9 Simms C, Milimo J, Bloom G. The Reasons for the Rise in Child-

hood Mortality during the 1980s in Zambia. IDS working Paper 76.

UK: Institute of Development Studies, 1998.

10 Simms C, Rowson M. Reassessment of health effects of the

Indonesian economic crisis: donors versus the data. Lancet 2003;

361: 1382–5.

11 Families USA Foundation. A Painful Recession: States Cut Health

Care Social Safety Net Programs. Washington, DC: Families USA

Foundation, 2008. http://www.familiesusa.org/assets/pdfs/a-painful-

recession.pdf.

doi: 10.1111/j.1742-1241.2009.02149.x

ED ITORIAL

Going back to the bladder basics

Every now and then we read something that brings us

back to the basics and reminds us of what to do, or

what we should be doing. Such is this month’s article

‘Practical aspects of lifestyle modifications and

behavioural interventions in the treatment of over-

active bladder and urgency urinary incontinence’ by

Wyman et al. (1). It should be of no surprise to those

who know me that I am fascinated by the world of

urologic disease. Granted, my wife and kids think that

may be a little strange and may not want to tell their

friends, but I like it. With regard to bladder control,

I think it is fantastic that we now have over half a

dozen medications for the patient suffering from over-

active bladder (OAB). This means lots of options

before a patient has to see a urologist and possibly

undergo more complex and invasive treatment. No

disrespect to my urologic colleagues but as far as I am

concerned the treatment of OAB starts in the office of

the primary care provider (PCP) and only the refrac-

tory case goes to the specialist (2). But after reading

the article I have to stop and remind myself that med-

ications are not always the correct first choice. Yes,

medications may be the ‘scalpel’ of the PCP and

appropriate in a large number of the patients, but is

not education the first intervention we should offer in

most diseases? We must remember, although the

prevalence of OAB is high, not everybody wants phar-

maceutical intervention. What they want is to under-

stand and make lifestyle changes if those are possible.

They want the provider to explain the disease and give

them the list of opportunities on how to fix it; this

may include medications or maybe just behavioural

interventions. In my experience, most, if not all

patients want to feel as if they have some control of

the own health.

In this comprehensive and superb piece, three of

the foremost OAB specialists in the world remind us

that behavioural interventions are the cornerstone of

treatment in this disease. In the article, they use

patient-empowering words and statements such as

restore, train, easy, early recognition and patient

preference. They do not discount medications at all,

yet they show us how to use non-invasive interven-

tion alone or in synergy with pharmaceuticals to

optimize outcomes. As I read this the first time, I

kept thinking maybe I should spend a little more

time with the symptomatic patient and really focus

on the things that they could do.

Oops, wakeup call! I do not have more time as I am

already bulging at the seams. Isn’t just writing a medi-

cation the best thing to do, the old ‘treat ‘‘em’’ and

street ‘‘em’’’? Wyman et al. seemed to anticipate my

visceral reaction by preparing a few patient handouts

that can assist me with this. Let us be honest, none of

us have huge slabs of time to discuss things, but we do

have the time to hand out a very instructive piece to

our patient. They feel good that we explained the

problem to them and gave them some self-help oppor-

tunities. I then feel good because I am not just a pre-

scription-writing machine and there is additional

value added to my interaction. Another pearl that they

offer is the tremendous benefit to having an ancillary

staff member who can promote these lifestyle and

behavioural changes. I have had the honour of work-

ing with Diane Newman for years and long ago she

taught me the value of having my nurse practitioner

becoming the educator in this regard. I can comfort-

ably say I believe I have the most competent and

patient educating nurse practitioner in the Midwest

with regard to bladder control. Ms. Page (the NP who

works with me) does this education that the authors

suggest in the office and this 1–2 punch is a tremen-

dous benefit to the patient.

There are always naysayers in the world and I am

sure some exist who question the value of behavioural

changes in OAB and bladder control. I thought about

that as I read this expert piece and I could not help but

think about my mother. According to her all the mem-

bers of my family were child prodigies as regards potty

training as we had her as a fabulous coach. There were

four of us and she got better and better with each new

addition to the family. In fact, legend tells us that she

Linked Comment: Wyman et al. Int J Clin Pract 2009; 63: 1177–91.

Not everybody

wants

pharmaceutical

intervention

1122 Editorials

ª 2009 Blackwell Publishing Ltd Int J Clin Pract August 2009, 63, 8, 1119–1127

was so good that when my little sister (the youngest of

the brood) was born, she was continent by the time the

doctor spanked her bottom in the delivery room.

Honestly, I did not believe any of these stories and I

thought it was just a yarn concocted by mommy.

However, when it came time to train my two children

in the art of the bladder control my superhero mother

came to the rescue. She watched our first child for my

wife and I while we went away for a meeting bragging

that upon our return there would be order in the uni-

verse. ‘Yea, right’ we thought as we boarded the plane

ready for a diaper free weekend. Indeed 2 days later

my 2 ½-year-old son was a master of the toilet. Okay,

we figured she just got lucky but this was repeated

with my daughter 3 years later.

How does this little anecdote jive with the

paper by Wyman et al.? It exemplifies the power of

education and behavioural modifications. OAB and

toddler control may be different, but the education

remains the same. It is cheap, it is easy, it cannot

hurt (so there is no downside) and it empowers the

individual. It all comes to education, explaining to

the patient what to expect of the bladder and then

how to work on control.

My wife and I are not planning any more children

but we do have a young, wild and occasional incon-

tinent dog. Maybe I could arrange a little competi-

tion Wyman, Burgio and Newman vs. Supermom.

Either way I win!

M. T. RosenbergMid-Michigan Health Centers, Jackson, MI, USA

Email: mattoren@yahoo.com

References1 Wyman JF, Butgio KL, Newman DK. Practical aspects of lifestyle

modifications and behavioural interventions in the treatment of

overactive bladder and urgency urinary incontinence. Int J Clin

Pract 2009; 63: 1177–91.

2 Rosenberg MT. Master of nothing but knower of all. Int J Clin

Pract 2008; 62: 668–9.

doi: 10.1111/j.1742-1241.2009.02148.x

ED ITORIAL

Erectile dysfunction: a harbinger for cardiovascularevents and other comorbidities, thereby allowinga ‘Window of Curability’

In his landmark 2005 report (1) of over 9400 men,

Thompson et al. posed the following questions:

‘With the high prevalence of erectile dysfunction

(ED) in aging men, do pharmacologic, lifestyle, or

behavioral interventions that are cardioprotective

also reduce or delay onset of ED? Could ED serve as

a surrogate measure of treatment efficacy in preven-

tive interventions for cardiac disease?’ Today, 4 years

later, these questions remain unanswered.

In the Thompson et al. study, as part of the Prostate

Cancer Prevention Trial, men aged 55 years and older

who were part of a placebo group (n = 9457) were

evaluated at 3-month intervals for ED and subsequent

cardiovascular disease. There were 4247 men with no

ED at study entry; 2420 developed incident ED

(defined as the first report of ED of any grade) over

5 years. Incident ED (adjusted for other cardiovascu-

lar risk factors) was associated with a hazard ratio

(HR) of 1.25 (95% confidence interval (CI) 1.04 to

1.53; p = 0.04) for subsequent cardiovascular events

including myocardial infarction, coronary revasculari-

sation, cerebrovascular accident, transient ischaemic

attack, congestive heart failure, fatal cardiac arrest or

non-fatal cardiac arrhythmia. The adjusted HR was

even higher (1.45; 95% CI 1.25–1.69; p < 0.001) for

men with either incident or prevalent ED (i.e. ED at

study entry). Therefore, the authors were able to con-

clude that incident ED had an effect equal to or

greater than the effects of family history of myocardial

infarction, cigarette smoking or measures of hyperlip-

idaemia on subsequent cardiovascular events (1).

This study lends further support to the notion that

ED is predominantly a disease of vascular origin with

endothelial cell dysfunction as the unifying link.

Investigations in diabetics have also supported this

concept, and in fact, suggest that ED is a predictor

of future cardiovascular events in this group.

Gazzaruso et al. (2) recruited 291 type 2 diabetic

men with silent coronary artery disease (CAD) and

found that those who developed major adverse

cardiac events over the course of approximately

4 years were more likely to have ED (61.2%) than

those who did not (36.4%). Through further multi-

variate analysis, ED remained an important predictor

Linked Comment: Hackett. Int J Clin Pract 2009; 63: 1205–13. Chronic

disease

management

protocols in

primary care in

the UK

continue to

ignore the

health

importance of

ED

Editorials 1123

ª 2009 Blackwell Publishing Ltd Int J Clin Pract August 2009, 63, 8, 1119–1127