Addressing the gender gap in urinary continence care

Urinary incontinence is a common condition that can affect both women and men of all ages, and it can have profoundly negative effects on quality of life (Nursing Times, 2019). Meeting the required needs of both male and female patients can be challenging, especially as incontinence is predominantly considered a female problem, with a ratio of nearly 2:1 female sufferers (approximately 55% cases are among females) (Helfand et al, 2018). This mindset has led to health inequalities and disparity in continence services provided for men with incontinence, with most male continence needs being unmet or neglected (Stenzelius, 2005; Nursing Times, 2019). The World Health Organization (WHO) defined health inequalities as differences in health status or in the distribution of health determinants among different population groups (NHS England, 2015). Health professionals are aware that men access healthcare less than women, with detrimental consequences (Lancet, 2019), and this is no different within continence care. Health professionals should not assume that guidance and clinical policies are adequate for addressing male incontinence, and this has been identified by the WHO, which now has a strategy to make health systems ‘gender responsive’ (Baker, 2019).

This article will address some of these issues by highlighting existing areas of care and guidance, identifying obstacles that men experience in accessing satisfactory continence care and considering areas of guidance, policies and research that need to be addressed to improve urinary continence care for men.

Prevalence

Urinary incontinence is defined by the International Continence Society (ICS) as ‘any involuntary leakage of urine’ (Abrams et al, 2003; Haylen et al, 2010). Prevalence figures depend on definitions and the study populations examined, and results need to be viewed with caution, as under-reporting by men may go some way to explaining the differences, thus supporting the myth that male urinary incontinence is infrequent (Helfand et al, 2018). Helfand et al (2018) stated that 55% of suffers of urinary incontinence are female, while Milsom (2000) compared studies on prevalence of urinary incontinence in men and women and generally found that this condition is three times more common in women than in men. NHS England (2018) estimated that, within the UK, there are over 14 million people who have bladder problems and urinary incontinence.

The difference in genders becomes less marked with age, as male incontinence is mainly associated with ageing (Nursing Times, 2019). Some 61% of the general population of men experience lower urinary tract symptoms (LUTS), and 34% of women live with urinary incontinence (NHS England, 2018). Buckley and Lapitan (2010) suggested that one-in-three older men have continence problems. Statistics in a systematic review (Shamliyan et al, 2009) showed that the prevalence of urinary incontinence rose from 5% in men aged 19–44 years to 11% in those aged 45–64 years and further rose to 21% in men aged over 65 years, with 8.3–9.3% experiencing daily incontinence and 4% having severe symptoms (Shamliyan, 2009; Nursing Times, 2019).

Recommendations for best practice guidance for men compared with that for women

For the majority of the population, urinary incontinence is, in simple terms, bladder leakage, but there are different types of this condition, with different presenting symptoms, terminology and treatment options. However, these presenting symptoms and associated terminology differ between the genders and have different causes. For example, stress urinary incontinence may present as leakage on coughing, sneezing and exertion in both sexes, and the underlying condition is linked to an incompetent urethral sphincter, but the initial cause is different between the genders: it is usually associated with childbirth and menopause in women, while it is mainly associated with prostate surgery in men. The majority of research undertaken in this area has been predominately directed towards the female gender, and continence issues for women are well documented. The ICS identified that, in the past, it has been possible to combine all definitions and terminology for lower urinary tract function for women, men and children into one report (D'Ancona et al, 2019). However, as early as 2010, it recognised that this process and the absence of female-specific terminology relating to specific presentations of urinary continence problems was not advantageous to women (D'Ancona et al, 2019). This process did not happen for men until 2019, when D'Ancona et al (2019) identified that, due to its increasing complexity, the terminology for male lower urinary tract and pelvic floor symptoms and dysfunction required a male-specific approach. Previous guidance had identified that 10–15% of men experience persistent urinary incontinence after prostate surgery (Macaulay et al, 2015) and lower urinary tract (LUT) problems, thus making urinary incontinence more likely, with 30% of men over 65 years reporting ‘bothersome symptoms’ (National Institute for Health and Care Excellence (NICE) (2010). Murphy et al (2020) stated that the majority of men undergoing prostate surgery for cancer would experience transitory urinary incontinence. The ICS is not the only organisation that has ignored the male gender; the same is true of NICE, which focuses on incontinence guidelines more for women than men, and there are fewer disease-specific continence guidelines published for men (Nursing Times, 2019). The NHS Long Term Plan's (NHS England, 2019) only reference to continence is pelvic floor dysfunction in women after childbirth. If these national and international organisations and the guidance do not reflect the importance of gender with regard to urinary incontinence, then what are general health professionals who assess the problem expected to?

Barriers to men accessing healthcare and subsequent complications

It is important to bear in mind that men experience incontinence differently to women (Esparza et al, 2018). Men, in general, are known not to access healthcare services as often as women. This statement is supported by Banks and Baker (2013), who identified that nearly twice as many men over 50 years have undiagnosed type 2 diabetes compared with women. Strong beliefs in norms, attitudes and stereotypes of masculinity are prevalent and harmful to men's health and expose them to greater risks, which create social barriers and lead to poorer health outcomes (Lancet, 2019). These risks can be behavioural, that is, smoking, alcoholism, non-adherence to medical treatments; emotional; sexual, that is, related to unsafe sexual practices; or even occupational, for example, men choosing occupations related to construction, driving, mining and the military (Lancet, 2019). Evidence suggests that men in the UK are diagnosed with certain conditions at later stages than women are, for example, urological cancers (Banks and Baker, 2013). Men are more reluctant to talk to health professionals about medical problems, especially urinary incontinence, as it may involve talking to a professional of the opposite sex and disclosing information that they see as embarrassing, which might make them see themselves as a failure. In the social context, it may also be harder for men to avoid situations where they experience leakage, for example, during work if it involves lifting or while playing sports. Additionally, embarrassment, lack of awareness of services and treatment options and fears of surgery may prevent men from seeking help. These can all lead to incontinence-related complications (Table 1).

Pathophysiology of urinary incontinence in men

With such little national guidance and many barriers with regard to men accessing professional services for urinary incontinence, it is no wonder that professionals are sometimes ill equipped to assessing men and helping them get the right care. Incontinence in the male, as in the female, can be broadly divided into causes related to bladder and/or sphincter dysfunction (Diaz et al, 2017). Risks factors for male urinary incontinence are summarised in Box 1.

Box 1.Risk factors for male urinary incontinence

• Poor general health
• Physical disabilities
• Cognitive impairment
• Comorbidities
• Urinary tract infections
• Prostate problems
• Neuropathic disease/conditions, e.g. stroke, diabetes, multiple sclerosis, spinal injury
• Advancing age and frailty.

(Shamliyan et al, 2009; Nursing Times, 2019)

A complete urinary continence assessment for LUTS in men refers to any problems with storage, voiding and/or post-micturition symptoms. There are numerous causes for these symptoms that are known but clinicians are not able to accurately assess, including prostate problems such as benign prostatic enlargement (BPE) or prostate cancer; urethra or bladder abnormalities (e.g. strictures); neurological disease; or sphincter insufficiency due to damage to the muscle, nerve and/or supporting structures (Diaz et al, 2017). Assessment of male urinary incontinence should include all the elements highlighted in Box 2.

Box 2.Assessment of lower urinary tract symptoms in men

• Medical history
• Medication review, including herbal, over the counter and recreational
• Physical examination, including abdomen, external genitalia, and digital rectal examination (if competent)
• Bothersome ratings
• Frequency volume chart/bladder diary
• Dipstick urinalysis to detect blood, glucose, protein, leucocytes, nitrites
• Prostate-specific antigen (PSA) testing
• Serum creatinine test for estimated glomerular filtration rate (eGFR) but only if renal impairment is suspected
• Validated symptom scoring
• Give reassurance
• If no response to conservative therapies/medication, refer for specialist assessment
• Refer for specialist assessment if recurrent, persistent or complicated urinary tract infections.

(National Institute for Health and Care Excellence, 2015)

Professional education

Even though there is guidance with regard to male urinary assessment and the United Kingdom Continence Society (UKCS) (2014) identified minimum standards for both first-line basic continence and specialist assessment, it rarely is completed satisfactorily. The UKCS recommends that staff be trained in the required skills and at a set level of competency. Staff trained in basic assessment for urinary incontinence should be able to:

• Promote continence awareness
• Use basic assessment techniques, including identification of red flag symptoms and reasons for early referral to specialist teams
• Conduct continence assessment with the goal of making a diagnosis and offering treatment. In a minority of cases, this goal may be modified to manage rather than resolve symptoms (UKCS, 2014).

Staff trained for specialist assessment of urinary incontinence should be able to:

• Demonstrate an appropriate knowledge of anatomy and pathophysiology of the male LUT in relation to dysfunction
• Understand the impact of LUTS on men
• Identify red flag symptoms and appropriate referral pathways
• Have an understanding of the types of male LUT dysfunctions
• Have an understanding of the management of these conditions
• Set goals and arrange appropriate review.

However, even though these standards have been identified by experts in the field, male patients are reporting that the services they receive can be poor (Nursing Times, 2019). This can be for a number of reasons:

• Lack of available education for professionals, as continence is not taught at professional pre-education level and accredited post-education courses are sparse throughout the UK
• Lack of staff training and awareness of male incontinence and the impact and consequences, especially compared with the impact on females
• Staff not asking the right questions or communicating in a way that does not inspire openness from men to discuss the issues
• Services/professionals failing to consider male attitudes, needs and preferences
• Gender-related barriers, for example, female nurses asking men about continence can be embarrassing for both parties
• Insufficient signposting to male continence support groups or peer support
• Lack of agreed evidence-based pathways for male incontinence, or lack of knowledge of these.

Although some of these reasons could also be seen as pertaining to women, it is definitely more prevalent for males to avoid accessing services, and, when they do, the outcomes are generally poorer. The Queen's Nursing Institute (QNI) (2018) identified tips for professionals working with men to circumvent these problems (Box 3).

Box 3.Tips for working with men

• Adopt targeted approaches for specific groups of men
• Sensitively explore staff skillset and attitudes, as upskilling may be required
• Be proactive and persistent, do not expect men to come to you
• Give men information and let them process it for themselves
• Do not confront men with questions about their health—they may find this challenging/offputting
• Consider service offered, tone you strike from the man's perspective
• Men are often reluctant to divulge information about their health. Try to rephrase questions in different ways
• Try and give men options and choices in their treatments
• Listen
• Men often reveal key issues when hovering at the door to leave.

(Queen's Nursing Institute, 2018)

Not all types of urinary continence are curable, and, for some, appropriate containment or management is the best outcome. Men are sometimes seen as lucky with regard to the range of appliances and equipment available for management of urinary incontinence, for example, sheaths (Figure 1), pubic pressure devices (Figure 2), washable pants (Figure 3) and urinals (Figure 4), to name a few (Cottenden et al, 2017).

Figure 1. Sheath Figure 2. Pubic pressure device Figure 3. Washable pants with dribble pouch Figure 4. Urinals

However, the most effective containment is the right product to meet the individuals' needs, taking into account leakage, daily activity, physical/cognitive factors and personal values (Murphy et al, 2020). Absorbent pad products are also an option for men with long-term incontinence, but the choices can be overwhelming (Murphy et al, 2020). Men, however, have no experience of selection of appropriate products and find the process to be alien. Women tend to have more knowledge. Men may require different styles of products for maintenance of their self-management, quality of life and independence. However, most manufacturers only make one type of product specifically recommended for men, with others mainly being unisex (Figure 5).

Figure 5. Male pad product and unisex products

Manufacturers provide a large range of products, but only supply information relating to their own range (Murphy et al, 2020). There is no comparison of products for either patients or professionals. As men do not access services like women do, they are generally reliant on professional advice with regard to appropriate products, and they are, therefore, unlikely to get containment products suited to their needs. This leads to confusion over products, ill-fitting products and a negative impact on quality of life. The ICS is trying to address this by designing an evidence-based decision aid for men, including treatment and care options (Cottenden et al, 2017; Murphy et al, 2020).

For more information related to continence equipment and pad products for men, professionals and patients can access Continence Product Advisor at https://www.continenceproductadvisor.org or Bladder and Bowel UK at https://www.bbuk.org.uk.

Recommendations to address the gender deficit

Undoubtedly, progress has been made to improve the standards of care for men with urinary incontinence, specifically, dedicated male continence terminology from the ICS, WHO's strategy to make health systems gender responsive (Baker, 2019), amendments to NICE guidance and introduction of minimal standards for assessment. Nonetheless, there is still a lot of work that needs to be done in this field, as summarised in (Table 2).

Conclusion

Incontinence is not just a female problem, and it affects men of all ages. However, gender-related health inequalities in incontinence care certainly exist and need addressing, nationally, locally and socially. Tackling these health inequalities is vital in order to improve access to services for men, health outcomes and men's experience of services and continence problems in general, as well as improving the services provided. Although work on has started on improving continence services and continence outcomes for men, there is still a long way to go for the care to be on par with what is provided to females. Health professionals are urged to carefully consider service provision and implement recommendations to improve care.

KEY POINTS

• Urinary incontinence in men is common, and increases with age, but there is little best practice evidence guidance to support, compared with female urinary incontinence
• Men are reluctant to access health care to discuss this problem and engagement with professionals is often poor
• Professionals need to approach male incontinence differently, so sensitivity, tact and knowledge of the condition is essential when assessing
• Healthcare professionals should be aware of the different types of urinary containment devices and understand the benefits and disadvantages of the different devices for managing urinary incontinence
• Manufacturers of continence equipment/products should engage with men when designing new products.

CPD REFLECTIVE QUESTIONS

• Is guidance that is already in place for male urinary incontinence appropriate?
• Reflect on the disparities that may exist between assessment, treatment and management of female urinary incontinence compared to male
• How do men access continence services and can this be improved?
• How can professionals influence the provision of adequate products for male individuals?