Differences in Pelvic Floor Symptoms During Pregnancy Between Hispanic and Non-Hispanic White Women.

OBJECTIVES: This study aimed to describe and compare pelvic floor symptoms and symptom burden between nulliparous Hispanic and non-Hispanic white women in the third trimester of pregnancy and to determine, in women with stress urinary incontinence (SUI), whether bother differs between groups, adjusted for UI severity. METHODS: In this cross-sectional analysis, participants completed the Epidemiology of Prolapse and Incontinence and Incontinence Severity Index questionnaires. We compared differences in symptom domains between groups using logistic regression and tested the effect of ethnicity on bother in women with SUI using linear regression. RESULTS: The sample comprised 418 non-Hispanic white and 154 Hispanic women. Prevalence rates of symptom domains ranged from 5.0% and 7.1% for pelvic organ prolapse to 95.2% and 94.2% for overactive bladder in non-Hispanic white and Hispanic women, respectively. After adjusting age, height, weight, education, physical activity, and gestational age, non-Hispanic whites had 2.37-fold increased odds (95% confidence interval, 1.44-3.92) for defecatory dysfunction and had nonsignificant increases in other symptom domains. Non-Hispanic whites were more likely to endorse symptoms in 3 or more domains than Hispanic women (58.9% vs 40.3%, respectively; P = 0.0001). Given the same UI severity (Incontinence Severity Index), Hispanic women with SUI reported 7.5 points greater bother (Epidemiology of Prolapse and Incontinence) than non-Hispanic white women (P = 0.07). CONCLUSIONS: After adjustment, we found few differences in the prevalence of pelvic floor symptom domains between Hispanic and non-Hispanic white women, apart from defecatory dysfunction. If differences by ethnicity in other pelvic floor symptoms exist, they do not seem to originate during the first pregnancy.

Repeat prostate biopsies prior to radical prostatectomy do not impact erectile function recovery and mid- to long-term continence.

BACKGROUND: A growing number of men undergo repeat biopsies prior to radical prostatectomy for prostate cancer. However, the long-term impact of repeat biopsies on functional outcomes in this patient population remains unelucidated. Thus, we compared functional outcomes between patients who underwent single biopsy versus repeat biopsies before radical prostatectomy. METHODS: From 1996 to 2015, 1015 consecutive patients underwent radical prostatectomy, and subsequently had urinary continence and erectile function assessed for >2 years follow-up. One-fourth of patients (275; 27%) had ≥2 biopsies before prostatectomy. Logistic regression models tested whether repeat biopsy before prostatectomy predicted continence or erectile function recovery. RESULTS: For the overall cohort, continence rates were 84%, 92%, 96%, and 98% at 3, 6, 12, and 24 months, respectively. Repeat biopsy before prostatectomy was associated with lower continence rate at 3 months compared to single biopsy (P = 0.03); however, no significant differences were observed at 6, 12, or 24 months. In multivariable analyses adjusting for age, body mass index and diabetes/cardiovascular disease/smoking, the association between repeat biopsy and lower likelihood of continence at 3 months remained (odds ratio 0.67, 95% confidence interval 0.47-0.97; P = 0.03). Overall erectile function recovery rates were 16%, 33%, 51%, and 55% at 3, 6, 12, and 24 months, respectively. No difference in erectile function recovery rates was seen at any time point for single biopsy versus repeat biopsy. In multivariable analyses, repeat biopsy was not predictive of erectile function recovery at any time point. CONCLUSIONS: Repeat biopsy before radical prostatectomy impairs early continence after surgery. However, erectile function recovery and mid-term to long-term continence are not affected. These data support the current trend towards active surveillance and delayed local treatment in patients with low- to intermediate-risk prostate cancer.

Racial Variation in Patient-Reported Outcomes Following Treatment for Localized Prostate Cancer: Results from the CEASAR Study.

BACKGROUND: Relatively little is known about the relationship between race/ethnicity and patient-reported outcomes after contemporary treatments for localized prostate cancer. OBJECTIVE: To test the hypothesis that treatment-related changes in urinary, bowel, sexual, and hormonal function vary by race/ethnicity. DESIGN, SETTING, AND PARTICIPANTS: The Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) study is a prospective, population-based, observational study that enrolled 3708 men diagnosed with localized prostate cancer in 2011-2012. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patient-reported disease-specific function was measured using the 26-item Expanded Prostate Index Composite (EPIC) at baseline and 6 and 12 mo after enrollment. Mean treatment differences in function were compared by race using risk-adjusted generalized estimating equations. RESULTS AND LIMITATIONS: While all race/ethnic groups reported considerable declines in scores for urinary incontinence after radical prostatectomy (RP) when compared to active surveillance, African-American men reported a greater difference than white men did (adjusted difference-in-differences 8.4 points, 95% confidence interval 2.0-14.8; p=0.01). No difference in bother scores was noted and the overall proportion of explained variation attributable to race/ethnicity was relatively small in comparison to primary treatment and baseline function. No clinically significant racial variation was noted for the sexual, bowel, irritative voiding, or hormone domains. Limitations include the lack of well-established thresholds for clinical significance using the EPIC instrument. CONCLUSION: While these data demonstrate that incontinence at 1 yr after RP may be worse for African-American compared to white men, the difference appears to be modest overall. Treatment selection and baseline function explain a much greater proportion of the variation in function after treatment. PATIENT SUMMARY: We observed that the effect of treatment for prostate cancer on patient-reported function did not vary dramatically by race/ethnicity. Compared to white men, African-American men experienced a somewhat more pronounced decline in urinary continence after radical prostatectomy, but the corresponding changes in bother scores were not significantly different between the two groups.

Urinary Incontinence and Health-Seeking Behavior Among White, Black, and Latina Women.

OBJECTIVE: Fewer than half of women with urinary incontinence (UI) seek care for their condition. Our objective was to qualitatively assess the themes surrounding treatment-seeking behaviors. METHODS: We conducted 12 focus groups with women and, using purposive sampling, we stratified by racial or ethnic group (white, black, Latina) and by UI frequency. All sessions were transcribed and coded for common themes. Comparative thematic analysis was used to describe similarities and differences among groups. RESULTS: In total, 113 (39 white, 41 black, and 33 Latina) community-dwelling women participated in focus groups. There were no differences in treatment-seeking themes between groups with different UI frequency. However, certain themes emerged when comparing racial/ethnic groups. Women from all groups shared experiences of embarrassment and isolation because of UI, which were impediments to care seeking. White and black women described discussions with close friends or family that led to normalization of symptoms and prevented care seeking. Latina women maintained more secrecy about UI and reported the longest delays in seeking care. Women articulated a higher likelihood of seeking care if they had knowledge of treatment options, but white women were more likely to seek UI-related knowledge compared with black or Latina women. Physician communication barriers were identified in all groups. CONCLUSIONS: Despite similar experiences, there are different perceptions about care seeking among white, black, and Latina women. Culturally relevant educational resources that focus on a range of treatment options may improve knowledge and thus improve care-seeking behaviors in women with UI.

Bladder Symptoms and Attitudes in an Ethnically Diverse Population.

OBJECTIVE: The aim of the study was to assess pelvic floor symptoms and attitudes in an ethnically diverse population. METHODS: We conducted a cross-sectional survey of women presenting to 2 community-based, ethnically diverse gynecology clinics. Before being seen by a provider, participants were asked to complete a questionnaire. RESULTS: A total of 312 women were included: 32.7% white, 50.3% African American, and 17.0% Hispanic. Other racial/ethnic groups were excluded secondary to small samples size. The median (interquartile range) age was 34.0 (27.0-44.0) years. The groups differed with respect to most demographic characteristics, such as income, education, and nation of origin. Nocturia and urinary frequency were the most commonly reported symptoms. African American respondents were more likely to report nocturia than white respondents (odds ratio, 2.4; 95% confidence interval, 1.2-4.8). Respondents' views of normal urinary function generally did not vary by race/ethnicity. However, Hispanic respondents were less likely than white respondents to agree that it is normal to leak urine after having children (odds ratio, 0.28; 95% confidence interval, 0.11-0.68). Among women who reported at least 1 symptom, 46.7% reported that at least 1 symptom bothered them, and this did not differ with respect to race/ethnicity (P ≥ 0.59). African American respondents were more likely than whites to report their urinary leakage to their doctors (P = 0.006). CONCLUSIONS: Our study demonstrates that with few exceptions, bladder symptoms and attitudes are similar among reproductive-age women of various racial/ethnic groups in a community setting.

Does Race Influence Health-related Quality of Life and Toxicity Following Proton Therapy for Prostate Cancer?

OBJECTIVE: This matched-paired analysis explores disparities in health-related quality of life (QOL) and common toxicities between African American (AA) and white patients following proton therapy for prostate cancer at our institution. MATERIALS AND METHODS: A total of 1536 men with clinically localized prostate cancer were treated from 2006 to 2009 with definitive proton therapy to a median dose of 78 Gy +/- androgen deprivation therapy. A cohort of 92 consecutively treated AA men was matched to a cohort of 92 white men on the basis of National Comprehensive Cancer Network risk category and age. The 2 groups were compared with regard to comorbidities, demographics, and treatment regimen. Differences in genitourinary and gastrointestinal (GI) toxicity according to the Common Terminology Criteria for Adverse Events scale and QOL data from the Expanded Prostate Index Composite 26-question questionnaire were reported. RESULTS: Median follow-up was 2.1 years. Baseline patient and treatment characteristics were similar between the 2 groups with the exception of prostate-specific antigen ≥10 (32% for AAs vs. 20% for whites; P=0.068) and use of androgen deprivation therapy (26% for AAs vs. 21% for whites; P=0.38). No difference in Expanded Prostate Index Composite 26-question sexual summary, urinary incontinence, urinary obstruction, or bowel summary scores was detected between the 2 groups, nor was there a difference in grade 2 or higher GI toxicity (P=0.45). AAs had a statistically nonsignificant higher absolute incidence of late grade 3 genitourinary toxicity (4.4% vs. 0%; P=0.12). CONCLUSIONS: After 2 years, there were no disparities in health-related QOL, physician-reported Common Terminology Criteria for Adverse Events GI toxicity, or biochemical relapse. Longer follow-up is needed to confirm these findings.

Barriers to urinary incontinence care seeking in White, Black, and Latina women.

OBJECTIVE: We compared barriers to urinary incontinence (UI) healthcare seeking between white, black, and Latina women. METHODS: This is a cross-sectional study using a convenience sample of white, black, and Latina women. Women completed the Barriers to Incontinence Care Seeking Questionnaire (BICS-Q), the Incontinence Quality of Life Instrument (I-QOL), the Questionnaire for Urinary Incontinence Diagnosis, and the Incontinence Severity Index (ISI). The primary objective was to assess barriers to UI care seeking among groups, as measured by the BICS-Q. Secondary objectives were to assess factors associated with barriers to incontinence care and to compare specific barriers using BICS-Q subscale scores. Regression analyses were used to further assess for differences among groups while adjusting for potential confounding variables. RESULTS: We included a total of 93 subjects, including 30 white, 33 black, and 30 Latina women. Mean I-QOL, Questionnaire for Urinary Incontinence Diagnosis, and ISI scores were not significantly different among our 3 groups. Barriers, based on BICS-Q scores, were lowest in white women and higher in blacks and Latinas (2.9 vs 7.3 vs 10.9, respectively; P < 0.001). When adjusting for potential confounders such as age, income, education, presence of UI, ISI score, and I-QOL score, Latinas continued to demonstrate higher barriers compared with white or black women (ß = 7.4; 95% CI, 2.2-12.7; P = 0.006). There were no significant differences between black women compared with other groups in the adjusted analyses. CONCLUSIONS: Latinas experience more barriers to UI healthcare seeking compared with white and black women.

Racial differences in self-reported healthcare seeking and treatment for urinary incontinence in community-dwelling women from the EPI Study.

AIMS: Objectives of this study are: (1) to examine the prevalence of healthcare seeking among black and white women with self-reported urinary incontinence (UI), (2) to investigate barriers to treatment for incontinence, and (3) To investigate commonly used therapeutic modalities for UI. METHODS: This is a planned secondary analysis of responses from 2,812 black and white community-dwelling women living in southeastern Michigan, aged 35-64 years, who completed a telephone interview concerning UI, healthcare-seeking behaviors and management strategies. The study population was 571 subjects (278 black, 293 white) who self-identified as having urinary incontinence. RESULTS: Of these women with UI, 51% sought healthcare with no statistically significant difference between the two races (53% black, 50.6% white, P = 0.64). In multivariate logistic regression analysis, a higher likelihood of seeking healthcare was associated with increased age, body mass index lower than 30 kg/m(2) , prior surgery for UI, having regular pelvic exams, having a doctor, and worsening severity of UI. There was no significant association between hypothesized barriers to care seeking and race. Almost 95% of the subjects identified lack of knowledge of available treatments as one barrier. Black and white women were similar in percentage use of medications and some self-care strategies, for example, pad wearing and bathroom mapping, but black women were significantly more likely to restrict fluid intake than white women and marginally less likely to perform Kegels. CONCLUSIONS: Black and white women seek healthcare for UI at similar, low rates. Improved patient-doctor relationships and public education may foster healthcare seeking behavior.

Fistula campaigns--are they of any benefit?

OBJECTIVE: Evaluation of the problems encountered during a voluntarily fistula campaign in a regional hospital of Niger (Africa). MATERIALS AND METHODS: Women underwent basic gynecological examination, methylene blue testing, and/or direct cystoscopy as necessary. According to their clinical condition, women were informed and surgical options offered as appropriate. Operations were performed under spinal or epidural anesthesia. Immediate postoperative outcomes were followed during the stay of the surgical team in the country. RESULTS: A total of 62 women were examined and 11 had causes of incontinence other than obstetric fistula. In 9.8% of the women, severe local infection precluding any surgical intervention was evident. In 58.8% of patients, the trigonal region and/or urethra were irreversibly damaged. A proportion of patients (9.8%) with large lesions and intact urethra that were offered vaginal layered closure refused the intervention. Of the women that were operated on (21.6%), six underwent vaginal layered closure with Martius fat flap and five women underwent a combined abdomino-vaginal approach. CONCLUSION: It is extremely difficult to meet the needs of this global problem with short term programs and volunteers. Directing these efforts to specialist fistula centers and creating reliable scientific evidence should be the main goal.

Prevalence of urinary incontinence in Korean women: results of a National Health Interview Survey.

OBJECTIVES: We determined the prevalence and types of urinary incontinence (UI) in Korean women and analyzed their attitude toward treatment. METHODS: This national survey was conducted as part of the Korean National Health Interview Survey to evaluate the prevalence of UI in Korean women between April and June 2005. In 13,345 Korean households, 13,484 women aged 19 years or older were interviewed by census takers. The subjects were asked about the type of UI that they had experienced and their treatment. UI was classified as "stress," "urge," "mixed" (stress and urge), or "other." RESULTS: The overall prevalence of UI in the subjects was 24.4%. Of those women, 48.8% reported stress UI only; 7.7%, urge UI only; 41.6%, mixed UI; and 1.9%, other type of UI. The prevalence of UI increased with age. Only 12.6% of the women with UI had sought medical care, and only 0.8% had undergone surgery for UI. Self-reported depression was higher in women with UI than in those without that disorder, and UI was more prevalent in women who were married, unemployed, and undereducated. According to national population data estimated by weighted UI numbers, about 4.2 million Korean women aged 19 years or older have experienced UI. CONCLUSIONS: The prevalence of UI among women aged 19 years or older in Korea was 24.4%, and stress UI was the most prevalent type. Many women with UI did not seek medical treatment for that condition.

Differences in urinary incontinence between Hispanic and non-Hispanic white women: a population-based study.

OBJECTIVE: To compare the prevalence of urinary incontinence (UI) between Hispanic and non-Hispanic White women in a population-based study. SUBJECTS AND METHODS: The prevalence of moderate to severe UI, defined as Sandvik severity score of >or=3, was assessed in relation to ethnicity by stratification, age adjustment and logistic regression models among 250 Hispanic and 491 non-Hispanic White women in Colorado, USA, who were participants in a breast cancer case-control study. RESULTS: Hispanic women reported more stress UI (odds ratio 1.7, P = 0.005) and mixed UI (odds ratio 1.8, P = 0.005) than did non-Hispanic White women. These higher prevalences were largely associated with ethnic differences in parity, body mass index, diabetes, hysterectomy and bilateral oophorectomy. CONCLUSIONS: The prevalence of moderate to severe UI in Colorado is higher among Hispanic women than among non-Hispanic white women. This difference is largely compatible with differences in reproductive history, adiposity and diabetes.

Factors associated with prevalent and incident urinary incontinence in a cohort of midlife women: a longitudinal analysis of data: study of women's health across the nation.

To compare the characteristics of and baseline factors associated with prevalent and incident urinary incontinence in a diverse cohort of midlife women, the authors analyzed the baseline and first five annual follow-up visits of the Study of Women's Health Across the Nation (SWAN), 1995-2001. From responses to annual questionnaires, the authors defined prevalent incontinence as at least monthly incontinence reported at baseline and incident incontinence as at least monthly incontinence first reported over follow-up. They used multiple logistic regression for their comparison. The mean age of their cohort at baseline was 45.8 (standard deviation: 2.7) years. Prevalent incontinence was 46.7%, and the average incidence was 11.1% per year. Most women reported stress, but a higher proportion developed urge incontinence (15.9% vs. 7.6% at baseline). African Americans (29.5%) and Hispanics (27.5%) had the lowest prevalence of incontinence; African Americans (11.6%) and Caucasians (13.4%) had the highest average annual incidence. Parity, diabetes, fibroids, and poor social support were associated with prevalent incontinence, while high body mass index, high symptom sensitivity, and poor health were associated with incident incontinence. In midlife women, incident incontinence is mild with different characteristics and baseline risk factors; overweight women have a higher risk of developing incontinence.

Risk factors for urinary incontinence among middle-aged women.

OBJECTIVE: The purpose of this study was to identify risk factors for urinary incontinence in middle-aged women. STUDY DESIGN: We conducted a cross-sectional analysis of 83,355 Nurses' Health Study II participants. Since 1989, women have provided health information on mailed questionnaires; in 2001, at the ages 37 to 54 years, information on urinary incontinence was requested. We examined adjusted odds ratios of incontinence using logistic regression. RESULTS: Forty-three percent of the women reported incontinence. After adjustment, black (odds ratio, 0.49; 95% CI, 0.40-0.60) and Asian-American women (odds ratio, 0.57; 95% CI, 0.46-0.72) were at reduced odds of severe incontinence compared with white women. Increased age, body mass index, parity, current smoking, type 2 diabetes mellitus, and hysterectomy all were associated positively with incontinence. Women who were aged 50 to 54 years had 1.81 times the odds of severe incontinence compared with women who were <40 years old (95% CI, 1.66-1.97); women with a body mass index of > or =30 kg/m2 had 3.10 times the odds of severe incontinence compared with a body mass index of 22 to 24 kg/m2 (95% CI, 2.91-3.30). CONCLUSION: Urinary incontinence is highly prevalent among these middle-aged women. Potential risk factors include age, race/ethnicity, body mass index, parity, smoking, diabetes mellitus, and hysterectomy.

Risk factors for urinary incontinence in African-American women.

The majority of research on urinary incontinence (UI) has been conducted with Caucasian populations. This correlational, descriptive study was designed to identify prevalence and risk factors for Ul and to determine the types of incontinence most commonly seen in healthy African-American women. Results of this study showed that age and education were risk factors for Ul in African-American women. It is suggested that African-American women be routinely screened for symptoms of Ul as a part of preventive health care.

Ambulatory procedures for urinary incontinence in the United States, 1994-1996.

OBJECTIVE: The objective of our study was to describe the national rates of ambulatory surgery for urinary incontinence in women. STUDY DESIGN: We used the National Survey of Ambulatory Surgery, a federal database that samples outpatient surgery in the United States. Data from 1994 to 1996 were analyzed for diagnoses and procedures coded using the International Classification of Diseases, 9th revision, Clinical Modification, classification system. Age-adjusted rates were calculated with use of the 1990 census population and compared for change over time by using the score test for linear trend. RESULTS: The estimated number of women undergoing outpatient surgery for urinary incontinence increased from 7,200 in 1994 to 15,900 in 1996 (P=.3), whereas the age-adjusted rate remained stable at approximately 10 procedures per 100,000 women per year. The procedures performed included "other repair of the bladder" (ICD-9-CM code 57.89), "other repair of urinary stress incontinence" (code 59.7), plication of the urethrovesical junction, suprapubic sling operation, retropubic urethral suspension, paraurethral suspension, and levator muscle operation. The mean age of women undergoing these procedures was 58+/-14.5 years. Women undergoing incontinence procedures were 76% white, 0.3% African American, and 24% other (including unknown). Ninety-two percent of the procedures were completed at hospitals, whereas 8% were performed at free-standing ambulatory surgery centers. CONCLUSION: Between 1994 and 1996, the number of ambulatory surgeries for urinary incontinence in women doubled.

Urinary incontinence predictors and life impact in ethnically diverse perimenopausal women.

OBJECTIVE: To document prevalence of mild, moderate, and severe urinary incontinence among ethnically diverse perimenopausal women, identify risk factors, and assess the effect of severity on women's daily lives using treatment seeking, bother, and nighttime voiding as indicators. METHODS: Baseline data from the longitudinal cohort of the Study of Women's Health Across the Nation, a prospective, multiethnic, multisite study of the natural history of menopausal transition was used (n = 3302). Interview and self-completed questionnaires assessed most variables of interest. Body mass index and diabetes mellitus were measured clinically. Incontinence severity was derived by multiplying frequency by volume leaked. Risk factors and effect on treatment seeking, bother, and nighttime voiding were assessed by the construction of multiple logistic regression models for each ethnic group and the total population. RESULTS: Mean age was 46.4 years. Incontinence prevalence was 57%, with nearly 15% categorized as moderate and 10% as severe. Biologic factors constituted the most important risk for severity, specifically perimenopausal compared with premenepausal status (odds ratio [OR] 1.35), body mass index (OR 1.04), diabetes mellitus (OR 1.55), and current smoking (OR 1.38). Nonwhite groups had lower risk, but the relationship of ethnicity is complex. Severity was associated with likelihood of discussing with a health care provider, with bothersomeness, and with likelihood of nighttime voiding. CONCLUSION: Large numbers of perimenopausal women experience urinary incontinence with 25% wearing protection or changing undergarments on several days per week. Mutable factors predicting severity included body mass index and current smoking.

Patient characteristics that are associated with urodynamically diagnosed detrusor instability and genuine stress incontinence.

OBJECTIVE: We sought to compare characteristics of patients with urodynamically diagnosed detrusor instability or genuine stress incontinence. STUDY DESIGN: A retrospective audit of 293 consecutive women who were referred to a urogynecologist for evaluation of urinary incontinence between June 1996 and April 2000. RESULTS: Of the 293 patients, 289 women had a physical examination and urodynamic testing, which revealed genuine stress incontinence (35%), detrusor instability (32%), mixed incontinence (29%), or normal urodynamic function (4%). Compared with patients with detrusor instability, those women with genuine stress incontinence were more likely to be white than African American (P <.0001) and to have a cystocele(P =.027), rectocele (P <.0001), or paravaginal defect (P =.004). No differences in age, gravidity, parity, estrogen treatment, or previous anti-incontinence procedure were identified between women with detrusor instability and women with genuine stress incontinence. CONCLUSION: In a tertiary referral center, the distribution of urinary incontinence is evenly divided among genuine stress incontinence, detrusor instability, and mixed incontinence. Patients with genuine stress incontinence are more likely to be white and to have pelvic floor prolapse and symptoms of pure stress incontinence.

Collagen injection in the management of post-radical prostatectomy intrinsic sphincteric deficiency.

Transurethral injection of collagen is a minimally invasive option for the treatment of urinary incontinence secondary to intrinsic sphincteric deficiency (ISD). We report on the results of transurethral injection in 21 men with urinary incontinence secondary to ISD. Twenty-one consecutive men with a mean age of 69.5 years (range, 51-84), with ISD documented by demonstrating urinary leakage with Valsalva maneuver on physical examination and by video-urodynamic studies were treated with transurethral collagen injection. The etiologies of the incontinence were radical retropubic prostatectomy (RRP) in seven (33.3%), RRP followed by external radiation therapy in seven (33.3%), and transurethral resection of the prostate (TURP) with subsequent RRP in seven (33. 3%). The mean total volume of collagen injected per patient was 18.4 mL (range, 1-44.5). The average number of injections was 2.9 (range, 1-5). The mean follow-up was 12.5 months (range, 1-39). One (5%) patient became dry, 12 (57%) had significant improvement, and eight (38%) had no change. Overall pad use decreased from 2.5 pads/day to 1.68 pads/day, before and after collagen injection (P = 0.014). No difference in outcomes was demonstrated in African American men versus Caucasian American men (P = 0.38), age (<65 and >65 years, P = 0.88), presence of erectile dysfunction, or duration of incontinence (<20 or >20 months, P = 0.71). There were no reported complications. Collagen injection has minimal morbidity and is a viable option for improving incontinence status in men. Neither age, race, erectile function, nor duration of incontinence appears to affect treatment outcome. Neurourol. Urodynam. 18:653-658, 1999.

Silent suffering.

PIP: This article focuses on the plight of women who are suffering from incontinence due to obstetrical fistula and other causes, and discusses the efforts of Dr. Hamlin and other individuals in helping these women. Obstetrical fistula is common in sub-Saharan Africa and has also been reported on the Indian subcontinent in Bangladesh, India, Nepal and Pakistan. The factors affecting this problem are complex. In some developing countries, childbearing is seen as a natural part of life wherein women usually give birth unaided, even when they have difficulties. Other factors include early pregnancy, continuous childbearing and breast-feeding, malnutrition, female genital mutilation, and inaccessibility of rural health services. Oftentimes, women with this condition have to suffer for many years before undergoing surgery. However, prevention is better than cure, prevention involves a better education and care for women during pregnancy and labor, with more trained midwives and traditional birth attendants who know when to call for medical help.^ieng