Facts About Urinary Incontinence
Urinary Incontinence (UI)
UI - “is objectively demonstrated involuntary urine loss that is sufficient to be a social or hygienic problem.”
From: Urinary Incontinence in Adults - Clinical Practice Guidelines, Agency for Health Care Policy and Research, U.S. Department of Health and Human Services, 1996
Demographics of Urinary Incontinence UI plagues 13 million Americans (AHCPR-USDHHS, 1996)
- Prevalence in population between 15 and 64 years old
1.5 to 5% of men 10 to 30% of women
- Prevalence in elderly (60 years and older)
15-35% of non-institutionalized (70% are female) 53% of homebound elderly at least 50% of 1.5 million nursing facility residents. 11% report UI at admission to hospital, 23% at discharge
- Because of the social stigma associated with Urinary Incontinence, the AHCPR states that UI is vastly underdiagnosed and underreported.
- UI is believed to affect more than 25 million Americans
- Prevalence in younger population
28% of 144 female exercisers between 18-21 yrs.
(Nygaard, Thompson, Svengalis, 1994) 26% of 3,100 females between 30-59 yrs.
(Elving, Foldspang, Lam, Mommsen, 1989)
- Prevalence in elderly
43.6% of women, 20.9% of men (Emory Univ., 1996) Estimated that 50% of elderly suffer from UI (85% are female) 1 of 12 subjects reported symptoms to caregiver, on average of 9 years after onset of the problem.
(Sandler, 1989)
Costs of Urinary Incontinence
Direct annual medical costs of caring for persons with UI is $16.4 billion. (AHCPR, 1996 - based on 1994 dollars) $11.2 billion in the community, $5.2 billion in nursing facilities, increase of 60% from previous estimate in 1990. Adult diaper sales exceeded $1.5 billion in 1996
- $173 million in 1982, $496 million in 1987
- Projected to exceed $2 billion in 1999
Typical UI sufferer spends approximately $1,000-$3,000 annually on absorbent products. Psychiatric Aspects of Lower Urinary Tract Dysfunction
- BLADDER IS THE MIRROR OF THE SOUL.
Chinese proverb
- Lower urinary tract disorders can be psychologically devastating due to profound psychosocial distress and disability.
Ostergard , Bent ( Urogynecology and Urodynamics, 1991)
- In 1990 Bierhoff described Bladder Neurosis.
Bierhoff F, Amer J Med Sci 1900;120:670
- Over 90 % of women with bladder instability appear to have no other recognizable pathology.
Fantl JA, Clin Obstet Gynecol 1984;27:474
- Bladder hyperfunction and frequency commonly associated with a reaction of anxiety and resentment accompanying conflict.
Straub LR, Ripley HS, Wolf S, JAMA 1949;141:1139
- Psychiatric assessment of 50 women with recurrent cystitis: 30 % had history of anxiety disorder and/or depression antedating the onset of urinary symptoms. In 24% psychiatric disorder resulted from urological disorder. Only 25% were free of psychiatric symptoms at all times.
Rees DLP, Farhoumand N, Psychiatric aspects of recurrent cystitis
in women. Brit J Urol 1977;49:211
- Mind Bladder Syndrome: Urgency, Frequency, Pain or Recurrent Retention without pathological urological findings.
Ostergard , Bent (Urogynecology and Urodynamics, 1991)
- While neurologic circuits necessary to maintain subconscious, involuntary, inhibitory control over the detrusor remain intact, the neurologic messages sent from the cortex to the bladder over these circuits are not strong enough to suppress reflex activation of the detrusor.
Sand PK, Detrusor Instability.
Amer Uro-Gyn Soc Quart Rep 1989:7(2)
- Patients were anxious, depressed and phobic as psychiatric patients, emphasizing the serious psychological morbidity experienced by patients with incontinence.
Macaulay AJ, Stern RS, Holmes DM, Stanton SL.
Brit. Med. Journal 294: 540-543
- Roughly a quarter of patients complained that life was not worth living because of their urinary symptoms.
Macaulay AJ, Stern RS, Holmes DM, Stanton SL.
Brit. Med. Journal 294: 540-543
- Quarter of patients with genuine stress symptoms also claimed that their urinary symptoms rendered life intolerable.
Macaulay AJ, Stern RS, Holmes DM, Stanton SL.
Brit. Med. Journal 294: 540-543
- Psychotherapy can have an impact on urinary symptoms. Nocturia, urgency and incontinence all improved significantly.
Macaulay AJ, Stern RS, Holmes DM, Stanton SL.
Brit. Med. Journal 294: 540-543
- The increased availability and appropriate application of bladder training and psychotherapy would produce benefits to patients and savings for the health service.
Macaulay AJ, Stern RS, Holmes DM, Stanton SL.
Brit. Med. Journal 294: 540-543
Other interesting facts about UI
- Many people believe UI is an inevitable part of aging.
- It is estimated that 30% of all sanitary napkins sold are used for UI.
- UI is the 2nd leading reason for institutionalization of elderly.
- Baby Boomers are quickly approaching 50 yrs of age, it is estimated that 25% of U.S. population will be over 50 yrs. old by 2001.
- On average, people are living longer, more active lives.
- Contribution of UI to hip fractures in the elderly?
Traditional treatment options for UI
- Surgery - bladder neck suspension, bladder tuck, collagen implants and/or injections
- Pharmaceuticals - anticholinergic agents, tricyclic antidepressants, beta-adrenergic agonists
- Catheterization - indwelling Foley catheter
- Absorbent Products - adult diapers and pads
Traditional treatment Side effects
- Surgery - expensive, involve hospitalization and extensive recovery time, long-term success rates? Complications may include; failure to cure incontinence, de novo detrusor instability, urogenital fistulas, bleeding complications, infection, damage to viscera, osteitis pubis, voiding dysfunction, Dyspareunia, chronic suprapubic pain, nerve injuries, genital prolapse, vaginal granulation tissue, incisional hernia, pulmonary emboli and sinus tracts.
- Pharmaceuticals - expensive with numerous side effects including dizziness, fatigue and respiratory problems.
- Catheterization - urinary tract (UT) infection, loss of mobility.
- Absorbent Products - expensive, addresses symptoms only,may contribute to skin breakdown and urinary tract infections.
Conservative Treatment of UI
Behavioral Techniques include:
- EMG Biofeedback Therapy
- PME’s - Pelvic Muscle Exercises
- Psychotherapy
- Bladder Training, Toilet Training, Timed Voiding
- Electrical Stimulation
- Vaginal Weights/Cones
AHCPR’s position on behavioral techniques The AHCPR’s three major categories of treatment for UI are:
Selection of the appropriate treatment for patients with UI “As a general rule, the first choice should be the least invasive treatment with the fewest potential adverse complications that is appropriate for the patient. For many forms of UI, behavioral techniques meet these criteria. This panel has concluded that behavioral techniques such as bladder retraining, biofeedback and pelvic muscle rehabilitation are effective, low-risk interventions that can significantly reduce incontinence in varied populations.” (AHCPR)
What is EMG biofeedback Therapy? EMG Biofeedback - instruments record minuscule amounts of muscle activity given off from specific skeletal muscles during a contraction. These micro-volt levels of muscle activity are then amplified, filtered and converted into audio and visual signals. Then, the patient is provided with this instantaneous, performance-contingent audio and visual feedback regarding the activity level of specific muscles. The patient can use this information to better activate weak muscles, relax overly tense muscles or better coordinate muscle activity between muscle groups. How does EMG Biofeedback therapy work for Patients with UI? Associated with many types of UI is profound pelvic muscle weakness. In the 1950’s, Dr. Arnold Kegel discovered that simple pelvic muscle strengthening exercises, now called Kegel exercises, significantly reduced the severity of incontinence in his patients. Unfortunately, most patients are unaware that these muscles even exist and find the Kegel exercises difficult to perform correctly. One study found that 51% of women performed Kegel exercises incorrectly when given verbal or written instructions only (Bump, 1991). EMG Biofeedback is used to record muscle activity from the pelvic floor and abdominal muscle groups. The patient uses the audio and visual information as an indicator of correct muscle performance during the Kegel exercises or functional activities. What does EMG Biofeedback therapy Provide for patients with UI?
- Helps the patient visualize and identify the appropriate muscles
- Differentiates muscle activity between muscle groups
- Reinforces patient’s efforts to perform Kegel exercises correctly
- Teaches patients how to contract the pelvic muscles “on demand”
- Motivates patient to “take control” of their UI problem
- Objectively documents the patient’s progress
which Types of UI can benefit from conservative management (Stress, Urge, Mixed, Overflow, Reflex, Functional)
- Stress - urine loss during physical activities that increaseabdominal pressure i.e. coughing, sneezing, laughing.
- Urge - urine loss associated with an abrupt and strong desireto void (urgency), also detrusor instability.
- Mixed - a combination of stress and urge incontinence. Thought to begin as stress, then later develop urge.
Of the several types of urinary incontinence, stress, urge and mixed account for over 90% of all UI. Pelvic muscle weakness is usually prevalent with these three types of UI and these patients would be appropriate for EMG Biofeedback therapy. How Effective IS conservative therapy?
- Studies on various applications of biofeedback combined with behavioral treatment report a range of 54-87% improvement in incontinence across various patient groups (AHCPR, 1996).
- The biofeedback protocol associated with the largest and most consistent symptom reduction is one that reinforces pelvic muscle contraction concurrently with inhibition of abdominal and detrusor contraction. Reports using this multi-measurement method show a 76-82% reduction in UI across 6 studies involving 166 subjects (Burgio, et al 1985-1992).
- Behavioral therapy consists of self regulated extension of voiding intervals. Various protocols, but cure or improvement reported in 70-90% of patients.
Ostergard , Bent ( Urogynecology and Urodynamics, 1991)
- Electrical Stimulation of Pudendal Nerve causes pelvic floor and periurethral muscle contraction. Improvement or cure in 70-75% of patients.
Bazeed MA, Thuroff JW, Schmidt RA, Wiggin DA, Tanagho EA,
Effect of chronic electrostimulation of sacral roots on striated
urethral sphincter. J Urol 1982;128:1357
- First reported case of cure of incontinence by psychiatric intervention.
Aboulker P, Chertok L, Psychosom Med 1962; 4:507
- Patients who have no other obvious cause and in whom other treatment measures have failed may respond to several psychotherapeutic measures.
Scotti RJ, Ostergard DR, Clin Obstet Gynecol 1984;27:515
- Smith described PSYCHOSOMATIC CYSTITIS and emphasized that psychotherapy was the definitive treatment.
Smith DR, J Urol 1962;82:359
Benefits from conservative Therapy
- Conservative - non invasive
- Motivational - actively involves patient in the treatment
- Objective - clearly indicates patient progression
- Inexpensive - low to moderate cost of treatment
- Effective - 85% of patients show improvement or cured
- Versatile - for stress, urge and mixed incontinence (90%)
- Compliance - better patient compliance
- Preference - patients prefer conservative management
- Low Risk - very little risk if any
- No Complications - no known complications
- Tolerance - well tolerated by patients
- Psychosocial - normalization of psychosocial status
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