Re: Effect of Urinary Incontinence on Older Nursing Home Residents’ Self-Reported Quality of Life

Re: Effect of Urinary Incontinence on Older Nursing Home Residents’ Self-Reported Quality of Life

1342 GERIATRICS Editorial Comment: These authors looked at various assessment techniques to objectify urethral sphincter function before and/or afte...

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Editorial Comment: These authors looked at various assessment techniques to objectify urethral sphincter function before and/or after radical prostatectomy. The substance of the article represents a useful review, and the conclusion, well known, is that a shorter urethral sphincter length and a lower urethral closing pressure are both associated with an increased risk of sphincteric post-radical prostatectomy incontinence. Specific conclusions based on their rating of evidence (Oxford CEBM Levels of Evidence) are as follows: 1) there is no evidence that sphincter electromyography predicts which patients will regain continence after radical prostatectomy (level 3); 2) perfusion sphincterotomy plays no part in the preoperative assessment of the urethral sphincter function of patients awaiting radical prostatectomy, although postoperative measurements of this parameter and leak point pressures correlate with “intrinsic sphincter deficiency” in patients with post-prostatectomy incontinence (2b to 3); 3) there is some evidence that preoperative urethral pressure profile parameters (maximum urethral closure pressure and functional profile length) can predict which men will regain continence (2b), although there is insufficient evidence to propose an exact cutoff value (2b); and 4) there is some evidence that magnetic resonance imaging (MRI) determination preoperatively of urethral sphincter length can predict which men will regain continence (2b), although there is insufficient evidence to propose an exact cutoff value (2b). My read is that the authors consider sphincter length analyzed by endorectal MRI is potentially a valuable predictor of continence status following radical prostatectomy but they point out the limitations of such measurements: there is no standardized method for measuring membranous urethral length by MRI and the reproducibility of such measurement is unknown. Although logically attractive, the issues surrounding the use of MRI for such a prediction are not new.1,2 Alan J. Wein, MD, PhD (hon) 1. Myers RP, Cahill DR, Devine RM et al: Anatomy of radical prostatectomy as defined by magnetic resonance imaging. J Urol 1998; 159: 2148. 2. Burnett AL and Mostwin JL: In situ anatomical study of the male urethral sphincteric complex: relevance to continence preservation following major pelvic surgery. J Urol 1998; 160: 1301.

Geriatrics Re: Effect of Urinary Incontinence on Older Nursing Home Residents’ Self-Reported Quality of Life D. Xu and R. L. Kane School of Public Health, University of Minnesota, Minneapolis, Minnesota, and School of Nursing, Shandong University, Jinan, Shandong Province, China J Am Geriatr Soc 2013; 61: 1473e1481.

Abstract available at Editorial Comment: Multiple studies have demonstrated that urinary incontinence (UI) can have negative outcomes on quality of life (QoL) and other health parameters in affected individuals. UI can be associated with increased rates of depression, limitations in activities and social isolation. However, most of this research has been conducted in community dwelling elderly populations, and relatively few studies have examined these associations specifically in elderly nursing home residents. This research evaluated older adults living in long-term care facilities in the state of Minnesota to determine the influence of UI on general and disease specific QoL. Data were obtained on 10,683 nursing home residents 65 years or older. The prevalence of UI was high, at 65.8%. Overall selfreported QoL was rated as good (higher than 0.7 on a scale ranging from 0 to 1) by 8,620 of participants (80.7%). It is noteworthy that UI, defined as urine leakage 2 or more times weekly, did not appear to influence overall QoL in this cohort. However, UI appeared to diminish several QoL subdomains, including dignity, autonomy and mood. Health care providers should focus on these areas



of potential need in working with nursing home residents who experience UI. Future work will help to provide insight on the potential role of treatment in improving these QoL components for older adults in this situation. Tomas L. Griebling, MD, MPH

Suggested Reading Zorn BH, Montgomery H, Pieper K et al: Urinary incontinence and depression. J Urol 1999; 162: 82.

Re: The Effect of Systematic Screening of Older Women for Urinary Incontinence on Treatment Uptake: The URINO Trial E. Visser, J. H. Dekker, K. M. Vermeulen, E. J. Messelink, A. J. Schram, M. Y. Berger and G. H. de Bock Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands Maturitas 2013; 74: 334e340.

Abstract available at Editorial Comment: Urinary incontinence (UI) is a common clinical condition in older women. There is a growing body of evidence regarding evaluation and treatment of UI in this population. This study sought to determine effects of a screening protocol among primary care physicians. These researchers demonstrated that a simple intervention asking about UI using a single question on an intake survey and encouraging additional evaluation and treatment led to improved outcomes as measured by validated questionnaires and bladder diaries compared to usual care. Using a conceptual framework for analysis of screening tests, the authors identified that use of a single question met the majority of widely accepted criteria for screening tests. Their findings include that UI is an important health topic with accepted treatments, facilities for diagnosis and treatment are widely available, suitable tests exist that are acceptable to the population, there is an agreed on policy regarding whom to treat and case finding is an ongoing process. Remaining questions that will require additional research include the natural history of UI in older women, whether there is a latent or early symptomatic stage and whether case finding is economically balanced related to potential expenditures for UI as a whole. However, the findings are valuable for continence promotion among patients and providers, and they highlight the importance of asking about UI and encouraging women to seek additional evaluation and treatment. Tomas L. Griebling, MD, MPH

Suggested Reading Dmochowski RR, Blaivas JM, Gormley EA et al: Update of the AUA guideline on the surgical management of female stress urinary incontinence. J Urol 2010; 183: 1906. Gormley EA, Lightner DJ, Burgio KL et al: Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol, suppl., 2012; 188: 2455.

Re: A Good Alternative to Indwelling Catheter Owing to Benign Prostate Hyperplasia in Elderly: Memotherm Prostatic Stent I. H. Bozkurt, F. Yalcinkaya, M. N. Sertcelik, K. Zengin, M. Ekici and O. Yigitbasi Department of Urology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey Urology 2013; 82: 1004e1007.

Abstract available at



Editorial Comment: Initial enthusiasm for use of prostatic urethral stents in the treatment of patients with obstructive benign prostatic hyperplasia has been tempered by the risks and complications associated with some devices. Migration and other complications have frequently necessitated surgical removal of the stent. Although general use of these types of devices has waned in recent years, there may still be a role for prostatic urethral stents in highly select men who otherwise may not be candidates for surgical therapy. Several different stent designs have been developed, each with associated advantages and disadvantages. This study again demonstrates the potential usefulness of prostatic urethral stents in elderly men with complex comorbidities that preclude adequate response to pharmacological therapy, administration of anesthesia and other forms of surgical intervention. The design of the specific product used in this series appears to minimize the risks commonly associated with other stents, although migration of the device into the bladder was seen in several patients. Nonetheless, in this select population insertion of prostatic urethral stents may obviate the need for either indwelling or intermittent catheterization. Tomas L. Griebling, MD, MPH

Suggested Reading Gesenberg A and Sintermann R: Management of benign prostatic hyperplasia in high risk patients: long-term experience with the Memotherm stent. J Urol 1998; 160: 72. Milroy E and Allen A: Long-term results of UroLume urethral stent for recurrent urethral strictures. J Urol 1996; 155: 904.

Benign Prostatic Hyperplasia Re: b3-Adrenoreceptor Agonist Mirabegron is Effective for Overactive Bladder that is Unresponsive to Antimuscarinic Treatment or is Related to Benign Prostatic Hyperplasia in Men H. Otsuki, T. Kosaka, K. Nakamura, J. Mishima, Y. Kuwahara and T. Tsukamoto Department of Urology, Nagakubo Hospital, Kunitachi, Tokyo, Japan Int Urol Nephrol 2013; 45: 53e60.

Abstract available at Editorial Comment: The myriad of symptoms and pathophysiological etiologies in men with lower urinary tract symptoms (LUTS) would obviously preclude any single agent as universally effective. Given variable prostate size, types of symptoms (ie storage vs voiding) and concomitant confounding factors such as obesity, diabetes and sleep apnea, we continue to look for ideal therapeutic strategies. During the last decade there has been an increasing awareness that targeting the bladder directly with antimuscarinic agents can help men with bothersome storage symptoms. It is interesting that these agents, once verboten in men, are now an accepted therapy in virtually every urological guideline. Yet they have not been as widely used as monotherapy because of overstated concerns of urinary retention. Most are used in combination with an alpha-blocker. More recently a new class of agents that target the bladder, b3-adrenoreceptor agonists such as mirabegron, have received regulatory approval as therapy for overactive bladder. In this study a group of Japanese men were treated with mirabegron, some of whom had already failed therapy with an antimuscarinic agent. In this short-term nonplacebo controlled trial the evidence suggests that mirabegron was effective and well tolerated, although recalcitrant erectile dysfunction developed in 1 patient. While the findings are not surprising, one should be leery of over extrapolating these results. Many men in the study were on concomitant alpha-blockers, and