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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
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
- 1 in 4 women ages 30-59 have experienced an episode of
- 50% or more of the elderly persons living at home or in
long-term care facilities are
- $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
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
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
5. Other factors can cause incontinence such as decreased
mobility, cognitive impairment
Treatment for UI depends on the type of incontinence, its causes,
and the capabilities of the
patient. The guideline update recommends the following
Pelvic Muscle Rehabilitation—to improve pelvic muscle
tone and prevent
- 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
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
Pharmacologic Therapies—to improve incontinence
- Oxybutynin (brand name Ditropan) prevents urge
incontinence by relaxing sphincter
- Estrogen, either oral or vaginal, may be helpful in
conjunction with other treatments
for postmenopausal women with UI.
Surgical Therapies—to treat specific anatomical
- Sling procedures, bulking injections (such as
collagen) and other surgical
procedures support or move the bladder to improve continence.
Treatment Recommendations for the Chronically
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
- 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
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
Bladder Health Council
c/o American Foundation for Urologic Disease
300 West Pratt Street, Suite 401
Baltimore, MD 21201
National Association For Continence
(formerly Help for Incontinent People)
P.O. Box 8310
Spartanburg, SC 29305
(800) BLADDER or
Simon Foundation for Continence
Wilmette, IL 60091
Current as of March 1996