The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society

Variables predictive of voiding disfunction following aponeurotic sling surgery: multivariate analysis

INTRODUCTION

Aponeurotic sling surgeries can evolve with obstruction or voiding dysfunction in 5 to 20% of patients. There are few studies on factors that could possibly predispose to voiding difficulties or urinary retention. The objective of this work is to identify these potential clinical or urodynamic factors.

MATERIALS AND METHODS

Records from 130 patients who underwent aponeurotic sling surgeries were reviewed. All patients underwent a throughout urodynamic study during pre-operative investigation. The variables studied were age above 65 years, previous pelvic surgeries, concomitant surgeries, post-voiding residue higher than 100 mL, vesical obstruction (according to Blaivas-Groutz nomogram) and urinary flow under 12 mL/s. Post-voiding residue was assessed on the seventh post-operative day through vesical catheterization. Recovering of spontaneous voiding after 7 post-operative days or with a residue higher than 100 mL, was regarded as voiding dysfunction. Univariate analysis was performed with qui-square test and Fisher's exact test, and multivariate analysis was performed by logistic regression with alpha = 5%.

RESULTS

Age in the studied group ranged from 41 to 83 years (mean 56.7 years), with 69 (53%) patients having urethral hypermobility and 61 (47%) having intrinsic urethral lesion. Normal voiding occurred in 97 (75.6%) women with 7 post-operative days. The only significant variable in the univariate (p = 0.014) and multivariate (p = 0.017) analysis was post-voiding residue higher than 100 mL.

CONCLUSION

Pre-operative presence of a post-voiding residual urine higher than 100 mL was the only variable predictive of voiding dysfunction.

Low Incidence of Acute Urinary Retention in the General Male Population: The Triumph Project

OBJECTIVE

To describe the incidence of acute urinary retention (AUR) in the general male population and in a population of men newly diagnosed with lower urinary tract symptoms suggestive of BPH (LUTS/BPH).

METHODS

We performed a retrospective cohort study in the Integrated Primary Care Information (IPCI) database, a GP research database in The Netherlands, during the period 1995-2000. All males, > or =45 years, without a history of AUR or radical cystectomy were included in the study. In addition, we followed a sub-cohort of men, newly diagnosed with LUTS/BPH. AUR was defined as the sudden inability to urinate, requiring catheterization.

RESULTS

Amongst 56,958 males with a mean follow-up of 2.8 years, 344 AUR cases occurred (incidence rate 2.2/1000 man-years) of whom more than 40% were precipitated. AUR was the first symptom of LUTS/BPH in 73 (49%) of the 149 AUR cases that occurred in men newly diagnosed with LUTS/BPH. The risk of AUR was 11-fold higher in patients newly diagnosed with LUTS/BPH (RR 11.5; 95%CI: 8.4-15.6) with an overall incidence rate of 18.3/1000 man-years (95%CI: 14.5-22.8).

CONCLUSIONS

The incidence rate of AUR is low in the general population but substantial in a population of men newly diagnosed with LUTS/BPH. The incidence rate increases with age and AUR is precipitated in approximately 40% of all cases. Within the LUTS/BPH cohort, AUR is the first presenting symptom of BPH in 50% of all AUR cases.

The responsiveness of the Overactive Bladder Questionnaire (OAB-q)

PURPOSE

The purpose of this study was to examine the responsiveness of the Overactive Bladder questionnaire (OAB-q) during anti-muscarinic treatment.

METHODS

OAB patients were treated with tolterodine ER 4 mg/day for 12 weeks. The OAB-q and 3-day micturition diaries were collected at baseline, 4, and 12 weeks. The patients' and physicians' perceptions of treatment benefit were assessed at 4 and 12 weeks. Responsiveness of the OAB-q was examined with effect sizes and comparisons to other measures using ANOVAs, t-tests, and correlations.

RESULTS

A total of 865 patients completed the 12-week study (mean age 61 years; 73% female; 89% Caucasian). From baseline to 4 weeks, significant improvements (p < 0.0001) occurred in all OAB-q subscales, which were maintained through week 12. The OAB-q was highly responsive with subscale effect sizes ranging from 0.44 (social interaction) to 1.2 (symptom bother). Significant score changes in all OAB-q subscales (p < 0.05) were associated with reductions of > or = 3 urgency episodes, > or = 3 micturitions, or > or = 1 incontinence episode per day. Improvements in OAB-q scales were associated with changes in patient and physician perceptions of treatment benefit.

CONCLUSIONS

The OAB-q was highly responsive and demonstrated responsiveness to reductions in urinary urgency, frequency, and incontinence during antimuscarinic treatment of OAB. The OAB-q appears to be a useful outcome measure for treatments of OAB.

Darifenacin: a novel M3muscarinic selective receptor antagonist for the treatment of overactive bladder

Darifenacin is a novel M3 muscarinic selective receptor antagonist for once-daily treatment of overactive bladder (OAB), a highly prevalent, chronic and debilitating disease defined by urinary urgency with or without urge incontinence, usually with increased frequency of micturition and nocturia. In vitro, darifenacin is a potent and specific muscarinic receptor antagonist with </= 59-fold higher selectivity for muscarinic M3 receptors relative to other muscarinic receptor subtypes. This profile may, therefore, confer clinical efficacy in the treatment of OAB, with a lower propensity for adverse effects and safety issues related to blockade of other muscarinic receptor subtypes. Indeed, consistent with its low relative affinity for M1 and M2 receptors, no effects on cognitive function and heart-rate variability, respectively, have been observed with darifenacin. Subsequent large-scale clinical trials have confirmed that darifenacin (at doses of 7.5 and 15 mg/day) results in central nervous system and cardiac adverse events comparable to placebo, and provides early and meaningful improvement across a range of OAB symptoms including incontinence episodes, urgency and urinary frequency. On the basis of such findings, darifenacin would appear to meet the current need for an effective OAB pharmacotherapy that is efficacious, well-tolerated and, more importantly, minimises the risk of safety-related adverse effects.

How do you stretch a bladder? A survey of UK practice, a literature review, and a recommendation of a standard approach

AIMS

To assess how and why hydrodistension of the bladder is performed by UK urologists and to compare this practise with the published literature on distension. To suggest a standardised technique for hydrodistension to allow comparison of diagnostic and therapeutic studies.

METHODS

A questionnaire was sent to all UK consultant urologists. Questions addressed the indications for short bladder distension (SBD), details of technique, evaluation of outcome, and awareness of evidence base. The literature on bladder distension was reviewed.

RESULTS

The majority of respondents perform SBD, principally in the diagnosis and therapy of interstitial cystitis (IC). There was considerable variation in the duration of distension, repetition of distension, the pressure used for distension, and the measurement of bladder capacity. The literature on the technique of hydrodistension is imprecise and no respondent was able to cite literature to support his or her practice. We suggest a simple, more objective technique for performing hydrodistension.

CONCLUSIONS

SBD is widely used. There is marked variability in technique and little more than anecdotal evidence to support any particular approach. Research into the evaluation and treatment of painful bladder syndrome in general and IC in particular would be facilitated by the adoption of a standardised technique.

Central nervous system safety of anticholinergic drugs for the treatment of overactive bladder in the elderly

BACKGROUND

Overactive bladder (OAB) is characterized by urgency and increased frequency of micturition, with or without urinary urge incontinence. Anticholinergic agents are important in the treatment of OAB. However, concerns have emerged about their central nervous system (CNS) safety and the associated risk of cognitive impairment.

OBJECTIVE

This article describes the CNS adverse effects of anticholinergic drugs used for the treatment of OAB, with particular emphasis on their use in the elderly. Its objective is to help physicians make optimal choices when selecting anticholinergic treatment for OAB.

METHODS

: Relevant data from the literature were identified primarily through a MEDLINE search of articles published through December 2003. The search terms included overactive bladder, central nervous system, anticholinergic, and antimuscarinic. This was not intended to be a systematic review, and articles were chosen for inclusion based on their pertinence to the focus on treatment of OAB in the elderly.

RESULTS

Several anticholinergic drugs are available for the treatment of OAB, including oxybutymn, tolterodine, trospium chloride, and propiverine (not available in the United States). Among the agents reviewed, penetration of the blood-brain barrier (as predicted by lipophilicity, polarity, and molecular size and structure) is highest for oxybutymn, lower for tolterodine, and lowest for trospium chloride; limited data are available for propiverine. The total anticholinergic drug burden may also be important in determining the potential for CNS adverse effects. The spectrum of anticholinergic CNS adverse effects ranges from drowsiness to hallucinations, severe cognitive impairment, and even coma. The immediate-release (IR) and extended-release (ER) formulations of oxybutynin have been associated with cognitive impairment. In the only published clinical trial that was identified, no significant differences in CNS adverse effects were observed between the IR and ER formulations of tolterodine. There were few clinical data on the use of propiverine in patients with OAB. Trospium chloride has shown favorable CNS tolerability in postmarketing surveillance studies.

CONCLUSION

When considering treatment choices for patients with OAB, particularly the elderly, the potential CNS adverse effects of each anticholinergic agent must be weighed against the severity of OAB symptoms.

Relationship between urinary symptoms reported in a postal questionnaire and urodynamic diagnosis

AIMS

To describe the relationship between symptoms reported in a self-completed postal questionnaire and urinary disorders based on urodynamic investigation.

METHODS

The study population was selected from women aged 40 years or over living in the community, who responded to a postal questionnaire. Following assessment and appropriate conservative interventions, those with a pre-defined level of severity of symptoms were offered urodynamic investigation. Logistic regression examined the association between urinary symptoms and the urodynamic diagnoses of detrusor overactivity (DO) and urodynamic stress incontinence (USI).

RESULTS

Four hundred eighty-eight women completed urodynamic investigation; 29.1% (142/488) were found to have DO, 33.6% (164/488) USI, 20.7% (101/488) mixed incontinence, and 16.6% (81/488) no urodynamic abnormality. Stress incontinence (SI) and urge incontinence (UI) were included in the risk model for USI. SI reported monthly or more was associated with increased risk of USI, and UI reported weekly or more with decreased risk (sensitivity 76.9%; specificity 56.3%; positive predictive value (PPV) 67.8%). For DO, strong or overwhelming urgency, UI monthly or more, and nocturia once a night or more were all significantly associated with an increased risk while reporting of SUI monthly or more reduced the risk (sensitivity 63.1%; specificity 65.1%; PPV 63.1%).

CONCLUSIONS

Urinary symptoms reported in a postal questionnaire are able to predict urodynamic diagnoses with moderate accuracy. These models may be useful tools with which to categorize urinary disorders for epidemiological study and, with further development, allocate first line treatment.

GAP-43 immunoreactivity of subepithelial and detrusor muscle nerve fibres in patients with refractory idiopathic detrusor overactivity

AIMS

To determine the relative density of nerve fibres immunoreactive to growth associated protein-43 (GAP-43, an indicator of neuronal sprouting) in the subepithelium and detrusor of patients with idiopathic detrusor overactivity (IDO). To investigate the effect, if any, of age and previous recurrent bacterial cystitis on neuronal sprouting in such patients.

MATERIALS AND METHODS

A series of 18 women with urodynamically proven IDO (median age 62 years, range 39-85), who were refractory to treatment, underwent cystoscopy and cold cup biopsy. Controls (n=26, median age 65, range 32-79) were females without urgency/urge incontinence, undergoing cystoscopy for other indications. Recurrent proven bacterial cystitis (rUTI) was documented. Frozen sections were stained with specific antibodies to GAP-43 and protein gene product 9.5 (PGP, a general neuronal marker). The area represented by immunoreactive (ir) subepithelial or muscle nerve fibres was measured.

RESULTS

The density of GAP-43ir and PGPir nerves did not differ significantly between IDO patients and controls, in either subepithelium or detrusor. The GAP-43ir nerve density (as percent of PGPir) increased significantly with advancing age amongst patients with IDO in the detrusor muscle but not in the subepithelium; density in controls was unaltered. In IDO patients with rUTI, a significant increase in GAP-43 (as percent of PGPir) was observed in the subepithelium.

CONCLUSIONS

Although we found no evidence of increased neuronal proliferation in patients with IDO generally, the increase in GAP-43 with age and with previous cystitis history suggests that neuronal sprouting is important in some subsets of patients with IDO.

EAU Guidelines on Chronic Pelvic Pain

OBJECTIVES

On behalf of the European Association of Urology (EAU) guidelines for diagnosis, therapy and follow-up of chronic pelvic pain patients were established.

METHOD

Guidelines were compiled by a working group and based on current literature following a systematic review using MEDLINE. References were weighted by the panel of experts.

RESULTS

The full text of the guidelines is available through the EAU Central Office and the EAU website (www.uroweb.org). This article is a short version of this text and summarises the main conclusions from the guidelines on management of chronic pelvic pain.

CONCLUSION

A guidelines text is presented including chapters on prostate pain and bladder pain syndromes, urethral pain, scrotal pain, pelvic pain in gynaecological practice, role of the pelvic floor and pudendal nerve, general treatment of chronic pelvic pain and neuromodulation. These guidelines have been drawn up to provide support in the management of the large and difficult group of patients suffering from chronic pelvic pain.

Comparison of measurements obtained with microtip and external water pressure transducers

The aim of this study was to compare pressure readings obtained with catheter-mounted microtip and external water pressure transducers using a mechanical model for vesical pressure during Valsalva straining and coughing. The two catheter-mounted pressure transducers were simultaneously placed in a vinyl i.v. bag designed to mimic the parameters of the human bladder to allow comparison of simultaneous readings from both transducers. Simulated cough and Valsalva maneuvers of various strengths at different volumes (100 ml, 200 ml, 300 ml) were performed and the pressure readings generated by the two systems compared. The Pearson correlation coefficient between the systems was 0.998 for coughs and 0.998 for Valsalva efforts. Data were also analyzed by volume and strength of simulated cough and Valsalva effort, and correlations were found to be high (> or = 0.940) for all subgroup analyses. Mean absolute differences between events recorded by the two systems were small, as indicated by the y-intercept of 3.76 cmH2O pressure. Neither transducer recorded consistently higher pressures than the other. We concluded that there is a high correlation between pressure measurements obtained from microtip and external water pressure transducers during simulated cough and Valsalva efforts in this model. As similar correlation should exist in vivo, urodynamic data generated by the two transducer types should be comparable.

DETRUSOR OVERACTIVITY. DOES IT REPRESENT A DIFFERENCE IF PATIENTS FEEL THE INVOLUNTARY CONTRACTIONS?

PURPOSE

We evaluated the differences between patients with overactive bladder (OAB) who felt involuntary detrusor contractions during cystometry (detrusor overactivity [DO]) and those who did not feel them.

MATERIALS AND METHODS

We prospectively studied 45 patients with symptoms of nonneurogenic, nonobstructed overactive bladder and with DO on cystometry. All patients underwent videourodynamics, the ice water test and electrical perception threshold determination. Continence, urodynamic parameters, data from specific sensory evaluation and outcome of drug treatment were examined.

RESULTS

Almost half of our patients did feel the contractions of DO and half did not. The groups differed significantly. Those without DO sensation were more frequently incontinent, had more involuntary detrusor contractions and these occurred earlier during bladder filling. They had involuntary start of voiding more frequently, more pathological sensation of bladder filling and lower electrical sensory thresholds. The results of drug treatment were better in the group who felt DO.

CONCLUSIONS

Contractions of DO are felt by some of the patients and they differ from those patients who do not feel such contractions. It is likely that this finding reflects the existence of different OAB conditions with a different neuropathological cause and a different treatment outcome. Therefore, we suggest that specific tests for the evaluation of sensation in the lower urinary tract should be part of the diagnosis of patients with DO and symptoms of OAB.

Mixed incontinence: Stressing about urge

Urgency and urinary urge incontinence are troublesome and complex symptoms that can complicate the diagnosis and treatment of stress urinary incontinence. Despite this fact, first-line intervention frequently is directed toward the incompetent bladder neck using surgical approaches. Persistent urgency or detrusor instability following anti-incontinence surgery reduces patient satisfaction and overall continence in most series. This article discusses current theories explaining the etiology of mixed incontinence. It also reviews the results of anti-incontinence surgery for mixed incontinence and discusses management strategies. Possible predictors of outcome after sling surgery in this complex group of patients also are presented.

Pharmacotherapy for stress urinary incontinence : present and future options

Stress urinary incontinence (SUI) is the accidental leakage of urine associated with physical activities such as running, jumping or lifting, or with sneezing and coughing. Worldwide, SUI is a highly prevalent condition, both in young and elderly women, and is a condition fraught with social isolation, loss of self-esteem and significant financial burden. Most women with SUI assume that it is an inevitable part of aging and "suffer in silence", relying on absorbent pads or lifestyle changes to cope with their condition.Unfortunately, for those who do seek medical treatment, the absence of effective and well tolerated pharmacological treatments for SUI limits the clinician's choices to behavioural modification, biofeedback and surgery. Many of the nonsurgical approaches have low success rates, particularly in the elderly and more severely afflicted. Although most continence surgeries have been reported to produce very high cure rates, many women are willing to live with their condition rather than undergo such invasive options. In an attempt to help these patients, some physicians prescribe off-label agents, including tricyclic antidepressants such as imipramine, alpha- and beta-adrenoceptor agonists, and estrogen replacement therapy. The use of these therapies has been limited by unpredictable results and adverse reactions. In addition, acetylcholine receptor antagonists are often prescribed for SUI, despite the fact that these medications have never been shown to be effective in this condition. This lack of a reliable pharmaceutical agent led to the development of duloxetine, a balanced dual reuptake inhibitor of serotonin and norepinephrine that is also being studied for the treatment of major depressive disorder. Based on in vivo data in animals, duloxetine is believed to increase the strength of urethral sphincter contractions and, thereby, prevent accidental urine leakage by increasing urethral closure forces. In clinical trials in women with SUI, duloxetine has demonstrated efficacy in reducing incontinence episodes and increasing the quality of life with no serious adverse effects. Nausea was the most common adverse event; however, in most patients it was reported early in treatment, mild-to-moderate in severity and transient. A medication such as duloxetine, if approved, would go a long way towards expanding the available treatment options for patients with SUI.

The repeatability of the 24-hour pad test

A prospective observational study was conducted in a tertiary urogynaecology unit in women with the primary symptom of urinary incontinence to assess the repeatability of the 24-hour pad test. One hundred and eight women undertook seven 24-hour pad tests over 7 consecutive days together with 7 simultaneous fluid and activity charts. The results were analysed collectively and according to urodynamic subsets. Repeatability was assessed by repeated measures analysis of variance and univariate analysis of variance for each urodynamic diagnosis group (USI, mixed and no USI). Variation between pad test weights over the 7 days was low, supporting good repeatability. The number of days of pad testing required to approximate the 7-day average was 3 days. However, a single 24-hour pad test correlated highly with the 7-day average (r=0.881) and was considered sufficient to gauge leakage severity.

Foley versus intermittent self-catheterization after transvaginal sling surgery: which works best?

OBJECTIVES

To determine whether the duration of catheter use differed between subjects using clean intermittent self-catheterization and those using continuous Foley catheterization after transvaginal sling surgery.

METHODS

We performed a retrospective analysis of postoperative bladder drainage in 167 consecutive women undergoing transvaginal suburethral sling placement for stress urinary incontinence. The primary outcome measure was the duration of catheter use. Normal voiding was defined as a voided volume equal to twice the residual volume and a residual volume of less than 100 mL for 24 hours. The groups were compared for differences in demographic, preoperative, and postoperative variables using univariate and multivariate analyses. The potential confounding effects of age, concomitant procedures, sling material, preoperative Valsalva voiding, and voiding pressures were investigated using general linear models.

RESULTS

A total of 122 subjects used clean intermittent self-catheterization and 45 had Foley catheter drainage. No differences were found between the groups in terms of concomitant procedures performed and preoperative diagnoses. The median duration of catheter use was 12 days (range 1 to 120) for women using clean intermittent self-catheterization versus 8 days (range 1 to 120) for those using Foley catheter drainage (P = 0.026). This difference was not influenced by age, concomitant procedures, sling material, preoperative Valsalva voiding, or preoperative voiding pressures according to the multivariate analyses.

CONCLUSIONS

Although many advocate bladder retraining for postoperative bladder rehabilitation, continuous bladder drainage may result in quicker recovery of normal voiding after sling procedures.

The wet patient: understanding patients with overactive bladder and incontinence

Overactive bladder (OAB) is a constellation of lower urinary tract symptoms, including urinary frequency and urgency,which can occur with or without urinary incontinence. Incontinence is present in over half of female patients with OAB. This condition affects more than 33 million Americans and imposes considerable economic, social, and psychological burdens. Although continued improvements in the pharmacologic management of lower urinary tract disorders have led to the availability of well-tolerated, characteristic features, prevalence and epidemiology, effective treatment options, the symptoms of OAB are generally underreported by patients and under treated by healthcare professionals. Heightened awareness of the multifaceted disease burden imposed by OAB and increased understanding of the characteristics of patients who are likely to be most severely affected, in particular those who suffer from incontinence, may improve the timely identification, diagnosis, and clinical management of the syndrome, enhancing both the health and quality of life of these patients. This review will summarize the clinical consequences, and management of OAB, with particular focus on the incontinent patient.

Diet as a risk factor for the development of stress urinary incontinence: a longitudinal study in women

OBJECTIVE

To assess the association between diet and the onset of stress urinary incontinence (SUI) in women aged 40 y plus.

DESIGN AND SETTING

The Leicestershire MRC Incontinence Study - a prospective longitudinal study of the prevalence, incidence and aetiology of urinary symptoms.

SUBJECTS AND METHODS

A total of 5816 women aged 40 y plus and living in the community. Urinary symptoms were reported in a postal questionnaire at baseline and at 1-y follow-up. Dietary intake was assessed in a food frequency questionnaire at baseline.

RESULTS

Intakes of total fat, saturated fatty acids and monounsaturated fatty acids were associated with an increased risk of SUI onset 1 y later. Of the micronutrients studied, zinc and vitamin B12 were positively associated with SUI onset.

CONCLUSION

The results from this prospective study suggest there may be an aetiological association between certain components of the diet and the onset of SUI. The findings need confirming and possible mechanisms to explain these associations need further investigation.

Urinary Side Effects of Duloxetine in the Treatment of Depression and Stress Urinary Incontinence

BACKGROUND: The efficacy and safety of duloxetine, a dual reuptake inhibitor of serotonin and norepinephrine at the recommended starting dose, have been demonstrated in the treatment of major depressive disorder (MDD) in men and women and in the treatment of stress urinary incontinence (SUI) in women. Since the mechanism of action of duloxetine in the treatment of SUI is believed to be related to enhanced urethral closure forces, it is important to clarify the risk of acute urinary retention. METHOD: The relationship between duloxetine and obstructive voiding symptoms was examined in 8 double-blind, 8- to 9-week, placebo-controlled studies and 1 open-label study in men and women treated for MDD with duloxetine 40 to 120 mg/day and in 4 double-blind, 12-week, placebo-controlled studies and 4 ongoing open-label studies in women treated for SUI with duloxetine 80 mg/day. RESULTS: In 378 men and 761 women with MDD treated in placebo-controlled trials, 0.4% (4/1139; 3 men and 1 woman) of those treated with active medication reported subjective urinary retention versus none (0/777) of those treated with placebo (p =.15). In 958 women with SUI treated with duloxetine in placebo-controlled trials, none reported subjective urinary retention. Overall, in the duloxetine placebo-controlled clinical studies in the treatment of MDD and SUI, obstructive voiding symptoms (reported either as subjective urinary retention or other obstructive voiding symptoms) occurred more often in patients receiving duloxetine (1.0%, 20/2097) than in patients receiving placebo (0.4%, 6/1732) (p <.05). Of the 4719 MDD and SUI patients treated with duloxetine in placebo-controlled and ongoing open-label studies, 2 men and 1 woman discontinued because of obstructive voiding symptoms. Although such an evaluation was not required by protocol, no cases of objective acute urinary retention with postvoid residual urine verified with a bladder scan or requiring catheterization were reported in patients treated with duloxetine. CONCLUSION: Duloxetine treatment in women and men with depression and in women with SUI was rarely associated with obstructive voiding symptoms, and no subjects had objective acute urinary retention requiring catheterization.

Transvaginal surgery in the octogenarian using cadaveric fascia for pelvic prolapse and stress incontinence: minimal one-year results compared to younger patients

OBJECTIVES

To evaluate prospectively our transvaginal surgery experience in octogenarian women and compare the results with those in younger patients. As our population has aged, the treatment of incontinence and prolapse in women older than 80 years, known as octogenarians, has become a significant clinical issue.

METHODS

To date, our prospective database includes 455 women who have undergone transvaginal sling surgery using nonfrozen cadaveric fascia lata with or without concurrent prolapse repair. Of these, 51 (11%) were at least 80 years old at surgery. Complete follow-up was defined as pelvic examination findings, validated questionnaire responses (incontinence and quality of life), and SEAPI (Stress, Emptying, Anatomy, Protection, and Instability) score. The outcomes analysis was focused on the 31 octogenarian women with a minimum of 1 year of complete follow-up and compared their data with the data of 234 younger women with an identical minimal follow-up time.

RESULTS

The mean octogenarian age was 83 years (maximal age 93). The mean octogenarian questionnaire and examination follow-up was administered at 21.4 months and 17.5 months, respectively. Of the 31 octogenarians, 17 (55%) reported continence improvement of greater than 70%, and 28 (90%) had no symptomatic recurrent prolapse. Compared with younger patients, no statistically significant difference in outcome parameters was identified. The rates of persistent urgency and urgency in dissatisfied patients were greater in octogenarian women, but did not reach statistical significance. Statistically significant improvement in the octogenarian quality-of-life measures was demonstrated. No perioperative complications occurred.

CONCLUSIONS

Transvaginal incontinence and/or prolapse surgery may be safely performed in octogenarian women, with resultant improvement in quality-of-life measures. Although outcomes after transvaginal surgery were comparable between octogenarian and younger women, persistent urgency may predict dissatisfaction in the octogenarian population.

Urodynamically Defined Stress Urinary Incontinence and Bladder Outlet Obstruction Coexist in Women

PURPOSE

The definition and significance of female bladder outlet obstruction (BOO) are poorly understood. We identified patients with urodynamic evidence of BOO in a cohort of women with stress urinary incontinence (SUI).

MATERIALS AND METHODS

Women with SUI were identified from a videourodynamic data base and pressure flow studies were reexamined. Subjects were excluded if detrusor pressures could not be measured. BOO was diagnosed if the maximum flow rate was less than 12 ml per second and detrusor pressure at maximum flow was greater than 20 cm water or maximum detrusor pressure was greater than 20 cm water in those without measurable flow. Clinical and urodynamic characteristics were compared in the obstructed and unobstructed groups.

RESULTS

Of 104 eligible subjects 19 (18.3%) had BOO. Maximum flow rate, mean flow rate and voided volume were significantly less in the BOO group than in the unobstructed group (8.7 vs 13.5 ml per second, p = 0.004, 5.9 vs 7.9 ml per second, p = 0.001 and 180 vs 272 ml, p = 0.008). Detrusor pressure at maximum flow, maximum detrusor pressure and post-void residual volume were significantly greater in the BOO group than in the unobstructed group (28 vs 15 cm water, p <0.0001, 31 vs 19 cm water, p <0.0001 and 71 vs 10 ml, p = 0.008). Etiologies of BOO identified in the 19 subjects included prior anti-incontinence or prolapse surgery in 6, neurological conditions in 4, cystocele in 2, dysfunctional voiding in 3 and idiopathic in 5.

CONCLUSIONS

SUI and BOO can coexist even in the absence of common causes of obstruction.

Patient-selected goals: a new perspective on surgical outcome

OBJECTIVE

This study was undertaken to study the relationship between achievement of patient goals, overall satisfaction, and objective outcome measures.

STUDY DESIGN

After Institutional Review Board approval, we prospectively evaluated 78 women undergoing pelvic reconstructive surgery at Loyola University Medical Center. After informed consent for surgery, patients were asked to state their goals for surgery. In a follow-up telephone conversation, these goals were reviewed and negotiated to modify expectations. The same physician investigator contacted women 3 months after surgery to assess goal achievement, overall satisfaction, and their surgical experience. Date were analyzed with Spearman correlation and Mann-Whitney tests.

RESULTS

Of 78 women, 75% indicated that they met most of their goals, and 72% were more than 80% satisfied. Patient satisfaction was moderately correlated to goal achievement (rho=0.57, P<.001). Objective cure, defined as no urodynamic stress incontinence and stage 0 or I prolapse, was not related to satisfaction (P=.14). Dissatisfaction was highly associated with feeling "unprepared for surgery" (P<.001).

CONCLUSION

Objective and subjective outcomes are necessary to predict patient satisfaction.

Nutrient composition of the diet and the development of overactive bladder: A longitudinal study in women

AIMS

Evidence for an association between diet and the symptom syndrome overactive bladder (OAB) would be valuable in understanding its aetiology. The present study investigates prospectively the association between the nutrient composition of the diet and the onset of OAB.

METHODS

A random sample of community dwelling women aged 40 years or over was studied. Baseline data on urinary symptoms and diet were collected from 6,371 women using a postal questionnaire and food frequency questionnaire. Follow-up data on urinary symptoms were collected from 5,816 of the women in a postal survey 1 year later. Logistic regression was used to investigate the association of diet (daily intakes of energy, macro and micronutrients) with 1 year incidence of OAB.

RESULTS

There was evidence that three nutrients may be associated with OAB onset. Higher intakes of vitamin D (P = 0.008), protein (P = 0.03), and potassium (P = 0.05) were significantly associated with decreased risks of onset. Although overall the associations with vitamin B6 and niacin were not significant (P = 0.08 and P = 0.13), there was some evidence of a decreased risk of onset with higher intakes.

CONCLUSIONS

The results from this prospective study suggest possible aetiological associations between certain nutrients and OAB onset. The findings need confirmation and possible mechanisms to explain these associations need further investigation.

Colpocleisis and urinary incontinence

OBJECTIVE

The study was undertaken to review results of colpocleisis performed for advanced pelvic organ prolapse (POP) in elderly women, with attention to perioperative stress incontinence.

STUDY DESIGN

We performed a retrospective chart review of all colpocleisis procedures performed July 2000 through March 2002.

RESULTS

Sixty-four women with median age 78 years (68-90 years) with symptoms and signs of advanced POP underwent partial vaginectomy and colpocleisis. Concomitantly, 21 (33%) women underwent suburethral sling and 12 (19%) underwent suburethral plication procedures for treatment of stress urinary incontinence (SUI). Three patients with dementia were unable to offer subjective symptoms. One patient died in hospital from multisystem organ failure unrelated to colpocleisis. When last seen, 2 (3%) of the remaining 60 patients had some persistence of symptoms of POP. Of 30 women without preoperative symptoms of SUI, 8 had new-onset SUI symptoms after surgery.

CONCLUSION

Colpocleisis is an effective method for treatment of advanced POP. Lower urinary tract evaluation and treatment remain challenging in this setting.

Management of the neuropathic bladder

Neurological injury and disease are common, and intimately related to abnormalities of the urinary system. The prevention and treatment of urological sequelae in patients with neurological injury or disease requires a clear multidisciplinary management strategy.

Evidence-based practice in urogynaecology

Urogynaecology practice is rapidly progressing, with a trend towards minimally invasive techniques. This article attempts to cover the evidence behind the assessment and treatment of urinary and anal incontinence, and vaginal prolapse.