Table of Contents
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1. 1 CHILDBIRTH
1.1.1 - Cesarean section reduces stress incontinence but not severe incontinence
1.1.2 - The relationship between incontinence after birth and trauma during delivery
1.1.3 - Having babies after age 36 increases the risk of stress urinary incontinence
1.2. HYSTERECTOMY
1.2.1 - Is urinary incontinence more common among women who have had a hysterectomy?
1.2.2 - Hysterectomy increases the risk for mild fecal incontinence
1.2.3 - Surgery for stress incontinence more than doubles among women who have had a hysterectomy
1.3. MENOPAUSE
1.3.1 - Menopause doesn't cause urinary incontinence, it brings improvement!
1.3.2 - Hormone replacement therapy increases the risk of urinary incontinence
1.3.3 - Pelvic floor disorders are common among women and age is not an independent risk factor
1.4. PROSTATE CANCER
1.4.1 - Prostate cancer and treatment increase risk for urinary and fecal incontinence
1. 1 CHILDBIRTH
1.1.1
Cesarean section reduces stress incontinence but not severe
incontinence
Press J, Klein M, Kaczorowski J et al. Does cesarean section reduce postpartum urinary Incontinence? A systematic review. Birth 2007;34(3):228-37.
Why they did the study
More and more women are choosing to give birth by elective
cesarean section, even when vaginal delivery is a safe
option. This new trend is partly attributed to women's
assumptions that vaginal delivery increases the chance of
developing urinary incontinence. The medical literature on
birth method and incontinence remains contradictory, as few
studies have accounted for the many different variables that
could be involved. Researchers at the University of British
Columbia wanted to clarify the situation and provide women
and their doctors with more conclusive evidence on which to
base their decisions about birth method.
How they did it
The researchers conducted a systematic review of studies
completed on birth method and incontinence between 1966 and
2005 to find out how often urinary incontinence occurred
following cesarean section compared to vaginal birth. Two
kinds of studies were included: cross-sectional studies,
which measure the prevalence of a condition in a population
along with risk factors thought to be associated with that
condition; and cohort studies, which follow a group of
people exposed to a risk factor to see what happens over
time. Randomized controlled trials, which take a uniform
group and assign them randomly to one option or another,
provide the most conclusive evidence about the effect of one
variable on outcome. But as it is unlikely that this will
ever be performed in this area, cohort and cross-sectional
studies are the best available.
Authors of the studies included in the review were asked to provide additional information about the type and severity of postpartum incontinence (stress, urge, mixed and unspecified urinary incontinence), the women's age at delivery and number of births (the latter two are thought to be risk factors for incontinence), and whether cesarean sections were planned or done after the woman was in labour. This new information was combined with data from the original studies and analyzed using statistical software.
What they found
Why it matters
This review showed a decrease in the risk of developing
postpartum stress urinary incontinence after cesarean
section compared with vaginal delivery. Women and their
doctors will have to weigh the benefits of reducing the risk
of any stress incontinence from about 22% with vaginal
delivery to about 6% with cesarean section against the risks
and potential complications of a cesarean section to both
mother and child. Women can also be reassured that severe
urinary incontinence occurs in only about 1%-2% of women
after birth, either vaginal or by cesarean section.
Next question
Given their findings, the authors think it is important to
find out whether obstetrical practices can be improved to
reduce the risk of pelvic floor injury during vaginal birth
and therefore reduce the incidence of stress urinary
incontinence in the years following a birth. Use of
episiotomy, epidurals and the lying down (lithotomy)
position are possible contributors to pelvic floor injury
that could be studied further.
1.1.2
The relationship between incontinence after birth and trauma
during delivery
Williams A, Herron-Marx S, Knibb R. The prevalence of enduring postnatal perineal morbidity and its relationship to type of birth and birth risk factors.
J Clin Nurs 2007 Mar;16(3):549-61.
Why they did the study?
We know that women suffer a significant number of perineal
problems following childbirth. These include urinary
incontinence and fecal incontinence, but also pain and
sexual problems. While women with very severe tears receive
follow-up from an obstetrician and/or physiotherapist, women
with smaller or no tears are assumed to be fine and receive
no follow-up. Following on a 2000 statement from the United
Kingdom's Royal College of Midwives that postnatal care was
undervalued, the authors set out to find out more about the
relationship between perineal problems following childbirth
and the trauma experienced during birth.
How they did it
The authors conducted a cross-sectional community survey to
explore problems experienced by women in Birmingham and
Solihull, UK, one year after childbirth. They received 482
responses after sending out 2,064 questionnaires asking
about different problems experienced "in the past month."
The authors acknowledge that women with problems may have
been more likely to respond to the questionnaire than those
without.
What they found
Why it matters
The authors point to a couple of findings as especially
important:
Overall, it appears that much more attention should be paid to women's perineal health in the year following childbirth, even when none of the traditionally defined birth traumas occur.
Next question
The authors think research is needed to see whether women
with 3rd and 4th degree tears have greater or less risk of
urinary incontinence than women who receive episiotomies.
Further research is also needed into trauma unrelated to
tears and episiotomies.
1.1.3
Having babies after age 36 increases the risk of stress
urinary incontinence
Groutz A, Helpman L, Gold R et al. First vaginal delivery at older age: Does it carry an extra risk for the development of stress urinary incontinence? Neurourol Urodyn 2007;26:779-82.
Why they did the study
It is increasingly common for women to have their first
child after age 36. Previous studies have identified older
maternal age as a risk factor for stress urinary
incontinence following childbirth. The increased risk
remains even when trauma to the perineal area (i.e. tears or
episiotomy) do not occur. Other studies have shown that
women who develop stress incontinence during pregnancy are
more likely to suffer incontinence in the years following
childbirth, indicating that factors of pregnancy other that
birth trauma are associated with the pelvic floor disorders
that contribute to urinary incontinence.
Before it is possible to make any recommendations on preventing stress incontinence among older women delivering their first child, it is important to sort out at what stage the lasting damage to the perineal area occurs. Does damage to the pelvic floor begin during pregnancy, before labour and delivery? Also, how much does maternal age itself affect the prevalence of incontinence after childbirth? The authors compared incontinence rates two years after childbirth among women over 36 years old and women under 29 years old who delivered a first child vaginally. They also compared these to rates of incontinence among women over 36 years who delivered a first child by elective cesarean section.
How they did it
The authors identified 186 women who delivered a first child
at a Tel Aviv hospital by either spontaneous vaginal
delivery (without the use of forceps or other instruments)
or elective cesarean section. The women were interviewed one
to two years after delivery regarding symptoms of stress
urinary incontinence. Not included in the study were women
who experienced stress incontinence before pregnancy.
What they found
Why it matters
Stress urinary incontinence is related to older age at first
delivery and to pregnancy itself, not just to trauma during
labour and birth. Elective cesarean section can reduce but
not fully prevent incontinence in the years following
childbirth. Women who experience stress urinary incontinence
during pregnancy are at higher risk for lasting symptoms,
whether they deliver vaginally or by elective cesarean
section. Elective cesarean section can prevent further
pelvic floor injury, but also carries other risks to mother
and child.
Next questions
Do the protective effects of cesarean section persist as
women age?
Are there protective measures that could prevent pelvic
floor damage during pregnancy and delivery?
Can the group at highest risk for future incontinence be
narrowed down further to provide guidance for recommending
cesarean section?
What happens during pregnancy and birth to damage the pelvic
floor?
1.1.4
Factors that increase the risk of fecal incontinence in
women with severe sphincter tears during childbirth
Burgio KL, Borello-France D, Richter HE et al for The Pelvic Floor Disorders Network. Risk factors for fecal and urinary incontinence after childbirth: the childbirth and pelvic symptoms study. Am J Gastroenterol 2007 Sep;102(9):1998-2004.
Why they did the study
Women who experience a sphincter tear (3rd or 4th degree)
during childbirth have about double the risk of developing
fecal incontinence as women who do not. However, only a
minority of women develop fecal incontinence after this type
of tear. As well, some women develop fecal incontinence
after childbirth without sphincter tear, possibly because of
unseen tears or physiologic changes that occur during
pregnancy and delivery. The authors aimed to see whether
maternal or obstetrical factors affected the lasting impact
of childbirth on fecal incontinence, in hopes of identifying
women who might be targeted for prevention or treatment
efforts.
How they did it
The study looked at 759 women delivering their first child
who had no history of fecal incontinence or bowel disease
before pregnancy. Women were interviewed while in hospital
and then by telephone six months after delivery. Information
about the birth was recorded. Study participants were
divided into three groups: the sphincter tear group,
including women who had a 3rd or 4th degree tear that was
repaired at the time of delivery; a control group of women
who delivered vaginally without anal sphincter tear; a third
group of women who delivered by elective cesarean section.
The authors analyzed information about the women's age, race, weight and history of incontinence during pregnancy, as well as details of the birth, to identify variables that might contribute to symptoms of fecal incontinence six months after the birth.
What they found
Next questions
Can early identification and treatment of women with weak
pelvic floor muscles, as manifested by urinary incontinence
that develops during pregnancy, reduce future problems with
fecal incontinence?
What physiological or anatomical features make white women
more susceptible than black women to fecal incontinence
after a severe tear?
1.1.5
Influence of childbirth and other factors on lifetime risk
of moderate to severe urinary incontinence
Connolly T, Litman H, Tennstedt S et al. The effect of mode of delivery, parity, and birth weight on risk of urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:1033-42.
Why they did the study
We know that childbirth is associated with a higher risk of
urinary incontinence and that cesarean section is
protective. It also appears that the number of pregnancies
and the baby's birthweight may contribute to the risk for
urinary incontinence, but studies looking at this question
did not take birth method into account. The authors felt
that a study looking at the number of prior deliveries,
method of delivery and birthweight simultaneously was needed
to guide clinical practice. Because there are also some
indications that a woman's race may affect risk of urinary
incontinence after childbirth, they also wanted to ensure
that a racially diverse group was studied.
How they did it
The authors designed the Boston Area Community Health Survey
to gather information through interviews with 3,205 women,
including roughly equal numbers of black, Hispanic and white
women, aged 30 to 79. The women were asked how many previous
pregnancies they had, how many deliveries, the method of
delivery and the birth weights of their babies. They were
also asked about symptoms of urinary incontinence: 390 women
were found to have symptoms of moderate/severe urinary
incontinence, and 515 reported mild incontinence.
The findings were analyzed to investigate the relationships
between moderate/severe incontinence and each of three
reproductive factors: mode of delivery, parity (number of
pregnancies) and maximum birth weight. Other variables
thought to be related to incontinence, such as weight,
activity levels, race, history of urinary tract infections,
hysterectomy and menopause were incorporated into these
analyses.
What they found
Why it matters
Next questions
Are there factors during vaginal delivery that affect risk
of urinary incontinence?
Does a woman's age at first delivery affect her risk for incontinence?
1.2. HYSTERECTOMY
1.2.1
Is urinary incontinence more common among women who have had
a hysterectomy?
van der Vaart CH, van der Bom JG. The contribution of hysterectomy to the occurrence of urge and stress urinary incontinence symptoms. BJOG 2002 Feb;109(2):149-54.
Why they did the study
By age 60, up to a quarter of women have had a hysterectomy
to relieve symptoms of non life-threatening conditions.
Previous studies have shown that hysterectomy may be
associated with the development of urinary incontinence
later in life. The authors wanted to more precisely quantify
how much hysterectomy increased odds of developing stress or
urge incontinence following hysterectomy to help women make
sound decisions.
How they did it
The authors surveyed a random sample of women 35 to 70 years
old in the Netherlands. 1,626 women responded to questions
about their obstetrical history, prior hysterectomy and
urinary incontinence. They did not ask women who had had a
hysterectomy to specify whether it was done abdominally or
intravaginally. The women were asked whether they
experienced stress incontinence -- "urine leakage related to
physical activity, coughing or sneezing" -- or urge
incontinence -- "leakage related to a feeling of urgency" --
and whether they were bothered by these symptoms.
Statistical analyses were then performed to calculate how much hysterectomy increased the odds of developing stress or urge incontinence. Other variables thought to be related to incontinence -- age, parity (number of previous pregnancies) and educational level -- were entered into the analysis one at a time to determine their effect on the relationship between incontinence and hysterectomy.
What they found
Why it matters
Urge incontinence has a negative impact on women's quality
of life, even more than stress incontinence. If hysterectomy
increases the risk of urge urinary incontinence, women
should be counselled about this risk when they are scheduled
for hysterectomy. They should be encouraged to weigh the
benefits of hysterectomy in resolving uterine bleeding
against the increased odds of developing urge incontinence
later in life.
Next question
Why hysterectomy is a risk factor for urge urinary
incontinence is not well understood. Does damage during
surgery, especially to the detrusor muscle, produce bladder
supersensitivity,?
1.2.2
Hysterectomy increases the risk for mild fecal incontinence
Forsgren C, Zetterström J, Lopez A et al. Effects of hysterectomy on bowel function: a three-year, prospective cohort study. Dis Colon Rectum 2007 Aug;50(8):1139-45.
Why they did the study
The authors wanted to find out whether hysterectomy affected
bowel function, including fecal incontinence and
constipation. They had previously looked at problems
occuring one year after hysterectomy, but wanted to find out
more about longer-term effects.
How they did it
A questionnaire was completed by 120 women undergoing either
vaginal or abdominal hysterectomy in Sweden. Follow-up
questionnaires were answered by 115 of the women one year
after the hysterectomy, and by 107 of the women three years
after the hysterectomy. They were asked about bowel habits
and difficulties with constipation and incontinence, using
recognized questionnaires.
What they found
Why it matters
Given that the increase in fecal incontinence symptom scores
were mild, generally reflecting a move from "perfect"
continence scores to "good" continence scores, the authors
question how much impact this increase would have on women's
quality of life.
Next question
The authors feel we need to take a closer look at women who
suffered an anal sphincter injury during childbirth to see
whether they are particularly vulnerable to further injury
during hysterectomy.
1.2.3
Surgery for stress incontinence more than doubles among
women who have had a hysterectomy
Altman D, Granath F, Cnattingius S, Falconer C. Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study. Lancet. 2007 Oct 27;370(9597):1494-9.
Why they did the study
Over 90% of hysterectomies are done for non life-threatening
conditions such as postmenopausal bleeding. The operation is
common in many countries, as it is considered a safe and
effective way to cure such problems definitively. While
studies have looked at rates of stress urinary incontinence
following hysterectomy, the results have been inconsistent.
How they did it
The authors used surgery for stress urinary incontinence as
a way to identify incontinence, thereby doing away with
problems of definition and severity seen in some other
studies. They used national health records to identify women
who had undergone hysterectomy and see whether surgery for
stress urinary incontinence was performed in the years
following hysterectomy. They also identified a population of
women who had not undergone hysterectomy for comparison.
They excluded women who had stress incontinence surgery
prior to hysterectomy. Women who had hysterectomy were
matched against similar aged women who had not, and
educational and parity information was collected on all the
women to examine the impact of these factors on the
development of stress urinary incontinence. The observation
period covered 30 years.
What they found
Why it matters
If the risk of stress urinary incontinence severe enough to
require surgery more than doubles following hysterectomy,
women (and the physicians who advise them) should be made
aware of this risk, weigh it against the benefits of
hysterectomy and perhaps contemplate other treatment methods
for their benign condition before considering hysterectomy.
Because the risk of incontinence increases along with the
number of vaginal births, women of high parity should be
even more cautious of hysterectomy.
The authors admit that using 'surgery for urinary incontinence' as a way to identify incontinence may not be valid, as women who would accept a hysterectomy in the first place may be more likely to consider surgery again. Many women suffer from incontinence but do not undergo surgery.
Next question
Are there factors that this study did not take into
consideration, such as smoking, strenuous work and body mass
index, that affect the risk of stress urinary incontinence
after hysterectomy?
1.3. MENOPAUSE
1.3.1
Menopause doesn't cause urinary incontinence, it brings
improvement!
Waetjen LE, Feng WY, Ye J et al. Factors associated with worsening and improving urinary incontinence across the menopausal transition. Obstet Gynecol 2008 Mar;111(3):667-77.
Why they did the study
The prevalence of urinary incontinence increases in the
45-55 age range, but it is not clear why this increase
occurs. Atrophy of the urogenital organs associated with
lower estrogen levels after menopause has been suggested as
one explanation, but others are also possible. The authors
wanted to see whether the menopausal transition was in
itself responsible for worsening urinary incontinence in
midlife women.
How they did it
The authors selected women from the Study of Women's Health
Across the Nation (SWAN) study who reported incontinenceonce
a month or more at the outset of the study and at six-month
follow-up. SWAN followed women aged 42 to 52 who were in
pre- or perimenopause through six annual follow-up visits
between 1995 and 2002. About 31% of the women reported only
stress urinary incontinence, 9% reported only urge
incontinence, and the remainder reported a combination of
the two.
To measure improvement or deterioration in urinary incontinence, authors assigned a score at each annual visit of 0 meaning no change, +1 meaning worsening, and -1 for improving. At the end of six years, the scores were added up; women with a negative score were considered improved, those with a positive score were considered to be worsening, and women with a score of 0 were said to be unchanged.
The authors matched these measures against menopausal status and use of hormone replacement therapy at each annual visit. The other variables they looked at were weight change and change in waist-to-hip ratio.
What they found
Why it matters
The study findings suggest a weak positive effect of the
menopause transition on stress, urge and mixed incontinence
symptoms. This goes against the belief that menopause
worsens incontinence. Some other studies have found that use
of hormone replacement therapy worsened stress and urge
incontinence symptoms. Although the evidence was
inconclusive, the present study found that starting hormones
before the last menstrual period did not lower the risk of
incontinence, and starting hormones at any time was only
associated with improvements in urge incontinence symptoms.
Women can be reassured that there is no "inevitable" worsening of urinary incontinence symptoms in menopause, and can also be encouraged that factors they may be able to do something about, such as weight gain, can increase their chances of improving continence.
1.3.2
Hormone replacement therapy increases the risk of urinary
incontinence
Hendrix SL et al. Effects of estrogen with and without progestin on urinary incontinence. JAMA 2005;293(8):935-48.
Why they did the study
Previously, menopausal hormone therapy with estrogen alone
or estrogen + progesterone was thought to have wide-ranging
benefits, including improving symptoms of urinary
incontinence. However, the large long-term US Women's Health
Initiative (WHI) study showed an increased risk of stroke
with hormone replacement therapy (HRT). Women and their
doctors are now much more judicious in taking or prescribing
HRT to menopausal women. The authors wanted to see what
impact HRT had on the incidence and severity of urinary
incontinence in postmenopausal women.
How they did it
The authors used the information collected on 23,000 women
in the WHI for whom information on urinary incontinence was
available at the start of the study and at one-year
follow-up. Women ranged in age from 50 to 79 years, with and
without prior hysterectomy, and were recruited into the
study between 1993 and 1998. One group was given active
estrogen + progesterone HRT, another received estrogen
alone, while the other group received placebo. Information
was gathered on general health status, smoking, weight and
births.
What they found
Why it matters
The increased risk for stroke found in postmenopausal women
on HRT means that it should be prescribed cautiously, and
only when real benefit will occur. This large study provided
solid evidence that HRT provides no benefit for the
prevention or treatment of urinary incontinence.
Estrogen alone and estrogen + progesterone increased the
risk of urinary incontinence among continent women, and
worsened symptoms of urinary incontinence among women who
already suffered a degree of incontinence prior to the
study. HRT should not be prescribed for the prevention or
relief of urinary incontinence.
1.3.3
Pelvic floor disorders are common among women and age is not
an independent risk factor
Lawrence JM, Lukacz ES, Nager CW et al. Prevalence and co-occurrence of pelvic floor disorders in community-dwelling women. Obstet Gynecol 2008 Mar;111(3):678-85.
Why they did the study
Pelvic floor disorders -- which include urinary
incontinence, overactive bladder, pelvic organ prolapse and
anal incontinence (which includes flatulence only as well as
fecal incontinence) -- have a very negative impact on
women's quality of life. These conditions are expensive to
manage and treat. However, because many women do not report
them to their physicians, it is not known just how
widespread these problems are among women living in the
community. Also unclear is the effect of age on the
prevalence of pelvic floor disorders once other variables
are taken into consideration. The authors wanted to quantify
the problem more precisely and see to what extent age itself
was a contributor.
How they did it
A sample population of women aged 25 to 84 was identified
from among Kaiser Permanente health plan members in
California in 2004. A total of 4,458 women completed a
questionnaire about pelvic floor disorder symptoms, births,
birthweights and method of delivery, menopausal status,
hormone replacement therapy use, smoking, chronic heavy
lifting, weight and medical conditions. The rates of pelvic
floor disorders were calculated for each age group, and then
controlling for other factors.
What they found
Why it matters
The study confirmed that pelvic floor disorders are common,
that they often occur together and that their overall
prevalence increases with age. But they should not be
considered an inevitable part of the normal aging process,
as the age effect disappeared when other factors -- some of
which are modifiable -- were taken into account. Doctors
treating women with one reported symptom of pelvic floor
disorder should be sure to inquire about others.
The authors did not ask about pelvic pain, especially
dyspareunia, which affects more than 10% of women, most of
whom are under 30.
1.4. PROSTATE CANCER
1.4.1
Prostate cancer and treatment increase risk for urinary and
fecal incontinence
Mols F, Korfage I, Vingerhoets J et al. Bowel, urinary and sexual problems among long-term prostate cancer survivors: A population-based study. Int J Radiat Oncol Biol Phys; 2008 Jun 4 (Epud ahead of print).
Why they did the study
A growing number of men are surviving many years with
prostate cancer. The authors wanted to find out how the
cancer and its treatment affected men's quality of life five
and 10 years after diagnosis. Urinary and bowel problems,
along with sexual function, are known to be common in the
prostate cancer survivor population less than five years
after diagnosis, but longer-term follow-up is needed because
of increased long-term survival rates and a trend towards
earlier treatment resulting from PSA testing. We do not know
how much more common these problems are in prostate cancer
survivors than in men of the same age without prostate
cancer. Nor do we know how different treatment methods
(primarily radical prostatectomy and radiation therapy)
compare in terms of long-term urinary and bowel problems.
The authors wanted to find out the long-term effects of
prostate cancer and its different treatments on bowel,
urinary and sexual function, and compare the incidence of
problems to men the same age without the condition.
How they did it
The authors surveyed men under 75 years old diagnosed with
prostate cancer between 1994 and 1998 in the Netherlands,
along with a group of age-matched men without prostate
cancer who had taken part in a screening study. The
questionnaires asked men about urinary and bowel function,
as well as sexual function. Information about their general
health, their cancer and treatment was taken from the men's
charts. In all, 547 men with prostate cancer and 3,810 men
without returned the questionnaire and were included in the
analysis.
What they found
Why it matters
The study confirms that urinary and bowel problems are more
common among men treated for prostate cancer than in
age-matched men without cancer, even 10 years after their
cancer diagnosis. Radical prostatectomy appears to produce
more urinary incontinence, while external beam radiation
therapy results in more bowel problems. The use of
three-dimensional radiation therapy in this study may be
associated with higher rates of bowel problems than
intensity-modulated radiation therapy.
Because the population in the study was treated in various general hospitals rather than exclusively specialized care centres or centres of excellence, and because the response rate was so high, results can be extrapolated to the general population.
Next question
Men who received the treatments analyzed in this study
differed in terms of age and the stage at which their cancer
was treated. These differences may play some part in the
continence-related outcomes of the therapies, but it is
difficult to know this with certainty. It will also be
important to learn whether newer forms of radiation therapy
reduce the risk of bowel incontinence.
1.4.2
The effects of radical prostatectomy and radiation on
incontinence five years after treatment
Potosky AL, Davis WW, Hoffman RM et al. Five-year
outcomes after
prostatectomy or radiation therapy for prostate cancer: the
prostate cancer outcomes study. J Natl Cancer Inst
2004;96:1358–67.
Why they did the study
No studies have yet been done to compare the survival
benefits of radiation therapy and radical prostatectomy for
men with localized prostate cancer. In the absence of clear
survival differences, the long-term impact on quality of
life of each treatment option may play a larger role in a
man's decision. The Prostate Cancer Outcomes Study (PCOS)
examined quality of life outcomes, including incontinence,
in a large group of men with prostate cancer. In this study,
the authors looked at five-year quality-of-life outcomes in
men participating in the PCOS to see whether differences
apparent at two years persisted, improved or worsened in
each treatment group.
How they did it
The PCOS conducted chart reviews of men diagnosed with
prostate cancer in six American regions, and mailed a survey
at six months, one year and two years following diagnosis to
ask about quality of life. The present study includes the
results of a five-year survey mailed to the same population.
Of the 1,591 men who completed the two-year survey, 1,187
also completed the five-year survey, including 901 men who
were treated with radical prostatectomy and 286 who received
external beam radiation therapy (EBRT).
The authors took into account extensive information about clinical status and pre-treatment conditions and co-morbidities when looking at differences in quality of life between treatment methods. They examined the results in two ways. A cross-sectional analysis compared urinary, bowel and sexual function between treatment groups to discover the probability of experiencing problems with each treatment method. A longitudinal analysis looked at how urinary, bowel and sexual function changed over time.
What they found
Why it matters
Men facing a choice between treatment methods for localized
prostate cancer should be well informed about the potential
for urinary, bowel and sexual dysfunction associated with
each option. Because men are living much longer after a
cancer diagnosis, the evolution of these effects over time
is also important. Urinary incontinence remains more
troublesome for men treated with radical prostatectomy, but
men treated with EBRT have a fair number of other urinary
complaints. The difference in bowel function narrows
slightly with time, as does the difference in sexual
function. The increase in sexual difficulties between year 2
and year 5 suggests that there may be long-term effects from
EBRT that need to be understood.
Next question
Treatment methods have improved since the men in this study
underwent therapy in 1994-95, and new treatments such as
brachytherapy have since been developed. Assessment of the
effect of each therapy on urinary, bowel and sexual function
must continue in order to help men make wise decisions about
their management.
1.4.3
Urinary incontinence can worsen between two and five years
after radical prostatectomy for prostate cancer
Penson DF, McLerran D, Feng Z et al. 5-year urinary and sexual outcomes after radical prostatectomy: results from the Prostate Cancer Outcomes Study. J Urol 2005 May;173(5):1701-5.
Why they did the study
Prior studies have found widespread urinary incontinence and
sexual dysfunction following radical prostatectomy, but
these had short follow-up periods (up to two years) and did
not take into account the impact of new sexual aids, the
phosphodiesterase type-5 (PDE-5) inhibitors (such as
Viagra®, Levitra® or Cialis®). The authors wanted to see how
radical prostatectomy affected urinary and sexual function
five years down the line and assess whether the availability
of the PDE-5 inhibitors made a difference in sexual
function.
How they did it
A population study approach was used to eliminate the chance
of selection bias. Men who underwent radical prostatectomy
in 1994-95 were identified from the National Cancer
Institute SEER (Surveillance, Epidemiology and End Results)
cancer registry and contacted for follow-up six months, one
year, two years and five years after surgery. Details of
their cancer and health status were taken from their charts,
while urinary and sexual function was assessed through
questionnaires.
What they found
Why it matters
The long-term quality-of-life outcomes after radical
prostatectomy are increasingly important as men survive
longer with prostate cancer. Men should be aware of the
risks of urinary incontinence and erectile dysfunction when
they are considering initial treatment. It is also important
for men and their physicians to know that the considerable
improvement in urinary and sexual function seen between six
months and two years after prostatectomy tapers off by year
five and that incontinence may worsen somewhat after that.