Comparison of responsiveness of validated outcome measures after surgery for stress urinary incontinence

A systematic review of utility-based and disease-specific quality of life measurement instruments for women with urinary incontinence

AIM

This systematic review aims to identify disease-specific and generic quality of life (QoL) outcome measurement instruments used in populations of women with urinary incontinence (UI) and to determine the most psychometrically robust and appropriate disease-specific and generic tools for measuring the quality of life in this population.

METHODS

A systematic search was conducted of PubMed, Embase, SCIELO, and CINAHL databases for studies evaluating measurement properties of QoL instruments in women with UI. The methodological quality of studies and the quality of measurement properties were evaluated using the COnsensus-based Standards for the selection of health status Measurement INtruments (COSMIN) checklist and quality criteria. Overall, evidence for measurement properties was graded using the modified grading of recommendations, assessment, development & evaluation approach.

RESULTS

A total of 73 studies were included, and 27 specific and 6 generic instruments were identified. The Incontinence QoL questionnaire (IQoL) had the highest overall psychometric quality for English-speaking populations and was the most widely translated tool. Evidence for generic QoL tools in this population is limited. Few studies evaluated measurement error or cross-cultural validity.

CONCLUSION

The IQoL is the most psychometrically robust disease-specific tool for use in this population. More research is needed to determine the most psychometrically robust generic tool. Future studies should also evaluate measurement error and cross-cultural validity as evidence for these properties is particularly lacking.

Pelvic floor distress inventory (PFDI)-systematic review of measurement properties

INTRODUCTION AND HYPOTHESIS

The Pelvic Floor Distress Inventory (PFDI) and PFDI-20 have been translated and validated into several languages ​​with different measurement property values ​​and are recommended by the International Consultation on Incontinence (ICI) as grade A for assessing pelvic floor dysfunction. Thus, the aim of the current study was to investigate the measurement properties of the PFDI and PFDI-20.

METHODS

Systematic review conducted in August 2020 through a search performed in PubMed, SCOPUS, WoS, ScienceDirect, CINAHL, and Google Scholar for studies that evaluated the measurement properties of the PFDI and PFDI-20. The data were analyzed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN).

RESULTS

Initially, 2857 studies were found, and 7 studies on PFDI and 25 on PFDI-20 were analyzed. The PFDI presented high quality of evidence for hypothesis testing, moderate for test-retest reliability and responsiveness, and very low quality of evidence for content validity. The PFDI-20 presented high quality of evidence for criterion validity, hypothesis testing, and responsiveness, moderate quality for test-retest reliability and measurement errors, and very low quality of evidence for content validity. It was not possible to rate the quality of evidence of the internal consistency of the PFDI and PFDI-20. No studies assessed the cross-cultural validity.

CONCLUSION

Only the hypothesis testing presented high quality of evidence for the PFDI. Criterion validity, hypothesis testing, and responsiveness presented a high quality of evidence for the PFDI-20. Due to the high degree of recommendation of the PFDI and PFDI-20 given by the ICI, further studies are needed to reevaluate all the measurement properties of these instruments.

Mid-urethral sling operations for stress urinary incontinence in women

BACKGROUND

Urinary incontinence is a very common and debilitating problem affecting about 50% of women at some point in their lives. Stress urinary incontinence (SUI) is a predominant cause in 30% to 80% of these women imposing significant health and economic burden on society and the women affected. Mid-urethral sling (MUS) operations are a recognised minimally invasive surgical treatment for SUI. MUS involves the passage of a small strip of tape through either the retropubic or obturator space, with entry or exit points at the lower abdomen or groin, respectively. This review does not include single-incision slings.

OBJECTIVES

To assess the clinical effects of mid-urethral sling (MUS) operations for the treatment of SUI, urodynamic stress incontinence (USI) or mixed urinary incontinence (MUI) in women.

SEARCH METHODS

We searched: Cochrane Incontinence Specialised Register (including: CENTRAL, MEDLINE, MEDLINE In-Process, ClinicalTrials.gov) (searched 26 June 2014); Embase Classic (January 1947 to Week 25 2014); WHO ICTRP (searched 30 June 2014); reference lists.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials amongst women with SUI, USI or MUI, in which both trial arms involve a MUS operation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of potentially eligible studies and extracted data from included trials.

MAIN RESULTS

We included 81 trials that evaluated 12,113 women. We assessed the quality of evidence for outcomes using the GRADE assessment tool; the quality of most outcomes was moderate, mainly due to risk of bias or imprecision.Fifty-five trials with data contributed by 8652 women compared the use of the transobturator route (TOR) and retropubic route (RPR). There is moderate quality evidence that in the short term (up to one year) the rate of subjective cure of TOR and RPR are similar (RR 0.98, 95% CI 0.96 to 1.00; 36 trials, 5514 women; moderate quality evidence) ranging from 62% to 98% in the TOR group, and from 71% to 97% in the RPR group. Short-term objective cure was similar in the TOR and RPR groups (RR 0.98, 95% CI 0.96 to 1.00; 40 trials, 6145 women). Fewer trials reported medium-term (one to five years) and longer-term (over five years) data, but subjective cure was similar between the groups (RR 0.97, 95% CI 0.87 to 1.09; 5 trials, 683 women; low quality evidence; and RR 0.95, 95% CI 0.80 to 1.12; 4 trials, 714 women; moderate quality evidence, respectively). In the long term, subjective cure rates ranged from 43% to 92% in the TOR group, and from 51% to 88% in the RPR group.MUS procedures performed using the RPR had higher morbidity when compared to TOR, though the overall rate of adverse events remained low. The rate of bladder perforation was lower after TOR (0.6% versus 4.5%; RR 0.13, 95% CI 0.08 to 0.20; 40 trials, 6372 women; moderate quality evidence). Major vascular/visceral injury, mean operating time, operative blood loss and length of hospital stay were lower with TOR.Postoperative voiding dysfunction was less frequent following TOR (RR 0.53, 95% CI 0.43 to 0.65; 37 trials, 6200 women; moderate quality evidence). Overall rates of groin pain were higher in the TOR group (6.4% versus 1.3%; RR 4.12, 95% CI 2.71 to 6.27; 18 trials, 3221 women; moderate quality evidence) whereas suprapubic pain was lower in the TOR group (0.8% versus 2.9%; RR 0.29, 95% CI 0.11 to 0.78); both being of short duration. The overall rate of vaginal tape erosion/exposure/extrusion was low in both groups: 24/1000 instances with TOR compared with 21/1000 for RPR (RR 1.13, 95% CI 0.78 to 1.65; 31 trials, 4743 women; moderate quality evidence). There were only limited data to inform the need for repeat incontinence surgery in the long term, but it was more likely in the TOR group than in the RPR group (RR 8.79, 95% CI 3.36 to 23.00; 4 trials, 695 women; low quality evidence).A retropubic bottom-to-top route was more effective than top-to-bottom route for subjective cure (RR 1.10, 95% CI 1.01 to 1.19; 3 trials, 477 women; moderate quality evidence). It incurred significantly less voiding dysfunction, and led to fewer bladder perforations and vaginal tape erosions.Short-and medium-term subjective cure rates between transobturator tapes passed using a medial-to-lateral as opposed to a lateral-to-medial approach were similar (RR 1.00, 95% CI 0.96 to 1.06; 6 trials, 759 women; moderate quality evidence, and RR 1.06, 95% CI 0.91 to 1.23; 2 trials, 235 women; moderate quality evidence). There was moderate quality evidence that voiding dysfunction was more frequent in the medial-to-lateral group (RR 1.74, 95% CI 1.06 to 2.88; 8 trials, 1121 women; moderate quality evidence), but vaginal perforation was less frequent in the medial-to-lateral route (RR 0.25, 95% CI 0.12 to 0.53; 3 trials, 541 women). Due to the very low quality of the evidence, it is unclear whether the lower rates of vaginal epithelial perforation affected vaginal tape erosion (RR 0.42, 95% CI 0.16 to 1.09; 7 trials, 1087 women; very low quality evidence).

AUTHORS' CONCLUSIONS

Mid-urethral sling operations have been the most extensively researched surgical treatment for stress urinary incontinence (SUI) in women and have a good safety profile. Irrespective of the routes traversed, they are highly effective in the short and medium term, and accruing evidence demonstrates their effectiveness in the long term. This review illustrates their positive impact on improving the quality of life of women with SUI. However, a brief economic commentary (BEC) identified three studies suggesting that transobturator may be more cost-effective compared with retropubic. Fewer adverse events occur with employment of a transobturator approach with the exception of groin pain. When comparing transobturator techniques of a medial-to-lateral versus a lateral-to-medial insertion, there is no evidence to support the use of one approach over the other. However, a bottom-to-top route was more effective than top-to-bottom route for retropubic tapes.A salient point illustrated throughout this review is the need for reporting of longer-term outcome data from the numerous existing trials. This would substantially increase the evidence base and provide clarification regarding uncertainties about long-term effectiveness and adverse event profile.

Predictive modeling and threshold scores for care seeking among women with urinary incontinence: The short forms of the Pelvic Floor Distress Inventory and Urogenital Distress Inventory

AIMS

To further the interpretability of the Pelvic Floor Distress Inventory (PFDI-20) and Urogenital Distress Inventory (UDI-6) by (i) evaluating the ability of these measures to distinguish between women with urinary incontinence who do and do not seek care, (ii) defining PFDI-20 and UDI-6 threshold scores above which women with urinary incontinence seek care, and (iii) developing a predictive model for incontinence care seeking.

METHODS

An observational study was conducted with two groups of women with urinary incontinence: 256 who had not sought care and 90 seeking initial care at a tertiary center. Sample sizes were based upon the prevalence of care seeking for urinary incontinence and the number of potential predictors for care seeking. Wilcoxon rank-sum tests, receiver operating characteristics, and multivariable logistic regression were use to achieve the study aims.

RESULTS

Women with urinary incontinence who sought care had higher median PFDI-20 and UDI-6 scores compared to non-care seekers (73.96 vs. 16.67, P < 0.0001, and 41.67 vs. 8.33, P < 0.0001). A PFDI-20 score of 33.33 (83.33% sensitivity and 79.30% specificity) had very good discriminatory accuracy in distinguishing care and non-care seekers (AUC 0.886 ± 0.019 [95%CI 0.8518, 0.9254] P < 0.0001). A UDI-6 score of 25.00 (83.33% sensitivity and 83.59% specificity) had excellent discriminatory accuracy in distinguishing care and non-care seekers (AUC 0.9025 ± 0.0190 [95%CI 0.8653, 0.9398] P < 0.0001). A multivariable predictive model accurately identified 82.4% of care and non-care seekers.

CONCLUSIONS

A PFDI-20 score of 33.33 and UDI-6 score of 25.00 provide meaningful benchmarks for care seeking among women with urinary incontinence. Neurourol. Urodynam. 35:949-954, 2016. © 2015 Wiley Periodicals, Inc.

Mid-urethral sling operations for stress urinary incontinence in women

BACKGROUND

Urinary incontinence is a very common and debilitating problem affecting about 50% of women at some point in their lives. Stress urinary incontinence (SUI) is a contributory or predominant cause in 30% to 80% of these women. Mid-urethral sling (MUS) operations are a recognised minimally invasive surgical treatment for SUI. MUS involves the passage of a small strip of tape through either the retropubic or obturator space, with entry or exit points at the lower abdomen or groin, respectively. This review does not include single incision slings.

OBJECTIVES

To assess the clinical effects of mid-urethral sling (MUS) operations for the treatment of stress urinary incontinence (SUI), urodynamic stress incontinence (USI) or mixed urinary incontinence (MUI) in women.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE in process, ClinicalTrials.gov and handsearching of journals and conference proceedings (searched 26 June 2014), Embase and Embase Classic (January 1947 to Week 25 2014), WHO ICTRP (searched on 30 June 2014) and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials amongst women with SUI, USI or MUI, in which both trial arms involve a MUS operation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of potentially eligible studies and extracted data from the included trials.

MAIN RESULTS

We included 81 trials that evaluated 12,113 women. We assessed the quality of evidence for outcomes using the GRADE assessment tool; the quality of most outcomes was moderate, mainly due to risk of bias or imprecision.Fifty-five trials with data contributed by 8652 women compared the use of the transobturator route (TOR) and retropubic route (RPR). There is moderate quality evidence that in the short term (up to one year) the rate of subjective cure of TOR and RPR are similar (RR 0.98, 95% CI 0.96 to 1.00; 36 trials, 5514 women; moderate quality evidence) ranging from 62% to 98% in the TOR group, and from 71% to 97% in the RPR group. Short-term objective cure was similar in the TOR and RPR groups (RR 0.98, 95% CI 0.96 to 1.00; 40 trials, 6145 women). Fewer trials reported medium-term (one to five years) and longer-term (over five years) data, but subjective cure was similar between the groups (RR 0.97, 95% CI 0.87 to 1.09; 5 trials, 683 women; low quality evidence; and RR 0.95, 95% CI 0.80 to 1.12; 4 trials, 714 women; moderate quality evidence, respectively). In the long term, subjective cure rates ranged from 43% to 92% in the TOR group, and from 51% to 88% in the RPR group.MUS procedures performed using the RPR had higher morbidity when compared to TOR, though the overall rate of adverse events remained low. The rate of bladder perforation was lower after TOR (0.6% versus 4.5%; RR 0.13, 95% CI 0.08 to 0.20; 40 trials, 6372 women; moderate quality evidence). Major vascular/visceral injury, mean operating time, operative blood loss and length of hospital stay were lower with TOR.Postoperative voiding dysfunction was less frequent following TOR (RR 0.53, 95% CI 0.43 to 0.65; 37 trials, 6200 women; moderate quality evidence). Overall rates of groin pain were higher in the TOR group (6.4% versus 1.3%; RR 4.12, 95% CI 2.71 to 6.27; 18 trials, 3221 women; moderate quality evidence) whereas suprapubic pain was lower in the TOR group (0.8% versus 2.9%; RR 0.29, 95% CI 0.11 to 0.78); both being of short duration. The overall rate of vaginal tape erosion/exposure/extrusion was low in both groups: 24/1000 instances with TOR compared with 21/1000 for RPR (RR 1.13, 95% CI 0.78 to 1.65; 31 trials, 4743 women; moderate quality evidence). There were only limited data to inform the need for repeat incontinence surgery in the long term, but it was more likely in the TOR group than in the RPR group (RR 8.79, 95% CI 3.36 to 23.00; 4 trials, 695 women; low quality evidence).A retropubic bottom-to-top route was more effective than top-to-bottom route for subjective cure (RR 1.10, 95% CI 1.01 to 1.19; 3 trials, 477 women; moderate quality evidence). It incurred significantly less voiding dysfunction, and led to fewer bladder perforations and vaginal tape erosions.Short-and medium-term subjective cure rates between transobturator tapes passed using a medial-to-lateral as opposed to a lateral-to-medial approach were similar (RR 1.00, 95% CI 0.96 to 1.06; 6 trials, 759 women; moderate quality evidence, and RR 1.06, 95% CI 0.91 to 1.23; 2 trials, 235 women; moderate quality evidence). There was moderate quality evidence that voiding dysfunction was more frequent in the medial-to-lateral group (RR 1.74, 95% CI 1.06 to 2.88; 8 trials, 1121 women; moderate quality evidence), but vaginal perforation was less frequent in the medial-to-lateral route (RR 0.25, 95% CI 0.12 to 0.53; 3 trials, 541 women). Due to the very low quality of the evidence, it is unclear whether the lower rates of vaginal epithelial perforation affected vaginal tape erosion (RR 0.42, 95% CI 0.16 to 1.09; 7 trials, 1087 women; very low quality evidence).

AUTHORS' CONCLUSIONS

Mid-urethral sling operations have been the most extensively researched surgical treatment for stress urinary incontinence (SUI) in women and have a good safety profile. Irrespective of the routes traversed, they are highly effective in the short and medium term, and accruing evidence demonstrates their effectiveness in the long term. This review illustrates their positive impact on improving the quality of life of women with SUI. With the exception of groin pain, fewer adverse events occur with employment of a transobturator approach. When comparing transobturator techniques of a medial-to-lateral versus a lateral-to-medial insertion, there is no evidence to support the use of one approach over the other. However, a bottom-to-top route was more effective than top-to-bottom route for retropubic tapes.A salient point illustrated throughout this review is the need for reporting of longer-term outcome data from the numerous existing trials. This would substantially increase the evidence base and provide clarification regarding uncertainties about long-term effectiveness and adverse event profile.

Sexual function before and after non-surgical treatment for stress urinary incontinence

OBJECTIVES: (1) to describe sexual function in women seeking treatment of stress urinary incontinence (SUI); (2) to compare the impact on sexual function of three SUI treatments; and (3) to investigate whether non-surgical treatment of SUI is associated with improved sexual function. METHODS: Women with SUI were randomized to continence pessary, behavioral therapy (pelvic floor muscle training and continence strategies), or combination therapy. Sexual function was assessed at baseline and 3-months using short forms of the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire (PISQ-12) and the Personal Experiences Questionnaire (SPEQ). Successful treatment of SUI was assessed with a patient global impression of improvement. ANOVA was used to compare scores between groups. RESULTS: At baseline, sexual function was worse among women with mixed incontinence compared to those with pure SUI. After therapy, successful treatment of SUI was associated with greater improvement in PISQ-12 score (2.26 ± 3.24 versus 0.48 ± 3.76, p=0.0007), greater improvement in incontinence with sexual activity (0.45 ± 0.84 versus 0.01 ± 0.71, p=0.0002), and greater reduction in restriction in sexual activity related to fear of incontinence (0.32 ± 0.76 versus -0.06 ± 0.78, p=0.0008). Among those successfully treated for SUI, improvement in continence during sexual activity was greater in both the combined therapy group (p=0.019) and the behavioral group (p=0.02) compared to the pessary group. CONCLUSIONS: Successful non-surgical treatment of SUI is associated with improvements in incontinence-specific measures of sexual function. Behavioral therapy may be preferred to pessary for treatment of SUI among women whose incontinence interferes with sexual function.