Synthetic vs nonsynthetic slings for female stress and mixed urinary incontinence: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to systematically review objective and subjective success and surgical outcomes of suburethral sling surgery for female patients with stress or mixed urinary incontinence using synthetic vs nonsynthetic material with corresponding surgical approaches (retropubic or transobturator). DATA SOURCES: We systematically searched Medline, Embase, EBM Reviews, ClinicalTrials.gov, and Web of Science Core Collection using standardized Medical Subject Headings (MeSH) without date restrictions (PROSPERO-registered). We double-screened studies and used backward citation chaining. STUDY ELIGIBILITY CRITERIA: We included peer-reviewed randomized controlled trials and prospective or retrospective comparative studies examining outcomes of retropubic or transobturator synthetic vs nonsynthetic (autologous, allograft, or xenograft) slings for female stress or mixed urinary incontinence, with available English or French full texts. We excluded minislings (single insertion point). We allowed slings for recurrent stress or mixed urinary incontinence, and slings concomitant with prolapse surgery, with at least 6 weeks of postoperative follow-up. We excluded systematic reviews, meta-analyses, review studies, case-control studies, case reports, studies that did not describe surgical approach or material, and studies of combination slings. METHODS: We evaluated study quality using RoB, the Cochrane risk-of-bias tool for randomized controlled trials, and the Newcastle-Ottawa scale for observational studies. We used pooled relative risk with 95% confidence intervals to estimate the effect of sling material type on each outcome through meta-analysis and meta-regression, as appropriate. RESULTS: We screened 4341 abstracts, assessed 104 full texts, and retained 35 articles (30 separate studies). For retropubic synthetic vs nonsynthetic slings, there was no difference in the number of objectively or subjectively continent patients. The rates of reoperation for stress urinary incontinence and overall were higher with nonautologous retropubic slings than with synthetic slings. Compared with autologous slings, retropubic synthetic slings were associated with higher subjective continence in populations with ≥25% recurrent stress urinary incontinence (relative risk, 1.27; 95% confidence interval, 1.12-1.43). There were no differences in continence between transobturator synthetic and nonsynthetic slings. Subjective satisfaction was better in the transobturator synthetic group than in the autologous sling group (relative risk, 1.42; 95% confidence interval, 1.03-1.94). CONCLUSION: Synthetic and nonsynthetic slings have comparable objective and subjective success, with synthetic materials generally showing better operative outcomes and fewer complications.

Urinary microbiome community types associated with urinary incontinence severity in women.

BACKGROUND: Urinary microbiome (urobiome) studies have previously reported on specific taxa and community differences in women with mixed urinary incontinence compared with controls. Therefore, a hypothesis was made that higher urinary and vaginal microbiome diversity would be associated with increased urinary incontinence severity. OBJECTIVE: This study aimed to test whether specific urinary or vaginal microbiome community types are associated with urinary incontinence severity in a population of women with mixed urinary incontinence. STUDY DESIGN: This planned secondary, cross-sectional analysis evaluated associations between the urinary and vaginal microbiomes and urinary incontinence severity in a subset of Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence trial participants with urinary incontinence. Incontinence severity was measured using bladder diaries and Urinary Distress Inventory questionnaires collected at baseline. Catheterized urine samples and vaginal swabs were concurrently collected before treatment at baseline to assess the urinary and vaginal microbiomes. Of note, 16S rRNA V4 to V6 variable regions were sequenced, characterizing bacterial taxa to the genus level using the DADA2 pipeline and SILVA database. Using Dirichlet multinomial mixtures methods, samples were clustered into community types based on core taxa. Associations between community types and severity measures (Urinary Distress Inventory total scores, Urinary Distress Inventory subscale scores, and the number of urinary incontinence episodes [total, urgency, and stress] from the bladder diary) were evaluated using linear regression models adjusted for age and body mass index. In addition, alpha diversity measures for richness (total taxa numbers) and evenness (proportional distribution of taxa abundance) were analyzed for associations with urinary incontinence episodes and community type. RESULTS: Overall, 6 urinary microbiome community types were identified, characterized by varying levels of common genera (Lactobacillus, Gardnerella, Prevotella, Tepidimonas, Acidovorax, Escherichia, and others). The analysis of urinary incontinence severity in 126 participants with mixed urinary incontinence identified a Lactobacillus-dominated reference group with the highest abundance of Lactobacillus (mean relative abundance of 76%). A community characterized by fewer Lactobacilli (mean relative abundance of 19%) and greater alpha diversity was associated with higher total urinary incontinence episodes (2.67 daily leaks; 95% confidence interval, 0.76-4.59; P=.007) and urgency urinary incontinence episodes (1.75 daily leaks; 95% confidence interval, 0.24-3.27; P=.02) than the reference group. No significant association was observed between community type and stress urinary incontinence episodes or Urogenital Distress Inventory total or subscores. The composition of vaginal community types and urinary community types were similar but composed of slightly different bacterial taxa. Vaginal community types were not associated with urinary incontinence severity, as measured by bladder diary or Urogenital Distress Inventory total and subscale scores. Alpha diversity indicated that greater sample richness was associated with more incontinence episodes (observed genera P=.01) in urine. Measures of evenness (Shannon and Pielou) were not associated with incontinence severity in the urinary or vaginal microbiomes. CONCLUSION: In the urobiome of women with mixed urinary incontinence, a community type with fewer Lactobacilli and more diverse bacteria was associated with more severe urinary incontinence episodes (total and urgency) compared with a community type with high predominance of a single genus, Lactobacillus. Whether mixed urinary incontinence severity is due to lesser predominance of Lactobacillus, greater presence of other non-Lactobacillus genera, or the complement of bacteria consisting of urobiome community types remains to be determined.

One-year outcomes of polyacrylamide hydrogel (Bulkamid) injection in women with stress and mixed urinary incontinence.

PURPOSE: This study aimed to evaluate the efficacy and safety following treatment with Bulkamid for stress urinary incontinence (SUI) or stress-predominant mixed urinary incontinence (MUI). METHODS: We retrospectively analyzed data of women diagnosed with SUI or stress-predominant MUI who underwent Bulkamid periurethral injection between November 2020 and January 2023 and completed 12 months of follow-up. The primary outcome of the study was to assess patient satisfaction, which was measured on a four-point scale, ranging from cured to worse, and through validated questionaries such as the International Consultation on Incontinence Questionnaire-short Form (ICIQ-UI SF) and Contilife Quality of Life questionnaire. RESULTS: Of the 70 patients included, 41 (59%) had MUI with predominant stress incontinence. Median age was 59 years (IQR 47-75), with a median BMI of 25 (18-40) and a median number of pregnancies of 2 (0-4). Forty-seven (67%) procedures were performed under sedation and 23 (33%) under local anesthesia. Forty-three (69%) women reported feeling cured or improved at 12 months follow-up and among them, 25 (40%) reported feeling cured. A total of 16 (23%) patients were subsequently treated, in detail 11 (16%) patients underwent MUS positioning, and 5 (7%) had an additional injection of Bulkamid. ICIQ and Contilife QoL showed a significant improvement at 1, 3, 6, and 12 months (all p < 0.001). CONCLUSIONS: Bulkamid injections are an effective and safe treatment option for women with SUI or stress-predominant MUI, providing good outcomes at 12 months.

Reproductive history of parous women and urinary incontinence in midlife: A National Birth Cohort follow-up study.

OBJECTIVE: To investigate how reproductive history was associated with urinary incontinence in midlife. DESIGN: A follow-up study. SETTING: Denmark. POPULATION: A total of 39 977 mothers who participated in the Maternal Follow up (2013-2014) in the Danish National Birth Cohort. National registries provided their reproductive history. METHODS: How parity, mode of birth and obstetric tears associated with urinary incontinence were estimated with adjusted odds ratios (OR) and 95% CI using logistic regression. MAIN OUTCOME MEASURES: Self-reported urinary incontinence including subtypes stress, urge and mixed urinary incontinence. RESULTS: At an average age of 44 years, the prevalence of any urinary incontinence was 32% (21% stress, 2% urge, and 8% mixed urinary incontinence). Women with two births more often had urinary incontinence than women with one birth (OR 1.20, 95% CI 1.10-1.31). Compared with women with only spontaneous births, a history of only caesarean sections was associated with much lower odds of urinary incontinence (OR 0.39, 95% CI 0.35-0.42) and a history of instrumental births with slightly lower odds (OR 0.92, 95% CI 0.86-0.98). Compared with no tear/first-degree tear as the largest tear, episiotomy was associated with less urinary incontinence (OR 0.91, 95% CI 0.86-0.97) whereas third/fourth-degree tears were associated with more (OR 1.14, 95% CI 1.04-1.25). Findings were mainly explained by similar associations with stress and mixed urinary incontinence. CONCLUSIONS: Vaginal birth was associated with a higher risk of long-term urinary incontinence, but our results indicate that this risk may be reduced by shortening the second stage of birth.

Management of mixed urinary incontinence: IUGA committee opinion.

INTRODUCTION AND HYPOTHESIS: Mixed urinary incontinence (MUI) is defined by the International Urogynecology Association (IUGA) and International Continence Society as the complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing. It therefore implies the coexistence of both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). MUI is a heterogeneous diagnosis that requires an assessment of its individual components of SUI and UUI. Management requires an individualised approach to the symptom components. The aim of this review is to identify the assessment/investigations and management options for MUI. METHODS: A working subcommittee from the IUGA Research & Development (R&D) Committee was created and volunteers invited from the IUGA membership. A literature review was performed to provide guidance focused on the recommended assessment and management of MUI. The document was then evaluated by the entire IUGA R&D Committee and IUGA Board of Directors and revisions made. The final document represents the IUGA R&D Committee Opinion. RESULTS: The R&D Committee MUI opinion paper provides guidance on the assessment and management of women with MUI and summarises the evidence-based recommendations. CONCLUSIONS: Mixed urinary incontinence is a complex problem and successful management requires alleviation of both the stress and urge components. Care should be individualised based on patient preferences. Further research is needed to guide patients in setting goals and to determine which component of MUI to treat first. The evidence for many of the surgical/procedural treatment options for MUI are limited and needs to be explored in more detail.

Urinary Incontinence in Midlife According to Weight Changes Across and After Childbearing Years.

INTRODUCTION AND HYPOTHESIS: The objective was to investigate how weight change across and after the childbearing years was associated with urinary incontinence (UI) in midlife. METHODS: Data were obtained from 35,645 women responding to the Maternal Follow-up questionnaire in the Danish National Birth Cohort in 2013-2014. Outcome was self-reported UI and its subtypes. Exposures were changes in body mass index (BMI) across and after the childbearing years. Adjusted odds ratios were estimated using logistic regression. RESULTS: At follow-up, the mean age was 44 years and 32% experienced UI. Compared with stable weight, weight gain across the childbearing years of > 1 to 3, > 3 to 5 or > 5 BMI units increased the odds of any UI by 15%, 27%, and 41% respectively. For mixed UI, the odds increased by 23%, 41%, and 68% in these groups. Weight gain after childbearing showed the same pattern, but with a higher increase in the odds of mixed UI (25%, 60%, and 95% in the respective groups). Women with any weight loss during this period had 9% lower odds of any UI than women with a stable weight. CONCLUSIONS: Weight gain across and after childbearing increased the risk of UI in midlife, especially the subtype mixed UI. Weight loss after childbearing decreased the risk.

Prevalence of urinary incontinence and associated factors, its impact on quality of life among pregnant women attending antenatal care at Asella teaching and referral hospital.

BACKGROUND: Urinary incontinence (UI) is defined as any involuntary leakage of urine. UI during pregnancy is a common health problem worldwide with prevalence ranging from 11.4 to 84.5%. In Ethiopia there has been limited research conducted on UI among pregnant women. The purpose of this study was to investigate the prevalence of UI, factors associated with UI and the impact on quality of life in pregnant women. METHOD: Cross-sectional study was conducted from December 1, 2022 to April 30, 2023. A total of 279 pregnant women attending Antenatal care were included. Data was entered into Epi-data version 3.1 and then exported to SPSS version 26 for cleaning and analysis. Chi-square test and logistic regression were done to look for factors associated with UI. We used 95% confidence interval of crude and adjusted odds ratios for analysis. Those variables with P-value < 0.05 were declared to be statistically significant. RESULT: Overall prevalence of UI was 18.6% (n = 52). Prevalence of each type of UI during pregnancy was 9.3% for Stress UI, 5% for Urge UI and 4.3% for mixed UI. Of all participants having UI, 2(3.8%) were having UI prior to pregnancy, while 3(5.8%), 16(30.7%) and 31(59.6) have encountered during first, second and third trimester respectively. Three fourth of the participants 38(73.1%) doesn't seek treatment for their UI. Presence of history of UI [AOR = 38.1, 95%CI: (7.95, 182.75)], previous history of instrumental delivery [AOR = 7.4, 95%CI: (3.05, 18.04)] and history of alcohol intake [AOR = 17.0, 95%CI: (1.49, 194.41)] were found to be significantly associated with UI while moderate severity UI [AOR = 12.9, 95%CI (1.46, 113.28)] and severe UI [AOR = 27, 95%CI (1.98, 138.38)] were significantly associated with Poor quality of life at p-value of < 0.05. Based on severity score UI was moderate in 34 (65.4%) and severe in 8 (15.4%) of the participants. CONCLUSION: UI affects one fifth of pregnant women (18.6%) and Stress UI is the most common type of UI during pregnancy. Previous history of UI, instrumental delivery and alcohol intake were found to be risk factors for UI. Pregnant women have to be advised to avoid or reduce alcohol consumption and to seek treatment for their problem. Follow up throughout pregnancy and postpartum period is very important to plan for further management of UI.

Mixed urinary incontinence: Are there effective treatments?

The aim of this debate article is to discuss whether effective treatments are available for mixed urinary incontinence (MUI). Because patients with MUI have both stress and urgency urinary incontinence (SUI and UUI) episodes and current treatment guidelines currently recommend treating the predominant symptom first, this article presents standard and emerging treatments for both SUI and UUI before discussing how well these treatments meet the medical needs of patients with MUI. Standard treatments presented include noninvasive options such as lifestyle changes and pelvic floor exercises, pharmacological agents, and surgery. Treatment of all three types of urinary incontinence (UI) is usually initiated with noninvasive options, after which treatment options diverge based on UI subtype. Multiple pharmacological agents have been developed for the treatment of UUI and overactive bladder, whereas surgery remains the standard option for SUI and stress-predominant MUI. The divide between UUI and SUI options seems to be propagated in emerging treatments, with most novel pharmacological agents still targeting UUI and even having SUI and stress-predominant MUI as exclusion criteria for participation in clinical trials. Considering that current treatment options focus almost exclusively on treating the predominant symptom of MUI and that emerging pharmacological treatments exclude patients with stress-predominant MUI during the development phase, effective treatments for MUI are lacking both in standard and emerging practice. Ideally, agents with dual mechanisms of action could provide symptom benefit for both the stress and urgency components of MUI.

Treatment outcome of women with urodynamic mixed urinary incontinence: an observational study.

INTRODUCTION AND HYPOTHESIS: Mixed urinary incontinence (MUI) is a common yet understudied condition. It remains a therapeutic challenge, with the presence of both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). There is limited information on the optimal management for women with urodynamic MUI (urodynamic stress incontinence and detrusor overactivity). We assessed the treatment outcome of pelvic floor muscle training (PFMT), medical treatment and surgery for women who were diagnosed with urodynamic MUI. METHODS: A prospective observational study was carried out on women with urodynamic MUI from 2010 to 2018. All women underwent clinical assessment and standardised urodynamic evaluation. All women received PFMT from a specialised continence advisor as initial management. Antimuscarinics and/or continence surgery were considered according to the woman's response and symptoms after PFMT. Subjective outcome after each treatment modality was analysed. RESULTS: A total of 198 women were included for analysis. All women received PFMT, 104 (52.5%) showing improvement in urinary incontinence. Eighty-seven (43.9%) women were offered antimuscarinics, of whom 58 (29.3%) showed subjective improvement in both SUI and UUI, and 10 (5%) reported a reduction in UUI but persistent SUI. A total of 55 (27.7%) women received surgical treatment, with 20 receiving continence procedures. Sixteen out of twenty (80%) of them reported improvement in both SUI and UUI. None reported worsening of urgency or UUI. Overall, across all treatment modalities, 73.8% of women showed improvement in both SUI and UUI. CONCLUSION: Future analyses can help to inform which patients will have a higher success rate after each treatment modality and help focus treatment effort on those with a high risk of persistent symptoms. This will provide relevant data in counselling women, giving reasonable expectations and directing the management of women with urodynamic MUI.

The effect of 12-month postoperative weight change on outcomes following midurethral sling for stress urinary incontinence: a secondary analysis of the ESTEEM and TOMUS randomized trials.

INTRODUCTION AND HYPOTHESIS: Prior studies demonstrate mixed results on the impact of obesity on the success of midurethral slings (MUS), with little known about how postoperative weight change affects outcomes. We aimed to examine the effect of postoperative weight change on outcomes 12 months after MUS for stress urinary incontinence (SUI). METHODS: This secondary analysis utilized data from two multicenter randomized trials of women undergoing MUS placement. Subjects were categorized into cohorts based on change in body weight at 12 months postoperatively: weight gain (≥5% increase); weight loss (≥5% decrease), and weight stable (<5% change). The primary outcome was SUI cure (no SUI episodes in a 3-day bladder diary). Patients with mixed urinary incontinence (MUI) were analyzed for changes in daily average urge incontinence (UUI) episodes in a 3-day diary. Penalized logistic regression assessed the impact of demographic and perioperative variables on the primary outcome. RESULTS: Of the 918 women included, 635 (70%) were weight stable, 144 (15%) had weight gain, and 139 (15%) had weight loss. Patients in the weight loss cohort had a higher smoking rate and a higher baseline body mass index (SD 0.29, 2.7 respectively). All cohorts experienced high SUI cure rates ranging from 77 to 81%, with no significant difference in SUI cure between cohorts (p = 0.607). Of 372 subjects with MUI, the weight loss cohort had significantly greater improvement in UUI episodes. CONCLUSIONS: Weight change at 12 months postoperatively did not significantly alter efficacy of MUS for treatment of SUI. Patients with MUI who lost ≥5% body weight had significantly greater improvement in UUI episodes.

The influence of age and health status for outcomes after mid-urethral sling surgery-a nationwide register study.

INTRODUCTION AND HYPOTHESIS: The efficacy of mid-urethral sling (MUS) surgery in older women and women with a significant disease burden is limited. We aimed to determine the influence of chronological age and physical status (assessed by the American Society of Anesthesiologists Physical Status, ASA) classification on outcomes. METHODS: Cure rate, change in frequency of lower urinary tract symptoms, satisfaction, impact, and adverse events after MUS surgery were assessed in 5200 women aged 55-94 years with MUS surgery (2010-2017). Data were analysed by multivariate logistic regression and Mantel-Haenszel chi-square statistics. RESULTS: The cure rate was 64.2% (95% CI, 60.0-68.4) in the ≥ 75-year cohort compared to 88.5% (95% CI, 87.1-89.8) in the 55-64-year cohort (trend p < 0.0001). The estimated probability of cure, improvement, and satisfaction with the procedure decreased by aOR10yr = 0.51 for cure to aOR10yr = 0.59 for satisfaction (all p < 0.0001). Women with a significant health burden (ASA class 3-4) had lower cure rates and satisfaction than those without (65.5% vs. 83.7%, p < 0.0001 and 65.7% vs. 80.6%, p < 0.0001). Older age was more likely to be associated with de novo urgency (p = 0.0022) and nocturia ≥ 2 (p < 0.0001). Adverse events, readmission, and 30-day mortality rates were low. Women, irrespective of age, were equally satisfied if they experienced a decrease of at least one step in leakage frequency. CONCLUSIONS: Even if MUS surgery in older women and those with ASA class 3-4 was associated with a lower cure rate and less satisfactory outcome, a majority were satisfied provided they experienced a reduction of incontinence episodes.

Prevalence and severity of urinary incontinence and associated factors in Iranian postmenopausal women: a cross-sectional study.

BACKGROUND: Urinary incontinence (UI) is one of the most common symptoms during menopause, leading to a decreased quality of life and limited social activities. This study aimed to determine the prevalence and severity of urinary incontinence and associated risk factors in postmenopausal women. METHODS: It was a cross-sectional study using cluster sampling on 433 postmenopausal women in Tabriz-Iran, 2021-2022. Data were collected using questionnaires of socio-demographic characteristics, Questionnaire for Urinary Incontinence Diagnosis (QUID), and International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UISF). Multivariate logistic regression was used to determine factors related to urinary incontinence. RESULTS: The overall prevalence of urinary incontinence was 39.5%; 20.6% stress urinary incontinence (SUI), 10.4% urgency urinary incontinence (UUI), and 8.5% mixed urinary incontinence (MUI). Multivariate logistic regression analysis showed that the prevalence of SUI (aOR 0.38; 95% CI 0.18-0.77) and UUI (aOR 0.38; 95% CI 0.15-0.94) was significantly lower in women with three childbirths than the ones with fewer childbirths. Also, the odds of UUI increased significantly in women at the 50-55 age range (aOR 3.88; 95% CI 1.16-12.93) than those less than 50 years. CONCLUSION: Due to the high prevalence of urinary incontinence in postmenopausal women, caregivers should screen for early diagnosis and appropriate treatment of urinary incontinence to prevent its destructive impact on the quality of life.

Effect of Nigella sativa L. seed oil on urinary incontinence and quality of life in menopausal women: A triple-blind randomized controlled trial.

Increased urinary incontinence is one of the most common changes during menopause. This study aimed to investigate the effect of Nigella sativa L. seed oil on urinary incontinence and quality of life (QoL) (primary outcomes) and sexual function (secondary outcome) in menopausal women. In this triple-blind randomized controlled trial, 60 women in Tabriz-Iran were equally allocated into two treatment and control groups using block randomization. The women applied 2-3 drops of Nigella sativa L. seed oil or placebo on their stomachs below the novel twice a day for 8 weeks. The data collection instruments were completed at baseline and just after the intervention. After intervention, the mean rank score of mixed urinary incontinence was significantly lower (p = .04) and the mean score of the incontinence-QoL was significantly higher (mean difference 12.63, 95% CI 2.33 to 22.93; p = .017) in the treatment group than the control group. However, there were no significant differences in stress incontinence, urge incontinence, sexual function, and menopause-specific QoL of women between the groups (p > .05). The results indicated the positive effect of the Nigella sativa L. seed oil on mixed incontinence and incontinence-QoL; nevertheless, to make a certain conclusion, further studies are required.

Association between the urogenital microbiome and surgical treatment response in women undergoing midurethral sling operation for mixed urinary incontinence.

BACKGROUND: The urogenital microbiome is associated with urgency and mixed urinary incontinence symptoms and differential treatment responses to pharmacotherapy for urgency urinary incontinence. OBJECTIVE: This study aimed to describe whether the preoperative urinary and vaginal microbiomes were associated with surgical treatment responses at 12 months after a midurethral sling operation in women with mixed urinary incontinence. STUDY DESIGN: This cohort study compared the preoperative microbiome compositions of urine and vaginal samples from a subset of women undergoing a midurethral sling operation in the Effects of Surgical Treatment Enhanced With Exercise for Mixed Urinary Incontinence trial (NCT01959347) and compared the microbiota in women who were surgical responders vs surgical nonresponders. Twelve-month objective response was defined as a ≥70% reduction from baseline urinary incontinence episodes on a 3-day diary. Subjective response was defined as a change from baseline in the Urogenital Distress Inventory scores. Bacterial abundance and beta diversity were assessed using 16S ribosomal RNA sequencing. The primary differential abundance analysis described predominant bacterial operational taxonomic units associated with responders vs nonresponders using unadjusted and age-adjusted linear models. RESULTS: Objective nonresponders (n=28) compared with responders (n=72) were older (58.5±10.7 vs 51.6±10.2 years) and more likely postmenopausal without hormone use (odds ratio, 6.4; 95% confidence interval, 1.8-22.6). Vaginal and urinary microbiota beta diversities were associated with age (P<.05) for both responders and nonresponders. Overall, predominant operational taxonomic units (genera) were Lactobacillus, Gardnerella, Tepidimonas, Escherichia, Streptococcus, and Prevotella. Operational taxonomic units from baseline urine samples were not significantly associated (P threshold=.05) with surgical treatment responses. A greater abundance of baseline vaginal Lactobacillus was associated with an objective response (P=.04) and Prevotella with an objective nonresponse (P=.01). Adjusting for age, only a greater abundance of baseline vaginal Prevotella was associated with an objective nonresponse (P=.01). Moreover, less abundant vaginal operational taxonomic units were associated with objective and subjective responses and persistent urinary incontinence symptoms (P<.05). CONCLUSION: Women meeting a 70% reduction of urinary incontinence treatment episodes (objective responders) had greater vaginal Lactobacillus at the time of the surgical procedure; however, controlling for age diminished this association. Women not meeting a 70% reduction of urinary incontinence episodes 1 year after a midurethral sling operation had greater vaginal Prevotella at the time of the midurethral sling operation. Further research is needed to determine whether therapy altering the vaginal microbiome may impact surgical treatment responses in women with mixed urinary incontinence.

Incidence and risk factors of female urinary incontinence: a 4-year longitudinal study among 24 985 adult women in China.

OBJECTIVE: To estimate the incidence of urinary incontinence (UI), including its subtypes stress UI (SUI), urgency UI (UUI) and mixed UI (MUI), and to examine risk factors for de novo SUI and UUI in Chinese women. DESIGN: Nationwide longitudinal study. SETTING: Six geographic regions of China. PARTICIPANTS: Women aged ≥20 years old were included using a multistage, stratified, cluster sampling method. METHODS: This study was conducted between May 2014 and March 2016, with follow up in 2018. Data on demographics, medical history, lifestyle and physiological and anthropometric information were collected. MAIN OUTCOME MEASUREMENTS: Incidence, rate ratio (RR). RESULTS: Analyses included 24 985 women (mean age 41.9 years).The follow-up response rate was 55.5%, median follow-up time was 3.7 years. The standardised incidences of UI, SUI, UUI and MUI were 21.2, 13.1, 3.0 and 5.1 per 1000 person-years, respectively. Risk factors for de novo SUI included delivery pattern (vaginal spontaneous delivery RR 2.12, 95% CI 1.62-2.78 and instrumental delivery RR 3.30, 95% CI 1.99-5.45), high body mass index (BMI) (overweight RR 1.52, 95% CI 1.33-1.74 and obesity RR 1.67, 95% CI 1.32-2.11), cigarette smoking (RR 1.54, 95% CI 1.12-2.12), chronic cough (RR 1.44, 95% CI 1.17-1.76), diabetes (RR 1.33, 95% CI 1.10-1.60) and older age (50-59 years RR 1.49, 95% CI 1.16-1.90 and 60-69 years RR 1.61, 95% CI 1.22-2.13).The risk factors significantly associated with de novo UUI were age (RR increased from 1.21, 95% CI 0.74-1.99, at 30-39 years to 6.3, 95% CI 3.85-10.30, at >70 years) and diabetes (RR 1.48, 95% CI 1.05-2.09). CONCLUSIONS: The incidence of female UI is 21.2 per 1000 person-years in China. Delivery (vaginal spontaneous delivery, instrumental delivery), high BMI, cigarette smoking, chronic cough, diabetes and older age were risk factors. TWEETABLE ABSTRACT: The incidence of female urinary incontinence was 21.2 per 1000 person-years in China. Delivery, BMI, diabetes and old age are risk factors.

Efficacy of combination therapy of mid-urethral sling and low-dose Abobotulinumtoxin-A injection in mixed urinary incontinence.

OBJECTIVES: To determine the outcome of combined transobturator tape sling (TOT) and low dose intradetrusor injection of Abobotulinumtoxin-A (Abobot-A, Dysport®) in women with mixed urinary incontinence (MUI). METHODS: This randomized, active comparator-controlled, parallel-group, two-part clinical trial was conducted on women who had positive Valsalva leak point pressure (VLPP) + detrusor overactivity (DO), cough-associated DO. In Part 1, 20 women with MUI who had a failure of medical and behavioral therapies to cure MUI, randomized in two groups receiving TOT surgery alone, or in combination with Dysport® injection (n = 10 in each group), and then Part 2 was initiated as a prospective open-label on 40 more patients. We performed cystoscopy and injected 300 U of Dysport®in 20-30 intradetrusor injection sites in each patient. RESULTS: The patient's symptoms in both groups decreased significantly after treatment. The symptoms were improved significantly in the combination therapy group according to the International Consultation on Incontinence Questionnaire-overactive bladder (ICIQ-OAB) questionnaire (p < .001), and International Consultation on Incontinence Questionnaire-urinary Incontinence-short form (ICIQ-UI-SF) (p = .041) in comparing with the TOT group. In Part 2, the mean score was 17.10 (4.75) for ICIQ-UI-SF and 9.22 (2.89) for ICIQ-OAB before the treatment. Twelve weeks after the intervention, the median (interquartile range: IQR) of ICIQ-OAB symptoms (2.0 [3.0]; p < .001) and ICIQ-UI-SF decreased, too (1. 0 [2.0]; p < .001). Considering improvement using Patient Global Impression of Improvement scale, 46 (92.0%) stated that they had significant subjective improvement of their symptoms. CONCLUSIONS: Combination therapy was accompanied with a promising effect in the patients with MUI according to the results of standardized questionnaires. However, further studies with controlled arms are recommended.

Healthcare resource use and cost burden of urinary incontinence to United States payers.

OBJECTIVE: To assess healthcare resource utilization and costs for female patients diagnosed with stress or mixed urinary incontinence (SUI/MUI) compared to a matched cohort of patients without SUI/MUI. METHODS: We conducted a retrospective matched cohort study of women using the IBM MarketScan research database. Women diagnosed with SUI/MUI between July 1, 2014 and June 30, 2016 were identified using International Classification of Diseases 9 and 10 codes for SUI or MUI with the date of first diagnosis as the index date from which 2-year postindex healthcare resource use and direct cost data were derived from claims, examined, and compared 1:1 with patients without a SUI/MUI diagnosis, matched by age and Charlson's Comorbidity Index. RESULTS: A total of 68 636 women with SUI/MUI were matched 1:1 with controls. In the 2-year postindex date, a significantly higher proportion of SUI/MUI patients had ≥1 inpatient visit and ≥1 outpatient visit compared to the control group (inpatient: 18.89% vs. 12.10%, p < 0.0001; outpatient: 88.44% vs. 73.23%, p < 0.0001). Mean primary care visits were significantly higher in SUI/MUI patients compared to controls (7.33 vs. 5.53; p < 0.0001) as were specialist visits (1.2 vs. 0.08; p < 0.0001). Mean all-cause outpatient costs were higher in SUI/MUI patients compared to controls ($7032.10 vs. $3348.50; p < 0.0001), as were inpatient costs ($3990.70 vs. $2313.70; p < 0.0001). CONCLUSION: Women with SUI/MUI consume significantly higher medical resources and incur higher costs to payers, compared to women without SUI/MUI. While reasons for this are not fully understood, improved and standardized treatment for women with SUI/MUI may positively affect cost and outcomes.

App-based self-management of urgency and mixed urinary incontinence in women: One-year follow-up.

AIMS: To evaluate the long-term effect of the Tät®II app for treatment of urgency (UUI) and mixed urinary incontinence (MUI). METHODS: Long-term follow-up of a randomized controlled trial, including 123 women ≥18 years old with UUI or MUI, without red-flag symptoms, and ≥2 leakages per week. All participants, regardless of group, had received the intervention, a treatment app, at the long-term follow-up. Long-term data were collected through web-based questionnaires 15 months after participants received the intervention. The app included pelvic floor muscle training, bladder training, psychoeducation, lifestyle advice, an exercise log, reminders, reinforcement messages, and tailored advice. The primary outcome was a change in incontinence symptoms (International Consultation on Incontinence Questionnaire [ICIQ]-Urinary Incontinence Short Form [ICIQ-UI SF]), from baseline to follow-up. Other outcomes were urgency symptoms (ICIQ-Overactive Bladder Module (ICIQ-OAB)), quality of life (ICIQ-Lower Urinary Tract Symptoms Quality of Life Module [ICIQ-LUTSqol]), and improvement (Patient's Global Impression of Improvement [PGI-I]). RESULTS: Of the 123 women, 102 (83%) completed the long-term follow-up. The ICIQ-UI SF mean score improved from 11.5 to 7.6 (mean difference 4.0, 95% CI 3.2-4.7). The ICIQ-OAB improved from 6.7 to 5.5 (mean difference 1.3, 95% CI 0.9-1.6) and the ICIQ-LUTSqol improved from 38.0 to 30.9 (mean difference 7.1, 95% CI 5.7-8.5). Of the 102 women, 74 (73%) reported improvement. CONCLUSIONS: Self-management with the Tät®II app for UUI and MUI had a significant effect across all outcome measures also long-term and might serve as an alternative first-line treatment for these conditions.

Effect of additional acupuncture to pelvic floor exercise on urinary incontinence: A randomized controlled trial.

AIMS: To investigate the additional benefit of acupuncture to pelvic floor exercise (PFE) on the improvement of urinary incontinence (UI) and quality of life (QoL) in women. METHODS: This was a single-blinded randomized controlled trial in a tertiary university hospital. Women with UI in various severity and types were randomized to receive either a weekly course of acupuncture with PFE or PFE alone for 6 weeks and then followed up for 24 weeks in every 6 weeks. Investigators were blinded to group allocation in pre- and postintervention assessments. Primary outcome was subjective changes of UI symptoms at 24 weeks. Secondary outcomes were episodes and severity of UI from bladder diary, severity by Visual Analogue Scale, and QoL scores by validated Chinese short-form of Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7). RESULTS: One hundred seventy-nine women were screened while 137 were randomized. Significant subjective improvement in UI symptoms was demonstrated at all follow-up, latest at 24 weeks (odds ratio [OR]: 2.29, 95% confidence Interval [CI]: 1.02-5.12, respectively), with reduced episodes and severity of UI after (p < 0.05), and a trend of improvement in IIQ-7 score (p = 0.05). No major adverse events occurred. History of 2 years or longer duration of UI symptoms was associated with lower effectiveness of acupuncture (OR: 0.08, 95% CI: 0.01-0.68).

Impact of preoperative pelvic floor muscle training (pretraining) on urinary storage and emptying symptoms in women undergoing sling surgery.

INTRODUCTION AND HYPOTHESIS: Although pelvic floor muscle training (PFMT) is an option for female mixed incontinence (MUI), the role of PFMT prior to midurethral sling (MUS) surgery is not well defined. We hypothesize that preoperative PFMT (pretraining) positively impacts urinary storage and voiding symptoms prior to retropubic MUS. METHODS: We carried out an institutional review board-approved, retrospective chart review of women with stress-predominant MUI undergoing a retropubic MUS. Seventy-two women elected for initial PFMT before MUS (group 1). These were age-matched with 72 women who underwent MUS only (group 2). The primary outcome was the change in urinary voiding and storage symptoms (Emptying [E] and Inhibition [I; UUI] subsets of the SEAPI classification). Additional outcomes were stress urinary incontinence (SUI) resolution and change in quality of life (QoL) indices. RESULTS: Mean age and follow-up were 49 ± 12 years and 33 ± 12 months respectively. After MUS, SUI resolved in 79.2% and 69.4% in groups 1 and 2 respectively (p > 0.05). In group 1, 18% and 20.8% had improvement/resolution in the E and I subsets prior to MUS. Postoperatively, similar rates of improvement/resolution in the E (25% for both) and I (68% vs 63.9%) subsets were observed in groups 1 and 2 respectively. Postoperative QoL indices were statistically improved in both groups, with no significant difference between groups. CONCLUSIONS: Pretraining with PFMT before MUS was associated with preoperative improvement in emptying symptoms and UUI. Although not statistically significant, pretraining was associated with a higher chance of SUI resolution in the long term. If pretraining is beneficial before MUS, the effect appears to be small.