Quality of life impact of urge incontinence in older persons: a new measure and conceptual structure.

OBJECTIVE: To develop a condition-specific measure for assessing the impact of urge urinary incontinence (UI) on the quality of life (QoL) of older persons. DESIGN: A 32-item Urge Impact Scale (URIS) was drafted using content area data from focus groups composed of urge incontinent older persons. Pilot testing in 21 urge incontinent persons (mean age 67.7 years) resulted in the elimination of eight items by internal consistency, skew, and patient response criteria. The resulting scale (URIS-24) was tested for reliability (internal consistency and test-retest correlation) and construct validity (correlation with UI severity from voiding records) in a separate group of 27 urge incontinent persons (89% women, mean age 72 years). Factor analysis of URIS-24 data from the combined 48 persons was used to explore the conceptual structure underlying urge UI-related QoL. SETTING: University-affiliated community-based practice and tertiary hospital. PARTICIPANTS: Community-dwelling women and men, older than age 60 and with urge incontinence at least twice weekly, recruited from newspaper, newsletter, and radio advertisements. RESULTS: Cronbach's alpha for URIS-32 was 0.84, and for URIS-24 it was 0.94. When administered (mean +/- standard deviation) 9.2 +/- 5.1 days apart, URIS-24 had good test-retest reliability for total scores (interclass coefficient = .88, concordance coefficient = .88), and individual item scores at time 2 were within 1 point (on a 5-category Likert scale) of time 1 answers for 89% of responses. URIS-24 scores had modest but nearly significant correlation with the number of UI episodes (r = -0.39, P = .05). Factor analysis revealed a three component structure corresponding to psychological burden, perception of personal control, and self concept. CONCLUSIONS: The URIS-24 is an internally-consistent, highly reproducible tool for the assessment of the QoL impact of urge UI on older persons. It can be used to evaluate QoL impact by specific items as well as by overall score. Compared with other UI-specific QoL measures, the URIS-24 had similar or superior internal consistency, test-retest reliability, and validity, but it is the first measure designed and tested specifically for older persons with urge UI. These results also highlight the multifactorial structure of urge UI-related QoL and the importance of its psychological dimensions.

Implications of the most bothersome prostatism symptom for clinical care and outcomes research.

OBJECTIVES: Because treatment of benign prostatic hyperplasia (BPH) is based largely on patients' symptoms, understanding and measuring the impact of these symptoms from the patient's perspective is critically important for clinical care. Such knowledge also is crucial for comparing patient-weighted outcomes because the increasing array of medical and surgical BPH treatments differ in their impact on specific symptoms. Our purpose was to determine the most bothersome symptom in older men seeking evaluation for symptomatic BPH and to examine whether age, comorbidity, or urodynamic evidence of prostatic obstruction were important covariates. DESIGN: Prospective evaluation of a consecutive series. SETTING: Veterans Affairs urology clinic. PARTICIPANTS: 115 men (age 69 +/- 6 years) presenting for initial evaluation of prostatism. MEASUREMENTS: Scores on standard symptom index and patients' reports of the most bothersome symptom. Bladder outlet obstruction was assessed by multichannel videourodynamic evaluation. RESULTS: An "irritative" symptom (frequency, urgency, or nocturia) was cited as most bothersome significantly more often than an "obstructive" symptom (weak stream, hesitancy, etc.) (53 vs. 35%, P < .05); older men were significantly more likely to name an irritative symptom as most bothersome (chi 2 for trend = 6.63, P < .025). Even among men with prostate obstruction, most cited an irritative symptom as the most bothersome, regardless of the severity of obstruction. These associations were not confounded by comorbid conditions or medications that independently may cause symptoms. CONCLUSIONS: Because irritative symptoms are most bothersome, have a diverse differential diagnosis, and do not respond as well to BPH treatment, neither providers nor researchers should rely solely on global assessments of symptom severity and bother in assessing men with voiding symptoms. Additional focus on individual symptom impact and etiology is needed, especially in older men.

The impact of urge urinary incontinence on quality of life: importance of patients' perspective and explanatory style.

OBJECTIVES: The impact of urinary incontinence (UI) on health-related quality of life (QoL) is significant yet variable, but little is known about patient-defined content areas regarding the influence of UI on QoL and whether patient-specific factors correlate with specific content areas of UI-related QoL. In order to identify the most valid content areas for a new UI-related QoL questionnaire, our primary goal was to determine the content areas of greatest concern regarding UI-related QoL among older persons with urge incontinence. The second goal was to examine the possible role of patients' explanatory style as a mediator of UI impact on health-related QoL. Data on the questionnaire will be presented elsewhere. DESIGN: Focus groups comprising urge-incontinent persons were used to obtain verbatim descriptions of the impact of UI on QoL. SETTING: A university-affiliated tertiary hospital. PARTICIPANTS: Community-dwelling women (n = 25) and men (n = 5) more than 60 years of age, with urge incontinence, recruited from newspaper, newsletter, and radio advertisements. MEASUREMENTS: Qualitative content analysis of focus group transcripts was used to determine QoL items. These were compared with previously described UI-related QoL items obtained from the literature. Subjects' statements regarding causes of UI were evaluated for predominant explanatory style. RESULTS: Thirty-two UI-related QoL items were identified, more than half of which were not described previously. Compared with expert-defined UI-related QoL items from the literature, patient-defined items focused more on coping with embarrassment and interference from UI than on prevention of actual activity performance. Explanatory statements were made frequently by patients talking about their UI. Although positive style explanatory statements were most common, they did not correlate with any QoL items. By contrast, there was a significant correlation between negative explanatory style and six specific UI-related QoL items. CONCLUSIONS: Focus groups of older persons with urge incontinence suggest that experts and patients view the impact of urge UI on QoL differently. Whereas experts focus more on functional impact, patients more often cite the impact of UI on their emotional well-being and on the interruption of activities. In addition, the association between negative explanatory style and specific UI-related QoL items suggests that explanatory style may be an important mediator of patients' perceptions of UI-related QoL.

Improving the utility of urine flow rate to exclude outlet obstruction in men with voiding symptoms.

OBJECTIVES: Many older men with voiding symptoms do not have bladder outlet obstruction (BOO) but have conditions amenable to medical treatment. If primary care providers could reliably exclude men who have BOO, then they could initiate appropriate evaluation and treatment in a substantial proportion of the remainder. Urine flow rate, although widely used, is insufficiently sensitive to exclude BOO reliably. We investigated whether the decline in flow rate with age could be utilized to improve the utility of flow rate for excluding BOO in symptomatic men, especially when combined with knowledge of the patient's postvoiding residual volume (PVR). DESIGN: Prospective study using two patient cohorts. SETTINGS: A Veterans Affairs urology clinic serving community-dwelling and institutionalized healthy older men. PARTICIPANTS: 111 men with voiding symptoms (mean age 72.4 +/- 9.2 years). MEASUREMENTS: Maximum urine flow rate, measured with standard flowmeter, and PVR, measured by catheterization. BOO was determined by multichannel videourodynamic testing. RESULTS: The sensitivity of flowrate for BOO increased significantly with age (P = .0001) and did not appear to be confounded by comorbid conditions. An algorithm incorporating age, flow rate, and PVR had a sensitivity of 90%, specificity of 43%, and accuracy of 74% in screening for BOO. The algorithm's sensitivity was better than that of flow rate alone (55%); its sensitivity was also similar to a "refer all" strategy (100%) but had improved specificity (41% vs 0%). CONCLUSIONS: Flow rate alone is insufficiently sensitive as a screening test to exclude BOO, but a simple diagnostic algorithm using age, flowrate, and PVR was more sensitive and accurate. This algorithm allows primary care evaluation and initial management of men with voiding symptoms while potentially reducing unnecessary referrals and costs.

Urinary incontinence knowledge among community-dwelling people 65 years of age and older.

OBJECTIVES: We determined elderly persons' knowledge about the epidemiology and treatment of urinary incontinence (UI) as part of a preintervention survey for the Educational Demonstration of Urinary Continence Assessment and Treatment for the Elderly (EDUCATE). DESIGN: An intact-group pretest-posttest design was employed to measure the effects of multimethod educational interventions on the knowledge, attitudes, and practices of physicians and older people concerning UI. PARTICIPANTS: A random sample of community-dwelling people aged 65 years and older from two counties in Massachusetts was selected (n = 1,140). MEASUREMENT: A 14-item urinary incontinence quiz was developed from information presented in the AHCPR UI Guideline Panel's recommendations. Participants answers to the quiz were part of a 20-minute telephone interview. RESULTS: For nine of the fact items, the elderly respondents were more likely to give the correct answer than the incorrect answer. However, for only four of those nine did the percentage of correct responses exceed 50% (there were substantial proportions of "don't know" responses). For several fact items, those who were younger, female, or had more formal education were more likely to provide correct responses. CONCLUSIONS: There are substantial gaps in the knowledge of older persons about urinary incontinence, especially among men, those age 85 and older, and those with lower levels of education. These knowledge gaps may contribute to misinterpretation of symptoms and underreporting of symptoms to health care professionals. This pattern of findings indicates a greater need for community education on urinary incontinence.

Interpreting the effect of common medical conditions on voiding dysfunction in the elderly.

Medical conditions often have an important causal role in urinary incontinence in the elderly. Aside from causing functional impairments, such diseases directly may involve the genitourinary system--particularly its neurologic control--resulting in specific lower urinary tract pathophysiology. Knowledge of the specific effects that medical conditions may have on the genitourinary system and continence can assist the urologic specialist in determining the often complex cause(s) of UI in older persons.

Evaluation of the causes and severity of geriatric incontinence. A critical appraisal.

The evaluation of urinary incontinence in the elderly differs from that in younger patients because of altered or nonspecific disease presentation, the different spectrum of pathophysiology, greater variation between individuals and, in some cases or settings, variable treatment goals. Evaluation must be multifactorial and extend beyond the genitourinary system, because many age-related conditions and the drugs used to treat them can cause or exacerbate urinary incontinence. Voiding records are a reliable measure of severity, although studies of their validity are still lacking. History-taking requires more time in this age group. Stress incontinence symptoms remain very sensitive, whereas obstructive symptoms fall in predictive value. Clinical algorithms based on a combination of symptoms and simple bedside examination and maneuvers may prove most useful in specific settings such as nursing homes. The targeting and interpretation of the physical examination must also change because of age-related conditions (e.g., BPH, atrophic vaginitis) and prevalent comorbid diseases, especially neurologic ones. The Q-tip, elevation, and pessary tests for stress incontinence offer little diagnostic or therapeutic information in the elderly. Routine laboratory tests should be performed to exclude reversible causes of urinary incontinence, while interpretation of the urinalysis must consider the prevalence of asymptomatic bacteriuria. No radiographic studies are routinely needed; bead-chain cystourethrography and IVU in particular probably offer little additional information. Voiding cystourethrography, although little studied, offers dynamic data that may be helpful, especially in evaluating outlet obstruction. Bedside cystometry is simple but may be insensitive to the most prevalent type of detrusor instability in the institutionalized elderly. Finally, multichannel urodynamic study is safe and feasible even in frail elderly patients and should be considered when empiric therapy is risky or has failed, complicated comorbidity exists, or surgery is anticipated.

Premature conclusions in the diagnosis of iron-deficiency anemia: cause and effect.

Case records of patients with iron-deficiency anemia were audited using a computer-based algorithm. In 24 of 35 cases, the diagnostic conclusion seemed unjustified and characteristic of premature closure, one of four recurring errors in diagnostic reasoning described previously. Premature closure appeared to originate from subjects at all levels of training, to be easily and unquestioningly accepted by other physicians, and to inappropriately condition diagnostic and therapeutic decisions. Heuristics and biases described by Tversky and Kahneman are considered as contributory factors and patient care and teaching implications are discussed.

Controversies in the diagnosis and management of benign prostatic hypertrophy.

The prevalence of BPH ensures a continuing need for internists to be aware of the issues regarding the evaluation and treatment of prostatism, while the developing role of nonoperative therapy and the growing recognition of the importance of patient preferences have opened the way for an expanded involvement of the primary care practitioner in the management of these patients. Prostatism remains a difficult clinical problem since many of the symptoms and diagnostic tests are nonspecific, especially in the elderly. Basic questions regarding the role of bladder outlet obstruction (BOO) in the development of symptoms and in predicting outcome from surgery await further study. Against this background of uncertainty, however, is the reassurance that the natural history of the process results in serious complications in only the minority of patients. Important work is under way that will incorporate quality of life outcomes, compare surgery with "watchful waiting," and randomize patients to surgical and nonsurgical treatments. In the interim, the internist may help patients with prostatism significantly by appreciating the natural history of the condition, treating the conditions that mimic or exacerbate it, understanding the clinical utility and limitations of current evaluation methods, becoming aware of the growing array of nonsurgical and minimal-surgery options, and assisting patients in weighing therapeutic risks and benefits with their concerns about symptoms.

Correlation between micturitional urethral pressure profile and pressure-flow criteria in bladder outlet obstruction.

PURPOSE: We correlate micturitional urethral pressure profilometry with pressure-flow diagnoses of outlet obstruction. MATERIALS AND METHODS: Urodynamic evaluation was done of 86 consecutive men with voiding symptoms. Obstruction criteria were a micturitional urethral pressure profile (MUPP) gradient greater than 5 cm. water, Schäfer's linear passive urethral resistance relation (PURR) greater than grade 1 and Abrams-Griffiths nomogram. RESULTS: Interpretable results were completed in 99% of the patients undergoing MUPP and 60% undergoing pressure-flow studies (p < 0.00001). MUPP diagnosis agreed with PURR (p = 0.0015) and Abrams-Griffiths nomogram results (p = 0.00004). MUPP gradients correlated well with PURR (r = 0.70, p < 0.00001). Using optimum cutoff values (11 cm. water), the sensitivity of MUPP was 83%, specificity 82% and positive predictive value 94%. CONCLUSIONS: MUPP correlates well with and yields interpretable results more often than pressure-flow studies.

Quest for a detrusor overactivity index.

PURPOSE: Urge incontinence, which is the predominant type of geriatric incontinence, is generally attributed to detrusor overactivity. However, detrusor overactivity is present in up to half of continent elderly individuals. We postulated that detrusor overactivity associated with urge incontinence would be more severe but there are no established criteria for judging severity. Using urge incontinence frequency as a yardstick and controlling for nonurodynamic contributing factors we sought intrinsic lower urinary tract parameters that reflect detrusor overactivity severity. We postulated that parameters in 1 or more of 5 domains would be important, namely characteristics of uninhibited contraction, bladder capacity, bladder proprioception, detrusor contractility and sphincter adequacy. MATERIALS AND METHODS: We analyzed data on 79 community dwelling incontinent individuals older than 60 years old. All subjects had urge incontinence on a 4-day voiding record and underwent multichannel videourodynamics. We examined the associations of urge incontinence frequency with the postulated key factors. RESULTS: Multivariable analysis revealed that 24-hour urine output and functional bladder capacity consistently predicted urge incontinence frequency. Bladder proprioception was significant in some models. Uninhibited contraction pressure was another predictor. Surprisingly higher uninhibited contraction pressure was associated with lower urge incontinence frequency. This negative correlation was more pronounced in a subgroup with a less adequate sphincter but absent in those with good sphincter function, implying that low uninhibited contraction pressure does not necessarily indicate less severe detrusor overactivity but rather reflects sphincter inadequacy in many patients. Age was not independently associated with urge incontinence frequency. CONCLUSIONS: We identified functional bladder capacity as a measure of detrusor overactivity severity. The measure commonly used, namely uninhibited contraction pressure, is inappropriate because it is severely confounded by sphincter function, especially in older individuals. Furthermore, we confirmed that urine output, and possibly bladder sensation and sphincter strength modify the clinical manifestation of detrusor overactivity.

Experience of an incontinence clinic for older women: no apparent age limit for potential physical and psychological benefits.

Urinary incontinence (UI) is a common but undertreated condition in older women. Although a variety of noninvasive interventions is available, older women may be hesitant to seek care for UI because of misconceptions about normal aging and treatment futility. We sought to evaluate the effectiveness of a UI clinic specifically tailored to the needs of older women to promote a sense of empowerment and to enhance satisfaction with treatment and outcome. We describe a case series of 52 women between the ages of 65 and 98 who were evaluated at the Geriatric Incontinence Clinic at the McGill University Health Centre over a 1-year period. A standardized telephone questionnaire was administered by a nurse consultant 6 months after each subject's final visit to assess patient satisfaction and current incontinence status. Forty-five women (86%) were available for telephone follow-up and completed the questionnaire. Mean age was 80 years, with urge incontinence in 45%, mixed incontinence (stress and urge) in 33%, impaired bladder emptying with urge symptoms in 10%, and other diagnoses in 12%. Overall, a mean reduction of 1.4 incontinent episodes per day was reported. At follow-up, 30% of the subjects reported being cured of their incontinence, 30% had improved, 20% were the same, and 20% were worse. Over 85% of all women reported satisfaction with their new incontinence status. Women of all ages, independent of the type of UI, type of treatment, and cognitive status, were able to achieve reductions in incontinence symptoms. All patients who had worsened were noncompliant with treatment recommendations at follow-up. Older women can derive significant benefit from a UI assessment. Neither advanced age nor category of incontinence precludes improvements or enhanced satisfaction with treatment. Efforts to improve targeting and compliance may improve outcomes.

Diagnosis and management of urinary incontinence in the older patient.

OBJECTIVES: To review the various causes of urinary incontinence (UI) in elderly patients and to outline a therapeutic approach to the clinical management of UI. DATA SOURCES: Online search of MEDLINE and additional references selected from the articles found during the search. STUDY SELECTION: All peer-reviewed articles and review articles listed on MEDLINE published between 1966 and 1999. Key search terms included urinary incontinence, geriatric, aging, pelvic floor rehabilitation, and indwelling catheter. DATA EXTRACTION: Articles with clinical relevance to the geriatric population were selected based on the robustness of the studies and reviews. If applicable, data from studies of healthier or younger populations was extrapolated to the elderly population examined in this review. DATA SYNTHESIS: UI is a common occurrence among older adults treated in rehabilitation settings. The causes of UI in the elderly vary, including transient causes, established pathologic states of the urinary tract, and systemic multifactorial influences. Both behavioral and pharmacologic management strategies can successfully be implemented for UI, even in the frail elderly. CONCLUSION: UI can be effectively investigated and treated by rehabilitation practitioners by following a simple, stepwise approach.

Voiding cystourethrography findings in elderly women with urge incontinence.

PURPOSE: We report voiding cystourethrography findings associated with urge incontinence in elderly women. MATERIALS AND METHODS: Two observers jointly reviewed voiding cystourethrograms of 50 cognitively intact and mobile elderly female participants in a drug trial for urge incontinence and 19 continent volunteers. Multichannel urodynamic testing was performed in all subjects. Bladder wall trabeculation and diverticula, cystocele and vesicoureteral reflux were noted. Maximal bladder capacity, post-void residual, and history of bladder suspension and hysterectomy were obtained from clinical records. RESULTS: Of the incontinent women 35 (70%) had trabeculation, which was mild in 30 (60%) and moderate in 5 (10%), and 41 (82%) had cystocele, which was mild in 23 (46%), moderate in 15 (30%) and severe in 3 (6%). Maximal bladder capacity ranged from less than 100 to more than 900 cc, and was greater than 500 in 37 incontinent women (74%). Of the continent women 16 (84%) had smooth bladders, 2 had mild (11%) and 1 had moderate (5%) trabeculation, and 11 (58%) had cystocele, which was mild in 8 (42%) and moderate in 3 (16%). In 7 continent women maximal bladder capacity was greater than 500 cc (37%). Differences between the 2 groups in regard to bladder wall trabeculation, maximal bladder capacity and presence of cystocele were significant at p<0.05. CONCLUSIONS: Large bladder capacity, bladder wall trabeculation and small to moderate cystocele on voiding cystourethrography are associated with urge incontinence in the elderly female population.

Continuous occlusion test to determine detrusor contractile performance.

PURPOSE: A study was conducted to determine the merits of the continuous occlusion test as a method of detrusor contractility assessment by comparing it with other stop tests and with contractility derived from pressure-flow analysis. MATERIALS AND METHODS: The continuous occlusion test was performed in elderly men by occluding the bladder outlet before the onset of a detrusor contraction and it was repeated to assess reproducibility. The magnitude of the isovolumetric contraction, maximum slope of the detrusor contraction, and duration of detrusor activation were determined. Voluntary and mechanical stop tests were performed during the mid voiding phase. Continuous occlusion test parameters were compared with the pressure-flow contractility parameters. RESULTS: The continuous occlusion test was evaluated in 159 patients. The maximum isovolumetric contraction pressure of the continuous occlusion test was significantly higher than that of the voluntary stop test (49 patients). Continuous occlusion test contractility parameters were reproducible. The maximum isovolumetric contraction pressure and the maximum slope of the detrusor contraction of the continuous occlusion test significantly correlated with the estimated maximum isovolumetric contraction pressure and estimated velocity of shortening (derived from pressure-flow), respectively (r = 0.79, p < 0.0001 and r = 0.385, p = 0.016, 39 patients). The watts factor was well correlated with maximum isovolumetric contraction pressure (r = 0.75, 39 patients). CONCLUSIONS: Our study suggests that the continuous occlusion test can be used as an effective alternative method of assessing detrusor contractility.

Correlation of American Urological Association symptom index with obstructive and nonobstructive prostatism.

The precise role of the American Urological Association (AUA) symptom index in the management of benign prostatic hyperplasia (BPH) is not well established. The AUA symptom index has been recommended only for quantifying the symptoms of BPH but not for its diagnosis. However, to our knowledge the ability to discriminate obstructive from nonobstructive BPH using the AUA symptom index has never been investigated. To establish the relationship between the AUA symptom index and prostatic obstruction 125 men (mean age 67.7 +/- 8.4 years) with voiding dysfunction presumably related to BPH were analyzed. Patients were given the AUA symptom questionnaire, following which video urodynamic studies were done, including micturitional urethral pressure profilometry for specifically diagnosing outlet obstruction. The patients were divided into 2 groups: group 1-78 with primary BPH dysfunction and group 2-47 with prostatism of ambiguous etiology. The mean AUA symptom index in group 1 (15.5 +/- 7.1) was not statistically different from that in group 2 (14.8 +/- 7.9). In both groups the mean AUA symptom index in the patients with obstruction (15.3 +/- 7.2 for group 1 and 13.9 +/- 7.9 for group 2) was not statistically different from that in the nonobstructed group (17.0 +/- 5.4 and 16.1 +/- 7.9, respectively). Of the severely symptomatic patients 22% did not have obstruction whereas all mildly symptomatic patients did. No significant correlations were found between the severity of obstruction and the AUA symptom index in either group. These observations indicate that the AUA symptom index cannot discriminate obstructed from nonobstructed BPH cases, not all severely symptomatic BPH patients will have outlet obstruction, a significant proportion of mildly symptomatic BPH patients can have outlet obstruction and voiding dysfunctions in elderly men, regardless of the etiology, produce similar symptoms.