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SUBJECT OF THE DEBATE: "Urethral failure is a critical factor in female urinary incontinence Now what?" The CASE FOR by Hokanson, DeLancey pinpointed inadequacy of bladder causation for urgency urinary incontinence (UUI) and poor urethral support for stress urinary incontinence (SUI) as responsible for long-standing lack of progress in incontinence science. They proposed "Urethral failure" as causation for SUI and UUI. The CASE AGAINST, by Peter Petros agrees "abnormal detrusor function as cause for (UUI) is a failed concept, and SUI surgery results are sometimes suboptimal, but rejects "urethral failure" as cause for UUI and SUI. In answer to, "Now what?," Petros presents the Integral Theory System. SUI and UUI are dysfunctions of the bladder's binary control mechanism, mainly ligament laxity because of defective collagen/elastin. The urethra is an emptying tube. Pelvic muscle forces reflexly contract against ligaments to close urethra, open it (micturition) and stretch the vagina underlying urethelial stretch receptors to mechanically support them, preventing premature activation of micturition (UUI). High validated cure rates for SUI and UUI by repair of weakened ligaments question viability of the "urethral failure" concept. CONCLUSIONS: The major achievement of this debate (both sides) is not what causes UUI or SUI, or what doesn't, though clearly, this is important. It is calling out a 50-year ossification of the whole construct of UUI, ranging from flawed definitions to systematic denial of known cures, all of which have stalled treatment of the one billion women who suffer with incontinence. The time has come for change.

AIMS To compare efficacy and safety between neurogenic and non-neurogenic women after adjustable continence therapy (ACT®) balloons implantation to treat stress urinary incontinence (SUI) due to intrinsic sphincter deficiency. METHODS In the present retrospective multicentric study, all neurogenic and non-neurogenic women implanted with ACT® balloons between 2000 and 2018 were considered for inclusion. Efficacy was compared 1 year after implantation, and women were allocated in three different groups as follows. Success: maximum 1 pad per day and patient's impression of improvement assessed using a numeral rating scale (NRS) ≥8/10. Improvement: decrease of daily pad use and/or NRS ≥5/10. Failure: increase or stability of daily pad use or NRS

Purpose To assess the relation between diabetic retinopathy (DR) severity and urinary incontinence (UI) in patients with diabetes mellitus (DM). Materials and methods This prospective and observational study included 153 subjects. Patients were divided into three subgroups, according to severity of DR, as: No-DR, nonproliferative DR (NPDR), and proliferative DR (PDR); 40 age-matched healthy subjects formed the control group. Turkish version of the Urogenital Stress Inventory 6 (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) were used to assess the UI symptoms and their effect on quality of life. The UDI-6 and IIQ-7 scores were the primary outcomes of the study. Results No significant difference was observed between groups regarding age, maternal parity, body mass index, type of delivery, menopausal status, and smoking. The mean UDI-6 urgency UI questions score was significantly higher in the PDR group and significantly higher in the NPDR group than in the control group. The mean UDI-6 stress UI questions score was similar between groups. The mean UDI-6 voiding difficulty questions score was significantly higher in the PDR group and no significant difference was observed between other groups. The mean IIQ-7 score was significantly lower in the PDR group. A moderate and positive correlation was found between glycated hemoglobin level and the UDI-6 urgency UI and voiding difficulty questions and total scores. A weak and positive correlation was found between the duration of DM and the all UDI-6 scores. Conclusion The present study showed that UI symptoms and their effect on QOL were more severe in patients with PDR.

Aims The objective of the 5th International Consultation on Incontinence (ICI) chapter on Adult Conservative Management was to review and summarize the new evidence on conservative management of urinary incontinence (UI) and pelvic organ prolapse (POP) in order to compile a current reference source for clinicians, health researchers, and service planners. In this paper, we present the review highlights and new evidence on female conservative management. Methods Revision and updates of the 4th ICI Report using systematic review covering years 2008–2012. Results Each section begins with a brief definition and description of the intervention followed by a summary, where possible, of both the state and level of evidence for prevention and treatment, and ends with a “grade of recommendation.” The paper concludes with areas identified as requiring further research. Conclusions For UI, there are no prevention trials on lifestyle interventions. There are, however, few new intervention trials of lifestyle interventions involving weight loss and fluid intake with improved levels of evidence and grade of recommendation. Outside of pre- and post-natal pelvic floor muscle training (PFMT) trials for the prevention of female UI, there is a dearth of PFMT prevention trials for women with UI. PFMT remains the first-line treatment for female UI with high levels of evidence and grades of recommendation. Bladder training levels of evidence and grades of recommendation are maintained. For POP, new evidence supports the effectiveness of physiotherapy in the treatment of POP and there are now improved levels of evidence and grades of recommendation. Neurourol. Urodynam. © 2014 Wiley Periodicals, Inc.

Aims To ascertain possible publication bias by examining the completeness and publication of studies on nonsurgical treatments for female urinary incontinence (UI). Methods We analyzed information about studies from several trial registries through May 2010. We searched Medline using study registration identifiers to determine publication status, and compared percentages of completed and published studies by study and subject characteristics. Results Among the 166 closed studies, we found 120 completed (73%), 12 terminated (7%), 3 withdrawn (2%), and 4 (2%) that provided no reasons for noncompletion. Only 17% of closed registered studies (28/166 studies) were published in peer-reviewed journals; publication that did occur was an average of 2.2 years after study completion. The proportion of studies published did not increase over time. Studies sponsored by industry were published less often than those funded by NIH (OR = 0.04; 95%CI: 0.004–0.38). Drug studies were published less often than studies of other interventions (OR = 0.22; 95%CI: 0.05–0.96). Of the 166 closed studies, 7 (4%) posted results on the ClinicalTrials.gov website. Of Phases III and IV trials, 7% and 3% posted results, respectively. Conclusions The absence of results from a substantial proportion of conducted studies suggests that treatment decisions for women with UI are based on selected rather than comprehensive evidence of benefits and harms. Regulatory policy for clinical research should guarantee availability of the outcomes for the public, clinicians, and policymakers. Neurourol. Urodynam. 31:22–29, 2012. © 2011 Wiley Periodicals, Inc.

Aims: To assess the impact of female urinary incontinence (UI) and urgency on women's and their partners' sexual life in sexually active couples and to elucidate the concordance of answers within c ...

To examine the impact of female urinary incontinence, urgency and frequency on quality of life, and partner relationship in women (18-74 years) and their partners, and make comparisons with the corresponding age groups in a Swedish population-based study.Women with urinary incontinence, urgency and frequency (n = 206) completed specific questionnaires concerning medical history and the Bristol Female Lower Urinary Tract Symptoms questionnaire. Women who had a stable relationship (n = 170) also answered a questionnaire regarding psychosocial situation, partner relationship and sexual life, and were asked to give a similar questionnaire to their partner. Totally, 109 partners participated.The vast majority of the women considered that their urinary problems affected their physical activities negatively and almost half reported negative consequences for social life and joint activities. One third of both women and men experienced a negative impact on their relationship and about every fifth felt it had a harmful influence on physical proximity, intimacy, affection, and warmth. Compared to the older women, the younger were less satisfied with their psychological health, sexual life, leisure and financial situation, and compared to the younger men, the young women were less content with their somatic health. Overall, women with urinary problems and their partners were less satisfied with their somatic health than the corresponding age groups in the national population-based study.Female urinary incontinence, urgency and frequency significantly impair the quality of life in both younger and older women, and also have negative effects on the partner relationship and the partner's life.

Pelvic floor muscle training (PFMT) has Level A evidence to treat female urinary incontinence (UI). Recently, indirect training of the pelvic floor muscles (PFM) via the transversus abdominis muscle (TrA) has been suggested as a new method to treat UI. The aim of this article is to discuss whether there is evidence for a synergistic co-contraction between TrA and PFM in women with UI, whether TrA contraction is as effective, or more effective than PFMT in treating UI and whether there is evidence to recommend TrA training as an intervention strategy.A computerized search on PubMed, and hand searching in proceedings from the meetings of the World Confederation of Physical Therapy (1993-2007), International Continence Society and International Urogynecology Association (1990-2007) were performed.While a co-contraction of the TrA normally occurs with PFM contraction, there is evidence that a co-contraction of the PFM with TrA contraction can be lost or altered in women with UI. No randomized controlled trials (RCTs) were found comparing TrA training with untreated controls or sham. Two RCTs have shown no additional effect of adding TrA training to PFMT in the treatment of UI.To date there is insufficient evidence for the use of TrA training instead of or in addition to PFMT for women with UI. Neurourol. Urodyn. 28:368-373, 2009. (c) 2009 Wiley-Liss, Inc.

Aims There remains no gold standard for quantification of voluntary pelvic floor muscle (PFM) strength, despite international guidelines that recommend PFM assessment in females with urinary incontinence (UI). Methods currently reported for quantification of skeletal muscle strength across disciplines are systematically reviewed and their relevance for clinical and academic use related to the pelvic floor are described. Methods A systematic review via Medline, PubMed, CINHAL, and the Cochrane database using key terms for pelvic floor anatomy and function were cross referenced with skeletal muscle strength quantification from 1946 to 2016. Full text peer-reviewed articles in English having female subjects with incontinence were identified. Each study was analyzed for use of controls, type of methodology as direct or indirect measures, benefits, and limitations of the technique. Results A total of 1586 articles were identified of which 50 met the inclusion criteria. Nine methodologies of determining PFM strength were described including: digital palpation, perineometer, dynamometry, EMG, vaginal cones, ultrasonography, magnetic resonance imaging, urine stream interruption test, and the Colpexin pull test. Thirty-two percent lacked a control group. Conclusion Technical refinements in both direct and indirect instrumentation for PFM strength measurement are allowing for sensitivity. However, the most common methods of quantification remain digital palpation and perineometry; techniques that pose limitations and yield subjective or indirect measures of muscular strength. Dynamometry has potential as an accurate and sensitive tool, but is limited by inability to assess PFM strength during dynamic movements.

Aims According to our knowledge, no study has attempted to explore the risk of urinary incontinence (UI) after traumatic brain injury (TBI). This study aimed to examine the relationship between TBI in Taiwanese women and their risk of developing UI. Methods The study was based on 2,416 female patients newly diagnosed with TBI together with 12,080 matched enrollees without a history of TBI as a comparison group. All patients were tracked for a 1-year period from their index date to identify those who developed subsequent UI. The stratified Cox proportional hazards models were performed to compute the risk of UI between groups. Results Of 14,496 patients, 104 (4.30%) from the TBI group and 192 (1.59%) from the comparison group had a diagnosis of UI during the follow-up period. The incidence rate of UI was 4.50 (95% CI: 3.69–5.43) per 100 person-years in patients with TBI and 1.62 (95% CI: 1.40–1.86) per 100 person-years in patients without TBI. The stratified Cox proportional analysis showed that after adjusting for socioeconomic status, obesity, hypertension, diabetes, and hysterectomy, the increased UI risk of patients with TBI persisted at about the same level as in the unadjusted analysis (hazard ratio = 2.78; 95% CI = 2.16–3.53). In addition, although patients with severe and moderate TBI had higher incidence rates of UI than patients with mild TBI, the difference did not reach a statistically significant level (P = 0.090). Conclusions Our results suggest that an increased risk of UI exists at the first year follow-up in patients with a TBI diagnosis. Neurourol. Urodynam. 32: 354–358, 2013. © 2012 Wiley Periodicals, Inc.

Aim To explore the relationship between urinary incontinence and genital sensory functioning in females with sexual dysfunction disorders. Methods A retrospective consecutive chart review was conducted for all women who were referred to our tertiary female urology clinic with a primary complaint of sexual dysfunction between October 1999 and January 2009. Our study sample included 177 women, all of whom underwent a thorough clinical evaluation. Urinary incontinence was diagnosed based on clinical history and physical examination by a urogynecologist. The Genital Thermal and Vibratory Sensory Analyzer (GSA) was used for sensory testing in the genital area. Independent t-test and multivariate linear regression were used for statistical analysis. Results Of the 177 study patients (median age 34, range 18–68), 63 (36%) had urinary incontinence. Women with urinary incontinence were found to be less sensitive to warm, cold, and vibratory thresholds at both the anterior and the posterior vaginal wall and the clitoral area (P

Aims The pelvic floor muscle (PFM) training is effective in alleviating the symptoms of urinary incontinence, but there are very few reports available on its long-term effectiveness. Therefore, 8-year follow-up data have been prospectively analyzed. Materials and Methods Originally 123 women with stress or mixed urinary incontinence participated in an 8-week intensive PFM training program. The training comprised repeated muscle contractions of the pelvic floor and the timely locking of the perineum. An average of 8 years (6–10) had elapsed between the time of present assessment and the completion of the original training. Seventy-nine women were subjected to the present analysis. Self-reported responses of “completely cured” and “more than 50% improved” were regarded as treatment success (TS). An 8-year transition tree and predictive parameters were analyzed. Results The success rate of the training was 39% at the 8-year follow-up. The transition tree demonstrated that the continence/incontinence status has been varying in 42% of the women, while it was stable in 58% throughout the follow-up period. The 6-year incidence and remission rates of incontinence were 34% and 18%, respectively. The higher pressure difference in the vaginal contraction strength between the baseline and strength at the end of the training is a predictive parameter of the long-term TS. Conclusions The results suggest that the 8-year TS rate was 39% and that the altered patterns of the continence status and incidence and remission rates of incontinence were similar to those observed in the general population. Neurourol. Urodynam. 26:495–501, 2007. © 2007 Wiley-Liss, Inc.

Aims To compare direct health care costs of treatment for stress urinary incontinence in Sweden with four different procedures: (i) open Burch colposuspension (OBC); (ii) laparoscopic colposuspension with sutures (LCS); (iii) laparoscopic colposuspension with mesh and staples (LCM), and (iv) Tension-free Vaginal Tape (TVT). Material and Methods A model was constructed representing a hospital with standardized surgical equipment, staff and average unit costs in 2003 Euros. The time used for anesthesia and surgery was calculated. Clinical data was collected from three different sources, a multicenter, randomized, prospective study comparing OBC with LCM with 1 year follow-up, a three-armed, prospective study where women were randomized to either OBC, LCM, or LCS with 1 year follow-up and a descriptive study reporting results of TVT with 5 year follow-up. Data collected from the studies and hospital cost data were put into the model to create the different cost elements. Results The total cost per individual, showed a lower cost for TVT compared to the other alternatives. The direct costs for a TVT, €1,366 were only 56% of the costs for an OBC, €2,431 (P

Aims The aim of this study was to determine the relationship between subjective symptom severity and clinical or urodynamic parameters and to compare these parameters according to subjective symptom severity. Methods A total of 268 female patients with grade II (n = 94) and grade III (n = 174) according to the Ingelman–Sundberg scale were included in the study. Mean patient age was 55.9 years (range 28–80). Of 268 patients, 196 women (73.1%) complained of stress urinary incontinence (SUI) and 72 (26.9%) reported additional symptoms of urge urinary incontinence (UUI). Fifty-four (20.1%) women previously had hysterectomies and 12 (4.5%) underwent surgery for UI. Results Patients with severe incontinence (grade III) are older, have longer duration of symptoms, concomitant urgency or UUI, and low maximal urethral closure pressure and low Valsalva leak point pressure (VLPP). No difference in other characteristics including pad test loss and urethral mobility was observed in the two groups. In the multivariate logistic regression analysis, a longer duration of symptoms was associated with an increased likelihood of severe symptoms (P = 0.025). Patients with mixed incontinence were at five-fold increased risk of severe symptoms compared with those with SUI only (P = 0.011). In the same model, increasing VLPP was associated with a decreased likelihood of severe symptoms (P = 0.037). Conclusions Longer symptom duration, mixed incontinence and low VLPP have independent effects on the severity of incontinence. Our findings suggest that incontinent patients with sphincteric impairment or urge component may have and increased probability of severe symptoms. Neurourol. Urodynam. © 2006 Wiley-Liss, Inc.

The objective of the 5th International Consultation on Incontinence (ICI) chapter on Adult Conservative Management was to review and summarize the new evidence on conservative management of urinary incontinence (UI) and pelvic organ prolapse (POP) in order to compile a current reference source for clinicians, health researchers, and service planners. In this paper, we present the review highlights and new evidence on female conservative management.Revision and updates of the 4th ICI Report using systematic review covering years 2008-2012.Each section begins with a brief definition and description of the intervention followed by a summary, where possible, of both the state and level of evidence for prevention and treatment, and ends with a "grade of recommendation." The paper concludes with areas identified as requiring further research.For UI, there are no prevention trials on lifestyle interventions. There are, however, few new intervention trials of lifestyle interventions involving weight loss and fluid intake with improved levels of evidence and grade of recommendation. Outside of pre- and post-natal pelvic floor muscle training (PFMT) trials for the prevention of female UI, there is a dearth of PFMT prevention trials for women with UI. PFMT remains the first-line treatment for female UI with high levels of evidence and grades of recommendation. Bladder training levels of evidence and grades of recommendation are maintained. For POP, new evidence supports the effectiveness of physiotherapy in the treatment of POP and there are now improved levels of evidence and grades of recommendation. Neurourol. Urodynam. 35:15-20, 2016. © 2014 Wiley Periodicals, Inc.

To ascertain possible publication bias by examining the completeness and publication of studies on nonsurgical treatments for female urinary incontinence (UI).We analyzed information about studies from several trial registries through May 2010. We searched Medline using study registration identifiers to determine publication status, and compared percentages of completed and published studies by study and subject characteristics.Among the 166 closed studies, we found 120 completed (73%), 12 terminated (7%), 3 withdrawn (2%), and 4 (2%) that provided no reasons for noncompletion. Only 17% of closed registered studies (28/166 studies) were published in peer-reviewed journals; publication that did occur was an average of 2.2 years after study completion. The proportion of studies published did not increase over time. Studies sponsored by industry were published less often than those funded by NIH (OR = 0.04; 95%CI: 0.004-0.38). Drug studies were published less often than studies of other interventions (OR = 0.22; 95%CI: 0.05-0.96). Of the 166 closed studies, 7 (4%) posted results on the ClinicalTrials.gov website. Of Phases III and IV trials, 7% and 3% posted results, respectively.The absence of results from a substantial proportion of conducted studies suggests that treatment decisions for women with UI are based on selected rather than comprehensive evidence of benefits and harms. Regulatory policy for clinical research should guarantee availability of the outcomes for the public, clinicians, and policymakers.

To assess the impact of female urinary incontinence (UI) and urgency on women's and their partners' sexual life in sexually active couples and to elucidate the concordance of answers within couples.Women aged 18-74 years with UI and/or urgency (n = 206) were consecutively recruited from four outpatient clinics. Those with a partner (n = 170) completed a questionnaire regarding relationship and sexual life and gave a similar questionnaire to him. The present paper focuses on 99 couples with an active sexual life.Twenty-two percent of the men and 43% of the women stated that the female urinary symptoms impaired their sexual life. Forty-nine percent of the women expressed worries about having urinary leakage during sexual activity, but most of their men, 94%, did not. Twenty-three percent of the men and 39% of the women responded that the woman leaked urine during sexual activity. The majority, 84%, of women considered this a problem, but 65% of their partners did not. Except for this disparity, the rest of the answers were significant concordant within the couples.Female UI and urgency negatively affected sexual life in almost half of the women and in every fifth partner. A need for information and advice concerning sexual issues due to the woman's urinary disorder was found in one fifth of the couples. The majority of women with urinary leakage during sexual activities considered this as a problem, but most of their partners did not. Overall, the concordance of the answers within the couples was high.

According to our knowledge, no study has attempted to explore the risk of urinary incontinence (UI) after traumatic brain injury (TBI). This study aimed to examine the relationship between TBI in Taiwanese women and their risk of developing UI.The study was based on 2,416 female patients newly diagnosed with TBI together with 12,080 matched enrollees without a history of TBI as a comparison group. All patients were tracked for a 1-year period from their index date to identify those who developed subsequent UI. The stratified Cox proportional hazards models were performed to compute the risk of UI between groups.Of 14,496 patients, 104 (4.30%) from the TBI group and 192 (1.59%) from the comparison group had a diagnosis of UI during the follow-up period. The incidence rate of UI was 4.50 (95% CI: 3.69-5.43) per 100 person-years in patients with TBI and 1.62 (95% CI: 1.40-1.86) per 100 person-years in patients without TBI. The stratified Cox proportional analysis showed that after adjusting for socioeconomic status, obesity, hypertension, diabetes, and hysterectomy, the increased UI risk of patients with TBI persisted at about the same level as in the unadjusted analysis (hazard ratio = 2.78; 95% CI = 2.16-3.53). In addition, although patients with severe and moderate TBI had higher incidence rates of UI than patients with mild TBI, the difference did not reach a statistically significant level (P = 0.090).Our results suggest that an increased risk of UI exists at the first year follow-up in patients with a TBI diagnosis.

To explore the relationship between urinary incontinence and genital sensory functioning in females with sexual dysfunction disorders.A retrospective consecutive chart review was conducted for all women who were referred to our tertiary female urology clinic with a primary complaint of sexual dysfunction between October 1999 and January 2009. Our study sample included 177 women, all of whom underwent a thorough clinical evaluation. Urinary incontinence was diagnosed based on clinical history and physical examination by a urogynecologist. The Genital Thermal and Vibratory Sensory Analyzer (GSA) was used for sensory testing in the genital area. Independent t-test and multivariate linear regression were used for statistical analysis.Of the 177 study patients (median age 34, range 18-68), 63 (36%) had urinary incontinence. Women with urinary incontinence were found to be less sensitive to warm, cold, and vibratory thresholds at both the anterior and the posterior vaginal wall and the clitoral area (P0.05).Women with urinary incontinence and sexual dysfunction are less sensitive to all sensory testing in the genital region than women with sexual dysfunction alone. This relationship may be attributable to afferent nerve damage and the critical role it may play in the etiology of urinary incontinence.

Of the conservative treatment modalities for stress urinary incontinence in females, the effectiveness of electric pelvic floor stimulation and exercise programs for reeducation of pelvic floor muscles are generally accepted and recognized. This prospective study reports on the analysis of subjective and objective pre- and post-treatment parameters in 12 selected female patients with stress incontinence who were enrolled in a physiotherapeutical training program consisting of acute intrarectal electrostimulation, pelvic floor exercises, and body posture correction (Mensendieck). Patients' symptom scores, performance status of pelvic floor muscles, body posture alterations as well as standard urodynamic parameters (maximal urethral closing pressure, functional urethral length, and maximum cystometric capacity), and telemetric ambulatory urodynamic parameters (pad-weighing test, urethral relaxations) were analyzed. This study shows the advantageous effect of pelvic floor reeducation and body posture correction for the treatment of female low-urethral-resistance urinary incontinence. A remarkable finding was the coalescence of genuine stress incontinence, proven on standard urodynamic investigation, and urethral instability on telemetric ambulatory urodynamic investigation in 10 of 12 patients (83%). This was very well treated by the training program. Pathophysiology of low-urethral-resistance urinary incontinence and the mode of action of the training program are discussed. © 1992 Wiley-Liss, Inc.

The pelvic floor muscle (PFM) training is effective in alleviating the symptoms of urinary incontinence, but there are very few reports available on its long-term effectiveness. Therefore, 8-year follow-up data have been prospectively analyzed.Originally 123 women with stress or mixed urinary incontinence participated in an 8-week intensive PFM training program. The training comprised repeated muscle contractions of the pelvic floor and the timely locking of the perineum. An average of 8 years (6-10) had elapsed between the time of present assessment and the completion of the original training. Seventy-nine women were subjected to the present analysis. Self-reported responses of "completely cured" and "more than 50% improved" were regarded as treatment success (TS). An 8-year transition tree and predictive parameters were analyzed.The success rate of the training was 39% at the 8-year follow-up. The transition tree demonstrated that the continence/incontinence status has been varying in 42% of the women, while it was stable in 58% throughout the follow-up period. The 6-year incidence and remission rates of incontinence were 34% and 18%, respectively. The higher pressure difference in the vaginal contraction strength between the baseline and strength at the end of the training is a predictive parameter of the long-term TS.The results suggest that the 8-year TS rate was 39% and that the altered patterns of the continence status and incidence and remission rates of incontinence were similar to those observed in the general population.

The aim of this study was to determine the relationship between subjective symptom severity and clinical or urodynamic parameters and to compare these parameters according to subjective symptom severity.A total of 268 female patients with grade II (n = 94) and grade III (n = 174) according to the Ingelman-Sundberg scale were included in the study. Mean patient age was 55.9 years (range 28-80). Of 268 patients, 196 women (73.1%) complained of stress urinary incontinence (SUI) and 72 (26.9%) reported additional symptoms of urge urinary incontinence (UUI). Fifty-four (20.1%) women previously had hysterectomies and 12 (4.5%) underwent surgery for UI.Patients with severe incontinence (grade III) are older, have longer duration of symptoms, concomitant urgency or UUI, and low maximal urethral closure pressure and low Valsalva leak point pressure (VLPP). No difference in other characteristics including pad test loss and urethral mobility was observed in the two groups. In the multivariate logistic regression analysis, a longer duration of symptoms was associated with an increased likelihood of severe symptoms (P = 0.025). Patients with mixed incontinence were at five-fold increased risk of severe symptoms compared with those with SUI only (P = 0.011). In the same model, increasing VLPP was associated with a decreased likelihood of severe symptoms (P = 0.037).Longer symptom duration, mixed incontinence and low VLPP have independent effects on the severity of incontinence. Our findings suggest that incontinent patients with sphincteric impairment or urge component may have and increased probability of severe symptoms.

In epidemiological surveys of female urinary incontinence, it is not feasible to demonstrate urine loss objectively. The aim of this study was to develop a valid epidemiological instrument (a severity index) for assessing the severity of incontinence. The severity index is based on information about frequency (four levels) and amount of leakage (two or three levels). By multiplication, an index value (1-8 or 1-12) is reached. This index value is further categorized into a severity index of three or four levels. The index was compared with the results of 315 pad-weighing tests performed by 265 women in hospital and general practice. Data from an epidemiological survey were also re-analyzed by applying the four-level severity index. Mean pad-weighing results (grams per 24 hours, 95% confidence interval) for the three-level severity index was slight (6; 2-9), moderate (17; 13-22), and severe (56; 44-67). For the four-level severity index, the results were slight (6; 2-9), moderate (23; 15-30), severe (52; 38-65), and very severe (122; 84-159). Spearman's correlation coefficient for pad-weighing results and the three-level severity index was 0.47 (P < 0.01) and for the four-level severity index 0.54 (P< 0.01). The four-level severity index gave a more balanced distribution among the women in the clinical materials, and data from the epidemiological survey showed that the four-level severity index identifies a sub-group of older women with very severe incontinence. The four-level severity index seems to be a valid representation of incontinence severity as measured by pad-weighing tests in women presenting for clinical care. It should be considered a potentially valid measure of incontinence severity in epidemiological studies. Neurourol. Urodynam. 19:137-145, 2000.

Pre- and postoperative data were reviewed in 33 female patients with urinary incontinence associated with demonstrated detrusor instability who underwent conventional anti-incontinence surgery (anterior colporrhaphy or colposuspension). Generally, the surgical result was poor. Only 27% (95% confidence limits 13–46%) were subjectively and objectively cured. In patients with a detrusor instability index ≤0.4 cure rate was significantly better compared to patients with an index > 0.4. In conclusion, simple cystometric data, in particular the detrusor instability index, seem to provide valuable predictive information regarding the outcome of conventional surgery in females with urinary incontinence associated with detrusor instability.

One hundred thirty-three women with urinary incontinence, including 51 patients who had undergone unsuccessful surgical treatment, were evaluated urodynamically. A high incidence (55%) of bladder instability was noted, and several patterns of instability were recognized. In 52% of the cases, provocation by erect fast fill and other provocative maneuvers were necessary to unmask the abnormal detrusor activity, and it was also noted that the patient's history did not accurately predict instability. A high incidence (33%) of seemingly inapproprate sphincter electrical silence occurred in those with an unstable bladder and appeared to be the precipitating event of the bladder contraction.

Enhorning's pressure transmission theory (PTT), though mortally wounded by multiple invalidations from the 1990 Integral Theory of female urinary incontinence (IT), like Rasputin, continues to survive as a theory for continence and incontinence.To examine the questions: How has the PTT survived? What is its contribution to knowledge?Eleven different invalidations are presented based on images, pressure readings, clinical examples, experiments by the author, and others, for example, flow mechanics, finite element models, and surgical operations.Each of the 11 invalidations prima facie invalidate the PTTs of enhorning and others."How has the PTT survived?" Having provided a plausible explanation for all abdominal stress urinary incontinence operations since 100 years, PTT, unsurprisingly, like climate change today, had become an entrenched convention which abdicated the need for midurethral sling (MUS) surgeons to learn the very different functional surgical anatomy underlying the MUS. "Has the PTT progressed knowledge, or retarded it?" This lack of knowledge by the surgeons of how and why the MUS works could be held responsible for the large number of major complications reported by the TVT: including, transected urethras, obturator nerve damage, perforation of external iliac vessels, more than 20 deaths. The role of the sling is to strengthen the pubourethral neoligament to prevent the urethra opening out under stress, not to elevate it. Elevating the sling remains the major cause of the most frequent complication of the MUS today, postoperative urinary retention.

AIMS To characterize the urinary incontinence observed in adult Gli2+/- ; Gli3Δ699/+ female mice and identify the defects underlying the condition. METHODS Gli2+/- and Gli3Δ699/+ mice were crossed to generate: wild-type, mutant Gli2 (Gli2+/- ), mutant Gli3 (Gli3Δ699/+ ), and double mutant (Gli2+/- ; Gli3Δ699/+ ) female mice, verified via Polymerase Chain Reactions. Bladder functional studies including cystometrogram (CMG), leak point pressure (LPP), and voiding testing were performed on adult female mice. Female bladders and urethras were also analyzed via ink injection and histological assays. RESULTS CMG tracing showed no signal corresponding to the filling of the Gli2+/- ; Gli3Δ699/+ bladders. LPP were significantly reduced in Gli2+/- ; Gli3Δ699/+ mice compared to wild-type mice. CMG studies revealed a decrease in peak micturition pressure values in Gli2+/- ; Gli3Δ699/+ mice compared with all other groups. No significant differences between mutant and wild-type mice were detected in urinary output. Histological analyses revealed Gli2+/- ; Gli3Δ699/+ mice exhibited a widened urethra and a decrease in smooth muscle layer thickness in the bladder outlet and urethra, with increased mucosal folding. CONCLUSIONS Gli2+/- ; Gli3Δ699/+ adult female mice display persistent urinary incontinence due to the malformation of the bladder outlet and urethra. This presents a consistent and reliable genetic mouse model for female urinary incontinence and alludes to the key role of genetic factors involved in the condition.

Aim Although research has demonstrated the efficacy of pelvic floor exercises (PFXs) for the prevention and treatment of female urinary incontinence (FUI), adherence to PFX regimens is commonly poor. There is some evidence that this finding is in part due to a lack of knowledge about how to perform PFXs correctly and misconceptions about the required frequency and duration of PFX regimens. Methods By using a sample of 720 postpartum women, this study investigates women's PFX regimens both before and during pregnancy and postpartum. Results Findings demonstrated that most women were aware of the required frequency for PFXs (at least every second day): just over half had done them this often during pregnancy and 91% intended to do so postpartum. However, few had done them at this level before pregnancy and less than half knew that PFXs should be carried out indefinitely throughout the lifetime. Moreover, only two thirds were confident that they were doing PFXs correctly. Conclusion The findings suggest that, despite good knowledge of the required frequency of PFXs, few women practise them regularly over their lifetime, many apparently perceiving PFXs as relevant only to the childbirth years. Implications for health professionals in addressing these gaps in women's knowledge and practises are discussed. Neurourol. Urodynam. 22:246–249, 2003. © 2003 Wiley-Liss, Inc.

Aims: To determine the age-specific prevalence rates of different types of urinary incontinence in women with urinary symptoms using urodynamic studies (UDS). Methods: One thousand five hundred women with urinary symptoms who underwent UDS in our department from January 1997 through December 1999 were enrolled. A detailed history, physical examination, and data of multi-channel UDS including uroflowmetry, filling and voiding cystometry, stress urethral pressure profile, and 20-minute pad test were obtained for each patient. The urodynamic findings of each patient were analyzed and correlated with age in decades. Results: Of 1,500 women, 329 were excluded from analysis because they had undergone anti-incontinence surgery (n=27), had undergone treatment for cervical cancer (n=147), or were being followed-up after medication (n=155). Of the remaining 1,171 patients, 656 (56%) had genuine stress incontinence (GSI), 68 (5.8%) had detrusor instability (DI), 187 (16%) had mixed GSI/DI, 245 (20.9%) had either voiding or storing dysfunction without concomitant incontinence, and 15 (1.3%) had normal urodynamic findings. The 41–50- and 51–60-year age groups had the highest prevalence rates of urinary incontinence, accounting for 31% and 28% of GSI cases, 35% and 25% of DI cases, and 40% and 27% of mixed GSI/DI cases, respectively. The prevalence of GSI and mixed GSI/DI increased consistently with age, but the prevalence of DI decreased after age 66. Thus, the prevalence rates of GSI, DI, and mixed GSI/DI were 56%, 5.8%, and 16%, respectively, in women with urinary symptoms. Conclusions: Female urinary incontinence had a biogenic peak prevalence in the 41–50-year and 51–60-year age groups. Neurourol. Urodynam. 22:29–32, 2003. © 2003 Wiley-Liss, Inc.

Stress incontinence is the most prevalent form of female urinary incontinence and it affects approximately 5% of younger women to nearly 50% of elderly women. Women have traditionally been treated with pelvic floor muscle exercises alone or with the use of vaginal cones. A new treatment mode, vaginal balls, has been developed. The aim of this study was to compare pelvic floor muscle training with and without vaginal balls and to collect information on women's subjective feelings about the two training modes. The study was carried out as a prospective randomized clinical trial. Thirty-seven women aged 25-65 were assigned either to a pelvic floor muscle training program or to a training program using weighted vaginal balls for 4 months. Treatment outcomes were assessed by a pad-test with a standardized bladder volume, vaginal palpation, and by women's self-reported perceptions. The sense of coherence score was compared with the score for a normal population. Ninety-three percent of the women completed the study. Both training modes were effective in reducing urinary leakage: with vaginal balls (P < 0.0001) and without (P < 0.019); and increasing pelvic floor muscle strength: with vaginal balls (P < 0.0039) and without (P < 0.0002). However, the reduction of urinary leakage after four months of exercise in the training group with vaginal balls was significantly better (P < 0.03) than the results in the group training with pelvic floor muscle exercises alone. The study found the weighted vaginal balls to be a good alternative for training pelvic floor muscles in women with stress urinary incontinence.

Maintenance of urinary continence is multifactorial and depends mainly on detrusor control and urethral closure function. The closure forces can be categorized as permanent closure forces active at rest, and adjunctive closure forces active during physical activities. The efficiency of these forces depends on the structural components in the urethral wall, the position of the bladder neck and proximal urethra, the periurethral striated muscles, and the pelvic floor muscles. By means of pudendal blockade and simultaneous recordings of pressure and cross-sectional area in the urethra, it has been demonstrated that the striated periurethral muscles and the pelvic floor muscles are of paramount importance for the closure function. This emphasizes the importance of well-functioning pelvic floor muscles to obtain continence, and probably explains the rationale for the effect of pelvic floor training in treating urinary incontinence. This study presents a review of the literature on female urinary incontinence, continence mechanisms, pelvic floor muscles, and pelvic floor training. Furthermore, a review of the literature on estrogen receptors in the pelvic floor muscles is given. Perineal ultrasonography, a method for visualization and measurement of thickness of the pelvic floor muscle, was developed and evaluated. This method was used to gain information on the thickness of the pelvic floor muscles in younger physiotherapists, healthy women, and women suffering from urinary incontinence, and to evaluate the effect of pelvic floor training. Additionally, a study of the Pelvic floor muscles was performed to assess the presence of estrogen receptors. Muscle thickness seems to decrease with age. In women over age 60 years, a significantly thinner pelvic floor muscle was found compared to younger women. The muscle increment during contraction decreased significantly with age, probably reflecting a stronger pelvic floor or a better awareness of pelvic floor function in the younger women. Incontinent women had a thinner pelvic floor muscle compared to healthy women. Hypertrophy of the muscles was demonstrated in urinary-incontinent women after pelvic floor training, and the difference in thickness of the muscles in these women before training compared to healthy women was eliminated by training. pelvic floor training reduced the use of incontinence appliances and urinary leakage both in stress and urge-incontinent women. Subjectively, 60% of the women gained a positive effect of the training. In spite of the fact that training increased muscle thickness and the increment of muscle thickness during contraction, no correlation between these parameters and subjective improvement or reduced urine loss in the pad weighing test could be demonstrated. Training may strengthen the pelvic floor without effect on the multifactorial continence mechanism in cases where urinary incontinence is caused by destruction of the urethral attachment to the surrounding tissue. No estrogen receptors were found in the nuclei of striated muscle cells in biopsies from levator ani muscles, using an immunohistochemical technique. Thus, the effect of estrogen treatment on the striated pelvic floor muscles is doubtful. A possible effect of estrogen treatment of urinary incontinence must be mediated via other structures than the pelvic floor muscles.

Menopause is presumed to have a causative role in the development of female urinary incontinence. While some clinical trials have shown that estrogen can affect urinary tract function, our knowledge of the pathophysiologic changes resulting from menopause and hormone replacement therapy is poor. The cynomolgus monkey is a well-established model for study of menopause and hormone replacement therapy, particularly in the cardiovascular arena. We have utilized this animal model to determine the histologic effects of estrogen and estrogen/progestin replacement therapy in the proximal urethra and vagina. Estrogen and estrogen/progestin replacement induced an increase in the amount of vaginal but not urethral epithelium. Hormone replacement also resulted in a significant increase in the loose, vascular component of the connective tissue layer of the urethra. The cynomolgus macaque shows promise as a useful model for further study of the effects of hormone replacement on the lower urinary tract.

Stress incontinence is the most prevalent form of female urinary incontinence and it affects approximately 5% of younger women to nearly 50% of elderly women. Women have traditionally been treated with pelvic floor muscle exercises alone or with the use of vaginal cones. A new treatment mode, vaginal balls, has been developed. The aim of this study was to compare pelvic floor muscle training with and without vaginal balls and to collect information on women's subjective feelings about the two training modes. The study was carried out as a prospective randomized clinical trial. Thirty-seven women aged 25-65 were assigned either to a pelvic floor muscle training program or to a training program using weighted vaginal balls for 4 months. Treatment outcomes were assessed by a pad-test with a standardized bladder volume, vaginal palpation, and by women's self-reported perceptions. The sense of coherence score was compared with the score for a normal population. Ninety-three percent of the women completed the study. Both training modes were effective in reducing urinary leakage: with vaginal balls (P0.0001) and without (P0.019); and increasing pelvic floor muscle strength: with vaginal balls (P0.0039) and without (P0.0002). However, the reduction of urinary leakage after four months of exercise in the training group with vaginal balls was significantly better (P0.03) than the results in the group training with pelvic floor muscle exercises alone. The study found the weighted vaginal balls to be a good alternative for training pelvic floor muscles in women with stress urinary incontinence.

Maintenance of urinary continence is multifactorial and depends mainly on detrusor control and urethral closure function. The closure forces can be categorized as permanent closure forces active at rest, and adjunctive closure forces active during physical activities. The efficiency of these forces depends on the structural components in the urethral wall, the position of the bladder neck and proximal urethra, the periurethral striated muscles, and the pelvic floor muscles. By means of pudendal blockade and simultaneous recordings of pressure and cross-sectional area in the urethra, it has been demonstrated that the striated periurethral muscles and the pelvic floor muscles are of paramount importance for the closure function. This emphasizes the importance of well-functioning pelvic floor muscles to obtain continence, and probably explains the rationale for the effect of pelvic floor training in treating urinary incontinence. This study presents a review of the literature on female urinary incontinence, continence mechanisms, pelvic floor muscles, and pelvic floor training. Furthermore, a review of the literature on estrogen receptors in the pelvic floor muscles is given. Perineal ultrasonography, a method for visualization and measurement of thickness of the pelvic floor muscle, was developed and evaluated. This method was used to gain information on the thickness of the pelvic floor muscles in younger physiotherapists, healthy women, and women suffering from urinary incontinence, and to evaluate the effect of pelvic floor training. Additionally, a study of the Pelvic floor muscles was performed to assess the presence of estrogen receptors. Muscle thickness seems to decrease with age. In women over age 60 years, a significantly thinner pelvic floor muscle was found compared to younger women. The muscle increment during contraction decreased significantly with age, probably reflecting a stronger pelvic floor or a better awareness of pelvic floor function in the younger women. Incontinent women had a thinner pelvic floor muscle compared to healthy women. Hypertrophy of the muscles was demonstrated in urinary-incontinent women after pelvic floor training, and the difference in thickness of the muscles in these women before training compared to healthy women was eliminated by training. pelvic floor training reduced the use of incontinence appliances and urinary leakage both in stress and urge-incontinent women. Subjectively, 60% of the women gained a positive effect of the training. In spite of the fact that training increased muscle thickness and the increment of muscle thickness during contraction, no correlation between these parameters and subjective improvement or reduced urine loss in the pad weighing test could be demonstrated. Training may strengthen the pelvic floor without effect on the multifactorial continence mechanism in cases where urinary incontinence is caused by destruction of the urethral attachment to the surrounding tissue. No estrogen receptors were found in the nuclei of striated muscle cells in biopsies from levator ani muscles, using an immunohistochemical technique. Thus, the effect of estrogen treatment on the striated pelvic floor muscles is doubtful. A possible effect of estrogen treatment of urinary incontinence must be mediated via other structures than the pelvic floor muscles.

Menopause is presumed to have a causative role in the development of female urinary incontinence. While some clinical trials have shown that estrogen can affect urinary tract function, our knowledge of the pathophysiologic changes resulting from menopause and hormone replacement therapy is poor. The cynomolgus monkey is a well-established model for study of menopause and hormone replacement therapy, particularly in the cardiovascular arena. We have utilized this animal model to determine the histologic effects of estrogen and estrogen/progestin replacement therapy in the proximal urethra and vagina. Estrogen and estrogen/progestin replacement induced an increase in the amount of vaginal but not urethral epithelium. Hormone replacement also resulted in a significant increase in the loose, vascular component of the connective tissue layer of the urethra. The cynomolgus macaque shows promise as a useful model for further study of the effects of hormone replacement on the lower urinary tract.

A prospective study was performed to evaluate the efficacy of transrectal electrical stimulation with the Incontan device in women with urinary incontinence. Since July 1986, 36 women with various types of urodynamically documented urinary incontinence were treated with an integrated, automatic, rectally inserted electrical stimulator (the Incontan device). Despite previous optimistic reports of successful treatment with this device, the study group experienced significant problems with electronic device failure (32 out of 64 Incontan devices distributed), as well as having a high “drop-out” rate (34 out of 36 women). At 6 months, only 2 of 36 women (6%) experienced subjective benefit from Incontan stimulation, although no significant change was documented on follow-up urodynamic study. Incontan transrectal electrical stimulation is not a viable treatment option for female urinary incontinence due to poor patient acceptance and an unacceptable electronic failure rate of the device.