This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Brittain, K. R. Articles by Castleden, C. M. Search for Related Content PubMed PubMed Citation Articles by Brittain, K. R. Articles by Castleden, C. M.

(Stroke. 1998;29:524-528.)
© 1998 American Heart Association, Inc.

Comments, Opinions, and Reviews

Stroke and Incontinence

K. R. Brittain, MA; S. M. Peet, PhD; C. M. Castleden, MD, FRCP

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

	Abstract

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
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.

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.

Key Words: urinary incontinence • fecal incontinence • stroke outcome • neurology

	Introduction

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
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.

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.

	Prevalence of Stroke

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
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

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
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 institution^{20 21 22} and again correlating lightly with the degree of cognitive and physical impairment experienced by this population.

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}

	Prevalence of Urinary and Fecal Incontinence in Stroke Survivors

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
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 this window] [in a new window]   Table 1. Prevalence of Urinary Incontinence After Stroke

	Onset of Incontinence in Stroke Survivors

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
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.

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.

	Neurological Lesions and Urinary Incontinence

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
The involvement of the frontal lobe in bladder control is frequently cited in the literature.^{5 6 39 40}

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.

	Bladder Characteristics in Stroke Survivors With Incontinence

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
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.

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.

	Nonurogenital Causes of Incontinence

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
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

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
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}

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.

	Why Is Urinary Incontinence Such a Good Predictor of Stroke Severity?

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
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

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment References

 
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}

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.

	Footnotes

 
The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

Received October 9, 1997; revision received November 18, 1997; accepted November 24, 1997.

	References

Top Abstract Introduction Prevalence of Stroke Prevalence of Incontinence Prevalence of Urinary and... Onset of Incontinence in... Neurological Lesions and Urinary... Bladder Characteristics in... Nonurogenital Causes of... Progress of the Stroke... Why Is Urinary Incontinence... Treatment 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.

2. Gotoh M, Yoshikawa Y, Saito M, Kato K, Kondo A, Miyake K. Results in treatment of urinary incontinence in the elderly [in Japanese]. Jpn J Urol. 1992;83:682–689.

3. Shiomi T, Yasukawa M, Yoshii M, Takahashi S, Yamamoto M, Momose H, Suemori T, Yamada K, Ozone s, Okajima E. Urinary managements of 332 stroke patients in the chronic phase [in Japanese]. Jpn J Urol.. 1992;83:2029–2036.

4. Burney TL, Senapati M, Desai S, Choudhary ST, Badlani GH. Effects of cerebrovascular accident on micturition. Urol Clin North Am. 1996;23:483–490.[Medline] [Order article via Infotrieve]

5. Sakabibara R, Hattori T, Yasuda K, Yamanishi T. Micturitional disturbance after acute hemispheric stroke: analysis of the lesion site by CT and MRI. J Neurol Sci. 1996;137:47–56.[Medline] [Order article via Infotrieve]

6. Tsuchida S, Hiromitsu N, Yamaguchi O, Itoh M. Urodynamic studies on hemiplegic patients after cerebrovascular accident. Urology. 1983;21:315–319.[Medline] [Order article via Infotrieve]

7. Effective Health Care Bulletin: Stroke Rehabilitation. Leeds: University of Leeds; March 1992, No 2.

8. Mulley GP. Stroke. In: Brocklehurst JC, Tallis RC, Fillit HM, eds. Textbook of Geriatric Medicine and Gerontology. 4th ed. New York, NY: Churchill Livingstone; 1992:365–388.

9. Isard PA, Forbes JF. The cost of stroke to the National Health Service in Scotland. Cerebrovasc Dis. 1992;2:47–50.

10. Wolfe CD, Taub NA, Woodrow J, Richardson E, Warburton FG, Burney PGJ. Patterns of acute stroke care in three districts of southern England. J Epidemiol Community Health. 1993;47:144–148.[Abstract/Free Full Text]

11. Smith N, Clamp M. Continence Promotion in General Practice. Oxford: Oxford University Press; 1991.

12. Thomas TM, Plymat KR, Meade TW. Prevalence of urinary incontinence. BMJ. 1980;281:1243–1245.

13. Kok ALM, Voorhorst FJ, Burger CW, Houten PV, Kenemans J, Janssens J. Urinary and faecal incontinence in community-residing elderly women. Age Ageing. 1992;21:211–215.[Abstract/Free Full Text]

14. Diokno AC, Brock BM, Brown MB, Herzog AR. Prevalence of urinary incontinence and other urological symptoms in the noninstitutionalized elderly. J Urol. 1986;136:1022–1025.[Medline] [Order article via Infotrieve]

15. Sandvik H, Hunskaar S, Seim A, Hermstad R, Vandik A, Bratt H. Validation of a severity index in female urinary incontinence and its implementation in epidemiological survey. J Epidemiol Community Health. 1993;47:497–499.[Abstract/Free Full Text]

16. Lagro-Jansson TLM, Smits AJA, Weel CV. Women with urinary incontinence: self perceived worries and general practitioners' knowledge of the problem. B J Gen Pract. 1990;40:331–334.

17. Sommer P, Bauer T, Nielsen KK, Kristensen ES, Hermann GG, Steven K, Nordling J. Voiding patterns and prevalence of incontinence in women: a questionnaire survey. Br J Urol. 1990;66:12–15.[Medline] [Order article via Infotrieve]

18. Holst K, Wilson PD. The prevalence of female urinary incontinence and reasons for not seeking treatment. N Z Med J. 1988;101:756–758.[Medline] [Order article via Infotrieve]

19. McGrother CW, Castleden CM, Duffin H, Clarke M. A profile of disordered micturition in the elderly at home. Age Ageing. 1987;16:105–110.[Abstract/Free Full Text]

20. Peet SM, Castleden CM, McGrother CW. Prevalence of urinary and faecal incontinence in hospitals and residential and nursing homes for older people. BMJ. 1995;311:1063–1064.[Free Full Text]

21. Tobin GW, Brocklehurst JC. The management of urinary incontinence in local authority residential homes for the elderly. Age Ageing. 1986;15:292–298.[Abstract/Free Full Text]

22. Palmer MH, German PS, Ouslander JG. Risk factors for urinary incontinence one year after nursing home admission. Res Nurs Health. 1991;14:405–412.[Medline] [Order article via Infotrieve]

23. Nelson R, Norton N, Cautley E, Furner S. Community-based prevalence of anal incontinence. JAMA. 1995;274:559–561.[Abstract/Free Full Text]

24. Nakanishi N, Tatara K, Naramura H, Fujiwara H, Takashima Y, Fukuda H. Urinary and fecal incontinence in a community-residing older population in Japan. J Am Geriatr Soc. 1997;45:215–219.[Medline] [Order article via Infotrieve]

25. Borrie MJ, Davidson HA. Incontinence in institutions: costs and contributing factors. Can Med Assoc J. 1992;147:322–328.[Abstract]

26. Wetle T, Scherr P, Branch LG, Resnick NM, Harris T, Evans D, Taylor JO. Difficulty with holding urine among older persons in a geographically defined community: prevalence and correlates. J Am Geriatr Soc. 1995;43:349–355.[Medline] [Order article via Infotrieve]

27. Brocklehurst JC, Andrews K, Richards B, Laycock PJ. Incidence and correlates of incontinence in stroke patients. J Am Geriatr Soc. 1985;33:540–542.[Medline] [Order article via Infotrieve]

28. Kamouchi M, Ibayashi S, Takaba H, Omae T, Sadoshima S, Yamashita Y, Fujishima M. Urinary incontinence in elderly patients in the chronic stage of stroke [in Japanese]. Jpn J Geriatr. 1995;32:741–746.

29. Anonymous. Clinical, and nursing epidemiology of patients with ictus [in Italian]. Rivista dell Infermiere. 1994;13:205–215.

30. Benbow S, Sangster G, Barer D. Incontinence after stroke. Lancet. 1991;338:1602–1603. Letter.

31. Henriksen T. Urinary incontinence after apoplexy [in Danish]. Ugeskr Laeger. 1993;155:1107–1109.[Medline] [Order article via Infotrieve]

32. Kalra L, Smith DH, Crome P. Stroke in patients aged over 75 years: outcome and predictors. Postgrad Med. 1993;69:33–36.[Abstract/Free Full Text]

33. Nakayama H, Jørgensen HS, Pedersen PM, Raaschou HO, Olsen TS. Prevalence and risk factors of incontinence after stroke: the Copenhagen stroke study. Stroke. 1997;28:58–62.[Abstract/Free Full Text]

34. Wade DT, Hewer RL. Outlook after an acute stroke: urinary incontinence and loss of consciousness compared in 532 patients. Q J Med. 1985;56:601–608.[Abstract/Free Full Text]

35. Ween JE, Alexander MP, D'Esposito M, Roberts S. Incontinence after stroke in a rehabilitation setting: outcome associations and predictive factors. Neurology. 1996;47:659–663.[Abstract/Free Full Text]

36. Wade DT, Hewer RL. Functional abilities after stroke: measurement, natural history and prognosis. J Neurol Neurosurg Psychiatry. 1987;50:177–182.[Abstract/Free Full Text]

37. Borrie MJ, Campbell AJ, Caradoc-Davies TH, Spears GFS. Urinary incontinence after stroke: a prospective study. Age Ageing. 1986;15:177–181.[Abstract/Free Full Text]

38. Gelber DA, Good DC, Layven LJ, Verhulst SJ. Causes of urinary incontinence after acute hemispheric stroke. Stroke. 1993;24:378–382.[Abstract/Free Full Text]

39. Khan Z, Hertanu J, Yang WC, Melman A, Leiter E. Predictive correlation of urodynamic dysfunction and brain injury after cerebrovascular accident. J Urol. 1981;126:86–88.[Medline] [Order article via Infotrieve]

40. Oostra K, Everaert K, Van Laere M. Urinary incontinence in brain injury. Brain Inj. 1995;10:459–464.

41. Reding MJ, Winter SW, Hochrein SA, Simon HB, Thompson MM. Urinary incontinence after unilateral hemispheric stroke: a neurologic-epidemiologic perspective. J Neurol Rehab. 1987;1:25–30.

42. Winter SW, Reding MJ. Urinary incontinence post stroke: CTT assessment of lesion size and location. Clin Res. 1988;36:353A. Abstract.

43. Andrew J, Nathan PW. Lesions of the anterior frontal lobes and disturbances of micturition and defaecation. Brain. 1964;87:233–262.[Free Full Text]

44. Anderson JT, Jacobsen O, Worm-Petersen J, Hald T. Bladder function in healthy elderly males. Scand J Urol Nephrol. 1978;12:123–127.[Medline] [Order article via Infotrieve]

45. Resnick NM, Elbadawi A, Yalla SV. Age and the lower urinary tract: what is normal? Neurol Urodyn. 1995;14:577–579. Abstract.

46. DeGroat WC. In: Ras S, ed. Neuroanatomy and Neurophysiology: Innovation of the Lower Urinary Tract In Female Urology. Philadelphia, Pa: WB Saunders Co; 1996:28–42.

47. Currie CT. Urinary incontinence after stroke. BMJ. 1986;293:1322–1323. Letter.

48. Iqbal P, Castleden CM. Management of urinary incontinence in the elderly. Gerontology. 1997;43:151–157.[Medline] [Order article via Infotrieve]

49. Greveson GC. Long-term outcome following stroke. Age Ageing. 1993;22:477. Letter.[Free Full Text]

50. Anderson CS, Jamrozik KD, Broadhurst RJ, Stewart-Wynne EG. Predicting survival for 1 year among different subtypes of stroke. Stroke. 1994;25:1935–1944.[Abstract]

51. Taub NA, Wolfe CDA, Richardson E, Burney PGJ. Predicting the disability of first-time stroke sufferers at 1 year: 12-month follow-up of a population-based cohort in Southeast England. Stroke. 1994;25:352–357.[Abstract]

52. Barer DH. Continence after stroke: useful predictor or goal of therapy? Age Ageing. 1989;18:183–191.[Abstract/Free Full Text]

53. O'Donnell BF, Drachman DA, Barnes HJ, Peterson KE, Swearer JM, Lew RA. Incontinence and troublesome behaviors predict institutionalization in dementia. J Geriatr Psychiatry Neurol. 1992;5:45–52.

54. Gross JC. Bladder dysfunction after a stroke. J Gerontol Nurs. 1990;16:20–25.

55. Castleden CM, Duffin HM, Mitchell EP. The effect of physiotherapy on stress incontinence. Age Ageing. 1984;13:235–237.[Abstract/Free Full Text]

56. Castleden CM, Duffin HM, Asher MJ, Yeomanson CW. Factors influencing outcome in elderly patients with urinary incontinence and detrusor instability. Age Ageing. 1985;14:303–307.[Abstract/Free Full Text]

57. Brocklehurst JC, Morris P, Andrews K, Richards B, Laycock P. Social effects of stroke. Soc Sci Med. 1981;15:35–39.

58. Greveson G, James O. Improving long-term outcome after stroke: the views of patients and carers. Health Trends. 1991;23:161–162.[Medline] [Order article via Infotrieve]

59. Williams A. Caregivers of persons with stroke: their physical and emotional well-being. Qual Life Res. 1993;2:213–220.[Medline] [Order article via Infotrieve]

60. Ouslander JG. Urinary incontinence in the elderly. West J Med. 1981;135:482–491.[Medline] [Order article via Infotrieve]

61. Ouslander JG, Kane RL, Abrass IB. Urinary incontinence in elderly nursing home patients. JAMA. 1982;248:1194–1198.[Abstract/Free Full Text]

62. Noekler LS. Incontinence in elderly cared for by family. Gerontologist. 1987;27:194–200.[Medline] [Order article via Infotrieve]

This article has been cited by other articles:

				S M Leary, C Liu, A L Cheesman, A Ritter, S Thompson, and R Greenwood Incontinence after brain injury: prevalence, outcome and multidisciplinary management on a neurological rehabilitation unit Clinical Rehabilitation, December 1, 2006; 20(12): 1094 - 1099. [Abstract] [PDF]

				E. R Skidmore, J. C Rogers, L. S Chandler, and M. B Holm Dynamic interactions between impairment and activity after stroke: examining the utility of decision analysis methods Clinical Rehabilitation, June 1, 2006; 20(6): 523 - 535. [Abstract] [PDF]

				J. J. Baztan, J. R. Domenech, and M. Gonzalez New-Onset Fecal Incontinence After Stroke: Risk Factor or Consequence of Poor Outcomes After Rehabilitation? Stroke, August 1, 2003; 34 (8): e101 - e102. [Full Text] [PDF]

				D. Harari, C. Coshall, A. G. Rudd, and C. D.A. Wolfe New-Onset Fecal Incontinence After Stroke: Prevalence, Natural History, Risk Factors, and Impact Stroke, January 1, 2003; 34(1): 144 - 150. [Abstract] [Full Text] [PDF]

				K. Tilling, J. A.C. Sterne, A. G. Rudd, T. A. Glass, R. J. Wityk, and C. D.A. Wolfe A New Method for Predicting Recovery After Stroke Stroke, December 1, 2001; 32(12): 2867 - 2873. [Abstract] [Full Text] [PDF]

				E. S. Lawrence, C. Coshall, R. Dundas, J. Stewart, A. G. Rudd, R. Howard, and C. D. A. Wolfe Estimates of the Prevalence of Acute Stroke Impairments and Disability in a Multiethnic Population Stroke, June 1, 2001; 32(6): 1279 - 1284. [Abstract] [Full Text] [PDF]

				T. P. Miles, R. F. Palmer, D. V. Espino, C. P. Mouton, M. J. Lichtenstein, and K. S. Markides New-Onset Incontinence and Markers of Frailty: Data From the Hispanic Established Populations for Epidemiologic Studies of the Elderly J. Gerontol. A Biol. Sci. Med. Sci., January 1, 2001; 56(1): 19M - 24. [Abstract] [Full Text]

				M. Patel, C. Coshall, A. G. Rudd, and C. D.A. Wolfe Natural History and Effects on 2-Year Outcomes of Urinary Incontinence After Stroke Stroke, January 1, 2001; 32(1): 122 - 127. [Abstract] [Full Text] [PDF]

				T. Brott and J. Bogousslavsky Treatment of Acute Ischemic Stroke N. Engl. J. Med., September 7, 2000; 343(10): 710 - 722. [Full Text] [PDF]

				B. Langhammer and J. K Stanghelle Bobath or Motor Relearning Programme? A comparison of two different approaches of physiotherapy in stroke rehabilitation: a randomized controlled study Clinical Rehabilitation, April 1, 2000; 14(4): 361 - 369. [Abstract] [PDF]

				K. R. Brittain, S. I. Perry, S. M. Peet, C. Shaw, H. Dallosso, R. P. Assassa, K. Williams, C. Jagger, J. F. Potter, and C. M. Castleden Prevalence and Impact of Urinary Symptoms Among Community-Dwelling Stroke Survivors Stroke, April 1, 2000; 31(4): 886 - 891. [Abstract] [Full Text] [PDF]

				C M CASTLEDEN and H. M DUFFIN Medical urology: a specialty long overdue. A personal view Postgrad. Med. J., January 1, 2000; 76(891): 1 - 3. [Full Text]

				A. Di Carlo, M. Lamassa, G. Pracucci, A. M. Basile, G. Trefoloni, P. Vanni, C. D. A. Wolfe, K. Tilling, S. Ebrahim, and D. Inzitari Stroke in the Very Old : Clinical Presentation and Determinants of 3-Month Functional Outcome: A European Perspective Stroke, November 1, 1999; 30(11): 2313 - 2319. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Brittain, K. R. Articles by Castleden, C. M. Search for Related Content PubMed PubMed Citation Articles by Brittain, K. R. Articles by Castleden, C. M.