A Healthy Bladder

A Consensus Statement

E. S. Lukacz; C. Sampselle; M. Gray; S. MacDiarmid; M. Rosenberg; P. Ellsworth; M. H. Palmer

Disclosures

Int J Clin Pract. 2011;65(10):1026-1036. 

In This Article

Background

Bladder health is an important component of an individual's overall health. Recently, experts from a variety of disciplines convened to develop a bladder health initiative. This expert panel was convened and sponsored by Pfizer Inc and was composed of the seven authors and three additional individuals acknowledged at the end of this article. This panel determined that a consensus statement was needed to raise awareness of the importance of bladder health among the general public, clinicians, policy makers and public health officials. In this consensus statement, a definition for 'bladder health' and areas for intervention are proposed. The goal of this statement is to minimise the negative impact of poor bladder health on individuals who are directly or indirectly affected, such as patients, family members, healthcare professionals, educators, employers and payors, and to stimulate efforts that may lead to prevention of bladder conditions that affect overall well-being.

An unhealthy bladder may be characterised by the presence of one or more symptoms or disease such as increased voiding frequency or cancer. A number of conditions may cause lower urinary tract symptoms (LUTS), including but not limited to overactive bladder (OAB), bladder outlet obstruction (BOO), bladder pain syndrome/interstitial cystitis (BPS/IC), urinary tract infection (UTI) and bladder cancers.[1] LUTS can be divided into three categories: storage, voiding and postmicturition (Table 1).[1] Storage symptoms include urinary incontinence (UI, including stress, urgency or mixed incontinence), increased daytime voiding frequency, nocturia and urgency. Voiding symptoms include hesitancy, slow stream, straining and spraying. Postmicturition symptoms include feeling of incomplete emptying and postmicturition leakage. BPS/IC is defined as an unpleasant sensation (pain, pressure discomfort) perceived to be related to the urinary bladder, associated with LUTS of more than 6 weeks duration, in the absence of infection or other identifiable causes[2]

Prevalence of Bladder Conditions

Bladder conditions affect a large proportion of the world population. It has been estimated that in 2008 over 45% of the world population aged ≥ 20 years (1.9 billion people) were affected by LUTS.[3] Approximately 8.2% (348 million) of the 2008 world population were estimated to be affected by UI, including 3.2% with stress UI, 1.2% with urgency UI, 1.3% with mixed UI and 2.5% with UI without symptoms of stress or urgency UI.[3] The prevalence of OAB, defined by urgency, with or without urgency UI, usually with increased daytime frequency and nocturia, is approximately 12% (men, 11%; women, 13%) in Europe and North America,[4] with almost 11% of the world population (455 million people) affected by OAB.[3] The worldwide prevalence of LUTS suggestive of BOO in 2008 was estimated to be 21.5% (917 million people).[3] The prevalence of BPS/IC is difficult to determine because of the lack of validated questionnaires for use in epidemiological studies and misunderstanding of the definition of IC.[5] However, one study conducted in the United States reported that the prevalence of BPS/IC symptoms among adults aged ≥ 30 years ranged from 0.83% to 2.71% in women and 0.25% to 1.22% in men,[6] whereas another US study estimated that the prevalence among women aged ≥ 18 years was approximately 3–6%.[7] UTI is among the most common reasons for treatment in adult primary care clinical practice.[8] It is the most common infectious disease among women worldwide (excluding intestinal disease) and is associated with a high recurrence rate.[9] Globally, bladder cancer is the 7th most common cancer in men and the 17th most common in women. However, the prevalence of bladder cancer varies among countries, with the highest prevalence in Western countries and lowest prevalence in Asian countries.[10–12] The risk of bladder cancer and associated mortality increases with age.[13]

Financial and Personal Burden of Bladder Conditions

Bladder conditions are associated with substantial costs to society both economically and socially. The mean cost of routine care (incontinence pads, laundry, etc.) per person among women with UI in 2005 were estimated at approximately $492 ± 898 US dollars per year and increased with UI severity.[14] In a study of women with stress UI, mean annual cost of incontinence management in 2007 was approximately $750, including the cost of pads and dry cleaning.[15] Urinary incontinence is also associated with a high risk of nursing home placement, which bears significant financial and emotional burdens.[16,17] The total (direct and indirect) costs associated with OAB in 2007 were estimated to be $65.9 billion in the US alone.[18] Costs for BPS/IC are also substantial;[19] annual per person costs in the USA in 2005 were estimated to range from $3631 (Medicare rates) to $7043 (non-Medicare rates).[20] There is also considerable annual cost associated with UTI, which was estimated to be approximately $1.6 billion in 2003.[21,22] Bladder cancer is associated with the highest lifetime cost per patient of any cancer, with the total annual cost estimated at $3.4 billion in the USA in 2002.[23]

In addition to the economic burden, bladder conditions negatively impact many aspects of the health-related quality of life (HRQL).[24] This is important, as the World Health Organization recognises that 'health is not only the absence of infirmity and disease but also a state of physical, mental and social well-being'.[25] Emotional well-being, a component of overall health, is known to be affected by bladder health. For example, LUTS are associated with increased anxiety and depression, decreased physical activity, reduced work productivity (absenteeism) and impaired sexual function.[26,27] OAB and UI are bothersome and both can be incapacitating conditions.[26,28,29] UI is associated with depression in men and women, with prevalence of depression increasing with severity of incontinence.[30–33] In men, UI is significantly associated with major depression (per 10-year increase, OR 2.7; 95% CI 1.6, 4.0);[30] similarly, depression is a predictor for urgency UI in women.[32,34] UI may be associated with high-impact physical activity in young women, as high rates of UI have been reported in female athletes,[35–38] dancers,[38] fitness instructors[39] and women in the United States Military Academy.[40] Among older men and women, OAB symptoms are associated with increased risk of falls and fractures, UTIs and perineal skin disorders including incontinence-associated dermatitis.[41] BPS/IC is associated with lower HRQL, poor sleep and increased anxiety, stress and depression compared with controls.[42]

The impact of UI on physical activity has far-reaching implications for prevention of cardiovascular disease, diabetes and other chronic illness. As UI severity increases, it imposes an increasingly greater barrier to physical exercise.[43] Several types of bladder conditions, including OAB, UI, stress UI, LUTS and BPS/IC are associated with lost work productivity.[26,27,44] Bladder cancer and its treatments also profoundly reduce HRQL in survivors and their families.[45–48] The impact of poor bladder health on society is not fully appreciated by most healthcare professionals or the general public, including the affected individuals, which likely account at least in part for the underdiagnosis and undertreatment of many bladder disorders.[49] We believe that by defining and promoting 'bladder health,' healthcare providers can improve the overall health of those directly and indirectly affected.

Developing a Bladder Health Consensus Statement

The International Consultation on Incontinence (ICI) has provided guidance on promoting continence, including raising awareness among sufferers, educating healthcare providers and primary prevention of UI, as well as pelvic organ prolapse and faecal incontinence.[50] Moreover, it has been demonstrated that bladder health programmes, such as community UI intervention and nurse continence programmes, can result in increased use of self-management strategies, reductions in UI episodes and incontinence pad usage, and improved HRQL.[51–55] Our goals in issuing this statement are to discuss the importance of bladder health as a component of overall health and to describe factors that influence bladder health. The statement is directed towards the general public, clinicians, policy makers and public health officials, and we believe that increased education through a consensus statement addressing major issues related to bladder health may help improve overall bladder health.

We acknowledge that there are several challenges associated with developing a consensus statement regarding bladder health. It is difficult to define or describe 'normal' or 'healthy' bladder function, as it is not simply the absence of disease. We also acknowledge that the causal relationship between bladder conditions and concomitant conditions are not entirely understood, such as the relationship between urgency UI and depression. Healthy habits do not guarantee healthy, normal bladder function, and normal function can be present despite poor habits. In addition, there is a lack of research regarding healthy bladder habits and/or normal bladder function.

Many factors, both internal and external to the individual, may influence bladder functioning. However, providing educational materials regarding healthy habits and function to symptomatic individuals seeking care, individuals who have symptoms but are not seeking care, and asymptomatic individuals has been shown to improve health-seeking behaviours[51] and thus may be applicable to bladder health. Finally, it is unclear whether all conditions are preventable or whether it is only possible to delay onset or reduce bothersome symptoms. Limited research has been conducted for primary prevention (education about behaviour changes and setting expectations for normal urinary tract function) of bladder dysfunction; most studies are focused on secondary prevention.[52,56]

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