Catherine S. Bradley

Pelvic organ prolapse in older women: prevalence and risk factors.

OBJECTIVE: We sought to estimate the prevalence of pelvic organ prolapse in older women using the Pelvic Organ Prolapse Quantification examination and to identify factors associated with prolapse. METHODS: Women with a uterus enrolled at one site of the Womens Health Initiative Hormone Replacement Therapy randomized clinical trial were eligible for this ancillary cross-sectional study. Subjects underwent a Pelvic Organ Prolapse Quantification examination during a maximal Valsalva maneuver and in addition completed a questionnaire. Logistic regression was used to identify independent risk factors for each of 2 definitions of prolapse: 1) Pelvic Organ Prolapse Quantification stage II or greater and 2) the leading edge of prolapse measured at the hymen or below. RESULTS: In 270 participants, age (mean ± SD) was 68.3 ± 5.6 years, body mass index was 30.4 ± 6.2 kg/m2, and vaginal parity (median [range]) was 3 (0–12). The proportions of Pelvic Organ Prolapse Quantification stages (95% confidence intervals [CIs]) were stage 0, 2.3% (95% CI 0.8–4.8%); stage I, 33.0% (95% CI 27.4–39.0%); stage II, 62.9% (95% CI 56.8–68.7%); and stage III, 1.9% (95% CI 0.6–4.3%). In 25.2% (95% CI 20.1–30.8%), the leading edge of prolapse was at the hymen or below. Hormone therapy was not associated with prolapse (P = .9). On multivariable analysis, less education (odds ratio [OR] 2.16, 95% CI 1.10–4.24) and higher vaginal parity (OR 1.61, 95% CI 1.03–2.50) were associated with prolapse when defined as stage II or greater. For prolapse defined by the leading edge at or below the hymen, older age had a decreased risk (OR 0.50, 95% CI 0.27–0.92) and less education, and larger babies had an increased risk (OR 2.38, 95% CI 1.31–4.32 and OR 1.97, 95% CI 1.07–3.64, respectively). CONCLUSION: Some degree of prolapse is nearly ubiquitous in older women, which should be considered in the development of clinically relevant definitions of prolapse. Risk factors for prolapse differed depending on the definition of prolapse used. LEVEL OF EVIDENCE: II-2

The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence

Context Clinicians and patients need simple, feasible ways to distinguish urge urinary incontinence from stress urinary incontinence. Contribution In this multicenter study, specialists evaluated and diagnosed incontinence in 301 middle-aged and older women who reported 3 or more episodes per week for at least 3 months. The authors developed a 3-item, self-administered questionnaire to classify women as having urge incontinence or stress incontinence. The answers to the questionnaire increased the likelihood of a final diagnosis of urge incontinence (positive likelihood ratio, 3.29) and stress incontinence (positive likelihood ratio, 2.13). Implications Asking patients some simple and quick questions may help clinicians distinguish urge urinary incontinence from stress urinary incontinence. The Editors Nearly 35% of women older than 40 years of age have urinary incontinence, which is associated with increased social isolation, falls, fractures, and admissions to specialized nursing units (1-3). Diagnosis and treatment of this common condition by primary care physicians would be optimal. Incontinence is generally classified as urge (urine leakage with the urge to urinate), stress (urine leakage when straining, coughing, or exercising), mixed (both types), or other uncommon types of incontinence (such as neurogenic and overflow). While both urge and stress incontinence may improve with behavioral interventions, such as bladder training, urge incontinence is effectively treated with antimuscarinic or anticholinergic medications (4, 5) and stress incontinence is treated with pelvic muscle exercises and surgery (6, 7). Because treatment differs, it is important to distinguish urge incontinence from stress incontinence. To distinguish urge from stress incontinence, current guidelines recommend a history, voiding diary, test for urinary tract infection, neurologic and pelvic examination, measurement of postvoid residual urine volume, and a cough stress test (8, 9). Completion of these tests is time-consuming, invasive, and expensive and is generally not feasible in primary care practice. On the basis of previous research (10, 11) and expert clinical opinion, we developed a brief, self-administered questionnaire to distinguish urge from stress incontinence that includes 3 questions (the 3 Incontinence Questions [3IQ]) and requires about 30 seconds to complete. To estimate the accuracy of the 3IQ, we conducted a prospective study among ambulatory women with incontinence at 5 academic medical centers in the United States. Methods The Diagnostic Aspects of Incontinence Study (DAISy) was a prospective multicenter study. We enrolled participants from April 2004 to December 2004 at the Loyola University of Chicago; University of Alabama at Birmingham; University of California, San Francisco (UCSF); University of Iowa, Iowa City; and University of Texas Health Science Center at San Antonio. We selected these 5 U.S. clinical sites because of their broad experience with diagnosis and treatment of urinary incontinence and the availability of a clinically active urologist or urogynecologist. We designed the study to assess the reproducibility and accuracy of the 3IQ, with an extended evaluation as the gold standard, in classifying a broad spectrum of urinary incontinence by type. The local investigational review boards of the 5 clinical sites and of UCSF, where the study was coordinated, approved the study protocol. All participants provided written informed consent. Participants We recruited women through newspaper advertisements and flyers (93.7%) and from urology and gynecology clinics (6.3%). Interested participants called trained research assistants, who screened the women over the telephone by using a standardized script. We chose eligibility criteria to define a community-dwelling sample of women with incontinence who were appropriate for evaluation and treatment in primary care settings. Eligible women were ambulatory, were 40 years of age or older, reported 3 or more episodes of incontinence per week for at least 3 months, did not have urinary tract infection, and were bothered enough by their incontinence to seek treatment. We excluded women with incontinence who had complex problems that were more appropriate for specialist referral, including 4 or more urinary tract infections in the preceding year; pregnancy within 6 months; previous anti-incontinence or urethral surgery or procedures; previous major pelvic or abdominal surgery; pelvic radiation within 6 months; or known diseases of the genitourinary tract, such as lower urinary tract or rectal fistula, congenital abnormality leading to incontinence, interstitial cystitis, severe symptomatic pelvic prolapse, current or past urogenital cancer, spinal cord lesions, multiple sclerosis, stroke with clinically significant residual disability, Parkinson disease, or other major central nervous system abnormality affecting the lower urinary tract. Since we wanted to test the accuracy of the 3IQ in distinguishing between urge and stress incontinence in women with newly identified incontinence and no previous evaluation, we also excluded women who had been treated for incontinence in the previous 3 months. Measurements At the initial visit, participants completed the 3IQ questionnaire without assistance (Figure 1). The first question establishes that incontinence has occurred in the past 3 months. The second question familiarizes the women with the types of incontinence: stress (associated with physical activity), urge (associated with the feeling of urge or the need to empty the bladder), or other (occurs without activity or urge to empty the bladder). The third question determines the category of incontinence: stress, urge, other, or mixed (stress and urge equally). Figure 1. The 3 Incontinence Questions ( 3IQ ). Participants also completed questionnaires on age, race or ethnicity, education, menopause status, parity, previous hysterectomy, smoking habits, alcohol consumption, overall health status, age of onset of incontinence, and duration (in years) of incontinence. A dipstick urinalysis was performed. To determine the reproducibility of the 3IQ, participants completed a second 3IQ questionnaire at home, 7 to 10 days after the initial administration. After completing the second questionnaire, participants completed a 3-day voiding diary at home. To assess the severity of incontinence and effect on quality of life, we asked participants to complete the Sandvik Severity Scale and a condition-specific quality-of-life instrument, the Incontinence Impact Questionnaire Short Form (IIQ-7), at a second visit. These instruments have been shown to be reliable, responsive to change over time, and valid and are widely used in incontinence research (12-14). The Sandvik Severity Scale is calculated from frequency and amount of urine loss on a scale of 1 to 12 (mild, 1 to 2; moderate, 3 to 6; severe, 8 to 9; or very severe, 12). The IIQ-7 is scored on a scale of 0 to 100, with a higher score representing greater negative effect on quality of life. Each participant also underwent an extended evaluation that included a medical, surgical, reproductive, and incontinence history; review of all medications; physical examination, including evaluation of sacral nerves 2 to 4 (deep tendon reflexes, anal wink, perineal sensation, and bulbocavernosus reflex); pelvic examination; cough stress test; measurement of postvoid residual volume (by catheter or ultrasonography); and review of the participants completed 3-day voiding diary. A urologist or urogynecologist at each clinical site supervised or performed the extended evaluation by using the sites own standard approach. One specialist performed all extended evaluations at 3 sites, 1 site used 2 specialists (University of Iowa), and 1 site used 3 specialists (Loyola University of Chicago). The urologist, urogynecologist, and supervised clinicians were blinded to the results of the 3IQ. The urologist or urogynecologist reviewed all elements of the extended evaluation and used clinical judgment to classify the participant by using the typical clinical categories of urge-only, urge-predominant, stress-only, stress-predominant, mixed, or other incontinence. We sent the complete records of the extended evaluation (without the final clinical classification) to a randomly selected second specialist at another DAISy clinical site for review. The second specialist independently classified the type of incontinence. If disagreement about type of incontinence occurred, the 2 specialists discussed the case and arrived at a consensus diagnosis. Eighty-three disagreements in diagnosis required discussion for a consensus diagnosis. To be consistent with the categories based on the 3IQ (stress, urge, other, or mixed), we combined the extended evaluation categories of urge-only and urge-predominant incontinence as urge incontinence and the stress-only and stress-predominant incontinence categories as stress incontinence. Investigators and study staff monitored serious adverse events (such as life-threatening condition, cancer, or inpatient hospitalization). They asked participants about serious adverse events, recorded any reported event on a standardized form, and faxed the form to the UCSF coordinating center within 24 hours for review. Treatment to improve both urge and stress incontinence is typically given to women with mixed incontinence. Thus, to test the accuracy of the 3IQ for selection of appropriate treatment, we assessed the accuracy of the questionnaire with respect to the extended evaluation (or gold standard test) to identify women with urge or mixed incontinence (vs. any other type of incontinence) and those with stress or mixed incontinence (vs. any other type of incontinence). Statistical Analysis We used the statistic, comparing the first and second set of 3IQ results to assess reproducibility (15). A statistic of 0.75 or greater indicates ex

The “Costs” of Urinary Incontinence for Women

OBJECTIVE: To estimate costs of routine care for female urinary incontinence, health-related quality of life, and willingness to pay for incontinence improvement. METHODS: In a cross-sectional study at 5 U.S. sites, 293 incontinent women quantified supplies, laundry, and dry cleaning specifically for incontinence. Costs were calculated by multiplying resources used by national resource costs and presented in 2005 United States dollars (

Sexual Function 6 Months After First Delivery

2005). Health-related quality of life was estimated with the Health Utilities Index. Participants estimated willingness to pay for 25–100% improvement in incontinence. Potential predictors of these outcomes were examined using multivariable linear regression. RESULTS: Mean age was 56 ± 11 years; participants were racially diverse and had a broad range of incontinence severity. Nearly 90% reported incontinence-related costs. Median weekly cost (25%, 75% interquartile range) increased from

Natural history of pelvic organ prolapse in postmenopausal women

0.37 (

Constipation in pregnancy: prevalence, symptoms, and risk factors

0, 4) for slight to

Continence pessary compared with behavioral therapy or combined therapy for stress incontinence: A randomized controlled trial

10.98 (

The MAPP research network: design, patient characterization and operations

4, 21) for very severe incontinence. Costs increased with incontinence severity (P < .001). Costs were 2.4-fold higher for African American compared with white women (P < .001) and 65% higher for women with urge compared with those having stress incontinence (P < .001). More frequent incontinence was associated with lower Health Utilities Index score (mean 0.90 ± 0.11 for weekly and 0.81 ± 0.21 for daily incontinence; P = .02). Women were willing to pay a mean of

Racial Differences in Pelvic Anatomy by Magnetic Resonance Imaging

70 ±

Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognized anal sphincter tears

64 per month for complete resolution of incontinence, and willingness to pay increased with income and greater expected benefit. CONCLUSION: Women with severe urinary incontinence pay