The prevalence and severity of urinary incontinence in women

Association of eating behavior with symptoms of pelvic floor disorders in middle-aged women: An observational study

BACKGROUND

Estrogen deficiency during menopause, aging, reproductive history, and factors increasing intra-abdominal pressure may lead to structural and functional failure in the pelvic floor. Lifestyle choices, such as eating behavior, may contribute to pelvic floor disorders.

OBJECTIVES

The objective of the study was to investigate associations of eating behavior with symptoms of pelvic floor disorders, that is, stress urinary incontinence, urgency urinary incontinence, fecal incontinence, and constipation or defecation difficulties among middle-aged women.

DESIGN

A cross-sectional, observational study was performed using a population sample of 1098 Finnish women aged 47-55 years.

METHODS

Eating behavior, food consumption frequency, demographical, gynecological, and physical activity variables were assessed using self-report questionnaires. Logistic regression models were used to assess the associations of eating behavior, food frequency, and symptoms of pelvic floor disorders. Models were adjusted with demographical, gynecological, and physical activity variables.

RESULTS

In adjusted models, middle-aged women with disordered eating style were more likely to experience the symptoms of stress urinary incontinence (odds ratio (OR) 1.5, p = 0.002), and constipation or defecation difficulties (OR 1.4, p = 0.041). Adding body mass index into the models abolished associations. Of the studied food items, more frequent consumption of ready-made, highly processed foods (OR 1.5, p = 0.001), and fast foods (OR 1.5, p = 0.005) were independently associated with symptoms of stress urinary incontinence regardless of eating style, whereas consuming ready-made foods (OR 1.4, p = 0.048) was associated with symptoms of urgency urinary incontinence. Daily consumption of fruits (OR 0.8, p = 0.034) was independently associated with symptoms of stress urinary incontinence. Furthermore, we observed that daily consumption of porridge was associated with symptoms of constipation or defecation difficulties (OR 1.7, p = 0.010) independently of eating style. Alcohol consumption (OR 0.9, p = 0.015) was inversely associated with constipation and defecation difficulties. Women with overall higher quality diet had lower odds for stress urinary incontinence (OR 0.9, p = 0.002).

CONCLUSION

This study provides proof-of-concept evidence to the hypothesis that eating behavior and consuming certain food items are associated with perceived pelvic floor disorders. As a preventive action, eating behavior of women with the risk of these symptoms should be assessed, and guidance toward healthy eating patterns should be provided.

Early adulthood and current physical activity and their association with symptoms of pelvic floor disorders in middle-aged women: An observational study with retrospective physical activity assessment

OBJECTIVE

To investigate associations of early and middle adulthood physical activity (PA) with symptoms of pelvic floor disorders (PFDs), i.e. stress urinary incontinence (SUI), urge urinary incontinence (UUI), faecal incontinence (FI), constipation or defecation difficulties (CDDs) and feeling of pelvic organ prolapse (POP) among middle-aged women.

DESIGN

A cross-sectional, observational study with retrospective PA assessment.

SETTING

University Research Laboratory.

SAMPLE

A random population sample of 1098 Finnish women aged 47-55 years.

METHODS

Early adulthood PA, current PA, and demographic and gynaecological variables were assessed using self-report questionnaires. Logistic regression analyses were applied to study associations of PA variables with symptoms of PFDs. Potential confounding effects of demographic and gynaecological variables were controlled in multiple logistic regression models.

MAIN OUTCOME MEASURES

Structured questionnaire-assessed retrospective PA assessment at the age of 17-29 years, current PA at middle age, and prevalence of symptoms of CDD, FI, POP, SUI and UUI.

RESULTS

Current PA was not independently associated with the occurrence of the symptoms of PFDs. Middle-aged women with an early adulthood history of competitive sports were more likely to experience symptoms of UUI (OR 2.16, 95% CI 1.10-4.24, p = 0.025) but not symptoms of SUI, FI, CDD or POP, whereas women with a history of regular PA were more likely to experience symptoms of FI (OR 4.41, 95% CI 1.05-18.49, p = 0.043) but no other symptoms of PFDs.

CONCLUSIONS

Competitive sports during early adulthood may increase the risk of UUI in middle age. Regular PA during early adulthood may increase the risk of FI.

Efficacy of Behavioral Interventions for Urinary Incontinence Among Women Residing in Nursing Homes: A Systematic Review

PURPOSE

The purpose of this systematic review was to summarize recent evidence on the efficacy of behavioral interventions for the management of urinary incontinence (UI) among women in nursing homes.

METHODS

Systematic review of the literature. For this review, behavioral interventions were defined as those that included some form of physical exercise or behavior modification such as scheduled toileting.

SEARCH STRATEGY

A search of MEDLINE/PubMed, CINAHL, Scopus, and Cochrane Library electronic databases was conducted seeking randomized controlled trials published since 2010 in female participants residing in long-term care facilities (nursing homes, skilled nursing facilities) and diagnosed with UI. Inclusion criteria were studies that addressed the effects of voiding regimens, lower extremity strengthening, functional training, food and fluid management, and pelvic floor muscle training. Independent reviewers extracted relevant data and assessed methodological quality using the PEDro scale.

FINDINGS

Five studies (pooled sample, N = 399) met inclusion criteria; mean age of participants was 81.1 ± 6.8 years; 85% were female. The PEDro scores ranged from 6 to 9; only 2 studies included residents with cognitive impairment. Interventions included voiding strategies, increasing physical activity, functional mobility training, pelvic floor muscle training, fluid management, and multicomponent combinations of approaches. Three of the 5 studies were multicomponent interventions and 2 focused on a single intervention. Outcomes included objective measures of incontinent episodes and subjective assessments of UI severity.

CONCLUSIONS

Behaviorally based interventions can be successful in improving UI among nursing residents with and with no cognitive impairment.

IMPLICATIONS

Future studies should examine logistic and labor costs associated with sustaining behavioral interventions using nursing home staff and investigate the effects of these therapies using appropriate quality-of-life metrics for this population.

Prevalence and risk factors of urinary incontinence among Iranian women

BACKGROUND

Urinary incontinence is a common condition among women. Although it is not a life-threatening condition, it dramatically influences the quality of life. This study aimed to estimate the prevalence of urinary incontinence and its risk factors among Iranian women in Kerman, Iran.

METHODS

This cross-sectional, population-based study was conducted on 3100 Iranian women aged 15-80 years in 2017 in Kerman, Iran. The participants were selected via cluster sampling and were invited to complete the questionnaires. Their demographic information and medical history were assessed, the urinary incontinence questionnaire was completed, and the associated risk factors were also recorded. Quantitative variables are reported as mean ± SD, while qualitative and ranked variables are expressed in percentage. All analyses were conducted in Stata version 12 (Stata Corp.).

RESULTS

The mean age of the participants was 46 years, and the overall prevalence of urinary incontinence was estimated to be 63%. The highest and lowest prevalence rates of urinary incontinence were reported in the elderly and the youth, respectively (79% and 41%, respectively). Age, increase of body mass index (BMI), pregnancy, diabetes, anxiety, and depression were the associated risk factors.

CONCLUSION

We found that the prevalence of urinary incontinence is high in Iran. Therefore, to control this condition and improve women's quality of life, effective plans are needed.

Use of bioactive extracellular matrix fragments as a urethral bulking agent to treat stress urinary incontinence

Injection of urethral bulking agents is a low-risk, minimally invasive surgical procedure to treat stress urinary incontinence (SUI). In this study, we developed a promising injectable bulking agent comprising extracellular matrix fragments of adipose-derived stem cell sheets (ADSC ECM) and investigated its effectiveness in urethral bulking therapy. The structural integrity and proteins of ADSC sheet ECM were well retained in decellularized ADSC ECM fragments. To locate transplanted ADSC ECM fragments, they were labeled with ultrasmall super-paramagnetic iron oxide nanoparticles, which enabled in vivo monitoring after implantation in a SUI rat model for up to 4 weeks. When ADSC ECM fragments were injected into the rat urethra, they became fully integrated with the surrounding tissue within 1 week. Four weeks after transplantation, host cells had regenerated within the ADSC ECM fragment injection area. Moreover, new smooth muscle tissue had formed around the ADSC ECM fragments, as confirmed by positive staining of myosin. These results indicate that injection of ECM fragments may be a promising minimally invasive approach for treating SUI.

Three-year follow-up in patients with urinary stress incontinence treated with Altis® single-incision sling

BACKGROUND

The purpose of the study is to report three years follow-up of single incision slings for the treatment of stress urinary incontinence (SUI). The main outcomes are to evaluate the efficacy of the device and to assess safety, adverse events, quality of life, demographic features of treated women and prognostic factors for SUI.

METHODS

We performed a retrospective, double-center, single-arm study. Data were collected by medical records and a telephone interview 3 years after the implant of the mini-sling. Complication rate, subjective efficacy and degree of satisfaction were investigated.

RESULTS

Fifty-four patients were treated between March 2015 and March 2017, of which 47 answered the survey. Forty-one of 47 procedures (87.2%) were considered effective. Among more relevant complications, there was one case of extrusion of mesh and three cases of new onset of urinary disfunction, of which two cases of urgency urinary incontinence (UUI) and one case of de-novo SUI. Most complications were solved within few days after the procedure. Concerning the subjective impression of improvement, investigated by using the Patient Global Impression of Improvement (PGI-I) questionnaires, 41 patients reported subjective satisfaction, three reported no change in quality of life and three patients had worsening of symptoms.

CONCLUSIONS

The procedure was safe and effective for the treatment of SUI but more data are needed to confirm our preliminary results.

The effects of testosterone administration on muscle areas of the trunk and pelvic floor in hysterectomized women with low testosterone levels: proof-of-concept study

OBJECTIVE

The aim of this study was to determine the effect of testosterone administration on trunk and pelvic floor muscle area in women with low testosterone levels.

METHODS

Participants were hysterectomized women with total testosterone<31 ng/dL and/or free testosterone<3.5 pg/mL; participating in the Testosterone Dose Response in Surgically Menopausal Women (TDSM) trial. All participants received a standardized transdermal estradiol regimen during the 12-week run-in period, and were then randomized to receive weekly intramuscular injections of placebo, or 3, 6.25, 12.5, or 25 mg testosterone enanthate for 24 weeks. Muscle areas of the trunk and pelvis were measured at baseline and end of treatment using 1.5 Tesla magnetic resonance imaging. Total and free testosterone levels were measured by liquid chromatography-tandem mass spectrometry and equilibrium dialysis, respectively. Testosterone effect on muscle areas was analyzed using linear regression models.

RESULTS

A total of 24 women who had available baseline and posttreatment magnetic resonance imaging were included in the analysis. Increased cross-sectional areas of the paraspinal, psoas, and abdominal wall muscles were seen after testosterone administration. The estimated mean change (95% CI; P value) between treatment groups was 4.07 cm (1.26-6.88; P = 0.007) for paraspinal, 1.60 cm (0.10-3.09; P = 0.038) for psoas major, and 7.49 cm (1.96-13.02; P = 0.011) for abdominal wall muscles. Increases in psoas muscle area were significantly associated with changes in free testosterone concentrations. No significant changes in obturator internus and pelvic floor muscle areas were observed.

CONCLUSION

Short-term testosterone administration in women with low testosterone levels was associated with increased trunk muscle area.

Uroflowmetric changes, success rate and complications following Tension-free Vaginal Tape Obturator (TVT-O) operation in obese females

OBJECTIVE

The goal of this study was to evaluate the outcome of Tension-free Vaginal Tape Obturator (TVT-O) operation in the treatment of urodynamic stress incontinence (USI) in obese females, with respect to uroflowmetric changes, success rate and postoperative complications.

METHODS

This prospective observational study included 26 patients with USI at the Obstetrics & Gynecology department-Cairo University hospital during the year 2015. The participants had body mass index (BMI)≥30. Patients underwent TVT-O operation. Follow up of the patients was performed by cough test and uroflowmetry after one week, one month, three months and six months. Postoperative complications such as groin pain, sense of incomplete emptying, need to strain to complete micturition and urinary tract infection were recorded. Comparisons between groups were done using Chi square, Phi-Cramer test for categorical variables.

RESULTS

The mean age for the subjects was 43.58±9.01years. The mean BMI was 33.4±2.1. The success rate of TVT-O operation was 21 out of 26 patients (≈81%). Normal maximum flow rate was in 88% of patients at week one and was normal in 100% of patients at months three and six (p=0.101 & 0.101). Postoperative groin pain was the main complaint during the first week after operation and decreased significantly from week one to the 1st month postoperative (84.62% & 65.38%, P=0.041).

CONCLUSION

TVT-O operation showed a high success rate in treatment of USI in obese patients without affecting the voiding function of the bladder as proven by the uroflowmetry. The main postoperative complaint was the groin pain which significantly improved after one month.

Relationship Between Back Pain and Urinary Incontinence in the Canadian Population

BACKGROUND

Back problems and urinary incontinence (UI) have been found to co-occur more frequently than would be predicted by chance.

OBJECTIVE

The aim of this study was to estimate the associations between UI and back problems in the Canadian men and women.

DESIGN

This was an observational, cross-sectional study.

METHODS

The 2011-2012 Statistics Canada Canadian Community Health Survey (CCHS) provided the data. The CCHS surveyed 125,645 adults, providing a representative sample of the Canadian population. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to quantify the strength of the associations among the variables.

RESULTS

Having UI increased the risk of also having back problems in both men (OR = 2.45; 95% CI = 2.06-2.91) and women (OR = 2.97; 95% CI = 2.64-3.35) compared with not experiencing UI. Among those participants with UI, men and women were at equal risk of experiencing back problems.

LIMITATIONS

The CCHS data are cross-sectional and self-reported, which prevents determining causality and carries a risk of response bias. Also, various diagnoses were grouped under the back problems and UI categories, which makes it difficult to propose possible explanations for this pattern of comorbidity.

CONCLUSIONS

This study provides firm evidence to support clinically observed associations between UI and back problems. The strength of the associations was essentially equal in men and women. These findings reinforce the importance of screening for these frequently coincident conditions.

Vasomotor symptoms and urogenital atrophy in older women: a systematic review

OBJECTIVE

Our aim was to systematically review published articles for the prevalence of persistent estrogen depletion symptoms among women aged 65+ years.

METHODS

A systematic literature search of English-language publications was performed using MEDLINE, EMBASE, CINAHL, and PsycINFO. Twenty-three studies that included information on the prevalence of vasomotor and/or urogenital atrophy symptoms among older women (65 + years) met our inclusion criteria. Risk of bias of the included studies was assessed using a risk-of-bias tool explicitly designed for the systematic review of prevalence studies.

RESULTS

The available data suggest that vasomotor symptoms are experienced by a considerable proportion of older women, that symptoms of urogenital atrophy including urinary incontinence are widespread, and that women remain sexually active well into later life. A high degree of variability was observed for the prevalence of estrogen deficiency symptoms for women age 65+ years. Discrepancies in modes of recruitment, sampling procedures, time frames over which symptoms were assessed and use of different and non-validated assessment tools contributed to the inconsistencies across the published studies.

CONCLUSION

Larger and appropriately sampled studies, employing validated questionnaires, are still needed to establish the prevalence of persistent estrogen depletion symptoms in women aged 65+ years.

Prevalence and risk factors of urinary incontinence in Indian women: A hospital-based survey

Background and Objectives:

Urinary incontinence is a problem that creates both physical and psychological nuisance to a woman. This problem needs to be studied in detail in Indian population because of lack of precise data. The objectives of this study were to study the prevalence and risk factors of urinary incontinence in Indian women.

Materials and Methods:

This hospital-based cross-sectional study conducted from August 2005 to June 2007 included women attending gynecology OPD (consulters) and hospital employees (nonconsulters). Subjects who were incontinent were asked a standard set of questions. Incontinence was classified as urge, stress, or mixed based on symptoms. A univariate followed by multivariate analysis was done to look for risk factors.

Results:

Of 3000 women enrolled, 21.8% (656/3000) women were incontinent. There was no significant difference in incontinence rate between consulters and nonconsulters [618/2804 (22.1%) vs. 38/196 (19.4%); P value = 0.6). Of the total women having incontinence, highest numbers were found to have stress incontinence [73.8% (484/656)] followed by mixed [16.8% (110/656)] and urge incontinence [9.5% (62/656)]. Age more than 40 years; multiparity; postmenopausal status; body mass index more than 25; history of diabetes and asthma; and habit of taking tea, tobacco, pan, and betel are risk factors found to be associated with increased prevalence of urinary incontinence in univariate analysis. On multivariate analysis, age more than 40 years, multiparity, vaginal delivery, hysterectomy, menopause, tea and tobacco intake, and asthma were found to be significantly associated with overall incontinence. Stress incontinence was separately not associated with menopause. Urge incontinence was not associated with vaginal delivery.

Conclusion:

Urinary incontinence is a bothersome problem for women. Simple questionnaire can help to detect this problem and diagnose associated risk factors, so that necessary steps can be taken in its prevention and treatment.

Predictors of variability in urinary incontinence and overactive bladder symptoms

AIMS

We used data from the General Longitudinal Overactive Bladder Evaluation (GLOBE) to understand predictors of variation in urgency and urinary incontinence (UI) symptoms over time.

METHODS

A random sample of Geisinger Clinic primary care patients (men and women) 40+ years of age were recruited for a survey of bladder control symptoms at baseline and 12 months later. Symptom questions used a 4-week recall period. Composite scores were derived for urgency and UI frequency. Logistic regression was used to evaluate predictors of variation in scores at cross-section and longitudinally.

RESULTS

A majority of those with UI symptoms and almost 40% of those with urgency symptoms reported episodes of once a week or less often; 17% had symptoms a few times a week or more often. Twenty-one percent with urgency symptoms and 25% with UI symptoms at baseline did not have active symptoms 12 months later. The strongest predictors of active symptoms at follow-up were baseline symptom score and duration of time since first onset of symptoms. Of those with no urgency symptoms at baseline, 22% had urgency at 12 months. Among those with no UI symptoms at baseline, 13% had UI symptoms 12 months later. Among the latter, age (males only) and BMI were the strongest predictors of symptoms at follow-up.

CONCLUSIONS

Inter-individual and intra-individual occurrences of urgency and UI symptoms are highly variable in the general population. Use of established predictors to select individuals with less variability in symptoms may help to reduce placebo rates in clinical trials.

Inpatient bladder retraining: is it beneficial on its own?

INTRODUCTION AND HYPOTHESIS

Urinary incontinence is a common problem with serious effect on the quality of life. Bladder training aims to increase the interval between voids, either by a mandatory or self-adjustable schedule, so that incontinence is avoided. This study aimed to assess the effectiveness of inpatient bladder retraining.

METHODS

A retrospective case-note analysis was conducted over a period of 24 months. Outcome measures were decrease in incontinence episode frequency (IEF) and nocturia and increase in interval between voids. Subjective improvement was assessed on a four-point scale.

RESULTS

The study revealed statistically significant decrease in IEF and nocturia and increase in the interval between voids. Twenty-three percent was cured of their symptoms, 36% reported improvement, 27% did not find any change, whereas 14% reported that they were worse off their after bladder retraining.

CONCLUSION

The study confirms the usefulness of inpatient bladder retraining as a treatment option, especially in people refractory to outpatient management.

Association of change in estradiol to lower urinary tract symptoms during the menopausal transition

OBJECTIVE

To estimate the relationship between changes in estradiol (E2) levels over time and lower urinary tract symptoms in premenopausal women as they transition to menopause.

METHODS

A self-administered validated questionnaire to measure lower urinary tract symptoms was administered to 300 women at the 11th assessment period on an ongoing longitudinal Penn Ovarian Aging cohort study. The association between the change in E2 over time through the menopausal transition and lower urinary tract symptoms (urinary incontinence, filling symptoms, voiding dysfunction) was determined. Risk factors associated with lower urinary tract symptoms were determined by univariable analysis and multivariable linear regression.

RESULTS

Estradiol levels and menopausal stage at one point in time were not associated with lower urinary tract symptoms. Women with a sharp decline in E2 levels over time had significantly lower urinary incontinence scores in comparison with women without a change in E2 levels through the study period (mean+/-standard deviation 3.11+/-2.86 compared with 2.08+/-2.43, adjusted mean difference -0.93, 95% confidence interval [CI] -1.8 to -0.02). Women between the ages of 45 years to 49 years had significantly higher urinary incontinence scores than women woman age older than 55 years (1.59+/-1.86 compared with 3.04+/-2.93, adjusted mean difference 1.0, 95% CI 0.01-2.1). Women with a body mass index greater than 35 also had significantly higher urinary incontinence scores than women in the normal weight range, (3.53+/-3.16 compared with 1.98+/-2.52, adjusted mean difference 1.5, 95% CI 0.59-2.3) after adjusting for changes of E2 through the menopausal transition. High anxiety was associated with worsening scores in all three lower urinary tract symptoms domains (incontinence, filling, voiding).

CONCLUSION

Women with a sharp decline in E2 through the menopausal transition have significantly lower urinary incontinence scores. Urinary filling symptoms and voiding dysfunction were not associated with changes in E2 through the menopausal transition.

LEVEL OF EVIDENCE

II.

Urinary incontinence prevalence: results from the National Health and Nutrition Examination Survey

PURPOSE

We determined racial differences in urinary incontinence prevalence using the 2001-2004 National Health and Nutrition Examination Survey.

MATERIALS AND METHODS

The National Health and Nutrition Examination Survey is a continuous survey of a representative sample of the noninstitutionalized United States population. Demographic, self-reported racial/ethnic data and responses to the urinary portion of the survey were available for 4,229 women older than 20 years. We classified women by urinary incontinence subtype, that is pure stress incontinence, pure urge incontinence or mixed incontinence. Logistic regression models were fitted to investigate racial differences by type of urinary incontinence.

RESULTS

The sample was racially and ethnically diverse with 58% white nonHispanic, 22% Mexican-American and 20% black nonHispanic. Women were divided into 3 age ranges of 20 to 39 years old (36.3%), 40 to 59 (28%), and 60 years old or older (35.7%). Of the 4,229 women in the analytical sample 49.6% (2,098) reported urinary incontinence symptoms. Of those reporting incontinence symptoms 49.8% reported pure stress incontinence, 34.3% mixed incontinence and 15.9% pure urge incontinence. The odds of pure stress incontinence in white and Mexican-American women were approximately 2.5 times higher than in black women (OR 2.79, CI 2.1-3.8 and OR 2.5, CI 1.9-3.4) after adjusting for age, parity, body mass index and activity level. In contrast, black and Mexican-American women were more likely to report pure urge incontinence compared to white women (OR 0.6, CI 0.43-0.8). The prevalence of mixed incontinence was not significantly different among race/ethnicity groups.

CONCLUSIONS

Race/ethnicity differences exist in self-reported urinary incontinence. While self-reported urinary incontinence is prevalent in United States community dwelling women regardless of racial background, the odds of pure stress incontinence are at least 2.5-fold higher in white and Mexican-American women than in black women.

Premenopausal women with sexual dysfunction: the need for a bladder function history

INTRODUCTION

Despite the high prevalence of both female sexual problems and bladder dysfunction in the premenopausal population, sexual history forms used in primary care offices rarely include questions about the impact of bladder dysfunction on sexual health.

AIM

To provide a review of the literature that illustrates the relationship between bladder problems and sexual performance of premenopausal women.

MAIN OUTCOME MEASURES

To objectively support by a review of the literature the need for a complete bladder history in when evaluating premenopausal women with female sexual dysfunction.

METHODS

Pubmed was searched for all articles (from November 1980 to June 2007) that reported on the effect bladder dysfunction has on premenopausal female sexual function.

RESULTS

The scant literature available strongly suggested that bladder dysfunction is a contributor to sexual dysfunction and that this medical concern should be considered in all women, regardless of age who present with sexual complaints.

CONCLUSION

Further studies need to be conducted in order to solidify a direct causal relationship between bladder dysfunction and premenopausal female sexuality. These studies should include a larger sample size, clearly defined types of sexual dysfunction and bladder dysfunction, and appropriate follow-up of patient responses using validated objective and subjective outcome modalities to confirm that the patient responses are factual.

Relationship between the type of urinary incontinence and falls among frail elderly women in Japan

Urinary incontinence and falls are serious problem among elderly people, because of restriction of the Activities of Daily Living (ADL) and Quality of Life. Previous studies have examined the association between urinary incontinence and falls. However, results have been inconsistent. In Japan, with the rapid aging of the society, the number of elderly women who have urinary incontinence and are at risk of falling is increasing. We investigated the relationship between type of urinary incontinence and risk of falls among elderly users of day-care services in a long-term care system. Our study population comprised 118 ambulatory women. At baseline, we evaluated incontinent status, lower extremity muscle strength, balance ability, ADL, and Instrumental ADL. We asked subjects about number of falls every 4 months during a year. In univariate analysis, lower extremity muscle strength (p = 0.001) and mixed incontinence (p = 0.050) differed significantly according to the fall status. Stress and urge incontinence were not significantly associated with falls. In logistic regression analysis, subjects who had mixed incontinence were 3.05 (95% confidence interval 1.01-10.2) times more likely to fall than those without. These results suggest that mixed incontinence have independent associations with falls. Incontinent status should be considered to prevent falls among elderly persons who are partially dependent and need support.

Stress Urinary Incontinence in Women: Review and Update on Neurological Control

BACKGROUND

Female stress urinary incontinence (SUI) is a common disease that involves leakage of urine during coughing, sneezing, or other increases in intraabdominal pressure. Treatments for SUI include pelvic floor muscle training, electrical stimulation, surgery, and off-label alpha-adrenergic agonists that stimulate contraction of the urethral smooth muscle. None of these treatments is universally or completely effective, and because drug therapy with the alpha- adrenergic agonists phenylpropanolamine and ephedrine can cause serious pressor adverse effects, the former has been banned in the United States, and the latter is under scrutiny. The central nervous system (CNS) affects reflexes that control urine storage and micturition, and norepinephrine and serotonin play a key role in maintaining storage capability by means of contraction of the external striated muscle of the urethral sphincter. Duloxetine hydrochloride, which inhibits reuptake of both of these neurotransmitters, has been shown to promote striated urethral sphincter contraction in animal models and to reduce the incidence of involuntary urine release in women with SUI without interfering with micturition.

CONCLUSION

Neuromodulation of noradrenergic and serotonergic neurotransmitters with such drugs as duloxetine provides an additional treatment option for women with SUI.

Abdominal obesity is associated with stress urinary incontinence in Korean women

This study investigated the relationship between abdominal obesity and stress urinary incontinence in Korean women. Women aged 30 and over, who visited the Department of Family Medicine of Asan Medical Center were recruited to participate in this study. Anthropometric measurements including body mass index (BMI) and waist circumference were taken, and associated factors of stress urinary incontinence was assessed by questionnaire. Stress urinary incontinence was significantly associated with physical work, vaginal delivery, and high waist circumference. In comparison with women in the lowest quartile of waist circumference, the odds ratios (OR) for stress urinary incontinence in women in the second, third, and fourth quartiles were increased significantly (1.79, 95% CI 1.07-2.98; 3.50, 95% CI 2.02-6.07; and 6.07, 95% CI 3.23-11.40, respectively). Our results indicate that high waist circumference may be a risk factor associated with stress urinary incontinence in women.

Epidemiology of prolapse and incontinence questionnaire: validation of a new epidemiologic survey

The epidemiology of prolapse and incontinence questionnaire (EPIQ) was developed to screen for female pelvic floor disorders (PFD). Content and face validity, reliability, internal consistency and criterion validity of the EPIQ to detect the presence of pelvic organ prolapse (POP), stress urinary incontinence (SUI), overactive bladder (OAB) and anal incontinence (AI) is presented. Cronbach's alpha; Spearman's, kappa, intraclass correlations, factor analysis and Chi-Squared tests were used for analysis. Questions related to PFD proved internally consistent (alpha = 0.91) and reproducible (correlations >0.70) for all but three items on the EPIQ. Positive and negative predictive values of the EPIQ to detect PFD were: POP = 76% and 97%, SUI = 88% and 87%, OAB = 77% and 90% and AI = 61% and 91% respectively. EPIQ is a psychometrically validated screening instrument that may identify women at high risk of having pelvic floor disorders in large undiagnosed populations.

Psychosocial impact of urinary incontinence in the elderly population

The impact of urinary incontinence extends well beyond the evident physical and physiologic sequelae. Incontinence may leave affected persons in social, emotional, and mental disarray. Measuring the psychosocial impact of a disease, however, is difficult,and there is no single best tool to achieve such an assessment. Several incontinence-specific tools have been devised to document the impact of this condition and are described briefly in this review. Outcome measures have, until recently, focused on objective data; however, from the patient's viewpoint, subjective psychosocial measures may be a better reflection of the success ofa treatment intervention. For a variety of reasons, the majority of affected persons do not seek help. If the full benefit of treatment options is to be realized, the health care provider actively should seek a history of incontinence in patients who may be ashamed or embarrassed.

mRNA assessment for procollagen production in women with genuine stress urinary incontinence

The aim of the study was to examine changes in the levels of mRNA for procollagen type I and III in women with or without genuine stress incontinence (GSI). The study was performed in the 2nd Department of Obstetrics and Gynecology of University of Athens. Sixty-eight women participated in the study and they were divided in two groups. We did not find statistically significant difference between the two groups of patients in relation to the amount of mRNA of procollagen type I and III (p>0.05), but the quantity of collagen type I and III was significantly reduced in patients with stress incontinence (p<0.05). The possible cause for the reduction in the amount of collagen in women with GSI could be attributed to either a disturbance in the translation of mRNA to protein (collagen) or increased catabolism of collagen by its collagenase.

Urinary incontinence as a worldwide problem

OBJECTIVES

This paper reviews the literature on the prevalence of urinary incontinence (UI) and demonstrates its impact as a worldwide problem.

METHODS

A MEDLINE search was performed to review population-based studies in English. Studies were grouped according to demographic variables and type of incontinence. Risk factors, help-seeking behavior, and quality of life measures were analyzed.

RESULTS

The median prevalence of female UI was 27.6% (range: 4.8-58.4%) and prevalence of significant incontinence increased with age. The commonest cause of UI was stress (50%), then mixed (32%) and finally urge (14%). Risk factors included parity, obesity, chronic cough, depression, poor health, lower urinary tract symptoms, previous hysterectomy, and stroke. Although quality of life was affected, most patients did not seek help.

CONCLUSION

UI is a prevalent cross-cultural condition. Future studies should rely on universally accepted standardized definitions to produce meaningful evidence-based conclusions, as well as project the costs of this global healthcare problem.

Prevalence and severity of urinary incontinence in elderly Mexican-American women

OBJECTIVES

To measure prevalence and characteristics of urinary incontinence in older Mexican-American women.

DESIGN

Cross-sectional analysis of a longitudinal survey of a representative sample of older Mexican Americans.

SETTING

Five southwestern states in the United States.

PARTICIPANTS

A total of 1589 Mexican-American women, aged 65 and older who were part of the Hispanic Established Population for the Epidemiologic Study of the Elderly.

MEASUREMENTS

Self-reported psychosocial, demographic, and health variables; self-reported history of symptoms of urinary incontinence.

RESULTS

Two hundred thirty-nine (15%) of the 1589 Mexican-American women reported having urinary incontinence. Almost 33% reported urge incontinence symptoms, 10% reported stress incontinence symptoms, and 42% had symptoms suggestive of mixed incontinence. Thirty-five percent of subjects reported incontinence episodes with moderate to large amounts of urine loss, and 15% reported that their urinary symptoms kept them from engaging in social activities. Age and body mass index were risk factors for incontinence (P=.02 and P=.03, respectively).

CONCLUSION

This is the first community-based survey examining rates of urinary incontinence in Mexican-American women. The prevalence of urinary incontinence may be lower in older Mexican-American women than in the general population. They may also have a higher percentage of urge as opposed to stress incontinence symptoms and may suffer from moderate to large volumes of urine loss associated with their incontinence episodes.

Economic and personal impact of fecal and urinary incontinence

Failure to control the elimination of urine or stool causes psychological stress, complicates medical illnesses and management, and has major economic consequences. Patients often describe the impact of both fecal and urinary incontinence in terms of shame and embarrassment and report that it causes them to isolate themselves from friends and family. Incontinence frequently results in an early decision to institutionalize elderly relatives because families have difficulty coping with incontinence at home. Not surprisingly, there is an increase in symptoms of depression and anxiety in patients with incontinence as well as degradation in quality of life that has been documented by standardized assessment instruments. The direct health care costs for urinary incontinence are estimated to be 16.3 billion dollars per year (1995 costs). Separate cost estimates for fecal incontinence are not available. There is an acute need for methodologically sound studies to document the economic and personal impact of incontinence to develop guidelines for the allocation of health care resources and research funding to this major public health problem. This need is especially great for fecal incontinence, for which there is much less health care economic data than for urinary incontinence.

Urinary incontinence across the lifespan

AIMS

The objectives of the current study were (1) to measure type and severity of urinary leakage and (2) to investigate the association between these factors and age-related life events and conditions in three groups of Australian women with a history of urinary leakage.

METHODS

Five hundred participants were randomly selected from women in the young (aged 18-22 in 1996), mid-age (45-50), and older (70-75) cohorts of the Australian Longitudinal Study of Women's Health (ALSWH) who had reported leaking urine in the 1996 baseline survey. Details about leaking urine (frequency, severity, situations) and associated factors (pregnancy, childbirth, body mass index [BMI]) were sought through self-report mailed follow-up surveys in 1999.

RESULTS & CONCLUSIONS

Response rates were 50, 83, and 80% in the young, mid-age, and older women, respectively. Most women confirmed that they had leaked urine in the past month, and the majority of these were cases of "mixed" incontinence. Incontinence severity tended to increase with BMI for women of all ages, and increased severity scores were associated with having urine that burns or stings. Additional independent risk factors for increasing incontinence severity were heavy smoking in young women, past or present use of hormone replacement therapy in older women, and BMI and history of hysterectomy in mid-age women.

Epidemiology and natural history of urinary incontinence in women

Understanding the epidemiology (distribution and determinants) of urinary incontinence (UI), as well as its natural history is a very important issue. In this article, we discuss prevalence, incidence, natural history, and the variations that may be related to race and ethnicity. We focus on epidemiologic population comprising community-dwelling women who are not institutionalized. Our review clearly shows that there is a lack of advanced epidemiologic analyses. Variables that better characterize UI include frequency measure, quantity of urine loss, duration, type, and severity. These factors should be incorporated into basic study design so that more advanced and informative analyses may be conducted.

The role of estrogens in female lower urinary tract dysfunction

The urogenital tract and lower urinary tract are sensitive to the effects of estrogen and progesterone throughout adult life. Epidemiologic studies have implicated estrogen deficiency in the etiology of lower urinary tract symptoms that occur after menopause. Although the role of estrogen replacement therapy in the management of postmenopausal urinary incontinence (UI) remains controversial, its use in the treatment of women with urogenital atrophy is now well established. This review summarizes recent evidence of the urogenital effects of hormone therapy, particularly emphasizing management of postmenopausal UI and recurrent lower urinary tract infections. Estrogen therapy alone has little effect in the management of urodynamic stress UI, although in combination with an alpha-adrenergic agonist, it may improve urinary leakage. Estrogen therapy may be of benefit for the irritative symptoms of urinary urgency, frequency, and urge UI, although this effect may result from reversal of urogenital atrophy rather than a direct action on the lower urinary tract. The role of estrogen replacement therapy in the treatment of women with recurrent lower urinary tract infections remains to be determined, although there is now some evidence that vaginal administration may be efficacious. Low-dose, vaginally administered estrogens have a role in the treatment of urogenital atrophy in postmenopausal women and appear to be as effective as systemic preparations.

Urinary incontinence in familial dysautonomia

The aim of this study was to determine the prevalence of urinary incontinence in women with familial dysautonomia (FD). A telephone survey was conducted on 68 known surviving female FD patients over 13 years of age registered with the Dysautonomia Centers in the USA and Israel. The mean age of the surveyed group was 27.1+/-9.8 years and 99% of the patients were nulliparous. The overall reported prevalence of urinary incontinence was 82% (n=56). Of the patients with incontinence, 59% (n=33) reported stress incontinence, 11% (n=6) reported urge incontinence, and 30% (n=17) reported symptoms of both, or mixed incontinence. In most women urinary loss was both small and infrequent, but 36% of women (n=20) with incontinence experienced a loss sufficient to necessitate the use of protection (panty liners, pads or diapers); in 7% (n=4) such loss occurred daily. Twelve per cent of all women with FD surveyed experienced primary nocturnal enuresis and 26% experienced nocturia. The prevalence of urinary incontinence is high in young female patients with familial dysautonomia. Neurophysiologic testing in this population may provide a better understanding of the role of the autonomic nervous system in urinary incontinence.

Double incontinence in urogynecologic practice: A new insight

OBJECTIVES

This study was undertaken to evaluate the prevalence of anal incontinence in an urogynecologic setting and to investigate the relationship between lower urinary tract dysfunction and anal incontinence.

STUDY DESIGN

The study included 504 women referred to our urogynecologic outpatient clinic who were prospectively investigated and asked specific questions on anal incontinence. Clinical and instrumental data were compared between women with urinary incontinence and with double incontinence, with further analysis for subgroups in the anal incontinent group of women (passive/urge). For continuous variables, the Wilcoxon rank sum test was used, and the Fisher exact test was applied to dicotomic variables. Logistic regression was used for categorical data. A level of P<.005 was considered significant.

RESULTS

Of the investigated women, 20.2% were also anally incontinent. Women with double incontinence showed higher scores for urinary urgency (P=.010), which reached the established level of significance only in the subgroup with urge anal incontinence (P=.003). In this group, a higher prevalence of detrusor overactivity was observed.

CONCLUSION

Anal incontinence is highly prevalent among women with lower urinary tract disorders. The existence of subgroups of patients having different kinds of anal and urinary disorders should be taken into consideration both for research purposes and for new treatment perspectives.

Menstrual phase-dependent gene expression differences in periurethral vaginal tissue from women with stress incontinence

OBJECTIVE

The mechanical stability of the genitourinary tract is dependent on intact collagen fibers that support the bladder neck, urethra, and pelvic organs. We hypothesize that genetic differences in collagen metabolism may contribute to stress urinary incontinence. Because sex hormones have substantial influence on the female lower urinary tract throughout adult life, we investigated the gene expression of vaginal tissue of women with stress incontinence compared with women with no stress incontinence in the proliferative phase of the menstrual cycle.

STUDY DESIGN

Quantitative competitive polymerase chain reaction was used to verify that the gene expressions were similar between periurethral vaginal tissue and pelvic ligamentous tissue. Labeled complementary RNA was obtained from periurethral vaginal tissue in five pairs of age- and menstrual phase-matched, premenopausal women with and without stress urinary incontinence. The vaginal tissues were then hybridized on HuGeneFL arrays that contained probes representing 6800 full-length human genes. The Student t test and Mann-Whitney ranking were used independently to select candidates with probability values <.05. Hierarchical clustering analysis was performed on the selected candidates to assess the ability of these genes to discriminate between normal and affected individuals.

RESULTS

Tissue inhibitor of metalloproteinases-1 and estrogen receptor-alpha messenger RNA expressions were found to be similar between uterosacral ligament and periurethral vaginal tissue in six participants. Of the 90 candidate genes that were identified, 62 genes were up-regulated and 28 were down-regulated in the stress urinary incontinence group. Genes that were involved in extracellular matrix activity in the up-regulated group include transforming growth factor-beta3, laminin, and collagen type VI. Down-regulated genes that may participate in collagen metabolism include laminin-related protein, collagen XVII, serine/threonine protein kinase, type II interleukin-1 receptor, and platelet-derived growth factor-associated protein.

CONCLUSION

In this preliminary study, we identified differential gene expressions that may contribute to extracellular matrix remodeling in pelvic tissue from women with stress urinary incontinence in the proliferative phase versus continent control subjects. The alteration in expression of these candidate genes suggests that they should be targets for further investigation.

A double-blind placebo-controlled trial on the effects of 25 mg estradiol implants on the urge syndrome in postmenopausal women

The aim of this prospective double-blind randomized placebo-controlled trial was to determine the effect of systemic estrogen on the 'urge syndrome' in postmenopausal women. The trial took place in a tertiary referral urogynecology unit. Postmenopausal women with the 'urge syndrome' were randomly allocated to receive a 25 mg 17beta-estradiol implant or placebo implant. Serum estradiol levels and endometrial thickness were measured on entry to the trial and at 1, 3 and 6 months. The following outcome measures were employed: videocystourethrography, frequency volume chart, visual analogue score of symptoms, and King's Health Care Quality of life Questionnaire. Forty women were included. Subjectively there was a significant improvement in urgency in both groups and urge incontinence in the estradiol group, but no significant differences between the groups. Objectively no significant differences were demonstrated between the groups. Nine women in the estradiol group had vaginal bleeding, and 5 had a hysterectomy during or after the study. Despite using numerous outcome measures to examine its effect, 25 mg estradiol implants did not produce a greater improvement in the 'urge syndrome' than placebo and had a high complication rate.

Prevalence of urinary incontinence in young and middle-aged women in an Italian urban area

OBJECTIVE

To investigate by questionnaire the prevalence and characteristics of urinary incontinence (UI) in a female population aged between 18 and 49.

STUDY DESIGN

Of 44,095 females aged 18-49.9 living in our urban area a sample of 10,000 subjects was sent a questionnaire and 3557 replied. The age-based analysis was performed on 2900 of these.

RESULTS

The overall prevalence of UI was 20%. 11% had suffered from nocturnal enuresis before 18 years old, 47% of parous women noted a relationship between the beginning of UI and delivery. Among the incontinent women 83% lost urine with physical exertion, and 44% had urge incontinence, 18% used diapers, 20% had consulted a physician and half of these had been referred for medical, surgical or rehabilitative therapy, 50% reported past or present urinary infections, 8% complained also of faecal incontinence, 22% considered loss of urine embarrassing and humiliating but only 6% revealed frustration and 2% were obliged to stay at home for long periods of time. Of the incontinents 62% defined themselves anxious or nervous and 22% of these ascribed an increase of urinary leakage to anxiety or to nervousness, 9% reported use of antidepressant drugs, 85% had sexual intercourse and only 2% considered UI as an impediment to a satisfying sexual activity.

CONCLUSIONS

UI is a common problem in young women. Urge incontinence seems to be prevalent in <30 aged women while stress incontinence occurs more frequently after this age.

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.

The menopause and HRT. Urogenital effects of hormone therapy

The urogenital tract and lower urinary tract are sensitive to the effects of oestrogen and progesterone throughout adult life. Epidemiological studies have implicated oestrogen deficiency in the aetiology of lower urinary tract symptoms occurring following the menopause. Although to date the role of oestrogen replacement therapy in the management of post-menopausal urinary incontinence remains controversial, its use in the management of women complaining of urogenital atrophy is now well established. This aim of this chapter is to review the recent evidence regarding the urogenital effects of hormone therapy with a particular emphasis on the management of post-menopausal urinary incontinence, recurrent lower urinary tract infections and urogenital atrophy.

Managing urinary incontinence across the lifespan

In the 1996 baseline surveys of the Australian Longitudinal Study of Women's Health (ALSWH), 36.1% of mid-age women (45-50) and 35% of older women (70-75) reported leaking urine. This study aimed to investigate (a) the range of self-management strategies used to deal with urinary incontinence (UI); (b) the reasons why many women who report leaking urine do not seek help for UI; and (c) the types of health professionals consulted and treatment provided, and perceptions of satisfaction with these, among a sample of women in each age group who reported leaking urine "often" at baseline. Five hundred participants were randomly selected from women in each of the mid-age and older cohorts of the ALSWH who had reported leaking urine "often" in a previous survey. Details about UI (frequency, severity, and situations), self-management behaviors and help-seeking for UI, types of health professional consulted, recommended treatment for the problem, and satisfaction with the service provided by health care professionals and the outcomes of recommended treatments were sought through a self-report mailed follow-up survey. Most respondents had leaked urine in the last month (94% and 91% of mid-age and older women, respectively), and 72.2% and 73.1% of mid-aged and older women, respectively, had sought help or advice about their UI. In both age groups, the likelihood of having sought help significantly increased with severity of incontinence. The most common reasons for not seeking help were that the women felt they could manage the problem themselves or they did not consider it to be a problem. Many women in both cohorts had employed avoidance techniques in an attempt to prevent leaking urine, including reducing their liquid consumption, going to the toilet "just in case," and rushing to the toilet the minute they felt the need to.

Urinary incontinence in female adolescents with cystic fibrosis

OBJECTIVES

Urinary incontinence is common in healthy women and occurs with increased frequency in adult women with chronic lung disease, including cystic fibrosis (CF). This study aimed to determine the prevalence, severity, and impact on daily life of urinary incontinence in female adolescents with CF.

METHODS

An interviewer-administered questionnaire was conducted with females who were aged 12 years and older and attend the CF Clinic at the Royal Children's Hospital in Melbourne, Australia.

RESULTS

Fifty-five (96%) of 57 eligible adolescents (age: 12-19 years) participated. Twenty-six (47%) reported ever having been incontinent of urine; 12 (22%) reported daytime incontinence twice a month or more. Median age of onset of incontinence was 13 years (range: 7-16 years). No relationship was seen with age, lung function, body mass index, or menarchal status. Coughing and laughing were the most commonly reported precipitants (affecting 84% and 68%, respectively). Of those with incontinence once a year or more, 42% reported that it sometimes prevented them from doing effective physiotherapy. Social life was affected by incontinence in approximately one third of respondents. Nearly half (42%) of affected adolescents had told no one, and only 2 had discussed the problem with their physician.

CONCLUSIONS

Urinary incontinence is common in female adolescents with CF and is not related to illness severity. Urinary incontinence has a negative impact on the performance of chest physiotherapy. Given the lack of adolescent report and knowledge of treatment availability, inquiry about symptoms of urinary incontinence should be part of the routine assessment of female adolescents with CF.

The risk of lower urinary tract symptoms five years after the first delivery

AIM OF THE STUDY

To estimate the prevalence and 5-year incidence of lower urinary tract symptoms (LUTS) after the first delivery and to evaluate the impact of pregnancy per se and delivery per se on long-lasting symptoms.

MATERIALS AND METHODS

A longitudinal cohort study of 305 primiparae questioned a few days, 3 months, and 5 years after their delivery. The questionnaire used was tested and validated, and the questions were formulated according to the definitions of the International Continence Society (ICS). Maternal, obstetric, and neonatal data concerning every delivery and objective data concerning surgeries during the observation period were obtained from the records. From the sample of 278 women (91%) who responded 5 years after their first delivery, three subpopulations were defined: 1) women without initial LUTS before or during the first pregnancy or during the puerperal period, 2) women with onset of LUTS during the first pregnancy, and 3) women with onset of LUTS during the first puerperium. The risk of LUTS 5 years after the first delivery was examined using bivariate analyses. The obstetric variables in the bivariate tests with a significant association with long-lasting urinary incontinence were entered into a multivariate logistic regression.

RESULTS

The prevalence of stress and urge incontinence 5 years after first delivery was 30% and 15%, respectively, whereas the 5-year incidence was 19% and 11%, respectively. The prevalence of urgency, diurnal frequency, and nocturia 5 years after the first delivery was 18%, 24%, and 2%, respectively, whereas the 5-year incidence was 15%, 20%, and 0.5%, respectively. The prevalence of all LUTS except nocturia increased significantly during the 5 years of observation. The risk of long-lasting stress and urge incontinence was related to the onset and duration of the symptom after the first pregnancy and delivery in a dose-response-like manner. Vacuum extraction at the first delivery was used significantly more often in the group of women with onset of stress incontinence during the first puerperium, whereas an episiotomy at the first delivery was performed significantly more often in the group of women with onset of stress incontinence in the 5 years of observation. The prevalence of urgency and diurnal frequency 5 years after the first delivery was not increased in women with symptom onset during the first pregnancy or puerperium compared with those without such symptoms. The frequency of nocturia 5 years after the first delivery was too low for statistical analysis.

CONCLUSION

The first pregnancy and delivery may result in stress and urge incontinence 5 years later. Women with stress and urge incontinence 3 months after the first delivery have a very high risk of long-lasting symptoms. An episiotomy or a vacuum extraction at the first delivery seems to increase the risk. Subsequent childbearing or surgery seems without significant contribution. Long-lasting urgency, diurnal frequency, or nocturia cannot be predicted from onset during the first pregnancy or puerperium.