Serum estradiol does not differentiate stress, mixed and urge incontinent women around menopause. A report from the Women's Health in the Lund Area (WHILA) study.

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

Cost-analyzes based on a prospective, randomized study comparing laparoscopic colposuspension with a tension-free vaginal tape procedure.

Background. The aim of this study was to compare laparoscopic colposuspension with tension-free vaginal tape (TVT) in terms of costs to the county. Methods. In a prospective, randomized study, we approached 270 consecutive women presenting for evaluation of stress urinary incontinence symptoms at one university hospital. Preoperatively, and at 1-year follow-up, the women underwent urodynamic evaluation, an ultra-short pad-test and completed a lower urinary tract symptoms questionnaire. We randomized 79 consenting, eligible women to either procedure; a 1-year follow-up examination was performed on 68/71 (96%) women that were available. The procedures were performed as described previously. Main outcome measures were all relevant costs for goods and services associated with the procedures. Results. The baseline characteristics of the two groups were similar. The TVT procedure was performed significantly faster than the laparoscopic colposuspension, i.e. 44.9 ± 14.2 min compared with 60.5 ± 13.4 min (p< 0.0001). Even so, procedural costs were significantly lower for laparoscopic colposuspension than for TVT (euro 1273.4 compared with euro 1342.8 p< 0.001). At the 1-year follow-up visit, three women operated on with TVT and one operated on with laparoscopic colposuspension required re-operation for continuous stress urinary incontinence. One women operated on with TVT had her sling cut for bladder-emptying problems. Total costs, including re-operations were euro 1462.6 for a TVT procedure andeuro 1314.5 for a laparoscopic colposuspension. Conclusion. In our hands, the laparoscopic colposuspension was less expensive to the county than the TVT procedure

Urinary incontinence in middle-aged women - a population-based study on prevalence, risk factors and the role of the urethra

Urinary incontinence classification is based on symptomatology, presuming that each symptom originates in a separate pathophysiology and demands its unique therapy. Women often present a mixture of symptoms inconsistent with urodynamic diagnosis, especially regarding urgency. Treatment of stress incontinence often relieves urge symptoms indicating a common pathophysiology. Our aims were to investigate urodynamic characteristics in 59 incontinent and 28 continent middle aged women recruited from the WHILA study and to compare the findings to those of patients with established incontinence; to investigate the prevalence of LUTS including overactive bladder and potential risk factors for overactive bladder and stress incontinence. Incontinent women produced a higher maximum urinary flow and a faster flow acceleration at an unchanged detrusor pressure level than the continent women regardless of stress, urge or mixed symptomatology. They also showed a decreased ability to increase the urethral pressure during short squeezes expressed as pressure rise amplitude and in a semiquantitative classification based upon the configuration of the pressure response curve. Pelvic floor exercises increased pressure response to the same level as in continent women. Urethral pressure fall during or immediately after squeeze was significantly more common in women with established incontinence. Urgency, stress incontinence and frequency were the most common LUTS. The calculated prevalence of urinary incontinence defined as involuntary urinary leakage was 66% compared to 32% when the definition demanded social and/or hygienic bother. Overactive bladder was intimately associated with stress incontinence. Both overactive bladder and stress incontinence were associated with metabolic factors mainly increased body mass index

Abnormal urethral motor function is common in female stress, mixed, and urge incontinence.

Aim: To investigate the urethral motor function in incontinent women. Materials and Methods: The intraurethral pressure was measured continuously in the high-pressure zone of the urethra at rest and during repeated short squeezes around the microtip transducer catheter in a group of 205 women with clinically manifest urinary incontinence (severe), and compared with the findings of investigations in 87 middle-aged women (53-63 years) with treatment naive incontinence (mild-to-mode rate) and healthy controls. Results: Women with established incontinence significantly (P < 0.001) more often (66%) had a pressure fall during or immediately following squeeze than women with treatment naive incontinence (35%) or asymptomatic women (25%). The acceleration of urinary flow and the maximal flow rate were significantly (P < 0.01) increased in patients with incontinence: acceleration was 13 +/- 2.2 (17.8), 20 +/- 2.8 (18.9), and 32 +/- 4.9 (24.9) degrees (mean +/- SEM;SD) for incontinence, naive incontinence and no incontinence, respectively; maximum urinary flow rate was 23, 22, and 16 ml/sec. No statistical differences in any of these measures were seen when stress and urge incontinence were compared. Conclusion: Women with stress, urge, and mixed urinary incontinence seem to have a primary neuromuscular disorder in the urethra, which presents itself as an overactive opening mechanism with a urethral pressure fall instead of a pressure increase on provocation during the filling phase of the bladder, and during bladder emptying a more efficient opening of the bladder outlet than in normal women. We suggest that one and the same pathophysiological mechanism participates in female stress, urge, and mixed incontinence

Urethral pressure response patterns induced by squeeze in continent and incontinent women.

Our aim was to compare the urethral pressure response pattern to pelvic floor muscle contractions in 20-27 years old, nulliparous continent women (n=31) to that of continent (n=28) and formerly untreated incontinent (n=59) (53-63 years old) women. These women underwent urethral pressure measurements during rest and repeated pelvic muscle contractions. The response to the contractions was graded 0-4. The young continent women showed a mean urethral pressure response of 2.8, the middle-aged continent women 2.2 (NS vs young continent), and the incontinent women 1.5 (p < 0.05 vs middle-aged continent, p < 0.001 vs young continent). Urethral pressures during rest were significantly higher in the younger women than in both groups of middle-aged women. The decreased ability to increase urethral pressure on demand seen in middle-aged incontinent women compared to continent women of the same age as well as young women seems to be a consequence of a neuromuscular disorder rather than of age

Efficacy and safety of pelvic organ prolapse surgery with porcine small intestinal submucosa graft implantation

Objective: The ideal implant material for the surgical repair of pelvic organ prolapse in women is yet to be found. This retrospective study aims to evaluate a porcine small intestinal submucosa (SIS) graft (Surgisis™). Study design: We reviewed the medical records of women that were operated upon for pelvic organ prolapse using implantation of SIS graft and we examined the short-term complications and recurrence rates. Results: A total of 155 surgical procedures were reviewed. SIS graft was placed in the anterior, posterior and middle compartments in 93 (60%), 71 (45.8%) and 13 (8.4%) cases, respectively. At three-month follow-up, 22.6% of anterior graft repairs displayed anatomical recurrence (POP-Q stage ≥ 2), compared to 4.8% of posterior and none of the middle compartment graft repairs. During the three postoperative months, 56% of the women were recorded with complications, mostly urinary retention (19%) and pain (12%). The incidence of grade III complications was 5.3%. Persistent complications at three months were observed in 28% of all cases. Logistic regression analysis showed that previous prolapse surgery at the same compartment was a significant predictor for recurrence of prolapse after SIS graft application, whereas lower age, smoking and longer duration of surgery were significant predictors for the development of complications. Younger women had higher risk of developing pain postoperatively. Conclusion: Pain and urinary tract symptoms hold a central position in the complications profile of SIS graft-augmented prolapse surgery. The relatively high recurrence rates do not suggest a clear benefit from SIS graft use

Impact of per-operative antibiotics on the urinary tract infection rate following mid-urethral sling surgery for urinary incontinence : a randomized controlled trial

Introduction and hypothesis: The objective was to compare the effect of antibiotics versus no antibiotics prophylaxis per-operatively on the frequency of urinary tract infection (UTI) following mid-urethral sling application to treat stress or mixed urinary incontinence. Methods: This study was designed as a multicenter prospective randomized trial. Women were included from eight centers in three countries. Women were aged under 60 years and had objectively verified stress urinary incontinence. Women with mixed urinary incontinence were also included. Randomization was held in blocks for operation with either antibiotics or no antibiotics. UTI was defined in accordance with the Centers for Disease Control (CDC) criteria for symptomatic UTI. Women were followed up at 3, 12, and 36 months. This was part of a trial comparing subjective cure rate in relation to application of Ajust® (single-incision mid-urethral slings) versus standard mid-urethral slings. Results: The main outcome was to evaluate if per-operative antibiotics had any impact on UTI following sling surgery. In total, 305 women were randomized (158 [52%] to antibiotics and 147 [48%] to no antibiotics). Demographic data disclosed no differences between the two groups. The trial did not show any difference between the two groups regarding the frequency of postoperative UTI. Logistic regression analysis disclosed only residual urine volume at 3 months’ follow-up as a significant risk factor for UTIs. Per-operative antibiotics had no influence on the frequency of mesh erosions or any other complication. Conclusions: Our trial does not suggest any beneficial effect of per-operative antibiotics on the risk of post-operative UTIs