Vatche A. Minassian

Urinary incontinence as a worldwide problem.

Objectives: This paper reviews the literature on the prevalence of urinary incontinence (UI) and demonstrates its impact as a worldwide problem. Methods: A MEDLINE search was performed to review population‐based studies in English. Studies were grouped according to demographic variables and type of incontinence. Risk factors, help‐seeking behavior, and quality of life measures were analyzed. Results: The median prevalence of female UI was 27.6% (range: 4.8–58.4%) and prevalence of significant incontinence increased with age. The commonest cause of UI was stress (50%), then mixed (32%) and finally urge (14%). Risk factors included parity, obesity, chronic cough, depression, poor health, lower urinary tract symptoms, previous hysterectomy, and stroke. Although quality of life was affected, most patients did not seek help. Conclusion: UI is a prevalent cross‐cultural condition. Future studies should rely on universally accepted standardized definitions to produce meaningful evidence‐based conclusions, as well as project the costs of this global healthcare problem.

Urinary incontinence in women: variation in prevalence estimates and risk factors.

OBJECTIVE: To understand variation in prevalence of urinary incontinence (UI) and risk factors, given different definitions. METHODS: The National Health and Nutrition Examination Survey 2001–2002 data on UI were used. Prevalence, severity, and associated risk factors of stress, urge, mixed, and any UI were estimated in 2,875 adult women. Severe UI was defined as incontinence a few times or more per week. Moderate UI was defined as an incontinence frequency of a few times per month only, and mild UI was defined as incontinence frequency of a few times per year only. Odds ratios for the association of potential risk factors were examined in a logistic regression model. RESULTS: The overall prevalence of stress, urge, mixed, and any UI was 23.7%, 9.9%, 14.5%, and 49.2%, respectively. Prevalence of stress UI peaked at the fifth decade. Prevalence of urge and mixed UI increased with age. The largest number of risk factors and the strongest associations were found with severe UI. Age, ethnic background, and weight were significant risk factors common to all UI severity levels. Although parity and hysterectomy were risk factors for moderate and severe UI, they were not for mild UI. CONCLUSION: Prevalence of UI varies substantially by type and case definition. The stronger associations of known risk factors with severe UI and the lack of risk factors with lesser UI severity types suggest that severe UI includes primarily clinically significant cases, whereas mild UI represents transient or nonpathologic states that may not be clinically significant. LEVEL OF EVIDENCE: III

Longterm central venous access in gynecologic cancer patients

BACKGROUND To assess the utility and safety of three different longterm indwelling intravenous catheters in patients with gynecologic malignancies. STUDY DESIGN A retrospective review was performed of the records of all women with gynecologic malignancies who required longterm venous access catheters and ports between 1990 and 1997. RESULTS Two hundred sixty-eight women underwent placement of 308 indwelling catheters, of which 305 were available for analysis. Of those, 68 (22%) were Hickman catheters, 162 (53%) were infusaports, and 75 (25%) were Peripheral Access System (PAS) ports. Venous access was obtained percutaneously in 152 (50%) patients and by cutdown in 153 (50%). Prophylactic anticoagulation was used with 96 catheters (31%). Catheter placement was associated with 12 (4%) immediate complications and 87 (29%) delayed complications. The average duration of a catheter in place was 5.6 months for the Hickman, 12.5 months for the infusaport, and 16.0 months for the PAS port (p < 0.001). Bacteremia was more likely to develop in patients with Hickman catheters when compared with those with infusaports and PAS ports (19% versus 6% and 5%, respectively, p = 0.002). Thrombosis was significantly less likely to develop in patients receiving prophylactic anticoagulation (11% versus 4%, p = 0.004). Overall, the complication rate was lower with cutdown versus percutaneous access (p = 0.004). There was no statistically significant difference between the frequency of complications when correlated with the stage of disease, patient age, body mass index, or type of malignancy. CONCLUSIONS Infusaports and PAS ports were associated with a lower risk of infection and have a longer life than Hickman catheters. The cutdown approach was associated with a lower complication rate. Low-dose prophylactic anticoagulation should be given to all patients with longterm central venous catheters.

Effect of childhood dysfunctional voiding on urinary incontinence in adult women.

OBJECTIVE: To determine whether a history of childhood dysfunctional voiding is associated with urinary incontinence in adulthood. METHODS: Using a case-control study, we surveyed patients presenting with or without urinary incontinence. Cases were patients referred to a tertiary urogynecology clinic, and controls were patients referred to a general gynecology clinic. Patients completed a validated childhood questionnaire about dysfunctional voiding. A total score of 6 or more in girls is indicative of dysfunctional voiding, a condition characterized by urgency, frequency, constipation, urinary or fecal incontinence, and/or urinary tract infections. Using an alpha of 0.05, a power of 80%, and a baseline prevalence of dysfunctional voiding of 8%, we determined that 170 patients were needed to show a 3-fold difference between groups. RESULTS: Cases (n = 84) and controls (n = 86) had similar baseline characteristics except for body mass index and incidence of previous pelvic surgery. Although the total dysfunctional voiding score was higher in cases than controls (7.3 versus 5.0, respectively; P = .001), the difference in the number (%) of patients with history of childhood dysfunctional voiding between the 2 groups was not significant (47 [56%] versus 36 [42%], respectively; odds ratio 1.76, 95% confidence interval 0.96–3.24; P = .07). When all patients from both groups were combined, there was a higher prevalence of a history of childhood dysfunctional voiding in women with or without current urinary frequency (P = .004), urgency (P = .03), stress incontinence (P = .01), and urge incontinence (P = .009). CONCLUSION: Women with adult lower urinary tract symptoms may have a higher prevalence of history of childhood dysfunctional voiding. LEVEL OF EVIDENCE: II-2

Randomized trial of lidocaine ointment versus placebo for the treatment of postpartum perineal pain.

OBJECTIVE To estimate the efficacy of lidocaine ointment in relieving pain after a vaginal delivery with an episiotomy or perineal laceration. METHODS In a randomized, double‐blind, placebo‐controlled trial, 200 women received lidocaine ointment (n = 108) or a placebo (n = 92). Pain relief was assessed by the amount of ointment used (weight of jar before use (weight of jar after use), total number of pain pills used, and a pain questionnaire. The sample size was calculated using a β of .2 and an β of .05 with an expected reduction of other pain medications from an average use of six pills to four pills for the population. RESULTS There was no significant difference in the amount of lidocaine versus placebo used for postpartum day 1 (5.1 g versus 4.0 g, respectively [P =.13]) or day 2 (3.7 g versus 2.6 g, respectively [P = 18]). Patients receiving lidocaine instead of the placebo showed no significant difference in the total amount of postpartum pain medications (6.3 versus 6.8 tablets, respectively [P = .53]), subjective pain parameters (P = .36), or satisfaction from ointment (P = .99). Patients with an episiotomy used more pain medications than those with a laceration (7.9 versus 5.6 tablets, respectively [P = .003]). Those with minor versus major lacerations required fewer pain pills (6.1 versus 10.8 tablets, respectively [P < .001]) and used less ointment (4.3 g versus 7.9 g, respectively [P = .02]) on the first postpartum day. CONCLUSION Topical application of 5% lidocaine ointment was not effective in relieving episiotomy or perineal laceration pain.

Voiding Patterns and Urodynamics After a Tension-Free Vaginal Tape Procedure

OBJECTIVE To evaluate changes in urodynamic parameters, therapeutic success, and complication rates after a tension-free vaginal tape (TVT) procedure in women with stress urinary incontinence (SUI). METHODS Sixty-three women who underwent a TVT procedure for SUI, between June 1999 and December 2001 at Mount Sinai Hospital in Toronto, Ontario, were prospectively followed. Pre- and postoperative clinical data were analyzed using the Mann-Whitney, chi-square, paired t-test, and Wilcoxon signed ranks tests. RESULTS The range of follow-up was 6 weeks to 3 years. Short-term voiding dysfunction occurred in 49% of the women but was completely resolved in all women by the 12-week follow-up. For the 45 women who completed their follow-up at 6 months or 1 year after TVT, the success rate was 85%. Provocative urodynamics at 1-year follow-up compared to preoperative data showed a decrease in maximum flow rate (P < 0.001), and increase in post-void residual urine volume (P < 0.001). CONCLUSION TVT is associated with a good short-term success rate at 6 months and 1 year. A low long-term complication rate and morbidity may be expected, but significant temporary voiding dysfunction, higher than previously reported, was observed.

Why do stress and urge incontinence co-occur much more often than expected?

Assuming stress and urge urinary incontinence (UI) are independent, mixed UI prevalence is 17 times higher than expected. We consider three explanatory models. We summarize evidence from previous studies on whether common Risk Factors, Liability (i.e., one UI subtype increases risk of the other), or Severity model (i.e., mixed UI represents an advanced and more persistent stage of a progressive disorder) explains the unexpectedly high prevalence of mixed UI. We found little support to indicate that the excess prevalence of mixed UI is explained by common risk factors. In contrast, evidence does indicate that onset of one UI subtype increases risk of onset of the other subtype. Finally, although the Severity model is intuitively attractive, there is little epidemiologic evidence to support it. Longitudinal studies are needed to determine which model offers a dominant explanation for the high prevalence of mixed UI.

Predictors of Care Seeking in Women with Urinary Incontinence

To determine predictors of health care utilization in women with urinary incontinence (UI) from the population to specialty care.

Predictors of Variability in Urinary Incontinence and Overactive Bladder Symptoms

We used data from the General Longitudinal Overactive Bladder Evaluation (GLOBE) to understand predictors of variation in urgency and urinary incontinence (UI) symptoms over time.

Randomized Trial of Oxybutynin Extended Versus Immediate Release for Women Aged 65 and Older with Overactive Bladder: Lessons Learned from Conducting a Trial

OBJECTIVE This trial was designed to investigate the effectiveness of extended release versus immediate release oxybutynin in reducing symptoms of overactive bladder in a community-dwelling female population over the age of 65. METHODS This was a prospective randomized 12-week, open-label study. The primary outcome was number of micturitions per 24 hours, 12 weeks after treatment. The a priori sample size estimate was 60 patients per group. RESULTS Of the 318 women approached, only 72 women (23%) were enrolled over 34 months (33 in the immediate release group, and 39 in the extended release group). The study was stopped prematurely because of recruitment difficulties and an interim analysis revealing the need for a much larger sample than had been estimated to show a significant difference between treatments. After 12 weeks of treatment, there was no difference between the oxybutynin extended release and immediate release groups in the number of micturitions per 24 hours or in other outcomes. CONCLUSION This study did not demonstrate differences between oxybutynin extended release and immediate release and in reducing symptoms of overactive bladder or quality of life, possibly because the study did not reach the necessary sample size. The difficulty in recruiting subjects for the trial likely resulted from the onerous study requirements (4 study visits required over 12 weeks) and the downtown location of the study centres: these factors would cause particular difficulties for women over age 65 with overactive bladder, for whom travelling may be a problem. Evidence is needed to guide prescribing for older patients, but designing research to obtain adequate sample sizes is difficult. Studies in older subjects should ensure that a much larger budget is allocated for recruitment than would be allocated for studies in younger subjects, that meticulous attention is paid to issues of transport and access, and that support is provided for subjects who agree to take part research.