Obesity and retropubic surgery for stress incontinence: is there really an increased risk of intraoperative complications?

OBJECTIVE: The objective of the study was to evaluate the impact of obesity on length of surgery, blood loss, and intra- and postoperative complications in women who underwent retropubic surgery for stress urinary incontinence. STUDY DESIGN: Of 449 women participating in a multicenter, randomized trial evaluating antibiotic prophylaxis in women with suprapubic catheters, 250 women underwent retropubic anti-incontinence procedures. This is a prospective nested cohort study of these women, 79 (32%) of whom were obese (body mass index 30 or greater) and 171 (68%) overweight or normal weight (body mass index less than 30). Data collected included demographic variables, past medical history, physical examination, and intraoperative and postoperative complications. Data were analyzed with Fisher's exact for dichotomous variables, Student t tests for continuous variables, and analysis of variance for multivariate analysis. Significance was set at P < .05. RESULTS: Obese women undergoing stress urinary incontinence surgery were younger than nonobese women (48.7 versus 51.9 years, respectively, P < .019). The number and type of additional surgeries performed were similar between groups with the exception that obese women were less likely to undergo abdominal apical suspensions (P = .006) or abdominal paravaginal repairs (P = .001); therefore, estimated blood loss, change in hematocrit, length of stay, surgery, and suprapubic catheterization comparisons are adjusted for the performance of these procedures. Estimated surgical blood loss was greater for obese women (344 versus 284 P = .03); however, change in hematocrit was lower for obese than nonobese women (6.6 versus 7.3, P = .048). Mean length of surgery was 15 minutes longer in obese women (P = .02). Length of hospital stay did not vary between groups (P = NS). Major intraoperative complications were uncommon (14 [5.6%]), with no difference between weight groups. Incidence of postoperative urinary tract infection, wound infections, or postoperative major complications were likewise similar between groups (all P > .05). CONCLUSION: Surgery takes longer for obese patients, but blood loss as recorded by change in hematocrit is lower. Major complications were rare and similar between weight groups, as were infectious complications.

Long-term results of the FemSoft urethral insert for the management of female stress urinary incontinence.

A 5-year ongoing, controlled multicenter study enrolled 150 women. Outcome measures included pad weight tests (PWT), voiding diary (VD), quality of life (QOL) and satisfaction questionnaires. Outcome measures during the baseline period were compared to evaluations during follow-up. Concurrent evaluations with and without device use were also performed. Safety evaluations included urinalysis and culture, leak-point pressure (LPP) and cystoscopy. Adverse events (AE) were recorded throughout the study. One to 2 years of follow-up were collected on all study participants (mean 15 months). Statistically significant reductions in overall daily incontinence episodes (P<0.001) and PWT urine loss (P<0.001) were observed with the device at all follow-up intervals, and 93% of women had a negative PWT at 12 months. Women were satisfied with ease of use of the device, comfort and dryness, and significant improvements in QOL were observed (P<0.001). Subgroup analysis revealed that the insert was effective, despite the presence of urgency, low LPP, failed surgery and advanced age. AE included symptomatic urinary tract infection in 31.3%, mild trauma with insertion in 6.7%, hematuria in 3.3%, and migration in 1.3% of women. The results of PWT and VD demonstrated device efficacy. Women were satisfied and significant improvements in QOL were observed. AE were transient and required minimal or no treatment. The urethral insert should be considered as an option for the management of SUI.

The standardization of terminology for researchers in female pelvic floor disorders.

The lack of standardized terminology in pelvic floor disorders (pelvic organ prolapse, urinary incontinence, and fecal incontinence) is a major obstacle to performing and interpreting research. The National Institutes of Health convened the Terminology Workshop for Researchers in Female Pelvic Floor Disorders to: (1) agree on standard terms for defining conditions and outcomes; (2) make recommendations for minimum data collection for research; and (3) identify high priority issues for future research. Pelvic organ prolapse was defined by physical examination staging using the International Continence Society system. Stress urinary incontinence was defined by symptoms and testing; 'cure' was defined as no stress incontinence symptoms, negative testing, and no new problems due to intervention. Overactive bladder was defined as urinary frequency and urgency, with and without urge incontinence. Detrusor instability was defined by cystometry. For all urinary symptoms, defining 'improvement' after intervention was identified as a high priority. For fecal incontinence, more research is needed before recommendations can be made. A standard terminology for research on pelvic floor disorders is presented and areas of high priority for future research are identified.

Resolution of urge symptoms following sling cystourethropexy.

PURPOSE: Persistence of urinary urge symptoms in women after pubovaginal sling cystourethropexy is a distressing problem. We assess the ability of preoperative video urodynamics to identify patients in whom urinary urge symptoms failed to resolve postoperatively. MATERIALS AND METHODS: The records of 84 consecutive women who had undergone pubovaginal sling cystourethropexy were reviewed. Preoperative video urodynamics revealed stress urinary incontinence in all cases and concomitant detrusor instability in some. Cases of motor urge, defined as urge symptoms plus detrusor instability, were divided into low and high pressure categories. Patients with urge symptoms but no demonstrable detrusor instability on video urodynamics were diagnosed with sensory urge. Postoperatively complete urge resolution was defined as total absence of symptoms without pharmacological therapy. Mean followup was 26.7 months (range 2 to 62). RESULTS: Of the 84 patients 41 with motor urge and 28 with sensory urge had preoperative urge symptoms. Complete resolution or improvement in urge symptoms occurred in 24 (58.5%) and 7 (17.1%) of the motor urge, and 11 (39.3%) and 9 (32.1%) of sensory urge cases, respectively. Of the 41 patients with motor urge 23 had low pressure instability, which completely resolved in 21 (91.3%) and improved in 2 (8.7%). Of the 18 remaining patients with high pressure motor urge only 5 (27. 8%) had complete resolution of urge and 5 (27.8%) had improvement. CONCLUSIONS: Our results suggest that patients with low pressure motor urge are significantly more likely to experience resolution of urinary urge symptoms after pubovaginal sling cystourethropexy than those with high pressure motor urge or sensory urge.

Reproducibility of the seven-day voiding diary in women with stress urinary incontinence.

In this study we aimed to assess the reproducibility of the 7-day voiding diary in women with stress urinary incontinence. We compared two 7-day voiding diaries completed at 4-week intervals by 138 women with stress urinary incontinence enrolled in an interventional trial. The correlation coefficient for the number of weekly incontinence episodes between the two diaries was 0.831. For 280 voiding diaries the results of the first 3 days correlated well with results of the last 4 days (r = 0.887). The number of incontinence episodes, as recorded on a 7-day voiding diary, is a reproducible outcome measure in women with stress urinary incontinence. Results from the first 3 days of a diary correlate well with the last 4 days, suggesting that a 3-day diary is an appropriate outcome measure for clinical trials evaluating treatments for stress incontinence.

Proceedings of the American Urogynecologic Society Multidisciplinary Symposium on Defecatory Disorders.

The Multidisciplinary Symposium on Defecatory Disorders was created to delineate the breadth of defecatory disorders and propose investigations to address identified knowledge deficits. Seven experts in defecatory disorders and 24 members of the American Urogynecologic Society were invited. The experts provided brief summaries of the scope of defecatory disorders from the perspectives of their specialties. The group then divided into 3 subgroups that focused on pathophysiology, imaging, and evaluation and treatment. Defecatory disorders, including anal incontinence and constipation, are common among women of all ages. Determination of their prevalence is complicated by a lack of standardized definitions. Defecatory disorders carry lengthy differential diagnoses. Imaging studies and anorectal testing, although not standardized, can aid in distinguishing different causes of dysfunction. The lack of uniformity in diagnosis and evaluation compromises comparisons of different treatments. Standardization of diagnoses and diagnostic modalities is essential to the design of meaningful evaluations of treatments for defecatory disorders.

Antenatal diagnosis of vesicouterine fistula.

BACKGROUND: In pregnancy, vesicouterine fistulas usually are diagnosed postpartum after cesarean deliveries. CASE: An 18-year-old woman, gravida 3, para 2, with two prior cesarean deliveries had pain and apparent rupture of membranes at 23 weeks' gestation. At 26 weeks' gestation, she developed increasing suprapubic pain and irregular contractions. Ultrasonographic findings included a small uterine defect and possible ballooning of membranes into her bladder. Cytoscopy showed ballooning of amnion into the bladder dome. A viable 900-g female infant was delivered by classic cesarean, the fistulous tract was excised, and the rupture sites were repaired. CONCLUSION: Vesicouterine fistulas might be diagnosed antenatally. With continued contractions and associated uterine rupture, cesarean delivery can be done with excision of the fistulous tract and repair of the rupture sites.

Pharmacologic management of pelvic floor dysfunction.

Pharmacologic therapy is an important part of the treatment armamentarium for urogynecologic disorders. Current and future research will determine the utility of such therapy as medications with fewer side effects and more targeted efficacy are developed.

Does prolonged high-impact activity contribute to later urinary incontinence? A retrospective cohort study of female Olympians.

OBJECTIVE: To determine whether women engaged in strenuous, provocative exercise are more likely to be incontinent in future life than similarly fit women who participated in less provocative exercise. METHODS: In this retrospective cohort study, female American Olympians who competed in swimming (low-impact group) and in gymnastics and track and field (high-impact group) between 1960 and 1976 completed a structured questionnaire. Primary outcome measures included the prevalence of the symptoms of stress and urge incontinence. Statistical analyses of results included chi2, Fisher exact test, two-tailed t tests, Wilcoxon rank sum test, and stepwise multiple logistic regression. P < .05 was considered significant. RESULTS: One hundred four women responded (response rate 51.2%). High-impact athletes were older (46.2 compared with 42.4 years) and were more likely to report incontinence when they were doing their sport as Olympians (35.8% compared with 4.5%) than low-impact athletes; low-impact athletes were more likely to be parous (83.3% compared with 60.7%). There was no difference in the prevalence of the symptom of stress incontinence between the high- versus low-impact groups: any incontinence, 41.1% compared with 50%; daily or weekly incontinence, 10.7% compared with 8.3%; and incontinence that bothered them moderately or greatly, 10.7% compared with 4.2%. With our sample size, this study had 80% power to detect a fourfold difference in daily or weekly incontinence between groups, but only a 30% power to detect a twofold difference, given a baseline prevalence of 10%. When age, body mass index (BMI), parity, Olympic sport group, and incontinence during Olympic sport were entered into stepwise logistic regression analyses, only BMI was significantly associated with regular stress or urge incontinence symptoms. CONCLUSION: Participation in regular, strenuous, high-impact activity when younger did not predispose women to a markedly higher rate of clinically significant urinary incontinence in later life.

Anal incontinence after anal sphincter disruption: a 30-year retrospective cohort study.

OBJECTIVE: To compare the prevalence of anal incontinence remote from delivery (approximately 30 years postpartum) in 29 women whose index delivery was complicated by anal sphincter disruption versus a matched control group of 89 women who had an episiotomy without extension to the anal sphincter and versus a group of 33 women who delivered via cesarean. METHODS: In this retrospective cohort study, a structured questionnaire was sent to women in the above categories who delivered at a university hospital between 1961 and 1965 and for whom we could obtain current addresses. Outcome measures included frequent fecal and flatus incontinence and bothersome fecal and flatus incontinence. RESULTS: The three groups did not differ significantly in age, weight, age at delivery, parity, weight of largest baby, postmenopausal status, estrogen replacement usage, most medical conditions, or rectocoele, rectovaginal fistula, or incontinence surgeries. Frequent flatus incontinence was reported by nine (31.0%), 38 (42.7%), and 12 (36.4%) women in the anal sphincter disruption, episiotomy, and cesarean groups, respectively (not significant). The number of women with bothersome flatus incontinence was higher in the anal sphincter disruption group: 17 (58.6%) versus 27 (30.3%) in the episiotomy only group and versus five (15.2%) in the cesarean group (P = .001). Frequent fecal incontinence was reported by two (6.9%), 16 (18.0%), and 0 women (P = .008 between cesarean and episiotomy only groups), whereas bothersome fecal incontinence was reported by eight (27.6%), 23 (25.8%), and five (15.2%) women (not significant) in the anal sphincter disruption, episiotomy only, and cesarean groups, respectively. CONCLUSION: Regardless of the type of delivery, anal incontinence occurs in a surprisingly large number of middle-aged women.

The role of estrogen replacement therapy in the management of urinary incontinence and urinary tract infection in postmenopausal women.

The hormonal changes associated with normal aging and menopause may contribute to the development of urinary disorders including both urinary incontinence and urinary tract infections. Estrogen replacement therapy has been used successfully in the treatment of both of these disorders in postmenopausal women. Although the selection of specific treatment modalities should be tailored to the individual patient, hormonal replacement should be considered a viable conservative treatment option for many older women with urinary complaints. Future research will help to delineate the most effective route of administration and type of estrogen used in treating these complaints.

Thirst at work--an occupational hazard?

Of 1492 teachers 791 (53%) responded to a survey addressing whether voiding habits at work or behavioral factors influenced by this occupation predisposed women to urinary tract infection. The mean number of voids during the work day was 2.7 +/- 1.4; 24.5% voided infrequently (never or only once) and 26.5% voided four or more times during the work day; 15.8% had had a urinary tract infection in the preceding year. Half of the respondents made a conscious effort to drink less while working, to avoid needing to use the toilet. There was no association between the prevalence of urinary tract infection and the number of voids or infrequent voiding at work. Compared to women who drank the volume they desired at work, those who drank less had a 2.21-fold higher risk (95% CI 1.45-3.38) of urinary tract infection after controlling for being parous, voiding infrequently at work, and urge incontinence. Further study is warranted to determine whether modification of behavioral factors at work can reduce the incidence of urinary tract infections. If this association holds, public policy must be changed to allow workers more adequate access to toilet facilities.

Nonoperative management of urinary incontinence.

Recent public health policies emphasize managing urinary incontinence nonoperatively, rather than proceeding directly to surgery. Advantages of this approach include decreased cost and risk. Additionally, incontinence treatment becomes accessible to many more women, by expanding care to nonspecialists. This article reviews data published in the past 18-24 months pertaining to conservative management of incontinence. Specific modalities reviewed include pelvic floor muscle exercises, electrical stimulation, medication, vaginal devices, and bladder training.

Urinary incontinence in rural older women: prevalence, incidence and remission.

OBJECTIVES: To determine the prevalence, incidence, and remission rates of urinary incontinence in a large group of older women over a 6-year time span and to assess factors associated with incontinence incidence and remission. DESIGN: Longitudinal cohort study. SETTING: Two rural counties in Iowa. PARTICIPANTS: 2025 women aged 65 years or older residing in rural Iowa, enrolled in the Iowa 65+ Rural Health Study of EPESE (Establishment of Populations for Epidemiologic Studies of the Elderly) were interviewed in person annually for 6 years; specific responses to queries about urinary incontinence were given at baseline, 3-, and 6-year intervals. MEASUREMENTS: Conditional multivariate logistic regression analysis was done to assess the relationship between incontinence symptoms and various factors previously found to be related to incontinence. RESULTS: The baseline prevalence of urge incontinence was 36.3%, and of stress incontinence it was 40.3%. For urge incontinence, the 3-year incidence and remission rates between the third and sixth years were 28.5% and 22.1%, respectively. For stress incontinence, the 3-year incidence and remission rates between years 3 and 6 were 28.6% and 25.1%, respectively. Seventy-six percent and 84% of women who reported no urge or stress incontinence, respectively, at the baseline interview were continent at both follow-up interviews. The only significant factors related to changes in incontinence status were age, which was associated with an increased incidence of urge incontinence (OR 1.11, P = .017, 95% CI 1.019-1.203), and improvement in activities of daily living, which was associated with a increased remission of urge incontinence (OR 0.50, P = .015, 95% CI 0.28-0.9) CONCLUSION: In some older women, urinary incontinence is a dynamic state, with women moving back and forth along a continuum between continence and incontinence. These results are tempered by limitations of the study, which include its questionnaire design and lack of ability to detect potential treatment effect.

Abdominal incisions from creation to closure.

Many of the techniques involved in creating and closing a surgical incision are based on tradition. Over the last several decades, randomized studies have addressed some of the steps in this process. Animal data and human data often have conflicting results. Randomized trials in human subjects indicate: 1) The incision can be made with one, rather than two, scalpels. 2) There is no advantage to using a laser rather than a scalpel when creating the incision. 3) Subcutaneous Penrose drains carried through the incision increase the infection rate. Closed suction drains in the subcutaneous space are rarely indicated. 4) The surgeon does not need to close peritoneum. 5) Time can be saved by closing the fascia in a continuous rather than interrupted fashion without causing an increase in postoperative wound separation or hernia formation. 6) Closing Camper's fascia after a cesarean delivery reduces the incidence of wound separation. 7) The cosmetic appearance of an incision is not improved by closing skin in a subcuticular rather than interrupted fashion.

Relationship between foot flexibility and urinary incontinence in nulliparous varsity athletes.

OBJECTIVE: To explore the relationship between urinary incontinence in elite nulliparous athletes and force absorption on impact, as assessed by foot arch flexibility. METHODS: One investigator measured medial longitudinal arch height in two gait stances (neutral and maximally dorsiflexed ankle positions) in 47 female varsity athletes representing five sports. Each athlete completed a questionnaire about urinary incontinence prevalence. We compared the change in arch height between the two gait stances with the prevalence of urinary incontinence. RESULTS: There was a statistically significant association between decreased foot flexibility and urinary incontinence; the mean percent change in arch height was 8.94 +/- 0.08% (standard deviation) in incontinent women and 13.70 +/- 0.09% in continent women (P = .03). CONCLUSION: How impact forces are absorbed may be one potential etiology for stress incontinence. An improved understanding of how impact forces are transmitted to the pelvic floor could provide important information about potential preventive interventions for urinary incontinence and other pelvic floor disorders, such as genital prolapse.

Postvoid residual volume cannot be accurately estimated by bimanual examination.

This study aimed to test the recommendation in the Agency for Health Care Policy and Research Practice Guideline on urinary incontinence that postvoid residual volume PVR estimates can be done by palpation. Postvoid residual volumes were obtained on 50 consecutive women presenting for evaluation of incontinence. Volumes were first estimated by bimanual examination and were then immediately measured by catheterization. Of 7 women who had a positive PVR, defined as greater than 50 ml, only 1 was estimated at greater than 50 ml on bimanual examination. The sensitivity of bimanual examination compared to catheterization to detect a positive PVR was 14%; specificity was 67%. Based on this assessment, the AHCPR guideline's inclusion of palpation estimates of PVR cannot be endorsed, unless a given practitioner has repeated a similar type of evaluation in his or her practice to determine whether the sensitivity is higher than that found in this study.

Spine update. Urological management in patients with spinal cord injuries.

In the past, urologic complications contributed greatly to spinal cord injury mortality. With improved evaluation and treatment, this is no longer the case. Treatment should be guided by urodynamic data gathered after the resolution of spinal shock symptoms. Goals of treatment are to facilitate voiding, reduce incontinence, and prevent renal damage. Indwelling catheters are almost never indicated for long-term treatment of the neurogenic bladder. Commonly used treatments include intermittent catheterization, condom catheter drainage with sphincter ablation, and pharmaceutical manipulation. Electrical stimulation of sacral nerve roots shows promise for future therapy.