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Prevalence and Physician Awareness of Symptoms of Urinary Bladder Dysfunction
European Urology
European Urology 41 (2002) 234±239
Prevalence and Physician Awareness of Symptoms of Urinary Bladder Dysfunction Mark Goepela,*, Josef A. Hoffmannb, Maria Pirob, Herbert RuÈbbena, Martin C. Michela a
Department of Urology and Medicine, University of Essen, 45122 Essen, Germany Pharmacia GmbH, Am Wolfsmantel 46, 91058 Erlangen, Germany
b
Accepted 26 December 2001
Abstract Purpose: To determine awareness of bladder dysfunction and attitudes towards its management among of®ce-based physicians. Materials and Methods: A total of 211,648 patients consulting of®ce-based primary care physicians (PCPs), gynaecologists (OBGs) or urologists (UROs) for any reason were given a questionnaire of four questions related to symptoms of bladder dysfunction. The physicians were asked to discuss the answers with their patients and to choose from a list of suspected diagnoses. They were also asked whether medical therapy would be initiated and/or the patient referred to a specialist. Results: Patients (57%) had a least one symptom of bladder dysfunction, with increased frequency being most common (41.9%), and symptoms of stress incontinence (30.6%), urgency (24.3%) and urge incontinence (20.2%) less frequent. However, patients with symptoms of overactive bladder (OAB), mixed incontinence or stress incontinence according to the questionnaire remained undiagnosed by their physician in 57.5, 47.5 and 38.1% of cases, respectively. When a diagnosis was suspected by the physician, it often did not match what would be expected based on the questionnaire, and in half of all cases did not result in medical treatment. Conclusions: Bladder dysfunction is highly prevalent among patients consulting an of®ce-based physician for any reason, but remains undiagnosed in many cases and untreated despite diagnosis in many others. Since various effective treatment options are available for bladder dysfunction, educational programs for patients and physicians appear necessary to improve the quality of diagnosis and treatment for this wide-spread condition. # 2002 Elsevier Science B.V. All rights reserved. Keywords: Epidemiology; Physician awareness; Stress incontinence; Urgency; Urge incontinence 1. Introduction A large fraction of the general population, particularly of the elderly, suffers from bladder dysfunction [1]. While previous studies have mainly focused on incontinence, more recently attention has also included overactive bladder (OAB). The latter is urodynamically characterised by involuntary contractions during the ®lling phase of the micturition cycle which result in a reduced functional bladder capacity and unpredictable *
Corresponding author. Present address: Urologische Klinik, Klinikum Niederberg, Robert-Koch-Str. 2, 42549 Velbert, Germany. Tel.: 49-2051-982-1900; Fax: 49-2051-982-1910. E-mail address: [email protected] (M. Goepel).
troublesome symptoms. The clinical diagnosis of OAB is usually based on the symptoms of frequency (>8 micturitions/24 h), urgency and urge incontinence, occurring either singly or in combination, which are not explained by metabolic (e.g. diabetes) or local pathological factors (e.g. urinary tract infection, stones, interstitial cystitis) [2]. A recent population-based prevalence study has found that 16.6% of the general population aged 40±75 suffer from OAB, but only 27% of the af¯icted patients were receiving treatment [3]. This seems surprising when the large personal and socio-economic impact of bladder dysfunction [4] on the one hand and the considerable progress in the development of effective medical treatment modalities for this condition [5] on the other hand are considered.
0302-2838/02/$ ± see front matter # 2002 Elsevier Science B.V. All rights reserved. PII: S 0 3 0 2 - 2 8 3 8 ( 0 2 ) 0 0 0 1 4 - 3
M. Goepel et al. / European Urology 41 (2002) 234±239
To gain insight into the physician awareness of and attitude towards management of bladder dysfunction, we have surveyed >200,000 unselected patients and their physicians. Our data indicate that a large fraction of patients with bladder dysfunction remains unrecognised, and hence, untreated by their physicians; even when bladder dysfunction is recognised, it is misclassi®ed and/or remains untreated in many cases. 2. Materials and methods Between March and July 1999, German primary care physicians (PCPs) (n 2051) and board-certi®ed, of®ce-based gynaecologists (OBGs) (n 446) and urologists (UROs) (n 165) were asked to give a self-administered written questionnaire to 100 consecutive, unselected patients (i.e. patients consulting their physician for any reason) aged 40 years or older (20 years or older for gynaecologists) prior to consultation. No speci®c selection criteria were used for the participating physicians, and they should be representative for entire Germany. The questionnaire asked for gender, age group and four symptoms related to major signs of bladder dysfunction such as increased frequency, urgency, urge incontinence and stress incontinence. (1) Do you have to empty your bladder more often lately (even after going to bed)? (2) Do you sometimes have a sudden feeling of uncontrollable urgency? (3) Do you sometimes have a strong feeling of uncontrollable urgency and lose urine before reaching a toilet? (4) Do you lose urine when you cough, sneeze, laugh, lift an object or strain your body?. The physicians were asked to discuss the answers with their patients during the same visit and to mark one of the suspected diagnoses ``none'', ``OAB'', ``mixed incontinence'' or ``stress incontinence'' on the questionnaire; to re¯ect real life practise, the participating physicians were not speci®cally instructed regarding de®nitions of bladder dysfunction. Moreover, they were asked whether they would initiate drug treatment of any type. PCPs were additionally asked whether the patient would be referred to a specialist for further diagnosis and/or treatment. The test-retest reliability of the questionnaire during a 2-week period without treatment had been documented in 40 patients yielding kappa coef®cients of 0.7867, 1.000, 0.7133 and 0.9441 for questions (1) to (4), respectively. A total of 211,648 patients were surveyed, 67.4% of whom were female. The age groups 20±29, 30±39, 40±49, 50±59, 60±79 and >80 years represented 4.2, 4.8, 22.8, 24.3, 37.7, and 6.2% of the overall patient population, respectively. PCPs, gynaecologists and urologists contributed 73.6, 19.5 and 6.9% of the patients, respectively. For the purpose of our analysis, a patient was considered to have no bladder-related symptoms, if all four items in the questionnaire were answered with ``no''. A patient was assumed to have an OAB when questions (1) (increased frequency), (2) (urgency) and/or (3) (urge incontinence) alone or in combination were answered with ``yes'' but stress incontinence was absent. Stress incontinence was assumed if only the question (4) was answered positively. Mixed incontinence was suspected if question (4) plus one or more of the other questions was answered with ``yes''. Based on these criteria and the physician's suspected diagnosis, we calculated the prevalence and physician awareness of and attitude towards management of bladder dysfunction. While not all questionnaires were ®lled completely, for any given question, <5% of answers were missing; percentages of patients were calculated based on the available answered questions. Data management and
235
descriptive statistical analysis were performed by ANFOMED (Moehrendorf, Germany).
3. Results Among patients visiting a PCP, gynaecologist or urologist for any reason, 57% had a least one symptom of bladder dysfunction, with increased frequency being the most common symptom (41.9%), and symptoms of stress incontinence (30.6%), urgency (24.3%) and urge incontinence (20.2%) being less frequent (Fig. 1). Compared to PCPs, urologists and gynaecologists were confronted more and less frequently, respectively, with frequency, urgency and urge incontinence (Fig. 1). While frequency and urgency occurred similarly often in male and female patients (42.8% versus 41% and 21.4% versus 25.4%, respectively), symptoms of urge and stress incontinence were more frequent in female than in male patients (22.8% versus 14.3% and 39.5% versus 11.6%, respectively), particularly, if only females aged 40 and older were analysed (data not shown). The prevalence of each symptom of bladder dysfunction increased with age (Fig. 2). While these data are in good agreement with those of numerous smaller studies in the past [1,3,6±8], the large number of patients in the present survey for the ®rst time allowed a logit analysis to determine the odds ratios associated with gender and age for any of the four symptoms (Table 1). Relative to males, each symptom was signi®cantly more frequent in females; while the relative increase was only modest for frequency and
Fig. 1. Prevalence of bladder symptoms in the overall study population (all) and those seen by primary care physicians (PCPs), gynaecologists (OBGs) and urologists (UROs). UI, urge incontinence; SI, stress incontinence.
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Fig. 2. Prevalence of frequency, urgency, urge incontinence and stress incontinence relative to age (4.2, 4.8, 22.8, 24.3, 37.7 and 6.2% of patients were aged 20±29, 30±39, 40±49, 50±59, 60±79 and >80 years, respectively). Note that only female patients seen by gynaecologists were included in the 20±39-year-age groups.
urgency and moderate for urge incontinence, it was very pronounced for stress incontinence (odds ratio 6.578). The odds ratio for each symptom increased with age, e.g. relative to 20±29-year-old patients, 50± 59-year-old patients had an odds ratio greater than 5 for frequency and urgency and greater than 8 for urge or stress incontinence, and patients 80 years and older had an odds ratio greater than 20 for frequency, urgency and stress incontinence and greater 40 for urge incontinence. Based on patient answers to the questionnaire and the earlier de®nitions, 26.5, 22.5 and 8% of patients appeared to suffer from OAB, mixed incontinence and stress incontinence, respectively. Given a choice of suspected diagnoses of OAB, mixed incontinence, stress incontinence or ``none'', physicians had chosen ``none'' in 57.5, 47.5 and 38.1% of cases with symptoms indicative of OAB, mixed incontinence or stress incontinence, respectively; except for a somewhat
Fig. 3. Percentage of patients with symptoms of overactive bladder (OAB), mixed incontinence (MI) or stress incontinence (SI) who were not detected by their primary care physician (PCP), gynaecologist (OBG) or urologist (URO).
better detection of stress incontinence by urologists, all physician groups had similar success rates in matching symptoms and suspected diagnosis (Fig. 3). In this context, it should be considered that based on our operative de®nition of OAB (see Section 2), an increased frequency alone was suf®cient to classify a patient as having OAB. While frequency (especially, if not accompanied by other symptoms) can also result from causes unrelated to OAB such as heart failure, benign prostatic hyperplasia or urinary tract infection, this is unlikely to fully explain the observation that 57.5% of patients with increased frequency, urgency and/or urge incontinence were not classi®ed as having bladder dysfunction. Indeed, even if a narrow de®nition of OAB was used (i.e. including only patients with urgency and/or urge incontinence), the fraction of patients classi®ed as not having bladder dysfunction remained at 15%. When a diagnosis of OAB, mixed incontinence or stress incontinence was suspected by the physician, comparison of diagnosis and patient questionnaire indicated a mismatch in 38.5, 20.5 and 53.5% of cases, respectively, in the overall population. While urologists
Table 1 Odds ratios for bladder symptoms relative to gender and age Symptom
Frequency
Urgency
Urge incontinence
Stress incontinence
Female 30±39 years 40±49 years 50±59 years 60±79 years Over 80 years
1.236 1.452 2.210 5.284 9.451 21.552
1.575 1.761 3.031 5.805 8.726 21.784
2.336 2.111 4.292 8.400 14.136 41.121
6.578 2.666 4.807 8.680 10.654 23.330
(1.211±1.262) (1.337±1.578) (2.065±2.365) (4.942±5.651) (8.846±10.097) (19.965±23.266)
(1.538±1.612) (1.572±1.972) (2.756±3.335) (5.284±6.378) (7.950±9.577) (19.737±24.045)
(2.275±2.399) (1.829±2.435) (3.796±4.853) (7.438±9.485) (12.532±15.946) (36.290±46.595)
(6.400±6.762) (2.432±2.923) (4.436±5.209) (8.013±9.403) (9.844±11.530) (21.381±25.456)
The odds ratios for each symptom were derived from a logit analysis of the entire database. The ratio for females is relative to males and those for the age groups relative to the 20±29-year-old age group. Note, that the analysis does not allow a direct assessment of the combined effect of gender and a given age group. Data are shown as odds ratios with 95% confidence intervals.
M. Goepel et al. / European Urology 41 (2002) 234±239
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even patients with all three symptoms of OAB or all four symptoms of mixed incontinence did not receive any form of medical treatment in 29.9 and 25.9% of cases, respectively, and this number was not markedly improved if only diagnosed patients were considered. 4. Discussion
Fig. 4. Percentage of patients diagnosed with overactive bladder (OAB), mixed incontinence (MI) or stress incontinence (SI) by their primary care physician (PCP), gynaecologist (OBG) or urologist (URO), in which the suspected diagnosis did not match the symptoms reported in the questionnaire.
appeared to be more successful in diagnosing OAB, no major differences between physician groups were found for other disease states (Fig. 4). Among all patients who had symptoms of OAB, mixed incontinence or stress incontinence only 34.0, 56.5 and 16.7%, respectively, were deemed candidates for medical therapy by their physicians or, in case of PCP, referred to a specialist for further diagnosis and/or treatment. In this regard, patients being seen by a urologist were most likely to receive treatment whereas those being seen by a gynaecologist were least likely (Fig. 5). While the probability of receiving some form of medical treatment increased with the number of symptoms in each physician group (data not shown),
Fig. 5. Percentage of patients with symptoms of overactive bladder (OAB), mixed incontinence (MI) or stress incontinence (SI) who were deemed candidates for medical treatment by their primary care physician (PCP), gynaecologist (OBG) or urologist (URO). Patients with symptoms deemed candidates for medical treatment or referred to specialist by their PCP (PCP).
Bladder dysfunction markedly affects quality of life by reducing social relationships and activities and impairing emotional and psychological well-being and sexual behaviour [4]. For many patients, bladder dysfunction requires often elaborate planning to conceal or prepare for incontinent episodes. It also constitutes a major socio-economic problem and e.g. is estimated to be responsible for 40±60% of all nursing home admissions and an estimated annual cost of US$ 8.1 billion [4]. Nevertheless, it was recently reported that only 27% of OAB patients are currently receiving treatment [3]. Therefore, the current survey was performed to determine whether and to which extent progress in the diagnosis and treatment of bladder dysfunction has affected current diagnostic and treatment patterns by PCPs and specialists. 4.1. Critique of methods The present survey of >200,000 patients is the largest of its kind, and has included >10 times the number of patients of the largest survey published previously [7]. While information on speci®c characteristics of the patient populations in the various practises (e.g. on socio-economic stratum) was not available to us, the large number of participating physicians makes it likely that the overall patient group surveyed here is fairly representative for the situation at least in the German health care system. The percentage of patients with at least one symptom of bladder dysfunction in our survey (57%) is somewhat greater than previously reported estimates of bladder dysfunction in the general population [1,3,7,8]. Reported differences in the prevalence of bladder control problems can be attributed to three main reasons, i.e. the de®nitions being used, the study methodology and the characteristics of the study population [7]. Since the present survey was primarily designed to determine physician awareness of bladder problems in a very large sample of physicians and patients, we were forced to strike a balance between precision of bladder dysfunction estimates and ease of test administration. Moreover, we wished to look at the entire spectrum of bladder dysfunction rather than at incontinence only. Therefore, we have not used the incontinence
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M. Goepel et al. / European Urology 41 (2002) 234±239
de®nition of the International Continence Society [9], but rather a self-designed four-item questionnaire. This questionnaire obviously has high face validity in detecting symptoms of bladder dysfunction such as frequency, urgency, urge and stress incontinence, and we have documented its test-retest reliability to be high. While urgency, urge and/or stress incontinence directly imply bladder dysfunction, increased frequency alone often is a sign of OAB, but could also be due to other causes such as congestive heart failure or, in men, benign prostatic hyperplasia; the presence of such comorbidities has not been assessed in the present study. Nevertheless, frequency alone was used as a de®ning criterion for OAB for the purpose of the present analysis in analogy to a recently published population-based study [3]. While this may have contributed to the relatively large prevalence of bladder dysfunction in the present study, our results on physician awareness of bladder problems are not fully explained by this very wide de®nition. With regard to study methodology, surveys such as the present study tend to report a higher prevalence of bladder dysfunction across all study populations than studies involving clinical or even urodynamic evaluations, possibly because incontinent patients tend to aggravate their problems [7]. With regard to study population, it is important that our survey was not population-based, but rather has included patients consulting a physician. While this may limit extrapolation to the general population, it should be considered that patients were included if they visited their physician for any reason and that patients had not been selected based on risk factors for bladder problems. Therefore, our patients should be representative for those typically being seen in a doctor's of®ce, and hence, should allow an analysis of physician awareness of and attitude towards bladder dysfunction. Moreover, the rank order of prevalence (i.e. frequency > urgency > urge incontinence) of symptoms of bladder dysfunction in the present survey is very similar to that in a recent population-based study in six European countries despite somewhat higher absolute prevalence estimates [3]. 4.2. Physician awareness and attitudes The key ®nding of our survey is the observation that 38±57% of patients with symptoms of bladder dysfunction remain undiagnosed by their physician and that specialists such as gynaecologists or urologists do only slightly better than PCPs in this regard, even though they should be better educated and even though they are more likely to encounter these symptoms. While
the participating physicians may have had additional information regarding their patients which may justify not to classify them as having bladder dysfunction despite their symptoms, this can only partly explain the large discrepancy between the percentage of patients reporting symptoms and those being classi®ed as having bladder dysfunction. Obviously, a de®nitive diagnosis of bladder dysfunction cannot rely on a simple questionnaire such as ours, but additionally will involve further basic examinations such as a micturition diary, urinalysis, uro¯owmetry and measurement of residual urine, particularly prior to initiating any kind of treatment. It is equally obvious, however, that a patient presenting with at least one of the symptoms listed in our questionnaire suffers from some type of lower urinary tract dysfunction. Therefore, it is surprising that about 50% of all patients with one or even multiple symptoms of bladder dysfunction according to our questionnaire did not receive any suspected diagnosis by their PCP, gynaecologist or urologist. This problem is aggravated by the observation that when a diagnosis was suspected, it did not match the reported symptoms in 20±53% of patients. Even when it is considered that our questionnaire allowed only limited options for a suspected diagnosis, our data indicate a surprising lack of physician awareness of various types of bladder dysfunction. In this regard, our survey may even overestimate physician awareness, because many patients reporting bladder symptoms in their questionnaire might not have reported them to their physician spontaneously during a routine consultation. Thus, it has recently been reported that 40% of patients with OAB had never spoken to a physician about their condition [3]. Taken together, the present data suggest that bladder dysfunction is markedly under-diagnosed, partly because patients do not spontaneously report their problems and partly because physicians fail to adequately diagnose it. Depending on the underlying aetiology, treatment of bladder symptoms may involve behavioural modi®cation, bladder retraining, pelvic ¯oor exercises, electrical stimulation and various forms of surgery [2]. Moreover, a number of medications are now available for the medical treatment of OAB and incontinence which include anti-cholinergics, a-adrenoceptor antagonists in case of benign prostatic hyperplasia, antibiotics in case of urinary tract infection or hormone replacement therapy in postmenopausal women. Upon adequate use, all of these can relieve bladder symptoms in a considerably fraction of patients. Nevertheless, only 17, 34 and 57% of patients with symptoms of stress incontinence, OAB and mixed incontinence,
M. Goepel et al. / European Urology 41 (2002) 234±239
respectively, in our survey were deemed candidates for any form of drug treatment or, in case of PCP, referred to a specialist for further diagnosis and treatment. These ®ndings are in good agreement with those from a smaller recent study in which only 27% of patients with OAB who had contacted a physician regarding their bladder problems, were currently receiving treatment whereas 53% had never been on medication [3]. While these numbers in part correctly re¯ect the fact that medical treatment of isolated stress incontinence is dif®cult, they contrast sharply the success rates of anticholinergic drugs in the treatment of OAB, which are effective in up to 80% of patients [5]. Even patients with all three symptoms of OAB (urgency, urge incontinence and frequency) or patients with all four symptoms of mixed incontinence (all of the above plus symptoms of stress incontinence) were not considered for medical treatment in 29.9 and 25.9% of cases. These numbers are only partly explained by the facts that not every patient with bladder dysfunction is suitable for additional diagnostic procedures or medical treatment and that some patients may have previously undergone treatment but failed for lack of ef®cacy and/or tolerability [3]. Therefore, our data indicate that patients with bladder dysfunction are not only under-diagnosed, but even if diagnosed frequently fail to receive potentially bene®cial medical treatment. This holds true even if it is considered that
239
some PCPs may have refrained from medical treatment in favour of referral to a specialist. 5. Conclusions Taken together these data demonstrate that despite the huge individual and socio-economic burden of bladder dysfunction, only a fraction of af¯icted patients is correctly diagnosed based on their symptoms and receives adequate treatment. Although the methodology of the present study does not allow a more detailed analysis of the reasons for incorrect diagnoses and reluctant drug prescriptions, our data show that increasing awareness of the symptoms of bladder dysfunction and available treatment options is necessary for all physician groups dealing with these conditions including specialists. In light of the major socio-economic burden associated with bladder dysfunction, such educational programs may not only make a better life for patients, but also be cost-effective from the society's point of view [4]. Acknowledgements This study has been sponsored by a grant from Pharmacia GmbH, Erlangen, Germany.
References [1] Hunskaar S, Arnold EP, Burgio K, Diokno AC, Herzog AR, Mallett VT. Epidemiology and natural history of urinary incontinence (UI). In: Abrams P, Khoury S, Wein A, editors. Incontinence. Plymouth: Plymbridge Distributors Ltd., 1999. p. 197±226. [2] Bulmer P, Abrams P. The overactive bladder. Rev Contemp Pharmacother 2000;11:1±11. [3] Milsom I, Abrams P, Cardozo L, Roberts RG, ThuÈroff JW, Wein AJ. How wide-spread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. BJU Int 2001; 87:760±6. [4] Luscombe FA. Socio-economic burden of urinary incontinence with focus on overactive bladder and tolterodine treatment. Rev Contemp Pharmacother 2000;11:43±62.
[5] Chapple CR. Muscarinic receptor antagonists in the treatment of overactive bladder. Urology 2000;55(Suppl 5A):33±46. [6] Resnick NM. Urinary incontinence. Lancet 1995;346:94±9. [7] Hampel C, Wienhold D, Dahms SE, ThuÈroff JW. Heterogeneity in epidemological investigations of bladder control problems: a problem of definition. BJU Int 1999;83(Suppl 2):10±5. [8] Schmidbauer J, Temml C, Schatzl G, Haidinger G, Madersbacher S. Risk factors for urinary incontinence in both sexes. Eur Urol 2001; 39:565±70. [9] International Continence Society. First report on the standardisation of terminology of lower urinary tract function. Br J Urol 1976;48: 39±42.
European Urology 41 (2002) 234±239
Prevalence and Physician Awareness of Symptoms of Urinary Bladder Dysfunction Mark Goepela,*, Josef A. Hoffmannb, Maria Pirob, Herbert RuÈbbena, Martin C. Michela a
Department of Urology and Medicine, University of Essen, 45122 Essen, Germany Pharmacia GmbH, Am Wolfsmantel 46, 91058 Erlangen, Germany
b
Accepted 26 December 2001
Abstract Purpose: To determine awareness of bladder dysfunction and attitudes towards its management among of®ce-based physicians. Materials and Methods: A total of 211,648 patients consulting of®ce-based primary care physicians (PCPs), gynaecologists (OBGs) or urologists (UROs) for any reason were given a questionnaire of four questions related to symptoms of bladder dysfunction. The physicians were asked to discuss the answers with their patients and to choose from a list of suspected diagnoses. They were also asked whether medical therapy would be initiated and/or the patient referred to a specialist. Results: Patients (57%) had a least one symptom of bladder dysfunction, with increased frequency being most common (41.9%), and symptoms of stress incontinence (30.6%), urgency (24.3%) and urge incontinence (20.2%) less frequent. However, patients with symptoms of overactive bladder (OAB), mixed incontinence or stress incontinence according to the questionnaire remained undiagnosed by their physician in 57.5, 47.5 and 38.1% of cases, respectively. When a diagnosis was suspected by the physician, it often did not match what would be expected based on the questionnaire, and in half of all cases did not result in medical treatment. Conclusions: Bladder dysfunction is highly prevalent among patients consulting an of®ce-based physician for any reason, but remains undiagnosed in many cases and untreated despite diagnosis in many others. Since various effective treatment options are available for bladder dysfunction, educational programs for patients and physicians appear necessary to improve the quality of diagnosis and treatment for this wide-spread condition. # 2002 Elsevier Science B.V. All rights reserved. Keywords: Epidemiology; Physician awareness; Stress incontinence; Urgency; Urge incontinence 1. Introduction A large fraction of the general population, particularly of the elderly, suffers from bladder dysfunction [1]. While previous studies have mainly focused on incontinence, more recently attention has also included overactive bladder (OAB). The latter is urodynamically characterised by involuntary contractions during the ®lling phase of the micturition cycle which result in a reduced functional bladder capacity and unpredictable *
Corresponding author. Present address: Urologische Klinik, Klinikum Niederberg, Robert-Koch-Str. 2, 42549 Velbert, Germany. Tel.: 49-2051-982-1900; Fax: 49-2051-982-1910. E-mail address: [email protected] (M. Goepel).
troublesome symptoms. The clinical diagnosis of OAB is usually based on the symptoms of frequency (>8 micturitions/24 h), urgency and urge incontinence, occurring either singly or in combination, which are not explained by metabolic (e.g. diabetes) or local pathological factors (e.g. urinary tract infection, stones, interstitial cystitis) [2]. A recent population-based prevalence study has found that 16.6% of the general population aged 40±75 suffer from OAB, but only 27% of the af¯icted patients were receiving treatment [3]. This seems surprising when the large personal and socio-economic impact of bladder dysfunction [4] on the one hand and the considerable progress in the development of effective medical treatment modalities for this condition [5] on the other hand are considered.
0302-2838/02/$ ± see front matter # 2002 Elsevier Science B.V. All rights reserved. PII: S 0 3 0 2 - 2 8 3 8 ( 0 2 ) 0 0 0 1 4 - 3
M. Goepel et al. / European Urology 41 (2002) 234±239
To gain insight into the physician awareness of and attitude towards management of bladder dysfunction, we have surveyed >200,000 unselected patients and their physicians. Our data indicate that a large fraction of patients with bladder dysfunction remains unrecognised, and hence, untreated by their physicians; even when bladder dysfunction is recognised, it is misclassi®ed and/or remains untreated in many cases. 2. Materials and methods Between March and July 1999, German primary care physicians (PCPs) (n 2051) and board-certi®ed, of®ce-based gynaecologists (OBGs) (n 446) and urologists (UROs) (n 165) were asked to give a self-administered written questionnaire to 100 consecutive, unselected patients (i.e. patients consulting their physician for any reason) aged 40 years or older (20 years or older for gynaecologists) prior to consultation. No speci®c selection criteria were used for the participating physicians, and they should be representative for entire Germany. The questionnaire asked for gender, age group and four symptoms related to major signs of bladder dysfunction such as increased frequency, urgency, urge incontinence and stress incontinence. (1) Do you have to empty your bladder more often lately (even after going to bed)? (2) Do you sometimes have a sudden feeling of uncontrollable urgency? (3) Do you sometimes have a strong feeling of uncontrollable urgency and lose urine before reaching a toilet? (4) Do you lose urine when you cough, sneeze, laugh, lift an object or strain your body?. The physicians were asked to discuss the answers with their patients during the same visit and to mark one of the suspected diagnoses ``none'', ``OAB'', ``mixed incontinence'' or ``stress incontinence'' on the questionnaire; to re¯ect real life practise, the participating physicians were not speci®cally instructed regarding de®nitions of bladder dysfunction. Moreover, they were asked whether they would initiate drug treatment of any type. PCPs were additionally asked whether the patient would be referred to a specialist for further diagnosis and/or treatment. The test-retest reliability of the questionnaire during a 2-week period without treatment had been documented in 40 patients yielding kappa coef®cients of 0.7867, 1.000, 0.7133 and 0.9441 for questions (1) to (4), respectively. A total of 211,648 patients were surveyed, 67.4% of whom were female. The age groups 20±29, 30±39, 40±49, 50±59, 60±79 and >80 years represented 4.2, 4.8, 22.8, 24.3, 37.7, and 6.2% of the overall patient population, respectively. PCPs, gynaecologists and urologists contributed 73.6, 19.5 and 6.9% of the patients, respectively. For the purpose of our analysis, a patient was considered to have no bladder-related symptoms, if all four items in the questionnaire were answered with ``no''. A patient was assumed to have an OAB when questions (1) (increased frequency), (2) (urgency) and/or (3) (urge incontinence) alone or in combination were answered with ``yes'' but stress incontinence was absent. Stress incontinence was assumed if only the question (4) was answered positively. Mixed incontinence was suspected if question (4) plus one or more of the other questions was answered with ``yes''. Based on these criteria and the physician's suspected diagnosis, we calculated the prevalence and physician awareness of and attitude towards management of bladder dysfunction. While not all questionnaires were ®lled completely, for any given question, <5% of answers were missing; percentages of patients were calculated based on the available answered questions. Data management and
235
descriptive statistical analysis were performed by ANFOMED (Moehrendorf, Germany).
3. Results Among patients visiting a PCP, gynaecologist or urologist for any reason, 57% had a least one symptom of bladder dysfunction, with increased frequency being the most common symptom (41.9%), and symptoms of stress incontinence (30.6%), urgency (24.3%) and urge incontinence (20.2%) being less frequent (Fig. 1). Compared to PCPs, urologists and gynaecologists were confronted more and less frequently, respectively, with frequency, urgency and urge incontinence (Fig. 1). While frequency and urgency occurred similarly often in male and female patients (42.8% versus 41% and 21.4% versus 25.4%, respectively), symptoms of urge and stress incontinence were more frequent in female than in male patients (22.8% versus 14.3% and 39.5% versus 11.6%, respectively), particularly, if only females aged 40 and older were analysed (data not shown). The prevalence of each symptom of bladder dysfunction increased with age (Fig. 2). While these data are in good agreement with those of numerous smaller studies in the past [1,3,6±8], the large number of patients in the present survey for the ®rst time allowed a logit analysis to determine the odds ratios associated with gender and age for any of the four symptoms (Table 1). Relative to males, each symptom was signi®cantly more frequent in females; while the relative increase was only modest for frequency and
Fig. 1. Prevalence of bladder symptoms in the overall study population (all) and those seen by primary care physicians (PCPs), gynaecologists (OBGs) and urologists (UROs). UI, urge incontinence; SI, stress incontinence.
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Fig. 2. Prevalence of frequency, urgency, urge incontinence and stress incontinence relative to age (4.2, 4.8, 22.8, 24.3, 37.7 and 6.2% of patients were aged 20±29, 30±39, 40±49, 50±59, 60±79 and >80 years, respectively). Note that only female patients seen by gynaecologists were included in the 20±39-year-age groups.
urgency and moderate for urge incontinence, it was very pronounced for stress incontinence (odds ratio 6.578). The odds ratio for each symptom increased with age, e.g. relative to 20±29-year-old patients, 50± 59-year-old patients had an odds ratio greater than 5 for frequency and urgency and greater than 8 for urge or stress incontinence, and patients 80 years and older had an odds ratio greater than 20 for frequency, urgency and stress incontinence and greater 40 for urge incontinence. Based on patient answers to the questionnaire and the earlier de®nitions, 26.5, 22.5 and 8% of patients appeared to suffer from OAB, mixed incontinence and stress incontinence, respectively. Given a choice of suspected diagnoses of OAB, mixed incontinence, stress incontinence or ``none'', physicians had chosen ``none'' in 57.5, 47.5 and 38.1% of cases with symptoms indicative of OAB, mixed incontinence or stress incontinence, respectively; except for a somewhat
Fig. 3. Percentage of patients with symptoms of overactive bladder (OAB), mixed incontinence (MI) or stress incontinence (SI) who were not detected by their primary care physician (PCP), gynaecologist (OBG) or urologist (URO).
better detection of stress incontinence by urologists, all physician groups had similar success rates in matching symptoms and suspected diagnosis (Fig. 3). In this context, it should be considered that based on our operative de®nition of OAB (see Section 2), an increased frequency alone was suf®cient to classify a patient as having OAB. While frequency (especially, if not accompanied by other symptoms) can also result from causes unrelated to OAB such as heart failure, benign prostatic hyperplasia or urinary tract infection, this is unlikely to fully explain the observation that 57.5% of patients with increased frequency, urgency and/or urge incontinence were not classi®ed as having bladder dysfunction. Indeed, even if a narrow de®nition of OAB was used (i.e. including only patients with urgency and/or urge incontinence), the fraction of patients classi®ed as not having bladder dysfunction remained at 15%. When a diagnosis of OAB, mixed incontinence or stress incontinence was suspected by the physician, comparison of diagnosis and patient questionnaire indicated a mismatch in 38.5, 20.5 and 53.5% of cases, respectively, in the overall population. While urologists
Table 1 Odds ratios for bladder symptoms relative to gender and age Symptom
Frequency
Urgency
Urge incontinence
Stress incontinence
Female 30±39 years 40±49 years 50±59 years 60±79 years Over 80 years
1.236 1.452 2.210 5.284 9.451 21.552
1.575 1.761 3.031 5.805 8.726 21.784
2.336 2.111 4.292 8.400 14.136 41.121
6.578 2.666 4.807 8.680 10.654 23.330
(1.211±1.262) (1.337±1.578) (2.065±2.365) (4.942±5.651) (8.846±10.097) (19.965±23.266)
(1.538±1.612) (1.572±1.972) (2.756±3.335) (5.284±6.378) (7.950±9.577) (19.737±24.045)
(2.275±2.399) (1.829±2.435) (3.796±4.853) (7.438±9.485) (12.532±15.946) (36.290±46.595)
(6.400±6.762) (2.432±2.923) (4.436±5.209) (8.013±9.403) (9.844±11.530) (21.381±25.456)
The odds ratios for each symptom were derived from a logit analysis of the entire database. The ratio for females is relative to males and those for the age groups relative to the 20±29-year-old age group. Note, that the analysis does not allow a direct assessment of the combined effect of gender and a given age group. Data are shown as odds ratios with 95% confidence intervals.
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even patients with all three symptoms of OAB or all four symptoms of mixed incontinence did not receive any form of medical treatment in 29.9 and 25.9% of cases, respectively, and this number was not markedly improved if only diagnosed patients were considered. 4. Discussion
Fig. 4. Percentage of patients diagnosed with overactive bladder (OAB), mixed incontinence (MI) or stress incontinence (SI) by their primary care physician (PCP), gynaecologist (OBG) or urologist (URO), in which the suspected diagnosis did not match the symptoms reported in the questionnaire.
appeared to be more successful in diagnosing OAB, no major differences between physician groups were found for other disease states (Fig. 4). Among all patients who had symptoms of OAB, mixed incontinence or stress incontinence only 34.0, 56.5 and 16.7%, respectively, were deemed candidates for medical therapy by their physicians or, in case of PCP, referred to a specialist for further diagnosis and/or treatment. In this regard, patients being seen by a urologist were most likely to receive treatment whereas those being seen by a gynaecologist were least likely (Fig. 5). While the probability of receiving some form of medical treatment increased with the number of symptoms in each physician group (data not shown),
Fig. 5. Percentage of patients with symptoms of overactive bladder (OAB), mixed incontinence (MI) or stress incontinence (SI) who were deemed candidates for medical treatment by their primary care physician (PCP), gynaecologist (OBG) or urologist (URO). Patients with symptoms deemed candidates for medical treatment or referred to specialist by their PCP (PCP).
Bladder dysfunction markedly affects quality of life by reducing social relationships and activities and impairing emotional and psychological well-being and sexual behaviour [4]. For many patients, bladder dysfunction requires often elaborate planning to conceal or prepare for incontinent episodes. It also constitutes a major socio-economic problem and e.g. is estimated to be responsible for 40±60% of all nursing home admissions and an estimated annual cost of US$ 8.1 billion [4]. Nevertheless, it was recently reported that only 27% of OAB patients are currently receiving treatment [3]. Therefore, the current survey was performed to determine whether and to which extent progress in the diagnosis and treatment of bladder dysfunction has affected current diagnostic and treatment patterns by PCPs and specialists. 4.1. Critique of methods The present survey of >200,000 patients is the largest of its kind, and has included >10 times the number of patients of the largest survey published previously [7]. While information on speci®c characteristics of the patient populations in the various practises (e.g. on socio-economic stratum) was not available to us, the large number of participating physicians makes it likely that the overall patient group surveyed here is fairly representative for the situation at least in the German health care system. The percentage of patients with at least one symptom of bladder dysfunction in our survey (57%) is somewhat greater than previously reported estimates of bladder dysfunction in the general population [1,3,7,8]. Reported differences in the prevalence of bladder control problems can be attributed to three main reasons, i.e. the de®nitions being used, the study methodology and the characteristics of the study population [7]. Since the present survey was primarily designed to determine physician awareness of bladder problems in a very large sample of physicians and patients, we were forced to strike a balance between precision of bladder dysfunction estimates and ease of test administration. Moreover, we wished to look at the entire spectrum of bladder dysfunction rather than at incontinence only. Therefore, we have not used the incontinence
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de®nition of the International Continence Society [9], but rather a self-designed four-item questionnaire. This questionnaire obviously has high face validity in detecting symptoms of bladder dysfunction such as frequency, urgency, urge and stress incontinence, and we have documented its test-retest reliability to be high. While urgency, urge and/or stress incontinence directly imply bladder dysfunction, increased frequency alone often is a sign of OAB, but could also be due to other causes such as congestive heart failure or, in men, benign prostatic hyperplasia; the presence of such comorbidities has not been assessed in the present study. Nevertheless, frequency alone was used as a de®ning criterion for OAB for the purpose of the present analysis in analogy to a recently published population-based study [3]. While this may have contributed to the relatively large prevalence of bladder dysfunction in the present study, our results on physician awareness of bladder problems are not fully explained by this very wide de®nition. With regard to study methodology, surveys such as the present study tend to report a higher prevalence of bladder dysfunction across all study populations than studies involving clinical or even urodynamic evaluations, possibly because incontinent patients tend to aggravate their problems [7]. With regard to study population, it is important that our survey was not population-based, but rather has included patients consulting a physician. While this may limit extrapolation to the general population, it should be considered that patients were included if they visited their physician for any reason and that patients had not been selected based on risk factors for bladder problems. Therefore, our patients should be representative for those typically being seen in a doctor's of®ce, and hence, should allow an analysis of physician awareness of and attitude towards bladder dysfunction. Moreover, the rank order of prevalence (i.e. frequency > urgency > urge incontinence) of symptoms of bladder dysfunction in the present survey is very similar to that in a recent population-based study in six European countries despite somewhat higher absolute prevalence estimates [3]. 4.2. Physician awareness and attitudes The key ®nding of our survey is the observation that 38±57% of patients with symptoms of bladder dysfunction remain undiagnosed by their physician and that specialists such as gynaecologists or urologists do only slightly better than PCPs in this regard, even though they should be better educated and even though they are more likely to encounter these symptoms. While
the participating physicians may have had additional information regarding their patients which may justify not to classify them as having bladder dysfunction despite their symptoms, this can only partly explain the large discrepancy between the percentage of patients reporting symptoms and those being classi®ed as having bladder dysfunction. Obviously, a de®nitive diagnosis of bladder dysfunction cannot rely on a simple questionnaire such as ours, but additionally will involve further basic examinations such as a micturition diary, urinalysis, uro¯owmetry and measurement of residual urine, particularly prior to initiating any kind of treatment. It is equally obvious, however, that a patient presenting with at least one of the symptoms listed in our questionnaire suffers from some type of lower urinary tract dysfunction. Therefore, it is surprising that about 50% of all patients with one or even multiple symptoms of bladder dysfunction according to our questionnaire did not receive any suspected diagnosis by their PCP, gynaecologist or urologist. This problem is aggravated by the observation that when a diagnosis was suspected, it did not match the reported symptoms in 20±53% of patients. Even when it is considered that our questionnaire allowed only limited options for a suspected diagnosis, our data indicate a surprising lack of physician awareness of various types of bladder dysfunction. In this regard, our survey may even overestimate physician awareness, because many patients reporting bladder symptoms in their questionnaire might not have reported them to their physician spontaneously during a routine consultation. Thus, it has recently been reported that 40% of patients with OAB had never spoken to a physician about their condition [3]. Taken together, the present data suggest that bladder dysfunction is markedly under-diagnosed, partly because patients do not spontaneously report their problems and partly because physicians fail to adequately diagnose it. Depending on the underlying aetiology, treatment of bladder symptoms may involve behavioural modi®cation, bladder retraining, pelvic ¯oor exercises, electrical stimulation and various forms of surgery [2]. Moreover, a number of medications are now available for the medical treatment of OAB and incontinence which include anti-cholinergics, a-adrenoceptor antagonists in case of benign prostatic hyperplasia, antibiotics in case of urinary tract infection or hormone replacement therapy in postmenopausal women. Upon adequate use, all of these can relieve bladder symptoms in a considerably fraction of patients. Nevertheless, only 17, 34 and 57% of patients with symptoms of stress incontinence, OAB and mixed incontinence,
M. Goepel et al. / European Urology 41 (2002) 234±239
respectively, in our survey were deemed candidates for any form of drug treatment or, in case of PCP, referred to a specialist for further diagnosis and treatment. These ®ndings are in good agreement with those from a smaller recent study in which only 27% of patients with OAB who had contacted a physician regarding their bladder problems, were currently receiving treatment whereas 53% had never been on medication [3]. While these numbers in part correctly re¯ect the fact that medical treatment of isolated stress incontinence is dif®cult, they contrast sharply the success rates of anticholinergic drugs in the treatment of OAB, which are effective in up to 80% of patients [5]. Even patients with all three symptoms of OAB (urgency, urge incontinence and frequency) or patients with all four symptoms of mixed incontinence (all of the above plus symptoms of stress incontinence) were not considered for medical treatment in 29.9 and 25.9% of cases. These numbers are only partly explained by the facts that not every patient with bladder dysfunction is suitable for additional diagnostic procedures or medical treatment and that some patients may have previously undergone treatment but failed for lack of ef®cacy and/or tolerability [3]. Therefore, our data indicate that patients with bladder dysfunction are not only under-diagnosed, but even if diagnosed frequently fail to receive potentially bene®cial medical treatment. This holds true even if it is considered that
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some PCPs may have refrained from medical treatment in favour of referral to a specialist. 5. Conclusions Taken together these data demonstrate that despite the huge individual and socio-economic burden of bladder dysfunction, only a fraction of af¯icted patients is correctly diagnosed based on their symptoms and receives adequate treatment. Although the methodology of the present study does not allow a more detailed analysis of the reasons for incorrect diagnoses and reluctant drug prescriptions, our data show that increasing awareness of the symptoms of bladder dysfunction and available treatment options is necessary for all physician groups dealing with these conditions including specialists. In light of the major socio-economic burden associated with bladder dysfunction, such educational programs may not only make a better life for patients, but also be cost-effective from the society's point of view [4]. Acknowledgements This study has been sponsored by a grant from Pharmacia GmbH, Erlangen, Germany.
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[5] Chapple CR. Muscarinic receptor antagonists in the treatment of overactive bladder. Urology 2000;55(Suppl 5A):33±46. [6] Resnick NM. Urinary incontinence. Lancet 1995;346:94±9. [7] Hampel C, Wienhold D, Dahms SE, ThuÈroff JW. Heterogeneity in epidemological investigations of bladder control problems: a problem of definition. BJU Int 1999;83(Suppl 2):10±5. [8] Schmidbauer J, Temml C, Schatzl G, Haidinger G, Madersbacher S. Risk factors for urinary incontinence in both sexes. Eur Urol 2001; 39:565±70. [9] International Continence Society. First report on the standardisation of terminology of lower urinary tract function. Br J Urol 1976;48: 39±42.