A MULTICENTRE STUDY OF ETHNICITY ANDDIAGNOSIS OF URINARY INCONTINENCE
G. THIAGAMOORTHY1, R.BRAY 2, J. E. HUNTER 1, G. ARAKLITIS 3,I. GIARENIS 4, L. CARDOZO 1, D. ROBINSON 1,V. KHULLAR 5;
1King's Coll. Hosp., London,United Kingdom, 2St Marys Hosp., london, United Kingdom,3Kings Coll. Hosp., London, United Kingdom, 4Norfolkand Norwich Univ. Hosp., Norwich, United Kingdom, 5ImperialColl. London, London, United Kingdom.
Introduction: Urinaryincontinence is a common problem affecting 42-71% of women and iscommonly divided into stress urinary incontinence (SUI), urgencyurinary incontinence (UUI) or a mixture of the two (MUI). To make adiagnosis, it is usual to take a detailed history, perform anexamination and if surgical treatment was considered, conductmulti‑channel filling and voiding cystometry. The currentNational Institute for Health and Care Excellence (NICE) guidance onthe management of SUI states that in cases of pure SUI, a clinicianshould not perform multi‑channel cystometry and whenconservative measures have failed, should consider surgery.[i]This may have been based upon the findings of two published trialswhich focussed on women with predominant SUI. However, these twotrials enrolled a mainly white cohort (~90%) and anecdotal evidencehas suggested that SUI symptoms caused by underlying detrusoroveractivity (DO) are more frequently found in the non-whitepopulation. This is a concern as DO has been shown in other researchas an independent risk factor for midurethral sling failure inwomen.[ii] In the current climate of mesh litigation andincreased numbers of mid-urethral tapes being removed from themarket, most specialist organisations have recommended robustcounselling of patients regarding risks.[iii]
Objective:The primary objective of this study was to investigate the influenceof ethnicity on urodynamic diagnosis and to consider whether contraryto these recommendations preoperative urodynamics may be appropriate,especially in women of non-white ethnic origin.
Methods:This was a multi-centre study of consecutive women at two inner citytertiary urogynaecology units recorded on a prospective database.Women who were over 18 years of age presenting with the predominantsymptom of SUI between April 2011 and June 2015 were included. Womenwho suffered recurrent urinary tract infections, were pregnant,puerperal or lactating were excluded. All women completed a three daybladder diary including a validated urgency scale (PPIUS) andvalidated quality of life scale (ICIQ). Ethnicity was self-reportedand grouped as either ‘white’ or ‘non-white’. The 'non-white'group included women who were Asian, Black, Mixed, Middle Eastern,and other. They subsequently underwent physical examination,urinalysis, uroflowmetry, cystourethrography and assessment ofpost-void residual. Statistical analysis was performed using IBM SPSSStatistics for Windows (Version 22.0. Armonk, NY: IBM Corp).
Results:655 women were included in the study, median age of 49 (range 18-84),median BMI of 26 (range 15-49). 399 of the women were white and 256were non-white. There was no difference with regards to BMI betweenthe groups but there were statistically significant differences withregards to age and parity but it is unlikely this was clinicallyrelevant (see Table 1).
Table1: Demographics of white vs non-white women presenting with SUI orMUI with predominantly SUI
This is the largest multi-centrestudy of ethnicity and urodynamic diagnosis. Our results (Table 2)demonstrate a large proportion of women presenting with SUI, afterUDS, are found to have DO instead. Non-white women are statisticallysignificantly at greater risk of DO than white women despite bothpresenting with the same symptoms suggestive of SUI. We found nodifference in the diagnosis of MUI or inconclusive urodynamic data.
Table2: Urodynamic findings between the white and non-white patients
Conclusions: Studiessuggesting that the office ‘stress test’ and symptoms aresufficient to make a diagnosis of USI prior to continence surgery maynot be valid in non-white women. Many large studies of incontinenceconcentrate on patients who are white, whereas in reality a large andgrowing proportion of our patients are from other ethnicities. Anover diagnosis of pure SUI based on symptoms and office basedassessments alone could have unfortunate consequences, especially inview of the ongoing controversy over the use of mid-urethral slings.Other medical specialties have recommendations stratified accordingto ethnicity and it may be time for Urogynaecology to consider doingthe same.
References: [i]https://www.nice.org.uk/guidance/cg171/chapter/1-Recommendations#assessment-and-investigation[ii]Int Urogynecol J. 2010 Feb;21(2):149-55[iii]http://iugasource.com/emails/2015/images/scooparticle072415.pdf