Ananias C. Diokno

Clean, Intermittent Self-Catheterization in the Treatment of Urinary Tract Disease

Based upon a series of studies involving urinary infection we postulated that most cases of urinary tract infection are due to some underlying structural or functional abnormality of the urogenital tract which leads to decreased resistance of tissue and to bacterial invasion. The urothelium or renal parenchyma can be affected through damage to its structural integrity by neoplasm, calculi, foreign bodies such as inlying catheters, traumatic instrumentation and so forth. However, the most common cause for increased susceptibility to bacterial invasion is decreased blood flow to the tissue. Blood flow to the bladder can be reduced by increased intravesical pressures and/or by overdistention of the organ. The resulting ischemic bladder tissue is then prey to invading gram-negative organisms from the patient’s own gut via the hematogenous or lymphogenous route. Transient bacteremia is believed to be a common phenomenon in healthy individuals. In the female patient poor voiding patterns, such as infrequent voiding, is the primary cause of cystitis whereas obstruction is the leading cause in the male patient.3–5 Thus, it can be inferred from our theory that maintenance of a good blood supply to the renal pelvis, ureter, bladder and urethra by avoiding high intraluminal pressures and over distension is the key to prevention of urinary tract infection. Residual urine in itself and organisms supposedly ascending through the urethra are of doubtful importance in the genesis of urinary infection. These ideas have led us to treat urinary tract infections in most girls and women with a regimen of frequent day and night voiding and appropriate antibacteria medication when indicated. We rarely have found it necessary to dilate the urethra or perform an operative procedure upon the lower or upper urinary tract, and this includes ureteral reimplantation for reflux. The concept under discussion provides an explanation for the tolerance of prolonged catheter drainage by many patients without becoming septic (for example cystostomy, ureterostomy and nephrostomy) and the excellent response of individuals following cutaneous vesicostomy, despite the fact that all of these people have continual bacteriuria. It will be observed readily, that the hypothesis serves also to account for the complications of catheter usage. As observed by Campbell “retention rather than catheterization is the thing to be feared.”7 A catheter which drains freely can provoke sepsis within minutes if it becomes obstructed and allows the bladder to overdistend or intravesical pressure to increase markedly. Under these circumstances the bacteria in the urine will be disseminated readily into the systemic circulation. Similarly intermittent catheterization becomes dangerous if the patient is catheterized and then the bladder is allowed to overdistend before catheterization is again performed. To recapitulate, intermittent catheterization of the bladder should be an innocuous procedure provided the bladder is not permitted to overdistend and it is performed in an atraumatic fashion. Furthermore, a clean and not an aseptic technique should suffice since any bacteria introduced by the catheter will be neutralized by the resistance of the host.

Epidemiology and Natural History of Urinary Incontinence

Abstract: This paper examines or current state of knowledge of the epidemiology of urinary incontinence. The population studied was community-dwelling non-institutionalized persons. The review includes discussion of the prevalence, incidence, natural history and presence of racial and ethnic differences in the epidemiology of urinary incontinence. We also review correlates and potential risk factors that have been revealed in epidemiological studies. Differences between epidemiological and clinical approaches to a health problem, help-seeking behavior and methodological issues for research are also discussed. We have reviewed a large number of completed studies in the field of urinary incontinence, and have emphasized high-quality and population-based studies. We also wished to present studies from a variety of countries. Because of the abundance of studies, only a small fraction can be presented here. Other studies may have equal standards and useful information, but lack of space precludes their inclusion.

Prevalence of Urinary Incontinence and Other Urological Symptoms in the Noninstitutionalized Elderly

The prevalences of urinary incontinence, difficulty in bladder emptying and irritative bladder symptoms are not known in the noninstitutionalized elderly in this country. A survey, consisting of a multi-stage probability sample of 13,912 households, was done in Washtenaw County, Michigan to estimate these prevalences. A total of 1,955 senior citizens 60 or more years old was interviewed. The prevalences of urinary incontinence, difficult bladder emptying and irritative bladder symptoms were 18.9, 22.1 and 11.8 per cent, respectively, in men, and 37.7, 10.8 and 17.4 per cent, respectively, in women. Urinary incontinence was significantly more prevalent among all respondents with bladder emptying and irritative symptoms than those without such symptoms (p less than 0.001). The frequency of voiding was significantly increased among respondents with incontinence, or emptying or irritative symptoms compared to asymptomatic respondents (p less than 0.001). These survey data are of importance to senior citizens, care providers and governmental agencies.

Prospective, Randomized, Double-Blind Study of the Efficacy and Tolerability of the Extended-Release Formulations of Oxybutynin and Tolterodine for Overactive Bladder: Results of the OPERA Trial

OBJECTIVE To compare the efficacy and tolerability of extended-release formulations of oxybutynin chloride and tolterodine tartrate in women with overactive bladder. PATIENTS AND METHODS The OPERA (Overactive bladder: Performance of Extended Release Agents) trial was a randomized, double-blind, active-control study performed at 71 US study centers from November 21, 2000, to October 18,2001. Extended-release formulations of oxybutynin at 10 mg/d or tolterodine at 4 mg/d were given for 12 weeks to women with 21 to 60 urge urinary incontinence (UUI) episodes per week and an average of 10 or more voids per 24 hours. Episodes of UUI (primary end point), total (urge and nonurge) incontinence, and micturition were recorded in 24-hour urinary diaries at baseline and at weeks 2, 4, 8, and 12 and compared. Adverse events were also evaluated. RESULTS Improvements in weekly UUI episodes were similar for the 790 women who received extended-release formulations of oxybutynin (n = 391) or tolterodine (n = 399). Oxybutynin was significantly more effective than tolterodine in reducing micturition frequency (P = .003), and 23.0% of women taking oxybutynin reported no episodes of urinary incontinence compared with 16.8% of women taking tolterodine (P = .03). Dry mouth, usually mild, was more common with oxybutynin (P = .02). Adverse events were generally mild and occurred at low rates, with both groups having similar discontinuation of treatment due to adverse events. CONCLUSIONS Reductions in weekly UUI and total incontinence episodes were similar with extended-release formulations of oxybutynin and tolterodine. In the oxybutynin group, micturition frequency was significantly lower, and the percentage of women reporting no urinary incontinence episodes was significantly higher compared with the tolterodine group. Dry mouth was more common with oxybutynin, but tolerability was otherwise comparable, including adverse events involving the central nervous system.

Epidemiology and natural history of urinary incontinence in women

Understanding the epidemiology (distribution and determinants) of urinary incontinence (UI), as well as its natural history is a very important issue. In this article, we discuss prevalence, incidence, natural history, and the variations that may be related to race and ethnicity. We focus on epidemiologic population comprising community-dwelling women who are not institutionalized. Our review clearly shows that there is a lack of advanced epidemiologic analyses. Variables that better characterize UI include frequency measure, quantity of urine loss, duration, type, and severity. These factors should be incorporated into basic study design so that more advanced and informative analyses may be conducted.

Health-related quality of life among adults with symptoms of overactive bladder: results from a U.S. community-based survey

OBJECTIVES To assess, by means of a survey, the impact of the symptoms of overactive bladder (urinary frequency, urgency, and urge incontinence) on the quality of life in a community-based sample of the U.S. population. METHODS A telephone survey was conducted in the United States among an age and sex-stratified sample of 4896 noninstitutionalized adults 18 years of age and older. From the responses to the telephone survey, a total of 483 individuals with symptoms of overactive bladder and 191 controls completed a mailed follow-up questionnaire to assess their quality of life using the Medical Outcomes Study Short-Form 20. RESULTS After adjustment for age, sex, and the use of medical care, the greatest differences in the quality-of-life scores between the patients with incontinent overactive bladders and the controls were in the health perception (17.6 points; P <0.001) and role functioning (13.0 points; P <0.001) scales. Those with an overactive bladder with the symptoms of frequency or urgency, or both, but without incontinence, also had significantly lower scores than did the controls in mental health (P = 0.026), health perception (P = 0.01), and bodily pain (P = 0.016). CONCLUSIONS These data indicate that individuals with an overactive bladder experience decrements in their quality of life relative to community controls. An important new finding from this study is that individuals with an overactive bladder, even without demonstrable urine loss, also have a poorer quality of life than that of controls.

Factors associated with women's decisions to seek treatment for urinary incontinence

BACKGROUND Urinary incontinence is a highly prevalent and burdensome condition among women. However, fewer than half of women with symptoms talk to a physician about incontinence, and the determinants of treatment seeking are not well understood. DESIGN A two-stage cross-sectional survey of adult U.S. women; 45,000 households participating in NFO Worldgroup survey research received a questionnaire to identify adults with incontinence. Based on stratified random sampling of identified incontinent women, 2310 women received a detailed questionnaire. RESULTS Among 1970 women with urinary incontinence symptoms, 38% had initiated a conversation with a physician about incontinence. In multivariate logistic regression analysis, some of the factors associated significantly with treatment seeking were symptom duration >3 years (OR 2.33, 95% CI 1.57-3.45), having a history of a noticeable accident (OR 1.41, 95% CI 1.06-1.87), worse disease-specific quality of life scores (OR 1.89, 95% CI 1.32-2.70), not being embarrassed to talk with a physician about urinary symptoms (OR 1.65, 95% CI 1.28-2.14), talking with others about urinary incontinence (OR 3.34, 95% CI 2.49-4.49), and keeping regular appointments for routine/preventive care (OR 2.25, 95% CI 1.54-3.29). CONCLUSIONS Less than half of community-dwelling adult U.S. women with symptoms of urinary incontinence have talked with a physician about urinary incontinence. In addition to duration of symptoms, factors associated with treatment seeking included the impact of incontinence on quality of life, lack of embarrassment about talking to a physician about urinary symptoms, and attitudes toward healthcare use. Concerns about the meaning of incontinence for overall and future health were important reasons for women choosing to seek treatment.

A digital test for pelvic muscle strength in women with urinary incontinence.

This article reports further experience with a Version 2 digital test performed on 208 community-residing women, 25 to 87 years old. Test-retest (n = 208) and interrater reliability (n = 36) scores for pressure, displacement, and duration were r = .54, .51, and .53 and r = .67, .73, and .55, respectively. Interrater reliability percentage agreement figures were exact for 94% of the women on pressure and 67% on displacement. With duration permitted to vary by 1 second, agreement was 75%. Validity was tested using vaginal electromyography score with correlation coefficients ranging from .37 to .63. A weak but significant correlation was found between the digital score and the stand-up test pad gain (r = -.12). No significant relationship was found between the digital test and a history of being able to stop the urine stream or other leakage measures. To address limitations in Version 2, a third version of the digital scale is proposed.

Medical correlates of urinary incontinence in the elderly

A probability sample of noninstitutionalized elderly people in Washtenaw County, Michigan, was interviewed to determine the relationship between urinary incontinence and various health conditions. The results show that between both male and female respondents physical mobility problems, specific neurologic symptoms, lower urinary tract problems, bowel problems, respiratory problems, and history of genital surgery are more prevalent among those who are incontinent than among those who are continent. Additional factors associated with incontinence in females are: history of parent and sibling incontinence, incontinence either during pregnancy or postpartum, hearing problems, use of female hormones, and vaginal infections. Incontinence among males is associated with vision problems and a history of and symptoms of cardiovascular disease. These findings suggest urinary incontinence is part of a complex and multifactorial problem. Further studies are needed to confirm and explain these findings.

Further Observations on Self-catheterization

A non-sterile technique of intermittent self-catheterization was used for 218 patients with an inability to void in a normal fashion because of obstructive uropathy, decompensated detrusor or neurogenic bladder. Marked improvement was noted in urinary continence, urinary infection, renal function, bladder emptying and, perhaps most important, the mental and emotional status of the patient and/or parents. The extremely low incidence of complications and its therapeutic efficacy clearly make clean, intermittent self-catheterization an outstanding weapon in the urological armamentarium and a most persuasive reminder that host resistance is still the primary factor in the occurrence of infection.