Urinary Incontinence in Adults: Clinical Practice Guideline Update

Overview

In 1992, the Agency for Health Care Policy and Research (AHCPR) released its first guideline on urinary incontinence. Since then the guideline has become the standard of care for incontinence in many settings across the country.

This update of the guideline reflects new findings in the rapidly changing field of treatment for urinary incontinence. To develop the update, AHCPR convened a multidisciplinary private-sector panel of physicians, nurses, allied health professionals, and health care consumers to study the effectiveness of diagnostic and treatment procedures for urinary incontinence, their costs, and how they affect patient outcomes.

The results of this research show that incontinence can be improved, and in some cases, even cured. Anecdotal evidence shows that long-term care facilities that have adopted the guideline have improved the quality of life of their patients and saved money at the same time.

What Is Urinary Incontinence?

Urinary incontinence (UI), or the unintentional loss of urine, is a problem for more than 13 million Americans—85 percent of them women. Although about half of the elderly have episodes of incontinence, bladder problems are not a natural consequence of aging, and they are not exclusively a problem of the elderly.

Incontinence has several causes. Women are most likely to develop incontinence either during pregnancy and childbirth, or after the hormonal changes of menopause, because of weakened pelvic muscles. Older men can become incontinent as the result of prostate surgery. Pelvic trauma, spinal cord damage, caffeine, or medications including cold or over-the-counter diet tablets also can cause episodes of incontinence.

But even though urinary incontinence can be improved in 8 out of 10 cases, fewer than half of those with bladder problems ever discuss the condition with their health care professional. The condition often goes untreated.

Facts About Incontinence

• 13 million Americans are incontinent; 11 million are women.
• 1 in 4 women ages 30-59 have experienced an episode of UI.
• 50% or more of the elderly persons living at home or in long-term care facilities are incontinent.
• $16.4 billion is spent every year on incontinence-related care: $11.2 billion for community-based programs and at home, and $5.2 billion in long-term care facilities.
• $1.1 billion is spent every year on disposable products for adults.

Types and Causes of UI

There are four common types of incontinence:

1. Stress incontinence happens when the bladder can't handle the increased compression during exercise, coughing, or sneezing. This kind of incontinence happens mostly to women under 60 and in men who have had prostate surgery.

2. Urge incontinence is caused by a sudden, involuntary bladder contraction. It is more common in older adults.

3. Mixed incontinence is a combination of both stress and urge incontinence, and is most common in older women.

4. Overflow incontinence, in which the bladder becomes too full because it can't be fully emptied, is rarer and is the result of bladder obstruction or injury. In men, it can be the result of an enlarged prostate.

5. Other factors can cause incontinence such as decreased mobility, cognitive impairment or medications.

Treatment Recommendations

Treatment for UI depends on the type of incontinence, its causes, and the capabilities of the patient. The guideline update recommends the following treatments:

Pelvic Muscle Rehabilitation—to improve pelvic muscle tone and prevent leakage.

• Kegel exercises. Regular, daily exercising of pelvic muscles can improve, and even prevent, urinary incontinence. This is particularly helpful for younger women. Should be performed 30-80 times daily for at least 8 weeks.
• Biofeedback. Used in conjunction with Kegel exercises, biofeedback helps people gain awareness and control of their pelvic muscles.
• Vaginal weight training. Small weights are held within the vagina by tightening the vaginal muscles. Should be performed for 15 minutes, twice daily, for 4 to 6 weeks.
• Pelvic floor electrical stimulation. Mild electrical pulses stimulate muscle contractions. Should be performed in conjunction with Kegel exercises.

Behavioral Therapies—to help people regain control of their bladder.

• Bladder training teaches people to resist the urge to void and gradually expand the intervals between voiding.
• Toileting assistance uses routine or scheduled toileting, habit training schedules, and prompted voiding to empty the bladder regularly to prevent leaking.

Pharmacologic Therapies—to improve incontinence medically.

• Oxybutynin (brand name Ditropan) prevents urge incontinence by relaxing sphincter muscles.
• Estrogen, either oral or vaginal, may be helpful in conjunction with other treatments for postmenopausal women with UI.

Surgical Therapies—to treat specific anatomical problems.

• Sling procedures, bulking injections (such as collagen) and other surgical procedures support or move the bladder to improve continence.

Treatment Recommendations for the Chronically Incontinent

Although many people will improve their continence through treatment, some will never become completely dry. They may need to take medications that cause incontinent episodes or have cognitive or physical impairments that keep them from being able to perform pelvic muscle exercises or retrain their bladders. Many will be cared for in long-term care facilities or at home. The guideline update makes the following recommendations to help caregivers keep the chronically incontinent drier and reduce their cost of care:

• Scheduled toileting—take people to the toilet every 2 to 4 hours or according to their toilet habits.
• Prompted voiding—check for dryness and encourage use of the toilet.
• Improved access to toilets—use equipment such as canes, walkers, wheelchairs, and devices that raise the seating level of toilets to make toileting easier.
• Managing fluids and diet—eliminate dietary caffeine (for those with urge incontinence) and encourage adequate fiber in the diet.
• Disposable absorbent garments—use to keep people dry.

Education

The guideline recommends that patients and professionals learn about the different treatment options for incontinence.

• Patients and their families should know that incontinence is not inevitable or shameful but is treatable or at least manageable. All management alternatives should be explained.
• Professional education about UI evaluation and treatment should be included in the basic curricula of undergraduate and graduate training programs of all health care providers, as well as continuing education programs.

For Further Information

Alliance for Aging Research
2021 K Street, N.W., Suite 305
Washington, DC 20006
(202) 293-2856

Bladder Health Council
c/o American Foundation for Urologic Disease
300 West Pratt Street, Suite 401
Baltimore, MD 21201
(410) 727-2908

National Association For Continence
(formerly Help for Incontinent People)
P.O. Box 8310
Spartanburg, SC 29305
(800) BLADDER or
(800) 252-3337

Simon Foundation for Continence
Box 835
Wilmette, IL 60091
(800) 23-SIMON
(800) 237-4666

Current as of March 1996