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Without accurate follow up, the paper by Kontos et al. could not have been written. None of the 80 or so papers that I have written on prognosis of breast cancer would have materialised. It is of concern that the progress in molecular biology is not always being matched by high quality clinical information. Theoretically, all patients who participate in randomised trials are being followed up, but not those who have been treated empirically. Academic breast units must find resources so that virtual follow up with annual mammography and an annual brief questionnaire should be the default position for all women who have been treated for breast cancer. Only in this way

References 1 Kontos M, Roy P, Rizos D, Petrou A, Hamed H. Contralateral relapse after surgery for breast cancer: evaluation of follow up paradigms. Int J Clin Prac 2013; 67: 1113–7. 2 Montgomery DA, Krupa K, Cooke TG. Follow-up in breast cancer: does routine clinical examination improve outcome? A systematic review of the literature. Br J Cancer 2007; 97: 1632–41.

can we construct accurate survival curves and monitor the impact of our therapies on women with this protean disease.

Disclosure No conflict of of interest disclosed. I. S. Fentiman Professor of Surgical Oncology Research Oncology, 3rd Floor Bermondsey Wing, Guy’s Hospital, London, UK Email: [email protected]

3 Mellink WAM, Holland R, Hendriks JHCL, Peeters PHM, Rutgers EJT, van Daal WAJ. The contribution of routine follow-up mammography to an early detection of asynchronous contralateral breast cancer. Cancer 1991; 67: 1844–8. 4 The GIVIO Investigators. Impact of follow-up testing on survival and health-related quality of life in breast cancer patients. A multicenter randomized controlled trial. JAMA 1994; 271: 1587–92.

5 Grunfeld E, Mant D, Yudkin P et al. Routine follow up of breast cancer in primary care: randomised trial. BMJ 1996; 313: 665–9. 6 National Institute for Clinical Excellence. Guidelines 2009. Early and locally advanced breast cancer. Diagnosis and treatment. 2009. doi: 10.1111/ijcp.12221

EDITORIAL

The burden of urgency urinary incontinence on health and wellbeing Linked Comment: Coyne et al. Int J Clin Pract 2013; 67: 1015–33.

Urgency, which is a compelling desire to pass urine which is difficult to defer, is a pivotal symptom of the overactive bladder symptom complex

We would like to congratulate the authors on this impressive and timely review of the world literature relating to urgency urinary incontinence. Overactive bladder (OAB) is a common, chronic lower urinary tract symptom syndrome that increases in frequency with age (1). Its most widely accepted definition is ‘urinary urgency with or without urgency incontinence usually accompanied by frequency and nocturia’ (2). The diagnosis necessitates the exclusion of other potential causes of symptoms such as urinary tract infection (UTI). The sine qua non of OAB is the sensory symptom of urinary urgency, described as a ‘sudden and compelling desire to void that is difficult to defer’ usually for fear of leaking (2,3). This was emphasized in a review of this subject which summarized the importance of urgency (Figure 1) (4). When the patient leaks before reaching the toilet this is termed urgency urinary incontinence (UUI),

albeit the term urge urinary incontinence, is still widely used in the literature and is a misnomer as urge is a normal sensation whilst urgency is a pathological sensation. Patients with urinary incontinence are unsurprisingly more bothered by OAB than those without (1). Non-voluntary contractions of the detrusor muscle, detrusor overactivity (DO), are often associated with UUI and more commonly in men than women (5). In women, stress urinary incontinence (SUI) is more prevalent which probably accounts for the weaker association between DO and UUI. A combination of UUI and SUI is termed mixed urinary incontinence (MUI). UUI and MUI are usually more bothersome than SUI (6) which can be attributed to the sudden and unexpected nature of urgency as contrasted to the latter where leakage can be controlled to an extent by anticipating the situations leading to incontinence. ª 2013 John Wiley & Sons Ltd Int J Clin Pract, November 2013, 67, 11, 1069–1075

Editorials

Urgency

Nocturia

Increased frequency

1/3

Incontinence

Reduced volume voided/micturition

Figure 1 The importance of urgency as the driver of other Overactive bladder (OAB) symptoms

The review by Coyne et al. for the first time presents a comprehensive synthesis of the literature on the burden of UUI and its correlates in terms of co-morbidities (7). A total of 71 studies in general populations and specific groups were included in the analysis. The presented data provides a contemporary insight into the profound impact UUI can have on the individuals’ physical, social and mental wellbeing as well as sexual function. Additionally the association of UUI with common co-morbidities and the nature of theses associations are evaluated. Falls are a major concern for many older people, their families and care givers due to the risk of significant morbidities that are associated with an incidence of mortality such as hip fractures and head injuries (8). Logically, the need to rush to get to the toilet in time may increase the risk of mechanical falls in older people with poor mobility. Although the causality of the association is not clear from the available evidence, in practice it is essential to consider this issue when treating elderly people with OAB or assessing those at risk of falls, especially in the context of prescribing pharmacotherapies that may affect vision, mental functioning or blood pressure. Patients with UUI should also be offered containment appliances that may provide security against soiling of clothes and furniture thereby maintaining social continence. The major limitation of population based studies of UUI is the variations in the way the symptom is defined as well as the reliance on participant based reporting which in turn is dependent upon a subjective interpretation of a subjective parameter. Further complicating matters, it is not altogether clear whether urgency is a binary or continuous phenomenon, as described by the analogy to a standard light switch (on/off) or dimmer switch (progressively increasing intensity). It must furthermore be appreciated that the terms urge and urgency cannot be inguistically easily differentiated in many languages. Differentiating urge, a normal sensation felt when the bladder is full, from urgency, a pathological ª 2013 John Wiley & Sons Ltd Int J Clin Pract, November 2013, 67, 11, 1069–1075

sensation, can be extremely challenging even in clinical practice. In women in particular there is a significant co-existence of UUI with stress urinary incontinence due to sphincter weakness, which emphasises that OAB is a non-specific storage symptom complex not a condition. This should be borne in mind when interpreting the meaning of any epidemiological data. Both UTI and diabetes mellitus are conditions that can manifest with symptoms of OAB and should be excluded (or adequately treated). This complicates any assessment of the association between these problems and the symptoms of OAB and UUI. A UTI is usually a transient event; as such UUI that may occur as a consequence of UTI would not normally be expected to lead to a persisting impact on quality of life and is clearly entirely different to OAB symptoms which have a chronic course. A study of patients attending primary care with OAB found that 27% were prescribed an antibiotic suggesting the distinction between the two is often missed in real clinical practice (9). A further complication is provided by the observation that detection of UTI can be difficult and that subclinical UTI’s may be associated with OAB symptoms (10). The bothersome impact of UUI also affects mental health, productivity and sexual function. Anxiety and depression are both consistently associated with UUI. In particular, the need to always be near toilet facilities can severely restrict a persons movements outside their home, with its impact on both work and social interaction and is a contributory factor to anxiety or depression (11). Work productivity can also be impaired by UUI, as demonstrated in the EpiLUTS study (12) whilst the EPIC study found that OAB sufferers are significantly more likely to be unemployed compared to controls (42.0% vs 33.6%) (13). Bearing these factors in mind when assessing patients and monitoring their response to treatment is essential to holistically managing the problem. The review by Coyne and colleagues clearly highlights the personal burden of UUI and emphasizes the importance of a comprehensive assessment that is not only limited to symptom severity and bother but in particular excludes other significant causes of OAB in the lower urinary tract and encompasses important aspects of health related quality of life that are important to patients.

Disclosure Christopher Chapple is a consultant and researcher for Allergan, Astellas, Pfizer, Recordati. Nadir Osman has no conflict of interest.

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N. I. Osman, C. R. Chapple Department of Urology, Royal Hallmashire Hospital, Sheffield, UK Email: [email protected]

References 1 Irwin DE, Milsom I, Hunskaar S et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: results of the EPIC study. Eur Urol 2006; 50: 1306–14. 2 Abrams P, Cardozo L, Fall M et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 2002; 21: 167–78. 3 Rosier BJ. A prospective study to find evidence for the ICS definition of urgency. Neurourol Urodyn 2006; 25: 517–8. 4 Chapple CR, Artibani W, Cardozo LD et al. The role of urinary urgency and its measurement in the overactive bladder symptom syndrome: current concepts and future prospects. BJU International 2005; 95: 335–40. 5 Hashim H, Abrams P. Is the bladder a reliable witness for predicting detrusor overactivity? J Urol 2006; 175: 191–4.

6 Coyne KS, Zhou Z, Thompson C, Versi E. The impact on health-related quality of life of stress, urge and mixed urinary incontinence. BJU International 2003; 92: 731–5. 7 Coyne K, Wein A, Nicholson S, Kvasz M, Chen C, Milson I. Comorbidities and Personal burden of urgency urinary incontinence: a systematic review. Int J Clin Pract 2013; 67: 1015–33. 8 Stevens JA, Hasbrouck LM, Durant TM et al. Surveillance for injuries and violence among older adults. MMWR CDC Surveill Summ 1999; 48: 27– 50. 9 Dallosso HM, Matthews RJ, Mcgrother CW, Donaldson MM, Shaw C. The association of diet and other lifestyle factors with the onset of overactive bladder: a longitudinal study in men. Public Health Nutr 2004; 7: 885–91. 10 Khasriya R, Sathiananthamoorthy S, Ismail S et al. The spectrum of bacterial colonisation associated with urothelial cells from patients with chronic

lower urinary tract symptoms. J Clin Microbiol 2013; [Epub ahead of print] 11 Molinuevo B, Batista-Miranda JE. Under the tip of the iceberg: psychological factors in incontinence. Neurourol Urodyn 2012; 31: 669–71. 12 Coyne KS, Sexton CC, Kopp ZS, Ebel-Bitoun C, Milsom I, Chapple C. The impact of overactive bladder on mental health, work productivity and health-related quality of life in the UK and Sweden: results from EpiLUTS. BJU international 2011; 108: 1459–71. 13 Coyne KS, Sexton CC, Irwin DE, Kopp ZS, Kelleher CJ, Milsom I. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional well-being in men and women: results from the EPIC study. BJU international 2008; 101: 1388–95. doi: 10.1111/ijcp.12206

EDITORIAL

Diabetes in sub-Saharan Africa: an economic and public health emergency Linked Comment: Assaad-Khalil et al. Int J Clin Pract 2013; 67: 1144–50.

Age-specific estimates of prevalence for African urban centres are already higher than for their Western counterparts: this situation is already serious and predicted to deteriorate significantly

Sub-Saharan Africa has changed a great deal over the last couple of decades and many countries have experienced ‘unprecedented high, sustained economic growth’ (1). This growth has, for the main, translated positively into improvements in health indicators in the region. African child mortality is now decreasing at twice the rate it was only 10 years ago. In addition, there has been a substantial reduction both in new HIV infections and HIV-related mortality over the same period (2). These are extremely encouraging signs. Despite this economic growth, maybe even because of it, the future is not rosy for all sub-Saharan inhabitants. Non-communicable ‘diseases of affluence’ including heart disease, stroke and diabetes are forcing their way onto the scene with a disturbing vigour. Diabetes mellitus, in particular, is already recognised as a global epidemic, and developing countries are expected to bear an increasing share of this burden as urbanisation increases (3). Age-spe-

cific estimates of prevalence for African urban centres are already higher than for their Western counterparts: this situation is already serious and predicted to deteriorate significantly (4). In many ways, this is reminiscent of the challenge posed by the HIV pandemic. Like HIV, diabetes has the potential both to devastate individual’s lives and to negatively impact the very economic growth currently driving population-wide health improvements (5). Burgess and his co-authors highlight the almost impossible challenge presented by diabetic retinopathy in sub-Saharan Africa and the costs of both action and inaction on this front (6). Specifically, the economic costs arise from time lost because of permanent disability and from premature mortality from diabetes in the working population of sub-Saharan Africa. Despite the social impact that diabetes is forecast to have, the outlook does not have to be bleak. Diabetic retinopathy screening and glycaemic control for diabetics have been shown to be cost-

ª 2013 John Wiley & Sons Ltd Int J Clin Pract, November 2013, 67, 11, 1069–1075

The burden of urgency urinary incontinence on health and wellbeing.

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