Overactive Bladder in Clinical Practice

Overactive Bladder in Clinical Practice

Alan J. Wein Christopher Chapple

Overactive Bladder in Clinical Practice

Authors Alan J. Wein Division of Urology University of Pennsylvania Health System Philadelphia USA

Christopher Chapple Department of Urology Royal Hallamshire Hospital Sheffield UK

ISBN 978-1-84628-830-2 e-ISBN 978-1-84628-831-9 DOI 10.1007/978-1-84628-831-9 Springer London Dordrecht Heidelberg New York British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Control Number: 2011944263 © Springer-Verlag London Limited 2012 Whilst we have made considerable efforts to contact all holders of copyright material contained in this book, we may have failed to locate some of them. Should holders wish to contact the Publisher, we will be happy to come to some arrangement with them. Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licenses issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc., in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com)

Contents

1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Socioeconomic Impact . . . . . . . . . . . . . . . . . . . . . . . . Who Seeks Treatment and Why? . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1 1 4 8 11 15 17

2

The Pathophysiology of Overactive Bladder . . . . . Anatomy and Pathophysiology of the Lower Urinary Tract . . . . . . . . . . . . . . . . Urinary Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . The Detrusor Muscle . . . . . . . . . . . . . . . . . . . . . . . . . Detrusor Overactivity . . . . . . . . . . . . . . . . . . . . . . Etiology of Detrusor Overactivity . . . . . . . . . . . . . . Neurogenic Factors . . . . . . . . . . . . . . . . . . . . . . . . Idiopathic Detrusor Overactivity . . . . . . . . . . . . Nocturia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

Diagnosis and Assessment . . . . . . . . . . . . . . . . . . . . . Reasons for Visiting the Primary Care Physician . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “Patient Flow”. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reasons for Visiting the Specialist . . . . . . . . . . . . . . Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pelvic Floor Muscles . . . . . . . . . . . . . . . . . . . . . . .

41

3

21 23 26 27 29 31 33 34 37

41 43 43 45 45 46 46 v

vi

Contents

Female Genitourinary System . . . . . . . . . . . . . . . Importance of Good Communication. . . . . . . . . Patient Questionnaires. . . . . . . . . . . . . . . . . . . . . . . . Patient Diaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Urinalysis and Other Readily Available Studies . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55 56

4

The Role of the Specialist . . . . . . . . . . . . . . . . . . . . . General Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Additional Investigations . . . . . . . . . . . . . . . . . . . . . Urodynamic Investigations . . . . . . . . . . . . . . . . . . . . Simple Urodynamic Investigations . . . . . . . . . . . Pressure/Flow Studies . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

59 59 60 61 62 62 63 66 73

5

Management of Overactive Bladder . . . . . . . . . . . . Principles of Management . . . . . . . . . . . . . . . . . . . . . The Role of the Primary Care Physician and the Specialist in Management . . . . . . . . . . Follow-Up Strategies . . . . . . . . . . . . . . . . . . . . . . . Self-care Practices and Lifestyle Changes . . . . . . . . Smoking Cessation. . . . . . . . . . . . . . . . . . . . . . . . . Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Behavioral Modification . . . . . . . . . . . . . . . . . . . . . . Patient Compliance . . . . . . . . . . . . . . . . . . . . . . . . Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Combined Behavior Modification and Drug Therapy . . . . . . . . . . . . . . . . . . . . . . . Acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75 75

6

Pharmacological Treatment of Overactive Bladder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Choosing a Drug Therapy for Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

46 47 47 49

76 77 77 78 78 78 80 80 80 81 82

83 83

Contents

vii

Overview of Key Drugs . . . . . . . . . . . . . . . . . . . . . . . Darifenacin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fesoterodine (Toviaz) . . . . . . . . . . . . . . . . . . . . . . Oxybutynin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Propiverine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Solifenacin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tolterodine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trospium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current Recommendations . . . . . . . . . . . . . . . . . . . . Efficacy of Antimuscarinic Drug Therapy . . . . . . . . Long-Term Tolerability and Compliance with Antimuscarinic Drug Therapy . . . . . . . . . Patient-Perceived Outcomes with Antimuscarinic Drug Therapy . . . . . . . . . Intradetrusor Botulinum Toxin Injection Therapy . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85 85 87 89 91 92 93 95 96 97

105 110

7

Neuromodulation and Surgical Approaches . . . . . . Surgery for Overactive Bladder . . . . . . . . . . . . . . . . Augmentation Cystoplasty . . . . . . . . . . . . . . . . . . Autoaugmentation . . . . . . . . . . . . . . . . . . . . . . . . . Sacral Neuromodulation . . . . . . . . . . . . . . . . . . . . . . Percutaneous Posterior Tibial Nerve stimulation . . Pudendal Nerve Stimulation . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

115 115 116 119 120 122 122 123

8

Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . Overactive Bladder in the Male . . . . . . . . . . . . . . . . Postradical Prostatectomy . . . . . . . . . . . . . . . . . . Prostate Enlargement and Bladder Outlet Obstruction . . . . . . . . . . . . . . . . . . . . . . . Nocturia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Incidence of Urine Retention in the Male . . . . . Elderly People. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Neurogenic Group . . . . . . . . . . . . . . . . . . . . . . . The Mixed Incontinence Group . . . . . . . . . . . . . . . .

125 125 128

102 104

129 133 134 134 136 136

viii

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Contents

Pregnancy and OAB. . . . . . . . . . . . . . . . . . . . . . . . . . Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

137 137 138

Comorbid Conditions and Complications . . . . . . . . Prevalence of Comorbid Conditions . . . . . . . . . . . . Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sexual Dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . Falls and Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . Cardiac Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gastrointestinal Disorders . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

143 143 144 144 145 145 146 146

Author Biographies

Alan J. Wein, MD, PhD (hon) is Professor and Chief of the Division of Urology in the Perelman School of Medicine of the University of Pennsylvania, Chief of Urology at the Hospital of the University of Pennsylvania and Director of the Residency Program in Urology at the University of Pennsylvania. He is a graduate of Princeton University and received his MD from the University of Pennsylvania School of Medicine. He completed training in surgery and urology at the University of Pennsylvania, including a fellowship at the Harrison Department of Surgical Research. He has been certified and recertified (voluntary) by the American Board of Urology. He was awarded an honorary PhD from the University of Patras, Greece in September 2005. Dr Wein’s affiliations and professional memberships include the American Association of Genitourinary Surgeons, Clinical Society of Genitourinary Surgeons, American Surgical Association, Society of Surgical Oncology, Society of Urologic Oncology, Society of Pelvic Surgeons, Society for Urodynamics and Female Urology, Société Internationale d’Urologie, American Urological Association (AUA) and the Royal Society of Medicine. He has served on the American Board of Urology (Vice President), the Examination Committee of the American Urological Association and the Residency Review Committee for Urology (Chair). He has held editorial positions on journals including the Journal of Urology, Neurourology and Urodynamics, Urology, British Journal of Urology International, International Urogynecology Journal, Current Urology Reports, Current Opinion in Urology and Nature Urology. He has been an editor of the textbook considered to be the gold standard in urology, Campbell-Walsh Urology, since 1992, and is currently the Editor-in-Chief. Dr Wein has authored or co-authored more than 880 articles and chapters and has edited or co-edited 28 books. His fields of interest are the evaluation and management of urologic cancer, the physiology and pharmacology of the lower urinary tract, the evaluation and management of voiding function and dysfunction, including problems related to prostate enlargement, urinary incontinence and neurologic disease. Christopher Chapple, MD, FRCS (Urol) is a Consultant Urological Surgeon at Sheffield Teaching Hospitals and visiting professor at Sheffield Hallam University, Sheffield, UK. He trained at the Middlesex

ix

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Author Biographies

Hospital where he subsequently completed his doctorate thesis on Pharmacological Control Mechanisms in the Lower Urinary Tract. His sub-specialist training was at the Middlesex Hospital and Institute of Urology in London and he provides a tertiary service in lower urinary tract reconstructive surgery. He has a particular interest in functional reconstruction of the lower urinary tract and the underlying pharmacological control mechanisms. He is Past Director of the European School of Urology and an Adjunct Secretary General to the European Association of Urology responsible for education. He is editor of the journal Neurourology and Urodynamics, and is on the editorial board of several other journals. Dr Chapple is a member of a number of urology societies including the American Association of Genitourinary Surgeons. He has co-authored over 300 articles in peer-reviewed journals and has written several books and a number of book chapters. He has chaired a number of guidelines initiatives including the recent UK male lower urinary tract symptoms (LUTS) guidelines report for the National Institute for Clinical Excellence (NICE). He was awarded the St Peter’s medal by the British Association of Urological Surgeons in 2011 and is an honorary member of several national urology associations.

Chapter 1 Introduction

Overactive bladder (OAB) is a prevalent condition that is chronic in its course and may be debilitating to those who have it [1–3]. Consequently, OAB can have a significant impact on an individual’s quality of life (QoL) and has significant costs for society [3]. It is therefore an important syndrome that has become a focus of research with respect to its basic and clinical science and the alleviation of symptoms [3].

Definition There remains a degree of debate as to what constitutes OAB, how the symptoms themselves should be defined, and the terminology used to describe patients’ experiences [4,5]. The term “overactive bladder” was first used in the International Continence Society (ICS) standardization of terminology report in 1988 to describe a chronic condition defined urodynamically as “detrusor overactivity” and characterized by involuntary bladder contractions during the filling phase of the micturition cycle [6]. The definition of OAB as a symptom syndrome was later refined by the ICS to serve as a symptomatic diagnosis that includes urinary urgency, with or without urgency incontinence, usually accompanied by urinary frequency (more than eight micturitions/24 hours) and nocturia (Figs. 1.1 and 1.2) [7]. For the diagnosis to be OAB, the symptoms must occur in the A.J. Wein, C. Chapple, Overactive Bladder in Clinical Practice, DOI 10.1007/978-1-84628-831-9_1, © Springer-Verlag London Limited 2012

1

2

Chapter 1. Introduction

Definitions of symptoms of overactive bladder Symptom

Definition

Urgency

Complaint of a sudden compelling desire to pass urine that is difficult to defer

Urgency urinary incontinence

Complaint of involuntary leakage accompanied by or immediately preceded by urgency

Increased daytime frequency

Complaint by patients who consider that they void too often by day

Nocturia

Complaint that the individual has to wake up at night one or more times to void

Figure 1.1 Definitions of symptoms of overactive bladder. Adapted from Abrams et al. [7, 8]

Diagram demonstrating the overlap between the different categories of storage symptoms

Mixed symptoms OAB symptoms

SUI Mixed incontinence UUI

Figure 1.2 Diagram demonstrating the overlap between the different categories of storage symptoms. Mixed symptoms represent overactive bladder (OAB) without urgency urinary incontinence (UUI) (OAB “dry”) plus stress urinary incontinence (SUI). Mixed incontinence represents OAB with UUI (OAB “wet”) plus SUI. Reproduced with permission from Wein and Rackley [2]

Definition

3

absence of pathological (eg, urinary tract infection, urinary stones, or interstitial cystitis) or metabolic factors (eg, diabetes mellitus) that would explain them. Although the symptoms are suggestive of detrusor overactivity (uro-dynamically demonstrable, involuntary bladder contractions), they can be due to other forms of storage or voiding dysfunction. Although OAB is therefore clearly distinct from urodynamically proven detrusor overactivity, most people with OAB are thought to have this underlying diagnosis. It should be noted that the standardized definition of OAB by the ICS is considered somewhat open to interpretation, particularly regarding whether “urgency” is a dichotomous or continuous variable and the utility of the word “sudden” [4,5,9]. In addition, the ICS definition of frequency as more than eight micturitions/24 hours may not always be accurate. A study of 284 asymptomatic US males aged 18–66 years indicated that the median void frequency was seven/24 hours, with 38% voiding eight or more times daily [10]. Convenience voids, when the bladder is emptied for solely social reasons, may also have an impact on voiding frequency, with 72% of 53 healthy volunteers in the UK reporting at least one convenience void per week, at an average of 4.6 and 3.4 convenience voids per week for men and women, respectively [11]. Moreover, it was found in a study of 1809 individuals aged ³18 years attending a tertiary referral center in the UK for urodynamics that OAB symptoms were better correlated with the urodynamic diagnosis of detrusor overactivity in men than in women [12]. Nevertheless, the ICS definition has facilitated rigorous examination of the prevalence, burden, and clinical management of the disorder. The concept of “urgency” as a subjective term for patients to describe their experience of OAB has also been called into question, because all individuals with sufficient bladder filling to capacity feel a compelling desire to pass urine, regardless of whether or not they have OAB [9]. What OAB patients do experience that sets them apart from other individuals is a “fear of leakage” [9]. It is helpful to consider urgency on a

4

Chapter 1. Introduction

Urgency: yes/no versus degree of sensation ON

or

or OFF

ON

OFF

Like a “dimmer”?

• Is the presence of a “sudden, compelling desire to void” similar to a light switch? − something (presumably a voiding reflex) gets triggered, then urgency occurs • Questioning the ICS definition of urgency − Seperation pathological sensation, or extreme form of a normal sensation? − Always suddenly, or gradual buildup of sensation?

Figure 1.3 Urgency: yes/no versus degree of sensation. ICS, International Continence Society

scale rather akin to what is seen with a rheostat. Bear in mind that urgency is a sensation and afferent impulses are transmitted to the central nervous system via the periaqueductal gray matter. When a threshold level is reached, there is a compelling desire to pass urine that will inevitably lead to voiding. This results in incontinence if the patient is unable to reach a toilet in time (urgency incontinence) [13]. This is illustrated in Fig. 1.3.

Epidemiology OAB increases in prevalence with age in both sexes (Fig. 1.4). Patients with stress incontinence can usually get to the toilet in time, but they are more likely to leak while taking exercise, coughing, or sneezing than those with OAB. Nocturia is less likely to be a prominent feature in patients with stress incontinence than in those with OAB or bladder outflow obstruction, for example. Nevertheless, nocturia occurs with increasing prevalence with age. Nocturia may occur as a consequence of either a bladder storage disorder (eg, detrusor overactivity) or increased production of urine at night (nocturnal polyuria), or from decreased functional bladder capacity caused by a

Epidemiology

5

Prevalence (%)

Prevalence of overactive bladder with age 40

Men*

35

Men† Women*

30

Women†

25 20 15 10 5

70 +

18 –2 9 30 –3 4 35 –3 9 40 –4 4 45 –4 9 50 –5 4 55 –5 9 60 –6 4 65 –6 9

0

Age (years)

Figure 1.4 Prevalence of overactive bladder with age. *Based on SIFO data from Milsom et al. [14]. †Based on data from Irwin et al. [15]

significant residual urine volume, or a combination of factors. Nocturnal polyuria increases with age in its prevalence and is identified as being a significant feature if the nocturnal urine output represents more than 33% of the total 24-hour urine production [7]. Nocturnal polyuria is often a result of cardiovascular or metabolic disorders (eg, diabetes) and may be associated with sleep apnea. Female patients, in particular, experience combined urgency and stress incontinence (socalled “mixed incontinence”). The differential diagnosis is aided by a careful medical history including a detailed assessment of symptoms and a targeted physical examination. The prevalence of OAB has been estimated in a wide range of countries. A cross-sectional, population-based survey of 19,165 men and women aged ³18 years from Canada, Germany, Italy, Sweden, and the UK conducted by Milsom et al., using the 2002 ICS definition of OAB, estimated the prevalence of OAB to be 10.8% in men and 12.2% in women [16]. In those aged ³40 years, the prevalence of OAB was 13.1% in men and 14.6% in women. Of OAB cases in individuals aged ³18 years, 28.0% of men and 44.5% of women

6

Chapter 1. Introduction Disposition of overactive bladder cases by sex, urinary incontinence, urinary status, troublesome symptoms, and initiation of conversation with healthcare provider OAB cases, n=1503

Bothered: 52.8%

Not bothered: 46.2%

Men with UI: 76.9%* Women with UI: 65.5%

Men with UI: 23.1% Women with UI: 33.1%

Men without UI: 44.0%* Women without UI: 35.2%

Men without UI: 55.4% Women without UI: 64.4%

Initiated conversation with healthcare provider: 51.4%†

Initiated conversation with healthcare provider: 21.2%

Men with UI: 66.7%† Women with UI: 52.6%†

Men with UI: 27.8% Women with UI: 30.9%

Men without UI: 45.5%† Women without UI: 41.9%†

Men without UI: 15.2% Women without UI: 17.3%

*P=0.05 bothered men vs bothered women by incontinence status †P=0.05 bothered vs not bothered within sex by incontinence status

Figure 1.5 Disposition of overactive bladder cases by sex, urinary incontinence, urinary status, troublesome symptoms, and initiation of conversation with healthcare provider. UI, urinary incontinence. Reproduced with permission from Milsom et al. [16]

experienced urinary incontinence (UI). Trouble from OAB was experienced by 52.8% of participants overall, at 76.9% and 66.5% of men and women, respectively, with UI, and 44.0% and 35.2% of men and women, respectively, without UI (Fig. 1.5). In those with and without UI, men were significantly more bothered than women [16]. The prevalence of OAB was also assessed in a large population-based survey in the USA: the National Overactive BLadder Evaluation (NOBLE) survey [17]. A sample of 5204 adults aged >18 years, and representative of the US population by sex, age, and geographical region, was assessed. The overall prevalence of OAB was similar between men (16.0%) and women (16.9%), and was quite similar to the results reported earlier from Europe [14].

Epidemiology

7

Recently, a study of the prevalence of lower urinary tract symptoms (LUTS) in the USA, the UK, and Sweden, involving a total of 30,000 participants aged ³40 years in a crosssectional population-representative survey, revealed that 72.3% of men and 76.3% of women had more than one LUTS “sometimes,” whereas 47.9% and 52.5%, respectively, had one or more symptom(s) “often” [18]. The most common voiding symptom was terminal dribble, which was reported by 45.5% and 38.3% of men and women, respectively; whereas the most common storage symptom was one or more episodes of nocturia, noted by 69.4% and 75.8%, respectively [18]. Overall, from these studies it can be concluded that, of these patients with OAB, approximately a third are troubled by incontinence (OAB “wet”) and two-thirds are not (OAB “dry”). Incontinence is far more likely to occur in women than in men, with particular risk factors in men being advanced age and having had surgery on the prostate, especially for prostate cancer. More recent data from the EPIC (European Prospective Investigation into Cancer and Nutrition) study suggest that the prevalence of OAB symptoms (using the 2002 ICS definition) is closer to 12% in the community, and of these individuals approximately 50% experience significant trouble from their symptoms [19]. The prevalence of OAB has also been estimated in Japan, in which the responses of 4570 men and women aged ³40 years to a self-administered questionnaire were analyzed [20]. This revealed that the prevalence of OAB was 14% for men and 11% for women and increased with age, rising from 5% of respondents aged 40–49 years to 37% of those aged ³80 years. The prevalence of OAB with UI was 6.4% overall, whereas that of OAB without UI was 6.0% [20]. A study of 1827 community-dwelling adults in Taiwan indicated that the age-adjusted prevalence of OAB was 16.9%, whereas that of OAB plus UI was 4.5% [21]. The ageadjusted prevalence of OAB was significantly higher in women than in men, at 18.3% versus 16.0%, and the prevalence increased with age. Frequency was detected in 79.5% of individuals with OAB; 63.2% had nocturia and 37.6% of women with OAB also reported stress UI [21].

8

Chapter 1. Introduction

In Brazil, the prevalence of OAB was estimated in a population-based study in which 848 individuals aged 15–55 years completed a self-administered questionnaire [22]. The overall prevalence was found to be 18.9% [22]. Although the prevalence of OAB was significantly higher in women than in men, at 23.2% versus 14.0%, there were no significant differences between age groups [22]. UI, frequency, and nocturia were reported by 5.4%, 13.5%, and 48.2% of the participants, respectively [22]. Of those with OAB, 19.2% had urgency as the only symptom, whereas 80.8% had at least one other associated symptoms [22].

Quality of Life OAB symptoms often have a profound negative influence on QoL. Using data from the EPIC study of individuals from Canada, Germany, Italy, Sweden, and the UK, Coyne et al. compared 1434 OAB cases with 1434 age-, gender-, and country-matched controls [23]. Patients had, compared with controls, significantly greater levels of depression, at 11.4% versus 3.6%, and unemployment, at 42.0% versus 33.6% [23]. Furthermore, patients were significantly more likely to have any form of work impairment than controls, at 24.7% versus 12.2%; less likely to have been sexually active in the past 12 months, at 62.4% versus 68.2%; more likely to report decreased enjoyment of sexual activity, at 15.4% versus 2.8%, and more likely to have moderate-to-complete impotence, at 9.8% versus 5.6% [23]. EQ-5D health status scores were also significantly lower in patients than in controls, at 0.85 versus 0.90 [23]. Finally, the investigators found that patients with the most severe OAB symptoms had significantly worse health-related quality of life (HRQoL) and troublesome symptom scores in the Overactive Bladder Questionnaire Short Form than other patients [23]. In another study, data from the NOBLE program in the USA on 171 incontinent individuals was used to compare the

Quality of Life

9

impact of stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed incontinence (MI) on HRQoL [24]. MI patients had a significantly lower HRQoL and more troublesome symptoms than SI patients, whereas UUI patients had significantly more trouble and lower sleep HRQoL than SI patients [24]. There were no significant differences in HRQoL and troublesome symptoms between UUI and MI patients [24]. The findings of a study of 14 incontinent OAB patients, 14 family members of incontinent OAB patients, and 17 spouses/ partners of continent OAB patients also indicated that both continent and incontinent OAB syndromes have a significant impact on family members, even if they do not live with the patient [25]. Urinary frequency was the most bothersome symptom for family members because it limited activities, whereas nocturia caused sleep disruption and fatigue [25]. There was also an emotional impact on family members in terms of embarrassment and reduction in sexual interactions and intimacy [25]. Although the symptoms of urinary urgency and frequency alone have a significant negative impact on patients’ QoL, UUI is more disruptive. However, despite the negative impact of these symptoms on QoL, “wet” patients frequently fail to seek medical help and often endure the inconvenience and unpleasantness of symptoms for many years (Fig. 1.6), relying on coping strategies (eg, voiding frequently in an effort to avoid leakage episodes, mapping out the location of toilets, drinking less, or using incontinence pads) that can be maladaptive. This might be because of embarrassment or, possibly, because of the mistaken opinion that effective treatment is not available (Fig. 1.7). The UK Leicestershire MRC study [27] showed that, when patients do mention the condition to their general practitioner, 27% were prescribed antibiotics, 20% were reassured that it was acceptable to be incontinent, and 30% were told to return only if the condition developed. So it seems that there is currently a problem with physicians not feeling

10

Chapter 1. Introduction

Prevalence of medical consultation and current medication in men and women aged 40–74 years with chronic overactive bladder Overactive bladder (n=1916)

Spoken to a doctor, 60%

Not spoken to a doctor, 40%

Currently on medication, 27%

Currently not on medication, 73%

Never tried, 73%

Tried but failed, 27%

Likely to discuss with a doctor again, 54%

Not likely to discuss again, 46%

Likely to discuss with a doctor again, 65%

Not likely to discuss again, 35%

Figure 1.6 Prevalence of medical consultation and current medication in men and women aged 40–74 years with chronic overactive bladder. Reproduced with permission from Milsom et al. [14]

confident about managing urinary incontinence and storage disorders of the bladder (ie, OAB). Men and women frequently do not seek professional advice for LUTSs and when they do they often do not receive active treatment (Fig. 1.8). Possible reasons for this include the following: • Lack of sufficient trouble to cause them to seek treatment • Acceptance of the symptoms as a natural phenomenon related to aging, living habits, heredity, or gender • Negative attitudes regarding the availability of interested and knowledgeable healthcare providers • Availability of effective treatment.

Socioeconomic Impact

11

Overactive bladder symptom perception grouped according to gender Something you have to learn to live with

*

Something few people my age may have Ignored by the medical community

*

A result of the way I live * Hereditary, so it can’t be helped A sign of more serious medical condition

*

Natural part of aging * Can’t be cured or helped Not really a medical condition

*

Not worth bothering a doctor about

* *P≤ 0.005 vs men

Total Men

0

10

20

Women

30

40

50

60

70

80

90

subjects (%)

Figure 1.7 Overactive bladder symptom perception grouped according to gender. Reproduced with permission from Irwin et al. [26]

Socioeconomic Impact In addition to the incalculable costs associated with the negative effects of OAB on physical and emotional well-being, especially in the “wet” patient, the disorder imposes a considerable financial burden on individuals, their families, and society. This includes both the direct costs associated with diagnosis and treatment of the disorder and its complications, and the indirect costs of lost wages and productivity (see Fig. 1.9) [29,30].

12

Chapter 1. Introduction

Healthcare-seeking behavior for and treatment of lower urinary tract symptoms Variable

V only

S only

Men, n

1704

1280

mean (SD) number of visits to a healthcare professional in past year†

3.5 (5.7)

3.6 (5.0)

n

1699

Sought treatment from a healthcare provider for urinary symptoms, n (%)† 95 (5.6)

140 (11.2)

n

1693

1250

• Prescription medications

50 (2.9)

75 (5.9)

• Physical therapy

1 (0.1)

11 (0.9)

• Self-treatment

31 (1.8)

32 (2.5)

• Coping strategies

53 (3.1)

96 (7.5)

• Surgery

19 (1.1)

42 (3.3)

• Other

19 (1.1)

23 (1.8)

Women, n

822

3545

mean (SD) number of visits to a healthcare professional in past year†

4.7 (7.0)

4.3 (7.1)

n

817

3526

Treatments for urinary symptoms, n (%)†

Sought treatment from a healthcare provider for urinary symptoms, n (%)† 66 (8.1)

274 (7.8)

n

810

3498

• Prescription medications

39 (4.8)

139 (3.9)

• Physical therapy

14 (1.7)

112 (3.1)

• Self-treatment

25 (3.1)

126 (3.5)

• Coping strategies

61 (7.4)

684 (19.3)

• Surgery

16 (2.0)

69 (1.9)

• Other

22 (2.7)

96 (2.7)

Treatments for urinary symptoms, n (%)

Figure 1.8 Healthcare-seeking behavior for and treatment of lower urinary tract symptoms.*All numbers presented are weighted; subgroups might or might not equal total number (n) because of rounding or weighted values. †Scheffe’s post-hoc pairwise comparisons indicated significant differences between the mean number of visits at P