Daniel Altman and colleagues (Oct 27, p 1494)1 found an increased risk of surgery for stress urinary incontinence after hysterectomy for benign indications, irrespective of surgical technique. However, an increased risk of surgery for stress urinary incontinence does not necessarily mean that these women also have an increased risk of stress urinary incontinence. The continence status of the investigated women is unknown.

Does hysterectomy itself predispose to stress urinary incontinence, or are women who undergo hysterectomy for benign indications just more disposed to surgery than are those who have not had (or are perhaps not willing to have) hysterectomies? Although Altman and colleagues used hallux valgus surgery and varicose-vein stripping as indicators of propensity for elective surgery, this cannot exclude (how could it?) an increased disposition to surgery for stress urinary incontinence of women who agree to hysterectomy.

Notwithstanding the fact that hysterectomy is undoubtedly associated with an at least statistically increased risk of surgery for stress urinary incontinence, this does not imply an increased risk of stress urinary incontinence. Thus, whether hysterectomy itself really predisposes to stress urinary incontinence remains to be elucidated.

Thomas M Kessler
Department of Urology, University of Bern, 3010 Bern, Switzerland

Available online 31 January 2008.

Urinary Incontinence: A Neglected Geriatric Syndrome in Nursing Facilities

Urinary incontinence (UI) is common but inadequately assessed and treated in nursing facility (NF) residents. The purpose of this study is two-fold: (1) to determine perceptions about the importance of UI and its management in the NF setting compared with other geriatric syndromes and (2) to compare barriers to UI care as perceived by physicians, geriatric nurse practitioners (GNPs), directors of nursing and other nurses in administrative positions (DONs), and nursing assistants (NAs).

Computer-based surveys of physicians and DONs and a hard copy survey of NAs at their national meetings; an online survey of GNPs.

Responses included 395 physicians (31% response rate), 152 DONs (34%), 118 GNPs (23%), and 277 NAs (60%). Physicians, GNPs, and DONs evaluated and managed UI significantly less often than 5 other geriatric syndromes (behavioral symptoms of dementia, falls, unintended weight loss, pain, and delirium). In contrast, NAs were more likely to be involved in UI care than in care provided for residents with any of the other 5 syndromes. All 4 groups agreed that UI has less effect on clinical outcomes than the other 5 syndromes. However, DONs rated UI first with respect to cost of care; NAs third behind falls and pain; and physicians and GNPs rated UI fourth behind falls, behavioral symptoms, and delirium. With respect to quality of life effects, physicians and GNPs rated UI fifth and fourth respectively and DONs fourth. In contrast, NAs rated UI second only to pain with respect to its effect on quality of life. Perceived barriers differ among the 4 groups with physicians relatively more concerned that drug treatment alone is ineffective (P = .002); GNPs relatively more concerned with lack of effective nondrug interventions (P = .001); and DONs relatively more concerned about sufficient time to assess and manage UI (P = .001). NA respondents rated concern about anticholinergic drug effects lower than did respondents in the other 3 groups (P = .001).

Conclusion

Physicians, GNPs, and DONs are more likely to be involved in evaluating and managing behavioral symptoms of dementia, pain, falls, delirium, and unintended weight loss than UI in the NF setting. This leaves NAs as first-line managers for a condition that they perceive to have an important impact on quality of life. Perceived barriers to improving UI care differ among the 4 groups suggesting that approaches to overcoming the barriers should be multi-faceted.

Larry W. Lawhorne MD, Joseph G. Ouslander MD, Patricia A. Parmelee PhD, Barbara Resnick PhD, CRNP, FAAN, FAANP and Barbara Calabrese RN, BA

Department of Geriatrics, Boonshoft School of Medicine, Wright State University, Dayton, OH
Division of Geriatric Medicine and Gerontology, Department of Medicine, Center for Health and Aging, Emory University School of Medicine and the Birmingham/Atlanta VA GRECC, Atlanta, GA
Department of Psychiatry and Behavioral Science, Emory University School of Medicine and Birmingham/Atlanta VA GRECC, Atlanta, GA
University of Maryland School of Nursing, Baltimore, MD
American Medical Directors Association Foundation, Columbia, MD.