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From the Division of Medicine for the Elderly, Leicester University,
Leicester General Hospital (UK).
Correspondence to K.R. Brittain, Division of Medicine for the Elderly, Leicester University, Leicester General Hospital, Gwendolen Rd, Leicester LE5 4PW, UK. E-mail krb7{at}leicester.ac.uk
Summary of Review—A number of studies have linked the presence of
bladder dysfunction in stroke survivors to various neurological lesions
in areas thought to be primarily involved in micturition. However,
neurological deficits may affect management of bladder control
secondarily by apraxia or aphasia, for example, and a significant
number of strokes occur in individuals already experiencing
incontinence.
Conclusions—Despite incontinence being such an important
prognostic feature, there are many gaps in our knowledge of the
relationship of stroke and incontinence, particularly fecal
incontinence. There are almost no studies on the influence of achieving
continence on outcome or how this might be brought about. This article
reviews the literature on this important topic and highlights
deficiencies in our knowledge and areas of future research.
Despite the importance of the association of urinary incontinence with
stroke, until recently there were relatively few reports on possible
neurological sites affected in such stroke survivors, on bladder
characteristics, or on the effect of nonneurological disabilities and
cognitive impairment on the prevalence of incontinence. Moreover, the
effect of treating urinary incontinence in stroke survivors has been
almost entirely ignored apart from a few reports in Japanese
journals.1 2 3 The treatment of fecal incontinence
in stroke survivors has hardly warranted a mention, despite the fact
that its presence can predict outcomes and cause decreased morale in
caregivers and sufferers.
The purpose of this article is to review current knowledge of the
association between urinary and fecal incontinence and stroke. In view
of the dearth of information on fecal incontinence in stroke survivors,
the article will necessarily concentrate mostly on urinary
incontinence. Other urinary tract symptoms are experienced by stroke
survivors, but most authors do not comment on such symptoms and
concentrate on incontinence. Studies that examine predictors of stroke
severity focus on urinary incontinence entirely, whereas only those
investigating stroke survivors with urodynamics also comment on
obstructive symptoms.4 5 6 This review therefore
focuses mainly on urinary incontinence as a symptom but recognizes the
importance of other socially disabling lower urinary tract
symptoms.
The prevalence of fecal incontinence is said to be lower than that of
urinary incontinence in the community. In a random sample of Dutch
women aged 60 years and over, 7.2% were found to be incontinent of
feces.13 In the overall population, the
prevalence of fecal incontinence is probably
2.2%.23 Daily fecal incontinence is said to
occur in 20 per 1000 (2%).24 In institutional
settings, fecal incontinence is remarkably common, occurring in 3% to
46% of residents in residential homes, nursing homes, and
hospitals.20 25
Incontinence as a single symptom may be too exclusive, and lower
urinary and fecal tract symptoms could deliver a better indication of
urinary symptoms in stroke survivors. For example, a stroke survivor
with bladder instability may not complain of urinary incontinence but
of frequency and nocturia.
In 1964 Andrews and Nathan43 pointed out that a
region in the frontal lobe was important in the higher control of
micturition and defecation. Their lengthy investigation in selected
cases that included cerebral tumors, intracranial aneurysms,
brain injury, and leukotomies suggested that frontal lobe damage was
liable to cause urinary dysfunction. Gelber et
al38 included 51 patients with unilateral
ischemic hemispheric stroke and excluded patients with
bilateral brain damage, brain stem stroke, and any previous
urological surgery and patients with a history of previous stroke. They
found an association between patients with poststroke urinary
incontinence and those with large infarcts, aphasia, cognitive
impairment, and functional disability. Burney et
al4 linked the frontal and temporal lobes and
internal capsule to urinary incontinence after stroke, but they failed
to identify which of the patients presented with urinary
symptoms. Further studies have identified the frontal cortex or the
frontoparietal lobes as being associated with urinary dysfunction after
stroke,4 5 6 39 40 and only one study failed to
find any such association.42
However, a recent study confirms that the size of the stroke is more
important, whereas the side of the stroke is
not.38 Only the occipital lobe seems to be free
of any connection with urinary incontinence.
There is no uniformity in the type of bladder lesion diagnosed on
urodynamic studies in stroke survivors. Studies have revealed that
incontinence in stroke survivors may be due to diagnoses similar to
those found in incontinent persons without stroke. There appears to be
a majority of survivors with detrusor dysfunction (hyperreflexia or
hyporeflexia).6 38 39 Outflow obstruction is
common but detrusor sphincter dyssynergia is
not.6 39 Hyperreflexia, if new, is probably due
to the stroke lesion itself. Normal storage and emptying of urine is
dependent on a number of reflexes of increasing complexity as the
spinal cord is ascended.46 Damage to the brain
can induce bladder overactivity by reducing suprapontine inhibition.
Detrusor sphincter dyssynergia arises from spinal lesions and therefore
is uncommon in stroke survivors, and if present it is unlikely to
be due to an intracerebral lesion.
Those who remain continent in the first few days after stroke
experience lower mortality. Of patients who experience urinary
incontinence, 52% are dead within 6 months compared with 7% of
patients who remain continent.33 Similarly, for
fecal incontinence the risk of death is greater. Of stroke patients who
experience fecal incontinence, 59% are dead within 6 months compared
with 7% of patients who initially had no fecal
incontinence.33 Anderson et
al50 reported that the relative risk of death
within 1 year in their 321 acute stroke patients was 3:9 if they had
had incontinence (95% confidence interval, 1.4 to 10.6). The
definition of urinary incontinence used in this study was broad and
included patients who had accidents or those who needed general help or
needed an indwelling catheter during admission to the hospital. None of
these studies made a distinction between urinary incontinence that
began before or after onset of stroke, and some recruited their sample
from hospital admissions, perhaps biasing their sample toward those
more severely affected.33
A number of studies have shown that urinary incontinence is not only an
active predictor of survival but also of recovery. For example, initial
incontinence in first-time stroke survivors younger than 75 years was
the best single predictor of severe or moderate disability at 3 months,
with a sensitivity of 60% and specificity of
78%.51 This study gathered information on
mobility status before the stroke, which was taken into account during
analysis. A Danish study reported a significant relationship
between the presence of urinary incontinence and length of hospital
stay, circumstances of discharge, and mobility.31
Barer52 found that stroke outcome was so much
better in those who remained or became continent that it seems possible
that recovery of continence may promote morale and self-esteem that
could actually hasten overall recovery. Although Barer was referring to
the early stages of stroke recovery, the possibility of an association
between continence, morale, and function in stroke survivors at a later
stage after their stroke remains an untested hypothesis. There has been
little work on how urinary incontinence may affect the psychosocial
experience of a stroke survivor and how changes in this may result from
treatment.
The place of discharge is also related to incontinence, with the latter
increasing the chance of being placed in institutional
care.35 53 Ween et al35
reported that 46% of 145 stroke survivors with incontinence returned
to their own home after hospitalization compared with 79% of 278
continent stroke survivors. Only 15% of those initially continent
after their stroke were later admitted to a nursing home compared with
38% of the incontinent group.
Based on the published evidence for treating nonstroke survivors with
incontinence, physiotherapy and bladder- retraining programs are
found to cure or very significantly improve
incontinence.55 56 This, however, has not been
investigated in a stroke population. A study is required to test
treatments for incontinence in a sample of stroke survivors to see
whether these patients can also be cured or made socially continent.
Barer's52 hypothesis that recovery of continence
in stroke survivors could lead to a more favorable outcome in the whole
stroke survival and recovery process also needs to be tested.
Caregivers of incontinent stroke survivors attract even less academic
interest, and the few available studies vary in the degree to which
they report how stressful or problematical for the carers
the incontinence is in the stroke survivor.57 58 59
Some indicate that urinary incontinence may influence the carers to
seek residential care for the stroke
survivor.60 61 62 The impact on the caregiver of
treating the urinary incontinence in the stroke survivor remains
unknown, but it is worthy of further research because so many of those
stroke survivors who return home could not do so if they were to live
alone.
The whole area of treating incontinence in stroke survivors and its
effect both on the survivor and the caregiver is in need of further
investigation. Not only could the quality of life for both be
considerably improved, but also the cost of untreated incontinence
could be reduced.
Received October 9, 1997;
revision received November 18, 1997;
accepted November 24, 1997.
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© 1998 American Heart Association, Inc.
Comments, Opinions, and Reviews
Stroke and Incontinence
Abstract
Background—Urinary incontinence in
the acute stage of stroke is seen as a predictor of death, severe
disability, and an important factor on hospital discharge destination.
Therefore, it is an important measure of stroke severity that not only
affects the lives of stroke survivors but also those of
caregivers.
Key Words: urinary incontinence • fecal incontinence • stroke outcome • neurology
Introduction
There is a high
prevalence of urinary incontinence in stroke survivors that is
associated with the size of the infarct or cerebral hemorrhage
and to the mortality, morbidity, and discharge destination of the
survivor. Such urinary incontinence causes considerable distress to
stroke survivors and caregivers alike, worsening morale and influencing
the ability to achieve optimum recovery.
Prevalence of Stroke
A typical health authority of 250 000 persons can expect 500 new
stroke cases and 1000 recurrent stroke cases each year, and at any one
time there will be approximately 1500 survivors of stroke living in the
community, of whom around 750 will have a significant level of
disability.7 Indeed, stroke is the major cause of
severe chronic disability in the UK, accounting for 4% of the total
National Health Service budget,8 9 with stroke
patients occupying approximately 12% of beds on general medical wards
and 12% of stroke survivors becoming institutionalized within 1
year.7 Wolfe and
colleagues10 reported that of 386 UK first-time
stroke patients, 78% were treated in the hospital, particularly those
who were younger and those who were incontinent. This shows that a
large percentage of persons suffering from stroke are admitted to the
hospital.
Prevalence of Incontinence
Daily incontinence, not only caused by a stroke, is common,
affecting 1 in 20 persons aged under 65 years, increasing to 1 in 12 in
those over 75 years of age.11 An average-size
general practice of 2200 patients would include approximately 25
persons under the age of 75 years and 15 persons 75 or over with
significant urinary incontinence, in addition to those in long-term
care.11 The prevalence of urinary incontinence
depends on the definition used, but it is reported to range between
11% and 38% in women over the age of 60 living in
noninstitutionalized settings.12 13 14 However,
several large studies agree that bothersome, severe incontinence occurs
in about 6% of a community population.15 16 17 18 19 The
prevalence increases still further in the physically impaired. Urinary
incontinence therefore will commonly occur in stroke survivors as a
consequence of their disability even if the stroke is not a cause of
the incontinence per se. As both incontinence and stroke are especially
common in the elderly, it is likely that stroke will occur in some
previously incontinent persons. The prevalence in institutions and
hospitals is far higher, being severe in perhaps 25% to 44% depending
on the institution20 21 22 and again correlating
lightly with the degree of cognitive and physical impairment
experienced by this population.
Prevalence of Urinary and Fecal Incontinence in Stroke
Survivors
Recent studies conducted throughout the world have demonstrated an
association between stroke and incontinence. A population census in the
United States reported that 36% of persons aged 65 years and over had
moderate difficulty in holding their urine some or all of the time and
that this difficulty was associated with stroke. In the 65- to 74-year
age group, the odds ratio for having had a stroke in women who
experienced severe difficulty holding urine was found to be
7.4.26 The majority of studies have, however,
reported the prevalence of incontinence in stroke survivors, and these
give a clear consensus of a high prevalence. Brocklehurst et
al27 found that 51% of 135 consecutive stroke
survivors were incontinent of urine and 23% were incontinent of feces
at some stage during their first year after a stroke. More recently,
Kamouchi et al28 reported that 69% of 106
elderly Japanese survivors of chronic stroke who were admitted to the
hospital had urinary incontinence. The rate was significantly higher in
those aged 75 years and over and in those with poor functioning in
activities of daily living or with dementia. A further Italian study of
293 stroke survivors in 17 hospitals reported that 32% were
incontinent 5 days after a stroke and 53% were
catheterized.29 Overall, the prevalence of
urinary incontinence in hospitalized patients from nine studies
published between 1985 and 1997 suggests that between 32% to 79% of
stroke patients at admission experience incontinence; at discharge,
25% to 28% experience incontinence, and between 12% to 19% will
still experience incontinence some months after the stroke (see the
Table
).27 28 29 30 31 32 33 34 35 Similarly, the
prevalence of fecal incontinence in hospitalized patients from two
studies published in 1987 and 1997 would suggest that between 31% to
40% will experience fecal incontinence on
admission,33 36 18% will experience this at
discharge,33 and between 7% to 9% will still
experience fecal incontinence 6 months after the
stroke.33 36
View this table:
[in a new window]
Table 1. Prevalence of Urinary Incontinence After Stroke
Onset of Incontinence in Stroke Survivors
The main complication in comparing different studies that
look at the prevalence of incontinence in stroke survivors is the
definition of any incontinence. The apparent association between stroke
and incontinence of urine is further complicated by premorbid and
late-onset urinary incontinence, which few studies define. Late-onset
urinary incontinence may be associated with the natural progression of
conditions associated with urinary incontinence per se or with further
strokes.27 Brocklehurst et
al27 found in their study that 6 additional
survivors at a 3-year follow-up became incontinent of urine, 4 of whom
subsequently died. Only 137 of 12 reports that
specifically sought a link between stroke or brain injury and
incontinence investigated the prevalence of premorbid
incontinence.4 5 6 27 33 35 38 39 40 41 42 This article
suggests that 17% of 151 stroke survivors may have had incontinence
before their stroke.37 The presence of premorbid
incontinence is clearly important because it affects the apparent
prevalence of incontinence due to stroke and because survivors who have
premorbid incontinence may be very different from those who become
incontinent after the stroke, with different morbidity and mortality.
The relationship between stroke and incontinence may not only be in one
direction.
Neurological Lesions and Urinary Incontinence
The involvement of the frontal lobe in bladder control is
frequently cited in the literature.5 6 39 40
Bladder Characteristics in Stroke Survivors With
Incontinence
Urinary incontinence in stroke survivors may not be due to the
stroke lesion per se but may have been there premorbidly from
nonurological causes (see below). It is the authors' experience that
the prevalence of prestroke incontinence and other lower urinary tract
symptoms are high in this population. If an accurate history cannot be
obtained and if nonurological causes of incontinence have been
excluded, further investigations of the urological symptoms are
indicated. Abdominal ultrasound importantly excludes retention, but it
can also assess whether bladder stones or other urinary tract
pathology, such as carcinoma, is present. Urodynamic examination
may reveal an overactive or underactive detrusor muscle and help to
decide whether outflow obstruction is present, but a cooperative
patient is necessary for the latter and investigators should be aware
of the presence of detrusor instability in continent, healthy
persons.44 45 Any results from urodynamic
examinations therefore need to be interpreted in the light of the
survivor's symptoms and holistic condition.
Nonurogenital Causes of Incontinence
There are other nonphysiological barriers to
maintaining continence, such as communication and
mobility.47 To remain continent a person must be
able to appreciate the need to void, communicate their need to a
caregiver, be motivated, be able to bear weight or assist in
transferring to a toilet or commode or use an appropriate appliance, to
delay voiding until the appropriate time, and to initiate voluntary
voiding.11 Dysphasia,37
aphasia,38 and impaired cognitive and functional
ability are all correlated with urinary incontinence, but so too are
nonurological complications of stroke such as fecal impaction, drug
therapy, or increased solute load. Any drug with
-adrenoreceptor blocking action will worsen the
urethral sphincter weakness, whereas anticholinergic drugs may
precipitate retention. Diuretics may lead to detrusor
contraction by causing rapid bladder filling, and stroke itself may
worsen diabetic control, increasing glycosuria. Finally, urinary tract
infection and low estrogen levels in postmenopausal women contribute to
poor bladder and sphincter control.48
Progress of the Stroke Survivor With Incontinence
Incontinence is a marker for stroke severity because of its
association with death and disability and its influence on the place of
discharge of stroke survivors.30 33 49
Why Is Urinary Incontinence Such a Good Predictor of Stroke
Severity?
Urinary incontinence is a marker of stroke severity. It is not
surprisingly closely related to coma, which itself is also a predictor
of death and disability.34 36 52 However, even in
those patients who are conscious after a stroke, incontinence is
related to outcome. Wade and Hewer34 found in
their study of hospitalized stroke patients that both a depressed level
of consciousness and urinary incontinence in conscious patients were
related to the severity of the stroke. Urinary incontinence may be a
good predictor of stroke severity because of its relationship with
infarct size and intracerebral hemorrhage, but
it also may have a more subtle effect on morale and therefore influence
response to rehabilitation. Stroke is often followed by depression and
feelings of apathy, which can have adverse effects on a person's
"normal" voiding behavior.54 Furthermore, the
relationship of urinary continence with the central nervous system is
complex. Not only may specific centers controlling micturition be
affected but also other nonurological centers in the central nervous
system, such as those affecting speech and mobility. These are also
known to be related to outcome and are important also for a continent
state.
Treatment
Because there is no clear understanding of the types and causes of
incontinence associated with stroke, it is perhaps not surprising that
the treatment of incontinence in stroke survivors has not been
adequately addressed despite the magnitude and severity of the problem.
The few studies that exist, almost entirely derived from the Japanese
academic press, indicate the potential benefits of treating
incontinence in stroke survivors. One benefit may be in transurethral
resection of the prostate in men with outflow obstruction in whom
conservative management techniques have failed.1
A further two small studies suggested that very considerable
improvements and cure of incontinence followed a range of
pharmacological, toileting regimen, surgical,
catheterization, and behavioral
therapies.2 3
Footnotes
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.
References
1.
Natsume O, Yasukawa M, Yoshii M, Takahashi SAU,
Yamamoto M, Momose H, Suemori T, Yamada K, Shiomi T. Transurethral
resection of the prostate in the urological management for patients
with stroke [in Japanese]. Acta Urologica
Japonica. 1992;38:1123–1127.
Top
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