- Email: [email protected]
Urinary Incontinence Symptoms Stratification: The Devil Is in the Details
EUROPEAN UROLOGY 61 (2012) 96–97
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 88–95 of this issue
Urinary Incontinence Symptoms Stratification: The Devil Is in the Details Jean-Nicolas Cornu * Department of Urology, Tenon Hospital, Groupe Hospitalo-Universitaire EST, Assistance Publique-Hoˆpitaux de Paris (AP-HP), University Paris VI, 4 rue de la Chine, 75970 Paris Cedex 20, France
Urinary incontinence is seen as a common and frequent health problem in the developed world. An estimated 5–69% of women and 1–39% of men have urinary incontinence to some degree. Although substantial epidemiologic data have been published in recent years, the estimates of the prevalence of urinary incontinence in both genders still vary widely [1]. Following consensual work led by international experts in the field of urology, the characteristics and subtypes of this highly prevalent symptom were defined based on clinical presentation and linked to underlying pathophysiologic mechanisms [2]. The terminology is updated regularly so practitioners worldwide can use a common language and promote innovative patient care in this functional part of urologic practice. From the patient’s point of view, urinary incontinence remains a taboo subject [3], which has prompted information campaigns from scientific societies. Through dedicated events [4], several countries and associations are trying to bring information on incontinence to the public. Academic research in the epidemiology of urinary incontinence has mainly focused on specific patient groups (eg, women, elderly people, patients with comorbid conditions) and has failed to produce an accurate estimate of the prevalence of urinary incontinence. Because of patients’ typical unwillingness to respond openly to so-called validated questionnaires and symptom scores by investigators, current studies do not have enough power to investigate the symptoms in depth in the general population. In the current issue of the Platinum Journal, Coyne et al [5] present a study that overcomes the limitations just described and creates a new picture about the prevalence of urinary incontinence subtypes and their associated patient
characteristics, including considerations about quality of life. Using a Web-based survey, authors were able to overcome patients’ reluctance to talk about their symptoms, and they gathered a powerful data set with a high response rate. To avoid being too suggestive, they did not reduce the descriptions of symptoms to the usual stress urinary incontinence and/or urge urinary incontinence, thus giving patients an opportunity to describe their clinical condition freely. With appropriate support, they also managed to get a multinational representative sample of the adult population. In the male sample, the results that Coyne et al present in their Figure 1 are a bit surprising at first [5]. The statistics presented show a high rate of incontinence in both the male and female samples, but the most important result is probably the proportion of patients in each category. In the men’s sample, the other incontinence (OI) category is the major group, and the usual categories of symptoms (stress urinary incontinence and/or urge urinary incontinence) are cited far less frequently. This result, which represents a new finding, should be considered a landmark in the field of male urinary incontinence. Indeed, postmicturition incontinence, which represents 93% of cases of OI in the study, has never before been highlighted as such a prevalent symptom in men. The relatively reduced impact on quality of life and bother associated with this problem may explain why it has been a hidden aspect of the problem until recently. However, it has to be considered in future investigations on patient care and evaluations of lower urinary tract symptoms (LUTS) in men because it is not part of the currently used evaluation tools [6,7]. In men >50 yr of age, postmicturition incontinence symptoms should be
DOI of original article: 10.1016/j.eururo.2011.07.049 * Tel. +33 1 56 01 64 95; Fax: +33 1 56 01 73 06. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2011.08.011
EUROPEAN UROLOGY 61 (2012) 96–97
screened more systematically in the general context of LUTS. The OI category highlights (even if the number is small) the largely unconsidered issue of gender-related leakage in men that remains poorly investigated. Far from being just descriptive, this study also looked for correlations between incontinence categories and qualityof-life parameters, bother, and consequences. The results point out that compared with other subtypes of urinary incontinence, urge urinary incontinence has a dramatic impact on quality of life by generating stress, intense bother, and a high level of treatment seeking. These findings show, if it was needed, that urgency is a major issue in male urinary incontinence management. I believe this is just another aspect of the common problem of the aging bladder in men, linked to overactive bladder (OAB) and more globally to the issue of storage symptoms in men. This field has gained interest in the past few years, but we are probably just at the beginning of the story for the following reasons: (1) OAB in men is not totally understood in the context of benign prostatic hyperplasia, and the respective role of the bladder and prostate in LUTS are not completely elucidated, (2) gender matters when dealing with OAB symptoms management, and (3) this problem will become an incredible burden in the near future given the aging of the population in Western countries. Thus all new reliable data about this phenomenon must be brought to light and published. Data about women have been more intensively explored in the literature before. However, the comprehensiveness of the study presented by Coyne et al can lead to useful comparisons about the influence of different subtypes of incontinence regarding quality of life and the impact of incontinence on mental health. Because urinary incontinence is truly considered a very frequent phenomenon, further research should be inspired by precisely assessing the symptoms of incontinence in women, since their impact in our patients may be specific—or at least different. If this paper brings significant information and a reliable basis for further investigations, it has the defects of its
97
virtues. As a secondary analysis of the EpiLUTS data set, the picture shown here is not able to make a causality link in the associations exposed. This limitation must be considered for the interpretation of data as mentioned by the authors. This study shows that rigorous and comprehensive clinical evaluation of urinary incontinence is a cornerstone of the diagnosis in functional urology. It underlines that the patient’s voice is always the best element to rely on, even in the fields of epidemiology and public health. At the individual and collective level, urologists must turn this message into action and clinical practice to handle the great challenge of LUTS incontinence management in the growing worldwide aging population. Conflicts of interest: The author has nothing to disclose.
References [1] Schro¨der A, Abrams P, Andersson K-E, et al. Guidelines on urinary incontinence. European Association of Urology Web site. http:// www.uroweb.org/gls/pdf/16_Urinary_Incontinence%202010.pdf. [2] Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 2010;21:5–26. [3] Margalith I, Gillon G, Gordon D. Urinary incontinence in women under 65: quality of life, stress related to incontinence and patterns of seeking health care. Qual Life Res 2004;13:1381–90. [4] International Incontinence Society. World Continence Week-USA, June 20–26, 2011. http://www.worldcontinenceweek-usa.org. [5] Coyne KS, Kvasz M, Ireland AM, Milsom I, Kopp ZS, Chapple CR. Urinary incontinence and its relationship to mental health and health-related quality of life in men and women in Sweden, the United Kingdom, and the United States. Eur Urol 2012;61: 88–95. [6] Jones C, Hill J, Chapple C. Guideline Development Group. Management of lower urinary tract symptoms in men: summary of NICE guidance. BMJ 2010; 340:c2354. DOI:10.1136/bmj.c2354. [7] American Urological Association. Management of BPH (revised, 2010). http://www.auanet.org/content/guidelines-and-qualitycare/clinical-guidelines.cfm?sub=bph.
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 88–95 of this issue
Urinary Incontinence Symptoms Stratification: The Devil Is in the Details Jean-Nicolas Cornu * Department of Urology, Tenon Hospital, Groupe Hospitalo-Universitaire EST, Assistance Publique-Hoˆpitaux de Paris (AP-HP), University Paris VI, 4 rue de la Chine, 75970 Paris Cedex 20, France
Urinary incontinence is seen as a common and frequent health problem in the developed world. An estimated 5–69% of women and 1–39% of men have urinary incontinence to some degree. Although substantial epidemiologic data have been published in recent years, the estimates of the prevalence of urinary incontinence in both genders still vary widely [1]. Following consensual work led by international experts in the field of urology, the characteristics and subtypes of this highly prevalent symptom were defined based on clinical presentation and linked to underlying pathophysiologic mechanisms [2]. The terminology is updated regularly so practitioners worldwide can use a common language and promote innovative patient care in this functional part of urologic practice. From the patient’s point of view, urinary incontinence remains a taboo subject [3], which has prompted information campaigns from scientific societies. Through dedicated events [4], several countries and associations are trying to bring information on incontinence to the public. Academic research in the epidemiology of urinary incontinence has mainly focused on specific patient groups (eg, women, elderly people, patients with comorbid conditions) and has failed to produce an accurate estimate of the prevalence of urinary incontinence. Because of patients’ typical unwillingness to respond openly to so-called validated questionnaires and symptom scores by investigators, current studies do not have enough power to investigate the symptoms in depth in the general population. In the current issue of the Platinum Journal, Coyne et al [5] present a study that overcomes the limitations just described and creates a new picture about the prevalence of urinary incontinence subtypes and their associated patient
characteristics, including considerations about quality of life. Using a Web-based survey, authors were able to overcome patients’ reluctance to talk about their symptoms, and they gathered a powerful data set with a high response rate. To avoid being too suggestive, they did not reduce the descriptions of symptoms to the usual stress urinary incontinence and/or urge urinary incontinence, thus giving patients an opportunity to describe their clinical condition freely. With appropriate support, they also managed to get a multinational representative sample of the adult population. In the male sample, the results that Coyne et al present in their Figure 1 are a bit surprising at first [5]. The statistics presented show a high rate of incontinence in both the male and female samples, but the most important result is probably the proportion of patients in each category. In the men’s sample, the other incontinence (OI) category is the major group, and the usual categories of symptoms (stress urinary incontinence and/or urge urinary incontinence) are cited far less frequently. This result, which represents a new finding, should be considered a landmark in the field of male urinary incontinence. Indeed, postmicturition incontinence, which represents 93% of cases of OI in the study, has never before been highlighted as such a prevalent symptom in men. The relatively reduced impact on quality of life and bother associated with this problem may explain why it has been a hidden aspect of the problem until recently. However, it has to be considered in future investigations on patient care and evaluations of lower urinary tract symptoms (LUTS) in men because it is not part of the currently used evaluation tools [6,7]. In men >50 yr of age, postmicturition incontinence symptoms should be
DOI of original article: 10.1016/j.eururo.2011.07.049 * Tel. +33 1 56 01 64 95; Fax: +33 1 56 01 73 06. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2011.08.011
EUROPEAN UROLOGY 61 (2012) 96–97
screened more systematically in the general context of LUTS. The OI category highlights (even if the number is small) the largely unconsidered issue of gender-related leakage in men that remains poorly investigated. Far from being just descriptive, this study also looked for correlations between incontinence categories and qualityof-life parameters, bother, and consequences. The results point out that compared with other subtypes of urinary incontinence, urge urinary incontinence has a dramatic impact on quality of life by generating stress, intense bother, and a high level of treatment seeking. These findings show, if it was needed, that urgency is a major issue in male urinary incontinence management. I believe this is just another aspect of the common problem of the aging bladder in men, linked to overactive bladder (OAB) and more globally to the issue of storage symptoms in men. This field has gained interest in the past few years, but we are probably just at the beginning of the story for the following reasons: (1) OAB in men is not totally understood in the context of benign prostatic hyperplasia, and the respective role of the bladder and prostate in LUTS are not completely elucidated, (2) gender matters when dealing with OAB symptoms management, and (3) this problem will become an incredible burden in the near future given the aging of the population in Western countries. Thus all new reliable data about this phenomenon must be brought to light and published. Data about women have been more intensively explored in the literature before. However, the comprehensiveness of the study presented by Coyne et al can lead to useful comparisons about the influence of different subtypes of incontinence regarding quality of life and the impact of incontinence on mental health. Because urinary incontinence is truly considered a very frequent phenomenon, further research should be inspired by precisely assessing the symptoms of incontinence in women, since their impact in our patients may be specific—or at least different. If this paper brings significant information and a reliable basis for further investigations, it has the defects of its
97
virtues. As a secondary analysis of the EpiLUTS data set, the picture shown here is not able to make a causality link in the associations exposed. This limitation must be considered for the interpretation of data as mentioned by the authors. This study shows that rigorous and comprehensive clinical evaluation of urinary incontinence is a cornerstone of the diagnosis in functional urology. It underlines that the patient’s voice is always the best element to rely on, even in the fields of epidemiology and public health. At the individual and collective level, urologists must turn this message into action and clinical practice to handle the great challenge of LUTS incontinence management in the growing worldwide aging population. Conflicts of interest: The author has nothing to disclose.
References [1] Schro¨der A, Abrams P, Andersson K-E, et al. Guidelines on urinary incontinence. European Association of Urology Web site. http:// www.uroweb.org/gls/pdf/16_Urinary_Incontinence%202010.pdf. [2] Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 2010;21:5–26. [3] Margalith I, Gillon G, Gordon D. Urinary incontinence in women under 65: quality of life, stress related to incontinence and patterns of seeking health care. Qual Life Res 2004;13:1381–90. [4] International Incontinence Society. World Continence Week-USA, June 20–26, 2011. http://www.worldcontinenceweek-usa.org. [5] Coyne KS, Kvasz M, Ireland AM, Milsom I, Kopp ZS, Chapple CR. Urinary incontinence and its relationship to mental health and health-related quality of life in men and women in Sweden, the United Kingdom, and the United States. Eur Urol 2012;61: 88–95. [6] Jones C, Hill J, Chapple C. Guideline Development Group. Management of lower urinary tract symptoms in men: summary of NICE guidance. BMJ 2010; 340:c2354. DOI:10.1136/bmj.c2354. [7] American Urological Association. Management of BPH (revised, 2010). http://www.auanet.org/content/guidelines-and-qualitycare/clinical-guidelines.cfm?sub=bph.