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Background: Tolterodine is a novel muscarinic receptor antagonist for the treatment of overactive bladder., Objective: The purpose of this study was to examine the cost-effectiveness of tolterodine for patients with urge incontinence (UI) who discontinue initial therapy with oxybutynin in a Canadian setting., Methods: We compared 2 treatment strategies for the management of adult patients with UI: (1) generic oxybutynin with no further treatment for patients who discontinue and (2) generic oxybutynin with switch to tolterodine (2 mg BID) for patients who discontinue. We developed a 1-year Markov model (4-week cycle length) with transitions between disease states of normal, mild, moderate, and severe. Transition probabilities over 12 weeks were obtained from randomized trial data, and drug discontinuation rates were obtained from Quebec prescription claims data. Outcome measures were time in "normal" health state and quality-adjusted life-years (QALYs) using EuroQol-5D utility scores from a survey of Swedish patients with overactive bladder. Costs to the health care payer and patient out-of-pocket costs (in Canadian dollars) were included., Results: For patients who discontinue oxybutynin, the use of tolterodine is associated with approximately 6 months per year in a normal health or mild disease state, compared with approximately 3 months for those who do not receive further drug therapy after discontinuation. Tolterodine use resulted in an annual additional cost per patient of Can $163. The incremental cost per QALY was Can $9,982 and appeared to be robust to alternative model parameter assumptions., Conclusion: Use of tolterodine in patients with UI who discontinue initial therapy with generic oxybutynin lies within currently accepted benchmarks for cost-effectiveness.

Despite improvements in surgical approaches to radical prostatectomy, many patients experience moderate to severe urinary incontinence during the first few postoperative weeks. For some patients, leakage continues for several months or years. Urinary incontinence has a significant impact on quality of life in these typically active patients. Surgical interventions are not recommended until after a 6 to 12 month trial of behavioral interventions. Behavioral interventions include supportive care, diet and medication management, pelvic floor rehabilitation, inhibition techniques, and patient education and support. This integrative review of the literature summarizes current knowledge of behavioral interventions for post-prostatectomy urinary incontinence for the primary care and home care clinician. Aspects of care specific to masculine culture are explored. Recommendations for further research include determination of optimal timing and protocols for pelvic floor rehabilitation, best practices for patient and family education, and development of a standard definition of urinary incontinence so the efficacy of treatments can be compared.

Objectives: To perform a prospective study using confidential patient-completed questionnaires about their urinary habits before and after laparoscopic radical prostatectomy. Published reports on urinary continence after radical prostatectomy vary depending on the definitions of urinary continence and methods of data collection., Methods: From May 1998 to February 2000, 228 men underwent laparoscopic radical prostatectomy for clinically localized prostate cancer. The patients were given questionnaires before surgery and at 1, 3, 6, and 12 months postoperatively., Results: Before surgery, no patient reported incontinence. At 1, 3, 6, and 12 months postoperatively, perfect diurnal urinary control (no pads, no leakage at all) was reported in 9.9%, 28.6%, 57.4%, and 56.8% of patients, respectively. No pads were used in 18.8%, 58.4%, 68.9%, and 78.4% at 1, 3, 6, and 12 months, respectively. No patient reported use of more than 1 pad daily at 6 months of follow-up., Conclusions: Continence after laparoscopic radical prostatectomy is comparable to the results after traditional radical retropubic prostatectomy. Ongoing use of the laparoscopic route for treating clinically localized prostate cancer is warranted.

Background: Patients' perceptions of treatment outcomes are important in the management of early prostate cancer, but few studies have offered reliable and responsive measures to assess the likely side effects of the most common treatments., Objective: To develop indexes of urinary, bowel, and sexual function, and related distress., Research Design: Prospective cohort study of the outcomes of treatment for early prostate cancer, with self-administered questionnaires completed before treatment, and 3 and 12 months afterward. Hypothesized indexes, based on a clinical model of pathophysiological side effects of treatment, were defined and evaluated with respect to reliability and validity., Subjects: Patients (n = 184) undergoing radical prostatectomy or external beam radiotherapy for early prostate cancer., Measures: Urinary and bowel items pertained to frequency or intensity of symptoms of dysfunction; parallel items assessed symptom-related distress. Sexual dysfunction items assessed the quality of erections, orgasm, and ejaculation; distress was assessed by 2 items adapted from the MOS Sexual Problems (MOS-SP) scale. HRQoL was assessed by the SF-36 and Profile of Mood States., Results: Symptom and symptom-related distress indexes for urinary incontinence, urinary obstruction/irritation, bowel dysfunction, and sexual dysfunction were defined. Symptom and distress indexes in each domain were highly correlated. Responsiveness was substantial and varied by treatment in ways consistent with clinical experience. The indexes accounted for significant proportions of the variance in HRQoL measures., Conclusions: These indexes may be used in monitoring outcomes of treatment for early prostate cancer.

Most of the 13 million Americans who have urinary incontinence are adults, and a significant number are never treated. Undertreatment is due in part to reluctance by patients and physicians to discuss an uncomfortable topic. Unmanaged incontinence restricts normal daily activity and fundamental human interactions. Intervention is important not only to control symptoms, prevent infection, and impede incontinence progression, but also to restore quality of life. In most cases, the physical exam and patient history provide the necessary information for diagnosis. Behavioral treatments are easy to implement and inexpensive, although patient nonadherence can undermine effectiveness.

We evaluated parameters for an expert system which will be designed to aid the differential diagnosis of female urinary incontinence by using knowledge discovered from data. To allow the statistical analysis, we applied means, regression and Expectation-Maximization (EM) imputation methods to fill in missing values. In addition, complete-case analysis was performed. Logistic regression results from the imputed data were reasonable. The significant parameters were mostly those that are important in the diagnostic work-up. Moreover, directions of relations between the parameters and the stress, mixed and sensory urge diagnoses were as expected. Analysis with the complete reduced data set gave clearly insufficient results. Imputed values had a moderate agreement, but odds ratios and classification accuracies of logistic regression equations were similar. Results suggest that with these data, simpler methods may be used to allow multivariate analysis and knowledge discovery, when better methods, such as EM imputation, are unavailable. Cluster analysis detected clusters corresponding to the small normal class, but was unable to clearly separate the larger incontinence classes.

Purpose: The purpose of this study was to determine the level of continence, satisfaction, and compliance with a maintenance pelvic muscle exercise program 12 months or more after discharge from a clinician-supervised pelvic floor muscle rehabilitation program., Setting and Subjects: Forty-nine female patients diagnosed with stress, urge, and mixed etiology urinary incontinence were treated with pelvic muscle re-education and biofeedback. Treatment was performed in a urology clinic setting with sessions supervised by a registered nurse., Methods: A retrospective chart review was performed for all female patients trained in pelvic muscle exercises from March 1997 through November 1997. Telephone interviews were conducted and questionnaires were administered to determine long-term efficacy of and compliance with pelvic muscle exercises 13 to 20 months after treatment., Results: Fifty-three percent of patients maintained their posttreatment level of continence, and 38% had improved when evaluated 13 to 20 months following treatment (x macro = 16.6 months). Sixty-nine percent continued to perform pelvic muscle exercises once weekly or several times per week., Conclusions: Clinician-supervised pelvic floor muscle rehabilitation is effective in improving stress and urge incontinence in community-dwelling women with stress, urge, and mixed urinary incontinence. This effect is durable for a period of 16 months, and the majority of women continue to perform pelvic muscle exercises one or more times per week.

Objective: Incontinence-specific and generic measures of well-being were regressed on potential predictors to identify incontinent respondents at risk for psychosocial distress and to understand the relationship between urinary incontinence (UI) and other determinants of social and emotional status., Design: Survey data were collected May 1994 through April 1996., Setting: Telephone interviews as a supplement to a nationally representative monthly consumer survey., Participants: Analyses were based on 1,116 continent and 206 incontinent respondents age 40 and older., Measurements: Incontinent respondents self-reported the extent to which urine loss restricted social activities or affected their feelings about themselves. All respondents were asked whether they felt depressed, lonely, or sad. Covariates included sex, age, race, education, social desirability, health status, frequency of urine loss, quantity of loss, and urgency., Results: The majority of incontinent respondents reported that urine loss did not restrict activities or diminish self-esteem. Incontinent respondents who were younger, male, less educated, lower in social desirability, in poorer health, or losing greater quantities of urine were more likely to report psychosocial distress, although these correlates were not consistently significant. Compared with continent respondents, significantly higher percentages of incontinent respondents reported feeling depressed, lonely, or sad. In the multivariate models, incontinence retained an independent association with loneliness, but not with sadness or depression., Conclusion: Even though the direct psychosocial impact of urine loss may be minor in many cases, UI is associated with a constellation of physical and behavioral factors that can impose a social and emotional burden. This suggests that UI cannot be adequately evaluated or treated without consideration of the patient's overall quality of life.

Objective: To examine the effects of oral estrogen/progestin on incontinence and related lower urinary tract conditions among female nursing home (NH) residents., Design: Randomized placebo-controlled trial., Setting: Five NHs., Participants: Thirty-two incontinent female residents of average age 88., Measurements: Subjects were randomized to receive either oral estrogen (0.625 mg) combined with progesterone (2.5 mg) or placebo, daily for 6 months. Measures of incontinence severity, the clinical appearance of the vagina, vaginal and urethral cytology, and urine and vaginal cultures were made at baseline, 3 months, and 6 months. In addition to active drug or placebo, all subjects received regular toileting assistance (prompted voiding) by trained research aides during 3-day data-collection periods to compensate for mobility and cognitive impairments., Results: At 3 and 6 months there were no significant differences between the groups in the severity of incontinence, the prevalence of bacteriuria, or the results of vaginal cultures. Several clinical findings associated with atrophic vaginitis improved more in the active than the placebo group and vaginal pH and vaginal and urethral cytology exhibited a partial estrogenic effect., Conclusions: Our results must be interpreted with caution because of the size and the select nature of our subject sample. Up to 6 months of oral estrogen had only a partial estrogenic effect on vaginal and urethral epithelium and no clinical effects in this patient population. We believe that future studies of estrogen for urinary incontinence in frail NH residents should utilize a topical preparation and consider targeting urinary tract infection as an additional outcome measure.

The purpose of this research was to evaluate the effectiveness of an individualized scheduled toileting (IST) program on incontinent, memory-impaired elders being cared for at home. Using a 2 x 2 mixed design analysis of variance (group by time), 118 patients were randomly assigned to experimental or control groups. Caregivers in the experimental group were taught the IST procedure. Urinary incontinence (UI) was measured at baseline and at 6 months. Weeklong voiding records were kept by caregivers and were used to calculate the percentage of times the incontinence occurred. UI significantly decreased in the experimental group, whereas in the control group it did not. The baseline cognitive ability, mobility, and consistency of implementing IST were entered into a discriminant function equation and significantly predicted patients who would improve with IST. Cognitive ability was the best predictor, with mobility also emerging as a meaningful predictor. Candidates for IST should be selected based on elders' cognitive ability and their ability to cooperate with toileting. Moderately cognitively impaired elders and ones able to cooperate with toileting protocols are prime candidates for IST., (Copyright 2001 John Wiley & Sons, Inc.)

Urinary incontinence (UI) affects many people in the United States. Although the prevalence of UI increases with age, it should not be considered part of the normal aging process. Medication to relax the bladder and behavioral therapy have been used to treat patients suffering from UI, but they often are unsuccessful or poorly tolerated. Neuromodulation through sacral nerve stimulation is a minimally invasive surgical procedure for treatment of urge incontinence. Neuromodulation is becoming the next logical step at many centers for treating urge incontinence after the failure of more conservative measures.

164 women from 18 to 74 years of age (mean 48.3) with urinary incontinence, previously not operated, with out any neurogenic symptoms, with sterile urine were studied. The kind of incontinence was estimated on the basis of clinical history and examination, the analysis of frequency/volume charts, free uroflowmetry and cystometry in sitting and standing positions. Genuine stress incontinence (GSI) was recognized in 121 (73.8%) women, urge incontinence (UI) in 15 (9.1%), and mixed incontinence (MI) in remaining 28 (17.1%) women. Women with UI and MI had significantly more often both daytime (12.5 +/- 6.4 and 10.3 +/- 2.5), and night-time mictions, comparing to GSI (7.2 +/- 2.8) with simultaneously smaller daytime voided volumes (91 +/- 36.0 ml and 125 +/- 50.0 ml) comparing to GSI (175 +/- 151 ml). Mean voided volume and Qmax in free uroflowmetry were significantly greater in GSI (293 +/- 124 ml, 24.6 +/- 8.4 ml/s comparing to 165 +/- 69.0 ml, 17.0 +/- 7.8 ml/s in UI). The bladders of women with UI showed motoric and sensoric hyperactivity, uninhibited detrusor contractions, decreased CysCapmax, higher PdetCysCapmax, and decreased compliance. Mean CysCapmax was 240 +/- 102 ml, with first sensation after filling mean 145 +/- 90.1 ml, with Pdet 29.3 +/- 13.4 cm H2O, and compliance 13.2 +/- 7.7 ml/cm H2O. In women with both GSI and MI the values were significantly higher and were respectively, for CysCapmax 455 +/- 148 ml, 308 +/- 58 ml, for VFD 237 +/- 76 ml and 169 +/- 25 ml, PdetCysCapmax 12.9 +/- 5.4 cm H2O and 16.5 +/- 4.9 cm H2O, and for C 41.7 +/- 20.5 ml/cm H2O and 28.2 +/- 8.1 ml/cm H2O. The urge syndrome accompanied by urine incontinence, decreased functional bladder capacity evaluated from frequency/volume charts and free uroflowmetry are the indications for performing cystometry with simultaneous monitoring of abdominal pressure. It allows to recognize urge and mixed incontinence.

Because the prevalence of urinary incontinence increases with age, a working knowledge of the diagnosis and treatment of the various types of urinary incontinence is fundamental to the care of women. As the population of the United States ages, primary care physicians can expect to see an increasing number of patients with urinary incontinence. By obtaining a careful medical history and performing a comprehensive physical examination, the primary care physician can initiate successful treatment for the majority of patients without the need for invasive testing. This article offers a comprehensive approach to the evaluation and management of urinary incontinence in women.

Loss of urinary control is closely linked with loss of independence. Most cases of urinary incontinence can be improved using behavioral and pharmacologic interventions. Several factors--including reluctance by physicians and patients to discuss and investigate symptoms--prevent patients from obtaining effective clinical management. In 1996, the Agency for Healthcare Research and Quality published a guideline for the management of acute and chronic urinary incontinence in adults. In addition to educating healthcare providers and patients about urinary incontinence, the guideline's mission includes improving the reporting, diagnosis, and treatment of the condition. The guideline offers a thorough discussion of urinary incontinence symptoms and subtypes, techniques for identifying and evaluating the condition, and treatment approaches.

Incontinence is a common problem in the frail elderly. We conducted interviews focusing on urinary incontinence with 249 elderly clients in the home care setting, and studied differences of the needs among three (mild, moderate, and catheter) groups based on incontinence level. The mild group had the highest number of professional care needs, although their problems were not as serious as the other two groups. The moderate group required the highest amount of daily care by caregiver. A similar need pattern was shown in the moderate and catheter groups, while more diversified needs were required in the mild group. Portable toilet, rehabilitation, and short-stay services were frequently used in the mild group. The use of telephone consultation was the highest in the moderate group, and the use of doctor visit and bathing service were higher in the catheter group. The most important challenge was significantly different in each group: preventive efforts to maintain activities of daily living (ADL) in the mild group, interpersonal relationships in the moderate group, and infection control in the catheter group. Education was necessary for caregivers in all three groups. These findings help to project realistic care needs for each client based on his or her incontinence level.

Purpose: To provide nurse practitioners (NPs) with an objective system for classification of urinary incontinence and protocols for treating the condition in the primary care setting., Data Source: Clinical practice guidelines and the author's clinical experience., Conclusions: By using tables of classifications of urinary incontinence, management strategies, and protocols, NPs can successfully manage mild urinary incontinence in primary care settings in a cost-effective manner., Implications for Practice: A thorough history and objective classification of the severity of incontinence provides the framework for treating urinary incontinence in a methodical and effective manner.

Purpose: We assessed the test-retest reliability of a 24, 48 and 72-hour micturition diary and pad test in patients referred for the evaluation of urinary incontinence and lower urinary tract symptoms., Materials and Methods: We prospectively enrolled 109 patients referred for the evaluation of lower urinary tract symptoms in our multicenter study. Patients were requested to complete a 72-hour micturition diary and pad test, and repeat each test during a 1-week interval. The test-retest reliability of various parameters of the 72-hour micturition diary and pad test was analyzed and compared. Further analysis was done to compare the test-retest reliability of 24, 48 and 72-hour studies performed on the same days after a 1-week interval. Reliability was assessed by Lin's concordance correlation coefficient (CCC) with a cutoff value of 0.7 indicating test-retest reliability., Results: Of the 109 patients 106 (97%) with a median age of 64 years completed the study. The number of pads and total weight gain appeared to be reliable measures of the 24, 48 and 72-hour pad tests. For the 24-hour diary the total number of incontinence episodes was a reliable measure, while the total number of voiding episodes was marginally reliable (mean CCC 0.785 and 0. 689, respectively). For the 48-hour diary the number of incontinence episodes and total number of voiding episodes were reliable measures (mean CCC 0.78 and 0.83, respectively), while for the 72-hour diary each parameter was highly reliable (CCC 0.86 and 0.826, respectively). However, an increased test period was associated with decreased patient compliance., Conclusions: The 24-hour pad test and micturition diary are reliable instruments for assessing the degree of urinary loss and number of incontinent episodes, respectively. Increasing test duration to 48 and 72 hours increases reliability but is associated with decreased patient compliance.

Urinary incontinence and nocturnal enuresis are frequently encountered problems in children. In this review some aspects will be highlighted. Especially the different types of monosymptomatic nocturnal enuresis as well as some recent developments in children with dysfunctional voiding will be discussed.

Through proper evaluation and assessment, a large number of patients suffering from urinary incontinence may be effectively treated. Urodynamic studies, which are tests used to assess lower urinary tract function, may be performed using elaborate machinery or simple equipment found in most office settings. Bedside urodynamic studies may be performed without machinery. Patients with symptoms of stress incontinence or urge incontinence are candidates for bedside urodynamic techniques. Using the assessment tool results, pharmacologic therapy and behavioral treatment may be instituted. This article discusses the components of bedside urodynamic studies and provides the clinician with improved proficiency in assessing urinary incontinence.

Urinary incontinence is a frequent condition that is usually clinically classified into three main subgroups: urge, stress and mixed. The latter, which can account for up to 50% of the patients, is notoriously heterogeneous. It is one of the reasons why the reports of therapeutic approaches to treat incontinence vary in the medical literature and it also explains the difficulty to compare results between studies. In an attempt to address this problem and to clarify the field of urinary incontinence, we have developed new clinical classification of urinary incontinence (FPSUND) where each symptom related to incontinence is rated from 0 (no symptoms) to 3 (severe symptoms). In this acronym, "F" stands for frequency of micturition, "P" for the use of protection, "S" for the stress component of incontinence, "U" for urgency, "N" for the number of nocturnal micturition and "D" for the number of diurnal micturition. Urologists from nine different centers across Canada were asked to evaluate female patients suffering from urinary incontinence using the FPSUND classification. A total of 148 women, aged 18 to 70, suffering from urinary incontinence were thus enrolled in the study. A second, independent evaluation of the same patients was performed by registered nurses or by urodynamic technicians. The reproducibility of the classification between two observers, as measured by the Weighted Kappa score was excellent, with kappa scores between 0.47 and 0.74 (p<0.05). Overall, the users of the classification found it very easy to use in a clinical setting. We would like to propose the FPSUND classification of urinary incontinence as a useful mean to evaluate patients suffering from incontinence and as a way to assess treatment outcome.

The first part of this article (Dorey, 2000) described the subjective and objective assessment of men with lower urinary tract symptoms (LUTS). This article will examine treatment protocols for stress incontinence, urge incontinence, post-prostatectomy incontinence, post-micturition dribble, overflow incontinence, reflex incontinence and functional incontinence. Pelvic floor muscle exercises, biofeedback, electrical stimulation, urge suppression techniques, and fluid intake are discussed. It is concluded that men with LUTS can benefit from conservative treatment.

Objective: To establish the prevalence of urinary incontinence in non-institutionalized Dutch women and determine the consequences of urinary incontinence for their quality of life., Design: Cross sectional questionnaire survey., Method: A random sample of 1905 women aged 45-70 years of the population of Zeist, the Netherlands, were sent a questionnaire. Generic quality of life was measured with the RAND-36 and disease specific quality of life was measured with a Dutch translation of the Urogenital Distress Inventory (UDI) and Incontinence Impact Questionnaire (IIQ). Based on the answers to the questionnaire four groups of women were formed: no incontinence, only stress, only urge or a combination of stress and urge incontinence. These 4 groups were compared as to questionnaire scores., Results: A total of 1086 questionnaires could be analysed. The prevalence of urinary incontinence was 57.1%: 28.7% stress incontinence, 5.6% urge incontinence and 22.7% both. Of those who reported urinary incontinence 6% were severely inconvenienced by it. Women with urinary incontinence reported a decrease in physical functioning and vitality as compared with women without incontinence (RAND-36). Especially women with urge or a combination of stress and urge incontinence had more severe impairment of their quality of life as compared to women with only stress incontinence., Conclusion: The prevalence of urinary incontinence is higher than it is usually reported. Especially the urge component affects the quality of life in a negative way.

Functional urinary incontinence in children may be caused by disturbances of the filling phase, the voiding phase or a combination of both. Detrusor overactivity may cause frequency and urgency, with or without urge incontinence. Girls present with symptoms of detrusor overactivity more often than boys, but sometimes other symptoms, e.g. urinary tract infections or constipation, prevail. Frequent contractions of the detrusor may cause the pelvic floor muscles to become overactive, resulting in staccato or fractionated voiding. When incontinence is the result of a voiding disorder the term 'dysfunctional voiding' is used. Bladder function in these children may be normal, but instability may be present. In children with a 'lazy' bladder, voiding occurs with no detrusor contractions, and postvoid residual volumes and overflow incontinence are the main characteristics. Diagnosis is based on the medical and voiding history, a physical examination, bladder diaries and uroflowmetry. The upper urinary tract should be evaluated in children with recurrent infections and dysfunctional voiding (reflux). Uroflowmetry can be combined with pelvic floor electromyography to detect overactivity of the pelvic floor muscles. Urodynamic studies are usually reserved for patients with dysfunctional voiding and those not responding to anticholinergic drugs. Treatment is usually a combination of 'standard therapy', behavioural therapy, bladder training, physiotherapy and medical treatment. The role of alpha-blockers needs to be evaluated further. Also, neuromodulation may have a place in treatment but the exact indications need to be defined. Clean intermittent self-catheterization is sometimes necessary in children with a lazy bladder and large residual volumes who do not respond to a more conservative approach. Future research needs to be directed towards improving understanding of the pathophysiology, epidemiology, classification and treatment modalities of functional incontinence in children.

Background: One of the more prevalent conditions associated with aging is urinary incontinence (UI), which may affect up to 55% of women and 34% of men older than 65 years. As a result of increasing longevity in developed nations, the proportion of UI-susceptible individuals continues to grow, presenting clinical and economic challenges to healthcare providers., Objective: To assist the clinician in making informed decisions regarding UI, provide information on the wider ramifications of the disease, and provide a comprehensive overview of the condition., Data Sources: MEDLINE (1966-December 1998) was searched for relevant publications using the following search terms: UI, UI in the elderly, treatment of UI, oxybutynin, flavoxate, vasopressin, quality of life in UI, and economic impact of UI., Data Synthesis: Key articles relating to the etiology, diagnosis, classification, economic burden, quality of life, and treatment of UI were retrieved, and this information formed the basis of the review., Conclusions: Although UI can be controlled relatively well with existing therapies, only about 50% of affected patients may actually seek care. There are a variety of therapeutic options available for the treatment of UI, although pharmacologic intervention is presently a relatively minor component of overall care; this suggests that effective drug therapy might play a more significant role in the future. The economic burden associated with the care of the incontinent patient is substantial, and in the US the direct medical cost of the disease was estimated at $25.5 billion in 1995. The disease also has a large impact on the individual UI patient, negatively affecting many parameters normally associated with a tolerable health-related quality of life.

Urinary incontinence is a common symptom affecting the physical, psychological, social and economic well-being of individuals and their families. It also poses a considerable economic burden on health and social services. The literature reports widely varying prevalence rates for incontinence that are partially explained by methodological differences between studies. However, community-based studies indicate that approximately 6% of the population, particularly women and older people, will have urinary incontinence of sufficient severity to interfere with their quality of life. This represents a significant demand for health care. Although further research on prevalence is unlikely to add anything new to current knowledge on the size of the problem, more information is needed on the onset, progression and risk factors of urinary incontinence to inform methods of effective treatment and preventive strategies. In addition, there has been little investigation of the triggers to seeking professional help or of the response of health professionals to patients' demands for treatment, either for incontinence or other lower urinary tract symptoms. The aetiology of incontinence is multifactorial; incontinence is caused by pathophysiological impairments to the lower urinary tract and neurological system, as well as a range of external factors. The key to effective management, therefore, is a comprehensive assessment of the patient, including other lower urinary tract symptoms, so that appropriate intervention is tailored on a diagnosis and not on symptoms.

One of the most important endpoints following a radical prostatectomy focuses on the recovery of urinary continence; however, the reported incontinence rates have been quite variable. In men with prostate cancer, it has been found that the physician's assessment of a patient's symptom does not correlate with the patient's own assessment. To further explore the differences in the reported outcomes between physicians and patients, we evaluated the assessment of urinary incontinence in a cohort of men undergoing radical prostatectomy. A total of 145 individuals completed a brief urinary continence questionnaire postoperatively at the 1-year anniversary of their operation and also had the physicians' assessment of incontinence documented in the medical record. Patient-reported incontinence rates varied from 13% to 65% depending on the definition of incontinence applied and the greatest agreement was seen when the physicians' assessment of incontinence was compared with the patient's report of pad use and urinary bother. These comparisons resulted in only moderate to good levels of agreement, which suggests that a more reliable and accurate means to evaluate urinary incontinence following radical prostatectomy needs to be developed.

Background: One earlier study and anecdotal evidence suggest a possible association between exposure to high +Gz forces and urinary incontinence in women. High +Gz could possibly contributes to the prolapse of the bladder neck, moving it into a position which decreases the leak point pressure resulting in urinary incontinence., Hypothesis: We tested the hypothesis that increased urinary incontinence is associated with high +Gz., Methods: 25 females were exposed to a high +Gz profile. Following the exposure they were asked to answer a questionnaire grading their urinary continence under high +Gz, and to provide a baseline grading of their urinary continence at +1.0 Gz and under increased abdominal stress at +1.0 Gz. Demographic data included parity and previous urogenital surgery. Graded responses were dichotomized and data was analyzed using Fischer's Exact Test for 2x2 tables with significance set at alpha = 0.05., Results: At high +Gz no significant association was found between reported urine incontinence and a history of urogenital surgery or parity. Only one of twenty-five subjects had any symptoms at high +Gz despite the fact that five had a predisposition. As expected, at +1.0 Gz and under increased abdominal stress at +1.0 Gz a significant association was found between reported urine incontinence and a history of urogenital surgery, while no significant association was found for parity., Conclusions: In this simple first look there was no increase in urinary incontinence at high +Gz even among those who reported a predisposition.

There are no standardized definitions for anti-incontinence therapy outcomes. The present study was conducted to evaluate whether the incorporation of several non-invasive outcome measures into a new score may serve as a meaningful outcome instrument. Ninety-four consecutive sphincteric incontinent women who underwent a pubovaginal sling by a single surgeon were enrolled. All patients underwent a full clinical evaluation, including pre- and post-operative questionnaires, 24-hour voiding diary, and 24-hour pad test. Surgery outcomes were classified twice: First, by analyzing the patient questionnaire, voiding diary, and pad test separately, according to previously published criteria, and second, by combining the three outcome tools into a new response score. The new score was constructed in a simple, easy-to-remember format and divided into five categories: cure, good response, fair response, poor response, and failure. All patients were evaluated at least 1 year post-operatively. Comparison of the old and new classifications suggests that the new response score provides a more accurate evaluation of the surgical outcomes. Although 64 to 69% of the patients were originally classified as cure according to the old classification, only 44.7% were re-classified as cure by the strict criteria employed in the new score. Furthermore, the response score also differentiates between various degrees of clinical improvement (i.e., good, fair, or poor response). Twenty-five (26.6%) patients, most of whom were previously classified as cure, were re-classified as good response, whereas 20 others were re-classified as fair (13. 9%), or poor (7.4%) response. Seven (7.4%) patients were re-classified as surgical failures. All were diagnosed pre-operatively as having complex sphincteric incontinence. Specific failure rates were therefore 11.3% for complex and 0% for simple cases. In conclusion, the suggested post-operative response score incorporates in a user-friendly format three popular outcome tools (i.e., 24-hour diary, 24-hour pad test, and patient questionnaire) and seems to reflect the surgical results more accurately. Further studies are needed to assess its validity and reproducibility in other treatment modalities. Neurourol Urodynam. 19:127-135, 2000., (Copyright 2000 Wiley-Liss, Inc.)

During the past decade, research on urinary incontinence and its management has grown significantly. Behavioral therapy is now viewed as an important first line of treatment for stress, urge, and mixed urinary incontinence. This chapter provides a critical review of the intervention studies on lifestyle modifications, bladder training, and pelvic floor muscle training conducted in adult ambulatory care populations that were published in 1988 through 1999. Recommendations for future research are provided.

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., (Copyright 2000 Wiley-Liss, Inc.)

Computerized EMG biofeedback therapy is a conservative treatment option for patients with urge incontinence, frequency, and certain types of stress urinary incontinence. Patient motivation to follow through with treatment and home exercise program is an important factor for successful therapy. The Health Promotion Lifestyle Profile (HPLP) II measures the frequency of health-promoting behaviors. A preliminary study of 45 patients suggested the HPLP II is a valid and reliable predictor of patient motivation. Further research is needed to ascertain if the tool may serve to predict patients' commitment to biofeedback and subsequent success with therapy. Effective screening of patients can also reduce overuse of services and ensure appropriate use of percapitated dollars.

Rationale: To prepare and validate a simple and self-administered questionnaire for the clinical rating of patients with urinary incontinence (UI) for use in the clinical practice., Methods: The questionnaire was prepared based on a review of the literature on urinary incontinence and the views of 7 urodynamic urologists. The initial questionnaire UI-5 included 5 items related to UI symptoms that divided patients into three categories: stress incontinence (UEI), urge incontinence (UUI) or mixed urinary incontinence (MUI). An additional question evaluates the impact of UI type on the quality of life. The of construct validity was analyzed correlating the responses to UI-5 items and the question on quality of life. The area under the ROC curve was calculated for each UI type correlating the UI-5 scores and the results of the urodynamic test. The cut-off values for each scale were determined based on sensitivity (SE) and specificity (SP)., Results: The study included 188 females with UI (73.4% with UEI, 13.3% with UUI and 13.3% with MUI; based on the urodynamics). Only 4.3% patients did not answer some UI-5 items. One item related to the protective material used was excluded as it was not related to UI types, and so the final questionnaire included only 4 items (UI-4). The results show that UI-4 discriminates the different types of incontinence: UEI (SE: 0.69/SP: 0.76; 1 item), UUI (SE: 0.83/SP: 0.65; 2 items), MUI (SE: 0.72/SP: 0.65; 1 item). 100% patients with MUI, 84% with UUI and 59.9% with UEI report some impact on their quality of life., Conclusions: UI-4 is simple, valid and easy to administer, and can be particularly valuable in the clinical rating of UI in settings where urodynamic testing is not easily available such is primary health care.

This study describes the urodynamic findings in 22 patients with posterior urethral valves and discusses their association with urinary incontinence, age, mode of primary treatment, renal function, and changes in the upper tracts. The patients' ages ranged from 3 to 26 years and 27% were either adolescents or older. The urodynamic findings were categorized into 5 main patterns, although mixed patterns were also observed; (1) normal capacity and compliance with normal detrusor contractility (2/22 patients, 9.1%); (2) small-capacity, hypocompliant bladder (8/22 patients, 36.4%); (3) unstable bladder (2/22 patients, 9.1%); (4) large-capacity, hypotonic bladder with decreased detrusor contractility (2/22 patients, 9.1%); and (5) normal capacity and compliance but with decreased detrusor contractility (8/22 patients, 36.4%). More than one-half of the patients (57.1%) evacuated their bladders incompletely, and this seemed to be associated with post-treatment episodes of urinary-tract infection. The commonest symptom was daytime frequency, urgency, and leak with nocturnal enuresis, which urodynamically correlated with a small-capacity, hypocompliant or unstable bladder or to incomplete evacuation of the bladder, leading to significant post-void residue. Significant detrusor dysfunction was identified in 2 asymptomatic patients as well, emphasizing the need to perform a routine urodynamic work-up on all valve patients. Urodynamic properties seemed to be associated with age. Small, hypocompliant, and unstable bladders were almost always seen in prepubertal boys and in the first 5 years following undiversion, whereas large, hypotonic bladders with impaired contractility were seen in post-pubertal boys. While the current policy is to avoid high diversion, data in this study suggest that disorders of detrusor capacity, compliance, and contractility exist in children treated by primary valve ablation and vesicostomy and that abnormal detrusor dynamics seem to be a reflection of inherent developmental detrusor dysfunction consequent to congenital infravesical obstruction.

Objective: The present study analyzes the main clinical types of urinary incontinence in the elderly population and its clinical-urodynamic correlation to facilitate definitive diagnosis., Methods/results: The study was conducted in 948 elderly patients (382 male, 566 female; mean age 72.4 years) with urinary incontinence. Patient clinical and urodynamic records were reviewed. The most common clinical types were urge-incontinence (56.4%) and incontinence with coughing associated with urge-incontinence (32.3%); the latter type was the most common in women. The most frequent urodynamic diagnoses were isolated bladder instability (29.9%), followed by obstruction (15.6%) and stress incontinence (14%)., Conclusions: The most common symptom in bladder instability was urge-incontinence, while incontinence with coughing was found to be the most common symptom in urinary stress incontinence. A significant correlation was found between the postvoid residual urine and the main urodynamic diagnoses. Multivariate analysis showed that classification by clinical types of incontinence together with measurement of residual urine can facilitate diagnosis, although this approach has a low sensitivity for the main forms of isolated incontinence. The mixed forms require a urodynamic study.

There is a lot of debate among continence specialists as to the impact that urinary incontinence (UI) has upon the sufferer's quality of life (QoL). Furthermore, healthcare professionals involved in delivering care are examining ways to measure the outcomes of their healthcare interventions, in terms of not only symptom relief, but also patient-specified improvements to QoL. Healthcare professionals have yet to agree upon one standard tool for measuring the effect of UI upon sufferers' QoL. This article examines some of the current research on UI as experienced by females living in their own homes and its impact on their QoL.