Proceedings of the National Institute of Diabetes and Digestive and Kidney Diseases International Symposium on Epidemiologic Issues in Urinary Incontinence in Women

Female urinary incontinence in China after 15 years' efforts: Results from large-scale nationwide surveys

Urinary incontinence (UI) is a disease that quietly yet seriously impacts women's health and represents a global health burden that is often neglected. This study aims to systematically assess the prevalence and dynamics of female UI in China, and can inform further policies and have international implications. This study used three nationwide investigations: A national cross-sectional survey in 2021; another nationwide cross-sectional survey in 2006; and data regarding the institutions and physicians providing pelvic floor rehabilitation services from 2005 to 2019. The weighted prevalence of female UI and its subtypes, including stress UI (SUI), urgency UI (UUI), and mixed UI (MUI), were estimated as primary outcomes. Knowledge, attitude and care-seeking behaviors of UI were evaluated. It was found that the weighted prevalence of female UI was 16.0 % (95% CI, 13.3 %-19.1%) with SUI remaining the predominant subtype (7.0%) in 2021, followed by MUI (6.5%) and UUI (1.9%). The estimated absolute number of Chinese adult women with UI was 85.8 million in 2021. 52.7% (95% CI, 45.9%-59.4 %) of women were aware that UI was a medical condition, and only 10.1% of women with UI sought health care. After 15 years of development, there were 8400 pelvic floor rehabilitation institutions and nearly 10,000 relevant physicians in China-they were found to be associated with UI prevalence. The UI prevalence in China was significantly lower in 2021 compared to that in 2006. Despite the achievement, UI remains a public health problem, especially given China's fast aging and three-child policy. More innovations, especially those that can facilitate care seeking, are needed to address this prevalent yet treatable condition.

Treating overactive bladder symptoms after transurethral prostatic surgery for benign prostatic hyperplasia - Which medication to choose?

Objectives

Overactive bladder (OAB) symptoms are often encountered in patients after transurethral resection of the prostate (TUR-P) or transurethral incision of the prostate (TUI-P) for benign prostatic obstruction (BPO). Either antimuscarinics or β-3 agonist has been found effective in relieving OAB symptoms. However, urologists usually do not prescribe such medication immediately after TUR-P or TUI-P to avoid an increase in postvoid residual and risk of urinary tract infection. If OAB medication can be used and adverse events (AEs) can be reduced to minimum, patients' quality of life after bladder outlet obstruction surgery could be improved. This study compared the safety and efficacy between solifenacin and mirabegron in men undergoing TUR-P or TUI-P.

Materials and Methods

This prospective, randomized trial compared the safety and efficacy of OAB medication on the reduction in Urgency Severity Score (USS), OAB Symptoms Score (OABSS), International Prostate Symptom Score, and urgency urinary incontinence episodes in men with BPO undergoing surgical intervention. All patients could void smoothly after catheter removal and were randomly received daily solifenacin 5 mg, mirabegron 50 mg, or no interventions for 4 weeks. At 2 and 4 weeks postoperatively, participants' OAB symptoms and AEs were evaluated.

Results

A total of 57 men were enrolled in this study with a mean age of 70.8 ± 6.1 years. At 2 weeks postoperatively, USS (1.56 ± 1.72 vs. 2.39 ± 1.72 vs. 2.26 ± 1.73, P < 0.011) and OABSS (5.33 ± 3.65 vs. 7.67 ± 4.19 vs. 8.58 ± 4.31, P < 0.000) were significantly reduced in patients taking solifenacin, mirabegron, or control, respectively. Two patients in the solifenacin group developed urinary retention. However, the changes of variables at 4 weeks postoperatively were insignificant among the three groups.

Conclusion

Solifenacin and mirabegron are two different drug classes both equally effective in treating immediate OAB symptoms after TUR-P or TUI-P. However, OAB symptoms could be relieved at 4 weeks without any medication. Considering AEs, β-3 agonist has a more favorable safety profile than antimuscarinics.

The impact of urinary incontinence on multiple health outcomes: an umbrella review of meta-analysis of observational studies

BACKGROUND AND AIM

We aimed to capture the breadth of health outcomes that have been associated with the presence of Urinary Incontinence (UI) and systematically assess the quality, strength, and credibility of these associations through an umbrella review and integrated meta-analyses.

METHODS

We assessed meta-analyses of observational studies based on random-effect summary effect sizes and their p-values, 95% prediction intervals, heterogeneity, small-study effects, and excess significance. We graded the evidence from convincing (Class I) to weak (Class IV).

RESULTS AND DISCUSSION

From 3172 articles returned in search of the literature, 9 systematic reviews were included with a total of 41 outcomes. Overall, 37 out of the 41 outcomes reported nominally significant summary results (p < 0.05), with 22 associations surviving the application of a more stringent p-value (p < 10^-6). UI was associated with worse scores than controls in female sexual function (Class II), while it was also associated with a higher prevalence of depression (odds ratio [OR] = 1.815; 95% confidence interval [CI]: 1.551-2.124), and anxiety (OR = 1.498; 95% CI: 1.273-1.762) (Class IV). UI was associated with poorer quality of life (QoL), higher rate of mortality (hazard ratio = 2.392; 95% CI: 2.053-2.787) an increase in falls, frailty, pressure ulcers, diabetes, arthritis, and fecal incontinence (Class IV).

CONCLUSIONS

UI is associated with female sexual dysfunction, with highly suggestive evidence. However, the evidence of other adverse outcomes including depression, anxiety, poorer QoL, higher mortality, falls, pressure ulcers, diabetes, arthritis, fecal incontinence, and frailty is only weak. A multidimensional approach should be taken in managing UI in the clinical setting.

Impact of bariatric surgery on urinary incontinence in morbidly obese individuals

BACKGROUND

There is scanty evidence on the impact of bariatric surgery on urinary incontinence (UI) in the Asian population.

METHODOLOGY

Patients who underwent bariatric surgery from June 2018 to June 2019 were screened using the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) questionnaire. Patients having UI were identified and followed until 1 year of surgery using the ICIQ-UI-SF. These were classified as having stress, urge, or mixed type of UI. The prevalence, change in scores, and the number of pads used were compared at baseline and at follow-up.

RESULTS

A total of 148 patients underwent bariatric surgery of whom, 41 patients (M = 2, F = 39) had UI. Stress incontinence was seen in 70.7%, 19.5% had urge incontinence, and rest had the mixed type. Using logistic regression, it was found that female gender was the most important predictor of having UI (OR: 8.33). The prevalence of UI decreased from 27.7% at baseline to 8.1% at 6 months and 3.4% at 12 months. The mean ICIQ-UI-SF score improved from 8.76 (SD = 3.2) at baseline to 0.66 (SD = 2.1) at 12 months of follow-up. The proportion of patients with UI using any number of pads decreased from 92.7% at baseline to 9.8% at 12 months. There was a decrease in the number of patients having moderate to very severe UI from 35 (85.4%) at baseline to 2 (4.9%) at 12 months. Proportion of patients showing resolution was highest among the stress incontinence group at 96.5%. Presence or absence of comorbidities did not significantly influence the ICIQ-UI-SF scores.

CONCLUSION

Bariatric surgery leads to profound improvement in UI in obese individuals which is well sustained until 1 year of follow-up. Resolution rates might be higher in Asian population.

Variation in availability and use of surgical care for female urinary incontinence: a mixed-methods study

Background

Urinary incontinence affects between 25% and 45% of women. The availability and quality of services is variable and inequitable, but our understanding of the drivers is incomplete.

Objectives

The objectives of the study were to model patient, specialist clinician, primary and secondary care, and geographical factors associated with referral and surgery for urinary incontinence, and to explore women’s experiences of urinary incontinence and expectations of treatments.

Design

This was a mixed-methods study.

Setting

The setting was NHS England.

Participants

Data were collected from all women with a urinary incontinence diagnosis in primary care data, and all women undergoing mid-urethral mesh tape surgery for stress urinary incontinence were included. Interviews were also carried out with 28 women from four urogynaecology clinics who were deciding whether or not to have surgery, and surveys were completed by 245 members of the Royal College of Obstetricians and Gynaecologists with a specialist interest in urinary incontinence.

Data sources

The sources were patient-level data from Hospital Episode Statistics, the Clinical Practice Research Datalink and the Office for National Statistics mortality data linked to Hospital Episode Statistics. Interviews were conducted with women. An online vignette survey was conducted with members of the Royal College of Obstetricians and Gynaecologists.

Main outcome measures

The main outcome measures were the rates of referral from primary to secondary care and surgery after referral, the rates of stress urinary incontinence surgery by geographical area, the risk of mid-urethral mesh tape removal and reoperation after mid-urethral mesh tape insertion.

Results

Almost half (45.8%) of women with a new urinary incontinence diagnosis in primary care were referred to a urinary incontinence specialist: 59.5% of these referrals were within 30 days of diagnosis. In total, 14.2% of women referred to a specialist underwent a urinary incontinence procedure (94.5% of women underwent a stress urinary incontinence procedure and 5.5% underwent an urgency urinary incontinence procedure) during a follow-up period of up to 10 years. Not all women were equally likely to be referred or receive surgery. Both referral and surgery were less likely for older women, those who were obese and those from minority ethnic backgrounds. The stress urinary incontinence surgery rate was 40 procedures per 100,000 women per year, with substantial geographical variation. Among women undergoing mid-urethral mesh tape insertion for stress urinary incontinence, the 9-year mesh tape removal rate was 3.3%. Women’s decision-making about urinary incontinence surgery centred on perceptions of their urinary incontinence severity and the seriousness/risk of surgery. Women judged urinary incontinence severity in relation to their daily lives and other women’s experiences, rather than frequency or quantity of leakage, as is often recorded and used by clinicians. Five groups of UK gynaecologists could be distinguished who differed mainly in their average inclination to recommend surgery to hypothetical urinary incontinence patients. The gynaecologists’ recommendations were also influenced by urinary incontinence subtype and the patient’s history of previous surgery.

Limitations

The primary and secondary care data lacked information on the severity of urinary incontinence.

Conclusions

There was substantial variation in rates of referrals, surgery, and mesh tape removals, both geographically and between women of different ages and women from different ethnic backgrounds. The variation persisted after adjustment for factors that were likely to affect women’s preferences. Growing safety concerns over mid-urethral mesh tape surgery for stress urinary incontinence during the period from which the data are drawn are likely to have introduced more uncertainty to women’s and clinicians’ treatment decision-making.

Future work

Future work should capture outcomes relevant to women, including ongoing urinary incontinence and pain that is reported by women themselves, both before and after mesh and non-mesh procedures, as well as following conservative treatments. Future research should examine long-term patient-reported outcomes of treatment, including for women who do not seek further health care or surgery, and the extent to which urinary incontinence severity explains observed variation in referrals and surgery.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 7. See the NIHR Journals Library website for further project information.

Antagonism of proNGF or its receptor p75NTR reverses remodelling and improves bladder function in a mouse model of diabetic voiding dysfunction

AIMS/HYPOTHESIS

Although 80% of diabetic patients will suffer from voiding difficulties and urinary symptoms, defined as diabetic voiding dysfunction (DVD), therapeutic targets and treatment options are limited. We hypothesise that the blockade of the pro-nerve growth factor (NGF)/p75 neurotrophin receptor (p75NTR) axis by an anti-proNGF monoclonal antibody or by a small molecule p75NTR antagonist (THX-B) can restore bladder remodelling (represented by bladder weight) in an animal model of DVD. Secondary outcomes of the study include improvements in bladder compliance, contractility and morphology, as well as in voiding behaviour, proNGF/NGF balance and TNF-α expression.

METHODS

In a streptozotocin-induced mouse model of diabetes, diabetic mice received either a blocking anti-proNGF monoclonal antibody or a p75NTR antagonist small molecule as weekly systemic injections for 4 weeks. Animals were tested at baseline (at 2 weeks of diabetes induction), and after 2 and 4 weeks of treatment. Outcomes measured were voiding function with voiding spot assays and cystometry. Bladders were assessed by histological, contractility and protein expression assays.

RESULTS

Diabetic mice showed features of DVD as early as 2 weeks after diabetes diagnosis (baseline) presented by hypertrophy, reduced contractility and abnormal cystometric parameters. Following treatment initiation, a twofold increase (p < 0.05) in untreated diabetic mouse bladder weight and thickness compared with non-diabetic controls was observed, and this change was reversed by p75NTR antagonism (37% reduction in bladder weight compared with untreated diabetic mice [95% CI 14%, 60%]) after 4 weeks of treatment. However, blocking proNGF did not help to reverse bladder hypertrophy. While diabetic mice had significantly worse cystometric parameters and contractile responses than non-diabetic controls, proNGF antagonism normalised bladder compliance (0.007 [Q1-Q3; 0.006-0.009] vs 0.015 [Q1-Q3; 0.014-0.029] ml/cmH2O in untreated diabetic mice, representing 62% reduction [95% CI 8%, 110%], p < 0.05) and contractility to KCl, carbachol and electrical field stimulation (p < 0.05 compared with the diabetic group) after 2 weeks of treatment. These effects were not observed after 4 weeks of treatment with proNGF antagonist. p75NTR antagonism did not show important improvements in cystometric parameters after 2 weeks of treatment. Slightly improved bladder compliance (0.01 [Q1-Q3; 0.009-0.012] vs 0.013 [Q1-Q3; 0.011-0.016] ml/cmH2O for untreated diabetic mice) was seen in the p75NTR antagonist-treated group after 4 weeks of treatment with significantly stabilised contractile responses to KCl, carbachol and electric field stimulation (p < 0.05 for each) compared with diabetic mice. Bladder dysfunction observed in diabetic mice was associated with a significant increase in bladder proNGF/NGF ratio (3.1 [±1.2] vs 0.26 [±0.04] ng/pg in control group, p < 0.05 at week 2 of treatment) and TNF-α (p < 0.05). The proNGF/NGF ratio was partially reduced (about 60% reduction) with both treatments (1.03 [±0.6] ng/pg for proNGF antibody-treated group and 1.4 [±0.76] ng/pg for p75NTR blocker-treated group after 2 weeks of treatment), concomitant with a significant decrease in the bladder levels of TNF-α (p < 0.05), despite persistent hyperglycaemia.

CONCLUSIONS/INTERPRETATION

Our findings indicate that blockade of proNGF and the p75NTR receptor in diabetes can impede the development and progression of DVD. The reported improvements in morphological and functional features in our DVD model validates the proNGF/p75NTR axis as a potential therapeutic target in this pathology. Graphical abstract.

Study protocol to investigate biomolecular muscle profile as predictors of long-term urinary incontinence in women with gestational diabetes mellitus

BACKGROUND

Pelvic floor muscles (PFM) and rectus abdominis muscles (RAM) of pregnant diabetic rats exhibit atrophy, co-localization of fast and slow fibers and an increased collagen type I/III ratio. However, the role of similar PFM or RAM hyperglycemic-related myopathy in women with gestational diabetes mellitus (GDM) remains poorly investigated. This study aims to assess the frequency of pelvic floor muscle disorders and pregnancy-specific urinary incontinence (PS-UI) 12 months after the Cesarean (C) section in women with GDM. Specifically, differences in PFM/RAM hyperglycemic myopathy will be evaluated.

METHODS

The Diamater is an ongoing cohort study of four groups of 59 pregnant women each from the Perinatal Diabetes Research Centre (PDRC), Botucatu Medical School (FMB)-UNESP (São Paulo State University), Brazil. Diagnosis of GDM and PS-UI will be made at 24-26 weeks, with a follow-up at 34-38 weeks of gestation. Inclusion in the study will occur at the time of C-section, and patients will be followed at 24-48 h, 6 weeks and 6 and 12 months postpartum. Study groups will be classified as (1) GDM plus PS-UI; (2) GDM without PS-UI; (3) Non-GDM plus PS-UI; and (4) Non-GDM without PS-UI. We will analyze relationships between GDM, PS-UI and hyperglycemic myopathy at 12 months after C-section. The mediator variables to be evaluated include digital palpation, vaginal squeeze pressure, 3D pelvic floor ultrasound, and 3D RAM ultrasound. RAM samples obtained during C-section will be analyzed for ex-vivo contractility, morphological, molecular and OMICS profiles to further characterize the hyperglycemic myopathy. Additional variables to be evaluated include maternal age, socioeconomic status, educational level, ethnicity, body mass index, weight gain during pregnancy, quality of glycemic control and insulin therapy.

DISCUSSION

To our knowledge, this will be the first study to provide data on the prevalence of PS-UI and RAM and PFM physical and biomolecular muscle profiles after C-section in mothers with GDM. The longitudinal design allows for the assessment of cause-effect relationships between GDM, PS-UI, and PFMs and RAMs myopathy. The findings may reveal previously undetermined consequences of GDM.

The prevalence and risk factors of urinary incontinence amongst Palestinian women with type 2 diabetes mellitus: A cross-sectional study

Objective: To determine the prevalence of urinary incontinence (UI) in women with type 2 diabetes mellitus (T2DM) in the North West Bank, Palestine, and to assess the role of potential risk factors including age and DM control.

Patients and methods: Adult women with DM attending governmental primary healthcare centres in the North West Bank were interviewed using the Centers for Disease Control and Prevention National Health and Nutrition Examination Survey (NHANES) standardised UI questionnaire. The prevalence of UI was estimated and differences between groups were evaluated using the chi-square test. A multivariate logistic model was used to estimate the adjusted relationships and to control for confounders. The statistical significance level was set at P < 0.05. The study was approved by the Institutional Review Board at An-Najah National University.

Results: The study included 381 women with T2DM, aged 30–83 years, of whom 43.2% (95% confidence interval [CI] = 37.9–47.8%) reported UI regardless of the type. About 40% reported that they were extremely bothered by the condition and 35.2% stated that their daily routine life was greatly affected. Amongst the women with UI, 133 (80.6%) and 128 (77.6%) were found to have urge and stress UI, respectively. UI was found to be significantly associated with a history of recurrent urinary tract infection (adjusted odds ratio [OR] 3.0, 95% CI 1.9–4.9; P < 0.001) and parity (adjusted OR 1.7, 95% CI 1.1–2.7; P = 0.04)

Conclusions: The prevalence of UI amongst Palestinian women with T2DM regardless of the type is high. The findings highlight the importance of educating women with T2DM about UI. The medical team should focus on this problem as it is often neglected; physicians should be alert for UI as it is often underreported and therefore undertreated.

Abbreviations: BMI: body mass index; (T2)DM: (type 2) diabetes mellitus; HbA_1c: haemoglobin A_1c; MoH: Ministry of Health; NHANES: National Health and Nutrition Examination Survey; OR: odds ratio; QoL: quality of life; (S)(U)UI: (stress) (urge) urinary incontinence.

Use of uniformly sized muscle fiber fragments for restoration of muscle tissue function

Treatment of extensive muscle loss due to traumatic injury, congenital defects, or tumor ablations is clinically challenging. The current treatment standard is grafting of autologous muscle flaps; however, significant donor site morbidity and graft tissue availability remain a problem. Alternatively, muscle fiber therapy has been attempted to treat muscle injury by transplanting single fibers into the defect site. However, irregularly organized long fibers resulted in low survivability due to delay in vascular and neural integration, thus limiting the therapeutic efficacy. Therefore, no effective method is available to permanently restore extensive muscle injuries. To address the current limitations, we developed a novel method that produces uniformly sized native muscle fiber fragments (MFFs) for muscle transplantation. We hypothesized that fragmentation of muscle fibers into small and uniformly sized fragments would allow for rapid reassembly and efficient engraftment within the defect site, resulting in accelerated recovery of muscle function. Our results demonstrate that the processed MFFs have a dimension of approximately 100 μm and contain living muscle cells on extracellular matrices. In preclinical animal studies using volumetric defect and urinary incontinence models, histological and functional analyses confirmed that the transplanted MFFs into the injury sites were able to effectively integrate with host muscle tissue, vascular, and neural systems, which resulted in significant improvement of muscle function and mass. These results indicate that the MFF technology platform is a promising therapeutic option for the restoration of muscle function and can be applied to various muscle defect and injury cases.

Effects of Radix Linderae extracts on a mouse model of diabetic bladder dysfunction in later decompensated phase

Background

This study aimed to elucidate the effects and mechanisms of Radix Linderae (RL) extracts on a mouse model of diabetic bladder dysfunction (DBD), especially on later decompensated phase.

Methods

Male C57BL/6J mice were intraperitoneally injected with streptozotocin (STZ) after 4 weeks of high-fat diet (HFD) feeding. DBD mouse models (later decompensated phase) were developed by 12-weeks persistent hyperglycemia and then treated with RL extracts for 4 weeks. During administration, the fasting blood glucose (FBG) test was performed once a week. Four weeks later, oral glucose tolerance test (OGTT), voided stain on paper (VSOP), and urodynamic alteration were explored. We also performed haematoxylin and eosin (H&E) and Masson’s trichrome staining to observe the histology of the bladder. Then, the contractile responses to α, β-methylene ATP, capsaicin (CAP), KCl and carbachol were measured. Moreover, qPCR assay was performed to analyse the bladder gene expression levels of M₃ receptors and TRPV1.

Results

The diabetic mice exhibited higher FBG, OGTT and urine production, and no substantial alteration was observed after RL treatment. Urodynamic test showed the maximum bladder capacity (MBC), residual volume (RV) and bladder compliance (BC), as well as the decrement of voided efficiency (VE) and micturition volume (MV), remarkably increased in the DBD mice. Furthermore, RL treatment significant improved urodynamic urination, with lower MBC, RV, and, BC, as well as higher VE and MV, as compared with the model groups. The wall thickness of the bladder and the ratio of smooth muscle/collagen remarkably increased, and RL could effectively attenuate the pathological change. The response of bladder strips to the stimulus was also reduced in the DBD mice, and RL treatment markedly increased the contraction. Furthermore, the gene expression levels of M₃ receptors and TRPV1 were down-regulated in the bladders of the diabetic mice, whereas RL treatment retrieved those gene expression levels.

Conclusions

RL extracts can improve the bladder voiding functions of the DBD model mice in later decompensated phase, and underlying mechanisms was associated with mediating the gene expression of M₃ receptors and TRPV1 in the bladder instead of improving blood sugar levels.

Electronic supplementary material

The online version of this article (10.1186/s12906-019-2448-1) contains supplementary material, which is available to authorized users.

Clinical Efficacy of Solifenacin in the Management of Diabetes Mellitus-Associated Versus Idiopathic Overactive Bladder Symptoms: A Multicenter Prospective Study

Purpose

To compare the clinical efficacy of anticholinergics for managing diabetes mellitus-associated overactive bladder (DM OAB) versus idiopathic overactive bladder (OAB) in Korean women.

Methods

We conducted a multicenter, prospective, parallel-group, open-label, 12-week study. Women (20–65 years old) with OAB symptoms for over 3 months were assigned to the DM OAB and idiopathic OAB groups. Changes in the Overactive Bladder Symptom Score (OABSS), urgency, urinary urgency incontinence, nocturia, daytime frequency according to a voiding diary, uroflowmetry, and postvoid residual urine volume (PVR) at the first visit (V1), week 4 (V2), and week 12 (V3) were compared.

Results

No significant difference was found between the baseline patient characteristics of the DM OAB and idiopathic OAB groups. Treatment with solifenacin was associated with improvements in urgency, urinary urgency incontinence, nocturia, frequency according to a voiding diary, and the total OABSS between V1 and V2 and between V1 and V3. Moreover, a significant improvement in urgency and urge incontinence was found between V2 and V3 in the DM OAB group. However, no significant changes were found in any other parameters. There were no significant differences between the DM OAB group and the idiopathic OAB group except for urgency and urge incontinence at V2 (3.71 vs. 2.28 and 0.47 vs. 0.32, respectively).

Conclusions

The patients who received solifenacin demonstrated improved urgency, urinary urgency incontinence, nocturia, frequency according to a voiding diary, and total OABSS. Management with solifenacin was equally effective for both DM-related OAB and idiopathic OAB.

Predictors of short-term and long-term incontinence after robot-assisted radical prostatectomy

Purpose

To determine retrospectively the prognostic factors for urinary incontinence following robot-assisted radical prostatectomy (RARP).

Methods

Altogether, 180 patients with localized prostate cancer underwent RARP (same surgeon). Preoperative physical status, disease characteristics, laboratory findings, and surgical technique were recorded and the patients checked 1, 6, 12, and 24 months after RARP regarding their contribution to predicting post-prostatectomy urinary incontinence (PPI).

Results

Overall, 114 (63.3%) patients had PPI 1 month after RARP and 19 patients (16.0%) at 24 months. Univariate analysis showed that age was a significant factor for predicting PPI at 1 month. PPI predictors at 24 months were age, body mass index, preoperative serum albumin level, previous transurethral resection of the prostate, total operative time, and bladder neck sparing. Multivariate analysis indicated that age and total operative time were significant predictors.

Conclusion

Older age and longer operative time were highly relevant to short- and long-term PPI occurrence after RARP.

Magnetization Transfer MR Imaging to Monitor Muscle Tissue Formation during Myogenic in Vivo Differentiation of Muscle Precursor Cells

Purpose To determine whether magnetization transfer (MT) magnetic resonance (MR) imaging may serve as a quantitative measure of the degree of fiber formation during differentiation of muscle precursor cells into engineered muscle tissue as a potential noninvasive monitoring tool in mice. Materials and Methods The study was approved by the local ethics committee (no. StV 01/2008) and the local Veterinary Office (license no. 99/2013). Human muscle progenitor cells (hMPCs) derived from rectus abdominis muscles were subcutaneously injected into CD-1 nude mice (CD-1 nude mice, Crl:CD1-Foxn1^nu; Charles River Laboratories, Wilmington, Mass) for development of muscle tissue. The mice underwent MR imaging examinations at 4.7 T at days 1, 3, 7, 14, 21, and 28 after cell transplantation by using a gradient-echo sequence with an MT prepulse and systematic variation of the off-resonance frequency (50-37 500 Hz) at an amplitude of 800°. Direct saturation was estimated from a Bloch equation simulation. The MT ratio (MTR) was correlated to immunohistochemistry findings, Western blot results, and results of myography. Data were analyzed by using one-way or two-way analysis of variance with the Sidak or Tukey multiple comparisons test. Results In the reference skeletal muscle, highest MT was found for 2500 Hz off-resonance frequency with an MTR ± standard deviation of 57.5% ± 3.5. The developing muscle tissue exhibited increasing MT values during the 28 days of myogenic in vivo differentiation and did not reach the values of native skeletal muscle. Mean values of MTR (2500 Hz) for hMPCs were 27.6% ± 6.3 (day 1), 24.7% ± 8.7 (day 3), 28.2% ± 5.7 (day 7), 35.9% ± 5.0 (day 14), 37.0% ± 7.9 (day 21), and 39.9% ± 8.1 (day 28). The results from MT MR imaging correlated qualitatively well with muscle tissue expression of specific skeletal markers, as well as muscle contractility. Conclusion MT MR imaging may be used to noninvasively monitor the process of myogenic in vivo differentiation of hMPCs as a biomarker of the quantity and quality of muscle fiber formation. ^© RSNA, 2016 Online supplemental material is available for this article.

New treatments for incontinence

Urinary incontinence (UI) is a common, yet underdetected and under-reported, health problem that can significantly affect quality of life. UI may also have serious medical and economic ramifications for untreated or undertreated patients, including perineal dermatitis, worsening of pressure ulcers, urinary tract infections, and falls. To prevent incontinence, the urethral sphincter must maintain adequate closure to resist the flow of urine from the bladder at all times until voluntary voiding is initiated and the bladder must accommodate increasing volumes of urine at a low pressure. UI can be categorized as a result of urethral underactivity (stress UI), bladder overactivity (urge UI), a combination of the 2 (mixed incontinence), or urethral overactivity/bladder underactivity (overflow incontinence). The main goal of therapy for the management of UI is to reduce the number of UI episodes, prevent complications, and, if possible, restore continence. This review highlights the existing treatment of stress, urge, mixed, and overflow UI in adult men and women and discusses many of the novel treatments including potential future or emerging therapies.

Effect of post-voiding urine volume on progression of renal function decline in patients with type 2 diabetes

Diabetic bladder dysfunction (DBD) is a common complication of type 2 diabetes mellitus (T2DM). The association between DBD and progression of diabetic nephropathy has not been clarified. In this study, we investigated the relationship between post-voiding residual urine (PVR) with decline in renal function in patients with type 2 diabetes. This retrospective study included 164 patients at a single center. We collected medical histories and laboratory findings of patients undergoing uroflowmetry from January 1, 2008 to October 30, 2013. Renal function was assessed by calculating the estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) study equation. We evaluated whether greater PVR was a risk factor for faster decline of GFR during a 1-year follow-up. The subjects' mean age was 65±12 years, duration of diabetes 12.8±8.8 years, baseline serum creatinine level 106.1±53.0 μmol/L, and eGFR was 64.6±25.2 mL/min/1.73 m(2). Mean PVR was 69.8±96.3 mL and in 17.7% of subjects, PVR>100 mL. In linear regression analysis, PVR was independently associated with GFR decrease (standardized β coefficient=0.2, P=0.009). Multiple logistic analysis showed that subjects with PVR>100 mL had a 2.8-fold higher risk of an eGFR change during 1 year higher than the median value of all subjects (95% confidence interval, 1.1-6.8; P=0.03). Increased PVR was independently associated with a more rapid decline in renal function in patients with type 2 diabetes.

The dose-effect safety profile of skeletal muscle precursor cell therapy in a dog model of intrinsic urinary sphincter deficiency

Locally injected skeletal muscle precursor cells (skMPCs) integrate into and restore the muscle layers, innervation, vasculature, and function of the sphincter complex in animal models of intrinsic urinary sphincter deficiency (ISD). The goal of the present study was to test the dose-effect safety profile of skMPC therapy in a dog model of ISD. Sphincter deficiency was created in 20 adult female dogs by surgically removing the skeletal muscle layer of the urinary sphincter complex. skMPCs isolated from the hind leg were expanded in culture and injected 4 weeks later into the sphincter complex at a dose of 25 million cells (n = 5), 50 million cells (n = 5), or 100 million cells (n = 5) per milliliter in a 2-ml volume. Five dogs received no sphincter injection. The measures of maximal sphincter pressure, complete blood count, and blood chemistry were performed monthly until their sacrifice at 9 months. At that point, full necropsy was performed to assess the safety of the skMPC injections. Injection of different doses of cells had no effects on the body weight, blood cell count, or kidney or liver function test results (p > .05 among the skMPC doses). Some incidental pathologic features were found in the lower urinary tract in all groups and were most likely associated with repeat catheterization. The maximal urinary sphincter pressure was higher in the 50 million cells per milliliter treatment group than in the other experimental groups (p < .05). The findings of the present study have confirmed that urinary sphincter injection of skMPCs results in no significant local or systemic pathologic features within the dose range that improves sphincter pressures.

A comprehensive review of urologic complications in patients with diabetes

Diabetes Mellitus (DM) is a chronic disease characterized by hyperglycemia, as a result of abnormal insulin production, insulin function, or both. DM is associated with systemic complications, such as infections, neuropathy and angiopathy, which involve the genitourinary tract. The three most significant urologic complications include: bladder cystopathy, sexual dysfunction and urinary tract infections. Almost half of the patients with DM have bladder dysfunction or cystopathy, which can be manifested in women as hypersensitivity (in 39-61% of the diabetic women) or neurogenic bladder. In males it can be experienced as lower urinary tract symptoms (in 25% of diabetic males with a nearly twofold increased risk when seen by age groups). Additionally, an increased prostate volume affects their micturition as well as their urinary tract. Involving sexual dysfunction in women, it includes reduced libido, decreased arousal, clitoral erectile dysfunction and painful or non-sensitive intercourse; and in diabetic males it varies from low libido, ejaculatory abnormalities and erectile dysfunction. Globally, sexual disorders have a prevalence of 18-42%. Erectile dysfunction is ranked as the third most important complication of DM. Urinary tract infections are observed frequently in diabetic patients, and vary from emphysematous infections, Fournier gangrene, staghorn infected lithiasis to repetitive bacterial cystitis. The most frequent finding in diabetic women has been lower urinary tract infections. Because of the high incidence of obesity worldwide and its association with diabetes, it is very important to keep in mind the urologic complication associated with DM in patients, in order to better diagnose and treat this population.

Viability, differentiation capacity, and detectability of super-paramagnetic iron oxide-labeled muscle precursor cells for magnetic-resonance imaging

Cell therapies are a promising approach for the treatment of a variety of human conditions including stress urinary incontinence, but their success greatly depends on the biodistribution, migration, survival, and differentiation of the transplanted cells. Noninvasive in vivo cell tracking therefore presents an important aspect for translation of such a procedure into the clinics. Upon labeling with superparamagnetic iron oxide (SPIO) nanoparticles, cells can be tracked by magnetic resonance imaging (MRI), but possible adverse effect of the labeling have to be considered when labeling stem cells with SPIOs. In this study, human muscle precursor cells (hMPC) were labeled with increasing concentrations of SPIO nanoparticles (100-1600 μg/mL) and cell viability and differentiation capacity upon labeling was assessed in vitro. While a linear dependence between cell viability and nanoparticle concentration could be observed, differentiation capacity was not affected by the presence of SPIOs. Using a nude mouse model, a concentration (400 μg/mL) could be defined that allows reliable detection of hMPCs by MRI but does not influence myogenic in vivo differentiation to mature and functional muscle tissue. This suggests that such an approach can be safely used in a clinical setting to track muscle regeneration in patients undergoing cell therapy without negative effects on the functionality of the bioengineered muscle.

Prevalence and trends of symptomatic pelvic floor disorders in U.S. women

OBJECTIVE

To estimate the prevalence and trends of these pelvic floor disorders in U.S. women from 2005 to 2010.

METHODS

We used the National Health and Nutritional Examination Survey from 2005-2006, 2007-2008, and 2009-2010. A total of 7,924 nonpregnant women (aged 20 years or older) were categorized as having: urinary incontinence (UI)-moderate to severe (3 or higher on a validated UI severity index, range 0-12); fecal incontinence-at least monthly (solid, liquid, or mucus stool); and pelvic organ prolapse-seeing or feeling a bulge. Potential risk factors included age, race and ethnicity, parity, education, poverty income ratio, body mass index ([BMI] less than 25, 25-29, 30 or greater), comorbidity count, and reproductive factors. Using appropriate sampling weights, weighted χ analysis and multivariable logistic regression models with odds ratios and 95% confidence intervals (95% CIs) were reported.

RESULTS

The weighted prevalence rate of one or more pelvic floor disorders was 25.0% (95% CI 23.6-26.3), including 17.1% (95% CI 15.8-18.4) of women with moderate-to-severe UI, 9.4% (95% CI 8.6-10.2) with fecal incontinence, and 2.9% (95% CI 2.5-3.4) with prolapse. From 2005 to 2010, no significant differences were found in the prevalence rates of any individual disorder or for all disorders combined (P>.05). After adjusting for potential confounders, higher BMI, greater parity, and hysterectomy were associated with higher odds of one or more pelvic floor disorders.

CONCLUSION

Although rates of pelvic floor disorders did not change from 2005 to 2010, these conditions remain common, with one fourth of adult U.S. women reporting at least one disorder.

LEVEL OF EVIDENCE

III.

Applications of tissue engineering in the genitourinary tract

Congenital abnormalities and acquired disorders can lead to organ damage or loss of tissue within the genitourinary tract. For reconstructive purposes, tissue-engineering efforts are currently underway for virtually every type of tissue and organ within the urinary tract. Tissue engineering incorporates the fields of cell transplantation, materials science and engineering for the purpose of creating functional replacement tissue. This article reviews some of the principles of tissue engineering and some of the applications of these principles to the genitourinary tract.

Long-term structural and functional effects of autologous muscle precursor cell therapy in a nonhuman primate model of urinary sphincter deficiency

PURPOSE

We measured the long-term efficacy of autologous muscle precursor cell therapy in premenopausal female nonhuman primates with sustained urinary sphincter deficiency.

MATERIALS AND METHODS

Urinary sphincter deficiency was created in adult premenopausal female cynomolgus monkeys by selectively cauterizing and then transecting the pudendal innervation to the sphincter complex. The monkeys were then treated (18) or not treated (18) with intra-urinary sphincter injections of 5 million autologous green fluorescent protein labeled skeletal muscle precursor cells. Four untreated, uninjured monkeys served as controls. Maximal urethral pressure measurement and corresponding histological analysis of the structural and cellular components of the sphincter complex were performed up to 12 months after injection.

RESULTS

Cell treatment produced sustained (12 months) increases in resting, somatic nerve stimulated and adrenergic nerve stimulated maximal urethral pressure, and a greater percent of sphincter area occupied by muscle as well as a decrease in the sphincter area occupied by collagen compared to the untreated group (each p>0.05). These results were within control values (each p>0.05). By 3 months after injection green fluorescent protein positive cells were found in the skeletal muscle layer, expressing desmin and connexin-43, and in the smooth muscle layer, expressing α-smooth muscle actin and connexin-43, and they were incorporated into the subendothelial vasculature, expressing Von Willebrand factor. Cell injected sphincter tissue contained a mixture of green fluorescent protein positive cells and predominantly green fluorescent protein negative cells.

CONCLUSIONS

Injected skeletal muscle progenitor cells incorporated into the injured sphincter complex resulted in long-term structural and functional restoration of the injured sphincter complex in this nonhuman primate model.

Prevalence and risk factors of urinary incontinence among Jordanian women: impact on their life

We estimate the prevalence and type of urinary incontinence (UI), possible associated risk factors, and the impact of UI on women's social and psychological well-being. The sample consisted of women attending a family medicine clinic at Jordan University Hospital (JUH) who answered a self-administered questionnaire. More than one-third of the sample reported the presence of UI. Stress type was the most frequently reported risk factor, followed by mixed incontinence, then urge. Age, diabetes, chronic cough, parity, and hysterectomy were positively associated with the presence of UI. Incontinence caused low self-esteem in more than half of the women who experienced it.

Caffeine intake and its association with urinary incontinence in United States men: results from National Health and Nutrition Examination Surveys 2005-2006 and 2007-2008

PURPOSE

Epidemiological studies in women have revealed an association between caffeine intake and urinary incontinence, although evidence among men is limited. Therefore, we evaluated the association between caffeine intake and urinary incontinence in United States men.

MATERIALS AND METHODS

Data were used from male NHANES (National Health and Nutrition Examination Surveys) 2005-2006 and 2007-2008 participants. Urinary incontinence was defined using a standard questionnaire with Incontinence Severity Index scores 3 or greater categorized as moderate to severe. Structured dietary recall was used to determine caffeine consumption (mg per day), water intake (gm per day) and total dietary moisture (gm per day). Stepwise multivariable logistic regression models were used to assess the association between caffeine intake at or above the 75th and 90th percentiles and moderate to severe urinary incontinence, controlling for potential confounders, urinary incontinence risk factors and prostate conditions in men age 40 years or older.

RESULTS

Of the 5,297 men 3,960 (75%) were 20 years old or older with complete data. Among these men the prevalence of any urinary incontinence was 12.9% and moderate to severe urinary incontinence was 4.4%. Mean caffeine intake was 169 mg per day. Caffeine intake at the upper 75th percentile (234 mg or more daily) and 90th percentile (392 mg or more per day) was significantly associated with having moderate to severe urinary incontinence (1.72, 95% 1.18-2.49 and 2.08, 95% 1.15-3.77, respectively). In addition, after adjusting for prostate conditions, the effect size for the association between caffeine intake and moderate to severe urinary incontinence remained.

CONCLUSIONS

Caffeine consumption equivalent to approximately 2 cups of coffee daily (250 mg) is significantly associated with moderate to severe urinary incontinence in United States men. Our findings support the further study of caffeine modification in men with urinary incontinence.

A nonhuman primate model of stable urinary sphincter deficiency

PURPOSE

The pathophysiology of urinary sphincter deficiency in women remains incompletely understood and current treatment options have limitations. Female nonhuman primates may represent a relevant animal model for studies of pathophysiology and treatment interventions because of their human-like reproductive and age associated stages of life (premenopause, perimenopause and postmenopause), lower urinary tract structure and bipedal posture. We developed and characterized a nonhuman primate model of defined injury to the urethral sphincter complex.

MATERIALS AND METHODS

We used 22 adult female cynomolgus monkeys in which injury to the sphincter complex was created by cauterizing and then transecting its pudendal innervation. Urodynamic studies were performed before and during pudendal and hypogastric nerve stimulation at baseline, and 3, 6 and 12 months after injury. We also analyzed sphincter structure in vivo by cystourethrography, and ex vivo by quantitative histology and immunohistochemistry at these time points.

RESULTS

Injury produced a 47% to 50% decrease in maximal urethral pressure (vs baseline p <0.05). It also abolished the increase in maximal urethral pressure in response to pudendal and hypogastric nerve stimulation (vs baseline p >0.05), which persisted more than 12 months after injury. Urodynamic changes were consistent with decreased skeletal and smooth muscle content, decreased nerve responses and an associated decrease in somatic and adrenergic innervation in the sphincter complex.

CONCLUSIONS

These structural and urodynamic changes are consistent with those in patients with stress urinary incontinence. They support the usefulness of nonhuman primates as translatable surrogates for pathophysiological studies of urinary sphincter deficiency and testing novel therapies for that condition.

Muscle Precursor Cells for the Restoration of Irreversibly Damaged Sphincter Function

Multiple modalities, including injectable bulking agents and surgery, have been used to treat stress urinary incontinence. However, none of these methods is able to fully restore normal striated sphincter muscle function. In this study, we explored the possibility of achieving functional recovery of the urinary sphincter muscle using autologous muscle precursor cells (MPCs) as an injectable, cell-based therapy. A canine model of striated urinary sphincter insufficiency was created by microsurgically removing part of the sphincter muscle in 24 dogs. Autologous MPCs were obtained, expanded in culture, and injected into the damaged sphincter muscles of 12 animals. The animals were followed for up to 6 months after injection, and urodynamic studies, functional organ bath studies, ultrastructural and histological examinations were performed. Animals receiving MPC injections demonstrated sphincter pressures of approximately 80% of normal values, while the pressures in the control animals without cells dropped and remained at 20% of normal values. Histological analysis indicated that the implanted cells survived and formed tissue, including new innervated muscle fibers, within the injected region of the sphincter. These results indicate that autologous muscle precursor cells may be able to restore otherwise irreversibly damaged urinary sphincter function clinically.

Stem cells for urinary tract regeneration

Regeneration of the urinary bladder is a complicated task, due to organ dimensions and diseases (cancer, interstitial cystitis) when autologous bladder cells cannot be used. Cancer is the most frequent indication for bladder removal (cystectomy). Stem cells can be used with the guarantee of the sufficient cell number for the in vitro construction of the urinary bladder wall. Tissue engineering techniques hold great promise for regeneration of dysfunctional urinary sphincter. Denervation following surgical procedures or injuries results in weakness of the urethral sphincter and stress urinary incontinence. Injectable therapies and the potential of stem cells for sphincter restoration was presented in this review. The aim of this review was to present possibilities of urinary bladder regeneration with the use of stem cells and tissue engineering techniques.

Does estrogen have any real effect on voiding dysfunction in women?

For many years, estrogen has been used to treat lower urinary tract dysfunction in postmenopausal women. The data supporting this practice vary. Large multi-institutional studies have shown little role for systemic estrogens in the treatment of urinary incontinence. Vaginal estrogen preparations show superiority to systemic estrogens for the treatment of irritative voiding symptoms in meta-analysis, but there is significant study heterogeneity and the practice remains debatable. Data from randomized controlled trials support estrogen use in the prevention of recurrent urinary tract infections. This article reviews the relevant literature addressing the role of estrogen therapy in urinary incontinence, irritative voiding symptoms, and recurrent urinary tract infections.

Fluid intake and risk of stress, urgency, and mixed urinary incontinence

OBJECTIVE

We investigated the relation between total fluid intake and incident urinary incontinence in the Nurses' Health Study cohorts.

STUDY DESIGN

We measured daily fluid intake using food frequency questionnaires among 65,167 women, who were 37-79 years old, without urinary incontinence at study baseline (2000-2001). Women reported incontinence incidence on questionnaires during 4 years of follow-up evaluation. Multivariable-adjusted hazard ratios and 95% confidence intervals were calculated with Cox proportional hazards models.

RESULTS

We found no association between total fluid intake and risk of incident incontinence (hazard ratio, 1.04; 95% confidence interval, 0.98-1.10; comparing top vs bottom quintile of fluid intake). In analyses of incontinence type, total fluid intake was not associated with risks of incident stress, urgency, or mixed incontinence.

CONCLUSION

No significant risk of incident urinary incontinence was found with higher fluid intake in women. These findings suggest that women should not restrict their fluid intake to prevent incontinence development.

Predicting improvement in urinary and bowel incontinence for home health patients using electronic health record data

PURPOSE

The purpose of the study was to discover which patient and support system characteristics and interventions documented by home health clinicians were associated with improvement in urinary and bowel incontinence contrasting logistic regression and data mining approaches.

SUBJECTS AND SETTING

Seventeen hundred ninety-three patients in this study experienced 2072 episodes of care. The study sample comprised all nonmaternity patients aged 18 years or older receiving skilled home health services in 2004. Subjects were drawn from a convenience sample of 15 home health agencies .

DESIGN

We completed a secondary analysis of data from 15 home health agencies' electronic health records. Data for this study were documented by home care clinicians using the Outcome and Assessment Information Set (OASIS) structured assessment form and the Omaha System interventions, which is a standardized terminology.

RESULTS

There were 684 patients with urinary incontinence and 187 with bowel incontinence. By discharge 38% improved in urinary incontinence and 45% improved their bowel incontinence. Using logistic regression, no patient or support system characteristics were identified that associated with improvement in either urinary or bowel incontinence, only a limited number of interventions were significant. A data mining decision tree was producible only for bowel incontinence, demonstrating a combination of patient and support system factors as well as selected interventions were important in determining whether patients would improve in bowel incontinence.

CONCLUSIONS

Home health patients have complex comorbid conditions requiring home care nurses to have broad, generalized knowledge. Future research is needed to determine if the inclusion of a certified WOC nurse would improve outcomes.

Predictors of Successful Pessary Fitting and Continued Use in a Nurse-Midwifery Pessary Clinic

Women with incontinence and/or pelvic organ prolapse presenting to an urogynecology service were offered referral to a dedicated midwifery pessary clinic. Charts of these women were reviewed for demographic information, physical examination, pelvic floor disorders, and details of pessary-fitting sessions. Successful fitting was defined as a comfortable fit and retention of the pessary with valsalva and voiding. Continuation was defined as a successfully fit patient who returned at least once after the initial fitting with the pessary still in use. Spearman's correlations identified variables associated with successful fitting and continuation of use. Logistic regression identified variables that predicted continued use. Eighty-six percent of women were successfully fit, and 89% continued pessary use for a mean of 6 months. Predictors of unsuccessful fitting included a history of a prior prolapse procedure or hysterectomy (P < or = .001). Severe posterior prolapse was associated with pessary discontinuation after adjustment for patient's age (P < .04). Success rates for treatment of stress urinary incontinence, pelvic organ prolapse, or both were not significantly different (success rates of 94%, 89%, and 81%, respectively; P = .50). Predictors of unsuccessful pessary fitting include history of a prior prolapse procedure and hysterectomy. Severe posterior prolapse was the single predictor of pessary discontinuation.

Common Problems of Urination in Nonpregnant Women: Causes, Current Management, and Prevention Strategies

This article uses a case-based approach to review common problems of urination in nonpregnant women, including overactive bladder; stress, urge, and mixed incontinence; and retention and prolapse. Up-to-date clinical issues related to assessment, diagnosis, treatment, and follow-up are reviewed, with a discussion of underlying pathophysiology and prevention strategies. Suggestions are made for relevant curriculum content at both the basic and advanced levels of advanced practice education.

Pudendal nerve injury reduces urethral outlet resistance in diabetic rats

Diabetics have voiding and continence dysfunction to which elevated levels of advanced glycation end products (AGE) may contribute. In addition, pudendal nerve injury is correlated with voiding dysfunction and stress incontinence in rats. The aim of this study was to investigate whether pudendal nerve crush (PNC) in diabetic rats alters urinary function. Female virgin Sprague-Dawley rats (144) were divided equally into diabetic, diuretic, and control groups. Half of the animals in each group were subjected to PNC, and the other half to sham PNC. Diabetes was induced 8 wk before PNC or sham PNC by streptozotocin injection (35 mg/kg). Animals underwent conscious cystometry and leak point pressure (LPP) testing 4 or 13 days after PNC or sham PNC. Tissues of half the animals were tested for levels of AGEs. Qualitative histological assessment was performed in the remaining animals. Diabetic rats 4 days after PNC voided significantly greater volume in a shorter time and with significantly less pressure than after sham PNC, suggesting that diabetic rats have a functional outlet obstruction that is relieved by PNC. LPP was significantly reduced 4 days after PNC in diabetic and diuretic animals and returned to normal 13 days after PNC. Diabetic rats with PNC demonstrated increased muscle fiber disruption and atrophy of the external urethral sphincter. AGEs were significantly elevated in diabetic rats. PNC relieves a functional outlet obstruction in diabetic rats. AGEs are elevated in diabetic rats and could play a role in urinary dysfunction and recovery from PNC.

Urge incontinence: estimating environmental and obstetrical risk factors using an identical twin study

INTRODUCTION AND HYPOTHESIS

The objective of this study was to determine risk factors for urge urinary incontinence (UUI).

METHODS

A multi-item survey was administered to a community sample of identical twin sisters from 2002-2008. Generalized estimating equations accounting for co-twin correlation were used to perform three different regression models on the outcome: UUI (yes vs. no).

RESULTS

Mean age, median parity, and BMI were 41.4 +/- 16.4 (18-85), 1.0, and 26.0 +/- 6.5 (13.5-55.8), respectively. Thirty-five percent of women were post-menopausal, and 27.5% had UUI. Urge urinary incontinence was reported in 40.1% of parous versus 14.1% among nulliparous women (p < .0001). The rate of UUI was 40.6% after vaginal delivery, 36.7% after cesarean delivery, and 14.1% in nulliparous women (p < .0001). Obesity, age >40, and chronic constipation were also identified as risk factors for urge urinary incontinence.

CONCLUSION

Risk factors for UUI include parity, age, obesity, and chronic constipation. There was a 2.5-fold increased risk of UUI after one or more births, regardless of type of delivery.

Diabetic bladder dysfunction: current translational knowledge

PURPOSE

Diabetes mellitus, a metabolic disorder caused by an absolute or relative deficiency of insulin, is a debilitating and costly disease with multiple serious complications. Lower urinary tract complications are among the most common complications of diabetes mellitus. The most common, bothersome lower urinary tract complication of diabetes mellitus is diabetic cystopathy or diabetic bladder dysfunction. We reviewed the current translational knowledge of diabetic bladder dysfunction.

MATERIALS AND METHODS

We performed a search of the English literature through PubMed. The key words used were diabetes and bladder dysfunction or cystopathy. Our data and perspective are provided for consideration of the future direction of research.

RESULTS

Despite traditional recognition of diabetic bladder dysfunction as a voiding problem characterized by poor emptying and overflow incontinence, recent clinical and experimental evidence indicate storage problems such as urgency and urge incontinence in diabetes mellitus cases. Recent experimental evidence from studies of diabetic bladder dysfunction in small animal models of diabetes mellitus show a temporal effect on diabetic bladder dysfunction. Early phase diabetes mellitus causes compensated bladder function and the late phase causes decompensated bladder function. The temporal theory could plausibly provide the scientific road map to correlate clinical and experimental findings, and identify the role of mechanisms such as polyuria, hyperglycemia, oxidative stress, autonomic neuropathy and decompensation of the bladder contractile apparatus in the creation of clinical and experimental manifestations of diabetic bladder dysfunction.

CONCLUSIONS

Diabetic bladder dysfunction includes time dependent manifestations of storage and emptying problems. Identifying mechanistic pathways would lead to the identification of therapeutic intervention.

Animal models of diabetic uropathy

PURPOSE

Diabetes mellitus is a group of debilitating and costly diseases with multiple serious complications. Lower urinary tract complications or diabetic uropathy are among the most common complications of diabetes mellitus, surpassing widely recognized complications such as neuropathy and nephropathy. Diabetic uropathy develops in individuals with types 1 and 2 diabetes, and little is known about the natural history of these common and troublesome complications. Animal models have the potential to reveal mechanisms and aid in the development of treatment strategies.

MATERIALS AND METHODS

We present a review of available animal models of diabetes mellitus relative to their use in the study of diabetic uropathy.

RESULTS

Large and small animal models of diabetes mellitus are available. While large animals such as dogs and swine may closely mirror the human disease in size and phenotype, the time between diabetic complication onset and development, and associated husbandry expenditures can make acquiring data on statistically valid sample sizes prohibitively expensive. In contrast, small animal models (rats and mice) have much lower expenditures for a larger number of animals and compressed observation time due to a shorter life span. Also, mice are readily manipulated genetically to facilitate the isolation of the effect of single genes (transgenic and knockout mice). Type 1 diabetes mellitus can be induced chemically with streptozotocin, which is selectively toxic to pancreatic beta cells. Type 2 diabetes mellitus models have been developed by selective breeding for hyperglycemia with or without associated obesity. Diabetic uropathy has been noted in several well characterized, predictable animal models of diabetes mellitus.

CONCLUSIONS

Diabetic uropathy, including diabetic bladder dysfunction, has been more frequently studied in small animals with type I diabetes. The recent availability of transgenic models provides a new opportunity for further studies of diabetic uropathy in mouse models of types I and II diabetes mellitus.

Ventricular dilation: association with gait and cognition

OBJECTIVE

Normal pressure hydrocephalus is characterized by gait impairment, cognitive impairment, and urinary incontinence, and is associated with disproportionate ventricular dilation. Here we report the distribution of ventricular volume relative to sulcal cerebrospinal fluid (CSF) volume, and the association of increasing ventricular volume relative to sulcal CSF volume with a cluster of gait impairment, cognitive impairment, and urinary incontinence in a stroke-free cohort of elderly persons from the general population.

METHODS

Data are based on 858 persons (35.4% men; age range, 66-92 years) who participated in the Age, Gene/Environment Susceptibility-Reykjavik Study. Gait was evaluated with an assessment of gait speed. Composite scores representing speed of processing, memory, and executive function were constructed from a neuropsychological battery. Bladder function was assessed with a questionnaire. Magnetic resonance brain imaging was followed by semiautomated segmentation of intracranial CSF volume. White matter hyperintensity (WMH) volume was assessed with a semiquantitative scale. For the analysis of ventricular dilation relative to the sulcal spaces, ventricular volume was divided by sulcal CSF volume (VV/SV).

RESULTS

Disproportion between ventricular and sulcal CSF volume, defined as the highest quartile of the VV/SV z score, was associated with gait impairment (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.1-3.3) and cognitive impairment (OR, 1.8; 95% CI, 1.1-3.0). We did not find an association between the VV/SV z score and bladder dysfunction.

INTERPRETATION

The prevalence and severity of gait impairment and cognitive impairment increases with ventricular dilation in persons without stroke from the general population, independent of WMH volume.

Oxybutynin extended release for the management of overactive bladder: a clinical review

Overactive bladder (OAB) is a common condition which negatively impacts the quality of life of afflicted patients. This can result in alterations in social interactions at home, in the workplace and in the community, often leading to depression and poor self esteem as well as loss of productivity. Traditional mainstays of treatment include both behavioral therapy and pharmacotherapy. Oxybutynin immediate release (IR) represents the first such medication approved by the FDA specifically for treatment of OAB in 1975. Nevertheless, bothersome side effects in addition to thrice daily dosing often led to treatment cessation which raised the question that patients may actually prefer to live with their OAB symptoms rather than incur side effects or complex dosing schemes. Pharmacological advances ultimately led to development of a long-acting formulation of oxybutynin in the form of oxybutynin extended release (ER) with the hope that this drug would maintain efficacy while decreasing bothersome side effects and improve compliance with the convenience of once daily dosing regimen. This paper will review the major clinical studies involving oxybutynin ER as well as its role in different patient populations and potential concerns with its use.

Diabetes related risk factors did not explain the increased risk for urinary incontinence among women with diabetes. The Norwegian HUNT/EPINCONT study

BACKGROUND

Previous studies have shown an association between diabetes mellitus (DM) and urinary incontinence (UI) in women, especially severe UI. The purpose of this study was to investigate whether diabetes related variables could explain this association.

METHODS

The study is part of the EPINCONT study, which is based on the large Nord-Trøndelag Health Study 2 (HUNT 2), performed in the county of Nord-Trøndelag, Norway, during the years 1995 - 1997. Questions on diabetes and UI were answered by a total of 21 057 women aged 20 years and older. Of these 685 were identified as having diabetes, and thus comprise the population of our study. A variety of clinical and biochemical variables were recorded from the participants.

RESULTS

Blood-glucose, HbA1c, albumine:creatinine ratio (ACR), duration of diabetes, diabetes treatment, type of diabetes, cholesterol and triglycerides did not significantly differ in women with and without UI in crude analyses. However, the diabetic women with UI had more hospitalizations during the last 12 months, more homecare, and a higher prevalence of angina and use of oestrogene treatment (both local and oral/patch). After adjusting for age, BMI, parity and smoking, there were statistically significant associations between any UI and angina (OR 1.89; 95% CI: 1.22 - 2.93), homecare (OR 1.72; 95% CI: 1.02 - 2.89), and hospitalization during the last 12 months (OR 1.67; 95% CI: 1.18 - 2.38). In adjusted analyses severe UI was also significantly associated with the same variables, and also with diabetes drug treatment (OR 2.10; 95% CI: 1.07 - 4.10) and stroke (OR 2.47; 95% CI: 1.09 - 5.59).

CONCLUSION

No single diabetes related risk factor seems to explain the increased risk for UI among women with diabetes. However, we found associations between UI and some clinical correlates of diabetes.

Estrogen and urinary incontinence

Hormone therapy (HT) has been one of the most commonly used methods to treat postmenopausal disorders including lower urinary tract symptoms such as urinary incontinence (UI). Although it has been suggested that HT improves urinary tract symptoms, little evidence has so far been presented to support this. Recently however, large randomized clinical trials have shown the adverse effects of estrogen on UI and indicate that HT should not be used for prevention or relief of UI in postmenopausal women. Here we review the effects of HT on UI in the light of these clinical trials.

Urinary incontinence among Taiwanese women: an outpatient study of prevalence, comorbidity, risk factors, and quality of life

The objective of this study was to evaluate comorbidity and risk factors associated with female urinary incontinence and to assess quality of life for women with different types of urinary incontinence. Subjects included 551 consecutive females who attended the outpatient clinic from 9 March to 8 July 2006 and did not have a chief complaint of incontinence. A four-item incontinence questionnaire and a Chinese version of the Incontinence-Quality of Life (I-QOL) questionnaire were completed in the waiting room. Patient characteristics and medical conditions were summarized from outpatient electronic databases. A total of 371 females were included for statistical analysis. Among them, 114 patients (30.7%) did not indicate any urinary incontinence, while 257 (69.3%) patients indicated symptoms of urge incontinence, stress incontinence, or mixed incontinence. Comorbidities significantly associated with incontinence included osteoarthritis (P = 0.001), peptic ulcer disease (P = 0.031), obesity (P < 0.001), and cardiac disease (P < 0.001). After multiple logistic regression analysis, obesity (OR 3.38, 95% CI 1.94-6.98) and postmenstrual status (OR 2.17, 95% CI 1.35-3.50) were found to be risk factors of incontinence (P < 0.001). Mixed incontinence patients exhibited the least satisfaction in quality of life, while no significant differences were observed between patients with urge incontinence and stress incontinence. In conclusion, the incidence of urinary incontinence may be greater in the outpatient population than previously thought. Osteoarthritis, peptic ulcer disease, and cardiac disease are more common in women with urinary incontinence, obesity and postmenopausal status appear predictive of incontinence, and women with mixed incontinence exhibit the least satisfying quality of life.

Do women have realistic expectations of treatment for stress urinary incontinence?

AIMS

Our objective was to determine what women find acceptable regarding treatment and outcomes for treatment of stress urinary incontinence (SUI), and correlate this to age, distress and quality of life (QOL).

MATERIALS AND METHODS

This prospective cross-sectional IRB-approved study evaluated women with primary SUI. One hundred sequential women (mean age, 53.8 years) answered questionnaires on initial interview, including the Urogential Distress Inventory (UDI-6), the American Urologic Association QOL questionnaire, as well as other validated questions regarding treatment options and possible outcomes. Statistical analysis was performed using Chi Squared, Fisher Exact, and t tests as well as the Wilcoxon Rank Score.

RESULTS

Of the 100 women who submitted questionnaires, 22% overall expected a complete cure, 57% a good improvement, 12% to be able to cope better, and 9% expected any improvement at all. We found this to be a realistic expectation of possible outcomes of treatment, with 79% expecting a good improvement or cure for their SUI. The women were also asked what type of treatment they found acceptable for their SUI: 22% found a major surgery acceptable, 39% found a minor surgery acceptable, 32% found a clinical procedure acceptable, and 7% found medication acceptable. The majority of women (71%) found a minor surgery, like a transobturator tape, or a clinical procedure, like collagen injection, most desirable. These results were then analyzed for correlation to age, degree of distress (measured by UDI-6), and QOL (measured by AUA QOL score).

CONCLUSIONS

Overall women have realistic expectations of treatment for SUI. They are willing to accept varied results depending on their distress regarding incontinence. Choices regarding treatments are influenced by age, severity and quality of life. It may be beneficial to include the UDI-6, age and QOL score as a part of the work up and planning for treatment of SUI to better meet patient's expectations.

Stress urinary incontinence in women with a history of gestational diabetes mellitus

OBJECTIVE

Stress urinary incontinence may serve as a barrier to lifestyle modification among women at high risk for diabetes, but the prevalence of stress urinary incontinence among women with histories of gestational diabetes mellitus (hGDM) is unknown. The purpose of this study was to examine the prevalence of stress incontinence among women with hGDM and to examine its association with their current physical activity.

METHODS

We surveyed women with hGDM within the past 5 years who were currently enrolled in a managed care plan (n = 228). In a cross-sectional analysis, self-reported weekly or more frequent stress incontinence was the primary independent variable and measures of physical activity and body mass index (BMI) were the outcomes of interest. We constructed multivariable models that adjusted for participant characteristics associated with the measure of incontinence or outcomes in bivariate analyses.

RESULTS

Of the 228 women with hGDM, 49% reported weekly or more frequent incontinence during pregnancy, and 28% reported that incontinence affected their activities during pregnancy. Fifty percent reported weekly or more frequent incontinence after delivery, with 27% reporting interference of incontinence with activity. Less than a third of women reported optimal physical activity, and 42% were obese. After adjustment for characteristics associated with measures of activity and incontinence, there was minimal association between levels of activity and stress urinary incontinence; similarly, there was no association between BMI and measures of stress incontinence.

CONCLUSIONS

Stress urinary incontinence is common among women with hGDM but does not appear to be associated with physical activity levels or BMI.

Proteomics analysis identifies molecular targets related to diabetes mellitus-associated bladder dysfunction

Protein expression profiles in rat bladder smooth muscle were compared between animal models of streptozotocin-induced diabetes mellitus (STZ-DM) and age-matched controls at 1 week and 2 months after induction of hyperglycemia with STZ treatment. At each time point, protein samples from four STZ-DM and four age-matched control rat bladder tissues were prepared independently and analyzed together across multiple DIGE gels using a pooled internal standard sample to quantify expression changes with statistical confidence. A total of 100 spots were determined to be significantly changing among the four experimental groups. A subsequent mass spectrometry analysis of the 100 spots identified a total of 56 unique proteins. Of the proteins identified by two-dimensional DIGE/MS, 10 exhibited significant changes 1 week after STZ-induced hyperglycemia, whereas the rest showed differential expression after 2 months. A network analysis of these proteins using MetaCore suggested induction of transcriptional factors that are too low to be detected by two-dimensional DIGE and identified an enriched cluster of down-regulated proteins that are involved in cell adhesion, cell shape control, and motility, including vinculin, intermediate filaments, Ppp2r1a, and extracellular matrix proteins. The proteins that were up-regulated include proteins involved in muscle contraction (e.g. Mrlcb and Ly-GDI), in glycolysis (e.g. alpha-enolase and Taldo1), in mRNA processing (e.g. heterogeneous nuclear ribonucleoprotein A2/B1), in inflammatory response (e.g. S100A9, Annexin 1, and apoA-I), and in chromosome segregation and migration (e.g. Tuba1 and Vil2). Our results suggest that the development of diabetes-related complications in this model involves the down-regulation of structural and extracellular matrix proteins in smooth muscle that are essential for normal muscle contraction and relaxation but also induces proteins that are associated with cell proliferation and inflammation that may account for some of the functional deficits known to occur in diabetic complications of bladder.

Overactive bladder in diabetes: a peripheral or central mechanism?

AIMS

To study diabetic cystopathy with reference to overactive bladder (OAB).

METHODS

We retrospectively analyzed diabetic cystopathy in our digitized database that comprised 2300 case records, including data from a lower urinary tract symptoms questionnaire, data from a urodynamic study, and data from neurological examinations.

RESULTS

Diabetic cystopathy was seen in 4% of cases (84 cases): 58 males, 26 females; mean age, 60.8 years; duration of diabetes, 143.5 months; HbA1C, 7.7 %. In addition to large post-void residual and decreased sensation, OAB, detrusor overactivity (DO), and increased bladder sensation were seen in 55%, 42%, and 14%, respectively. The frequency of DO in patients with increased bladder sensation was 58%. DO increased with age, but not with the duration of diabetes. A brain MRI was performed in 32 cases. The frequency of multiple cerebral infarction (MCI) in patients with DO was 76.5%. The remaining 23.5% of patients with DO had no MCI, and the remaining 42% with increased bladder sensation had no DO.

CONCLUSIONS

OAB commonly occurs in diabetic cystopathy. Both central and peripheral mechanisms are involved, e.g., MCI due to diabetic cerebral vasculopathy for the DO, and, to a lesser extent, peripheral nerve irritation for the DO and increased bladder sensation.