Urinary incontinence after radical retropubic prostatectomy is not related to patient body mass index.

To determine if a relationship exists between patient body habitus and urinary incontinence after radical retropubic prostatectomy (RRP) for clinically localized prostate cancer. A questionnaire developed by combining parts of lower urinary tract symptom questionnaires concerning voiding symptoms after RRP was mailed to 268 consecutive patients who underwent RRP over a 2-year period. The interval between surgery and questionnaire administration was greater than 24 months for each patient. No interval was greater than 54 months. The questionnaire attempted to overcome the subjectivity of patient documented urinary incontinence by probing different aspects of each patient's voiding symptoms. Body mass index (BMI), obtained from preoperative anesthesia records, was used as the measurement for body habitus. Pearson correlations were used to determine relationships between BMI and responses and the independent t-test was used to determine differences between grouped responses and BMI. One hundred and eighty-two of 268 (68%) questionnaires were returned. No relationship was detected between BMI and patient estimates of urinary control, QOL relating to urinary symptoms, severity of stress incontinence, or use of protection (pad use). As well, no statistically significant relationship was found between BMI and a patient's willingness to undergo RRP again, based on his voiding symptoms, if given the choice. In conclusion, although patient body habitus may be related to other clinical outcomes following RRP, there does not appear to be a relationship of BMI to post-RRP urinary incontinence.

A pilot clinical trial of oral pentosan polysulfate and oral hydroxyzine in patients with interstitial cystitis.

PURPOSE: This pilot study was designed to evaluate the feasibility of a multicenter, randomized, clinical trial in interstitial cystitis (IC). Secondary objectives were to evaluate the safety and efficacy of oral pentosan polysulfate sodium (PPS), hydroxyzine, and the combination to consider their use in a larger randomized clinical trial. MATERIALS AND METHODS: A 2 x 2 factorial study design was used to evaluate PPS and hydroxyzine. Participants met the National Institutes of Health-National Institute for Diabetes and Digestive and Kidney Diseases criteria for IC and reported at least moderate pain and frequency for a minimum of 6 months before study entry. The primary end point was a patient reported global response assessment. Secondary end points included validated symptom indexes and patient reports of pain, urgency and frequency. The target sample size was 136 participants recruited during 10 months. RESULTS: A total of 121 (89% of goal) participants were randomized over 18 months and 79% provided complete followup data. The response rate for hydroxyzine was 31% for those treated and 20% for those not treated (p = 0.26). A nonsignificant trend was seen in the PPS treatment groups (34%) as compared to no PPS (18%, p = 0.064). There were no treatment differences for any of the secondary end points. Adverse events were mostly minor and similar to those in previous reports. CONCLUSIONS: The low global response rates for PPS and hydroxyzine suggest that neither provided benefit for the majority of patients with IC. This trial demonstrated the feasibility of conducting a multicenter randomized clinical trial in IC using uniform procedures and outcomes. However, slow recruitment underscored the difficulties of evaluating commonly available IC drugs.

Office assessment of patient outcome of pharmacologic therapy for urge incontinence.

Thirty adult women with urge urinary incontinence were included in this study. After completing the basic evaluation, including a self-administered incontinence questionnaire, patients were treated with a bladder relaxant preparation for 6-8 weeks. At follow-up the incontinence questionnaire and a global assessment of outcome scale were administered. Data were analyzed using the Mann-Whitney and Kruskal-Wallis tests, with a subsequent Tukey's test. After 6-8 weeks of therapy, 63% of patients reported that they were greatly or moderately improved, with a significant mean decrease in their total urge score of 51%. Subjects slightly improved (12%) and unimproved/worse (20%) had no significant change in their mean urge score. Most patients with great or moderate improvement continued with their initial drug treatment. Successful pharmacotherapy for urinary urge incontinence may be assessed by a simple global scale which correlated well with response to the MESA questionnaire. Moderate and greatly improved patients correlated with a 50% mean decrease in urge score and continued their initial drug therapy.

Coping strategies and health care-seeking behavior in a US national sample of adults with symptoms suggestive of overactive bladder.

BACKGROUND: Although millions of individuals have symptoms suggestive of overactive bladder (OAB), few ever seek or receive medical treatment for their condition. OBJECTIVE: The purpose of this study was to describe coping strategies and health care-seeking behavior in a community-based sample of adults with symptoms suggestive of OAB. METHODS: A cross-sectional household telephone survey of an age- and sex-stratified sample of adults was conducted. The survey consisted of general health-related questions as well as questions related to OAB symptoms. A total of 4896 adults completed the interview Respondents were considered to have OAB if they reported > or = 1 symptom of urinary urgency, frequency, or urge incontinence. A follow-up questionnaire was then mailed to a subsample of the telephone interview respondents. The mailed questionnaire contained questions related to type and severity of OAB symptoms, coping strategies, medical care/treatment, feelings/beliefs about OAB, and quality of life. Half of the phone respondents with urinary incontinence (n = 638) and a random sample of all other phone respondents received the mailed questionnaire (n = 873); 1,034 questionnaires were returned. RESULTS: Of the respondents with OAB, 69.6% tried > or = 1 nonmedical coping strategy. Respondents with incontinent OAB were significantly more likely than those with continent OAB or those with no OAB (controls) to use nonmedical coping strategies (incontinent OAB, 76.1%; continent OAB, 59.0%; controls, 31.9%; P < 0.001). Fewer than half of the respondents with OAB (43.5%) had spoken with a provider about OAB in the previous 12 months. Medical consultation was associated with sex, type and severity of OAB, number of nonmedical coping strategies tried, number of OAB information sources consulted, inclination to try new OAB medications, and feelings/beliefs about OAB. In 90% of patient-provider discussions about OAB, the patient initiated the topic. CONCLUSIONS: Individuals manage symptoms suggestive of OAB primarily by using nonmedical coping strategies rather than consulting health care providers. Results of this study support the need for improved clinical recognition of OAB and increased patient-provider communication about this condition.

Health-related quality of life among adults with symptoms of overactive bladder: results from a U.S. community-based survey.

OBJECTIVES: To assess, by means of a survey, the impact of the symptoms of overactive bladder (urinary frequency, urgency, and urge incontinence) on the quality of life in a community-based sample of the U.S. population. METHODS: A telephone survey was conducted in the United States among an age and sex-stratified sample of 4896 noninstitutionalized adults 18 years of age and older. From the responses to the telephone survey, a total of 483 individuals with symptoms of overactive bladder and 191 controls completed a mailed follow-up questionnaire to assess their quality of life using the Medical Outcomes Study Short-Form 20. RESULTS: After adjustment for age, sex, and the use of medical care, the greatest differences in the quality-of-life scores between the patients with incontinent overactive bladders and the controls were in the health perception (17.6 points; P <0.001) and role functioning (13.0 points; P <0.001) scales. Those with an overactive bladder with the symptoms of frequency or urgency, or both, but without incontinence, also had significantly lower scores than did the controls in mental health (P = 0.026), health perception (P = 0.01), and bodily pain (P = 0.016). CONCLUSIONS: These data indicate that individuals with an overactive bladder experience decrements in their quality of life relative to community controls. An important new finding from this study is that individuals with an overactive bladder, even without demonstrable urine loss, also have a poorer quality of life than that of controls.

Epidemiology and natural history of urinary incontinence.

This paper examines or current state of knowledge of the epidemiology of urinary incontinence. The population studied was community-dwelling non-institutionalized persons. The review includes discussion of the prevalence, incidence, natural history and presence of racial and ethnic differences in the epidemiology of urinary incontinence. We also review correlates and potential risk factors that have been revealed in epidemiological studies. Differences between epidemiological and clinical approaches to a health problem, help-seeking behavior and methodological issues for research are also discussed. We have reviewed a large number of completed studies in the field of urinary incontinence, and have emphasized high-quality and population-based studies. We also wished to present studies from a variety of countries. Because of the abundance of studies, only a small fraction can be presented here. Other studies may have equal standards and useful information, but lack of space precludes their inclusion.

A comparison of external beam radiation therapy versus radical prostatectomy for patients with low risk prostate carcinoma diagnosed, staged, and treated at a single institution.

BACKGROUND: The authors retrospectively reviewed their institution's long term experience treating a group of comparably staged low risk prostate carcinoma patients with either radical prostatectomy or external beam radiation therapy (RT) to determine whether the method of treatment resulted in significant differences in biochemical control and/or survival. METHODS: From January of 1987 through December of 1994, 382 patients (157 who underwent radical prostatectomy and 225 who received external beam RT) were treated with curative intent for localized prostate carcinoma at William Beaumont Hospital. All patients had a pretreatment serum prostate specific antigen (PSA) level < or =10.0 ng/mL and a biopsy Gleason score or =0.2 ng/mL at any time after prostatectomy. For RT patients, biochemical failure was defined according to the American Society for Therapeutic Radiology and Oncology Consensus Panel definition. Pretreatment PSA levels and Gleason scores were not significantly different between patients treated with radical prostatectomy or RT. The median follow-up in each treatment group was 5.5 years. RESULTS: The 7-year actuarial rates of biochemical control and cause specific survival were not significantly different between patients treated either with radical prostatectomy or RT (67% vs. 69% for biochemical control and 99% vs. 97% for cause specific survival, respectively). A number of clinical, pathologic, and treatment-related factors were analyzed for an association with biochemical failure (i.e., age, pretreatment PSA, Gleason score, and treatment modality). Only pretreatment PSA and Gleason score were significantly related to outcome in both univariate and multivariate analyses. CONCLUSIONS: Low risk prostate carcinoma patients with similar pretreatment PSA levels and biopsy Gleason scores treated at the same institution with either radical prostatectomy or RT achieved similar 7-year rates of biochemical control and cause specific survival, regardless of treatment technique. These findings suggest that for patients with pretreatment PSA levels

Preliminary study on urinary cytokine levels in interstitial cystitis: does intravesical bacille Calmette-Guérin treat interstitial cystitis by altering the immune profile in the bladder?

OBJECTIVES: To obtain preliminary urinary cytokine data on subjects with active interstitial cystitis (IC), subjects with IC in remission after bacille Calmette-Guérin (BCG), and control (non-IC) subjects. IC is a severe, debilitating bladder disease of unknown etiology and no cure. In controlled clinical trials, intravesical BCG has been shown to be an effective and durable treatment for IC. The durability of this treatment led us to speculate on the mechanism by which intravesical BCG may treat IC. Evidence exists that IC may be mediated by an abnormal immune profile within the bladder. Intravesical BCG is known to stimulate the immune system of the bladder. METHODS: Fresh voided urine was collected from 15 subjects with active IC, 9 subjects with IC who received intravesical BCG and had been in remission for an average of 2.6 years, and 11 non-IC subjects. The urine was immediately centrifuged, aliquoted, and frozen in liquid nitrogen. At the time of urine collection, a validated IC questionnaire was completed. The enzyme-linked immunosorbent assay technique was used to determine levels of urinary cytokines interleukin (IL)-2, IL-4, IL-6, IL-8, IL-10, IL-12, tumor necrosis factor (TNF), human granulocyte-macrophage colony stimulating factor (hGM-CSF), IL-1beta, and interferon-gamma (IFN-gamma). RESULTS: Cytokines IL-4, IL-10, IL-12, TNF, hGM-CSF, IL-1beta, and IFN-gamma were not detected. Significant elevations in symptom scores and IL-2, IL-6, and IL-8 were found in the urine of subjects with active IC compared with subjects with IC in remission and control subjects. The urinary cytokine levels and symptom scores were identical in the IC group who had received BCG and the control group. CONCLUSIONS: Elevations in symptom scores and urinary cytokine levels were seen in subjects with active IC, suggesting an abnormal immune profile in this disease. Subjects with IC in remission after receiving BCG had identical cytokine levels and symptom scores as non-IC control subjects. Intravesical BCG may be effective in treating IC by correcting an aberrant immune imbalance in the bladder, leading to long-term symptomatic improvement. A prospective study is ongoing to further investigate the role of the immune system in IC.

Prevalence and severity of urinary incontinence in older African American and Caucasian women.

BACKGROUND: Few studies have investigated the prevalence and severity of urinary incontinence in older African American women. Comparisons of findings with those for older Caucasian women could provide important clues to the etiology of urinary incontinence and be used in planning screening programs and treatment services. METHODS: Data are from the first wave of the Asset and Health Dynamics Among the Oldest Old (AHEAD) study. A nationally representative sample of noninstitutionalized adults 70 years of age and older was interviewed. African Americans were oversampled to ensure that there would be enough minority respondents to compare findings across racial groups. RESULTS: A statistically significant relationship was found between race and urinary incontinence in the previous year: 23.02% of the Caucasian women reported incontinence, compared with 16.17% of the African American women. Other factors that appear to increase the likelihood of incontinence include education, age, functional impairment, sensory impairment, stroke, body mass, and reporting by a proxy. Race was not related to the severity (as measured by frequency) of urine loss among incontinent older women. CONCLUSION: This study identifies or confirms important risk factors for self-reported urinary incontinence in a national context, and suggests factors leading to protection from incontinence. Race is found to relate to incontinence, with older African American women reporting a lower prevalence.

Office based criteria for predicting type II stress incontinence without further evaluation studies.

PURPOSE: The 1996 Agency for Health Care Policy and Research Clinical Practice Guidelines for Urinary Incontinence suggested that surgery may be performed after basic evaluation without further testing in cases of uncomplicated nonrecurrent type II stress urinary incontinence. However, they failed to recommend explicit office based criteria to identify this condition without further invasive testing. We establish such criteria and test the efficacy. MATERIALS AND METHODS: Records of 101 women with urinary incontinence who underwent complete evaluation from June 1995 to September 1997 were reviewed. Basic evaluation consisted of medical history, physical/pelvic examination and the validated Medical, Epidemiologic and Social Aspects of Aging Urinary Incontinence Questionnaire, while further testing included cystourethroscopy, urodynamics and lateral stress cystogram. All cases diagnosed as pure type II stress urinary incontinence after basic and further testing were identified, and office based findings were characterized, which included medical history, questionnaire scores, vaginal speculum examination results and post-void residual urine volume. These criteria were applied in a blinded fashion to the initial group of 101 patients and then to a new group of 45 women with incontinence who recently underwent complete evaluation. RESULTS: Specificity and positive predictive value were 100% in both groups for nonsurgical cases, compared to 81 and 71% in the initial, and 75 and 60% in the new group, respectively, for surgical cases. CONCLUSIONS: Our office based criteria are 100% specific for predicting pure type II stress urinary incontinence in women with no suspension surgery and, thus, have the potential of reducing the need for further invasive testing and consequently the cost of preoperative evaluation.

Post prostatectomy urinary incontinence.

The specific incidence rate of post prostatectomy incontinence is difficult to ascertain. However, regardless of the type of prostatectomy, whether it be transurethral, radical retropubic or radical perineal prostatectomy, or the nature of the prostatic disease, several risk factors are common to all. The most significant risk factors include pre-existing detrusor and/or sphincter dysfunction, increasing age, and surgical expertise. Management options include behavioral techniques, pharmacologic therapy, surgical intervention, and other supportive measures. While no definitive preventive measures can be recommended at this time, reducing the incidence of post prostatectomy urinary incontinence should be the goal.

Frequency urgency syndrome following urinary bladder suspension.

Bladder suspension for urinary incontinence secondary to bladder neck hypermobility is highly successful. Of those who fail, however, a subset will develop new onset or markedly worsened irritative voiding symptoms. A series of such patients were identified to study the associated urodynamic abnormalities of this symptom complex. The charts of female patients presenting for incontinence from 1992-94 were reviewed. Forty-six patients with a mean age of 59.4 (range 28-79) fulfilled the inclusion criteria of developing new onset or markedly worsened post-operative frequency, urgency and urge incontinence within two years of undergoing bladder suspension. All had been evaluated with thorough history, physical examination, and urodynamic testing. Seventeen patients were found to have recurrent hypermobility. Eighteen had a diagnosis of intrinsic sphincter deficiency (ISD), including six that also had another diagnosis. Four patients were diagnosed with detrusor overactivity and seven with other miscellaneous diagnoses. Patients presenting with this symptom complex should be evaluated so that treatment can be tailored appropriately.

The efficacy of intravesical bacillus Calmette-Guerin in the treatment of interstitial cystitis: long-term followup.

PURPOSE: Interstitial cystitis is a severe debilitating bladder disease characterized by unrelenting pelvic pain and urinary frequency. A prospective, double-blind, placebo controlled study of the use of intravesical bacillus Calmette-Guerin (BCG) in the treatment of interstitial cystitis was recently completed with a mean followup of 8 months. Results demonstrated a 60% BCG response rate, compared to a 27% placebo response rate. We now report the long-term followup results of those patients who received intravesical BCG. MATERIALS AND METHODS: Subjects randomized to receive BCG were followed at routine intervals with questionnaires and voiding diaries identical to those in the blinded study. Adverse events were closely monitored in the treatment and followup phases of the study. Subject baseline values were compared to followup data. RESULTS: Of the BCG responders mean followup was 27 months (range 24 to 33), and 8 of 9 (89%) continue to have an excellent response in all parameters measured. The global interstitial cystitis survey improved 70%, daily voids decreased 31%, nocturia improved 54%, mean voided volume increased 61%, pelvic pain decreased 81%, vaginal pain decreased 71%, urgency decreased 71% and dysuria decreased 82%. Overall well-being improved 54% and the Rand-36 quality of life survey overall improved 64%. In 86% of the patients (6 of 7) dyspareunia resolved. Of the initial BCG nonresponders there was no significant difference in interstitial cystitis symptomatology from baseline to last followup, suggesting that BCG does not worsen interstitial cystitis symptoms. No long-term adverse events from BCG were noted. CONCLUSIONS: Intravesical Tice BCG is safe, effective and durable in the treatment of interstitial cystitis. Of those patients who received only 6 weekly treatments and responded favorably 89% continue to have an excellent response with followup ranging from 24 to 33 months.

Associations among urodynamic findings and symptoms in women enrolled in the Interstitial Cystitis Data Base (ICDB) Study.

OBJECTIVES: The goal of this study was to correlate the cystometric findings with the presenting symptoms of the 388 women enrolled in the NIH/NIDDK-funded interstitial Cystitis Data Base (ICDB) Study as of December 31, 1995. METHODS: All patients underwent a complete history and physical and completed standardized questionnaires to assess voiding symptoms and quality of life (QOL). A 3-day voiding log was also obtained, followed by a baseline urodynamic exam. All results are expressed as mean values +/- 1 standard deviation, and all reported correlations were significant. RESULTS: A correlation was seen between reported daytime, nighttime, and 24-hour frequency, and both volume at first sensation to void (VFSV) and maximal cystometric capacity (VMCC). Patients with constant severe urgency had smaller VFSV, 63 +/- 59 mL versus 108 +/- 90 mL, and lower VMCC, 163 +/- 102 mL versus 288 +/- 135 mL, than patients without the complaint. A negative trend was seen for both VFSV and VMCC versus the global severity. An inverse trend was seen between minimal and maximal pain scores over the 4 weeks before the exam and VMCC. (No correlation existed between current pain noted during baseline screening visits and VFSV or VMCC). No urodynamics correlates were seen with global measures of body pain and global health. Uninhibited detrusor contractions (UDCs) were seen in 56 of 384 patients (14.6%). A positive correlation was seen between urgency symptoms and the presence of UDCs. Correlations between the VFSV and VMCC were made with both the average voided volume (AVV) and the average maximal voided volume (AMVV) as determined by a 3-day voiding log. Significant positive correlations were seen with each pair-wise comparison (P = 0.001). CONCLUSION: These findings confirm that subjective measurements of symptoms associated with interstitial cystitis can be confirmed objectively with urodynamic studies.

Value of urinary cytology in women presenting with urge incontinence and/or irritative voiding symptoms.

PURPOSE: A retrospective study was done to determine whether voided urinary cytology was necessary in women with irritative voiding symptoms without hematuria. MATERIALS AND METHODS: A total of 202 cytology studies was obtained from 128 women presenting with urge incontinence and/or irritative voiding symptoms between 1990 and 1995. RESULTS: Five patients with irritative symptoms and hematuria were diagnosed with transitional cell carcinoma. Cytology was positive in 3 patients, atypical in 1 and normal in 1. No positive cytology studies or carcinomas were noted in patients without hematuria. Urinary tract carcinoma was confirmed by cystoscopy and biopsy if necessary. CONCLUSIONS: The benefits of cytology for patients without hematuria are questioned in the cost-effective treatment of female patients with irritative bladder symptoms.