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Editor,—We describe the last two years' activity in our continence clinic as support for the thesis of Castleden and Duffin that a strong case can be made for the development of a specialty of medical urology.1
In our area many community nurses have undergone training by the continence advisers and are able to deal with simple lower urinary tract problems.
During the years 1998 and 1999 we saw 141 patients in the clinic (125 female). The age range was 19 to 96 years with a median of 70 years. The main sources of referral were community based nurses: 56 referrals, general practitioners: 51, geriatricians: nine, consultant gynaecologists: eight, and consultant in rehabilitation medicine: seven.
All patients underwent a thorough clinical assessment including measurement of a flow rate and post-void residual (using bladder scanner) and the great majority of patients completed a frequency/volume chart. The average number of visits was 2.8 (range 1–8). The diagnoses made on these 141 patients are listed in table 1; a number of patients had more than one diagnosis.
Thirty five patients underwent filling and voiding cystometry, usually when treatment after a clinical diagnosis had failed and also in the few patients who were referred for a surgical opinion.
The treatment offered to patients with overactive bladders included habit retraining, regular and prompted voiding, and antimuscarinic drugs (oxybutynin, tolterodine, and imipramine most commonly). Those with genuine stress incontinence (GSI) were taught to do pelvic floor exercises using digital assessment and a perineometer. Vaginal cones were employed in a number of cases.
In those with voiding problems a few were treated with clean intermittent catheterisation (CIC) either done by the patient, a family member, or district nurse. Fluid intake was adjusted where appropriate. An afternoon diuretic was employed successfully in a number of patients with nocturnal polyuria. Constipation was treated with laxatives and/or enemas, urinary infections with antibiotics, and post- micturition dribble exercises were employed in the few with this problem. The outcomes in these patients are listed in table 2.
It was possible, therefore, to achieve relief of symptoms in the great majority of these patients. In those few in whom this was not possible appropriate advice about containment was given.
A very small number of these patients were referred for a surgical assessment, in fact a larger number was referred from the gynaecologists to this clinic.
Urinary incontinence remains one of the “giants of geriatrics”2 and as a consequence a number of geriatricians run such clinics. The evidence base for useful conservative treatments for incontinence is growing,3-5and their effectiveness should continue to increase with time. The co-morbidity seen in old age (as stated by Castleden and Duffin) also makes the geriatrician an appropriate physician to run such clinics.
The medical specialty of urology (or urogynaecology) probably exists already but is not fully recognised. Our experience is that it has an important place in the management of lower urinary tract symptoms. Multidisciplinary working especially with continence advisers is imperative and also close links need to be maintained with surgical colleagues.