Compliance to Individualized Recommendations Based on an Evidence based Algorithm for Behavioral Management of Lower Urinary Tract Symptoms

Abstract

Purpose

The aim of this study was to evaluate patient compliance to individualized recommendations for self-management of fluid intake, bladder irritants, and timing of fluid consumption.

Design

Single group, before-after pilot study

Subjects and Setting

The sample comprised 22 patients (17 male and 5 females, mean age 62 years, age range 27 to 84 years). The study setting was the uroflow clinic at Southmead Hospital, Bristol, UK, a tertiary level referral hospital for complex evaluation and treatment of urological patients.

Methods

Patients were given a bladder diary to complete after two weeks, which was compared with the bladder diary they had originally brought to clinic, to see if the advice was followed. The bladder diary used required the patient document the times and volumes of urination over a period of 3 days, magnitude of urinary urgency felt at the time, along with fluid intake timing, amount and type of beverage. The study was not designed to measure changes in symptoms, but observed changes recorded in the bladder diaries are reported.

Results

All 6 of the 22 participants who were advised to increase the volume of fluid intake complied, with an increased average intake of a mean of 520 ml (range 100 to 1450 ml). Similarly, one participant advised to reduce fluid intake decreased their fluid intake by 1800 ml per day. Thirteen out of 16 patients (81%) who were advised to remove caffeine, alcohol or artificial sweeteners from their diet complied, indicated by no bladder irritant being recorded on their bladder diary. Nine out of 12 patients (75%) advised to reduce fluid intake in the evenings complied, decreased fluid intake after 6:00 pm by an average of 240 mL (range 100 to 550 mL less)

Conclusions

A majority of participants given fluid intake advice that is specific to their symptoms and lifestyle complied with recommendations. Simple guidance could usefully be given to patients before they are referred to specialist urological care or undergo urodynamic testing.

Introduction

Patients may be referred to a urologist or urogynecologist for urinary incontinence or related lower urinary tract symptoms even first line behavioral interventions such as fluid management have not yet been attempted. Despite guidelines clearly recommending behavioral intervention as first line therapy, I have encountered multiple patients who were referred to a consulting urologist for complex urodynamic testing without adequate management of intake of fluid and dietary intake, particularly volume of fluids consumed, timing of fluid consumption, and caffeine intake.^{1, 2} For example, Figure 1 summarizes bladder diary data of a patient who complained of frequent urination and nocturia. The cause of his complaints is readily suggested by the intake being almost entirely caffeinated tea and several drinks after 9:00 pm. In this case, we would recommend switching to decaffeinated beverages and restricting fluid intake after 6:00 pm which may alleviate bothersome nocturia without the need for additional investigations.

Figure 1.

A bladder diary from a patient referred to a tertiary hospital with frequency, urgency and nocturia. Clearly the amount of caffeine intake needs addressing before further investigation. Bladder sensation is recorded as ‘0’: no sensation; ‘1’: normal desire, no urgency; ‘2’: momentary urgency; ‘3’: prolonged urgency, no leakage; ‘4’: urgency with leakage.

We developed an easy-to-use, evidence-based system to give personalized advice on fluid intake, in order to assist self-management of fluids. In order first to check the project’s feasibility, we investigated the response of patients to a personalized fluid management advice, made on the basis of published evidence for conservative measures. Given the lack of evidence on the uptake of continence advice, this study was designed to measure the compliance of patients to personalized fluid intake suggestions (change of intake volume and/or timing, elimination of bladder irritants) given on the basis of symptoms, bladder diary and fluid intake.

Methods

Participants were recruited at a urine flow clinic based in the urology outpatient department of a regional referral hospital located in Bristol England. Patients attending clinic are asked to complete a 3-day bladder diary with urine output times and volumes, urgency scores and fluid intake timing, volume and fluid type for up to three days. An example of the bladder diary we use is shown in Figure 1. In the row corresponding to the hour of the day, the patient records the volume of urine passed, and the urgency sensed using ‘0’ for no sensation, ‘1’ for normal desire with no urgency, ‘2’ for momentary urgency, ‘3’ for prolonged urgency with no leakage, and ‘4’ for urgency with leakage. In further columns, the patient is asked to record the volume of fluid drunk and a description of the type of fluid. Patients with urinary tract infection, diabetes mellitus, any history of heart disease or who were taking medication for non-urological issues (with the possibility of effects on diuresis etc.) were excluded from the study. Eligible patients were those who recorded frequent urination (>8 urinations per waking day), urgency (bladder diary urgency scores >1) or nocturia (>1 urination at night) on their bladder diaries, and whose fluid intake record indicated possible causes of these symptoms. Specifically, we evaluated bladder diaries for 2 indications of potential response to fluid management: 1) presence of urgency or frequent urination along with bladder irritant intake, or 2) presence of nocturia along with intake after 6:00 pm. Ethical approval for the study was obtained from the South West Frenchay Research Ethics Committee (UK) reference 15/SW/0190.

We recorded participants’ height, weight, self-reported exercise level, and lower urinary tract symptoms. Recommended fluid intake amounts were calculated based on the US National Academies of Science Institute of Medicine (US IOM) reference intake guidance.² The exercise levels descriptions from that guidance (Fig 4-20, p.156) were used and assigned the following codes: 0= sedentary; 1= low active; 2= active; 3= very active, based on the patient’s own assessment of their activity. A simple algorithm based on published evidence, described in detail below, was applied and fluid management advice given (Figure 2). Patients were asked to fill in a second 3-day bladder diary at home after two weeks of attempting to follow that advice, and differences between the first and second bladder diaries were compared to assess adherence with recommended behavioral recommendations. Specifically, these differences measured were: change in average frequency of urination per day; change in fluid volume intake over 24 hours; change in fluid volume intake between 6 pm and bedtime; and consumption of bladder irritants.

Figure 4. Comparison of different sources’ recommendations for daily fluid intake.

Figure 2.

Flowchart of evidence-based self-managed action given on the basis of patient symptoms and lifestyle. Note that this should only be followed by patients without pain, haematuria, pregnancy, heart disease or other medical issues.

Algorithm development

Although good quality evidence is sparse for conservative measures^{3, 4}, several studies have shown that patients can experience improvement in lower urinary tract symptoms through lifestyle adjustments that can be self-managed.^5–8 A recent systematic review recognized that higher quality evidence is needed, but that associations between increased fluid intake and urinary frequency/urgency are reported in the literature.³ Hashim and Abrams⁵ showed that overactive bladder (OAB) symptoms can be relieved by reducing fluid intake by 25%. There are several studies that show reducing caffeine intake also can alleviate OAB symptoms^6,7,8, and one study reported improvements after reducing intake of saccharine and carbonated beverages.⁹ Although alcohol intake is commonly thought to increase OAB symptoms¹⁰, there is no evidence that removing it from diet reduces urge incontinence.¹¹ There is, however, evidence that alcohol acts as a diuretic.¹² Artificial sweeteners were found to enhance bladder contractions associated with OAB syndrome in an animal (rat) model¹³ and eliminating these and other potential bladder irritants has been shown to reduce lower urinary tract symptoms in humans¹⁰. Raising legs in the afternoon to drain fluid from the lower limbs before sleep is recommended for those affected by nocturia¹⁴, although it is supported by more consensus than evidence.⁴ It has been shown that reducing evening fluid intake reduces nocturia.¹⁵ Losing weight is associated with a reduction in stress incontinence and stopping smoking can have a similar effect.^16–18 Bladder training may be helpful in controlling leakage^19,20 and pelvic floor muscle exercises have been shown to alleviated stress, urge and mixed incontinence.²¹ These evidence-based recommendations are summarized graphically in the flowchart in Figure 2.

Fluid intake recommendations

The US Institute of Medicine has published recommended fluid intake for different levels of activity and ambient temperature². The graphs in this report can be characterized by the equation:

$$\text{Recommended}\text{intake}\text{in}\text{litres}\text{per}\text{day}=(0.05*A+0.1)*T+0.2$$

where T is the dry bulb temperature in °C, and A is the Activity Level (0= sedentary; 1= low active; 2= active; 3= very active). The model specifies the weight as 70 kg, and since diuresis is proportional to body weight²², we may assume that water requirements are too. Thus, Equation 1 should be adjusted for weight compared to 70 kg. The US IOM estimates food fluid content to account for 20% of cumulative fluid intake, so fluid intake through drinks should therefore be 80% of the recommended intake amount. Thus Equation 1, when factored for weight and for fluid content of food becomes:

$$\text{Recommended}\text{litres}\text{of}\text{fluid}\text{drunk}\text{per}\text{day}=0.8*\frac{\text{w}}{70}*(0.05*A+0.1)*T+0.2$$

where W is the person’s weight in kg.

To develop ‘High’ and ‘Low’ benchmarks for fluid intake, we applied evidence suggesting that a 25% reduction in fluid intake exerts a beneficial effect on OAB symptoms.⁵ Thus, high fluid intake would defined as 33% greater than the recommended value, in order for a 25% reduction to come back to normal intake. In order to guard against excessive reduction of fluid intake, a mirror threshold 33% below the recommended intake was used to signify low fluid intake.

Algorithm application

It has been shown that self-monitoring with basic health information input can significantly improve continence symptoms in some patients²³. We assert that improvements in affected individual’s health related quality of life and medical costs could be achieved through a public health information campaign based on the approaches summarized in Figure 2. Recommendations include regulating fluid intake to appropriate amounts, reducing intake of bladder stimulants, bladder or habit training and reducing consumption of fluids prior to sleep. For patients with urinary incontinence, losing weight, stopping smoking and undertaking moderate exercise are also recommended.

Data Analysis

Data from 22 patients were predicted to give 90% power for detecting a 260 mL difference in fluid intake, using data from the ICIQ bladder diary development study²⁴. This amount is well within the 25% reduction used by Hashim and Abrams⁵, so the recommended reduction would be adequately detected.

Compliance with advice given was measured by changes in accordance with that advice between data from the initial bladder diary and the diary returned after two further weeks. Change in fluid intake was measured by comparison between diaries of average daily fluid intake volumes and of intake volumes after 6pm. Compliance with elimination from diet of caffeine, alcohol or sweeteners was recorded if all these were completely absent from the second bladder diary.

Results

Twenty-two participants completed both bladder diaries, their compliance with advice given is summarized in Table 1. Sixteen patients had been advised to completely remove caffeine and alcohol from their diet, and 13 (81%) complied (i.e. no bladder diary recorded artificially sweetened drinks). Twelve participants had been advised to reduce evening drinks, and 9 (75%) complied, reducing their intake after 6 pm by a mean of 240 mL (range 100 to 550mL) (Figure 3A). Six had been advised to increase fluid intake, and all complied with this advice, increasing daily fluid intake by a mean of 520 mL (range 100 to 1450 mL). One patient was advised to reduce fluid intake and did so by 1800 mL (Figure 3B). Compliance with some evidence-based advice was not possible to gauge from the bladder diary used to collect data such as delaying urination (bladder or habit training) (number advised, n=6) and raising their legs in the afternoons (n=7).

Table 1. Results of pilot study of compliance with individualized fluid management advice.

Fluid management advice given	No. of patients receiving advicea	No. of patients complyingb	Other commentsc
Reduce fluid intake	1	1	Micturitions reduced from 13 /day to 10 /day
Increase fluid intake	6	6	4 increase daytime micturitions, 0 increase night time micturitions
Discontinue intake of caffeine and alcohol	16	13	10/16 reduced total micturitions, 2/13 noted urgency stopped, 3/13 reduced nocturia.
Reduce evening drinks	12	9	3/9 reduced nocturia

^amany patients received more than one piece of advice. The total number of participants was 22.

^baccording to the bladder diaries sent in 2 weeks following the advice in clinic

^cthis study was not designed to measure changes in symptoms, but some notable changes occurred

Figure 3.

Changes in fluid intake reported in bladder diaries after: A) recommendation to reduce fluid intake after 6pm; and B) recommendation to change total daily intake.

While this study was not designed to measure changes in symptoms, we found 12 patients out of the 22 participants (55%) achieved relief from at least one lower urinary tract symptom after following the advice given. Of the 13 patients who complied with advice to remove stimulants (caffeine, alcohol) from their intake, 8 (62 %) patients had a reduction in daytime voids (median of 2, range 1 to 6 fewer urinations), 4 (31 %) had an increase (median of 2, range 1 to 2 more urinations) and 1 (7 %) had no change at 4 urinations per day. Among the 13 participants advised to remove irritants, 3 (23 %) reported reduced nocturia (median 1.5, range 1 to 2 fewer urinations), 2 (15 %) had an increase of 1 urination per night and the remainder were unchanged. There were 9 patients complying with advice to reduce evening drinks, and of those 3 (33 %) had a reduction in nocturia of between 1 and 2 urinations.

Discussion

There is a general lack of evidence for the effectiveness of conservative measures on lower urinary tract symptoms, despite these being inexpensive, carryng a very low risk of adverse side effects, and easy to implement. Bradley and colleagues¹ reviewed 110 articles and concluded that although the evidence grade was generally low and was mostly observational, fluid intake was associated with urinary frequency and urgency in both men and women. They also reported some small studies that showed limited evidence that caffeine reduction may decrease OAB symptoms in women. Miller and associates¹⁰ studied the compliance of 30 women with advice to eliminate consumption of potential bladder irritants, and found that though symptoms did improve, full elimination was difficult for patients to achieve.

Furthermore, adoption of continence guidelines is known to be poor.⁴ All of the participants in this study had been referred to a tertiary level urology department for management of lower urinary tract symptoms, but none were aware of being previously advised to regulate intake of caffeine or reduce volume of fluid intake immediately prior to sleep. It is possible that had they been so advised and had complied; these symptoms would have diminished to the extent that referral and additional evaluation would not have been needed. Based on these findings, I assert that the effect of compliance to advice on self-management of fluid intake is worthy of additional study.

Findings from this feasibility study suggest that patients are able to comply with personalized advice based on their own bladder diary. I have further observed that completion of a bladder diary is an educational experience, and some may be able to change their fluid and dietary intake even without advice from a continence specialist. Nevertheless, the algorithm presented in this feasibility study are evidence based, and can be used with confidence by continence nurse specialists including WOC nurses, primary care providers, and health care professionals with no particular training in continence management.

Even though participants were evaluated in our tertiary referral center for continence management, many were unaware of these simple behavioral interventions that may lead to clinically relevant alleviation of lower urinary tract symptoms. Wyman and colleagues²⁵ pointed out that much of such advice has been published in journals and academic references intended for continence specialists, and it may not have been adequately disseminated to primary care providers.

There are a number of sources publicly available that give varying advice on recommended fluid intake, which are compared in Figure 4. The primary source appears to be the US IOM study used as the basis for the above algorithm, which was based on the median value of a US population-wide survey. This is available interactively on a web page²⁶ and is also used by another online intake calculator.²⁷ In the UK, very precise recommendations for fluid intake have been available in the past^28,29, and these were similar to the US IOM² derived figures. The European Food Safety Authority recommends 2 – 2.5 L/day based on urine osmolarity and survey studies³⁰, with appropriate increases recommended during physically active periods, and quotes a study, reflected in another online source³¹, that recommends 37 mL total water per day per kg body weight. These sources of information vary in the amounts suggested, as Figure 4 shows, indicating consensus is still lacking, and they do not link their recommendations with both lower urinary tract symptoms and environment, as our system does.

In terms of potential cost savings, it is difficult to ascertain what proportion of patients could be saved hospital or local doctor appointments by following the above advice. Our own hospital database suggests that 3% of patients seen for urodynamics have no obvious physiological reason for their LUTS and that advice on fluid intake could potentially have resolved the problem, which may result in a savings of over £7 million (approximately $8.7 million USD) in the UK alone.

Strengths and Limitations

I completed a feasibility study and described findings using descriptive rather than inferential statistical analyses. Findings from this study do not demonstrate efficacy of these interventions. Nevertheless, these findings support additional investigation in this area. Our group plans to develop both paper-based and web-based materials to test whether the symptomatic improvements from simple, personalized fluid intake advice are as significant as the above data suggest they could be.

Conclusions

Study findings suggest that results indicate that when patients are given fluid intake advice that is specific to their symptoms and lifestyle, the majority comply. This suggests that guidance, albeit simple, could usefully be given to patients before they are referred to specialist care for lower urinary tract symptoms. We plan a full investigation into the effect of such advice on symptoms, as this study suggests that a number of patients can find relief from symptoms through self-managed changes to fluid intake alone.