Algorithmic method for assessing urinary incontinence in elderly women.

In young patients the assessment of urinary incontinence is based increasingly on the results of complex urodynamic investigations. The value of such techniques in the elderly, however, is as yet unproved. Based on the clinical and urodynamic findings in 100 incontinent elderly women an algorithmic method for managing such patients was devised. A retrospective study comparing the algorithmic outcome with the results of standard urodynamic assessment showed that 60% of invasive investigations could be avoided by this method with minimal loss of diagnostic accuracy.     

Prevalence of urinary incontinence.

The prevalence of urinary incontinence was investigated by determining the number of incontinent patients under the care of various health and social service agencies in two London boroughs and by a postal survey of the 22 430 people aged 5 years and over on the practice lists of 12 general practitioners in different parts of the country. The prevalence of incontinence known to the health and social service agencies was 0.2% in women and 0.1% in men aged 15-64 and 2.5% in women and 1.3% in men aged 65 and over. The postal survey, to which 89% of the people whose correct address was known replied, showed a prevalence of urinary incontinence of 8.5% in women and 1.6% in men aged 15-64 and 11.6% in women and 6.9% in men aged 65 and over. Nulliparous women had a lower prevalence than those who had had one, two, or three babies, but within the parity range of one to three there were no differences in prevalence. The prevalence was appreciably increased in women who had had four or more babies. Incontinence was moderate or severe in a fifth of those who reported it in the postal survey, of whom less than a third were receiving health or social services for the condition. Incontinence is a common symptom, and many unrecognised cases appear to exist. There may be considerable scope for improving its management.     

Results of Parks operation for faecal incontinence after anal sphincter injury.

Parks operation for faecal incontinence was performed on 97 patients with total loss of anorectal control due to injury. All had sustained complete division of the anal sphincters as a result of trauma, anal surgery, or obstetric tears and either were incontinent or had been given a colostomy. In all patients the divided sphincters were repaired using an overlapping technique; in 93 the repair was protected by a temporary defunctioning stoma. There was no operative mortality. Continence was completely restored in 65 (78%) and improved in a further 11 (13%) of the 83 patients assessed from four to 116 months postoperatively. Minor complications which did not affect the eventual clinical outcome occurred in 23 patients. Factors associated with failure of the operation included breakdown of the repair in the early postoperative period, fistula, and pelvic floor neuropathy. The results show that even after severe injury to the sphincters surgical reconstruction can restore continence in most patients.     

Dilatation and closing anal reflexes. Description and clinical significance of new reflexes: preliminary report.

The present communication describes new reflexes which are called 'dilatation and closing anal reflexes', and discusses their clinical significance. The study comprised 21 healthy volunteers and 15 incontinent patients (7 with partial fecal incontinence and 8 with urinary stress incontinence). The technique comprised the introduction into the rectal neck of a balloon-tipped catheter. The balloon was inflated with air in increments of 10 ml up to 50 ml, and the EMG response of the external and urethral sphincters to balloon inflation and deflation was recorded. A new device called 'switch inflation' apparatus was used to inflate the balloon simultaneously with switching of the EMG apparatus. Rapid rectal neck inflation and deflation evoked external anal and urethral sphincter contraction. Slow and gradual inflation or deflation did not initiate the response. The anesthetized external anal sphincter did not respond to the stimulus, while the saline-infiltrated sphincter responded. The latency of the reflexes was recorded. In fecal incontinent patients, the external anal sphincter, on rapid rectal neck inflation or deflation, showed lower EMG activity and longer latency than in normal volunteers; the external urethral sphincter responded as in normal volunteers. In urinary stress incontinent patients, the external anal sphincter responded normally for both rectal neck inflation and deflation. The external urethral sphincter showed lower EMG activity and prolonged latency than normal on rectal neck inflation; it did not respond to deflation. The dilatation and closing reflexes seem to play a role in fecal and urinary continence as well as in fecal sampling. Detectable changes in latency or amplitude of the evoked response indicate a defect in the reflex pathway.(ABSTRACT TRUNCATED AT 250 WORDS)     

Behavioural treatment of urinary incontinence in geriatric patients.

Urinary incontinence and a program to treat it were studied in a geriatric hospital. Of 161 men, 58 (36%) were incontinent. The most common probable causes were cerebrovascular accident and organic brain syndrome. Evaluation by cystometry (after treatment of infections) in 30 patients showed 24 (80%) to have detrusor hyperreflexia. Twenty patients with hyperreflexia completed a timed-voiding routine, which benefited 17 of them (85%).     

Urinary incontinence: prevalence,need for treatment,and effectiveness of intervention by nurse.

OBJECTIVE--To measure the unmet need of patients with regular urinary incontinence (incontinence twice or more a month) treatable by a nurse. DESIGN--Self completed postal questionnaire and randomised controlled trial of assessment and intervention by a nurse. SETTING--One urban and one rural general practice in Somerset. SUBJECTS--7300 adults randomly selected from 10,300 aged 35 and over on the combined practice lists. 515 women and 185 men with regular incontinence were offered assessment and treatment, of whom 134 women and 49 men had no intervention for three months (historical controls). They then joined the assessment and treatment programme. INTERVENTION--Four sessions of pelvic floor exercises and bladder retraining supervised by non-specialist nurse who had taken a three week course on assessing and treating uncomplicated incontinence. MAIN OUTCOME MEASURES--Number of patients desiring treatment; self reported cure, improvement, or deterioration in continence after three months. RESULTS--The questionnaire achieved a 79% response. Validated responses showed a prevalence of 4.4% in men and 16.4% in women aged 35-64. 315 (45%) of the 700 patients offered assessment refused it and seven had moved away or died, 64 men and 41 women were referred to their general practitioner. 197 of 292 treated women (68%) reported cure or improvement compared with seven (5%) of controls. 22 of the 86 men desiring treatment were suitable for intervention by the nurse. Seventeen were cured or improved compared with none of the men in the control group. CONCLUSIONS--About half the people with regular urinary incontinence took up the offer of treatment (9.2% of women and 3.4% of men in the study population). This condition can be effectively managed by a nurse with limited training.     

Recent clinical studies of new pharmacologic agents and their efficacy in the treatment of incontinence

Two agents for the control of overactive bladder-tolterodine (TOL) and extended-release oxybutynin (Oxy-XL)-have been evaluated in a number of studies for their efficacy in urge incontinence. Studies have demonstrated that TOL achieved a 20% reduction in the frequency of voiding and a 45% reduction in urge incontinent episodes. Efficacy was comparable between TOL and immediate-release oxybutinin (Oxy-IR), the standard anticholinergic comparator. There is a delay of some weeks in achieving relief with TOL, but thereafter there is a continued decrease in the total number of both micturitions and incontinent episodes in 24 hours. Trials demonstrated that there were no safety concerns at all with TOL. In particular, there was a lower incidence of dry mouth with TOL than with Oxy-IR. Dose-ranging studies established that TOL produced the lowest incidence of side effects while maintaining efficacy. In a long-term, community-use study of Oxy-XL, there was a very low incidence of central nervous system side effects, including mental acuity and memory. Among elderly nursing home patients, Oxy-XL achieved a 90% reduction in weekly urge incontinence episodes and an 86% decrease in pad use. Oxy-XL was shown to cause a significantly lower reduction in salivary output than Oxy-IR and TOL. In a recent head-to-head comparison study, there were significant differences found between Oxy-XL and TOL. Other studies have shown that the administration of Oxy-XL results in a significantly lower production of the metabolites responsible for anticholinergic side effect, particularly dry mouth, than with the standard release form, owing largely to the elimination of a first-pass effect. A long-acting form of TOL resulted in a 53% reduction in incontinent episodes. Both these anticholinergic agents have been shown to have excellent efficacy and tolerability. But the future of OAB therapy lies in targeting other mechanisms responsible for incontinence.     

Urinary incontinence in the community--analysis of a MORI poll.

OBJECTIVES--To investigate the prevalence of urinary incontinence among people living at home, their responses to it, and its emotional and social effects. DESIGN--Random sample of 4007 adults interviewed in their own homes. SETTING--Random sample of 178 constituency sampling points throughout Great Britain. SUBJECTS--1883 men, 2124 women aged 30 and over. MAIN OUTCOME MEASURES--Responses to questionnaire. RESULTS--6.6% (125) men and 14.0% (297) women had been incontinent of urine at some time--2.8% (52) men and 7.5% (159) women in the previous two months and 61% (124) of these for more than four years. 52% (108) had consulted their general practitioner at the onset of incontinence and a further 31% (65) later. Doctors commonly took a urine sample (163, 54%), referred the patient to a specialist (127, 42%), and prescribed tablets (109, 36%); only 22% (66) carried out an abdominal, rectal, or vaginal examination. Patients were not embarrassed in seeing their doctor and most thought they were treated sympathetically. 60% (265) of all those affected were concerned or worried about their incontinence, and in almost half incontinence limited their daily social activities. CONCLUSION--More people with incontinence seem to be consulting their doctors about it than has been found in previous studies, but the procedures carried out by general practitioners still seem to be suboptimal. Urinary incontinence has a profound effect on the day to day lives of most of those who suffer from it.     

Effect of a long acting GnRH analogue or placebo on plasma LH/FSH, urethral pressure profiles and clinical signs of urinary incontinence due to Sphincter mechanism incompetence in bitches

In 23 bitches with urinary incontinence due to spaying, the effect of treatment with a long-acting formulation of leuprolide acetate on frequency of incontinence, plasma gonadotropin levels and urodynamic parameters was evaluated. In addition, the clinical effect was compared with that of treatment with alpha-adrenergics. Before treatment, the dogs' incontinent episodes occurred, on average, 4 times per day on up to 6 days per week. In the pre-trial after therapy with phenylpropanolamine (n=23) the episodes of incontinence decreased by 92%, in the double-blind study 5 weeks after GnRH-analogue (n=11) by 71%; and by 28% after the placebo (n=12). By the end of the study, nine of twenty-two leuprolide treated bitches responded completely to treatment and were continent for periods lasting 70-575 days after treatment. In another 10 dogs, response to therapy was partial and the frequency of incontinence was reduced by at least 50%. After therapy with placebo, one bitch had no episodes of incontinence for 412 days. Treatment with the GnRH-analogue significantly decreased the plasma gonadotropin levels but there was no correlation between the effect on gonadotropin levels and response to treatment. Treatment with leuprolide or placebo had no effect on urethral closure pressure regardless of the response to treatment. The hypothesis that the change of the plasma gonadotropin levels after spaying is the cause of reduced urethral closure function was not supported by the results of this study. A possible direct effect of GnRH-analogues on the bladder is discussed. Long acting GnRH analogues appear to be a well-tolerated alternative for urinary incontinence treatment, but they appear to be less effective than the alpha-adrenergics.     

The role of the primary care physician in the management of bladder dysfunction

Urinary incontinence is a major health challenge for primary care physicians. Unfortunately, the majority of incontinent patients remain untreated. Primary care physicians are ideally positioned to screen for and manage urinary incontinence. A knowledge of basic micturition physiology is important for the physician to accurately identify the cause of incontinence and arrive at the correct treatment course. To this end, this article reviews the physiology of the lower urinary tract, describes the clinical types of urinary incontinence, and outlines a stepwise approach for the primary care physician to the basic evaluation and management of patients with this condition.     

New objective measures to quantify stress urinary incontinence in a novel durable animal model of intrinsic sphincter deficiency

Existing animal models of stress urinary incontinence (SUI) are limited because of the low rate of incontinence seen in the animals and to their relatively low durability. In addition, most methods described to measure incontinence are operator-dependent. The aim of this study was to develop a new durable animal model of SUI and establish objective measures to quantify SUI. We subjected female rats to transabdominal urethrolysis. At baseline and at 1, 4, 8, 12, and 24 wk after intervention, animals underwent cystometry and evaluation with abdominal leak point pressure (ALPP). Urethral resistance was evaluated by retrograde urethral perfusion pressure (RUPP). Tissues were obtained for histology and immunohistochemistry. Normal female rats had an average ALPP of 19.4 cmH2O and RUPP of 22.6 cmH2O at baseline. More than 93% of the animals had significantly decreased ALPP and RUPP after the procedure. The mean ALPP and RUPP decreased to 9.8 cmH2O and 11.2 cmH2O, respectively, by 1 wk after urethrolysis. These changes were maintained for up to 24 wk. Changes seen in urethral resistance and ALPP appear to be mediated by apoptosis, decreased neuronal mass, and smooth muscle atrophy. These results indicate that transabdominal urethrolysis is a reliable method of achieving durable decreased urethral resistance in a SUI model. RUPP and ALPP are objective and reproducible methods of assessing urethral resistance. Changes in continence and urethral resistance appear to be mediated by denervation and smooth muscle atrophy, which are seen in both elderly incontinent patients and in patients with intrinsic sphincter dysfunction.     

Pads and pants for urinary incontinence.

Fifty-one female patients, incontinent of urine, were asked to compared two different combinations of pants and pads used in the ambulatory management of their incontinence. They were offered the Kanga pant with a Kanga pad and the Sandra pant with a Bambi pad. Each patient tried both pants and pads and thus comparisons could be made on a within-patient basis. Both systems kept a similar proportion of patients dry during the day and night. In terms of comfort, however, the Kanga pant was quite clearly preferred to the Sandra. The Bambi pad was rated more highly than the Kanga pad, although the difference between the two pads was not so pronounced as that between pants.     

Changing attitudes in the management of urinary incontinence-the need for specialist nursing.

Much interest has been shown recently in the plight of the incontinent patient and how incontinence should be managed. Incontinence has a complex aetiology and may be part of many medical and social problems. Because there is a delay between completing investigations and making a diagnosis we have established a system of nursing care. Initially this was meant to provide the person protective garments and appliances, but it now covers management in both the community and the hospital. The preliminary results show that patient assessment is effective and that specialist nurses and a co-ordinated scheme to educate both doctors and nurses are needed.     

Gonadotropin-releasing hormone immunization for the treatment of urethral sphincter mechanism incompetence in ovariectomized bitches

We have investigated GnRH immunization for the treatment of urethral sphincter mechanism incompetence in ovariectomized bitches. It has been reported that decreasing LH secretion through the use of GnRH agonists temporarily restores continence in some bitches. Therefore, decreasing the circulating LH concentrations by immunizing against GnRH might temporarily maintain continence in incontinent dogs. Sixteen incontinent dogs given phenylpropanolamine (PPA) to control incontinence were recruited for this study. Eleven dogs were immunized against GnRH (novel treatment group) at week 0, and nine dogs were vaccinated again 4 weeks later. Five dogs (standard treatment group) were vaccinated with a placebo twice at 4-week intervals. PPA was discontinued in the novel treatment group 2 weeks after revaccination, and standard-treatment dogs were given PPA for the duration of the study. Blood samples were collected before each treatment and at 6, 8, 10, 12, 16, 20, and 24 weeks and owners recorded episodes of incontinence throughout the study. Ten of the eleven dogs in the novel treatment group experienced side effects as a result of vaccination; two of these dogs experienced more severe side effects after the first vaccination and were withdrawn from the study as a result. Of the nine dogs that completed the vaccination series, four dogs remained continent after PPA was discontinued. For these four dogs, there was no difference in incontinent episodes when they were given PPA versus treatment with the vaccine. All nine novel-treatment dogs developed a GnRH antibody titer and experienced a significant decrease in circulating LH concentrations. In conclusion, GnRH immunization was effective in maintaining continence in four of the nine incontinent ovariectomized dogs, and in these dogs, treatment with the vaccine was comparable with treatment with PPA.     

Potential application of stem cells in urogynecology

Recent advances in stem cells therapy and tissue engineering techniques hold great promise for recovery of external urethral sphincter proper functioning and urinary incontinent patients treatment. Adult stem cells (ASCs) may be derived from striated muscles, fat tissue or as mesenchymal cells from bone marrow. These cells can differentiate in functionally normal smooth or striated muscle cells. ASCs injected to external urethral sphincter or bladder neck cause the increase in urethral closure pressure. Favourable findings of trials in animal models and in vitro encouraged to first trials in humans and hold a promising future for the treatment of urinary incontinence.     

The effect of GnRH analogs on urinary incontinence after ablation of the ovaries in dogs

After removal of the ovaries approximately 20% of dogs develop urinary incontinence. Removal of the gonads results in estrogen deficiency and chronic elevation in the production and secretion of FSH and LH. The gonadotrophins may directly or indirectly, adversely affect the sphincter function of the urethra. Estrogen replacement therapy and treatment with sympathomimetics, such as ephedrine or phenylpropanolamine (PPA), are effective only in some of the affected dogs, and many of these subsequently become nonresponsive. Since the role of the elevated gonadotrophins has not been elucidated, we used depot preparations of GnRH analogues to down-regulate gonadotrophins once or twice in 13 ovariectomized (ovx), incontinent dogs, which were either refractory to alpha-adrenergics (n=11) or in which alpha-adrenergics were contraindicated (n=2). Dogs were treated with leuprolide, deslorelin, buserelin or triptorelin. In 7 dogs treatments with GnRH analogues alone (n=11) resulted in continence for 50-738 days (mean 247). In all dogs except one, where GnRH treatments did not resolve the incontinence completely, additional treatment with phenylpropanolamine was successful. With additional treatment of phenylpropanolamine complete continence was restored for 21-367 days (mean 159). All treatments caused long-term reduction of circulating FSH and LH concentrations to very low or undetectable levels. No adverse effects of treatments were observed.     

Predicting the leakage performance of bodyworn disposable incontinence pads using laboratory tests

An international multi-centre project (The ISO Pad Leakage Project) was conducted to study the leakage performance of large bodyworn incontinence pads for heavily incontinent users and to create international standards for measuring their absorption capacities in the laboratory. This was achieved by recruiting 13 user test centres through which over 100 incontinent subjects tested each of six different products (each in three different sizes) for a period of about a week to a common protocol. Over 10 000 used pads were collected and weighed and the severity of leakage from each of them recorded. Correlations were sought between these data and the results from some 50 technical tests performed in a total of 16 technical test centres in order to discover the impact of different technical parameters on clinical pad performance. It was found that at low urine weights (less than 50 g, say) pad shaping was the most important predictor of pad leakage performance: shaped pads leaked less. With increasing urine weight, absorption capacity and absorption time increased in importance until at 350 g of urine these two parameters and shaping were of about equal significance: shaped pads with high absorption capacity and fast absorption time leaked least. A second series of analyses identified two absorption capacity tests which produced data correlating well with the overall leakage performance of pads, considering all urine weights together. Both tests were checked for repeatability (precision within laboratories) and reproducibility (precision between laboratories) and have been written up as working draft standards. In due course, either or both of them should be adopted as International Standards for measuring the absorption capacity of pads for heavily incontinent users. A second, similar project (ISO Pad Leakage Project 2) has begun. It focuses on small pads for lightly incontinent ambulatory women.     

Impact of surgery for stress incontinence on morbidity: cohort study.

OBJECTIVES: To describe the impact of surgery for stress incontinence on the severity of symptoms, other mental and physical symptoms, and overall health. To describe the incidence of postoperative complications. DESIGN: Prospective cohort study; questionnaires completed by patients before and 3, 6, and 12 months after surgery. Questionnaires completed by surgeons both before and after surgery. SETTING: 18 hospitals in the North Thames region. SUBJECTS: 442 women treated surgically for stress incontinence between January 1993 and June 1994. 367 women returned the 3 month questionnaire; 364 returned the 6 month questionnaire; and 359 returned the 12 month questionnaire. 49 surgeons provided perioperative information on 285 of the 442 women and postoperative information on 278. MAIN OUTCOME MEASURES: Stress incontinence symptom severity index, other urinary symptoms, bowel function, mental health, complications, global measures. RESULTS: Most women (288; 87%) reported an improvement in the severity of their stress incontinence, though only 92 (28%) were cured (continent). These improvements persisted for at least 12 months. The likelihood of improvement was similar regardless of whether urodynamic pressure studies had been conducted before surgery. Following surgery, women were less likely to suffer from urinary frequency, nocturia, postvoid fullness, dysuria, and urgency. While mental health improved for 194 (71%), a quarter of women reported deterioration. Only 37 (10%) were satisfied with postoperative pain control. A third experienced one or more complications while in hospital, most commonly difficulty urinating. This problem affected 1 in 11 women after discharge. A year after surgery two thirds of women reported feeling better (251; 72%), that the outcome met or exceeded their expectations (230; 66%), and that they would recommend the operation to a friend in a similar situation (239; 68%), and that they would recommend the operation to a friend in a similar situation (239; 68%). Surgeons tended to be more optimistic about the effects of surgery; they were satisfied with the outcome in 176 (85%) cases and would again treat 245 (94%) of the women as they had done previously. CONCLUSIONS: Although surgery reduces the severity of stress incontinence it is not as effective as current textbooks suggest. Women considering surgery should be provided with more accurate information on the likelihood of an improvement in symptoms and the occurrence of complications, including postoperative pain. Urgency and urge incontinence should not be considered contraindications to surgery. The need for urodynamic assessment before surgery should be reappraised.     

Smoking among morbidly obese patients

Background

Urinary incontinence (UI) is a distressing problem for older people. To investigate the relationship between UI and respiratory symptoms among middle-aged and older men, a community-based study was conducted in Japan.

Methods

A convenience sample of 668 community-dwelling men aged 40 years or above was recruited from middle and southern Japan. The International Consultation on Incontinence Questionnaire-Short Form, the Medical Research Council's dyspnoea scale and the Australian Lung Foundation's Feeling Short of Breath scale, were administered by face-to-face interviews to ascertain their UI status and respiratory symptoms.

Results

The overall prevalence of UI was 7.6%, with urge-type leakage (59%) being most common among the 51 incontinent men. The presence of respiratory symptoms was significantly higher among incontinent men than those without the condition, especially for breathlessness (45% versus 30%, p = 0.025). The odds of UI for breathlessness was 2.11 (95% confidence interval 1.10-4.06) after accounting for age, body mass index, smoking and alcohol drinking status of each individual.

Conclusions

The findings suggested a significant association between UI and breathlessness in middle-aged and older men.     

FSH and LH plasma levels in bitches with differences in risk for urinary incontinence

To determine whether the height of the plasma gonadotropin levels after spaying is associated with urinary incontinence, the concentrations of plasma follicle stimulating hormone (FSH) and luteinizing hormone (LH) were determined once in 191 intact and 308 spayed bitches. The bitches were grouped according to their risk for urinary incontinence and the medians of their respective gonadotropin levels were compared. For intact anestrous bitches, the FSH- and LH-plasma concentrations were 5.2 (4, 8) ng/mL (median (Q1, Q3)) and 0.5 (0.5-0.5) ng/mL, respectively. In the first year after spaying, the gonadotropin concentrations rose significantly, then stabilised at a level around 10 times those of intact bitches (FSH 62.5 (44, 91) ng/mL; LH 6.1(4, 11) ng/mL). The plasma gonadotropin concentrations of long-term spayed (>12 months) continent bitches (n=209) were higher (FSH 66.8 (46, 104) ng/mL; LH 6.5 (4, 11) ng/mL) than in spayed incontinent bitches (n=60) (FSH 51.5 (38, 74) ng/mL; LH 5.5 (3, 8) ng/mL), the latter also had a higher body weight. Multiple regression analysis showed that the FSH-plasma concentration and not the body weight was decisive for the occurrence of urinary incontinence. The results of this study suggest that levels of gonadotropins are associated, directly or indirectly in the pathophysiology of urinary incontinence after spaying.