Practical aspects of lifestyle modifications and behavioural interventions in the treatment of overactive bladder and urgency urinary incontinence

Prevalence, associated factors, and relationship to quality of life of lower urinary tract symptoms: a cross-sectional, questionnaire survey of cancer patients

BACKGROUND

Few studies conducted outside of Asia have shown that lower urinary tract symptoms (LUTS) could be a concern for cancer patients. This gap necessitates more research on LUTS among cancer patients in Asia, particularly regarding associated factors and the relationship between quality of life and LUTS.

OBJECTIVES

This study investigates the prevalence, associated factors, and relationship to quality of life of LUTS based on a sample of cancer patients.

DESIGN

A cross-sectional, questionnaire survey.

SETTINGS/PARTICIPANTS

This study was conducted at two oncology outpatient departments in two hospitals in Taiwan, and included 134 Asian cancer patients.

METHODS

We collected information about each participant's individual characteristics, personal habits, LUTS, and quality of life by using a questionnaire. We calculated descriptive statistics to demonstrate the distribution of collected information, and used multivariate logistic regression to identify the factors associated with LUTS. We used Student's t-test to compare the mean quality of life scores for participants with and without LUTS.

RESULTS

Ninety-nine (73.9%) participants experienced at least one type of LUTS, and the prevalence rates for various types of LUTS ranged from 3.7% to 52.2%. Radiotherapy and the time since the diagnosis of cancer were associated with LUTS. Participants with LUTS reported lower quality of life scores than participants without LUTS.

CONCLUSIONS

The high prevalence of LUTS suggests that cancer treatment might be linked to LUTS, which in turn has a negative effect on a patient's quality of life. These results suggest that future research should involve studies in larger, more homogeneous samples. Health care providers should monitor the presence of LUTS and deliver the management and treatments of LUTS to optimise cancer patients' quality of life.

Impact of behaviour and lifestyle on bladder health

Bladder conditions, including UTI, UI, and bladder cancer, are highly prevalent and affect a wide range of populations. There are a variety of modifiable behavioral and lifestyle factors that influence bladder health. Some factors, such as smoking and obesity, increase the risk or severity of bladder conditions, whereas other factors, such as pelvic floor muscle exercise, are protective. Although clinical practice may be assumed to be the most appropriate ground for education on behavioral and lifestyle factors that influence bladder health, it is also crucial to extend these messages into the general population through public health interventions to reach those who have not yet developed bladder conditions and to maximize the prevention impact of these behaviors. Appropriate changes in these factors have the potential for an enormous impact on bladder health if implemented on a population-based level.

The use of botulinum toxin for the treatment of overactive bladder syndrome

Over the last 50 years, botulinum toxin has been transformed from a cause of life-threatening disease to an effective medical therapy. It has been used in a variety of specialties for different indications, significantly improving patient quality of life. A recent growing body of evidence suggests that intra-detrusor injection of botulinum toxin may have beneficial effects in patients with medication refractory detrusor overactivity and may offer a new minimally invasive alternative to patients with severe overactive bladder symptoms. To review current data regarding the effects of botulinum toxin in patients with overactive bladder, a MEDLINE^®/PubMed^® literature search was carried out. The mechanism of action, clinical usage, adverse effects, and treatment efficacy were reviewed and the results are presented in this paper.

Identifying urinary incontinence in the home setting: part 1-assessment, diagnosis, and strategies to treat incontinence

Urinary incontinence is a prevalent but difficult dysfunction for many older adults. Living with urinary incontinence can have a profound impact on one's quality of life. The purpose of this case study and article is to identify and describe treatment techniques used to treat urinary incontinence.

Short-term Effects of a Systematized Bladder Training Program for Idiopathic Overactive Bladder: A Prospective Study

PURPOSE

This study was to investigate whether a systematized bladder training (BT) program is effective for patients with idiopathic overactive bladder (OAB).

METHODS

A prospective study was conducted on 105 patients with OAB from March 2009 to November 2011. We developed a 30 minutes BT program, which consisted of first, refraining from going to the bathroom after feeling an urge to void, second, in order to stop thinking about voiding, ceasing action and thought temporarily, and third, performing pelvic floor exercises 5 to 6 times. Before and after BT, the patients filled out voiding diaries as well as the following questionnaires; International Consultation on Incontinence Questionnaire for overactive bladder (ICIQ-OAB), International Prostate Symptom Score (IPSS), overactive bladder questionnaire (OAB-q), the short form 36-item health survey (SF-36) questionnaire, the work productivity and activity impairment questionnaire, and a patients' perception of treatment benefit (PPTB).

RESULTS

A final analysis was performed from on 85 patients (38 male, 47 female) with idiopathic OAB. After the first BT, the results of the ICIQ-OAB showed improvement in frequency, nocturia, and urgency (P<0.05), and all domains of IPSS questionnaires showed significant improvement (P<0.05). Among the SF-36 domains, the role-physical domain showed significant improvement after the first BT, and the general health domain showed significant improvement after the second. The voiding diaries showed statistically significant changes in maximal voided volume after the first BT, and nocturia index and nocturnal polyuria index after the second BT. According to the PPTB questionnaire, the perceived usefulness of BT increased after each session, and almost all of the patients replied that BT improved their symptoms.

CONCLUSIONS

Our results demonstrated that BT was effective in improving many OAB related symptoms and quality of life in patients with idiopathic OAB. More clinical application of BT could be implemented in the future.

Caffeine intake and risk of urinary incontinence progression among women

OBJECTIVE

To estimate the association between long-term caffeine intake and risk of urinary incontinence (UI) progression over 2 years among women with moderate UI.

METHODS

We conducted a prospective cohort study in 21,564 women with moderate UI enrolled in the Nurses' Health Study and Nurses' Health Study II. Incontinence progression was identified from questionnaires during 2 years of follow-up. Baseline caffeine intake (ie, average intake during the previous year) and change in caffeine intake during the 4 years before baseline were measured using food frequency questionnaires. Odds ratios (ORs) for incontinence progression according to caffeine intake were calculated for each cohort separately, and then for both cohorts combined.

RESULTS

The percentage of women with UI progression was similar across categories of baseline level of caffeine intake and change in caffeine intake before baseline. For example, percentages were 21% compared with 22% comparing 450 mg or more to less than 150 mg of caffeine per day (adjusted OR 0.87, 95% confidence interval 0.70-1.08). Comparing women with increased caffeine intake to those with stable caffeine intake, percentages with progression were 22% compared with 20% (OR 1.08, 95% confidence interval 0.95-1.22). Results were similar in separate analyses of urge and stress UI.

CONCLUSION

Long-term caffeine intake over 1 year was not associated with risk of UI progression over 2 years among women with moderate incontinence, although we could not examine acute effects of caffeine. Improved understanding of the effect of caffeine on the bladder is needed to better-advise women with incontinence about caffeine intake.

LEVEL OF EVIDENCE

II.

Severe Pelvic Floor Symptoms After Cervical Cancer Treatment Are Predominantly Associated With Mental and Physical Well-Being and Body Image: A Cross-Sectional Study

Objective

To identify associations between demographic, disease-related, and psychological variables and severe distress from pelvic floor symptoms (PFSs) after cervical cancer treatment.

Methods

This study was cross-sectional and questionnaire based. We included patients with cervical cancer treated between 1997 and 2007 in the Academic Medical Center, Amsterdam. Pelvic floor symptoms were assessed with urogenital distress inventory and defecatory distress inventory. Scores were dichotomized into severe (>90th percentile) versus nonsevere distress. Disease-related variables were extracted from medical files. Psychological factors included mental and physical well-being, optimism, and body image, which were assessed with standardized questionnaires. Univariate and multivariate logistic regression analyses were performed.

Results

A total of 282 patients were included: 148 were treated with radical hysterectomy and pelvic lymph node dissection, 61 patients were treated with surgery and adjuvant radiotherapy, and 73 patients were treated with primary radiotherapy. Demographic: Multivariate analyses showed no significant relation between demographic variables and symptoms. Disease-related: None of these variables were significantly associated in multivariate analyses. Psychosocial: In all treatment groups, multivariate associations were found. In general, better mental and physical well-being was associated with nonsevere PFSs. Increased body image disturbance was associated with severe defecation symptoms.

Conclusions

Few associations were found between demographic and disease-related variables and distress from PFS after cervical cancer treatment. However, better mental and physical well-being is associated with nonsevere distress from urogenital and defecation symptoms and more body image disturbance with severe PFSs. Improving these factors might reduce distress from PFSs and should be a focus of future research.

Patient-reported outcomes and different approaches to urinary parameters in overactive bladder: what should we measure?

Overactive bladder (OAB) is highly prevalent and associated with considerable impact on patient health-related quality of life (HRQoL). Assessment of HRQoL can reveal the burden of disease and post-intervention improvement. This review aims to highlight the importance of HRQoL assessment and outline the tools available for use in clinical trials and real-world clinical practice. A number of validated measures of HRQoL specific to OAB have been developed, offering greater sensitivity and responsiveness over generic instruments. These condition-specific, multi-dimensional and single-item global questionnaires are particularly useful for the multiple and varied symptoms of OAB, as they reflect the patient's needs, concerns and values. Measurements for lower urinary tract symptoms, e.g. bladder diaries, are being compared with HRQoL instruments to provide greater understanding of the disease and treatment from the patient's perspective. Therapeutic interventions to improve OAB symptoms should also be evaluated for their effect on the patient's HRQoL.

A healthy bladder: a consensus statement

A panel of experts in urology, urogynecology, nursing, and behavioral therapy convened in 2010 to discuss the importance of a healthy bladder on overall health. They determined that a consensus statement was necessary to raise awareness among the general public, healthcare providers, payors, and policymakers, with the goals of minimizing the impact of poor bladder health and stimulating primary prevention of bladder conditions. In this statement, 'healthy' bladder function is described, as well as internal and external factors that influence bladder health. It is suggested that primary prevention strategies should be aimed at providing education regarding normal lower urinary tract structures and functioning to the public, including patients and healthcare providers. This education may promote the achievement of optimal bladder health by increasing healthy bladder habits and behaviors, awareness of risk factors, healthcare seeking, and clinician engagement and reducing stigma and other barriers to treatment. Promoting optimal bladder health may reduce the personal, societal and economic impact of bladder conditions, including anxiety and depression and costs associated with conditions or diseases and their treatment. While adopting healthy bladder habits and behaviors and behaviors may improve or maintain bladder health, it is important to recognize that certain symptoms may indicate the presence of conditions that require medical attention; many bladder conditions are treatable with a range of options for most bladder conditions. Lastly, the authors propose clinical directives based on persuasive and convergent research to improve and maintain bladder health. The authors hope that this statement will lead to promotion and achievement of optimal bladder health, which may improve overall health and help minimize the effects of bladder conditions on the public, healthcare professionals, educators, employers, and payors. The advisors are in consensus regarding the recommendations for improving and maintaining bladder health presented herein.

Understanding stress urinary incontinence

Underreported and undertreated, stress urinary incontinence leads to decreased quality of life in sufferers and financial burdens for both the patient and the healthcare industry. Nurse practitioners should understand their role in identifying, diagnosing, and treating the condition.

Fluid intake and risk of stress, urgency, and mixed urinary incontinence

OBJECTIVE

We investigated the relation between total fluid intake and incident urinary incontinence in the Nurses' Health Study cohorts.

STUDY DESIGN

We measured daily fluid intake using food frequency questionnaires among 65,167 women, who were 37-79 years old, without urinary incontinence at study baseline (2000-2001). Women reported incontinence incidence on questionnaires during 4 years of follow-up evaluation. Multivariable-adjusted hazard ratios and 95% confidence intervals were calculated with Cox proportional hazards models.

RESULTS

We found no association between total fluid intake and risk of incident incontinence (hazard ratio, 1.04; 95% confidence interval, 0.98-1.10; comparing top vs bottom quintile of fluid intake). In analyses of incontinence type, total fluid intake was not associated with risks of incident stress, urgency, or mixed incontinence.

CONCLUSION

No significant risk of incident urinary incontinence was found with higher fluid intake in women. These findings suggest that women should not restrict their fluid intake to prevent incontinence development.

Prevalence and effect on health-related quality of life of overactive bladder in older americans: results from the epidemiology of lower urinary tract symptoms study

OBJECTIVE

To evaluate the prevalence and effect of overactive bladder (OAB) on healthcare-seeking behavior, mental health, and generic and condition-specific health-related quality of life (HRQL) in older adults.

DESIGN

Secondary analysis of the U.S. sample of the Epidemiology of Lower Urinary Tract Symptoms (EpiLUTS) study-a population-based, cross-sectional, Internet-based survey.

SETTING

Community.

PARTICIPANTS

Two thousand four hundred eighty-five men and 2,877 women aged 65 and older.

MEASUREMENTS

Prevalence and effect on HRQL of urinary symptoms, including OAB. OAB was defined as the presence of urinary urgency and/or urinary urgency incontinence. Descriptive analyses and subgroup comparisons were conducted to evaluate the prevalence of OAB in men and women aged 65 and older and the effect of OAB on various aspects of HRQL.

RESULTS

The survey response rate was 46.9% of men and 61.0% of women. Prevalence rates of OAB at least "sometimes" were 40.4% in men and 46.9% in women. OAB was associated with significant impairments across all domains of patient-reported outcomes, including general HRQL (Medical Outcomes Study 12-item Short-Form Survey), ratings of anxiety and depression (Hospital Anxiety and Depression Scale), and urinary condition-specific outcomes (Overactive Bladder Questionnaire Short Form and Patient Perception of Bladder Condition) (P<.001).

CONCLUSION

OAB is common in older adults in the United States and is associated with substantial impairment in mental health and HRQL, but rates of treatment seeking behavior are low. Older patients should be assessed for OAB.

Exercise improves bladder function in diabetic mice

AIMS

We determined the effect of exercise on bladder dysfunction and voiding frequency in db/db mice.

MATERIALS AND METHODS

Diabetic db/db female mice (BKS.Cg-Dock7m +/+ Leprdb/J strain) and their age-matched wild-type controls (WT) were equally divided into sedentary and exercise groups. Mice were exercised for 1 hr everyday for 8 weeks (speed of 5.2 m/min). We performed a voiding pattern test, cystometric analysis and reactivity of isolated bladder strips in WT and db/db mice, both sedentary and exercised.

RESULTS

Diabetes increased the frequency of voiding, bladder capacity, and residual volume. Exercise decreased voiding frequency in db/db mice; voiding frequency was 5.8 ± 0.5 (db/db exercise) versus 10.8 ± 1.1 (db/db control, P < 0.001). In cystometric analysis, the bladder capacity of db/db sedentary mice was 0.27 ± 0.05 ml and was 0.14 ± 0.02 ml in the db/db exercise group (P < 0.05), whereas the residual volume was 0.2 ± 0.03 ml in db/db sedentary mice and 0.06 ± 0.02 ml in db/db Ex mice. Isolated strips of bladder muscle from sedentary db/db mice were more responsive to carbachol than strips from db/db exercise mice. Exercise did not improve the urodynamic properties of WT mice, both sedentary and exercised.

CONCLUSIONS

Exercise improves bladder function in diabetic mice by reducing voiding frequency and improving urodynamic parameters.

Do gender, age or lifestyle factors affect responses to antimuscarinic treatment in overactive bladder patients?

AIMS

Gender, age, obesity, smoking and alcohol or caffeine intake have been shown or proposed to be risk factors for the prevalence and/or severity of the overactive bladder symptom complex (OAB) or related parameters. We have explored whether any of these factors affect the therapeutic response to a muscarinic receptor antagonist during routine clinical use.

METHODS

Data were analysed from 3766 OAB patients (77.1% woman, age 62.6 +/- 12.8 years) participating in an observational, open-label postmarketing surveillance study of the safety and efficacy of darifenacin. Multiple logistic regression models were applied to explore the effect of potential OAB risk factors on the darifenacin treatment-associated improvement of OAB symptoms, patient's subjective rating of bladder problems and global efficacy and tolerability.

RESULTS

Age and (less consistently) gender were statistically significantly correlated with efficacy parameters, but the extent of their impact was judged to be too small to be clinically relevant. Except for a very small effect of body mass index on urgency episode improvement, none of the lifestyle-associated factors had significant effects on the efficacy of darifenacin. Except for a very small age effect, none of the potential risk factors had significant effects on global tolerability.

DISCUSSION AND CONCLUSIONS

We conclude that the efficacy and tolerability of a muscarinic receptor antagonist, such as darifenacin is largely independent of potential OAB risk factors, such as gender, age, obesity, smoking and alcohol or caffeine intake.

Dynamic progression of overactive bladder and urinary incontinence symptoms: a systematic review

CONTEXT

Overactive bladder (OAB) and urinary incontinence (UI) are worldwide public health problems. Longitudinal epidemiologic studies that assess the natural history of OAB and UI are valuable in making accurate prognoses, determining causes and consequences, and predicting resource utilization.

OBJECTIVE

Our aim was to assess whether the severity of OAB and UI symptoms progress dynamically over time, with the secondary aim of assessing factors that may be associated with symptom progression and regression.

EVIDENCE ACQUISITION

A systematic review of English articles published between January 1, 1990, and September 20, 2009, was conducted using PubMed and Embase. Search terms included longitudinal, natural history, overactive bladder, incontinence, progression, remission, and regression. Eligibility was assessed by Dr. Irwin with editorial assistance. Studies were required to be longitudinal and population based; meeting abstracts and conference proceedings were excluded. Results were assessed qualitatively.

EVIDENCE SYNTHESIS

Overall, the 7 longitudinal studies of OAB and 14 longitudinal studies of UI reviewed reported an increase in the incidence and remission/regression of both OAB and UI symptoms over time that varied across studies (eg, OAB incidence, 3.7-8.8%; UI incidence, 0.8-19%). The studies provide evidence for a dynamic progression of OAB and UI symptoms (eg, among women with OAB without urge urinary incontinence [UUI], 28% reported OAB with UUI 16 yr later) and also show that although symptom severity progresses dynamically, for many individuals symptoms also persist over long time periods.

CONCLUSIONS

The results support the hypothesis that OAB and UI symptom severity progress dynamically and are also sustained over time. However, the variations in symptom definitions and methods used across studies prevent statistical determinations of overall incidence rates. The recognition of OAB and UI as progressive conditions allows for a shift from the current treatment paradigm of symptom control alone to one of symptom management.

Efficacy of fesoterodine over 24 hours in subjects with overactive bladder

OBJECTIVE

Fesoterodine is an antimuscarinic agent indicated for the treatment of overactive bladder (OAB) symptoms. The objective of this study was to evaluate the efficacy of fesoterodine versus placebo over selected intervals during a 24-hour period in subjects with OAB.

RESEARCH DESIGN AND METHODS

In a post hoc analysis, data were analyzed from two randomized, double-blind, placebo-controlled 12-week phase III trials in which subjects with a history of OAB symptoms for >or=6 months were treated with morning doses of fesoterodine 4 mg, fesoterodine 8 mg, or placebo.

CLINICAL TRIAL REGISTRATION

These trials are registered at ClinicalTrials.gov (NCT00220363 and NCT00138723).

MAIN OUTCOME MEASURES

Changes were evaluated in number of micturitions, urgency episodes, urgency urinary incontinence (UUI) episodes, and mean voided volume (MVV) divided into three 8-hour intervals: 08:00-15:59 (daytime), 16:00-23:59 (evening), and 00:00-07:59 (nighttime). Comparisons with placebo were made using analysis of covariance (for least squares mean changes) and Wilcoxon rank sum test (for median percent changes); differences were considered significant at p < 0.05.

RESULTS

Data from 1674 subjects, 80% of whom were women, were included in the analysis. At the end of treatment, the least squares mean change from baseline for all efficacy endpoints was significantly greater with fesoterodine 4 mg and fesoterodine 8 mg compared with placebo during each 8-hour time interval (all p < 0.05). Median percent change in number of micturitions, urgency episodes, and UUI episodes also was significantly greater with both fesoterodine doses compared with placebo during all time intervals (all p < 0.05).

CONCLUSIONS

Fesoterodine 4 mg and 8 mg given once daily demonstrated efficacy over placebo for OAB symptoms during all three 8-hour intervals of a 24-hour period, thus providing clinical support for once-daily dosing. Limitations include that this was a post hoc analysis.

Overactive Bladder: Diagnosis and Treatment

Overactive bladder syndrome is a chronic condition that requires long-term management and is associated with a significant impairment in the quality of life of the individual as well as having an economic impact on healthcare. Behavioral interventions, along with lifestyle modifications, are effective, but medical management remains the mainstay of treatment. Challenges to improving the overactive bladder syndrome burden and outcomes include underdiagnosis, undertreatment and patient nonadherence to medication. Recent pharmacological advances, along with behavioral interventions, have helped to improve patient compliance. Healthcare providers should acknowledge the need for education regarding overactive bladder syndrome symptoms, its diagnosis and its management options. This article gives an overview of overactive bladder syndrome, its diagnosis and the different treatment options available, as well as discussing recent advances in the field.

Predictors of discontinuing overactive bladder medications

OBJECTIVE

To identify predictors of self-reported discontinuation of overactive bladder (OAB) medication using a three-phase survey.

PATIENTS AND METHODS

In January 2005, a phase 1 survey was sent to 260 000 households in the USA to assess the prevalence of OAB symptom bother, treatment patterns and healthcare consulting behaviour. In July 2005, a detailed phase 2 follow-up survey was sent to 6577 phase 1 respondents who had used one or more OAB medications within the 12 months before phase 1; the phase 2 survey included questions about respondents' sociodemographic characteristics, general health status, OAB symptom bother, healthcare consulting behaviour, beliefs about OAB and treatment options, and medication usage. Six months later, a phase 3 survey was sent to 3387 phase-2 respondents who were persistent with OAB medication or had discontinued within <18 months of phase 2; the phase 3 survey measured the same variables as phase 2. Only phase 3 respondents who were persistent with OAB medication at phase 2 were included in the analyses reported here. Assessed were the proportions of respondents who were still persistent with OAB medication at phase 3 and who discontinued OAB medication between phases 2 and 3. The variables measured during the phase 2 survey were screened as potential predictors of discontinuation at phase 3 using univariate analysis and then assessed using multivariate logistic regression.

RESULTS

Among 2838 respondents at phase 3 (84% response rate), 1194 had recently discontinued and 1644 were persistent with medication at phase 2. Among phase-3 respondents who were persistent at phase 2, 1040 (66%) continued to be persistent at phase 3, 280 (18%) had discontinued between phases 2 and 3, and 261 (17%) had switched medication between phases 2 and 3; 63 respondents had missing prescription information at phase 3. Predictors of discontinuing at phase 3 included smoking (odds ratio 1.80; 95% confidence interval 1.15-2.83; P = 0.010), not knowing whether treating bladder problems requires multiple daily doses of medication (1.71, 1.10-2.67; P = 0.018), believing (2.11, 1.34-3.33; P = 0.001) or not knowing (1.76, 1.23-2.52; P = 0.002) whether adverse effects of OAB medications are often severe, and being bothered 'quite a bit or more' by a sudden urge to urinate (1.54, 1.05-2.26; P = 0.028). Respondents taking two or more medications were less likely to discontinue (odds ratio 0.45-0.58; P < 0.05).

CONCLUSION

Persistence with OAB medications might be improved by addressing predictors of discontinuation in the management of OAB, by proactively informing patients about the severity of antimuscarinic adverse effects, and dosing regimens. Bother associated with the key OAB symptom, urgency, is a predictor of discontinuation of treatment.