Prevalence. The overall prevalence of UI among inpatients was 13.3% in the total study population. It is important to emphasize that all patients had urinary loss before hospitalization (ie, hospitalization was not a factor of loss of urinary control due to the deterioration of health status). UI was more predominant in women and in elderly persons (60 or older).
An overall prevalence of 13% (11.5% in men, 13.5% in women; not significantly different) also was noted for 6 hospitals in Indonesia between 2008 and 2011.9 The population of the study included children, adults, and elderly patients who underwent treatment at the pediatric, urology, obstetrics and gynecology, and geriatric outpatient clinics of those hospitals. UI prevalence in the current study was lower than the study conducted in Brazil at a university hospital, which found a prevalence of 22.9%.6
The role of age and gender. UI is a common problem that can affect people of all age groups, but its occurrence increases as the population ages.9-11 UI prevalence also increases with age. In one review of 36 studies from 17 countries about the prevalence of UI,10 40% of women 70 years or older were affected, prevalence rates were found to be even higher in the elderly and among nursing home patients, and UI prevalence among women ranged from ~5% to 69%. Similar data were found in the study conducted in Indonesia,9 where UI prevalence among elderly persons was 22.2%. This rate was significantly higher (P <.001) than the 10.8% prevalence in persons less than 60 years old.
The association between aging and altered urinary function (ie, urgency and urinary incontinence) can be explained by the structural alterations of the detrusor, such as the development of fibrosis, reduced bladder capacity and hypersensitivity to norepinephrine, determining involuntary contractions of the muscle.12 Because UI prevalence is strongly related to the age of the woman and with the increase in mean life expectancy, overall UI prevalence in women is expected to increase in the future.10
The loss of urinary control is a significant health condition for the elderly. It is not considered a disease but rather a circumstance that physically and psychologically affects this population, with data supported by results of a national, quantitative, cross-sectional study11 conducted in a geriatric outpatient clinic in São Paulo, Brazil. In this study, among the 100 elderly patients interviewed, 65% reported UI. The results also identified that urinary tract infections, loss of mobility, and gender were factors associated with UI in elderly individuals.11
A prevalence study13 conducted in the Netherlands found UI prevalence among adults (N = 1257) was 36.8%. Women experienced UI significantly more often than men (49.0% vs. 22.6%, respectively, P <.001), and UI prevalence increased in both men and women with age (P = .003 and P <.001, respectively). In a prevalence study14 conducted in Brazil among 622 women aged 50 years or older with a mean age of 64 years, UI prevalence was 52.3%.
UI type. In addition to gender and age, prevalence is affected by UI type. In a prevalence study15 performed in western Turkey among a random sample of women and men aged ≥18 years (N = 1555; 636 men [40.9%] and 919 women [59.1%]), the most prevalent UI symptom was urgency (reported in 29.3% of the study population [20.1% of men, 35.6% of women]). The prevalence of urge, stress, and mixed UI was 6.5% (3.9% men, 8.2% women), 14.1% (3.9% men, 21.2% women) and 5.6% (0.8% men, 9.0% women), respectively.
Clinical factors. The clinical factors in the present study are similar to those described in other prevalence and incidence studies that identified that most women with UI had vaginal delivery, were menopausal, and had not undergone hormone replacement16,17; the most important factor in men was a history of urological surgery. A cross-sectional study in the Netherlands with a sample of 1257 participants13 identified that diabetes mellitus, fecal incontinence, and constipation were overall risk factors for developing UI; for women, the risk factors included obesity, vaginal hysterectomy, and vaginal delivery, and for men prostate surgery was the main risk factor. In other prevalence and incidence studies,17,18 the main risk factors associated with UI in women were increasing age, deliveries, menopause, history of gynecological surgeries, and intestinal constipation.
Functional performance/mobility. Another factor often related to UI is functional performance capacity. People with reduced mobility tend to have a higher prevalence of UI.12 In the current study, most patients presented some type of functional limitation. The same result was found in a prevalence study19 conducted with a sample of 686 elderly individuals in which the prevalence of UI was 23.2% among men and 31.1% among women, and functional limitations included walking with assistance, reported falling in the last year, and fragility. In addition, the elderly women in this sample reported negative self-perception of health, arthritis/arthrosis/rheumatism, and fragility. Both the current and previous studies suggest that the greater the degree of dependence in the elderly, the greater the prevalence of UI.
A literature review18 revealed overlapping potential causes of incontinence, including dysfunction of the detrusor muscle or muscles of the pelvic floor, dysfunction of the neural controls of storage and voiding, and perturbation of the local environment within the bladder. In men, the most important cause was prostatectomy. This result was confirmed in the current study; in the studied sample, 25.0% of the men had undergone prostatectomy. Post-prostatectomy UI is a functional complication and has a significant impact on the QoL of patients diagnosed with prostate cancer. Incontinence due to surgical intervention was demonstrated in a longitudinal cohort study20 of 211 Korean men diagnosed with prostate cancer who had undergone radical prostatectomy; urinary function and incontinence did not return to baseline for 14.2% of patients who remained incontinent 12 months after surgery.
QoL. The qualification of urinary loss and QoL in patients with incontinence were measured using the validated instrument ICIQ-SF.8 In the present study, the mean score for interference of urine loss (several times a day) in the daily life of the patients was 4.1 ± 4.0. The sum of the scores that reflects the severity of the disease had a mean of 12.1 ± 5.86 (moderate UI ).
UI has been found to be related to QoL. A cross-sectional study21 in South Korea with a sample of 444 elderly patients evaluated UI-related QoL using the third ICIQ-SF subscale. Patients with 5 or more points were categorized as having poor QoL, while patients with 4 points or less were classified as having good QoL. Of all patients with UI, 32.5% reported poor QoL, and patients with depression were more likely to have poor QoL. In the current study, 47.7% participants were categorized as having poor QoL, considering the authors’ classification (patients with 5 or more points).
A cross-sectional study22 (N = 556 women) performed at an urogynecology outpatient unit in Brazil to compare the impact of different types of UI on QoL found women with mixed UI experienced a greater impact on QoL, concluding that all types of UI interfere both in general and specific QoL.
Assessment and documentation. In the current study, 28.6% of the patients did not have UI documented in their medical charts. In these cases, UI was identified by the nursing team by physical examinations including inspection of perianal, perigenital, and adjacent area skin conducted as part of study. Many people, especially women, wrongly assume incontinence is part of the aging process.17 They are unaware of the current treatments or do not seek help of a health care professional.
Risk factors. In the sample composed of elderly patients, it was important to evaluate how nurses treat UI and its relation to accidents related to falls, which is a multifactorial adverse event that can affect the patients. In the present study, 76.2% of medical charts lacked documentation that identified UI as a predictive factor for risk of falls. A national prospective cohort study,23 conducted in clinical units of 3 hospitals in Brazil among 221 inpatients more than 60 years old, analyzed the effect of UI as a predictor for the incidence of falls among hospitalized elderly patients. It concluded UI was a strong predictor of falls in the elderly surveyed. A methodological study24 recommended instituting prevention practices for hospitalized elderly patients with UI and/or specific risk factors. Better practices have been adopted in the facilities of the studies mentioned to optimize care quality, including the use of the John Hopkins Fall Risk Assessment Tool, in which incontinence is considered a predictive factor for falls.23,24 Strategies for preventing falls in inpatients should be based on established programs that use validated protocols to identify and implement risk reduction actions.
Management. The management of incontinence involves lifestyle changes such as losing weight; restricting water before bedtime; restricting caffeine, alcohol, and intense physical activities; and encouraging smoking cessation and pelvic floor muscle training programs including (in women with stress urinary incontinence and surgery) supervised pelvic floor exercises and the use of biofeedback.4
In the sample studied, 33.3% of the women had previously undergone surgical procedures to cure UI. Anterior vaginal repair (anterior colporrhaphy) is an operation traditionally used for moderate or severe stress UI in women. However, a systematic review25 found insufficient data to allow the comparison of anterior vaginal repair with exercises for the pelvic floor muscles (biofeedback, electrostimulation, vaginal cone) for primary urinary stress incontinence in women.
With regard to the nurse-implemented strategies for the treatment and management of UI, a Cochrane systematic review25 highlighted care that involved nutrition, water intake, and urinary and intestinal habits, as well as urinary training exercises, hygienic habits, catheter manipulation and environmental aspects, investing in self-care, guidelines for family members and caregivers, favoring continence, and improving QoL. The current study showed UI management in hospitalized patients included hygienic care, use of containment devices (disposable diapers and urinary devices), and application of skin protectors.
Diapers. The disposable diaper is a containment device used to absorb urinary and/or fecal flow. Guidelines26 and an observational, cross-sectional study27 note diapers should be indicated for patients with incontinence or severe mobility restrictions at hospital institutions. This product is noninvasive, and the cost is low when compared to other technologies for the management of incontinence.
The use of disposable diapers by adults and the elderly is widespread in daily life; the risks associated with this product have not been evaluated. Results of a cross-sectional study27 indicate the indiscriminate use of diapers, often aimed at patient safety and comfort, can come with harmful risk of mobility limitation, decreased self-esteem, urinary tract infections, dermatitis, and pressure injury. The indiscriminate use of diapers was confirmed in a transversal study28 among adult inpatients (N = 228) in which 34.4% of the patients used diapers despite the fact 30.1% did not have an indication to use them. Diaper use was considered inadequate in half the patients.
In the current study, diapers were used by 100% of the patients. It is well known that diaper use simplifies care — it avoids calls for going to the bathroom and reduces the risk of falling, especially at night. The diaper can be a good resource for incontinence management, but routine use without clinical reasoning can induce other problems, such as IAD.
Protecting the skin against moisture damage is an important component of care. Interventions to protect and prevent damage to the skin associated with moisture include the application of barrier creams, liquid polymers, and cyanoacrylates to the skin to form a protective layer; maintaining hydration; and blocking external sources of moisture and irritants. These products are recommended in a scoping review29 for patients considered to be at risk of developing IAD. No particular barrier has been found to be better than another; the performance of each product depends on the general formulation and frequency of application.
The evaluation of perianal, perigenital, and adjacent areas of skin among patients in this study found the presence of IAD in 10 patients without the presence of fungal infection. However, zinc oxide containing nystatin was the most widely used product for the prevention and treatment of IAD, followed by barrier cream and hydrocolloid powder, without differentiating among products used for skin protection and treatment of dermatitis. A review of literature30 concluded antifungals and corticosteroids can be used in the treatment phase of dermatitis, depending on its cause. Professionals should be mindful that routine use of these medications may expose patients to other risks, such as bacterial infection.
In the current study, dermatitis was present in 23.8% of the patients and occurred more frequently in women. This finding confirms the importance of adopting effective measures for the management of incontinence in addition to in-service education. In a cohort study31 among 10 713 elderly people 65 years of age and older who were newly residing in nursing homes, the incidence of dermatitis was 5.5%. The same study showed not receiving preventive interventions was a significant predictor of dermatitis. Nurses should implement care plans for patients with incontinence and specific care with professional hygiene and skin protection.