Clinical versus urodynamic diagnosis in an incontinent geriatric female population

Safety and efficacy of polydimethylsiloxane (Macroplastique®) in women with stress urinary incontinence: analysis of data from patients who completed three years follow-up

Introduction and hypothesis

This study aimed to report 3-year completed follow-up of the safety and efficacy of Macroplastique® (MPQ) in women with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD).

Methods

This is a retrospective analysis of all women who completed 3-year follow-up post-MPQ injection(s) at ten medical centers. We used the ROSE registry data report of Macroplastique® [Macroplastique® Real-time Observation of Safety and Effectiveness (ROSE) registry P040050/PAS001 on 2017]. Subjective incontinence outcome and adverse effects were assessed.

Results

The study included all patients (n = 70) who completed 3-year follow-up after the last MPQ injection. Twenty-four of 70 (34%) patients had two injections; 21/70 (30%) patients reported Stamey grade 0 and 28/70 (40%) reported Stamey grade 1. The overall patient satisfaction was 68% who completed 3-year follow-up. The composite success rate (I-QoL, PGI-S, and Stamey grade improvement) was 51.4%. No serious adverse events (AE) were reported within the completed 3-year follow-up.

Conclusions

MPQ was found to be safe and efficacious for the treatment of SUI secondary to ISD in women. The overall high satisfaction rate was sustained from baseline to 3 years post-injection. Most complications were minor and transient without sequelae.

Relationship between urinary incontinence symptoms and urodynamic findings using a validated Arabic questionnaire

BACKGROUND

Urinary incontinence is common, particularly in women. Urodynamic studies (UDS) can accurately assess the condition. Less invasive objective measuring tools correlate with urodynamic findings, but the Arabic version of the Urogenital Distress Inventory-6 (UDI-6) questionnaire has not been previously correlated with UDS in Arabian patients.

OBJECTIVE

To correlate the Arabic version of the UDI-6 with urodynamic findings in Arabian women with urinary incontinence.

DESIGN

Prospective.

SETTING

Tertiary referral urology clinic.

PATIENTS AND METHODS

All female patients presenting with urinary incontinence between July 2013 to March 2014. Patients answered the Arabic UDI-6 questionnaire and underwent a history and clinical examination, urine culture and UDS.

MAIN OUTCOME MEASURES

Correlation between Arabic UDI-6 questionnaire score and urodynamic diagnosis.

RESULTS

Eighty-seven women with a mean age of 57 (range, 22-72) years completed the UDI-6 and underwent UDS. The questionnaire revealed that 20 (23%) patients had urge incontinence, 28 (32%) had stress incontinence and 39 (45%) had mixed incontinence. As diagnosed by UDS, 26 (30%) had urge incontinence, 37 (42%) had stress incontinence, 16 (18%) had mixed incontinence and 8 (9%) had no abnormality. Eighty-six percent of patients (24/28) with pure stress urinary incontinence (SUI) symptoms had a positive UDS, and 55% (11/20) of patients with pure urge incontinence symptoms had a positive UDS. Of all patients with positiveresponse to the question for SUI, 53/67, 79% had positive UDS diagnosis with a correlation coefficient of 0.65 (P < .01). Of all patients with positive responses for urge incontinence, 27/59, 45.8% had positive UDS diagnosis with a moderate correlation coefficient of 0.38 (P < .01).

CONCLUSIONS

The validated Arabic UDI-6 correlates significantly with UDS findings in Arabian women, particularly in women with SUI.

LIMITATIONS

The sample size was relatively small, which prevented sub-analyses. Patient comorbidities were not evaluated.

Role of urodynamics in stress urinary incontinence: A critical appraisal

Introduction:

Role of urodynamics prior to surgery of stress urinary incontinence (SUI) is under constant debate. Demonstration of the presence of detrusor overactivity is the only aspect that has been emphasized in the literature so far. We believe that there are number of other factors which may influence the evaluation and in turn the choice of surgical management and prediction of outcome of treatment. They are as follows: (1) Presence of voiding inefficiency, (2) asymptomatic detrusor overactivity, (3) and severity of SUI. These features may complicate the precise evaluation of patients of SUI. The main objective of this study is to analyze the dynamics of leakage and voiding using urodynamics. This study also aims at correlating these findings with clinical information.

Materials and Methods:

One hundred consecutive cases referred to our center for preoperative evaluation of SUI were recruited in the study prospectively. All patients were interrogated using International Consultation on Incontinence Questionnaire. All patients underwent complete urodynamic evaluation including uroflowmetry, filling cystometry, leak point pressure measurement, and pressure flow studies, according to Good Urodynamic Practice guidelines. Patients’ symptoms were correlated with urodynamic findings, with special emphasis on the presence of detrusor overactivity, severity of SUI, voiding efficiency, and presence of bladder outlet obstruction. Clinical information and urodynamic findings were correlated using Chi-square test.

Results:

There is a statistically significant correlation between the presence of symptoms of urge urinary incontinence and urodynamic findings of detrusor overactivity at P < 0.05. There is a statistically significant correlation between the symptoms of urge incontinence (in addition to SUI) and urodynamic findings of intrinsic sphincter deficiency at P < 0.05. Fifteen of 51 patients who did not have associated storage symptoms were found to have some degree of detrusor overactivity on urodynamic evaluation. There was no statistically significant correlation between asymptomatic cases of urge incontinence and incidental finding of detrusor overactivity at P < 0.05. There is no statistically significant correlation between the urodynamic findings of symptoms of voiding dysfunction and urodynamic findings, suggestive of the same value at P < 0.05.

Conclusions:

Urodynamic study in SUI has a potential of giving much more information than demonstration of Detrusor Overactivity alone. The predominant symptom of urge urinary incontinence can predictably diagnose detrusor overactivity in these cases. However, the incidence of asymptomatic detrusor overactivity remains as high as 15% and may have implication in postoperative results. This study clearly shows that there is a definite incidence of significant voiding dysfunction, which cannot be reliably evaluated without properly conducted pressure flow study. This factor may govern the choice of correct treatment which also predicts the outcome more reliably. Preoperative urodynamic study thus adds a dimension of precision to evaluation of the patients of SUI and may also influence technique and outcome measures in this group of patients.

Diagnosis and surgical treatment of stress urinary incontinence

Stress urinary incontinence (SUI) is a major problem affecting more than 20% of the nation's female population, with increasing prevalence as our population continues to age. Incontinence places a great burden on individuals, and the economic effect is large. Stress urinary incontinence occurs when there is involuntary leakage of urine during coughing, laughing, sneezing, or physical activity. It can be diagnosed during physical examination and by using low-cost office diagnostics. Although nonsurgical treatments provide some benefit, surgical interventions have demonstrated superiority with respect to subjective and objective cure and better long-term improvement. Corrective surgeries for SUI can be grouped into four categories: 1) slings (midurethral slings and slings placed at the ureterovesical junction), 2) retropubic urethropexy, 3) urethral bulking agents, and 4) artificial sphincters. The success and failure of each approach needs to be assessed in the context of individual patients and their circumstances. Slings and retropubic urethropexy are considered first-line surgical options. Since the advent of minimally invasive retropubic midurethral slings such as the tension-free vaginal tape, transobturator tension-free vaginal tape, and single-incision sling, retropubic urethropexy have fallen out of favor. Warnings about mesh use may contribute to a resurgence of retropubic urethropexy procedures such as the Burch procedure. A Burch procedure should still be considered for patients who have an aversion to mesh or if they are undergoing concurrent abdominal approach surgery. Urethral bulking agents are usually reserved for patients with a fixed, nonmobile urethra who cannot tolerate an operative experience or have failed previous antiincontinence procedures. Artificial sphincters should be considered an operation of last resort.

Correlation between urodynamic tests, history and clinical findings in treatment of women with urinary incontinence

ABSTRACT Objective: The aim of this study was to evaluate the role of urodynamic test in diagnosis of urinary incontinence, comparing detailed data of history and physical examination, and some easy- to-apply clinical tests. Methods: A cross-sectional retrospective study was carried out by reviewing the medical charts of 55 patients with complaint of loss of urine, seen at the Urogynecology Service of Women's Health Outpatient Clinic of Hospital Universitário de Jundiaí, between October 2006 and March 2007. The patients answered a specific questionnaire involving the epidemiological and physical examination variables considered in this study. They were submitted to physical examination and urodynamic tests. Results: The complaint of loss of urine upon exertion, either isolated or associated with urge incontinence, was confirmed by urodynamic tests in most women, and only 4 of 49 symptomatic women had negative results. The clinical sign was present in 35 patients (63.6%), and 46 patients (83.6%) had the exertion component in the urodynamic test. The exertion component was observed in 10 (18%) out of 15 patients without symptoms (30%). The positive and negative predictive values of the clinical sign for diagnosis of any type of urinary incontinence in this studied group were 97.1 and 26.7%, respectively. As for the clinical complaint of urinary loss upon exertion, the positive and negative predictive values for any type of urinary incontinence were 92 and 40%, respectively. For the clinical complaint of urge incontinence, the positive and negative predictive values of 92.5 and 23.1%, respectively. Conclusions: It was concluded that the urodynamic evaluation is an important instrument to evaluate the severity of incontinence, although it was not necessary to diagnose loss of urine. The finding of urinary loss during physical examination had low sensitivity and specificity in diagnosis of the type of loss of urine. Urodynamic tests had better performance in demonstrating urinary incontinence in patients with complaint of incontinence upon exertion and without loss of urine seen upon physical examination than in confirming urge incontinence in patients with those symptoms.

Do women with pure stress urinary incontinence need urodynamics?

OBJECTIVES

To evaluate the value of performing urodynamic investigations in the assessment of women with a history of pure stress urinary incontinence (SUI).

METHODS

Consecutive women with lower urinary tract symptoms were studied retrospectively. Urinary symptoms were determined from the frequency-volume chart and symptom section of the King's Health Questionnaire. Only women with pure SUI symptoms were included.

RESULTS

A total of 3428 women aged 24-81 years were studied. Only 308 women (8.9%) could be classified as having pure SUI from the questionnaire. Of these, 241 of women (78.2%) had urodynamic stress incontinence, 23 women (7.5%) had detrusor overactivity, 9 women (2.9%) had mixed urodynamic diagnosis, and 35 women (11.4%) had inconclusive urodynamics. Postvoid residual volumes greater than 100 mL were noted in 24 (7.8%) women.

CONCLUSIONS

Our results show that urodynamic investigations provide useful information in the assessment of women with a history of pure SUI, because as many as 20% of them might not need surgery as the first line of treatment.

The reproducibility of urodynamic studies of neurogenic bladders in spinal cord injury

OBJECTIVE

To evaluate the reproducibility (test-retest reliability) of urodynamic studies in neurogenic bladders of subjects with spinal cord injuries (SCI).

DESIGN

Retrospective case series.

SETTING

Urology department of a major rehabilitation center.

SUBJECTS

Fifty individuals with SCI who had urodynamic studies performed from February 2000 to April 2000.

MAIN OUTCOME MEASURES

Two trials (Time 1 and Time 2) of urodynamic studies done 5 minutes apart, with the following collected: bladder volume at first sensation, maximum cystometric capacity, presence of uninhibited contractions, opening pressure, maximum detrusor pressure, duration of bladder contraction, volume voided, and post-void residual (PVR) volume. The corresponding data were then compared. Statistical analysis was performed using the Lin's concordance correlation coefficient and kappa.

RESULTS

Analysis of the data showed statistically significant levels of agreement between Time 1 and Time 2 with regard to the various corresponding parameters for both the filling and voiding phases. For 3 of the most important parameters-the opening pressure, maximum detrusor pressure, and duration of contraction-the Lin's concordance correlation coefficient (r(c)) was .86 (95% CI, .78-.95; p < .0005), .91 (95% CI, .86-.96; p < .0005), and .97 (95% CI, .95-.99, p < .0005), respectively.

CONCLUSION

The study demonstrates good short-term intrasubject reproducibility of urodynamic studies in individuals with SCI.

Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence

AIMS

To evaluate the performance of all tests proposed for the diagnosis of urinary incontinence.

METHODS

A systematic review and meta-analyses of the published literature of methods for diagnostic assessment of urinary incontinence.

RESULTS

One hundred twenty-one papers were included in the full review [Martin et al., 2006]. The quality of reporting in the primary studies was poor which reduced the number of studies that could be included in the data analysis. The literature suggests that women with urodynamic stress incontinence (USI) can be correctly identified in primary care from clinical history alone with a sensitivity of 0.92 (95% C.I.: 0.91-0.93) and specificity of 0.56 (0.53-0.60). A clinical history for the diagnosis of detrusor overactivity (DO) was found to be 0.61 (0.57-0.65) sensitive and 0.87 (0.85-0.89) specific. Within secondary care imaging of leakage by ultrasound was found to be effective in the diagnosis of USI in women with a sensitivity of 0.89 (0.84-0.93) and specificity of 0.82 (0.73-0.89).

CONCLUSIONS

Clinical interpretation of the results of the review is difficult because few studies could be synthesized and conclusions made. The published evidence suggests that a large proportion of women with USI can be correctly identified in primary care from history alone. Ultrasound offers a useful diagnostic tool which could be used prior to, and possibly instead of, multi-channel urodynamics in some circumstances. If a patient is to undergo urodynamic testing, multi-channel urodynamics is likely to give the most accurate result. Further primary studies adhering to STARD guidelines are required on commonly used tests.

Systematic review: efficacy of silicone microimplants (Macroplastique) therapy for stress urinary incontinence in adult women

OBJECTIVE

To assess the efficacy of silicone microimplants (Macroplastique; polydimethylsiloxane) therapy for stress urinary incontinence in adult women, using a systematic review of identified studies.

MATERIALS AND METHODS

A computer-aided and manual search for published studies investigating silicone microimplants therapy for stress urinary incontinence in adult women. The methodological quality of the included studies was assessed using criteria based on generally accepted principles of interventional research.

RESULTS

Only two RCTs, only published as an abstract, were found. Eleven pre-experimental or observational studies were identified. Overall, the methodological quality was low. The main methodological shortcomings of the studies were: no random allocation procedure, lack of prestratification on prognostic determinants, no blinding, small sample sizes, and lack of proper analysis and presentation of results. There was variability in the indication for implantation, implantation procedure, rate and volume of silicone microimplants. The use of different outcome measures in most of the trials made comparison between studies difficult.

CONCLUSIONS

Because of the low methodological quality of included studies, results should be interpreted with caution and no firm conclusions about the efficacy of silicone microimplants were possible. Randomized clinical trials, using valid and reliable subjective and objective measurements, are necessary to establish the efficacy of silicone microimplants therapy in treating stress urinary incontinence in adult women.

Stress incontinence surgery for patients presenting with mixed incontinence and a normal cystometrogram

OBJECTIVE

To evaluate the outcome of surgery for stress urinary incontinence (SUI) in patients presenting with a combination of stress and sensory urge UI.

PATIENTS AND METHODS

The study comprised 75 women presenting with mixed incontinence; the most important inclusion criterion was a negative cystometrogram for detrusor overactivity. Based on random selection, a third of the patients received a 6-month course of anticholinergic treatment (group 1) and 50 (group 2) had surgery for SUI. The surgical procedure depended on the Valsalva leak-point pressure (VLPP); those with a VLPP of > or = 90 cmH2O underwent Burch retropubic bladder neck suspension (group 2a, 24 patients) while 26 (group 2b) with a VLPP of < 90 cmH2O had pubovaginal sling (PVS) surgery. A further group of 20 patients with pure SUI (no urge UI) underwent surgery (PVS in 12 and Burch in eight) as a control group (group 3). After at least 6 months of follow-up (mean 9.3, sd 1.7), 68 patients were evaluable; they were assessed subjectively and objectively for dryness, and by a urodynamic evaluation and quantitative assessment using the SEAPI scoring system.

RESULTS

In group 1 none of the patients became completely dry; there was persistent stress with and without urge UI in nine (43%) and 12 (57%) of the available 21 patients, respectively. Only three of those who had persistent SUI with no urge in the whole study group were satisfied and chose to continue anticholinergic therapy despite SUI. In this group the mean (sd) improvement in the subjective and objective SEAPI score was 3.4 (1.0) and 2.3 (3.8), respectively. In group 2a, 20 of the available 23 patients (87%) became completely dry (both stress and urge continent). The mean improvement in the SEAPI scores was 7.8 (0.9) and 7.8 (1.3), respectively. In group 2b, 20 of the 24 patients (83%) became completely dry, with mean improvements in SEAPI scores of 8.2 (0.4) and 7.9 (0.3), respectively. The improvement was statistically significant after surgery, vs anticholinergic therapy, for all variables (P < 0.05). The incidence of persistent urge UI was highest in group 1 (43%), being 13% in group 2 (13% and 12% in 2a and b, respectively). In group 3 there was de novo urge UI in four of the 20 patients, and not significantly different from that in group 2.

CONCLUSION

Most patients with mixed stress and urge UI and a normal cystometrogram were cured of both symptoms by surgery. The incidence of residual urge in such patients was no higher than that of de novo urge after surgery in patients with genuine SUI.

Are urodynamic tests useful tools for the initial conservative management of non-neurogenic urinary incontinence? A review of the literature

OBJECTIVES

To summarise the evidence for the role of urodynamic tests in the diagnosis and classification of urinary incontinence.

METHODS

Reference lists in relevant papers were reviewed and MEDLINE searches conducted.

RESULTS

The mean sensitivity (specificity) of clinical history versus urodynamic tests was 0.82 (0.57) for stress incontinence, 0.69 (0.60) for urge incontinence/overactive bladder, and 0.51 (0.66) for patients with mixed incontinence. The proportion of women with a clinical diagnosis of urinary incontinence but with normal findings from urodynamic tests ranged from 3 to 8%. Overall sensitivity of urodynamic tests was about 85-90% in the diagnosis of urodynamic stress incontinence, but generally lower following diagnosis of urge and mixed incontinence. No relationship emerged between urodynamic test results and response to medical treatment.

CONCLUSIONS

This literature review shows that the sensitivity of clinical history versus urodynamic tests was 0.82, 0.69 and 0.51 respectively for stress, urge and mixed urinary incontinence. It also suggests that urodynamic diagnosis does not predict response to treatment. These data add to the ongoing 'urodynamics or no urodynamics' debate in the evaluation of urinary incontinence and show that urodynamic testing may not be helpful for patients receiving initial non-invasive therapy. These data are in line with the conclusions of the 1st and 2nd International Consultations on incontinence.

Which women with stress incontinence require urodynamic evaluation?

OBJECTIVE

This study was undertaken to determine the predictive value of the symptom of stress urinary incontinence and to evaluate the ability of other factors suggested by a published Agency for Health Care Policy and Research guideline for the discrimination of patients unlikely to require urodynamic testing before surgical management.

STUDY DESIGN

We evaluated 950 consecutive women without advanced (stage III or IV) pelvic organ prolapse who were referred with symptoms of incontinence. Incontinence was recorded by means of standard forms and was characterized as "any stress loss" (76.4%), "primarily stress loss" (58.9%), "stress loss only" (29.8%), "stress and urge loss" (52.2%), "urge loss only" (13.8%), "constant and stress loss" (1.9%), or "constant loss" (2.3%). Other variables were assessed by means of a standardized history, physical examination (including urethral axis determination and stress test), 1-week urinary diary, and postvoid residual volume measurement. A urodynamic diagnosis of pure genuine stress incontinence was used as the criterion standard. Sensitivity, specificity, and positive and negative predictive values were calculated. Logistic regression models incorporating various combinations of stress loss only, previous prolapse or incontinence surgery, nocturia, voiding frequency, urethral hypermobility, and postvoid residual volume <100 mL (the factors recommended by the Agency for Health Care Policy and Research guidelines), along with age and race as predictors of genuine stress incontinence, were constructed to evaluate the predictive ability of the guideline in a subset of 447 patients for whom data on all variables were available.

RESULTS

Of the entire population 480 (50.5%) had pure genuine stress incontinence, 134 (14.1%) had both genuine stress incontinence and detrusor instability, 180 (18.9%) had pure detrusor instability, and 40 (4.2%) had intrinsic sphincter deficiency. Fifty-four (5.7%) had normal study results, and 62 (6.5%) had other nonincontinence diagnoses. Among the subjects with symptoms of stress loss only, 10.8% did not have genuine stress incontinence confirmed on urodynamic examination. Agency for Health Care Policy and Research guideline criteria had excellent discrimination (C statistic of 0.807) compared with the sole criterion of stress urinary incontinence only (C statistic of 0.574), with a positive predictive value of 85.7%. Only 7.8% of subjects met all the criteria, however, and 5.7% of these ultimately had a urodynamic diagnosis of either detrusor instability or normal study result.

CONCLUSION

The predictive value of stress symptoms alone was not high enough to serve as the basis for surgical management. Agency for Health Care Policy and Research guidelines improved the predictive value but were applicable to only a small subset of patients referred with urinary incontinence.

Urinary tract infections in pregnancy

Although pregnancy does not increase the prevalence of ASB in women, it does enhance the progression rate from asymptomatic to symptomatic disease. Furthermore, ASB is associated with preterm delivery. Given the fact that identification and eradication of ASB in pregnant women can lower the likelihood of pyelonephritis and prevent preterm delivery, every gravida should be systematically screened for ASB and appropriately treated. In the authors' opinion, a first-trimester urine culture remains the screening test of choice; reliance on symptoms to prompt screening is inadequate because the state of pregnancy can provoke frequency and nocturia. Multiple antibiotic regimens for ASB are safe during pregnancy and effective.

Periurethral injection for the treatment of urinary incontinence

Periurethral injection of substrates that compress, support, or narrow the bladder neck for the treatment of stress incontinence is not new. Several injectable compounds have been used in a small number of patients during the 1940s and through the 1960s; however, the results were not very successful and often led to significant complications. More recently, two major materials have been developed that seem to be useful in treating stress incontinence by periurethral injection: Polytef paste and GAX collagen. Other injectables include autologous fat tissue and silicone microimplants. The most suitable patients for periurethral injection are elderly women, patients who constitute high operative risk, and those with stress incontinence due to intrinsic sphincter failure. Patients with stress incontinence due to a combination of urethral hypermobility and intrinsic sphincter deficiency with failure of suspension procedure may also benefit from the procedure. The reported long-term (more than 24 months) success rates according to the various substances are as follows: Teflon (Polytef) (E.I.du Pont de Nemours and Co, Wilmington, DE): 30 to 38 percent cured or improved; repeated injections usually do not improve the outcome; mostly minor complications with case reports of more serious side effects such as periurethral granuloma formation and bladder outlet obstruction. GAX collagen: 69 to 77 percent subjectively cured or improved after 24 months; 54 to 57 percent objectively cured or improved, the reported morbidity in these procedures is minimal; repeated injections can improve the outcome. The experience with autologous fat and silicone microimplants is insufficient, with an overall success rate of 70 percent (1-40 months follow-up; mean 12 months) and 58 to 70 percent (17-36 months), respectively. Most of the procedures are performed as outpatient cases, and some under local anesthesia. These procedures are minimally invasive, usually safe and well tolerated, require shorter hospitalization, and are cost effective. In conclusion, in carefully selected patients, periurethral injection seems to be a reasonable option in the modern treatment of female stress incontinence.

Incontinence in elderly women: is periurethral collagen an advance?

OBJECTIVE

To determine whether periurethral collagen is an effective, safe and practical day-case procedure to control genuine stress incontinence (urethral sphincter incompetence) in the elderly female.

DESIGN

Prospective longitudinal study using subjective and objective outcome measures with long term follow up.

SETTING

A teaching hospital tertiary referral centre.

SAMPLE

Thirty-two women over 65 years of age with a urodynamic diagnosis of genuine stress incontinence.

RESULTS

At one year, 22 women (79%) were subjectively cured or improved, and 14 (50%) were objectively cured; at two years, 18 (69%) and 14 (54%), respectively. Symptoms of urgency, urge incontinence, frequency and nocturia improved, while voiding difficulty remained unchanged. Brief urinary retention was encountered in seven women. No long term side effects or complications were encountered. Urodynamic studies suggest that collagen works by preventing premature bladder neck opening through physical stress, rather than by obstruction. This would account for the slight increase in functional urethral length.

CONCLUSIONS

Contigen collagen is a simple and effective day case procedure as an alternative to major surgery and is without significant morbidity or complication. It is ideal for the elderly.

The effect of ovariectomy on the contractile response of the rat isolated detrusor muscle and urethra

Contractile responses induced by carbachol on the detrusor muscle and by noradrenaline on the isolated urethra were compared between ovariectomized rats pretreated with estradiol (50 microg/animal s.c. twice daily for five days), untreated ovariectomized rats and intact animals. In the detrusor muscle, contractions induced by 30 microM carbachol, when normalized with respect to KCl 100 mM-induced contraction, were similar for the three groups. Furthermore, contractions induced by 100 microM noradrenaline in the isolated urethra were not significatively different between groups. However, the pD2 value for noradrenaline was greater in urethral tissue from ovariectomized rats compared with ovariectomized -estrogen treated and control rats. A similar result was found for pD2 values for carbachol-induced contractions on the detrusor muscle. These results suggest that ovariectomy increases the sensitivity of the urinary bladder and urethra to the contractile effects of carbachol and noradrenaline, respectively and that this effect is reversed by in vivo estrogen pretreatment.

Urologic care in long-term facilities

The urologic care of the institutionalized elderly is confounded by the high prevalence of comorbid conditions. There is also a challenge to provide cost effective care to this group that requires a disproportionate share of health care resources. Bacteriuria, hematuria, and problems of urine control and drainage provide unique clinical conditions that must be dealt with.

Misdiagnosis of urinary incontinence in nursing home women: prevalence and a proposed solution

Because of the high prevalence of detrusor hyperactivity with impaired contractility (DHIC) in incontinent institutionalized women, we postulated that: 1) single-channel cystometry, the most commonly used diagnostic test, would be inadequate when used alone but that 2) its accuracy could be greatly enhanced by combining it with a previously-performed stress test. To test the hypothesis, we used blinded comparison of a clinical stress test and single-channel cystometry with multichannel videourodynamic evaluation (criterion standard), a strategy designed a priori. Subjects were 97 incontinent women who were considered representative of incontinent nursing home women nationally. With cystometry alone, 9 of 37 women with DHIC (24%) were misdiagnosed as stress-incontinent vs. 1 of 25 with DH (P = .03). In each case, misdiagnosis was due to failure to recognize low-pressure involuntary bladder contractions. Combining cystometry with the stress test improved diagnostic accuracy markedly. Of the 77% of women in whom the results of both tests were congruent, all were correctly classified. When results of the two tests were discordant, neither was superior. Significantly, no woman with stress incontinence was missed by the two-test strategy, nor was anyone with detrusor hyperactivity misclassified. We conclude that in institutionalized elderly women, DHIC commonly mimics other types of urinary tract dysfunction. Thus, single-channel cystometry alone is an inadequate diagnostic test in this population. However, a strategy that combines cystometry with a clinical stress test can correctly classify the majority of such women and identify those in whom the diagnosis is less secure. Use of this simple strategy would facilitate correct diagnosis and initial treatment of most institutionalized women without referral, and also enrich the referred population with those most likely to benefit. Such an approach could significantly improve the approach to this costly and morbid condition.

Mixed incontinence: a new nursing diagnosis?

Consistent efforts to identify and clinically validate new nursing diagnosis within recognized categories are essential to taxonomy development. Mixed incontinence is a clinical condition resulting in leakage of urine associated with increased intra-abdominal pressure (stress) and inability to delay voiding (urge). The presence of mixed incontinence was clinically validated in two populations (n = 9, n = 40) of community-dwelling women and initial defining characteristics were identified. Research findings from both studies support the addition of a proposed sixth nursing diagnosis, mixed incontinence, to the diagnostic category, alteration in urinary elimination.

Prognostic factors for the operative correction of stress urinary incontinence

Investigating the reliability of using some clinical and laboratory parameters as long-term prognostic factors in properly selected patients for stress urinary surgery could help in the prediction of the long-term result in each case. Toward this goal 51 women were examined prospectively, after they were assessed by clinical and laboratory exams with particular emphasis on urodynamic studies. Out of this group, 41 patients had genuine stress incontinence, and 10 had mixed stress incontinence. Twenty-seven women underwent Burch colposuspension while 24 had Stamey endoscopic bladder neck suspension. In all patients clinical and urodynamic evaluation was done with the same methodology before the operation, and after one month and six months, respectively. The study indicated that 73% of the incontinent women were cured. According to the "analysis of variance" and "correlation analysis" methods the factors which were found to influence the operative result were as follows: (1) Clinical factors including preoperative urgency, U.T.I. and previous gynaecological operations. These factors had negative prognostic value, while the grade of incontinence did not influence at all the outcome of surgery. (2) Urodynamic factors including preoperative residual urine, immediate operative first sensation of micturition, maximum urine flow rate, pre- and immediate postoperative bladder capacity and functional length. These factors influence the operative result negatively or positively according to the deviation from the normal values. Furthermore, the important immediate postoperative change of the urodynamic values was found to determine the result of the operation.

Stamey endoscopic vesical neck suspension in female urinary stress incontinence: results and changes in various urodynamic parameters

A total of 32 female patients with urinary stress incontinence who underwent a Stamey endoscopic bladder neck suspension were clinically and urodynamically studied pre- and postoperatively. Complete cure was obtained in 78% of the patients and improvement in 6%, the overall success rate being 84% for a mean follow-up of 11.1 months (range 6-19). Complications occurred in 22% of the patients. Comparison of the pre- and postoperative urodynamic data revealed that the maximum urine flow rate, functional urethral length and maximum urethral closure pressure were changed significantly after operation. In addition, when studying the abdominal pressure transmission to the entire urethra during stress, there was a significant conversion of negative to positive pressure transmission after surgical repositioning of the urethra.

Simple screening for urinary incontinence in the elderly: comparison of simple and multichannel cystometry

Urinary incontinence is a major cause of suffering and disability especially in the elderly. Accurate diagnosis is important to optimize treatment and multichannel cystometry is regarded as the gold standard. Simple cystometry is a technique of bedside cystometry using a single lumen catheter and filling syringe. Simple cystometry was compared with multichannel cystometry in 83 patients (mean age 73.5 years) and was found to have a specificity of 75 percent and a sensitivity of 88 percent for the diagnosis of detrusor instability. Simple cystometry is a quick, easy, and useful test which can be readily performed in the elderly by a doctor or trained nurse. Residual urine measurement, testing for stress incontinence, and estimation of flow rate can be performed at the same time. It can enable the most appropriate treatment to be initiated by improving the diagnostic accuracy of the clinical assessment when more complex resources and expertise is not available. In a proportion of patients further referral and investigation may be necessary.

The Raz bladder neck suspension in patients 65 years old and older

We reviewed the charts of 92 women 65 years old and older (mean age 72 years, range 65 to 87 years) who underwent the Raz bladder neck suspension between January 1984 and June 1990 for stress urinary incontinence. Mean followup was 17 months. Overall, a successful outcome (cure or rare stress urinary incontinence not requiring protection) was achieved in 81 patients (88%). The 2-sample Wilcoxon rank sum test showed that the only predictor of outcome was the subjective degree of preoperative stress urinary incontinence (mild, moderate or severe, p = 0.0148). When the results were stratified by degree of incontinence preoperatively 8 of 8 patients (100%) with mild, 62 of 67 (93%) with moderate and 11 of 17 (65%) with severe incontinence had a successful outcome. Prior hysterectomy, number and type of previous anti-incontinence procedures, and the presence of urgency, urgency incontinence or urodynamic instability were not statistically significant predictors of outcome. In addition, the degree of clinical instability preoperatively had no correlation with the degree of postoperative instability. Of 11 failures 10 occurred within 1 year postoperatively. Significant urgency incontinence was present preoperatively in 32% of the patients with postoperative resolution in 60%. De novo urgency and urgency incontinence occurred in 24% and 13% of the patients, respectively. There was no statistically significant difference in the outcome of surgery in patients 65 years old and older compared to 141 patients less than 65 years old with respect to success, cure of stress urinary incontinence, cure of significant urgency and urgency incontinence, and appearance of de novo instability. The Raz bladder neck suspension is a safe and efficacious treatment for stress incontinence in elderly women. Outcomes can be expected to be the same as in younger women.

Self-care practices of women with urinary incontinence--a preliminary study

The purpose of this preliminary study was twofold: (a) to explore self-care practices of 10 noninstitutionalized women who experience urinary incontinence (UI) and (b) to evaluate two instruments, the Urinary Incontinence Interview Guide and the Self-Care Responses Questionnaire. Data analysis was accomplished by data reduction and tabulation and comparison of responses from both instruments. Data are presented in a descriptive format. The most frequently reported self-care practices included regular toileting, alteration of fluid intake, exercises, weight reduction, seeking medical treatment, and protection to contain the problem. Half of the women reported embarrassment and all reported some negative feelings about UI. Recommendations are made in relation to both instruments for future use with UI research.

Basic evaluation of female urinary incontinence

Urinary incontinence is a common disorder that is frequently underreported because of its social implications. Although several types of urinary incontinence are recognized, they can be generally classified as failure of the bladder to store or failure of the urethral mechanism. A systematic approach for the evaluation of incontinence that includes history, physical examination, basic laboratory tests, and often urodynamic evaluation, offers the most comprehensive assessment of the etiology of incontinence.

Reliability of the patient's history in the diagnosis of urinary incontinence

The reliability of a patient's history has been challenged in the preoperative evaluation of stress urinary incontinence. In this study, 122 consecutive patients referred to our Gynecology/Urology clinic were evaluated and an additional 32 control patients (continent women with no urinary symptoms) were evaluated. All patients answered a detailed 64-item questionnaire, and all patients received a complete urodynamic evaluation. Our detailed questionnaire provided a mean positive predictive value of 80% for genuine stress incontinence and 25% for detrusor instability. The conditions leading to a false positive history suggestive of genuine stress incontinence were detrusor instability and urethral diverticulum. The conditions leading to a false positive history suggestive of detrusor instability were urethritis, unstable urethra, vaginitis and polyuria. History alone can be misleading in diagnosing urinary incontinence.

Practical management of urinary incontinence

A comprehensive evaluation of incontinence using office-based techniques may discover reversible problems such as delirium, urinary infections, vaginitis, depression, drug effects, endocrinologic causes, immobility, or impaction. Treatment of these causes may alleviate incontinence. Bedside urodynamics are a sensitive, specific, and useful office-based technique that can identify detrusor instability, overflow incontinence, or stress incontinence. Low urinary flow rate, difficulty with catheterization, slow bladder filling or severe urgency, bladder capacity over 600 ml, and post-void residual over 150 ml need referral. Patients with hematuria, recurrent infections, recent surgery or pelvic irradiation, and pelvic or prostatic masses also need further evaluation. A number of medical and behavioral therapies are available for stress incontinence and detrusor instability that can substantially reduce incontinence, but most patients with overflow have more complicated problems requiring further evaluation, surgery, or long-term bladder drainage.

Simple versus multichannel cystometry in the evaluation of bladder function in an incontinent geriatric population

Bladder capacity and stability were determined among 171 incontinent geriatric patients (mean age 80 years) with 2 techniques: a simple procedure for cystometry involving incremental bladder filling by gravity and a continuous water filling multichannel cystometrogram. Bladder capacities measured by both methods in 164 patients were correlated significantly by simple linear regression (r equals 0.75, p equals 0.0001) and they were not significantly different by paired t tests (t equals 1.20, p equals 0.23). Of the patients 110 (64 per cent) had detrusor motor instability or hyperreflexia on the multichannel cystometrogram, and simple cystometry had a sensitivity of 75 per cent, specificity of 79 per cent and positive predictive value of 85 per cent for this finding. The simple procedure was practical, well tolerated and helped to provide information for management decisions that would have been difficult to obtain from many of these geriatric patients without a formal and more complex urodynamic evaluation. When performed with other simple tests of lower urinary tract function and interpreted in conjunction with a few straightforward clinical criteria, simple cystometry can be helpful to assess bladder function among incontinent geriatric patients in settings in which formal urodynamics are either unavailable or impractical.