Treatment of urinary incontinence in homebound older adults: interface between research and practice

Urinary incontinence is one of the most common problems afflicting older adults and a major contributor to healthcare costs for homebound older individuals. The authors conducted a randomized controlled clinical study examining the effectiveness of biofeedback-assisted pelvic floor muscle training and prompted voiding in treating urinary incontinence in homebound older adults. This article briefly describes the assessment and treatment protocols utilized during this study and describes their subsequent application to clinical practice within a large urban home health agency.     

Continence consultation for the rural homebound

Because an estimated 10 million Americans have urinary incontinence, home care continence services are in demand. In March 1992, the Agency on Health Care Policy and Research recommended behavioral therapy as a first step in treatment options for urinary incontinence. Nurses are best prepared to meet the challenges of providing behavioral therapy to people who are incontinent and are being cared for in their homes. This article describes the development of a nursing practice that provides assessment and treatment of urinary incontinence to people who are homebound in rural Northern Vermont.     

Metabolism of an anionic fluorescent dye, 1-anilino-8-naphthalene sulfonate (ANS) by rat liver microsomes

OBJECTIVE: To examine the association between chronic illness and functional status change during a 3-year period in older people enrolled in an in-home comprehensive geriatric assessment (CGA) and preventive care program. DESIGN: Secondary analysis of data from a longitudinal cohort study. SETTING: Santa Monica, California. PARTICIPANTS: Two hundred two community-dwelling older persons (mean age at baseline was 81 years, 70% were women, and 72% reported good health) randomized to the intervention group in a trial of in-home comprehensive geriatric assessment and preventive care. MEASUREMENTS: We studied 13 common chronic illnesses/conditions determined clinically from an annual comprehensive evaluation by gerontologic nurse practitioners (GNPs) in consultation with study geriatricians. These target conditions included hypertension, osteoarthritis, coronary artery disease, obesity, undernutrition, urinary incontinence, sleep disorders, falls, gait/balance disorders, hearing and vision deficits, depression, and unsafe home environment. The dependent variable was functional change as measured by instrumental activities of daily living (IADL) and basic activities of daily living (BADL) assessed at baseline and annually for 3 years by independent research personnel. Potential confounding variables, including comorbid conditions and other subject characteristics, were controlled for in the analyses. RESULTS: Although functional status was similar at baseline, the presence of certain target conditions in this sample was associated significantly with functional decline in IADL and BADL during the 3-year period. Four conditions (gait/balance disorders, depression, unsafe home environment, and coronary artery disease) were associated with significant declines in IADL, and four conditions (gait/balance disorders, depression, hypertension, and urinary incontinence) were associated with significant declines in BADL. Conversely, subjects with obesity had no significant change in IADL or BADL throughout the study period and had less decline in IADL compared with nonobese subjects. CONCLUSIONS: Certain chronic conditions, particularly gait/balance disorders and depression, are associated with significant decline in functional status in older persons who receive CGA. These findings may help identify older persons at risk for greatest functional decline despite participation in CGA and may also suggest the need for more effective intervention strategies in these individuals.     

Evaluation of a nurse-led continence service in the south-west of Glasgow, Scotland

This paper reports the results of a pilot study of a nurse-led continence promotion service in both the community and a local nursing home. Telephone and written referrals were made to the service from 28 primary care teams in Glasgow, Scotland. In the nursing home all patients were assessed and an appropriate management plan implemented. A full assessment was carried out in all community patients, including an appraisal of contributory factors, urinalysis and diaries of food and drink intake. A management plan suited to the patient was then implemented. Patients' levels of incontinence in both arms of the study were assessed objectively using the Lagro-Janssen method. The cost incurred in both arms of the study were measured. There was a 69% improvement in the level of incontinence in the community group compared with 30% in the residents wing and 13% in the hospital wing. The savings in the nursing home amounted to Pounds 4152 in the residents' wing and Pounds 1959 in the hospital wing. In summary, a nurse dedicated to urinary incontinence in the community allows improved management, a greater level of awareness and results in resource savings, whilst increasing patient accessibility to a service.     

Arginine vasopressin levels in nursing home residents with nighttime urinary incontinence

OBJECTIVES: To examine the relationship between diurnal urine volume and plasma arginine vasopressin levels (AVP) in nursing home residents with nighttime urinary incontinence and a comparison group of frail but nondemented, continent geriatric board and care residents. DESIGN: Case series. SETTING: Four nursing homes and two board and care facilities. PARTICIPANTS: Sixty-two nursing home residents and 27 board and care residents. MEASUREMENTS: Daytime (7:00 a.m. to 7:00 p.m.) and nighttime (7:00 p.m. to 7:00 a.m.) urine volumes of incontinent nursing home residents were measured over 3 days and 3 nights by reweighing preweighed adults diapers and toileting inserts emptied by research staff for the comparison group. AVP levels were drawn in the early morning (5:00 a.m. to 7:00 a.m.) before subjects arose and in the evening after an hour of lying in bed (8:00 p.m. to 11:00 p.m.), and plasma levels were determined by radioimmunoassay. RESULTS: Half of the nursing home residents and 82% of the comparison group had night/total urine volume ratios > or = 50%. Forty-nine percent of the total of 89 subjects had undetectable morning AVP levels, 61% had undetectable evening AVP levels, and 42% had undetectable AVP levels in both morning and evening. There were no significant differences in AVP levels between those with night/total urine volume ratios > or = 50% and < 50% in either the nursing home or comparison groups though the small number of comparison group subjects with ratios < 50% may have limited our statistical power to detect differences. CONCLUSION: Our data suggest that a substantial proportion of both nursing home residents with nighttime incontinence and frail geriatric patients with a reversal of the normal diurnal pattern of urine excretion have an accompanying deficiency in AVP production and/or secretion. More detailed physiologic studies are needed to understand better the pathophysiology of geriatric nocturia and nighttime incontinence and the role that AVP deficiency may play in these conditions. Until such studies are carried out, we do not recommend the routine use of exogenous AVP for geriatric patients with unexplained nocturnal polyuria.     

Pelvic floor rehabilitation in women affected with stress urinary incontinence. Authors' experience

BACKGROUND: This study evaluated pelvic floor rehabilitation as a possible treatment for urinary stress incontinence: a challenge to tradition. METHODS: In this study 20 female subjects with urinary stress incontinence had rehabilitation therapy, at first in the outpatients clinic with motivated physiotherapists and afterwards by home exercises. RESULTS: At the end of 3 months of training, stress incontinence had disappeared in 7 patients (35%), while an improvement was recorded in 13 (65%). CONCLUSIONS: In summary, pelvic floor rehabilitation program can be an effective alternative to surgical approach in reducing the frequency of urinary leakage. Further studies are needed to identify factors predicting success and to improve the techniques of pelvic floor rehabilitation.     

Urinary incontinence and psychological distress among older adults.

We examined the relationship between urinary incontinence and psychological distress in a sample of community-dwelling older adults. The data are from a probability sample of Washtenaw County, Michigan residents ages 60 years and older, who were interviewed in 1983 and 1984. A total of 747 women and 431 men were included in the analyses. Experiencing urinary incontinence, particularly in a severe form, was weakly related to depression, negative affect, and low life satisfaction. These relationships are partly explained by the fact that incontinent respondents are less healthy than are continent respondents. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Urinary incontinence in rural older women: prevalence, incidence and remission

OBJECTIVES: To determine the prevalence, incidence, and remission rates of urinary incontinence in a large group of older women over a 6-year time span and to assess factors associated with incontinence incidence and remission. DESIGN: Longitudinal cohort study. SETTING: Two rural counties in Iowa. PARTICIPANTS: 2025 women aged 65 years or older residing in rural Iowa, enrolled in the Iowa 65+ Rural Health Study of EPESE (Establishment of Populations for Epidemiologic Studies of the Elderly) were interviewed in person annually for 6 years; specific responses to queries about urinary incontinence were given at baseline, 3-, and 6-year intervals. MEASUREMENTS: Conditional multivariate logistic regression analysis was done to assess the relationship between incontinence symptoms and various factors previously found to be related to incontinence. RESULTS: The baseline prevalence of urge incontinence was 36.3%, and of stress incontinence it was 40.3%. For urge incontinence, the 3-year incidence and remission rates between the third and sixth years were 28.5% and 22.1%, respectively. For stress incontinence, the 3-year incidence and remission rates between years 3 and 6 were 28.6% and 25.1%, respectively. Seventy-six percent and 84% of women who reported no urge or stress incontinence, respectively, at the baseline interview were continent at both follow-up interviews. The only significant factors related to changes in incontinence status were age, which was associated with an increased incidence of urge incontinence (OR 1.11, P = .017, 95% CI 1.019-1.203), and improvement in activities of daily living, which was associated with a increased remission of urge incontinence (OR 0.50, P = .015, 95% CI 0.28-0.9) CONCLUSION: In some older women, urinary incontinence is a dynamic state, with women moving back and forth along a continuum between continence and incontinence. These results are tempered by limitations of the study, which include its questionnaire design and lack of ability to detect potential treatment effect.     

Urinary bladder incontinence after prostatectomy. Urodynamic evaluation and results of therapy

Forty-seven males referred due to postprostatectomy urinary incontinence (34 after transurethral resection of prostatic adenoma and 13 after open suprapubic adenomectomy) were retrospectively studied. Urodynamic evaluation identified 19 (40.4%) men with incontinence due solely to sphincter incompetence, and 19 (40.4%) men, in addition to sphincter incompetence, had urinary bladder dysfunction (unstable detrusor and/or reduced bladder compliance). Seven (14.8%) men had pure bladder dysfunction as the only cause of urinary incontinence. Two patients had normal urodynamic findings (N = 2; 4.2%). Men with urinary incontinence due only to sphincter incompetence were treated by insertion of artificial sphincter devices or condom catheter drainage (lack of artificial sphincters), while others were treated pharmacologically (imipramine, propantheline, oxybutynin or their combinations ... N = 25), or by augmentation cystoplasty using ileum after unsuccessful pharmacological treatment (N = 3). Out of 25 patients with pharmacological treatment, 21 were available for the final assessment of the treatment efficacy. Eleven (52.3%) patients were "socially continent" after the treatment. It is concluded that in the assessment of the cause of postprostatectomy urinary incontinence urodynamic evaluation is mandatory, and that the treatment should be based on the results of such studies. The role of bladder dysfunction as a cause of postsurgical urinary incontinence is again strongly emphasized.     

Estimation of direct cost and resource allocation in intensive care: correlation with Omega system

Physical disorders and pharmacotherapy for all 134 people with mental retardation ages 65 years and over living in Leicestershire, United Kingdom, were examined. Results were compared with a randomly selected group of 73 younger adults with mental retardation. Group comparisons revealed higher rates of urinary incontinence, immobility, hearing impairments, arthritis, hypertension, and cerebrovascular disease among the older group. The younger group had higher rates of dermatological disorders; congenital heart disease; ear, nose, and throat (ENT) disorders; and neurological disorders (excluding Parkinson disease). The older group took more drugs for physical illness. The effect of ageing on physical morbidity outweighs the effect of people with more severe mental retardation dying younger: Older people with mental retardation have significant physical health needs.     

Use of spiral computed tomography for multiplanar dental reconstruction

This was a community-based study to evaluate the prevalence and characteristics of female urinary incontinence in women aged 18 and above in the Shatin District of Hong Kong. Of a total of 1018 female households contacted, 362 individuals were successfully interviewed and 123 women (34%) reported they had experienced at least one episode of urinary incontinence as adults. Of these, 18.5% reported persistent incontinence and 15.5% reported absence of incontinence after a single episode of urine loss. The risk factors for incontinence revealed by this study were body mass index and parity. Women who had never been incontinent had a lower body mass index and were usually nulliparous. Most of the respondents (43.9%) who had urinary incontinence considered the condition to be a minor problem and did not seek professional advice. This investigation indicates that a territory-wide study should be carried out to determine the incidence of urinary incontinence throughout Hong Kong.     

Skin disorders and moisture in incontinent nursing home residents: intervention implications

OBJECTIVE: To provide data needed to design an intervention trial to prevent or treat skin disorders in a high risk, incontinent nursing home population. DESIGN: The incidence and prevalence of nine common skin disorders were measured prospectively over a 60-day period using trained observers. Urinary and fecal incontinence frequency were measured over 24 hours, and mobility was measured with subjects both in and out of bed. Direct measures of skin moisture were taken with an impedance device in the presence and absence of urinary incontinence. Multiple regression analyses were used to relate the incontinence and mobility variables to the presence and development of skin disorders. SETTING: Four nursing homes. PARTICIPANTS: One hundred incontinent nursing home residents. MAIN OUTCOME MEASURES: Prospective measures of nine common skin disorders and skin moisture in four perineal regions under continent and incontinent conditions. RESULTS: All subjects had at least one skin condition identified during the 60-day data collection period. The most commonly observed skin condition was blanchable erythema, which occurred in 94% of the subjects, predominantly in the front and back regions that were closest to the urethra and rectum. Twenty-one percent of residents developed either a Stage 1 (nonblanchable erythema) or 2 pressure ulcer. All skin conditions were transient when measured every 3 weeks with the exception of blanchable erythema, which showed stability. Stage 3 or greater pressure ulcers and edema were not observed, and interrater reliability for the measure of papules was poor. Measures of urinary and fecal incontinence severity were correlated with blanchable erythema severity, and blanchable erythema and low bed mobility were predictive of pressure ulcer severity. Blanchable erythema severity was also predictive of Stage 1 and 2 pressure ulcers. Skin moisture levels in the back perineal farthest from the rectum (peripheral) were affected most by urinary incontinence. CONCLUSION: A trial to detect a 50% preventive effect on Stage 1 and 2 pressure ulcers would require that 167 subjects be monitored for 60 days. The transient nature of the skin effects require that skin be monitored at least once a week. Because blanchable erythema is so prevalent and appears to be associated with more severe skin conditions, it would make an excellent marker for beginning to assess the potential preventive effects of various interventions on the incidence of pressure ulcers and other related skin disorders in incontinent patients. It is likely that the back area peripheral to the urethra and rectum would experience the greatest benefit from an intervention trial to reduce moisture caused by incontinence.     

Evaluating the culture of fetal erythroblasts from maternal blood for non-invasive prenatal diagnosis

The aim of this study was to identify the prevalence of homebound elderly (defined as people whose daily activities were limited to their home) and factors related to it among 300 community elderly residents aged 60 and over in Yamagata city. In 1995, the baseline survey was performed and the follow-up survey was conducted one year later. Subjects were divided into two groups according to the extent of their daily activities: the non-homebound group (defined as people whose daily activities extended into their community) and the homebound group. The main results were as follows; 1. The prevalence of homebound elderly was 7.7% in 1995. 2. Chi-square test or t test was performed to examine the relationship between homebound and various factors. Significant factors were age, history of hypertension, history of mental disease, incompetence of ADLs (walking, eating, toileting, bathing, dressing), interpersonal dependency, subjective health, 'ikigai' (meaningfulness of life), life style (cooking, cleaning, reading newspaper or magazine, watching TV, exercise, associate with friend) and TMIG (Tokyo Metropolitan Institute of Gerontology) index of competence. The present study reveals that daily activities in community elderly residents is related to not only physical factors but also psychosocial factors. Using the significant variables in univariate analysis, multiple logistic regression analysis controlling for age was performed. Significant factors for homebound were incompetence of ADLs (walking, toileting), subjective health and TMIG index of competence. 3. Three out of 214 non-homebound elderly persons in 1995 changed to homebound in 1996.     

Urinary stress incontinence. Comparison of the Raz technique and the Bologna technique. Analysis of a series of 188 patients

OBJECTIVE: Our purpose was to evaluate and compare the perioperative morbidity and the long-term results of the Raz colposuspension and the Bologna operation for the treatment of stress urinary incontinence in women. STUDY DESIGN: Data of 188 women who underwent either a Bologna operation (group 1) or a Raz colposuspension (group 2) for the treatment of stress urinary incontinence between January 1, 1987 and December 1, 1995 were analysed retrospectively regarding history, preoperative evaluation, associated surgical procedures, complications and cure and failure rate. POPULATION AND METHODS: 80 patients were treated with the Bologna operation and 108 with the Raz colposuspension. Patients with prior anti-incontinence surgery, and patients with a preoperative diagnosis of urge incontinence were excluded from the study. Success was defined both subjectively (complete absence of complaint of stress urinary incontinence) and objectively (no evidence of loss of urine on cough provocation during physical examination). Survival curves were generated in each group for time to event data: "time to recurrent stress incontinence" and compared by the logrank test. A multivariate analysis using a Cox proportional hazards regression model was performed to indentify possible outcome predictors. RESULTS: The success rate of group 1 was significantly higher than that of group 2 (p = 0.00001). The median of success was 51 months in group 1 and 21 months in group 2 (p = 0.00001). The incidence of intraoperative complications in each group (inadvertent cystostomy, hemorrhage) did not differ. The multivariate analyses using the Cox regression model showed that the most highly correlated variable with the surgical cure rate was the type of surgical anti-incontinence procedure adopted: Bologna or Raz (p = 0.00001) CONCLUSION: In our hands, the Bologna operation has a higher cure rate than the Raz colposuspension. For us, when treating patients with stress urinary incontinence by the vaginal route, the Bologna operation is indicated when sufficient anterior vaginal tissue is available to create vaginal bands.     

Effects of neutralizing on intrusive thoughts: an experiment investigating the etiology of obsessive-compulsive disorder

OBJECTIVE: To determine the effect of pelvic floor muscle exercises combined with electrical stimulation of pelvic floor on lower urinary tract dysfunction in multiple sclerosis (MS) patients with near normal (< 100 ml) postvoid residual volumes. DESIGN: Open, controlled, randomized study in two parallel groups. SETTING: Rehabilitation centre for MS patients. SUBJECTS: Fifty women and 30 men with definite MS and current symptoms of lower urinary tract dysfunction. OUTCOME: The muscle activity of the pelvic floor muscles was tested using surface EMG. Subjective urinary symptoms were assessed using a questionnaire. INTERVENTIONS: Pelvic floor muscles were stimulated using electrical stimulation at six sessions. During and after the final session the patients were taught to exercise their pelvic floor muscles and advised to continue these exercises regularly for at least six months. The control group was not treated. RESULTS: The maximal contraction power and endurance of the pelvic floor muscles increased after six sessions of electrical stimulation with interferential currents. Symptoms of urinary urgency, frequency and incontinence were significantly less frequent in the treated group than in the untreated subjects. Male patients appeared to respond better to the treatment than female patients. Compliance with the pelvic floor exercises was over 60% at the end of a follow-up for six months. Most drop-outs were due to the disappearance of urinary tract symptoms or to severe relapses in MS. CONCLUSIONS: The present study indicates that pelvic floor muscle exercises combined with electrical stimulation of the pelvic floor constitute an effective treatment for lower urinary tract dysfunction at least in male patients with MS.     

Predicting nursing home admissions among incontinent older adults: a comparison of residential differences across six years

Whether or not rates of nursing home admissions among elders with urinary incontinence varied by their place of residence was investigated. We also examined whether any observed residential differences could be accounted for by factors other than incontinence that are known to influence rates of institutionalization. Data from the Longitudinal Study on Aging (1984-1990) were used to examine a sample who at baseline lived in community settings and reported problems with urinary incontinence (n = 719). Analyses indicate that residents of less urbanized and thinly populated nonmetropolitan counties were more likely to have a nursing home admission than elders in any other residential context. More importantly, these residential differences persisted in multivariate logistic regression models after controls were introduced for sociodemographic characteristics, measures of health status, and indicators of the social support networks of the elders.     

Dose-ranging study of tolterodine in patients with detrusor hyperreflexia

Tolterodine is a potent antimuscarinic agent specifically developed for the treatment of urinary urge incontinence and other symptoms related to the overactive bladder. In order to assess the optimum dosage for use in future clinical studies, a double-blind, randomized, placebo-controlled, parallel-group, multicenter study was performed in 90 patients with detrusor hyperreflexia and symptoms of urinary urgency, frequency, and/or urge incontinence. Urodynamic variables, micturition diary variables, and subjective urinary symptoms were measured before and after 2 weeks' treatment with either placebo or tolterodine 0.5, 1, 2, or 4 mg twice daily (bd). Serum drug concentrations, electrocardiogram recordings, blood pressure, and incidence of adverse events were also assessed. Linear regression analysis showed a significant dose-response relationship for several clinically relevant urodynamic variables, while there was a trend towards an improvement in micturition diary variables and subjective assessment of symptoms with increasing dosages of tolterodine. There were no safety or tolerability concerns regarding any of the dosages of tolterodine investigated, although 2 patients treated with a dosage of 4 mg bd experienced urinary retention that necessitated dosage reduction. The results of this study suggest that tolterodine is well-tolerated and exerts a dose-dependent effect on bladder function in patients with detrusor hyperreflexia. The optimum dosage of tolterodine for use in future studies is 1-2 mg bd.     

Collagen injections for intrinsic sphincter deficiency in the neuropathic urethra

Twelve subjects experiencing stress urinary incontinence caused by spinal injury or myelomeningocele were treated by periurethral injection of a bulking agent, glutaraldehyde cross-linked (GAX) collagen. Of the 11 subjects who completed the program, seven were either cured or improved and four were only slightly improved or no better following injection. The valsalva (abdominal) leak point pressure (LPP) rose an average of 57 cm H2O (pre-treatment mean of 60 cm H2O versus post-treatment mean of 117 cm H2O) and none of the patients experienced significant complications during the mean follow-up period of 24 months. Every subject injected was able to maintain an intermittent catheterization program after treatment. These data support the use of GAX collagen as an alternative or adjunct therapy to pharmacotherapy, surgical reconstruction or implantation of a prosthesis in the management of stress urinary incontinence in the neuropathic urethra.     

A method of determining the specific volume of liposomes with Turnbull blue]

OBJECTIVES: To present the results obtained in patients with stress urinary incontinence treated with periurethral collagen injection. METHODS: 26 female patients with stress urinary incontinence were treated with bovine collagen injection; mean volume 10.8 cc. The results achieved by this therapeutic modality are described herein. RESULTS: Control evaluations performed during a period of one year showed highly satisfactory results had been achieved initially and the success rate gradually increased over the 12 months follow-up. Overall the final results showed a success rate of 34.6%, 38.4% showed frank improvement and 26.9% had a failed procedure. There were no significant differences in the results for both types of stress urinary incontinence. The results correlated with the severity of incontinence; the success rate was higher in the patients with low grade incontinence. CONCLUSIONS: Periurethral collagen injection is indicated in patients with type I and type III stress urinary incontinence who cannot benefit from surgery. Patients with type II stress urinary incontinence, however, do not benefit from this therapeutic modality.