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urinary incontinence ( ui ) is an important and common health problem , whose prevalence increases with age.[13 ] common types of incontinence affecting the elderly are : stress incontinence , urge incontinence , overflow incontinence , and mixed type incontinence . concerning stress incontinence , females are predominant in comparison with males because of their shorter urethral tract . in contrast , urinary incontinence with urge symptoms is mostly affected by neurogenic issues affecting geriatric detrusor function .
both have been reported to be signs of a poor prognosis in patients with stroke .
however , these signs were judged in the subacute or chronic phase during hospitalization , and only nakayama et al .
evaluated 32% of the patients with stroke in the subacute phase together with those in the acute phase .
, that have evaluated the relationship between stroke and urinary incontinence , have excluded the patients with subarachnoid hemorrhage ( sah ) , because sah required a head ct examination to obtain a correct diagnosis . at ken - o tokorozawa hospital in saitama prefecture , located near tokyo , we perform ct examinations for all patients who have had a possible stroke , including those suspected to have a sah , and we routinely record whether the patient had urinary incontinence upon arrival .
accordingly , we retrospectively investigated the prognostic factors including urinary incontinence among the patients with both ischemic and hemorrhagic stroke .
the institutional review board of ken - o tokorozawa hospital approved this retrospective study and waived the requirement of informed consent .
ken - o tokorozawa hospital is located in saitama prefecture close to tokyo , and has 100 beds including stroke care unit .
this hospital had one ct and two mri instruments , and stroke patients can be evaluated by ct or mri at any time .
a medical chart review was retrospectively performed for patients with stoke admitted between january 2010 and december 2010 .
stroke was defined clinically according to the world health organization criteria , and the pathological subtype classification as ischemic stroke ( is ) , including transient ischemic attack , intracerebral hemorrhage ( ich ) or subarachnoid hemorrhage ( sah ) , was confirmed by ct and/or mri .
the diagnosis of sah was made based on the existence of sah in the basal cistern on the initial ct without evidence of a contusion or fracture of the skin or skull .
a transient ischemic attack ( tia ) is a transient episode of neurologic dysfunction caused by ischemia which subsided within 24 h without any high intensity lesions in diffusion weighted image .
the subjects were divided into a control group ( functional outcome with modified rankinscale ( mrs ) 0 - 3 at 3 months ) and a poor group ( severe disability or death , mrs 4 - 6 ) .
the exclusion criteria were delayed arrival over 48 h from when the initial signs and symptoms started , or from the last moment confirmed by other people .
another exclusion criterion was preexisting micturition disturbances . the patients age , sex ratio , physical data on arrival ( glasgow coma scale , systolic blood pressure , heart rate and temperature ) , past history of hypertension , diabetes mellitus and stroke , duration of admission and the survival rate were all compared between the two groups .
the statistical analyses were performed using unpaired student 's t - tests and the  analysis .
a multivariate analysis using a logistic regression analysis was used to evaluate the independent factors regarding the outcome ( favorable vs. poor ) .
the variables included in the multivariate analysis were those with significance levels of p < 0.05 based on a univariate analysis . the odds ratio and the corresponding 95% confidence intervals were also calculated .
during the target period , there were 1540 patients who were admitted to ken - o tokorozawa hospital , 258 of whom had experienced a stroke . among them , 18 patients arrived over 48 h from the occurrence of stroke and another 3 patients had had urinary incontinence prior to the occurrence of stroke , so that 237 patients were finally included as study subjects . there were 37 cases of non - traumatic sah , 72 cases of ich and 128 cases of is .
all subjects who had a hemorrhagic stroke ( sah + ich ) underwent a ct examination . concerning sah ,
there were 34 cases of ruptured cerebral aneurysms , and 2 cases of dissecting aneurysms were confirmed by ct or conventional angiography .
the other case became brain dead on the first hospital day , and the bleeding source of this case was not identified .
all of the subjects with is , except for this one , who became brain dead due to complications of hemorrhagic transformation confirmed by ct , underwent mri examination . among them
, six cases did not show ischemic changes on diffusion weighted images which were re - evaluated over 24 h from the occurrence of signs and symptoms .
all six cases who had no ischemic lesions showed the disappearance of their symptoms within 24 h from onset , and were considered to have had a transient ischemic attack . among the subjects , there were 160 cases who had favorable outcome ( the control group ) and 77 cases who had poor outcome ( the poor group ) .
there were no significant differences between the two groups concerning the sex ratio , systolic blood pressure , heart rate , temperature , ratio of diabetes mellitus .
however , the average age , ratio of hemorrhagic stroke , ratio of patients with a previous stroke , ratio of urinary incontinence upon admission , and duration of hospitalization in the poor group was significantly higher than in the control group .
the glasgow coma scale upon admission and ratio of hypertension in the poor group was significantly lower than that in the control group .
concerning the outcome , the average modified rankin scale and mortality rate in the ui group was significantly higher than those in the control group . using a multiple logistic regression analysis , urinary incontinence ( odds ratio , 3.17 ; 95% confidence interval , 1.45 - 6.93 ;
p = 0.002 ) , age ( odds ratio , 1.04 ; 95% confidence interval , 1.01 - 1.07 ; p = 0.003 ) , and glasgow coma scale ( odds ratio , 0.87 ; 95% confidence interval , 0.78 - 0.97 ; p = 0.01 ) were found to be factors independently associated with a poor outcome .
among the patients with strokes , the presence of urinary incontinence on arrival , the old age , and the level of consciousness are important prognostic factors . among factors ,
in addition , age and the level of consciousness had already reported to be risk factors for urinary incontinence .
the mechanism of micturition is controlled by multiple pathways at many levels by brain , the spinal cord , and the peripheral nervous system , and is mediated by multiple neurotransmitters .
functional mri studies that investigated which brain areas are involved in the regulation of micturition revealed that the thalamus , the insula , the prefrontal cortex , the anterior cingulate , the periaqueductal grey , the pons , the medulla , and the supplementary motor area are all activated during urinary storage . a preliminary conceptual framework , based on functional brain - imaging studies , suggested a mechanism wherein there are connections between various forebrain and brainstem structures that are involved in the control of the bladder and the sphincter in humans . as age increases , the probability of the occurrence of asymptomatic or symptomatic cerebral infraction or minute hemorrhages increases .
accordingly , patients with a high age or a past history of stroke tended to be at higher risk for urinary incontinence .
in addition , the arousal center is located in anascendingreticular activating system , which involves the medulla , pons , thalamus , and hypothalamus , which also regulates micturition , so that consciousness disturbances also tended to be associated with urinary incontinence . of interest , the patients with urinary incontinence who had good consciousness on arrival also had a poorer functional recovery in comparison with the patients without urinary incontinence .
the impairment of the multiple neuronal pathways which regulate micturition may also have been associated with a poorer recovery of other functions .
previous reports also suggested that the presence of urinary incontinence during the subacute or chronic phase was an independent prognostic factor among stroke patients.[1921 ] there have been a few reports which investigated the relationship between sah and urinary incontinence.[2224 ] patient with sah often showed no focal signs , so that a correct diagnosis of sah required ct examination .
all of our cases of sah except for one had a clearly identified bleeding source .
the other patient had developed a sudden onset headache without trauma . in this study ,
all of cases with urinary incontinence in the sah group had sum of glasgow coma scaleunder 8 , so the level of consciousness is an important factor that can contribute to the presence of urinary incontinence in patients with sah . as a result ,
previously reported that the only 3.1% of the patients with sah had urinary incontinence , and that urinary incontinence was not prognostic factor .
in addition , many medical staff members did not know about the clinical importance of urinary incontinence , so they might have failed to record urinary incontinence , so the frequency of urinary incontinence in the patients with sah was low .
their study demonstrated that 92% of the patients with sah had urinary incontinence , and that the urinary incontinence in the patients with stroke was independently associated with death and severe disability .
among the patients with strokes including sah , the presence of urinary incontinence on arrival , the old age and the level of consciousness are important prognostic factors .
physicians should therefore check for these factors especially for urinary incontinence when evaluating a patient who has experienced a stroke or suspected stroke .
purpose : we retrospectively investigated prognostic factors including urinary incontinence on arrival among the patients with stroke.materials and methods : a medical chart review was retrospectively performed for patients with stoke admitted between january 2010 and december 2010 in ken - o tokorozawa hospital which had stroke care unit . 
 the subjects were divided into a control group ( functional outcome with modified rankin scale ( mrs ) 0 - 3 at 3 months ) and a poor group ( severe disability or death , mrs 4 - 6).results : there were 160 cases that had favorable outcome ( the control group ) and 77 cases that had poor outcome ( the poor group ) . 
 there were no significant differences between the two groups concerning the sex ratio , systolic blood pressure , heart rate , temperature , ratio of diabetes mellitus . 
 however , the average age , ratio of hemorrhagic stroke , ratio of patients with a previous stroke , ratio of urinary incontinence upon admission , and duration of hospitalization in the poor group was significantly higher than in the control group . 
 the glasgow coma scale upon admission and ratio of hypertension in the poor group were significantly lower than that in the control group . using a multiple logistic regression analysis , urinary incontinence ( odds ratio , 3.17 ; 95% confidence interval , 1.45 - 6.93 ; 
 p = 0.002 ) , age ( odds ratio , 1.04 ; 95% confidence interval , 1.01 - 1.07 ; p = 0.003 ) and glasgow coma scale ( odds ratio , 0.87 ; 95% confidence interval , 0.78 - 0.97 ; p = 0.01 ) were found to be factors independently associated with a poor outcome.conclusion:among the patients with strokes , the presence of urinary incontinence on arrival , the old age , and the level of consciousness are important prognostic factors . 
 physicians should therefore check for these factors when evaluating a patient who has experienced a stroke or suspected stroke .