Predicting who will undergo surgery after physiotherapy for female stress urinary incontinence

Minimum important difference of the ICIQ-UI SF score after self-management of urinary incontinence

BACKGROUND

This study aimed to evaluate clinically relevant improvement after conservative self-management of urinary incontinence via a mobile app. It further aimed to establish Minimum Important Differences (MIDs) based on the severity and type of urinary incontinence.

METHODS

Data was collected in a prospective cohort study that evaluated the freely available app Tät®. The app provided pelvic floor muscle training (PFMT) and life-style advice. Non-pregnant, non-postpartum women (≥ 18 years) who downloaded the app to treat urinary incontinence were included, if they completed the Patient Global Impression of Improvement (PGI-I) question at the 3-month follow-up (n = 1,733). Participants answered the International Consultation on Incontinence Questionnaire (ICIQ-UI SF) at baseline and after 3 months. The score change was analysed for correlation (Spearman) with the PGI-I. We then analysed one-way ANOVAs to determine whether there were significant differences between the groups based on the answers to the PGI-I. The MID was set to the mean change of the group that selected the answer "a little better" to the PGI-I question.

RESULTS

The one-way ANOVA showed significant differences between PGI-I groups (p < 0.001). The MID for the general group was set to 1.46 (95% Confidence Interval [CI] 1.26-1.67). In the sub-group analyses, a MID for the group with slight incontinence could not be determined. For the group with moderate severity the MID was determined to be 1.33 (95% CI 1.10-1.57) and for the severe/very severe group it was 3.58 (95% CI 3.08-4.09). Analysis of different types of incontinence showed no difference in MIDs.

CONCLUSIONS

The MID for self-management via a mobile app was lower than previously established MIDs, but differed depending on baseline severity. This study shows that MIDs need adjustment for baseline severity and treatment intensity when interpreting clinical trial results. If using MIDs as exact numbers, the study population and the treatment must be comparable.

App-based pelvic floor muscle training in pregnant and postnatal women: A prospective cohort study exploring factors associated with prevention and improvement of urinary incontinence

Background and Aims

Pelvic floor muscle training (PFMT) is recommended for continent pregnant women and postnatal women experiencing urinary incontinence (UI). The app Tät® has been developed for the treatment of stress UI with a focus on PFMT. The aim of this study was to investigate factors associated with the improvement of incontinence symptoms and retained continence in pregnant and postnatal women who used the app.

Methods

A prospective cohort study was carried out based on user questionnaires from the app Tät®. We included pregnant and postnatal women who answered the inclusion questionnaire between June 19, 2019 and September 19, 2020. The questionnaire included questions about the frequency and amount of leakage, the impact that UI has on everyday life, and experienced improvements at follow-up. We analyzed factors associated with improvement and retained continence using logistic regression.

Results

We included 10,307 pregnant and 13,670 postnatal women, and 44% of the pregnant women and 52% of the postnatal women were incontinent. A total of 3680 women were included in the follow-up analysis, and 52% of the pregnant incontinent women and 73% of the postnatal incontinent women experienced improvement. Pregnant women who performed PFMT and used the app at least once per week had increased odds of improvement (odds ratio [OR]: 1.83, 95% confidence interval [CI]: 1.01-3.29 and OR: 3.38, 95% CI: 1.94-5.90, respectively) compared to those who performed no training and had no app usage. Postnatal women who used the app at least once per week and had more severe incontinence had increased odds of improvement (OR: 4.26, 95% CI: 2.37-7.64 and OR: 1.11, 95% CI: 1.05-1.16, respectively).

Conclusions

The app Tät® is widely used by pregnant and postnatal women in Sweden for the prevention and treatment of UI. Majority of the women with incontinence experienced improvement after using the app. Regular PFMT and app use seemed to be important factors for experiencing improvement.

Self-management of incontinence using a free mobile app: factors associated with improvement

Background

Pelvic floor muscle training (PFMT) is first-line treatment for urinary incontinence (UI) in women. Self-management via a mobile app is a new cost-effective method for PFMT delivery. This study analyzes factors associated with improvement among app users.

Methods

A pragmatic observational study in a community setting. Upon downloading the app Tät®, users answered questions regarding their age, education, residence, and UI symptoms. After 3 months, users answered follow-up questions regarding symptoms and frequency of training and app usage, and the validated Patient Global Impression of Improvement (PGI-I) questionnaire. Only non-pregnant, non-postpartum adult women with UI who answered the PGI-I questionnaire were included. Multivariate logistic regression was used to analyze possible associations between these factors with any improvement and with great improvement according to the PGI-I. The models were adjusted for age.

Results

The study included 2,153 participants who had completed self-management, that is, 11.5% of eligible women who completed the baseline questionnaire. Of these participants, 65.6% reported improvement of UI. Any improvement was associated with age, frequency of PFMT, and app use, accounting for 27.9% of variability (Nagelkerke R²). Lower incontinence severity, frequency of PFMT, and app use were associated with great improvement.

Conclusion

Self-management of urinary incontinence is easily accessible to many women and improvement rates are comparable with other forms of PFMT. Demographic factors and incontinence severity showed no or incongruent association, whereas regular PFMT and app use predicted any and great improvement. App use showed an additional effect beyond frequency of training.

Association of baseline severity of lower urinary tract symptoms with the success conservative therapy for urinary incontinence in women

INTRODUCTION AND HYPOTHESIS

To identify the association between the symptom severity and outcome of conservative management for OAB, SUI and MUI. Conservative treatments are recommended for overactive bladder (OAB), stress urinary incontinence (SUI) and mixed incontinence (MUI). It is unclear whether disease severity affects treatment outcome.

METHODS

Patients receiving conservative management were reviewed. Disease-specific questionnaires (OAB-q SF, ICIQ-UI SF) and bladder diaries recorded baseline symptoms. Success was defined by Patient Global Impression of Improvement questionnaire (PGI-I) response of "very much better" or "much better". Non-parametric statistical tests and logistic regression were used.

RESULTS

In 50 OAB patients success was associated with lower symptom severity [30 (0-80) vs. 80 (23-100), p = 0.0001], fewer urgency episodes [4 (0-12) vs. 6 (0-11), p = 0.032] and lower ICIQ-UI SF [5.5 (0-20) vs. 15 (0-21), p = 0.002], but higher QoL [67 (20-101) vs. 24 (6-58), p = 0.0001]. In 50 MUI patients, variables were fewer urgency episodes [3 (0-10) vs. 6 (0-16), p = 0.004] and lower ICIQ-UI [11 (1-18) vs. 15 (5-21), p = 0.03]. In 40 SUI patients, variables were fewer incontinence episodes [1 (0-4) vs. 2 (0-5), p = 0.05] and lower ICIQ-UI [11 (6-16) vs. 13.5 (11-19), p = 0.003]. Multiple regression confirmed OAB-q QoL [odds ratio (OR) 1.10 (95% confidence intervals 1.04, 1.1)] for OAB, urgency episodes [OR 0.74 (0.56, 0.98)] and ICIQ-UI [OR 0.83 (0.71, 0.98] for MUI and ICIQ-UI [OR 0.57 (0.40, 0.83)] for SUI.

CONCLUSIONS

Milder baseline disease severity was associated with successful outcome. There is potential for triage at initial assessment to second-line interventions for women unlikely to achieve success.

Pelvic floor morphometry: a predictor of success of pelvic floor muscle training for women with stress and mixed urinary incontinence

INTRODUCTION AND HYPOTHESIS

The aim of this study was to determine if pelvic floor muscle (PFM) morphometry at baseline, as measured by MRI, can predict response to PFM training in women with stress or mixed urinary incontinence (UI).

METHODS

This study was a prospective quasi-experimental pre-test, post-test cohort study of women with UI, aged 60 years and older. All participants completed a baseline assessment of UI severity and impact, using the 72-h bladder diary and the Incontinence Impact Questionnaire. They underwent a pelvic MRI examination to assess the PFM anatomy. Women then participated in a 12-week PFM training program. Finally, they attended a post intervention assessment of UI severity and impact. The association between morphometry and PFM training response was assessed by univariate analysis, multivariate analysis, and receiver operating characteristic (ROC) curve analysis.

RESULTS

The urethro-vesical junction height at rest, as measured by MRI before treatment, was associated with response to PFM training both on univariate (p ≤ 0.005) and multivariate analyses (p = 0.007). The area under the ROC curve was 0.82 (95% confidence interval [CI]: 0.67-0.96). Using a cut-off point of 11.4 mm, participants' response to PFM training was predicted with a sensitivity of 77% and a specificity of 83%. Incontinent women with a urethro-vesical junction height above this threshold were 35% more likely to respond to PFM training (OR 1.35; 95% CI: 1.08-1.67).

CONCLUSION

In older women with UI, a urethro-vesical junction height at rest of at least 11.4 mm appears to be predictive of PFM training response.

Non-face-to-face treatment of stress urinary incontinence: predictors of success after 1 year

Introduction and hypothesis

The objective was to determine predictors of long-term success in women with stress urinary incontinence (SUI) treated with a 3-month pelvic floor muscle training (PFMT) program delivered via the Internet or a brochure.

Methods

We included 169 women with SUI ≥1 time/week who completed the 1-year follow-up (n = 169, mean age 50.3, SD 10.1 years). Three outcome variables defined success after 1 year: Patient Global Impression of Improvement (PGI-I), International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF), and sufficient treatment. Using logistic regression, we analyzed data from the baseline, and from the 4-month and 1-year follow-ups, for potential predictors of success.

Results

Of the participants, 77 % (129 out of 169) were successful in ≥1 of the outcomes, 23 % (37 out of 160) were successful in all 3. Participants with successful short-term results were more likely to succeed in the corresponding outcome at 1 year than those without successful short-term results (adjusted odds ratios [ORs]: PGI 5.15, 95 % confidence interval [CI] 2.40–11.03), ICIQ-UI SF 6.85 (95 % CI 2.83–16.58), and sufficient treatment 3.78 (95 % CI 1.58–9.08). Increasing age predicted success in PGI-I and sufficient treatment (adjusted OR 1.06, 95 % CI 1.02–1.10, and 1.08, 95 % CI, 1.03–1.13 respectively). Compared with not training regularly, regular PFMT at 1 year predicted success for PGI and sufficient treatment (adjusted OR 2.32, 95 % CI 1.04–5.20, and 2.99, 95 % CI 1.23–7.27 respectively).

Conclusion

The long-term success of a non-face-to-face treatment program for SUI with a focus on PFMT can be predicted by successful short-term results, increasing age, and the performance of regular PFMT after 1 year.

Age-stratified trends in 20 years of stress incontinence surgery in Australia

BACKGROUND

Stress urinary incontinence (SUI) is a common, debilitating condition in Australian women. Since its introduction in 1998-1999, the less invasive mid-urethral sling (MUS) procedure has become the new standard for surgical correction of SUI and overall numbers of continence procedures increased. Trends since 2009 have not been analysed.

AIMS

To identify patterns in the surgical treatment of women with SUI in Australia from January 1994 to December 2014 stratified by age.

MATERIALS AND METHODS

Gender- and age-specific data from Medicare Australia between January 1994 and December 2014 were extracted and the patterns of SUI surgery analysed for the 20-year period. Data on gynaecologists and urologists performing MUS and colposuspension were collected from Department of Human Services.

RESULTS

Following the introduction of MUS, total SUI operations increased with the peak in 2002, a plateau between 2006 and 2011, and a new decline from 2012 onwards. There has been a sustained 51.7% increase in total SUI operations in 75- to 84-year-old women, and a 105.2% increase in women aged over 84. However, SUI operations in 45- to 64-year-olds decreased below pre-MUS baseline in 2014.

CONCLUSIONS

Mid-urethral sling has become the standard SUI procedure being performed in Australia since its introduction in 1999. SUI operations have increased each year for patients aged over 65, with the greatest increase seen in patients aged over 84 - indicating expanded eligibility for SUI surgery in older women. However, since 2010, there has been a fall in SUI operations to below the pre-MUS baseline.