IS NON PHARMACOLOGIC MANAGEMENT OFOVERACTIVE BLADDER UNDERUTILIZED?. RESULTS OF A SURVEY OF PHYSICIANSIN LEBANON.
A. ITANI1, M. JAFFAL1, T. BAZI 2;
1American Univ. ofBeirut, Beirut, Lebanon, 2OBGYN - urogynecology, AmericanUniv. of Beirut, Beirut, Lebanon.
Introduction: The management ofOveractive bladder (OAB) includes non-pharmacological treatment,pharmacological treatment and surgical intervention in refractorycases. Current guidelines support the initial use of avariety of non-pharmacological approaches such as behavioralmodification, scheduled voiding, Kegel exercise, weight reduction inoverweight women, and urge suppression. These optionsare not only effective, but also cost-free and without sideeffects.
Objective: To evaluate the approachof urologists and gynecologists in Lebanon in the initial managementof OAB in women.
Methods: Printed surveys addressing theinitial management of OAB were distributed and recollectedanonymously during national urology and gynecology conferences inBeirut, Lebanon. Data analysis was performed using descriptivestatistics; Chi squared test and Fischer’s exact test were used tocompare categorical variables.
Results: 130 completedsurveys (91 gynecologists and 39 urologists) were analyzed.
19.2%of respondents were younger than 35 years, 32.3% were 35-50 y.o,33.1% were 51-60 y.o,, and 15.4% were older than 60. 60.8% werepracticing at University affiliated hospitals. 46.9% reported thatthey evaluate 10-40 OAB patients per year, while 25.4% evaluate <10patients, and 27.7% evaluate > 40 OAB patients per year.
Exclusivenon-pharmacological treatment regimens for OAB are started by 25.4%of respondents, a combination of pharmacological andnon-pharmacological treatment is used by 43.8%, while 30.8% prescribeexclusive pharmacological treatment at the initial visit.
Specialtysignificantly correlated to initial treatment modality (p=0.043).Compared to gynecologists, urologists were 1.91 times more likely tostart exclusive pharmacological treatment, (CI 1.16-3.14).
Thechoice of treatment modality was not correlated to the number ofyears in practice (p=0.223) or university affiliation (p=0.433).While the number of OAB patients evaluated per year did notsignificantly correlate to the three treatment modalities (p= 0.224),practitioners evaluating <10 OAB patients per year were 2.6 timesmore likely to start exclusive non-pharmacological treatment comparedto those who evaluate > 40 patients per year (CI 1.03-6.64).
Amongnon-pharmacological treatment options, behavioral therapy was themost frequently used (94.4%), followed by weight reduction (82.2%),scheduled voiding (71.1%), and Kegel exercises(67.8%), and urgesuppression (31.1%).
Practitioners who start exclusivenon-pharmacological treatment justified their decision on the basisof medication cost (75.7%), or medication side effects(24.3%). Only30% of all respondents believe that OAB medications are effectivelong term (>6 months), and 40% believe that only a minority ofpatients will be using these medications after 6months.
Practitioners who only prescribe medications at theinitial visit cited the lack of effectiveness as the most commonreason for excluding non-pharmacological treatment options. Withinthis group, there was a statistically significant difference betweenthe two extremes of age brackets (<35 y.o vs >60 y.o) whereolder physicians were more likely to believe that mostnon-pharmacological options are not effective, compared to theiryounger colleagues (Behavioral therapy, p=002; Kegel exercises,p=0.001; scheduled voiding, p=0.011; weight reduction, p=0.006).There was no statistically significant difference between universityaffiliated and non-university affiliated practitioners in theirattitude towards "lack of effectiveness" of all fivenon-pharmacological treatment options.
68.5% of respondentsacknowledge there is a gap in their specialty training regarding atleast one aspect of OAB (diagnosis, pharmacological treatment,non-pharmacological treatment) with no difference betweengynecologists and urologists (p=0.48). However, whennon-pharmacological treatment is specified, only 1 in 39 urologistsand 10 in 91 gynecologists admit the presence of such gap. Whenanalyzing the answers of those who believe there is no gap in anyaspect of their OAB training, 26.9%, 29.3%, and 31.0% stated thatthere is no effectiveness of behavioral treatment, weight reduction,and scheduled voiding respectively.
Conclusions: Factorsaffecting the initial management of OAB in Lebanon include physicianspecialty and physician's age. A lower "OAB patient load"correlated with higher use of non-pharmacological treatment. Abouttwo-thirds of respondents admit the presence of some gap in theirtraining in regard to OAB. Up to 31% of those who are totallysatisfied with their OAB training did not believe in the value ofwell-established non-pharmacological treatment options ofOAB.
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