A severity index for epidemiological surveys of female urinary incontinence: comparison with 48-hour pad-weighing tests

Prevalence of post-micturition symptoms in association with lower urinary tract symptoms and health-related quality of life in men and women

OBJECTIVE

• To estimate the prevalence of post-micturition symptoms (a feeling of incomplete emptying following urination and post-micturition dribble) in a population-based sample of men and women, and to examine overlap with storage and voiding LUTS and associations with health-related quality of life (HRQL).

PATIENTS AND METHODS

• Data were obtained by in-person interview in the Boston Area Community Health survey, a population-based random sample of 2301 men and 3202 women aged 30-79 years in the USA. • Lower urinary tract symptoms (LUTS) were defined using the International Prostate Symptom Score and standardized terminology. • Multivariate linear regression was used to evaluate associations between urological symptoms and validated HRQL measures (SF-12 and activities interference) cross-sectionally.

RESULTS

• The overall prevalence of post-micturition symptoms was 11.8% in men and 8.5% in women. • The prevalence increased with age in men but not women. • In men, post-void dribbling contributed to much of the post-micturition symptoms, whereas, in women, incomplete emptying was more common. • For both genders, over 50% with voiding symptoms also had post-micturition symptoms, compared to less than 50% of respondents who reported storage symptoms. • The presence of post-micturition symptoms, particularly incomplete emptying, was indicative of mildly impaired physical HRQL and activities interference in men and women, and mental HRQL in men (P < 0.01).

CONCLUSIONS

• Post-micturition symptoms were more prevalent than any individual voiding symptom and commonly overlapped with other LUTS. • Over half of men and women with a voiding symptom also had a post-micturition symptom. • The presence of post-micturition symptoms was indicative of impaired HRQL.

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.

Self-assessment of fluid intake behavior in women with urinary incontinence

OBJECTIVE

To determine if women with urinary incontinence are able to recognize patterns of fluid intake associated with lower urinary tract symptoms.

METHODS

We performed a cross-sectional study of 256 consecutive women with urinary incontinence at an initial visit to a urogynecology practice. Data from the Questionnaire-Based Voiding Diary, a validated instrument that measures volume of fluid intake, fluid intake behavior, and lower urinary tract symptoms, were abstracted. Carbonated, caffeinated, and total fluid intake volumes were analyzed. Behaviors of excess consumption of caffeinated, carbonated, and total fluid intake as well as restriction of fluid intake were measured. Fluid intake volumes were divided into quartiles and correlated to fluid intake behavior and lower urinary tract symptoms.

RESULTS

Fluid intake behaviors of drinking excess carbonated and caffeinated beverages were significantly associated with the volume of carbonated (p<0.001) and caffeinated fluid intake (p<0.001). The behavior of drinking excess fluid was significantly associated with the total volume of fluid intake (p=0.019). A significant relationship between quartiles of total fluid intake and increasing number of daily voids (p<0.001) and quartiles of caffeinated fluid intake and increasing severity of urgency urinary incontinence (p=0.038) was noted. A direct statistical association between fluid intake behavior and lower urinary tract symptoms was not noted.

CONCLUSIONS

Women with urinary incontinence recognize their pattern of fluid intake and fluid intake behavior. The type and volume of fluid intake are significantly associated with symptoms of urinary frequency and urgency urinary incontinence.

Prevalence and trends of urinary incontinence in adults in the United States, 2001 to 2008

PURPOSE

We estimate trends in the prevalence of urinary incontinence in the adult population of the United States from 2001 through 2008 before and after adjusting for other potential associated factors.

MATERIALS AND METHODS

We analyzed data on 17,850 adults 20 years old or older who participated in the 2001 to 2008 cycles of the National Health and Nutrition Examination Survey. Any urinary incontinence was defined as a positive response to questions on urine leakage during physical activity, before reaching the toilet and during nonphysical activity. During this period changes in demographic and clinical factors associated with urinary incontinence included age, race/ethnicity, obesity, diabetes and chronic medical conditions (prostate disease in men). Age standardized prevalence estimates and prevalence ORs of urinary incontinence trends were determined using adjusted multivariate models with appropriate sampling weights.

RESULTS

The age standardized prevalence of urinary incontinence in the combined surveys was 51.1% in women and 13.9% in men. Prevalence in women increased from 49.5% in 2001 to 2002, to 53.4% in 2007 to 2008 (Ptrend=0.01) and in men from 11.5% to 15.1%, respectively (Ptrend=0.01). In women increased prevalence was partially explained by differences in age, race/ethnicity, obesity, diabetes and select chronic diseases across the survey periods. After adjustment the prevalence OR for 2007 to 2008 vs 2001 to 2002 decreased from 1.22 (95% CI 1.03-1.45) to 1.16 (95% CI 0.99-1.37). In men adjustment for potentially associated factors did not explain the increasing prevalence of urinary incontinence.

CONCLUSIONS

The age standardized prevalence of urinary incontinence increased in men and women from 2001 through 2008. Decreasing obesity and diabetes may lessen the burden of urinary incontinence, especially in women.

Moderating perceptions of bother reports by individuals experiencing lower urinary tract symptoms

We compared reports of symptom bother for the same urinary symptoms to understand why symptom severity and bother do not correspond in a straightforward manner. We used a grounded theory approach to analyze qualitative data from 123 individual interviews and developed a conceptual framework, identifying three symptom perceptions that might moderate symptom bother: causal, relative, and uncertainty. Symptom bother was lower for respondents who viewed symptoms causally (symptoms seemed explainable or "normal") or relatively (urinary symptoms were compared to other symptoms or conditions). Bother tended to be higher for respondents who viewed symptoms with uncertainty (when symptom etiology and course were unknown). A greater portion of respondents in the causal perception group had not sought health care for their symptoms. This conceptual framework is useful for understanding the relationship between reactions to and health care seeking for other symptoms.

Do Women Understand Urogynecologic Terminology?

OBJECTIVES: The aims of this study were to describe women's stated knowledge of the primary urogynecologic diagnostic terms (urinary incontinence, pelvic floor disorder, and pelvic organ prolapse) and to assess factors associated with knowledge. METHODS: Before any education about pelvic floor disorders, 376 women presenting to primary care-level gynecologic clinics were asked whether they knew what the terms urinary incontinence, pelvic organ prolapse, and pelvic floor disorder meant. χ(2) and t tests were used to compare characteristics of women with complete knowledge versus partial or no knowledge of terms. P < 0.05 was considered significant. RESULTS: Of all women, 25% knew all 3 terms and 18% knew none. Moreover, 80%, 52%, and 27% of women reported that they knew the meaning of the terms urinary incontinence, pelvic organ prolapse, and pelvic floor disorder, respectively. Of women with stress urinary incontinence symptoms, 88% knew the term urinary incontinence compared with 78% without stress urinary incontinence (P = 0.07). Of 41 women, 31 (76%) with the symptom of vaginal bulge knew the term pelvic organ prolapse compared with 49% without (P = 0.001). Only higher education and symptom of vaginal bulge were associated with complete knowledge of the 3 terms; 30% of women who completed college or higher reported complete knowledge compared with 18% who did not (P = 0.013). CONCLUSIONS: Public health campaigns using terms pelvic organ prolapse or pelvic floor disorders are unlikely to reach most women. Further education and research are needed to improve women's health literacy in urogynecology.

Improved sexual and urinary function in women with sacral nerve stimulation

OBJECTIVES

  Urinary and sexual function improve following sacral nerve stimulation (SNS) for refractory overactive bladder. No significant associations between these changes have been found. Whether improvements in sexual function are independent of or secondary to improvements in urinary function remains unclear. The aim of this study was to analyze changes in urinary and sexual function in a homogeneous sample of patients undergoing SNS for urge urinary incontinence and subsequently identify associations between the two.

MATERIALS AND METHODS

  A prospective database was created. Enrollees underwent a full history and physical examination at the first office visit. Multiple-day voiding diaries with validated and investigator-designed questionnaires were administered at baseline and follow-up as standard implantation procedures and to assess changes in urinary and sexual function, respectively. Analyses were completed using data from patients who were sexually active at baseline and follow-up.

RESULTS

  Statistically significant improvements in urinary and sexual function occurred according to multiple metrics. Patient global impression scales categorized all patients' urinary conditions as improved, with most being less severe. Validated urinary symptom and quality of life scores improved significantly. After treatment, most patients were incontinent less often with sexual activity and felt less restricted from sexual activity by fear of incontinence. Validated quantification of sexual function demonstrated significant improvements in overall sexual function, arousal, and satisfaction. No significant associations between changes in urinary and sexual function were noted; however, trends appeared to exist between the two.

CONCLUSIONS

  Improved sexual function was not significantly associated with improved urinary function after SNS despite apparent trends between the two. Larger samples are required to definitively demonstrate this conclusion.

Effect of pelvic-floor muscle strengthening on bladder neck mobility: a clinical trial

BACKGROUND

Pelvic-floor muscle (PFM) strengthening has been widely used to treat people with urinary incontinence (UI). However, its effect on bladder neck position and stiffness is unknown.

OBJECTIVE

The aim of the study was to investigate the effect of PFM strengthening on bladder neck mobility for women with stress UI (SUI) or mixed UI (MUI).

DESIGN

This study was conducted as a single-group pretest-posttest design.

SETTING

This study was conducted mainly at the Life Quality & Health Promotion Laboratory at National Taiwan University and partly in the Ultrasonography Room of the Department of Obstetrics and Gynecology at National Taiwan University Hospital. Patients Twenty-three patients (mean age=51.9 years, SD=6.1) participated in the study.

INTERVENTION AND MEASUREMENTS

Each participant underwent a PFM strengthening program for 4 months. Bladder neck position at rest and during a cough, the Valsalva maneuver, and a PFM contraction was assessed by transperineal ultrasonography before and after the intervention. Severity Index score, self-reported improvement, PFM strength (force-generating capacity), and vaginal squeeze pressure were assessed for treatment effect.

RESULTS

The position of the bladder neck at PFM contraction and bladder neck mobility for maximal incursion from rest to PFM contraction were elevated, with effect sizes of 0.48 and 0.84, respectively. Bladder neck position and bladder neck mobility were not changed during a cough and the Valsalva maneuver. All participants reported diminution of incontinence, and PFM strength and maximal vaginal squeeze pressure were improved after the intervention. Limitations The limitations of the present trial included the pretest-posttest design and the absence of intra-abdominal pressure measuring and exercise adherence recording.

CONCLUSIONS

Four months of daily PFM strengthening can significantly improve the ability of the PFM to elevate the bladder neck voluntarily, but may not improve its stiffness during a cough and the Valsalva maneuver for women with SUI and MUI.

Preoperative and postoperative predictors of satisfaction after surgical treatment of stress urinary incontinence

OBJECTIVE

The purpose of this study was to assess which preoperative and postoperative variables correlated with satisfaction after surgical treatment of urinary incontinence.

STUDY DESIGN

We conducted a retrospective cohort study of 371 women who underwent rectus fascial or midurethral sling procedure. Satisfaction was defined as a questionnaire response of "completely satisfied." Incontinence symptoms were based on responses to validated questionnaires. Associations between preoperative and postoperative variables and satisfaction were assessed with the use of logistic regression models.

RESULTS

Increasing patient age (odds ratio [OR], 0.8; P = .002), body mass index (OR, 0.8; P = .003), and an autologous rectus fascial sling (compared with a midurethral sling; OR, 0.5; P = .003) were associated with decreased odds of satisfaction in a multivariate model. Furthermore, patients who required urethrolysis or had severe lower-urinary tract symptoms were significantly less likely to report satisfaction.

CONCLUSION

Increasing age, body mass index, and type of operation were associated with decreased odds of satisfaction.

Effects of prolonged second stage, method of birth, timing of caesarean section and other obstetric risk factors on postnatal urinary incontinence: an Australian nulliparous cohort study

OBJECTIVE

To investigate the contribution of prolonged labour, method of birth, timing of caesarean section and other obstetric risk factors to postpartum urinary incontinence.

DESIGN

Prospective pregnancy cohort.

SETTING

Six metropolitan public hospitals in Victoria, Australia.

SAMPLE

A total of 1507 nulliparous women recruited to the maternal health study in early pregnancy (≤24 weeks).

METHOD

Data from hospital medical records and self-administered questionnaires/telephone interviews at ≤24 and 30-32 weeks of gestation and 3 months postpartum analysed using univariable and multivariable logistic regression.

MAIN OUTCOME MEASURE

Urinary incontinence 3 months postpartum in women continent before the index pregnancy.

RESULTS

Of the women continent before pregnancy, 26% reported new incontinence at 3 months postpartum. Compared with women who had a spontaneous vaginal birth, women who had a caesarean section before labour (adjusted odds ratio [OR] 0.2, 95% CI 0.1-0.5) or in the first stage of labour (adjusted OR 0.2, 95% CI 0.1-0.4) were less likely to be incontinent 3 months postpartum. Adjusted OR for incontinence after caesarean section in the second stage of labour compared with spontaneous vaginal birth was 0.5 (95% CI 0.2-1.0). Prolonged second stage labour was associated with increased likelihood of postpartum incontinence in women who had a spontaneous vaginal birth (adjusted OR 1.9, 95% CI 1.1-3.4) or operative vaginal birth (adjusted OR 1.7, 95% CI 1.0-2.8).

CONCLUSIONS

In addition to pregnancy itself, physiological changes associated with the second stage of labour appear to play a role in postpartum urinary incontinence.

Dietary macronutrient intake and lower urinary tract symptoms in women

PURPOSE

To examine associations between macronutrient and total energy intakes with lower urinary tract symptoms (LUTS) in women.

METHODS

Cross-sectional analysis of 2060 women aged 30-79 years in the population-based Boston Area Community Health Survey (2002-2005). Data were collected by validated food frequency questionnaire and in-person interviews. Outcomes for multivariate logistic regression were moderate-to-severe total LUTS, storage, voiding, and postmicturition symptoms.

RESULTS

Greater total energy intake was positively associated with LUTS, specifically among women with lower waist circumferences (<76 cm, p = .005, p(interaction) = .01). Increased saturated fat intake was associated with postmicturition symptoms (Quintile 5 vs. 1, odds ratio 3.94, 95% confidence interval 1.57-9.89, p(trend) = .04). High protein intake was positively associated with storage symptoms (p(trend) = .03), particularly nocturia. No consistent associations were observed for carbohydrate, monounsaturated, or polyunsaturated fat intakes.

CONCLUSIONS

Among women with low waist circumferences, high total daily calorie intake was associated with moderate-to-severe LUTS. Although greater saturated fat intake was linked to postmicturition symptoms, the possibility that postmicturition symptoms in women represent more extensive or severe conditions should be explored in future research. These novel results indicate that dietary contributors to LUTS in women are distinct from those in men and may depend on symptom subtype and body size.

Birth outcomes, postpartum health and primary care contacts of immigrant mothers in an Australian nulliparous pregnancy cohort study

To investigate differences and similarities in birth outcomes, postpartum health and primary care contacts of mothers born overseas of non-English speaking background (NESB) compared with Australian-born mothers. Nulliparous women were recruited in early pregnancy (< or =24 weeks gestation) to a prospective pregnancy cohort study from six metropolitan public hospitals in Victoria, Australia. Analyses are based on questionnaires completed in pregnancy and at 3 months postpartum. Of the 1,507 women recruited in the study, 1,431 women (95%) were followed up at 3 months postpartum. Immigrant mothers of NESB (n = 212) and Australian born mothers (n = 1,074) had similar obstetric outcomes and postpartum physical health outcomes. Immigrant women were more likely to say they had been depressed for 2 weeks or longer since the birth (Adj OR = 1.92, 95% CI 1.3-2.8); to report relationship problems (Adj OR = 1.39, 95% CI 0.9-2.1) and to report lower emotional satisfaction with their relationship with the partner (Adj OR = 1.69, 95% CI 1.1-2.6) after adjusting for age, education status, income, method of birth and genital tract trauma. Immigrant mothers were less likely to be asked about feeling low or depressed by general practitioners (OR = 0.79, 95% CI 0.5-0.9) and about relationship problems by maternal and child health nurses (OR = 0.68, 95% CI 0.5-0.9). Immigrant women of NESB reported greater psychological distress, less emotional satisfaction with their partner and more relationship problems in the first 3 months postpartum than Australian born women. Although immigrant mothers had an equivalent level of contact with primary care practitioners in the first 3 months postpartum, they were less likely to be asked about their emotional well-being or about relationship problems by health professionals.

The questionnaire for urinary incontinence diagnosis (QUID): validity and responsiveness to change in women undergoing non-surgical therapies for treatment of stress predominant urinary incontinence

AIMS

The Questionnaire for Urinary Incontinence Diagnosis (QUID), a 6-item urinary incontinence (UI) symptom questionnaire, was developed and validated to distinguish stress and urge UI. This study's objective was to evaluate QUID validity and responsiveness when used as a clinical trial outcome measure.

METHODS

Participants enrolled in a multi-center trial of non-surgical therapy (continence pessary, pelvic floor muscle training or combined) for stress-predominant UI and completed baseline and 3-month diaries, the Urinary Distress Inventory (UDI) and QUID. Data from all treatment groups were pooled. QUID internal consistency (Cronbach's alpha) and convergent/discriminant validity (Pearson correlations) were evaluated. Responsiveness to change was assessed with 3-month score outcomes and distribution-based measurements.

RESULTS

Four hundred forty-four women (mean age 50) were enrolled with stress (N = 200) and mixed (N = 244) UI; 344 had 3-month data. Baseline QUID Stress and Urge scores (both scaled 0-15, larger values indicating worse UI) were 8.4 +/- 3.2 and 4.5 +/- 3.3, respectively. Internal consistency of QUID Total, Stress, and Urge scores was 0.75, 0.64 and 0.87, respectively. QUID Stress scores correlated moderately with UDI-Stress scores (r = 0.68, P < 0.0001) and diary stress UI episodes (r = 0.41, P < 0.0001). QUID Urge scores correlated moderately with UDI-Irritative scores (r = 0.68, P < 0.0001) and diary urge UI episodes (r = 0.45, P < 0.0001). Three-month QUID Stress and Urge scores improved (4.1 +/- 3.4 and 2.2 +/- 2.7, both P < 0.0001). QUID Stress score effect size (1.3) and standardized response mean (1.2) suggested a large change after therapy.

CONCLUSION

The QUID has acceptable psychometric characteristics and may be used as a UI outcome measure in clinical trials.

The outcome of adding peripheral neuromodulation (Stoller afferent neuro-stimulation) to anti-muscarinic therapy in women with severe overactive bladder

OBJECTIVE

Anti-muscarinic treatment alone and peripheral neuromodulation with concomitant anti-muscarinic treatment were compared in patients with severe overactive bladder.

METHODS

In this prospective study, 40 women with severe overactive bladder according to the 7-day voiding diary without any prior treatment completed the Incontinence Impact Questionnaire (IIQ-7) and were randomised into anti-muscarinic-alone and combination treatment groups. Twenty women received daily 4 mgs of tolterodine orally and in 20 women Stoller afferent neuro-stimulation (SANS) therapy was performed concomitantly for 12 weeks to the same anti-muscarinic regimen. After 12 weeks of therapy, two of the patients drop out of the study and remaining patients filled out the IIQ-7 questionnaire and the 7-day voiding diary again. Pretreatment and post-treatment QoL scores and the 7-day voiding diaries were compared. Mann-Whitney U, Wilcoxon and two sided significance tests were used.

RESULTS

Thirty-eight women fulfilling the criteria were included in the study. Severity of overactive bladder symptoms decreased significantly in both treatment groups. However, the decrease in combination treatment group was more significant than the anti-muscarinic-alone group. Adverse events were similar between the two groups.

CONCLUSION

Combining SANS and anti-muscarinic therapy resulted in significantly better clinical outcomes and IIQ-7 scores as compared with anti-muscarinic treatment alone in patients with severe overactive bladder.

Prevalence of urinary incontinence in men: results from the national health and nutrition examination survey

PURPOSE

We estimated the prevalence of urinary incontinence in the United States adult male population and identified associated factors.

MATERIALS AND METHODS

Data were analyzed for 5,297 men 20 years old or older who participated in the 2005 to 2006 and 2007 to 2008 cycles of the National Health and Nutrition Examination Survey, a cross-sectional, nationally representative survey of the United States noninstitutionalized population. Urinary incontinence (score of 3 or greater on a validated incontinence severity index, indicating moderate to severe leakage) was assessed. Potential associated factors included age, race/ethnicity, education, self-reported health status, prior diagnosis of prostate cancer and/or enlarged prostate (men 40 years old or older), chronic diseases and depression status. Prevalence ORs were estimated from a multivariable logistic regression analysis using appropriate sampling weights.

RESULTS

The prevalence of moderate/severe urinary incontinence was 4.5% (95% CI 3.8, 5.4). Prevalence increased with age from 0.7% (95% CI 0.4, 1.6) in men 20 to 34 years old, to 16.0% (95% CI 13.0, 19.4) in men 75 years old or older (p <0.001). We found no difference in prevalence by racial/ethnic group (p = 0.38). Factors significantly associated (p <0.05) with urinary incontinence were age (per 10-year increase, OR 1.8; 95% CI 1.6, 2.0), major depression (OR 2.7; 95% CI 1.6, 4.0) and hypertension (OR 1.3; 95% CI 1.1, 1.5).

CONCLUSIONS

Age and race adjusted prevalence estimates for urinary incontinence in men are consistent with other estimates using a similar definition. To our knowledge this is the first study that identifies factors associated with moderate to severe urinary incontinence in men.

Urinary and fecal incontinence after bariatric surgery

BACKGROUND

Morbidly obese women have markedly high rates of urinary and fecal incontinence. Weight loss reduces prevalence and severity of urinary incontinence; however, the effect of weight loss on fecal incontinence is unknown.

AIMS

The aim of this study was to document the prevalence of urinary and fecal incontinence in subjects who underwent bariatric surgery and associated weight loss.

METHODS

We mailed a detailed survey to all 404 adults who underwent bariatric surgery at the University of Wisconsin prior to May 2006. Type and severity of urinary and fecal incontinence was obtained using previously validated questionnaires. Perceived effect of surgery on bowel and bladder function was also assessed.

RESULTS

Forty-eight percent (193) of the surveys were returned. Urinary incontinence was reported in 72% of the women, 39% of whom perceived improvement after surgery. Only 21% of the men reported urinary incontinence. In contrast, fecal incontinence was common in both men and women; 48% of the women and 42% of the men reported liquid stool incontinence and 21% of the women and 30% of the men reported solid stool incontinence. Fifty-five percent of the women and 31% of the men with fecal incontinence perceived worsening after surgery. Women with diarrhea were four times more likely to report fecal incontinence (P<0.0001). Furthermore, women who perceived worsening of diarrhea after surgery were significantly more likely to have fecal incontinence (P=0.003).

CONCLUSIONS

Both fecal and urinary incontinence were common after bariatric surgery. Risk factors for fecal incontinence in women after bariatric surgery include diarrhea and worsening of diarrhea; we suggest that such surgery may uncover prior weaknesses in the continence mechanism.

Women with diabetes: understanding urinary incontinence and help seeking behavior

PURPOSE

We examined the association of urinary incontinence with diabetes status and race, and evaluated beliefs about help seeking for incontinence in a population based cohort of women with vs without diabetes.

MATERIALS AND METHODS

We performed a cross-sectional analysis of 2,270 middle-aged and older racially/ethnically diverse women in the Diabetes Reproductive Risk factors for Incontinence Study at Kaiser. Incontinence, help seeking behavior and beliefs were assessed by self-report questionnaires and in-person interviews. We compared incontinence characteristics in women with and without diabetes using univariate analysis and multivariate models.

RESULTS

Women with diabetes reported weekly incontinence significantly more than women without diabetes (weekly 35.4% vs 25.7%, p <0.001). Race prevalence patterns were similar in women with and without diabetes with the most vs the least prevalence of incontinence in white and Latina vs black and Asian women. Of women with diabetes 42.2% discussed incontinence with a physician vs 55.5% without diabetes (p <0.003). Women with diabetes were more likely than those without diabetes to report the belief that incontinence is rare (17% vs 6%, p <0.001).

CONCLUSIONS

Incontinence is highly prevalent in women with diabetes. Race prevalence patterns are similar in those with and without diabetes. Understanding help seeking behavior is important to ensure appropriate patient care. Physicians should be alert for urinary incontinence since it is often unrecognized and, thus, under treated in women with diabetes.

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.

Predictors of variability in urinary incontinence and overactive bladder symptoms

AIMS

We used data from the General Longitudinal Overactive Bladder Evaluation (GLOBE) to understand predictors of variation in urgency and urinary incontinence (UI) symptoms over time.

METHODS

A random sample of Geisinger Clinic primary care patients (men and women) 40+ years of age were recruited for a survey of bladder control symptoms at baseline and 12 months later. Symptom questions used a 4-week recall period. Composite scores were derived for urgency and UI frequency. Logistic regression was used to evaluate predictors of variation in scores at cross-section and longitudinally.

RESULTS

A majority of those with UI symptoms and almost 40% of those with urgency symptoms reported episodes of once a week or less often; 17% had symptoms a few times a week or more often. Twenty-one percent with urgency symptoms and 25% with UI symptoms at baseline did not have active symptoms 12 months later. The strongest predictors of active symptoms at follow-up were baseline symptom score and duration of time since first onset of symptoms. Of those with no urgency symptoms at baseline, 22% had urgency at 12 months. Among those with no UI symptoms at baseline, 13% had UI symptoms 12 months later. Among the latter, age (males only) and BMI were the strongest predictors of symptoms at follow-up.

CONCLUSIONS

Inter-individual and intra-individual occurrences of urgency and UI symptoms are highly variable in the general population. Use of established predictors to select individuals with less variability in symptoms may help to reduce placebo rates in clinical trials.

Dietary macronutrient and energy intake and urinary incontinence in women

Weight loss involving diet modification improves urinary incontinence (UI) in women, but little is known about dietary correlates of UI. The authors examined intakes of total energy, carbohydrate, protein, and fats in relation to UI in a cross-sectional sample of 2,060 women in the population-based Boston Area Community Health Survey (2002-2005). Data were collected from in-person home interviews and food frequency questionnaires. Logistic regression was used to calculate odds ratios and 95% confidence intervals for the presence of moderate-to-severe UI; a severity index was analyzed in secondary analysis of 597 women with urine leakage. Greater total energy intake was associated with UI (P(trend) = 0.0001; highest quintile vs. lowest: adjusted odds ratio = 2.86, 95% confidence interval: 1.56, 5.23) and increased severity. No associations were observed with intake of carbohydrates, protein, or total fat. However, the ratio of saturated fat intake to polyunsaturated fat intake was positively associated with UI (highest quintile vs. lowest: adjusted odds ratio = 2.48, 95% confidence interval: 1.22, 5.06) and was strongly associated with severity (P(trend) < 0.0001). Results suggest that dietary changes, particularly decreasing saturated fat relative to polyunsaturated fat and decreasing total calories, could independently account for some of the benefits of weight loss in women with UI.

Parity is not associated with urgency with or without urinary incontinence

INTRODUCTION AND HYPOTHESIS

Evidence varies on the relation between parity and urgency or urge incontinence (UUI). We used data from the General Longitudinal Overactive Bladder Evaluation to determine whether differences in case definitions could account for variation in findings.

METHODS

We simulated case criteria to correspond to studies of urgency, UUI, and parity using data from 1,880 patients. Logistic models were run for each case-control scenario corresponding to previously used case definitions.

RESULTS

Parity was significantly associated with urgency (odds ratios (OR) 1.70; CI: 1.30-2.22) and UUI (odds ratios (OR) 1.87; CI: 1.34-2.60) only when the case criteria included individuals with stress incontinence (SUI). Parity was not associated with UUI when individuals with SUI were excluded or with urgency when individuals with incontinence were excluded.

CONCLUSIONS

Neither urgency nor UUI symptoms appear to be associated with parity among women 40 years of age and older. Previous associations appear to be explained by inclusion of individuals with SUI.

The Hordaland Women's Cohort: prevalence, incidence, and remission of urinary incontinence in middle-aged women

INTRODUCTION AND HYPOTHESIS

The aim of study is to prospectively investigate the prevalence, incidence, and remission of urinary incontinence (UI) in a cohort of middle-aged women.

METHODS

In 1997-1999, 2,229 randomly selected women aged 41-45 agreed to participate in the Hordaland Women's Cohort, and six almost identical postal questionnaires were sent them during the following 10 years. Response rate was 95.7% at inclusion and has remained 87% to 93% in subsequent waves; 64.1% answered all six questionnaires. UI variables include type, amount, frequency, and severity.

RESULTS

Prevalence of UI increased by age until a peak in age group 51-52 years for any (50.3%) and significant (10.0%) UI. There was then a decrease in prevalence caused by a decrease in incidence and decrease in remission. Stress UI was the major type and most UI was of low severity.

CONCLUSION

Prevalence of any UI is high in middle-aged women but reaches a peak followed by a decrease.

Urinary and anal incontinence during pregnancy and postpartum: incidence, severity, and risk factors

OBJECTIVE

To estimate frequency and severity and to identify risk factors of urinary incontinence (UI) and anal incontinence during pregnancy and after delivery in previously continent nulliparous women.

METHODS

We designed a cohort study of healthy, continent, nulliparous pregnant women attending public health care services. The field work was conducted during the control visits of the three trimesters of pregnancy, at the time of delivery, and postpartum. A self-administered questionnaire was used to assess UI (validated and adapted) and anal incontinence. Frequency of UI and anal incontinence and their confidence intervals (95% CIs) were calculated. The correlations between the severity of UI and the degree of effect on daily life were also estimated. Multivariable Cox models were applied to estimate hazard ratios for both incontinences (urinary/anal) during pregnancy and postpartum.

RESULTS

The cumulative incidence rate during pregnancy was 39.1% (95% CI 36.3-41.9) for UI and 10.3% (95% CI 8.3-12.3) for anal incontinence. The correlation between severity of UI and effect on daily life was moderate. Age, baseline body mass index, and family history of UI were significantly associated with the occurrence of UI during pregnancy, while age and excess weight gain during pregnancy were associated with the occurrence of anal incontinence during pregnancy. Postpartum, the identified risk factors for both incontinences were incontinence during pregnancy and vaginal delivery.

CONCLUSION

The occurrence of UI and anal incontinence during the postpartum period is related to the presence of incontinence in pregnancy, and vaginal delivery increases the risk of persistent incontinence. Some risk factors for both incontinences during pregnancy and postpartum are related to lifestyles and obstetric practices.

[Prevalence of urinary incontinence in Catalonia, Spain]

BACKGROUND AND OBJECTIVE

To study the prevalence and severity of urinary incontinence (IU) in the population of Catalonia.

DESIGN

Descriptive and cross-sectional study.

PATIENTS AND METHOD

Sample of 18.126 individuals, representative of the population of Catalonia, not institutionalized. 15.926 of them were older than 15 years and answered the Survey of Health of Catalonia (ESCA). Two questions about frequency and quantity of leakages of urine were added to the ESCA, a health questionnaire with 197 questions. Questions about UI were the Spanish version of Incontinence Severity Index (ISI).

RESULTS

In Catalonia (Spain) 7.9% of the population (more than 500.000 persons) had symptoms of IU, corresponding to 12.2% of the women and 3.6% of the men. 77.8% of the total population with UI symptoms were women. The prevalence increased with age in both sexes. 12% of women with an age between the 45-64-years, 26.6% between 65-74 years and 41.8% with 75 years or more, had UI symptoms. Symptoms of UI were present in only 2.8% of the men between 45-64 years , 10.2% between 65-74 years and 22.7% of those of 75 years or more.

CONCLUSIONS

A high prevalence of IU was found in the population of Catalonia. In two thirds of individuals with IU, their symptoms were moderate to severe. Severity of UI increases with age in men and women. Overall, symptoms of UI are 3 times more prevalent in women than in men.

The effects of severity of urine leakage on quality of life in Hispanic, white, and black men and women: the Boston community health survey

OBJECTIVES

To investigate the relationship between the severity of urine leakage and quality of life (QOL) in men and women of different race/ethnicity.

METHODS

An epidemiologic survey was conducted with a population-based random sample of 3202 women and 2301 men (1767 black, 1877 Hispanic, 1859 white) aged 30-79 years in Boston, MA. Severity of leakage was based on frequency and amount by the Sandvik Severity Scale. QOL was measured with physical and mental component summaries of Medical Outcomes Study Short Form-12. Covariates included race/ethnicity, age, socioeconomic status, urinary incontinence risk factors, and comorbidities. Analysis included multivariate linear regression modeling by gender.

RESULTS

Urine leakage, most of which was mild or moderate, was reported in 30% of women and 18% of men. Women (5.1%) were more likely than men (0.9%) to report severe leakage. In multivariate analysis, as severity of leakage increased, both components of QOL declined, with decreases in scores of 7-8 points for men (P < or = .001 for each) and 4-6 points (P < .05 and P = .001, respectively) for women. Severe leakage was associated with a greater decline in QOL than that observed for most other comorbidities considered. The effect of urine leakage on QOL was similar among racial and ethnic groups.

CONCLUSIONS

Urine leakage impairs QOL for both men and women, with no evidence of different effects by racial/ethnic group. Leakage has clinically significant effects on physical health-related QOL for men and on mental health QOL for both men and women.

Urinary incontinence in nulliparous women before and during pregnancy: prevalence, incidence, and associated risk factors

INTRODUCTION

Few studies have examined associations of prepregnancy urinary incontinence (UI).

METHODS

Multicentre prospective pregnancy cohort study (n = 1,507) using standardised measures to assess frequency and severity of UI.

RESULTS

Prevalence of UI increased from 10.8% in the 12 months before the index pregnancy to 55.9% in the third trimester. Stress incontinence (36.9%) and mixed incontinence (13.1%) were more common during pregnancy than urge incontinence alone (5.9%). UI before pregnancy was associated with childhood enuresis (adjusted odds ratio (AdjOR) = 2.4, 95% confidence interval (CI) 1.6-3.4), higher maternal body mass index (AdjOR = 2.3, 95% CI 1.4-3.8), and previous miscarriages or terminations (AdjOR = 1.6, 95% CI 1.1-2.3). The strongest predictor of incident UI in pregnancy was occasional leakage (less than once a month) before pregnancy (AdjOR = 3.6, 95% CI 2.8-4.7).

CONCLUSIONS

Further research is needed to elucidate the complex interplay of prepregnancy and pregnancy-related factors in the aetiology of UI in nulliparous women.

Comparison of two questionnaires for assessing the severity of urinary incontinence: The ICIQ-UI SF versus the incontinence severity index

AIMS

To compare the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) with the Incontinence Severity Index (ISI), and to propose intervals for four severity levels of ICIQ-UI SF.

METHODS

Cross-sectional, Internet-based study of 1,812 women responding to a general health questionnaire. Four severity levels for the ICIQ-UI SF scores were constructed by iteratively adjusting the ranges for these levels until maximum Kappa scores were obtained when cross-tabulated with the ISI in a random sample of half of the women with urinary incontinence. Using these intervals, weighted Kappa was calculated for the remaining women as a validation process.

RESULTS

Three hundred forty-three women had urinary incontinence, and completed the ISI and the ICIQ-UI SF. A high correlation between the ISI and ICIQ-UI SF scores with versus without the QoL item was found (Spearman's rho = 0.62, P < 0.01 vs. rho = 0.71, P < 0.01, respectively). Maximum Kappa with quadratic weighting was obtained for the following scale for the ICIQ-UI SF: slight (1-5), moderate (6-12), severe (13-18) and very severe (19-21) (Kappa = 0.61), and without the QoL item: slight (1-3), moderate (4-5), severe (6-9) and very severe (10-11) (Kappa = 0.71) in the development sample. Correspondingly, for the validating sample, maximum Kappa with quadratic weighting was 0.61 and 0.74.

CONCLUSIONS

A high correlation between the ICIQ-UI SF and the ISI was found. The ICIQ-UI SF may be divided into the following four severity categories: slight (1-5), moderate (6-12), severe (13-18) and very severe (19-21). Neurourol. Urodynam. 28:411-415, 2009. (c) 2009 Wiley-Liss, Inc.

Diabetes related risk factors did not explain the increased risk for urinary incontinence among women with diabetes. The Norwegian HUNT/EPINCONT study

BACKGROUND

Previous studies have shown an association between diabetes mellitus (DM) and urinary incontinence (UI) in women, especially severe UI. The purpose of this study was to investigate whether diabetes related variables could explain this association.

METHODS

The study is part of the EPINCONT study, which is based on the large Nord-Trøndelag Health Study 2 (HUNT 2), performed in the county of Nord-Trøndelag, Norway, during the years 1995 - 1997. Questions on diabetes and UI were answered by a total of 21 057 women aged 20 years and older. Of these 685 were identified as having diabetes, and thus comprise the population of our study. A variety of clinical and biochemical variables were recorded from the participants.

RESULTS

Blood-glucose, HbA1c, albumine:creatinine ratio (ACR), duration of diabetes, diabetes treatment, type of diabetes, cholesterol and triglycerides did not significantly differ in women with and without UI in crude analyses. However, the diabetic women with UI had more hospitalizations during the last 12 months, more homecare, and a higher prevalence of angina and use of oestrogene treatment (both local and oral/patch). After adjusting for age, BMI, parity and smoking, there were statistically significant associations between any UI and angina (OR 1.89; 95% CI: 1.22 - 2.93), homecare (OR 1.72; 95% CI: 1.02 - 2.89), and hospitalization during the last 12 months (OR 1.67; 95% CI: 1.18 - 2.38). In adjusted analyses severe UI was also significantly associated with the same variables, and also with diabetes drug treatment (OR 2.10; 95% CI: 1.07 - 4.10) and stroke (OR 2.47; 95% CI: 1.09 - 5.59).

CONCLUSION

No single diabetes related risk factor seems to explain the increased risk for UI among women with diabetes. However, we found associations between UI and some clinical correlates of diabetes.

Protocol for Physiotherapy Or TVT Randomised Efficacy Trial (PORTRET): a multicentre randomised controlled trial to assess the cost-effectiveness of the tension free vaginal tape versus pelvic floor muscle training in women with symptomatic moderate to severe stress urinary incontinence

Background

Stress urinary incontinence is a common condition affecting approximately 20% of adult women causing substantial individual (quality of life) and economic (119 million Euro/year spent on incontinence pads in the Netherlands) burden. Pelvic floor muscle training (PFMT) is regarded as first line treatment, but only 15-25% of women will be completely cured. Approximately 65% will report that their condition improved, but long term adherence to treatment is problematic. In addition, at longer term (2-15 years) follow-up 30-50% of patients will end up having surgery. From 1996 a minimal invasive surgical procedure, the Tension-free Vaginal Tape (TVT) has rapidly become the gold standard in surgical treatment of stress urinary incontinence. With TVT 65-95% of women are cured. However, approximately 3-6% of women will develop symptoms of an overactive bladder, resulting in reduced quality of life. Because of its efficacy the TVT appears to be preferable over PFMT but both treatments and their costs have not been compared head-to-head in a randomised clinical trial.

Methods/Design

A multi-centre randomised controlled trial will be performed for women between 35 - 80 years old with moderate to severe, predominantly stress, urinary incontinence, who have not received specialised PFMT or previous anti-incontinence surgery. Women will be assigned to either PFMT by a specialised physiotherapist for a standard of 9-18 session in a period of 6 months, or TVT(O) surgery. The main endpoint of the study is the subjective improvement of urinary incontinence. As secondary outcome the objective cure will be assessed from history and clinical parameters. Subjective improvement in quality of life will be measured by generic (EQ-5D) and disease-specific (Urinary Distress Inventory and Incontinence Impact Questionnaire) quality of life instruments. The economical endpoint is short term (1 year) incremental cost-effectiveness in terms of costs per additional year free of urinary incontinence and costs per Quality Adjusted Life Years (QALY) gained. Finally, treatment strategy and patient characteristics will be combined in a prediction model, to allow for individual treatment decisions in future patients. Four hundred female patients will be recruited from over 30 hospitals in the Netherlands

Trial registration

Nederlands trial register: NTR 1248

Fecal incontinence in US adults: epidemiology and risk factors

BACKGROUND & AIMS

The study aims were to estimate the prevalence of different types and frequencies of fecal incontinence (FI), describe demographic factors, and identify risk factors.

METHODS

The National Health and Nutrition Examination Survey (NHANES) assesses health status in the civilian noninstitutionalized US population. The validated Fecal Incontinence Severity Index was added to NHANES in 2005-2006. Participants were 2229 women and 2079 men aged 20 years or older. FI was defined as accidental leakage of solid, liquid, or mucus at least once in the preceding month. Sampling weights were used to obtain prevalence estimates for the national population. Multivariate logistic regression identified independent risk factors.

RESULTS

The estimated prevalence of FI in noninstitutionalized US adults is 8.3% (95% confidence interval, 7.1-9.5) and consists of liquid stool in 6.2%, solid stool in 1.6%, and mucus in 3.1%. It occurs at least weekly in 2.7%. Prevalence is similar in women (8.9%) and men (7.7%) and increases with age from 2.6% in 20 to 29 year olds up to 15.3% in participants aged 70 years and older. FI is not significantly associated with race/ethnicity, education, income, or marital status after adjusting for age. Independent risk factors in women are advancing age, loose or watery stools, more than 21 stools per week, multiple chronic illnesses, and urinary incontinence. Independent risk factors in men are age, loose or watery stools, poor self-rated health, and urinary incontinence.

CONCLUSIONS

FI is a prevalent age-related disorder. Chronic diarrhea is a strong modifiable risk factor that may form the basis for prevention and treatment.

Diversity of Urinary Symptoms in Patients Tentatively Diagnosed with Benign Prostatic Hyperplasia Referred to a Urologic Clinic in Norway

OBJECTIVE

Lower urinary tract symptoms (LUTS) has become the preferred term used to classify the urinary symptoms of elderly men. This term places more emphasis on clinical appearance rather than being restricted to the functional pathophysiology. The objective of this study was to investigate this new concept in a group of patients who had been tentatively diagnosed with benign prostatic hyperplasia (BPH). The range of urinary symptoms, incontinence, sexual function and impact on daily living were registered.

MATERIAL AND METHODS

Data from a group of 480 men awaiting urologic assessment were collected by questionnaire shortly after referral from their general practitioner between 1997 and 2000. The questionnaires used were the International Prostate Symptom Score (IPSS), the Symptom Problem Index, the International Continence Society-BPH, the Sandvik Incontinence Severity Index and the BPH-specific Interference with Activities.

RESULTS

The mean age of the subjects was 67.0 years. As assessed by the IPSS, 15%, 54% and 31% of the men had mild, moderate and severe symptoms, respectively. Men who gave positive answers to questions regarding the frequency, amount and type of leakage were considered to have urinary incontinence (UI), which was found in 37% of cases. The majority of men had mild or moderate UI. Influence on daily living varied with the severity of symptoms. However, no significant differences in influence on daily living were found between groups with different degrees of severity of incontinence as all groups reported a relatively high impact.

CONCLUSIONS

Our results show that UI is fairly common, very bothersome and socially embarrassing in male LUTS patients waiting for urologic evaluation. Although UI is not typically associated with BPH and is not regarded as a crucial component of LUTS, this study indicates that more emphasis should be placed on UI in the terminology of LUTS. UI may also act as an indicator of a need for healthcare.

Mechanisms of pelvic floor muscle function and the effect on the urethra during a cough

BACKGROUND

Current measurement tools have difficulty identifying the automatic physiologic processes maintaining continence, and many questions still remain about pelvic floor muscle (PFM) function during automatic events.

OBJECTIVE

To perform a feasibility study to characterise the displacement, velocity, and acceleration of the PFM and the urethra during a cough.

DESIGN, SETTING, AND PARTICIPANTS

A volunteer convenience sample of 23 continent women and 9 women with stress urinary incontinence (SUI) from the general community of San Francisco Bay Area was studied.

MEASUREMENTS

Methods included perineal ultrasound imaging, motion tracking of the urogenital structures, and digital vaginal examination. Statistical analysis used one-tailed unpaired student t tests, and Welch's correction was applied when variances were unequal.

RESULTS AND LIMITATIONS

The cough reflex activated the PFM of continent women to compress the urogenital structures towards the pubic symphysis, which was absent in women with SUI. The maximum accelerations that acted on the PFM during a cough were generally more similar than the velocities and displacements. The urethras of women with SUI were exposed to uncontrolled transverse acceleration and were displaced more than twice as far (p=0.0002), with almost twice the velocity (p=0.0015) of the urethras of continent women. Caution regarding the generalisability of this study is warranted due to the small number of women in the SUI group and the significant difference in parity between groups.

CONCLUSIONS

During a cough, normal PFM function produces timely compression of the pelvic floor and additional external support to the urethra, reducing displacement, velocity, and acceleration. In women with SUI, who have weaker urethral attachments, this shortening contraction does not occur; consequently, the urethras of women with SUI move further and faster for a longer duration.

Mixed urinary incontinence: greater impact on quality of life

PURPOSE

We compared the impact of mixed, stress and urge urinary incontinence on quality of life in middle-aged or older women.

MATERIALS AND METHODS

We analyzed cross-sectional data from a population based cohort of 2,109 ethnically diverse middle-aged or older women. Among participants reporting weekly incontinence, clinical type of incontinence was assessed by self-reported questionnaires and disease specific quality of life impact was evaluated using the Incontinence Impact Questionnaire. Multivariable logistic regression was used to compare the odds of greater quality of life impact from incontinence, defined as an Incontinence Impact Questionnaire score in the 75th percentile or greater in women with stress, urge and mixed incontinence.

RESULTS

More than 28% (598) of women reported weekly incontinence, including 37% with stress, 31% with urge and 21% with mixed incontinence. Unadjusted Incontinence Impact Questionnaire scores were higher for women with mixed vs urge or stress incontinence (median score 29 vs 17 and 13, respectively, p <0.01). Adjusting for age, race/ethnicity, health status and clinical incontinence severity, women with mixed incontinence were more likely to report a greater overall quality of life impact compared to those with stress incontinence (OR 2.5, 95% CI 1.4-4.3), as well as a greater specific impact on travel (OR 2.2, 95% CI 1.3-3.7) and emotional (OR 1.8, 95% CI 1.0-3.4) Incontinence Impact Questionnaire domains. The overall impact of urge incontinence did not differ significantly from that of stress (urge vs stress OR 1.6, 95% CI 0.9-2.7) or mixed incontinence (mixed vs urge OR 1.6, 95% CI 0.9-2.8) in adjusted models.

CONCLUSIONS

In middle-aged or older women mixed incontinence is associated with a greater quality of life impact than stress incontinence independent of age, race, health or incontinence severity. Identification of women with mixed incontinence symptoms may be helpful in discovering which women are most likely to experience functional limitations and decreased well-being from incontinence.

Influence of maternal weight on the new onset of stress urinary incontinence in pregnant women

INTRODUCTION AND HYPOTHESIS

The aim of the study was to investigate the incidence and severity of stress urinary incontinence (SUI) in primigravid women at term and its association with maternal body weight.

METHODS

This was an observational study of 458 primigravid women who came to give birth at Donostia Hospital during 2007. Urinary symptoms were investigated (2002 ICS definitions), and a physical examination including height, weight, pelvic floor muscle strength, and fetal presentation was performed. We calculated the incontinence severity index (ISI) and the women answered the International Consultation on Incontinence short form questionnaire.

RESULTS

SUI affected 139 (30.3%) primigravid women. The ISI distribution was 40.3% slight, 54.7% moderate, 4.3% severe, and 0.7% very severe. Pregnant women at term with body weight >or=75 kg appear to have more than doubled the risk of presenting SUI.

CONCLUSIONS

The incidence of SUI is high in pregnancy. Increased maternal body weight at term is an independent risk factor for incontinence.

The minimum important differences for the urinary scales of the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire

OBJECTIVE

We sought to estimate the minimum important difference (MID) for the Urinary Distress Inventory (UDI), UDI-stress subscale of the Pelvic Floor Distress Inventory, and Urinary Impact Questionnaire (UIQ) of the Pelvic Floor Impact Questionnaire.

STUDY DESIGN

We calculated MID using anchor- and distribution-based approaches from a randomized trial for nonsurgical stress incontinence treatment. Anchors included a global impression of change, incontinence episodes from a urinary diary, and the Incontinence Severity Index. Effect size and standard error of measurement were the distribution methods used.

RESULTS

Anchor-based MIDs ranged from -22.4 to -6.4 points for the UDI, -16.5 to -4.6 points for the UDI-stress, and -17.0 to -6.5 points for the UIQ. These data were supported by 2 distribution-based estimates.

CONCLUSION

Reasonable estimates of MID are 11, 8, and 16 points for the UDI, UDI-stress subscale, and UIQ, respectively. Statistically significant improvements that meet these thresholds should be considered clinically important.

Fecal incontinence in obese women with urinary incontinence: prevalence and role of dietary fiber intake

OBJECTIVE

This study estimates the prevalence of fecal incontinence (FI) in overweight and obese women with urinary incontinence and compares dietary intake in women with and without FI.

STUDY DESIGN

A total of 336 incontinent and overweight women in the Program to Reduce Incontinence by Diet and Exercise clinical trial were included. FI was defined as monthly or greater loss of mucus, liquid, or solid stool. Dietary intake was quantified using the Block Food Frequency Questionnaire.

RESULTS

Women had a mean (+/- SD) age of 53 +/- 10 years, body mass index of 36 +/- 6 kg/m(2), and 19% were African American. Prevalence of FI was 16% (n = 55). In multivariable analyses, FI was independently associated with low fiber intake, higher depressive symptoms, and increased urinary tract symptoms (all P < .05).

CONCLUSION

Overweight and obese women report a high prevalence of monthly FI associated with low dietary fiber intake. Increasing dietary fiber may be a treatment for FI.

The Ontario Mother and Infant Study (TOMIS) III: a multi-site cohort study of the impact of delivery method on health, service use, and costs of care in the first postpartum year

BACKGROUND

The caesarean section rate continues to rise globally. A caesarean section is inarguably the preferred method of delivery when there is good evidence that a vaginal delivery may unduly risk the health of a woman or her infant. Any decisions about delivery method in the absence of clear medical indication should be based on knowledge of outcomes associated with different childbirth methods. However, there is lack of sold evidence of the short-term and long-term risks and benefits of a planned caesarean delivery compared to a planned vaginal delivery. It also is important to consider the economic aspects of caesarean sections, but very little attention has been given to health care system costs that take into account services used by women for themselves and their infants following hospital discharge.

METHODS AND DESIGN

The Ontario Mother and Infant Study III is a prospective cohort study to examine relationships between method of delivery and maternal and infant health, service utilization, and cost of care at three time points during the year following postpartum hospital discharge. Over 2500 women were recruited from 11 hospitals across the province of Ontario, Canada, with data collection occurring between April 2006 and October 2008. Participants completed a self-report questionnaire in hospital and structured telephone interviews at 6 weeks, 6 months, and 12 months after discharge. Data will be analyzed using generalized estimating equation, a special generalized linear models technique. A qualitative descriptive component supplements the survey approach, with the goal of assisting in interpretation of data and providing explanations for trends in the findings.

DISCUSSION

The findings can be incorporated into patient counselling and discussions about the advantages and disadvantages of different delivery methods, potentially leading to changes in preferences and practices. In addition, the findings will be useful to hospital- and community-based postpartum care providers, managers, and administrators in guiding risk assessment and early intervention strategies. Finally, the research findings can provide the basis for policy modification and implementation strategies to improve outcomes and reduce costs of care.

Sexual function among overweight and obese women with urinary incontinence in a randomized controlled trial of an intensive behavioral weight loss intervention

PURPOSE

We examined sexual function in overweight and obese women with urinary incontinence, and evaluated the effects of an intensive behavioral weight reduction intervention on sexual function in this population.

MATERIALS AND METHODS

A total of 338 overweight and obese women reporting 10 or more incontinence episodes weekly were randomized to an intensive behavioral change (226) or structured education program (112) for 6 months. Sexual function was assessed using self-administered questionnaires. Multivariate regression was used to examine factors associated with baseline and 6-month change in sexual function as well as intervention effects.

RESULTS

Two-thirds of participants (233) were sexually active at baseline but more than half (188) reported low desire and a quarter (91) were sexually dissatisfied. More than half of sexually active participants (123) reported problems with arousal, lubrication, orgasm or incontinence during sex. Compared to controls women in the intervention group demonstrated a borderline increase in frequency of sexual activity at 6 months (OR 1.34, 95% CI 0.99-1.81, p = 0.06) but no differences in satisfaction (OR 1.28, 95% CI 0.83-1.99, p = 0.26), desire (OR 1.12, 95% CI 0.79-1.61, p = 0.52) or problems (beta +/- SE 0.03 +/- 0.07, p = 0.68 for intervention effects on problems score). Neither clinical incontinence severity nor body mass index was independently associated with baseline or 6-month change in function (p >0.10 for all).

CONCLUSIONS

Sexual dysfunction is common in overweight and obese women with incontinence but the severity of this dysfunction may not be directly related to the severity of incontinence or obesity. An intensive 6-month behavioral weight reduction intervention did not significantly improve sexual function in this population relative to controls.