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List of Contributors
Steinar Hunskaar,MD,PhD
Section for General Practice, University of Bergen, Kalfarveien 31,5018 Bergen,
Norway (e-mail: steinar.hunskar@isf.uib.no)
Lilli Hutzel, MD
Klinik und Poliklinik für Chirurgie, Universitätsklinikum,
Franz-Josef-Strauss-Allee 11,93053 Regensburg (e-mail: dr.hutzel@t-online.de)
Ekkehard C. Jehle, MD
Oberschwabenklinik, Krankenhaus St. Elisabeth,Elisabethenstrasse 15,
88212 Ravensburg, Germany (e-mail: Ekkehard.Jehle@oberschwabenklinik.de)
Sibylle Klosterhalfen, MD
Universitätsklinik Düsseldorf, Institut für Medizinische Psychologie,Moorenstraße 5,
40225 Düsseldorf, Germany (e-mail: klosterh@uni-duesseldorf.de)
Heinz Kölbl, MD
Universitätsfrauenklinik, Langenbeckstrasse 1, 55101 Mainz,Germany
(e-mail: koelbl@frauenklinik.uni-mainz.de)
Martin E. Kreis, MD
Klinikum Großhadern,Allgemeine Viszeral- und Transplantationschirurgie,
Marchioninistraße 15,81377 München, Germany
(e-mail: martin.kreis@med.uni-muenchen.de)
XI
Paul-Antoine Lehur, MD
Clinique Chirurgicale 2, Hotel Dieu,CHU de Nantes,44093 Nantes, France
(e-mail: paulantoine.lehur@chu-nantes.fr)
Tom F. Lue, M D
UCSF Medical Center,Department of Urology, 400 Parnassus Avenue,
A-633 San Francisco, CA 94131,USA (e-mail: tlue@urol.ucsf.edu)
Helmut Madersbacher,MD
Abteilung für Neurologie, Universitätshospital Innsbruck,Anichstrasse 35,
6020 Innsbruck,Austria (e-mail: Helmut.Madersbacher@tilak.at)
Klaus E. Matzel, MD
Chirurgische Klinik mit Poliklinik, Universität Erlangen,Krankenhausstrasse 12,
91054 Erlangen, Germany (e-mail: Klaus.Matzel@chir.imed.uni-erlangen.de)
Catherine W. McGrother, MD
Department of Epidemiology and Public Health, University of Leicester,
22–28 Princess Road West, Leicester,LE1 6TP,UK (e-mail: sk29@leicester.ac.uk)
Guillaume Meurette,MD
Clinique Chirurgicale 2, Hotel Dieu,CHU de Nantes,44093 Nantes, France
(e-mail: guillaume.meurette@chu-nantes.fr)
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List of Contributors
Roberto Merletti, PhD
COREP – Politecnico di Torino, Dipartimento di Electtronica,
Corso Duca degli Abruzzi 24, 10129 Torino,Italy (e-mail: roberto.merletti@polito.it)
Gert Naumann, MD
Universitätsfrauenklinik, Langenbeckstrasse 1, 55101 Mainz,Germany
(e-mail: gnaumann@uni-mainz.de)
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: tlue@urol.ucsf.edu)
Roberto Olianas, MD
Allgemeines Krankenhaus Hamburg-Harburg, Eissendorfer Pferdeweg 52,
21075 Hamburg, Germany (e-mail: roberto.oleanas@planet-interkom.de)
Christian Paetzel, MD
Institut für Röntgendiagnostik, Universitätsklinikum,Franz-Josef-Strauss-Allee 11,
93053 Regensburg (e-mail: christian.paetzel@klinik.uni-regensburg.de)
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: perucchini@hin.ch)
Ursula M. Peschers, MD
Frauenklinik,Amper Kliniken AG, Konrad Adenauer Strasse 30,85221 Dachau,
Germany (e-mail: Ursula.Peschers@amperkliniken.de)
Aniceto Puigdollers,MD
Hospital de Mollet,Barcelona, Spain
Nicolas Regenet, MD
Clinique Chirurgicale 2, Hotel Dieu,CHU de Nantes,44093 Nantes, France
(e-mail: nicolas.regenet@chu-nantes.fr)
Christl Reisenauer,MD
Universitätsfrauenklinik, Calwerstrasse 7,72076 Tübingen, Germany
(e-mail: christl.reisenauer@med.uni-tuebingen.de)
Ella Retzlaw,MD
Universitätsfrauenklinik, Calwerstraße 7,72076 Tübingen, Germany
(e-mail: ella.retzlaw@med.uni-tuebingen.de)
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: rockw001@umn.edu)
Harald R. Rosen, MD
Ludwig Boltzmann Institut für Chirurgische Onkologie, Donauspital / SMZ-Ost,
Langobardenstrasse 122, 1220 Vienna, Austria (e-mail: rosensurg@compuserve.com)
Andreas Schreyer, MD
Institut für Röntgendiagnostik, Universitätsklinikum,Franz-Josef-Strauss-Allee 11,
93053 Regensburg (e-mail: andreas.schreyer@klinik.uni-regensburg.de)
Daniela Schultz-Lampel, MD
Klinikum der Stadt Villingen-Schwenningen,Kontinenzzentrum Südwest,
Röntgenstrasse 20,78054 Villingen-Schwenningen, Germany
(e-mail: Ksw@Klinikumvs.de)
Julian R. Shah,MD
Institute of Urology and Nephrology,48 Riding House Street, London,WIP 7PN, UK
(e-mail: pjrshahsec@hotmail.com)
Karl-Dietrich Sievert, MD
Universitätsklinik für Urologie,Hoppe-Seyler-Straße 3,72076 Tübingen, Germany
(e-mail: karl.sievert@med.uni-tuebingen.de)
XIII
Uwe Stadelmaier, MD
Chirurgische Klinik mit Poliklinik, Universität Erlangen,Krankenhausstrasse 12,
91054 Erlangen, Germany (e-mail: Uwe.Stadelmaier@web.de)
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: urologie@med.uni-tuebingen.de)
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: agthorson@msn.com)
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: r.tunn@alexius.de)
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List of Contributors
Diethelm Wallwiener, MD
Universitätsfrauenklinik, Calwerstrasse 7,72076 Tübingen, Germany
(e-mail: diethelm.wallwiener@med.uni-tuebingen.de)
William E.Whitehead, PhD
University of North Carolina at Chapel Hill, CB 7080,724 Burnett-Womack Building,
Chapel Hill, NC 27599,USA, (e-mail: william_whitehead@med.unc.edu)
Tilman T. Zittel, MD
Universitätsklinik für Allgemeine,Viszeral- und Transplantationschirurgie,
Hoppe-Seyler Strasse 3,72076 Tübingen, Germany
(e-mail: tilman.zittel@med.uni-tuebingen.de)
Wolfgang Zubke, MD
Universitätsfrauenklinik, Calwerstrasse 7,72076 Tübingen, Germany
(e-mail: wolfgang.zubke@med.uni-tuebingen.de)
Part I
Epidemiologic and Health Costs
of Incontinence
I
Chapter 1
Chapter 1 Epidemiology of Urinary Incontinence
Epidemiology of Urinary Incontinence
Steinar Hunskaar
3
1
Contents
1.1 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2 Epidemiology of Nocturnal Enuresis . . . . . . . . . . . . 4
1.2.1 Survey Studies . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2.2 Remission and Natural History . . . . . . . . . . . . . . . 5
1.2.3 Potential Risk Factors of Nocturnal Enuresis . . . . . . . 5
1.3 Epidemiology of Urinary Incontinence in Women . . . . . 5
1.3.1 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.3.2 Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.3.3 Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.3.4 Incidence, Remission, and Natural History . . . . . . . . . 8
1.3.5 Racial and Ethnic Differences . . . . . . . . . . . . . . . . 8
1.3.6 Potential Risk Factors . . . . . . . . . . . . . . . . . . . . 8
1.4 Epidemiology of Urinary Incontinence in Men . . . . . . 9
1.4.1 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.4.2 Type and Severity . . . . . . . . . . . . . . . . . . . . . . . 10
1.4.3 Potential Risk Factors . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1
4
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.
5
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
1
6
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)
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