In January 1994 a national center for geriatric incontinence was founded in Israel. The Center, situated at Rambam Hospital in Haifa, consists of professionals that have joined from different institutions (medical centers, public health and community services) and from diversified professional backgrounds (urologists, geriatricians, community health nurses and geriatric nurses and a social worker). This unique combination allowed promotion of interdisciplinary exchange as well as maximum cooperation between a large medical center and the community health services - all essential components for the success of such a project.

During the past three years the center has gained much experience in training and education of professionals, mainly primary care physicians and nurses. At the time the Center was established little or no notice was given to incontinence on the part of the health service in Israel, and there was a desperate need for promoting as well as teaching the topic among health care staff.

After experiencing and redeveloping training programs, we chose to train two main sections - professional staff at peripheral clinics belonging to the largest sick fund in Israel, and those in homes for the aged. (It is only during the last few months that other health insurance funds became interested in joining our training programs. These will have to be adapted and changed accordingly).

The programs include initial basic lectures and seminars on all aspects of incontinence continued by instruction and practice on the spot - at the peripheral clinics or homes for the aged. The training program does not begin without first selecting a team, usually a physician and a nurse, who will be in charge of this field and will supervise the staff.

We also had to face the problem of "maintaining" what has already been achieved. We noticed that after allowing the staff to act independently, the frequency of detection and as a result treatment decreased. Therefore ongoing support and supervision is strictly preserved by the leading team.

We grant additional training to this team and prepare them to be professionally able to supervise the others and to provide diagnosis and treatment at the clinic. In addition, for the community clinics, we have trained a physician and a nurse in each region to be in charge of incontinent patients in their own area. Practically, professionals from the clinics may turn to those in charge at the clinic, those can turn to the "regional" advisors, and these can turn to the Center for consultation. This system offers professionals an easy access to local or regional advisors, and does not prevent them from having direct contact with the Center.

Initially, the center was totally dependent on the support of "ESHEL", Rambam medical center, "Kupat Holim" (the biggest health insurance fund in Israel), and "Fleiman" Geriatric Rehabilitation Center.

Today, partial income is obtained from our services - counselling, evaluation (including urodynamics), various treatments at the Center's clinic (including biofeedback and electrostimulation) and training at homes for the aged. Research has brought the Center into contact with academic institutions (the Technion - the Israel Institute of Technology and Haifa University) as well as with other organisations which were willing to support research in this field (e. g the national lottery).

In one of our studies we have also found that treatment of incontinence in large medical centers is neglected and that they unawares contribute to incontinence in the community by discharging patients catheterized during hospitalisation. This has led us to develop a model of an incontinence clinic in a medical center which will promote continence in the various departments and will manage, in collaboration with the Urology department, cases of incontinence detected during hospitalization. Hopefully we will soon be able to report on our progress in establishing such a clinic.

We have already established a model incontinence clinic in a Geriatric Rehabilitation Center (first of its kind in Israel). Results are promising, and the mere fact that 62% of the incontinent patients were discharged with full bladder control justifies its existence.

The Center developed, produced and supplied effective tools intended for professional staff - a management manual, an audio-cassette and booklet on pelvic muscle training, questionnaires, a urinary diary and other various information brochures. Much of the material was translated (with permission) and adapted to our country’s cultural background. These tools are used daily by the healthcare staff and help maintain continuous detection and treatment of new patients. We have collected video tapes and filmed exceptional cases that were successfully resolved, and these today are part of our collected material for professionals who train at our center.

Data is collated each month from the clinics and homes for the aged. This is important to us, since we now have epidemiological data, data on detection rates at each clinic as well as success rates of treatment. We can also control results of our training program and improve it or give more support to a certain clinic which did not achieve expected results.

The Center has been giving advisory services to many physicians and nurses, and has evaluated and treated many patients with complex incontinence (24% of the patients were detected in the trained clinics). A whole range of diagnostics and treatment modalities is available. We try to provide a comprehensive solution from all aspects - medical, social, nursing, functional, mental and financial. Conservative treatment modalities (biofeedback, electrostimulation, clean intermittent catheterization etc), minor invasive procedures (urethral stents, collagen injections) as well as common surgical procedures (Burch, Raz etc), major (bladder augmentations etc) and new procedures (transvaginal sling, bone anchoring suspension) are all available at our center. We believe that with time, more patients will be treated in the peripheral clinic and we expect a rate of only 10% referral to the Center.

We are only at the beginning of including treatment of faecal incontinence as part of our service. At this stage we have assigned one nurse to dedicate herself to this topic and we are looking for ways to properly include this topic in our training programs.

We are now in the process of creating a catalogue of products for incontinence, containing all products available in Israel. A catalog of this kind has never been published in Israel before and we believe that in addition to it being informative it will also increase public awareness of incontinence.

As part of the promotion program, the Center, with generous help and support of ESHEL, organised the first national meeting on geriatric incontinence, held in Jerusalem last year. Professionals participated from all over the country - urologists, gynaecologists, geriatricians, gastroenterologists, proctologists, nurses, physiotherapists, social workers and others. There is no doubt that this meeting has "spread the seeds" for promotion of continence throughout Israel.

During the past year the Center has also had some distinguished guests from abroad who have expressed interest in visiting our Center. These meetings are important and contribute to worldwide collaboration and to fruitful exchange of ideas.

A countrywide program for establishing satellite centers is currently in progress. We do find the need to increase the number of staff members in these centers and recommend adding a gynaecologist and a physiotherapist to the staff.

Ongoing research assures that the results of the Center's programs will be evaluated and used to help improve its services both locally and nationally. Plans for the near future are to establish a Hotline for the public, to promote education programs in nursing and medical schools, hospitals and nursing homes, to publish a quarterly newsletter and to develop guidelines for detection and management of incontinence by primary healthcare staff.

We hope that in the near future, by pursuing these activities, incontinence will be recognised throughout Israel as a problem to be challenged and not to be ignored.

Ilan Gruenwald MD