Incidence and remission rates of lower urinary tract symptoms at one year in women aged 40-60: longitudinal study
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7247.1429 (Published 27 May 2000) Cite this as: BMJ 2000;320:1429
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Dear Editor - We read with interest the study by Moller et al [1] who
found that the remission rate of lower urinary tract symptoms was as high
as 27.8% and that no single treatment modality including antibiotic
therapy was found to be beneficial on these symptoms overall.
This has important practical implications, especially for those who
see patients with this disorder regularly in the primary care setting. In
our hospital, we have conducted a study examining the extent of non-
compliance in patients prescribed with antibiotics in the Accident and
Emergency department and found that 31% of patients admitted to taking
none or substantially less than the full course of antibiotics.[2]
Given the fact that a quarter of women with lower urinary tract
symptoms remit in one year with or without treatment and that on average
one out of three patients will not be compliant with the antibiotic
therapy, it seems rational therefore to limit the use of empirical
antibiotics especially in those with equivocal evidence of infection.
Perhaps more emphasis should be placed on communication with the patient
together with appropriate advice and reassurance, for example information
leaflets. Moreover, when treatment is indicated, we would advocate a
short course (three days) of antibiotics which has been shown to be as
effective as a seven [3] or ten [4] day therapy. This is in line with the
recommendation by the SMAC Report striving to reduce the selection
pressure for antibiotic resistance.[5]
References:
[1] Moller LA, Lose G, Jorgenson T. Incidence and remission rates of
lower urinary tract symptoms at one year in women aged 40-60: longitudinal
study. BMJ 2000; 320: 1429-32.
[2] F. Lam, F. Stevenson, N. Britten, I. Stell. Compliance to
antibiotics prescribed in Accident and Emergency : the influence of
consultation factors. The Journal of Accident and Emergency Medicine.
2000; 17: 71.
[3] Trienekens TAM, Stobberingh EE, Winkens RAG, Houben AW.
Different lengths of treatment with co-trimoxazole for acute uncomplicated
urinary tract infections in women. British Medical Journal 1989; 299:
1319-1322.
[4] Charlton CAC, Crowther A, Davies JG, Dynes J, Haward MWA, Mann
PG, Rye S. Three day and ten day chemotherapy for urinary tract
infections in general practice. British Medical Journal 1976; 1:124-126.
[5] Standing Medical Advisory Committee Sub-Group on Antimicrobial
Resistance 'The path of least resistance' published by The Department of
Health. 1997
Mr Francis Lam MRCS(Ed) ( Senior House Officer ),
Dr Stefan Nash FRCS (Ed) ( Consultant )
From the Department of Accident and Emergency, Bromley Hospital, Kent.
Correspondence to Mr F.Lam, 4 Middlefield, London NW8 6NE
Competing interests: No competing interests
Jackson, Donovan and Abrams enquire about the reliability of our
study. The problem is: are reported changes in LUTS real or a
methodological artefact because of poor reproducibility?
This is a very
relevant and an important topic. We apologise that it is difficult to find
all relevant data in the published paper to fully assess this problem. We
are therefore pleased hereby to be able to elaborate further on our data.
Our questionnaire was based on The Bristol Female Lower Urinary Tract
Symptoms as mentioned. However, the number of answering categories was
shortened as to "never", "sometimes", "weekly or more (often)" or "daily
or more (each time)". In our experience a more detailed division only
tends to weaken reproducibility. To test reproducibility we asked a
subgroup of 100 women from the study to fill in identical questionnaires
two weeks apart. The subgroup comprised 50 women reporting one or more
LUTS and 50 women reporting no LUTS. Otherwise selection was randomised.
Response rate was 77%. In terms of calculating reproducibility data were
divided into two groups comprising women with symptoms more than or equal
to symptoms weekly (often) and women with less/no symptoms, respectively.
Classification into these groups was not arbitrary but thought to be a
clinical relevant cut off line as the line as well separated women with
from women with out bothersomeness (1). Regarding urinary incontinence the
test-retest showed an agreement in women with symptoms more than or equal
to symptoms weekly (often) on 86.4%, in women with less/no symptoms on
94.5%; overall 92.2%. Regarding LUTS calculated agreements were 93.1% and
97.9%, respectively; overall 96.1%.
In comparison Jackson et al found that 78% of symptom questions were
answered identically on both occasion (2). We assume this number is an
overall estimate? It is, however, well known that reproducibility
associates with the prevalence of a specific disease. If the prevalence is
low (as it usually is) overall reproducibility is misleading and one
should consider using kappa. At least one should specifically report
reproducibility in the symptom group as well as in the asymptomatic group.
Moreover, by using an overall estimate Jackson et al in their study
indirectly assume an underlying continuos scale, that the distance from
one category to another is equal regardless types of category. As
previously mentioned: we believe this is not the case as we observed a
sharp increment in bothersomennes when moving from women with symptoms
sometimes to women with symptoms weekly (often) (1).
In conclusion we believe that the instrument we have used is capable to
measure incidence and remission rates of urinary incontinence and LUTS.
However, we agree with the Bristol group that our estimated rates should
be interpreted with caution, as some fluctuation inevitably are part of a
questionnaire design. Thus the true incidence and remission rate could be
lower than reported.
1. Møller LA, Lose G, Jørgensen T. The prevalence and bothersomeness
of lower urinary tract symptoms in women 40-60 years of age. Acta Obstet
Gynecol Scand 2000; 79: 298-305.
2. Jackson S, Donovan J, Brookes S, Eckford S, Swithinbank L, Abrams P.
The Bristol female lower urinary tract symptoms questionnaire: development
and psychometric testing. Br J Urol 1996; 77: 805-812
Lars Alling Møller,
clinical research fellow
Gunnar Lose,
professor,
Department of Obstetrics and Gynaecology,
Glostrup County Hospital,
University of Copenhagen,
DK-2600 Glostrup, Denmark.
Competing interests: No competing interests
Moller et al are to be congratulated on their longitudinal study of
female lower urinary tract symptoms. The questionnaire used was not
described in detail but appears to be based upon 2 different instruments
(1,2).
The Bristol Female Lower Urinary Tract Symptoms (B-FLUTS)
questionnaire (2) uses a 5 point scale for reporting symptoms, respondents
have the option of replying "never", "occasionally", "sometimes", "most of
the time" or "all of the time" to a particular symptom, and when asked
about frequency they can reply "never", "once or less per week", "2-3
times per week", "once per day" or "several times per day".
This raises
the issue of reproducibility when the questionnaire is completed on more
than one occasion. Reproducibility of our instrument was good when a test-
retest analysis was performed at a two week interval, there being no
apparent change in the underlying condition during that time; 78% of
symptom questions were answered identically on both occasions, with no
responses changing by more than 2 categories. The instrument used by
Moller is reported to have "fair to excellent" reproducibility but details
are not supplied.
The definition used in their paper for incidence was
"the proportion of women in whom symptoms arise, or increase from
sometimes to weekly or more". Remission is defined as "the proportion of
women with symptoms occurring weekly or more in whom symptoms decreased to
less than weekly". It would appear therefore that a change in
questionnaire response by one category could be recorded as incidence or
remission. If reproducibility is similar to the B-FLUTS questionnaire over
20% of women, in whom there has been no apparent change in their
underlying condition, will change their response by 1 category or more
over a two week period.
Standardised questionnaires that have been tested
for validity and reliability should be used whenever possible so that
these sorts of measurement errors can be calculated. Moller may simply be
confirming test-retest error and the conclusion that there is an incidence
and remission rate of 10.0% and 27.8% for female lower urinary tract
symptoms over the course of one year should be interpreted with caution.
1 Bernstein I, Sejr T, Able I, Andersen JT, Fischer-Rasmussen W,
Klarskov P, et al. Assessment of lower urinary tract symptoms in women by
a self-administered questionnaire: test-retest reliability Int Urogynecol
J Pelvic Floor Dysfunction 1996;7:37-47
2 Jackson S, Donovan J, Brookes S, Eckford S, Swithinbank L, Abrams
P. The Bristol female lower urinary tract symptoms questionnaire:
development and psychometric testing. Br J Urol 1996; 77: 805-12.
Simon Jackson.
Consultant Obstetrician and Gynaecologist
John Radcliffe Hospital, Oxford
OX3 9DU
Jenny Donovan
Reader and Graduate Tutor
Department of Social Medicine, Bristol
University BS8 2PR
Paul Abrams
Professor of Urology,
Southmead Hospital, Bristol BS10 5NB
Competing interests: No competing interests
Incidence & remission rates of lower uri nary tract symptoms
Dear Sir - We read with interest the article by Moller et al1.
Although a well conducted study, it was disappointing to find that the
analysis and interpretation were poorly developed, making it potentially
misleading to some readers and difficult to appreciate the full value of
such prospective studies.
Incidence tells us the rate of development of new cases within a continent
population, whilst remission tells us the rate of recovery within an
incontinent population. Clearly these two rates cannot be directly
compared. If the actual number of new cases and remissions had been shown
in Table 2, they would probably have conveyed a fairly steady state of
prevalence which is actually the case.
The authors claim their incidence rate (5.8%) is comparable with other
studies (2-2.5%) but we have seen incidence rates of 1-22%2,3,4.
Similarly, they compare their remission rate of 38% with other studies (3-
13%) but we have found remission rates varying between 6 and 26%4,5.
Undoubtedly
differences in definition are important, but what is especially different
in this study is the age range 40-60 compared to 65 and over in previous
studies. It is quite plausible that younger cohorts have relatively low
incidence and high remission rates. It is also relevant that all the
studies are small scale and subject to substantial variation due to
chance.
The association between remission and certain factors is also explored in
this paper and it is suggested that symptoms improved as a consequence of
medical awareness or drug treatment. No consideration is given to the
likely connection with other, possibly transient, morbidity and the
natural tendency to heal which could render contact with services
confounding rather than causal.
Finally, the overall interpretation of the added value of this study is
especially vague. It would have been appropriate for example, to point
out that an incidence rate is a guide to the number of new cases needing
assessment in a population each year in comparison with other conditions.
Remission rates are useful reference points for interpreting the magnitude
of an effect of treatment in uncontrolled trials. Together these rates
allow a deeper understanding of the behaviour of the problem and its
prognosis.
Dr C.W. McGrother, Senior Lecturer in Epidemiology
Dr H. Dallosso, Research Associate
Mrs M. Donaldson, Research Associate
and the MRC Incontinence Study Team
Department of Epidemiology and Public Health, University of
Leicester, 22-28
Princess Road West,
Leicester, LE1 6TP
References
1. Moller et al. Incidence and remission rates of lower urinary
tract symptoms at one year in women aged 40-60: a longitudinal study. BMJ
27 May 2000; 320: 1429-1432.
2. Holtedahl K, Hunskaar S. Prevalence, 1-year incidence and
factors associated with urinary incontinence: a population based study of
women 50-74 years of age in primary care. Maturitas Journal of the
Climacteric and
Postmenopause 1998; 28:205-211.
3. Burgio KL, Matthews KA, and Engel BT. Prevalence, incidence
and correlates of urinary incontinence in healthy, middle-aged women. J.
Urol 1991; 146:1255-1259.
4. Herzog AR, Diokno AC, Brown MB, Normolle DP, Brock BM. Two
year incidence, remission and change patterns of urinary incontinence in
non-institutionalised older adults. J Gerontol 1990; 45: M67-M74.
5. Nygaard IE and Lemke JH. Urinary incontinence in rural older
women: prevalence, incidence and remission. J Am Geriat Soc 1996;44:1049-
1054.
Competing interests: No competing interests