The effect of the COVID-19 lockdown on women presenting with pelvic organ prolapse.

PURPOSE: To determine whether there is a difference in pelvic organ prolapse (POP) stage at time of presentation after lifting coronavirus disease (COVID-19) lockdown restrictions, as compared to before the lockdown. Enhancing our understanding of how healthcare utilization for pelvic floor disorders may be affected by limited accessibility, such as the COVID-19 pandemic, could prove invaluable for similar future circumstances. METHODS: This is a retrospective study of women with POP at their initial visit. Patients were grouped into two cohorts based on their initial presentation time: pre-COVID-19 lockdown (before March 2020) and post-COVID-19 lockdown (after December 2020). The cohorts were compared using demographic, clinical, and surgical variables. A logistic regression controlling for confounders was used to evaluate the influence of the COVID-19 lockdown on prolapse stage. RESULTS: There were 656 (50.3%) patients in the pre-COVID-19 lockdown cohort and 648 (49.7%) in the post-COVID-19 lockdown cohort. All baseline characteristics were similar between both cohorts except for race (p = 0.015). Treatment choices differed with the post-COVID-19 lockdown cohort having a lower proportion (26.5%) opting for surgery and a higher proportion (50.5%) of patients opting for nonsurgical interventions compared to the pre-COVID-19 lockdown cohort (p = 0.0005). A higher proportion of women presented with stages I and II prolapse in the post-COVID-19 lockdown (70.4%) cohort as compared to the pre-COVID-19 lockdown (62.5%) cohort (p = 0.002). CONCLUSIONS: Women in the post-COVID-19 lockdown cohort presented with early stage prolapse with preference for more conservative treatment options.

Effect of Dietary Choline Consumption on the Development of Urinary Urgency Incontinence in a Longitudinal Cohort of Women.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to determine whether differences in the cumulative dietary intake of choline, is associated with the risk of developing urge urinary incontinence (UUI). METHODS: This was an analysis within the Nurses' Health Study (NHS) I and II. The main exposure was the cumulative daily intake for each choline-containing compound obtained from a detailed daily food frequency questionnaire. The primary outcome was UUI, defined as urine loss with a sudden feeling of bladder fullness or when a toilet is inaccessible, occurring >1/month. Cox proportional hazards regression models were used to calculate multivariate-adjusted relative risks and 95% confidence intervals (CIs) for the association between total choline and choline derivatives and risk of UUI. Fixed effects meta-analyses of results from NHSI and NHSII were performed for postmenopausal women only to obtain a pooled estimate of the impact of choline consumption on UUI. RESULTS: There were 33,273 participants in NHSI and 38,732 in NHSII who met all the criteria for inclusion in the analysis. The incidence of UUI was 9.41% (n=3,139) in NHSI and 4.25% (n=1,646) in NHSII. After adjusting for confounders choline was not found to be associated with UUI in postmenopausal women. However, in premenopausal women, relative to the lowest quartile, the highest quartile of consumption of total choline (aRR = 0.79, 95% CI: 0.64-0.99), free choline (aRR = 0.74, 95% CI: 0.58-0.94), and phosphocholine (aRR = 0.77, 95% CI: 0.61-0.96) were associated with a reduced risk of UUI. CONCLUSIONS: Increased dietary choline consumption was associated with a reduced risk of UUI among premenopausal women.

Establishing urogynecology subspecialty in Armenia: The Armenia project.

It is well known that there are many countries in the world where Urogynecology is not an existing subspecialty, and women are not receiving appropriate care for their pelvic floor disorders (PFD). One of these countries is the Republic of Armenia. Given the lack of expertise in the field of Urogynecology in Armenia, we conducted a study on the prevalence of PFDs and the degree of bother among women of all ages across the country, which was published in 2020. This led to the creation of the International Urogynecology Association for Armenia, comprising seven physicians from different countries: five from the USA, one urogynecologist from Lebanon, and one urologist from Russia. We implemented hybrid teaching based on Zoom lectures, case presentations, journal clubs, and live visits of mentors to Armenia on a regular basis to see patients and operate with our five fellows. We introduced our fellows to research and statistics by assigning research topics for different projects. Our fellows presented evidence-based presentations and extensive literature reviews on a regular basis. Our program will continue to grow the next 2-3 years. The success of this project holds significance for governmental, public, and healthcare entities in Armenia and across the world, where this subspecialty is non-existent, in preparing future female pelvic surgeons to care for the growing needs of women with these conditions. Replicating this program in other parts of the world will compound the benefits and successes of Urogynecology care across different societies, cultures, and people around the globe.

The effect of preoperative scopolamine patch use on postoperative urinary retention in urogynecologic surgeries.

INTRODUCTION AND HYPOTHESIS: This study aims to determine whether the use of preoperative transdermal scopolamine is associated with an increased risk of postoperative urinary retention in urogynecologic surgeries. METHODS: This is a retrospective chart review study of women who underwent surgery between January 1, 2018, and December 31, 2020. Patients who received a scopolamine patch versus those who did not were compared using demographic and perioperative variables utilizing Pearson's chi-squared test and t-test of Wilcoxon rank-sum. A logistic regression was performed to evaluate the effect of scopolamine on the patients' postoperative voiding trial results, controlling for confounders. P-value < 0.05 was considered statistically significant. RESULTS: A total of 449 women underwent a vaginal or laparoscopic hysterectomy, midurethral sling placement, uterosacral or sacrospinous ligament suspension, sacrocolpopexy, anterior/posterior colporrhaphy, or other urogynecologic surgeries with 109 (24.2%) having received transdermal scopolamine. A significantly higher number of women with preoperative scopolamine [n = 50 (45.9%)] failed their voiding trial compared to those without scopolamine [n = 100 (29.4%), p = 0.0016]. The adjusted model yielded an odds ratio of 1.75 (95% CI: 1.08-2.85) of a failed voiding trial in the scopolamine group. When comparing the odds of failing voiding trial by surgery type, those with a midurethral sling placed during surgery had an adjusted odds ratio of 3.12 (95% CI: 2.01-4.87), as compared to those without a midurethral sling. CONCLUSIONS: Use of a transdermal scopolamine patch for nausea and vomiting prophylaxis is associated with increased risk of postoperative urinary retention across all urogynecologic surgeries.

Impact of microbiota and host immunologic response on the efficacy of anticholinergic treatment for urgency urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Studies within the past decade have suggested associations among composition of the urinary microbiota, local immune responses, and urinary incontinence symptoms. To investigate these relationships, we evaluated the structure of the urinary microbiome, local inflammatory markers, and patient responses prior to and at 6-weeks after treatment with anticholinergic medication for urgency urinary incontinence (UUI). METHODS: Using a prospective pilot study, we enrolled women who presented with UUI symptoms and were prescribed treatment with anticholinergics. Catheterized urine samples were collected from participants at their baseline and 6-week follow-up visits for microbiological (standard and 16S rRNA gene phylotyping analyses) and cytokine analysis along with the UDI-6 questionnaire and 2-day bladder diary. RESULTS: Patients were Caucasian, post- menopausal, with a median age of 64 and median BMI of 30.1 kg/m2. Among the patients, 75% had UUI symptoms for less than 2 years, but with a frequency of at least a few times a week or every day. Most women were prescribed 10 mg oxybutynin ER daily at enrollment. Patients had varied urinary microbiota by culture and 16S phylotyping, with species of Lactobacillus being the most common, in six samples, in addition to taxa associated with Enterococcus, Staphylococcus, and mixed flora. Cytokine levels showed no differences before and after treatment with anticholinergics, nor correlation with urinary bacteria or microbiome composition. CONCLUSIONS: Our pilot study suggests factors in addition to the urinary microbiome and local immune responses may be involved in patients' response to anticholinergics for UUI.

Perioperative use of pain medications in vaginal versus laparoscopic pelvic organ prolapse surgery.

INTRODUCTION AND HYPOTHESIS: There has been renewed interest in the management of postoperative pain after benign gynecological surgery. The purpose of the study was to determine if the use of intraoperative and immediate postoperative pain medication differs between vaginal and laparoscopic surgery in women with pelvic organ prolapse. METHODS: The study included women who had undergone pelvic organ prolapse repair between 2014 and 2019 in two tertiary care hospitals. We collected demographic data and pain medication used during and after surgery, including opioids, local anesthetics, gabapentin, ketorolac, ibuprofen, and acetaminophen. Data analyses were performed using STATA Version 16.1. A p value <0.05 was considered to indicate statistical significance. RESULTS: A total of 195 women were included in the study, with 98 in the vaginal and 97 in the laparoscopic group. Intraoperative opioid use in the two groups was similar (25 morphine milligram equivalent [MME], p = 0.34). However, women in the laparoscopic group received significantly more intravenous and local anesthesia (lidocaine: 60 vs 40 mg; bupivacaine 49.6 vs 20 ml, p < 0.001). Postoperatively, although women in the vaginal group required almost twice as many narcotics as those in the laparoscopy group (MME = 28 vs 15, p < 0.001), after controlling for confounders in the multivariate analysis, there were no differences in postoperative pain requirements between the two groups. Recovery time had a significant impact on opioid and acetaminophen use (p < 0.05). CONCLUSION: Use of pain medication was similar in the intraoperative and immediate postoperative period after pelvic organ prolapse surgery when comparing the vaginal and laparoscopic approaches after controlling for potential confounding factors.

Pelvic organ prolapse after 3 modes of hysterectomy: long-term follow-up.

BACKGROUND: There are various indications and approaches for hysterectomy; yet, the difference in long-term risk of subsequent prolapse after surgery is not well studied. OBJECTIVE: To assess the risk of prolapse after abdominal, vaginal, and laparoscopic or robotic hysterectomy for up to 17 years from surgery. STUDY DESIGN: A retrospective chart review study of women undergoing hysterectomy across all indications (benign and malignant) between 2001 and 2008 was conducted. An equivalent random sample of hysterectomy patients was selected each year. We compared demographic and other surgical characteristics data including age, race, parity, body mass index, indication and year of hysterectomy, blood loss, cervix removal, cuff suspension, and complications using chi-square, Kruskal-Wallis test, and Fisher's exact across the 3 groups. Presence and treatment of subsequent prolapse (based on patient symptoms, pelvic exam, International Classification of Diseases, Ninth Revision diagnosis, and current procedural terminology pessary or surgical codes) were compared with Kaplan-Meier survival analysis and Cox proportional hazards regression. RESULTS: Of the 2158 patients, 1459, 375, and 324 underwent open, vaginal, and laparoscopic or robotic hysterectomy, respectively. The vaginal group (56) was older than the abdominal (52) or laparoscopic or robotic (49) groups, with a P value of <.05. Most patients were White with a mean body mass index of 30 kg/m2. The main indication was cancer for abdominal (33%) and laparoscopic or robotic hysterectomy (25%) and prolapse for vaginal hysterectomy (60%). Time to prolapse was shortest after vaginal surgery (27 months) and longest after laparoscopic or robotic surgery (71 months). After controlling for confounders, including surgery indication, the hazard ratio for subsequent prolapse was no different among vaginal (hazard ratio=1.36 [0.77-2.45]), laparoscopic or robotic (hazard ratio=1.47 [0.80-2.69]), or open (reference) hysterectomy. Prolapse grade was similar across the 3 groups. About 50% of women with recurrent prolapse received physical therapy, pessary, or surgical treatment. CONCLUSION: At the 17-year follow-up, the route of hysterectomy is not associated with a difference in recurrence, grade, or subsequent treatment of prolapse when the indication for hysterectomy is considered. Prolapse, as an indication for hysterectomy, increases risk for recurrence. Women planning a hysterectomy should be counseled appropriately about the risk of subsequent prolapse.

Surgical approach and unplanned readmission following pelvic organ prolapse surgery: a retrospective cohort study using data from the National Surgical Quality Improvement Program Database (NSQIP).

INTRODUCTION AND HYPOTHESIS: To define the reasons for hospital readmissions following surgery for pelvic organ prolapse by surgical approach. METHODS: Patients undergoing surgery for pelvic organ prolapse from 2012 to 2018 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology and International Classification of Diseases codes. Hazard risks of readmission by surgical approach (vaginal, laparoscopic, abdominal, or combined) were determined by multivariable cox regression. Diagnoses and timing of readmission by surgical approach were examined. RESULTS: Of 57,233 women undergoing surgery for pelvic organ prolapse during the study period, 1073 (1.9%) were readmitted to the hospital within 30 days postoperatively. After adjusting for prespecified potential confounders, laparoscopic and abdominal surgical approaches were associated with higher risks of readmission relative to a vaginal approach (aHR 1.30, 95% CI 1.08-1.57, and 1.97, 95% CI 1.44-2.71, respectively). The most common reason for readmission was a gastrointestinal issue among those undergoing both laparoscopic (28.0%) and abdominal surgery (30.2%). Surgical site infection was the most common readmission diagnosis among women undergoing vaginal surgery (16.2%). Of the 418 women readmitted within 7 days of surgery, the most common diagnoses were gastrointestinal issues (26.6%), medical disorders (12.0%), or surgical complications (e.g., bleeding) (11.0%). CONCLUSIONS: Women undergoing laparoscopic or abdominal surgery for pelvic organ prolapse were at higher risk of readmission relative to those undergoing surgery via a vaginal approach. The reasons and timing of readmission differed based on surgical approach.

Genome-Wide Association Study for Urinary and Fecal Incontinence in Women.

PURPOSE: Urinary incontinence and fecal incontinence are common disorders in women that negatively impact quality of life. In addition to known health and lifestyle risk factors, genetics may have a role in continence. Identification of genetic variants associated with urinary incontinence and fecal incontinence could result in a better understanding of etiologic pathways, and new interventions and treatments. MATERIALS AND METHODS: We previously generated genome-wide single nucleotide polymorphism data from Nurses' Health Studies participants. The participants provided longitudinal urinary incontinence and fecal incontinence information via questionnaires. Cases of urinary incontinence (6,120) had at least weekly urinary incontinence reported on a majority of questionnaires (3 or 4 across 12 to 16 years) while controls (4,811) consistently had little to no urinary incontinence reported. We classified cases of urinary incontinence in women into stress (1,809), urgency (1,942) and mixed (2,036) subtypes. Cases of fecal incontinence (4,247) had at least monthly fecal incontinence reported on a majority of questionnaires while controls (11,634) consistently had no fecal incontinence reported. We performed a genome-wide association study for each incontinence outcome. RESULTS: We identified 8 single nucleotide polymorphisms significantly associated (p <5×10-8) with urinary incontinence located in 2 loci, chromosomes 8q23.3 and 1p32.2. There were no genome-wide significant findings for the urinary incontinence subtype analyses. However, the significant associations for overall urinary incontinence were stronger for the urgency and mixed subtypes than for stress. While no single nucleotide polymorphism reached genome-wide significance for fecal incontinence, 4 single nucleotide polymorphisms had p <10-6. CONCLUSIONS: Few studies have collected genetic data and detailed urinary incontinence and fecal incontinence information. This genome-wide association study provides initial evidence of genetic associations for urinary incontinence and merits further research to replicate our findings and identify additional risk variants.

The natural history of urinary incontinence subtypes in the Nurses' Health Studies.

BACKGROUND: Urinary incontinence subtypes often differ by symptom severity and treatment profiles; in particular, mixed urinary incontinence is generally associated with worse symptoms and less successful treatment. Yet, limited information exists on the natural history of different urinary incontinence subtypes, which could help to better identify and treat patients prior to development of more intractable disease. OBJECTIVE: To evaluate the onset of urinary incontinence subtypes, and transitions between subtypes over 8 years, using 2 large cohorts of middle-aged and older women with incident urinary incontinence. MATERIALS AND METHODS: We identified 10,349 women with incident urinary incontinence (stress, urgency, and mixed subtypes) from the Nurses' Health Study and the Nurses' Health Study II who were 41-83 years of age, using repeated mailed questionnaires. We defined stress urinary incontinence as leakage with coughing, sneezing, or activity; urgency urinary incontinence as urine loss with a sudden feeling of bladder fullness or when a toilet was inaccessible; and mixed urinary incontinence when women reported that stress and urgency symptoms occurred equally. In subsequent questionnaires 4 and 8 years later, we continued to track symptom severity and subtypes. In addition, to obtain predicted probabilities of urinary incontinence subtypes 4 years and 8 years after urinary incontinence onset, we used multivariable-adjusted generalized estimating equations with a multinomial outcome. RESULTS: At urinary incontinence onset in 2004-2005, 56% of women reported stress urinary incontinence symptoms, 23% reported urgency urinary incontinence symptoms, and 21% reported mixed urinary incontinence symptoms. Women with stress urinary incontinence or urgency urinary incontinence at onset were likely to report the same urinary incontinence type 4 and 8 years later (stress urinary incontinence at onset: 70% and 60% reported stress urinary incontinence at years 4 and 8, respectively; urgency urinary incontinence at onset: 68% and 64% reported urgency urinary incontinence at years 4 and 8, respectively). Nonetheless, for both stress and urgency urinary incontinence, women with more severe symptoms at onset were more likely to progress to mixed urinary incontinence. Women with mixed urinary incontinence at onset had more variation over time, although the largest subset continued to report mixed urinary incontinence (45% reported mixed urinary incontinence at year 4; 43% reported mixed urinary incontinence at year 8). Few women across all urinary incontinence subtypes reported resolution of symptoms over 4-8 years of follow-up (4-12%). When considering the likelihood of remaining with or progressing to mixed urinary incontinence over follow-up, according to age, body mass index, and urinary incontinence severity, we found that older and younger women had similar predicted probability of remaining with or progressing to mixed urinary incontinence (eg, women <60 years of age at onset with severe mixed urinary incontinence had a 54% (95% confidence interval, 53-55) probability of mixed urinary incontinence 8 years later, vs 57% (95% confidence interval, 56-58) of women ≥70 years of age with severe mixed urinary incontinence at onset). Obese women were somewhat more likely to progress to mixed urinary incontinence regardless of urinary incontinence type at onset (eg, women with body mass index <25 kg/m2 at onset with severe stress urinary incontinence had a 30% predicted probability of mixed urinary incontinence 8 years after onset, vs 36% of women with body mass index of 30+ kg/m2 at onset with severe stress urinary incontinence). CONCLUSION: Most women with incident stress and urgency urinary incontinence continued to experience similar subtype symptoms over 8 years. However, obese women and those with more severe symptoms were more likely to remain with or progress to mixed urinary incontinence.

Outpatient Evaluation and Management Visits for Urinary Incontinence in Older Women.

PURPOSE: The aims of this investigation were to examine how often outpatient visits addressing urinary incontinence in women with self-reported incontinence symptoms occur and to explore characteristics associated with an outpatient visit for incontinence. MATERIALS AND METHODS: We studied the records of 18,576 women from the Nurses' Health Study who were 65 years old or older, reported prevalent incontinence symptoms in 2012 on a mailed questionnaire and were linked with Medicare utilization data. We compared demographic, personal and clinical characteristics in women with and without claims for outpatient visits for urinary incontinence. In logistic regression models we controlled for potential confounding factors, including age, race, parity, body mass index, medical comorbidities, smoking status, health seeking behavior, disability, physical function and geographic region. RESULTS: In this linkage between symptom report and insurance claims data we found that only 16% of older women with current incontinence symptoms also had an outpatient visit addressing incontinence in the prior 2 years. In multivariable adjusted models severe vs slight incontinence (OR 3.75, 95% CI 3.10-4.53) and urgency vs stress incontinence (OR 1.80, 95% CI 1.56-2.08) were the strongest predictors of undergoing outpatient evaluation. CONCLUSIONS: Overall only a small percent of women who report urinary incontinence symptoms also have medical outpatient visits for incontinence, which is a marker of care seeking. Our study highlights the discordance between the high prevalence of incontinence in older women and the lack of clinical assessment despite symptoms even among nurses with high health care literacy.

IUGA committee opinion: laser-based vaginal devices for treatment of stress urinary incontinence, genitourinary syndrome of menopause, and vaginal laxity.

This committee opinion reviews the laser-based vaginal devices for treatment of genitourinary syndrome of menopause, vaginal laxity, and stress urinary incontinence. The United States Food and Drug Administration has issued a warning for unsubstantiated advertising and use of energy-based devices. Well-designed case-control studies are required to further investigate the potential benefits, harm, and efficacy of laser therapy in the treatment of genitourinary syndrome of menopause, vaginal laxity, and stress urinary incontinence. The therapeutic advantages of nonsurgical laser-based devices in urogynecology can only be recommended after robust clinical trials have demonstrated their long-term complication profile, safety, and efficacy.

The Impact of Bariatric Surgery on Pelvic Floor Dysfunction: A Systematic Review.

OBJECTIVE: To determine the effect of bariatric surgery (BS) on the prevalence of pelvic floor dysfunctions (PFD), specifically on urinary incontinence (UI), pelvic organ prolapse (POP), and fecal incontinence (FI). DATA SOURCES: A systematic review (PROSPERO registration no. CRD42017068452) with a literature search was performed using the PubMed, Scopus, and SciELO databases for all publications related to BS and PFD, with no language restrictions, from inception to September 2018. METHODS OF STUDY SELECTION: Two authors screened for study eligibility and extracted data. Only prospective cohorts assessing women with morbid obesity and the prevalence of PFD before and after BS in multiple academic and private centers were included. UI, POP, and FI were defined according to the International Urogynecological Association/International Continence Society joint consensus, and diagnosis was made based on self-report or questionnaires. TABULATION, INTEGRATION, AND RESULTS: Our search strategy retrieved 957 results. Of those, 28 studies were included for full analysis, and 20 studies (n = 3684 patients) were selected for final analysis. The main reasons for exclusion were missing data before and after BS (n = 7) and combined data of men and women who underwent BS (n = 1). Laparoscopic Roux-en-Y gastric bypass was the most common surgical technique. Pooled analysis (16 studies) showed that women had a mean body mass index reduction of 12.90 kg/m2 after treatment (95% confidence interval [CI], -14.82 to -10.97; p < .0001). The relative risk reduction was 67% (n = 19; odds ratio [OR], 0.33; 95% CI, 0.26-0.41; p < .0001) for UI, 52% (n = 5; OR, 0.48; 95% CI, 0.22-1.07; p = .07) for POP, and 20% (n = 9; OR, 0.80; 95% CI, 0.53-1.21; p = .29) for FI. Funnel plots for UI and FI did not suggest any publication bias. With regard to the standardized questionnaires for PFD, the International Consultation on Incontinence-Short Form, Pelvic Floor Impact Questionnaire-7 and its subscale Colorectal-Anal Impact Questionnaire-7, Pelvic Floor Distress Inventory-20, and its subscale Urinary Distress Inventory-6 showed statistically significantly lower scores. Sexual function, represented by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12, showed no statistically significant improvement after surgery. CONCLUSION: BS has a significant impact on reducing UI, but FI and POP, in obese women.

A prospective study of the natural history of urinary incontinence in women.

BACKGROUND: Symptoms of urinary incontinence are commonly perceived to vary over time; yet, there is limited quantitative evidence regarding the natural history of urinary incontinence, especially over the long term. OBJECTIVE: We sought to delineate the course of urinary incontinence symptoms over time, using 2 large cohorts of middle-aged and older women, with data collected over 10 years. STUDY DESIGN: We studied 9376 women from the Nurses' Health Study, age 56-81 years at baseline, and 7491 women from the Nurses' Health Study II, age 39-56 years, with incident urinary incontinence in 2002 through 2003. Urinary incontinence severity was measured by the Sandvik severity index. We tracked persistence, progression, remission, and improvement of symptoms over 10 years. We also examined risk factors for urinary incontinence progression using logistic regression models. RESULTS: Among women age 39-56 years, 39% had slight, 45% had moderate, and 17% had severe urinary incontinence at onset. Among women age 56-81 years, 34% had slight, 45% had moderate, and 21% had severe urinary incontinence at onset. Across ages, most women reported persistence or progression of symptoms over follow-up; few (3-11%) reported remission. However, younger women and women with less severe urinary incontinence at onset were more likely to report remission or improvement of symptoms. We found that increasing age was associated with higher odds of progression only among older women (age 75-81 vs 56-60 years; odds ratio, 1.84; 95% confidence interval, 1.51-2.25). Among all women, higher body mass index was strongly associated with progression (younger women: odds ratio, 2.37; 95% confidence interval, 2.00-2.81; body mass index ≥30 vs <25 kg/m2; older women: odds ratio, 1.93; 95% confidence interval, 1.62-2.22). Additionally, greater physical activity was associated with lower odds of progression to severe urinary incontinence (younger women: odds ratio, 0.86; 95% confidence interval, 0.71-1.03; highest vs lowest quartile of activity; older women: odds ratio, 0.68; 95% confidence interval, 0.59-0.80). CONCLUSION: Most women with incident urinary incontinence continued to experience symptoms over 10 years; few had complete remission. Identification of risk factors for urinary incontinence progression, such as body mass index and physical activity, could be important for reducing symptoms over time.

Does transition of urinary incontinence from one subtype to another represent progression of the disease?

INTRODUCTION AND HYPOTHESIS: Mixed urinary incontinence (UI) is, on average, more severe than urgency UI or stress UI. We tested the hypothesis that mixed UI is a more advanced stage of UI by comparing transition probabilities among women with stress, urgency, and mixed UI. METHODS: We used data from the General Longitudinal Overactive Bladder Evaluation Study-UI, which included community-dwelling women, aged 40+ years, with UI at baseline. Study participants completed two or more consecutive bladder health surveys every 6 months for up to 4 years. Using sequential 6-month surveys, transition probabilities among UI subtypes were estimated using the Cox-proportional hazards model, with the expectation that probabilities from stress or urgency UI to mixed UI would be substantially greater than probabilities in the reverse direction. RESULTS: Among 6,993 women 40+ years of age at baseline, the number (prevalence) of women with stress, urgency, and mixed UI was 481 (6.9%), 557 (8.0%), and 1488 (21.3%) respectively. Over a 4-year period, the transition probabilities from stress UI (34%) and urgency UI (27%) to mixed UI was significantly higher than probabilities from mixed to stress UI (6%) or to urgency UI (rate = 9%). The adjusted transition hazard ratio for stress UI and urgency UI was 2.06 (95% CI: 1.73-2.92) and 1.85 (95% CI: 1.63-2.57) respectively compared with mixed UI. CONCLUSION: The substantially higher transition from stress UI and urgency UI to mixed UI supports the hypothesis that mixed UI might represent a more advanced stage of UI that may have implications for understanding disease progression.

Clinical epidemiological insights into urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is very common and heterogeneous among women with limited knowledge of progression or prognosis. Evidence based on clinical epidemiology can help to better understand the natural history of UI. METHODS: We examine the challenges of UI definition and its subtypes, its impact on quality of life and health-seeking behavior. We review the proposed pathophysiology of UI subtypes and known risk factors as they relate to our current knowledge of the disease state. Finally, we emphasize the role of epidemiology in the process of acquiring new insight, improving knowledge, and translating this information into clinical practice. RESULTS: Stress UI is most common overall, but mixed UI is most prevalent in older women. The three UI subtypes have some common risk factors, and others that are unique, but there remains a significant gap in our understanding of how they develop. Although the pathophysiology of stress UI is somewhat understood, urgency UI remains mostly idiopathic, whereas mixed UI is the least studied and most complex subtype. Moreover, there exists limited information on the progression of symptoms over time, and disproportionate UI health-seeking behavior. We identify areas of exploration (e.g., epigenetics, urinary microbiome), and offer new insights into a better understanding of the relationship among the UI subtypes and to develop an integrated construct of UI natural history. CONCLUSION: Future epidemiological strategies using longitudinal study designs could play a pivotal role in better elucidating the controversies in UI natural history and the pathophysiology of its subtypes leading to improved clinical care.

Prevalence and degree of bother of pelvic floor disorder symptoms among women from primary care and specialty clinics in Lebanon: an exploratory study.

INTRODUCTION AND HYPOTHESIS: The prevalence of pelvic floor disorders (PFD) and their impact on quality of life of women vary among different populations. The purpose of this study was to assess the prevalence of symptoms of PFD, and their degree of bother in a convenience sample of Lebanese women, and to evaluate health-care seeking (HCS) behavior related to PFD. METHODS: Women visiting clinics in a University Medical Center in Beirut, Lebanon, completed the self-filled validated Arabic version of the Global Pelvic Floor Bother Questionnaire (PFBQ). Data covering demographics, comorbidities, and HCS behavior related to PFD were collected. Total individual PFBQ scores, individual PFD symptom scores and HCS behavior were correlated to demographic data and comorbidities. RESULTS: The study participants included 900 women. PFBQ scores were significantly higher in women of older age, women with a lower level of education, women with higher vaginal parity, and women who engaged in heavy lifting/physical activity. BMI >25 kg/m2 was the strongest independent risk factor for the presence of PFD symptoms. The overall prevalence of urinary incontinence was 42 %. Anal incontinence was the most bothersome PFD. Almost two thirds of the women reported HCS due to any aspect of PFD. Among symptomatic women who believed that their PFD warranted HCS, financial concern was the most common obstacle irrespective of age and educational level. CONCLUSIONS: In this convenience sample of Lebanese women, PFD symptoms were common and were significantly correlated with demographic characteristics and self-reported comorbidities. The key reason for not seeking health care related to PFD was financial concern.

Mixed Incontinence Masked as Stress Induced Urgency Urinary Incontinence.

PURPOSE: We sought to understand variations in the expression and temporal relation of bladder control episodes among women with mixed urinary incontinence. MATERIALS AND METHODS: A random sample of women 40 years old or older with mixed urinary incontinence on GLOBE-UI (General Longitudinal Overactive Bladder Evaluation-Urinary Incontinence) was recruited in a digital daily diary study using a smartphone application. When a bladder control event occurred, women were instructed to answer episode specific questions. Episodes were defined as urgency, and urinary incontinence with and urinary incontinence without urgency. Women and episodes were compared by the type of activity preceding each episode. Urinary incontinence episodes were further defined as stress urinary incontinence, urgency urinary incontinence, stress induced urgency urinary incontinence and other. The chi-square and Wilcoxon tests were used for categorical and continuous variables, respectively. RESULTS: Of 40 women with a mean age of 65.5 years 35 provided complete 30-day diary data. Of the 950 bladder control episodes reported 25% were urgency only, 55% were urinary incontinence with urgency and 19% were urinary incontinence without urgency. Of the urinary incontinence episodes without urgency 82% occurred after a stress activity (eg coughing or sneezing). Notably, a stress activity also occurred just before 52.5% of the urgency urinary incontinence episodes (p <0.001). A total of 24 women (69%) reported at least 1 episode of stress induced urgency urinary incontinence, which was the most prevalent urinary incontinence subtype episode, followed by urgency urinary incontinence and stress urinary incontinence (29% vs 27% and 16%, respectively). The mean number of daily episodes was 1 or 2 across all groups. CONCLUSIONS: Women with mixed urinary incontinence express a heterogeneous set of bladder control episodes with stress induced urgency urinary incontinence as the dominant type.

Clinical validation of the Bladder Health Survey for urinary incontinence in a population sample of women.

INTRODUCTION AND HYPOTHESIS: Our aim was to clinically validate the Bladder Health Survey (BHS) for detecting urinary incontinence (UI) in population-based surveys. METHODS: A random sample of women ≥40 years was recruited from primary care practices. We assessed the BHS content validity with an expert advisory board. Test-retest reliability of UI questions was measured. BHS UI definitions included noncases, active (more than three symptoms in the prior 6 months), inactive (past but no current symptoms), and incident (new onset over the past 2 years) cases. To assess criterion validity, we compared BHS diagnosis to an expert clinical diagnosis using structured history, pelvic exam, voiding diary, and urodynamics (if needed). Construct validity was assessed comparing the BHS UI score and case status to Sandvik's score. RESULTS: Among 322 patients, the BHS identified 17 % as noncases, 70 % as active, 10 % as inactive, and 3 % as incident cases. Using the clinical diagnosis as the gold standard, the percent of true-positive UI cases was 98 % (active), 84 % (inactive), and 80 % (incident). A total of 75 % of BHS noncases were true negatives. The receiver operating characteristic c-statistic was 0.86. Sensitivity and specificity of the BHS were 91 % and 84 %, respectively. The Sandvik score for active cases (median = 4) was significantly greater than it was for inactive (median = 1), incident (median = 1), and noncases (median = 0) (p < 0.001). The BHS UI score was significantly correlated with the Sandvik severity score (r = 0.68, p < 0.01). CONCLUSION: The BHS is highly reliable, with robust content and construct validity for detecting UI for use in population samples.