Lily A. Arya

Discontinuation rates of anticholinergic medications used for the treatment of lower urinary tract symptoms.

OBJECTIVE: To estimate the discontinuation rates of anticholinergic medications used for the treatment of lower urinary tract symptoms in women. METHODS: A large administrative database was used for this study. Women aged 18 years and older who were prescribed anticholinergic medications were included. An overall and drug-specific discontinuation rate for nine different anticholinergic medications was estimated. Covariates examined included number of prior drug classes used, number of switches performed, number of prior drug episodes, year of initiation, age, and history of smoking. The Kaplan-Meier method was used to estimate an overall discontinuation rate. A Cox multivariable regression was performed for the drug-specific analysis. RESULTS: There were 49,419 episodes of anticholinergic therapy available for analysis from 29,369 women. The average number of treatment episodes and number of drug classes prescribed per patient were 1.65±1.31 and 1.54±0.57, respectively. The median time for overall anticholinergic drug discontinuation was 4.76 months. The 6-month unadjusted cumulative incidence of discontinuation was 58.8% (95% confidence interval [CI] 58.4–59.3). The percentage of episodes in which women switched to another medication was 15.8% (95% CI 15.4–16.1). At 6 months, the adjusted cumulative incidence of discontinuation was as follows: oxybutynin 71% (95% CI 68.4–73.5), tolterodine tartrate 61% (59.4,64.3), extended-release oxybutynin 57% (95% CI 55.1–59.4), and extended-release tolterodine tartrate 54% (95% CI 52.3–57.7). CONCLUSION: Discontinuation rates for anticholinergic medications are high regardless of the class of medication used. LEVEL OF EVIDENCE: II

Vaginal paravaginal repair with an AlloDerm graft

OBJECTIVE This study was undertaken to describe outcomes of a technique of vaginal paravaginal repair that used AlloDerm graft (LifeCell, Branchburg, NJ) in women with recurrent stage II or with primary or recurrent stage III/IV anterior vaginal wall prolapse. STUDY DESIGN This was an observational study. Thirty-three women underwent a vaginal paravaginal repair using AlloDerm graft. Anterior vaginal wall prolapse was staged using the pelvic organ prolapse quantification system preoperatively and every 6 months after surgery. Recurrence of prolapse, changes in functional status (urinary symptoms, prolapse symptoms, and sexual activity), and complications were recorded. Objective failure was defined as recurrent anterior vaginal wall prolapse, stage II or greater, and subjective failure as symptomatic recurrent anterior vaginal wall prolapse. Life-table analysis evaluated objective and subjective failure. Risk factors for recurrent anterior vaginal wall prolapse were evaluated. RESULTS The mean age was 65.2 years and 93% of the women were white. Preoperatively, 6 women had recurrent stage II, 24 women had stage III, and 3 women had stage IV anterior vaginal wall prolapse. The median length of follow-up was 18 months. Postoperatively, 12 women had asymptomatic stage II anterior vaginal wall prolapse (not beyond the hymen) develop, and 1 woman had symptomatic stage II prolapse develop. Thus, there were 13 (41%) objective failures and 1 (3%) subjective failure. Life-table analysis demonstrated the cumulative probability of an objective failure was 0.24 at 1 year and 0.50 at 2, 3, and 4 years. The cumulative probability of a subjective failure was 0.00 at 1 and 2 years and 0.11 at 3 and 4 years. No risk factors for objective failure were identified. Voiding complaints resolved in 11 of 14 (79%) women (P=.004), incontinence symptoms resolved in 17 of 19 (89%) women (P<.001), and urgency symptoms resolved in 20 of 23 (87%) women (P<.001) (all two-tailed Fisher exact test). Twenty-one women (64%) were sexually active, and none complained of postoperative dyspareunia. Complications included 1 case of febrile morbidity, 1 cystotomy, and 1 anterior wall breakdown secondary to hematoma formation caused by heparin therapy. No other erosions or rejections were seen. CONCLUSION Vaginal paravaginal repair with AlloDerm graft in women with recurrent stage II or stage III/IV anterior vaginal wall prolapse is safe and has good subjective but only fair objective success within the first 2 years.

OnabotulinumtoxinA vs Sacral Neuromodulation on Refractory Urgency Urinary Incontinence in Women: A Randomized Clinical Trial.

Importance Women with refractory urgency urinary incontinence are treated with sacral neuromodulation and onabotulinumtoxinA with limited comparative information. Objective To assess whether onabotulinumtoxinA is superior to sacral neuromodulation in controlling refractory episodes of urgency urinary incontinence. Design, Setting, and Participants Multicenter open-label randomized trial (February 2012-January 2015) at 9 US medical centers involving 381 women with refractory urgency urinary incontinence. Interventions Cystoscopic intradetrusor injection of 200 U of onabotulinumtoxinA (n = 192) or sacral neuromodulation (n = 189). Main Outcomes and Measures Primary outcome, change from baseline mean number of daily urgency urinary incontinence episodes over 6 months, was measured with monthly 3-day diaries. Secondary outcomes included change from baseline in urinary symptom scores in the Overactive Bladder Questionnaire Short Form (SF); range, 0-100, higher scores indicating worse symptoms; Overactive Bladder Satisfaction questionnaire; range, 0-100; includes 5 subscales, higher scores indicating better satisfaction; and adverse events. Results Of the 364 women (mean [SD] age, 63.0 [11.6] years) in the intention-to-treat population, 190 women in the onabotulinumtoxinA group had a greater reduction in 6-month mean number of episodes of urgency incontinence per day than did the 174 in the sacral neuromodulation group (-3.9 vs -3.3 episodes per day; mean difference, 0.63; 95% CI, 0.13 to 1.14; P = .01). Participants treated with onabotulinumtoxinA showed greater improvement in the Overactive Bladder Questionnaire SF for symptom bother (-46.7 vs -38.6; mean difference, 8.1; 95% CI, 3.0 to 13.3; P = .002); treatment satisfaction (67.7 vs 59.8; mean difference, 7.8; 95% CI, 1.6 to 14.1; P = .01) and treatment endorsement (78.1 vs 67.6; mean difference; 10.4, 95% CI, 4.3 to 16.5; P < .001) than treatment with sacral neuromodulation. There were no differences in convenience (67.6 vs 70.2; mean difference, -2.5; 95% CI, -8.1 to 3.0; P = .36), adverse effects (88.4 vs 85.1; mean difference, 3.3; 95% CI, -1.9 to 8.5; P = .22), and treatment preference (92.% vs 89%; risk difference, -3%; 95% CI, -16% to 10%; P = .49). Urinary tract infections were more frequent in the onabotulinumtoxinA group (35% vs 11%; risk difference, -23%; 95% CI, -33% to -13%; P < .001). The need for self-catheterization was 8% and 2% at 1 and 6 months in the onabotulinumtoxinA group. Neuromodulation device revisions and removals occurred in 3%. Conclusions and Relevance Among women with refractory urgency urinary incontinence, treatment with onabotulinumtoxinA compared with sacral neuromodulation resulted in a small daily improvement in episodes that although statistically significant is of uncertain clinical importance. In addition, it resulted in a higher risk of urinary tract infections and need for transient self-catheterizations.

Exercise and urinary incontinence in women

Urinary incontinence is a common problem in women and may significantly impair their quality of life. Although women often report stress urinary incontinence during exercise, current data indicates that most types of exercise are not a risk factor for the development of urinary incontinence. However, certain extreme high-impact sports such as parachute jumping may cause pelvic organ support defects that result in stress urinary incontinence. Eating disorders also increase the risk of urinary incontinence in athletes. Overall, women should be encouraged to pursue physical activity that will benefit their general health without the risk of development of urinary incontinence later in life. Women athletes should be counseled about the increased risk of urinary incontinence with ultra high-impact sports and eating disorders. Target Audience: Obstetricians & Gynecologists, Family Practitioners Learning Objectives: After completion of this article, the reader should be able to list the most common types of urinary incontinence, to outline the risk factors for the development of urinary incontinence, and to describe the pathogenesis of exercise-associated urinary incontinence.

Investigating the Associations Between Nocturia and Sleep Disorders in Perimenopausal Women

PURPOSE We determined the associations between nocturia and sleep disorders in perimenopausal women. MATERIALS AND METHODS A total of 100 women with nocturia were compared to 200 without nocturia. Obstructive sleep apnea, insomnia, anxiety and menopausal stage were assessed using validated questionnaires. Comorbidities associated with nocturia were determined by bivariate analysis and multivariate logistic regression. RESULTS Independent associations for nocturia were anxiety (OR 2.11, 95% CI 1.08-4.13), black American race (OR 2.00, 95% CI 1.06-3.85), obstructive sleep apnea symptoms (OR 1.73, 95% CI 1.18-2.53) and insomnia (OR 1.11, 95% CI 1.05-1.12). CONCLUSIONS Nocturia is associated with sleep disorders in perimenopausal women.

Association of change in estradiol to lower urinary tract symptoms during the menopausal transition.

OBJECTIVE: To estimate the relationship between changes in estradiol (E2) levels over time and lower urinary tract symptoms in premenopausal women as they transition to menopause. METHODS: A self-administered validated questionnaire to measure lower urinary tract symptoms was administered to 300 women at the 11th assessment period on an ongoing longitudinal Penn Ovarian Aging cohort study. The association between the change in E2 over time through the menopausal transition and lower urinary tract symptoms (urinary incontinence, filling symptoms, voiding dysfunction) was determined. Risk factors associated with lower urinary tract symptoms were determined by univariable analysis and multivariable linear regression. RESULTS: Estradiol levels and menopausal stage at one point in time were not associated with lower urinary tract symptoms. Women with a sharp decline in E2 levels over time had significantly lower urinary incontinence scores in comparison with women without a change in E2 levels through the study period (mean±standard deviation 3.11±2.86 compared with 2.08±2.43, adjusted mean difference –0.93, 95% confidence interval [CI] –1.8 to –0.02). Women between the ages of 45 years to 49 years had significantly higher urinary incontinence scores than women woman age older than 55 years (1.59±1.86 compared with 3.04±2.93, adjusted mean difference 1.0, 95% CI 0.01–2.1). Women with a body mass index greater than 35 also had significantly higher urinary incontinence scores than women in the normal weight range, (3.53±3.16 compared with 1.98±2.52, adjusted mean difference 1.5, 95% CI 0.59–2.3) after adjusting for changes of E2 through the menopausal transition. High anxiety was associated with worsening scores in all three lower urinary tract symptoms domains (incontinence, filling, voiding). CONCLUSION: Women with a sharp decline in E2 through the menopausal transition have significantly lower urinary incontinence scores. Urinary filling symptoms and voiding dysfunction were not associated with changes in E2 through the menopausal transition. LEVEL OF EVIDENCE: II

Pelvic floor muscle training for urgency urinary incontinence in women: a systematic review

The objective of this study is to evaluate the effectiveness of existing physiotherapy modalities for the treatment of urge urinary incontinence (UUI). A systematic review was performed for primary studies of physiotherapy techniques for UUI published in English between 1996 and August 2010 in major electronic databases. Only randomized clinical trials that reported outcomes separately for women with UUI were included. Outcomes assessed were reduction in UUI, urinary frequency, and nocturia. Data from 13 full-text trials including the modalities of pelvic floor muscles exercises with or without biofeedback, vaginal electrical stimulation, magnetic stimulation, and vaginal cones were analyzed. The methodologic quality of these trials was fair. Significant improvement in UUI was reported for all physiotherapy techniques except vaginal cone therapy. There are insufficient data to determine if pelvic physiotherapy improves urinary frequency or nocturia. Evidence suggests that physiotherapy techniques may be beneficial for the treatment of UUI.

Clinical significance of obstructive defecatory symptoms in women with pelvic organ prolapse

To determine whether the presence of obstructive defecatory symptoms is associated with the site and severity of pelvic organ prolapse. Methods: A cross‐sectional study was performed of women with pelvic organ prolapse of grade 2 or greater who had completed a validated questionnaire that surveyed pelvic floor symptoms. Associations between patient characteristics, site and severity of prolapse, and obstructive bowel symptoms were investigated.

Functional status and postoperative morbidity in older women with prolapse.

PURPOSE We determined the relationship of preoperative functional status to postoperative morbidity after pelvic organ prolapse surgery in women older than 60 years. MATERIALS AND METHODS We performed a retrospective cohort study of 223 women older than 60 years who underwent surgery for stage II or greater pelvic organ prolapse. Our exposure was preoperative functional status, defined as American Society of Anesthesiologists (ASA) physical status class. We compared postoperative outcomes (length of stay in a medical facility, and number and severity of postoperative complications) in women with low functional status (ASA class III) to those in women with high functional status (ASA classes I and II). We determined the association of preoperative functional status with postoperative outcomes on multivariate analysis. RESULTS Women in ASA class III were significantly likely to be older (mean ± SD age 72.7 ± 7.3 vs 68.3 ± 6.5 years) and of nonwhite ethnicity (36.1% vs 20.1%), have a higher body mass index (mean 29.5 ± 5.6 vs 26.1 ± 3.8 kg/m(2)) and worse functional comorbidity score (median 3 vs 2), and have undergone obliterative surgery (33.3% vs 9.1%) than women in ASA classes I and II (each p <0.05). Low preoperative functional status was independently associated with increased length of stay in a medical facility (2.13 days, 95% CI 0.57, 3.70, p <0.01) and postoperative complications (OR 2.17, 95% CI 1.03, 4.56), after adjusting for age, body mass index, nonwhite ethnicity, number of comorbidities, surgeon and type of surgery. CONCLUSIONS As defined by ASA class, preoperative functional status is significantly associated with postoperative length of stay and complications. Preoperative functional status is useful for predicting postoperative outcomes in older women who undergo pelvic organ prolapse surgery.

Sexual dysfunction among women of low‐income status in an urban setting

To determine demographic and clinical conditions associated with sexual dysfunction among women of low‐income status living in an urban setting.