Mapping the Future for Incontinence Treatment Worldwide

First International Consultation on Incontinence

MEETING REVIEW Mapping the Future for Incontinence Treatment Worldwide Highlights from the First International Consultation on Incontinence June 28-July 1, 1998, Monaco [Rev Urol. 1999;1(3):145-147] The last medical taboo of the 20th century in our field is urinary incontinence and bladder control problems. The subject of perhaps the most important meeting ever held in the field of urinary incontinence took place last summer: the First International Consultation on Incontinence, sponsored by the World Health Organization (WHO) and organized by the International Continence Society and International Consultation on Urological Diseases. Organization and Mission Two hundred of the world’s best in the field of incontinence gathered in Monaco. I was lucky enough to be asked to participate on one of the 23 committees at this meeting. The congress was a lot of work, but being in Monaco made up for it a little. The mission from WHO was to define the pathophysiology and impact of urinary incontinence and to assess the value of our present treatment options. Urinary incontinence is a devastating medical problem, not only in developed countries such as the United States, but also in third world countries. In the United States alone, there are an estimated 17 million men and women with urinary incontinence. It costs over $1,000 per patient per year to deal with the disease and treat patients Reviewed by Michael B. Chancellor, MD, University of Pittsburgh School of Medicine, Pittsburgh, Pa. with urinary incontinence. The total cost of urinary incontinence in the United States is over $26 billion per year! It is estimated that only 10% to 20% of patients with urinary incontinence and voiding dysfunction have overcome their embarrassment and discussed the problem with their doctors. The fields of neurourology and urinary incontinence are the greatest growth areas in urology practice today and will continue to be so for the next decade. The president of the meeting was Emil Tanagho, MD, professor emeritus at the University of California, San Francisco, School of Medicine. The chairman of the meeting was Paul Abrams, MD, FRCS, from the Bristol Urological Institute, Bristol, England. The secretary was Saad Khoury, MD, professor of urology at La Pitié Hospital, Paris. Twenty-three committees were chosen with several members from basic sciences and from nursing as well as from the clinical disciplines. Experts from different specialties and continents were selected, making this consultation truly multidisciplinary and global in scope. The committees were divided into 3 broad categories: basic science, patient assessment, and treatment. (I was cochair of the committee on Clinical Neurophysiology.) Each committee had the mission to assess what we know, what we think we know, what we don’t know, and what we need to know and to set standards and define strategies in both education and research. Evidence-based consensus papers will be produced by each committee (see page 147). Strategies for the management of incontinence based on defined assessment and diagnostic criteria were developed, as was research priority for the next 5 to 10 years for use in both the world’s most advanced research laboratories and in the developing world. Because the design and mission of this consultation were different from most scientific conferences, where abstracts on new research are presented, I cannot present any new scientific breakthrough in the field of incontinence. I can say, however, that the experts from around the world have defined urinary incontinence as a disease that deserves much more medical attention and public education. With the commitment of WHO and the enthusiasm I saw on the faces of experts from all corners of the earth, I am convinced we will see major progress in the care of patients with urinary incontinence. Take-Home Messages What are the take-home messages from this meeting? One important one is from the Promotion, Organization, and Education in Continence Care committee: Urinary incontinence should be considered a disease rather than symptoms and conditions. The bottom line is that conditions and symptoms do not get taken seriously, but diseases do. With disease classification, hopefully medical SUMMER 1999 REVIEWS IN UROLOGY 145 Incontinence continued Key words Urinary incontinence • Overactive bladder • World Health Organization • Bladder • Urethra Main Points • In the United States alone, there are an estimated 17 million men and women with urinary incontinence; the annual cost is over $26 billion. • A key purpose of the WHO meeting was to set standards and define strategies in both education and research. Research priority for the next 5 to 10 years was developed for use in both the world’s most advanced research laboratories and in the developing world. • An interesting drug presented at the meeting involves a new pharmacologic concept—targeting mechanisms in the central nervous system to increase sphincter activity and bladder capacity. It may be helpful for patients with mixed urge and stress incontinence. The anticholinergic oxybutynin is still standard therapy for urge incontinence, although newer agents may have fewer side effects. • Colposuspension keeps about 80% of patients dry for up to 5 years; 55% of patients report being satisfied with results of surgery. • Surgical management with use of an artificial sphincter has cured about 75% of men with stress urinary incontinence. About half of men treated with collagen injection are improved or cured. Committee members point to the need for prospective, randomized clinical trials for new surgical approaches using slings and muscle transfer procedures. eduucation will improve and, with it, medical care for patients with incontinence. The overall consensus is that the subjects of voiding dysfunction and urinary incontinence are not well taught in medical and nursing schools across the developed countries. If incontinence can be defined as a range of diseases, medical and nursing schools will be forced to give proper instruction to their students. Because of the aging population across the world, many more people will be affected by incontinence in the coming years, noted Alexander Kalache, MD, PhD, chief of the WHO Ageing and Health Programme. Experts estimate 200 million men and women worldwide are affected by bladder control problems. The problem seems to be divided evenly between the developing and industrialized nations. According to Kalache, by 2020 approximately 15% of the earth’s population will be over age 65. This will more than double the 7% over age 65 we now have. The rate of incontinence and cost to take 146 REVIEWS IN UROLOGY SUMMER 1999 care of patients with it will also rise in proportion. From the Pharmacotherapy committee, chaired by Karl-Erik Andersson, MD, professor and chairman of clinical pharmacology at University Hospital in Lund, Sweden, came an excellent review of drug treatment for patients with voiding dysfunction. Dr. Andersson’s committee reviewed over 500 peer-reviewed papers on pharmacotherapy for urinary incontinence. This committee was disappointed that there are several major drawbacks with many studies on urinary incontinence. Despite the prevalence of dry mouth associated with the anticholinergic oxybutynin, the committee reported it to be the current standard of pharmacologic treatment for urge incontinence. Two new drugs, tolterodine and constant release oxybutynin, have been introduced recently in the United States with great fanfare and have generated great interest. These drugs have demonstrated similar efficacy as conventional oxybutynin but have sig- nificantly fewer side effects. Another interesting drug presented at the meeting, duloxetine, involves using a new pharmacologic concept. This serotonin and norepinephrine reuptake inhibitor may increase sphincter activity and bladder capacity by targeting mechanisms in the central nervous system (CNS). This is the first drug using the CNS route for the treatment of patients with urinary incontinence. Karl Thor, PhD, of Duke University Medical Center in Durham, N.C., spoke about duloxetine, which was developed for the treatment of patients with depression but was not found to be effective. However, some of the depressed patients reported a decrease in urinary frequency and incontinence, thereby altering the directional course of this drug. Thor and others considered the drug as a potential treatment for patients with stress and urge incontinence. In a recent study, duloxetine reduced the volume and frequency of involuntary urine loss by 70% in about half of 21 patients who had stress incontinence. Few of those patients, however, remained completely dry. Therefore, duloxetine may be most effective as an adjunct to pelvic floor exercises. Andersson commented that the duloxetine mechanism of action offers an interesting principle for pharmacotherapy, yet he expressed skepticism about using a CNS route to treat patients with urinary incontinence. Andersson believes it is very difficult to selectively target the lower urinary tract through the CNS, because there are so many other sites that could be affected. Obviously, this could increase the potential for side effects significantly. What about surgical treatment of urinary incontinence? This was a hot topic of discussion and controversy among urologists and gynecologists at the WHO meeting. Edward McGuire, MD, professor and chief of urology at the University of Texas Medical School at Houston, spoke out Incontinence on this topic. He reported there are only a few studies that looked at outcomes of surgical therapy versus biofeedback and physical therapy. Dr. McGuire said studies show that with colposuspension, about 80% of patients are dry for up to 5 years; 55% of patients are satisfied with the surgery. When laparoscopic bladder suspension is compared with the open procedure, McGuire said a larger percentage of patients are dry for up to 3 years with the open procedure. However, he added that we should really wait for 5-year outcomes before making a final judgment. The present consensus is that laparoscopic bladder suspension has not met the test of time and should be considered investigational. McGuire’s committee recommended more research and that new surgical treatment of incontinence be considered experimental unless it has at least 2 years’ follow-up. One committee was assigned the task of evaluating conservative therapy for women. This included lifestyle changes, physical therapy, behavioral therapy, intravaginal devices, and absorbent pads. This committee also recommended more randomized, controlled trials to compare these differing approaches. Studies show pelvic floor muscle exercises are more effective than doing no exercise, and bladder training is as effective as anticholinergic drugs over the short term. COMING David Fonda, MBBS, of Caulfield General Medical Centre and Alfred Hospital in Caulfield, Australia, and chair of the committee on conservative treatment in the elderly, reported encouraging news in the evaluation and treatment of incontinence in the elderly. Fonda encouraged physicians, particularly with elderly patients, to review medications that may cause incontinence as a side effect and to look at comorbidities, such as stroke and Parkinson’s disease, as a cause of incontinence. The elderly should not be denied surgery as an option for managing incontinence. One method that may help some elderly people remain continent is dependent continence or prompted voiding. This requires the availability of someone to accompany the elderly patient to the bathroom or a system of reminders to use the bathroom at designated times. If surgery or the use of behavioral techniques is not entirely successful in elderly patients, Fonda said such patients can still stay dry by using an absorbent pad, con- dom, or other type of aid. WHO did not ignore urinary incontinence in men. Although we know that urinary incontinence is less prevalent in men than women, it is no less a problem. Overactive bladder and urge incontinence are by far the most common manifestations. Detrusor instability related to benign prostatic hyperplasia is the main culprit. Stress incontinence is rare and occurs most commonly after prostate surgery. According to the committees on conservative and surgical treatments for men, anticholinergic drugs are effective for urge incontinence, yet behavioral therapy, such as bladder training, is also successful. Use of the artificial sphincter to manage male stress urinary incontinence has a success rate of about 75%. About half of men who are treated with collagen injection are improved or cured, the committee stated. New surgical approaches using slings and muscle transfer procedures need prospective, randomized clinical trials. ■ The book written by the committees from this meeting, Incontinence, was published in April (1000 pages, color, hard cover). If you are even the least bit interested in female urology and/or voiding dysfunction, you should get this book. It will be the world’s standard on urinary incontinence. It is available from Plymbridge Distributors Ltd, Estover Road, Plymouth PL6 7PY, United Kingdom. Tel:+44-1752-202301; fax: +44-1752-202331; e-mail: cservs@plymbridge.com IN NEPHRON-SPARING SURGERY RENAL CELL CARCINOMA FOR SUMMER 1999 REVIEWS IN UROLOGY 147