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a Urology, William Beaumont Hospital, Royal Oak, Michigan
Ananias C. Diokno, Chief of Urology, William Beaumont Hospital, Royal Oak, Michigan 48073 E-mail: jrace{at}smtpgw.beaumont.edu.
Decision Editor: John E. Morley, MB, BCh
AS we enter the third millennium, the landscape for the field of urinary incontinence (UI) has started to form a clearer pathway. Thanks to the early efforts of pioneers in this field, we now have a greater understanding of the magnitude of this problem, the many mechanisms of why incontinence occurs, and the several options available to manage this condition. Unfortunately, the pathway is far from clear, and the end is nowhere in sight. As the saying goes, the work has just begun.
In this issue, the article by Maggi and associates (1) clearly shows the big picture. UI is highly prevalent; whether you look at North America, Asia, or Europe, the picture is the same. However, there is a glimmer of hope that perhaps the incidence of UI is decreasing. Although it is impossible to compare surveys between different time periods, countries, or even authors from the same continent or country, the numbers reported decades ago seem higher than the reported prevalence of recent past. Certainly this could all be technical, but, could there have been some influence from the management that caregivers are offering now? This question brings up a very important issue in epidemiology. We must have a uniform survey questionnaire that is as applicable in North America as it is in Asia and Europe. Without standardizing the questionnaires, we will continue to have reports that may not be meaningful for all interested parties, and it will be impossible to compare the outcomes of different studies.
In determining the severity of incontinence, the frequency of UI is important, but equally important is the volume loss. It is my experience that the majority of women suffering from stress incontinence with small volume loss will usually cope with their problem and not necessarily seek medical care, whereas an individual who experiences an episode of one big volume loss will be at your office the next day seeking help. It is therefore imperative that, when obtaining history and performing a survey, volume loss in addition to frequency be part of the information. Recording this information would make it possible to measure the severity on the basis of a combination of these parameters.
The type of urine loss is also of utmost importance. We all know that there are different types and that each has its own unique signs and symptoms and unique methods of management. Urge type and mixed stress and urge incontinence appear to be the most common forms of UI in elderly men and women. If we are to understand UI better, we have to know which type we are dealing with.
The correlates of UI are well known. Several surveys may report a specific condition that may be unique in their setting, such as chronic diarrhea (which was only associated in men but not in women in the Maggi article). However, we all know that, in general, pulmonary conditions, lower gastrointestinal disturbances, neurologic and mobility problems, poor health status, certain medications, and of course lower urinary tract and genital conditions are highly correlated with UI. Furthermore, we know that each of the correlates may be linked with a specific type of incontinence.
A major epidemiologic question in this area of UI is the issue of racial and ethnic differences. There are reports that white women have a higher prevalence of UI than black women (2). Likewise, there seems to be a difference in the subtype of incontinence with which they present; that is, it appears that stress incontinence is more prevalent among white women. A major flaw in these observations is the lack of power because the populations of black women and other ethnic groups are very low compared with the populations of white women in these surveys. There is certainly a greater need to study these apparent discrepancies.
A great disappointment in most of the epidemiologic studies related to UI is the lack of a follow-up survey and, therefore, a lost chance to measure the incidence and potentially true cause-and-effect relationships among the various correlates of UI. In addition to follow-up surveys, it would be beneficial to perform confirmatory tests or studies on the respondents along the way to learn the natural history of this condition. This is certainly an expensive and invasive approach. However, it is important to recognize that establishing a prevalence study is only half the battle; one who is embarking on this type of study must strive to complete the investigation, especially after laying the groundwork for follow-up. As for confirmatory studies, our experience with the Medical, Epidemiologic, and Social Aspects of Aging project was extremely encouraging (3). We had respondents, both continent and incontinent, who agreed to and completed the physical examination and urodynamics studies with alacrity. Concerns for complications such as infection were unfounded; in our experience the incidence of complications was extremely low.
Finally, conventional epidemiologic studies must incorporate issues relevant to all individuals suffering from incontinence, including quality of life (social and emotional well being), financial burden, effects on work and home life, and potential barriers for seeking help. It is also a perfect time to start concentrating on preventative measures. Since we now have a good knowledge of prevalence rate, a rudimentary knowledge of incidence and remission rate and risk factors, and a fair knowledge of some of the management options that work, programs on prevention of UI are now ripe for initiation. As I stated earlier in this editorial, the work has just begun! Now, lets do it!
Received August 2, 2000
Accepted August 4, 2000
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This article has been cited by other articles:
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  M.-M. G. Wilson Guest Editorial. Urinary Incontinence: Bridging the Gender Gap J. Gerontol. A Biol. Sci. Med. Sci., August 1, 2003; 58(8): M752 - 755. [Full Text] [PDF]
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J. E. Morley Editorial: Drugs, Aging, and the Future J. Gerontol. A Biol. Sci. Med. Sci., January 1, 2002; 57(1): M2 - 6. [Full Text] [PDF]
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