Long-term efficacy of nonsurgical urinary incontinence treatment in elderly women.

BACKGROUND: Although urinary incontinence affects up to 35% of community-dwelling elderly women, the long-term efficacy of conservative treatment in this population is unknown. METHODS: Between April 1991 and January 1994, 81 community-dwelling women over age 60 underwent nonsurgical incontinence treatment that included pelvic muscle exercises, bladder retraining, estrogen replacement, biofeedback, functional electrical stimulation, and pharmacologic therapy. Information about intercurrent medical problems, urogynecologic diagnoses, treatment recommendations, and provider-documented outcome were collected from medical records. We mailed structured questionnaires evaluating persistent incontinence, treatment efficacy, interval therapy, and quality of life to women who had last attended clinic at least one year previously. RESULTS: Fifty-three of 81 (65%) women, mean age (+/- SD) 76 +/- 8 years, returned the questionnaire. The mean follow-up interval was 21 +/- 8 months. At follow-up, 43% of women reported incontinence was not a problem or mild, 33% reported moderate incontinence, and 21% reported severe incontinence. When patients compared their initial with current incontinence severity, improvement was significant (p < .01). Genuine stress incontinence was diagnosed in 18 women, detrusor overactivity in 14, and mixed incontinence in 13. Improvement did not vary consistently by incontinence diagnosis. Older patients had more severe incontinence at presentation (r = .94, p = .02) and reported less improvement (r = .97, p < .01) than younger ones. However, the overall likelihood of improvement was greatest among patients with the most severe incontinence at presentation (r = .534, p < .001). Subjects considered pelvic muscle exercises, delayed voiding, and caffeine restriction most effective in reducing incontinence severity. CONCLUSIONS: Elderly women derive long-term clinical benefit from nonsurgical incontinence therapy. Younger patients and those with more severe incontinence are most likely to respond to treatment.

Postoperative catheterization, urinary retention, and permanent voiding dysfunction after polytetrafluroethylene suburethral sling placement.

OBJECTIVE: To determine the incidence of permanent voiding dysfunction after polytetrafluoroethylene suburethral sling placement, and to assess the effect of voiding mechanism and uroflowmetry on the duration of postoperative catheterization. METHODS: Between January 1986 and April 1991, 108 patients underwent suburethral sling procedures to treat genuine stress incontinence. Medical records were reviewed to collect urodynamic and catheterization data. One year or longer after surgery, 98 women completed a telephone interview evaluating incontinence, self-catheterization, and voiding symptoms. RESULTS: The mean duration of postoperative cathtrerization was 10.7 weeks. There was no significant relationship between preoperative uroflow indices and the duration of catheterization. The presence of a preoperative detrusor contraction was associated with a shorter mean duration of postoperative catheterization (6.1 versus 14.8 weeks, P = .07) and a lower risk of sling removal for retention (7 versus 33%, P = .04). Eight patients continued self-catheterization. Fourteen patients reported other micturition problems: three used the Credé maneuver or double voided to facilitate emptying and 11 were unable to urinate when seated upright. There was no correlation between the duration of catheterization and ongoing voiding dysfunction. Among nine women who underwent further surgery to treat postoperative urinary retention, three continue to catheterize, one performs Credé, and one urinates standing. CONCLUSIONS: Polytetrafluoroethylene suburethral sling placement commonly produces permanent voiding difficulty. Patients who void without a detrusor contraction are at increased risk for prolonged postoperative catheterization. Sling removal does not ensure resolution of urinary retention and may be no better than leaving the sling in place.

Long-term clinical and urodynamic evaluation of the polytetrafluoroethylene suburethral sling for treatment of genuine stress incontinence.

OBJECTIVE: To assess long-term clinical and urodynamic outcomes of suburethral sling procedures using polytetrafluoroethylene grafts. METHODS: Between January 1986 and May 1991, 108 women underwent suburethral sling placement to treat genuine stress incontinence. At least 1 year after surgery, 62 women participated in a telephone interview about surgical outcome and completed a follow-up urodynamic evaluation. RESULTS: Seventy-three percent of patients reported stress incontinence cure and 61% were objectively cured. Neither low urethral closure pressure nor a history of multiple prior anti-incontinence procedures, singly or in combination, adversely affected outcome. Postoperative maximum urethral closure pressure and functional urethral length were significantly greater in patients who were cured of their incontinence than in those whose surgery failed. Patients who were cured had higher amplitude detrusor contractions during micturition and greater post-void residual urine than those who were not cured. Thirty-three percent of patients with urodynamically stable bladders preoperatively developed detrusor instability after surgery. Detrusor instability remitted after surgery in half of the patients who had this condition preoperatively. Postoperative wound complications developed in 40% of patients who underwent sling placement, and 22% of the grafts were eventually removed. CONCLUSION: Polytetrafluoroethylene suburethral sling placement is an effective treatment for stress incontinence and low urethral pressure. Urodynamic data suggest that urethral obstruction is responsible for surgical cure. Patients should be warned of the high complication rate for this suburethral sling procedure and that graft removal may be necessary.

Accuracy of the Papanicolaou smear in the diagnosis of asymptomatic infection with Trichomonas vaginalis.

OBJECTIVE: To assess the accuracy of Papanicolaou smears in reporting cytologic evidence of Trichomonas vaginalis in asymptomatic women attending a resident clinic. METHODS: In phase I of this study, we prospectively enrolled 100 asymptomatic gynecologic patients to be screened for vaginal trichomoniasis using wet preparation, vaginal culture, and Papanicolaou smear. During phase II, asymptomatic patients (40 gynecologic and 20 obstetric) whose screening Papanicolaou smears showed cytologic evidence of trichomoniasis returned for wet preparation, culture, and repeat Papanicolaou smear. Patients were considered infected with T vaginalis if either the wet preparation or culture was positive, and uninfected if both tests were negative. The cytopathologist was not informed of the patient's enrollment in this study or of the results of culture or wet preparation. RESULTS: The prevalence of asymptomatic trichomonas infection in gynecologic patients enrolled in phase I was 6%. In asymptomatic gynecologic patients enrolled in phase II, repeat Papanicolaou smear had a sensitivity and specificity of 86 and 83%, respectively, when diagnosing infection. Thirty percent of these patients would have been treated unnecessarily for trichomoniasis based upon screening Papanicolaou smear. In obstetric patients, the sensitivity of repeat Papanicolaou smear was 94% and specificity was 100%. Had therapy been initiated based on screening cytology, 20% of obstetric patients would have received unindicated therapy. The differences in sensitivity and specificity between the groups were statistically significant (P < .05). CONCLUSION: When a screening Papanicolaou smear reports cytologic evidence of T vaginalis infection in the asymptomatic patient, a confirmatory test should be performed before initiating therapy.

Intravenous aminophylline dosage. Use of serum theophylline measurement for guidance.

A practical method for monitoring serum theophylline concentrations has been used to investigate intravenous aminophylline dosage requirements. Initial serum theophylline concentrations were found to vary widely and correlate poorly with drug history. Aminophylline loading doses determined from these values more frequently resulted in drug concentrations in the therapeutic range (10 mug to 20 mug/ml) than when therapy was given without knowledge of serum theophylline concentrations. Continuous intravenous aminophylline therapy administered in a standardized dosage (0.9 mg/kg/hr in adults and 1.0 mg/kg/hr in children) produced variable and often excessive serum concentrations. This resulted from variable drug clearance rates, which in adults averaged 0.64 +/- 0.38 ml/kg/min (mean +/- SD), only half that previously reported. These observations suggest that it is not possible to achieve optimal therapeutic aminophylline dosage without monitoring serum theophylline concentrations.