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Reaching a consensus on incontinence
REACHING A CONSENSUS ON INCONTINENCE Having weighed the evidence, the NIH panel offers direction for assessing and treating urinary incontinence. U
rinary incontinence is not the disease; it is the sign. In some cases, it is a transient sign of a medication action; in others, it indicates acute illness such as urinary tract infection. There is a persistent myth that urinary incontinence is a normal consequence of aging. While age-related changes in the lower urinary tract predispose to urinary incontinence, normal aging does not cause it. To resolve issues regarding the incidence, causes, and treatment of urinary incontinence, the National Institutes of Health convened a consensus development conference last October.* After experts involved with urinary incontinence reported current data, a consensus panel with representatives from geriatrics, urology, nursing, basic sciences, and the public considered the evidence and tried to answer some questions.
Rashes, pressure sores, skin and urinary tract infections, and activity restrictions are some problems that could be prevented or treated if the underlying incontinence was properly diagnosed and treated. In nursing homes, very few residents with incontinence have had any diagnostic evaluation. Many incontinent residents are'managed with indwelling catheters, which carry the risk of significant urinary tract infection. The annual direct cost of caring for incontinent nursing home residents is approximately $3.3 billion.
What factors lead to incontinence?
A reasonable estimate of urinary incontinence among [about 28 million] community-dwelling elders is 15 to 30 percent. In nursing homes, 50 percent or more of the 1.5 million residents suffer from incontinence. A highly conservative estimate of the direct costs of incontinence for people living in the community is $7 billion annually in the United States.
Urinary continence requires a compliant bladder and active sphincters, such that maximum pressure in the urethra stays higher than pressure in the bladder. Bladder pressure can be raised by involuntary detrusor muscle contractions (unstable bladder or detrusor hyperreflexia), acute or chronic bladder overdistension (urinary retention with overflow), or an increase in intraabdominal pressure. Similarly, a decrease in urethral pressure may result from uninhibited sphincter relaxation (unstable urethra), loss of pelvic floor support (genuine stress incontinence), and urethral wall defects from trauma, surgery, or neurologic disease. Clinically, the most common types of urinary incontinence in adults are stress, urge, and overflow.
*This article is based on the consensus statement developed at the October 3 to 5, 1988, conference sponsored by the National Institute on Aging,NIH Officeof Medical Applications of Research, National Institute of Diabetes and Digestiveand Kidney Diseases, National Center for Nursing Research, National Institute of Neurologicaland Communicative Disorders and Stroke, and Veterans Administration. Members ofthe consensus development panel wereJohn Rowe, MD, Mt. Sinai School of Medicine, New York, NY; Richard Besdine, MD, U/Connecticut Health Center, Farmington, CT; Amasa Ford, MD, Case Western Reserve University School of Medicine, Cleveland, OH; Cheryle Gartley, Simon Foundationfor Continence and Continence Awareness, Research, and Education Center, Wilmette, IL; Donald Gleason,
MD, Tucson Medical Center, Tucson, AZ; Frank Greiss, Jr., MD, Bowman Gray School of Medicine of Wake Forest University, WinstonSalem, NC; William de Groat, PhD, University of Pittsburgh Medical School, Pittsburgh, PA; ArgyeHillis, PhD, Texas A & M Collegeof Medicine, Temple, TX; Jeanie Kayser-Jones, RN, PhD, FAAN, U/California, San Francisco, CA; George Kaplan, PhD, California Department of Health Services, Berkeley, CA; Richard Kendall, MD, Temple University School of Medicine, Philadelphia, PA; Neal Miller, PhD, DSc, Yale University, New Haven, CT; James Scott, MD, U/Utah School of Medqcine, Salt Lake City, UT; Joanne Sabol Stevenson, RN, PhD, Ohio State University College of Nursing, Columbus, OH; and Robert Wallace, MD, MSe, U/Iowa, Iowa City, IA.
What is the prevalence and impact of urinary incontinence?
78 Geriatric Nursing March/April 1989
PRINCIPLES OF TREATMENT • All people with incontinence must be considered for evaluation and treatment. • Treatment decisions must be based on a diagnosis made after a reasonable evaluation of anatomy and function of urine storage and emptying. • Treatment must be designed to fit the individual's personality, environment, expectations, and clinical status. • The patient must be given sufficient information to make an educated choice among therapeutic options. • Strategies to circumvent such common impediments as environmental constraints in the community or institution must be
included as part of therapy. • An adequate number of properly constructed public toilets must be made available.
In stress incontinence, urine leaks as intraabdominal pressure exceeds urethral resistance during coughing, bending, or lifting heavy objects. Volume of urine leakage is generally modest and, in uncomplicated cases, postvoid residuali volume is low. Stress incontinence has many causes, !ncluding anatomic damage to the urethral sphincter and weakened bladder neck supports, as is often associated with childbirth. Urge inconiinence occurs when a patient senses the urge to void, but is unable to inhibit leakage long enough to reach the toilet. Urine loss is moderate in volume, occurs at intervals of several hours, and postvoid residual volume is low.Among the causes of urge incontinence are such central nervous system lesions as stroke or demyelinating disease and such local irritating factors as urinary infection or bladder tumors. In reflex incontinence, a variant of urge incontinence, urine is lost during uninhibited bladder contractions without the urge to void. Overflow incontinence occurs when the bladder cannot empty and becomes overdistended, leading to frequent, sometimes nearly constant, urine loss. Causes include neurologic abnormalities, such as spinal cord lesions that impair detrusor contractility and any factor that obstructs outflow, such as drugs, tumors, benign strictures, and prostatic hypertrophy. The term functional incontinence is applied to those people in whom the lower urinary tract is intact, but other factors such as immobility or severe cognitive impairment result in urinary incontinence. In elders, cognitive decline, musculoskeletal impairments, and restricted access to toilets all may convert a marginally continent system to incontinence.
What diagnostic information should be obtained in assessing incontinence? The evaluation ofaU patients with incontinence requires a thorough history: the duration, frequency, volume, and type of incontinence should be described and validated by a voiding diary. Other important information for the clinician to gather includes associated illnesses, previous operations, and current medications.
In the physical examination, it is important to evaluate mental status, mobility, and dexterity, as well as neurologic, abdominal, rectal, and pelvic status. A provoked full-bladder stress test is recommended. Since prostate enlargement is often asymmetric, the size of the prostate as estimated on the rectal exam may be misleading when evaluating the contribution of prostatic hypertrophy to urinary obstruction. Core measurements include urinalysis, serum creatinine or blood urea nitrogen, and postvoid residual urine volume. Other tests such as urine culture, blood glucose, and urinary cytology may be useful. Based on results of the core evaluation, a decision regarding how to treat or whether to evaluate further must be made, taking into consideration the type and degree of incontinence. Tests for specialized study include: cystometrogram, electrophysiologic sphincter testing, bladder and kidney ultrasound, cystourethroscopy, uroflowmetry (wide application in men, but a limited role in women), videourodynamic evaluation, urethral pressure profilometry (controversial, requires further validation before recommendation for widespread use).
What are the efficacies and limitations of treatments? A
Most drugs now used in managing urinary incontinence have not been studied in well-designed clinical trials. Nevertheless, many agents seem to be beneficial. Basic categories include bladder relaxants, bladder outlet stimulants, and estrogens. Bladder relaxants are the drugs most likely to be used in the treatment of urge incontinence. • Anticholinergic agents inhibit detrusor contraction and may increase bladder capacity, plus delay and reduce amplitude of involuntary contractions. Propantheline is frequently effective, although high doses may produce such unacceptable side effects as dry mouth, dry eyes, constipation, confusion, or precipitation of glaucoma. • Smooth muselerelaxantsworkdirectlyonbladder(detrusor) muscle, but have mild anticholinergic effects as well. A randomized, double-blind, placebo-controlled study has shown oxybutynin to be beneficial in patients with detrusor instability--some, but not all of whom, were incontinent. Favorable reports also exist on flavoxate and dicyclomine, the other two agents in this class. • Calcium channel blockers, used clinically for cardiovascular problems, have a depressant effect on the bladder as well. They have not been studied rigorously for the treatment of urge incontinence. But in the patient being treated for heart disease, the bladder effects of calcium antagonists must be kept in mind for both their potential benefit as well as risk of retention. • Imipramine, a tricyclic antidepressent, has anticholinergic and direct relaxant effects on the detrusor muscle and an alpha-adrenergic enhancing (contracting) effect on the bladder outlet, all Of which enhance continence. Although imipramine is commonly used, potential side
Geriatric Nursing March/April 1989 79
:ffects of postural hypotension and sedation, as well as peripheral anticholinergic effects, make caution imperative when considering this agent in older people. Bladder outlet stimulants, such as alpha-adrenergic agonists, contract smooth muscle at the bladder outlet and may improve stress continence. Pseudoephedrine and ephedrine both are active, but phenylpropanolamine is used most often. Estrogen replacementdoes not seem to improve stress incontinence, but, in several studies, it has improved women's postmenopausal urgency, frequency, and urge incontinence. Surgery is particularly effective in treating pure stress incontinence associated with urethrocoele. Transvaginal or transabdominal suspension of the bladder neck has been 80 to 95 percent successful in appropriate patients at one-year follow-up. When incontinence in men is secondary to outflow obstruction and chronic retention is secondary to prostatic enlargement, it is best treated with prostatectomy. When incontinence is due to sphincter dysfunction after the shrgical trauma of radical prostatectomy or sphincter denervation, implantable prostheticsphincters have restored compression in 70 to 90 percent of patients. But a complication rate greater than 20 percent includes erosion ofthe urethra, infection, and mechanical failure. Reoperations frequently are required. Urethralslingprocedures pass a ribbon of fascia or artificial material beneath the urethra. The sling, fixed to the anterior body wall, elevates and compresses the urethra, restoring continence in 80 percent of patients. BEHAVIORAL TECHNIQUES • Pelvic muscle exercises strengthen the voluntary periurethral
and pelvic floor muscles, the contraction of which exerts a closing force on the urethra. These techniques have been emphasized for women with stress incontinence but appear to be useful in men as well. Benefit has been reported in 30 to 90 percent of women, but criteria for improvement differ among studies. • Biofeedback uses visual or auditory instruments to give patients moment-to-moment information on how well they are controlling the sphincter, detrusor, and abdominal muscles. Successful patients typically learn to relax the detrusor (bladder) and abdominal muscles and/or contract the sphincter relatively automatically. When used in patients with stress or urge incontinence, biofeedback can result in complete continence in approximately 20 to 25 percent of patients and provides important improvement in another 30 percent. There are two caveats: The degree of improvement is variable, and long-term follow-up data are not available. It also requires sophisticated equipment and training. The benefit of adding biofeedback in pelvic muscle exercise regimens has not been adequately evaluated. • Bladdertrainingteachespatientstovoidatregularshortintar-
vals, usually hourly during the day, and then at progressively longer intervals of up to three hours over a training pedod of a few to a dozen weeks. Bladder training appears to be effective in reducing the frequency of stress and urge incontinence. Studies have indicated cure rates of 10 to 15 percent and improvement in the majority of patients. • Prompted voiding--frequent checks (every one to two hours) for dryness, reminders to void, and praise when successful-appears to reduce incontinence in some patients.
80 Geriatric Nursing March/April 1989
Bladder augmentation with bowel segments can increase bladder capacity and vent excess pressure. The procedure is limited to such specific problems as the contracted bladder of neurologic disease or tuberculosis. Behavioral techniques attempt to increase the patient's awareness of the lower urinary tract. (See lower left box.) They are generally free of side effects and do not limit future options, but require time, effort, and practice. Those who appear to benefit most are highly motivated persons without cognitive deficits. These techniques can help people with stress and urge incontinence but are generally of no use with severe sphincter damage.
What is appropriate when no treatment is effective or indicated? Even when permanent improvement is not expected, techniques such as frequent toileting and reminders may reduce incontinence. Careful evaluation of the timing and pattern of incontinence may suggest helpful changes--for example, bedtime fluid restriction, easier access to toilet facilities, and temporary or permanent protection for patients, their clothing, and environment. Currently available modes of protection include absorbent pads or garments, indwelling catheters, and external collection devices such as condom catheters. Absorbent pads or garments provide comfort and convenience when used temporarily with therapy; none is entirely satisfactory for long-term use. For men, external collection devices are inexpensive and require a small amount of time for patients and caregivers, but they are associated with increased incidence of urinary tract infection and other complications. Practical external collection devices for women are not generally available. Indwelling urethral or suprapubic catheters may be necessary for some patients, but almost invariably lead to bacteriuria and are associated with sepsis.
What strategies are effective in improving public and professional knowledge about incontinence? The scientific study of incontinence and the dissemination of findings will help professionals and laypersons realize that loss of continence need not be inevitable or shameful. Mandatory labeling of all absorbent products is one innovative way to inform the public that persistent urinary incontinence should be evaluated and treated. Contrary to popular opinion, most cases of urinary incontinence can be cured or improved. Unfortunately, medical and nursing education falls short on urinary incontinence. And often, inadequate nursing home staffing prohibits proper treatment. This can be improved, however, with curriculum development and sufficient staffing. Everyone with urinary incontinence is entitled to evaluation and consideration for treatment. GN
rinary incontinence is not the disease; it is the sign. In some cases, it is a transient sign of a medication action; in others, it indicates acute illness such as urinary tract infection. There is a persistent myth that urinary incontinence is a normal consequence of aging. While age-related changes in the lower urinary tract predispose to urinary incontinence, normal aging does not cause it. To resolve issues regarding the incidence, causes, and treatment of urinary incontinence, the National Institutes of Health convened a consensus development conference last October.* After experts involved with urinary incontinence reported current data, a consensus panel with representatives from geriatrics, urology, nursing, basic sciences, and the public considered the evidence and tried to answer some questions.
Rashes, pressure sores, skin and urinary tract infections, and activity restrictions are some problems that could be prevented or treated if the underlying incontinence was properly diagnosed and treated. In nursing homes, very few residents with incontinence have had any diagnostic evaluation. Many incontinent residents are'managed with indwelling catheters, which carry the risk of significant urinary tract infection. The annual direct cost of caring for incontinent nursing home residents is approximately $3.3 billion.
What factors lead to incontinence?
A reasonable estimate of urinary incontinence among [about 28 million] community-dwelling elders is 15 to 30 percent. In nursing homes, 50 percent or more of the 1.5 million residents suffer from incontinence. A highly conservative estimate of the direct costs of incontinence for people living in the community is $7 billion annually in the United States.
Urinary continence requires a compliant bladder and active sphincters, such that maximum pressure in the urethra stays higher than pressure in the bladder. Bladder pressure can be raised by involuntary detrusor muscle contractions (unstable bladder or detrusor hyperreflexia), acute or chronic bladder overdistension (urinary retention with overflow), or an increase in intraabdominal pressure. Similarly, a decrease in urethral pressure may result from uninhibited sphincter relaxation (unstable urethra), loss of pelvic floor support (genuine stress incontinence), and urethral wall defects from trauma, surgery, or neurologic disease. Clinically, the most common types of urinary incontinence in adults are stress, urge, and overflow.
*This article is based on the consensus statement developed at the October 3 to 5, 1988, conference sponsored by the National Institute on Aging,NIH Officeof Medical Applications of Research, National Institute of Diabetes and Digestiveand Kidney Diseases, National Center for Nursing Research, National Institute of Neurologicaland Communicative Disorders and Stroke, and Veterans Administration. Members ofthe consensus development panel wereJohn Rowe, MD, Mt. Sinai School of Medicine, New York, NY; Richard Besdine, MD, U/Connecticut Health Center, Farmington, CT; Amasa Ford, MD, Case Western Reserve University School of Medicine, Cleveland, OH; Cheryle Gartley, Simon Foundationfor Continence and Continence Awareness, Research, and Education Center, Wilmette, IL; Donald Gleason,
MD, Tucson Medical Center, Tucson, AZ; Frank Greiss, Jr., MD, Bowman Gray School of Medicine of Wake Forest University, WinstonSalem, NC; William de Groat, PhD, University of Pittsburgh Medical School, Pittsburgh, PA; ArgyeHillis, PhD, Texas A & M Collegeof Medicine, Temple, TX; Jeanie Kayser-Jones, RN, PhD, FAAN, U/California, San Francisco, CA; George Kaplan, PhD, California Department of Health Services, Berkeley, CA; Richard Kendall, MD, Temple University School of Medicine, Philadelphia, PA; Neal Miller, PhD, DSc, Yale University, New Haven, CT; James Scott, MD, U/Utah School of Medqcine, Salt Lake City, UT; Joanne Sabol Stevenson, RN, PhD, Ohio State University College of Nursing, Columbus, OH; and Robert Wallace, MD, MSe, U/Iowa, Iowa City, IA.
What is the prevalence and impact of urinary incontinence?
78 Geriatric Nursing March/April 1989
PRINCIPLES OF TREATMENT • All people with incontinence must be considered for evaluation and treatment. • Treatment decisions must be based on a diagnosis made after a reasonable evaluation of anatomy and function of urine storage and emptying. • Treatment must be designed to fit the individual's personality, environment, expectations, and clinical status. • The patient must be given sufficient information to make an educated choice among therapeutic options. • Strategies to circumvent such common impediments as environmental constraints in the community or institution must be
included as part of therapy. • An adequate number of properly constructed public toilets must be made available.
In stress incontinence, urine leaks as intraabdominal pressure exceeds urethral resistance during coughing, bending, or lifting heavy objects. Volume of urine leakage is generally modest and, in uncomplicated cases, postvoid residuali volume is low. Stress incontinence has many causes, !ncluding anatomic damage to the urethral sphincter and weakened bladder neck supports, as is often associated with childbirth. Urge inconiinence occurs when a patient senses the urge to void, but is unable to inhibit leakage long enough to reach the toilet. Urine loss is moderate in volume, occurs at intervals of several hours, and postvoid residual volume is low.Among the causes of urge incontinence are such central nervous system lesions as stroke or demyelinating disease and such local irritating factors as urinary infection or bladder tumors. In reflex incontinence, a variant of urge incontinence, urine is lost during uninhibited bladder contractions without the urge to void. Overflow incontinence occurs when the bladder cannot empty and becomes overdistended, leading to frequent, sometimes nearly constant, urine loss. Causes include neurologic abnormalities, such as spinal cord lesions that impair detrusor contractility and any factor that obstructs outflow, such as drugs, tumors, benign strictures, and prostatic hypertrophy. The term functional incontinence is applied to those people in whom the lower urinary tract is intact, but other factors such as immobility or severe cognitive impairment result in urinary incontinence. In elders, cognitive decline, musculoskeletal impairments, and restricted access to toilets all may convert a marginally continent system to incontinence.
What diagnostic information should be obtained in assessing incontinence? The evaluation ofaU patients with incontinence requires a thorough history: the duration, frequency, volume, and type of incontinence should be described and validated by a voiding diary. Other important information for the clinician to gather includes associated illnesses, previous operations, and current medications.
In the physical examination, it is important to evaluate mental status, mobility, and dexterity, as well as neurologic, abdominal, rectal, and pelvic status. A provoked full-bladder stress test is recommended. Since prostate enlargement is often asymmetric, the size of the prostate as estimated on the rectal exam may be misleading when evaluating the contribution of prostatic hypertrophy to urinary obstruction. Core measurements include urinalysis, serum creatinine or blood urea nitrogen, and postvoid residual urine volume. Other tests such as urine culture, blood glucose, and urinary cytology may be useful. Based on results of the core evaluation, a decision regarding how to treat or whether to evaluate further must be made, taking into consideration the type and degree of incontinence. Tests for specialized study include: cystometrogram, electrophysiologic sphincter testing, bladder and kidney ultrasound, cystourethroscopy, uroflowmetry (wide application in men, but a limited role in women), videourodynamic evaluation, urethral pressure profilometry (controversial, requires further validation before recommendation for widespread use).
What are the efficacies and limitations of treatments? A
Most drugs now used in managing urinary incontinence have not been studied in well-designed clinical trials. Nevertheless, many agents seem to be beneficial. Basic categories include bladder relaxants, bladder outlet stimulants, and estrogens. Bladder relaxants are the drugs most likely to be used in the treatment of urge incontinence. • Anticholinergic agents inhibit detrusor contraction and may increase bladder capacity, plus delay and reduce amplitude of involuntary contractions. Propantheline is frequently effective, although high doses may produce such unacceptable side effects as dry mouth, dry eyes, constipation, confusion, or precipitation of glaucoma. • Smooth muselerelaxantsworkdirectlyonbladder(detrusor) muscle, but have mild anticholinergic effects as well. A randomized, double-blind, placebo-controlled study has shown oxybutynin to be beneficial in patients with detrusor instability--some, but not all of whom, were incontinent. Favorable reports also exist on flavoxate and dicyclomine, the other two agents in this class. • Calcium channel blockers, used clinically for cardiovascular problems, have a depressant effect on the bladder as well. They have not been studied rigorously for the treatment of urge incontinence. But in the patient being treated for heart disease, the bladder effects of calcium antagonists must be kept in mind for both their potential benefit as well as risk of retention. • Imipramine, a tricyclic antidepressent, has anticholinergic and direct relaxant effects on the detrusor muscle and an alpha-adrenergic enhancing (contracting) effect on the bladder outlet, all Of which enhance continence. Although imipramine is commonly used, potential side
Geriatric Nursing March/April 1989 79
:ffects of postural hypotension and sedation, as well as peripheral anticholinergic effects, make caution imperative when considering this agent in older people. Bladder outlet stimulants, such as alpha-adrenergic agonists, contract smooth muscle at the bladder outlet and may improve stress continence. Pseudoephedrine and ephedrine both are active, but phenylpropanolamine is used most often. Estrogen replacementdoes not seem to improve stress incontinence, but, in several studies, it has improved women's postmenopausal urgency, frequency, and urge incontinence. Surgery is particularly effective in treating pure stress incontinence associated with urethrocoele. Transvaginal or transabdominal suspension of the bladder neck has been 80 to 95 percent successful in appropriate patients at one-year follow-up. When incontinence in men is secondary to outflow obstruction and chronic retention is secondary to prostatic enlargement, it is best treated with prostatectomy. When incontinence is due to sphincter dysfunction after the shrgical trauma of radical prostatectomy or sphincter denervation, implantable prostheticsphincters have restored compression in 70 to 90 percent of patients. But a complication rate greater than 20 percent includes erosion ofthe urethra, infection, and mechanical failure. Reoperations frequently are required. Urethralslingprocedures pass a ribbon of fascia or artificial material beneath the urethra. The sling, fixed to the anterior body wall, elevates and compresses the urethra, restoring continence in 80 percent of patients. BEHAVIORAL TECHNIQUES • Pelvic muscle exercises strengthen the voluntary periurethral
and pelvic floor muscles, the contraction of which exerts a closing force on the urethra. These techniques have been emphasized for women with stress incontinence but appear to be useful in men as well. Benefit has been reported in 30 to 90 percent of women, but criteria for improvement differ among studies. • Biofeedback uses visual or auditory instruments to give patients moment-to-moment information on how well they are controlling the sphincter, detrusor, and abdominal muscles. Successful patients typically learn to relax the detrusor (bladder) and abdominal muscles and/or contract the sphincter relatively automatically. When used in patients with stress or urge incontinence, biofeedback can result in complete continence in approximately 20 to 25 percent of patients and provides important improvement in another 30 percent. There are two caveats: The degree of improvement is variable, and long-term follow-up data are not available. It also requires sophisticated equipment and training. The benefit of adding biofeedback in pelvic muscle exercise regimens has not been adequately evaluated. • Bladdertrainingteachespatientstovoidatregularshortintar-
vals, usually hourly during the day, and then at progressively longer intervals of up to three hours over a training pedod of a few to a dozen weeks. Bladder training appears to be effective in reducing the frequency of stress and urge incontinence. Studies have indicated cure rates of 10 to 15 percent and improvement in the majority of patients. • Prompted voiding--frequent checks (every one to two hours) for dryness, reminders to void, and praise when successful-appears to reduce incontinence in some patients.
80 Geriatric Nursing March/April 1989
Bladder augmentation with bowel segments can increase bladder capacity and vent excess pressure. The procedure is limited to such specific problems as the contracted bladder of neurologic disease or tuberculosis. Behavioral techniques attempt to increase the patient's awareness of the lower urinary tract. (See lower left box.) They are generally free of side effects and do not limit future options, but require time, effort, and practice. Those who appear to benefit most are highly motivated persons without cognitive deficits. These techniques can help people with stress and urge incontinence but are generally of no use with severe sphincter damage.
What is appropriate when no treatment is effective or indicated? Even when permanent improvement is not expected, techniques such as frequent toileting and reminders may reduce incontinence. Careful evaluation of the timing and pattern of incontinence may suggest helpful changes--for example, bedtime fluid restriction, easier access to toilet facilities, and temporary or permanent protection for patients, their clothing, and environment. Currently available modes of protection include absorbent pads or garments, indwelling catheters, and external collection devices such as condom catheters. Absorbent pads or garments provide comfort and convenience when used temporarily with therapy; none is entirely satisfactory for long-term use. For men, external collection devices are inexpensive and require a small amount of time for patients and caregivers, but they are associated with increased incidence of urinary tract infection and other complications. Practical external collection devices for women are not generally available. Indwelling urethral or suprapubic catheters may be necessary for some patients, but almost invariably lead to bacteriuria and are associated with sepsis.
What strategies are effective in improving public and professional knowledge about incontinence? The scientific study of incontinence and the dissemination of findings will help professionals and laypersons realize that loss of continence need not be inevitable or shameful. Mandatory labeling of all absorbent products is one innovative way to inform the public that persistent urinary incontinence should be evaluated and treated. Contrary to popular opinion, most cases of urinary incontinence can be cured or improved. Unfortunately, medical and nursing education falls short on urinary incontinence. And often, inadequate nursing home staffing prohibits proper treatment. This can be improved, however, with curriculum development and sufficient staffing. Everyone with urinary incontinence is entitled to evaluation and consideration for treatment. GN