Periurethral injection therapy for urinary incontinence in women

Effect of conservative treatment of pelvic floor dysfunctions in women: An umbrella review

OBJECTIVE

Due to their high worldwide prevalence, pelvic floor dysfunctions (PFD's) are a public health problem. There is high heterogeneity in the types and effectiveness of conservative treatment. The objective was to analyze the scientific evidence on conservative treatment of PFDs in women.

METHODS

Umbrella review, covering MEDLINE (1950-2019), Scopus (1960-2019), Web of Science (1980-2019), and Cochrane Library (2000-2019). Inclusion criterion: review on conservative treatments about pelvic floor disorders in the adult women, in Spanish or English; exclusion criterion: studies about other urological, gynecological, and coloproctological pathologies, among others.

RESULTS

Thirty-two reviews (2000-2019) and 12 meta-analyses were included. 53.1% showed an improvement on urinary incontinence. Pelvic floor muscle training worked on 70.6% of them, followed by electrical stimulation and estrogen (11.7%), and weight loss (5.9%). 6.3% of reviews and meta-analyses fulfilled all items in PRISMA, and 93.7% of them fulfilled more than 60% of the checklist. 60% de los ítems.

CONCLUSIONS

PFMT and weight loss are the most effective treatments for UI, but there is no evidence for other PFDs. The methodological quality of conservative treatments must be improved for a more effective treatment of PFDs in women. Pelvic floor muscle training and weight loss are the most effective treatments for urinary incontinence. Only 6.3% of the reviews fulfilled all PRISMA ítems.

Deflux® (NASHATM/Dx) urethral bulking injections: Outcomes over a decade in women with stress urinary incontinence

Objectives:

Urethral bulking injections are thought to be a low risk minimally invasive but temporary treatment option for women with stress urinary incontinence (SUI) with increasing prominence especially in the current era of the mesh controversy. However, little is known about their long-term effects. This study aims to evaluate the efficacy and long-term outcomes of Deflux®, a non-animal stabilised hyaluronic acid/dextranomer (NASHATM/Dx) gel, when used as a urethral bulking agent in the treatment of SUI in women.

Methods:

All women with SUI treated with Deflux® from 2001 to 2007 were analysed. The success rates, duration of efficacy and short- and long-term complications of the treatment were recorded.

Results:

A total of 142 women with a follow-up of up to 13 years (mean 8.8 years) were included. Subjective treatment success was achieved in 92/142 (65%) patients. In those who achieved continence, the mean efficacy was 4.7 years. Side effects were uncommon with 12 (6%) of 209 experiencing transient urinary retention and 11 (5%) of 209 experiencing pseudocyst formation. All pseudocysts were treated successfully with an incision and drainage under either general or local anaesthetic. Sixty (42%) of 142 patients went on to have subsequent definitive incontinence surgery, and Deflux® treatment was found not to have negatively impacted the operation.

Conclusion:

Deflux® urethral bulking injections appear to be efficacious and safe when used as a treatment for SUI in women with a longer duration of efficacy than previously thought and a low side effect profile. This study provides a valuable timeline to help manage the expectations of patients considering urethral bulking treatment.

Level of evidence:

4

Underactive Bladder and Bladder Outlet Procedures in Women

Purpose of review

This review outlines current options for women suffering from both stress urinary incontinence (SUI) and underactive bladder (UAB). This is often a challenging patient population; however, many treatment options are available including behavioral, pharmacologic, and surgical. Therapies can be divided into those specifically targeting either the bladder or the bladder outlet.

Recent findings

For patients with SUI and UAB, several clinical trials have helped to formulate current guidelines. Also, a number of novel techniques and therapeutic agents are currently under investigation. Current surgical treatments frequently employed for SUI include midurethral slings and urethral bulking agents. In contrast, the current treatments for UAB are limited to either sacral neuromodulation in women with Fowlers syndrome or in the majority, clean intermittent catheterization. Recent studies have investigated the use of adjustable urethral slings and novel modes of neuromodulation with varying degrees of success.

Summary

Choosing the best treatment plan for SUI combined with UAB involves a thorough understanding of a patient's preferences and goals. Fortunately, women have many options that can significantly benefit their quality of life.

An animal experimental study on pubourethral ligament restoration with platelet rich plasma for the treatment of stress urinary incontinence

Introduction

Minimally invasive methods for injured ligament and tendon restoration have been developed and gained popularity in recent years. Injury and relaxation of the pubourethral ligament (PUL) can lead to stress urinary incontinence (SUI). The aim of this study was to investigate the impact of injecting platelet rich plasma (PRP) into the PUL following its surgical transection resulting in SUI, confirmed by leak point pressure (LPP) measurements pre- and post-intervention in an experimental animal model.

Material and methods

Twenty female adult Sprague-Dawley rats were assigned in 2 groups: 1) treatment group with transection of the PUL and application of PRP at the time of transection and at one month follow-up and 2) a control group, with transection of the PUL only. Leak point pressures (LPPs) were measured prior to transection, immediately following the transection and at 1 and 2 months in both groups.

Results

The median LPPs for the control group were: LPP – preT: 35.6 (29.8–44.8) cmH₂O, LPP – postT: 14.6 (5.8–19.0) cmH₂O, LPP – 1 month: 27.3 (19.2–33.8) cmH₂O, LPP – 2 months: 29.0 (27.0–34.0) cmH₂O, whereas for the PRP group were: LPP-preT: 40.5 (33.2–46.3) cmH₂O, LPP – postT: 15.7 (3.0–24.0) cmH₂O, LPP – 1month: 31.6 (24.8–37.4) cmH₂O, LPP – 2 months: 36.8 (32.5–45.4) cmH₂O. PRP injections on transected PULs significantly increased LPPs at one month follow-up [31.6 cmH₂O vs. 27.3 cmH₂O, p = .043]. This effect was confirmed at two months [36.8 cmH₂O vs. 29.0 cmH₂O, p <.001].

Conclusions

Injection of PRP into transected PULs significantly improved LPPs at one and two months' follow-up. However, further experimental and clinical research is needed to evaluate the safety and efficacy of this treatment, in clinical practice.

Prevention of polydimethylsiloxane microsphere migration using a mussel-inspired polydopamine coating for potential application in injection therapy

The use of injectable bulking agents is a feasible alternative procedure for conventional surgical therapy. In this study, poly(dimethylsiloxane) (PDMS) microspheres coated with polydopamine (PDA) were developed as a potential injection agent to prevent migration in vocal fold. Uniform PDMS microspheres are fabricated using a simple fluidic device and then coated with PDA. Cell attachment test reveals that the PDA-coated PDMS (PDA-PDMS) substrate favors cell adhesion and attachment. The injected PDA-PDMS microspheres persist without migration on reconstructed axial CT images, whereas, pristine PDMS locally migrates over a period of 12 weeks. The gross appearance of the implants retrieved at 4, 8, 12 and 34 weeks indicates that the PDA-PDMS group maintained their original position without significant migration until 34 weeks after injection. By contrast, there is diffuse local migration of the pristine PDMS group from 4 weeks after injection. The PDA-coated PDMS microspheres can potentially be used as easily injectable, non-absorbable filler without migration.

Anterior vaginal repair for urinary incontinence in women

BACKGROUND

Anterior vaginal repair (anterior colporrhaphy) is an operation traditionally used for moderate or severe stress urinary incontinence (SUI) in women. About a third of adult women experience urinary incontinence. SUI imposes significant health and economic burden to the society and the women affected.

OBJECTIVES

To determine the effects of anterior vaginal repair (anterior colporrhaphy) on urinary incontinence in comparison with other management options.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 1 September 2009) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included anterior vaginal repair for the treatment of urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed trial quality. Three trial investigators were contacted for additional information.

MAIN RESULTS

Ten trials were identified which included 385 women having an anterior vaginal repair and 627 who received comparison interventions.A single small trial provided insufficient evidence to assess anterior vaginal repair in comparison with physical therapy. The performance of anterior repair in comparison with bladder neck needle suspension appeared similar (risk ratio (RR) for failure after one year 1.16, 95% confidence interval (CI) 0.86 to 1.56), but clinically important differences could not be confidently ruled out. No trials compared anterior repair with suburethral sling operations or laparoscopic colposuspensions, or compared alternative vaginal operations.Anterior vaginal repair was less effective than open abdominal retropubic suspension based on patient-reported cure rates in eight trials both in the medium term (failure rate within one to five years after anterior repair 97/259 (38%) versus 57/327 (17%); RR 2.29, 95% confidence Interval (CI) 1.70 to 3.08) and in the long term (after five years, (49/128 (38%) versus 31/145 (21%); RR 2.02, 95% CI 1.36 to 3.01). There was evidence from three of these trials that this was reflected in a need for more repeat operations for incontinence (25/107 (23%) versus 4/164 (2%); RR 8.87, 95% CI 3.28 to 23.94). These findings held, irrespective of the co-existence of prolapse (pelvic relaxation). Although fewer women had a prolapse after anterior repair (RR 0.24, 95% CI 0.12 to 0.47), later prolapse operation appeared to be equally common after vaginal (3%) or abdominal (4%) operation.In respect of the type of open abdominal retropubic suspension, most data related to comparisons of anterior vaginal repair with Burch colposuspension. The few data describing comparison of anterior repair with the Marshall-Marchetti-Krantz procedure were consistent with those for Burch colposuspension.

AUTHORS' CONCLUSIONS

There were not enough data to allow comparison of anterior vaginal repair with physical therapy or needle suspension for primary urinary stress incontinence in women. Open abdominal retropubic suspension appeared to be better than anterior vaginal repair judged on subjective cure rates in eight trials, even in women who had prolapse in addition to stress incontinence (six trials). The need for repeat incontinence surgery was also less after the abdominal operation. However, there was not enough information about postoperative complications and morbidity.A Brief Economic Commentary (BEC) identified one study suggesting that vaginoplasty may be more cost-effective compared with tension-free vaginal tape (TVT-O).

Laparoscopic colposuspension for urinary incontinence in women

BACKGROUND

Stress urinary incontinence (SUI) imposes significant health and economic burden on society and the women affected. Laparoscopic colposuspension was one of the first minimal access operations for the treatment of women with SUI, with the presumed advantages of avoiding major incisions, shorter hospital stays and quicker return to normal activities.

OBJECTIVES

To determine the effects of laparoscopic colposuspension for urinary incontinence in women.

SEARCH METHODS

We searched the Cochrane Incontinence Group Trials Register (searched 2 July 2009), and sought additional trials from other sources and by contacting study authors for unpublished data and trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptomatic or urodynamic diagnosis of stress or mixed incontinence that included laparoscopic surgery as the intervention in at least one arm of the studies.

DATA COLLECTION AND ANALYSIS

The review authors evaluated trials for methodological quality and their appropriateness for inclusion in the review. Two review authors extracted data and another cross checked them. Where appropriate, we calculated a summary statistic.

MAIN RESULTS

We identified 22 eligible trials. Ten involved the comparison of laparoscopic with open colposuspension. Whilst the women's subjective impression of cure seemed similar for both procedures, in the short- and medium-term follow-up, there was some evidence of poorer results of laparoscopic colposuspension on objective outcomes. The results showed trends towards fewer perioperative complications, less postoperative pain and shorter hospital stay for laparoscopic compared with open colposuspension, however, laparoscopic colposuspension was more costly.Eight studies compared laparoscopic colposuspension with newer 'self-fixing' vaginal slings. There were no significant differences in the reported short- and long-term subjective cure rates of the two procedures but objective cure rates at 18 months favoured slings. We observed no significant differences for postoperative voiding dysfunction and perioperative complications. Laparoscopic colposuspension had a significantly longer operation time and hospital stay. We found significantly higher subjective and objective one-year cure rates for women randomised to two paravaginal sutures compared with one suture in a single trial. Three studies compared sutures with mesh and staples for laparoscopic colposuspension and showed a trend towards favouring the use of sutures.

AUTHORS' CONCLUSIONS

Currently available evidence suggests that laparoscopic colposuspension may be as good as open colposuspension at two years post surgery. However, the newer vaginal sling procedures appear to offer even greater benefits, better objective outcomes in the short term and similar subjective outcomes in the longer term. If laparoscopic colposuspension is performed, the use of two paravaginal sutures appears to be the most effective method. The place of laparoscopic colposuspension in clinical practice should become clearer when there are more data available describing long-term results. A brief economic commentary (BEC) identified three studies suggesting that tension-free vaginal tape (TVT) may be more cost-effective compared with laparoscopic colposuspension but laparoscopic colposuspension may be slightly more cost-effective when compared with open colposuspension after 24 months follow-up.

Traditional suburethral sling operations for urinary incontinence in women

BACKGROUND

Stress urinary incontinence constitutes a significant health and economic burden to society. Traditional suburethral slings are one of the surgical operations used to treat women with symptoms of stress urinary incontinence.

OBJECTIVES

To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence.

DATA COLLECTION AND ANALYSIS

At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, we calculated a summary statistic: a relative risk for dichotomous data and a weighted mean difference for continuous data.

MAIN RESULTS

We included 26 trials involving 2284 women. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6 to 24 months.One medium-sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of women with mixed urinary incontinence. Surgery appeared to be more effective than drugs in treating participant-reported incontinence (n = 75, risk ratio (RR) 0.18, 95% confidence interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21, 95% CI 0.09 to 0.21)Seven trials compared slings with open abdominal retropubic colposuspension. Participant-reported incontinence was lower with the slings after one year (RR 0.75, 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long-term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve trials addressed the comparison between traditional sling operations and minimally invasive sling operations. These seemed to be equally effective in the short term (RR for incontinence within first year 0.97, 95% CI 0.78 to 1.20) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Participant-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45, 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Gore-Tex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting participant characteristics.For most of the comparisons, clinically important differences could not be ruled out.

AUTHORS' CONCLUSIONS

Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long-term adverse event profile is still unclear. A brief economic commentary (BEC) identified two studies suggesting that traditional slings may be more cost-effective compared with collagen injection but not cost-effective when compared with minimally invasive sling operations. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.

Urethral injection therapy for urinary incontinence in women

BACKGROUND

Urinary incontinence imposes a significant health and economic burden to society. Periurethral or transurethral injection of bulking agents is a minimally invasive surgical procedure used as one the surgical treatments of stress urinary incontinence (SUI) in adult women.

OBJECTIVES

To assess the effects of periurethral or transurethral injection therapy on the cure or improvement of urinary incontinence in women.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Trials Register (searched 8 November 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of treatment for urinary incontinence in which at least one management arm involved periurethral or transurethral injection therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed methodological quality of each study using explicit criteria. Data extraction was undertaken independently and clarification concerning possible unreported data sought directly from the investigators.

MAIN RESULTS

Excluding duplicate reports, we identified 14 trials (excluding one that was subsequently withdrawn from publication and not included in this analysis) including 2004 women that met the inclusion criteria. The limited data available were not suitable for meta-analysis because they all came from separate trials. Trials were small and generally of moderate quality.One trial of 45 women that compared injection therapy with conservative treatment showed early benefit for the injectable therapy with respect to continence grade (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.52 to 0.94) and quality of life (mean difference (MD) 0.54, 95% CI 0.16 to 0.92). Another trial, comparing Injection of autologous fat with placebo, terminated early because of safety concerns. Two trials that compared injection with surgical management found significantly better objective cure in the surgical group (RR 4.77, 95% CI 1.96 to 11.64; and RR 1.69, 95% CI 1.02 to 2.79), although the latter trial data did not reach statistical significance if an intention-to-treat analysis was used.Eight trials compared different agents and all results had wide confidence intervals. Silicone particles, calcium hydroxylapatite, ethylene vinyl alcohol, carbon spheres and dextranomer hyaluronic acid combination gave improvements which were not shown to be more or less efficacious than collagen. Dextranomer hyaluronic acid compound treated patients appeared to have significantly higher rates of injection site complications (16% with the hyaluronic acid compound versus none with collagen; RR 37.78, 95% CI 2.34 to 610.12) and this product has now been withdrawn from the market.A comparison of periurethral and transurethral methods of injection found similar outcomes but a higher (though not statistically significant) rate of early complications in the periurethral group. One trial of 30 women showed a weak (but not clinically significant) advantage for patient satisfaction (data not suitable for analysis in RevMan) after mid-urethral injection in comparison to bladder neck injection but with no demonstrable difference in continence levels.

AUTHORS' CONCLUSIONS

The available evidence base remains insufficient to guide practice. In addition, the finding that placebo saline injection was followed by a similar symptomatic improvement to bulking agent injection raises questions about the mechanism of any beneficial effects. One small trial comparing silicone particles with pelvic floor muscle training was suggestive of benefit at three months but it is not known if this was sustained, and the treatment was associated with high levels of postoperative retention and dysuria. Greater symptomatic improvement was observed with surgical treatments, though the advantages need to be set against likely higher risks. No clear-cut conclusions could be drawn from trials comparing alternative agents, although dextranomer hyaluronic acid was associated with more local side effects and is no longer commercially available for this indication. There is insufficient evidence to show superiority of mid-urethral or bladder neck injection. The single trial of autologous fat provides a reminder that periurethral injections can occasionally cause serious side effects. Also, a Brief Economic Commentary (BEC) identified three studies suggesting that urethral bulking agent might be more cost-effective compared with retropubic mid-urethral slings, transobturator or traditional sling procedure when used as an initial treatment in women without hypermobility or as a follow-up to surgery failure provided injection is kept minimal. However, urethral bulking agent might not be cost-effective when compared with traditional sling as an initial treatment of SUI when a patient is followed up for a longer period (15 months post-surgery).

Para-Urethral Injections with Urolastic® for Treatment of Female Stress Urinary Incontinence: Subjective Improvement and Safety

INTRODUCTION

Female stress urinary incontinence (SUI) is often treated surgically. Urethral bulking agents are a minimally invasive alternative, especially in patients suffering from intrinsic sphincter deficiency, but often with limited long-term efficacy. Urolastic® is a non-deformable, non-resorbable silicone elastomer that is used as an injectable. Its properties might result in a more durable response after injection. If this durability factor can be combined with a low complication rate, this can become a useful treatment option. We therefore assessed the subjective improvement and safety after treatment with Urolastic®.

MATERIALS AND METHODS

In 2 Dutch hospitals, 65 patients were treated with Urolastic®. The subjective improvement was assessed and the medical charts were reviewed for complications that appeared during the follow-up period. The complications were classified using the Clavien-Dindo classification.

RESULTS

We found that 76-88% of the patients showed subjective improvement at 12-25 months follow-up. The rate of improvement experienced was 50-70%. The rate of complications classified as Clavien-Dindo >II was 24-33%. The 12 patients with 75-100% subjective improvement after 2 months, showed 85% improvement after a median of 25 months.

CONCLUSIONS

With careful patient selection, Urolastic® seems to be a safe, durable and effective treatment option for female SUI.

Surgical Management of Female Voiding Dysfunction

Surgical intervention for female voiding dysfunction is common, involving a single or multifaceted approach affecting multiple organ systems in the pelvis. Surgical success relies on knowledge of surgical history, anatomic approaches, and judicious use of supports or materials. Owing to the varied repairs used over the last few decades, it is important for the general surgeon to understand both current and historic approaches. This understanding will help in planning future pelvic surgery as well as in evaluating current ramifications of prior surgery.

Collagenoma and voiding dysfunction as complications of periurethral bulking

Peri-urethral bulking agents are used as a management option for selected patients with stress urinary incontinence (SUI). We present a case of urinary retention and a large firm para-urethral vaginal mass as a complication of peri-urethral collagen injections 3 years before presentation. The patient was managed successfully with complete surgical resection of the mass. Subsequent recurrent SUI was managed using a rectus fascial sling.

Injectable treatments for female stress urinary incontinence

The use of injectable agents for the treatment of stress urinary incontinence (SUI) is an option for female patients who are unwilling to undergo surgery, or have concurrent conditions or diseases that render surgical treatment unsuitable. To be effective for SUI, an injectable agent must be nonimmunogenic, hypoallergenic, biocompatible, permanent, nonerosive, nonmigratory and painless. It must also heal with minimal fibrosis, possess a long-term bulking effect, and be easily stored and handled. Glutaraldehyde cross-linked bovine collagen (Contigen), silicone polymers (Macroplastique), Durasphere, calcium hydroxyapatite (Coaptite), polyacrylamide hydrogel (Aquamid, Bulkamid), Permacol, and stem cell therapy have been used as injectable agents. Patients must be informed that treatment with injectable agents is not as effective as surgical treatment, and that such agents might necessitate additional and repeated administrations in order to achieve the desired therapeutic effect.

Internal anal sphincter augmentation and substitution

There is an increasing recognition of the importance of internal anal sphincter (IAS) dysfunction presenting as passive faecal incontinence. This problem may manifest after anal sphincterotomy or following the more minimally invasive operations for haemorrhoids, as well as with advancing age. Because of the poor results of IAS plication and the beneficial outcomes with peri-urethral bulking agents in urology, these materials have been developed for use in IAS dysfunction. This review outlines the basic purported mechanisms of action, defining the materials in clinical use, their methods of deployment, complications and reported outcomes. There is still much that is unknown concerning the ideal agent or the volume and the technique of deployment, which will only be answered by powerful, prospective, randomized, controlled trials. The specific role of autologous stem cells designed to regenerate the sphincters in cases of functional impairment or muscle loss is yet to be seen.

Infusion therapy and implantables for the urologist

The specialty of urology has historically adapted to the changing health care environment. Urologists have been quick to adopt new technology, new therapeutics, and devices to render state-of-the-art patient care with improved clinical outcomes. The busy urology practice is now in the position to deliver many novel and unique therapies across multiple disease states. As a result, clinicians can provide state-of-the-art care in a clinic setting and potentially reduce the overall costs of health care delivery. This article reviews some of these potential new opportunities available to the practicing urologist.

Development of quality indicators for women with urinary incontinence

AIMS

To develop a means to measure the quality of care provided to women treated for urinary incontinence (UI) through the development of quality-of-care indicators (QIs).

METHODS

We performed an extensive literature review to develop a set of potential quality indicators for the management of UI. QIs were modeled after those previously described in the Assessing the Care of Vulnerable Elders (ACOVE) project. Nine experts ranked the indicators on a nine-point scale for both validity and feasibility. We analyzed preliminary rankings of each indicator using the RAND Appropriateness Method. A forum was then held in which each indicator was thoroughly discussed by the panelists as a group, after which the indicators were rated a second time individually using the same nine-point scale.

RESULTS

QIs were developed that addressed screening, diagnosis, work-up, and both non-surgical and surgical management. Areas of controversy included whether routine screening for incontinence should be performed, whether urodynamics should be performed before non-surgical management is initiated, and whether cystoscopy should be part of the pre-operative work-up of uncomplicated stress incontinence. Following the expert panel discussion, 27 of 40 potential indicators were determined to be valid for UI with a median score of at least seven on a nine-point scale.

CONCLUSIONS

We identified 27 quality indicators for the care of women with UI. Once these QIs are pilot-tested for feasibility, they will be applied on a larger scale to measure the quality of care provided to women with UI in the United States.

Long-term outcomes after stress urinary incontinence surgery

OBJECTIVES

To compare the long-term risk of repeat stress urinary incontinence (SUI) surgery after different types of initial SUI surgery and to identify predictors of time to repeat SUI surgery in a large, population-based cohort.

METHODS

We used de-identified, adjudicated health care claims data from approximately 100 employer-based plans across the United States from 2000 to 2009. We identified the index SUI surgery in women aged 18 to 64 years. Kaplan-Meier survival curves were used to estimate cumulative incidence of repeat surgery through 9 years. Cox proportional hazards models were used to estimate the adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for factors associated with recurrent SUI surgery.

RESULTS

Over 10 years, we identified 155,458 eligible women who underwent one or more SUI surgeries, with a total of 294,855 person-years of follow-up. Of these index surgeries, 127,848 (82.2%) were slings. The 9-year cumulative incidence of repeat surgery after any SUI surgery was 14.5% (95% CI 13.4-15.5). As expected, bulking agents had the highest cumulative incidence of repeat surgery (61.2%, 95% CI 56.3-66.0) followed by needle suspension (22.2%, 95% CI 16.5-27.9); the lowest 9-year incidences were for Burch (10.8%, 95% CI 9.3-12.3) and sling (13.0%, 95% CI 11.7-14.3). In a Cox proportional hazards model that adjusted for age, year of index surgery, and region of the United States, the rate of repeat surgery was 28% higher for slings compared with Burch (adjusted HR 1.28, 95% CI 1.19-1.37).

CONCLUSION

In this population-based analysis of women aged 18 to 64 years, Burch procedures had the lowest 9-year cumulative incidence of repeat SUI surgery.

Two-year follow-up of an open-label multicenter study of polyacrylamide hydrogel (Bulkamid®) for female stress and stress-predominant mixed incontinence

INTRODUCTION AND HYPOTHESIS

Polyacrylamide hydrogel (PAHG, Bulkamid®) is a promising urethral bulking agent. This article presents the 2-year follow-up results of a multicenter study of PAHG injections for treating stress and stress-predominant mixed urinary incontinence.

METHODS

Submucosal injection of PAHG was performed in 135 women with urinary incontinence, with subjective and objective assessment of the efficacy and safety 24 months postinjection.

RESULTS

At 24 months, the subjective responder rate was 64 % (a statistically non-significant reduction from 67 % at 12 months). The decreased number of incontinence episodes and urine leakage were maintained compared with the result from the 12-month evaluations, as were objective result rates and quality of life data. No safety issues occurred.

CONCLUSIONS

PAHG is an effective and safe treatment option for women with stress-predominant mixed urinary incontinence, with maintained medium-term responder rates.

Urethral bulking: a urology perspective

Urethral bulking therapy (UBT) is a minimally invasive procedure for stress urinary incontinence that is beneficial for properly selected patients. Many different materials are available for UBT, although none fulfill all the qualities of an ideal agent. In general, short-term clinical results are encouraging; however, over longer follow-up, results are disappointing and retreatment is often necessary. Proper patient selection and management of patient expectations are paramount to successful application of UBT.

What do we do when a midurethral tape fails? Rediscovery of open colposuspension as a salvage continence operation

INTRODUCTION AND HYPOTHESIS

Our aim was to evaluate the outcome of open colposuspension for women with urodynamic stress incontinence who had previously undergone a failed midurethral tape.

METHODS

A retrospective study of 13 women who had undergone open colposuspension after a failed midurethral tape was conducted.

RESULTS

At a median follow-up of 12 months, subjective and objective cure rate were 85% and 77%, respectively. Thirty percent of the women developed de novo detrusor overactivity that responded to antimuscarinic treatment. Long-term voiding difficulty was observed in only one patient, who performed clean intermittent self-catheterization for 3 months. Posterior vaginal wall prolapse requiring pelvic floor repair was found in three women (23%) postoperatively.

CONCLUSIONS

Open colposuspension is an effective option for treating persistent or recurrent stress urinary incontinence after failed midurethral tape, with a high success rate.

Nonsurgical outpatient therapies for the management of female stress urinary incontinence: long-term effectiveness and durability

Objective. To evaluate long-term effectiveness and safety of conservative and minimally invasive outpatient treatments for female stress urinary incontinence (SUI) through a review of the literature. Methods. PubMed was searched for reports on prospective clinical trials with at least 12-month follow-up of minimally invasive treatments, pelvic floor rehabilitation, or pharmacotherapy in women with SUI. Each report was examined for long-term rates of effectiveness and safety. Results. Thirty-two clinical trial reports were included. Prospective long-term studies of pelvic floor rehabilitation were limited but indicated significant improvements with treatment adherence for at least 12 months. Poor initial tolerability with duloxetine resulted in substantial discontinuation. Most patients receiving transurethral radiofrequency collagen denaturation or urethral bulking agents reported significant long-term improvements, generally good tolerability, and safety. Conclusions. Conservative therapy is an appropriate initial approach for female SUI, but if therapy fails, radiofrequency collagen denaturation or bulking agents may be an attractive intermediate management step or alternative to surgery.

The treatment of female stress urinary incontinence: an evidenced-based review

OBJECTIVE

To review the literature on the surgical and nonsurgical treatment options for stress urinary incontinence in women, focusing exclusively on randomized clinical trials and high quality meta-analyses.

MATERIALS AND METHODS

A computer-aided and manual search for published randomized controlled trials and high quality meta-analyses investigating both conservative and surgical treatment options for stress urinary incontinence. In the case of a treatment that is not studied in these formats large case series have been used.

RESULTS

Articles were reviewed and the results summarized on pelvic floor physical therapy, pharmacotherapy, bulking agents, and surgery (open and minimally invasive).

CONCLUSION

There are numerous high quality studies in the literature. It can be difficult to make definitive conclusions on the most appropriate treatment options due to the variability in the outcomes used to define success in these articles. There is also a dire lack of studies evaluating and comparing the surgical options for patients with intrinsic sphincter deficiency.

Traditional suburethral sling operations for urinary incontinence in women

BACKGROUND

Traditional suburethral slings are surgical operations used to treat women with symptoms of stress urinary incontinence.

OBJECTIVES

To determine the effects of traditional suburethral slings on stress or mixed incontinence in comparison with other management options.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 3 June 2010) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised trials that included traditional suburethral slings for the treatment of stress or mixed urinary incontinence.

DATA COLLECTION AND ANALYSIS

At least three reviewers independently extracted data from included trials onto a standard form and assessed trial methodological quality. The data abstracted were relevant to predetermined outcome measures. Where appropriate, a summary statistic was calculated: a relative risk for dichotomous data and a weighted mean difference for continuous data.

MAIN RESULTS

Twenty six trials involving 2284 women were included. The quality of evidence was moderate for most trials and there was generally short follow-up ranging from 6-24 months.One medium sized trial compared traditional suburethral sling operations with oxybutynin in the treatment of mixed urinary incontinence patients. Surgery appeared to be more effective than drugs in treating patient-reported incontinence (n = 75, Risk Ratio (RR) 0.18, 95% Confidence Interval (CI) 0.08 to 0.43).One trial found that traditional slings were more effective than transurethral injectable treatment (RR for clinician-assessed incontinence within a year 0.21; 95% CI 0.09 to 0.21), and also cheaper on average cost.Seven trials compared slings with open abdominal retropubic colposuspension. Patient-reported incontinence was lower with the slings after one year (RR 0.75; 95% CI 0.62 to 0.90), but not when assessed by clinicians. Colposuspension, however, was associated with fewer peri-operative complications, shorter duration of use of indwelling catheter and less long term voiding dysfunction. One study showed there was a 20% lower risk of bladder perforation with the sling procedure but a 50% increase in urinary tract infection with the sling procedure compared with colposuspension. Fewer women developed prolapse after slings (compared with after colposuspension) in two small trials but this did not reach statistical significance.Twelve trials addressed the comparison between traditional sling operations and minimally invasive sling operations.These seemed to be equally effective in the short term (RR for incontinence within first year 0.97; 95% CI 0.78 to 1.20) but minimally invasive slings had a shorter operating time, fewer peri-operative complications (other than bladder perforation) and some evidence of less post-operative voiding dysfunction and detrusor symptoms.Six trials compared one type of traditional sling with another. Materials included porcine dermis, lyophilised dura mater, fascia lata, vaginal wall, autologous dermis and rectus fascia. Patient-reported improvement rates within the first year favoured the traditional autologous material rectus fascia over other biological materials (RR 0.45; 95% CI 0.21 to 0.98). There were more complications with the use of non-absorbable Goretex in one trial.Data for comparison of bladder neck needle suspension with suburethral slings were inconclusive because they came from a single trial with a small specialised population.No trials compared traditional suburethral slings with anterior repair, laparoscopic retropubic colposuspension or artificial sphincters. Most trials did not distinguish between women having surgery for primary or recurrent incontinence when reporting patient characteristics.For most of the comparisons, clinically important differences could not be ruled out.

AUTHORS' CONCLUSIONS

Traditional slings seem to be as effective as minimally invasive slings, but had higher rates of adverse effects. This should be interpreted with some caution however, as the quality of evidence for the studies was variable, follow-up short and populations small, particularly for identifying complication rates. Tradional sling procedures appeared to confer a similar cure rate in comparison to open retropubic colposuspension, but the long term adverse event profile is still unclear. Reliable evidence to clarify whether or not traditional suburethral slings may be better or worse than other surgical or conservative management options is lacking.

Quality of life after periurethral injection with polyacrylamide hydrogel for stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The purpose of this observational study was to examine the effect of periurethral injections with polyacrylamide hydrogel (PAHG) on quality of life (QoL) in selected patients with stress urinary incontinence (SUI).

METHODS

Fifty-four women with comorbidities or other reasons precluding other surgery received PAHG for SUI. Patient-reported outcomes were assessed with the "Incontinence Outcome Questionnaire" (IOQ) 9 months postoperatively. The IOQ is a 27-item, condition-specific instrument that assesses patient-reported outcomes after incontinence surgery.

RESULTS

Forty-two women (78%) completed the questionnaire. Responses ranged from considerable (40%) and slight improvement (21%) to no change (29%) and worsening of symptoms (10%).

CONCLUSION

Periurethral injections with PAHG are likely to provide relief of symptoms and improvement in QoL.

An open multicenter study of polyacrylamide hydrogel (Bulkamid®) for female stress and mixed urinary incontinence

Introduction

Polyacrylamide hydrogel (PAHG, Bulkamid®) is a promising urethral bulking agent. This multicenter study was carried out to evaluate safety and efficacy of Bulkamid® for female stress and mixed urinary incontinence.

Methods

Submucosal injection of Bulkamid® was performed in 135 women with urinary incontinence (stress, 67; mixed, 68) followed for 12 months. Forty-seven had a reinjection (35%).

Results

At 12 months, the subjective response rate was 66%. Incontinence episodes/24 h and urine leakage g/24 h decreased significantly (from 3.0 to 0.7 and 29 g to 4 g, respectively). Additionally, the median International Consultation on Incontinence Questionnaire score was reduced to approximately 50%, and the overall quality of life visual analogue scale score was decreased significantly (from 72 to 20). Efficacy was very similar between patients with stress and mixed incontinence. Thirty treatment-related adverse events were registered. The most frequent was urinary tract infection (n = 10). No polyacrylamide hydrogel-specific adverse events were seen.

Conclusions

Bulkamid® is an effective and safe bulking agent in women with stress or mixed incontinence.

Polymeric Microspheres for Medical Applications

Synthetic polymeric microspheres find application in a wide range of medical applications. Among other applications, microspheres are being used as bulking agents, embolic- or drug-delivery particles. The exact composition of the spheres varies with the application and therefore a large array of materials has been used to produce microspheres. In this review, the relation between microsphere synthesis and application is discussed for a number of microspheres that are used for different treatment strategies.

Urinary incontinence in women: part 1 of a series of articles on incontinence

BACKGROUND

Urinary incontinence can arise in a woman of any age. Its prevalence is between 10% and 40%. The main clinical problems in urogynecology are stress urinary incontinence (involuntary leakage of urine on exertion, sneezing, or coughing) and the overactive bladder syndrome (nycturia, pollakisuria, and urinary urgency with or without incontinence).

METHOD

Selective literature search, with special attention to large-scale studies and to the guidelines of the German Society of Obstetrics and Gynecology (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and its Task Force on Urogynecology and Pelvic Floor Reconstruction (Arbeitsgemeinschaft Urogynäkologie und Beckenbodenrekonstruktion).

RESULTS

There are many diagnostic and therapeutic options, whose use should be based on the degree of the patient's suffering and on her motivation to be treated. Anticholinergic drugs are of established value in the treatment of overactive bladder. They are used in combination with possible lifestyle changes and bladder training. In some circum-stances, botulinum toxin injections can be considered as well. Stress incontinence should be treated conservatively (with pelvic floor training) before any surgical treatment is provided. The new tension-free vaginal tapes are just as effective as classic treatments, such as colposuspension, while being less invasive and enabling a more rapid recovery.

CONCLUSION

All women with urinary incontinence should undergo appropriate, specialized diagnostic evaluation and well-founded counseling in order to benefit from individualized treatment.

Cell-based therapy for urinary incontinence

Urinary incontinence has become a societal problem that affects millions of people worldwide. Although numerous therapeutic modalities are available, none has been shown to be entirely satisfactory. Consequently, cell-based approaches using regenerative medicine technology have emerged as a potential solution that would provide a means of correcting anatomical deficiencies and restoring normal function. As such, numerous cell-based investigations have been performed to develop systems that are focused on addressing clinical needs. While most of these attempts remain in the experimental stages, several clinical trials are being designed or are in progress. This article provides an overview of the cell-based approaches that utilize various cell sources to develop effective treatment modalities for urinary incontinence.

The medical management of urinary incontinence

Urinary incontinence is the involuntary leakage of urine; it affects millions of people worldwide, causing significant detrimental effects on their quality of life. Direct expenses, such as containment products, long-term drug prescriptions and surgery, complemented by indirect costs, such as reduced employment productivity, result in overall expenditure running to billions of dollars. Stress urinary incontinence (SUI) occurs on physical exertion, and results from weakness of the bladder outlet. Urgency urinary incontinence (UUI) results from inability to resist a sudden compelling desire to pass urine, arising as a consequence of bladder dysfunction. Clinical evaluation clarifies the underlying mechanisms and excludes diseases causing similar symptoms. Urodynamic studies to measure bladder and abdominal pressures and deduce the bladder and outlet function are undertaken when invasive treatments are being considered or when the nature of the incontinence is not entirely clear. Initial management of SUI involves pelvic floor muscle exercise training; if insufficient symptom improvement results, surgical measures are needed. UUI treatment commences with advice on suitable fluid intake and measures to improve ability to defer voiding, followed by antimuscarinic drugs. Refractory UUI is a difficult problem, currently managed with a range of surgical interventions, including bladder injections of botulinum-A neurotoxin, augmentation cystoplasty and nerve stimulation methods. New treatment options are needed, because of the risk of impeding voiding function, resulting in urinary retention. Persistent leakage is controlled with containment products, such as pads, or collection devices, such as catheters.

Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women

BACKGROUND

Stress urinary incontinence (SUI) is a common condition affecting up to 30% of women. Minimally invasive synthetic suburethral sling operations are among the latest forms of procedures introduced to treat SUI.

OBJECTIVES

To assess the effects of minimally invasive synthetic suburethral sling operations for treatment of SUI, urodynamic stress incontinence (USI) or mixed urinary incontinence (MUI) in women.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 20 March 2008), MEDLINE (January 1950 to April 2008), EMBASE (January 1988 to April 2008), CINAHL (January 1982 to April 2008), AMED (January 1985 to April 2008), the UK National Research Register, ClinicalTrials.gov, and reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials amongst women with SUI, USI or symptoms of stress or mixed urinary incontinence, in which at least one trial arm involved a minimally invasive synthetic suburethral sling operations.

DATA COLLECTION AND ANALYSIS

Two review authors assessed the methodological quality of potentially eligible studies and independently extracted data from the included trials.

MAIN RESULTS

Sixty two trials involving 7101 women were included. The quality of evidence was moderate for most trials. Minimally invasive synthetic suburethral sling operations appeared to be as effective as traditional suburethral slings ( trials, n = 599, Risk Ratio (RR) 1.03, 95% Confidence Interval (CI) 0.94 to 1.13) but with shorter operating time and less post-operative voiding dysfunction and de novo urgency symptoms.Minimally invasive synthetic suburethral sling operations appeared to be as effective as open retropubic colposuspension (subjective cure rate at 12 months RR 0.96, 95% CI 0.90 to 1.03; at 5 years RR 0.91, 95% CI 0.74 to 1.12) with fewer perioperative complications, less postoperative voiding dysfunction, shorter operative time and hospital stay but significantly more bladder perforations (6% versus 1%, RR 4.24, 95% CI 1.71 to 10.52).There was conflicting evidence about the effectiveness of minimally invasive synthetic suburethral sling operations compared to laparoscopic colposuspension in the short term (objective cure, RR 1.15, 95% CI 1.06 to 1.24; subjective cure RR 1.11, 95% CI 0.99 to 1.24). Minimally invasive synthetic suburethral sling operations had significantly less de novo urgency and urgency incontinence, shorter operating time, hospital stay and time to return to daily activities.A retropubic bottom-to-top route was more effective than top-to-bottom route (RR 1.10, 95% CI 1.01 to 1.20; RR 1.06, 95% CI 1.01 to 1.11) and incurred significantly less voiding dysfunction, bladder perforations and tape erosions.Monofilament tapes had significantly higher objective cure rates (RR 1.15, 95% CI 1.02 to 1.30) compared to multifilament tapes and fewer tape erosions (1.3% versus 6% RR 0.25, 95% CI 0.06 to 1.00).The obturator route was less favourable than the retropubic route in objective cure (84% versus 88%; RR 0.96, 95% CI 0.93 to 0.99; 17 trials, n = 2434), although there was no difference in subjective cure rates. However, there was less voiding dysfunction, blood loss, bladder perforation (0.3% versus 5.5%, RR 0.14, 95% CI 0.07 to 0.26) and shorter operating time with the obturator route.

AUTHORS' CONCLUSIONS

The current evidence base suggests that minimally invasive synthetic suburethral sling operations are as effective as traditional suburethral slings, open retropubic colposuspension and laparoscopic colposuspension in the short term but with less postoperative complications. Women were less likely to be continent after operations performed via the obturator (rather than retropubic) route, but they had fewer complications. Most of the trials had short term follow up and the quality of the evidence was variable.

Open retropubic colposuspension for urinary incontinence in women

BACKGROUND

Urinary incontinence is a common and potentially debilitating problem. Open retropubic colposuspension is a surgical treatment which involves lifting the tissues near the bladder neck and proximal urethra in the area behind the anterior pubic bones to correct deficient urethral closure.

OBJECTIVES

To assess the effects of open retropubic colposuspension for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 30 June 2008) and reference lists of relevant articles. We contacted investigators to locate extra studies.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in women with symptoms or urodynamic diagnoses of stress or mixed urinary incontinence that included open retropubic colposuspension surgery in at least one trial group.

DATA COLLECTION AND ANALYSIS

Studies were evaluated for methodological quality/susceptibility to bias and appropriateness for inclusion and data extracted by two of the reviewers. Trial data were analysed by intervention. Where appropriate, a summary statistic was calculated.

MAIN RESULTS

This review included 46 trials involving a total of 4738 women.Overall cure rates were 68.9% to 88.0% for open retropubic colposuspension. Two small studies suggest lower failure rates after open retropubic colposuspension compared with conservative treatment. Similarly, one trial suggests lower failure rates after open retropubic colposuspension compared to anticholinergic treatment. Evidence from six trials showed a lower failure rate for subjective cure after open retropubic colposuspension than after anterior colporrhaphy. Such benefit was maintained over time (RR of failure 0.51; 95% CI 0.34 to 0.76 before the first year, RR 0.43; 95% CI 0.32 to 0.57 at one to five years, RR 0.49; 95% CI 0.32 to 0.75 in periods beyond 5 years). In comparison with needle suspensions there was a lower failure rate after colposuspension in the first year after surgery (RR 0.66; 95% CI 0.42 to 1.03), after the first year (RR 0.48; 95% CI 0.33 to 0.71), and beyond five years (RR 0.32; 95% CI 15 to 0.71). Evidence from twelve trials in comparison with suburethral slings found no significant difference in failure rates in all time periods assessed. Patient-reported failure rates in short, medium and long-term follow-up showed no significant difference between open and laparoscopic retropubic colposuspension, but with wide confidence intervals. In two trials failure was less common after Burch (RR 0.38 95% CI 0.18 to 0.76) than after the Marshall Marchetti Krantz procedure at one to five year follow-up. There were few data at any other follow-up time.In general, the evidence available does not show a higher morbidity or complication rate with open retropubic colposuspension, compared to the other open surgical techniques, although pelvic organ prolapse is more common than after anterior colporrhaphy and sling procedures.

AUTHORS' CONCLUSIONS

The evidence available indicates that open retropubic colposuspension is an effective treatment modality for stress urinary incontinence especially in the long term. Within the first year of treatment, the overall continence rate is approximately 85 to 90%. After five years, approximately 70% of patients can expect to be dry. Newer minimal access procedures like tension free vaginal tape look promising in comparison with open colposuspension but their long-term performance is not known and closer monitoring of its adverse event profile must be done. Laparoscopic colposuspension should allow speedier recovery but its relative safety and effectiveness is not known yet.

Oestrogen therapy for urinary incontinence in post-menopausal women

BACKGROUND

It is possible that oestrogen deficiency may be an aetiological factor in the development of urinary incontinence in women.

OBJECTIVES

To assess the effects of local and systemic oestrogens used for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register of trials (2 April 2009) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included oestrogens in at least one arm, in women with symptomatic or urodynamic diagnoses of stress, urgency or mixed urinary incontinence or other urinary symptoms post-menopause.

DATA COLLECTION AND ANALYSIS

Trials were evaluated for methodological quality and appropriateness for inclusion by the review authors. Data were extracted by at least two authors and cross checked. Subgroup analyses were performed grouping participants under local or systemic administration. Where appropriate, meta-analysis was undertaken.

MAIN RESULTS

Thirty- three trials were identified which included 19,313 (1,262 involved in trials of local administration) incontinent women of whom 9417 received oestrogen therapy. Sample sizes ranged from 16 to 16,117. The trials used varying combinations of type of oestrogen, dose, duration of treatment and length of follow up. Outcome data were not reported consistently and were available for only a minority of outcomes.Systemic administration (of oral oestrogens) resulted in worse incontinence than on placebo (RR 1.32, 95% CI 1.17 to 1.48). This result is heavily weighted by a subgroup of women from the Hendrix trial, which had large numbers of participants and a longer follow up of one year; all the women had had a hysterectomy and the treatment used was conjugated equine oestrogen. The result for women with an intact uterus where oestrogen and progestogen combined were used also showed a statistically significant worsening of incontinence (RR 1.11, 95% CI 1.04 to 1.18).There was some evidence that oestrogens used locally (for example vaginal creams or tablets) may improve incontinence (RR 0.74, 95% CI 0.64 to 0.86). Overall, there were around one to two fewer voids in 24 hours and nocturnal voids amongst women treated with local oestrogen, and there was less frequency and urgency. No serious adverse events were reported although some women experienced vaginal spotting, breast tenderness or nausea.Women who were continent and received systemic oestrogen replacement, with or without progestogens, for reasons other than urinary incontinence were more likely to report the development of new urinary incontinence in one large study.The data were too few to address questions about oestrogens compared with or in combination with other treatments, different types of oestrogen or different modes of delivery.

AUTHORS' CONCLUSIONS

Local oestrogen treatment for incontinence may improve or cure it, but there was little evidence from the trials on the period after oestrogen treatment had finished and none about long-term effects. However, systemic hormone replacement therapy, using conjugated equine oestrogen, may make incontinence worse. There were too few data to reliably address other aspects of oestrogen therapy, such as oestrogen type and dose, and no direct evidence on route of administration. The risk of endometrial and breast cancer after long-term use suggests that oestrogen treatment should be for limited periods, especially in those women with an intact uterus.

Where should bulking agents for female urodynamic stress incontinence be injected?

For bulking agents used for female stress urinary incontinence, the recommendation for the anatomical placement varies as some injectables are to be placed close to the bladder neck and others midurethrally. Aim of the study was to determine if there are differences concerning the outcome after transurethral collagen injections depending on the anatomical placement midurethrally or at the bladder neck. We randomly assigned 30 elderly female patients with urodynamic stress incontinence to either transurethral collagen injection midurethrally or to the bladder neck. Prior to injection and at ten month follow-up, maximum urethral closure pressure (MUCP), functional urethral length (FUL), maximum flow rate and cough test were performed and the patient was asked to estimate her bladder condition using a visual analogue scale. Postoperative contentness was 8 (median, 95% confidence interval 5-9) in the midurethral group and 8 (median, 95% confidence interval 7-10) in the bladder neck group with a p value of 0.012, 95% confidence interval -2.464 to -0.2859, in favour to midurethral injections. MUCP and FUL increased significantly in both groups and flow rate decreased in both groups. Continence was 66.6% in the midurethral group and 60% for the bladder neck group respectively. Both midurethral and bladder neck collagen injections improve patients' satisfaction almost equally with a small advantage for midurethral injections.