Untreated Urinary Incontinence Research Articles

Perceptions and help‐seeking behaviours among community‐dwelling older people with urinary incontinence: A systematic integrative review

To synthesize research evidence on perceptions and help-seeking behaviours in community-dwelling older people with urinary incontinence based on the Capability-Opportunity-Motivation-Behaviours model. Urinary incontinence is highly prevalent in community-dwelling older people, yet only a small proportion seek help from health professionals. Untreated urinary incontinence has a detrimental impact on older people's quality of life and distresses their caregivers. Systematic integrative review. Ten databases were searched systematically between 9 November 2020 and 17 December 2020 including Medline (PubMed), CINAHL, Ageline, Web of Science, Scopus, ProQuest, Psyclnfo, CNKI, Wanfang and Vip. Quality appraisal was applied to assess the quality of selected articles. Data relevant to the review aim were extracted from included articles for analysis. Convergent qualitative synthesis was used to synthesize findings. Twenty articles were included and two main themes with six sub-themes were identified. Theme one described three common perceptions including urinary incontinence as a part of normal ageing, a stigma and a health problem. Each perception had a profound impact on older people's motivation to self-report the problem to health professionals. Theme two revealed three main help-seeking approaches comprising self-help, help from friends and help from health professionals. Of these, self-help was the dominant approach used to conceal urinary incontinence and contributed to social isolation. Improving urinary incontinence management in community-dwelling older people requires the development of their capability and motivation, and increased opportunities to access and gain help from skilled health professionals. Findings can facilitate resource development to improve health literacy for the general public pertinent to urinary incontinence and associated stigma. Moreover, findings can inform a user-friendly reporting and referral system for the problem. In addition, findings can inform education and skill training for health professionals, older people and their caregivers to effectively manage the problem.

When Symptomatic Treatment Becomes Antitumor Treatment for Vipoma: Opportunity for Frail Elderly Adults

To the Editor: An 82-year-old woman was admitted to the emergency department because of a fall with head injury and loss of consciousness. Her hospital record revealed a history of untreated urinary incontinence, dyslipidemia, and hypertension. During the previous 6 weeks, she had had untreated profuse diarrhea (>10 watery stools per day), a 10-kg loss of weight, and severe asthenia. On examination, she showed evidence of delirium with fluctuating level of consciousness and disorientation, ophthalmic zoster lesions, and severe dehydration. Laboratory tests showed hypokalemia 1.5 mmol/L (normal range 3.5–5.0 mmol/L), hypercalcemia 3.2 mmol/L (normal range 2.2–2.6 mmol/L), and acute renal failure. Her electrocardiogram showed inverted T waves and ST depression. Fluid and electrolyte replacement urgently performed under cardiac monitoring led to partial improvement of her condition. Thoracoabdominal computed tomography was performed to investigate the profuse diarrhea and showed a 7-cm hypervascularized tumor in the tail of the pancreas, with nodes of peritoneal carcinomatosis and lesions in the liver and lungs, and a bilateral pulmonary embolism. Emergency physicians consulted the mobile geriatric team, and she was admitted to the geriatric ward, because it was best suited to provide the comprehensive care required. Anticoagulant therapy was initiated, and in consultation with gastroenterologists, short-acting octreotide (somatostatin analogue) 100 μg twice a day for symptomatic diarrhea was initiated, leading to dramatic improvement. To implement the best care plan, comprehensive geriatric assessment was performed 3 weeks after admission.1, 2 Of the 10 standard domains assessed, six were impaired: mild cognitive impairment, mobility and balance disturbance, activity of daily living impairment, malnutrition, and social isolation. It was decided to investigate further her pancreatic tumor to determine the best treatment. Computed tomography–guided needle biopsy of the pancreatic mass diagnosed a well-differentiated neuroendocrine tumor. Chromogranin A was 143 ng/mL (normal <85 ng/mL) and vasoactive intestinal peptide (VIP) was 157 ng/L (normal 23–63 ng/L). Indium-111-octreotide scintigraphy showed an isolated strong uptake in the tail of the pancreas. A potential diagnosis of metastatic VIPoma was reached. The institutional tumor board chose palliative care for this frail 82-year-old woman and decided to switch to a long-acting somatostatin analogue for its antisecretory and antitumor effects. She died 5 months later, before progression of the tumor could be assessed. VIPoma is a rare functional neuroendocrine tumor of the pancreas (pNET) that secretes VIP. Although VIPoma is rare (estimated incidence 0.05–0.2/1,000,000 individuals), the incidence of NET is rising and could be more common in elderly adults.3-5 The typical clinical features of VIPoma result from excessive secretion of VIP and include large-volume secretory diarrhea, hypokalemia, and dehydration.3 Somatostatin analogues, which inhibit the release of neuroendocrine hormones, control hormone-related symptoms in up to 70% to 90% of symptomatic pNETs.6 Forty percent to 95% of VIPomas are metastatic at presentation, and the symptoms related to excessive secretion of VIP are more likely to shorten life expectancy than tumor growth.7 Thus, management of these tumors in frail elderly adults requires collaboration between endocrinologists and geriatricians to weigh the pros and cons of each therapeutic option. Two new therapeutic options are worth mentioning. First, two targeted therapies everolimus and sunitinib, have recently been approved for treatment of progressive metastatic pNET, although no evidence of efficacy in older adults is available.8 Second, somatostatin analogues, which have an excellent tolerance profile, have been shown to have an antitumor effect: in retrospective studies, stabilizing up to 50% of 60% of NET, and in two randomized controlled trials of octreotide long-acting release in metastatic midgut NET and nonfunctioning gastroenteropancreatic NET.6, 9, 10 Somatostatin analogues are thus recommended for antiproliferative purposes in nonresectable, slowly progressive, low proliferative NET.6, 8 Even though there is no evidence of efficacy in older adults, somatostatin analogues have been used in elderly adults for their antisecretory effects and could be a nonaggressive alternative treatment for frail elderly adults. In conclusion, this case illustrates that multidisciplinary collaboration enabled the choice of adequate treatment for this frail elderly woman. Moreover, a well-known symptomatic treatment has been proven to have an antitumor effect, increasing the spectrum of treatment options in this population. Conflict of Interest: All the authors declare no conflict of interest. Author Contributions: All the authors met the ICMJE criteria to be considered as authors. Sponsor's Role: No sponsor.

Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women

More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated. We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women. We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment. Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ≥ $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ≥ $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician. Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

Antimuscarinic use among individuals with urinary incontinence who reside in long-term care facilities

To assess appropriateness of antimuscarinic use in long-term care facilities (LTCFs) among treated and untreated urinary incontinence (UI) residents from 2007 to 2009. We conducted a retrospective analysis using the AnalytiCare(SM) database consisting of minimum data sets (MDS) assessments and prescription records of 90,660 residents from 2007 to 2009. UI (MDS H1b ≥ 1) residents with ≥ 14-day LTCF stay were identified and categorized as treated if they had ≥ 1 antimuscarinic prescription and untreated if they had no antimuscarinics. A random sample of untreated residents was matched based on treated residents' type of MDS assessment. We defined appropriate antimuscarinic use if residents had adequate cognitive function [≤ 4 on the cognitive performance scale (0 = intact to 6 = very severe impairment)] and mobility [scoring <4 on mobility for toileting scale (MDS item G1iA 0 = independent to 4 = total dependent)]. Chi-square tests were used to detect statistical difference between cohorts. A total of 5,327 residents (2,840 treated; 2,487 untreated) were selected [mean age (standard deviation) 80 (8), 81 (8) years; female (76, 65 %), respectively]. On study-defined MDS assessment, 63 % of treated and 69 % of untreated residents had UI (P < 0.01). Approximately 84 % of treated and 74 % of untreated residents may have had cognitive function and mobility sufficient for appropriate antimuscarinic use (P < 0.01). Our study identified a high percentage of LTCF residents with UI who may have been candidates for antimuscarinics. However, due to the MDS limitation, we were unable to identify overactive bladder patients among these untreated residents with UI. It is possible that untreated control residents had UI due to other factors not amenable to treatment with antimuscarinic agents. Therefore, choice of treatment for each resident needs to be individualized and carefully monitored for efficacy and adverse effects. This retrospective analysis requires prospective confirmation. Proper patient selection for antimuscarinic treatment requires careful assessment of underlying physical status including cognitive function, mobility, and comorbidities.

Managing urinary incontinence in the community

Urinary incontinence is the involuntary loss of urine. There are many types of incontinence and different management options available, ranging from lifestyle modifications, medication to surgical intervention. Untreated urinary incontinence can result in a myriad of problems, including skin irritations, infections, social phobia, major depression and premature institutionalisation of elderly family members. Common barriers to optimal management include the socially embarrassing nature of the condition, which impedes open discussion, as well as the misperceptions that management must be invasive and the condition cannot be adequately managed within the community. We discuss the common types of incontinence encountered in the community and their management in the primary care setting.

Do nurses promote urinary continence in hospitalized older people?: an exploratory study

The aim of this paper is to explore whether nurses working in elderly medicine and in acute medical settings promote urinary continence in older people or in reality use containment strategies. Untreated urinary incontinence in older adults can result in prolonged hospital admission and increased risk of admission to long-term care. Urinary incontinence can also have severe psychosocial effects on older people. Most studies relating to this topic have relied on quantitative approaches to data collection with a seeming lack of qualitative investigation into how nursing staff promote urinary continence in hospitalized older people. Focus groups and one-to-one semi-structured interviews were carried out in two NHS regions in Scotland. Registered and non-Registered Nurses were invited to participate. Five focus groups (n = 17) and four single interviews (n = 4) were conducted. Data generated were analysed thematically using QSR N-VIVO 2. Some nurses believe that older people accept urinary incontinence as a consequence of ageing. Lack of assessment results in older people being labelled as incontinent of urine. Assessment strategies in medicine for the elderly tend to focus on product identification and management of incontinence. Although nurses from all clinical areas identify the importance of promoting continence, the problem continues to be contained rather than treated. Conflicting clinical priorities, varying staff approaches to urinary continence and deficits in education are cited among the barriers to promoting continence. The results suggest that nurses continue to contain urinary incontinence rather than promoting continence in older people. Nursing staff need to be aware of the impact of untreated urinary incontinence on older people. Practitioners should promote continence rather than employing containment strategies. A validated assessment tool for older people needs to be developed. Views of older people should be sought regarding their attitudes towards urinary incontinence.

Urodynamic Characterisation of Women with Naive Urinary Incontinence: A Population-Based Study in Subjectively Incontinent and Healthy 53–63 Years Old Women

To compare the urodynamic characteristics in a group of middle-aged women with untreated urinary incontinence with the findings in a control group of healthy women. Sixty women with mild-to-moderate urinary incontinence and 28 symptom-free women, 53-63 years old, were randomly chosen out of a large health questionnaire study. All were investigated with a detailed history, gynaecological examination, urinalysis, frequency-volume chart, and urodynamics including cystometry and pressure-flow analysis. The maximum urinary flow was significantly higher in the incontinent group of women, 22+/-1ml/s, than in the healthy controls, 16+/-2ml/s (p<0.01). The acceleration of flow, with a theoretical maximum of 0 degrees, was also significantly faster in the incontinent, 20 degrees, than in the healthy women, 32 degrees (p=0.01). In the five women with urge incontinence only, maximum urinary flow was 26+/-2.4ml/s and the flow acceleration 7 degrees. In incontinent women, both a lower opening pressure and detrusor pressure at maximum flow were seen compared with the healthy women, though the difference did not reach statistical significance. The incontinent and the healthy women did not differ regarding bladder volumes or pressures during filling. The findings of this study indicate the presence of an increased efficiency of the urethral opening mechanism in incontinent women compared to normal, irrespective of the type(s) of symptoms present.