Female urinary incontinence (UI) is a condition with severe economic and psychosocial impact (described below). I have studied the epidemiology of UI in the general female population and the prevailing management of UI by Norwegian general practitioners (GPs). Those who are interested in more details, may take a look at this synopsis. The main conclusions that may be drawn from these studies are that UI is very prevalent among adult women, mostly in the form of stress incontinence. At least 6% may be regarded as potential patients. Although complicated by methodological difficulties, studies of GPs' management indicate that available therapeutic tools are not used to their full potential. A literature review demonstrates that the history is the most important diagnostic tool in general practice, and that the value of clinical investigations is poorly documented.Given the uncertain prevalence of UI, estimates of the economical impact of incontinence will also be questionable. In 1987 Hu estimated the cost of incontinence in USA to USD 10 billion (USD 41 per inhabitant), not including indirect costs.(1) Milsom et al. have estimated the costs for managing UI in Sweden to almost SEK 2 billion in 1990, two per cent of the total health expenses (USD 38 per inhabitant).(2)
According to Milsom et al. the major contributors to the economical impact are care for incontinent persons in nursing homes and the use of incontinence aids.(2) Several studies have demonstrated that UI is an important factor predicting institutionalizing of geriatric or demented patients,(3,4) and according to Ouslander & Kane UI accounts for 3-8% of the costs of nursing home care.(5) In Norway the National Insurance spends approximately NOK 200 million on incontinence pads (USD 7 per inhabitant).(6)
However, the costs of UI go beyond the money expended. The psychosocial impact of UI has been studied in two main settings; clinical studies of selected patients or as part of epidemiological surveys on the prevalence of UI.(7) Norton interviewed women attending a urodynamic clinic. Among the major problems reported by these women were fear of smell, embarrassment, and sexual difficulties. The degree of disability did not correlate with the degree of leakage, type of incontinence or age of the patient.(8) Wyman interviewed a sample of women participating in a clinical trial on behavioural treatment. These women reported most severe restrictions in activities involving unfamiliar places where the availability of restrooms was unknown. Subjects with detrusor instability reported higher impact than subjects with sphincteric incompetence alone, but only moderate correlation was found between degree of leakage and psychosocial impact scores.(9)
Similar findings were reported by Hunskaar & Vinsnes who interviewed a sample of women visiting a resource and information center for incontinent people, using the Sickness Impact Profile and a visual analogue scale.(10,11) In this study younger women were considerably more restricted by stress incontinence than older women, a difference not found in the urge group.(10) These findings were repeated in a sample of women who had responded to a marketing campaign for incontinence aids.(12) In another Norwegian study 2/3 of sedentary women (aged 24-64) stated stress incontinence as the main reason for their inactivity.(13)
Incontinent women identified in epidemiological surveys report considerably less psychosocial impact than the selected samples mentioned above. Yarnell et al. found that although 45% admitted to some degree of incontinence, only 3% reported almost continuous embarrassment.(14) Two Dutch studies found that only 13.3% and 15.7% of incontinent women considered themselves handicapped or much restricted by the symptoms.(15,16)
Many surveys of female UI have revealed that only a minority of incontinent women consult a doctor because of the disorder.(15,17-22) The main reason for not seeking help is that they consider the symptoms to be insignificant,(16,23,24) but there are also those who delay or refrain from consulting because of embarrassment or fear of surgery.(23,25,26) Older women tend to view UI as an inevitable manifestation of old age, and therefore hesitate to seek help, believing that nothing can be done about it.(27)
The nihilistic belief that nothing can be done is an old one.(28) However, modern scientific evidence substantiates a more optimistic view. The following chapters will discuss possible diagnostic and therapeutic tools for the management of female incontinence in general practice.
1. Hu TW. Impact of urinary incontinence on healthcare costs. J Am Geriatr Soc 1990; 38: 2925.
2. Milsom I, Fall M, Ekelund P. Urininkontinens en kostnadskrävande folksjukdom. Läkartidningen 1992; 89: 17724.
3. Ekelund P, Rundgren A. Urinary incontinence in the elderly with implications for hospital care consumption and social disability. Arch Gerontol Geriatr 1987; 6: 118.
4. O'Donnell BF, Drachman DA, Barnes HJ, Peterson KE, Swearer JM, Lew RA. Incontinence and troublesome behaviors predict institutionalization in dementia. J Geriatr Psychiatry Neurol 1992; 5: 4552.
5. Ouslander JG, Kane RL. The costs of urinary incontinence in nursing homes. Med Care 1984; 22: 6979.
6. Sandvik H, Hunskår S. Hjelpemidler ved urininkontinens. En trygdeepidemiologisk kartlegging for perioden 1/1092 til 30/993. Bergen: RTV, mai 1994.
7. Wyman JF, Harkins SW, Fantl JA. Psychosocial impact of urinary incontinence in the communitydwelling population. J Am Geriatr Soc 1990; 38: 2828.
8. Norton C. The effects of urinary incontinence in women. Int Rehabil Med 1982; 4: 914.
9. Wyman JF, Harkins SW, Choi SC, Taylor JR, Fantl JA. Psychosocial impact of urinary incontinence in women. Obstet Gynecol 1987; 70: 37881.
10. Hunskaar S, Vinsnes A. The quality of life in women with urinary incontinence as measured by the Sickness Impact Profile. J Am Geriatr Soc 1991; 39: 37882.
11. Vinsnes AG, Hunskaar S. Distress associated with urinary incontinence, as measured by a visual analogue scale. Scand J Caring Sci 1991; 5: 5761.
12. Sandvik H, Kveine E, Hunskaar S. Female urinary incontinence psychosocial impact, self care, and consultations. Scand J Caring Sci 1993; 7: 536.
13. Bø K, Hagen R, Kvarstein B, Larsen S. Female stress urinary incontinence and participation in different sports and social activities. Scand J Sports Sci 1989; 11: 11721.
14. Yarnell JW, Voyle GJ, Richards CJ, Stephenson TP. The prevalence and severity of urinary incontinence in women. J Epidemiol Community Health 1981; 35: 714.
15. Rekers H, Drogendijk AC, Valkenburg H, Riphagen F. Urinary incontinence in women from 35 to 79 years of age: prevalence and consequences. Eur J Obstet Gynecol Reprod Biol 1992; 43: 22934.
16. LagroJanssen TLM, Smits AJ, van Weel C. Women with urinary incontinence: selfperceived worries and general practitioners' knowledge of problem. Br J Gen Pract 1990; 40: 3314.
17. Fall M, Frankenberg S, Frisén M, Larsson B, Petrén M. 456 000 svenskar kan ha urininkontinens. Endast var fjärde söker hjälp för besvären. Läkartidningen 1985; 82: 20546.
18. Thomas TM, Plymat KR, Blannin J, Meade TW. Prevalence of urinary incontinence. Br Med J 1980; 281: 12435.
19. Holst K, Wilson PD. The prevalence of female urinary incontinence and reasons for not seeking treatment. N Z Med J 1988; 101: 7568.
20. Burgio KL, Matthews KA, Engel BT. Prevalence, incidence and correlates of urinary incontinence in healthy, middleaged women. J Urol 1991; 146: 12559.
21. Herzog AR, Fultz NH, Normolle DP, Brock BM, Diokno AC. Methods used to manage urinary incontinence by older adults in the community. J Am Geriatr Soc 1989; 37: 33947.
22. Kato K, Kondo A. Prevalence of urinary incontinence in working women. 1986; 77: 15015.
23. Jolleys JV. Reported prevalence of urinary incontinence in women in a general practice. Br Med J 1988; 296: 13002.
24. Reymert J, Hunskaar S. Why do only a minority of perimenopausal women with urinary incontinence consult a doctor? Scand J Prim Health Care 1994; 12: 1803.
25. Norton PA, MacDonald LD, Sedgwick PM, Stanton SL. Distress and delay associated with urinary incontinence, frequency, and urgency in women. Br Med J 1988; 297: 11879.
26. Simeonova Z, Bengtsson C. Prevalence of urinary incontinence among women at a Swedish primary health care centre. Scand J Prim Health Care 1990; 8: 2036.
27. Gjørup T, Hendriksen C, Lund E, Strømgård E. Is growing old a disease? A study of the attitudes of elderly people to physical symptoms. J Chron Dis 1987; 40: 10958.
28. Petraeus H. De symptomatibus mictionis urinae incontinentia, ischuria, diabete, dysuria, mictu cruento, purulento & pilare. In: Nosologia Harmonica Dogmatica et Hermetica. Marburg, 1615.
Home Page Department
Home Page
University
Department of Public Health and Primary Health Care, last updated 16.03.96
Hogne.Sandvik@isf.uib.no