A clinical nurse specialist conducted a health assessment visit with an 81-year-old woman who was living alone in a 1-bedroom apartment. The elderly woman had experienced 2 cerebrovascular accidents that contributed to uncontrolled urinary incontinence. Her home smelled of urine. Towels covered the kitchen chair seats and a living room chair. The woman was neatly dressed and appeared well nourished and hydrated. Close contact revealed a strong urine smell emitting from her clothing. During the interview, the client shared that she could not afford incontinence products. Rent, bills, specialist and primary care co-pays, and medications left approximately $100 by the end of the month. This money was needed for food, already scarce despite supplementation by charitable food supports. She was embarrassed by her incontinence and saddened by her diminished socialization opportunities, given her inability to manage her incontinence using products that she knew would work but were often financially out of reach.

Urinary incontinence is a burdensome and costly worldwide phenomenon. Prevalence estimates among older noninstitutionalized adults 65 years or older in the United States support that more than 50% of women and more than 25% of men experience some sort of urine leakage.1 The severity of this urinary incontinence varies from minor to severe leakage. Data from the 2007-2010 National Health and Nutrition Examination Survey, 2010 National Survey of Residential Care Facilities, 2007 National Home and Hospice Care Survey, and 2009 Long Term Care Minimum Data Set were analyzed to provide national incontinence prevalence estimates for people 65 years and older based on sociodemographic characteristics between 2007 and 2010.1 This national report provides a concerning picture of urinary incontinence as a high-frequency condition with major negative effects on quality of life. Findings support the need for regular and close attention to bladder incontinence as well as the importance of provider awareness of the particular challenges of living life with urinary leakage, particularly for those with scarce financial resources.

Published research findings support that people around the world avoid sharing their incontinent condition with physicians or other providers. One study using a cross-sectional design with Polish women experiencing stress incontinence (N = 147) revealed that less than half had shared their urinary issues with their physician.2 Many with stress urinary incontinence waited more than 10 years before sharing the problem and concurrently experienced negative effects on quality of life.3 A study of a cross section of Jamaican men older than 60 years (N = 454) found that 10.6% of respondents lived with incontinence and 30.2% of these men had not discussed their incontinence with their physicians.4 Of those men who did not report their urine leakage, a majority thought it preferable for the provider to open discussion about incontinence concerns.4

The causes of urine leakage are diverse and include chronic illnesses, diabetes, dementia, arthritis, neuromuscular disease, cerebrovascular accidents, adverse postoperative sequelae, pelvic floor dysfunction, and many other varied conditions. The severity of urinary incontinence may be quantified using the long-term or short-term pad tests, questionnaires, voiding diaries, and urodynamic tests.4 Following diagnostic testing and completion of available treatments, urinary incontinence may persist for many as a chronic health condition requiring incontinence products as a long-term solution to leakage concerns.

Bladder incontinence is expensive. Annual estimates of the cost of urinary incontinence in the United States for community residents exceed approximately $15 billion.1 Individuals can expect to pay approximately $100 to $200 monthly for incontinent pads and products, depending on the severity of leakage and the frequency of diaper/pad changes. Given the number of elders on fixed incomes, relying predominately on Social Security with an average of $1354 per month, the out-of-pocket expense is a significant percentage of monthly income.5 This expense does not include laundry costs, as well as other expenses associated with leaks, stains, and replacement clothing. The addition of indirect costs related to psychosocial and work-related consequences increases the negative financial consequences of urinary incontinence.6

Incontinence products may be federal tax-deductible, provided the supplies are used to address the effects of a specific disease.7 For those individuals who itemize their taxes, it may be worthwhile to suggest exploring the deductibility of incontinence products, provided that there is a documented medical condition that supports the need for liners, pads, protective underwear, adult diapers, and other products specifically addressing the urine leakage. Other financial options include Flexible Spending Accounts and Health Savings Accounts; however, these opportunities are often unavailable to seniors living on fixed incomes. State sales tax on adult incontinence pads varies by state, with some enacting no sales tax and others taxing or exempting adult diapers.7 The National Diaper Bank Network in partnership with Yale Law School Arthur Liman Research Project students conducted a Fifty States Survey on the Sales Tax Treatment of Diapers Survey. Survey results revealed mixed tax treatment of adult incontinence pads and variable tax rates.8

There are opportunities to save some money by buying in bulk and buying online. A Web search did reveal that name-brand incontinent pads and briefs were often lower when purchased in larger quantities. These opportunities are limited to those who have access to online shopping sources and also to those with the means to make a single large purchase rather than more frequent smaller purchases that may cost more in total but are more easily managed within a weekly or biweekly budget spent at a local store.

A quick review using a few popular search engines reveals that many adult incontinence product manufacturers do provide samples. This is an important opportunity because it gives the user a chance to try various types of fits, styles, and absorbencies prior to a purchase commitment. Online searches also revealed that there are many product manufacturers beyond the brands that are often found on store shelves or advertised on television. Providers may want to consider pulling together a list of resources that would likely be helpful to clients, making certain to include Web site addresses and phone numbers for those who do not use computer technologies.

The Simon Foundation for Continence is an excellent resource both for those who experience incontinence and for caregivers. Its mission is to encourage open communication about incontinence, urinary and fecal, to remove stigma and to provide support.9 This foundation maintains a database of diaper banks in the United States for adult absorbent products.10 Banks are organized by state. There are many other resource links, including information about treatments, new investigations, and helpful agencies' contact information. Personalized service is available via The CareGiver Partnership, a company that provides personalized assistance with incontinence products and has online tools (as well as telephone-based assistance) to facilitate decisions about a product that might be best for the specific type of incontinence experience.11

Holistic care providers may want to consider soliciting adult incontinence product contributions from patients and then donating these products to local diaper collection agencies. It is not uncommon for families to have incontinence product supplies that have not been used by a loved one by the time of death or following a postoperative or high-acuity event that once resolved no longer warrants pad usage. It is likely that patients and caregivers would feel some sense of satisfaction by contributing these items to someone in need. A recent experience with a post-prostatectomy patient who had purchased several unnecessary boxes of incontinence pads and was looking for a way to donate them provides a good example of how a practice might work to openly encourage dialogue about incontinence while providing patients and families with an option to contribute rather than discard unopened products.

Nurses and other providers may also want to provide information about products other than adult diapers, including washable and reusable briefs or pads that can improve living circumstances, reduce wastage, and positively affect workload. Health care providers are often far more familiar with the available array of incontinence products than are lay people, particularly those newly experiencing the demands of incontinence. Washable padded bed linens, waterproof mattress protectors, washable incontinence briefs, skin barriers for protection against breakdown related to urine leakage, and other products may be unfamiliar aids that could be helpful to caregivers and people living with incontinence. It is quite possible that connecting people to online and in-person supports could provide people with a support system and informational network that may contribute to an improved quality of life.

Each patient encounter provides the holistic practitioner with a potential opportunity to openly ask about incontinence, thereby reinforcing that there should be no stigmatization of urinary leakage. Although there are needs for practice and system improvements related to urine leakage, some opportunities do currently exist for helping those who live with incontinence. Providers need to consider how they might actively contribute to improving the system of care while also supporting those who need support and guidance related to treating and living with urinary incontinence.

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