Comparison of "subjective" and "objective" measures of severity of urinary incontinence in women. Program for Women Research Group

An exploratory study comparing psychological profiles and its congruence with clinical performance among patients with functional or motility digestive disorders

Functional gastrointestinal disorders have been related with different psychological conditions. On the contrary, the role of psychological factors within gastrointestinal motor disorders remains unclear. The objective of this study was to explore the differences and congruence with clinical performance of the psychological profile and subjective functionality among patients diagnosed with functional gastrointestinal disorders and gastrointestinal motor disorders. Using a double-blind design, 56 inpatients from a Gastroenterology Department were included in the study. No major differences were detected between the two groups. However, clinical performance was coherent with subjective physical functioning only among patients diagnosed with gastrointestinal motor disorders. These results may provide useful information for gastroenterologists dealing with patients' complaints not consistent with their clinical profile.

Pelvic floor muscle training added to another active treatment versus the same active treatment alone for urinary incontinence in women

BACKGROUND

Pelvic floor muscle training (PFMT) is a first-line conservative treatment for urinary incontinence in women. Other active treatments include: physical therapies (e.g. vaginal cones); behavioural therapies (e.g. bladder training); electrical or magnetic stimulation; mechanical devices (e.g. continence pessaries); drug therapies (e.g. anticholinergics (solifenacin, oxybutynin, etc.) and duloxetine); and surgical interventions including sling procedures and colposuspension. This systematic review evaluated the effects of adding PFMT to any other active treatment for urinary incontinence in women

OBJECTIVES

To compare the effects of pelvic floor muscle training combined with another active treatment versus the same active treatment alone in the management of women with urinary incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 5 May 2015), and CINAHL (January 1982 to 6 May 2015), and the reference lists of relevant articles.

SELECTION CRITERIA

We included randomised or quasi-randomised trials with two or more arms, of women with clinical or urodynamic evidence of stress urinary incontinence, urgency urinary incontinence or mixed urinary incontinence. One arm of the trial included PFMT added to another active treatment; the other arm included the same active treatment alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for eligibility and methodological quality and resolved any disagreement by discussion or consultation with a third party. We extracted and processed data in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Other potential sources of bias we incorporated into the 'Risk of bias' tables were ethical approval, conflict of interest and funding source.

MAIN RESULTS

Thirteen trials met the inclusion criteria, comprising women with stress urinary incontinence (SUI), urgency urinary incontinence (UUI) or mixed urinary incontinence (MUI); they compared PFMT added to another active treatment (585 women) with the same active treatment alone (579 women). The pre-specified comparisons were reported by single trials, except bladder training, which was reported by two trials, and electrical stimulation, which was reported by three trials. However, only two of the three trials reporting electrical stimulation could be pooled, as one of the trials did not report any relevant data. We considered the included trials to be at unclear risk of bias for most of the domains, predominantly due to the lack of adequate information in a number of trials. This affected our rating of the quality of evidence. The majority of the trials did not report the primary outcomes specified in the review (cure or improvement, quality of life) or measured the outcomes in different ways. Effect estimates from small, single trials across a number of comparisons were indeterminate for key outcomes relating to symptoms, and we rated the quality of evidence, using the GRADE approach, as either low or very low. More women reported cure or improvement of incontinence in two trials comparing PFMT added to electrical stimulation to electrical stimulation alone, in women with SUI, but this was not statistically significant (9/26 (35%) versus 5/30 (17%); risk ratio (RR) 2.06, 95% confidence interval (CI) 0.79 to 5.38). We judged the quality of the evidence to be very low. There was moderate-quality evidence from a single trial investigating women with SUI, UUI or MUI that a higher proportion of women who received a combination of PFMT and heat and steam generating sheet reported a cure compared to those who received the sheet alone: 19/37 (51%) versus 8/37 (22%) with a RR of 2.38, 95% CI 1.19 to 4.73). More women reported cure or improvement of incontinence in another trial comparing PFMT added to vaginal cones to vaginal cones alone, but this was not statistically significant (14/15 (93%) versus 14/19 (75%); RR 1.27, 95% CI 0.94 to 1.71). We judged the quality of the evidence to be very low. Only one trial evaluating PFMT when added to drug therapy provided information about adverse events (RR 0.84, 95% CI 0.45 to 1.60; very low-quality evidence).With regard to condition-specific quality of life, there were no statistically significant differences between women (with SUI, UUI or MUI) who received PFMT added to bladder training and those who received bladder training alone at three months after treatment, on either the Incontinence Impact Questionnaire-Revised scale (mean difference (MD) -5.90, 95% CI -35.53 to 23.73) or on the Urogenital Distress Inventory scale (MD -18.90, 95% CI -37.92 to 0.12). A similar pattern of results was observed between women with SUI who received PFMT plus either a continence pessary or duloxetine and those who received the continence pessary or duloxetine alone. In all these comparisons, the quality of the evidence for the reported critical outcomes ranged from moderate to very low.

AUTHORS' CONCLUSIONS

This systematic review found insufficient evidence to state whether or not there were additional effects by adding PFMT to other active treatments when compared with the same active treatment alone for urinary incontinence (SUI, UUI or MUI) in women. These results should be interpreted with caution as most of the comparisons were investigated in small, single trials. None of the trials in this review were large enough to provide reliable evidence. Also, none of the included trials reported data on adverse events associated with the PFMT regimen, thereby making it very difficult to evaluate the safety of PFMT.

Comparison of seven-day and repeated 24-hour recall of symptoms in the first 100 days after hematopoietic cell transplantation

CONTEXT

Patient-reported outcomes (PROs) provide a way to understand the effects of hematopoietic cell transplantation (HCT)-related stress on patients' lives. We previously reported that weekly collection of PROs is feasible.

OBJECTIVES

Here, we report on the feasibility of daily patient-reported symptom collection and examine the relationship between daily vs. weekly symptom reporting over time.

METHODS

We analyzed data from 32 autologous and allogeneic HCT patients obtained until Day (D) +100. We used questions from the PRO version of the Common Terminology Criteria for Adverse Events to capture symptoms.

RESULTS

We found that overall rates of daily survey completion were moderate to high (range 67%-86%). The effect size of the difference between the maximum daily severity score and the weekly severity score ranged from 0.15 to 0.35, and the concordance correlation coefficient ranged from 0.513 to 0.834. Concordance of daily and weekly surveys was higher for maximum daily severity rating and mean daily severity rating than for minimum daily severity rating or most recent daily severity rating.

CONCLUSION

We conclude that a seven-day recall period for symptom severity provides acceptable accuracy and precision in the first 100 days after HCT. Further studies to explore the utility of daily symptom reporting within specific clinical contexts may be warranted.

Pelvic floor muscle training added to another active treatment versus the same active treatment alone for urinary incontinence in women

BACKGROUND

Pelvic floor muscle training (PFMT) is a first-line conservative treatment for urinary incontinence in women. Other active treatments include: physical therapies (e.g. vaginal cones); behavioural therapies (e.g. bladder training); electrical or magnetic stimulation; mechanical devices (e.g. continence pessaries); drug therapies (e.g. anticholinergics (solifenacin, oxybutynin, etc.) and duloxetine); and surgical interventions including sling procedures and colposuspension. This systematic review evaluated the effects of adding PFMT to any other active treatment for urinary incontinence in women

OBJECTIVES

To compare the effects of pelvic floor muscle training combined with another active treatment versus the same active treatment alone in the management of women with urinary incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, and handsearching of journals and conference proceedings (searched 28 February 2013), EMBASE (January 1947 to 2013 Week 9), CINAHL (January 1982 to 5 March 2013), ClinicalTrials.gov (searched 30 May 2013), WHO ICTRP (searched 3 June 2013) and the reference lists of relevant articles.

SELECTION CRITERIA

We included randomised or quasi-randomised trials with two or more arms in women with clinical or urodynamic evidence of stress urinary incontinence, urgency urinary incontinence or mixed urinary incontinence. One arm of the trial included PFMT added to another active treatment; the other arm included the same active treatment alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for eligibility and methodological quality and resolved any disagreement by discussion or consultation with a third party. We extracted and processed data in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. Other potential sources of bias we incorporated into the 'Risk of bias' tables were ethical approval, conflict of interest and funding source.

MAIN RESULTS

Eleven trials met the eligibility criteria for inclusion, comprising women with stress urinary incontinence (SUI), urgency urinary incontinence (UUI) or mixed urinary incontinence (MUI), and they compared PFMT added to another active treatment (494 women) with the same active treatment alone (490 women). The pre-specified comparisons were reported by single trials except electrical stimulation which was reported by two trials. However, the two trials reporting electrical stimulation could not be pooled as one of the trials did not report any relevant data. We considered the included trials to be at unclear risk of bias for most of the domains, predominantly due to the lack of adequate information in a number of trials. This affected our rating of the quality of evidence. The majority of the trials did not report the primary outcomes specified in the review (cure/improvement, quality of life) or measured the outcomes in different ways. Effect estimates from small, single trials across a number of comparisons were indeterminate for key outcomes relating to symptoms and we rated the quality of evidence, using the GRADE approach, as either low or very low. There was moderate-quality evidence from a single trial investigating women with SUI, UUI or MUI that a higher proportion of women who received a combination of PFMT and heat and steam generating sheet reported cure compared to those who received the sheet alone: 19/37 (51%) versus 8/37 (22%) with a risk ratio (RR) of 2.38, 95% confidence interval (CI) 1.19 to 4.73). More women reported cure or improvement of incontinence in another trial comparing PFMT added to vaginal cones to vaginal cones alone: 14/15 (93%) versus 14/19 (75%), but this was not statistically significant (RR 1.27, 95% CI 0.94 to 1.71). We judged the quality of the evidence to be very low. Only one trial evaluating PFMT when added to drug therapy provided information about adverse events (RR 0.84, 95% CI 0.45 to 1.60; very low-quality evidence).With regard to condition-specific quality of life, there were no statistically significant differences between women (with SUI, UUI or MUI) who received PFMT added to bladder training and those who received bladder training alone at three months after treatment either on the Incontinence Impact Questionnaire-Revised scale (mean difference (MD) -5.90, 95% CI -35.53 to 23.73) or on the Urogenital Distress Inventory scale (MD -18.90, 95% CI -37.92 to 0.12). A similar pattern of results was observed between women with SUI who received PFMT plus either a continence pessary or duloxetine and those who received the continence pessary or duloxetine alone. In all these comparisons, the quality of the evidence for the reported critical outcomes ranged from moderate to very low.

AUTHORS' CONCLUSIONS

This systematic review found insufficient evidence to state whether or not there were additional effects of adding PFMT to other active treatment when compared with the same active treatment alone for urinary incontinence (SUI, UUI or MUI) in women. These results should be interpreted with caution as most of the comparisons were investigated in small, single trials. None of the trials in this review were large enough to provide reliable evidence. Also, none of the included trials reported data on adverse events associated with the PFMT regimen, thereby making it very difficult to evaluate the safety of PFMT.

Data for free--can an electronic medical record provide outcome data for incontinence/prolapse repair procedures?

PURPOSE

We determined whether a custom computer program can improve the extraction and accuracy of key outcome measures from progress notes in an electronic medical record compared to a traditional data recording system for incontinence and prolapse repair procedures.

MATERIALS AND METHODS

Following institutional review board approval, progress notes were exported from the Epic electronic medical record system for outcome measure extraction by a custom computer program. The extracted data (D1) were compared against a manually maintained outcome measures database (D2). This work took place in 2 phases. During the first phase, volatile data such as questionnaires and standardized physical examination findings using the POP-Q (pelvic organ prolapse quantification) system were extracted from existing progress notes. The second phase used a progress note template incorporating key outcome measures to evaluate improvement in data accuracy and extraction rates.

RESULTS

Phase 1 compared 6,625 individual outcome measures from 316 patients in D2 to 3,534 outcome measures extracted from progress notes in D1, resulting in an extraction rate of 53.3%. A subset of 3,763 outcome measures from D1 was created by excluding data that did not exist in the extraction, yielding an accuracy rate of 93.9%. With the use of the template in phase 2, the extraction rate improved to 91.9% (273 of 297) and the accuracy rate improved to 100% (273 of 273).

CONCLUSIONS

In the field of incontinence and prolapse, the disciplined use of an electronic medical record template containing a preestablished set of key outcome measures can provide the ideal interface between required documentation and clinical research.

Comparison of 7-day recall and daily diary reports of COPD symptoms and impacts

OBJECTIVE

Patient reporting of symptoms in a questionnaire with a 7-day recall period was expected to differ from symptom reporting in a 7-day symptom diary on the basis of cognitive theory of memory processes and several studies of symptoms and health behaviors.

METHODS

A total of 101 adults with chronic obstructive pulmonary disease (COPD) completed a daily diary of items measuring symptoms and impacts of COPD for 7 days, and on the seventh day they completed a questionnaire of the same items with a 7-day recall period. The analysis examined concordance of 7-day recall with summary descriptors of the daily responses, examined the magnitude and covariates (patient characteristics and response patterns) of the difference between 7-day recall and mean of daily responses, and compared the discriminant ability and ability to detect change of 7-day recall and mean of daily responses.

RESULTS

A 7-day recall was moderately concordant with the mean and maximum of daily responses and was 0.34 to 0.50 SDs higher than the mean of daily responses. Only the weekly report itself was a covariate of the difference. The discriminant ability and ability to detect change were equivalent.

CONCLUSIONS

In measuring the weeklong experience of COPD symptoms and impacts on groups of patients, the 7-day recall scores were higher than the daily diary scores, but equivalent in detecting change over time.

Patient satisfaction with stress incontinence surgery

AIMS

To identify predictors and correlates of patient satisfaction 24 months after Burch colpopexy or autologous fascial sling for treatment of stress urinary incontinence (SUI).

METHODS

Participants were the 655 randomized subjects in the Stress Incontinence Surgical Treatment Efficacy Trial (SISTEr). Variables potentially associated with satisfaction were tested in bivariate analysis, including demographics, baseline clinical characteristics of incontinence, and outcomes on validated subjective and objective measures. Satisfaction with treatment was defined as a response of "completely satisfied" or "mostly satisfied" on the Patient Satisfaction Questionnaire (PSQ) at 24 months. Variables significantly related to satisfaction were entered into multivariable regression models to test their independent association with satisfaction.

RESULTS

At 24 months post-surgery, 480 (73%) participants completed the PSQ. Mean (±SD) age of the sample was 52 (±10) years and 77% were white. Most (82%) were completely or mostly satisfied with their surgery related to urine leakage. In the final multivariable model, patient satisfaction was associated with greater reduction in SUI symptoms (from baseline to 24 months; OR = 1.17, 95% CI: 1.10, 1.24) and greater reductions in symptom distress (OR = 1.16; CI: 1.08, 1.24). Lower odds of satisfaction were associated with greater urge incontinence symptoms at baseline (OR = 0.09, CI: 0.04, 0.22), detrusor overactivity at 24 months (OR = 0.29, CI: 0.12, 0.69), and a positive stress test at 24 months (OR = 0.45, CI: 0.22, 0.91).

CONCLUSIONS

Stress incontinent women who also have urge incontinence symptoms may benefit from additional preoperative counseling to set realistic expectations about potential surgical outcomes or proactive treatment of urge incontinence symptoms to minimize their post-operative impact.

Urodynamics, the supine empty bladder stress test, and incontinence severity

AIMS

Determine whether urodynamic measures of urethral function [(valsalva leak point pressure (VLPP), maximum urethral closure pressure (MUCP), functional urethral length (FUL)] and the results of the supine empty bladder stress test (SEBST) correlate with each other and with subjective and objective measures of urinary incontinence (UI).

METHODS

Data were collected preoperatively from subjects enrolled in a multicenter surgical trial of mid-urethral slings. Subjective measures included questionnaire scores from the Medical Epidemiological and Social Aspects of Aging Questionnaire, Urogenital Distress Inventory, and Incontinence Impact Questionnaire. Objective measures included a 24-hr pad weight test, incontinence episode frequency on a 3-day voiding diary, and a SEBST.

RESULTS

Five hundred ninety-seven women enrolled. Three hundred seventy-two women had valid VLPP values; 539 had valid MUCP/FUL values. Subjective measures of severity had weak to moderate correlation with each other (r = 0.25-0.43) and with objective measures of severity (r = -0.06 to 0.45). VLPP and MUCP had moderate correlation with each other (r = 0.36,  P< 0.001). Urodynamic measures of urethral function had little or no correlation with subjective or objective measures of severity. Subjects with a positive SEBST had more subjective and objective severity measures compared to the negative SEBST group, but they did not have significantly different VLPP and MUCP values.

CONCLUSIONS

VLPP and MUCP have moderate correlation with each other, but each had little or no correlation with subjective or objective measures of severity or with the results of the SEBST. This data suggests that the urodynamic measures of urethral function are not related to subjective or objective measures of UI severity.

Distress and quality of life characteristics associated with seeking surgical treatment for stress urinary incontinence

BACKGROUND

Current research focuses on three variables in evaluating the impact of stress urinary incontinence (SUI) on daily living: severity of incontinence, distress or bother resulting from incontinence, and effect on health related quality of life (HRQoL). Understanding the impact of these variables is important as they are the driving force behind women seeking surgical treatment. Given the importance of HRQoL in determining need for treatment, as well as evaluating treatment success, this review provides an assessment of the degree to which HRQoL is impaired in women seeking surgical treatment.

METHODS

PubMed searches for the terms "quality of life and distress and urinary incontinence" and "quality of life and bother and urinary incontinence" were performed with limits of English, human and female subjects through May 2008. All studies using validated instruments were included. No time limit was placed on the search.

RESULTS

Of 178 articles retrieved, 21 met the inclusion criteria, and 17 reported methods of scoring. The studies used the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). Wide ranges of mean and individual levels of severity of symptoms, UDI and IIQ scores were seen among women seeking surgical treatment. Fourteen studies reported baseline and post-surgical treatment distress and QoL data. Statistically significant improvements between baseline and post-surgical UDI and IIQ scores were reported in 12 studies. Reported cure rates ranged from 46% to 97%. Satisfaction with the procedure was reported in 4 studies and ranged from 84% to 91%. A minority of studies reported the relationship between reduction in symptoms and change in HRQoL.

CONCLUSION

HRQoL is the main reason women seek surgical treatment for incontinence and surgical treatment leads to a significant improvement in mean HRQoL scores. Assessment of HRQoL has proved less useful in identifying why individual women seek treatment for incontinence. Preliminary work has begun to characterize the interaction between severity of symptoms, distress or bother resulting from these urinary symptoms, impact on HRQoL, and treatment seeking behavior, but further research is needed. Greater standardization in the reporting of results of distress or bother and HRQoL would allow for comparison across studies.

Validity of a self-administered questionnaire, with reference to a clinical stress urinary incontinence test

OBJECTIVE

To estimate the criterion validity of a self-administered questionnaire on urinary incontinence (UI) using a clinical stress UI test as reference.

MATERIAL AND METHODS

A total of 4710 women aged 20-59 years randomly selected from the municipalities of Aarhus and Randers (Denmark) participated in a population survey on UI. A sub-sample of 96 women stratified by the duration and frequency of UI answered an assisted, self-administered questionnaire concerning UI during the preceding 6 months. Subsequently, a clinical stress UI test was performed with the researchers being blinded with regard to the questionnaire information.

RESULTS

Based on the clinical stress test and questionnaire, 22 (22.7%) and 21 women (21.6%) had stress UI, respectively. UI occurring in more than drops and UI lasting for > 4 weeks were found to be adequate predictors of UI (odds ratio 8.9 and 4.6; p < 0.001 and p < 0.05). Regarding all forms of UI, the agreement between the stress UI test result and the questionnaire data ranged from 51.0% to 77.1%. The probability of finding a positive stress UI test was 62% among women who answered that UI had lasted for > 4 weeks and occurred in more than drops, compared to 22.9% in the total study group. The sensitivity and specificity of the stress UI test among women in whom UI lasted for > 4 weeks and occurred in more than drops were 22.7% and 95.9%, respectively.

CONCLUSIONS

These findings suggest that there is a greater probability of finding severe UI if the women have experienced it in more than drops and it has lasted for > 4 weeks and it is therefore necessary to estimate the degree of incontinence further by means of a stress UI test. In contrast, women who experienced UI in less than drops and for a duration of < 4 weeks only suffered from a very mild degree of UI.

Systematic reviews of bladder training and voiding programmes in adults: a synopsis of findings from data analysis and outcomes using metastudy techniques

AIM

This paper reports a comparison of the data analysis and outcomes from four Cochrane systematic reviews on bladder training and voiding programmes for the management of urinary incontinence using metastudy descriptive techniques to inform clinical practice, generate new ideas and identify future research directions.

BACKGROUND

Bladder training is used for cognitively and physically able adults to regain continence by increasing the time interval between voids. Prompted voiding, habit retraining and timed voiding, collectively known as voiding programmes, are generally used for people with cognitive and physical impairments in institutional settings. Bladder training and voiding programmes feature as common clinical practice for the management of urinary incontinence.

METHODS

A synopsis of four Cochrane systematic reviews that included randomized controlled trials on bladder training, prompted voiding, habit retraining and timed voiding was undertaken using metastudy techniques for the synthesis of qualitative research, and has provided a discursive comparison and contrast of the meta-data analysis and outcomes of these reviews.

RESULTS

Frequency of incontinence was the most common and constant outcome measure of effectiveness in the reviews. Limited data were available on other health outcomes, change in dependency status, quality of life and cost-effectiveness. The systematic review on bladder training included different types of urinary incontinence, whereas those on voiding programmes did not differentiate the type of incontinence. There is evidence on the effectiveness of bladder training but long-term follow up studies are needed. Evidence on the effectiveness of voiding programmes is limited and not available for many outcomes.

CONCLUSION

Future research needs to consider the theory underpinning interventions for bladder training and voiding programmes for urinary incontinence and should incorporate recognized 'quality' research designs, established outcomes and long-term follow up. It is unclear whether health outcomes for people with comorbidities, cognitive and physical impairments will improve if extensive diagnostic and assessment investigations are undertaken.

The relationships among measures of incontinence severity in women undergoing surgery for stress urinary incontinence

PURPOSE

We assessed the relationships among severity measures of urinary incontinence in women with stress predominant symptoms enrolled in a randomized clinical trial comparing 2 surgical techniques (Burch colposuspension vs pubovaginal sling) for stress urinary incontinence.

MATERIALS AND METHODS

A total of 655 women underwent a standardized preoperative assessment that included the Medical, Epidemiological and Social Aspects of Aging questionnaire, Urogenital Distress Inventory, Incontinence Impact Questionnaire, 3-day voiding diary, 24-hour pad test, a supine empty bladder stress test and Valsalva leak point pressure measurements. Correlations were estimated using Spearman correlation coefficients and 95% confidence intervals. T tests at alpha=0.05 were conducted to compare the distributions of the continuous severity measure between patients with positive and negative supine empty bladder stress test.

RESULTS

Baseline mean scores on Medical, Epidemiological and Social Aspects of Aging, Urogenital Distress Inventory and Incontinence Impact Questionnaire were 25.8, 151 and 171, respectively. Mean incontinence episode frequency and pad weight were 3.2 per day and 43.5 gm, respectively. Supine empty bladder stress test was positive in 218 patients, and 428 patients had valid Valsalva leak point pressure measurements with a mean Valsalva leak point pressure of 80 cm H(2)O. Weak to moderate correlations were observed between Medical, Epidemiological and Social Aspects of Aging, incontinence episode frequency, pad weight, Incontinence Impact Questionnaire and Urogenital Distress Inventory. On the other hand, Valsalva leak point pressure correlated poorly with all variables measured. The sensitivity and specificity of the supine empty bladder stress test to predict intrinsic sphincter dysfunction were 49% and 60%, respectively.

CONCLUSIONS

Urinary incontinence severity measures correlate moderately with each other at best. While Medical, Epidemiological and Social Aspects of Aging demonstrated stronger correlations with the other measures of severity and quality of life, Valsalva leak point pressure did not. Supine empty bladder stress test did not demonstrate a clinically significant association among severity measures.

A systematic review of the reliability of frequency-volume charts in urological research and its implications for the optimum chart duration

OBJECTIVE

To determine how the reliability of frequency-volume charts (FVCs) vary with their duration when used to assess patients with lower urinary tract symptoms (LUTS) and whether the duration influences patient compliance.

METHODS

Peer-reviewed studies involving patients with LUTS were searched systematically, with the selected studies assessed for their internal and external validity and statistical quality. Details of the patients and type of FVC used were summarized, and reliability coefficients and levels of compliance were extracted for commonly assessed FVC variables.

RESULTS

In all, 13 studies were considered to meet the review criteria; they assessed the reliability of FVCs lasting 1, 2, 3 and 7 days. The reliability coefficients for 3- and 7-day FVCs were generally >0.8; those for shorter charts tended to be lower, but strong conclusions could not be drawn due to study limitations. There was no obvious relationship between the duration of the FVC and the level of compliance.

CONCLUSIONS

Strong recommendations cannot be made about what duration of an FVC should be used to assess or monitor patients with LUTS. The current consensus on using FVCs of > or = 3 days seems to be the most defensible policy, but more research of high quality is required, especially into the relationship of FVC duration with compliance.

Systematic reviews of bladder training and voiding programmes in adults: a synopsis of findings on theory and methods using metastudy techniques

AIM

This paper reports a comparison of four Cochrane systematic reviews on bladder training and voiding programmes for the management of urinary incontinence using metastudy descriptive techniques. It presents a synopsis of findings on theory and methods for interventions.

BACKGROUND

From the mid-1970s bladder training, prompted voiding, habit retraining and timed voiding have been developed and form the basis of nursing practice for the management of urinary incontinence in adults in institutional and community settings.

METHODS

A synopsis of four Cochrane systematic reviews was undertaken using metastudy techniques developed for qualitative research and has provided a discursive comparison and contrast of the selection and appraisal of primary research, meta-theory and meta-method.

FINDINGS

All programmes share a therapeutic focus on voiding and the degree and active participation of the client and caregiver. Bladder training focuses on the restoration of continence, while prompted voiding, habit retraining and timed voiding focus on the avoidance of incontinence. Bladder training and prompted voiding share the two characteristics of cognitive behavioural modification and active client participation. Habit retraining and timed voiding pre-empt episodes and avoid incontinence using operant conditioning rather than modifying behaviour. Variability of methods and operational terminology makes comparison between studies difficult. Use of cognitive behavioural approaches and operant conditioning need to be better understood in relation to future theory, interventions and study design. Bladder training is aimed at people who are cognitively and physically able, while the other voiding programmes are mainly used with for people with cognitive and physical impairments reliant on caregivers.

CONCLUSION

The theoretical approaches underpinning bladder training and voiding programmes, their components and suitability for patients need to be re-considered when designing future studies. There is a need for long-term follow-up in future studies. Future trials should adhere to recognized standards of good practice and incorporate outcomes from existing systematic reviews to enable future meta-analysis to be undertaken. Metastudy techniques for the synthesis of qualitative research provide useful methods for the descriptive synopsis of quantitative systematic reviews.

Pelvic floor muscle training effect on urinary incontinence knowledge, attitudes, and severity: An experimental study

This study of Taiwanese women investigated effects of pelvic floor muscle training (PFMT) on urinary incontinence (UI) severity and on participants' knowledge and attitudes regarding UI and PFMT. Of 114 participants in a 4-h PFMT program, 55 suffering from UI completed 2 questionnaires, 1 before and 1 after the program. Among them, 78% reported experiencing UI under increased abdominal pressure, and 82% had suffered the condition for more than 1 year. Participants achieved reductions in UI severity after PFMT; and the program produced a significant difference in their knowledge about, though not in their attitudes toward, both UI and PFMT.

Bladder-health diaries: an assessment of 3-day vs 7-day entries

OBJECTIVES

To assess the reliability of symptom reports in 3-day vs 7-day bladder diaries used in clinical trials of patients with overactive bladder (OAB) and to compare those results and related issues with previous reports.

MATERIALS AND METHODS

We analysed two large-scale, randomized, phase 3 clinical trials of the use of transdermal oxybutynin for treating patients with OAB. The first trial (Trial A, 520 patients) compared three doses of transdermal oxybutynin (1.3, 2.6 and 3.9 mg/day) with placebo. Patients documented their OAB symptoms in a 7-day diary. The second clinical study (Trial B, 361 patients) compared the efficacy of 3.9 mg/day transdermal oxybutynin with 4 mg/day extended-release tolterodine and with placebo; this trial required symptom recording for only 3 days. The internal consistency of the data from the 7-day trial was determined and then compared with the 3-day trial results.

RESULTS

Patients on transdermal oxybutynin or long-acting tolterodine for their OAB symptoms showed a clinically and statistically significant improvement, results that were documented in both 3-day and 7-day bladder diaries. However, compared with 7-day symptom records, 3-day diaries were associated with significantly better compliance with record-keeping (P < 0.001).

CONCLUSIONS

Seven-day diaries used in clinical trials supply accurate and reproducible data on clinical manifestations of OAB, but 3-day diaries are equally effective and have the potential for better accuracy through increased patient convenience. Three-day diaries may also reduce the tendency for patients to complete gaps in record-keeping from memory.

The standard 1-hour pad test: does it have any value in clinical practice?

OBJECTIVES

The aim of this study was to determine whether self subjective assessment of urinary incontinence as perceived by female patients could replace the standard 1-hour pad test in clinical practice.

DESIGN

Prospective cohort study.

SETTING

District General Hospital, South West of England.

METHODS

Ninety women awaiting surgical treatment for urodynamic stress incontinence were recruited. They underwent 160 pad tests; on each test women were asked to classify themselves on a four point scale into one category (0: totally continent to urine, 1: mild/occasional urinary incontinence (UI), 2: moderate UI, 3: severe UI), to complete the King's Health Questionnaire (KHQ) and carry out the standard International Continence Society 1-hour pad test. A pad gain >1 gm was considered a positive result.

MAIN OUTCOME MEASURES

Women perception for severity of UI, 1-hour pad gain, KHQ scores.

RESULTS

Self subjective assessment of UI (continent vs. incontinent) had good correlation (r = 0.88) with the pad test result (negative vs. positive), and correlated well with the KHQ scores (r = 0.79). Poor correlation was seen between the pad gain and the KHQ scores (r = 0.48) and between the pad gain and the self subjective assessment of UI scale (r = 0.48). The self subjective assessment of UI (incontinent vs. continent) had sensitivity 95.65% and specificity 93.33% to detect the pad test results (positive vs. negative).

CONCLUSION

This study suggest that, in either the pre- or postoperative phase, simply asking a woman if she is continent for urine or not was as good as doing the pad test and correlated better with the patient quality of life.

Pad tests and self-reports of continence in men awaiting radical prostatectomy: establishing baseline norms for males

AIMS

In this study, we report normal pad weight gain in a group self-reported continent men and compare the self-report data with the 24-hr pad test and the International Prostate Symptom Score (IPSS).

MATERIALS AND METHODS

Subjects awaiting radical prostatectomy were consecutively recruited. Exclusion criteria were a previous history of urologic surgery, reported urinary incontinence, or a medical problem which could affect bladder function.

RESULTS

Two hundred forty five men were enrolled. All were Caucasian, mean age 62.7 years, mean Gleason score 6.5, and mean PSA 8.3. At initial interview, all described themselves as continent of urine and 26 declined the 24-hr pad test because they were emphatic that they were continent. Of the 220 remaining, mean pad weight gain was 4.0 g on 24-hr pad test (SD 3.8; range 0-35.0 g), mean IPSS score was 7.23; 95 subjects scored > or = 8 (moderate), 13 scored > or = 20 (severe). The IPSS single Quality of Life (QOL) question and the 24 hr pad weight were not correlated; the summary IPSS score and pad weight had a correlation of 0.16 (P = 0.02) and the QOL question and the summary IPSS score had a correlation of 0.63 (P < 0.001). IPSS QOL scores were worse for those recording > or = 8 (P < 0.001).

CONCLUSIONS

The range of weight gain between 0 and 35 g suggests that self-report alone of urinary continence is an inaccurate measure of continence for research purposes. We propose that a pad weight gain of 8 g or less is indicative of urinary continence in men.

Bladder training for urinary incontinence in adults

BACKGROUND

Urinary incontinence is a common and distressing problem. Bladder training aims to increase the interval between voids and is widely used for the treatment of urinary incontinence.

OBJECTIVES

To assess the effects of bladder training for the treatment of urinary incontinence.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group trials register (January 2003). The reference lists of relevant articles were searched, and trialists contacted for details of other trials. Date of the most recent search: January 2003.

SELECTION CRITERIA

Randomised or quasi-randomised trials of bladder training for the treatment of any type of urinary incontinence.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed trial quality and independently extracted data. Five primary outcomes were prespecified: participant's perception of cure of urinary incontinence; participant's perception of improvement of urinary incontinence; number of incontinent episodes; number of micturitions; and quality of life. Adverse events were also noted. Three hypotheses were tested: bladder training is better than no bladder training; bladder training is better than other treatments; and combining bladder training with another treatment is better than that other treatment alone.

MAIN RESULTS

We assessed 73 reports of 36 potentially relevant trials; 28 reports of ten trials were eligible for inclusion with a total of 1366, predominantly female, participants. Not all participants' with overactive bladder, in five trials had urinary incontinence. Data from five trials with 467 participants, all female, are therefore included in the review. The quality of trials was variable. Few data describing long term follow up are available.Is bladder training better than no bladder training? Data were available for 149 women from two trials comparing bladder training with no bladder training. These described only a limited number of prespecified outcomes, which varied across the two trials. Point estimates of effect favoured bladder training however confidence intervals were wide and no statistically significant differences were found for primary outcome variables.Is bladder training better than other treatments? Only two trials including 125 women compared bladder training with drugs: one with oxybutynin and one with imipramine plus flavoxate. In the former trial the only outcomes demonstrating a statistically significant difference were participant's perception of cure at six months (RR 1.69; 95% CI 1.21 to 2.34) and adverse events (RR 0.03; 95% CI 0.00 to 0.44), both favouring bladder training. In the latter trial participant's perception of cure immediately after treatment just achieved statistical significance (RR 1.50; 95% CI 1.02 to 2.21) favouring bladder training, and this difference was maintained at approximately two months post treatment. One comparison of bladder training with pelvic floor muscle training plus biofeedback included 132 women: none of the differences in the primary outcomes achieved statistical significance.Is combining bladder training with another treatment better than that other treatment alone? One trial compared pelvic floor muscle training plus biofeedback supplemented with bladder training versus pelvic floor muscle training plus biofeedback alone and included 125 women. Of the primary outcomes both participants' perception of improvement and quality of life, both immediately after treatment, achieved statistical significance, favouring the bladder training combined with pelvic floor muscle training and biofeedback group (perception of improvement: RR 1.18; 95% CI 1.01 to 1.39; quality of life: MD -47.20; 95% CI -87.03 to -7.37), this was not sustained at three months.

REVIEWER'S CONCLUSIONS

The limited evidence available suggests that bladder training may be helpful for the treatment of urinary incontinence, but this conclusion can only be tentative as the trials were of variable quality and of small size with wide confidence intervals around the point estimates of effect. There was also not enough evidence to determine w evidence to determine whether bladder training was useful as a supplement to another therapy. Definitive research has yet to be conducted: more research is required.

Correlations among measures of bladder function and comfort

There is a need for standard functional and psychosocial measurements of compromised urinary bladder syndrome (CUBS). Utilizing Kolcaba's Comfort Theory, the purpose of this study was to assess the psychometric properties and relationships among 8 measures of comfort, status of urinary frequency and incontinence, and quality of life. A convenience sample of 47 persons (45 women, 2 men) ages 25 to 92, who had UI for more than 6 months, was recruited. Data were collected twice with a 2-week interval. We examined (a) 1 measure of the immediate outcome of comfort related to CUBS, (b) 5 measures of UI status, and (c) 2 measures of quality of life. Reliabilities were adequate for all measures. Relationships among variables are presented and discussed. Recommendations are made for measures that detect improvement over time related to first line interventions.

Voiding and incontinence frequencies: variability of diary data and required diary length

Frequencies of voiding and urinary incontinence are commonly measured by a patient's recall or a diary. The recommended diary length varies from 1 to 14 days, with 7 days apparently being most common. To examine the statistical precision of these different modalities, we analyzed recall data and diary data of 74 patients with urinary frequency, incontinence, or both. Recall data on voiding and incontinence frequency were systematically higher and more variable than diary data. Longer diary length provided less variable diary data. The confidence interval of diary data was calculated by applying the normal distribution to daytime voiding frequency and the Poisson distribution to daytime incontinence frequency. For daytime voiding frequency, the 95% confidence interval was estimated to be (x - 2.65, x + 2.65) (x - 1.53, x + 1.53) (x - 1, x + 1), where x is the 1-day, 3-day, and 7-day diary mean, respectively. For daytime incontinence frequency, the confidence interval depended on both the diary length and the diary mean. It was estimated to be (0, 6.39), (1.72, 4.28), (2.36, 3.64), by using a diary mean of 3 or 1-day, 7-day, and 28-day diaries, respectively. Also, it was estimated to be (0, 1.02), (1.72, 4.28), (7.66, 12.34), when the 7-day diary mean was 0.5, 3, and 10, respectively. Studies with different samples of genuine stress incontinence (n = 37) and urge incontinence (n = 25) confirmed these results. In conclusion, we believe the 7-day diary is highly reliable for estimating voiding frequency and is a reasonable option for predicting incontinence episodes. However, the diary length should be extended in a patient with rarer events of incontinence, and it should be shortened for those who are incontinent more often or who are diagnosed with voiding frequency only.

Biofeedback vs verbal feedback as learning tools for pelvic muscle exercises in the early management of urinary incontinence after radical prostatectomy

OBJECTIVE

To evaluate the comparative effectiveness of electromyographic (EMG) biofeedback with verbal instructions as learning tools of pelvic muscle exercises (PMEs) in the early management of urinary incontinence after radical prostatectomy.

PATIENTS AND METHODS

Forty-two consecutive patients (mean age 64 years, sd 4.2), with urinary incontinence after radical retropubic prostatectomy for localized prostate cancer, were randomized to receive biofeedback (group A, 28 men) or verbal feedback (group B, 14 men) as learning tools for PMEs immediately after catheter removal. Group A received 15 sessions of EMG biofeedback (three times weekly, 30 min each) and group B verbal instructions. Evaluation at baseline and 1, 2, 3 and 6 months included the 1-h pad-test and a questionnaire (number of pads/day and incontinence episodes).

RESULTS

By the last follow-up, 27 patients had received biofeedback and 15 verbal instructions. Data were analysed according to the intention-to-treat principle. Urine loss as assessed by the 1-h pad-test at baseline, 1, 2, 3 and 6 months was 39, 18, 7, 4 and 3 g for group A and 31, 11, 3, 1 and 0 g for group B, respectively (P > 0.05). The number of pads/day was 3.9, 3.4, 1.2, 0.8 and 0.4 for group A and 3.6, 1.8, 0.9, 0.4 and 0.2 for group B, respectively (P > 0.05). The overall continence rate at 6 months was objectively (urine loss > 1 g) 91% and subjectively (0-1 pad/day) 95%.

CONCLUSION

Intensive verbal instructions and biofeedback were both very effective behavioural methods and learning tools for PMEs in the early management of urinary incontinence after radical prostatectomy.

Good practice in continence care: development of nurse-led service

The implementation of evidence-based interventions in clinical practice is often alluded to in the literature; however, the development of these interventions is rarely documented. Within continence care, there is a larger body of relevant literature on which primary clinical interventions can be based. The Leicestershire Medical Research Council (MRC) Incontinence Study is a series of inter-related studies exploring the epidemiology of urinary symptoms, including incontinence, and evaluating service provision and treatment options for these symptoms. This article describes one aspect of the Leicestershire study, namely the development of evidence-based intervention protocols for use in a new nurse-led continence service. This service is currently being evaluated in a randomised controlled trial.

Inadequate repeatability of the one-hour pad test: the need for a new incontinence outcome measure

OBJECTIVE

To assess the reproducibility of two one-hour pad tests performed within one week using serial ultrasound scanning to obtain identical bladder volumes, and to measure the effect of patient anxiety upon test reproducibility.

DESIGN

Prospective observational study.

SETTING

Tertiary urogynaecological unit.

SAMPLE

Fifty-six incontinent women undergoing 112 pad tests.

METHOD

Two one-hour pad tests were performed with natural diuresis one week apart prior to treatment. At the second test, serial ultrasound scans were performed until bladder volume reached that of the first test, followed by identical provocation.

MAIN OUTCOME MEASURES

One-hour pad loss, bladder volumes (Vol1, Vol2), anxiety VAS questionnaire.

RESULTS

Despite serial scanning, bladder volumes differed significantly. Median volume before second pad test was 541 mL, compared with 433 mls before first test (P < 0.001). The second pad test was also significantly larger than first (median 16g vs 4g, P = 0.017), and 13/56 (23%) women were dry on the first test but incontinent on the second. In 26 women (46%) both bladder volumes were similar, but the second pad loss was still significantly greater (median 14g vs 4g, P = 0.037). The mean difference between tests was 10g and the limits of agreement were wide (ranging from -44 to +66 g difference for the test result). Women were more anxious about leaking during the first test (Median VAS during the first test was 2.8cm, compared with 0.6cm during the second test, P = 0.008). 42.5% found the second test to be more typical.

CONCLUSION

In women with similar bladder volumes, the test-retest reliability of the one-hour pad test was judged to be clinically inadequate, as the first and second pad test could differ by -44 to +66g. Lower anxiety levels at the second test may account for this finding. The one-hour pad test is a useful baseline measure of incontinence, but the poor repeatability suggests that is not an optimal measure of post-treatment change.

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

In epidemiological surveys of female urinary incontinence, it is not feasible to demonstrate urine loss objectively. The aim of this study was to develop a valid epidemiological instrument (a severity index) for assessing the severity of incontinence. The severity index is based on information about frequency (four levels) and amount of leakage (two or three levels). By multiplication, an index value (1-8 or 1-12) is reached. This index value is further categorized into a severity index of three or four levels. The index was compared with the results of 315 pad-weighing tests performed by 265 women in hospital and general practice. Data from an epidemiological survey were also re-analyzed by applying the four-level severity index. Mean pad-weighing results (grams per 24 hours, 95% confidence interval) for the three-level severity index was slight (6; 2-9), moderate (17; 13-22), and severe (56; 44-67). For the four-level severity index, the results were slight (6; 2-9), moderate (23; 15-30), severe (52; 38-65), and very severe (122; 84-159). Spearman's correlation coefficient for pad-weighing results and the three-level severity index was 0.47 (P < 0.01) and for the four-level severity index 0.54 (P< 0.01). The four-level severity index gave a more balanced distribution among the women in the clinical materials, and data from the epidemiological survey showed that the four-level severity index identifies a sub-group of older women with very severe incontinence. The four-level severity index seems to be a valid representation of incontinence severity as measured by pad-weighing tests in women presenting for clinical care. It should be considered a potentially valid measure of incontinence severity in epidemiological studies. Neurourol. Urodynam. 19:137-145, 2000.

On the lack of correlation between self-report and urine loss measured with standing provocation test in older stress-incontinent women

This study examined the association between the measured amount of urine lost during a standardized series of coughs in clinic (paper towel test) and questionnaire estimates of stress-related urine loss in 51 older women with mild to moderate urinary incontinence. It also examined the relationship between these questionnaire estimates and a 6-day urinary diary self-report of incontinence frequency and voiding episodes. Pearson's correlation coefficient and percent agreement were used to analyze the relationship between the variables. No significant correlations were found between the paper towel test results and questionnaire items reporting volume of urine loss. The relationship between urinary diary results and questionnaire items regarding the number of incontinence occurrences was weak but significant (r = 0.33, p = 0.045), with agreement in 53% of cases. Agreement was achieved in 68% of cases for number of voids per day recorded by urinary diary and reported by questionnaire (r = 0.65, p = 0.000). This study has quantified a weak correlation between objective and subjective measures of urine loss. These weak correlations could arise from either methodologic limitations in quantifying incontinence or the degree to which differences arise because different phenomena are being measured.

The accuracy of the frequency-volume chart: comparison of self-reported and measured volumes

OBJECTIVE

To assess the accuracy of frequency-volume charts recorded by patients with voiding symptoms by comparing self-reported voiding data with the volumes of urine collected in same period.

PATIENTS AND METHODS

The study comprised 18 patients (median age 63 years, range 20-80) and lasted 3 days, during which the patients recorded their fluid intake and voided volumes, and collected 24 h urine samples.

RESULTS

The recorded volumes exceeded or underestimated the collected volume in 49% and 51%, respectively, of the samples, but the agreement between the accumulated daily voiding volumes on the charts and the volumes collected was acceptable. The median difference between volumes recorded on the charts and collected as samples was 100 (0-1450) mL per 24 h or 10 (0-117) mL per voiding (not significant). The median daily variation of creatinine in the urine was 1.1 (0.1-9.4) mmol (not significant), indicating that the 24 h collection periods were respected.

CONCLUSION

Recordings on frequency-volume charts are valid and useful in the investigation of patients with voiding symptoms.