MISDIAGNOSIS OF URINARY-INCONTINENCE IN NURSING-HOME WOMEN - PREVALENCE AND A PROPOSED SOLUTION

Because of the high prevalence of detrusor hyperactivity with impaired contractility (DHIC) in incontinent institutionalized women, we postu lated that: 1) single-channel cystometry, the most commonly used diagn ostic test, would be inadequate when used alone but that 2) its accura cy could be greatly enhanced by combining it with a previously-perform ed stress test. To test the hypothesis, we used blinded comparison of a clinical stress test and single-channel cystometry with multichannel videourodynamic evaluation (criterion standard), a strategy designed a priori. Subjects were 97 incontinent women who were considered repre sentative of incontinent nursing home women nationally. With cystometr y alone, 9 of 37 women with DHIC (24%) were misdiagnosed as stress-inc ontinent vs. 1 of 25 with DH (P = .03). In each case, misdiagnosis was due to failure to recognize low-pressure involuntary bladder contract ions. Combining cystometry with the stress test improved diagnostic ac curacy markedly. Of the 77% of women in whom the results of both tests were congruent, all were correctly classified. When results of the tw o tests were discordant, neither was superior. Significantly, no woman with stress incontinence was missed by the two-test strategy, nor was anyone with detrusor hyperactivity misclassified. We conclude that in institutionalized elderly women, DHIC commonly mimics other types of urinary tract dysfunction. Thus, single-channel cystometry alone is an inadequate diagnostic test in this population. However, a strategy th at combines cystometry with a clinical stress test can correctly class ify the majority of such women and identify those in whom the diagnosi s is less secure. Use of this simple strategy would facilitate correct diagnosis and initial treatment of most institutionalized women witho ut referral, and also enrich the referred population with those most l ikely to benefit. Such an approach could significantly improve the app roach to this costly and morbid condition. (C) 1996 Wiley-Liss, Inc.