Tag Archive for: AOTM-May-2020

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Editorial: Guidelines on urinary incontinence: it is time to join forces!

Urinary incontinence is not life‐threatening and does not kill patients, but it is highly prevalent affecting millions of people worldwide, it significantly impairs quality of life, and the related health‐care costs are enormous. Thus, guidelines are crucial for helping us to achieve an optimal management of our patients with urinary incontinence.

In this month’s issue of the BJUI, Sussman et al. present a Guideline of Guidelines on urinary incontinence in women. They reviewed the guidelines of the American College of Obstetrics and Gynecology (ACOG) / American Urogynecologic Society (AUGS), American Urological Association (AUA) / Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU), European Association of Urology (EAU), International Consultation on Incontinence (ICI), and National Institute for Health and Care Excellence (NICE). The recommendations of the different guidelines were similar for the initial evaluation and conservative therapies but differed considerably in some points of invasive management. In brief, the most essential issues are the following: Basic work‐up includes detailed history taking and specifying the type of urinary incontinence, urodynamics is performed when it changes management and in cases of recurrent urinary incontinence after interventions, treatment follows a stepwise approach starting with conservative therapy and moving to invasive options as appropriate, and treatment of women with mixed urinary incontinence is focused on the predominant symptom.

Although the management of urinary incontinence is well defined and excellently summarised by Sussman et al., treatment often remains demanding in daily clinical practice due to insufficient effectiveness or relevant side effects, so that new therapeutic options are urgently needed. Vibegron is a novel β3‐adrenoreceptor agonist, and Yoshida et al. present in the current issue of the BJUI promising findings with this drug for treating severe urgency urinary incontinence related to overactive bladder. In a post hoc analysis of a randomised, placebo‐controlled, double‐blind, comparative phase 3 study, vibegron significantly reduced the number of urgency urinary incontinence episodes and significantly increased voided volume per micturition with a response rate exceeding 50% [Yoshida et al]. These results are encouraging and warrant further randomised controlled trials, but also vibegron seems not to be a miracle agent showing effects in the range of mirabegron or antimuscarinics. However, there is some light at the end of the tunnel: Closed‐loop optogenetic neuromodulation systems targeting specific neurons to control urinary tract function might completely revolutionise the field, although there are still relevant hurdles to overcome.

Guidelines should result from a rigorous and transparent process informed by the best available up‐to‐date evidence and safeguarded against biases and conflict of interests. This is a major challenge, and from a bird’s eye view, it is hard to comprehend that several guidelines on the same topic exist and it is even more difficult to understand that the recommendations of these guidelines are not congruent and sometimes even contradictory. For instance, in the case of a pelvic organ prolapse repair in a continent woman, the ACOG / AUGS, AUA / SUFU, and EAU guidelines discuss prophylactic anti‐incontinence surgery as an option, whereas ICI and NICE guidelines explicitly recommend against it. The redundancy is enormous, but societies and organisations still create their own guidelines – an unnecessary waste of resources. In recent times, the coronavirus pandemic has rapidly changed our life and paralysed our usual activities, we have to stand together, it is definitively time to join forces! The relevant societies and organisations should consult each other and coordinate their efforts. Together we are strong, let’s move forward to joint guidelines!

Article of the Month – Guidelines of the Guidelines: Urinary Incontinence in Women

Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial prepared by a prominent member of the urological community and a video by the authors; we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this month, we recommend this one. 

Guidelines of the Guidelines: Urinary Incontinence in Women

Rachael D. Sussman*, Raveen Syan and Benjamin M. Brucker
*Department of Urology, MedStar Georgetown University Hospital, Washington, DC, Department of Urology, Stanford School of Medicine, Stanford, CA, and Department of Urology, New York University Medical Center, New York, NY, USA

Introduction

Urinary incontinence (UI) is a common disease, with prevalence rates as high as 44–57% in middle‐aged and post‐menopausal women. Those with UI may experience physical, functional, and psychological limitations and diminished quality of life (QoL) at home and at work. The financial burden of UI care is significant, with an estimated direct cost of $19.5 billion (American dollars) in the USA alone.

UI can be classified into a number of different categories, with stress UI (SUI) and urgency UI (UUI) being the most common. Many professional organisations have created guidelines to help clinicians navigate the diagnosis and evaluation of UI, as well as the treatments including conservative, pharmacological, and surgical. The methodologies upon which most guidelines are based are similar, starting with systematic reviews and grading of available literature. Organisations then make recommendations with different definitions and strengths. Guidelines are not exhaustive, but rather serve as a practical review of evidence‐based management of ‘index patients’.

The present ‘Guideline of guidelines,’ updated from a 2016 publication, reviews various international guidelines that have been updated at different time intervals and provides an updated summary of the important similarities and differences on the management of UI in women.

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