Urodynamic tests for female geriatric urinary incontinence

Role of videourodynamic study in precision diagnosis and treatment for lower urinary tract dysfunction

Lower urinary tract symptoms (LUTS) are complicated and cannot be used alone to diagnose lower urinary tract dysfunctions (LUTDs) and guide treatment. Patients with bladder outlet obstruction (BOO), impaired detrusor contractility, and hypersensitive bladder might present with voiding predominant symptoms, whereas patients with detrusor overactivity (DO), dysfunctional voiding, or BOO might also present with storage symptoms. To clearly identify the pathophysiology of LUTD, a comprehensive urodynamic study (UDS) including pressure flow and image during the storage and emptying phases, naming videourodynamic study (VUDS), is necessary. This study is especially mandatory in the diagnosis of (1) male LUTS refractory to medical treatment for benign prostatic hyperplasia, (2) female voiding dysfunction and urinary retention, (3) diagnosis of overactive bladder syndrome refractory to first-line medication, (4) management of female stress urinary incontinence and postoperative LUTS, (5) diagnosis and management of neurogenic LUTD, (6) pediatric urinary incontinence and enuresis, (7) geriatric urinary incontinence, and (8) recurrent bacterial cystitis. Although VUDS should not be used as a screening test for any LUTS, it should be considered when the initial management cannot relieve LUTS, or when invasive surgical procedure is planning to undertake for patients with refractory LUTS. VUDS should be recommended as the second-line investigation when the initial diagnosis and treatment based on the symptoms alone or noninvasive tests fail to improve LUTS.

Screening for Urinary Incontinence in Women: A Recommendation From the Women's Preventive Services Initiative

DESCRIPTION

Recommendation on screening for urinary incontinence in women by the Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient representatives. The WPSI's recommendations are intended to guide clinical practice and coverage of services for the Health Resources and Services Administration and other stakeholders. The target audience for this recommendation includes all clinicians providing preventive health care for women, particularly in primary care settings. This recommendation applies to women of all ages, as well as adolescents.

METHODS

The WPSI developed this recommendation after evaluating evidence regarding the benefits and harms of screening for urinary incontinence in women. The evaluation included a systematic review of the accuracy of screening instruments and the benefits and harms of treatments. Indirect evidence was used to link screening and health outcomes in the chain of evidence that might support screening in the absence of direct evidence. The WPSI also considered the effect of screening on symptom progression and avoidance of costly and complex treatments, as well as implementation factors.

RECOMMENDATION

The WPSI recommends screening women for urinary incontinence annually. Screening ideally should assess whether women experience urinary incontinence and whether it affects their activities and quality of life. The WPSI recommends referring women for further evaluation and treatment if indicated.

Screening for Urinary Incontinence in Women: A Systematic Review for the Women's Preventive Services Initiative

BACKGROUND

Urinary incontinence is infrequently addressed during routine health care despite its high prevalence and adverse effects on health.

PURPOSE

To evaluate whether screening for urinary incontinence in women not previously diagnosed improves outcomes (symptoms, quality of life, and function) and to evaluate the accuracy of screening methods and potential harms of screening.

DATA SOURCES

English-language searches of Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews (1 January 1996 to 30 March 2018); ClinicalTrials.gov (April 2018); and reference lists of studies and reviews.

STUDY SELECTION

Randomized trials, cohort studies, systematic reviews of studies that enrolled nonpregnant women without previously diagnosed urinary incontinence and compared clinical outcomes and adverse effects between women who were and were not screened, and diagnostic accuracy studies that reported performance measures of screening tests.

DATA EXTRACTION

Dual extraction and quality assessment of individual studies.

DATA SYNTHESIS

No studies evaluated the overall effectiveness or harms of screening. Seventeen studies evaluated the diagnostic accuracy of 18 screening questionnaires against a clinical diagnosis or results of diagnostic tests. Of these, 14 poor-quality studies were based in referral clinics, enrolled only symptomatic women, or had other limitations. One good-quality and 2 fair-quality studies (evaluating 4 methods) enrolled women not recruited on the basis of symptoms. Areas under the receiver-operating characteristic curve for stress, urge, and any type of incontinence in these studies were 0.79, 0.88, and 0.88 for the Michigan Incontinence Symptom Index; 0.85, 0.83, and 0.87 for the Bladder Control Self-Assessment Questionnaire; and 0.68, 0.82, and 0.75 for the Overactive Bladder Awareness Tool. The Incontinence Screening Questionnaire had a sensitivity of 66% and specificity of 80% for any type of incontinence.

LIMITATION

Studies enrolled few participants, often from symptomatic referral populations; used various reference standards; and infrequently reported CIs.

CONCLUSION

Evidence is insufficient on the overall effectiveness and harms of screening for urinary incontinence in women. Limited evidence in general populations suggests fairly high accuracy for some screening methods.

PRIMARY FUNDING SOURCE

Health Resources and Services Administration.

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.

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.

Fluid intake and risk of stress, urgency, and mixed urinary incontinence

OBJECTIVE

We investigated the relation between total fluid intake and incident urinary incontinence in the Nurses' Health Study cohorts.

STUDY DESIGN

We measured daily fluid intake using food frequency questionnaires among 65,167 women, who were 37-79 years old, without urinary incontinence at study baseline (2000-2001). Women reported incontinence incidence on questionnaires during 4 years of follow-up evaluation. Multivariable-adjusted hazard ratios and 95% confidence intervals were calculated with Cox proportional hazards models.

RESULTS

We found no association between total fluid intake and risk of incident incontinence (hazard ratio, 1.04; 95% confidence interval, 0.98-1.10; comparing top vs bottom quintile of fluid intake). In analyses of incontinence type, total fluid intake was not associated with risks of incident stress, urgency, or mixed incontinence.

CONCLUSION

No significant risk of incident urinary incontinence was found with higher fluid intake in women. These findings suggest that women should not restrict their fluid intake to prevent incontinence development.

Incidence and remission of urinary incontinence in middle-aged women

OBJECTIVE

The objective of the study was to describe changes in urinary incontinence in middle-aged women.

STUDY DESIGN

A prospective analysis of 64,650 women aged 36-55 years in the Nurses' Health Study II. Participants reported urine leaking in 2001 and 2003. Two-year incidence and remission proportions were estimated.

RESULTS

The 2-year incidence of incontinence was 13.7%. Incidence generally increased through age 50 years and then declined slightly in older women. Among women with incident incontinence at least weekly, the incidence of stress incontinence increased through age 50 years (2-year incidence 1.7%), and the incidence of urge incontinence was stable across age groups (2-year incidence 0.4%). Also, a minority (38%) mentioned leaking to their physician. Complete remission of symptoms occurred in 13.9% of women with incontinence at baseline.

CONCLUSION

We found that incontinence occurs frequently in middle-aged women. Yet few women mentioned incontinence to their physicians; thus, it may be important to initiate conversations about urinary symptoms even among younger patients.

Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence

AIMS

To evaluate the performance of all tests proposed for the diagnosis of urinary incontinence.

METHODS

A systematic review and meta-analyses of the published literature of methods for diagnostic assessment of urinary incontinence.

RESULTS

One hundred twenty-one papers were included in the full review [Martin et al., 2006]. The quality of reporting in the primary studies was poor which reduced the number of studies that could be included in the data analysis. The literature suggests that women with urodynamic stress incontinence (USI) can be correctly identified in primary care from clinical history alone with a sensitivity of 0.92 (95% C.I.: 0.91-0.93) and specificity of 0.56 (0.53-0.60). A clinical history for the diagnosis of detrusor overactivity (DO) was found to be 0.61 (0.57-0.65) sensitive and 0.87 (0.85-0.89) specific. Within secondary care imaging of leakage by ultrasound was found to be effective in the diagnosis of USI in women with a sensitivity of 0.89 (0.84-0.93) and specificity of 0.82 (0.73-0.89).

CONCLUSIONS

Clinical interpretation of the results of the review is difficult because few studies could be synthesized and conclusions made. The published evidence suggests that a large proportion of women with USI can be correctly identified in primary care from history alone. Ultrasound offers a useful diagnostic tool which could be used prior to, and possibly instead of, multi-channel urodynamics in some circumstances. If a patient is to undergo urodynamic testing, multi-channel urodynamics is likely to give the most accurate result. Further primary studies adhering to STARD guidelines are required on commonly used tests.

FACTORS THAT DISTINGUISH CONTINENT FROM INCONTINENT OLDER ADULTS WITH DETRUSOR OVERACTIVITY

PURPOSE

In older adults detrusor overactivity (DO) is almost as common in continent individuals as in those with urge incontinence (UUI). Thus, UUI likely reflects the contribution of additional factors. We postulated that of functionally independent individuals in whom transient causes were excluded those in whom DO was accompanied by UUI would be more likely to have smaller functional bladder capacity, less warning and less ability to avert urine loss in the face of DO.

MATERIALS AND METHODS

While blinded to continence status, we reviewed the records of all 52 cognitively intact and nonobstructed volunteers older than 65 years who had DO associated with urgency during urodynamic testing and had been asked to try to prevent leakage for 2 minutes. Of these individuals 31 were continent at home.

RESULTS

In patients with UI mean functional bladder capacity +/- SD was smaller (313 +/- 153 vs 390 +/- 178 ml, p = 0.06) and warning was briefer (87 +/- 81 vs 120 +/- 116 ml), although the association with warning was less impressive (p = 0.14). The ability to forestall leakage for at least 2 minutes correlated strongly with being continent at home (p < 0.002). For continence detrusor suppression at the onset of DO was more important than sphincter contraction.

CONCLUSIONS

Urge incontinence in older adults involves more than simply the presence of DO. Physical function, cognitive function and medications are already known to be important for continence. Our data suggest that functional bladder capacity and the ability to suppress involuntary contraction (and possibly warning) are also potentially important covariates. These factors may represent additional potential targets for behavioral and pharmacological therapy.

Preoperative pressure-flow studies: useful variables to predict the outcome of continence surgery

OBJECTIVE

To determine whether the acceleration of flow rate (AFR), pressure flow variables and urethral pressure profilometry (UPP) measurements might have a role in evaluating women with urodynamic stress incontinence (USI), to predict the surgical outcome and de novo detrusor overactivity after Burch colposuspension.

PATIENTS AND METHODS

Women with a urodynamic diagnosis of USI (209) who had a modified Burch colposuspension were assessed retrospectively. The AFR, the opening (ODP) and closing detrusor pressure (CDP), DP at maximum flow rate and UPP values were calculated for each woman before surgery.

RESULTS

The preoperative AFR was significantly higher in women who developed de novo detrusor overactivity after surgery. The women who had persistent USI after colposuspension had significantly lower preoperative ODP and CDP than women who were continent after colposuspension. Other variables were not significantly different between the groups of women.

CONCLUSIONS

The AFR and ODP appear to be useful preoperative measures to predict the outcome of continence surgery and the emergence of de novo detrusor overactivity.

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

OBJECTIVE

The purpose of this study was to assess the effect of detrusor overactivity and bladder filling on urethral function with the use of urethral profilometry.

STUDY DESIGN

Women with symptoms of urinary incontinence were recruited from our urodynamic clinic. All of the women underwent videocystourethrography and urethral pressure profilometry with the bladder empty and then full. The maximum urethral closure pressure, mean urethral pressure, functional urethral length, and pressure transmission ratios for each quartile were analyzed.

RESULTS

Thirty-five women were recruited: 17 women had urodynamic stress incontinence, and 18 women had detrusor overactivity. In women with urodynamic stress incontinence, there was a significant increase in maximum urethral closure pressure and pressure transmission ratios over all quartiles when the bladder was full compared with empty. In women with detrusor overactivity, there was a significant decrease in functional urethral length and pressure transmission ratios in the second and third quartile of the urethral pressure profiles when the bladder was full compared with empty.

CONCLUSION

Decreases in functional urethral length and pressure transmission ratios with bladder filling in those women with detrusor overactivity are at variance with the normal physiologic response to bladder filling, which suggests that urethral function is affected by the presence of abnormal detrusor activity and that the valid assessment of urethral function may not be possible if the detrusor overactivity is not treated.

Voiding dysfunction and urodynamic abnormalities in elderly patients

Lower urinary tract dysfunction is a major cause of morbidity and decreased quality of life in elderly men and women. With the progressive aging of the population, it is important to understand common micturitional disorders that may occur in this population. Most urinary problems in the elderly are multifactorial in origin, demanding a comprehensive assessment of the lower urinary tract organs, functional impairments, and concurrent medical diseases. Urodynamics is a highly valuable tool in the investigation of elderly patients with lower urinary tract symptoms. Urodynamic tests are not always necessary, being indicated after excluding potentially reversible conditions outside the urinary tract that may be causing or contributing to the symptoms. Although urodynamic tests may reveal common diagnoses such as bladder outlet obstruction and stress urinary incontinence in the elderly population, findings such as detrusor overactivity and impaired detrusor contractility are common and have important prognostic and therapeutic implications. The purpose of this article is to describe common urologic problems in the elderly and review the indications for and clinical aspects of urodynamic studies in these conditions.

Urodynamically age-specific prevalence of urinary incontinence in women with urinary symptoms

AIMS

To determine the age-specific prevalence rates of different types of urinary incontinence in women with urinary symptoms using urodynamic studies (UDS).

METHODS

One thousand five hundred women with urinary symptoms who underwent UDS in our department from January 1997 through December 1999 were enrolled. A detailed history, physical examination, and data of multi-channel UDS including uroflowmetry, filling and voiding cystometry, stress urethral pressure profile, and 20-minute pad test were obtained for each patient. The urodynamic findings of each patient were analyzed and correlated with age in decades.

RESULTS

Of 1,500 women, 329 were excluded from analysis because they had undergone anti-incontinence surgery (n=27), had undergone treatment for cervical cancer (n=147), or were being followed-up after medication (n=155). Of the remaining 1,171 patients, 656 (56%) had genuine stress incontinence (GSI), 68 (5.8%) had detrusor instability (DI), 187 (16%) had mixed GSI/DI, 245 (20.9%) had either voiding or storing dysfunction without concomitant incontinence, and 15 (1.3%) had normal urodynamic findings. The 41-50- and 51-60-year age groups had the highest prevalence rates of urinary incontinence, accounting for 31% and 28% of GSI cases, 35% and 25% of DI cases, and 40% and 27% of mixed GSI/DI cases, respectively. The prevalence of GSI and mixed GSI/DI increased consistently with age, but the prevalence of DI decreased after age 66. Thus, the prevalence rates of GSI, DI, and mixed GSI/DI were 56%, 5.8%, and 16%, respectively, in women with urinary symptoms.

CONCLUSIONS

Female urinary incontinence had a biogenic peak prevalence in the 41-50-year and 51-60-year age groups.

Urethral pressure measurement--problems and clinical value

Urethral pressure measurements are in use to assess urethral closure and voiding function. The lack of general agreement on an explicit definition of urethral pressure and standardisation of the methodology for measurement has limited the clinical utility of urethral pressure measurements.

Tension-free vaginal tape evaluated using patient self-reports and urodynamic testing--a two-year follow-up

OBJECTIVE

Urinary incontinence entails both reduced quality of life for many women and considerable public expense. Compared with other methods aimed at alleviating incontinence, tension-free vaginal tape (TVT) is minimally invasive, can be performed under local anaesthesia and results in less morbidity and shorter hospitalization. The present study was carried out to evaluate early and late complications and as a 2-year follow-up after surgery.

MATERIAL AND METHODS

In 1996-98, 75 women underwent TVT sling plasty; mean time for surgery was 39 min and for hospitalization 24 h. The procedure caused bladder perforation in 3 women, but this was detected by cystoscopy and immediately corrected. Postoperative retention occurred in 9 patients but was transient.

RESULTS

After surgery 80% were cured, 9% showed improvement and 11% were failures. Two women exhibited vaginal erosion, and one of these had previously undergone radiation therapy. One sling caused obstruction and had to be cut. Improvements included less impact on social and physical activities and mental status and significant reduction of voiding frequency, leakage episodes and pad use.

CONCLUSIONS

The TVT technique seems to provide results comparable with those obtained with Burch colposuspension, but it entails less risk of obstruction than previous slings techniques because it causes no compression of the urethra. TVT is effective in women with genuine stress incontinence due to urethral hypermobility and in elderly women with sphincter incompetence, although the outcome is better in the former.

Identifying and treating urinary incontinence. The crucial role of the primary care physician

Urinary incontinence is a widespread problem that often goes undiagnosed and untreated. Many patients are unwilling to discuss it with their physician because of embarrassment or the belief that nothing can be done. Consequently, physicians need to routinely inquire about symptoms so incontinent patients can be identified. Physicians should reassure patients that urinary incontinence is usually a symptom of a correctable problem. Careful evaluation and office tests to determine the type and cause of urinary incontinence, together with appropriate treatment, often lead to improvement in symptoms or return to continence.

Diagnostic assessment of geriatric urinary incontinence

Urinary incontinence affects 15% to 30% of the population and 50% of those living in nursing homes. Care for incontinence is difficult because this condition is underreported by patients and underdiagnosed by physicians. This article describes the medical and nursing diagnostic assessment of urinary incontinence of geriatric populations, and the criteria for referral. Comprehensive review of urinary incontinence, including treatment, is available elsewhere. Although this article focuses on the assessment of urinary incontinence, the type of treatment being considered guides the scope of the evaluation, and therefore, treatment of incontinence is discussed.

Urinary incontinence management in the USA: the role of the nurse

Urinary incontinence (UI) is a prevalent medical problem in the USA. Approximately 12 million Americans are incontinent of urine. Hu et al (1994) estimate that the costs of managing the problem are $10 billion annually. In persons aged 65 years and older the incidence of UI is 30% or more it is estimated that more than 60% of people with UI never mention their problem to a doctor of nurse. This is a sad fact considering that UI is a highly treatable, if not curable, problem. In the USA, advanced practice nurses, nurse practitioners and clinical nurse specialists who have advanced educational and master's degrees and clinical practice requirements are making a significant impact on the management of UI. This article outlines the role of advanced practice nurses in the diagnosis and behavioural management of UI.

Misdiagnosis of urinary incontinence in nursing home women: prevalence and a proposed solution

Because of the high prevalence of detrusor hyperactivity with impaired contractility (DHIC) in incontinent institutionalized women, we postulated that: 1) single-channel cystometry, the most commonly used diagnostic test, would be inadequate when used alone but that 2) its accuracy could be greatly enhanced by combining it with a previously-performed stress test. To test the hypothesis, we used blinded comparison of a clinical stress test and single-channel cystometry with multichannel videourodynamic evaluation (criterion standard), a strategy designed a priori. Subjects were 97 incontinent women who were considered representative of incontinent nursing home women nationally. With cystometry alone, 9 of 37 women with DHIC (24%) were misdiagnosed as stress-incontinent vs. 1 of 25 with DH (P = .03). In each case, misdiagnosis was due to failure to recognize low-pressure involuntary bladder contractions. Combining cystometry with the stress test improved diagnostic accuracy markedly. Of the 77% of women in whom the results of both tests were congruent, all were correctly classified. When results of the two tests were discordant, neither was superior. Significantly, no woman with stress incontinence was missed by the two-test strategy, nor was anyone with detrusor hyperactivity misclassified. We conclude that in institutionalized elderly women, DHIC commonly mimics other types of urinary tract dysfunction. Thus, single-channel cystometry alone is an inadequate diagnostic test in this population. However, a strategy that combines cystometry with a clinical stress test can correctly classify the majority of such women and identify those in whom the diagnosis is less secure. Use of this simple strategy would facilitate correct diagnosis and initial treatment of most institutionalized women without referral, and also enrich the referred population with those most likely to benefit. Such an approach could significantly improve the approach to this costly and morbid condition.

Urinary incontinence in the elderly population

OBJECTIVE

To describe the causes, evaluation, and management of urinary incontinence in the elderly population.

DESIGN

We reviewed pertinent articles in the medical literature and summarized the types of incontinence and contributing factors.

RESULTS

Urinary incontinence is common in elderly patients and often has a major role in determining whether a person can remain independent in the community or requires nursing home placement. Urinary incontinence is not a single entity but rather several different conditions, each with specific symptoms, findings on examination, and recommended treatment. Thus, accurate classification is important for appropriate management. Because of the complexity of urinary incontinence, many physicians are uncomfortable with undertaking assessment and treatment. Hence, many patients are not asked about incontinence, and the condition remains untreated and often considered a natural consequence of the aging process. Urinary incontinence can be treated and either cured or alleviated with treatment.

CONCLUSION

Elderly patients should be asked about symptoms of urinary incontinence because appropriate assessment and treatment can usually provide relief.

Urinary incontinence as a risk factor for mortality

OBJECTIVE

To determine whether mortality is independently associated with urinary incontinence.

DESIGN

6-year prospective study that started in 1983/84.

SETTING

A Midwestern County.

PARTICIPANTS

Probability sample of 1956 community-residing persons 60 years of age and older in 1983/84.

MEASUREMENTS

The independent variables of urinary incontinence, its types and severity, were measured by survey self-report, which was validated with clinical exams. The control variables of age, education, and health status were also self-reported. The dependent variable of death was established during follow-up interviews from reports of previously designated contact persons.

RESULTS

Neither incontinence status nor its severity level or types were found to be positively associated with 6-year mortality in logistic regression analyses that adjusted for age, education, and health status.

CONCLUSION

Whereas urinary incontinence can be an embarrassing and socially debilitating condition, it does not itself predict or contribute to mortality.