Is urethral pressure profilometry a useful diagnostic test for stress urinary incontinence?

Urethral pressure profilometry is commonly used as a diagnostic test for stress urinary incontinence. The objective of this article is to review the published literature on urethral pressure profilometry to summarize its usefulness. MEDLINE was used to search the published English literature from 1966 to October 2000 for full-length original research articles on urethral pressure profilometry and stress urinary incontinence in women. Terms related to urethral pressure profilometry are defined consistently but techniques are not standardized, introducing variation in test results. Reproducibility of urethral pressure profilometry parameters is poor, both because of biological variation and variation within the test procedure itself (related in part to lack of standardization). Parameters of urethral pressure profilometry do not distinguish between continent and incontinent women and do not characterize the severity of incontinence or urethral incompetence. It is, therefore, concluded that urethral pressure profilometry is not a useful diagnostic test for stress urinary incontinence in women. Its use in clinical management is not supported by current evidence.     

Is urinary incontinence a barrier to exercise in women?

OBJECTIVE: To describe the prevalence of urinary incontinence during exercise in women, estimate whether exercise intensity is related to leakage severity, and report women's assessments of incontinence as a barrier to exercise. METHODS: Questionnaires were mailed to 5,130 women aged 18-60 years drawn from National Family Opinion research panels. Physical activity levels were assessed by the International Physical Activity Questionnaire. Urinary incontinence, defined as involuntary leakage in the last 30 days, was assessed with the Sandvik Severity Index and a global measure of bother. Prevalence estimates were adjusted via post-stratification weighting. RESULTS: A total of 3,364 eligible women responded (68%), of whom 34.6% were insufficiently active (95% confidence interval [CI] 32.7-36.5%), 29.7% were sufficiently active (95% CI 27.9-31.5%), and 35.7% were highly active (95% CI 33.8-37.6%). Urinary incontinence prevalence was 34.3% (95% CI 32.5-36.1%). One in seven women experienced urinary leakage during physical activity; this was more common among highly active (15.9%) than less active women (11.8%) (P = .01). After adjusting for age, comorbidities, education, and race, women with very severe incontinence were 2.64 times (95% CI 1.25-5.55) more likely to be insufficiently active than continent women. Incontinence was a moderate or substantial barrier to exercise for 9.8% (95% CI 8.8-10.9%) of women. Of incontinent women, the proportion for whom incontinence was a moderate or substantial barrier to exercise increased with each severity category: 9.2%, slight; 37.8%, moderate; 64.6%, severe; and 85.3%, very severe (P < .01). CONCLUSION: Urinary incontinence is perceived as a barrier to exercise, particularly by women with more severe leakage.     

What is the success of drug treatment in urge urinary incontinence? What should be measured?

Purpose

The aim of this study is to evaluate the efficacy and the tolerability of three classic antimuscarinic drugs used in the treatment of over active bladder syndrome using clinical data and quality of life tests, and to evaluate the parameters affecting the success of these drugs.

Methods

A total of 90 patients with urge urinary incontinence were randomly allocated into three groups either to receive tolterodine (group A), trospium chloride (group B) or oxybutynin (group C). Urogenital distress inventory short form (UDI-6) and Incontinence impact questionnaire short form (IIQ-7) of the Turkish Urogynecology and Pelvic Reconstructive Surgery Association were performed to each patient before and after treatment to evaluate the effectiveness and tolerability of the antimuscarinic drugs. Adverse events were also recorded during treatment.

Results

Improved urodynamic test values were recorded after 6 weeks of treatment in each group. Similarly, statistically significant differences were observed in UDI-6 and IIQ-7 test scores before and after treatment. Complete cure was achieved in 86 % of patients in group A; however, complete cure rates were 67 and 80 % in group B and C, respectively. Although, patients reported comparable tolerability against trospium chloride (77 %) and tolterodine (80 %), only 23 % of patients using oxybutynin considered the drug as tolerable. The most common side effect was dry mouth, followed by insomnia. Both dry mouth and insomnia was highest in group C (50 %). One patient (0.3 %) in group B and two patients (0.7 %) in group C reported that they did not want to continue to use the drug.

Conclusion

Antimuscarinic medications are very successful in the treatment of urge urinary incontinence; however, the success of treatment is not only limited to clinical improvement. Patients do not regard a drug as successful unless it is tolerable, easy to adapt to the daily life and improve the quality of life even it has very successful clinical outcomes.     

Tension-free vaginal tape procedure: an effective minimally invasive operation for the treatment of recurrent stress urinary incontinence?

The aim of this study was to evaluate the results of tension-free vaginal tape (TVT) surgery in women with recurrent stress urinary incontinence (SUI). Fifty-one women with recurrent SUI were treated with TVT and followed prospectively for a minimum of 2 years according to a protocol. Twenty percent of the women had already undergone two previous continence procedures, whereas 80% had undergone only one. The mean follow-up period was 25.3 months. The objective cure rate was 89.6%, and the subjective cure rate 80.4%. No serious complications occurred. The majority of the patients were discharged in the afternoon of the operation day. No significant difference was observed between pre- and postoperative residual urine, maximal urethral closure pressure, and total and maximum voided urine volume values. However, the changes in urinary frequency, minimum voided volume, pad test results, and visual analog scale scores were highly significant. TVT appears to be a safe and suitable treatment for recurrent SUI.     

Pelvic floor muscle training in the prevention and treatment of urinary incontinence in women - what is the evidence?

Many women suffer from urinary incontinence (UI). During and after pregnancy, women are advised to perform pelvic floor muscle training (PFMT) to prevent the development of UI. In established UI, PFMT is prescribed routinely as first-line treatment. Published studies are small, underpowered and of uneven methodological quality. Variations in study populations, intervention types and outcome measures make comparisons difficult. While further studies are needed, the available evidence suggests a lack of long-term efficacy of peripartum PFMT. In established UI, there seems to be a modest immediate response to PFMT. Based on the available evidence, we believe that a critical reappraisal of PFMT is needed, and judgments on the place of PFMT in current clinical practice should be reserved until further evidence, including cost-benefit analyses, has unequivocally demonstrated a clinically relevant efficacy.     

The suburethral sling for female stress urinary incontinence: a retropubic or obturator approach?

STUDY OBJECTIVE: To evaluate the feasibility and safety of the obturator approach for placement of a vaginal suburethral sling indicated for women with stress urinary incontinence. DESIGN: Retrospective cohort analysis (Canadian Task Force classification IV). SETTING: University teaching hospital. PATIENTS: Forty-nine women suffering from stress incontinence. INTERVENTION: Analysis of the suburethral sling according to surgical approach during two consecutive periods: retropubic from January 1, 2001 through September 30, 2001, and obturator from October 1, 2001 through January 31, 2002. MEASUREMENTS AND MAIN RESULTS: During the study period, 25 patients underwent surgery with the retropubic approach and 24 with the obturator approach. The patient characteristics did not differ between the two groups. The obturator approach was feasible in all attempted procedures. The mean operative time was 46 minutes (range 20-90) for the retropubic approach compared with 32 minutes (range 15-50) for the obturator approach (p = .03). Two bladder injuries occurred with the former, none with the latter (although cystoscopy was not routinely performed) (p = .49). Similarly, significantly more patients in the retropubic approach group had difficulty with postoperative voiding compared with those in the obturator approach group (10 [40%] vs 2 [8%], p = .01). Only two patients, both in the retropubic group, had voiding difficulties for longer than 1 week. One month after surgery, continence results did not differ significantly between the two groups (p = .30). In the retropubic approach group, 20 (80%) of the women were cured, and substantial improvement was experienced by 5 (20%). In the obturator approach group, these figures were 20 (83%) and 3 (12.5%), respectively, with one surgical failure (4%). Those initial results were unchanged at last follow-up (mean follow-up was 13.7 +/- 3 months for the retropubic approach group and 7.2 +/- 2 months for the obturator approach group). CONCLUSION: The obturator approach for suburethral slings is feasible and safe and may limit both preoperative and postoperative complications. Our short-term continence results compare well with those achieved with the retropubic approach. A randomized study is now needed to compare these two approaches.     

Does electrical stimulation of the pelvic floor make any change in urodynamic parameters? When to expect a cure and improvement in women with stress urinary incontinence?

OBJECTIVE: Our study aimed at determining the effects of pelvic floor electrical stimulation assessed by the number of leakages per day recorded in a voiding diary over 90 days of treatment and urodynamic parameters. STUDY DESIGN: This prospective study was carried out with 34 patients presenting stress urinary incontinence who were treated and evaluated by voiding diaries and urodynamic tests. The primary outcome measure was the number of leakages during the 90 days of treatment. Urodynamic tests were performed before and after treatment. RESULTS: In our series, average and maximum flow rates and residual urine volume were within normal range in all subjects before and after treatment. Maximum urethral closure pressure and functional profile length on urethral pressure profiles did not change after treatment. In the cystometry, bladder capacities at the first (p < 0.0082) and maximum sensations (p < 0.01) improved significantly after treatment. During the 90 days of treatment, we observed a gradual drop in the number of leakages. This decrease began around day 22. It dropped in half around day 45, tending to zero close to day 90 of treatment (p < 0.01). CONCLUSIONS: The number of incontinent leakage dropped to half around the 8th week, and on average, there was a tendency of the patients to be cured after the 12th week of treatment. At urodynamic studies we observed a significant increase in bladder capacity at the first desire to void and in the maximum cystometric capacity.     

Transobturator vaginal tape for the treatment of stress urinary incontinence in elderly women without concomitant pelvic organ prolapse: is it effective and safe?

Objective

To evaluate the efficacy and safety of the transobturator approach (TVT-O) for the surgical management of stress urinary incontinence (SUI) in older women.

Study design

Between 2007 and 2010, all consecutive women with SUI undergoing an isolated TVT-O procedure were prospectively enrolled in this study. Patients were divided into two groups by age: older women (≥70 years old) were included in group 1, while younger women (<70 years old) in group 2. Intra- and post-operative outcomes were compared between the groups.

Results

During the study period 181 women met the inclusion criteria and were included for final analysis. Among these women, 60 (33.1%) and 121 (66.9%) were included in groups 1 and 2 respectively. After a median follow-up of 26 (IQR 15–41) months for the younger and 25 (IQR 18–40) months for older patients (p > 0.99), no differences were observed between the two groups in terms of cure rate (92.5% vs. 88.3%; p = 0.40). No differences were observed in terms of voiding dysfunction, vaginal erosion and persistent groin pain, or in terms of onset of de novo overactive bladder (9.0% vs. 13.3%; p = 0.44).

Conclusions

TVT-O appears to be a safe and effective procedure for the management of stress urinary incontinence also in elderly population.     

Optimal primary minimally invasive treatment for patients with stress urinary incontinence and symptomatic pelvic organ prolapse: Tension free slings with colporrhaphy,or Prolift with the tension free midurethral sling?

Objective

Comparison of procedures in patients with concomitant stress urinary incontinence (SUI) and pelvic organ prolapse (POP) was performed. Tension free vaginal tape (TVT) or transobturator tape (TOT) with colporrhaphy was compared with fixed mesh (Prolift™) applied with a tension free suburethral sling.

Study design

A total of 76 women with both SUI and POP were evaluated. TVT or TOT with colporrhaphy was performed in 39 patients and Prolift™ with the midurethral sling in 37 patients. Anatomy, symptoms and quality of life (QOL) were evaluated prior to, and at 1, 6 and 12 months after surgery.

Results

Continence was achieved in both groups equally (p = 0.57). The better anatomic outcome regarding the correction of POP was in the Prolift™ group but with a higher rate of additional procedures and complications. QOL was better in patients with grade III–IV POP corrected with Prolift™ (p = 0.05) and equal in both groups with grade I–II POP during the follow-up. Impairment of sexual life was present in both groups before surgery. After surgery, there was no improvement in sexual life regardless of correction of both anatomy and incontinence.

Conclusion

Both procedures are effective and safe. TVT or TOT performed with colporrhaphy looks a better primary choice for grade II POP and SUI. Results for grade III–IV POP and SUI are better with the Prolift™ with the sling. Sexual life could not be improved effectively with these types of surgery.     

Urethral device in women with chronic urinary retention: an alternative to self-catheterization?

OBJECTIVE: To assess the efficacy and safety of a new urethral prosthesis in the management of chronic urinary retention in women as an alternative to intermittent or indwelling catheterization. METHODS: Between May 1999 and July 2000, 60 women with chronic urinary retention were prospectively enrolled in the study. The prosthesis was inserted under local anaesthesia. A magnetic control unit activates the urethral device to achieve micturition. Duration of the experience, complications and compliance were evaluated. RESULTS: Thirty patients were satisfied with the device. Discontinuation occurred in the first two weeks following implantation in 50% of cases. Bladder migration of the prosthesis occurred in two cases, urinary leakage around the device in four patients, spontaneous expulsion in two women and cystitis was diagnosed in two cases. CONCLUSION: This intraurethral prosthesis is an attractive, simple technique for use as an alternative to catheterization. Some untoward events and technical complications explained the number of discontinuations.     

Tubo-ovarian abscess in older women: is the woman's age a risk factor for failed response to conservative treatment?

OBJECTIVE: To assess retrospectively if there is a trend of change in the epidemiology of tubo-ovarian abscess (TOA) and to define the epidemiologic, clinical and laboratory risk factors associated with failed response to conservative antibiotic therapy. STUDY DESIGN: The charts of 60 patients, admitted with clinically and sonographically diagnosed TOA between January 1995 and December 2000, were reviewed. On admission, all patients were treated with broad-spectrum antibiotics, and were divided into two groups according to the response to medical treatment. Forty-three patients, responding to antibiotic therapy, constituted group A, whereas 17 patients who did not respond and were further treated by sonographically guided drainage or surgery, were included in group B. The groups were compared with respect to patient characteristics, clinical and sonographic presentation, laboratory findings, duration of hospital stay and recovery rate of different pathogens from the endocervix. RESULTS: The mean age of patients responding to medical therapy (group A) was significantly lower (39.6 +/- 8.3) than the age of patients who did not respond (group B) (45.3 +/- 6.6) (p = 0.02). The gravidity as well as the percentage of menopausal women were significantly increased in group B (p = 0.03 and p = 0.02, respectively). There was a significantly lower incidence of previous pelvic surgery and past history of PID in group B versus group A (p = 0.02 and p = 0.03, respectively), yet the duration of IUD use was significantly prolonged in group B (p = 0.02). The size of TOA, evaluated clinically and sonographically, was significantly increased in group B compared with group A (p = 0.04 and p = 0.009, respectively). Pelvic peritonitis was observed in 40% of group B patients and in none of group A patients (p = 0.0001). The only laboratory finding differentiating between the two groups was the mean sedimentation rate, being significantly higher in group B than in group A (p = 0.0005). The time interval from admission to afebrile condition as well as the duration of hospitalization were significantly shorter in group A (6.1 +/- 2.3 days) than in group B (10.7 +/- 4.7 days) (p = 0.00003). The incidence of positive culture from the endocervix was significantly higher in group B than in group A (p = 0.007). One hundred percent of patients in group B versus 65.2% of patients in group A were treated with triple agent therapy (p = 0.007). CONCLUSION: The results of the current study strengthen our previous assumption that there is probably a new trend in the epidemiology of TOA, occurring in older women, who do not present the traditional risk factors for pelvic inflammatory disease and TOA.     

Increment in β-hCG in the 48-h period prior to treatment: a new variable predictive of therapeutic success in the treatment of ectopic pregnancy with methotrexate

Objectives To evaluate the efficacy of oral progestogen, chlormadinone acetate, and intramuscular (IM) progesterone for luteal support in patients, undergoing assisted reproductive technology (ART) treatment, who were treated with a gonadotropin-releasing hormone agonist (GnRHa). Methods This was a prospective randomized study of 40 patients with normal and high response (serum estradiol > 2,000 pg/ml) in GnRHa down-regulation. Patients were randomized to receive either oral chlormadinone acetate or IM progesterone. The outcomes of ART treatment, including pregnancy and embryo implantation rates, were analyzed. Results There were no significant differences in the clinical pregnancy rates (25 vs. 20%) and in the implantation rates (12.7 vs. 9.1%) of patients who received IM progesterone and oral chlormadinone acetate. Endometrial thickness was also comparable between oral chlormadinone acetate and IM progesterone. Conclusion Oral progestogen, chlormadinone acetate showed a comparable pregnancy rate and live birth rate with IM progesterone as luteal support for the high responders. The optimal methods for luteal support may be dependent on responses to stimulation with gonadotropin, although it is not concluded that oral chlormadinone acetate is recommended as an option for luteal support in high responders.     

Pelvic radiotherapy in patients with hydronephrosis in stage IIIB cancer of the cervix: renal effects and the optimal timing for urinary diversion?

BACKGROUND AND PURPOSE: Many patients with Stage IIIB cervix cancer (Ca) and hydronephrosis will require ureteral stenting. The timing is important as delays or prolonged overall treatment times adversely affect outcome. Our aim was to measure the effect of pelvic radiotherapy (R/T) on renal function and identify a subset of patients at high risk of acute urinary obstruction during R/T. PATIENTS AND METHODS: From 1/1/2000 to 1/1/2002, all patients with Stage IIIB cervix Ca and hydronephrosis were analysed retrospectively. To quantify the impact of pelvic R/T, all eligible patients from 1/7/2002-1/7/2004 had prospectively recorded baseline biochemistry, creatinine clearance and renal ultrasounds; these were repeated weekly to detect any change in renal function or degree of hydronephrosis. RESULTS: 13 eligible patients were analysed retrospectively, 5 with unilateral hydronephrosis with 40% requiring urinary diversion (UD). 8 had bilateral hydronephrosis, with 75% requiring UD; 50% before R/T and 35% during R/T. Average creatinine clearance (CrCl) was 74 mL/min (1.24 mL/s) in unilateral hydronephrosis , bilateral = 52 mL/min (0.87 mL/s), in those stented during R/T it was < 40 mL/min (0.67 mL/s). The resulting break in R/T was 6 and 19 days. In the prospective study, 5 patients were eligible and 4 consented. 75% had unilateral hydronephrosis and did not require UD with an average CrCl = 71 mL/min (1.19 mL/s). 1 patient with bilateral hydronephrosis had a CrCl of < 20 mL/min (0.33 mL/s) with bilateral stents placed before R/T. CONCLUSIONS: Patients with bilateral hydronephrosis and a low CrCl < 50 mL/min (0.84 mL/s) should be considered for elective UD prior to R/T. Pelvic R/T did not induce any deterioration in renal function or degree of hydronephrosis.     

Is diminished pubocervical fascia collagen content a risk factor for failure of surgical management of genuine stress urinary incontinence in women?

OBJECTIVE: The assessment of relationship between pubocervical collagen content and clinical results of surgical treatment of genuine stress urinary incontinence (GSUI) in women. METHODS: Twenty-four women treated for genuine stress urinary incontinence were included into the study. All women underwent the same surgical procedure. The samples of pubocervical fascia were taken at the time of surgery. The contents of acid soluble, pepsin soluble, insoluble fraction of collagen, total collagen and collagen crosslinks were measured. The study of pubocervical fascia collagen metabolism included also estimation of collagenase activity. At follow-up done 5 years following surgery, 20 patients reported symptoms of GSUI (study group). Four women were still without symptoms of urine leakage (control group). RESULTS: The biochemical parameters of pubocervical fascia did not show, statistically significant differences between compared groups. CONCLUSION: The pubocervical fascia collagen metabolism does not have impact on the results of anti-incontinence surgery.