Urinary incontinence. (Editorial).

Unless one has experienced urinary incontinence, it is difficult to understand and appreciate the embarrassment, humiliation, psychologic distress, and tremendous impact this symptom has on one's life. Incontinence is usually the straw that breaks the camel's back, the last arrow that finally kills the hunted victim who has survived the impact of several other arrows. The older person may have been able to sustain the effects of several assaults, such as arthritis, impaired hearing, impaired vision, heart failure, and even impaired mental functions, and may have been able to successfully adjust to the new limitations imposed by these conditions. Urinary incontinence is often the final blow. Patients and caregivers find it difficult to adjust to that new insult.

When urinary incontinence first manifests itself, the patient is often too embarrassed to admit being incontinent and even if seen by a clinician may not readily acknowledge having this problem. Often patients with urinary incontinence try to cover up for their problem. Unfortunately, most of the time the patient may not think that urinary incontinence could be a treatable condition and may not be aware of the various aids available, and regrettably may either resort to rudimentary means or fall victim to unscrupulous marketers who do not hesitate to drain the person's precious assets.

The patient's relatives may have been able to cope with progressively worsening physical and mental capabilities, but once incontinence starts an entirely new dimension is added. Even the most dedicated relatives and caregivers find it difficult to cope with a loved one with urinary incontinence. The stench of urine is difficult to hide, social activities are curtailed, and the patient becomes rapidly isolated. In many instances, institutionalization is the only way out of this tangled web.

Urinary incontinence is frequently the main cause that precipitates a catastrophic reaction and forces the relatives to institutionalize their loved one at very short notice, without any significant preparation. Often the first available vacant place is taken without either the patient or the relatives having had enough time to learn more about the living conditions in that institution and especially without any mental preparation to adjust to this important new step.

It is not surprising that often the patient and relatives view the institutionalization as a "punishment." Everybody resents it; the patient feels rejected, and the relatives feel guilty and tend to be uncooperative with the staff of the institution where the patient has been admitted. This in turn generates a great deal of friction between relatives and staff. The relatives become more and more critical of the care provided to their loved one, the staff more and more defensive, and the patient more and more isolated!

It is regrettable that many people still believe that incontinence is part of the aging process and that little can be done to help patients with this condition. It is also unfortunate that many health care providers often adopt a defeatist attitude and blame either the aging process or the patient's underlying condition for the incontinence and are not interested in either investigating or referring the patient for further tests. This is most disappointing because many causes of incontinence are curable. More important still, if a cure cannot be effected, several resources are available that would allow the patient, relatives, and caregivers to lead as "normal" a life as possible.

Urinary incontinence is neither part of the normal aging process, nor is it an incurable disease. In fact, it is not even a disease; it is just a symptom. Clinicians should address urinary incontinence with the same enthusiasm they address other symptoms, such as chest pain. An element of urgency is necessary because unless adequately addressed, urinary incontinence will not get better and the patient will be drawn in a downward spiral culminating in isolation and, in many instances, institutionalization.

A number of guidelines are available to help clinicians optimize the workup and management of patients with urinary incontinence. Most clinicians delivering primary care should be able to adequately investigate and manage patients with urinary incontinence. In many instances, a reversible cause for the incontinence can be identified. Geriatricians and urologists are resources clinicians should not hesitate to use when faced with a patient with urinary incontinence who is not readily responding to their efforts.

For patients in whom the incontinence cannot be reversed, a number of "continence programs" have been developed. Unfortunately, in real life, most of these programs are on paper only, and most have a dismal success rate in most institutions, probably because the continence care of incontinent patients is usually relegated to the most junior and often most inexperienced member of the team. This is regrettable because, if properly instituted and diligently followed, the success rate of many continence programs is significant.

It is time for clinicians and health care providers to take the dust off these various programs and apply them with dedication and energy to better help patients with urinary incontinence. More important still, it is time for clinicians to change their attitude toward urinary incontinence and treat it with the same diligence, dedication, and fervor they have when addressing other symptoms, such as chest pain or fever.

It gives me great pleasure to introduce Dr. Ivan Merkelj, who is the guest editor of this month's Special CME Feature devoted to urinary incontinence. Dr. Merkelj is the Medical Director of the Nursing Home Care Unit of the Veterans Affairs Medical Center, Johnson City, Tennessee, and is Assistant Professor in Geriatric Medicine at the James H. Quillen College of Medicine, East Tennessee State University, Johnson City.

Ronald C. Hamdy, MD, FRCP, FACP 

Editor