Continence Promotion, Education & Primary Prevention

1643

Committee 21

Continence Promotion, Education

& Primary Prevention

Chair

D. K. N

EWMAN (USA)

Members

C. H. E

(Singapore),

D. G

ORDON (Australia),

V. S. S

RINI (India),

K. W

ILLIAMS (U.K)

Consultants

B. C

AHILL

(Australia)

Continence Foundation of Australia

B. GORDON (USA),

Interstitial Cystitis Association, USA

T. GRIEBLING (USA),

K. N

ISHIMURA (Japan),

Japan Continence Society, Japan

N. N

ORTON

(USA)

International Foundation for Functional Gastrointestinal Disorders, USA

1644
1. BACKGROUND 
2. CONTINENCE PROMOTION PROGRAMS
3. CONTINENCE ADVOCACY
1. BACKGROUND
2. PHYSICIANS (FAMILY PHYSICIANS/ GENE-
RAL PRACTITIONERS/PRIMARY CARE
PHYSICIANS) 
3. NURSING PROFESSIONALS 
4. PHYSIOTHERAPY AND OTHER ALLIED
HEALTH PROFESSIONALS
5. IMPACT OF UI GUIDELINES
6. RECOMMENDATIONS FOR PROFESSIONAL
EDUCATION
1. BACKGROUND
2. POPULATION-BASED PREVENTION
3. RISK FACTORS
4. PREVENTION OF CHILDBIRTH-RELATED
INCONTINENCE
5. PREVENTION OF PROSTATECTOMY-RE-
LATED URINARY INCONTINENCE
6. PREVENTION OF URINARY INCONTINENCE
IN OLDER ADULTS
7. PREVENTION OF PELVIC ORGAN
PROLAPSE 
8. PREVENTION OF FAECAL INCONTINENCE
9.  RECOMMENDATIONS FOR PRIMARY
PREVENTION
APPENDIX 1 –
DIRECTORY OF CONTINENCE
ORGANIZATIONS 
REFERENCES 
IV. PRIMARY PREVENTION 
III. PROFESSIONAL EDUCATION
II. CONTINENCE AWARENESS
I. INTRODUCTION
CONTENTS

1645

Continence promotion, education and primary

prevention involves informing and educating the public

and health care professionals that urinary incontinence

and faecal incontinence are not inevitable, but are

treatable or at least manageable. In addition, other

bladder disorders such as bladder pain syndrome/

painful bladder syndrome/interstitial cystitis and pelvic

organ prolapse can be treated successfully. Taboos

on mentioning disorders of the bladder and bowel are

gradually lifting in most cultures. Two decades ago it

was almost impossible to have urinary incontinence

discussed in the media. Today, in most countries,

consensus panels, government funding of continence

initiatives and practice guidelines have been developed

in the area of urinary and faecal incontinence, and

many are referenced in this chapter. Around the world,

expert panels have suggested that urinary and faecal

incontinence be combined through a multidisciplinary

approach to further research priorities.

Thus, there have been advances in promoting

awareness of both urinary and faecal incontinence.

Popular magazines, local and national papers, radio,

and television, regularly cover topics on urinary

incontinence in most developed countries. Many

countries have run national or local public awareness

campaigns, usually spearheaded by a national

continence organisation. Many also have confidential

help lines, which can be accessed anonymously. The

World Wide Web provides a convenient source of

health information for a growing number of consumers.

Some experts believe that persons with incontinence

might get valuable advice and comfort by using

interactive services such as the chat rooms on the

internet. However, in developing countries, public

information and campaigns through these mediums

is limited or non-existent.

This chapter updates previous International

Consultation on Incontinence (ICI) chapters on three

areas: continence promotion, education and primary

prevention.

The majority of information available in these areas

is on urinary and faecal incontinence which are the

primary focus of this chapter. The first section reviews

continence awareness by discussing health promotion

and care-seeking behaviours for these conditions. It

is evident that progress has been made in the

promotion of continence on a worldwide basis but not

much has changed in help-seeking behaviour for

these disorders.

There is a lack of evidence on translating awareness

into behavioural change and on what triggers help-

seeking behaviour. Information is provided on

continence promotion programs and advocacy through

service delivery, models of care and worldwide

organizations. Although there is a great deal of

published information on building public and health

care professional awareness of incontinence, there is

minimal information on the effectiveness of changing

public and professional attitudes and knowledge about

it. Documentation of the success of campaigns is

lacking and should be measured by behavioural

changes and ultimately by improved patient outcomes.

A second topic reviewed in this chapter is the education

of professionals in the areas of urinary incontinence,

faecal incontinence, pelvic organ prolapse and bladder

pain syndrome. The use of medical guidelines and care

pathways will be discussed. Finally, as these conditions

are prevalent but often ignored by sufferers and

professional, the third topic addressed is primary

prevention with identification of modifiable risk factors.

There is a need for further research to substantiate

the benefits of primary preventative strategies,

including long term follow-up.

I. INTRODUCTION

Continence Promotion, Education &

Primary Prevention

D. K. NEWMAN

C. H. EE, D. GORDON,V. S. SRINI, K. WILLIAMS

B. CAHILL, B. G

ORDON,T. GRIEBLING, K. NISHIMURA, N. NORTON

1646

LITERATURE SEARCH

The online databases Medline, Embase, Biosis, Cinahl,

Pychinfo, ERIC and Cochrane were searched, with

focus on literatures published in and after 2003. The

following search terms were used: awareness,

consumer, education, urinary incontinence (UI), faecal

incontinence (FI), incontinence, continence, continence

awareness, continence promotion, health education,

public education, public awareness, pelvic organ

prolapse (POP), interstitial cystitis (IC), bladder pain

syndrome (BPS), painful bladder syndrome (PBS)

and outcome measures. Non-English language papers

were noted but excluded from the review unless they

contained English-language abstract providing

sufficient information.

1. BACKGROUND

For a health-related issue like incontinence, the

altruistic reason to educate consumers – referring

mainly those with incontinence and their family

members or informal caregivers, as well as individuals

at risk – must be to increase awareness of incontinence

and the benefits of prevention and management, with

the noble goals of eliminating stigma, promoting

disclosure and care-seeking, and reducing suffering

[1]. Much of the health promotion efforts related to

continence issues are undertaken by the many non-

governmental continence organisations, professional

and advocacy groups listed in Appendix I. Although

in some countries, there is also strong governmental

support, including a national advocacy on achieving

an effective health literacy system. Components of

such a system involving many levels of educational,

health-care, and community service providers have

been identified and include: (a) an information

dissemination system providing materials that are

readable, comprehensible, trustworthy, and culturally

sensitive; (b) a coordinated health literacy learning

system; (c) a measurement and assessment system;

(d) a formal and informal health advice system,

including a hotline, handbook, and online support;

and (e) a health care professional educational system

[2].

Consumer education in terms of having access to

information about incontinence in this age of digital

technology is a non-issue, especially for those internet

users who tend to have a higher literacy level [2]. In

light of the reluctance of those affected by stigmatized

illnesses such as incontinence to seek treatment or

to ask health care professionals for information, the

internet may prove to be a useful tool for patient

education and public health outreach. [3, 4].

The internet is widely accessible and frequently

searched for health information. Recent estimates

indicate that around 20% of U.S.A. adults use the

internet for health information [5]. Among those who

do not use the internet, 60% are aware of publicly

available internet access points within their community

[6]. Also, the internet can be searched anonymously

and informally. People with low levels of education and

low socioeconomic status are less likely to use the

internet [7]. Health care professionals can assist

consumers to find reliable information sources by

providing details of reputable web sites [8].

In a national survey of internet users in the U.S.A., [9]

Berger 2005, found a trend among people with a

stigmatized illness such as UI to more likely report that

using the internet increased their health care utilization

and communication with a health care provider.

A Google search for “urinary incontinence (UI)” and

“faecal incontinence (FI)” yielded about 1.7 million and

62,800 websites respectively; “interstitial cystitis (IC)”

- 828,000 sites, “painful bladder syndrome (PBS)” –

38,000 sites and “pelvic organ prolapse (POP)” –

120,000 sites. Many were repetitions. For “continence

promotion”, the yield was about 6,450 sites, and for

“continence awareness (CA)”, it was about 2,840. There

was reference to 114 sites for “continence awareness”

and “UI” or “FI”; 35 sites for “continence awareness” and

“IC”, and 40 sites for “continence awareness” and

“POP”. Many of the sites were related to non-

government organisations such as the International

Continence Society (ICS), the National Association for

Continence (NAFC) and the Interstitial Cystitis

Association (ICA), and the International Foundation for

Functional Gastro-intestinal Disorders (IFFGD).

a) Health promotion

Efforts to promote continence may be enhanced by

adopting evidence based theories and methods from

the field of health promotion. Health promotion was

defined by the Ottawa Charter for Health Promotion

in 1986 as “the process of enabling people to increase

control over and to improve their health” [10]. Hence,

health promotion is an important factor in primary,

secondary and tertiary prevention efforts directed at

individuals, communities and populations with or at risk

of developing incontinence.

Health promotion frameworks can be used to plan

and evaluate the effectiveness of strategies and

programs used to promote continence. When planning

health promotion interventions consideration needs to

be given to the demographic features of target groups

including age, gender, culture, language and

socioeconomic background. Health promotion

strategies need to address issues such as accessibility,

availability of transport and the cost of health promotion

programs [11]. Other considerations include commu-

nication strategies. As noted above, there is an

increasing trend for consumers to search and obtain

information from the internet.

II. CONTINENCE AWARENESS

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Palmer and Newman [12] reported on a U.S.A. health

promotion project conducted in 2000 to determine

the needs of senior citizens concerning bladder control

issues. Focus groups of older adults attending health

seminars in urban, community and church settings

were conducted. The primary objective of the project

was to determine the understanding of older adults in

the areas of general health and their beliefs

surrounding the problem of UI. The 82 participants

were predominantly African-American women

representing all socio-economic levels. Seniors

expressed confusion when asked if “overactive

bladder, bladder control issues and urinary

incontinence” were the same condition. Most seniors

said they felt comfortable about discussing bladder

control issues, but most admitted that their physician

had never asked them, nor had they raised the issue.

However, they did discuss UI with family members and

friends and they were aware that many persons with

whom they socialize might have a problem with UI.

The majority of seniors answered “no cure” when

asked if treatments were successful.

b) Care-seeking (help-seeking) behaviour

Despite the considerable impact of incontinence on

quality of life (QoL), many people never seek help for

their incontinence and are thus uncounted [13]. Current

research in the area of care–seeking (also referred to

as “help-seeking” or health-seeking”) behaviour

(seeking help from a health care provider or

professional) in women with UI has determined that

fewer than 38% sought help for their condition, and

they waited more than a year to do so [14]. A European

survey reported that patients wait from 2 to 11 or more

years before seeking treatment [15]. Huang et. al.[16]

reported that fewer than 50% of women in the U.S.A.

with clinically significant UI reported seeking treatment.

This was despite the fact that all women in this study

had heath insurance that would pay for services and

had continuous access to a primary care provider.

Women with stress UI are more likely to seek help

when there is severe leakage that is having a

significant impact on their QoL [17]. Shaw and

colleagues [18] surveyed adult women attending

primary care practices in UK and of those who noted

UI symptoms (n=3273), only a total of 15.8% of women

with stress UI, 32.3% of those with urge UI and 33.7%

with mixed UI had sought help for urinary symptoms

during the preceding 12 months. This study also found

that when women sought help for UI, only one-third

will receive appropriate treatment [17].

Men tend to be less proactive in health seeking

behaviour. Gender specific strategies to address this

should be considered [19]. Men with lower urinary

tract symptoms (LUTS) have been found to seek help

less frequently than women [20]. Conversely, a study

into the prevalence of UI in men in the U.S.A. found

that whilst only 50% of men with continence issues

sought help, these men consulted their doctor within

12 months of the onset of symptoms [21]. This time

period is much shorter than the length of time taken

by women to seek help [21]. Men are more likely to

seek help for LUTS if they have had advice from

others or received information in the media, than

seeking help as a result of their symptoms [22]..

In a population-based study in Sweden (a supplement

to a comprehensive survey of public health and general

living conditions), a postal questionnaire comprising

12 questions on UI received a response rate of 64.5%

from 15,360 randomly selected residents (aged 18–79

years) [23]. The prevalence of UI was 19% (when

defined as “any leakage”) and most considered their

problems to be minor. Only 18% of those with UI

desired treatment. Of the 17% who had reported

severe problems that interfered with daily life, 42% did

not want treatment. The authors suspect that lack of

knowledge, worries about different procedures and

negative expectations may be important factors. They

concluded that UI may not be an unrecognised major

problem except for a limited group, and suggested that

healthcare resources should be optimized to identify

and meet the needs of those who are most afflicted.

Muller [24] reported on several epidemiologic surveys

conducted over a 5 year period by the U.S.A.

continence advocacy group, the NAFC. These surveys

indicated that UI and overactive bladder (OAB) are

prevalent problems and that most people do not

understand these conditions. In one survey, conducted

in 2000, only 26% of respondents (18% of men and

33% of women) reporting bladder control symptoms

had discussed them with a doctor. This survey

attempted to examine bathroom-related attitudes and

behaviours and found that most feel the bathroom is

a “haven” for refuge while others feel it represents a

symbol of incarceration because of the preoccupation

with the need to be near one frequently.

Bathroom privacy, cleanliness and ease of accessibility

were voiced as concerns with only 20% of respondents

noting that they are comfortable using a bathroom

outside their home. A second survey by this group

was conducted online (over the internet) and includes

1,025 interviews of U.S.A. adults (ages 30 to 70).

This survey showed that women wait longer (average

6.5 years) than men (4.2 years) to seek out a diagnosis

for their symptoms.

Barriers to seeking help for continence issues have

been frequently identified in the literature and include

embarrassment, social stigma and the mistaken belief

that incontinence is either inevitable, untreatable and

a normal part of aging [25]. Women with POP have

also reported that fear and embarrassment are barriers

to seeking help. Other barriers include the perception

that incontinence and LUTS are not serious [26].

However symptoms such as nocturia have been linked

with serious consequences such as falls and

associated morbidity in older adults.

1648

Bladder and bowel continence is an adjustment to

the social norm, especially in Western cultures, which

have developed acceptable rules and behaviour for

bladder and bowel emptying. [27, 28]. If incontinence

occurs in adulthood, persons revive those childhood

beliefs and begin to internalize their condition causing

a decrease in self-esteem and feelings of not being

“normal” [29]. These barriers are shared by the public

as well as by many health care providers [30].

Unfortunately, factors that promote health seeking

behaviour for continence issues remain less well

researched and the triggers for help-seeking behaviour

are complex and multifactorial. With chronic problems

like UI, FI, POP and BPS/IC/PBS, it is important to

understand what triggers the patient to consult a

health care provider [28].. Older people may be keen

to seek help if they are concerned that a health issue

such as incontinence impacts on their ability to remain

independent and living in the community [31].

In certain parts of the world, the gender of the person

with UI may be a factor in help-seeking behaviour

and the gender of the health care provider may be a

barrier. Doshani and colleagues [32] explored views

and experiences of South Asian Indian women with

UI and found that feelings of embarrassment were

present, especially with male health care providers.

Rizk [33] identified reasons why women in the United

Arab Emirates (UAB) were not seeking medical help

for UI. Data from questionnaires was collected on

400 women (mean age 54.2) out of 448 enrolled

subjects and noted that, 81 (20.3%) admitted UI and

only 25 of these (30.9%) had sought medical advice.

The reasons were embarrassment (38.2%), choice of

self-treatment because of low expectations from

medical care (38.2%), preferring to discuss the matter

with friends, and assuming that UI is normal (23.3%).

Women with UI were troubled by their inability to pray

(90%) and to have sexual intercourse (33.3%). Saleh

[34] found similar results when surveying women in

Qatari who reported that UI interfered with their ability

to pray (64%) because of lack of cleanliness and need

to void and 47% reported that UI interfered with marital

relationships.

Rizk and colleagues [35] also investigated the

prevalence and help-seeking behaviour of women (n

= 400, mean age 37.9) with FI using the same method.

Fifty-one participants (11.3 %) admitted FI; 26 (5.8 %)

were incontinent to liquid stool and 25 (5.5 %) to solid

stool. Thirty-eight patients (8.4 %) had double (urinary

and fecal) incontinence. Sixty-five patients (14.4 %)

were incontinent to flatus only but not to stools. Only

21 incontinent patients (41 %) had sought medical

advice. Women did not seek medical advice because

they were embarrassed to consult their physician

(64.7 %), they preferred to discuss the difficulty with

friends, assuming that FI would resolve spontaneously

(47.1 %) or was normal (31.3 %), and they chose

self-treatment as a result of low expectations for

medical care (23.5 %). Women with FI were bothered

by the inability to pray (92.2 %) and to have sexual

intercourse (43.1 %). These studies note that both

UI and FI are common yet underreported by UAE

women because of cultural attitudes and inadequate

public knowledge. These authors felt that male provider

gender may also be a barrier to seeking health care

in Middle Eastern women with UI. They were also

surprised to find that women perceive their problem

to be a neurological or “senile” disorder rather than

related to childbirth or menopause.

There are several strategies that can be used to

promote help-seeking behaviours and they need to

include those that are culturally appropriate [36, 37].

Minority and disadvantaged groups have lower rates

of health seeking behaviour for UI that may relate to

a number of factors such as access to care and

socioeconomic factors [38]. . Understanding the

reasons why people do or do not seek treatment for

incontinence is hampered by the ethnic homogeneity

of the existing data as most is derived primarily from

white Caucasian populations and there is a lack of

comparisons with ethnic minority populations.

Factors that enhance or enable people to change

health behaviours include advice given by physicians

[39]. Opportunities to promote continence can present

themselves during other health screening activities

such as cervical cancer screening [40]. Whilst health

care professionals may enable people to seek help,

those who have a lack of interest in incontinence can

negatively affect health seeking behaviour in

consumers [41, 12]. Other initiatives to promote health

seeking behavior can include providing written

information [42]. Continence health promotion

information provided in a brochure [43] and in a

computer based program [44] were found to improve

health seeking behaviour.

Language, level of education and cultural factors may

also be barriers to seeking help [45]. Consideration

should be given to health literacy in target populations.

Health literacy affects the ability to read and understand

health information in written formats. Poor health

literacy results in lower rates of health seeking behavior

[46].

One of the most supportive government sponsored

initiatives is from Australia. The National Continence

Management Strategy (NCMS) was established in

1998 by the Australian Government Department of

Health and Ageing. Funding of over $33 million AUD

has been allocated for the period from 1998 – 2010.

More than 120 projects have received funding for

research, public awareness activities, continence

education, resource development and continence

service development. The Strategy is now in its third

phase of activity. A final evaluation report on Phase

1 and 2 of the NCMS was released in September

2006 [47, 48]. In the area of continence awareness,

1649

the report noted that recognition of the barriers to

help-seeking behaviour and identification of the most

appropriate terminology and key messages would

strengthen awareness raising strategies. The provision

of an incontinence specific helpline (the National

Continence Helpline) has been an important aware-

ness raising initiative. Table 1 reviews the specific

programs developed and implemented by the NCMS.

2. CONTINENCE PROMOTION PROGRAMS

Continence promotion programs vary across countries

and cultures, but the singular aim of creating

awareness is similar. There is no standard model

promotion program nor is there a standard outcome

measure to determine the effectiveness of the program.

While the current level of evidence for effectiveness

of continence promotion program in raising awareness

generally is level 4, there is a need for research to

provide a higher level of evidence to affirm its

effectiveness to generate higher interest and support.

Efforts to raise awareness of continence issues need

to consider the following:

•Target population - Continence promotion

programs need to consider age, gender and culture

of target populations. It is necessary to consult

with target groups when planning programs in

order to meet the needs of these groups and to

enhance help-seeking behaviour [49].

•Target issues - A continence promotion program

needs to address risk factors and management

options in different target groups.

•Promotional material – Newman [50] reported

on a mail survey of 1,500 women, noting that most

of the 422 respondents wanted more information

regarding UI, and while they may not be equipped

to fully understand the problem, they expect

doctors, nurses, medical professionals, retail

outlets, medical supply companies, and mail order

houses to provide the information, including

information through consumer advertising.

• Channels of communication – Health care

professionals may launch campaigns or seminars

to increase practice revenues. Commercial

companies often fund public campaigns in order

to sell their products. Continence organizations

may be driven by missionary zeal or organizational

growth. Regardless of motivation, care should be

taken to avoid raising public expectations beyond

what the services or products can deliver.

Individualised “coaching” of the affected is one key

channel that continence nurses use in the

promotion of continence [51].

a) Creating public awareness

In the area of UI, building awareness among the

general public is usually attempted via the media.

Table 1. NCMS Continence Awareness Programs

Program Description

Bladder and Bowel Health Information and advice on the prevention and management of bladder control and

website bowel problems for consumers, carers, health professionals, service providers and

www

.bladderbowel.gov.au researchers. It also contains information about the Continence Aids Assistance

Scheme.

Continence Outcomes Development and delivery of a translation program of continence outcomes mea-

Measures (COMS) sures to national and international clinicians. Further work is being proposed to

Dissemination Project conduct field trials to establish the validity, reliability and suitability of the

continence outcome measures in Australian treatment settings and then to

translate these for use by health care professionals. The reports are:

• Measuring Incontinence in Australia 2006

• Continence Outcomes Measurement Suite together with Review of Patient

Satisfaction Measures 2006

• Framework for Economic and Cost Evaluation for Continence Conditions 2006

• Measuring Patient Satisfaction with Incontinence Treatment 2006

• Refining Continence Measurement Tools 2006

• Incontinence and Patient Satisfaction Tools and Instructions

National Men’s Continence Raise the awareness of the causes of poor bladder and bowel health, specifically

Awareness Project targeting men.

Pharmacy Continence Delivery of a training package to educate pharmacists and pharmacy assistants to

Care Project enable them to better inform clients about continence care and management.

Daily Living Self Offers strategies for people with incontinence to help with their work life, family life

Management Resources and social life.

• Live Better - for people with urinary incontinence

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Using the media to disseminate information in the

form of Public Service Announcements (called PSAs)

has been practised extensively in the U.S.A. to

promote AIDS awareness and as anti-smoking

campaigns. The U.S.A. National Institutes of Health,

in partnership with the American Uro-Gynecologic

Association, American Urological Association,

American Foundation for Urologic Disease, National

Association For Continence, Society of Urologic

Nurses and Associates and the Simon Foundation

for Continence, launched a national awareness

campaign in 1997. The Let’s Talk About Bladder

Control for Women awareness campaign (http://kidney.

niddk.nih.gov/ kudiseases/ pubs/bcw_ez/index.htm)

offers easy-to-read booklets explaining the symptoms,

types and causes of poor bladder control, as well as

treatment options. The materials are designed to

encourage and enhance communication between and

among women and their health care providers. Free

consumer and health care provider kits are available

through a toll-free phone number. In 2001, the NAFC

in the U.S.A. produced and disseminated continence

awareness PSAs to 380 television media markets,

including Hispanic outlets.

In many cultures, one of the best vehicles to reaching

the public is through an informed journalist. Journalists

often use a “media hook,” an interesting story that

will take priority over other news on the television,

radio or newspaper. Having a spokesperson with the

problem or finding a celebrity who is willing to speak

for the cause can help [27]. These individuals can act

as “influence leaders.”

The Japan Continence Action Society held a “Toll

Free Telephone Clinic” and callers were asked how

they heard about the line. The responses in 2006

were: 30% from television, 16% from the web, 11%

from a newspaper, 9% from a book, 6% from a friend,

5% from a brochure, 3% from a magazine and 20%

others and/or unknown. In a UK campaign, Norton [52]

found that newspapers were by far the most common

source of information, followed by radio.

A media campaign should use multiple channels to

ensure the broadest coverage [53]. An initial channel

should include print media, television and radio. The

Internet, phones, and other mobile devices are also

effective outreach channels [54]. A second channel

could be specialised age and health publications. A

third channel could be the use of posters and

brochures placed in medical offices, hospitals, senior’s

centre, pharmacies and churches. A final channel

could be direct presentations to the public, such as

at senior’s centres [55].

Roe [56] suggested that local initiatives on the

availability of services and how to access them, as well

as health education information on UI, may be more

effective in raising public awareness and should

supplement national campaigns. Awareness raising

materials include pamphlets, self-care instructions,

visual aids, pictographs, posters, banners, decals and

advertisements in newspapers, magazines,

newsletters, CD and films. Muller [57] believed that

the change related to increased public awareness

and help-seeking behaviour for continence care is

likely to fuel the demand for innovation in technology

and products. The Simon Foundation for Continence

developed an innovative community education initiative

The Bladder Health Mobil. This initiative provides

education, increase public awareness, and promote

early diagnosis and proper treatment of UI and other

bladder control problems. It also facilitates dialogue

between consumers and their health care profes-

sionals [58].

Terminology used when discussing urinary and bowel

incontinence is important. The words “continence” or

“incontinence”, “interstitial cystitis” or “painful bladder

syndrome” and “pelvic organ prolapse” are poorly

understood and simpler terms may achieve greater

public recognition in many languages and cultures. The

use of “overactive bladder” in advertising has increased

reporting of the condition to primary care professionals

in the U.S.A. In the area of bowel disorders such as

FI, it is felt that people find it difficult to find the right

words to discuss their symptoms [27]. The International

Foundation for Functional Gastrointestinal Disorder

(IFFGD) in the U.S.A. has found that people will often

report having diarrhea to their physician. If the

physician or nurse does not question the patient any

further regarding the ability to control gas, liquid or solid

stool, the incontinence may not be discovered.

b) Program evaluation

Evaluation methods need to be established prior to

developing the continence promotion program.

Evaluation should include quantitative measurements

and qualitative measures. Open-ended questions

may be more sensitive than “direct satisfaction”

questions [59, 60].

Health promotion evaluation methods include process

evaluation, impact evaluation and outcome evaluation.

Evaluation measures can include the number of media

responses to a media release, or numbers of people

who sought help.

In the evaluation report of the Australian NCMS, a

total of 16 projects were undertaken for raising

continence awareness, with focus on the development

and distribution of information resources for use by the

general community and specific target groups [47,

48, 61]. As of June 2006, a market survey found that

9 of the completed projects with measurable outcomes

had generally shown favorable outcome.

Evaluation of the effectiveness of leaflets or brochures

is gathering better evidence. An Australian study found

that provision of a continence education package,

which included a Continence Educational Brochure

1651

helped to improve the health-seeking behaviours of

participants who were bothered by UI symptoms [62].

Within 3 months following the education, of the 111

participants who were bothered by UI symptoms, 49

participants (44.1%) indicated that they had discussed

the issue of bladder or bowel problems with someone

directly because of the study or the information

contained in the brochure. More than 94% of partici-

pants who remembered the brochure indicated that

they believed it would be helpful if given to other

people. In a study of 1175 participants, Wagg et al [63]

reported that a self-help standard treatment leaflet is

as effective as structured help from a continence

nurse in reducing bothersome urinary symptoms in

women. Similarly, a Swedish population-based study

found that the distribution of a brochure on UI to the

general public was well received and can be an efficient

method to spread knowledge and encourage self-

management [64].

The interventions that are most effective in reaching

the public and triggering the desired behaviour seem

to vary between countries and cultures. Television

and newspapers work best in Singapore, with a “cured”

patient bearing testimony to former suffering and its

alleviation having the most impact. In the U.S.A.,

television advertising targeting OAB, funded primarily

by pharmaceutical companies, has yielded a significant

response. Nationwide television reaches more people

than the circulation of any single newspaper or the

distribution of a booklet through physician offices. In

March 2008, Japanese National Television broadcast

a program about UI during “golden time” (2000 to

2045 hours). The audience rating was 15.6%, the

highest in a year (usual rating 12%), and more than

500 calls were received in one night, requesting repeat

broadcast and more details about treatment. There are

also cultural differences in the online health information

is used, as well as the types of sites users prefer to

surf [54].

In France, the effect of health education was evaluated

in a randomized study in sheltered accommodations

for the elderly [65]. Twenty centers were randomized

to either a single one-hour health information meeting

or control group. During a 30-minute talk, a nurse

encouraged people to visit a physician if they had

urinary problems. A questionnaire three months later

found that the experimental group was much more

likely to have had treatment if they were incontinent

(41% vs. 13% controls) and 82% said that they had

received some information about UI in the previous

3 months (compared to 22% controls).

A health promotion project called ‘Dry Expectations’

was developed and implemented in six ethnically

diverse, predominantly minority, and inner city senior

centres in the U.S.A. in 1996 [55]. The program was

designed to address an older population. The project

consisted of three phases: orientation and training of

key staff members/peer educators at the centres

(train-the-trainer model); educating seniors through four

one-hour weekly sessions involving visual aids and

completion of bladder records and quizzes; and follow

up sessions with senior staff/peer educators to

reinforce the previous training. The program was very

well received by the participants, and approximately

80% felt they had more control over their bladder by

the end of the last session.

The impact and success of any continence promotion

program must surely be its sustained effectiveness

many years down the road, be it for primary prevention

or treatment. A randomized controlled study of 359

community-dwelling older women showed that group

instruction supplemented with brief individual

instruction as needed is an effective teaching method

for the acquisition of knowledge and motor skill in

bladder training (BT) and pelvic floor muscle training

(PFMT). The 1 year adherence following a behavioural

modification program ranged from 63 to 82% for PFMT

and 58 to 67% for BT [66]. Adherence is reduced over

time and the marked benefit of intensive PFMT seen

short-term may not be maintained and the long-term

adherence to training can be low [67].

c) Recommendations for Continence Awa-

reness and Promotion

Based on the literature reviewed in this section, the

following recommendations can be made:

• Continence awareness should be included in

any national advocacy program that is working

towards an effective health literacy system, as it

is consistent with and requires the involvement

of many levels of educational, health-care, and

community service providers, namely a(n):

- Information dissemination system providing

materials that are readable, compre-

hensible, trustworthy, and culturally sensi-

tive;

- Coordinated health literacy learning system;

- Measurement and assessment system;

- Formal and informal health advice system,

including a helpline, handbook, and online

support; and

- Professional health care provider learning

system.

(Grade D)

• Continence awareness should be part of the

main stream and on-going health education and

advocacy programs with emphasis on eliminating

stigma, promoting disclosure and help-seeking

behaviour and improving quality of life. (Grade

• There is a need for research to provide higher

level of evidence on the effectiveness of

continence promotion programs to increase

awareness, be it for primary prevention, treatment

or management. (Grade D)

1652

3. CONTINENCE ADVOCACY

Advocacy is defined as act or process of defending

or maintaining a cause or proposal. Advocacy, as it

pertains to incontinence, involves assisting individuals

in finding necessary health care and treatment.

Organisations consisting of professional and public

members promote continence advocacy as a core

mission.

a) Service delivery

The provision of continence care and services in each

country will depend on the organisation and

infrastructure of its health services. It is difficult to

make recommendations that will apply in such a variety

of contexts. In addition, UI is so widespread and

affects so many different types of people that they

can present for help to literally any health care

professional. This means that there will seldom be

one portal of entry to a continence service.

When new services are created, there is a temptation

to focus on the high technology investigation and

medical treatment elements without considering the

infrastructure needed to support that service [68].

However, there has never been a comprehensive

examination of an optimal service. It is not known

whether academic, specialist-led centres will achieve

better and more cost-effective results than primary

care clinics, domiciliary services or any other model.

However, most experts believe that female UI is initially

most effectively diagnosed and managed by primary

care providers compared to specialist services.

In 2000, the UK’s Department of Health issued

guidance on continence services that outlined a good

practice model to achieve more responsive, equitable,

effective continence services [69]. In the U.S.A., the

primary sources of care for the majority of Medicare

patients (primarily an elderly population) are family

physicians and primary care physicians [70]. Less

than 1 person in 1000 is admitted to an academic,

medical centre hospital [71]. Thus, in the U.S.A.,

elderly persons with UI and FI will probably be seen

by primary care physicians for initial assessment. This

is unlikely to address the needs of developing countries

(such as the Asia Pacific area or in Africa) where

dissemination of expertise to rural communities and

isolated community health care workers is more logical.

They are being implemented in several countries

using shared teaching and educational resources

through co-operative arrangements of the respective

Continence Foundations. Thus, the general practitioner

or family physician plays an important role in the first

line treatment of UI that may be treated successfully

with conservative treatments in the majority of patients

[72, 73].

In some health systems, both UI and FI have

traditionally been seen solely as a nursing problem,

with little interest or input from other members of a

multidisciplinary medical team. Except for a few

isolated areas, the main intervention has been trying

to help the individual and caregivers cope with

symptoms rather than attempting to treat the underlying

cause of the UI. For example, in the UK, it is common

for an elderly person presenting with UI to be referred

directly to the district nurse “for assessment for pads

and pants,” with no physical examination or further

investigation considered.

In fact, UI is often a complex and multi-faceted

problem, particularly in frail or dependent individuals,

and it may require input from a wide variety of

disciplines to tackle it effectively. Symptoms typically

associated with incontinence may also be indicative

of other conditions as evidenced by the urgency and

frequency symptoms of BPS, also referred to as IC

and PBS, a chronic inflammatory condition of the

bladder [74, 75]. The ICI Committee 19, addresses

bladder pain syndrome. While it may not be practical

for all specialities to work in close proximity, there is

a need to consider carefully who does what, with

protocols to guide appropriate referral and ensure

good liaison. It is important that there are neither

gaps, nor overlaps, in the service.

In countries such as Australia, New Zealand and the

UK, where there is a national network of Continence

Nurse Advisors (CNAs) or Continence Nurses. These

nurses liaise, integrate services, and guide individuals

through the referral route most appropriate to their

individual needs.

The efficacy of Continence Nurse Practitioners (CNPs)

in the UK was reported by Matharu and associates [76]

who studied four hundred and fifty (450) women over

40 years of age who underwent urodynamic studies

in the UK after seeing a trained CNP. In patients

diagnosed with detrusor overactivity, the CNP had

prescribed 79% to have drug therapy and 64.8% to

have PFMT. In those with urodynamic stress UI, 88%

had appropriately been assigned to have PFMT.

Nursing assessment has the potential to assign

patients to the correct conservative treatment thereby

shortening waiting times for urodynamics and specialist

assessment.

• There is a need for research on the most

effective means to educate the public and

professional groups on continence issues.

Specifically, there is need for research on:

- Identification and understanding of barriers

to health-seeking behaviours

- Translation of research into improved

clinical practice and identification of

methods by which this happens.

- Effectiveness and impact of consumer

education initiatives.

(Grade D)

1653

Shaw, Williams, and Assassa [77] conducted a postal

survey of people in the UK receiving services for UI

by CNPs. Participants expressed satisfaction with

nurse-led services because of the interpersonal skills,

technical skills, and communication and information-

giving abilities of the nurses. There is more evidence

that treatment of incontinent community-dwelling

individuals by a “continence nurse” is beneficial in

terms of clinical outcomes [78].

Although some might see multidisciplinary working

as the ideal, the reality is not always smooth. In some

situations, rivalries and competition between disciplines

and medical specialities is evident. This may be

because of competition for patients and revenue, or

because of disputes over the demarcation of the scope

of different disciplines (such as the boundary between

urology and gynaecology, or between nursing and

physiotherapy).

There are no studies directly comparing the

effectiveness of specific delivery systems for

continence care. In certain cases, enthusiasts have

conducted research and results may not generalize

to the wider setting. Others have combined the

expertise of multidisciplinary teams to maximize service

delivery. The level of evidence on service delivery

models is 4.

i) The need for service

As discussed at the beginning of this chapter, the

majority of people (60-70%) who admit to UI in

prevalence surveys do not seek professional help

[13, 71, 79]. Not all incontinent people want or need

help, and this may vary considerably between different

cultures. For example, a postal questionnaire asking

about urinary symptoms found that nocturnal problems

caused the most bother (69% were bothered by

nocturnal enuresis, 63% by nocturia). Only 50% found

stress UI a bother and only 56% were bothered by urge

UI [80]. A community based study found that only

15% of severely incontinent women (daily incontinence

requiring protective pads most of the time) were

worried about it, 15% felt that their activities were

restricted and the majority seemed able to cope [81].

Overall, 78% were not worried by their incontinence

and the authors suggested that services should be

targeted towards the minority who do

find it a problem.

In Japan, it has been found that 55% of elderly

incontinent people do not consider incontinence a

bother, but 15% did not leave home, 10% found it

difficult to leave home, and 10% felt that they caused

bother to family and neighbours [82]. However it is

pertinent to note that, there is significant underreporting

by patients of UI and the severity of symptoms [83].

It is also evident from this data that the burden of

incontinence, is responsible for 20% of healthy life

lost for 75 year olds and older [84] and has the third

highest impact on QoL of major chronic conditions

[85].

A Japanese survey of over 1,000 caregivers of elderly

incontinent people in the community found that more

than 80% of caregivers are female and over half were

more than 60 years old [82]. The caregivers felt that

incontinence caused problems with the home getting

dirty (10%); extra laundry (9%), need to wake at night

(7%), and not being able to go out because of

incontinence (9%). When asked what kind of

government service they wanted, caregivers replied

“health training” (10%), “knowledge about incon-

tinence” (10%), and “supply of a portable toilet” (3%).

Only 6% wanted the government to send them

professional caregivers and only 4% desired referral

to a specialist physician.

Incontinence is responsible for up to 30 - 50% of

admissions into nursing homes, often precipitated by

the burden of care on caregivers who spend half of

their care-giving time providing personal care such as

toileting assistance [86].

Some people seem to cope better than others with

symptoms, and some had coping strategies, which

were easily undermined by any suggestion that

professional help was required [87]. Few people seem

prepared to take action to prevent UI.

This can create a dilemma and raises many questions.

Should health care professionals attempt to persuade

or educate people who do not see UI as a problem

that it is an abnormal condition? Should a patient who

is “not bothered” by symptoms be treated because the

partner or caregiver requests the physician’s

assistance? This may be of concern, as Rodriquez,

et al. [88] found that physicians underestimated the

degree to which patients were bothered by their

symptoms 25% to 37% of the time. Is lack of bother

genuine or simply a defense against having to tackle

an unpleasant problem? Does early intervention

prevent later deterioration in symptoms? Does delay

in treatment mean that success rates are lowered?

There is scant evidence on any of these issues, or on

the most acceptable way of providing help.

It is the impression of all members of this committee

that, specifically for the field of UI, due to the high

percentage of people not seeking help (for all the

above mentioned reasons), that health care

professionals must develop a concept of a “reaching-

out” service and to actively provide service for

incontinence care, meaning promoting awareness,

openly discussing and actively detecting UI and

providing simple and efficient therapy.

b) Models of continence care

Continence care was defined by the Canadian

Continence Foundation as “all measures directed

toward the prevention, improvement and or mana-

gement of urinary incontinence” [89]. In this chapter,

anal and faecal incontinence will be included within

the concept of continence care.

1654

As noted above continence care is well suited to

management in the primary care setting. A range of

models are described below.

1. S

INGLE SPECIALIST MODEL - This is a service led by

a consultant or specialist physician (urologist,

gynaecologist or urogyaecologist), often focused

around an “urodynamic unit” providing medical or

surgical treatment. This is the most common model

in developed countries; the best of them have a nurse

continence advisor or continence nurse specialist as

an integrated part of the service.

In some countries, physiotherapists (PTs) have also

developed a specialized practice with incontinent

patients. In France, all women, after childbirth, are

entitled to a maximum of 10 sessions of pelvic floor

muscle physiotherapy, paid for by the government. In

Australia, Scandinavia and the UK, research on PFMT

has been led by PTs. However, there is a lack of

consensus as to best practices for UI. In a postal

survey of British PTs, many were providing specialized

service. Gynaecologists were the most common

source of referral. The majority said physiotherapy

was the first line of treatment. Pelvic floor muscle

exercises and electrical stimulation were the most

used modalities. However, there was little consensus

about optimum treatment regimes amidst a wide

variety in the details of therapies used [90].

2. N

URSE CONTINENCE ADVISOR MODEL - The nurse

continence advisor (NCA) may be independent but is

usually associated with community/area health centres,

where they may have variable professional support

from general practitioners (GP) and family physicians.

Continence nurses often work in both hospital and

community, and the service is focused on primary

care, particularly district nurses. Key roles include

patient assessment and implementation of

conservative management strategies where appro-

priate and facilitating patient access to incontinence

product subsidies or schemes.

The Department of Health in the UK has commissioned

an evaluation of different models of nursing services,

with and without specialist NCAs. It was found that

where there is a continence nurse, incontinent people

are more likely to receive targeted referral to specialists

such as an urologist, and are more likely to have had

investigations such as urodynamic testing and to

receive more appropriate treatment and care for their

UI. These patients were also more likely to report

satisfaction with the service. In contrast there is still

concerns that general nurses continue to “contain the

problem” instead of promoting continence despite

acknowledging its importance [91].

In a series of studies performed in Leicestershire UK,

the short and long-term outcomes of a new CNP-led

service for urinary symptoms (3 and 6 months after

implementing the program) were examined and

evaluated [87, 92, 93]. Williams, et al. [93] reported

on a randomized, controlled study of 3,746 community-

dwelling individuals greater than 40 years of age (61%

women) who had incontinence, frequency, urgency,

and nocturia all impacting QoL. The experimental

group was comprised of 2,958 patients. The standard

care was the control group (n=788) who accessed

GP services and existing continence services in the

area. The experimental group received an 8-week

primary intervention package by the CNP (21 generalist

nurses who trained as CNPs), delivered evidence-

based behavioural interventions using predetermined

care pathways in four visits over an 8-week period.

Interventions included advice on diet, fluids, BT, pelvic

floor muscle awareness and healthy eating. Individuals

whose symptoms persisted after primary intervention

were offered urodynamic testing. The CNP led service

had a 10% higher cure rate than standard care with

statistically and clinically significant reductions in

urgency, frequency, nocturia and UI. In addition, QoL

improvements were greater in users of the CNP led

service and higher levels of patient satisfaction were

achieved. This is the first study to show the

effectiveness of nursing services on urinary storage

symptoms (rather than simply incontinence) and

associated QoL. The authors noted that the public

health value of a 10% reduction in symptoms is

substantial when applied to such a common problem.

A similar RCT in Australia compared outcomes in 145

women presenting with stress UI, with or without urge

UI, randomly allocated to a standardised regimen with

the NCA or treatment by an urogynaecologist [94].

After 12 weeks, 110 women were evaluated. Sixty-four

percent (n=58) of the NCA group and 52% (n=52) of

the urogynaecologist group were asymptomatic with

a dry pad test. There were no significant differences

between the groups for incontinence scores, pad test

changes, voids/day or scores on Urogenital Distress

Inventory or Incontinence Impact Questionnaire. The

treatment by the NCA took a median of 160 minutes,

but cost AUD59.20 compared with 90 minutes of

gynaecologist time at a cost of AUD189.70. At 2.5

years, 29% of the NCA group and 41% of the other

group were dry. The authors concluded that similar

results were achieved at lower cost using the NCA.

An additional number of studies support the efficacy

of specialist NCA in the delivery of community

continence care [72, 95, 96]. In the U.S.A., urology

nurses have been trained as “teachers” to successfully

implement behavior modification program to groups

[97].

In the U.S.A., there has also been an increase in

nurses who specialize in dealing with patients with

pelvic floor disorders including UI, FI, POP and

BPS/IC/PBS, although there are no academic or

clinical proficiency requirements in order to be

considered a CNP or “continence nurse specialist.”

Those nurses who do specialize in continence care

have obtained their knowledge and skills through self-

1655

motivated activities [98]. Masters prepared or educated

“advanced practice nurses” (APNs) have become

increasingly interested in and knowledgeable about

the assessment, diagnosis, and treatment of people

suffering with UI. These nurses are developing a

nursing subspecialty in the care of individuals with UI

and related pelvic floor dysfunction and provide

comprehensive assessment and treatment (drug and

conservative therapy) and act as educators and

researchers [25].

A 2000 study in the U.S.A. demonstrated significantly

improved outcomes for three clinical problems: UI,

depression, and pressure ulcers when advanced

practice gerontological nurses (APNs) worked with

nursing home (NH) staff to implement scientifically

based protocols [99]. In addition to working with NHs

to provide resident evaluation as physician extenders,

this research indicates that this service model using

an APN can be an effective link between current

research based knowledge about clinical problems

and NH staff. This study also showed that consistent

educational efforts with staff and NH residents

demonstrated that interventions could improve or

stabilize the level of UI in these individuals.

In some countries the NCA is attached to a district

nursing service providing expert advice and support

for non-specialist nurses with patients who have

continence problems.

3. M

ULTIDISCIPLINARY RESOURCE AND REFERRAL CENTRE

MODEL

- Multidisciplinary clinics, as service models,

have been shown to provide comprehensive

continence care. In multidisciplinary clinics, such as

a “Pelvic Floor Clinic”, gynaecologist, urologist,

colorectal surgeon, and continence nurse work

together [100]. Some pelvic floor clinic staffing models

also include physical therapists and registered

dieticians.

An Australian study took all community referrals of

those who had been incontinent for at least two months

and had at least one episode in the preceding 2 weeks

to a continence clinic. [101]. Patients were randomised

to conservative treatment or control, with a crossover

design. Patients were asked subjective questions

about embarrassment, odour, depression, family

relationships, isolation and laundry on a 4-point scale

ranging from no effect to major effect upon life. The

questionnaire was completed at the start, and at 2, 4,

8, and 12 months. Seventy-eight patients entered the

study: 87% improved with treatment (vs. 41% controls).

Fifty-two percent were moderately or severely

embarrassed at the start of the study period, but at 4

months, only 17% were. Depression decreased from

49% to 22% and isolation from 28% to 12%. Odour

and the use of extra laundry also decreased. All

benefits were maintained at 12 months. Controls did

not improve on these items until crossed over to active

treatment, despite feeling better. The authors conclude

that conservative treatment in a multidisciplinary

community clinic improves continence and well being.

The Continence Foundation of Australia is funded by

the Australian Government to employ continence

nurse advisors in the National Continence Helpline to

provide advice to consumers and health professionals,

including referral advice. Evaluation of the helpline

by Deakin University showed the majority of callers

took action to improve the incontinence issues they

enquired about and, the most common course of

action following the phone call was to change how they

dealt with incontinence [48].

An expansion of this service provision is exemplified

by the National Centre for Continence in Israel, which

aimed to provide an integrated service [102]. The

Center’s professional team not only treats incontinent

patients but also educates GPs and nurses who come

from pre-selected peripheral/outlying clinics, and

provides ongoing support and advice as well as a

pathway for tertiary referral. A local team (GP and

nurse) are also selected to be in charge of promotion,

detection and treatment of incontinence at the clinic.

They later become “in charge” of incontinence in their

region. This model allows national distribution of

continence services with support from the resource

centre and provides interdisciplinary exchange, as

well as, maximum co-operation between Medical

Centres and community health services. The national

centre is funded by government and industry to provide

a “Hotline” for the public, to promote education

programmes in nursing and medical schools, hospitals

and nursing homes, and to develop guidelines for

diagnosis and management of incontinence by primary

healthcare staff.

A report on continence care services worldwide noted

that services were scattered, inconsistent and

considerable discrepancies exist in their funding. It was

concluded that there is a need for accessible (and

affordable) continence care and multidisciplinary

teamwork [103].

4. P

RIMARY CARE MODEL - There are many factors that

can persuade health care planners about the

importance of adequate investment in community

continence services: the prevalence and the number

of incontinent people is likely to increase with an

aging and increasingly dependent population and

many frail, disabled or elderly people are incontinent

for reasons extraneous to the urinary system (such

as poor mobility, an inappropriate physical environment

or lack of an individualised care regime). It is often best

to provide an initial assessment for such individuals

in their usual surroundings and to reserve hospital or

clinic (specialist or academic) referral for those who

do not respond to simple measures such as treatment

of constipation, modifying a diuretic medication, or

provision of accessible toilet facilities. A number of

guidelines have suggested an algorithmic, step-wise

1656

approach to assessment and treatment of urinary

incontinent patients and many conservative treatments

have a good success rate in primary care [104, 105,

106, 107,108].

A New Zealand study of 600 family physicians found

that most respondents provided continence care and

2.6% offered special clinics for continence promotion

[109]. Fewer than half felt confident to diagnose the

causes of incontinence. Confidence in managing

incontinence in children was consistently lower than

for other childhood problems. There was no difference

by sex in confidence, although female respondents

were more likely to consider management of

continence care as part of a practice nurse’s role and

to routinely ask women about UI during a “well” visit.

Most respondents (71.9%) could not remember having

had any formal training in the management of

incontinence either at the undergraduate or

postgraduate level. Recall of postgraduate education

was associated with greater levels of confidence in

management of incontinence problems.

Family physicians have been shown to be successful

in treating UI. A UK study examined assessment and

treatment of 65 women, who were treated according

to their type of UI [110]. Those with stress UI were

treated by PFMT, those with urge UI by BT and

medication, and those with mixed UI by both. Patients

with stress UI or urge UI, but not mixed, improved

compared to controls at 12 weeks. A Dutch study of

110 women reporting UI to a family physician was

randomly assigned to the treatment or control group.

Treatment was PFMT for stress UI and bladder training

for urge UI [81]. Patients were interviewed at 3 and

12 months, with crossover at 3 months for controls.

At 3 months, 60% were dry or only slightly incontinent.

Mean wet episodes were down from 27 to 7 per week.

Seventy-four percent felt improved or cured and there

was further slight improvement at 1 year.

A study in a community clinic in Israel showed that after

training, family physicians detected 98 patients with

UI during a period of 19 months [111]. Mean age of

the 94 females and 4 males was 71years (range 56-

89). Most patients (53) were detected by the physicians

on direct questioning, some by nurses (29) and only

18 by self-referral. After a mean follow up of 10 months,

35 were dry and 32 significantly improved. Cure or

improvement was achieved at the clinic with no

involvement of an urologist or gynaecologist.

5. O

THER SERVICE MODELS - Acute or sub acute care

to community- Patients with UI who receive care in

acute care hospitals have been shown to lack

appropriate care because of the lack of knowledge

amongst acute care nurses about assessment or

management of UI [112] Nursing education will have

to change to affect this situation. The value of tackling

this is shown in a retrospective review of 6,773

episodes of care in 54 medical facilities [113]. The

discharge destination was altered by the presence

or absence of UI – 57% vs. 82% being discharged

home, respectively, and 29% vs. 12% being discharged

to a nursing home or other health care venue. In

addition, the time in rehabilitation was 185.6 days

with UI compared with 156.8 days without UI, and

geriatric costs in evaluation and management were

higher in the UI group. The level of functional

independence and motor function also impacted

outcome.

Elder services (e.g long term care or nursing

homes) There is growth worldwide in the use of APN

“continence” specialists practicing in home care and

LTC settings, providing expert consultation in UI and

related disorders [25, 98]. Many have developed

innovative approaches to management of UI in nursing

homes. Bucci [114] developed the CHAMMP

(Continence, History, Assessment, Medications,

Mobility, Plan) tool to educate nursing home staff in

the U.S.A. on a comprehensive continence

assessment and to assist in implementation of

individualized plans of care. The CHAMMP program

improved one facility’s Quality Measure Indicator

Report. ICI Committee 11 discusses services for frail

elders.

Services in developing nations - The potential

demand for UI services in developing nations far

outstrips the resources that are available. The provision

of services will depend on dedicated healthcare

professionals with support by government or industry

and by a local continence organisation to educate a

new generation of service providers who will carry

the services to remote communities. In some

instances, consideration will have to be given to

cultural, social mores and taboos.

For example Ethiopia’s Health Minister has stressed

the need to develop rural health services to reduce

the incidence of fistula and to have first time mothers

examined by Traditional Birth Attendants (TBAs). The

ICI Committee 18, Vesico vaginal fistula in the

developing world addresses service for this specific

condition. It is planned that TBAs will be trained to

identify high-risk women, and thereby divert

expenditure from high cost physicians and urban

health services to training community health workers

and health education. Attitudes on female circumcision,

contraception and women’s health, which are often

decided by their husbands, obviously have much

wider implications than just continence care.

Continence services are a relative luxury, to which

countries with a low per capita income are unlikely to

devote scarce resources whilst other population health

issues have precedence. For example, in Brazil,

priorities for their health budget are childhood

immunizations, AIDS/STDs, basic sanitation, healthy

environment and literacy to help with the problem of

street children.

1657

c) Worldwide organisations

The stigma associated with incontinence is similar to

other conditions and is associated with public

ignorance and lack of awareness [114]. Despite all this,

it is important to understand how attitudes and stigma

have changed for these conditions. An important

component is breaking the cycle of public and personal

ignorance through education and public awareness

programs. Patient advocacy organisations for UI have

been formed worldwide to promote awareness. But

for any advocacy group to be successful, there needs

to be a partnership between health care professionals,

governments, and industry groups with a vested

interest to work together to break the cycle of ignorance

and negative attitude.

Professionals (e.g. urologists, urogynecologists,

gynaecologists, primary care practitioners, physio-

therapists, nurses) and professional organi-zations

have been instrumental in promoting awareness of

continence in all care settings. The International

Continence Society (ICS) established the Continence

Promotion Committee (CPC) to promote education,

services and public awareness about incontinence

throughout the world, and to facilitate communication,

exchange of information and partnerships between

continence organizations, health care professionals,

governments, and industry. The CPC’s multinational

and multidisciplinary representation aims to identify

broad issues through an international forum that can

facilitate translation at the local and national level.

Each year at the ICS’s annual meeting, the CPC has

held workshops around various themes that have a

broad national focus such as prevention; general

practitioner education; and promotional strategies. Its

relevance, as is the case with each of the national

organizations, is to recognize the interface between

continence management and continence awareness

and promotion. The CPC is increasing continence

awareness through the hosting of Public Forums in

conjunction with the ICS annual meeting. In 2009, it

will sponsor World Continence Week.

Although it may not be practical to develop global and

uniform strategies for continence promotion and public

awareness, much can be learned from the positive and

negative experiences of other organisations in other

countries.

Continence promotion is a most challenging endea-

vour. Although the ratio between affected patient

populations and continence organisations funding

has not been formally studied, anecdotal information

suggests that fund-raising for continence programmes

is among the most difficult of medical problems for

which to obtain funding. In view of all these challenges,

the proliferation of new continence organisations,

especially in the Far East and in South America, is a

validation of both the need for continence promotion

and the dedication of those who have recognized and

are addressing this need.

1. C

ONTINENCE ORGANISATIONS In the past fifteen years,

several national organizations have been formed

under various auspices to tackle issues to do with

incontinence awareness, education and promotion.

Organizations which promote continence are as

diverse as the cultures they serve. They represent a

wide diversity of models, including consumer-led,

company sponsored, patient-only, professionals only,

and organizations which have deliberately set about

trying to bring together all relevant stakeholders in a

relatively democratic model. In every part of the world,

these organizations play a dynamic role in building both

public and professional awareness of this underserved

and underreported condition.

Most continence organizations are poorly capitalized,

being either under- or unfunded (i.e. run by volunteers)

and are held together initially by either a dedicated

patient advocate or an energized healthcare

professional. In most cases, this professional is an

urologist or nurse whose patient population includes

persons with UI.

As of 2008, there are 47 Continence Organisations

in 34 countries world wide with an additional 2

international patient-based organisations. Appendix 1

is a directory and provides the contact details of

various national continence organisations. Most of

them function as multi-disciplinary bodies. The previous

ICI chapter published results of a survey conducted

on these organizations [117] Findings include:

• More than 50% of these organizations have been

in existence for more than 10 years and that

membership includes both professionals and the

public.

• Organizations have oversight from advisory boards

consisting of consumers (lay public) and health

care professional members.

• Most have developed medical guidelines for

continence care which represent solo efforts by

the organization or in collaboration with the medical

community and the government.

• Funding is an ongoing challenge for most of these

organizations. Very few receive government funds,

and most rely on support from industry or

manufacturers of drugs and products for specific

projects.

• Continence awareness is being provided generally

to a public that has ‘very little’ to ‘no understanding’

of incontinence.

• There is now an increase in media interest in

continence

Education about incontinence has been identified as

the most important method to decrease the perceived

stigma associated with the disease. A successful

method to educate has been through public awareness

campaigns, health promotion projects, or health fairs.

1658

Information is provided on the internet through

websites developed by each continence organization.

These websites provide useful information on

incontinence, what it is, and how it can be managed,

treated, and cured. They provide frequently asked

questions (FAQs) as well as useful links to other

continence related websites.

A needed service identified by several organizations

concerns the management or containment of urine

leakage through the use of products and devices. A

guide to continence products has been developed by

many organizations and is available to the members

as well as health care professionals. This is aimed at

providing useful information about the range of different

products available.

Most have developed a directory of health care

professionals who have expertise in the area of incon-

tinence and its management. Certain organizations

have this directory available through their website.

Organisations that primarily target the general public

typically do not participate in educating professionals.

Those countries where a consumer-based organisation

does not exist do engage in educating professionals

as well as raising the awareness of incontinence to

the population in general. In those countries that have

consumer-based continence organisations, there are

national public awareness campaigns (e.g. the U.S.A.

has a designated Bladder Health Week every fall and

November is Bladder Health Awareness Month). It is

generally felt that media coverage is inadequate.

However, in a recent article, the NAFC (U.S.A.) strongly

advocates enlisting the help of the media as one of

the 3 main strategies that will help to improve the

quality of life for many incontinence sufferers in future

[57].

There is a paucity of published work on the formation

of national organisations that target consumers or the

general public. The level of evidence on the impact

of national organisations increasing continence

awareness is Level 3.

2. N

ETWORKING OF CONTINENCE ORGANISATIONS While

there is little data on the outcomes of the use of

organisations to change consumers’ views and

awareness of incontinence, sharing of experience

and collaboration amongst countries could lead to

more efficient use of resources. For instance, in 1998,

the Asia Pacific Continence Advisory Board (APCAB)

was established with a mission to develop Continence

Promotion programmes that work together with health

care professionals and the general public to develop

strategies to increase awareness and reduce the

social burden of UI in the Asia Pacific Rim.

The APCAB member countries are Thailand, Korea,

China, Hong Kong, Taiwan, Malaysia, Indonesia, India,

Philippines, Singapore and Pakistan.

d) Recommendations for Continence Advocacy

LITERATURE SEARCH

The online databases Medline, Embase, Biosis,

Science Citation index, Web of science and Cinahl

were used to obtain the literature, additional databases

of ERIC (an education database) and psychlit were

also searched. The focuses of the searches were

between 2004-2008, although literature from the

preceding 10 years was also scanned to ensure

thorough coverage. The objective was to obtain

relevant literature relating to incontinence education.

The following search terms were used: incontinence,

overactive bladder, health education, education, allied

health care professionals, doctors, nurses, consumer,

and public education. There was significant overlap

between the searches made on different databases

as would be expected. The search largely identified

the literature already used for the chapter in 2002/2004.

Additional references from the preceding 4 years were

included and references found which had not been

previously identified were also incorporated.

III. PROFESSIONAL EDUCATION

Based on the literature reviewed in this section, the

following recommendations can be made:

• Government support and co-operation are

needed to develop services, and responsibility

for this should be identified at a high level in each

Health Ministry. Incontinence should be identified

as a separate issue on the health care agenda.

There is a need for funding as a discrete item

and for funding, not

to be linked to any one

patient group (e.g. elderly or disabled), and

should be mandatory. (Grade D)

• No single model for Continence services can be

recommended. In all health care systems, much

will depend on the local health care structure.

Because of the magnitude of UI, prevalence,

detection and basic assessment will need to

be performed by primary care providers.

Specialist consultation should generally be

reserved for those patients where appropriate

conservative treatments have failed, or for

specified indications. (Grade D)

• There is a need for research on outcomes, not

just the process of service delivery. This research

should have patient-focused outcomes, evaluate

the outcomes for all sufferers who present for

care, use validated audit tools/outcome

measures and longitudinal studies of the

outcomes of services provided. (Grade D)

• There is a need for cost-effectiveness studies

of services currently being provided. (Grade D)

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1. BACKGROUND

With the continued advances in health care, increasing

public pressure to provide high quality evidence based

care, limited time for health professionals to update

their knowledge and the recognised ineffectiveness

of passive ‘lecture style’ education provision, the need

for new models to change health care providers

behaviour is essential. Nowhere is this more relevant

than in the provision of care for those with UI and FI

where traditionally educational provision has been

inconsistent at best.

Professional education is a key component in the

provision and care of individuals with UI and FI. In their

state-of- the-science statement on the prevention of

faecal and urinary incontinence, Landfeld et al [1]

identified that education of health care providers alone

is insufficient to improve detection and treatment of

UI and FI. However they recognise that in order to

appropriately detect and evaluate incontinence,

professional education is required along with outreach

and practice based resources. To date, the education

and training of those involved in the provision of

continence care has been poor.

It is well recognised internationally, that continence care

provision in the area of UI has developed at different

rates within differing care models, resulting in scattered

and inconsistent services [103]. There are wide

variations in health care professional input and a lack

of continuity of care between primary and secondary

care providers [117] Central to the provision of high

quality continence care is the education of the

individuals providing care, including physicians, nurses,

and allied health care professionals. There is limited

literature on the educational preparation and ongoing

training of those health care professionals engaged

in continence promotion, care, and referral and even

less on the evaluation of education programmes in

terms of educational or practice outcomes. It has long

been recognised that professional education with

reference to UI and FI remains only a small part of the

basic training of physicians, nurses, or allied health

professionals and on-going training is largely ‘ad-hoc’

with huge variations in the types, content and quality

of such training. An early survey in the UK found

minimal attention given to incontinence in both medical

and nurse training, and a key recommendation for

improving continence care was an increase in quality

and quantity of professional education [117]. This has

clearly not occurred. While educational initiatives have

been undertaken, they remain fragmented and

inconsistent internationally. Most notable is the

absence of evidence demonstrating an impact of

professional or public education on the burden of

suffering posed by OAB and UI. The ICS has

established an Education Committee to promote,

organise and co-ordinate all educational advances

undertaken under the auspices of the ICS. This

promises to be a step forward in defining core

competencies and educational goals and objectives

for trainers and trainee alike. Subcommittees in

medical student and resident education, nurse

education, physiotherapy education have been

established. Though to date, educational initiatives

are broadly medical. Details are available on the ICS

website (www

.icsoffice.org).

There is a paucity of published work on professional

education on UI or FI. Similarly, there are few studies

addressing the effectiveness of education in improving

the knowledge of learners, or on whether improved

knowledge impacts on patient outcomes. Since the

publication of the ICI chapter in 2005 [116], the

evidence has been building but the level of evidence

on the effectiveness of professional education remains

This section will examine the available evidence on

the effectiveness of professional education on

incontinence for different groups of health care

professionals.

2. PHYSICIANS (FAMILY PHYSICIANS/ GENE-

RAL PRACTITIONERS/PRIMARY CARE

PHYSICIANS)

Physicians (general, primary care, and family

physicians) often have a gate-keeping role in

continence provision as they are often the most likely

first point of contact when patients seek formal help

for their incontinence [118] They may refer their patients

to other health care professionals in primary care,

such as a continence advisor (nurse or other allied

health care provider), or, to a specialist in secondary

care. Physicians provide this service without having

undergone essential training in the management of

patients with urinary symptoms, as this is largely

unavailable.

a) Medical education

Most physicians have received little education about

incontinence, fail to screen for it, and view the likelihood

of successful treatment as low [119]. At the same

time, there are no data confirming the benefits of

screening as a method to reduce the burden of

suffering from UI. A postal survey noted that only 18%

of respondents said providers asked them to complete

a questionnaire about bladder control during routine

office visits and a majority (69%) felt it would be very

helpful in prompting discussion if their physician or

health care professional provided a form for them to

check off symptoms of incontinence [50].

Traditionally, UI and FI have formed only a very small

part of the undergraduate medical curriculum.

Education on UI has usually been fragmented across

different organ systems, with training scattered

between gynaecology, urology, and geriatric medicine.

Bladder and pelvic floor anatomy is poorly covered in

preclinical training and relevant physiology is rarely

1660

mentioned. A survey of urology residency directors,

medical student educators in urology, and urology

applicants identified UI as one of the 8 most commonly

cited topics to be included in a core urology curriculum

[120]. Co-ordination between the disciplines is rare,

although there are some international examples of

joint seminars/modules on urinary and faecal

incontinence (University of New South Wales) and

inter-disciplinary input into curriculum (University of

Newcastle). Minimal training is provided on paediatric

continence issues.

There is a clear history of inadequacies in continence

care which have been acknowledged for some time.

In 1983, the Incontinence Action Group published a

report [121] which identified ‘the huge gap which exists

between available knowledge of the causes and

methods of management and that which is actually

known to practising nurse and doctors.’ In their review

of the evaluation and treatment of women with UI in

the primary care setting, Walters and Realini [122]

found that UI can be diagnosed accurately by family

physicians using basic tests.

A later study found that outpatient geriatric assessment

units were better than physicians in community based

practices at identifying patients with both mild and

severe incontinence [123]. There is clear evidence

that there is a need for further education of health

care professionals. Brocklehurst [118] found that less

than 25% of patients with UI were given a full

examination by their GPs. Deficits in the knowledge

of GPs about UI were found by Jolleys and Wilson

[124] in a survey of 1284 GPs. They also found that

GPs lacked confidence in their abilities to diagnose

and manage UI, although this lack of confidence was

not related to length of practice as a GP. In an analysis

of incontinence in the community, the action taken by

many GPs was found to be suboptimal, with

considerable geographical variation [125]. Fewer than

5% of those who consulted a doctor in this survey

were referred to a nurse or incontinence clinic. It also

suggested that medication was often prescribed

without clinical examination and probably without a

diagnosis being made. In a study by Briggs and

Williams [126], 42 of 101 general practitioners

surveyed never used the service of a continence

advisor for older patients although the service was

available to them.

There have been efforts to educate family physicians

in Australia; in 1989, the New South Wales state

government gave AUD 25000 to the Continence

Foundation of Australia to develop an educational

package (15000 copies) on incontinence to be

distributed to all family physicians in the country [127].

An evaluation of the package was undertaken to

determine whether the package significantly improved

knowledge of incontinence. There was no difference

in initial knowledge between the intervention and

control groups, but there was a significant difference

in post-pack scores between the groups with no

difference in scores on questions not in the pack.

Sixty-three percent continued to use components of

the package later in clinical practice. However,

response rate from the 510 family physicians contacted

was only 16%.

Two studies have reported that family physicians can

be effective in treating UI by using conservative

treatments when educated and motivated [95,128]

with cure or improvement rates reported at 60 - 70%.

Education can also increase referral rates to specialist

practitioners [129]. However, the best format for

education initiatives to all professionals needs further

delineation. The use of road shows (e.g. continuing

medical education [CME] seminars), teleconferences,

guidelines, booklets and face-to-face teaching are

commonly used but rarely evaluated.

There is very little available literature on knowledge

amongst family doctors on faecal incontinence. A

study has recently been undertaken to explore GPs

awareness of surgical treatment options for FI. [130].

A postal questionnaire was mailed to 1,100 GP’s in

Yorkshire region in the UK, a response rate of 48.5%

was achieved. The questionnaire assessed basic

knowledge of FI and treatment options. Overall

knowledge was poor, with the majority unaware of

available investigations, treatments and specialist

centres. The authors recommend better commu-

nication between specialist centres and GPs, as well

as CME programme implementation.

There is growing evidence to suggest that traditional

‘lecture style’ medical education is ineffective in

changing physician behaviour and ultimately patient

outcomes [131]. More innovative teaching methods

are clearly required. Levine and colleagues [132] used

a train-the –trainer model to evaluate the management

of a number of common geriatric conditions including

incontinence. This model involved training, by an

expert faculty, a team of non-expert peer educators.

These peer educators used a toolkit, to conduct small

group learning sessions.

These sessions were evaluated immediately after

and 6 months after the education sessions. The model

used principles of knowledge translation and active

teaching using tool kits based on guidelines to train

geriatricians. Results showed statistically significant

improvements in self reported knowledge, attitudes and

office based practices. The study concluded that

modest changes in practice in relation to geriatric

conditions were achieved using this peer led approach.

Whilst such evaluations are promising, such models

are difficult to sustain and costly. Perhaps most

importantly they point to the need to use innovative

teaching methods to ensure that educational efforts

actually make a difference.

1661

b) Medical specialists

There is little new published evidence on medical

specialist training in the form of effective training

interventions. Specialist training in incontinence is

not always adequate. A survey of urological trainees

between 1988 and 1994 in Australia showed many felt

their training in the management of incontinence had

not been adequate [133]. The Colleges of Obstetrics

and Gynaecology in the United Kingdom and Australia

and the American Board of Obstetrics and Gynae-

cology have developed courses and credentialing of

specially trained urogynaecologists with separate

examinations. Similarly, both the American Urologic

Association and the European Board of Urology

conduct courses, CME programmes and set standards

in UI management. However, both UI and FI still may

be perceived as exclusive to “super-specialists,”

potentially alienating colleagues.

A survey of 163 urodynamic services in the UK found

that half the respondents felt their training in

urodynamics was inadequate [134]. This led Ellis-

Jones and colleagues [135] to explore whether a

recognised education and training programme for

urodynamics led to changes in urodynamic practice.

They asked programme delegates to complete a

questionnaire (n=84) pre and post education

programme and found that 79% reported a change in

practice following completion of the course. This type

of evaluation of an education programme is essential

to determine the value of such courses, however the

evaluation of programmes are often undertaken by

those delivering the programme and the need for

independent evaluation should not be underestimated.

Committee 7, Dynamic Testing, of the ICI recommends

that invasive urodynamic studies should be performed

in accredited urodynamic laboratories, by trained and

certified staff, with formal control of the quality of the

results. This committee highly recommends the

establishment of national accreditation, training,

certification and quality-control programmes.

3. NURSING PROFESSIONALS

Nurses have a significant role to play in the area of

incontinence as they are the largest single group of

health care professionals around the world and are

often the first to become aware that the patient is

experiencing incontinence. Cheater and colleagues

[136] found that in the UK, an average community

nurse case load will comprise approximately one-

third of patients with UI. There have been a number

of recent studies which explore the use of new

innovative methods of education provision for nurses.

Rogalski [137] reports persistence in the lack of

educational emphasis on common symptoms like UI

and recommends a curriculum model based on

existing guidelines and the best available evidence

which could address this shortfall and would increase

the quality of continence service provision.

A common theme that runs through the international

nursing literature over the past two decades is that

nursing staff recognise a lack of knowledge of UI and

indicate that they would like further training [138, 139,

140]. There are significant gaps in knowledge and

clinical practice adoption related to both UI and FI

although nurses worldwide have played a major role

in developing new information and testing interventions

[141]. Although nurses can provide effective

interventions in the area of UI, there is limited research

on effective interventions for FI.

Innovative methods of improving knowledge amongst

nurses have undergone recent evaluation. An

important study undertaken by Cheater and colleagues

[142] adds to the debate by examining the value of

audit and feedback and educational outreach which

in the past has often focused on doctors’ behaviours

rather than nurses. In this study, the researchers

undertook a cluster randomised trial to evaluate 194

nurses in 157 family practices with 1078 patients with

a diagnosis of UI. They found that when compared to

educational materials alone, there were no

improvements in care for either educational outreach

or audit and feedback (all groups did improve but

differences between groups were not significant).

McConnell et al [41] describes how advanced practice

nurses learned evidence based approaches to

managing complex cases including incontinence in

nursing home residents. Advanced practice skills

included assessment and diagnosis appraisal of

evidence for management. The authors suggest that

such practices can enhance both student and facility

outcomes, although no systematic evaluation was

undertaken.

Ostaszkiewski [143] describes a nursing leadership

model to enhance continence care in older adults.

Evaluation of the programme suggests improved

management and assessment of incontinence for

individuals sustained after a two year period.

Leadership programmes have proved effective in a

number of areas in nursing provision.

Within these more recent studies, the use of innovative

methods of knowledge transfer and education are

beginning to be adopted, such methods, used in other

areas of professional education may be well suited to

UI and FI.

Some self-study materials have been developed which

link issues on continence care with other regulatory

and policy content such as recognition and reporting

of elder abuse and neglect [144].

a) Specialist nurses

Educational courses on incontinence are available

for nurses in the UK, U.S.A., Europe and Australia and

are beginning to appear in Asia, notably Hong Kong

and Singapore. These courses vary from 2 to 4 weeks

of face to face didactic courses to distance learning

1662

courses lasting 4 to 6 months that lead to a post-

basic nursing certificate.

In the UK, education programmes are documented at

the Association for Continence advice website

(http://www

.aca.uk.com/education_modules.php) and

comprise information on 1 day courses as well as

diploma courses, degree modules and masters level

study. Such databases of courses offer an excellent

overview for students and providers.

Williams et al [145] conducted a small study in the UK

that showed improvements in both knowledge and

attitudes of nurses who undertook a specially designed

full time, 3 month programme that included a

continence module.

Internationally, there is inconsistency in the provision

of specialist education to prepare nurses to practice

as experts in the field of incontinence. Programmes

of study are developed, but rarely fully evaluated. The

need for innovative web-based learning programmes

incorporating modern information and communication

technology (e-learning) may offer one way of providing

standardised programmes of study to practitioners.

Beitz and Snarponis [146] describe their innovative on-

line learning programme which includes continence

nursing. They feel that such teaching strategies are

acceptable to nurses.

As with physicians, it is unlikely that improving nursing

knowledge alone will translate into improved clinical

practice, or into the ultimate goal of improved patient

outcomes. A review of hospital policies and community

nursing practice in an area with a well-established

continence service and education program

demonstrated very little evidence that improved

education had a tangible effect on practice [147]. The

authors concluded that nurse specialists are most

usefully employed providing a clinical service to

individual patients rather than spending their time

educating other nurses.

There is a lack of consensus on what should be taught

to different nursing groups at each educational level.

It is not clear how educational needs can be met or

who will pay for the time and expertise required to

provide educational initiatives. Governments, as

primary payer of nursing home care, have a vested

interest in promoting continence in order to minimise

costs. It is likely that the continent nursing home

resident requires less nursing time than an incontinent

resident. It therefore falls to the payer to underwrite

the education that is needed to promote continence.

In the U.S.A., the Centers for Medicare and Medicaid

Services has developed a “guidance” for UI care in

nursing homes and provided web-based education

to staff. (www

.cms.internetstreaming.com)

More emphasis on incontinence care and the nurses’

role in continence promotion should be encompassed

in basic nurse training courses. Specialist continence

nurse practitioners and nurse continence advisors

are likely to be the best instructors to provide this

education.

Standard Setting, care pathways and level of

continence knowledge - Standard setting has been

one method by which general nurses can acquire

skills to meet set standards of practice. But a more

effective method may be care pathways which map

out a timed process of patient-focused care which

specifies key events, tests and assessments to

produce the best-prescribed outcomes, within the

limits of the resources available, for an appropriate

episode of care [148].

The use of Continence Care Pathways has been

evaluated amongst generalist nurses. It was found

that the use of such pathways has aided in the

identification of reversible causes of incontinence

(e.g., UTI, medication, fluid intake, constipation,

dexterity and mobility issues), and addressed poor

quality of life and bothersomeness issues [149]. In a

recent audit of 144 continence care providers in the

UK, this group found that nearly half of them were

using the guidelines and found them to be effective

in helping with assessment and management of

patients [150]. By using care pathways, patients could

be referred to specialist nursing care more appro-

priately for specific treatment beyond the scope of

the generalist nurse, or when they failed to respond

to first line therapy. The care pathway identified the

needs of the patient, directed simple investigation

and primary therapy, but also identified the resources

needed by the nurses (e.g., urine testing dipsticks, lists

of drugs, frequency/volume charts). The pathway

could be modified according to the equipment and

expertise locally available. Educating large numbers

of general nurses to follow a simple pathway with

basic continence-care competencies [151] may allow

better use of specialist nursing time and specialized

skills [152].

Jha, Moran, Blackwell, and Greenham [153] conducted

a small study of women attending gynaecology

outpatient departments with incontinence problems.

Thirty-five percent (7/20) patients did not need to see

a doctor as they were symptom free following treatment

recommendations by continence nurses using an

integrated care pathway. The authors felt this process

facilitated earlier diagnosis, improved access to

specialist services and discharge from secondary

care.

The level of knowledge about UI within the general

nursing community appears to be less than ideal in

both the U.S.A. [151, 154] and Sweden [139]. Many

non-specialist nurses (referred to as general nurses)

desire, and have a need for, more education about

what they can do to better manage incontinent patients.

Moreover, the quality of life of the incontinent nursing

home resident is often more dependent upon the skill,

1663

education, and attitudes of the nursing aide than of

the qualified nursing staff.

In an older UK study of learner and qualified nurses’

knowledge, only 12% of qualified nurses had received

any education on incontinence in the previous 12

months, and for those who had, most was on products

[155]. Forty-four percent of charge nurses and 81%

of staff nurses had received no additional training on

incontinence since qualifying. Further work on attitudes

via a questionnaire to qualified nurses on hospital

wards found predominantly therapeutic, rehabilitative

attitudes, but also a number of misconceptions. Twenty

one percent thought their primary role with incontinent

patients should be supplying products and 11% saw

incontinence as an inevitable part of aging. Sixteen

percent agreed that incontinence was often due to

laziness and 28% thought that incontinence was more

distressing for a younger than for an older adult [156].

In a further survey of trained nurses, the author found

that nurses still focus primarily on palliative rather

than therapeutic care and lacked knowledge on which

to base care [157]. However, nurses with a post-basic

qualification or in-service education were more likely

to have positive attitudes, although it was not clear

whether this was as a result of the education, or

whether these nurses already had a positive attitude

and had therefore self-selected to receive further

education.

More recently, Rigby [158] explored whether increased

continence knowledge amongst general nurses

resulted in changes in clinical practice using an

opportunistic sample of 130 general nurses achieving

a 54% response rate to all stages of the study. The

results demonstrated a significant change in

knowledge score for nurses following a continence

study day, but showed that application in clinical

practice of this knowledge posed significant problems.

This study had a number of limitations using a small

opportunistic sample with poor response, however

the real challenge remains of not simply increasing

knowledge, but translating that knowledge into

improvements in clinical practice.

In the U.S.A., although there are a growing number

of nurses who are developing expertise caring for

incontinent patients, there are no academic or clinical

proficiency requirements to be considered a

“continence nurse practitioner or specialist.” In 1993,

the Wound, Ostomy, and Continence Nurses Society

developed the first certification program for continence

care nurses in the U.S.A. The Society of Urologic

Nurses and Associates certifies different levels of

nurses in the area of urology and in urodynamic

testing. The norm is that most “continence” nurses in

the U.S.A. obtain their knowledge and skill through self-

motivated activities. A survey of nurses attending a

national nursing conference on UI asked about

educational preparation related to this condition [159].

Respondents reported that less than half (40%)

received academic education including course work

in accredited post-baccalaureate or graduate

programmes related to UI. However, most nurses

(76%) obtained instruction at professional conferences,

continence clinics supervised by nurse practitioners

or physicians, “on-the-job” training, self-study, or in-

service programmes.

In another UK study of general nurses’ knowledge of

UI, a clinical handbook was evaluated using a pre- and

post-test design with an experimental and control

group [112]. This study showed that the use of the

handbook, which consisted of a decanted, user-

friendly, research-based resource on continence care,

improved nurses’ knowledge of incontinence. A

significant improvement in reported clinical practice

was found for 86% of variables in the experimental

group compared to a 59% improvement in controls.

However, only 54% of those approached agreed to

enter the study, suggesting a general lack of interest

and motivation.

4. PHYSIOTHERAPY AND OTHER ALLIED

HEALTH PROFESSIONALS

Physiotherapists or physical therapists (PT) have long

played a part in continence care and the management

of UI. In some countries, patient self-referral to

specializing physiotherapists has become common-

place. Physiotherapists’ involvement in UI appears

to be either on the basis of individual interest or through

association with women’s hospitals or obstetric

departments, rather than as part of a general

physiotherapy practice [160]. As such, they tend to be

highly motivated and enthusiastic.

Pharmacists have a variety of roles to play in

continence care. In Australia, they have been avid

consumers of continence education programmes. In

2004, the Pharmacy Guild launched an educational

and promotional program for their members with

appropriate outcome evaluation measures. The public

sees pharmacists as important and approachable

sources of health information, especially information

on medicines that may cause or exacerbate UI and

FI. Many retail pharmacies display health promotion

literature on a range of subjects including UI.

Pharmacists may also advise the consumer on

appropriate continence products. Educational seminars

for pharmacists are generally well received. There

are a growing number of CME programmes for

pharmacists on the Internet either through new

products or through sites such as www

.worldwide

Learn.com

which aims for on-line CME for pharmacists

and technicians.

There is also a need to address the training needs of

nursing assistants and aides, particularly in the nursing

home setting. In the U.S.A. and many other countries,

one concern is the high turnover rate among first-line

1664

caregivers in institutional and home care settings,

making it difficult to maintain desired training levels.

Nursing assistants are often the people providing

‘hands-on’ incontinence care and yet, often with the

least training. Certainly, in terms of published evidence

there are few reports of efforts to train nursing

assistants.

Regulatory issues are often linked not only to quality

of care, but also to reimbursement for clinical care and

services. Reimbursement policies for services often

determine which professionals are able to provide

continence care. In the Netherlands, for example, the

government pays for up to 14 visits to a physiotherapist

for incontinence therapy. In the U.S.A., patient’s visits

to a physiotherapist are restricted.

5. IMPACT OF UI GUIDELINES

The development of guidelines, primarily on UI and

more recently FI, has increased significantly in recent

years throughout the world [104,161,162,163,

164,165,166,167,168]. In 1992 and 1996 (revised), the

U.S.A. Agency for Healthcare Research and Quality

(AHRQ) (formerly known as the Agency for Health

Care Policy Research (AHCPR), sponsored the

development of clinical practice guidelines that were

produced to help standardize the assessment and

management of urinary incontinence in adults [104,

161]. Aimed at health care professionals, the guidelines

are widely quoted, but they have failed to impact the

practice of physicians or trainees [169]. A more recent

study in North Carolina, U.S.A. used a multifaceted

educational intervention based on the 1996 AHCPR

guideline in 20 of 41 primary care practices and failed

to show an effect in increasing screening or

management of UI by PCPs [170]. They concluded the

guidelines may not be the best approach to treating

UI in this setting. Similar disappointing results have

been reported in Europe [107]. However, nurses have

used the AHCPR recommendations more effectively

than physicians, incorporating them into curricula,

evidence-based clinical practice, and care pathways

[171. 172, 173].

More recently, Penning-van Beest et al [174] report

on the impact of the Dutch College of General

Practitioners, treatment guidelines for incontinence.

They identified a cohort of women with newly identified

incontinence (n=1663), they found that the majority of

women did not receive active treatment within 1 year

of identification, many received no active treatment and

use of pads was high. They recommend that this lack

of active treatment could be addressed through better

physician education.

Many of the published guidelines focus on younger,

healthy, community dwelling adults. Guidelines for

evaluation and treatment of UI and FI in children and

the elderly population or those with significant

comorbidity need to be developed. These will need to

take into account issues such as cognitive impairment

which can influence continence status in older adults

[175].

Fung [176], in a small study in a large academic

Veterans Affairs medical centre in the U.S.A., used

guidelines to develop condition-specific computerized

templates to serve as guides for clinicians to ask

questions and perform elements of a physical

examination for two specific medical conditions UI

and falls. This study demonstrated that a set of

templates can be developed within an existing

electronic heath record system and can be used to

prompt a clinician to obtain elements of a history and

to perform physical exam elements in relation to falls

and UI.

Changing the current patterns of medical care with

respect to detection and management of incontinence

through education is a difficult task [177]. Guidelines

for medical practice can contribute to improved care

only if they succeed in moving practice closer to the

guideline recommendations [178]. Unless there are

other incentives or the removal of disincentives,

guidelines are unlikely to effect rapid changes in actual

practice. It is recognized that other tools or strategies

are needed to augment and build on educational

endeavours [179]. Strategies that aid in implementation

of a guideline include reminder systems to remember

when to implement guidelines, tracking systems to

identify patients who need follow-up and continuous

quality improvement monitoring and regulations.

Educational programmes alone may change

knowledge and attitude, but rarely change behaviours.

Guidelines combined with continuing medical

education programmes may be more successful [105].

Even evidence-derived guidelines may not always

result in better practice or outcomes. The

implementation and evaluation of such a guideline in

one primary care practice in the UK from which 1503

patients were randomly selected has been reported

[171]. Thirty-five percent of women and 9.9% of men

suffered from incontinence in the previous two months,

but 61% had never sought help. Of those who did, 63%

were referred to specialists, 53% had a urine test, 1

in 4 women had a vaginal examination, and 4 of 206

persons with UI were asked to complete a frequency/

volume chart. After implementing the guideline, two

abdominal examinations and one new rectal

examination were performed, but no new vaginal

examinations were performed. Frequency/volume

charts were given to three people. Two patients used

fewer drugs. The severity of incontinence was

unchanged following the intervention. Family

physicians did not effectively implement the guideline.

It remains to be tested whether, properly used,

guidelines can improve incontinence in practice.

In 2006, a national UK guideline was produced on UI

in women [165]. Within the document the area of

1665

surgeons competence is discussed however there is

no mention of other care providers education and

training (including GPs, nurses, physiotherapists etc).

In order for services to be delivered effectively, primacy

needs to be given to practitioners education and

training in such documents.

In a 1999 repeat of a 1996 survey, among 6481

patients older than 50 years, it was found that after

numerous UI awareness and education campaigns,

German physicians were even less likely to address

incontinence than 3 years earlier [180]. The “don’t

ask, don’t tell” attitude between physicians and

patients, has significant fiscal implications for health

care. The consequence of not treating the condition

may increase the annual cost of care by an estimated

USD 3941 per individual [181]. Funding for conser-

vative management of UI, or better-informed public

demand, may stimulate more interest and improved

performance among this important group. It remains

critically important that PCPs have an understanding

of how to manage UI effectively [182].

DuBeau et al [183] assessed the knowledge and

attitudes of nursing home staff (including directors of

nursing and nursing home surveyors) following revised

U.S. government guidelines on continence care (Tag

F315- http://www

.cms.hhs.gov/transmittals/downloads

/R8SOM.pdf).

They used a questionnaire in a convenience sample

of 558 staff attending workshops. The authors report

striking deficiencies in knowledge amongst staff, and

identified managerial structures as barriers to guideline

implementation. They suggest such barriers need to

be overcome in order to improve the quality of care.

A number of CME programmes for PCPs on UI are

now available through Internet sites. One by the

American Geriatrics Society covers screening for UI,

history taking, ruling out other factors, urinalysis,

behavioural therapy and challenges in impaired people.

Pharmacy Times site offers a free Temple University

program with 2 CME credits on medical management

of UI.

It covers differentiation between transient and

established incontinence, identification of medications

which can contribute to UI and agents which can be

used to manage the various types of UI, how to assess,

choose appropriate pharmacotherapy and identifying

which agents should not be used.

In 1998 the Japan Continence Action Society compiled

a Continence Educational set (CE-set) for profes-

sionals to use in the community. The CE-set comprised

text books, lantern slides, and a CD-ROM based on

current evidence. Fifty five CE-sets were distributed

to Health Education centres in each prefecture. In

2008, only 11 of the CE-sets had been used, whilst

44(80%) remained unused. The single factor that

encouraged use was whether a continence course

had been provided in the region or not.

Realistically the likelihood of obtaining adequate

independent funding for effective professional educa-

tion on UI and FI is unlikely in the current economic

climate.

6. RECOMMENDATIONS FOR PROFESSIONAL

EDUCATION

Based on the literature reviewed in this section, the

following recommendations can be made:

• There remains a need for rigorously evaluated

continence education programmes which

adhere to defined minimum standards for

continence specialists and, generalists, utilizing

web-based and distance learning techniques

alongside audit and feedback, train-the trainer

models and leadership models as well as

traditional methods. The following should be

considered:

- Compulsory inclusion of a specified number

of hours of incontinence education in the

basic curriculum (physicians, nurses,

physiotherapists and other allied health

professionals). Ideally incontinence should

be identified, planned and taught as a

separate topic.

- Specific education programmes adhering

to approved standards should be reported

to a recognized central body linked to

appropriate evidence and guidance.

- Where possible, education programmes

should be independently evaluated using

appropriate research methods.

(Grade D)

• There is a need for research on the most

effective means to educate professional groups

on continence issues. Specifically, there is need

for research on:

- The effectiveness of innovative teaching

methods in improving knowledge and

practice

- Translation of research into improved clinical

practice and identification of methods by

which this happens.

- Mechanisms for increasing professional

motivation to acquire education and improve

performance.

(Grade D)

1666

LITERATURE SEARCH

The following key words were used in the literature

search: prevention + primary/secondary/tertiary,

prevention + incontinence /urinary incontinence/

fecal/anal incontinence, prevention + population,

continence + promotion, health promotion, health

promotion + continence, risk (factors) + incontinence,

urinary /faecal incontinence + BMI/obesity,

incontinence + diabetes, urinary incontinence , diet/

caffeine/fluid intake, physical activity + incontinence,

mental health + incontinence/ painful bladder

syndrome, urinary /faecal incontinence + (cigarette)

smoking, pregnancy/ childbirth/antenatal/ postnatal/

postpartum + incontinence, occupation + incontinence,

pelvic floor muscle exercises + pregnancy/childbirth/

antenatal/postnatal/postpartum + incontinence,

pregnancy/childbirth/antenatal/postnatal/ postpartum

+ incontinence + prevention, pelvic floor muscle

exercises + prostatectomy, post prostatectomy +

incontinence + prevention, conservative management

+ incontinence, risk factors + urinary incontinence,

risk factors + faecal incontinence/ anal incontinence,

occupation + risk + incontinence, painful bladder

syndrome + prevention, painful bladder syndrome +

risk, pelvic organ prolapse, prevention, pelvic organ

prolapse + risk, older adults, urinary incontinence +

prevention, self-efficacy + incontinence, falls + risk +

incontinence. Search strategy included a range of

electronic databases as follows: Ageline, AMI:

Australasian Medical Index, AMED Allied and

Complementary Medicine, Australian Institute of Health

and Welfare: Publications, Blackwell Scientific now

joined with Wiley Interscience, BMJ Journals online,

Cambridge Journals on line, Cinahl, Cochrane Library

EBSCO Host, Google, Health and Medical Complete,

Meditext, Medline, Ovid, Oxford Journals

Pedro, Proquest, Pubmed, Springer, Wiley Inter-

science, Wilson

1. BACKGROUND

Urinary incontinence is a highly prevalent and chronic

condition that can be prevented by addressing

modifiable risk factors through primary prevention.

Although the evidence base for FI and POP is more

limited than that for UI, the conditions share many

similarities with respect to risk and treatment,

suggesting that similar benefits may derive from

population-based strategies [116]. These strategies

may also be relevant to people with bladder pain

syndrome (also referred to as interstitial cystitis, painful

bladder syndrome and urologic chronic pelvic pain),

although there is no research on primary prevention

for this condition.

In the past few years, substantive work has examined

the evidence base for preventative strategies for

incontinence. This work included a Cochrane Review

of conservative management for post prostatectomy

urinary incontinence [184], an extensive Evidence

Report conducted for the U.S.A. AHRQ on prevention

of urinary and fecal incontinence in adults, [167], and

a state of the science conference also on the

prevention of urinary and fecal incontinence in adults,

sponsored by the National Institutes of Health in the

U.S.A. [166].

Primary prevention refers to efforts directed at a

community or population level to promote protective

health behaviors [185] in order to reduce the incidence

of UI, FI and POP. Other preventative measures

include secondary prevention (where screening of

asymptomatic people occurs in order to detect

symptoms early and provide treatment) and tertiary

prevention (where efforts are directed at curing,

rehabilitating, restoring function and preventing of

future relapse of symptoms) [186]. This section will

focus on primary prevention of UI and POP. Additional

and more in-depth information is presented by the

ICI Committee 4, Pathophysiology of Urinary Incon-

tinence, Fecal Incontinence and Pelvic Organ

Prolapse; Committee 12, Conservative management

of urinary incontinence (men and women), and pelvic

organ prolapse. Primary prevention of FI is addressed

by Committee 16, Conservative and Pharmacological

Management of Faecal Incontinence in Adults. There

is no evidence concerning addressing secondary and

tertiary prevention of bladder pain syndrome.

2. POPULATION-BASED PREVENTION

Prevention should include education about behavioural

changes that increase the probability of incontinence,

the normal functioning of the urogenital and gastro-

intestinal tracts, expected age related and develop-

mental changes, and how to find the appropriate

treatment providers. Raising awareness of health

problems and providing information on terms used to

describe symptoms assists in promoting help-seeking

behaviour [187].

The 3rd ICI stressed the importance of all healthcare

professionals promoting primary prevention of

incontinence [116]. It was acknowledged that this

would require raising the level of community

awareness, providing public education as well as

addressing healthcare professionals’ education. Whilst

some advances have been made, these strategies

remain a priority. The challenges of dealing with an

ageing population are likely to result in urological

symptoms including incontinence being as prevalent

as cardiovascular disease in the U.S.A. by 2025 [188,

189] and is likely to result in an increased demand for

hospital and long term care [190]. As noted above,

incontinence is responsible for up to 30 - 50% of

admissions into nursing homes, often precipitated by

the burden of care on care givers who spend half of

IV. PRIMARY PREVENTION

1667

their care-giving time providing personal care such as

toileting assistance [84]. Caregivers of people with

dementia living in the community have been shown

to benefit from learning strategies to assist in

preventing and managing FI [191]. This study highlights

the need to include carers in primary and secondary

prevention strategies.

Programs developed to raise awareness of continence

issues should consider targeting a range of groups

including people of different ages and genders [47].

Consideration should be given to the setting in which

the health promotion program is to be delivered such

as schools, work places, community groups and health

care institutions [192]. It is acknowledged that whilst

some nations are successfully implementing primary

prevention strategies, others are yet to effectively

implement secondary prevention measures such as

assessment and management of continence

conditions [193]. In Australia, the UK and the U.S.A,

continence organizations have received addi-tional

support from national governmental departments and

agencies resulting in greater resources being applied

to preventative and continence promotion programs.

The evidence for population-based prevention

strategies remains at Level 4, Grade C.

3. RISK FACTORS

There is an increasing body of evidence linking

incontinence with other conditions. These links provide

opportunities to benefit from cooperative efforts with

other health promotion initiatives. Identification of

individuals who have the potential for becoming

incontinent is an important primary prevention activity.

Level 3 Grade B evidence exists for general risk

factors of age, pregnancy, parity, [194, 195, 196].

Earlier studies reported Level 3 evidence regarding

the risk of overweight and obesity in women [92, 197].

More recently a systematic review has found Level 2

and Level 3 evidence that establishes overweight and

obesity as independent risk factors for the development

of UI in women [198]. Women with obesity and

diabetes have a greater risk of developing pelvic floor

disorders, including UI, FI and pelvic organ prolapse

[199]. There is a 91% prevalence of these pelvic floor

disorders in morbidly obese women [200].

Higher body mass index (BMI) and greater weight

are independent risk factors for stress and mixed UI

in middle-aged and menopausal women [198. 201].

There is Level 3 evidence to recommend that women

with a BMI over 30 should be advised to lose weight

to reduce their UI [165]. Randomised control trials

have found that women who are overweight or obese

can reduce the frequency of urine loss by losing

between 3 - 5% of body weight [202] and 7% of body

weight [203]. Bariatric surgery for morbidly obese

women has resulted in “significant improvement” of

UI and has reduced the prevalence of FI from 19%

to 9 % [204]. A weight reduction program focusing on

avoiding weight gain and maintaining a waist

circumference within a normal range may lower the

risk of UI in women [205].

Diabetes - Lower urinary tract symptoms and changes

in bladder function occur in over 50% of men and

women with diabetes [206; 207]. In middle-aged

women, diabetes is the strongest risk associated with

the development of UI [197] and the increase in

severity of UI [208, 209]. The risk of pathological

bladder changes and incontinence may be reversed

if diabetes can be prevented by lifestyle interventions

including weight loss [206; 209] and physical activity

[206]. Providing this information to patients may be a

strategy to motivate people to take positive action to

improve their health.

Fluid intake - Urinary symptoms may be adversely

affected by extremes of fluid intake. Amending high

or low fluid intake improves UI and OAB [165]. Patients

who decrease an excessive fluid intake experience

decreased urinary frequency and urgency to

statistically significant levels [165; 210]

Diet - The effect of diet on urinary function is not well

studied, however it has been reported that eating a

diet containing vitamin D, potassium, chicken,

vegetables, bread and protein may lead to a reduction

in the risk of stress UI and OAB [165]. Diets containing

carbonated drinks, high fat levels, cholesterol, vitamin

B12, zinc [166] and spicy foods and artificial swee-

teners were associated with an increased risk of UI

or an increase in the severity of OAB. There are mixed

results on the effects of caffeine upon nocturia and

OAB, with one study of normal volunteers reporting

no change in nocturia [211] and others that showed

an association with caffeine ingestion and nocturia

but not urinary urgency [212, 213]. A recent study

with normal volunteers found that artificial sweeteners

had a significant effect upon increasing urinary

frequency and urgency [212].

Diet is also implicated in the exacerbation of urinary

symptoms in BPS/IC/PBS. The types of food and

drink reported to aggravate these symptoms include

chocolate, citrus fruits, and tomatoes, carbonated

drinks, [214], alcohol, coffee, and tea, [214, 215, 216].

Physical activity - Low impact physical activity in

younger women appears to assist in promoting

continence [217]. Conversely high impact, strenuous

physical activity can aggravate symptoms of PBS

[218]. Older women who engage in regular physical

activity such as walking have significantly lower levels

of UI [219] and are less likely to have urgency if they

exercise at least weekly. It is not clear if commencing

exercise could reduce urgency [165]. Severity of UI

in women is related to the perception of UI being a

barrier to exercise, and women with severe UI are

less likely to achieve recommended amounts of

1668

physical activity required for good health. Women

with less severe incontinence are more likely to wear

a pad or restrict their fluid intake in an attempt to

minimize UI when exercising [220].

Depression and mental health - Incontinence has

been linked with mental health issues, including

depression and self-harm. This may be due to a

common underlying causality rather than incontinence

causing depression or risk of self-harm [218]. Severity

of incontinence is strongly associated with major

depression in women [222] and screening for

depression should be considered when a women

presents with severe UI. The World Health

Organization (WHO) predicts that by 2020 depression

will be the second highest cause of disability for all

ages and genders [223]. It is likely that the prevalence

of incontinence will rise as a consequence of this. IC

is also associated with a higher risk of depression

[218, 224]. Symptoms are exacerbated by

psychological stress [215]. This syndrome is frequently

associated with fibromyalgia and irritable bowel

syndrome [215, 224]. A recent study however has

found that women with fibromyalgia have a pattern of

urinary symptoms that are distinct from those

experienced by women with PBS/IC [225].

Cigarette smoking Whilst cigarette smoking has

previously been shown to exacerbate OAB and has

been linked with UI and FI [167], research has not yet

demonstrated that smoking cessation results in

changes to UI or FI [164, 165].

Occupational risk factors Increasing voiding intervals

have been reported in workers who have limited

access to toilet facilities (such as teachers, nurses

and production workers). This is thought to result in

reducing bladder sensation and lead to UI [167]. An

earlier study found that women in the military and the

occupations described above deliberately restricted

their fluid intake in order to control their UI [226]. A

recent study of teachers in Taipei found that UI

occurred more often in those who had a higher BMI,

poor bladder habits and lack of access to toilets [213].

Heavy lifting was shown to increase the risk of urgency

in teachers [213]. Women living in rural Thailand

performing laboring duties had a higher risk of UI

[227].There are still no intervention studies that have

been reported in these at-risk populations.

4. PREVENTION OF CHILDBIRTH-RELATED

INCONTINENCE

Recent studies suggest that the percentage of women

experiencing UI prior to pregnancy ranges from 15%

[228] to 39% [217]. Women who engaged in high

impact physical activity during pregnancy were at

greater risk of UI, whereas a protective effect for UI

was noted in women who undertook low impact

physical activity prior to and during pregnancy [217].

During pregnancy, approximately 50% of primiparous

women experience UI [229]. UI during pregnancy has

been reported as a risk factor for UI later on in life [228,

230]. Pelvic floor disorders, particularly POP have

been associated with women who delay pregnancy

and childbirth until they are older [231].

A systematic review conducted in 2005 found that

whilst PFMT is associated with reduction or

amelioration of UI in pregnancy and postpartum, there

is no evidence to support PFMT as a strategy to

prevent UI from occurring. [232]. It has also been

found that self-reported PFMT does not affect the

onset of UI during pregnancy [233]. There is some

suggestion that PFMT appears to be effective in

preventing UI in the post partum period in those women

who do not experience UI during pregnancy [230]. A

recent randomised control trial of women with UI

during pregnancy who were given three PFMT

sessions for a period during pregnancy, and one

session post partum found no effect upon UI six

months post partum compared with controls who

received standard advice [234].

Management of the second stage of labour may also

affect continence. Pelvic floor muscle trauma may be

reduced by allowing the woman to bear down when

she has an urge to push and avoiding instrumental

delivery when possible [235].

When clinical guidelines have provided an indication

for the use of an episiotomy, debate has ensued as

to whether a midline or mediolateral episiotomy will

provide the best protection to the perineum. A case-

control study found that a mediolateral incision reduced

the risk of third degree tearing of the perineum. The

angle of the episiotomy resulted in a 50% relative

reduction of sustaining a third degree perineal tear for

each 6° away from the midline [43].

Previously Level 2 and Level 3 evidence suggested

that elective caesarean delivery could be considered

as a UI prevention strategy. Women who had a

caesarean section have less UI at three months post

partum [233], however the risk of UI is not completely

eliminated as 14% of women still report UI [236]. More

research is required into UI occurring before and

during pregnancy due to the strong link to UI occurring

postpartum [237]. In addition, antenatal UI has been

found to be an independent risk for postpartum FI

[167; 229].

Despite a significant body of evidence that advocates

PFMT before, during and after pregnancy to prevent

and treat UI during pregnancy and in the postnatal

period, [204]; [167], the actual number of women

performing regular PFMT during pregnancy varies

from 17% in Norway, 69 % in the UK and 54.5 % in

Australia [238]. Poor adherence to PFMT is also an

issue [239]. The effectiveness of PFMT in preventing

1669

childbirth related UI, in conjunction with the non-

invasive nature of this self-care strategy, makes it a

logical focus for UI prevention efforts among women

during the period of childbearing. [240]. Due to the lack

of research, there is only Level 4 evidence to support

the use of PFMT to prevent incontinence during

pregnancy and in the post natal period.

5. PREVENTION OF PROSTATECTOMY-RE-

LATED URINARY INCONTINENCE

Prostatectomy remains an established risk factor for

UI in men [241], resulting in postoperative pad use

[242] and decreased quality of life [243]. Despite

advances in surgical techniques that have reduced the

risk of UI, it remains a distressing post-operative

complication for many men [244]. It is of concern that

over 40% of men in one study claimed not to have

received preoperative information that they may

develop UI following prostate surgery [245].

Pre-operative UI is a significant risk for UI following

a radical prostatectomy [246].

A Cochrane Review published in 2008 found few

studies on the effect of PFMT undertaken prior to

radical prostatectomy on the development of UI post-

operatively [247].

One RCT compared subjects given biofeedback and

daily home exercise to controls given usual post-

operative instruction to cut off the flow of urine when

urinating [285]. The intervention group achieved

continence faster and suffered less severe UI than

controls.

Secondary prevention of UI with men undergoing

PFMT following radical prostatectomy also shows

conflicting results, with some showing no change on

UI [249] and others showing improvement in men

who underwent PFMT compared to men who did not

[250]. The Cochrane Review concluded that the

evidence was inconclusive and that there was a paucity

of quality research in this area, [247].

Whilst there is a focus on UI and erectile dysfunction

after radical prostatectomy, a number of men

experience fecal urgency and FI post-operatively, with

a small percentage of men developing FI two years

post-operatively. It is suggested that there may be a

higher number of men with FI post-operatively than

currently reported [245].

Researchers are urged to investigate preventative

strategies for FI and faecal urgency following radical

prostatectomy [166] as currently there appears to be

no research into this area.

In regards to prostatectomy, there remains mixed

Level 2 evidence to support the use of PFMT pre and

post-operatively for UI. There is no evidence to either

support or refute the use of PFMT pre and post

operatively to prevent FI.

6. PREVENTION OF URINARY INCONTINENCE

IN OLDER ADULTS

It is predicted that the number of people aged over 60

will increase from 650 million in 2005 to over 2 billion

in 2050 [223]. Whilst ageing does not cause

incontinence it is acknowledged that the risk of

incontinence increases with advancing age and is

associated with a concomitant increase in a range of

co-morbid conditions.

Older adults are a heterogeneous group, and therefore

preventative strategies for older adults need to take

into consideration the well aged as well as the frail

aged. It is important to involve older people and

upcoming generations in health promotion research

and health promotion intervention programs targeted

at older people [251].

Due to the association of diabetes and UI, geron-

tologists have an important role to play in screening

older women with diabetes for UI so that they can

receive treatment [206].

Well older adults - There is Level 2 evidence to

support the use of preventative strategies in well older

adults. These strategies include promoting self-efficacy

such that the individual has a belief that they have the

capacity and skills to improve their own health. In

addition, self-efficacy improves the ability to cope

better with symptoms and is linked to motivation,

knowledge of the benefits of making changes, and

adherence to behavior change [252; 253]. Self

–efficacy over UI may be enhanced if women are

taught self monitoring techniques such as adjusting

fluid and caffeine intake, resolving constipation, pelvic

floor muscle training in “Quick Kegel” contractions

and monitoring voiding intervals [254]. These self-

monitoring techniques resulted in decreased volumes

of urine loss and improved quality of life [254].

Promoting self-efficacy results in good adherence to

PFMT in older, well educated women [255]. Self-

efficacy measures such as the Geriatric Self-Efficacy

Index for Urinary Incontinence can be used to

determine adherence to behavioural programs

developed for the prevention and management of UI

[253].

A behavioural modification program delivered to

women aged over 55 years reported the preventative

effects of increasing pelvic floor muscle strength and

increasing time between voids upon continence status,

suggesting that preventative strategies are effective

in older women [66, 256; ]. A recent systematic review

concluded that there was “moderate evidence” to

support the use of PFMT and bladder training in

resolving UI in women [257]. An older study reported

that these interventions were “very successful” in

treating UI in elderly community dwelling people [258].

Frail older people Correlations have been found

between poor general health and severe urinary and/or

1670

fecal incontinence in frail older people [259]. Incon-

tinence is the second main reason for frail aged people

to seek admission into nursing homes in the UK and

the U.S.A., and is the third main reason in Australia

[86]. Incontinence in nursing home residents has

negative effects upon the morale of residents, families

and staff. Conversely the time and effort spent in

promoting continence through toileting programs and

other strategies is labour intensive and also places

strain upon staff [129].

A recent study has found that there is a greater risk

of functional disabilities in men and women who are

obese, specifically those with higher waist

circumference measurements [260]. These disabilities

are associated with a range of chronic health

conditions, including incontinence. Prevention of

obesity may prevent the development of functional

disabilities, chronic health problems and incontinence

in the frail aged [260].

Treatment of poor mobility and communication

difficulties [259], UTI, environmental barriers and

removing physical restraints [261], could reverse or

ameliorate urinary and/or fecal incontinence. Despite

this, a UK survey of continence practices in care

homes there were few mobility programs in place to

promote continence [88].

Falls have been associated with a range of factors,

including UI and taking medicines such as diuretics

[262, 263]. Falls have also been associated with OAB,

urge UI and nocturia [264]. Opportunities exist to link

with other health promotion programs targeted at

older adults such as falls prevention programs [262].

However opportunities to promote continence are not

currently being adopted in these programs, despite

incontinence being a known risk for falls

[264]. A number of factors have been identified linking

the risk of incontinence to chronic health conditions

in the frail aged. Screening is recommended to identify

risk factors for incontinence in the early stages when

it may be easier to adopt preventative strategies [167]..

Whilst strategies to address these factors have been

recommended there is a lack of studies to show the

efficacy of these interventions. Due to the paucity of

research in this area there is Level 4 evidence to

recommend the use of preventative strategies

described above to prevent incontinence and promote

continence in frail aged adults.

7. PREVENTION OF PELVIC ORGAN

PROLAPSE

Some degree of POP is reported in 51% of women

aged over 50 years who have had children [265].

Whilst clinical assessment of POP has revealed higher

prevalence, mild degrees of prolapse may be

asymptomatic. There is mixed evidence related to

risk factors associated with developing POP. Smoking,

increased waist circumference and higher BMI were

not associated with POP in one study [266]. Another

study reported that grand multiparity (defined as five

or more vaginal deliveries) and raised BMI are risk

factors for POP [267]. It was also found that in older

women that POP worsened and resolved over time

[267]. Irritable bowel syndrome was found to be

associated with POP [268].

A systematic review of POP conducted in 2007

concluded that whilst there is currently no research

to demonstrate effective prevention, conservative

strategies such as weight loss, avoiding heavy lifting,

resolving constipation, pelvic floor physiotherapy and

addressing obstetric risk factors should be considered

[269]. One report presents Level II-3 evidence that

symptoms of POP are relieved by the use of a vaginal

pessary. This is of relevance to women who choose

or are not able to have surgery and those who are

awaiting surgery [265].

Pelvic organ prolapse in women may be decreased

following the long term use of a vaginal pessary [265].

The use of a pessary may also assist in improving

bladder, bowel and sexual functioning but there is

mixed evidence for improvement of stress urinary

incontinence and urge urinary incontinence [265].

A Cochrane Review of pessary use in 2004 was unable

to find any randomised control trials assessing the

efficacy of pessary use [269]. These authors also

note that despite this lack of evidence, pessaries have

been used for centuries and are currently used in

clinical practice by the vast majority of gynaecologists,

urogynaecologists and nurse specialists.

8. PREVENTION OF FAECAL INCONTINENCE

Whilst it appears that people are seeking help more

readily for UI, the problem of FI remains under–

reported [130] especially in older people [270] and

few physicians ask patients about it [271]. Analysis of

studies on FI is hampered by a lack of standardised

terminology with regards to stool consistency, gas

leakage and frequency of incontinent episodes [166,

272, 273]. Whilst acknowledging that prevention of FI

is important, it is recognized that more research is

needed to determine the risk factors and interventions

to prevent FI [274]. An extensive systematic review

of risk factors associated with FI is reported by

Committee 4, Pathophysiology of Urinary Incontinence,

Fecal Incontinence and Pelvic Organ Prolapse and

hence only a brief summary is provided below. Risk

factors for developing FI include diarrhoea [274],

irritable bowel syndrome (IBS), UI [271], [272], and

obesity, particularly for people with a BMI more than

40 [272, 274]. Morbidly obese women may have rates

of FI as high as 63% [271]. Chronic obstructive

pulmonary disease, diabetes, colectomy and

cholecystectomy are also associated with an increased

risk of FI [275]. An association with FI has been found

in postmenopausal women [275]. Conversely it was

also found that the use of hormone replacement

therapy in women increased the risk of FI [275].

1671

9. RECOMMENDATIONS FOR PRIMARY

PREVENTION

1. Landefeld, C.S., Bowers, B.J., Feld, A.D., et al.: NIH

Consensus State Sci Statements. NIH State-of-the-Science

Conference Statement on Prevention of Fecal and Urinary

Incontinence in Adults. Dec 12-14; 24(1):1-40, 2007.

2. Kerka, S.: Health Literacy beyond Basic Skills. ERIC Digest.

2003.

3. Diering, C. and Palmer, M.H.: Professional information about

urinary incontinence on the World Wide Web: Is it timely?

Is it accurate? J Wound Ostomy Continence Nursing, 27:1-

9, 2001.

4. Sandvik, H.: Health information and interaction on the Internet:

a survey of female urinary incontinence Br Med J.: 319:29-

32, 1999

5. Baker, L., Wagner, T. H., Singer, S., and Bundorf, M. K.: Use

of the internet and e-mail for health care information: Results

from a national survey. JAMA, 298(18), 2400–2406, 2003.

6. Lenhart, A., Horrigan, J., Rainie, L., Allen, K., Boyce, A.,

Madden, M., and O’Grady, E.: The ever shifting internet

population: A new look at internet access and the digital

divide (p. 46). Washington, DC: Pew Internet and American

Life Project, 2003.

7. Pefia-Purcell N.: Hispanic's use of internet health information:

an exploratory study. J Med Library Association. 96(2):101-

7, 2008.

8. Al-Shammary N., Awan, S., Butt, K., and Yoo, J. Internet

use before consultation with a health professional. Primary

Health Care. December;17(10):18 – 21, 2007.

9. Berger M, Wagner T.H., and Baker L.C.: Internet use and

stigmatized illness. Soc Sci Med. Oct;61(8):1821-7, 2005.

10. Ottawa Charter for Health Promotion, First International

Conference on Health Promotion, Ottawa, 21,

WHO/HPR/HEP/95.1 Document Number, November 1986.

http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf.

Accessed November 1, 2008.

11.Tannenbaum C. and Shatenstein, B.: Exercise and nutrition

in older Canadian women. Canadian Journal of Public Health.

May - June;98(3):187 – 93, 2007.

12. Palmer M.H. and Newman, D.K.: Bladder control educational

needs of older adults. Journal of Gerontological Nursing,

32(1): 28-32, 2006.

13. Kinchen, K.S., Burgio, K., Diokno, A., et al. Factors associated

with women's decisions to seek treatment for urinary

incontinence. J Womens Health, 12:687-98 2003.

14. Koch, L.H. Help-seeking behaviors of women with urinary

incontinence: An integrative literature review. Journal of

Midwifery and Women’s Health, 51(6), e39–e44, 2006.

15. Sykes, D., Castro, R., Pons, M.E., Hampel, C., Hunskaar,

S., Papanicolaoi, S., et al.: Characteristics of female

outpatients with urinary incontinence participating in a 6-

month observational study in 14 European countries.

Maturitas, 52(Suppl. 2), S13–S23, 2005.

16. Huang, A.J., Brown, J.S., Kanaya, A.M., Creasman, J.M.,

Ragins, A.I., van den Eeden, S.K., et al.: Quality-of-life impact

and treatment of urinary incontinence in ethnically diverse

older women. Archives of Internal Medicine, 166, 2000–2006,

2006.

17. Shaw, C, Das Gupta, R., Williams, K.S., Assassa, R.P., and

McGrother, C.: A survey of help-seeking and treatment

provision in women with stress urinary incontinence. BJU

International. 97:752 – 7, 2006.

18. Shaw, C, Das Gupta, R., Bushnell, D.M., Assassa, R.P.,

Abrams, P., Wagg, A., Mayne, C., Hardwick, C and Martin,

M.: The extent and severity of urinary incontinence amongst

REFERENCES

Health promotion strategies aimed at individual,

interpersonal, community and population levels

are needed in order to promote urinary and fecal

continence [192]. Educating people about

continence issues and ways in which they can

improve their bladder and bowel health will also

assist in removing some of the stigma that

surrounds continence issues [167]. Conversely,

care needs to be taken to ensure that incontinence

is not “normalised” as this can have the unintended

consequence of people not seeking help for a

condition deemed to be “normal” [276]. For

moderately overweight women, the Third

International Consultation on Incontinence

recommended programs such Weight Watchers®

to encourage moderate weight loss as first line

therapy in overweight women. There is little

evidence at this stage to demonstrate that these

recommendations have been followed. The

acceptance of public health programs to reduce

obesity, increase physical activity and promote

eating fruits and vegetables can be built upon to

promote good bladder and bowel habits, including

PFMT and BT for the primary prevention of UI.

Based on the literature reviewed in this section, the

following recommendations can be made:

• Primary prevention studies should not be limited

to individual interventions, but also test the

impact of population-based public health

strategies (Grade C)

• PFMT should be a standard component of

prenatal and postpartum care. Due to the

number of women who experience incontinence

prior to pregnancy, measures need to be taken

to instruct women in PFMT prior to pregnancy

(Grade C)

• Randomised controlled trials (RCTs) should be

conducted to test the preventative effect of

PFMT for men post-prostatectomy surgery

(Grade B)

• Further investigation is warranted to assess the

efficacy of PFMT and BT for primary prevention

of UI in well older adults (Grade B)

Primary prevention efforts should be aimed at

interventions to promote a healthy body weight to

assist in the prevention of incontinence (Grade

A).

1672

women in UK GP waiting rooms. Family Practice

Oct;23(5):497-506, 2006.

19. Harris MF, and McKenzie, S. Men's health: what's a GP to

do? Medical Journal of Australia. October; 185(8):440 – 4,

2006.

20. Engstrom, G., Walker-Engstrom, M-L., Loof, L. and Leppert,

J.: Prevalence of three lower urinary tract symptoms in men-

a population-based study. Family Practice. 20(1):7 – 10.

2003.

21. Diokno, A.C., Estanol, M.V., and Ibrahim, I.A,

Balasubramaniam, M.: Prevalence of urinary incontinence

in community dwelling men: a cross sectional nationwide

epidemiological survey.Int Urol Nephrol. 39(1):129-36, 2007.

22. Wolters, R., Wensing, M., van Weel C., van der Wilt G.J.,

and Grol, R.P.: Lower urinary tract symptoms: social influence

is more important than symptoms in seeking medical care.

BJU Int. Nov;90(7):655-61, 2002.

23. Andersson, G., Johansson, J.E., Garpenholt, O¨.R., et al.:

Urinary Incontinence - Prevalence, impact on daily living

and desire for treatment: A population-based study. Scand

J Urol Nephrol 38: 125–130; 2004.

24. Muller, N. What Americans understand and how they are

affected by bladder control problems: highlights of recent

nationwide consumer research. Urol Nurs. Apr;25(2):109-15,

2005.

25. Newman, D.K. and Wein, A.J., Managing and Treating Urinary

Incontinence, Second Edition. Health Professions Press,

Baltimore, Maryland, In Press, 2009.

26. Herschorn S, Gajewski, J., Schutz, J., and Corcos, J.: A

population-based study of urinary symptoms and

incontinence: the Canadian Urinary Bladder Survey BJU

International;101:52-8, 2007.

27. Norton, N.J.: The perspective of the patient.

Gastroenterology, 126 (suppl 1):S175-179, 2004.

28. Newman, D.K.: Community awareness and education. In

G. H. Badlani, G. W. Davila, M. C. Michel, J. J.M.C.H. de la

Rosette. (Eds) Continence: Current Concepts and Treatment

Strategies Springer-Verlag, (London) Ltd, 521-532, 2009.

29. Garcia, J.A., Crocker, J., and Wyman, J.F.: Breaking the

cycle of stigmatization. J Wound Ostomy Continence Nurs.

32(1):38-52, 2005.

30. Norton, C.: Nurses, bowel continence and taboos. J Wound

Ostomy Continence Nurs. 31:85-94, 2004.

31. Guimmarra MJ, Haralambous, B., Moore, K., and Nankervis,

J. The concept of health in older age: views of older people

and health professionals. Australian Health Review.

November;31(4):642 – 50, 2007.

32. Doshani, A., Pitchforth, E., Mayne, CJ., and Tincello, D.G..:

Culturally sensitive continence care: a qualitative study

among South Asian Indian women in Leicester. Fam Pract.

Dec;24(6):585-93, 2007.

33. Rizk, D.E., Shaheen, H., Thomas, L., Dunn, E., Hassan,

M.Y.: The prevalence and determinants of health care-

seeking behavior for urinary incontinence in United Arab

Emirates women. Int Urogynecol J Pelvic Floor Dysfunct.

10(3):160-5, 1999.

34. Saleh N., Bener A., Khenyab N., Al-Mansori Z., and Al Muraikhi

A.: Prevalence, awareness and determinants of health care-

seeking behaviour for urinary incontinence in Qatari women:

a neglected problem? Maturitas. Jan 10;50(1):58-65, 2005.

35. Rizk, D.E., Hassan, M.Y., Shaheen, H., Cherian, J.V., Micallef,

R,, Dunn, E.: The prevalence and determinants of health care-

seeking behavior for fecal incontinence in multiparous United

Arab Emirates females. Dis Colon Rectum. Dec;44(12):1850-

6, 2001.

36. Anthony J.S.: Self-advocacy in health care decision-making

among elderly African Americans. Journal of Cultural Diversity.

14(2):88 – 95, 2007.

37. Downes, L.: Motivators and barriers of a healthy lifestyle

scale: development and psychometric characteristics Journal

of Nursing Measurement. 16(1):3 – 15, 2008.

38. Howard, D.L., Edwards, B.G., Whitehead, K., Amamoo, A.,

and Godley, P.A.: Healthcare practices among blacks and

whites with urinary tract symptoms. J National Medical

Association. April;99(4):404 – 11, 2007.

39. Mills A.L., and Pierce, J.P.: Editorial Using Teachable moments

to improve nutrition and physical activity in patients. American

Family Physician. 77(11):1510-11, 2008.

40. Hope C.: Promoting continence positively, J Community

Nursing. November; 21(11):24 – 7, 2007.

41. McConnell E.S., Lekan-Rutledge D., Nevidjon B., and

Anderson R.: Complexity theory: a long-term care specialty

practice exemplar for the education of advanced practice

nurses. J Nursing Education 3 (2):84-7, 2004.

42. Gunzler C., Kriston, L., Stodden, V., Leiber, C., and Berner,

M.M.: Can written information material help to increase

treatment motivation in patients with erectile dysfunction? A

survey of 1188 men. International J Impotence

Research.19:330 – 5, 2007.

43. Eogan M, Daly, L., O'Connell, P.R., and O'Herlihy, C.: Does

the angle of episiotomy affect the incidence of anal sphincter

injury? BJOG : An International J Obstetrics and Gyaecology.

113(2):190 -4, 2006.

44. Boyington, A.R., Dougherty, M.C., & Yuan-Mei, L. Analysis

of interactive continence health information on the web. J

Wound, Ostomy, Continence Nurs, 30, 280–286, 2005.

45. Zarate-Abbott P., Etnyre, A., Gilliland, I., Mahon, M., Allwein,

D., Cook, J., Mikan, V., Rauschhuber, M., Sethness, M.,

Munoz, L., Lowry, J., and Jones, M.E.: Workplace health

promotion - strategies for low-income Hispanic immigrant

women. AAOHN Journal. 56(5):217 – 22, 2008.

46. Ishikawa H., Takeuchi, T., and Yano, E.: Measuring functional,

communicative, and critical health literacy among diabetic

patients. Diabetes Care. 31(5):874 – 9, 2008.

47. McCallum J, Millar. L., Burston, L., Dong, T. Framework for

evaluation of the national continence management strategy.

Australasian J Ageing. 26(s1): A1 - A44. Special Issue,

2007.

48. Australian Government Initiative, National Continence

Management Strategy (NCMS), Evaluation Framework,

Victoria University. March, 2008, http://www.bladder

bowel.gov.au/%5Cdoc%5CNCMSEvaluationFrameworkGuid

elinesV2.pdf Accessed November 21, 2008.

49. Wilson LF.: Adolescents' attitudes about obesity and what they

want in obesity prevention programs. J School Nursing.

August;23(4):229 – 38, 2007.

50. Newman, D.K.: Report of a mail survey of women with

bladder control disorders. Urol Nurs. Dec; 24(6):499-507,

2004.

51. Kelly, A.M. and Byrne, G.: Role of the continence nurse in

health promotion. J Wound Ostomy Continence Nurs. Jul-

Aug;33(4):389-95, 2006.

52. Norton, C., Brown, J., and Thomas, E.: Continence: a phone

call away. Nurs Standard, 9: 22-23, 1995.

53. McFall, S.L., Yerkes, A.M., Belzer, J.A., et al.: Urinary

incontinence and quality of life in older women: a community

demonstration in Oklahoma. Family & Community Health,

17:64-75, 1994.

54. Morahan-Martin, J.M.: How internet users find, evaluate,

and use online health information: a cross-cultural review.

Cyberpsychol Behav. Oct;7(5):497-510, 2004.

55. Newman, D.K., Wallace, J., and Blackwood, N.: Promoting

1673

healthy bladder habits for seniors. Ostomy Wound

Management, 42:18-28, 1996.

56. Roe, B., Wilson, K., and Doll, H.: Public awareness and

health education: findings from an evaluation of health

services for incontinence in England. Int J Nurs Stud.

38(1):79-89, Feb 2001.

57. Muller, N.: What the future holds for continence care. Urol

Nurs. 24(3):181-6. Jun 2004.

58. Gartley, C.B.: Bringing Mohammed to the mountain: educating

the community for continence. Urol Nurs. 26(5):387-93; Oct

2006.

59. Levy-Storms, L., Schnelle, J.F., and Simmons, S.F.: What do

family members notice following an intervention to improve

mobility and incontinence care for nursing home residents?

An analysis of open-ended comments. Gerontologist,

47(1):14-20, Feb 2007.

60. Simmons S.F. and Ouslander J.G.: Resident and family

satisfaction with incontinence and mobility care: sensitivity

to intervention effects? Gerontologist. Jun;45(3):318-26,

2005.

61. Australian Government Initiative, National Continence

Management Strategy (NCMS), Evaluation Framework and

Guidelines, Victoria University. September 18, 2007, http://

www.bladderbowel.gov.au/%5Cdoc%5CNCMSEvaluationFra

meworkGuidelinesV2.pdf Accessed November 21, 2008.

62. O’Connell, B., Wellman, D., Baker, L., et al.: Does a

continence educational brochure promote health-seeking

behavior? J Wound, Ostomy, Continence Nurs.33(4):389-95;

Jul-Aug 2006.

63. Wagg, A.R., Barron, D., Kirby, M., et al.: A randomized

partially controlled trial to assess the impact of self-help vs

structured help from a continence nurse specialist in women

with undiagnosed urinary problems in primary care. Int J

Clin Pract, 61, 11, 1863-73, Nov 2007.

64. Franzen, K., Johansson, J.E., Andersson, G., et al.: Urinary

incontinence: Evaluation of an information campaign directed

towards the general public. Scand J Urol Nephrol. Jul 10:1-

5, 2008.

65. Beguin, A.M., Combes, T., Lutzler, P., et al.: Health education

improves older subjects' attitudes toward urinary incontinence

and access to care: a randomised study in sheltered

accommodation centers for the aged (letter). J Am Geriatrics

Soc, 45: 391-392, 1997.

66. Sampselle, C.M., Messer, K.L., Seng, J.S., et al.: Learning

outcomes of a group behavioral modification program to

prevent urinary incontinence. Int Urogynecol J Pelvic Floor

Dysfunct. 16(6):441-6. Nov-Dec 2005.

67. Bo, K., Kvarstein, B., Nygaard, I.: Lower urinary tract

symptoms and pelvic floor muscle exercise adherence after

15 years. Obstet Gynecol. 105(5 Pt 1):999-1005. May 2005.

68. National Association for Continence: Recommendations for

two models of continence care, Charleston, South Carolina,

1994.

69. Department of Health. United Kingdom, Good Practice for

Continence Care, 2004, http://www.continence-foundation.

org. uk/ campaigns/goodpracticecontinence.pdf, Accessed

November 6, 2008.

70. Mold, J.W., Fyer, G.E., Phillips, R.L., Dovey, S.M., and Green

L.A.: Family physicians are the main source of primary

health care for the Medicare population. Am Fam Physician,

66:2032, 2002.

71. Green, L.A., Fryer, G.E., Yawn, B.P, Lanier, D., and Dovey,

S.M.: The ecology of medical care revisited. N Engl J Med,

344:2021-2025, 2001.

72. O'Brien, J. and Long, H.: Urinary incontinence: long tern

effectiveness of nursing intervention in primary care. Br

Med J, 311: 1208, 1995.

73. Seim, A., Hermstad, R., Hunskaar, S.: Female urinary

incontinence: long term follow-up after treatment in general

practice. Br J Gen Pract, 48:1727-1728, 1998.

74. Greenberg P., Brown J., Yates T., Brown V., Langenberg P.,

and Warren J.W.: Voiding urges perceived by patients with

interstitial cystitis/painful bladder syndrome. Neurourol

Urodyn. 27(4):287-90, 2008.

75. Peters K.M., Carrico D.J., and Diokno A.C.: Characterization

of a clinical cohort of 87 women with interstitial cystitis/painful

bladder syndrome. Urology. Apr;71(4):634-40, 2008.

76. Matharu, G.S., Assassa, R.P., Williams, K.S., Donaldson,

M.K., Matthews, R.J., Tincello, D.G., and Mayne, C.J.:

Continence nurse treatment of women’s urinary symptoms.

Br J Nurs, 13: 140-3, 2004.

77. Shaw C., Williams K.S., and Assassa R.P.: Patients' views

of a new nurse-led continence service. J Clin Nurs, 9:574-

82, 2000.

78. Du Moulin, M.F., Hamers, J.P., Paulus, A., Berendsen, C.,

& Halfens, R. Effects of introducing a specialized nurse in

the care of community-dwelling women suffering from urinary

incontinence. JWOCN. Nov/Dec, 34(6): 631-640, 2007.

79. Handa V.I., Harris T.A., and Ostergard D.R:. Protecting the

pelvic floor: Obstetric management to prevent incontinence

and pelvic organ prolapse. Obstet Gynecol, 88: 470-8, 1996.

80. Swithinbank, L. V., Donovan, J., Shepherd, A. M., and

Abrams, P.: Female urinary symptoms: just how much

"bother" are they? Proceedings of the International

Continence Society, Tokyo; 431-432, 1997.

81. Lagro-Janssen. A.L.M., Smits. A.J.A., and Van Weel. C.:

Women with urinary incontinence - self-perceived worries and

general practitioner's knowledge of the problems. Br J Gen

Practice, 40:331-334, 1990.

82. Kitagawa, K.: Annual report on Health and Welfare 1995-6.

Tokyo, Ministry of Health & Welfare of Japan, 1997.

83. National Continence Management Strategy, 2004, Personal

Communication. Kerry Markoulli. www.continence. health.

gov.au.

84. Australian Institute of Health and Welfare, (AIHW), Australian

incontinence data analysis and development, Canberra, 2

March 2006. http://www.aihw.gov.au/publications /index.

cfm/title/10201, Accessed November 3, 2008.

85. Schultz S.E. and Kopec J.A.: Impact of chronic conditions.

Health Rep. Aug;14(4):41-53, 2003.

86. Australian Institute of Health and Welfare (AIHW) Older

Australia at a glance: 4th edition. 22 November 2007; ISBN-

13 978 1 74024 732 0; AIHW cat. no. AGE 52; 224pp, 2007;

http://www.aihw.gov.au/publications/index.cfm/title/10402,

Accessed December 12, 2008.

87. Talbot, L.A: Coping with urinary incontinence: a

conceptualization of the process. Ostomy Wound Manag,

40:28-37, 1994.

88. Rodriguez, N.A., Sackley, C.M.; and Badger, F.J.::Exploring

the facets of continence care: a continence survey of care

homes for older people in Birmingham. Journal of Clinical

Nursing; 16:954 – 62, 2007.

89. Canadian Continence Foundation; Canadian consensus

conference on urinary incontinence working models of

continence care. 2000 http://www.continence-fdn.ca/health-

profs/workingmodels.html, Accessed December 12, 2008

90. Ashworth, P.D. and Hagan, M.T.: The meaning of incontinence:

a qualitative study of non- geriatric urinary incontinence

sufferers. J Advanced Nurs, 18:1415-1423, 1993.

91. Dingwall, L., McLafferty, E.: Do nurses promote urinary

continence in hospitalized older people? An exploratory

study. J Clin Nurs. Oct;15(10):1276-86, 2006.

92. Townsend M.K, Danforth, K.N., Rosner, B., Curhan, G.C.,

1674

Resnick, N.M., and Grodstein, F.: Body mass index, weight

gain, and incident urinary incontinence in middle-aged

women. Obstetrics & Gynecology. 110:346 – 53, 2007.

93. Williams, K.S., Assassa, R.P., Cooper, N.J., Turner, D.A.,

Shaw, C., Abrams, K.R., et al. for the Leicestershire MRC

Incontinence Study Team.: Clinical and cost-effectiveness of

a new nurse-led continence service: A randomised controlled

trial. British J General Practice, 55, 696–703, 2005.

94. Moore K.H., O’Sullivan R.J., Simons A., Prashar S., Anderson

P., and Louey M.: Randomised controlled trial of nurse

continence advisor therapy compared with standard

urogynaecology regimen for conservative incontinence

treatment: efficacy costs and two year follow-up. Br J Obstet

Gynaecol, 10:649-57, 2003.

95. Borrie, M.J., Bawden, M.E., Kartha, A.S., et al: A

nurse/physician continence clinic triage approach for urinary

incontinence: a 25 week randomised trial. Neurourol Urodyn,

11: 364-365, 1992

96. Saltmarche, A., Reid, D., W., Harvey, R., and Linton, L.: A

community nurse continence service delivery model - a

demonstration project. Proceedings of the International

Continence Society meeting, Halifax, Nova Scotia. 274-

274. 1992.

97. Lajiness, M.J., Wolfert, C., Hall, S., Sampselle, C., & Diokno,

A.C. Group session teaching of behavioral modification

program for urinary incontinence: Establishing the teachers.

Urologic Nursing, 27, 124–127, 2007.

98. Newman, D.K.: The Roles of the Continence Nurse Specialist.

In L. Cardozo, D. Staskin, (Eds) Textbook of Female Urology

and Urogynecology, 2nd Edition. Isis Medical Media, LTD.

United Kingdom: 91-8, 2006.

99. Ryden, M.B., Snyder, M., Gross, C.R., Savik, K., Pearson,

V., Krichbaum, K., and Mueller, C.: Value-added outcomes:

the use of advanced practice nurses in long-term facilities.

Gerontologist, 40:654-662, 2000.

100. Nijeholt, A.A.B.: The Leiden pelvic floor center: a patient-

oriented multidisciplinary diagnostic center. Proceedings

of the International Continence Society, Jerusalem, 1998.

101. Fonda D., Woodward M., and D'Astoli M., et al: Effect of

continence management programme on cost and useage

of continence pads. Neurourol Urodyn, 12:389-391, 1993.

102. Gruenwald, I.: The Center for Continence: A different concept

for an old problem. J Am Geriatrics Soc, 47:912-914, 1999

103. Milne, J.L. and Moore, K.N.: An exploratory study of

continence care services worldwide. Int J Nurs Studies,

40:235-247, 2003.

104. Fantl, J.A., Newman, D.K., Colling, J. et.al.: Urinary

Incontinence in Adults: Acute and Chronic Management

Clinical Practice Guideline, No 2, Update, Rockville, MD:

US Department of Health and Human Services. Public

Health Service, Agency for Health Care Policy and Research,

AHCPR Publication No. 96-0682. March, 1996.

105. Davis, D.A., Thomson, M.A., Oxman, A.D., and Haynes,

B.: Changing physician performance: A systematic review

of the effect of continuing medical education strategies.

JAMA. September, 274:700-705, 1995.

106. Viktrup L., Summers K.H., and Dennett S.L.: Clinical practice

guidelines on the initial assessment and treatment of urinary

incontinence in women: a US focused review. Int J Gynaecol

Obstet. Jul;86 Suppl 1:S25-37, 2004.

107. Viktrup, L., Summers, K.H., and Dennett, S.L.: Clinical

guidelines on the initial management of urinary incontinence

in women: A European-focused review. BJU Int, 94, Suppl

1, 14-22, 2004.

108. Wilson, P.D., Berghamns, B., Hagen, S., Hay-Smith, J.,

Moore, K., Nygaard, I., et al. (2005). Adult conservative

management. In P. Abrams, L. Cardozo, S. Khoury, & A.

Wein (Eds.), Incontinence: Proceedings from the Third

International Consultation on Incontinence, (pp. 855–964).

Plymouth, UK: Health Publications, Ltd, 2005.

109. Dovey, S., McNaughton, T., and Tilyard, M.: General

practitioner’s opinions of continence care training. New

Zealand Med J,109:340-343, 1996

110. Jolleys JV: Diagnosis and management of female urinary

incontinence in general practice. J Royal College of General

Practitioners, 39:277-279, 1989.

111. Aharoni, L., Gruenwald, I., Rosen, T., and Vardi, Y.:

Management of urinary incontinence for the old aged in

the primary care clinic. Proceedings of the International

Continence Society, Jerusalem, 1998.

112. Williams, K.S., Crichton, N.J., and Roe, B.: Disseminating

research evidence. A controlled trial in continence care. J

Advanced Nurs, 25:691-698, 1997.

113. Green, J.P., Smoker, I., Ho, M.T., and Moore, K.H.: Urinary

incontinence in subacute care – a retrospective analysis of

clinical outcomes and costs. Med J Aust. 178:550-3, 2003.

114. Bucci, A.T. Be a continence champion: Use the CHAMMP

Tool to individualize the plan of care. Geriatric Nursing, 28,

120–124, 2007.

115. Fonda, D. and Newman, D.K. Tackling the stigma of

incontinence – Promoting Continence Worldwide. In

Cardozo, L., Staskin, D. (Eds) Textbook of Female Urology

and Urogynecology. 2nd Edition. Isis Medical Media, LTD.

United Kingdom: 75-80, 2006.

116. Newman, D.K., Denis, L., Gruenwald, I., Ee, C.H., Millard,

R., Roberts, R., et al.: Promotion, education and organization

for continence care. In P.A. Abrams, L. Cardozo, S. Khoury,

& A.J. Wein (Eds.), Incontinence: Proceedings from the

Third International Consultation on Incontinence. Plymouth,

UK: Health Publications, Ltd:35-72, 2005.

117. McGrother, C.W., Donaldson, M.M., Wagg, A., Matharu,

G., Williams, K.S., Watson, J., Warsame, J., Assassa, R.P.,

et al.: Health care needs assessment. Incontinence, 2004

http://hcna.radcliffe-oxford.com/contframe.htm, Accessed

November 4, 2008.

118. Brocklehurst J.C.: Urinary-incontinence in the community

- analysis of a MORI poll. BMJ. 306: 832-4, 1993.

119. Resnick, N.: Improving treatment of urinary incontinence

JAMA, 280: 2034-5, 1998.

120. Kerfoot B.P. and Turek P.J. What every graduating medical

student should know about urology: the stakeholder

viewpoint. Urology. Apr;71(4):549-53, 2008.

121. King's Fund Centre. Action on incontinence: report of a

working group. King's Fund Project Paper, No 83, King

Edward’s Hospital Fund for London, London, 1983

122. Walters M.D. and Realini J.P.: The evaluation and treatment

of urinary incontinence in women: a primary care approach.

J Am Board Fam Pract. May-Jun;5(3):289-301, 1992.

123. McDowell B.J., Silverman M., Martin D., Musa D., and

Keane C.: Identification and intervention for urinary

incontinence by community physicians and geriatric

assessment teams. Journal of the American Geriatric Society

42: 501-5, 1994.

124. Jolleys, J.V. and Wilson, J.: GPs lack confidence (Letter).

Br Med J, 306:1344, 1993.

125. Henalla S.M., Hutchins C.J., Robinson P., and Macvicar J.:

Non-operative methods in the treatment of female genuine

stress-incontinence of urine. J Obstetrics and Gynaecology.;

9: 222-5, 1989.

126. Briggs M. and Williams E.S.: Urinary Incontinence British

Medical J.304(6821):255, 1992.

127. Szonyi, G. and Millard, R.J.: Controlled trial evaluation of a

general practitioner education package on incontinence:

1675

use of a mailed questionnaire. Br J Urology, 73:615-620,

1994.

128. Lagro-Janssen, A.L.M., Debruyne, F.M.J., Smits, A.J.A., et

al: The effects of treatment of urinary incontinence in general

practice. Family Practice, 9:284-289, 1992.

129. Durrant JS, and Snape, J.: Urinary incontinence in nursing

homes for older people. Age and Ageing. 32:12-8, 2003.

130. Thekkinkattil, D.K., Lim M., Finan P.J., Sagar P.M., Burke

D.: Awareness of investigations and treatment of faecal

incontinence among the general practitioners: a postal

questionnaire survey. Colorectal Disease 10 (3):263-267,

2008.

131. Mazmanian P.E. and Davis D.A.: Continuing medical

education and the physician as a learner: guide to the

evidence. JAMA. Sep 4;288(9):1057-60, 2002.

132. Levine S.A., Brett B., Robinson B.E., Statos G.A. et al.:

Practicing physician education in geriatrics: lessons learned

for the train-the-trainer model. J American Geriatrics Society,

55,8:1281-1286, 2007.

133. Nichol, D., Ward, J., McMullin, R., et al: Urological training

in Australasia: perceptions of recent fellows and current

trainees. Australian and New Zealand J Surg, 65:278-283,

1995.

134. Hosker, G.L., Kilcoyne, P.M., Lord, J.C., et al: Urodynamic

services, personnel and training in the UK. Br J Urology,

79:159-162, 1997.

135. Ellis-Jones J., Swithinbank L., and Abrams P.:The impact

of formal education and training on urodynamic practice in

the United Kingdom: a survey. Neurourol Urodyn. 25(5):406-

10, 2006.

136. Cheater F.M., Baker R., Gillies C., Wailoo A., Spiers N.,

Reddish S., Robertson N., and Cawood C.: The nature and

impact of urinary incontinence experienced by patients

receiving community nursing services: a cross-sectional

cohort study. Int J Nurs Stud. Mar;45(3):339-51, 2008.

137. Rogalski, N.M. A graduate nursing curriculum for the

evaluation and management of urinary incontinence.

Educational Gerontology 31, 2:139-159, 2005.

138. Cheater, F.M.: Nurses' educational and knowledge

concerning continence promotion. J Advanced Nurs,

17:328-338, 1992.

139. Mansson-Linstrom, A., Dehlin, O., and Isacsson, A.: Urinary

incontinence in primary health care: perceived knowledge

and training among various categories of nursing personnel

and care units. Scand J Primary Health Care, 12:169-174,

1994.

140. Palmer, M.H. Nurses’ knowledge and beliefs about

continence interventions in long-term care. Journal of

Advanced Nursing, 21, 1065–1072, 1995.

141. Wyman, J.F., Bliss, D.Z., Dougherty, M.C., Gray, M., Kaas,

M., Newman, D.K., and Palmer, M.H.: Shaping future

directions in incontinence research in aging adults. Nursing

Research, 53(suppl):S1-10, 2004.

142. Cheater FM, Baker R, Reddish S, Spiers N, Wailoo A, Gillies

C et al. Cluster randomised controlled trial of the

effectiveness of audit and feedback and educational outreach

on improving nursing practice and patient outcomes. Medical

Care, 44,6:542-51, 2006.

143. Ostaszkiewski J. A clinical nursing leadership model for

enhancing continence care for older adults in a subacute

inpatient setting. J WOCN. 33 (6):624-9, 2006.

144. DeLaine C., Scammell J., and Heaslip V: Continence care

and policy initiatives. Nursing Standard 2002 Oct 30-Nov

5;17(7):45-51, 2002.

145. Williams, K.S., Assassa, R.P., Smith, N.K., Shaw, C., and

Carter, E.: Educational preparation: specialist practice in

continence care. Br J Nurs, 8:1198 – 1207, 1999.

146. Beitz, JM and Snarponis, JA.: Strategies for online teaching:

lessons learned. Nurse Educator, 31, 1:20-5, 2006.

147. Wells, A. and Malone-Lee, J. G.: The assessment of a

continence advisory service. 146-146. Rome, International

Continence Society, 1993.

148. Wilson J., An introduction to multidisciplinary Pathways of

Care. Northern Region Health Authority, Newcastle upon

Tyne; 1992.

149. Bayliss, V., Cherry, M., Locke, R., and Salter, E.: Pathways

for continence care: development of pathways. Br J Nurs.

9:1165-1172, 2000.

150. Bayliss, V. : Pathways for continence care: an audit to

assess how they are used, Br J Nurs. 12, 857-863, 2003.

151. Jirovec, M.M., Wyman, J.F., and Wells, T.J.: Addressing

urinary incontinence with educational continence-care

competencies. Image J Nurs Sch, 30:375-8, 1998.

152. Hall, C., Castleden, C.M., and Grove, G.J.: Fifty six continence

advisers, one peripatetic teacher. Br Med J, 297:1181-2,

1988.

153. Jha S., Moran P., Blackwell A., and Greenham H.: Integrated

care pathways: the way forward for continence services?

Eur J Obstet Gynecol Reprod Biol. Sep;134(1):120-5, 2007.

154. Connor, P.A. and Kooker B.M.: Nurses knowledge, attitudes

and practices in managing urinary incontinence in the acute

care setting. Medsurg Nurs, 5:87-92, 1996.

155. Cheater, F. M.: Urinary incontinence in hospital in-patients.

A nursing perspective. University of Nottingham, UK, 1990.

156. Cheater, F.M.: Attitudes towards urinary incontinence.

Nursing Standard, 5: 23-27, 1991.

157. Cheater, F.M.: Nurses' educational preparation and

knowledge concerning continence promotion. J Adv Nurs.

Mar;17(3):328-38, 1992.

158. Rigby, D.: The value of continence training: does it change

clinical practice? Br J Nurs, 12: 484-492, 2003.

159. Jacobs, M., Wyman, J.F., Rowell, P., and Smith D.;

Continence nurses: A survey of who they are and what they

do. Urologic Nurs, 18:13-20, 1998.

160. Slack A., Hill A., and Jackson S.: Is there a role for a specialist

physiotherapist in the multi-disciplinary management of

women with stress incontinence referred from primary care

to a specialist continence clinic? J Obstet Gynaecol.

May;28(4):410-2, 2008.

161. Agency for Health Care Policy and Research. Urinary

incontinence in adults: Clinical practice guideline. (AHCPR

Publication No. 92-0038). Rockville, MD: Author, 1992.

162. Rao S.S.: American College of Gastroenterology Practice

Parameters Committee. Diagnosis and management of

fecal incontinence. American College of Gastroenterology

Practice Parameters Committee. Am J Gastroenterol. 2004

Aug;99(8):1585-604, 2004.

163. American College of Obstetricians and Gynecologists

(ACOG). Urinary incontinence in women. Washington (DC):

American College of Obstetricians and Gynecologists

(ACOG); Jun. 13 p. (ACOG practice bulletin; no. 63), 2005.

164. National Institute for Health and Clinical Excellence (NICE)

guideline. Faecal incontinence: the management of faecal

incontinence in adults NICE Clinical Guideline June 2007.

http://www.nice.org.uk/nicemedia/pdf/CG49NICEGuidance.p

df, Accessed September 14, 2008.

165. National Institute for Health and Clinical Excellence (NICE)

guideline. Urinary Incontinence- The management of urinary

incontinence in women. NICE Clinical Guideline October

2006.http://www.nice.org.uk/nicemedia/pdf/CG40NICEguidel

ine.pdf, Accessed December 14, 2008.

166. NIH State-of-the-Science Conference on Prevention of Fecal

1676

and Urinary Incontinence in Adults. National Institutes of

Health, Office of Director, 24(1); December 10-12, 2007,

http://consensus.nih.gov/2007/2007IncontinenceSOS030Sta

tementpdf.pdf, Accessed on November 15, 2008.

167. Shamliyan, T., Wyman, J., Bliss, DZ., Kane, RL., and Wilt,

TJ.: Prevention of Urinary and Fecal Incontinence in Adults,

Evidence Report/Technology Assessment, Number 161

Agency for Healthcare Research and Quality, Publication

No. 08-E003, December 2007, http://www.ahrq.gov/

downloads/pub/evidence/pdf/fuiad/fuiad.pdf, Accessed

September 14, 2008.

168. Nishizawa, O., Ishizuka, O., Okamura, K., Gotoh, M.,

Hasegawa, T., Hirao, Y. Guidelines for management of

urinary incontinence. International Journal of Urology. 15(10);

October: 857-874, 2008.

169. McFall, S., Yerkes, A.M., Bernard, M., and Le Rud T.:

Evaluation and treatment of urinary incontinence. Report

of a physician survey. Arch Fam Med, 6:114-9, 1997.

170. Bland, D.R., Dugan, E., Cohen, S.J., Preisser J., Davis,

C.C., McGann, P.E., Suggs, P.K. and Pearce K.F.: The

effects of implementation of the Agency for Health Care

Policy and Research urinary incontinence guidelines in

primary care practices. J Am Geriatrics Society, 51: 979-

984, 2003.

171. Button, D., Roe, B., Webb, C., Frith, T., Colin-Thome, D.,

and Gardner L.: Consensus guidelines for the promotion and

management of continence by primary health care teams:

development, implementation and evaluation. J Adv Nurs.

l27: 91-99, 1998.

172. Sampselle C.M., Wyman J.F., Thomas K.K., Newman D.K.,

Gray M., Dougherty M., Burns P.A.: Continence for women:

a test of AWHONN's evidence-based protocol in clinical

practice. Association of Women's Health Obstetric and

Neonatal Nurses. J Obstet Gynecol Neonatal Nurs. Jan-

Feb;29(1):18-26, 2000.

173. Watson, N.M., Brink, C.A., Zimmer, J.G., and Mayer, R.D.

Use of the Agency for Health Care Policy and Research

Urinary Incontinence Guideline in nursing homes. J American

Geriatrics Society, 51: 1779–1786, 2003.

174. Penning-van Beest F.J., Sturkenboom M.C., Bemelmans B.L,

and Herings R.M.: Undertreatment of urinary incontinence

in general practice. Ann Pharmacother. 2005 Jan;39(1):17-

21, 2005.

175. Woodford, H.; NICE Guidelines on urinary incontinence in

women (letter to the editor) Age Ageing 36, 349-350, 2007.

176. Fung CH. Computerized condition-specific templates for

improving care of geriatric syndromes in a primary care

setting. J Gen Intern Med. Sep;21(9):989-94, 2006.

177. Cohen, S.J, Robinson D., Dugan, E., Howard, G., Suggs,

P.K., Pearce, K.F., Carroll, D.D., McGann P., and Preisser

J.: Communication between older adults and their physicians

about urinary incontinence. J Gerontology, 54A: M34-M37,

1999.

178. Lomas, J., Anderson, G.M., Domnick-Pierre, K., Vayda, E.,

Enkin, M.W., and Hannah, W.J.: Do practice guidelines

guide practice? The effect of a consensus statement on

the practice of physicians. N Eng J Med. 321(19):1306-11,

1989.

179. Woolf, S.H: Changing physician practice behavior: the

merits of a diagnostic approach. J Fam Pract, 49:126-9,

2000.

180. Welz-Barth, A., Fusgen, I., and Melchior, H.J.: A 1999 rerun

of the 1996 German Urinary Incontinence Survey: will

doctors ever ask? World J Urol. 18:436-8, 2000.

181. Cochran, A. Don’t ask, don’t tell: the incontinence conspiracy.

Manag Care Q, 8(1):44-52, 2000.

182. Holroyd-Leduc, J.M and Strauss, S.E.: Management of

urinary incontinence in women, scientific review. JAMA,

291:986-995, 2004.

183. DuBeau C., Ouslander J.G., Palmer M.H. Knowledge and

attitudes of nursing home staff and surveyors about the

revised federal guidance for continence care. Gerontologist

47 (4):468-79, 2007.

184. Hunter, K.F., Moore, K.N., Cody, D.J., and Glazener, C.M.:

Conservative management for postprostatectomy urinary

incontinence. Cochrane Database Syst Apr

18;(2):CD001843, Rev.2007.

185. Russell LM, Rubin, G., L., and Leeder, S.R. . Preventive

health reform: what does it mean for public health. Medical

Journal of Australia. June 16;188(12):715 – 9, 2008.

186. Froom P, and Benbassat, J.: Inconsistencies in the

classification of preventive interventions. Preventive

Medicine. 31(2):153 – 8, 2000.

187. Jarrett N.C., Bellamy, C.D., and Adeyemi, S.A.: Men's health

help-seeking and implications for practice. American Journal

of Health Studies. 22(2):88 – 95, 2007.

188. Litman HJ and McKinlay JB.; The future magnitude of

urological symptoms in the USA: projections using the

Boston Area Community Health survey. BJU International.

100:820 – 5, 2007.

189. Farage MA., Miller, K.W.; Berardesca, E.; and Maibach,

H.I.: Psychosocial and societal burden of incontinence in

the aged population: a review. Arch Gynecol Obstet.

277:285–90, 2008.

190. McCallum,J., Simon, L., and Simons, J. The Dubbo study

of the health of the elderly.1998 – 2002:An epidemiological

study of hospital and residential care. Aust Health Policy

Institute, University of Sydney, Commissioned paper series

2003-06. 2006

http://www.dubbostudy.org/dubbostudy.nsf/main/unisyd/$File

/dubbo%20study.pdf Accessed Nov 6, 2008.

191. Clemesha L, and Davies, E:. Educating home carers on

faecal continence in people in dementia Nursing Standard.

May 5;18(34):33 – 40, 2004.

192. Rimer BK and Glanz K.: Theory at a glance: a guide for

health promotion practice (Second edition). National

Institutes of Health [NIH], National Cancer Institute,

Bethesda, Maryland, NIH Publication No. 05-3896, 2005.

193. Albers-Heitner P, Berghmans, B.; Nieman, F.; Largo-

Janssen, T, and Winkens, R.: How do patients with urinary

incontinence perceive care given by their general

practitioner? A cross-sectional study. International Journal

of Clinical Practice. March;62(3):503 – 15, 2008.

194. Rortveit, G., Daltveit, A.K., Hannestad, Y.S., and Hunskaar,

S.: Urinary incontinence after vaginal delivery or caesarean

section. New Eng J Med, 348:900-907, 2003.

195. Sampselle, C.M., Harlow, S.D., Skurnick, J., Brubaker, L.,

and Bondarond, I.: Urinary incontinence predictors and life

impact in ethnically diverse perimenopausal women. Obstet

Gynecol, 100(6):1230-1238, 2002.

196. Hunskaar, S., Arnold, E.P, Burgio, K., Diokno, A.C., Herzog,

A.R., and Mallett, V.T.: Epidemiology and natural history of

urinary incontinence. Int Urogyn J Pelvic Floor Dysfunction,

11:301-19, 2000.

197. Waetjen EL, Liao, S., Johnson, W.O., Sampselle, C.M.,

Strenfield, B., Harlow, S.D., and Gold, E.B.: Factors

associated with prevalent and incident urinary incontinence

in a cohort of midlife women: a longitudinal analysis of data.

American Journal of Epidemiology. 165(3):309 – 18, 2007.

198. Hunskaar, S.: A systematic review of overweight and obesity

as risk factors and targets for clinical intervention for urinary

incontinence in women. Neurourol Urodyn. 27(8):749-57,

2008.

1677

199. Lawrence JML, E.S.;Lui, I-L.A.; Nager, C.W.; and Luber,

K.M.: Pelvic floor disorders, diabetes and obesity in women.

Diabetes Care. 30:2356 – 41, 2007.

200. Wasserberg N, Haney, M., Petrone, P., Ritter, M., Emami,

C., Rosca, J., Siegmund, M., and Kaufman, H.S.: Morbid

obesity adversely impacts pelvic floor function in females

seeking attention for weight loss surgery. Diseases of the

Colon & Rectum. 50:2096 -103, 2007.

201. Waetjen E, Feng, W-Y., Ye, J., Johnson, W.O., Greendale,

G.A., Sampselle, C.M., Sternfield, B., Harlow, S.D., and

Gold, E.B.: Factors associated with worsening and improving

urinary incontinence across the menopausal transition

Obstetrics and Gynecology. 111:667 – 77, 2008.

202. Subak LL, Johnson C, Whitcomb E, Boban D, Saxton J,

Brown JS. Does weight loss improve incontinence in

moderately obese women? Int Urogynecol J Pelvic Floor

Dysfunct. 13(1):40-3, 2002.

203. Brown J.S., Wing R., Barrett-Connor E., Nyberg L.M., Kusek

J.W., Orchard T.J., Ma Y., Vittinghoff E., Kanaya A.M. and

Diabetes Prevention Program Research Group: Lifestyle

intervention is associated with lower prevalence of urinary

incontinence: the Diabetes Prevention Program. Diabetes

Care. Feb;29(2):385-90, 2006.

204. Burgio K.L., Richter H.E., Clements R.H., Redden D.T.,

and Goode P.S..: Changes in urinary and fecal incontinence

symptoms with weight loss surgery in morbidly obese

women. Obstet Gynecol. Nov;110(5):1034-40, 2007.

205. Townsend M.K., Curhan G.C., Resnick N.M., and Grodstein

F.: BMI, waist circumference, and incident urinary

incontinence in older women. Obesity (Silver Spring).

Apr;16(4):881-6, 2008.

206. Brown J.: Urinary incontinence: an important and

underrecognized complication of type 2 diabetes mellitus.

JAGS. 53:2028 – 9, 2005.

207. Goldstraw MAK, M.G.; Bhardwa, J.and Kirby, R.S.: Diabetes

and the urologist: a growing problem. BJU International.

99:513 – 7, 2006.

208. Jackson SLS, D.; Boyko, E.J.; Abraham, L.; and Fihn, S.:

Predictors of urinary incontinence in a prospective cohort

of postmenoapusal women Obstetrics & Gynecology.

108(4):855 – 62, 2006.

209. Lifford KL, Curhan, G.C., Hu, F.B., Barbieri, R.L., and

Grodstein, F.: Type 2 Diabetes Mellitus and risk of developing

urinary incontinence Journal of the American Gerontology

Association 53:1851 – 7, 2005.

210. Hashim H. and Abrams, P.: How should patients with

overactive bladder manipulate their fluid intake? BJU

International. (February):1 – 5, 2008

211. Bird, E.T., Parker, B.D., Kim, H.S., and Coffield, K.S.:

Caffeine ingestion and lower tract symptoms in healthy

volunteers. Neurourology and urodynamics. 24:611 – 5,

2005

212. Cartwright, R, Srikrishna, S., Cardozo, L., and Gonzalez, J.:

Does diet coke cause overactive bladder? a 4-way crossover

trial, investigating the effect of carbonated soft drinks on

overactive bladder symptoms in normal volunteers.

Presented at 37th Annual Scientific Meeting of the

International Continence Society Rotterdam, The

Netherlands 2007 as a poster presentation.

213. Liao, Y-M, Dougherty, M.C., Biemer, P.P., Liao, C-T., Palmer,

M.H., Boyington, A.R., and Connolly, A.: Factors related to

lower urinary tract symptoms among a sample of employed

women in Taipei. Neurourology and Urodynamics. 27:52 –

9, 2008.

214. Warren, J.W., Brown, J., Tracy, J.K., Langenberg, P.,

Wesselmann U, and Greenberg, P.: Evidence-Based Criteria

for Pain of Interstitial Cystitis/Painful Bladder Syndrome in

Women. Urology. 71(3):444 – 8, 2008.

215. Theoharides, T.C.: Treatment approaches for painful bladder

syndrome/interstitial cystitis. [Review]. Drugs. 2007;

67(2):215-35.

216. Shorter, B.: Topics in Clinical Nutrition. The Potential Role

of Diet in the Treatment of Interstitial Cystitis/Painful Bladder

Syndrome.[Review] October/December 21(4):312-9, 2006.

217. Eliasson K, Norlander, I., Larson, B., Hammarstrom, M.,

and Mattsson, E. Influence of physical activity on urinary

leakage in primiparous women. Scandanavian Journal of

Medical Science Sports. May 21;15:87 – 94, 2005.

218. Gray M, Albo, M., and Huffstutler, S. Interstitial Cystitis: A

Guide to Recognition, Evaluation, and Management for

Nurse Practitioners. Journal of Wound, Ostomy &

Continence Nursing. 29:93 – 102, 2002.

219. Danforth KN, Shah, A.D.; Townsend, M.K.; Lifford, K.L.;

Curhan, G.C.; Resnick, N.M.; and Grodstein, F. Physical

Activity and Urinary Incontinence Among Healthy, Older

Women Obstetrics & Gynecology. 109(3):721 – 7, 2007.

220. Nygaard I, Girts, T.; Fultz, N.H.; Kinchen, K.; Pohl, G.; and

Sternfeld, B. Is urinary incontinence a barrier to exercise?

Obstetrics & Gynecology. August;106(2):307 – 14, 2005.

221. Goldacre MJ, Abisgold, J.D., Yeates, D.G.R., Voss, S. and

Seagroatt, V. Self-harm and depression in women with

urinary incontinence: a record-linkage study. BJU

International. September;99:601 – 5, 2006.

222. Melville JLD, K.; Newton, K.; and Katon, W. Incontinence

severity and major depression in incontinent women

Obstetrics & Gynecology. 106(3):585 – 92, 2005.

223. World Health Organization (WHO). Programmes and

projects main content The world is fast ageing - have we

noticed? 2008, Available from: http://www.who.int/ ageing/

en/. Accessed November 3, 2008.

224. Mayer R. Interstitial cystitis pathogenesis and treatment.

Current Opinion in Infectious Diseases. 20:77–82, 2007.

225. Brand K, Littlejohn G, Kristjanson L, Wisniewski S, Hassard

T. The fibromyalgia bladder index. Clin Rheumatol. Dec;

26(12) :2097-103, 2007.

226. Sampselle, C.M., Palmer, M.K., Boyington, A. R., O’Dell,

K.K., and Wooldridge, L.: Prevention of urinary incontinence

in adults. Nurs Res, 53, Suppl 6.,S61-67, 2004.

227. Manonai J, Poowapiron, A., Kittipiboon, S., Patrachai, S.,

Udomubpayakul, U., and Chittacharoen. Female urinary

incontinence: a cross-sectional study from a rural Thai area

International Urogynecology Journal. 17(4):321 – 5, 2006.

228. Wesnes S, Rortveit, G., Bo, K., and Hunskaar, S. Urinary

incontinence during pregnancy Obstetrics & Gynecology.

109(4):922 – 8, 2007.

229. Pretlove SJ, Thompson, P.J., Toozs-Hobson,P.M., Radley,

S., and Khana, K.S.: Does the mode of delivery predispose

women to anal incontinence in the first year postpartum?

A comparative systematic review. International Journal of

Obstetrics and Gynaecology.115:421 – 34, 2008.

230. Stainton MC, Strahle A, Fethney J. Leaking urine prior to

pregnancy: a risk factor for postnatal incontinence. Aust N

Z J Obstet Gynaecol. Aug;45(4):295-9, 2005.

231. Dietz HP, Simpson JM. Does delayed child-bearing increase

the risk of levator injury in labour? Aust N Z J Obstet

Gynaecol. Dec;47(6):491-5, 2007.

232. Haddow G, Watts, R., and Robertson, J. Effectiveness of

a pelvic floor muscle exercise program on urinary

incontinence following childbirth. International Journal of

Evidence Based Healthcare. 3:103 – 46, 2005.

233. Glazener C, Herbison G, MacArthur C, Lancashire R, McGee

M, Grant A, Wilson P. New postnatal urinary incontinence:

obstetric and other risk factors in primiparae. BJOG;

113:208–217, 2006.

1678

234. Woldringh C, van den Wijngaart M, Albers-Heitner P,

Lycklama à Nijeholt AA, Lagro-Janssen T. Pelvic floor muscle

training is not effective in women with UI in pregnancy: a

randomised controlled trial. Int Urogynecol J Pelvic Floor

Dysfunct. Apr;18(4):383-90, 2007.

235. Herbruck LF. Stress urinary incontinence: Prevention,

management and provider education Urologic Nursing.

June;28(3):200 – 6, 2008.

236. MacArthur, C., Glazener, C.M.A., Wilson, D., Lancashire,

R.J., Herbison, G.P., and Grant, A.M.: Persistent urinary

incontinence and delivery mode history: A six-year

longitudinal study, BJOG; 113:218-224-2006.

237. Foldspang A, Hvidman L, Mommsen S, Nielsen JB. Risk of

postpartum urinary incontinence associated with pregnancy

and mode of delivery. Acta Obstet Gynecol Scand.

Oct;83(10):923-7, 2004.

238. Bo K, Haakstad, L.A.H., and Volner, N. Do pregnant women

exercise their pelvic floor muscles? International

Urogynecology Journal. 18:733 – 6. 2007.

239. Freeman R. Initial management of stress urinary incontinence:

pelvic floor muscle training and duloxetine. BJOG : An

International Journal of Obstetrics and Gynaecology.

113(s1):10 – 6, 2006.

240. Hay-Smith J, Mørkved S, Fairbrother KA, Herbison GP.

Pelvic floor muscle training for prevention and treatment of

urinary and faecal incontinence in antenatal and postnatal

women. Cochrane Database Syst Rev. Oct 8;(4):CD007471,

2008.

241. Van Kampen, M., DeWeerdt, H., VanPoppel, H., DeRidder,

D., Feys, H., and Baert, L.: Effect of pelvic floor re-education

on duration and degree of incontinence after radical

prostatectomy: A randomized controlled trial. Lancet, 355:98-

102, 2000.

242. Sueppel, C., Kreder, K., and See, W.: Improved continence

outcomes with preoperative pelvic floor muscle strengthening

exercises. Urologic Nurs, 21:201-209, 2001.

243. Moorhouse, D.L., Robinson, J.P., Bradway, C, Zoltick, B.H.,

and Newman, D.K.: Behavioral treatments for post

prostatectomy incontinence. Ostomy Wound Management,

47:30-42, 2001.

244. Nahon I., Dorey G., Waddington G., and Adams R.

:Systematic review of the treatment of post-prostatectomy

incontinence. Urol Nurs. Dec;26(6):461-75, 482, 2006.

245. O'Connell, B., Baker, L., and Munro, I.: The nature and

impact of incontinence in men who have undergone prostate

surgery and implications for nursing practice Contemporary

Nurse. February 24(1):65 – 78, 2007.

246. Moore KN, Truong, V., Estey, E., and Voaklander, D.C.:

Urinary Incontinence after radical prostatectomy:can men

be identified preoperatively? Journal of Wound, Ostomy &

Continence Nursing. 34(3):270 – 9, 2007.

247. Hunter, K.F., Moore, K.N., Cody, D.J., & Glazener, C.M.

Conservative management for postprostatectomy urinary

incontinence. Cochrane Database Syst Apr 18;(2):

CD001843, Rev.2007.

248. Burgio K.L, Goode, P.S., Urnab, D.A., Umlauf, M.G., Locher,

J.L., Bueschen, A., and Redden, D.T. Pre-operative

biofeedback assisted behavioral training to decrease post-

prostatectomy incontinence: a randomized, controlled trial

The Journal of Urology. January;175(1):196 – 201, 2006.

249. Robinson J.P.B., Nuamah, I.; Pickett, M.; and McCorkle,

R.: Systematic pelvic floor training for lower urinary tract

symptoms post prostatectomy: a randomised clinical trial.

International Journal of Urological Nursing. 2(1):3 – 13,

2008.

250. MacDonald RF, H.A; Huckabay, C.; Monga, M.; and Wilt,

T.J. Pelvic floor muscle training to improve urinary

incontinence after radical prostatectomy: a systematic

review of effectiveness. BJU International; 100:76 – 81,

2007.

251. Howat P, Boldy, D., and Horner, B. Promoting the health of

older Australians: program options, priorities and research.

Australian Health Review. 27(1):49 – 55, 2004.

252. Gieck DJ, and Olsen, S. Holistic Wellness as a means to

developing a lifestyle approach to health behavior among

college students Journal of American College

Health;56(1):29 – 35, 2007.

253. Tannenbaum C, Brouillette, J., Korner-Bitensky, N., Dumoulin,

C., Corcos, J., Tu, L.M., Lemieux, M-C, Oullet, S., and

Valiquette, L. Creation and testing of the Geriatric Self-

Efficacy Index for urinary incontinence. JAGS.

March;56(3):S42-S7, 2008.

254. Kincade J.E., Dougherty, M.C., Carlson, J.R., Hunter, G.S.,

and Whitehead, J.B. Randomized clinical trial of efficacy of

self-monitoring techniques to treat urinary incontinence in

women Neurourology and Urodynamics. 26:507 – 11,

2007.

255. Messer K.L, Hines, S.H., Raghunathan, T.E., Seng, J.S.,

Diokno, A.C., and Sampselle, C.M.: Self-efficacy as a

predictor to PFMT adherence in a prevention of urinary

incontinence trial Health Education and Behavior. 34:942

– 52, 2007.

256. Diokno, A.C., Sampselle, C.M., Herzog, A.G., Raghunathan,

T.E., Hines, S., and Messer K.L., et al: Prevention of urinary

incontinence by behavioral modification program: A

randomized controlled trial among older women in the

community. J Urology, 171(3):1165-71, 2004.

257. Shamliyan T.A, Kane, R.L., Wyman, J., and Wilt, T.J.:

Systematic review: Randomized, controlled trials of

nonsurgical treatments for urinary incontinence in women.

Annals of Internal Medicine. March 18;148(6):1 – 15, 2008.

258. Teunissen T.A.M., Largo-Janssen, A.L.M., van den Bosch,

W.J.H.M., and van den Hoogen, H.J.M.: Prevalence of

urinary, fecal and double incontinence in the elderly living

at home International Urogynecology Journal 15:10 – 3,

2005.

259. Stenzelius K, Mattiasson, A., Hallberg, I. R., and Westergren,

A.: Symptoms of urinary and faecal incontinence among man

and women 75+ in relations to health complaints and quality

of life. Neurourology and urodynamics. 23:211-22, 2004.

260. Chen, H. and Guo, X.: Obesity and functional disability in

elderly Americans. JAGS 56:689-94, 2008.

261. Landi F., Cesari, M., Russo, A., Onder, G., Lattanzo, F.,

and Bernabei, R.: Potentially reversible risk factors and

urinary incontinence in frail older people living in the

community. Age and Ageing. 32(2):194-9, 2003.

262. Hill, K:. Clinical Perspectives Assessment and management

of falls in older people. International Medical Journal 34,

557-564, 2004.

263. Laidlaw S. and Gillespie, N.: A review of diuretic use in older

people. Reviews in Clinical Gerontology. 16:281 – 9, 2006.

264. Morris, V. and Wagg, A.: Lower urinary tract symptoms,

incontinence and falls in elderly people: time for an

intervention study. Int J Clin Pract.61 (2): 320 -323, 2007.

265. Fernando R.J., Thakar, R., Sultan, A.H., and Shah, S.M.:

Effect of vaginal pessaries on symptoms associated with

pelvic organ prolapse. Obstetrics & Gynecology.

July;108(1):93 – 9, 2006.

266. Nygaard I., Bradley, C., and Brandt, D.: Pelvic organ prolapse

in older women: prevalence and risk factors. Obstetrics &

Gynecology. 104(3):489 – 97, 2004.

267. Bradley C.S., Zimmerman, M.B., Qi, Y., and Nygaard, I.E.:

Natural history of pelvic organ prolapse in postmenopausal

women Obstetrics & Gynecology. 109(4):848 – 54, 2007.

1679

268. Rortveit G., Brown, J.S, Thom, D.H., Van Den Eeden, S.K.,

Creasman, J.M., and Subak, L.L.: Symptomatic pelvic organ

prolapse. Obstetrics & Gynecology. June;109(6):1396 –

403, 2007.

269. Jelovsek J.E., Maher, C., and Barber, D.: Pelvic organ

prolapse. Lancet. March 24;369(9566):1027 – 38, 2007.

270. Teunissen, T.A.M., Largo-Janssen, A.L.M., van den Bosch,

W.J.H.M., and van den Hoogen, H.J.M.: Prevalence of

urinary, fecal and double incontinence in the elderly living

at home International Urogynecology Journal 15:10 – 3,

2005.

271. Wasserberg, N, Haney, M., Petrone, P., Crookes, P., Rosca,

J., Ritter, M., and Kaufman, H.S.: Fecal incontinence among

morbid obese women seeking for weight loss surgery: an

underappreciated association with adverse impact on quality

of life Int J Colorectal Dis 23:493–497, 2008

272. Varma, M.G., Brown J.S., Creasman J.M., Thom D.H., Van

Den Eeden S.K., Beattie M.S. and Subak L.L.: Reproductive

Risks for Incontinence Study at Kaiser (RRISK) Research

Group. Fecal incontinence in females older than aged 40

years: who is at risk? Dis Colon Rectum. Jun;49(6):841-51,

2006.

273. Bartlett, L, Nowak M, Ho Y-H.: Reasons for non-disclosure

of faecal incontinence: a comparison between two survey

methods. Techn Coloproct; 11: 251-57, 2007.

274. Bharucha, A.E., Zinsmeister, A.R., Locke, G.R., Seide, B.M.,

McKeon, K., Schleck, C.D., et al. Risk factors for fecal

incontinence: A population-based study in women. American

Journal of Gastroenterology, 101,1305–1312, 2006.

275. Boreham, M.K., Richter H.E., Kenton K.S., Nager, C.W.,

Gregory, W. T., Aronson, M.P.,Vogt, V.Y., McIntire, D. D., and

Schaffer, J.I.: Anal incontinence in women presenting for

gynecologic care: prevalence, risk factors, and impact upon

quality of life. American Journal of Obstetrics and

Gynecology. 192:1637– 42, 2005.

276. Gulec, H.: Normalizing attributions may contribute to non-

help seeking behavior in people with fibromyalgia syndrome.

Psychosomatics. May - June;49(3):212 – 7, 2008.

1680

AUSTRALIA

*Continence Foundation of Australia Ltd

AMA House, 293 Royal Parade

Parkville, Victoria 3052

Tel: 03 9347 2522

Fax: 03 9347 2533

website: www

.continence.org.au

Email: [email protected]

AUSTRIA

*Medizinische Geseelschaft fur

Inkontinenhlife Osterreich

Speckbacherstrasse 1 A-6020, Innsbruck

Tel: (43) 512 58 38 03

Fax: (43) 512 58 94 86

Website: www

.inkontinenz.at

Email: [email protected]

BELGIUM

*U-Control vzw,

(Belgian Association for Incontinence)

Leopoldstraat 24

B-30000 Leuven

Tel: 32 8161 6455/32 38213047

Fax: 32 816 16270/32 382 14475

Email: [email protected]

BRAZIL

*Urobel Belgian association for urological

nurses and associates

De Pintelaan 185, BE-9000, Gent

Tel.: 09/240.27.65

Fax: 09/240.38.89

Website: www.urobel.be

*Brazilian Foundation for Continence Promotion

Email: [email protected]

CANADA

*The Canadian Continence Foundation

PO Box 417, Peterborough, Ontario, K9J6Z3

Tel: (1) 705-750-4600

Fax: (1) 705-750-1770

Website: www

.canadiancontinance.ca

CZECH REPUBLIC

*Inco Forum

Tel: (420) 02-61-082135

Fax: (420) 02-61-082135

Website: www.incoforum.cz/

DENMARK

*Kontinensoreningen-

Danish Continence Association

(The Danish Association of Incontinent People)

Vesterbrogade 64, 1620 Copenhagen V

Website: www.kontinens.dk/

FRANCE

*Feemes pour Toujourns

Nicole Kremer, President

17 rue des Nanettes, Paris 75011

Tel: 33 (0) 147000002

33 (0) 826623195

Fax: 33 (0) 147000006

Website: www

.femsante.com

GERMANY

*Deutsche Kontinenz Gesellschaft e.V.

Friedrich-Ebert-Strasse 124

34119 Kassel

Tel: (49) 561 78 06 04

Fax: (49) 561 77 67 70

Website: www

.gih.de

HONG KONG

*Hong Kong Continence Society

c/o Dept of Medicine and Geriatrics

United Christian Hospital

130 Hip Wo Street, Kwun Tong.

Kowloon, Hong Kong

Tel: 852 237 94822 Fax: 852 234 72325

Email: [email protected]

HUNGARY

*Inko Forum

Levelezeski cim

Budapest, Pf 701/153, 1399

Phone: 06 80 730 007 Website: www

.inkoforum.hu

INDIA

*Indian Continence Foundation

273/1005 1st Block, 19th C Main,

Rajajinagar, Bangalore 560 010 India

Tel: 91 80 3131833 / 3424728

Fax: 91 80 3131833/ 3325824

Website: www.indiancontinencefoundation.org

INDONESIA

*Indonesian Continence Society

Sub Dept of Urogynecology, Dept of OBGYN Medical

Faculty of University

Dr. Cipto Margunkusuma Hospital Indonesia

Tel: 62 21 392874/392/3632

Fax: 62 21 392874/3145592

Email: [email protected]

APPENDIX 1 –

DIRECTORY OF CONTINENCE ORGANIZATIONS

1681

ISRAEL

*National Center for Continence

Rambam Medical Centre, POB-9602

Haifa 31096

Tel: 972-485 43197

Fax: 972-4854 2098

Email: [email protected]

KOREA

*Korea Continence Foundation

388-1 Dep of Urology Asan Center,

Ulsan University College of Medicine

(138-736) Pungnap-2dong, Songpa-gu,

Seoul 138-736, Korea

Tel: 82 2 3010-3735

Fax: 82 2 477-8928

Website: www

.kocon.or.kr

ITALY

*Fondazione Italiana Continenza

(The Italian Continence Foundation)

Via dei Contarini, 7

201 33 Milano

Website: www.continenza-italia.org

Email: [email protected]

*Associazione Italiana Donne Medico (AIDM)

Tel: 39 335 282045/39 065 811390

Website: www

.donnemedico.org

*The Federazione Italiana INCOntinenti (FINCO)

Segreteria/Presidenza

V.le O Flacco, 24-70124 Bari

Tel: 080-5093389

Fax: 0805619181

Website: www.finco.org

JAPAN

*Japan Continence Action Society

103 Juri Heim, 1-4-2 Zenpukuji

Suginami-Ku, Tokyo, Japan 1670041

Tel: 81 3 3301 3860

Fax: 81 3 3301 3587

Website: www

.jcas.or.jp

MALAYSIA

*Continence Foundation (Malaysia)

c/o University Hospital, Lembah

Pantai, Kuala Lumpur 59100

Tele: 603 7956 4422

Fax: 603 758 6063

Email: [email protected]

MEXICO

*Asociacion de Enfremadades Uroginecologicas

ACI Mexuci AC

Tel: 53-74-36-91

Website: www

.asenug.org

NETHERLANDS

*Pelvic Floor Netherlands

PO Box 23594, 1100EB

Amsterdam

Tel: 31 20 69 70 304

Fax: 31 20 69 71 191

*Pelvic Floor Patients Foundation (SBP)

Stichting Bekkenbodem Patienten

Stationspleing

3818 LE Amersfoort

Tel: 0031-900-111999

Website: www

.bekkenbodem.net

*Vereniging Nederlandse Incontinentie,

Verpleegkundigen (V N I V)

Postbus 1206, 3434 CA Nieuwegein

Tel: (31) 30 606 0053

Fax: (31) 30 608 1312

Website: www

.cvnc.nl/

NORWAY

*NOFUS (Norwegian Society for Patients with

Urologic Diseases)

Oyjordsveien 71, 5038 Bergen

Tel: 47 55 95 35 88 – 55 33 09 30

Fax: 47 55 33 09 31

Website: www

.nofus.no

PHILIPPINES

*Continence Foundation of the Philippines

Room 201,#319 Katipunan Road

Loyola Heights, Quezon City 1108

Tel: (63) 2 4333602

Email: [email protected]

POLAND

*NTM (INCO) Forum

(The Polish Continence Organisation)

Ksiecia Janusza 64 Street

01-452 Warsaw, Poland

Tel: 48 22 8774787

Fax: 48 22 8772522

Website: www

.ntm.pl

SINGAPORE

*Society for Continence (Singapore)

Gleneagles Medical Center

6 Napier Road #06-02

Singapore 258499

Tel: (65) 6787 0337 Fax: (65) 6588 1723

Website: www

.sfcs.org.sg

NEW ZEALAND

*New Zealand Continence Assn Inc

PO Box 270

Drury, Auckland 1730

Tel: 64 9 2947738 Fax: 64 9 2947116

Website: www

.continence.org.nz

1682

SOUTH AFRICA

*Continence Association of South Africa

(CASA)

Affiliated to Association of Continence Advice

PO Box 6479, Westgate 1734

Helpline: 072 2108769

Email: [email protected]

Tel: 022 475 9700,

Fax: 011 475 8282

SPAIN

*Association National de Ostomizados e

Incontinentes (ANOI)

Tel: 34 98. 556 322

Email: [email protected]

Website: www.coalicion.org

SWEDEN

*Swedish Urotherapists

Nordensioldsgatan 10, S-413 09

Goteborg

Tel: 46 31 50 26 39

Fax: 46 31 53 68 32

Email: [email protected]

*SINOBA

Tel: 46 8 585 826 89

Email: [email protected]

Website: www.sinoba..se

SWITZERLAND

*Schweizerische Gesellschaft fur Blasenschwache

Gewerbestrasse 12 CH-8132 Egg

Tel: 41 1 994 74 30

Fax: 41 1 994 74 31

Website: www

.inkontinex.ch

Email: [email protected]

THAILAND

*Department of Surgery

Ramathibodi Hospital & Medical School

Rama6 Road, Bangkok 10400

Tel: 662-201 1315

Fax: 662-201 1316

Email: [email protected]

SLOVAKIA

*Slovakia Inco Forum

Website: www

.incoforum.sk

TAIWAN

*Taiwan Continence Society

Division of Urology,

Taipei Veterans General Hospital.

201 Sec, 2, Shih-Pai Road, Taipei, Taiwan 112

Tel: + 886 2 2871 1132

Fax: + 886 2 2871 1162

Website: http://www

.tcs.org.tw

Email: [email protected]

UNITED KINGDOM

*Association For Continence (ACA)

102a Astra House, Arklow Road

New Cross, London SE14 6EB

Tel: (44) 020 8692 4680

Fax: (44) 020 8692 6217

Website: www

.aca.uk.com

Email: [email protected]

*The Bladder and Bowel Foundation (F&BF)

Nurse helpline: 0845 345 0165

Counselor Helpline: 0870 770 3246

General Enquiries: 01536 533255

www.bladderandbowelfoundation.org

*Enuresis Resource and Information Centre (ERIC)

34 Old School House, Britannia Road

Kingswood, Bristol BS15 2DB

Tel: (44) 117 960 3060

Fax: (44) 117 960 0401

Website: www

.eric.org.uk

*Royal College of Nursing Continence Care Forum

(Royal College of Nursing)

20 Cavendish Square, London, WIM OAB

Tel: 44 020 7409 3333

Website: http://www.rcn.org.uk/

UNITED STATES

* American Urological Association Foundation

(AUAF)

1000 Corporate Boulevard

Linthicum, MD 21090

Tel: 866-746-4282

Fax: 410-689-3800

Website: http://www

.auafoundation.org/

*International Foundation for Functional

Gastrointestinal Disorders (IFFGD)

PO Box 170864

Milwaukee WI 53217-8076

Tel: 414 964 1799

Fax: 414 964 7176

Website: www.iffgd.org www.aboutincontinence.org

Email: iffgd@iffgd.org

*Interstitial Cystitis Association (ICA)

110 North Washington Street

Rockville, MD 20850

Website: www.ichelp.org

Email: [email protected]

*National Association For Continence (NAFC)

PO Box 1019, 62 Columbus Street

Charleston, SC 29402

Tel: 843 377 0900

Fax: 843 377 0905

Website: www

.nafc.org

1683

*Simon Foundation for Continence

PO Box 815, Wilmette Illinois 60091

Tel: (1) 847 864 3913

Fax: (1) 847 864 9758

Website: www

.simonfoundation.org

*Society of Urologic Nurses & Associates (SUNA)

East Holly Avenue, Box 56, Pitman, NJ 08071-0056

Tel: 888-827-7862

Website: www

.suna.org

Email: [email protected]

OTHER ADVOCACY ORGANIZATIONS

*International Painful Bladder Foundation (IPBF)

Email: info@painful-bladder

.org

Website: www.painful-bladder.org

*World Federation of Incontinent Patients (WPIF)

Email: [email protected]

Website: www

.wfip.org

1684