Why do stress and urge incontinence co-occur much more often than expected?

Muscle mechanical properties of pelvic floor and paravertebral muscles in women with and without urge urinary incontinence: a case-control study

BACKGROUND

Muscle mechanical properties (MMPs) are relevant in the pathophysiology of lumbopelvic disorders. However, they have not been described in the pelvic floor muscles (PFM) and lumbar paravertebral muscles (LPM) of women with urge urinary incontinence (UUI).

OBJECTIVE

To identify differences between MMPs of PFM and LPM in patients with UUI and healthy controls. Secondarily also aimed to observe the relationship between sociodemographic and clinical variables with the PFM and LPM MMPs.

METHODS

The participants of this case-control study comprised 34 women with UUI (UUI group) and 34 continent women (control group). Sociodemographic variables were obtained together with data on the clinical status of the pelvic floor. The MMPs, i.e., frequency (tone), stiffness, decrement (inverse of elasticity), and viscoelastic properties (VP), such as relaxation time and creep, of PFM and LPM were assessed with a hand-held tonometer. Between-group differences and intra-group correlations were identified.

RESULTS

The UUI group presented higher frequency and stiffness, as well as lower relaxation time in PFM, whereas the LPM had lower tone and stiffness, and higher VP, compared to the control group (p < 0.05). The UUI group showed a pattern of moderate correlations (|0.403|

CONCLUSION

The presence of UUI may influence MMPs at PFM and LPM levels, increasing the tone and stiffness of PFM, whereas these properties are reduced in LPM. These findings emphasize the clinical interest of the lumbopelvic determination of MMPs, obtained through externally applied hand-held instruments, in the pathophysiology of UUI.

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Key Words

• Pelvic floor disorders
• Regional interdependence
• Tonometry

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Affiliation(s)

María Teresa Garzón-Alfaro Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain
Inés Cruz-Medel Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain
Sandra Alcaraz-Clariana Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain
Lourdes García-Luque Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain
Cristina Carmona-Pérez Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain
Juan Luis Garrido-Castro Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain; Department of Computer Science and Numerical Analysis, Rabanales Campus, University of Córdoba, Córdoba, Spain
Francisco Alburquerque-Sendín Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain; Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain.
Daiana Priscila Rodrigues-de-Souza Department of Nursing, Pharmacology and Physical Therapy, Faculty of Medicine and Nursing, University of Córdoba, Córdoba, Spain; Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Córdoba, Spain

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Advances in the natural history of urinary incontinence in adult females

The aim of this review is to summarise the related characteristics of the natural history of female urinary incontinence (UI) using a narrative descriptive approach. PubMed, EMBASE and Web of Science were searched for articles published from 1 January 2010 to 1 January 2020 on the natural history of female UI, which including incidence, persistence, progression, remission, and regression of a single subtype of UI and the mutual influence of different UI subtypes. This literature review includes 15 articles published, indicates that UI is highly dynamic, with symptoms varying according to disease severity and subtype and influenced by multiple factors at different disease stages. Recent studies have increased our understanding of the natural history of UI. Future research should systematically analyse the progression of each subtype of UI and interactions between subtypes to prevent the progression of UI across females life course.

Urgency and urgency incontinence following stress urinary incontinence surgery: A review of evaluation and management

The presence of urgency urinary incontinence (U/UUI) after sling surgery is a common reason for dissatisfaction and imposition on quality of life. We aimed to evaluate and analyze the pathophysiology, evaluation, and treatment of U/UUI after sling surgery. A MEDLINE review was performed for relevant, English-language articles relating to storage and emptying symptoms after sling surgery. U/UUI may persist, be improved, or worsen in women with preoperative mixed urinary incontinence and may appear de novo in those women originally presenting with pure stress urinary incontinence (SUI). While the exact mechanism is not clear, partial bladder outlet obstruction (BOO) should always be suspected, especially in those women with worsened or de novo symptoms soon after sling surgery. Initial workup should elucidate the temporality, quality, and bother associated with symptoms and to evaluate the woman for urinary tract infection (UTI), pelvic organ prolapse (POP), or perforation of the lower urinary tract. The utility of urodynamics in attaining a definitive diagnosis of BOO is inconclusive. Treatment options include reevaluation of the patient after sling incision or after addressing UTI, POP, and perforation of the bladder or urethra. Women also typically undergo a multitiered approach to storage lower urinary tract symptoms outlined in the American Urological Association/Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction Overactive Bladder Guidelines. While improvement is typically seen with multimodality treatment, all women should be counseled regarding need for additional treatment for U/UUI, BOO, and SUI in the future.

Combination therapy with botulinum toxin and bulking agent-An efficient, sustainable, and safe method to treat elderly women with mixed urinary incontinence

Aims

To evaluate the efficacy, sustainability and safety of combined botulinum toxin and polyacrylamide hydrogel (PAHG) therapy to treat urgency and stress components of therapy‐refractory mixed urinary incontinence (MUI) in an elderly study population.

Methods

Fifty‐five women with therapy‐refractory MUI were treated with botulinum toxin and PAHG in one surgical procedure. Urgency urinary incontinence (UUI) and stress urinary incontinence (SUI) outcomes were separately assessed after 4 and 12 months by objective UUI episodes/24 h and cough test, subjective impact of UUI and SUI on quality of life, and subjective International Consultation on Incontinence Questionnaire‐Urinary Incontinence Short Form (ICIQ‐UI SF). MUI outcome was calculated by combining UUI and SUI outcomes. Complications were monitored throughout the study.

Results

At 4 months, objective cure rates were 73%, 53%, and 42%, and subjective cure rates were 71%, 52%, and 50% for SUI, UUI, and MUI. At 12 months, objective cure rates were 73%, 56%, 50% and subjective cure rates were 78%, 42%, and 40% for SUI, UUI, and MUI. The ICIQ‐UI SF score decreased by 9.0 and 8.7 points after 4 and 12 months. All complications were transient and included 22% clean intermittent catheterization immediately after surgery, 33% postvoid residual volumes >100 ml at 14 days, and 13% symptomatic urinary tract infection within the first postoperative month.

Conclusions

The combination of botulinum toxin and PAHG is effective, sustainable and safe to treat therapy‐refractory MUI, even in an elderly and frail study population. Patients benefit from the short surgical procedure without the need for general anaesthesia or discontinuation of anticoagulation.

Is a 50% improvement threshold adequate to justify progression from sacral neuromodulation testing to implant?

PURPOSE

A ≥50% subjective improvement in urinary symptoms during sacral neuromodulation testing (SNM-I) is currently used as the indication for progression to second-stage implantation (SNM-II). While most patients will have successful SNM-I and proceed to SNM-II, deterioration in efficacy over time has been reported. It remains unclear if the durability of efficacy is related to the initial symptom reduction. We sought to determine if the degree of improvement after SNM-I is sufficient to predict long-term success.

METHODS

The records of all patients who underwent sacral neuromodulation (SNM) for overactive bladder were reviewed. Subjects were divided into those who reported 50%-75% improvement (Group 1) and more than 75% improvement (Group 2) after SNM-I. Differences in clinical variables and long-term device efficacy were compared between groups.

RESULTS

Of 213 patients who underwent SNM-I, 137 underwent permanent device implantation. A total of 76 (55%) and 61 (45%) patients reported 50%-75% (Group 1) and more than 75% (Group 2) symptomatic improvement, respectively. With a mean follow-up of 46 months, 44% of Group 1 patients and 68% of Group 2 patients still had a functioning device providing the symptomatic benefit (p = 0.007). Univariate analyses identified the presence of stress urinary incontinence at baseline and having a more than 75% improvement after SNM-I as predictors of long-term functional success.

CONCLUSIONS

Compared to patients reporting 50%-75% symptomatic reduction after SNM-I, individuals with a more than 75% improvement during SNM-I were more likely to maintain device efficacy over time. Additional study is warranted to determine if the improvement threshold for progression to SNM-II should be increased.

Content analysis of nursing diagnoses related to urinary incontinence

OBJECTIVE

To analyze the content of nursing diagnoses related to urinary incontinence according to NANDA International and others identified in the literature.

METHOD

Methodological study conducted with judges who were experts in urinary dysfunctions and nursing diagnosis. The analysis included diagnoses of Stress Urinary Incontinence, Urgency Urinary Incontinence, Functional Urinary Incontinence, Urinary Incontinence due to Neurogenic Detrusor Overactivity (previously denominated Reflex Urinary Incontinence in NANDA International's taxonomy), Mixed Urinary Incontinence, and Transient Urinary Incontinence. Wilcoxon test was applied and Content Validity Index ≥ 0.85 was considered appropriate.

RESULTS

Fifty-one judges participated in this study. The judges recommended modifications in elements of all diagnoses (inclusion, exclusion or change of previous element type).

CONCLUSION

The four diagnoses analyzed in NANDA International's taxonomy are recommended to be maintained with modifications; inclusion of nursing diagnoses Mixed and Transient Urinary Incontinence is also recommended.

Interventions and Quality of Life in Stress Urinary Incontinence

Introduction:

Stress urinary incontinence (SUI), though is more prevalent than many chronic diseases, has remained largely underreported and underdiagnosed condition. We aimed to find the improvement in the quality of life (QoL) of women with SUI after individual interventions, namely mid-urethral sling (MUS), pelvic floor muscle training (PFMT), and no treatment/control group, as primary treatment modalities.

Materials and Methods:

This was a prospective interventional case–control study conducted at a university teaching hospital, over a period of 2 years. Parous women with at least one vaginal delivery, attending the gynecology outpatient department, were encouraged to fill the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form. Those with SUI were divided into three arms (MUS, PFMT, and no treatment/control group), according to the informed decision for choice of management. Baseline QoL was documented for all with King's Health Questionnaire. QoL was again recorded after 3 months of the start of treatment and was compared with the baseline.

Results:

In our study cohort, the prevalence of SUI was 15.2%, with a consultation rate of only 30.7%. MUS surgery improves QoL significantly in women with SUI, followed by PFMT. We found 100% symptomatic relief, high rate of improvement in QoL with minimal easy to manage complications, in the surgical intervention arm. PFMT, though has a positive impact on QoL, requires continuous motivation, as 22% discontinued. Without treatment, QoL in SUI patients remained more or less the same.

Conclusion:

The help-seeking behavior (consultation rate) for SUI is poor. MUS (surgical arm) had 100% symptom relief in 3-month follow-up. MUS showed the best results in terms of QoL improvement, followed by PFMT in SUI in our study. It is important not only to educate women about the problem but also to encourage them to seek treatment and indicate that it is a treatable condition.

Management of Occult Urinary Incontinence with Prolapse Surgery

PURPOSE OF REVIEW

The purpose of this paper is to review (1) the epidemiology and pathophysiology of pelvic organ prolapse (POP) and occult stress urinary incontinence (SUI), (2) examine the data on combined operative management of POP and occult SUI, (3) discuss the approaches to clinical decision making, and (4) present future therapies.

RECENT FINDINGS

Prospective data on many approaches to concomitant treatment of prolapse and occult stress urinary incontinence, such as minimally invasive sacrocolpopexy and midurethral sling, or older approaches that have regained favor among patients and clinicians wishing to avoid synthetic mesh, such as native tissue prolapse repair and pubovaginal sling, are limited. Safe durable treatments with absorbable graft materials that promote a beneficial host response are intriguing but may be far from clinical implementation. Stem cell therapy for the treatment of stress urinary incontinence has demonstrated benefit in phase I/II trials but has not been studied in the setting of concomitant treatment of occult SUI with POP surgery and remains in the preclinical phase for the treatment of POP. A personalized approach to concomitant SUI surgery that incorporates individual risk assessment as well as informed patient preferences likely optimizes the risk/benefit ratio and patient satisfaction. Novel therapies, including graft materials and cellular therapies that stimulate a regenerative response, may improve or maintain continence outcomes while mitigating risk and alter the approach to both POP and SUI surgery.

Does transition of urinary incontinence from one subtype to another represent progression of the disease?

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (UI) is, on average, more severe than urgency UI or stress UI. We tested the hypothesis that mixed UI is a more advanced stage of UI by comparing transition probabilities among women with stress, urgency, and mixed UI.

METHODS

We used data from the General Longitudinal Overactive Bladder Evaluation Study-UI, which included community-dwelling women, aged 40+ years, with UI at baseline. Study participants completed two or more consecutive bladder health surveys every 6 months for up to 4 years. Using sequential 6-month surveys, transition probabilities among UI subtypes were estimated using the Cox-proportional hazards model, with the expectation that probabilities from stress or urgency UI to mixed UI would be substantially greater than probabilities in the reverse direction.

RESULTS

Among 6,993 women 40+ years of age at baseline, the number (prevalence) of women with stress, urgency, and mixed UI was 481 (6.9%), 557 (8.0%), and 1488 (21.3%) respectively. Over a 4-year period, the transition probabilities from stress UI (34%) and urgency UI (27%) to mixed UI was significantly higher than probabilities from mixed to stress UI (6%) or to urgency UI (rate = 9%). The adjusted transition hazard ratio for stress UI and urgency UI was 2.06 (95% CI: 1.73-2.92) and 1.85 (95% CI: 1.63-2.57) respectively compared with mixed UI.

CONCLUSION

The substantially higher transition from stress UI and urgency UI to mixed UI supports the hypothesis that mixed UI might represent a more advanced stage of UI that may have implications for understanding disease progression.

Clinical epidemiological insights into urinary incontinence

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is very common and heterogeneous among women with limited knowledge of progression or prognosis. Evidence based on clinical epidemiology can help to better understand the natural history of UI.

METHODS

We examine the challenges of UI definition and its subtypes, its impact on quality of life and health-seeking behavior. We review the proposed pathophysiology of UI subtypes and known risk factors as they relate to our current knowledge of the disease state. Finally, we emphasize the role of epidemiology in the process of acquiring new insight, improving knowledge, and translating this information into clinical practice.

RESULTS

Stress UI is most common overall, but mixed UI is most prevalent in older women. The three UI subtypes have some common risk factors, and others that are unique, but there remains a significant gap in our understanding of how they develop. Although the pathophysiology of stress UI is somewhat understood, urgency UI remains mostly idiopathic, whereas mixed UI is the least studied and most complex subtype. Moreover, there exists limited information on the progression of symptoms over time, and disproportionate UI health-seeking behavior. We identify areas of exploration (e.g., epigenetics, urinary microbiome), and offer new insights into a better understanding of the relationship among the UI subtypes and to develop an integrated construct of UI natural history.

CONCLUSION

Future epidemiological strategies using longitudinal study designs could play a pivotal role in better elucidating the controversies in UI natural history and the pathophysiology of its subtypes leading to improved clinical care.

Mixed Incontinence Masked as Stress Induced Urgency Urinary Incontinence

PURPOSE

We sought to understand variations in the expression and temporal relation of bladder control episodes among women with mixed urinary incontinence.

MATERIALS AND METHODS

A random sample of women 40 years old or older with mixed urinary incontinence on GLOBE-UI (General Longitudinal Overactive Bladder Evaluation-Urinary Incontinence) was recruited in a digital daily diary study using a smartphone application. When a bladder control event occurred, women were instructed to answer episode specific questions. Episodes were defined as urgency, and urinary incontinence with and urinary incontinence without urgency. Women and episodes were compared by the type of activity preceding each episode. Urinary incontinence episodes were further defined as stress urinary incontinence, urgency urinary incontinence, stress induced urgency urinary incontinence and other. The chi-square and Wilcoxon tests were used for categorical and continuous variables, respectively.

RESULTS

Of 40 women with a mean age of 65.5 years 35 provided complete 30-day diary data. Of the 950 bladder control episodes reported 25% were urgency only, 55% were urinary incontinence with urgency and 19% were urinary incontinence without urgency. Of the urinary incontinence episodes without urgency 82% occurred after a stress activity (eg coughing or sneezing). Notably, a stress activity also occurred just before 52.5% of the urgency urinary incontinence episodes (p <0.001). A total of 24 women (69%) reported at least 1 episode of stress induced urgency urinary incontinence, which was the most prevalent urinary incontinence subtype episode, followed by urgency urinary incontinence and stress urinary incontinence (29% vs 27% and 16%, respectively). The mean number of daily episodes was 1 or 2 across all groups.

CONCLUSIONS

Women with mixed urinary incontinence express a heterogeneous set of bladder control episodes with stress induced urgency urinary incontinence as the dominant type.

Patient-reported outcomes in overactive bladder due to idiopathic detrusor overactivity: A correlation of two multi-domain questionnaires with a focus on quality of life and lifestyle goals

Aims:

The aims of this article are to correlate two multi-domain patient questionnaires for overactive bladder (OAB) and to assess their performance against quality-of-life measures.

Methods:

Patients with OAB symptoms due to idiopathic detrusor overactivity completed an Overactive Bladder Symptom Score (OABSS), an ICIQ-OAB questionnaire and a Likert quality of life (QoL) score before and six weeks following intravesical botulinum toxin treatment. They also listed lifestyle goals to which they aspired following treatment. Correlations between domains, total scores, QoL and goal achievement were calculated.

Results:

Fifty-seven patients returned 113 sets of questionnaires for analysis. A very close correlation was found between individual symptoms scores (Spearman r ranging from 0.93 for nocturia to 0.74 for urgency incontinence) and between the total scores of the two questionnaires ( r = 0.83). The sum of the OABSS+QoL scores also correlated strongly with total ICIQ-OAB scores ( r = 0.85). The correlation between total problem scores on the ICIQ-OAB and the Likert QoL was lower ( r = 0.689) but remained significant. The effect sizes (ES) were large (ranging from r = 0.6 to r = 1.0) and the standard response means (SRM) varied between 0.6 and 1.1, indicating a good correlation between the two questionnaires.

Conclusions:

Both questionnaires provide similar information in terms of symptom presence or absence and their impact on QoL. The addition of the QoL score to the standard OABSS did not add to its benefit.

The interaction of stress and urgency urinary incontinence and its effect on quality of life

INTRODUCTION AND HYPOTHESIS

The objective was to estimate the impact of stress and urgency urinary incontinence (UI) on the quality of life (QOL), and to determine whether the impact varies according to UI severity.

METHODS

We used data from the General Longitudinal Overactive Bladder Evaluation-UI study in women. Stress and urgency UI symptom severity scores ranged from 0 to 8. We used logistic regression to test the relation among different severity levels of stress and urgency UI, and their interaction with the Incontinence Impact Questionnaire (IIQ-7). This was categorized according to percentage ranges as 0-40% (reference), 41-80%, and 81-100%.

RESULTS

Both stress and urgency UI were significantly associated with IIQ-7. Higher scores had higher odds ratios (ORs). The OR for urgency vs stress UI was greater at the same severity level. For instance, comparing IIQ-7 quintiles (0-40% vs 41-80%), the OR for an association with an urgency UI score of 5-6 was 5.27 (95% CI = 3.78-7.33) vs 2.76 (95% CI = 2.07-3.68) for a stress UI score of 5-6. Both UI subtypes were more strongly related to the upper (81-100%) than the to the lower (41-80%) quintiles. There was a strong positive urgency UI and stress UI interaction with the upper (i.e., 81-100%) but not the two next lower (41-80%) quintiles.

CONCLUSION

The impact of UI subtypes on QOL varies according to the score of IIQ-7, stress and urgency UI, and their interaction. Urgency vs stress UI has a stronger impact. The effect is greatest for high IIQ-7 scores with a significant share mediated by the interaction of the two UI subtypes.

Urgency urinary incontinence in women 50 years or older: incidence, remission, and predictors of change

OBJECTIVES

: To estimate 2-year incidence, remission, and predictors of urgency urinary incontinence (UUI) in a community-based population of women 50 years or older.

METHODS

: We analyzed the 2004 to 2006 data in the Health and Retirement Study. Subjects were women 50 years or older with baseline and follow-up UUI information. Urgency urinary incontinence incidence and remission were calculated. Predictors of UUI progression and improvement were estimated controlling for age, ethnicity, body mass index, parity, psychiatric illness, medical comorbidities, functional limitations, and stress urinary incontinence. We evaluated whether baseline UUI status predicted follow-up status and used multivariable logistic regression to identify predictor variables.

RESULTS

: A total of 8581 women reported UUI status at baseline and follow-up. Of 7244 women continent at baseline, 268 affirmed UUI at follow-up for a 2-year incidence of 3.7%. Of 581 women with UUI at baseline, 150 were continent at follow-up for a 2-year remission of 25.8%. Predictors of UUI development included increased age (7th and 10th decades compared with 6th decade; OR, 1.5 and 7.2; confidence interval [CI], 1.1-2.1 and 4.2-12.5, respectively), obesity (OR, 1.6; CI, 1.2-2.1), history of psychiatric illness (OR, 1.6; CI, 1.3-2.0), functional limitations (OR, 6.2; CI, 4.2-9.2), and stress urinary incontinence (OR, 5.0; CI, 3.0-8.3). Women who denied UUI at baseline were also likely to deny UUI at follow-up (OR, 47.4; CI, 22.9-98.1).

CONCLUSIONS

: In this community-based population of women 50 years or older, UUI incidence was low and remission was high. Predictors of UUI included increased age, severe obesity, functional limitations, a positive psychiatric history, and incontinence status at baseline.

Surgical treatment of mixed and urge urinary incontinence in women

BACKGROUND/AIMS

The etiology of urge urinary incontinence is unknown. Pharmacological treatments are disappointing, since they are only slightly more effective than a placebo. In this study, we analyzed whether the surgical replacement of the uterosacral ligaments by an alloplastic tape can cure patients with mixed and urge urinary incontinence.

METHODS

This study was a nonrandomized clinical trial. The study was performed in the Department of Gynecology of a general hospital and a university clinic. 135 women with urge or mixed urinary incontinence were operated on. The utero-sacral ligaments as well as the pubo-urethral ligaments - if necessary - were replaced by alloplastic tapes. Clinical outcome was evaluated immediately after surgery, 3 months later and 1 year later. Outcome was classified as cure, improvement or failure and recurrences.

RESULTS

102 patients (77%) were cured and a further 24 patients (18%) showed improvement after surgery. 19 patients developed a recurrence between 5 and 33 months after surgery.

CONCLUSION

We therefore conclude that most patients with urge and mixed urinary incontinence can be cured by surgery.

The iceberg of health care utilization in women with urinary incontinence

INTRODUCTION AND HYPOTHESIS

The objective of the study was to estimate prevalence of urinary incontinence (UI) health care utilization in women from the population up to specialty care.

METHODS

The General Longitudinal Overactive Bladder Evaluation-UI (GLOBE-UI) is a population-based study on the natural history of UI in women  ≥  40 years of age. Prevalence of UI was estimated by using the Bladder Health Survey (BHS). Survey data were linked with electronic health records to build the different steps of the iceberg of disease. Descriptive statistics were used to estimate the prevalence estimates at all levels of the iceberg.

RESULTS

A total sample of 7,059 women received the BHS. Of those, 3,316 (47 %) responded. Prevalence of UI was 1,366 (41 %). Women with or without UI did not differ by age or marital status. However, women with versus without UI were more parous (91 vs 87 %), significantly more overweight or obese (74 vs 61 %), and more likely to have a college education or higher (54 vs 46 %), P < 0.01. Nine hundred fifty-eight (73 %) women with UI reported duration of more than 2 years and 72 % reported moderate to severe UI symptoms. Of all 1,366 women with BHS UI diagnosis, only 339 (25 %) sought care, 313 (23 %) received some care, and 164 (12 %) received subspecialty care.

CONCLUSIONS

UI is a highly prevalent disease. Only a minority with UI appears to seek care and a fraction sees a pelvic floor specialist. It is important not only to educate women, but also primary care providers about this highly prevalent yet treatable condition.

Predictors of care seeking in women with urinary incontinence

AIMS

To determine predictors of health care utilization in women with urinary incontinence (UI) from the population to specialty care.

METHODS

The General Longitudinal Overactive Bladder Evaluation-UI is a population-based study on the natural history of UI in women ≥40 years of age. Prevalence of UI was estimated using the Bladder Health Survey (BHS). Survey data were linked with electronic health records (EHRs) to examine factors associated with a clinical UI diagnosis using logistic regression. Risk factors analyzed included: UI symptoms, subtypes, bother, severity, duration, and effect on quality of life, and demographic and other health characteristics. All statistical tests were two-sided with a P-value < 0.05 being significant.

RESULTS

The overall prevalence of any UI based on responses to the BHS was 1,618/4,064 (40%). Of the 1,618 women with UI, there were only 398 (25%) women with EHR (clinical) diagnosis of UI. Women with UI versus those without UI were more likely to be have a BMI >25 kg/m(2) (70% vs. 58%), more likely to be parous (91% vs. 87%) and college educated (54% vs. 46%), P < 0.001. After adjusting for confounders in the model, variables significantly associated with clinical UI diagnosis included: older age (OR = 1.96), higher parity (> 1 birth) (OR = 1.76), higher urgency UI (OR = 1.08), adaptive behavior (OR = 1.2), and UI bother scores (OR = 1.01), as well as more frequent outpatient visits (OR = 1.03), P < 0.05.

CONCLUSIONS

UI is a highly prevalent condition with only a minority of women seeking care. Factors associated with health care utilization include older age, parity (1+), number of doctor visits, urgency UI subtype, UI bother, and impact on behavior.

Effectiveness of midurethral slings in mixed urinary incontinence: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Mixed urinary incontinence (MUI) is a coexistence of stress (SUI) and urgency urinary incontinence (UUI). There is conflicting evidence on the effectiveness of midurethral slings (MUS) in this condition. The objective of this study is to evaluate the effectiveness of MUS in women with MUI by systematic review of the literature.

METHODS

Systematic literature search was carried (June 2010) using relevant search terms in Medline, EMBASE, CENTRAL and Google Scholar. Relevant randomised controlled trials (RCT) and prospective studies were selected and then analysed by two independent reviewers. Meta-analysis was performed with random effects model using STATA 8.

RESULTS

There were six randomised trials and seven prospective studies with average to good quality included in this systematic review. There was heterogeneity in outcomes reported. The overall subjective cure from seven prospective nonrandomised studies that included patients with symptomatic ± urodynamically proven MUI was found to be 56.4% (95% confidence interval 45.7-69.6%) at 34.9 ± 22.9 months follow-up. The overall cure of urgency and UUI component was 30-85% at a follow-up of few months up to 5 years. Most of the studies described that this cure does not persist over the time. The cure rate of SUI following MUS varies from 85% to 97%. On meta-analysis of five RCTs which included women with MUI symptoms, the odds of overall subjective cure with TVT versus transobturator tapes are similar at 6-33 months follow-up (OR, 0.9; 95% CI, 0.63-1.27). This was true when a subgroup analysis was performed on women with MUI who were negative for DO on UDS (OR, 1.21; 95% CI, 0.7-2.08)

CONCLUSIONS

There is evidence of persistent and good cure of stress component following MUS in women with MUI. The cure of the urge component is variable but less than stress component. Methodologically sound RCTs of retropubic and transobturator tapes with long-term follow-up are needed specifically for women with urodynamically proven and symptomatic mixed incontinence.

Mixed incontinence: comparing definitions in non-surgical patients

PURPOSE

We aimed to explore operational definitions of mixed urinary incontinence (MUI) for use in incontinence outcomes research for non-surgical patient populations.

METHODS

A secondary analysis of women with urge incontinence or urge predominant MUI enrolled in the Urinary Incontinence Treatment Network BE-DRI randomized clinical trial was performed. Subjects were characterized at baseline for urinary incontinence severity and incontinence subtype (stress or urge) using the Medical, Epidemiologic, and Social Aspects of Aging (MESA) questionnaire, the Urogenital Distress Inventory, and a 7-day urinary diary. Various different definitions of MUI, ranging from low to high threshold, were created using a combination of these baseline incontinence measures. Prevalence of MUI based on each definition was described and compared to treatment response. Logistic regression analysis was used to estimate the association between the study outcomes and the different definitions of MUI.

RESULTS

The 307 participants in the BE-DRI study had a mean age of 56.9 (± 13.9) years with a mean total MESA score of 21.7 (± 8.9) and a mean total UDI score of 120.5 (± 49.6). The proportion of women diagnosed with MUI varied significantly by definition ranging from 63.5% to 96.4%. Low threshold symptom-based definitions resulted in nearly universal diagnosis of MUI. No strict cut-off value for these baseline measures was identified to predict clinical outcomes.

CONCLUSIONS

Current MUI definitions do not adequately categorize clinically relevant UI subgroups. For research purposes we believe it necessary to describe the severity of each incontinence subtype separately in subjects with MUI.

Predictors of variability in urinary incontinence and overactive bladder symptoms

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Does the Incidence of Urgency Symptoms Increase Along with the Severity of Stress Urinary Incontinence?

Purpose

Materials and Methods

Results

Conclusions