Bladder management experiences among people living with neurologic disease: A systematic review and meta-synthesis of qualitative research

How Do Surgical Interventions for Neurogenic Lower Urinary Tract Dysfunction Impact Quality of Life?

OBJECTIVE

Adult patients with neurogenic lower urinary tract dysfunction (NLUTD) often have urinary symptoms that impact their quality of life (QOL). Our objective is to identify and summarize studies evaluating QOL changes across different NLUTD surgical interventions.

METHODS

A systematic rapid evidence review was carried using EMBASE and MEDLINE. We included adult patients (> 18 years old) with NLUTD who underwent a relevant surgery and had a measurement of QOL. We included pre-post study designs (primary focus) and cross-sectional studies (secondary focus). Studies were reviewed and data extracted by multiple assessors. Standardized data extraction tables were used, and qualitative synthesis was performed.

RESULTS

Of the 1074 screened articles 26 were included. There were 3/15 studies that evaluated reconstructive surgery (augmentation and/or catheterisable channel) pre-post intervention (n = 94 patients); there was a 7%-28% relative improvement in bladder related and overall QOL using validated questionnaires, and a large magnitude of improvement in studies using unvalidated questionnaires. There were 3/7 studies that looked at urinary diversion pre-post intervention (n = 153 patients) and showed an approximately 20%-60% improvement in validated questionnaires assessing bladder specific quality of life, and 0%-25% improvement in overall quality of life. Finally, 3/4 studies were pre-post stress incontinence surgeries (n = 67 patients) and they found an improvement in the ICIQ questionnaire scores and study-specific questionnaires.

CONCLUSION

The literature supporting a change in QOL in adult NLUTD patients undergoing surgical interventions is extremely limited due to a lack of pre-post studies, and the frequent use of unvalidated outcome measures.

Internal and External Barriers to Bladder Management in Persons with Neurologic Disease Performing Intermittent Catheterization

People living with neurogenic lower urinary tract dysfunction (NLUTD) often have to use clean intermittent catheters (CIC) to manage their bladder function. The use of catheters presents multiple unique challenges, based on both the person's inherent characteristics and on the external limitations imposed by public toilets. We review the impact of age, sex, upper limb function, caregiver assistance, time required to perform CIC, and urinary incontinence on CIC in NLUTD, with special reference to their interaction with societal and public health factors. Public toilet limitations, such as lack of availability, adequate space and special accommodation for CIC, cleanliness, and catheter design are also reviewed. These potential barriers play a significant role in the perception and performance of bladder care in people living with NLUTD.

Factors influencing decisions about neurogenic bladder and bowel surgeries among veterans and civilians with spinal cord injury

OBJECTIVE

This study investigated factors influencing surgical decision-making (DM) to treat neurogenic bladder and bowel (NBB) dysfunction for veterans and civilians with spinal cord injury (SCI) in the United States (US).

DESIGN

Semi-structured interviews complemented by survey measures.

SETTING

Community-dwelling participants who received treatment at a major Midwestern US medical system, a nearby Veterans Affairs (VA) facility, and other VA sites around the US.

PARTICIPANTS

Eighteen participants with SCI who underwent surgeries; completed semi-structured interviews and survey measures.

INTERVENTIONS

Not applicable.

OUTCOMES MEASURES

Semi-structured interviews were coded to reflect factors, DM enactment, and outcomes, including surgery satisfaction and quality of life (QOL). Quantitative measures included COMRADE, Ways of Coping Questionnaire, Bladder and Bowel Treatment Inventory, PROMIS Global Health and Cognitive Abilities scales, and SCI-QOL Bladder and Bowel short form.

RESULTS

Themes identified about factors influencing DM included: recurrent symptoms and complications; balancing dissatisfaction with NBB management against surgery risks; achieving independence and life style adjustments; participant's driven solutions; support and guidance and trust in doctors; and access and barriers to DM. DM enactment varied across surgeries and individuals, revealing no clear patterns. Most participants were satisfied with the surgery outcomes. Some differences in demographics were observed between veterans and civilians.

CONCLUSIONS

We have attempted to illustrate the process of NBB DM as individuals move from factors to enactment to outcomes. Attending to the complexity of the DM process through careful listening and clear communication will allow clinicians to better assist patients in making surgical decisions about NBB management.

The relationship between severity of overactive bladder symptoms and cognitive dysfunction, anxiety and depression in female patients with multiple sclerosis: Running head: OAB-V8, BICAMS and HAD scale in MS

BACKGROUND

Overactive bladder (OAB), cognitive dysfunction, depression and anxiety are common problems encountered in MS. This study was planned to investigate the relationship between the severity of OAB symptoms and cognitive function, anxiety and depression in MS.

METHODS

100 patients with MS diagnosis with OAB symptoms were recruited. OAB symptoms was assessed with the OAB-V8 questionnaire. Symbol Digit Modalites Test (SDMT), California Verbal Learning Test II (CVLT-II) and Brief Vasospatial Memory Test-Revised (BVMT-R) in BICAMS Battery were used to evaluate cognitive function. Depression and anxiety were assessed with the Hospital Anxiety Depression (HAD) Scale.

RESULTS

The mean age of the patients was 40.9±12.3, the duration of the disease was 9.03±6.89 years, and the mean OAB-V8 score was 17.6±8.9. SDMT test (r=-0.299, p<0.01) showed a moderately significant, CVLT-II (r= -0.219, p<0.05) and BVMT-R (r=-0.218, p<0.05) tests showed a weakly significant negative correlation with OAB-V8 score. There was a moderate positive correlation between the OAB-V8 score and HAD-D (r=0.279, p=0.005) and HAD-A (r=0.318, p=0.001) scores. SDMT and BVMT-R scores were significantly lower in anticholinergic (Ach) drug users (especially oxybutynin users) compared to those who did not use Ach drugs.

CONCLUSIONS

It has been observed that the severity of OAB symptoms is related to worsening of information processing speed and an increase in depression and anxiety. It has been determined that there is a significant effect on information processing speed, visual learning and memory in patients using Ach drugs, especially in those using oxybutynin, compared to those who do not use Ach drugs.

Variation in Provider Practice Patterns and the Perceived Need for a Shared Decision-making Tool for Neurogenic Lower Urinary Tract Dysfunction

OBJECTIVE

To evaluate neurogenic lower urinary tract dysfunction (NLUTD) care providers' current practice patterns, their perceived need for a shared decision-making tool for NLUTD management.

METHODS

We developed an electronic survey to assess multiple factors surrounding NLUTD management including practice patterns, perceived need for a decision aid and willingness to use it. Prior to survey dissemination, a panel of expert NLUTD care providers reviewed and provided a critique of the survey. It was delivered via email to the members of the Genitourinary Reconstructive Surgeons, and the Society of Urodynamics, female pelvic medicine and urogenital reconstruction between March and May 2022.

RESULTS

A total of 117 NLUTD care providers from 11 countries participated in this survey. Most participants were urologists (n: 109, 93%) working at academic teaching hospitals (n: 82, 70%). The most common treatments the providers had provided for stress urinary incontinence and detrusor overactivity were sling procedures (n: 76, 65%) and anticholinergics (n: 111, 95%). Participants believed that NLUTD management can be highly patient-specific and extensively vary from one individual to another. Most participants believed that patients performing clean intermittent catheterization have better QoL compared to those utilizing indwelling urinary catheters (n: 81, 69%). Participants believed there is a need for a NLUTD decision aid, and they expressed their willingness to use one if available.

CONCLUSION

We found discordances between guideline recommendations, provider practice patterns, and patient-reported outcome measures and essential attributes that indicated the need for a decision aid to improve patient-provider communication and shared decision-making in NLUTD management.

General and bladder-related quality of life: A focus on women living with spinal cord injury

OBJECTIVE

To compare bladder symptoms, and urinary and overall quality of life (QOL) among women and men after Spinal cord injury (SCI), and to describe specific aspects of QOL among women with SCI.

METHODS

We used data from a prospective, multi-center, and cross-sectional study that was carried out from May 2019 to September 2020. Clinical and demographic details were obtained and participants completed two patient reported outcomes: the neurogenic bladder symptoms score-short form (NBSS-SF, which measures bladder symptoms and QOL) and the SF-12 (which measures overall physical and mental health QOL).

RESULTS

Our cohort included 135 women and 210 men with SCI. Among the women, the median age was 50, and 40% had a cervical SCI. For general QOL, women with SCI had physical functioning scores similar to men, but lower mental health scores on the SF-12 (46.85 vs. 49.76, p = 0.01). Women had significantly worse overall NBSS (10.76 vs. 9.08, p < 0.001) and NBSS continence domain scores (4.71 vs. 3.66, p < 0.001) compared to men. There were significant differences between overall QOL measures, and bladder symptoms based on bladder management techniques among the women. NBSS-SF symptom scores were better among women who used overactive bladder medications compared to women who did not (8.43 vs. 11.9, p = 0.02) and NBSS-SF QOL domain scores were significantly better among women who underwent surgery and those that used overactive bladder medications.

CONCLUSIONS

Women have more bladder symptoms (specifically incontinence) compared to men. Symptom burden and overall QOL vary among women who use different bladder management techniques and treatments.

Results of the patient report of intermittent catheterization experience (PRICE) study

AIMS

Patient satisfaction is paramount to health-related quality of life (HR-QoL) outcomes. High quality, quantitative data from the US describing patients' actual experiences, difficulties, and HR-QoL while on an intermittent self-catheterization (ISC) regimen is very scarce. Our objective was to better understand patient practices with and attitudes towards ISC.

METHODS

This is a cross-sectional, multi-centered, clinical study of adult men and women performing ISC in the United States. Data collected included demographics, medical history, catheter characteristics, specific self-catheterization habits and two validated HR-QoL questionnaires: The Intermittent Self-Catheterization Questionnaire (ISC-Q) and the Intermittent Catheterization Difficulty Questionnaire (ICDQ).

RESULTS

Two hundred participants were recruited from six sites; 70.0% were male, 73.5% were Caucasian with a median age was 51.0 years (range 19-90 years). The ISC-Q showed that the vast majority of participants reported ease with ISC (82.0% satisfaction score) had confidence in their ability to perform ISC (91.9% satisfaction score); yet, many felt self-conscious about doing so (58.3% satisfaction score) and had concerns about long-term adverse effects (58.1% satisfaction score). The ICDQ indicated little to no difficulty for most participants with all routine ISC practices. A small minority of participants reported some difficulty with a "blocking sensation" during initiation of catheterization, leg spasticity, and painful catheterization. Multivariate linear regression results are also reported.

DISCUSSION/CONCLUSION

Participants are confident with ISC and have little overall difficulty, which may be a product of successful education and/or catheter design. urinary tract infections (UTIs) were common (yet variable) and may contribute to the noted long-term ISC concerns. Limitations exist including various selection biases leading to concerns of external validity. Future educational interventions in this population may further improve HR-QoL, optimize UTIs prevention, and diminish concerns with long-term ISC.

Using conjoint analysis to measure the importance of psychosocial traits in the choices of bladder management after spinal cord injury

OBJECTIVE

To conduct a conjoint analysis experiment to better understand the psychosocial priorities related to bladder management in individuals after spinal cord injury (SCI).

METHODS

We developed a conjoint analysis survey that included 11 psychosocial attributes phrased in the context of bladder management (including attributes for urinary infections, and incontinence). We then performed a multi-center prospective cross-sectional study of adults with existing SCI which consisted of a baseline interview, followed by the online conjoint analysis survey (delivered through Sawtooth software). Hierarchical Bayes random effects regression analysis was used to determine the relative importance of the attributes.

RESULTS

A total of 345 people complete the study. There was good representation of both men and women, and individuals with cervical and thoracic or lower lesions. The most important attribute was the frequency of urinary infections. Age, sex, and level of SCI were generally not related to the attributes measured in the study. In the subgroup of 256 patients who used a catheter for bladder management, significantly more importance was placed on urinary tract infections, time, fluid intake, and social life among indwelling catheter users compared to intermittent catheter users.

CONCLUSIONS

Most bladder-related psychosocial priorities are not impacted by a patient's age, sex or level of SCI. Differences in psychosocial priorities between indwelling and intermittent catheter users may represent factors that should be focused on to optimize bladder management after SCI.

Management strategies for neurogenic lower urinary tract dysfunction: a qualitative study of the experiences of people with multiple sclerosis and healthcare professionals

PURPOSE

Urinary symptoms are highly prevalent among people with MS. This study aimed to explore the experiences of people with MS and HCPs in managing urinary symptoms and explore their views on using TTNS to treat urinary symptoms.

MATERIALS AND METHODS

Audio-recorded semi-structured, interviews were employed with people with MS and HCPs. All transcribed interviews were exported to NVivo software (Version 12) and analyzed using a reflexive approach to thematic analysis.

RESULTS

Four main themes were identified; The wide-ranging negative impacts of urinary symptoms ("It's limited everything else"), Gaps in urinary services ("Is there somebody like that, sort of specialized in that area?"), Management strategies ("I don't go too far from the toilet in case I need to use one"), and optimism about TTNS ("Are you giving Me Hope?").

CONCLUSION

Urinary symptoms are common and very troublesome for people with MS. Despite their prevalence, many people with MS continue to suffer in silence. People with MS require skilled multidisciplinary services guided by clinical care pathways to improve service provision and to address urinary symptoms. HCP's and people with MS are open to the use of TTNS for urinary symptoms and have clear preferences for location and duration of intervention delivery.Implications for rehabilitationUrinary symptoms are very common and troublesome for people with multiple sclerosis, yet many continue to suffer in silence.People with multiple sclerosis lack knowledge about treatment options for urinary symptoms.There is an on-going need for healthcare provider education on guidelines for screening and managing urinary symptoms in people with MS and the role of specialist urinary service providers.HCP's and people with MS are open to the use of TTNS for urinary symptoms.