Assessment of lower urinary tract symptoms in women by a self-administered questionnaire: test-retest reliability

Lower urinary tract symptoms after total and subtotal hysterectomy: results of a randomized controlled trial

The aim of this Danish multicenter trial was to compare the proportion of women with lower urinary tract symptoms after total abdominal hysterectomy (TAH) and subtotal abdominal hysterectomy (SAH) for benign uterine disorders. A total of 319 women were randomized to TAH (n = 158) or SAH (n = 161). Women were followed up for 1 year by strict data collection procedures, including postal questionnaires. Results were analyzed by intention-to-treat analyses. Urinary incontinence was found less often among TAH women than among SAH women. This was due to a larger reduction of the number of women with stress and urinary incontinence in the TAH group. No other differences were found between the two operation methods. The number of women with urinary incontinence and frequency was reduced from study entry for follow-up, while double/triple voiding was increased. Incontinent women had significantly lower quality of life scores than continent women

Test-retest reliability of four questionnaires for patients with overactive bladder: The overactive bladder questionnaire (OAB-q), patient perception of bladder condition (PPBC), urgency questionnaire (UQ), and the primary OAB symptom questionnaire (POSQ)

AIMS

This study examined test-retest reliability of four patient-reported outcome measures for patients with overactive bladder (OAB): Overactive Bladder Questionnaire (OAB-q), Patient Perception of Bladder Condition (PPBC), Urgency Questionnaire (UQ), and Primary OAB Symptom Questionnaire (POSQ).

METHODS

Patients recruited from urology clinics were scheduled for two visits 2 weeks apart and completed all questionnaires at both visits. A demographic form was completed at Visit 1; and a treatment effect scale was completed at Visit 2. Test-retest reliability was examined among stable patients using intraclass correlations (ICC), Spearman's correlations, paired t-tests, Feldt's statistic, and kappas.

RESULTS

A total of 47 patients enrolled (mean age = 66.0 years, 74.5% female), with 46 completing both visits; 35 were classified stable. Statistically significant correlations were present between Visits 1 and 2 (P < 0.05) for all subscales of the OAB-q, UQ, and POSQ. Subscale ICCs were moderate to high (OAB-q > or = 0.83, UQ > or = 0.46, POSQ continuous items > or = 0.68). No significant differences between Visit 1 and 2 were noted, except for the OAB-q symptom bother scale (change of 5.8 points on a 100-point scale). The multi-item subscales of the OAB-q and the UQ demonstrated good internal consistency (Cronbach's alpha > or = 0.83 for all subscales) across both visits. Test-retest reliability of the PPBC was somewhat weaker than the other three measures, but still acceptable for use as a global, single-item outcome measure.

CONCLUSIONS

The OAB-q, POSQ, and UQ demonstrated good test-retest reliability, with ICCs roughly equivalent or superior to those previously reported for 7-day micturition diaries. Findings suggest that the four measures examined in this study demonstrate the necessary reproducibility for use as outcome measures for OAB treatments.

A new questionnaire for urinary incontinence diagnosis in women: development and testing

OBJECTIVE

The purpose of this study was to develop a questionnaire for urinary incontinence diagnosis in women and to test its reliability and validity, with incontinence specialists' clinical evaluations as the gold standard.

STUDY DESIGN

One hundred seventeen urogynecology outpatients with urinary incontinence symptoms completed the Questionnaire for Urinary Incontinence Diagnosis at enrollment and 1 week and 9 months later. Baseline clinical diagnoses were compared with Questionnaire for Urinary Incontinence Diagnosis diagnoses (criterion validity). Nine-month Questionnaire for Urinary Incontinence Diagnosis change scores were compared across treatment groups (responsiveness).

RESULTS

Clinical diagnoses included stress (n = 15), urge (n = 26), and mixed urinary incontinence (n = 72). Internal consistency and test-retest reliability estimates were good. Sensitivity and specificity were 85% (95% CI, 75%, 91%) and 71% (95% CI, 51%, 87%), respectively, for stress urinary incontinence and 79% (95% CI, 69%, 86%) and 79% (95% CI, 54%, 94%), respectively, for urge urinary incontinence. The Questionnaire for Urinary Incontinence Diagnosis correctly diagnosed urinary incontinence type in 80% of subjects. Questionnaire for Urinary Incontinence Diagnosis Stress and Urge scores decreased significantly in treated subjects.

CONCLUSION

The Questionnaire for Urinary Incontinence Diagnosis, a new 6-item questionnaire for female urinary incontinence type diagnosis, is reliable and able to diagnose stress urinary incontinence and urge urinary incontinence in a referral urogynecology patient population with accuracy.

The outcome of pelvic examinations in women 40-60 years of age with lower urinary tract symptoms

We set out to assess the outcome of pelvic examination in women 40-60 years of age with one or more lower urinary tract symptoms. This was an ongoing longitudinal cohort study set in one rural and one urban county in Denmark. One hundred and ninety-six women with one or more lower urinary tract symptoms occurring at least weekly were selected at random. Ages ranged from 40 to 60 years. Pelvic findings involving genital prolapse, signs of vaginal atrophy, and pelvic mass as well as a history of hormonal status and estrogen deficiency symptoms were documented and assessed. One hundred and six women (54.1%) were recruited. First degree cystocele, rectocele, and uterine prolapse occurred in 24 (22.6%), seven (6.6%), and six (5.7%), women respectively. No significant association between first-degree genital prolapse and subtypes of lower urinary tract symptoms (LUTS) was observed. The number of women with second or third degree cystocele, rectocele, and uterine prolapse was three (2.8%), two (1.9%), and two (1.9%), respectively. The positive predictive vaginal findings in each subtype of LUTS indicating an oestrogen deficiency were in the interval 72.0- 90.0 while the negative predictive vaginal findings were in the interval 24.7-27.6%, respectively. In six women (5.7%) a leiomyoma was observed. In one woman the size of the uterus exceeded the size of a 12-week pregnancy. Genital prolapse more than first degree and pelvic masses were infrequent findings among women with LUTS. Signs of vaginal atrophy associated poorly with a history of hormonal depletion and symptoms indicating oestrogen deficiency. However even an infrequent pathologic finding is significant. Therefore we still recommend pelvic examinations in all women with LUTS.

Reproducibility and validity of simple questions to identify urinary incontinence in elderly women

BACKGROUND

Epidemiologic studies are dependent on simple and valid questions to assess the prevalence and type of urinary incontinence.

OBJECTIVE

To examine the reproducibility and validity of two standardized questions seeking to identify stress and urge incontinence among elderly women.

METHODS

A random sample of 421 women 75 years or older living in the center of Odense, Denmark, were invited to participate, and 223 (53%) accepted a first interview in their home. A sample of 154 women were selected for a second interview with the same questions [accepted by 144 (94%)]. The second visit also included a long open interview about incontinence and was followed by a prospective registration of leakages.

RESULTS

In the first interview 39% (95% confidence interval (CI) 34-47%) of the elderly women reported incontinence. The reliability of the questions was acceptable [kappa of 0.81 (95% CI 0.34-0.89)] with percent agreement of 90% (95% CI 84-95%) between first and second interviews for all incontinence (stress and/or urge). When the open interview was used as a "gold standard," the questions showed acceptable validity: a sensitivity of 0.91 (95% CI 0.86-0.96) and a specificity of 0.86 (95% CI 0.80-0.92) for all incontinence.

CONCLUSION

Standardized questions about incontinence give reproducible answers and produce information that is comparable to a long open interview.

Criterion validity, test-retest reliability and sensitivity to change of the St George urinary incontinence score

OBJECTIVE

To assess the criterion validity, test-retest reliability and the sensitivity to change after treatment of the St George Urinary Incontinence Score (SGUIS).

PATIENTS AND METHODS

Women presenting with urinary incontinence completed two SGUIS tests one week apart. A frequency-volume chart (FVC) was completed before the first attendance and the women had a 1-h pad test before treatment. Patients were treated conservatively under the care of a urogynaecologist or nurse continence advisor, or surgically with an open or laparoscopic colposuspension. After treatment, the SGUIS, FVC and 1-h pad test were repeated.

RESULTS

The SGUIS correlated moderately well with the number of leaks per week (Spearman's r = 0.610, 95% confidence interval 0.516-0.689, P < 0.001) but less well with the 1-h pad test loss (r = 0.257, 0.124-0.380, P = 0.002). The test-retest reliability was acceptable, as the mean (SD) difference between the first and second SGUIS was 0.337 (2.675), with limits of agreement of -5.012 to -5.686. The change in the SGUIS after treatment correlated well with the improvement in the number of leaks per week (r = 0.742, 0.662-0.805, 156 samples, P < 0.001) but not as well with the change in 1-h pad test loss (r = 0.531, 0.405-0.636, 151, P < 0.001), although the trend was similar.

CONCLUSION

The criterion validity of the SGUIS appeared adequate for both the number of leaks per week on the FVC and leakage on the 1-h pad test. The statistical reproducibility of the test was adequate and appeared more responsive to change after treatment than the other measures. The score is suitable for rapid self-administration by patients with a range of incontinence types, unlike most other currently available test instruments.

Motor evoked potentials from the pelvic floor

AIMS

Proper function of the lower urinary tract depends on the integrity of the central and peripheral nervous pathways on multiple levels, and the complexity of this system leaves it susceptible to even minor lesions. While dysfunction of the lower urinary tract is prevalent amongst patients with nervous system disease, e.g., multiple sclerosis (MS), most women with lower urinary tract dysfunction (LUTD) have no overt neurological cause. Refined neuro-diagnostic approaches are needed to reveal neurogenicity in these patients. A potential method is transcranial magnetic stimulation (TMS), which is used routinely to test the motor innervation of limb muscles, but also can be applied to test pelvic floor efferents. To resolve the lack of methodological clarity and the need for normative values for the use of pelvic floor motor evoked potentials (MEPs), 30 healthy women and 16 women with MS were studied.

METHODS

The healthy women underwent MEP studies with various stimulus and recording modalities, and, to test reproducibility, 18 of them were retested at a separate session. The women with MS underwent MEP testing as well as urodynamic studies.

RESULTS

From the methodological studies of healthy women, the use of invasive concentric needle electrodes was found to be superior to surface electrodes. When applying magnetic stimuli over the sacral region, various methodological problems were encountered. In the healthy women, a large variability of responses was noted, the long-term reproducibility of pelvic floor MEP latencies was poor, and in some cases responses could not be obtained. In the study of women with MS, prolonged central conduction times were found, along with many cases of unevokable responses, and a poor correlation of MEPs to urodynamic findings. The problems of obtaining selective recordings from the inaccessible pelvic floor musculature are discussed, and possible sources of variability in MEPs from the pelvic floor are considered. By relating the findings in the present studies to those of others using different modalities, some reflections are presented on the nature of the neural pathways to the pelvic floor activated by magnetic stimulation. As unevokable responses from the pelvic floor were an occasional finding among the healthy women, it is argued that a pelvic floor non-response in a patient with suspected corticospinal lesion should be interpreted with care, and should not carry the same clinical significance as an absent limb response.

CONCLUSIONS

The inherent limitations of pelvic floor MEPs are discussed, and it is concluded that while there seems to be only limited clinical value of pelvic floor MEP testing, there might be some interesting scientific perspectives in studies that aim to control and explain the variability of responses.

Motor evoked potentials from the striated urethral sphincter: a comparison of concentric needle and surface electrodes

AIMS

The aim of this study is to compare two different surface electrodes (intravaginal and intraurethral) with the concentric needle as a criterion standard and concomitant testing of the levator ani as a potential contaminator.

METHODS

Thirty healthy women with a mean age of 52 years. Bland-Altman plots were used to compare recorded latencies from the various electrodes and muscles.

RESULTS

There was no significant difference between the latencies recorded with the various electrodes from either muscle, but the limits of agreement were wide. However, the concentric needle electrodes proved more reliable with a higher rate of reproducible responses.

CONCLUSIONS

We did not encounter major difficulties in using the concentric needle electrode for recordings in the external urethral sphincter, and this electrode was also more reliable than either surface electrode. Therefore, we advocate the use of concentric needle electrodes in future studies.

Motor evoked potentials from the striated urethral sphincter and puborectal muscle: normative values

AIMS

Transcranial magnetic stimulation enables the study of corticospinal motor pathways through evoked potential testing. By separate stimulation of cortical centers and spinal roots, it is possible to test motor conduction times segmentally. This method enables the localization of central or peripheral demyelinating neuropathies. As lower urinary tract dysfunction often accompanies these diseases, we wanted to present normative data for the motor innervation of the external urethral sphincter (EUS) and the puborectal muscle (PR).

METHODS

Thirty healthy women without evidence of neurologic or lower urinary diseases were studied. They had a mean age of 52 years. Transcutaneous magnetic stimulations were applied to the vertex, the upper lumbar spine, and the sacrum. Evoked potentials were recorded with concentric needle electrodes placed in the EUS and the PR by a transvaginal route. Stimulations were performed with relaxed pelvic floor and with tonic contraction (facilitated responses). At least three responses were recorded for each modality. Stepwise multiple regression analysis was performed to test for the effect of age, height, body mass index, vaginal parity, and menopause.

RESULTS

In some subjects, it was only possible to record cortical latencies with facilitation. Technical difficulties were encountered with spinal stimulations. Reference values are presented as means with 95% confidence intervals. Regression analysis revealed height as a dependent factor for sacral latencies.

CONCLUSIONS

Our data can serve as reference values for future studies of the fast conducting fibers in patients with sphincter dysfunction. The height of the patient should be taken into account. The clinical applicability of the method is questionable.

Questionnaires for women with urinary symptoms

AIMS

To identify the characteristics of optimal symptom questionnaires in women with lower urinary tract symptoms (LUTS).

METHODS

Literature review.

RESULTS

Although numerous questionnaires have been developed for the evaluation of female LUTS, no one instrument has emerged as that preferred for collecting and reporting subjective information about LUTS in women. Questionnaires currently available range widely in intended purpose, extent and style, and in the quality of testing used to validate them.

CONCLUSIONS

Questionnaires should be constructed based on scientifically sound validation techniques that reflect disease and/or symptoms in the target population. They should be concise, easily administered and scored, discriminant between sphincter and bladder causes of incontinence, and able to measure severity and the effect of the symptom on the patient.

Short-term reproducibility of cystometry and pressure-flow micturition studies in healthy women

AIMS

To evaluate the reproducibility of cystometry and pressure flow studies in women. We wanted to explore any clinically relevant effect of repeated, same-session cystometry.

METHODS

Thirty healthy women with a mean age of 52 years were investigated with repeat medium-fill water cystometry and pressure-flow micturition studies in a single session.

RESULTS

Large test-retest variability was noted, with wide limits of agreement. Of statistical significance was an increase of first desire (FD) and normal desire (ND), and a decrease in bladder opening pressure. Maximum cystometric capacity was unchanged.

CONCLUSIONS

Although the nature of the conditioning effect of the first fill remains to be explored, the phenomenon could possibly be used for improved urodynamic diagnosis.

Randomized clinical trial of total vs. subtotal hysterectomy: validity of the trial questionnaire

BACKGROUND

To ensure the internal validity of a trial it is recommended to undertake a validation study of the method measuring the outcome.

AIMS

To validate a self-administered, postal questionnaire (http://www.gyncph.suite.dk/praes/gimbel/gihtm) used for measuring the outcomes of a randomized clinical trial of total vs. subtotal abdominal hysterectomy.

METHODS

A study of the content validity (10 patients) and a combined qualitative and quantitative validation study (20 patients) were performed.

RESULTS

The median kappa of the 74 questions was 0.71 (range 0.22-1.00) and the median overall agreement was 0.76 (range 0.25-1.00). Five questions (7%) had kappa values below 0.40, 11 questions (15%) between 0.40 and 0.60, and 58 questions (78%) above 0.61. Three questions with a kappa value below 0.40 had an overall agreement of 0.75 or more. Significant logical inconsistencies were found in five questions, where the operation method was expected to be known. The qualitative validation resulted in a total of 80 comments. The number of comments for any given subject ranged from 0 to 12. The comments could be grouped and processed into four categories.

CONCLUSIONS

The agreement was high. Inconsistencies regarding questions on the operation methods were found. Potential problems were identified in five questions (7%). The validation studies resulted in some changes to the questionnaire and we became aware of areas in which caution should be taken in the interpretation of the results of the randomized trial.

Validity and reliability of an interviewer-administered questionnaire to measure the severity of lower urinary tract symptoms of storage abnormality: the Leicester Urinary Symptom Questionnaire

OBJECTIVE

To develop a valid and reliable interviewer-administered questionnaire to measure the presence and severity of storage abnormality symptoms of incontinence, urgency, frequency and nocturia.

SUBJECTS AND METHODS

Subjects were 930 men and women aged >/=40 years, taking part in a randomized controlled trial of a continence nurse practitioner (CNP) service. Criterion validity was tested by comparing questionnaire responses to 24-h pad test and 3-day urinary diary. Responsiveness was assessed by comparing questionnaire responses before and after treatment. Questions about urgency were investigated for construct validity in patients taking part in the trial who underwent urodynamic investigation (243). Test-retest and inter-rater reliability was measured at approximately 6 days in subjects recruited to an associated epidemiological study (104 and 102, respectively).

RESULTS

The questionnaire responses showed significant associations with pad-test and diary measures. Questions about the severity of daytime incontinence performed better than those measuring night-time incontinence. The response categories of soaked, wet, damp and almost dry had better associations with the pad test than other measures of the severity of incontinence. Test-retest and inter-rater reliability was good for all questions, and all were responsive to change in symptoms, showing significant differences before and after treatment.

CONCLUSION

There is a clear need for standardization of measurement using well-validated instruments. This interviewer-administered questionnaire is valid, reliable and sensitive to change in a wide range of severity of symptoms, and in both men and women aged >/=40 years. The questionnaire provides a useful assessment tool for primary and secondary care in research and clinical settings.

Oestradiol-releasing vaginal ring versus oestriol vaginal pessaries in the treatment of bothersome lower urinary tract symptoms

OBJECTIVES

To assess the efficacy of an oestradiol-releasing vaginal ring and oestriol pessaries in the alleviation of lower urinary tract symptoms occurring after the menopause.

DESIGN

Randomised, parallel group, controlled trial.

SETTING

Twenty-six clinics of practising gynaecologists and one outpatient clinic at a department of obstetrics and gynaecology.

POPULATION

Two hundred and fifty-one postmenopausal women, with a mean age of 66 years, reporting at least one bothersome lower urinary tract symptom.

METHODS

One hundred and thirty-four women were treated with the oestradiol-releasing ring for 24 weeks; 117 women were treated with oestriol pessaries 0.5 mg every second day for 24 weeks.

MAIN OUTCOME MEASURES

Subjective scores of urgency, frequency, nocturia, dysuria, stress incontinence and urge incontinence.

RESULTS

The two treatments were equally efficacious in alleviating urinary urgency (51% vs 56%), urge incontinence (58% vs 58%), stress incontinence (53% vs 59%) and nocturia (51% vs 54%). Dysuria was alleviated in 76% vs 67%, equivalence was not demonstrated. No statistically significant difference was found for any primary efficacy endpoint. Sixty percent of the participants rated the form of administration via the vaginal ring as excellent, compared with 14% for the pessaries (P < 0.0001).

CONCLUSIONS

Low dose vaginally administered oestradiol and oestriol are equally efficacious in alleviating lower urinary tract symptoms which appear after the menopause. The form of administration of the vaginal ring, seems to be more acceptable than oestriol pessaries.

Incidence and remission rates of lower urinary tract symptoms at one year in women aged 40-60: longitudinal study

OBJECTIVES

To determine the incidence and rates of remission of lower urinary tract symptoms at one year in women aged 40-60, and to assess factors associated with remission.

DESIGN

Ongoing longitudinal cohort study.

SETTING

One rural and one urban county in Denmark.

PARTICIPANTS

4000 women recruited on a random basis, 2860 of whom were followed up at one year.

MEASUREMENTS

Incidence and rates of remission of lower urinary tract symptoms.

RESULTS

Prevalence, incidence, and rates of remission of lower urinary tract symptoms in 2284 women were respectively 28.5% (95% confidence interval 26.7% to 30.4%), 10.0% (8.5% to 11.4%), and 27.8% (25.6% to 30.0%). Overall, symptoms were not significantly associated with events performed or initiated in the study period: medical consultation (1.6, 0.8 to 2.8), pelvic floor physiotherapy (0.9, 0.5 to 1.8), treatment with antibiotics on suspicion of a lower urinary tract infection (1.3, 0.8 to 2.2), or other treatment (1.7, 0.7 to 4. 1). Many of the individual symptoms were, however, associated with seeking professional help.

CONCLUSIONS

Lower urinary tract symptoms constitute dynamic conditions, with women experiencing more or fewer symptoms, and eventually a cessation of symptoms. The distinction between permanent and fluctuating cases may have important clinical and scientific implications.

Evaluation of a simple, non-surgical concept for management of urinary incontinence (minimal care) in an open-access, interdisciplinary incontinence clinic

Our objective was to evaluate a new concept for assessment and treatment of urinary incontinence in an open-access, interdisciplinary incontinence clinic. A standardized program for investigation and treatment of incontinence was based on minimal relevant investigations, primarily non-surgical treatment with a limited consumption of resources ("minimal care"). This was a prospective observational study of 408 consecutive women examined and treated in the clinic. The main characteristics of the women were a high median age and a high prevalence of severe concomitant diseases with possible influence on lower urinary tract function. More than half of the patients had urge or mixed incontinence. Most of the patients were managed with conservative treatment. Fifteen percent were referred to in-hospital treatment, with 5% to incontinence surgery. In total 44% felt cured or very much improved. Before and after treatment one third of the women completed quality-of-life questions and voiding charts, while 43% completed the pad tests. Quality of life improved significantly. Objectively leakage on pad test and voiding charts was significantly improved. The patients were in general very satisfied with clinic's program. Almost one fourth of the women were followed up for 6 months after discharge. No significant deterioration in the subjective results were found compared to status at discharge. In conclusion, the results highlight the need for advice and treatment of patients with incontinence. The minimal care program and interdisciplinary structure in the incontinence clinic offer effective and low cost treatment for urinary incontinence. The open-access, interdisciplinary incontinence clinic model is recommended. Neurourol. Urodynam. 18:9-17, 2000.

The patient with an overactive bladder--symptoms and quality-of-life issues

OBJECTIVES

Psychosocial adjustment to illness is an important as the status of the physical disease itself; focusing on this necessitates some measurement of abstract, subjective feelings of "quality of life" (QOL). Assessments of QOL are particularly important for conditions such as urinary incontinence (UI) that have little or no impact on mortality.

METHODS

This presentation describes the reasons for, and methods of, measuring lower urinary tract symptoms and disease impact. Validated instruments available for such measurements are reviewed, as are published studies that address the impact of UI (and urge incontinence in particular) on QOL. Potential applications for these new disease measures are discussed.

RESULTS

The bladder is an unreliable witness, and symptom assessment is diagnostically disappointing; cystometry is essential if a definitive diagnosis is required. However, objective tests take no account of the patient's perception of the problem. General health status questionnaires have been used to show that urge incontinence is associated with emotional problems, reduced social and recreational activity, and sexual dysfunction. Newly developed, condition-specific instruments have greater specificity and, hence, improved sensitivity for measuring incontinence and its impact. These instruments have the potential for monitoring disease progression and evaluating treatment outcome.

CONCLUSIONS

In a proportion of people with bladder overactivity, the disorder has a profound impact on the QOL. Methods of measuring this impact have been developed that may allow identification of this group of individuals while also improving the assessment of treatment efficacy. However, this science is in its infancy and these dimensions await further exploration.