A comparison of urinary incontinence among African American, Asian, Hispanic, and white women

OBJECTIVE: This study was undertaken to compare urodynamic findings and the rate of incontinence diagnoses among various ethnic groups. STUDY DESIGN: Data were collected for all new patients referred to the urogynecology clinic during a 10-year period. One hundred ninety-five Hispanic, 95 white, 66 Asian, and 59 African American women had urodynamic testing and were included in the study. All women had a complete history, physical examination, and multichannel urodynamic studies. Demographic data, urodynamic data, and final diagnoses differences were analyzed. RESULTS: African American women had higher maximum urethral closure pressures than Hispanic, white, or Asian women (58 cm H2O vs 47, 47, and 48 cm H2O; P =.001, P =.005, and P =.02). African American women were less likely to be diagnosed with genuine stress incontinence than were Hispanic or white women (42% vs 67% and 59%; P <.001 and P =.046). Detrusor instability was diagnosed more often in African American women than in Hispanic, white, or Asian women (29% vs 8%, 15%, and 14%; P <.001, P =.04, and P =.04). CONCLUSIONS: African American women with urinary incontinence have different urodynamic diagnoses than Hispanic, white, or Asian women. Hispanic, white, and Asian women have similar rates of genuine stress incontinence. Although African American women have lower rates of genuine stress incontinence than Hispanic and white women, they have higher rates of detrusor instability than all 3 groups.     

Stress Incontinence Diagnosed Without Multichannel Urodynamic Studies

Objective: To determine if the clinical diagnosis of stress urinary incontinence made on the basis of simple criteria correlates with the diagnosis of genuine stress incontinence as determined by provocative multichannel urodynamic testing.Methods: The charts of 652 women who presented for clinical evaluation of a variety of lower urinary tract complaints were reviewed if they met all of the following criteria: 1) a predominant complaint of stress incontinence, 2) positive cough stress-test results, 3) postvoid residual urine volume no more than 50 mL, 4) a functional bladder capacity of at least 400 mL as determined by a completed 24-hour frequency-volume chart, and 5) a full multichannel urodynamic evaluation. Seventy-four patients met all these criteria. The clinical diagnosis of stress incontinence was based on the presence of factors 1–4; this diagnosis then was compared with the results of provocative multichannel urodynamic testing.Results: Genuine stress incontinence was confirmed in 72 (97%) of 74 patients meeting the aforementioned clinical criteria. In one patient, detrusor instability alone was demonstrated during urodynamic testing. In 11 patients with genuine stress incontinence (15%), an element of detrusor instability was also present at the time of urodynamic testing. One patient had normal urodynamic study findings, with no incontinence demonstrated.Conclusion: Rigorously defined clinical criteria are highly reliable in predicting the presence of genuine stress incontinence at the time of urodynamic testing. Because of the potential implications of this finding for clinical practice, further investigation is warranted.     

Reliability of the patient's history in the diagnosis of urinary incontinence

The reliability of a patient's history has been challenged in the preoperative evaluation of stress urinary incontinence. In this study, 122 consecutive patients referred to our Gynecology/Urology clinic were evaluated and an additional 32 control patients (continent women with no urinary symptoms) were evaluated. All patients answered a detailed 64-item questionnaire, and all patients received a complete urodynamic evaluation. Our detailed questionnaire provided a mean positive predictive value of 80% for genuine stress incontinence and 25% for detrusor instability. The conditions leading to a false positive history suggestive of genuine stress incontinence were detrusor instability and urethral diverticulum. The conditions leading to a false positive history suggestive of detrusor instability were urethritis, unstable urethra, vaginitis and polyuria. History alone can be misleading in diagnosing urinary incontinence.     

Pure stress leakage symptomatology: is it safe to discount detrusor instability?

OBJECTIVE: To determine whether the combination of a urological history and urinary diary, with rigorous selection criteria, can be used to define a group of women on whom urodynamic assessment is unnecessary prior to offering surgery for urinary stress incontinence. DESIGN: Retrospective review of the urodynamic records of women attending for assessment between January 1992 and December 1996. SETTING: Urodynamic Department, Southmead Hospital, Bristol. POPULATION: 5193 women who attended the urodynamic clinic during the five year study period. METHODS: Self-completion of a urinary diary in the preceding week before urodynamic assessment and a detailed urological history before undergoing cystometry by all women in the study period. Data were entered onto a computer database. Women reporting stress incontinence in the absence of bladder filling symptoms, with a normal urinary diary showing daytime frequency of seven times or less and nocturia of no more than once, had the results of their filling cystometry analysed. RESULTS: Of 5193 women, 555 had symptoms of pure stress incontinence and a normal urinary diary. Incontinence was confirmed objectively in 81%, with 9% having incontinence secondary to detrusor instability; 5% had detrusor instability as the sole cause of their incontinence with 4% having a mixed picture of detrusor instability incontinence and urethral sphincter weakness. CONCLUSION: Genuine stress incontinence cannot be diagnosed reliably from a urological history, even when rigorous selection criteria are used in combination with a normal urinary diary. Without cystometry, incontinence secondary to detrusor instability will be missed.     

Urethral sphincter morphology in women with detrusor instability.

OBJECTIVE: To determine whether sonographic urethral sphincter morphology is different in patients with detrusor instability than in those with normal urodynamic testing. METHODS: Patients from a population of women presenting for evaluation of urinary incontinence or pelvic organ prolapse underwent intraurethral ultrasonography before multichannel urodynamic testing. Maximal rhabdosphincter thickness, total urethral diameter, total urethral circumference, and longitudinal smooth muscle thickness, diameter, and circumference were measured. For patients with detrusor instability, the strength of the involuntary detrusor contraction and the bladder volume at its onset were recorded. These data were compared with information from history questionnaires and urodynamic evaluations. RESULTS: The 17 patients with detrusor instability and 16 patients with normal urodynamic testing did not differ with respect to age, vaginal parity, race, weight, body mass index, prior continence surgery, or maximal total urethral closure pressure. Patients with detrusor instability, had decreased urethral longitudinal smooth muscle thickness (3.0 +/- 0.9 mm vs 4.1 +/- 0.7 mm, P =.001), total urethral diameter (18.0 +/- 1.6 mm vs 19.4 +/- 1.4 mm, P =.01), and total urethral circumference (5.65 +/- 0.5 cm vs 6.1 +/- 0.4 cm, P =.012) compared with those with normal urodynamic tests. A linear relationship between rhabdosphincter thickness and strength of involuntary detrusor contraction was observed (r =.686, P =.002). CONCLUSION: Urethral sphincter morphology is different in patients with detrusor instability compared with those who have normal urodynamic tests. These findings provide an anatomic basis for the physiologic findings in patients with "urethrogenic" detrusor instability.     

Detrusor instability following colposuspension for urinary stress incontinence

Summary. Sixty-two patients with genuine stress incontinence (group A) and 30 women with combined detrusor instability and genuine stress incontinence (group B) had a colposuspension operation. The proportion with symptoms of detrusor instability was significantly reduced from 24% before operation to 9% after operation in group A and from 73% to 33% in group B. Urodynamically, detrusor instability developed after surgery in 17 of the 62 patients (27%) in group A whereas only 12 of the 30 women (40%) in group B had detrusor instability after surgery. No urodynamic explanation was found to explain the effect of colposuspension in relieving the symptoms of detrusor instability in some and causing them in others. Nevertheless, it is suggested that colposuspension is helpful for most patients with combined detrusor instability and genuine stress incontinence.     

Prevalence of faecal incontinence among women with urinary incontinence

Four hundred and sixty-five women attending a urodynamic clinic were interviewed, and completed a detailed bowel questionnaire, about their urinary and bowel symptoms. All the women underwent video-cystourethrography with pressure and flow studies. The reported incidence of faecal incontinence was 15.3% (   n = 71  ) on direct questioning and 26% 0(  n = 121  ) on the postal questionnaire. Faecal incontinence was more common in women with a urodynamic diagnosis of detrusor instability (30'%1 (   n = 26  )) than among women diagnosed as having genuine stress incontinence (21% (   n = 38  )). Denervation and myogenic injuries sustained during childbirth have been suggested as a common cause for genuine stress and faecal incontinence, but there may be an alternative mechanism to explain why women with detrusor instability suffer from faecal incontinence.     

Detrusor instability--an important but underestimated factor in urinary incontinence in women

157 consecutive female patients complaining of urinary incontinence were studied by history and urodynamics. 21 of them (13.4%) demonstrated urge-incontinence due to severe detrusor instability, 20 (12.7%) showed mixed (both urge and stress) incontinence, 14 (9%) only detrusor instability and 12 (7.6%)--stress incontinence accompanied by detrusor instability. Pure stress incontinence was diagnosed in 79 cases (50.3%) while 11 patients (7%) manifested no abnormality during the urodynamics. A total of 67 patients (42.7%) showed urodynamic evidence of detrusor overactivity. In 55 (35% of the studied subjects) it was the main urodynamic finding. The prevalence of detrusor instability was higher among those with recurrent incontinence and was the highest (60%) among the women with more than one previous operations. When urge incontinence was present it occurred at detrusor pressures lower than the maximum urethral closure pressure, which implies possible failure of the sphincteric mechanisms associated with detrusor instability. 14% of the women with detrusor instability did not report complaints typical for this disorder but had history of stress incontinence alone. The authors confirm the necessity of objective assessment of the lower urinary tract in all cases with history suspicious of detrusor instability as well as when surgical treatment for stress incontinence is planned.     

Obesity and urinary incontinence in women

Summary. In a series of 368 incontinent women who presented to our urodynamic clinic for assessment, 232 (63%) were diagnosed as having genuine stress incontinence, and 136 (27%) as having detrusor instability. Obesity (>20% more than average weight for height and age) was significantly more common in women with genuine stress incontinence and detrusor instability than in the normal population. In those with detrusor instability the body mass index was found to increase with age and parity. In women with genuine stress incontinence the body mass index increased with age and the number of previous incontinence operations; it was higher in nulliparous than in parous women. There was no significant difference between obese and nonobese women in any of the urodynamic variables measured in the two incontinence groups.     

Obesity and urinary incontinence in women

In a series of 368 incontinent women who presented to our urodynamic clinic for assessment, 232 (63%) were diagnosed as having genuine stress incontinence, and 136 (27%) as having detrusor instability. Obesity (greater than 20% more than average weight for height and age) was significantly more common in women with genuine stress incontinence and detrusor instability than in the normal population. In those with detrusor instability the body mass index was found to increase with age and parity. In women with genuine stress incontinence the body mass index increased with age and the number of previous incontinence operations; it was higher in nulliparous than in parous women. There was no significant difference between obese and nonobese women in any of the urodynamic variables measured in the two incontinence groups.     

Which women with stress incontinence require urodynamic evaluation?

OBJECTIVE: This study was undertaken to determine the predictive value of the symptom of stress urinary incontinence and to evaluate the ability of other factors suggested by a published Agency for Health Care Policy and Research guideline for the discrimination of patients unlikely to require urodynamic testing before surgical management. STUDY DESIGN: We evaluated 950 consecutive women without advanced (stage III or IV) pelvic organ prolapse who were referred with symptoms of incontinence. Incontinence was recorded by means of standard forms and was characterized as "any stress loss" (76.4%), "primarily stress loss" (58.9%), "stress loss only" (29.8%), "stress and urge loss" (52.2%), "urge loss only" (13.8%), "constant and stress loss" (1.9%), or "constant loss" (2.3%). Other variables were assessed by means of a standardized history, physical examination (including urethral axis determination and stress test), 1-week urinary diary, and postvoid residual volume measurement. A urodynamic diagnosis of pure genuine stress incontinence was used as the criterion standard. Sensitivity, specificity, and positive and negative predictive values were calculated. Logistic regression models incorporating various combinations of stress loss only, previous prolapse or incontinence surgery, nocturia, voiding frequency, urethral hypermobility, and postvoid residual volume <100 mL (the factors recommended by the Agency for Health Care Policy and Research guidelines), along with age and race as predictors of genuine stress incontinence, were constructed to evaluate the predictive ability of the guideline in a subset of 447 patients for whom data on all variables were available. RESULTS: Of the entire population 480 (50.5%) had pure genuine stress incontinence, 134 (14.1%) had both genuine stress incontinence and detrusor instability, 180 (18.9%) had pure detrusor instability, and 40 (4.2%) had intrinsic sphincter deficiency. Fifty-four (5.7%) had normal study results, and 62 (6.5%) had other nonincontinence diagnoses. Among the subjects with symptoms of stress loss only, 10.8% did not have genuine stress incontinence confirmed on urodynamic examination. Agency for Health Care Policy and Research guideline criteria had excellent discrimination (C statistic of 0.807) compared with the sole criterion of stress urinary incontinence only (C statistic of 0.574), with a positive predictive value of 85.7%. Only 7.8% of subjects met all the criteria, however, and 5.7% of these ultimately had a urodynamic diagnosis of either detrusor instability or normal study result. CONCLUSION: The predictive value of stress symptoms alone was not high enough to serve as the basis for surgical management. Agency for Health Care Policy and Research guidelines improved the predictive value but were applicable to only a small subset of patients referred with urinary incontinence.     

Mixed urinary incontinence symptoms: urodynamic findings,incontinence severity,and treatment response

OBJECTIVE: To investigate the relationship between the symptom of mixed urinary incontinence and incontinence severity, urodynamic findings, and treatment response. METHODS: This is a secondary analysis of data from 553 women randomized into a double-blind, placebo-controlled study evaluating duloxetine (serotonin-norepinephrine reuptake inhibitor) for the treatment of predominant stress urinary incontinence. Assessment variables included incontinent episode frequency, the Incontinence Quality of Life Questionnaire (I-QOL), and the Patient Global Impression of Severity Scale (PGI-S). Urge symptoms were identified with three urge I-QOL questions not included in corrected I-QOL calculations. RESULTS: At baseline, 171 women (31%) had mixed urinary incontinence. They had more severe baseline urinary incontinence than did those with stress urinary incontinence (mean incontinent episode frequency 14.3 versus 10.5; PGI-S normal or mild 26.5% versus 70.4%; mean corrected I-QOL 59.1 versus 79.9; all Ps <.001). Baseline urodynamics were performed on a subset of 86 women. Subjects with both urodynamic stress incontinence and detrusor overactivity had less severe incontinence compared with subjects with only urodynamic stress incontinence. Both mixed urinary incontinence and stress urinary incontinence groups had significant decreases in median incontinent episode frequency at a 40 mg per day (62% and 58%, respectively) and 80 mg per day (63% and 65%) duloxetine dose compared with placebo (33% and 44%; all Ps <.05). Response was not dependent on the type of symptoms (interaction P =.47). CONCLUSION: For women presenting with predominant stress urinary incontinence symptoms, the major determinant of concurrent urge symptoms was incontinence severity and not the pathophysiologic condition(s) causing the incontinence; duloxetine demonstrated equal efficacy for women with mixed urinary incontinence and pure stress urinary incontinence.     

Can ultrasound replace ambulatory urodynamics when investigating women with irritative urinary symptoms?

Objective To determine whether transvaginal ultrasound measurement of bladder wall thickness could replace ambulatory urodynamics when investigating women with lower urinary tract dysfunction not explained by conventional laboratory urodynamic studies.
Design A blinded prospective study.
Setting Tertiary referral unit in a London teaching hospital.
Population One hundred and twenty-eight women referred for ambulatory urodynamics with equivocal laboratory urodynamic findings or whose symptoms were not explained by the laboratory urodynamic findings.
Methods Transvaginal ultrasound assessment of bladder wall thickness was performed in three planes with an empty bladder prior to ambulatory urodynamics. Mean bladder wall thickness was calculated and the results analysed with respect to the ambulatory urodynamic diagnosis.
Main outcome methods Mean bladder wall thickness in women with a normal ambulatory study or a diagnosis of detrusor instability, genuine stress incontinence (GSI) or mixed incontinence.
Results Using a one way analysis of variance (ANOVA) bladder wall thickness was found to be significantly different in all diagnostic groups and this reached significance (   P = 0.0001  ). There was no overlap in the 95% confidence intervals representing a diagnosis of detrusor instability or genuine stress incontinence.
Conclusions Transvaginal ultrasound assessment of mean bladder wall thickness is a sensitive screening tool, which can detect detrusor instability in those women with equivocal laboratory urodynamics. In women who have no evidence of GSI on laboratory studies, a cutoff of 6.0mm is highly suggestive of detrusor instability. However, in those women with GSI then ambulatory studies probably remain the investigation of choice.     

Effects of aging on generic SF-36 quality of life measurements in Hong Kong Chinese women with urinary incontinence

BACKGROUND: To evaluate the relationship between aging, urodynamic diagnosis and generic quality of life measurement in Chinese women with urinary incontinence. METHODS: A total of 170 women presented to a university teaching hospital with urinary incontinence were recruited. The women completed the medical outcome survey, short form-36 (SF-36), immediately before they had the urodynamic investigation. The women were classified into either (1) genuine stress incontinence (n = 94) or (2) detrusor instability (n = 76). The relationships between aging, the transformed subscale scores, the population standardized component summary scores of the SF-36, and the two groups of women were studied using simultaneous multiple regression analysis. RESULTS: There was no significant difference in the age distribution between the two groups of patients (median age: 47 vs. 48, p = 0.18). However, aging causes significant impairment in the physical functioning (p < 0.001), role physical (p = 0.002) and bodily pain (p = 0.047) domains as well as the physical component scale (p < 0.001) of generic SF-36 quality of life measurements. There was no significant difference in the transformed subscale scores and the component summary scores with respect to different urodynamic diagnoses after adjustment for the effect of age. CONCLUSIONS: Aging causes significant deterioration on physical performance for Chinese women suffering from urinary incontinence. The generic SF-36 questionnaire was unable to detect a significant difference in quality of life measurement between women suffering from genuine stress incontinence and detrusor instability.     

Usefulness of urodynamic investigations in female incontinence.

Urinary incontinence in females has been evaluated in a prospective series of 408 patients by comparing the clinical diagnosis and the subsequent urodynamic findings. The presenting symptoms or combination of symptoms were shown to have only a limited diagnostic predictive value as measured by urodynamic diagnostic criteria. The symptom of stress incontinence was a sensitive detector of genuine stress incontinence (94% sensitivity) but was not very specific (65%). The symptoms of urgency and urge incontinence were found to have limited sensitivity (62%) and specificity (47%) in the detection of detrusor instability. Even patients with isolated complaints of stress incontinence have an incidence of detrusor instability of 52%, whereas 76% of those with a history of isolated urgency and urge incontinence had detrusor instability. An urodynamic evaluation should be performed on most female patients suffering from urinary incontinence and is essential for patients who are being considered for surgery of stress incontinence.     

Race as a predictor of urinary incontinence and pelvic organ prolapse

OBJECTIVE: The purpose of this study was to assess the effect of race on the results of a standardized evaluation of urinary incontinence and prolapse in African Americans and Caucasians. STUDY DESIGN: This was an analysis of 183 African Americans and 132 Caucasians referred consecutively for symptoms associated with urinary incontinence, pelvic organ prolapse, or both. RESULTS: Genuine stress incontinence, detrusor instability, mixed incontinence, or other condition was diagnosed in 22%, 30%, 16%, and 32% of the African-American subjects, respectively, compared with 46%, 13%, 11%, and 31% of the Caucasian subjects (P =.001). There was no significant racial difference in the presence or severity of pelvic organ prolapse. With the use of stepwise logistic regression to compare risk factors for incontinence, Caucasian race was the most significant predictor of genuine stress incontinence (odds ratio 2.21; 95% confidence interval 1.31-3.73), and African-American race was the only significant predictor of detrusor instability (odds ratio 2.6; 95% confidence interval 1.45-4.80). CONCLUSION: Risk factors for and conditions of urinary incontinence differed significantly between African-American and Caucasian women in this population. Racial differences in risk factors and in prevalence of incontinence subtypes may have importance for the diagnosis and prevention of urinary incontinence.     

The Burch colposuspension for recurrent urinary stress incontinence following retropubic continence surgery.

OBJECTIVE: To evaluate the Burch colposuspension with Cherney incision in women with recurrent urinary stress incontinence after retropubic continence surgery. DESIGN: A retrospective review. PARTICIPANTS: All 53 women had recurrent urinary stress incontinence after retropubic continence surgery with an average of 2.1 (range 1-5) previous failed continence procedures per woman. MAIN OUTCOME MEASURES: Subjective and objective success rates and complications including detrusor instability, voiding difficulties and genital prolapse. RESULTS: Forty-seven women (89%) had no or occasional (< one episode per week) stress or urge incontinence. One woman had persistent stress incontinence and five urge incontinence. Forty-two women (80%) rated their surgery as being highly successful and 38 women (72%) had no urinary leakage due to genuine stress incontinence or detrusor instability on repeat urodynamic evaluation. Three women (6%) developed de novo detrusor instability post-operatively. Two women (4%) had voiding difficulties post-operatively that necessitated the use of intermittent self-catheterisation for at least four months. The median length of follow up was nine months (4-72). In 39 women (73%), marked retropubic fibrosis was found at the time of surgery. CONCLUSIONS: Marked retropubic fibrosis should be expected in women with recurrent stress incontinence after retropubic continence surgery. The Burch colposuspension with the assistance of the Cherney incision and sharp dissection of retropubic fibrosis is an effective and safe procedure for women with this condition.     

Incontinence history as a predictor of detrusor stability

Between January 1983 and July 1985, 218 women underwent preliminary evaluation and urodynamic testing in our laboratory. Their symptoms and urodynamic diagnoses were compared to evaluate the ability of a patient's history to predict the stability of the detrusor. The symptom of stress incontinence was a sensitive detector of genuine stress incontinence (100% sensitivity) but was not very specific (65.2%). The symptoms of urgency and urge incontinence were found to have limited sensitivity (77.9%) and specificity (38.7%) in the detection of detrusor instability. Even patients with isolated complaints of stress incontinence had an incidence of detrusor instability of 34.9%, whereas 76.9% of those with a history of isolated urgency and urge incontinence had detrusor instability. Three percent of patients complaining of either type of incontinence had no objective evidence of incontinence on urodynamic investigation. The results of this study demonstrate that a patient's history is a poor predictor of the underlying cause of incontinence.     

Psychosexual study of women with detrusor instability

Clinical impression suggests that many cases of detrusor instability are psychosomatic. We evaluated 63 women with urinary incontinence and 27 continent controls using the Minnesota Multiphasic Personality Inventory, Uplift and Hassle Scales, and a structured questionnaire screening sexual dysfunction. All incontinent women underwent diagnostic urodynamic studies including uroflowmetry, subtracted water cystometry with provocation, and urethral closure pressure profilometry. Thirty-five women had genuine stress incontinence and 28 had detrusor instability, including nine with mixed incontinence. No differences in psychological test results were noted between the detrusor-instability and genuine-stress-incontinence groups. On the Minnesota Multiphasic Personality Inventory, subjects with detrusor instability scored significantly higher than controls on the hypochondriasis (P = .006), depression (P = .01), and hysteria (P = .0009) scales. Compared with continent controls, the detrusor-instability group reported a lower frequency of uplifts (P less than .05) and a greater intensity of hassles (P less than .05). Both incontinent groups reported more sexual dysfunction than did controls. We conclude that many women with urinary incontinence have abnormal psychological and sexual test results reflecting moodiness, feelings of helplessness and sadness, pessimism, general hypochondriasis/somatization, and sexual dysfunction. These abnormalities appear to be associated with urinary incontinence in general rather than with specific diseases of the urinary tract.     

Urinary incontinence during sexual intercourse: a common, but rarely volunteered, symptom

A total of 400 women referred consecutively to a gynaecological urology clinic was questioned with regard to their sexual activity and were subsequently investigated by cystometry to establish the prevalence of urinary incontinence occurring during intercourse, and to define the urodynamic background of sufferers. Of the 400 women 324 were sexually active, and of these 79 (24%) experienced incontinence during intercourse; in two thirds of sufferers incontinence occurred on penetration, whereas in the remaining one third urine leakage was restricted to orgasm. Of the former group 70% were shown to have genuine stress incontinence and 4% detrusor instability; of the latter, 42% had genuine stress incontinence and 35% detrusor instability. A comparison of cystometric variables in these two index groups and matched controls failed to identify any specific abnormality of bladder function associated with these symptoms.