The Financial Burden of Stress Urinary Incontinence Among Women in the United States
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- Chong, E.C., Khan, A.A. & Anger, J.T. Curr Urol Rep (2011) 12: 358. doi:10.1007/s11934-011-0209-x
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Stress urinary incontinence (SUI) is a common medical problem affecting 25% to 50% of women in the United States. This article reviews the literature on the current systems- and population-based costs of management of SUI in women. A PubMed search was conducted to seek studies examining the cost of various management options. Both nonsurgical and surgical management can effectively improve symptoms of SUI at a wide spectrum of costs. Over $12 billion are spent annually, an amount that continues to grow. Patients pay out-of-pocket for 70% of conservative management, amounting to a significant individual financial burden. Systems-based cost of SUI management continues to rise with the aging population. Costs to both individuals and systems may be mitigated if more patients are treated with intent to cure and as surgical management transitions from inpatient to outpatient procedures.
KeywordsStress urinary incontinenceSUIFinancial burdenCostFemale urologyWomen’s healthIncontinence managementQuality-adjusted life earsQALY
Urinary incontinence is a prevalent condition that impacts an estimated 25% to 50% of the female population in the United States [1–5]. Studies have estimated that up to one third of women over the age of 40 years experiences urinary incontinence of some kind [1–5]. Symptoms of stress urinary incontinence (SUI), a disorder defined as the uncontrollable leakage of urine precipitated by exertion, are reported by 10% to 25% of women [1–7].
The women most likely to suffer from SUI have recognized risk factors, including age (incidence peaks between 45–49 years old), white race (compared with blacks and Hispanics), obesity, pregnancy, and vaginal delivery [1, 3, 4, 8•]. Other potential risk factors include smoking, thyroid disease, diabetes, stroke, asthma, caffeine intake, and congestive heart failure, but there has not been reproducible data to support their association with SUI [1–3]. Though urinary incontinence has been traditionally deemed a condition of middle-aged to older adults, it is estimated that it also affects about 18% of women between the ages of 25 and 39 years, of whom a small percentage are nulliparous .
Millions of individuals are affected by SUI, so it follows that the total systemic expenditure on management and treatment is substantial. Not only is SUI management expensive for the health care system, but it also is a significant financial burden on individual patients; nearly 70% of expenditures is attributed to routine care costs (including pads, diapers, laundry, and dry cleaning), which are often paid out-of-pocket [9, 10].
Financial, social, and psychological burden all contribute to the cost of SUI, and thus, it is difficult to quantify its true economic impact. Nevertheless, it is clear that the systemic cost of SUI treatment and management is rising. The escalating cost has been attributed to a number of causes. These include increasing prevalence of urinary incontinence, increased desire for improved quality of life, improved recognition of the condition, increasing use of surgical management versus nonsurgical management, and improved health care accessibility [7, 11–13]. This paper reviews the literature on the current costs of SUI among women on both a population- and systems-based level.
A PubMed MeSH (Medical Subject Headings) search was performed using the keywords “stress urinary incontinence” and “cost.” This search generated 80 articles, 10 of which included full free text. Five of the remaining articles were deemed relevant, and the references of those papers were examined, producing an additional 15 studies.
The cost of SUI management and treatment can be divided into direct and indirect costs. Direct costs are those associated with diagnosis, treatment, and routine care, while indirect costs are those that are more difficult to quantify, such as lost work days and decreased productivity. Though much of the following discussion is focused on direct costs based on accessibility of data, the economic impact of indirect costs should not be underemphasized [7, 10].
The cost of treatment options can be compared using an analysis of cost utility, an estimate which incorporates both cost of a procedure along with the improved quality of life associated with it. The measurement is based on the average cost difference between treatment modalities (referred to as incremental cost) and the average difference in quality-adjusted life years (QALY [referred to as incremental effectiveness]). QALY is a numeric representation of how much and how long one’s quality of life improves after treatment. When intervention results in 100% cure, the QALY equals 0.05. If treatment accomplishes less than 100% cure, the QALY is calculated linearly such that 25% cure equals 0.0125 . A treatment is deemed cost-effective if it falls under one of several criteria: if it is less expensive and more effective than another treatment option, if it is more expensive and the individual is willing to assume the difference in cost for a greater improvement in quality of life, or if it is less effective and less expensive but the other option is too expensive and the improved quality of life is not great enough to warrant increased spending .
Management of SUI can be divided largely between nonsurgical and surgical options. Nonsurgical therapy should be considered and attempted before surgical intervention. Nonsurgical management begins with lifestyle changes such as weight loss, smoking cessation, decreased caffeine and alcohol consumption, and optimization of comorbidities such as chronic obstructive pulmonary disease and diabetes. The cost of medical optimization and lifestyle changes vary immensely, ranging from none at all (for example, walking three times per week), to an estimated $50 per month for a gym membership, to thousands of dollars a year for complex medical optimization [8•].
Nonsurgical management also includes the use of absorptive devices, including incontinence pads, sanitary napkins, and diapers for those individuals with more substantial urine leakage. Nearly 70% of the total cost of SUI care comes from routine management including pads, diapers, laundry, and dry cleaning [9, 10]. In 2008, Subak et al.  conducted the Stress Incontinence Surgical Treatment Efficacy (SISTEr) Trial, a study estimating the individual cost of SUI management in 655 incontinent women seeking surgical correction of SUI. The study found that the individual costs amounted to almost 1% of the median annual household income ($50,000–$59,999). The mean weekly cost of management amongst the women reporting any cost at all was $15 ± $25, an amount totaling $751 ± $1277 annually. The weekly amount spent on management increased with the severity of symptoms. For example, women reporting up to one incontinent episode daily spent a weekly mean of $8 ± $19 compared with $27 ± $37 in the group experiencing 4.5 episodes daily .
Another study by Subak et al.  from 2007, the Reproductive Risks for Incontinence Study at Kaiser, examined the direct cost of management in 2109 incontinent community-dwelling women. Weekly symptoms of UI were reported by 528 of enrolled women, 220 of whom experienced symptoms of SUI only. The cost of pads, diapers, laundry, and dry cleaning were estimated for these individuals. Results showed that women with SUI spent a mean of $3.91 ± $11.11 per week leading to an annual cost of $204 ± $578. Community-dwelling women with urinary incontinence incur fewer costs than a population that includes nursing-home residents with more comorbidities .
The first step in treatment of SUI is the implementation of pelvic floor muscle training (PFMT, also known as Kegel exercises), which strengthens urethral sphincter tone, thus decreasing urine leakage during episodes of increased intraabdominal pressure. PFMT has been shown to be more effective in alleviating symptoms of SUI compared to no therapy and placebo . However, the success of pelvic floor muscle strengthening is largely dependent on patient compliance and requires that a woman perform the exercises on a daily basis for an indefinite amount of time. The recommended frequency of contractions ranges from 8 to 10 contractions three to four times a week to 50 contractions daily [3, 4]. Furthermore, this means of treatment requires that a woman understands how to contract her pelvic muscles correctly, education which can be achieved through demonstration or manual examination by the physician or patient herself [3, 8•]. The addition of biofeedback to PFMT has not shown to be beneficial over PFMT alone . Vaginal cones also may be used as an additional component of weight training to the pelvic floor muscles; they also may be used as monotherapy [8•].
PFMT varies in cost depending on the nature of the exercise. When used alone, the method is essentially free, aside from the cost of one clinical encounter during which the patient is taught to perform Kegel exercises. PFMT can be combined with other treatments such as biofeedback, electrical stimulation, and vaginal cones, but they come with additional costs. In a systematic review of the cost-effectiveness of nonsurgical SUI management by Imamura et al. [8•] in 2010, the estimated price in British pounds for 3 months of basic PFMT, PFMT plus biofeedback, and PFMT plus electrical stimulation were £189, £224, and £398, respectively (converted to $291, $345, and $612 using the 2010 US dollar [USD]–to-pound exchange rate of 0.65).
Pharmacotherapy, though not considered standard of care for SUI, also can be considered for nonsurgical candidates. Medical therapy traditionally has included α-agonists and estrogen, but more recently has included serotonin-norepinephrine reuptake inhibitors (SNRIs). The proposed mechanism of action of estrogen is its preservation of pelvic floor muscle along with increased sealing of urethral mucosa. However, multiple studies have shown that oral estrogen in fact increases UI symptoms in postmenopausal women, and it is therefore not recommended for treatment of SUI [8•]. α-Agonists increase sphincter tone, but studies have shown only minimal improvement in SUI symptoms [3, 8•]. Based on animal studies, SNRIs improve continence by increasing striatal periurethral sphincter tone and relaxing the detrusor muscle. Research regarding duloxetine use for SUI treatment is scant, but some studies have shown that duloxetine improves SUI symptoms compared with no treatment [3, 4, 16]. It can be used in combination with PFMT for even greater relief of symptoms . Despite symptomatic improvement, side effects (most commonly nausea) limit many individuals from continuing SNRI treatment [3, 16]. A year’s worth of duloxetine costs an estimated £402 (roughly $618). Though some studies have suggested that the combined use of PFMT and duloxetine for SUI treatment may be superior to either modality alone, the enormous cost of duloxetine along with side effects may hinder many individuals from utilizing both treatments .
Vaginal devices (pessaries) also are acceptable treatments for SUI. Pessaries are intravaginal devices that support the urethra posteriorly. They must be fitted for maximal efficacy. In addition, they should be removed regularly to prevent infection. Though pessaries are an option for women who cannot undergo or who do not desire surgical treatment, their use is often limited by increased vaginal discharge, which some women find troublesome. There is no current data comparing the effectiveness of these mechanical devices to other nonsurgical treatments, but one randomized control study demonstrated equivocal efficacy between pessaries and tampon use . Vaginal incontinence pessaries generally range from $40 to $60, in addition to the physician fee for pessary placement and periodic vaginal examination by a physician.
Another popular method of treatment is the use of periurethral bulking agents, which are injected either periurethrally or transurethrally to thicken the tissue surrounding the urethral sphincter and hence improve continence. Many different agents exist, but the most common include collagen and Coaptite (Boston Scientific, Natick, MA). Short-term efficacy of bulking agents can be as high as 75%, but symptoms return with time, and it is likely that a patient will need additional injections every other year . Additional costs of collagen involve the need for skin testing before placement of the collagen.
Surgical intervention in the treatment of SUI has changed rapidly over the past several decades. The most common surgeries are slings and the Burch colposuspension, while needle suspensions and anterior repairs have fallen out of favor due to inferior long-term cure rates [3, 4]. A randomized control trial comparing transvaginal tape (TVT) to open colposuspension found faster recovery time and fewer postoperative complications in the former group and more intraoperative complications (such as bladder injury) in the latter group . Transobturator tape (TOT) procedures are similar to TVT except the tape is passed through the obturator foramen instead of the retropubic space. Studies have shown TOT to have similar efficacy when compared to TVT [17••].
Multiple studies have evaluated the cost-effectiveness between various surgical treatments. A Markov model study compared the cost utility of TVT versus duloxetine. Using a QALY estimate in which 100% cure rates equated to a 0.05 QALY gain, the study concluded that duloxetine treatment is a less expensive option than TVT initially ($390 versus $5420), but TVT resulted in larger QALY gain over a 2-year follow up (0.0067 vs 0.0869). In other words, while duloxetine is more immediately economical, the long-term costs surpass those from TVT due to superior longevity of TVT treatment. Furthermore, the QALY gain from TVT increased incrementally with the number of follow-up years . Another study comparing the cost-effectiveness of TVT versus PFMT is currently taking place and results are pending .
Several studies have demonstrated that TVT is more cost-effective than either laparoscopic or open colposuspensions. In a Swedish study, a constructed model compared the cost (using the value of the Euro in 2003) of three procedures: TVT, open colposuspension, and laparoscopic colposuspension. It found the following costs: €1366 for TVT versus €2431 for an open colposuspensions and €2310 for the laparoscopic procedure. Using the 2003 average conversion rate of 1.12 USD: 1 Euro, these values come out to be $1529.92, $2722.72, and $2587.20 respectively . TVT procedures range from £741 to £1357 ($1140–$2,088) for inpatient procedures with a mean of 2 hospital days and £456 to £828 ($702–$1,274) for outpatient procedures. Open colposuspension with a 2-day hospital stay ranges from £1011-£2013 ($1555-$1960) [8•].
Another study compared the cost-effectiveness of TVT and TOT over a 12-month period. At 1 postoperative year, there was no significant difference in cure rates, but 80% of TOT women versus 30% of TVT women had palpable vaginal tape, and vaginal pain was present in 15% of TOT women versus 6% of TVT women. There was a non–statistically significant $1133 of savings in the TOT group and no difference in QALY. Based on 1 year of follow-up, the results did not suggest that one procedure was more cost-effective than the other .
A small retrospective study in 1997 compared periurethral injection to sling surgery. Though the sling cost nearly twice as much as the injections ($10,382 versus $4996 in 1995 USD), follow-up at 15 months revealed that 71.4% of women in the sling group were symptom-free compared with only 26.7% in the injection group . The results of this study suggest that the sling is a more cost-effective treatment than periurethral bulking agents due to the better efficacy of the former.
The cost of SUI treatment certainly can pose great financial difficulties to many individuals. Even so, many women with SUI are willing to financially invest for improvement of their symptoms. Subak et al.  in 2008 evaluated the monetary extent to which a woman would pay to alleviate or cure her SUI symptoms. Overall, women were willing to spend increasing amounts for greater improvements of symptoms. Women were amenable to paying $31 ± $76 per month for a 25% reduction in symptoms (for example, an improvement from four to three episodes of daily leakage). The willingness to spend increased to $44 ± $80 for 50% reduction and $118 ± $132 for 100% cure.
The cost of SUI treatment has risen significantly in the past few decades. The escalating cost has been attributed to a number of causes: increasing prevalence of urinary continence, increased desire for improved quality of life, improved recognition of the condition, increasing use of surgical management versus nonsurgical management, and improved health care accessibility [7, 9, 10].
The estimated annual direct cost of UI in women and men in 1995 USD totaled over $16 billion, an amount of spending surpassing that to treat pneumonia and influenza [7, 10]. Over $12 billion of the $16 billion spent was specifically for female incontinence. When analyzing for type of UI, SUI accounted for 82% ($13.12 billion dollars) of the total cost. Spending on SUI specifically exceeds that on breast cancer ($8.9 billion) and rivals that of osteoporosis ($13.8 billion). Of the total spending, 70% was spent on routine care (eg, primary care visits and purchasing pads), 14% on nursing-home admission, 9% on treatment, 6% to address complications, and 1% on diagnosis .
Additionally, Medicare spending to treat urinary incontinence continues to increase dramatically. An analysis of Medicare claims as part of the Urologic Diseases in America Project revealed a dramatic increase in spending from 1992 to 1998; from $128 million to $234 million . This represents a nearly twofold increase that cannot be accounted for by inflation alone. While the overall cost nearly doubled, the cost per capita decreased about 15%, meaning that the surge in spending could be largely explained by more women seeking treatment and/or more Medicare beneficiaries. Direct care cost analysis done by Wilson et al.  supports the latter hypothesis in that urinary incontinence treatment costs in those over 65 years old are more than two times that of patients younger than 65 years old.
The same study demonstrated an evolution in the composition of spending. With the development of minimally invasive procedures such as TVT and slings, outpatient surgeries have become increasingly popular compared with the traditional open colposuspensions. Outpatient surgeries are more economical on a per capita basis and result in shorter recovery times, though there may be more intraoperative complications . Between 1992 and 1998, outpatient treatment spending increased from 29% to 52.7% of the total expenditure while inpatient treatment dropped from 70.6% to 47% .
As the number of elderly women increases, the prevalence of SUI will continue to grow. The management of SUI amounts to substantial costs to not only individual patients but also to the health care system as a whole. Conservative management of SUI composes about 70% of total expenditure; because most of this cost is out-of-pocket, patients assume great financial responsibility in managing their SUI [9, 10]. The number of outpatient procedures continues to grow. Because ambulatory services are less expensive than inpatient procedures, their increased utilization hopefully will dampen systemic health care costs as the number of women seeking treatment of SUI rises [7, 10].
No potential conflicts of interest relevant to this article were reported.