CONSENSUS STATEMENT
FIRST INTERNATIONAL CONFERENCE FOR THE
PREVENTION OF INCONTINENCE
DANESFIELD HOUSE U.K. JUNE 25-27 1997

6-8 cups of fluids per day, more when it is hot or when exercising.

Most people empty the bladder about every 3-4 hours during the day ( 4-8 times in 24 hours). Getting up once at night to empty the bladder is not abnormal. Being awakened more than twice is abnormal.

Don't strain to empty the bladder or the bowel.

Don't ignore feelings that the bowels need emptying.

Any leakage of urine from the bladder occurs (incontinence). Pain is experienced when passing urine. Any blood is seen in urine.

Acquisition of general continence abilities are probably innate in neurologically intact humans.

Toileting skills and behaviour that are learned, have a certain plasticity, and vary across cultures.

Although there are undoubtedly many cultural influences on the acquisition of toilet skills, we do not have much evidence of the effect of these on later bladder habits and continence.

There is little evidence that adults with bladder problems pass on abnormal patterns to their offspring. We do not know if these have an impact on the genesis of later dysfunction.

Genetic research has identified a marker for one type of nocturnal enuresis, but not as yet for other bladder dysfunctions.

It is shown that children with severe mental retardation can often acquire continence if systematically trained using behaviour techniques.

Urinary tract infection in childhood should be investigated and appropriately treated as there may be long-term adverse sequelae.

Schools and teachers need to promote positive attitudes to toileting and to promote an open positive culture about bodily functions.

The value of preventive pelvic floor education or bladder awareness in schools is unproven.

Children with congenital or acquired neurological impairments are not inevitably incontinent if a systematic planned approach is implemented early.

Environmental influence on the acquisition of toileting skills

Longitudinal studies to determine the effect of early training or childhood dysfunction on continence in later life

Inter-relationship of skills for bladder and bowel continence

Constipation, obesity, smoking and some medications (e.g. alpha blockers, caffeine and diuretics) may be risk factors.

Asymptomatic bacteriuria is not linked to incontinence.

Adults with neurological disease often have inevitable bladder or sphincter impairment, but active management may prevent this manifesting as incontinence.

For women, the major risk factor is undoubtedly vaginal delivery during childbirth.

Caesarean section appears to prevent incontinence, certainly for the first baby, possibly less so for multiple births.

Vacuum extraction rather than forceps is preferred for assisted delivery to prevent incontinence.

The relation of episiotomy to incontinence is unclear.

There is weak evidence that antenatal pelvic floor exercise may be protective in the postnatal period. Longer term benefit is unproven.

Excessive physical stress during exercise or repeated lifting may be a risk factor in the development of incontinence in women.

Young men are a low risk group for incontinence (with the exception of nocturnal enuresis).

Prospective studies of risk factors in continent women (including further work on caffeine, medications and obesity).

Further study the effect of childbirth practices such as episiotomy and assisted delivery on long-term continence.

Further study on the effect of pre- or post-natal pelvic floor education and exercise.

Study the effect of exercise and lifting on the pelvic floor.

Prospective study of the effect of constipation in continent females.

Methods to improve bladder emptying and prevent complications in patients with neurological disease (e.g. does the Crede manoeuvre create long-term problems?)

Radiotherapy for pelvic malignancies is associated with increased urinary incontinence.

For women the link with vaginal delivery becomes less clear than in younger women.

The role of oestrogen and menopause is likewise unclear. It is not known if hormone replacement therapy (HRT) helps to prevent the development of urinary incontinence.

Urinary incontinence is clearly linked to obesity in women.

The role of smoking is less clear, as is the role of hysterectomy and of straining due to chronic constipation.

Sometimes repair of a vaginal prolapse can unmask a tendency to urinary incontinence.

Incidence of incontinence in women tends to level off with advancing years; stress incontinence may even decrease with age. Only when dementia, immobility or general frailty develop does the prevalence increase with age.

Men continue to be a low risk group, until the age where the prostate becomes troublesome for some and may need intervention.

Radical prostatectomy is associated with urinary incontinence. Specialised centres should be developed for the treatment of prostate cancer (performing more than 20 operations per year), and men need improved information about incontinence risks to enable an informed choice on intervention.

Pre-operative detrusor dysfunction may make urinary incontinence more likely after transurethral resection of the prostate (TURP).

Post-micturition dribbling can often be prevented by simple education.

In men with symptoms suggestive of prostatic hyperplasia and coexisting Parkinsonism, particular care should be taken not to misdiagnose Multiple System Atrophy (MSA) as Parkinson's disease. Removal of the prostate is inadvisable in men with MSA.

Prospective study of the effect of hysterectomy on bladder function.

Long-term effects of childbirth, including obstetric practices and age of childbearing.

Study further the role of collagen.

Investigate the effect of menopause and hormone replacement therapy on the urinary tract.

Study the effects of prolapse and its repair, other pelvic surgery, and continence.

Long-term sequelae of untreated obstruction or its medical management in men.

Prospective study of pre-operative risk factors and continence after prostatectomy.

Development of a standardized outcome questionnaire, including continence status, to be used with patients undergoing radical prostatectomy. Comparison of continence results from different surgeons and centres.

Previous genito-urinary surgery.

Impaired mobility.

Chronic cough.

Functional disability.

Stroke.

Respiratory illness.

Sedatives and hypnotics.

Faecal incontinence or impaction.

bacteriuria without dysuria, caffeine, alcohol, race, ethnicity.

It was noted that studies have largely been cross-sectional and have not fully considered the effect of confounding factors.

Prospective longitudinal study of these risk factors.

Relationship of urinary and defaecation problems.

Effect of general fitness and mobility.

The prevention model outlined in section B. is not appropriate for many frail older adults who are dependent on caregivers for toileting and maintaining continence. Therefore the concept of "Dependent Continence" is most applicable.

Immobility

Impaired cognition, especially spatial

Drugs, particularly sedatives and diuretics

Complexity of physical environment and barriers (e.g. the number of points where the individual must make a decision on the way to the toilet)

Impaired activities of daily living, particularly dressing dependence

Caregiver attitudes/beliefs/knowledge

Disease e.g. Parkinson's, CVA, diabetes, fractured neck of femur

Retention of urine or an elevated post-micturition residual: urologic causes or post-operative.

Does identification of co-morbidity lead to improvement?

What are clinically (as opposed to statistically) relevant outcomes for this group?

Measurement and modification of caregiver attitudes/knowledge/ expectations and how to change them, with what clinical effect?

Why some individuals with increased risk become incontinent while others maintain continence.

Catheter management.

Retention and its relevance.

Minimising impact on quality of life for intractable incontinence.

The general public should be informed about healthy bladder habits and when/how to seek help.

Parents should know about the possible effects of toilet training practices and attitudes.

Teachers and schools should be informed about the importance of healthy bladder habits and appropriate toilet environments.

People with neurological disease (and their doctors) should know that management is possible.

Relatives of people with existing incontinence might prove the most receptive and relevant audience to target with a prevention message. More research is needed to determine the most effective delivery of continence health education.