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A Medium Term Analysis of the Subjective Efficacy of Treatment for Women with Detrusor Instability and Low Bladder Compliance
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY
influence on immunological events, long-term graft function or cyclosporine delivery. The data indicate that obese patients with a history of ischemic heart disease are high risk candidates who should not undergo transplantation without prior weight reduction. This restriction is particularly important because weight reduction after transplantation is most unlikely among these individuals. Control of serum lipids by dietary and pharmacological interventions is also important in obese transplant recipients. Andrew C. Novick, M.D.
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY Efficacy of Nonsurgical Therapy for Urinary Incontinence M. M. KARRAM, L.PARTOLL AND J.RAHE, Division of Urogynecology,Department of Obstetrics and Gynecology, Good Samaritan Hospital, University of Cincinnati, Cincinnati, Ohio J. Reprod. Med., 41: 215-219, 1996 OBJECTIVE: To assess the efficacy of aggressive nonsurgical therapy for urinary incontinence in women and to determine if it is advantageous to perform invasive urodynamic testing prior to initiating treatment. STUDY DESIGN: We subjectively assessed 202 incontinent women three months to four years following nonsurgical therapy for urinary incontinence. Therapy in all patients included behavioral modification in the form of timed voiding and pelvic floor exercises. Depending on the suspected diagnosis and menopausal state, patients were also treated with various combinations of pharmacologic agents and estrogen replacement therapy. Based on initial evaluation, patient preference and referring physician preference, 100 women were started on therapy after a minimal evaluation, while 102 women were treated based on invasive urodynamic testing. A subjective assessment of treatment outcome was made via a telephone interview in which patients were asked standardized questions. RESULTS: One hundred nineteen cases (59%) were subjectively improved or cured with nonsurgical therapy. Performing urodynamic testing prior to initiating therapy did not increase the overall success rate: 69 of 100 patients (69%) treated on the basis of history, physical examination and a minimal office evaluation were improved or cured, while only 50 of 102 patients (49%) having electronic multichannel urodynamic testing were improved or cured. CONCLUSION: All women with urinary incontinence should be initially offered nonsurgical therapy since a large percentage will obtain satisfactory results. It is not beneficial or cost-effective to perform electronic urodynamic testing prior to initiating therapy. Editorial Comment: In the words of the authors, “Our results confirm that aggressive, directed, nonsurgical therapy is successful in improvhg or curing incontinence in a significant number of women.” The subjective cure rate was 5% in patients believed to be incontinent due to stress incontinence and/or detrusor instability. The lowest rate of improvement was noted in patients with urodynamically proved detrusor instability (23%). Although the authors concluded that ”. . . performing urodynamic testing prior to the initiation of conservative therapy did not improve the overall outcome,” the routine office evaluation consisted of the patient voiding in private and the urine volume being recorded. Residual after voiding was obtained by inserting a catheter through which the bladder was manually filled with mom temperature sterile water. Sensation, fullness and maximum capacity were recorded. Unprovoked increases in the column of water during filling, consistent with involuntary bladder contractions, were noted. The catheter was then removed and the patient was asked to cough in the standing position to see if any visual loss of urine was noted. I consider this to be a form of urodynamic evaluation, albeit simple rather than electronic. However, the main point of the article, which is aggressive directed nonsurgical therapy, using multiple modalities simultaneously is an effective management strategy for a large number of women with urinary incontinence, seems valid. Alan J. Wein, M.D.
A Medium Term Analysis of the Subjective Efficacy of Treatment for Women with Detrusor Instability and Low Bladder Compliance C. J. KELLEHER, L. D. C m z o , V. KHULLAR AND S. SALVATORE, Department of Urogynaecology,Kings College Hospital, London, United Kingdom Brit. J. Obst. Gynec., 104: 988-993, 1997 Objective. m e aims ofthis study were to determine the medium term subjective outcome of treatment for women with a d y n a m i c diagnosis of detrusor instability and low bladder compliance.
1109
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VOIDING FUNCTION AND DYSFUNCTION, AND FEUALE UROLOGY
Setting. A tertiary referral urogynaecology clinic. Participants and methods. One thousand one hundred and five women referred for the investigation of their urinary symptoms were entered into a prospective, long term, quality of life study. Of these, 348 had a videourodynamic diagnosis of detrusor instability or low bladder compliance and form the basis of this paper. Women were contacted by post at least six months following their urodynamic assessment and asked to complete a questionnaire detailing their treatment, its efficacy and side effects, and any residual urinary symptoms. Results. Two hundred and fiftv-six women (73.6%)responded to follow up; only 5.5% were cured of their urinary symptoms. The majority (90.2%)had received anticholinergic medication, although only 18.2% continued with this treatment in excess of six months. Many women had residual urinary symptoms following their investigation and treatment. Conclusion. The medium tern efficacy of the treatment of detrusor instability and low compliance is disappointing, and a large part of this failure may be attributable to poor treatment efficacy, side effects of medication, or inadequate follow up following the diagnosis and instigation of therapy.
Editorial Comment: The main point of this article is that, despite a urodynamically accurate diagnosis, only 53.9% of respondents were cured or improved by subsequent treatment. Furthermore, of all 231 women prescribed anticholinergic therapy only 18.2% took it for longer than 3 months. Overall, 52.3% of women prescribed anticholinergic medication believed that they were cured or improved by this treatment, and, as the authors state, this is “almost identical to the 52.2% efficacy described by women who discontinue treatment due to side effects whilst they were able to tolerate it.” Particularly significant is the fact that “of the women commencing anticholinergic therapy, only 42 (18.%) were still taking it on a regular basis six months following initial Prescription.” Although some of these women stopped allegedly because they were out of tablets, presumably if the therapeutic benefit-to-sideeffect ratio had been favorable, they would have renewed the prescription and continued taking the medication. The authors conclude, after reviewing the data, that ”this would offer strong support to the need for different drugs, different routes of administration, or different prescribing protocols to limit systemic side effects.” The data would also seem to strengthen the argument for the inclusion of a significant quality of life assessment in the objective evaluations of any therapy for voiding dysfunction. In other words, it does not much matter if a particular treatment is capable of producing an objective change in a urodynamic parameter if the patient finds that the overall quality of life is no better or even worse and elects to discontinue the regimen. Alan J. Wein, M.D. Transurethral Collagen Iqjection for Treatment of Postprostatectomy Urinary Incontinence in Men T. L. GRIEBLING, K. J. KREDER, JR.AND R. D. WILLIAMS, Department of Urology, University of Iowa, Iowa City, Iowa Urology, 49: 907-912, 1997 Objectives. Transurethral injection of glutaraldehyde cross-linked bovine collagen has recently been advocated as a potentially useful treatment modality for management of urinary incontinence. The reported clinical experience with urethral collagen injection in adult males has been limited. Methods. This study summarizes the current literature and reviews the clinical results of collagen injection in a group of 25 men with incontinence after either transurethral or radical prostatectomy. Results. The overall results in this series were disappointing. Only 2 patients (8%)achieved significant improvement with this treatment. Eight patients (32%) experienced minimal improvement in symptoms, and 15 (60%)remained incontinent with no improvement in symptoms after collagen injection. The number of injection procedures and volume of collagen material implanted did not correlate with clinical outcome. Five patients (20%)have subsequently required placement of an artificial urinary sphincter to control their incontinence. Conclusions. We conclude that transurethral injection of glutaraldehyde cross-linked bovine collagen has a limited role in the management of urinary incontinence in adult men after prostatectomy. Percutaneous Antegrade Collagen Injection Therapy for Urinary Incontinence Following Radical hstatectomy R. A. APPELL,S. P. VASAVADA, R. R. RACKLEY AND J. C. WINTERS, Section of Voiding Dysfunction, Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio UroIogy, 48 769-772, 1996 Objectives. To determine the potential utility of glutaraldehyde cross-linked collagen (GM-collagen) administered in an antegrade fashion into the submucosa of the bladder neck in patients who present with post-prostatectomy urinary incontinence. Methods. Twenty-four men aged 59 to 76 years (mean 69.0)with stress type urinary incontinence after
influence on immunological events, long-term graft function or cyclosporine delivery. The data indicate that obese patients with a history of ischemic heart disease are high risk candidates who should not undergo transplantation without prior weight reduction. This restriction is particularly important because weight reduction after transplantation is most unlikely among these individuals. Control of serum lipids by dietary and pharmacological interventions is also important in obese transplant recipients. Andrew C. Novick, M.D.
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY Efficacy of Nonsurgical Therapy for Urinary Incontinence M. M. KARRAM, L.PARTOLL AND J.RAHE, Division of Urogynecology,Department of Obstetrics and Gynecology, Good Samaritan Hospital, University of Cincinnati, Cincinnati, Ohio J. Reprod. Med., 41: 215-219, 1996 OBJECTIVE: To assess the efficacy of aggressive nonsurgical therapy for urinary incontinence in women and to determine if it is advantageous to perform invasive urodynamic testing prior to initiating treatment. STUDY DESIGN: We subjectively assessed 202 incontinent women three months to four years following nonsurgical therapy for urinary incontinence. Therapy in all patients included behavioral modification in the form of timed voiding and pelvic floor exercises. Depending on the suspected diagnosis and menopausal state, patients were also treated with various combinations of pharmacologic agents and estrogen replacement therapy. Based on initial evaluation, patient preference and referring physician preference, 100 women were started on therapy after a minimal evaluation, while 102 women were treated based on invasive urodynamic testing. A subjective assessment of treatment outcome was made via a telephone interview in which patients were asked standardized questions. RESULTS: One hundred nineteen cases (59%) were subjectively improved or cured with nonsurgical therapy. Performing urodynamic testing prior to initiating therapy did not increase the overall success rate: 69 of 100 patients (69%) treated on the basis of history, physical examination and a minimal office evaluation were improved or cured, while only 50 of 102 patients (49%) having electronic multichannel urodynamic testing were improved or cured. CONCLUSION: All women with urinary incontinence should be initially offered nonsurgical therapy since a large percentage will obtain satisfactory results. It is not beneficial or cost-effective to perform electronic urodynamic testing prior to initiating therapy. Editorial Comment: In the words of the authors, “Our results confirm that aggressive, directed, nonsurgical therapy is successful in improvhg or curing incontinence in a significant number of women.” The subjective cure rate was 5% in patients believed to be incontinent due to stress incontinence and/or detrusor instability. The lowest rate of improvement was noted in patients with urodynamically proved detrusor instability (23%). Although the authors concluded that ”. . . performing urodynamic testing prior to the initiation of conservative therapy did not improve the overall outcome,” the routine office evaluation consisted of the patient voiding in private and the urine volume being recorded. Residual after voiding was obtained by inserting a catheter through which the bladder was manually filled with mom temperature sterile water. Sensation, fullness and maximum capacity were recorded. Unprovoked increases in the column of water during filling, consistent with involuntary bladder contractions, were noted. The catheter was then removed and the patient was asked to cough in the standing position to see if any visual loss of urine was noted. I consider this to be a form of urodynamic evaluation, albeit simple rather than electronic. However, the main point of the article, which is aggressive directed nonsurgical therapy, using multiple modalities simultaneously is an effective management strategy for a large number of women with urinary incontinence, seems valid. Alan J. Wein, M.D.
A Medium Term Analysis of the Subjective Efficacy of Treatment for Women with Detrusor Instability and Low Bladder Compliance C. J. KELLEHER, L. D. C m z o , V. KHULLAR AND S. SALVATORE, Department of Urogynaecology,Kings College Hospital, London, United Kingdom Brit. J. Obst. Gynec., 104: 988-993, 1997 Objective. m e aims ofthis study were to determine the medium term subjective outcome of treatment for women with a d y n a m i c diagnosis of detrusor instability and low bladder compliance.
1109
1110
VOIDING FUNCTION AND DYSFUNCTION, AND FEUALE UROLOGY
Setting. A tertiary referral urogynaecology clinic. Participants and methods. One thousand one hundred and five women referred for the investigation of their urinary symptoms were entered into a prospective, long term, quality of life study. Of these, 348 had a videourodynamic diagnosis of detrusor instability or low bladder compliance and form the basis of this paper. Women were contacted by post at least six months following their urodynamic assessment and asked to complete a questionnaire detailing their treatment, its efficacy and side effects, and any residual urinary symptoms. Results. Two hundred and fiftv-six women (73.6%)responded to follow up; only 5.5% were cured of their urinary symptoms. The majority (90.2%)had received anticholinergic medication, although only 18.2% continued with this treatment in excess of six months. Many women had residual urinary symptoms following their investigation and treatment. Conclusion. The medium tern efficacy of the treatment of detrusor instability and low compliance is disappointing, and a large part of this failure may be attributable to poor treatment efficacy, side effects of medication, or inadequate follow up following the diagnosis and instigation of therapy.
Editorial Comment: The main point of this article is that, despite a urodynamically accurate diagnosis, only 53.9% of respondents were cured or improved by subsequent treatment. Furthermore, of all 231 women prescribed anticholinergic therapy only 18.2% took it for longer than 3 months. Overall, 52.3% of women prescribed anticholinergic medication believed that they were cured or improved by this treatment, and, as the authors state, this is “almost identical to the 52.2% efficacy described by women who discontinue treatment due to side effects whilst they were able to tolerate it.” Particularly significant is the fact that “of the women commencing anticholinergic therapy, only 42 (18.%) were still taking it on a regular basis six months following initial Prescription.” Although some of these women stopped allegedly because they were out of tablets, presumably if the therapeutic benefit-to-sideeffect ratio had been favorable, they would have renewed the prescription and continued taking the medication. The authors conclude, after reviewing the data, that ”this would offer strong support to the need for different drugs, different routes of administration, or different prescribing protocols to limit systemic side effects.” The data would also seem to strengthen the argument for the inclusion of a significant quality of life assessment in the objective evaluations of any therapy for voiding dysfunction. In other words, it does not much matter if a particular treatment is capable of producing an objective change in a urodynamic parameter if the patient finds that the overall quality of life is no better or even worse and elects to discontinue the regimen. Alan J. Wein, M.D. Transurethral Collagen Iqjection for Treatment of Postprostatectomy Urinary Incontinence in Men T. L. GRIEBLING, K. J. KREDER, JR.AND R. D. WILLIAMS, Department of Urology, University of Iowa, Iowa City, Iowa Urology, 49: 907-912, 1997 Objectives. Transurethral injection of glutaraldehyde cross-linked bovine collagen has recently been advocated as a potentially useful treatment modality for management of urinary incontinence. The reported clinical experience with urethral collagen injection in adult males has been limited. Methods. This study summarizes the current literature and reviews the clinical results of collagen injection in a group of 25 men with incontinence after either transurethral or radical prostatectomy. Results. The overall results in this series were disappointing. Only 2 patients (8%)achieved significant improvement with this treatment. Eight patients (32%) experienced minimal improvement in symptoms, and 15 (60%)remained incontinent with no improvement in symptoms after collagen injection. The number of injection procedures and volume of collagen material implanted did not correlate with clinical outcome. Five patients (20%)have subsequently required placement of an artificial urinary sphincter to control their incontinence. Conclusions. We conclude that transurethral injection of glutaraldehyde cross-linked bovine collagen has a limited role in the management of urinary incontinence in adult men after prostatectomy. Percutaneous Antegrade Collagen Injection Therapy for Urinary Incontinence Following Radical hstatectomy R. A. APPELL,S. P. VASAVADA, R. R. RACKLEY AND J. C. WINTERS, Section of Voiding Dysfunction, Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio UroIogy, 48 769-772, 1996 Objectives. To determine the potential utility of glutaraldehyde cross-linked collagen (GM-collagen) administered in an antegrade fashion into the submucosa of the bladder neck in patients who present with post-prostatectomy urinary incontinence. Methods. Twenty-four men aged 59 to 76 years (mean 69.0)with stress type urinary incontinence after