Mixed urinary incontinence��time to uncouple urgency from stress?

Introduction  

“Mixed incontinence” is defined as a combination of stress and urge symptoms. Over time, it has morphed into a single entity, encompassing etiology and treatment. My perspectives are: (a) Stress incontinence (SI) and urge incontinence (UI) are different symptoms with often different anatomical causation and so should be treated separately; (b) It is illogical to group urgency with SI. Urgency may also be associated with frequency, nocturia, abnormal emptying and pelvic pain in patients with no SI (“posterior fornix syndrome”); and (c) There is growing evidence that urgency may be cured by surgical correction of a cystocele and/or apical prolapse in up to 80% of patients who do not have SI. In this anatomical context, sensory urgency, urge incontinence and urodynamic detrusor overactivity may all be hypothesized as different manifestations of a prematurely activated micturition reflex, caused by a lax vagina’s inability to support bladder base stretch receptors. This statement can be tested with a simple clinical test, “simulated operations”, whereby digitally supporting in turn the midurethra, bladder base and posterior vaginal fornix may cause a significant decrease in the urgency felt by the patient.     

Efficacy and safety of onabotulinumtoxinA injection in patients with refractory overactive bladder: First multicentric study in Turkish population

Aims

To investigate the efficacy and safety of intradetrusor onabotulinumtoxinA (onaBoNT‐A) injection in patients with overactive bladder (OAB) refractory to antimuscarinic treatment.

Methods

A total of 80 patients with OAB symptoms were enrolled in this prospective multicenter study and received 100 U intradetrusor onaBoNT‐A injection.The changes from baseline in the frequency of voiding, urge urinary incontinence (UI) and urge episodes, mean and maximum bladder capacities, uroflowmetry, post‐void residual urine volume (PVR), quality of life score, and treatment benefit scale score were assessed. The need for a second injection,and treatment‐related adverse events were also examined postoperatively.

Results

OnaBoNT‐A injection significantly decreased the UI episodes(P = 0.0001), the mean voiding frequency (P = 0.0001), and the urgency episodes (P = 0.0001) in the third month compared to baseline. Similarly, the mean bladder capacity, and maximal bladder capacity were increased (P < 0,05). The quality of life scores improved by 57.1% compared to the pre‐treatment rate (P = 0,0001). No significant change was observed in the PVR or maximum flow rate. Urinary retention developed in 3 (3.75%) patients and urinary infection and transient hematuria were observed in five patients (6.25%) each. The UI episodes, voiding frequency and urgency episodes were significantly lower at the 9th month than at baseline (all P = 0.0001). Overall 67% of the patients continued to experience benefits from the injection. Sixteen patients (20%) required a second injection in the third month. Eight patients were lost to follow‐up at the last visit in the 9th month, and 34 of the remaining 56 patients required a second injection at the 9th month. Cumulatively, 50 (63%) patients needed re‐injections.

Conclusions

Our results demonstrated that the onaBoNT‐A injection produced significant improvement in all OAB symptoms with a low incidence of treatment related adverse events.     

How widespread are the symptoms of an overactive bladder and how are they managed? A population-based prevalence study.

OBJECTIVE: To determine the prevalence of chronic and debilitating symptoms of the overactive bladder, defined here as the presence of chronic frequency, urgency and urge incontinence (either alone or in any combination), and presumed to be caused by involuntary detrusor contractions. Subjects and methods Data were collected using a population-based survey (conducted by telephone or direct interview) of men and women aged >/= 40 years, selected from the general population in France, Germany, Italy, Spain, Sweden and the United Kingdom, using a random stratified approach. The main outcome measures were: prevalence of urinary frequency (> 8 micturitions/24 h), urgency and urge incontinence; the proportion of participants who had sought medical advice for symptoms of an overactive bladder; and current or previous therapy received for these symptoms. RESULTS: In all, 16 776 interviews were conducted in the six European countries. The overall prevalence of overactive bladder symptoms in individuals aged >/= 40 years was 16.6%. Frequency (85%) was the most commonly reported symptom, followed by urgency (54%) and urge incontinence (36%). The prevalence of overactive bladder symptoms increased with advancing age. Overall, 60% of respondents with symptoms had consulted a doctor but only 27% were currently receiving treatment. Conclusion Symptoms of an overactive bladder, of which frequency and urgency are as bothersome as urge incontinence, are highly prevalent in the general population. However, only a few affected individuals currently receive treatment. Taken together, such findings indicate that there is considerable scope for improvement in terms of how physicians diagnose and treat this condition.     

Tolterodine is equally effective in patients with mixed incontinence and those with urge incontinence alone

OBJECTIVE: To examine the efficacy of tolterodine, an antimuscarinic agent with a bladder-selective profile, in patients with mixed incontinence (MI, stress and urge) compared with patients with urge incontinence (UI) alone. PATIENTS AND METHODS: The study included 239 patients with MI (urge predominating) and 755 with urge incontinence alone from a single-blind, multicentre trial of 1380 patients (80% female) with an overactive bladder. Those completing the trial were analysed 'per-protocol'. After a 7-day washout and a 3-day run-in to collect baseline information, patients were treated with tolterodine twice daily for 16 weeks. The two groups were compared for incontinence episodes/24 h, voiding frequency, nocturia episodes and pad usage after 16 weeks of treatment. RESULTS: After 16 weeks the median changes from baseline for all voiding variables were statistically significant for the MI and the UI groups (P < 0.001), with no apparent significant between-group differences. The median percentage reduction in incontinence episodes from baseline was 67% for the MI and 75% for the UI groups (P = 0.39). 'Dry' rates for the MI and UI groups at the end of the study were 39% (66/171) and 44% (243/552), respectively, whilst 24% of patients in each group (MI 40/170; UI 130/551) achieved a voiding pattern of < 8 voids/24 h. 'Cure' rates for nocturia and the reduction in the number of patients not using pads used were also similar between the groups. CONCLUSION: Tolterodine is as effective in reducing leakage and other symptoms of an overactive bladder in patients with MI as it is in patients with UI alone.     

A double-blind randomized dose-response study comparing daily doses of 5, 10 and 15 mg controlled-release oxybutynin: balancing efficacy with severity of dry mouth

OBJECTIVE: To assess the efficacy, incidence of dry mouth and overall satisfaction with initial doses of 5, 10 and 15 mg of a new, once-daily, controlled-release (CR) form of oxybutynin for treating urge urinary incontinence (UUI). PATIENTS AND METHODS: Patients who reported urinary incontinence (UI) (one or more episodes/diary) and voiding frequency (eight or more voids/day) or urgency (one or more episodes/diary) during a 2-week baseline were randomized to once-daily 5, 10 or 15 mg CR oxybutynin for 4 weeks. Daily episodes of UI, voids, urgency, adverse events, dry mouth and satisfaction were recorded in a 3-day diary at baseline and after 4 weeks of treatment. In all, 237 patients were randomized and evaluated. RESULTS: Episodes of UI, voids and urgency were significantly reduced over the study period at all doses. Daily UI episodes were significantly lower with 15 mg/day than 5 and 10 mg/day. Dry mouth symptoms were similar in the 10 and 15 mg/day groups, and higher than in the 5 mg/day group. However, significantly greater overall satisfaction was reported with 15 than 5 mg/day. CONCLUSIONS: There were significant dose-response relationships with CR oxybutynin for both UI episodes and dry mouth. The greatest satisfaction was with 15 mg/day, and the severity of dry mouth was comparable at 10 mg/day, indicating that greater efficacy at the higher dose did not compromise tolerability.     

Efficacy of tolterodine in preventing urge incontinence immediately after prostatectomy

Purpose: Urgency and urge incontinence are frequently observed after prostatectomy. Although symptoms ameliorate within a relatively short time, they usually cause significant stress and anxiety to the patient as far as their duration is concerned. Aim of our study was to determine the efficacy of tolterodine in preventing urgency and urge incontinence after catheter removal in patients that underwent prostatectomy for benign prostate hyperplasia. Patients and methods: Twenty-seven patients with moderate/severe lower urinary tract symptoms due to benign prostatic enlargement, scheduled for prostatectomy, were randomised into two groups, Group A (14 pts) received tolterodine 2 mg b.i.d starting the day of surgery, while group B patients received no such treatment. Tolterodine treatment was discontinued 15 days after catheter removal. All patients completed the International Prostatic Symptom Score (IPSS) and the International Continence Society (ICS-BPH) forms the day before surgery, and three times more, one, fifteen and thirty days after catheter removal. Results: Pre-operative total 1PSS and frequency of urgency/urge incontinence as determined by questions 3 and 4 of the ICS-BPH questionnaire were equally distributed between groups. Tolterodine was well tolerated and no adverse effects were reported. Post-operative IPSS and QoL scores did not differ between groups. However, the frequency of urge incontinence both the first day and fifteen days after catheter removal was significantly lower in the tolterodine group (16.6% vs. 69.2%, p=0.004 and 8.3% vs. 38.4%, p=0.039, respectively). Conclusion: Tolterodine was well tolerated in all patients and had a beneficial effect regarding the postoperative urge incontinence. Trials of a larger scale could determine which patients would benefit more, especially according to the presence of storage lower urinary tract symptoms prior to surgery.     

Relationship between urinary symptoms reported in a postal questionnaire and urodynamic diagnosis

AIMS: To describe the relationship between symptoms reported in a self-completed postal questionnaire and urinary disorders based on urodynamic investigation. METHODS: The study population was selected from women aged 40 years or over living in the community, who responded to a postal questionnaire. Following assessment and appropriate conservative interventions, those with a pre-defined level of severity of symptoms were offered urodynamic investigation. Logistic regression examined the association between urinary symptoms and the urodynamic diagnoses of detrusor overactivity (DO) and urodynamic stress incontinence (USI). RESULTS: Four hundred eighty-eight women completed urodynamic investigation; 29.1% (142/488) were found to have DO, 33.6% (164/488) USI, 20.7% (101/488) mixed incontinence, and 16.6% (81/488) no urodynamic abnormality. Stress incontinence (SI) and urge incontinence (UI) were included in the risk model for USI. SI reported monthly or more was associated with increased risk of USI, and UI reported weekly or more with decreased risk (sensitivity 76.9%; specificity 56.3%; positive predictive value (PPV) 67.8%). For DO, strong or overwhelming urgency, UI monthly or more, and nocturia once a night or more were all significantly associated with an increased risk while reporting of SUI monthly or more reduced the risk (sensitivity 63.1%; specificity 65.1%; PPV 63.1%). CONCLUSIONS: Urinary symptoms reported in a postal questionnaire are able to predict urodynamic diagnoses with moderate accuracy. These models may be useful tools with which to categorize urinary disorders for epidemiological study and, with further development, allocate first line treatment.     

Urgency, urge incontinence and voiding symptoms in men and women aged 70 years and over

OBJECTIVE: To evaluate the prevalence of urgency, urge incontinence and voiding symptoms, and their associations in older men and women. SUBJECTS AND METHODS: A population-based cross-sectional survey was conducted involving 171 men and 227 women aged > or = 70 years. The data were collected by interview, with a response rate of 92.8%. Voiding symptoms were defined as weakened and/or intermittent stream. The prevalence of urgency, urge incontinence and voiding symptoms were calculated for men and women aged 70-79 and > or = 80 years. Logistic regression models were used to examine the association of voiding symptoms with urgency, with or without incontinence, adjusted in the separate models for age and in the combined model also for gender. RESULTS: The prevalence of urge incontinence was higher than urgency alone in both men and women (23.9% vs. 9.8% and 36.4% vs. 8.6%, respectively); 71.9% of the men and 48.3% of the women reported voiding symptoms (P < 0.001). Men and women with voiding symptoms were both significantly more likely to report urgency with or without incontinence than those with no voiding symptoms (odds ratio 3.49, 95% confidence interval 1.42-8.57, and 2.34, 1.31-4.17, respectively). Age had no independent effect in men, and in women the effect was marginal. In the combined model female gender (1.98, 1.25-3.16) increased the risk of urgency with or without incontinence. CONCLUSION: Urgency, urge incontinence and voiding symptoms are common and associated with each other in older men and women; the association is stronger in men. Women are at greater risk of having urgency with or without incontinence. Because the study was cross-sectional a causal relationship cannot be confirmed.     

DETRUSOR INSTABILITY IN MEN: CORRELATION OF LOWER URINARY TRACT SYMPTOMS WITH URODYNAMIC FINDINGS

PURPOSE: We evaluated the correlation of lower urinary tract symptoms suggestive of detrusor instability with urodynamic findings in men. MATERIALS AND METHODS: Enrolled in our prospective study were 160 consecutive neurologically intact men referred for urodynamic evaluation of persistent lower urinary tract symptoms. All patients had storage symptoms suggestive of detrusor instability. Patients were further clinically categorized according to the chief complaint of urge incontinence, frequency and urgency, nocturia or difficult voiding. The clinical and urodynamic diagnosis in all patients as well as specific urodynamic characteristics of those with detrusor instability were analyzed according to the these 4 clinical categories. RESULTS: Mean patient age was 61 +/- 15 years. The chief complaint was urge incontinence in 28 cases (17%), frequency and urgency in 57 (36%), nocturia in 30 (19%) and difficult voiding in 45 (28%). Detrusor instability was diagnosed in 68 cases (43%). A higher incidence of detrusor instability was associated with urge incontinence than with the other clinical categories (75% versus 36%, p <0.01). Of the patients 109 (68%) had bladder outlet obstruction, including 50 (46%) with concomitant detrusor instability. The prevalence of bladder outlet obstruction was similar in all patients regardless of the chief complaint. All other urodynamic diagnoses were also similar in the 4 clinical categories. The mean bladder volume at which involuntary detrusor contractions occurred were lower in patients with urge incontinence and frequency and urgency than in those with nocturia and difficult voiding (277.1 +/- 149.4 and 267.7 +/- 221.7 versus 346.7 +/- 204.6 and 306.2 +/- 192.1 ml., respectively, not statistically significant, p = 0.07). CONCLUSIONS: Detrusor instability and bladder outlet obstruction are common in men with lower urinary tract symptoms. The symptom of urge incontinence strongly correlated with detrusor instability. Other lower urinary tract symptoms did not correlate well with any urodynamic findings. Therefore, we believe that an accurate urodynamic diagnosis may enable focused and more efficient management of lower urinary tract symptoms in men.     

Urgency is the core symptom of female overactive bladder syndrome, as demonstrated by a statistical analysis

PURPOSE: We determined overactive bladder symptoms in combination with other lower urinary tract symptoms and illustrated their relationships using a statistical analysis. Furthermore, we also describe the potential contributory factors and adaptation strategies in patients that are associated with overactive bladder subtypes. MATERIALS AND METHODS: A total of 1,930 women with a mean age +/- SD of 46 +/- 15 years (range 15 to 91) with troubling lower urinary tract symptoms were successfully interviewed with a validated questionnaire at the urology and urogynecology clinics at 14 medical centers in Taiwan. The questionnaire was constructed to evaluate 6 lower urinary tract symptoms and 7 adaptation strategies. A log linear statistical model and multiple logistic regression analysis were used to assess the associations among lower urinary tract symptoms and the potential overactive bladder contributory factors, respectively. RESULTS: No single or isolated symptom presented in patients with overactive bladder. Most patients reported a combination with other lower urinary tract symptoms. These female patients can be categorized into 3 groups, including 1 is associated with dry symptoms (urgency, frequency and nocturia), 1 associated with wet symptoms (urgency, urge incontinence and mixed stress incontinence) and a small group that may have overactive bladder symptoms combined with voiding difficulty symptoms. in contrast to patients with dry overactive bladder (urgency associated with frequency and/or nocturia without urge incontinence), after multiple logistic regression analysis patients with wet overactive bladder (urgency with urge incontinence) had a greater average age and higher body mass index, and made more adaptation efforts (p <0.05). CONCLUSIONS: We used statistical analysis to determine and suggest that urgency is the core symptom of female overactive bladder syndrome and there are 3 distinctive overactive bladder subtypes, which differ in their symptom combinations. Different symptom combinations and patient characteristics affect female adaptation to overactive bladder syndrome.     

Terbutaline (Bricanyl) in the treatment of female urge incontinence

Fifteen women with idiopathic urge incontinence (8 motor and 7 sensory urge incontinence) were treated with a beta 2-adrenoceptor-stimulating agent, terbutaline (Bricanyl) for 3 months. A subjective effect on the symptoms urgency and frequency was found in 14 patients, and 12 patients (80%) became continent. In 6 of 8 cases the detrusor became stable. The drug was generally well tolerated; however, a high incidence of transient side effects were observed. Terbutaline seems to be valuable in the treatment of idiopathic female urge incontinence.     

Higher glycosylated hemoglobin levels increase the risk of overactive bladder syndrome in patients with type 2 diabetes mellitus

Objectives: To assess overactive bladder and its component symptoms among patients with type 2 diabetes mellitus and to explore whether higher glycosylated hemoglobin and other factors increase the risk of overactive bladder symptoms. Methods: A total of 279 diabetes mellitus patients from our outpatient clinic, and 578 age‐ and sex‐matched subjects without diabetes mellitus from public health centers were enrolled from May to September of 2010. The collected data included overactive bladder and its component symptoms measured by using the Overactive Bladder Symptom Score, and collecting demographic and clinical data. Overactive bladder was defined as total Overactive Bladder Symptom Score ≥3 and urgency score ≥2 (once a week or more). Results: Diabetes mellitus patients had a significantly higher proportion of overactive bladder symptoms/urgency compared with the controls (28.0% vs 16.3%, odds ratio 2.03, 95% confidence interval 1.44–2.86), as well as nocturia (48.0% vs 39.1%, odds ratio 1.44, 95% confidence interval 1.08–1.93). There were no significant effects of diabetes mellitus on urge urinary incontinence (14.0% vs 10.9%, odds ratio 1.32, 95% confidence interval 0.86–2.04) and daytime frequency (26.9% vs 32.4%, odds ratio 0.77, 95% confidence interval 0.56–1.05). After adjusting for all variables, high glycosylated hemoglobin levels were significantly associated with overactive bladder/urgency (odds ratio 1.24, 95% confidence interval 1.06–1.45), urge urinary incontinence (odds ratio 1.20, 95% confidence interval 1.00–1.45) and nocturia (odds ratio 1.17, 95% confidence interval 1.01–1.35). Conclusions: Patients with type 2 mellitus present more overactive bladder symptoms/urgency and nocturia than controls. Among diabetic patients, higher glycosylated hemoglobin level represents an independent predictor of overactive bladder /urgency, urge urinary incontinence and nocturia.     

Final diagnosis and therapeutic implications of mixed symptoms of urinary incontinence in women.

The final diagnosis of 244 females who presented with mixed symptoms of stress incontinence (SI) and urge incontinence (UI) was made based on clinical, urodynamic, and cystoscopic findings. The UD studies consisted of cystometrogram, uroflow and urethral pressure profiles in the supine and standing positions. Diagnosis of genuine stress urinary incontinence (GSI) in 72 patients (30%) was based on the presence of positive Marshall test result or maximum urethral closure pressure 40 cm of water or less, in addition to the symptoms of stress incontinence. Diagnosis of reduced bladder storage (RBS) in 36 patients (15%) was based on MCC 300 mL or less, or the findings of bladder instability on cystometrogram in addition to the symptoms of urge incontinence. Ninety-five patients (39%) with the criteria of both GSI and RBS were classified as the mixed group. The diagnosis of interstitial cystitis in 19 patients (8%) was made according to the criteria outlined by Messing. Urethral stenosis was diagnosed in 6 patients (2%) based on a reduced maximal flow rate by at least 2 S.D. and a tight urethra to F16 calibration at cystoscopy. Sixteen patients (7%) with inconclusive diagnosis had symptoms only of SI and UI but no objective findings. The clinical and urodynamic findings in each group and the results of the surgical and medical treatment are compared.     

Clinical and urodynamic features according to subjective symptom severity in female urinary incontinence

AIMS: The aim of this study was to determine the relationship between subjective symptom severity and clinical or urodynamic parameters and to compare these parameters according to subjective symptom severity. METHODS: A total of 268 female patients with grade II (n = 94) and grade III (n = 174) according to the Ingelman-Sundberg scale were included in the study. Mean patient age was 55.9 years (range 28-80). Of 268 patients, 196 women (73.1%) complained of stress urinary incontinence (SUI) and 72 (26.9%) reported additional symptoms of urge urinary incontinence (UUI). Fifty-four (20.1%) women previously had hysterectomies and 12 (4.5%) underwent surgery for UI. RESULTS: Patients with severe incontinence (grade III) are older, have longer duration of symptoms, concomitant urgency or UUI, and low maximal urethral closure pressure and low Valsalva leak point pressure (VLPP). No difference in other characteristics including pad test loss and urethral mobility was observed in the two groups. In the multivariate logistic regression analysis, a longer duration of symptoms was associated with an increased likelihood of severe symptoms (P = 0.025). Patients with mixed incontinence were at five-fold increased risk of severe symptoms compared with those with SUI only (P = 0.011). In the same model, increasing VLPP was associated with a decreased likelihood of severe symptoms (P = 0.037). CONCLUSIONS: Longer symptom duration, mixed incontinence and low VLPP have independent effects on the severity of incontinence. Our findings suggest that incontinent patients with sphincteric impairment or urge component may have and increased probability of severe symptoms.     

Clinical efficacy of oxybutynin on sensory urgency as compared with that on motor urgency.

OBJECTIVE: Anticholinergic drug is widely accepted as an effective medication for frequency, urgency and urge incontinence related to detrusor overactivity (motor urgency). In order to elucidate whether anticholinergic drug is also effective for these symptoms related to bladder hypersensitivity (sensory urgency), clinical efficacy of oxybutynin on sensory urgency was compared with that on motor urgency. METHOD: Twenty-four patients with sensory urgency, and 53 patients with motor urgency were treated with oxybutynin (6 mg/day) for 4 weeks and subjective and objective efficacies were evaluated. Subjective parameters were quantified with urge score (grade 0-3) and daily numbers of voiding and incontinence. Objective efficacies were evaluated with pre-/ postcomparison of cystometric parameters. RESULTS: Excellent or good overall efficacy was obtained in 62.5% (15/24) of the sensory urgency group and 60.4% (32/53) of the motor urgency group. There was no statistical difference between these two groups. Objective cystometric parameters, bladder volume at first sensation and maximum cystometric capacity, statistically improved after the treatment in both groups. CONCLUSION: The results suggest that oxybutynin works as well on sensory urgency as it does on motor urgency.     

Do sensation-related bladder diaries differ between patients with urodynamically confirmed and non-objectivised urinary incontinence?

The aim of the study is to investigate whether sensation-related bladder diary (SR-BD) differs between women with symptoms of urinary incontinence (UI) in whom incontinence is not demonstrated during investigation and women with demonstrated UI. Two hundred and six patients with stress UI, urge UI and mixed UI filled out a SR-BD for 3days. They graded the perception of bladder sensation at each micturition and measured the voided volume. Incontinence episodes and the severity of leakage were recorded. All had cystometrogram. The patients were divided in urodynamically confirmed and non-objectivised UI within each type. More disturbed bladder sensation was present in urodynamically confirmed urge UI and to a lesser extent in mixed UI than in the respective non-confirmed groups. No such difference could be seen in stress UI. Close interpretation of the SR-BD may indicate to a certain extent the presence of detrusor overactivity in urge UI and to a lesser degree in mixed UI.     

Duloxetine compared with placebo for treating women with symptoms of overactive bladder

OBJECTIVE: To evaluate duloxetine (a serotonin-noradrenaline reuptake inhibitor) in women with symptoms of overactive bladder (OAB), as it has been shown to increase the bladder capacity in an animal model. PATIENTS AND METHODS: In all, 306 women (aged 21-84 years) were recruited and randomly assigned to placebo (153) or duloxetine (80-mg/day for 4 weeks increased to 120-mg/day for 8 weeks; 153). Symptoms of OAB were defined as bothersome urinary urgency and/or urge urinary incontinence (UI) for > or =3 months. Participants were also required to have a mean daytime voiding interval (VI) of < or=2 h and urodynamic observations of either detrusor overactivity (DOA) or urgency which limited bladder capacity to <400 mL, both with no stress UI (SUI). The primary efficacy analysis compared the treatment effects on mean change from baseline to endpoint in the mean number of voiding episodes (VE)/24 h. The secondary efficacy analyses compared the treatment effects on the number of UI episodes (IE)/24 h, in the Incontinence Quality of Life questionnaire (I-QOL) score, and on the mean daytime VI. Safety was assessed with vital signs, adverse event reporting, routine laboratory testing, electrocardiogram, and the measurement of postvoid residual urine volumes (PVR). RESULTS: Patients randomized to duloxetine had significant improvements over those randomized to placebo for decreases in VE and IE, for increases in the daytime VI, and for improvements in I-QOL scores at both doses of duloxetine. Urodynamic studies showed no significant increases in maximum cystometric capacity or in the volume threshold for DOA. The most common treatment-emergent adverse events with duloxetine (nausea, 31%; dry mouth, 16%; dizziness, 14%; constipation, 14%; insomnia, 13%; and fatigue, 11%) were the same as those reported by women with SUI and were significantly more common with duloxetine than placebo. Laboratory assessments, vital signs and electrocardiograms were stable relative to baseline, with no relevant differences detected between groups. There was a significant difference in the change in PVR with duloxetine (<5 mL mean increase) but no patient reported hesitancy or retention. CONCLUSION: In this trial, duloxetine was better than placebo for treating women with 'wet' and 'dry' symptoms of OAB associated with DOA or a bladder capacity of <400 mL.     

Factors influencing self-perceived disease severity in women with stress urinary incontinence combined with or without urge incontinence

AIMS: The aim of this study was to assess the impact of patient-perceived disease severity (PPDS) on the quality of life (QoL) of women with urinary incontinence (UI) and to identify factors predicting PPDS. METHODS: A total of 109 women (mean age 54.9; range 31-77) with stress UI combined with or without urge UI were included in the primary analyses. The incontinence quality of life (I-QoL) devised during the course of this study was used to assess the QOL impact of UI. RESULTS: PPDS of women with UI increased as I-QoL scores decreased (P<0.001). When analyzed by patient characteristics and objective test results, PPDS increased only with the number of episodes (P=0.005) and pad test weight increased (P=0.010). By multivariate regression analysis, patients who complained of UI "three to four times a day or more" had 6.4-fold higher risk (P=0.027) of perceiving that their symptoms were more severe than those who complained of a UI "one to two times per week or less." Patients with a pad test weight of >25 g had a 4.7-fold higher risk of perceiving their symptoms were more severe than those with a pad test weight of <15 g. CONCLUSIONS: Our results suggest that the frequency of UI episodes and the volume of urine loss are associated with PPDS. In addition, the I-QoL scores deteriorated significantly as the PPDS of incontinence increased. Thus, PPDS may impact on the QoL of women with stress UI combined with or without urge UI.     

Colposuspension for urinary stress incontinence in postmenopausal patients

Eighty-seven postmenopausal patients had a colposuspension for urinary stress incontinence. A significant postoperative reduction (p<0.001) of symptoms of frequency, nocturia, urgency and urge incontinence was obtained. The cure rate for urinary incontinence was 77%. Twenty patients were found to be wet postoperatively, 8 due to stress incontinence and 12 due to detrusor instability, 9 of whom had detrusor instability preoperatively.No differences were found pre- and postoperatively in the cystometric and uroflowmetric values or in the urethral pressure profile measurements. The pressure transmission ratios were significantly improved postoperatively.During operation and postoperatively, minor complications occurred in this group of patients. In 5 patients blood transfusion was needed. Urinary tract infection was diagnosed in 21 patients, wound infections in 4 patients and enterocele in 5 patients.Colposuspension for urinary stress incontinence in postmenopausal patients is a safe procedure with a reasonable cure rate indicating that a surgical approach should be adopted in such patients.Editorial Comments: This is an extension of the authors' previously published series in SGO [2] now dealing exclusively with postmenopausal patients. Although they state that their overall cure rate was 77%, in fact the cure rate for stress incontinence was 79/87 or 91%. Adding the patients with detrusor instability gives the lower cure rate of 77%. An important contribution of this article is the documentation of a decrease of symptoms of urgency, frequency and urge incontinence subsequent to a modified Burch colposuspension. In addition they document that the pressure-transmission ratios were less than 100% in all of their failed cases. Further studies are needed in the elderly to document success or failure in this group since we will be faced with an ever increasing elderly population in years to come.