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Re: Self Management of Men with LUTS: A worthwhile option
- TOLULOLA. O. TAIWO (23 November 2006)
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Is intervention in small groups easily available?
- Ramesh Munjal (8 January 2007)
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Taking responsibility for your health
- Kenneth A Hoekstra, PhD (9 January 2007)
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Self-management in men with uncomplicated lower urinary tract symptoms: Does it really work?
- Rasheed A Saad (10 January 2007)
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Urinary Tract Symptoms in Men
- Rosalind Maskell (12 January 2007)
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TOLULOLA. O. TAIWO, Resident/fellow Care of the Elderly program, Dept of Family Medicine, University of Alberta, Edmonton, AB T6G2S2
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Brown et al in their study comparing self-management versus the standard of care in the management of LUTS provide the prospect of a cost- effective non-pharmacological option in the management of this common condition. Self-management measures are worthwhile options in patients in whom the use of medications, particularly anticholinergics, is contraindicated. Their study appears to be based on the premise that active involvement of individuals in their health yields dividends - a fact well known to public health practitioners. The authors properly identified the small sample size as a potential limitation. Other limiting factors were the stringent inclusion criteria used in the selection process. A reasonable proportion of the patients we cater to have significant cognitive impairment and medical co-morbidities. Thirdly, well trained personnel appear to be central to the effectiveness and overall success of the program. This is likely to make the adoption of all the measures tenious. It would be useful if future studies are conducted to measure (the) long term benefits of self-management as nearly one-third (31%) of the particpants in that arm of the study were considered treatment failures at 12 months. The self-management option is definitely worth a try! Competing interests: None declared |
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Ramesh Munjal, Physician Sheffield
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Self management is usually the key to success for the management of many conditions. Men are not particularly forthcoming with LUTS and unless trained personnel are freely available, the risk of missing serious diagnosis may be high. Is there any value in doing tests like PSA as a base in this group (self management)of patients.It is not clear if baseline investigations are done or not. Competing interests: None declared |
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Kenneth A Hoekstra, PhD, Assistant Professor of Pathology Western States Chiropractic College
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I read with interest the article by van der Meulen et al. titled Self management for men with lower urinary tract symptoms: randomised controlled trial (BMJ 2007; 334: 25). The authors evaluated the effectiveness of a self management program as a first line intervention for men with lower urinary tract symptoms, and concluded that this health deliverty tactic significantly reduced the frequency of treatment failure and reduced urinary symptoms (1). As mentioned by the authors, similar studies have been demonstrated effective for chronic diseases such as type 2 diabetes, arthritis, and asthma (2), and a recent review highlighted self-management goals in congested heart failure patients (3). As academics, educators, practioners and preachers of health-related care, we long for the day where patients begin to take responsibility for their health, urinary or other. From infection-control practices to lifestyle modifications, patients have a direct influence on the outcome and future of their health. Direct, educated patient involvement in the prevention and/or treatment process of most diseases should only help not hinder the health-care provider. 1. van der Meulen J, Brown CT, Yap T, Cromwell DA, Rixon L, Steed L, Mulligan K, Mundy A, Newman SP, Emberton M. 2007. Self management for men with lower urinary tract symptoms: randomised controlled trial. BMJ 334:25 -28. 2. Newman S, Steed L, Mulligan K. 2004. Self-management interventions for chronic illness. Lancet 364:1523-37. 3. Jovicic A, Holroyd-Leduc JM, Straus SE. 2006. Effects of self- management intervention on health outcomes of patients with heart failure: a systematic review of randomized controlled trials. BMC Cardiovasc Disord. 6:43. Competing interests: None declared |
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Rasheed A Saad, Specialist Registrar Southampton General Hospital, Tremona Road, Southampton SO16 6YD
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Brown et al's trial of self-management in men with lower urinary tract symptoms (LUTS) (1) has a number of important limitations. Firstly, the nearly twofold difference in higher education qualifications between the standard care and self-management groups does call the integrity of the randomisation procedure of this rather small trial into question. Moreover, given the 'complex' nature of the 'problem- solving' and 'goal-setting' skills required by those undergoing self- management (1), this difference may well account for its apparent superiority. Secondly, in many respects what is most striking about this trial is not so much the efficacy of self-management but rather how dismally ineffective standard care appears to be. The authors have unfortunately failed to adequately describe what their “standard” care of men with LUTS actually entailed, a recurrent theme in previous self-management trials (2). One could reasonably argue that most of the components of the authors' self-management programme are an integral part of what a standard urological clinic consultation of any patient with LUTS should include (3). If this was not the case, the authors' results may well reflect the provision of inadequate "standard" care to these patients rather than genuine additional benefit conferred by self-management. Thirdly, it is conceivable that the trial’s single-blind design has fundamentally flawed the credibility of what is a principally symptom- driven (IPSS rise+/- alpha-blocker prescription) primary endpoint (4), resulting in patients in the self-management arm being less inclined to report their symptoms than those who received standard care alone. Lastly, the authors assert that they have adjusted their results to differences in clinical characteristics between the two intervention groups. Yet, it is highly questionable that this risk-adjustment was either valid or reliable given the relatively small number of treatment failures in the trial (5). Given the above methodological flaws, the authors' claim that self- management is as effective as drug therapy for men with LUTS remains unproved and requires re-examination in a larger better designed randomised controlled trial. References 1. Brown CT, Yap T, Cromwell D, Rixon L, Steed L, Mulligan K, Mundy AR, Newman S, Van der Meulen J, Emberton M. Self-management benefits men with lower urinary tract symptoms: a randomised controlled trial. BMJ 2007;334:25 2.Newman S, Steed L, Mulligan K. Self-management interventions for chronic illness. Lancet 2004; 364:1523-37. 3.Brown CT, Van der Meulen J, Mundy AR, Emberton M. Lifestyle and behavioural interventions for men on watchful waiting with uncomplicated lower urinary tract symptoms: a national multidisciplinary survey. BJU Int 2003; 92:53-7. 4.Day SJ, Altman DG. Statistics notes: blinding in clinical trials and other studies. BMJ. 2000; 321:504. 5.Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996; 49:1373-9. Competing interests: None declared |
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Rosalind Maskell, Retired PO9 6BS
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Dear Dr Godlee, In The Week in Quotes of the first number of the new BMJ you refer to 'lower urinary tract infection' whereas the paper and accompanying Editorial are actually about 'uncomplicated lower urinary tract symptoms in men'. Perhaps your slip allows me to make a brief comment on urinary tract infection in men? This is a fairly common and clinically unpleasant condition which affects men over a wide age range. The bacteriological diagnosis may be missed if the high numerical criterion of significance used in specimens from women is applied to those from men. In women, common bacteria are usually multiplying freely in bladder urine, whereas in men the infection is likely to spread to the prostate and is sometimes caused by unusual organisms. Furthermore, some antibacterial agents which are used successfully for treatment of women, for example nitrofurantoin and ampicillin, do not achieve a therapeutic concentration in prostatic tissue. Unlike women, in whom very short courses of treatment are usually effective, men require treatment for at least a week with an agent, for example doxycycline or ciprofloxacin, which penetrates the prostate. Some or all of these considerations may play a part in unsatisfactory treatment leading to long term problems. I suspect that they are still insufficiently recognised by both laboratories and clinicians. I have elaborated all these points, with extensive references, in print elsewhere (1). Despite the fact that nearly 20 years have elapsed since publication I suspect, from conversations with friends and erstwhile colleagues, that nothing has changed. 1 Maskell R. Urinary tract Infection in Clinical and Laboratory Practice. London: Edward Arnold, 1988. Dr Rosalind Maskell DM FRCP, Rowlands Castle, Hampshire, PO9 6BS Competing interests: None declared |
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