Editor—In their review of the management of urinary incontinence in women, Thakar and Stanton say that patients with chronic urinary incontinence, particularly elderly patients, may be easier to manage with a permanent indwelling catheter.1 As one of the “geriatric giants” described by Isaacs in 1992, urinary incontinence is a serious problem in older patients, with a prevalence of one in five to 10 in women older than 65 years, rising to two in three in residents of nursing homes.2,3 These patients deserve the same attention and assessment as their younger counterparts, even if they have medical conditions that preclude appropriate surgical treatment, or cognitive impairment that prevents them from complying with pelvic floor exercises or bladder retraining.
Simple measures can often noticeably improve symptoms. These might include switching to decaffeinated tea or coffee, excluding urinary tract infections or causes of polyuria such as diabetes mellitus or hypercalcaemia, reviewing drug treatment, including the use of diuretics and drugs that predispose to urinary retention, and practical measures to ensure that those with physical disabilities have easy access to toileting facilities. Cognitively impaired patients may benefit from timed, prompted voiding. Liaison with the continence nurse adviser may help with the provision of aids that make management of continence acceptable to carers.
Long term urinary catheterisation causes inevitable bacteriuria, which is difficult to eradicate and increases the risk of pyelonephritis, bacteraemia, and sepsis. It is an invasive procedure with an appreciable morbidity and mortality,4 a fact that should be taken into consideration before applying it to frail elderly patients. In addition, in a condition with such a high prevalence, widespread use of long term urinary catheters for incontinence has important cost implications, with the cost of medical consequences of catheterisation outweighing the savings in continence devices.5 Long term urinary catheterisation should be considered only in women with urinary retention for whom intermittent self catheterisation is not appropriate, and as a last resort in patients in patients with excoriated skin or pressure sores in whom other measures have failed.
References
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