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Numerous measures of UI severity exist, but there is no universally accepted standard for the assessment of incontinence severity.
A self-reported symptom measure (MESA) correlates well with other measures of severity, including UI-specific quality of life measures (UDI, IIQ), number of incontinence episodes, pad weight, empty bladder stress test.
An objective measure of severity, valsalva leak point pressure (VLPP), does not correlate strongly with these measures of severity, suggesting that it is a poor measure of UI severity or it relates to severity differently than the other measures.
The autologous fascial sling results in a higher rate of successful treatment of stress incontinence than does the Burch colposuspension.
Women who underwent the sling procedure had more urinary tract infections, difficulty voiding, and postoperative urge incontinence than did women who received the Burch colposuspension.
The term mixed urinary incontinence, when defined for research
purposes, is problematic and broadly inclusive; this analysis demonstrated
that it is important to describe both subcomponents of mixed urinary incontinence.
The use of the term mixed urinary incontinence in women planning stress
incontinence surgery should be replaced by quantification of both urge
and stress incontinence.
Two years after surgery for treatment of stress urinary incontinence,
patient satisfaction was associated with greater reduction in stress
incontinence symptoms and greater reductions in symptom distress.
Lower odds of patient satisfaction were associated with greater urge
incontinence symptoms at baseline, detrusor overactivity at two years,
and a positive stress test at two years.
Stress incontinent women who also have urge incontinence symptoms
may benefit from additional preoperative counseling to set realistic
expectations about potential surgical outcomes or proactive treatment
of urge incontinence symptoms to minimize their post-operative impact.
The objective of this analysis was to describe how clinical pelvic floor muscle (PFM) strength is related to patient characteristics, lower urinary tract symptoms and fecal incontinence symptoms in women enrolled in the SISTEr trial.
We used baseline data from women participating in the SISTEr trial. Patient demographic variables, baseline urinary and fecal incontinence symptom questionnaires, urodynamic data and urinary diary data, pad test results, and standardized assessment of pelvic organ support were compared to PFM strength as described by the Brink scoring system. Bivariate analysis of factors associated with the Brink score was done using analysis of variance and linear regression. Multivariate analysis included patient variables that were significant on bivariate analysis.
The range of Brink score in SISTEr participants was small (mean Brink score 9, standard deviation 2) and overall, PFM strength was good in this highly select group of stress incontinent patients. This may have limited our ability to detect important relationships, and may reflect a weakness in the suitability of the Brink scoring system as a clinical and/or research tool. It is possible the Brink scale does not reflect real clinical differences in PFM strength.
We found a weak but statistically strong relationship between age and Brink score, but Brink scores were not related to diary and pad test measures of incontinence severity.
In order to assess the value of preoperative voiding detrusor pressures
in predicting postoperative outcomes after stress incontinence surgery,
we measured opening detrusor pressures, detrusor pressures at maximum
flow, and closing detrusor pressures in preoperative urodynamics
studies performed during SISTEr. We found no relationship between
preoperative voiding detrusor pressures and postoperative success,
detrusor overactivity, or treatment for urge incontinence after
Burch or autologous fascial sling continence surgeries.
We found no difference in the presence of preoperative after-contractions
in subjects who received treatment for postoperative urge incontinence
compared to those who did not.
In order to assess the value of preoperative voiding detrusor pressures
in predicting postoperative outcomes after stress incontinence surgery,
we measured opening detrusor pressures, detrusor pressures at maximum flow,
and closing detrusor pressures in preoperative urodynamics studies
performed during SISTEr.
We found no relationship between preoperative voiding detrusor pressures
and postoperative success, detrusor overactivity, or treatment for urge
incontinence after Burch or autologous fascial sling continence surgeries.
We found no difference in the presence of preoperative after-contractions
in subjects who received treatment for postoperative urge incontinence
compared to those who did not.
Using a multivariate analysis, the only demographic parameters found to correlate with VLPP were age (negative correlation; older age - lower VLPP), and BMI (positive correlation; higher BMI - higher VLPP).
The only urodynamic correlates were Qmax (negative correlation) and maximum cystometric capacity (positive).
The finding that many other demographic parameters thought to possibly correlate with complexity of incontinence and therefore severity (ie prior incontinence surgeries) did not in fact correlate with VLPP, and that Qmax did, suggests that VLPP may provide information about urethral function, but not necessarily severity of incontinence.
Urodynamic predictors of postoperative objective voiding dysfunction were sought.
The vast majority of patients with voiding dysfunction were in the sling arm of SISTEr.
No preoperative urodynamic parameter (flow rate, voiding pressure during maximum flow, post void residual, straining, capacity, etc.) was predictive of the development of voiding dysfunction in either Burch or sling patients, a group of patients who, at baseline, appeared to be at an overall relatively low risk for the development of voiding dysfunction postoperatively.
In the SISTEr surgical trial, 16% of women with SUI also had isolated liquid and solid FI at least monthly.
Factors associated with fecal incontinence in multivariable analysis included decreased anal sphincter tone on physical examination, menopausal status, and prior surgery for urinary incontinence.
Given the high rate of fecal incontinence in this cohort, evaluation of FI symptoms before surgical intervention for urinary incontinence is important.
Ten percent of women who qualified for stress incontinence surgery with a positive cough stress test on physical exam did not demonstrate urodynamic stress incontinence (USI) and less than 10% of subjects in this study demonstrated detrusor overactivity.
Results from a large cohort of women with SUI are now available for quantitative plausibility assessments or as reference values when interpreting urodynamic studies.
UDS Interpretation Guidelines and a standardized UDS protocol are available to urodynamic investigators on the Urinary Incontinence Treatment Network website: http://www.uitn.net/physicians.asp
Multicenter UDSs require a continuous quality improvement process and the development of UDS testing procedures and interpretation
We found a nearly statistically significant trend that women with urodynamic stress incontinence are twice as likely to have a successful overall outcome from surgical management of stress urinary incontinence as women without urodynamic stress incontinence.
The level of Valsalva leak point pressure and the presence of detrusor overactivity do not predict the success outcomes after the Burch or autologous fascia sling procedures in women with pure or predominant stress urinary incontinence.
in a multivariable model, severity of incontinence was positively associated with BMI (P=0.0003) and current smoking (p=0.01)
severity of incontinence was negatively associated with prolapse stage (p<0.0001) and Q-tip displacement (p=0.042)
in a surgical population, incontinence severity was independently associated with 2 modifiable risk factors, obesity and tobacco use, as well as pelvic support
A secondary analysis of subjects in the SISTEr Trial
severity of urge incontinence symptoms (p=0.041), prolapse stage (p=0.013) and being postmenopausal without hormone therapy (p=0.023) were significant predictors of stress failure
odds of nonstress failure quadrupled for every 10 point increase in MESA urge subscale score (OR 3.93, CI:1.45, 10.65) and decreased more than 2 times for every 10 point increase in stress score (OR 0.36, CI: 0.16, 0.84)
associations of risk factors and failure were similar regardless of surgical group (Burch or autologous rectus fascial sling)
A secondary analysis of subjects in the SISTEr trial.
2 year outcomes of women at least 65 years of age were compared to those younger than 65 years
older women were more likely to have a positive stress test (OR3.7, 95% CI: 1.7, 7.97); less subjective improvement in stress and urge symptoms (8 point lesser decrease on MESA, 95% CI: 1.5, 14.1; 7 point lesser decrease, 95% CI: 1.5, 12.2, respectively); and were more likely to undergo surgical retreatment for stress incontinence (OR 3.9, 95% CI: 1.3, 11.48)
there was no difference in short-term perioperative outcomes between younger and older women
Tennstedt S, Borello-France D, FitzGerald MP, Goode P, Kraus S, Kusek J, Mallett V, Nager C, Stoddard A, Xu Y, Zimmern P for the Urinary Incontinence Treatment Network. Quality of life in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(5):543-9.
Prior to surgery, lower incontinence-related quality of life (QoL) was related to the greater frequency of stress UI symptoms, increasing UI severity, greater symptom bother, prior UI surgery or treatment, and sexual dysfunction (if sexually active).
Health and sociodemographic factors associated with lower incontinence-related QoL included current tobacco use, younger age, lower socioeconomic status, and Hispanic ethnicity.
After surgery, incontinence-specific QoL improvement was related to decreased UI symptom bother, greater improvement in UI severity, younger age, Hispanic ethnicity and receiving Burch surgery.
Among sexually active women, worsening sexual function had a negative impact on QoL.
Improved QoL was explained most by UI symptom improvement.
With proper quality control measures in place and a set of standardized interpretative guidelines, excellent
inter-rater reliability between local and central reviewers can be achieved for numerical cystometrogram
variables.
The term mixed urinary incontinence, when defined for research purposes, is problematic and broadly inclusive; this analysis demonstrated that it is important to describe both subcomponents of mixed urinary incontinence.
The use of the term mixed urinary incontinence in women planning stress incontinence surgery should be replaced by quantification of both urge and stress incontinence.
Combining antimuscarinic drug therapy with supervised behavioral training did not improve the ability of women with urge predominant incontinence to discontinue medication and maintain improvements in urinary incontinence 8 months later.
The addition of behavioral training to drug therapy is of possible benefit for reducing incontinence frequency during active treatment; a higher proportion of patients in combined therapy achieved ?70% reduction of incontinence than in drug therapy alone at 10 weeks.
Combined therapy yielded better outcomes than drug therapy alone on patient satisfaction, patient-perceived improvement, and reducing other bladder symptoms.
In women with urge-predominant incontinence, urinary urgency scores decreased significantly with both drug therapy alone and combined drug + behavioral therapy.
Combined drug and behavioral therapy did not improve urgency more than drug alone, but did produce better outcomes on 24-hour voiding frequency.
Improvement in urgency was associated with greater baseline urgency and black ethnicity.
Improvement in voiding frequency was associated with combined treatment, higher baseline frequency, and lower baseline incontinence episode frequency.
The objective of this analysis was to determine whether participants in either arm of the BEDRI trial experienced reduction in the frequency of nocturia and/or nocturnal leakage episodes during treatment.
We analyzed urinary diary data relating to nocturia and nocturnal incontinence before and after 8 weeks of study treatment in the BEDRI trial. Chi-square tests assessed whether nocturia and nocturnal incontinence prevalence varied by treatment arm and paired t tests assessed the change in mean frequency of nocturia and nocturnal leakage.
Among 305 women, 210 (69%) had an average of at least one nocturia episode at baseline. There were small but statistically significant differences (p<0.001) in mean nocturia frequency and nocturnal incontinence frequency with both treatments after 8 weeks, but no significant difference between study treatment groups.
We concluded that among BEDRI participants, who had low levels of nocturia at baseline, neither study treatment had significant clinical impact on either nocturic frequency or nocturnal incontinence.
Fecal incontinence is common among women with urge incontinence (18% have urinary and fecal incontinence).
Significant impairments in quality of life are seen in women with fecal and urge urinary incontinence.
Factors affecting the pelvic floor, such as a prior vaginal delivery, posterior compartment pelvic organ prolapse, and increased body weight, may be associated with fecal incontinence in women with urge urinary incontinence.
A secondary analysis of subjects in the BE-DRI Trial
after controlling for group, only younger age was associated with short-term success of treatment for urge incontinence (OR 0.8, 95% CI: 0.66, 0.96)
at 6 months controlling for group and short-term outcome, only greater anterior vaginal wall prolapse was associated with successful drug discontinuation (POP-Q point Aa; OR 1.33, 95% CI: 1.03, 1.7)
this information might be used to promote realistic expectations when counseling patients on the benefits of medication and behavioral therapy for the treatment of urge urinary incontinence
General fluid instructions may contribute to the reduction in UUI symptoms for women taking anticholinergic medications, but additional individualized instructions along with other behavioral therapies did little to improve outcome further.
VLPP and MUCP have moderate correlation with each other, but each had little or no correlation with subjective or objective measures of severity or with the results of the SEBST.
This data suggests that the urodynamic measures of urethral function are not related to subjective or objective measures of UI severity.
597 women with symptoms of predominant stress urinary incontinence and a positive cough stress test underwent urodynamic evaluation (surgeons were blinded to these results)
Baseline measures included: sociodemographic characteristics, past clinical characteristics of UI, physical examination
Self report of urinary incontinence (subjective outcomes) included the MESA questionnaire and 3-day bladder diary; objective outcomes included a 24 hour pad test and stress test
Outcomes collected at 2 and 6 weeks; 6 and 12 months post randomization
Primary Outcomes at 12 months consisted of Objective Cure: negative stress test, negative 24 hour pad test, no retreatment; and Subjective Cure: no self reported SUI symptoms, no leakage on 3-day voiding diary and no retreatment
Other outcomes included patient satisfaction and adverse events using the Dindo classification system
294 women in each group provided 80% power at a 5% significance level using a 2-sided equivalence test of proportions with an equivalence margin of + 12%. If entire 95% CI for difference in the 2 cure rates were in this equivalence margin, equivalence declared
Objective treatment success rates were 80.8% in the retropubic group and 77.7% in the transobturator group (3.0 percentage point difference; 95% CI, -3.6 to 9.6, meeting the prespecified criteria for equivalence.
Subjective success rates were similar, 62.2% in the retropubic group and 55.8% in the transobturator group (6.4 percentage-point difference; 95% CI, -1.6 to 14.3), but did not meet the prespecified criteria for equivalence.
Rates of voiding dysfunction requiring surgery were 2.7% in the retropubic group and 0% in those receiving a transobturator sling, p=0.004.
Rates of neurologic symptoms were 4.0% of subjects in the retropubic group and 9.4% of subjects in the transobturator group, p=0.01.
There were no differences between the 2 groups in post-operative urge incontinence rates, satisfaction with procedure results of impact on quality of life.
A baseline analysis of subjects in the SISTEr and TOMUS trials.
baseline urinary incontinence severity measures and the impact of stress incontinence were compared in normal, overweight and obese women in the SISTEr (N=655) and TOMUS (N=597) trial; analyses were performed for each trial separately
in SISTEr subjects, multivariable regression analyses showed that higher weight category was independently associated with higher mean UDI score (p=0.003), incontinence episode frequency (p<0.0001), valsalva leak point pressure (p=0.003) and IIQ (p=0.0004).
in TOMUS subjects, higher weight category was associated with higher incontinence episode frequency (p=0.0003), valsalva leak point pressure (p=0.0006) and IIQ (p<0.0001).
obese women undergoing surgery for stress incontinence report more incontinence episodes, more symptom distress and worse quality of life despite better measures of urethral function (higher valsalva leak point pressure) on urodynamics
The paper described the design of the MIMOSA trial, a randomized
trial comparing two initial approaches to the treatment of mixed urinary
incontinence.
The use of a pragmatic design posed challenges, including the feasibility
of randomizing participants to surgical vs. non-surgical initial treatment.
