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An interview with Prof. Philip Van Kerrebroeck
In this interview Professor Philip Van Kerrebroeck, Department of Urology, University Hospital of Maastricht, the Netherlands discusses the current awareness of nocturia amongst general practitioners, specialists and patients. He highlights recent initiatives such as the Nocturia Think Tank and Nocturia consensus statement which summarised current knowledge, treatment options and proposed key areas for research in this prevalent condition that has a major impact on patient quality of life.
Please find below the Transcription of the Interview on nocturia with Prof Philip Van Kerrebroeck, conducted by Prof Antonella Giannantoni and the PDF
AG: What is the patient’s experience of nocturia?
PvK: Patients with nocturia are a very varied population. Patients presenting with nocturia as the primary problem generally have very severe nocturia, however, the majority present with nocturia as one of a number of other symptoms. In fact, many patients will only confess that they have nocturia when questioned, indicating that there still is a taboo around nocturia because patients think it’s related to ageing. This reluctance of patients to discuss their nocturia may be reinforced through their interactions with GPs, who when presented with complaints of nocturia can be dismissive of the condition making comments such as ‘this is not a problem’, ‘you’re menopausal’ or ‘you are 70 years old’. Consequently, patients may then be reluctant to ask urologists about nocturia, creating a problem that urologists, the people treating these patients, need to tackle. I challenge urologists to ask their patients about nocturia, they will often see that patients are relieved that a doctor is
finally asking this question.
AG: How can the consensus statement for evaluating and treating nocturia be used by doctors?
PvK: I was very happy with that initiative because there is an unmet need to increase knowledge about nocturia. Until recently, nocturia was seen as a symptom related to prostate enlargement in men and did not exist in women. We now have good epidemiological studies that indicate nocturia is a widespread problem and is as prevalent in women as in men. However, the average doctor, including the urologist, does not recognise this condition because they are not aware of this information. The main aim of the consensus statement was to provide a state of the art document containing the most recent information on all aspects of nocturia, not only epidemiology but also the pathophysiology and treatment options.
The consensus statement was produced not only by expert urologists but also included experts on hormonal balance and sleep specialists because nocturia is a night-time problem. This was, I would say, an intellectual challenge but I hoped we could develop a document that really reviewed the existing information, and I’m quite confident that this is happening, a document that helps our colleagues to become interested in the problem, stimulating discussion with their patients and facilitating diagnosis and treatment.
AG: What key lessons can you share from the Nocturia Think Tank initiative?
PvK: This is another interesting initiative expanding on the International Consultation on Incontinence, which focussed on clinical problems, and the International Consultation on Incontinence and Research Society (ICI-RS) to investigate what is lacking in our current knowledge. I had the pleasure and the privilege to be Chairman of a sub-committee that focused on nocturia. We discovered that many of the things that we take for granted and that we believe are true, have in fact never been properly investigated. We took these points and developed proposals for research topics, both clinical and fundamental research, that could help us in better understanding the mechanisms behind nocturia and also guide us in developing a treatment rationale.
One persistent problem that we have is that while we generate proposals, it remains diffi cult to fi nd sponsorship or funding from scientifi c organisations for nocturia research. Personally, I think it’s very important to fund this research because nocturia has been shown to be a prevalent problem, with a major impact on patient quality of life. In addition, more and more data are being published indicating that nocturia increases morbidity and potentially even mortality. Therefore, from a general health point of view, it is an important problem that merits much more attention than it is currently receiving.
This initiative, combined with the Consensus Meeting and the Research Society Meeting, can only contribute to progress – too slow in my opinion but still progress, so I’m happy to see that. Compared with where we were ten years ago, in terms of the depth of knowledge and the appreciation of the problem, we have come a long way.
AG: How do we engage and inform General Practitioners about diagnosing and treating nocturia?
PvK: It’s very important to approach GPs and make them aware of the relevant information. So far our efforts have mainly focussed on specialist doctors, specifically urologists but we now know that there are many patients who are not referred to the urologist and are instead seen by GPs who do not see nocturia as a problem, giving patients messages like ‘this is not a problem’; ‘you’re a menopausal woman, so why bother’; or ‘you’ve had prostate surgery, you just have to cope with it’.
Another problem with nocturia is that it is a simple problem to treat, but has a complex pathophysiological background. Personally, that’s why I find nocturia an intellectual challenge as a urologist. To help address this, we have now established some algorithms that are a very simple and easy way to find out what is going on.
One of the basic elements essential within these algorithms is the inclusion of voiding charts. I always say in my lectures, for urologists diagnosing functional problems of the lower urinary tract, the voiding chart is the equivalent to the ECG for a cardiologist.
All you require is a patient who can read and write, a piece of paper and a pencil and you ask the patient to record the amount of urine that they void during the day and during the night; and you will have information about night time voiding, the number of voids, the volume of urine produced. After exclusion of some concomitant factors, such as sleeping or cardiovascular problems, which are not too difficult and generally GPs are well informed of, the GPs will have a rich source of information which will enable them to make an accurate diagnosis. Whether or not the GP will then refer the patient or themselves take a therapeutic approach will depend on the individual interest of the GP.
There is definitely an unmet need in nocturia, I remember that ten years ago when we were doing the first clinical trials with desmopressin, a drug that can be and is used in the majority of patients with nocturia based on nocturnal polyuria, the company organising these trials was asking us to recruit as many male patients as female patients. Back then, I was very critical about doing research in females – in males the problem was recognised, but not in females. We placed an advertisement in one of the local newspapers and were surprised that within two weeks, we recruited all the patients that we needed. We asked these individuals why they were participating in this trial. The consistent responses were ‘well for years I’ve had this problem, I didn’t dare to go to my GP’; ‘I went to my GP two or three years ago and they said it is the prostate’ or ‘this is menopausal’. As a result, these participants were reluctant to go back to see a physician about the same problem. When they saw the advertisement, they were happy that finally they could come to our centre for further diagnosis and possible treatment.
This was indirect proof of the unmet need that exists at the patient level and also of the need to educate GPs; however, I’m afraid that it will still take some time before we can get direct information because, for the GP, nocturia is just one problem amongst many that they see in their patient population.
AG: Should urologists cooperate with other physicians to treat patients with nocturia?
PvK:Again, a very interesting question and a great challenge for the future. Personally, I’m a urologist and I consider urology a unique speciality within the surgical specialities because we have both surgical aspects and the diagnostics of problems of the lower urinary tract.
We can make our own diagnosis and we should use this opportunity and not see nocturia as purely a surgical problem. As urologists we should also develop internal medicine skills. Having said that, it is problematic because urology is still a surgical speciality and I think from my previous comments it’s obvious that when you see a patient with nocturia and you really want to understand the cause of the problem, you need some time. You have to talk to the patient; you have to evaluate general health factors, cardiovascular factors, hypertension, venous oedema, and things like that, which most urologists are not used to assessing. Therefore there are two possibilities: either you develop your own skills, I think any urologist can do that, or you cooperate with other colleagues who have more internal medicine specialisation.
My own practice is based in a tertiary referral centre, so I see the more complex patients. In particular, for elderly people that take multiple medications for their multiple health problems, the cause behind nocturia can be difficult to ascertain. I work together with a geriatrician who was initially reluctant to treat nocturia, his first response was ‘oh nocturia, well... is that the problem, they have hypertension, they have venous problems, and so on and so on’. After that he said, ‘please can you see some of my patients because I’m in trouble, it’s quite complex and I would like to have your support’ so he referred those patients to me, but even that took some time. Now we have been working together for several years and it’s very nice. I’ve been able to see that, for example, geriatricians in general are conservative in their approach but once they see a problem in their patients, they’re very motivated to do something about it. Wanting to solve the problem is where urologists and geriatricians can meet and work together for greater patient benefit.
As another example from my personal experience, one of the causes of nocturia is sleep apnoea. I must confess before I was in these committees and this standardisation group of the ICS, I had never made a diagnosis of sleep apnoea. Now, on an annual basis, I will see three to four patients who receive sleep apnoea therapy because their nocturia led them to seek treatment. This is a small group of patients and I see them on average more than the general urologist because of my referral situation, but these are the things that I think we still have to raise awareness of in the urology community. I still find every day an intellectual challenge when dealing with these types of patients, and I hope to emphasise that challenge and interest to my colleagues in urology.
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