The impact of urge urinary incontinence on quality of life: importance of patients' perspective and explanatory style

Validity and reliability of the Persian version of the PRAFAB questionnaire in Iranian women with urinary incontinence

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is a common disorder in women that can affect a person's quality of life. There are several instruments to assess the severity of urinary incontinence. One of the common tools is the Protection, Amount, Frequency, Adjustment, Body image (PRAFAB) questionnaire. Therefore, this study was performed with the aim of assessing the validity and reliability of the Persian version of the PRAFAB questionnaire.

METHODS

First, the English version of the questionnaire was translated into Persian. Second, the psychometric properties of the Persian version were collected in 60 women with urinary incontinence referred to Al-Zahra Hospital by an expert team. Content validity (CV) was evaluated through CV index (CVI) and CV ratio (CVR). Construct validity was evaluated using exploratory factor analysis and reproducibility was tested based on test-retest reliability using intraclass correlation coefficient (ICC). Internal consistency was calculated using Cronbach's α.

RESULTS

The results showed acceptable CVI in relevancy, clarity, and simplicity, acceptable CVR for all items, good internal consistency (Cronbach's alpha = 0.738) and excellent repeatability (ICC = 0.98).

CONCLUSION

The Persian version of the PRAFAB questionnaire has acceptable validity and reliability and in future it can be used as a suitable evaluation instrument to assess urinary incontinence in Iranian women.

Patient-reported outcome measures for pain in women with pelvic floor disorders: a systematic review

INTRODUCTION AND HYPOTHESIS

Patient-reported outcome measures (PROMs) are helpful instruments when measuring and reporting changes in patient health status (Al Sayah et al. J Patient Rep Outcomes 5 (Suppl 2):99, 2021) such as the health-related quality of life (HrQoL) of women with pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The Australasian Pelvic Floor Procedure Registry (APFPR) aims to increase capacity for women to report surgical outcomes through the collection of HrQoL data (Ruseckaite et al. Qual Life Res. 2021) but currently lacks a pain-specific PROM for women with pelvic floor disorders (PFDs), particularly POP and SUI. This review aims to systematically review the existing literature and identify instruments that measure pain in women with POP and SUI for inclusion within the APFPR, which reports on complications from these conditions.

METHODS

We conducted a literature search on OVID MEDLINE, Embase, CINAHL, PsycINFO and EMCARE databases in addition to Google Scholar and grey literature to identify studies from inception to April 2021. Full-text studies were included if they used PROMs to measure pain in women with POP and SUI. Two authors independently screened articles, extracted data and assessed methodological quality.

RESULTS

From 2001 studies, 23 publications describing 19 different PROMs were included for analysis. Eight of these instruments were specific to the pelvic floor; four were only specific to pain and used across multiple disorders; three were generic quality of life instruments and four were other non-validated instruments such as focus group interviews. These instruments were not specific to pain in women with POP or SUI, as they did not identify all relevant domains such as the sensation, region and duration of pain, or incidents where onset of pain occurs.

CONCLUSIONS

The findings of this review suggest there are no current PROMs that are suitable pain-specific instruments for women with POP or SUI. This knowledge may inform and assist in the development of a new PROM to be implemented into the APFPR.

Relationship between urinary incontinence symptoms and urodynamic findings using a validated Arabic questionnaire

BACKGROUND

Urinary incontinence is common, particularly in women. Urodynamic studies (UDS) can accurately assess the condition. Less invasive objective measuring tools correlate with urodynamic findings, but the Arabic version of the Urogenital Distress Inventory-6 (UDI-6) questionnaire has not been previously correlated with UDS in Arabian patients.

OBJECTIVE

To correlate the Arabic version of the UDI-6 with urodynamic findings in Arabian women with urinary incontinence.

DESIGN

Prospective.

SETTING

Tertiary referral urology clinic.

PATIENTS AND METHODS

All female patients presenting with urinary incontinence between July 2013 to March 2014. Patients answered the Arabic UDI-6 questionnaire and underwent a history and clinical examination, urine culture and UDS.

MAIN OUTCOME MEASURES

Correlation between Arabic UDI-6 questionnaire score and urodynamic diagnosis.

RESULTS

Eighty-seven women with a mean age of 57 (range, 22-72) years completed the UDI-6 and underwent UDS. The questionnaire revealed that 20 (23%) patients had urge incontinence, 28 (32%) had stress incontinence and 39 (45%) had mixed incontinence. As diagnosed by UDS, 26 (30%) had urge incontinence, 37 (42%) had stress incontinence, 16 (18%) had mixed incontinence and 8 (9%) had no abnormality. Eighty-six percent of patients (24/28) with pure stress urinary incontinence (SUI) symptoms had a positive UDS, and 55% (11/20) of patients with pure urge incontinence symptoms had a positive UDS. Of all patients with positiveresponse to the question for SUI, 53/67, 79% had positive UDS diagnosis with a correlation coefficient of 0.65 (P < .01). Of all patients with positive responses for urge incontinence, 27/59, 45.8% had positive UDS diagnosis with a moderate correlation coefficient of 0.38 (P < .01).

CONCLUSIONS

The validated Arabic UDI-6 correlates significantly with UDS findings in Arabian women, particularly in women with SUI.

LIMITATIONS

The sample size was relatively small, which prevented sub-analyses. Patient comorbidities were not evaluated.

Quality of life of women with urinary incontinence in rehabilitation treatment

This article analyzed how sexual satisfaction, suffering, severity and impact of urinary incontinence, and psychological morbidity affected women's quality of life and whether suffering mediated the relationship between psychological morbidity and quality of life. The study included 80 women diagnosed with urinary incontinence receiving rehabilitation treatment. Regression analysis showed that sexual satisfaction, suffering, and urinary incontinence severity and impact predicted quality of life and that suffering mediated the relationship between psychological morbidity and quality of life. The findings suggest that interventions should be tailored according to the suffering reported by women and the impact of the urinary incontinence on the couple's sexual relationship.

Caffeine Intake Is Associated with Urinary Incontinence in Korean Postmenopausal Women: Results from the Korean National Health and Nutrition Examination Survey

INTRODUCTION

The objective of this study was to investigate whether caffeine intake is associated with urinary incontinence (UI) and quality of life (QOL) in Korean postmenopausal women.

MATERIALS AND METHODS

We included 4,028 postmenopausal women who had participated in the Korea National Health and Nutrition Examination Survey IV (KNHANES IV). From the KNHANES questionnaire data, we ascertained the UI status of participants, defined as self-reported or medically diagnosed UI, and calculated their total daily caffeine intake through questions regarding the frequency of food consumption. The EuroQoL-5 Dimension (EQ-5D) descriptive system was used to evaluate QOL among the study population.

RESULTS

The mean age of the study population was 63.19±0.25 years. Among the 4,028 women, the prevalence of medically diagnosed UI was 2.6% (n = 151), the prevalence of self-reported UI was 11.9% (n = 483), and the lifetime prevalence of UI was 15.8% (n = 639). In the study population, the presence of UI was not significantly different by age group, but daily caffeine consumption and the percentage of caffeine consumer decreased with age (P<0.001). Higher caffeine intake led to significantly higher prevalence of both medically diagnosed UI (p = 0.012) and self-reported UI (p = 0.040) in the study population. Even after adjusting for factors including age, parity, smoking status, hypertension and diabetes in logistic regression analysis, the positive association between caffeine intake and UI prevalence was observed in both medically diagnosed UI and self-reported UI (P = 0.017) among participants. In a subgroup analysis for EQ-5D (using continuous variables) in which we categorized participants into four groups according to UI presence and caffeine consumption, the EQ-5D scores were lower in the caffeine non-user group with UI than in the caffeine consumer group with or without UI.

CONCLUSION

In a sample of Korean postmenopausal women, the prevalence of UI increased with higher caffeine consumption. Additionally, QOL was lower in caffeine non-users with UI than in the caffeine consumer groups. However, additional prospective studies are required to identify clear causation between caffeine consumption, UI prevalence and QOL.

Population-based survey on disease insight, quality of life, and health-seeking behavior associated with female urinary incontinence

Purpose:

To evaluate disease insight, personal distress, and healthcare-seeking behavior of women with urinary incontinence (UI) to improve women’s health in Korea.

Methods:

In October 2012, 500 Korean women residing around Seoul, Incheon, and Gyeonggi-do were selected by random sampling for a population-based cross-sectional survey conducted by computer-aided telephone interview. Sixteen questions, which included information on demographic characteristics, information sources, disease insights, and general health-seeking behavior, were used for data collection.

Results:

Among the responders, 23.8% experienced UI, the prevalence of which increased with increasing age; 83.3% knew about UI through the mass media out of 98.2% apprehended people. Regarding general awareness of UI, 77.2% understood that UI is caused by aging. A total of 48.7% of subjects experienced societal restrictions because of UI. Most women in their 30s (25.6%) acquired UI information from the Internet, while those in their 50s and 60s (50–59 years, 51.1%; 60–64 years, 42.4%) learned about UI through friends. Among subjects who did not have UI, 89.37% intended to see a doctor or consult a professional if they developed UI (83.2%). Among those with UI, however, only 59.0% had talked about UI; 79.7% had talked with friends or associates, whereas only 23.2% had consulted a professional.

Conclusions:

Most respondents tended to obtain information on UI through the mass media. Subjects who did not have UI expressed their intention to consult a professional if they developed UI, while the percentage of subjects with UI who had consulted a professional was very low. Many women are ashamed of UI in Korea, which may be changed by providing efficient advertising with the right information and establishing a new perception of UI.

Comorbidities and personal burden of urgency urinary incontinence: a systematic review

AIMS

Studies on the burden and comorbidities associated with urgency urinary incontinence (UUI) are difficult to compare, partly because of the evolution of definitions for lower urinary tract symptoms and the various instruments used to assess health-related quality of life (HRQL). This article summarises published evidence on comorbidities and the personal burden associated specifically with UUI to provide clinicians with a clear perspective on the impact of UUI on patients.

METHODS

A PubMed search was conducted using the terms: (urgency urinary incontinence OR urge incontinence OR mixed incontinence OR overactive bladder) AND (burden OR quality of life OR well-being OR depression OR mental health OR sexual health OR comorbid), with limits for English-language articles published between 1991 and 2011.

RESULTS

Of 1364 identified articles, data from 70 retained articles indicate that UUI is a bothersome condition that has a marked negative impact on HRQL, with the severity of UUI a predictor of HRQL. UUI is significantly associated with falls in elderly individuals, depression, urinary tract infections, increased body mass index, diabetes and deaths. The burden of UUI appears to be greater than that of stress urinary incontinence or overactive bladder symptoms without UUI. UUI adversely impacts physical and mental health, sexual function and work productivity.

CONCLUSIONS

UUI is associated with numerous comorbid conditions and inflicts a substantial personal burden on many aspects of patients' lives. Healthcare providers should discuss UUI with patients and be aware of the impact of UUI and its associated comorbidities on patients' lives.

Factors Influencing the Sexual Function of Women with Urinary Incontinence

PURPOSE

Sexual function involves a complex interaction of emotions, body image, and intact physical responses. The purpose of this study was to determine the sexual functioning of women who are incontinent and to identify associated factors.

METHODS

For this descriptive correlation study, data were collected from 147 women with urinary incontinence. Data were analyzed using t-test, ANOVA, and stepwise multiple regression.

RESULTS

Mean scores were 22.39 (sexual dysfunction < or =26.55) for sexual function, 13.38 (of 63) for depression, and 55.47 (range of score 17~85) for body image. Urinary symptoms and daily life symptoms averaged 36.04 (range of score 20~100) and 16.03 (range of score 8~40). Sexual function had a positive correlation with body image and negative correlation with daily life symptoms. Sexual satisfaction, daily life symptoms, marital satisfaction, and frequency of sexual intercourse were factors affecting sexual function.

CONCLUSION

Study results indicate that urinary incontinence has a negative impact on various aspects of sexual function. Nurses should be aware of the wider consideration that needs to be made in relation to general and sexual quality of life when caring for clients suffering from urological diseases.

Long-term safety, tolerability and efficacy of flexible-dose fesoterodine in elderly patients with overactive bladder: open-label extension of the SOFIA trial

AIMS

To assess the long-term safety, tolerability, and efficacy of flexible-dose fesoterodine in elderly patients with OAB.

METHODS

Patients aged ≥65 years who completed a 12-week, randomized, double-blind, placebo-controlled trial were eligible for the 12-week, open-label (OL) extension phase. Patients who received double-blind placebo started on fesoterodine 4 mg and could increase to 8 mg after 4 or 8 weeks of OL treatment, while fesoterodine-treated patients continued on their double-blind dose; only one dose escalation or de-escalation was permitted. Discontinuations and adverse events (AEs) were monitored, and patients completed 3-day bladder diaries and patient-reported outcomes at the beginning and end of the 12-week OL phase.

RESULTS

Six hundred fifty-four patients entered the 12-week OL extension (mean age 72 years; 52% women). AEs were reported by 30.7% and 48.1% of patients who had received double-blind fesoterodine and placebo, respectively; 1.9% and 9.4%, discontinued due to AEs, respectively. Patients who received double-blind fesoterodine maintained their efficacy response. After 12 weeks of OL treatment, efficacy outcomes in patients who received double-blind placebo were similar to those who had received double-blind fesoterodine. On average, the efficacy response was maintained for the duration of the study.

CONCLUSIONS

Fesoterodine was well tolerated and improvements in OAB symptoms and quality of life measures were not diminished with longer-term treatment of patients aged ≥65 years.

Efficacy and tolerability of fesoterodine versus tolterodine in older and younger subjects with overactive bladder: a post hoc, pooled analysis from two placebo-controlled trials

AIMS

To assess the efficacy and tolerability of fesoterodine 8 mg versus tolterodine extended release (ER) 4 mg in subjects with overactive bladder (OAB) stratified by age (<65, 65-74, and ≥75 years).

METHODS

This was a post hoc analysis of data from two double-blind trials. Subjects reporting ≥1 urgency urinary incontinence (UUI) episode and ≥8 micturitions/24 hr at baseline were randomized to fesoterodine (4 mg for 1 week, 8 mg for 11 weeks), tolterodine ER 4 mg, or placebo. Subjects completed 3-day bladder diaries, Urgency Perception Scale (UPS), Patient Perception of Bladder Condition (PPBC), and OAB questionnaire (OAB-q) at baseline and week 12. The primary endpoint in both studies was change from baseline to week 12 in UUI episodes.

RESULTS

Among subjects <65 years (n = 2,670), improvements in UUI episodes, micturitions, urgency episodes, severe urgency episodes, frequency-urgency sum, UPS, PPBC, and all OAB-q scales and domains were significantly greater with fesoterodine versus tolterodine ER, and diary-dry rates were significantly higher. Among subjects 65-74 years (n = 990), improvements in mean voided volume per void, PPBC, and OAB-q Symptom Bother and Coping were significantly greater with fesoterodine versus tolterodine ER. Among subjects aged ≥75 years (n = 448), improvements in urgency episodes, severe urgency episodes, frequency-urgency sum, UPS, and OAB-q Symptom Bother were significantly greater with fesoterodine versus tolterodine ER. Both active treatments produced significant improvements in most outcomes versus placebo across age groups. Adverse event rates were similar among age groups.

CONCLUSIONS

Fesoterodine 8 mg consistently improved several OAB-related variables versus tolterodine ER 4 mg in subjects aged <65, 65-74, and ≥75 years, with some differences reaching statistical significance, and was generally well tolerated.

Patient expectations did not predict outcome of drug and behavioral treatment of urgency urinary incontinence

OBJECTIVES

: This study aimed to determine whether expectations of treatment outcomes in women participating in a drug and behavioral treatment trial for urge urinary incontinence are related to patient factors, demographics, health-related locus of control, and treatment outcomes.

METHODS

: Baseline assessments included expectations (improvement in bladder condition, time to improvement in bladder condition, and duration of improvement) and the Medical Health Locus of Control (MHLC) scale. Outcomes were measured by the Patient Global Impression of Improvement scale (PGI-I) at the end of active treatment (10 weeks) and 8 months after trial start.

RESULTS

: At baseline among 173 subjects, 114 (66%) believed their incontinence would get "very much better," 94 (55%) expected improvement by 1 month, and 111 (66%) expected improvement would last for the rest of their lives. There were no significant associations between baseline expectations or MHLC with the Patient Global Impression of Improvement scale at 10 weeks or 8 months.

CONCLUSIONS

: Expectations of treatment outcome and MHLC did not predict eventual patient-reported treatment outcome in this sample of women with urge-predominant urinary incontinence participating in a trial of drug and behavioral therapy.

Overactive bladder syndrome: an underestimated long-term problem after treatment of patients with localized prostate cancer?

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? In this study we observed courses of micturition symptoms and differentiated degrees of symptoms for each point in time while also considering the impact of bothersomeness. Our data show that not only significantly more patients who have undergone BT suffer from OAB than those who have undergone RP, but also that those affected show significantly higher values for severity of OAB symptoms throughout the whole observation period of 36 months. Our data analysis further shows that variability of OAB symptoms as well as fluctuation of severity of OAB symptoms vary to a significantly higher degree after BT than after RP. Looking only at mean figures at a given point in time clearly underestimates the underlying problem. This fact is not reflected in the literature.

OBJECTIVE

• To look at individual courses of postoperative micturition symptoms, especially urgency, in patients treated either with radical prostatectomy (RP) or with brachytherapy (BT).

PATIENTS AND METHODS

• In a prospective longitudinal study we investigated individual changes in micturition symptoms before treatment, and 6, 12, 24 and 36 months after treatment. • All patients received the European Organization for the Research and Treatment of Cancer quality-of-life questionnaire, QLQ-C30, and the International Continence Society male questionnaire at each assessment. • We looked at long-term results as well as changes in time using repeated measures analysis of variance. We further analysed fluctuation of symptoms using sum of changes.

RESULTS

• Of the 389 patients treated consecutively in our clinic over the last few years, 99 patients with a mean (sd) age of 65 (6.3) years had completed all five questionnaires and thus were further analysed. Of these, 66 (66.7%) were treated with RP and 33 (33.3%) with BT. • With the exception of age, no significant difference was found between the treatment groups either in physical functioning or in prevalence and severity of overactive bladder (OAB) symptoms. • Adjusted for age and pretreatment symptoms in analysis of covariance, we found that there were statistically more symptoms of OAB 36 months after BT compared with those patients treated with RP (P < 0.025). Whereas 30% of patients complained about severe symptoms of urgency after BT, only 11% did so after RP. • Changes of severity of OAB symptoms over the course of time (P < 0.007) using analysis of repeated measures as well as variability of OAB symptoms (P < 0.033) using the two-sided Wilcoxon t-test were significantly higher in patients treated with BT than in patients treated with RP.

CONCLUSIONS

• Independently of age and physical functioning, BT is significantly associated with higher rates of long-term urgency symptoms, even after 3 years. • Repeated measurements show that OAB symptoms are highly fluctuating and that in patients treated with BT, severity of symptoms as well as variability of symptoms was significantly higher than in those patients treated with RP. • Persistent OAB seems to be an underestimated problem after treatment for localized prostate cancer, especially in patients treated with BT.

Long-term efficacy of pelvic floor muscle rehabilitation for older women with urinary incontinence

OBJECTIVES

To determine the efficacy of pelvic floor muscle (PFM) rehabilitation for elderly women with urinary incontinence after five years of follow-up, and to assess the adherence to PFM exercises five years after physiotherapy.

METHODS

We conducted a retrospective chart review of women ≥ 60 years old who underwent PFM physiotherapy for urinary incontinence between September 1999 and February 2004. PFM rehabilitation techniques were taught to patients by a certified physiotherapist. The mean number of sessions was eight. Telephone surveys were conducted at two months, six months, and one to five years after physiotherapy. Objective data on the efficacy of treatment (number of voids, incontinence, use of pads) and on adherence to PFM exercises were collected using a uniform grid. Data were used to determine the continence status at follow-up and compared with the data collected at the end of the PFM training sessions (improved, maintained, or deteriorated).

RESULTS

Of 89 older women (mean age 70 years; range 60 to 81) treated during the study period, 40 were followed up to five years and were suitable for analysis. At five years of follow-up, 27.5% had improved, 57.5% remained stable, and 15% had deteriorated compared with their post-treatment continence status. Twenty-nine patients (72.5%) were continuing their PFM exercises, and 42.5% were performing the exercises daily. All adherent patients had "improved" or "stable" status after five years versus 45.5% of non-adherent patients (P < 0.05).

CONCLUSION

Pelvic floor muscle rehabilitation for urinary incontinence remains highly effective for up to five years in older women. Most women continue to perform PFM exercises five years after completing their physiotherapy education sessions.

An investigation of the relationship between anxiety and depression and urge incontinence in women: Development of a psychological model

OBJECTIVES

The study investigated the association between anxiety and depression and urge incontinence and the direction of causal pathways between these variables.

DESIGN

A prospective longitudinal postal survey.

METHOD

A random sample of women aged 40 years or more, registered with a general practitioner in Leicestershire or Rutland, was mailed a postal questionnaire. The questionnaire included questions on general health, urinary symptoms and the Hospital Anxiety and Depression Scale (HADS). In total, 12,568 women responded to the baseline postal survey (65.3% response rate) and 9,596 to the first annual follow-up (79.8% response rate). The prevalence and one-year incident rates of these symptoms were compared and contrasted, whilst controlling for confounding variables.

RESULTS

A significant proportion of women with urge incontinence reported symptoms of anxiety (56.6%) and depression (37.6%). Anxiety and depression were associated with a number of urinary symptoms and were not exclusive to urge incontinence. Incident cases of anxiety and depression were predicted by the presence of urge incontinence at baseline. Incident cases of urge incontinence were predicted by anxiety at baseline, but not depression. Anxiety, urge incontinence and frequency appeared to interact and exacerbate each other.

CONCLUSIONS

The findings demonstrated the relevance of emotional factors in the development and maintenance of urge incontinence. Currently, assessment and treatment protocols for urge incontinence concentrate on physical symptoms and toilet behaviours. A more integrated psychological model of urge incontinence is proposed.

Assessing patients' descriptions of lower urinary tract symptoms (LUTS) and perspectives on treatment outcomes: results of qualitative research

AIMS

Understanding the patient's experience and symptom descriptions is critical to assess outcomes. Thus, there is a need for qualitative research to better understand how patients describe their symptoms and treatment expectations.

METHODS

Eight focus groups were conducted in two research phases: Phase 1 focused on eliciting patient's descriptions of urinary symptoms, and Phase 2 assessed patient perspectives on treatment outcomes. Participants with a range of lower urinary tract symptoms (LUTS) were recruited from urology clinics and community settings in the United States. All interviews were audio recorded and transcribed. Content and descriptive analyses were performed.

RESULTS

A total of 33 men and 30 women participated. Mean ages for men and women were 55 and 61 in Phase 1, and 57 and 61 in Phase 2, respectively. About 73% of participants were white people, and most had a high school education or greater. A wide range of LUTS were emergently described, and the words, concepts and phrases were generally similar across groups. Most participants identified with the word 'bother', and thought it was important to assess both the frequency and bother of each symptom. Reasons for seeking care included symptom bother and fears about cancer and bladder infections. Most participants thought that a 50% improvement in a single symptom or group of symptoms would be a meaningful treatment outcome.

CONCLUSION

This qualitative research provides a better understanding on how men and women describe their LUTS and their perspectives on treatment outcomes. This research can be used to inform the development of a new LUTS outcomes' tool.

Somatically ill persons' self-nominated quality of life domains: review of the literature and guidelines for future studies

OBJECTIVE

To review which domains somatically ill persons nominate as constituting their QoL. Specific objective is to examine whether the method of enquiry affect these domains.

METHODS

We conducted two literature searches in the databases PubMed/Medline, CINAHL and Psychinfo for qualitative studies examining patients' self-defined QoL domains using (1) SEIQoL and (2) study-specific questions. For each database, two researchers independently assessed the eligibility of the retrieved abstracts and three researchers subsequently classified all QoL domains.

RESULTS

Thirty-six eligible papers were identified: 27 studies using the SEIQoL, and nine presenting data derived from study-specific questions. The influence of the method of enquiry on patients' self-nominated QoL domains appears limited: most domains were presented in both types of studies, albeit with different frequencies.

CONCLUSIONS

This review provides a comprehensive overview of somatically ill persons' self-nominated QoL domains. However, limitations inherent to reviewing qualitative studies (e.g., the varying level of abstraction of patients' self-defined QoL domains), limitations of the included studies and limitations inherent to the review process, hinder cross-study comparisons. Therefore, we provide guidelines to address shortcomings of qualitative reports amenable to improvement and to stimulate further improvement of conducting and reporting qualitative research aimed at exploring respondents' self-nominated QoL domains.

Assessment of treatment outcomes in patients with overactive bladder: importance of objective and subjective measures

Overactive bladder (OAB) is a highly prevalent symptom syndrome that negatively affects health-related quality of life (HRQL). In clinical practice, the diagnosis and treatment of OAB are largely driven by a patient's reporting of symptoms, often in combination with objective assessment. Thus, OAB provides the opportunity to examine the relations between objective (eg, urodynamic studies, bladder diary variables) and subjective (eg, symptom bother, HRQL) outcomes. We compared objective and subjective results from 27 trials recently evaluated in a systematic review and meta-analysis of antimuscarinic agents used to treat OAB. Many studies demonstrated concurrent improvements in both types of outcomes. However, several reports showed that although pharmacotherapy may reduce micturition frequency or increase bladder capacity, treated patients may not perceive a significant benefit to HRQL. We conclude that objective assessments can help determine the underlying causes of OAB symptoms and assess the effects of treatment, but that these results are not always predictive of subjective outcomes, which are influenced by a patient's priorities and lifestyle, and thus highly individualized. A patient's perception of treatment success should be regarded as an important measure of efficacy because a patient considers the trade-offs between symptom improvement, adverse events, and effects on daily life when assessing overall treatment benefit. We recommend that subjective measures become standard considerations in the initial evaluation and treatment of patients with OAB.

Patient-reported outcomes in overactive bladder: The influence of perception of condition and expectation for treatment benefit

Patient perceptions of overactive bladder (OAB) symptoms, expectations for treatment benefit, and overall treatment satisfaction share complex relations. Multiple studies have demonstrated associations between factors, such as age, sex, and ethnicity, and patient perceptions of OAB symptoms, especially urgency urinary incontinence. Perceptions of OAB are also shaped by symptom severity and impact on health-related quality of life, as well as by perceptions of family members, caregivers, and clinicians. The literature further suggests discrepancies in the reporting among patients, physicians, and family members/caregivers of the impact that urinary symptoms have on patients' emotional well-being, productivity, and daily life. Understanding the factors that affect patients' perceptions is important because these perceptions affect treatment expectations, which may predict treatment outcomes. Studies designed to evaluate the relations between expectations for OAB treatment and patient satisfaction have not been performed to date, but studies in other patient populations suggest that expectations of positive outcomes are associated with greater treatment satisfaction. We emphasize that patient satisfaction with treatment is directly related to fulfillment of positive expectations, and that patient expectations should be realistic and agreed on by patient and physician. We also discuss strategies that may be used by physicians managing patients with OAB to develop stronger patient-physician partnerships, including the effective communication required to make treatment decisions and set realistic expectations.

Urinary incontinence: economic burden and new choices in pharmaceutical treatment

In the year 2000, an estimated 17 million community-dwelling adults in the United States had daily urinary incontinence (UI), and an additional 33 million suffered from the overlapping condition, overactive bladder. Estimates of the total annual cost of these conditions range up to 32 billion US dollar; the largest components are management costs and the expenses associated with nursing home admissions attributable to UI. In most cases, patients with UI can be treated with pharmaceutical agents, in addition to behavioral therapy. Until recently, pharmaceutical therapy for UI has been limited, especially because the adverse effects of available agents resulted in poor adherence to treatment regimens. Recent innovations in molecular design and new dosage forms of UI medications offer the promise of fewer and less severe adverse effects and, thus, better treatment outcomes for patients. Additionally, the availability of multiple agents within a therapeutic class offers health care providers a spectrum of choices with which to personalize treatment for each individual patient. New pharmacologic treatment options for UI have the potential to allow greater independence for older persons who reside at home and to delay or avoid the costs of admission to long-term care facilities. Alternate dosage forms, which include patches and sustained-release formulations, may benefit patients who have difficulty chewing, swallowing, or remembering to take medications. Although these newer products are generally more expensive than older forms of therapy, they typically have more favorable cost-effectiveness ratios. Access to these new medications for patients enrolled in public and private health care plans may help to reduce the economic and social burden of UI care.

The Causes and Consequences of Overactive Bladder

Overactive bladder (OAB) is a syndrome characterized by symptoms of urinary urgency with or without urgency urinary incontinence (UUI), usually with frequency and nocturia. OAB affects approximately 17% of women in the United States and Europe. The causes of OAB, as with many bladder disorders, are multifactorial and are not completely understood. The primary functions of the lower urinary tract (bladder and bladder outlet mechanism) are storage and evacuation of urine. The bladder and the micturition cycle are under complex neural control involving both the sympathetic and parasympathetic nervous systems. Micturition may occur in response to the activation of receptors in the bladder muscle and detection of chemical stimuli by receptors within the bladder lining. Neurogenic or myogenic bladder dysfunction can lead to the symptoms of urgency, frequency, and UUI that characterize OAB. The consequences of this condition are far-reaching and include direct medical consequences and coping strategies that adversely affect quality of life. Although the prevalence of OAB increases with age, it is not a normal consequence of aging. Antimuscarinic agents (e.g., oxybutynin, tolterodine, trospium, solifenacin, and darifenacin) have demonstrated efficacy for the treatment of OAB symptoms in multiple clinical trials. This review explores the physiological basis for OAB, the effects of OAB on health-related quality of life, and the pharmacotherapies that may provide relief to patients with this distressing condition.

Antimuscarinic drugs for the treatment of female urinary incontinence

Overactive bladder syndrome, urge syndrome or urgency-frequency syndrome is defined as 'urgency with or without urge incontinence, usually with frequency and nocturia'. Although this definition indicates that these symptoms are suggestive of detrusor overactivity (the observation of involuntary detrusor contractions during the filling phase of cystometry), a urodynamic demonstration of detrusor overactivity is not necessary in order to make the diagnosis. Nevertheless, patients with overactive bladder syndrome represent a substantial proportion of patients suffering with urinary symptomatology, and approximately a third of individuals with overactive bladder suffer from incontinence. Furthermore, as compared with those patients with stress urinary incontinence, women with urge incontinence have a poorer overall quality of life, perhaps related to both the volume of urine lost as well as the unpredictable nature of the leakage. When combined with behavioral modification, antimuscarinic pharmacotherapy remains the mainstay of treatment for this condition. A number of these agents are available for the treatment of overactive bladder-related incontinence, each with unique pharmacokinetic and pharmacodynamic properties. In order to optimize therapy for patients suffering from this type of incontinence, it is necessary to understand the mechanism of action of these agents, as well as to be familiar with the differences between them with respect to efficacy, safety and tolerability.

FACTORS THAT DISTINGUISH CONTINENT FROM INCONTINENT OLDER ADULTS WITH DETRUSOR OVERACTIVITY

PURPOSE

In older adults detrusor overactivity (DO) is almost as common in continent individuals as in those with urge incontinence (UUI). Thus, UUI likely reflects the contribution of additional factors. We postulated that of functionally independent individuals in whom transient causes were excluded those in whom DO was accompanied by UUI would be more likely to have smaller functional bladder capacity, less warning and less ability to avert urine loss in the face of DO.

MATERIALS AND METHODS

While blinded to continence status, we reviewed the records of all 52 cognitively intact and nonobstructed volunteers older than 65 years who had DO associated with urgency during urodynamic testing and had been asked to try to prevent leakage for 2 minutes. Of these individuals 31 were continent at home.

RESULTS

In patients with UI mean functional bladder capacity +/- SD was smaller (313 +/- 153 vs 390 +/- 178 ml, p = 0.06) and warning was briefer (87 +/- 81 vs 120 +/- 116 ml), although the association with warning was less impressive (p = 0.14). The ability to forestall leakage for at least 2 minutes correlated strongly with being continent at home (p < 0.002). For continence detrusor suppression at the onset of DO was more important than sphincter contraction.

CONCLUSIONS

Urge incontinence in older adults involves more than simply the presence of DO. Physical function, cognitive function and medications are already known to be important for continence. Our data suggest that functional bladder capacity and the ability to suppress involuntary contraction (and possibly warning) are also potentially important covariates. These factors may represent additional potential targets for behavioral and pharmacological therapy.

Update on the role of anticholinergic drug therapy in the management of overactive bladder

OBJECTIVE

To review the published literature and describe the pathophysiology and management of overactive bladder (OAB), with emphasis on the comparative efficacy and adverse event profiles of anticholinergic agents approved for the management of OAB symptoms and evaluation of their place in therapy.

DATA SOURCES

A MEDLINE search of English language literature that addresses the pathophysiology and management of OAB symptoms. The references in identified articles were evaluated for additional relevant articles. Drug Topics' Red Book was referenced for cost comparisons, and package inserts were used for specific drug and dosing information.

STUDY SELECTION

Human studies that presented efficacy and safety data with respect to anticholinergic medications in the treatment of OAB were selected.

DATA EXTRACTION

Studies were abstracted to identify key characteristics with respect to efficacy and safety in OAB, in particular anticholinergic side effects, with the greatest weight given to studies that compared two or more anticholinergic medications.

DATA SYNTHESIS

Epidemiologic studies have shown that the unpredictable and bothersome symptoms associated with OAB occur in approximately 16% of the worldwide adult population. Conservative management of OAB should include a combination of pharmacologic and nonpharmacologic interventions that have been found to improve outcomes when used in appropriately selected patients. Although long recognized as the most effective pharmacotherapy for OAB, anticholinergic agents have been associated with poor tolerability attributable to anticholinergic adverse events. New medications, formulations, and drug delivery systems have been developed with the goal of achieving effective treatment with improved tolerability.

CONCLUSIONS

Among these agents, extended-release and transdermal formulations have improved tolerability while retaining at least comparable efficacy. More research is needed regarding other routes of administration and new drug entities that specifically target the pathologic mechanisms involved in OAB.

?Unblinding? in randomized controlled drug trials for urinary incontinence: Implications for assessing outcomes when adverse effects are evident

AIMS

To determine whether women with urinary incontinence (UI) can identify their allocation in a randomized controlled trial (RCT) of tolterodine (TOL), and whether correct identification is associated with outcomes and adverse effects (AEs).

METHODS

Exploratory analysis of a randomized, double-blind, placebo (PLC)-controlled trial of TOL 4 mg daily for 8 weeks in 743 women with urge-predominant mixed UI. Patient perception of their randomization was assessed at trial end. Main outcome measures were 7-day bladder diaries, patient perception of improvement, and UI-specific quality of life (QoL).

RESULTS

TOL produced a significant decrease in urge UI episodes compared to PLC (78% vs. 51%, P = 0.0001). Fifty-one percent of women correctly identified their randomization (58% on TOL vs. 37% on PLC, P < 0.001). Women who assumed they took TOL had better bladder diary outcomes than those who assumed they took PLC. Within each assumption group, patient perception outcomes were similar, regardless of actual randomization. QoL improved in all domains except general health for women on TOL. In women who assumed they took TOL, significant drug benefit was evident in three domains. Moderate-severe dry mouth was higher in those who assumed they took TOL (7.3% vs. 0%, P < 0.0001).

CONCLUSIONS

Greater than fifty percent of women in this RCT of antimuscarinic treatment were "unblinded" to their randomization. Patient assumption of randomization was associated with bladder diary and perception outcomes, specific QoL domains, and dry mouth. Efficacy of urge incontinence drugs should be considered in the context of patient assumptions, expectations, and "unblinding" by easily evident side effects.

EFFECTS OF Urinary Incontinence: Psychological Well-Being and Distress in Older Community-Dwelling Women

Urinary incontinence (UI) has been related to lower quality of life. However, the research has generally been cross-sectional, and causal relationships have not been determined. This research was a secondary analysis of a 6-year longitudinal study of chronic illness and psychological well-being in older (mean age = 73 at Time 1), community-dwelling women (n = 103). Over time, women with UI reported significantly lower subjective health, purpose in life, affect balance, personal growth, positive relations with others, and self-esteem and higher scores for depression, compared to women without UI. Incontinence had broad effects on multiple domains of psychological well-being that persisted over time and need to be addressed by clinicians.

Symptoms of urinary and faecal incontinence among men and women 75+ in relations to health complaints and quality of life

AIMS

The aim was to investigate the prevalence of self-reported symptom of urinary, faecal, and double incontinence (UI, FI, and DI) in men and women 75+ and to identify how other health complaints and Quality of Life (QoL) relate to incontinence symptoms.

METHODS

A randomised sample, stratified for age, of eligible men and women from the population were included in the study and 4,277 out of 8,500 completed a postal questionnaire (61.6% women). The questions focused on difficulties in controlling urine and faeces, other health complaints, socio-economic background, and social relations.

RESULTS

Among all respondents 39% reported symptom of UI (more so among women P < 0.001), symptom of FI in 16.9% (ns between sexes), DI, i.e., a combination of UI and FI, was reported among 14.5% (ns between sexes). Incontinence increased with age, and persons reporting incontinence also had significantly more of all other health complaints compared with persons without incontinence. Those reporting DI comprised an especially vulnerable group. Health complaints associated with UI were communicative and mobility problems, other urinary complaints, dizziness, cough, and fatigue. FI was associated with diarrhoea, stomach pain, fatigue, and other pain. Risk factors for DI were diarrhoea, communication, and mobility problems.

CONCLUSIONS

UI and FI were common among elderly men and women and increased with age. Furthermore, incontinence was associated with many other co-existing health complaints, and the most frail were those with DI.

Burden of stress urinary incontinence for community-dwelling women

OBJECTIVE

The purpose of this study was to better understand the subjective bothersomeness of stress urinary incontinence symptoms and their impact on the quality of life of community-dwelling women.

STUDY DESIGN

We conducted a mail survey of 605 women in the United States who reported symptoms of stress urinary incontinence.

RESULTS

More than three fourths of the respondents reported their symptoms to be bothersome, with approximately 29% reporting their symptoms to be moderately to extremely bothersome. The odds of moderate-to-extreme bother decreased with age and increased with symptom severity. Concerns about social embarrassment were evident.

CONCLUSION

Stress urinary incontinence symptoms can impose a significant burden on the women who have them. The results reinforce the need for health care professionals to be proactive in questioning and educating patients about this common lower urinary tract symptom.

Life with an indwelling urinary catheter: the dialectic of stigma and acceptance

The purpose of this hermeneutic phenomenology was to describe and interpret the lived experience of long-term users of urinary catheters. Living with a urinary catheter involved a dialectical swing between acknowledgment that the catheter was "a part of me" and feelings of alienation and vulnerability when it was experienced as a stigma. Themes include Adjusting to embodied changes by perceiving the catheter as a "part of me," Shame and responding to shame by normalizing, and Embarrassment and coping with embarrassment by humor. Providers can minimize stigma related to the visibility of the catheter by coaching patients in strategies to manage going out of the home with a minimum of urine accidents or by helping develop ways to conceal the urine bag.

Measuring patients' perceptions of the outcomes of treatment for early prostate cancer

BACKGROUND

Compared with careful attention to the physical (eg, urinary, bowel, sexual) dysfunction that may follow treatment, little attention has been given to the behavioral, emotional, and interpersonal changes that the diagnosis of early prostate cancer and subsequent physical dysfunction may bring.

OBJECTIVE

To construct patient-centered measures of the outcomes of treatment for early prostate cancer.

RESEARCH DESIGN

Qualitative study followed by survey of early prostate cancer patients and group of comparable patients with no history of prostate cancer. Analysis of focus groups identified relevant domains of quality of life, which were represented by Likert scale items included in survey questionnaires. Psychometric analyses of survey data defined scales evaluated with respect to internal consistency and validity.

RESULTS

Qualitative analysis identified three domains: urinary control, sexuality, and uncertainty about the cancer and its treatment. Psychometric analysis defined 11 scales. Seven were generically relevant to most older men: urinary control (eg, embarrassment with leakage), sexual intimacy (eg, anxiety about completing intercourse), sexual confidence (eg, comfort with sexuality), marital affection (eg, emotional distance from spouse/partner), masculine self esteem (eg, feeling oneself a whole man), health worry (eg, apprehensiveness about health changes), and PSA concern (eg, closely attending to one's PSA). Four scales were specific to the treatment experience: perceived cancer control, quality of treatment decision making, regret of treatment choice, and cancer-related outlook.

CONCLUSION

The scales provide definition and metrics for patient-centered research in this area. They complement measures of physical dysfunction and bring into resolution outcomes of treatment that have gone unnoticed in previous studies.

Questionnaires for women with urinary symptoms

AIMS

To identify the characteristics of optimal symptom questionnaires in women with lower urinary tract symptoms (LUTS).

METHODS

Literature review.

RESULTS

Although numerous questionnaires have been developed for the evaluation of female LUTS, no one instrument has emerged as that preferred for collecting and reporting subjective information about LUTS in women. Questionnaires currently available range widely in intended purpose, extent and style, and in the quality of testing used to validate them.

CONCLUSIONS

Questionnaires should be constructed based on scientifically sound validation techniques that reflect disease and/or symptoms in the target population. They should be concise, easily administered and scored, discriminant between sphincter and bladder causes of incontinence, and able to measure severity and the effect of the symptom on the patient.

Urgency and urge incontinence in an older population: ten-year changes and their association with mortality

BACKGROUND AND AIMS

Urgency and urge incontinence are common urinary symptoms among older people, both men and women. The aim of this population-based prospective cohort study was to examine the independent association of urgency and urge incontinence with 10-year mortality in older men and women, and to describe the changes in these symptoms during those 10 years.

METHODS

At baseline, 1052 persons (524 men and 528 women) aged 60-89, selected by random sampling and stratified by 5-year age group and sex, were interviewed for the Tampere Longitudinal Study on Ageing. In 10 years, 541 persons had died, and 435 persons (175 men and 260 women) were re-interviewed. Cox proportional hazards models were used to examine the independent association of urgency and urge incontinence in each gender with 10-year mortality, adjusted for age, chronic diseases, activities of daily living (ADL) disability, socioeconomic status, smoking and alcohol use.

RESULTS

In 10 years, 86% of men and 54% of women who reported at least urgency at baseline had died. The respective figures for men and women without urgency were 57 and 38%. Adjusted for age, both urgency without incontinence (Risk Ratio 1.87; 95% Confidence Interval 1.28-2.74) and urge incontinence (RR 3.13; 95% CI 2.054.77) significantly predicted mortality in men, while only urge incontinence was a statistically significant predictor in women (RR 1.63; 95% CI 1.03-2.57). After further adjusting for chronic diseases and ADL disability, urge incontinence lost its predictive power (RR 1.44; 95% CI 0.88-2.23) in women, while the significant predictive power of urgency alone and urge incontinence in men persisted even after additional adjustment for socioeconomic status, smoking and alcohol use (RR 1.80; 95% CI 1.20-2.71, and RR 1.97; 95% CI 1.25-3.10, respectively).

CONCLUSIONS

Urgency and urge incontinence are significant prognostic indicators of mortality especially in older men. This emphasizes the importance of evaluation and treatment of urinary symptoms as a part of comprehensive geriatric assessment and management.

Health-related quality of life issues in urinary urge incontinence

Urinary incontinence is a highly prevalent condition which affects the physical, social, psychological and economic well-being of individuals and their families. The assessment of health-related quality of life has been increasingly applied to urinary incontinence. Of the three major types of urinary incontinence (stress, urge or mixed), urge and mixed urinary incontinence have been proven to have the worst effect on health-related quality of life. This paper reviews the health-related quality of life questionnaires designed specifically for urge urinary incontinence patients, describing their main characteristics and limitations. Four additional health-related quality of life questionnaires for urinary incontinence patients are also described, either because of their widespread use or because of their proven utility in the evaluation of urge urinary incontinence.

Urinary incontinence in the elderly: relation to cognitive and motor function

Urinary incontinence is a common problem in older subjects, very often wrongfully accepted as a normal part of the aging process. A total of 520 subjects (208 males and 312 females; mean age 74.8 +/- 11.8 years), from both private- and nursing-home dwelling populations, were included in this study aimed to estimate the incidence of urinary incontinence and identify factors associated with condition, in aged subjects. The incidence and type of urinary incontinence (stress, urge or mixed incontinence) were assessed by structured questionnaires and diagnosis was confirmed by a seven-day consecutive voiding diary. Assessment of physical, cognitive and emotional functions was performed on each subject using the Mini Mental State Examination (MMSE), Instrumental Activities of Daily Living Scale (IADL), Tinetti Scale (gait), Tinetti Scale (balance) and Geriatric Depression Scale (GDS) instruments. In the total population sample the incidence of urinary incontinence was 47.9%. The incontinence cases were classified, according to the different types, as: stress incontinence (males: 3.4%; females: 8.7%; males+females: 6.5%); urge incontinence (males: 27.4%; females: 31.4%; males+females: 29.8%); mixed incontinence (males: 20.2%; females: 5.8%; males+females: 11.5%). In the total population sample, no significant relationship was found between age and prevalence of urinary incontinence. In the elderly female group, age significantly correlated in a direct manner with urge incontinence (P<0.01) and inversely with stress incontinence (P<0.001). Only in the male sex group age significantly correlated with mixed incontinence (P<0.005). Multiple linear regression analysis showed that the dependent variable 'incontinence' could be predicted by MMSE (P<0.001) in the male sex group and by the Tinetti Scale (gait) (P<0.001) in the female sex group.