Communication between older adults and their physicians about urinary incontinence

Prevalence and Influencing Factors of Help-Seeking Behavior Among Women with Urinary Incontinence: A Systematic Review and Meta-Analysis

Purpose: This systematic review and meta-analysis aimed to investigate the mean (weighted) prevalence of help-seeking behavior among women with urinary incontinence (UI) in relevant subgroups and the related influencing factors. Materials and Methods: Six English and four Chinese databases were systematically searched between 1996 and July 10, 2022. Two researchers independently screened the literature, extracted data, and evaluated the quality of the included studies. All statistical analyses were conducted using RevMan 5.4. Results: The mean (weighted) prevalence of help-seeking behavior based on the 41 included studies, including a total of 32,640 women with UI, was 28% (95% confidence interval [CI]: 22%-34%). We performed a subgroup analysis based on UI type, population, region, publication time, case definition of help-seeking, and use of validated tools to determine UI. The results of the subgroup analysis showed that the pooled prevalence of help-seeking behavior was 23% (95% CI: 14%-32%) among pregnant and maternity women, 27% (95% CI: 19%-35%) among menopausal women, 24% (95% CI: 14%-35%) among 20- to 50-year-old women, 31% (95% CI: 25%-36%) among those older than 50 years, 24% (95% CI: 17%-30%) in Asia, and 33% (95% CI: 22%-44%) in Europe. Meanwhile, the pooled odds ratio showed that education level, UI type, UI severity, and quality of life significantly influenced help-seeking behavior among women with UI. Conclusions: This systematic review revealed that the pooled prevalence of help-seeking behaviors among women with UI is 28%. These influencing factors have important implications for adapting to health care and social care systems.

Preferences for Public Health Messaging Related to Bladder Health in Adolescent and Adult Women

Objective: The purpose of this analysis was to explore adolescent and adult women's preferences for the content and delivery of public health messaging around bladder health. Materials and Methods: This was a directed content analysis of focus group data from the Study of Habits, Attitudes, Realities, and Experiences, which explored adolescent and adult women's experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health and function across the life course. This article reports an analysis of the "Public Health Messaging" code, which includes participants' views on what information is needed about bladder health, attributes of messaging, and preferred locations and delivery methods. Results: Forty-four focus groups were conducted with 360 participants (ages 11-93 years) organized into six age groups. Across age groups, participants wanted messaging on maintaining bladder health and preventing bladder problems. They offered suggestions for a wide variety of methods to deliver bladder health information. Ideas for delivery methods fell into three broad categories: (1) traditional in-person modes of delivery, which included individual communication with providers in clinical settings and group-based methods in schools and other community settings where adolescent and adult women naturally gather; (2) internet-based website and social media delivery methods; and (3) static (noninteractive) modes of delivery such as pamphlets. Participants recommended the development of multiple delivery methods to be tailored for specific audiences. Conclusions: These findings can inform development of broad ranging public health messaging tailored to audiences of all ages with a goal of engaging adolescent and adult women across the bladder health risk spectrum.

Need for Public Health Messaging Related to Bladder Health from Adolescence to Advanced Age

Objective: The purpose of this analysis was to explore adolescent and adult women's interest in public health messaging around bladder health and perceptions of its usefulness. Materials and Methods: Directed content analysis of focus group data from the Study of Habits, Attitudes, Realities, and Experiences, which explored adolescent and adult women's experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health across the life course. This article reports an analysis of the "Public Health Messaging" code, which included participants' desire or need for information about bladder health and recommendations for appropriate priority audiences. Results: Forty-four focus groups were conducted with 360 participants organized into six age groups (11-93 years). There was consensus across age groups that more information about the bladder is wanted and needed throughout the life course, as there is currently a lack of reliable educational resources. Information on bladder health was seen as useful and important because it enables people to anticipate negative changes in bladder health and act to prevent these. Several priority audiences were identified based on their risk of developing symptoms, but participants also saw value in educating the general public regardless of risk status. They also recommended education for parents and teachers who are in positions to control bathroom access. Conclusions: Results indicate a uniform desire for information on women's bladder health and a need for more research to develop individual prevention strategies and public health messaging for women of all ages, as well as guidance for organizations with a role in supporting bladder health.

Urinary incontinence in women: treatment barriers and significance for Danish and German GPs

BACKGROUND

Female urinary incontinence (UI) is common. Only scant information exists on the significance of UI for GPs' consultations.

OBJECTIVES

(i) To assess the significance of female UI for GPs and to look at barriers that could be detrimental to treatment by comparing GPs from Denmark and Germany, with different health systems and access to UI guidelines. (ii) To assess whether GPs' gender and age were relevant to the discussion of UI.

METHODS

We conducted a cross-sectional survey. In the Fehmarn belt-region, a Danish-German border region, a self-developed questionnaire was sent to all the GPs (n = 930).

RESULTS

In total, 407 GPs returned the questionnaire (43%); 403 questionnaires were analysed. Using a scale from 0 (never) to 10 (always), addressing UI was reported with an average score of 3.8 (SD: 2.1) among Danish and 3.5 (SD: 2.1) among German GPs. The topic was discussed more frequently with female (4.2; SD 2.2) than with male GPs (3.2; SD 2.0). Danish GPs estimated the prevalence among their female patients at 10% (SD: 8.0) and German GPs at 14% (SD: 11.2). 61% of the Danish and 19% of the German GPs used UI guidelines. German GPs significantly more often reported the barrier 'uncertainty of how to treat UI' [OR = 5.39 (95% CI: 2.8; 10.4)].

CONCLUSIONS

In consultations with female GPs, UI was discussed significantly more frequently than with male GPs. Compared with the Danish GPs, German GPs stated significantly more uncertainties regarding UI treatment measures, and tended not to use UI guidelines.

Increasing Discussion Rates of Incontinence in Primary Care: A Randomized Controlled Trial

BACKGROUND

A minority of women with urinary incontinence (UI) and even fewer with fecal incontinence (FI) report having discussed it with a health care provider in the past year. Thus our aim was to evaluate whether the use of an electronic pelvic floor assessment questionnaire (ePAQ-PF) improves communication about incontinence in primary care.

METHODS

Women 40 years and older who were scheduled for an annual wellness physical at an internal medicine clinic between August 2007 and August 2008 were randomized to complete the ePAQ-PF prior to (n = 145) or after (n = 139) their visit. Clinicians of women in the intervention group received the ePAQ-PF report prior to the visit. Outcome measures from clinic note abstraction included mention of UI (primary) and FI. Participant-reported outcome measures included discussion of UI and FI and initiator of discussion.

RESULTS

Discussions of UI was more common in the intervention group than the control group: (27% vs. 19%; odds ratio [OR], 1.6 95% confidence interval [95%CI] 0.9-2.8, particularly for women over 60 (33% vs. 12%; OR 3.8, 95%CI 1.2-11.8) and for women with UI (42% vs. 25%; OR 2.2, 95%CI 1.1-4.1). The intervention primarily led to an increase in clinician-initiated UI discussions which were more common in the intervention group (18% vs. 4%, OR 4.8, 95%CI 1.9-12.0) Participants in the intervention group more frequently reported discussion of FI (14% vs. 6%; OR 2.5, 95%CI 1.1-6.0) which was clinician initiated in over half the cases (9% vs. 3%; OR 3.5, 95%CI 1.1-11.0).

CONCLUSIONS

Use of the ePAQ-PF prior to clinic visits increases discussion of UI and FI, particularly clinician-initiated discussion. These findings suggest that such instruments may increase the detection and treatment of this often "silent" affliction.

Improving resident screening and workup of urinary incontinence in an OB/GYN residency program: a randomized controlled study

OBJECTIVES

: With an aging US population, an increased prevalence of urinary incontinence, rising health care costs, and a disease that remains largely unidentified, there is an immediate need to train physicians to screen for and treat incontinence. We aim to evaluate resident physician screening of urinary incontinence with a chart-based review.

METHODS

: This study entailed 2 parts: a retrospective chart review (part 1) and a prospective randomized trial (part 2). Charts of 200 patients were retrospectively evaluated for documentation of bladder symptoms and incontinence for part 1. In part 2, patients' charts were prospectively randomized to receive a chart-alert sticker ("Do you leak urine?") that reminded resident physicians to ask about urinary incontinence in their general gynecology clinics. The primary outcome was documentation of urinary incontinence. Secondary outcomes were initiation of workup, diagnoses made, and treatment plans. Overall, 200 charts were needed for the prospective study to provide 80% power.

RESULTS

: Residents documented any type of bladder symptom (incontinence, urgency, frequency, dysuria, nocturia) in 32 (16.3%) of 196 charts in part 1 and 45 (23.7%) of the 190 randomized charts in part 2 (P = 0.154). In the prospective study, 88 included charts were randomized to receive the "Do you leak urine?" chart-alert sticker and 102 were randomized to no sticker. Residents documented that they asked about incontinence in 30 (34.1%) of the charts with stickers versus 4 (3.9%) of the charts without (P = 0.001).

CONCLUSIONS

Overall, the rate that resident physicians inquired about incontinence increased with the alert-sticker from 4% to 34%. Directed education will likely further this improvement.

The greatest taboo: urinary incontinence as a source of shame and embarrassment

INTRODUCTION

While urinary incontinence is often labeled as a taboo in the literature, we found no scientific data addressing this issue exclusively. The aim of our study was to measure the perception of urinary incontinence as a taboo and how this compares to other medical conditions that may be embarrassing.

METHODS

150 test persons completed a self-administered 13-item questionnaire about perception and knowledge of urinary incontinence. Data were analysed with the SPSS 10.0.5 software package using the U-test, Chi-square-test, Yates-correction, Fisher's exact test and Kolmogorov-Smirnov test.

RESULTS

Eighty-six (60.6%) of 142 respondents thought that urinary incontinence constituted a taboo in Austria. To be incontinent was considered significantly more embarrassing than depression or cancer, respectively (p = 0.001).

CONCLUSION

Despite its high prevalence, urinary incontinence is still considered a taboo in up to 60% of our Austrian test persons. The level of shame and embarrassment of urinary incontinence is significantly higher than that of depression and cancer.

Overactive bladder: the importance of tailoring treatment to the individual patient

INTRODUCTION

Overactive bladder (OAB) is a prevalent and persistent condition that is often under-diagnosed and under-treated, and which frequently requires tailored treatment for successful management.

METHODS

This consensus opinion-based review summarizes the discussions of a group of experts in the field of OAB that were assembled to evaluate the importance of correct diagnosis and appropriate pharmacotherapy in patients with OAB.

RESULTS

A thorough diagnostic process is crucial for allowing exclusion of underlying medical issues and differentiation from genitourinary conditions other than OAB. In addition, selecting the most appropriate pharmacotherapy needs to be carefully considered in the context of each patient with OAB. In general, patients with OAB tend to be older with various comorbidities and often receiving multiple concomitant medications. Treatment decisions should take into consideration the differing potential for antimuscarinic medications to alter cognitive and cardiovascular functions, both of which may be compromised in this patient population.

CONCLUSION

Tailoring treatment to individual patients by comprehensive patient assessment may lead to more effective management of patients with OAB, especially those receiving polypharmacy for comorbidities.

Patient experience with darifenacin - results of a short-term community-based survey in managing overactive bladder

OBJECTIVE

This community-based program evaluated patients' experiences with darifenacin over 3 weeks' treatment in a predominantly primary care clinical practice setting.

METHODS

Physicians (n = 2117, 50% primary care physicians, 35% urologists, 10% obstetrician/gynecologist, 5% other) were asked to introduce the program to patients with overactive bladder (OAB). Patients received an enrollment kit including a 30-day darifenacin voucher, activated if patients registered for the program via telephone or online. Patients (≥ 18 years of age) completed a brief automated survey to evaluate frequency of urge urinary incontinence episodes (UUIEs), micturitions/24 hours, urge severity/24 hours (10 point scale: 0 = not at all severe; 10 = very severe), and treatment tolerability (10 point scale: 0 = very poorly tolerated; 10 = very well tolerated). Patients also completed a second survey 3 weeks after starting darifenacin. Statistical analyses were not prospectively planned or performed.

RESULTS

A total of 2165 patients completed both surveys. At baseline, mean age of completers was 66 years, 76% were female, and 47% reported prior use of OAB medications. After 3 weeks' treatment, patients experienced reductions in UUIEs and micturitions. Urge severity was reduced by >30% after 3 weeks (mean scores: 6.7 at baseline vs. 4.6 after 3 weeks' treatment) and treatment was well tolerated (mean score: 7.7). Overall, 85% of patients who participated in the program did so due to physician influences.

CONCLUSIONS

The results of this 3-week, self-reported community-based survey indicate that patients were generally satisfied with darifenacin treatment and experienced a reduction in OAB symptoms. Darifenacin was generally well tolerated.

Low dose oral desmopressin for nocturnal polyuria in patients with benign prostatic hyperplasia: a double-blind, placebo controlled, randomized study

PURPOSE

We evaluated the long-term efficacy and safety of low dose oral desmopressin in elderly patients with benign prostatic hyperplasia with more than nocturnal voids and nocturnal polyuria more than 30% of total daily urine volume.

MATERIALS AND METHODS

Eligible patients with benign prostatic hyperplasia older than 65 years with nocturia, nocturnal polyuria and International Prostate Symptom Score 14 or greater were included in the study. All patients received placebo or 0.1 mg desmopressin orally at bedtime. Patients were required to visit the outpatient clinic from the first visit, and after 1, 3, 6 and 12 months of treatment. Patients maintained flow volume charts and used diaries to record voiding data throughout the study. During followup urinalysis, urine sodium, urine osmolality, serum electrolytes, prostate specific antigen, International Prostate Symptom Score, quality of life, transrectal ultrasonography of prostate, uroflowmetry and post-void residual urine volume were performed at each visit.

RESULTS

A total of 115 patients were enrolled in the study and randomized as 58 in the placebo group and 57 in the desmopressin group. Desmopressin significantly decreased nocturnal urine output and the number of nocturia episodes, and prolonged the first sleep period (p < 0.01). Compared to before treatment desmopressin gradually decreased serum sodium and induced statistically but not clinically significant hyponatremia after 12 months of treatment. No serious systemic complications were found during medication.

CONCLUSIONS

Low dose oral desmopressin is an effective and well tolerated treatment for nocturnal polyuria in the lower urinary tract symptoms of patients with benign prostatic hyperplasia. Long-term desmopressin therapy gradually decreases serum sodium and it might induce hyponatremia even in patients without initial hyponatremia. For long-term desmopressin administration serum sodium should be assessed carefully, at least at 1 week after treatment.

[Communication about incontinence between affected individuals and health care providers - the patients' perspective]

Communication is a key competence for medical and nursing health care providers alike. However, there appear to be areas of "speechlessness" regarding specific medical problems, including the "taboo" disease incontinence. There is a lack of scientific data regarding incontinence in the context of communication among patients and health care professionals.The descriptive study was designed to provide insights how female and male patients alike perceive communications about incontinence with doctors and nurses, respectively. 22 structured interviews were conducted and taped with 16 elderly female and 6 male patients (age >/= 60 years, mean: 81 years, demented patients excluded, n = 19 analysable), and five interviews each with doctors and nurses within the setting of a rehabilitation hospital for geriatric patients (not reported here). We used published methodology to interpret the diversity of patients' verbal communications to the female interviewer.Results suggest that patients wish to find a relationship based on sympathy, empathy and trust. If incontinence is addressed, it is by doctors, not patients. Statements by patients suggest that they differentiate between expectations addressing the professional level of medical care, and a level perhaps best described as the quality of the personal relationship between the patient and doctor. However, these twofold expectations were not distinguishable regarding nursing professionals, they were perceived on a "personal care level" only, not the professional level regarding incontinence. Independent of professional affiliation, patients expect empathy, understanding, and respect. They selectively criticize manners of (some) nurses and lack of understandable transfer of information by doctors. The gender of the care providers was not an issue for patients regarding communication about incontinence. The preliminary results show that there is room for improvement for better communication regarding incontinence. However, areas affected appear to differ between nursing and medical professionals.

Effectiveness of a new self-positioning pessary for the management of urinary incontinence in women

OBJECTIVE

The objective of the study was to evaluate the effectiveness of a new self-positioning women's incontinence pessary.

STUDY DESIGN

Thirty-two women were enrolled and followed up for 12 months. Evaluation included baseline questionnaires, physical examination including pelvic organ prolapse quantification (POP-Q) scores, cotton swab testing, and assessment of Kegel strength. A pad test and 7 day urolog were also performed before and after pessary fitting.

RESULTS

Incontinence questionnaire scores were all significantly reduced as percent of baseline: stress incontinence, 7 of 15 (47%) (P = .000); urge incontinence, 5 of 14 (36%) (P = .002); the urogenital distress inventory (short form); 2 of 6 (33%) (P = .002); and incontinence impact questionnaire (short form), 4 of 8 (50%) (P = .002). Leaking episodes decreased by 4 (7 day urolog) (P = .028) and pad weights by 11 g (P = .006). Among women successfully fitted at 2 weeks, 16 of 21 or 76% continued using their pessary at 1 year. There were no complications with pessary use.

CONCLUSION

The Uresta incontinence pessary significantly reduces urinary incontinence and is easy for women to use.

A survey of Canadian websites providing information about female urinary incontinence

OBJECTIVE

Urinary incontinence (UI) is a prevalent health issue that has significant detrimental effects on quality of life. The Internet offers a unique vehicle for incontinent women to access information that could facilitate conservative self-help therapy. An evaluation of Canadian websites offering female UI information was conducted to determine their quality and readability.

METHODS

We evaluated websites using published general quality criteria for health sites and a quality assessment tool compiled by the authors for specific UI information derived from published, peer-reviewed clinical practice guidelines. Three health care professionals reviewed sites for quality, Canadian content, and interactivity. The readability of health information was also evaluated.

RESULTS

Fifty-six Canadian sites (18 professional, 22 organizational, 16 commercial) were evaluated. Significant agreement was found among the raters' evaluations on all measures. For all sites, the mean scores were general quality, 9/14; specific UI quality, 30/122; reading ease, 37/100; grade level, 10.9. The median score for Canadian content was high, but for interactivity it was low. The only significant difference between site types was for general quality (F [2,165]=3.38, P=0.036). Post hoc Tukey's tests showed a significant difference between organizational and commercial sites, with organizational sites having higher general quality.

CONCLUSION

Canadian websites providing female UI information have moderately high general quality, low specific UI information quality, minimal interactivity, and more than minimal Canadian content. The reading level of most sites is too high for average consumers. A webliography of the best sites has been developed to guide patients.

Bladder control educational needs of older adults

Bladder control problems, especially urinary incontinence (UI) and urinary freqency and urgency, are prevalent among older adults. The purpose of this project was to determine older adults' educational needs, preferred format, and interest in bladder control educational materials. Eighty-one older adults participated in focus groups conducted at senior centers, churches, and senior apartment dwellings located in Philadelphia, PA. A doctorally prepared nurse acted as the moderator, using a questionnaire that included items on general health issues and specific questions about bladder control issues. Participants showed interest in learning more about bladder control issues, discussed their preferences in relation to format for receiving health-related information, and expressed their interest in bladder control educational materials. This information can be used to devise an educational program about bladder control that is acceptable to older adults and can be easily accessed in settings where they reside or recreate.

Validation of a two-item quantitative questionnaire for the triage of women with urinary incontinence

OBJECTIVE

To evaluate the reproducibility, construct validity, and preferences for the 2-item Stress/Urge Incontinence Questionnaire.

METHODS

The questionnaire asks a patient to recall the number of stress urinary incontinence and urge urinary incontinence episodes she experienced during the preceding week. The 4-week prospective study included 3 office visits and enrolled women with stress, urge, or mixed urinary incontinence symptoms. The test-retest reproducibility was assessed after 3 days, and the construct validity of the questionnaire was evaluated against a diary and other measures of incontinence severity and effect. The bother associated with completing (patients) or analyzing (physicians) the diary was assessed. Both groups also reported their time requirements and preferences for the questionnaire or diary.

RESULTS

Reproducibility for the classification of symptoms was moderately strong (kappa = .536). Test-retest agreement was good (64-80%) for all but balanced mixed incontinence (38%). Intraclass correlations revealed good reproducibility for the number of stress (.694), urge (.703), and total (.726) incontinence episodes. Significant (P < .01) correlations with other measures of incontinence established construct validity. Patients and physicians reported it took less time to complete the questionnaire than the diary, but the majority said the completion or analysis of the diary was of little or no bother and preferred the diary.

CONCLUSION

The Stress/Urge Incontinence Questionnaire is a valid tool that can be used in clinical practice to differentiate between symptoms of stress and urge urinary incontinence to make an initial diagnosis, especially in primary care where incontinence is not a focus of the practice.

Effectiveness of a Computer-Based System to Deliver a Continence Health Promotion Intervention

OBJECTIVE

The objective of this study was to test a computer-based system for continence health promotion that included self-management techniques for women with symptoms of involuntary urine loss, urinary frequency or urgency, or nocturia.

DESIGN

A quasi-experimental trial design with repeated measures was used.

SETTING AND SUBJECTS

Older women (n = 71) with continence problems were recruited and completed a computer session.

INSTRUMENTS

Outcomes were measured with the Urogenital Distress Inventory-Short Form, the Incontinence Impact on Life Questionnaire-Short Form, and a bladder diary. A modified Questionnaire for User Interface Satisfaction was used to measure satisfaction with the system.

METHODS

Participants assigned to the intervention group (n = 36) used the computer-based system for continence health promotion, and those in the wait list control group (n = 35) used an alternate system. Data were collected at baseline and 8 weeks after the computer session.

RESULTS

Analysis of covariance results on symptom distress and quality of life scores showed no significant treatment effect, although a trend toward improvement was observed. The intervention group improved significantly on urogenital distress (P = .01) and quality of life (P = .003) outcomes, but the control group did not. Women had little difficulty using the system and expressed satisfaction with the individualized information provided.

CONCLUSIONS

Although the computer-based system did not result in significantly improved outcomes when comparing women in the 2 groups, the computer-based group improved significantly from baseline to follow-up. Further research on a computer-based system that women could access independently or that nurses could use to supplement traditional care is warranted.

Validation of an overactive bladder awareness tool for use in primary care settings

Overactive bladder (OAB)--a syndrome characterized by urinary urgency, with or without urge incontinence, urinary frequency and nocturia--is estimated to affect 10% to 20% of the US and European populations. This study was carried out to validate a patient-administered screening awareness tool to identify patients with bothersome OAB symptoms. Patients were recruited from 12 primary care and 1 gynecology practice during regularly scheduled appointments. Enrollees completed an 8-item questionnaire assessing the amount of "bother" they associated with OAB symptoms. Clinicians then asked the patients 4 questions regarding urinary frequency, urgency, nocturia, and incontinence. If the screening was positive for symptoms of OAB or if the patient provided positive responses to the urinary symptom questions, the clinician asked additional questions regarding lifestyle and coping behaviors. The clinician then diagnosed the patient, placing him or her in the "No OAB," "Possible OAB," or "Probable OAB" category. Multivariable logistic regressions controlling for age and sex were performed to assess the applicability of the tool for identifying patients with OAB. A total of 1,299 patients were enrolled, and 1,260 provided complete data. Patients were aged 51.6+/-17.0 years, 62% were female, most (89%) were Caucasian, 22% experienced urinary urgency, and 18% experienced urge incontinence. The prevalence of Probable OAB was 12%. The c-index of the model identifying patients with a diagnosis of Probable OAB was 0.96, with a sensitivity and specificity of 98.0 and 82.7. For OAB-V8 scores >or=8, the odds ratio for Probable OAB was 95.7 (95% CI: 29.3; 312.4). The OAB-V8 performed well in helping clinicians identify patients with bothersome OAB symptoms in a primary care setting and will assist clinicians in identifying patients who may benefit from treatment.

Stress Urinary Incontinence in Active Elderly Women

Urinary incontinence in the elderly is a significant health problem fraught with isolation, depression, and an increased risk of institutionalization and medical complications. Stress urinary incontinence (SUI), the complaint of involuntary loss of urine during effort or exertion or during sneezing or coughing, is the most common type of urinary incontinence. SUI can seriously degrade the quality of life for many active seniors, and has become an economic challenge for society. With the rapid increase in the active elderly worldwide, SUI is becoming a significant global problem. However, since only a fraction of women with SUI have consulted a physician, the clinical extent and public health impact of SUI are probably underestimated. The mounting social, medical, and economic problem of SUI in active elderly women as a rapidly growing segment of the population worldwide is reviewed. We evaluate the age-related changes of the lower urinary tract, examine risk factors, and suggest different treatment options shown to be effective in reducing SUI in this population.

An evaluation of three community-based projects to improve care for incontinence

The Australian National Continence Management Strategy commissioned the implementation and evaluation of three community-based projects designed to improve care for people with incontinence by improving the detection and treatment of urinary incontinence. Projects were located in demographically diverse areas, overseen by co-operating professional groups with an interest in continence and aimed at facilitating a pathway of care for those with incontinence. Project activities focused on health care provider training and improving local referral networks, as well as raising public awareness. Multifaceted evaluation of each project was designed to inform principles for a national approach to continence care. The evaluation indicated that providers involved in each project became more confident in their ability to manage incontinence, had significantly increased knowledge of issues around incontinence and became more aware of local options for referral. However, there was little evidence that projects achieved an increase in seeking professional help among those with incontinence. From the evaluation, six principles were developed to guide future models of community-based continence care.

Urinary incontinence: a treatise on gender, sexuality, and culture

Attitudes toward older adults with incontinence vary significantly between societies and cultures. Intangible consequences arising from such attitudes may exert enormous psychosocial strain on affected older adults, caregivers, family members, and social networks. Health providers should consider psychologic, gender based,and sociocultural differences in formulating efficient screening and therapeutic strategies for older adults who have UI.

Factors associated with women's decisions to seek treatment for urinary incontinence

BACKGROUND

Urinary incontinence is a highly prevalent and burdensome condition among women. However, fewer than half of women with symptoms talk to a physician about incontinence, and the determinants of treatment seeking are not well understood.

DESIGN

A two-stage cross-sectional survey of adult U.S. women; 45,000 households participating in NFO Worldgroup survey research received a questionnaire to identify adults with incontinence. Based on stratified random sampling of identified incontinent women, 2310 women received a detailed questionnaire.

RESULTS

Among 1970 women with urinary incontinence symptoms, 38% had initiated a conversation with a physician about incontinence. In multivariate logistic regression analysis, some of the factors associated significantly with treatment seeking were symptom duration >3 years (OR 2.33, 95% CI 1.57-3.45), having a history of a noticeable accident (OR 1.41, 95% CI 1.06-1.87), worse disease-specific quality of life scores (OR 1.89, 95% CI 1.32-2.70), not being embarrassed to talk with a physician about urinary symptoms (OR 1.65, 95% CI 1.28-2.14), talking with others about urinary incontinence (OR 3.34, 95% CI 2.49-4.49), and keeping regular appointments for routine/preventive care (OR 2.25, 95% CI 1.54-3.29).

CONCLUSIONS

Less than half of community-dwelling adult U.S. women with symptoms of urinary incontinence have talked with a physician about urinary incontinence. In addition to duration of symptoms, factors associated with treatment seeking included the impact of incontinence on quality of life, lack of embarrassment about talking to a physician about urinary symptoms, and attitudes toward healthcare use. Concerns about the meaning of incontinence for overall and future health were important reasons for women choosing to seek treatment.

Use of the Agency for Health Care Policy and Research Urinary Incontinence Guideline in Nursing Homes

The objective of this study was to assess the use of the Agency for Health Care Policy and Research (now called the Agency for Healthcare Research and Quality) Urinary Incontinence (UI) Guideline (1996) in nursing homes (NHs) using retrospective chart review and nursing assistant screening interviews. The study was conducted in a nonrandom sample of 52 NHs in upstate New York. Two hundred residents developing new UI or newly admitted with UI on the dayshift and who met criteria for evaluation and treatment/management were evaluated in the 12 weeks after onset of or admission with UI. Fifteen percent of newly admitted residents needed evaluation. Of residents already in NHs, 2.3 per 100 beds developed new UI over the 12 weeks. Aspects of UI evaluation rarely done were rectal examination (15%), digital examination of prostate (15%), and pelvic examination (2%). Sixty-eight percent had a culture/sensitivity, 56% a urinalysis, and 6% a postvoid residual. Eighty-one percent had a reversible cause at the time of onset, but only 34% had all addressed. Few (2%) needed urologist evaluation. Treatment was rare (3%), but management using toileting and absorbent products were common. Only 6% achieved resolution of UI. These results suggest that assessment and treatment of UI is manageable (a total of 4.2 new cases per 100 beds per 12 weeks) but quality is not adequate. On average, only 20% of the standards applicable were met, due primarily to lack of awareness of new UI and lack of familiarity with the guideline. Thus, improvements are needed. Recommendations for guideline revision are made.

[Prevalence of urinary incontinence and linked factors in men and women over 65]

OBJECTIVES

To calculate the prevalence of urinary incontinence and to identify linked factors in a population of elderly people living in their homes.

DESIGN

Population survey.

SETTING

Leganés (Madrid).

PARTICIPANTS

Representative sample of people over 65 registered in Leganés (n=1560). Two interviews at home were conducted. The second interview included a medical examination. The reply rate was 75% (n=1150).

MAIN MEASUREMENTS

Frequency of involuntary losses of urine and use of medication and absorbents, health status, use of diuretics and oxybutinin, and demographic and social variables.

RESULTS

The prevalence of urinary incontinence was 14% (95% CI, 11%-17%) in men and 30% (95% CI, 26%-34%) in women. Advanced age was associated with greater prevalence in men but not in women. In the multivariate analysis, factors associated with urinary incontinence were comorbidity and cognitive deficit. In addition, in women, high Body Mass Index and seriously limited movement were added factors. 20% of women and 5% of men over 65 used absorbents. The use of diuretics and the low number of patients receiving specific treatment for urinary incontinence suggested that there was low detection of this problem.

CONCLUSIONS

Urinary incontinence is common and could be better detected and treated in primary care. Prevention of urinary incontinence in women should begin before old age.

The effects of implementation of the Agency for Health Care Policy and Research urinary incontinence guidelines in primary care practices

OBJECTIVES

To determine whether a multifaceted intervention based on the Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guidelines for Urinary Incontinence would increase primary care physician screening for and management of urinary incontinence (UI).

DESIGN

Group randomized trial, conducted from 1996 to 1997.

SETTING

Internal medicine and family medicine community practices.

PARTICIPANTS

Forty-one primary care practices, including 57 physicians and their staff and 1,145 patients aged 60 and older.

INTERVENTION

Twenty of the 41 primary care practices in North Carolina were randomized to a composite intervention that included a 3-hour continuing medical education accredited course, training in management of UI, patient educational materials, and on-site physician and office support. The remaining 21 practices served as "usual care" controls. Telephone surveys of UI status and quality of life were obtained from 1,145 patients before the intervention. At 1 year, patients and physicians were contacted by telephone and mail to determine the effect of the educational intervention.

MEASUREMENTS

Patients completed telephone surveys to assess screening for UI, UI status, treatment interventions, and quality of life. Physicians completed surveys related to UI treatment and practice patterns.

RESULTS

Baseline and endpoint telephone surveys were completed by 668 of 1,145 (58%) of patients, who were cared for by 45 physicians (10 internists, 35 family medicine). Physician screening rates for UI were 22% for those patients who did not report UI. UI was reported by 39.5% of patients at baseline, of whom 30% reported being asked about UI by their primary care physician during the study. Rates of assessment and management of existing UI were low in both the control and intervention groups. Additional historical questioning indicated that 54.2% reported that they had ever undergone assessment, including history, urinalysis, or testing, or had had management of their UI by any physician.

CONCLUSION

Attempts at increasing screening and management of UI by primary care physicians using the AHCPR standardized guidelines using a multifaceted system of educational and logistical support were not successful. These guidelines may not be the best approach to treating UI in the primary care setting.

Promoting Self-Management of Urinary Incontinence in a Geropsychiatric Day Treatment Program

As the number of older adults in the United States increases, the number of older adults with mental illnesses also will increase. There will be a corresponding increase in prevalence of UI and its associated problems--medical problems, loss of independence or need for institutionalized care, diminished quality of life, and increased costs. Psychiatric nurses are in a position to help older adults with mental illnesses improve their overall health and quality of life by preventing the problems associated with untreated UI. Within their practice, psychiatric nurses have the opportunity to ensure clients receive the comprehensive assessments needed to establish their functional, physical, behavioral, emotional, and social support status--information that forms the foundation for developing individualized treatment interventions. Psychiatric nurses have the expertise to integrate physical and mental health care for older adults with mental illnesses and co-occurring conditions, such as UI. Promoting self-management of UI among older adults with mental illnesses potentially will enable them to participate in psychiatric rehabilitation programs; improve their overall health and quality of life; prevent falls and fractures that often cause them to lose their independent community living status and to be admitted to long-term care facilities; and reduce the cost to mental health care providers of managing UI in the treatment setting.

Clinical approach to urinary incontinence: a comparison between internists and geriatricians

To compare the initial approach and pattern of practice between internists and geriatricians in treating urinary incontinence. A retrospective chart review of 300 consecutive charts of elderly patients over the age of 65, seen by either internists (IM) or Geriatricians (GERI) for urinary incontinence at the Cleveland Clinic Florida was performed. The clinical approaches to the management of urinary incontinence were compared between IM and GERI groups by using a Student's t test. The mean age for these patients was 77 y for the IM group and 79 y for the GERI group. Majority of patients suffered from two chronic illnesses. We found that geriatricians performed more initial work up such as urodynamic testing before referring, while internists obtained more referrals to gynecologist with special interest in urologic disorders (currently called urogynecologist) without initial workup. IM and GERI groups equally prescribed medications for incontinence. However, the GERI group recommended Kegel exercises more frequently. This study showed that geriatricians manage urinary incontinence more extensively by performing more initial work up including urodynamics and providing initial behavioral therapy (Kegel exercise and toilet schedule) before referring to specialists. Perhaps geriatricians feel more comfortable treating urinary incontinence as shown by their lower frequency of referrals and are therefore more comfortable than internists at addressing this medical issue. On the contrary, the internist did the initial evaluation but preferred to get a referral perhaps due to less familiarity with urinary incontinence.

Efficacy of desmopressin in the treatment of nocturia: a double-blind placebo-controlled study in men

OBJECTIVE

To investigate the efficacy and safety of oral desmopressin in the treatment of nocturia in men.

PATIENTS AND METHODS

Men aged >/=18 years with verified nocturia (>or=two voids/night) and nocturnal urine production greater than their maximum functional bladder capacity were recruited. A 3-week dose-titration phase established the optimum desmopressin dose (0.1, 0.2 or 0.4 mg). After a 1-week 'washout' period, patients who responded in the dose-titration period were randomized to receive the optimal dose of desmopressin or placebo in a double-blind design for 3 weeks.

RESULTS

In all, 151 patients entered the double-blind period (86 treated with desmopressin, 65 with placebo). In the desmopressin group 28 (34%) patients and in the placebo group two (3%) patients (P<0.001) had fewer than half the number of nocturnal voids relative to baseline; the mean number of nocturnal voids decreased from 3.0 to 1.7 and from 3.2 to 2.7, respectively, reflecting a mean decrease of 43% and 12% (P<0.001). The mean duration of the first sleep period increased by 59% (from 2.7 to 4.5 h) in the desmopressin group, compared with an increase of 21% (from 2.5 to 2.9 h) in the placebo group (P<0.001). The mean nocturnal diuresis decreased by 36% (from 1.5 to 0.9 mL/min) in the desmopressin group and by 6% (from 1.7 to 1.5 mL/min) in the placebo group (P<0.001). The mean ratio of night/24-h urine volume decreased by 23% and 1% (P<0.001), and the mean ratio of night/day urine volume decreased by 27% and increased by 3% (P<0.001) for the desmopressin and placebo groups, respectively. In the double-blind treatment period, similar numbers of patients had adverse events; 15 (17%) patients in the desmopressin and 16 (25%) patients in the placebo group. Most adverse events were mild. Serum sodium levels were <130 mmol/L in 10 (4%) patients and this occurred during dose-titration.

CONCLUSIONS

Orally administered desmopressin is an effective and well-tolerated treatment for nocturia in men.

Comprehensive geriatric assessment: making the most of the aging years

The elderly population is the most rapidly growing segment of our population. This group utilizes the highest proportion of medical care of any age group. Comprehensive geriatric assessment involves the evaluation of the physical, psychosocial and environmental factors that impact on the well-being of older individuals. The use of an organized approach with objective measurements helps target key areas of functional status. Important areas include the evaluation of activities of daily living, cognition, mood, social supports, gait and falls, nutrition, sensory impairments, incontinence, polypharmacy, elder abuse, pressure sores, pain, and advance directives. The provision of primary and secondary prevention is also increasingly important for older individuals. The components of a successful geriatric assessment program are outlined, with suggestions to improve compliance.

Urinary incontinence, the hidden health problem of Cretan women: report from a primary care survey in Greece

OBJECTIVE

The prevalence of urine leakage and care-seeking rates of women 35-75 years of age who visited GPs in two rural areas of Crete were investigated.

PARTICIPANTS

All the women who visited their family physician in two primary care units during the period of August to November 1997 (N = 251) were asked if they had experienced symptoms of involuntary urine leakage. A set of questions was addressed to the women who replied positively.

RESULTS

Sixty-nine of the 251 women (27.5%) reported symptoms of involuntary urine leakage, and among the incontinent women 11 (15.9%) had previously contacted the health services about their problem. Only six out of thirty (20%) of the incontinent women who report effects on household activities, social and sexual life had contacted a physician about urinary incontinence (UI). The most common reason reported for not consulting the physicians was that the symptoms were not considered serious (35 women out of 58, 60.3%).

CONCLUSION

This study points out the need for further awareness programs for both women and healthcare professionals to be set up in countries like Greece, in which a low care-seeking rate of incontinent women has been reported.

Why older community-dwelling adults do not discuss urinary incontinence with their primary care physicians

OBJECTIVES

This study explored reasons why older adults with urinary incontinence (UI) do not initiate discussions with or seek treatment for UI from their primary care provider.

DESIGN

A randomized, prospective controlled trial involving 41 primary care sites.

SETTING

Primary care practice sites.

PARTICIPANTS

49 older adults age 60 and older not previously screened for UI by their primary care doctor.

MEASUREMENTS

Demographic data, self-reported bladder-control information using questionnaires, and health status.

RESULTS

Adults who did not discuss UI were older, had less-frequent leaking accidents and fewer nighttime voids and were less bothered by UI than those who did. The two main reasons why patients did not seek help were the perceptions that UI was not a big problem (45%) and was a normal part of aging (19%).

CONCLUSIONS

Embarrassment or lack of awareness of treatment options were not significant barriers to discussing UI. Adults with a fairly high frequency of UI (average of 1.7 episodes per day) did not view UI as abnormal or a serious medical condition.

The association of depressive symptoms and urinary incontinence among older adults

OBJECTIVES

To examine the relationship of urinary incontinence (UI) and depressive symptoms (DS) in older adults.

DESIGN

A randomized, controlled trial to determine the effects of clinical practice guideline implementation on provider attitudes and behavior, and patients' UI, health status, quality of life, and satisfaction with care. Baseline and endpoint data were collected from patients via computer-assisted telephone interviewing.

SETTING

Forty-one nonacademic primary care practices (PCP) in North Carolina.

PARTICIPANTS

A total of 668 community-dwelling adults (age > 60) who had visited the one of the selected PCPs.

INTERVENTION

PCPs in the intervention group were given instruction in the detection and management of UI, educational materials for providers and patients, office system supports, and academic detailing.

MEASUREMENTS

The dependent measure was assessed using an eight-item screener for DS. UI (status, frequency, amount), health (physical, mental), and demographic (age, gender, marital status) and self-report information about bladder control served as predictors.

RESULTS

Wilcoxon rank sum tests showed that UI status was associated with moderate to severe DS (43% vs 30%, P = .05). Multivariate analyses showed that UI status, physical and mental health, and gender were significant predictors of DS. Among UI adults (n = 230), physical and mental health, life satisfaction, and the perception that UI interfered with daily life were significant predictors of DS.

CONCLUSIONS

This study provides clear evidence that UI is related to DS in older adults.

A thorough going over: evidence for health assessments for older persons

OBJECTIVE

To review published randomised controlled trials of health assessments for older people; consider the effects of assessments in maintaining health and quality of life for older people; and identify those factors associated with more successful health assessment programs.

METHODS

A systematic literature search and methodological review of published studies of health assessments for people aged 65 years and over, living in the community.

RESULTS

Twenty-one trials were identified. They were widely heterogeneous in terms of methodological quality, assessment content and outcome variables. While the studies' results are inconsistent, the majority of the more methodologically sound studies report improvements in health. The studies reporting positive health outcomes were not specifically targeted to particular groups at high need, but were applied to all people in the source population who had reached a set age, usually 75 plus. In the majority of studies reviewed, the assessments were conducted by non-medical personnel (nurse, lay interviewer/volunteer or office staff).

CONCLUSIONS

Health assessments have been associated with improved health outcomes for older people. An evidence base for specific components to be included in the assessments is yet to be derived.

IMPLICATIONS

In November 1999, new Medicare items to provide for health assessments for persons in Australia aged 75 years and over were introduced. The acceptability, adoption and effectiveness of these items needs careful monitoring.