What Type of Urinary Incontinence Does This Woman Have?
Holroyd-Leduc JM, Tannenbaum C, Thorpe KE, Straus SE.
JAMA 2008;299:1446–1456.
Authorities from a number of leading medical centers in Canada, including the University of Calgary, Calgary, Alberta; the Institute Universitaire de Geriatrie de Montreal, Montreal, Quebec; and the University of Toronto, Toronto, Ontario, Canada, recently published a review article in JAMA on the office assessment of urinary incontinence. The objective of this article was to critically assess the evidence about the most accurate way to determine the type of urinary incontinence during an office assessment.
Using the range of years from 1966 to 2007, medical databases were searched using terms including urinary incontinence, diagnostic tests, medical history taking, physical examination, cough stress test, and urodynamics. Cohort studies of patients undergoing history, physical examination, and/or office procedures (excluding urodynamics) for diagnosing the type of urinary incontinence were included. English-language articles were identified that addressed the office diagnosis of urinary incontinence in adults excluding data from case reports. Case-control studies were considered when there was insufficient data available from cohort studies. Minimum inclusion criteria were completion of an appropriate reference standard in all patients and the ability to extract relevant data. Forty articles were identified for inclusion. Minimal data were available for men.
The authors reported that a positive bladder stress test might help diagnose stress urinary incontinence; however, a negative test is not as useful. An assessment combining the history, physical examination, and results of bedside tests to establish a clinical diagnosis appears to be of modest value in diagnosing stress urinary incontinence. The authors concluded that the most helpful component for diagnosing urge urinary incontinence is a history of urine loss associated with urgency. A bladder stress test may be helpful for diagnosing stress urinary incontinence.
We believe what is helpful in this report is the rigorous and scientific way the authors went about assessing the art of physician diagnosis and attempting to standardize what works and what may not be accurate. One concern is because of the rigorous inclusion criteria necessary, only 40 of 1896 articles were acceptable for inclusion. We feel that many urologists would say that although the other reports may not be perfect, there have been more than 40 good papers on this topic since 1966. The conclusions confirm the opinions of many urologists we have talked to in that a positive stress test validates stress urinary incontinence but a negative stress test may not. That may be the case where urodynamics may add value, but urodynamics were not considered in this review. Another limitation of the study was the focus only on women.
Development and Validation of the Overactive Bladder Satisfaction (OAB-S) Questionnaire
Piault E, Evans CJ, Espindle D, et al.
Neurourol Urodyn 2008;27:179–190.
This excellent international research team published an interesting work that develops and validates a measure of patient satisfaction with treatment in overactive bladder: the Overactive Bladder Satisfaction Questionnaire (OAB-S). Development of the questionnaire included a comprehensive literature review, development of a conceptual model, item elicitation and cognitive debriefing interviews with US-English- and US-Spanish-speaking patients, and assessment of the questionnaire’s translatability in other languages. Psychometric validation of the questionnaire was run on a longitudinal, nonrandomized study involving 201 OAB patients. Analyses included construct validity, concurrent validity, tests of reliability, known-group validity, and responsiveness (exploratory).
The OAB-S is a patient-completed questionnaire including 5 scales: OAB Control Expectations (10 items); Impact on Daily Living with OAB (10 items); OAB Control (10 items); OAB Medication Tolerability (6 items); and Satisfaction with Control (10 items). Additionally, the OAB-S has 5 single-item overall assessments including patient’s fulfillment of OAB medication expectations, interruption of day-to-day life due to OAB, overall satisfaction with OAB medication, willingness to continue OAB medication, and improvement in day-to-day life due to OAB medication. The hypothesized structure of the questionnaire was supported by statistical analyses. Internal consistency reliability and test-retest reliability were good for all dimensions. All dimensions except tolerability discriminated well according to self-reported OAB severity level and incontinence status. A key limitation of this instruction is that the effect for responsiveness was only low to moderate. This might be a shortcoming of the OAB-S and may be due to the wide distribution in this small sample size.
The authors concluded that the OAB-S is a valid, comprehensive instrument that assesses satisfaction with treatment of OAB based on independent scales that have demonstrated satisfactory psychometric performance. We believe that the OAB-S is a valuable tool in researching new OAB treatments. It is not something the average urologist will use clinically, however, as patients are usually forthcoming in terms of satisfaction when we prescribe a pill or perform surgery. But in a scientific trial we need such a validated instruction that can be used effectively among investigators to determine how satisfied patients really are because minute changes, such as a 2-episode/24-hour decrease in micturition frequency, may or may not translate into modest, moderate, or significant outcome satisfaction. Also, it seems that a great deal of work went into developing an extensive instrument, but the foundation was based only on a modest number of patients.