Evaluation and outcome measures in the treatment of female urinary stress incontinence: International Urogynecological Association (IUGA) guidelines for research and clinical practice

Autologous versus synthetic midurethral transobturator sling: A systematic review and meta-analysis of outcomes

INTRODUCTION

There have been concerns around the use of synthetic mesh for stress urinary incontinence (SUI) surgery with a renewed interest in the use of autologous tissues. Recently, an autologous transobturator sling (aTOT) has been described, but the comparative data with synthetic transobturator sling (sTOT) is limited. The objective of this systematic review and meta-analysis was to assess the outcome of aTOT and compare it with sTOT.

METHODS

A systematic search of PubMed, Scopus, and Web of Science databases was performed and all articles available up to December 31, 2023 were screened. Studies reporting on the outcomes of aTOT and those comparing aTOT with sTOT were included. This review was performed as per Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

Eleven studies evaluating 323 patients that met the criteria were included in the final analysis, of which 6 were single arm (155 patients) and 5 were comparative. In single-arm studies, the pooled success rate, defined as negative cough stress test at 12 months follow-up was 96.8%, 3.8% had postoperative urinary retention, 6.1% had graft site-related complications and 7.6% required additional intervention for persistent SUI. The overall complication rate was 20.6% and there were no Clavien III-V complications. aTOT had similar success and complication rates when compared with sTOT but had a significantly longer operative time (weighted mean difference: 22.35 min, p < 0.00001) and superior sexual function outcomes.

CONCLUSIONS

aTOT, at short-term follow-up (12 months), has similar efficacy and complication rates when compared to sTOT. However, given that the data is limited and not of very good quality, and the fact that long-term follow-up is not available, further studies are required to better define the role of aTOT in the management of female patients with SUI.

Vaginal erbium laser treatment for stress urinary incontinence: A multicenter randomized sham-controlled clinical trial

OBJECTIVE

To evaluate the efficacy and safety of non-ablative vaginal Er:YAG laser device in stress urinary incontinence (SUI) treatment.

METHODS

We conducted a multicenter blinded randomized sham-controlled trial in which women with urodynamic SUI were randomization to active arm using Er:YAG laser therapy, and sham arm using sham handpiece. Patients received two treatments 1 month apart. The primary outcomes measure was 1 h pad weight test measured at 6 months. Secondary outcomes were durability of treatment success at 12 months, and questionnaires for assessment of SUI severity (ICIQ-UI SF), sexual function (PISQ-12) and HRQoL (KHQ), and incidence and severity of device related adverse events and pain (VAS).

RESULTS

A total of 110 participants with SUI were recruited; 73 in the active arm and 37 in the sham arm. Two participants were excluded; one was assigned the wrong treatment and one withdrew their consent. Treatment success was observed in 36% of the sham arm and 59% of the active arm; in the latter, odds of achieving treatment success were more than three-fold higher (OR 3.63, 95% CI: 1.3-11.2, P = 0.02). HRQoL by KHQ showed significant improvement in the active versus the sham arm (OR 0.36, 95% CI: 0.15-0.87, P = 0.003). Similarly, subjective patient assessment of general and sexual function improvement with PISQ-12 and PGI-I showed superior effect over sham (OR 2.8, 95% CI: 1.2-7.0, P = 0.02 and OR 0.13, 95% CI: 0.05-0.36, P < 0.001, respectively).

CONCLUSION

Non-ablative vaginal Er:YAG laser therapy significantly improves SUI symptoms versus sham treatment. Er:YAG laser therapy should be considered as a non-surgical treatment option for SUI patients.

The Role of the Supine Empty Stress Test in the Evaluation of Women with Stress Urinary Incontinence: A Retrospective Cohort Study

The International Continence Society recommends the supine empty stress test (SEST) as an accessory test in the evaluation of women with urinary incontinence, especially for the presence of intrinsic sphincter deficiency (ISD). The aim of this study was to investigate the relationship between the SEST and clinical findings in women diagnosed with stress urinary incontinence with single voiding cycle ambulatory urodynamics (AUM). AUM tracings of patients with lower urinary tract symptoms (LUTS = Lower urinary tract symptoms) (n = 513) were retrospectively reviewed, and 364 charts with urodynamic SUI were analyzed. Demographics, examination findings, scores of the Sandvik Incontinence Severity Index and validated questionnaires, and AUM findings were compared between SEST-positive and -negative groups. Additionally, the diagnostic accuracy of the SEST in the diagnosis of low abdominal leak point pressure (ALPP ≤ 60 cm H2O) in women with pure urodynamic SUI was calculated. The SEST was positive in 41.8% (n = 152) of the cohort. Women with a positive SEST had higher scores on the Sandvik severity index (9.2 ± 3.6 vs. 7.5 ± 3.8, p = 0.003) and lower ALPP (79.6 ± 29.3 vs. 98.4 ± 31.3, p < 0.001). The negative predictive value of the SEST for ISD was found to be 92.4%. Thus, the SEST seems to be an objective clinical test reflecting urinary incontinence severity while excluding the presence of ISD.

Comparison of Low-Energy Radiofrequency Thermal Vaginal Therapy with Sham Treatment for Stress Urinary Incontinence in Postmenopausal Women: A Randomized Controlled Trial

Introduction and Hypothesis

Low-energy radiofrequency (RF) thermal vaginal therapy for vaginal laxity and the genitourinary syndrome of menopause denatures collagen fibrils in the endopelvic fascia; fiber tightening during healing may stabilize the urethra and bladder neck, thereby resolving female stress urinary incontinence (SUI), especially in postmenopausal women. This study compared RF vaginal therapy with sham treatment for mild to moderate SUI.

Methods

This double-blinded, randomized controlled trial, conducted at a tertiary center from September 2018 to April 2021, recruited postmenopausal women with mild to moderate degree of SUI who had never undergone surgery, energy-based therapy, or vaginal estrogen treatment. The intervention group received vaginal RF laser treatment; the sham group did not. The primary outcome was the 1-hour pad-weight test (PWT) result. Secondary outcomes were Incontinence Quality of Life (I-QOL), Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), Patient Global Impression of Improvement (PGI-I), percentage of improvement among all participants, and adverse events. Data were analyzed using STATA 17.0.

Results

Forty-nine participants randomized to RF (n = 23) and sham (n = 26) groups were eligible for analysis. PWT decreased during follow-up in the RF group but remained stable in the sham group; PWT did not significantly differ between groups. The 1-year post-treatment success rate was higher in the RF group (69.6%) than in the sham group (38.5%). At 1 year post-treatment, there were no statistically significant differences in any secondary outcomes.

Conclusion

Low-energy RF vaginal therapy is an alternative treatment for mild to moderate SUI in postmenopausal women without serious adverse events. Larger randomized controlled trials should be conducted.

Methodology for studying Relative Energy Deficiency in Sport (REDs): a narrative review by a subgroup of the International Olympic Committee (IOC) consensus on REDs

In the past decade, the study of relationships among nutrition, exercise and the effects on health and athletic performance, has substantially increased. The 2014 introduction of Relative Energy Deficiency in Sport (REDs) prompted sports scientists and clinicians to investigate these relationships in more populations and with more outcomes than had been previously pursued in mostly white, adolescent or young adult, female athletes. Much of the existing physiology and concepts, however, are either based on or extrapolated from limited studies, and the comparison of studies is hindered by the lack of standardised protocols. In this review, we have evaluated and outlined current best practice methodologies to study REDs in an attempt to guide future research.This includes an agreement on the definition of key terms, a summary of study designs with appropriate applications, descriptions of best practices for blood collection and assessment and a description of methods used to assess specific REDs sequelae, stratified as either Preferred, Used and Recommended or Potential Researchers can use the compiled information herein when planning studies to more consistently select the proper tools to investigate their domain of interest. Thus, the goal of this review is to standardise REDs research methods to strengthen future studies and improve REDs prevention, diagnosis and care.

Healthy bladder storage and emptying functions in community-dwelling women measured by a 2-day bladder health diary

INTRODUCTION

The prevalence of healthy bladder storage and emptying function in community-dwelling women is not well established.

METHODS

A planned secondary analysis of a US cross-sectional study designed to validate a bladder health instrument was conducted in women aged ≥18 years. A subset was invited to complete the novel 2-day bladder health diary capturing bladder storage and emptying experiences. Overall healthy bladder function was defined as ≤8 waking/daytime voids and ≤1 void during sleeping/nighttime; along with the absence of leakage, urgency, emptying difficulties (initiation, flow, efficacy, relief of urge sensation) and pain. Descriptive statistics of healthy bladder functions and regression models of factors associated with healthy function are reported.

RESULTS

Of the 383 invited, 237 (62%) eligible women returned complete dairies. Of these, 12% (29/237) met criteria for overall healthy bladder function. Most (96%) denied pain, 74% had healthy daytime and 83% had healthy nighttime voiding frequency, 64% were continent, 36% reported healthy emptying and 30% denied any urgency episodes. Middle income (odds ratio [OR]:95% confidence interval [CI] = 11.4:1.9-67.4 for $75k-$99 999 vs. $25 000-$49 999), Graduate education (4.8:1.4-17) and previously seeking treatment for bladder problems (OR:95%CI = 0.1; 0-0.9) were associated with overall healthy function.

CONCLUSION

The prevalence of overall healthy bladder function was very low based on our strict definition of health as measured on a 2-day diary. However, most women had healthy voiding frequency and denied pain or urinary leakage. Postvoid dribbling and urgency most commonly contributed to an overall unhealthy bladder. Further investigation is needed to determine whether these diary derived measures are meaningful for patient-oriented bladder health research.

FIGO recommendations: Use of midurethral slings for the treatment of stress urinary incontinence

BACKGROUND

Stress urinary incontinence (SUI) is a global problem. It can significantly adversely impact a woman's quality of life. The use of synthetic mesh in vaginal surgery is controversial, especially when used for pelvic organ prolapse surgery. Although negative effects have been reported, the synthetic mesh midurethral sling (MUS) is considered to be safe and effective in the surgical treatment of SUI.

OBJECTIVES

To provide evidence-based data and recommendations for the obstetrician/gynecologist who treats women with SUI and performs or plans to perform MUS procedures.

METHODS

Academic searches of MEDLINE, the Cochrane Library, Embase, and Google Scholar articles published between 1987 and March 2020 were performed by a subgroup of the Urogynecology and Pelvic Floor Committee, International Federation of Gynecology and Obstetrics (FIGO).

SELECTION CRITERIA

The obtained scientific data were associated with a level of evidence according to the Oxford University Centre for Evidence-Based Medicine and GRADE Working Group system. In the absence of concrete scientific evidence, the recommendations were made via professional consensus.

RESULTS

The FIGO Urogynecology and Pelvic Floor Committee reviewed the literature and prepared this evidence-based recommendations document for the use of MUS for women with SUI.

CONCLUSIONS

Despite the extensive literature, there is a lack of consensus in the optimal surgical treatment of SUI. These recommendations provide a direction for surgeons to make appropriate decisions regarding management of SUI. The MUS is considered safe and effective in the treatment of SUI, based on many high-quality scientific publications and professional society recommendations. Comprehensive long-term data and systemic reviews are still needed, and these data will become increasingly important as women live longer. These recommendations will be continuously updated through future literature reviews.

Efficacy Comparison between Kegel Exercises and Extracorporeal Magnetic Innervation in Treatment of Female Stress Urinary Incontinence: A Randomized Clinical Trial

Background and Objectives: To estimate the effectiveness of Kegel exercises versus extracorporeal magnetic innervation (EMI) in the treatment of stress urinary incontinence (SUI). Materials and Methods: A parallel group, randomized clinical trial was conducted in the Department of Obstetrics and Gynecology, Clinical Hospital Centre Zagreb, Croatia. After assessing the inclusion/exclusion criteria, each eligible participant was randomized to one of the two observed groups by flipping a coin: the first group underwent treatment with Kegel exercises for 8 weeks, while the second group underwent EMI during the same time interval. The primary outcome was the effectiveness of treatment as measured by the ICIQ-UI-SF overall score, eight weeks after the commencement of treatment. Results: During the study period, 117 consecutive patients with SUI symptoms were assessed for eligibility. A total of 94 women constituted the study population, randomized into two groups: Group Kegel (N = 48) and Group EMI (N = 46). After 8 weeks of follow-up, intravaginal pressure values in the EMI group were 30.45 cmH2O vs. the Kegel group, whose values were 23.50 cmH2O (p = 0.001). After 3 months of follow-up, the difference was still observed between the groups (p = 0.001). After the end of treatment and 3 months of follow-up, the values of the ICIQ-UI SF and ICIQ-LUTSqol questionnaires in the EMI group were lower than in the Kegel group (p < 0.001). Treatment satisfaction was overall better in the EMI group than in the Kegel group (p < 0.001). Conclusions: Patients treated with EMI had a lower number of incontinence episodes, a better quality of life, and higher overall satisfaction with treatment than patients who performed Kegel exercises.

Estimated costs of preoperative evaluation of postmenopausal hysterectomy for prolapse at a safety-net hospital: an observational descriptive study

BACKGROUND

In practice, preoperative evaluation prior to hysterectomy varies. Unnecessary preoperative evaluation may add cost and risk with little benefit to the patient.

OBJECTIVE

This study aimed to describe practice patterns and the associated costs related to preoperative evaluations before hysterectomy for prolapse at a safety-net hospital.

STUDY DESIGN

This was a retrospective cohort study of postmenopausal women who underwent a hysterectomy for prolapse. Nonfacility-associated cost data were obtained from the Centers for Medicare Services. The biopsy cost was estimated to be $172.55 and $125.23 for ultrasounds.

RESULTS

A total of 505 postmenopausal cases were identified. Of those, 155 (31%) underwent a preoperative biopsy, 305 (60%) had an ultrasound, and 124 (25%) had both. Of those, 72.9% had an indication for a biopsy. A total of 64 biopsies and 216 ultrasounds lacked clear indication. Of those, 56 biopsies were performed for bleeding in cases with an endometrial thickness of <4 mm. The total cost of nonvalue-added testing was $42,576.

CONCLUSION

Adherence to a strict preoperative algorithm would have saved $38,092 over the study period, although 0.50% of these biopsies would potentially have detected endometrial cancer preoperatively. These results underscore the value of clinical algorithms at teaching institutions.

Adherence to professional society guidelines among women with stress or mixed urinary incontinence

Aims

The objective of this analysis was to describe longitudinal adherence with recommended urinary incontinence (UI) evaluation and treatment guidelines over a 2‐year period in patients newly diagnosed with stress (SUI) or mixed UI (MUI), and average 2‐year cost associated with initial treatment.

Methods

A retrospective claims analysis using the IBM MarketScan database was conducted. Women diagnosed with SUI/MUI between July 1, 2014 and June 30, 2016 were identified using the International Classification of Diseases (ICD) 9 and 10 codes for SUI or MUI. Newly diagnosed SUI/MUI patients who did not have a UI‐related diagnosis for at least 1 year before their index date were assessed.

Results

103 813 patients with newly diagnosed SUI or MUI were identified. Of those, 96.15% (99 821/103 813) received an initial evaluation in accordance with professional guidelines (e.g., patient history, physical examination, urinalysis). Only 6.8% (5086/74 925) and 7.7% (2229/28 888) of patients with SUI and MUI, respectively, received a first‐line behavioral treatment (e.g., pelvic floor muscle exercises, bladder training), according to guidelines. The 2‐year average UI‐related medical costs associated with guideline adherence for SUI were $5770.93 ± $9454.81 and for MUI, $4416.16 ± $7401.53. Nonadherence was observed in 59.2% (44 382/74 925) of SUI and 64.1% (18 530/28 888) of MUI patients. Two‐year average UI‐related medical costs for the nonadherent group were $8568.00 ± $11 275.52 for SUI and $6986.66 ± $10 765.55 for MUI, significantly more than the adherent group (p < 0.0001).

Conclusion

The majority of SUI or MUI patients do not receive a documented behavioral intervention as their first‐line treatment, which is a recommendation by professional society guidelines. This was found to affect the cost burden for payers; those that were nonadherent had significantly higher costs 2‐year postindex.

Clinical Study on the Treatment of Female Stress Urinary Incontinence With Modified Buzhong Yiqi Decoction

Purpose

To study the clinical application value of Modified Buzhong Yiqi Decoction in the treatment of female stress urinary incontinence (SUI).

Methods

A total of 103 female patients with SUI were included in this study, 13 were lost to follow-up, and the final number of studies was 90. General information about the patients, including age, years of menopause, body mass index (BMI), reproductive history, chronic respiratory disease, hypertension, and diabetes, were recorded. All the patients were treated with Modified Buzhong Yiqi Decoction alone for 4 weeks. The Patient Global Impression of Improvement (PGI-I), the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICI-QSF) and 72-h voiding diary were used to evaluate the patients' subjective symptoms and urinary incontinence degree before treatment, 1 month after treatment and 1 year after treatment, the efficacy and efficacy-related factors of Modified Buzhong Yiqi Decoction in the treatment of female SUI were analyzed.

Results

One month after Modified Buzhong Yiqi Decoction treatment, compared with before treatment, the PGI-I questionnaire was very much better (68.89%), much better (8.89%), a little better (12.33%), no change (8.89%), the ICI-QSF score decreased (P < 0.05), and 72-h urine leakage frequency decreased (P < 0.05); One year after treatment compared with before treatment, the PGI-I questionnaire was very much better (40.00%), much better (17.78%), a little better (12.22%), no change (30.00%), the ICI-QSF score decreased (P < 0.05), and 72-h urine leakage frequency decreased (P < 0.05); and 1 year after treatment compared with 1 month after treatment, the ratio of very much better at 1 year after treatment was significantly decreased (P < 0.05), the score of the ICI-QSF was significantly increased (P < 0.05), and 72-h urine leakage frequency was significantly increased (P < 0.05). The correlation analysis showed that the efficacy at 1 month after treatment was negatively correlated with the severity of SUI and chronic respiratory diseases, but was not significantly correlated with age, menopause status, BMI, number of pregnancies, and number of births. The efficacy at 1 year after treatment was negatively correlated with the severity of SUI, chronic respiratory disease, age, and number of births and was positively correlated with BMI, but not significantly correlated with menopause status and number of pregnancies.

Conclusion

Modified Buzhong Yiqi Decoction can effectively treat SUI in women. The efficacy is related to the severity of SUI and chronic abdominal hypertension, but the long-term efficacy decreases.

Vaginal erbium laser for treatment of stress urinary incontinence: optimization of treatment regimen for a sustained long-term effect

Stress urinary incontinence (SUI) is a common health problem that affects roughly 35% of women in the reproductive period. A prospective uncontrolled study was conducted to assess the long-term efficacy and safety of a non-ablative Er:YAG laser treatment of SUI. Forty-three patients participated in the study. All women underwent three sessions of IncontiLase® procedure, and efficacy of laser treatment was assessed by 1-h pad test, 24-h pad test, 3-day voiding diary, and ICIQ-UI SF questionnaire at multiple follow-ups. Statistical analysis was performed using one-way repeated measures ANOVA. Patients were questioned about discomfort during treatment and any adverse events following the laser procedures. All outcome measures showed a significant change over a period of the entire clinical trial. Eighteen-month follow-up revealed a fading of the effect, which was alleviated by single-session maintenance treatments every 6 months. There were no serious adverse events reported during the study. All reported side effects were mild and transient. The application of non-ablative Er:YAG laser for SUI treatment significantly improves the SUI symptoms. High improvement rates and patient satisfaction can be maintained with single-session maintenance treatments performed every 6 months. Long-term safety profile of multiple non-ablative Er:YAG laser treatment is shown. NCT04348994, 16.04.2020, retrospectively registered.

Level of agreement and acceptance of the 20-Minute versus 60-Minute sanitary pad test as a method for measuring the severity of stress urinary incontinence: randomised crossover trial

We aimed to measure the level of agreement and acceptance ratio of the 20-minute versus 60-minute sanitary pad test in female patients with stress urinary incontinence (SUI). This is one-sample cross-experimental design. SUI patients at the Urogynecology Outpatient Clinic at Cipto Mangunkusumo Hospital in Jakarta, Indonesia were consecutively enrolled as participants. We first administered the 20-minute test, followed by the 60-minute test, or vice versa, within 1 week. The participants did not know the type of test performed or asked during the interview. Random Number Generator software by stattrek.com was used to determine which test was performed first for each participant. Participants were interviewed using a questionnaire at the end of each test. The 20-minute sanitary pad test exhibited a good level of agreement with the 60-minute sanitary pad test (kappa R = 0.84). Forty-two respondents (84.0%) reported that they were "satisfied" with the 20-minute sanitary pad test and eight respondents (16.0%) reported that they were "very satisfied". There was a good agreement between the 20-minute and 60-minute sanitary pad test for assessing the severity of SUI. The 20-minute sanitary pad test achieved a relatively higher level of participant satisfaction.Impact statementWhat is already known on this subject? Patients at the Urogynecology Outpatient Clinic at Cipto Mangunkusumo Hospital have a positive acceptance in the 20-minute and 60-minute sanitary pad test for assessing the severity of SUI.What do the results of this study add? From this result, the authors considered that this method can help in assessing the severity of SUI, especially in Indonesia.What are the implications of these findings for clinical practice and/or further research? As these findings, the authors think that they might be useful as a standard of assessed the severity of SUI. This method does not harmful and easy to apply for every patient with SUI.

Periurethral injection with polyacrylamide after previous TVT surgery

INTRODUCTION AND HYPOTHESIS

The aim of this registry study was to assess the clinical utility of using periurethral bulking with polyacrylamide hydrogel in women with stress urinary incontinence (SUI) after previous midurethral sling surgery.

METHODS

The study period was 2007 through 2019. Using data from the Norwegian Female Incontinence Registry we included 57 women who had received Bulkamid® because of insufficient improvement or recurrent SUI after previous retropubic TVT surgery. The primary outcome was cure of SUI, and secondary outcomes were patient satisfaction, degree of leakage, change in urgency incontinence (UUI), free flow rate, postvoid residual volume, and complications. Descriptive statistics were used to characterize data and Wilcoxon signed-rank test to compare pre- and postoperative results for pairs, with level of significance at p < 0.05.

RESULTS

Pure SUI was seen in 19 (33.3%) while 38 (66.7%) had mixed incontinence. Postoperatively 72.9% had a negative stress test and 73.7% were satisfied with treatment. There was only 1 complication in 67 injections (1.5%). De novo UUI occurred in five patients, corresponding to 8.8% of the whole study group, but 26.3% among those with no preoperative UUI problems. Among the patients with preoperative UUI, 39.5% were cured of this problem and a further 36.8% were improved.

CONCLUSIONS

The cure rate and satisfaction rate of periurethral bulking with polyacrylamide after previous MUS are favorable and complications are rare. There seems to be a risk of overactive bladder symptoms developing in women with no such symptoms preoperatively.

Artificial intelligence models derived from 2D transperineal ultrasound images in the clinical diagnosis of stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of the study was to develop artificial intelligence (AI) algorithms using 2D transperineal ultrasound (TPUS) static images to simplify the clinical process of diagnosing stress urinary incontinence (SUI) in practice.

METHODS

The study involved 400 patients in total, including 265 SUI patients and 135 non-SUI patients who underwent a routine clinical evaluation process by urologists and TPUS. They were classified into different groups based on the International Consultation on Incontinence Questionnaire (ICIQ) to assess the impact of inconvenience on patients' lives. Four AI models were developed by 2D TPUS images: Model A (a single-mode model based on Valsalva maneuver images to classify G-0, G-1, and G-2); Model B (a dual-mode model based on Valsalva maneuver and resting state images to classify G-0, G-1, and G-2); Model C (a single-mode model based on Valsalva maneuver images to classify G-2 and G-01); Model D (a dual-mode model based on Valsalva maneuver and resting state images to classify G-2 and G-01). The performance of the four models was evaluated by confusion matrices and the area under the receiver-operating characteristic curve (AUC).

RESULTS

The dual-mode model based on the Valsalva maneuver and resting-state images (Model D) had a higher accuracy of 86.3% and an AUC of 0.922, which was significantly higher than the AUCs of the other three models: 0.771, 0.862, and 0.827.

CONCLUSIONS

The AI algorithm using 2D TPUS static images of the Valsalva maneuver and resting state may be a promising tool in the diagnosis of SUI patients in to relieve clinical processes in practice given its ease of use in clinical applications.

Adult female urinary incontinence guidelines: a systematic review of evaluation guidelines across clinical specialties

INTRODUCTION AND HYPOTHESIS

To systematically review evaluation guidelines of uncomplicated urinary incontinence (UI) in community-dwelling adult women to assess guidance available to the full range of providers treating UI.

METHODS

Systematic literature search of eight bibliographic databases. We included UI evaluation guidelines written for medical providers in English after January 1, 2008.

EXCLUSION CRITERIA

guidelines for children, men, institutionalized women, peripartum- and neurologic-related UI. A quantitative scoring system included assessed components and associated recommendation level and clarity.

RESULTS

Twenty-two guidelines met the criteria. All guidelines included: history taking, UI characterization, physical examination (PE) performance, urinalysis, and post-void residual volume assessment. At least 75% included medical and surgical history assessment, other disease process exclusion, medication review, impact on quality of life ascertainment, observing stress UI, mental status assessment, performing a pelvic examination, urine culture, bladder diary, and limiting more invasive diagnostics procedures. Fifty to 75% included other important evaluation components (i.e., assessing obstetric history, bowel symptoms, fluid intake, patient expectations/preferences/values, obesity, physical functioning/mobility, other PE [abdominal, rectal, pelvic muscle, and neurologic], urethral hypermobility, and pad testing. Less than 50% of guidelines included discussing patient treatment goals. Guidelines varied in level of detail and clarity, with several instances of unclear or inconsistent recommendations within the same guideline and evaluation components identified only by inference from treatment recommendations. Non-specialty guidelines reported fewer components with a lesser degree of clarity, but this difference was not statistically significant (p = 0.20).

CONCLUSIONS

UI evaluation guidelines varied in level of comprehensiveness, detail, and clarity. This variability may lead to inconsistent evaluations in the work-up of UI, contributing to missed opportunities for individualized care.

Impact of bariatric surgery in patients with stress urinary incontinence

Objective:

To examine epidemiologic, anthropometric and clinical variables associated with stress urinary incontinence in obese women, before and after bariatric surgery, and to identify predictive factors of stress urinary incontinence resolution.

Methods:

Prospective observational study with women enrolled in a bariatric surgery program between 2015 and 2016. Patients were assessed prior to and 6 months after bariatric surgery using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, the Patient Global Impression of Improvement and the Visual Analogue Scale. Patient assessment also included physical examination and bladder stress tests.

Results:

A total of 43 women completed the study. There was a 72.7% reduction in stress urinary incontinence (p=0.021). Predictive factors for preoperative diagnosis of stress urinary incontinence included age (p=0.024) and abdominal waist circumference (p=0.048). Urinary symptoms improved after weight loss, especially nocturia (p=0.001) and stress urinary incontinence (p=0.026). Menopause was the most significant predictive factor for persistence of stress urinary incontinence within six months of bariatric surgery (p=0.046). Self-reported outcomes and scores obtained in the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, the Patient Global Impression of Improvement and the Visual Analogue Scale were associated with significant improvement (p=0.012, p=0.025, and p=0.002 respectively).

Conclusion:

Older women with larger waist circumference have a higher risk of developing stress urinary incontinence prior to bariatric surgery. Menopausal women are highly prone to persistent stress urinary incontinence, even after weight loss. Weight loss achieved through bariatric surgery improved stress urinary incontinence symptoms and mitigated related impacts on quality of life in the vast majority of women.

Present value of the Urethral mobility test as a tool to assess Stress urinary incontinence due to Intrinsic sphincteric deficiency

Q-tip test offers a simple approach for identifying urethral hypermobility. Considering surgical treatment, stress urinary incontinence (SUI) must be classified and the contribution of intrinsic sphincter deficiency (ISD) and/or urethral hypermobility must be determine. We believe there's a correlation between abdominal leak point pressure (ALPP) and urethral mobility degree, and the aim of this study is to explore it using Q-tip. We conducted a prospective study, between years 2014 and 2016. Females over 18 years presenting with signs and symptoms of SUI according to the 2002 ICS Standardization of Terminology were included. Assessment was made with the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF), the Q-tip test and invasive urodynamics. Urethral mobility (UM) and ALPP were analyzed. We built two composite variables based on reported risk factors for ISD, defined as composite variable A (equal to a Q-tip test < 30° AND ICIQ-SF ≥ 10 points) and composite variable B (equal to low urethral mobility AND/OR hypoestrogenism AND/OR history of radiotherapy AND/OR previous pelvic surgery). Correlation analyzes were made according to the type of variable. A total of 221 patients were included. Incontinence was rated as moderate and severe by 65.3% and 6.8%, respectively. The analysis showed a 61.75%, 51.61% and 70.6% agreement between ALPP and UM, ALPP and composite variable A and ALPP and composite variable B respectively. Correlation and concordances were low (r = 0.155, r_s = − 0.053 and r_s = − 0.008), (rho_c = 0.036, k = 0.116 and k = 0.016). Neither the degree of UM, nor the composite variables, correlate or agree with urethral function tests in UDS, suggesting that the ALPP cannot be predicted using the Q-tip test or the ICIQ-SF for classifying patients with SUI.

Can conventional urodynamic variables help to predict the necessity of overactive bladder symptomatic therapy in women after transobturator tape surgery?

Introduction

The aim of this study was to find out if there are any conventional urodynamic (UDS) variables that would help to predict the necessity of overactive bladder (OAB) symptomatic therapy in women after transobturator tape surgery (TOT).

Material and methods

A total of 487 females after TOT were enrolled in this retrospective study. Inclusion criteria (UDS before surgery, follow-up visit within 2–6 month after TOT) were met in 169 women. Based on patient history, questionnaires and physical examination, two groups were distinguished: pure stress urinary incontinence (SUI) and stress-predominant mixed urinary incontinence (MixUI). A statistical analysis was performed including age and UDS variables. T-test was used for continuous data and Chi-squared test for categorical data. Combinations of these factors were analyzed using binary logistic regression and surgery outcome as the target variable.

Results

Significant correlations between the probability of a need for OAB therapy after TOT were observed with age (higher age increases OAB therapy necessity, p <0.001) and such UDS variables as cystometric capacity (CC) p <0.001; maximum flow rate (Qmax) p <0.001; detrusor contractility index (DCI) p <0.015 – higher value decreased the need for OAB therapy. Critical limit for these values: 60 years for age, 300 ml for CC, 15 ml/s for Qmax, but no specific value for DCI was observed. Binary logistic regression showed that the UI Group (p <0.01) and CC (p = 0.01) allow correctly classify 78.9% of TOT outcome (increased CC and SUI group are factors for TOT normal outcome).

Conclusions

UI group, age, CC, Qmax, DCI can help to predict the necessity of OAB symptomatic therapy in women after TOT.

The role of vaginal palpation in motor learning of the pelvic floor muscles for women with stress urinary incontinence: study protocol for a randomized controlled trial

BACKGROUND

Approximately 30 to 50% of women are unable to correctly perform pelvic floor muscle (PFM) contractions. For women to benefit from a pelvic floor muscle training (PFMT) programme for stress urinary incontinence (SUI), the awareness phase of PFMT cannot be omitted. The purpose of this study is to evaluate whether vaginal palpation together with verbal instructions about PFMs and body awareness techniques helps women with SUI learn how to correctly contract the PFMs and improve their functions.

METHODS

This single-centre, double-blind randomized controlled trial with two intervention groups was designed following the standard protocol items for randomized interventional trials (SPIRIT). The results will be reported in a manner consistent with the Consolidated Standards of Reporting Trials (CONSORT) guidelines. Patients with SUI (n = 172) will be recruited. The experimental group will receive verbal instructions about PFM function and body awareness techniques together with vaginal palpation; the control group will receive similar protocol without vaginal palpation. The primary outcome includes the number of fast-twitch muscle fibres assessed by vaginal palpation and visual observation. Secondary outcomes include power and muscular endurance that will be assessed by visual observation and vaginal palpation (Oxford scale), the use of accessory muscles during the voluntary contraction of PFMs, and the self-efficacy and the expectations for the results using the self-efficacy scale of pelvic floor exercises.

DISCUSSION

This study will determine whether vaginal palpation can help women with SUI to correctly perform PFM contractions and improve their functions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03325543 . Registered on 30 November 2017. Study protocol version 1; 30 November 2020. Prospectively registered.

Systematic review of guidelines for urinary incontinence in women

INTRODUCTION AND OBJECTIVE

Urinary incontinence in women is the subject of multiple recommendations all over the world. The aim of our study was to compare methodologies and search for inconsistencies in texts and grades in these guidelines.

METHODS

Seventeen recommendations from different medical societies in English, French and German were included. Their methodologies were analyzed, including writing methods, cyclicity, level of evidence (LE) and grades. The recommendations were synthesized and inconsistencies in texts and grades were studied. The quality of recommendations was evaluated with the Appraisal of Guidelines for Research and Evaluation (AGREE II) scale.

RESULTS

Methods, rigour and cyclicity varied depending on societies. LE and grades are broadly consensual for higher LE and grades and less so for lower LE and grades. The Collège National des Gynécologues et Obstétriciens Français, the Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, the European Association of Urology, the International Consultation on Urological Diseases and the National Institute for Health and Care Excellence have an AGREE score ≥ 80 % (third quartile). Grading and textual inconsistencies are explained by the order of studies or the absence of high LE.

CONCLUSION

With the present study we closely explored comparatively the methods and semantics of recommendations for urinary incontinence in women.

Has the use of preoperative urodynamics for stress urinary incontinence surgery changed following the VALUE study?

AIMS

To assess whether routine urodynamic testing (UDT) in women undergoing slings for uncomplicated stress urinary incontinence (SUI) has decreased following publication of the landmark VALUE study, which recommended against routine UDT in uncomplicated SUI.

METHODS

We identified women in the Virginia All Payers Claims Database diagnosed with SUI between 2011 and 2016 using International Classification of Disease (ICD) codes (N39.3, 625.6). Appropriate ICD/CPT (current procedural terminology) codes were used to exclude non-index patients (prior anti-incontinence/prolapse surgery, urge incontinence, neurogenic bladder). Beta regression was used to assess for changes in the monthly proportion of urethral slings with preoperative UDT. Interventional ARIMA modeling was used to assess for a relationship between the date of VALUE (The Value of Urodynamic Evaluation) publication and the incidence of slings with preoperative UDT.

RESULTS

Analysis identified 6740 women with SUI undergoing sling placement, with 343 non-index patients excluded. Of 6397 remaining women, 4026 (62.9%) underwent preoperative UDT. The annual number of slings with preoperative UDT declined from 748 to 402 between 2011 and 2016. Beta regression analysis demonstrated a decrease in the proportion of slings with preoperative UDT over the study (68%, 2011; 58%, 2016), with a statistically significant decrease in the proportion of slings with UDT after May 2012 (β coefficient, -.0093; P < .001). Interventional ARIMA models showed a trend toward decreasing slings with preoperative UDT after the VALUE trial (P = .057).

CONCLUSIONS

Our analysis demonstrated a decrease in the proportion of women undergoing preoperative UDT in uncomplicated SUI patients following the VALUE study. Further research is needed to examine factors underlying UDT utilization trends and promote value-driven care.

Valsalva urethral profile (VUP): A urodynamic measure to assess stress urinary incontinence in women

AIMS

We aimed to assess the value of the Valsalva urethral profile (VUP) in case of stress urinary incontinence (SUI).

METHODS

Six hundred and ninety-four women without pelvic organ prolapse were included in this prospective monocentric study. SUI was diagnosed from symptoms using the International Continence Society definition, and severity using two validated questionnaires (USP and ICIQ-SF). The urodynamic parameters studied were maximal urethral closure pressure (MUCP) and functional length (FL). Both were performed at rest, during a Valsalva maneuver (v-MUCP and v-FL) and again at rest. Correlation analyses and ROC curves were used to assess the value of the clinical and urodynamic measurements.

RESULTS

In our population, based on the questionnaires, 172 (24.8%) women were diagnosed with pure SUI on symptoms, 71 (10.2%) with urgency urinary incontinence and 392 (56.5%) with mixed urinary incontinence; 59 (8.5%) women were continent. The v-MUCP was the most correlated parameter to the severity of SUI (ρ: -0.63) and the most predictive of SUI risk, with a threshold value of 35 cm H₂ O (Se = 0.82, Sp = 0.86). The v-FL was significantly shortened in case of SUI.

CONCLUSIONS

The v-MUCP and v-FL are global measurements of urethral resistance during stress. With a threshold value of 35 cm H₂ O, the v-MUCP was the most discriminating parameter for the diagnosis of SUI, with a good reliability.

Pelvic floor muscle training for female stress urinary incontinence: a randomised control trial comparing home and outpatient training

INTRODUCTION AND HYPOTHESIS

In the literature, it is suggested that supervised pelvic floor muscle training (PFMT) might be the first option treatment for female stress urinary incontinence (SUI). However, inadequate accessibility to health care and scarce individual resources may prevent adherence to the treatment. Our study is aimed at comparing the efficacy of performing PFMT in an outpatient clinic and at home in Brazilian incontinent women, and to verify if home PFMT may be an alternative to those not able to attend the outpatient sessions.

METHODS

A total of 69 women with predominant SUI were randomised into two groups: outpatient PFMT and home PFMT. The primary outcome was the cure of SUI defined as <2 g of leakage in a 20-min pad test. Secondary outcomes were: pelvic floor muscle function; urinary symptoms; quality of life; patient satisfaction; and adherence to home exercise sets. The assessments were conducted at baseline and after 3 months of treatment. Statistical analyses consisted of Student's t, Mann-Whitney U, Chi-squared, and Wilcoxon tests, with a 5% cut-off for significance.

RESULTS

A superior objective cure of SUI was observed in the outpatient clinic (62%) compared with the home (28%) PFMT groups (OR: 4.0 [95% CI: 1.4-11.0]; p = 0.011). Secondarily, there was no difference between groups regarding the following: satisfaction with the treatment; quality of life; function of the PFMs; and number of episodes of urine leakage per week. The home adherence to the exercises was superior in the outpatient PFMT group only during the first-month training.

CONCLUSIONS

Outpatient PFMT was associated with a higher objective cure of SUI than home PFMT. However, subjective findings show equal benefit of home PFMT providing evidence that this may be an alternative treatment to our population.

Comparison of retropubic midurethral slings in the treatment of female stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Over 50 different types of midurethral slings have been marketed. They have generally been considered comparable in performance. Many studies have compared retropubic with obturator slings, but few have compared different makes of retropubic slings with each other. We have compared the performance of retropubic slings using data from the Norwegian Female Incontinence Registry.

METHODS

From June 2015 through 2017, 2843 women underwent a retropubic sling procedure, with 6-12-month follow-up data available for 2612 (92%). Results for six different types of slings used in this time period are presented: TVT Exact, TVT Classic, Advantage, Advantage Fit, TVT A.M.I. and RetroArc. The TVT Exact was the most prevalent sling, and the outcomes were compared with this sling as reference using chi-square and Dunnet's tests with significance at 0.05.

RESULTS

There were only small differences among the four slings, TVT Exact, TVT Classic, Advantage and Advantage Fit, with subjective cure rates from 77.7 to 81.9% and objective cure rates from 90.8 to 96.6%. The TVT A.M.I. sling had a high cure rate but significantly fewer satisfied patients and less improvement in urgency bother. The Retro Arc's results were clearly inferior. There was little difference in terms of obstruction or de novo urgency incontinence among the six slings. Most complication rates were not statistically different.

CONCLUSIONS

At 6-12-month follow-up there was no significant difference in clinical results between the TVT Exact, TVT Classic, Advantage and Advantage Fit slings, while RetroArc and to some extent TVT A.M.I. slings underperformed.

Can Stress Urinary Incontinence Be Predicted by Ultrasound?

OBJECTIVE. The purpose of this study is to determine the value of translabial real-time 3D ultrasound for predicting stress urinary incontinence (SUI). SUBJECTS AND METHODS. From December 2012 to August 2016, women with or without SUI diagnosed by urologists via urodynamics were prospectively recruited. All subjects underwent translabial real-time 3D ultrasound at one institution. Volume data were analyzed offline by a radiologist who was blinded to the diagnosis and who evaluated the bladder neck position on maximal Valsalva maneuver, the levator hiatus area on maximum Valsalva maneuver, bladder neck descent, and the urethral rotation angle. Combinations of two, three, and four parameters were analyzed using Fisher linear discriminant analysis. ROC curves were constructed to determine the optimal cutoff values of the four parameters and all combinations of parameters to predict SUI. RESULTS. A total of 321 women with SUI (mean [± SD] age, 35 ± 11 years) and 90 women without SUI (mean age, 31 ± 8 years) were included. Only 337 women were included in the final study, to eliminate the confounder of age. The cutoff values for the bladder neck position on maximal Valsalva maneuver, the levator hiatus area on maximum Valsalva maneuver, bladder neck descent, and the urethral rotation angle as parameters predicting SUI were 1 mm, 19 cm², 24 mm, and 45°, respectively. For all combinations of parameters, the negative predictive values were more than 90%, although none of the combinations had a sensitivity higher than 70%. The specificities were approximately 95% when three or four parameters were included. The positive predictive value of the combinations ranged from 49.2% to 84.8%. CONCLUSION. Translabial real-time 3D ultrasound is insufficient for predicting SUI, but it can be used to identify women without the condition.

Molecular aspects of collagenolysis associated with stress urinary incontinence in women with urethral hypermobility vs intrinsic sphincter deficiency

AIMS

We aimed to assess the alterations in specific molecular mechanisms associated with collagenolysis and their correlation in cases of stress urinary incontinence (SUI) by urethral hypermobility (UH) and by intrinsic sphincter deficiency (ISD).

METHODS

We evaluated the messenger RNA (mRNA) expression of matrix metalloproteinases (MMP1, MMP2, and MMP9), specific tissue inhibitors of metalloproteinases (TIMPs), and associated proteins (TIMP1, TIMP2, and α-2-macroglobulin [A2McG]) in the suburethral tissue of women with SUI (half with SUI by UH and half with SUI by ISD) by reverse-transcriptase quantitative polymerase chain reaction and determined the correlations of the expression of these proteins on each pathological condition.

RESULTS

In the suburethral tissue, we found significantly altered MMP2 mRNA levels, being higher in women with ISD than in those with UH. Still, MMP1 and MMP9 exhibited a tendency to a higher expression in women with ISD. Concerning the TIMPs expression, no significant statistical differences were found between women with UH and ISD. When evaluating the MMP/TIMP ratios, we found significant statistical differences between MMP9/TIMP1 and MMP9/A2McG. In fact, the correlations of the expression MMP9 with TIMP1 and A2McG were lost for women with UH. The ratios between MMP1/TIMP1 and MMP1/A2McG were similar, although there was a tendency of higher ratio in ISD for MMP2/TIMP2 and MMP2/A2McG.

CONCLUSION

Our results point toward higher collagenolysis in the suburethral tissue of women with SUI by ISD.

Electronic Personal Assessment Questionnaire-Pelvic Floor: Italian cultural adaptation and face validity

INTRODUCTION

Electronic questionnaires offer invaluable advantages over paper-based ones. The aims of this study were to make available to Italian clinicians a culturally adapted version of the multidimensional electronic Personal Assessment Questionnaire-Pelvic Floor and to test face validity and factorial analysis for the Urinary section.

METHODS

The original English-language version of electronic Personal Assessment Questionnaire-Pelvic Floor was cross-culturally adapted to the Italian language. At the Urogynaecology Unit of Buzzi Hospital in Milan, the Urinary section of the Italian version was completed by women symptomatic for pelvic floor dysfunction. Time to questionnaire completion was recorded, and a nine-item paper questionnaire about the questionnaire was completed. Descriptive analysis to define patient population characteristics and nine-item paper questionnaire analysis were performed. Factorial analyses on the Urinary section of the questionnaire and on the nine-item paper questionnaire were performed, and internal reliability was assessed using Cronbach's alpha.

RESULTS

A culturally adapted Italian version of electronic Personal Assessment Questionnaire-Pelvic Floor was provided. In total, 95 women complaining of pelvic floor dysfunction took part in the study. Mean time to electronic questionnaire completion was 9 min (range: 5-17), with 95% of patients completing within 15 min. More than 95% of women considered the Italian version of electronic Personal Assessment Questionnaire-Pelvic Floor helpful, relevant, easy to use and comprehensive and would be happy to use it again. The questionnaire being overly long was an issue for 17% of women. The internal consistency of items in the nine-item paper questionnaire was confirmed with Cronbach's alpha scores > 0.8 for both the 'Value' and 'Burden' domains.

DISCUSSION

Our Italian cultural adaptation of electronic Personal Assessment Questionnaire-Pelvic Floor was well accepted by an appropriate target population. A full psychometric validation is now warranted.

Urinary Incontinence

Urinary incontinence is a common, often undertreated, condition that impacts millions of Americans. Primary care physicians are well equipped to diagnose and treat urinary incontinence. Key to successful treatment is accurately determining the type of incontinence that ails the patient and using patient-reported quality-of-life indicators to guide stepwise treatment.

A Prospective Study of Minimally Invasive Paravaginal Repair of Cystocele and Associated Pelvic Floor Defects: Our Experience

Aims and objectives

To assess the outcome of minimally invasive paravaginal repair of symptomatic cystocele and to correlate postoperative outcome with preoperative presentation. The primary outcome was the anatomical outcome measured by postoperative physical examination and the functional outcome was assessed by subjective symptoms and questionnaires. The secondary outcomes were perioperative and postoperative complications.

Materials and methods

In this longitudinal prospective observational study, 44 women underwent laparoscopic or robotic paravaginal cystocele repair from January 2016 to July 2016 and they were followed up to 1 year after surgery in a tertiary advanced laparoscopic center. All patients had a symptomatic lateral cystocele ≥ grade 2 according to Baden-Walker classification. Other coexisting defects like apical cystocele or combined defects were corrected concomitantly. The anatomical outcome was measured by physical examination and functional outcome was assessed by questionnaires-Pelvic Organ Prolapse Distress Inventory 6 and Urinary Distress Inventory 6 preoperatively and during postoperative follow-up.

Results

All 44 patients were followed up to 12 months after surgery. The anatomical cure rate for cystocele was 97.7%. There were no major complications. All subjective symptoms and quality of life scores improved significantly during postoperative follow-up. The anatomical recurrence rate in our study was 2.3%.

Conclusion

Minimally invasive paravaginal repair of cystocele is an effective advanced laparoscopic procedure. It can be concomitantly performed with other surgical procedures to correct coexisting defects. The anatomical and functional results were outstanding with minimum perioperative morbidity and encouraging long-term outcome.

Effectiveness of Pelvic Floor Muscle Training Alone and in Combination With Biofeedback, Electrical Stimulation, or Both Compared to Control for Urinary Incontinence in Men Following Prostatectomy: Systematic Review and Meta-Analysis

BACKGROUND

The efficacy of pelvic floor muscle training (PFMT) alone and in combination with biofeedback (BFB), electrical stimulation (ES), or both for urinary incontinence in men following prostatectomy is inconclusive.

PURPOSE

The purpose of this study was to determine whether PFMT works well alone or in combination with BFB, ES, or both in comparison with a control.

DATA SOURCES

The databases Ovid Medline, EMBASE, CENTRAL, Scopus, and Web of Science, and the specialized register of the Citroen Incontinence Review Group were searched from study inception to August 2017. Abstract proceedings from urological meetings, including the European Association of Urology and the American Urological Association, were also searched.

STUDY SELECTION

Randomized controlled trials that compared PFMT alone and PFMT with ES, BFB, or both and no treatment, placebo, or sham were included in the review.

DATA EXTRACTION, SYNTHESIS, AND QUALITY

Two independent reviewers completed data extraction and quality appraisal. The Grading of Recommendations, Assessment, Development, and Evaluation tool was used for quality appraisal. Meta-analysis was done with software used for preparing and maintaining Cochrane reviews.

LIMITATIONS

Methodological flaws in the included studies limited internal validity.

CONCLUSIONS

PFMT alone, PFMT plus BFB and ES, and PFMT plus ES were more effective than the control for urinary incontinence following prostatectomy. The effect of PFMT plus BFB on postprostatectomy incontinence remains uncertain.

A double-blind, randomized, placebo-controlled clinical trial evaluating the safety and efficacy of autologous muscle derived cells in female subjects with stress urinary incontinence

PURPOSE

The purpose of the study was to assess safety and efficacy of autologous muscle derived cells for urinary sphincter repair (AMDC-USR) in female subjects with predominant stress urinary incontinence.

METHODS

A randomized, double-blind, multicenter trial examined intra-sphincteric injection of 150 × 10⁶ AMDC-USR versus placebo in female subjects with stress or stress predominant, mixed urinary incontinence. AMDC-USR products were generated from vastus lateralis needle biopsies. Subjects were randomized 2:1 to receive AMDC-USR or placebo and 1:1 to receive 1 or 2 treatments (6 months after the first). Primary outcome was composite of ≥ 50% reduction in stress incontinence episode frequency (IEF), 24-h or in-office pad weight tests at 12 months. Other outcome data included validated subject-recorded questionnaires. Subjects randomized to placebo could elect to receive open-label AMDC-USR treatment after 12 months. Subject follow-up was up to 2 years.

RESULTS

AMDC-USR was safe and well-tolerated with no product-related serious adverse events or discontinuations due to adverse events. Interim analysis revealed an unexpectedly high placebo response rate (90%) using the composite primary outcome which prevented assessment of treatment effect as designed and thus enrollment was halted at 61% of planned subjects. Post hoc analyses suggested that more stringent endpoints lowered placebo response rates and revealed a possible treatment effect.

CONCLUSIONS

Although the primary efficacy finding was inconclusive, these results inform future trial design of AMDC-USR to identify clinically meaningful efficacy endpoints based on IEF reduction, understanding of placebo response rate, and refinement of subject selection criteria to more appropriately align with AMDC-USR's proposed mechanism of action.

TVT Abbrevo and Miniarc suburethral sling in women with stress urinary incontinence - A randomised controlled trial

INTRODUCTION

Single incision slings (SIS) were introduced in an attempt to decrease the complications associated with retropubic and transobturator slings. The TVT Abbrevo is a modification of the TVT-O with a reduced length and less immediate postoperative pain. The Miniarc SIS has been shown to be equivalent to outside-in transobturator sling, Monarc at 12 month follow-up.

OBJECTIVE

To evaluate objective and subjective outcomes of MiniArc SIS and TVT Abbrevo midurethral sling (MUS) in women with stress urinary incontinence.

METHODS

Female subjects who were assessed and referred for stress urinary incontinence surgery were eligible to participate in this study. Exclusion criteria included women with intrinsic sphincter deficiency previous failed midurethral or fascial sling, untreated detrusor overactivity or significant voiding dysfunction. Patients' randomisation was performed with computer-generated blocks of 4-8, with concealed allocation. Assuming an objective cure rate of 90% for TVT AbbrevoTMwith a power of 80%, a sample size of 79 in each arm was required to detect a clinical difference of 15%, using a one sided alpha of 0.05. The target recruitment number was 220 allowing for an attrition rate of 15%. Institution ethics approval (11261B) was obtained and the trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611001151921). Routine preoperative assessment was conducted for objective data, whilst patient reported outcome tools (PRO) were utilised for subjective outcomes. These include ICIQ UI SF, ICIQ OAB, IIQ7, EQ5D, PISQ12, PGIs & PGII. TVT AbbrevoTM or MiniarcTMwere performed in a standardized fashion, together with any concomitant prolapse surgery. Review was conducted at 6 weeks and at 6 and 12 months. Objective cure was defined as a negative cough stress test with a comfortably full bladder. Subjective cure was defined as no report of leakage with physical exertion. All Data was collected and outcomes were analysed statistically.

RESULTS

Between February 2011 and January 2016,a total of 246 women were randomized to receive MiniArc (121) or TVT Abbrevo (125). Baseline characteristics were clinically balanced in both groups. At 6 months subjective (94.4% vs 95.7% p=0.74) and Objective (92.9% vs 95.9% p=0.49) cure rates were high and not statistically different. At 12 months there were also no differences in subjective (73.6% vs 76.9% p=0.73) or objective (90.5% vs 96.0% p=0.21) cure rates. No differences were found in functional outcomes or when adjusted for potential confounding factors such as age, parity, BMI or menopausal status.

CONCLUSION

We found no significant differences in subjective and objective cure rates at 6 and 12months between MiniArc and TVT Abbrevo.

Functional outcomes and quality of life after transobturatory slings: hand - made vs. commercial slings

Surgical correction is the most efficient treatment for stress urinary incontinence (SUI), and transobturator sling (TO) has optimal results. The high cost of commercially available sling kits makes it difficult the access in most Brazilian public health services. Hand-made polypropylene slings, on the other hand, have been previously reported. The aim of the present study was to compare the effectiveness and safety of commercial vs. hand-made polypropylene mesh slings. Data from 57 women who underwent consecutive TO sling surgery to treat SUI were pros-pectively collected between 2012 and 2014, and divided in two groups for further comparison. In Group-1, 31 women underwent surgery with commercial slings. In Group-2, 26 women underwent hand-made polypropylene slings. Women were compared according to epidemiological data, perioperative evaluation, quality of life, urodynamic study, cure and complication rates. Results were objectively (stress test with Valsalva maneuver, with at least 200mL vesical repletion) and subjectively evaluated by the Patient Global Impression of Improvement(PGI-I), Visual Analog Scale (VAS) and ICIQ-SF. Success was defined as PGI-I, VAS and negative stress test. Group-1 (n=31) and Group-2 (n=26) had a mean age of 60 vs. 58years (p=0.386). All de-mographic data were similar. The mean VLPP was 75.6cmH2O vs. 76.6cmH2O (p=0.88). The mean follow-up was 24.3 vs. 21.5months (p=0.96). Success rates were 74.2% vs. 80.2% (p=0.556), with ICIQ-SF variation of 12.6 vs.15.5 (p=0.139) and PGI-I of 71% vs. 80% (p=0.225). There was only one major complication (urethrovaginal fistula in Group-1). In conclusion, handmade and commercial slings have similar effectiveness and safety. The manufacture technique has important key-points stated in the present manuscript.

Urinary incontinence in women

Urinary incontinence symptoms are highly prevalent among women, have a substantial effect on health-related quality of life and are associated with considerable personal and societal expenditure. Two main types are described: stress urinary incontinence, in which urine leaks in association with physical exertion, and urgency urinary incontinence, in which urine leaks in association with a sudden compelling desire to void. Women who experience both symptoms are considered as having mixed urinary incontinence. Research has revealed overlapping potential causes of incontinence, including dysfunction of the detrusor muscle or muscles of the pelvic floor, dysfunction of the neural controls of storage and voiding, and perturbation of the local environment within the bladder. A full diagnostic evaluation of urinary incontinence requires a medical history, physical examination, urinalysis, assessment of quality of life and, when initial treatments fail, invasive urodynamics. Interventions can include non-surgical options (such as lifestyle modifications, pelvic floor muscle training and drugs) and surgical options to support the urethra or increase bladder capacity. Future directions in research may increasingly target primary prevention through understanding of environmental and genetic risks for incontinence.

Nonmotor Symptoms in Vascular and Other Secondary Parkinsonism

Vascular parkinsonism (VP) is a relatively frequent variant of secondary parkinsonism caused by ischemic or hemorrhagic lesions of basal ganglia, midbrain, or their links with frontal cortex. According to different investigations, various forms of cerebrovascular disease cause 1%-15% of parkinsonism cases. Nonmotor symptoms are frequently found in VP and may negatively influence on quality of life. However, nonmotor symptoms such as hallucinations, orthostatic hypotension, REM-sleep behavior disorder, and anosmia are rarely revealed in VP, which may be noted to another diagnosis or mixed pathology. Clinical value of nonmotor symptoms in normal pressure hydrocephalus, toxic, and drug-induced parkinsonism is also discussed.

Pelvic floor muscle training protocol for stress urinary incontinence in women: A systematic review

Summary Introduction: Strengthening exercises for pelvic floor muscles (SEPFM) are considered the first approach in the treatment of stress urinary incontinence (SUI). Nevertheless, there is no evidence about training parameters. Objective: To identify the protocol and/or most effective training parameters in the treatment of female SUI. Method: A literature research was conducted in the PubMed, Cochrane Library, PEDro, Web of Science and Lilacs databases, with publishing dates ranging from January 1992 to March 2014. The articles included consisted of English-speaking experimental studies in which SEPFM were compared with placebo treatment (usual or untreated). The sample had a diagnosis of SUI and their age ranged between 18 and 65 years. The assessment of methodological quality was performed based on the PEDro scale. Results: Seven high methodological quality articles were included in this review. The sample consisted of 331 women, mean age 44.4±5.51 years, average duration of urinary loss of 64±5.66 months and severity of SUI ranging from mild to severe. SEPFM programs included different training parameters concerning the PFM. Some studies have applied abdominal training and adjuvant techniques. Urine leakage cure rates varied from 28.6 to 80%, while the strength increase of PFM varied from 15.6 to 161.7%. Conclusion: The most effective training protocol consists of SEPFM by digital palpation combined with biofeedback monitoring and vaginal cones, including 12 week training parameters, and ten repetitions per series in different positions compared with SEPFM alone or a lack of treatment.

Use of Urodynamic Studies among Certifying and Recertifying Urologists from 2003 to 2014

INTRODUCTION

Guidelines for the use of urodynamics have undergone a significant narrowing of scope in recent years, particularly as they pertain to the use of urodynamics for stress incontinence in women. Whether these changes have affected the use of urodynamics in practice is unknown. The goal of this study is to quantify the percentage of urologists who are performing urodynamics, to determine how trends have changed during the time studied and to better understand why these studies are being performed by identifying the associated diagnosis codes.

METHODS

We queried the 6-month procedure logs submitted by applicants for part II ABU (American Board of Urology) certification or recertification between 2003 and 2014. The number of procedures with urodynamics CPT codes were abstracted (51725, 51726, 51772, 51784, 51785, 51792, 51795, 5179, 51797) along with the certification year, patient gender and ICD-9 diagnosis used for each procedure.

RESULTS

During the 11-year period of data 7,849 practice logs were submitted to the ABU. Overall 91% of certifying applicants and 89.5% of recertifying applicants performed urodynamics. This number increased from 82.6% of certifying urologists and 70.3% of recertifying urologists in 2003 to 94.7% of recertifying urologists and 93.7% of certifying urologists in 2014. In 2003, on average, each certifying applicant performed 99 urodynamics procedures. This number increased to 149 procedures per applicant in 2014, for a 49.8% increase overall from the start of the study period. For recertification candidates an average of 125 procedures was performed per candidate in 2003. The average increased to 187 procedures per candidate in 2014 for a 49.5% increase in procedures performed. Videourodynamics were performed by 8.1% of certification or recertification applicants overall. This increased from 1% of recertification applicants and 1.8% of certification applicants in 2003 to 6% and 12.5% of recertification and certification applicants, respectively, in 2013. The ICD-9 codes most frequently associated with pressure flow studies were 625.6 (stress urinary incontinence-female) and 788.41 (urinary frequency). The ICD-9 code most commonly associated with videourodynamics across our study was 625.6 (stress urinary incontinence-female).

CONCLUSIONS

Since 2003 the percentage of applicants for ABU certification or recertification using urodynamics in their practice has increased from 76.5% to 94.2%. There has also been a 49.7% increase in the number of urodynamics procedures performed per candidate during that period, indicating an overall increase in the use of urodynamic studies.

Outpatient biofeedback in addition to home pelvic floor muscle training for stress urinary incontinence: a randomized controlled trial

AIMS

To test if biofeedback (BF) added to pelvic floor muscle training (PFMT) increases the frequency of home exercises performed by women with stress urinary incontinence (SUI).

METHODS

72 incontinent women were randomized to BF (outpatient BF + home PFMT) or PFMT (outpatient PFMT + home PFMT) groups.

ASSESSMENTS

baseline, after 3 months of supervised treatment, at 9-month follow-up (after six additional months of home PFMT only).

PRIMARY OUTCOME

frequency of monthly exercises sets performed (exercise diary) after 3-month treatment.

SECONDARY OUTCOMES

adherence, urinary symptoms, severity and cure of SUI (pad test <2 g leakage), muscle function, quality of life, and subject cure (satisfaction report with no desire for different treatment) at the two time-points.

STATISTICAL ANALYSES

ANOVA and Student's t-test with 5% cut-off for significance.

RESULTS

It was observed similar frequency of monthly home exercises sets performed by BF (67.9 out of 82) and PFMT (68.2 out of 82) groups at 3 months. Secondarily, equal satisfaction, but superior objective cure of SUI for BF group after 3-month treatment (P = 0.018; OR: 3.15 [95% CI: 1.20-8.25]). At 9-month follow-up, the adherence to home exercises was similar (around 50%) and significantly dropped in both groups compared to the 3-month results (around 85%). No difference was detected in the objective and subjective cure of SUI between the groups after 9 months. Both therapies similarly improved the muscle function and quality of life during the study (P < 0.005).

CONCLUSIONS

Adjunct BF did not increase the frequency of home exercises performed by SUI patients.