Urinary incontinence (UI) is defined by the Inter- national Continence Society (ICS) as involuntary loss of urine in the bladder storage phase (1). UI ranged from approximately 5% to 70%, with most studies re- porting a prevalence of any UI in the range of 25–45% (2). Approximately 25% of women of reproductive age, 44-57% of women in middle age and postmenopausal period, and 75% of women over 65 years of age have urinary incontinence (3). Urinary incontinence affects 14-86% of women in Turkey (4-6). UI is a health prob- lem that creates a serious economic burden on the in- dividual, family, community, and healthcare services. The economic burden of a disease is the total cost of all resources used or lost by patients and society as a result of the disease (7). Estimating healthcare costs for urinary incontinence is quite difficult because most of the affected individuals do not apply (for reasons such as embarrassment and disregard) to the healthcare ser- vices (8). Therefore, the actual number of individuals with urinary incontinence and the actual burden of the disease are thought to be much higher than the current estimates. Among the reasons why individuals with UI do not present to healthcare institutions are feelings of embarrassment, disbelief in effective treatment of the disease, lack of information, assumption that the dis- ease is a natural phenomenon with advanced age, and unawareness about treatment options (9). The aim of this review is to investigate the disease burden and cost of urinary incontinence according to the literature, with an intent to present its current state.
Disease Burden
The concept of disease burden allows making esti- mations on risk factors related to particular diseases, health problems, injuries and comparing countries ac- cording to standard parameters. In addition, it provides evidence-based data for decision-makers and evaluates of the impact of interventions on public health and of cost-related data (10).
The criteria developed under the disease burden, which is a criterion of public health, are as follows:
• Disability-Free Life Expectancy - DFLE
• Healthy Life Expectancy - HALE
• Disability-Adjusted Life Years - DALY
• Healthy Life Year - HeaLY
• Disability-Adjusted Life Expectancy - DALE
• Quality-Adjusted Life Years - QALY (10).
In order to calculate the economic burden of UI, the disease burden must be determined (11). In stud- ies, the most commonly used criterion for determining the disease burden of UI is the Quality-Adjusted Life Years (QALY) (10). In analyses regarding the distribu- tion of limited healthcare resources among healthcare programs, QALY enables decision-makers to measure the impact of relevant improvements on life expectan- cy and quality of life (10). QALY is a numeric repre- sentation of how much and how long one’s quality of life improves after treatment (12). This concept, which is used in economic evaluations, involves calculation of Incremental Cost-Effectiveness Ratio (ICER). ICER is a statistic used in cost-effectiveness analysis to sum- marise the cost-effectiveness of a health care interven- tion. It is defined by the difference in cost between two or more (behavioral treatment, drug treatment, surgi- cal treatment) possible interventions, divided by the difference in their effect (13).
Determination of Direct Costs Related to Uri- nary Incontinence
Urinary incontinence creates a serious economic
burden on individuals and the health system. Econom- ic burden can be measured by treatment and cost per patient. Total cost related to UI can be divided into two as direct and indirect costs (Table 1). Standardised di- agnostic and treatment procedures costs can be used to determine direct costs (8). Direct costs related to UI can be divided into four as diagnosis, treatment, rou- tine care and UI outcome costs (costs of health-related consequences; e.g., falls, skin conditions, urinary tract infections). The cost of incontinence includes both di- rect use of resources for incontinence care and treat- ment, and indirect economic effects resulting from in- continence (e.g. morbidity or loss of productivity due to disability). The economic costs of incontinence are equal to the sum of resources used or lost by patients, healthcare professionals, government agencies or oth- er segments of society as a direct or indirect result of incontinence. The resources used in treatment such as medical staff, equipment, materials, clinical facilities, etc. vary widely. Therefore, it is easier to estimate direct costs by identifying the types of treatment services, measuring the units of these treatment services, and multiplying them with the cost. Meanwhile, the finan- cial burden of UI can also be determined by calculating individual expenditures in direct proportion with the prevalence (11). While most of the total cost includes direct costs (e.g. diagnostic tests, inpatient and outpa- tient care, laundry, drug treatment, behavioral treat- ment, etc.) and indirect costs (expenditure for paid or unpaid caregivers) constitute only 4% of the total UI cost (8). The majority of the studies conducted world- wide focus on costs related to overactive bladder and urgency incontinence problems (7, 14, 15).
According to the 2010 Deloitte report, It was esti- mated total cost of incontinence 67 billion Australian dollars in Australia (16). In a systematic review, it is indicated that the total national cost of urgecy inconti- nence in the United States of America (USA) was 65.9 billion USD in 2007, 76.2 billion USD in 2015, and it is estimated to be 82.6 billion USD in 2020, with direct costs being the main portion of the overall cost of ur- gency incontinence. It is stated that this will increase gradually in the following years (14). The most com- prehensive study in the USA was conducted in 1995, and the cost of direct care of UI was calculated as 16.3 billion USD. In the USA, annual direct costs of urinary incontinence are reported to be higher in women in nursing homes (8.6 billion USD) than in women in hospitals (3.8 billion USD). Similarly, the cost for wom-en over 65 years of age is more than twice the cost for women under 65 (7.6 and 3.6 billion USD, respective- ly), the largest cost category being routine care costs (70%), followed by nursing home admissions (14%), treatment (9%), complications (6%), and diagnosis and examinations (1%) (17). In a study conducted to de- termine the use of medical resources and direct treat- ment costs for women with UI in European countries (Germany, Spain, United Kingdom (UK)/Ireland), di- rect costs were calculated as annual costs per patient
Table 2. Direct costs of urinary incontinence by country according to type of UI. Data on these costs are given in Table 2. In the study, it was determined that mixed UI (MUI) was the UI type with the highest costs (18).
In Turkey, there is no registration system or re- search yet concerning the disease burden of UI, and available data is limited to the costs of diagnosis and treatment specified in the Annex-2B of Healthcare Im- plementation Communiqué (SUT) (19). Diagnosis and treatment costs per patient indicated in the SUT are given in Table 3.
Diagnostic Costs of Urinary Incontinence
Laboratory tests, physical examination, consulta- tions and urodynamic evaluations are used in the di- agnostic process of urinary incontinence. The rate of use of diagnostic tests is significant in determining the costs related to UI diagnosis.
In a study, it was determined that urinalysis, uro- genital examination and ultrasound are the most wide- ly used diagnostic procedures in Germany, Spain, and England/Ireland, respectively (18). In the study in which direct costs of urinary incontinence were estimated based on the data of the Italian National Health Service, it was stated that consultation cost constitutes 20% of the total, diagnostic tests 36%, and hospital ad- missions for diagnostic procedures 44% (20). Hu et al.
(11) reported the annual diagnosis costs per case as 26 USD for hospitalized individuals and 24.5 USD for in- dividuals in the community. In their study, Papanico- laou et al. (18) reported that the diagnostic costs were 48 Euro in Germany, 177 Euro in Spain and 24 Euro in UK/Ireland.
Treatment Costs of Urinary Incontinence
The management of UI symptoms involves a mul- tifaceted and complex treatment process. In UI, it is recommended to plan and implement conservative treatment before surgery (21). Conservative treatment includes lifestyle changes such as losing weight, smok- ing cessation, reducing caffeine and alcohol consump- tion, and management of comorbid diseases such as chronic obstructive pulmonary disease and diabetes. The cost of medical optimization and lifestyle changes (e.g. walking three times a week) do not include any additional costs or may involve fees such as monthly membership in a gym, whereas the cost can vary up to thousands of USD per year for complex medical opti- mization (22).
Behavioral therapy and pharmacotherapy togeth- er are necessary within the scope of treatment, and it is stated that these combinations cannot be evaluated in terms of cost-effectiveness (23). Pharmacological agents frequently used in UI treatment are anticholin- ergics, alpha-adrenergic agonists, Beta adrenergic ago- nists (mirabegron), duloxetine and estrogen (24). The costs of these pharmacological agents range between 1140-3480 USD per year (23). In their study, Hu et al. (11) stated that annual pharmacological treatment cost per case was 6 USD for hospitalized individuals and 14.4 USD for individuals in the community. In a study by Papanicolaou et al. (18), the annual cost of pharmacological treatment per patient was reported to be 77 Euro in Germany, 41 Euro in Spain and 81 Euro in UK/Ireland. The first step in treatment of UI is the implementation of pelvic floor muscle training (PFMT), which strengthens urethral sphincter tone, thus decreasing urine leakage during episodes of in- creased intraabdominal pressure. When used alone, the method is essentially free. PFMT can be combined with other treatments such as biofeedback, electrical stimulation, and vaginal cones, but they come with additional costs. For basic level PFMT, the average cost of a three-month treatment cycle is 189 Euro, for biofeedback combination 224 Euro, and for electrical stimulation combination 398 Euro (12). In a study con- ducted in the UK in 2010, the estimated prices for the three-month basic PFMT, PFMT and biofeedback, and PFMT and electrical stimulation were determined as 291 USD, 345 USD and 612 USD, respectively (22). In the study by Simpson et al. (25), the results of cost-ef- fectiveness analysis indicated that PFMT was the most cost-effective non-surgical treatment option for stress urinary incontinence.
The two surgical treatment options applied in UI are colposuspension and retropubic tape (RT). In a 10-year screening study conducted in the USA, RT (8651 USD) was found to be a cost-effective treatment compared to colposuspension (10545 USD) (26). Ac- cording to the UK National Health Service reference costs, average RT and Transobturator tape (TOT) costs are reported to be 1135 Euro (741-1357 Euro) for an average two-day hospital stay and 629 Euro (456-828 Euro) for same-day surgical treatment. Average colpo- suspension costs for an average two-day hospital stay are €1396 (1011-2013 Euro) (27). Another study has shown that TOT is cost effective compared with RT in the treatment of stress urinary incontinence (28).
In a systematic review, the estimated total cost of treatment procedures is reported to be 1114 Euro for RT, 1317 Euro for colposuspension, 1340 Euro for tra- ditional sling, 1317 Euro for laparoscopic colposus- pension and 1305 Euro for injectable pharmacological agents. RT is cost-effective compared to other surgical procedures that are assumed to be equally effective as a traditional sling and open colposuspension. RT more costly than laparoscopic colposuspension is equally ef- fective as or less effective than open colposuspension with similar costs, and injectable agents are less effec- tive but also more costly than RT (29). In a systematic review (30), costs related to surgical procedures were classified on Table 4.
Routine Care Costs in Urinary Incontinence
Routine care costs include various items such as pads, menstruation pads, incontinence pads, dispos- able or reusable underwear, laundry, dry-cleaning, skin care and odor control products. Laundry costs re- lated to incontinence include cleaning the bed sheets, bed pads and clothes. It is quite difficult to find data specifying the indirect costs associated with the symp- tomatic treatment of UI. Many adults who prefer to treat their condition personally to trust pads, diapers, and changing clothes frequently (23). Routine care costs are difficult to calculate. A majority (50-75%) of the cost of incontinence includes the costs of routine care, including absorbent pads, protection, and laun- dry (28). Adults with UI often use pads and diapers as incontinence support products. Since pads are dispos- able, they require high costs. Adult diapers can be dis- posed of or reused after use. Washable diapers are more expensive initially, but their cost is reduced over time due to their reusability. Bed and chair underpads can be disposable or reusable, with varying costs according to the feature (23). The Australian Institute of Health and Welfare (AIHW) estimates that the expenditure on incontinence products was 101 million Australian Dollars in 2003. This amount does not include other personal expenses such as laundry or government ex- penditures for incontinence support programs (31).
UI patients need constant care to change their in- continence pads, underwear and clothing and to en- sure proper skin care. In the community, this routine care is usually performed by the individual, while in the nursing home or in case of a disability, by caregiv- ers. The two environments being different, the cost of routine care is different in the community and in the nursing home. In addition, the accuracy of data col- lection varies in the community and in the nursing home. Data collection regarding routine care costs is easier and more accurate in nursing homes than in the community. The reported costs in the community are largely based on the statement of the individual, and the types of products used vary, making it difficult to calculate the cost (11). In a study in which the cost of pads, diapers, laundry and dry-cleaning for women liv- ing in nursing home was calculated, it was found that an average of 3.91±11.11 USD per week was spent for women with SUI, and this expenditure was 204±578 USD annually. Women with UI living in the commu- nity have been found to have lower treatment and care costs than those with more comorbidities living in nursing home (32).
In a study conducted in the USA (2006) with 273 women with UI in order to determine the costs of routine care, 90% of the women reported costs related to UI, and the average weekly cost rose to 0.37 USD with mild UI, and 10.98 USD with severe UI, mean- ing that costs increased with the severity of the disease. In addition, it was found that approximately 75% used pads (minipad being the most common), more than half reported laundry burden, and 18% had additional dry-cleaning costs per week due to UI (33) (Table 5).
One of the parameters of routine care is the nursing workforce. Incontinence nurses work in many health institutions, including inpatient services, community clinics, continence helpline and rehabilitation services (34). It was also reported that women without inconti- nence received an average of 5.9 hours of care per week, women with incontinence not using pads 7.6 hours, and women with incontinence using pads 10.7 hours. Annual informal costs of care associated with incon- tinence were reported to be 1700 USD and 4000 USD for men with incontinence not using pads and using pads, respectively, while 700 USD and 2,000 USD per year for women in these groups, with a total national cost of over 6 USD billion per year for care associated with incontinence (34). In a study, it was shown that incontinence nurses in first-line healthcare services had an important role in reducing the costs of UI (35). In another study, it was found that more patients were detected by a continence nurse specialists than other health professionals because of the questioning of in- continence, and more treatment and improvement was achieved. The increased percentages of successfully treated and improved patients have been found to re- duce the costs of formal home care, informal care and containment products (36).
Outcome Costs Caused by Urinary Incontinence UI directly cause to many secondary diagnoses, including skin lesions, urinary tract infections (UTI), depression, falls, and fractures (9). Skin irritation and falls are assumed to occur in 50% of the elderly. It is in- dicated that 1% of patients with UTI in nursing homes require rehospitalization. It is reckoned that 5% of nursing home admissions primarily result from incon- tinence and that incontinence is effective in determin- ing the place of residence of the elderly (17). There are no present data on costs of secondary health problem associated with urinary incontinence.
Indirect Costs Related to Urinary Incontinence It is known that UI seriously affects the quality of life and causes various comorbidities and functional limitations. Individuals with UI experience unemploy- ment or early retirement due to mental problems such as depression, isolation and lack of confidence, and expenses related to these constitute indirect costs. In addition, the employment status of family members or
friends who help the patient with UI care are also in- cluded in indirect costs (8, 23). It is stated that, in Can- ada, 7% of the female working population and 3.5% of the male population had UI complaints and that the disease caused an average of 11 days of workforce loss and $182.27 of financial loss per day for employers (37). Low employment rates in individuals with incon- tinence may present an additional cost to the economy due to loss in productivity and income (38). Indirect costs of UI cannot be scientifically calculated, but in- direct costs are estimated to constitute a greater share than direct costs (15). In a study, it was determined that employees with UUI had statistically significant- ly higher medical costs (131%), drug costs (52%), sick leave (30%) and short-term disability (74%). It was found that employees with UUI had 117% more med- ical and drug costs, 47% higher total absenteeism cost in daily activities and 63% more absenteeism at work than employees without UUI (15).
INTRODUCTION
Urinary incontinence (UI) is defined by the Inter- national Continence Society (ICS) as involuntary loss of urine in the bladder storage phase (1). UI ranged from approximately 5% to 70%, with most studies re- porting a prevalence of any UI in the range of 25–45% (2). Approximately 25% of women of reproductive age, 44-57% of women in middle age and postmenopausal period, and 75% of women over 65 years of age have urinary incontinence (3). Urinary incontinence affects 14-86% of women in Turkey (4-6). UI is a health prob- lem that creates a serious economic burden on the in- dividual, family, community, and healthcare services. The economic burden of a disease is the total cost of all resources used or lost by patients and society as a result of the disease (7). Estimating healthcare costs for urinary incontinence is quite difficult because most of the affected individuals do not apply (for reasons such as embarrassment and disregard) to the healthcare ser- vices (8). Therefore, the actual number of individuals with urinary incontinence and the actual burden of the disease are thought to be much higher than the current estimates. Among the reasons why individuals with UI do not present to healthcare institutions are feelings of embarrassment, disbelief in effective treatment of the disease, lack of information, assumption that the dis- ease is a natural phenomenon with advanced age, and unawareness about treatment options (9). The aim of this review is to investigate the disease burden and cost of urinary incontinence according to the literature, with an intent to present its current state.
Disease Burden
The concept of disease burden allows making esti- mations on risk factors related to particular diseases, health problems, injuries and comparing countries ac- cording to standard parameters. In addition, it provides evidence-based data for decision-makers and evaluates of the impact of interventions on public health and of cost-related data (10).
The criteria developed under the disease burden, which is a criterion of public health, are as follows:
• Disability-Free Life Expectancy - DFLE
• Healthy Life Expectancy - HALE
• Disability-Adjusted Life Years - DALY
• Healthy Life Year - HeaLY
• Disability-Adjusted Life Expectancy - DALE
• Quality-Adjusted Life Years - QALY (10).
In order to calculate the economic burden of UI, the disease burden must be determined (11). In stud- ies, the most commonly used criterion for determining the disease burden of UI is the Quality-Adjusted Life Years (QALY) (10). In analyses regarding the distribu- tion of limited healthcare resources among healthcare programs, QALY enables decision-makers to measure the impact of relevant improvements on life expectan- cy and quality of life (10). QALY is a numeric repre- sentation of how much and how long one’s quality of life improves after treatment (12). This concept, which is used in economic evaluations, involves calculation of Incremental Cost-Effectiveness Ratio (ICER). ICER is a statistic used in cost-effectiveness analysis to sum- marise the cost-effectiveness of a health care interven- tion. It is defined by the difference in cost between two or more (behavioral treatment, drug treatment, surgi- cal treatment) possible interventions, divided by the difference in their effect (13).
Determination of Direct Costs Related to Uri- nary Incontinence
Urinary incontinence creates a serious economic
burden on individuals and the health system. Econom- ic burden can be measured by treatment and cost per patient. Total cost related to UI can be divided into two as direct and indirect costs (Table 1). Standardised di- agnostic and treatment procedures costs can be used to determine direct costs (8). Direct costs related to UI can be divided into four as diagnosis, treatment, rou- tine care and UI outcome costs (costs of health-related consequences; e.g., falls, skin conditions, urinary tract infections). The cost of incontinence includes both di- rect use of resources for incontinence care and treat- ment, and indirect economic effects resulting from in- continence (e.g. morbidity or loss of productivity due to disability). The economic costs of incontinence are equal to the sum of resources used or lost by patients, healthcare professionals, government agencies or oth- er segments of society as a direct or indirect result of incontinence. The resources used in treatment such as medical staff, equipment, materials, clinical facilities, etc. vary widely. Therefore, it is easier to estimate direct costs by identifying the types of treatment services, measuring the units of these treatment services, and multiplying them with the cost. Meanwhile, the finan- cial burden of UI can also be determined by calculating individual expenditures in direct proportion with the prevalence (11). While most of the total cost includes direct costs (e.g. diagnostic tests, inpatient and outpa- tient care, laundry, drug treatment, behavioral treat- ment, etc.) and indirect costs (expenditure for paid or unpaid caregivers) constitute only 4% of the total UI cost (8). The majority of the studies conducted world- wide focus on costs related to overactive bladder and urgency incontinence problems (7, 14, 15).
According to the 2010 Deloitte report, It was esti- mated total cost of incontinence 67 billion Australian dollars in Australia (16). In a systematic review, it is indicated that the total national cost of urgecy inconti- nence in the United States of America (USA) was 65.9 billion USD in 2007, 76.2 billion USD in 2015, and it is estimated to be 82.6 billion USD in 2020, with direct costs being the main portion of the overall cost of ur- gency incontinence. It is stated that this will increase gradually in the following years (14). The most com- prehensive study in the USA was conducted in 1995, and the cost of direct care of UI was calculated as 16.3 billion USD. In the USA, annual direct costs of urinary incontinence are reported to be higher in women in nursing homes (8.6 billion USD) than in women in hospitals (3.8 billion USD). Similarly, the cost for wom-en over 65 years of age is more than twice the cost for women under 65 (7.6 and 3.6 billion USD, respective- ly), the largest cost category being routine care costs (70%), followed by nursing home admissions (14%), treatment (9%), complications (6%), and diagnosis and examinations (1%) (17). In a study conducted to de- termine the use of medical resources and direct treat- ment costs for women with UI in European countries (Germany, Spain, United Kingdom (UK)/Ireland), di- rect costs were calculated as annual costs per patient
Table 2. Direct costs of urinary incontinence by country according to type of UI. Data on these costs are given in Table 2. In the study, it was determined that mixed UI (MUI) was the UI type with the highest costs (18).
In Turkey, there is no registration system or re- search yet concerning the disease burden of UI, and available data is limited to the costs of diagnosis and treatment specified in the Annex-2B of Healthcare Im- plementation Communiqué (SUT) (19). Diagnosis and treatment costs per patient indicated in the SUT are given in Table 3.
Diagnostic Costs of Urinary Incontinence
Laboratory tests, physical examination, consulta- tions and urodynamic evaluations are used in the di- agnostic process of urinary incontinence. The rate of use of diagnostic tests is significant in determining the costs related to UI diagnosis.
In a study, it was determined that urinalysis, uro- genital examination and ultrasound are the most wide- ly used diagnostic procedures in Germany, Spain, and England/Ireland, respectively (18). In the study in which direct costs of urinary incontinence were estimated based on the data of the Italian National Health Service, it was stated that consultation cost constitutes 20% of the total, diagnostic tests 36%, and hospital ad- missions for diagnostic procedures 44% (20). Hu et al.
(11) reported the annual diagnosis costs per case as 26 USD for hospitalized individuals and 24.5 USD for in- dividuals in the community. In their study, Papanico- laou et al. (18) reported that the diagnostic costs were 48 Euro in Germany, 177 Euro in Spain and 24 Euro in UK/Ireland.
Treatment Costs of Urinary Incontinence
The management of UI symptoms involves a mul- tifaceted and complex treatment process. In UI, it is recommended to plan and implement conservative treatment before surgery (21). Conservative treatment includes lifestyle changes such as losing weight, smok- ing cessation, reducing caffeine and alcohol consump- tion, and management of comorbid diseases such as chronic obstructive pulmonary disease and diabetes. The cost of medical optimization and lifestyle changes (e.g. walking three times a week) do not include any additional costs or may involve fees such as monthly membership in a gym, whereas the cost can vary up to thousands of USD per year for complex medical opti- mization (22).
Behavioral therapy and pharmacotherapy togeth- er are necessary within the scope of treatment, and it is stated that these combinations cannot be evaluated in terms of cost-effectiveness (23). Pharmacological agents frequently used in UI treatment are anticholin- ergics, alpha-adrenergic agonists, Beta adrenergic ago- nists (mirabegron), duloxetine and estrogen (24). The costs of these pharmacological agents range between 1140-3480 USD per year (23). In their study, Hu et al. (11) stated that annual pharmacological treatment cost per case was 6 USD for hospitalized individuals and 14.4 USD for individuals in the community. In a study by Papanicolaou et al. (18), the annual cost of pharmacological treatment per patient was reported to be 77 Euro in Germany, 41 Euro in Spain and 81 Euro in UK/Ireland. The first step in treatment of UI is the implementation of pelvic floor muscle training (PFMT), which strengthens urethral sphincter tone, thus decreasing urine leakage during episodes of in- creased intraabdominal pressure. When used alone, the method is essentially free. PFMT can be combined with other treatments such as biofeedback, electrical stimulation, and vaginal cones, but they come with additional costs. For basic level PFMT, the average cost of a three-month treatment cycle is 189 Euro, for biofeedback combination 224 Euro, and for electrical stimulation combination 398 Euro (12). In a study con- ducted in the UK in 2010, the estimated prices for the three-month basic PFMT, PFMT and biofeedback, and PFMT and electrical stimulation were determined as 291 USD, 345 USD and 612 USD, respectively (22). In the study by Simpson et al. (25), the results of cost-ef- fectiveness analysis indicated that PFMT was the most cost-effective non-surgical treatment option for stress urinary incontinence.
The two surgical treatment options applied in UI are colposuspension and retropubic tape (RT). In a 10-year screening study conducted in the USA, RT (8651 USD) was found to be a cost-effective treatment compared to colposuspension (10545 USD) (26). Ac- cording to the UK National Health Service reference costs, average RT and Transobturator tape (TOT) costs are reported to be 1135 Euro (741-1357 Euro) for an average two-day hospital stay and 629 Euro (456-828 Euro) for same-day surgical treatment. Average colpo- suspension costs for an average two-day hospital stay are €1396 (1011-2013 Euro) (27). Another study has shown that TOT is cost effective compared with RT in the treatment of stress urinary incontinence (28).
In a systematic review, the estimated total cost of treatment procedures is reported to be 1114 Euro for RT, 1317 Euro for colposuspension, 1340 Euro for tra- ditional sling, 1317 Euro for laparoscopic colposus- pension and 1305 Euro for injectable pharmacological agents. RT is cost-effective compared to other surgical procedures that are assumed to be equally effective as a traditional sling and open colposuspension. RT more costly than laparoscopic colposuspension is equally ef- fective as or less effective than open colposuspension with similar costs, and injectable agents are less effec- tive but also more costly than RT (29). In a systematic review (30), costs related to surgical procedures were classified on Table 4.
Routine Care Costs in Urinary Incontinence
Routine care costs include various items such as pads, menstruation pads, incontinence pads, dispos- able or reusable underwear, laundry, dry-cleaning, skin care and odor control products. Laundry costs re- lated to incontinence include cleaning the bed sheets, bed pads and clothes. It is quite difficult to find data specifying the indirect costs associated with the symp- tomatic treatment of UI. Many adults who prefer to treat their condition personally to trust pads, diapers, and changing clothes frequently (23). Routine care costs are difficult to calculate. A majority (50-75%) of the cost of incontinence includes the costs of routine care, including absorbent pads, protection, and laun- dry (28). Adults with UI often use pads and diapers as incontinence support products. Since pads are dispos- able, they require high costs. Adult diapers can be dis- posed of or reused after use. Washable diapers are more expensive initially, but their cost is reduced over time due to their reusability. Bed and chair underpads can be disposable or reusable, with varying costs according to the feature (23). The Australian Institute of Health and Welfare (AIHW) estimates that the expenditure on incontinence products was 101 million Australian Dollars in 2003. This amount does not include other personal expenses such as laundry or government ex- penditures for incontinence support programs (31).
UI patients need constant care to change their in- continence pads, underwear and clothing and to en- sure proper skin care. In the community, this routine care is usually performed by the individual, while in the nursing home or in case of a disability, by caregiv- ers. The two environments being different, the cost of routine care is different in the community and in the nursing home. In addition, the accuracy of data col- lection varies in the community and in the nursing home. Data collection regarding routine care costs is easier and more accurate in nursing homes than in the community. The reported costs in the community are largely based on the statement of the individual, and the types of products used vary, making it difficult to calculate the cost (11). In a study in which the cost of pads, diapers, laundry and dry-cleaning for women liv- ing in nursing home was calculated, it was found that an average of 3.91±11.11 USD per week was spent for women with SUI, and this expenditure was 204±578 USD annually. Women with UI living in the commu- nity have been found to have lower treatment and care costs than those with more comorbidities living in nursing home (32).
In a study conducted in the USA (2006) with 273 women with UI in order to determine the costs of routine care, 90% of the women reported costs related to UI, and the average weekly cost rose to 0.37 USD with mild UI, and 10.98 USD with severe UI, mean- ing that costs increased with the severity of the disease. In addition, it was found that approximately 75% used pads (minipad being the most common), more than half reported laundry burden, and 18% had additional dry-cleaning costs per week due to UI (33) (Table 5).
One of the parameters of routine care is the nursing workforce. Incontinence nurses work in many health institutions, including inpatient services, community clinics, continence helpline and rehabilitation services (34). It was also reported that women without inconti- nence received an average of 5.9 hours of care per week, women with incontinence not using pads 7.6 hours, and women with incontinence using pads 10.7 hours. Annual informal costs of care associated with incon- tinence were reported to be 1700 USD and 4000 USD for men with incontinence not using pads and using pads, respectively, while 700 USD and 2,000 USD per year for women in these groups, with a total national cost of over 6 USD billion per year for care associated with incontinence (34). In a study, it was shown that incontinence nurses in first-line healthcare services had an important role in reducing the costs of UI (35). In another study, it was found that more patients were detected by a continence nurse specialists than other health professionals because of the questioning of in- continence, and more treatment and improvement was achieved. The increased percentages of successfully treated and improved patients have been found to re- duce the costs of formal home care, informal care and containment products (36).
Outcome Costs Caused by Urinary Incontinence UI directly cause to many secondary diagnoses, including skin lesions, urinary tract infections (UTI), depression, falls, and fractures (9). Skin irritation and falls are assumed to occur in 50% of the elderly. It is in- dicated that 1% of patients with UTI in nursing homes require rehospitalization. It is reckoned that 5% of nursing home admissions primarily result from incon- tinence and that incontinence is effective in determin- ing the place of residence of the elderly (17). There are no present data on costs of secondary health problem associated with urinary incontinence.
Indirect Costs Related to Urinary Incontinence It is known that UI seriously affects the quality of life and causes various comorbidities and functional limitations. Individuals with UI experience unemploy- ment or early retirement due to mental problems such as depression, isolation and lack of confidence, and expenses related to these constitute indirect costs. In addition, the employment status of family members or
friends who help the patient with UI care are also in- cluded in indirect costs (8, 23). It is stated that, in Can- ada, 7% of the female working population and 3.5% of the male population had UI complaints and that the disease caused an average of 11 days of workforce loss and $182.27 of financial loss per day for employers (37). Low employment rates in individuals with incon- tinence may present an additional cost to the economy due to loss in productivity and income (38). Indirect costs of UI cannot be scientifically calculated, but in- direct costs are estimated to constitute a greater share than direct costs (15). In a study, it was determined that employees with UUI had statistically significant- ly higher medical costs (131%), drug costs (52%), sick leave (30%) and short-term disability (74%). It was found that employees with UUI had 117% more med- ical and drug costs, 47% higher total absenteeism cost in daily activities and 63% more absenteeism at work than employees without UUI (15).