Ambulatory urodynamics in urge incontinence evaluation

The identification of bladder instability is essential for the appropriate treatment of incontinent women. In-office stationary urodynamics may miss up to 50% of unstable bladder diagnoses. Multichannel microtip transducer ambulatory urodynamics were performed on 27 women with urgency-associated urinary incontinence, utilizing two commercially produced systems. All the women had previously undergone inoffice multichannel testing. An additional 12 cases of bladder instability were identified. Three cases of bladder instability were confirmed. Satisfactory monitoring was performed for a period of up to 8 hours. Problems with catheter migration/expulsion and timer correlation led to diagnostic difficulties, especially as related to urethral pressure tracings. Essentially a bladder holter monitor, ambulatory monitoring can augment the diagnostic accuracy of cystometric testing. This technique should reach widespread acceptance as a useful complement to current diagnostic tools.     

Intrafascial versus extrafascial abdominal hysterectomy: effects on urinary urge incontinence

Our aim was to evaluate urinary urge incontinence following intrafascial and extrafascial abdominal hysterectomies in a prospective randomized study. Women scheduled for total abdominal hysterectomy were randomized to the extrafascial (n=38) and the intrafascial techniques (n=42). The groups were controlled for demographic variables, obstetric and gynecologic history, uterine size, indications for hysterectomy, and preoperative hemoglobin values. Short-term surgical morbidity and presence of urge incontinence defined as urodynamically established detrusor overactivity at the end of 12 months were the main outcome measures. Major surgical morbidity did not differ between the two groups. Percentages of women with urge incontinence at the end of the follow-up period were also similar. However, when women with pre-existing urge incontinence were evaluated separately, there was a trend towards the intrafascial operation to be associated with more urge-incontinence-free patients at the end of the follow-up period ( p =0.06, borderline significant). As a result, short-term surgical morbidity seems to be similar across the intrafascial and extrafascial techniques of abdominal hysterectomy. The effects of intrafascial abdominal hysterectomy on women presenting with urge incontinence in the preoperative period merit further investigation. Editorial Comment: The intrafascial abdominal hysterectomy as described by Richardson may preserve more of the neurovascular supply to the bladder by dissecting the fibromuscularis from the vaginal mucosa. This preservation of more fibromuscularis that is included in the extrafascial hysterectomy may have significance in urinary urge incontinence. Many gynecologists perform the extrafascial hysterectomy, as there may be less blood loss and it is usually easier to perform. Many of our younger gynecologists no longer know how to perform this procedure, which is poorly covered in current textbooks of gynecologic surgery. The intrafascial technique is helpful when dealing with difficult anatomy from adhesive disease such as endometriosis and large myomas that increase the risk of injury to bowel, bladder and ureters     

Difference in quality of life in women with urge urinary incontinence compared to women with stress urinary incontinence

Introduction  We evaluated whether women with urge urinary incontinence (UUI) have lower quality of life (QOL) than women with other forms of urinary incontinence. Methods  Patients completed three validated questionnaires when presenting for evaluation at a urogynecology practice and were divided into four groups based on their responses: those with symptoms of stress urinary incontinence (SUI), UUI, both SUI and UUI (mixed UI), and neither SUI nor UUI (controls). Results  A total of 465 women were included: 53 women with UUI (11.4%), 101 with SUI (21.7%), 200 with mixed UI (43%), and 111 controls (23.9%). Overall, there was a significant difference (p < 0.001) in PFIQ bladder scale scores as a function of UI group, with individual mean PFIQ scores of 17.1 for controls, 22.3 for SUI, 32.7 for UUI, and 36.8 for mixed UI. Individually, all seven questions in the PFIQ bladder domain were significantly different by group (p ≤ 0.001). Conclusions  Women with UUI and mixed UI have lower QOL scores than women without incontinence or with only SUI. The project was approved by the IRB at Hartford Hospital.     

Why do stress and urge incontinence co-occur much more often than expected?

Assuming stress and urge urinary incontinence (UI) are independent, mixed UI prevalence is 17 times higher than expected. We consider three explanatory models. We summarize evidence from previous studies on whether common Risk Factors, Liability (i.e., one UI subtype increases risk of the other), or Severity model (i.e., mixed UI represents an advanced and more persistent stage of a progressive disorder) explains the unexpectedly high prevalence of mixed UI. We found little support to indicate that the excess prevalence of mixed UI is explained by common risk factors. In contrast, evidence does indicate that onset of one UI subtype increases risk of onset of the other subtype. Finally, although the Severity model is intuitively attractive, there is little epidemiologic evidence to support it. Longitudinal studies are needed to determine which model offers a dominant explanation for the high prevalence of mixed UI.     

Rehabilitation vs drug therapy for urge urinary incontinence: short-term outcome

The objective of this study was to compare the short-term effectiveness of rehabilitation treatment with a standard drug treatment for urge urinary incontinence (UUI). The study design includes parallel clinical trial in an outpatient urogynecologic clinic setting. The subjects were 44 women who suffered from UUI and who were systematically assigned to a rehabilitation group (REH) (N=24) or a medication group (MED) (N=20). The intervention for REH was consisted of five visits during a 3-month period of pelvic floor muscle training and behavioral training, whereas for MED was extended release oxybutynin at 5 mg/day, for 3 months. The urinary symptoms considered were frequency of voiding per day and night (freq/day and freq/night), number of incontinent episodes per week based on a bladder diary, and data based on the Incontinence Quality of Life Instrument (I-QoL). In the within-group comparison, both groups had improved significantly over time with respect to urinary symptoms and I-QoL (p<0.01). In addition, there was a significant group–time interaction effect on freq/day. While REH improved during the 3-month follow-up period, the MED group deteriorated to mean baseline value (p<0.01). A significant negative association was found between the urinary symptoms and the I-QoL at the end of follow-up (r _p=−0.35 to −0.62, p<0.05). Three months after the intervention, both groups maintained the achievements of the intervention period. In addition, the REH group demonstrated additional improvement in mean freq/day while the condition of MED patients deteriorated to baseline values. At the time this paper was prepared, Prof. Langer passed away at the age of 57. This paper is therefore in memory of an outstanding physician, mentor and researcher.     

Rehabilitation versus drug therapy for urge urinary incontinence: long-term outcomes

The objective of this study was to compare the residual effect of a 3-month rehabilitation treatment and a standard drug treatment for urge urinary incontinence (UUI) 21 months post intervention. Forty-four women (ages 27–68 years) who were diagnosed with overactive bladder (OAB) were divided into 2 treatment groups over 3 months: 24 women received rehabilitation (REH) and 20 women were treated with medication (MED) (oxybutynin ER). Outcomes measures included frequency of urination, quality of life (QoL), and number of side effects (no/SE), which were measured upon entry into the study (entry), completion of the intervention (3 months), and at follow-up 3 and 21 months after completion of treatment. In the follow-up period, there was a significant group–time interaction effect on freq/day and freq/night (p < 0.01). At the end of follow-up, the mean number of no/SE was significantly greater in the MED group compared to the REH group (3.3 ± 0.5 vs 2.4 ± 0.4; p < 0.05). A significant negative association was found between the urinary symptoms and the I-QoL at the 21-month follow-up (r _p = −0.45 to−0.57, p < 0.05). In the long-term, the REH patients maintained and even improved the achievements of the intervention period while the MED patients deteriorated to baseline values in urinary frequency. The suggestion for future work is to investigate the effect of each REH treatment component on UUI symptoms.     

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.     

Postpartum depression,urge urinary incontinence,and overactive bladder syndrome: is there an association?

The purpose of this prospective, cross-sectional study was to determine if there was an association between postpartum depression and symptoms of overactive bladder in postpartum women. At their 6 week postpartum visit, participants completed questionnaires regarding lifestyle, personal health, urinary incontinence, and depression symptoms, including the Urge-Urinary Distress Inventory (URGE-UDI), the Urge-Incontinence Impact Questionnaire (URGE-IIQ), and the Edinburgh Postnatal Depression Scale (EPDS). Past medical history, including obstetric variables, family history, and medications were extracted from the medical record. One hundred patients completed the questionnaires at the University of Michigan Hospital and 46 patients at the University of Virginia Hospital (mean age 29.2 ± 6.1 years; 18–47 years) at their postpartum visit (mean time 45.2 ± 9.4 days postpartum; 11–79 days). Sixteen percent of the women had depression (EPDS score of >12) or were borderline (EPDS score of 9–12) for postpartum depression. There was no difference in age and race in women with and without depression. Type of delivery, vaginal vs cesarean section did not significantly impact their URGE-UDI or URGE-IIQ score. There was a significant correlation between the URGE-IIQ score and depression (0.24, p = 0.003), but not the URGE-UDI score. In this cross-sectional study, we found an association between postpartum depression and symptoms of urge incontinence. Because birth is a predictable event, further studies evaluating the causal relationships and physiologic changes linking depression and incontinence can be studied using this model.     

经膀胱镜局部注射肉毒素A治疗逼尿肌反射亢进所致顽固性急迫性尿失禁

目的：探讨经膀胱镜局部注射肉毒素A治疗逼尿肌反射亢进所致顽固性急迫性尿失禁的疗效。方法：对9例确诊为逼尿肌反射亢进且保守治疗无效的急迫性尿失禁患者行膀胱镜引导下逼尿肌内注射肉毒素A,每次剂量300U。术前注意排除伴有膀胱颈梗阻者。比较手术前后患者的临床症状、控尿能力、剩余尿量、初尿意膀胱容量及膀胱最大容量有无差异,有无肉毒素所致的不良反应以及多次注射者有无抗药性产生。结果：9例患者手术过程顺利,术后临床症状、控尿能力、初尿意膀胱容量及膀胱最大容量均较术前有明显改善。剩余尿量无明显变化,无不良反应发生,无肉毒素A的抗药性产生。结论：膀胱镜引导下逼尿肌内注射肉毒素A是一种微创、简便、有效而安全的治疗顽固件逼尿肌反射亢讲的方法。     

Desensitization of bladder sensory fibers by intravesical capsaicin or capsaicin analogs. A new strategy for treatment of urge incontinence in patients with spinal detrusor hyperreflexia or bladder hypersensitivity disorders

Recent experimental studies have identified a category of unmyelinated type C bladder afferent fibers in the pelvic nerves which are extremely sensitive to capsaicin. Sensory input conveyed by these fibers triggers a spinal reflex which, in chronic spinalized animals, facilitates and controls micturition. In addition, bladder C fibers were also shown to have a role in bladder pain perception. In humans capsaicin-sensitive afferent fibers also innervate the bladder and contribute to the reflexogenic control of the detrusor muscle and to bladder pain perception. Desensitization of such fibers by intravesical administration of capsaicin, presumably by blocking sensory transmission, has been shown to reduce involuntary micturition and to increase bladder capacity in patients with detrusor hyperreflexia of spinal origin, and to reduce the intensity of bladder pain in patients with bladder hypersensitivity. Very recently, resiniferatoxin, an ultrapotent capsaicin analog, was shown to have a similar clinical effect in this subset of patients. However, unlike capsaicin, resiniferatoxin did not evoke acute irritative urinary symptoms during bladder instillation.     

Tension-free vaginal tape,suprapubic arc sling,and transobturator tape in the treatment of mixed urinary incontinence in women

We evaluated the outcome at least 6 months after tension-free vaginal tape (TVT), suprapubic arc (SPARC) sling, or transobturator tape (TOT) procedure in women with mixed urinary incontinence and identified factors predicting the outcome in these patients. A total of 144 women, 29 to 77 years old (mean age 57.3), were included in the study; TVT (n = 72), SPARC (n = 22), and TOT (n = 50). The mean follow-up time was 10.9 months (range 6 to 52). There were no significant differences in the three groups in terms of the cure rate for stress urinary incontinence (SUI; TVT, 95.8%; SPARC, 90.0%; TOT, 94.0%; P = 0.625) and urinary incontinence (UUI; TVT, 81.9%; SPARC, 86.4%; TOT, 82.0%; P = 0.965). In the multivariate model, there is no influencing factor for treatment failure of SUI, while maximum urethral closure pressure (MUCP) and the diagnosis of uninhibited detrusor contraction during cystometry were independent risk factors for treatment failure of UUI. Decreasing MUCP was associated with an increased likelihood of treatment failure of UUI [odds ratio (OR), 0.974; 95% confidence interval (CI), 0.950–0.998; P = 0.034]. In the same model, uninhibited detrusor contraction was associated with 3.4-fold risk of treatment failure of UUI (OR, 3.351; 95% CI, 1.031–10.887; P = 0.044). Our findings suggest that low MUCP and the presence of uninhibited detrusor contraction during cystometry should be considered to be at high risk of treatment failure of UUI after surgery in these patients.     

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.     

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.     

Anticholinergic drugs,bladder retraining and their combination for urge urinary incontinence: a pilot randomised trial

Bladder retraining and anticholinergic drugs in women with urge urinary incontinence need to be compared. Women with urge urinary incontinence were recruited by advertisements, from primary care and from a urogynaecology clinic. Women were randomised using a web page to bladder retraining, anticholinergic drugs or both and followed up at 3 and 12 months. No blinding was attempted. The primary outcomes were the trial process and the Overactive Bladder Questionnaire (OAB-q) quality-of-life measure. Recruitment was much slower than anticipated. There were no differences in the OAB-q at 12 months (87.9 SD 11.6 bladder retraining, 81.6 SD 19.3 drug therapy and 88.9 SD 9.9 combination) but dry mouth was more common in those taking drugs. It is feasible to run a pragmatic randomised trial with 12-month follow-up for women with urinary urge incontinence. This will require about 500 participants per arm. Trial registration  This trial was registered as ISRCTN 66713401.     

Posterior tibial nerve stimulation in the treatment of urge incontinence

AIMS: The objective of this study was to evaluate the effect of posterior tibial nerve stimulation (PTNS) for treatment of urge incontinence. METHODS: In a prospective multicentre study, 35 patients with complaints of urge incontinence underwent 12 weekly sessions of PTNS at one of five sites in the Netherlands and one site in Italy. Frequency/volume charts and I-QoL and SF-36 questionnaires were completed at 0 and 12 weeks. Success was analysed by using subjective and objective criteria. Overall subjective success was defined as the willingness to continue treatment, whereas objective success was defined as a significant decrease (to<50%) in total number of leakage episodes. RESULTS: Twenty-two patients (63%) reported a subjective success. Twenty-four patients (70%) showed a 50% or greater reduction in total number of leakage episodes. Sixteen (46%) of these-patients were completely cured (i.e., no leakage episodes) after 12 sessions. Quality of life parameters improved significantly. CONCLUSIONS: We conclude that posterior tibial nerve stimulation is an effective, minimally invasive option for treatment of patients with complaints of urge incontinence, as improvement was seen in subjective as well as objective parameters.     

Reductions in overactive bladder-related incontinence from pooled analysis of phase III trials evaluating treatment with solifenacin

The embarrassment and social stigma associated with urinary incontinence (UI) in overactive bladder syndrome (OAB) sufferers is a major reason for individuals to seek help for their condition. An analysis of 1,873 subjects with OAB with UI was conducted to assess the efficacy of solifenacin in reducing incontinence in a pooled population from four phase III clinical trials, stratified by severity of incontinence, urgency, and other key factors at baseline. Subjects were randomized to either 5 or 10 mg of solifenacin once daily or placebo for 12 weeks. More than 50% of the total population became continent at study end, with either dose of solifenacin (P<0.01 vs placebo). Significant reductions in incontinence episodes and higher rates of attainment of continence vs placebo were observed irrespective of age or severity of incontinence or urgency at baseline with solifenacin treatment. Treatment was well tolerated, with the majority of adverse events being mild in nature. Solifenacin is an effective antimuscarinic agent for the treatment of incontinence associated with OAB.     

Urodynamic characteristics of mixed urinary incontinence and idiopathic urge urinary incontinence

PURPOSE: To evaluate and compare the clinical and urodynamic findings in patients with either mixed urinary incontinence (MUI) or simple urge urinary incontinence (UUI). MATERIALS AND METHODS: A series of 100 consecutive female patients with MUI and UUI were identified from a database. Patients with neurogenic bladder, fistula, urethral diverticulum, prior urologic surgery or known urinary tract obstruction were excluded. All patients were classified according to the urodynamic classification of overactive bladder of Flisser et al. and all patients underwent history, physical examination, validated incontinence questionnaire, 24-hour voiding diary, 24-hour pad test, video urodynamic study (VUDS), and cystoscopy. RESULTS: A significantly higher proportion of patients with UUI exhibited detrusor overactivity at VUDS, (67% of the patients with UUI vs. 24% of the MUI, P < 0.05). Patients with UUI had fewer episodes of incontinence (6.7 vs. 4.2, P < 0.05) with slightly less objective urine loss (24-hour pad test 94 gm vs. 128 g of loss, P < 0.05) and voided at higher pressures (p(det) at Q(max) 21.4 vs. 15.6 cm H(2)O, P < 0.05). Patients in both groups had functional and urodynamic bladder capacities that were not statistically different. CONCLUSIONS: Women with UUI were more likely to exhibit detrusor overactivity but experienced fewer episodes of incontinence and less urinary loss when compared with women who had MUI. The "urge incontinence" component of MUI appears to be different than that of UUI, and suggests that urge incontinence may be overdiagnosed in patients with SUI who misinterpret their fear of leaking (because of SUI) for urge incontinence.     

The effect of cannabis on urge incontinence in patients with multiple sclerosis: a multicentre, randomised placebo-controlled trial (CAMS-LUTS)

Objective: To test whether cannabinoids reduce urge incontinence episodes without affecting voiding in patients with multiple sclerosis. This was part of the multicentre trial of the Cannabinoids in Multiple Sclerosis (CAMS) study. Subjects and methods: The CAMS study randomised 630 patients to receive oral administration of cannabis extract, Δ⁹-tetrahydrocannabinol (THC) or matched placebo. For this substudy subjects completed incontinence diaries. Results: All three groups showed a significant reduction, p<0.01, in adjusted episode rate (i.e. correcting for baseline imbalance) from baseline to the end of treatment: cannabis extract, 38%; THC, 33%; and placebo, 18%. Both active treatments showed significant effects over placebo (cannabis extract, p=0.005; THC, p=0.039). Conclusion: The findings are suggestive of a clinical effect of cannabis on incontinence episodes in patients with MS. This is in contrast to the negative finding of the CAMS study, where no difference was seen in the primary outcome of spasticity.     

Prevalence of hand-washing urinary incontinence in healthy subjects in relation to stress and urge incontinence

Hand-washing urinary incontinence is involuntary urine loss in response to washing hands, hearing the sound of running water, or exposing oneself to cold wind in the winter season. The prevalence of this incontinence in relation to stress and urge incontinence was studied in healthy community-dwelling subjects of 1,636 females and 3,010 males. The afflication rate of both genders was 3% for those in their 50s and younger and 16% for those in their 60s and older, which was significantly different (P < 0.01). Females (10%) suffered more from this incontinence compared to males (5%) (P < 0.01). The prevalence of this incontinence was approximately the same as that of stress and urge incontinence in each gender except females' stress incontinence, which was 3 times more than the other two. Seventytwo percent of subjects with hand-washing incontinence also had either urge incontinence, stress incontinence, or both.     

Stress inconthence and detrusor instability/urge incontinence

The overall incidence of detrusor instability in 603 women with stress incontinence was 30%. One hundred seventy-two women had detrusor instability and/or urge incontinence preoperatively. Twenty-three additional women developed detrusor instability and/or urge incontinence only after operation. By eight weeks after operation 4% of the entire group or 14% of those who had detrusor instability or urge incontinence at any time pre-or postoperatively still had the difficulty with incontinence. These findings indicate that a small number of women with both stress incontinence and detrusor instabilty and/or urge incontinence will still have symptomatic urinary loss as a result of persistent detrusor abnormalities at eight weeks after operation.