Pad Testing in Incontinent Women: A Review

This article reviews the literature on pad-weighing tests used for objectifying and quantifying incontinence in urinary incontinent women. The patients wear pads weighed before and after the test period. A weight gain is taken as a measure of the amount of urine loss. The tests are in principle of two different types: short-term office tests and long-term home tests, and measure different aspects of urinary control and dysfunction. Both have an inherent large intra- and interindividual variability. Pad weight gains obtained from patients referred for incontinence and those from self-reported continent controls overlap to a certain degree, and it is not possible to identify distinct numerical cut-off values separating continence from incontinence. This suggests that incontinence is a complex condition in which the amount of leakage, other sources of weight gain, and differences in the individual patients’ personal characteristics influence the identification and quantification of the problem. In spite of the shortcomings the pad tests remain a valuable tool for both the clinician and the researcher. The home pad tests are superior to the office tests in terms of authenticity, and should be performed with a concomitant systematic registration of the participant’s voidings, fluid intake and episodes of incontinence.     

Pharmacologic Causes of Female Incontinence

The etiology of female urinary incontinence is complex and multifactorial. Many medications have adverse effects on the lower urinary tract, including the promotion of incontinence in certain women. Medications may cause incontinence through three main mechanisms: decreased intraurethral pressure, increased intravesical pressure, and indirect effects on the lower urinary tract. Careful adjustments of a patient’s medications based on a knowledge of pharmacologic mechanisms of action may restore continence in some women.     

Urinary Incontinence in Elite Female Athletes and Dancers

The aim of this study was, to determine the frequency of urinary loss in elite women athletes and dancers. Elite athletes in eight different sports, including ballet, filled in an evaluated questionnaire about urinary incontinence while participating in their sport/dancing and during daily life activities. A total of 291 women with a mean age of 22.8 years completed the questionnaire, providing a response rate of 73.9%. Overall, 151 women (51.9%) had experienced urine loss, 125 (43%) while participating in their sport and 123 (42%) during daily life. The proportion of urinary leakage in the different sports was: gymnastics 56%, ballet 43%, aerobics 40%, badminton 31%, volleyball 30%, athletics 25%, handball 21% and basketball 17%. During sport 44% had experienced leakage a few times, 46.4% now and then, and 9.6% frequently. During daily life the figures were: 61.7% a few times, 37.4% now and then, and 0.8% frequently. Of those who leaked during sport, 95.2% experienced urine loss while training versus only 51.2% during competition (P<0.001). The activity most likely to provoke leakage was jumping. Sixty per cent (91/151) occasionally wore pads or panty shields because of urine loss. Urinary leakage is common among elite athletes and dancers, particularly during training, but also during daily life activities.     

Long-Term Results of the FemSoft1 Urethral Insert for the Management of Female Stress Urinary Incontinence

A 5-year ongoing, controlled multicenter study enrolled 150 women. Outcome measures included pad weight tests (PWT), voiding diary (VD), quality of life (QOL) and satisfaction questionnaires. Outcome measures during the baseline period were compared to evaluations during follow-up. Concurrent evaluations with and without device use were also performed. Safety evaluations included urinalysis and culture, leak-point pressure (LPP) and cystoscopy. Adverse events (AE) were recorded throughout the study. One to 2 years of follow-up were collected on all study participants (mean 15 months). Statistically significant reductions in overall daily incontinence episodes (P<0.001) and PWT urine loss (P<0.001) were observed with the device at all follow-up intervals, and 93% of women had a negative PWT at 12 months. Women were satisfied with ease of use of the device, comfort and dryness, and significant improvements in QOL were observed (P<0.001). Subgroup analysis revealed that the insert was effective, despite the presence of urgency, low LPP, failed surgery and advanced age. AE included symptomatic urinary tract infection in 31.3%, mild trauma with insertion in 6.7%, hematuria in 3.3%, and migration in 1.3% of women. The results of PWT and VD demonstrated device efficacy. Women were satisfied and significant improvements in QOL were observed. AE were transient and required minimal or no treatment. The urethral insert should be considered as an option for the management of SUI.     

A Critical View on the Value of Urodynamics in Non-Neurogenic Incontinence in Women

The requirements for reliable urodynamics are standardized techniques, including uniform pressure sensors, filling rates, position and posture during the investigation, and uniform diuresis. Physiological variations in flow and urethral pressure profile (UPP) (menstrual cycle, intensity of coughing, circadian variations) must be considered. Parameters of the UPP (maximum (closure) urethral pressure, pressure–transmission ratio and leak-point pressure) are useful if interpreted with caution. Uninhibited detrusor contractions are more frequently recorded in ambulatory urodynamics, and range from ‘subthreshold’ to very strong. No quantification formulae correlate with subjective symptoms or degree of urge (incontinence). Mixed incontinence can make the results of surgery worse, but do not so necessarily. Postoperative dysuria cannot be predicted from urodynamics, as surgical factors are more important. Electromyography is not useful in non-neurogenic female incontinence. For routine non-neurogenic incontinence extensive urodynamic testing can be reduced to one pressure measurement; more complicated cases must be tested by a physician with large practical experience and a theoretical background.     

Correlates of Urinary Incontinence in Pregnancy

In a population sample, the period prevalence of urinary incontinence (UI) during pregnancy was found to be 19.9% and 24.1% among 352 nulliparous and 290 primiparous women, respectively. The first UI episode ever was experienced by 16.7% and 7.0% during the two last trimesters of the first and second pregnancies, respectively. None of the pregnancy-specific risk factors, such as emesis and birthweight, was significantly associated with UI during pregnancy. Previous UI was a significant risk factor for period prevalent UI during pregnancy, explaining 34% and 83% of pregnancy UI for the nulliparous and the primiparous, respectively. The present data suggest pregnancy UI not to be provoked by the mere onset of pregnancy, but by increasing hormonal concentrations or local tissue changes caused by hormones, whereas there was no support for a theory based on increasing pressure on the bladder caused by the weight of the fetus.     

A Vaginal Device (Continence Guard) in the Management of Urge Incontinence in Women

The aim of the study was to assess the efficacy of a disposable vaginal device in the management of urge incontinence. A total of 38 women with urge incontinence and uninhibited bladder contractions during cystometry were included. They wore the device from morning to night. Before, and again after, using the device for 1 month the women were assessed by pelvic examination, uroflowmetry, postvoid residual urine, two 24-hour pad-tests, a 3-day voiding diary and vaginal and urine cultures. A questionnaire about the subjective effect and adverse events was completed. Thirty women (79%) completed the study. Two (6.7%) were subjectively cured when using the device, 15 (50%) were improved, and 13 (43.3%) experienced unchanged incontinence. The 24-hour pad-test leakage showed a statistically significant decrease (P = 0.001) – in 11 women (36.7%) the decrease was more than 50%. The other urodynamic results were unchanged. A significant decrease in the number of daily micturitions was found in the group of responders (P = 0.02). No vaginal infections were found; 4 women (13%) had uncomplicated urinary tract infection during the test-period. Subjective complaints were few, and 21 women (70%) wanted to continue the treatment with the device. The vaginal device constitutes a new option in the management of urge incontinence, with a subjective and objective cure/improvement rate of 56.7%. The device is easy to use and well accepted.     

VLPP in the Evaluation of the Female with Stress Urinary Incontinence

The Valsalva leak-point pressure has become an important urodynamic test in the evaluation of incontinent women. A review of the history of the test, its methodology, and variables that can influence its performance is presented. Correlation with clinical findings, reproducibility and comparison with other urodynamic tests are discussed. Although the test is still evolving and several major variables have been recognized as affecting its results, it remains sound and reliable. It has excellent correlation with the clinical severity of incontinence and a high degree of inter- and intraexaminer reproducibility.     

Treatment of Female Urinary Incontinence with EMG-Controlled Biofeedback Home Training

The aim of the study was to evaluate the efficacy of pelvic floor training with EMG-controlled home biofeedback in the treatment of stress and mixed incontinence in women. Subjects were recruited from the urodynamic outpatient clinic and performed pelvic muscle training with an EMG-controlled biofeedback device for 20 minutes daily for 6 months. The number of pads used per day, the number of incontinence and urgency episodes, voiding frequency, maximum urethral closure pressure, functional urethral length and pressure/transmission ratio during stress were assessed before and after treatment. Thirty-three patients (13 with stress and 20 with mixed incontinence) completed the study. There was a significant decrease in the number of pads used per day, the number of incontinence and urgency episodes, and the voiding frequency. Twenty-eight patients (85%) reported that they were cured or improved. Urodynamic parameters did not change significantly. It was concluded that home pelvic floor training with EMG-controlled biofeedback is efficient in 85% of patients in alleviating the symptoms of genuine stress and mixed incontinence without causing side effects.     

Identifying Bone-Mass-Related Risk Factors for Fracture to Guide Bone Densitometry Measurements: A Systematic Review of the Literature

Available evidence suggests that fracture prediction with bone densitometry may improve when used on people at high risk of osteoporotic fractures. The objectives of this literature review were: (1) to identify risk factors for fracture that are associated with the development of a low bone mass for both men and women; (2) to describe and assess the relationship between these factors and the risk of fracture; and (3) to classify them according to the strength of their association with fracture incidence. Studies were identified from MEDLINE (1982-1997), HealthSTAR (1975-1997) and The Cochrane Library (1997) databases. Pre-stated inclusion criteria (original analytic studies assessing risk factors for osteoporotic fractures in men and women) and methodologic quality were assessed by two independent investigators. Information on the study design and analysis, characteristics of participants, exposure (risk factor) and outcome measures (relative risk and odds ratios for fracture incidence), control for potential confounding factors and risk estimates was extracted using a standardized protocol. Qualitative and meta-analytic techniques were used for data synthesis. As a result, risk factors were classified into three groups according to their strength of association with fracture: high risk (RR > or = 2), moderate risk (1 < RR < 2) and no risk or protective (RR < or = 1). Of approximately 80 risk factors identified from 94 cohort and 72 case-control studies, 15% were classified in the high-risk group, including low body weight, loss of weight, physical inactivity, the consumption of corticosteroids or anticonvulsants, primary hyperparathyroidism, diabetes mellitus type 1, anorexia nervosa, gastrectomy, pernicious anemia, and aging (> 70-80 years). Eighteen percent and 8% of risk factors were classified in the moderate and no risk group respectively, whereas 60% showed either a lack of scientific evidence confirming their association with fracture or contradictory results. An efficient strategy for bone densitometry provision may thus be its selective use in those individuals who present with several strong or moderate risk factors for fracture related to bone mass loss.     

A Systematic Review of Estrogens for Recurrent Urinary Tract Infections: Third Report of the Hormones and Urogenital Therapy (HUT) Committee

Our objective was to apply a meta-analysis to the available data to evaluate the effect of estrogen supplementation in the prevention of recurrent urinary tract infections in postmenopausal women. The literature review incorporated articles based on a search of Excerpta Medica, Medline, Science Citation Index and a manual search of commonly read journals in the fields of urology, gynecology, gerontology and primary healthcare, from January 1969 to December 1998. The search was not limited to English-language publications. Inclusion criteria were peer-reviewed articles containing original data with a primary outcome of symptomatic urinary tract infections and an estrogen-treated group. Articles were categorized into randomized controlled trials, case–control studies and self-controlled series. Of the articles reviewed, five were randomized controlled trials, two were case–control studies and three were self-control series. Meta-analysis of data from 334 subjects revealed a significant benefit from estrogen over placebo (odds ratio = 2.51, 95% confidence interval = 1.48–4.25). The most convincing results were obtained using the vaginal route of administration. A variety of different estrogen preparations have been employed in the few published reports, making comparison of the data difficult. However, vaginal administration seems to be effective in the prevention of recurrent urinary tract infections in postmenopausal women.     

Predictive Value of Clinical Evaluation of Stress Urinary Incontinence: A Summary of the Published Literature

Our objective was to evaluate the symptom and sign of stress incontinence in predicting the presence of urodynamically diagnosed genuine stress incontinence (GSI). The study was a computation of the sensitivity and predictive values from the published literature (1975–1998), evaluating the history and/or physical examination for the diagnosis of GSI, with calculation of efficacy variables. Results show that the isolated symptom of stress incontinence has a positive predictive value (PPV) of 56% for the diagnosis of pure GSI and 79% for GSI with additional abnormalities. The PPV of stress incontinence in association with other symptoms is 77% in detecting GSI (with or without additional abnormalities). A positive cough stress test has a PPV of 55% for detecting pure GSI and 91% for the mixed condition (GSI plus additional diagnosis). When isolated, the symptom or the sign of stress incontinence is a poor predictor of GSI. In combination, the prediction may be more promising.     

The Prevalence and Determinants of Health Care-Seeking Behavior for Urinary Incontinence in United Arab Emirates Women

The aim of this study was to determine the prevalence and sociodemographics of urinary incontinence (UI) in women in the United Arab Emirates (UAE). Women at risk, such as multiparous and climacteric women, were selected from the community (n= 200) and health-care centers (n= 200) and interviewed about inappropriate urine loss in the past 12 months, using a structured and pretested questionnaire. Of these, 81 (20.3%) admitted UI; only 25 of these (30.9%) had sought medical advice. The reasons were embarrassment (38.2%), choice of self-treatment because of low expectations from medical care (38.2%), and preferring to discuss the matter with friends, assuming that UI is normal (23.3%). Sufferers were troubled by their inability to pray (90%) and to have sexual intercourse (33.3%). Perceived causes of UI were paralysis (45%), childbirth (35.4%) and old age or menopause (33.7%). UI is common yet underreported by UAE women because of cultural attitudes and inadequate public knowledge.     

Urinary Diversion for Incontinence in Women

Urinary incontinence is a common condition affecting up to 50% of the female population, but only a third seek medical help. Although the majority of these are satisfactorily managed with conservative or conventional surgical treatment, 10%–15% continue to remain incontinent despite intervention. Urinary diversion is a management option for this group. The different techniques of urinary diversion, their results, complications and long-term sequelae are discussed, with a review of the literature.     

The Prevalence of Urinary and Fecal Incontinence in Canadian Secondary School Teenage Girls: Questionnaire Study and Review of the Literature

The purpose of this study was to examine the prevalence of pelvic floor dysfunction and incontinence in the Canadian nulligravid secondary school female teenage population. During the University of Toronto day in 1996, female visitors to the Obstetrics and Gynecology Department booth were asked to complete anonymous pelvic floor and continence questionnaires, which were thoroughly explained to them and completed during their visit. Out of the 332 completed forms, 69% were completed by nulligravid teenagers in secondary school. These students formed our study population. The prevalence of urgency urinary incontinence (UUI) symptoms was 17% and of stress urinary incontinence (SUI) symptoms was 15%. In all candidates these reported symptoms were mild, occurring less than once a week. Occasional minor fecal incontinence (involuntary loss of flatus or fecal staining) was 38%; of these, 92% reported loss of flatus. Major fecal incontinence with loose bowel movements was reported by 3% of the study population. Two girls (1%) reported nocturnal enuresis. Weight directly correlated with SUI symptoms and fecal incontinence, but not with UUI. Fecal incontinence correlated with SUI symptoms (P = 0.0152), but not with UUI. Ten per cent of the study population were sexually active, but sexual activity did not correlate with incontinence problems. Voiding habits were markedly variable: 30% were infrequent voiders (three times or fewer per day). Nocturia was reported by 3%. We concluded that in nulligravid teenage female students minor fecal incontinence appears to be the most common incontinence type; urge incontinence was slightly more common than SUI. Unlike UUI, SUI symptoms were more prevalent with fecal incontinence, which were affected by weight. There appears to be a problem with a high prevalence of poor voiding habits.     

Results and Complications of Tension-Free Vaginal Tape (TVT) for Surgical Treatment of Female Stress Urinary Incontinence

Thirty-one patients with stress urinary incontinence were operated on using tension-free vaginal tape (TVT). All were evaluated preoperatively with urodynamics, pad test and stress test. Conservative treatment was without significant effect. Three months after the operation no patients had stress incontinence but 1 with mixed incontinence experienced deterioration of her urge incontinence and 2 experienced de novo urge incontinence. The de novo urge incontinence was significantly improved and the urodynamic investigation normal after approximately 5 months. One patient with a previous operation with Kelly sutures under the urethra developed a urethrovaginal fistula. Fifteen patients were observed for 1 year. One patient who was continent after 3 months developed slight stress incontinence.     

Long-term Assessment of the Incontinence Ring Pessary for the Treatment of Stress Incontinence

A prospective cohort of 38 women who presented with predominantly stress incontinence symptoms were fitted with an incontinence ring pessary. They had documented stress incontinence on multichannel urodynamic testing. Nine women (24%) were not leaking by subjective measures. Six women (16%) continued using the pessary. This group of women had no statistically identifiable parameters that distinguished them from women who had not wanted to continue using the pessary. There was a trend showing that successfully fitted women were younger (41 vs 52 years old), had less pelvic surgery and leaked less on semiquantitative pad testing (10.7 g vs 19.2 g). In women who chose to continue using the pessary there was a trend showing a decrease in the semiquantitative pad score (1.2 g from 10.7 g) and 7-day voiding diary (1.5 episodes from 4.1). In conclusion, the incontinence pessary was successful in a small proportion of women with stress incontinence.     

Urogynecologic Ultrasound is a Useful Aid in the Assessment of Female Stress Urinary Incontinence – A Prospective Study with TVT Procedure

The aims of the study were to study the suitability of certain urogynecologic ultrasound parameters, e.g. descent of the urethrovesical (UV) junction on Valsalva, posterior urethrovesical (PUV) angle both at rest and on Valsalva, and funneling of the vesical neck, in the pre- and postoperative assessment of stress urinary incontinence (SUI) and to evaluate the efficacy and safety of tension-free vaginal tape (TVT) for the surgical treatment of SUI. Forty-six consecutive women (mean age 61 years) with symptoms of SUI underwent TVT placement. The patients were examined prior to and on average of 11 weeks after the operation with perineal ultrasound. An upright coughing test on standing was performed every time. Operative success rate was 94% in this series. Urogynecologic perineal ultrasound examination seemed strongly to support an anamnestic diagnosis of genuine SUI, and TVT proved to be a safe and effective ambulatory procedure for the surgical treatment of SUI.     

Controversies in Female Urethral Anatomy and their Significance for Understanding Urinary Continence: Observations and Literature Review

To re-examine the anatomy of the female urethra and related structures, three female pelves serially sectioned in sagittal, coronal or transverse planes, and four sets of transverse histological slides of female urethras, were studied. The observations were assembled, rendered as illustrations, and correlated with published works to present an overall explanation of the gross and histological anatomy of the female pelvis and perineum as related to continence. The figures accompanying the text present the anatomy in a series of views in the three anatomical planes. The anatomical relationships of the paraurethral and paravaginal tissues are examined in relation to the conflicting nomenclature applied to these structures. The figures show the spatial relationships within the pelves and perineum that explain their effective function in urinary continence.     

Outcome of Burch Retropubic Urethropexy and the Effect of Concomitant Abdominal Hysterectomy: A Prospective Long-term Follow-up Study

A prospective follow-up study was performed to evaluate the effect of a concomitant abdominal hysterectomy with Burch colposuspension. Sixty-five women underwent Burch colposuspension (the Burch group) and 78 women colposuspension with concomitant abdominal hysterectomy (the hysterectomy group) during a 1-year period in Turku University Hospital. Subjective outcome was assessed with three questionnaires: at 6 weeks, 1 year, and a mean of 4.9 years after the operation. Complications related to the operation occurred in 19 patients (29.2%) in the Burch group and in 36 (46.2%) in the hysterectomy group (P= 0.038). No statistically significant difference in the frequency of any subgroup of complications was found. Instead, complications cumulated to fewer patients in the Burch group. During postoperative care in the hospital intermittent catheterization to treat transient urinary retention was needed more frequently in the Burch group than in the hysterectomy group (10.8% vs. 1.3%, P= 0.046). No significant difference was found in subjective short- and long-term outcome. In the long-term follow-up 79% were subjectively cured or improved, 77% in the Burch group and 81% in the hysterectomy group.