International Continence Society 2018 - Key Highlights
Leonie Yeap, Clinical Manager at WMHP, and I were fortunate enough to travel to Philadelphia, USA to attend the 48th
annual meeting of the International Continence Society held in August. The meeting, attended by around 1500 delegates from across the globe, is a forum for researchers, clinicians and students to explore the latest research on urinary and faecal incontinence and pelvic floor disorders. Our favourite workshop was one titled The Overactive Pelvic Floor
which inspired another of our articles in this newsletter on Provoked Vestibulodynia
. There were many interesting presentations and we explore five of them.
1. Better Patient Outcomes When Physio Is Combined With Mid-urethral Sling Surgery For MUI
This award-winning paper (best conservative management) titled the ESTEEM trial by Sung et al1, aimed to assess whether the addition of behavioural and pelvic floor therapy prior to Midurethral Sling (MUS) surgery leads to improved outcomes. It was a randomized, multi-center trial of 472 women undergoing MUS for Mixed Urinary Incontinence (MUI) (based on the Urogenital Distress Inventory (UDI)).
The physiotherapy intervention included education on voiding habits, pelvic floor muscle training and bladder training that commenced 1 month prior to surgery, and continued for 6 months post-op. The primary outcome was change in MUI symptoms 12 months post-surgery measured by UDI. Secondary outcomes included a range of patient related outcome measures.
The study found the addition of physiotherapy to surgery led to a significant improvement in MUI symptoms, including reduced UUI episodes, urinary frequency, pad use and improved quality of life, when compared to the MUS alone. The need for additional urinary treatment (ie OAB medication) was also decreased.
The researchers concluded that although the surgery improved MUI symptoms, combining it with behavioural and pelvic floor therapy was associated with greater improvements in urinary symptoms and quality of life at 12 months.
2. More Evidence Of Central Sensitisation Contributing To Overactive Bladder
There is a growing body of evidence regarding Central Sensitisation and Overactive Bladder. In our February 2017 newsletter
we explored this connection. At ICS there were further interesting papers exploring this concept. One of these was from the US group based in Nashville2
. In this presentation from William Reynolds the group hypothesizes that it is plausible that Central Sensitisation (CS) may contribute to Overactive Bladder (OAB) symptoms and that those with CS report greater psychosocial burden.
The aim of their study was to determine if subgroups of women with OAB and psychosocial characteristics demonstrate different degrees of CS seen via heat pain temporal summation. Study participants completed a range of questionnaires including OAB questionnaire, ICIQ-female LUTS, PROMIS depression, anxiety and the Central Sensitisation Index (CSI). The participants also underwent thermal cutaneous temporal testing.
The results identified a subgroup of women with increased psychosocial and somatic burden who also demonstrated more severe OAB and LUTS symptoms plus higher levels of CS. The researchers concluded that their findings support the hypothesis that CS contributes to OAB in some women. At WMHP we are now using the CSI for OAB patients to identify those who may benefit from management directed at central mechanisms.
3. Don’t Forget About The Bowels In OAB Patients
Previous studies have suggested an association between OAB and Bowel Dysfunction (constipation and IBS) with the two often co-existing. In another interesting study from the Reynolds group3, they aimed to determine if this association influences the severity of lower urinary tract symptoms.
99 women with OAB completed urinary symptom and bowel function questionnaires and were then categorised into three groups based on bowel dysfunction. They found that women with OAB and either constipation or IBS appear to have more severe OAB symptoms. Their results also suggest an association between OAB severity and constipation severity.
The researchers conclude the severity of concomitant bowel and bladder symptoms has implications for OAB patients, and that there may be underlying pathophysiological mechanisms. This research further supports the importance of assessing and managing Bowel Dysfunction for OAB patients, as highlighted in our Case Study of Jill
4. Migabegron Effective And Well Tolerated In Older Patients
This very large, multi-center study in the USA and Canada, led by Geriatrician Adrian Wagg4 aimed to assess the efficacy, safety and tolerability of mirabegron (a beta-3-agonist) vs placebo in adults over 65 with OAB. Patients were randomised to receive either 25mgs of mirabegron or placebo over 12 weeks. There was a flexible dosing regimen, with the option of titrating up to 50mg mid-way through the study. Outcome measures included 3-day bladder diary, a symptom bother score, and the Montreal Cognitive Assessment score.
The study found 39.3 % and 35.8% of patients taking Mirabegron 25mg and 50mg respectively were “cured” of incontinence at week 12, compared with 28.8% of placebo recipients. The authors interpreted this to mean that mirabegron was statically superior to placebo in alleviating major OAB symptoms and associated bother. Escalation to migabegron 50mg was not associated with additional benefit. There was no statistically significant change in cognition over the course of the study in any of the groups.
5. Round Table On Patient Communication And Medical Self-regulation
This was an unexpectedly fascinating session with 3 speakers. The first, Dr Arun Sahai a UK based Urologist challenged how we approach informed consent. Dr Thomas Lendvay a Urologist based at the University of Washington spoke about the teaching and assessment of surgical skills and importance of feedback.
Our favourite presentation was from Dr Shirley Moore, a nurse researcher from Ohio who heads a Centre of Excellence in Self-Management Research. The center focusses on the development of new knowledge regarding patient self-management of chronic conditions with an emphasis on the neurobiological mechanisms of health behaviour change. Her presentation provided an overview of recent advances in the science of behaviour change and self-management of chronic illness. She also explored evidence of the effectiveness of selected behaviour change techniques and delivery formats.
Shirley defined self-management as the ability of an individual, in conjunction with family, community and health care professionals, to manage symptoms, treatments, lifestyle changes and psychosocial, cultural and spiritual consequences of chronic illness. Self-management encompasses many different concepts; self-care, self-monitoring, adherence, health behaviour change, health education and collaborative care. It can apply to health promotion interventions, prevention strategies, acute care and chronic conditions.
The “hidden health care system”
The presentation explored the elements required to enhance self-management. They include collaborative definition of problems, goal setting and planning. It also includes the creation of a continuum of self-management training and support services that teach skills related to healthcare regimen, guide behaviour change and provide emotional support and finally active and sustained follow up.
Living with a chronic illness requires management of the illness itself (ie medication, exercise, symptoms), management of daily activities and roles (ie as a spouse, parent, worker) and management of the emotions (ie anger, fear, depression, isolation). Shirley suggests that self-care is a “hidden health care system” as it makes up 80% of health care, compared to 20% provided by professional care. She presented the systematic reviews in this area, concluding that the research base supporting self-management interventions is large and growing however there are gaps in terms of target conditions ie nothing on incontinence.
The ideal self-manager
Shirley’s final discussion explored whether or not we can identify the phenotype of the ideal self-manager. She wonders; do they have biological and behavioural markers and can we assess who is more likely to adequately manage their symptoms and use health promoting behaviours? How useful would this be!
Her Centre has been researching brain activation in self- management and the ability to differentiate emotion / empathetic processing from analytic processing. Their neurocognitive hypothesis is that in response to health information the brain will shift from emotion processing to analytic processing to support optimal self-management – meaning the individual can set goals and take action on them.
As clinicians who require our patients to undertake self-management interventions we have been “re-wiring” brains for a long time. Shirley suggests that understanding this, the mechanisms and how people process health information should help us determine the type, dose and timing of health information – to help us achieve “precision health care”.
1 Sung VW, Newman DK, Borello-france D, Richter HE, Lukacz E, Moalli P, Weidner A, Smith A, Dunivan GC, Ridgeway B, Mazloomdoost D, Carper B, Gantz M. A randomized trial comparing combined midurethral sling and behavioral/pelvic floor therapy to midurethral sling alone for mixed urinary incontinence – the ESTEEM trial. Abstract 3, Podium session 1, Best clinical, ICS 2018
2 Reynolds WS, Kaufman MR, Dmochowski R, Bruehl S. Temporal summation is elevated in women with OAB reporting high psychosocial burden. Abstract 266, Overactive Bladder 1, Scientific Podium Short Oral Session 15, ICS 2018
3 Reynolds WS, Kaufman MR, Dmochowski R. Overlap of bowel dysfunction and urinary symptom severity in women with overactive bladder. Abstract 271, Overactive Bladder 1, Scientific Podium Short Oral Session 15, ICS 2018.
4 Wagg A, Staskin D, Engel E, Herschorn S, Kristy RM, Schermer CR. A phase 4, double-blind, randomized, placebo-controlled, parallel group, multi-centre study to evaluate the efficacy, safety, and tolerability of mirabegron in older adult patients with overactive bladder syndrome (PILLAR). ABSTRACT 268, Overactive Bladder 1, Scientific Podium Short Oral Session 15, ICS 2018.