Urinary Incontinence in Women

Transcription

1 C H A P T E R 5 Urinry Incontinence in Women Ingrid Nygrd, MD, MS Professor of Urogynecology nd Reconstructive Pelvic Surgery Deprtment of Obstetrics nd Gynecology University of Uth School of Medicine Slt Lke City, Uth Dvid H. Thom, MD, PhD Associte Professor of Fmily nd Community Medicine University of Cliforni, Sn Frncisco Sn Frncisco, Cliforni Elizbeth Clhoun, PhD Associte Professor nd Senior Reserch Scientist Division of Helth Policy nd Administrtion School of Public Helth University of Illinois t Chicgo Chicgo, Illinois

2 Contents INTRODUCTION DEFINITION AND DIAGNOSIS PREVALENCE AND INCIDENCE RISK FACTORS TREATMENT TRENDS IN HEALTHCARE RESOURCE UTILIZATION Inptient Cre Surgicl Procedures Outptient Cre Nursing Home Cre ECONOMIC IMPACT RECOMMENDATIONS

3 Urinry Incontinence in Women Ingrid Nygrd, MD, MS Dvid H. Thom, MD, PhD Elizbeth A. Clhoun, PhD INTRODUCTION Urinry incontinence ffects from 15% to 50% of community-dwelling women of ll ges. It is one of the most prevlent chronic diseses, lthough it is often not recognized by the US helthcre system. The direct cost of urinry incontinence for women in the United Sttes ws $12.4 billion in 1995 dollrs (1). Approximtely one in ten women in the United Sttes undergoes surgery for urinry incontinence or pelvic orgn prolpse, nd sizble minority of women ber the cost of pds, medictions, nd nonsurgicl therpies. Popultion-bsed studies estimte tht lrge proportion of dult women report the symptom of urinry incontinence. As mny s three-fourths of US women report t lest some urinry lekge nd studies consistently find tht 20 to 50% report more-frequent lekge. While some uthors hve interpreted this to men tht nerly hlf of Americn women suffer from incontinence, others point out tht mny women with occsionl incontinence re not sufficiently bothered by it to seek cre. Of greter clinicl relevnce is n improved understnding of the number of women with severe or more-frequent lekge, estimted firly uniformly t 7% to 10% by vrious reserchers. Currently, there is little understnding of the number of women whose lives re truly impcted by urinry incontinence or of its true burden on Americn women. Indeed, the demrction between incontinence s symptom nd incontinence s disese is fr from cler. For exmple, 25% of femle college vrsity thletes lose urine when doing provoctive exercise, nd most do not consider it problem; indeed, most experts would gree tht these young women do not hve mjor helth problem. Conversely, most experts would gree tht middle-ged women who lose urine throughout the dy, wer pds, curtil desired ctivities becuse of lekge, nd truly suffer hve disese nd would benefit from tretment. Studies tht inquire bout the presence of ny or occsionl incontinence my overestimte the ctul burden of incontinence on the helthcre system, but vilble dt on incontinence tretment underestimte the ctul burden, given tht mny women with bothersome lekge do not seek cre. While redily vilble informtion bout incontinence tretment in dult women in the United Sttes indictes only the lowest possible burden urinry incontinence presents to the helthcre system, it does provide foundtion on which to bse future studies nd to project future cre. This chpter uses dt from vrious sources to begin defining not only the prevlence of incontinence, but lso its impct on the US helthcre system. At this time, eqully importnt informtion bout the burden of disese on women who re not seeking tretment is not vilble. The impct of incontinence on the women themselves, their fmilies, their work, nd society is lso not yet well defined in the literture. DEFINITION AND DIAGNOSIS Urinry incontinence is defined by the Interntionl Continence Society s the complint of 159

4 Urologic Diseses in Americ Tble 1. Codes used in the dignosis nd mngement of femle urinry incontinence Femles 18 yers or older, with one of the following ICD-9 dignosis codes, but not coexisting 952.XX or 953.XX code: Hypertonicity of bldder Low bldder complince Other functionl disorder of bldder Other specified disorders of urethr nd urinry trct Urethrl hypermobility Intrinsic (urethrl) sphincter deficiency (ISD) Urethrl instbility Other specified disorders of urethr Stress incontinence, femle Urinry incontinence Urinry incontinence unspecified Urge incontinence Mixed incontinence, mle, femle Incontinence without sensory wreness Continuous lekge Fistule Intestinovesicl fistul Vesicl fistul not elsewhere clssified Digestive-genitl trct fistul, femle Urinry-genitl trct fistul, femle Spinl cord injury-relted incontinence (When ssocited with other ICD-9 dignosis codes for spinl cord injury 952.XX or 953.XX) Cud equin syndrome with neurogenic bldder Hypertonicity of bldder (specified s overctive bldder in 2001; included if ssocited with dignosis code 952.XX) Low complince bldder Neurogenic bldder, NOS Detrusor sphincter dyssynergi Other functionl disorder of bldder Other specified disorders of urethr nd urinry trct Other specified disorders of urethr Stress incontinence femle Urinry incontinence Urinry incontinence, unspecified Urge incontinence Stress incontinence mle Mixed incontinence, mle nd femle Incontinence without sensory wreness Continuous lekge Other urinry incontinence 160

5 Urinry Incontinence in Women ny involuntry lekge of urine (2). This supplnts the group s previous long-held definition, in which the dignosis of incontinence required tht the lekge be socil or hygienic problem. The less restrictive definition is likely to cpture more individuls who experience incontinence, including the mny women who my lek dily but do not describe lekge s socil or hygienic problem. A dignosis of urinry incontinence cn be bsed on the ptient s symptoms, the sign of incontinence noted during physicl exmintion, or dignostic urodynmic testing. Tble 1 lists ICD-9 codes commonly used to identify urinry incontinence. The Interntionl Continence Society further ctegorizes types of incontinence, s well s other bldder symptoms. Stress urinry incontinence is the complint of involuntry lekge on effort or exertion or on sneezing or coughing. Stress urinry incontinence lso describes the sign, or observtion, of lekge from the urethr synchronous with coughing or exertion. When stress incontinence is confirmed during urodynmic testing by identifying lekge from the urethr coincident with incresed bdominl pressure (for exmple, during cough or sneeze) but in the bsence of bldder contrction, the dignosis of urodynmic stress incontinence is mde. Urge urinry incontinence is the complint of involuntry lekge ccompnied by or immeditely preceded by n urge to urinte nd my be further defined with urodynmic investigtion. Conventionl urodynmic studies tke plce in lbortory nd involve filling the bldder with liquid, then ssessing bldder function during filling nd emptying. If during urodynmic testing the ptient demonstrtes either spontneous or provoked involuntry detrusor contrctions while filling, she is sid to hve detrusor overctivity. If relevnt neurologic condition exists, the detrusor overctivity is further ctegorized s neurogenic; when no such condition is identified, the overctivity is termed idiopthic. These terms replce the previously used detrusor hyperreflexi nd detrusor instbility. Mny women with urge incontinence do not mnifest detrusor overctivity on urodynmic testing. This my be due in prt to the fct tht such testing, which lsts pproximtely n hour, is merely snpshot of the ptient s overll bldder function. Ambultory urodynmic studies cn lso be performed to document the ptient s lekge during everydy ctivities; such studies identify more detrusor contrctions during filling thn do conventionl ones. Nonetheless, tretment for urge incontinence is often bsed on implicit clinicl ssessment becuse of the low predictive vlue of negtive test. Other dignostic tests my be used to help chrcterize incontinence nd its severity. A pd test quntifies the volume of urine lost by weighing perinel pd before nd fter some type of lekge provoction. This type of test hs lso been used in ttempts to distinguish continent from incontinent women. Pd tests cn be divided into short-term tests, usully performed under stndrdized office conditions, nd long-term tests, usully performed t home for 24 to 48 hours. Short-term pd tests re generlly performed with symptomticlly full bldder or with certin volume of sline instilled into the bldder before the ptient begins series of exercises. A voiding diry, or bldder chrt, is record mintined by the ptient of her urinry frequency nd lekge, voided volumes, nd fluid intke over 3- to 7-dy period. This noninvsive test provides useful informtion bout bldder cpcity, type of incontinence symptoms, diurnl versus nocturnl voiding ptterns, nd ppropriteness of fluid intke. PREVALENCE AND INCIDENCE As noted bove, wide rnge in the prevlence of urinry incontinence hs been reported. One compiltion of such studies (3) indictes tht pproximtely 50% of dults report ny incontinence, while 5% to 25% note lekge t lest weekly, nd 5 to 15% note it dily or most of the time (Tble 2). Rtes of incontinence severity ptterns re depicted in Figure 1. The rte of urge incontinence tends to rise with ge, while the rte of stress incontinence decreses somewht in the oldest ge groups, possibly due to lower ctivity levels (Figure 2). In lrge popultion of Norwegin women, the rte of stress incontinence peked t pproximtely 60% in women 40 to 49 yers of ge; urge incontinence begn to rise in women 50 to 59 yers of ge nd peked t roughly 20% in women between 80 nd 89 yers of ge (4). Resons for the divergence of estimtes include vritions in definitions, smpling methodologies, response rtes, nd question formts (5). 161

6 Urologic Diseses in Americ Tble 2. Prevlence of urinry incontinence by frequency nd gender in older dults, proportion (counts) Prevlence Study Age Frequency Women Men Thoms, ever 25.80% (403/1562) 15.30% (169/1102) 1.7 Rekers, ever 19.70% (50/254) Hellstrom, ever 34.70% (191/551) 18.40% (49/266) 1.9 Milsom, ever 22.70% (962/4238) Brockelhurst, ever 16.80% (141/840) 12.80% (90/701) 1.3 Lr, ever 50.70% (71/140) Sommer, ever 44.90% (62/138) Sndvik, 1993 & Sim, ever 31.5%* (NR) Wetle, ever difficulty 44.40% (1045/2360) 34.10% (494/1449) 1.3 Nygrd, ever difficulty 55.10% (1116/2025) Diokno, / 12 months 37.70% (434/1150) 18.90% (152/805) 2.0 Yrnell, / 12 months 16.90% (37/219) 10.70% (18/169) 1.6 Yrnell, / 12 months 49.60% (89/180) Holst, /12 months 36.50% (66/181) Milne, 1972 & Milne, current 41.50% (114/272) 25.10% (54/215) 1.7 Cmpbell, current 22.10% (64/290) 21.60% (29/134) 1.0 Hunter, current 6.00% (120/2002) Nknishi, occsionlly or 9.70% (82/842) 9.80% (55/563) 1.0 more often Brockelhurst, / 2 months 10.20% (86/840) 5.30% (37/701) 1.9 Diokno, / month 21.70% (250/1150) 10.40% (84/805) 2.0 Brown, / month 41.30% (3285/7949) Thoms, / month 11.40% (178/1562) 6.90% (76/1102) 1.7 Brockelhurst, / month 10.20% (86/840) 5.30% (37/701) 1.9 Holst, / month 21.50% (39/181) Diokno, / week 12.60% (145/1150) 5.50% (44/805) 2.4 Brockelhurst, / week 8.30% (70/840) 3.70% (26/701) 2.2 Hellstrom, / week 27.00% (149/551) 15.00% (40/266) 1.8 Rekers, / week 6.30% (16/254) Kok, / week 22.90% (164/715) Cmpbell, / week 5.10% (15/290) 3.70% (5/134) 1.4 Wetle, most or ll of 8.80% (208/2360) 5.80% (84/1449) 1.5 the time Sommer, often or lwys 8.70% (12/138) Nygrd, most or ll of 8.30% (168/2025) the time Diokno, / dy 5.20% (60/1150) 1.70% (14/805) 3.1 Hellstrom, / dy 16.70% (92/551) 10.50% (28/266) 1.5 Kok, / dy 14.00% (NR) Brown, / dy 14.20% (1130/7949) Nknishi, / dy 2.50% (21/842) 2.10% (12/563) 1.2 NR, not reported; F, femle; M, mle. *Men of prevlence by 10-yer ge groups. SOURCE: Adpted from Thom D, Vrition in estimtes of urinry incontinence prevlence in the community: effects of differences in definition, popultion chrcteristics, nd study type, Journl of the Americn Geritrics Society, 46, , Copyright 1998, with permission from the Americn Geritrics Society. F/M Rtio 162

7 Urinry Incontinence in Women Rte per 100, Figure 1. 0 Rz-type Pubovginl Peyrer suspension sling procedure Estimted urge incontinence prevlence rtes by ge nd interview. Collgen injection* Anterior urethropexy Follow-ups III nd IV include responses 3 nd 6 yers fter bseline, respectively. SOURCE: Adpted from Nygrd IE, Lemke JH, Urinry incontinence in rurl older women: prevlence, incidence, nd remission, Journl of Americn Geritrics Society, 44, 1,049 1,054, Copyright 1996, with permission from the Americn Geritrics Society. Figure 2. PREVALENCE (%) EITHER URGE STRESS YEAR AGE GROUP Prevlence of incontinence by ge groups t bseline. Ech ge represents the midpoint of 3-yer ge rnge. Becuse of the smll number of women bove ge 90, the grph ends with ge rnge Urge nd stress refer to women who nswered ffirmtively to the urge nd stress incontinence questions, respectively. Either refers to women who reported ny incontinence (either urge or stress). SOURCE: Adpted from Nygrd IE, Lemke JH, Urinry incontinence in rurl older women: prevlence, incidence, nd remission, Journl of Americn Geritrics Society, 44, 1,049 1,054, Copyright 1996, with permission from the Americn Geritrics Society. 163

8 Urologic Diseses in Americ Tble 3. Prevlence of difficulty controlling bldder mong dult women Difficulty Controlling Bldder Totl Yes No Refused to Answer or Don t Know Totl 23,477,726 8,929,543 (38%) 14,449,905 (62%) 98,278 (0%) Age t screening ,699,785 2,168,863 (38%) 3,530,922 (62%) 0 (0%) ,895,878 1,785,380 (36%) 3,110,498 (64%) 0 (0%) ,505,164 1,683,804 (37%) 2,818,651 (63%) 2,709 (0%) ,453,472 1,515,900 (44%) 1,873,616 (54%) 63,956 (2%) ,981, ,003 (33%) 1,967,390 (66%) 25,165 (1%) 85+ 1,941, ,593 (41%) 1,148,828 (59%) 6,448 (0%) Rce/ethnicity Non-Hispnic white 18,729,539 7,662,444 (41%) 11,041,930 (59%) 25,165 (0%) Non-Hispnic blck 1,941, ,480 (20%) 1,554,789 (80%) 0 (0%) Mexicn Americn 649, ,567 (36%) 409,279 (63%) 9,157 (1%) Other Hispnic 1,576, ,823 (30%) 1,107,596 (70%) 0 (0%) Other rce 581, ,229 (31%) 336,311 (58%) 63,956 (11%) Eduction Less thn high school 8,374,762 2,692,649 (32%) 5,682,113 (68%) 0 (0%) High school 7,692,149 3,484,970 (45%) 4,207,179 (55%) 0 (0%) High school+ 7,212,158 2,725,611 (38%) 4,461,382 (62%) 25,165 (0%) Refused 103,678 26,313 (25%) 13,409 (13%) 63,956 (62%) Don t know 87,647 0 (0%) 85,822 (98%) 1,825 (2%) Missing 7,332 0 (0%) 0 (0%) 7,332 (100%) Poverty income rtio PIR=0 111,440 31,876 (29%) 79,564 (71%) 0 (0%) PIR<1 3,145,548 1,116,508 (35%) 2,026,331 (64%) 2,709 (0%) 1.00<=PIR<=1.84 5,520,548 2,193,641 (40%) 3,326,907 (60%) 0 (0%) PIR>1.84 9,649,331 3,538,606 (37%) 6,085,560 (63%) 25,165 (0%) Refused 2,090, ,112 (36%) 1,331,298 (64%) 0 (0%) Don t know 1,560, ,618 (48%) 817,031 (52%) 1,825 (0%) Missing 1,399, ,182 (39%) 783,214 (56%) 68,579 (5%) See glossry for definition of poverty income rtio. The dt in this tble re bsed on question KIQ.040: In the pst 12 months, hve you hd difficulty controlling your bldder, including leking smll mounts of urine when you cough or sneeze? (Do not include bldder control difficulties during pregnncy or recovery from childbirth.) SOURCE: Ntionl Helth nd Nutrition Exmintion Survey,

9 Urinry Incontinence in Women Tble 4. Frequency of bldder control problems mong those who responded yes to difficulty controlling bldder Frequency of Bldder Control Problems Totl Every Dy Few per Week Few per Month Few per Yer Don t Know Totl 8,929,543 3,255,587 (36%) 2,408,421 (27%) 2,016,715 (23%) 1,082,624 (12%) 166,196 (2%) Age t screening ,168, ,213 (32%) 429,351 (20%) 563,017 (26%) 490,282 (23%) 0 (0%) ,785, ,030 (27%) 511,356 (29%) 479,229 (27%) 172,781 (10%) 146,984 (8%) ,683, ,681 (39%) 536,511 (32%) 338,233 (20%) 145,379 (9%) 0 (0%) ,515, ,823 (38%) 448,955 (30%) 286,739 (19%) 204,383 (13%) 0 (0%) , ,355 (46%) 233,503 (24%) 258,379 (26%) 21,554 (2%) 19,212 (2%) , ,485 (51%) 248,745 (32%) 91,118 (12%) 48,245 (6%) 0 (0%) Rce/ethnicity Non-Hispnic white 7,662,444 2,759,807 (36%) 1,914,582 (25%) 1,909,818 (25%) 912,041 (12%) 166,196 (2%) Non-Hispnic blck 386, ,544 (55%) 74,408 (19%) 45,752 (12%) 53,776 (14%) 0 (0%) Mexicn Americn 230,567 89,173 (39%) 73,734 (32%) 26,952 (12%) 40,708 (18%) 0 (0%) Other Hispnic 468,823 77,927 (17%) 315,040 (67%) 7,880 (2%) 67,976 (14%) 0 (0%) Other Rce 181, ,136 (64%) 30,657 (17%) 26,313 (15%) 8,123 (4%) 0 (0%) Eduction Less thn high school 2,692,649 1,381,281 (51%) 566,047 (21%) 463,584 (17%) 281,737 (10%) 0 (0%) High school 3,484,970 1,104,097 (32%) 730,106 (21%) 1,040,720 (30%) 510,224 (15%) 99,823 (3%) High school+ 2,725, ,209 (28%) 1,112,268 (41%) 486,098 (18%) 290,663 (11%) 66,373 (2%) Refused 26,313 0 (0%) 0 (0%) 26,313 (100%) 0 (0%) 0 (0%) Poverty income rtio PIR=0 31,876 0 (0%) 0 (0%) 31,876 (100%) 0 (0%) 0 (0%) PIR<1 1,116, ,675 (49%) 182,029 (16%) 241,012 (22%) 151,792 (14%) 0 (0%) 1.00<=PIR<=1.84 2,193, ,902 (37%) 668,567 (30%) 394,473 (18%) 265,876 (12%) 53,823 (2%) PIR>1.84 3,538, ,094 (28%) 1,110,863 (31%) 952,372 (27%) 374,904 (11%) 112,373 (3%) Refused 759, ,391 (36%) 150,098 (20%) 143,238 (19%) 191,385 (25%) 0 (0%) Don t know 741, ,985 (44%) 140,318 (19%) 186,751 (25%) 88,564 (12%) 0 (0%) Missing 548, ,540 (57%) 156,546 (29%) 66,993 (12%) 10,103 (2%) 0 (0%) See glossry for definition of poverty income rtio. The dt in this tble re bsed on question KIQ.060: How frequently does this (referring to KIQ.040) occur? Would you sy this occurs every dy, few times week, few times month, or few times yer? SOURCE: Ntionl Helth nd Nutrition Exmintion Survey,

10 Urologic Diseses in Americ 85+ Age No lekge Reported lekgge Refused to nswer or don't know % 20% 40% 60% 80% 100% Figure 3. Difficulty controlling bldder mong femle responders. Age Every dy Few per week Few per month Few per yer Don't know % 10% 20% 30% 40% 50% Figure 3b. Frequency of bldder control problems mong femle responders who nswered yes to difficulty controlling bldder. SOURCE: Ntionl Helth nd Nutrition Exmintion Survey, Consistent with the Norwegin study, the Ntionl Helth nd Nutrition Exmintion Survey (NHANES) sked ntionl smple of communitydwelling dults, In the pst 12 months, hve you hd difficulty controlling your bldder, including leking smll mounts of urine when you cough or sneeze (exclusive of pregnncy or recovery from childbirth)? NHANES found the overll prevlence of urinry incontinence in women, s defined in this question, to be 38% in (Tble 3). When broken down by frequency of episodes, 13.7% of ll women in NHANES reported dily incontinence, nd n dditionl 10.3% reported weekly incontinence (Tble 4). Prevlence ws higher in non-hispnic whites (41%) thn in non-hispnic blcks (20%) or Mexicn Americns (36%). The prevlence of dily incontinence incresed with ge, rnging from 12.2% in ll women 60 to 64 yers of ge to 20.9% in those 85 yers of ge nd over (Figure 3). Women with less thn high school eduction reported incontinence less often thn did those with t lest high school eduction. Other lrge popultion-bsed studies hve lso reported higher rtes of urinry incontinence mong non-hispnic whites thn in other ethnic or rcil groups. In lrge cohort of 50- to 69- yer- 166

11 Urinry Incontinence in Women Tble 5. Rcil differences in urodynmic dignoses nd mesures Dignosis Africn Americn Cucsin (n = 183) (n = 132) P-vlue GSI (%) 41 (22) 60 (46) Detrusor instbility (%) 54 (30) 17 (13) Mixed incontinence (%) 29 (16) 14 (11) Other (%) 59 (32) 41 (31) Mesures (men ± SE) Full volume (ml) 279 ± ± MCC (ml) 458 ± ± MUCP (cm H 2 O) 68 ± 3 55 ± MUCP <20 cm H 2 O (%) 15 (8) 30 (23) GSI, genuine stress incontinence; full volume, volume noted t fullness during filling cystometry; MCC, mximum cystometric cpcity; MUCP, mximum urethrl closure pressure. Rcil comprison of dignoses by chi 2 or Fisher exct test. Rcil comprison of mesures by student t test. SOURCE: Reprinted from Americn Journl of Obstetrics nd Gynecology, 185, Grhm CA, Mllet VT, Rce s predictor of urinry incontinence nd pelvic orgn prolpse, , Copyright 2001, with permission from Elsevier. old women enrolled in the Helth nd Retirement Survey, non-hispnic blcks nd Hispnics were both 60% less likely to hve severe incontinence thn were non-hispnic whites, fter djusting for vrious comorbidities (6). Similrly, bseline dt from the Hert nd Estrogen/Progestin Replcement Study showed tht non-hispnic whites were 2.8 times more likely to hve weekly stress incontinence thn were non-hispnic blcks, fter djusting for relevnt fctors (7). This epidemiologic trend ppers consistent with lbortory findings s well. Grhm nd collegues noted tht mong women presenting for incontinence tretment, stress incontinence ws dignosed more frequently in Cucsin women, nd detrusor overctivity ws seen more often in Africn Americn women (8). These dignoses were lso consistent with the study s finding tht Cucsin women hd lower urethrl closure pressures thn did Africn Americn women, while Africn Americn women hd lower bldder cpcity thn Cucsin women (Tble 5). A recent nlysis of dt from the Study of Women s Helth Across the Ntion (SWAN), which included 3,302 women 42 to 52 yers of ge provided closer look t nunces relted to rce/ethnicity nd urinry incontinence (9). Africn Americn women with leiomyomt hd 1.81-fold higher risk of urinry incontinence thn did Cucsin women, while Africn Americn women without fibroids hd decresed risk of urinry incontinence (OR 0.31). Hispnic nd Jpnese women hd lower risk thn did Cucsin women (OR 0.44 nd 0.58, respectively). In Chinese women, the risk of incontinence ws modified by eductionl sttus; the OR of those with less thn college eduction ws 0.35 reltive to tht of Cucsin women, nd 2.53 for those with t lest college eduction. Dt from the Veterns Helth Affirs (VA) were used to estimte the utiliztion of outptient cre for urinry incontinence mong femle veterns ccessing VA helth services. Of ll women who received outptient cre in the VA system, urinry incontinence s percentge of ny dignosis ws 2.7% in 1999, 3.6% in 2000, nd 3.8% in 2001 (Tble 6). These proportions re substntilly lower thn the rtes of dily incontinence reported in popultionbsed surveys, suggesting tht the mjority of women with incontinence do not seek medicl cre for it. As expected, the prevlence of mediclly recognized urinry incontinence incresed with ge, with the most mrked increse occurring between the 25- to 34- yer-olds nd the 45- to 54- yer-olds. Incontinence ws more thn twice s common mong non- Hispnic whites s it ws mong Africn Americns nd pproximtely 50% more common mong non- Hispnic whites thn mong Hispnics. Incontinence ws most common in the Western region of the United Sttes nd lest common in the Estern region, except in 2001, lthough these differences were not djusted for differences in ge or rce/ethnicity. Less is known bout incontinence incidence, remission, nd nturl history. In prospective cohort studies using survey design, 10% to 20% of women report remission or recurrence of incontinence over 1- to 2-yer-period (10). Whether this reflects the nturl history of incontinence, ctive intervention, or decresed physicl ctivity (relevnt to stress incontinence) is not cler. 167

12 Urologic Diseses in Americ Tble 6. Frequency of urinry incontinence listed s ny dignosis in femle VA ptients seeking outptient cre, count b, rte c Count Rte Count Rte Count Rte Totl 3,780 2,679 5,426 3,597 6,196 3,757 Age ,882 1,020 2,449 1,052 2, ,262 1,531 4,374 1,817 4, , , , , , , ,412 1,261 6,927 1,440 6, , , ,257 Rce/ethnicity White 2,378 4,212 3,343 5,496 3,665 5,565 Blck 406 2, , ,518 Hispnic 83 3, , ,767 Other 31 4, , ,950 Unknown 882 1,412 1,428 2,169 1,807 2,485 Region Midwest 715 2,574 1,084 3,713 1,169 3,808 Northest 672 2, ,842 1,036 3,162 South 1,354 2,584 2,083 3,682 2,294 3,606 West 1,039 3,228 1,397 4,020 1,697 3,162 Insurnce sttus No insurnce/self-py 2,186 2,204 2,978 2,902 3,345 3,084 Medicre/Medicre supplementl 849 5,425 1,467 7,347 1,715 6,819 Medicid 8 2, , ,697 Privte insurnce/hmo/ppo 662 2, , ,675 Other insurnce 69 3, , ,512 Unknown 6 4, , ,435 HMO, helth mintennce orgniztion; PPO, preferred provider orgniztion. Represents dignosis codes for femle urinry incontinence (including stress incontinence nd fistule). b The term count is used to be consistent with other UDA tbles; however, the VA tbles represent the popultion of VA users nd thus re not weighted to represent ntionl popultion estimtes. c Rte is defined s the number of unique ptients with ech condition divided by the bse popultion in the sme fiscl yer x 100,000 to clculte the rte per 100,000 unique outptients. NOTE: Rce/ethnicity dt from clinicl observtion only, not self-report; note lrge number of unknown vlues. SOURCE: Outptient Clinic File (OPC), VA Austin Automtion Center,

13 Urinry Incontinence in Women RISK FACTORS Most dt on risk fctors for urinry incontinence come from clinicl trils or cross-sectionl studies using survey designs. Some risk fctors hve been more rigorously studied thn others. Hence, the vilble informtion hs limited generlizbility nd cuslity cnnot be inferred from it. Bering these limittions in mind, the literture does suggest tht ge, pregnncy, childbirth, obesity, functionl impirment, nd cognitive impirment re ssocited with incresed rtes of incontinence or incontinence severity. Some fctors pertin more to certin ge groups thn to others. For exmple, in older women, childbirth disppers s significnt risk fctor, possibly due to incresed comorbidities nd other intervening fctors, such s dibetes, stroke, nd spinl cord injury. Other fctors bout which less is known or findings re contrdictory include hysterectomy, constiption, occuptionl stressors, smoking, nd genetics. TREATMENT Fewer thn hlf of the women with urinry incontinence report seeking medicl cre (11). Johnson nd collegues (12) found tht the incontinent people most likely to contct medicl doctor re those who use pds, those who hve lrge volume ccidents, those who hve impirment in ctivities of dily living; lso, men re more likely to seek medicl cre thn women re (Tble 7). Mny incontinent people prctice behviorl modifictions such s limiting trips, fluids, nd routine ctivities. These restrictions re prticulrly striking in women with concomitnt fecl incontinence (Tble 8). Most tretment for urge incontinence is nonsurgicl. Common therpeutic modlities include phrmcologic tretment, physiotherpy, biofeedbck, Sling 40% ** Trnsvginl needle suspension 27% * 71% Open retropubic suspension Lproscopic retropubic suspension 3% 21% 25% 1999 (n=473) 1995 (n=484) Periuretherl collgen injection 2% Anterior colporrhphy 1% Other 2% 2% Don't know/refused 3% 2% 0% 20% 40% 60% 80% 100% Figure 4. Most common surgicl tretments in women with stress urinry incontinence ssocited with hypermobility, s indicted by prctitioners treting femles with urinry incontinence. *Significntly lower thn 1995 (p < 0.05) **Significntly higher thn ny other tretment nd 1995 (p < 0.05) SOURCE: Adpted from O Lery MP, Gee WF, Holtgrewe HL, Blute ML, Cooper TP, Miles BJ, Nellns RE, Thoms R, Pinter MR, Meyer JJ, Nslund MJ, Gormley EA, Blizzrd R, Fenninger RB, 1999 Americn Urologicl Assocition Gllup Survey: chnges in physicin prctice ptterns, tretment of incontinence nd bldder cncer, nd impct of mnged cre, Journl of Urology, 164, 1,311 1,316, Copyright 2000, with permission from Lippincott Willims & Wilkins. 169

14 Urologic Diseses in Americ Tble 7. Reltionship between disposble pd use nd contcting n MD mong subjects reporting urinry incontinence Contcting MD Fctor Bivrite Odds Rtio (95% CI) Multivrite Odds Rtio (95% CI) Disposble Pd Usge Non-user User 2.81 ( ) 3.02 ( ) Gender Femle Mle 1.73 ( ) 2.51 ( ) Age group ( ) 1.12 ( ) ( ) 0.83 ( ) Severity of urinry incontinence Mild-Mod 1.0 Severe 2.77 ( ) NS How often hve difficulty holding Less thn 1/wk 1.0 More thn 1/wk 1.60 ( ) NS Ever lek/lose urine with cough/lugh No 1.0 Yes 1.05 ( ) NS How often lose urine completely Never Sometimes 1.99 ( ) 1.90 ( ) Often 3.53 ( ) 2.45 ( ) Mobility ADL No impirment 1.0 Impirment 3.48 ( ) NS Instrumentl ADL Not impired Impirment 3.07 ( ) 3.22 ( ) Bsic ADL Not impired Impirment 1.48 ( ) 0.38 ( ) Bowel incontinence None 1.0 Weekly 2.77 ( ) NS NS, not significnt; ADL, ctivity of dily living. 95% confidence intervls for ge nd gender my include 1.0 for odds rtio. In the cse of bivrite nlysis, the criterion ws to include vribles significnt t α = For multivrite nlysis, ge nd gender vribles were forced into ll finl models becuse they were the strtifiction vribles of the smple. SOURCE: Reprinted from Johnson TM, Kincde JE, Bernrd SL, Busby-Whitehed J, DeFriese GH, Self-cre prctices used by older men nd women to mnge urinry incontinence: Results from the ntionl follow-up survey on self-cre nd ging, Journl of the Americn Geritrics Society, 48, , Copyright 2000, with permission from the Americn Geritrics Society. 170

15 Urinry Incontinence in Women Tble 8. Estimtes of self-cre prctice for those with urinry incontinence, by presence of fecl incontinence, severity of urinry incontinence, nd gender All UI (95% CI) UI without Fecl Incontinence (95% CI) UI with Fecl Incontinence (95% CI) Mild or Moderte UI (95% CI) Severe UI (95% CI) Women with UI (95% CI) Men with UI (95% CI) In the lst 12 months hve you used: Disposble pds 36.8% ( ) 33.6% ( ) 45.2% ( ) 27.7% ( ) 60.1% ( ) 44.5% ( ) 15.1% ( ) Lundry service 2.3% ( ) 2.5% ( ) 1.7% (0 4.4) 1.7% ( ) 3.9% (0 8.5) 1.6% ( ) 4.2% (0 8.8) Plstic sheets 11.2% ( ) 9.5% ( ) 39.6% ( ) 7.1% ( ) 20.6% ( ) 11.3% ( ) 11.0% ( ) Chnged dy-to-dy routine ctivities: Limited trips 27.6% ( ) 21.4% ( ) 56.2% ( ) 15.2% ( ) 55.8% ( ) 25.6% ( ) 33.0% ( ) Limited fluids 36.6% ( ) 32.6% ( ) 57.6% ( ) 29.3% ( ) 55.3% ( ) 39.4% ( ) 28.5% ( ) Bldder exercise 11.7% ( ) 12.5% ( ) 8.1% (0 20.0) 10.4% ( ) 15.9% ( ) 14.2% ( ) 4.3% ( ) Contcted n MD 39.8% ( ) 34.5% ( ) 62.9% ( ) 31.2% ( ) 59.2% ( ) 37.1% ( ) 47.4% ( ) Hs someone helped you mnge by: Chnging disposble pds 15.3% ( ) 11.3% ( ) 60.1% ( ) 12.9% ( ) 16.4% ( ) 11.4% ( ) 47.6% ( ) Any ssistnce b 23.2% ( ) 21.2% ( ) 63.8% ( ) 18.8% ( ) 34.3% ( ) 21.1% ( ) 31.7% ( ) Excludes ll subjects reporting fecl incontinece. All other ctegories my include those with dul incontinence (mximum of 8% of totl smple). b Any ssistnce includes receiving diet nd exercise dvice, help with chnging bedding, help with doing lundry, ssistnce in using the bthroom, help with bedpn or urinl. SOURCE: Reprinted from Johnson TM, Kincde JE, Bernrd SL, Busby-Whitehed J, DeFriese GH, Self-cre prctices used by older men nd women to mnge urinry incontinence: Results from the ntionl follow-up survey on self-cre nd ging, Journl of the Americn Geritrics Society, 48, , Copyright 2000, with permission from the Americn Geritrics Society. 171

16 Urologic Diseses in Americ Tble 9. Age-specific incidence (nnul procedure rte) of surgiclly mnged prolpse nd incontinence per 1000 womn-yers Age Group (y) Popultion of Women t Risk All Cses (n = 384) POP Only (n = 152) UI Only (n = 138) , POP + UI (n = 82) , , , , , , Totl 149, POP, pelvic orgn prolpse; UI, urinry incontinence. Includes primry nd repet procedures. SOURCE: Reprinted with permission from the Americn College of Obstetricins nd Gynecologists (Obstetrics nd Gynecology, 1997, 89, ). bldder retrining, nd electricl stimultion. For women with intrctble, severe urge incontinence, direct neuromodultion of the scrl spinl cord is n incresingly populr option. Surgicl therpy designed to increse bldder cpcity nd decrese contrctility is rrely used. In contrst, surgery is minsty of therpy for stress urinry incontinence. Surgeries performed frequently for stress incontinence in the pst nterior colporrhphies nd needle suspension procedures hve more recently been supplnted by retropubic urethropexies, pubovginl slings (using vrious types of sling mterils), nd collgen injections. Bsed on vilble evidence tht the long-term (3 to 5 yers) success rte of nterior colporrhphy nd needle suspension procedures is significntly lower thn tht of the other two procedures, the Agency for Helthcre Reserch nd Qulity (AHRQ), (13) nd the Americn Urologicl Assocition (14) hve both tken the position tht retropubic urethropexies nd pubovginl slings re the procedures of choice for stress incontinence. This trend is seen clerly in study describing the trends in surgicl mngement by Americn urologists between 1995 nd 1999 (15) (Figure 4). Nonsurgicl therpies re lso prominent in the tretment of women with stress urinry incontinence. The primry modlity used is pelvic muscle rehbilittion ( Kegel exercises ). Vginl nd urethrl devices, bldder trining, nd biofeedbck re lso frequently used. In the ner future, new phrmcologic gents will be vilble s well. While nonsurgicl therpies for urge nd stress urinry incontinence render only minority of women completely dry, more thn hlf of the women who prticipte in trils tht ssess such therpies report t lest 50% improvement in incontinence episodes. There is Level 1 evidence to support the use of pelvic muscle rehbilittion, bldder trining, nd nticholinergic therpy in women with some types of urinry incontinence. However, the literture on lrge, well-designed trils tht re generlizble to the popultion seeking cre is limited. Dt re lcking on the long-term follow-up of nonsurgicl tretment. TRENDS IN HEALTHCARE RESOURCE UTILIZATION Inptient Cre Surgicl Tretment Surgicl tretment for urinry incontinence cn be more esily trcked in existing dtbses thn cn non-surgicl mngement. Surgicl therpy ccounts for considerble proportion of the cost relted to incontinence. Although only smll frction of ll women with urinry incontinence seek surgicl intervention, the number of women treted with surgery is substntil. Using lrge mnged-cre dtbse, Olsen nd collegues (1997) reported n 11.1% lifetime risk of undergoing single opertion for urinry incontinence or pelvic orgn prolpse by ge 80 (Tble 9) (16). Using dt from the 1998 Ntionl Hospitl Dischrge Survey nd the 1998 Ntionl Census, Wetjen nd collegues (2003) clculted tht pproximtely 135,000 women in the United Sttes hd inptient surgery for stress urinry incontinence in 1998 (17). Dt from the Helthcre Cost nd Utiliztion Project (HCUP) indicte tht the nnul rte of hospitliztions for primry dignosis of urinry incontinence remined stble t 51 to 54 per 100,000 between 1994 nd 1998, then dropped to 44 per 100,000 in 2000 (Tble 10). It is uncler whether this drop reflects n ctul trend, potentilly ttributble to newer mbultory surgicl techniques. The nnul rte of hospitliztions ws higher for women 45 to 84 yers of ge, peking in the 65 to 74 ge group t

17 Urinry Incontinence in Women Tble 10. Inptient hospitl stys by dult femles with urinry incontinence listed s primry dignosis, count, rte b (95% CI) Count Rte Count Rte Count Rte Count Rte Totl c,d 49, (48 54) 54, (51 58) 53, (48 56) 46, (41 47) Age ( ) * * * * * * , (10 13) 2, (8.9 12) 2, (10 12) 1, (8.0 10) , (39 47) 9, (40 47) 9, (37 44) 8, (34 41) , (81 94) 15, (89 102) 14, (77 90) 12, (61 71) , (88 104) 10, (92 107) 11, (95 112) 10, (76 90) , (99 117) 11, ( ) 10, (97 114) 8, (81 98) , (60 73) 4, (64 79) 4, (58 70) 4, (56 71) (14 23) (19 34) (20 31) (16 26) Rce/ethnicity White 34, (44 50) 37, (47 53) 35, (44 51) 30, (37 43) Blck 1, (8.4 14) 1, (9 14) 1, (9.4 14) 1, (7.3 10) Asin/Pcific Islnder (6.6 12) ( ) (5.5 11) ( ) Hispnic 1, (20 28) 2, (22 34) 2, (19 27) 2, (23 31) Region MSA Midwest 12, (46 59) 11, (45 57) 11, (44 57) 10, (37 50) Northest 6, (29 38) 8, (38 50) 8, (34 49) 8, (32 46) South 18, (49 61) 22, (56 69) 21, (52 65) 17, (43 53) West 12, (53 69) 11, (47 62) 11, (45 60) 10, (37 51) Rurl 8, (29 40) 9, (36 47) 9, (37 50) 7, (27 37) Urbn 40, (53 61) 44, (54 62) 42, (50 58) 39, (44 52) Dischrge Sttus Routine 46, (45 51) 51, (48 55) 50, (46 53) 44, (39 46) Short-term * * * * * * * * Skilled nursing fcility ( ) ( ) Intermedite cre * * * * Other fcility * * * * ( ) ( ) Home helthcre 2, ( ) 2, ( ) 2, ( ) 1, ( ) Aginst medicl dvice * * * * * * * * Died * * * * * * * * dt not vilble. *Figure does not meet stndrd of relibility or precision. MSA, metropolitn sttisticl re. Excludes hospitliztions ssocited with primry gynecologicl dignosis (e.g., pelvic orgn prolpse). b Rte per 100,000 bsed on 1994, 1996, 1998, 2000 popultion estimtes from Current Popultion Survey (CPS), CPS Utilities, Unicon Reserch Corportion, for relevnt demogrphic ctegories of US femle dult civilin non-institutionlized popultion. c Counts my not dd to totls becuse of rounding. d Persons of other rces, missing or unvilble rce nd ethnicity, nd missing MSA re included in the totls. NOTE: Counts my not sum to totls due to rounding. SOURCE: Helthcre Cost nd Utiliztion Project Ntionwide Inptient Smple, 1994, 1996, 1998,

18 Urologic Diseses in Americ Tble 11. Inptient stys by femle Medicre beneficiries with urinry incontinence listed s primry dignosis, count, rte b (95% CI) Count Rte Count Rte Count Rte Totl c 16, (80 83) 19, (97 100) 17, (92 94) Totl < 65 1, (49 55) 2, (90 97) 2, (87 94) Totl , (84 87) 17, (98 100) 15, (92 95) Age , ( ) 11, ( ) 9, ( ) , (72 76) 5, (85 90) 5, (85 90) (34 39) (31 36) (29 34) (16 26) (15 24) Rce/ethnicity White 14, (87 90) 18, ( ) 16, ( ) Blck (25 30) (32 38) (31 37) Asin (12 31) (56 80) Hispnic (67 92) (62 79) N. Americn Ntive (68 179) ( ) Region Midwest 4, (96 101) 5, (98 104) 4, (94 100) Northest 2, (43 47) 2, (57 61) 2, (57 62) South 5, (81 86) 7, ( ) 7, ( ) West 3, ( ) 3, ( ) 2, ( ) dt not vilble. Unweighted counts multiplied by 20 to rrive t vlues in the tble. b Rte per 100,000 Medicre beneficiries in the sme demogrphic strtum. c Persons of other rces, unknown rce nd ethnicity, nd other region re included in the totls. NOTE: Counts less thn 600 should be interpreted with cution. SOURCE: Centers for Medicre nd Medicid Services, MedPAR nd 5% Crrier File, 1992, 1995, per 100,000 (Figure 5). Hospitliztions were most common in women residing in the South nd West nd lest common in women living in the Northest. Women living in urbn res hd higher rte of hospitliztions thn did those in rurl res. Most of the hospitliztions for urinry incontinence were probbly for surgicl tretments. The number of hospitliztions in Tble 10 represents roughly one-hlf of the number of incontinence procedures reported by Wetjen, et. l. This is most likely due to the fct tht Wetjen included inptient stys in which the primry dignosis ws gynecologicl (such s pelvis orgn prolpse) nd in whom n incontinence procedure ws done in concert with other procedures to repir the primry gynecologicl problem. Future nlyses will ddress this issue. Similr trends for older women were found in Medicre (Tble 11) nd HCUP (Tble 10). The rte of inptient stys for urinry incontinence for older women enrolled in Medicre (those 65+) rnged from 86 to 99 per 100,000 nnully, with women between 65 nd 74 more likely thn the other ge groups to be hospitlized. Geogrphic nd rcil/ethnic distributions were similr to those found in HCUP nd significnt differences mong rcil/ethnic groups were lso noted. Among women with commercil helth insurnce, the rte of inptient hospitliztions for incontinence procedures (primry or ny procedure) rnged from 123 per 100,000 women in 1994 to 114 per 100,000 in 2000 (Tble 12). Most of these procedures were performed in conjunction with other surgicl procedures nd re thus listed s ny procedure. 174

19 Urinry Incontinence in Women Rte per 100, * Age Figure 5. Inptient hospitl stys by femles with urinry incontinence listed s primry dignosis, by ge nd yer. *Figure does not meet stndrd for relibility or precision. SOURCE: Helthcre Cost nd Utiliztion Project, 1994, 1996, 1998, Tble 12. Inptient procedures for femles with urinry incontinence hving commercil helth insurnce, count, rte b Count Rte Count Rte Count Rte Count Rte As Primry Procedure Totl Age * 2 * 0 * 0 * * 16 * 14 * 25 * * 9 * 10 * 18 * * 1 * 1 * 2 * * 0 * 0 * 0 * As Any Procedure Totl , , Age * 3 * 2 * 0 * * 18 * 26 * * 3 * 5 * 3 * * 0 * 0 * 1 * *Figure does not meet stndrd for relibility or precision. Counts less thn 30 should be interpreted with cution. b Rte per 100,000 bsed on member months of enrollment in clendr yers for femles in the sme demogrphic strtum. SOURCE: Center for Helth Cre Policy nd Evlution, 1994, 1996, 1998,

20 Urologic Diseses in Americ Tble 13. Trends in men inptient length of sty (dys) for dult femles hospitlized with urinry incontinence listed s primry dignosis Length of Sty Totl Age * * * Rce/ethnicity White Blck Asin/Pcific Islnder Hispnic Other Region MSA Midwest Northest South West Rurl Urbn Dischrge sttus Routine Short-term * * * * Skilled nursing fcility Immedite cre * * Other fcility * * Home helthcre Aginst medicl dvice * * * * Died * * * *. dt not vilble. *Figure does not meet stndrd for relibility or precision. MSA, metropolitn sttisticl re. SOURCE: Helthcre Cost nd Utiliztion Project Ntionwide Inptient Smple, 1994, 1996, 1998, Hospitliztions for incontinence surgeries s primry procedures rnged from 59 per 100,000 women in 1994 to 33 per 100,000 in These dt suggest trend towrd decresing numbers of inptient surgeries for incontinence; if this trend is substntited in future yers, it my reflect either the incresed emphsis on nonsurgicl tretment for urinry incontinence tht followed the dissemintion of the AHRQ guidelines or incresed utiliztion of mbultory incontinence surgeries. Consistent with decresing lengths of inptient sty for other conditions during the pst decde, length of sty for women with urinry incontinence s their primry dischrge dignosis decresed stedily, from 3.1 dys in 1994 to 2.1 dys in 2000 (Tble 13). Women in the oldest ge groups were hospitlized longer thn were those younger thn 75. For exmple, in 2000, length of sty remined stble t 2.1 dys in women between 18 nd 74 yers of ge, nd vried from 2.7 to 2.9 dys in women older thn 75. Length of sty ws similr cross rcil/ethnic groups nd regions of the country. Surgicl Procedures In 1998, the most commonly performed surgicl procedures for femle urinry incontinence were collgen injections, pubovginl slings, nd nterior urethropexies (Tble 14). Becuse nterior colporrhphies my be performed for either urinry incontinence ( condition for which they re not currently recommended tretment) or nterior pelvic orgn prolpse (cystocele), rtes for this procedure re not described. A striking decrese ws seen in both Rz nd Peyrer needle suspension procedures between 1992 nd 1998: Rz procedures decresed from 4,364 per 100,000 women in 1992 to 1,564 per 100,000 in 1998, while Peyrer procedures were done too infrequently by 1998 to be detected in the dt. Concomitntly, pubovginl slings incresed from 621 per 100,000 women in 1995 to 2,776 per 100,000 in The number of women undergoing nterior urethropexy decresed, though less drmticlly, from 3,941 per 100,000 women in 1992 to 2,364 per 100,000 in Despite n increse in cesren deliveries nd complex lproscopic pelvic surgeries (two mjor sources of urogenitl fistule) during the time frme studied, ntionl hospitliztion dt showed no 176

21 Urinry Incontinence in Women Tble 14. Surgicl procedures used to tret urinry incontinence mong femle dult Medicre beneficiries, count, rte b Count Rte Count Rte Count Rte Totl 18,820 10,475 32,880 13,096 36,400 11,033 Anterior urethropexy, (e.g., MMK) 7,080 3,941 8,180 3,258 7,800 2,364 Ambultory surgery center Inptient 6,720 3,740 7,740 3,082 7,200 2,182 Hospitl outptient Physicin office Rz-type suspension 7,840 4,364 10,540 4,198 5,160 1,564 Ambultory surgery center Inptient 7,400 4,119 9,780 3,895 4,400 1,333 Hospitl outptient Physicin office Lproscopic repir Ambultory surgery center Inptient Hospitl outptient Physicin office Collgen injection 0 0 9,300 3,704 12,040 3,649 Ambultory surgery center 0 0 7,900 3,146 9,120 2,764 Inptient Hospitl outptient Physicin office , Hysterectomy with colpo-urethropexy 1,920 1,069 2, , Ambultory surgery center Inptient 1,920 1,069 2, , Hospitl outptient Physicin office Pubovginl sling , ,160 2,776 Ambultory surgery center , Inptient , ,800 2,364 Hospitl outptient Physicin office Peyrer procedure 1, Ambultory surgery center Inptient 1, Hospitl outptient Physicin office Kelly pliction Ambultory surgery center Inptient Hospitl outptient Physicin office Unweighted counts multiplied by 20 to rrive t vlues in the tble. b Rte per 100,000 femle dult Medicre beneficiries with dignosis of urinry incontinence. NOTE: Confidence intervls could not be clculted becuse of multiple dt sources. SOURCE: Centers for Medicre nd Medicid Services, 5% Crrier nd Outptient File, 1992, 1995,

22 Urologic Diseses in Americ Tble 15. Inptient hospitl stys for dult femles with urinry incontinence cused by urinry fistule listed s primry dignosis, count, rte (95% CI) Count Rte Count Rte Count Rte Count Rte Totl b 6, ( ) 7, ( ) 6, ( ) 7, ( ) Age ( ) ( ) ( ) * * , ( ) 1, ( ) ( ) ( ) , ( ) 1, ( ) 1, ( ) 1, ( ) ( ) ( ) ( ) 1, ( ) ( ) (7.2 10) ( ) ( ) , (11 14) 1, (12 16) 1, (10 14) 1, (10 13) , (15 20) 1, (18 24) 1, (15 20) 1, (14 19) (15 24) (17 27) (19 31) (17 26) Rce/ethnicity White 4, ( ) 4, ( ) 4, ( ) 4, ( ) Blck ( ) ( ) ( ) ( ) Asin/Pcific Islnder * * * * * * * * Hispnic ( ) ( ) ( ) ( ) Region Midwest 1, ( ) 2, (7.2 10) 1, ( ) 1, ( ) Northest 1, ( ) 1, ( ) 1, ( ) 1, ( ) South 2, ( ) 2, ( ) 2, ( ) 2, ( ) West 1, ( ) 1, ( ) 1, ( ) 1, ( ) *Figure does not meet stndrd of relibility or precision. Rte per 100,000 bsed on 1994, 1996, 1998, 2000 popultion estimtes from Current Popultion Survey (CPS), CPS Utilities, Unicon Reserch Corportion, for relevnt demogrphic ctegories of US femle dult civilin non-institutionlized popultion. b Persons of other rces nd missing or unvilble rce nd ethnicity re included in the totls. NOTE: Counts my not sum to totls due to rounding. SOURCE: Helthcre Cost nd Utiliztion Project Ntionwide Inptient Smple, 1994, 1996, 1998,