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Overactive Bladder in Women: Symptom Impact and Treatment Expectations

Posted on: Saturday, 15 October 2005, 03:00 CDT

By MacDiarmid, Scott; Rosenberg, Matt

Key words: Nocturia - OAB - Quality of life - Urinary incontinence - Urinary symptoms

ABSTRACT

Objective: The objectives of this survey were to understand (1) the effects of overactive bladder (OAB) and urinary incontinence (UI) on women's lives and to understand (2) women's needs and expectations of health care providers and treatment related to these disorders.

Methods: Women (N= 1046) with self-reported symptoms of UI completed a survey via electronic mail about the impact of urinary symptoms, health care provider interactions, treatment practices and expectations, and co-morbid conditions.

Results: The majority of women rated urinary symptoms such as frequency (61%), urgency (80%), nocturia (72%), and UI (69%-88% by type of incontinence) as moderately or extremely bothersome. Over half of women with UI (55%) had not sought medical treatment, but instead used a variety of non-medical coping mechanisms for symptom management. More than one third of women (37%) would prefer that their health care provider initiate discussion about urinary symptoms. Approximately half of the women with UI in this survey desired a greater than 70% reduction in incontinence episodes in order to consider treatment effective.

Conclusion: Women are making an effort to cope with disruptive symptoms of OAB. However, a communication gap between health care providers and patients with urinary symptoms may be a barrier to appropriate medical therapy. Health care providers should routinely query patients about urinary symptoms. In addition to choosing a medical treatment that can produce a meaningful reduction in symptoms, health care providers should set expectations for patients and monitor patient satisfaction with the prescribed treatment regimen.

Introduction

Overactive bladder (OAB) is defined by the International Continence Society (ICS) as a symptom complex of urinary urgency (with or without urge incontinence), urinary frequency (voiding 8 or more times in a 24-h period), and nocturia (awakening at night to void)1,2. Symptoms of OAB, in particular urinary urgency and urinary incontinence, can have a major impact on quality of life (QOL)3,4.

Symptoms of OAB are prevalent in men and women, and the risk of developing OAB increases with age5. In a large US population-based survey among adults 18 years of age or older, the prevalence of OAB was approximately 16% among men and approximately 17% among women6. The prevalence of OAB increased with age, with a sharp increase among patients 40 years of age or older, and the increase was similar for men and women6.

Up to approximately two thirds (62%) of patients with OAB are incontinent7-9. More women than men experience urge incontinence in association with OAB6,7. In the National Overactive Bladder Evaluation (NOBLE) survey, 55% of women with OAB experienced urge incontinence, compared with only 16% of men with OAB6.

Even though symptoms of OAB, particularly incontinence, may have a substantial negative impact on daily activities, patients are often hesitant to discuss their urinary symptoms with health care providers. The rate at which patients consult with a physician regarding their symptoms ranges from 60% to as low as 6%3,7,10. Reasons for not seeking medical attention include embarrassment, lack of knowledge of treatment options, and the belief that urinary symptoms are a normal part of aging11. Importantly, one study showed that the main trigger for a patient seeking medical help was the degree to which urinary symptoms caused the patient distress and disrupted their daily life11. Thus, there is an important need to understand how OAB symptoms affect patients' daily lives, and to identify strategies that can improve communication between patients and their health care providers.

Patients with symptoms of OAB often rely on nonmedical coping strategies to manage their symptoms9. In a study of premenopausal women with urinary incontinence who are employed full time, 25% reported restricting fluid intake as a means of coping with urine loss10. Although OAB without incontinence may not be socially disabling, urinary incontinence appears to have a substantial negative impact on the everyday lives of women3. Among relatively young women with urinary incontinence (30-59 years of age), 19.4% avoided at least 1 social activity and 15.7% avoided sports due to their condition3. Patients may suffer from OAB symptoms for more than 2 years before seeking medical attention5.

Table 1. Definitions1 and survey questions related to urinary incontinence*

The objectives of this survey were to understand (1) the effects of OAB and urinary incontinence on women's lives and (2) the needs of women and their expectations of health care providers and treatment.

Methods

From September 10 to 16, 2004, a nationwide survey was conducted in the United States by random electronic mailing to adult members of a multimillion-member online panel of participants. The mailing described the research in general terms and directed interested respondents to a password-protected survey site. The survey contained questions about the occurrence and nature of urinary symptoms, and examined health care provider-patient communication, treatment practices, and co-morbid conditions. Participants were not paid cash incentives for their participation, nor were any other incentives provided. The survey questions were designed by the authors in conjunction with Harris Interactive and Nancy Mueller, executive director of the US National Association for Continence (NAFC). The survey was field tested by soliciting feedback from patients with selfreported urinary incontinence with regard to the clarity and appropriateness of the survey questions. The survey was modified based on this feedback.

During initial screening, the prevalence of urinary symptoms among women in the population was determined. Only women 30 years of age or older with urinary incontinence were included in the survey. Table 1 shows the specific survey questions used to determine the type of incontinence, which was based on the ICS definitions of UUI (urge urinary incontinence), SUI (stress urinary incontinence), and MUI (mixed urinary incontinence)1. Participants who reported only stressrelated urinary loss were classified as having symptoms of SUI, and those who reported only urge losses were classified as having symptoms of UUI. Women who reported both types of urinary loss were classified as having symptoms of MUI.

To adjust for any bias that might result from the propensity of individuals to participate in an online survey, rim weighting techniques were used to match the demographics of the US population (i.e., race, age, socioeconomic status, and geographic distribution). A separate analysis determined the probability that an individual would participate in a telephone survey generated by random-digit dialing compared with the probability of participating in an online survey. Based on this probability, propensity scores were assigned based on demographic, behavioral, and attitudinal responses. These propensity scores and demographic variables such as sex, age, education, income, and race were then used to weight the online data to be representative of the combined online/offline population of interest. Categorical and continuous data were compared using a traditional 2-group f test. Statistical significance was determined at the 95% confidence level.

Results

A total of 2951 women completed the initial screening, of whom 1139 (38.6%) reported urinary symptoms associated with OAB including urgency, frequency, urge incontinence, and/or nocturia. Based on a self-report of urinary incontinence, 1046 of 2951 (35.4%) women were selected for the analysis. Among the population of women with incontinence 389 (37%) reported MUI, 386 (37%) reported SUI alone, and 271 (26%) reported UUI alone (Figure 1).

Table 2. Demographic characteristics *[dagger]

Figure 1. A majority of women with incontinence experience urge incontinence. MUI = mixed urinary incontinence; SUI = stress urinary incontinence; UUI = urge urinary incontinence

The demographic characteristics of the participants are presented in Table 2. Age ranged from 30 to 85 years (mean, 53 years). Most participants were white (88%), and a little over half (52%) had completed at least some college.

Risk factors and co-morbidities

Participants selected survey responses that best described their typical daily consumption of caffeine and alcohol, as well as their smoking habits (Table 3). A minority of women with urinary incontinence consumed alcohol (39%) or smoked cigarettes (26%). Most (59%) consumed a moderate amount of caffeine (defined as 3 or fewer cups of caffeinated coffee, tea, or soda per day).

Table 3. Participant self-reported usage: caffeine, alcohol, and smoking* [dagger]

Table 4. Participants' medical history*

Participant reports of co-morbidities are shown in Table 4. A majority of women within each category of urinary incontinence (57%- 64%) had experienced vaginal childbirth. Obesity (39%), constipation (39%), and arthritis (36%) were the most common medical problems reported by participants. Diabetes and poor circulation were significantly more common in women with UUI or MUI compared to women with SUI (p < 0.05). Women with MUI were more likely to report sleep apnea, estrogen deficiency, and difficulty emptying their bl\adder than those with UUI and SUI (p < 0.05).

Symptoms and impact

Participants were asked to identify how bothered they were by each symptom on a 5-point scale (1 = not at all bothersome, 5 = extremely bothersome). As shown in Figure 2, a majority of women (61%-81%) with urinary incontinence reported that symptoms associated with OAB (i.e., nocturia, frequency, urgency, and urge incontinence) were very or extremely bothersome. Higher percentages of women with symptoms of UUI (82%-83%) reported high or extreme bother with their symptoms compared to women with symptoms of SUI (52%).

Overall, 21% of women reported that their urinary symptoms had a significant impact on daily life and activities: 34% of patients with MUI and 21% of patients with UUI strongly or completely agreed with this statement, compared with only 8% of patients with SUI. Urinary symptoms caused sleep disruption in all categories of urinary incontinence (Figure 3), however, more women with MUI or UUI reported considerable sleep disruption (54% and 39%, respectively) compared to women with SUI (22%). Participants also reported that urinary symptoms made them want to avoid social situations (24% of women with MUI, 13% of patients with UUI, and 4% of patients with SUI) and negatively affected their work or job (18% of patients with MUI, 8% of patients with UUI, and 3% of patients with SUI).

Figure 2. Women with urinary incontinence are bothered by their symptoms. Participants were asked the degree to which symptoms (shown on the x-axis) were bothersome. The percentage of women who reported that the symptoms were very or extremely bothersome is shown

Figure 3. Urinary symptoms disrupt sleep patterns. Participants were asked the degree to which they agreed or disagreed with the following statement: 'My urinary symptoms affect my sleep'. The percentage of women who reported that they strongly or completely agree is shown. SUI = stress urinary incontinence; UUI = urge urinary incontinence; MUI = mixed urinary incontinenc

Patient-health care provider dynamics

Almost half (44%) of all women in this survey were either 'somewhat comfortable' or 'not comfortable' discussing sensitive health issues with their primary care physician (PCP). Among the survey participants, 471 (45%) had talked to a doctor about their symptoms. Of those women, the vast majority (65%) talked to a PCP (Table 5). Women with SUI (25%) were more likely to discuss their symptoms with an obstetrician/gynecologist compared to women with UUI (14%) or MUI (15%). Importantly, about one third of women with urinary incontinence (37%) reported that they would be more comfortable discussing symptoms if a health care provider initiated the conversation (Figure 4). However, only 28% of women reported that their PCP asked about urinary symptoms.

Treatment expectations and experiences

A majority of women were receptive to discussing treatment options for urinary symptoms with their health care provider (Figure 5). Women reported using a variety of approaches to cope with their urinary symptoms, including pads or panty liners, bathroom 'mapping', pelvic floor exercises, prescription medication, and bladder training. However, only a minority reported marked or complete symptom relief from these methods, including prescription medications (Table 6).

Figure 4. Women prefer health care providers to initiate discussion about urinary symptoms. Participants were asked the degree to which they agreed or disagreed with the following statement: 'I would be more comfortable discussing urinary symptoms if my health care provider brought up the topic.' The percentage of women who reported that they strongly or completely agree is shown. SUI = stress urinary incontinence; UUI = urge urinary incontinence; MUI - mixed unnary incontinence

Table 5. Type of medical specialist women use for bladder symptom management*

Women were asked to identify a level of reduction (in 10% increments) in leakage episodes at which they would begin to consider prescription therapy effective. Approximately half of all women in the survey (49%) and of women with UUI alone (51%) indicated that they desired a greater than 70% reduction in leakage episodes to consider prescription therapy effective. Approximately one quarter of all women in the survey (26%) desired at least a 90% reduction in leakage episodes.

Discussion

This US study describes the impact and perceptions of urinary incontinence among women with SUI, UUI, or MUI. In addition, the results of this survey advance the current understanding of the dynamics between patients and health care providers in discussing and managing urinary symptoms, especially urinary incontinence.

In this study, we found that 1139 (38.6%) women reported at least 1 symptom related to OAB. Of the 1139 women with OAB-related symptoms, 660 (58%) had UUI alone or in conjunction with SUI (MUI). This finding is similar to the results of the NOBLE study in which 55% of women with OAB reported UUI6. This study confirms that UUI is a common symptom among women with OAB in the United States.

The overall rate of urinary incontinence was 35.4%. In other published surveys of urinary incontinence, the prevalence of this condition has been reported to range from 5% to 58%10,12,13. Therefore, our results are within the range for self-reported urinary incontinence. Among the patients with incontinence, 37% reported MUI or SUI, and 26% reported UUI. The distribution of different types of incontinence varies by the definitions used however, our findings are similar to those in other published reports4'12. Urinary incontinence compromised both sleep and daily activities and was associated with lifestyle constraints such as using pads and always knowing the location of the nearest bathroom. Particularly among women with MUI, social and work-related activities were also negatively affected. In this survey, women reported that the symptoms of UUI and MUI were more bothersome than were symptoms of SUI.

Figure 5. Most women are receptive to discussing treatment options with their health care provider. Participants were asked the degree to which they agreed or disagreed with the following statement: 'I am open to discussing treatment options that may improve my urinary symptoms with my doctor'. The percentage of women who reported that they strongly or completely agree is shown. SUI = stress urinary incontinence; UUI = urge urinary incontinence; MUI = mixed urinary incontinence

Table 6. Approaches women use to manage urinary symptoms*

The medical histories of women participating in this survey were consistent with known risk factors associated with urinary incontinence. For example, there is a higher prevalence of urinary incontinence among women who are overweight and/or have diabetes14,15. Although comorbidities and other aspects of medical history were based on patient self-report, they generally follow the known prevalence of these conditions in the general female population. A minority of women with urinary incontinence consumed alcohol or smoked cigarettes. While most of the women in the survey consumed a moderate amount of caffeine, the association between urinary incontinence and consumption of coffee versus tea is unclear15.

A communication gap may exist between heath care providers and women with symptoms of OAB. Women were receptive to talking about their OAB symptoms and treatment options but many did not want to begin the conversation themselves. These findings suggest that PCPs and other health care providers should initiate discussion of urinary symptoms with their patients. There are several validated patient questionnaires that could assist with screening for urinary symptoms, and be used as a starting point for a discussion of this sensitive topic16,17.

Despite the use of various coping mechanisms for OAB symptoms, the study results indicated that women were not experiencing effective symptom relief. Approximately half of the participants in this survey, whether classified as having SUI, UUI, or MUI, set 70% as the minimum reduction in incontinence episodes that they would consider clinically meaningful. Moreover, more than 1 in 4 women indicated a reduction of 90% or greater as the minimum response they would accept. Thus, health care providers should place greater emphasis on managing OAB symptoms with effective treatment strategies, and should ensure that they assess patient satisfaction with the treatment.

Limitations

The questionnaire used in this survey was not an Independent Review Board (IRB)-approved or validated tool; however, the information we were seeking to capture, including symptom impact, patient-physician communication, and treatment expectations, was more wide-ranging than what many validated tools encompass. This survey focused on women only because urge incontinence is more common among women. Our study participants were volunteers with self- reported symptoms of urinary incontinence. Thus, we cannot be certain that all women were correctly classified as having SUI, UUI, or MUI, nor can we confirm that the self-reported co-morbidities are bona fide. Some of the patients may have had functional incontinence, rather than the 3 types of incontinence described in this survey. However, the prevalence of functional incontinence is quite low relative to SUI, UUI, or MUI, particularly among the nonelderly18, and is therefore unlikely to be a substantial factor in this population in which the majority of women were under 65 years of age.

Although this survey was conducted among a population of women with access to e-mail and the Internet, weighting techniques were used to ensure that the data accurately reflected US demographics with regard to age, race, socioeconomic status, and geographic distribution. In support of this approach, our findings on the associations between OAB symptoms and co-morbidities, impaired daily activities, non-medical coping strate\gies, and health care provider- patient dynamics are consistent with the findings from other published reports of US population-based surveys4,8,9,14,19. However, the survey population does not match the US population with regard to race distribution. The original population that answered the online survey was so heavily biased to white participants that excessive weighting would have been required to meet the targets, which would have reduced weighting efficiency.

Conclusion

Greater emphasis should be placed on addressing the needs of patients with OAB, particularly those with urinary incontinence. Health care providers may want to use a simple screening mechanism to proactively identify patients with OAB. For example, health care providers can incorporate clinical inquiries about OAB symptoms onto inoffice patient medical history forms, and/or verbally query patients about urinary symptoms at regular office visits.

The goal of therapy for patients with OAB is to alleviate disruptive OAB symptoms and provide patients with relief from the constraints of OAB. Health care providers should choose treatments that provide a meaningful reduction in symptoms of urinary incontinence. For optimal clinical outcome, expectations should be outlined for patients and patient satisfaction with treatment strategies should be assessed routinely as part of a plan for follow- up care.

References

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2. Ouslander JG. Management of overactive bladder. New Engl J Med 2004;350:786-99

3. Abrams P, Kelleher CJ, Kerr LA, Rogers RG. Overactive bladder significantly affects quality of life. Am J Manag Care 2000;6(Suppl):S580-90

4. Coyne KS, Zhou Z, Thompson C, Versi E. The impact on health- related quality of life of stress, urge and mixed urinary incontinence. Br J Urol Int 2003;92:731-5

5. Wein AJ, Rovner ES. The overactive bladder: an overview for primary care health providers. Int J Fertil Women's Med 1999;44:56- 66

6. Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol 2003;20:327-36

7. Milsom I, Abrams P, Cardozo L, Roberts RG, Thuroff J, Wein AJ. How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study. Br J Urol Int 2001;87:760-6

8. Coyne KS, Payne C, Bhattacharyya SK, et al. The impact of urinary urgency and frequency on health-related quality of life in overactive bladder: results from a national community survey. Value in Health 2004;7:455-63

9. Ricci JA, Baggish JS, Hunt TL, et al. Coping strategies and health care-seeking behavior in a US national sample of adults with symptoms suggestive of overactive bladder. Clin Ther 2001;23:1245- 59

10. Fitzgerald ST, Palmer MH, Kirkland VL, Robinson L. The impact of urinary incontinence in working women: a study in a production facility. Women Health 2002;35: 1-16

11. Shaw C, Tansey R, Jackson C, Hyde C, Allan R. Barriers to help seeking in people with urinary symptoms. Fam Pract 2001; 18:48- 52

12. Minassian VA, Drutz HP, Al-Badr A. Urinary incontinence as a worldwide problem. Int J Gynaecol Obstet 2003;82: 327-38

13. Harrison GL, Memel DS. Urinary incontinence in women: its prevalence and its management in a health promotion clinic. Br J Gen Pract 1994;44:149-52

14. Brown JS, Grady D, Ouslander JG, Herzog AR, Varner RE, Posner SF, for the Heart & Estrogen/Progestin Replacement Study (HERS) Research Group. Prevalence of urinary incontinence and associated risk factors in postmenopausal women. Obstet Gynecol 1999;94:66-70

15. Hannestad YS, Rortveit G, Daltveit AK, Hunskaar S. Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT Study. Br J Obstet Gynaecol 2003; 110:247-54

16. Coyne K, Revicki D, Hunt T, et al. Psychometric validation of an overactive bladder symptom and health-related quality of life questionnaire: the OAB-q. Qual Life Res 2002;11:563-74

17. Seim A, Talseth T, Haukeland H, Hye K, Berg N, Bergeland T. Validation of a simple patient questionnaire to assist selfdetection of overactive bladder. A study in general practice. Scand J Prim Health Care 2004;22:217-21

18. Hunskaar S, Burgio K, Diokno A, Herzog AR, Hjlms K, Lapitan MC. Epidemiology and natural history of urinary incontinence in women. Urology 2003;62(Suppl 4A):16-23

19. Coyne KS, Zhou Z, Bhattacharyya SK, Thompson CL, Dhawan R, Versi E. The prevalence of nocturia and its effect on healthrelated quality of life and sleep in a community sample in the USA. Br J Urol Int 2003;92:948-54

CrossRef links are available in the online published version of this paper: http://www.cmrojournal.com

Paper CMRO-3013_3, Accepted for publication: 29 June 2005

Published Online: 12 August 2005

cloi: 10.1185/030079905X59076

Scott MacDiarmid(a) and Matt Rosenberg(b)

(a) Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA

(b) Mid-Michigan Health Centers, Jackson, MI, USA

Address for correspondence: Scott MacDiarmid, MD, Wake Forest University School of Medicine, Department of Urology, Medical Center Boulevard, Winston-Salem, NC 27157, USA. Tel.: +1 336 716 4310; Fax: +1 336 716 5711; email: smacdiar@wfubmc.edu

Acknowledgments

Declaration of interest: This publication is supported by Ortho Urology, a unit of Ortho-McNeil Pharmaceutical, Inc.

Dr. MacDiarmid has served on the speaker's bureaus and/or advisory boards of Odyssey, Ortho-McNeil Pharmaceutical, Pfizer, Watson, and Yamanouchi.

Dr. Rosenberg has received grant/research support, served as a consultant for, and/or served on the speaker's bureaus of GlaxoSmithKline, Lilly, Novartis, OrthoMcNeil Pharmaceutical, Pfizer, and Reliant.

Copyright Librapharm Sep 2005

Source: Current Medical Research and Opinion

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