Systematic review and evaluation of methods of assessing urinary incontinence

OBJECTIVES

To identify and synthesise studies of diagnostic processes of urinary incontinence and to construct an economic model to examine the cost-effectiveness of simple, commonly used primary care tests.

DATA SOURCES

The electronic databases MEDLINE (1966--2002), CINAHL (1982--2002) and EMBASE (1980--2002).

REVIEW METHODS

Studies were selected and assessed using the Quality Assessment of Diagnostic Studies (QUADAS) tool. Studies that reported the results of applying the same diagnostic procedure using the same threshold value (cut-off) were pooled using a random effects meta-analysis model to produce pooled estimates of sensitivity, specificity and diagnostic odds ratio together with 95% confidence intervals.

RESULTS

In total, 6009 papers were identified from the literature search, of which 129 were deemed relevant for inclusion in the review, and these papers compared two or more diagnostic techniques. The gold-standard diagnostic test for urinary incontinence with which each reference test was compared was multichannel urodynamics. In general, reporting in the primary studies was poor; there was a lack of literature in the key clinical areas and minimal literature dealing with diagnosis in men. Only a limited number of studies could be combined or synthesised, providing the following results when compared with multichannel urodynamics. A clinical history for diagnosing urodynamic stress incontinence (USI) in women was found to have a sensitivity of 0.92 and specificity of 0.56 and for detrusor overactivity (DO) a sensitivity of 0.61 and specificity of 0.87. For validated scales, question 3 of the Urogenital Distress Inventory was found to have a sensitivity of 0.88 and specificity of 0.60. Seven studies compared a pad test with multichannel urodynamics; however, four different pad tests were studied and therefore it was difficult to draw any conclusions about diagnostic accuracy. Of the four studies comparing urinary diary with multichannel urodynamics, only one presented data in a format that allowed sensitivity and specificity to be calculated. Their reported values of 0.88 and 0.83 suggest that a urinary diary may be effective in the diagnosis of DO in women. Examination of the incremental cost-effectiveness of three primary care tests used in addition to history found that the diary had the lowest cost-effectiveness ratio of between pound 35 and pound 77 per extra unit of effectiveness (or case diagnosed). Imaging by ultrasound to determine leakage was found to be effective in the diagnosis of USI in women, with a sensitivity of 0.94 and specificity of 0.83.

CONCLUSIONS

This is the first systematic review of methods for diagnosing urinary incontinence. As reporting of the primary studies was poor, clinical interpretation was often difficult because few studies could be synthesised and conclusions made. The report found that a large proportion of women with USI can be correctly diagnosed in primary care from clinical history alone. On the basis of diagnosis the diary appears to be the most cost-effective of the three primary care tests (diary, pad test and validated scales) used in addition to clinical history. Ultrasound imaging may offer a valuable alternative to urodynamic investigation. The clinical stress test is effective in the diagnosis of USI. Adaptation of such a test so that it could be performed in primary care with a naturally filled bladder may prove clinically useful. If a patient is to undergo an invasive urodynamic procedure, multichannel urodynamics is likely to give the most accurate result in a secondary care setting. There is a dearth of literature on the diagnosis of urinary incontinence in men, with no studies meeting the study criteria for data extraction in the diagnosis of bladder outlet obstruction. There is a need for large-scale, high-quality primary studies evaluating the use of a number of diagnostic methods in a primary care setting to be undertaken so that the results of this systematic review can be verified or not. Such studies should include not only an assessment of clinical effectiveness, in this case diagnostic accuracy, but also an assessment of costs and quality of life/satisfaction to inform future health policy decisions. Studies carried out should be reported to a better standard. The recommendations of the Standards for Reporting Diagnostic Accuracy (STARD) initiative should be followed to ensure the accuracy and completeness of reporting design and results.

Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence

AIMS

To evaluate the performance of all tests proposed for the diagnosis of urinary incontinence.

METHODS

A systematic review and meta-analyses of the published literature of methods for diagnostic assessment of urinary incontinence.

RESULTS

One hundred twenty-one papers were included in the full review [Martin et al., 2006]. The quality of reporting in the primary studies was poor which reduced the number of studies that could be included in the data analysis. The literature suggests that women with urodynamic stress incontinence (USI) can be correctly identified in primary care from clinical history alone with a sensitivity of 0.92 (95% C.I.: 0.91-0.93) and specificity of 0.56 (0.53-0.60). A clinical history for the diagnosis of detrusor overactivity (DO) was found to be 0.61 (0.57-0.65) sensitive and 0.87 (0.85-0.89) specific. Within secondary care imaging of leakage by ultrasound was found to be effective in the diagnosis of USI in women with a sensitivity of 0.89 (0.84-0.93) and specificity of 0.82 (0.73-0.89).

CONCLUSIONS

Clinical interpretation of the results of the review is difficult because few studies could be synthesized and conclusions made. The published evidence suggests that a large proportion of women with USI can be correctly identified in primary care from history alone. Ultrasound offers a useful diagnostic tool which could be used prior to, and possibly instead of, multi-channel urodynamics in some circumstances. If a patient is to undergo urodynamic testing, multi-channel urodynamics is likely to give the most accurate result. Further primary studies adhering to STARD guidelines are required on commonly used tests.

Continence nurse treatment of women's urinary symptoms

The aim of this study was to establish how accurately a trained continence nurse could allocate appropriate second-line conservative treatment to women without urodynamic investigations. Depending on the number of patients coming taking up the service, there were between five and 12 nurses operating at any one time. Women aged 40 years and over, of which there were 2421 reporting lover urinary tract symptoms, were randomly allocated to a new nurse-led continence service. Of these women, 450 subsequently underwent urodynamic investigation, before which the nurses documented which second-line conservative treatment would be appropriate. The results showed that of all women with detrusor overactivity, 79.1% were correctly allocated anticholinergic treatment, and 64.8% were allocated pelvic floor exercises (PFE). Of all women with urodynamic stress incontinence, 88.8% were allocated only one treatment. This study showed that a trained continence nurse is able to allocate conservative treatment appropriately to the majority of women without the need for urodynamic investigation. This indicated that the management of urinary dysfunction by a team of trained, dedicated nurses has the potential to reduce waiting lists for urodynamic investigation, avoid unnecessary investigations and achieve greater patient satisfaction.

Validity and reliability of a questionnaire to measure the impact of lower urinary tract symptoms on quality of life: The Leicester impact scale

AIMS

To develop a condition specific quality of life measure for males and females with urinary storage symptoms of urgency, frequency, nocturia and incontinence.

MATERIALS AND METHODS

A sample of community dwelling males and females aged 40 years or more who were taking part in an epidemiological study provided data for development and validation of the scale. Questions were developed from literature review and discussions with clinicians and patients. Inclusion of items was dependent on levels of missing data and principal components analysis. Validity was assessed by comparison with the Hospital Anxiety and Depression Scale, the Bradburn Negative Affect Scale and single questions concerning the problematic nature of symptoms. Construct validity was assessed by comparing cases and non-cases, and patients with different symptom patterns. Test-retest and inter-rater reliability statistics were calculated for individual items. Responsiveness to change was measured in subjects taking part in a randomised controlled trial of a nursing intervention.

RESULTS

The scale showed high levels of internal consistency and measures of construct validity were as hypothesised. Test-retest and inter-rater reliability was moderate to excellent. The distribution of scores was skewed with low levels of impact but the questionnaire was responsive to conservative treatments in patients receiving a nursing intervention.

CONCLUSIONS

The questionnaire proved to be a valid and reliable interviewer administered instrument for measuring impact of urinary symptoms.

Validity and reliability of an interviewer-administered questionnaire to measure the severity of lower urinary tract symptoms of storage abnormality: the Leicester Urinary Symptom Questionnaire

OBJECTIVE

To develop a valid and reliable interviewer-administered questionnaire to measure the presence and severity of storage abnormality symptoms of incontinence, urgency, frequency and nocturia.

SUBJECTS AND METHODS

Subjects were 930 men and women aged >/=40 years, taking part in a randomized controlled trial of a continence nurse practitioner (CNP) service. Criterion validity was tested by comparing questionnaire responses to 24-h pad test and 3-day urinary diary. Responsiveness was assessed by comparing questionnaire responses before and after treatment. Questions about urgency were investigated for construct validity in patients taking part in the trial who underwent urodynamic investigation (243). Test-retest and inter-rater reliability was measured at approximately 6 days in subjects recruited to an associated epidemiological study (104 and 102, respectively).

RESULTS

The questionnaire responses showed significant associations with pad-test and diary measures. Questions about the severity of daytime incontinence performed better than those measuring night-time incontinence. The response categories of soaked, wet, damp and almost dry had better associations with the pad test than other measures of the severity of incontinence. Test-retest and inter-rater reliability was good for all questions, and all were responsive to change in symptoms, showing significant differences before and after treatment.

CONCLUSION

There is a clear need for standardization of measurement using well-validated instruments. This interviewer-administered questionnaire is valid, reliable and sensitive to change in a wide range of severity of symptoms, and in both men and women aged >/=40 years. The questionnaire provides a useful assessment tool for primary and secondary care in research and clinical settings.

Prevalence of faecal incontinence in adults aged 40 years or more living in the community

BACKGROUND

Prevalence studies of faecal incontinence in the general population are rare and the impact of faecal incontinence on quality of life has not been previously addressed.

AIMS

To establish the prevalence of faecal incontinence in adults in terms of frequency of leakage, degree of soiling, and level of impact on quality of life.

METHODS

In a cross sectional postal survey, 15 904 adults aged 40 years or more (excluding residents of nursing and residential homes) were selected randomly by household from the Leicestershire Health Authority patient register. Participants were asked to complete a confidential health questionnaire. Major faecal incontinence was defined as soiling of underwear or worse with a frequency of several times a month or more. Respondents were also asked if bowel symptoms had an impact on their quality of life.

RESULTS

From a total sample of 10 116 respondents, 1.4% reported major faecal incontinence and 0.7% major faecal incontinence with bowel symptoms that had an impact on quality of life. Major faecal incontinence was significantly associated with a lot of impact on quality of life (odds ratio 12.4, 95% confidence interval 7.5-20.6). Incontinence was more prevalent and more severe in older people but there was no significant difference between men and women.

CONCLUSIONS

This study has confirmed that faecal incontinence is a fairly common symptom, particularly in older people. Faecal incontinence in men has received little attention in the past and the results from this study indicate that it is as much of a problem in men as it is in women while the level of unmet need in this group is high. Estimates of need for health care for this symptom should be multidimensional and assess both the severity of symptoms and the impact it has on quality of life.

Male lower urinary tract symptoms: is surgery always necessary?

A transurethral resection of the prostate is a good operation to relieve bladder outflow obstruction and has a low incidence of complications. However, recent work suggests that many men with symptoms may not require an operation, and it can probably be delayed in a majority for many years. This may be particularly important in old and frail patients. Many men with outflow obstruction have irritative symptoms such as urgency, frequency and nocturia; these could be treated with anticholinergics, provided they have normal flow rates and small or absent residual urine volumes. Pharmacological treatment to relieve outflow obstruction is disappointing. There may be some benefit from alpha-adrenoreceptor antagonists, but the place for 5 alpha-reductase inhibitors is still unsure. All drugs have side effects which are unacceptable in patients who are not bothered by their urinary symptoms and can wait for active treatment.

Patients' views of a new nurse-led continence service

This study used qualitative methods to assess patients' views of a new nurse-led continence service that was being evaluated in a randomized trial as part of the Leicestershire Medical Research Council (MRC) Incontinence Study. The service was provided by a team of five nurses who had received a 3-month training programme on the assessment procedures and the evidence-based practice protocols. In-depth qualitative interviews were carried out by four trained interviewers with 23 respondents, seven male & 16 female (mean age 58 years), and were analysed using NUD*IST software. The main themes to emerge were related to the interpersonal skills and technical skills of the nurse and how these impacted on the effectiveness of treatment. An informal, friendly approach by nurses with good communication skills relieved patients' embarrassment and anxiety, giving them confidence and trust in the nurses, thus facilitating information exchange and effectiveness of care. Good communication skills conveyed the nurses' specialist technical skills and knowledge, encouraging patient compliance with treatments.

Development, implementation and evaluation of a new nurse-led continence service: a pilot study

The Leicestershire Medical Research Council (MRC) Incontinence Study is a series of interrelated studies exploring the epidemiology of urinary symptoms, including incontinence, and evaluating service provision and treatment options for these symptoms. This paper describes one aspect of the Leicestershire MRC Incontinence Study, namely the development, implementation and evaluation of a new nurse-led continence service. When developing a new service it is important to determine its acceptability and suitability to the target population. The new mode of service delivery was dependent on specially trained Continence Nurse Practitioners (CNP) delivering predefined evidence-based treatment interventions. Objective and subjective outcome measures were used to evaluate the service. The service was shown to be effective in reducing urinary symptoms and led to high levels of patient satisfaction. This service is currently being evaluated in a randomized controlled trial.

Prevalence and impact of urinary symptoms among community-dwelling stroke survivors

BACKGROUND AND PURPOSE

To establish prevalence of urinary symptoms among community-dwelling stroke survivors and how these symptoms affected lives of these survivors compared with a nonstroke population.

METHODS

The present study was a community-based postal survey in Leicestershire community, UK (that excluded institutional settings), that was designed to track stroke, urinary, and bowel symptoms and the effect of such symptoms on relationships, social life, daily activities, and overall quality of life. Subjects included 14 600 people who were living in the community and </=40 years of age, randomly selected from the Leicestershire Health Authority Register.

RESULTS

A 70% response rate was achieved with the return of 10 226 questionnaires. Prevalence of reported stroke was 4% (n=423). Prevalence of urinary symptoms was 34% (n=3197). Overall, stroke survivors had a higher prevalence of symptoms than the nonstroke population (64% to 32%, respectively). These symptoms were reported to have more of an effect on the lives of the stroke survivors compared with the nonstroke population even when adjusted for age and sex differences. This reported impact was not related to the stroke per se but to the severity of the urinary symptoms.

CONCLUSIONS

These data show a high prevalence of urinary symptoms among community-dwelling stroke survivors. These symptoms were reported to have considerable impact on the lives of stroke survivors, which needs to be taken into account in future research and clinical practice.

Educational preparation: specialist practice in continence care

Contributing factors to effective continence service provision include funding, organization, and expert knowledge among the individuals providing care. Expert knowledge can be gained through clinical experience and appropriate ongoing education. It has been widely reported that undergraduate education in this area for nurses, doctors and physiotherapists is limited (Brocklehurst, 1990; Swaffield, 1994; Laycock, 1995). Many nurses providing continence care have accumulated knowledge through experience and trial and error. Little is known about the effectiveness of advanced postgraduate education of 'experts' in continence care. This article outlines a continence education module developed to prepare a specialist group of nurses to provide a high standard of continence care that is both safe and effective in a clinical environment. This module was designed and evaluated specifically as part of the Leicestershire Medical Research Council (MRC) Incontinence Study. Changes in continence knowledge, attitudes to research, and acceptability of the module have been explored. When setting up a new nurse-led continence service, it is of great importance to systematically detail the components of the educational preparation of the nurses providing the service. Open discussion of any problems in the design and implementation of this module may inform future modules in this and other areas.