Urinary incontinence (UI) plagues 10-35 percent of adults and at least half of the 1.5 million nursing home residents in the United States. Because of the social stigma of UI, many sufferers do not even report the problem to a health care provider. In addition, when it is reported, many physicians and nurses, who need to be educated in this area, fail to pursue investigation of UI. As a result, this medical problem is vastly underdiagnosed and underreported.

The prevalence of UI, its toll on physical and psychological health, large variations in UI care practices and costs, and the urgent need to educate health care providers and the public about this condition prompted the selection of UI as a clinical guideline topic.

The purpose of this guideline is to improve reporting, diagnosis, and treatment of UI; reduce variations in clinical practice; educate health care providers and consumers about this condition; and, finally, encourage further biomedical, clinical, and cost research on UI. The guideline should help clinicians, caregivers, patients, and patients' families understand the assessment, management, and treatment of UI in adults. Specific reimbursement issues are not addressed.

The guideline recommendations apply to the diagnosis and treatment of acquired incontinence in ambulatory and nonambulatory patients in outpatient, inpatient, and long-term care settings. Not addressed are extraurethral UI, which is involuntary loss of urine through channels other than the urethra, UI in children, and UI due to neuropathic conditions.

To develop and update the guideline AHCPR convened a multidisciplinary, private-sector panel of physicians, nurses, allied health professionals, and health care consumers. The panel conducted extensive literature reviews of UI in adults, heard public testimony at national hearings, and examined information gathered from consultants. It studied the effectiveness and appropriateness of diagnostic and treatment procedures for UI, how they affect outcomes important to patients, their benefits and adverse consequences, and costs incurred from their use.

The panel found evidence in the literature that the treatment of UI can improve or "cure" most patients. It determined that UI in the adult requires a comprehensive approach by health professionals in the initial evaluation and treatment with behavioral and pharmacologic interventions and requires specialists for further diagnostic evaluation and surgical intervention.

The guideline provides practice recommendations in three areas:

• Prevention, identification, and evaluation. Specific risk factors for incontinence can be both identified and remediated with targeted interventions and prevention programs. The identification and documentation of UI can be improved with more thorough medical history taking, physical examination, and recordkeeping. Routine tests of lower urinary tract function should be performed for initial identification of UI. Situations that require further evaluation by qualified specialists include uncertain diagnosis, lack of correlation between symptoms and clinical findings, failure to respond to adequate therapeutic trial, hematuria without infection, presence of other comorbid conditions, and confirmation of diagnosis of incontinent patients being considered for surgical therapy. The specialized tests recommended for further diagnosis are detailed.

• Selection of appropriate therapy. The guideline provides an informed framework for selecting appropriate behavioral, pharmacologic, and surgical treatments and supportive devices that can be used to manage UI. The panel concluded that behavioral techniques such as bladder retraining and pelvic muscle rehabilitation are effective, low-risk interventions that can reduce incontinence significantly in varied populations. The guideline outlines what drugs can be used effectively for certain types of incontinence, including dosages and possible side effects. The panel recognizes the effectiveness of surgical interventions in well-selected cases. Behavioral and pharmacologic treatments may reduce the need for surgical interventions and may be considered in the initial management. A new chapter on long-term management of chronic intractable UI has been added to the updated chapters from the 1992 guideline. Specific recommendations on management of patients with this condition are provided.

• Education of health professionals and the public. Finally, the guideline calls for continued efforts to educate health care providers about this condition so that they are sufficiently knowledgeable to diagnose and treat it. It recommends that the public be advised to report incontinence problems once they occur and be informed that incontinence is not inevitable or shameful but is a treatable or at least manageable condition.

This is an update of the guideline, Urinary Incontinence in Adults first published in March 1992. This update reflects new research findings and experience with emerging technologies and innovative approaches for UI assessment and relief. The Agency for Health Care Policy and Research and the guideline development panel welcome comments and suggestions regarding the current guideline. Please address written comments to: Director, Office of the Forum for Quality and Effectiveness in Health Care, Agency for Health Care Policy and Research, 6000 Executive Boulevard, Suite 310, Rockville, MD 20852.