American Journal of Epidemiology Advance Access originally published online on January 7, 2008
American Journal of Epidemiology 2008 167(4):404-405; doi:10.1093/aje/kwm353
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Tennstedt et al. Respond to "BACH and the Epidemiology of Urinary Incontinence"
1 New England Research Institutes, Watertown, MA
2 University of Virginia Health System, Charlottesville, VA
Correspondence to Dr. Sharon L. Tennstedt, New England Research Institutes, 9 Galen Street, Watertown, MA 02472 (e-mail: stennstedt{at}neriscience.com).
Received for publication October 29, 2007. Accepted for publication November 2, 2007.
In his commentary (1) on our article (2), Dr. David Thom has identified an important issue in epidemiologic studies of urinary incontinence: the selection of an operational definition. The International Continence Society's definition (3) requires objective demonstration of urine leakage, precluding its use in many epidemiologic studies, which often cannot include invasive clinical measures. The operational definition in the Boston Area Community Health (BACH) Survey was based pragmatically on symptoms. Dr. Thom's point that the interview questions were derived from studies of women is also important (probably reflecting society's ill-founded view that urinary incontinence is predominantly a women's issue). While the questions have face validity, self-reported leakage in men has not been clinically validated. As Thom suggests, this is probably contributing to difficulty classifying incontinence type in men. Urinary incontinence is not an isolated problem in men. It often occurs with other urogenital symptoms such as hesitancy or terminal dribbling. Consequently, men might have difficulty responding to these questions—for example, by not being able to distinguish dribbling from urinary incontinence. We fully concur with Thom's recommendation for developing and validating incontinence measures in men, as was done by Sandvik et al. (4) with women. Without this work, the accuracy of incontinence prevalence rates in men will be questionable.
The same point can be made about the validity of classifying type of urinary incontinence on the basis of self-reports. Again, validation studies of incontinence type by Sandvik et al. (4) have been conducted only with women. Furthermore, Sandvik et al. concluded that the prevalence of mixed incontinence in women is probably overreported in epidemiologic studies (4). This suggests that studies of incontinence type might require clinical measures and cannot rely on self-reports, or at least on the self-report measures currently available. Fortunately, urinary incontinence is one urologic condition for which there is a reasonable gold standard in urodynamic studies for clinical validation.
Thom describes enrollment in the BACH Survey as "fewer than 25 percent of eligible community members" (1, p. 401). However, lacking information on the eligibility of persons not screened, 25 percent represents the lower bound, with 60 percent as the upper bound (5, 6). In a recent report, Galea and Tracy (7) described reasons for declining participation rates in epidemiologic studies, including a proliferation of research studies, which are often confused with marketing surveys; a general decline in voluntarism in the United States; limitation of participation to studies with personal salience (urologic studies are a "hard sell"); and increased study complexity and burden. Certainly we experienced these challenges and made diligent and exhaustive efforts to enroll a sample with the desired diversity (5).
Dr. Thom places the findings from this study in the context of reports from prior studies. The BACH findings make an important contribution by confirming what has been reported from studies of nonrepresentative area or clinical samples. The age and racial/ethnic diversity of the sample underscores this contribution.
Finally, we fully concur with Thom's call for studies of urinary incontinence incidence, progression, and natural history in both men and women. Previous work by our colleagues has shown remission rates of 50–60 percent for other urologic problems (erectile dysfunction, androgen deficiency) (8, 9; V. Kupelian, New England Research Institutes, unpublished data). The ongoing 5-year follow-up interview with BACH respondents will provide a wealth of information on urinary incontinence and a range of other urologic symptoms with which to fill this gap in knowledge.
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ACKNOWLEDGMENTS |
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Conflict of interest: none declared.
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References |
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 TOP References |
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- Thom DH. Invited commentary: the contribution of the BACH Survey to the epidemiology of urinary incontinence. Am J Epidemiol (2008) 167:400–3.
[Abstract/Free Full Text] - Tennstedt SL, Link CL, Steers WD, et al. Prevalence of and risk factors for urine leakage in a racially and ethnically diverse population of adults: The Boston Area Community Health (BACH) Survey. Am J Epidemiol (2008) 167:390–9.
[Abstract/Free Full Text] - Abrams P, Blaivas JG, Stanton SL, et al. The standardisation of terminology of lower urinary tract function. The International Continence Society Committee on Standardisation of Terminology. Scand J Urol Nephrol Suppl (1988) 114:5–19.[Medline]
- Sandvik H, Seim A, Vanvik A, et al. A severity index for epidemiological surveys of female urinary incontinence: comparison with 48-hour pad-weighing tests. Neurourol Urodyn (2000) 19:137–45.[CrossRef][Web of Science][Medline]
- McKinlay J, Link C. Measuring the urologic iceberg: design and implementation of the Boston Area Community Health (BACH) Survey. Eur Urol (2007) 52:389–96.[CrossRef][Web of Science][Medline]
- American Association for Public Opinion Research. Standard definitions: final dispositions of case codes and outcome rates for surveys. (2005) Lenexa, KS: American Association for Public Opinion Research.
- Galea S, Tracy M. Participation rates in epidemiologic studies. Ann Epidemiol (2007) 17:643–53.[CrossRef][Medline]
- Travison TG, Shabsigh S, Araujo AB, et al. The natural progression and remission of erectile dysfunction: results from the Massachusetts Male Aging Study. J Urol (2006) 177:241–6.[CrossRef]
- Araujo AB, O'Donnell AB, Brambilla DJ, et al. Prevalence and incidence of androgen deficiency in middle-aged and older men: estimates from the Massachusetts Male Aging Study. J Clin Endocrinol Metab Dec (2004) 89:5920–6.[CrossRef]
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Related articles in Am. J. Epidemiol.:
- Prevalence of and Risk Factors for Urine Leakage in a Racially and Ethnically Diverse Population of Adults: The Boston Area Community Health (BACH) Survey
- Sharon L. Tennstedt, Carol L. Link, William D. Steers, and John B. McKinlay
Am. J. Epidemiol. 2008 167: 390-399.[Abstract] [FREE Full Text]
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