The relationship between urinary symptom questionnaires and urodynamic diagnoses: an analysis of two methods of questionnaire administration

European Urogynaecological Association Position Statement: The role of urodynamics in stress urinary incontinence evaluation and treatment decision

Stress urinary incontinence (SUI) is defined as a condition characterized by the involuntary leakage of urine during activities that increase intra-abdominal pressure which may decrease quality of life with a significant economic impact on health systems, necessitating the implementation of cost-effective management plans. Urodynamics (UDS) has been considered during the last decades as the gold standard for assessment of lower urinary tract symptoms (LUTS) due to their high reproducibility. At the same time, concerns about the systematic use of UDS before SUI surgery were raised due to a limited evidenced base to recommend their routine use. In uncomplicated female patients with SUI, UDS can offer further insights into LUTS, potentially assisting the physician in determining the appropriate therapeutic approach. However, it has not been shown that preoperative UDS can directly impact the surgical outcome for continence. Indeed, evidence supports the conclusion that pre-operative UDS in women with uncomplicated, clinically demonstrable, SUI does not improve the outcome of surgery for SUI. Nevertheless, asymptomatic detrusor overactivity (DO) identified by urodynamic testing or pre-existing voiding dysfunction are associated with an increased occurrence of postoperative overactive bladder (OAB) and voiding dysfunction, respectively. The EUGA Working Group concluded that the evidence does not support the systematic preoperative use of UDS for uncomplicated cases. However, in cases where mixed symptoms, voiding dysfunction, previous surgery, or concomitant prolapse are present, preoperative UDS are advised as they can be beneficial in anticipating postoperative outcomes. This aids in conducting comprehensive and thorough preoperative counseling. The Group recommend performing preoperative UDS considering the patient's specific clinical situation and the surgeon's judgment, with consideration given to the potential benefits, risks, and impact on treatment decisions and patient outcomes.

Advances in the natural history of urinary incontinence in adult females

The aim of this review is to summarise the related characteristics of the natural history of female urinary incontinence (UI) using a narrative descriptive approach. PubMed, EMBASE and Web of Science were searched for articles published from 1 January 2010 to 1 January 2020 on the natural history of female UI, which including incidence, persistence, progression, remission, and regression of a single subtype of UI and the mutual influence of different UI subtypes. This literature review includes 15 articles published, indicates that UI is highly dynamic, with symptoms varying according to disease severity and subtype and influenced by multiple factors at different disease stages. Recent studies have increased our understanding of the natural history of UI. Future research should systematically analyse the progression of each subtype of UI and interactions between subtypes to prevent the progression of UI across females life course.

When should we use urodynamic testing? Recommendations of the Italian Society of Urodynamics (SIUD). Part 1 - Female population

Although, until a few years ago, the diagnostic power of urodynamic testing had never been questioned, recent studies in the literature have raised some doubts on the routine use of this tool. The benefits of the urodynamic studies (UDS) should be weighted against costs, time-consumption and patient discomfort. These recommendations are intended to guide clinicians in the right selection of the female patients to submit to a urodynamic evaluation. We reviewed the literature, regarding the use of UDS in female adults with lower urinary tract symptoms (LUTS) and pelvic floor dysfunction. Specifically, we analyzed and compared the guidelines and recommendations of the most important urology and uro-gynecology international scientific societies. These publications were used to create the evidence basis for characterizing the recommendations to perform urodynamic testing. A panel of 10 experts was composed and Delphi process was followed to obtain the panelist consensus. The final recommendations were approved by the unanimous consensus of the panel and compared with the best practice recommendations available in the literature. The recommendations are provided for diagnosis and management of common LUTS in female population. This review provides a summary of the most effective utilization of urodynamic studies for the global evaluation of patients with lower urinary tract symptoms and how to use them when really needed, avoiding unnecessary costs and patient inconveniences.

When should we use urodynamic testing? Recommendations of the Italian Society of Urodynamics (SIUD). Part 2 - Male and neurogical population

Recent studies in literature, have raised some doubts on the routine use of urodynamic testing. Many physicians and articles recommend a selective use of this tool, considering carefully risks and benefits. These recommendations are intended to guide clinicians in the right selection of the male and neurological patients to submit to a urodynamic evaluation. This is the second part of a previous article regarding the urodynamic recommendations in the female population. We reviewed the literature, regarding the use of UDS in male and neurological population with lower urinary tract symptoms (LUTS). Specifically, we analyzed and compared the guidelines and recommendations of the most important urology and urogynecology international scientific societies. These publications were used to create the evidence basis for characterizing the recommendations to perform urodynamic testing. A panel of 10 experts was composed and Delphi process was followed to obtain the panelist consensus. The final recommendations were approved by the unanimous consensus of the panel and compared with the best practice recommendations available in the literature. The recommendations are provided for diagnosis and management of common LUTS in male and neurological population. This review provides a summary of the most effective utilization of urodynamic studies for the global evaluation of patients with LUTS, and how to use them when really needed, avoiding unnecessary costs and patient inconveniences.

The role of urodynamics in the management of female stress urinary incontinence

AIM

The role of urodynamic study (UDS) in the management of female stress urinary incontinence (SUI) is one of the most controversial and debated topic in urogynecology. Here, we aimed to systematically assess the most relevant available evidence on urodynamics' value in the management of women with stress urinary incontinence.

METHODS

A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was performed in May 2018. Only randomized clinical trials, prospective studies, or retrospective studies articles evaluating the use of urodynamic studies in women with stress urinary incontinence were included.

RESULTS

After screening a total of 3055 records, 39 studies published from 1996 to 2018 were included.

CONCLUSIONS

In an uncomplicated population of women with SUI, it is not demonstrated that preoperative urodynamic evaluation can improve the outcome of continence surgery; however, UDS provides additional information regarding lower urinary tract function that could guide the physician to make the right therapeutic choice. UDS should be considered mandatory before surgery in complicated patients, but its use should also be evaluated in index patients when the results may help counseling and management of these women.

Rationales for a Urodynamic Study in Patients with Cervical Spondylotic Myelopathy

BACKGROUND

Detrusor sphincter dyssynergia, involuntary detrusor contractions (IDCs), and poor bladder compliance are common urodynamic findings in cervical spondylotic myelopathy (CSM). There is little information regarding the role of a urodynamic study after decompression surgery for CSM.

METHODS

Urodynamic study was performed before and 6 months after decompression of CSM. Japanese Orthopaedic Association score for cervical myelopathy and Neck Disability Index functional score were applied. International Prostate Symptom Score was applied in male patients, and 6-item Urogenital Distress Inventory was applied in female patients.

RESULTS

Mean patient age was 61.3 years. Final follow-up was obtained in 17 of 32 patients. Neurogenic bladder was confirmed in 11 (64.7%) patients, with 7 patients having poor bladder compliance, 3 patients having IDCs, and 6 patients having detrusor sphincter dyssynergia. Poor bladder compliance was normalized in 4 of 7 patients. IDCs disappeared in 2 (phasic IDCs) of 3 patients and improved in 1 (terminal IDC) patient. Detrusor sphincter dyssynergia markedly improved in 4 of 6 patients. Bladder compliance in 17 patients was 45.52 ± 23.71 before decompression surgery and 77.07 ± 39.85 after decompression surgery (P = 0.004). Both Japanese Orthopaedic Association and Neck Disability Index scores improved (P = 0.007 and P = 0.001, respectively). International Prostate Symptom Score and 6-item Urogenital Distress Inventory were not changed 6 months after surgery.

CONCLUSIONS

Neurogenic bladder could be partially controlled in patients with CSM after surgical decompression. The neurogenic component in the urodynamic study findings varied. Depending on the findings, further appropriate urologic treatments after neurologic decompression surgery should be considered.

Screening for Urinary Incontinence in Women: A Recommendation From the Women's Preventive Services Initiative

DESCRIPTION

Recommendation on screening for urinary incontinence in women by the Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient representatives. The WPSI's recommendations are intended to guide clinical practice and coverage of services for the Health Resources and Services Administration and other stakeholders. The target audience for this recommendation includes all clinicians providing preventive health care for women, particularly in primary care settings. This recommendation applies to women of all ages, as well as adolescents.

METHODS

The WPSI developed this recommendation after evaluating evidence regarding the benefits and harms of screening for urinary incontinence in women. The evaluation included a systematic review of the accuracy of screening instruments and the benefits and harms of treatments. Indirect evidence was used to link screening and health outcomes in the chain of evidence that might support screening in the absence of direct evidence. The WPSI also considered the effect of screening on symptom progression and avoidance of costly and complex treatments, as well as implementation factors.

RECOMMENDATION

The WPSI recommends screening women for urinary incontinence annually. Screening ideally should assess whether women experience urinary incontinence and whether it affects their activities and quality of life. The WPSI recommends referring women for further evaluation and treatment if indicated.

Screening for Urinary Incontinence in Women: A Systematic Review for the Women's Preventive Services Initiative

BACKGROUND

Urinary incontinence is infrequently addressed during routine health care despite its high prevalence and adverse effects on health.

PURPOSE

To evaluate whether screening for urinary incontinence in women not previously diagnosed improves outcomes (symptoms, quality of life, and function) and to evaluate the accuracy of screening methods and potential harms of screening.

DATA SOURCES

English-language searches of Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (1 January 1996 to 30 March 2018); ClinicalTrials.gov (April 2018); and reference lists of studies and reviews.

STUDY SELECTION

Randomized trials, cohort studies, systematic reviews of studies that enrolled nonpregnant women without previously diagnosed urinary incontinence and compared clinical outcomes and adverse effects between women who were and were not screened, and diagnostic accuracy studies that reported performance measures of screening tests.

DATA EXTRACTION

Dual extraction and quality assessment of individual studies.

DATA SYNTHESIS

No studies evaluated the overall effectiveness or harms of screening. Seventeen studies evaluated the diagnostic accuracy of 18 screening questionnaires against a clinical diagnosis or results of diagnostic tests. Of these, 14 poor-quality studies were based in referral clinics, enrolled only symptomatic women, or had other limitations. One good-quality and 2 fair-quality studies (evaluating 4 methods) enrolled women not recruited on the basis of symptoms. Areas under the receiver-operating characteristic curve for stress, urge, and any type of incontinence in these studies were 0.79, 0.88, and 0.88 for the Michigan Incontinence Symptom Index; 0.85, 0.83, and 0.87 for the Bladder Control Self-Assessment Questionnaire; and 0.68, 0.82, and 0.75 for the Overactive Bladder Awareness Tool. The Incontinence Screening Questionnaire had a sensitivity of 66% and specificity of 80% for any type of incontinence.

LIMITATION

Studies enrolled few participants, often from symptomatic referral populations; used various reference standards; and infrequently reported CIs.

CONCLUSION

Evidence is insufficient on the overall effectiveness and harms of screening for urinary incontinence in women. Limited evidence in general populations suggests fairly high accuracy for some screening methods.

PRIMARY FUNDING SOURCE

Health Resources and Services Administration.

Can we predict detrusor overactivity in women with lower urinary tract symptoms? The King's Detrusor Overactivity Score (KiDOS)

OBJECTIVE

Traditionally, urodynamic studies (UDS) have been used to assess lower urinary tract symptoms (LUTS), but their routine use is now discouraged. While urodynamic stress incontinence is strongly associated with the symptom of stress urinary incontinence (SUI) and a positive cough test, there is a weak relationship between symptoms of overactive bladder and detrusor overactivity (DO). The aim of our study was to develop a model to predict DO in women with LUTS.

STUDY DESIGN

This prospective study included consecutive women with LUTS attending a urodynamic clinic. All women underwent a comprehensive clinical and urodynamic assessment. The effect of each variable on the odds of DO was estimated both by univariate analysis and adjusted analysis using logistic regression.

RESULTS

1006 women with LUTS were included in the study with 374 patients (37%) diagnosed with DO. The factors considered to be the best predictors of DO were urgency urinary incontinence, urge rating/void and parity (p-value<0.01). The absence of SUI, vaginal bulging and previous continence surgery were also good predictors of DO (p-value<0.01). We have created a prediction model for DO based on our best predictors. In our scoring system, presence of UUI scores 5; mean urge rating/void≥3 scores 3; parity≥2 scores 2; previous continence surgery scores -1; presence of SUI scores -1; and the complaint of vaginal bulging scores -1. If a criterion is absent, then the score is 0 and the total score can vary from a value of -3 to +10. The Receiver Operating Characteristic (ROC) analysis for the overall cut-off points revealed an area under the curve of 0.748 (95%CI 0.741, 0.755).

CONCLUSION

This model is able to predict DO more accurately than a symptomatic diagnosis alone, in women with LUTS. The introduction of this scoring system as a screening tool into clinical practice may reduce the need for expensive and invasive tests to diagnose DO, but cannot replace UDS completely.

Is It Possible to Predict Urodynamic Stress Urinary Incontinence in Women with Minimal Diagnostic Evaluation?

<b><i>Objectives:</i></b> To determine whether it is possible to predict urodynamic stress urinary incontinence (uSUI) in women with minimal diagnostic evaluation. <b><i>Materials and Methods:</i></b> Medical records of 2,643 female incontinent patients were reviewed and 301 women were eligible for this study. The positive predictive values (PPV), sensitivity, specificity and negative predictive values (NPV) for uSUI and uSUI with or without detrusor overactivity (DO), and DO patients of pure SUI symptom (group 1), combination of pure SUI symptom and positive provocative stress test (+PST; group 2) and combination of pure SUI symptom, +PST and absence of overactive bladder symptoms (group 3) were calculated for each group. <b><i>Results:</i></b> Mean age was 51.03 years (22-88). PPV, sensitivity and specificity values for uSUI with or without DO of group 3 were 100, 7.4, and 100%, while these values for pure uSUI were 93.3, 9.3, and 99.3%, respectively. Interestingly, none of the patients in groups 2 and 3 had DO. <b><i>Conclusions:</i></b> Our results show that it was possible to predict uSUI with high accuracy using minimal diagnostic evaluation in a group of female patients with pure stress incontinence symptoms +PST while it was also possible to eliminate DO accurately in this group of patients.

Urodynamic studies for management of urinary incontinence in children and adults

BACKGROUND

Urodynamic tests are used to investigate people who have urinary incontinence or other urinary symptoms in order to make a definitive, objective diagnosis. The aim is to help select the treatment most likely to be successful. The investigations are invasive and time consuming.

OBJECTIVES

The objective of this review was to determine if treatment according to a urodynamic-based diagnosis, compared to treatment based on history and examination, led to more effective clinical care of people with urinary incontinence and better clinical outcomes.The intention was to test the following hypotheses in predefined subgroups of people with incontinence:(i) urodynamic investigations improve the clinical outcomes;(ii) urodynamic investigations alter clinical decision making;(iii) one type of urodynamic test is better than another in improving the outcomes of management of incontinence or influencing clinical decisions, or both.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE In-Process, handsearching of journals and conference proceedings (searched 19 February 2013), and the reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing clinical outcomes in groups of people who were and were not investigated using urodynamics, or comparing one type of urodynamic test against another were included. Trials were excluded if they did not report clinical outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

Eight trials involving around 1100 people were included but data were only available for 1036 women in seven trials, of whom 526 received urodynamics. There was some evidence of risk of bias. The four deaths and 12 dropouts in the control arm of one trial were unexplained.There was significant evidence that the tests did change clinical decision making. Women in the urodynamic arms of three trials were more likely to have their management changed (proportion with change in management compared with the control arm 17% versus 3%, risk ratio (RR) 5.07, 95% CI 1.87 to 13.74), although there was statistical heterogeneity. There was evidence from two trials that women treated after urodynamic investigations were more likely to receive drugs (RR 2.09, 95% CI 1.32 to 3.31). On the other hand, in five trials women undergoing treatment following urodynamic investigation were not more likely to undergo surgery (RR 0.99, 95% CI 0.88 to 1.12).There was no statistically significant difference however in the number of women with urinary incontinence if they received treatment guided by urodynamics (37%) compared with those whose treatment was based on history and clinical findings alone (36%) (for example, RR for the number with incontinence after the first year 1.02, 95% CI 0.86 to 1.21). It was calculated that the number of women needed to treat was 100 women (95% CI 86 to 114 women) undergoing urodynamics to prevent one extra individual being incontinent at one year.One trial reported adverse effects and no significant difference was found (RR 1.10, 95% CI 0.81 to 1.50).

AUTHORS' CONCLUSIONS

While urodynamic tests did change clinical decision making, there was some evidence that this did not result in better outcomes in terms of a difference in urinary incontinence rates after treatment. There was no evidence about their use in men, children, or people with neurological diseases. Larger definitive trials are needed in which people are randomly allocated to management according to urodynamic findings or to management based on history and clinical examination to determine if performance of urodynamics results in higher continence rates after treatment.

Objective Evaluation of Overactive Bladder: Which Surveys Should I Use?

Overactive bladder (OAB) is a common condition that affects many adults, and prevalence increases with age in both men and women. It is characterized by symptoms of urinary frequency and urgency with or without urge incontinence in the absence of another proven etiology. As a diagnosis based solely on urinary symptoms, proper evaluation of OAB often depends on the use of psychometrically validated questionnaires to assess symptom severity and degree of bother. General urinary assessment forms can evaluate many urinary symptoms while modular questionnaires can focus on the most bothersome complaints. Many questionnaires have been formulated and validated to achieve these goals. Currently, the ideal questionnaire does not exist. This review attempts to outline the range of questionnaires available to the clinician to assist in evaluating symptoms as well as degree of impact on quality of life.

[Urodynamic aspects of feminine urinary incontinence treated with slings]

OBJECTIVES

Treatment of feminine stress urinary incontinence (SUI) with slings aims to supplement the function of the damaged ligaments, favoring the correct transmission of the tensions. Our objective is to determine which preoperative variables could predict the outcome of surgical treatment of SUI and to study the urodynamic changes produced by the surgery.

MATERIAL AND METHODS

139 women (age X =61.7; σ=10.88) operated on due to SUI were studied retrospectively. In 118 cases (84.8%), sling techniques (TVT, TOT, TVT-Safyre, REEMEX) were used. Clinical evaluation and complete preoperative video -urodynamics were made pre-operatively and at 3 months of surgery. A statistical study (Fisher's test, Wilcoxon, Friedman, Student's T and Pearson's χ(2)) and analysis of multivariant logistic regression analysis by step elimination method were performed.

RESULTS

Post-operatively, the SUI (p=0.000) and bladder hyperactivity syndrome decreased. The success percentages (urodynamic absence of SUI) for each technique were: TVT-Safyre (75%), TOT (73%), TVT (60%) and REEMEX (57%), without significant differences. Age (ROC cut-off: 61 years) was a prognostic factor of success (p=0.024). Preoperative maximum flow (Qmax) (16 ml/s) constituted the only urodynamic parameter with a predictive value for success (p=0.026). An open bladder neck was a risk factor for persistence of postoperative SUI (RR=2.78). A significant decrease of the postsurgical Qmax (p=0.017) was verified, without increase of the post micturation residue or of the Wmax. An increase of the postsurgical urethral resistance (UR) was also observed (p=0.004).

CONCLUSIONS

The pre-operative Qmax is the most important urodynamic prognostic parameter in feminine SUI surgery, its normality being associated to a greater probability of cure of the incontinence. In the cases of decreased preoperative flow, use of slings that increase urethral resistance more (REEMEX) is not recommended. Hyperactivity of the preoperative detrusor does not significantly modify the results of surgery of the SUI.

Treatment of mixed urinary incontinence

INTRODUCTION

Mixed urinary incontinence (MUI) is a prevalent condition and imposes a significant impact on a woman's quality of life. Treatment is often challenging, as a single modality may be inadequate for alleviating both the urge and stress component.

MATERIALS AND METHODS

A MEDLINE search was conducted regarding English-language literature pertaining to the pathophysiology, diagnosis of, and treatment for MUI. Non-English language articles were considered if they could be translated into English using GOOGLE translator.

RESULTS

The identification of an ideal single treatment has also been made more challenging by the poor characterization of the pathophysiology of MUI. Behavioral and lifestyle modification, as well as pelvic floor muscle therapy, should be considered first-line options for all women with MUI. Treatment of the urge component with anti-muscarinics is effective; however the stress component is likely to persist after therapy. Anti-incontinence surgery may have a positive impact on both the stress and urge components of MUI, with emerging evidence suggesting that transobturator MUS may be associated with lower rates of de novo and persistent urge component compared to other procedures. The presence of concomitant, preoperative detrusor overactivity has not been consistently associated with postoperative outcomes.

CONCLUSIONS

The optimum treatment of MUI may often require multiple treatment modalities. While surgery may have a positive impact on both the urge and stress component, its implementation should be approached with caution and patients should be carefully selected. Detailed informed consent in women with MUI cannot be overstated.

A review of the concordance of diagnoses made after multi-channel urodynamics and video urodynamics in women with urinary incontinence

OBJECTIVE

Symptoms of urinary incontinence often do not correlate well with the diagnosis provided by urodynamic investigations. Video urodynamics has been described as the "gold standard" investigation for patients with lower urinary tract symptoms. The aim of our study was to determine the concordance of diagnoses made on multi-channel and video urodynamics in women presenting with urinary incontinence to a tertiary care urogynaecology unit.

MATERIALS AND METHODS

We performed a retrospective chart review of 38 women who had video urodynamics and a multi-channel study completed within a one-year period. All patients had a complete history and pelvic floor assessment. The investigators completing each study were blinded to the clinical diagnoses, the physical findings, and the other urodynamics diagnoses. International Continence Society standards were followed for completion of all urodynamics investigations. Multi-channel studies were completed with the patient lying supine and video studies were performed with the patient sitting on a commode. The level of agreement of the diagnoses was calculated using a kappa (kappa) statistic with 95% confidence intervals (CI).

RESULTS

The median age of subjects was 61 years (range 14-79), with a median duration of lower urinary tract symptoms of 6.0 years (range 0.5-41). Patients had had a median of two previous bladder surgeries (range 0-5). The level of concordance of the two diagnoses gave a kappa of 0.16 (95% CI 0.06-0.26).

CONCLUSIONS

There was poor concordance between the diagnoses made on multi-channel and video urodynamics when the two tests were performed on the same patient. Prospective studies are required to evaluate the reproducibility of diagnoses made on cystometry.

Related factors of urge, stress, mixed urinary incontinence and overactive bladder in reproductive age womenin Tabriz, Iran: a cross-sectional study

Urinary incontinence remains a pressing problem, particularly for women. So this study was conducted to assess risk factors for stress, urge, mixed urinary incontinence and overactive bladder (OVB). Three hundred and thirty women aged 15-49, non-pregnant, non-breastfeeding who were referred to gynecologic clinics were surveyed. A questionnaire was used to collect data. Women with no symptoms related to urinary incontinence (UI) and OVB served as the reference group. The risk of all types of UI and OVB increased with constipation. Posterior pelvic organ prolapse was associated with stress and urge incontinence. Vaginal delivery was a predictor of stress, urge and mixed incontinence. BMI and PID were predictors of OVB. Pelvic muscle strength was a predictor of stress incontinence. Vaginal length was associated with mixed incontinence. Optimal weight gain, having a healthy lifestyle, treatment of constipation and pelvic organ prolapse, and improving pelvic floor muscle strength can be suggested as preventive measures against UI and OVB. Pelvic measurement can be included in evaluation of UI.

A prospective assessment of overactive bladder symptoms in a cohort of elderly women who underwent transvaginal surgery for advanced pelvic organ prolapse

OBJECTIVE

The objective of this study was to evaluate the impact of transvaginal prolapse surgery on overactive bladder symptoms in elderly women.

STUDY DESIGN

Women (> or = 65 years old) with stage III or IV prolapse who enrolled in a prospective study that compared vaginal reconstructive surgery (n = 39) to obliterative surgery (n = 26) and who underwent preoperative urodynamics are the subjects of this study. The women completed the Pelvic Floor Distress Inventory at baseline and again 6 months and 12 months after surgery. Postoperative changes in symptoms of urinary urgency, frequency, and urge urinary incontinence were assessed. The association between a baseline urodynamic diagnosis of detrusor overactivity and pre- and postoperative overactive bladder symptoms was also determined.

RESULTS

Data were analyzed from 65 subjects with a mean age of 75.3 years (range, 65.5-87.0 years). Detrusor overactivity was documented in 25% of subjects. There was no difference in the proportion of baseline urge incontinence (P = .38), urinary frequency (P = .53), or urgency (P = .76) in comparing women with and without detrusor overactivity. Surgery resulted in a significant reduction of urgency and frequency symptoms 6 months after surgery and a similar significant reduction in urgency and urge incontinence at 1 year after surgery. Overall, a clinically and statistically significant improvement in the irritative subscale of the Pelvic Floor Distress Inventory was noted at 6 months (18.3%; P < .0001) and 12 months (17.6%; P < .0001) after surgery. In our cohort, performance of a mid urethral sling, a bladder neck sling, or a Kelly plication was not associated with a reduction in postoperative symptoms of urgency, frequency, or urge incontinence (P = .48). Likewise, there was no difference in postoperative symptom reduction (urgency, frequency, or urge incontinence) between women who received reconstructive surgery vs women who had obliterative surgery (P = .84).

CONCLUSION

Vaginal surgery for stage III or IV pelvic organ prolapse significantly reduces overactive bladder symptoms in elderly women. In our cohort, symptom reduction was unrelated to the type of vaginal surgery (obliterative vs reconstructive) or the inclusion of a procedure to treat stress incontinence. Furthermore, preoperative urodynamic findings did not correlate with the presence or absence of overactive bladder symptoms.

Detrusor overactivity does not predict outcome of sacral neuromodulation test stimulation

The aim of this study is to determine if urodynamic findings in patients with urge incontinence predicts response to sacral neuromodulation test stimulation. One hundred four patients with refractory urinary urge incontinence who had undergone sacral neuromodulation test stimulation were retrospectively reviewed. Pre- and post-test stimulation incontinence parameters and pelvic floor muscle (PFM) contraction strength was documented. Urodynamics were reviewed on all patients, and the presence or absence of detrusor overactivity (DO) was noted. Patients were then divided into two groups: responders to the test stimulation and non-responders. A positive response was considered to be a >or=50% improvement in the number of incontinent episodes per day (IE/day) and/or pad weight with test stimulation. Of the 104 patients evaluated, 64% (N = 67) responded to the test stimulation, while 36% (N = 37) were non-responders. The mean age was 59.7 and 67.0 among responders and non-responders (p = .01). There was a significant difference in the number of IE/day between non-responders and responders (p = .02). There was no relationship found between the presence or absence of DO and the likelihood for test stimulation success, patient demographics or pre test stimulation incontinence variables. Our study provides no statistically significant evidence that the presence or absence of DO on urodynamics predicts a response to sacral neuromodulation test stimulation. An important finding, however, was that patients without demonstrable DO on urodynamics may still have a positive response to sacral neuromodulation.

Is the prevalence of overactive bladder overestimated? A population-based study in Finland

BACKGROUND

In earlier studies, one in six adults had overactive bladder which may impair quality of life. However, earlier studies have either not been population-based or have suffered from methodological limitations. Our aim was to assess the prevalence of overactive bladder symptoms, based on a representative study population and using consistent definitions and exclusions.

METHODOLOGY/PRINCIPAL FINDINGS

The aim of the study was to assess the age-standardized prevalence of overactive bladder defined as urinary urgency, with or without urgency incontinence, usually with urinary frequency and nocturia in the absence of urinary tract infection or other obvious pathology. In 2003-2004, a questionnaire was mailed to 6,000 randomly selected Finns aged 18-79 years who were identified from the Finnish Population Register Centre. Information on voiding symptoms was collected using the validated Danish Prostatic Symptom Score, with additional frequency and nocturia questions. Corrected prevalence was calculated with adjustment for selection bias due to non-response. The questionnaire also elicited co-morbidity and socio-demographic information. Of the 6,000 subjects, 62.4% participated. The prevalence of overactive bladder was 6.5% (95% CI, 5.5% to 7.6%) for men and 9.3% (CI, 7.9% to 10.6%) for women. Exclusion of men with benign prostatic hyperplasia reduced prevalence among men by approximately one percentage point (to 5.6% [CI, 4.5% to 6.6%]). Among subjects with overactive bladder, urgency incontinence, frequency, and nocturia were reported by 11%, 23%, and 56% of men and 27%, 38%, and 40% of women, respectively. However, only 31% of men and 35% of women with frequency, and 31% of subjects of both sexes with nocturia reported overactive bladder.

CONCLUSIONS/SIGNIFICANCE

Our results indicate a prevalence of overactive bladder as low as 8% suggesting that, in previous studies, occurrence has been overestimated due to vague criteria and selected study populations regarding age distribution and low participation.

[Lower urinary tract symptoms in women and impact on quality of life. Results of the application of the King's Health Questionnaire]

BACKGROUND

The self-assessment of quality of life (QoL) of women with urinary symptoms may help in selecting the best treatment in each case.

METHOD

Epidemiologic, observational, cross-sectional and multicentric study of 674 women who underwent to a gynecology unit with symptoms suggesting Overactive Bladder, with or without urinary incontinence (UI). All women fill out the King's Health Questionnaire. Sociodemographic data and a complete register of urinary symptoms and the degree of afectation which caused, were also collected.

RESULTS

Most frequent symptoms were "frequency" (612 women-90.8%), followed by "urgency" (562-83.4%), "nocturia" (543-80.6%) and "stres UI" (535-79.4%). Symptoms of "frecuency", "nocturia", "urgency" and "urgency UI" were more frequent in women aged 65 or under 65 years and that of "stress UI", in women over 65 years (79.8% vs 77.9%). 210 women did not fill out all the KHQ dimensions, mainly "Personal Limitations", "Personal Relationship", "Social limitations" and "Incontinence Impact". Global KHQ score was38.3 (SD=19.2). Higher scores (worse QoL) corresponded to "Incontinence Impact", "Severity Measures", "Personal Limitations" and "Role Limitations". Variables associated to global KHQ score were (multiple linear regression): age, BMI, urgency UI, UI in sexual intercourse, frequent urinary infections.

CONCLUSIONS

QoL impact in women with urinary symptoms is important. The symptoms with higher association with QoL are: UI in sexual intercourse, urgency UI and frequent urinary infections.

Nocturia and obesity: a population-based study in Finland

The authors' aim in this study was to analyze the association of nocturia with overweight and obesity. In 2003-2004, a questionnaire was mailed to 6,000 randomly selected Finns aged 18-79 years who were identified from the Finnish Population Register Centre. Information on nocturia was collected through questionnaires using the Danish Prostatic Symptom Score and the American Urological Association Symptom Index. Self-reported body weight and height were used to calculate body mass index (BMI; weight (kg)/height (m)2). Subjects were classified on the basis of BMI as nonoverweight (BMI<25), overweight (BMI 25-29.9 kgm2), or obese (BMI>or=30). Of the 6,000 subjects, 62.4% participated. Among men, the age-standardized prevalence of nocturia, defined as at least one void per night, was 33.4% (95% confidence interval (CI): 28.5, 38.3) in the nonoverweight, 35.8% (95% CI: 31.4, 40.1) in the overweight, and 48.2% (95% CI: 38.8, 57.6) in the obese. Among women, the corresponding figures were 37.2% (95% CI: 33.0, 41.5) in the nonoverweight, 48.3% (95% CI: 42.5, 54.2) in the overweight, and 53.6% (95% CI: 43.9, 63.2) in the obese. The associations remained similar when nocturia was defined as two or more voids per night. The age-standardized attributable fraction (population) of increased BMI for nocturia was 17.7% for men and 18.5% for women, corresponding to an 8.5% increase in the crude prevalence of nocturia in men and a 13.9% increase in women. The authors conclude that obesity is associated with increased nocturia, more strongly among women than among men.

An evidence-based approach to the evaluation and management of stress incontinence in women

PURPOSE OF REVIEW

The aim of this article is to use evidence-based criteria to review recent publications on the evaluation and management of stress urinary incontinence in women.

RECENT FINDINGS

Longitudinal studies suggest that a familial predisposition towards stress urinary incontinence may exist. There is mounting evidence that cesarean section may play a protective role against pelvic floor damage due to labor, but this continues to be investigated. Objective parameters in the evaluation of stress urinary incontinence, such as questionnaires, pad test, and urodynamic studies, continue to undergo refinements to become more clinically relevant outcome tools. Non-invasive and minimally-invasive therapies for stress urinary incontinence are expanding. The search continues for the optimal non-autologous material in the pubovaginal sling procedure. Despite concerns over the use of synthetic material and better defined early complications, midurethral slings continue to enjoy popularity with short-term and intermediate success.

SUMMARY

Further research into the cause of stress urinary incontinence is necessary. There is still no unified protocol in the evaluation of the condition and its severity. Mid-urethral slings appear to be as efficacious as more established procedures (bladder neck suspensions, pubovaginal slings), but long-term results on safety and efficacy remain scarce.

A randomized crossover trial to examine administration techniques related to the Bristol female lower urinary tract symptom (BFLUTS) questionnaire

AIMS

To investigate whether two methods of assessing lower urinary tract symptoms, interview-assisted standardized questionnaires, and self-completed standardized questionnaires, were comparable.

METHODS

Women referred to a tertiary urogynecology urodynamic clinic with lower urinary tract symptoms were recruited. The psychometrically robust Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaire was used to assess urinary symptoms. A randomized crossover design for questionnaire completion was used: Group A-an initial interview-assisted questionnaire at the urodynamic clinic with a follow-up postal questionnaire; or Group B-an initial pre-out-patient postal questionnaire followed up by a second interview-assisted questionnaire whilst attending a scheduled urodynamic clinic.

RESULTS

A total of 114 women were randomized for initial questionnaire administration method to achieve 72 completed sets (63%). Total scores were higher on self-completion compared to interview, this difference was not significant [t = -1.951, P > 0.05]. No item had perfect agreement between postal and interview methods and generally, interview-assisted questions had lower scores, indicating better health status. The items with the worst agreement (slight or moderate) were those concerned with sexual health, with women giving lower scores, exaggerating health on interview. For example bother of vaginal discomfort (kappa(w) = 0.09), compared to question assessing frequency (kappa(w) = 0.65).

CONCLUSIONS

This data suggests women respond differently to the BFLUTS questionnaire when data is collected by self-completion in the woman's home compared to interviews. No individual question item had perfect agreement between the two methods of administration. Overall, individual question items were scored higher on self-completion than interview.

Application of the Blaivas-Groutz bladder outlet obstruction nomogram in women with urinary incontinence

AIMS

To test the applicability of the Blaivas-Groutz nomogram for female bladder outlet obstruction in urinary incontinent women presenting in a general gynecologic practice and to determine how the nomogram results related to the presence of obstructive symptoms according to a standardized questionnaire.

METHODS

All women with complaints of urinary incontinence underwent multichannel urodynamic testing, free uroflowmetry and were asked to complete a standardized quality of life questionnaire consisting of the urogenital distress inventory (UDI). The patients were classified according to the Blaivas-Groutz nomogram.

RESULTS

One hundred and nine patients were classified according to the nomogram. Thirty-three patients (30.3%) were classified as unobstructed, 63 patients (57.8%) as mildly, 12 patients (11%) as moderately, and 1 patient (0.9%) was classified as severely obstructed. Fifty patients correctly completed the UDI. There was no significant difference (P = 0.61) in the score on the domain UDI obstruction between, according to the nomogram, obstructed and unobstructed patients. Only 18% of the obstructed patients had isolated voiding symptoms suggestive of obstruction. Forty-nine percent of the obstructed patients had urgency-frequency symptoms as well as voiding symptoms suggestive of obstruction. There was no correlation (Pearson, r = -0.06, P = 0.61) between the severity of the symptoms (assessed by the UDI scale) and the degree of obstruction (the four nomogram zones).

CONCLUSIONS

Application of the Blaivas-Groutz nomogram gave an unlikely high prevalence of obstruction in our patient group, which showed no correlation with symptoms when measured with the UDI.