URINARY INCONTINENCE

For example, at a BMI greater than 35 kg/m², the likelihood of:

• any incontinence increased by a factor of about 2 (OR, 2.11; 95% confidence interval [CI], 1.84–2.42)
• frequent incontinence increased by a factor of almost 4 (OR, 3.85; 95% CI, 3.05–4.85)
• severe incontinence increased by a factor of more than 5 (OR, 5.52; 95% CI, 3.72–8.18).

The trend for weight gain was similar, with a gain of more than 30 kg showing odds ratios and 95% confidence intervals of similar magnitude to those seen with a BMI greater than 35.

But one third of incontinent women improved after 2 years

Although urinary incontinence is usually understood as a chronic condition, albeit under the influence of other factors, such as weight gain, data on remission are even scarcer than data on incidence. Using the same dataset, the authors determined that almost 31,000 women were incontinent at baseline in 2001, with incontinence occurring at least monthly. Complete remission, defined as no leaking in 2003, occurred in almost 14% of women. One third reported improvement, defined as either complete remission or a decrease in leaking frequency from 2001 to 2003.

It’s interesting that complete remission was more common in younger women. It also was more common in women who experienced frequent incontinence than in those who reported occasional incontinence. The remaining percentage of women—almost 60%—reported a similar or increased frequency of incontinence over the 2 years of follow-up.

The authors did not collect data on treatment. Estimates of persistence, improvement, and remission could be affected, therefore, if women received effective treatment between 2001 and 2003. However, only about one third of women reported mentioning their symptoms to a physician, and only 13% reported receiving treatment for incontinence. The magnitude of the effect of treatment on remission or improvement of urinary incontinence symptoms therefore seems limited.

Women remain reticent about incontinence

Several points underline the clinical importance of these data, including the relatively high incidence of incontinence symptoms and the strong influence of BMI and weight gain on that incidence. Also notable, and described in previous studies, is the vast underreporting and undertreatment of incontinence in women—an observation that should motivate all clinicians to include screening for urinary incontinence as part of regular well-woman care. Clinicians should also be prepared to refer women with incontinence or to initiate evaluation and management.

Some reports have suggested that the stigma of urinary incontinence has diminished slightly in light of widespread direct-to-consumer advertising for products related to the care (e.g., pads) or treatment (e.g., pharmaceuticals) of incontinence. The data from Townsend and colleagues are relatively recent, yet the majority of women failed to report their symptoms, and an even higher percentage received no treatment. The authors recommend that health-care providers initiate a discussion of urinary symptoms even in middle-aged women, who may be targeted for screening less frequently than older women.

In fascial sling vs Burch, sling prevails but is linked to more adverse effects

Albo ME, Richter HE, Brubaker L, et al, for the Urinary Incontinence Treatment Network. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med. 2007;356:2143–2155; comment: 2198–2200.

Eagerly anticipated results of the Urinary Incontinence Treatment Network’s first surgical trial, which compared the fascial sling procedure with Burch colposuspension for stress incontinence, were published in May in the New England Journal of Medicine. The Urinary Incontinence Treatment Network is a multicenter clinical trials group that was established in 2000 and is sponsored by the National Institutes of Health (specifically, by the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute of Child Health and Human Development).

Women were eligible for the trial if they experienced symptoms of stress incontinence; symptoms of mixed incontinence were allowed as long as stress symptoms predominated. Of 655 women in the trial, 326 were randomly assigned to undergo placement of an autologous rectus fascia pubovaginal sling, and 329 were randomized to Burch colposuspension.

Overall success was defined as:

• negative pad test
• no urinary incontinence reported in a 3-day diary
• negative stress test to cough and Valsalva maneuver
• no self-reported symptoms of stress incontinence
• no retreatment for stress incontinence.

“Stress success,” or stress continence, was defined using the last three criteria.

At 2 years after the index surgery, 520 women (79%) were available for follow-up. Overall success and stress success were slightly higher in women who underwent sling placement than in those treated by Burch: overall success, 47% versus 38%, and stress success, 66% versus 49%, respectively. However, women who had slings experienced more adverse outcomes, including urinary tract infection, difficulty voiding, and postoperative urge incontinence.