A scored form of the Bristol Female Lower Urinary Tract Symptoms questionnaire: data from a randomized controlled trial of surgery for women with stress incontinence

Female sexual dysfunction: a new urogynaecological research field

OBJECTIVE

To critically review published data on the urogynaecological aspects of female sexual dysfunction (FSD), as FSD is a developing multidisciplinary issue associated with several biological, medical and psychological factors.

METHODS

The reported prevalence of FSD is 19-50% and women with lower urinary tract symptoms or urinary incontinence (UI) not only complain of a deteriorating of quality of life but also of sexual life with an incidence as high as 26-47%. Furthermore, urogynaecological surgery represents an important but underestimated cause of FSD. Different databases (Pub Medical, Medline, serial titles, the Cochrane library and the NLM gateway database) were searched for the keywords 'sexuality; sexual function; urinary incontinence; pelvic organ prolapse; questionnaire; symptom severity; epidemiology; quality of life; instruments; sexual health; vagina; vaginal surgery; pelvic surgery'.

RESULTS

There is a lack of a standardized instrument for assessing FSD. Recent studies investigate the impact of UI on sexual function, but the pathophysiology has not been elucidated. Vaginal or pelvic surgery does not affect overall sexual satisfaction.

CONCLUSIONS

Our investigation highlights the need for studies to assess the anatomical, physiological and sensory mechanisms related to FSD. Specific questionnaire are needed to quantify the problem. In the definition, symptoms assessment and preoperative counselling is important, to make a distinction between overall sexual function and individual parameters, such as psychosocial context. Only in this way, will it be possible to identify new therapeutic targets. A definition of success in urogyneacological terms should include aspects of quality of life and quality of sexual life. Immediate research in this field is needed.

Health-related quality of life and sexual function in women with stress urinary incontinence and overactive bladder

BACKGROUND

We evaluated the impact of stress urinary incontinence (SUI) and overactive bladder (OAB) on health-related quality of life (HRQOL) and sexual function.

METHODS

A total of 245 women (SUI; n = 123 and OAB; n = 122) from 21 to 79 years old (mean 50.4) were included in the primary analyses. To obtain HRQOL and sexual function assessments, patients were asked to fill in the 'Bristol Female Lower Urinary Tract Symptoms (BFLUTS)' and the 'Medical Outcomes Study Short Form (SF-36)' questionnaires.

RESULTS

Of the eight domains in the SF-36 questionnaire, only 'general health' was significantly different between the groups. Patients with SUI had a better general health than those with OAB (P = 0.016). When comparing the BFLUTS scores in the two groups, the score for 'BFLUTS-filling symptoms' was higher in the OAB group (P = 0.002) but that for 'BFLUTS-incontinence symptoms' was higher in the SUI group (P < 0.001). The score for 'BFLUTS-sex' was higher in the SUI group than in the OAB group but this was not statistically significant (P = 0.096). Of the 169 patients who had a sex life, the SUI group had experienced pain (P = 0.033) and leakage (P = 0.056) more frequently during intercourse than the OAB group.

CONCLUSION

Both SUI and OAB have a detrimental impact on patient HRQOL in Korean women. In addition, our findings suggest that women with SUI had more frequently experienced pain during intercourse and coital incontinence than those with OAB.

Generic and disease-specific health-related quality of life in women with coital incontinence: a prospective, multicenter study

OBJECTIVE

This study was carried out to evaluate the impact of coital incontinence on health-related quality of life (HRQOL) in women with lower urinary tract symptoms.

METHODS

A total of 180 women with sexual activity were evaluated. To obtain HRQOL assessments, patients were asked to fill out the Bristol Female Lower Urinary Tract Symptoms and the Medical Outcomes Study Short Form (SF-36) questionnaires.

RESULTS

The coital incontinence group had more frequently symptoms including urgency, urge incontinence, bladder pain, stress incontinence, unpredictable incontinence, nocturnal incontinence, reduced stream, and stopping flow than the no coital incontinence group. The frequency of incontinence and volume of leakage were also higher in the coital incontinence group than the no coital incontinence group. All symptom questions regarding sexual matters and quality of life except cutting down on fluid were more frequent in patients with coital incontinence than those without coital incontinence. Of the eight domains in the SF-36 questionnaire, five domains, namely, Physical functioning, Role-physical functioning, Social functioning, Role-emotional functioning, and Mental health were significantly different between the two groups. When comparing the Bristol Female Lower Urinary Tract Symptoms scores in the two groups, the scores in all domains except Voiding symptoms in the coital incontinence group were significantly higher than those in the no coital incontinence group. Patients with coital incontinence had more HRQOL impairment than those without coital incontinence.

CONCLUSIONS

Our study reveals that more emphasis should be placed on coital incontinence in the terminology of urinary incontinence.

Comparison of three disease-specific quality-of-life questionnaires (Bristol Female Lower Urinary Tract Symptoms, Incontinence Quality of Life and King's Health Questionnaire) in women with stress urinary incontinence

OBJECTIVES

To examine the impact of stress urinary incontinence (UI) on quality of life (QOL) using three disease-specific QOL instruments and compare the results obtained with these instruments.

MATERIAL AND METHODS

A total of 28 women (age range 36-74 years) with stress UI were included in the study. To obtain QOL assessments, patients were asked to complete the Bristol Female Lower Urinary Tract Symptoms (BFLUTS), Incontinence Quality of Life (I-QoL) and King's Health Questionnaire (KHQ) instruments.

RESULTS

One domain in the BFLUTS (Incontinence symptoms) and one in the KHQ (Severity measures) correlated inversely with the Valsalva leak point pressure and the cough leak point pressure, respectively; however, other domains in the three questionnaires did not correlate with objective data. Two BFLUTS domains (Incontinence symptoms and QOL) correlated weakly or moderately with six KHQ domains; however, other BFLUTS domains did not correlate with most KHQ domains. Significant negative correlations were noted between two BFLUTS domains (Incontinence symptoms and QOL) and most I-QoL domains; however, other BFLUTS domains did not correlate with the I-QoL. Role limitations, Emotional problems and Severity measures in the KHQ correlated weakly or moderately with the I-QoL; however, General health and Personal relationships did not correlate significantly with the I-QoL.

CONCLUSIONS

Subjective QOL results of stress UI using condition-specific QOL questionnaires may differ because there are a plethora of measurement instruments that vary in terms of their scope and content. Our findings suggest that, before deciding on an instrument, its contents should be thoroughly reviewed to ensure that a particular aspect of QOL does not need additional assessment.

Relationships among symptoms, bother, and treatment satisfaction in overactive bladder patients

AIMS

We have studied the association between various symptoms, bother, and patient treatment satisfaction in overactive bladder (OAB).

METHODS

Episodes of urgency, incontinence, daytime frequency and nocturia and responses to the patient perception of bladder condition scale, the urgency perception scale, and visual analog scales of limitations in daily life and of treatment satisfaction were evaluated in 3,824 OAB patients at baseline and during 9 months treatment with tolterodine ER (4 mg q.d.) in an open-label, observational study. Relationships amongst number of symptoms/ 24 hr and scales were explored. Treatment satisfaction was correlated with improvements in symptoms and scales.

RESULTS

At baseline, the number of episodes of the four OAB symptoms correlated only poorly with each other and with the two bother-related scales, while the two scales assessing bother correlated much stronger with each other. Factor analysis identified four components which described "bother," "incontinence," "urgency/frequency," and "nocturia" and in combination explained 81.9% of the total variance. The component "bother" had the strongest individual effect accounting for 42.1% of the total variance. While improvements of symptoms and bother were seen with tolterodine treatment, patient treatment satisfaction correlated strongest with improvements of the two bother-related scales.

CONCLUSIONS

We conclude that the counting of episodes of OAB symptoms only insufficiently describes the afflicted patients. Patient bother is the strongest individual component but only poorly explained by episodes of the four symptoms defining OAB. Alterations of bother may better reflect patient-relevant outcomes in OAB treatment than alterations in the number of symptom episodes.

Questionnaires to Assess Urinary and Anal Incontinence: Review and Recommendations

PURPOSE

We reviewed and provide recommendations about the most scientifically robust and appropriate questionnaires for evaluating symptoms and the quality of life impact of urinary and/or anal incontinence, and vaginal and pelvic floor problems. We also investigated the use of these questionnaires in randomized, controlled trials of treatment strategies.

MATERIALS AND METHODS

The Symptom and Quality of Life Committee of the International Consultation on Incontinence performed a systematic review of questionnaires related to urinary and anal incontinence, and vaginal and pelvic floor problems, searching MEDLINE, The Cochrane Library and other electronic databases between 2001 and 2004.

RESULTS

A total of 23 robust and relevant questionnaires could be recommended in clinical practice and research. The development of questionnaires to assess anal incontinence, and pelvic floor and vaginal problems has been limited with some promising measures but with none achieving the highest level of rigor. From 2001 to 2004 there were 150 published randomized trials of treatments for incontinence. Increasingly trials of incontinence are using recommended measures (38% of those for urinary incontinence and 22% of those for anal incontinence used the highest quality questionnaires in 2001 to 2004) but none of vaginal and pelvic floor problems used recommended questionnaires.

CONCLUSIONS

With increasing acknowledgment of the value of patient based assessment much attention has been given to the development of questionnaires to assess symptoms and quality of life. Sufficient measures are now available for urinary incontinence, and researchers and clinicians are encouraged to use the 18 achieving the highest level of rigor and their validated translations. In contrast, the development of questionnaires for anal incontinence and pelvic/vaginal problems is in its infancy and further study in this area is needed. Randomized trials of treatments for incontinence should use only questionnaires achieving the highest level of scientific rigor.

Lower urinary tract disease: what are we trying to treat and in whom?

The diseases of the lower urinary tract are traditionally divided into abnormalities of storage and abnormalities of emptying. The targets for therapy were the organs most responsible for influencing storage and emptying. Modern understanding places the symptomatic status of the patient as the overriding criterion for treatment. It also accommodates a broader understanding of multiple and overlapping systems. Symptoms of voiding dysfunction have been clearly shown to be associated with symptoms of other genitourinary disease, for example, erectile dysfunction (ED). Treatment of voiding dysfunction has also been shown to have effects (adverse or beneficial) in these other domains. Thus, the symptoms of lower urinary tract disease (LUTD) that have to be considered now as targets relevant to these therapies include ED, ejaculatory dysfunction, sexual desire, sexual pain disorders and female sexual dysfunction. The anatomic, neural and endocrine systems that support these symptomatic functions and dysfunctions span the range from the urogenital smooth muscle to the hypothalamus, the bladder sensory output to the micturition centre and growth factors to androgens. Potentially important targets also include vascular and spinal structures, sex hormones and nitric oxide as well as the obvious genes, enzymes and receptors. The epidemiological studies prove the convergence of LUTD when viewed through the lens of the current patient-related outcomes and problem constructs. This convergence serves as a clear guidance to include wide ranging outcome instruments in all future studies with compounds being investigated for the treatment of LUTD. Out of these will come evidence of expected and unexpected collateral effects. The convergence should open the possibility to a different business model for developing therapeutic concepts. The blockbuster drug for a monolithic indication may be supplemented by agents with single or multiple pathway activity with smaller parallel targets. Using an approach based on patient reported outcomes to therapeutic targets not only widens the range of conditions, but also the patient types who can be considered as having LUTD.

The International Consultation on Incontinence Modular Questionnaire: www.iciq.net

PURPOSE

In 1998 the first ICI was held in Monaco, sponsored by WHO and organized by the International Continence Society and International Consultation on Urological Diseases. The Scientific Committee recognized the need to develop a universally applicable questionnaire for wide application across international populations in clinical practice and research to assess urinary incontinence, facilitating the comparison of findings from different settings and studies, in a manner similar to the International Prostate Symptom Score.

MATERIALS AND METHODS

An Advisory Board was formed to steer the development of the ICIQ and a decision was made to extend the concept further, developing the ICIQ Modular Questionnaire.

RESULTS

The first module developed was the ICIQ Short Form Questionnaire for urinary incontinence. ICIQ modules have been developed or adapted for urinary tract symptoms and they are being developed for vaginal and lower bowel symptoms. Additional sexual matters and quality of life modules will become available for each condition area. Modules to assess patient satisfaction are expected to be of particular use for assessing treatment effectiveness. The ICIQ Advisory Board recently proposed the development of the ICIQ website, which is anticipated to be crucial for informing potential users of the phase of development of all ICIQ modules.

CONCLUSION

The ICIQ can offer a full range of urinary tract symptom questionnaires. The website will aim to attract collaborators committed to the concept of this internationally accepted modular questionnaire who are willing to help with its development.

Objective and Subjective Cure Rates after Trans-Obturator Tape (OBTAPE®) Treatment of Female Urinary Incontinence

OBJECTIVE(S)

To evaluate the safety and efficacy of a thermally bonded nonwoven polypropylene mesh in a transobturator suburethral tape procedure (OBTAPE), Mentor-Porges, Le Plessis Robinson, France) for women with stress urinary incontinence.

METHODS

Between January 2003 and January 2005, 129 consecutive women (mean age 57.2 years) underwent OBTAPE) in two academic centers. All the patients had stress urinary incontinence preoperatively. Detrusor instability was ruled out by cystometry. The women were evaluated 1, 6 and 12 months postoperatively. The objective cure rate was evaluated by clinical examination and the subjective cure rate was assessed using the KHQ and BFLUTS questionnaire.

RESULTS

Mean follow-up was 17.2+/-4.7 months (range 4 to 28 months). The objective and subjective cure rates were respectively 89.9% and 77.5%. Most of the patients received general anesthesia (85.3%). Urinary retention was observed in two women (1.5%), necessitating tape adjustment. Voiding difficulties were observed in 7 cases (5.4%) necessitating intermittent self-catheterization for 4.2+/-2.4 days (range 1 to 7 days). Seven patients developed vaginal erosion (one with vaginal extrusion, and two with an obturator abscess). Complete mesh removal was necessary in 6 patients, four of whom had recurrent stress urinary incontinence.

CONCLUSIONS

Our results suggest that the OBTAPE) is an effective treatment for women with stress urinary incontinence. However, vaginal mesh erosion occurred in 6.2% of women, and this implies the need for careful follow-up.

CORTICAL REPRESENTATION OF THE URGE TO VOID: A FUNCTIONAL MAGNETIC RESONANCE IMAGING STUDY

PURPOSE

The urge to void generally increases with bladder distention but the relationship between the 2 factors is complex. When the bladder is moderately filled, the desire to void can be called forth deliberately but it can also be suppressed. To elucidate human brain mechanisms that are active during such intentional modulations of the desire to void we performed functional magnetic resonance imaging in healthy volunteers.

MATERIALS AND METHODS

Brain activity was studied in 22 young women. At moderate bladder filling (about 350 ml) they periodically suppressed or enhanced the urge to void without allowing urine to pass. A manual task with a dynamometer, in which the current urge to void was expressed as grip force, demonstrated that the intensity of sensations could be influenced voluntarily. We also examined brain activity during repetitive (1 Hz) contractions of pelvic floor muscles after the bladder was emptied.

RESULTS

Significant brain activity associated with an increased urge to void was found in the insular cortex, frontal opercula, supplementary motor area (SMA), cingulate motor area (CMA), right posterior parietal cortex, left prefrontal cortex and cerebellum. Trends toward activation were detected in the thalamus, peri-aquaeductal gray matter and ventral pons. Suppression of the urge to void significantly activated the left superior frontal lobe. The SMA and CMA were active during voluntary rhythmical contractions of pelvic floor muscles.

CONCLUSIONS

Sensation intensity of the desire to void can be influenced intentionally. Frontoparietal cortical areas and the SMA/CMA seem to be involved in this process.

Incontinence-specific quality of life measures used in trials of treatments for female urinary incontinence: a systematic review

This systematic review examined the use of incontinence-specific quality of life (QOL) measures in clinical trials of female incontinence treatments, and systematically evaluated their quality using a standard checklist. Of 61 trials included in the review, 58 (95.1%) used an incontinence-specific QOL measure. The most commonly used were IIQ (19 papers), I-QoL (12 papers) and UDI (9 papers). Eleven papers (18.0%) used measures which were not referenced or were developed specifically for the study. The eight QOL measures identified had good clinical face validity and measurement properties. We advise researchers to evaluate carefully the needs of their specific study, and select the QOL measure that is most appropriate in terms of validity, utility and relevance, and discourage the development of new measures. Until better evidence is available on the validity and comparability of measures, we recommend that researchers consider using IIQ or I-QOL with or without UDI in trials of incontinence treatments.

Scores de symptômes et de qualité de vie au cours des troubles vésicosphinctériens

OBJECTIVES

To identify all available symptom and quality of life questionnaires for men and women with urinary disorders and assess their psychometric properties.

METHODS

We systematically reviewed the literature in Medline using the key words urinary disorders, urinary incontinence, bladder, score, quality of life, questionnaire, and psychometric validation.

RESULTS

The first search using the terms urinary incontinence and quality of life resulted in 1018 Abstracts. Articles mentioning but not measuring quality of life were not investigated. Questionnaires were selected because their psychometric properties were tested and they assessed how much a person was bothered by urinary symptoms or quality of life specific to urinary disorders. The questionnaires were usually gender specific. Their psychometric value was far from uniform, and, for most, responsiveness was not reported.

CONCLUSION

Few quality of life questionnaires are at an advanced stage of validation to be applied in clinical practice. They need to be shorter, responsive and validated in different populations to permit their easy use.