Incontinence

REVIEWING THE LITERATURE News and Views from the Literature Incontinence Using Electrical Stimulation for Urinary Incontinence Reviewed by Ji-Youl Lee, MD,* Michael B. Chancellor, MD† *Catholic University of Korea, Seoul, Korea; † Department of Urology, University of Pittsburgh School of Medicine, Pittsburgh, PA [Rev Urol. 2002;4(1):49–50] © 2002 MedReviews, LLC n this review we would like to take a critical look at electrical stimulation (ES) for incontinence. We find it very interesting that ES, as an incontinence treatment modality, has not been widely embraced in the United States but is yet quite popular in other parts of the world, especially Scandinavia. We will review two companion papers that report a large-scale study on ES from Norway. We would like to ask you to look at the author's data and judge for yourself whether you feel the efficacy of ES is validated in their study. I A Norwegian National Cohort of 3198 Women Treated with Home-Managed Electrical Stimulation for Urinary Incontinence: Demography and Medical History Indrekvam S, Fosse OA, Hunskaar S. Scand J Urol Nephrol. 2001;35:26–31. A Norwegian National Cohort of 3198 Women Treated with Home-Managed Electrical Stimulation for Urinary Incontinence: Effectiveness and Treatment Results Indrekvam S, Sandvik H, Hunskaar S. Scand J Urol Nephrol. 2001;35:32–39. From the Section for General Practice, Department of Public Health and Primary Health Care at the University of Bergen in Norway comes this large-scale report on the use of ES for incontinence in over 3000 women. Owing to the large size of this project, the authors divided the results and discussion into two articles: the first presented demographic data and history of the women, the second, ES treatment outcome. We will review the two companion articles together. This prospective cohort study investigated 3198 women treated with home-managed ES in Norway from 1992 to 1994. Data were collected on questionnaires from patients and physicians both before and after treatment. ES for urinary incontinence appears to be covered by insurance in Norway. Patients were recruited from referral by primary care, Ob/Gyn, and other medical specialists for reimbursable ES therapy. The majority of the women were managed with other treatments before ES. The most frequent interventions were pelvic floor exercises (61%), bladder training (38%), and estrogen therapy (26%). Fifteen percent of the women had been treated with surgery, 7% had used drugs (eg, anticholinergics or alpha-agonists), and 7% had undergone other interventions. Electrical stimulation, as an incontinence treatment modality, has not been widely embraced in the United States but is yet quite popular in other parts of the world, especially in Scandinavia. Severity of incontinence was directly related to age. In the group aged 70 years and older, 84% reported severe or very severe incontinence. There was an underrepresentation of elderly women in this patient population, indicating that the medical community in Norway has a lower propensity to offer ES to older women. There were two main types of electrostimulator, both of which used vaginal/anal probes. Long-term stimulation (20–50 Hz) was delivered below the sensory threshold. Devices were to be used for 6 to 8 hours/day for at least 3 months before assessment of outcome. Maximal stimulation (10–20 Hz) used a high-intensity stimulus for no more than 20 minutes daily and no less than twice weekly. The stimulator was used at least 10 to 20 times before evaluation of the effect. Let’s take a look at the reported outcome. Mean age was 53 years. According to the physicians, 43%, 15%, 37%, and 5% of the patients had stress, urge, mixed incontinence, and VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY 49 Incontinence continued other diagnoses, respectively. Fifty-five percent of the women had symptoms for 5 years or more, 62% had urinary loss every day/night, and 59% of the patients were classified as having severe or very severe incontinence according to a validated severity index. Fifty-two percent of the women used a long-term stimulator and 48% a maximal stimulator. Of 645 physicians who requested stimulators, 65% were general practitioners. Gynecologists requested 53% of the stimulators. Most patients with urge incontinence used a maximal stimulator (94%), and most patients with stress incontinence used a long-term stimulator (84%). Maximal stimulators were used by 64% and long-term stimulators by 36% of patients with mixed incontinence. Altogether, 61% of evaluable women were improved, based on a self-assessment of improvement. Twenty-nine Why were urology or gynecology department faculty not involved in this large-scale project? design or analysis of this study? Second, only 16% of patients using pads stopped or only rarely used pads after 3 months with this intensive therapy. Is this is good outcome? Our impression from this monumental study is that a highly motivated woman with a great deal of free time and who does not have to pay for ES may improve moderately with ES in the short term. Urinary Tract Infection Recurrent Uncomplicated Urinary Tract Infections: Can Young Women Diagnose and Treat Themselves? Reviewed by J. Curtis Nickel, MD, FRCSC Department of Urology, Queen’s University, Kingston, Ontario, Canada percent were cured or much improved. According to the physicians’ assessment, 33% were cured or much improved, and altogether 55% were improved. There was a moderate agreement between patients and physicians (kappa 0.54, improvement versus no improvement). Two thirds of the patients were regarded as compliant. The proportion of patients who regarded themselves as cured or much improved was 37% for compliers and 12% for noncompliers. The corresponding physicians’ figures were 43% and 9%, respectively. Overall, the daily use of pads was significantly reduced: 15% used more and 30% fewer pads than before treatment. The average daily use of pads was 2.7 before treatment and 2.4 after treatment, a reduction of 0.3 (12%) pads per 24-hour period (paired sample, P < .001). Sixteen percent of the women using pads daily before treatment did not need pads or used pads only occasionally after ES. We find the authors' conclusions fascinating: “The Norwegian reimbursement system can be said to be a numeric success. ES is a treatment option for everyday use in Norway." Women treated with ES for urinary incontinence experienced a significant reduction in incontinence problems, both subjectively and semi-objectively. The treatment results seem to be strongly dependent on good acceptance of the treatment. Our interpretation of the data is a little more skeptical. We have two concerns. First, why were urology or gynecology department faculty not involved in this large-scale project? Were urology or gynecology faculty involved with 50 VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY [Rev Urol. 2002;4(1):50–51] © 2002 MedReviews, LLC or years, actually decades, a few of us interested in urologic infectious disease have advocated a simple approach to treating young, sexually active women with recurrent urinary tract infections (UTIs). In seminars, lectures, and courses we have tried to convince physicians, particularly urologists, that women with recurrent, uncomplicated cystitis do not usually require urine cultures, history and physical examination, an antibiotic prescription, and a “test of cure" follow-up culture for each and every episode. From some, the response was, “Blasphemy! Totally non-traditional and dangerous to allow women to self-diagnose and treat a urologic infectious disease! The approach would lead to overdiagnosis, underdiagnosis, overuse of antibiotics, incorrect use of antibiotics, and possible progression to significant morbidity and perhaps even mortality!" However, those of us who have used a patient-initiated diagnostic and treatment plan in knowledgeable, competent, and motivated women have found that none of these fears were realized. But the evidence to support a claim that patient-initiated management is safe, efficacious, and perhaps even cost-effective, remained unproven; in other words, the management plan was not evidence-based. In 2001, the publication of an important study should change the perception of many physicians. Patient-initiated management of recurrent, uncomplicated UTI is not only feasible, but safe and efficacious. F Urinary Tract Infection Patient-Initiated Treatment of Uncomplicated Recurrent Urinary Tract Infections in Young Women Gupta K, Hooton TM, Roberts PL, Stamm WE. Ann Intern Med. 2001;135:9–16. To determine the safety and feasibility of patient-initiated treatment of recurrent UTIs, the authors designed a prospective clinical trial. Women of at least 18 years of age, followed in a university-based primary health care clinic, who had a history of recurrent UTIs and no recent pregnancy, hypertension, diabetes, or renal disease, were invited to participate. Based on symptoms alone, the patients self-diag- Patient-initiated management of recurrent, uncomplicated UTI is not only feasible, but safe and efficacious. nosed their own UTI and immediately initiated therapy with a 3-day course of a fluoroquinolone antibiotic (ofloxacin or levafloxacin). To analyze the accuracy of selfdiagnosis, the patients were asked to perform a clean-catch urine collection, which they refrigerated at home and subsequently submitted to the laboratory for culture. In addition to routine cultures, testing for chlamydia and gonorrhea was also undertaken. Patients also submitted repeat urine samples 10 days and 30 days after they initiated self-treatment. Post-therapy interviews were conducted to evaluate patient’s satisfaction with this management program. A total of 172 women (average age of 23 years) who were predominantly white, unmarried, and sexually active were recruited. The women had had at least two UTIs in the previous year. Of the 172 women, 88 (about half) self-diagnosed a total of 172 urinary tract infections. Laboratory evaluation showed a uropathogen in 84% and sterile pyuria in a further 11%. In only nine instances (5%) were no pyuria or bacteruria evident. Clinical cures (complete resolution of symptoms) occurred in 92%, and microbiological cures (eradication of bacteria) occurred in 96% of the cultureconfirmed episodes. There were no adverse events reported by any of the women in the study. This study clearly shows that women with recurrent cystitis can accurately self-diagnose and self-treat UTI as accurately as any physician. What does this mean for physicians and urologists? Are we superfluous in the management of recurrent UTIs in young, sexually active women? Not at all! Patient-initiated treatment of recurrent cystitis remains a physician-directed management strategy. The approach saves valuable time (both the physicians’ and the patients’), expense (cost of extra cultures, visits to physicians and time off work for the patient) and allows for early initiation of therapy with no apparent increase in treated episodes (in other words, no significant over-treatment). Although the design of this particular study necessitated evaluations for culture and pyuria prior to initiation of therapy and 10 and 30 days after therapy, these tests were performed to evaluate the accuracy of self-diagnosis and the efficacy of self-treatment. These cultures are not really required in a patient-initiated management program. How can urologists use the results from this important study to change not only their own management of recurrent UTIs, but that of their referring primary care physicians? A practical approach used by the author of this review is described. Patients are considered for a self-diagnosis and treatment program if they have had recurrent cystitis with previously documented positive cultures. The patients must have typical symptoms, uncomplicated cystitis, and must be intelligent and motivated enough to understand the diagnostic and therapeutic plan. I prescribe enough antibiotic to cover four potential episodes (3 days of treatment each) and carefully make sure the patient understands the following instructions. When she is sure that she is developing the signs and symptoms of cystitis (based on her previous experience), she will initiate a 3-day course of antibiotic therapy. If her symptoms have not improved within 24 to 36 Are urologists superfluous in the management of recurrent UTIs in young, sexually active women? hours, she will perform a clean-catch urine collection (a specimen bottle will be provided with the appropriate requisition) and deliver that to the laboratory immediately, at the same time contacting the physician’s office so that if symptoms persist, the antibiotic can be changed based on antibiotic sensitivities. The patient is asked to record in a diary when each episode occurred and the time to resolution of symptoms once she has initiated antibiotic therapy. Depending on the frequency of recurrent UTI prior to introducing this treatment plan, the patient will be seen in the office every 6 to 12 months and instructed to bring her bottle of antibiotics with her for a pill count. Our clinical experience using this approach for almost 2 decades mirrors the result of the prospective treatment trial of Gupta et al: women can accurately self-diagnose and effectively selftreat recurrent UTIs. This clinical approach is satisfying for physicians, empowering for patients, and we now have the evidence that it is safe and effective. VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY 51