Medical correlates of urinary incontinence in the elderly

Global Prevalence of Fecal Incontinence in Community-Dwelling Adults: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Fecal incontinence (FI) can considerably impair quality of life. Through a systematic review and meta-analysis, we sought to determine the global prevalence and geographic distribution of FI and to characterize its relationship with sex and age.

METHODS

We searched PubMed, Web of Science, and Cochrane Library databases to identify population-based surveys of the prevalence of FI.

RESULTS

Of the 5175 articles identified, the final analysis included 80 studies; the median response rate was 66% (interquartile range [IQR], 54%-74%). Among 548,316 individuals, the pooled global prevalence of FI was 8.0% (95% confidence interval [CI], 6.8%-9.2%); by Rome criteria, it was 5.4% (95% CI, 3.1%-7.7%). FI prevalence was greater for persons aged 60 years and older (9.3%; 95% CI, 6.6%-12.0%) compared with younger persons (4.9%; 95% CI, 2.9%-6.9%) (odds ratio [OR], 1.75; 95% CI, 1.39-2.20), and it was more prevalent among women (9.1%; 95% CI, 7.6%-10.6%) than men (7.4%; 95% CI, 6.0%-8.8%]) (OR, 1.17; 95% CI, 1.06-1.28). The prevalence was highest in Australia and Oceania, followed by North America, Asia, and Europe, but prevalence could not be estimated in Africa and the Middle East. The risk of bias was low, moderate, and high for 19 (24%), 46 (57%), and 15 (19%) studies, respectively. Exclusion of studies with high risk of bias did not affect the prevalence of FI or heterogeneity. In the meta-regression, the high study heterogeneity (I2 = 99.61%) was partly explained by age.

CONCLUSIONS

Approximately 1 in 12 adults worldwide have FI. The prevalence is greater among women and older people.

The Role of Gene Expression in Stress Urinary Incontinence: An Integrative Review of Evidence

Stress urinary incontinence (SUI) is defined as unintentional urine leakage occurring as a consequence of increased intraabdominal pressure due to absent or weak musculus detrusor contractility. It affects postmenopausal women more often than premenopausal and is associated with quality of life (QoL) deterioration. The complex SUI etiology is generally perceived as multifactorial; however, the overall impact of environmental and genetic influences is deficiently understood. In this research report, we have disclosed the upregulation of 15 genes and the downregulation of 2 genes in the genetic etiology of SUI according to the accessible scientific literature. The analytical methods used for the analysis of gene expression in the studies investigated were immunohistochemistry, immunofluorescence staining, PCR, and Western blot. In order to facilitate the interpretation of the results, we have used GeneMania, a potent software which describes genetic expression, co-expression, co-localization, and protein domain similarity. The importance of this review on the genetic pathophysiology of SUI lies in determining susceptibility for targeted genetic therapy, detecting clinical biomarkers, and other possible therapeutic advances. The prevention of SUI with the timely recognition of genetic factors may be important for avoiding invasive operative urogynecological methods.

Does the climacteric influence the prevalence, incidence and type of urinary incontinence?

Divergent opinions have been reported in the literature regarding the influence of the climacteric on the prevalence, incidence and types of urinary incontinence. In addition, the influence of hormonal therapy in the climacteric (HRT) on the occurrence of urinary incontinence in the perimenopausal period has been the subject of much discussion. This review evaluates the current literature regarding any possible association between the climacteric and the prevalence, incidence and types of urinary incontinence as well as illustrating the possible influence of HRT on urinary incontinence. Urinary incontinence is more common in women than in men and there is evidence to suggest that the prevalence of urinary incontinence in women increases in a linear fashion with age. There is no conclusive evidence to support a specific increase in the prevalence of urinary incontinence at the time of the menopause. Stress urinary incontinence is more common in premenopausal women and urgency urinary incontinence and mixed incontinence are more common in postmenopausal women. Women receiving systemic estrogen, with or without progestogen, are more likely to develop or experience worsening of incontinence.

Molecular Regulation of Concomitant Lower Urinary Tract Symptoms and Erectile Dysfunction in Pelvic Ischemia

Aging correlates with greater incidence of lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) in the male population where the pathophysiological link remains elusive. The incidence of LUTS and ED correlates with the prevalence of vascular risk factors, implying potential role of arterial disorders in concomitant development of the two conditions. Human studies have revealed lower bladder and prostate blood flow in patients with LUTS suggesting that the severity of LUTS and ED correlates with the severity of vascular disorders. A close link between increased prostatic vascular resistance and greater incidence of LUTS and ED has been documented. Experimental models of atherosclerosis-induced chronic pelvic ischemia (CPI) showed increased contractile reactivity of prostatic and bladder tissues, impairment of penile erectile tissue relaxation, and simultaneous development of detrusor overactivity and ED. In the bladder, short-term ischemia caused overactive contractions while prolonged ischemia provoked degenerative responses and led to underactivity. CPI compromised structural integrity of the bladder, prostatic, and penile erectile tissues. Downstream molecular mechanisms appear to involve cellular stress and survival signaling, receptor modifications, upregulation of cytokines, and impairment of the nitric oxide pathway in cavernosal tissue. These observations may suggest pelvic ischemia as an important contributing factor in LUTS-associated ED. The aim of this narrative review is to discuss the current evidence on CPI as a possible etiologic mechanism underlying LUTS-associated ED.

Urinary bladder wall thickness in type 2 diabetes mellitus patients

Introduction

Diabetes mellitus is an increasing health challenge with accompanying urological complications. Over 50% of men and women with diabetes have bladder dysfunction. According to the current understanding of bladder dysfunction, it refers to a progressive condition encompassing a broad spectrum of lower urinary tract symptoms including urinary urgency, frequency, nocturia, and incontinence. Urinary bladder dysfunction has been classically described as diminished bladder sensation, poor contractility, and increased post-void residual urine, termed bladder cystopathy. Ultrasonography of the urinary bladder, which is a cheap, safe, radiation free, non-invasive and reliable imaging modality, may help to identify diabetes mellitus patients prone to develop urinary bladder dysfunction.

Method

The study population comprised 80 diabetic subjects recruited from the diabetic outpatient clinic and another 80 age- and sex-matched asymptomatic control subjects. Ultrasound scan of their urinary bladder wall was performed using a curvilinear transducer to determine the thickness and other sonographic features.

Results

Out of the 80 diabetic subjects, 30 (37.5%) were males, while 50 (62.5%) were females; of 80 non-diabetic control subjects, 40 (50%) were males and 40 (50%) were females. The mean age of the diabetic subjects was 59.5 ± 10.4 years with a range of 40–82 years, while that of the controls was 60.2 ± 7.4 years with a range of 40–85 years. There was no statistically significant difference (p = 0.637) between the mean age of the diabetic and control subjects. The mean urinary bladder wall thickness in the diabetics was greater than in the non-diabetics in the study subjects. There was a statistically significant difference between the urinary bladder thickness of diabetic subjects and the control group (p <0.001). The mean urinary bladder wall thickness of the male and female subjects included in this study was 2.84 ± 1.31 mm and 2.9 ± 1.37 mm, respectively, with no statistically significant difference between them (p = 0.159). It was statistically significant between diabetic men and women (p = 0.027). Using Spearman’s rank correlation to test the relationship between the glycaemic haemoglobin level of diabetic subjects and urinary bladder wall thickness, it was revealed that there was no correlation between these variables (Spearman’s rho = 0.119, p = 0.309). The relationship between the urinary bladder volume of diabetic subjects and their mean urinary bladder wall thickness showed no correlation either (Spearman’s rho = –0.009, p = 0.937). Only gender was a statistically significant predictor of urinary bladder wall thickness among other variables.

Conclusion

Mean bladder wall thickness in patients with type 2 diabetes mellitus was greater than in the control subjects, and also greater in diabetic men compared to diabetic women, but the difference did not attain statistical significance. Urinary bladder wall thickness of the diabetics did not correlate with their glycaemic haemoglobin levels. Only gender was found to be a predictor of bladder wall thickness.

[Urinary incontinence: a good diagnosis as a basis for treatment]

Urinary incontinence: a good diagnosis as a basis for treatment Abstract. Abtract: Everyone has experienced incontinence at an early age. However, it also affects approximately 200 million people worldwide at the adult age. This common condition is frequently underreported by patients but can dramatically limit their social life. Subject to appropriate differential diagnosis, urinary incontinence is a condition that can be treated with good results in the majority of patients. This article provides a review of the essential symptomatology and current treatments, so that clinicians confronted with the problem may adopt the appropriate management.

Cellular Stress and Molecular Responses in Bladder Ischemia

The concept of bladder ischemia as a contributing factor to detrusor overactivity and lower urinary tract symptoms (LUTS) is evolving. Bladder ischemia as a consequence of pelvic arterial atherosclerosis was first documented in experimental models and later in elderly patients with LUTS. It was shown that early-stage moderate ischemia produces detrusor overactivity, while prolonged severe ischemia provokes changes consistent with detrusor underactivity. Recent studies imply a central role of cellular energy sensors, cellular stress sensors, and stress response molecules in bladder responses to ischemia. The cellular energy sensor adenosine monophosphate-activated protein kinase was shown to play a role in detrusor overactivity and neurodegeneration in bladder ischemia. The cellular stress sensors apoptosis signal-regulating kinase 1 and caspase-3 along with heat shock proteins were characterized as important contributing factors to smooth muscle structural modifications and apoptotic responses in bladder ischemia. Downstream pathways seem to involve hypoxia-inducible factor, transforming growth factor beta, vascular endothelial growth factor, and nerve growth factor. Molecular responses to bladder ischemia were associated with differential protein expression, the accumulation of non-coded amino acids, and post-translational modifications of contractile proteins and stress response molecules. Further insight into cellular stress responses in bladder ischemia may provide novel diagnostic and therapeutic targets against LUTS.

Autonomic neuropathy and urologic complications in diabetes

Diabetic autonomic neuropathy affects the entire autonomic nervous system and can lead to dysfunction of the cardiovascular, gastrointestinal, and genitourinary organ systems. Genitourinary dysfunction associated with diabetic autonomic neuropathy includes diabetic bladder dysfunction, sexual dysfunction, and recurrent urinary tract infections. Urological complications in diabetes mellitus are very common; in fact, genitourinary complications are more common than diabetic neuropathy or nephropathy. While several studies have reported on genitourinary dysfunction in individuals with diabetes, UroEDIC, an ancillary study to the Diabetes Control and Complications Trial (DCCT) and its observational follow up, the Epidemiology of Diabetes Interventions and Complications study (EDIC), comprehensively characterized the association between urologic complications and cardiovascular autonomic neuropathy. UroEDIC demonstrated significant associations between autonomic neuropathy and urologic complications in type 1 diabetes, specifically erectile dysfunction, female sexual dysfunction, and lower urinary tract symptoms. In this narrative review, we review the current literature on urological complications in diabetes.

LncRNA and mRNA Expression Profiling in the Periurethral Vaginal Wall Tissues of Postmenopausal Women with Stress Urinary Incontinence

Stress urinary incontinence (SUI) is one of the major pelvic floor disorders affecting postmenopausal women. To investigate the lncRNA and mRNA expression profiling of SUI in postmenopausal women, we used a microarray analysis to examine the differentially expressed long noncoding RNAs (lncRNAs) and messenger RNAs (mRNAs) in the periurethral vaginal wall of postmenopausal women with SUI. A total of 8840 lncRNAs and 7102 mRNAs were dysregulated in the two groups (absolute fold change ≥ 2 and P < 0.05). The expression levels of five randomly selected lncRNAs and mRNAs were validated by quantitative real-time PCR. A functional analysis revealed that several lncRNAs are involved in the lysosome pathway associated with extracellular matrix (ECM) remodeling. In addition, we also found several mRNAs involved in fibroblast pseudopodia formation, fibroblast growth, and the regulation of smooth muscle cell differentiation in the urinary tract. Our study offers essential data regarding differentially expressed lncRNAs and mRNAs and may provide new potential candidates for the study of SUI.

EAU Guidelines on Assessment and Nonsurgical Management of Urinary Incontinence

CONTEXT

The European Association of Urology guidelines on urinary incontinence (UI) have been updated in cyclical fashion with successive major chapters being revised each year. The sections on assessment, diagnosis, and nonsurgical treatment have been updated as of mid-2016.

OBJECTIVE

We present a condensed version of the full guideline on assessment and nonsurgical management of UI, with the aim of improving accessibility and increasing their dissemination.

EVIDENCE ACQUISITION

Our literature search was updated from the previous cut-off of July 2010 up to April 2016. Evidence synthesis was carried out by a pragmatic review of current systematic reviews and any newer subsequent high-quality studies, based on Population, Interevention, Comparator, and Outcome questions. Appraisal was conducted by an international panel of experts, working on a strictly nonprofit and voluntary basis, to develop concise evidence statements and action-based recommendations using modified Oxford and GRADE criteria.

EVIDENCE SYNTHESIS

The guidelines include algorithms that summarise the suggested pathway for standard, uncomplicated patients with UI and are more useable in daily practice. The full version of the guideline is available at http://uroweb.org/guideline/urinary-incontinence/.

CONCLUSIONS

These updated guidelines provide an evidence-based summary of the assessment and nonsurgical management of UI, together with a clear clinical algorithm and action-based recommendations. Although these guidelines are applicable to a standard patient, it must be remembered that therapy should always be tailored to individual patients' needs and circumstances.

PATIENT SUMMARY

Urinary incontinence is a very common condition which negatively impacts patient's quality of life. Several types of incontinence exist and since the treatments will vary, it is important that the diagnostic evaluation establishes which type is present. The diagnosis should also identify patients who need rapid referral to an appropriate specialist. These guidelines aim to provide sensible and practical evidence-based guidance on the clinical problem of urinary incontinence.

Targets, Messages, and Channels for Educational Interventions on Urinary Incontinence

This article documents a collaborative health agency-university community demonstration project on urinary incontinence in older women. The basic program-research division of respon sibility was blurred substantially in this collaboration. The article focuses on a telephone survey of 321 elderly women conducted as part of a needs assessment, which also served as baseline data in the evaluation of a public education initiative. The survey provided information for defin ing target populations, shaping educational messages, and selecting communication channels. The prevalence of involuntary urine loss was 34%, with 20% of all women reporting weekly in continence. There were few differences by continence status in health, sociodemographic char acteristics, orbeliefs about incontinence. Women used many communication channels for health information and had a preference for information from health professionals. Factors that con tributed to the collaborative relationship included technical expertise, diversity of expertise and perspectives, and the enhancement of capacity in collaborators.

LUTS in pelvic ischemia: a new concept in voiding dysfunction

Lower urinary tract symptoms (LUTS) are a group of voiding symptoms affecting both genders as they age. Traditionally, LUTS in men were commonly attributed to bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE). It was later shown that, in approximately one-third to more than one-half of cases, LUTS in men are not associated with BOO. Urodynamic changes in the male bladder and symptom scores in aging men were found to be identical to their age-matched female counterparts. These observations suggested that LUTS in the elderly do not necessarily relate to BOO and may result from local changes in bladder muscle, nerves, and blood vessels. However, aging factors predisposing to bladder dysfunction and LUTS remain unknown. Growing evidence suggests that aging-associated pelvic ischemia may be a primary factor in the development of nonobstructed nonneurogenic overactive bladder and LUTS. First identified in experimental models and later in clinical studies, pelvic ischemia has been shown to compromise the lower urinary tract structure and lead to dysfunction. Structural and functional consequences of bladder and prostate ischemia have been documented in animal models. Clinical studies have shown that bladder and prostate blood flow decreases with aging. The severity of LUTS in elderly patients correlates with the degrees of bladder ischemia. LUTS improvement with α blockers has been associated with increased bladder blood flow. Pelvic ischemia may be an independent factor in nonobstructed nonneurogenic bladder instability and LUTS. Further research into the pathophysiology of LUTS in pelvic ischemia may lead to better management of this problem in the elderly population.

[Urinary tract infections in the elderly]

Urinary tract infections (UTIs) and asymptomatic bacteriuria are frequent in elderly patients. Distinguishing UTI from asymptomatic bacteriuria in older adults, particularly those living in long-term care facilities, might be a challenge for physicians due to the presence of confounding factors, such as an overactive bladder, prostate enlargement, and an indwelling bladder catheter. The absence of standards in the definition and treatment of UTI in the elderly frequently leads to overtreatment. Consequently, antibiotic selection pressure increases and as a result multidrug-resistant organisms might arise. On the other hand, insufficient treatment can result in prolonged and complicated courses of infections or increased morbidity. This review covers the definition, prevalence, diagnosis and management of UTI in older adults.

MRI for pelvic floor dysfunction: can the strain phase be eliminated?

PURPOSE

The purpose of the study was to determine if the strain phase of an MR defecography (MRD) protocol is redundant and can be eliminated without a loss of diagnostic information.

MATERIALS AND METHODS

Institutional review board approval was obtained and the requirement for informed consent was waived. A retrospective single-center review of 80 MRD examinations (68 female, 12 male, mean age 55 years old) was conducted. Two radiologists blinded to patient information evaluated in consensus the strain and evacuation phases separately and in a random order. Each phase was assessed for the presence and degree of posterior compartment descent, cystocele, urethral hypermobility, uterovaginal prolapse, rectocele, rectal intussusception, and enterocele. The degree of pelvic floor descent was compared using a paired t test and McNemar's test was used to compare the proportion of abnormal findings.

RESULTS

The evacuation phase identified all abnormalities identified on the strain phase and also identified both additional and more pronounced abnormalities, including an additional 34 cystoceles, 20 cases of urethral hypermobility, 13 uterovaginal prolapses, 36 rectoceles, 5 rectal intussusceptions, and 6 enteroceles (all p < 0.02). The mean posterior compartment descent was 24.1 mm greater on the evacuation phase than the strain phase (p < 0.0001).

CONCLUSION

The strain phase is redundant and we propose that it can be eliminated from a routine MRD protocol. This will help streamline the examination, simplify patient instructions, and reduce both imaging and reporting time.

Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women

BACKGROUND

More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated.

OBJECTIVE

We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women.

STUDY DESIGN

We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment.

RESULTS

Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ≥ $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ≥ $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician.

CONCLUSION

Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

Fecal Incontinence: Community Prevalence and Associated Factors--A Systematic Review

BACKGROUND

Fecal incontinence is a chronic and debilitating condition with significant health burden. Despite its clinical relevance, the prevalence of fecal incontinence remains inconsistently described.

OBJECTIVE

This study aimed to systematically review the literature regarding the prevalence of and factors associated with fecal incontinence among community-dwelling adults.

DATA SOURCES

A search of the PubMed, Embase, and Cochrane databases was performed.

STUDY SELECTION

Studies that reported the prevalence of fecal incontinence and/or associated factors in a community-based (ie, unselected) adult population were included. Two independent assessors reviewed eligible articles.

MAIN OUTCOME MEASURES

Relevant data were extracted from each study and presented in descriptive form. The main outcome measures included the prevalence of fecal incontinence (adjusted and/or unadjusted), stratified for age and sex if reported; factors associated (and not associated) with fecal incontinence; and study quality, assessed using predefined criteria.

RESULTS

Of 3523 citations identified, 38 studies were included for review. The reported median prevalence of fecal incontinence was 7.7% (range, 2.0%-20.7%). Fecal incontinence equally affected both men (median, 8.1%; range, 2.3%-16.1%) and women (median, 8.9%; range, 2.0%-20.7%) and increased with age (15-34 years, 5.7%; >90 years, 15.9%). The study populations and diagnostic criteria used were heterogeneous, precluding any meaningful pooling of prevalence estimates. Study quality assessment revealed 6 high-quality studies, of which only 3 were performed in a representative sample. The median prevalence of fecal incontinence was higher in these studies at 11.2% (range, 8.3%-13.2%). The factors most commonly reported to be associated with fecal incontinence included increasing age, diarrhea, and urinary incontinence.

LIMITATIONS

Heterogeneity of studies precluded meaningful pooling or meta-analysis of data.

CONCLUSIONS

Fecal incontinence is a prevalent condition of equal sex distribution, affecting ≈1 in 8 community adults, and has identifiable associated factors. The paucity of high-quality prevalence studies emphasizes the need for future population-based studies that use standardized diagnostic criteria for fecal incontinence.

Continence Index: a new screening questionnaire to predict the probability of future incontinence in older women in the community

PURPOSE

Urinary incontinence (UI) is a chronic, costly condition that impairs quality of life. To identify older women most at risk, the Medical Epidemiologic and Social Aspects of Aging (MESA) datasets were mined to create a set of questions that can reliably predict future UI.

METHODS

MESA data were collected during four household interviews at approximately 1 year intervals. Factors associated with becoming incontinent at the second interview (HH2) were identified using logistic regression (construction datasets). Based on p values and odds ratios, eight potential predictive factors with their 256 combinations and corresponding prediction probabilities formed the Continence Index. Its predictive and discriminatory capability was tested against the same cohort's outcome in the fourth survey (HH4 validation datasets). Sensitivity analysis, area under receiver operating characteristic (ROC) curve, predicted probabilities and confidence intervals were used to statistically validate the Continence Index.

RESULTS

Body mass index, sneezing, post-partum UI, urinary frequency, mild UI, belief of developing UI in the future, difficulty stopping urinary stream and remembering names emerged as the strongest predictors of UI. The confidence intervals for prediction probabilities strongly agreed between construction and validation datasets. Calculated sensitivity, specificity, false-positive and false-negative values revealed that the areas under the ROCs (0.802 and 0.799) for the construction and validation datasets, respectively, indicated good discriminatory capabilities of the index as a predictor.

CONCLUSION

The Continence Index will help identify older women most at risk of UI in order to apply targeted prevention strategies in women that are most likely to benefit.

A current perspective on geriatric lower urinary tract dysfunction

Lower urinary tract dysfunction-such as urinary incontinence (UI), detrusor overactivity, and benign prostatic hyperplasia-is prevalent in elderly persons. These conditions can interfere with daily life and normal functioning and lead to negative effects on health-related quality of life. UI is one of the most common urologic conditions but is poorly understood elderly persons. The overall prevalence of UI increases with age in both men and women. Elderly persons often neglect UI or dismiss it as part of the normal aging process. However, UI can have significant negative effects on self-esteem and has been associated with increased rates of depression. UI also affects quality of life and activities of daily living. Although UI is more common in elderly than in younger persons, it should not be considered a normal part of aging. UI is abnormal at any age. The goal of this review is to provide an overview of the cause, classification, evaluation, and management of geriatric lower urinary tract dysfunction.

Systematic review and metaanalysis of genetic association studies of urinary symptoms and prolapse in women

OBJECTIVE

Family studies and twin studies demonstrate that lower urinary tract symptoms and pelvic organ prolapse are heritable. This review aimed to identify genetic polymorphisms tested for an association with lower urinary tract symptoms or prolapse, and to assess the strength, consistency, and risk of bias among reported associations.

STUDY DESIGN

PubMed and HuGE Navigator were searched up to May 1, 2014, using a combination of genetic and phenotype key words, including "nocturia," "incontinence," "overactive bladder," "prolapse," and "enuresis." Major genetics, urology, and gynecology conference abstracts were searched from 2005 through 2013. We screened 889 abstracts, and retrieved 78 full texts. In all, 27 published and 7 unpublished studies provided data on polymorphisms in or near 32 different genes. Fixed and random effects metaanalyses were conducted using codominant models of inheritance. We assessed the credibility of pooled associations using the interim Venice criteria.

RESULTS

In pooled analysis, the rs4994 polymorphism of the ADRB3 gene was associated with overactive bladder (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.7-3.6; n = 419). The rs1800012 polymorphism of the COL1A1 gene was associated with prolapse (OR, 1.3; 95% CI, 1.0-1.7; n = 838) and stress urinary incontinence (OR, 2.1; 95% CI, 1.4-3.2; n = 190). Other metaanalyses, including those for polymorphisms of COL3A1,LAMC1,MMP1,MMP3, and MMP9 did not show significant effects. Many studies were at high risk of bias from genotyping error or population stratification.

CONCLUSION

These metaanalyses provide moderate epidemiological credibility for associations of variation in ADRB3 with overactive bladder, and variation of COL1A1 with prolapse. Clinical testing for any of these polymorphisms cannot be recommended based on current evidence.

Does urinary bladder shape affect urinary flow rate in men with lower urinary tract symptoms?

We aimed to investigate the role of urinary bladder shape which may potentially change with advancing age, increased waist circumference, pelvic ischemia, and loosening of the urachus on bladder emptying and UFR. We retrospectively investigated the medical records of 76 men. The patients were divided into two groups according to bladder shapes in MRI scan (cone and spheric shapes). There was a significant difference between the two groups in terms of IPSS, Qmax, Qave, and waist circumference. A positive correlation has been demonstrated between mean peak urinary flow rate measured with UFM and mean flow rate calculated using the CP. There was a significant difference between mean urinary flow rates calculated with CP of cone and sphere bladder shapes. The change in the bladder shape might be a possible factor for LUTS in men and LUTS may be improved if modifiable factors including increased waist circumference and loosening of the urachus are corrected.

The evaluation of bioelectrical activity of pelvic floor muscles depending on probe location: a pilot study

Objectives. The main objective was to determine how the depth of probe placement affects functional and resting bioelectrical activity of the PFM and whether the recorded signal might be dependent on the direction in which the probe is rotated. Participants. The study comprised of healthy, nulliparous women between the ages of 21 and 25. Outcome Measures. Bioelectric activity of the PFM was recorded from four locations of the vagina by surface EMG and vaginal probe. Results. There were no statistically significant differences between the results during functional sEMG activity. During resting sEMG activity, the highest bioelectrical activity of the PFM was observed in the L1 and the lowest in the L4 and a statistically significant difference between the highest and the lowest results of resting sEMG activity was observed (P = 0.0043). Conclusion. Different electrodes placement during functional contraction of PFM does not affect the obtained results in sEMG evaluation. In order to diagnose the highest resting activity of PFM the recording plates should be placed toward the anterior vaginal wall and distally from the introitus. However, all of the PFM have similar bioelectrical activity and it seems that these muscles could be treated as a single muscle.

Increased bladder wall thickness in diabetic and nondiabetic women with overactive bladder

Purpose

Bladder wall thickness has been reported to be associated with overactive bladder (OAB) in women. Diabetic women have an increased risk for OAB syndrome and may have an increased risk for bladder wall thickness.

Methods

A total of 235 female patients aged 40 to 75 years were categorized into four groups. The first group consisted of women free of urgency or urge urinary incontinence. The second group included nondiabetic women with idiopathic OAB. The third group consisted of women with diabetes and clinical OAB, and women with diabetes but without OAB constituted the fourth group. Bladder wall thickness at the anterior wall was measured by ultrasound by the suprapubic approach with bladder filling over 250 mL.

Results

The diabetic (third group) and nondiabetic (second group) women with OAB had significantly greater bladder wall thickness at the anterior bladder wall than did the controls. However, the difference was not significant between the diabetic (third group) and the nondiabetic (second group) women with OAB. Women with diabetes but without OAB (fourth group) had greater bladder wall thickness than did the controls but this difference was not significant. Additionally, the difference in bladder wall thickness between diabetic women with (third group) and without (fourth group) OAB was not significant.

Conclusions

This is the first study to show that bladder wall thickness is increased in diabetic women with and without OAB. Additionally, nondiabetic women with OAB had increased bladder wall thickness. Further studies may provide additional information for diabetic and nondiabetic women with OAB, in whom the etiopathogenesis of the disease may be similar.

Effects of coenzyme Q10 on bladder dysfunction induced by chronic bladder ischemia in a rat model

PURPOSE

We investigated the protective effects of coenzyme Q10 on bladder dysfunction in a rat model of atherosclerosis induced chronic bladder ischemia.

MATERIALS AND METHODS

A total of 24 male Sprague-Dawley® rats at age 16 weeks were divided into 4 groups of 6 each, including group 1--untreated, sham operated rats, group 2--coenzyme Q10 treated, sham operated rats, group 3--untreated rats with chronic bladder ischemia and group 4--coenzyme Q10 treated rats with chronic bladder ischemia. Groups 3 and 4 received an endothelial injury to the iliac arteries and were fed a 2% cholesterol diet for 8 weeks. Groups 2 and 4 were treated with coenzyme Q10 and the others were treated with vehicle for 4 weeks. Eight weeks postoperatively we performed continuous in vivo cystometry, an in vitro detrusor muscle strip study and a malondialdehyde assay. Histological examination of the bladder walls and iliac arteries was also done.

RESULTS

In vivo cystometry revealed that coenzyme Q10 administration after the induction of chronic bladder ischemia prolonged micturition frequency and the intercontraction interval, and increased bladder capacity compared to those in untreated rats with chronic bladder ischemia. In the detrusor muscle strip study coenzyme Q10 administration after the induction of chronic bladder ischemia increased contractile responses compared to those in untreated rats with chronic bladder ischemia. Rats with chronic bladder ischemia also showed higher malondialdehyde in bladder tissue and serum than the other groups. Chronic bladder ischemia induced submucosal fibrosis of the bladder walls and a degenerative change in the blood vessel tunical media, as shown on histological examination.

CONCLUSIONS

Our study suggests that coenzyme Q10 acts as an antioxidant to protect bladder function in this chronic bladder ischemia model.

Novel application of statistical methods to identify new urinary incontinence risk factors

Longitudinal data for studying urinary incontinence (UI) risk factors are rare. Data from one study, the hallmark Medical, Epidemiological, and Social Aspects of Aging (MESA), have been analyzed in the past; however, repeated measures analyses that are crucial for analyzing longitudinal data have not been applied. We tested a novel application of statistical methods to identify UI risk factors in older women. MESA data were collected at baseline and yearly from a sample of 1955 men and women in the community. Only women responding to the 762 baseline and 559 follow-up questions at one year in each respective survey were examined. To test their utility in mining large data sets, and as a preliminary step to creating a predictive index for developing UI, logistic regression, generalized estimating equations (GEEs), and proportional hazard regression (PHREG) methods were used on the existing MESA data. The GEE and PHREG combination identified 15 significant risk factors associated with developing UI out of which six of them, namely, urinary frequency, urgency, any urine loss, urine loss after emptying, subject's anticipation, and doctor's proactivity, are found most highly significant by both methods. These six factors are potential candidates for constructing a future UI predictive index.

Stress urinary incontinence: What, when, why, and then what?

Stress urinary incontinence (SUI) has a significant impact on the quality of life for many women. Most women do not seek medical attention for this condition. Treatment for this problem includes initial conservative therapies and then surgery is an option. More than 200 surgical procedures have been described in the literature for the treatment of stress incontinence. The gold-standard surgical treatment of SUI in patients with a mobile bladder neck and normally functioning urethra has been accomplished through a retropubic approach using either a Burch or Marshall-Marchetti-Krantz procedure. By the absolute success of Trans obturator tape (TOT) application in treatment of SUI and the niche it has created for itself in the maze of treatment modalities available for SUI, there seems to be little doubt that TOT is all set to become the new Gold Standard for treatment of SUI in times to come. It is difficult to imagine any further improvements in the midurethral sling procedures or surgeries for SUI. However 10 years ago, no one could have imagined the progress and development that has been seen over these few short years in the treatment of SUI. The future may hold promise in technologies such as stem cells that may be injected in or around the urethral support structures and provide regeneration of the lacking support structures. What so ever, it's definitely time to provide millions of women with knowledge that empowers them to make lifestyle changes to decrease their risk of SUI and to understand the reality that they are not alone if they have SUI.

Acidic fruit intake in relation to incidence and progression of urinary incontinence

INTRODUCTION AND HYPOTHESIS

Acidic fruits are commonly cited in the lay press as potential bladder irritants that may promote urinary incontinence (UI), but no epidemiologic studies have examined this issue. We hypothesized that higher intake of acidic fruits might be related to greater risk of UI incidence and progression in women.

METHODS

In one set of analyses, we included women without UI at study baseline in the Nurses' Health Studies (NHS), with 34,144 women aged 54-79 in NHS I and 31,024 women aged 37-54 in NHS II. These cohorts were established among women living in the USA. Incident UI was ascertained over 4 years of follow-up, and acidic fruit consumption was measured by food frequency questionnaire prior to UI onset. In a second set of analyses, we examined UI progression over 2 years of follow-up among 11,764 women in NHS I and 11,299 women in NHS II with existing UI. Multivariable-adjusted relative risks were calculated for the associations of acidic fruit intake and UI incidence and progression.

RESULTS

We found no relation between acidic fruit intake and risk of developing UI, including urgency, mixed, and stress UI. In addition, there was no association between consumption of acidic fruits and UI progression, regardless of UI type.

CONCLUSIONS

No associations were detected between acidic fruit intake and UI in this large, prospective study of women. These data have implications for the development of evidence-based dietary guidelines around acidic fruits and UI, particularly because acidic fruits likely have many health benefits.

Impact of cough and urinary incontinence on quality of life in women and men with chronic obstructive pulmonary disease

AIMS AND OBJECTIVES

The aim of this study was to investigate the impact of cough and urinary incontinence on quality of life in women and men with chronic obstructive pulmonary disease in primary health care.

BACKGROUND

Existing information on the impact of cough and urinary incontinence on quality of life in patients with chronic obstructive pulmonary disease is scant.

DESIGN

A questionnaire survey.

METHOD

The study included 391 women and 337 men, aged 50-75 years, with chronic obstructive pulmonary disease. A self-administered questionnaire consisted of CCQ and SF-12 questionnaires. A response rate of 66% was obtained. Most patients had been diagnosed with moderate (Stage II) chronic obstructive pulmonary disease.

RESULTS

Women and men with urinary incontinence showed a significantly higher presence of symptomatic cough and phlegm production than did women and men without incontinence. Women with incontinence had a significantly higher burden of CCQ symptoms, functional and mental state than did women without incontinence. Concerning quality-of-life scores, women with incontinence had lower physical state scores (37·6 ± 10·4 vs. 41·4 ± 9·9; p < 0·001) and mental state scores (44·3 ± 10·2 vs. 47·1 ± 10·5; p < 0·007) than did women without incontinence. Men with incontinence had a significantly higher burden of CCQ symptoms and mental state than did men without incontinence. When examining the quality-of-life scores, men with incontinence had lower mental state scores than did men without incontinence (46·0 ± 9·7 vs. 49·8 ± 9·7; p < 0·001).

CONCLUSION

The present results indicate that cough and urinary incontinence lead to poor quality of life in women and men with chronic obstructive pulmonary disease.

RELEVANCE TO CLINICAL PRACTICE

In the context of primary health care, appropriate questions concerning urinary incontinence and quality of life should be included in care plans for women and men living with chronic obstructive pulmonary disease.

Prevalence of fecal incontinence and its relationship with urinary incontinence in women living in the community

OBJECTIVE

The aim of this study was to document the age-specific prevalence of fecal incontinence (FI), as well as its relationship to childbirth and urinary incontinence (UI), in a community-based sample of Australian women.

METHODS

A total of 444 women aged 26 to 82 years, originally recruited from a community-based research database, completed a self-administered study questionnaire. Prevalence of FI was assessed using the Pelvic Floor Distress Inventory, and UI and its subtypes were determined using the Questionnaire for Urinary Incontinence Diagnosis. Univariate (Pearson's χ tests) and multivariate logistic regression analyses were used to assess the relationship between FI type and UI adjusting for age and body mass index (BMI).

RESULTS

Data were analyzed for 442 women. The overall prevalence of any FI was 20.7% (95% CI, 16.9%-24.5%). Loose FI was reported by 91 of 442 women, yielding a prevalence of 20.7% (95% CI, 16.9%-24.5%). Well-formed FI was reported by 20 of 442 women, yielding a prevalence of 4.5% (95% CI, 2.6%-6.4%). All the women with well-formed FI also reported problems of loose FI. The prevalence of FI increased with age up to 75 years for both types of FI. FI was not related to parity (P = 0.9). The highest proportion of any FI (24.4%) occurred in women with a parity of four or greater; however, 20.3% of nulliparous women reported FI. Within parous women, there was no significant association found between FI and history of self-reported instrumental delivery (P = 0.4). About two thirds of the women with loose and well-formed FI also reported coexisting UI. Loose FI was significantly associated with any UI (odds ratio, 2.8; 95% CI, 1.7-4.8) after adjusting for age and BMI (P < 0.001). Well-formed FI was not significantly associated with any UI after adjusting for age and BMI.

CONCLUSIONS

FI is a common condition affecting one in five adult women in the community. In our study, women with loose FI, but not well-formed FI, were more likely to have UI independent of their age and BMI. Being parous was not associated with an increased risk of any FI.

Significant linkage evidence for a predisposition gene for pelvic floor disorders on chromosome 9q21

Predisposition factors for pelvic floor disorders (PFDs), including pelvic organ prolapse (POP), stress urinary incontinence (SUI), urge urinary incontinence (UUI), and hernias, are not well understood. We assessed linkage evidence for PFDs in mostly sister pairs who received treatment for moderate-to-severe POP. We genotyped 70 affected women of European descent from 32 eligible families with at least two affected cases by using the Illumina 1 million single-nucleotide polymorphism (SNP) marker set. Parametric linkage analysis with general dominant and recessive models was performed by the Markov chain Monte Carlo linkage analysis method, MCLINK, and a set of SNPs was formed, from which those in high linkage disequilibrium were eliminated. Significant genome-wide evidence for linkage was identified on chromosome 9q21 with a HLOD score of 3.41 under a recessive model. Seventeen pedigrees (53%) had at least nominal evidence for linkage on a by-pedigree basis at this region. These results provide evidence for a predisposition gene for PFDs on chromosome 9q.

Six-year follow-up and predictors of urgency-associated urinary incontinence and bowel symptoms among the oldest old: a population-based study

Urinary urgency with incontinence, and fecal incontinence and constipation were followed up over a 6-year period in 398 subjects aged 70 years and over at baseline. Age- and gender-adjusted and multivariate Cox proportional hazard models were used to examine the associations of urinary urgency and fecal incontinence and constipation with mortality, and logistic regression models to determine predictors of incident symptoms among the survivors. The proportion of incident cases of urinary urgency with incontinence, fecal incontinence and constipation in the 252 survivors were 17% (n=46), 9% (n=34) and 13% (n=36), respectively. Frequently reported urinary urgency (hazard ratio, HR=2.23; 95% confidence interval, CI=1.37-3.61) and frequently reported fecal incontinence (HR=4.99; CI=2.11-11.79) were associated with mortality when adjusted for age and gender only. In the multivariate analyses, comorbidity (odds ratio, OR=5.54; CI=2.03-15.14), depressive mood (OR=5.78; CI=1.35-24.79) and instrumental activities of daily living (IADL) disability (OR=4.18, CI=1.52-11.50) predicted incident urgency urinary incontinence. Comorbidity (OR=2.91; CI=1.09-7.77) predicted incident fecal incontinence, while no significant predictors were identified for the incident symptom of constipation. Comorbidities and disabilities explain the association of severe urinary and fecal incontinence with mortality.

Diabetes mellitus and female lower urinary tract symptoms: a review

Diabetes mellitus (DM) has reached epidemic proportions world wide. Many chronic complications of DM, including neuropathy, retinopathy and nephropathy, have been well studied and although urologic complications have been recognized since 1935, little is known about DM as a pathophysiological risk factor for development of lower urinary tract symptoms (LUTS) in women. Diabetic nephropathy, a life-threatening condition, has received considerable attention in the last few years. Diabetic cystopathy, on the other hand, has received far less attention despite having a significant impact on quality of life, and with significant individual health risks. Initial studies suggested that long standing DM causes paralysis of the detrusor muscle leading to voiding difficulties and this has been the received wisdom regarding diabetic cystopathy for many years. In this review, we discuss what is currently known about lower urinary tract function and urinary incontinence in diabetic females, with a critical analysis of the available evidence and suggest areas for future research.

Pelvic ischemia is measurable and symptomatic in patients with coronary artery disease: a novel application of dynamic contrast-enhanced magnetic resonance imaging

INTRODUCTION

Pelvic ischemia can manifest as vascular-mediated erectile dysfunction (ED) and lower urinary tract symptoms (LUTS), and is associated with cardiac ischemia.

AIMS

We aimed to develop a dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) technique to measure pelvic perfusion in benign tissue.

METHODS

Nine men with coronary artery disease (CAD) were compared with nine without. Images were acquired at 3T with T1-weighted DCE-MRI for perfusion. Two-compartment pharmacokinetic modeling was employed to fit signal enhancement from prostate, corpus cavernosal, and spongiosal tissues.

MAIN OUTCOME MEASURES

Perfusion parameters and validated pelvic symptom scores were compared.

RESULTS

The mean International Index of Erectile Function (IIEF) total score was worse in CAD (41.3 +/- 19.7) vs. controls (59.4 +/- 14.9, P = 0.04). The IIEF erectile function domain score trended to worse in CAD (13.7 +/- 9.7) vs. controls (22.0 +/- 9.9, P = 0.09). The mean total International Prostate Symptom Score (IPSS) trended to worse in CAD patients (13.2) than controls (7.0) (P = 0.10). Magnetic resonance perfusion analysis demonstrated lower mean maximal percent enhancement to P < 0.0001 in the CAD group vs. controls for all the following comparisons: prostate in CAD (22.4 +/- 0.4) vs. controls (26.3 +/- 0.1); cavernosal tissue in CAD (9.3 +/- 0.2) vs. controls (16.6 +/- 0.8); and spongiosal tissue in CAD (20.6 +/- 1.2) vs. controls (24.0 +/- 0.6). Comparison of mean wash-in rates in the unit of 10(-3)/second was also highly significant (P < 0.0001 for all tissues): prostate in CAD (574.0 +/- 18.0) was lower than controls (1,035.0 +/- 29.0); slower wash-in rates were seen in CAD cavernosal (58.0 +/- 4.0 vs. 139.0 +/- 9.0 in controls) and spongiosal tissue (134.0 +/- 6.0 vs. 278.0 +/- 12.0 in controls).

CONCLUSION

These initial data demonstrate that pelvic perfusion can be measured in noncancerous tissues, and that perfusion correlates with validated measures of ED and LUTS.

The epidemiology of urinary incontinence in older women: incidence, progression, and remission

OBJECTIVES

To examine the epidemiology of urinary incontinence (UI) in older women.

DESIGN

Prospective study.

SETTING

Nurses' Health Study.

PARTICIPANTS

Incidence of UI was determined in 23,792 women aged 54 to 79 without UI at baseline. Progression or remission of UI was determined in 28,813 women with UI at least monthly at baseline.

MEASUREMENTS

UI was ascertained according to questionnaires in 2000 and 2002. Rates of incident UI and progression or remission of prevalent UI were calculated. Logistic regression was used to estimate relative risks of UI associated with risk factors.

RESULTS

In women with no urine leakage at baseline, 9.2% reported leakage at least monthly after 2 years. For women with leakage at least weekly, the incidence was 3.6%; of these cases, stress UI had the highest incidence, followed by mixed and urge UI. Relationships between UI and age differed for stress UI, which decreased with age (relative risk (RR)=0.63, 95% confidence interval (CI)=0.43-0.92 for aged 70-79 vs 54-59), and urge and mixed UI, which increased with age (RR=2.28, 95% CI=1.09-4.75 and RR=2.11, 95% CI=1.24-3.61, respectively). For prevalent UI in 2000, 32.1% of subjects with leakage once a month progressed to leakage at least once a week over follow-up. Only 8.9% with frequent leakage in 2000 reported improvement to monthly leakage or less, with 2.0% having complete remission.

CONCLUSION

The incidence of UI is high in older women, and progression from occasional to frequent leaking is common. Urge UI, for which there are limited effective treatments, increases with age, thus research on UI prevention in older women is particularly important.

Association of lower urinary tract symptoms and chronic ischaemia of the lower urinary tract in elderly women and men: assessment using colour Doppler ultrasonography

OBJECTIVES

To investigate, using transrectal colour Doppler ultrasonography, (TRCDUS) whether perfusion of the bladder and prostate is reduced in elderly patients with lower urinary tract symptoms (LUTS), common in later life, as experimental data suggest that chronic ischaemia has a key role in the development of LUTS.

PATIENTS, SUBJECTS AND METHODS

In 32 elderly patients with LUTS (12 women, mean age 82.3 years, group 1; and 20 men, 79.4 years, group 2) perfusion of the bladder neck (in women) and of the bladder neck and prostate (in men) was measured using TRCDUS and the resistive index (RI) and colour pixel density (CPD) determined, assessed by a TRUS unit and special software. To assess the age-related effect two control groups of 10 young healthy women (mean age 42.3 years, group 3) and 10 age-matched healthy men (mean age 41.5 years, group 4) were also enrolled.

RESULTS

Irrespective of gender, there was markedly lower bladder perfusion in elderly patients with LUTS than in the younger subjects. The mean (SD) RI of the bladder neck in group 1, of 0.88 (0.06), and group 2, of 0.80 (0.08), was higher than in control groups 3, of 0.62 (0.05), and group 4, of 0.64 (0.09). The results were similar for the CPD measurements. The frequency of daily and nightly micturition showed a strong negative correlation with perfusion in the urinary bladder.

CONCLUSION

In elderly patients with LUTS there was decreased perfusion of the bladder neck and prostate when assessed using TRCDUS. Therefore, decreased perfusion in the urinary bladder might be responsible for the development of LUTS with advancing age.

Comparison of the long-term effects of simple total abdominal hysterectomy with transcervical endometrial resection on urinary incontinence

OBJECTIVE

To test the hypothesis that the hospital referral rate for urinary incontinence (UI) symptoms, within 10 years of a simple total abdominal hysterectomy (TAH) for dysfunctional uterine bleeding (DUB), would differ to that after a transcervical resection of the endometrium (TCRE).

DESIGN

Retrospective case note review.

SETTING

Teaching hospital in north east Scotland.

POPULATION

All women who had a TAH (316) or a TCRE (229) for DUB, during the period from 1 January 1990 to 31 December 1994, who had never been referred for symptoms of UI prior to their operation.

METHODS

Independent t tests, Mann-Whitney U tests and Chi-squared tests were used to compare the two study groups in terms of demographic details and outcome measures. Newcombe's method for the comparison of two unpaired proportions was used to calculate 95% CIs for the differences in outcome measures between the two operations. Logistic regression was conducted to investigate associations with hospital referral for UI.

MAIN OUTCOME MEASURES

Hospital referral for UI at 10 years follow up.

RESULTS

There were significantly more hospital referrals for UI in the TAH group compared with the TCRE group (46 [15%] versus 16 [7%]; OR 2.27, 95% CI 1.25-4.12). More women were referred for urological investigations after a TAH than after a TCRE (39 [12%] versus 13 [6%], 95% CI for the difference in proportions 2-11%). A higher, but statistically nonsignificant, proportion of women had objectively demonstrated UI after a TAH than after a TCRE (25 [8%] versus 10 [4%], 95% CI for the difference in proportions -1 to 8%). There were a greater number of hospital referrals for treatment of UI in the TAH group (36, 11%) than in the TCRE group (12, 5%), 95% CI for the difference in proportions (1-11%). After adjusting for age, weight, smoking status and mode of delivery, the increased rate of hospital referral for UI after TAH remained, with an odds ratio of 2.31, 95% CI 1.24-4.30.

CONCLUSIONS

TAH is associated with a significantly increased incidence of hospital referral for UI, urological investigations and treatment for UI at 10 years of follow up compared with TCRE.

Fibroid-induced acute urinary retention: treatment by uterine artery embolization

A 39-year-old gravida 2 para 2 woman presented to our Hospital's Emergency Department with complaints of difficulty voiding. She had an enlarged leiomyomatous uterus, for which she was not receiving any current treatment. A Foley catheter placed yielded 1,500 cc of clear yellow urine; however, the patient remained Foley-dependent for 2 weeks until she underwent uterine artery embolization (UAE). Twenty-four hours afterwards, the Foley catheter was removed and the patient spontaneously voided with negligible post-void residual. There was no recurrence of urinary retention or development of any other urinary symptoms during the outpatient follow-up period. Repeat pelvic magnetic resonance imaging (MRI) 1 week after UAE showed negligible reduction in the size of the fibroids and uterus in comparison with a pre-procedure MRI. The Vascular Steal Theory, first presented in this paper, discusses this improvement in symptoms without significant change in size.

The neurogenic hypothesis of stress incontinence

There are a number of causes of incontinence. The common forms of urinary incontinence, faecal incontinence or double incontinence, are stress related, in that voiding of urine or faeces occurs in response to a sudden increase in pressure in the bladder or anorectum that is not opposed by an adequate pressure increase in the sphincteric region. This weakness of the sphincter mechanism is due to chronic partial denervation of the striated sphincter muscles of the pelvic floor, comprising the external and sphincter muscle and puborectalis (puboanalis) components of the voluntary anal sphincter musculature, and the periurethral and intramural components of the urinary striated sphincter musculature. Denervation of these muscles occurs progressively following injury initiated during childbirth and then sustained by repeated stretch-induced injury during straining behaviour at stool. Age-related changes to this innervation may also be important. Weakness of the pelvic floor, and perineal descent during straining, lead to secondary changes in the anatomy of the bladder neck, of the anorectal angle, and of the smooth muscle of the internal urinary and anal sphincters. The cystometric and anal manometric changes found in patients with stress incontinence are secondary to this neurogenic weakness of the pelvic floor.

Duloxetine treatment of stress urinary incontinence in women: effects of demographics, obesity, chronic lung disease, hypoestrogenism, diabetes mellitus, and depression on efficacy

OBJECTIVE

To identify poor responders, we evaluated the impact of demographic characteristics and comorbidities on efficacy using an integrated database including data from four large randomized controlled trials. Duloxetine has been shown to be effective in women with stress urinary incontinence (SUI).

STUDY DESIGN

A total of 1913 women 22-83 years of age with predominant SUI (diagnosed using a validated clinical algorithm) were randomly assigned to receive placebo (n = 955) or duloxetine (n = 958) for 12 weeks. Efficacy outcome variables included a weekly incontinence episodes frequency (IEF) from patient-completed diaries, the Incontinence Quality-of-Life (I-QOL) questionnaire score, and a Patient Global Impression of Improvement rating. Subgroups selected a priori included: ethnicity, age, body mass index (BMI), chronic lung disease, hypoestrogenism, diabetes mellitus, and depression. For safety comparisons, adverse events were compared across age and ethnicity subgroups.

RESULTS

Reduction in IEF was minimal and not significantly different between duloxetine and placebo in women with chronic lung disease. The decrease in IEF for women > or =65 years of age was slightly diminished for duloxetine and placebo groups, but the treatment differences were maintained. There was a significantly different I-QOL improvement by BMI subgroup, with greater increases in scores associated with a higher BMI (>28 kg/m2). There were no other notable subgroup impacts on efficacy.

CONCLUSIONS

With the possible exception of chronic lung disease, no characteristic was identified that predicted a lack of treatment response with duloxetine in the treatment of women with SUI. Elderly patients may experience lower response rates to duloxetine presumably due to age related changes in the lower urinary tract.

Body mass index, weight gain, and incident urinary incontinence in middle-aged women

OBJECTIVE

To describe the relations between body mass index (BMI; kg/m(2)), weight gain, and incident urinary incontinence in middle-aged women.

METHODS

This was a prospective study in the Nurses' Health Study II. Participants reported their weight at age 18 years, and current weight and height in 1989; weight was updated on subsequent biennial questionnaires. From 2001-2003, incident cases with at least monthly incontinence were identified among 30,982 women aged 37 to 54 years who reported no incontinence in 2001. Information on incontinence type was collected from incident cases with at least weekly incontinence. Multivariable-adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between BMI in 2001, weight change from age 18 years to 2001, and incident incontinence were estimated using multivariable logistic regression models.

RESULTS

Increasingly higher BMI was related to increasing odds of developing incontinence (P for trend<.001). Comparing women with BMI greater than or equal to 35 kg/m(2) with lean women (BMI 21-22.9 kg/m(2)), the OR for at least monthly incontinence was 2.11 (95% CI 1.84-2.42). These increases were similar for all incontinence types. The odds of incontinence also increased with increasing adult weight gain (P for trend<.001); compared with women who maintained their weight within 2 kg, the OR for at least weekly incontinence was 1.44 (95% CI 1.05-1.97) among women who gained 5.1 to 10 kg and 4.04 (95% CI 2.93-5.56) among women who had gained more than 30 kg since early adulthood. We found no effect modification by initial weight in analyses of weight gain from age 18 years to 2001.

CONCLUSION

Adiposity and weight gain seem to be strong independent risk factors for incontinence development in middle-aged women.

LEVEL OF EVIDENCE

II.