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The general practitioner can do much to manage incontinence and to promote continence
MJA1996; 165: 124-125.
Readers may print a single copy for personal use. No further reproduction or distribution of the articles in whole or in part should proceed without the permission of the publisher. For copyright permission, contact the Australasian Medical Publishing Company
Urinary incontinence regularly disrupts the lives of about 5% of home-dwelling adults; 1 it afflicts 3% of children aged 7-12 2 and 27% of adults over the age of 60. 3 Of the 75 000 people in Australian nursing homes, about 50% are "wet". 4 Extrapolation of the prevalence figures in the three overseas studies above 1-3 to the Australian population indicates that more than one million people in this country suffer from urine leakage. In the United States, the use of continence pads costs US$1000 per person every year, as estimated by the US Consensus Conference on Incontinence. 5 Thus, by extrapolation, incontinence, in terms only of the use of continence pads, costs Australians more than one billion dollars (US) each year, not including the costs incurred by nursing home residents (which are poorly documented in this country).
It would seem fortunate that this common and costly problem is eminently treatable in the community setting. However, many family doctors have scant knowledge about the different types of incontinence or their underlying causes, and do not understand how to assess or treat the problem. 6 Why is this so?
Incontinence is a Cinderella subject. Most doctors now in practice would have received little or no training about the issue in medical school, as much of our knowledge has developed in the last two decades. The condition is not glamorous: on the screen, movie stars might swoon with migraine or collapse with a heart attack; they seldom wet themselves. Nobody dies from incontinence. Patients often do not want to talk about it: history-taking can be time-consuming, examination may be embarrassing, and the temptation to refer to a specialist may be overwhelming.
It is a pity that more general practitioners do not do more for their incontinent patients. What is required is a short, focused history to distinguish stress leak from urge leak or obstructive symptoms; this, combined with a simple examination to exclude obstructive prolapse or prostatomegaly, a urine culture and a postvoid ultrasound of residual urine volume, can establish a working diagnosis in most instances.
Why should the family doctor be managing such patients? Because many studies have shown that conservative regimens, which are readily administered by community caregivers, are highly efficacious. Bladder-training programs for detrusor instability have success rates of up to 85% of cases. 7 Pelvic floor muscle exercise regimens for stress incontinence are successful in up to 65% of cases. 8 In both detrusor instability and stress incontinence, earlier treatment of less severe symptoms, avoiding the delay often incurred by specialist referral, is very advantageous. Other problems, such as neuropathic or overflow incontinence, may be treated by intermittent clean self-catheterisation, with success in 90% of cases. 9
Such treatment programs should be initiated, at the very first mention of the problem, by general practitioners, working together with community-based specialist nurse continence advisers. Only when these simple measures fail should more sophisticated and invasive tests, such as video- urodynamic studies, cystoscopy, dynamic urethroscopy, transvaginal ultrasound or other "high-tech" methods, be employed to establish a more precise diagnosis.
General practitioners are also ideally placed to implement strategies that promote continence. Important risk prevention regimens include avoidance of obesity, correction of constipation, treatment of chronic cough, and administration of topical or systemic oestrogens to women with urogenital atrophy. In the elderly, correction of impaired mobility, maintenance of adequate hydration (together with prevention of bacterial cystitis) and avoidance of a -blocking antihypertensive drugs (such as prazosin) that relax the bladder neck are all helpful in maintaining continence. 10 General practitioners can, and should, contribute in all of these areas. This is particularly important for older patients, because incontinence may precipitate a family's decision to institutionalise an elderly relative.
Continence care in Australia, centred on the Continence Foundation of Australia, has made great advances over the last 10 years. Continence advice centres and clinics have been established, and the Foundation's efforts to educate the public and the medical profession about conservative treatment options have made appropriate care more accessible for both young and old.
Australia has a relatively high concentration of nurse continence advisers who are skilled in assessing patients. These advisers can also institute appropriate conservative regimens, which are aimed at curing the problem, rather than just recommending pads or appliances. This source of local expertise can be reached through the national office of the Continence Foundation of Australia (phone 03-941-60857) or through the Bladder Helpline (FREECALL [outside Sydney metropolitan area] 1-800-069-789. Within Sydney, call the Continence Promotion Centre, phone 630 0477).
Surgical advances have also been made worldwide. A recent meta-analysis of outcomes for stress incontinence surgery showed that colposuspension and sling procedures were significantly more effective than needle suspensions and vaginal repairs. 11 A recent 20-year follow-up of colposuspension showed a 90% success rate at one year and success in 69% of cases in the long term. 12 By contrast, periurethral collagen injections were successful in 48% of cases at two years. 13 The field is still evolving.
Outcome data such as these obscure the reality that, for some patients, a minor procedure with a lower success rate may be more acceptable or safer than a major abdominal procedure. For many elderly people, a reduction in the number or severity of incontinence episodes (rather than total cure) may be the desired outcome, as it may enable them to stay at home and maintain their quality of life rather than seek institutional care. Hence the value of conservative treatment.
Pharmacological advances have been slow. However, the world standard anticholinergic agent, oxybutynin, was recently approved by the Australian Drug Evaluation Committee for general use in Australian patients with detrusor instability. Also, desmopressin spray is now NHS-listed for refractory nocturnal enuresis in childhood.
Aids and appliances schemes have also become more consumer-focused and effective. The federal Continence Aids Assistance Scheme (CAAS) for disabled patients, the federal Program of Aids for Disabled People (PADP) and the Continence Products Discount Service (in Victoria) make these options more accessible and more affordable. But the future of such schemes, from a political perspective, will depend on public awareness of the burden of incontinence.
The message is clear. Urinary incontinence is costing the people of Australia a great deal of money. As the population becomes older, the costs will become greater. Despite its Cinderella status, most incontinence can now be significantly ameliorated or cured. Too little is being done, too late, by too few. A major new initiative, funded by a forward-thinking government, is required to increase doctors' treatment skills and awaken public opinion generally if the escalating costs of incontinence are to be curtailed. If not, the problem will need more than a glass slipper to put it right.
Richard J Millard
Associate Professor of Urology, Prince Henry Hospital, Sydney, NSW
Kate H Moore
Senior Lecturer, The Pelvic Floor Unit, St George Hospital, Sydney,
NSW
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