Are there differences between women with urge predominant and stress predominant mixed urinary incontinence?

OBJECTIVE: We sought to determine if there are differences in clinical and urodynamic parameters between women with urge predominant and those with stress predominant mixed urinary incontinence (MUI). METHODS: Charts of 99 female patients with complaints of MUI were reviewed. Patients were divided into two groups based on the subjective predominance of either stress incontinence (MSUI) or urge incontinence (MUUI). All patients completed a subjective evaluation including an AUA Symptom Index, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7). Objective non-invasive measures included physical exam, 48-hr voiding diary, and a 24-hr pad test. Videourodynamics studies (VUDS), performed in all patients, were reviewed and the presence and characteristics of detrusor overactivity (DO) and stress incontinence were noted. RESULTS: There were no significant differences between groups with respect to symptom scores. MUUI patients had significantly higher pad usage, and lower maximum and average voided volumes than MSUI patients. They were also more likely to have lower urodynamic bladder capacities and demonstrable DO (70% vs. 26%) on VUDS with contractions occurring at lower bladder volumes and with higher amplitude. MSUI patients were more likely to have demonstrable SUI on physical examination (63% vs. 16%) and on VUDS (100% vs. 61%). CONCLUSIONS: There do appear to be differences in clinical and urodynamic parameters between patients with stress predominant and urge predominant MUI. These may help to determine which component of the mixed incontinence is more problematic.     

An algorithm for the management of urinary stress incontinence

An algorithm for the management of urinary incontinence in the female is presented. The performance of history, physical examination, and simple office bladder testing are reviewed. Patients are categorized into a complex group which require multichannel urodynamic testing or a non-complex group which may proceed to surgical intervention without such testing. Indications for collagen injection and pubo-vaginal sling procedure are discussed.     

Incidence of stress urinary incontinence among women in Turkey

The aim of this study was to determine the incidence of stress urinary incontinence among women at the age of 15 and above who applied to the primary health care centers in Ankara, Turkey. We applied the urinary stress incontinence questionnaire to 2,601 women at the age of 15 or above who consulted to the “mother–child health care and family planning centers” in January 2002. To evaluate the urinary incontinence status with respect to age groups and other risk factors, chi-square test was used. Stress incontinence prevalence was 16.1% in our population. Age was a statistically significant risk factor affecting the incidence of stress incontinence. As the number of gravida increases, the frequency of stress incontinence increases (p<0.05). Presence of a systemic disease was also an important risk factor (p<0.05). Alcohol use and smoking were not found to affect the incidence of urinary stress incontinence (p>0.05). As urinary incontinence greatly influences life quality and social and psychological status of the person, and also creates economic burden, predisposing factors of stress incontinence should be well defined and measures should be taken to encourage women experiencing this problem to visit a doctor and to get an efficient treatment.     

Electrovesicogram in stress urinary incontinence: A preliminary study

Electrovesicograms (EVG) were studied in 20 women with stress urinary incontinence (SUI) and 12 healthy female volunteers with a mean age of 44.8 and 48.2 years, respectively. Recordings were performed by means of three electrodes applied to the skin in the hypogastric area and one reference electrode to the lower limb. In the 12 healthy women pacesetter potentials (PPs) were recorded as regular triphasic waves. Of the 20 SUI patients 16 showed normal EVG, and the remaining 4 exhibited tachyvesica, i.e. increased PP frequency. These 4 patients proved to have combined urge and stress incontinence with detrusor hyperreflexia. It was concluded that SUI patients have normal EVG unless there is an associated pathology.EDITORIAL COMMENT: Genuine stress urinary incontinence (SUI) can be associated with detrusor instability, which results in urgency and urge incontinence. The results of SUI surgery are poor if this is not detected preoperatively. The electrovesicogram may be a useful new study replacing urodynamic studies to detect detrusor instability. However, the present study is too small to come to this conclusion. It is recommended that the study be continued to include a large number of patients, with comparison of results to CMG, before a conclusion can be reached.     

Differences in urinary incontinence between Hispanic and non-Hispanic white women: a population-based study

OBJECTIVE

To compare the prevalence of urinary incontinence (UI) between Hispanic and non‐Hispanic White women in a population‐based study.

SUBJECTS AND METHODS

The prevalence of moderate to severe UI, defined as Sandvik severity score of ≥3, was assessed in relation to ethnicity by stratification, age adjustment and logistic regression models among 250 Hispanic and 491 non‐Hispanic White women in Colorado, USA, who were participants in a breast cancer case‐control study.

RESULTS

Hispanic women reported more stress UI (odds ratio 1.7, P = 0.005) and mixed UI (odds ratio 1.8, P = 0.005) than did non‐Hispanic White women. These higher prevalences were largely associated with ethnic differences in parity, body mass index, diabetes, hysterectomy and bilateral oopherectomy.

CONCLUSIONS

The prevalence of moderate to severe UI in Colorado is higher among Hispanic women than among non‐Hispanic white women. This difference is largely compatible with differences in reproductive history, adiposity and diabetes.     

Overview on the management of adult urinary incontinence

Urinary incontinence is a major health issue that affects more than 300 million people worldwide. Prevalence estimates vary depending on the group investigated and how incontinence is defined. The condition is significant in terms of the distress it causes patients and the costs it incurs on healthcare systems. It is generally classified as either stress, urge or mixed incontinence. Although there is higher prevalence in women, increasing interventions for the prostate for both benign and malignant conditions, has increased the prevalence in men. Detailed assessment is necessary to guide management. Conservative management includes treatment of constipation, the use of containment devices, weight loss, bladder training and pelvic floor muscle training. Medical management frequently consists of the use of antimuscarinics and beta 3 agonists for urgency. Surgical management is considered if previous therapies fail. Prior to undertaking invasive procedures, urodynamic assessment and subsequent multidisciplinary team review is commonly undertaken. Surgical options commonly include colposuspension, slings, bulking agents, and the artificial urinary sphincter for stress incontinence. For urgency incontinence minimally invasive options include botulinum toxin A and neuromodulation, with augmentation cystoplasty or urinary diversion used only rarely for refractory cases. A recommendation by the Independent Medicines and Medical Devices Safety Review has meant that synthetic mid-urethral slings for female stress incontinence are no longer in use in the UK at the present time.     

Prevalence and incidence of urinary incontinence in women: Review of the literature and investigation of methodological issues

Objectives:   Urinary incontinence in women is common and has a significant impact on the physical, psychological and socio-economic aspects of life. The aims of this study were to review the published reports on the prevalence and incidence of urinary incontinence in Australian women and to examine the methodological issues associated with these studies.
Methods:   Electronic searches of Medline, EMBASE and the Current Index to Nursing and Allied Health Literature databases were undertaken using 'Medical Subject Heading' terms and 'free text' words. We retrieved papers that investigated the prevalence and/or incidence of urinary incontinence in Australian women and were published in English after 1980. Methodological data from each study were tabulated.
Results:   Seven studies were identified which examined the prevalence of urinary incontinence and two studies that reported its incidence. The prevalence of urinary incontinence varied between 12.8% and 46.0%. Study heterogeneity was a consequence of response rates, the inclusion of women in institutional care, the method of data collection, the questions used to identify different types of urinary incontinence and the way these questions were reported, the period over which the urinary incontinence had occurred and the severity of the incontinence. Two studies which examined incidence provided evidence that urinary incontinence can be a transient phenomenon.
Conclusions:   Research into the incidence and prevalence of urinary incontinence in Australian women exhibits significant heterogeneity in the findings due to methodological limitations. There is a need for future studies to employ validated instruments and give careful attention to the selection of participants and the reporting of age-specific data.     

Comparison of anchors used in anti-incontinence surgery

Objectives. To compare the resistance to caudally directed force at different fixation points used in female anti-incontinence surgery.Methods. Sutures were placed in Cooper’s ligament, rectus fascia, and in bone anchors on the pubic symphysis in 6 fresh, unembalmed cadavers and transposed vaginally with a ligature carrier. Force was applied in a caudal direction to each suture. Displacement of the suture with increasing force and the force required to overcome the cranial fixation point were measured with a highly precise force gauge. Two measurements were made for each anchor point and the measurements were averaged.Results. With caudally directed force, sutures fixed to Cooper’s ligament were displaced to an equal extent as sutures attached to a bone anchor. Sutures anchored to the rectus fascia were displaced the most with increasing force. The maximal force supported by Cooper’s ligament fixation and bone anchors was similar. The event limiting each test was suture breakage, except when one suture anchored in the rectus fascia tore out.Conclusions. In a cadaver model, bone anchors placed in the pubic symphysis offer no structural advantage over Cooper’s ligament fixation.     

Fecal incontinence: a review of prevalence and obstetric risk factors

Anal incontinence (AI) is a significant problem that causes social and hygienic inconvenience. The true prevalence of AI is difficult to estimate due to inconsistencies in research methods, but larger studies suggest a rate of 2–6% for incontinence to stool. There is a significant association between sonographically detected anal sphincter defects and symptoms of AI. The intrapartum factors most consistently associated with a higher risk of AI include: forceps delivery, third or fourth degree tears, and length of the second stage of labor. Fetal weight of > 4,000 g is also associated with AI. Repair of the sphincter can be performed in either an overlapping or an end-to-end fashion, with similar results for both methods. The role of cesarean delivery for the prevention of AI remains unclear, and further study should be devoted to this question.     

Urinary incontinence symptoms during and after pregnancy in continent and incontinent primiparas

Objective Examine patterns of urinary incontinence during and after pregnancy, as recalled by incontinent and continent primiparas. Study design Primiparous women reporting no pre-pregnancy incontinence, were recruited 6 to 9 months postpartum. Those reporting current continence and demonstrating a negative stress test were considered “Primiparous Continent” (PC, n=64). Those reporting current incontinence and demonstrating a positive stress test were considered “Primiparous Incontinent” (PI, n=57). Subjects self-administered a questionnaire recalling leakage during and after pregnancy. Results Sixteen percent of PC women leaked during pregnancy. Of these, 70% experienced frequent leakage during pregnancy. Seventy-eight percent of PI women leaked both during and after pregnancy. Several patterns arose surrounding leakage frequency for PI women: 19% only leaked frequently during pregnancy, 4% only leaked frequently after pregnancy, and 51% leaked frequently both during and after pregnancy. Conclusion Nearly five times as many primiparous incontinent women, compared with primiparous continent women, leaked during pregnancy.     

The pathophysiology of genuine stress incontinence

Urinary continence in the female is maintained as long as intraurethral pressure exceeds bladder pressure. The elements which maintain this condition at rest and during stress include: internal urethral sphincter, external urethral sphincter, anatomic support of the urethrovesical junction, and intact innervation. Urethral junction and presence of genuine stress incontinence may be best assessed by measurement of resting and stress urethral closure pressure profiles using multichannel urodynamic testing. The findings subsequent to urethral closure pressure profilometry influence the kind of therapy selected, including types of surgery, when this treatment option is chosen.     

Duloxetine compared with placebo for the treatment of women with mixed urinary incontinence

AIMS: Evaluate duloxetine in the treatment of women with mixed urinary incontinence (MUI). MATERIALS AND METHODS: 588 women, 19-85 years old with >or=4 incontinence episodes/week were randomly assigned to duloxetine 80 mg/day (N = 300) or placebo (N = 288). Patients were classified into three symptom subgroups: stress or urge predominant MUI (SPMUI or UPMUI) or balanced MUI (BMUI) based on their responses to the validated Stress/Urge Incontinence Questionnaire. Half the population was randomly assigned to have urodynamics; SPMUI, UPMUI, and BMUI condition diagnoses were based on signs, symptoms, and urodynamic observations. The primary outcome measure was the change in incontinence episode frequency (IEF). Secondary outcome measures included the Incontinence Quality of Life (I-QOL) scores, the ICI Quality of Life (ICIQ-SF) score, and the Patient Global Impression of Improvement (PGI-I) rating. RESULTS: At baseline, women with SPMUI averaged 15.9 IEF/week (61% stress), those with UPMUI averaged 13.2 (70% urge), and those with BMUI averaged 16.5 (52% urge). Overall IEF decreases were significantly greater with duloxetine than placebo (median percent reduction 60% vs. 47%, P < 0.001); both UUI and SUI episodes were significantly decreased with duloxetine (median SUI IEF reduction 59% vs. 43%, P = 0.001; UUI IEF reduction 58% vs. 40%, P < 0.001). Duloxetine IEF decreases were significantly greater for patients with SPMUI conditions and symptoms and for those with UPMUI conditions but not symptoms. Significant benefits were also demonstrated with duloxetine for improvements in I-QOL total score (11.5 points vs. 8.1 points, P = 0.002), all three I-QOL subscale scores, and for the ICIQ-SF score (-2.6 vs. -1.7, P = 0.002) as well as for PGI-I ratings (much/very much better 44.2% vs. 27.3%, P = 0.001). CONCLUSION: Duloxetine demonstrated significant efficacy in this population of women with MUI.     

Urinary incontinence across the lifespan

AIMS: The objectives of the current study were (1) to measure type and severity of urinary leakage and (2) to investigate the association between these factors and age-related life events and conditions in three groups of Australian women with a history of urinary leakage. METHODS: Five hundred participants were randomly selected from women in the young (aged 18-22 in 1996), mid-age (45-50), and older (70-75) cohorts of the Australian Longitudinal Study of Women's Health (ALSWH) who had reported leaking urine in the 1996 baseline survey. Details about leaking urine (frequency, severity, situations) and associated factors (pregnancy, childbirth, body mass index [BMI]) were sought through self-report mailed follow-up surveys in 1999. RESULTS & CONCLUSIONS: Response rates were 50, 83, and 80% in the young, mid-age, and older women, respectively. Most women confirmed that they had leaked urine in the past month, and the majority of these were cases of "mixed" incontinence. Incontinence severity tended to increase with BMI for women of all ages, and increased severity scores were associated with having urine that burns or stings. Additional independent risk factors for increasing incontinence severity were heavy smoking in young women, past or present use of hormone replacement therapy in older women, and BMI and history of hysterectomy in mid-age women.     

Mixed incontinence is more bothersome than pure incontinence subtypes

The purpose of the study was to compare incontinence bother in women with mixed incontinence versus pure incontinence subtypes. This is an institutional review board-approved study comparing physical exam findings and responses to the Medical Epidemiologic and Social Aspects of Aging (MESA) questionnaire and the Urinary Distress Inventory (UDI-6). The MESA responses were used to classify women as mixed, pure stress, or pure urge incontinence. This analysis includes 551 women with a mean age of 56 ± 16 years. Most women were Caucasian (86%) with 7% African American and 5% Hispanic. UDI scores were significantly higher in women with mixed incontinence (61 ± 23) than those with pure stress incontinence (40 ± 26) or pure urge incontinence (40 ± 25; p < 0.0001). Women with mixed incontinence report greater incontinence bother than women with either pure stress or urge incontinence.