Urinary incontinence, the involuntary loss of urine, occurs more often in women than in men. It is more prevalent than one might expect -- 25% to 35% of older people admitted to hospital have been reported to have incontinence, and this figure rises to 70% for nursing home patients. Incontinence is not only a distressing and embarrassing condition, it is also the cause of considerable expenses in elderly care. Most research has been done on the circumstances that predispose people to become incontinent, either immediately or in later life. A recent review has discussed the various approaches to preventing this all-too- common condition.¹

Attempts at prevention can be made relatively early, by addressing predisposing conditions such as pelvic muscle weakness, or later in life, by trying to reverse obvious existent circumstances, such as inappropriate medicines. Finally, one can try to prevent people who are already incontinent from the more distressing social or disabling effects of a worsening of the condition.

The risk factors commonly accepted as being associated with urinary incontinence include the following:

• increasing age
• female sex
• reduced mobility
• disabilities
• stroke
• diabetes
• enlarged prostate gland
• constipation
• chronic cough
• unsuitable medicines (sleeping pills, diuretics, i.e. water pills)

Clearly, not much can be done about the first two factors. There is no firm evidence that alcoholic drinks, coffee or tea directly cause incontinence, but they may contribute to the symptoms.

Old people who are frail often have conditions that make the situation worse. These include osteoarthritis, Alzheimer's disease and severe constipation. Sometimes retention of urine occurs -- this is when the bladder doesn't empty, and becomes over-filled. Retention of urine is often seen in patients after a fractured hip or a stroke. Sometimes it is not recognized by the medical staff, and it leads to incontinence - termed, appropriately enough, overflow incontinence.

In order to prevent or delay the onset of incontinence, the physician should try to eliminate, or reduce, the predisposing conditions. For instance, pelvic floor exercises done for a long period, improved bowel habits, reduced prostate size and the control of conditions like diabetes or Parkinson's disease can reduce some of the risks of incontinence. Lowering the frequency of stroke or Alzheimer's disease by changing life styles will also help eliminate cases of incontinence. A healthy life style can improve one's chances of avoiding more than one enfeebling condition.

If the predisposing conditions are advanced, the likelihood of incontinence is also high. It is necessary for physicians and nurses to be alert to the risks, and take the necessary steps -- for instance, inappropriate medicines must be avoided in patients with a fractured hip or a stroke.

Once incontinence is present, steps must be taken to prevent it worsening. Several treatment forms have been advocated -- medicines, surgery, and behavioral programs. The authors of the review are somewhat skeptical of the value of many of these, as they believe they have not been tested in a vigorous fashion. That is to say, the measures of successful treatment have not been defined well enough to allow one to say that one treatment is better than another. Perhaps the best that can be achieved is what they call "dependent continence" by regular toileting programs, or "social continence" with the help of aids such as pads or catheters.

Obviously it is better to hinder the onset of incontinence in the first place, rather than merely trying to stop it getting worse. However, until we know much more about the best way to prevent this distressing condition, one should probably address all identified risk factors as early and as efficiently as possible.