with urgency and 0.9ms-1 with distraction (p = 0.008 and p<0.001 respectively). Stride length also decreased, from 1.2m to 1.1m with urgency and 1.0m with distraction (p<0.001 for both). The presence of detrusor overactivity did not influence these results (p = 0.77).

CONCLUSIONS

In older adults with OAB, urinary urgency induced similar changes in gait to those caused by a distracting task. These gait changes are associated with increased fall risk. This may be part of the explanation for the association between falls and lower urinary tract symptoms in older people. Future research should examine the effect of pharmacological treatment of OAB on gait and on the effect of dual-task training on gait when experiencing urgency.

Diagnosis and Non-Surgical Management of Urinary Incontinence - A Literature Review with Recommendations for Practice

Urinary incontinence (UI) is a bothersome symptom with population studies suggesting a prevalence of 13.1% in women and 5.4% in men. While a significant cohort of patients with this complaint may ultimately require surgical management to achieve complete continence, a number of non-surgical measures exist to improve symptoms and quality of life. A range of guidelines exist on this topic, including those published by the European Association of Urology (EAU), the International Continence Society (ICS), the American Urological Association (AUA) and the UK's National Institute for Health and Care Excellence (NICE). The aim of our study is to provide an overview of the initial assessment of patients with UI including history taking, examination and basic investigations. Our review outlines non-surgical management strategies for UI, including conservative measures, behavioral and physical therapies and drug treatment. We shall also examine the above guidelines and present a narrative overview of the literature surrounding the diagnosis and non-surgical management of urinary incontinence.

Incontinence in frail elderly persons: Report of the 6th International Consultation on Incontinence

BACKGROUND

Evidence-based guidelines for the management of frail older persons with urinary incontinence are rare. Those produced by the International Consultation on Incontinence represent an authoritative set of recommendations spanning all aspects of management.

AIMS

To summarize the available evidence relating to the management of urinary incontinence in frail older people published since the 5th International Consultation on Incontinence.

MATERIALS AND METHODS

A series of systematic reviews and evidence updates were performed by members of the working group to update the 2012 recommendations.

RESULTS

Along with the revision of the treatment algorithm and accompanying text, there have been significant advances in several areas of the management of lower urinary tract symptoms in frail older people.

DISCUSSION

The committee continues to note the relative paucity of data concerning frail older persons and draw attention to knowledge gaps and research opportunities. Clinicians treating older people with lower urinary tract symptoms should use the available evidence from studies of older people combined with careful extrapolation of those data from younger subjects. Due consideration to an individual's frailty and wishes is crucial.

Urinary incontinence onset predictors in community-dwelling older women: A prospective cohort study

AIM

We aimed to investigate whether physical function was associated with urinary incontinence (UI) onset in community-dwelling older Japanese women.

METHODS

This was a 4-year prospective cohort study. After excluding participants with UI and missing data in the baseline survey, we included 890 participants in the analyses. Physical function including grip strength, maximal walking speed, knee extension strength, single-leg balance, and timed up and go (TUG) were measured. The primary outcome was the onset of all UI and different types of UI (urge, stress and mixed) based on the questionnaire survey. Binary logistic regression analysis was applied to calculate the adjusted odds ratios and 95% confidence intervals for the association between physical function and the risk of all UI and different types of UI incident.

RESULTS

Among the 890 participants, 221 (25%) developed UI during the 4-year follow-up. After adjusting for confounders, better knee extension strength, maximal walking speed and TUG were significantly associated with a lower risk of all UI and urge UI onset, and better single-leg balance and TUG were significantly associated with a lower risk of mixed UI onset (P for trend <0.05). No significant association was found between physical function and the risk of stress UI onset.

CONCLUSIONS

This study confirmed that better lower extremity physical function is associated with lower risk of urge and mixed UI onset, indicating that exercise programs focusing on maintaining and improving lower extremity physical function may be useful for reducing such events among older women. Geriatr Gerontol Int 2021; 21: 178-184.

Longitudinal studies of ageing: from insights to impacts: commentary to accompany themed collection on longitudinal studies

'Time is the best diagnostician': who has not thought this? In clinical practice, presentations are often subtle and decisions made in the face of a 'snapshot.' Crystal balls do not exist; yet, insights from longitudinal studies can help to recognise emerging pictures and anticipate typical trajectories. In the multifactorial, biopsychosocial world of geriatrics, the determinants of those trajectories, and hence opportunities to modify them, can be better understood through careful longitudinal disentangling of the wider determinants of health, and this can be done at multiple levels of analysis, from molecules to society. With this collection and commentary, we highlight the approaches, scope and impacts of a selection of longitudinal studies of ageing published in Age and Ageing within the past 10 years. Longitudinal studies can illuminate disease mechanisms, how declines in multiple domains of intrinsic capacity interact, how losses in one domain may influence the path of another, and in turn, how these changes translate to functional disability, or not. Observing trajectories of geriatric syndromes can suggest opportunities for optimisation and prevention in clinical practice and policy. With global opportunities for harmonising data, longitudinal studies are already offering the opportunity for cross-national comparisons and for developing hypotheses about the relative contributions of time, place and society in the trajectories of frailty, disability and quality of life. We also include studies which show how research-based longitudinal data can be synthesised or be linked to administrative datasets. We hope you find this collection as interesting and encouraging as we have.

Association between parity and the risk for urinary incontinence in women: A meta-analysis of case-control and cohort studies

Urinary incontinence (UI) is a common complaint for adult female. Cross-sectional studies suggested parity may link with UI, but the association between them was not well-established. We conducted a meta-analysis to investigate the association between parity and UI.Medline and Embase were searched for eligible case-control and cohort studies about parity and UI. Two authors screened the literature and extracted the data independently. Odds ratio (OR) was used as the measure of the effect of parity on UI. We pooled the ORs of different number of parity by a random-effect model. Subgroup analysis was conducted by a subtype of UI. Sensitivity analysis was conducted to see whether the results were stable.Thirteen studies (8 cohorts and 5 case-controls) were included in our meta-analysis, with a total of 74,883 adult females. Our meta-analysis showed that compared with nulliparity, ORs of women with 1, 2, and ≥3 parity were 1.43 [95% confidence interval (95% CI): 0.90-2.28; I = 81.4%; n = 4], 1.50 (95% CI: 1.02-2.20; I = 82.5%; n = 4), and 1.58 (95% CI: 1.22-2.03; I = 70.1%; n = 7) compared with nulliparity. The OR for any multiparity to nulliparity was 1.68 (95% CI: 1.39-2.03; I = 0%; n = 4). Subgroup analysis showed that parity was associated with an increased risk of stress UI (OR = 2.32, 95% CI: 1.41-3.81; I = 0%; n = 2; 1 compared with null parity) but not urgent UI; However, the definition of parity varies across studies and studies defined parity as delivery times showed higher pooled OR than those not. Sensitivity analysis showed our results were stable.Current evidence suggested that parity was associated with an increased risk of overall and stress UI but not urgency UI, though the definition of parity may differ. Higher parity may have a more significant effect on overall UI. Standardized definition of parity is needed.

A prospective study of the natural history of urinary incontinence in women

BACKGROUND

Symptoms of urinary incontinence are commonly perceived to vary over time; yet, there is limited quantitative evidence regarding the natural history of urinary incontinence, especially over the long term.

OBJECTIVE

We sought to delineate the course of urinary incontinence symptoms over time, using 2 large cohorts of middle-aged and older women, with data collected over 10 years.

STUDY DESIGN

We studied 9376 women from the Nurses' Health Study, age 56-81 years at baseline, and 7491 women from the Nurses' Health Study II, age 39-56 years, with incident urinary incontinence in 2002 through 2003. Urinary incontinence severity was measured by the Sandvik severity index. We tracked persistence, progression, remission, and improvement of symptoms over 10 years. We also examined risk factors for urinary incontinence progression using logistic regression models.

RESULTS

Among women age 39-56 years, 39% had slight, 45% had moderate, and 17% had severe urinary incontinence at onset. Among women age 56-81 years, 34% had slight, 45% had moderate, and 21% had severe urinary incontinence at onset. Across ages, most women reported persistence or progression of symptoms over follow-up; few (3-11%) reported remission. However, younger women and women with less severe urinary incontinence at onset were more likely to report remission or improvement of symptoms. We found that increasing age was associated with higher odds of progression only among older women (age 75-81 vs 56-60 years; odds ratio, 1.84; 95% confidence interval, 1.51-2.25). Among all women, higher body mass index was strongly associated with progression (younger women: odds ratio, 2.37; 95% confidence interval, 2.00-2.81; body mass index ≥30 vs <25 kg/m²; older women: odds ratio, 1.93; 95% confidence interval, 1.62-2.22). Additionally, greater physical activity was associated with lower odds of progression to severe urinary incontinence (younger women: odds ratio, 0.86; 95% confidence interval, 0.71-1.03; highest vs lowest quartile of activity; older women: odds ratio, 0.68; 95% confidence interval, 0.59-0.80).

CONCLUSION

Most women with incident urinary incontinence continued to experience symptoms over 10 years; few had complete remission. Identification of risk factors for urinary incontinence progression, such as body mass index and physical activity, could be important for reducing symptoms over time.

Development and initial psychometric properties of the 'ICIQ-Cog': a new assessment tool to measure the disease-related impact and care effort associated with incontinence in cognitively impaired adults

OBJECTIVES

To develop a new assessment tool, the ICIQ-Cog, to measure the disease-related impact of incontinence in cognitively impaired adults and the effort associated with the care of this population, and to present the initial psychometric properties of this tool and outline the possible clinical implications.

PARTICIPANTS AND METHODS

The ICIQ-Cog consists of two scales: a 12-item scale measuring disease-specific bother (ICIQ-Cog-P) and a four-item scale assessing efforts associated with care of people with incontinence and cognitive impairment (ICIQ-Cog-C). Data on 60 nursing home residents with incontinence and cognitive impairment were obtained in a test-retest research design. The psychometric properties of the ICIQ-Cog were examined using a combination of classic and item response theory methods.

RESULTS

Factor analyses resulted in a three-factor solution for the ICIQ-Cog-P, with interrelated factors. Rasch analysis showed a good model fit when collapsing response categories. The ICIQ-Cog-C fitted to one dimension. The ICIQ-Cog tool provided reliable measures in terms of internal consistency (0.69-0.82) and retest reliability (0.71-0.83). The preliminary results on external validity showed that the ICIQ-Cog assessed disease-specific aspects linked to the group of cognitively impaired people with incontinence.

CONCLUSION

The ICIQ-Cog tool has appropriate psychometric and clinometric properties and is therefore useful for making decisions about treatment in cognitively impaired adults with incontinence.

EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence

CONTEXT

The European Association of Urology guidelines on urinary incontinence (UI) have been updated in cyclical fashion with successive major chapters being revised each year. The sections on assessment, diagnosis, and nonsurgical treatment have been updated as of mid-2016.

OBJECTIVE

We present a condensed version of the full guideline on assessment and nonsurgical management of UI, with the aim of improving accessibility and increasing their dissemination.

EVIDENCE ACQUISITION

Our literature search was updated from the previous cut-off of July 2010 up to April 2016. Evidence synthesis was carried out by a pragmatic review of current systematic reviews and any newer subsequent high-quality studies, based on Population, Interevention, Comparator, and Outcome questions. Appraisal was conducted by an international panel of experts, working on a strictly nonprofit and voluntary basis, to develop concise evidence statements and action-based recommendations using modified Oxford and GRADE criteria.

EVIDENCE SYNTHESIS

The guidelines include algorithms that summarise the suggested pathway for standard, uncomplicated patients with UI and are more useable in daily practice. The full version of the guideline is available at http://uroweb.org/guideline/urinary-incontinence/.

CONCLUSIONS

These updated guidelines provide an evidence-based summary of the assessment and nonsurgical management of UI, together with a clear clinical algorithm and action-based recommendations. Although these guidelines are applicable to a standard patient, it must be remembered that therapy should always be tailored to individual patients' needs and circumstances.

PATIENT SUMMARY

Urinary incontinence is a very common condition which negatively impacts patient's quality of life. Several types of incontinence exist and since the treatments will vary, it is important that the diagnostic evaluation establishes which type is present. The diagnosis should also identify patients who need rapid referral to an appropriate specialist. These guidelines aim to provide sensible and practical evidence-based guidance on the clinical problem of urinary incontinence.

Ten-Year Prevalence and Incidence of Urinary Incontinence in Older Women: A Longitudinal Analysis of the Health and Retirement Study

OBJECTIVES

To measure the incidence of urinary incontinence (UI) over 10 years in older women who did not report UI at baseline in 1998, to estimate the prevalence of female UI according to severity and type, and to explore potential risk factors for development of UI.

DESIGN

Secondary analysis of a prospective cohort.

SETTING

Health and Retirement Study.

PARTICIPANTS

Women participating in the Health and Retirement Study between 1998 and 2008 who did not have UI at baseline (1998).

MEASUREMENTS

UI was defined as an answer of "yes" to the question, "During the last 12 months, have you lost any amount of urine beyond your control?" UI was characterized according to severity (according to the Sandvik Severity Index) and type (according to International Continence Society definitions) at each biennial follow-up between 1998 and 2008.

RESULTS

In 1998, 5,552 women aged 51 to 74 reported no UI. The cumulative incidence of UI in older women was 37.2% (95% confidence interval (CI)=36.0-38.5%). The most common incontinence type at the first report of leakage was mixed UI (49.1%, 95% CI=46.5-51.7%), and women commonly reported their symptoms at first leakage as moderate to severe (46.4%, 95% CI=43.8-49.0%).

CONCLUSION

Development of UI in older women was common and tended to result in mixed type and moderate to severe symptoms.

Continence care for people with dementia living at home in Europe: a review of literature with a focus on problems and challenges

AIMS AND OBJECTIVES

To report the findings of a review of literature relating to the continence care of community-dwelling people with dementia in Europe.

BACKGROUND

More than two-thirds of people with dementia live at home, and many experience continence problems. Incontinence is a significant contributor towards institutionalisation. Care and support is often inadequate or inappropriate, and guidelines are lacking. This represents a failure to respect the human rights and dignity of this group.

DESIGN

A structured review of the literature relating to the continence care of community-dwelling people with dementia in Europe with a focus on problems and challenges.

METHODS

Search terms reflecting dementia, continence, care/management and guidelines for community-dwelling people with dementia were applied to four databases. Hand-searching was also carried out. A total of 208 articles were searched for content relating to problems and challenges linked to continence care for this group.

RESULTS

Six relevant articles were fully reviewed. The main difficulties and challenges included the following: (1) perceptions, (2) availability/provision of support and care, (3) financial cost, (4) mobility and the environment, (5) relationships and social inclusion and (6) emotional issues.

CONCLUSION

Dementia and incontinence have profound effects on quality of life. The dearth of good quality data within this area and the findings of the review confirm the need for expert, consensus-based guidelines and appropriate research to ensure that the rights and dignity of people with dementia are respected.

RELEVANCE TO CLINICAL PRACTICE

The findings of the review will hopefully raise awareness amongst healthcare professionals in community practice of unmet needs of people with dementia and continence problems, and their caregivers, especially those related to social, financial, emotional and relational issues. The review does not provide solutions or guidance but is helpful in highlighting some of the key areas where special attention is needed.

Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion

INTRODUCTION AND HYPOTHESIS

Pelvic floor disorders (PFD), including urinary incontinence, anal incontinence, and pelvic organ prolapse, are common and have a negative effect on the quality of life of women. Treatment is associated with morbidity and may not be totally satisfactory. Prevention of PFDs, when possible, should be a primary goal. The purpose of this paper is to summarise the current literature and give an evidence-based review of the prevention of PFDs METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the prevention of PFDs was drafted, based on a review of the English-language literature. After evaluation by the entire IUGA R&D Committee, revisions were made. The final document represents the IUGA R&D Committee Opinion on the prevention of PFDs.

RESULTS

This R&D Committee Opinion reviews the literature on the prevention of PFDs and summarises the findings with evidence-based recommendations.

CONCLUSIONS

Pelvic floor disorders have a long latency, and may go through periods of remission, thus making causality difficult to confirm. Nevertheless, prevention strategies targeting modifiable risk factors should be incorporated into clinical practice before the absence of symptomatology.

Weight Gain, Overweight, and Obesity: Determinants and Health Outcomes from the Australian Longitudinal Study on Women's Health

Recent estimates suggest that 35.3 % of adult Australians are overweight and a further 27.5 % are obese. The Australian Longitudinal Study on Women's Health (ALSWH) is a prospective study of women's health that commenced in Australia in 1996. The study recruited approximately 40,000 women in three birth cohorts, 1973-1978, 1946-1951 and 1921-1926, who have since been followed up approximately every three years using self-report surveys. Six surveys have been completed to date. This review aims to describe the changes in weight and weight status over time in the three ALSWH cohorts, and to review and summarise the published findings to date relating to the determinants and health consequences of weight gain, overweight and obesity. Future plans for the ALSWH include on-going surveys for all cohorts, with a seventh survey in 2013-2015, and establishment of a new cohort of women born in 1990-1995, which is currently being recruited.

Urinary incontinence incidence: quantitative meta-analysis of factors that explain variation

PURPOSE

We sought to explain variation in female age specific incidence rates for urinary incontinence using published, population based studies.

MATERIALS AND METHODS

We performed an extensive MEDLINE® review of published, population based studies of the female urinary incontinence incidence rate from 1966 to 2011 using a combination of symptom and epidemiological search terms. A total of 18 reports described 17 unique incidence studies. We abstracted the features of each study (eg sample size, followup, etc) along with detailed data on 109 age specific incidence rates (ie new cases per 1,000 person-years). Because the Nurses' Health Study had unique demographics and was dominant in sample size, analyses were completed with and without this study. Weighted (ie square root of sample size) linear regression was used to determine factors (ie age, source population, race, frequency score, etc) explaining variance among age specific incidence rates.

RESULTS

Age and case definition accounted for 60% of the variation in incidence rates among studies. The age specific incidence was less than 2/1,000 person-years before age 40 years and it increased thereafter. For a given age group incidence rates varied as much as sixfold across studies, a finding that was largely explained by variation in case definition.

CONCLUSIONS

The case definition accounts for substantial variation in urinary incontinence incidence estimates. Developing standards for reporting would provide a foundation for policy guidance and understanding etiology. We recommend that quantitative frequency criteria (eg 2 times or more per month) be reported vs vague thresholds (eg sometimes or often).

Do continence management strategies reduce falls? a systematic review

Urinary incontinence is associated with increased fall risk, and fall prevention programs include recommendations to manage continence as one component of fall reduction. However, the evidence to support this recommendation is unclear. The aim of this study was to identify continence management interventions that are effective in decreasing falls. A systematic review of the literature was conducted. Studies were included if they evaluated the effect of any type of continence management strategy on falls in older adults. The included studies were assessed for quality, and data relating to participants, interventions and outcomes were extracted by two independent reviewers. Four articles met the inclusion criteria. Two studies were randomised controlled trials, one a retrospective cohort study and one an uncontrolled intervention study. Interventions included pharmacological agents, a toileting regime combined with physical activity and an individualised continence program. Only the study evaluating the combination of physical activity and prompted voiding found an effect on falls. It is surprising that there has been so little research into continence management interventions that include fall outcomes. A toileting regime combined with physical activity may reduce falls in residential care. There is a need for further studies investigating the impact of continence management on falls.

Prevalence, incidence and remission of urinary incontinence in women: longitudinal data from the Norwegian HUNT study (EPINCONT)

Background

To determine incidence and remission of UI as well as changes in UI prevalence in the Norwegian EPINCONT surveys.

Methods

The EPINCONT surveys were conducted in the county of Nord-Trøndelag, Norway, as part of two large cross-sectional health surveys (HUNT2 and HUNT3) in 1995 – 1997 (EPINCONT1 (E1)), and 2006 – 2008 (EPINCONT2 (E2)). EPINCONT collected information about prevalence of UI, as well as information about type and severity of UI.

Results

A 16% relative increase in UI prevalence was found in 11 years. The women who answered E2 were significantly older, had a higher BMI and higher prevalence of diseases such as asthma, diabetes and angina compared with the women who answered E1.

The incidence of UI was 18.7%. Increase in BMI (OR 1.03, 95% CI: 1.02 – 1.04), weight increase (OR 1.29 (95% CI: 1.14 – 1.45) for gaining 3 – 10 kilos and OR 1.71 (95% CI: 1.47 – 1.99) for gaining 10 kilos or more) and parity (OR 1.37 (95% CI: 1.04 – 1.79) for 1 childbirth, OR 1.28 (95% CI: 1.03 – 1.61) for 2 childbirths, and OR 1.56 (95% CI: 1.26 – 1.95) for 3 or more childbirths when participating in E2) were all found to be associated with increased odds of incident UI in adjusted regression analyses. Increasing age reduced the odds of incident UI. The 11 year remission of UI was 34.1%. Increasing age (OR 0.98, 95% CI: 0.98 – 0.99), increasing BMI (OR 0.96, 95% CI: 0.95 – 0.98) and large weight gains of 10 kilos or more (OR 0.69, 95% CI: 0.54 – 0.88) were all associated with reduced remission of UI.

Conclusion

Crude UI prevalence increased between the studies. Changes in known risk factors for UI such as age, BMI, weight and parity could explain some of the relative increase in prevalence, and were also found to be associated with either incidence of UI, remission of UI or both.

[European Association of Urology guidelines on assessment and nonsurgical management of urinary incontinence]

CONTEXT

The previous European Association of Urology (EAU) guidelines on urinary incontinence comprised a summary of sections of the 2009 International Consultation on Incontinence. A decision was made in 2010 to rewrite these guidelines based on an independent systematic review carried out by the EAU guidelines panel, using a sustainable methodology.

OBJECTIVE

We present a short version of the full guidelines on assessment, diagnosis, and nonsurgical treatment of urinary incontinence, with the aim of increasing their dissemination.

EVIDENCE ACQUISITION

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches, based on Population, Intervention, Comparator, Outcome questions. Appraisal of papers was carried out by an international panel of experts, who also collaborated on a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

EVIDENCE SUMMARY

The full version of the guidelines is available online (http://www.uroweb.org/guidelines/online-guidelines/). The guidelines include algorithms that refer the reader back to the supporting evidence, and they are more immediately useable in daily clinical practice.

CONCLUSIONS

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where such evidence does not exist, they present a consensus of expert opinion.

EAU guidelines on surgical treatment of urinary incontinence

CONTEXT

The European Association of Urology (EAU) guidelines on urinary incontinence published in March 2012 have been rewritten based on an independent systematic review carried out by the EAU guidelines panel using a sustainable methodology.

OBJECTIVE

We present a short version here of the full guidelines on the surgical treatment of patients with urinary incontinence, with the aim of dissemination to a wider audience.

EVIDENCE ACQUISITION

Evidence appraisal included a pragmatic review of existing systematic reviews and independent new literature searches based on Population, Intervention, Comparator, Outcome (PICO) questions. The appraisal of papers was carried out by an international panel of experts, who also collaborated in a series of consensus discussions, to develop concise structured evidence summaries and action-based recommendations using a modified Oxford system.

EVIDENCE SUMMARY

The full version of the guidance is available online (www.uroweb.org/guidelines/online-guidelines/). The guidance includes algorithms that refer the reader back to the supporting evidence and have greater accessibility in daily clinical practice. Two original meta-analyses were carried out specifically for these guidelines and are included in this report.

CONCLUSIONS

These new guidelines present an up-to-date summary of the available evidence, together with clear clinical algorithms and action-based recommendations based on the best available evidence. Where high-level evidence is lacking, they present a consensus of expert panel opinion.

Does improved functional performance help to reduce urinary incontinence in institutionalized older women? A multicenter randomized clinical trial

Background

Urinary incontinence (UI) is a major problem in older women. Management is usually restricted to dealing with the consequences instead of treating underlying causes such as bladder dysfunction or reduced mobility.

The aim of this multicenter randomized controlled trial was to compare a group-based behavioral exercise program to prevent or reduce UI, with usual care. The exercise program aimed to improve functional performance of pelvic floor muscle (PFM), bladder and physical performance of women living in homes for the elderly.

Methods

Twenty participating Dutch homes were matched and randomized into intervention or control homes using a random number generator. Homes recruited 6–10 older women, with or without UI, with sufficient cognitive and physical function to participate in the program comprising behavioral aspects of continence and physical exercises to improve PFM, bladder and physical performance. The program consisted of a weekly group training session and homework exercises and ran for 6 months during which time the control group participants received care as usual. Primary outcome measures after 6 months were presence or absence of UI, frequency of episodes (measured by participants and caregivers (not blinded) using a 3-day bladder diary) and the Physical Performance Test (blinded). Linear and logistic regression analysis based on the Intention to Treat (ITT) principle using an imputed data set and per protocol analysis including all participants who completed the study and intervention (minimal attendance of 14 sessions).

Results

102 participants were allocated to the program and 90 to care as usual. ITT analysis (n = 85 intervention, n = 70 control) showed improvement of physical performance (intervention +8%; control −7%) and no differences on other primary and secondary outcome measures. Per protocol analysis (n = 51 intervention, n = 60 control) showed a reduction of participants with UI (intervention −40%; control −28%) and in frequency of episodes (intervention −51%; control −42%) in both groups; improvement of physical performance (intervention + 13%; control −4%) was related to participation in the exercise program.

Conclusions

This study shows that improving physical performance is feasible in institutionalized older women by exercise. Observed reductions in UI were not related to the intervention. [Current Controlled Trials ISRCTN63368283]

Impact of cough and urinary incontinence on quality of life in women and men with chronic obstructive pulmonary disease

AIMS AND OBJECTIVES

The aim of this study was to investigate the impact of cough and urinary incontinence on quality of life in women and men with chronic obstructive pulmonary disease in primary health care.

BACKGROUND

Existing information on the impact of cough and urinary incontinence on quality of life in patients with chronic obstructive pulmonary disease is scant.

DESIGN

A questionnaire survey.

METHOD

The study included 391 women and 337 men, aged 50-75 years, with chronic obstructive pulmonary disease. A self-administered questionnaire consisted of CCQ and SF-12 questionnaires. A response rate of 66% was obtained. Most patients had been diagnosed with moderate (Stage II) chronic obstructive pulmonary disease.

RESULTS

Women and men with urinary incontinence showed a significantly higher presence of symptomatic cough and phlegm production than did women and men without incontinence. Women with incontinence had a significantly higher burden of CCQ symptoms, functional and mental state than did women without incontinence. Concerning quality-of-life scores, women with incontinence had lower physical state scores (37·6 ± 10·4 vs. 41·4 ± 9·9; p < 0·001) and mental state scores (44·3 ± 10·2 vs. 47·1 ± 10·5; p < 0·007) than did women without incontinence. Men with incontinence had a significantly higher burden of CCQ symptoms and mental state than did men without incontinence. When examining the quality-of-life scores, men with incontinence had lower mental state scores than did men without incontinence (46·0 ± 9·7 vs. 49·8 ± 9·7; p < 0·001).

CONCLUSION

The present results indicate that cough and urinary incontinence lead to poor quality of life in women and men with chronic obstructive pulmonary disease.

RELEVANCE TO CLINICAL PRACTICE

In the context of primary health care, appropriate questions concerning urinary incontinence and quality of life should be included in care plans for women and men living with chronic obstructive pulmonary disease.

Fatores associados à incontinência urinária em idosos com critérios de fragilidade

Este estudo teve como objetivo analisar os fatores associados à incontinência urinária entre idosos, com critérios de fragilidade (pré-frágeis e frágeis). Trata-se de um estudo transversal, de natureza quantitativa. Foram entrevistados 100 idosos no ambulatório de geriatria de um hospital universitário do município de Campinas, São Paulo. Referiram incontinência urinária 65,0% dos idosos; destes, 40 (61,4%) relataram perda de urina diversas vezes ao dia e em pequena quantidade. A análise de regressão multivariada apontou relação estatisticamente significativa entre sexo (OR=3.67), infecção do trato urinário (OR=6.16) e escore da Medida de Independência Funcional (mobilidade) (OR=0.85). Os resultados mostraram que a infecção do trato urinário, a perda de mobilidade e o sexo são fatores associado á incontinência urinária em idosos com critérios de fragilidade. Esses fatores são passiveis de intervenções, visando à prevenção, e até mesmo, a redução dos episódios de queixa de incontinência urinária.

Theories of urinary incontinence causation: aetiological descriptions by sub-Saharan African women

OBJECTIVE

To describe the perceived causes of urinary incontinence (UI) and factors associated with awareness of causes of UI among women in the community.

STUDY DESIGN

Secondary analysis of data extracted from the Ibadan Urinary Incontinence Household Survey (IUIHS), a multi-stage community survey conducted among 5001 women in Nigeria.

RESULTS

The mean age was 34.8 years (SD=14.2). The majority had at least secondary education and were currently married. Within this population, 13% had ever leaked urine. On their perception of possible aetiological factors of UI, 20.5% mentioned pelvic floor or bladder-related causes such as stress incontinence triggers and bladder problems; 14.6% mentioned uncontrollable factors such as medical comorbidity, age and prior surgery; 8.8% attributed the cause to being female; and 6.8% mentioned sex-related factors. Multiple logistic regression analysis revealed significantly lower odds of awareness of the aetiology of urinary incontinence among women aged less than 30 years, those with lower level of education, rural women, those with five or more children and women without history of urine leakage.

CONCLUSIONS

The study shows a low level of awareness of possible cause of UI amongst women surveyed. We recommend health education and mobilization of women on the right aetiological factors of UI.

Aging and disease prevention

This article reviews evidence-based recommendations for geriatric prevention disciplines and topics including health behaviors (e.g., smoking cessation, physical activity), metabolic disorders, cardiovascular diseases, cancers, immunizations, depression, the promotion of independence,and polypharmacy. Recommendations for both the one-on-one, clinic-based setting and for community-wide initiatives are covered for each topic, as appropriate.

Is urinary continence considered in the assessment of older people after a fall in England and Wales? Cross-sectional clinical audit results

OBJECTIVES

To investigate adherence to the urinary function assessments of the national falls guidelines for England and Wales.

STUDY DESIGN

Secondary data analysis of the 2006 National Clinical Audit of Falls and Bone Health.

SETTING

Acute hospitals in the UK.

PARTICIPANTS

Patients aged 65 years and older with a fragility fracture as a result of a fall.

MAIN OUTCOME MEASURES

Data were analysed to determine whether patients with fragility fractures received an assessment of urinary function including continence status; whether impairment was detected and if action was taken to prevent continence related falls.

RESULTS

63% (2009) of 3184 patients were assessed for urinary continence following a hip fracture and 41% (817) of these identified a problem. 21% (1187) of 5642 patients with nonhip fragility fractures were assessed and a problem was found in 27% (316). Hip fracture patients were more likely (p<0.0001) to receive a continence assessment and have problems detected. Only about half of those with problems had any intervention or a referral to a continence service. Admission to hospital for nonhip fracture patients was a strong predictor of being assessed (p<0.0001).

CONCLUSION

Rates of assessment and action for those with who fall and have continence problems are low despite current national guidelines.

Prevalence of urinary incontinence in a random sample of the urban population of Pouso Alegre, Minas Gerais, Brazil

This study determines and analyzes the prevalence of Urinary Incontinence (UI) and its demographic and clinical predictors. This epidemiological and cross-sectional study was approved by the Research Ethics Committee of the University of São Paulo, Nursing School. The sample was randomly selected by cluster technique and included 519 individuals aged≥18 years, living in 341 houses in urban areas. Data were analyzed through Chi-Square, Hosmer Lemeshow's test and multivariate logistic regression (stepwise). Prevalence rates were standardized by gender and age. Of the 519 people composing the sample: 20.1% had UI, 32.9% were women and 6.2% were men. Longer duration of losses (OR=29.3; p<0.001), diabetes mellitus (OR=17.7; p<0.001), stroke (OR=15.9; p<0.001), and cystocele (OR=12.5; p<0.001) were the factors most strongly associated with UI. This study enabled the identification of UI epidemiology and can contribute to the development of public policies for its primary and secondary prevention and treatment, even if such measures are initially implemented at the city level.

Urinary incontinence in the aging female: etiology, pathophysiology and treatment options

Not only does the prevalence of incontinence increase with age, but the incidence does as well, in no small part due to the greater recognition of its signs and symptoms and the significant negative impact on quality of life. Elderly women differ from their younger counterparts by the presence of several physiologic changes in the urinary tract, as well as the presence of concomitant morbidity and polypharmacy. While the elderly have the same treatment options as younger women, they may experience a greater incidence of adverse events due to urologic and nonurologic factors. The objective of this article is to elucidate the unique changes in the elderly population and summarize the treatment options.

Dynamic progression of overactive bladder and urinary incontinence symptoms: a systematic review

CONTEXT

Overactive bladder (OAB) and urinary incontinence (UI) are worldwide public health problems. Longitudinal epidemiologic studies that assess the natural history of OAB and UI are valuable in making accurate prognoses, determining causes and consequences, and predicting resource utilization.

OBJECTIVE

Our aim was to assess whether the severity of OAB and UI symptoms progress dynamically over time, with the secondary aim of assessing factors that may be associated with symptom progression and regression.

EVIDENCE ACQUISITION

A systematic review of English articles published between January 1, 1990, and September 20, 2009, was conducted using PubMed and Embase. Search terms included longitudinal, natural history, overactive bladder, incontinence, progression, remission, and regression. Eligibility was assessed by Dr. Irwin with editorial assistance. Studies were required to be longitudinal and population based; meeting abstracts and conference proceedings were excluded. Results were assessed qualitatively.

EVIDENCE SYNTHESIS

Overall, the 7 longitudinal studies of OAB and 14 longitudinal studies of UI reviewed reported an increase in the incidence and remission/regression of both OAB and UI symptoms over time that varied across studies (eg, OAB incidence, 3.7-8.8%; UI incidence, 0.8-19%). The studies provide evidence for a dynamic progression of OAB and UI symptoms (eg, among women with OAB without urge urinary incontinence [UUI], 28% reported OAB with UUI 16 yr later) and also show that although symptom severity progresses dynamically, for many individuals symptoms also persist over long time periods.

CONCLUSIONS

The results support the hypothesis that OAB and UI symptom severity progress dynamically and are also sustained over time. However, the variations in symptom definitions and methods used across studies prevent statistical determinations of overall incidence rates. The recognition of OAB and UI as progressive conditions allows for a shift from the current treatment paradigm of symptom control alone to one of symptom management.