The world's population is ageing rapidly. In 2020, the share of the global population aged 60 years and over was estimated to be 1 billion; this number is projected to increase to 1.4 billion by 2030 and 2.1 billion by 2050, with the number of persons aged 80 years or older expected to triple between 2020 and 2050, to reach 426 million (World Health Organization, 2024).
Urinary incontinence (UI) is a common condition that is especially prevalent among older adults, with a profound impact on wellbeing and quality of life. The National Institute for Health and Care Excellence (NICE) (2024) defines UI as any involuntary leakage of urine and highlights that the main risk factor underlying this condition is older age, with prevalence increasing up to middle age, plateauing or decreasing between 50 and 70 years of age, and rising again with advanced age.
UI may occur as a result of a number of abnormalities of the function of the lower urinary tract or as a result of other illnesses that tend to cause leakage. For many, it is a consequence of the natural physiological changes that occur with ageing (NICE, 2024). These age-related changes in the lower urinary tract include decreased bladder capacity and a feeling of fullness, decreased detrusor muscle contraction rate, decreased pelvic floor muscle strength and increased residual urine volume (Batmani et al, 2021).
While there are many types of UI, instances most commonly encountered in practice fall under the categories of stress, urgency and mixed UI, which each have their own unique symptomatology and treatment approach:
It is estimated that 14 million people in the UK experience some degree of UI, with women making up the majority of this number (Lewis and Powell, 2023; NICE, 2024). Women are disproportionately affected by UI for a variety of reasons. Factors such as pregnancy, multiple vaginal deliveries, menopause, obesity and pelvic surgeries, such as hysterectomy, are significant contributors to the development of UI. In addition, pelvic organ prolapse, commonly occurring postmenopausal or after childbirth, is often associated with incontinence (Lugo et al, 2024). In primary care in the UK, 8.4% of women reported a vaginal bulge or lump; prolapse is also present in up to 50% of women on examination (NICE, 2019). Owing to the ageing population, there is likely to be an increasing need for surgery for UI and pelvic organ prolapse (NICE, 2019). Damage to the nerves that control the bladder from conditions such as multiple sclerosis, diabetes or Parkinson's disease, or conditions such as arthritis that may make it difficult to get to the bathroom in time, may also contribute to the development of UI (National Institute on Aging, 2022).
The impact on quality of life
The prevalence of this condition does not belie its severe impact on quality of life. The literature surrounding UI in women is in overwhelming consensus: its impact is profound in every aspect of health and wellbeing, particularly around body image and sexuality. Research demonstrates findings relating to discomfort, low self-esteem, anxiety, depression, mood disorders, forced isolation, impaired sexual function and alterations to lifestyle and, as a result, the deterioration of women's personal, social and professional lives, and marital and intimate relationships (Blanco Gutiérrez et al, 2023). Physical consequences of UI include pressure sores, sleep disturbances and decreased sleep quality, urinary tract infections and falls and fractures, which are the leading causes of death in people aged over 65 years (Batmani et al, 2021). In an attempt to manage and exert control over their symptoms, women experiencing UI often feel compelled to enact change in every domain of their lives, including restricting outdoor activities and time spent outside of the home, altering their choice of clothing, limiting or controlling their consumption of food and fluids and adapting, or even ceasing, performance of religious rituals (Javanmardifard et al, 2022).
Of a study cohort of 1415 UK women, the prevalence of UI was 39.9%; of these, participants reporting feeling a bit (34%), a lot (9%) and very much (4%) affected by their bladder symptoms, with many expressing embarrassment (16%), unhappiness (12%) and extreme unhappiness (4%) (Cooper et al, 2015).
However, despite the demonstrated impact of UI on women's quality of life, and despite the prevalence of UI in women being estimated to be double that of men, it is more likely for men to be referred to specialist care because of the condition's potential relation with cancer. On the contrary, UI in women is often regarded as a minor issue (Blanco Gutiérrez et al, 2023). Women who are personally affected by UI often perceive the condition as an inevitable part of the ageing process and of womanhood, thereby promoting the normalisation of this chronic health issue and contributing to their disengagement with health services, preventing help-seeking behaviours (Blanco Gutiérrez et al, 2023). Feelings of self-blame were commonly identified among Black, Arab, Hispanic and Asian women in particular (Blanco Gutiérrez et al, 2023).
Healthcare professionals and services contribute significantly to this minimalisation of UI. Of the 1415 survey respondents examined in Cooper et al (2015), while 17.0% of participants sought professional help for their symptoms, only 7.4% of women with stress UI and 20% of women with mixed UI reported receiving supervised pelvic floor muscle retraining of at least 3 months' duration. Furthermore, bladder retraining was offered to only 5.2% of patients who reported urgency UI and 9.4% of patients who reported mixed UI.
The severe impact of UI on women's health and wellbeing is evident. Community nurses, with their expertise, ability to leverage the therapeutic relationship and intimate access to their patients' lives and daily routines, have the capacity to effect real change. To be able to provide informed and high quality care, the community nurse should be cognisant of the information and best practice developed in regard to UI, with the prevalence of and factors related to UI in the older female population being especially relevant.
Prevalence
Prevalence estimates are mixed because of differences among the populations studied, definitions and measurements used. It is also possible that any estimates are likely to be inaccurate, as underreporting is approximated to be relatively common among people experiencing UI because of the intimate nature of the condition. However, the literature generally indicates that rates of UI occurrence, especially in older populations, are high. For instance, in a study aiming to update estimates of UI prevalence for adult women in the US, using the National Health and Nutrition Examination Survey (NHANES) data from 2015 to 2018, it was found that more than 60.0% of adult women in community settings experience UI of some type or severity, which represented an increase from prior estimates (38.0%–49.0%) based on NHANES data from 1999 to 2004. Of these, more than 20.0% experience moderate or more severe UI (Patel et al, 2022). In weighted analyses, this 61.8% of adult women with UI was revealed to correspond to a staggering 7 829 7094 women, with 32.4% of all women reporting symptoms at least monthly (Patel et al, 2022). Of those with UI, 37.5% had stress UI, 22.0% had urgency UI, 31.3% had mixed symptoms, and 9.2% had unspecified incontinence (Patel et al, 2022).
Results from the Epidemiology of LUTS study (a cross-sectional, population-representative survey conducted via the internet in the US, the UK and Sweden comprising 30 000 respondents) revealed that the prevalence of at least one lower urinary tract symptom (LUTS) was at least ‘sometimes’ 72.3% for men and 76.3% for women, and 47.9% and 52.5% for at least ‘often’ for men and women, respectively (Coyne et al, 2009).
In a Chinese context, a population-based prospective study and a follow-up survey encompassing a final total of 24 985 women aged over 20 years demonstrated a crude UI incidence rate of 19.6 (95% CI 18.7–20.5) per 1000 person-years (Pang et al, 2022). The age-specific incidence rate of UI rose significantly with age (Ptrend<0.0001 for urban and rural areas) from 10.2 per 1000 person-years in the aged 20–30 years group, to 43.0 per 1000 person-years in the aged >70 years group (Pang et al, 2022). The standardised incidence rate of UI was 21.2 per 1000 person-years for all women (Pang et al, 2022). In regard to UI subtypes, the crude incidence rates of female stress UI, urgency UI and mixed UI were 12.4 (95% CI 11.7–13.2), 2.7 (95% CI 2.4–3.0) and 4.4 (95% CI 4.0–4.9) per 1000 person-years, respectively (Pang et al, 2022). For stress UI, the crude incidence initially increased and then decreased with age, peaking at 60–69 years; the crude incidence of urgency UI and mixed UI monotonically increased with age, especially in the age group aged >70 years, which was much higher than other age groups (P < 0.0001) (Pang et al, 2022). The standardised incidence rates of stress UI, urgency UI and mixed UI were 13.1, 3.0 and 5.1 per 1000 person-years, respectively (Pang et al, 2022).
Patient-related factors
Risk factors
While UI is not an inevitable result of ageing, it is particularly common in older people. There are many risk factors for the condition, some of which intersect with increasing age. In a comprehensive systematic review and meta-analysis of 29 observational studies, encompassing a sample size of 51 8465 women in the age range of 55–106 years, the most frequently identified factors affecting UI incidence were age, obesity based on the body mass index (BMI), diabetes, women's education, delivery rate, hypertension, smoking and urinary tract infections (Batmani et al, 2021).
Pang et al's (2022) population-based prospective study and follow-up survey, encompassing a final total of 24 985 women aged over 20 years, demonstrated similar results. In a multivariable analysis, middle and older age, higher BMI, race, higher education, vaginal spontaneous delivery, instrumental delivery, chronic cough, diabetes and cigarette-smoking were identified as risk factors for de novo stress UI (P<0.05) (Pang et al, 2022). Women who were overweight (risk rate (RR) 1.52, 95% CI 1.33–1.74) and obese (RR 1.67, 95% CI 1.32–2.11) were more likely to have stress UI than women with a normal BMI (Pang et al, 2022). With regard to delivery pattern, women who had experienced vaginal spontaneous delivery (RR 2.12, 95% CI 1.62–2.78) and instrumental delivery (RR 3.30, 95% CI 1.99–5.45) were more likely to have stress UI than nulliparous women (Pang et al, 2022). Vaginal delivery is likely correlated with the development of stress UI because of injury to the pelvic floor structures, such as muscles, nerves, organs and the extracellular matrix responsible for continence. Instrumental delivery—especially forceps delivery—is associated with significant increased long-term risk of stress UI compared with other vaginal deliveries for women aged ≤50 years (Pang et al, 2022). Univariate and multivariable analyses revealed that the risk factors positively associated with de novo urgency UI were older age and diabetes; the RR of urgency UI increased with age, from 1.96 (95% CI 1.24–3.12) in the 40–49 years group to 6.30 (95% CI 3.85–10.30) in the >70 years group compared with the 20–29 years group (Pang et al, 2022).
Patient demographics
In a UK context, a cohort study using primary care data from April 2004 to March 2013 from over 600 general practices contributing to the Clinical Practice Research Datalink was conducted to investigate the characteristics associated with referrals from primary to specialist secondary care for UI. It encompassed 104 466 women who met the study's inclusion criteria, with a median age of 58 years (Gurol-Urganci et al, 2020).
About two-thirds of women were overweight (32.1%), obese (29.1%) or severely obese (8.2%); of the women with available ethnicity data, 92.4% were White, 3.7% Asian/Asian British and 2.0% Black (Gurol-Urganci et al, 2020). Of the 104 466 women with UI, 47 838 had a referral to a UI specialist in secondary care at some point during the study period (45.8%); of these, 14 158 women (13.6, 95% CI 13.3–13.8%) had a referral recorded on the same day as the index UI diagnosis (Gurol-Urganci et al, 2020). Age and ethnicity were strongly associated with referral, with older women and those from minority ethnic backgrounds being much less likely to be referred to a specialist than younger women and White women. The rate of referral within 30 days of the recording of the index UI diagnosis was highest in women aged 40-49 years (34.3%), and the 30-day referral rate rapidly decreased with age to 15.4% in women aged 80 years or above (Gurol-Urganci et al, 2020).
Women who were underweight (adjusted odds ratio (OR) compared to normal weight 0.85, 95% CI 0.79–0.91) and those who were severely obese (adjusted OR 0.84, 95% CI 0.78–0.90) were referred less often than women with a BMI in the normal range (Gurol-Urganci et al, 2020). Women who were smokers were referred less often than non-smokers (adjusted OR 0.94, 95% CI 0.90–0.98), which was similar to women with a diagnosis of pelvic organ prolapse (adjusted OR 0.77, 95% CI 0.68–0.87), women with type 2 diabetes (adjusted OR 0.92, 95% CI 0.85–0.99) and women diagnosed with cancer (adjusted OR 0.84, 95% CI 0.75–0.94) (Gurol-Urganci et al, 2020).
The role of the community nurse
Community nurses have the capacity to effect real change in UI care and management. However, there seems to be wider systemic barriers to high-quality care provision related to both education for community nurses about UI and the ways in which healthcare systems approach resourcing and management of UI care. For instance, based on their findings from over UK 600 general practices, Gurol-Urganci et al (2020) emphasise that the delivery and organisation of continence services in primary and secondary care should be scrutinised. Clear referral pathways and investment in capacity—for example, through the provision of more trained staff and a higher profile for continence care within medical training—were identified as possible facilitators for the delivery of high quality and equitable continence services (Gurol-Urganci et al, 2020).
Additionally, in a systematic review concerning community nurses' attitudes, knowledge and educational needs in relation to urinary continence, McCann et al (2022) highlighted that community nurses' perceptions may be less favourable with regard to older people with UI. Specific attitudes identified included the misconception that UI becomes less distressing as people get older, with twice-hourly toileting and the use of incontinence pads as the only treatment option for older people (McCann et al, 2022). Nurses' attitude scores were also found to be the lowest for incontinence management when compared to three other areas of older person care, leading to nurses often using diapers and indwelling catheters to manage incontinence (McCann et al, 2022). A reliance on incontinence pads as a first-line treatment option, although contrary to best practice guidelines, has been also reported across other healthcare settings, with a national audit reporting that older people received continence care that was focused mainly on the use of containment products (Kelly, 2023).
To facilitate person-centred, evidence-based UI care in the community, proactive promotion of continence treatment options is essential. Systemic changes to improve UI outcomes, especially among older populations, should include education initiatives that address both the knowledge and attitude aspects to UI care and re-prioritise UI as a negative impact healthcare issue, rather than an inevitable consequence of ageing. These changes should also address knowledge deficits in anatomy and physiology, risk factors, symptoms, causes, assessment and prevention, treatment and management, including aids and appliances (McCann et al, 2022).