The prevalence of detrusor overactivity amongst patients with symptoms of overactive bladder: a retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Overactive bladder (OAB) is a symptom-based condition consisting of urgency, with or without incontinence, usually with frequency and nocturia. There are many potential causes of OAB, yet many patients are prescribed anticholinergic medications empirically. This study aimed to determine what proportion of patients presenting for urogynecologic assessment with symptoms of OAB had urodynamic detrusor overactivity (DO). METHODS: Retrospective chart review was performed for 220 consecutive patient referrals. Demographic data, physical exam information, and urodynamic results were collected. The t test and Fisher's exact test were used for statistical analyses. RESULTS: The prevalence of DO was 11.8 % in this population. Urogenital atrophy and incomplete emptying were more common. Patients with DO were older and more often menopausal than those without DO. Significant prolapse was a common finding amongst patients with OAB symptoms. CONCLUSIONS: Patients with symptoms of OAB should undergo pelvic examination and assessment of post-void residuals before being initiated on anticholinergic medication.

Vaginal delivery and pelvic floor dysfunction: current evidence and implications for future research.

Vaginal delivery is the major risk factor for the development of pelvic organ prolapse and urinary and fecal incontinence, resulting from damage to the pelvic floor muscles, nerves and connective tissue. This article reviews the perineal trauma mechanism during vaginal delivery and discusses implications of current and future research projects.

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.

Safety and efficacy of sacrospinous vault suspension.

The objective of the study was to determine the success rate and complications of sacrospinous vault suspension when performed by an experienced surgeon. Retrospective data collection was performed for 293 women who had undergone sacrospinous vault suspension at Mount Sinai Hospital, Toronto, between November 1993 and 19 December 1998. Primary outcome measures were complication rates (acute and long term) and success rate, with failure defined as any degree of vault prolapse requiring repeat operation, any degree of symptomatic isolated vault prolapse, or any vault prolapse at or beyond the introitus. Statistical analysis was performed using simple descriptive techniques. During the study period, 305 sacrospinous vault suspensions were performed; however, 12 cases were excluded because of inaccessible records. This study therefore comprised the remaining 293 cases: 129 at the time of vaginal hysterectomy, 5 with transvaginal cervical stump excision, 155 for post-hysterectomy vault prolapse, and 4 without hysterectomy. Two hundred had follow-up of 1 year or more, with maximum follow-up 5 years. Of these 200, there were 6 failures (3%). There were no acute hemorrhages and no deaths. There was a complaint of postoperative right buttock pain in 18 of the 293 procedures (6.1%), with this persisting on a chronic basis in 3 patients. Eight patients complained of new-onset postoperative dyspareunia. Nine patients had postoperative stress urinary incontinence, and 14 patients had de novo anal incontinence. Postoperatively, there were 17 patients with a cystocele and 7 with a rectocele. There were three other complications: one pelvic hematoma at the sacrospinous suspension site, one right foot drop which spontaneously resolved, and one case of pain in the right sciatic nerve distribution which spontaneously resolved. Forty-three patients complained of anal incontinence preoperatively, and 38 (88.4%) had the symptoms resolved postoperatively. It was concluded that, when performed by a surgeon experienced in the procedure, sacrospinous vault suspension is safe and effective, with a successful result at 1 year in more than 90% of cases, and rare major complications.

Perineal pad test in evaluating outcome of treatments for female incontinence: a systematic review.

Our objective was to systematically review clinical studies of incontinence treatments for women that used pad tests to assess outcome, to determine how closely the ICS guidelines had been followed. Our review (Medline 1988-2000, plus referenced studies) identified 75 relevant papers, carrying out pad tests in clinics ( n = 53) or patients' homes ( n = 28). Clinic pad tests lasted between 60 seconds and 2 hours, with inconsistent starting bladder volumes, activities carried out, other test details and presentation of results. Home pad tests lasted between 1.5 and 48 hours: the conduct and reporting of these tests were also variable. Only 25 studies used pad tests that were apparently consistent with ICS guidelines. Pad tests are important in identifying urine loss in clinical evaluations; however, we found wide variations in their conduct and reporting. We recommend that the ICS should review the guidelines, and that further research should develop clinically valid pad tests. Authors and journal editors should ensure that pad test details are fully reported.

The role of intraoperative cystoscopy in prolapse and incontinence surgery.

OBJECTIVE: Unrecognized ureteral and bladder injury are a known source of morbidity and mortality in gynecologic surgery. The objective of this study was to determine the frequency that intraoperative cystoscopy during prolapse and incontinence procedures produced a change in intraoperative management to prevent ureteric and bladder injury. STUDY DESIGN: This study reviewed the charts and operative reports of 235 cases of routine intraoperative cystoscopy during prolapse and incontinence surgery during a 2-year period in a tertiary care urogynecology unit. Demographic data and potential risk factors for intraoperative urinary tract injury were recorded. Cases that involved a change in management brought about by intraoperative cystoscopy with intravenous indigo carmine were compared with cases in which intraoperative cystoscopy was normal. Variables were compared with use of the Student t test and the chi(2) test. RESULTS: Of 235 cases, 11 were excluded. Of the 224 remaining cases, 12 (5.3%) underwent changes in intraoperative management as a result of cystoscopic findings. Eight cases involved ureteric blockage. Patients with abnormal cystoscopies did not differ from patients with normal intraoperative findings with regard to age, weight, parity, maximum grade of prolapse, estimated blood loss, or previous surgery. In 58% of patients with abnormal cystoscopies, there was no suspicion of technical difficulty on the basis of previous surgical history. Preoperative renal imaging did not predict cases with abnormal cystoscopy. There were no cases of complications caused by the intraoperative cystoscopy. CONCLUSION: Intraoperative cystoscopy with intravenous injection of indigo carmine is a safe technique that can detect otherwise undetected intraoperative compromise of the urinary tract during prolapse and incontinence surgery. It is recommended that cystoscopy be used liberally to reduced the frequency of serious sequelae from urinary tract injury.

Is transabdominal repair of mild to moderate cystocele necessary for correction of prolapse during a modified Burch procedure?

A nonconcurrent cohort study by chart review of cases was carried out at the Urogynecology Unit of Mount Sinai Hospital in Toronto, Canada, in 380 patients with stress urinary incontinence (SUI) undergoing Burch retropubic urethropexy (RPU) with or without transabdominal internal anterior repair (TIAR). There were 191 subjects (group A) who had both RPU and TIAR, and 189 (group B) who had RPU alone. The main outcome measures were postoperative recurrence of cystocele and SUI. Statistical analysis was performed using multiple regression analysis; P<0.05 was considered statistically significant. Of patients with preoperative cystocele grade 1 and 2 (mild to moderate) followed-up at 1 year, recurrence in groups A and B, respectively, was found in 13/114 (11.4%) vs. 4/99 (4.0%) (P<0.05). Regression analysis showed this trend of greater recurrence with TIAR to persist at 5 years, although a significant number of patients were lost to follow-up. There was no statistically significant difference in the cure of SUI between the groups. There was a 2.1% incidence of inadvertent cystotomy during TIAR (with no bladder injuries in group B), although this complication was always recognized and repaired without sequelae. In patients with both SUI and mild to moderate cystocele, TIAR may not be a necessary addition to RPU for treatment of the cystocele, although a randomized clinical trial is needed to determine the optimal transabdominal treatment in such cases. There is no detrimental effect of TIAR on the Burch procedure's success in curing SUI.

Treatment of overactive bladder: long-term tolerability and efficacy of tolterodine.

Previously available antimuscarinic therapies for overactive bladder are poorly tolerated due to a high incidence of adverse events, notably dry mouth. Tolterodine is a bladder-selective, antimuscarinic agent for the treatment of frequency, urgency, and urge incontinence that characterize overactive bladder. In a 9-month open-label study, the safety, tolerability, and clinical efficacy of tolterodine 2 mg twice daily was evaluated in 854 patients with overactive bladder symptoms who had completed one of four 12 week randomized, controlled trials of tolterodine. Safety and tolerability were assessed in terms of adverse events and clinical/laboratory variables. Efficacy was assessed using micturition diaries and patient perception of their bladder condition. In all, 70% of patients remained on treatment for 9 months. Dry mouth was the most frequently reported adverse event, occurring in 28% of patients (intensity: 19% mild, 7% moderate, 2% severe). A total of 9% of patients withdrew due to adverse events. Dosage reduction occurred in 13% of patients. Significant improvements (P < 0.0001) in micturitions per 24 h (-22%), urge incontinence episodes per 24 h (-76%) and volume voided per micturition (+22%) were observed after 9 months of treatment, with 65% of patients reporting an improvement in perception of their bladder problems. The incidence of adverse events and improvements in micturition diary variables during open-label treatment were comparable with those observed during a 12 week randomized treatment. It was concluded that tolterodine is well tolerated and maintains its clinical efficacy during 9 months of treatment. The high proportion of patients remaining on treatment indicates that tolterodine is an effective long-term treatment for overactive bladder.

The prevalence of urinary and fecal incontinence in Canadian secondary school teenage girls: questionnaire study and review of the literature.

The purpose of this study was to examine the prevalence of pelvic floor dysfunction and incontinence in the Canadian nulligravid secondary school female teenage population. During the University of Toronto day in 1996, female visitors to the Obstetrics and Gynecology Department booth were asked to complete anonymous pelvic floor and continence questionnaires, which were thoroughly explained to them and completed during their visit. Out of the 332 completed forms, 69% were completed by nulligravid teenagers in secondary school. These students formed our study population. The prevalence of urgency urinary incontinence (UUI) symptoms was 17% and of stress urinary incontinence (SUI) symptoms was 15%. In all candidates these reported symptoms were mild, occurring less than once a week. Occasional minor fecal incontinence (involuntary loss of flatus or fecal staining) was 38%; of these, 92% reported loss of flatus. Major fecal incontinence with loose bowel movements was reported by 3% of the study population. Two girls (1%) reported nocturnal enuresis. Weight directly correlated with SUI symptoms and fecal incontinence, but not with UUI. Fecal incontinence correlated with SUI symptoms (P = 0.0152), but not with UUI. Ten per cent of the study population were sexually active, but sexual activity did not correlate with incontinence problems. Voiding habits were markedly variable: 30% were infrequent voiders (three times or fewer per day). Nocturia was reported by 3%. We concluded that in nulligravid teenage female students minor fecal incontinence appears to be the most common incontinence type; urge incontinence was slightly more common than SUI. Unlike UUI, SUI symptoms were more prevalent with fecal incontinence, which were affected by weight. There appears to be a problem with a high prevalence of poor voiding habits.

Periurethral autologous fat injection as treatment for female stress urinary incontinence: a randomized double-blind controlled trial.

PURPOSE: We evaluated the effectiveness of periurethral autologous fat injection as treatment for female stress urinary incontinence. MATERIALS AND METHODS: Women with stress incontinence were randomized in a double-blind fashion to receive periurethral injections of autologous fat (treatment group) or saline (placebo group). After injection patients were evaluated monthly for 3 months by a validated standardized incontinence questionnaire, 1-hour pad test and cough test. Patients who remained incontinent were offered repeat injection using the same initial agent to a maximum of 3 injections. Every 3 months after injection patients were assessed by a standardized questionnaire, pad test, cough test and urodynamics. Those who did not qualify for repeat injection at 3 months were then followed 6, 9, 12, 18 and 24 months or until failure. RESULTS: Of the 68 women enrolled 35 received fat and 33 received saline injections. The groups were comparable in terms of baseline parameters. A total of 56 patients completed the study, including 27 in the fat and 29 in the placebo group, for a total of 189 injections (91 fat and 98 saline). At 3 months 6 of 27 (22.2%) and 6 of 29 (20.7%) women were cured or improved in the fat and saline groups, respectively. Complications included cystitis in 9 of 189 injections, urinary retention in 6 in the fat injection group, urge incontinence in 9 of 68 patients and pulmonary fat embolism resulting in death in 1 of 189 procedures. CONCLUSIONS: In this study periurethral fat injection did not appear to be more efficacious than placebo for treating stress incontinence.

The association of smoking with vaginal flora, urinary tract infection, pelvic floor prolapse, and post-void residual volumes.

OBJECTIVE: This study examined the association of smoking with changes in vaginal flora, the prevalence of urinary tract infection, genital prolapse, and incomplete bladder emptying. METHODS: The authors conducted a retrospective review of charts for 305 women. In addition to smoking habits, data on age, parity, degree of genital prolapse, vaginal flora, urinary residual, urinary tract infection, and hormone replacement therapy were collected and analyzed. RESULTS: Smoking did not correlate with urinary tract infection, the amount of post-void urine residual volumes, or pessary use. Smoking was significantly associated with the presence of a severe degree of genital prolapse. Smoking independently affected vaginal flora, increasing the odds of developing bacterial vaginosis. CONCLUSION: Smoking was associated with an increased risk of developing bacterial vaginosis and having severe genital prolapse. Smoking was not associated with urinary tract infection or the amount of post-void residual urine.

Bacterial vaginosis increases in pessary users.

The purpose of this study was to examine the association between pessary use, smoking and changes in the vaginal flora. Patients using pessaries were age matched with non-pessary using controls. All candidates examined were women attending the Mount Sinai Hospital, Toronto, for genitourinary problems. Vaginal cultures were routinely performed on all women attending the unit, irrespective of symptoms. Forty-four pessary users were age matched with 176 controls (4 controls per case). The mean age was 60.1 +/- 12.6 years, and 15% of these were premenopausal. The duration of pessary use ranged from 0.5 to 8 years (mean 3.3 +/- 1.7). Weight, parity, smoking status, diabetes mellitus, thyroid disease, UTI and postvoid residual urine volume were not significantly different between pessary users and controls. Bacterial vaginosis (BV) was noted in 32% of pessary users, versus 10% of controls. The relative risk of developing BV in pessary users was 3.3 (OR, 4.37; 95% CI, 2.15-9.32), P = 0.0002. Smoking independently affected the vaginal flora, increasing the relative risk of developing BV to 2.9 (OR, 3.78; 95% CI, 2.05-8.25), P = 0.0013. It was concluded that pessary use is a very effective and conservative method for the treatment of genital prolapse. However, we found that the presence of a foreign body was associated with changes in the vaginal flora, thereby increasing the odds of developing bacterial vaginosis to 4.37; this was further compounded by smoking.

Surgical management of recurrent stress urinary incontinence: A 12-year experience.

OBJECTIVE: The goal of the study was to evaluate the surgical procedures used to manage recurrent stress urinary incontinence in a tertiary referral center, to compare the procedures with respect to efficacy and failure rates, and to identify risk factors for failure. STUDY DESIGN: The health records of patients who underwent surgical treatment of recurrent stress urinary incontinence performed by the senior author (H.P.D.) between 1984 and 1995 were reviewed. The objective cure rate was evaluated by means of urodynamic studies and physical assessment, and the subjective cure rate was determined by means of historical report. In light of our selection criteria, the time to failure, the number of previous anti-incontinence procedures needed to give the best cure rate, and the risk factors for failure of the 3 predominantly used surgical techniques were determined. The statistical methods used were the chi(2) test with 95% confidence interval, the Cox proportional hazard model with logistic regression, and survival analysis. RESULTS: One hundred ninety-eight female patients were surgically treated for recurrent stress urinary incontinence between January 1, 1984, and December 31, 1995. Four surgical techniques were used: (1) the combined abdominovaginal (2-team) polypropylene (Marlex; Phillips Petroleum Company, Bartlesville, Okla) sling (group 1, n = 70), (2) the modified urethral Marlex sling (group 2, n = 68), (3) Burch retropubic colpourethropexy (group 3, n = 49), and (4) suburethral Marlex sling (group 4, n = 11). The study population consisted of 118 patients. The rest of the original 198, including all the patients in group 4, were excluded. Objective and subjective cure rates of 69% and 89%, 66% and 96%, and 69% and 88% were calculated for groups 1, 2, and 3, respectively. By 6 years after the operation 100% of the failures in groups 1 and 2 had occurred, and 88% of the group 3 failure occurred within 2 years after the operation. Cure rates of 77%, 73%, and 38% (P =.320) were achieved with the 2-team sling procedure (group 1) after 1, 2, and 3 previous anti-incontinence operations, respectively, whereas cure rates of 81%, 25%, and 0% (P =.001) were obtained with the Burch procedure (group 3) after 1, 2, and 3 previous anti-incontinence operations, respectively. This indicates that the Burch procedure should be avoided after >1 previous operation, whereas the 2-team sling can be used after >/=3 previous anti-incontinence procedures. Statistical significance could not be determined for group 2 because that procedure was not used to treat any patient with 3 previous operations. Age was a marginal risk factor for failure in group 1. No statistically significant risk factors were identified for group 2. The number of previous anti-incontinence procedures was the major risk factor for failure in group 3 when age, parity, gravidity, weight, hormone replacement therapy, number of previous anti-incontinence procedures, and urethral closure pressure were covariables. CONCLUSION: According to our data, both sling procedures and Burch retropubic colpourethropexy can be used to surgically manage recurrent stress urinary incontinence with selection criteria such as those that we used. In our opinion comparative prospective studies of different surgical techniques with similar selection criteria, long-term follow-up of >/=10 years, and the inclusion of urodynamic studies may be the most ethical way to determine the right operations for recurrent stress urinary incontinence.

The surgical management of recurrent stress urinary incontinence.

Recurrent stress urinary incontinence is a distressing problem. Its causes are multifactorial and the literature continually provides suggestions for changes to the surgical approach. Over 200 surgical procedures exist for the treatment of stress urinary incontinence, and this leaves the practising surgeon with an overwhelming range of choice. This article will review current available techniques for the surgical treatment of recurrent stress urinary incontinence.

Clinical efficacy and safety of tolterodine compared to oxybutynin and placebo in patients with overactive bladder.

This study compared the clinical efficacy (determined from micturition diaries) and safety of 12 weeks' treatment with either tolterodine 2 mg twice daily, oxybutynin 5 mg three times daily or placebo in patients with an overactive bladder. A total of 277 patients were randomized and treated at 25 centers. Both tolterodine and oxybutynin significantly increased volume voided/micturition compared to placebo. Both treatment groups evoked greater decreases in micturitions per 24 hours and incontinence episodes per 24 hours compared to placebo; however, only tolterodine was significantly better than placebo in reducing micturition frequency. Tolterodine and oxybutynin were equivalent in their effectiveness. Tolterodine was significantly better tolerated than oxybutynin when adverse events (particularly frequency and intensity of dry mouth), dose reduction and patient withdrawals were considered. Oxybutynin is an effective drug whose frequent adverse effects limit its clinical usefulness. Tolterodine has equivalent efficacy to oxybutynin, but with less severe adverse effects. This will allow patients to receive more effective treatment for their condition, with better compliance.

The accuracy of portable abdominal ultrasound equipment in measuring postvoid residual volume.

This study examines the accuracy of a new portable abdominal ultrasound machine (Bladder Scan, BVI 2500) used to measure postvoid urine residual (PVR). Using this machine, we started prospectively measuring residual urine in the first 80 women undergoing uroflowmetry in our urodynamic unit. Ultrasound PVR measurements were done immediately prior to catheterization while the patient was in the supine position. The catheterized postvoid residual was used as the gold standard. Eighty paired measurements were done on 78 women. Compared to catheterized PVR, ultrasound PVR measurements tend to underestimate and correlated poorly with the actual residual volume. The reading was considered accurate if it was within 25% of the catheterized PVR. The ultrasound PVR measurements were most accurate (60.6%) when the readings were below 50 ml and least accurate (10%) when readings were higher than 150 ml. Readings between 50 and 150 ml were 27% accurate. A measurement of zero '000' was common (44%), usually reflecting volumes of less than 50 ml (84% of cases). However, it could indicate that the bladder had been missed altogether. Partial measurement of the bladder volume, where the lateral bladder borders are missing, produces readings much below the actual volume: a 'tip of the iceberg' phenomenon. We therefore advocate caution when interpreting PVR measurements from portable abdominal ultrasound machines, and if an accurate measurement of PVR is necessary, catheterization remains a more reliable method.