Testing and Treating Women after Unsuccessful Conservative Treatments for Overactive Bladder or Mixed Urinary Incontinence: A Model-Based Economic Evaluation Based on the BUS Study

Urogynaecology and Ehlers-Danlos syndrome

Ehlers-Danlos syndrome (EDS) can lead to a presentation to urogynaecology services with multiple symptoms including vaginal prolapse, overactive bladder symptoms, voiding dysfunction, bladder pain syndrome, recurrent urinary tracts infections, stress urinary incontinence, recurring bladder diverticula, vesicoureteral reflux, pelvic floor pain or spasms, and complicated postnatal perineal wounds. This article explores the pathophysiology of these conditions in causing urinary urgency, incontinence, and infections; highlighting the key investigations and management considerations for women with EDS including conservative, pharmacological, and surgical.

Metaepidemiological Inventory of Diagnostic Studies on Urodynamics

BACKGROUND

Urodynamic investigations have a pivotal role in the diagnosis of lower urinary tract symptoms. Despite expert statements and guidelines supporting their usefulness for clinical decision making in various clinical domains, the academic debate remains controversial.

OBJECTIVE

To provide a metaepidemiological inventory of studies assessing the diagnostic properties of urodynamic investigations.

DESIGN, SETTING, AND PARTICIPANTS

Systematic searches without language restrictions were performed in (Pre-)Medline, EMBASE, and the Cochrane Library from inception until August 31, 2018. Checking of reference lists of included studies and reviews complemented searches. Records were compiled and screened for possible inclusion by reading title and abstracts by two teams of two research fellows. Inclusion criteria were as follows: prospective data collection and urodynamic investigations performed either as a diagnostic test or using a therapy monitoring instrument. No a priori selection on clinical domain was done. Double reading was performed on records marked "included." Extraction into a developed and piloted matrix was performed in duplicate and checked by a third research fellow.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Of each included article, study specifics, objective, study design, type of data collection, clinical domain, type and description of test used, and type of outcome were extracted and attributed to a framework.

RESULTS AND LIMITATIONS

Electronic searches retrieved 20 841 records. After screening, 299 abstracts were considered relevant. The main reasons for exclusion were as follows: animal studies, no primary data, editorial/opinion based on published data or reviews, primary objective of the study being not the assessment of urodynamic investigations, and post hoc (opportunistic) correlation studies.

CONCLUSIONS

To our knowledge, this is the first comprehensive collection of studies assessing the clinical usefulness of urodynamic investigations. The collection is the starting point for a series of systematic reviews assessing the diagnostic properties of urodynamic investigations.

PATIENT SUMMARY

The usefulness of urodynamic investigations for clinical decision making is under debate. We established an inventory of diagnostic studies on urodynamics to assess the value of urodynamics in various clinical applications.

The role of conventional urodynamic in diagnosing specific types of urinary incontinence in women

OBJECTIVE

To analyze the association between patient history profile, conventional urodynamic variables, and specific types of urinary incontinence (UI) in order to establish the role of urodynamic in differentiating various types of UI in women.

MATERIAL AND METHODS

This cross-sectional study enrolled 547 women with UI. All patients were divided into three groups according to the UI type based on questionnaires: stress UI (SUI), mixed UI (MixUI), and urgent UI (UUI). Patient history taking, physical examination, and conventional urodynamics were performed. The association between patient profile characteristics, urodynamic data, and type of UI were assessed using one-way analysis of variance and chi-square tests.

RESULTS

Significant correlations were observed between the age, body mass index (BMI), cystocele, menopausal status, and most urodynamic data in at least one UI group (p<0.05). Age differed among all three groups (p<0.001), with SUI group consisting the youngest patients. BMI was higher in the MixUI group (p=0.001). The maximum cystometric capacity differed among all three groups (p<0.001), with the highest in the SUI. The maximum flow rate was higher in the SUI group than that in the UUI group (p<0.001). Residual urine, opening detrusor pressure, and pressure transmission ratio were significantly higher in the UUI group. Detrusor overactivity and menopause were less frequently observed in the SUI group. The least pronounced urodynamic SUI was found in the UUI group. Spearman correlation for cystocele was negative in the SUI and positive in the UUI group.

CONCLUSION

Conventional urodynamics give additional information to correctly diagnose specific types of UI in women.

Invasive urodynamic testing prior to surgical treatment for stress urinary incontinence in women: cost-effectiveness and value of information analyses in the context of a mixed methods feasibility study

BACKGROUND

INVESTIGATE-I (INVasive Evaluation before Surgical Treatment of Incontinence Gives Added Therapeutic Effect?) was a mixed methods study to assess the feasibility of a future randomised controlled trial of invasive urodynamic testing (IUT) prior to surgery for stress urinary incontinence (SUI) in women. Here we report one of the study's five components, with the specific objectives of (i) exploring the cost-effectiveness of IUT compared with clinical assessment plus non-invasive tests (henceforth described as 'IUT' and 'no IUT' respectively) in women with SUI or stress-predominant mixed urinary incontinence (MUI) prior to surgery, and (ii) determining the expected net gain (ENG) from additional research.

METHODS

Study participants were women with SUI or stress-predominant MUI who had failed to respond to conservative treatments recruited from seven UK urogynaecology and female urology units. They were randomised to receive either 'IUT' or 'no IUT' before undergoing further treatment. Data from 218 women were used in the economic analysis. Cost utility, net benefit and value of information (VoI) analyses were performed within a randomised controlled pilot trial. Costs and quality-adjusted life years (QALYs) were estimated over 6 months to determine the incremental cost per QALY of 'IUT' compared to 'no IUT'. Net monetary benefit informed the VoI analysis. The VoI estimated the ENG and optimal sample size for a future definitive trial.

RESULTS

At 6 months, the mean difference in total average cost was £138 (p = 0.071) in favour of 'IUT'; there was no difference in QALYs estimated from the SF-12 (difference 0.004; p = 0.425) and EQ-5D-3L (difference - 0.004; p = 0.725); therefore, the probability of IUT being cost-effective remains uncertain. The estimated ENG was positive for further research to address this uncertainty with an optimal sample size of 404 women.

CONCLUSIONS

This is the largest economic evaluation of IUT. On average, up to 6 months after treatment, 'IUT' may be cost-saving compared to 'no IUT' because of the reduction in surgery following invasive investigation. However, uncertainty remains over the probability of 'IUT' being considered cost-effective, especially in the longer term. The VoI analysis indicated that further research would be of value.

TRIAL REGISTRATION

ISRCTN. ISRCTN71327395. Registered 7 June 2010.

Poznavanje funkcij mišic medeničnega dna in pomena komplementarnih konservativnih pristopov za njihovo krepitev pri ženskah

Uvod: Urinska inkontinenca je pogosto posledica oslabelih mišic medeničnega dna, ki se lahko zdravi konservativno ali medikamentozno. Namen raziskave je bil ugotoviti, kakšno je znanje žensk o  funkcijah mišic medeničnega dna in kako ocenjujejo koristnost komplementarnih konservativnih pristopov za njihovo krepitev.Metode: Uporabljena je bila eksplorativna kvantitativna metoda dela. Vprašalnik je bil sestavljen na podlagi pregledane literature, oblikovan je bil v spletnem orodju 1KA. Priložnostni vzorec so predstavljale ženske, stare med 20 in 64 let (n = 356). Podatki so bili analizirani z deskriptivno statistiko in faktorsko analizo.  Rezultati: Vaj za krepitev mišic medeničnega dna ne izvaja 190 anketirank (52,4 %). Rezultati so pokazali, da pri vadbi za učinkovito krepitev mišic medeničnega dna pripomočke uporablja 12 anketirank (7 %).  Diskusija in zaključek: Faktorska analiza je potrdila uporabnost za raziskavo oblikovanega inštrumenta. Anketirane ženske dobro poznajo funkcije mišic medeničnega dna, povezane z inkontinenco urina, vendar slabo skrbijo za krepitev mišic medeničnega dna. Spolne pripomočke štejejo le za zabavo in za popestritev spolnosti, ni pa jim znana možnost njihove uporabe za krepitev mišic medeničnega dna.