What's a 'cure'? Patient-centred outcomes of treatments for stress urinary incontinence.
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Female↗
Biomedical subjects
R M Freeman
Publications and source records attributed to R M Freeman.
The effect of cannabis on urge incontinence in patients with multiple sclerosis: a multicentre, randomised placebo-controlled trial (CAMS-LUTS).
OBJECTIVE: To test whether cannabinoids reduce urge incontinence episodes without affecting voiding in patients with multiple sclerosis. This was part of the multicentre trial of the Cannabinoids in Multiple Sclerosis (CAMS) study. SUBJECTS AND METHODS: The CAMS study randomised 630 patients to receive oral administration of cannabis extract, Delta(9)-tetrahydrocannabinol (THC) or matched placebo. For this substudy subjects completed incontinence diaries. RESULTS: All three groups showed a significant reduction, p<0.01, in adjusted episode rate (i.e. correcting for baseline imbalance) from baseline to the end of treatment: cannabis extract, 38%; THC, 33%; and placebo, 18%. Both active treatments showed significant effects over placebo (cannabis extract, p=0.005; THC, p=0.039). CONCLUSION: The findings are suggestive of a clinical effect of cannabis on incontinence episodes in patients with MS. This is in contrast to the negative finding of the CAMS study, where no difference was seen in the primary outcome of spasticity.
Analgesics, Non-Narcotic↗
Initial management of stress urinary incontinence: pelvic floor muscle training and duloxetine.
Stress urinary incontinence (SUI) is common among women of all ages and can have a negative impact on quality of life (QoL). Often, women refrain from seeking treatment due to the fear that surgery might be the only option, or that no other treatments exist. SUI symptoms can often be treated with simple measures such as pelvic floor muscle training (PFMT), weight loss, devices, etc. However, PFMT has low compliance rates, and few continue long term. More recently, another treatment option has been introduced, i.e. the relatively balanced serotonin and noradrenaline reuptake inhibitor (SNRI) duloxetine. PFMT and/or SNRI are recommended as a first-line therapy for the initial management of SUI in women in the guidelines of the third International Consultation on Incontinence. SNRI have received a grade A recommendation. As PFMT and duloxetine target different areas (i.e. pelvic floor muscle and distal urethral sphincter/rhabdosphincter, respectively), combined therapy might provide additional benefit. A recent study comparing the effect of combined treatment with no active treatment found that combination therapy was significantly better for all outcomes, including frequency of SUI episodes, pad use, improvements in QoL and global impression of improvement scores. The data suggest that combination therapy might provide another treatment option for SUI symptoms in women.
Adrenergic Uptake Inhibitors↗
Overactive bladder.
The overactive bladder is a common condition, which has significant effects on quality of life. The aetiology in most cases is unknown, and treatment outcomes have until recently been unsatisfactory. Management includes excluding pathology and implementing behavioural changes such as caffeine reduction, bladder and pelvic floor training, as well as antimuscarinic drug therapy. Compliance is often problematic, and this can be improved with some of the newer antimuscarinics with fewer side-effects, and a good therapist/patient relationship. In the majority of cases this 'treatment package' is successful, but in those where it is not, intravesical therapies have been introduced, e.g. neuromodulation, alternative drug therapies (e.g. vanilloids, botox) and surgery. With a better understanding of the aetiology and identification of risk factors better outcomes from treatment are likely.
Behavior Therapy↗
How urgent is urgency? A review of current methods of assessment.
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Humans↗
Is the pelvic organ prolapse quantification system (POPQ) being used? A survey of members of the International Continence Society (ICS) and the American Urogynecologic Society (AUGS).
The authors performed a web-based questionnaire survey of 667 members of the ICS and AUGS to determine the current use of the pelvic organ prolapse quantification (POPQ) system by members of the professional societies which have advocated its use. Three hundred and eighty (57%) gynecologists responded. This international survey shows that only 40.2% of ICS and AUGS members who responded routinely use the POPQ system in their clinical practice and provides information on the most common reasons for not using it. The results highlight some of the concerns regarding the complex nature of the system and its acceptance and use by specialists worldwide. It also suggests the need for a simplified version of the classification system that is user-friendly and can be adopted by all practitioners.
Female↗
Prevalence of bladder neck mobility in asymptomatic non-pregnant nulliparous volunteers.
Antenatal bladder neck mobility is known to be associated with postpartum stress incontinence. Whether this represents a normal feature of pregnancy or a pathological process is unclear. Forty-eight nulliparous volunteers had perineal ultrasound scans to assess bladder neck mobility. Using previously defined cutoffs (for incontinence), 50% had increased linear movement and 39% increased angle of rotation. This suggests that bladder neck mobility is common in asymptomatic nulliparous women. Furthermore, it could represent a risk factor for stress incontinence after pregnancy and in the longer term.
Adult↗
The role of pelvic floor muscle training in urinary incontinence.
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Biofeedback, Psychology↗
How colposuspensions are performed in the UK: a survey of gynecologists' practice.
The authors performed a self-administered postal questionnaire survey of 690 consultant gynecologists in the UK to determine the current surgical and perioperative practice in relation to colposuspension; 350 (51%) responded. One hundred and twelve (32%) identified themselves as having a specialist interest in urogynecology. The study shows the variation in the surgical technique of colposuspension and perioperative care among gynecologists, and it provides information that may help in the development of guidelines for those involved in the surgical treatment of female urinary incontinence.
Female↗
Improving the diagnosis of genuine stress incontinence in symptomatic women with negative cough stress test: the Distal Urethral Electrical Conductance test (DUEC) revisited.
This retrospective descriptive study was performed to assess the practice of using the distal urethral electrical conductance (DUEC) test to objectively demonstrate urinary incontinence in symptomatic women with a negative cough stress test on examination. One hundred women had stable bladders on cystometry (CMG). Genuine stress incontinence (GSI) was diagnosed during CMG in 45 (45%). DUEC performed prior to cystometry had revealed stress incontinence in an additional 13 with negative CMG, thereby improving the diagnosis of GSI by 13%. The test detected urge incontinence in one (1%). The DUEC test improves the detection of stress incontinence. However, it should not be considered as an alternative to cystometry, but as an additional test when stress incontinence cannot be demonstrated clinically.
Cough↗
Do bladder neck position and amount of elevation influence the outcome of colposuspension?
OBJECTIVE: To determine whether the amount of bladder neck elevation and the position of the bladder neck after surgery influence the cure rate after colposuspension. DESIGN: Prospective, observational study. SETTING: Urogynaecology unit, district general hospital. POPULATION: Seventy-seven women undergoing colposuspension for urodynamic stress incontinence. METHODS: The bladder neck was imaged pre-operatively and one week after surgery using magnetic resonance imaging. The position of the bladder neck after surgery and the amount of elevation were correlated to continence outcome one year after surgery (subjective and objective evidence of stress incontinence). MAIN OUTCOME MEASURES: Subjective and urodynamic stress incontinence one year after surgery. RESULTS: At one year the subjective and objective failure rates were 11.6% and 10.5%, respectively. Measures using magnetic resonance imaging were obtained in 73 women. No association was found between continence outcome and post-operative bladder neck position and elevation. CONCLUSION: The post-operative position of the bladder neck and the amount of elevation do not influence continence outcome. Post-operative morbidity (voiding dysfunction and detrusor instability) might be preventable by avoiding excessive bladder neck elevation and compression, without compromising the success of the procedure.
Adult↗
Objective assessment of bladder neck elevation and urethral compression at colposuspension.
OBJECTIVES: 1. To assess whether magnetic resonance imaging and intra-operative measurements are useful in assessing bladder neck elevation and urethral compression at colposuspension; 2. to see if intra-operative measurements could be a substitute for magnetic resonance scan measurements. DESIGN: Prospective, observational study. SETTING: Urogynaecology Unit, NHS Trust hospital. POPULATION: Seventy-seven women undergoing colposuspension. METHODS: Bladder neck elevation was assessed using magnetic resonance imaging and measuring the amount of suture bow-stringing intra-operatively. Urethral compression was assessed using magnetic resonance imaging and by two intra-operative measurements: the distance between the medial sutures (with a ruler) and the distance between the urethra and the pubic bone (using paired Hegar dilators). RESULTS: The assessment of bladder neck elevation and compression against the pubic bone using magnetic resonance imaging was reliable (95% limits of agreement: -7.1mm to +7.1mm and -1.7mm to +3.8mm, correlation coefficient 0.92 and 0.87, respectively). The intra-operative assessment of urethral compression with a ruler was also reproducible at both paravaginal and pectineal sites (95% limits of agreement -2.6mm to +2mm and -2.1mm to +2.4mm, respectively; correlation coefficient 0.99 for both distances). Other intra-operative measurements of bladder neck elevation (suture bow-stringing) and urethral compression (Hegars) did not correlate with equivalent magnetic resonance scan measurements (kappa =-0.046, P = 0.31; kappa = 0.052, P = 0.41, respectively). CONCLUSIONS: Measurements have been found that can reliably assess bladder neck elevation and urethral compression at colposuspension. These measurements should be suitable for investigating morbidity following colposuspension.
Adult↗
Why do women have voiding dysfunction and de novo detrusor instability after colposuspension?
OBJECTIVE: To investigate the causes of voiding dysfunction and new detrusor instability after colposuspension. DESIGN: Prospective, observational study. SETTING: Urogynaecology unit, district general hospital. POPULATION: Seventy-seven women undergoing colposuspension for genuine stress incontinence. METHODS: The following factors were investigated: 1. bladder neck elevation by magnetic resonance imaging before and after surgery; 2. urethral compression by measuring bladder neck approximation to the pubis with magnetic resonance imaging after surgery (anterior compression) and the distance between the medial stitches during surgery (lateral compression); 3. clinical and urodynamic factors. MAIN OUTCOME MEASURES: 1. Post-operative voiding function (i.e. first day of voiding and day of catheter removal); 2. objective evidence of detrusor instability three months post-operatively. RESULTS: Pre-operative peak flow rate (P = 0.004), straining during voiding (P = 0.005), increasing age (P < 0.001), operative elevation (P < 0.001) and anterior urethral compression (P = 0.001) were associated with the number of days of post-operative catheterisation. Increasing age (P = 0.02), previous bladder neck surgery (P = 0.04), operative elevation (P = 0.049) and anterior urethral compression (P < 0.001) were associated with detrusor instability at three months. CONCLUSION: Surgical factors (bladder neck elevation and compression) are associated with voiding dysfunction and detrusor instability after colposuspension. These findings have implications for prevention.
Adult↗
Prevention of postpartum stress incontinence in primigravidae with increased bladder neck mobility: a randomised controlled trial of antenatal pelvic floor exercises.
OBJECTIVE: To test whether supervised pelvic floor exercises antenatally will reduce the incidence of postpartum stress incontinence in at-risk primigravidae with bladder neck mobility, ultrasonically proven. DESIGN: Single blind, randomised controlled trial. SETTING: Antenatal clinic in a UK NHS Trust Hospital. SAMPLE: Two hundred and sixty-eight primigravidae attending an antenatal clinic at approximately 20 weeks of gestation with bladder neck mobility, on standardised valsalva, of 5 mm or more linear movement. The median age was 28, ranging from 16 to 47 years. INTERVENTION: Patients randomised to supervised pelvic floor exercises (n = 139) attended a physiotherapist at monthly intervals from 20 weeks until delivery. The exercises comprised three repetitions of eight contractions each held for six seconds, with two minutes rest between repetitions. These were repeated twice daily. At 34 weeks of gestation the number of contractions per repetition was increased to 12. Both the untreated control group and the study group received verbal advice on pelvic floor exercises from their midwives antenatally. MAIN OUTCOME MEASURES: Subjective reporting of stress incontinence at three months postpartum. Pelvic floor strength, using perineometry, and bladder neck mobility measured by perineal ultrasound. RESULTS: Of the 268 women enrolled, information on the main outcome variable was available for 110 in the control group and 120 in the study group. Fewer women in the supervised pelvic floor exercise group reported postpartum stress incontinence, 19.2% compared with 32.7% in the control group (RR 0.59 [0.37-0.92]). There was no change in bladder neck mobility and no difference in pelvic floor strength between groups after exercise, although all those developing postpartum stress incontinence had significantly poorer perineometry scores than those who were continent. CONCLUSIONS: The findings suggest that antenatal supervised pelvic floor exercises are effective in reducing the risk of postpartum stress incontinence in primigravidae with bladder neck mobility.
Adolescent↗
Female urinary incontinence: aetiology and pathophysiology.
Genuine stress incontinence and detrusor instability are the main causes of female urinary incontinence. Treatments are not always satisfactory and a better understanding of the aetiology and pathophysiology should result in more successful therapies and aid prevention.
Adult↗
Urinary tract infection after urodynamic studies in women: incidence and natural history.
OBJECTIVE: To study the incidence, natural history and symptomatic effects of bacteriuria after urodynamic studies in women. PATIENTS AND METHODS: In a prospective study in the urogynaecology clinic of a large District General Hospital, 214 women (mean age 52.3 years, range 23-81) underwent urodynamic studies. Bacteriuria was detected by semiquantitative culture at 2 and 7 days after the test. Women completed a 7-day diary of symptoms and events. RESULTS: The incidence of bacteriuria after urodynamic studies was 7.9%. Bacteriuria was transient in four of 17 women but persisted in nine and developed late in four; only one of 17 infections gave rise to symptoms. Irritative bladder symptoms after the test occurred in 34% of women, but only three went to their doctors because of concern about a possible urinary tract infection. Advancing age was the only variable associated with bacteriuria after urodynamic studies (P= 0.05). Menopausal status, past history of urinary tract infection, number of urethral instrumentations required, order number in a session, peak urinary flow rate and urodynamic diagnosis were not associated variables. CONCLUSIONS: In a large series of women presenting to a urogynaecology clinic, urodynamic investigations were associated with a high incidence of transient irritative symptoms but a low incidence of bacteriuria (8%). Infection was asymptomatic in most patients, but its natural history was unpredictable. Transient, persistent and late cases of bacteriuria all occurred. In this population, urodynamic studies are associated with a low level of morbidity.
Adult↗
Psychological investigation in female patients suffering from urinary incontinence.
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Female↗
Recurrence of stress incontinence after vault suspension: can it be prevented?
Management of vault prolapse in a patient who has previously undergone successful colposuspension has not been considered in the literature. The two cases presented highlight the risk of incontinence and illustrate measures that should help to reduce it. The approach aims to reveal potential stress incontinence and to prevent excessive stretching of the upper anterior vaginal wall during surgical correction. Potential stress incontinence is revealed by a cough stress test while reducing the prolapse without a speculum, a 'pessary test' for a few days, and urodynamics both with and without a pessary. Patients with potential incontinence undergo perineal ultrasound to assess bladder neck position. If sacrospinous fixation is used, epidural anesthesia is recommended so as to allow the patient to cough during the procedure to ensure accurate suture placement. When sacrocolpopexy is done, preoperative assessment of the degree of 'safe elevation' ensures accurate suture placement.
Aged↗