High Prevalence of Stress Urinary Incontinence in Adult Patients with Bronchiectasis
N Duignan1, MJ McDonnell1, MC Mokoka2, RM Rutherford1
1Department of Respiratory Medicine, Galway University Hospitals, Newcastle Road, Galway, H91 YR71, Ireland
2Beaumont Hospital, Beaumont, Dublin 9, Dublin Ireland
Stress urinary incontinence (SUI) is frequently under-reported in patients with chronic lung disease and may have negative psychosocial consequences. We conducted a prospective study to determine the prevalence, severity and treatment outcomes of SUI in female bronchiectasis patients referred for airway clearance techniques. Nineteen out of 40 (48%) patients reported SUI symptoms. Of these, 14 (74%) reported a reduced quality of life secondary to SUI. Following personalised intervention, symptom improvement was observed in 13/19 (68%). Five out of 19 (26%) required specialist referral for further continence care. No associations with lung disease severity and SUI were noted. SUI is common in adult female bronchiectasis patients and should be routinely screened for to improve patients’ overall quality of life.
The majority of bronchiectasis patients suffer from sporadic cough and often need to perform deliberate repeated cough manoeuvres to assist sputum clearance. Female patients may also have the additional burden of cough-related stress urinary incontinence (SUI). This symptom is rarely mentioned by the patient nor enquired about by medical personnel. SUI may be socially embarrassing, potentially leading to cough suppression, reduced sputum clearance performance and social withdrawal. Only a small number of studies have specifically looked at SUI in bronchiectasis. We therefore conducted a study looking at the prevalence, severity and treatment outcomes of SUI in our female bronchiectasis population.
This was a prospective analysis of adult female bronchiectasis patients routinely referred to our physiotherapy service for airway clearance techniques (Jan 2013-Jun 2014). All patients were systematically assessed by our chest physiotherapist for the presence, frequency and severity of SUI. Patients were asked to complete the International Consultation on Incontinence-Short Form (ICIQ-SF) symptom and quality of life (QoL) questionnaire. All patients with SUI were given a personalised treatment plan based on treatments relating to general bladder health, training in pelvic floor strengthening, and education of the ‘knack’ technique-whereby patients tighten their pelvic floor muscles just before initiating a hard cough and maintain the contraction throughout. Patient demographics, lung function, body mass index (BMI) and bacterial colonisation status were recorded to determine potential associations with bronchiectasis severity.
Of 40 patients assessed, 19 (48%) reported SUI with cough-related leakage of small to moderate amounts of urine occurring at least 2-3 times per week. Mean age was 63 years (range 38–86). Mean ICIQ score was 3.7 (range 0-13). Fourteen (74%) reported SUI interfering with their everyday QoL. A follow-up phone call to assess need for referral to women’s health specialist physiotherapy was made in 18 (95%) of SUI-positive patients; 12 (68%) felt their symptoms had significantly improved, 5 (26%) requested specialist referral for further continence care. We were unable to contact one patient on follow-up. On comparing patients with and without SUI, only older age was significantly associated with SUI (62.9 (12.5) vs 45.9 (20.8), p=0.004); no associations were observed for lung function, BMI or bacterial colonisation status.
This study shows the benefit of targeted multi-disciplinary care of bronchiectasis patients. Medical doctors often do not enquire regarding SUI, and many patients fail to mention these symptoms, often through embarrassment which may be exaggerated when reviewed by male doctors, or due to an expectation that nothing can be done or that it is not within the remit of respiratory staff to deal with.
Our respiratory physiotherapist routinely assesses female patients referred for sputum clearance for SUI providing treatment or referral to specialist services where initial treatment fails. Just under a half of our female patients had SUI, similar to two UK studies within this patient group1,2. Two-thirds gained significant benefit from treatment, a figure, again, very similar to one of the other interventional studies2. Patients with SUI were significantly older than their counterparts reflecting epidemiological data on SUI in the general population3. However, SUI does not appear to be related to underlying lung disease severity.
It is clear from our improvement rates of 68% post-intervention that targeting this patient population is essential to reduce SUI symptom prevalence and severity. Behavioural strategies to potentially reduce SUI are: avoidance of drinking large volumes of fluid before leaving home, or opportunistic micturition-voiding little and often. Respiratory-specific treatments include maximising sputum clearance techniques, including use of oscillation devices, which also has the benefit of expectorating at a time and place that suits the patient; prophylactic macrolide therapy, which has been shown to reduce exacerbation frequency in bronchiectasis and decrease sputum volume4; and inhaled corticosteroids, which have been shown to reduce sputum volume in patients colonised with Pseudomonas aeruginosa5. Bronchodilators and mucolytics may also ease expectoration and potentially reduce symptoms of SUI.
In conclusion, SUI is common in adult female patients with bronchiectasis and should be routinely screened for. SUI is rarely self-reported and negatively affects QoL. The majority of patients can be significantly helped by pelvic floor retraining and a significant number may also benefit from referral to specialist services.
Correspondence: Dr. Robert Rutherford, Consultant Respiratory Physician, Galway University Hospitals, Newcastle Road, Galway, H91 YR71, Ireland
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