Full text of DOI:10.2165/00002512-200118030-00006

Drugs & Aging 2001; 18 (3): 213-223
1170-229X/01/0003-0213/$22.00/0
REVIEW ARTICLE
© Adis International Limited. All rights reserved.
Economics of Lower Urinary Tract
Symptoms (LUTS) in Older People
Usman Azam,1 Mark Castleden2 and David Turner1
1
2
Leicestershire MRC Incontinence Study, Department of Epidemiology and Public Health,
University of Leicester, Leicester, England
Leicester General Hospital, Leicester, England
Contents
Abstract
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
1. How Big Is the Problem? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
2. How Much Can Lower Urinary Tract Symptoms (LUTS) be Corrected . . . . . . . . . . . . . . . . . 215
3. The Economics of Untreated LUTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
3.1 Burden . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
3.2 Efficiency of Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
3.3 Quantification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
3.4 Willingness to Pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
4. Treatment of LUTS, Associated Conditions and its Costs . . . . . . . . . . . . . . . . . . . . . . . . 217
4.1 Drug Treatment of Urinary Tract Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
4.2 Drug Treatment of the Overactive Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
4.1.1 Imipramine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
4.1.2 Oxybutynin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
4.1.3 Tolterodine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
4.1.4 Propiverine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
5. Estrogen Replacement Therapy in Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
6. Treatment of Voiding Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
7. Incontinence Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
8. The Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Urinary incontinence is an area of clinical and social importance to older
people and providers of care. This article provides an update on the ‘symptom’
of urinary incontinence and reviews the concept of lower urinary tract symptoms
(LUTS). The challenges facing health services researchers working in this field
are also discussed in terms of trying to quantify the size and extent of the under-
lying problem. Economic issues and work undertaken to evaluate the cost of
LUTS are appraised and the common nonsurgical treatments for LUTS are de-
scribed together with associated conditions and their cost implications. The cost
to individuals and society of LUTS is generally underestimated and the impor-
tance of reducing its severity (if cure is not achievable) makes clinical and eco-
nomic sense.
Abstract

214
Azam et al.
Present demographic changes in world popula-
not related to urinary incontinence. For example,
the disruption caused by lost sleep due to nocturia
and alterations in usual activities due to frequency
are extremely difficult to evaluate. Therefore the
cost of LUTS may be greater than the cost of uri-
nary incontinence alone.
This review provides a background to the prob-
lem of LUTS in older people. It covers epidemiol-
ogy, economics, the cost of current practical treat-
ments of LUTS in the older population (excluding
surgical interventions) and suggests ideas for fur-
ther research.
tions will continue for some time with marked in-
creases in the very old who consume more health
resources than any other age group.
Urinary incontinence, whilst lacking the glam-
our of other medical conditions, is nevertheless a
‘geriatric giant’ and as such is an area of health
needs in which fiscal policy will play a major role
in future service provision. Indeed a recent televi-
sion campaign in the UK by Pharmacia and Upjohn
encouraged the public to seek help with regards to
urinary incontinence,[1] ensuring that economic
evaluation of incontinence will have a prominent
role to play in health services research in the future.
In the medical model, incontinence is a symp-
tom. It is, however, only one among several sig-
nificant lower urinary tract symptoms (LUTS), a
term first introduced by Abrams in 1994 in an at-
tempt to critically evaluate the impact of individual
urinary symptoms and to promote a more detailed
enquiry as to the root of the patients urinary prob-
lems.[2-4] LUTS may have components of both stor-
age abnormality symptoms and voiding abnormal-
ity symptoms (table I).
In terms of the classification of diseases, incon-
tinence is no more of a disease of the lower urinary
tract than cough is a disease of the lungs. In this
review we will wherever possible encourage the
use of the concept of LUTS. Unfortunately, to
date, most of the work conducted in this area has
not taken into account individual symptoms. This
poses problems when performing economic evalu-
ations. Addressing urinary incontinence alone does
not produce the whole picture. There may be costs
associated with nocturia and frequency which are
1. How Big Is the Problem?
One of the great challenges facing researchers
working in the field of urinary dysfunction (partic-
ularly in older people) is the conflict in reporting
of epidemiology. It is generally now accepted that
whatever perspective is used, the problem is still
underestimated and is big one.[5]
Indicators of prevalence are further compli-
cated by researchers concentrating on inconti-
nence rather than LUTS. Herzog and Fultz esti-
mated the prevalence of urinary incontinence as 10
and 20% in men and women, respectively.[6] Later
works by Diokno et al.[7] and Herzog and Fultz[8]
have concluded that 19 and 38% of men and
women, respectively, are more realistic figures for
urinary incontinence.
Other important confounding issues in epidemi-
ological research have been those of population
demographics, namely the setting for the problem
(community based or residential homes), gender,
age and racial variations. All of the above points
(and the lack of measures of disease severity) fur-
ther compound the problem of what is the percep-
tion of need in the older population.
Table I. Lower urinary tract symptoms
Urgency
It is well known that the prevalence of LUTS is
greater in the residential home setting than in the
community. Ouslander et al.[9] suggested that ap-
proximately 50% of the nursing home population
had incontinence problems. Peet et al.[10] reported
that problems with incontinence in the nursing
home population are are not only greater but also
more severe.[10]
Frequency
Nocturia
Pain
Straining
Incomplete emptying
Hesitancy
Weak stream
Intermittency
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Drugs & Aging 2001; 18 (3)

Economics of LUTS in Older People
215
Studies of aging and incontinence have shown
increases in prevalence with age from 15 to 35%
between the ages of 65 and 90 years.[11] This in-
crease may be due to the increased burden of men-
tal and physical handicaps with aging rather than a
true ageing phenomenon.[12] Bjornsdottir et al.[13]
found that 50% of octogenarians had daily symp-
toms of urinary incontinence.
There is a relative dearth of studies in older
males. Tsang and Garraway[14] suggested that be-
nign prostatic hypertrophy (BPH), which com-
monly causes LUTS in men, may affect 40% of
men over the age of 65 years.
Post micturition dribble can be severely bother-
some to elderly males and is under-reported.[15]
Beier-Holgersen and Brun[16] have suggested that,
regardless of nature or severity, men more readily
accept their urinary symptoms. However, with in-
creasing health awareness, particularly with re-
gards to prostatic cancer, a shift in reporting may
be evident in the future.
Traditional thoughts as to why LUTS in females
have a higher prevalence has centred around post-
menopausal changes in hormonal status resulting
in changes in detrusor, urethral and pelvic floor
function. However, the exact mechanisms are not
clearly understood (see section 5).
of symptoms and causes, in a logical manner and
to investigate them. This would also seem to make
economical sense (see section 3).
3. The Economics of Untreated LUTS
At the core of the contribution of health eco-
nomics to healthcare provision is the idea that mar-
kets fail to provide an adequate solution to the
problems of how much healthcare to produce, what
sort of healthcare to provide and who to provide it
for. Therefore, decisions on these questions have
to be made on behalf of society. In relation to
LUTS, health economics can make contribution in
2 particular ways. The first is to quantify the size
of the economic burden of LUTS. The second is to
answer particular questions on the most efficient
ways to provide particular services and to address
particular problems.
Farrar and Donaldson[19] have provided exam-
ples of the above in relation to care of older people.
At the macro level one question is whether the
aging population is a growing burden that can be
afforded by Western societies. They break this
question down to 2 issues. First, is an aging popu-
lation going to constitute an economic burden?
Second, what does ‘affordability’ mean in relation
to healthcare?
The vast majority of the above work has been
undertaken across the continents of North America
and Northern Europe. The problem of LUTS is sig-
nificant and difficult to quantify in the older pop-
ulation in the developed world. To quantify the
problem and the impact on a global scale is a dif-
ficult task, but there is no reason to suppose that
that people in Third World countries suffer less
than those in developed countries.[17,18]
3.1 Burden
Economists can work with epidemiologists and
social scientists to quantify the economic burden
of LUTS so that a picture of current burden and
possible future trends is formed. This may then be
related to the cost of addressing these changing
patterns so that estimates of healthcare costs and
expenditure are made. This information can give
an estimate of the burden and importance of a con-
dition. It can also be used to estimate the effects of
changes, such as an aging of the population, or an
increase or decrease in prevalence. When doing
this it is essential to include the costs borne by all
relevant sectors regardless of budget demarcations
(e.g. primary and secondary health services, social
services, voluntary sector) as well as the public and
wider society.
2. How Much Can Lower Urinary Tract
Symptoms (LUTS) be Corrected
By the time most older people receive clinical
attention for their LUTS, cure may not be feasible.
The aim should then be to reduce the severity of
LUTS and improve the quality of life for these pa-
tients. Therefore, it is appropriate to seek underly-
ing urinary problems in older people, both in terms
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Drugs & Aging 2001; 18 (3)

216
Azam et al.
3.2 Efficiency of Healthcare
For their estimation, costs were described as
direct (those associated with providing a health-
care intervention e.g. diagnosis, inpatient services,
outpatient care, cleaning of laundry, medications)
and indirect (those arising because of the interven-
tion but not a direct consequence of the healthcare
being provided e.g. lost productivity due to time
off work). Intangible costs (the monetary value of
the pain and suffering resulting from urinary incon-
tinence) were not included in their analysis. For the
purposes of prevalence they used the estimates of
Diokno et al.[7] for community-based incontinence
and Dey[22] for institution-based incontinence.
Using Hu’s original data from 1984 and updat-
ing this with national hospital discharge surveys,
Wagner and Hu[20] assumed that 2% of individu-
als with incontinence in the community and 5% of
those living in institutions sought treatment. Their
framework for direct costing incorporated fea-
tures such as diagnostic costs, treatment costs (be-
havioural, pharmacological, surgical), routine care
costs, and incontinence consequence costs [skin
irritation, urinary tract infections (UTIs), falls].
These were all considered at the community and
institutional level.
The authors assumed that 30% of those aged
>65 years incurred indirect costs. By combining
direct and indirect costs they came to the figure
quoted above ($US26.3 billion) the vast majority
of which was due to direct costs (US$25.6 billion)
i.e. 97%. However, their study gave no information
on whether or not this is money well spent. It says
nothing about the health benefit of this spending or
whether more benefit could be created by different
patterns of spending. This limitation was discussed
by the authors.
Efficiency can be thought of as producing health-
care so that the maximum benefits are produced for
a given cost. Efficiency is a desirable aim as there
is a fixed budget for healthcare so it is important to
maximise the benefits produced by that fixed bud-
get. Health economists address the issue of effi-
ciency by looking at both costs and benefits, i.e.
how much do you get from a particular cost outlay.
If one intervention produces more benefits per unit
of cost than another it will be preferred on an effi-
ciency basis.
3.3 Quantification
Not surprisingly, attempting to quantify the
health economics of LUTS is difficult. Many issues
come into play, all of which need to be accounted
for in an economic evaluation. Costs attributable
to LUTS impose burdens on individuals, families,
carers and healthcare institutions. LUTS are a cause
for admission to hospital or nursing home.[12] Many
individuals who experience LUTS pay for aids,
such as pads, from their own pocket and also have
to account for the cost of laundry of soiled clothing.
The impact on the quality of life of the carer is a
further issue. It is also difficult to quantify the ben-
efits of an improvement in an individual’s urinary
incontinence.
Recently, 2 excellent reviews have addressed
the issues of the economics of incontinence. The
first study by Wagner and Hu[20] updated the work
originally conducted by Hu[21] in 1984 and publish-
ed in 1986.
They estimated the annual costs (in 1995) of
urinary incontinence in the US for individuals over
the age of 65 years as $US26.3 billion, or $US3565
per individual with urinary incontinence.
As uncertainty existed around prevalence, num-
bers of patients treated, different treatments, aver-
age cost of treatments and supplies, they used a
sensitivity analysis. This involved the systematic
variation of key parameters to determine the im-
pact on total costs.[23] Each of the important param-
eters was adjusted one at a time in the sensitivity
analysis. The parameters that they emphasised were
prevalence, proportion of individuals seeking treat-
They used the principle of cost of illness as first
described by Hu.[21] This involved aggregating
individual level data pertaining to the average cost
of treatment and the average amount of healthcare
use in order to form population estimates. Combin-
ing these aggregated estimates with disease preva-
lence they provided the above fiscal estimates.
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Drugs & Aging 2001; 18 (3)

Economics of LUTS in Older People
217
ment, proportion of different treatments (behavi-
oural, pharmacological, surgical), the average an-
nual cost of these treatments and cost of supplies
of routine care. The sensitivity analysis revealed
that total costs were minimally affected by most of
the above – all except prevalence (by taking a very
conservative estimate of 9% prevalence rate for
community based incontinence, as opposed to
18%, the total cost decreased from US$26.3 billion
to US$16.1 billion). This cost of illness study
showed the size of the problem but did not assess
the effect of treatments.
sample consisted of 541 patients of whom 461
(85%) replied.
Patients were asked about their willingness to
pay for a hypothetical treatment and 2 levels of
improvement were offered (25 and 50% improve-
ments in their symptoms). Patients were willing
to pay approximately twice as much for a 50%
improvement compared with a 25% improvement.
Patients with greater severity of incontinence were
also prepared to pay more.
The baseline QOL scores of these patients were
lower than those of the general Swedish population
and the scores correlated significantly with the
combined symptoms (p < 0.001). The EuroQol
scores also correlated with combined symptoms
(p < 0.001). When scores were taken for individual
symptoms and correlated both symptoms had ap-
proximately the same weight. The authors con-
cluded that the severity of symptoms expressed
as frequency and incontinence is correlated with
QOL, health status and willingness to pay for a
given percentage reduction in their symptoms.
This study (using 1996 prices and the exchange
rate of £1 = 11.5 Swedish Krona) produced median
willingness to pay of between £12 and £57 per
month. These values do not correspond to any pur-
chases of services so would not appear in most
evaluations or cost of illness studies. This would
mean that estimates of the burden of incontinence
are likely to be biased downwards as reported by
Drummond.[28]
3.4 Willingness to Pay
The above study was descriptive in nature,
which is invaluable in providing basic information
for policy makers but it is also necessary to have
comparative studies using alternative economic
evaluation techniques which allow us to answer the
question: what is the best way to do something?[24]
Methods of economic evaluation include cost
minimisation, cost effectiveness, cost utility and
cost benefit. In cost benefit analysis, both costs and
benefits are assigned a monetary value. The bene-
fits of any intervention can then be compared
directly with any costs incurred. One way to do
this is to determine the ‘willingness to pay’.[25]
This is based on observed trade offs between re-
sources and states of ill health. Respondents are
asked what is the maximum amount of money they
are prepared to pay for the commodity (in this case,
an improvement in incontinence).
4. Treatment of LUTS, Associated
Conditions and its Costs
Willingness to pay for a reduction in the number
of micturitions and leakage episodes was used in a
Swedish study where frequency of micturition and
involuntary loss of urine were combined as an out-
come measure.[26]
4.1 Drug Treatment of Urinary
Tract Infections
To see if combining frequency and leakage was
an appropriate outcome measure, quality-of-life
(QOL) scores together with scores from the Euro-
Qol instrument[27] were correlated with frequen-
cies and incontinence both individually and to-
gether.
The incidence of UTI is high in older people and
is the most common cause of acute bacterial sepsis
in those aged >65 years. It can also be the basis
for LUTS in older people. Asymptomatic patients
must have a urine culture threshold of 1 x 105 c.f.u/
ml of a single species for diagnosis but this is low-
ered to 1 x 102 c.f.u/ml in symptomatic patients.[29]
Asymptomatic bacteriuria is more common in
This qualitative and economic health study was
undertaken in the form of a questionnaire. The
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Drugs & Aging 2001; 18 (3)

218
Azam et al.
Table II. Cost of common antibacterial treatments for urinary tract
tients must take the drug to have a certain number
improved or cured. The duration of treatment and
how long patients are likely to continue or comply
with treatment is also not clear. Larger, well con-
structed, randomised, controlled clinical trials need
to be performed to answer these questions.
infections in the UK (year 2000 prices)
Antibacterial and dose
Amoxicillin 500mg tid
Cefalexin 250mg qid
Erythromycin 250mg qid
Trimethoprim 200mg bid
Nitrofurantoin 50mg qid
Nalidixic acid 1g qid
Cost of 7-day treatment (£)
1.05
2.02
0.82
0.54
1.96
12.83
4.1.1 Imipramine
Imipramine[35,36] is a tricyclic antidepressant
with central and peripheral anticholinergic effects,
sedative and antihistamine properties, local anaes-
thetic properties, calcium antagonist properties,
adrenergic properties and a nocturnal effect in re-
ducing urine production.[37] It is the latter property
that can make this an attractive drug for treating
nocturia. However, caution is needed especially
when given with other antidepressants, antipsy-
chotics, alcohol, anticoagulants and cimetidine.
Postural hypotension is a potentially dangerous
adverse effect of imipramine. Its long half-life (3
days) means titration should be a slow process
starting with 25mg once a day. The average recom-
mended dose is 50mg daily, but up to 150mg may
be used.
bid = twice daily; qid = 4 times daily; tid = 3 times daily.
older people but it is not clear if treating it is
cost effective or cost beneficial, especially if the
adverse effects of antibacterials are also consid-
ered.[30]
Table II provides the cost of common antibacte-
rial treatments for UTIs in the UK. The above cost-
ing is based on non-proprietary tablet preparations.
Costs increase with capsular and liquid prepara-
tions.
Bacterial resistance, especially to ampicillin
(to which approximately 50% of Escherichia coli
are now resistant), has increased the importance
of urine culture prior to therapy.[31] The principle
that treatment of symptomatic UTIs is cost effec-
tive is not challenged. What is questionable is
which antibacterial should be used to achieve the
desired effect at the lowest cost.
4.1.2 Oxybutynin
Oxybutynin is a tertiary amine with powerful
anticholinergic, local anaesthetic and papaverine-
like properties.[38]
It is renally excreted and has a half-life of 3
hours.[39] Adverse effects include dry mouth, con-
stipation, reflux oesophagitis, dry skin, visual ac-
commodation problem and minor ankle swelling.
These adverse effects cause poor compliance. A
low dose regimen of 2.5mg twice daily is recom-
mended in older people initially with upwards ti-
tration depending on desired and unwanted ef-
fects.[40,41]
4.2 Drug Treatment of the
Overactive Bladder
Drug treatment for LUTS in older people pri-
marily centres around the treatment of the unstable
or overactive bladder (the urodynamic diagnosis
being detrusor instability or detrusor hyper-
reflexia).
Whilst the use of drugs requires careful con-
sideration in older people this must be weighed
against the possible benefits that certain med-
ications may provide. These medications should
be given in combination with bladder re-educa-
tion.[32-34]
Table III. Cost of drugs used to treat the overactive bladder (year
2000 prices)
Medication
Cost for 1 month’s treatment (£)
Imipramine 75 mg/day
Oxybutynin 5mg tid
Tolterodine 2mg bid
Propiverine
0.42
12
32
Table III compares the cost of medications used
to treat overactive bladder. It is not clear what the
response rate with each drug is i.e. how many pa-
32
bid = twice daily; tid = 3 times daily.
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Drugs & Aging 2001; 18 (3)

Economics of LUTS in Older People
219
4.1.3 Tolterodine
ine stress incontinence. However, objective meas-
ures showed no improvement in the amount of
urine lost. Trials investigating detrusor instability
and estrogen are limited.[51,52] These have shown
an improvement in subjective symptoms, such as
urgency, but no objective improvement in inconti-
nence. Work is ongoing in assessing the benefits of
topical localised estrogen and LUTS.
Topical estrogen may, however, be beneficial in
treating vaginal atrophism and the accompanying
symptoms of frequency, urgency, nocturia and dys-
uria. Although objective changes in incontinence
states may not be noticed, the QOL for some older
women maybe improved.
Tolterodine is a more specific muscarinic recep-
tor antagonist. It is as effective as oxybutynin in
reducing urinary symptoms but may have a signif-
icantly improved tolerability profile, with a lower
incidence of dry mouth.[42-44]
4.1.4 Propiverine
Propiverine has both anticholinergic and cal-
cium channel antagonistic actions.[45] It has a doc-
umented beneficial effect in the treatment of
detrusor hyperreflexia.[46,47]
5. Estrogen Replacement
Therapy in Women
Table IV enumerates the types of local/topical
preparations available in the UK, duration of rec-
ommended use and costs. Note that long term
unopposed estrogens in women with a uterus is
contraindicated due to the risk of endometrial
hyperplasia and endometrial carcinoma. However,
the risk of such pathologies developing with short
term topical treatments is negligible.
All manufacturers recommend that topical treat-
ment be discontinued periodically and the need
for further treatment be reassessed. Many older
women do not like to apply vaginal creams which
are messy and stain clothes. They may be cheaper
than other forms of estrogen but also ineffective
because they are not used as prescribed.
The female lower urinary tract is estrogen sen-
sitive. Falling estradiol levels after menopause
lead to reduced vascularity of tissues, particularly
of the vagina. This, together with a decreased gly-
cogen content of the cells, leads to a fall in lacto-
bacilli levels and an increase in vaginal pH. This
environment encourages the growth of certain
bacteria, including coliforms and streptococci, and
predisposes to urinary tract infections. The fall in
estrogen has also been implicated as a factor in the
development of peri- and postmenopausal stress
incontinence by affecting the integrity of the ure-
thra and possibly bladder neck.[48,49]
On the whole, the clinical trials addressing in-
continence and the role of hormone replacement
therapy have not produced conclusive evidence for
the role of estrogen in the management of inconti-
nence (stress or urge). There are, however, major
methodological problems with most of these stud-
ies. These problems have centred around the type
of estrogen used (e.g. estriol, estradiol) and the
route of administration (topical or systemic).
Many of the studies consisted of a heterogeneous
group of patients both in terms of menopausal sta-
tus, the numbers treated and reported symptoms.
Fantl et al.[50] undertook a systematic review of
systemic oestrogen for treatment of incontinence
in postmenopausal women. This analysis consisted
of 6 controlled trials and 17 uncontrolled studies
and showed that there was a significant subjective
improvement for all patients and those with genu-
6. Treatment of Voiding Disorders
It is now recognised that older people of both
sexes can have high post-void residuals of urine,
with or without coexisting pathologies (such as
detrusor instability).[53,54]
It can be particularly
problematic in older patients with underlying neu-
rological disease.
The technique of clean intermittent self-cath-
eterisation achieves good results in bladder empty-
ing. A residual volume of urine of >150ml (in the
absence of an obstruction) can be considered as
threshold for treatment. Patients (or their spouses/
carers) can be taught this technique and a twice
daily regimen is usually sufficient to improve post-
void residuals. However, there can be practical dif-
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Drugs & Aging 2001; 18 (3)

220
Azam et al.
Table IV. Topical estrogens used to treat lower urinary tract symptoms in the UK (year 2000 prices)
Estrogen preparation
Ortho Dinoestrol®
Ortho Gynest®
Type
Cream
Duration of use
3-6mo
3-6mo
Cost per month (£)
2.61
2.72
5.29
5.21
2.19
7.00
14.62
32.90 per 3 mo
Intravaginal cream
Pessaries
Intravaginal cream
Intravaginal cream
Pessaries
Ovestin®
2-3mo
1mo
3wks
3mo
Premarin®
Tampovagan®
Vagifem®
Estring®
Tablets
Vaginal ring
2y (replace every 3mo)
ficulties and patients and their families may need
an initial intense period of support before the tech-
nique is mastered. The schedule suggested by Sheri
and Barnes[55] is suitable for use in community and
hospital based environments.
bypassing, encrustation and stone formation and
trauma to the urethra. All catheters are expensive
in terms of the time needed to change and manage
them.
Pad use is invaluable in patients whilst a cure is
being sought, and in some with dementia and pro-
gressive disability. However, it may be inappropri-
ate in the long term and lead to inertia in locating
an underlying cause for the patients symptoms and
condition.
The products currently available and their cost
in the UK can be found in the Association of Con-
tinence Advisers’Directory of Continence and Toi-
leting Aids.[63]
7. Incontinence Products
It is beyond the scope of this review to describe
the various products and designs available on the
market. Excellent reviews exist elsewhere.[56-59]
Wagner and Hu’s estimates in 1995 considered
the cost of these products as part of the direct cost-
ing strategy.[20] This was calculated to be $US10.5
billion dollars. The true figure may be much higher.
The use of pads and their cost to health resources
and patients themselves is extremely difficult to
quantify.[60] Quite often, the cost of these is borne
by the patients themselves. Smith suggested that
£24 million was spent per annum on pads and pants
alone in the UK.[61]
8. The Future
Any meaningful economic evaluation of LUTS
first requires the development and instigation of
interventions that have beneficial, quantifiable and
validated outcomes.
The use of catheters and pads has become an
integral part of the management of LUTS in older
people, however wrong this approach might be.
Crow et al.[62] reported that 10 to 12% of patients
admitted to hospital in the UK have an indwelling
urethral catheter in situ. Catheters are available on
prescription from the National Health Service in
the UK.
Unfortunately, all too often clinicians and con-
tinence advisers are faced with problems arising
from the long term use of these devices which may
have been instigated with the carer in mind rather
than the needs of the individual patient. Chronic
urethral catheterisation predisposes to infections,
Fonda et al.[64] succinctly comment on the prob-
lems plaguing research in this area. They highlight
that research of older patients suffering LUTS is
different from those of younger patients and that
studies should aim to reflect this. They advocate a
‘back to basics’approach where researchers should
concentrate on cure and preventative measures to
combat the problem.
Another problem is what actually constitutes a
continence service within a particular community.
A study of 3 locations in the UK showed wide vari-
ations in the range of services available to patients
and their families.[65] We are currently evaluating
a new continence service in the community. Health
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Drugs & Aging 2001; 18 (3)

Economics of LUTS in Older People
221
economic analysis will play an integral part in the
overall evaluation of this novel model of care. Our
model will, however, approach economic evalua-
tions from a new perspective.
We aim to provide a quantitative estimate of the
level of expenditure by health and social services,
and by individuals themselves, on the management
of LUTS. The problem with previous studies is that
they obtained estimates of the cost of incontinence
(not LUTS) by extrapolating the results of smaller
surveys and samples to the whole of the popula-
tion.
We are collecting economic data on a subset of
800 patients who have been identified as having
LUTS from a large epidemiological prevalence
study in which 55 000 men and women, based in
the community and aged >40 years, have reported
their LUTS in a postal questionnaire. These 800
patients, together with 800 non-LUTS patients,
have undergone face-to-face home interviews. Re-
spondents were asked a range of questions to elicit
any National Health Service and private costs they
bear as a result of their LUTS. These were covered
in a number of areas:
these studies. We hope to report and publish all
these findings in a series of papers in 2001.
It is hoped that this practical framework for es-
timating the cost of LUTS will be applied to the
residential and nursing homes within our regional
setting.
At best, present cost evaluations are flawed,
probably an underestimate and little better than a
‘guesstimate’ with a few notable exceptions. What
is agreed is that the cost is large because the prob-
lem is so common. What is also agreed is that the
cost to those with LUTS and society is high and
that despite the current costs of treatment, they are
not universally acceptable or effective.
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