Preventing incontinence

Robert W. Griffith, MD
April 28, 1999 (Reviewed: January 21, 2005)

Introduction

Urinary incontinence increases with age and frailty. Women are affected twice as often as men are. Although prevalence is hard to estimate accurately, reported figures are 13-53% for homebound older adults, 25-35% for older patients admitted to acute hospitals and up to 70% for nursing home patients. It is small wonder that incontinence presents a vast social and economic problem. Although its management has been well researched, there is little published work on the prevention of incontinence. Dr. Fonda and his colleagues have published an excellent review of the approaches that may prevent this distressing and all too common condition.

The authors used definitions similar to those for the prevention of myocardial infarction: primary prevention: interventions to prevent predisposing conditions such as pelvic muscle weakness or detrusor overactivity; secondary prevention: those measures aimed at reversing the predisposing conditions or preventing their progression to symptomatic incontinence; and tertiary prevention: management strategies to decrease the severity and results of established incontinence.

Most research in the filed has been concerned with the identification of risk factors. Although association is not causality, it seems logical that control or reversal of risk factors or predisposing conditions would reduce the likelihood of a patient developing incontinence. However, well-conducted studies using validated outcome measures are lacking, to date.

Risk factors for incontinence

The available data suggest that incontinence in the elderly is associated with the following factors or conditions:

• increasing age
• female sex
• impaired mobility
• functional disability
• cerebral vascular disease
• diabetes
• constipation
• chronic cough
• other lower urinary tract symptoms
• intake of sedatives
• intake of diuretics

There is no firm evidence that alcohol, coffee or tea consumption have a positive association.

Frailty and disability add a further dimension to the risk factors. In frail people, immobility, chronic degenerative disease, impaired cognition and fecal impaction are additional bivariate risk factors. Similarly, immobility, Parkinson's disease, dementia, stroke and diabetes have been shown to be relevant synergistic factors for a nursing home population.

Urinary retention occurs frequently in elderly hospitalized patients, although it is often unrecognized. Patients with a fractured hip are particularly at risk, with over half experiencing urinary retention in the postoperative period. Almost half of all stroke patients are incontinent in the first week, and half of these have urinary retention.

Primary prevention

Attempts at reducing or reversing the conditions responsible for increased risk of incontinence include the following:

• improved obstetric management to reduce the vesicovaginal fistula, long-term pelvic floor exercises, bowel-management protocols, and use of medications to reduce prostatic size and hence retention.
• energetic treatment of diabetes, Parkinson's disease and multiple sclerosis.
• reduction of the prevalence of conditions such as dementia, stroke etc. by addressing their risk factors.

Addressing these actors may prove effective in preventing the development of incontinence.

Secondary prevention

Potentially incontinent patients rarely present while they are asymptomatic, so that it is difficult to evaluate the benefits of attempts at secondary prevention. For example, would pelvic muscle exercises in a 50-year-old woman with a weak pelvic floor from childbirth prevent incontinence? It might be feasible to find secondary prevention strategies for healthy older persons, such as fitness and activity programs, or rehabilitation after injury or severe illness. To date, however, there are no data to show that such measures have reduced the prevalence of incontinence. Reduction in the use of drugs likely to cause incontinence is a valid approach to secondary prevention. In particular, diuretics or sedatives should be eliminated or cut back. An event such as a hip fracture or a stroke should trigger an alert for any contributory factors to the risk of incontinence, such as urinary retention or the prescription of unsuitable medication.

Tertiary prevention

When incontinence is present, steps must be taken to prevent progression of the symptoms. The lack of data using validated outcome measures, especially in the frail elderly, puts severe reservations concerning the efficacy of such measures as behavioral management strategies.¹ It may be that the best that can be achieved is "dependent continence" by use of regular toileting programs, or "social continence" using a various aids such as pads or catheters.

Conclusions

The authors emphasize that research in this field is at a relatively primitive stage, compared for instance with research on preventing myocardial infarction. Validated outcome measures that have been developed and tested in an elderly population are a first essential. The needs of frail and/or disabled older subjects require special study designs before different interventions can be studied. Developing valid results will take many years. Until more data are available, it is reasonable to address appropriately each of the risk factors identified in an individual patient in an attempt to avoid, or at least postpone, the onset of incontinence.

Source

• Prevention of urinary incontinence in older people D. Fonda, NM. Resnick, R. Kirschner-Hermann, Br J Urol, 1998, vol. 82 Suppl 1, pp. 5--10

Footnotes
1. Behavioral vs drug treatment for urge urinary incontinence in older women. KL. Burgio, JL. Locher, PS. Goode, JAMA, 1998, vol. 280, pp. 1995--2000

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