International Urogynecology Journal

, Volume 15, Issue 1, pp 10–13

Prevalence of urinary, fecal and double incontinence in the elderly living at home

Authors

    • Department of General Practice and Social MedicineUniversity of Nijmegen
  • A. L. M. Lagro-Janssen
    • Department of General Practice and Social MedicineUniversity of Nijmegen
  • W. J. H. M. van den Bosch
    • Department of General Practice and Social MedicineUniversity of Nijmegen
  • H. J. M. van den Hoogen
    • Department of General Practice and Social MedicineUniversity of Nijmegen
Original Article

DOI: 10.1007/s00192-003-1106-8

Cite this article as:
Teunissen, T.A.M., Lagro-Janssen, A.L.M., van den Bosch, W.J.H.M. et al. Int Urogynecol J (2004) 15: 10. doi:10.1007/s00192-003-1106-8

Abstract

The aim of this study was to evaluate the prevalence of urinary, fecal and double incontinence in the elderly, through a population-based cross-sectional survey. The study included all patients aged 60 and over of nine general practices in the Nijmegen Monitoring Project. Patients living in a home for the elderly were excluded, as well as patients with dementia, patients who were too ill to participate and patients with a catheter. There were 5278 selected patients who received a postal questionnaire. Of these, 88% returned it. Nineteen percent of the respondents had involuntary loss of urine twice a month or more, 6% loss of feces and 3% both. The prevalence of urinary, fecal and double incontinence increased with age in both men and women, and especially in men in the oldest age group. Urinary incontinence was more prevalent in women than in men. The prevalence of fecal incontinence showed no sex differences, but the type of fecal incontinence did differ between men and women. In men loss of mucus was twice as common as in women. Double incontinence was also equally prevalent in men and women, except in the age group 65–74 years. In conclusion, urinary, fecal and double incontinence are common conditions in the community-dwelling population. The prevalence rates increase with age. Urinary incontinence is more prevalent in women. There were no sex differences in the prevalence of fecal incontinence but the type of fecal incontinence was different in men and women.

Keywords

Double incontinence Elderly Fecal incontinence Prevalence Sex differences Urinary incontinence

Abbreviations

FI

Fecal incontinence

UI

Urinary incontinence

Introduction

Incontinence may be a cause of great discomfort, embarrassment and loss of self-confidence, and may interfere with daily life, general health, and the overall quality of life [1, 2]. Incontinence may also lead to possible rejection on the part of a relative and may therefore be an important factor in the decision whether or not to institutionalize an elderly person. Several studies have determined the prevalence of urinary incontinence (UI) and fecal incontinence (FI) in nursing homes. The reported prevalence rates are approximately 50% for UI [3] and 20%–40% for FI [4, 5]. Studies into the prevalence of UI and FI in older people living at home are relatively scarce. The prevalence rates of UI in the elderly in the community range between 3.75 and 55% [6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18] (Table 1). This great variability is attributable mainly to methodological differences between studies, the use of different definitions of incontinence and differences in study samples.
Table 1

Previous studies about the prevalence of urinary incontinence in community-dwelling elderly

First author, year

Age

Number of patients and sex (n)

Definition

Prevalence

Branch [8] 1994

>65

M+F (1590)a

Once or more a month

17% (M/F?)

Brockelhurst [6] 1993

>60

M+F (4007)b

Last week

3.7% M; 8.3% F

Damian [9] 1998

>65

M+F (589)b

Six times or more a year

15.5% M; 15.5% F

Diokno [10] 1986

>60

M+F (1955)b

Six times or more a year

18.9 M; 37.7 F

Jitapunkul [11] 1998

>60

M+F (703)b

Ever

22.2% (M/F?)

Kok [12] 1992

>60

F (8967)c

Twice a week or more

23.5%

Maggi [13] 2001

>65

M+F (2398)c

Less than once a month

31.6% M; 26.5% F

Once or twice a month

13.9% M; 14.5% F

Every week

17.7% M; 13.6% F

Every day

36.8% M; 45.4% F

Molander [14] 1990

>55

F (10000)c

Ever

23%

Nygaard [7] 1996

>65

F (2025)c

Ever

55%

Teasdale [15] 1988

>65

M+F (843)c

Once a 6 month or more

22% M; 37% F

Thomas [16] 1980

>65

M+F (1562)c

Twice or more a month

6% M; 11% F

Tseng [17] 2000

>65

M+F (504)b

Ever

15% M; 27.7% F

Vetter [18] 1987

>70

M+F (1541)c

Ever

7.3% M; 18.2% F

aTelephone interview

bInterview at home

cPostal questionnaire

Studies into the prevalence of fecal incontinence in the older general population are even more infrequent, and prevalence rates range between 1% and 19.4% [5, 12, 19, 20, 21] (Table 2). The prevalence of double incontinence (DoI) in the community-dwelling elderly has not previously been investigated.
Table 2

Previous studies about the prevalence of fecal incontinence in community dwelling elderly

First author, year

Age

Number of patients and sex (n)

Definition (involuntary loss of)

Prevalence

Johanson [5] 1996

>70

M+F (6959)a

Stool/soiling. Ever

19.4%

Kok [12] 1992

>60

F (8967)c

Feces. Ever

16.9 F

Nakanishi [19] 1997

>65

M+F (1405)b

Soil yourself. Twice or more a month

8.7% M; 6.7% F

Talley [20] 1992

>65

M+F (328)c

Stool. Once a week or more

4% M; 3% F

Thomas [21] 1984

>65

M+F (1562)c

Feces. Twice a month or more

1% M: 1.3% F

aTelephone interview

b Interview at home

cPostal questionnaire

Incontinence is important because of the effects on health and quality of life, and also because of economic costs. Conservative therapies such as pelvic floor muscle training and bladder training are very successful also in the elderly [22, 23, 24, 25]. Nevertheless, only half the number of people with symptoms of incontinence seek help [26]. Knowing the prevalence of incontinence will help us decide on the relevance of further research with regard to causes, management and prevention. Because of a lack of population-based surveys using a well-defined definition of incontinence in the elderly, we decided to perform this epidemiological study in The Netherlands.

The aim of this study was to estimate the prevalence of urinary, fecal and double incontinence in men and women aged 60 years and older in the general population.

Materials and methods

In the period January 1999 to August 2001 we carried out a cross-sectional study in the eastern part of The Netherlands. Subjects were patients aged 60 years and older of nine general practices in the Nijmegen Monitoring Project, the academic registration network of the Department of General Practice of the University of Nijmegen [27]. These practices were computerized and used fixed patient lists. Patients who lived in homes for the elderly were excluded from the study, as well as patients with dementia, patients who were too ill to participate, and patients with a catheter. The selected patients received an anonymous questionnaire, with a reminder after 2 weeks. The definition of UI we used is based on the definition of the Guidelines on Urinary Incontinence of the Dutch College of General Practitioners [28]. UI was defined as involuntary loss of urine twice or more a month, FI as involuntary loss of feces twice or more a month, and DoI as involuntary loss of urine and feces twice or more a month. In cases of UI we asked the following questions: ‘1) Do you have involuntary loss of urine twice or more a month?’ For men who answered yes we asked: ‘2) is the involuntary loss of urine only a few drops after voiding?’ We excluded men with only postvoid dribbling because this problem requires a different type of management and is not considered as urinary incontinence. In case of FI we asked: ‘3) do you have involuntary loss of feces twice or more a month? 4) If yes, are the feces solid, liquid or mucoid in consistency?’ A positive answer to questions 1 and 3 was defined as DoI.

Data from the questionnaires were analyzed in five age groups. Differences between these five groups and sex differences were calculated using the χ2test.

Results

The nine general practices who participated contained 5748 patients aged 60 and over: 2589 men and 3159 women. After exclusion, 5278 questionnaires were sent (Table 3). The overall response rate was 88%; the response was similar in men and women and in the different age groups.
Table 3

The study population

Men

Women

Total

60 years and over

2589

3159

5748

Excluded

169

293

462

  Living in homes for the elderly

48

157

205

  Dementia

17

37

54

  Too ill

104

102

206

  Catheter

4

1

5

Questionnaires

2416 (94%)

2862 (90%)

5278 (92%)

Response rate

2137 (88%)

2513 (88%)

4650 (88%)

Nineteen percent of the elderly population had involuntary loss of urine, 6% loss of feces and 3% both (Table 4). The prevalence of UI, FI and DoI increased with age for both men and women.
Table 4

Prevalence of urinary (UI), fecal (FI) and double incontinence (DoI) in % (95% CI)

Age

UI men

UI women

UI total

FI men

FI women

FI total

DoI men

DoI women

DoI total

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

% (95% CI)

1

2

3

1

2

3

1

2

3

60–64

5 (3.6–6.8)

22 (19.2–25.1)a

14 (12.3–15.9)

6 (4.4–8.1)

4 (2.8–5.7)

5 (4.0–6.3)

1 (0.5–1.8)

3 (1.9–4.6)

2 (1.4–2.8)

65–69

6 (4.3–8.2)

26 (22.6–29.7)a

16 (14.0–18.2)

6 (4.2–8.4)

5 (3.5–7.1)

5 (3.9–6.4)

1 (0.5–2.0)

4 (2.6–6.0)a

3 (2.1–4.3)

70–74

8 (5.6–11.3)

29 (25.1–33.3)a

20 (17.4–22.8)

8 (4.6–11.3)

7 (5.0–9.7)

8 (6.3–10.1)

2 (1.0–3.9)

5 (3.3–7.4)a

4 (2.8–5.6)

75–79

14 (10.2–18.9)

36 (30.9–41.5)a

26 (22.6–29.7)

9 (5.9–13.3)

8 (5.4–11.5)

8 (6.1–10.5)

4 (2.1–7.2)

7 (4.6–10.4)

6 (4.2–8.4)

>80

21 (14.7–28.9)

38 (32.4–44.2)a

33 (28.5–37.9)

16 (10.4–23.7)

8 (5.1–12.1)

10(7.4–13.4)

6 (2.8–11.9)

6 (3.6–9.7)

6 (4.0–8.9)

Total

9 (7.4–10.9)

29 (27.2–30.9)a

19 (17.9–20.2)

7 (6.0–8.2)

6 (5.1–7.0)

6 (5.4–6.7)

2 (1.5–2.6)

4 (3.3–4.8)a

3 (2.6–3.5)

1 χ2 test relation between age and incontinence in men. (p<0.01) UI, (p<0.05) FI, (p<0.05) DoI

2 χ2 test relation between age and incontinence in women. (p<0.01) UI. (p<0.05) FI. (p<0.05) DoI

3 χ2 test relation between age and incontinence in the total group. (p<0.01) UI. (p<0.05) FI. (p<0.05) DoI

a χ2 test difference between men women significant for this age group (p<0.05)

Definition of UI (involuntary loss of urine twice or more a month)

Definition of FI (involuntary loss of feces twice or more a month)

Definition of DoI (involuntary loss of urine twice or more a month and involuntary loss of feces twice or more a month)

Urinary incontinence in men was two to three times lower than in women. The prevalence of fecal incontinence showed no gender difference, but the severity of fecal incontinence did differ in men and women. In men the loss of mucoid stool was significantly more prevalent than in women (Table 5). The prevalence of double incontinence was also similar in men and women except in the age group 65–74 years, where it was higher in women.
Table 5

Severity of fecal incontinence

Sex

Solid stool

Liquid stool

Mucoid stool

Men a

41 (30%)

13 (10%) b

80 (60%) b

Women

52 (42%

37 (29%)

37 (29%)

Total

93 (36%)

50 (19%)

117 (45%)

a χ2 test difference type of incontinence in men compared with type of incontinence in women (p<0.01)

b χ2 test difference men–women (p<0.01)

Focusing on patients with UI, one-fourth of the men and one-seventh of the women were also suffering from FI.

Discussion

Urinary incontinence is very common in the elderly living at home: 29% in women and 9% in men.

Five previous studies investigated the prevalence of UI in the general population using a well-worded definition [6, 8, 12, 13, 16]. Four of them had much lower response rates than we had. The response rate of 88% in our study was high. A likely explanation for this is that each patient received the questionnaire from their own general practice, with an invitation letter from their own GP to participate. Maggi et al. [13] also had a high response of 88% in their survey. Because the use of different definitions and the different spread of ages in the study samples the overall prevalence rate in the different surveys were not comparable. Because the prevalence of UI increased with age, if the spread of age in the study samples were not equal the prevalence rates should be different.

The prevalence of 7% for FI in this study showed that FI is also common in older people, especially those aged 80 and over. Previous community-based prevalence studies in the elderly by Nakanishi et al. [19] and Talley et al. [20] found comparable prevalence rates of FI. Thomas et al. [21] found much lower prevalences in men and women, but in FI the prevalence also increased with age, so the different surveys could not be compared.

An even more terrible condition is DoI. We were not able to find a previous survey regarding the prevalence of DoI. The estimate of 3% appears rather low but, focusing on patients with UI, one-fourth of the men and one-seventh of the women also suffered from FI.

A two-times higher prevalence rate of UI in women than in men corresponds with other studies [6, 10, 15, 16, 17, 18]. Women are more at risk of developing UI than men because of their different anatomy, especially the weaker structure of their proximal urethra and the hypermobility of the bladder outlet.

The equal prevalence rate of FI in men and women in this study is remarkable. In most studies FI is more frequent in women than in men, but all these studies are based on a population younger than 65 years. In this younger group obstetric injuries to the pudendal nerve or sphincter muscle are described as an important risk factor. At an older age other factors seem to be important. Also, Nakanishi et al. [19], Talley et al. [20] and Thomas et al. [21] found the same prevalence in elderly men and women.

Another important finding in this study is the difference in severity of fecal incontinence in men and women. In men loss of mucoid stool is more common and loss of liquid stool is less common than in women. This finding suggests another pathophysiology for FI in older women than in older men. We have no clear explanation for this and further studies are needed.

The limitation of this study was that the questionnaire we used was not validated, in particular the question about the severity of FI.

In conclusion, UI, FI and DoI are very common conditions in the older general population. About half of patients with UI do not seek help, and we do not know why. Conservative treatment of UI has proved to be successful [22, 23, 24, 25]. Little is known about the effect of conservative management of FI in the elderly, nor how many of them seek medical advice. Further studies into the reasons for not seeking help and the effect of conservative management of FI in older community-based people are needed.

Copyright information

© International Urogynecological Association 2004