Long-term effects ten years after maximal electrostimulation of the pelvic floor in women with unstable detrusor and urge incontinence.

OBJECTIVE: The purpose was to study any long-term therapeutic effects of maximal electrical stimulation in female urge incontinence. METHODS: A postal questionnaire containing six questions about urinary incontinence was distributed to 30 women who had been treated with maximal stimulation because of unstable detrusor and urge incontinence 9-13 years earlier. The response rate was 90% (27 women). The mean age at follow-up was 62 years. RESULTS: Twenty-one (78%) women reported symptoms of urge incontinence. Among them, 13 had this problem daily, whereas eight only had problems weekly or even more seldom. Nineteen (70%) women reported symptoms of stress incontinence. Twenty-one women would have recommended maximal stimulation to a friend today. CONCLUSION: After approximately ten years most of the women had symptoms of urge incontinence. This was, however, a minor problem among a third of them. A majority of the women were satisfied with maximal stimulation as a treatment modality. The treatment had not prevented a later occurrence of stress incontinence.

A study of female urinary incontinence in general practice. Demography, medical history, and clinical findings.

The aim of this study was to provide valid data on the demography, medical history and clinical findings among adult women presenting with urinary incontinence to general practitioners. In a rural community in Norway, all women > 20 years who consulted their general practitioner for urinary incontinence during a 3 year period were included in a prospective study. A thorough medical history and both a general and focused clinical examination were undertaken. Gynecological examination, stress provocation test, and 48 h frequency/volume chart and pad weighing test were also performed. 105 women were included (4.4% of women > 20 years in the total population). Mean age was 57 years, 64% were postmenopausal. A lot of comorbidity was reported. Duration of incontinence was > 5 years in 49%. By a severity index, 64% were classified as severe, 28% as moderate and 8% as having slight incontinence. 59% were using protective pads or garments. Mean leakage per 24 h was 31 g. 38% had significant genital prolapse. Contractility of the pelvic floor muscles was weak in 28%. Diagnostic classification revealed 50% stress incontinence, 10% urge and 40% mixed incontinence. 42% of the patients were a great deal or much bothered by their incontinence. Patients with stress incontinence were less bothered than others. Women presenting with urinary incontinence at a primary care level are prevalent, and often have significant incontinence. It is a challenge for the general practitioners to investigate and treat these patients optimally.

Validity of a scored urological history in detecting detrusor instability in female urinary incontinence.

BACKGROUND: Kauppila and co-workers published in 1982 a detrusor instability score (DIS) for women with urinary incontinence. The aim of this study was to determine the validity of the DIS in an outpatient clinic for urogynecology. METHODS: The DIS questionnaire was incorporated as part of an independent history at the first consultation. The DIS was compared with clinical diagnosis in 250 patients consecutively referred for evaluation. Sensitivity, specificity. positive predictive value (PPV), negative predictive value (NPV) and overall accuracy of the DIS in diagnosing genuine stress incontinence (GSI) were calculated using the gynecologist's clinical diagnosis based on urodynamic findings as the gold standard. An ROC-curve was constructed for determining the optimum cut-off point for the DIS for women with GSI. RESULTS: A cut-off point at 7 for the DIS, yielded sensitivity = 0.77, specificity = 0.52, PPV = 0.74, NPV = 0.52 and an overall accuracy = 0.68. Optimum cut-off point for GSI according to the ROC-curve was at a DIS-value of 5, yielding sensitivity = 0.60, specificity = 0.77, PPV = 0.82, NPV = 0.52 and overall accuracy = 0.66. CONCLUSIONS: A cut-off point at 7 diagnosed 159 women (64%) as having GSI, 41 of them (16% of 250) having a false positive DIS. Similarly, a cut-off point at 5 diagnosed 112 women (45%) as having GSI, 20 of them (8% of 250) having a false positive DIS. These women, if otherwise feasible and indicated, might perhaps undergo continence surgery without preoperative urodynamics. A lower cut-off point than originally proposed ought therefore to be used if the DIS is to become a useful preoperative tool for this kind of surgery.

Treatment of urinary incontinence in women in general practice: observational study.

OBJECTIVE: To examine what is attainable when treating urinary incontinence in women in general practice. DESIGN: Observational study with 12 months' follow up. Interview and clinical examination before, during, and after treatment of women seeking help for urinary incontinence in general practice. SETTING: General practice in the rural district of Rissa, Norway. SUBJECTS: 105 women aged 20 or more with urinary incontinence. INTERVENTIONS: Treatment with pelvic floor exercises, electrostimulation, oestrogen, anticholinergic drugs, bladder training, and protective pads. MAIN OUTCOME MEASURES: Subjective and objective measures of urinary incontinence; number of patients referred to a specialist. RESULTS: After 12 months' follow up 70% (69/99) of the women were cured or much better; the mean score on a 100 mm visual analogue scale decreased from 37 to 20 mm; and the proportion of women who were greatly bothered by their incontinence decreased by 62%. 20% (20/98) of women became continent, and the percentage of women with severe incontinence decreased from 64% (63/99) to 28% (27/98). Mean leakage per 24 hours measured by a pad test decreased from 28 g at the start of treatment to 13 g after 12 months. The number of light weight pads or sanitary towels decreased from 1.6 to 0.6 a day. In all, 17/105 (16%) patients were referred to a specialist. CONCLUSIONS: Urinary incontinence in women can be effectively managed in general practice with fairly simple treatment. Most women will be satisfied with the results.

[A special clinic for investigation of urinary incontinence in women]. / Spesialistpoliklinikk for utredning av urininkontinens hos kvinner.

This article describes the findings in 228 women with urinary incontinence consecutively referred to the outpatient clinic at the University Hospital in Trondheim. A urotherapist used a structured questionnaire to record the history and also gathered other relevant information, prior to the examination by the specialist in urogynaecology. The mean age (+/- SEM) was 49 years (+/- 1), and 96 women (42%) had been incontinent for more than ten years. Urodynamic investigations revealed stress incontinence in 58%, sensory urgency in 19%, motor urgency in 17%, and positive urethral closing pressure in 21%. Normal cystometry was found in 55% of the women. The urogynaecologist's clinical diagnosis was pure stress incontinence in 45%, pure urgency in 21% and mixed incontinence in 32%. Using a severity index, we found that 7% had mild, 25% moderate, and 68% severe urinary incontinence. General practitioners seem to refer fewer old women than we consider to be appropriate. GPs themselves should handle the primary investigations and conservative measures for the majority of their patients with urinary incontinence. Specialist services should on the other hand take care of the doubtful cases and of patients where non-surgical and simple therapeutic management has failed to achieve a cure.

[Urogenital estrogen deficiency syndrome. Investigation and treatment with special reference to hormone substitution]. / Urogenital østrogenmangel-syndrom. Utredning og behandling med vekt på hormonsubstitusjon.

The risk of developing urogenital disorders increases after menopause due to decline in oestrogen production in postmenopausal women. Symptoms due to atrophy of the squamous epithelium in the vagina, urethra and bladder, recurrent urinary tract infections and abnormal function of lower urinary tract comprise the urogenital oestrogen-deficiency syndrome. The symptoms are directly related to atrophic changes in the urogenital tract. They cause reduced quality of life and persist lifelong if not treated. The present review discusses the incidence, symptoms, pathogenesis and treatment of this syndrome. Substitution therapy with oestriol is effective and has no metabolic effects or serious side effects at the recommended dosage. Oestriol should be used lifelong. The syndrome is underreported and undertreated in Norway. Therefore, an evaluation of the general health condition of elderly women, should include direct questions about these symptoms, and oestriol treatment should be offered liberally. It is effective, safe and cost-effective.

[Study and treatment of urinary incontinence in women. A case load based study by general practitioners and gynecologists]. / Utredning og behandling av urininkontinens hos kvinner. En kasuistikkbasert studie blant allmennpraktikere og gynekologer.

139 general practitioners and 190 gynaecologists responded to a case-history questionnaire about female urinary incontinence. More gynaecologists than general practitioners reported more frequent use of leakage provocation test, neurological examination, frequency-volume chart, and measurement of residual urine. Among the less relevant procedures, use of blood tests was reported more frequently by general practitioners, and use of x-rays and ultrasonography by gynaecologists. General practitioners preferred urine microscopy to urine culture. The opposite was true for the gynaecologists. 50% of the gynaecologists would prescribe oestrogens for the postmenopausal women, as against 25% of the general practitioners. Young women were instructed in pelvic floor exercises, incontinence pads were prescribed for elderly women.

Management of urinary incontinence in women in general practice: actions taken at the first consultation.

The investigators set out to find out how Norwegian general practitioners (GPs) manage women suffering from urinary incontinence by using responses to a questionnaire containing six typical case histories. Questionnaires were sent to 191 GPs, of whom 139 (73%) replied. In 93% of all case histories the GPs responded that they would conduct some kind of investigation or treatment. Gynaecological examination and microscopy of the urine were the most frequent investigations stated. Drugs were prescribed in 41% of cases, mainly following appropriate indications. Instruction in pelvic floor exercises was predominant for the younger patients, while old patients were prescribed incontinence pads. Thus it seems that the therapeutic ambitions of the practitioner are reduced as the patients get older. Bladder training was only stipulated in 14% of cases. Adequate treatment is defined as relevant drugs and exercises in combination with pads, or referral. According to this definition 46% of the patients were treated adequately, 28% by the GPs themselves. Twenty five percent of the patients were referred to a gynaecologist.

Management of urinary incontinence in gynecological practice in Norway.

In order to investigate how Norwegian gynecologists manage female urinary incontinence in their daily practice, a questionnaire about six typical case histories was sent to the members of the Norwegian Gynaecological Association. The questionnaire comprised questions about investigations, use of laboratory tests and treatment options. Of 268 questionnaires sent out, 190 were returned (71%). Frequency-volume charts were recommended by 42% of the doctors and pad-weighting tests by 12%. Urodynamic examination was recommended for 55% of the cases, but mainly in mixed incontinence (76 and 77%). Pelvic floor exercises were suggested more often to younger patients than to the elderly. Drugs were infrequently suggested, mainly following appropriate indications. Drugs and pads were recommended especially for the elderly. The recommendation rate for surgical repair was higher for young age and greater degree of stress incontinence. The modest therapeutic ambition on behalf of the elderly women lacks basis in clinical research. A general management program for female urinary incontinence would possibly standardize and improve the quality of incontinence care by gynecologists in Norway.

Long-term effectiveness of the Burch colposuspension in female urinary stress incontinence.

Of 91 women who underwent Burch colposuspension, 86 were available for clinical, urodynamic and isotope renographic follow-up examinations 5 years after surgery for evaluation of late complications and long-term effectiveness in urinary stress incontinence. A repeat urodynamic examination was accepted by 76 patients. Stress incontinence was cured in 71% of the patients with a stable bladder preoperatively, and in 57% with stress incontinence and detrusor instability (non-significant difference). Cure rate was not significantly related to age, hormonal status or previous anterior vaginal repair. The urodynamic measurements at follow-up showed a significant increase in the functional urethral length in the cured group, as compared with the improved group. The mean maximum urethral closure pressure was reduced in both groups. Symptomatic detrusor instability was found in 18% of the preoperative stable bladders, while 67% of the unstable bladders had become stable. Only 29% of the patients with a preoperative unstable bladder had a normal lower urinary tract function at follow-up. Late voiding difficulties were observed in 3% of the study group; enterocele, requiring surgical repair, developed in 7%. One patient suffered a damaged kidney due to undetected ureteral obstruction after surgery. Irritative bladder symptoms such as urgency, frequency, stranguria and nocturia represent a long-term problem after colposuspension. At the 5-year follow-up, only 52% of the study group were completely dry and free of complications, and about 30% needed further incontinence therapy. This may be due to some neurogenic factor which is not corrected by surgery.

Long-term electrostimulation of the pelvic floor: primary therapy in female stress incontinence?

A prospective evaluation of the therapeutic effect of neuromuscular electrical pelvic floor stimulation was performed in 55 women with urinary stress incontinence awaiting surgical repair. Chronic stimulation was applied anally or vaginally by an integrated plug electrode for a median of 5.4 months. After therapy, 68% of the patients were continent or had improved so such that the planned operation was cancelled. At 2-year follow-up, the persisting success rate after electrostimulation was reduced to 56%, 31% had undergone surgical repair or were awaiting colposuspension, 9% were still incontinent, but refused surgery, and 4% were deceased. However, in the high-compliance group of 45 patients who had used the device regularly for at least 3 months, the success rate of pelvic floor stimulation was 72% at 2-year follow-up. The therapeutic effect could be verified objectively by positive changes in clinical stress test and dynamic urethral pressure profile. Approximately 2,300 pounds were saved for each patient avoiding surgery. A 40% reduction of the total cost of stress incontinence therapy was attained by the presented model.

Effect of anal electrostimulation with the 'Incontan' device in women with urinary incontinence.

An integrated, automatic electrical stimulator has been developed to treat urinary incontinence. A group of 121 women with either stress-, motor urge- or mixed incontinence was selected for treatment, but 23 discontinued the treatment within 3 months and were excluded from the study. In the study group of 98 women, anal stimulation was applied for an average of 9 months (range 3-36 months). Between 9 and 36 months after the treatment was completed, 91% were either continent or had improved significantly, but in 9% the stimulation had no effect. Significant improvement occurred on clinical and urodynamic testing. There were no serious side-effects. Intra-anal electrostimulation therapy provides an alternative to surgery in patients with stress incontinence, and could be the first choice of treatment in women with combined stress and motor urge incontinence.

Changes in urodynamic measurements after successful anal electrostimulation in female urinary incontinence.

Fifty-five of 71 women with stress, motor urge and mixed stress and motor urge urinary incontinence were treated successfully with a new integrated electrostimulation device (Incontan) used anally. Changes in urodynamic measurements were evaluated when the patients themselves reported cure or significant improvement. The duration of the treatment was 9 to 20 h/day for at least 2 months (mean 9 months). According to the patients' subjective evaluation, 71% were cured of their incontinence and 29% were markedly improved. In motor urge and mixed incontinence a significant increase in bladder volume at first sensation and at maximum cystometric capacity was found, and 45% of these patients had a normal, stable bladder after treatment. A significant increase in functional urethral length was observed in patients who had had stress incontinence, but the measured increase in maximum urethral pressure was not significant. Of the 16 patients with stress and mixed incontinence who reported cure, 15 had a positive urethral closure pressure during coughing after treatment. Urodynamic analysis confirmed the positive clinical effect observed after electrostimulation therapy. It is recommended as primary therapy in stress, motor urge and mixed stress and motor urge incontinence in women.

Anal electrostimulation in urinary incontinence. Technical description of a new device.

A new electrical anal stimulator has been developed to treat urinary incontinence. The device is automatic and fully integrated with both battery and electronics in the plug. Shape, plastic material, electrodes, electrical parameters and electronic circuits have been carefully selected for optimal acceptability and therapeutic effect. A pilot study was performed in 24 women with stress, motor urge and mixed stress and motor urge incontinence where traditional incontinence therapy had failed. When the stimulator had been used for an average of 3.5 months, 25% were continent, 54% much improved and 21% without any effect of the treatment. Improved incontinence status was verified by positive changes in the urodynamic parameters in some of the patients after the treatment. No serious side effects have been observed. The present device is simple to handle for the patient and has satisfactory technical and mechanical properties. The preliminary clinical results are promising.

Prognostic value of ultrasound, HCG and progesterone in threatened abortion.

The diagnostic and prognostic value of ultrasound, beta-HCG subunit, and progesterone are evaluated in a prospective study in 169 patients with threatened abortion. Ultrasound diagnosis had just been introduced at the hospital when the study began and clinicians accepted the patients for treatment without receiving the ultrasound, HCG, or progesterone results. With ultrasound, a correct diagnosis of the in utero situation (true positive and true negative) was made at admission in 93% and after 1 week in 99% of the cases; in 1% of the cases intact pregnancies were mistaken for abortions (false positive). For the tests applied, ultrasound had the highest sensitivity in detecting a pathologic pregnancy and also the best predictive value when a pathologic condition was discovered.