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

Does Urodynamic Stress Incontinence Increase After the Menopause?: Results from 2,994 Urodynamic Studies in Australian Women

INTRODUCTION AND HYPOTHESIS

Most studies attempting to estimate the age-related prevalence of urinary incontinence (UI) have used questionnaires. In the present study we analysed a consecutive series of urodynamic test results to determine the distribution of the different types of UI in pre- and post-menopausal women. We hypothesised that the prevalence of urodynamic stress incontinence (USI) would be significantly greater in pre-menopausal than in post-menopausal women.

METHODS

All women from a large tertiary urogynaecology department, who underwent urodynamic tests during the years 2000-2015 were included. Patient history and test results were collected. A sample size of 1,475 was calculated, based on the hypothesis that the prevalence of USI will be 20% larger in the pre- versus the post-menopausal group.

RESULTS

A total of 2,994 women with UI on urodynamics were available. There was a significant difference between pre- and post-menopausal status for each of the three diagnoses: USI 483 (59.3%) versus 912 (41.8%), detrusor overactivity (DO) 125 (15.4%) versus 399 (18.3%) and USI with concomitant DO 206 (25.3%) versus 869 (39.9%). A bimodal pattern of age was seen in women with USI, with a peak in the 46-50 and 61-65 age group, before decreasing with age. DO generally increased with age. USI with concomitant DO increased steadily after the menopause, becoming the predominant type after the age of 66.

CONCLUSIONS

In this large cohort of women attending urodynamics, we have shown that USI is the predominant type of incontinence in pre-menopausal women; however, USI with concomitant DO increases after menopause, eventually predominating.

Lower Urinary Tract Symptoms in Greek Women After Menopause: The LADY Study

INTRODUCTION AND HYPOTHESIS

The genitourinary syndrome of menopause (GSM), apart from symptoms related to vulvovaginal atrophy (VVA), also consists of lower urinary tract symptoms (LUTS). Based on the common embryological origin of the genital and lower urinary system, the presence of estrogen receptors, and the high prevalence of VVA and LUTS in the menopausal population, the two conditions can coexist. This study is aimed at investigating the prevalence and risk factors of LUTS in a sample of Greek peri- and postmenopausal women.

METHODS

Four hundred and fifty (450) women, aged 40-70 years, attending three outpatient gynecology clinics for routine examination, completed a structured interview and responded to a validated questionnaire (International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms, ICIQ-FLUTS).

RESULTS

Urinary urgency or frequency affected 51.6% and dysuria 43.6% of the participants. Mild urgency or frequency was described by 25.6%, moderate by 14.4%, and severe by 11.6% of the women. Mild dysuria was reported by 26.26%, moderate by 5.8%, and severe by 11.6%. Age, weight, BMI, and number of pregnancies and abortions correlated with a higher ICIQ-FLUTS score. Women with moderate/severe symptoms of VVA, such as irritation, a burning sensation, and pruritus of the vulva or vagina, had a higher ICIQ-FLUTS score than women without such symptoms (beta coefficient 2.42, CI 1.204, 3.635, p < 0.001).

CONCLUSIONS

Lower urinary tract symptoms are very common among peri- and postmenopausal women and are linked to symptoms of VVA. Our data support the need for prompt evaluation of women transitioning to menopause, as these symptoms compromise the quality of life.

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.

The effect of vitamin D on urgent urinary incontinence in postmenopausal women

INTRODUCTION AND HYPOTHESIS

Conflicting results have been reported on the effect of vitamin D supplementation on urinary incontinence (UI). Therefore, the aim of this study was to evaluate the effect of consuming vitamin D oral supplements on improving urge UI (UUI) in postmenopausal women with vitamin D deficiency.

METHODS

This randomized clinical trial was conducted in 2019-2020 in postmenopausal women with UUI or nocturia more than once at night with vitamin D levels less than 30 ng/ml. After recording the severity of UI and its impact on the patient's daily life, patients were randomly divided into two groups of 45 patients: one taking vitamin D3 (50,000 IU) tablets and one taking placebo weekly for 8 weeks.

RESULTS

There was no significant difference between the two groups in terms of the severity of UI and the frequency of nocturia before treatment. However, after treatment, in the vitamin D group, the severity of UI and the frequency of nocturia significantly reduced. Before treatment, the impact of UI on patients' daily life was reported to be high in more than 70% of patients in both groups, which was not significantly different; however, after treatment, its impact was significantly reduced in the vitamin D group.

CONCLUSIONS

The findings of the present study showed that in postmenopausal women with UUI or nocturia, weekly use of vitamin D 50,000 IU tablets for 8 weeks can reduce the severity of UI and the frequency of nocturia, and reduce their impact on disruption in daily life.

Does the climacteric influence the prevalence, incidence and type of urinary incontinence?

Divergent opinions have been reported in the literature regarding the influence of the climacteric on the prevalence, incidence and types of urinary incontinence. In addition, the influence of hormonal therapy in the climacteric (HRT) on the occurrence of urinary incontinence in the perimenopausal period has been the subject of much discussion. This review evaluates the current literature regarding any possible association between the climacteric and the prevalence, incidence and types of urinary incontinence as well as illustrating the possible influence of HRT on urinary incontinence. Urinary incontinence is more common in women than in men and there is evidence to suggest that the prevalence of urinary incontinence in women increases in a linear fashion with age. There is no conclusive evidence to support a specific increase in the prevalence of urinary incontinence at the time of the menopause. Stress urinary incontinence is more common in premenopausal women and urgency urinary incontinence and mixed incontinence are more common in postmenopausal women. Women receiving systemic estrogen, with or without progestogen, are more likely to develop or experience worsening of incontinence.

A prospective study of the natural history of urinary incontinence in women

BACKGROUND

Symptoms of urinary incontinence are commonly perceived to vary over time; yet, there is limited quantitative evidence regarding the natural history of urinary incontinence, especially over the long term.

OBJECTIVE

We sought to delineate the course of urinary incontinence symptoms over time, using 2 large cohorts of middle-aged and older women, with data collected over 10 years.

STUDY DESIGN

We studied 9376 women from the Nurses' Health Study, age 56-81 years at baseline, and 7491 women from the Nurses' Health Study II, age 39-56 years, with incident urinary incontinence in 2002 through 2003. Urinary incontinence severity was measured by the Sandvik severity index. We tracked persistence, progression, remission, and improvement of symptoms over 10 years. We also examined risk factors for urinary incontinence progression using logistic regression models.

RESULTS

Among women age 39-56 years, 39% had slight, 45% had moderate, and 17% had severe urinary incontinence at onset. Among women age 56-81 years, 34% had slight, 45% had moderate, and 21% had severe urinary incontinence at onset. Across ages, most women reported persistence or progression of symptoms over follow-up; few (3-11%) reported remission. However, younger women and women with less severe urinary incontinence at onset were more likely to report remission or improvement of symptoms. We found that increasing age was associated with higher odds of progression only among older women (age 75-81 vs 56-60 years; odds ratio, 1.84; 95% confidence interval, 1.51-2.25). Among all women, higher body mass index was strongly associated with progression (younger women: odds ratio, 2.37; 95% confidence interval, 2.00-2.81; body mass index ≥30 vs <25 kg/m²; older women: odds ratio, 1.93; 95% confidence interval, 1.62-2.22). Additionally, greater physical activity was associated with lower odds of progression to severe urinary incontinence (younger women: odds ratio, 0.86; 95% confidence interval, 0.71-1.03; highest vs lowest quartile of activity; older women: odds ratio, 0.68; 95% confidence interval, 0.59-0.80).

CONCLUSION

Most women with incident urinary incontinence continued to experience symptoms over 10 years; few had complete remission. Identification of risk factors for urinary incontinence progression, such as body mass index and physical activity, could be important for reducing symptoms over time.

High dose vitamin D may improve lower urinary tract symptoms in postmenopausal women

Lower urinary tract symptoms (LUTS) are common in postmenopausal women, and have been reported inversely associated with vitamin D intake and serum 25-hydroxyvitamin D (25(OH)D) levels. The aim of this study was to investigate if high dose vitamin D supplementation would affect LUTS in comparison to standard dose. In a randomized controlled study including 297 postmenopausal women with low bone mineral density, the participants were allocated to receive capsules of 20 000IU of vitamin D₃ twice a week (high dose group) or similar looking placebo (standard dose group). In addition, all the participants received 1g of calcium and 800IU of vitamin D daily. A validated questionnaire regarding LUTS was filled in at baseline and after 12 months. At baseline, 76 women in the high dose group and 82 in the standard dose group reported any LUTS. Levels of serum 25(OH)D increased significantly more in the high dose group (from 64.7 to 164.1nmol/l compared to from 64.1 to 81.8nmol/l, p<0.01). No differences between the groups were seen regarding change in LUTS except for a statistically significant reduction in the reported severity of urine incontinence in the high dose group as compared to the standard dose group after one year (p<0.05). The results need confirmation in a study specifically designed for this purpose.

Ten-Year Prevalence and Incidence of Urinary Incontinence in Older Women: A Longitudinal Analysis of the Health and Retirement Study

OBJECTIVES

To measure the incidence of urinary incontinence (UI) over 10 years in older women who did not report UI at baseline in 1998, to estimate the prevalence of female UI according to severity and type, and to explore potential risk factors for development of UI.

DESIGN

Secondary analysis of a prospective cohort.

SETTING

Health and Retirement Study.

PARTICIPANTS

Women participating in the Health and Retirement Study between 1998 and 2008 who did not have UI at baseline (1998).

MEASUREMENTS

UI was defined as an answer of "yes" to the question, "During the last 12 months, have you lost any amount of urine beyond your control?" UI was characterized according to severity (according to the Sandvik Severity Index) and type (according to International Continence Society definitions) at each biennial follow-up between 1998 and 2008.

RESULTS

In 1998, 5,552 women aged 51 to 74 reported no UI. The cumulative incidence of UI in older women was 37.2% (95% confidence interval (CI)=36.0-38.5%). The most common incontinence type at the first report of leakage was mixed UI (49.1%, 95% CI=46.5-51.7%), and women commonly reported their symptoms at first leakage as moderate to severe (46.4%, 95% CI=43.8-49.0%).

CONCLUSION

Development of UI in older women was common and tended to result in mixed type and moderate to severe symptoms.

Hysterectomy is not associated with de-novo urinary incontinence: A ten-year cohort study

OBJECTIVE

To determine prevalence, incidence proportion, and changes of urinary incontinence (UI) 10-13 years after hysterectomy compared to two control groups.

STUDY DESIGN

A longitudinal cohort study of 661 women with follow-up for ten years. Originally, 866 women answered a questionnaire on continence status preoperatively. Ten years postoperatively the queries were repeated in 371 with a hysterectomy, 89 with laparoscopic cholecystectomy (LC), and 201 with transcervical endometrial resection (TCRE). Significant incontinence was UI at least once a week. The main outcome measures were prevalence and incidence proportions of UI.

RESULTS

The overall prevalence of stress UI ten years after surgery was 23% compared to 12% preoperatively. Urge UI was prevalent in 12% compared to 5% preoperatively. Incidence proportions of stress UI were in hysterectomies 21%, in LC 15%, and in TCRE 18%. Similarly, incidence proportions of urge UI were in hysterectomies 11%, in LC 11%, and in TCRE 8%. No significant differences between surgical procedures were found; however, we found substantial amount of changes in continence status from continent to incontinent and vice versa in all three groups.

CONCLUSIONS

No significant difference was found after hysterectomy compared to controls in the prevalence or incidence proportions of UI after 10 years follow-up. Hysterectomy is not a risk factor of UI.

Use and discontinued use of menopausal hormone therapy by healthy women in Norway: the Hordaland Women's Cohort study

OBJECTIVE

This work aims to study the use of hormone therapy (HT) in a representative cohort of Norwegian women during the menopausal transition, to identify predictors of HT use, and to describe the reappearance of symptoms in former HT users.

METHODS

In 1997, 2,229 women in Hordaland County, aged 40 to 44 years, were selected randomly from a national health survey and followed up with seven postal questionnaires in 1999-2010. Data from 2,002 women (90%) were eligible for analysis. Summary statistics and multiple logistic regression analysis were used. We studied the reappearance of symptoms after HT discontinuation using a subcohort based on their propensity scores for HT use.

RESULTS

The 2-year incidence of new HT users dropped from 8.2% (95% CI, 7.0-9.5) in 2002 to 4.3% (95% CI, 3.4-5.2) in 2004 and remained stable despite an increasing prevalence of symptoms in the cohort. Self-rated health was stable during the period. The mean duration of HT use was 4.5 years (95% CI, 4.0-5.0). The odds of HT use were higher among women with daily hot flushes than among those who never or rarely experienced them (odds ratio, 3.2; 95% CI, 2.3-4.4). After HT cessation, hot flushes returned and corresponded to those in untreated controls.

CONCLUSIONS

The 2-year incidence of HT users decreased almost 50% after 2002. Increasing symptoms and decreasing incidence of HT use did not influence self-rated health. Hot flushes were the strongest predictor of HT use. Symptoms reappeared in most women after HT cessation.

Prevalence, incidence and remission of urinary incontinence in women: longitudinal data from the Norwegian HUNT study (EPINCONT)

Background

To determine incidence and remission of UI as well as changes in UI prevalence in the Norwegian EPINCONT surveys.

Methods

The EPINCONT surveys were conducted in the county of Nord-Trøndelag, Norway, as part of two large cross-sectional health surveys (HUNT2 and HUNT3) in 1995 – 1997 (EPINCONT1 (E1)), and 2006 – 2008 (EPINCONT2 (E2)). EPINCONT collected information about prevalence of UI, as well as information about type and severity of UI.

Results

A 16% relative increase in UI prevalence was found in 11 years. The women who answered E2 were significantly older, had a higher BMI and higher prevalence of diseases such as asthma, diabetes and angina compared with the women who answered E1.

The incidence of UI was 18.7%. Increase in BMI (OR 1.03, 95% CI: 1.02 – 1.04), weight increase (OR 1.29 (95% CI: 1.14 – 1.45) for gaining 3 – 10 kilos and OR 1.71 (95% CI: 1.47 – 1.99) for gaining 10 kilos or more) and parity (OR 1.37 (95% CI: 1.04 – 1.79) for 1 childbirth, OR 1.28 (95% CI: 1.03 – 1.61) for 2 childbirths, and OR 1.56 (95% CI: 1.26 – 1.95) for 3 or more childbirths when participating in E2) were all found to be associated with increased odds of incident UI in adjusted regression analyses. Increasing age reduced the odds of incident UI. The 11 year remission of UI was 34.1%. Increasing age (OR 0.98, 95% CI: 0.98 – 0.99), increasing BMI (OR 0.96, 95% CI: 0.95 – 0.98) and large weight gains of 10 kilos or more (OR 0.69, 95% CI: 0.54 – 0.88) were all associated with reduced remission of UI.

Conclusion

Crude UI prevalence increased between the studies. Changes in known risk factors for UI such as age, BMI, weight and parity could explain some of the relative increase in prevalence, and were also found to be associated with either incidence of UI, remission of UI or both.

Vaginal weights for pelvic floor training: a multiple participant case report

Activity-related incontinence is a problem for women, many with limited access to specialty clinics and practitioners. Incontinence inhibits participation in health-promoting levels of physical activity. Vaginal weights are a treatment option available without a prescription for home use that may help some of these women. This multiple baseline across-participant case study investigated the use of weights in a 'hands-off' pelvic floor exercise program for pre-menopausal women. Three of four participants improved, but did not cure, their incontinence with use of the weights. A fourth participant was unable to successfully use the weights. Referral to a women's health physical therapist was suggested for her. Poor adherence was noted at follow-up in two of three participants, with the one who maintained practice demonstrating continued improvement and increased physical activity. Weights provide a low-cost exercise adjunct to women interested in a flexible and independent incontinence management program. For continued improvement, behavioral factors promoting adherence should also be addressed. Weights are one of the options for women wanting a low-cost solution for activity-related urinary leakage. Problems using the weights or failure to benefit from their use may be indicators of a need for more advanced evaluation by women's health specialists.