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Textbook of Female Urology and Urogynecology 3rd
Edition Linda Cardozo Digital Instant Download
Author(s): Linda Cardozo, David Staskin (Editors)
ISBN(s): 9781841846927, 1841846929
Edition: 3
File Details: PDF, 45.13 MB
Year: 2010
Language: english
Textbook of Female Urology and Urogynecology

Cardozo • Staskin
Third edition
Volume 1
Editors in Chief
Linda Cardozo MD, FRCOG
Professor of Urogynaecology, King’s College Hospital, London, UK

Textbook of
and
David R Staskin, MD
Director, Female Urology and Male Voiding Dysfunction, St. Elizabeth’s
Medical Center and Associate Professor of Urology, Tufts University
School of Medicine, Boston, Massachusetts, USA Volume 1

Featuring contributions by an international team of the world’s experts

in urology and gynecology, this third edition reinforces its status as the
standard reference work on female urology and urogynecology and an
Female Urology
and Urogynecology

and Urogynecology
Textbook of Female Urology
essential clinical textbook in the field.

The sections have now been revised to cover:

• Background Issues
• Patient Reported Outcome Measures and Health Economics
• Basic Science: Structure and Function of the Lower Urinary and
Anorectal Tracts in Women

Third Edition
• Diagnostic Evaluation of Incontinence and Urogenital Prolapse
• Non Surgical Treatment of Incontinence Prolapse and Related
Conditions
• Associated Disorders
• Surgery for Urinary Incontinence
• Surgery for Urogenital Prolapse
• Laparoscopy and Robotics
• Complex Problems

The previous edition was awarded Best New Edition of an Edited

Medical Book by the Society of Authors and the Royal Society of Section Editors
Medicine in their 2006 book awards.
Dudley Robinson
Cornelius J Kelleher
Jacek L Mostwin
Sender Herschorn
Eric Rovner
Philip Toozs-Hobson
Editors-in-Chief
Roger R Dmochowski
Peter K Sand Linda Cardozo
Third
Anthony RB Smith
Victor Nitti David Staskin
Edition

Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK

52 Vanderbilt Avenue, New York, NY 10017, USA

www.informahealthcare.com ISBN 9781841846927

Textbook of Female Urology
and Urogynecology
Third Edition

Volume 1

Editors-in-Chief
Linda Cardozo MD, FRCOG
Professor of Urogynaecology,
King’s College Hospital,
London, U.K.

and

David R Staskin MD
Director, Female Urology and Male Voiding Dysfunction,
St. Elizabeth’s Medical Center, Associate Professor of Urology,
Tufts University School of Medicine, Boston, Massachusetts, U.S.A.
First published in 2001 by Isis Medical Media Ltd, United Kingdom
This edition published in 2010 by Informa Healthcare, Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK.
Simultaneously published in the USA by Informa Healthcare, 52 Vanderbilt Avenue, 7th floor, New York, NY 10017, USA.

© 2010 Informa UK Ltd, except as otherwise indicated.

No claim to original U.S. Government works.

Reprinted material is quoted with permission. Although every effort has been made to ensure that all owners of copyright material have been acknowl-
edged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic,
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Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to
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This book contains information from reputable sources and although reasonable efforts have been made to publish accurate information, the publisher
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Contents

List of Contributors vii 13 Patient Reported Outcome Questionnaires

Foreword xiii to Assess Health Related Quality of Life
Preface xiv and Symptom Impact 96
Cornelius J Kelleher
VOLUME ONE 14 PRO Questionnaires to Screen and Measure
Satisfaction, Expectations, and Goal Achievement 114
SECTION 1: BACKGROUND ISSUES Zoe S Kopp, Christopher J Evans, and Linda P Brubaker
Section Editor: Dudley Robinson
15 Questionnaires to Assess Sexual Function 125
1 History of Urogynecology and Female Urology 1 Claudine Domoney and Tara Symonds
Jane A Schulz, Harold P Drutz, and Jack R Robertson
16 Questionnaires to Assess Bowel Function 133
2 Epidemiology: U.S.A. 8 Anton Emmanuel and Dave Chatoor
Scott E Kalinowski, Benjamin J Girdler,
17 International Consultation on Incontinence
and Ananias C Diokno
Modular Questionnaire (ICIQ) 138
3 Epidemiology: South America 16 Nikki Cotterill and Paul Abrams
Paulo Palma, Miriam Dambros, and Fabio Lorenzetti
18 Questionnaires to Assess Pelvic Organ Prolapse 146
4 Epidemiology: Europe 21 Vanja Sikirica and Mark Slack
Ian Milsom
19 Economic Aspects of Urinary Incontinence 153
5 Epidemiology: Australia 27 Kate H Moore
Richard J Millard and Dudley Robinson
SECTION 3: BASIC SCIENCE: STRUCTURE
6 Epidemiology: Asia 37 AND FUNCTION OF THE LOWER
SS Vasan and Reena S Yalaburgi URINARY AND ANORECTAL
7 Epidemiology of Incontinence in Africa 48 TRACTS IN WOMEN
Peter de Jong and Stephen Jeffery Section Editor: Jacek Mostwin

8 Tackling the Stigma of Incontinence: Promoting 20 Anatomy 162

Continence Worldwide 52 John OL DeLancey
Diane K Newman 21 Embryology of the Female Urogenital System
9 Natural History and Prevention of Urinary and Clinical Applications 172
Incontinence and Urogenital Prolapse 57 Sarah M Lambert and Stephen A Zderic
Ruben Trochez and Robert M Freeman 22 Tissue Engineering and Regenerative Medicine
10 Medical Error and Patient Safety in Surgery 68 for the Female Genitourinary System 185
Roxane Gardner Anthony Atala

11 Patient Safety in the Operating Room 79 23 Physiology of Micturition 200

Michael L Stitely and Robert B Gherman Naoki Yoshimura and Michael B Chancellor

24 Pharmacology of the Bladder 212

SECTION 2: INTRODUCTION: THE ROLE OF PATIENT Karl-Erik Andersson
REPORTED OUTCOME MEASURES
AND HEALTH ECONOMICS 25 Classification of Lower Urinary Tract
Section Editor: Cornelius J Kelleher Dysfunction in the Female Patient 227
David R Staskin and Alan J Wein
Section Introduction: The Role of Patient
Reported Outcome Measures and SECTION 4: DIAGNOSTIC EVALUATION
Health Economics 86 OF INCONTINENCE AND
Cornelius J Kelleher UROGENITAL PROLAPSE
Section Editor: Sender Herschorn
12 Patient Reported Outcomes: From Development
to Utilization 88 26 History and Examination 235
Karin Coyne and Chris Sexton Vik Khullar and Demetri C Panayi

iii
 contents

27 Voiding Diary 244 45 Pessaries and Devices: Nonsurgical Treatment of

Matthew Parsons Pelvic Organ Prolapse and Stress Urinary
Incontinence 457
28 Pad Tests 250
Catherine S Bradley
Marie-Andrée Harvey
46 Catheters; Pads and Pants; Appliances 464
29 Uroflowmetry 257
Lynette E Franklin
Matthias Oelke and Jean-Jacques Wyndaele
30 Cystometry 267 SECTION 6: ASSOCIATED DISORDERS
Hashim Hashim and Paul Abrams Section Editor: Philip Toozs-Hobson

31 Pressure–Flow Plot in the Evaluation of Female 47 The Overactive Bladder 477

Incontinence and Postoperative Obstruction 276 Rob Jones and Marcus Drake
Rashel Haverkorn, Jason Gilleran and Philippe Zimmern
48 Neurologic Disorders 485
32 Tests of Urethral Function 290 Ricardo R Gonzalez, David W Goldfarb, Renuka Tyagi,
Ahmet Bedestani, Christopher J Chermansky, and Alexis E Te
Mohamed Ghafar, and J Christian Winters
49 Non-Neurogenic Voiding Dysfunction
33 Clinical Neurophysiologic Testing 305 and Urinary Retention 498
David B Vodušek and Clare J Fowler Bernard T Haylen
34 Videourodynamics 320 50 Pathophysiological Mechanisms
Sender Herschorn and Blayne Welk of Chronic Pelvic Pain 511
Ursula Wesselmann
35 Ambulatory Urodynamics 335
Stefano Salvatore, Vik Khullar, and Linda Cardozo 51 Painful Bladder Syndrome/Interstitial Cystitis 518
Edward J Stanford and Candice Hinote
36 Imaging of the Upper and Lower Urinary Tract
(Radiology and Ultrasound) 345 52 Lower Urinary Tract Infections—Simple
Andrea Tubaro, Kirsten Kluivers, and Antonio Carbone and Complex 530
37 Magnetic Resonance Imaging James Gray and Dudley Robinson
and the Female Pelvic Floor 365 53 Vaginitis 544
Lennox Hoyte James Gray and Andrew Hextall
38 Endoscopy 377 54 Pregnancy and Childbirth and the Effect
Lesley Carr and Geoffrey W Cundiff on the Pelvic Floor 554
Charlotte Chaliha
SECTION 5: NONSURGICAL TREATMENT 55 Problems Associated with Sexual Activity 567
OF INCONTINENCE, PROLAPSE, Swati Jha
AND RELATED CONDITIONS
Section Editor: Eric Rovner 56 The Menopause 576
Timothy C Hillard
39 The Role of the Continence Nurse 388
Angie Rantell 57 Sports and Fitness Activities 589
Jeanette Haslam, Kari Bø, and Philip Toozs-Hobson
40 Behavioral Therapies and Management
of Urinary Incontinence in Women 398 58 Anal Incontinence 595
Kathryn L Burgio Tony Mak and Simon Radley

41 Physiotherapy for Urinary Incontinence 405 59 Constipation 604

Bary Berghmans Nadia Ali-Ross and Anthony RB Smith

42 Drug Treatment of Voiding Dysfunction 60 Female Sexual Dysfunction 619

in Women 418 Irwin Goldstein
Ariana L Smith and Alan J Wein
VOLUME TWO
43 Peripheral Neuromodulation 447
John Heesakkers and Michael van Balken SECTION 7: SURGERY FOR URINARY
INCONTINENCE
44 Sacral Neuromodulation in the Treatment
Section Editor: Roger R Dmochowski
of Female Overactive Bladder Syndrome
and Non-obstructive Urinary Retention 452 61 How and Why Incontinence Surgery Works 635
JLH Ruud Bosch Jerry G Blaivas, Matthew P Rutman, and Rhonda Walsh
iv
 contents

62 Peri- and Postoperative Care 645 78 Rectocele—Anatomic and Functional Repair 799
Sushma Srikrishna and Linda Cardozo Apurva B Pancholy, William A Silva,
and Mickey M Karram
63 Traditional Surgery and Other Historical
Procedures for Stress Incontinence 652 79 Vaginal Approach to Fixation of Vaginal Apex 813
Malcolm Lucas May Alarab and Harold P Drutz
64 Retropubic Urethropexy 676 80 Abdominal Approach to Supporting
Dudley Robinson and Linda Cardozo the Vaginal Apex 824
Aimee Nguyen, Sylvia Botros, and Peter K Sand
65 Fascial Slings 687
Alex Gomelsky 81 Prolapse of the Uterus: Epidemiology
and Treatments 829
66 Retropubic Tension-Free Vaginal Tape
Procedures for Treatment of Female Roger P Goldberg
Urinary Stress Incontinence 693 82 Biological Grafts in Pelvic Surgery 839
Carl Gustaf Nilsson Manhan Vu and Peter K Sand
67 Transobturator Slings 700 83 Mesh Complications in Prolapse Surgery 846
Alex Gomelsky and Roger R Dmochowski Stergios K Doumouchtsis and Michelle M Fynes
68 Single Incision Slings 708 84 Episiotomy and Perineal Repair 855
Apurva B Pancholy and Mickey M Karram Ranee Thakar and Christine Kettle

69 Readjustable Slings: Safyre and Remeex 713 85 Primary Repair of Obstetric Anal
Paulo Palma and Cassio Riccetto Sphincter Injuries 863
Abdul H Sultan
70 Urethral Injection Therapy for Stress
Urinary Incontinence 723 86 Surgery for Fecal Incontinence 871
W Stuart Reynolds and Roger R Dmochowski Klaus E Matzel and Manuel Besendörfer

71 Nonsurgical Transurethral Radiofrequency 87 Combined Genital and Rectal Prolapse 878

Collagen Denaturation of the Bladder Neck Vanessa Banz, Jürg Metzger, and Bernhard Schuessler
and Proximal Urethra for the Treatment
of Stress Urinary Incontinence 734
Saad Juma SECTION 9: LAPAROSCOPY AND ROBOTICS
Section Editor: Anthony RB Smith
72 The Artificial Urinary Sphincter for Treatment
of Stress Urinary Incontinence in Women 741 Section Introduction: The Role of
Roger R Dmochowski and David R Staskin Laparoscopic Surgery 890
Anthony RB Smith
73 Diagnosis and Treatment of Obstruction
Following Incontinence Surgery—Urethrolysis 88 Pelvic Anatomy Through the Laparoscope 891
and Other Techniques 749 Fiona Reid
Sagar R Shah and Victor W Nitti
89 Laparoscopic Treatment of Pelvic Pain 896
74 Complications of Stress Urinary Christopher Sutton and Richard Dover
Incontinence Surgery 763
90 Laparoscopic Colposuspension 909
Melissa R Kaufman, Harriette M Scarpero,
and Roger R Dmochowski Arvind Vashisht and Alfred Cutner

91 Laparoscopic Sacrocolpopexy 920

SECTION 8: SURGERY FOR UROGENITAL Marcus P Carey
PROLAPSE
Section Editor: Peter K Sand 92 Other Laparoscopic Support Procedures 929
Rohna Kearney
75 Classification and Epidemiology
of Pelvic Organ Prolapse 771 93 Prevention, Recognition, and Treatment
Steven E Swift of Complications in Laparoscopic
76 Anterior Vaginal Wall Prolapse 779 Pelvic Floor Surgery 935
Mark D Walters Christopher Maher

77 Enterocele 789 94 Robotic Surgery 942

Kaven Baessler and Bernhard Schuessler Megan Tarr and Kimberly Kenton

v
 contents

SECTION 10 COMPLEX PROBLEMS APPENDICES

Section Editor: Victor W Nitti
I Standardization of Terminology 1075
Dirk De Ridder
95 Urogenital Fistula 951
Michael S Ingber, Sandip P Vasavada, II The Standardization of Terminology of Lower
and Raymond Rackley Urinary Tract Function: Report from
the Standardization Sub-Committee
96 Urogenital Fistulae: Obstetric 960 of International Continence Society 1079
Andrew Browning Paul Abrams, Linda Cardozo, Magnus Fall,
Derek Griffiths, Peter Rosier, Ulf Ulmsten,
97 Urethral Diverticulum and Fistula 971 Philip van Kerrebroeck, Arne Victor, and Alan J Wein
Kenneth C Hsiao, Alvaro Lucioni,
and Kathleen C Kobashi III An International Urogynaecological Association
(IUGA)/International Continence Society (ICS)
98 Electrical Implants and Sacral Joint Report on the Terminology for Female
Neuromodulation for the Treatment Pelvic Floor Dysfunction 1090
of Urinary Incontinence 991 Bernard T Haylen, Dirk De Ridder, Robert M Freeman,
Sandip P Vasavada and Raymond R Rackley Steven E Swift, Bary Berghmans, Joseph Lee, Ash Monga,
Eckhard Petri, Diaa E Rizk, Peter K Sand,
99 Complex Reconstructive Surgery 998 and Gabriel N Schaer
Christopher R Chapple
IV Commentary on the 2009 IUGA/ICS Joint
100 Gynecological Developmental Abnormalities 1023 Report on the Terminology for Female
Melissa C Davies and Sarah M Creighton Pelvic Floor Dysfunction 1106
Rufus Cartwright
101 Pediatric Urogynecology 1032
Jonathan D Kaye, Howard M Snyder, V The Standardization of Terminology of Female
and Andrew J Kirsch Pelvic Organ Prolapse and Pelvic
Floor Dysfunction 1113
102 The Effect of Hysterectomy (Simple and Radical) Richard C Bump, Anders Mattiasson, Kari Bø,
on the Lower Urinary Tract 1045 Linda P Brubaker, John OL DeLancey, Peter Klarskov,
Christopher Jayne and Bianca A Gago Bob L Shull, and Anthony RB Smith

103 Recognition and Management of Urological VI Good Urodynamic Practices: Uroflowmetry,

Complications of Gynecological Surgery 1049 Filling Cystometry, and Pressure-Flow Studies 1121
Kevin R Loughlin Werner Schaefer, Paul Abrams, Limin Liao,
Anders Mattiasson, Francesco Pesce, Anders Spangberg,
104 Vaginal Rejuvenation and Cosmetic Arthur M Sterling, Norman R Zinner,
and Philip van Kerrebroeck
Vaginal Surgery 1056
Robert D Moore and John R Miklos Index 1133

vi
List of Contributors

Paul Abrams Andrew Browning MBBS, MRCOG

Professor, Bristol Urological Institute, Southmead Hospital, Bristol, Medical Director, Barhirdar Hamlin Fistula Centre, Barhirdar,
U.K. Ethiopia
May Alarab, MBChB MRCOG, MRCPI, MSc Linda P Brubaker
Assistant Professor, Staff, Division of Urogynecology, Department of Section of Urogynecology and Reconstructive Plastic Surgery, Loyola
Obstetrics and Gynecology, and Reconstructive Pelvic Surgery, Mount University Medical Center, Maywood, Illinois, U.S.A.
Sinai Hospital, Toronto, Ontario, Canada
Richard C Bump
Nadia Ali-Ross Eli Lilly & Co Corporate Center, Indianapolis, Indiana, U.S.A.
Obstetrics and Gynaecology, Salford Royal Foundation Trust, Greater Kathryn L Burgio PhD
Manchester, U.K. University of Alabama at Birmingham and Birmingham/Atlanta
Karl-Erik Andersson MD, PhD Geriatric Research, Education, and Clinical Center, Department of
Wake Forest Institute for Regenerative Medicine, Wake Forest Veterans Affairs, Birmingham, Alabama, U.S.A.
University School of Medicine, Winston Salem, North Carolina, U.S.A. Antonio Carbone MD
Anthony Atala, MD Department of Urology, First School of Medicine, La Sapienza
Department of Urology and Wake Forest Institute for Regenerative University–General Hospital, Terracina, Italy
Medicine, Wake Forest University School of Medicine, Winston-Salem, Linda Cardozo MD, FRCOG
North Carolina, U.S.A. Professor of Urogynaecology, King’s College Hospital, London, U.K.
Kaven Baessler
Marcus P Carey
Department of Obstetrics and Gynecology, Charité Hospital, Berlin,
Urogynaecology, Royal Women’s Hospital, Melbourne, Victoria,
Germany
Australia
Michael van Balken
Department of Urology, Rijnstate Hospital, Arnhem, Lesley Carr
The Netherlands Urology, Sunnybrook Health Sciences Centre, Toronto, Ontario,
Canada
Vanessa Banz
Department of Visceral Surgery and Medicine, University Hospital Rufus Cartwright
Berne, Berne, Switzerland Institute of Reproductive and Developmental Biology, Hammersmith
Hospital, London, U.K.
Ahmet Bedestani MD
Fellow, Female Pelvic Medicine and Reconstructive Surgery, Charlotte Chaliha MB BChir, MA MD, MRCOG
Departments of Urology and Gynecology, Louisiana State University Consultant Obsetrician and Gynaecologist, Sub-specialist in
Health Sciences Center, New Orleans, Louisiana, U.S.A. Urogynaecology, Royal London and St Bartholomew’s Hospitals,
London
Bary Berghmans PhD, MSC, RPT
Clinical Epidemiologist, Health Scientist, Pelvic Physiotherapist, Pelvic Michael B Chancellor MD
Care Center Maastricht, Maastricht University Medical Center, Clinical Professor and Director of Neurology Program, Oakland
Maastricht, The Netherlands University William Beaumont School of Medicine, Royal Oak,
Michigan, U.S.A.
Manuel Besendörfer
Section of Coloproctology, Department of Surgery, University of Christopher R Chapple BSC, MD, FRCS (Urol), FEBU
Erlangen, Erlangen, Germany Consultant Urological Surgeon, Royal Hallamshire Hospital, Honorary
Senior Lecturer of Urology, University of Sheffield, Visiting Professor of
Jerry G Blaivas MD Urology, Sheffield Hallam University, Adjunct Secretary Responsible for
Clinical Professor of Urology, Weill Medical College of Cornell Education, European Association of Urology
University New York, New York, and Adjunct Professor of Urology,
SUNY Downstate Medical School, Brooklyn, New York, U.S.A. Dave Chatoor MBBS, FRCS
Research Fellow in GI Physiology, Gastroenterology, University College
Kari Bø Hospital, London, U.K.
Norwegian University of Sport and Physical Education, Oslo, Norway
Christopher J Chermansky MD
JLH Ruud Bosch MD, PhD Assistant Professor, Department of Urology, Section of Female Urology
Professor and Chairman, Department of Urology, University Medical and Voiding Dysfunction, Louisiana State University Health Sciences
Center Utrecht, Utrecht, The Netherlands Center, New Orleans, Louisiana, U.S.A.
Sylvia Botros MD, MS Nikki Cotterill
Evanston Continence Center, Division of Urogynecology and Recon- Bristol Urological Institute, Southmead Hospital, Bristol, U.K.
structive Pelvic Surgery, Department of Obstetrics and Gynecology,
NorthShore University HealthSystem, Evanston, Illinois, U.S.A. Karin Coyne PhD, MPH
United BioSource Corp, Bethesda, Maryland, U.S.A.
Catherine S Bradley MD, MSCE
Associate Professor of Obstetrics and Gynecology and of Epidemiology, Sarah M Creighton MD, FRCOG
Division Director, Urogynecology and Reconstructive Pelvic Surgery, Consultant Gynaecologist, Elizabeth Garrett Anderson UCL Institute of
University of Iowa Carver, College of Medicine, Iowa City, Iowa, U.S.A. Women’s Health, University College Hospitals, London, U.K.

vii
 list of contributors

Geoffrey W Cundiff MD, FAOCG, FACS, FRCSC Robert M Freeman

Professor, Department of Obstetrics and Gynaecology, University of Professor in Urogynaecology, Peninsula Medical School,
British Columbia, Vancouver, British Columbia, Canada Urogynaecology Unit, Directorate of Obstetrics and Gynaecology,
Derriford Hospital, Plymouth, U.K.
Alfred Cutner
Obstetrics and Gynaecology, University College London Hospitals, Michelle M Fynes MD, MRCOG, DU
London, U.K. Lead Consultant Urogynaecologist and Honorary Senior Lecturer,
Department of Reconstructive Pelvic Surgery and Urogynaecology,
Miriam Dambros St Georges Hospital, and Medical School University of London,
Head of the Geriatric Urology Division, Federal University of São London, U.K.
Paulo, São Paulo, Brazil
Bianca A Gago MD
Melissa C Davies MD, MRCS Vanguard Urologic Research Foundation, Houston, Texas, U.S.A.
Female Urology Fellow, Leicester General Hospital, Leicester, U.K.
Roxane Gardner MD, MPH
Peter Dejong Assistant Professor of Obstetrics, Gynecology and Reproductive Biology,
Gynecology, Groote-Schuur Hospital, Cape Town, South Africa Harvard Medical School, Department of Obstetrics and Gynecology,
Brigham and Women’s Hospital, Boston, Massachusetts, U.S.A. and
John OL DeLancey Center for Medical Simulation, Cambridge, Massachusetts, U.S.A.
Pelvic Floor Research Group, Gynecology, University of Michigan
Medical School, Ann Arbor, Michigan, U.S.A. Mohamed Ghafar MD
Fellow, Female Pelvic Medicine and Reconstructive Surgery,
Dirk De Ridder MD, PhD, FEBU Departments of Urology and Gynecology, Louisiana State University
Chairman of the ICS Standardisation Committee, Department of Health Sciences Center, New Orleans, Louisiana, U.S.A.
Urology, University Hospitals KU Leuven, Leuven, Belgium
Robert B Gherman MD
Ananias C Diokno Department of Obstetrics and Gynecology, Division of Maternal/Fetal
Department of Urology, William Beaumont Hospital, Royal Oak, Medicine, Prince George’s Hospital Center, Cheverly, Maryland, U.S.A.
Michigan, U.S.A.
Jason Gilleran MD
Roger R Dmochowski MD Urology, Ohio State University Medical Center, Columbus,
Department of Urologic Surgery, Vanderbilt University Medical Center, Ohio, U.S.A.
Nashville, Tennessee, U.S.A.
Benjamin J Girdler
Claudine Domoney Department of Urology, McKee Medical Center, Loveland, Colorado,
Department of Academic Obstetrics and Gynaecology, Chelsea & U.S.A.
Westminster Hospital, London, U.K.
Roger P Goldberg MD, MPH
Stergios K Doumouchtsis Clinical Assistant Professor of Obstetrics and Gynecology, University of
Department of Pelvic Reconstructive Surgery and Urogynaecology, Chicago Pritzker School of Medicine, Chicago, Illinois, U.S.A. and
St George’s Hospital, London, U.K. Division of Urogynecology, NorthShore University HealthSystem,
Evanston, Illinois, U.S.A.
Richard Dover
Obstetrics and Gynaecology, Royal North Shore Hospital, Sydney, David W Goldfarb
New South Wales, Australia Department of Urology, Baylor College of Medicine, Houston,
Texas, U.S.A.
Marcus Drake
Bristol Urological Institute, Southmead Hospital, Bristol, U.K. Irwin Goldstein MD
Director, Sexual Medicine, Alvarado Hospital, San Diego, California,
Harold P Drutz MD, FRCS(C) Director, San Diego Sexual Medicine, Clinical Professor of Surgery,
Professor and Head, Division of Urogynecology, Department of University of California at San Diego, Editor-in-Chief, The Journal of
Obstetrics and Gynecology, University of Toronto, Mount Sinai Sexual Medicine, San Diego, California, U.S.A.
Hospital, Toronto, Ontario, Canada
Alex Gomelsky MD
Anton Emmanuel BSC, MD, FRCP Department of Urology, LSU Health Sciences Center, Shreveport,
Research Fellow in GI Physiology, University College Hospital, Louisiana, U.S.A.
London, U.K.
Ricardo R Gonzalez
Christopher J Evans PhD, MPH Department of Urology, Baylor College of Medicine, Houston Metro
Director of Economics and Outcomes, Mapi Values, Boston, Urology, Houston, Texas, U.S.A.
Massachusetts, U.S.A.
James Gray
Magnus Fall Department of Microbiology, Birmingham Women’s Hospital,
Department of Urology, Sahlgrenska University, Göteborg, Sweden Birmingham, U.K.

Clare J Fowler Derek Griffiths

Department of Uro-Neurology, National Hospital for Neurology and Geriatric Continence Unit, Montefiore Hospital, Pittsburgh,
Neurosurgery, London, U.K. Pennsylvania, U.S.A.

Lynette E Franklin MSN, APRN-BC, CWOCN Marie-Andrée Harvey MD, MSC, FRCSC, FACOG
Department of Urology-Bladder and Pelvic Health Program, Assistant Professor, Department of Obstetrics and Gynaecology and
Medical University of South Carolina, Charleston, Department of Urology, Queen’s University, Kingston General Hospital,
South Carolina, U.S.A. Kingston, Ontario, Canada

viii
 list of contributors

Hashim Hashim Jonathan D Kaye MD

Bristol Urological Institute, Southmead Hospital, Bristol, U.K. Georgia Urology, PA, Children’s Healthcare of Atlanta, Department
of Urology, Emory University School of Medicine, Atlanta,
Jeanette Haslam Georgia, U.S.A.
Specialist Physiotherapist in Women’s Health (Retired), Cumbria, U.K.
Rohna Kearney
Rashel Haverkorn Department of Obstetrics and Gynaecology, Addenbrooke’s Hospital,
Urology, University of Texas Southwestern Medical Center, Dallas, Cambridge, U.K.
Texas, U.S.A.
Cornelius J Kelleher MD, FRCOG
Bernard T Haylen
Department of Obstetrics and Gynaecology, Guy’s and St Thomas’
Department of Gynaecology, St Vincent’s Hospital, Darlinghurst,
Hospital NHS Trust, London, U.K.
New South Wales, Australia
Kimberly Kenton MD, MS
John Heesakkers
Female Pelvic Medicine and Reconstructive Surgery, Obstetrics and
Radboud University Nijmegen Medical Centre, Department of Urology,
Gynecology and Urology, Loyola University Stritch School of Medicine,
Nijmegen, The Netherlands
Maywood, Illinois, U.S.A.
Sender Herschorn MD, FRCSC
Division of Urology, Sunnybrook and Women’s College Health Science Philip van Kerrebroeck
Centre, Toronto, Ontario, Canada Department of Urology, University Hospital Maastricht, Maastricht,
The Netherlands
Andrew Hextall MD, FRCOG
Consultant Gynaecologist, Department of Urogynaecology, West Christine Kettle
Hertfordshire Hospitals NHS Trust, St Albans, U.K. Department of Obstetrics and Gynaecology, Staffordshire University,
Stafford, U.K.
Timothy C Hillard DM, FFSRH, FRCOG
Consultant Obstetrician and Gynaecologist, Poole Hospital, Poole, Vik Khullar
Dorset, U.K. Urogynaecology, St Mary’s Hospital, London, U.K.
Candice Hinote MD Andrew J Kirsch MD
Department of Obstetrics and Gynecology, University of Tennessee at Georgia Urology, PA, Children’s Healthcare of Atlanta, Department
Memphis, Menphis, Tennessee, U.S.A. of Urology, Emory University School of Medicine, Atlanta,
Georgia, U.S.A.
Lennox Hoyte
Division of Urogynecology and Pelvic Reconstructive Surgery, Peter Klarskov
University of South Florida College of Medicine, Tampa, Florida, U.S.A. Department of Neurology, Copenhagen University Hospital, Herlev,
Kenneth C Hsiao MD Denmark
Norcal Urology, Walnut Creek, California, U.S.A.
Kirsten Kluivers MD
Christopher Jayne Department of Gynecology, UMC St Radboud, Nijmegen, The
Urogynecology and Voiding Dysfunction, Rodney A. Appell Center for Netherlands
Continence and Pelvic Health at Vaguard Urologic Institute, Assistant
Professor Scott Department of Urology, Baylor College of Medicine, Kathleen C Kobashi MD
Houston, Texas, U.S.A. Co-Director, The Continence Center, Virginia Mason Medical Center,
Seattle, Washington, U.S.A.
Michael S Ingber
Center for Female Pelvic Medicine and Reconstructive Surgery, Zoe Kopp
Glickman Urological and Kidney Institute, Cleveland Clinic, Outcomes Research, Pfizer, Inc., New York, New York, U.S.A.
Cleveland, Ohio, U.S.A.
Sarah M Lambert MD
Swati Jha MRCOG Department of Surgery, University of Pennsylvania School of Medicine,
Department of Urogynaecology, Sheffield Teaching Hospitals NHS Philadelphia, Pennsylvania, U.S.A.
Foundation Trust, Sheffield, U.K.
Joseph Lee
Rob Jones Department of Urology, Mercy Hospital for Women, Melbourne,
Bristol Urological Institute, Southmead Hospital, Bristol, U.K. Victoria, Australia
Saad Juma MD, FACS
Limim Liao
Director, Incontinence Research Institute, Encinitas,
California, U.S.A. Department of Urology, China Rehabilitation Research Center, Beijing,
China
Scott E Kalinowski
Department of Urology, William Beaumont Hospital, Royal Oak, Fabio Lorenzetti MD, PhD
Michigan, U.S.A. Geriatric Urology Division, Federal University of São Paulo, São Paulo,
Brazil
Mickey M Karram MD
Director, Division of Urogynecology and Pelvic Reconstructive Surgery, Kevin R Loughlin
Department of Obstetrics and Gynecology, Good Samaritan Hospital, Division of Urology, Brigham and Women’s Hospital, Harvard Medical
and University of Cincinnati College of Medicine, Cincinnati, Ohio, School, Boston, Massachusetts, U.S.A.
U.S.A.
Malcolm Lucas MDchM, FRCS
Melissa R Kaufman Consultant Urologist, Morriston Hospital, Swansea, U.K. and
Department of Urologic Surgery, Vanderbilt University Medical Center, Honorary Senior Lecturer Swansea University Medical School,
Nashville, Tennessee, U.S.A. Swansea, U.K.

ix
 list of contributors

Alvaro Lucioni MD Paulo Palma

Fellow, Female Urology, The Continence Center, Virginia Mason Professor and Chairman, Division of Urology, State University of
Medical Center, Seattle, Washington, U.S.A. Campinas, São Paolo, Brazil
Christopher Maher Demetri C Panayi
Department of Urogynaecology, Royal Women’s and Mater Hospital, Urogynaecology, St Mary’s Hospital, London, U.K.
Brisbane, Queensland, Australia
Apurva B Pancholy MD
Tony Mak Fellow, Division of Urogynecology, Department of Obstetrics and
Department of Surgery, University Hospital Birmingham, Gynecology, Good Samaritan Hospital, Cincinnati, Ohio, U.S.A.
Birmingham, U.K.
Matthew Parsons MRCOG
Anders Mattiasson Consultant, Department of Urogynaecology, Birmingham Women’s
Department of Urology, University Hospital, Lund, Sweden Hospital, Edgbaston, Birmingham, U.K.
Klaus E Matzel Francesco Pesce
Professor, Chirurgische Klinik mit Poliklinik der Universität Erlangen, Urology and Neurology, University of Verona, Verona, Italy
Section of Coloproctology, Department of Surgery, University of
Erlangen, Erlangen, Germany Eckhard Petri
Klinikum Schwerin, Schwerin, Germany
Jürg Metzger
Department of Visceral Surgery, Cantonal Hospital, Lucerne, Raymond R Rackley MD
Switzerland Professor of Surgery, The Cleveland Clinic Lerner College of Medicine
John R Miklos of Case Western Reserve University, Center for Female Pelvic Medicine
Atlanta Center for Laparoscopic Urogynecology, Vaginal Rejuvenation and Reconstructive Surgery, Glickman Urological and Kidney Institute,
Center of Atlanta, Atlanta Medical Research, Inc, Atlanta, Georgia, Cleveland Clinic, Cleveland, Ohio, U.S.A.
U.S.A. Simon Radley
Richard J Millard Department of Surgery, University Hospital Birmingham,
Department of Urology, Prince of Wales Hospital, Sydney, New South Birmingham, U.K.
Wales, Australia Angie Rantell
Ian Milsom MD, PhD Senior Urogynaecology Nurse Specialist, King’s College Hospital,
Department of Obstetrics and Gynecology, Sahlgrenska Academy at London, U.K.
Gothenburg University, Gothenburg, Sweden
Fiona Reid MD, MRCOG
Ash Monga Consultant Urogynaecologist, The Warrell Unit, St Mary’s Hospital,
Department of Urology, Princess Anne Hospital, Southampton, U.K. Manchester, U.K.
Kate H Moore W Stuart Reynolds
Associate Professor, Head of Department of Urogynaecology, University Department of Urologic Surgery, Vanderbilt University Medical Center,
of New South Wales, St George Hospital, Sydney, New South Wales, Nashville, Tennessee, U.S.A.
Australia
Cassio Riccetto
Robert D Moore Associate Professor of Urology, Universidade Estadual de Campinas,
Atlanta Center for Laparoscopic Urogynecology, Vaginal Rejuvenation São Paulo, Brazil
Center of Atlanta, Atlanta Medical Research, Inc, Atlanta, Georgia,
U.S.A. Diaa E Rizk
Department of Urology, Ain Shams University, Cairo, Egypt
Jacek Mostwin
James Buchanan Brady Urological Institute, Johns Hopkins Medical Jack R Robertson MD
Institutions, Baltimore, Maryland, U.S.A. Urogynecologist and Professor Emeritus, University of Nevada Medical
School, Reno, Nevada, U.S.A.
Diane K Newman RNC, MSN, CRNP, FAAN
Co-Director, Penn Center for Continence and Pelvic Health, Division Dudley Robinson MD, MRCOG
of Urology, University of Pennsylvania Health System, Philadelphia, Consultant Urogyanecologist Honorary Senior Lecturer, Department of
Pennsylvania, U.S.A. Urogynaecology, King’s College Hospital, London, U.K.
Aimee Nguyen MD
Peter Rosier
Evanston Continence Center, Division of Urogynecology and
Department of Urology, University Medical Centre Utrecht, Utrecht,
Reconstructive Pelvic Surgery, Department of Obstetrics and
The Netherlands
Gynecology, NorthShore University HealthSystem, Evanston,
Illinois, U.S.A. Eric Rovner
Section of Voiding Dysfunction, Female Urology, and Urodynamics,
Carl Gustaf Nilsson
Department of Obstetrics and Gynecology, Helsinki University Central Department of Urology, Medical University of South Carolina,
Hospital, Helsinki, Finland Charleston, South Carolina, U.S.A.

Victor W Nitti Matthew P Rutman MD

Department of Urology, New York University School of Medicine, New Assistant Professor of Urology, Columbia University College of
York, New York, U.S.A. Physicians and Surgeons, New York, New York, U.S.A.
Matthias Oelke MD, FEBU Stefano Salvatore
Urologist, Vice-Chairman, Department of Urology, Hannover Medical Division of Gyncologic Surgery, Bassini Hospital, University of Milan,
School, Hannover, Germany Milan, Italy

x
 list of contributors

Peter K Sand MD Arthur M Sterling

Evanston Continence Center, Division of Urogynecology and Department of Chemical Engineering, Louisiana State University,
Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Baton Rouge, Louisiana, U.S.A.
NorthShore University HealthSystems, Evanston, Illinois, U.S.A.
Michael L Stitely MD
Harriette M Scarpero Department of Obstetrics and Gynecology, West Virginia University
Department of Urologic Surgery, Vanderbilt University Medical Center, School of Medicine, Morgantown, West Virginia, U.S.A.
Nashville, Tennessee, U.S.A.
Abdul H Sultan MB.ChB, MD, FRCOG
Werner Schaefer Obstetrics and Gynaecology, Mayday University Hospital,
Continence Research Unit, University of Pittsburgh, Montefiore Croydon, U.K.
Hospital, Pitteburgh, Pennsylvania, U.S.A.
Christopher Sutton
Gabriel N Schaer
Gynaecological Surgery, University of Surry, Royal Surrey County
Kantonsspital, Aarau, Switzerland
Hospital, Guildford, and Chelsea and Westminster Hospital,
Bernhard Schuessler London, U.K.
Department of Obstetrics and Gynecology, Cantonal Hospital, Lucerne,
Steven E Swift
Switzerland
Department of Obstetrics and Gynecology, Medical University of South
Jane A Schulz MD Carolina, Charleston, South Carolina, U.S.A.
Urogynecologist and Associate Professor, Department of Obstetrics and
Gynecology, University of Alberta, Edmonton, Alberta, Canada Tara Symonds
Outcomes Research, Pfizer, Inc., New York, New York, U.S.A.
Chris Sexton PhD
United BioSource Corp, Bethesda, Maryland, U.S.A. Megan Tarr MD
Female Pelvic Medicine and Reconstructive Surgery, Obstetrics and
Sagar R Shah
Gynecology and Urology, Loyola University Stritch School of Medicine,
New York University Urology Associates, New York, New York, U.S.A.
Maywood, Illinois, U.S.A.
Bob L Shull
Scott and White Women’s Health Center, Temple, Texas, U.S.A. Alexis E Te
Department of Urology, Weill Medical College, Cornell University,
Vanja Sikirica PharmD New York, New York, U.S.A.
Associate Director, Health Economics and Reimbursement, Ethicon
Medical Devices, Somerville, New Jersey, U.S.A. Ranee Thakar
Obstetrics and Gynaecology, Mayday University Hospital,
William A Silva MD
Croydon, U.K.
Division of Urogynecology and Plastic and Reconstructive Surgery,
Department of Obstetrics and Gynecology, Good Samaritan Hospital, Philip Toozs-Hobson
Cincinnati, Ohio, U.S.A. Urogynaecology, Birmingham Women’s Hospital, Birmingham, U.K.
Mark Slack FRCOG Ruben Trochez
Urogynaecology and Pelvic Reconstructive Surgery, Addenbrooke’s Subspecialty Trainee in Urogynaecology, Urogynaecology Unit,
Hospital, Cambridge, U.K. Directorate of Obstetrics and Gynaecology, Derriford Hospital,
Anthony RB Smith Plymouth, U.K.
Obstetrics and Gynaecology, St Mary’s Hospital for Women and
Andrea Tubaro MD, FEBU
Children, Manchester, U.K.
Department of Urology, Second School of Medicine, La Sapienza
Ariana L Smith University–Sant’Andrea Hospital, Rome, Italy
Division of Urology, Hospital of the University of Pennsylvania,
Pennsylvania Hospital, Philadelphia, Pennsylvania, U.S.A. Renuka Tyagi
Department of Urology, Weill Medical College, Cornell University,
Howard M Snyder MD New York, New York, U.S.A.
Division of Urology, Children’s Hospital of Philadelphia, The University
of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, U.S.A. Ulf Ulmsten
Deceased
Anders Spangberg
Department of Urology, University Hospital, Linköping, Sweden SS Vasan
Director, Ankur - NeuroUrology and Continence, Director, Manipal
Sushma Srikrishna MRCOG Andrology and Reproductive Services, Bangalore, India
Subspecialty Trainee in Urogynaecology, Department of
Urogynaecology, King’s College Hospital, London, U.K. Sandip P Vasavada MD
Associate Professor of Surgery, The Cleveland Clinic Lerner
Edward J Stanford MD, MS College of Medicine of Case Western Reserve University,
Department of Obstetrics and Gynecology, University of Tennessee at Center for Female Pelvic Medicine and Reconstructive Surgery,
Memphis, Menphis, Tennessee, U.S.A. Glickman Urological and Kidney Institute, Cleveland Clinic,
Cleveland, Ohio, U.S.A.
David R Staskin MD
Director, Female Urology and Male Voiding Dysfunction, St Elizabeth’s Arvind Vashisht
Medical Center, Associate Professor of Urology, Tufts University School Obstetrics and Gynaecology, University College London Hospitals,
of Medicine, Boston, Massachusetts, U.S.A. London, U.K.

xi
 list of contributors

Arne Victor J Christian Winters MD, FACS

Medical Product Agency, Uppsala, Sweden H Eustis Reily Professor of Urology and Gynecology, Chairman,
David B Vodušek Department of Urology, Louisiana State University Health Sciences
Division of Neurology, University Medical Centre, Ljubljana, Slovenia Center, New Orleans, Louisiana, U.S.A.

Manhan Vu DO Jean-Jacques Wyndaele MD, PhD

Division of Female Pelvic Medicine and Reconstructive Surgery, Urologist, Chairman, Department of Urology, University of Antwerp,
Department of Obstetrics and Gynecology, NorthShore University Antwerp, Belgium
HealthSystem, Evanston, Illinois, U.S.A.
Rhonda Walsh MD Reena S Yalaburgi
Urology Group of New Jersey, West Orange, New Jersey, U.S.A. Associate Consultant, Ankur, Bangalore, India
Mark D Walters Naoki Yoshimura MD, PhD
Professor and Vice Chair of Gynecology, Obstetrics, Gynecology and Professor of Urology and Pharmacology University of Pittsburgh School
Women’s Health Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A. of Medicine, Pittsburgh, Pennsylvania, U.S.A.
Alan J Wein MD
Division of Urology, Hospital of the University of Pennsylvania, Stephen A Zderic MD
Philadelphia, Pennsylvania, U.S.A Department of Surgery, University of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania, U.S.A.
Blayne Welk MD, FRCSC
Division of Urology, Sunnybrook and Women’s College Health Science
Philippe Zimmern MD
Centre, Toronto, Ontario, Canada
Urology, University of Texas Southwestern Medical Center, Dallas,
Ursula Wesselmann MD, PhD Texas, U.S.A.
Edward A. Ernst Endowed Professor of Anesthesiology, Department of
Anesthesiology, Division of Pain Treatment, University of Alabama at Norman R Zinner
Birmingham, Birmingham, Alabama, U.S.A. Aurologic Medical Corp., Torrance, California, U.S.A.

xii
Foreword

Successful textbooks make it sometimes to a second edition, bladder are included. The editors focus attention on outcome
rarely to a third edition. The criteria have to be that the vol- measures, including patient centered goals, and new chapters
ume is in demand and that there have been substantial include cosmetic genital surgery, female sexual dysfunction,
advances. Linda Cardozo and David R Staskin and the con- and robotic surgery.
tributors are to be congratulated on producing an interna- Medico-legal problems abound now in all disciplines of
tional, readable, comprehensive, and up to date medicine and this is recognized by the inclusion of chapters on
urogynecological tome—essential reading for the trainee medical errors and patient safety in the operative room and
through to the urogynecological consultant and beyond—to further chapters on complications of surgery and how to man-
the consultant gynecologist, urologist, and continence nurse age them.
specialist. The editors acknowledge that urogynecology is a The book concludes by summarizing important standard-
global sub-speciality and have enrolled international contrib- ization reports from the international continence society and
utors who focus on significant research and the clinical is a timely reminder that only by speaking the same language
advances that have followed from this. There is a logical path can we truly communicate and appreciate the globalization of
from epidemiology, through basic medical science to clinical medicine. This book is a must.
and investigatory assessment and then management of clini-
cal problems. Important advances such as improvements in Stuart L Stanton
continence surgery, the use of prosthetic meshes for prolapse Professor of Urogynaecology
surgery, and the expansion of available drugs for the overactive London University

xiii
Preface

We are proud to present a third edition of the Textbook of training, and interests. Once again our mission was to produce
Female Urology and Urogynecology and would like to take this a comprehensive textbook which would identify past contri-
opportunity to thank all those of you who have contributed. butions to the field and document and analyze the present
We are particularly grateful to our section editors and appreci- state of the art as well as serve as a foundation for future devel-
ate how much time and effort they have put in to making this opments in the field.
an authoritative comprehensive reference book which will The text is arranged in sections enabling the reader to access
hopefully appeal to both urologists and gynecologists as well areas of interest and extensive bibliographies are intended to
as other healthcare professionals involved in the management facilitate further study of the subject. The section on surgery
of pelvic floor problems on both sides of the Atlantic and else- has been formatted to serve as both an evidence-based text and
where in the world. atlas and is intended to provide information pertaining to the
We would also like to take this opportunity to thank all those decision making process as well as the technical aspects of the
who contributed to the second edition of Textbook of Female surgical procedures. We recognize that in this rapidly advanc-
Urology and Urogynecology which was awarded first prize by ing field it is difficult to remain completely up to date.
the Society of Authors and the Royal Society of Medicine as As editors we are truly grateful to our publishers who have
the best new edition of an edited medical book. We felt that facilitated the production of this book and once again would
this was a great honor and reflects well on all of you. It is of like to thank all our authors for the time they have sacrificed
course this success which has stimulated us to produce this outside their working hours to make this project successful.
third edition which we hope will be even more successful than Finally we are most grateful to our patients who place their
the previous two. Once again we have involved the group of trust in all of us every day and we hope that this textbook will
authors, some of whom have an international reputation and contribute to their quality of care and to the ability of those
others are new comers to the field, which we hope has pro- who will treat them in the future.
duced a good balance of knowledge, expertise, and writing
skills without the polarization of ideas that occurs in many Linda Cardozo
textbooks as a natural product of the contributors’ geography, David R Staskin

xiv
1 History of Urogynecology and Female Urology
Jane A Schulz, Harold P Drutz, and Jack R Robertson

introduction floor between urologists, urogynecologists, gynecologists,

As we have moved into the new millennium, accompanied by and colorectal surgeons. This political feud is cleverly illus-
many new advances in the field of urogynecology and recon- trated in the article of Louis Wall and John DeLancey with its
structive pelvic surgery, it is appropriate to take time to reflect well-known drawing of the competing urologist, gynecolo-
on the events of the last century, and to make suggestions for gist, and colorectal surgeon (3). This is one of the many chal-
future directions. With the significant increase in our post- lenges that must be overcome in providing overall women’s
menopausal female population there is a growing demand for healthcare as we move into the 21st century. A multidisci-
improved quality of life and management of pelvic floor dys- plinary approach to managing female pelvic floor dysfunc-
function. No longer do we contemplate whether women will tion must be advocated to provide women with appropriate
grow older but, rather, how they will grow older. The life expec- care in the areas of urinary and fecal incontinence, urogenital
tancy for women has almost doubled through the 20th cen- aging, conservative management, and reconstructive pelvic
tury. In 1923, Professor Sir Arthur Keith, in his Hunterian surgery (4).
Lecture on “Man’s Posture: It’s Evolution and Disorders” (1) Voltaire, the French philosopher of the “age of enlighten-
stated: ment,” said “these truths are not for all men nor for all times.”
From this we must humbly accept the concept that the truths
Every movement of the arms, cough, or strain sets going a we believe in today regarding our management of women with
multitude of “water hammers” within the abdominal and pelvic pelvic floor disorders must be constantly reassessed and modi-
cavities. Every impulse sets the bladder knocking at the vaginal fied with scientific advancements and research. Similarly, the
exit … it is the continual repetition of small forces, more
epigram by Alphonse Karr (1849) “plus ça change plus c’est la
frequently than the sudden application of a great effort which
wear down the vaginal defense.
même chose” (the more things change, the more they stay the
same) also reflects the changes during the past century espe-
Although it has long been recognized that factors such as cially in the field of surgical intervention, where in many cases
childbearing and chronic increases in intra-abdominal pres- we have continued to reinvent the wheel.
sure contributed to pelvic floor prolapse, only recently has
there been growing demand to manage all of the resulting history of the international
problems. Urinary incontinence is now the most common rea- urogynecology association (iuga)
son for admission to long-term institutionalized centers in At the Federation International of Gynecology and Obstetrics
Canada and the United States. Billions of dollars are spent (FIGO) meeting in Mexico City in 1976, two medical friends,
every year on nappy (diaper) and pad products, but this does Professor Axel Ingelman-Sundberg, of Stockholm, Sweden,
nothing to correct the underlying problem of incontinence. and Jack Rodney Robertson, of California, U.S.A., met. It was
Since the inception of medical writing, gynecologic and time to form a new society. The objective was to further the
urologic conditions have been reported. The Kahun papyrus, urinary health of females and both physicians were deeply
circa 2000 B.C., described diseases of women, including dis- involved in this work.
eases of the urinary bladder. The Ebers papyrus, 1550 B.C., Axel Ingelman-Sundberg, renowned for his research, his
classified diseases by systems and organs. Section 6 includes a pioneering work in gynecologic surgery, and his teaching at
prescription for the cure of a woman suffering from disease of the Karolinska Institute in Stockholm, Sweden, was the cata-
her urine, as well as her womb. Urinary fistula is an example lyst. Sweden had been a founding member of FIGO. Axel tried
of the intimate relationship of the urinary and genital systems to persuade FIGO to make International Urinary Incontinence
in women. Henhenit lived in the court of Menuhotep II, a subcommittee, but they declined. In his capacity as Vice
about 2050 B.C. Her mummy, found in 1935, revealed by President of FIGO, Axel reserved a special room for the forma-
radiography an extensive urinary fistula (2). tion of the IUGA. He was elected the first president, to serve
Reviewing the last century of progress in the new sub- five years, 1976 to 1980, by the colleagues who registered as
specialty of urogynecology and reconstructive pelvic surgery members. They were: Abbo Hassan Abbo, M.D., Sudan;
proved to be a tremendous, and somewhat daunting, task. Wolfgang Fisher, M.D., East Germany; Bozo Kralj, M.D.,
Perhaps the quotation that best summarizes the events that Yugoslavia; Oscar Contreras Ortiz, M.D., Argentina; Donald R.
have occurred is the opening sentence from Charles Dickens’ Ostergard, M.D., U.S.A.; Eckard Petrie, M.D., West Germany;
A Tale of Two Cities: “It was the best of times, it was the worst Jack R. Robertson, M.D., U.S.A.; Mr. Stuart Stanton, M.D.,
of times.” Undoubtedly, we have made tremendous progress U.K.; Ulf Ulmsten, M.D., Sweden; and David W. Waller, M.D.,
in this burgeoning new field; however, a political battlefield U.K. Ulf Ulmsten, then professor of Obstetrics and Gynecology
was perpetuated with the division of the female pelvic in Aarhus, Denmark, was chosen as secretary.

1
 background issues

The next meeting followed in Sheffield, U.K., in July 1977, in 1989 and contained the abstracts of the Riva del Garda meet-
connection with the local gynecological meeting. At Bergen, ing. The associate editors, section editors, and editorial board
Norway, in 1978, IUGA met along with the Scandinavian represent countries all around the world.
Congress of Obstetrics and Gynecology. In 1979 in Tokyo, The 1987 meeting was in Ljubljana, Yugoslavia, organized by
IUGA met again with FIGO; this time IUGA was a special sec- Bozo Kralj, of Slovenia, with 200 members worldwide. Bozo
tion of the program. In October 1980, IUGA met in New became the fourth president at the 1988 memorable meeting
Orleans, organized by Jack Robertson, in connection with the at Iguazu Falls, Argentina, hosted by Oscar Contreras Ortiz,
newly formed Gynecological Urology Society (GUS), later to who Hans Van Geelen said “made every effort, and succeeded
become the American Urogynecological Society (AUGS). in strengthening social ties.” In 1989, Rudolfo Milani hosted
The fifth IUGA meeting was held in Stockholm, September the meeting in Riva Del Garda, Italy.
1981, at the Wenner-Gren Center, famous for Nobel Prize pre- Next elected was Eckhard Petri of Germany, 1990 to 1992,
sentations. The banquet was at the Royal Opera House, with a inaugurated at the Stockholm, Sweden, meeting organized by
special program by the famous Swedish opera singer, Kerstin Ulf Ulmsten. Peter Dwyer says of this meeting: “One of the
Dellert. Jack Robertson was elected president, and served until most low key of all the meetings, it was possibly one of the
1985. Peter Sand, of Chicago, Illinois, became the general most enjoyable. It was basic but had good science. The chair-
secretary. During this time the association was growing in man’s dinner was held in Ulf ’s department at the Uppsala Uni-
membership. versity cafeteria.” The 16th annual IUGA meeting was held in
In the United States, Jack Robertson had found that women Sydney, Australia, in 1991, and the host and hostess were Jim
were being treated as second class citizens, being examined and Peggy Gibson. They had a fabulous chairman’s reception
with male instruments for their incontinence problems. An which was held at the farm they owned at the time, called
alarming number of women were incontinent after their hys- “Stanton Hall.”
terectomy surgery. Robertson devised a system of viewing the In 1992, IUGA combined with AUGS, in Boston, Massachu-
bladder, using carbon dioxide instead of water. In 1968, he setts, with a lobster bake party at the famous Aquarium. James
went to Germany and convinced the famous endoscope maker, Gibson, Australia, was elected sixth president. He presided at
Karl Storz, who had recently acquired the technique of fiber the 1993 meeting in Nimes, France, which was coordinated
optics, to produce a female urethroscope to Robertson’s speci- with International Continence Society (ICS) in Rome. Gibson
fications. Storz immediately liked the idea of not using water, organized Organon to give IUGA $10,000 each year for five
and made the first Robertson Female Urethroscope. Instead of years for the best presentation at each meeting. He also hosted
just resting their instruments upon it, this was the first time the Kuala Lumpur meeting in 1995 at which Harold Drutz
doctors could view the female urethra and its pathology. This presided. In 1994, Harold Drutz hosted the meeting in Toronto,
was the beginning of a pioneering path with Robertson giving Canada, at which he was elected the seventh president. He pre-
seminars to physicians anxious to learn about the female uri- sided as well at the Kuala Lumpur meeting in 1995, hosted by
nary tract, which had not been included in their gynecologic Jim Gibson, which, he says, was one of the first meetings to
training. An immediate result was a sharp rise in the diagnoses make a profit.
of urethral diverticula. In September 1996, the meeting, organized by Paul Riss, was
In 1982 the meeting at Santa Barbara, California, organized held in Vienna, Austria. This was a glorious site at which Oscar
by Jack Robertson, was combined with the GUS, organized by Contreras Ortiz, Buenos Aires, Argentina, was elected eighth
Don Ostergard. In 1983 IUGA met in Mainz, Germany, and in president. The 1997 meeting occurred in Amsterdam, arranged
1984, IUGA met at the famous Breakers Hotel in West Palm with the combined efforts of Hans Van Geelen, Harry Vervest,
Beach, Florida. and Mark Vierhout. The meeting location was planned in
At the 1985 meeting in Budapest, Hungary, physicians came Europe as FIGO was in Copenhagen. In 1998, Buenos Aires,
from behind the Iron Curtain. It was vital for them to present Argentina, was the venue for IUGA, hosted by Oscar Contreras
their work at the meeting, as they would rise in professional Ortiz. Linda Cardozo, London, U.K., was ninth president. In
and, most importantly, pay levels as a result. When one group 1999, in Denver, Colorado, Willy Davila organized IUGA with
from Poland presented a problem, the audience asked why Rick Schmidt of ICS to allow the first combined meeting of the
ultrasound had not been used, which at that time would have two societies.
been the obvious method of treatment. The physicians from The 2000 IUGA meeting in Rome, Italy, organized by Mauro
Poland replied simply, “We do not have ultrasound.” Donald Cervini, chose Hans Van Geelen, from the Netherlands, as
Ostergard was elected the third president and presided at the president. The largely attended meeting was enlivened by an
1986 meeting at Yale University, organized by Ernest Kohorn. audience with Pope John Paul II, celebrating the millennium
Don’s memories include “a lot of work organizing individuals year. The Pope blessed the IUGA in his Papal Address during
to take the financial risks to hold a meeting.” the meeting. Hans Van Geelen recalls that at an early IUGA
An important event occurred at the 1986 Yale meeting. The meeting the attendance was so small that the members could
International Urogynecology Journal was born. Oscar Contre- sit around one round table, discussing the clinical relevance of
ras Ortiz was nominated editor in chief. Donald Ostergard urodynamics. He too says that “in the beginning, hosting a
became the first managing editor and later, the editor in chief. meeting was a delicate task.”
He was followed by Linda Brubaker, Mickey Karram, and, now, In 2001, the IUGA meeting moved to the southern hemi-
Peter Dwyer. The first issue, Volume 1, was printed in September sphere again with Peter Dwyer as host in Melbourne, Australia,

2
 history of urogynecology and female urology

combined with the Australian Continence Foundation. Axel cystoscope, and was the first person to insert urethral catheters
Ingelman-Sundberg was awarded a lifetime achievement under direct vision. Kelly’s successor, Guy Hunner described
award, via a live television connection, at the 2001 meeting. Hunner’s Ulcer, which today is called interstitial cystitis. Suc-
The 2002 meeting was held in Prague, with Michael Halaska as ceeding Hunner was Houston Everett, whose contribution was
organizer. The River Moldau flooded the inner town, and Pro- the relationship of the urinary tract to cervical cancer. In 1914,
fessor Halaska had to change the venue of the gala dinner, and Latzko perfected the cure of post-hysterectomy vesical vaginal
take out new insurance. In Prague, Peter Dwyer, Melbourne, fistula. Next, Richard TeLinde added water endoscopy to the
Australia, was elected president. Peter comments that IUGA Hopkins female urology program. Most teaching programs at
became not only a scientific society, but developed a true the time gave little or no exposure to female urology (2).
camaraderie of friendship. He says that the young urogyne- In 1892, Poussan proposed the concept of urethral advance-
cologists appreciated the emphasis on the clinic rather than ment for the management of urinary incontinence (5). He
the basic science (rats). Peter writes: “Presenting our own suggested “introducing a bougie into the urethra, resecting the
research internationally and getting ideas for our next projects external meatus and portion of the urethra, and then after tor-
was also very important, and the meetings were great fun.” sion of the canal to one hundred and eighty degrees, it is trans-
In 2003, IUGA was back in Buenos Aires, again organized by planted to a point just below the clitoris.” By the turn of the
Oscar Contreras Ortiz. August 2004 saw a spectacular meeting century, four main treatments for stress urinary incontinence
of IUGA in Paris, France, combined for the second time with were outlined:
the ICS. The Chairman’s dinner held at Maxim’s Restaurant,
1. injection of paraffin into the region of the urethra;
honored Jack R. Robertson with a lifetime achievement award.
2. massage and electricity;
The Palais Versailles was the unbelievable site of the gala din-
3. torsion of the urethra;
ner, all hosted by Bernard Jacquetin for IUGA and Francois
4. advancement of the external urethral meatus.
Haab for ICS. Paul Riss of Moeding, Austria, was elected to
serve as president from 2004 to 2006. Copenhagen, Denmark, A century later we are still trying to identify the best urethral
was the site of the August 2005 IUGA meeting, organized by bulking agent. Although it is no longer paraffin, research with
Gunnar Lose. Teflon [poly(tetrafluoroethylene)], silicone, collagen, autolo-
The two old friends, Axel Ingelman-Sundberg and Jack R. gous fat, hyaluronic acid, carbon particles, and various copoly-
Robertson met in Munich, Germany, in August of 2004. The mers has failed to identify an ideal medium.
meeting in Copenhagen in 2005 was an exciting meeting at a In his landmark paper in 1913 Kelly outlined operations for
unique venue with the first discussion of some of newer mesh managing urinary incontinence in women (6). These included
kits. In 2006, the annual IUGA meeting was in the beautiful the following:
historic city of Athens, with many social events being held at
some of the ancient historic sites. Professor Oscar Contreras • puncture of the bladder and insertion of a catheter;
Ortiz received a prestigious lifetime achievement award. The • closing the urethra and creating a vesico-abdominal
fistula;
year 2007 found us back across the Atlantic in Cancun Mexico
with a stunning gala dinner at sunset on the beach. At the Can- • closing the vagina and creating a rectovaginal
fistula;
cun meeting Professor Donald Ostergard received a lifetime
achievement award. Despite difficult weather caused by a • compression of the urethra with an anterior
colporrhaphy;
number of typhoons, many were still able to attend the
2008 meeting in Taipei, where Professor Harold Drutz was • periurethral injection of paraffin;
awarded a lifetime achievement award from the IUGA for his • advancement of the urethral meatus to the clitoris.
ongoing contributions to the society (including the only Cana- Kelly suggested that “the torn or relaxed tissues of the vesical
dian to have been president of the society, 1994–1996). The neck should be sutured together using two or three vertical
stunning venue of Lake Como, Italy was the site for the mattress sutures of fine silk linen passed from side to side.” In
2009 meeting, where Professor Jim Gibson received a lifetime his first publication, he described 16 patients as being well and
achievement award. The year 2010 will see another joint meet- four patients in whom the procedure was not successful, giv-
ing of the ICS and IUGA hosted by Professors Drutz and ing a success rate of 80%. However, further evaluation has
Herschorn in Toronto, Canada. revealed that the long term success, using only these sutures to
correct stress incontinence falls to roughly 60% (7). This
progress in the 20th century decline is possibly related to gradual postoperative elongation
Treatment of the smooth muscle in which the sutures were placed (8).
Marion Sims, in the United States, was one of the first to estab- With coincident suburethral plication of the pubourethrovag-
lish the relationship of urology and gynecology. Determined inal ligaments of the urogenital diaphragm, the long-term
to cure vesico-vaginal fistulas, he finally used silver wire and results of a Kelly plication are significantly better (9).
announced in 1852 the cure of 252 out of 320 attempts. Sling procedures were pioneered in the early 1900s by three
Howard A. Kelly, the first professor of gynecology at the Johns European physicians. Goebell first suggested transplantation
Hopkins Medical School, believed that gynecology and urol- of the pyramidalis muscle in 1910 (10). This was followed
ogy were so closely related that a physician could not be trained by Frankenheim who, in 1914, recommended using the pyra-
in either field and ignore the other. In 1893, he invented a midalis or strips of rectus muscle as a suburethral sling

3
 background issues

by attaching the muscle to overlying fascia (11). In 1917, Diagnosis and Investigation
Stoeckel suggested combining the techniques of Goebell and As the number of procedures offered for the treatment of stress
Frankenheim and adding plication of the vesical neck (12). incontinence increased, there were also significant advances in
Throughout the 20th century, there have been many variations the urogynecological diagnostic procedures available. In 1882,
of sling procedures described in the literature. In 1907, Mosso and Pellacani described cystometry using a smoked
Giordano suggested the use of the gracilis muscle by wrapping drum and a water manometer (24). An aneroid barometer for
it around the urethra (13). Shortly thereafter, in 1911, Souier cystometric evaluation was developed by Lewis in 1939 (25).
described the use of levator ani muscles by placing them Jeffcoate and Roberts, in 1952, introduced the concept of
between the vagina and urethra (14), and, in 1923, Thompson radiographic changes in the posterior urethrovesical angle
recommended the use of strips of rectus muscle, surrounded (26). These changes were further modified in 1956, by Bailey
by fascia, to be passed in front of the pubic bones and around in England, who described seven variations in the urethrovesi-
the urethra (15). The next key event in the development of cal angle on radiographic studies (27). Later modifications
surgery to the anterior compartment was the development of were performed by Tom Green in the United States in 1962,
the bulbocavernosus muscle fat pad graft by Martius in 1929 when he described Green types 1 and 2 incontinence (28).
(16). This has found wide use in fistula repairs and reconstruc- Identification of the posterior urethrovesical angle by lateral
tion of the anterior vaginal wall. In 1968, John Chasser Moir bead chain cystography was introduced by Hodgkinson in
(17) introduced the concept of the gauze hammock operation 1953 (29).
as a modification of the original Aldridge (18) sling procedure By 1956, Von Garrelts had introduced the concept of uro-
described in 1942. Chasser Moir recognized that “operations flowmetry (30). In 1964, Enhorning, Miller, and Hinman
of this type do no more than support the bladder neck and combined cystometry with radiographic screening of the
urethrovesical junction and so prevent the undue descent of bladder (31); this was followed a few years later in 1969 by
parts when the woman strains or coughs.” Brown and Wickham’s introduction of urethral pressure pro-
Victor Bonney, in 1923, stated, “Incontinence depends in filometry (32). Another landmark occurred in 1971, when
some way upon a sudden and abnormal displacement of the Patrick Bates, Sir Richard Turner-Warwick, and Graham
urethra and urethrovesical junction immediately behind the Whiteside introduced synchronous cine pressure–flow cys-
symphysis” (19). This was followed in 1924 by a description tography, with pressure and flow studies (33). This was the
from B.P. Watson of “the muscle sheet that normally sup- beginning of the field of video urodynamics. Equipment was
ports the base and neck of the bladder” and his statement further expanded with the introduction of the microtip trans-
that “so far as the incontinence of urine is concerned, the ducer, in 1975 by Asmussen and Ulmsten, for measuring
important sutures are those which overlap the fascia at the urethral closure pressure (34).
neck of the bladder and so restore it to its normal position.” Further investigational advances occurred in the latter part
In reviewing Watson’s work with anterior colporrhaphy, he of the 20th century. These included the introduction of the
was able to obtain “perfect control” in 65.7% of cases, Urilos monitor in 1974 by James, Flack, Caldwell, and Smith (35).
“improvement” in 21.9%, and “no success” in 12.4% (20). This device allowed evaluation of the symptom of dampness
These figures are in keeping with others that have been for whether the fluid lost was urine. In 1981, Sutherst, Brown,
reported for anterior colporrhaphy. Therefore, it was appar- and Shawer developed the pad-weighing test as an objective
ent that hypermobility of the bladder neck was an issue, measure of the severity of urinary incontinence (36).
and that the anterior colporrhaphy was not a satisfactory In 1961, Enhorning suggested that “surgical treatment for
operation for stress incontinence. stress incontinence is probably mainly beneficial because it
The next landmark in genitourinary surgery occurred in restores the neck of the bladder and the upper part of the ure-
1949 with the publishing of the paper of Marshall, Marchetti, thra to the influence of intra-abdominal pressure” (37). This
and Krantz on “The correction of stress incontinence by sim- introduced the concept of pressure transmission ratios, and
ple vesicourethral suspension.” They suggested that this opera- the idea that successful operations for stress urinary inconti-
tion was “particularly valuable for patients whose first nence worked by restoring the urethrovesical junction to an
procedure failed.” In their first 44 patients they described 82% intra-abdominal position. In 1956, Jeffcoate added further
of patients with excellent results, 7% with improvement, and interpretation of our investigative techniques when he
an 11% failure rate (21). Shortly thereafter, in 1950, H.H. Fou- attempted to caution gynecologists, stating that “the absence
racre Barns described the “round ligament sling operation for of the posterior urethrovesical angle is merely a sign of incom-
stress incontinence”; this technique was popularized by Paul petence of the internal sphincter. The presence of an angle is a
Hodgkinson (22). In 1961, John Burch first described his function of the involuntary muscle at the urethrovesical junc-
modification of the Marshall–Marchetti–Krantz procedure tion, not of the muscle of the pelvic floor” (38), and so the
which involved a retropubic colpourethropexy that took the simplistic approach of static cystourethrograms began to be
anterolateral aspects of the vault of the vagina and attached questioned. Green had suggested that if one saw a radiographic
them to Cooper’s ligament (23). Burch recognized the poten- diagnosis of type 1 incontinence this could readily be repaired
tial complications of this procedure if done alone including, with an anterior colporrhaphy; the type 2 stress incontinence
the creation of an enterocele or rectocele, the development required a retropubic urethropexy. A number of authors,
of ventral/incisional hernias, and even the possibility of a including Drutz in 1978 (39), have confirmed the limited
vesicovaginal fistula. accuracy of static cystourethrograms.

4
 history of urogynecology and female urology

By 1953, Paul Hodgkinson had recommended, “If on Robertson, with Bergman and Elia, in 2004, has described an
anteroposterior straining radiograph, the urethrovesical enhancement of Kegel’s exercise, when done in a magnetic
junction is depressed 4 cm below the lower border of the field, combined with DeLancey’s “knack procedure,” to give
symphysis, I believe the objective of the operation can be support to the urethra when it is most needed (47).
accomplished through anterior colporrhaphy” (28). A decade
later Hodgkinson commented on the frequency of detrusor the way ahead
dyssynergia, with grade 1 defined as a detrusor contraction Now as we approach the 21st century, we must consider what
in response to coughing and heel bouncing; grade 2 was lies ahead. The main fields of responsibility as urogynecolo-
spontaneous automatic detrusor contractility when recum- gists and reconstructive pelvic surgeons include the following:
bent. Hodgkinson recognized the importance of discovering
this condition prior to performing any surgery for stress • education;
urinary incontinence (40). • surgery;
• uropharmacology;
Success Rates • neurophysiology;
As we approached the 1970s, we began to recognize that oper- • behavior modification;
ative failures in the treatment of stress urinary incontinence • collagen;
involve three areas (41), as follows: • ultrasonography/MRI;
• stem cells.
1. incorrect diagnosis and the fact that bladder insta-
Regarding education, we need to focus on education of our
bility (and not just simple stress incontinence) may
colleagues in obstetrics and gynecology, family practice, geri-
have been the cause of the incontinence;
atrics and community health care, allied health professionals
2. the wrong operation may have been chosen and some
such as nursing and physiotherapy, as well as the public. The
operations probably give better long-term results;
awareness must be increased that incontinence is not a normal
3. the concept of technical failure.
effect of aging; the many myths, including “everyone gets it”
We recognized that the vaginal approach to primary stress and “it can’t be treated,” must be dispelled. Urogenital aging
incontinence probably only gave a 50% to 60% success rate, must be stressed as part of menopause management, and con-
whereas the suprapubic approach gave success rates of at least servative management in the community should be promoted.
80%. J.E. Morgan, in 1973, discussed indications for primary The other aspect of education is the training of new subspe-
retropubic urethropexy: these included minimal pelvic floor cialists in the field of urogynecology and reconstructive pelvic
relaxation, chronic chest disease, occupations involving heavy surgery. Board certification is now available in Australia and
lifting, and patients who were heavily involved in athletics, and board recognition of training programs has been established
obesity (42). In 1970, Hodgkinson stated that “the most dura- in the United States. The IUGA is now establishing interna-
ble operation for stress incontinence is a retropubic ure- tional standards for training in conjunction with FIGO and
thropexy and the least durable is a vaginal repair.” Hodgkinson the WHO.
quoted a 92.1% success rate with his own 404 patients that had Within the field of surgery for pelvic floor problems, we
a retropubic urethropexy (40). The other movement in the need to re-evaluate what we do. Over 200 operations have
1970s was of the urologists and gynecologists toward endo- been described for stress incontinence. Randomized con-
scopic bladder-neck suspensions such as the Pereyra, Raz, and trolled trials, with adequate patient numbers and follow-up
Stamey suspensions; numerous variations including the Gittes of at least two years, are required for evaluation of new and
and Cobb-Raagde were described in the literature. In the existing procedures. The role of bulking agents is still contro-
1990s, we have now realized that the long-term results of these versial and the ideal medium has yet to be discovered. A vari-
needle suspension procedures are also not as good as the ety of fascia and mesh is available for use in pelvic floor
retropubic procedures. reconstructive procedures; however, the long-term durability
The 1990s have also seen the advent of minimally invasive and consequences of these are still unknown. This includes
sling procedures for stress urinary incontinence. The first of many new mesh devices and kits for pelvic floor reconstruc-
these, the tension free vaginal tape, and the concomitant inte- tion. Concerns have been raised about the ethics of some of
gral theory of the pathophysiology of incontinence, were these newer mesh devices (48). New pharmacologic agents
described by Ulmsten and Petros in the early 1990s (43,44). continue to be produced; well designed, placebo controlled
There are now multiple variations of this procedure including trials are mandatory for their evaluation. Neurophysiology is
the transobturator approach. Success rates are reported to be another developing area; work is being done to determine if
similar to that of the Burch repair (45). More recently, single there are certain factors in labor that lead to irreversible
incision midurethral slings have been advocated although changes to the pelvic floor. Other questions that have been
the long-term success of these new procedures is yet to be raised include whether abnormalities in the electromyo-
established. graphic patterns predict success or failure of different treat-
The great champion of pelvic floor exercises, Arnold Kegel, ments. We continue to develop new modes of conservative
reported pre- and post-operative benefits of the properly per- management, including behavior modification and devices;
formed exercises (46). Unfortunately, many patients are placed further studies are needed to clarify the specific areas of use
on this regimen only after an unsuccessful surgical procedure. for these therapies.

5
 background issues

The role of collagen in pelvic floor disorders is a fascinating management of women with urinary and/or fecal inconti-
area. We need both effective qualitative and quantitative assays nence, persistent genitourinary complaints, and disorders of
to determine whether there are certain defects of collagen in pelvic floor supports.
patients with pelvic floor dysfunction. Also, we need to estab- As Marcel Proust said, “We must never be afraid to go too
lish whether there may be potential genetic markers that may far, for the truth lies beyond.” We must humbly accept that the
be screened for to determine certain “at-risk” patients. Per- “truths” that we identify today, certainly will have to be changed
haps there exists a select group of patients that should be in the future. However, if we work collaboratively to produce
counseled to have delivery by caesarean section; this group well-designed scientific research, we should be able to establish
may also require the use of synthetic materials in reconstruc- truths that stand the test of time in our ongoing quest to
tion of their pelvic floor. We need to look at the relationship improve the quality of life for women with pelvic floor
of collagen to estrogen and the general effects of urogenital problems.
aging to see if they are independent factors. Research into
genetic components of pelvic floor prolapse is exciting. At
acknowledgment
Mount Sinai Hospital in Toronto, Dr. May Alarab and her
This chapter includes major segments of text adapted from the
associates have shown that genes that both promote the
IUGA Presidential Address given by Professor Harold Drutz at
build-up of extracellular matrix and cause its degradation are
the 21st Annual Meeting of the IUGA held in Vienna in 1996.
different in pre-menopausal women with prolapse compared
The text was later published: Drutz HP. The first century of
to controls.
urogynecology and reconstructive pelvic surgery: where do we
We are in the midst of a revolution in imaging and diagnos-
go from here? Int Urogynecol J 1996; 7: 348−53.
tic technology. The development of three-dimensional ultra-
sound (49) and the progress with MRI has allowed a new
approach to evaluating defects associated with stress urinary references
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flow cystography: a method of routine urodynamic investigation. Br J 48. Ross S, Robert M, Harvey MA, et al. Ethical issues associated with the
Radiol 1971; 44: 44–50. introduction of new surgical devices, or just because we can, doesn’t mean
34. Asmussen M, Ulmsten U. Simultaneous urethrocystometry and urethral we should. J Obstet Gynaecol Can 2008; 30: 508–13.
pressure profile measurements with a new technique. Acta Obstet 49. Khullar V, Salvatore S, Cardozo LD, Hill S, Kelleher CJ. Three-dimensional
Gynaecol 1975; 54: 385–6. ultrasound of the urethra and urethral sphincter: a new diagnostic tech-
35. James ED, Flack F, Caldwell KP, Smith M. Urine loss in incontinence nique. Neurourol Urodyn 1994; 13: 352–3.
patients: how often, how much? Clin Med 1974; 4: 13–17. 50. Shaer G, Koelbl H, Voigt R, et al. Recommendations of the German Asso-
36. Sutherst JL, Brown M, Shawer M. Assessing the severity of urinary incon- ciation of Urogynecology on functional sonography of the lower female
tinence in women by weighing perineal pads. Lancet 1981; 1: 1128–30. urinary tract. Int Urogynecol J 1996; 7: 105–8.
37. Enhorning G. Simultaneous recording of intravesical and intraurethral 51. Hermans RK, Klein HM, Muller U, Schafer W, Jakse G. Intraurethral
pressure: a study of urethral closure pressures in normal and incontinent ultrasound in women with stress incontinence. Br J Urol 1994; 74:
women. Acta Chir Scand 1961; 276(Suppl): 1. 315−18.
38. Jeffcoate TNA. Bladder control in the female. Proc Roy Soc Med 1956; 49: 52. Slack M, Culligan P, Tracey M, et al. Relationship of urethral retro-resis-
652–60. tance pressure to urodynamic measurements and incontinence severity.
39. Drutz HP, Shapiro BJ, Mandel F. Do static cystourethrograms have a role Neurourol Urodyn 2004; 23: 109−14.
in the investigation of female incontinence? Am J Obstet Gynecol 1978; 53. Turner-Warwick R. International Continence Society Proceedings.
130: 516–20. Boston, MA, USA, 1986.

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2 Epidemiology: U.S.A.
Scott E Kalinowski, Benjamin J Girdler, and Ananias C Diokno

introduction of stress and mixed incontinence were reported by

Epidemiology is defined as the study of the relationships of African-American women when compared with white
various factors determining the frequency and distribution of women (5). Hispanic and Asian American women have been
diseases in a community (1). The epidemiological study of uri- shown to have equivalent urodynamic stress incontinence
nary incontinence (UI) has advanced over the past several rates to white women, whereas the African-American women
years. However, most of these studies are cross-sectional. A had higher rates of detrusor overactivity than the other three
need exists for more longitudinal studies to evaluate the inci- groups (6). African-American women were found to have
dence, remission, risk factors, and prevention of this disease statistically significant smaller bladder capacities, smaller
process. The methodologies to evaluate the epidemiology of maximum cystometric capacities, and higher maximum
UI vary greatly. Furthermore, there is no consensus on the urethral closure pressures compared to Caucasians (7). A
definition of UI among investigators dealing with this subject. more recent study by Fenner et al. looked at incontinence
As a consequence, there is conflicting information, especially rates in African-American and Caucasian women in south-
in the prevalence rates. Another major issue in studying UI is eastern Michigan. They observed similar racial differences
the fact that incontinence itself is a condition with many var- in prevalence, type, and quantity of urine loss, but failed to
ied types, occurring in many different segments of the popula- find support for the belief that risk factors for UI differed
tion. Students of the epidemiology of UI must therefore between Caucasian and African-American women (8).
account for all these variables when evaluating data from these
studies. incidence and remission
Incidence is the probability of becoming incontinent during a
prevalence of ui defined period of time. Determining the incidence of a condi-
The prevalence of UI is defined as the probability of being tion or disease is helpful in determining the onset of the condi-
incontinent within the defined population group within a spe- tion as well as in understanding the risk factors of the condition.
cific period of time. The first comprehensive epidemiologic The MESA survey established the incidence rate of UI in the
study of incontinence in the United States was conducted by United States (9). The incidence rate among women who were
Diokno et al. (2) in 1983 in Washtenaw County, Michigan. The continent during the initial baseline interview and became
Medical, Epidemiologic, and Social Aspects of Aging (MESA) incontinent a year later was 22.4%. For those who remained
study showed the prevalence of incontinence among women continent at the one-year follow-up visit, the incidence in the
60 years and older living in the community to be 38%. Other second year of follow-up was 20.2%. Hagglund et al. found a
more recent studies have agreed with this prevalence rate such mean 4% annual incidence rate of UI reporting on a Swedish
as the data reported by Fultz et al. A 14-item questionnaire was community of 10,500 inhabitants aged between 22 and 50 years
returned by 29,903 people of whom 37% reported inconti- (10). An annual incidence rate of 6.3% for people greater than
nence in the past 30 days (3). or equal to 40 years old was found in McGrother et al.’s study
The prevalence of UI in women increases with age. A postal in the United Kingdom (11). Two thousand twenty-five women
survey was conducted by Thomas et al. (4) to selected health older than 65 years in rural Iowa were evaluated by Nygaard
districts in the London boroughs and neighboring health dis- and Lemke. The three-year incidence rate for urge inconti-
tricts in the late 1970s. In that survey, incontinence was defined nence and stress incontinence were 28.5% and 28.6%,
as involuntary excretion or leakage of urine in inappropriate respectively (12).
places or at inappropriate times twice or more a month, The MESA survey also analyzed the remission rate for UI.
regardless of the quantity of urine lost. Incontinence was fur- The remission rate—that is, women who were incontinent at
ther subdivided into regular UI for a loss twice or more per the baseline (first) interview and became continent during the
month, and occasional for less than twice per month. The second interview a year later—was 11.2%. A similar rate
response rate was excellent at 89%. Table 2.1 shows the preva- (13.3%) of incontinent respondents at the second interview
lence rates for regular and occasional incontinence in women reported being continent a year later at the third interview.
aged 15 to more than 85 years. Three age tiers to the prevalence Hagglund et al. reported a 4% mean annual remission rate in
of regular incontinence in women were noted: the first level, the same Swedish community as above (10). Nygaard and
15 to 34 years (prevalence 4–5.5%); the second tier, 35 to Lemke’s three-year remission rates for urge and stress inconti-
74 years (prevalence 8.8–11.9%); the third, 75 years and older nence were 22.1% and 25.1%, respectively (12). Townsend
(prevalence 16–16.2%). et al. looked at remission rates in 64,650 women 36 to 55 years
Several studies have investigated incontinence in women of age participating in the Nurses’ Health Study II. They
of different races and found intriguing results. Lower rates reported remission rates of 13.9% at two year follow-up.

8
 epidemiology: u.s.a.

100
Table 2.1 Prevalence of Urinary Incontinence (UI)
90
in Women
80
Age group
70

Prevalence (%)
(yrs) Regular UI (%) Occasional UI (%) Total UI (%) Either
60
15–24 4.0 11.9 15.9
25–34 5.5 20.0 25.5 50
35–44 10.2 20.7 30.9 40
45–54 11.8 21.9 32.9 30 Urge Stress
55–64 11.9 18.6 30.5 20
65–74 8.8 14.6 22.4
10
75–84 16.0 13.6 29.6
>85 16.2 16.2 32.4 0
Source: Data adapted from Ref. 4. 66 69 72 75 78 81 84 87
Age
Figure 2.1 Prevalence of incontinence by age groups at baseline. Each age rep-
However, when the group was further delineated by age group resents the midpoint of a three-year age range. Because of the small number of
they found significantly higher remission rates in women 36 to women above age 90, the graph ends with age range 86–88 years. “Urge” and
45 years of age when compared to those 46 to 55 years of age “stress” refer to women who answered affirmatively to the urge and stress
incontinence questions, respectively. “Either” refers to women who reported
(17.1% vs. 11.9%) (13). any incontinence (either urge or stress). Source: Data adapted from Ref. 12.
These findings suggest a proportion of women affected by
UI will improve over time without intervention. Because UI
can be affected by many factors such as acute illness, seasonal and 59% of women reporting only urge incontinence (17).
changes, and fluctuating medical illnesses, it can be assumed Some of this can likely be explained by the artificial nature of
that when questioned longitudinally many women would office urodynamics and other technical issues, but patient’s
report varying degrees and prevalence of incontinence. Imply- poor understanding of the different types of UI and incom-
ing that for many patients, UI is not necessarily a progressive plete history taking may also be implicated.
condition, but rather a dynamic process that may come and go The age of onset may be an important factor in the type of
with or without medical or surgical intervention. Further UI experienced. Kinchen et al. found the median age of
studies are needed to determine which respondents tend to American women reporting stress incontinence was 48 years,
have remission, and which tend to persist or progress. It is also mixed incontinence was 55 years, and urge incontinence was
important to consider the possibility of spontaneous remis- 61 years (18). Luber et al. evaluated 642 incontinent women
sion when reviewing “cure” rates reported in treatment trials and discovered that stress incontinence was more common in
and to discuss the possibility of remission/recurrence when younger women aged 30 to 49 years (78%) versus those aged
counseling patients. 50 to 89 years (57%). Urge incontinence predominates in
the older population (67%) versus women under the age of
types and severity of ui 50 years (56%) (19).
Prevalence and Incidence of Types of UI According to Nygaard et al., the rate of urge incontinence
In epidemiological studies, as in clinical investigations, the tends to rise with age, while the rate of stress incontinence
type of UI must be defined. In general, incontinence is consid- decreases somewhat in the oldest age groups, possibly due to
ered to be of the stress type when the urine loss was experi- lower activity levels (12) (Fig. 2.1).
enced at the time of physical exertion (such as coughing, The MESA survey conducted by Diokno et al. (2) in
laughing, sneezing, etc.). Urge incontinence is defined as invol- Washtenaw County, Michigan, reported the prevalence of
untary loss of urine preceded by a sudden urge to void. When the types of clinical incontinence encountered among their
the urine loss is associated with both stress and urge, it is con- respondents. The most common type reported by these women
sidered to be of the mixed type. Because of the difficulty in aged 60 years and older was the mixed stress and urge type
identifying the overflow type, when the urine loss is associated (55.5%), followed by the stress type (26.7%), the urge (9.0%),
with neither the stress nor the urge type, the incontinence is and other types (8.8%).
labeled “other.” However, when the survey respondents were A meta-analysis of published studies of UI epidemiology
taken one step further into urodynamic testing, the type of in the world suggested that stress incontinence is the most
incontinence has been classified into the various urodynamic common form (20). Stress incontinence accounted for almost
types according to the pathophysiological abnormality. half of the total worldwide prevalence of UI and mixed
Interestingly, when urodynamic testing is performed on incontinence constituted 29% of the total prevalence. The
women with UI, there is often a disconcordance between sub- analysis showed that urge incontinence was less common,
jective and objective findings (14–16). Cundiff et al. evaluated consistent with the U.S. and European surveys.
535 women over a ten year period via detailed history and
physical exam, urinary diary, and urodynamics. They found Prevalence and Incidence of Severity of UI
that by utilizing symptoms alone, a misdiagnosis would be In epidemiological studies, severity has been categorized by
made in 13% of women reporting only stress incontinence the frequency of incontinent episodes, by the volume of urine

9
 background issues

Table 2.2 Percentage of Severe Incontinence, as Judged by Volume and Frequency of Urine Loss, in 60-Year-Old Women
No. of days with urine loss
Volume of urine lost in 24 hrs 1–9 10–49 50–299 300–365 Total percentagea
Drops < ½ tsp 16.1 11.6 5.6 3.0 36.3 (135)
½ tsp – <1 tbsp 9.7 9.7 7.5 3.2 30.1 (112)
1 tbsp – <¼ cup 4.6 4.6 5.4 3.2 17.8 (66)
¼ cup or more 2.4 2.4 4.3 6.7 15.8 (59)
Totala 32.8 (122) 28.3 (105) 22.8 (85) 16.1 (60) 100.0 (372)
Respondents with mild incontinence were those who reported low frequency (1–9 days/year) and/or small volume (<½ teaspoon/day for <300 days/year); those
with severe incontinence were those who reported high frequency (≥300 days/year) and/or large volumes (>¼ cup/day on ≥50 days/year); those respondents
with intermediate volume and/or frequency were considered to have moderate incontinence.
a
Number of patients in parentheses.
Source: Data adapted from Ref. 2.

loss or by the frequency of difficulty in controlling the flow of abnormal voiding (2). It appears that the normal daily fre-
urine. The Diokno MESA study (2) reported the severity of UI quency of urination in this age group is no more than eight
among its 60-year-old respondents in terms of the number of times, as 88% of all our asymptomatic respondents reported
days per year that urine loss was experienced and the volume that range. To be more specific, 47.3% of asymptomatic
of urine loss per day. As shown in Table 2.2, if severe or sig- women reported that they voided six to eight times, 34.8%
nificant UI is considered to be the loss of at least a quarter cup voided four or five times, and 5.5% voided one to three times
of urine per day on 50 or more days/year, or frequency of daily. FitzGerald et al. reevaluated the definition of urinary
incontinence is 300 or more days/year, then 20.4% of women frequency by evaluating 300 asymptomatic women aged 18 to
respondents age 60 years and older at the time of the MESA 91 (median 40 years) who volunteered from a large metro-
survey had severe incontinence. politan community. These women completed a 24-hour log
The patterns of change in the severity of UI in the MESA of fluid intake and volumes voided. They found a median of
survey were also analyzed (9). Based on the severity levels eight voids in 24 hours with 95% of subjects recording less
described in Table 2.2, continent respondents who became than 13 voids per 24 hours. Their conclusion was that using
incontinent were most likely to develop a mild form of incon- greater than or equal to eight voids per 24 hours as the defini-
tinence. About half of those who were classified originally as tion of “frequency” may be inappropriate, suggesting that
mildly incontinent remained so and very few became severely “frequency” may be greater than or equal to 13 voids in
incontinent. Among those who reported moderate inconti- 24 hours (22). Since the information came from a self-selected
nence, most remained moderately incontinent or changed to group of volunteers that reside in a large metropolitan area,
mildly incontinent, with very few advancing to severe inconti- their findings may not represent the true frequency of voiding
nence. Among women who were severely incontinent at in the general community.
baseline, most remained severely incontinent. In an investigation by the Bladder Diary Research Team, 161
Kinchen et al. revealed that over 50% of incontinent respon- asymptomatic women from 19 to 81 years of age were recruited
dents have urine loss at least once per week (18). The severity at four independent research sites. Each subject completed a
of incontinence symptoms influences a woman’s willingness three-day bladder diary to establish normative values based on
to discuss the symptoms with a physician. Fewer than 20% of age and 24-hour urine volumes. They found that there was a
women report discussing incontinence with a physician within statistically significant increase in frequency with increased
the past year when symptoms are mild. The proportion age and 24-hour volume. They also found a mean of 7.1 voids
increases to 42% of women when symptoms are severe (21). per 24 hours, with a range of 2 to 13, and that 95% of subjects
recorded less than 10.4 voids per 24 hours (23). The same
Prevalence of Voiding Frequency group looked at 92 asymptomatic males from 20 to 84 years of
The prevalence of voiding frequency is receiving greater age. They found a mean frequency of 6.6 with a range of 3 to
attention as more and more studies are being conducted for 14 and 95% voiding less than 9.5 times per 24-hours (24).
conditions related to bladder dysfunction. For example, phar- While the numbers are slightly lower than those from the
macological interventions as well as behavioral techniques MESA study, they bolster their conclusion that utilizing eight
aimed at improving bladder function usually affect the fre- voids as the definition of frequency may be incorrect and may
quency of voiding day and night. It is therefore imperative that need to be adjusted based on age and 24-hour urine volume.
a comparative standard is available on which to base any obser- In terms of nocturia—which was defined as the frequency of
vations related to frequency of voiding prior to, during, and being awakened from sleep and getting up to void—93% of
after an intervention. asymptomatic women voided no more than twice at night. In
The MESA study has established the distribution of voiding contrast, 25% of women with irritative symptoms and 24% of
frequency among the elderly (60 years and older) living in a women with difficulty in emptying the bladder voided three or
community, who are likely to be the subjects of pharmaco- more times each night (2). These data suggest that abnormal
logical and behavioral interventions aimed at controlling bladder function has a significant effect on the frequency of

10
 epidemiology: u.s.a.

voiding. Incontinent women are voiding much more fre- increments of 100 ml. When volume was controlled, the mean
quently than continent women. FitzGerald et al. (22) recorded PFR and AFR did not differ significantly between respondents
nighttime voids in 44% or their population. Thirty-six percent who were continent and those who were incontinent. The flow
voided once during the night while 8% voided greater than or rates did not differ between women with competent sphincters
equal to two times per night. The number of nighttime voids and those with urethral incompetence. The continuity of the
was dependent only on the patient age. urinary stream was not associated with continence status nor
with the clinical type of incontinence (i.e., urge, stress, etc.).
quality of life
UI has a significant impact on a woman’s quality of life. Fultz Post-Void Residual Volume
et al. examined 174 respondents who were moderately to A post-void residual volume of 0 to 50 ml was found in 78.1%
extremely bothered by stress incontinence symptoms. Of of continent and 86.5% of incontinent women; 9.7% and 8.4%
these women 54.4% reported that their symptoms had a had residuals of 51 to 100 ml; 2.4% and 1.6% had residuals of
moderate to extreme impact on physical activities, 42.7% 101 to 150 ml, and 9.7% and 3.5% had residuals of 151 ml or
perceived such impact on confidence, 38.6% on daily activi- more, respectively. There was no statistical difference between
ties, and 36.5% on social activities (3). The odds of moderate- continent and incontinent women with regard to prevalence
to-extreme bother/burden decreased with age and increased of a residual urine volume greater than 50 ml. This data gives
with symptom severity. rise to questions regarding the post-void residual volume in
The relative risk of admission to a nursing home is two times relation to the diagnosis of overflow incontinence: the deter-
greater for incontinent women according to Thom et al. (25). mining factor for overflow incontinence may be the same fac-
Over half of all female nursing home residents are reported to tor as for urge and/or stress incontinence, and the abnormal
have “difficulty controlling urine,” and over half need assistance post-void residual volume may be coincidental or a contribu-
in using the toilet (26). tory factor rather than a primary reason for the incontinence.

prevalence of urodynamic measures among Bladder Capacity

continent and incontinent elderly women Among the women volunteers, 79% of continent volunteers
To establish the urodynamic characteristics of both continent and 64% of incontinent volunteers had a bladder capacity of
and incontinent elderly women living in a community, a series 300 ml or more; however, this difference in bladder volume
of urodynamic tests were conducted on those MESA respon- between continent and incontinent subjects was not signifi-
dents who volunteered to undergo such tests (27,28). This cant. The mean cystometric bladder capacities among 60 to
study provided information on the prevalence of the various 64-year-old continent and incontinent subjects were 381.8
parameters in the urodynamic tests that are of interest in the and 442.7 ml, respectively; for 65 to 69-year-old subjects they
evaluation of incontinent patients but for which there are no were 421.6 and 370.0 ml, for those aged 70 to 74 years they
well established data from control subjects. The MESA survey were 410.3 and 414.2 ml; for those aged 75 to 79 years
data established the sensitivity and specificity of the various they were 350.3 and 426.8 ml, and for those aged 80 years old
urodynamic tests, from which it was concluded that such or more they were 318.3 and 408.3 ml, respectively. These
tests—including uroflow, cytometrography, static urethral results refute the notion that the bladder capacity of the
profilometry, and stress cystography—should be used, not elderly is smaller than normal, if we consider a bladder capacity
to screen and diagnose UI but, rather, to confirm clinical of 300 ml or more to be normal.
manifestation. Recent studies confirmed the lack of concor-
dance between clinical manifestations and urodynamic Uninhibited Detrusor Contraction
findings (14–16). The diagnosis of uninhibited detrusor contraction was based on
The MESA survey studied a random sample of non- the definition by the International Continence Society. The
institutionalized ambulatory elderly women, both continent overall prevalence of uninhibited detrusor contraction in
and incontinent; an initial clinical evaluation was followed by women was 7.9%; the prevalence of uninhibited detrusor con-
a series of urodynamic evaluations. A total of 258 self-reported traction among continent respondents was 4.9%, whereas for
continent and 198 self-reported incontinent women under- incontinent subjects it was 12.2%. The difference between the
went the clinical evaluation comprising history taking, physi- two prevalence rates was not significant. However, comparison
cal examination (including pelvic examination) and urinalysis. of the bladder capacity between female respondents showed
From these groups, 67 continent and 100 incontinent women that the capacity in women with uninhibited detrusor contrac-
underwent urodynamic testing including an initial non- tion was 364 ml, whereas in those without uninhibited contrac-
instrumented uroflow test, followed by catheterized post-void tions it was 404 ml; the difference was statistically significant at
volume measurements, followed by filling cystometry, static p < 0.05. This may explain the increased frequency, urgency, and
and dynamic urethral profilometry, provocative stress test, and smaller voided volumes of patients with detrusor overactivity.
lateral stress resting and straining cystogram.
Static and Dynamic Urethral Pressure Profilometry (UPP)
Uroflowmetry The mean functional urethral length (FUL) did not change
The uroflow measures of peak flow rate (PFR) and average flow significantly as the age of the subjects increased, but the values
rate (AFR) were analyzed according to the voided volume at of the maximum urethral pressure (MUP) and the maximum

11
 background issues

closure pressure (MCP) showed a significant progressive medical correlates of ui

reduction as age increased (p = 0.002 and p = 0.0003, respec- Several medical conditions have been associated with UI in
tively). This progressive reduction of MUP and MCP rein- women. Difficulties with physical mobility, lower urinary tract
forces the belief that elderly women are more predisposed to symptoms, bowel problems, and diabetes are more common
stress urine loss. in women with incontinence. Other factors associated with UI
The parameters of UPP for supine subjects did not show any include a family history of incontinence, vaginal childbirth,
significant difference between continence and incontinence. and estrogen hormone use. Many of these associations were
However, for standing subjects, significant differences were identified through the MESA survey (29).
observed between continent and incontinent groups with Patients who used wheelchairs or walking aids, had a diag-
respect to MUP, which was significantly (p = 0.0025) lower in nosis of arthritis or who had fallen in the past year were defined
the incontinent compared with the continent group. Likewise, as having mobility difficulties in the MESA survey. In women
the MCP and the FUL were significantly reduced in standing with mobility problems, urge incontinence was more common
but not in supine incontinent subjects when compared with than any other type.
the continent group. Regarding urinary tract and bowel problems, women with
The results of dynamic profilometry were reported as either UI had a history of more urinary tract infections, dysuria, hes-
positive (zero or positive reading), corresponding to inconti- itancy, urgency, and slow stream than continent women. In
nence, or negative (corresponding to continence). There was addition, those who had more fecal incontinence or constipa-
no significant difference between incontinent and continent tion had a higher rate of UI. Women with stress incontinence
subjects in the supine position, but there was between the were the least likely of all urinary incontinent patients to lose
groups in the standing position. Despite this significant differ- control of their bowels.
ence, there was a great deal of overlap between the results for Diabetes effects more than 12% of adults older than 40 and
the continent and incontinent groups, invalidating a diagnosis the prevalence increases to 19% of adults older than 60 (30).
based on this test alone. Diabetic women have a 30% to 70% increased risk of UI
(29,31,32). The risk of urge incontinence was increased about
Lateral Stress Cystography 50% among women with diabetes, while they had no
Comparison between continent and incontinent subjects and increased risk of stress UI (33). The mechanism for the
between those with different types of incontinence, with regard incontinence is unclear. Possibilities include hyperglycemia
to urethral axis, posterior urethrovesical angle (PUV), and dis- (34) and microvascular complications causing altered inner-
tance of urethrovesical junction to the urogenital diaphragm vation to the bladder (35). Most prior studies on diabetic
(UGD), showed that incontinent respondents had a signifi- people with incontinence were conducted on elderly patients
cantly (p = 0.001) wider PUV angle than did continent respon- with type 1 diabetes who may have had other neurological or
dents; however, no significant difference was observed between urological reasons for their incontinence. A recent cross-sec-
stress and non-stress types of incontinence. There was no dif- tional analysis of a younger cohort of type 1 diabetics from
ference in the urethral axis and the position of the bladder the Epidemiology of Diabetes Intervention and Complica-
neck in relation to the UGD between the groups according to tion study demonstrated a twofold greater odds of urge
continence status or clinical type of incontinence. There was a incontinence and 50% greater odds of stress incontinence
significantly greater mean PUV angle among incontinent sub- compared to a matched cohort from the National Health and
jects with an incompetent sphincter than among continent Nutrition Examination Survey (36). Furthermore, UI was
subjects with a competent sphincter (p = 0.004); however, nei- found to be more prevalent than neuropathy, retinopathy, or
ther the measurements of the urethral axis nor the location of nephropathy. New data from the prospective, observational
the UGD differed between these two groups. Nurses’ Health Study cohort of more than 70,000 married
registered nurses found type 2 diabetes to be a strong inde-
Provocative Stress Test pendent risk factor for UI (37,38). In addition, the study
A provocative cough stress test was found to be significantly found that the risk of incontinence increases with the dura-
correlated to continence and incontinence status and, more tion of type 2 diabetes allowing the investigators to conclude
specifically, to the stress type of urine loss with or without urge that simply delaying the onset of diabetes could have impor-
loss (p ⁄ 0.0005). The result of the stress cystogram, when cor- tant public health implications. Data from the Diabetes Pre-
related with the stress test, showed a strong association (p = vention Program in pre-diabetic women showed that total
0.009). A urethral axis of 30 degrees or more is more likely to weekly incontinence at three years was lowest in women ran-
give rise to a positive stress test than is an axis less than 30 domized to the intensive lifestyle (34%) compared with met-
degrees. The stress test can be performed as part of the initial formin (48%) or placebo (46%) (39). Weight loss accounted
office evaluation and does not require special equipment: there for the largest impact on incontinence in this study, and
is no morbidity, it is inexpensive and (more importantly) it underscores the difficulty the role of many confounding fac-
has extremely high specificity; it should be a part of everyone’s tors such as parity, stroke, diabetes, age and body weight play
initial evaluation. However, a negative test in someone who is in drawing causative conclusions. Further research is needed
experiencing UI does not rule out its existence, as sensitivity of to define the role diabetes plays in UI and the impact
the test often is only 40%. intervention may have on decreasing its incidence.

12
 epidemiology: u.s.a.

Females with incontinence more often reported a parent or those in the younger (18–29 years) age range (55). Numerous
sibling with UI than continent women. It was also noted that epidemiological studies have demonstrated an association
UI patients had a higher rate of personal UI during adoles- between obesity and stress UI. Women with a median body
cence versus continent patients. mass index (BMI) of 28.2 had a higher incidence of UI than
There is an increased risk of later UI after a vaginal delivery, those with a BMI of 25.5 (normal range) (56). Odds ratios as
even after the first delivery (40). An increased risk of surgery high as 1.6 per 5 unit increase in BMI have been demonstrated
for the stress UI is also seen after a vaginal delivery (41). Dur- (55). The additional weight is believed to results in higher
ing pregnancy there is an increased prevalence of incontinence, pressures on the bladder and causes an increase in urethral
especially in the third trimester, which usually resolves shortly hypermobility. In a urodynamic evaluation study of subjects
after delivery (42). Possible etiologies are hormonal changes from the Program to Reduce Incontinence by Diet and Exer-
during pregnancy, damage to the pelvic muscles, and nerve cise trial, BMI had a stronger association with intra-abdominal
injury during labor and delivery (43). It is difficult to identify pressure than with intravesical pressure (57). The authors
the specific parturition risk factors as there are many potential, suggested that increasing weight may push women closer to
interrelated factors that occur during a single pregnancy and their threshold for UI episodes, even if their intrinsic conti-
delivery. Most observational studies have demonstrated that nence mechanisms are comparable. Randomized non-surgical
cesarean sections are protective against incontinence versus weight reduction studies suggest losing 5% or more of body
vaginal deliveries (44,45). The EPINCONT study of more than weight can lower UI episodes by as much as 70% (55). In fact,
15,000 Norwegian women demonstrated overall incontinence reduction in UI frequency has been suggested to be a powerful
rates of 10% of nulliparous, 16% of cesarean section, and 21% motivator for lifestyle modification. UI following gastric
in vaginal delivery only women (46). However, the protective bypass surgery has resulted in similar reductions, which
role of cesarean section diminished when adjusted with correlate significantly with decrease in BMI (55,58).
increasing age. An interesting study of identical twins at the
annual Twins Day Festival in Twinsburg, Ohio, found that patterns of reporting of ui
vaginal delivery more than doubled the report of stress UI According to a nationwide, two-staged, cross-sectional postal
compared to cesarean section (47). In 2007, a systematic review survey conducted by the NFO Worldgroup (59), 41.6% of
of the literature by Press found that cesarean section reduced incontinent women believed their incontinence was a natural
the risk of postpartum stress UI from 16% to 9.8% in six cross- part of growing older and 47.0% accepted it as a part of their
sectional studies and from 22% to 10% in 12 cohort studies life.
(48). From this data, they calculated that between 10 and 15 Approximately 86% of women reported being bothered by
cesarean sections would need to be performed to prevent one symptoms of UI, with 25.6% reported being moderately both-
woman from developing SUI. Less is known about the cesar- ered, 14.5% very bothered, and 8.5% extremely bothered. Only
ean section timing (before labor, in labor but without pushing, 44.9% of these incontinent women had ever talked to a physi-
or in labor and pushing) and its effect on incontinence. A cian about it. Those who were more bothered by their symp-
study of Israeli women one-year after their first delivery found toms were more likely to have talked to a physician (not
similar stress UI rates in women undergoing vaginal deliveries bothered, 25.2%; slightly bothered, 37.1%; moderately to
(10%) and cesarean for obstructed labor (12%) compared to extremely bothered, 56.5%). Older women were also more
planned cesareans (3%) (49). likely to talk to a physician than a younger women (53.5% vs.
Historically estrogen, either vaginal or oral, was thought to 39.8%).
improve incontinence episodes in post-menopausal women. Of the incontinent women who spoke with a physician,
The trigone and urethra are covered by nonkeratinized 42.9% first talked with a family practitioner, 35.1% with an
squamous epithelium and these tissues contain estrogen recep- obstetrician-gynecologist, 10.9% with an internist, and 4.4%
tors (50) and respond to estrogen (51). There have been many with an urologist. Of all women who initially spoke with an
uncontrolled trials demonstrating subjective improvement in internist or family practitioner, 19.0% were later referred to a
incontinence, while a few randomized controlled trials showed urologist and 17.3% to a gynecologist.
no significant difference between control and treatment groups
(52,53). Recently, the Heart Estrogen Replacement Study coping strategies to control ui
found intriguing UI outcomes when comparing a regimen of Patient self-care practices were also evaluated by the NFO
conjugated estrogen and medroxyprogesterone acetate with Worldgroup (59). Of all the women surveyed (bothered and
placebo (54). Incontinence improved in 26% of women given non-bothered by UI), 42.1% currently used panty liners,
placebo compared to 21% assigned to combined estrogen/ 33.5% used the toilet frequently even when they did not have
progestin, whereas 27% worsened in the placebo group com- an urge to urinate, and 29.5% sought out a toilet immediately
pared to 39% receiving hormonal replacement. They con- upon arriving at an unfamiliar location. Of the incontinent
cluded the effect of estrogen might be canceled by the women, 23.3% limited their fluid intake and pelvic floor mus-
progesterone, as progestin has been shown to decrease intrau- cle exercises were performed by 19.9% of all UI women and by
rethral closing pressure. 20.3% of women with stress symptoms only. Only 6.3% of all
In the United States, approximately 31% of adults are obese the women are currently being treated with prescription med-
and 33% are overweight, with the most rapid increase among ications and 2.1% have had surgery for their UI.

13
 background issues

continent surgery and its outcomes women’s satisfaction rates with the treatment is not as high as
An estimated 126,000 continence surgeries are performed some physicians perceive it.
annually in the United States (60). A review of the literature
demonstrates that the median proportion of women cured or
references
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et al. in 2002 by analyzing women who enrolled in the adults. J Gerontol 1990; 45: 67–74.
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Clinical Trial (63). They found in women with a uterus, the incontinence and quality of life after four years. A population-based study
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and African-Americans had the lowest risk. Finally, parity alence, incidence, and remission. J am Geriatr Soc 1996; 44: 1049–54.
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The direct and indirect financial impact of UI on our health 15. Summitt RL Jr, Stovall TG, Bent AE, Ostergard DR. Urinary incontinence:
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UI was $19.5 billion (year 2000 dollars) (64): $14.2 billion was dynamic testing. Am J Obstet Gynecol 1992; 166: 1835–40.
due to community residents and $5.3 billion due to institu- 16. Walters MD, Shields LE. The diagnostic value of history, physical exami-
nation, and the Q-tip cotton swab test in women with urinary inconti-
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nence. Am J Obstet Gynecol 1988; 159: 145–9.
which included absorbent products, laundry, treatment, and 17. Cundiff GW, Harris RL, Coates KW, Bump RC. Clinical predictors of uri-
consequences (UTIs, etc.), were $13.66 billion. Indirect costs, nary incontinence in women. Am J Obstet Gynecol 1997; 177: 262–6.
which involved lost productivity secondary to missing work, 18. Kinchen K, Gohier J, Obenchain R, et al. Prevalence and frequency of
for community residents was estimated to be $553 million, stress urinary incontinence among community-dwelling women. Eur
Urol 2002; 40(Suppl 1): 85.
with a $393 million loss for women and $159 million loss for
19. Luber KM, Boero S, Choe JY, et al. The demographics of pelvic floor dis-
men. For the institutionalized individual, the direct cost is orders: current observations and future projections. Am J Obstet Gynecol
$5.32 billion. 2001; 184: 1496–501; discussion 1501–3.
20. Hampel C, Wienhold D, Benken N, et al. Definition of overactive bladder
conclusion and epidemiology of urinary incontinence. Urology 1997; 50(6A Suppl):
4–14.
UI is a prevalent condition that can affect women of all ages. 21. Herzog AR, Fultz NH, Normolle DP, et al. Methods used to manage uri-
The incidence is especially high in the elderly population. UI is nary incontinence by older adults in the community. J Am Geriatr Soc
associated with many medical conditions. Urodynamic testing 1989; 37: 339–47.
can help explain the mechanism of UI. Many women with UI 22. FitzGerald MP, Stablein U, Brubaker L. Urinary habits among asymptom-
atic women. Am J Obstet Gynecol 2002; 187: 1384–8.
think that it is a part of the normal aging process and do not
23. Amundsen CL, Parsons M, Tissot B, et al. Bladder diary measurements in
talk to their physicians about this condition. Despite the asymptomatic females: functional bladder capacity, frequency, and 24-hr
advancement in medical and surgical treatment of UI, many volume. Neurourol Urodynam 2009; 26: 341–9.

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 epidemiology: u.s.a.

24. Tissot W, Amundsen CL, Diokno AD, et al. Bladder diary measurements 44. Wohlrab KJ, Radin CR. Impact of route of delivery on continence and
in asymptomatic males: frequency, volume per void, and 24-hr volume. sexual function. Clin Perinatol 2008; 35: 583–90.
Neurourol Urodynam 2008; 27: 198–204. 45. Rogers RG, Leeman LL. Postpartum genitourinary changes. Urol Clin N
25. Thom DH, Haan MN, Van Den Eeden SK. Medically recognized urinary Am 2007; 34: 12–21.
incontinence and risks of hospitalization, nursing home admission and 46. Rortveit G, Daltveit AK, Hannestad YS, et al. Urinary incontinence after
mortality. Age Ageing 1997; 26: 367–74. vaginal delivery or cesarean section. N Eng J Med 2003; 348: 900–7.
26. Nygaard I, Thom DH, Calhoun EA. Urinary incontinence in women. In: 47. Goldberg RP, Abramov Y, Botros S, et al. Delivery mode is a major environ-
Litwin MS, Saigal CS, eds. Urologic Diseases in America. US Government mental determinant of stress urinary incontinence: results of the Evanston-
Publishing Office, 2004; (Table 22): 71–103. Northwestern Twin Sisters Study. Am J Obstet Gynecol 2005; 193: 2149–53.
27. Diokno AC, Brown MB, Browk BM, et al. Clinical and cystometric char- 48. Press JZ, Klein MC, Kaxzorowski J, et al. Does cesarean section reduce
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Urol 1988; 140: 567-71. 228–37.
28. Diokno AC, Normalle DP, Brown MB, et al. Urodynamic tests for female 49. Groutz A, Rimon E, Peled S, et al. Cesarean section: does it really prevent
geriatric urinary incontinence. Urology 1990; 36: 431–39. the development of postpartum stress urinary incontinence? A prospec-
29. Diokno AC, Brock BM, Herzog AR, et al. Medical correlates of urinary tive study of 363 women one year after their first delivery. Neurourol Uro-
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30. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired 50. Iosif CS, Batra S, Ek A, et al. Estrogen receptors in the human female lower
fasting glucose, and impaired glucose tolerance in US adults: the Third urinary tract. Am J Obstet Gynecol 1981; 141: 817–20.
National Health and Nutrition Examination Survey, 1988–1994. Diabetes 51. Van der Kinden MC, Gerretsen G, Brandhorst MS, et al. The effect of
Care 1998; 21: 518–24. estriol on the cytology of urethra and vagina in post-menopausal women
31. Brown J, Seeley D, Fong J, et al. Urinary incontinence in older women: with genitourinary symptoms. Eur J Obstet Gynecol Reprod Biol 1993;
who is at risk? Obstet Gynecol 1996; 87: 715–21. 51: 29–33.
32. Wetle T, Scherr P, Branch LG, et al. Difficulty with holding urine among 52. Fantl JA, Bump RC, Robinson D, et al. The Continence Program for
older persons in a geographically defined community: prevalence and Women Research Group. Efficacy of estrogen supplementation in the
correlates. J Am Geriatric Soc 1995; 43: 349–55. treatment of urinary incontinence. Obstet Gynecol 1996; 88: 745–9.
33. Brown JS, Grady D, Ouslander J, et al. Prevalence of urinary incontinence 53. Jackson S, Shepherd A, Brooks S, et al. The effect of estrogen supplemen-
and associated risk factors in postmenopausal women. Heart and tation in treatment of urinary stress incontinence: a double blind place-
Estrogen/ Progestin Replacement Study (HERS) Research Group. Obstet bo-controlled trial. Br J Obstet Gynaecol 1999; 106: 711–18.
Gynecol 1999; 94: 66–70. 54. Grady D, Brown S Vittinghoff E, et al. HERS Research Group. Postmeno-
34. Belis J, Curley R, Lang C. Bladder dysfunction in the spontaneously dia- pausal hormones and incontinence: The Heart and Estrogen/Progestin
betic male Abyssinian-Hartley guinea pig. Pharmacology 1996; 53: Replacement Study. Obstet Gynecol 2001; 97: 116–20.
66–70. 55. Greer WJ, Richter HE, Bartolucci AA, et al. Obesity and pelvic floor disor-
35. Ellenberg M. Development of urinary bladder dysfunction in diabetes ders: a systematic review. Obstet and Gynecol 2008; 112: 341–9.
mellitus. Ann Intern Med 1980; 92: 321–3. 56. Elia G, Dye TD, Scariati PD. Body mass index and urinary symptoms in
36. Sarma AV, Kanaya AM, Nyberg LM, et al. Urinary incontinence among women. Int Urogynecol J 2001; 12: 366–9.
women with type 1 diabetes – how common is it? J Urol 2009; 181: 57. Richter HE, Creasman JM, Myers DL, et al. Urodynamic characterization
1224–30. of obese women with urinary incontinence undergoing weight loss pro-
37. Danforth, KN, Townsend MK, Curhan GC, et al. Type 2 diabetes mellitus gram: the Program to Reduce Incontinence by Diet and Exercise (PRIDE)
and risk of stress, urge and mixed urinary incontinence. J Urol 2009; 181: trial. Int Urogynecol J 2008; 19: 1653–8.
193–7. 58. Burgio KL, Richter HE, Clements RH, et al. Changes in urinary and fecal
38. Lifford KL, Curhan GC, Hu FB, et al. Type 2 diabetes mellitus and risk of incontinence symptoms with weight loss surgery in morbidly obese
developing urinary incontinence. J Am Geriatr Soc 2005; 53: 1851–7. women. Obstet Gynecol 2007; 110: 1034–40.
39. Brown JS, Wing R, Barrett-Connor E, et al. Lifestyle intervention is associ- 59. Diokno AC, Burgio K, Fultz NH, et al. Medical and self-care practices
ated with lower prevalence of urinary incontinence. Diabetes Care 2006; reported by women with urinary incontinence. Am J Manag Care 2004;
29: 385–90. 10: 69–78.
40. Milsom I, Ekelund P, Molander U, et al. The influence of age, parity, oral 60. Brown JS, Waetjen LE, Subak LL, et al. Pelvic organ prolapse surgery in the
contraception, hysterectomy and menopause on the prevalence of urinary United States, 1997. Am J Obstet Gynecol 2002; 186: 712–16.
incontinence in women. J Urol 1993; 149: 1459–62. 61. Leach GE, Dmochowski RR, Appell RA, et al. Female stress urinary incon-
41. Persson J, Wolner-Hanssen P, Rydhstroem H. Obstetric risk factors for tinence clinical guidelines panel summary report on surgical manage-
stress urinary incontinence: a population based study. Obstet Gynecol ment of female stress urinary incontinence. J Urol 1997; 158: 875–80.
2000; 96: 440–5. 62. Diokno AC, Burgio K, Fultz NH, et al. Prevalence and outcomes of conti-
42. Viktrup L, Lose G, Rolgg M, et al. The symptom of stress incontinence nence surgery in community dwelling women. J Urol 2003; 170: 507–11.
caused by pregnancy or delivery in primiparas. Obstet Gynecol 1992; 79: 63. Hendrix SL, Clark A, Nygaard I, et al. Pelvic organ prolapse in the Wom-
945–9. en’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol 2002;
43. Smith AR, Hosker GL, Warrell DW. The role of partial denervation of the 186: 1160–6.
pelvic floor in the aetiology of genitourinary prolapse and stress inconti- 64. Hu TW, Wagner TH, Bentkover JD, et al. Costs of urinary incontinence
nence of urine: a neurophysiological study. Br J Obstet Gynaecol 1989; 96: and over active bladder in the United States: a comparative study. Urology
24–8. 2004; 63: 461–5.

15
3 Epidemiology: South America
Paulo Palma, Miriam Dambros, and Fabio Lorenzetti

introduction in October 2005 and assessed the prevalence, severity, and

Worldwide, urinary incontinence (UI) is a common problem impact of UI on QoL by means of International Consultation
which affects 17% to 45% of adult women. The high cost in on Incontinence Questionnaire-Short Form (ICIQ-SF) (12).
terms of personal well-being (1) and financial expenditure for The mean age was 37.7 years (ranging from 12 to 79) and the
both individuals and society (2) makes this syndrome a major general UI prevalence rate reached was 34.8%. The ICIQ-SF
public health concern. The most prevalent type is stress incon- final score from the whole population sample was 3.1 (ranging
tinence, being responsible for 48% of all cases. After stress from 0 to 21) increasing to 8.9 in the incontinent group. Age,
incontinence, urge incontinence is the second most prevalent literacy, diabetes, and hypertension were associated with UI
cause of incontinence (17%) (3). Mainly due to shame, taboo, and were identified as risk factors along with frequency of
and unawareness of treatment possibilities, only a minority of pregnancies (Table 3.1). Family wages per month (<4), neuro-
women suffering from incontinence seek professional help. In logical diseases, parity, and mode of delivery (vaginal delivery
daily practice, patients usually seek help only when urine loss or CS) were not considered risk factors in this study. Elderly
leads to significant mental, physical, and social problems, as women (older than 60 years) had three times the odds of UI
well as discomfort, often after many years of suffering. The compared to those younger than 40 years. Women with hyper-
prevalence of UI is the probability of being incontinent within tension had 1.7 the odds of UI compared to those with no
a defined population at a defined point in time, estimated as hypertension. UI was highly prevalent among this sample of
the proportion of incontinent respondents identified in a population in our area. Furthermore, UI caused moderate
cross-sectional survey (4). The WHO defines health not only impairment on QoL (Table 3.2) of women who sought cancer
as the absence of disease, but also a “state of physical, emo- screening. UI should be considered a major public health
tional, and social well being” (5). According to the previous problem in the studied area. Risk factors identified were age,
International Continence Society definition, UI causes hygienic literacy, diabetes, hypertension, and frequency of pregnancy.
and social problems (6), and results in quality of life (QoL) Overall, elderly women with hypertension are at a high risk of
impairment, depression, and sexual problems (7). UI has a sig- UI (13).
nificant impact on the QoL of 20% of women (8). Epidemio- Latin America has one of the highest rates of CS in the world,
logic studies dealing with UI are sparse and methodologies with a tendency towards a further increase. Recent estimates
varied. In South America very little research has been done on indicate that the incidence varies between 16.8% and 40% in
this subject, and, as a consequence, there is conflicting infor- most Latin American countries (14), and that this rate is higher
mation, especially in respect to South American prevalence in private hospitals than in public hospitals. In addition, the
rates. incidence of CS is greater in those Latin American countries
with a higher per capita gross domestic product. Although
etiologic factors strategies to reduce CS rates have been proposed, very few have
It is generally believed that the main etiologic factor leading to been assessed through randomized controlled trials.
UI is one or more vaginal deliveries, with an increase in risk
with greater parity (9). Possible etiologies for UI include dis- urinary incontinence, qol,
tension or disruption of the muscles, ligaments, and nerves and sexual function
responsible for bladder control that occurs during vaginal Recently, many studies have measured the QoL in inconti-
delivery (10). Other authors, however, have found that the nent patients, using a number of different self administered
occurrence of UI during pregnancy in nulliparous women has condition-specific and generic QoL questionnaires. The
a stronger association with persistent incontinence after deliv- impact of UI on patients’ lives does not appear to be directly
ery than with parity (11). This would suggest a more signifi- related to the volume of urine loss, although it does appear to
cant effect from pregnancy itself than the process of vaginal be related to the overall burden of symptoms (15).
delivery. Women who are not exposed to vaginal childbirth by An open prospective study was carried out at our institu-
having all their babies by caesarean section (CS) offer the tion, enrolling patients with UI. The aim was to look at the
opportunity to check the relative relevance of pregnancy itself, relationship of UI and QoL issues, particularly with respect to
as compared with vaginal delivery, as a risk factor for UI. altered sexual function. The study population consisted of 30
Tamanini et al. evaluated women to identify prevalence, women aged between 31 and 51 years (mean 43 years). The
associated factors, and risk factors for UI as well as impact duration of symptoms ranged from 12 to 53 months. All the
on QoL in women seeking for cancer prevention screening. patients were multiparous and 60% of women had incom-
They performed a cross sectional analysis of 646 women who plete elementary education. Two sexual function question-
sought cancer prevention screening in an Oncologic Hospital naires were completed by respondents. The Female Sexual

16
 epidemiology: south america

Table 3.1 Demographic Data on Continent Patients Table 3.2 The Impact of QoL on Urinary Incontinence
(ICIQ-SF Final Score = 0) as well as Incontinent Patients Using the ICIQ-SF Final Score (n = 225)
(3 ≥ ICIQ-SF Final Score ≤ 21) (n = 646) Impact of QoL Score n %
Urinary incontinence
None 0 45 20
Yes No Slight 1–3 75 33.3
n % n % p-Valuea Moderate 4–6 45 20
Severe 7–9 20 8.9
Age (years) Very severe 10 40 17.8
12–40 122 18.9 268 41.6 0.0002
41–60 78 12.1 137 21.3 Abbreviations: QoL, quality of life; ICIQ-SF, International Consultation on
Incontinence Questionnaire-Short Form.
>60 25 3.9 14 2.2
Salary per family
1a2? 87 13.5 139 21.5 0.3535
3a4? 90 13.9 186 28.8
Table 3.3 Most Frequent Problems Identified
>4 ? 48 7.5 96 14.8 in Urinary Incontinence
Diabetes mellitus Problem Frequency (%)
No 213 34 413 66 0.0164
Yes 12 60 8 40 Bad smell and use of tampon 13 (43)
Hypertension Involuntary loss and wetness 12 (40)
No 177 32.2 373 67.8 0.0003 Surgery indication 2 (07)
Yes 48 50.5 47 49.5 Stress incontinence 1 (03)
Neurological disease Urinary frequency 1 (03)
No 219 34.9 409 65.1 0.8925 Urine loss in the presence of the husband 1 (03)
Yes
Abbreviation: ICIQ-SF, International Consultation on Incontinence
Questionnaire-Short Form.
to annual in one (6%), and from weekly to no relationship in
one (6%). Differences in sexual function before and after the
onset of incontinence were established. Ten variables related
to sexuality were studied: desire, excitement, vaginal lubrica-
Function Index identifies problems related to sexual response
tion, foreplay, masturbation, oral sex in the partner and in
and possible dysfunctions, as well as issues related to libido,
the patient, vaginal penetration, anal penetration, and
excitement, lubrication, orgasm, pleasure, and pain. The
orgasm. Six variables were significantly different following
Impact of UI on the Sexual Response/RJ questionnaire (16,17)
the onset of urinary leakage, with a worsening of sexual
identifies the effects of UI on sexual function, social problems,
desire, masturbation and foreplay, vaginal penetration, anal
and self-esteem. It also evaluates adaptive changes to cope
penetration, and orgasm. Abdo et al. studied the sexual lives
with urinary symptoms, and sexual behavior before and after
of 1502 healthy Brazilian women and concluded that in
the onset of UI.
34.6% the greatest complaint was a lack of desire and in
Of the 30 women participating in the study, 26 (86%) were
29.3% was orgasmic dysfunction (18). These results demon-
married and all had only one partner; 19 (63%) were Catholic,
strated a reasonable degree of sexual dysfunction amongst
and 18 (60%) had incomplete elementary education. Con-
the general Brazilian population although this appears to be
cerning the effects of UI on daily life ( Table 3.3), the major
greater in the presence of UI.
problems identified were the bad smell caused by urinary
leakage, the need to use pads for 13 patients (43%), and the
involuntary loss and wetness for 12 (40%). In addition to the Prevalence of Climacteric, Urogenital, and Sexual
results in Table 3.3, the study also showed that there were sig- Symptoms in a Population of Brazilian Women
nificant effects of UI on self-esteem; 11 patients (37%) having A cross-sectional, descriptive, population-based study (19)
the feeling of being less valued, with 17 (57%) women having was also carried out at the State University of Campinas on
a worsening of their sexual lives as a result of their urinary 456 women aged 45 to 60 years, living in Campinas, SP, Brazil,
symptoms. Twenty-three patients (76%) related that they in 1997. Data were collected via home interviews, using struc-
had urinary loss during sexual intercourse. Among these, 17 tured validated questionnaires. The results showed that cli-
(74%) claimed it had a negative influence on their sexual life. macteric symptoms in the population were highly prevalent
Of the 23 patients, 6 (26%) did not complain, 2 (9%) consid- and similar to those described in developed Western countries.
ered it a mild interference, four (17%) evaluated it as moder- Figure 3.1 shows the most prevalent symptoms identified. Hot
ate, and 11 (48%) indicated it as a severe interference. flushes, sweating, and insomnia as expected were significantly
Regarding the frequency of sexual intercourse before and more prevalent in peri- and post-menopausal women. The
after the onset of incontinence, 17 patients (57%) expressed severity of vasomotor and psychological symptoms did not
altering patterns. Sexual activity changed from weekly to vary according to the menopause phase. Decreased libido was
monthly in seven patients (41%), from daily to weekly in five the most frequent sexual complaint. It was also observed that
(29%), from daily to monthly in three (18%), from monthly some climacteric complaints were interrelated.

17
 background issues

90 although none of the sociodemographic factors studied was

80 associated with the risk of SUI (Table 3.4).
70 In addition, parity did not significantly alter SUI risk. Other
factors, such as previous gynecologic surgery, body mass
60
index, smoking habits, menopausal status, and hormone
50
replacement therapy, were not associated with the prevalence
40 of SUI and there were no racial variations. In the international
30 literature, most prevalence studies are conducted amongst
20 Caucasian women and only few studies have assessed racial
10
differences in the prevalence of UI. In the few studies which
have included other racial groups, a significantly larger per-
0
centage of Caucasian women appear to report UI compared

es
a

ce

es
ss

y
to African-American or Hispanic women (21). Urodynamic
ch
ni

tin

ili t
en

un
ch
ne

eu

da
ea

ib
in
ry

fl u

vo
at
ar

diagnosis showed that SUI was more frequent in Caucasian

ea
Sw
nt
ld

Ir r

er
sp

ot
co

H
na

N
H
y

women compared to African-Americans. However, more

in
D
gi
Va

y
ar

research with regard to racial differences in the prevalence of

rin
U

UI is necessary to make significant conclusions regarding

Figure 3.1 The most climacteric and urogenital prevalent symptoms found in
the study of Pedro et al. (19).
inter-racial differences in incontinence.

urinary incontinence among elderly people

in the municipality of são paulo, brazil
Over the period from 1980 to 2025, the population aged
Table 3.4 Background Data for All Patients Assessed
60 years and over in Latin America and the Caribbean is
by Guarisi et al. (20)
expected to at least double in size and, in more than half of
Stress urinary incontinence these countries, to triple in size, before reaching the year
Most times or 2025 (22). This rapid and accentuated aging of the popula-
sometimes Never tion will have a significant impact on social, economic, and
(n = 160) (n = 295) health demands. Prominent among the health demands
Prevalence
n % n % ratio will be those relating to chronic diseases and their inca-
Age (years) pacitating sequelae and other complaints such as UI, which
45–49 69 40.4 102 59.6 Reference are all included among the so-called “giants of geriatrics,”
50–54 50 34.7 94 65.3 0.8 given their negative consequences on QoL among elderly
55–60 41 29.3 99 70.7 0.7 people (23).
Race The Pan-American Health Organization and WHO (24)
Caucasian 96 37.4 161 62.6 Reference coordinated a multicenter study named Health, Well-being,
Black, brown 46 36.8 79 63.2 1.0 and Aging (SABE study) in elderly people living (over 60 years
Others 18 24.7 55 75.3 0.6
old) in seven countries of Latin America and the Caribbean. In
Literacy
Literate 28 38.9 44 61.1 Reference
Brazil, the study population was carried out in São Paulo in
Incomplete 81 33.3 162 66.7 0.9 the year 2000 and the total Brazilian sample was 2143 people.
elementary The data were collected simultaneously, by means of home
school interviews, using a standardized instrument consisting of 11
Complete 32 39.5 49 60.5 1.0 thematic sections: personal data, cognitive assessment, heath
elementary status, functional status, medications, use of and access to ser-
school vices, family and social support networks, work history and
High school, 19 32.2 40 67.8 0.8 sources of income characteristics of the home, and flexibility
college and mobility tests (Table 3.5).
Source: Data adapted from Ref. 20. The prevalence of self reported UI was 11.8% among men
and 26.2% for women. It was verified that among those
reporting UI, 37% also reported stroke, 34% depression
(Table 3.6). It was found that increasing dependency in the
Prevalence of Stress UI (SUI) and its Associated elderly was associated with increasing prevalence of UI. The
Factors in Perimenopausal Women associated factors found were depression [odds ratio (OR) =
A descriptive, exploratory, population-based study with sec- 2.49], female (OR = 2.42), advanced age (OR = 2.35), impor-
ondary analysis of a population-based household survey on tant functional limitation (OR = 2.01). UI is a highly preva-
the perimenopause and menopause was conducted among lent symptom among the elderly population of the
women living in a Brazilian city (20). Through a sampling pro- municipality of São Paulo, especially among women. The
cess, 456 women between 45 and 60 years old were selected. adoption of preventive measures can reduce the negative
Thirty-five percent of the interviewees complained of SUI effects of the UI.

18
 epidemiology: south america

Table 3.5 Distribution of Elderly People According to the Presence of Urinary Incontinence, Sociodemographic Variables,
Health Status, and Functional Status. Municipality of São Paulo, 2000
60–74 years ≥ 75 years
Yes No Yes No
Sociodemographic variables
Age group 16.5 83.5 33.3 66.7
Sex
Male 8.9 91.1 23.8 76.2
Female 22.2 77.8 38.6 61.7
Self-reported ethnicity
White 15.5 84.5 33.3 66.7
Non-white 18.8 81.2 33.6 66.4
Schooling (years)
Up to 3 years 18.2 81.8 36.2 63.8
4 years or more 15.3 84.7 28.6 71.4
Health status
Self-reported diseases/conditions
Diabetes mellitus 23.8 76.2 42.4 57.6
Arterial hypertension 19.9 80.1 36.2 63.8
COPD 20.7 79.3 35.8 64.2
Stroke 31.1 68.9 54.6 45.4
Depression 31.2 68.8 49.8 50.2
Self-reported health status
Excellent/very good/good 7.1 92.9 22.5 77.5
Regular/poor 25.0 75.0 41.6 58.4
Body mass index
Low 15.8 84.2 34.2 65.8
Normal 14.7 85.3 26.6 73.4
Overweight 11.9 88.2 36.8 63.2
Obese 24.3 75.7 43.8 56.2
Functional status
Difficulty in
Mobility in general 27.2 72.8 60.4 39.6
Going to the bathroom alone 45.1 54.9 73.1 26.9
Doing basic ADLs 32.7 67.3 56.5 43.5
Doing instrumental ADLs 18.4 81.6 35.7 64.3
Abbreviations: ADLs, activities of daily livings; COPD, chronic obstructive pulmonary disease.

Table 3.6 Final Model from Univariate and Multivariate Analysis for the Presence of Urinary Incontinence, According to
Sociodemographic, Clinical, and Functional Characteristics of the Elderly People in the Municipality of São Paulo, Brazil, 2000
Urinary incontinence
Confidence interval
a
Characteristics OR SD p-Value Lower limit Upper limit
Sex
Female 2.42 0.43 0.0000 1.70 3.43
Age
75 years and over 2.35 0.33 0.0000 1.78 3.10
Presence of self-reported diseases/conditions
Depression 2.49 0.43 0.0000 1.77 3.50
Stroke 1.69 0.45 0.049 1.01 2.85
Obesity 1.63 0.27 0.003 1.17 2.26
Diabetes mellitus 1.56 0.29 0.019 1.08 2.25
Functional status
Difficulty in doing basic activities of daily living 2.01 0.35 0.0000 1.44 2.83
a
Adjusted OR (95% confidence interval) = OR (95% confidence interval) adjusted using the logistic regression method, one by one for all variables and in the
final model only for the significant variables.
Abbreviation: OR, odds ratio.

19
 background issues

conclusion 13. Tamanini JT, Tamanini MMM, Mauad LMQ, Auler AMBAP. Urinary
incontinence: prevalence and risk factors in women seeking for gyneco-
UI is a highly prevalent condition in South America, as it is in
logical cancer revention screenin. BEPA 2006; 3: 34.
many other parts of the world. Very few studies have concen- 14. Osis MJD, Pádua KS, Duarte GA, Souza TR, Faúndes A. The opinion of
trated on South American populations alone but those that Brazilian women regarding vaginal labor and cesarean section. Int J Gyne-
have show a significant impact of UI on the QoL of sufferers. col Obstet 2001; 75: S59–66.
15. Wyman JF, Harkins SW, Choi SC, et al. Psychosocial impact of urinary
references incontinence in women. Obstet Gynecol 1987; 70: 378–81.
1. Thomas TM, Plymat KR, Blannin J, Meade TW. Prevalence of urinary 16. Rezende RCA. A Influência da Incontinência Urinária na Resposta Sex-
incontinence. Br Med J 1980; 281: 1243–5. ual Feminina. Rio de Janeiro: Mestrado em Sexologia da Universidade
2. Hu TW. Impact of urinary incontinence on health-care costs. J Am Geri- Gama Filho, M2000. Masters Degree, Brazil: University of Rio de
atric Soc 1990; 38: 292–5. Janeiro.
3. Norton PA, MacDonald LD, Sedgwick PM, Stanton SL. Distress and delay 17. Palma PCR, Thiel RRC, Thiel M, et al. Impacto da incontinência urinária
associated with urinary incontinence, frequency, and urgency in women. na qualidade de vida e sexualidade feminina. Urodinamica Uroginecolo-
Br Med J 1988; 297: 1187–9. gai 2003; 2: 71–6.
4. Hunskaar S, Burgio K, Dioko AC, et al. Epidemiology and natural history 18. Abdo CHN, Oliveira WM Jr, Moreira ED, et al. Perfil sexual da população
of urinary incontinence. In: Abrams P, Cardozo L, Khoury S, Wein A, eds. Brasileira: Resultados do Estudo de Com portamento Sexual (ECOS) do
Incontinence, 2nd ed. Plymouth: Plymbridge Distributors, 2002: 165. Brasileiro. Rev Brasileira de Medicina 2002; 59: 250–7.
5. Corcos J, Beaulieu S, Donovan J, et al. Quality of life assessment in men 19. Pedro AO, Pinto-Neto AM, Costa-Paiva LHS, Osis MJD, Hardy EE.
and women with urinary incontinence. J Urol 2002; 168: 896–905. Climacteric syndrome: a population-based study in Brazil. Rev Saúde
6. Blaivas JG, Appell RA, Fantl JA, et al. Standards of efficacy for evaluation Publica 2003; 37: 735–42.
of treatment outcomes in urinary incontinence: recommendations of the 20. Guarisi T, Pinto-Neto AM, Osis MJ, et al. Urinary incontinence among
Urodynamic Society. Neurourol Urodyn 1997; 16: 145–7. climacteric Brazilian women: household survey. Rev Saúde Publica 2001;
7. Hafner RJ, Stanton SL, Guy LA. A psychiatric study of women with 35: 428–35.
urgency and urgency incontinence. Br J Urol 1977; 49: 211–14. 21. Sze EHM, Jones WP, Ferguson JL, Barker CD, Dolezal JM. Prevalence of
8. Burgio KL, Matthews KA, Engel BT. Prevalence, incidence and correlates urinary incontinence symptoms among Black, White and Hispanic
of urinary incontinence in healthy middleaged women. J Urol 1991; 146: women. Obstet Gynecol 2002; 99: 572–5.
1255–9. 22. Palloni A, Peláez M. Histórico e natureza do estudo. In: Lebrão ML,
9. Foldspang A, Mommsen S, Djurhuus JC. Prevalent urinary incontinence Duarte YAO, eds. O Projeto SABE no Município de São Paulo: uma abor-
as a correlate of pregnancy, vaginal childbirth, and obstetrics techniques. dagem inicial. Brasília: OPAS/Ministério da Saúde, 2003: 15–32.
Am J Public Health 1999; 89: 209–12. 23. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento
10. Allen RE, Hosker GL, Smith ARB, Warrell DW. Pelvic floor damage and child- de Atenção Básica. Envelhecimento e saúde da pessoa idosa/Ministério
birth: a neurophysiological study. Br J Obstet Gynaecol 1990; 97: 770–9. da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica
11. Viktrup L, Lose G, Rolff M, Barfoed K. The symptom of stress inconti- – Brasília: Ministério da Saúde. 2006; 192 (Série A. Normas e Manuais
nence caused by pregnancy or delivery in primiparas. Obstet Gynecol Técnicos) (Cadernos de Atenção Básica, n. 19).
1992; 79: 945–9. 24. Tamanini JTN, Lebrão ML, Duarte YAO, Santos JLF, Laurenti R. Analysis
12. Tamanini JTN, Dambros M, D´Ancona CAL, Palma PCR, Netto NR Jr. of the prevalence of and factors associated with urinary incontinence
Validation of the “International Consultation on Incontinence Question- among elderly people in the municipality of São Paulo – Study (Health,
naire – Short Form for Portuguese. Rev Saúde Pública 2004; 38: 438–44. Well, Being and Aging- Sabe). In press.

20
4 Epidemiology: Europe
Ian Milsom

introduction Thomas et al. (5) investigated the prevalence of UI in two

Urinary incontinence (UI), overactive bladder (OAB), and London boroughs by a postal survey (Fig. 4.1A). The reported
other lower urinary tract symptoms (LUTS) are highly preva- prevalence of UI increased from 5.1% in girls aged 5 to 14 years
lent conditions with a profound influence on well-being and to 16.2% in 85-year-old women. There was, however, little or
quality of life as well as being of immense economic impor- no change in prevalence rates up to 35 years of age. The preva-
tance for the health service (1–3). Millions of women through- lence rates then increased to approximately 10% in the 35 to
out the world are afflicted (2) and there has been a growing 44 years age group. There was no significant increase at the
interest in these symptoms in recent years as a consequence of time of the menopause but a further increase to approximately
the increased awareness of the human and social implications 16% occurred in women ≥75 years. On the other hand, Iosif
for the individual sufferer. Population studies have demon- et al. (6) and Jolleys (13) (Fig. 4.1B) reported a maximum
strated that UI is more common in women than men and that prevalence of UI at the time of the menopause. Hannestad
approximately 10% of all women suffer from UI (2). Preva- et al. (26), in a large Norwegian study, demonstrated an
lence figures increase with increasing age and in women aged increased prevalence during the perimenopausal years, with
≥70 years more than 20% of the female population are affected. prevalence rates being lower both before and after the time of
Inappropriate leakage of urine is perceived by many women the menopause (Fig. 4.2A).
but is not always reported to the doctor. However, an increas- Conditions in Sweden are extremely favorable for epidemio-
ing awareness of the problem has in recent years attracted logic studies, in particular longitudinal studies. The Swedish
more patients to seek advice. In elderly women UI may lead to Population Register, with its personal number system, pro-
possible rejection on the part of a relative and may be an vides up-to-date information on the total population and can
important factor in the decision whether or not to institution- be used to obtain random and, in some cases, representative
alize an elderly person. UI and other LUTS not only causes subgroups of the total population for the purpose of epide-
considerable personal suffering for the individual afflicted but miologic studies. There are several large population-based
are also of immense economic importance for the health ser- studies from Sweden describing the prevalence of UI in women.
vice (3). The annual cost of UI in Sweden, for example, has Figure 4.3A illustrates the results from two independent stud-
been reported to account for approximately 2% of the total ies of UI in women. In both studies, prevalence was restricted
healthcare budget (1). to women who had urinary leakage at least once per week.
Although the study performed by Samuelsson and co-workers
urinary incontinence (24) was undertaken in a rural area and that by Simeonova
This chapter describes the results of epidemiologic studies et al. (26) was carried out in an inner city, there are strong
performed in Europe. The reported prevalence of UI among similarities between the results of the two studies, with a linear
women varies widely in different studies due to the use of dif- increase in the prevalence of UI which continues over the
ferent definitions, the heterogenicity of different study popu- perimenopausal years.
lations and population sampling procedures. In addition, In contrast, another Swedish population study (22) (Fig.
different definitions of UI have been applied. UI has been 4.3B) failed to demonstrate any increase in the prevalence of
defined by the International Continence Society as any invol- UI between women aged 46 and 56 years of age (prevalence
untary leakage of urine (4). However, some authors have cho- 12% for both cohorts). The majority of 46-year-old women
sen to restrict prevalence figures according to the frequency of were premenopausal whereas the majority of 56-year-old
involuntary urinary leakage—for example, based only on women were postmenopausal. There were no differences in
daily, weekly, monthly, or annual urinary leakage. Thus, for prevalence rates between pre- and postmenopausal women
the reasons given above, it is difficult to compare the results of within the respective birth cohorts (Fig. 4.4A). Thus there was
different population studies. However, when reviewing the no evidence to suggest that the prevalence of UI increased at
literature, there is considerable evidence to support the theory the time of the last menstrual period. However, this is not nec-
that the prevalence of UI in women increases with age, but essarily synonymous with the fact that the reduction in circu-
there are divergent opinions regarding the pattern of this lating estrogens is not associated with an increase in the
increase (5–34). In a review (2) of population studies from prevalence of UI in women after the menopause.
numerous countries the prevalence of UI ranged from The prevalence of UI in women has been compared with the
approximately 5% to 70%, with most studies reporting a prevalence in men of the same age in two large Swedish studies
prevalence of any UI in the range of 25% to 45%. For daily (Fig. 4.3B) (22,34). As can be seen from the results illustrated
incontinence, prevalence estimates typically range between in Figure 4.3b, there is a higher prevalence of UI in women
5% and 15% for middle-aged and older women. than in men in all the age groups studied. In general, the

21
 background issues

Jolleys et al. (13)

16 60
Thomas et al. (5)
14
50
12
40
10
Percentage

Percentage
8 30

6
20
4
10
2

0 0
5–14 15–24 25–34 35–44 45–54 55–64 65–74 75–84 85+ –25 25–34 35–44 45–54 55–64 65–74 75–84 85+
(A) Age range (yrs) (B) Age range (yrs)
Figure 4.1 Comparison of the prevalence of female urinary incontinence in two British studies. (A) The study by Thomas et al. (5) was performed in 9323 British
women and (B)the study by Jolleys et al. (13) was performed in 833 British women.

45
40
Prevalance rate

35
30
25
20
15
10
5
0
20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85–89 90+
Age (yrs)
(A)

Other

MUI
SUI

UUI

(B)
Figure 4.2 Prevalence of urinary incontinence in Norwegian women grouped (A) by age, and (B) type of incontinence. Abbreviations: MUI, mixed urinary incon-
tinence; SUI, stress urinary incontinence; UUI, urge urinary incontinence. Source: Based on data from Ref. 26.

16
30
14 Samuelsson et al. (24)
Simeonova et al. (25) Women
12 25
Men
Percentage

10 20
Percentage

8
15
6
10
4
2 5

0 0
20–29 30–39 40–49 50–59 46 56 66 76 86
(A) Age (yrs) (B) Age (yrs)
Figure 4.3 Comparison of the prevalence of urinary incontinence: (A) in two population-based studies of Swedish women in a rural area [Samuelsson et al. (24)]
and in an inner city [Simeonova et al. (25)]; (B) in two population-based Swedish studies in women (n = 7459) (22) and men (n = 7763) (48) of the same ages.

22
 epidemiology: europe

18
14 16
Age 46
12 Age 46 14

Percentage
12 Age 56
10 Age 56

Percentage
10
8
8
6
6
4 4
2 2
0 0
Pre-MP Post-MP 0 1 2 3
Parity
(A) (B)

35
Hysterectomy
30
No hysterectomy
25
Percentage

20
15
10
5
0
Age 66 Age 71 Age 76 Age 81 Age 86 All
(C)
Figure 4.4 Prevalence of urinary incontinence: (A) in a random sample of 46- and 56-year-old women grouped according to menopausal (MP) status; (B) in a
random sample of 46- (n = 1530) and 56-year-old (n = 1638) women grouped according to parity; (C) in a random sample of 66-, 71-, 76-, 81-, and 86-year-old
women grouped according to history of hysterectomy. Source: Data from Ref. 22.

prevalence of UI is approximately three times more common between countries based on separate studies is difficult due to
in women than in men. differences in methods and definitions, as well as language,
The majority of the population studies referred to in this cultural, and social differences. One of the few studies to esti-
chapter have been performed by means of postal question- mate the prevalence of UI in more than one country found
naires. In several of the studies, attempts have been made to similar prevalences of any UI (41–44%) in three of the four
determine the proportion of women suffering from the differ- countries examined (France, Germany, and U.K.) but a lower
ent types of urinary leakage, i.e., stress urinary leakage (SUI), prevalence (23%) in the fourth country (Spain) (27). There
urge urinary leakage (UUI), and mixed urinary leakage (MUI). was no apparent reason for the lower prevalence in Spain.
The distribution of the various types of incontinence in the UI is, however, not static but dynamic and many factors may
large Norwegian study by Hannestad et al. (26) is shown in contribute to incidence, progression, or remission. There are a
Figure 4.2B. In the literature, SUI tends to dominate among few studies describing progression as well as remission, in the
younger women while the number of women with urge short term, of UI in the general population as well as in selected
incontinence and mixed incontinence increases with age. groups of the population. The mean annual incidence of UI
More recent studies (26,29–34) have added important infor- seems to range from 1% to 9% while estimates of remission
mation on prevalence of incontinence in women younger than are vary more, 4% to 30% (34–36).
30 and older than 80 years of age, particularly for prevalence of Wennberg et al. (34) studied the prevalence of UI in the
incontinence by type. These studies are consistent with previ- same women (aged ≥20 years) over time in order to assess pos-
ous studies reporting that older women are more likely to have sible progression or regression. A self administered postal
mixed and urge incontinence while young and middle-aged questionnaire with questions regarding UI, OAB, and other
women generally report stress incontinence. Overall, approxi- LUTS was sent to a random sample of the total population of
mately half of all incontinent women are classified as stress women in 1991. The same women who responded to the ques-
incontinent. A smaller proportion are classified as mixed tionnaire in 1991 and who were still alive and available in the
incontinent and the smallest fraction as urge incontinent. A population register 16 years later were re-assessed using a sim-
recent study which included the entire adult age range by Han- ilar self-administered postal questionnaire. The overall preva-
nested et al. (26) demonstrated a fairly regular increase in lence of UI, increased from 15% to 28% (p < 0.001) from 1991
prevalence of mixed incontinence across the age range, and a to 2007 and the incidence rate of UI was 21% while the corre-
decrease in prevalence of stress incontinence from the 40- to sponding remission rate was 34% (Fig. 4.5).
49-year-old age group through the 60- to 69-year-old group. Thus, in summary, when reviewing the literature, there is
There is no hard evidence for different prevalences of UI considerable evidence to support the theory that the preva-
among Western countries. However, comparing prevalence lence of UI increases in a linear fashion with age as shown

23
 background issues

Table 4.1 Risk Factors for Urinary Incontinence in Women

1991 1991 • Age
No UI UI
• Sex
• Smoking
• Chronic bronchitis, asthma
• Ethnic group
• Obesity
• Pregnancy
• Vaginal delivery
• Collagen defect
21%
34% • Hysterectomy
• Dementia
79% 66%
2007 2007 • Stroke, Parkinson’s disease, etc.
• Physical activity
• Medication
Figure 4.5 The incidence and regression of urinary incontinence (UI) in the
• Constipation
same women assessed in 1991 and 2007. Source: From Ref. 34.
• Diuretics
• Enuresis
• Chronic illness
45
40
35
30 Several studies suggest that the risk of UI “runs in the fam-
Percentage

25
ily” (28,37,38). Family history studies have found a two to
three fold greater prevalence of stress UI among first degree
20
relatives of women with stress UI compared to first degree
15 relatives of continent women. In the Norwegian Nord-
10 Trøndelag health survey (EPINCONT), daughters of mothers
5 with UI had an increased risk of stress incontinence, mixed
0 incontinence, and urgency incontinence (28). In general the
0 10 20 30 40 50 60 70 80 90 risk was somewhat higher for sisters of a woman with UI than
Age (yrs) for daughters.
A study from the Swedish twin register indicated that herita-
Figure 4.6 Prevalence of female urinary incontinence (≥1/week) which affected
the woman’s way of life (summary of 19 population studies, based on Ref. 49). bility contributes to the liability of developing surgically man-
aged pelvic organ prolapse and stress UI. The authors presented
evidence that for both disorders genetic and non-shared envi-
in Figure 4.6 which includes pooled data from 19 epidemio- ronmental factors equally contributed 40% of the variation in
logic studies where UI was reported to occur at least once liability (38). Although study methodology and the magnitude
per week. of the risk estimates vary, studies on familial transmission of
incontinence are in agreement (28,37): Having a first degree
factors influencing the prevalence of ui female family member with stress UI increases the risk for an
Risk factors described in the literature are shown in Table 4.1 individual becoming afflicted by the same disorder.
(29–31,36,37). For the majority of these risk factors there are
at present no controlled trials demonstrating that intervention OAB and Other LUTS
reduces the incidence, prevalence, or degree of severity of UI. In recent years, several epidemiological studies have also been
The influence of various factors on the prevalence of UI was conducted in order to better understand the prevalence and
evaluated by means of a postal questionnaire in women aged the impact of OAB and other LUTS. OAB is defined as the
46 to 86 years resident in the city of Gothenburg, Sweden (22). presence of urgency and frequency (either daytime or night
Age, parity, and a history of hysterectomy were all correlated to time), with or without UI (4). OAB is often divided into OAB
the prevalence of UI which increased in a linear fashion from without UI (OABdry) and those with OAB and UI (OABwet).
12.1% in women 46 years of age to 24.6% in women aged The reported prevalence of OAB in females varied between
86 years of age (Fig. 4.3B). The prevalence of UI was greater 7.7% to 31.3% and, in general, prevalence rates increased with
in parous women compared to nulliparous women, and age (39–42). OAB has been shown to be associated with other
prevalence increased with increasing parity (Fig. 4.4B). UI was chronic debilitating illnesses such as depression, constipation
more prevalent in women who had undergone a hysterectomy and diabetes as well as neurological illnesses. OAB is com-
(Fig. 4.4C). The prevalence of UI was unaffected by the dura- monly associated with other LUTS which was well illustrated
tion of previous oral contraceptive usage and there was no evi- by the cluster analysis performed by Coyne et al. (43).
dence to suggest that the prevalence of UI increased at the time The prevalence of OAB symptoms was estimated in a large
of the last menstrual period. European study involving more than 16,000 individuals

24
 epidemiology: europe

45 The progression or regression of OAB and other LUTS was

40 Men
Women
studied by Wennberg et al. (34) in the same women (aged
35
≥20 years) followed over a period of 16 years (from 1991 to
Precentage

30
25 2007). The overall prevalence of OAB, nocturia and daytime
20 micturition frequency of eight or more times per day increased
15 by 9%, 20% (p < 0.001), and 3% (p < 0.05) respectively from
10
5
1991 to 2007. The incidence of OAB was 20 % and the corre-
0 sponding remission rate 43%. Women with OAB symptoms
40–44 45–49 50–54 55–59 60–64 65–69 70–74 75+ were classified as OAB dry or wet depending on the presence
(A)
or absence of concomitant UI. The prevalence of OAB dry did
25
Men
not differ between the two assessment occasions (11% and
20 Women 10% respectively), but the prevalence of OAB wet increased
from 6% to 16% (p < 0.001). Among women with No OAB in
Percentage

15 1991 the prevalence in 2007 were 8% and 12% for OAB dry
and wet, respectively. There was a progression from OAB dry
10 to wet in 28%. Remission from OAB dry or wet to No OAB
occurred in 50% and 26% respectively (Fig. 4.8).
5

0 socioeconomic considerations
France Germany Italy Spain Sweden U.K. All The economic consequences of UI and other LUTS have
(B)
recently been reviewed (3) and there are now numerous reports
Figure 4.7 Prevalence of overactive bladder symptoms: (A) grouped according to support the statement that UI and LUTS have a huge bear-
to age and sex; (B) in a random sample of the total population aged ≥40 years
from six European countries. Source: Adapted from Ref. 39.
ing on health care costs (1,3,44–47). The economic conse-
quences of UI in Sweden in 1990 were assessed by Milsom
et al. (1,49). The estimated annual cost for UI in Sweden at that
2007
time was 1.8 billion Swedish Crowns. The Swedish Health Care
No OAB OAB dry OAB wet Total (%)
budget for 1990 amounted to 93 billion Crowns. Based on the
NO OAB 634 64 93 791 (83%) results of this evaluation, the annual costs of UI in Sweden
accounted for approximately 2% of the total healthcare costs.
OAB dry 52 24 29 105 (11%)
1991

The mean life expectancy of women in Sweden is at present

OAB wet 14 11 28 53 (6%) 83 years, which is higher than in many other Western countries,
and 19% of all persons are at present >65 years of age. The pro-
Total (%) 700 (74%) 99 (10%) 150 (16%) 949 (100%)
portion of elderly women in many Western countries is currently
1991 1991 increasing, and it is estimated that in many European countries
there will be a substantial increase in the number of women aged
No OAB OAB dry OAB wet
>65 years by the year 2025 (50). Thus, the number of women
requiring treatment for UI is expected to increase in the future.
12% Another important factor to consider, apart from the
8%
28% 26%
numerical increase in the number of elderly women, is the fact
49% 53% that many elderly women of today suffer in silence, accepting
80% 23% 21% these symptoms as a normal part of the aging process. Women
2007 2007
who are at present 30 and 40 years of age have other demands
Figure 4.8 The percentage distribution of overactive bladder (OAB) symp- on their physical condition and will undoubtedly not accept
toms in the same women assessed in 1991 and 2007. Source: From Ref. 34.
what their older counterparts accepted later in life.

(39). Data were collected using a population-based survey references

(conducted by telephone or face-to-face interview) of men 1. Ekelund P, Grimby A, Milsom I. Urinary incontinence: social and finan-
and women aged >40 years, selected from the general popu- cial costs high. Br Med J 1993; 306: 1344.
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the International Continence Society. The standardisation of terminology
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Gynaecol Reprod Biol 1992; 43: 229–34. 41. McGrother CW, Donaldson MMK, Hatward T, et al. Urinary storage
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urinary incontinence in women. J Urol 1993; 149: 1459–62. urinary tract symptoms at one year in women aged 40–60: longitudinal
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sultation, behaviour and patient experiences: an epidemiological survey 45. Hu T, Wagner T, Bentkover J, et al. Costs of urinary incontinence and
in a Norwegian community. Fam Pract 1995; 12: 18–21. overactive bladder in the United States; a comparative study. Urology
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and wish for treatment. Acta Obstet Gynecol Scand 1997; 76: 74–80. cost of overactive bladder in five European countries. Eur Urol 2006; 50:
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incontinence and its influence on the quality of life in women from an 47. Irwin DE, Mungapen L, Milsom I, et al. The economic impact of overac-
urban Swedish population. Acta Obstet Gynecol Scand 1999; 78: 546–51. tive bladder syndrome in six Western countries. BJU Int 2008; 103:
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miological survey of female urinary incontinence: the Norwegian EPIN- 48. Malmsten UG, Milsom I, Molander U, et al. Urinary incontinence and
CONT study. J Clin Epidemiol 2000; 53: 1150–7. lower urinary tract symptoms: an epidemiological study of men aged 45
27. Hunskaar S, Lose G, Sykes D, et al. The prevalence of urinary incontinence to 99 years. J Urol 1997; 158: 1733–7.
in women in four European countries. BJU Int 2004; 93: 324–30. 49. Milsom I. Prevalence and risk factors. In: Treatment of Urinary Inconti-
28. Hannestad YS, Lie RT, Rortveit G, et al. Familial risk of urinary inconti- nence. The Swedish Council on Technology Assessment in Health Care
nence in women: population based cross sectional study. BMJ 2004; 329: Report on Urinary Incontinence. Stockholm: SBU, 2000.
889–91. 50. WHO Report. Population Statistics. Geneva: WHO, 1993.

26
5 Epidemiology: Australia
Richard J Millard and Dudley Robinson

introduction Three hospitals (1666 beds) and 15 nursing homes (1631

In geographical terms, Australia is the driest continent on beds) were also surveyed by questionnaires sent to staff, and
earth; regrettably the same cannot be said of its inhabitants. the data from these establishments were analyzed separately.
The Australian population is multicultural, having been A total of 293 individuals admitted to some degree of pres-
derived largely from waves of immigrants from Britain and the ent UI or leakage by day, and 51 also had some loss of urine at
Mediterranean and Balkan countries for much of its 200 year night. In all, 301 persons (24%)—13% of the male and 34% of
post-colonization history, and from Asian and Central the female respondents—had some degree of urinary loss.
European countries more recently. Studies show that 5% to Eight people were incontinent only at night. The male-to-
6% of adult Australians have regular or severe urinary inconti- female ratio among those with urinary leakage was 1:2.7, with
nence (UI), a prevalence remarkably similar to that reported females accounting for 73% of sufferers. The frequency of
from other basically Caucasian populations (1,2). urinary loss is shown in Table 5.1.
Data regarding prevalence in Australia have been available Leakage was more common in members of blue-collar fam-
since a study in Sydney in 1983 (3,4). No systematic study of ilies (27%) than in members of white-collar families (25%).
general prevalence has been conducted since that time. How- Students and those in full-time employment tended to have
ever, the longitudinal Women’s Health Australia study, half the prevalence of incontinence (13% and 16%, respec-
involving over 40,000 women (5), has provided new data on tively) reported by the other groups (30–34%). Housewives
prevalence in women (6) and may yield further data on the had the highest prevalence of incontinence overall (40%).
incidence of incontinence over the next 10 to 20 years as the The mean duration of all leakage problems was 8.8 years;
cohorts age. 18% reported leakage for less than a year, whereas 23% had
The problem with all surveys aimed at assessing the preva- had problems for 15 or more years; 17% could not specify the
lence of incontinence is how to define UI. Do we wish to know duration of their problem.
only how many people have regular and severe incontinence, The 293 positive respondents were asked to specify circum-
assuming that we could even define what we meant by this stances under which they experienced leakage (more than one
term? Alternatively, is it relevant to know about all levels of UI answer was allowed) (Table 5.2).
that occur in the community? Is whether the individual All 293 individuals who reported some current degree of
chooses to wear an incontinence pad or appliance a good leakage were asked to quantify the severity of the urine loss
indicator of significant incontinence? (Table 5.3).
Equally, research into the incidence and prevalence of UI in Severe incontinence was twice as common in blue-collar as
Australian women has been shown to exhibit significant het- in white-collar families, but minor degrees of leakage were
erogenicity in the findings due to methodological limitations. equally prevalent. The type of incontinence was correlated
Consequently there is a need for future studies to use validated with severity and frequency of leakage episodes as shown in
instruments and report age specific data (7). Some of the more Table 5.4.
recent studies reviewed in this chapter fulfill these criteria. In most cases, incontinence occurred infrequently and was
To circumvent these issues, the 1983 Sydney survey attempted of minor severity. What stands out is the relatively more fre-
to ascertain the prevalence of all past and present UI and to quent nature of the leakage of the quiet dribbling incontinence
stratify the type, severity, and frequency of occurrence of the type, which occurs without warning or provocation.
incontinence problems discovered in the study population.
The study was designed to ascertain the prevalence of UI in Nocturnal Incontinence
Australia. Prevalence was correlated with age, gender, and Incontinence at night was reported by 51 (26 female and
socioeconomic stratification. An attempt was made to define 25 male) individuals, a prevalence of 4% of the population
at-risk groups, types, and severity of incontinence, and use of over the age of 10 years. The frequency of nocturnal inconti-
protective appliances. A detailed, 38-question, self-report nence is shown in Table 5.5, correlated with sex and age
questionnaire was devised and tested for comprehensibility in group.
small focus groups before distribution. A multistage cluster-
sampling technique was used to target 3000 adults in Treatment Experience
1000 homes, randomly selected from 100 postal districts. All Perhaps reflecting the minor nature of the problem for the
3000 were telephoned to increase compliance and to check majority of the positive respondents, 70% of the 301 with
data received, and a total of 1256 completed questionnaires leakage had never sought any treatment. However, 31% of
were analyzed. the women and 26% of the men had sought help from

27
 background issues

general practitioners (24%), from specialists (14%), or from

Table 5.1 Frequency of Incontinence Episodes
other health professionals (1%). (Respondents may have
Percentage of respondents sought help from more than one healthcare professional.)
Frequency Male Female Overall Those most likely to seek help were over 60 years of age, and
either blue-collar or unemployed persons. This may be
Often wet 2 4 3 explained by the fact that it is the elderly and those from
Once a day 2 4 3
blue-collar families who have the highest prevalence of
Once a week 1 3 2
Once or twice a month 0 4 2
urinary leakage and also the more severe degrees of
Rarely 8 18 13 incontinence.
Never wet 87 66 76 At the time of the study, 93 people were having treatment
for incontinence, representing 31% of the 301 with current
leakage. This is similar to the treatment rate reported by
Thomas et al. (1). The types of treatment being received
were pharmaceutical agents in 33%, appliances in 8%,
bladder/muscle training in 13%, and surgery in 24% of
Table 5.2 Circumstances in which Respondents patients.
Experienced Leakage
Percentage of respondents
Males (n = 79) Females (n = 214)
Coughing or sneezing 5 61
Straining or lifting 5 12 Table 5.4 Percentage Frequency and Severity of Leakage
Urge 27 35
in 293 Respondents Wet by Daya
Giggle 9 30
No warning or 1 7 Frequency
provocation Type of
incontinence Often 1/day 1/week 2/month Rarely
Postmicturition dribble 59 8
With urinary infections 8 10 Coughing 15 12 9 12 52
Other 8 9 Strain 31 7 7 14 41
Totala 122 172 Urge 20 11 8 10 50
a
Respondents may have more than one type of incontinence. Giggle 15 13 7 8 56
No warning 38 19 6 6 31
Postmicturition 22 15 4 11 48
Other 12 15 4 19 50
Severity

Table 5.3 Quantification of Severity of Urinary Loss Always Flood Moderate Slight Drops
in 293 Respondents Coughing 1 2 2 46 48
Strain 7 3 10 38 41
Percentage of respondents
Urge 1 3 7 35 52
Urinary loss Male (n = 79) Female (n = 214) Overall No warning 19 6 6 38 19
Postmicturition 2 2 2 27 69
Always wet 0 2 2
With UTI – – 7 37 56
Flooding 0 2 1
Other 4 4 8 50 35
Moderate loss 8 5 5
a
Slight loss 25 41 37 A patient may have more than one type of incontinence.
Just a spot 66 49 54 Abbreviation: UTI, urinary tract infection.

Table 5.5 Frequency of Nocturnal Incontinence, Correlated to Sex, and Age Group
No. and sex Age group (years)
Overall
Frequency percentage M F 10–29 30–44 45–59 60–74 75+
Most nights 8 2 2 2 0 1 1 0
Once a month 4 2 0 1 0 1 0 0
Occasionally 16 5 3 6 1 1 0 0
Rarely 73 16 21 19 7 8 0 3
Percentage wet in age group 28 8 11 1 3
5.6 2.3 4.4 1 8

28
 epidemiology: australia

relationship between incontinence The association of age and UI has also been documented in
and age group a recent questionnaire based study of 542 community dwell-
The prevalence of incontinence and its relationship to age ing women aged 24 to 80 years. The overall prevalence of any
group and gender is shown in Figure 5.1 and in Table 5.6. The UI was 41.7% [95% confidence interval (CI): 37.2–45.8] with
increased prevalence seen with increasing age is particularly a response rate of 93.4%. Of the 210 women reporting UI
prominent in men over 60 years of age. The normal female 16% (95% CI: 12.9–19.3) reported stress only, 7.5% (95% CI:
preponderance is lost in old age, with a consequent rise in 5.2–9.8) reported urge only and 18% (95% CI: 14.7–21.5)
overall prevalence. The high (40%+) prevalence rate in the reported mixed symptoms. Stress incontinence was found to
over-60 age groups is similar to that found in other studies (8) be most common amongst middle aged women whilst urge
and to the prevalence of incontinence found in nursing homes incontinence was most common in women over the age of
(9). Those over 60 years of age reported more severe and more 75 years. Logistic regression revealed a significant association
frequent episodes of incontinence than did younger people. with obesity and parity with stress incontinence. Increasing
Even young women have a higher prevalence of inconti- age, being over weight, and previous hysterectomy was
nence than young men, and this trend is accentuated after associated with urge incontinence (10).
30 years of age, possibly as a result of pregnancy and child-
birth. This was particularly apparent in the rates of stress UI, precipitating factors
which increased from 7% in the 10- to 29-year-old group to The 301 individuals who were “wet day or night” were requested
26% in 30- to 44-year-old women and to 36% in the 45- to to identify the “cause” of their leakage problem (Table 5.8).
60-year-old group. These data are similar to those obtained Hysterectomy was blamed for incontinence in 7% of the
from the Women’s Health Australia study (6). The relationship women, mostly by women from blue-collar families or those
between incontinence type and age group is shown in Table 5.7, off the workforce, compared with only 1% of the women from
which emphasizes the rising prevalence of urge incontinence white-collar families. Incontinence associated with urinary
in the elderly and the high rate of simple stress incontinence in tract infection was also twice as common in women from blue-
middle age. collar families. The association between incontinence and

60
4+ children
Recurrent UTI
50 Locomotor
Pregnant problems
Prevalence (%)

40
Median
of female
30

20

10 Median of male

0
10–29 30–44 45–59 60–74 75+
Age (yrs)
Figure 5.1 Prevalence of incontinence according to age and sex [red line: female (n = 214); blue line: male (n = 79)].

Table 5.6 Prevalence of Incontinence, and Its Relationship to Age Group and Gender
Age group (years)
No. of individuals 10–29 30–44 45–59 60–74 75+ Overall
Sample total 498 354 250 117 37 1256
Female 243 194 129 64 21 651
Weta 47 75 64 19 9 214
(19) (39) (50) (30) (43) (33)
Male 255 160 121 53 16 605
Weta 25 20 16 11 7 79
(10) (13) (13) (21) (44) (13)
a
Percentages in parentheses.

29
 background issues

Table 5.7 Relationship Between Incontinence Type and Age Group

Percentage in age group (years)
Incontinence Percentage female 10–29 30–44 45–59 60–74 75+ Overall percentage
Cough/sneeze 97 25 53 63 33 44 46
Strain/lift 86 7 13 12 7 – 10
Urge 78 31 29 28 50 56 33
Giggle 90 29 25 24 13 19 24
No warning 94 6 5 6 3 6 5
Postmicturition 37 26 24 18 23 6 22
With UTI 78 11 12 4 7 13 9
Other 77 14 10 5 7 6 9
No./group size 72/498 97/354 78/250 30/117 16/37
Prevalence (%) 14 27 31 26 43 30
Percentage of
150 171 161 143 150 159
responses/sufferersa
a
A patient may have more than one type of incontinence.
Abbreviation: UTI, urinary tract infection.

60

Prevalence of incontinence (%)

Table 5.8 Cause of Leakage Identified by 301 Individuals
Who were “Wet Day or Night” 50

Percentage of individuals 40
Cause Male Female
30
Urinary tract infection 5 13
Hysterectomy – 7 20
Childbirth/pregnancy – 31
Menopause – 5 10
Prostatectomy 5 –
Other operation 4 2 0
n = 220 n = 41 n = 135 n = 97 n = 55
Miscellaneous 13 32
Nil 1 2 3 4
No cause identified 69 32
Number of children
Figure 5.2 Relationship between incontinence and number of children.

hysterectomy and other pelvic surgery has been observed in

other studies by Foldspang et al. (11) and Parys et al. (12). trimester of the most recent pregnancy, whereas, for 20%,
The relationship between incontinence and number of chil- leakage had begun in a previous pregnancy, in 6% it began
dren is shown in Figure 5.2. The first child and pregnancy vir- after the birth of a previous child, and only 3% indicated that
tually doubled the prevalence of incontinence in women from they had been incontinent before any of their pregnancies.
20% to about 40%. There was no change then until the fourth For 49%, leakage was not at all bothersome, 31% found it a
child, when the prevalence rose to 56%. The effect of parity has little bothersome, 16% quite bothersome, and 4% extremely
been noted from other studies (1,2,8,13). Women from blue- bothersome.
collar families were more likely than others to blame childbirth Chi-square analysis showed four factors to be significantly
for their incontinence. associated with continence status: previous delivery mode,
A recent study of incontinence during pregnancy was parity, chronic cough, and bouts of sneezing. Women who had
reported by Chiarelli and Campbell (14). In a cross-sectional previous vaginal deliveries were 2.5 times more likely to be
descriptive study using a five-item structured interview, 336 incontinent than those who had no previous delivery or had
women were approached and 304 participated (90%): overall, only cesarean section. Those who reported previous forceps
64% reported stress UI during pregnancy; in the last month of delivery were 10 times more likely to be incontinent than those
pregnancy 57% reported stress incontinence (with or without with no prior delivery. Only 8% of the women had had their
urge incontinence); while 42% had urge incontinence (with or pelvic floor muscles tested during their pregnancy (14).
without stress incontinence). Among the 195 women experi-
encing incontinence, 25% lost only a few drops, 57% lost suf- risk factors influencing incontinence
ficient to dampen the underwear or pad, and 18% reported An analysis of potential risk factors was undertaken. The
severe loss. The leakage had started during the first trimester groups found to be associated with higher rates of inconti-
in 8%, in 18% in the second trimester, and in 47% in the last nence are shown in Table 5.9.

30
Other documents randomly have
different content
 I did not resent this; I only suffered. I suffered the more because
of supposing that she suffered too. And yet when I next saw her I
found nothing to support that theory.
When I went to New York for a few days in February I called, but
they were not at home. Having left my card, I waited for a message
that would name an hour when I should find them; but I waited in
vain. During the four days my visit lasted I heard nothing kindlier
than what Cantyre repeated, that they were sorry to have been out
when I came.
As I sent them flowers before leaving the city, a note from Mrs.
Barry thanked me for them cordially; but there was not a syllable in
it that gave me an excuse for writing in response. Reason told me
that it was better that it should be so, but reason had ceased to be
sufficient as a guide.
In March I made an errand that took me to town for a week-end,
and on the Sunday afternoon I called again at the house which had
so curiously become the focusing-point of my destiny. Miss Barry
was at home and receiving. I found her with two or three other
people, and she welcomed me as doubtless she had welcomed
them. Even when I had outstayed them she betrayed none of that
matter-of-course intimacy which had marked her attitude toward me
in December. She seemed to have retired behind all sorts of mental
fortifications over which I couldn’t at first make my way.
When we were seated in the style of Darby and Joan at the
opposite corners of a slumbering fire she told me her father had
made one hurried visit from California, and that, now that he had
returned to the Pacific coast, she and her mother were thinking of
joining him there. Should they do so, they would probably remain till
it was time to go to Long Island in June. Two or three protestations
against this absence came to my lips, but of course I couldn’t utter
them.
I could have sworn that she was saying to herself, “You don’t
seem to care!” though aloud it became, “We’ve never been in
California, and we want to see what it’s like.”
I seized the opportunity to rejoin, “You’ve a fancy for seeing what
things are like, haven’t you?”
She took up the challenge instantly. “Why do you say that?”
“Only because of what you’ve said at different times yourself.”
“Such as?”
“I don’t want to quote. I was thinking of the taste you’ve
frequently acknowledged for making experiments.”
“Experiments in things—or people?”
“I was thinking of people.”
She marched right into my camp by saying, boldly, “Oh, you mean
the number of times I’ve—I’ve broken engagements?”
“Perhaps I mean rather the number of times you’ve formed them.”
“Did you ever buy a house?”
I replied with some wonder that I had not.
“Well, we’ve bought two—this one and the one at Rosyth. But
before buying either we rented each for a season to see whether or
not we liked it.”
“And you did.”
“But we’ve rented others which we didn’t. So you see.”
“I see that experiments are justified. Is that what you mean?”
“If one is satisfied with anything that comes along, by all means
take it. But if one only wants what one wants—”
“And you know what you want?”
Her eyes were all fire; her lips had the daring scarlet of a poppy.
“I’ve never got beyond knowing what I don’t want.”
 “That is, you’ve never taken anything up except in the long run to
throw it down?”
“Your expressions are too harsh. One doesn’t throw down
everything one doesn’t want. One sets it aside.”
“And would it be discreet to ask why you—why you set certain
things—and people—aside?”
She looked at the fire as if considering.
“Do you mean—men?”
“To narrow the inquiry down, suppose I say I do.”
“And”—she threw me a swift, daring glance—“and marriage?”
“That defines the question still further.”
Her words came as the utterance of long, long thoughts.
“One couldn’t marry a man one didn’t trust.”
“No; of course not.”
“Nor a milksop.”
“You couldn’t.”
“Nor a man who wasn’t a thoroughbred.”
“Just what do you mean by that?”
“Oh, don’t you know? If not I can’t explain. All I can say is that
there are things a thoroughbred couldn’t do.”
“What sort of things?”
“Why should you want me to tell you? You know as well as I do.
The things that make a man impossible—mean things—ignoble
things.”
“Criminal things?”
“Criminal things, too, I suppose. I don’t know so much about
them; but I do see a lot of meanness and pettiness and— Oh, well,
the sort of lack of the fastidious in honor that—that puts a man out
of the question.”
“Aren’t you very hard to please?”
“Possibly.”
“And if you don’t find what—what you’re looking for?”
“I shall do without it, I suppose.”
“And if you think you find it—and then discover that, after all—”
She shrugged her shoulders.
“I don’t know. I’ve never been absolutely disillusioned so far.
When disillusion has come to me—as it has—I could see it on the
way. But if I—I cared for some one and found I was deceived in him
— But what’s the use in talking of it?” she laughed. “Please don’t
think I’m putting forth a claim to be treated better than the average.
It’s only when I see the average—”
“The average of men?”
“No, the average of women. When I see what they’re willing to
take—and marry—and live with—I can only say that I find myself
very well off as I am.”
This conversation did not make it easier for me to go back to the
starting-point of our acquaintance; but the moment came when I did
it.
 CHAPTER XVI
I did not, however, do it that spring, since the event that
compelled me at last to the step took up all my attention.
It was toward the end of April that I received a telegram signed by
my sister’s name:
“Mother seriously ill. Wants to see you. Come at once.”
In spite of my alarm at this summons I saw the opportunity of
putting up a good front before my relatives. Taking Lovey with me as
valet, and stopping at the best hotel, I presented the appearance of
a successful man.
Though anxiety on my mother’s account made my return a matter
of secondary interest, I could see the surprise and relief my
apparent prosperity created. My brothers had been expecting one of
whom they would have to be ashamed. Furthermore, they had not
been too confident as to my attitude with regard to my father’s will.
Looking for me to contest it, they had suspected that behind my
acquiescence lay a ruse. When they saw that there was none, that I
made no complaint, that I seemed to have plenty of money, that I
traveled with a servant, that I had the air of a man of means—a
curious note of wonder and respect stole into their manner toward
me. I know that in private they were saying to each other that they
couldn’t make me out; and I gave them no help in doing so.
I gave them no help during all the month I remained in Montreal.
I arranged with Coningsby to take that time, and my little stock of
savings was sufficient to finance me. Though I was once more
putting up a bluff, it was a bluff that I felt to be justified; and in the
end it found its justification.
I have no intention of giving you the details of those four weeks of
watching beside a bed where the end was apparent from the first.
Now that I look back upon them, I can see that they were not
without their element of happiness, since to my mother at least it
was happiness to know that I was beside her. The joy in heaven over
one sinner that repenteth was on her face from the day I appeared,
and never left it up to that moment when we took our last look at
her dear smiling features.
When the lawyer came to read us her will I found, to my
amazement, that she had left me everything she possessed.
It was then that I reaped that which I had sown at Andy
Christian’s suggestion. Since with a good grace I had accepted my
father’s will, the rest of the family could hardly do otherwise with
regard to my mother’s. She left a note saying that, had my father
lived a few months longer, he would have seen that I had re-
established myself sufficiently to be allowed to share equally with
the rest of the family in what he had to leave; but, as it was too late
for that, she was endeavoring to right the seeming injustice—which
he had not meant as an injustice—as far as lay in her power. These
words from her pen being much more emphatic than any I could
remember from her lips, my brothers and sisters, whatever they felt
inwardly, could only give their assent to them.
What my mother possessed included not only the personal estate
she had inherited from her father, considerably augmented by her
husband’s careful management, but books, furniture, and jewelry.
The books and furniture I made over to my sister to remain in the
two houses, the one in Montreal, the other on the Ottawa. Some of
the jewelry I gave to her, to my sister in England, and to my two
sisters-in-law, though keeping the bulk for my wife—when I got one.
For I was now in a position to marry. Though my mother had had
no great wealth, what she left me, together with the trust fund
established by my father and what I earned, would assure me
enough to live in at least as much comfort as Ralph Coningsby. I
could, therefore, propose to Regina Barry and feel I could make a
home for her.
 I had again come to the conclusion that if I asked her she would
accept me. I make no attempt to analyze this feeling on her part,
because I saw plainly enough that it was founded on mistake. That
is to say, having developed an ideal of the man whom she could
marry, she had nursed herself into the belief that I came up to it,
when, as a matter of fact, I did not.
Now I had seen enough of husbands and wives to know that in
most marriages there is some such illusion as this, and that it can be
successfully maintained for years. When the illusion itself has faded
it can live on as the illusion of an illusion. By the time there is no
illusion or shadow of illusion left at all it has ceased in the majority
of cases to matter. Time has welded what mutual distaste might
have put asunder, and the married state remains undisturbed.
I was, therefore, obliged to face the consideration that if I married
the woman I loved she would probably never discover what I felt it
my duty to confess. Was it really, then, my duty to confess it? Since
no one knew it but myself, was it not rather my duty to keep it
concealed? Other men had secrets from their wives—especially those
that concerned the days when they were unmarried—and all were
probably the happier for the secrecy. Even Ralph Coningsby, who
was the most model husband I could think of, had said that if he
were to tell his wife all he could tell her about himself he would be
ashamed to go home. There were weeks when I debated these
questions every day and night, arriving at one conclusion by what I
may call my rough horse sense, and at another by my instinct. Horse
sense said, “Marry her and keep mum.” Instinct warned, “You can
never marry her and be safe and happy with such a secret as this to
come between you.”
Throughout this wavering of opinion I knew that when the time
came I should act from instinct. It wasn’t merely that I wanted to be
safe; it was also that, all pros and cons apart, there was such a thing
as honor. Not even to be happy—not even to make the woman I
cared for happy—could I ignore that.
 I am not sure how much Andrew Christian understood of the
circumstances when, without giving him the facts or mentioning a
name, I asked his advice. He only said:
“You’ve had some experience, Frank, of the potency of love,
haven’t you? Well, love has a twin sister—truth. In love and truth
together there’s a power which, if we have the patience to wait for
its working out, will solve all difficulties and meet all needs.”
My experiences during the past few months having given me some
reason to believe this, I decided, so far as I came actively to a
decision, to let it rule my course; but in the end the critical moment
came by what you would probably call an accident.
It was the last Sunday in June. My work in Atlantic City being over,
Mrs. Grace had asked me to come down for the week-end to her
little place in Long Island. It was not exactly a party, though there
were two or three other people staying in the house. My chief
reason for accepting the invitation—as I think it was the chief reason
for its being given—was that the Barry family were in residence on
the old Hornblower estate, which was the adjoining property.
As a matter of fact, Mrs. Grace and her guests were all asked to
Idlewild, as the late Mrs. Hornblower had named her house, to
Sunday lunch.
The path from the one dwelling to the other was down the gentle
slope of Mrs. Grace’s gardens, across a meadow, at the other side of
which it joined the Idlewild avenue, and then up a steep hill to the
rambling red-and-yellow house. Here one dominated the Sound for a
great part of the hundred and twenty miles between Montauk Point
and Brooklyn.
Sauntering idly through the hot summer noon, I found myself
beside Mrs. Grace, while the rest of the party straggled on ahead. As
my hostess was not more free than other women from the match-
making instinct, it was natural that she should give to the
conversation a turn that she knew would not be distasteful to me.
 “She’s a wonderful girl,” she observed, “with just that danger to
threaten her that comes from being over-fastidious.”
“I know what you mean by her being over-fastidious; but why is it
a danger?”
“In the first place, because people misunderstand her. They’ve
ascribed to light-mindedness what has only been the thing that
literary people call the divine searching for perfection.”
“And do you know the kind of thing she’d consider perfect?”
It was so stupid a question that I couldn’t be surprised to see a
gleam of quiet mischief in her glance as she replied, “From little
hints she’s dropped to me, quite confidentially, I rather think I do.”
Fair men blush easily, but I tried to ignore the fact that I was
doing it as I said, “That’s quite a common delusion at one stage of
the game; but suppose she were to find that she was mistaken?”
The answer shelved the question, though she did it
disconcertingly: “Oh, well, in the case she’s thinking of I don’t
believe she will.”
I was so eager for data that I pushed the inquiry indiscreetly.
“What makes you so sure?”
“One can tell. It isn’t a thing one can put into words. You know by
a kind of intuition.”
“Know what?”
“That a certain kind of person can never have had any but a
certain kind of standard.” She gave me another of those quietly
mischievous glances. “I’ll tell you what she said to me one day not
long ago. She said she’d only known one man in her life—known him
well, that is—of whom she was sure that he was a thoroughbred to
the core.”
“But you admitted at the beginning that that kind of conviction is a
danger.”
 “It would be a danger if her friends couldn’t bear her out in
believing it to be justified.”
Unable to face any more of this subtle flattery, I was obliged to let
the subject drop.
The lunch was like any other lunch. As an unimportant person at a
gathering where every one knew every one else more or less
intimately, I was to some extent at liberty to follow my own
thoughts, which were not altogether happy ones. For telling what I
had to tell, the necessity had grown urgent. What was lacking, what
had always seemed to be lacking, was the positive opportunity. This
I resolved to seek; but suddenly I found it before me.
This was toward the middle of the afternoon, when the party had
broken up. It had broken up imperceptibly by dissolving into groups
that strolled about the lawns and descended the long flights of steps
leading to the beach below. As I had not been seated near Miss
Barry at table, it was no more than civil for me to approach her
when the party was on the veranda and the lawn. Our right to
privacy was recognized at once by a withdrawal of the rest of the
company. It was probably assumed that I was to be the fourth in the
series of experiments of which Jim Hunter and Stephen Cantyre had
been the second and the third; and, though my fellow-guests might
be sorry for me, they would not intervene to protect me.
Considering it sufficient to make their adieux to Mrs. Barry, they
left us undisturbed in a nook of one of the verandas. Here we were
out of sight of any of the avenues and pathways to the house, and
Mrs. Barry was sufficiently in sympathy with our desire to be alone
not to send any one in search of us. On the lawn robins were
hopping, and along the edge of shorn grass the last foxgloves made
upright lines of color against the olive-green scrub-oak. Far down
through the trees one caught the silvery glinting of water.
The sounds of voices and motor wheels having died away, Miss
Barry said, languidly: “I think they must be all gone. They’ll say I’m
terribly rude to keep myself out of sight. But it’s lovely here, isn’t it?
And this is such a cozy spot in which to smoke and have coffee. I
read here, too, and— Oh, dear, what’s happening?”
It was then that the little accident which was to play so large a
part in my life occurred. She had leaned forward from her wicker
chair to set her empty coffee-cup on the table. As she did so the
string of pearls which she wore at the opening of her simple white
dress loosened itself and slipped like a tiny snake to the floor of the
veranda. From a corresponding chair on the other side of the table I
sprang up and stooped. When I raised myself with the pearls in my
right hand I slipped them into my pocket.
Between the fingers of my left hand I held a lighted cigar.
Bareheaded, I was wearing white flannels and tennis shoes. Now
that the moment had come, I felt extraordinarily cool—as cool as on
the night when I had slipped this string of pearls into my pocket
before. I looked down and smiled at her. Leaning back in her chair,
she looked up and smiled at me.
I shall always see her like that—in white with a slash of silk of the
red of her lips somewhere about her waist, and a ribbon of the same
round her dashing Panama hat. Her feet in little brown shoes were
crossed. With an elbow on the arm of her chair, she held a small red
fan out from her person, though she wasn’t actively using it.
“What does that mean?” she asked, idly, at last.
 “Didn’t you ever see any one put these pearls into his pocket
before?”

“Doesn’t it remind you of anything?”

“No—of nothing.”
“Didn’t you ever see any one put these pearls into his pocket
before?”
 “Why, no!” She added, as if an idea had begun to dawn in the
back of her memory, “Not in that way.”
“Oh, I remember. You didn’t see him put them in at all. You only
saw him take them out.”
The smile remained on her features, but something puzzled gave
it faint new curves.
“Why—”
“It was like this, wasn’t it?”
I drew out the pearls and threw them on the table.
She bent forward slightly, still smiling, like a person watching with
bewildered intensity a conjurer’s trick.
“Why—”
“Only your gold-mesh purse was with them—and your diamond
bar-pin—and your rings.”
“Why—who, who on earth could have told you?”
I, too, continued to smile, consciously wondering if I should be as
calm as this in the hour of death.
“Who do you think?”
“It wasn’t Elsie Coningsby?”
“No. She was in the house, but—”
“How did you know that?” She uttered a mystified laugh. “She was
there! It was one of the nights she stayed with me when papa and
mamma were down here superintending some changes before we
could move in. But I never told her anything about it.”
“Why didn’t you—when she was right on the spot?”
“Oh, because.”
The smile disappeared. She stopped looking up at me to turn her
eyes toward the foxgloves and scrub-oak.
 “Yes? Because—what?”
“Because I promised—that man—I wouldn’t.”
“Why should you have made him such a promise?”
“Oh, I don’t know. Just at the time I was—I was sorry for him.”
“And aren’t you sorry for him still?”
She looked up at me again with one of her bright challenges.
“Look here! Do you know him?”
“Tell me first what I asked you. Aren’t you sorry for him still?”
“I dare say I am. I don’t know.”
“What did you—what did you—think of him at the time?”
“I thought he was—terrible.”
“Terrible—in what way?”
“I don’t know that I can tell you in what way. It was so awful to
think that a man who had had some advantages should have sunk to
that. If he’d been a real burglar—I mean a professional criminal—I
should have been afraid of him; but I shouldn’t have had that
sensation of something meant for better things that had been
debased.”
“Didn’t he tell you he was hungry?”
The smile came back—faintly.
“You seem to know all about it, don’t you? It’s the strangest thing
I ever knew. No one in this world could have told you but himself.
Yes, he did say he was hungry; but then, a man who’d been what he
must have been shouldn’t have got into that condition. He’d stolen
into our pantry, poor creature, and drunk the cooking-wine. He told
me that—” Without rising, her figure became alert with a new
impulse. “Oh, I see! You do know him. He was an Englishman. I
remember that.”
I placed myself fully before her. “No, he wasn’t an Englishman.”
 “He spoke like one.”
“So do I, for the matter of that.”
“Then he was a Canadian. Was he?”
“He was a Canadian.”
“Oh, then that accounts for it. But you did puzzle me at first. But
how did you come to meet him? Was it at that Down and Out Club
that papa and Mr. Christian are so interested in? You go to it, too,
don’t you? I think Stephen Cantyre said you did.”
“Yes, I go to it, too.”
She grew pensive, resting her chin on a hand, with her elbow on
the arm of the chair.
“I suppose it’s all right; but I never can understand how men can
be so merciful to one other’s vices. It looks as if they recognized the
seed of them within themselves.”
“Probably that’s the reason.”
“Women don’t feel like that about one another.”
“They haven’t the same cause.”
“I hope he’s doing better—that man—and picking up again.”
“He is.”
She asked, in quite another tone, “You’re not going back to New
York to-morrow, are you?”
“I’m not sure—yet.”
“Hilda said she was going to try to persuade you and the Grahams
to stay till Tuesday. If you can stay, mamma and I were planning—”
I put myself directly in front of her, no more than a few feet away,
my hands in the pockets of my jacket.
“Look at me again. Look at me well. Try to recall—”
 Slowly, very slowly, she struggled to her feet. The color went out
of her lips and the light from her eyes as she backed away from me
in a kind of terror.
“What—what—are you trying to make me—to make me
understand?”
“Think! How should I know all that I’ve been saying if—”
“If the man himself didn’t tell you. But he did.”
“No, he didn’t. No one had to tell me.”
She reached the veranda rail, which she clutched with one hand,
while the other, clenched, was pressed against her breast.
“You don’t mean—”
“Yes, I do mean—”
“Oh, you can’t?”
“Why can’t I.”
“Because—because it isn’t—it isn’t possible! You”—she seemed to
be shivering—“you could never have—”
“But I did.”
She gasped brokenly. “You? You?”
I nodded. “Yes—I.”
I tried to tell her, but I suppose I did it badly. Put into a few bald
words the tale was not merely sordid, it was low. I could give it no
softening touch, no saving grace. It was more beastly than I had
ever imagined it.
Fortunately she didn’t listen with attention. The means were
indifferent to her when she knew the end. For the minute, at any
rate, she saw me not as I stood there, clean and in white, but as I
had been a year before, dirty and in rags. But she saw more than
that. With every word I uttered she saw the ideal she had formed
broken into shivers, like a shattered looking-glass.
 She interrupted my preposterous story to gasp, “I can’t believe it!”
“But it’s true.”
“Then you mustn’t mind if—if I put you to a test. Did you—did you
write anything while you were there?”
“I printed something—in the same kind of letters you’ve seen at
the bottom of architects’ plans.”
“And how did you come to do it?”
I recounted the circumstance, at which she nodded her head in
verification.
“So that was how you knew the words you repeated to me a few
months ago?”
“That was how. I said there were men in the world different from
any you’d seen yet; and I told you to wait.”
She made a tremendous effort to become again the daring
mistress of herself which she generally was. She smiled, too,
nervously, and with a kind of sickening, ghastly whiteness.
“Funny, isn’t it? There are men in the world different from any I’d
seen before that time. I’ve—I’ve waited—and found out.”
Before I could utter a rejoinder to this she said, quite courteously,
“Will you excuse me?”
I bowed.
With no further explanation she marched down the length of the
veranda—carrying herself proudly, placing her dainty feet daintily,
walking with that care which people show when they are not certain
of their ability to walk straight—and entered the house.
I didn’t know why she had gone; but I knew the worst was over.
Though I felt humiliation to the core of the heart’s core, I also felt
relief.
With a foot dangling, I sat sidewise on the veranda rail and
waited. Glancing at my watch, I saw it was not yet four, and I had
lived through years since I had climbed the hill at one. My
sensations were comparable only to those of the man who has been
on trial for his life and is waiting for the verdict.
I waited nervously, and yet humbly. Now that it was all over, it
seemed to me that the bitterness of death was past. Whatever else I
should have to go through in life, nothing could equal the past
quarter of an hour.
The sensations I hadn’t had while making my confession began to
come to me by degrees. Looking back over the chasm I had crossed,
I was amazed to think I had had the nerve for it. I trembled
reminiscently; the cold sweat broke out on my forehead. It was
terrible to think that at that very minute she was in there weighing
the evidence, against me and in my favor.
Mechanically I relighted the cigar that had gone out. Against me
and in my favor! I was not blind to the fact that in my favor there
was something. I had gone down, but I had also struggled up again;
and you can make an appeal for the man who has done that.
She was long in coming back. I glanced at my watch, and it was
nearly half past four. Her weighing of the evidence had taken her
half an hour, and it was evidently not over yet. Well, juries were
often slow in coming to a verdict; and doubtless she was balancing
the extenuating circumstance that I had struggled up against the
main fact that I had gone down.
What she considered her ideal had during the past few weeks
been gradually transferring itself from her mind to my own. She
wouldn’t marry a man she couldn’t trust; she wouldn’t marry a man
who hadn’t what she called spirit; she wouldn’t marry a milksop. But
she had well-defined—and yet indefinable—conceptions as to how
far in spirit a man should go, and of the difference between being a
milksop and a man of honor. She might find it hard to admit that the
pendulum of human impulse that swung far in one direction might
swing equally far in the other; and therein would lie my danger.
 But I must soon know. It was ten minutes of five. The jury had
been out more than three-quarters of an hour.
A new quality was being transmuted into the atmosphere. It was
as if the lightest, flimsiest veil had been flung across the sun. In the
distant glinting of the sea, which had been silver, there came a
tremulous shade of gold. The foxgloves bowed themselves like men
at prayer. The robins betook themselves to the branches. From
unseen depths of the scrub-oak there was an occasional luscious
trill, as the time for the singing of birds wasn’t over yet.
Round me there was silence. I might have been sitting at the door
of an empty house. I listened intently for the sound of returning
footsteps, but none came.
At a quarter past five a chill about the heart began to strike me. I
had been waiting more than an hour. Could it be possible that...?
It would be the last degree of insult. Whatever she did, she
wouldn’t subject me to that. It would be worse than her glove across
the face. It was out of the question. I couldn’t bear to think of it.
Rather than think of it, I went over the probabilities that she would
come back with the smile of forgiveness. It would doubtless be a
tearful smile, for tears were surely the cause of her delay. When she
had controlled them, when she was able to speak and bid me be of
good comfort, I should hear the tap of her high heels coming down
the uncarpeted stairway. No red Indian ever listened for the tread of
a maid’s moccasins on forest moss so intently as I for that staccato
click.
But only the birds rewarded me, and the cries of boys who had
come to bathe on the beach below. There was more gold in the
light; more trilling in the branches; a more pungent scent from the
trees, the flowers, and the grass; and that was all.
It was half past five; it was a quarter to six; it was six.
At six o’clock I knew.
My hat was lying on a chair near by. I picked it up—and went.
 I went, not by the avenue and the path, but down the queer,
rickety flights of steps that led from one jutting rock to another over
the face of the cliff, till I reached the beach. It was a broad, whitish,
sandy beach, with a quietly lapping tide almost at the full. Full tide
was marked a few feet farther up by a long, wavy line of seaweed
and other jetsam.
It was the delicious hour for bathing. As far as one could see in
either direction there were heads bobbing in the water and people
scrambling in and out. Shrill cries of women and children, hoarse
shouts of men, mingled with the piping of birds overhead. Farther
out than the bathers there were rowboats, and beyond the rowboats
sails. In the middle of the Sound a steamer or two trailed a lazy flag
of smoke. Far, far to the south and the west a haze like that round a
volcano hung over New York. I should return there next day to face
new conditions. I only wished to God that it could be that night.
The new conditions were, briefly, three: I could use the revolver
still lying in my desk; or I could begin to drink again; or, like the bull
wounded in the ring, I could seek shelter in the dumb sympathy of
the Down and Out.
The last seemed to me the least attractive. I had climbed that hill,
and found it led only to a precipice that I had fallen over.
Neither did the first possibility charm me especially. Apart from the
horror of it, it was too brief, too sudden, too conclusive. I wanted
the gradual, the prolonged.
It was the second course to which my mind turned with the
nearest approach to satisfaction. Christian had told me that some of
my severest tussles lay ahead; and now I had come to the one in
which I should go under. In that the flesh at least would get its hour
of compensation, when all was said and done.
At the foot of Mrs. Grace’s steps I paused to recall Christian’s
words of a few days previously:
“In love and truth together there’s a power which, if we have the
patience to wait for its working out, will solve all difficulties and
meet all needs.”
I had tried that—love and truth together!—and at the result I
could only laugh.
My immediate fear was lest Mrs. Grace and the Grahams would be
on the veranda, vaguely expecting to offer me their congratulations.
When half-way up the steps I heard voices and knew that they were
there. So be it! I had faced worse things in my life; and now I could
face that.
But as I advanced up the lawn I saw them moving about and
talking with animation. As soon as Mrs. Grace caught sight of me
she hurried down the steps, meeting me as I passed among the
flower-beds. She held a newspaper marked Extra in her hand, and
seemed to have forgotten that I had love-affairs.
“Have you seen this? Colt, the chauffeur, was at the station and
brought it back. It’s just come down from New York.”
Glad of anything that would distract attention from myself, I took
the paper in my hand and pretended to be reading it. All I got was
the vague information that some one had been assassinated—some
man and his morganatic wife. What did it matter to me? What did it
matter to any one? Of all that was printed there, only five syllables
took possession of my memory—and that because they were
meaningless, “Gavrilo Prinzip!”
I was repeating them to myself as I handed the paper back, and
we exchanged comments of which I have no recollection. More
comments were passed with the Grahams, and then, blindly,
drunkenly, I made my way to my room.
There I found nothing to do less classic than to sit at the open
window, to look over at the red-and-yellow house on the opposite
hill. It was my intention to think the matter out, but my brain
seemed to have stopped working. Nothing came to me but those
barbaric sounds, that kept repeating themselves with a kind of hiss:
“Gavrilo Prinzip! Gavrilo Prinzip!”
 From my stupefied scanning of the paper I hadn’t grasped the fact
that a name utterly unknown that morning was being flashed round
the world at a speed more rapid than that of the earth round the
sun. Still less did I suspect that it was to become in its way the most
sinister name in history. I kept repeating it only as you repeat
senseless things in the minutes before you go to sleep.
“Gavrilo Prinzip! Gavrilo Prinzip! Gavrilo Prinzip!”
 CHAPTER XVII
I came back as Major Melbury, of one of the Canadian regiments.
It was in November, 1916, that I was invalided home to Canada,
lamed and wearing a disfiguring black patch over what had been my
left eye.
There were other differences of which I can hardly tell you in so
many words, but which must transpire as I go on. Briefly, they
summed themselves up in the fact that I had gone away one man
and I was coming back another. My old self had not only been
melted down in the crucible, but it had been stamped with a new
image and superscription. It was of a new value and a new currency,
and, I think I may venture to add, of that new coinage minted in the
civil strife of mankind.
The day of my sailing from Liverpool was exactly two years four
months and three weeks from that on which I had last seen Regina
Barry; and because it was so I must tell you at once of an incident
that occurred at the minute when I stepped on board.
Having come up the long gangway easily enough, I found that at
the top, where passengers and their friends congregate, my
difficulties began.
When my left eye had been shot out the right had suffered in
sympathy, and also from shock to the retina. For a while I had been
blind. Rest and care in the hospital my sister, Mabel Rideover,
maintained at Taplow had, however, restored the sight of my right
eye; and now my trouble was only with perspective. People and
things crowded on one another as they do in the vision of a baby. I
would dodge that which was far away, and allow myself to bump
into objects quite near me.
 As I stepped on deck I had a minute or two of bewilderment.
There were so many men more helpless than I that whatever care
there was to give was naturally bestowed on them. Moreover, most
of those who thronged the top of the gangway had too many
anxieties of their own to notice that a man who at worst was only
half blind didn’t know which way to turn.
But I did turn—at a venture. The venture took me straight into a
woman holding a baby in her arms, whom I crushed against the
nearest cabin wall. The woman protested; the baby screamed. I was
about, in the rebound, to crash into some other victim when I felt
from behind me a hand take me by the arm. An almost invisible
guide began to pilot me through the crowd. All I caught sight of was
a Canadian nurse’s uniform.
It is one of the results of the war that men, who are often reduced
to the mere shreds of human nature, grow accustomed to being
taken care of by women, who remain the able-bodied ones.
“Thanks,” I laughed, as the light touch pushed me along, slightly
in advance. “You caught me right in the nick of time. I can see
pretty well with my good eye, only I can’t measure distances. They
tell me that will come by degrees.”
Even though occupied with other thoughts, I was surprised that
my rescuer didn’t respond to my civility, for another result of the war
is the ease with which the men and women who have been engaged
in it get on terms of natural acquaintanceship. When artificial
barriers are removed, it is extraordinary how quickly we go back to
primitive human simplicity. Social and sex considerations have thus
been minimized to a degree which, it seems to me, will make it
difficult ever to re-establish them in their old first place. They say it
was an advance in civilization when we ceased to see each other as
primarily males and females and knew we were men and women.
Possibly the war will lead us a step farther still and reveal us as
children of one family.
 That a nurse shouldn’t have a friendly word for a partly
incapacitated man struck me, therefore, as odd, though my mind
would not have dwelt on the circumstance if she hadn’t released my
arm as abruptly as she had taken it. Having helped me to reach a
comparatively empty quarter of the deck, she had counted,
apparently, on the slowness and awkwardness of my movements to
slip away before I could turn round.
When I managed this feat she was already some yards down the
length of the deck, hurrying back toward the crowd from which we
had emerged. I saw then that she was too little to be tall and too tall
to be considered little. Moreover, she carried herself proudly, placing
her dainty feet daintily, and walking with that care which people
display when they are not certain of their ability to walk straight.
Reaching one of the entrances, she went in, exactly as I had seen a
woman pass through a doorway two years four months and three
weeks before.
I was sure it was she—and yet I told myself it couldn’t be. I told
myself it couldn’t be, for the reason that I had been deceived so
frequently before that I had grown distrustful of my senses. All
through the intervening time I had been getting glimpses of a slight
figure here, of an alert movement there, of the poise of a head, of
the wave of a hand—that for an instant would make my heart stop
beating; but in the end it had meant nothing but the stirring of old
memories. In this case I could have been convinced if the
coincidence had not put too great a strain on all the probabilities.
I was to learn later that there was no coincidence; but I must tell
my story in its right order.
The right order takes me back to my return to New York, after my
week-end at Mrs. Grace’s, on the morning of June 29, 1914.
During the two or three hours of jogging down the length of Long
Island in the train I tried to keep out of my mind all thoughts but
one; having deposited my bags at my rooms, I should go to
Stinson’s.
 With regard to this intention I was clearly aware of a threefold
blend of reaction.
First, there was the pity of it. I could take a detached view of this
downfall, just as if I had heard of it in connection with Beady
Lamont or old Colonel Straight. Though I should be only a man
dropped in the ranks, while they would have been leaders, the grief
of my comrades over my collapse would be no less sincere.
But by tearing my mind away from that aspect of the case I
reverted to the satisfaction at being in the gutter, of which the
memories had never ceased to haunt me. I cannot expect to make
you, who have always lived on the upper levels, understand this
temptation; I can only tell you that for men who have once been
outside the moral law there is a recurrent tugging at the senses to
get there again. I once knew an Englishman who had lived in the
interior of Australia and had “gone black.” On his return to make his
home in England he was seized with so consuming a nostalgia for
his black wives and black children that in the end he went back to
them. Something like this was the call I was always hearing—the call
of Circe to go down.
But I knew, too, that there was method in this madness. I was
deliberately starting out to earn the wages of sin; and the wages of
sin would be death. I must repeat that going to Stinson’s would be
no more than a slow, convenient process of committing suicide. It
would be committing suicide in a way for which Regina Barry would
not have to feel herself responsible, as she would were I to use the
revolver. Having brought so much on her, I was unwilling to bring
more, even though my heart was hot against her.
My heart was hot against her—and yet I had to admit that she
had been within her rights. When all was said that could be said in
my favor, I had deceived her. I had let her go on for the best part of
a year believing me to be what I was not, when during much of the
time I could see that such a belief was growing perilous to her
happiness. I had been a coward. I should have said from the first
moment—the moment when she took me for my brother Jack—“I
am a crook.” Then all would have been open and aboveboard
between us; but as it was there was only one way out. Any other
way—any way that would have allowed me to go on living longer
than the time it would take drink to kill me—would have been
unbearable.
The checkmate to these musings came when my eyes fell upon
Lovey. He was at the door of the apartment, not only to welcome
me, but to give me ocular demonstration that he had kept the faith
while I had been away. It was the first time since the beginning of
our association that I had left him for forty-eight hours; and that he
was on his honor during those two days was no secret between us.
The radiant triumph of his greeting struck into me like a stab.
For Lovey now was almost as completely reconstructed as I. I use
the qualifying “almost” only because the longer standing of his
habits and the harder conditions of his life had burnt the past more
indelibly into him. Of either of us one could say, as the Florentines
are reported to have said of Dante, “There goes a man who has
been in hell”; but the marks of the experience had been laid more
brutally on my companion than on me.
Otherwise he showed cheering signs of resuscitation. Neat, even
at the worst of times, he was now habitually scrubbed and shaved,
and as elegant as Colonel Straight’s establishment could turn him
out. He had, in fact, for the hours he had free from washing
windows, metamorphosed himself into the typical, self-respecting
English valet, with a pride in his work sprung chiefly of devotion.
And for me he made a home. I mean by that that he was always
there—something living to greet me, to move about in the dingy
little apartment. As I am too gregarious, I may say too affectionate,
to live contentedly alone, it meant much to me to have some one
else within the walls I called mine, even if actual companionship was
limited.
But whatever it was, I was about to destroy it. I could scarcely
look him in the eyes; I could hardly say a word to him.
 While unpacking my suit-case he said, timorously, “Y’ain’t sick,
Slim?”
I began to change the suit I had been wearing for one that would
attract less attention at Stinson’s.
“No, Lovey; I’m all right. I’m just—I’m just going out.”
And I went out. I went out without bidding the poor old fellow
good-by, though I knew it was the last the anxious pale-blue eyes
would see of me in that phase of comradeship. When next we met I
should probably be drunk, and he would have come to get drunk in
my company. It would then be a question as to which of us would
hold out the longer.
And that was the thought that after an hour or two turned me
back. I could throw my own life away, but I couldn’t throw away his.
However reckless I might be on my own account, I couldn’t be so
when I held another man’s fate in my hand.
Even so, I didn’t go back at once. Half-way to Stinson’s—I was on
foot—I came to a sudden halt. It was as if the sense of responsibility
toward Lovey wouldn’t allow me to go any farther. I said to myself
that I must think the matter out—that I must find and would find
additional justification for my course before going on.
To do that I turned into a chance hotel.
I like the wide hospitality of American hotels, where any tired or
lonesome wayfarer can enter and sit down. I have never been a
clubman. Clubs are too elective and selective for my affinities; they
are too threshed and winnowed and refined. I have never in spirit
had any desire to belong to a chosen few, since not only in heart,
but in tastes and temperament, I belong to the unchosen many. I
enjoy, therefore, the freedom and promiscuity of the lobby, where
every Tom, Dick, and Harry has the same right as I.
Annoyed by the fact that a halt had been called in my errand of
self-destruction, I began to ask myself why. The only answer that
came to me was that this old man, this old reprobate, if one chose
to call him so, cared for me. He had been giving me an affection that
prompted him to the most vital sacrifice, to the most difficult kind of
self-control.
Then suddenly that truth came back to me which Andrew Christian
had pointed out a few months earlier, and which in the mean time
had grown dim, that any true love is of God.
I was startled. I was awed. In saying these things I am trying only
to tell you what happened in my inner self; and possibly when a
man’s inner self has plumbed the depths like mine it means more to
him to get a bit of insight than it does to you who have always been
on the level. In any case this question rose within me: Was it
possible that out of this old man, this drunkard, this murderer, cast
off by his children, cast out by men, some feeble stream was welling
up toward me from that pure and holy fountain that is God? Was it
possible that this strayed creature had, through what he was giving
me—me!—been finding his way back to the universal heart? If ever
a human being had been dwelling in love he had been dwelling in it
for a year and more; and there were the words, distilled out of the
consciousness of the ages, and written for all time, “He that dwelleth
in love dwelleth in God.” Was it God that this poor, purblind old
fellow had all unconsciously been bringing me, shedding round us,
keeping us straight, making us strong, making us prosperous,
helping us to fight our way upward?
I went back.
But on the way I had another prompting—one that took me into
the office of a tourist company to consult time-tables and buy
tickets.
“Lovey,” I said, when I got home, “we must both begin packing for
all we’re worth. We’re leaving for Montreal to-night.”
“Goin’ to see your people, Slim, and stay in that swell hotel?”
“Not just now, Lovey. Later, perhaps. First of all we’re going for a
month into the woods north of the Ottawa.”
 His jaw dropped. “Into the woods?”
“Yes, old sport. You’ll like it.”
“Oh no, I won’t, Slim. I never was in no woods in my life—except
London and New York. There’s one thing I never could abide, and
that’s trees.”
“You won’t say that when you’ve seen real trees. We’ll shoot and
fish and camp out—”
“Camp out? In a tent, like? Oh, I couldn’t, sonny! I’d ketch me
death!”
“Then if you do we’ll come back; only, we’ve got to go now.”
“Why have we? It’s awful nice here in New York; and I don’t pay
no attention to people that says it’s too hot.”
I made the appeal which I knew he would not resist. Laying my
hand on his shoulder, I said: “Because, old man, I’m—I’m in trouble.
I want to get away where—where I sha’n’t see—some one—again—
and I need you.”
“It ain’t that girl, Slim? She—she haven’t turned you down?”
The words took me so much by surprise that I hadn’t time to get
angry. All I could feel was a foolish, nervous kind of coolness.
“Lovey, what I want you to know I’ll tell you; and at present I’m
telling you this: I’ve got to get out; I’ve got to get out quick; and I
need you to buck me up. No one can buck me up like you.”
“Oh, if it’s that!” He would have followed me then to places more
dreadful than the Canadian woods. “Will you take all your suits—or
only just them new summer things?”
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