Mixed incontinence: Stressing about urge

Urgency and urinary urge incontinence are troublesome and complex symptoms that can complicate the diagnosis and treatment of stress urinary incontinence. Despite this fact, first-line intervention frequently is directed toward the incompetent bladder neck using surgical approaches. Persistent urgency or detrusor instability following anti-incontinence surgery reduces patient satisfaction and overall continence in most series. This article discusses current theories explaining the etiology of mixed incontinence. It also reviews the results of anti-incontinence surgery for mixed incontinence and discusses management strategies. Possible predictors of outcome after sling surgery in this complex group of patients also are presented.     

Development of de novo urge incontinence in women post sling: the role of preoperative urodynamics in assessing the risk

AIMS: The study was undertaken to investigate if there are specific identifiable risk factors on the preoperative history or urodynamics testing associated with an increased risk for the development of symptoms of de novo urge urinary incontinence after a minimally invasive sling procedure. METHODS: Two hundred eighty-one women who had undergone minimally invasive sling surgery for stress urinary incontinence between January 2000 and December 2003 were identified. The records of 92 patients were included in this review. RESULTS: Twenty-five patients (27%) reported urge urinary incontinence on postoperative questioning. Clinical and urodynamic parameters were correlated with the development of de novo urge urinary incontinence. Preoperative history parameters were not predictive of the increased risk of de novo urge urinary incontinence, with the exception of increased preoperative daytime frequency (OR 3.3 (1.2, 9.1)). Of 16 women whose detrusor pressure during the filling phase of cystometry exceeded 15 cm H(2)O, de novo urge urinary incontinence developed in 9 (56%) vs. 16 (21%) of 76 women, whose detrusor pressure was < or = 15 cm H(2)O (OR 4.6 (1.4, 15.0)). CONCLUSIONS: Directed patient history is only minimally helpful in the identification of women at increased risk for the development of de novo urge urinary incontinence, with the exception of the complaint of increased daytime frequency. Women with elevated detrusor pressure during the filling phase of cystometry were more likely to develop urge urinary incontinence postoperatively. Therefore, we suggest that preoperative urodynamic evaluation, and specifically detrusor pressure > 15 cm H(2)O may help identify patients at increased risk of developing de novo urge urinary incontinence following the minimally invasive sling procedure.     

Complications in carotid endarterectomy are predicted by qualifying symptoms and preoperative CT findings.

OBJECTIVES: To relate the 30-day perioperative rate of stroke or death in carotid endarterectomy (CEA) to preoperative qualifying symptoms and to the presence of cerebral infarction (CI) demonstrated on computed tomography (CT). DESIGN: Retrospective clinical study. MATERIAL AND METHODS: Two hundred and seventy-two consecutive CEAs for symptomatic stenosis in 262 patients were analysed. RESULTS: The total complication rate was 5.9%. Patients with retinal symptoms (n = 81) had no complications, TIA patients (n = 76) had 6.6% (p < 0.001). Patients qualifying with minor stroke (n = 113) had complications in 9.7% (N.S. compared to TIA patients). Patients qualifying with cortical symptoms had a significantly higher complication rate compared to those with retinal (8.4% vs. 0%, p = 0.004). The presence of a preoperative CT-verified infarction resulted in a higher risk for stroke or death (9.8% vs 2.8%, p = 0.008). Within the subgroup presenting with minor stroke, the presence of CI resulted in stroke or death in 13.9%. In patients without CI the corresponding figure was 2.4% (p = 0.017). CONCLUSION: The qualifying symptoms and the presence of CI visualized by CT influence the complication rate in CEA. When evaluating risk and comparing outcome, these parameters should be included in reporting standards.     

Implantable neuromodulation for urinary urge incontinence and fecal incontinence: a urogynecology perspective

Implantable sacral nerve stimulation is a minimally invasive, durable, and reversible procedure for patients with urinary urge and fecal incontinence who are refractory to conservative therapy. The therapy is safe compared with other surgical options. An intact external or internal rectal sphincter is not a prerequisite for success in patients with fecal incontinence.     

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.     

The value of preoperative urodynamics according to gynecologists and urologists with special interest in stress urinary incontinence

Introduction and hypothesis  

The aim of this study is to assess variations in practice in the use of preoperative urodynamics in women with stress urinary incontinence (SUI).     

A self-directed home biofeedback system for women with symptoms of stress, urge, and mixed incontinence.

PURPOSE: To evaluate a self-directed home biofeedback treatment system in a group of community dwelling, otherwise healthy women with symptoms of stress, urge, and mixed urinary incontinence (UI). SETTING AND SUBJECTS: Fifty-five women, aged 25 to 81 years, participated in the study. METHODS: Initial evaluation included a self-reported continence assessment, a 24-hour bladder and fluid habits diary, severity indices for stress and urge UI, and assessment of pelvic floor strength using a pneumatic biofeedback device. Subjects completed a 16-week self-directed program. Assessment and severity index data were self-reported using a continence assessment form, a 24-hour bladder habit and fluid form, and stress and urge incontinence severity indices. Strength level of the trainer, number of digital bands lit on the screen during contraction, number of sessions, and program (starter, intermediate, advanced, or maintenance) were recorded on data sheets. INSTRUMENTS: The treatment system includes an 8-minute educational and motivational video; a journal for education, instructions, and daily documentation forms; and a home biofeedback trainer with pneumatic vaginal sensors that displays the strength of pelvic muscle contraction. RESULTS: Forty-four women completed the 16-week program. At the end of treatment, 19 (43%) were dry and 16 (36%) reported 50% or more improvement in number of leaks per day, number of voids per day, or both. Women with stress leakage experienced a significant reduction in the number of incontinent episodes per day and the mean severity index of incontinence (P < .001). Participants with urge UI experienced a significant reduction in the mean number of voids per day and mean severity index for UI (P < .001). Younger subjects were more likely to improve when compared with older participants, but no significant differences were found when comparing women who take estrogen with those who do not take estrogen or when comparing those with a history of bladder surgery with those who had no previous surgery. CONCLUSIONS: These data suggest that self-selected healthy women with symptoms of urge, stress, and mixed incontinence can improve their symptoms and lower their severity index with a minimal intervention, comprehensive, self-directed home biofeedback continence system.     

Urethral instability: related to stress and/or urge incontinence?

Urethral instability (pressure variations of more than 15 cm. water during bladder filling) was noted in 12 of 34 women with bladder instability and 13 of 139 with a stable bladder. Of the patients 10 had urge, 5 mixed and 8 genuine stress incontinence, while 1 had enuresis and 1 had recurrent cystitis. A clear correlation between urethral pressure variations and electromyographic fluctuations in the anal and/or urethral sphincter was found in 14 of 17 patients. Only urethral pressure variations of more than 35 cm. water are reported as provoking urgency. Different types of pressure fluctuations are described but no fundamental differences or causative factors were found. A nervous rather than a vascular factor is designated as the main cause for urethral instability.     

Esophagotomy during laparoscopic Heller myotomy cannot be predicted by preoperative therapies and does not influence long-term outcome

The conventional wisdom is that inadvertent esophagotomy complicates laparoscopic Heller myotomy. This study was undertaken to determine if esophagotomy at myotomy can be predicted by preoperative therapy, and if esophagotomy and/or its repair jeopardizes outcomes. Of 222 laparoscopic Heller myotomies undertaken since 1992, inadvertent esophagotomy occurred in 16 patients (7%); 60 patients who underwent myotomy without esophagotomy were utilized for comparison. Dysphagia and reflux before/ after myotomy were scored by patients on a Likert scale (0-5). The median (mean _ SD) follow-up after myotomy with esophagotomy was 38.8 months (31.6 ± 21.9 months) versus 46.3 months (51.0 ± 21.2 months) after myotomy alone. All esophagotomies were immediately recognized and repaired. Patients who experienced esophagotomy were similar to those who did not in application of Botox (56% vs. 77%) or dilation (44% vs. 65%), years of dysphagia (7.3 ± 5.4 vs. 7.4 ± 6.0), and mean preoperative dysphagia score (4.9 ± 0.4 vs. 4.8 ± 0.4). Esophagotomy led to longer hospitalizations (5.2 days ± 2.5 days vs. 1.5 days ± 0.7 days, P < 0.05) but not different postoperative dysphagia scores (1.5 ± 1.7 vs. 2.1 ± 1.4), reflux scores (1.4 ± 1.7 vs. 2.3 ± 1.3), or good or excellent outcomes (86% vs 84%). Esophagotomy during laparoscopic Heller myotomy is infrequent and cannot be predicted by preoperative therapy or duration or severity of dysphagia. Furthermore, complications after esophagotomy are infrequent and outcomes are indistinguishable from those of patients undergoing uneventful myotomy. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (poster presentation).     

Reliability and validity of King's Health Questionnaire in patients with symptoms of overactive bladder with urge incontinence in Japan

AIMS: The purpose of this study is to evaluate the psychometric properties of the Japanese version of the King's Health Questionnaire (KHQ) in patients with symptoms of overactive bladder (OAB) with urge incontinence. METHODS: Data from a 12-week, randomized, double-blind, placebo-controlled clinical trial comparing tolterodine with oxybutynin in patients with symptoms of OAB in Japan were analyzed. Cronbach's alpha coefficient was calculated as a reliability index. Inter-domain correlation was calculated for convergent and discriminant validity assessment. A factor analysis was conducted to explore the underlying factor structure of the KHQ. Sensitivity to clinical change was also evaluated. RESULTS: The psychometric properties and clinical validity of the KHQ Japanese version were confirmed in this study population, and were similar between males and females. The KHQ's good reliability was evidenced by Cronbach's alpha coefficients of >0.60, indicating reasonable consistency except for the personal relationship domain in males (0.47) and severity (coping) measure domain in females (0.59). Discriminant, convergent, and construct validity of the KHQ were also good, with the factor analysis identifying those factors which the KHQ was intended to measure. Finally, KHQ domains were generally responsive to clinical efficacy variables; the KHQ also showed statistically significant sensitivity to change in patients' perception of bladder condition in all domains, except General Health Perception. CONCLUSIONS: Our analyses confirm psychometric properties and clinical validity of the KHQ Japanese version, which appears to offer a valid and reliable HRQoL instrument for use in clinical trials of antimuscarinics in Japan.     

Transurethral incision of the prostate: a preoperative and postoperative analysis of symptoms and urodynamic findings

The efficacy of transurethral incision of the prostate was evaluated prospectively in 26 men with urodynamic evidence of outlet obstruction secondary to small prostate glands (estimated size less than 30 gm). All men completed preoperative and postoperative symptom questionnaires and extensive urodynamic testing with a median postoperative followup of 16.25 months. There was a significant improvement in subjective symptom analysis and objective urodynamic parameters (peak and mean uroflow rates, maximal detrusor pressure at peak flow, volume at first urge and post-void residual volume) as a result of transurethral incision of the prostate with minimal postoperative morbidity. Antegrade ejaculation was preserved in 55% of the men with normal preoperative ejaculation. Based on subjective and objective criteria, transurethral incision of the prostate is an effective treatment option for selected men with outlet obstruction.     

Gallbladder management during laparoscopic Roux-en-Y gastric bypass surgery: routine preoperative screening for gallstones and postoperative prophylactic medical treatment are not necessary

In the bariatric surgery literature, the optimum approach to the gallbladder is controversial. Recommendations range from concomitant cholecystectomy to selective screening and postoperative medical prophylaxis. At our institution, we have taken a highly selective approach where patients are not routinely screened for gallstones, nor are they medically treated postoperatively with bile salts. We have reviewed our experience with this approach. From January 2003 to January 2005, 407 laparoscopic Roux en Y gastric bypasses were performed at UCLA and postoperative outcomes were collected into a prospective database. Exclusion criteria included previous cholecystectomy, a follow-up period less than 6 months, or incomplete records. One hundred ninety-nine patients were included in the study. With a mean follow up period of 17.8 months, 12 (6%) patients required cholecystectomy for gallstone-induced pathology. Laparoscopic removal was performed in 11 (92%) patients. Indications for surgery included acute cholecystitis in five (2.5%) patients, gallstone pancreatitis in two (1%) patients, and biliary colic alone in another five (2.5%) patients. The incidence of symptomatic gallstones requiring cholecystectomy after laparoscopic Roux en Y gastric bypass is low. These results are similar to those from institutions where routine preoperative screening and prophylactic postoperative medical therapy is used. Routine preoperative screening or medical prophylaxis may not be necessary.     

Stroke after carotid endarterectomy: risk as predicted by preoperative computerized tomography

In patients undergoing carotid endarterectomy, the role of preoperative computerized tomographic head scanning in predicting the risk of postoperative neurologic deficit was determined by a retrospective evaluation of a select group of 107 consecutive patients with preoperative scans. Patients with infarction determined preoperatively by computerized tomography were found to be at a significantly higher risk for postoperative neurologic deficit than patients with a normal preoperative computerized tomographic scan. History and physical examination alone detected only 66 percent of the infarctions found with preoperative computerized tomographic scanning in these patients. Because the incidence of infarction revealed computerized tomography in patients with symptoms of a reversible ischemic neurologic deficit was 22 percent, we have proposed a new definition of reversible ischemic neurologic deficit to include the necessary finding of a normal computerized tomographic scan. Patients who presented with transient ischemic attack and the unexpected finding of a subclinical infarction on the preoperative scan were at the same significantly higher risk for postoperative stroke and a permanent neurologic deficit. Computerized tomographic scanning of potential carotid endarterectomy patients is of benefit not only to rule out other sources of neurologic symptoms, but also to predict more accurately the risk of postoperative neurologic deficit.     

Mixed incontinence: Current evidence and future perspectives

The epidemiology and treatment of mixed incontinence has received relatively little attention. However, mixed incontinence—defined as the combination of stress and urge incontinence accounts for ～33% of all cases of incontinence in women. The condition often responds poorly to treatment, either pharmacologic or surgical. Potential pharmacologic approaches for mixed incontinence include antimuscarinic agents, estrogen replacement therapy (for postmenopausal women), and dopamine, serotonin, or norepinephrine reuptake inhibitors. In a large‐scale, multinational, placebo‐controlled, clinical trial, the antimuscarinic agent tolterodine significantly reduced incontinence episodes in women with mixed symptoms. The benefits of tolterodine continued to increase during the 8 weeks of the trial and extended to additional end points, including frequency, urgency, and urge incontinence. A limited number of studies have examined the use of estrogen for mixed incontinence and have produced conflicting results. Duloxetine oxalate, a combined serotonin/norepinephrine reuptake inhibitor, has shown great promise in animal studies, as well as in phase 2 and 3 clinical trials. This agent is the first to demonstrate efficacy as a sole therapy for stress incontinence and has exhibited favorable effects on bladder capacity, suggesting possible benefits in mixed incontinence. Only five studies (two of which were conducted during the 1980s) have specifically examined the use of surgery for the treatment of mixed incontinence; the cure rates reported have varied. The current body of information supports use of an antimuscarinic agent as initial therapy for mixed incontinence, although long‐term trials are needed to shed more light on the duration of benefit. Neurourol. Urodynam. 29:618–622, 2010. Copyright © 2010 Wiley‐Liss, Inc.     

Tethered cord syndrome: cause for urge incontinence and pain in lower extremities.

An eight-year-old girl has had urge incontinence for the last three years and muscle weakness and pain in the lower extremities for one month. Urodynamic study revealed a bladder instability of severe degree. Tethered cord syndrome caused by a tight filum terminale was identified by metrizamide myelography. An untethering of the filum terminale resolved her symptomatology completely. The urologist should be aware of this syndrome in a patient presenting with incontinence that has persisted for a long time or has recurred.