December 2003
Q & A: Experts Answer Questions About Overactive Bladder
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Alfred E. Bent, MD Greater Baltimore Medical Center Baltimore, Maryland

Roger R. Dmochowski, MD, FACS Vanderbilt University Nashville, Tennessee

Catherine E. DuBeau, MD University of Chicago Chicago, Illinois

Steven R. Gambert, MD Johns Hopkins University School of Medicine Sinai Hospital of Baltimore Baltimore, Maryland

Jack D. McCue, MD, FACP, AGSF University of Maryland School of Medicine Baltimore, Maryland

Diane K. Newman, RNC, MSN, CRNP, FAAN University of Pennsylvania Health System Philadelphia, Pennsylvania

Norman Zinner, MD UCLA School of Medicine Los Angeles, California

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1. Common misconceptions about overactive bladder (OAB) are that it is a normal part of the aging process and that it cannot be treated. What treatment options are available for OAB?

Dr. Norman Zinner: Although OAB is prevalent in older adults,1-3 it is not a normal part of the aging process. Afflicted patients can suffer greatly and are more likely to require extensive care. OAB is often the cause of movement to long-term care facilities. Shame, depression, reduced socialization, and loss of self-esteem are commonly experienced by patients with OAB. It is important that physicians address OAB symptoms when suspected to preserve each patient’s quality of life.

Older patients are more likely to have comorbidities that can increase the chances of urge incontinence (UI) occurring. These include neurological disorders or injuries, cognitive impairment, symptomatic urinary tract infection, atrophic vaginitis and urethritis, decreased mobility (due to arthritis, poor eyesight, fear of falling, etc), and medications such as antipsychotics, sedatives, diuretics, anticholinergics, narcotics, alpha-adrenergic blockers and agonists, beta-adrenergic agonists, and calcium channel blockers. In rare cases, OAB symptoms occur as a result of bladder obstruction or injury.3 These other causes of incontinence and OAB should be considered when evaluating and treating patients with symptoms of OAB.

Once OAB is diagnosed, the treatment option we select depends on the patient’s physical and cognitive abilities, the patient’s willingness to comply with a treatment regimen or behavioral technique, and the impact of incontinence on the patient’s quality of life (QOL). Behavioral techniques, such as timed voiding, bladder training, or pelvic floor muscle exercises, require a commitment from the patient. In some cases, they require sufficient cognitive ability.4,5 Timed voiding refers to the practice of voiding according to a schedule, without waiting for a physical prompt.6 By voiding before it becomes absolutely necessary, the patient may avoid embarrassing accidents or leakage. By gradually increasing the time between voiding (bladder training), the patient can increase the bladder’s ability to store urine. Exercises, such as Kegel exercises, that strengthen the pelvic floor muscles may help in reducing or eliminating overactive bladder.7,8 With these exercises, patients practice contracting and relaxing the perineal muscles while the abdominal and gluteal muscles remain relaxed. Biofeedback can be used to help patients identify the specific muscles to contract.9,10

Pharmacologic treatments for OAB comprise mostly of the antimuscarinics oxybutynin and tolterodine. Similar agents that will be available in the near future include solifenacin, darifenacin, and trospium chloride. These agents, called muscarinic antagonists, prevent stimulation of muscarinic receptors by naturally occurring acetylcholine.11 However, because these agents are not selective for the bladder, they affect other organs, such as the salivary glands and the gastrointestinal tract. These undesirable side effects include dry mouth, constipation, and other adverse events associated with anticholinergic therapy. Oxybutynin and tolterodine are available in immediate-release (IR) and extended-release (ER) formulations. Oxybutynin is the only treatment for OAB that is available in a transdermal formulation. Transdermal oxybutynin has been associated with a low incidence of anticholinergic adverse events when compared with oral formulations of oxybutynin and tolterodine.12,13

Intravaginal electrical stimulation, intended to strengthen pelvic musculature, has been attempted in patients with OAB. This method of treatment requires initial office visits with a trained clinician, use of a vaginal or rectal sensor, and compliance on the part of the patient as daily stimulation is performed at home with a small portable unit.14 Efficacy of this method was tested in a prospective, double-blind trial that examined 121 women with urge, mixed, or stress incontinence. OAB was cured in 49% of women with UI (not stress) who used an active electrode (P = 0.0004) but there was no statistically significant change observed in women who used a sham device.15 However, other studies had different findings. In a single-blind, randomized, controlled clinical trial, electrical stimulation was less effective than pelvic floor muscle exercises for stress incontinence.16 In yet another study, electrical stimulation did not add to the benefit obtained from behavioral training.17 Finally, there has been little research on the use of this method in older adults. As a result, this method may not be recommended for older patients with OAB.

When medical therapy and/or electrical stimulation fail, surgical intervention, such as augmentation or urinary diversion, may be attempted.18 Recently a hospital conducting orthotopic ileal neobladder constructions (N = 51) reported that this procedure significantly reduced daytime incontinence as well as nocturia in recipients.19 However, a single patient died perioperatively and early complications occurred in 57% of patients. Because of its invasive nature, high cost, and high level of risk, surgery is only used as a last resort and is not recommended for older patients.

2. Should behavioral therapy always be tried before pharmacologic therapy?

Dr. Catherine DuBeau: Several studies have demonstrated that behavioral therapy is effective treatment for OAB.4,20 In a systematic review of eight studies using pelvic floor muscle exercises to treat OAB, women performing these exercises were much more likely to be dry or mildly incontinent compared with patients who received no treatment (61% vs 3%).20 In another study of homebound adults aged 60 years and older, those receiving biofeedback-assisted pelvic floor muscle training achieved a 75% reduction in urinary accidents compared with a 6.4% reduction in the control group (P < 0.001), despite a high degree of comorbidity and functional impairment.4 For behavior therapy to be successful, patients must make a commitment to comply with treatment. Because this therapy offers some improvement and is minimally invasive, it is useful in patients who have an ability to modify their behavior and is preferred when pharmacologic therapy is contraindicated. In patients with impaired cognition, bladder training and pelvic floor muscle exercise may not be possible, but habit training and prompted voiding may be options.3 Combined drug and behavioral therapy appears to be more efficacious than either treatment alone.

3. What specific symptoms of OAB improve with antimuscarinic therapy?

Dr. Steven Gambert: Symptoms commonly associated with OAB include urinary frequency (> 8 times per day), urinary urgency, UI, and nocturia (> 2 times per night). All of these symptoms usually improve with treatment. In addition, there are other variables that may be used to evaluate efficacy of treatment.

In double-blind, randomized, placebo-controlled trials, patients treated with transdermal oxybutynin reported fewer episodes of incontinence per day and reduced frequency.12,21 Volume of urine per micturition also increased. However, other variables are affected by treatment. Earlier trials with oral IR oxybutynin revealed statistically significant increases in overall cystometric capacity, volume at which the patient had the first desire to void, volume at which patients felt a strong desire to void, and significant decreases in detrusor pressure rise during filling and maximum detrusor pressure rise.22-24 Patients are not able to discern these improvements but they may be observed with urodynamics.

4. What is the evidence showing that transdermal oxybutynin is effective? What are the potential advantages of using this most recent FDA-approved agent over oral antimuscarinics in older patients?

Dr. Jack McCue: Transdermal oxybutynin is a thin, flexible, transparent matrix that is applied as a patch to the abdomen, hip, or buttocks twice weekly.25 Data from double-blind, randomized, controlled clinical trials have revealed that treatment efficacy comparable to oral anticholinergics is maintained; however, tolerability, particularly regarding anticholinergic adverse events, is improved with this formulation.13,21

Two randomized, double-blind studies evaluated the clinical efficacy and safety of transdermal oxybutynin over 12 weeks in patients with OAB and urge or mixed UI.12,21 In the first trial (N = 520), patients receiving transdermal oxybutynin achieved statistically significant reductions in weekly incontinence episodes, reductions in urinary frequency, and an increase in urinary void volume compared with placebo (P < 0.03 for all parameters).12 The second study compared transdermal oxybutynin with extended-release tolterodine 4 mg/d and with placebo in 361 previously treated patients with urge or mixed incontinence.21 Patients receiving oxybutynin in this study also achieved reductions in daily incontinence episodes (P = 0.01) and in daily urinary frequency (P = 0.1), and an increase in urinary void volume (P = 0.001). No statistically significant differences in efficacy were detected between transdermal oxybutynin and extended-release tolterodine. Most importantly, the incidence of anticholinergic side effects observed with transdermal oxybutynin was statistically indistinguishable from the placebo groups in each of these two trials.

The side-effect profile of anticholinergics is particularly bothersome in older patients. This population of patients is more likely to suffer from constipation and dry mouth due to advanced age. Because treatment of older patients is often complicated by their inability to tolerate medication side effects, the improved tolerability profile of transdermal oxybutynin is potentially valuable in this particular population. Generally, increased attention must be paid to potential drug interactions and to combined drug toxicity in older patients. For this reason, it is often recommended to “start low and go slow” with older patients when treating a variety of disease states.26,27 This approach is helpful in minimizing the intensity of certain iatrogenic side effects. However, anticholinergic side effects do not decrease with time, unlike many other types of side effects. Dry mouth is the most common reason patients discontinue therapy with anticholinergics. Therefore, the importance of providing tolerable therapy with the first treatment option is high in older patients with OAB.

Polypharmacy is also common in older patients. Transdermal formulations not only eliminate the chances of the delivered agent being involved in drug–drug interactions in the gastrointestinal tract, they also provide a wider therapeutic index for agents delivered via this mechanism by maintaining constant serum concentrations.28 The transdermal oxybutynin formulation represents a favorable treatment option for older patients with OAB.

5. Compared with the recommended dosages of oral oxybutynin, the daily dose of oxybutynin in transdermal oxybutynin is lower. Can this dose be increased, if necessary?

Dr. Roger Dmochowski: The IR formulation of oxybutynin is dosed at 2.5 to 5 mg, 2-3 times per day,29 and the ER formulation is most commonly dosed at 10 mg once daily.30 In contrast, the average daily dose of oxybutynin delivered via the transdermal system is 3.9 mg.25 When administered orally, oxybutynin is associated with poor bioavailability (˜6%) because of extensive first-pass metabolism.31,32 With the transdermal system, oxybutynin passively diffuses through the skin and bypasses first-pass gastrointestinal and hepatic metabolism so that, at steady-state, serum concentrations are comparable to or higher than those achieved with the oral formulations.13 In a pharmacokinetic study, transdermal oxybutynin delivered a mean of 3.0 mg of oxybutynin to the blood stream per day, whereas 5 mg of IR oxybutynin delivered an average of only 0.32 mg.33 Thus transdermal oxybutynin provides an increase in systemic oxybutynin exposure along with reduced N-desethyloxybutynin metabolite formation (Figure). Maximum concentrations and bioavailability are similar when transdermal oxybutynin is applied to the abdomen, buttock, or hip.25,34 Absorption and its resulting bioavailability if the patch is applied to another body area are not known.

A dose-escalation study is under way to assess the efficacy and safety of even higher daily doses of oxybutynin via the transdermal system.35 The findings of this study may possibly result in the availability of a system that delivers greater doses of oxybutynin into the blood-stream per day. A previous analysis has documented good tolerability of transdermal oxybutynin up to 5.2 mg/d.36 Dry mouth, dizziness, and nausea were each reported by 3.8% of the study population, and somnolence by 7.7% at this dose (N = 26). No patient reported constipation.37

6. Is the severity of OAB associated with any economic consequences?

Ms. Diane Newman: OAB symptoms, particularly urinary incontinence, are associated with several direct and indirect economic consequences. Direct costs include the use of disposable and reusable absorbent pads and adult briefs, new clothing, added laundry, catheterization or other collection devices, treatment of adverse consequences (skin ulcers, rash, or urinary tract infections), and institutional nursing care (changing, cleaning, applying protective skin products).14,38 Indirect costs include those related to work disruption that are due to visits to the toilet, nocturia, and caregiver burden, especially in the home.38,39 The effects on work productivity are a greater concern among younger adults who are still in the workforce.38 However, older patients often require long-term care assistance and are more likely to incur caregiver expenses. Direct medical costs in adults older than 65 years have been estimated to be as high as $25 billion, or about $3500 per patient.38 In nursing homes, UI has been estimated at 3-8% of total costs. For patients living in the community, the annual cost-of-care estimate in men with mild-to-moderate incontinence who did not use pads was $1700, while for men with more severe incontinence who use pads it was $4000. For women with mild-to-moderate or more severe incontinence, the yearly cost associated with incontinence was $700 and $2000, respectively.40 Costs associated with improved care and outcomes (eg, more diligence in keeping skin clean and dry, prompted voiding) are also considerable.41 In another recent study, labor costs were estimated at $3.31 (per shift) for patients with occasional UI compared with $5.16 (per shift) for patients with frequent UI.42 For patients with frequent UI, this translates to $4957 in annual labor costs for long-term care.42

Therapeutic interventions also induce costs, with surgery being the most expensive option in the short term; costs of surgical interventions are generally offset in approximately 10 years.43 Costs of pharmacologic treatments are much lower. For the antimuscarinic pharmacologic treatments available, costs are similar. Therefore, selection should be based on efficacy and tolerability.

7. Is quality of life important in determining the optimal therapeutic approach to OAB? What are the benefits and limitations of current quality-of-life instruments used in patients with OAB?

Dr. Roger Dmochowski: Quality of life is an important factor to consider in patients with OAB. In clinical practice, a rough estimation of the impact of incontinence on quality of life can be ascertained by asking patients about coping strategies and how incontinence impacts their daily activities, and their opinion of the most bothersome aspects of living with OAB. In clinical trials, QOL measures (questionnaires) are utilized to obtain this information at baseline and after treatment.

Symptom questionnaires are designed to yield a single numerical score that reflects a patient’s symptoms. It is difficult to construct a questionnaire that will reflect both subjective and objective clinical findings; therefore, concerted effort is applied to the construction of different questionnaires.44 Psychometric validity and reliability are important qualities of such instruments.

Validated instruments available to assess the impact and patient response to incontinence include the Incontinence Impact Questionnaire (IIQ), the Uro­genital Distress Inventory (UDI), the Incon­tinence Quality of Life (I-QOL) Measure, the Urge Impact Score (URIS-24), the York Incontinence Perception Scale (YIPS), and the Kings Health Questionnaire.44

The I-QOL, YIPS, and Kings Health Question­naire assess the impact of incontinence. The UDI and the IIQ assess both impact and patient response to incontinence. The URIS-24 assesses the impact of urge symptoms in older patients.45 This instrument is more appropriate for older adults because, unlike other instruments, it avoids using questions that concern activities they are not typically involved in, and it better addresses areas of particular concern to older patients with UI. Findings from the UDI and the IIQ were found to correlate well with several general health and urinary-specific questionnaires.46 Both of these instruments now have short forms available that correlate highly with the originals.47 These questionnaires have also been adapted to better assess the urge component of incontinence.48 The UDI and the IIQ are the questionnaires most commonly used in evaluating the impact of UI on QOL.

In summary, questionnaires vary, depending on their intended purpose and target population. No single comprehensive questionnaire is available. However, a perfect one would be short, easy to ad- minister and score, differentiate between stress and urge incontinence, evaluate severity, and evaluate the impact of the disorder on the patient.44 Currently the use of a combination of two or more questionnaires may often be necessary to obtain comprehensive information.

8. What is the overall impact of transdermal oxybutynin on quality of life?

Dr. Catherine DuBeau: In a double-blind comparison of transdermal oxybutynin and placebo, the use of transdermal oxybutynin was associated with a significant positive effect on the mean total impact IIQ score by the end of the study. Total scores decreased by 39% in the group receiving transdermal oxybutynin and by 28% in the placebo group (P = 0.03; a decrease in score represents an improvement in disease state).12 Significant improvements were also noted in several subscales, including physical activity (P = 0.047), travel (P = 0.0193) at week 6 of the study period, and emotional status (P = 0.048). Overall, improvements were also seen in Urinary Distress Inventory scores, with statistically significant differences seen only in women starting at week 7.

In another randomized, double-blind study comparing transdermal oxybutynin with long-acting tolterodine and placebo, improvements in incontinence-specific QOL were also documented using the IIQ (P = 0.027).49 An improvement was also seen in Global Assessment of Disease State in patients on transdermal oxybutynin (P = 0.0106) and long-acting tolterodine (P = 0.0001) compared with placebo. These findings suggest that patients are likely to experience improvements in their QOL following treatment with transdermal oxybutynin and other agents effective in the treatment of OAB.

9. Patches may cause local skin reactions in some patients. How are these reactions best managed if they occur with the use of transdermal oxybutynin?

Dr. Alfred Bent: Application site reactions are the most commonly reported adverse events associated with transdermal systems; however, with appropriate management, they will not prohibit use of the product. The incidence of application site reactions reported with transdermal oxybutynin is similar to the incidence reported with other available transdermal systems.28 To reduce the chances of application site reactions, patients are advised to apply the patch to a clean, dry area, to change the site of application each time a new patch is applied, and to apply moisturizers after system removal. If pruritus is bothersome, a topical corticosteroid or Benadryl® cream may be applied to the area after removal of the patch. Treatment with transdermal oxybutynin should be discontinued if the skin reaction does not respond to the recommended topical creams or if the reaction spreads beyond the site of application.

Products used for removal of medical adhesives, such as Medisol®, may be utilized if adhesive material accumulates around the patch. This product contains aloe vera and glycerin, which help to moisturize the skin and to remove the residual adhesive. Mineral or baby oil also work well. Residual adhesive should not be removed with mechanical scrubbing or harsh chemicals (eg, nail polish remover, or alcohol) as they could cause irritation.

References 1. Wein AJ, Rovner ES. Definition and epidemi­ology of overactive bladder. Urology 2002;60:7-12; discussion 12. 2. Ouslander JG. Geriatric considerations in the diagnosis and management of overactive bladder. Urology 2002;60:50-55; discussion 55. 3. Shah D, Badlani G. Treatment of overactive bladder and incontinence in the elderly. Reviews in Urology 2002;4(Suppl 4):S38-S43. 4. McDowell BJ, Engberg S, Sereika S, et al. Effectiveness of behavioral therapy to treat incontinence in homebound older adults. J Am Geriatr Soc 1999;47:309-318. 5. Burgio K, Locher J, Goode P, et al. Behavioral vs drug treatment of urge urinary incontinence in older women: A randomized controlled trial. JAMA 1998;280:1995-2000. 6. Godec CJ. “Timed voiding”: A useful tool in the treatment of urinary incontinence. Urology 1984;23:97-100. 7. Kolcaba K, Dowd T, Winslow EH, et al. Kegel exercises: Strengthening the weak pelvic floor muscles that cause urinary incontinence. Am J Nurs 2000;100:59. 8. Kegel A. Stress incontinence of urine in women: Physiologic treatment. Am J Obstet Gynecol 1948;25:487-499. 9. Payne CK. Overactive bladder. Urology 1998;51:1062. 10. Cardozo LD. Biofeedback in overactive bladder. Urology 2000;55:24-28; discussion 31-22. 11. Chapple CR, Rechberger T, Al-Shukri S, et al. A double-blind, randomised, placebo and tolterodine controlled trial with YM905 in symptomatic overactive bladder. Presented at: Annual Meeting of the American Geriatrics Society; May 14-18, 2003; Baltimore, MD. 12. Dmochowski RR, Davila GW, Zinner NR, et al. Efficacy and safety of transdermal oxybutynin in patients with urge and mixed urinary incontinence. J Urol 2002;168:580-586. 13. Davila GW, Daugherty CA, Sanders SW. A short-term, multicenter, randomized double-blind dose titration study of the efficacy and anticholinergic side effects of transdermal compared to immediate release oral oxybutynin treatment of patients with urge urinary incontinence. J Urol 2001;166:140-145. 14. Wilson L, Brown JS, Shin GP, et al. Annual direct cost of urinary incontinence. Obstet Gynecol 2001;98:398-406. 15. Brubaker L, Benson JT, Bent A, et al. Transvaginal electrical stimulation for female urinary incontinence. Am J Obstet Gynecol 1997;177: 536-540. 16. Bø K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 1999;318:487-493. 17. Goode PS, Burgio KL, Locher JL, et al. Effect of behavioral training with or without pelvic floor electrical stimulation on stress incontinence in women: A randomized controlled trial. JAMA 2003;290:345-352. 18. Gross M, Boone TB, Appell RA. Surgical management of overactive bladder. Curr Urol Rep 2002;3:388-395. 19. Verleyen P, Billiet I, Mattelaer J, et al. Cystectomy and orthotopic ileal neobladder construction: Evaluation of continence and complications in a regional hospital. Urol Int 2003;71:255-261. 20. Berghmans LC, Hendriks HJ, De Bie RA, et al. Conservative treatment of urge urinary incontinence in women: a systematic review of randomized clinical trials. BJU Int 2000;85:254-263. 21. Dmochowski RR, Sand PK, Zinner NR, et al. Comparative efficacy and safety of transdermal oxybutynin and oral tolterodine versus placebo in previously treated patients with urge and mixed urinary incontinence. Urology 2003;168:580-586. 22. Holmes DM, Montz FJ, Stanton SL. Oxybutinin versus propantheline in the management of detrusor instability: A patient-regulated variable dose trial. Br J Obstet Gynaecol 1989;96:607-612. 23. Riva D, Casolati E. Oxybutynin chloride in the treatment of female idiopathic bladder instability: Results from double blind treatment. Clin Exp Obstet Gynecol 1984;11:37-42. 24. Tapp AJ, Cardozo LD, Versi E, et al. The treatment of detrusor instability in post-menopausal women with oxybutynin chloride: A double blind placebo controlled study. Br J Obstet Gynaecol 1990;97:521-526. 25. Oxytrol [package insert]. Corona, CA: Watson Pharma, Inc.; 2003. 26. McDonald WM, Salzman C, Schatzberg AF. Depression in the elderly. Psychopharmacol Bull 2002;36:112-122. 27. Manfredi R. HIV disease and advanced age: An increasing therapeutic challenge. Drugs Aging 2002;19:647-669. 28. Murphy M, Carmichael AJ. Transdermal drug delivery systems and skin sensitivity reactions: Incidence and management. Am J Clin Dermatol 2000;1: 361-368. 29. Ditropan [package insert]. Mountain View, CA: ALZA Corporation; 1998. 30. Ditropan XL [package insert]. Mountain View, CA: ALZA Corporation; Revised 2003. 31. Douchamps J, Derenne F, Stockis A, et al. The pharmacokinetics of oxybutynin in man. Eur J Clin Pharmacol 1988;35:515-520. 32. Gupta SK, Sathyan G. Pharmacokinetics of an oral once-a-day controlled-release oxybutynin formulation compared with immediate-release oxybutynin. J Clin Pharmacol 1999;39:22-29. 33. Zobrist RH, Schmid B, Feick A, et al. Pharmacokinetics of the R- and S-enantiomers of oxybutynin and N-desethyloxybutynin following oral and transdermal administration of the racemate in healthy volunteers. Pharm Res 2001;18:1029-1034. 34. Zobrist RH, Quan D, Thomas HM, et al. Pharmacokinetics and metabolism of transdermal oxybutynin: In vitro and in vivo performance of a novel delivery system. Pharm Res 2003;20:103-109. 35. Data on file. Corona, CA: Watson Pharma, Inc.; 2003. 36. Davila GW, Neimark M. The overactive bladder: Prevalence and effects on quality of life. Clin Obstet Gynecol 2002;45:173-181. 37. Davila GW, Dmochowski R, Sanders SW. Transdermal and oral oxybutynin: Comparison of anticholinergic side effects. Presented at: American Urogynecologic Society Annual Scientific Meeting; 2002; San Francisco, CA. 38. Wagner TH, Hu TW. Economic costs of urinary incontinence in 1995. Urology 1998;51:355-361. 39. Kirkland VL, Palmer MH, Fitzgerald ST. Incontinence in a manufacturing setting: Women’s perceptions and responses. Public Health Nurs 2001;18:312-317. 40. Langa KM, Fultz NH, Saint S, et al. Informal caregiving time and costs for urinary incontinence in older individuals in the United States. J Am Geriatr Soc 2002;50:733-737. 41. Frantz RA, Xakellis GC Jr, Harvey PC, et al. Implementing an incontinence management protocol in long-term care: Clinical outcomes and costs. J Gerontol Nurs 2003;29:46-53. 42. Shih YC, Hartzema AG, Tolleson-Rinehart S. Labor costs associated with incontinence in long-term care facilities. Urology 2003;62:442-446. 43. Ramsey SD, Wagner TH, Bavendum TG. Estimating costs of treating urinary incontinence in elderly women according to the AHCPR clinical practice guidelines. Am J Manag Care 1996;2:147-154. 44. Graham CW, Dmochowski RR. Questionnaires for women with urinary symptoms. Neurourol Urodyn 2002;21:473-481. 45. DuBeau CE, Levy B, Mangione CM, et al. The impact of urge urinary incontinence on quality of life: Importance of patients’ perspective and explanatory style. J Am Geriatr Soc 1998;46:683-692. 46. Shumaker SA, Wyman JF, Uebersax JS, et al. Health-related quality of life measures for women with urinary incontinence: The Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program in Women (CPW) Research Group. Qual Life Res 1994;3: 291-306. 47. Uebersax JS, Wyman JF, Shumaker SA, et al. Short forms to assess life quality and symptom distress for urinary incontinence in women: The Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn 1995;14:131-139. 48. Brown JS, Posner SF, Stewart AL. Urge incontinence: New health-related quality of life measures. J Am Geriatr Soc 1999;47:980-988. 49. Dmochowski RR, Miklos JR, Norton PA, et al. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. J Urol 2003;170:1259-1263.

Dr. Bent reported that he receives grant/research support from CRBard, Q-Med, Eli Lilly, Ethicon, Genyx Medical, and Mentor, is a consultant for Gynecare, is on the speaker's bureau for Watson, and is on the advisory board for Eli Lilly.

Dr. Dmochowski reported that he is a consultant for Watson.

Dr. DuBeau reported that she is a consultant for Pfizer, Eli Lilly, Watson, and Schwartz.

Dr. McCue reported that he a consultant for Watson, and is on the speaker's bureau for Ortho-McNeil.

Ms. Newman reported that she is on the speaker's bureau for Watson.

Dr. Zinner reported that he is a consultant for Indevus, Watson, and Pfizer, and is on the speaker's bureau for Watson and Pfizer.