Norra MacReady

October 12, 2010

October 12, 2010 (Long Beach, California) — Depression and multiple or severe comorbidities are independent predictors of urinary urgency symptoms, according to a prospective analysis of 2 large cohorts of women.

The findings point to a multifactorial genesis of urge urinary incontinence (UUI), lead investigator Leslie M. Rickey, MD, MPH, a urogynecologist and assistant professor of surgery at the University of Maryland School of Medicine in Baltimore, said here at the American Urogynecologic Society 31st Annual Scientific Meeting.

"This study provides further evidence that lower urinary tract symptoms [LUTS] can be influenced by urologic and vascular pathways that affect a wide range of systems. It presents an opportunity to look at the pathways of urgency and urge incontinence, especially the central, peripheral, and neurovascular mechanisms," Dr. Rickey noted.

Dr. Rickey and colleagues analyzed data from 2 prospective randomized controlled trials comparing the outcomes of different surgical procedures for the management of stress urinary incontinence: the Stress Incontinence Surgical Treatment Efficacy (SISTEr; n = 655) trial and the Trial Of Mid-Urethral Slings (TOMUS; n = 597).

"We felt that having this large database of very well-characterized women with a large number of baseline variables that might be associated with urge incontinence in this population would yield important information," she explained. "We also thought that characterizing the risk factors for urge urinary incontinence in this population might help in developing interventions and improving outcomes."

The investigators hypothesized that factors such as demographics, medical history, and symptom severity might be predictive of UUI or symptoms of urge incontinence, Dr. Rickey said.

At baseline, the participants in both studies completed standardized assessments of quality of life, symptom severity, and objective measures of urine loss, including the Incontinence Impact Questionnaire (IIQ), which measures the effect of urinary incontinence on the patient's activities and emotional states, and the Urogenital Distress Inventory, which determines how troubling the patients find their symptoms. Changes in incontinence pad weight also were tracked. The TOMUS participants also completed the Charlson Comorbidity Index, Patient Global Impression of Severity, and Patient Health Questionnaire-9. A score greater than 10 on the Patient Health Questionnaire-9 suggests moderate to severe depression; the median score in both groups was less than that.

At baseline, 70% of the SISTEr and 68% of the TOMUS participants rated their UUI as "moderately bothersome." In both studies, a higher IIQ score was predictive of UUI, such that "the odds of UUI increased for each 10-unit change in IIQ total symptom score" (odds ratio, 1.07; 95% confidence interval, 1.05 - 1.09; P < .0001), Dr. Rickey said.

Number of comorbidities, as measured by the Charlson Comorbidity Index, also was associated with a higher score on the irritative subset of the Urogenital Distress Inventory (P = .0002), as were higher scores on the depression scale (P < .0001). Parity, medical history (including history of any prior incontinence treatment or surgery), smoking or hormonal status, and frequency of incontinence episodes did not independently predict either UUI or degree of bother from UUI or LUTS.

Other investigators have obtained similar findings of "no relationship between parity and urge incontinence or urgency," Dr. Rickey said.

The relationship between depression and UUI or urgency symptoms suggests that the 2 conditions might share a common neurological pathway, she added.

Mikio Nihira, MD, MPH, associate professor of female pelvic medicine and reconstructive surgery in the Department of Obstetrics and Gynecology at the University of Oklahoma College of Medicine in Oklahoma City, wondered about the clinical applicability of these data. "Have your findings and literature searches changed the way you counsel patients before surgery?" he asked during a question-and-answer period. Dr. Nihira was not involved in this study.

"I don't know that we've identified enough modifiable risk factors that would help us optimize incontinence surgery, but it did help us hone in on some of the more interesting comorbidities associated with UUI," Dr. Rickey replied. "The relationship between comorbidity level, depression, and worsening UUI or urgency symptoms provides further evidence that LUTS are related to processes and pathology beyond the bladder and deserve increased recognition."

Dr. Rickey and Dr. Nihira have disclosed no relevant financial relationships.

American Urogynecologic Society 31st Annual Scientific Meeting: Paper 3. Presented October 1, 2010.


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