Urinary incontinence in nulliparous women before and during pregnancy: prevalence, incidence, type, and risk factors.

INTRODUCTION: While many women report urinary incontinence (UI) during pregnancy, associations with pre-pregnancy urinary leakage remain under-explained. METHODS: We performed a multi-strand prospective cohort study with 860 nulliparous women recruited during pregnancy. RESULTS: Prevalence of any urinary leakage was 34.8% before and 38.7% during pregnancy. Prevalence of UI, leaking urine at least once per month, was 7.2% and 17.7% respectively. Mixed urinary incontinence (MUI) was reported by 59.7% of women before and 58.8% during pregnancy, stress urinary incontinence (SUI) by 22.6% and 37.2%, and urge urinary incontinence (UUI) by 17.7% and 4.0%, respectively. SUI accounted for half (50.0%), MUI for less than half (44.2%), and UUI for 5.8% of new-onset UI in pregnancy. Pre-pregnancy UI was significantly associated with childhood enuresis [adjusted odds ratio (AOR) 2.9, 95% confidence interval (CI) 1.5-5.6, p = 0.001) and a body mass index (BMI) ≥30 kg/m2 (AOR 4.2, 95% CI 1.9-9.4, p <0.001). Women aged ≥35 years (AOR 2.8, 95% CI 1.4-5.9, p = 0.005), women whose pre-pregnancy BMI was 25-29.99 kg/m2 (AOR 2.0, 95% CI 1.2-3.5, p = 0.01), and women who leaked urine less than once per month (AOR 2.6, 95% CI 1.6-4.1, p  <0.005) were significantly more likely to report new-onset UI in pregnancy. CONCLUSION: Considerable proportions of nulliparous women leak urine before and during pregnancy, and most ignore symptoms. Healthcare professionals have several opportunities for promoting continence in all pregnant women, particularly in women with identifiable risk factors. If enquiry about UI, and offering advice on effective preventative and curative treatments, became routine in clinical practice, it is likely that some of these women could become or stay continent.

Diagnosis and classification of female stress urinary incontinence by transperineal two-dimensional ultrasound.

OBJECTIVE: This study was designed to evaluate the significance of transperineal two-dimensional ultrasound in the diagnosis and classification of female stress urinary incontinence (SUI). METHODS: A total of 87 preoperative SUI patients (group A) from the Department of Gynecology of Peking University People's Hospital were included into this study. These patients were further divided into two groups (groups A1 and A2) according to the severity of their disease. In addition, during the same period, 72 age-matched women without SUI were enrolled into this study and assigned as the control group (group B). Through transperineal two-dimensional ultrasound technique, detrusor wall thickness (DWT) was measured in the resting state, the bladder neck descent (BND) was measured under the maximal valsalva maneuver, the proximal urethral rotation angle (α angle) and posterior vesicourethral angle (ß angle) were measured, and the formation of the funnel-shaped urethra was observed. RESULTS: Under the resting state, differences in DWT between groups A and B, as well as between groups A1 and A2, were not statistically significant (P> 0.05). The BND, α and ß angles were significantly larger in group A than in group B under the maximal Valsalva maneuver; and the differences were statistically significant (P< 0.05). The formation rate of the funnel-shaped urethra was significantly higher in group A (94%) than in group B (3%), and the difference was statistically significant; while the difference between groups A1 and A2 was not statistically significant (P> 0.05). CONCLUSION: Transperineal two-dimensional ultrasound can play an assistant role in the diagnosis of female SUI. However, its role in the assessment of the severity of SUI remains to be studied.

Is there a link between preoperative fluoroscopic cough stress testing and synthetic midurethral tape outcome?

OBJECTIVES: The primary aim of our study was to assess the utility of fluoroscopic cough stress testing as a predictor of synthetic midurethral tape (MUT) outcome. The secondary aim was to examine whether baseline demographics, clinical symptoms and urodynamic variables could predict MUT success. STUDY DESIGN: We carried out a retrospective study including women with stress urinary incontinence (SUI) who underwent retropubic MUT in a tertiary referral urogynaecology unit. We excluded cases where concurrent pelvic organ prolapse surgery was performed. Patients were subdivided into groups based on the pre-operative fluoroscopic cough stress testing, using Blaivas and Versi classifications. Subjective outcome was evaluated at 6 weeks based on self-reported SUI in the symptom domain of the King's Health Questionnaire. Logistic regression models were used to identify predictors of treatment success. RESULTS: 143 patients were included in the study. Blaivas and Versi classifications were not useful in predicting subjective success (p=0.44 and p=0.40, respectively). Baseline demographics, clinical and other urodynamic variables failed to predict subjective outcome. CONCLUSIONS: Fluoroscopic cough stress testing is not a useful predictor of MUT outcome. No preoperative variables have been found to predict MUT success.

Classification of stress urinary incontinence.

INTRODUCTION: The relevant terminology for stress urinary incontinence (SUI) is affected by the context, namely the clinical assessment (the symptom of SUI elicited on history taking and the sign of SUI observed during examination) or diagnostic investigations (urodynamic stress incontinence). In some cases, SUI may only be observed after the reduction in coexistent prolapse (occult SUI). Classifying SUI often relies on distinguishing between intrinsic sphincter deficiency (ISD), and urethral malposition or hypermobility, although this potentially an over-simplification. REVIEW: Classification systems have been derived based on clinical assessment and diagnostic testing, notably videourodynamics. Modern developments in imaging technology may allow other techniques such as ultrasound to offer additional basis for future developments in classification. Other urodynamic approaches include urethral pressure profilometry and Valsalva leak point pressure; these may offer indicators of thresholds below which ISD is more likely to explain SUI, but they are not generally accepted in routine practice. CONCLUSIONS: While SUI classification is potentially relevant to treatment selection, evidence for influence on management outcome is limited. Generating a high-quality evidence base for treatment selection on these criteria is problematic, particularly due to the range of confounding factors. In practice, the modern practitioner relies on various tools to form an opinion on some key aspects, using the findings to derive a treatment strategy. Accordingly, there remains a need to confirm how a classification of SUI translates into treatment selection and better outcomes.

Prevalence of postmicturition urinary incontinence in Japanese men: comparison with other types of incontinence.

OBJECTIVE: To investigate the prevalence and correlates of postmicturition urinary incontinence in Japanese men, and to compare with those of other types of urinary incontinence. METHODS: A total of 3224 male participants in a community-based survey were investigated. Three types of urinary incontinence were assessed; that is, postmicturition urinary incontinence, stress urinary incontinence and urge urinary incontinence. Age, body mass index, alcohol intake, cigarette smoking, and medical history of 18 diseases and conditions were the dependent variables for candidate correlates of the three types of incontinence. RESULTS: Unlike stress urinary incontinence and urge urinary incontinence, the prevalence of postmicturition urinary incontinence was constant throughout all generations (6.5% for the 30 s, 6.6% for the 40 s, 6.0% for the 50 s, 6.3% for the 60 s and 5.1% for the 70 s). The independent correlates for postmicturition urinary incontinence were asthma (P < 0.001; odds ratio 3.01), prostatic disease (P < 0.001; odds ratio 2.38), rhinosinusitis (P = 0.001; odds ratio 1.92), low back pain (P = 0.003; odds ratio 1.58), sleeplessness (P = 0.013; odds ratio 1.86), depression (P = 0.024; odds ratio 3.41) and body mass index (P = 0.025; odds ratio 0.73). CONCLUSIONS: Postmicturition urinary incontinence has different characteristics from those of stress urinary incontinence and urge urinary incontinence. Unlike stress urinary incontinence and urge urinary incontinence, postmicturition urinary incontinence is not age-dependent. Several diseases related to an allergic status, such as asthma and rhinosinusitis, are correlates for postmicturition urinary incontinence.

A randomized trial of urodynamic testing before stress-incontinence surgery.

BACKGROUND: Urodynamic studies are commonly performed in women before surgery for stress urinary incontinence, but there is no good evidence that they improve outcomes. METHODS: We performed a multicenter, randomized, noninferiority trial involving women with uncomplicated, demonstrable stress urinary incontinence to compare outcomes after preoperative office evaluation and urodynamic tests or evaluation only. The primary outcome was treatment success at 12 months, defined as a reduction in the score on the Urogenital Distress Inventory of 70% or more and a response of "much better" or "very much better" on the Patient Global Impression of Improvement. The predetermined noninferiority margin was 11 percentage points. RESULTS: A total of 630 women were randomly assigned to undergo office evaluation with urodynamic tests or evaluation only (315 per group); the proportion in whom treatment was successful was 76.9% in the urodynamic-testing group versus 77.2% in the evaluation-only group (difference, -0.3 percentage points; 95% confidence interval, -7.5 to 6.9), which was consistent with noninferiority. There were no significant between-group differences in secondary measures of incontinence severity, quality of life, patient satisfaction, rates of positive provocative stress tests, voiding dysfunction, or adverse events. Women who underwent urodynamic tests were significantly less likely to receive a diagnosis of overactive bladder and more likely to receive a diagnosis of voiding-phase dysfunction, but these changes did not lead to significant between-group differences in treatment selection or outcomes. CONCLUSIONS: For women with uncomplicated, demonstrable stress urinary incontinence, preoperative office evaluation alone was not inferior to evaluation with urodynamic testing for outcomes at 1 year. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT00803959.).

Two-year follow-up of an open-label multicenter study of polyacrylamide hydrogel (Bulkamid®) for female stress and stress-predominant mixed incontinence.

INTRODUCTION AND HYPOTHESIS: Polyacrylamide hydrogel (PAHG, Bulkamid®) is a promising urethral bulking agent. This article presents the 2-year follow-up results of a multicenter study of PAHG injections for treating stress and stress-predominant mixed urinary incontinence. METHODS: Submucosal injection of PAHG was performed in 135 women with urinary incontinence, with subjective and objective assessment of the efficacy and safety 24 months postinjection. RESULTS: At 24 months, the subjective responder rate was 64 % (a statistically non-significant reduction from 67 % at 12 months). The decreased number of incontinence episodes and urine leakage were maintained compared with the result from the 12-month evaluations, as were objective result rates and quality of life data. No safety issues occurred. CONCLUSIONS: PAHG is an effective and safe treatment option for women with stress-predominant mixed urinary incontinence, with maintained medium-term responder rates.

Can we, and do we need to, define bladder neck hypermobility and intrinsic sphincteric deficiency? ICI-RS 2011.

AIMS: Bladder neck hypermobility (BNH, also called urethral hypermobility), and intrinsic sphincteric deficiency (ISD) are terms frequently used in the clinical evaluation and management of stress urinary incontinence, and as subject qualifiers in clinical research. The terms also infer pathophysiologic concepts, as BNH and ISD appear to represent two different aspects of failure of the continence mechanism. Unfortunately, neither term is well-defined, and the various clinical and urodynamic characterizations of these terms do not correlate well with one another. METHODS: The value of these concepts and these specific terms was debated at the ICI-RS meeting, Bristol, UK, June 2011. Two clinicians were asked to take opposing viewpoints, with three weeks lead-time prior to the meeting. Each discussant presented one viewpoint, "for" or "against," followed by a brief discussion to review the presentations. RESULTS: The consensus was that, while we currently cannot adequately define these terms, there is a need to develop terminology employing these concepts. CONCLUSIONS: Terminology should permit improved definition of the sphincteric mechanism, allow individual patient characterization and serve as useful waypoints in treatment decisions.

TVT SECUR System: Final results of a prospective, observational, multicentric study.

INTRODUCTION AND HYPOTHESIS: This is an observational multicentre prospective study into the complications and effectiveness of TVT SECUR™. METHODS: One hundred forty-seven patients with urodynamic or occult Stress Urinary Incontinence (SUI) were enrolled. Outcome measures at 6, 12 and 24 months were: objective cough test; subjective responses to PGI-S questionnaire and Visual Analogue Score. STATISTICAL ANALYSIS: Wilcoxon Test; Monte Carlo Exact Test. RESULTS: Ninety-five urodynamic SUI and 41 occult SUI patients were treated using transobturator (H-position) or retropubic (U-position) approach (110 vs. 26 patients). Cure rates at 6, 12, and 24 months were 87.5%, 88.6% and 89.5%. Failure rates at all follow-ups were similar for urodynamic and occult SUI. The U-position failure rate was comparable to H-position at short-term but significantly higher at mid-term. Familiarity with the technique brought significantly higher success rates. CONCLUSIONS: TVT SECUR is safe, effective and versatile, but has an appreciable learning curve.

Non-invasive diagnosis of stress urinary incontinence sub types using wavelet analysis, shannon entropy and principal component analysis.

Urinary incontinence is a common female disorder. Although generally not a serious condition, it negatively affects the lifestyle and daily activity of subjects. Stress urinary incontinence (SUI) is the most versatile of several incontinence types and is distinguished by physical degeneration of the continence-providing mechanism. Some surgical treatment methods exist, but the success of the surgery mainly depends upon a correct diagnosis. Diagnosis has two major steps: subjects who are suffering from true SUI must be identified, and the SUI sub-type must be determined, because each sub-type is treated with a different surgery. The first step is straightforward and uses standard identification methods. The second step, however, requires invasive, uncomfortable urodynamic studies that are difficult to apply. Many subjects try to cope with the disorder rather than seek treatment from health care providers, in part because of the invasive diagnostic methods. In this study, a diagnostic method with a success rate comparable to that of urodynamic studies is presented. This new method has some advantages over the current one. First, it is noninvasive; data are collected using Doppler ultrasound recording. Second, it requires no special tools and is easy to apply, relatively inexpensive, faster and more hygienic.

Overactive bladder in Taiwanese women: re-analysis of epidemiological database of community from 1999 to 2001.

AIMS: To update our previous computerized epidemiological data according to the new taxonomy, we re-evaluated and re-analyzed the data using the current definitions of lower urinary tract symptoms (LUTS) which were approved and published by the ICS in 2002 and 2010 according to patient perception. Further, we divided overactive bladder (OAB) symptoms into OAB dry and OAB wet to assess their prevalence percentages by using the current definitions. METHODS: OAB syndrome in our computerized database was re-defined as having the following storage symptoms present, that is, frequency, urgency, nocturia, urgency incontinence, or stress urinary incontinence (SUI). The prevalence of OAB syndrome was determined with a different taxonomy for those five storage symptoms either singly or in combination. OAB symptoms which were probably associated with mixed incontinence were either ignored or excluded. RESULTS: The prevalence of OAB syndrome varied from 34.76% to 28.33% to 20.95% using different classifications of the above five storage symptoms. The prevalence of OAB wet symptoms increased with advancing age and this finding was consistent with three different definitions. CONCLUSIONS: The prevalence of OAB using the current definition is slightly higher than the result found in our previous published data using a defective classification system of OAB symptoms. The effects of mixed symptoms and probable misclassification cannot be overlooked because many women with OAB (with or without urgency incontinence) might also have SUI.

Urinary incontinence self-report questions: reproducibility and agreement with bladder diary.

INTRODUCTION AND HYPOTHESIS: This study aims to measure self-report urinary incontinence questions' reproducibility and agreement with bladder diary. METHODS: Data were analyzed from the Reproductive Risk of Incontinence Study at Kaiser. Participating women reporting at least weekly incontinence completed self-report incontinence questions and a 7-day bladder diary. Self-report question reproducibility was assessed and agreement between self-reported and diary-recorded voiding and incontinence frequency was measured. Test characteristics and area under the curve were calculated for self-reported incontinence types using diary as the gold standard. RESULTS: Five hundred ninety-one women were included and 425 completed a diary. The self-report questions had moderate reproducibility and self-reported and diary-recorded incontinence and voiding frequencies had moderate to good agreement. Self-reported incontinence types identified stress and urgency incontinence more accurately than mixed incontinence. CONCLUSIONS: Self-report incontinence questions have moderate reproducibility and agreement with diary, and considering their minimal burden, are acceptable research tools in epidemiologic studies.

Mixed urinary incontinence--time to uncouple urgency from stress?

INTRODUCTION: "Mixed incontinence" is defined as a combination of stress and urge symptoms. Over time, it has morphed into a single entity, encompassing etiology and treatment. My perspectives are: (a) Stress incontinence (SI) and urge incontinence (UI) are different symptoms with often different anatomical causation and so should be treated separately; (b) It is illogical to group urgency with SI. Urgency may also be associated with frequency, nocturia, abnormal emptying and pelvic pain in patients with no SI ("posterior fornix syndrome"); and (c) There is growing evidence that urgency may be cured by surgical correction of a cystocele and/or apical prolapse in up to 80% of patients who do not have SI. In this anatomical context, sensory urgency, urge incontinence and urodynamic detrusor overactivity may all be hypothesized as different manifestations of a prematurely activated micturition reflex, caused by a lax vagina's inability to support bladder base stretch receptors. This statement can be tested with a simple clinical test, "simulated operations", whereby digitally supporting in turn the midurethra, bladder base and posterior vaginal fornix may cause a significant decrease in the urgency felt by the patient. CONCLUSIONS: The term "mixed incontinence" is only valid if both symptoms are caused by a lax pubourethral ligament. However, urgency may be caused by laxity in other parts of the vagina. Regarding stress and urge as separate entities will remove the confusion resulting from this definition, creating new directions for science and therapy.

Severe stress urinary incontinence: Objective analysis of risk factors.

OBJECTIVE: To assess differences between patients suffering from severe degree of stress urinary incontinence versus those with mild degree and to detect the risk factors of severity. MATERIALS AND METHODS: 118 patients suffered from pure SUI were enrolled in a prospective study. According to VLPP, patients were categorized into 2 groups: mild (VLPP>60) and severe (VLPP<60). Risk factors included age, parity, gravidity, menopausal status, co-morbidities and surgical history were investigated. RESULTS: 35 patients had severe SUI; their mean VLPP±SD was 47±8cm H2O, while in 83 patients with mild SUI, mean VLPP was 90±20cm H2O. No significant difference was detected between both groups concerning clinical parameters except for the presence of bronchial asthma in which the difference was approaching statistical significance (P=0.07). Patients with multiple deliveries have triple risk to develop severe SUI. Obese patients with BMI>30 and those with bronchial asthma are more prone to develop severe type (OR: 1.9, 95%CI: .07-5 and OR: 9.4, 95% CI: 0.7-25 respectively). CONCLUSIONS: Bronchial asthma, obesity and multiple parities might be associated with low VLPP. Severe SUI is a resultant of multi-factors rather than one risk factor.

Distress and quality of life characteristics associated with seeking surgical treatment for stress urinary incontinence.

BACKGROUND: Current research focuses on three variables in evaluating the impact of stress urinary incontinence (SUI) on daily living: severity of incontinence, distress or bother resulting from incontinence, and effect on health related quality of life (HRQoL). Understanding the impact of these variables is important as they are the driving force behind women seeking surgical treatment. Given the importance of HRQoL in determining need for treatment, as well as evaluating treatment success, this review provides an assessment of the degree to which HRQoL is impaired in women seeking surgical treatment. METHODS: PubMed searches for the terms "quality of life and distress and urinary incontinence" and "quality of life and bother and urinary incontinence" were performed with limits of English, human and female subjects through May 2008. All studies using validated instruments were included. No time limit was placed on the search. RESULTS: Of 178 articles retrieved, 21 met the inclusion criteria, and 17 reported methods of scoring. The studies used the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). Wide ranges of mean and individual levels of severity of symptoms, UDI and IIQ scores were seen among women seeking surgical treatment. Fourteen studies reported baseline and post-surgical treatment distress and QoL data. Statistically significant improvements between baseline and post-surgical UDI and IIQ scores were reported in 12 studies. Reported cure rates ranged from 46% to 97%. Satisfaction with the procedure was reported in 4 studies and ranged from 84% to 91%. A minority of studies reported the relationship between reduction in symptoms and change in HRQoL. CONCLUSION: HRQoL is the main reason women seek surgical treatment for incontinence and surgical treatment leads to a significant improvement in mean HRQoL scores. Assessment of HRQoL has proved less useful in identifying why individual women seek treatment for incontinence. Preliminary work has begun to characterize the interaction between severity of symptoms, distress or bother resulting from these urinary symptoms, impact on HRQoL, and treatment seeking behavior, but further research is needed. Greater standardization in the reporting of results of distress or bother and HRQoL would allow for comparison across studies.

[Leaking index--a new urodynamic parameter in the diagnosis of female stress urinary incontinence]. / Wskaznik wyciekania--nowy parametr urodynamiczny w ocenie wysilkowego nietrzymania moczu u kobiet.

UNLABELLED: Stress urinary incontinence is the most prevalent kind of urinary incontinence in women. Treatment efficiency depends on the type of stress urinary incontinence. PURPOSE OF THE STUDY: The purpose of the study was to assess the differences of values of leaking indexes in women with different types of stress urinary incontinence. MATERIAL AND METHODS: 64 patients were hospitalized at Obstetrics and Gynecology Department of Silesian Medical University between 2005 and 2007. All patients included in the study were diagnosed with stress urinary incontinence (SUI) based on medical history clinical evaluation, pad test and urodynamic evaluation. The study population was divided into three groups according to VLPP and MUCP. Leaking indexes were calculated as a quotient of the area under the curve of leakage and the area under the curve of bladder pressure during the Valsalva manoeuvre. RESULTS: The values of leaking indexes and relative leaking indexes in different types of SUI were compared. Statistically significant differences between relative leaking indexes for groups of women divided according to MUCP and VLPP criterion were found. CONCLUSIONS: Judging from statistically significant differences in relative leaking indexes between groups of women with different types of SUI, relative leaking indexes might be of use in differential diagnosis of types of SUI.