Urinary and Fecal Incontinence: An Interdisciplinary Approach

Horst-Dieter Becker · Arnulf Stenzl Diethelm Wallwiener · Tilman T. Zittel Editors Urinary and Fecal Incontinence An Interdisciplinary Approach

Horst-Dieter Becker · Arnulf Stenzl Diethelm Wallwiener · Tilman T. Zittel Editors

Urinary and Fecal Incontinence An Interdisciplinary Approach

With 95 Figures, 43 in Color and 89 Tables

Prof. Dr. Horst-Dieter Becker Universitätsklinik für Allgemeine, Viszeral- und Transplantationschirurgie Zentrum für Medizinische Forschung Waldhörnlestrasse 22 72072 Tübingen Germany

Prof. Dr. Diethelm Wallwiener Universitätsfrauenklinik Calwerstrasse 7 72076 Tübingen Germany

Prof. Dr. Arnulf Stenzl Universitätsklinik für Urologie Hoppe-Seyler-Strasse 3 72076 Tübingen Germany

PD Dr.Tilman T. Zittel Universitätsklinik für Allgemeine, Viszeral- und Transplantationschirurgie Hoppe-Seyler Strasse 3 72076 Tübingen Germany

Library of Congress Control Number: 2004116516 ISBN-10 3-540-22225-1 Springer Berlin Heidelberg New York ISBN-13 978-3-540-22225-5 Springer Berlin Heidelberg New York This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law. Springer is a part of Springer Science+Business Media springeronline.com © Springer-Verlag Berlin Heidelberg 2005 Printed in Germany The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: the publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Editor: Desk Editor: Meike Stoeck, Heidelberg, Germany Production: ProEdit GmbH, 69126 Heidelberg, Germany Cover: Frido Steinen-Broo, EStudio Calamar, Spain Typesetting: K. Detzner, 67346 Speyer, Germany Printed on acid-free paper

21/3151 ML

543210

V

Contents

Contents

Part I Epidemiology and Health Costs of Incontinence 1

Epidemiology of Urinary Incontinence . . . . . . . . . . . . . . . . . . Steinar Hunskaar

2

Epidemiology of Fecal Incontinence: A Review of Population-based Studies . . . . . . . . . . . . . . . . . . Catherine W. McGrother, Madeleine Donaldson

1

13

3

Economic Costs of Urinary Incontinence in Germany . . . . . . . . . . Günter Neubauer, Sandra Stiefelmeyer

25

4

Perception of Incontinence in and by Society . . . . . . . . . . . . . . Paul Enck, Sibylle Klosterhalfen

33

Part II Pelvic Anatomy, Physiology and Etiology of Incontinence 5

An Attempt at an Explanation of Stress Urinary Incontinence Through the Rodent Animal Model . . . . . . . . . . . . . . . . . . . . Karl-Dietrich Sievert, Emer Bakircioglu, Lora Nunes, Tony Tsai, Tom F. Lue

41

6

Birth Trauma and Incontinence Ralf Tunn, Ursula Peschers

. . . . . . . . . . . . . . . . . . . . . .

87

7

Neurogenic Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . Helmut Madersbacher

95

8

Fecal Incontinence after Rectal and Perianal Surgery . . . . . . . . . . 103 Alan G. Thorson

VI

Contents

Part III Diagnostic Methods to Detect Incontinence 9

Evaluation of Anorectal and Pelvic Floor Muscle Function . . . . . . . 119 Fernando Azpiroz, Aniceto Puigdollers, Carlos Amselem

10

Imaging of the Pelvic Floor – Videoproctography and Dynamic MRI of the Pelvic Floor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 Alois Fürst, Lilli Hutzel, Klaus Guenther, Andreas Schreyer, Christian Paetzel

11

Diagnostic Methods to Detect Female Urinary Incontinence . . . . . 155 Heinz Koelbl, Gert Naumann

Part IV Conservative Therapy of Incontinence 12

Pharmacological Treatment of Urinary Incontinence . . . . . . . . . . 167 Gert Naumann, Heinz Koelbl

13

Medical, Behavioural and Minimally Invasive Therapy – A Urologist’s View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Christopher R. Chapple, Sawrabh Bhargava, Karl-Erik Andersson

14

Medical and Behavioral Treatment of Fecal Incontinence . . . . . . . 199 William E. Whitehead

Part V Operative Therapy of Urinary Incontinence 15

Innovative and Minimally Invasive Treatment of Stress Urinary Incontinence . . . . . . . . . . . . . . . . . . . . . . . 211 Christl Reisenauer, Konstantinos Gardanis, Diethelm Wallwiener

16

Abdominal, Vaginal or Laparoscopic Approach for Urinary Incontinence? . . . . . . . . . . . . . . . . . . . . . . . . . . 231 Wolfgang Zubke, Ines Gruber, Diethelm Wallwiener

17

Diagnostic and Surgical Management of Stress Urinary Incontinence Karl-Dietrich Sievert, Arnulf Stenzl

18

The Artificial Urinary Sphincter Roberto Olianas, M. Fisch

251

. . . . . . . . . . . . . . . . . . . . . . 271

Contents

Part VI Operative Therapy of Fecal Incontinence 19

Sphincteroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Tilman T. Zittel

20

Dynamic Graciloplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Cor G.M.I. Baeten, Jarno Melenhorst

21

The Artificial Bowel Sphincter in the Treatment of Severe Fecal Incontinence in Adults . . . . . . . . . . . . . . . . . . 297 Nicolas Regenet, Guillaume Meurette, Paul-Antoine Lehur

22

Innovations in Fecal Incontinence: Sacral Nerve Stimulation Klaus E. Matzel, Uwe Stadelmaier, Werner Hohenberger

23

Stoma Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 Martin E. Kreis, Ekkehard C. Jehle

. . . . . 311

Part VII Postoperative Care of Patients After Pelvic Operations 24

Postoperative Management After Surgery for Incontinence and Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 Ursula M. Peschers, Ralf Tunn

25

Postoperative Management of Urinary Incontinence After Urologic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Daniela Schultz-Lampel

26

Incontinence Treatment After Rectal or Perianal Surgery Christoph A. Ausch, Harald R. Rosen

. . . . . . . 357

Part VIII Quality of Life and Long-term Results After Incontinence Treatment . . . . . . . . . . 369

27

Quality of Life with Urinary and Fecal Incontinence Todd H. Rockwood

28

Long-Term Results After Surgery for Urinary Incontinence Wolfgang Zubke, Ella Retzlaw, Diethelm Wallwiener

. . . . . . 385

VII

VIII

Contents

29

Long-term Results of Surgery for Stress Urinary Incontinence – A Urologist’s View . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 Prasad Patki, Rizwan Hamid, Julian R. Shah

30

Long-term Results After Fecal Incontinence Surgery . . . . . . . . . . 403 Tilman T. Zittel

31

Quality of Life with a Permanent Colostomy . . . . . . . . . . . . . . . 429 Brigitte Holzer, Harald R. Rosen

Part IX How can we Improve the Treatment of Incontinence? 32

Is Urinary or Fecal Incontinence a Preventable Event? . . . . . . . . . 439 Daniele Perucchini, Daniel Faltin

33

Concept of the Pelvic Floor as a Unit: The Case for Multi-disciplinary Pelvic Floor Centers G. Willy Davila

. . . . . . . . . . 457

Part X On Asymmetry in Sphincters 34

Functional Asymmetry of Pelvic Floor Innervation and Its Potential Role in the Pathogenesis of Fecal and Urinary Incontinence – Report from the EU-Sponsored Research Project OASIS (On Asymmetry In Sphincters)   .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 467 Paul Enck, Fernando Azpiroz, Roberto Merletti

Subject Index   .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .

491

Contents

List of Contributors

Carlos Amselem, MD Pelvic Floor Institute, Barcelona, Spain Karl-Erik Andersson, MD Lund University Hospital, Department of Clinical Pharmacology, 22185 Lund, Sweden (e-mail: [email protected]) Christph A. Ausch, MD Chirurgische Abteilung, Donauspital / SMZ-Ost, Langobardenstrasse 122, 1220 Vienna, Austria (e-mail: [email protected]) Fernando Azpiroz, MD University of Barcelona, Hospital General Vall d’ Hebron, Digestive System Research Unit, 08035 Barcelona, Spain (e-mail: [email protected]) Cor G.M.I. Baeten, MD, PhD Maastricht University Hospital, Department of Surgery, P. Debyelaan 25, 6202 AZ Maastricht, The Netherlands (e-mail: [email protected]) M. Emer Bakircioglu, MD TAS Mektep S. No 59/12, Erenkoy, Istanbul 81060, Turkey (e-mail: [email protected]) Horst-Dieter Becker, MD Universitätsklinik für Allgemeine, Viszeral- und Transplantationschirurgie, Zentrum für Medizinische Forschung, Waldhörnlestrasse 22, 72072 Tübingen, Germany (e-mail: [email protected]) Sawrabh Bhargava, MD Royal Hallamshire Hospital, Department of Urology, Glossop Road, Sheffield, S10 2JF, UK Christopher R. Chapple, MD Royal Hallamshire Hospital, Department of Urology, Glossop Road, Sheffield, S10 2JF, UK (e-mail: [email protected])

IX

X

List of Contributors

Madeleine Donaldson Department of Epidemiology and Public Health, University of Leicester, 22–28 Princess Road West, Leicester, LE1 6TP, UK Paul Enck, MD Medizinische Klinik VI, Psychosomatische Medizin und Psychotherapie, Schaffhausenstr. 113, 72072 Tübingen, Germany (e-mail: [email protected]) G. Willy Davila, MD Cleveland Clinic Florida, Department of Gynecology, 2950 Cleveland Clinic Blvd., Weston, FL 33331, USA (e-mail: [email protected]) Daniel Faltin, MD Universitätsspital Zürich, Departement Frauenheilkunde, Frauenklinikstrasse 10, 8091 Zürich, Switzerland (e-mail: [email protected]) M. Fisch, MD Allgemeines Krankenhaus Hamburg-Harburg, Eissendorfer Pferdeweg 52, 21075 Hamburg, Germany Alois Fürst, MD, PhD Caritas-Krankenhaus St. Josef, Landshuterstr. 65, 93053 Regensburg (e-mail: [email protected]) Konstantinos Gardanis, MD Universitätsfrauenklinik, Calwerstraße 7, 72076 Tübingen, Germany (e-mail: [email protected]) Ines Gruber, MD Universitätsfrauenklinik, Calwerstraße 7, 72076 Tübingen, Germany (e-mail: [email protected]) Klaus Günther, MD Klinikum Fürth, Jakob-Henle-Str. 1, 90766 Fürth (e-mail: [email protected]) Rizwan Hamid, MBBS, FRCS Institute of Urology & Nephrology, 48, Riding House Street, London W1W 7EY, United Kingdom (e-mail: [email protected]) Werner Hohenberger, MD Chirurgische Klinik mit Poliklinik, Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany (e-mail: [email protected]) Brigitte Holzer, MD Ludwig Boltzmann Institut für Chirurgische Onkologie, Donauspital / SMZ-Ost, Langobardenstrasse 122, 1220 Vienna, Austria

List of Contributors

Steinar Hunskaar, MD, PhD Section for General Practice, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway (e-mail: [email protected]) Lilli Hutzel, MD Klinik und Poliklinik für Chirurgie, Universitätsklinikum, Franz-Josef-Strauss-Allee 11, 93053 Regensburg (e-mail: [email protected]) Ekkehard C. Jehle, MD Oberschwabenklinik, Krankenhaus St. Elisabeth, Elisabethenstrasse 15, 88212 Ravensburg, Germany (e-mail: [email protected]) Sibylle Klosterhalfen, MD Universitätsklinik Düsseldorf, Institut für Medizinische Psychologie, Moorenstraße 5, 40225 Düsseldorf, Germany (e-mail: [email protected]) Heinz Kölbl, MD Universitätsfrauenklinik, Langenbeckstrasse 1, 55101 Mainz, Germany (e-mail: [email protected]) Martin E. Kreis, MD Klinikum Großhadern, Allgemeine Viszeral- und Transplantationschirurgie, Marchioninistraße 15, 81377 München, Germany (e-mail: [email protected]) Paul-Antoine Lehur, MD Clinique Chirurgicale 2, Hotel Dieu, CHU de Nantes, 44093 Nantes, France (e-mail: [email protected]) Tom F. Lue, MD UCSF Medical Center, Department of Urology, 400 Parnassus Avenue, A-633 San Francisco, CA 94131, USA (e-mail: [email protected]) Helmut Madersbacher, MD Abteilung für Neurologie, Universitätshospital Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria (e-mail: [email protected]) Klaus E. Matzel, MD Chirurgische Klinik mit Poliklinik, Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany (e-mail: [email protected]) Catherine W. McGrother, MD Department of Epidemiology and Public Health, University of Leicester, 22–28 Princess Road West, Leicester, LE1 6TP, UK (e-mail: [email protected]) Guillaume Meurette, MD Clinique Chirurgicale 2, Hotel Dieu, CHU de Nantes, 44093 Nantes, France (e-mail: [email protected])

XI

XII

List of Contributors

Roberto Merletti, PhD COREP – Politecnico di Torino, Dipartimento di Electtronica, Corso Duca degli Abruzzi 24, 10129 Torino, Italy (e-mail: [email protected]) Gert Naumann, MD Universitätsfrauenklinik, Langenbeckstrasse 1, 55101 Mainz, Germany (e-mail: [email protected]) Günter Neubauer, MD Institut für Gesundheitsökonomik, Nixenweg 2b, 81739 Munich, Germany Lora Nunes, MD UCSF Medical Center, Department of Urology, 400 Parnassus Avenue, A-633 San Francisco, CA 94131, USA (e-mail: [email protected]) Roberto Olianas, MD Allgemeines Krankenhaus Hamburg-Harburg, Eissendorfer Pferdeweg 52, 21075 Hamburg, Germany (e-mail: [email protected]) Christian Paetzel, MD Institut für Röntgendiagnostik, Universitätsklinikum, Franz-Josef-Strauss-Allee 11, 93053 Regensburg (e-mail: [email protected]) Prasad Patki, MBBS, FRCS, FEBU Royal National Orthopaedic Hospital, Stanmore, Middlesex, HA7 4LP, United Kingdom Daniele Perucchini, MD Universitätsspital Zürich, Departement Frauenheilkunde, Frauenklinikstrasse 10, 8091 Zürich, Switzerland (e-mail: [email protected]) Ursula M. Peschers, MD Frauenklinik, Amper Kliniken AG, Konrad Adenauer Strasse 30, 85221 Dachau, Germany (e-mail: [email protected]) Aniceto Puigdollers, MD Hospital de Mollet, Barcelona, Spain Nicolas Regenet, MD Clinique Chirurgicale 2, Hotel Dieu, CHU de Nantes, 44093 Nantes, France (e-mail: [email protected]) Christl Reisenauer, MD Universitätsfrauenklinik, Calwerstrasse 7, 72076 Tübingen, Germany (e-mail: [email protected]) Ella Retzlaw, MD Universitätsfrauenklinik, Calwerstraße 7, 72076 Tübingen, Germany (e-mail: [email protected])

List of Contributors

Todd H. Rockwood, PhD University of Minnesota, Cities Institute for Public Health Research, Division of Health Services Research, Policy & Administration, 420 Delaware Street S.E., Mayo Mail Stop 729, Minneapolis, MN 55455-0392, USA (e-mail: [email protected]) Harald R. Rosen, MD Ludwig Boltzmann Institut für Chirurgische Onkologie, Donauspital / SMZ-Ost, Langobardenstrasse 122, 1220 Vienna, Austria (e-mail: [email protected]) Andreas Schreyer, MD Institut für Röntgendiagnostik, Universitätsklinikum, Franz-Josef-Strauss-Allee 11, 93053 Regensburg (e-mail: [email protected]) Daniela Schultz-Lampel, MD Klinikum der Stadt Villingen-Schwenningen, Kontinenzzentrum Südwest, Röntgenstrasse 20, 78054 Villingen-Schwenningen, Germany (e-mail: [email protected]) Julian R. Shah, MD Institute of Urology and Nephrology, 48 Riding House Street, London, WIP 7PN, UK (e-mail: [email protected]) Karl-Dietrich Sievert, MD Universitätsklinik für Urologie, Hoppe-Seyler-Straße 3, 72076 Tübingen, Germany (e-mail: [email protected]) Uwe Stadelmaier, MD Chirurgische Klinik mit Poliklinik, Universität Erlangen, Krankenhausstrasse 12, 91054 Erlangen, Germany (e-mail: [email protected]) Sandra Stiefelmeyer, MD Institut für Gesundheitsökonomik, Nixenweg 2b, 81739 Munich, Germany Arnulf Stenzl, MD Universitätsklinik für Urologie, Hoppe-Seyler-Strasse 3, 72076 Tübingen, Germany (e-mail: [email protected]) Alan G. Thorson, MD Creighton University School of Medicine, Section of Colon and Rectal Surgery, 9850 Nicholas Street, Suite 100, Omaha, NE 68114, USA (e-mail: [email protected]) Tony Tsai, MD The New York Medical Center of Queens, Reproductive Endocrinology & Infertility, Department OB/GYN, 45-56 Main Street, New York, NY 1355, USA Ralf Tunn, MD Urogynäkologie, Deutsches Beckenbodenzentrum, St. Hedwig-Krankenhaus, Grosse Hamburger Strasse 5–11, 10115 Berlin, Germany (e-mail: [email protected])

XIII

XIV

List of Contributors

Diethelm Wallwiener, MD Universitätsfrauenklinik, Calwerstrasse 7, 72076 Tübingen, Germany (e-mail: [email protected]) William E. Whitehead, PhD University of North Carolina at Chapel Hill, CB 7080, 724 Burnett-Womack Building, Chapel Hill, NC 27599, USA, (e-mail: [email protected]) Tilman T. Zittel, MD Universitätsklinik für Allgemeine, Viszeral- und Transplantationschirurgie, Hoppe-Seyler Strasse 3, 72076 Tübingen, Germany (e-mail: [email protected]) Wolfgang Zubke, MD Universitätsfrauenklinik, Calwerstrasse 7, 72076 Tübingen, Germany (e-mail: [email protected])

Part I

Epidemiologic and Health Costs of Incontinence

I

Chapter 1

Chapter 1

3

Epidemiology of Urinary Incontinence

1

Epidemiology of Urinary Incontinence Steinar Hunskaar

Contents

1.1

Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . .

4

1.2 1.2.1 1.2.2 1.2.3

Epidemiology of Nocturnal Enuresis . . . . . . . . Survey Studies . . . . . . . . . . . . . . . . . . . . . Remission and Natural History . . . . . . . . . . . Potential Risk Factors of Nocturnal Enuresis . . .

. . . .

. . . .

. . . .

. . . .

4 5 5 5

1.3 1.3.1 1.3.2 1.3.3 1.3.4 1.3.5 1.3.6

Epidemiology of Urinary Incontinence in Women Prevalence . . . . . . . . . . . . . . . . . . . . . . Type . . . . . . . . . . . . . . . . . . . . . . . . . Severity . . . . . . . . . . . . . . . . . . . . . . . Incidence, Remission, and Natural History . . . . Racial and Ethnic Differences . . . . . . . . . . . Potential Risk Factors . . . . . . . . . . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

. . . . . . .

5 5 7 7 8 8 8

1.4 1.4.1 1.4.2 1.4.3

Epidemiology of Urinary Incontinence in Men . . Prevalence . . . . . . . . . . . . . . . . . . . . . . . Type and Severity . . . . . . . . . . . . . . . . . . . Potential Risk Factors . . . . . . . . . . . . . . . .

. . . .

. . . .

. . . .

. . . .

9 9 10 10

References . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

4

1

Steinar Hunskaar

The understanding of epidemiology – the study of the distribution and determinants of disease – is critical in the search for the risk and protective factors that lead to primary or secondary disease prevention. This chapter reviews some of the knowledge of the epidemiology of urinary incontinence (UI). The review uses only a fraction of the high-quality, population-based studies available. More comprehensive reviews have been published (Hampel et al. 1997; Thom 1998; Hunskaar et al. 2000, 2002).

1.1 Definitions Studies of disease frequency should rely on a very specific definition of the condition under investigation. The lack of unifying definitions for UI is a fundamental problem in assessing and comparing the findings in different studies. The International Continence Society (ICS) previously defined ”urinary incontinence” as “a condition where involuntary loss of urine is a social or hygienic problem and is objectively demonstrable.” From 2002 the definition reads “The complaint of any involuntary leakage of urine.” The old definition was not achievable outside clinical settings. It added a subjective aspect (“problem”) and therefore confounded the analyses of prevalence and risk factors. The new definition is well suited for epidemiological studies, but not appropriate for defining a patient. It should therefore be combined with validated instruments for type, severity, and QoL, in addition to investigations, for the clinical setting. “Prevalence” is defined as the probability of being incontinent within a defined population and at a defined point in time. The concept is important for establishing the distribution of the condition in the population and for projecting the need for health and medical services.”Incidence” is defined as the probability of developing the condition under study during a defined time period. Incidence is usually reported for 1-, 2-, or 5-year time intervals. Epidemiological surveys must often take a pragmatic approach and therefore define ”incontinence type” based on the symptoms alone. The classification can be made either by researchers or by the respondent’s confirmation of a typical description. Clinical assessment allows for more differentiation of subtypes, but is difficult to perform on a large-scale basis. Severity of incontinence is another important factor for the estimate of prevalence. ”Severity” can be defined by factors such as frequency, amount, and subjective bother (Sandvik et al. 2000).

1.2 Epidemiology of Nocturnal Enuresis Most epidemiological studies link primary and secondary enuresis together and may include both monosymptomatic and polysymptomatic cases. Also, enuresis is defined in different ways, and in many papers there is no frequency defined at all. The best studies are longitudinal cohort studies, but many are cross-sectional (Krantz et al. 1994). In some cultures, parents are more complacent about bedwetting than in others and do not regard it as a problem requiring attention. Nocturnal enuresis is caused by relative nocturnal polyuria and/or nocturnal bladder overactivity combined with lack of arousal at the time when the bladder needs to be emptied. These factors have a different weight in different enuretic children. The pathophysiology is thus a mixed mechanism, which explains difficulties encountered when trying to define enuresis in a consistent way. Stringent epidemiological studies would need to evaluate nocturnal urine production, nocturnal bladder activity, sleep

Chapter 1

Epidemiology of Urinary Incontinence

and arousal in each of the probands. Needless to say, there is no large populationbased study using such diagnostic evaluation.

1.2.1 Survey Studies Prevalence of nocturnal enuresis at age 7 years is significant since many children start school then, meaning more exposure to the environment and thus a greater awareness of the problem. At this age, the prevalence of nocturnal enuresis seems to be between 7% and 9% (Spee-van der Wekke et al. 1998; Hunskaar et al. 2002). In the early ages, the prevalence in boys is reported to be higher than in girls by a 2 : 1 ratio in Western countries. In studies from other countries, the figures are more similar in boys and girls, but there is always a predominance of boys. It seems that the sex difference diminishes with age and becomes less obvious among older children. In a French study (Lottmann 1999), the severity and consequences of enuresis were reported: 66% had more than one wet night per month, 37% more than one wet night per week, and 22% wet the bed every night. Regarding consequences, 42% were “bothered a lot” while 15% were “not bothered at all” by their enuresis. In contrast, 92% of the mothers declared that the enuresis had no significant effect on family life or the child’s behavior at school. Fourteen percent of mothers punished their child and only 13% intended to seek treatment for their child. Even if there are some ethnic and cultural differences in the prevalence of enuresis, with higher rates generally reported from Eastern countries, there is nonetheless a remarkable similarity of prevalence rates of nocturnal enuresis in populations from all parts of the world.

1.2.2 Remission and Natural History Primary nocturnal enuresis usually remits with age. The spontaneous cure rate seems to be around 15% annually between the ages of 5 and 19. The risk for an enuretic 7year-old boy to remain enuretic throughout life may be calculated at 3%. In a largely untreated adult population, the prevalence is around 0.5%.

1.2.3 Potential Risk Factors of Nocturnal Enuresis Several risk factors have been established or suggested by epidemiological studies; the most important are shown in Table 1.1

1.3 Epidemiology of Urinary Incontinence in Women Differences in sample, definition and measurement, and survey methodology continue to make reviews challenging.

1.3.1 Prevalence More epidemiological research is available on older women of all ages because UI is considered to be a health condition of older age. Reviews of several European and

5

6

1

Steinar Hunskaar Table 1.1. Risk factors of nocturnal enuresis and day and day/night wetting Nocturnal enuresis Family history Behavioral disturbances Nocturnal polyuria Sleep and arousal Nocturnal bladder dysfunction Other factors Day and day/night wetting Family history Psychological disorders and sexual abuse Disorders of bladder-sphincter nerve control Urinary tract infections Infravesical obstruction Epispadias

American epidemiological studies of women living in the community identify a 10%–40% range of prevalence estimates of the experience of any UI and suggest a UI prevalence of 40% or even greater in the elderly. These studies also suggest that the wide range can be attributed to the definition of UI and the sample and potentially to the format of the questions about UI. The median level of prevalence estimates gives a picture of increasing prevalence during young adult life (prevalence, 20%–30%), a broad peak around middle age (prevalence, 30%–40%), and then a steady increase in the elderly (prevalence, 30%–50%). Two recent studies of European women of all ages illustrates these findings (Fig. 1.1) (Hannestad et al. 2000; Hunskaar et al. 2004). Prevalence has always been higher in institutions because the residents tend to be older and more impaired than community-residing women. Several recent studies from around the world suggest prevalence of 50% or higher.

Fig. 1.1. Prevalence of urinary incontinence in women by age. Data from Hannestad et al. (2000) and Hunskaar et al. (2004)

Chapter 1

Epidemiology of Urinary Incontinence

1.3.2 Type Only symptoms can be recorded in surveys based on questionnaires or interviews. Typically, stress incontinence is identified when the respondent reports UI to occur with physical activity and urge incontinence when it occurs in the context of a sudden urge to urinate. Proportions of types of UI differ with age. In general, studies indicate that approximately half of all incontinent women are classified as stress incontinent, making this group the largest among urge, mixed, and stress types. A smaller proportion is classified as mixed incontinent, the smallest one as urge incontinent. An analysis of type distribution in 15 studies showed median values of 49% for stress, 21% for urge, and 29% for mixed type. In a recent European study, the figures were 46%, 26%, and 28%, respectively (Hunskaar et al. 2004). Unfortunately, not all studies have carefully assessed the different types (and even fewer have examined their correlates). Therefore, proportions of stress, urge, and mixed types among women are difficult to estimate and estimates vary considerably. But there are intriguing differences between the different types, which suggests that the types may reflect quite different pathologies and that differentiating the types in future research might prove useful.

1.3.3 Severity The characterization of severity has been made using two methods. The first approach is a simple attempt to operationalize the frequency of urine loss, where severe incontinence is defined by weekly or more frequent loss. The second approach uses quantity of loss, as well as perception differences, personal hygiene, and coping ability. Typically, slight incontinence denotes leakage of drops a few times a month, moderate incontinence daily leakage of drops, and severe incontinence larger amounts at least once a week (Sandvik et al. 2000). The severity of incontinence varies between the different types. The fraction of severe incontinence is much lower in the stress group compared to the urge and mixed groups. In one major study, slight incontinence was found in 53% of the stress group, 39% of the urge group, and 31% of the mixed group. Within each type of incontinence, severity increased with increasing age (Hannestad et al. 2000). Prevalence is also dependent on thresholds for diagnosis or severity. For example, one researcher found that nearly 50% of cases were classified as slight incontinence and only 27% as severe (Sandvik et al. 1993). Studies also investigated the “bother” factor and found that different levels of bother significantly affected the prevalence estimates and that approximately one-fifth of incontinent women suffer from severe incontinence, if only moderate or severe incontinence and an indication of bother is considered (Sandvik et al. 1993; Hannestad et al. 2000). Even though the definition of severe or significant UI varies between authors, its prevalence is considerably less variable across different studies than prevalence of any UI. Most prevalence estimates vary between 6% and 10%. The lesser variance among these estimates suggests that severe incontinence is less easy to deny and better understood by participants than any incontinence and thus may represent a more reliable figure.

7

8

1

Steinar Hunskaar

1.3.4 Incidence, Remission, and Natural History Very few studies have reported on the incidence of UI. A study of community-dwelling women aged 60 years or older found that 20% of the originally continent women had developed some level of UI during the 1-year study period. In another study, a cohort of healthy middle-aged women was examined over 3 years. Of the previously continent women, 8% reported at least monthly leakage; higher rates have been found in the elderly. One-year incidence rates of 6% and 3% have been reported for young and middleaged women, respectively (Hunskaar et al. 2002). Similarly, rates of remission (the probability of becoming continent among previously incontinent women) vary considerably across the few studies that have investigated them, ranging over 1 year between a maximum of 38% to a minimum of 6% among middle-aged and younger women, and 10% for older women. It is not clear whether the level of remission reflects active treatment or intervention or whether it is part of the natural course of incontinence.

1.3.5 Racial and Ethnic Differences Most epidemiological studies of UI have been conducted on white populations. Research on other populations shows a wide variation in prevalence. These studies have used different methods and definitions, and the quality is mixed. Therefore, the results are difficult to compare, and most of the studies do not lend themselves easily to crosscultural or cross-national comparisons. Some data for black women exist, and they indicate that white women may be more susceptible to UI than black women. US clinical data suggest that black women have higher urethral closure pressure, larger urethral volume, and greater vesical mobility.

1.3.6 Potential Risk Factors Epidemiological studies conducted in various populations reveal a number of variables related to UI, including several possible risk factors or contributing variables (Table 1.2) (Brown et al. 1996; Hunskaar et al. 2002). Most of the data regarding risk fac-

Table 1.2. Proposed risk factors for urinary incontinence Established factors

Suggested factors

Age (Fig. 1) Pregnancy Childbirth (Fig. 2) Obesity Lower urinary tract symptoms Functional impairment

Menopause Hysterectomy Caffeine intake Cognitive impairment Family history and genetics Exercise Smoking Respiratory problems Constipation

Chapter 1

Epidemiology of Urinary Incontinence

Fig. 1.2. Prevalence of urinary incontinence by age groups and parity. Data from Rortveit et al. (2001)

tors for the development of UI have been derived from cross-sectional studies of volunteer and clinical subjects. Risk factors such as smoking (Hannestad et al. 2003), menopause (Brown et al. 1999), restricted mobility, chronic cough, chronic straining for constipation, and urogenital surgery (Thom and Brown 1998) have not been as rigorously studied as age (Hannestad et al. 2000; Hunskaar et al. 2004), parity (Fig. 1.2) (Rortveit et al. 2001, 2003), and obesity (Mommsen and Foldspang 1994; Hannestad et al. 2003). This provides us with information of limited generalizability and restricts the level of inference regarding causality.

1.4 Epidemiology of Urinary Incontinence in Men The epidemiology of UI in men has not been investigated to the same extent as for females. In almost all studies, the prevalence rates of UI continue to be reported to be less in men than in women by a 1 : 2 ratio. The type and age distribution are much different between the sexes, and risk factors, although less investigated in men, seem to be different. It is also important not to consider UI as an isolated problem in men, but rather as a component of a multifactorial problem, including postprostatectomy incontinence. Often other urogenital symptoms such as weak stream, hesitancy, dribbling or impotence exist.

1.4.1 Prevalence Some of the major reviews also discuss the prevalence of UI in men (Fultz and Herzog 1996; Hunskaar et al. 2002), ranging from 3% to about 10%. There are no studies reporting prevalence for men according to the ICS definition. But for any definition, there is a steady increase in prevalence with increasing age.

9

10

1

Steinar Hunskaar

1.4.2 Type and Severity Due to differences in the pathological anatomy and pathophysiology of UI in men, there is a different distribution in incontinence subtypes. Recent studies confirm the predominance of urge incontinence (40%–80%), followed by mixed forms of UI (10%–30%), and stress incontinence (