The Hordaland Women's Cohort: a prospective cohort study of incontinence, other urinary tract symptoms and related health issues in middle-aged women

Habitus and Pelvic Floor Symptoms and Support 1 Year Postpartum

OBJECTIVE

To estimate the association between habitus measures and pelvic floor support and symptoms in primiparous women 1 year after term vaginal delivery.

METHODS

In this cross-sectional study including women enrolled at seven academic and community sites, we assessed pelvic floor support, weight, height, waist circumference, and percent fat using air displacement plethysmography and participants completed questionnaires, all at one year postpartum. We tested the association of quintiles of habitus measure, including body mass index (BMI), waist circumference, percent body fat, and waist/height ratio, with the primary outcomes: anatomic support, dichotomized as maximal vaginal descent less than 0 cm (better support) compared with 0 cm or more (worse support) per the pelvic organ prolapse quantification examination and symptom burden (positive with bothersome symptoms in two or more of six symptom domains), and on five secondary outcomes. The sample size provides 90% power to detect odds ratios (ORs) of 1.78 or greater between women at mean compared with mean+1 SD of habitus measure.

RESULTS

Of 592 participants, 55 (9.3%) demonstrated worse support and 321 (54.2%) symptom burden. In multivariable analyses, habitus measures were not significantly associated with anatomic support or, except for the highest waist/height ratio quintile, with symptom burden. Compared with women in the first quintile of each habitus measure, those in most higher quintiles demonstrated elevated odds of moderate to severe urinary incontinence (UI); increased odds for stress urinary incontinence (SUI) were mainly limited to the highest quintile. After adjusting for percent body fat, the increased odds for BMI on SUI (OR 2.47, 95% CI 1.43-4.28) were no longer significant (OR 1.38, 95% CI 0.54, 3.51).

CONCLUSION

Habitus in primiparous patients at 1 year postpartum was not associated with anatomic support or symptom burden. Habitus was more associated with moderate to severe UI than mild UI. The association of higher BMI with SUI was attenuated by fitness, reflected by fat percentage.

Clinical epidemiological insights into urinary incontinence

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is very common and heterogeneous among women with limited knowledge of progression or prognosis. Evidence based on clinical epidemiology can help to better understand the natural history of UI.

METHODS

We examine the challenges of UI definition and its subtypes, its impact on quality of life and health-seeking behavior. We review the proposed pathophysiology of UI subtypes and known risk factors as they relate to our current knowledge of the disease state. Finally, we emphasize the role of epidemiology in the process of acquiring new insight, improving knowledge, and translating this information into clinical practice.

RESULTS

Stress UI is most common overall, but mixed UI is most prevalent in older women. The three UI subtypes have some common risk factors, and others that are unique, but there remains a significant gap in our understanding of how they develop. Although the pathophysiology of stress UI is somewhat understood, urgency UI remains mostly idiopathic, whereas mixed UI is the least studied and most complex subtype. Moreover, there exists limited information on the progression of symptoms over time, and disproportionate UI health-seeking behavior. We identify areas of exploration (e.g., epigenetics, urinary microbiome), and offer new insights into a better understanding of the relationship among the UI subtypes and to develop an integrated construct of UI natural history.

CONCLUSION

Future epidemiological strategies using longitudinal study designs could play a pivotal role in better elucidating the controversies in UI natural history and the pathophysiology of its subtypes leading to improved clinical care.

Use and discontinued use of menopausal hormone therapy by healthy women in Norway: the Hordaland Women's Cohort study

OBJECTIVE

This work aims to study the use of hormone therapy (HT) in a representative cohort of Norwegian women during the menopausal transition, to identify predictors of HT use, and to describe the reappearance of symptoms in former HT users.

METHODS

In 1997, 2,229 women in Hordaland County, aged 40 to 44 years, were selected randomly from a national health survey and followed up with seven postal questionnaires in 1999-2010. Data from 2,002 women (90%) were eligible for analysis. Summary statistics and multiple logistic regression analysis were used. We studied the reappearance of symptoms after HT discontinuation using a subcohort based on their propensity scores for HT use.

RESULTS

The 2-year incidence of new HT users dropped from 8.2% (95% CI, 7.0-9.5) in 2002 to 4.3% (95% CI, 3.4-5.2) in 2004 and remained stable despite an increasing prevalence of symptoms in the cohort. Self-rated health was stable during the period. The mean duration of HT use was 4.5 years (95% CI, 4.0-5.0). The odds of HT use were higher among women with daily hot flushes than among those who never or rarely experienced them (odds ratio, 3.2; 95% CI, 2.3-4.4). After HT cessation, hot flushes returned and corresponded to those in untreated controls.

CONCLUSIONS

The 2-year incidence of HT users decreased almost 50% after 2002. Increasing symptoms and decreasing incidence of HT use did not influence self-rated health. Hot flushes were the strongest predictor of HT use. Symptoms reappeared in most women after HT cessation.

Urinary incontinence incidence: quantitative meta-analysis of factors that explain variation

PURPOSE

We sought to explain variation in female age specific incidence rates for urinary incontinence using published, population based studies.

MATERIALS AND METHODS

We performed an extensive MEDLINE® review of published, population based studies of the female urinary incontinence incidence rate from 1966 to 2011 using a combination of symptom and epidemiological search terms. A total of 18 reports described 17 unique incidence studies. We abstracted the features of each study (eg sample size, followup, etc) along with detailed data on 109 age specific incidence rates (ie new cases per 1,000 person-years). Because the Nurses' Health Study had unique demographics and was dominant in sample size, analyses were completed with and without this study. Weighted (ie square root of sample size) linear regression was used to determine factors (ie age, source population, race, frequency score, etc) explaining variance among age specific incidence rates.

RESULTS

Age and case definition accounted for 60% of the variation in incidence rates among studies. The age specific incidence was less than 2/1,000 person-years before age 40 years and it increased thereafter. For a given age group incidence rates varied as much as sixfold across studies, a finding that was largely explained by variation in case definition.

CONCLUSIONS

The case definition accounts for substantial variation in urinary incontinence incidence estimates. Developing standards for reporting would provide a foundation for policy guidance and understanding etiology. We recommend that quantitative frequency criteria (eg 2 times or more per month) be reported vs vague thresholds (eg sometimes or often).

Prevalence, incidence and remission of urinary incontinence in women: longitudinal data from the Norwegian HUNT study (EPINCONT)

Background

To determine incidence and remission of UI as well as changes in UI prevalence in the Norwegian EPINCONT surveys.

Methods

The EPINCONT surveys were conducted in the county of Nord-Trøndelag, Norway, as part of two large cross-sectional health surveys (HUNT2 and HUNT3) in 1995 – 1997 (EPINCONT1 (E1)), and 2006 – 2008 (EPINCONT2 (E2)). EPINCONT collected information about prevalence of UI, as well as information about type and severity of UI.

Results

A 16% relative increase in UI prevalence was found in 11 years. The women who answered E2 were significantly older, had a higher BMI and higher prevalence of diseases such as asthma, diabetes and angina compared with the women who answered E1.

The incidence of UI was 18.7%. Increase in BMI (OR 1.03, 95% CI: 1.02 – 1.04), weight increase (OR 1.29 (95% CI: 1.14 – 1.45) for gaining 3 – 10 kilos and OR 1.71 (95% CI: 1.47 – 1.99) for gaining 10 kilos or more) and parity (OR 1.37 (95% CI: 1.04 – 1.79) for 1 childbirth, OR 1.28 (95% CI: 1.03 – 1.61) for 2 childbirths, and OR 1.56 (95% CI: 1.26 – 1.95) for 3 or more childbirths when participating in E2) were all found to be associated with increased odds of incident UI in adjusted regression analyses. Increasing age reduced the odds of incident UI. The 11 year remission of UI was 34.1%. Increasing age (OR 0.98, 95% CI: 0.98 – 0.99), increasing BMI (OR 0.96, 95% CI: 0.95 – 0.98) and large weight gains of 10 kilos or more (OR 0.69, 95% CI: 0.54 – 0.88) were all associated with reduced remission of UI.

Conclusion

Crude UI prevalence increased between the studies. Changes in known risk factors for UI such as age, BMI, weight and parity could explain some of the relative increase in prevalence, and were also found to be associated with either incidence of UI, remission of UI or both.

The Hordaland Women's Cohort: prevalence, incidence, and remission of urinary incontinence in middle-aged women

INTRODUCTION AND HYPOTHESIS

The aim of study is to prospectively investigate the prevalence, incidence, and remission of urinary incontinence (UI) in a cohort of middle-aged women.

METHODS

In 1997-1999, 2,229 randomly selected women aged 41-45 agreed to participate in the Hordaland Women's Cohort, and six almost identical postal questionnaires were sent them during the following 10 years. Response rate was 95.7% at inclusion and has remained 87% to 93% in subsequent waves; 64.1% answered all six questionnaires. UI variables include type, amount, frequency, and severity.

RESULTS

Prevalence of UI increased by age until a peak in age group 51-52 years for any (50.3%) and significant (10.0%) UI. There was then a decrease in prevalence caused by a decrease in incidence and decrease in remission. Stress UI was the major type and most UI was of low severity.

CONCLUSION

Prevalence of any UI is high in middle-aged women but reaches a peak followed by a decrease.

Bladder neck evaluation by perineal ultrasound before and after reconstructive surgery for pelvic organ prolapse

PURPOSE

To study the correlation between stress urinary incontinence (SUI) and the mobility and funneling of the bladder neck (BN) by observation of pre- and postoperative course by perineal ultrasound (PUS).

METHODS

We investigated 123 cases that underwent reconstructive surgery for pelvic organ prolapse (POP). We prospectively checked bladder neck mobility (BNM) during the Valsalva maneuver and funneling of the BN at rest by PUS. We defined the width multiplied by the depth of the funnel-like profile of the BN as the funneling index (FI). We checked BNM, FI, and the presence of SUI just before the operation, and we checked the postoperative course of BNM and SUI.

RESULTS

When BNM was ≥10 mm before surgery, the odds ratio for accompanying SUI was 2.68 relative to BNM <10 mm (p = 0.031). When FI was ≥150 before surgery, the odds ratio for accompanying SUI was 4.12 relative to FI <150 (p = 0.004). Although postoperative BNM values were significantly improved immediately after surgery, they gradually increased within 2 years. Among the cases with preoperative SUI, the recurrence rate was significantly higher in the patients whose FI was <150 (p = 0.019).

CONCLUSIONS

Our results yielded by PUS suggested that larger BNM and FI values were the causative factors of SUI. PUS may be beneficial for selecting a suitable surgical procedure for POP, and it may also be helpful for assessing surgical efficacy.