Be vigilant in diagnosing urinary incontinence
Urinary incontinence is a common problem that can have significant impact on quality of life. Yet studies have indicated that most patients rarely discuss this problem with their physicians, and few physicians ask about it during patient screenings.
At an Assembly clinical seminar on incontinence, David Thom, M.D., assistant professor in the family and community medicine division, Stanford University School of Medicine, discussed the individual and public health impact of urinary incontinence and identified clinical presentations, diagnoses and treatments for the condition.
"While urinary incontinence is seldom life threatening," he said, "it often does have a significant impact on a patient's quality of life. In dependent, elderly adults, it can add significantly to caregiver burden and may increase the risk of nursing home admission."
Urinary incontinence receives little attention, Thom said, because patients and some physicians wrongly assume that it is a minor problem and that treatment is difficult or ineffective.
In the United States, an estimated 25 percent of women 30 to 60 years old suffer from urinary incontinence, compared to only 4 percent of men in the same age group. For those older than 60, the prevalence of urinary incontinence rises to 35 percent among women and 17 percent in men.
Thom discussed the four types of urinary incontinence:
- Stress -- urethral insufficiency. This affects 55 percent of women 40 to 64 years old and 30 percent of women 65 and older.
- Urge -- detruser instability or hyperreflexia. This affects 15 percent of women 40 to 64, and 30 percent of women 65 and over.
- Mixed -- instability plus insufficiency. This affects 30 percent of women 40 to 64, and 40 percent of women over the age of 65.
- Overflow -- an obstructive or a/hypodynamic detrusor.
"Recent studies have shown that less than half of women with urinary incontinence tell their doctor," he noted. "And only about 10 percent of women with urinary incontinence are currently under treatment. Clearly, underdiagnosis is a critical problem."
Another study highlighted this point, according to Thom, when it showed that primary care providers ask their patients about urinary incontinence only 18 percent of the time.
"And once urinary incontinence was identified, providers rarely asked key questions about frequency and duration of symptoms, dysuria, urgency or nocturia," he said.
Thom suggested the following screening questions to detect urinary incontinence:
- Have you had any problems with your bladder?
- Have you ever leaked urine, even a little bit?
- How often has this happened in the last 30 days?
- Do you consider this accidental loss of urine a problem that interferes with your day-to-day activities or bothers you in other ways?
Treatments include correction of reversible causes, such as infection, constipation or use of certain medications; implementation of behavioral changes and exercises, such as biofeedback, scheduled voiding and habit training; use of pharmacologic treatments, including phenylpropanolamine for stress incontinence; or correction of the problem through surgery.
Thom discussed other treatments, including pessaries, indwelling catheters, intermittent catheterization, absorbent garments, external urine collection systems and new devices such as the urethral plug.
"The family physician should consider referral to a specialist when the patient fails to respond to treatment and if there are recurrent infections," he said.
