Comparing Vitamin D Supplementation Versus Placebo for Urgency Urinary Incontinence: A Pilot Study

OBJECTIVES

To estimate the efficacy of vitamin D supplementation to reduce urgency urinary incontinence (UUI) episodes.

DESIGN

Pilot, two-arm, randomized trial conducted from 2013 to 2017. Interventions were 12 weeks of weekly oral 50,000 IU vitamin D3 or placebo.

SETTING

Academic, university-based outpatient clinic.

PARTICIPANTS

Community-dwelling postmenopausal women, 50 years or older, with at least three UUI episodes on 7-day bladder diary and serum vitamin 25-hydroxyvitamin D (25[OH]D) of 30 ng/mL or less.

MEASUREMENTS

The primary efficacy estimate was the percentage change in UUI episodes. Secondary estimates included changes in other lower urinary tract symptoms, along with exploratory subgroup analysis by race/ethnicity and obesity.

RESULTS

We randomized 56 women (aged 50-84 years; mean = 60.5 ± 8.2 years), 28 to vitamin D and 28 to placebo; 51 completed treatments. Mean serum 25(OH)D at baseline (21.2 ± 5.2 and 18.2 ± 5.6, P = .30) improved to 57.9 ± 16.3 ng/mL with vitamin D3 and 21.9 ± 8.2 ng/mL with placebo (P < .001). UUI episodes per 24-hour day decreased by 43.0% with vitamin D3 compared to 27.6% with placebo (P = .22). Among black women (n = 33), UUI episodes decreased by 63.2% with vitamin D3 compared to 22.9% with placebo (P = .03). Among obese women, UUI episodes decreased by 54.1% with vitamin D compared to 32.7% with placebo (P = .29). For all women, changes in voiding frequency (P = .40), nocturia (P = .40), urgency (P = .90), incontinence severity (P = .81), and overactive bladder symptom severity (P = .47) were not different between arms.

CONCLUSIONS

Postmenopausal women with UUI and vitamin D insufficiency demonstrated a greater than 40% decrease in UUI episodes, which did not reach statistical significance compared to placebo, except in the subset of black women. The results of this pilot study support further investigation of vitamin D3 alone or in combination with other treatments for UUI, particularly for women in higher-risk subgroups. J Am Geriatr Soc 67:570-575, 2019.

Palliative Care and Hospice Interventions in Decompensated Cirrhosis and Hepatocellular Carcinoma: A Rapid Review of Literature

BACKGROUND

Patients with decompensated cirrhosis (DC) and/or hepatocellular carcinoma (HCC) have a high symptom burden and mortality and may benefit from palliative care (PC) and hospice interventions.

OBJECTIVE

Our aim was to search published literature to determine the impact of PC and hospice interventions for patients with DC/HCC.

METHODS

We searched electronic databases for adults with DC/HCC who received PC, using a rapid review methodology. Data were extracted for study design, participant and intervention characteristics, and three main groups of outcomes: healthcare resource utilization (HRU), end-of-life care (EOLC), and patient-reported outcomes.

RESULTS

Of 2466 results, eight were included in final results. There were six retrospective cohort studies, one prospective cohort, and one quality improvement study. Five of eight studies had a high risk of bias and seven studied patients with HCC. A majority found a reduction in HRU (total cost of hospitalization, number of emergency department visits, hospital, and critical care admissions). Some studies found an impact on EOLC, including location of death (less likely to die in the hospital) and resuscitation (less likely to have resuscitation). One study evaluated survival and found hospice had no impact and another showed improvement of symptom burden.

CONCLUSION

Studies included suggest that PC and hospice interventions in patients with DC/HCC reduce HRU, impact EOLC, and improve symptoms. Given the few number of studies, heterogeneity of interventions and outcomes, and high risk of bias, further high-quality research is needed on PC and hospice interventions with a greater focus on DC.

Cluster analysis of multiple chronic conditions associated with urinary incontinence among women in the USA

OBJECTIVE

To identify patterns of prevalent chronic medical conditions among women with urinary incontinence (UI).

MATERIALS AND METHODS

We combined cross-sectional data from the 2005-2006 to 2011-2012 US National Health and Nutrition Examination Surveys, and identified 3 800 women with UI and data on 12 chronic conditions. Types of UI included stress UI (SUI), urgency UI (UUI), and mixed stress and urgency UI (MUI). We categorized UI as mild, moderate or severe using validated measures. We performed a two-step cluster analysis to identify patterns between clusters for UI type and severity. We explored associations between clusters by UI subtype and severity, controlling for age, education, race/ethnicity, parity, hysterectomy status and adiposity in weighted regression analyses.

RESULTS

Eleven percent of women with UI had no chronic conditions. Among women with UI who had at least one additional condition, four distinct clusters were identified: (i) cardiovascular disease (CVD) risk-younger; (ii) asthma-predominant; (iii) CVD risk-older; and (iv) multiple chronic conditions (MCC). In comparison to women with UI and no chronic diseases, women in the CVD risk-younger (age 46.7 ± 15.8 years) cluster reported the highest rate of SUI and mild UI severity. In the asthma-predominant cluster (age 51.5 ± 10.2 years), women had more SUI and MUI and more moderate UI severity. Women in the CVD risk-older cluster (age 57.9 ± 13.4 years) had the highest rate of UUI, along with more severe UI. Women in the MCC cluster (age 61.0 ± 14.8 years) had the highest rates of MUI and the highest rate of moderate/severe UI.

CONCLUSIONS

Women with UI rarely have no additional chronic conditions. Four patterns of chronic conditions emerged with differences by UI type and severity. Identification of women with mild UI and modifiable conditions may inform future prevention efforts.

Report and Research Agenda of the American Geriatrics Society and National Institute on Aging Bedside-to-Bench Conference on Urinary Incontinence in Older Adults: A Translational Research Agenda for a Complex Geriatric Syndrome

The American Geriatrics Society, with support from the National Institute on Aging and other funders, held its ninth Bedside-to-Bench research conference, entitled "Urinary Incontinence in the Older Adult: A Translational Research Agenda for a Complex Geriatric Syndrome," October 16 to 18, 2016, in Bethesda, Maryland. As part of a conference series addressing three common geriatric syndromes-delirium, sleep and circadian rhythm disturbance, and urinary incontinence-the series highlighted relationships and pertinent clinical and pathophysiological commonalities between these conditions. The conference provided a forum for discussing current epidemiology, basic science, and clinical and translational research on urinary incontinence in older adults; for identifying gaps in knowledge; and for developing a research agenda to inform future investigative efforts. The conference also promoted networking involving emerging researchers and thought leaders in the field of incontinence, aging, and other fields of research, as well as National Institutes of Health program personnel.

Impact of New Medications and $4 Generic Programs on Overactive Bladder Treatment Among Older Adults in the United States, 2000-2015

BACKGROUND

Despite several new medications being Food and Drug Administration-approved for overactive bladder (OAB) and new prescription drug payment programs, there are limited population-based data regarding OAB medication use among older adults.

OBJECTIVES

To examine: (1) impacts of new medications and $4 generic programs on time trends for OAB-related medication dispensing for older adults in the United States; (2) differences by age and sex; and (3) temporal changes in OAB-related medication payments.

METHODS

Using Truven Health Analytics' Medicare Supplemental Database (2000-2015), we analyzed OAB-related medication claims for 9,477,061 Medigap beneficiaries age 65-104. We estimated dispensing rates (per 1000 person-months), assessed dispensing trends using interrupted time-series methods, compared dispensing rates by age and sex, and summarized payment trends.

RESULTS

From 2000 to 2015, 771,609 individuals filled 13,863,998 OAB-related prescriptions. During 2000-2007, 3 new extended-release medications became available (tolterodine, darifenacin, solifenacin), leading to increases in overall OAB-related dispensing rates by 19.1 (99% confidence interval, 17.0-21.2), a 92% increase since 2000; overall rates remained stable during 2008-2015. By 2015, the most common medications were oxybutynin (38%), solifenacin (20%), tolterodine (19%), and mirabegron (12%). Dispensing rates peaked at age 90 (rate, 53.4; 99% confidence interval, 53.1-53.7). Women had higher rates than men at all ages (average ratewomen-ratemen, 22.0). The gap between upper and lower percentiles of medication payments widened between 2008-2015; by 2015, 25% of reimbursed dispensed prescriptions had total payments exceeding $250.

CONCLUSIONS

Medication-specific dispensing rates for OAB changed when new alternatives became available. Recent changes in utilization and cost of OAB medications have implications for clinical guidelines, pharmacoepidemiologic studies, and payment policies.

An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department

OBJECTIVE

To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician-pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED).

METHODS

This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention.

RESULTS

Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug-disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 ( P < .0001).

CONCLUSION

Academic detailing led by a physician-pharmacist pair resulted in improved confidence in physician residents' ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.

Increased odds of bladder and bowel symptoms in early Parkinson's disease

AIMS

To compare the prevalence of urinary and bowel symptoms in a sample of adults with early Parkinson's disease (PD) and healthy controls (HC).

METHODS

Data were obtained from the Michael J. Fox Parkinson's Progression Markers Initiative (PPMI). Prevalent bladder (urinary incontinence (UI) and nighttime voiding) and bowel (constipation and fecal incontinence (FI)) symptoms were defined as occurring at least sometimes when queried using the Scale for Outcomes in PD for Autonomic Symptoms.

RESULTS

The proportion of men (65% vs 64%) and the mean age (61.0 ± 9.7 vs 60.2 ± 11.2 years) was similar between early PD (n = 423) and HC (n = 195). UI and constipation were more prevalent among early PD versus HC (UI: 26.7% vs 8.2%, constipation: 32.4% vs 11.8%; P's < 0.0001). Prevalent nighttime voiding was high among both groups, but not significantly different (82.5% vs 84.1%, P = 0.62). FI was infrequent in both. The odds of UI and constipation were significantly higher in early PD even after adjustment for age, sex, cognition, and overactive bladder (UI model only), constipation (UI and constipation models only), depression, and anxiety medication usage (UI: OR: 4.39 [95% CI: 2.92, 5.87]; constipation: 3.34 [2.20, 4.42]; P's < 0.0001).

CONCLUSIONS

While constipation is known to precede PD diagnosis, these data suggest that the occurrence of UI is elevated in early PD compared to a well-matched HC population.

Nocturia is Associated with Poor Sleep Quality Among Older Women in the Study of Osteoporotic Fractures

OBJECTIVES

(1) To examine relationships between frequency of nocturia and self-reported sleep quality and objective sleep measures in older women, and (2) to estimate the amount of variation in sleep measures that is specifically attributable to frequency of nocturia.

DESIGN AND SETTING

Secondary, cross sectional analysis of the multicenter prospective cohort Study of Osteoporotic Fractures (SOF).

PARTICIPANTS

Community-dwelling women aged ≥80 years.

MEASUREMENTS

Frequency of nocturia in the previous 12 months, Pittsburgh Sleep Quality Index sleep quality subscale, and actigraphy-measured wake after sleep onset (WASO) and total sleep time (TST).

RESULTS

Of 1,520 participants, 25% (n = 392) reported their nocturia frequency was 3-4 times/night and an additional 60% (n = 917) reported their nocturia frequency was 1-2 times/night. More frequent nocturia was associated with poor sleep quality (3-4/night: 26.8% reported fairly bad or very bad sleep quality; 1-2/night: 14.7%; 0/night: 7.7%; P < .001) and longer WASO (3-4/night: 89.8 minutes; 1-2/night: 70.6; 0/night: 55.5; P < .001). In nested regression models, a nocturia frequency of 3-4/night quadrupled the odds of poor sleep quality (odds ratio: 4.26 [95% CI 1.65, 11.01]; P = .003) and was associated with a 37-minute worsening in WASO (95% CI 26.0, 49.0; P < .001). Frequency of nocturia explained an additional 6% variation in WASO, above and beyond demographic, medical/psychiatric conditions, and medication factors (∆R² = 0.06).

CONCLUSIONS

Nocturia is common among octogenarian and nonagenarian women and is independently associated with poor sleep quality and longer wake time at night. Interventions that improve nocturia may be useful in improving sleep quality and wake time at night.

Improving biofeedback for the treatment of fecal incontinence in women: implementation of a standardized multi-site manometric biofeedback protocol

BACKGROUND

Standardized training and clinical protocols using biofeedback for the treatment of fecal incontinence (FI) are important for clinical care. Our primary aims were to develop, implement, and evaluate adherence to a standardized protocol for manometric biofeedback to treat FI.

METHODS

In a Pelvic Floor Disorders Network (PFDN) trial, participants were enrolled from eight PFDN clinical centers across the United States. A team of clinical and equipment experts developed biofeedback software on a novel tablet computer platform for conducting standardized anorectal manometry with separate manometric biofeedback protocols for improving anorectal muscle strength, sensation, and urge resistance. The training protocol also included education on bowel function, anal sphincter exercises, and bowel diary monitoring. Study interventionists completed online training prior to attending a centralized, standardized certification course. For the certification, expert trainers assessed the ability of the interventionists to perform the protocol components for a paid volunteer who acted as a standardized patient. Postcertification, the trainers audited interventionists during trial implementation to improve protocol adherence.

KEY RESULTS

Twenty-four interventionists attended the in-person training and certification, including 46% advanced practice registered nurses (11/24), 50% (12/24) physical therapists, and 4% physician assistants (1/24). Trainers performed audio audits for 88% (21/24), representing 84 audited visits. All certified interventionists met or exceeded the prespecified 80% pass rate for the audit process, with an average passing rate of 93%.

CONCLUSIONS & INFERENCES

A biofeedback protocol can be successfully imparted to experienced pelvic floor health care providers from various disciplines. Our process promoted high adherence to a standard protocol and is applicable to many clinical settings.

Pilot Results from a Randomized Trial in Men Comparing Alpha-Adrenergic Antagonist versus Behavior and Exercise for Nocturia and Sleep

PURPOSE

Nocturia and sleep problems are common in older adults. We developed and tested a novel intervention, multicomponent behavioral treatment and exercise therapy (M-BET), that may reduce nocturia and improve sleep in men. We compared reductions in nocturia and improvement in sleep in men with M-BET versus an active drug comparator (α-blocker) used alone or in combination (M-BET + α-blocker) METHODS: This randomized, controlled trial was conducted in the ambulatory setting in 2 US Department of Veterans Affairs medical centers in men at least 40 years of age with nocturia (defined as ≥2 nightly episodes). Participants were randomized to receive either M-BET, including pelvic floor muscle training, urge-suppression techniques, delayed voiding, fluid management, sleep hygiene, and peripheral edema management; an active comparator of known efficacy (the α-blocker tamsulosin, one 0.4-mg tablet nightly); or both therapies combined. Participants received interventions over 12 weeks. Outcomes were assessed via voiding diaries, wrist actigraphy, and validated questionnaires. The primary outcome was change in diary-recorded nocturia, assessed using ANCOVA for the between-group changes and paired t tests for within-group changes.

FINDINGS

A total of 72 men with a mean age of 65.8 years participated. At 12 weeks, mean diary-recorded nocturia changed with M-BET by -1.39 episodes/night (P < 0.001), with α-blocker therapy by -0.59 episodes/night (P < 0.01), and with combination therapy by -1.03 episodes/night (P < 0.01). Reductions were not statistically different across treatment groups (P = 0.41). M-BET also showed statistically significant improvements in sleep quality, bother from nocturia, and nocturia-specific quality of life. All treatment groups indicated global satisfaction with treatment.

IMPLICATIONS

Behavioral therapy in men, alone or combined with α-blocker therapy, consistently showed large and statistically significant nocturia reductions and favorable effects on sleep and quality of life. Based on these findings, behavioral therapy, while not statistically superior to α-blocker therapy, may provide a meaningful treatment option for men with nocturia. Future research should include the development of behavioral treatment and exercise therapy interventions that could be more easily deployed. ClinicalTrials.gov identifier: NCT00824200.

Differences in the Association of Nocturia and Functional Outcomes of Sleep by Age and Gender: A Cross-sectional, Population-based Study

PURPOSE

Nocturia is associated with poor sleep quality; however, little is known about the relationship between nocturia and sleep quality across different workforce-relevant age groups of adults. This has implications for developing new treatment strategies that are well tolerated across populations.

METHODS

We conducted a cross-sectional study involving merged data from the 2005-2006 and 2007-2008 waves of the National Health and Nutrition Examination Survey. Participants responded to validated questions on nocturia frequency and sleep from the Functional Outcomes of Sleep Questionnaire General Productivity subscale (FOSQ-gp, range 1-4). Analyses included multivariable linear regression with stratification by gender to examine associations between nocturia frequency (higher worse) and the FOSQ-gp scores (lower scores indicating worse daytime function related to sleep disturbance).

FINDINGS

Of 10,512 adults aged ≥20 years who completed the survey, 9148 (87%) had complete nocturia and FOSQ-gp data. The population age-adjusted prevalence of nocturia at least twice nightly was 21.1% among men and 26.6% among women (P < 0.001), and nocturia increased with age (P < 0.001). Compared with those with no or 1 episode of nocturia, those with nocturia at least twice nightly reported lower mean FOSQ-gp scores (3.65; 95% CI, 3.61-3.69 vs 3.19; 95% CI, 3.09-3.31 for men and 3.52; 95% CI, 3.48-3.56 vs 3.09; 95% CI, 3.02-3.16 for women). Older adults (aged >65 years) with greater nocturia frequency reported worse FOSQ-gp scores compared with younger adults with similar nocturia frequency (P < 0.001 among men and women).

IMPLICATIONS

In a population-based sample of community-dwelling men and women, the association between nocturia and worsened functional outcomes of sleep was greater among adults older than 65 years-a group more vulnerable to drug side effects, and in whom nocturia is typically multifactorial. Additionally, these analyses found that the association between nocturia and functional outcomes of sleep is stronger with increasing age among men. Effective treatment strategies that are well tolerated by older adults, such as multicomponent treatments that simultaneously address the combined effects of lower urinary tract and sleep dysfunction, are needed.

Incidence and Remission of Nocturia: A Systematic Review and Meta-analysis

CONTEXT

Although vital for decision-making about management, the natural history of nocturia remains uncertain. A systematic review would clarify the issue, but because natural history reviews are uncommon it would require methodological innovations.

OBJECTIVE

To estimate the incidence and remission of nocturia, and refine methods for meta-analyses assessing natural history.

EVIDENCE ACQUISITION

We conducted a comprehensive search of PubMed, Scopus, and Cumulative Index of Nursing and Allied Health Literature databases and abstracts of major urologic meetings as far as August 31, 2015. Random effects meta-analyses addressed incidence/remission rates of nocturia; meta-regression explored potential determinants of heterogeneity. Studies were categorized as either low or high risk of bias using a novel instrument specifically designed for longitudinal symptom studies aimed at the general population.

EVIDENCE SYNTHESIS

Of 4165 potentially relevant reports, 16 proved eligible. Pooled estimates from 13 studies (114 964 person-years of follow-up) demonstrated that annual incidence was strongly associated with age: 0.4% (0-0.8%) for adults aged < 40 yr; 2.8% (1.9-3.7%) for adults aged 40-59 yr; and 11.5% (9.1-14.0%) for adults aged ≥ 60 yr. Of those with nocturia, each year 12.1% (9.5-14.7%) experienced remission.

CONCLUSIONS

The available evidence suggests that nocturia onset is strongly associated with age, with much higher rates in those over 60 yr; remission occurs in approximately 12% each year. These estimates can aid with management decisions and counseling related to nocturia.

PATIENT SUMMARY

We reviewed all previous studies of progression of night-time urination (nocturia). We found that in any given year 0.4% of adults aged < 40 yr, 3% of adults aged 40-59 yr, and 12% of adults aged ≥ 60 yr will develop nocturia, while overall 12% of those with nocturia will improve. These findings may be helpful in making decisions about coping with or treating nocturia.

Anal Intercourse and Fecal Incontinence: Evidence from the 2009-2010 National Health and Nutrition Examination Survey

OBJECTIVES

The aim of this study was to assess the prevalence and associations between anal intercourse and fecal incontinence.

METHODS

Analyses were based on data from 6,150 adults (≥20 years) from the 2009-2010 cycle of the National Health and Nutrition Examination Surveys. Fecal incontinence was defined as the loss of liquid, solid, or mucus stool occurring at least monthly on a validated questionnaire. A gender-specific sexual behavior questionnaire assessed any anal intercourse via an audio computer-assisted personal interview. Co-variables included: age, race, education, poverty income ratio, body mass index, chronic illnesses, depression, loose stool consistency (Bristol Stool Scale types 6 or 7), and reproductive variables in women. Prevalence estimates and prevalence odds ratios (PORs) were analyzed in adjusted multivariable models using appropriate sampling weights.

RESULTS

Overall, 4,170 adults aged 20-69 years (2,070 women and 2,100 men) completed sexual behavior questionnaires and responded to fecal incontinence questions. Anal intercourse was higher among women (37.3%) than men (4.5%), P<0.001. Fecal incontinence rates were higher among women (9.9 vs. 7.4%, P=0.05) and men (11.6 vs. 5.3%, P=0.03) reporting anal intercourse compared with those not reporting anal intercourse. After multivariable adjustment for other factors associated with fecal incontinence, anal intercourse remained a predictor of fecal incontinence among women (POR: 1.5; 95% confidence interval (CI): 1.0-2.0) and men (POR: 2.8; 95% CI: 1.6-5.0).

CONCLUSIONS

The findings support the assessment of anal intercourse as a factor contributing to fecal incontinence in adults, especially among men.

Impact of Clinical Pharmacy Specialists on the Design and Implementation of a Quality Improvement Initiative to Decrease Inappropriate Medications in a Veterans Affairs Emergency Department

BACKGROUND

As the proportion of older adult patients who interface with the health care system grows, clinical pharmacy specialists (CPS) have a pivotal role in reducing potentially inappropriate medication (PIM) use in this population.

OBJECTIVES

To (a) describe CPS involvement in the design and implementation of a quality improvement (QI) initiative to decrease PIM prescribing in a Veterans Affairs (VA) emergency department (ED) and (b) report on changes in PIM prescribing before and after the initiative.

METHODS

Enhancing Quality of Prescribing Practices for Veterans Discharged from the Emergency Department (EQUiPPED) is an ongoing multisite QI project that aims to decrease ED PIM prescribing. We used a mixed-method approach that applied qualitative and quantitative measures in describing the CPS role and evaluating PIM rates. PIMs were defined using the 2012 Beers Criteria. We reported monthly PIM rates in patients aged 65 years and older who were discharged from the ED from January 2012 to November 2014. A piecewise, nonlinear regression model evaluated the pattern in PIM prescriptions over time.

RESULTS

At the Durham, North Carolina, VA Medical Center, a total of 4 CPS were involved with tailoring the design and implementation of the EQUiPPED intervention for local use. CPS input led to 3 key innovations: academic detailing performed by a physician-CPS pair, medication alert messages identifying medications as PIMs in the computerized patient record system, and automated reports describing the frequency and type of PIMs prescribed by each ED provider. Between February 2013 and November 2014, 73 ED providers received the academic detailing. The ED facility experienced a relative reduction of 47.5% in the rate of PIM prescribing over the observation period.

CONCLUSIONS

This QI project resulted in a meaningful decrease in PIM prescribing in older ED adults. CPS contributions to QI can extend beyond pharmacotherapy and provider education to also include information technology tools using formulary management expertise.

Psychometric evaluation of an online and paper accidental bowel leakage questionnaire: The ICIQ-B questionnaire

AIMS

To evaluate the psychometric properties of an online versus paper US-English version of the International Consultation on Incontinence Questionnaire-Bowel (ICIQ-B).

METHODS

The ICIQ-B includes 17 items under 3 domains: bowel pattern (5 items), bowel control (7 items), and quality of life (5 items). We recruited community-dwelling adults seeking treatment for ≥monthly bowel leakage from specialty clinics within a VA medical center and university affiliate. An online versus paper version was evaluated at baseline, 2 weeks later, and 3 months after nonsurgical treatments per usual care. We assessed test-retest reliability (Pearson correlations) at 2 weeks, internal consistency (Cronbach's alpha), and convergent validity (Pearson correlations). Sensitivity to change was the difference between the baseline and post-treatment (3-month) scores.

RESULTS

Mean age was 58.0 ± 11.9; 36% Veterans, 52% women. At baseline, 2 weeks, and 3 months, we found no differences in the online vs paper scores for the bowel control and quality of life domains. The ICIQ-B demonstrated fair internal consistency for the bowel pattern domain (Cronbach's α = 0.36-0.54). Internal consistency on the bowel pattern domain was better with the paper version than the online version at 2 weeks (P < 0.05) and 3 months (P < 0.01) with no difference at baseline. All other domains had good internal consistency (Cronbach's α > 0.80), good retest reliability (r ≥ 0.70, P < 0.001), domain-specific convergent validity for stool consistency (P < 0.05), incontinence severity (P ≤ 0.002), and quality of life impact (P < 0.05). After nonsurgical treatments, we found a reasonable response to change (P ≤ 0.05).

CONCLUSIONS

Online and paper versions had robust psychometric data for use among U.S. men and women, including Veterans. Neurourol. Urodynam. 36:166-170, 2017. © 2015 Wiley Periodicals, Inc.

Controlling anal incontinence in women by performing anal exercises with biofeedback or loperamide (CAPABLe) trial: Design and methods

The goals of this trial are to determine the efficacy and safety of two treatments for women experiencing fecal incontinence. First, we aim to compare the use of loperamide to placebo and second, to compare the use of anal sphincter exercises with biofeedback to usual care. The primary outcome is the change from baseline in the St. Mark's (Vaizey) Score 24weeks after treatment initiation. As a Pelvic Floor Disorders Network (PFDN) trial, subjects are enrolling from eight PFDN clinical centers across the United States. A centralized data coordinating center supervises data collection and analysis. These two first-line treatments for fecal incontinence are being investigated simultaneously using a two-by-two randomized factorial design: a medication intervention (loperamide versus placebo) and a pelvic floor strength and sensory training intervention (anal sphincter exercises with manometry-assisted biofeedback versus usual care using an educational pamphlet). Interventionists providing the anal sphincter exercise training with biofeedback have received standardized training and assessment. Symptom severity, diary, standardized anorectal manometry and health-related quality of life outcomes are assessed using validated instruments administered by researchers masked to randomized interventions. Cost effectiveness analyses will be performed using prospectively collected data on care costs and resource utilization. This article describes the rationale and design of this randomized trial, focusing on specific research concepts of interest to researchers in the field of female pelvic floor disorders and all other providers who care for patients with fecal incontinence.

Urinary, fecal, and dual incontinence in older U.S. Adults

OBJECTIVES

To estimate the prevalence of urinary (UI), fecal (FI), and dual incontinence (DI) and to identify shared factors associated with each type of incontinence in older U.S. women and men.

DESIGN

Population-based cross-sectional study.

SETTING

National Health and Nutrition Examination Survey (NHANES, 2005-2010).

PARTICIPANTS

Women and men aged 50 and older.

MEASUREMENTS

UI was defined as moderate to severe (≥3 on a validated UI severity index, range 0-12); FI was at least monthly loss of solid, liquid, or mucus stool; and DI was the presence of UI and FI.

RESULTS

Women were more likely than men to report UI only and DI but not FI only (UI only, women 19.8%, men 6.4%; FI only, women 8.2%, men 8.4%; DI women, 6.0%, men 1.9%). In both sexes, prevalence increased with age. In regression models adjusted for parity and hysterectomy, DI in women was associated with non-Hispanic white race (odds ratio (OR)=2.3, 95% confidence interval (CI)=1.5-3.4), depression (OR=4.7, 95% CI=2.0-11.1), comorbidities (OR=4.3, 95% CI=1.9-9.6 for ≥3 comorbidities vs none), hysterectomy (OR=1.8, 95% CI=1.2-2.7), and diarrhea (OR=2.8, 95% CI=1.5-5.0). In men, ADL impairment (OR=2.4, 95% CI=1.2-4.9) and poorer self-rated health (OR=2.8, 95% CI=1.5-5.30) were associated with DI.

CONCLUSION

UI, FI, and DI are common in older women and men. Factors associated with DI were distinct from those associated with UI and FI. There were also differences according to sex, with DI associated with depression and comorbid diseases in women and lack of functional ability and poorer self-rated health in men.

Postoperative bowel function, symptoms, and habits in women after vaginal reconstructive surgery

INTRODUCTION AND HYPOTHESIS

The objective was to characterize postoperative bowel symptoms in women undergoing vaginal prolapse reconstructive surgery randomized to preoperative bowel preparation vs a regular diet.

METHODS

Subjects (N = 121) completed two bowel diaries: a 7-day bowel diary immediately before surgery and a 14-day diary postoperatively. Self-reported bowel diary data and symptoms included the time to first bowel movement (BM), daily number of BMs, Bristol Stool Form Scale score, pain, and urgency associated with BM, episodes of fecal incontinence, and use of laxatives. Antiemetic use was abstracted from medical records. Outcomes of groups were compared using Chi-squared/Fisher's exact test or Student's t test as appropriate.

RESULTS

Mean time to first postoperative BM was similar in the bowel preparation (n = 60) and control groups (n = 61), 81.2 ± 28.9 vs 78.6 ± 28.2 h, p = 0.85. With the first BM, there were no significant differences between bowel preparation and control groups regarding pain (17.2 vs 27.9 %, p = 0.17), fecal urgency with defecation (56.9 vs 52.5 %, p = 0.63), fecal incontinence (14.0 vs 15.0 %, p = 0.88) and >1 use of laxatives (93.3 vs 96.7 % p = 0.44) respectively. Antiemetic use was similar in both groups (48.3 vs 55.7 % respectively, p = 0.42).

CONCLUSIONS

There were no differences in the return of bowel function and other bowel symptoms postoperatively between the randomized groups. Lack of bowel preparation does not have an impact on the risk of painful defecation postoperatively. This information may be used to inform patients regarding expectations for bowel function after vaginal reconstructive surgery.

Epidemiology, pathophysiology, and classification of fecal incontinence: state of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop

In August 2013, the National Institutes of Health sponsored a conference to address major gaps in our understanding of the epidemiology, pathophysiology, and management of fecal incontinence (FI) and to identify topics for future clinical research. This article is the first of a two-part summary of those proceedings. FI is a common symptom, with a prevalence that ranges from 7 to 15% in community-dwelling men and women, but it is often underreported, as providers seldom screen for FI and patients do not volunteer the symptom, even though the symptoms can have a devastating impact on the quality of life. Rough estimates suggest that FI is associated with a substantial economic burden, particularly in patients who require surgical therapy. Bowel disturbances, particularly diarrhea, the symptom of rectal urgency, and burden of chronic illness are the strongest independent risk factors for FI in the community. Smoking, obesity, and inappropriate cholecystectomy are emerging, potentially modifiable risk factors. Other risk factors for FI include advanced age, female gender, disease burden (comorbidity count, diabetes), anal sphincter trauma (obstetrical injury, prior surgery), and decreased physical activity. Neurological disorders, inflammatory bowel disease, and pelvic floor anatomical disturbances (rectal prolapse) are also associated with FI. The pathophysiological mechanisms responsible for FI include diarrhea, anal and pelvic floor weakness, reduced rectal compliance, and reduced or increased rectal sensation; many patients have multifaceted anorectal dysfunctions. The type (urge, passive or combined), etiology (anorectal disturbance, bowel symptoms, or both), and severity of FI provide the basis for classifying FI; these domains can be integrated to comprehensively characterize the symptom. Several validated scales for classifying symptom severity and its impact on the quality of life are available. Symptom severity scales should incorporate the frequency, volume, consistency, and nature (urge or passive) of stool leakage. Despite the basic understanding of FI, there are still major knowledge gaps in disease epidemiology and pathogenesis, necessitating future clinical research in FI.

Life Space Assessment in Older Women Undergoing Non-Surgical Treatment for Urinary Incontinence

OBJECTIVES

Urinary incontinence (UI) impacts all aspects of life activities. This study aims to characterize change in mobility within the community utilizing the Life Space Assessment (LSA) questionnaire in women undergoing non-surgical UI treatment.

DESIGN

Prospective cohort study, performed from July 2007 to March 2009, which followed women seeking non-surgical UI treatment and assessed their mobility and symptoms using LSA, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7) at baseline and 2, 6, and 12 months post-treatment. Estimated Percent Improvement (EPI) and Patient Satisfaction Question (PSQ) were obtained post-treatment.

SETTING

Outpatient tertiary-care clinic.

PARTICIPANTS

70 ambulatory, community-dwelling women, aged 65 years or older, seeking non-surgical care for UI.

INTERVENTION

Multi-component behavioral and/or pharmacologic therapies.

MEASUREMENTS

We hypothesized LSA would improve with treatment. Repeated measures analysis with Tukey's HSD and backwards selection linear regression model were performed.

RESULTS

LSA score decreased from baseline to 2 months (mean±SD; 63±29 to 56±28, p<0.001) and was sustained at 6 and 12 months (54±28, 54±28). UDI scores improved from 36±23 to 25±24, p<0.001, at 2 months, and improvement persisted at 6 and 12 months (22±22, 21±24). Improvements in UDI and patient perceived improvement in UI were not associated with LSA change. Age, race, and depression impacted LSA, which decreased 1-point for each additional year of age (p=0.004), 6-points for each point higher on the Geriatric Depression Scale (GDS) (p=0.002), and 6-points for African American race (p=0.048).

CONCLUSION

Decreased mobility represented by LSA was related to age, depression, and race, but not UI symptom improvement.

Vitamin D deficiency is associated with increased fecal incontinence symptoms

INTRODUCTION AND HYPOTHESIS

Vitamin D is an important micronutrient in muscle function. We hypothesize that vitamin D deficiency may contribute to fecal incontinence (FI) symptoms by affecting the anal continence mechanism. Our goal was to characterize the association of vitamin D deficiency as a variable affecting FI symptoms and its impact on health-related quality of life (HR-QoL).

METHODS

This case-control study assessed women seen at a tertiary-care referral center. Participants were identified as having had a serum vitamin D level obtained within a year of their visit: cases were women presenting for care for FI symptoms; controls were women without any pelvic floor symptoms presenting to the same clinical site for general gynecologic care. Cases completed the Modified Manchester Health Questionnaire (MMHQ) and the Fecal Incontinence Severity Index to measure symptom severity and burden on QoL.

RESULTS

Among the 31 cases and 81 controls, no demographic or medical differences existed. Women with FI had lower vitamin D levels (mean 29.2 ± 12.3 cases vs. 35 ± 14.1 ng/ml controls p = 0.04). The odds of vitamin D deficiency were higher in women with FI compared with controls [odds ratio (OR) 2.77, 95 % confidence interval (CI) 1.08-7.09]. Among cases, women with vitamin D deficiency (35 %) had higher MMHQ scores, indicating greater FI symptom burden [51.3 ± 29.3 (vitamin D deficient) vs. 30 ± 19.5 (vitamin D sufficiency), p = 0.02]. No differences were noted for FI severity, p = 0.07.

CONCLUSIONS

Vitamin D deficiency is prevalent in women with fecal incontinence and may contribute to patient symptom burden.

The fluctuation of nocturia in men with lower urinary tract symptoms allocated to placebo during a 12-month randomized, controlled trial

PURPOSE

We determined the fluctuation of nocturia in a 12-month period in men with lower urinary tract symptoms.

MATERIALS AND METHODS

Men with lower urinary tract symptoms were allocated to the placebo arm of the United States Department of Veterans Affairs Cooperative Studies Program Benign Prostatic Hyperplasia Study. Reported nocturia frequency using the American Urological Association Symptom Index was collected at 6 time points (2, 4, 13, 26, 39 and 52 weeks). Repeat measurements of nocturia during a 1-year period were analyzed using a generalized mixed linear model.

RESULTS

Of the 305 men allocated to the placebo group 256 participants (84%) gave answers for all 6 time points. In the entire sample the mean nocturia count did not significantly vary from baseline (week 2) after adjusting for covariates (p = 0.542). However, there was considerable fluctuation in nocturia during 1 year. Of the 93 men with 3 or 4 episodes at baseline 47% had improvement and 12% had worsening at 1 year. Of the 184 men who reported 2 or greater nocturia episodes at baseline 15% reported 0 or 1 at 52 weeks. Depending on the case definition during followup the probability of nocturia progression varied between 8% and 54% while nocturia regression varied between 2% and 33%.

CONCLUSIONS

Using repeat questionnaire based assessments we observed considerable fluctuation in nocturia. However, overall there was no significant increase in prevalence in a 1-year period. These findings may be reassuring to providers and patients who elect to delay interventions for nocturia.

Surgical preparation: are patients "ready" for stress urinary incontinence surgery?

INTRODUCTION AND HYPOTHESIS

Patient preparedness for stress urinary incontinence (SUI) surgery is associated with improvements in post-operative satisfaction, symptoms and quality of life (QoL). This planned secondary analysis examined the association of patient preparedness with surgical outcomes, treatment satisfaction and quality of life.

METHODS

The ValUE trial compared the effect of pre-operative urodynamic studies with a standardized office evaluation of outcomes of SUI surgery at 1 year. In addition to primary and secondary outcome measures, patient satisfaction with treatment was measured using a five-point Likert scale (very dissatisfied to very satisfied) that queried subjects to rate the treatment's effect on overall incontinence, urge incontinence, SUI, and frequency. Preparedness for surgery was assessed using an 11-question Patient Preparedness Questionnaire (PPQ).

RESULTS

Based on PPQ question 11, 4 out of 5 (81 %) of women reported they "agreed" or "strongly agreed" that they were prepared for surgery. Selected demographic and clinical characteristics were similar in unprepared and prepared women. Among SUI severity baseline measures, total UDI score was significantly but weakly associated with preparedness (question 11 of the PPQ; Spearman's r = 0.13, p = 0.001). Although preparedness for surgery was not associated with successful outcomes, it was associated with satisfaction (r s = 0.11, p = 0.02) and larger PGI-S improvement (increase; p = 0.008).

CONCLUSIONS

Approximately half (48 %) of women "strongly agreed" that they felt prepared for SUI. Women with higher pre-operative preparedness scores were more satisfied, although surgical outcomes did not differ.

Impact of obesity on urinary storage symptoms: results from the FINNO study

PURPOSE

Urinary storage symptoms are the most common and most bothersome urinary symptoms. Many studies on the relation between body weight and urinary symptoms have focused on urinary incontinence in women. We evaluated the association of obesity with urinary storage symptoms in a population based study of men and women age 18 to 79 years old.

MATERIALS AND METHODS

Questionnaires were mailed to 6,000 adults randomly identified from the Finnish Population Register. Self-reported height and weight were used to calculate body mass index. Urinary frequency, nocturia, urgency, stress urinary incontinence and urgency urinary incontinence were assessed using validated instruments. Multivariate logistic regression analyses (adjusted for age, comorbidity and medications, and sociodemographic, lifestyle and reproductive factors) were performed to evaluate associations between body mass index and each symptom.

RESULTS

Of the 6,000 individuals approached 3,727 participated (62.4% response, 53.7% women). In men and women obesity was associated with nocturia (adjusted OR 2.0, 95% CI 1.2-3.3 for men; OR 2.4, 95% CI 1.5-3.8 for women) but not with urgency (adjusted OR 1.2, 95% CI 0.7-2.3 for men; OR 1.2, 95% CI 0.7-2.1 for women). In men obesity was also associated with urinary frequency (OR 2.0, 95% CI 1.0-3.9), and in women it was associated with stress urinary incontinence (OR 1.9, 95% CI 1.2-3.0) and urgency urinary incontinence (OR 3.0, 95% CI 1.2-7.4). However, the number of men with stress urinary incontinence or urgency urinary incontinence was insufficient for precise analyses.

CONCLUSIONS

This study extends previous research by providing symptom specific associations between obesity and urinary storage symptoms in a population based sample of men and women. Obesity impacts individual urinary storage symptoms differently and these associations may be influenced by gender.

Caffeine intake and its association with urinary incontinence in United States men: results from National Health and Nutrition Examination Surveys 2005-2006 and 2007-2008

PURPOSE

Epidemiological studies in women have revealed an association between caffeine intake and urinary incontinence, although evidence among men is limited. Therefore, we evaluated the association between caffeine intake and urinary incontinence in United States men.

MATERIALS AND METHODS

Data were used from male NHANES (National Health and Nutrition Examination Surveys) 2005-2006 and 2007-2008 participants. Urinary incontinence was defined using a standard questionnaire with Incontinence Severity Index scores 3 or greater categorized as moderate to severe. Structured dietary recall was used to determine caffeine consumption (mg per day), water intake (gm per day) and total dietary moisture (gm per day). Stepwise multivariable logistic regression models were used to assess the association between caffeine intake at or above the 75th and 90th percentiles and moderate to severe urinary incontinence, controlling for potential confounders, urinary incontinence risk factors and prostate conditions in men age 40 years or older.

RESULTS

Of the 5,297 men 3,960 (75%) were 20 years old or older with complete data. Among these men the prevalence of any urinary incontinence was 12.9% and moderate to severe urinary incontinence was 4.4%. Mean caffeine intake was 169 mg per day. Caffeine intake at the upper 75th percentile (234 mg or more daily) and 90th percentile (392 mg or more per day) was significantly associated with having moderate to severe urinary incontinence (1.72, 95% 1.18-2.49 and 2.08, 95% 1.15-3.77, respectively). In addition, after adjusting for prostate conditions, the effect size for the association between caffeine intake and moderate to severe urinary incontinence remained.

CONCLUSIONS

Caffeine consumption equivalent to approximately 2 cups of coffee daily (250 mg) is significantly associated with moderate to severe urinary incontinence in United States men. Our findings support the further study of caffeine modification in men with urinary incontinence.

Caffeine and urinary incontinence in US women

INTRODUCTION AND HYPOTHESIS

The goal of this study was to characterize associations between caffeine consumption and severity of urinary incontinence (UI) in US women. We hypothesized that moderate and high caffeine intake would be associated with UI in US women when controlling for other factors associated with UI.

METHODS

US women participated in the 2005-2006 and 2007-2008 National Health and Nutrition Examination Survey (NHANES), a cross-sectional, nationally representative survey. Using the Incontinence Severity Index, UI was categorized as "any" and "moderate/severe". Types of UI included stress, urge, mixed, and other. Food diaries were completed, and average water (grams/day), total dietary moisture (grams/day), and caffeine (milligrams/day) intake were calculated into quartiles. Stepwise logistic regression models were constructed adjusting for sociodemographics, chronic diseases, body mass index, self-rated health, depression, physical activity, alcohol use, dietary water and moisture intake, and reproductive factors.

RESULTS

From the 4,309 nonpregnant women (aged ≥20 years) who had complete UI and dietary data, UI prevalence for any UI was 41.0 % and 16.5 % for moderate/severe UI, with stress UI the most common type (36.6 %). Women consumed a mean caffeine intake of 126.7 mg/day. After adjusting for multiple factors, caffeine intake in the highest quartile (≥204 mg/day) was associated with any UI [prevalence odds ratio (POR) 1.47, 95 % confidence interval (CI) 1.07-2.01], but not moderate/severe UI (POR 1.42, 95 % CI 0.98-2.07). Type of UI (stress, urgency, mixed) was not associated with caffeine intake.

CONCLUSIONS

Caffeine intake ≥204 mg/day was associated with any UI but not with moderate/severe UI in US women.

Vitamin D and lower urinary tract symptoms among US men: results from the 2005-2006 National Health and Nutrition Examination Survey

OBJECTIVE

To evaluate the association of vitamin D levels and lower urinary tract symptoms (LUTS) among US men.

MATERIAL AND METHODS

Data were analyzed for 2387 men (≥20 years) who participated in the 2005-2006 cycle of the National Health and Nutrition Examination Survey, a cross-sectional survey of the US noninstitutionalized population. LUTS included nocturia, incomplete emptying, hesitancy, and urinary incontinence (UI). Plasma 25-hydroxyvitamin D was categorized as ≥30 ng/mL (normal), 20-30 ng/mL (insufficiency), and <20 ng/mL (deficiency). Other factors included age, race/ethnicity, education, body mass index, self-reported health status, chronic diseases, and prior diagnosis of benign prostatic enlargement and/or prostate cancer (men ≥40 years of age). Prevalence and prevalence odds ratios (POR) were estimated from a multivariable logistic regression analysis using appropriate sampling weights.

RESULTS

A majority (89%, n = 1241) had vitamin D levels <30 ng/mL, of whom 55% (n = 684) had vitamin D levels <20 ng/mL. Vitamin D levels ranged from 2-56 ng/mL (median 19 ng/mL, mean ± SD 19.9 ± 8.0). Among the 1388 (58%) men with LUTS data and vitamin D levels, 48% (n = 666) had at least 1 LUTS. In multivariable analyses adjusting for age and race norms, vitamin D deficiency was associated with the presence of moderate-severe UI (POR 1.8, 95% CI 1.1, 3.0) and at least 1 LUTS (POR 1.4, 95% CI 1.0, 2.0).

CONCLUSION

Vitamin D insufficiency and deficiency are highly prevalent among adult men in the US, and vitamin D deficiency is associated with moderate-severe UI and the presence of at least 1 LUTS.

Weight loss improves fecal incontinence severity in overweight and obese women with urinary incontinence

INTRODUCTION/HYPOTHESIS

To estimate the effect of weight loss on fecal incontinence (FI) severity among overweight and obese women with urinary incontinence, we analyzed data from women randomized to a weight loss intervention or control condition.

METHODS

The modified Fecal Incontinence Severity Index (FISI) was administered at 6, 12, and 18 months in 338 women. Repeated measures analyses identified factors associated with improved FISI scores among women with baseline scores >0.

RESULTS

FISI scores improved in 45 (13%) across all time points among the 291 women (87%) completing the trial. Improved scores were associated with a one-point lower urinary tract symptoms (LUTS) score, p < 0.01. Improved liquid stool FI frequency was associated with ≥ 5 kg weight loss (p = 0.001), 10-g increase in fiber intake (p = 0.05), and decreased LUTS (p = 0.003).

CONCLUSIONS

FI severity improved with weight loss. Women with liquid stool FI losing at least 5 kg and/or increased dietary fiber intake had improved FI frequency.

Incontinence

Urinary incontinence is a common problem among older women and men. Older adults are reluctant to seek treatment, and health care providers should inquire about symptoms. Treatment of urinary incontinence includes multiple, office-based modalities, such as behavioral approaches, medications, and devices. Older adults may also consider surgical options to improve urinary incontinence. Special consideration should be given to older adults with cognitive impairment and incontinence.

Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial

CONTEXT

Although behavioral therapy has been shown to improve postoperative recovery of continence, there have been no controlled trials of behavioral therapy for postprostatectomy incontinence persisting more than 1 year.

OBJECTIVE

To evaluate the effectiveness of behavioral therapy for reducing persistent postprostatectomy incontinence and to determine whether the technologies of biofeedback and pelvic floor electrical stimulation enhance the effectiveness of behavioral therapy.

DESIGN, SETTING, AND PARTICIPANTS

A prospective randomized controlled trial involving 208 community-dwelling men aged 51 through 84 years with incontinence persisting 1 to 17 years after radical prostatectomy was conducted at a university and 2 Veterans Affairs continence clinics (2003-2008) and included a 1-year follow-up after active treatment. Twenty-four percent of the men were African American; 75%, white.

INTERVENTIONS

After stratification by type and frequency of incontinence, participants were randomized to 1 of 3 groups: 8 weeks of behavioral therapy (pelvic floor muscle training and bladder control strategies); behavioral therapy plus in-office, dual-channel electromyograph biofeedback and daily home pelvic floor electrical stimulation at 20 Hz, current up to 100 mA (behavior plus); or delayed treatment, which served as the control group.

MAIN OUTCOME MEASURE

Percentage reduction in mean number of incontinence episodes after 8 weeks of treatment as documented in 7-day bladder diaries.

RESULTS

Mean incontinence episodes decreased from 28 to 13 per week (55% reduction; 95% confidence interval [CI], 44%-66%) after behavioral therapy and from 26 to 12 (51% reduction; 95% CI, 37%-65%) after behavior plus therapy. Both reductions were significantly greater than the reduction from 25 to 21 (24% reduction; 95% CI, 10%-39%) observed among controls (P = .001 for both treatment groups). However, there was no significant difference in incontinence reduction between the treatment groups (P = .69). Improvements were durable to 12 months in the active treatment groups: 50% reduction (95% CI, 39.8%-61.1%; 13.5 episodes per week) in the behavioral group and 59% reduction (95% CI, 45.0%-73.1%; 9.1 episodes per week) in the behavior plus group (P = .32).

CONCLUSIONS

Among patients with postprostatectomy incontinence for at least 1 year, 8 weeks of behavioral therapy, compared with a delayed-treatment control, resulted in fewer incontinence episodes. The addition of biofeedback and pelvic floor electrical stimulation did not result in greater effectiveness.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00212264.

Factors impacting quality of life in women with fecal incontinence

PURPOSE

The aim of this study was to characterize differences in health-related quality of life among women presenting for treatment of fecal incontinence.

METHODS

Among 155 women presenting for treatment of fecal incontinence in a specialty clinic, validated questionnaires measured impact on quality of life (Modified Manchester Health Questionnaire) and severity (the Fecal Incontinence Severity Index). Bowel symptoms, including frequency, urgency, and stool consistency, were ascertained. Comorbid diseases were self-reported. Linear regression models were constructed from significant univariate variables to examine differences observed in quality of life scores.

RESULTS

The average age was 58.7 +/- 11.5 years, with no differences found in quality of life scores according to race, body mass index, or number of vaginal deliveries (P > .05). Younger age, increased urinary incontinence symptoms, prior cholecystectomy, prior hysterectomy, and severity of bowel symptoms correlated with a negative impact on quality of life in univariate analysis (P < .05). Average severity scores were 30.5 +/- 13.7, with moderate correlation seen with increasing severity and quality of life scores (R2 = 0.60). After controlling for severity, women had increased quality of life scores with more bowel urgency (15 points; 95% CI, 8.1-21.2), harder stool consistency (10 points; 95% CI, 3.8-16.3), and prior hysterectomy (9 points; 95% CI, 2.7-15.4).

CONCLUSION

Bowel symptoms and having undergone a hysterectomy had the greatest negative impact on quality of life in women seeking treatment for fecal incontinence. Targeting individualized treatments to improve bowel symptoms may improve quality of life for women with fecal incontinence.

Incontinence in older women

Urinary incontinence is a common geriatric syndrome that affects at least 1 in 3 older women and can greatly diminish quality of life. Incontinence has been associated with increased social isolation, falls, fractures, and admission to long-term care facilities. Often unreported and thus untreated, it is important to include incontinence as part of the review of systems for all older women. Using the case of Mrs F, we highlight the chronicity of incontinence and discuss the evidence base for evaluation of incontinence in older women, with proper initial diagnosis of the type of incontinence-stress, urgency, or mixed-in order to prescribe optimal treatment. We present an evidence-based discussion of available incontinence treatments including pelvic floor muscle exercises, stress strategies, urge-suppression strategies, fluid management, medications, intravaginal pessaries, intravesical injection of botulinum toxin, percutaneous tibial nerve stimulation, sacral neuromodulation, and surgical procedures for stress incontinence. Special considerations in evaluation and treatment of patients with dementia are presented. Urinary incontinence treatments yield high levels of patient satisfaction and improvements in quality of life.

Incidence and risk factors for fecal incontinence in black and white older adults: a population-based study

OBJECTIVES

To determine the incidence of fecal incontinence (FI) in community-dwelling older adults and identify risk factors associated with incident FI.

DESIGN

Planned secondary analysis of a longitudinal, population-based cohort study.

SETTING

Three rural and two urban Alabama counties (in-home assessments 2000-2005).

PARTICIPANTS

Stratified random sample of 1,000 Medicare beneficiaries: 25% African-American men, 25% white men, 25% African-American women, 25% white women, aged 65 and older. Eligible participants for this analysis were continent at baseline and community-dwelling 4 years later (n=557).

MEASUREMENTS

FI was defined as any loss of control of bowels occurring during the previous year. Independent variables were sociodemographics, Charlson comorbidity counts, self-reported bowel symptoms (chronic diarrhea and constipation), depression, and body mass index (BMI). Multivariable logistic regression models were constructed using incident FI as the dependent variable.

RESULTS

The incidence rate of FI at 4 years was 17% (95% confidence interval (CI)=13.7-20.1), with 6% developing FI at least monthly (95% CI=4.0-8.3). White women were more likely to have incident FI (22%) than African-American women (13%, P=.04); no racial differences were observed in men. Controlling for age, comorbidity count, and BMI, significant independent risk factors for incident FI in women were white race, depression, chronic diarrhea, and urinary incontinence (UI). UI was the only significant risk factor for incident FI in men.

CONCLUSION

The occurrence of new FI is common in men and women aged 65 and older, with a 17% incidence rate over 4 years. FI and UI may share common pathophysiologic mechanisms and need regular assessment in older adults.

Prevalence and correlates of nocturia in community-dwelling older adults

OBJECTIVES

To determine the prevalence and correlates of nocturia in community-dwelling older adults.

DESIGN

Planned secondary analysis of cross-sectional data from the University of Alabama at Birmingham Study of Aging population-based survey.

SETTING

Participants' homes.

PARTICIPANTS

One thousand older adults (aged 65-106) recruited from Medicare beneficiary lists between 1999 and 2001. The sample was selected to include 25% each African-American women, African-American men, white women, and white men.

MEASUREMENTS

In-person interviews included sociodemographic information, medical history, Mini-Mental State Examination (MMSE) score, and measurement of body mass index (BMI). Nocturia was defined in the main analyses as rising two or more times per night to void.

RESULTS

Nocturia was more common in men than women (63.2% vs 53.8%, odds ratio (OR)=1.48, 95% confidence interval (CI)=1.15-1.91, P=.003) and more common in African Americans than whites (66.3% vs 50.9%, OR=1.89, 95% CI=1.46-2.45, P<.001). In multiple backward elimination regression analysis in men, nocturia was significantly associated with African-American race (OR=1.54) and BMI (OR=1.22 per 5 kg/m(2)). Higher MMSE score was protective (OR=0.96). In women, nocturia was associated with older age (OR=1.21 per 5 years), African-American race (OR=1.64), history of any urine leakage (OR=2.17), swelling in feet and legs (OR=1.67), and hypertension (OR=1.62). Higher education was protective (OR=0.92).

CONCLUSION

Nocturia in community-dwelling older adults is a common symptom associated with male sex, African-American race, and some medical conditions. Given the significant morbidity associated with nocturia, any evaluation of lower urinary tract symptoms should include assessment for the presence of nocturia.