Effects of Metabolic Syndrome on Chronic Kidney Disease

PURPOSE: Metabolic syndrome (MS) has been identified as a causal risk factor for cardiovascular disease, stroke, and cardiovascular mortality. Recent studies have suggested a possible relation between MS and renal function. The aim of this study was to evaluate the influence of MS on renal function. MATERIALS AND METHODS: We analyzed 12,348 healthy Koreans who underwent a general health checkup. MS was defined as 3 or more of the criteria according to the National Cholesterol Education Program Adult Treatment Panel guidelines III (NCEP ATP III). The glomerular filtration rate (GFR) was estimated by the redefined Modification of Diet in Renal Disease formula. Chronic kidney disease (CKD) was categorized into 3 categories according to the Kidney Disease: Improving Global Outcomes guidelines; I: GFR> or =90 ml/min, II: 60-89 ml/min, III: 30-59 ml/min. RESULTS: The overall proportion with MS was 19.3%. Compared with populations without MS, those with MS showed a significantly decreased GFR. The prevalence of CKD increased with the number of MS components, and it was prominent in the group of males over 40 years of age. In multivariate analyses using age, sex, and individual MS components, age (odds ratio [OR]=20.40; 95% CI: 10.81-38.49), sex (OR=1.98; 95% CI: 1.51-2.60), and obesity (OR=1.48; 95% CI: 1.13-1.93) were strongly associated with CKD. CONCLUSIONS: This study showed that MS is a significant determinant of CKD. Handling of correctable factors such as obesity may be considered one of the preventive modalities against the development of CKD.

Comparison of Patient-centeredness Changes between Medical School Graduates and Medical Students after Psychiatric Clerkship / 한국의학교육

PURPOSE: The aim of this study was to compare patient-centeredness changes between medical school graduates and medical students after a psychiatric clinical clerkship. METHODS: We focused on 40 medical school graduates. We received permission to use data from a 2006 study on patient-centeredness of 94 medical students. The following was repeated before and after clerkship: Minnesota Multiphasic Personality Inventory (MMPI), Meyers-Briggs type indicator (MBTI), Patient-practitioner Orientation Scale (PPOS) and Authoritarian Personality (AP) scale. RESULTS: In the 2006 study on patient-centeredness of medical students, the AP scores were significantly lower than before clerkship and the PPOS scores were significantly higher than before clerkship. AP score changes were related to MBTI, correlated with MMPI subscales, but inversely correlated with PPOS changes. In this study, the change in PPOS scores was not significant after clerkship in case of medical school graduates. AP score changes inversely correlated with PPOS changes, but neither correlated with MMPI subscales or MBTI. CONCLUSION: Considering previous findings, medical school graduates tend to be more patient-centered than medical students, but medical students can adopt a more patient-centered attitude than graduates through a psychiatric clinical clerkship.

An Ileocutaneous Fistula That Developed 12 Years after Repair of an Abdominal Wall Defect Using Intraperitoneal Placement of High-density Polypropylene Mesh (Marlex(R))

Although prosthetic materials are commonly used to repair abdominal wall defects, they are also associated with postoperative complications. These complications could be prevented by the adoption of uniform guidelines on surgical methods and materials, but the best anatomical position for placement of prosthetic meshes is unclear. We report a case of an enterocutaneous fistula that developed after an abdominal wall defect was repaired by intraperitoneal application of a prosthetic mesh (Marlex(R)) to raise awareness of the consequences of improper use of prosthetic materials.

The Relating Factor and Quality of Life of Overactive Bladder in Adults / 가정의학회지

BACKGROUND: Overactive bladder syndrome (OAB) is a common disorder in primary care that affects negatively on the quality of life of outpatients. However, little information is available on related factors and the quality of life in adults with overactive bladder. The purpose of this study was to find related factors of overactive bladder and to measure the quality of life in adults with overactive bladder. METHODS: Among the people who visited a hospital in Seoul and Chung-ju for a health examination or primary care between October 1 and December 31, 2008, we selected 327 participants over 20 years old. We measured their Overactive Bladder Questionnaire (OAB-q), took medical history and reviewed their demographic data. The relationship between OAB, other independent variables and health related quality of life (HRQL) were analyzed. RESULTS: Of 327 respondents, the prevalence of OAB in adults was 38 (11.6%). The factors related to OAB were age (P = 0.007), history of prescription for congestive heart failure (P = 0.023), benign prostatic hyperplasia (BPH) (P = 0.002), and depression (P = 0.008). OAB was significantly associated with BPH medication (P = 0.042; OR = 8.757) and depression medication (P = 0.005; OR = 9.977) in multivariable logistic regression analysis. In each T-test analysis, OAB decreased in HRQL. CONCLUSION: OAB is a common disorder in adults, history of BPH medication and depression medication is more common in OAB. The symptoms that were suggestive of OAB were affected negatively on the quality of life in adults. Effective health care polices and prompt management of OAB should be implemented.

Proteomic Analysis of Penile Protein Alterations in a Rat Model of Cavernous Nerve Injury

PURPOSE: Cavernous nerve resection (CNR) in rats is a standard model of animal experiments on erectile dysfunction (ED) that occurs after radical prostatectomy (RP). Injured cavernous nerves after surgery can cause fibrosis and apoptosis that lead to penile structural changes that may be accompanied by alterations of protein expression. This study aimed to analyze the changes in protein after CNR in Wistar Kyoto rats. MATERIALS AND METHODS: Using 8-week-old male Wistar Kyoto rats, sham and CNR operation under a microscope were performed. Two and 8 weeks after surgery, we applied 2-DE and MALDI-TOF/TOF (AB 4700) to identify differently expressed penile proteins after CNR. 2-DE gels were stained with silver nitrate and were analyzed with PDQuest. After in-gel digestion, peptide mass spectra were obtained by MALDI-TOF/TOF mass spectrometry in the positive ion reflector mode. The obtained data were screened with a rat database from both the NCBI and the Swiss-Prot/TrFMBL home page. RESULTS: The proteins that were changed more than 1.5-fold compared with the sham group were annexin A4 and pyruvate kinase (PK). Annexin A4 was increased by 1.75-fold after 2 weeks, whereas PK was decreased by 4.16 after 8 weeks. These results were confirmed by immunohistochemistry. CONCLUSIONS: Annexin A4 in the CNR group was increased, which may be related to emiocytosis during apoptosis. The decrease in PK of the CNR group is assumed to be related to a decrease in efficacy during glycolysis. Further study will be needed to elucidate the molecular pathophysiology of ED after cavernous nerve injury.

The Correlation of Intravesical Prostatic Protrusion with Storage Symptoms, as Measured by Transrectal Ultrasound / 대한비뇨기과학회지

PURPOSE: Intravesical prostatic protrusion(IPP) is a morphological change that's due to excessive growth of the median and lateral lobes of the prostate into the bladder. Few studies have been performed regarding the correlation between IPP and the voiding/storage symptoms. The aim of this study is to identify the clinical significance of IPP by defining its relationship with the prostate volume(PV), the International Prostate Symptom Score (IPSS), the uroflowmetry results and the medication response. MATERIALS AND METHODS: We performed a retrospective study of 95 male patients who were examined between August 2006 and July 2007. The patients were evaluated with the IPSS/quality of life(QoL) test, uroflowmetry(Urodyn-1000(TM); Medtronic), the post void residual urine(PVR), and IPP and PV by transrectal ultrasound(TRUS)(PROSOUND SSD-3500(TM); ALOKA). The IPP was compared with the total IPSS, the voiding and storage symptom score, uroflowmetry parameters and the flow patterns (normal, obstructive, detrusor impairment, Valsalva). The patients were classified into two groups(the IPP and non-IPP groups) based on the presence of IPP as identified by TRUS. RESULTS: The PV and IPP showed a significant correlation(r=0.627, p<0.001). There was no correlation between IPP and total IPSS(p=0.444); however, the storage symptom score was significantly increased in proportion to IPP(p=0.030). With an IPP increase, the Qmax was decreased (r=??0.319, p<0.001) and the PVR was increased(r=0.388, p=0.002). The IPP group showed a lower decrease of the QoL score after 8 weeks of medication, as compared to the non-IPP group(p=0.034). CONCLUSIONS: The IPP showed significant correlation with the storage symptoms, but not with the total IPSS. Theoretically, IPP is a unique anatomical configuration of the prostate, and it may worsen the prominent storage symptoms that are the result of irritation of the bladder neck and trigone. IPP should be checked carefully during TRUS as IPP could potentially be a useful marker for the assessment and management of lower urinary tract symptoms.

Usefulness of a Sonographic Bladder Scan for Uroflowmetry and the Evaluation of the Anxiety Level Associated with Uroflowmetry / 대한비뇨기과학회지

PURPOSE: Uroflowmetry (UFM) requires at least 125ml to 150ml of urine volume for an adequate interpretation. It is common to repeat UFM in clinical settings because of an insufficient voided volume, which may be induced by increased anxiety. To reduce performing repeated UFMs, we evaluate the usefulness of performing a prevoiding sonographic bladder scan and we determined the anxiety level before performing UFM. MATERIALS AND METHODS: We enrolled one hundred two patients (mean age: 62.6+/-15.0 years) who visited our clinic due to voiding dysfunction. The bladder volume prior to UFM was measured by an automated bladder scan (Biocon-500(TM), Mcube Technology) when the patients felt a strong fullness sensation. All the patients kept a voiding diary for 3 days, and they underwent the State-Trait Anxiety Inventory questionnaire, the fullness scale and UFM. RESULTS: The mean prevoiding volume was 307+/-124ml and the mean voided volume was 271+/-129ml. There was a correlation between the prevoiding scan volume and the voided volume: voided volume=17.502+(0.724xprevoiding volume) (r=0.851, p<0.001). Among the 333 patients without a bladder scan and who had UFM performed, 25.8% showed insufficient voided volumes of less than 125ml, and 32.4% showed voided volumes of less than 150ml. However, among the 102 patients who underwent a bladder scan, 9.8% showed insufficient voided volumes of less than 125ml and 12.7% showed voided volumes of less than 150ml (p<0.001). The patients who had a higher state of anxiety than trait anxiety before their UFM revealed a relatively decreased functional bladder capacity (p=0.013). CONCLUSIONS: Although UFM is simple, the patient may feel embarrassed before test. Anxiety can cause a decreased functional bladder capacity. A prevoiding sonographic bladder scan can reduce the incidence of insufficiently voided UFM.

The Expression and Clinical Implications of Forkhead Trasnscription Factor FKHR (FOXO1) in Human Bladder Cancer / 대한비뇨기과학회지

PURPOSE: Forkhead transcription factor FKHR (FOXO1) is one member of the Forkhead transcription factor family, and it is thought to regulate the glucose metabolism in human and to be related to both cell cycle progression and cell apoptosis. Herein, we investigated the expression level of FOXO1 and its clinical implications in bladder cancer. MATERIALS AND METHODS: From June 1992 to June 2005, 145 specimens were harvested from primary bladder cancer and 102 specimens were harvested from normal-looking tissue surrounding the tumor mass; these specimens were investigated for determining the mRNA expression levels of FOXO1 with using the real-time PCR method. The expression levels of FOXO1 were compared statistically with such clinical variables as stage, grade, recurrence and progression. Survival analysis was performed using the Kaplan-Meier model. RESULTS: The expression levels of FOXO1 in the bladder cancer specimens (28.19pg/ml) were significantly higher than those of the corresponding normal bladder tissues (8.87pg/ml) that surrounded the tumor mass (p<0.001), and the expression levels of FOXO1 were significantly correlated with stage and the progression of superficial disease (p<0.05 each). Also, the expressions of FOXO1 of the patients who remained alive during the study period were higher than those of the nonsurviving patients (p<0.001). A higher expression of FOXO1 in the patients with superficial bladder tumor showed more survival benefit than a lower expression (p=0.004). But the recurrence and differentiation of bladder cancer were not correlated with the expression level of FOXO1. CONCLUSIONS: This data indicate that the expression level of FOXO1 can be recommended as a useful marker to predict disease occurrence as well as the progression and survival of patients with superficial bladder cancer.

Polypharmacy and Central Nervous System Adverse Effects of Anticholinergic Agents in the Men with Benign Prostate Hyperplasia

PURPOSE: Elderly patients commonly receive multiple drugs compared to young patients because of high comorbidity. Some common illnesses in the elderly with underlying diseases are complicated or aggravated by treatment with anticholinergic agents. We evaluated the use of anticholinergic agents and their adverse effects in the men with benign prostate hyperplasia. MATERIALS AND METHODS: One hundred-eighty four patients over 40 years-old who visited hospital for the treatment of benign prostate hyperplasia and prescribed more than one anticholinergic agent from January 2005 to June 2006 were enrolled. The patients who took anticholinergics during less than 2 months or suffered from psychiatric problems were excluded. One hundred-fifteen patients were included and all prescribed drugs were classified and counted. The number of anticholinomimetic agents and their 10 adverse effects were checked. RESULTS: Mean age was 67.0+/-10.6 years and mean cormobidity diseases counted 1.1+/-1.1. Mean pill and mean anticholinergic agents counted 7.3+/-4.3 and 1.8+/-1.1, respectively. Prescribed anticholinergic agents count increased with patient's age(p=0.401). As the patients took more medications, they had higher possibility to take anticholinergic agents. And as the patients took more anticholinergic agents, they showed more anticholinergic adverse effects(p<0.001). CONCLUSION: Elderly patients mistakenly tend to attribute drug-induced changes in memory and cognitive function to aging or comorbid conditions. Therefore prescribers should consider an anticholinergic agent's receptor selectivity, ability to cross the blood-brain barrier, and pateint's medical history in elderly patients. Additionally physicians can actively perform Mini-Mental Status Examination for evaluation of the patient's cognitive functions under anticholinergic medication.

Extraperitoneal Bladder Rupture following a Normal Spontaneous Vaginal Delivery / 대한비뇨기과학회지

The urinary bladder is seldom injured by external forces, as it is located in the pelvic cavity, behind the symphysis pubis, and protected by the bony pelvis. Gynecological procedures are a major cause of bladder injury. Herein, a case of extraperitoneal bladder rupture, identified 6 days after vaginal delivery in a 27-year-old woman, with no history of cesarean section or pelvic surgery, and who was cured of the bladder rupture using conservative treatment with the indwelling of a urethral Foley catheter, is reported.

Laparoscopic Management of Complicated Urachal Remnant in a Child

A few cases of laparoscopic surgery for urachal remnant in children has been reported in English literature. With recent developments in minimal invasive surgery, laparoscopic approach for urachal remnant in adulthood is recommended by some laparoscopic surgeons because of its technical feasibility and safety as well as cosmesis. Recently we experienced a case of complicated urachal remnant in a 14-month-old girl, who was managed by laparoscopic approach. At presentation, she complained of high fever and lower urinary tract symptoms. After 6 weeks of antibiotics therapy, laparoscopic surgery was performed transperitoneally via 3 ports. Our experience suggests that laparoscopic excision of urachal remnant can be performed easily and safely in children.

The Clinical Significance of Serum C-reactive Protein in Patients with Acute Uncomplicated Pyelonephritis / 대한비뇨기과학회지

PURPOSE: To evaluate the predicted results of treatment and to decide the time of using parenteral antibiotics to oral medication in Acute Uncomplicated Pyelonephritis, the serum C-reactive protein (CRP), WBC counts and body temperature (BT) were compared. MATERIALS AND METHODS: Between May 2003 and August 2004, 59 female patients with acute uncomplicated pyelonephritis were enrolled. The serum CRP, WBC counts and BT were measured on the first, third, fifth and seventh day after admission, and on the seventh day following discharge. The durations and patterns of the serum CRP, WBC counts and BT were statistically assessed after the use of parenteral antibiotics. RESULTS: The serum CRP, WBC counts and BT were increased in all patients on the first hospital day, but only the serum CRP was statistically correlated with the clinical course, with an average level of 11.83mg/dl. After the use of parenteral antibiotics, the mean serum CRP decreased to 8.38, 4.00 and 1.92mg/dl on the third, fifth and seventh day after admission, respectively. There were no cases increased serum CRP level or recurrence of inflammation during the follow-up period. The initial serum CRP level was also correlated with the disease severity when over 15mg/dl, the longer use of parenteral antibiotics and the longer stay in hospital were needed. CONCLUSIONS: Clinically, the level of serum CRP was a better indicator in determining the therapeutic effect of parenteral antibiotics use in patients with acute uncomplicated pyelonephritis than either the WBC counts or BT. Especially, in patients whose serum CRP level was decreased below 2.00mg/dl during the early days of the hospital stay, a decreased use of parenteral antibiotics and decreased hospital stay were observed. The initial serum CRP level was also correlated with disease severity.

The Incidental Polyorchidism and Treatment: Report of 2 cases / 대한비뇨기과학회지

Herein, polyorchidism possessing of more than the usual number of testicles, which was found in two patients, is reported. Both patients had three testes, and one presented with painful swelling of the right scrotum caused by torsion of the testis and the other revealed a non-palpable testis in the right hemiscrotum. Both patients were managed surgically with orchiopexy and an orchiectomy, respectively, followed by the insertion of an artificial testis.

Biofeedback and Functional Electrical Stimulation Therapy for Patients with Intractable Chronic Pelvic Pain Syndrome / 대한비뇨기과학회지

PURPOSE: Chronic pelvic pain syndrome(CPPS) is a debilitating condition characterized by pelvic pain and voiding symptoms. Pelvic floor tension myalgia is hypothesized to be a contributing factor in CPPS. The therapeutic effect of biofeedback and electrical stimulation for CPPS was evaluated prospectively. MATERIALS AND METHODS: Thirteen patients with CPPS intractable to conventional medication were enrolled. The patients were treated by domestic KontinenceTM equipment 2 times a week for 6 weeks. Patients completed the National Institute of Health Chronic Prostatitis Symptom Index(NIH-CPSI) before and after treatment. RESULTS: The average score for all 3 domains in NIH-CPSI significantly decreased. Pain domain decreased from 12.9+/-3.4 to 9.8+/-1.7(p=0.002), voiding symptoms from 4.5+/-1.6 to 3.2+/-0.9(p=0.006), and impact plus quality of life from 7.3+/-2.2 to 4.7+/-1.5(p=0.003). CONCLUSIONS: Biofeedback with electrical stimulation therapy can provide significant improvement in CPPS intractable to medication. Large, randomized trials are needed to confirm its efficacy.

The Effect of Angiogenin on the Development of Human Bladder Tumor / 대한비뇨기과학회지

PURPOSE: Angiogenin is involved in tumor angiogenesis, an important process for the growth and metastatic potential of solid tumors. This study was performed to evaluate the expression of angiogenin in the tumor tissues of patients with bladder tumors. The correlations of angiogenin with the tumor grade and stage were also evaluated. MATERIALS AND METHODS: The quantification for the expression of angiogenin mRNA was assessed in 106 human bladder tumor tissues, 19 normal mucosae surrounding the bladder tumor and 17 normal bladder mucosae, using a quantitative competitive polymerase chain reaction (QC-PCR). We compared the levels of angiogenin mRNA expression between the bladder tumors and the normal bladder mucosae of the controls, the bladder tumors and the normal bladder mucosae surrounding the tumors, and with regard to the tumor grades and stages. RESULTS: The levels of angiogenin mRNA expression in the bladder tumor tissues were significantly higher than in the normal bladder mucosae of the controls and the normal bladder mucosae surrounding the tumors. The angiogenin expression levels in the bladder tumors at stages T1 or above T2 were significantly higher than in the bladder tumors at stage Ta. There was no significant difference in angiogenin expressions with regard to the tumor grade. CONCLUSIONS: These data suggest that angiogenesis, mediated by angiogenin, may be involved in the tumorigenesis of the urinary bladder and the invasiveness of bladder tumors.

Expression of Vascular Endothelial Growth Factor in Human Transitional Cell Carcinoma / 대한비뇨기과학회지

PURPOSE: Both the development and progression of a tumor are angiogenesis dependent, the induction of which is mediated by several angiogenic factors, such as vascular endothelial growth factor (VEGF). This study was performed to evaluate the expression of VEGF in the tumor tissues of patients with bladder tumors. The correlation of VEGF with the tumor grade and stage was also evaluated. MATERIALS AND METHODS: The quantification for the VEGF mRNA expression was assessed in 117 human bladder tumor tissues and 17 normal bladder mucosae of controls, using a quantitative competitive polymerase chain reaction (QC-PCR). We compared the levels of VEGF mRNA expression between the bladder tumors and the normal bladder mucosae of the controls, the bladder tumors and the surrounding normal bladder mucosae, and according to tumor grades and stages. RESULTS: The VEGF mRNA expression in the bladder tumor tissues was significantly higher than in the normal bladder mucosae of the controls and the surrounding normal bladder mucosae. The VEGF expression was significantly higher in the grade III than the grade I bladder tumors. There was no significant difference in VEGF expression with regard to the tumor stage. CONCLUSIONS: These data suggest that angiogenesis, mediated by VEGF, may be involved in the neoplastic growth of bladder tumors and the tumor's aggressiveness.

Metastatic Transitional Cell Carcinoma of the Penis / 대한비뇨기과학회지

Metastatic cancers of the penis are rare, and are usually secondary to other genitourinary primaries. The two most common primary genitourinary tumors are prostatic adenocarcinomas and transitional cell carcinomas of the bladder. They can present with a variety of symptoms and signs. A biopsy is required to confirm the tumor infiltration of the lesion. Generally, the prognosis of penile metastasis has been poor. We report one case of a metastatic transitional cell carcinoma of the penis, which showed a good response to gemcitabine-cisplatin combination chemotherapy.

The Roles of P53, Rb and Ki-67 LI on Bladder Tumor / 대한비뇨기과학회지

PURPOSE: This study was performed to evaluate whether the overexpression of p53 and Ki-67, and loss or overexpression of Rb were associated with clinical parameters of bladder tumor. MATERIALS AND METHODS: Fifty-two archival tumor specimens from transitional cell carcinoma of the urinary bladder in 42 male and 10 female patients ranging from 30 to 83 years old (mean age : 63.5 years old) were investigated for the expression of mutant p53, Rb and Ki-67 immunohistochemically. They were divided into 36 superficial and 16 invasive bladder tumors, and grade I in 10, II in 25 and III in 17. RESULTS: p53 positivity and Ki-67 LI were significantly associated with tumor stage and grade(p<0.05 in each), but not with tumor recurrence. Loss of Rb gene expression or Rb overexpression was only correlated with stage. All specimens with p53 positivity and overexpression or loss of Rb protein simultaneously expressed higher Ki-67 compared to other bladder tumors. CONCLUSIONS: p53 positivity, loss or overexpression of Rb and the level of Ki-67 LI were significantly correlated with tumor stage and grade, but not with bladder tumor recurrence. Also, correlations existed among them, especially p53 positivity was tightly connected with Ki-67 LI(r=0.778) in linear regression analysis. These results suggest that changes of p53 and Rb expression may have an important role in aggressiveness of human bladder tumor.

Prostatic Size Variation with Age: Randomized Community-based Survey in Chungbuk Province / 대한비뇨기과학회지

PURPOSE: It is known that size of the prostate increases with age, but there is no guideline of size of the prostate to be applied to Korean men. This study reports the size change of prostate with age in Korean men. MATERIALS AND METHODS: To determine the prostatic size, 645 volunteers(539 normal group and 106 BPH group) from Chungbuk province underwent transrectal ultrasonography (Scanner 200, Pie Medical, Netherlands). Size of the prostate was estimated as a weight by the elliptical method. RESULTS: The mean prostate weight was 22.4+/-8.4gm(range 7~83gm). The relationship between prostate volume and age was statistically significant in 645 volunteers(r=0.17, p0.1). CONCLUSIONS: Size and rate of growth of the prostate were smaller compared to the western society, nevertheless, prostate size increased with age. For accurate and reasonable age-specific size of the prostate of Korean male, community based multicenter study will be needed with more accurate measurement techniques such as step-section planimetry for the prostatic volume estimation.

Early Experience of the Transvaginal Burch Bladder Neck Suspension for Female Stress Urinary Incontinence / 대한비뇨기과학회지

Ever since Pereyra described needle suspension of the bladder neck as a form of surgical therapy for the treatment of stress urinary incontinence in women numerous modifications have been presented. Each of these modifications has helped to found healthy anatomical and surgical principles that ensure patient safety, decrease morbidity and improve effectiveness. We had treated 8 patients of stress urinary incontinence with or without cystocele by transvaginal Burch procedure. By fixing suspension sutures to the Cooper`s ligament we expected to achieve a static suspension independent of everyday patients` activities. The duration of follow up was 3 months to 6 months. Them were no serious operative complications. Incontinence was completely disappeared in 6 patients (75%) and significantly improved in 1 patient (12.5%), and failed in 1 patients (12.5%). Although the small number of patients and limited follow up, we believe that fixation of suspension sutures to the Cooper`s ligament can favorably influence long-term results of treatment for female stress urinary incontinence.