Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis.

BACKGROUND: Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review. METHODS: We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI. RESULTS: We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21-30, I2 = 91 %), and 19 % experienced anal incontinence (95 %CI, 14-25, I2 = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10-17, I2 = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6-24, I2 = 95 %). Following primary repair of OASIS, 55 % (46-63, I2 = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33-43, I2 = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17-6.45, I2 = 98 %). INTERPRETATION: Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.

Postpartum pelvic floor trauma.

PURPOSE OF REVIEW: There is strong epidemiological evidence linking vaginal childbirth and the development of postpartum incontinence and prolapse. This article examines possible mechanisms of pelvic floor damage related to delivery and their possible consequences. RECENT FINDINGS: Histology, imaging and physiology studies have revealed that vaginal delivery results in direct pelvic muscle trauma, disruption of fascial supports and pudendal nerve injury. SUMMARY: Epidemiology studies implicate parity and childbirth in the development of incontinence and prolapse; however, despite imaging and functional studies revealing damage to the pelvic floor muscles, nerves and fascial supports, it is unclear what the clinical significance of these findings is. In addition, the effect of mode of delivery is uncertain, and although cesarean section reduces the risk of pelvic floor trauma, it is not entirely protective. Further research is required into the effect of pregnancy on pelvic floor dysfunction and the effect of mode of delivery.

Reliability testing of urodynamics, pressure flow studies and cough leak point pressure in women with urodynamic stress incontinence with and without detrusor overactivity.

Urodynamic studies which included cough leak point pressure (CLPP) and pressure flow studies were performed at two visits 2 weeks apart. Reproducibility between the two visits and also between the two diagnostic groups, urodynamic stress incontinence (USI) and urodynamic mixed incontinence (UMI) were analysed. Thirty-one women completed both visits, of those 14 had USI in both sets of urodynamic studies, 11 had UMI on both visits, six had USI on one visit and UMI in the other. The urodynamic variables of maximum cystometric capacity and CLPP have the most repeatability. Analysis in women with USI alone compared to USI with detrusor overactivity (DOA) showed that the repeatability for pressure flow parameters and CLPP was better in women without DOA, of which the CLPP was significantly different (p = 0.036). Urodynamic variables are inconsistent. This may reflect variations in urinary tract behaviour.

Sacral neurostimulation for urinary retention: 10-year experience from one UK centre.

OBJECTIVES: To report our 10-year experience of sacral neurostimulation (SNS) for women in urinary retention, comparing the original one-stage with the newer two-stage technique, as SNS therapy is a well-established treatment for urinary retention secondary to urethral sphincter overactivity (Fowler's syndrome). PATIENTS AND METHODS: Between 1996 and 2006, 60 patients with urinary retention had a SNS device inserted; their case records were reviewed and data on efficacy, follow-up, need for continued clean intermittent self-catheterization (CISC), complications and operative revision rate were assessed. RESULTS: Overall, 43 of 60 (72%) women were voiding spontaneously, with a mean postvoid residual volume of 100 mL; 30 (50%) no longer needed to use CISC. During a total of 2878 months of SNS experience, adverse event episodes included lead migration in 20, 'box-site' pain in 19, leg pain/numbness in 18 and loss of response/failure in 18 patients; 53% of the women required a surgical revision related to their implanted stimulator. The efficacy of the two-stage was similar to that of the one-stage procedure (73% vs 70%). Women with a normal urethral sphincter electromyogram had worse outcomes than women with an abnormal test (43% vs 76%). Although the efficacy was no different in those taking analgesia/antidepressant medication, this group of women had a higher surgical revision rate. Failure and complications for the one-stage procedure were not restricted to the early follow-up period. The mean battery life of the implant was 7.31 years. CONCLUSIONS: SNS has sustained long-term efficacy but the procedure has a significant complication rate. At present, the two-stage technique has comparable efficacy to the one-stage technique but a longer-term follow-up is required. The National Institute of Clinical Excellence recommended the use of SNS in women with urinary incontinence who fail to respond adequately to anticholinergic therapy, but patients choosing this treatment should be made aware of the high complication rate associated with the procedure.

Do overactive bladder symptoms improve after repair of anterior vaginal wall prolapse?

This study aims to evaluate the changes of overactive bladder symptoms to anterior vaginal wall prolapse repair. Ninety-three consecutive women with symptomatic anterior vaginal wall prolapse >or= stage II and coexistent overactive bladder symptoms were prospectively studied using a urinalysis, urodynamics, King's Health Questionnaire (KHQ), Prolapse Quality of Life (P-QOL) questionnaire and pelvic organ prolapse quantification (POP-Q) system before and 1 year after surgery. All women underwent a standard fascial anterior repair. Postoperatively, urinary frequency, urgency and urge incontinence disappeared in 60, 70 and 82% of women respectively (p value < 0.001). The vaginal examination findings as well as the quality of life of the women assessed using KHQ and P-QOL significantly improved after surgery (p value < 0.001). This study has demonstrated that anterior vaginal repair does produce significant improvement in overactive bladder symptoms. A larger longer-term study is required to assess if these changes persist over time.

The relationship of urethral resistance pressure and pressure flow parameters in women with lower urinary tract symptoms.

This prospective study aims to evaluate the relationship between urethral resistance pressure (URP) and pressure flow parameters in women with lower urinary tract symptoms (LUTS). Consecutive women with LUTS attending three tertiary referral urodynamic clinics were asked to undergo urodynamic evaluation, pressure flow studies and URP measurement. The pressure flow parameters such as detrusor pressures at the start of flow (ODP), detrusor pressure at peak flow rate (PdetQmax), peak flow rate (Qmax) and detrusor pressure at the end of flow (CDP) were measured. The relationship between URP and pressure flow parameters was evaluated as well as differences between each urodynamic group. Two hundred seventy-nine women attended for urodynamic investigations. Two hundred twenty-three (79.9%) women had good quality pressure flow measurements and were included in the study. The mean age was 58 years (range 21-83). Women with urodynamic stress incontinence had significantly lower URP and ODP than those with detrusor over-activity [54.8 (+/-17.9) and 12.4 (+/-4.1) cmH(2)O, respectively, vs 85.6 (+/-21.4) and 33.7 (+/-13.3) cmH(2)O, respectively) (p<0.05, Bonferroni test). Furthermore, women with urodynamic stress incontinence have significantly lower PdetQmax values as well as higher Qmax than women with competent urethral sphincters (p<0.05, Bonferroni test). There was a significant correlation between ODP, PdetQmax, Qmax and URP measurements. In urodynamic stress incontinence, both URP and pressure flow parameters are reduced. Although the trend for values of both tests were similar and there was a significant correlation between these tests, we should consider that urethral function at rest differ from that during voiding due to activation of additional mechanisms. Therefore, further study is needed to confirm our results.

The effects of duloxetine on urethral function and sphincter morphology.

The aim of our study was to investigate the effect of duloxetine on urethral function and sphincter ultrasound morphology in 54 women, who were referred to a urogynecology unit, with urodynamic stress incontinence. All completed a King's Health Questionnaire and a patient global assessment of improvement (PGI-I) question and underwent urethral pressure profilometry, measurement of urethral retro-resistance pressure (URP), and ultrasound of the striated urethral sphincter. The investigations were repeated after 8 weeks of duloxetine 40 mg twice daily in 36 women who continued the medication. After 8 weeks of duloxetine, the mean URP increased significantly compared to baseline (53.8 to 60.8 cm H2O; p=0.001), and sphincter thickness was significantly higher (1.8 to 2.0 mm; p<0.001). There was a significant increase in the maximum urethral closure pressure (MUCP) (52.7 to 59.2 cm H2O; p=0.006) but not of functional urethral length. Subanalysis of responders (improved on duloxetine) showed a significant increase in URP (50.3 to 59.1 cm H2O; p=0.001), sphincter thickness (1.7 to 2.1 mm; p<0.001), and MUCP (50.2 to 58.1 cm H2O; p=0.03). These changes were not seen in nonresponders. This study has demonstrated objective changes in urethral ultrasound morphology and function after duloxetine therapy, which relate to improved continence. A larger longer term study is required to assess if these changes persist over time. In summary, duloxetine therapy for urodynamic stress incontinence results in an increase in urethral closure pressure, URP measurement, and urethral striated sphincter thickness.

SIS graft for anterior vaginal wall prolapse repair--a case-controlled study.

The purpose of this study was to assess the effect on quality of life and prolapse severity of traditional anterior repair compared to anterior repair with a small intestine submucosa (SIS) graft. This report was designed as a case-control study. The sample of this study consisted of 14 women who underwent traditional anterior repair and 14 women who underwent anterior repair with SIS graft (SG) at a London teaching hospital. All women were assessed preoperatively and at 6 and 24 months postoperatively using a validated prolapse quality of life questionnaire and pelvic organ quantification system (POP-Q). Quality-of-life outcomes included the following: (1) General health perception, (2) Prolapse impact, (3) Role limitations, (4) Physical limitations, (5) Social limitations, (6) Personal relationships, (7) Emotions, (8) Sleep/Energy, and (9) Severity measures. The pelvic organ quantification measurement measured nine specific points relating to the anterior and posterior wall of the vagina, vaginal apex, genital hiatus (GH) and perineal body (PB). At 6-month follow-up, the SG repair group showed significant improvement in all quality-of-life parameters measured. In comparison to traditional repair, it was significantly better in improving role limitations, physical limitations and emotions. Both operations significantly improved prolapse quality-of-life severity measures. SG repair improved all POP-Q measurements significantly, except total vaginal length (TVL), whereas traditional repair improved some measurements (AA, midline point of anterior vaginal wall 3 cm proximal to the external urethral meatus; BA, most distal dependant position of the anterior vaginal wall from the vaginal vault or anterior fornix to AA; C, most distal/dependant edge of cervix or vault; AP, point on midline posterior vaginal wall 3 cm proximal to hymenal ring; BP, most distal/dependant point on the posterior vaginal wall from vault or posterior fornix to AP) but not others (location of posterior fornix (D), TVL, GH and PB). At 2-year follow-up, there was no significant difference between the two groups in terms of quality-of-life outcomes or prolapse severity measurements. Surgery for vaginal prolapse results in marked improvement in quality of life and prolapse severity. The greater improvement seen initially in the SG anterior group was not seen at 2-year follow-up.

Urethral retro-resistance pressure and urodynamic diagnoses in women with lower urinary tract symptoms.

OBJECTIVE: This study determines whether the retrograde urethral retro-resistance pressure (URP) measurement discriminates between urodynamic diagnoses in a group of women. DESIGN: A prospective observational study. SETTING: Urogynaecology units of three tertiary referral teaching hospitals. POPULATION: Women with lower urinary tract symptoms. METHODS: Consecutive women attending the urodynamic clinics of three tertiary referral teaching hospitals were studied using a validated urinary symptom questionnaire, URP measurement and urodynamic evaluation between February and July 2004. The URP mean values were compared with urinary symptoms and urodynamic diagnoses, using the independent t test correction for multiple measurements. MAIN OUTCOME MEASURES: Retrograde URP, urodynamic diagnoses and urinary symptoms. RESULTS: One hundred and eighty-five women were recruited. Women with urodynamic stress incontinence (USI) have significantly lower URP than women with competent urethral sphincters (P < 0.05, independent t test). Women with mixed urodynamic incontinence had values of URP intermediate between women with detrusor overactivity (DOA) and those with USI. In the mixed group, URP mean values were not significantly different from those with DOA and competent sphincters or USI (P > 0.05, independent t test). There was no significant difference between mean URP values and different urinary symptoms (P > 0.05, independent t test). CONCLUSIONS: There are significantly different URP measurements between women with DOA and those with USI. However, the URP is not a diagnostic tool.

Changes in urethral resistance in the presence of detrusor activity.

This was a prospective study performed at two tertiary referral teaching hospitals. The aim of our study was to investigate changes in urethral resistance with the bladder full compared to empty in women with different urodynamic diagnoses. Consecutive women attending the urodynamic clinics were asked to undergo urethral retro-resistance pressure (URP) measurement with the bladder empty and then full. 106 women were recruited - 25 had normal urodynamic studies, 17 had detrusor overactivity, 57 had urodynamic stress incontinence and 7 had mixed incontinence. Women with urodynamic stress incontinence have lower URP values than women with normal urodynamic studies or those with detrusor overactivity with the bladder empty (p = 0.01). Women with normal urodynamic studies and urodynamic stress incontinence showed a statistically significant rise in URP with the bladder full (p = 0.013 and p = 0.003, respectively). In women with detrusor overactivity, the converse was seen - URP was significantly lower with the bladder full compared to empty (p = 0.004). Our study has shown that bladder filling alters URP measurement and bladder volume should be standardised for reporting URP.

Surgical repair of vaginal prolapse: a gynaecological hernia.

Female pelvic organ prolapse refers to the descent of the pelvic organs towards or through the vagina. The similarities between vaginal prolapse and herniae in their aetiology and treatment make this an interesting area for all those operating in the pelvis. It is a common condition with prevalence estimates varying from 2% for symptomatic prolapse to 50% for asymptomatic prolapse [Samuelsson EC, Arne Victor FT, Tibblin G, Svardsudd KF. Signs of genital prolapse in a Swedish population 20 to 59 years of age and possible related factors. Am J Obstet Gynecol 1999;180:299-305]. Approximately 50% of parous women will have some degree and only 10-20% of these seek medical help [Beck RP. Pelvic relaxation prolapse. In: Kase NG, Weingold AB, editors. Principles and practice of clinical gynecology. New York: John Wiley; 1983. p. 677-85]. The lifetime risk for surgery for prolapse has been estimated to be around 11.1%, and 30% will undergo re-operation for recurrent prolapse [Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapsed and urinary incontinence. Obstet Gynecol 1997;89:501-6]. The aetiology of prolapse is multifactorial. Advancing age, parity and collagen weakness are all quoted as significant predisposing factors [Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapsed and urinary incontinence. Obstet Gynecol 1997;89:501-6; Maclennan AH, Taylor AW, Wilson, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. Br J Obstet Gynaecol 2000;107:1460-70]. Pathophysiological mechanisms that have been proposed include pelvic floor denervation, direct trauma to the pelvic floor musculature, abnormal synthesis and degradation of collagen and defects in endopelvic fascia [Al-Rawi ZS, Al-Rawi ZT. Joint hypermobility in women with genital prolapse. Lancet 1982;I:439-41; Gilpin SA, Gosling JA. Smith ARB, Warrell DW. The pathogenesis of genitourinary prolapse and stress incontinence in women. A histological and histochemical study. Br J Obstet Gynaecol 1989;96:15-23; Smith ARB, Hosker GL, Warrell DW. The role of partial denervation of the pelvic floor in the aetiology of genitourinary prolapse and stress incontinence of urine. A neurophysiological study. Br J Obstet Gynaecol 1989;96:24-8; Allen RE, Hosker GL, Smith ARB, Warrell DW. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol 1990;97:770-9]. The procedure of choice for reconstructive surgery to the vagina should be tailored to the individual patient and be of low morbidity and mortality, but at the same time with long-term durability.

Management of vaginal prolapse.

Vaginal prolapse is a common health problem, and although severe morbidity is rare, it can have marked effects on quality of life. The treatment of vaginal vault prolapse can be a difficult and challenging problem. A detailed history and clinical evaluation is required in order to plan the appropriate choice of procedure. There are numerous surgical procedures that have been described using either abdominal or vaginal approaches. The choice of procedure is often dependent on the individual surgeon's choice and experience, and should be tailored to the individual patient. The ideal procedure should have a low risk of morbidity and mortality, but should also have long-term durability. There is a need for large, randomized trials to evaluate surgical techniques to correct vaginal prolapse and related urinary, bowel and sexual dysfunction.

The relationship of vaginal prolapse severity to symptoms and quality of life.

OBJECTIVE: To assess the relationship and location of vaginal prolapse severity to symptoms and quality of life. DESIGN: A prospective observational study. SETTING: Urogynaecology Unit, Imperial College, St Mary's Hospital, London. POPULATION: Women with and without symptoms of vaginal prolapse. METHODS: All women completed a validated Prolapse Quality of Life (P-QOL) questionnaire. This included a urinary, bowel and sexual symptom questionnaire. All women were examined using the Pelvic Organ Prolapse Quantification system (POP-Q). POP-Q scores in those with and without prolapse symptoms were compared. Urinary and bowel symptoms and sexual function were compared and related to prolapse severity and location. MAIN OUTCOME MEASURES: POP-Q scores, P-QOL scores, urinary and bowel symptoms and sexual function. RESULTS: Three hundred and fifty-five women were recruited-233 symptomatic and 122 asymptomatic of prolapse. The median P-QOL domain scores ranged between 42-100 in symptomatic women and 0-25 in those who were asymptomatic. The stage of prolapse was significantly higher in those symptomatic of prolapse (P < 0.001) except for perineal body (PB) measurement. Urinary symptoms were not correlated with uterovaginal prolapse severity whereas bowel symptoms were strongly associated with posterior vaginal wall prolapse. Cervical descent was found to have a relationship with sexual dysfunction symptoms. CONCLUSIONS: Women who present with symptoms specific to pelvic organ prolapse demonstrate greater degrees of pelvic relaxation than women who present without symptoms. Prolapse severity and quality of life scores are significantly different in those women symptomatic of prolapse. There was a stronger relationship between posterior prolapse and bowel symptoms than anterior prolapse and urinary symptoms. Sexual dysfunction was related to cervical descent.

A randomized crossover trial to examine administration techniques related to the Bristol female lower urinary tract symptom (BFLUTS) questionnaire.

AIMS: To investigate whether two methods of assessing lower urinary tract symptoms, interview-assisted standardized questionnaires, and self-completed standardized questionnaires, were comparable. METHODS: Women referred to a tertiary urogynecology urodynamic clinic with lower urinary tract symptoms were recruited. The psychometrically robust Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaire was used to assess urinary symptoms. A randomized crossover design for questionnaire completion was used: Group A-an initial interview-assisted questionnaire at the urodynamic clinic with a follow-up postal questionnaire; or Group B-an initial pre-out-patient postal questionnaire followed up by a second interview-assisted questionnaire whilst attending a scheduled urodynamic clinic. RESULTS: A total of 114 women were randomized for initial questionnaire administration method to achieve 72 completed sets (63%). Total scores were higher on self-completion compared to interview, this difference was not significant [t = -1.951, P > 0.05]. No item had perfect agreement between postal and interview methods and generally, interview-assisted questions had lower scores, indicating better health status. The items with the worst agreement (slight or moderate) were those concerned with sexual health, with women giving lower scores, exaggerating health on interview. For example bother of vaginal discomfort (kappa(w) = 0.09), compared to question assessing frequency (kappa(w) = 0.65). CONCLUSIONS: This data suggests women respond differently to the BFLUTS questionnaire when data is collected by self-completion in the woman's home compared to interviews. No individual question item had perfect agreement between the two methods of administration. Overall, individual question items were scored higher on self-completion than interview.

Changes in urethral function with bladder filling in the presence of urodynamic stress incontinence and detrusor overactivity.

OBJECTIVE: The purpose of this study was to assess the effect of detrusor overactivity and bladder filling on urethral function with the use of urethral profilometry. STUDY DESIGN: Women with symptoms of urinary incontinence were recruited from our urodynamic clinic. All of the women underwent videocystourethrography and urethral pressure profilometry with the bladder empty and then full. The maximum urethral closure pressure, mean urethral pressure, functional urethral length, and pressure transmission ratios for each quartile were analyzed. RESULTS: Thirty-five women were recruited: 17 women had urodynamic stress incontinence, and 18 women had detrusor overactivity. In women with urodynamic stress incontinence, there was a significant increase in maximum urethral closure pressure and pressure transmission ratios over all quartiles when the bladder was full compared with empty. In women with detrusor overactivity, there was a significant decrease in functional urethral length and pressure transmission ratios in the second and third quartile of the urethral pressure profiles when the bladder was full compared with empty. CONCLUSION: Decreases in functional urethral length and pressure transmission ratios with bladder filling in those women with detrusor overactivity are at variance with the normal physiologic response to bladder filling, which suggests that urethral function is affected by the presence of abnormal detrusor activity and that the valid assessment of urethral function may not be possible if the detrusor overactivity is not treated.

Caesarean section is protective against stress urinary incontinence: an analysis of women with multiple deliveries.

All women who had three elective caesarean sections were selected from a database of 40,000 women delivering between 1977 and 1998, and age-matched with women having three vaginal births. They all completed a (validated) urinary and bowel symptom questionnaire. Women who had vaginal births had a significantly higher prevalence of stress incontinence but not other urinary or faecal symptoms compared with those delivered by caesarean section. The prevalence of faecal incontinence was lower than the prevalence of urinary incontinence. Although the prevalence of faecal incontinence was lower after caesarean delivery, this was not statistically different. These data have shown that caesarean section was associated with a lower risk of urinary incontinence, although a protective effect on development of faecal symptoms was not seen.

The relationship between urinary symptom questionnaires and urodynamic diagnoses: an analysis of two methods of questionnaire administration.

OBJECTIVE: To assess whether method of administration of a standard urinary symptom questionnaire alters the relationship of symptoms with urodynamic diagnoses. DESIGN: Randomised crossover study. SETTING: Tertiary Urogynaecology Unit, London, UK. PARTICIPANTS: One hundred and fourteen women attending a tertiary urogynaecology clinic. METHODS: Women were randomised to either an initial interview-assisted questionnaire in the clinic with a follow up postal questionnaire or an initial pre-outpatient questionnaire followed by an interview-assisted questionnaire at the clinic visit. Video cystourethrography or saline cystometry was performed at the clinic visit. MAIN OUTCOME MEASURES: Question responses were compared with urodynamic diagnoses. RESULTS: With an interview method, only severity of incontinence was significantly associated with detrusor overactivity (U= 593.5, P= 0.012). With self-completion, severity of nocturia (U= 477, P < 0.05), urgency (U= 395, P= 0.003), urge urinary incontinence (U= 392, P= 0.003), leakage without warning (U= 443, P= 0.035) and incomplete voiding (U= 413, P= 0.01) were significantly associated with detrusor activity. On interview the symptom of stress urinary incontinence (U= 523, P= 0.002) and use of pads (U= 564.5, P= 0.011) were significantly associated with a diagnosis of urodynamic stress incontinence. Severity of stress urinary incontinence (U= 276, P < 0.001), frequency of leakage (U= 348.5, P= 0.004), use of protection (U= 432.5, P < 0.018), nocturnal incontinence (U= 393.5, P= 0.002) and quantity of leakage (U= 441.5, P < 0.05) on self-completion were strongly associated with diagnosed urodynamic stress incontinence. There was no association between the symptoms of urgency or urge incontinence and the urodynamic stress incontinence. CONCLUSIONS: Postal questionnaire responses have a better relationship with urodynamics, both for urodynamic stress incontinence and detrusor over activity, than interview-assisted questionnaire responses. However, no symptom has a high enough specificity and sensitivity to replace urodynamic testing.

Mixed incontinence.

The epidemiology and treatment of mixed incontinence has received relatively little attention. However, mixed incontinence--defined as the combination of stress and urge incontinence--accounts for approximately 33% of all cases of incontinence in women. The condition often responds poorly to treatment, either pharmacologic or surgical. Potential pharmacologic approaches for mixed incontinence include antimuscarinic agents, estrogen replacement therapy (for postmenopausal women), and dopamine, serotonin, or norepinephrine reuptake inhibitors. In a large-scale, multinational, placebo-controlled, clinical trial, the antimuscarinic agent tolterodine significantly reduced incontinence episodes in women with mixed symptoms. The benefits of tolterodine continued to increase during the 8 weeks of the trial and extended to additional end points, including frequency, urgency, and urge incontinence. A limited number of studies have examined the use of estrogen for mixed incontinence and have produced conflicting results. Duloxetine oxalate, a combined serotonin/norepinephrine reuptake inhibitor, has shown great promise in animal studies, as well as in phase 2 and 3 clinical trials. This agent is the first to demonstrate efficacy as a sole therapy for stress incontinence and has exhibited favorable effects on bladder capacity, suggesting possible benefits in mixed incontinence. Only 5 studies (2 of which were conducted during the 1980s) have specifically examined the use of surgery for the treatment of mixed incontinence; the cure rates reported have varied. The current body of information supports use of an antimuscarinic agent as initial therapy for mixed incontinence, although long-term trials are needed to shed more light on the duration of benefit.

Urinary symptoms in pregnancy: are they useful for diagnosis?

This is the second part of a study assessing 161 women 12 weeks after their first delivery. The urodynamic data have previously been published [Br J Obstet Gynaecol 2000;107:1354]. The symptoms have been assessed using a (non-validated) urinary symptom questionnaire. There was no correlation between symptoms and urodynamic findings and most importantly between the symptom of stress incontinence, a diagnosis of urodynamic stress incontinence (USI) and vaginal delivery. Symptoms of incontinence and abnormal urodynamic findings were also found in women who underwent caesarean section. These data explain why caesarean section does not appear to be wholly protective in preventing postpartum incontinence. This suggests that the aetiology of postpartum incontinence is multifactorial and urinary symptoms are misleading in determining the underlying causes.