Guest Editorial: Urinary and Fecal Incontinence in Men: An Underserved Area of Care
Urinary and fecal incontinence adversely affect the lives of 400 million individuals.1 Reported prevalence rates of urinary incontinence (UI) in adult men <65 years of age vary from 3% to 5%; the number of men with UI increases with age, reaching 11% to 34% in the general population and as high as 50% of elderly men residing in nursing homes.2 Prevalence rates of fecal incontinence (FI) also increase proportionally as men age; sparse research suggests the probable reported prevalence rate in younger adult men is ~6%, increasing to ~15% in older men and as high as 50% in men residing in nursing homes.3 Double UI and FI are also prevalent in older men and those residing in nursing homes.
The negative impact of UI, FI, or double incontinence is substantial. Physical consequences include an increased likelihood of urinary tract infection, skin damage (especially in those with FI or double incontinence), and a poorly understood but strong association with declining health in aging adults.2,4 These significant negative physical consequences are no less important to the individual and his family or partner than the devastating psychosocial consequences that negatively affect multiple components of health-related quality of life, including intimate and social relationships, self-esteem, and personal dignity.5,6
Despite these profoundly negative consequences, incontinence remains a largely neglected area of care in all adults and particularly in men. The reasons for the lack of focus on research and innovation in the management of FI and UI in adult and aging men may be attributable to multiple factors. UI, in particular, often is overlooked in men because of its comparatively lower prevalence when compared to adult and aging women. The National Association For Continence notes the approximate proportion of women to men who suffer from UI varies from 2:1 to as much as 10:1 depending on age. As a result, lower urinary tract symptoms in men, including incontinence, are typically attributed solely to prostate enlargement (benign prostatic hyperplasia or hypertrophy) rather than more comprehensive lower urinary tract function and dysfunction. FI also tends to be more prevalent in younger adult women, probably due to the risk of injury during labor and delivery, enhancing an inaccurate sense that incontinence is a women’s health issue rather than an issue affecting all adults and especially aging individuals and persons with neurological disorders or cognitive impairment.
In addition, labeling incontinence a disease by the World Health Organization2 (WHO) may have inadvertently fostered a loss of hope concerning progress in the treatment of FI, UI, and double incontinence. While I continue to loudly applaud the WHO for recognizing the magnitude of incontinence as a personal and public health burden, labeling it a disease may have shifted focus from management to an expectation for “cure” in the majority of patients. A systematic review1 of cure rates in patients with double incontinence, FI, and UI found most patients with incontinence were not cured despite aggressive treatments. In addition, limited evidence1,2 and my clinical experience strongly suggest most individuals with incontinence, and especially elderly men and women, manage their incontinence with a combination of coping strategies such as use of absorptive products and behaviors designed to contain or conceal urinary or fecal leakage from others. I believe the disparity between the reality of our daily experiences and expectations for treatments designed to cure or control incontinence has promoted a nonproductive sense of pessimism. Nevertheless, while I do not believe we are on the threshold of a cure for UI, FI, and double incontinence, our management of these chronic conditions has improved significantly. Ongoing research into strategies to improve our ability to effectively contain incontinence, to alleviate rather than eradicate all episodes of urinary or fecal leakage, is no less important than our ultimate goal of curing these disorders.
The articles in this issue of OWM recognize the immediate need for additional research into the science of caring for men and women with incontinence and the poorly understood links between UI and FI, preservation of skin integrity, and promotion of optimal health in an aging population.
1. Reimsma R, Hagen S, Kirschner-Hermanns R, et al. Can incontinence be cured? A systematic review of cure rates. BMC Med. 2017;15:63. doi:10.1186/s12916-017-0282-2.
2. Milsom I, Altman D, Cartwright R, et al. Epidemiology of urinary incontinence (UI) and other lower urinary tract symptoms (LUTS), pelvic organ prolapse (POP), and anal (AI) incontinence. In: Abrams P, Cardozo L, Wagg A, Wein A. Incontinence: 6th ed. Tokyo, Japan: ICI;2017:4–93.
3. Pretlove SJ, Radely S, Toozs-Hobson PM, Thompson PJ, Soomarasamy A, Khan KS. Prevalence of anal incontinence according to age and gender: a systematic review and meta-regression analysis. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(4):407–417.
4. Gray M, Giuliano KK. Incontinence-associated dermatitis and immobility as pressure injury risk factors: a multisite epidemiologic analysis. J Wound, Ostomy and Continence Nurs. Published online ahead of print November 14, 2017. doi:10.1097/WOCN.00000000000000390.
5. Coyne KS, Wein A, Nicholson S, Kvasz M, Chen CI, Milsom I. Comorbidities and personal burden or urgency urinary incontinence: a systematic review. Int J Clin Pract. 2013;67(10):1015–1033.
6. Saldana Ruiz M, Kaiser AM. Fecal incontinence — challenges and solutions. World J Gastroenterol. 2017;23(1):11–24.
Dr. Gray is a Professor, University of Virginia, Charlottesville, VA. Please send correspondence to: email@example.com. This article was not subject to the Ostomy Wound Management peer-review process.