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Knowledge, Attitudes, and Practices of Physicians Regarding Urinary Incontinence in Persons Aged greater than or equal to 65 Years -- Massachusetts and Oklahoma, 1993

Urinary incontinence (UI) -- the involuntary loss of urine sufficient to be a problem for the patient or caregivers (1) -- affects an estimated 15%-30% of persons aged greater than or equal to 60 years in the United States and is a major cause of admittance to nursing homes (2). UI may be associated with a variety of medical (e.g., rashes, skin infections, pressure sores, urinary tract infections, and falls) and psychosocial problems (e.g., depression, embarrassment, restricted social interaction, reduced activities outside the home, reduced sexual activity, and sleep disturbances) (2-5). Despite the dissemination of clinical practice guidelines for UI by the Agency for Health Care Policy and Research (AHCPR) (1), many physicians do not know how to diagnose or treat UI. Beginning in 1992, CDC and AHCPR funded demonstration projects in Massachusetts and Oklahoma to educate the public, patients, and health-care professionals about UI. In both projects, physicians were assessed regarding baseline attitudes toward UI, knowledge of the causes and treatment of UI, preparedness to evaluate and treat UI, and current practices regarding UI. This report summarizes findings from the two projects during 1993.

Massachusetts. During March-May 1993, the Massachusetts Department of Public Health conducted a telephone survey of 350 eligible physicians who were sampled randomly in Essex and Norfolk counties; 163 (47%) participated. Of the 163 participants, 124 (76%) were primary-care physicians; 23 (14%), gynecologists; and 16 (10%), urologists. Overall, 34% reported that they had asked at least three fourths of their elderly patients about UI during the previous month; urologists (75%) and gynecologists (74%) were more likely to report asking than primary-care physicians (21%) (p less than 0.01). Seventy-two percent of physicians indicated that less than 10% of their patients aged greater than or equal to 65 years mentioned experiencing UI, and 68% that less than 10% of patients aged greater than or equal to 65 years who were asked about UI reported having this condition. The most common reasons that prevented physicians from asking patients about UI included lack of time (36%), lack of available and effective treatments (28%), and patient embarrassment (26%). A total of 73% underestimated the correct proportion (two thirds) of elderly patients with UI who could benefit from therapy. Most urologists (97%) and gynecologists (91%) and 46% of primary-care physicians rated themselves as prepared to treat UI.

Oklahoma. During May-September 1993, the Oklahoma State Department of Health mailed a survey to 194 eligible physicians who were randomly selected in four counties (Canadian, Cleveland, Logan, and Oklahoma) in the vicinity of Oklahoma City; 155 (80%) participated. Of the 155 participants, 120 (78%) were primary-care physicians; 26 (15%), gynecologists; and nine (6%), urologists. Overall, one third (33%) reported always asking all new patients about UI; urologists (89%) and gynecologists (58%) were more likely than primary-care physicians (23%) to always ask (p less than 0.01). Of all respondents, 16% reported they were "fully prepared" and 13% reported they were "poorly prepared" to evaluate UI; 62% of the primary-care physicians rated themselves as "somewhat prepared" or "poorly prepared" to evaluate UI. Nearly one third (32%) of respondents reported incorrectly that elderly persons with chronic UI were unlikely to improve. Most (90%) believed that physicians should be more active in asking the patient about problems with bladder control, and 78% believed that physicians should emphasize behavioral treatments (e.g., bladder training and pelvic muscle exercises) for UI.

Reported by: L Branch, PhD, ABT Associates Inc; N Resnick, MD, C DuBeau, MD, Harvard Medical School; A Balsam, PhD, C Bottum, MPH, D Siegal, MPA, Massachusetts Dept of Public Health, Boston. A Yerkes, MPH, Oklahoma State Dept of Health; S McFall, PhD, College of Public Health, Univ of Oklahoma Health Sciences Center, Oklahoma City. Health Interventions and Translation Br, and Aging Studies Br, Div of Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: In addition to its clinical effects, UI results in substantial health-care costs: in 1987, the annual direct costs for care of patients with UI were estimated to exceed $10.3 billion (2). Although existing therapies can improve two thirds of UI cases, the findings in this report suggest that most primary-care physicians neither routinely ask their elderly patients about UI nor believe they are adequately prepared to evaluate and treat UI. Previous studies have indicated that approximately half of patients with UI reported their physicians had never asked about UI, treated the condition, or referred them for treatment (6-9).

One of the national health objectives for the year 2000 is to increase to 60% the proportion of primary-care providers (i.e., physicians, physicians' assistants, nurses, and physical and occupational therapists) who routinely evaluate their patients aged greater than or equal to 65 years for UI (objective 17.17) (10). In both Massachusetts and Oklahoma, interventions were conducted after the surveys to prepare physicians to evaluate and treat UI. In Massachusetts, these interventions included a local conference about UI for urologists and chiefs of gynecology, organization of a series of hospital grand rounds presentations about UI by urologists, and a statewide mailing of program materials and information about the AHCPR guidelines to primary-care physicians. In Oklahoma, some physicians at area hospitals received briefings at department or general medical staff meetings to reinforce the importance of asking patients about UI; in addition, the Oklahoma Geriatric Education Center conducted an education session about treatment options for UI.

The health-care impact of UI is likely to increase because of the changing demographic composition of the U.S. population. As a consequence, clinical providers and public health programs will need to strengthen capacities to prevent UI and to ensure that patients with this condition can receive appropriate treatment. Health-care providers should routinely ask elderly patients about this condition and associated problems, educate patients about noninvasive behavioral interventions for UI, and if necessary, refer patients for appropriate treatment.


  1. Urinary Incontinence Guideline Panel, Public Health Service. Urinary incontinence in adults: clinical practice guideline. Rockville, Maryland: Agency for Health Care Policy and Research, 1992; publication no. (AHCPR)92-0038.

  2. Consensus Conference. Urinary incontinence in adults. JAMA 1989; 261:2685-90.

  3. Harris T. Aging in the eighties: prevalence and impact of urinary problems in individuals age 65 years and over. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, NCHS, 1986. (Advance data no. 121).

  4. Wetle TT, Scherr P, Branch LG, et al. Difficulty with holding urine among older persons in a geographically-defined community: prevalence and correlates. J Am Geriatr Soc 1995;43:349-55.

  5. Wyman JF, Harkins SW, Fantl JA. Psychosocial impact of urinary incontinence in the community-dwelling population. J Am Geriatr Soc 1990;38:282-8.

  6. Goldstein M, Hawthorne E, Engberg S, et al. Urinary incontinence: why people do not seek help. J Gerontol Nurs 1992;18:15-9.

  7. Burgio KL, Ives DG, Locher JL, Arena VC, Kuller LH. Treatment seeking for urinary incontinence in older adults. J Am Geriatr Soc 1994;42:208-12.

  8. Branch LG, Walker LA, Wetle TT, DuBeau CE, Resnick NM. Urinary incontinence knowledge among community-dwelling people 65 years of age and older. J Am Geriatr Soc 1994;42:1257-63.

  9. Mitteness LS. Knowledge and beliefs about urinary incontinence in adulthood and old age. J Am Geriatr Soc 1990;38:374-8.

  10. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

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