Original Research

Discontinuation of Treatment Using

Anticholinergic Medications in Patients
With Urinary Incontinence
Matthias Kalder, MD, PhD, Konstantinos Pantazis, MD, Konstantinos Dinas, MD, PhD,
Ute-Susann Albert, MD, PhD, Christina Heilmaier, MD, and Karel Kostev, PhD
OBJECTIVE: To evaluate the discontinuation rates of
anticholinergics prescribed in patients with urinary
incontinence (UI).
METHODS: Data from a Disease Analyzer database
including 988 general, 95 urologist, and 203 gynecologic
practices were examined. Twenty six thousand eight
hundred thirty-four patients were identified as having
received a first-time anticholinergic prescription for
UI, namely darifenacin, fesoterodine, oxybutynin, propiverine, solifenacin, tolterodine, or trospium, between
2005 and 2012. Covariates studied included demographic
data, concomitant diagnoses, and potential druginduced side effects. The cumulative discontinuation rate
of initial treatment was estimated using a KaplanMeier
analysis. A Cox proportional hazard regression model
was used to estimate the relationship between discontinuation and the demographic and clinical variables for
up to 36 months.
RESULTS: An increasing discontinuation rate was observed
in years 1, 2, and 3 (74.8%, 77.6%, 87%). Within 3 years,
discontinuation rates were higher for men than for women
(87.9%, 86.5%; P5.056; hazard ratio [HR] 1.14, 95% confidence interval [CI] 1.111.18; P,.001), for patients treated in

From the Department of Obstetrics and Gynecology, Philipps University of

Marburg, Marburg, FOM University of Applied Sciences, Essen, and IMS
Health, Frankfurt, Germany; and the 1st Department of Obstetrics and
Gynecology and the 2nd Department of Obstetrics and Gynecology, Medical
School, Aristotle University, Thessaloniki, Greece.
Professional English-language editing services were provided by Claudia Jones,
MA, Radford, Virginia.
Corresponding author: Matthias Kalder, MD, PhD, Philipps University of
Marburg, Department of Obstetrics and Gynecology, Baldingerstrasse, 35043
Marburg, Germany; e-mail: kalder@med.uni-marburg.de.
Financial Disclosure
Dr. Kostev is an employee of IMS Health. The other authors did not report any
potential conflicts of interest.
2014 by The American College of Obstetricians and Gynecologists. Published
by Lippincott Williams & Wilkins.
ISSN: 0029-7844/14

794

VOL. 124, NO. 4, OCTOBER 2014

gynecologic practices and general practices than those treated in urologist practices (HR 1.60; 95% CI 1.521.67,
P,.001 and HR 1.24, 95% CI 1.201.29, P,.001, respectively)
and for younger patients than those older than 80 year old
(60 years or younger, HR 1.27, 95% CI 1.221.33; 6170
years, HR 1.16, 95% CI 1.111.21; 7180 years, HR 1.14,
95% CI 1.091.18, P,.001). Those using propiverine or solifenacin were less likely to discontinue treatment than those
using oxybutynin (HR 0.94, 95% CI 0.880.99, P5.024 and
HR 0.93, 95% CI 0.870.98, P5.004, respectively).
CONCLUSION: Patients with UI demonstrate high discontinuation rates for anticholinergics with only slight
variations between the various drugs in this category.
(Obstet Gynecol 2014;124:794800)
DOI: 10.1097/AOG.0000000000000468

LEVEL OF EVIDENCE: III

t has been predicted that the worldwide prevalence

of lower urinary tract symptoms will increase by
18.4% between 2008 and 2018.1 In 2018, 2.3 billion
persons are expected to have these symptoms, including an estimated increase in those with urinary incontinence (UI) (8.221.6%).1,2
The prevalence of urge UI (UUI) is reported as
ranging between 1.8% and 30.5% in Europe, 1.7
36.4% in the United States, and 1.515.2% in Asia
and is known to depend on gender and age.3 Current
evidence reveals that UUI represents a substantial
economic burden on patients and communities worldwide. In several cost-of-illness studies for UUI, the
estimated costs ranged from $9.6 to $66 billion
(2005, 2007). According to current forecasts, costs will
increase noticeably as populations age.3
Side effects and efficacy of anticholinergics in the
treatment of symptoms associated with UUI and overactive bladder have been acknowledged in previous
studies.47 Anticholinergics reduce intravesical pressure, increase bladder capacity, and appear to provide

OBSTETRICS & GYNECOLOGY

significant symptomatic relief to those with urinary

urgency and frequency and UUI or mixed UI. The
side effect profile (for instance xerostomia, obstipation,
and headache) in this class is reported to be relatively
mild. However, long-term discontinuation rates in
a population-based setting are rarely reported.8,9
The primary aim of the present study was to
assess the discontinuation rate of anticholinergics in
patients diagnosed with UI. Secondary aims were to
evaluate the discontinuation rates for the various
anticholinergics and to identify contributing factors
for discontinuation among urologist, gynecologist,
and general practitioner practices.

MATERIALS AND METHODS

We collected data from the Disease Analyzer database
(IMS Health), a nationwide electronic database that
compiles drug prescription, diagnosis, and other basic
medical and demographic data obtained directly from
local computer systems in the practices of general
practitioners and specialists throughout Germany.10
Diagnoses (International Statistical Classification of
Diseases and Related Health Problems, 10th Revision),
prescriptions (Anatomical Therapeutic Chemical Classification System), and the quality of reported data are
continuously monitored by IMS Health on the basis of
a number of criteria, which include completeness of
documentation, consistency of diagnoses and prescriptions, etc. Data are entered directly in the physicians
practices through a standardized interface and provide
daily routine information on patient diseases and therapies. A practice transmits patient data stored on the
physicians computer to IMS Health on a monthly
basis; all data are anonymized and the terms patient,
doctor, medical practice, prescriber, and pharmacy do not refer to personal data but rather to exclusively anonymous information (in accordance with
Section 36 of the German Federal Data Protection
Act). Data are also encrypted on transmission for data
protection purposes in connection with data and figures
used in terms. The validity of the Disease Analyzer
data has already been evaluated and described.10,11 It
has formed the basis of a number of studies and peerreviewed scientific publications in the fields of epidemiology as well as research on treatment discontinuation rates for several medical conditions.12,13
We included patients with first-time prescription
of a UI product (Anatomical Therapeutic Chemical
Classification System: G04D4) between the index
dates of January 1, 2005, and December 31, 2012,
with a diagnosis of stress UI (SUI) (N39.3) or other
specified UI (N39.4); the latest follow-up date was set
as December 31, 2013.

VOL. 124, NO. 4, OCTOBER 2014

Patients with a follow-up time of less than 365

days before the index date were excluded to allow for
the correct identification of treatment initiation. Further inclusion criteria included age at the index date
(older than 18 years).
The main outcome measure was treatment discontinuation rate for UI within 36 months after the
index date. Treatment discontinuation was defined as
a period of 90 days without prescription of UI therapy
but with at least one visit to the same doctor after 90
days.8 A longitudinal medication supply data set was
established and the UI therapy discontinuation rate
calculated for each individual patient. The number
of days of drug supply was calculated on the basis of
the quantity and dosage information associated with
each prescription record.
Demographic data included age, health insurance
type (private or statutory), treating physician specialty
(general practitioner, gynecologist, or urologist), and
practice region (East compared with West Germany).
Medical costs were either covered by private or by
statutory health insurance bodies including coverage
from the social welfare system. Although the German
health system is available to anyone in the country,
the range of medical services provided to patients with
private and statutory health insurance varies
considerably.
The anticholinergics included in the study were:
darifenacin, fesoterodine, oxybutynin, propiverine,
solifenacin, tolterodine, and trospium. Codiagnoses
were determined on the basis of primary care
diagnoses within 365 days before the index date and
these included diabetes mellitus (E10E14), depression (F32, F33), neurologic disease associated with
dementia (F01, F03, G30), overweight or adiposity
(E6568), obstipation (K59.0), movement disorders
including Parkinsons disease (G2026), epilepsy
(G4041), migraine (G43), and multiple sclerosis
(G35). We defined an adverse drug reaction as the
diagnosis of xerostomia (K11.7, R68.2), fatigue
(R53), headache (R51), obstipation (K59.0), and stomach upset (R10) within 183 days after the index date.
Glaucoma (H40), which is a contraindication, was
included in the adverse drug reaction list and was
studied as a covariate for drug continuation with the
limitation that it is probably a reflection of clinician
awareness and readiness to refer patients to ophthalmology rather than a true side effect in terms of
epidemiology.
The cumulative discontinuation rate of initial
treatment was estimated using a KaplanMeier analysis. A Cox proportional hazards regression model
was used to estimate the relationship between

Kalder et al

Discontinuation of Incontinence Treatment

795

discontinuation and the demographic and clinical variables described previously for a maximum follow-up
period of 36 months. A stepwise selection procedure
with an entry criterion of P,.1 was used to select the
final optimal model. The adjusted hazard ratios (HRs)
and 95% confidence intervals are presented for the
independent variables.
The proportional hazard assumption was assessed
and upheld for all analyses. Furthermore, potential
confounders (age, urologist, gynecologist and general
practitioner care, private health insurance, and practice situated in West Germany), codiagnoses, and
adverse side effects were included as independent
variables. Two-sided tests were used and a P value of
,.05 was considered statistically significant. All calculations were carried out using SAS 9.3. Best-practice
methods for retrospective database studies were taken
into consideration.14
The study was conducted in accordance with the
Declaration of Helsinki; it was reviewed by the
institutional review board of IMS Health and was
considered exempt from the requirement for ethical
approval.

RESULTS
Altogether, 26,834 patients with first-time prescriptions
of a UI product were identified (Fig. 1). These patients
were treated in 203 gynecologic, 95 urological, and 988
general practices. Patient characteristics are shown separately for each substance prescribed initially (Table 1).
Mean age was 69.4 years (standard deviation 13.2) and
64.0% of patients were female. The proportion of
female patients was different for urologists (43.5%)
and general practitioners (74.9%). Only female patients
were treated in gynecologic practices.
An increasing discontinuation rate of 74.8% in
year 1, 77.6% in year 2, and 87% in year 3 was
observed (Fig. 2). After 1 year of follow-up, 74.6% of
female and 75.1% of male patients had discontinued
their treatment (refill gap of 90 days). Within 3 years
of follow-up, discontinuation rates increased to 86.5%
for women and 87.9% for men (P5.056).
We also investigated whether discontinuation was
dependent on the doctor specialty and found a significant difference in the discontinuation rate within 3
years for patients treated by gynecologists (92.0%),
urologists (85.7%), and general practitioners (86.8%)
(P,.001). Moreover, the proportion of patients who
discontinued therapy depended on age; it was 89.7%
in patients aged 60 years or younger, 87.9% in
patients aged 6170 years, 86.8% in patients aged
7180 years, and 83.0% in patients aged older than
80 years (reference group; P,.001).

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Kalder et al

Diagnosis of stress urinary incontinence (ICD-10: N39.3)

or other specified urinary incontinence (ICD-10: N39.4),
January 1, 2005December 31, 2012
(n=199,563)

Patients without a first-time

prescription of an anticholinergic
within the index dates,
January 1, 2005December 31, 2012
(n=140,071)

Patients with first-time prescription

of an anticholinergic within the index
dates, January 1, 2005December
31, 2012 (n=59,492)
Patients in general practices: 14,340
Patients in urologist practices: 37,173
Patients in gynecologist practices: 7,979
Patients with a follow-up
time of less than 365 days
prior to the index date
(n=32,658)

Patients with a follow-up time of at

least 365 days prior to the index date
(n=26,834)
Patients in general practices: 10,158
Patients in urologist practices: 12,615
Patients in gynecologist practices: 4,061

Fig. 1. Study design. ICD-10, International Classification of

Diseases, 10th Revision.
Kalder. Discontinuation of Incontinence Treatment. Obstet Gynecol
2014.

The proportion of patients who experienced side

effects of UI treatment defined in the study was very
similar for each of the study substances. Thirty-two to
38% of patients received a referral to an ophthalmologist
and 0.31.2% of patients was diagnosed with glaucoma
for the first time. A diagnosis of upset stomach was
recorded in 4.28.6% of patients, obstipation in 5.4
9.8%, headache in 2.23.6%, and fatigue in 2.83.5%.
A diagnosis of xerostomia was documented in just 0.3
0.6% of patients receiving UI treatment (Table 1).
The multivariate HRs of the Cox regression
models are shown in Table 2. Hazard ratios for risk
of therapy discontinuation at 36 months were adjusted
for demographic and clinical variables. There was
a significantly higher risk of treatment discontinuation
in male patients (HR 1.14; P,.001) than in female
patients. Patients treated in gynecologic practices
and general practices demonstrated significantly higher discontinuation rates than those who obtained their
prescriptions in a urologist practice (HR 1.60, P,.001
and HR 1.24, P,.001, respectively). Patients in younger age groups were more likely to discontinue therapy than the reference group of patients older than
80 years, whereas discontinuation rates were higher in

Discontinuation of Incontinence Treatment

OBSTETRICS & GYNECOLOGY

Table 1. Baseline Characteristics, Comorbidities, and Side Effects of Study Patients

Variable

Darifenacin Fesoterodine Oxybutynin Propiverine Solifenacin Tolterodine Trospium

n
1,995
Demographics
Age (y)
70.3612.6
General practitioners
43.3
Gynecologists
11.4
Urologists
45.3
Male gender
37.4
Private insurance
12.7
West Germany
84.0
Comorbidities
Stress incontinence
25.2
Other incontinence
89.5
Diagnoses at baseline
Diabetes
28.5
Overweight or
11.7
adiposity
Obstipation
11.4
Depression
31.3
Movement disorders or
8.7
Parkinsons disease
Epilepsy
2.4
Migraine
6.5
Dementia including
9.9
Alzheimers
disease
Multiple sclerosis
1.4
Glaucoma
3.1
Prescription of
4.6
physical therapy
within 6 mo before
index date
Referral to
35.7
ophthalmologists
within 3 mo after
therapy start
Side effects
Confirmed diagnosis
0.8
of glaucoma
Xerostomia
0.5
Fatigue
3.2
Headache
3.6
Stomach upset
6.3
Obstipation
7.1
Dry eyes
0.4

811

3,813

2,714

4,844

1,814

10,843

69.3613.5
40.9
11.6
47.5
36.3
12.7
85.6

68.8613.6
38.5
16.5
45.0
32.7
3.2
87.8

66.3618.2
31.6
4.6
63.8
42.5
5.6
74.5

68.0613.7
35.8
29.6
33.7
27.1
10.0
79.9

24.5
88.9

23.9
89.8

23.5
87.6

23.4
91.6

23.2
89.1

23.7
90.0

.241
.205

32.2
17.2

29.4
13.4

27.5
11.3

29.4
13.0

25.1
11.8

30.7
13.5

.392
.589

14.8
30.4
12.1

10.6
29.5
7.2

10.3
25.4
7.5

10.3
30.2
9.0

9.9
28.7
7.2

13.7
31.6
9.1

.015
.218
.503

1.8
4.5
11.5

1.8
5.3
9.1

2.5
4.9
9.8

2.0
4.8
9.7

2.9
4.8
9.2

2.1
4.9
11.2

.913
.116
.085

0.3
3.0
5.6

1.6
2.9
2.9

1.5
4.8
3.9

1.2
3.7
4.4

2.2
3.6
4.4

1.5
4.2
4.1

.383
.153
.697

31.6

35.5

36.5

37.7

31.3

35.1

.621

1.2

0.3

0.9

0.6

0.6

0.6

.665

0.6
3.3
3.3
7.8
8.4
0.0

0.3
3.4
2.5
8.6
6.0
0.5

0.6
2.8
2.7
7.0
5.4
0.6

0.3
3.3
2.2
8.0
7.0
0.3

0.3
3.5
2.2
4.2
7.5
0.4

0.3
3.5
2.7
8.0
9.8
0.5

.525
.582
.290
.714
,.001
.793

69.4613.4 70.1613.2 ,.001

56.4
35.4
,.001
19.1
11.1
,.001
24.5
53.5
,.001
27.0
41.2
,.001
12.1
5.6
,.001
89.3
89.6
,.001

Data are mean6standard deviation or % unless otherwise specified.

patients with private health insurance than in those

with statutory insurance.
Not surprisingly, there was a much higher risk of
treatment discontinuation in patients experiencing
side effects, namely headache (HR 1.27; P5.002),
stomach upset (HR 1.20; P,.001), and glaucoma
(HR 1.46; P,.001).
By contrast, a significantly lower risk of treatment
discontinuation was recorded in patients using propiverine (HR 0.94; P5.022) or solifenacin (HR 0.93;

VOL. 124, NO. 4, OCTOBER 2014

P5.003) as compared with oxybutynin; however,

the absolute difference was relatively small. The presence of comorbidities such as diabetes, Parkinsons
disease, epilepsy, dementia, and multiple sclerosis
was associated with decreased risk of treatment discontinuation, whereas patients with a prior diagnosis
of migraine ran a higher risk of discontinuation.
No significant correlation was found between
a diagnosis of SUI, localization in West Germany, or
comedications and risk of treatment discontinuation.

Kalder et al

Discontinuation of Incontinence Treatment

797

100

90

80

Continuation rate (%)

70

60

50

40

30

20

10

0
0

12

18

24

30

36

2,381

1,743

1,291

Months since start of therapy

Patients at risk

26,834

7,979

4,820

3,281

Fig. 2. KaplanMeier curves for continuation over 36 months in patients with urinary incontinence treatment (refill gap of
90 days).
Kalder. Discontinuation of Incontinence Treatment. Obstet Gynecol 2014.

DISCUSSION
Like previous reports, this study revealed an increasing high discontinuation rate for treatment with
anticholinergics in patients with UI at 12, 24, and 36
months (74.8%, 77.6%, and 87%, respectively).8,1517
These findings are consistent with previous studies, in
which discontinuation rates between 62% and 77.2%
at 12 months and 92% at 36 months were reported.8,9
Our study focused on the symptom of UI rather
than overactive bladder and notably the type of
incontinence did not appear to represent a significant
prognostic factor for the treatment discontinuation
rate. Although the study data set did not provide
information on the rationale of prescribing anticholinergics to patients with SUI, the similar discontinuation rate for all types of incontinence raises concerns
in its own right regarding the long-term effectiveness
of the treatment.
The discontinuation rate at 3 years was higher in
the younger age groups than in the oldest (89.7% in
patients 60 years or younger compared with 83.0% in
those 80 years old or older), which confirms the
results of a recent study.9 This is an interesting finding
considering that a common belief among clinicians is
that the elderly are less tolerant to side effects.

798

Kalder et al

Those patients who were prescribed the anticholinergic by a urologist were less likely to stop the
medication than those prescribed treatment by a gynecologist (85.7% and 92%, respectively, by 3 years);
this cannot be attributed to gender differences because
the male gender was associated with increased risk of
treatment discontinuation (HR 1.14). Significant differences were also observed between gynecologists
and general practitioners (92% and 86.8%, respectively, by 3 years). Although it is impossible to deduce
a causative relationship between the prescribing
doctors specialty and differences in discontinuation
rates, it is important to bring the findings to the attention of physicians; physicians awareness may lead to
adequate counseling and regular reassessment for
these patients, especially of young ones. Counseling
should address improvement of symptoms, obviating
the need for continued therapy.
The most common side effect reported was
obstipation (5.49.8%) followed by gastric disturbances (4.28.6%). Those taking propiverine and solifenacin were less likely to discontinue treatment,
because these drugs are known to have milder side
effects than oxybutynin.9,18,19 Overall, the side effects
were most likely underreported as a result of the

Discontinuation of Incontinence Treatment

OBSTETRICS & GYNECOLOGY

Table 2. Association Between Treatment Discontinuation Within 36 Months and Defined Variables (Cox
Regression Analysis)
Outcome Variable
Propiverine
Solifenacin
Fesoterodine
Tolterodine
Trospium
Darifenacin
Age (y)
60 or younger
6170
7180
Male gender
Private insurance
West Germany
Stress incontinence
Gynecologists
General practitioners
Diabetes
Depression
Obstipation
Overweight or obesity
Movement disorders or Parkinsons disease
Epilepsy
Migraine
Dementia
Multiple sclerosis
Glaucoma
Headache
Stomach upset
Xerostomia
Fatigue
Dry eyes

Crude HR (95% CI)

Adjusted HR* (95% CI)

0.89
0.98
1.00
1.06
0.97
1.00

(0.840.94)
(0.941.03)
(0.921.09)
(0.991.12)
(0.931.01)
(0.941.06)

,.001
.514
.993
.085
.146
.926

0.94 (0.880.99)
0.93 (0.870.98)

1.33
1.22
1.16
1.01
1.16
1.04
1.11
1.56
1.14
0.85
1.08
1.06
0.98
0.85
0.81
1.38
0.71
0.78
1.37
1.37
1.25
1.00
1.01
1.16

(1.271.39)
(1.171.28)
(1.121.21)
(0.981.04)
(1.101.22)
(1.001.08)
(1.081.15)
(1.501.62)
(1.111.17)
(0.810.88)
(1.031.12)
(1.001.12)
(0.941.02)
(0.800.91)
(0.710.92)
(1.261.50)
(0.660.76)
(0.69-0.89)
(1.091.72)
(1.211.55)
(1.171.33)
(0.911.09)
(0.901.13)
(0.851.59)

,.001
,.001
,.001
.561
,.001
.062
,.001
,.001
,.001
,.001
.001
.064
.316
,.001
.009
,.001
,.001
,.001
.007
,.001
,.001
.956
.886
.339

1.27
1.16
1.14
1.14
1.14

(1.221.33)
(1.111.21)
(1.091.18)
(1.111.18)
(1.081.20)

,.001
,.001
,.001
,.001
,.001

1.60
1.24
0.88
1.06

(1.521.67)
(1.201.29)
(0.850.91)
(1.021.10)

,.001
,.001
,.001
.005

0.88
0.76
1.21
0.75
0.74
1.46
1.27
1.20

(0.820.94)
(0.670.87)
(1.111.32)
(0.701.80)
(0.650.85)
(1.161.84)
(1.121.43)
(1.121.27)

,.001
,.001
,.001
,.001
,.001
.001
,.001
,.001

.024
.004

HR, hazard ratio; CI, confidence interval.

* Stepwise selection; adjusted for age, physician specialty (general practitioner, gynecologist, urologist), gender, private health insurance,
region (Western or Eastern Germany), urinary incontinence diagnosis (stress or other), diagnoses at baseline (diabetes, overweight or
obesity, obstipation, depression, movement disorders or Parkinsons disease, epilepsy, migraine, dementia including Alzheimers disease
(%), multiple sclerosis, glaucoma, dry eyes.

Reference is oxybutynin.

Reference is age group older than 80 y.

Reference is urologists.

nature of the database and rarer than in clinical

trials.18,19
Discontinuation of treatment was lower among
those with chronic diseases (movement disorders and
Parkinsons disease, epilepsy, dementia, and multiple
sclerosis). This finding is puzzling unless one presumes that it may be indicative of lifestyle adjustments
that affect treatment, for instance patients with serious
comorbidities who are exhibiting higher compliance
with treatment.
Pelvic floor physiotherapy was administered to
a modest 4.6% of patients, although SUI was present
in one fourth of the study population. This may be the
result of reimbursement restrictions in the health system.

VOL. 124, NO. 4, OCTOBER 2014

Individuals with private health insurance have

easier access to prescriptions in Germany than those
with statutory cover. Therefore, the significant discontinuation rate (P,.001) in patients with private
health insurance is quite reasonable, because starting
or discontinuing treatment is cost-neutral for them.
These findings may be applicable to different health
care systems that have private health insurance
available.20
Our analysis has several strengths. This study is
a country-wide, population-based study on long-term
discontinuation rates of seven different anticholinergic
drugs. Therefore, findings are based on clinically
indicated prescriptions and represent an accurate

Kalder et al

Discontinuation of Incontinence Treatment

799

estimation of the effect of treatment in the affected

population. Furthermore, we revealed an association
between a considerable number of confounders and
discontinuation rates for the first time on this subject;
the relationship to chronic disease in particular is
reported clearly in our study.
This study has some limitations, most of which
are inherent to database studies. First, the documentation of side effects (such as constipation) of anticholinergic treatment available in the database cannot be
considered exhaustive. In addition, the assessment of
comorbidities relies exclusively on diagnosis codes.
Data on socioeconomic status and lifestyle-related risk
factors that were likely to affect discontinuation rates
were not obtainable.
This study reflects the results of previous studies
in the same area, revealing that discontinuation rates
for treatment with anticholinergics are quite high and
sheds further light onto the factors that contribute to
this disappointing finding. Considering that UI, particularly when associated with idiopathic overactive
bladder, is a long-lasting and frequently recurring
condition, it appears necessary to consider treatments
(such as bladder training and pelvic floor physiotherapy) as a mandatory addition to drug therapy; besides,
patients concerned need adequate counseling and
regular reassessment to enhance long-term adherence
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Discontinuation of Incontinence Treatment

OBSTETRICS & GYNECOLOGY