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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
Steinar Hunskaar
1
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) Menopause
Pregnancy Hysterectomy
Childbirth (Fig. 2) Caffeine intake
Obesity Cognitive impairment
Lower urinary tract symptoms Family history and genetics
Functional impairment 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.
9
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.
10
Steinar Hunskaar
1
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 (<10%). The increasing prevalence of UI as age
increases observed in men is largely due to the contribution of the urge incontinence
rather than stress incontinence.One study demonstrated an increasing rate of urge UI
from 0.7% in respondents between age 50 and 59 years, 2.7% between 60 and 69 and
3.4% for 70 years and older. Stress UI was steady at 0.5%, 0.5% and 0.1% for the above
groups, respectively (Ueda et al. 2000). One survey found an overall prevalence of
overactive bladder with urge incontinence of 2.6% in men 18 years and older, increasing with age from less than 1% in the age group 18–44 to 9% in age group 65+.
Most studies have a large fraction of other and unclassified types. One recent study
found that constant dribbling was reported by 7.4% of their respondents. Terminal
dribbling or postvoid dribbling is another type of leakage in men that is difficult to assign to the conventional subtypes of UI (Hunskaar et al. 2002).
When it comes to severity, the sex differences do not seem to be different from
those for any incontinence. Estimates for severe UI in older women tend to be more
than twice as high as for older men.
1.4.3 Potential Risk Factors
There is relatively little research concerning conditions and factors that may be associated with UI in men, and clear risk factors are scientifically documented less often.
However, a few available studies have identified the following potential risk factors:
age, lower urinary tract symptoms (LUTS), functional and cognitive impairment,neurological disorders, prostatectomy, and some other factors.
References
Brown JS,Seeley DG, Fong J,Black DM, Ensrud KE,Grady D (1996) Urinary incontinence in old-
er women: who is at risk? Obstet Gynecol 87:715–721
Brown JS,Grady D,Ouslander JG, Herzog AR,Varner RE, Posner SF (1999) Prevalence of urinary
incontinence and associated risk factors in postmenopausal women. Heart & Estrogen/Pro-
gestin Replacement Study (HERS) Research Group.Obstet Gynecol 94:66–70
Fultz NH, Herzog R (1996) Epidemiology of urinary symptoms in the geriatric population.Ger-
iatr Urol 23: 1–10
Hampel C,Wienhold D,Benken N, Eggersmann C,Thuroff JW (1997) Prevalence and natural his-
tory of female incontinence. Eur Urol 2 [Suppl 32]: 3–12
Hannestad YS, Rortveit G, Sandvik H, Hunskaar S (2000) A community-based epidemiological
survey of female urinary incontinence. The Norwegian EPINCONT study. J Clin Epidemiol
53: 1150–1157
Hannestad YS, Rortveit G, Daltveit AK,Hunskaar S (2003) Are smoking and other lifestyle factors
associated with female urinary incontinence? The Norwegian EPINCONT study. Br J Obstet
Gynaecol 110: 247–254
Hunskaar S,Arnold EP, Burgio K, Diokno AC, Herzog AR, Mallett VT (2000) Epidemiology and
natural history of urinary incontinence. Int Urogynecol J 11:301–319
Hunskaar S,Burgio K, Diokno AC, Herzog AR, Hjälmås K,Lapitan MC (2002) Epidemiology and
natural history of urinary incontinence (UI). In:Abrams P, Cardozo L, Khoury S,Wein A (eds)
Chapter 1 Epidemiology of Urinary Incontinence
Incontinence. 2nd international consultation on incontinence, 2nd edn. Health Publication
Ltd, Plymouth, pp 165–201
Hunskaar S,Lose G, Sykes D,Voss S (2004) The prevalence of urinary incontinence in women in
four European countries. BJU Int 93: 324–330
Krantz I, Jylkäs E, Ahlberg BM, Wedel H (1994) On the epidemiology of nocturnal enuresis: a
critical review of methods used in descriptive epidemiological studies on nocturnal enuresis.
Scand J Urol Nephrol Suppl 163: 75–82
Lottmann H (1999) Enuresis treatment in France. Scand J Urol Nephrol Suppl 33:66–69
Mommsen S,Foldspang A (1994) Body mass index and adult female urinary incontinence. World
J Urol 12: 319–322
Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S (2001) Age- and type-dependent effects of
parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol 98:
1004–1010
Rortveit G,Daltveit AK,Hannestad YS, Hunskaar S (2003) Urinary incontinence after vaginal de-
livery or Cesarian section. N Engl J Med 348:900–907
Sandvik H, Hunskaar S,Seim A, Hermstad R, Vanvik A,Bratt H (1993) Validation of a severity in-
dex in female urinary incontinence and its implementation in an epidemiological survey. J
Epidemiol Community Health 47: 497–499
Sandvik H, Seim A,Vanvik A, Hunskaar S (2000) A severity index for epidemiological surveys of
female urinary incontinence: comparison with 48-hour pad-weighing tests. Neurourol Uro-
dyn 19 : 137–145
Spee-van der Wekke J,Hirasing RA, Meulmeester JF, Radder JJ (1998) Childhood nocturnal enu-
resis in The Netherlands.Urology 51: 1022–1026
Thom D (1998) Variation in estimates of urinary incontinence prevalence in community: effects
of differences in definition, population characteristics, and study type. J Am Geriatr Soc 46 :
473–480
Thom DH, Brown JS (1998) Reproductive and hormonal risk factors for urinary incontinence in
later life: a review of the clinical and epidemiologic literature.J Am Geriatr Soc 46 :1411–1417
Ueda T, Tamaki M, Kageyama S, Yoshimura N, Yoshida O (2000) Urinary incontinence among
community-dwelling people aged 40 years or older in Japan: prevalence,risk factors, knowl-
edge and self-perception. Int J Urol 7: 95–103
11
Chapter 2
Chapter 2 Epidemiology of Faecal Incontinence
Epidemiology of Faecal Incontinence:
A Review of Population-Based Studies
Catherine W. McGrother
13
2
Contents
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2 Prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.3 Associated Factors . . . . . . . . . . . . . . . . . . . . . . 20
2.4 Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . 21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2
14
Catherine W. McGrother
2.1 Introduction
Two recent reviews provide perspective on the prevalence of faecal incontinence. Matibag et al.(2003) suggest a range of 1%–11% in population-based studies and 4%–50%
in other,mainly clinic-based studies. Harrari (2002) suggests a range of 2%–18% in the
community as distinct from 13%–54% in long-term care. The issues raised by these
and other reviews (Tariq et al. 2003) include a lack of definition of concepts and indicators,inconsistent age and gender relationships, lack of information on social groups
and differences in health-related risk factors identified. The aim of this paper is to review all the evidence from population-based studies and thereby clarify the epidemiology of faecal incontinence.
The search strategy included electronic search of Medline and Embase for English
language papers concerning ‘faecal incontinence’. Separate searches were carried out
for ‘prevalence’ (1984–2003) and ‘risk factors’, ‘correlates’ or ‘predictors’ (1996–2003).
Exclusion criteria for prevalence studies were: non-population-based; response rate of
less than 60%; data collection from third parties; and lack of definition of faecal incontinence as a whole and as distinct from anal incontinence.Studies concerning risk
factors were excluded if they concerned selected groups (e.g.clinical series and longterm care), local conditions affecting the pelvic floor (e.g. obstetric factors and cancer), or children. All eligible studies were methodologically evaluated for potential
biases. Information on prevalence and risk correspond to levels of evidence II-3 and
II-2, respectively (Canadian Task Force on Preventive Care).
Table 2.1. Threshold ratings for terms used to describe the severity of faecal incontinence
Minor Moderate Major
1. Any, ever,yearly 1. Monthly 1. Weekly or more
Leakage Leakage Leakage
Staining staining,etc.
Loss
Accident
Release
We t
Liquid
2. Occasional 2. Any, ever,yearly 2. Monthly or more
Incontinence Soiling Soiling
Solid Solid
Problem Problem
Control Control
Difficulty Difficulty
Tro u bl e Tro u bl e
Loss Loss
3. Regular 3. Frequent
Incontinence Incontinence
Chapter 2 Epidemiology of Faecal Incontinence
For the purposes of this review, faecal incontinence (FI) was conceptualised as involuntary leakage of liquid or solid from the bowel, and severity as frequency volume.
Reported definitions were rated into thresholds of minor,moderate or major incontinence based on the implicit and explicit severity of the wording (Table 2.1). For example,‘any’,‘yearly’ and ‘ever’ were rated as similar and less severe than ‘monthly’,‘weekly’ or ‘daily’.Descriptors such as ‘leakage’ and ‘staining’were rated as similar and less
severe than ‘difficulty in control’and ‘soiling’. This approach was based on experience
with piloting and interviewing in a variety of population groups using such terms
(McGrother et al.1996, 2004; Peet et al. 1995, 1996).
2.2 Prevalence
A total of 15 eligible population-based studies were identified between 1984 and 2003,
and these are profiled for potential methodological sources of variation in Table 2.2.
There was little suggestion of association with response rate or postal/interview type
of approach. There was some suggestion that studies based on total populations (i.e.
including elderly people in long-term care) provided slightly higher estimates compared to community-based studies. Similar estimates excluded from this analysis also
fell within the range (Nuotio et al. 2003; Nelson et al. 1995; Drossman et al. 1993) or
could not be equated because traits of solid or liquid were reported rather than faecal
incontinence as a whole (Eva et al.2003).
These 15 studies provided 21 prevalence estimates for individual thresholds (Table 2.3). The overall range of prevalence was 0.7%–13.1% for adults of various ages. Full
ranges for specific thresholds were: minor,6.2%–13.1%; moderate, 2.8%–10%;and major, 0.7%–3.8%. Overall, there was good correlation between threshold rating and
prevalence.There was evidence of correlation with age within the major threshold, but
no suggestion of any correlation with either place or time of reporting studies.
15
Age Group. Among those studies that considered age, all described some degree of
increase in prevalence with age.All but one study (Roberts et al. 1999) showed a continuing increase with advancing age. The increase was present to a slightly greater extent for women compared to men (Figs. 2.1 and 2.2).Some apparent decline in prevalence in extreme old age was reported (Talley et al. 1992), but the estimate was based
on very small numbers.
Gender. Among studies that considered gender, the overall range of female: male
ratios was 0.36–4.0. In the majority (85%) of studies, the range was considerably narrower, 0.73–1.43, and consistent with no difference between the two. Other than sampling error,there was no clear explanation for the variation, although females possibly
predominated at minor levels and males at major levels of FI: Comparing F : M ratios
age-specifically, males consistently predominated at younger ages but there was some
variability in the degree of predominance of females in old age (Fig. 2.3). Taking into
account issues of sample size and type, it seems likely that the prevalence in elderly
women exceeds that in men slightly in the total population, i.e. including long-term
care.
There were substantial increases in prevalence with age for daily, weekly and
monthly leakage but little increase for yearly leakage in a recent large-scale community study, suggesting monthly leakage may provide a threshold for abnormality or
impairment (Fig. 2.4).
16
Catherine W. McGrother
Table 2.2. Methodological features of population-based prevalence studies of faecal incontinence, 1984 and 2003
2
Aut hor Th resh oldaPopul ation N sub- Approach Response Age Prev-
Roberts Minor Mayo 1,540 Postal 66 50+ 13.1
et al. (1999) Clinic
Kalantar Minor Total 651 Postal 66 18+ 11.2
et al. (2002)
Crome Minor Total 1,608 Interview 79–94 70+ 10.0
et al. (2001)
Walter Minor- Total 1,610 Postal 80 31–76 10.0
et al. (2002) mod
Clarke Minor- Com- 1,201 Interview 95 75+ 9.4
et al. (1984) mod munity
Wetle Moderate Com- 3,809 Interview 85 65+ 8.1
et al. (1995) munity
Lam Minor- Population 618 Postal 71 20+ 7.8
et al. (1999) mod
Nakanishi Minor Total 1,405 Interview 95 65+ 7.5
et al. (1997)
Kok Minor Com- 719 Postal 69 60+ 7.2 F
et al. (2002) munity
Perry Minor Com- 1,0116 Postal 70 40+ 6.2
et al. (2002) munity
Talley Major Mayo 328 Postal 77 65+ 3.7
et al. (1992) Clinic
Campbell Moderate Com- 555 Interview 95 60+ 3.1
et al. (1985) munity
Edwards and Moderate Com- 2,818 Interview 94 65+ 3.0
Jones (2001) munity
Chen Moderate Population 1,253 Interview 79 20+ 2.8 F
et al. (2003)
Thomas Mod- Com- 14,844 Postal 89 15+ 1.4
et al. (1984) major munity
a
Minimum threshold.
jects % group alence
Residence. Several studies of isolated care facilities suggest relatively high preva-
lence in long-term care (Harrari 2002).However, only one study compared type of residence within a total population (Crome et al.2001). For people aged 70 or more, this
study in the UK shows occasional (minor) incontinence affects 6.5% of people who
owned their own home, 8.5% of people living in public rented homes, 9.6% of people
living in sheltered housing, 19.2% of people living with relatives, and 45.2% of people
living in residential or nursing homes. The corresponding rates for frequent (major)
incontinence were 2.5%,2.5%, 3.8%,7.7% and 21.0%,respectively.
These results are consistent with other recent estimates identified for long-term
care facilities in the UK (13%–52%) (Peet et al. 1995; Brocklehurst et al. 1999), the US
and Canada (17%–46%) (Harrari et al. 1994; Johanson et al. 1997) and France 54%
(Chassagne et al. 1999).Dependency levels are highly correlated with prevalence (Peet
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