Analysis of clinical interventional strategy for women with urinary incontinence complicated with diabetes mellitus

Gestational diabetes is associated with alteration on pelvic floor muscle activation pattern during pregnancy and postpartum: Prospective cohort using electromyography assessment

Background and objective

Gestational diabetes mellitus (GDM) is a comorbidity which may cause acute and lifelong disorders to mother and child. Alterations in muscular and connective tissues have been associated with GDM in translation studies, characterizing gestational diabetic myopathy. Pregnancy-specific urinary incontinence and sexual disabilities, disorders that depend on the pelvic floor muscle (PFM) integrity, are also associated with GDM both during and after pregnancy. The aim was to compare PFM activation patterns between GDM and non-GDM women from 24-30 gestational weeks to 18-24 months postpartum during a standard clinical test during gestation and postpartum.

Methods

We conducted a prospective three-time-point cohort study from gestation (24-30 weeks-T1, and 36-38 weeks-T2) to 18-24 months postpartum (T3). PFM electromyography was recorded in primigravida or primiparous women with one previous elective c-section with or without the diagnosis of GDM according to the American Diabetes Association criteria. A careful explanation of the muscle anatomy and functionality of the PFM was given to participants before EMG assessment. The outcome measures were PFM activation patterns assessed during pregnancy and postpartum, comparing intra and between groups. PFM activation patterns were assessed by normalized electromyography signal at rest and during 1-second (sec) phasic, 10-sec hold, and 60-sec sustained contractions.

Results

Demographic and obstetric data showed homogeneity between groups. The GDM group achieved peak PFM EMG amplitudes similarly to the non-GDM group, but they took longer to return to baseline levels during the ~1-sec contraction (flicks). During 10-sec hold contractions, the GDM group sustained lower levels of PFM activation than the non-GDM group at both 36-38 weeks of gestation and 18-24 months postpartum when compared to the non-GDM group.

Conclusion

The results suggest that GDM impaired PFM control mainly on 1-sec flicks and 10-sec hold contraction, which appears to develop during late pregnancy and extends long-term postpartum. This motor behavior may play a role on pelvic floor dysfunctions.

Relationship Between Blood Glucose Level and Prevalence and Frequency of Stress Urinary Incontinence in Women

OBJECTIVES

The purpose of this study was to evaluate the relationship between blood glucose level and the prevalence and frequency of stress urinary incontinence (SUI) in women.

METHODS

We conducted a cross-sectional study of female participants in the National Health and Nutrition Examination Survey database between 2007 and 2016. Dose-response analysis curves and univariate and multivariate logistic regressions were used to determine the relationship between blood glucose level and the prevalence and frequency of SUI.

RESULTS

A total of 10,771 participants were included in this study, of which 6,466 (60.0%) reported no SUI, 4,305 (31.1%) reported monthly SUI, and 953 (8.8%) reported weekly SUI. We found that the blood glucose levels were higher in the weekly SUI group than in the monthly SUI and no SUI groups. Based on blood glucose levels, participants were divided into 3 groups: ≤86.0 mg/dL group, >86.0 to 98.0 mg/dL group, and >98.0 mg/dL group. Dose-response curves showed a nonlinear positive correlation between blood glucose levels and the prevalence and extent of SUI, and participants in the glucose >98.0 mg/dL group had a 15.2% higher risk (adjusted odds risk, 1.152; 95% confidence interval, 1.027-1.293; P = 0.016) of SUI prevalence and 12.5% higher risk (adjusted odds risk 1.125; 95% confidence interval, 1.009-1.255; P = 0.034) of SUI frequency than participants in the glucose ≤86.0 mg/dL group.

CONCLUSIONS

We found that the prevalence and frequency of SUI in women were positively correlated with blood glucose levels, and these findings warrant further study and application to clinical practice to control SUI in women.

Percutaneous Tibial Nerve Stimulation in Diabetic and Nondiabetic Women With Overactive Bladder Syndrome: A Retrospective Cohort Study

OBJECTIVES

The primary objective of this study was to compare optimal response ("very much better" or "much better" on the Patient Global Impression of Improvement [PGI-I] index) to posterior tibial nerve stimulation (PTNS) for overactive bladder (OAB) in patients with and without diabetes mellitus. Secondary outcomes included longitudinal data regarding PTNS use in patients with diabetes and controls.

METHODS

We performed a retrospective cohort analysis of women in our tertiary care center who completed at least 10 weekly and 1 maintenance PTNS treatments for OAB, excluding patients who were treated with PTNS for a non-OAB primary diagnosis. Participants were grouped into those with diabetes mellitus and those without. Previous research demonstrated a 20% difference in subjective response to anticholinergics in persons with diabetes versus persons without diabetes with OAB. To demonstrate a 20% difference in optimal PGI-I with 80% power, our analysis required 92 patients in each group.

RESULTS

We identified 356 patients: 96 with diabetes mellitus, and 260 controls. There was no statistically significant difference in the primary outcome, with 43 (44.8%) of 96 persons with diabetes versus 115 (44.2%) of 260 controls demonstrating optimal PGI-I response (P = 0.92). Among patients with diabetes, no baseline variables were found to predict treatment response, including hemoglobin A1c greater than 7%, diabetes with sequelae, or higher Charlson Comorbidity Index.

CONCLUSIONS

In women undergoing PTNS for OAB, the optimal PGI-I response rate is similar in patients with and without diabetes.

Glycaemic control and risk of incident urinary incontinence in women with Type 1 diabetes: results from the Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study

AIMS

To study the impact of glycaemic control on urinary incontinence in women who participated in the Diabetes Control and Complications Trial (DCCT; 1983-1993) and its observational follow-up study, the Epidemiology of Diabetes Interventions and Complications (EDIC; 1994-present).

METHODS

Study participants were women who completed, at both years 10 (2003) and 17 (2010) of the EDIC follow-up, the urological assessment questionnaire (UroEDIC). Urinary incontinence was defined as self-reported involuntary leakage of urine that occurred at least weekly. Incident urinary incontinence was defined as weekly urinary incontinence present at EDIC year 17 but not at EDIC year 10. Multivariable regression models were used to examine the association of incident urinary incontinence with comorbid prevalent conditions and glycaemic control (mean HbA_1c over the first 10 years of EDIC).

RESULTS

A total of 64 (15.3%) women with Type 1 diabetes (mean age 43.6 ± 6.3 years at EDIC year 10) reported incident urinary incontinence at EDIC year 17. When adjusted for clinical covariates (including age, DCCT cohort assignment, DCCT treatment arm, BMI, insulin dosage, parity, hysterectomy, autonomic neuropathy and urinary tract infection in the last year), the mean EDIC HbA_1c was associated with increased odds of incident urinary incontinence (odds ratio 1.03, 95% CI 1.01-1.06 per mmol/mol increase; odds ratio 1.41, 95% CI 1.07-1.89 per % HbA_1c increase).

CONCLUSIONS

Incident urinary incontinence was associated with higher HbA_1c levels in women with Type 1 diabetes, independent of other recognized risk factors. These results suggest the potential for women to modify their risk of urinary incontinence with improved glycaemic control. (Clinical Trials Registry no: NCT00360815 and NCT00360893).

Diabetes, Glycemic Control, and Urinary Incontinence in Women

OBJECTIVES

To estimate the association between urinary incontinence and glycemic control in women ages 20 to 85 years.

METHODS

We included 7270 women from the 2005 to 2010 National Health and Nutrition Examination Survey, stratified into three groups of glycemic control defined by hemoglobin A1c (HbA1c): (i) those below the diagnostic threshold (HbA1c < 6.5%), (ii) those with relatively controlled diabetes (HbA1c, 6.5-8.5%), and (iii) those with poorly controlled diabetes (HbA1c > 8.5%) to allow for a different relationship between glycemic control and urinary incontinence within each group. The primary outcomes were the presence of any, only stress, only urgency, and mixed urinary incontinence. We calculated adjusted risk ratios using Poisson regressions with robust variance estimates.

RESULTS

The survey-weighted prevalence was 52.9% for any, 27.2% for only stress, 9.9% for only urgency, and 15.8% for mixed urinary incontinence. Among women with relatively controlled diabetes, each one-unit increase in HbA1c was associated with a 13% (95% confidence interval, 1.03-1.25) increase for any urinary incontinence and a 34% (95% confidence interval, 1.06-1.69) increase in risk for only stress incontinence but was not significantly associated with only urgency and mixed incontinence. Other risk factors included body mass index, hormone replacement therapy, smoking, and physical activity.

CONCLUSIONS

Worsening glycemic control is associated with an increased risk for stress incontinence for women with relatively controlled diabetes. For those either below the diagnostic threshold or with poorly controlled diabetes, the risk may be driven by other factors. Further prospective investigation of HbA1c as a modifiable risk factor may motivate measures to improve continence in women with diabetes.