Does Estrogen Have Any Real Effect on Voiding Dysfunction in Women?

For many years, estrogen has been used to treat lower urinary tract dysfunction in postmenopausal women. The data supporting this practice vary. Large multi-institutional studies have shown little role for systemic estrogens in the treatment of urinary incontinence. Vaginal estrogen preparations show superiority to systemic estrogens for the treatment of irritative voiding symptoms in meta-analysis, but there is significant study heterogeneity and the practice remains debatable. Data from randomized controlled trials support estrogen use in the prevention of recurrent urinary tract infections. This article reviews the relevant literature addressing the role of estrogen therapy in urinary incontinence, irritative voiding symptoms, and recurrent urinary tract infections.     

Diversity of urinary symptoms in patients tentatively diagnosed with benign prostatic hyperplasia referred to a urologic clinic in Norway

OBJECTIVE: Lower urinary tract symptoms (LUTS) has become the preferred term used to classify the urinary symptoms of elderly men. This term places more emphasis on clinical appearance rather than being restricted to the functional pathophysiology. The objective of this study was to investigate this new concept in a group of patients who had been tentatively diagnosed with benign prostatic hyperplasia (BPH). The range of urinary symptoms, incontinence, sexual function and impact on daily living were registered. MATERIAL AND METHODS: Data from a group of 480 men awaiting urologic assessment were collected by questionnaire shortly after referral from their general practitioner between 1997 and 2000. The questionnaires used were the International Prostate Symptom Score (IPSS), the Symptom Problem Index, the International Continence Society-BPH, the Sandvik Incontinence Severity Index and the BPH-specific Interference with Activities. RESULTS: The mean age of the subjects was 67.0 years. As assessed by the IPSS, 15%, 54% and 31% of the men had mild, moderate and severe symptoms, respectively. Men who gave positive answers to questions regarding the frequency, amount and type of leakage were considered to have urinary incontinence (UI), which was found in 37% of cases. The majority of men had mild or moderate UI. Influence on daily living varied with the severity of symptoms. However, no significant differences in influence on daily living were found between groups with different degrees of severity of incontinence as all groups reported a relatively high impact. CONCLUSIONS: Our results show that UI is fairly common, very bothersome and socially embarrassing in male LUTS patients waiting for urologic evaluation. Although UI is not typically associated with BPH and is not regarded as a crucial component of LUTS, this study indicates that more emphasis should be placed on UI in the terminology of LUTS. UI may also act as an indicator of a need for healthcare.     

Saw palmetto for the treatment of men with lower urinary tract symptoms

PURPOSE: A comprehensive review of the literature on the use of saw palmetto in men with lower urinary tract symptoms is provided. MATERIALS AND METHODS: A literature search of studies that have assessed the mechanism of action and clinical results of saw palmetto in men with benign prostatic hyperplasia was performed. RESULTS: A variety of potential mechanisms of action of saw palmetto have been demonstrated through in vitro studies, including 5-alpha reductase inhibition, adrenergic receptor antagonism and intraprostatic androgen receptor blockade. Clinical evidence of the relevance of these effects is largely unavailable. The use of saw palmetto in men with benign prostatic hyperplasia is safe with no recognized adverse effects. No effect on serum prostate specific antigen has been noted. Placebo controlled trials and meta-analyses have suggested that saw palmetto leads to subjective and objective improvement in men with lower urinary tract symptoms. However, most studies are significantly limited by methodological flaws, small patient numbers and brief treatment intervals. CONCLUSIONS: Evidence suggests that saw palmetto may have a significant effect on urinary flow rates and symptom scores compared to placebo in men with lower urinary tract symptoms. However, large scale, placebo controlled trials are needed to assess the efficacy of saw palmetto.     

Botulinum toxin for treatment of urinary incontinence due to detrusor overactivity: a systematic review of effectiveness and adverse effects

STUDY DESIGN: Systematic review. OBJECTIVE: To evaluate effectiveness and adverse effects of botulinum toxin (BTX) for treatment of urinary incontinence (UI) due to detrusor overactivity (DO). METHODS: Randomized controlled trials published in English before November 2006 were included if they enrolled subjects with UI caused by DO and reported incontinence outcomes. RESULTS: Three trials totaling 104 subjects with DO refractory to antimuscarinic treatment were included. Two BTX-A trials enrolled primarily patients with NDO secondary to spinal cord injury (SCI) (93%). BTX-A decreased daily UI episodes compared to placebo but the reductions were only significantly different at a few of the time intervals during 24 weeks of follow-up. BTX-A was superior in reducing daily UI episodes in SCI subjects compared to intravesical resiniferatoxin at 12 and 18 months after injections. A small crossover study found BTX-B significantly more effective than placebo in reducing weekly UI episodes in subjects with predominately idiopathic DO. Adverse events (AEs) in BTX-A-treated subjects included urinary tract infection, pain at the injection site, hematuria and autonomic dysreflexia. Four subjects treated with BTX-B reported autonomic AEs. CONCLUSIONS: BTX may improve UI for subjects with refractory DO. The preferred dose and type of BTX is not known. Long-term efficacy and safety remain unclear and require conduct of larger RCT using standardized and validated clinical outcomes measures.     

The Menopause and Bladder Weight

The aim of the study was to determine, whether bladder weight changes in the menopause and whether there is any correlation between lower urinary tract symptoms and bladder weight or the duration of menopause. A total of 94 women (30 without gynecologic or obstetric complaints, 31 with menopause less than 5 years and 33 menopause of 5 years or longer) were entered into the study. Bladder weights were determined ultrasonographically. The International Prostate Symptom Score questionnaire was used to evaluate lower urinary tract symptoms. A negative correlation was found between bladder weight and the duration of menopause. There was no significant difference between the three groups in terms of overall symptom scores. However, urgency incontinence score was the highest in the early postmenopausal period. In addition, the postmenopausal women had a significant negative correlation between the duration of menopause and frequent voiding scores. It was concluded that, ultrasonographically measured bladder weight decreases with the duration of menopause. Detailed studies with larger numbers of older women are needed to determine clearly whether this decrease in bladder weight has more significant effects on lower urinary tract symptoms.     

The placebo effect in the pharmacologic treatment of patients with lower urinary tract symptoms

OBJECTIVES: We reviewed placebo responses in randomised controlled trials (RCTs) for pharmacologic treatment of lower urinary tract symptoms (LUTS), including urinary incontinence (UI), overactive bladder, and benign prostatic hyperplasia. Review papers on placebo effects in non-urologic disorders were assessed to compare the magnitude of placebo responses in drugs for LUTS with those reported for other diseases. METHODS: Data were retrieved from registration trials for LUTS drugs on the Web sites of the Food and Drugs Administration and the European Medicines Agency. Reviews were retrieved from Medline using the MeSH term "placebo effect" (English language; published between 1990 and 2005). RESULTS: Placebo treatment of LUTS yields reductions in incontinence episodes (IEs) ranging from 32% to 65%, whereas prostate or UI symptom scores are reduced by 9-34%. Genuine drugs decrease IEs by 45-77% and symptom scores by 22-45%. Placebo responses are much lower when objective changes in voided volume or peak flow rate are assessed. CONCLUSIONS: The placebo effect in LUTS has a strong behavioural component as patients become aware of their voiding habits and potential risk factors. Symptom severity, treatment naivety, study duration, and interaction with health care providers may also influence it. Proper patient selection, study duration, and objective and subjective outcome measures may better separate genuine treatment effects from artefacts. Observational studies with patients representative for real-life situations and covering a sufficient period of time could allow for better understanding of RCT results and their applicability in clinical practice.     

Urinary Tract Stones and Osteoporosis: Findings From the Women's Health Initiative

Kidney and bladder stones (urinary tract stones) and osteoporosis are prevalent, serious conditions for postmenopausal women. Men with kidney stones are at increased risk of osteoporosis; however, the relationship of urinary tract stones to osteoporosis in postmenopausal women has not been established. The purpose of this study was to determine whether urinary tract stones are an independent risk factor for changes in bone mineral density (BMD) and incident fractures in women in the Women's Health Initiative (WHI). Data were obtained from 150,689 women in the Observational Study and Clinical Trials of the WHI with information on urinary tract stones status: 9856 of these women reported urinary tract stones at baseline and/or incident urinary tract stones during follow‐up. Cox regression models were used to determine the association of urinary tract stones with incident fractures and linear mixed models were used to investigate the relationship of urinary tract stones with changes in BMD that occurred during WHI. Follow‐up was over an average of 8 years. Models were adjusted for demographic and clinical factors, medication use, and dietary histories. In unadjusted models there was a significant association of urinary tract stones with incident total fractures (HR 1.10; 95% CI, 1.04 to 1.17). However, in covariate adjusted analyses, urinary tract stones were not significantly related to changes in BMD at any skeletal site or to incident fractures. In conclusion, urinary tract stones in postmenopausal women are not an independent risk factor for osteoporosis. © 2015 American Society for Bone and Mineral Research.     

Genetics and the lower urinary tract

Many complex disorders have been found to have a heritable component, including lower urinary tract dysfunction. Twin studies have indicated that genetic contributions to urinary incontinence (UI) may be as important as environmental influences. Linkage to chromosome 9 has been demonstrated in families with pelvic organ prolapse and stress UI. An increasing number of incontinence specialists are studying subjects with lower urinary tract dysfunction using single nucleotide polymorphisms, linkage analyses of siblings, and large association studies. These findings have exciting implications for future prevention and treatment of UI. Neurourol. Urodynam. 29:609–611, 2010. © 2010 Wiley‐Liss, Inc.     

Urinary incontinence in persons with Prader‐Willi Syndrome

Study Type – Symptom prevalence (non‐consecutive cohort)
Level of Evidence 3b

OBJECTIVE

To assess and identify the frequency and type of urinary incontinence (UI), as well as associated symptoms in persons with Prader‐Willi syndrome (PWS). PWS is characterized by mental retardation, short stature, obesity and hypogonadism. The behavioural phenotype includes eating problems, temper outbursts, affective disorders, stereotypies and speech abnormalities. UI is common in children with mental retardation in general, but has not been reported systematically in children with PWS so far.

MATERIALS AND METHODS

The Dutch version of the ‘Parental Questionnaire: Enuresis/Urinary Incontinence’ was completed by 118 parents of children with PWS. This questionnaire includes items referring to day‐ and night‐time wetting, toilet habits, observable voiding behaviours and reactions, urinary tract infections, stool habits and behavioural symptoms.

RESULTS

The rate of nocturnal enuresis in persons with PWS was 13.6% (16) at a mean age of 15.1 years. 3.8% (5) had additional daytime urinary incontinence, and 3.3% (4) had faecal incontinence. Lower urinary tract symptoms were commonly indicative of overactive bladder, dysfunctional voiding and postponement. Also, the rate of internalizing and externalizing behavioural problems was high.

CONCLUSION

Urinary incontinence is more common in persons with PWS than in typically developing children, adolescents and adults. As lower urinary tract symptoms are common, detailed assessment and specific treatment of UI should be part of the care of all persons with PWS.     

The effect of overactive bladder syndrome on the sexual quality of life in Korean young and middle aged women

Some reports showed that urinary incontinence (UI) or female lower urinary tract symptoms (LUTS) affect life quality and sexual activity. In clinical practice, it is commonly found that not only the symptoms of UI but also overactive bladder (OAB) syndrome affect daily lifestyle and sexual activity, especially in women in the most active era in their social and personal life. However, there is lack of data proving the effect of OAB syndrome on sexual activity or sexual life quality in sexually active age group. This study aimed at evaluating the effect of OAB syndrome and UI on the sexual activity and on the sexual quality of life (QoL) of Korean women age from 20s to 40s. We investigated 3372 women aged between 20 and 49 y, enrolled via a multicenter internet survey. A structured questionnaire was used to collect data about their LUTS and sexual activities. The prevalence of OAB syndrome and UI in 3372 women was 12.7 and 21.0%, respectively. Mean subject age was 26.4+/-4.8 y and 79.5% of subjects were 20-29 y old. Having OAB syndrome or UI were found to be significant predictors of sexual life problems (OAB syndrome: OR=5.08, 95% CI=3.68-7.01; UI: OR=4.16, 95% CI=3.06-5.67). Sexual activity was significantly reduced in OAB syndrome and UI versus the asymptomatic group (OAB syndrome: OR=4.8, 95% CI=3.14-6.83; UI: OR=3.9, 95% CI=2.81-5.27). This study is the first internet-based study concerning the sexual QoL in UI and OAB syndrome. In this study, OAB syndrome was found to cause a greater deterioration in the sexual QoL than UI. These results suggest that these symptoms have a significant impact upon women's personal and social lives and markedly affect the QoL.     

Frequency and distribution of uropathogenic Escherichia coli adhesins: a clinical correlation over 2,000 cases.

In order to determine the pathogenic responsibility of Escherichia coli adhesins (ADHs) in urinary infections (UI), 2,000 different patients suffering different clinical urinary and male sexual gland infections were monitored. The ADHs were determined by agglutination techniques with human and guinea-pig red blood cells, Candida albicans and Saccharomyces cerevisiae cells and latex sensitized with GAL-GAL. In uncomplicated UIs, the possession of ADH is the main invasion mechanism for E. coli. The rate of E. coli ADH strains is very high (89%) in acute cases (727 of 818 cases: 310 of 362 cystitis; 104 of 113 recidivant cystitis; 120 of 126 pyelonephritis; 158 of 173 prostatitis, and 34 of 43 orchiepididymitis) and rare (10%) in asymptomatic or chronic cases (24 of 235 cases: 14 of 148 bacteriurias; 8 of 74 prostatitis, and 2 of 13 orchiepididymitis). A close relation is established between the presence of ADH and clinical symptoms. 90% (218 of 242) of acute cases with systemic symptoms are due to MR-type ADH strains, especially the P subtype. 71% (409 of 576) of acute cases with local symptoms are due to MS-type ADH strains. In complicated UIs the expression of ADH is not an essential condition for the invasion of the urinary apparatus. It has been strongly suggested that males are significantly more resistant to UI, both in the tract and parenchyma, than women. It can be deduced that the underlying disease is more liable to UI the lower the adherence level shown by isolated strains. Thus catheters, reflux and neurogenic bladder are, by far, more aggressive alterations than the prostatic adenoma, vesical tumor or lithiasis.     

The association between lower urinary tract symptoms and sexual dysfunction: fact or fiction?

PURPOSE OF REVIEW: Both lower urinary tract symptoms and sexual dysfunction are common conditions in aging men. In the past few years, increasing attention has been paid to the question of whether these conditions are associated in any way. The conventional belief of the majority of urologists so far has been that the coexistence of these two conditions is coincidental. This review was conducted to discuss the recent literature on this issue. In addition we will concisely address the effect of the different treatment modalities on sexual function. RECENT FINDINGS: Several trials were conducted recently to assess the association between lower urinary tract symptoms and sexual dysfunction. These trials all made use of self-reported questionnaires on urinary symptoms and sexual function sent to representative samples of the community. The occurrence of urinary symptoms appeared to be a risk factor for the development of erectile dysfunction, ejaculation disorder and decreased libido. Importantly, this association was independent of age and various co-morbidities. SUMMARY: In contrast to long-established opinion, an age-independent association between lower urinary tract symptoms and sexual dysfunction was found in several recent population-based trials. The nature of this association, however, remains unclear. Future study is required to gain a better understanding of the possible underlying mechanisms.     

Lower urinary tract symptoms in women with pelvic organ prolapse

Introduction and hypothesis  

The objective of this study was to describe lower urinary tract symptoms (LUTS) and urinary incontinence (UI) symptoms in women with prolapse.     

Relevance and variability of the severity of incontinence, and increased daytime and night-time voiding frequency, associated with quality of life in men with lower urinary tract symptoms

OBJECTIVES: To estimate the distribution of the severity of urinary incontinence (UI) and daytime and night-time voiding in patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH); to estimate the proportion of 'subjectively relevant' symptoms within each severity category; to identify differences in quality of life (QoL) by degree of subjectively relevant daytime and night-time symptoms; and to identify differences in QoL in men with subjectively relevant UI or no UI. PATIENTS AND METHODS: Data from a group of 480 men awaiting urological assessment for LUTS suggestive of BPH were collected by questionnaire shortly after referral from their general practitioner in 1997-2000. The International Continence Society--Benign Prostatic Hyperplasia Index, Sandvik's Incontinence Severity Index, and the World Health Organization Quality of Life Survey--Abbreviated Version (WHOQoL-bref) were used to assess symptoms and QoL. RESULTS: There was a large heterogeneity of self-reported symptom severity and related bother in the three symptoms of UI, increased daytime voiding frequency and night-time voiding in these referred patients. The WHOQoL-bref showed significant group differences of subjectively relevant symptoms. CONCLUSION: The perception of increased night and daytime frequency, as measured by symptom severity and bother, varied greatly. The severity of UI and its effect on men waiting for a urological assessment of LUTS suggestive of BPH also varied widely. In general, the symptoms and their impact were slight to moderate. The WHOQoL-bref could be used to differentiate among groups of subjectively relevant symptoms, and in so doing supported information generated by the bother question.     

Estrogens and the lower urinary tract

The urogenital tract is sensitive to the effect of oestrogen and progesterone throughout adult life. Epidemiological studies have implicated oestrogen deficiency in the aetiology of lower urinary tract symptoms occurring following the menopause. Although to date the role of oestrogen replacement therapy in the management of postmenopausal urinary incontinence remains controversial its use in the management of women complaining of urogenital atrophy is now well established. This aim of this paper is to review the recent evidence regarding the urogenital effects of hormone therapy with a particular emphasis on the management of postmenopausal urinary incontinence, overactive bladder, recurrent lower urinary tract infections and urogenital atrophy. In addition to a review of the available evidence suggestions are also made regarding priorities for further research in the field.     

The effect of concealed concomitant anal incontinence symptoms in patients with urinary incontinence on their quality of life

Introduction and hypothesis

We evaluated the bother of concomitant anal incontinence (AI) in women with urinary incontinence (UI) who do not primarily report their anal symptoms.

Methods

This prospective study assessed patients with complaings of primary UI without initially reporting anal symptoms. After urogynecological assessment, all patients were asked to complete the validated versions of the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire (IIQ-7), Pelvic Floor and Incontinence Sexual Impact Questionnaire (PISQ-12), Wexner Incontinence Scale (WIS) score, and Beck Anxiety Inventory (BAI). Patients who scored nil in the WIS constituted the group of only UI, and patients with scores ≥1 were grouped as double incontinence (DI)., and the groups were compared.

Results

Among 136 women, 69.1 % (94) had only UI, whereas 30.9 % (42) had DI. There were no differences in age, parity, body mass index (BMI), and prolapse status between patients with UI and those with DI, except menopausal status. Women with DI scored worse for IIQ-7, PISQ-12, and BAI questionnaires compared with women with UI. This difference was not statistically significant for IIQ-7 only.

Conclusions

Our data show that concealed AI symptoms may contribute to the anxiety of the patient and even alter the perception of urinary symptoms. Actually, a significant number of women suffer from DI without reporting their anal symptoms, which results in underdiagnosing of concomitant AI. To prevent the suboptimal management of patients with lower urinary tract symptoms, standardized questionnaires for AI should be included in the evaluation of all patients with lower urinary tract symptoms.     

A population-based study of urinary symptoms and incontinence: the Canadian Urinary Bladder Survey

OBJECTIVE

To ascertain the prevalence of lower urinary tract symptoms (LUTS) and urinary incontinence (UI) in Canada, using a cross‐Canada telephone survey, as there is a wide discrepancy in the reported prevalence of these conditions.

SUBJECTS AND METHODS

A random survey with a standardized questionnaire was conducted to elicit responses from 1000 adults, aged ≥ 18 years; the sample was intended to reflect the population census. Data on age, level of education and household income were obtained from all respondents. All participants were questioned about urinary symptoms and daytime and night‐time voids. For those who reported more symptoms than one episode of nocturia a more detailed questionnaire was used to ascertain symptom severity and duration.

RESULTS

Data were analysed from 1000 respondents (482 men, mean age 44 years; 518 women, mean age 45 years). Half the respondents (43% of men and 57% of women) reported one or more LUTS, with nocturia the most common, at 36%. Overactive bladder (OAB) symptoms (urgency, with or with no urgency UI, usually with frequency and nocturia) were reported by 13.9% of respondents (13.1% of men and 14.7% of women). UI was reported by 28.8% of women with the 68% of these having stress UI (SUI), followed by mixed UI (MUI) in 21%, and urgency UI (UUI) in 11%. Of the 5.4% of men with UI, 27% had SUI, 15% had MUI, and 58% had UUI. Overall, the prevalence of LUTS increased with age. Respondents reported that symptoms were present for a median of 5 years.

CONCLUSION

LUTS and UI are common in the Canadian population and increase with age. The prevalence in Canada of these conditions is similar to that seen in other countries.     

绝经后与育龄期女性泌尿道微生态的复杂多样化及与尿路感染关系的研究

目的探讨女性泌尿道宿主、环境、微生物菌群间的关系及宿主反应性变化,证明泌尿道存在特征性菌群;探讨菌群变化与尿路感染的关系,对尿路感染诊疗产生观念性改变。方法临床资料收集于2018年2月至2018年3月期间,应用16SrRNA基因测序对健康绝经后(A组,5例)、健康育龄期(B组,5例)及尿路感染的绝经后女性(C组,14例)尿液进行菌群测定,分析泌尿道菌群结构和组成的多样性及差异性。结果女性尿液中包含种类繁多的微生物菌群,构成多样化,个体差异明显,一般以一种或两种菌种占优势,健康育龄期、绝经后女性组优势菌种主要为乳酸杆菌属、加德纳菌属及鞘氨醇单胞菌属,而鞘氨醇单胞菌属在尿路感染绝经后女性组丰度则明显下降;同时,尿路感染组优势菌群主要为肠杆菌科及乳酸杆菌属,且肠杆菌科丰度明显高于另外两组;而乳酸杆菌属丰度水平在健康育龄期组则明显高于绝经后两组。结论女性泌尿道菌群以乳酸杆菌属为优势菌,绝经后尿路感染女性泌尿道菌群表现为乳酸杆菌属、鞘氨醇单胞菌属显著减少及肠杆菌科丰度增加,提示这可能是引起绝经后妇女尿路感染发病率升高的重要原因,为诊断尿路感染及非抗菌素手段治疗尿路感染提供思路。     

Male overactive bladder: The role of urodynamics and anticholinergics

Millions of men suffer from overactive bladder and lower urinary tract symptoms. The adverse effects on quality of life and costs associated with the condition have been well described. In men, the pathophysiology of lower urinary tract symptoms may be from a number of causes including bladder outlet obstruction, detrusor overactivity, or both. Increasing data and clinical experience support the efficacy and safety of anticholinergics in men; the rate of urinary retention has been equal to that of placebo in short-term studies. Urodynamics play a vital role in defining the bladder and/or outlet dysfunction and help direct one’s therapy.     

选择性雌激素受体调节剂与女性压力性尿失禁

雌激素疗法治疗女性尿失禁存在争议。本文综述雌激素与尿失禁的关系,及选择性雌激素受体调节剂(selective estrogen receptor modulators,SERMs)对尿失禁的临床观察及机制研究,为尿失禁的治疗提出新的前景。