Diagnostic value of nerve growth factor in detrusor overactivity: a study on women with mixed urinary incontinence

OBJECTIVE

Urinary incontinence has a profound impact on women's quality of life. Studies have shown that changes in urinary protein levels could be a potential diagnostic biomarker in some urological diseases. The aim of present study is to determine the diagnostic value of nerve growth factor (NGF) in women with mixed urinary incontinence (MUI) as a diagnostic biomarkers of detrusor overactivity (DO).

METHODS

Seventy women aged between 20 and 75 years with MUI were enrolled in this prospective study. All participants underwent urodynamic study. Urine NGF levels were measured using an ELISA method. NGF level was compared between groups using Mann-Whitney U test. Receiver Operator Characteristic (ROC) analysis was employed to evaluate the diagnostic performance of urinary NGF.

RESULTS

The results showed that the median (min, max) of NGF in patients with DO was significantly higher in comparing to its level in women without DO [184.10 (31, 346.60) pg/ml vs. 151.80 (21, 210.70)], respectively (P = 0.035). Using receiver-operator characteristics analysis, the threshold urinary NGF value of 102.00 pg/ml provided a sensitivity of 88% and specificity of 40% in diagnosing DO, PPV of 39.1%, and NPV of 88.2%, positive likelihood ratio 2.18 and negative likelihood ratio of 0.45 (P = 0.02).

CONCLUSION

Based on high sensitivity and low specificity, we can conclude that NGF can be a good tool for ruling out the OAB when the test is negative. However, the future investigations are needed to expand the observed correlation in larger groups of women with DO.

Inflammatory and tissue remodeling urinary biomarkers before and after mid urethral sling surgery for stress urinary incontinence

PURPOSE

Urinary biomarkers were measured in women at baseline and 1 year after surgery for stress urinary incontinence, and associations with clinicodemographic covariates and outcomes were analyzed.

MATERIALS AND METHODS

Preoperative and postoperative urine specimens from 150 women were assayed for inflammatory biomarkers (tumor necrosis factor-α, interferon-γ, interleukin-1β, interleukin-6, interleukin-10, interleukin-12p70, interleukin-17 and nerve growth factor) and tissue remodeling biomarkers (collagenase activity, matrix metalloproteinases-1, 2, 9 and 13, and NTx [N-telopeptide cross-linked collagen], epidermal growth factor and heparin-binding epidermal growth factor-like growth factor). Paired t-tests were used to compare changes in biomarkers during 1 year (significance p <0.05). Linear regression models correlated baseline and changes in biomarker levels with covariates (significance p ≤ 0.001). Logistic regression models, controlling for age, were used to analyze associations of baseline and changes in biomarker levels with surgical failure (significance p <0.05).

RESULTS

During 1 year interleukin-12p70 decreased (mean ± SD 0.53 ± 1.4 to 0.28 ± 0.62 pg/mg creatinine, p = 0.04) and nerve growth factor increased (0.034 ± 0.046 to 0.044 ± 0.060 pg/ml/mOsm, p = 0.03). Baseline NTx level per mg creatinine was positively associated with age and postmenopausal status (p = 0.001), and negatively associated with current estrogen use (p = 0.0001). Baseline collagenase activity per mg creatinine was positively associated with age (p = 0.001). Epidermal growth factor per mOsm, NTx per mOsm and interferon-γ per mOsm were negatively correlated with age, current estrogen use and UDI (Urogenital Distress Inventory)-irritative subscale score, respectively (p ≤ 0.001). Subjects with lower baseline NTx per mg creatinine were less likely to experience surgical failure (OR 0.49, 95% CI 0.26-0.93, p = 0.03). Changes in biomarker levels were not associated with any covariates or surgical failure.

CONCLUSIONS

Stress urinary incontinence surgery was significantly less likely to fail in women with lower baseline NTx levels. Studies are needed to validate NTx as a possible independent biomarker for stress urinary incontinence surgery outcomes.

Bacteriuria is associated with urge urinary incontinence in older women

OBJECTIVE

To investigate the association between bacteriuria and frequency and type of urinary incontinence in elderly people living in the community. Bacteriuria and urinary incontinence are common conditions and often coexisting in this population; the authors have previously reported the prevalence of bacteriuria to be 22.4% in women and 9.4% in men.

DESIGN

Cross-sectional study.

SETTING

The catchment area of a primary healthcare centre in a Swedish middle-sized town.

SUBJECTS

Residents, except for those in nursing homes, aged 80 and over. Participation rate: 80.3% (431/537).

MAIN OUTCOME MEASURES

Urinary cultures and questionnaire data on urinary incontinence.

RESULTS

In women the OR for having bacteriuria increased with increasing frequency of urinary incontinence; the OR was 2.83 (95% CI 1.35-5.94) for women who were incontinent daily as compared with continent women. Reporting urge urinary incontinence increased the risk of having bacteriuria: 3.36 (95% CI 1.49-7.58) in comparison with continent women while there was no significant association between stress urinary incontinence and bacteriuria. The prevalence of bacteriuria among men was too low to make any meaningful calculations about the association between bacteriuria and frequency and type of incontinence.

CONCLUSION

Bacteriuria is associated with more frequent leakage and predominantly with urge urinary incontinence. The causes of this association and their clinical implications remain unclear. There might be some individuals who would benefit from antibiotic treatment, but further studies are warranted.

Association between valsalva and cough leak point pressures and pelvic organ prolapse quantification in women with stress incontinence

PURPOSE

Women with urodynamically documented stress urinary incontinence (SUI) and urethral hypermobility may have a higher pelvic organ prolapse quantification (POP-Q) stage according to anterior POP-Q measurements. In this study we determined if POP-Q system anterior components representing the urethrovesical junction (anterior wall point Aa/Ba) and/or POP-Q stage has a relationship with leak point pressure testing.

MATERIALS AND METHODS

Of the 1,511 women who underwent video fluoro-urodynamics during 1997 to 2003 at our institution 88 with only evidence of SUI with negative Valsalva leak point pressure and positive cough leak point pressure (CLPP) were selected.

RESULTS

Average patient age was 58.6 years (range 32 to 89). Of the 88 women 82 had complete POP-Q examinations available, which revealed stages 0 to III in 21 (25.61%), 20 (24.39%), 40 (48.78%) and 1 (1.22%), respectively. The association between POP-Q stage/components and positive CLPP showed no significant difference in mean positive CLPP among POP-Q stages (p = 0.178) or components (p = 0.42 to 0.97). The test for linear trend was not significant (p = 0.636) for POP-Q stages/components (p = 0.40 to 0.93). No significant difference in volume at which positive CLPP occurred was observed among POP-Q stages (p = 0.283) or components (p = 0.13 to 0.75). The proportion of patients with leakage at 200 cc did not differ significantly among POP-Q stages (p = 0.119) or components (p = 0.15 to 0.60).

CONCLUSIONS

Analysis of women with urodynamic evidence of SUI with negative Valsalva leak point pressure and positive CLPP did not show any significant association with components of the POP-Q system or with POP-Q stages. Findings support that POP-Q measurements should not be interpreted as indicators of urethral hypermobility when evaluating women with SUI.

Expanded paper towel test: An objective test of urine loss for stress incontinence

AIM

To investigate the repeatability of a short stress test of coughing and jumping (the expanded Paper Towel Test (PTT)) to quantify urine loss in stress incontinent adult women.

MATERIALS AND METHODS

In the laboratory, the reliability of two methods of measuring the size of the wet area, produced by a typical volume of water titrated onto paper towel was investigated and some absorbency properties of the brand of towel used were quantified. Thirty one women performed a provocative coughing and jumping test on consecutive days using a "perineal pad" of paper towel. The repeatability coefficient was calculated.

RESULTS

The provocative test was repeatable to within 2.8 ml of urine loss, but with the exclusion of one anomalous result, the repeatability improved to lie within 1 ml. The coefficient of variation (CV) for the between-method differences (computer scanning and graph paper) was 1.27%. A volume of 1 ml of water produced a wet area of 25.7 cm2. The range of measurable areas corresponded to volumes of 0.005-8 ml. Standardization of method is required because the size of the wet area differed by manufacturer of paper towel (P < 0.01, two products compared) and with time elapsed since titration (P < 0.01).

CONCLUSIONS

The "expanded PTT" is a simple tool for quantification of urine loss (0.005-8 ml) in women to 72 years with stress incontinence. With a suggested modification, it should prove reliable for detection of between-visit differences of 1 ml. The reliability of the test is dependent upon the use of standard protocol and paper towel with known volume-area ratio. To improve clinical diagnosis, it can also be used with any brand of paper towel to confirm the sign of stress incontinence on exertion.

Excretion of collagen derived peptides is increased in women with stress urinary incontinence

AIMS

The objective of this study was to demonstrate that weakened pelvic floor support of the lower genitourinary tract in women with stress urinary incontinence (SUI) is due to increased collagenolysis. When fibrillar collagen is degraded, pyridinium (PYD) crosslinks are released and excreted in the urine. Degradation of collagen also results in peptide fragments of various lengths which are excreted in the urine. Degradation of mature fibrillar collagen and collagen which has not been crosslinked can be assessed independently by measurement of both PYD and collagen-derived peptides in the urine.

METHODS

Twenty-four hour urine collections were obtained from women with SUI (n = 23) and women without urinary incontinence (n = 39). Urinary PYD concentration was assayed by ELISA. The urinary concentration of helical peptide alpha1 (I) 620-633 fragments derived from collagen was assayed by competitive enzyme immunoassay. Values were normalized to creatinine.

RESULTS

The mean urine PYD concentration for women with SUI (110.8 +/- 19.7 nM/mM creatinine) was not significantly different than that for women without SUI (85.2 +/- 13.7 nM/mM creatinine). The mean urine concentration of helical peptide alpha1 (I) 620-633 for women with SUI (0.80 +/- 0.13 microg/mg creatinine) was significantly (P < 0.02) higher than that for women without SUI (0.49 +/- 0.06 microg/mg creatinine).

CONCLUSIONS

These data suggest that collagenolytic activity in women with SUI is elevated compared to continent controls, as measured by urinary helical peptide alpha1 (I) 620-633 excretion. The lack of difference in urinary PYD excretion between the two populations suggests that the increased collagenolytic activity in women with SUI, compared to continent controls, is restricted to uncrosslinked collagen.

Urinary profile of endogenous steroids in postmenopausal women with stress urinary incontinence

OBJECTIVE

To predict the role of estrogen in prevention of and therapy for stress urinary incontinence by comparing the urinary levels of estrogens and androgens and, to indirectly evaluate metabolism of estrogens and androgens by comparing the concentration ratios of precursor metabolites with those in controls (normal subjects).

STUDY DESIGN

Urine samples collected for 24 hours were obtained from postmenopausal women with stress urinary incontinence (n = 20) and from age-matched, postmenopausal, normal female subjects (n = 14). The urinary levels of 20 estrogens and 25 androgens were analyzed by gas chromatography/mass spectrometry.

RESULTS

The urinary levels of androgens were significantly higher in patients with stress urinary incontinence than normal subjects, and the urinary levels of estrogens were somewhat higher in patients than normal subjects. However, there were no significant differences between the groups, nor were there significant differences in the metabolism of estrogens and androgens between two groups.

CONCLUSION

The urinary levels of endogenous steroids were rather higher in patients with stress urinary incontinence than in normal subjects, so it appears that estrogen should not play a significant role in prevention of and therapy for stress urinary incontinence.

Results of a multicenter trial of the CapSure (Re/Stor) Continence shield on women with stress urinary incontinence

OBJECTIVES

To prospectively study the impact of the CapSure (Re/Stor) Continence shield for the treatment of stress urinary incontinence.

METHODS

One hundred women with pure stress urinary incontinence were enrolled in a 6-month study. Objective measures of urine loss included pad weight test (PdWt) and provocative stress test (PST). Subjective measures included incontinence diaries documenting the number of incontinence episodes per day (IEPD), quality of life questionnaires, and satisfaction surveys. Objective and subjective measures were performed prior to enrollment, during use of the CapSure shield, and after discontinuation of the device.

RESULTS

During the 12-week device utilization period, PdWt measurements demonstrated a 96% reduction in urine loss by week 1 and 97% by week 12. Eighty-two percent of subjects were completely dry by week 12. PST demonstrated 100% reduction in urine loss at each visit, with 91% of subjects completely dry by week 12. IEPD also demonstrated a 91% reduction in incontinence episodes by week 12. Quality of life scores and patient satisfaction surveys demonstrated significant improvement. During the 6-week post device utilization period (PUP), subjects continued to demonstrate a reduction in urine loss compared to pre-enrollment data, despite discontinuation of use. PdWt measurements demonstrated a 73% and 79% reduction in urine loss at weeks 14 and 18, respectively. Measurements of PST and IEPD demonstrated significant reductions in urine loss at weeks 14 and 18. A 1.5% prevalence of positive urine cultures was noted during device use. Bothersome vaginal or urethral irritation occurred in 12% of patients. Adverse events were few and required no therapeutic intervention.

CONCLUSIONS

The CapSure shield is a safe and efficacious method of managing stress urinary incontinence in women.

[Uroflowmetry in diagnosis of urinary stress incontinence in women]

The authors' aim was to evaluate the range of uroflowmetry in diagnostics of stress urinary incontinence (sui) in women. The examinations were carried out in 59 women with sui, aged from 35 to 45 years (group I). The control group consisted of 20 asymptomatic women (group II). To evaluate volumes of urine voided during micturition in a unit of time a urological flowmeter UF-1 (produced by COTM, Białystok) was used. Numeric data of flow were analysed, as well as registered curves of flow were ascribed to one of the following flow patterns: normal, multi-peak or interrupted. The conducted studies revealed statistically significant differences in flow values in group I, compared to group II. A more frequent incidence of multi-peak and interrupted flow patterns was found in women with sui, which could be related to a neurogenic component in etiology of the disease.

Urodynamic tests for female geriatric urinary incontinence

Most urodynamic tests currently in use in the evaluation of female urinary incontinence have not been applied to a community-based sample to determine their specificity. In this study of a random sample of noninstitutionalized elderly, 258 self-reported continent and 198 self-reported incontinent women sixty years and older, who participated in a household survey, underwent a clinic evaluation (history, physical examination, and urinalysis); of these 67 continent and 100 incontinent female respondents underwent urodynamic testing. The uroflowmetry, cystometry, and supine static urethral pressure profilometry (UPP) findings did not differ significantly between continent and incontinent subjects (whether based on a self-report or a clinician's diagnosis of urinary continence status). Standing static and dynamic UPP and lateral cystography showed significant differences between self-reported continent and incontinent respondents. The provocative stress test significantly distinguishes continence from incontinence, and stress incontinence from other types. The sensitivity of the provocative stress test was 39.5 percent, whereas its specificity is 98.5 percent. Urodynamic testing including uroflow study, static UPP, and lateral cystography should not be used as a screening test but rather selectively as a confirmatory test, and to determine the therapeutic approach, and to assess the outcome of therapy.

Microbiological look at urodynamic studies

Urine samples were cultured for aerobic, fastidious, and anaerobic bacteria in 88 patients (66 F, 22 M) before and after standard urodynamic investigations. 37 of 42 women with detrusor instability, and 14 of 17 women with stress incontinence, had evidence of bacteriuria with aerobic or fastidious bacteria before investigation, as did 6 of 13 men with bladder outflow obstruction. 8 men (36%) acquired bacteriuria with aerobic bacteria after investigation, compared with 10 women (15%). Recalcitrant, irritative urinary symptoms in women may be caused by an underlying infection, the urodynamic changes being secondary. In men who have urodynamic studies, antibiotic prophylaxis should be considered.

Modified retropubic cystourethropexy

A variation of retropubic suspension of the urethrovesical junction was performed on 26 patients with urinary stress incontinence. Access to the retropubic space was through a low transverse muscle-splitting incision. Surgical technique consisted of securing a helical Prolene suture in the paraurethral fascia at each side of the bladder neck. Each suture was then passed through the abdominal wall fascia, exiting just above the symphysis pubis on either side of the midline, and tied to the opposite suture above the rectus fascia. The desired amount of elevation of the vesical neck was gauged by a Q-tip applicator inserted into the urethra just before the Prolene sutures were tied down. A cystotomy was performed to rule out any inadvertent penetration of the bladder by the nonabsorbable suture material, and the bladder was drained suprapubicly. The small number of cases and short follow-up times do not allow conclusions to be drawn at this time, but results to date have been encouraging.

Reproducibility and reliability of urinary incontinence assessment with a 60 min test

Urinary incontinence was objectively assessed in 50 patients. The urine loss was measured as weight gain of perineal pads worn during a 60 min standardized activity period. The test was initiated by drinking 500 ml (not milk and soda water). The patients were instructed not to void before and during the test. After the test, the voided volume was collected. The test proved handy, reproducible and reliable compared to the subjective day-time incontinence. Prior to the actual test, 15 patients participated in a pilot study having an initial voiding and a test period of 3 1/2 hours. This longer test period was not found practical and the gain in positive diagnosis was minimal compared to the disadvantages with a higher number of unscheduled voidings.

Fluid weight uroflowmetry in women

This study evaluates fluid weight uroflowmetry as a screening technique for urogynecologic conditions. Sixty women with no known pathologic condition volunteered for the evaluation of normal uroflowmetric parameters and curve patterns. Forty were menstruating cyclically, and 20 were postmenopausal. The parameters studied included: (1) total voided volume, (2) flow time, (3) peak flow rate, and (4) time to peak flow rate. In addition, uroflowmetric tracings were classified according to their patterns of configuration into: (1) normal, (2) multiple peak, and (3) interrupted. The parameters studied showed no difference in the two normal groups. A wide range of values was observed. Neither age, parity, weight, height, nor menstrual cycle phase affected the data. Values obtained from patients with idiopathic instability of the detrusor muscle, sensory urgency, and stress urinary incontinence did not show differences or trends. Seventeen percent of the tracings of the normal population group showed either multiple peak or interrupted patterns. Patients with sensory urgency (p less than 0.001) had a higher incidence of multiple peak and interrupted flow rate patterns.