Racial disparity seen with SUI surgical restoration

San Diego-In another potential sign of racial disparities in urologic care, a new study finds that urologic restoration surgery is significantly less likely to be used to treat African-American men with stress urinary incontinence (SUI) than Caucasian men, although African-Americans appear to have higher rates of SUI.

"There is an imbalance in racial composition between the two groups, and the imbalance is opposite from what you would expect based on data regarding prevalence of the conditions," said Kara E. McAbee, MD, a urology resident at Wake Forest Baptist Health, who spoke in an interview with Urology Times.

Dr. McAbee is first author of the study, which was presented at the 2017 American College of Surgeons clinical congress in San Diego. She worked on the study with Ryan Terlecki, MD, and colleagues.

In 2006, a study reported that 21% of African-American men surveyed reported urinary incontinence over the past year, the highest of any ethnic group. The overall prevalence in men was 17% (J Urol 2006; 176:2103-8).

Urologist Charles Modlin, MD, MBA, who is familiar with the study findings, said in an interview that African-American men may have higher rates of SUI because of delayed presentation to physicians.

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In part due to lack of health insurance, they "are less commonly referred by primary care doctors to urologists for treatment of benign prostate disease and even for screening for prostate cancer and therefore often present to urologists with advanced prostate cancer compared to their white male counterparts," said Dr. Modlin, who studies racial disparities in urology. He is founder and director of the Cleveland Clinic Minority Men’s Health Center.

For the new study, the authors analyzed a prospectively collected single-surgeon database for the years 2011-2016.

"We wanted to determine if the racial composition of men receiving prosthetic surgery for ED was different from that of our population undergoing surgical correction of SUI," Dr. McAbee said.

The authors found a difference in the racial makeup of the cases: Of the 247 inflatable penile prosthesis cases, 77.7% were Caucasian, 19.0% African-American, and 2.8% other. Among the 110 artificial urinary sphincter and male sling cases, 87.2% were Caucasian, 9% African-American, and 3.6% other.

The etitologies for the inflatable penile prosthesis cases were prior prostatectomy (34.4%) and benign disease (65.6%). For the other cases, the etitologies were cancer (95%) and benign disease (5%).

The authors found that African-Americans were significantly less likely to receive surgical restoration for SUI compared to erectile dysfunction (p=.018).

The authors also discovered that 82.5% of all urologic prosthetic surgery in African-American men was for erectile dysfunction compared to 66.7% in Caucasian men, "which makes sense given both prostate cancer and ED are more common in African-American males," Dr. McAbee said.

Next: Possible reasons for discrepancy

Possible reasons for discrepancy

Why does the SUI discrepancy exist?

"There may be racial differences in the degree of bother of symptoms of erectile dysfunction versus incontinence," Dr. McAbee said. "Within different populations, there also may be a difference of knowledge of procedures available for the correction of erectile dysfunction or incontinence."

Other possible reasons for the discrepancy include "access to care, payer difference, referral patterns, surgeon race, surgeon communication skills, and comorbidities preventing elective surgery," Dr. McAbee said.

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Dr. Modlin pointed to the possibility of "unconscious/implicit bias or unequal treatment on the part of the health provider." Also, he said, African-American males "may be offered more medical treatments rather than offered options for surgical treatment. Additionally, they may themselves be more likely to not select surgical SUI treatment."

What now? "We need to be aware that disparities in delivery of urologic care exist," Dr. McAbee said, "and we must actively work to eliminate them through collaboration with other providers, better patient education, and community outreach."

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