Fourth International Consultation On Incontinence (ICI) - Initial Assessment Including Quality Of Life Committee Highlights

Main Category: Urology / Nephrology
Article Date: 25 Jul 2008 - 1:00 PDT

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PARIS, FRANCE (UroToday.com) - Dr. Staskin began the afternoon session by focusing on the initial assessment of UI in men and women. In women, the most important first steps are identifying incontinence and determining the degree of bother and the desire for treatment. In contrast to the previous consultation, this committee did not feel it necessary to identify the subtype of incontinence as part of the initial evaluation as long as conservative treatments are being used. Only if pharmacotherapy is to be started need the subtypes of incontinence be identified. Another change from the previous consultation is that in cases of mixed incontinence, initial treatment may be directed toward either component (stress or urge), not necessarily the more severe or bothersome one. Overall, the committee gave the history and physical examination component of the initial assessment a Grade D recommendation.

The importance of fluid/voiding diaries was stressed and given a Grade C recommendation. Dr. Staskin noted that the EAU recommends at least a 3-day diary, but the committee felt 1-day diaries were sufficient. Pad tests were not recommended (Grade D), but assessment for prolapse and urinalysis were (Grade D). As in the evaluation of male LUTS, the utility of routine post-void residual (PVR) measurement remains controversial for women. This committee recommended PVR determination in women with symptoms of voiding dysfunction or recurrent UTIs (Grade B), and that bladder scan testing is generally preferable to catheterization (Grade D). Dr. Staskin then went on to highlight several differences with the EAU recommendations, notably questioning the utility of treating vaginal tissue atrophy with estrogen.

Dr. Staskin then reviewed a recent publication from JAMA (Holroyd-Leduc J, Tannenbaum C, Thorpe H, etal. JAMA, 2008 299(12): 1446-1456), which reviewed 40 years of studies regarding the best way to determine the type of incontinence during the initial assessment. The review found that a simple question was the best way to diagnose urge incontinence, but that a systematic assessment was modestly helpful in diagnosing SUI. In addition, the paper concluded that a positive bladder stress test is helpful in diagnosing SUI, but a negative test is not as useful. He suggested areas for future research, including the need of PVR determination and the predictive outcome on different treatment types, and patient satisfaction with specialist vs. non-specialist care.

Dr. Staskin also spent a few minutes on the initial assessment of POP, which is very similar to the above recommendations for UI but with special attention to the physical exam of the vaginal vault. In general, conservative treatments should be offered initially to determine response and patient satisfaction. Areas suggested for future study included correlation of specific POP-Q findings with disease progression and outcomes of conservative and surgical therapy. The initial assessment of male UI was addressed by Dr. Staskin, and the recommended initial assessment was presented in flow-chart form. Again, the initial assessment that was recommended is very similar to the initial assessment for women. The committee noted, however, several important gender differences. For example, the incidence of OAB wet is lower in men until the 7th decade of life, male SUI is almost universally associated with prostate surgery or treatments for prostate cancer, and prostatic enlargement should be considered and addressed in male patients with OAB symptoms. Dr. Staskin noted several areas for future study, including the development of improved questionnaires for male UI with attention to incontinence and further study to aid in understanding the complex role of obstruction in incontinence generation.

Dr. Staskin then turned the podium over to Dr. Kelleher who presented the committee's recommendations on patient reported outcomes (PRO) assessment. Much of this portion of the presentation focused on the ongoing development of the ICIQ modular questionnaire. Dr. Kelleher pointed out that the current committee included assessment of all types of PROs, whereas the previous consultations focused on health-related quality of life questionnaires. He stressed the wide variety of types of PROs and the importance of the patient's subjective experience across a wide spectrum of outcome measures. Dr. Kelleher cautioned that not all of the recommended questionnaires meet regulatory requirements for clinical trials (i.e. FDA approval) and that the appropriate regulatory agencies be consulted early in the trial design process.

The next section regarding grading of questionnaires generated some controversy during the Q&A time. The committee stated their preference for adopting the ICIQ modular questionnaire whenever possible for standardization purposes, even though many of the modules have yet to be validated or even completed and other "Grade A" questionnaires already exist. The ICIQ modular questionnaire was then outlined; it is essentially a mix-and-match series of questionnaires that can be tailored to specific diseases. Each global questionnaire will generally contain a core element, an optional longer form element, disease specific and general HRQoL components, sexual function component, and a post-treatment module. All of the completed core modules, including the ICIQ-MLUTS (formerly ICS Male short form), ICIQ-FLUTS (BFLUTS short form), and the ICIQ-UI Short Form, were given Grade A recommendations by the committee.

Dr. Kelleher next went on to list other recommended questionnaires for UI/LUTS, POP, FI and sexual function. He reinforced the committee's unanimous conclusion that the ICIQ modular questionnaire should be used whenever possible. He encouraged everyone to consider working with the ICIQ project to develop new questionnaires in specific areas of need.

David Staskin, MD, and Con Kelleher, MD, Committee Chairs

Moderated by Saad Khoury, MD, and Tomohiro Ueda, MD, at the Fourth International Consultation on Incontinence (ICI) - July 5 - 8, 2008. Palais des Congres, Paris, France.

Written by William Jaffe, MD, a Contributing Editor with UroToday.

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