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Background Urinary incontinence affects between 25% and 45% of women. The availability and quality of services is variable and inequitable, but our understanding of the drivers is incomplete. Objectives The objectives of the study were to model patient, specialist clinician, primary and secondary care, and geographical factors associated with referral and surgery for urinary incontinence, and to explore women’s experiences of urinary incontinence and expectations of treatments. Design This was a mixed-methods study. Setting The setting was NHS England. Participants Data were collected from all women with a urinary incontinence diagnosis in primary care data, and all women undergoing mid-urethral mesh tape surgery for stress urinary incontinence were included. Interviews were also carried out with 28 women from four urogynaecology clinics who were deciding whether or not to have surgery, and surveys were completed by 245 members of the Royal College of Obstetricians and Gynaecologists with a specialist interest in urinary incontinence. Data sources The sources were patient-level data from Hospital Episode Statistics, the Clinical Practice Research Datalink and the Office for National Statistics mortality data linked to Hospital Episode Statistics. Interviews were conducted with women. An online vignette survey was conducted with members of the Royal College of Obstetricians and Gynaecologists. Main outcome measures The main outcome measures were the rates of referral from primary to secondary care and surgery after referral, the rates of stress urinary incontinence surgery by geographical area, the risk of mid-urethral mesh tape removal and reoperation after mid-urethral mesh tape insertion. Results Almost half (45.8%) of women with a new urinary incontinence diagnosis in primary care were referred to a urinary incontinence specialist: 59.5% of these referrals were within 30 days of diagnosis. In total, 14.2% of women referred to a specialist underwent a urinary incontinence procedure (94.5% of women underwent a stress urinary incontinence procedure and 5.5% underwent an urgency urinary incontinence procedure) during a follow-up period of up to 10 years. Not all women were equally likely to be referred or receive surgery. Both referral and surgery were less likely for older women, those who were obese and those from minority ethnic backgrounds. The stress urinary incontinence surgery rate was 40 procedures per 100,000 women per year, with substantial geographical variation. Among women undergoing mid-urethral mesh tape insertion for stress urinary incontinence, the 9-year mesh tape removal rate was 3.3%. Women’s decision-making about urinary incontinence surgery centred on perceptions of their urinary incontinence severity and the seriousness/risk of surgery. Women judged urinary incontinence severity in relation to their daily lives and other women’s experiences, rather than frequency or quantity of leakage, as is often recorded and used by clinicians. Five groups of UK gynaecologists could be distinguished who differed mainly in their average inclination to recommend surgery to hypothetical urinary incontinence patients. The gynaecologists’ recommendations were also influenced by urinary incontinence subtype and the patient’s history of previous surgery. Limitations The primary and secondary care data lacked information on the severity of urinary incontinence. Conclusions There was substantial variation in rates of referrals, surgery, and mesh tape removals, both geographically and between women of different ages and women from different ethnic backgrounds. The variation persisted after adjustment for factors that were likely to affect women’s preferences. Growing safety concerns over mid-urethral mesh tape surgery for stress urinary incontinence during the period from which the data are drawn are likely to have introduced more uncertainty to women’s and clinicians’ treatment decision-making. Future work Future work should capture outcomes relevant to women, including ongoing urinary incontinence and pain that is reported by women themselves, both before and after mesh and non-mesh procedures, as well as following conservative treatments. Future research should examine long-term patient-reported outcomes of treatment, including for women who do not seek further health care or surgery, and the extent to which urinary incontinence severity explains observed variation in referrals and surgery. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 7. See the NIHR Journals Library website for further project information.

Introduction The aim of this study was to determine how recommendations of gynaecologists on surgical treatment for stress urinary incontinence (SUI) were influenced by patient characteristics. Methods Two hundred forty-five gynaecologists in the UK fully responded to an online questionnaire including 18 vignettes describing 7 clinical characteristics of women with SUI (age, body mass index, SUI type, previous SUI surgery, frequency of leakage, bother, physical status). The gynaecologists scored recommendations for surgery ranging from 1 ‘certainly not’ to 5 ‘certainly yes’. Mean scores were used to calculate the relative impact (‘weight’) of each clinical characteristic. Latent class analysis was used to distinguish groups of gynaecologists with a particular practice style because they responded to the patient characteristics captured in the case vignettes in a similar way. Results The gynaecologists’ overall average recommendation score was 2.9 (interquartile range 2 to 4). All patient characteristics significantly influenced the recommendation scores (p always < 0.001) but their impact was relatively small. SUI type was most important (weight 23%), followed by previous SUI surgery (weight 21%). Latent class analysis identified five groups of gynaecologists with practice styles that differed mainly with respect to their mean recommendation score, ranging from 1.3 to 4.0. Conclusions Surgical treatment advice in response to case vignettes was only minimally influenced by patient characteristics. There were five groups of gynaecologists whose inclination to recommend surgical treatment varied. This suggests that there is lack of consensus on the role of surgery as a treatment for SUI. A considerable number of gynaecologists were reluctant to recommend surgery.

Aims To compare current General Medical Practitioner treatment as usual (TAU) for the treatment of female urinary incontinence with a novel disposable home electro-stimulation device (Pelviva). Methods Open label, Primary Care post-market evaluation. 86 women with urinary incontinence were randomly assigned to one of two 12-week treatments: TAU or Pelviva for 30 min every other day plus TAU. Outcome measures included ICIQ-UI (primary), PISQ-IR, PGI-S / PGI-I and FSFI (secondary) at recruitment and immediately after intervention, 1-h pad test at recruitment and usage diaries throughout. Results Pelviva plus TAU produced significantly better outcome than TAU alone: 3 versus 1 point for ICIQ-UI (Difference − 1.8 95% CI: − 3.5 to − 0.1, P = 0.033). Significant differences were also observed for PGI-I at both 6 weeks (P = 0.001) and 12 weeks (P P = 0.032) seemingly related to impact (P = 0.027). No other outcome measures reached statistical significance. Premature termination due to COVID-19 meant only 86 women were recruited from a sample size of 264. TAU did not reflect NICE guidelines. Conclusions This study suggests Pelviva is more successful than TAU in treating urinary incontinence in Primary Care. The study had reduced power due to early termination due to COVID-19 and suggests TAU does not follow NICE guidelines.

Introduction: To reduce the risk of avoidable damage to the patient when training surgeons, one must predefine what standards to achieve, as well as supervise and monitor trainees' performance. The aim of this study is to establish a quality reference, to devise comprehensive tension-free vaginal tape (TVT) learning curves and to compare trainees' results to our quality reference. Material and methods: Using the Swedish National Quality Register for Gynecologic Surgery, we devised TVT learning curves for all Swedish TVT trainees from 2009 to 2017, covering their first 50 operations. These outcomes were compared with the results of Sweden's most experienced TVT surgeons for 14 quality variables. Results: In all, 163 trainees performed 2804 operations and 40 experienced surgeons performed 3482 operations. For our primary outcomes - perioperative bladder perforations and urinary continence after 1 year - as well as re-admission, re-operation and days to all daily living activities, there was no statistically significant difference between trainees and experienced surgeons at any time. For the first 10 trainee operations only, there were small differences in favor of the experienced surgeons: patient-reported minor complications after discharge (14% vs 18.4%, P = .002), 1-year patient-reported improvement (95.9% vs 91.8%, P < .000), and patient satisfaction (90.9% vs 86.2%, P = .002). For both trainee operations 1-10 and 11-50, compared with experienced surgeons, operation time (33.8 vs 22.2 min, P < .000; 28.3 vs 22.2 min, P < .000) and hospital stay time (0.16 vs 0.06 days, P < .001; 0.1 vs 0.06 days, P < .001) were longer, perioperative blood loss was higher (27.7 vs 24.4 mL, P = .001; 26.5 vs 24.4 mL, P = .004), and patient-reported catheterization within 8 weeks was higher (3.9% vs 1.8%, P < .000; 2.5% vs 1.8%, P = .001). One-year voiding difficulties for trainee patients (operations 1-10:14.2%, P = .260; operations 11-50:14.5%, P = .126) were comparable to the experienced surgeons (12.4%). Conclusions: There is a learning curve for several secondary outcomes but the small effect size makes it improbable that the difference has clinical significance. Our national Swedish results show that it is possible to train new TVT surgeons without exposing patients to noteworthy extra risk and achieve results which are equivalent to the most experienced Swedish surgeons.

Background Female urinary incontinence is underdiagnosed and undertreated in primary care. There is little evidence on factors that determine whether women with urinary incontinence are referred to specialist services. This study aimed to investigate characteristics associated with referrals from primary to specialist secondary care for urinary incontinence. Methods We carried out a cohort study, using primary care data from over 600 general practices contributing to the Clinical Practice Research Datalink (CPRD) in the United Kingdom. We used multi-level logistic regression to estimate adjusted odds ratios (aOR) that reflect the impact of patient and GP practice-level characteristics on referrals to specialist services in secondary care within 30 days of a urinary incontinence diagnosis. All women aged ≥18 years newly diagnosed with urinary incontinence between 1 April 2004 and 31 March 2013 were included. One-year referral was estimated with death as competing event. Results Of the 104,466 included women (median age: 58 years), 28,476 (27.3%) were referred within 30 days. Referral rates decreased with age (aOR 0.34, 95% CI 0.31–0.37, comparing women aged ≥80 with those aged 40–49 years) and was lower among women who were severely obese (aOR 0.84, 95% CI 0.78–0.90), smokers (aOR 0.94, 95% CI 0.90–0.98), women from a minority-ethnic backgrounds (aOR 0.76, 95% CI 0.65–0.89 comparing Asian with white women), women with pelvic organ prolapse (aOR 0.77, 95% CI 0.68–0.87), and women in Scotland (aOR 0.60, 95% CI 0.46–0.78, comparing women in Scotland and England). One-year referral rate was 34.0% and the pattern of associations with patient characteristics was almost the same as for 30-day referrals. Conclusions About one in four women with urinary incontinence were referred to specialist secondary care services within one month after a UI diagnosis and one in three within one year. Referral rates decreased with age which confirms concerns that older women with UI are less likely to receive care according to existing clinical guidelines. Referral rates were also lower in women from minority-ethnic backgrounds. These finding may reflect clinicians’ beliefs about the appropriateness of referral, differences in women’s preferences for treatment, or other factors leading to inequities in referral for urinary incontinence.

Introduction: Urinary incontinence is a common problem that can affect the quality of life of women of all ages and can negatively influence the exercise of sexuality. Aim: The aim of this study was to compare sexual function of women before and after surgical treatment for urinary incontinence. Method: The sample consisted of 38 women with urinary incontinence and surgical treatment (Burch or Sling procedure). The Female Sexual Function Index (FSFI) was used to evaluate sexual dysfunction before and after surgical treatment. Results: The mean age of the women in the study was 48 ± 8.8 years, and 58% were 50 years old or younger. By analyzing FSFI, it was observed that the majority of subjects had an overall index of sexual dysfunction (score < 26 points) before surgery. The desire and arousal domains improved significantly after surgery for all women included in the study. It was also observed that women with higher levels of education had more positive results related to desire. Conclusions: In our sample, in general, sexual function improved after surgical treatment of urinary incontinence, regardless of technique used, particularly in the discounter and pain domain. There was a substantial improvement of the sexual function among women who had presented with cystocele. Desire and arousal improved significantly after surgery, very likely due to the improvement of self-esteem after surgery.

International audience

OBJECTIVE: To assess the prevalence of nocturnal enuresis (NE) in Egyptian women, its relation to urinary incontinence (UI), and the impact on their quality of life (QoL). SUBJECTS AND METHODS: This was a cross-sectional study involving 350 women, using multistage sampling to recruit them. The inclusion criterion was women aged ⩾18 years who lived in the Ismailia governorate. Four trained nurses interviewed the women at their houses in two areas selected randomly, one rural and one urban. The Arabic validated International Consultation on Incontinence Questionnaire-Short Form was used to assess the symptoms of UI, frequency and severity of urinary leakage, impact on QoL, and the presence of NE. The results were analysed statistically using appropriate methods. RESULTS: The mean age of the women was 42.46 years. The prevalence of adult-onset NE was 12/350 (3.4%), and this increased significantly with increasing age and history of previous surgery (e.g., hysterectomy) (P

International audience; Our aim was to study risk factors associated with the prevalence, incidence and remission of urinary incontinence (UI) between 4 and 24 months postpartum. Longitudinal study (EDEN cohort). Two French university hospitals. 1643 women completed the questionnaire at 4 months and 1409 at 24 months, including 1354 who completed it both times. Multivariate analyses identified risk factors for UI prevalence at 24 months postpartum, persistent UI versus remission, de novo UI versus continence, de novo UI versus persistent UI, and changes in IU severity between 4 and 24 months postpartum. Postnatal UI and Sandvik UI severity score. UI prevalence was 20.7% (340/1643) at 4 months and 19.9% (280/1409) at 24 months. Significant factors associated with UI at 24 months were older age [OR = 1.07/year (95%CI 1.04-1.11)], BMI [2.35 (1.44-3.85) ≥30 versus

The pharmacological treatment of urinary incontinence and overactive bladder (OAB) has been, for a longer time, based on antimuscarinic agents. In recent years, two other pharmacological principles have been introduced for the treatment of OAB and urgency urinary incontinence: the β3-adrenergic agent mirabegron and botulinum neurotoxin. Meanwhile, there is lack of effective drugs for the treatment of stress incontinence.This literature review presents synthetic compounds aimed to treat female urinary incontinence that are in phase II-III clinical development.Antimuscarinic agents will continue to represent the current gold standard for the first-line pharmacological management of OAB and urgency urinary incontinence. The class of β3-agonists will certainly expand with the discovery and clinical development of novel agents. Combination therapy of antimuscarinic agents and β3-agonists could offer an alternative treatment in these patients, including those with symptoms refractory to first-line monotherapy. A huge number of preclinical studies are underway in this field exploring the therapeutic potential of many novel compounds while some have advanced to clinical phases of development.

Stress urinary incontinence (SUI) has always been a major health issue for women. With the progression of technology and surgical techniques, mid urethral slings (MUS) used in both transvaginal and transobturator routes have become the gold standard in the treatment of SUI. There is ample short to mid-term data confirming the efficacy and safety in using MUS in treating SUI in women. However, long-term data supporting the use of MUS in women to treat SUI is scarce. There has been much controversy surrounding the US Food and Drug Administrations' (FDA) public notification of potential complications surrounding the use of transvaginal mesh, which has been magnified and generalised by the media; but despite this there has still been substantial growth and uptake of MUS for treating SUI. In this review, we aim to explore some of the issues with MUS, the factors around litigation with mesh use, the impact of FDA's notification on the uptake of MUS and ultimately, the results and efficacy of MUS for the treatment of SUI.

Urinary incontinence remains a worldwide problem for both men and women. This lecture will concentrate on the treatment options for female urinary incontinence. The most important decision is determining what type of incontinence the patient has. The two major subtypes are stress incontinence and urge incontinence. The reason for this distinction is that the treatments are very different and using a sling in a patient with urge incontinence can have disastrous consequences. In addition, we will discuss the controversy surrounding the use of synthetic mesh in female incontinence and prolapse surgery. We will touch upon how you should use this material in your clinical practice.

Re: 5-Year Longitudinal Follow-up after Retropubic andTransobturator Midurethral SlingsKenton K, Stoddard AM, Zyczynski H, et alJ Urol. In press. http://dx.doi.org/10.1016/j.juro.2014.08.089Experts’ summary:The observational study by Kenton et al [1] includes a largepercentage of women enrolled in the TOMUS trial, a random-ized equivalence trial of retropubic and transobturator mid-urethral sling (MUS) approaches, published in 2010. In thisarticle, the authors present the 5-yr outcomes for 404 womenin terms of success, satisfaction, symptom-specific distress,quality of life, and adverse events after MUS. Treatmentsuccess was defined as no retreatment and no self-reportedsymptomsofstressurinaryincontinence.Ananswerof‘‘never’’or ‘‘rarely’’ to all stress-specific questions was considered neg-ative for symptoms. Treatment success declined over-time inboth group, and 5 yr after surgery it was 51.3% and 43.4% afterretropubic and transobturator MUS, respectively. In addition,the proportion of women who stated they were ‘‘very muchbetter’’ or ‘‘much better’’ according to a patient global impres-sion of improvement declined over-time in both groups(p < 0.0001). However, a greater proportion of women in thetransobturator group reported that they were ‘‘very muchbetter’’ or ‘‘much better’’ at 5 yr (88% vs 77%, p = 0.01). Theauthorsconcludedthatlong-termtreatmentsuccessandsatis-faction for both retropubic and transobturator MUS declineover time; nevertheless, women undergoing transobturatorMUSreportedagreaterimprovementinurinarysymptoms[1].Experts’ comments:In the present midurethral sling era, the medium- and long-term outcomes for MUS and comparisons between retropubicand transobturator MUS are the two most debated topics.Several randomized or prospective studies showed veryhigh and long-lasting objective cure rates using MUS[2–4]. A recently published randomized control trialcomparing the retropubic tension-free vaginal tape (TVT)procedure with transobturator TVT (TVT-O) showed thatobjective cure rates remained very high forboth approaches(84.7% and 86.2%, respectively) at 5 yr after surgery.Furthermore,subjectivetreatmentsatisfactionwasexcellent(94.2% in the TVT group and 91.7% in the TVT-O group). Nodifferences in terms of objective or subjective cure ratesbetweenretropubicandtransobturatorMUSwerefound[5].The great merit of the study by Kenton et al [1] is that itfocuses attention on these hot topics. However, data on theefficacyofMUStreatmentat5-yrfollow-uparesignificantlylowerincomparisontothosereportedinthevastmajorityoftheliteratureonthisissue.Theauthorsrepeatedlyunderlinethat in their study, pelvic examinations were performed atannual visits to assess for visual and palpable evidence ofmesh exposure and patient symptoms associated withphysical findings. This is a strength of the study, but it isunusual that no objective methods were used during theseannual examinations to assess the efficacy of MUS position-ing. In the study, success was defined as no retreatment andno self-reported symptoms of stress urinary incontinence.However, using this definition, the success rate of MUSappears to be unusually low (43–51%) at 5-yr follow-up; inaddition, the rate is not in agreement with data reported byother authors on this topic or with findings by the sameauthors in terms of patient satisfaction (79–85%).Therefore, we believe that this study offers interestingdataforphysiciansandpatients,butitisnotveryrealistictoattribute a success rate

A prospective analysis of 166 women with genuine stress incontinence was performed comparing Valsalva leak-point pressure (VLPP) and maximum urethral closure pressure (MUCP) with age, previous urogynecologic surgery and/or hysterectomy, poor urethral mobility, weight, menopause and vaginal deliveries, to find correlations with intrinsic sphincter deficiency (ISD). Cut-off value for VLPP were 60 cmH2O and for MUCP 30 cmH2O. MUCP < or = 30 cmH2O identifies a group of patients with more severe incontinence, a shorter urethral functional length (UFL) (P = 0.02), more previous urogynecologic operations and the menopause (P = 0.004 and P = 0.000), and older age (P = 0.000). VLPP < or = 60 cmH2O identifies a group of patients with more severe incontinence, a shorter UFL (P = 0.005), more previous urogynecologic surgery (P=0.006) and poorer urethral mobility (P = 0.004). As these two tests measure different components of urethral functions we can hypothesize that they detect different pathogenic processes contributing to ISD. When one or both tests is abnormal incontinence is more severe and the incidence of poor prognostic factors is increased.

Introduction: To evaluate the cost-utility of incontinence treatments, particularly anticholinergic therapy, by examining costs and quality-adjusted life years. Materials and methods: A prospective cohort study of women who were consecutively referred by general practitioners (GPs) to the Urology Department because of urinary incontinence. The primary outcome was evaluation of the cost-utility of incontinence treatments (surgery, medical therapy and physiotherapy) for stress and/or urgency incontinence by examining costs and quality-adjusted life years. Results: 137 consecutive female patients (mean age 60.6 ± 11.6; range 36-81) were enrolled and stratified according to pathologies: SUI and UUI. Group A: SUI grade II-III: 43 patients who underwent mid-urethral sling (MUS); Group B: SUI grade I-II 57 patients who underwent pelvic floor muscle exercise and Group C: UUI: 37 patients who underwent antimuscarinic treatment with 5 mg solifenacin daily. The cost utility ratio (CUR) was estimated as saving more than €1200 per QALY for surgery and physiotherapy and as costing under € 100 per QALY for drug therapy. Conclusions: This study shows that appropriate diagnosis and treatment of a patient with incontinence lowers National Health Service costs and improves the benefits of treatment and quality of life.

The International Continence Society defines stress urinary incontinence (SUI) as involuntary urine leakage on effort, exertion, sneezing, or coughing and defines mixed urinary incontinence (MUI) as involuntary leakage associated with urgency (a sudden, compelling desire to pass urine that is difficult to defer), exertion, effort, sneezing, or coughing [1]. In the fourth edition of the International Consultation on Incontinence (ICI), a review of 36 general population studies from 17 countries reported that prevalence estimates for the most inclusive urinary incontinence (UI) definitions (‘‘ever,’’ ‘‘any,’’ or ‘‘at least once in the past 12 mo’’) ranged from 5% [2] to 69% [3]. SUI is reported to account for 49% of female UI, urgency incontinence for 22%, and MUI for 29%. Although the prevalence of UI may be surprising to many clinicians, women often underreport the problem or delay seeking treatment for several years after the problem has become bothersome. Incontinence has a major impact on quality of life (QoL), which is often not appreciated by health care providers [4]. Surgery for SUI has changed dramatically in the last 2 decades. Since Ulmsten and Petros originally described the tension-free vaginal tape (TVT) procedure [5] for female SUI in 1995, the midurethral tape has become widespread in clinical practice, and many other techniques, materials, and approaches have been proposed [6]. The number of procedures appears to be on the increase, with a remarkable shift in the relative numbers of different devices. Safety and efficacyare confirmedover time [7,8]. Evidenceemerged that the retropubic TVT and the transobturator (TOT)midurethral slings were as effective as traditional fascial sling operations (level of evidence 1/2) [9] and more effective than Burch colposuspension. Operating time, hospital stay, and time to resumption of normal daily activity are shorter with the midurethral tape than with colposuspension. Postoperative

Objetivo: analisar os resultados cirúrgicos após slings com mucosa vaginal, realizados pelo setor de Uroginecologia e Cirurgia Vaginal da UNIFESP/EPM, no tratamento de mulheres incontinentes com hipermobilidade do colo vesical, que apresentam alto risco de falha cirúrgica para outras técnicas ou naquelas com defeito esfincteriano intrínseco e, ainda, recidivas cirúrgicas. Métodos: foram avaliadas 21 pacientes submetidas à cirurgia para correção de incontinência urinária pela técnica de sling vaginal, no período de dezembro de 1997 a fevereiro de 1999, com seguimento pós-operatório que variou de 1 a 14 meses (média de 8,2). A média de idade das pacientes foi de 56 anos (39 a 77 anos), sendo que 15 (71,4%) encontravam-se na menopausa e 6 (28,6%) no menacme. Todas as pacientes foram avaliadas antes da cirurgia por meio de anamnese, exame clínico, estudo ultra-sonográfico e urodinâmico, sendo o grau de perda urinária acentuado em 66,7% e moderado em 33,3% das pacientes. Todas as pacientes apresentavam hipermobilidade da junção uretrovesical (superior a 10 mm) e 12 pacientes apresentavam cirurgia prévia para correção de incontinência urinária. Ao estudo urodinâmico, as pacientes apresentavam perda urinária com pressão máxima de fechamento uretral (PMFU) variando de 20 a 124 cmH2O (média de 55,2) e Valsalva leak point pressure (VLPP) variando de 18 a 128 cmH2O (média de 60,3). As indicações das cirurgias foram: defeito esfincteriano (11 pacientes - 52,4%), obesidade (5 pacientes - 23,8%), defeito esfincteriano e obesidade (2 pacientes - 9,5%), recidiva cirúrgica (2 pacientes - 9,5%) e defeito esfincteriano e prolapso uterino de 1º grau (1 paciente - 4,8%). Resultados: como complicações, 6 pacientes (28,6%) apresentaram retenção urinária temporária no pós-operatório, 1 (4,8%) infecção do trato urinário, 1 (4,8%) presença de fio de polipropileno na vagina, 1 (4,8%) infecção da ferida cirúrgica, 4 pacientes (19%) evoluíram com urgência/incontinência, 1 (4,8%) com urgência miccional e 1 (4,8%) com dificuldade para urinar (elevado resíduo pós-miccional). O grau de satisfação das pacientes foi satisfatório, com 15 pacientes (71,4%) referindo cura, 3 (14,3%) melhora, 2 (9,5%) quadro de perda urinária inalterado e 1 (4,8%) piora da perda urinária. Conclusões: a cirurgia de sling com mucosa vaginal é eficaz para o tratamento de casos específicos de incontinência urinária de esforço, destacando-se defeito esfincteriano, recidivas cirúrgicas e fatores predisponentes para falha de outras técnicas. Purpose: to analyze the surgical results after slings with vaginal wall, performed by the Urogynecology and Vaginal Surgery Sector of UNIFESP/EPM, for the treatment of incontinent women with hypermobility of the bladder neck, who show great risk of surgery failure with other techniques or in those with intrinsic sphincteric deficiency (ISD) and, also, surgery recurrence. Methods: we studied 21 patients submitted to surgery in order to correct urinary incontinence by the vaginal wall sling technique, in the period from December 1997 to February 1999, with postoperative follow-up which varied between 1 and 14 months (average 8.2). The mean age of patients was 56 years (39 to 77 years), 15 (71.4%) were in menopause and 6 (28.6%) in menacme. All patients were evaluated before the surgery through medical interview, physical examination, ultrasound and urodynamic study, the grade of urinary loss being high in 66.7% and moderate in 33.3% of the patients. All patients showed hypermobility of the bladder neck (more than 10 mm) and 12 patients had previous surgery to correct the urinary incontinence. Regarding the urodinamic study, the patients manifested urinary loss with maximum pressure of urethral closure (MPUC) varying from 20 to 124 cmH2O (average 55.2) and Valsalva leak point pressure (VLPP) varying from 18 to 128 cmH2O (average 60.3). The indications of surgery were: ISD (11 patients -- 52.4%), obesity (5 patients -- 23.8%), ISD and obesity (2 patients -- 9.5%), surgery recurrence (2 patients -- 9.5) and ISD and first grade womb prolapse (1 patient -- 4.8%). Results: as complications, 6 patients (28.6%) showed temporary urinary retention after surgery, 1 patient (4.8%) infection in the urinary tract, 1 patient (4.8%) presence of polypropylene suture in the vagina, 1 patient (4.8%) infection of the surgery wound, 4 patients (19%) developed urgency/incontinence, 1 (4.8%) urgency and 1 (4.8%) difficulty in urinating (high postvoiding residue). The grade of the patients' satisfaction was satisfactory, with 15 patients (71.4%) referring cure, 3 patients (14.3%) improvement, in 2 patients (9.5%) the urinary loss remained unchanged and in 1 patient (4.8%) the urinary loss got worse. Conclusions: the vaginal wall sling surgery is efficient for the treatment of specific cases of stress urinary incontinence, emphasizing intrinsic urethral sphincteric incompetence, surgery recurrence and predisposing factors to failure of other techniques. Universidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Departamento de Tocogi-necologia UNIFESP, EPM, Depto. de Tocogi-necologia SciELO

OBJECTIVE: To outline serum estradiol levels in perimenopausal women with stress, mixed or urge incontinence. We believe the majority of urgency symptoms in perimenopausal women to be caused by a pelvic floor dysfunction and a hypermobility of the bladder neck. If this is the case, there would be no difference in estradiol levels between the groups. STUDY DESIGN: Setting: University hospital. In the observational Women's Health in the Lund Area study, a subset of 400/2221 women reporting urinary incontinence completed a detailed questionnaire regarding lower urinary tract symptoms and had their serum steroid hormone levels measured. Statistical analyses were made by Chi-square test, nonparametrical tests, ANOVA, multi- and univariate logistic regression analysis. RESULTS: Stress incontinence was reported by 196, mixed incontinence by 153 and urge incontinence by 43 women; in 369, serumestradiol values were available. Serum estradiol did not differ significantly between stress incontinent (median 49.5pmo/l, range 2.63-875.4), urge incontinent (median 31.6pmol/l, range 2.63-460.7) or mixed incontinent women (median 35.5pmol/l, range 2.63-787.9, p=0.62). Logistic regression analysis correcting for age, parity, hormonal status, smoking, hysterectomy and BMI also failed to show any difference in estradiol levels between the groups (p=0.41-0.58). CONCLUSION: No significant differences in serum estradiol levels between stress, mixed or urge incontinent perimenopausal women could be demonstrated.

Aim: To analyze the sensitivity and specificity of the 1-hour pad test, as suggested by the International Continence Society, in the diagnosis of female urinary incontinence. Methods: 158 female patients, with or without urinary incontinence, underwent a 1-hour pad test. The pad test was assessed as positive or negative and pad weight was recorded. Uni- and multivariate analysis investigated correlation with age, body mass index (BMI), symptoms, prolapse grade, urinary incontinence grade and type, number of pads daily, urodynamic variables and Urogenital Distress Inventory and Incontinence Impact Quality of Life questionnaires. Results: A positive 1-hour pad test was significantly associated with urinary incontinence grade, with a positive stress test, with detrusor overactivity (DO), urine leakage and a positive Valsalva leak point pressure at urodynamics. The association between presence/absence of incontinence and DO, stress test, urine leakage and pad weight had 83% sensitivity and 89% specificity in predicting urinary incontinence. When the 1-hour pad test result was added to stress test and urine leakage versus presence/absence of incontinence, the sensitivity was 90%, and specificity 65%. Conclusions: Our data seem to confirm the 1-hour pad test has poor predictive value in the diagnosis of female urinary incontinence when associated to stress test and urine leakage.

To investigate by questionnaire the prevalence and characteristics of urinary incontinence (UI) in a female population aged between 18 and 49.Of 44,095 females aged 18-49.9 living in our urban area a sample of 10,000 subjects was sent a questionnaire and 3557 replied. The age-based analysis was performed on 2900 of these.The overall prevalence of UI was 20\%. 11\% had suffered from nocturnal enuresis before 18 years old, 47\% of parous women noted a relationship between the beginning of UI and delivery. Among the incontinent women 83\% lost urine with physical exertion, and 44\% had urge incontinence, 18\% used diapers, 20\% had consulted a physician and half of these had been referred for medical, surgical or rehabilitative therapy, 50\% reported past or present urinary infections, 8\% complained also of faecal incontinence, 22\% considered loss of urine embarrassing and humiliating but only 6\% revealed frustration and 2\% were obliged to stay at home for long periods of time. Of the incontinents 62\% defined themselves anxious or nervous and 22\% of these ascribed an increase of urinary leakage to anxiety or to nervousness, 9\% reported use of antidepressant drugs, 85\% had sexual intercourse and only 2\% considered UI as an impediment to a satisfying sexual activity.UI is a common problem in young women. Urge incontinence seems to be prevalent in

Surgery for stress urinary incontinence (SUI) has changeddramatically in the past two decades. Since Ulmsten andPetros originally described the tension-free vaginal tape(TVT)procedureforfemaleSUIin1995,themidurethraltapehas become widespread in clinical practice, and many othertechniques, materials, and approaches have been proposed.Thenumberofproceduresappearstobeontheincrease,witha remarkable shift in the relative numbers of differentdevices. Safety and efficacy were confirmed over time[1–5].Rigorousscientificassessmentof theoutcomeof surgeryfor urinary incontinence provides us with an idea ofwhat we are achieving in this field of non–life-threateningdisease.Surgeonscanbenchmarktheirpracticeandidentifycost-effective treatments, whichare crucially needed in ourbudget-restricted health care systems. Moreover, when weprovide the right information, patients can make informeddecisions in light of demonstrated risks and benefits.The remarkable gain in life expectancy in developedcountries, with more marked increases in Japan and someEuropean countries like Spain and Italy, stands out as one ofthe most important achievements of the last century. If thepresent yearly growth in life expectancy continues throughthe 21st century, most babies born in the year 2000 orafterwards in countries with long-lived residents willcelebrate their 100th birthdays This scenario is the resultofprojections,butwedonothavetolooktothefuturetoseethe challenges of an ageing population: The oldest old group(>85 yr of age) has over the past decades been the mostrapidly expanding segment of the population in developedcountries,andtodaywearetreatingthefemalebabyboomerswho are not willing to fade into the sunset of their goldenyears. Consequently, we will operate on more and morepeople who live longer, and our results need to be durableover time.All of us who are engaged in the treatment of urinaryincontinence use outcome measures such as urodynamics,pad tests, bladder diaries, symptom questionnaires, symp-tom-bother questionnaires, quality-of-life (QoL) instru-ments, and measures of satisfaction. Probably none ofthese is the ideal instrument [6–8]. In fact, any outcomemeasureshouldbereliable,valid,responsivetochangeovertime, and interpretable within clinical practice, but that isnot yet sufficient. Extending follow-up becomes essential ifwe are to know—not just wonder—how our surgery holdsup over time. Long-term follow-up is the main factoraffecting the validity of interstudy comparisons of theefficacy and safety of treatment for SUI. We would like topraise Zullo and co-workers [9], who compared the use ofTVT and transobturator TVT (TVT-O) over a 5-yr follow-upand concludedthatresults aresimilarwithbothtechniques(72.9% and 71% of patients objectively cured after TVT-Oand TVT, respectively). Complication rates were low (16.1%and 17.2%, respectively, for TVT-O and TVT), even after 5 yr.Interestingly, the authors also reported that the develop-ment of complications such as dyspareunia or incontinenceduring intercourse may lessen patient satisfaction, even indry patients. Thus, we have to go back to the patient’sperspective and expectations. Independent of incontinencestatus, other factors may change the outcome’s perception.For example, the patient’s age, general health, or comorbid-ities may worsen QoL and affect the outcome of inconti-nence surgery even if not directly related to it.In the first edition of the International Consultation onIncontinence, members and delegates reached the consen-susthatshort-termsurgicalfollow-upshouldbeconsideredasbeingupto3mo,mediumtermfrom3to12mo,andlongterm over12 mo[10].There are occasions whenshort-termtrial follow up and the early presentation of outcomes may