Jean F. Wyman

Urinary Incontinence: Does it Increase Risk for Falls and Fractures?

OBJECTIVE: To determine if urge urinary incontinence is associated with risk of falls and non‐spine fractures in older women.

Predictors of nursing home admission for persons with dementia

Objective:The objective of this systematic review was to identify factors that consistently predict nursing home admission (NHA) in persons with dementia. Methods:Studies published in English were retrieved by searching the MEDLINE (1966–2006), PSYCINFO (1950–2006), CINAHL (1982–2006), and Digital Dissertations (1950–2006) databases. Bibliographies of retrieved studies were also searched. Information on study characteristics and empirical results were extracted using a standardized protocol. Results:Of 782 relevant studies identified 80 were selected for review based upon eligibility criteria. The most consistent predictors of NHA in persons with dementia included severity of cognitive impairment, Alzheimer disease diagnosis, basic activity of daily living dependencies, behavioral symptoms, and depression. Caregivers who indicated greater emotional stress, a desire to institutionalize the care recipient, and feelings of being “trapped” in care responsibilities were more likely to admit persons with dementia to nursing homes. Demographic variables, incontinence, and service use did not consistently predict NHA. Conclusions:Several results seemed to challenge conventional assumptions of what precipitates NHA among persons with dementia. Caregiver stressors in conjunction with care recipient characteristics are important to consider when assessing NHA risk. The findings emphasize the need to construct more complex models of institutionalization when designing risk measures to target interventions.

Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction.

Forty-seven women had urethral pressure profile determinations performed at rest and during a Kegel pelvic muscle contraction, after brief standardized verbal instruction. Twenty-three (49%) had an ideal Kegel effort--a significant increase in the force of urethral closure without an appreciable Valsalva effort. Twelve subjects (25%) displayed a Kegel technique that could potentially promote incontinence. Age, parity, weight, estrogen deprivation, prior continence surgery or hysterectomy, and passive urethral function did not predict a successful effort. We concluded that simple verbal or written instruction does not represent adequate preparation for a patient who is about to start a Kegel exercise program.

Sexual function in women with urinary incontinence and pelvic organ prolapse

OBJECTIVE To compare sexual function in women with urinary incontinence and pelvic organ prolapse and to determine the effects of therapy on sexual function. METHODS 343 community‐dwelling women older than 45 years with urinary incontinence or advanced prolapse were recruited into a multi‐armed clinical trial. Women with incontinence were stratified to receive estrogen therapy, behavioral therapy, or surgical therapy. Women with prolapse were enrolled in a randomized surgical trial. All women completed a standardized urogynecologic evaluation and a sexual function questionnaire at baseline and after therapy. RESULTS Women with prolapse or detrusor instability were more likely to cite pelvic floor symptoms as a reason for sexual inactivity than were women with other conditions. One third of patients with prolapse reported that their pelvic floor condition affected their ability to have sexual relations “moderately” or “greatly” significantly more than did other groups. Patients with genuine stress incontinence who underwent surgical or behavioral therapy were less likely to report being worried about urine leakage during intercourse after therapy than at baseline. After surgery, women with prolapse were less likely to report that their symptoms affected their ability to have sexual relations compared with baseline. Overall sexual satisfaction was the same at baseline and remained unchanged in all therapeutic groups at 6 months. CONCLUSION Prolapse is more likely than urinary incontinence to result in sexual inactivity and to be perceived as affecting sexual relations. However, overall sexual satisfaction appears to be independent of diagnosis of or therapy for urinary incontinence or prolapse.

Comparative efficacy of behavioral interventions in the management of female urinary incontinence

OBJECTIVEnWe compared the efficacy of bladder training, pelvic muscle exercise with biofeedback-assisted instruction, and combination therapy, on urinary incontinence in women. The primary hypothesis was that combination therapy would be the most effective in reducing incontinent episodes.nnnSTUDY DESIGNnA randomized clinical trial with three treatment groups was conducted in gynecologic practices at two university medical centers. Two hundred and four women diagnosed with genuine stress incontinence (n = 145) and/or detrusor instability (n = 59) received a 12-week intervention program (6 weekly office visits and 6 weeks of mail/telephone contact) with immediate and 3-month follow-up. Outcome variables included number of incontinent episodes, quality of life, perceived improvement, and satisfaction. Data analyses consisted of analysis of covariance using baseline values as covariates and chi2 tests.nnnRESULTSnThe combination therapy group had significantly fewer incontinent episodes, better quality of life, and greater treatment satisfaction immediately after treatment. No differences among groups were observed 3 months later. Women with genuine stress incontinence had greater improvement in life impact, and those with detrusor instability had less symptom distress at the immediate follow-up; otherwise, no differences were noted by diagnosis, incontinence severity, or treatment site.nnnCONCLUSIONSnCombination therapy had the greatest immediate efficacy in the management of female urinary incontinence regardless of urodynamic diagnosis. However, each of the 3 interventions had similar effects 3 months after treatment. Results suggest that the specific treatment may not be as important as having a structured intervention program with education, counseling, and frequent patient contact.

Systematic Review: Randomized, Controlled Trials of Nonsurgical Treatments for Urinary Incontinence in Women

Prevalence estimates of urinary incontinence vary according to the definition and the method of data collection (113). In general, urinary incontinence affects about 19% of women age 19 to 44 years, 25% of those age 45 to 64 years, and 30% of those age 65 years and older. About 18% of younger women (19 to 44 years of age) (14) and 28% of women older than age 65 years (15) experience daily urinary incontinence, whereas 30% of women older than age 65 years (8, 1620) and 27% of middle-aged women (17, 18, 21) report severe urinary incontinence. The severity of incontinence influences quality of life and treatment decisions (22, 23). Clinical interventions to reduce urinary incontinence (2434) have been extensively reviewed by the Cochrane Collaboration, the International Consultation on Incontinence (22, 23, 35), and the Agency for Healthcare Research and Quality (36, 37). Most studies examined short-term curative effects of treatment in participants with urinary incontinence. The basis for measuring successful treatment varied across the studies that examined different interventions. The present review synthesizes evidence on the effectiveness of nonsurgical clinical interventions to treat urinary incontinence in community-dwelling women. This review was commissioned as background material for a National Institutes of Health Office of the Medical Applications of Research State of the Science Conference on Prevention of Fecal and Urinary Incontinence. The full report can be found at www.ahrq.gov/downloads/pub/evidence/pdf/fuiad/fuiad.pdf. Methods Data Sources We identified studies from MEDLINE (via PubMed), CINAHL, Cochrane databases, and manual searches of reference lists from systematic reviews and the proceedings of the International Continence Society (Appendix Table 1). Study Selection Two investigators independently decided on study eligibility according to recommendations from the Cochrane Handbook for Systematic Reviews of Interventions (38) to include original publications of randomized, controlled trials (RCTs) that were published in English from 1990 to May 2007. Full texts of the RCTs that examined the effects of nonsurgical clinical interventions on urinary incontinence in community-dwelling women were eligible for the review. We excluded secondary data analyses, case reports, case series, and RCTs that did not report patient outcomes. We also excluded RCTs that analyzed surrogate outcomes of subjective and objective measures of severity of urinary incontinence, including continuous changes in the number of incontinence episodes or pad use, and urodynamic variables. We excluded, but further assessed for selection bias, 17 RCTs published before 1990, 2 RCTs conducted in nursing home residents (39, 40), and 2 RCTs that examined long-term indwelling catheters or bed pads (41, 42). One study of eligible medications was analyzed in the Cochrane review (43) and is included in our present analysis (44). Several RCTs examined drugs that were not eligible for our review (4547). We concluded that we did not omit clinically important, relevant information by restricting our review to articles published from 1990 to May 2007. The information about all outcomes can be found in the full-text report, available at www.ahrq.gov/downloads/pub/evidence/pdf/fuiad/fuiad.pdf. Data Extraction and Quality Assessment Two researchers abstracted the data by using standardized forms that elicited information about study samples, interventions, designs, and outcomes. Study quality was analyzed by using the following criteria: participant selection, length and loss of follow-up, use of intention-to-treat principle, masking of the treatment status, randomization scheme, adequacy of randomization and allocation concealment, and justification of sample sizes (evidence tables can be found at www.ahrq.gov/clinic and in Appendix Tables 2 and 4 to 10) (48). We used the Grading of Recommendations Assessment, Development and Evaluation working group definitions to evaluate the overall strength of the evidence as high, moderate, low, very low, or insufficient (49, 50). The number of events, including prevalence of urinary incontinence, improvement of urinary incontinence, and continence after interventions in the active treatment and control groups, was abstracted to calculate relative risk and risk difference with 95% CIs among randomly assigned women; the intention-to-treat principle was applied (51, 52). The number of events among treatment groups was calculated from the reported rates among randomly assigned or analyzed women for intention-to-treat analysis. Baseline data were compared in the studies to test differences in the target population and unusual patterns in the data (53, 54). Errors in data extractions were assessed by comparing the established ranges for each variable and the data charts with the original articles. Reproducibility of the results was confirmed by repeating the calculations with different models. The analytic framework for the systematic review and meta-analyses was created according to the Quality of Reporting of Meta-Analyses statement (55). Applicability of the population was estimated by evaluating the inclusion of women in clinical trials (56). Applicability of the intervention duration was high for studies with a follow-up of 1 year or more and was acceptable for studies with a follow-up of 6 to 12 months. We used several strategies to reduce bias, including a comprehensive literature search of published and unpublished evidence in several databases, a search of reference lists of systematic reviews and proceedings of the International Continence Society, and contacts with experts for additional references. Data Synthesis and Statistical Analysis We report clinical definitions of urinary incontinence as they were used by the authors of the original studies and with calculated rates of continence and improvement for purposes of comparison: the number of participants continent after the clinical interventions, the number of participants with improvement in severity of urinary incontinence, and the number of participants with prevalent cases of urinary incontinence. We defined long-term (>6 months duration at follow-up) continence as a primary outcome for the present review because continence is the better-defined and most important clinical outcome. In contrast, definitions of urinary incontinence and improvement in urinary incontinence included presence as well as frequency and severity of symptoms. The rates of continence could not always be interpreted as the reciprocal of the rates of incontinence if trials reported only cases of urinary incontinence but excluded cases of improved urinary incontinence. The efficacy of clinical interventions was analyzed from the trials that compared active treatments with placebo, regular care, or no active treatments. The comparative effectiveness of the interventions was analyzed from the trials with active controls, long-term follow-up, adequate sample size, and intention-to-treat analysis (57). Pooling criteria included RCTs that reported outcomes after the same clinical interventions (58). Meta-analysis was used to assess the consistency of the association between treatments and urinary incontinence outcomes with random-effects models (59). Consistency in results was tested by comparing the direction and strength of the association. Chi-square tests and I 2 tests were used to assess heterogeneity in study resultsa P value less than 0.01 and an I 2 value greater than 50% were considered high (60, 61). We conducted meta-regression analyses by using the dose of the drug tested in individual RCTs (62). We could not perform formal meta-analyses for all treatments and outcomes because of methodologic diversity among the trials and different measurements and definitions of the outcomes. The absolute risk difference in rates of outcomes in the active and control groups was calculated for each study and in pooled analysis (63, 64). To permit the studies with zero events in one group to have the correct CIs (65, 66), we used 0.5 zero-cell correction (65) and compared the results of Peto, MantelHaenszel, and DerSimonian and Laird random-effects and fixed-effects method summary estimates (65, 66). Calculations were performed by using STATA software (STATA, College Station, Texas) at a 95% CI (63). Role of the Funding Source The Agency for Healthcare Research and Quality suggested the initial questions and provided copyright release for this manuscript but did not participate in the literature search, data analysis, or interpretation of the results. Results Of 248 RCTs on urinary incontinence interventions, we included 96 that examined nonsurgical treatments in women and reported patient outcomes (Figure 1). The Table shows evidence grades and a summary of the comparative conclusions. The studies included women with mixed urinary incontinence, predominant symptoms of stress urinary incontinence (6778), urodynamic stress urinary incontinence (7987), predominant urge urinary incontinence (88), overactive bladder with urge urinary incontinence (8994), or minimal urinary incontinence (9597) (Appendix Tables 2 and 4 to 10). The studies did not explicitly exclude women with other types of urinary incontinence; therefore, the effects of the treatments can be applied to women with mixed urinary incontinence. Figure 1. Study flow diagram. PFMT = pelvic floor muscle training; UI = urinary incontinence. *Literature search was conducted to examine diagnosis of, prevalence of, incidence of, risk factors for, and clinical interventions for UI and fecal incontinence. Some randomized, controlled trials examined several interventions. Table. Evidence of the Comparative Effectiveness of Clinical Interventions on Urinary Incontinence in Community-Dwelling Women Urinary continence after various interventions was defined as self-reported ability to control urination according to voiding diaries

Test-retest reliability of the sensory organization test in noninstitutionalized older adults

The purpose of this study was to determine the 1-week test-retest reliability of the Sensory Organization Test (SOT), using computer-generated scores and loss of balance (LOB) episodes in noninstitutionalized older adults. The SOT was administered to each subject on two separate days 1 week apart in an out-patient clinic. A volunteer sample of 40 individuals who were at least 65 years of age participated in this study. The main outcome measures were computer-generated scores for the first trial and the average of the three trials in each of the six sensory conditions of the SOT; computer-generated composite score of the six conditions; LOB on the first trial and any of three trials in each condition. The intraclass correlation coefficients (ICC) for the SOT first trial data ranged from .15 in Condition 3 to 0.70 in Condition 5. The ICCs for the SOT average of three trials ranged from 0.26 in Condition 3 to 0.68 and 0.64 in Conditions 5 and 6. Percent agreement was 77% to 100% for LOB on the first trial, as well as LOB on any of three trials of Conditions 1 through 6. As the conditions became more difficult, an increasing number of subjects experienced LOB. Analysis revealed fair to good test-retest reliability for computer-generated scores and good reliability for LOB across some conditions of the SOT. A modification to the current scoring system is suggested which would improve the reliability of the computer-generated scores of the SOT.

Measurement characteristics of a voiding diary for use by men and women with overactive bladder

OBJECTIVESnTo examine the test-retest reliability and the validity of a voiding diary designed to assess the symptoms of frequency, urgency, and urge urinary incontinence (UI).nnnMETHODSnVoiding diaries serve as the primary tool to assess symptoms of overactive bladder in clinical settings and in clinical trials of treatment for overactive bladder. Despite the widespread use of these instruments, few studies have documented their measurement properties or investigated the number of days required to assess symptoms accurately. Study participants included 21 men and 133 women at least 20 years of age recruited from urogynecology and urology clinics. All had a history of urge incontinence or mixed incontinence with urge as the primary component. Participants completed a 7-day voiding diary on two occasions, separated by at least 1 week.nnnRESULTSnMen and women reported a daily average of approximately 10 micturitions, 7 occurrences of strong urge, and 2 episodes of urge urinary incontinence. The diary exhibited good to excellent reliability, with estimated intraclass correlation coefficients (ICCs) ranging from 0.81 to 0.86 for the symptoms of strong urge, diurnal and nocturnal micturitions, total incontinence, and urge incontinence episodes. Estimates did not differ appreciably between men and women. Moderate correlations with global questions on micturition frequency and UI episodes supported the validity of the diary. Diaries completed for 3 and 4 days were similar, with only slightly lower estimates of reliability (ICC 0.79 to 0.84).nnnCONCLUSIONSnThe voiding diary completed for 7 days, following detailed instruction, is reliable and appears to be valid for documenting the change in symptoms of overactive bladder in men and women with predominantly urge incontinence. Because of comparable reliability and reduced patient burden, diaries of shorter duration may also be acceptable to assess the symptoms of overactive bladder, depending on the degree of precision required.

Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse

OBJECTIVEnSevere prolapse may mask potential genuine stress urinary incontinence in women. Some have suggested that a suspending urethropexy be performed in women who have potential genuine stress incontinence demonstrated by barrier reduction of the prolapse preoperatively. Our aim was to compare outcomes after prolapse surgery that included a formal bladder neck suspension with those operations that did not.nnnSTUDY DESIGNnThis prospective randomized clinical trial assigned 32 women with bladder neck hypermobility and stage III or IV pelvic organ prolapse to receive either a needle colposuspension or bladder neck endopelvic fascia plication as part of the vaginal reconstructive surgery. Twenty-nine subjects underwent detailed clinical, anatomic, urodynamic, and quality-of-life evaluations before and 6 weeks and 6 months after surgery; 23 completed urinary diary and quality-of-life evaluations after a mean of 2.9 years.nnnRESULTSnNeedle colposuspension increased short-term complications without providing additional protection from de novo stress incontinence. Barrier testing before surgery predicted urethral sphincteric resistance after surgery; however, such testing neither predicted a patients function after surgery nor indicated the need for a suspending urethropexy. The combination of a needle colposuspension with a sacrospinous ligament suspension predisposed to the early development of support defects of the upper anterior vaginal segment and to failure of bladder neck support.nnnCONCLUSIONSnPreoperative barrier testing in women with severe prolapse is not useful in identifying individuals who require a suspending urethropexy. Needle colposuspension increases short-term complications, lacks durability, and may predispose to early and severe recurrent anterior prolapse when performed with a sacrospinous ligament vault suspension.

Psychometric Properties of the Activities-Specific Balance Confidence Scale and the Survey of Activities and Fear of Falling in Older Women

OBJECTIVES: To compare the psychometric properties of the Activities‐specific Balance Confidence Scale (ABC) and the Survey of Activities and Fear of Falling in the Elderly (SAFE).