Alayne D. Markland

Prevalence and Trends of Urinary Incontinence in Adults in the United States, 2001 to 2008

PURPOSE We estimate trends in the prevalence of urinary incontinence in the adult population of the United States from 2001 through 2008 before and after adjusting for other potential associated factors. MATERIALS AND METHODS We analyzed data on 17,850 adults 20 years old or older who participated in the 2001 to 2008 cycles of the National Health and Nutrition Examination Survey. Any urinary incontinence was defined as a positive response to questions on urine leakage during physical activity, before reaching the toilet and during nonphysical activity. During this period changes in demographic and clinical factors associated with urinary incontinence included age, race/ethnicity, obesity, diabetes and chronic medical conditions (prostate disease in men). Age standardized prevalence estimates and prevalence ORs of urinary incontinence trends were determined using adjusted multivariate models with appropriate sampling weights. RESULTS The age standardized prevalence of urinary incontinence in the combined surveys was 51.1% in women and 13.9% in men. Prevalence in women increased from 49.5% in 2001 to 2002, to 53.4% in 2007 to 2008 (Ptrend=0.01) and in men from 11.5% to 15.1%, respectively (Ptrend=0.01). In women increased prevalence was partially explained by differences in age, race/ethnicity, obesity, diabetes and select chronic diseases across the survey periods. After adjustment the prevalence OR for 2007 to 2008 vs 2001 to 2002 decreased from 1.22 (95% CI 1.03-1.45) to 1.16 (95% CI 0.99-1.37). In men adjustment for potentially associated factors did not explain the increasing prevalence of urinary incontinence. CONCLUSIONS The age standardized prevalence of urinary incontinence increased in men and women from 2001 through 2008. Decreasing obesity and diabetes may lessen the burden of urinary incontinence, especially in women.

Prevalence and Effect on Health-Related Quality of Life of Overactive Bladder in Older Americans:: Results from the Epidemiology of Lower Urinary Tract Symptoms Study

OBJECTIVE: To evaluate the prevalence and effect of overactive bladder (OAB) on healthcare‐seeking behavior, mental health, and generic and condition‐specific health‐related quality of life (HRQL) in older adults.

Behavioral Therapy With or Without Biofeedback and Pelvic Floor Electrical Stimulation for Persistent Postprostatectomy Incontinence: A Randomized Controlled Trial

CONTEXT Although behavioral therapy has been shown to improve postoperative recovery of continence, there have been no controlled trials of behavioral therapy for postprostatectomy incontinence persisting more than 1 year. OBJECTIVE To evaluate the effectiveness of behavioral therapy for reducing persistent postprostatectomy incontinence and to determine whether the technologies of biofeedback and pelvic floor electrical stimulation enhance the effectiveness of behavioral therapy. DESIGN, SETTING, AND PARTICIPANTS A prospective randomized controlled trial involving 208 community-dwelling men aged 51 through 84 years with incontinence persisting 1 to 17 years after radical prostatectomy was conducted at a university and 2 Veterans Affairs continence clinics (2003-2008) and included a 1-year follow-up after active treatment. Twenty-four percent of the men were African American; 75%, white. INTERVENTIONS After stratification by type and frequency of incontinence, participants were randomized to 1 of 3 groups: 8 weeks of behavioral therapy (pelvic floor muscle training and bladder control strategies); behavioral therapy plus in-office, dual-channel electromyograph biofeedback and daily home pelvic floor electrical stimulation at 20 Hz, current up to 100 mA (behavior plus); or delayed treatment, which served as the control group. MAIN OUTCOME MEASURE Percentage reduction in mean number of incontinence episodes after 8 weeks of treatment as documented in 7-day bladder diaries. RESULTS Mean incontinence episodes decreased from 28 to 13 per week (55% reduction; 95% confidence interval [CI], 44%-66%) after behavioral therapy and from 26 to 12 (51% reduction; 95% CI, 37%-65%) after behavior plus therapy. Both reductions were significantly greater than the reduction from 25 to 21 (24% reduction; 95% CI, 10%-39%) observed among controls (P = .001 for both treatment groups). However, there was no significant difference in incontinence reduction between the treatment groups (P = .69). Improvements were durable to 12 months in the active treatment groups: 50% reduction (95% CI, 39.8%-61.1%; 13.5 episodes per week) in the behavioral group and 59% reduction (95% CI, 45.0%-73.1%; 9.1 episodes per week) in the behavior plus group (P = .32). CONCLUSIONS Among patients with postprostatectomy incontinence for at least 1 year, 8 weeks of behavioral therapy, compared with a delayed-treatment control, resulted in fewer incontinence episodes. The addition of biofeedback and pelvic floor electrical stimulation did not result in greater effectiveness. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00212264.

Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop.

In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.

Incontinence in Older Women

Urinary incontinence is a common geriatric syndrome that affects at least 1 in 3 older women and can greatly diminish quality of life. Incontinence has been associated with increased social isolation, falls, fractures, and admission to long-term care facilities. Often unreported and thus untreated, it is important to include incontinence as part of the review of systems for all older women. Using the case of Mrs F, we highlight the chronicity of incontinence and discuss the evidence base for evaluation of incontinence in older women, with proper initial diagnosis of the type of incontinence-stress, urgency, or mixed-in order to prescribe optimal treatment. We present an evidence-based discussion of available incontinence treatments including pelvic floor muscle exercises, stress strategies, urge-suppression strategies, fluid management, medications, intravaginal pessaries, intravesical injection of botulinum toxin, percutaneous tibial nerve stimulation, sacral neuromodulation, and surgical procedures for stress incontinence. Special considerations in evaluation and treatment of patients with dementia are presented. Urinary incontinence treatments yield high levels of patient satisfaction and improvements in quality of life.

Incidence and risk factors for fecal incontinence in black and white older adults: a population-based study.

OBJECTIVES: To determine the incidence of fecal incontinence (FI) in community‐dwelling older adults and identify risk factors associated with incident FI.

Association of low dietary intake of fiber and liquids with constipation: Evidence from the national health and nutrition examination survey

OBJECTIVES:Epidemiological studies support an association of self-defined constipation with fiber and physical activity, but not liquid intake. The aims of this study were to assess the prevalence and associations of dietary fiber and liquid intake to constipation.METHODS:Analyses were based on data from 10,914 adults (≥20 years) from the 2005–2008 cycles of the National Health and Nutrition Examination Surveys. Constipation was defined as hard or lumpy stools (Bristol Stool Scale type 1 or 2) as the “usual or most common stool type.” Dietary fiber and liquid intake from total moisture content were obtained from dietary recall. Co-variables included: age, race, education, poverty income ratio, body mass index, self-reported general health status, chronic illnesses, and physical activity. Prevalence estimates and prevalence odds ratios (POR) were analyzed in adjusted multivariable models using appropriate sampling weights.RESULTS:Overall, 9,373 (85.9%) adults (4,787 women and 4,586 men) had complete stool consistency and dietary data. Constipation rates were 10.2% (95% confidence interval (CI): 9.6, 10.9) for women and 4.0% (95% CI: 3.2, 5.0) for men (P<.001). After multivariable adjustment, low liquid consumption remained a predictor of constipation among women (POR: 1.3, 95% CI: 1.0, 1.6) and men (POR: 2.4, 95% CI: 1.5, 3.9); however, dietary fiber was not a predictor. Among women, African-American race/ethnicity (POR: 1.4, 95% CI: 1.0, 1.9), being obese (POR: 0.7, 95% CI: 0.5,0.9), and having a higher education level (POR: 0.8, 95% CI: 0.7, 0.9) were significantly associated with constipation.CONCLUSIONS:The findings support clinical recommendations to treat constipation with increased liquid, but not fiber or exercise.

Behavioral Versus Drug Treatment for Overactive Bladder in Men: The Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial

To compare the effectiveness of behavioral treatment with that of antimuscarinic therapy in men without bladder outlet obstruction who continue to have overactive bladder (OAB) symptoms with alpha‐blocker therapy.

Urinary incontinence in frail elderly persons: Report from the 5th International Consultation on Incontinence

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

Population Based Study of Incidence and Predictors of Urinary Incontinence in Black and White Older Adults

PURPOSE We determined the incidence and predictors of incident urinary incontinence over 3 years in community dwelling older adults. MATERIALS AND METHODS A population based, prospective cohort study was conducted with a random sample of Medicare beneficiaries stratified to be 50% black, 50% men and 50% rural. In-home baseline assessment included standardized questionnaires and short physical performance battery. Three annual followup interviews were conducted by telephone. Incontinence was defined as any degree of incontinence occurring at least once a month in the last 6 months. RESULTS Participants were 490 women and 496 men 65 to 106 years old (mean age 75). Prevalence of incontinence at baseline was 41% in women and 27% in men. Three-year incidence of incontinence was 29% (84 of 290) in women and 24% (86 of 363) in men. There were no differences by race in prevalent or incident incontinence. In multivariable logistic regression models for women, significant independent baseline predictors of new incontinence included stroke (OR 3.4, p = 0.011), less than monthly incontinence (OR 3.3, p = 0.001), past or current postmenopausal estrogen (OR 2.3, p <0.006), slower time to stand from a chair 5 times (OR 1.3, p <0.045) and higher Geriatric Depression Scale Score (OR 1.2, p = 0.016). For men significant independent baseline predictors of new incontinence included less than monthly incontinence (OR 4.2, p <0.001) and lower score on the composite Physical Performance Score (OR 1.2, p <0.001). CONCLUSIONS Prevalence of incontinence among community dwelling older adults was high with an additional 29% of women and 24% of men reporting incident incontinence over 3 years of followup. Infrequent incontinence is a strong risk factor for developing at least monthly incontinence in both men and women.