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Strategies for evaluating self-efficacy and observed success in the practice of yoga postures for therapeutic indications: methods from a yoga intervention for urinary incontinence among middle-aged and older women. BMC complementary medicine and therapies Nicosia, F. M., Lisha, N. E., Chesney, M. A., Subak, L. L., Plaut, T. M., Huang, A. 2020; 20 (1): 148
Abstract

Most clinical investigations involving yoga lack adequate description of the specific yoga elements, including physical postures. Few studies have measured self-efficacy regarding the performance of yoga postures or assessed observed success in performing postures.We developed and piloted several tools to evaluate self-efficacy and observed success in practicing yoga in the context of a randomized feasibility trial of an Iyengar-based yoga intervention for urinary incontinence in ambulatory women ?50?years. At the end of the 12-week yoga intervention involving twice weekly group yoga classes and once weekly home practice, participants rated their self-efficacy in performing each of the included 15 yoga postures on a 5-point Likert scale. During the 12th week, an expert yoga consultant observed participants and rated their competency in performing postures on a 5-point scale. Participants completed a questionnaire about self-efficacy in adhering to home yoga practice. We examined the distribution of and correlations between scores on the above measures.Among 27 participants (mean age 65?years), the range of means for self-efficacy ratings for individual postures was 3.6 to 4.5. The range of means for observed competency ratings for individual postures was 3.3 to 5.0. Mean self-efficacy rating for confidence in adhering to the assigned once-weekly home yoga practice was 2.8 (range 1 to 5). Posture self-efficacy was inversely correlated with participant age (p?=?0.01) and positively correlated with self-reported physical function (p?=?0.03) and mobility (p?=?0.01). No significant correlations were found between posture self-efficacy scale scores and expert-observed yoga competency ratings or practice adherence self-efficacy scores.These measures hold promise for advancing yoga research and practice by describing methods to: 1) measure self-efficacy in performing specific yoga postures; 2) use an expert observer to assess participants' competence in performing yoga postures; and 3) measure self-efficacy in adhering to home practice. These proposed measures can be used to describe specific components of yoga interventions, to assess whether study participants are able to learn to practice physical aspects of yoga and/or maintain this practice over time, as well as to investigate relationships between self-efficacy and competency in performing yoga postures to achieve specific health outcomes.ClinicalTrials.gov, NCT02342678, January 21, 2015.

View details for DOI 10.1186/s12906-020-02934-3

View details for PubMedID 32408868
A Randomized Controlled Trial of Device Guided, Slow-Paced Respiration in Women with Overactive Bladder Syndrome JOURNAL OF UROLOGY Huang, A. J., Grady, D., Mendes, W. B., Hernandez, C., Schembri, M., Subak, L. L. 2019; 202 (4): 787?94
View details for DOI 10.1097/JU.0000000000000328

View details for Web of Science ID 000488886100089
Changes in Sexual Functioning in Women and Men in the 5 Years After Bariatric Surgery JAMA SURGERY Steffen, K. J., King, W. C., White, G. E., Subak, L. L., Mitchell, J. E., Courcoulas, A. P., Flum, D. R., Strain, G., Sarwer, D. B., Kolotkin, R. L., Pories, W., Huang, A. J. 2019; 154 (6): 487?98
View details for DOI 10.1001/jamasurg.2018.1162

View details for Web of Science ID 000472168400008
Nocturia and sleep disruption among women with overactive bladder in a randomized trial of slow-guided respiration Savoie, M. B., Lee, K. A., Subak, L., Schembri, M., Hernandez, C., Fung, C., Huang, A. WILEY. 2019: S301
View details for Web of Science ID 000463149000873
Changes in Sexual Functioning in Women and Men in the 5 Years After Bariatric Surgery. JAMA surgery Steffen, K. J., King, W. C., White, G. E., Subak, L. L., Mitchell, J. E., Courcoulas, A. P., Flum, D. R., Strain, G., Sarwer, D. B., Kolotkin, R. L., Pories, W., Huang, A. J. 2019
Abstract

Importance: Short-term improvements in sexual functioning are reported after bariatric surgery, but to our knowledge, little is known about the durability of these improvements.Objective: To determine the percentage of adults with impairment in sexual functioning who experience durable improvements in sexual functioning after bariatric surgery and to identify factors associated with improvements.Design, Setting, and Participants: The Longitudinal Assessment of Bariatric Surgery-2 is an observational cohort study conducted at 10 hospitals in 6 US clinical centers. Adults undergoing their first bariatric procedure were recruited from 2005 through 2009, data were collected through August 2014. Data analysis was conducted from 2016 to April 2018.Interventions: Participants completed assessments before the procedure and annually thereafter for 5 years.Main Outcomes and Measures: A self-administered questionnaire was used to assess clinically meaningful differences before and after surgery in past-month sexual satisfaction, desire, and activity and physical health limitations to sexual activity among subgroups who reported sexual functioning at less than domain-specific thresholds before surgery.Results: Of 2215 participants eligible for sexual function follow-up, 2036 (91.9%) completed 1 or more follow-up assessment (1431 [64.6%] at year 5), of whom 1607 (78.9%) were women. At the presurgery assessment, median (interquartile range) age was 47 (37-55) years, and the median (interquartile range) body mass index was 45.8 (41.7-51.3). Among those who were not satisfied with their sexual life before surgery (1015 of 1456 women [69.7%]; 304 of 409 men [74.3%]), 56.0% of women (95% CI, 52.5%-59.5%) and 49.2% of men (95% CI, 42.4%-55.9%) experienced clinically meaningful improvements at year 1; these percentages did not significantly differ during further follow-up. Among those who reported physical limitations to sexual activity at baseline (892 of 1490 women [59.9%] and 267 of 406 men [65.8%]), the percentage experiencing improvement in this domain decreased during follow-up, but 73.6% (95% CI, 69.3%-78.0%) of women and 67.6% (95% CI, 59.6%-75.6%) of men continued to report improvements at year 5. Greater postsurgical reduction in depressive symptoms was independently associated with improvement in 4 domains of sexual life among women (frequency of sexual desire: adjusted relative risk [aRR] per 5-point decrease in Beck Depression Inventory score, 1.12 [95% CI, 1.07-1.18]; P<.001; frequency of sexual activity: aRR, 1.13 [95% CI, 1.08-1.18]; P<.001; the degree to which physical health limited sexual activity: aRR, 1.19 [95% CI, 1.14-1.23]; P<.001; and satisfaction with sexual life: aRR, 1.25 [95% CI, 1.19-1.31]; P<.001) and 2 domains among men (physical health limitations: aRR, 1.14 [95% CI, 1.04-1.26]; P=.008 and satisfaction with sexual life: aRR, 1.55 [95% CI, 1.33-1.81]; P<.001). Surgical procedure was not associated with improvement.Conclusions and Relevance: Per this study, approximately half of women and men who were not satisfied with their sexual life prior to bariatric surgery experienced improvements in satisfaction in 5 years of follow-up.Trial Registration: ClinicalTrials.gov Identifier: NCT00465829.

View details for PubMedID 30785625
Interpersonal Trauma as a Marker of Risk for Urinary Tract Dysfunction in Midlife and Older Women. Obstetrics and gynecology Boyd, B. A., Gibson, C. J., Van Den Eeden, S. K., McCaw, B., Subak, L. L., Thom, D., Huang, A. J. 2019
Abstract

To examine relationships between interpersonal trauma exposures and urinary symptoms in community-dwelling midlife and older women.We analyzed cross-sectional data from a multiethnic cohort of women aged 40-80 years enrolled in an integrated health care system in California. Lifetime history of intimate partner violence (IPV) and sexual assault, current posttraumatic stress disorder (PTSD) symptoms, and current urinary symptoms were assessed using structured-item questionnaires. Multivariable-adjusted logistic regression models examined associations between traumatic exposures and PTSD symptoms with any weekly urinary incontinence, stress-type incontinence, urgency-type incontinence, and nocturia two or more times per night.Of the 1,999 participants analyzed, 21.7% women reported lifetime emotional IPV, 16.2% physical IPV, 19.7% sexual assault, and 22.6% reported clinically significant PTSD symptoms. Overall, 45% reported any weekly incontinence, 23% stress-type incontinence, 23% urgency-type incontinence, and 35% nocturia. Exposure to emotional IPV was associated with any weekly incontinence (odds ratio [OR] 1.33, 95% CI 1.04-1.70), stress-type incontinence (OR 1.30, 95% CI 1.00-1.65), urgency-type incontinence (OR 1.30, 95% CI 1.00-1.70), and nocturia (OR 1.73, 95% CI 1.36-2.19). Physical IPV exposure was associated with nocturia (OR 1.35, 95% CI 1.04-1.77), but not incontinence. Sexual assault history was not associated with weekly incontinence of any type or nocturia. Symptoms of PTSD were associated with all urinary symptoms assessed, including any weekly incontinence (OR 1.46, 95% CI 1.15-1.85), stress-type incontinence (OR 1.70, 95% CI 1.32-2.20), urgency-type incontinence (OR 1.60, 95% CI 1.24-2.06), and nocturia (OR 1.95, 95% CI 1.55-2.45).More than 20% of women in this multiethnic, community-based cohort reported a history of IPV, PTSD symptoms, or both, which were associated with symptomatic urinary tract dysfunction. Findings highlight the need to provide trauma-informed care of midlife and older women presenting with urinary symptoms.

View details for DOI 10.1097/AOG.0000000000003586

View details for PubMedID 31809425
Beyond the bladder: poor sleep in women with overactive bladder syndrome. American journal of obstetrics and gynecology Savoie, M. B., Lee, K. A., Subak, L. L., Hernandez, C., Schembri, M., Fung, C. H., Grady, D., Huang, A. J. 2019
Abstract

Nocturnal bladder symptoms and sleep disruption commonly co-exist in middle-aged and older women. While sleep disruption is often attributed to nocturnal bladder symptoms in women with overactive bladder syndrome, non-bladder factors may also influence sleep in this population. Many women with overactive bladder are eager to identify non-pharmacologic strategies for both bladder symptoms and sleep disruption, given the potential adverse effects of sedative and anticholinergic bladder medications in this population.To provide greater insight into the complex relationship between nighttime overactive bladder symptoms and sleep disruption, and to evaluate the effects of a guided slow-paced respiration intervention on sleep outcomes in women with overactive bladder.We conducted an ancillary study within a randomized trial of slow-paced respiration in women with overactive bladder symptoms. Ambulatory community-dwelling women who reported ?3 episodes/day of urgency-associated voiding or incontinence were randomized to use either a portable biofeedback device (RESPeRATE, Intercure, Ltd) to practice guided slow-paced respiration exercises daily for 12 weeks (N=79) or an identical-appearing device programmed to play non-rhythmic music without guiding breathing (N=82). At baseline and after 12 weeks, bladder symptoms were assessed by voiding diary, sleep duration and disruption were assessed by sleep diary corroborated by wrist actigraphy, and poor sleep quality was determined by a Pittsburgh Sleep Quality Index global score >5.Of the 161 women randomized, 31% reported at least twice nightly nocturia, 26% nocturnal incontinence, and 70% poor sleep quality at baseline. Of the 123 reporting any nighttime awakenings, 89% averaged one or more nighttime awakenings, and 83% attributed at least half of awakenings to using the bathroom. Self-reported wake time after sleep onset increased with increasing frequency of nocturnal bladder symptoms (p = 0.01 for linear trend). However, even among women without nocturia, average sleep quality was poor (Pittsburg Sleep Quality Index global score mean of 7.3, 95% confidence interval 6.0-8.6). Over 12 weeks, women assigned to slow-paced respiration (N=79) experienced modest improvements in mean nocturnal voiding frequency (0.4 fewer voids/night), sleep quality (1.1 point score decrease), and sleep disruption (1.5% decreased wake time after sleep onset). However, similar improvements were detected in the music control group (N=81), without significant between-group differences.Many women with overactive bladder syndrome experience disrupted sleep, but not all nocturnal awakenings are attributable to bladder symptoms and average sleep quality tends to be poor even in women without nocturia. Findings suggest that clinicians should not assume that poor sleep in women with OAB is primarily caused by nocturnal bladder symptoms. Guided slow-paced respiration was associated with modest improvements in nocturia frequency and sleep quality in this trial, but results do not support clinician recommendation to use this technique over other behavioral relaxation techniques for improving sleep.

View details for DOI 10.1016/j.ajog.2019.12.005

View details for PubMedID 31836545
A group-based yoga program for urinary incontinence in ambulatory women: feasibility, tolerability, and change in incontinence frequency over 3 months in asingle-center randomized trial. American journal of obstetrics and gynecology Huang, A. J., Chesney, M., Lisha, N., Vittinghoff, E., Schembri, M., Pawlowsky, S., Hsu, A., Subak, L. 2019; 220 (1)
Abstract

BACKGROUND: Because of the limitations of existing clinical treatments for urinary incontinence, many women with incontinence are interested in complementary strategies for managing their symptoms. Yoga has been recommended as a behavioral self-management strategy for incontinence, but evidence of its feasibility, tolerability, and efficacy is lacking.OBJECTIVE: To evaluate the feasibility and tolerability of a group-based therapeutic yoga program for ambulatory middle-aged and older women with incontinence, and to examine preliminary changes in incontinence frequency as the primary efficacy outcome after 3 months.MATERIALS AND METHODS: Ambulatory women aged 50 years or older who reported at least daily stress-, urgency-, or mixed-type incontinence, were not already engaged in yoga, and were willing to temporarily forgo clinical incontinence treatments were recruited into a randomized trial in the San Francisco Bay area. Women were randomly assigned to take part in a program of twice-weekly group classes and once-weekly home practice focused on Iyengar-based yoga techniques selected by an expert yoga panel (yoga group), or a nonspecific muscle stretching and strengthening program designed to provide a rigorous time-and-attention control (control group) for 3 months. All participants also received written, evidence-based information about behavioral incontinence self-management techniques (pelvic floor exercises, bladder training) consistent with usual first-line care. Incontinence frequency and type were assessed by validated voiding diaries. Analysis of covariance models examined within- and between-group changes in incontinence frequency as the primary efficacy outcome over 3 months.RESULTS: Of the 56 women randomized (28 to yoga, 28 to control), the mean age was 65.4 (�8.1) years (range, 55-83 years), the mean baseline incontinence frequency was 3.5 (�2.0) episodes/d, and 37 women (66%) had urgency-predominant incontinence. A total of 50 women completed their assigned 3-month intervention program (89%), including 27 in the yoga and 23 in the control group (P= .19). Of those, 24 (89%) in the yoga and 20 (87%) in the control group attended at least 80% of group classes. Over 3 months, total incontinence frequency decreased by an average of 76% from baseline in the yoga and 56% in the control group (P= .07 for between-group difference). Stress incontinence frequency also decreased by an average of 61% in the yoga group and 35% in controls (P= .045 for between-group difference), but changes in urgency incontinence frequency did not differ significantly between groups. A total of 48 nonserious adverse events were reported, including 23 in the yoga and 25 in the control group, but none were directly attributable to yoga or control program practice.CONCLUSION: Findings demonstrate the feasibility of recruiting and retaining incontinent women across the aging spectrum into a therapeutic yoga program, and provide preliminary evidence of reduction in total and stress-type incontinence frequency after 3 months of yoga practice. When taught with attention to women's clinical needs, yoga may offer a potential community-based behavioral self-management strategy for incontinence to enhance clinical treatment, although future research should assess whether yoga offers unique benefits for incontinence above and beyond other physical activity-based interventions.

View details for PubMedID 30595143
More Similarities Than Differences? An Exploratory Analysis Comparing the Sexual Complaints, Sexual Experiences, and Genitourinary Health of Older Sexual Minority and Sexual Majority Adults. The Journal of Sexual Medicine Obedin-Maliver, J., LIsha, N., Breyer, B., Subak, L., Huang, A. 2019; 16 (3): 347-350
View details for DOI 10.1016/j.jsxm.2019.01.308
A Randomized Controlled Trial of Device-Guided Slow-Paced Respiration In Women with Overactive Bladder Syndrome. The Journal of urology Huang, A. J., Grady, D., Mendes, W. B., Hernandez, C., Schembri, M., Subak, L. L. 2019: 101097JU0000000000000328
Abstract

To evaluate the effects of device-guided slow-paced respiration on urgency-associated urinary symptoms, perceived stress and anxiety, and autonomic function in women with overactive bladder syndrome.We conducted a randomized, parallel-group trial of slow-paced respiration to improve perceived stress and autonomic dysfunction as potential contributors to overactive bladder. Ambulatory women reporting at least 3 voiding or incontinence episodes per day associated with moderate-to-severe urgency were randomized to use a portable biofeedback device to practice daily slow-guided breathing exercises or use an identical-appearing control device reprogrammed to play music without guiding breathing. Over 12 weeks, changes in urinary symptoms were evaluated by voiding diaries, perceived stress and anxiety were assessed by validated questionnaires, and autonomic function was examined using heart rate variability and impedance cardiography.Among the 161 participants randomized (82 to paced respiration, 79 to control), the average baseline frequency of voiding or incontinence associated with moderate-to-severe urgency was 6.9 (�3.4) episodes/day. Compared to controls, participants randomized to paced respiration demonstrated greater improvements in perceived stress (average decrease in Perceived Stress Scale score of 2.8 versus 1.1, P=.03), but not autonomic function markers. Over 12 weeks, the average frequency of voiding or incontinence associated with moderate-to-severe urgency (primary outcome) decreased by 0.9 (�3.2) episodes/day, but no significant between-group differences were detected.Among women with overactive bladder, slow-paced respiration was associated with modest improvements in perceived stress over 12 weeks, but was not superior to a music-listening control in reducing urinary symptoms or changing autonomic function.

View details for PubMedID 31075059
Associations of Intimate Partner Violence, Sexual Assault, and Posttraumatic Stress Disorder With Menopause Symptoms Among Midlife and Older Women JAMA INTERNAL MEDICINE Gibson, C. J., Huang, A. J., McCaw, B., Subak, L. L., Thom, D. H., Van den Eeden, S. K. 2019; 179 (1): 80?87
View details for DOI 10.1001/jamainternmed.2018.5233

View details for Web of Science ID 000455259300017
A group-based yoga program for urinary incontinence in ambulatory women: feasibility, tolerability, and change in incontinence frequency over 3 months in a single-center randomized trial Huang, A. J., Chesney, M., Lisha, N., Vittinghoff, E., Schembri, M., Pawlowsky, S., Hsu, A., Subak, L. MOSBY-ELSEVIER. 2019
View details for DOI 10.1016/j.ajog.2018.10.031

View details for Web of Science ID 000454239900017
More Similarities Than Differences? An Exploratory Analysis Comparing the Sexual Complaints, Sexual Experiences, and Genitourinary Health of Older Sexual Minority and Sexual Majority Adults. The journal of sexual medicine Obedin-Maliver, J., Lisha, N., Breyer, B. N., Subak, L. L., Huang, A. J. 2019; 16 (3): 347?50
Abstract

Little is known about sexual problems and genitourinary health of older sexual minority adults, who comprise up to 4% of the adult population but may differ in experiences of genitourinary aging, given known health disparities and behavior differences.To examine and compare genitourinary and sexual complaints among older sexual minority and sexual majority adults.We analyzed data from the 2010-2011 National Social Life, Health, and Aging Project (NSHAP), a nationally representative sample of older community-dwelling U.S. adults. Sexual minority men were defined as those who have sex with men or with both women and men. Sexual minority women were those who have sex with women or with both women and men. Descriptive statistics, weighted frequencies, and the chi-square test were used to compare outcomes by sexual orientation group and gender.Structured questionnaires examined sexual activity, practices, and genitourinary problems such as erectile dysfunction, insufficient vaginal lubrication, and urinary incontinence (UI).Of 2,813 participants (median age 69.6 years), 4.2% were sexual minorities (5.3% of men, 3.5% of women). Among men, sexual minorities were more likely to report UI (35.6% vs 21.8%; P�= .029), but otherwise the 2 groups had similar prevalences of other urinary symptoms, importance of sexual activity, sexual practices, sexual activity within the last 3 months, and erectile difficulty (P > .10 for all). Among women, sexual minorities were more likely to report receiving oral sex (42.5% vs. 21.2%; P�= .004), but otherwise the 2 groups had similar prevalences of UI, other urinary symptoms, importance of sexual activity, sexual activity within the last 3 months, and difficulty with lubrication (P > .10 for all).Sexual activity and sexual problems may be as common among older sexual minority adults as in their sexual majority counterparts, whereas UI may be more common in sexual minority men compared with sexual majority men. Therefore, clinicians should employ culturally-relevant health screening, diagnosis, and treatment to ensure reaching all adults regardless of sexual orientation.Strengths include a national population-based sample of older adults that describes sexual and genitourinary health. Statistical power was limited by the small numbers of sexual minority individuals.Here we provide new evidence that older sexual minority men may experience UI more often than sexual majority men, and that sexual practices may differ between sexual minority and majority women, but frequency of sexual problems is similar. Given the challenges faced by sexual minority individuals in accessing equitable health care, clinicians must ensure that diagnosis and treatment are relevant to people of all sexual�orientations. Obedin-Maliver J, Lisha N, Breyer BN. More Similarities Than Differences? An Exploratory Analysis Comparing the Sexual Complaints, Sexual Experiences, and Genitourinary Health of Older Sexual Minority and Sexual Majority Adults. J Sex Med 2019;16:347-350.

View details for PubMedID 30846110
Associations of Intimate Partner Violence, Sexual Assault, and Posttraumatic Stress Disorder With Menopause Symptoms Among Midlife and Older Women. JAMA internal medicine Gibson, C. J., Huang, A. J., McCaw, B., Subak, L. L., Thom, D. H., Van Den Eeden, S. K. 2018
Abstract

Importance: Little is known about the prevalence of traumatic exposures among midlife and older women and the association of these traumatic exposures with health issues.Objective: To examine the associations of intimate partner violence (IPV), sexual assault, and posttraumatic stress with menopause symptoms among midlife and older women.Design, Setting, and Participants: A cross-sectional analysis of data from a multiethnic cohort of 2016 women 40 to 80 years of age in the Kaiser Permanente Northern California health care system was conducted from November 15, 2008, to March 30, 2012. Statistical analysis was conducted from June 8, 2016, to September 6, 2017.Exposures: Lifetime physical or emotional IPV, sexual assault, and current symptoms of posttraumatic stress disorder, assessed with standardized questionnaires.Main Outcomes and Measures: Difficulty sleeping, vasomotor symptoms, and vaginal symptoms, assessed with standardized questionnaires.Results: Among the 2016 women enrolled, the mean (SD) age was 60.5 (9.5) years, and 792 of 2011 with race/ethnicity data (39.4)% were non-Latina white (403 [20.0%] Latina, 429 [21.3%] black, and 387 [19.2%] Asian). Lifetime emotional IPV was reported by 423 women (21.0%), lifetime physical IPV was reported by 316 women (15.7%), sexual assault was reported by 382 women (18.9%), and 450 of 2000 women (22.5%) had current clinically significant symptoms of posttraumatic stress disorder. In multivariable analyses adjusted for age, race/ethnicity, educational level, body mass index, menopause status, hormone therapy, and parity, symptoms of posttraumatic stress disorder were associated with difficulty sleeping (odds ratio [OR], 3.02; 95% CI, 2.22-4.09), vasomotor symptoms (hot flashes: OR, 1.69; 95% CI, 1.34-2.12; night sweats: OR, 1.72; 95% CI, 1.37-2.15), and vaginal symptoms (vaginal dryness: OR, 1.73; 95% CI, 1.37-2.18; vaginal irritation: OR, 2.20; 95% CI, 1.66-2.93; pain with intercourse: OR, 2.16; 95% CI, 1.57-2.98). Emotional IPV was associated with difficulty sleeping (OR, 1.36; 95% CI, 1.09-1.71), night sweats (OR, 1.50; 95% CI, 1.19-1.89), and pain with intercourse (OR, 1.60; 95% CI, 1.14-2.25). Physical IPV was associated with night sweats (OR, 1.33; 95% CI, 1.03-1.72). Sexual assault was associated with vaginal symptoms (vaginal dryness: OR, 1.41; 95% CI, 1.10-1.82; vaginal irritation: OR, 1.42; 95% CI, 1.04-1.95; pain with intercourse: OR 1.44; 95% CI, 1.00-2.06).Conclusions and Relevance: Lifetime history of IPV or sexual assault and current clinically significant symptoms of posttraumatic stress disorder are common and are associated with menopause symptoms. These findings highlight the need for greater recognition of these exposures by clinicians caring for midlife and older women.

View details for PubMedID 30453319
Effect of Group-Administered Behavioral Treatment on Urinary Incontinence in Older Women A Randomized Clinical Trial JAMA INTERNAL MEDICINE Diokno, A. C., Newman, D. K., Low, L. K., Griebling, T. L., Maddens, M. E., Goode, P. S., Raghunathan, T. E., Subak, L. L., Sampselle, C. M., Boura, J. A., Robinson, A. E., McIntyre, D., Burgio, K. L. 2018; 178 (10): 1333?41
Abstract

Urinary incontinence (UI) guidelines recommend behavioral interventions as first-line treatment using individualized approaches. A one-time, group-administered behavioral treatment (GBT) could enhance access to behavioral treatment.To compare the effectiveness, cost, and cost-effectiveness of GBT with no treatment for UI in older women.Multisite randomized clinical trial (the Group Learning Achieves Decreased Incidents of Lower Urinary Symptoms [GLADIOLUS] study), conducted from July 7, 2014, to December 31, 2016. The setting was outpatient practices at 3 academic medical centers. Community-dwelling women 55 years or older with UI were recruited by mail and screened for eligibility, including a score of 3 or higher on the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), symptoms of at least 3 months' duration, and absence of medical conditions or treatments that could affect continence status. Of 2171 mail respondents, 1125 were invited for clinical screening; 463 were eligible and randomized; 398 completed the 12-month study.The GBT group received a one-time 2-hour bladder health class, supported by written materials and an audio CD.Outcomes were measured at in-person visits (at 3 and 12 months) and by mail or telephone (at 6 and 9 months). The primary outcome was the change in the ICIQ-SF score. Secondary outcome measures assessed UI severity, quality of life, perceptions of improvement, pelvic floor muscle strength, and costs. Evaluators were masked to group assignment.Participants (232 in the GBT group and 231 in the control group) were aged 55 to 91 years (mean [SD] age, 64 [7] years), and 46.2% (214 of 463) were African American. In intent-to-treat analyses, the ICIQ-SF scores for GBT were consistently lower than control across all time points but did not achieve the projected 3-point difference. At 3 months, the difference in differences was 0.96 points (95% CI, -1.51 to -0.41 points), which was statistically significant but clinically modest. The mean (SE) treatment effects at 6, 9, and 12 months were 1.36 (0.32), 2.13 (0.33), and 1.77 (0.31), respectively. Significant group differences were found at all time points in favor of GBT on all secondary outcomes except pelvic floor muscle strength. The incremental cost to achieve a treatment success was $723 at 3 months; GBT dominated at 12 months.The GLADIOLUS study shows that a novel one-time GBT program is modestly effective and cost-effective for reducing UI frequency, severity, and bother and improving quality of life. Group-administered behavioral treatment is a promising first-line approach to enhancing access to noninvasive behavioral treatment for older women with UI.ClinicalTrials.gov identifier: NCT02001714.

View details for PubMedID 30193294
INTERPERSONAL VIOLENCE, POSTTRAUMATIC STRESS DISORDER, AND AGING-RELATED GENITOURINARY DYSFUNCTION IN AN ETHNICALLY-DIVERSE, COMMUNITY-BASED SAMPLE OF WOMEN Huang, A., Gibson, C., Mccaw, B., Shan, J., Subak, L., Thom, D., Van Den Eeden, S. ELSEVIER SCI LTD. 2018: S104?S105
View details for Web of Science ID 000433425400018
Association of Pharmacologic Treatment of Urgency Urinary Incontinence With Sleep Quality and Daytime Sleepiness EDITORIAL COMMENT OBSTETRICAL & GYNECOLOGICAL SURVEY Warsi, Q. A., Huang, A. J., Hess, R., Arya, L. A., Richter, H. E., Bradley, C. S., Rogers, R. G., Myers, D. L., Johnson, K. C., Winkelman, W. D., Gregory, W., Kraus, S. R., Schembri, M., Brown, J. S., Stone, K. L., Subak, L. L. 2018; 73 (5): 273?74
View details for DOI 10.1097/OGX.0000000000000556

View details for Web of Science ID 000435375100010
Sleep Quality and Daytime Sleepiness Among Women With Urgency Predominant Urinary Incontinence Winkelman, W. D., Warsi, A., Huang, A. J., Schembri, M., Rogers, R. G., Richter, H. E., Myers, D. L., Kraus, S. R., Johnson, K. C., Hess, R., Gregory, T., Bradley, C. S., Arya, L. A., Brown, J. S., Stone, K. L., Subak, L. L. LIPPINCOTT WILLIAMS & WILKINS. 2018: 76?81
Abstract

The objective of this study was to examine the strength and direction of the association between urinary symptoms and both poor quality sleep and daytime sleepiness among women with urgency urinary incontinence.A planned secondary analysis of baseline characteristics of participants in a multicenter, double-blinded, 12-week randomized controlled trial of pharmacologic therapy for urgency-predominant urinary incontinence in ambulatory women self-diagnosed by the 3 Incontinence Questions was performed. Urinary symptoms were assessed by 3-day voiding diaries. Quality of sleep was assessed using the Pittsburgh Sleep Quality Index (PSQI) and daytime sleepiness using the Epworth Sleepiness Scale.Of the 640 participants, mean (SD) age was 56 (�14) years and 68% were white. Participants reported an average of 3.9 (�3.0) urgency incontinence episodes per day and 1.3 (�1.3) episodes of nocturia per night. At baseline, 57% had poor sleep quality (PSQI score, >5) and 17% reported daytime sleepiness (Epworth Sleepiness Scale score, >10). Most women (69%) did not use sleeping medication during the prior month, whereas 13% reported use of sleeping medication 3 or more times per week. An increase in total daily incontinence episodes, total daily urgency incontinence episodes, total daily micturitions, and moderate to severe urge sensations were all associated with higher self-report of poor sleep quality according to the PSQI (all P ? 0.01). Higher scores on the Bother Scale and the Health-Related Quality of Life for overactive bladder on the Overactive Bladder Questionnaire were similarly associated with higher rates of poor sleep quality (both P ? 0.01). In subgroup analysis of those who took sleeping medications less than twice a week, there was still a significant relationship between incontinence measures and quality of sleep as measured by the PSQI. In multivariable analyses, greater frequency of nighttime urgency incontinence was associated with poor sleep quality (P = 0.03).Among ambulatory women with urgency urinary incontinence, poor sleep quality is common and greater frequency of incontinence is associated with a greater degree of sleep dysfunction. Women seeking urgency urinary incontinence treatment should be queried about their sleeping habits so that they can be offered appropriate interventions.

View details for DOI 10.1097/SPV.0000000000000547

View details for Web of Science ID 000426823700003

View details for PubMedID 29300259

View details for PubMedCentralID PMC5909832
Association of Pharmacologic Treatment of Urgency Urinary Incontinence With Sleep Quality and Daytime Sleepiness Warsi, Q. A., Huang, A. J., Hess, R., Arya, L. A., Richter, H. E., Bradley, C. S., Rogers, R. G., Myers, D. L., Johnson, K. C., Winkelman, W. D., Gregory, W., Kraus, S. R., Schembri, M., Brown, J. S., Stone, K. L., Subak, L. L. LIPPINCOTT WILLIAMS & WILKINS. 2018: 204?11
Abstract

To evaluate the association between pharmacologic therapy for urgency urinary incontinence (UUI) and sleep quality.We conducted a planned secondary data analysis of sleep outcomes in a previously conducted multicenter, double-blind, 12-week randomized trial of pharmacologic therapy for urgency-predominant incontinence among community-dwelling women self-diagnosed using the 3-Incontinence Questions questionnaire. Participants (N=645) were assigned randomly to 4-8 mg antimuscarinic therapy daily or placebo. At baseline and 12 weeks, participants completed a validated voiding diary to evaluate incontinence and voiding symptoms, the Pittsburgh Sleep Quality Index to evaluate sleep quality, and the Epworth Sleepiness Scale to evaluate daytime sleepiness.Mean (SD) age was 56 (�14) years, 68% were white, and 57% had poor sleep quality (Pittsburgh Sleep Quality Index score greater than 5). Mean frequency of any urinary incontinence and UUI was 4.6 and 3.9 episodes/d, respectively. After 12 weeks, women randomized to the antimuscarinic group reported greater decrease compared with the placebo group in UUI frequency (0.9 episodes/d; P<.001) and diurnal and nocturnal voiding frequency (P<.05). As compared with the placebo group, women in the antimuscarinic group also reported greater improvement in sleep quality (total Pittsburgh Sleep Quality Index score 0.48; P=.02) with greater improvement in sleep duration and sleep efficiency subscales (P<.05). The intervention did not affect daytime sleepiness.Pharmacologic treatment of UUI is associated with decreased incontinence frequency and nocturia and improvement in overall sleep quality, sleep duration, and sleep efficiency.ClinicalTrials.gov, NCT00862745.

View details for PubMedID 29324595
RANDOMIZED CONTROLLED TRIAL OF GROUP-ADMINSITERED BEHAVIORAL TREATMENT IN REDUCING URINARY INCONTINENCE IN ADULT WOMEN Newman, D., Diokno, A., Burgio, K., Low, L., Griebling, T., Maddens, M., Subak, L., Goode, P., Sampselle, C., Robinson, A., Raghunathan, T., Boura, J., McIntyre, D., Magno, A., Stambakio, H. WILEY. 2018: S564?S565
View details for Web of Science ID 000427016100077
TRAINING FIDELITY AND QUALITY CONTROL IN CLINICAL BEHAVIORAL RESEARCH FOR URINARY INCONTINENCE: THE GLADIOLUS TRIAL Griebling, T. L., Diokno, A., Newman, D., Burgio, K., Low, L., Maddens, M., Subak, L., Goode, P., Sampselle, C., Robinson, A., Raghunathan, T., Boura, J., McIntyre, D., Gladiolus Res Team WILEY. 2018: S633?S634
View details for Web of Science ID 000427016100189
A Behavioral Weight Loss Program and Nonurinary Incontinence Lower Urinary Tract Symptoms in Overweight and Obese Women with Urinary Incontinence: A Secondary Data Analysis of PRIDE JOURNAL OF UROLOGY Breyer, B. N., Creasman, J. M., Richter, H. E., Myers, D., Burgio, K. L., Wing, R. R., West, D., Kusek, J. W., Subak, L. L., PRIDE 2018; 199 (1): 215?21
Abstract

We sought to determine whether a behavioral weight reduction intervention would improve nonurinary incontinence lower urinary tract storage symptoms at 6 months, including urinary frequency, nocturia and urgency, compared to a structured education program serving as the control group among overweight and obese women with urinary incontinence.PRIDE (Program to Reduce Incontinence by Diet and Exercise) was a randomized clinical trial performed in 338 overweight or obese women with urinary incontinence. Participants were randomized, including 226 to 6-month behavioral weight loss intervention and 112 to the control group. All participants received a self-help behavioral treatment booklet to improve bladder control. On this secondary data analysis we examined changes in nonurinary incontinence lower urinary tract storage symptoms from baseline to 6 months and the impact of treatment allocation (intervention vs control), weight loss and physical activity.Nonurinary incontinence lower urinary tract storage symptoms were common at baseline, varying from 48% to 62%. In the 2 groups combined women experienced significant improvement in nocturia, urgency and International Prostate Symptom Score at 6 months (all p <0.001). However, lower urinary tract storage symptom outcomes at 6 months did not differ between the intervention and control groups. Similarly no difference was observed in the amount of weight lost (5% or greater vs less than 5%) or physical activity (1,500 kcal or greater expenditure per week compared to less than 1,500 kcal).Lower urinary tract storage symptoms were common among overweight and obese women with urinary incontinence. The prevalence decreased significantly after 6 months independent of treatment group assignment, amount of weight lost or physical activity. These improvements may have been due to self-help behavioral educational materials, trial participation or repeat assessment of symptoms.

View details for DOI 10.1016/j.juro.2017.07.087

View details for Web of Science ID 000419429700094

View details for PubMedID 28807645
Search Images and Extrapolation Risk Reply JAMA INTERNAL MEDICINE Grady, D., Subak, L. 2017; 177 (12): 1870
View details for PubMedID 29204638
Interpersonal Violence, Posttraumatic Stress Disorder, and Menopause-Related Sexual Dysfunction in an Ethnically-Diverse, Community-Based Sample of Women Gibson, C., Huang, A., McCaw, B., Shan, J., Subak, L., Thom, D., Van den Eeden, S. LIPPINCOTT WILLIAMS & WILKINS. 2017: 1433
View details for Web of Science ID 000423298900059
Characterizing the Functional Decline of Older Women With Incident Urinary Incontinence Parker-Autry, C., Houston, D. K., Rushing, J., Richter, H. E., Subak, L., Kanaya, A. M., Kritchevsky, S. B. LIPPINCOTT WILLIAMS & WILKINS. 2017: 1025?32
Abstract

To characterize change in physical performance and differential prevalence of low skeletal muscle mass and strength (sarcopenia) and lower 25-hydroxyvitamin D concentrations among older women who developed urinary incontinence (UI) symptoms.This is a secondary analysis of the Health, Aging, and Body Composition Study. Urinary incontinence symptoms were assessed using validated questions. The Short Physical Performance Battery measured physical performance. Sarcopenia, defined by low muscle mass and strength, was determined using validated cutoffs for gait speed, grip strength, and appendicular skeletal muscle mass. All parameters were evaluated at baseline and year 4. Serum 25-hydroxyvitamin D concentrations were assessed at year 2. The primary outcome was change in Short Physical Performance Battery total scores. Sarcopenia and lower serum 25-hydroxyvitamin D concentrations have been independently associated with poor physical performance and UI and were therefore included as secondary outcomes. Univariate and multivariate analyses were used to characterize the associations of change in physical performance from baseline to year 4, incidence of sarcopenia, and lower serum 25-hydroxyvitamin D on the development of UI symptoms.Of the 1,583 women enrolled, 910 were excluded (730 had baseline UI; 180 with missing data). Six hundred seventy-three women were continent at baseline; 223 (33%) developed UI symptoms at year 4. SPPB total scores significantly declined in women with UI versus continent women (mean difference continent-incident UI 0.32, 95% CI 0.04-0.60, P=.02). Of subscale measures, standing balance showed the greatest decline at 0.20 (0.05-0.36; continent-incident UI, respectively; P=.009). Sarcopenia developed at a higher rate with incident UI (adjusted odds ratio [OR] 1.7, 95% CI 1.0-2.9). Low 25-hydroxyvitamin D was not associated with incident UI (adjusted OR 1.1, 95% CI 0.7-1.6 and 1.1, 95% CI 0.7-1.6 for deficient or insufficient versus sufficient status, respectively).We observed a significant decline in standing balance among older women who developed UI symptoms. This decline may be associated with coinciding development of sarcopenia.

View details for PubMedID 29016492
Development and Feasibility of a Group-Based Therapeutic Yoga Program for Women with Chronic Pelvic Pain PAIN MEDICINE Huang, A. J., Rowen, T. S., Abercrombie, P., Subak, L. L., Schembri, M., Plaut, T., Chao, M. T. 2017; 18 (10): 1864?72
Abstract

To develop a group-based therapeutic yoga program for women with chronic pelvic pain (CPP) and explore the effects of this program on pain severity, sexual function, and well-being.A yoga therapy program for CPP was developed by a multidisciplinary panel of clinicians, researchers, and yoga consultants. Women reporting moderate to severe pelvic pain for at least six months were recruited into a single-arm trial. Participants attended twice weekly group classes focusing on Iyengar-based yoga techniques and were instructed to practice yoga at home an hour a week for six weeks. Participants self-rated the severity of their pelvic pain using daily logs. The impact of participants' pain on everyday activities, emotional well-being, and sexual function was assessed using an Impact of Pelvic Pain (IPP) questionnaire. Sexual function was further assessed using the Sexual Health Outcomes in Women Questionnaire (SHOW-Q).Among the 16 participants (age range = 31-64 years), average ratings of the severity of pain "at its worst," "at its best," and "on average" decreased by 29%, 32%, and 34%, respectively, from start to six weeks (P?
View details for DOI 10.1093/pm/pnw306

View details for Web of Science ID 000412780300005

View details for PubMedID 28419385

View details for PubMedCentralID PMC6279262
Urine leakage during sexual activity among ethnically diverse, community-dwelling middle-aged and older women AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Munaganuru, N., Van den Eeden, S. K., Creasman, J., Subak, L. L., Strano-Paul, L., Huang, A. J. 2017; 217 (4): 439.e1?439.e8
Abstract

Urinary incontinence is associated with decreased female sexual function, but little is known about the prevalence, predictors, and impact of urine leakage during sexual activity among women in the community.The purpose of this study was to evaluate the prevalence and impact of urine leakage during sex in ethnically diverse, community-dwelling midlife and older women.Urinary incontinence and sexual function were assessed by structured questionnaire in a multiethnic, community-based cohort of women enrolled in Kaiser Permanente Northern California, an integrated healthcare delivery system in California. All women were aged 40-80 years and sampled from 1 of 4 racial/ethnic groups (20% black, 20% Latina, 20% Asian, and 40% non-Latina white). Differences in frequency, bother, and fear of urine leakage during sexual activity were examined among women with monthly, weekly, and daily urinary incontinence and across different types of urinary incontinence (stress, urgency, mixed, and other type urinary incontinence), with the use of chi-square tests. Independent risk factors for urine leakage during sexual activity were identified through multivariable logistic regression.Of the 509 women who reported being sexually active and having at least monthly urinary incontinence, 127 of them (25%) reported experiencing any urine leakage during sex during the past 3 months. Nineteen percent of the women reported being subjectively bothered by leakage during sex, and 16% of them reported restricting sexual activity because of fear of leakage. Women with more frequent underlying urinary incontinence were more likely to report experiencing or being bothered by leakage during sex and restricting sexual activity because of fear of leakage (P<.001 for all). Participants with predominantly stress or mixed type urinary incontinence were more likely to report experiencing leakage during sex and being subjectively bothered by this leakage (P<.002 for all). Factors independently associated with leakage during sex were depression (odds ratio,1.96; 95% confidence interval, 1.20-3.20), symptomatic pelvic organ prolapse (odds ratio, 2.10; 95% confidence interval, 1.11-3.98), mixed vs urgency type urinary incontinence (odds ratio, 3.16; 95% confidence interval, 1.70-5.88), stress vs urgency type urinary incontinence (odds ratio, 1.94; 95% confidence interval, 1.01-3.70), and frequency of sexual activity (odds ratio, 1.6395% confidence interval, 1.05-2.55), but not age or race/ethnicity.Up to a quarter of women with at least monthly urinary incontinence in the community may experience urine leakage during sexual activity. Many incontinent women who leak urine during sex remain sexually active, which indicates that the preservation of sexual function should still be a priority in this population. Among incontinent women, depression, pelvic organ prolapse, and stress mixed-type urinary incontinence may be associated with urine leakage during sexual activity.

View details for DOI 10.1016/j.ajog.2017.05.069

View details for Web of Science ID 000411434300015

View details for PubMedID 28602772

View details for PubMedCentralID PMC5614816
Future Directions of Research and Care for Urinary Incontinence: Findings from the National Institute of Diabetes and Digestive and Kidney Diseases Summit on Urinary Incontinence Clinical Research in Women JOURNAL OF UROLOGY Chai, T. C., Asfaw, T. S., Baker, J. E., Clarkson, B., Coleman, P., Hoffstetter, S., Konkel, K., Lavender, M., Nair, S., Norton, J., Subak, L., Visco, A., Star, R. A., Bavendam, T. 2017; 198 (1): 22?29
Abstract

Female urinary incontinence is prevalent, costly and morbid. Participants in a NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases) sponsored summit reviewed findings from NIH (National Institutes of Health) funded clinical research on urinary incontinence in women and discussed the future of urinary incontinence research.The NIDDK convened the Summit on Urinary Incontinence Clinical Research in Women on March 14, 2014. Participants representing a broad range of clinical expertise reviewed completed NIH sponsored urinary incontinence related studies, including results from community based epidemiological studies such as the BACH (Boston Area Community Health) Survey and from randomized clinical trials such as PRIDE (Program to Reduce Incontinence by Diet and Exercise), and studies conducted by the Pelvic Floor Disorders Network and the Urinary Incontinence Treatment Network.BACH Survey results improved our understanding of precursors, incidence, prevalence and natural history of urinary incontinence in a diverse group of women. The Pelvic Floor Disorders Network study found that anticholinergic medications and onabotulinumtoxinA are efficacious for treating urge urinary incontinence, and Burch colposuspension and retropubic mid urethral polypropylene slings are efficacious for decreasing stress urinary incontinence following pelvic organ prolapse surgery in women with potential stress urinary incontinence. The Urinary Incontinence Treatment Network study found that fascial slings were better than colposuspension, and that retropubic and transobturator mid urethral polypropylene slings were equivalent for stress urinary incontinence. In patients with stress urinary incontinence a preoperative urodynamic study was noninferior to basic office examinations for surgical outcome. The addition of behavioral intervention did not allow female patients to discontinue antimuscarinics for urge urinary incontinence. PRIDE showed that modest weight reductions significantly decreased urinary incontinence.Strategies for future research on urinary incontinence should include a focus on early disease, risk factor identification, better phenotyping, incorporation of new technologies, patient centered research and prevention.

View details for DOI 10.1016/j.juro.2016.10.133

View details for Web of Science ID 000402985200006

View details for PubMedID 28286067
Asymptomatic Microscopic Hematuria-Rethinking the Diagnostic Algorithm JAMA INTERNAL MEDICINE Subak, L. L., Grady, D. 2017; 177 (6): 808?9
View details for DOI 10.1001/jamainternmed.2017.0758

View details for Web of Science ID 000402715900011

View details for PubMedID 28418525
Modifiers of Response to Treatment With Fesoterodine for Urgency-Predominant Urinary Incontinence in a Randomized Controlled Trial Winkelman, W. D., Huang, A. J., Schembri, M., Rogers, R. G., Richter, H., Myers, D. L., Kraus, S. R., Johnson, K. C., Hess, R., Gregory, T., Bradley, C. S., Arya, L., Brown, J. S., Subak, L. L. LIPPINCOTT WILLIAMS & WILKINS. 2017: 151?56
Abstract

The aim of this study was to identify clinical and demographic characteristics that moderate response to treatment with fesoterodine among women with a diagnosis of urgency-predominant urinary incontinence.A multicenter, double-blinded, 12-week randomized controlled trial of pharmacologic therapy for urgency-predominant urinary incontinence in community-dwelling women diagnosed by the 3-item Incontinence Questionnaire (3IQ) was previously performed. Participants (N = 645) were randomized to fesoterodine therapy (4-8 mg daily; n = 322) or placebo (n = 323). Urinary incontinence was assessed by 3-day voiding diaries. In this secondary analysis, a "responder" was defined as reduction of 50% or greater in overall incontinence episode frequency compared with baseline. Clinical and demographic characteristics that may moderate treatment response were assessed by testing for interaction between characteristics and intervention in logit models of responders, adjusting for clinical site.Participants' ages were a mean of 56 (SD, 14) years, 68% were white race, and they had a mean of 3.9 (SD, 3.0) urgency incontinence episodes per day. There were no baseline differences in demographic, clinical, or incontinence characteristics between treatment and placebo groups or between responders and nonresponders. There was an increase in the proportion of responders to fesoterodine with increasing age (P = 0.04) and parity (0.04) and among married women (P = 0.03), but no effect modification was observed by race/ethnicity, body mass index, education, employment status, or alcohol or tobacco use.In ambulatory women with urgency-predominant urinary incontinence, older age, being married, and higher parity significantly moderated and potentiated the effects of pharmacologic therapy on incontinence frequency. This study identifies certain populations who may have increased responsiveness to treatment with antimuscarinic therapy and may be used to inform and guide future therapy.

View details for DOI 10.1097/SPV.0000000000000396

View details for Web of Science ID 000395579800017

View details for PubMedID 28118174

View details for PubMedCentralID PMC5323297
Sexual functioning of men and women with severe obesity before bariatric surgery SURGERY FOR OBESITY AND RELATED DISEASES Steffen, K. J., King, W. C., White, G. E., Subak, L. L., Mitchell, J. E., Courcoulas, A. P., Flum, D. R., Strain, G., Sarwer, D. B., Kolotkin, R. L., Pories, W., Huang, A. J. 2017; 13 (2): 334?43
Abstract

Obesity may impair sexual function through multiple mechanisms, but little is known about sexual dysfunction among adults with severe obesity seeking bariatric procedures.To describe sexual function and associated factors before bariatric surgery.Ten U.S. clinical facilities.Before bariatric surgery, 2225 of 2458 Longitudinal Assessment of Bariatric Surgery-2 study participants (79% female, median age 45 years and median body mass index 46 kg/m2) completed a survey about sexual function over the past month. Mixed effects ordinal logistic regression models were used to identify factors independently related to 4 domains of sexual function.One third of women (34%) and one quarter of men (25%) were not sexually active, alone or with a partner, in the past month. Twenty-six percent of women and 12% of men reported no sexual desire. Physical health limited sexual activity at least moderately in 38% of women and 44% of men. About one half of the women (49%) and the men (54%) were moderately or very dissatisfied with their sexual life. Among women, older age, being Caucasian, urinary incontinence, depressive symptoms, and antidepressant medication use were associated with poorer sexual function in multiple domains. In men, older age, not being married, depressive symptoms, and antidepressant medication use were associated with poorer sexual function in multiple domains.Before bariatric surgery, approximately one half of women and men with severe obesity are dissatisfied with their sexual life. Older age, severity of depressive symptoms, and antidepressant medication use are associated with poorer sexual function in both sexes.

View details for DOI 10.1016/j.soard.2016.09.022

View details for Web of Science ID 000396802900033

View details for PubMedID 27986585

View details for PubMedCentralID PMC6067110
Urinary Incontinence in Older Women: The Role of Body Composition and Muscle Strength: From the Health, Aging, and Body Composition Study JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Suskind, A. M., Cawthon, P. M., Nakagawa, S., Subak, L. L., Reinders, I., Satterfield, S., Cummings, S., Cauley, J. A., Harris, T., Huang, A. J., Hlth ABC Study 2017; 65 (1): 42?50
Abstract

To evaluate prospective relationships between body composition and muscle strength with predominantly stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) in older women.Prospective community-dwelling observational cohort study (Health, Aging, and Body Composition study).Women initially aged 70 to 79 recruited from Pittsburgh, Pennsylvania, and Memphis, Tennessee (N = 1,475).Urinary incontinence was assessed using structured questionnaires. Body mass index (BMI), grip strength, quadriceps torque, and walking speed were assessed using physical examination and performance testing. Appendicular lean body mass (ALM) and whole-body fat mass were measured using dual-energy X-ray absorptiometry.At baseline, 212 (14%) women reported at least monthly predominantly SUI and 233 (16%) at least monthly predominantly UUI. At 3 years, of 1,137 women, 164 (14%) had new or persistent SUI, and 320 (28%) had new or persistent UUI. Women had greater odds of new or persistent SUI if they demonstrated a 5% or greater decrease in grip strength, (adjusted odds ratio (AOR) = 1.60, P = .047) and lower odds of new or persistent SUI if they demonstrated a 5% or greater decrease in BMI (AOR = 0.46, P = .01), a 5% or greater increase in ALM corrected for BMI (AOR = 0.17, P = .004), or a 5% or greater decrease in fat mass (AOR = 0.53, P = .01). Only a 5% or greater increase in walking speed was associated with new or persistent UUI over 3 years (AOR = 1.54, P = .04).In women aged 70 and older, changes in body composition and grip strength were associated with changes in SUI frequency over time. In contrast, changes in these factors did not influence UUI. Findings suggest that optimization of body composition and muscle strength is more likely to modify risk of SUI than of UUI in older women.

View details for DOI 10.1111/jgs.14545

View details for Web of Science ID 000394551300012

View details for PubMedID 27918084

View details for PubMedCentralID PMC5258849
Bladder Symptoms in the Early Menopausal Transition JOURNAL OF WOMENS HEALTH Jones, H. J., Huang, A. J., Subak, L. L., Brown, J. S., Lee, K. A. 2016; 25 (5): 457?63
Abstract

Bladder symptoms are common in women and result in use of healthcare resources and poor quality of life. Bladder symptoms have been linked to age and menopause, but debate exists in the literature. This article examines factors associated with bladder symptoms and compares women in late reproductive stage with those in menopausal transition.We analyzed cross-sectional data from a prospective cohort study of midlife women (mean age, 48; range, 44-54 years) in northern California. The sample consisted of 158 women in late reproductive stage or menopause transition. Assessments included anthropometrics, menstrual cycle lengths and symptoms, urine samples for follicle-stimulating hormone level, and self-reported health perception and depressive symptoms. Analyses included descriptive bivariate statistics, group comparisons, and regression models.The most common bladder symptoms were nocturia (72%) at least once per night and urinary incontinence (50%) at least once per week. Incontinence was less prevalent in African American women compared to European Americans and Latinas (p?=?0.001) and more prevalent in late reproductive stage than in menopause transition (p?=?0.024). Controlling for age, women in late reproductive stage were more likely to report nocturia compared to those in menopause transition. Reproductive stage (p?=?0.016), higher body mass index (p?=?0.007), and race (p?=?0.017) contributed to the variance in weekly nighttime urinary frequency.Bladder symptoms were associated with reproductive stage. Women in late reproductive stage were more likely to experience nocturia and incontinence than those in menopause transition. The higher rates of nocturia and incontinence in late reproductive stage are intriguing. Future studies should include analysis of pelvic organ prolapse degree and other structural differences.

View details for DOI 10.1089/jwh.2015.5370

View details for Web of Science ID 000376478100009

View details for PubMedID 26741199

View details for PubMedCentralID PMC4876519
The FDA and the Vaginal Mesh Controversy-Further Impetus to Change the 510(k) Pathway for Medical Device Approval JAMA INTERNAL MEDICINE Jacoby, V. L., Subak, L., Waetjen, L. 2016; 176 (2): 277?78
View details for DOI 10.1001/jamainternmed.2015.7155

View details for Web of Science ID 000369627600037

View details for PubMedID 26720520
Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Duralde, E. R., Walter, L. C., Van den Eeden, S. K., Nakagawa, S., Subak, L. L., Brown, J. S., Thom, D. H., Huang, A. J. 2016; 214 (2): 266.e1?266.e9
Abstract

More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated.We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women.We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment.Mean age of the 969 participants was 59.9 (�9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ? $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ? $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician.Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

View details for DOI 10.1016/j.ajog.2015.08.072

View details for Web of Science ID 000369518200019

View details for PubMedID 26348382

View details for PubMedCentralID PMC4830485
Urinary Incontinence Before and After Bariatric Surgery JAMA INTERNAL MEDICINE Subak, L. L., King, W. C., Belle, S. H., Chen, J., Courcoulas, A. P., Ebel, F. E., Flum, D. R., Khandelwal, S., Pender, J. R., Pierson, S. K., Pories, W. J., Steffen, K. J., Strain, G. W., Wolfe, B. M., Huang, A. J. 2015; 175 (8): 1378?87
Abstract

Among women and men with severe obesity, evidence for improvement in urinary incontinence beyond the first year after bariatric surgery-induced weight loss is lacking.To examine change in urinary incontinence before and after bariatric surgery and to identify factors associated with improvement and remission among women and men in the first 3 years after bariatric surgery.The Longitudinal Assessment of Bariatric Surgery 2 is an observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. Participants were recruited between February 21, 2005, and February 17, 2009. Adults undergoing first-time bariatric surgical procedures as part of clinical care by participating surgeons between March 14, 2006, and April 24, 2009, were followed up for 3 years (through October 24, 2012).Participants undergoing bariatric surgery completed research assessments before the procedure and annually thereafter.The frequency and type of urinary incontinence episodes in the past 3 months were assessed using a validated questionnaire. Prevalent urinary incontinence was defined as at least weekly urinary incontinence episodes, and remission was defined as change from prevalent urinary incontinence at baseline to less than weekly urinary incontinence episodes at follow-up.Of 2458 participants, 1987 (80.8%) completed baseline and follow-up assessments. At baseline, the median age was 47 years (age range, 18-78 years), the median body mass index was 46 kg/m2 (range, 34-94 kg/m2), and 1565 of 1987 (78.8%) were women. Urinary incontinence was more prevalent among women (49.3%; 95% CI, 46.9%-51.9%) than men (21.8%; 95% CI, 18.2%-26.1%) (P?
View details for PubMedID 26098620
The Impact of Multimorbidity on Sexual Function in Middle-Aged and Older Women: Beyond the Single Disease Perspective JOURNAL OF SEXUAL MEDICINE Appa, A. A., Creasman, J., Brown, J. S., Van den Eeden, S. K., Thom, D. H., Subak, L. L., Huang, A. J. 2014; 11 (11): 2744?55
Abstract

Little is known about sexual activity and function in women with multiple chronic health conditions.To examine the impact of multimorbidity on sexual activity and function in middle-aged and older women.Multiethnic cross-sectional cohort of 1,997 community-dwelling women (mean age of 60.2 [�9.5] years) in California. Structured questionnaires assessed prior diagnoses of common cardiometabolic, colorectal, neuropsychiatric, respiratory, musculoskeletal, and genitourinary conditions.Sexual desire, frequency of sexual activity, overall sexual satisfaction, and specific sexual problems (i.e., difficulty with arousal, lubrication, orgasm, and pain) were assessed by structured questionnaires.Seventy-one percent of women had two or more diagnosed chronic conditions. Fifty-nine percent reported low sexual desire, 53% reported less than monthly sexual activity, and 47% reported low overall sexual satisfaction. Multimorbidity was associated with increased odds of reporting low sexual desire (OR?=?1.11, 95% CI?=?1.06-1.17, per each additional chronic condition), less than monthly sexual activity (OR?=?1.11, 95% CI?=?1.05-1.17 per each additional condition), and low sexual satisfaction (OR?=?1.10, 95% CI?=?1.04-1.16 per each additional condition), adjusting for age, race/ethnicity, and partner status. Depression and urinary incontinence were each independently associated with low desire (OR?=?1.53, 95% CI?=?1.19-1.97, and OR?=?1.23, 95% CI?=?1.00-1.52, respectively), less than monthly sexual activity (OR?=?1.39, 95% CI?=?1.06-1.83, and OR?=?1.29, 95% CI?=?1.02-1.62, respectively), and low sexual satisfaction (OR?=?1.49, 95% CI?=?1.14-1.93, and OR?=?1.38, 95% CI?=?1.11-1.73, respectively), adjusting for other types of conditions. After adjustment for total number of chronic conditions, age remained a significant predictor of low desire and less than monthly sexual activity, but not sexual satisfaction.Women with multiple chronic health conditions are at increased risk for decreased sexual function. Depression and incontinence may have particularly strong effects on sexual desire, frequency of activity, and satisfaction in women, independent of other comorbid conditions. Women's overall sexual satisfaction may be more strongly influenced by multimorbidity than age.

View details for DOI 10.1111/jsm.12665

View details for Web of Science ID 000344473800013

View details for PubMedID 25146458

View details for PubMedCentralID PMC4309673
Urinary incontinence management costs are reduced following Burch or sling surgery for stress incontinence AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Subak, L. L., Goode, P. S., Brubaker, L., Kusek, J. W., Schembri, M., Lukacz, E. S., Kraus, S. R., Chai, T. C., Norton, P., Tennstedt, S. L., Urinary Incontinence Treatment Net 2014; 211 (2): 171.e1?7
Abstract

The objective of the study was to estimate the effect of Burch and fascial sling surgery on out-of-pocket urinary incontinence (UI) management costs at 24 months postoperatively and identify predictors of change in cost among women enrolled in a randomized trial comparing these procedures.Resources used for UI management (supplies, laundry, dry cleaning) were self-reported by 491 women at baseline and 24 months after surgery, and total out-of-pocket costs for UI management (in 2012 US dollars) were estimated. Data from the 2 surgical groups were combined to examine the change in cost for UI management over 24 months. Univariate and bivariate changes in cost were analyzed using the Wilcoxon signed rank test. Predictors of change in cost were examined using multivariate mixed models.At baseline mean (�SD) age of participants was 53 � 10 years, and the frequency of weekly UI episodes was 23 � 21. Weekly UI episodes decreased by 86% at 24 months (P < .001). The mean weekly cost was $16.60 � $27.00 (median $9.39) at baseline and $4.57 � $15.00 (median $0.10) at 24 months (P < .001), a decrease of 72%. In multivariate analyses, cost decreased by $3.38 � $0.77 per week for each decrease of 1 UI episode per day (P < .001) and was strongly associated with greater improvement in Urogenital Distress Inventory and Incontinence Impact Questionnaire scores (P < .001) and decreased 24-hour pad weight (P < .02).Following Burch or fascial sling surgery, the UI management cost at 24 months decreased by 72% ($625 per woman per year) and was strongly associated with decreasing UI frequency. Reduced out-of-pocket expenses may be a benefit of these established urinary incontinence procedures.

View details for DOI 10.1016/j.ajog.2014.03.012

View details for Web of Science ID 000340259300025

View details for PubMedID 24631433

View details for PubMedCentralID PMC4349353
Adding Evidence-Based Behavioral Weight Loss Strategies to a Statewide Wellness Campaign: A Randomized Clinical Trial AMERICAN JOURNAL OF PUBLIC HEALTH Leahey, T. M., Thomas, G., Fava, J. L., Subak, L. L., Schembri, M., Krupel, K., Kumar, R., Weinberg, B., Wing, R. R. 2014; 104 (7): 1300?1306
Abstract

We determined the efficacy and cost-effectiveness of adding an evidence-based Internet behavioral weight loss intervention alone or combined with optional group sessions to ShapeUp Rhode Island 2011 (SURI), a 3-month statewide wellness campaign.We randomized participants (n = 230; body mass index = 34.3 �6.8 kg/m(2); 84% female) to the standard SURI program (S) or to 1 of 2 enhanced programs: SURI plus Internet behavioral program (SI) or SI plus optional group sessions (SIG). The primary outcome was weight loss at the end of the 3-month program.Weight losses differed among all 3 conditions (S: 1.1% �0.9%; SI: 4.2% �0.6%; SIG: 6.1% �0.6%; Ps ? .04). Both SI and SIG increased the percentage of individuals who achieved a 5% weight loss (SI: 42%; SIG: 54%; S: 7%; Ps < .001). Cost per kilogram of weight loss was similar for S ($39) and SI ($35); both were lower than SIG ($114).Although weight losses were greatest at the end of SURI with optional group sessions, the addition of an Internet behavioral program was the most cost-effective method to enhance weight losses.

View details for DOI 10.2105/AJPH.2014.301870

View details for Web of Science ID 000341809500047

View details for PubMedID 24832424

View details for PubMedCentralID PMC4056209
A Group-Based Yoga Therapy Intervention for Urinary Incontinence in Women: A Pilot Randomized Trial FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY Huang, A. J., Jenny, H. E., Chesney, M. A., Schembri, M., Subak, L. L. 2014; 20 (3): 147?54
Abstract

The aim of this study is to examine the feasibility, efficacy, and safety of a group-based yoga therapy intervention for middle-aged and older women with urinary incontinence.We conducted a pilot randomized trial of ambulatory women aged 40 years and older with stress, urgency, or mixed-type incontinence. Women were randomized to a 6-week yoga therapy program (n = 10) consisting of twice weekly group classes and once weekly home practice or a wait-list control group (n = 9). All participants also received written pamphlets about standard behavioral self-management strategies for incontinence. Changes in incontinence were assessed with 7-day voiding diaries.The mean (SD) age was 61.4 (8.2) years, and the mean baseline frequency of incontinence was 2.5 (1.3) episodes/d. After 6 weeks, the total incontinence frequency decreased by 70% (1.8 [0.9] fewer episodes/d) in the yoga therapy versus 13% (0.3 [1.7] fewer episodes/d) in the control group (P = 0.049). Participants in the yoga therapy group also reported an average of 71% decrease in stress incontinence frequency (0.7 [0.8] fewer episodes/d) compared with a 25% increase in controls (0.2 [1.1] more episodes/d) (P = 0.039). No significant differences in reduction in urgency incontinence were detected between the yoga therapy versus control groups (1.0 [1.0] versus 0.5 [0.5] fewer episodes/d; P = 0.20). All women starting the yoga therapy program completed at least 90% of the group classes and practice sessions. Two participants in each group reported adverse events unrelated to the intervention.Findings provide preliminary evidence to support the feasibility, efficacy, and safety of a group-based yoga therapy intervention to improve urinary incontinence in women.

View details for DOI 10.1097/SPV.0000000000000072

View details for Web of Science ID 000347114400007

View details for PubMedID 24763156

View details for PubMedCentralID PMC4310548
What constitutes an adequate evaluation of device-guided breathing? JAMA internal medicine Huang, A. J., Subak, L. L. 2014; 174 (4): 637
View details for DOI 10.1001/jamainternmed.2013.13791

View details for PubMedID 24711181
What Constitutes an Adequate Evaluation of Device-Guided Breathing? Reply JAMA INTERNAL MEDICINE Landman, G. D., van Hateren, K. J., Kleefstra, N. 2014; 174 (4): 638
View details for Web of Science ID 000471917200002

View details for PubMedID 24711183
What Constitutes an Adequate Evaluation of Device-Guided Breathing? JAMA INTERNAL MEDICINE Landman, G. D., van Hateren, K. J., Kleefstra, N. 2014; 174 (4): 637-+
View details for Web of Science ID 000336841900034
What Constitutes an Adequate Evaluation of Device-Guided Breathing? JAMA INTERNAL MEDICINE Huang, A. J., Subak, L. L. 2014; 174 (4): 637
View details for Web of Science ID 000471917200001
Childbirth and Female Sexual Function Later in Life OBSTETRICS AND GYNECOLOGY Fehniger, J. E., Brown, J. S., Creasman, J. M., Van Den Eeden, S. K., Thom, D. H., Subak, L. L., Huang, A. J. 2013; 122 (5): 988?97
Abstract

To examine relationships among parity, mode of delivery, and other parturition-related factors with women's sexual function later in life.Self-administered questionnaires examined sexual desire, activity, satisfaction, and problems in a multiethnic cohort of women aged 40 years and older with at least one past childbirth event. Trained abstractors obtained information on parity, mode of delivery, and other parturition-related factors from archived records. Multivariable regression models examined associations with sexual function controlling for age, race or ethnicity, partner status, diabetes, and general health.Among 1,094 participants, mean (standard deviation) age was 56.3 (�8.7) years, 568 (43%) were racial or ethnic minorities (214 African American, 171 Asian, and 183 Latina), and 963 (88%) were multiparous. Fifty-six percent (n=601) reported low sexual desire; 53% (n=577) reported less than monthly sexual activity, and 43% (n=399) reported low overall sexual satisfaction. Greater parity was not associated with increased risk of reporting low sexual desire (adjusted odds ratio [OR] 1.08, confidence interval [CI] 0.96-1.21 per each birth), less than monthly sexual activity (adjusted OR 1.05, CI 0.93-1.20 per each birth), or low sexual satisfaction (adjusted OR 0.96, CI 0.85-1.09 per each birth). Compared with vaginal delivery alone, women with a history of cesarean delivery were not significantly more likely to report low desire (adjusted OR 0.71, CI 0.34-1.47), less than monthly sexual activity (adjusted OR 1.03, CI 0.46-2.32), or low sexual satisfaction (adjusted OR 0.57, CI 0.26-1.22). Women with a history of operative-assisted delivery were more likely to report low desire (adjusted OR 1.38, CI 1.04-1.83).Among women with at least one childbirth event, parity and mode of delivery are not major determinants of sexual desire, activity, or satisfaction later in life.II.

View details for DOI 10.1097/AOG.0b013e3182a7f3fc

View details for Web of Science ID 000330448500010

View details for PubMedID 24104776

View details for PubMedCentralID PMC3813451
Fecal Incontinence Decreases Sexual Quality of Life, But Does Not Prevent Sexual Activity in Women DISEASES OF THE COLON & RECTUM Imhoff, L. R., Brown, J. S., Creasman, J. M., Subak, L. L., Van den Eeden, S. K., Thom, D. H., Varma, M. G., Huang, A. J. 2012; 55 (10): 1059?65
Abstract

The impact of anal incontinence on women's sexual function is poorly understood.The aim of this study was to investigate the relationship between anal incontinence and sexual activity and functioning in women.This is a cross-sectional study.This investigation was conducted in a community-based integrated health care delivery system.Included were 2269 ethnically diverse women aged 40 to 80 years.Self-administered questionnaires assessed accidental leakage of gas (flatal incontinence) and fluid/mucus/stool (fecal incontinence) in the past 3 months. Additional questionnaires assessed sexual activity, desire and satisfaction, as well as specific sexual problems (difficulty with arousal, lubrication, orgasm, or pain). Multivariable logistic regression models compared sexual function in women with 1) isolated flatal incontinence, 2) fecal incontinence (with or without flatal incontinence), and 3) no fecal/flatal incontinence, controlling for potential confounders.Twenty-four percent of women reported fecal incontinence and 43% reported isolated flatal incontinence in the previous 3 months. The majority were sexually active (62% of women without fecal/flatal incontinence, 66% with isolated flatal incontinence, and 60% with fecal incontinence; p = 0.06). In comparison with women without fecal/flatal incontinence, women with fecal incontinence were more likely to report low sexual desire (OR: 1.41 (CI: 1.10-1.82)), low sexual satisfaction (OR: 1.56 (CI: 1.14-2.12)), and limitation of sexual activity by physical health (OR: 1.65 (CI: 1.19-2.28)) after adjustment for confounders. Among sexually active women, women with fecal incontinence were more likely than women without fecal/flatal incontinence to report difficulties with lubrication (OR: 2.66 (CI: 1.76-4.00)), pain (OR: 2.44 (CI: 1.52-3.91)), and orgasm (OR: 1.68 (CI: 1.12-2.51)). Women with isolated flatal incontinence reported sexual functioning similar to women without fecal/flatal incontinence.The cross-sectional design prevented evaluation of causality.Although most women with fecal incontinence are at high risk for several aspects of sexual dysfunction, the presence of fecal incontinence does not prevent women from engaging in sexual activity. This indicates that sexual function is important to women with anal incontinence and should be prioritized during therapeutic management.

View details for DOI 10.1097/DCR.0b013e318265795d

View details for Web of Science ID 000308797600020

View details for PubMedID 22965405

View details for PubMedCentralID PMC3720983
Diabetes Mellitus and Sexual Function in Middle-Aged and Older Women OBSTETRICS AND GYNECOLOGY Copeland, K. L., Brown, J. S., Creasman, J. M., Van Den Eeden, S. K., Subak, L. L., Thom, D. H., Ferrara, A., Huang, A. J. 2012; 120 (2): 331?40
Abstract

Diabetes mellitus is an established risk factor for sexual dysfunction in men, but its effect on female sexual function is poorly understood. We examined the relationship of diabetes to sexual function in middle-aged and older women.Sexual function was examined in a cross-sectional cohort of ethnically diverse women aged 40-80 years using self-administered questionnaires. Multivariable regression models compared self-reported sexual desire, frequency of sexual activity, overall sexual satisfaction, and specific sexual problems (difficulty with lubrication, arousal, orgasm, or pain) among insulin-treated diabetic, non-insulin-treated diabetic, and nondiabetic women. Additional models assessed relationships between diabetic end-organ complications (heart disease, stroke, renal dysfunction, and peripheral neuropathy) and sexual function.Among the 2,270 participants, mean�standard deviation age was 55�9.2 years, 1,006 (44.4%) were non-Latina white, 486 (21.4%) had diabetes, and 139 (6.1%) were taking insulin. Compared with 19.3% of nondiabetic women, 34.9% of insulin-treated diabetic women (adjusted odds ratio [OR] 2.04, 95% confidence interval [CI] 1.32-3.15) and 26.0% of non-insulin-treated diabetic women (adjusted OR 1.42, 95% CI 1.03-1.94) reported low overall sexual satisfaction. Among sexually active women, insulin-treated diabetic women were more likely to report problems with lubrication (OR 2.37, 95% CI 1.35-4.16) and orgasm (OR 1.80, 95% CI 1.01-3.20) than nondiabetic women. Among all diabetic women, end-organ complications such as heart disease, stroke, renal dysfunction, and peripheral neuropathy were associated with decreased sexual function in at least one domain.Compared with nondiabetic women, diabetic women are more likely to report low overall sexual satisfaction. Insulin-treated diabetic women also appear at higher risk for problems such as difficulty with lubrication and orgasm. Prevention of end-organ complications may be important in preserving sexual activity and function in diabetic women.II.

View details for DOI 10.1097/AOG.0b013e31825ec5fa

View details for Web of Science ID 000306713100020

View details for PubMedID 22825093

View details for PubMedCentralID PMC3404429
Decrease in Urinary Incontinence Management Costs in Women Enrolled in a Clinical Trial of Weight Loss to Treat Urinary Incontinence OBSTETRICS AND GYNECOLOGY Subak, L. L., Pinto, A., Wing, R. R., Nakagawa, S., Kusek, J. W., Herman, W. H., Kuppermann, M., Program Reduce Incontinence Diet 2012; 120 (2): 277?83
Abstract

To estimate the effect of a decrease in urinary incontinence (UI) frequency on UI management costs among women enrolled in a clinical trial of a weight loss intervention and to identify factors that predict change in cost.This is a secondary cohort analysis of 338 obese and overweight women with 10 or more weekly episodes of UI enrolled in an 18-month randomized clinical trial of a weight loss intervention compared with a structured education program to treat UI. Quantities of resources used for incontinence management, including pads, additional laundry, and dry cleaning, were reported by participants. Direct costs for UI management ("cost") were calculated by multiplying resources used by national resource costs (in 2006 U.S. dollars). Randomized groups were combined to examine the effects of change in incontinence frequency on cost. Possible predictors of change in cost were examined using generalized estimating equations controlling for factors associated with change in cost in univariable analyses.Mean age�standard deviation was 53�10 years and baseline weight was 97�17 kg. Mean weekly UI frequency was 24�18 at baseline and decreased by 37% at 6 months and 60% at 18 months' follow-up (both P<.001). At baseline, adjusted mean cost was $7.76�$14 per week, with costs increasing significantly with greater incontinence frequency. Mean cost decreased by 54% at 6 months and 81% at 18 months (both P<.001). In multivariable analyses, cost independently decreased by 23% for each decrease of seven UI episodes per week and 21% for each 5 kg of weight lost (P<.001 for both).In obese and overweight women enrolled in a clinical trial of weight loss for UI, incontinence management cost decreased by 81% at 18 months ($327 per woman per year) and was strongly and independently associated with decreasing incontinence frequency.II.

View details for DOI 10.1097/AOG.0b013e31825dd268

View details for Web of Science ID 000306713100012

View details for PubMedID 22825085

View details for PubMedCentralID PMC3404427
Pharmacologic treatment for urgency-predominant urinary incontinence in women diagnosed using a simplified algorithm: a randomized trial AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Huang, A. J., Hess, R., Arya, L. A., Richter, H. E., Subak, L. L., Bradley, C. S., Rogers, R. G., Myers, D. L., Johnson, K. C., Gregory, W., Kraus, S. R., Schembri, M., Brown, J. S. 2012; 206 (5): 444.e1?11
Abstract

The purpose of this study was to evaluate clinical outcomes associated with the initiation of treatment for urgency-predominant incontinence in women diagnosed by a simple 3-item questionnaire.We conducted a multicenter, double-blinded, 12-week randomized trial of pharmacologic therapy for urgency-predominant incontinence in ambulatory women diagnosed by the simple 3-item questionnaire. Participants (N = 645) were assigned randomly to fesoterodine therapy (4-8 mg daily) or placebo. Urinary incontinence was assessed with the use of voiding diaries; postvoid residual volume was measured after treatment.After 12 weeks, women who had been assigned randomly to fesoterodine therapy reported 0.9 fewer urgency and 1.0 fewer total incontinence episodes/day, compared with placebo (P ? .001). Four serious adverse events occurred in each group, none of which was related to treatment. No participant had postvoid residual volume of ? 250 mL after treatment.Among ambulatory women with urgency-predominant incontinence diagnosed with a simple 3-item questionnaire, pharmacologic therapy resulted in a moderate decrease in incontinence frequency without increasing significant urinary retention or serious adverse events, which provides support for a streamlined algorithm for diagnosis and treatment of female urgency-predominant incontinence.

View details for DOI 10.1016/j.ajog.2012.03.002

View details for Web of Science ID 000303211100029

View details for PubMedID 22542122

View details for PubMedCentralID PMC3570031
Summary of Research Recommendations From the Inaugural American Urogynecologic Society Research Summit FEMALE PELVIC MEDICINE AND RECONSTRUCTIVE SURGERY Nygaard, I., Chai, T. C., Cundiff, G. W., Delancey, J. L., FitzGerald, M., Heit, M., Moalli, P., Richter, H. E., Subak, L., Swift, S. 2011; 17 (1): 4?7
View details for DOI 10.1097/SPV.0b013e3182042168

View details for Web of Science ID 000209176000002

View details for PubMedID 22453666
Incidence of and Risk Factors for Change in Urinary Incontinence Status in a Prospective Cohort of Middle-Aged and Older Women: The Reproductive Risk of Incontinence Study in Kaiser JOURNAL OF UROLOGY Thom, D. H., Brown, J. S., Schembri, M., Ragins, A. I., Subak, L. L., Van Den Eeden, S. K. 2010; 184 (4): 1394?1401
Abstract

Urinary incontinence is a dynamic condition that can progress and regress but few groups have examined risk factors for change in incontinence status.We used stratified random sampling to construct a racially and ethnically diverse, population based cohort of 2,109 women 40 to 69 years old. Data were collected by questionnaires and medical record review. A second survey approximately 5 years later was completed by 1,413 women (67%) from the original cohort. The frequency of urinary incontinence was categorized as less than weekly, weekly and daily. Change in incontinence status was defined as new onset incontinence, incontinence progression or regression between frequency categories and resolution of incontinence. Predictor variables were demographics, body mass index and other medical conditions. We used logistic regression to estimate the adjusted OR and 95% CI.Compared to white nonHispanic women, black women were less likely to have incontinence progression (OR 0.46, 95% CI 0.24-0.88). New onset incontinence was more common in women with a higher body mass index at baseline (p = 0.006) and those who experienced increased body mass index (p = 0.03) or decreased general health (p = 0.007) during the study. Participants with chronic obstructive pulmonary disorder at baseline were more likely to report incontinence progression (OR 2.64, 95% CI 1.22-5.70). Baseline incontinence type was not significantly associated with the risk of change in continence status independent of frequency.Identifying risk factors for change in incontinence status may be important to develop interventions to decrease the burden of incontinence in the general population.

View details for DOI 10.1016/j.juro.2010.05.095

View details for Web of Science ID 000282615400056

View details for PubMedID 20727544

View details for PubMedCentralID PMC2939171
Urinary incontinence, fecal incontinence and pelvic organ prolapse in a population-based, racially diverse cohort: prevalence and risk factors. Female pelvic medicine & reconstructive surgery Rortveit, G., Subak, L. L., Thom, D. H., Creasman, J. M., Vittinghoff, E., Van Den Eeden, S. K., Brown, J. S. 2010; 16 (5): 278?83
Abstract

OBJECTIVES: : We investigated the prevalence of and risk factors for combinations of urinary incontinence (UI), fecal incontinence (FI) and pelvic organ prolapse (POP) in racially diverse women older than 40 years.METHODS: : The Reproductive Risks for Incontinence Study at Kaiser is a population-based study with data from 2106 women older than 40 years. Pelvic floor conditions were determined by self-report. Risk factors were assessed by self-report, interview and record review. Independent risk factors were identified by multinomial logistic regression analysis.RESULTS: : At least one pelvic floor condition was reported by 714 (34%) women. Of these, 494 (69%) had only UI, 60 (8%) only POP, and 46 (6%) only FI. Both UI and FI were reported by 64 (9%) and both UI and POP by 51 (7%). Among women with FI, 60% reported more than one condition. Corresponding figures for POP and UI were 49% and 18%. Estrogen use and constipation were shared risk factors for UI, FI and POP. Body mass index was a unique risk factor UI only, diabetes FI only and parity POP only. No clear pattern could be found to support the hypothesis that risk factors for single conditions are more strongly associated with combined conditions.CONCLUSIONS: : Patients with FI or POP often have concomitant UI. These diseases both share and have unique risk factors in a complex pattern.

View details for DOI 10.1097/SPV.0b013e3181ed3e31

View details for PubMedID 22453506
An Intensive Behavioral Weight Loss Intervention and Hot Flushes in Women ARCHIVES OF INTERNAL MEDICINE Huang, A. J., Subak, L. L., Wing, R., West, D., Hernandez, A. L., Macer, J., Grady, D., Program Reduce Incontinence Diet 2010; 170 (13): 1161?67
Abstract

Higher body mass index is associated with worse hot flushes during menopause but the effect of weight loss on flushing is unclear.Self-administered questionnaires were used to assess bothersome hot flushes in a 6-month randomized controlled trial of an intensive behavioral weight loss program (intervention) vs a structured health education program (control) in 338 women who were overweight or obese and had urinary incontinence. Weight, body mass index, abdominal circumference, physical activity, calorie intake, blood pressure, and physical and mental functioning were assessed at baseline and at 6 months. Repeated-measures proportional odds models examined intervention effects on bothersome hot flushes and potential mediating factors.Approximately half of participants (n = 154) were at least slightly bothered by hot flushes at baseline. Among these women, the intervention was associated with greater improvement in bothersome flushes vs control (odds ratio [OR] for improvement by 1 Likert category, 2.25; 95% confidence interval [CI], 1.20-4.21). Reductions in weight (OR, 1.32; 95% CI, 1.08-1.61; per 5-kg decrease), body mass index (1.17; 1.05-1.30; per 1-point decrease), and abdominal circumference (1.32; 1.07-1.64; per 5-cm decrease) were each associated with improvement in flushing, but changes in physical activity, calorie intake, blood pressure, and physical and mental functioning were not related. The effect of the intervention on flushing was modestly diminished after adjustment for multiple potential mediators (OR, 1.92; 95% CI, 0.95-3.89).Among women who were overweight or obese and had bothersome hot flushes, an intensive behavioral weight loss intervention resulted in improvement in flushing relative to control. Trial Registration clinicaltrials.gov Identifier: NCT00091988.

View details for DOI 10.1001/archinternmed.2010.162

View details for Web of Science ID 000279797700015

View details for PubMedID 20625026

View details for PubMedCentralID PMC3030922
Talking About Incontinence The First Step Toward Prevention and Treatment JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Wagner, T. H., Subak, L. L. 2010; 303 (21): 2184?85
View details for PubMedID 20516420
An Innovative Program to Train Health Sciences Researchers to Be Effective Clinical and Translational Research Mentors ACADEMIC MEDICINE Johnson, M. O., Subak, L. L., Brown, J. S., Lee, K. A., Feldman, M. D. 2010; 85 (3): 484-489
Abstract

The creation of the Clinical Translational Science Awards for academic health sciences campuses in 2006 was implicitly accompanied by a call for a new paradigm of faculty development and mentoring to train the next generation of researchers and leaders in this new approach to research. Effective mentoring is critical to help early-career investigators become successful, independent researchers, and a new approach to mentoring is vital to recruit, advance, and retain fellows and junior faculty engaged in clinical and translational research. However, in addition to the many rewards of mentoring, there are numerous substantive barriers to effective mentoring. These barriers include a lack of training in how to be a mentor, lack of time and structural and financial support for mentoring, and competing personal, administrative, and clinical demands. The authors describe an innovative program, the University of California, San Francisco Mentor Development Program (MDP), established in 2006 and designed to train midcareer academic health sciences researchers to be more effective as clinical and translational research mentors. Using a framework for presenting innovations in academic research, they present the rationale, design, implementation, and mechanisms being used to evaluate and sustain the MDP. Specific details of the objectives and content of the MDP sessions are provided as well as evaluation criteria and a link to specific curriculum materials.

View details for DOI 10.1097/ACM.0b013e3181cccd12

View details for Web of Science ID 000276132100023

View details for PubMedID 20182122

View details for PubMedCentralID PMC2856696
Pelvic floor disorders and quality of life in women with self-reported irritable bowel syndrome ALIMENTARY PHARMACOLOGY & THERAPEUTICS Wang, J., Varma, M. G., Creasman, J. M., Subak, L. L., Brown, J. S., Thom, D. H., van den Eeden, S. K. 2010; 31 (3): 424?31
Abstract

Quality of life among women with irritable bowel syndrome may be affected by pelvic floor disorders.To assess the association of self-reported irritable bowel syndrome with urinary incontinence, pelvic organ prolapse, sexual function and quality of life.We analysed data from the Reproductive Risks for Incontinence Study at Kaiser Permanente, a random population-based study of 2109 racially diverse women (mean age = 56). Multivariate analyses assessed the association of irritable bowel syndrome with pelvic floor disorders and quality of life.The prevalence of irritable bowel syndrome was 9.7% (n = 204). Women with irritable bowel had higher adjusted odds of reporting symptomatic pelvic organ prolapse (OR 2.4; 95% CI, 1.4-4.1) and urinary urgency (OR 1.4; 95% CI, 1.0-1.9); greater bother from pelvic organ prolapse (OR 4.3; 95% CI, 1.5-11.9) and faecal incontinence (OR 2.0; 95% CI, 1.3-3.2); greater lifestyle impact from urinary incontinence (OR 2.2; 95% CI, 1.3-3.8); and worse quality of life (P < 0.01). Women with irritable bowel reported more inability to relax and enjoy sexual activity (OR 1.8; 95% CI, 1.3-2.6) and lower ratings for sexual satisfaction (OR 1.8; 95% CI, 1.3-2.5), but no difference in sexual frequency, interest or ability to have an orgasm.Women with irritable bowel are more likely to report symptomatic pelvic organ prolapse and sexual dysfunction, and report lower quality of life.

View details for DOI 10.1111/j.1365-2036.2009.04180.x

View details for Web of Science ID 000273300700009

View details for PubMedID 19863498

View details for PubMedCentralID PMC2807921
Obesity and Urinary Incontinence: Epidemiology and Clinical Research Update Subak, L. L., Richter, H. E., Hunskaar, S. ELSEVIER SCIENCE INC. 2009: S2?S7
Abstract

We reviewed the epidemiological literature on the association of obesity and urinary incontinence, and summarized clinical trial data on the effect of weight loss on urinary incontinence.We systematically searched for published community based prevalence studies with bivariate or multivariate analysis of the association of urinary incontinence and overweight/obesity in women. Case series and randomized controlled trials of the effect of surgical, behavioral and pharmacological weight loss on urinary incontinence are summarized.Epidemiological studies showed that obesity is a strong independent risk factor for prevalent and incident urinary incontinence. There was a clear dose-response effect of weight on urinary incontinence with each 5-unit increase in body mass index associated with about a 20% to 70% increase in the urinary incontinence risk, and the maximum effect of weight rarely exceeded an OR of greater than 4 to 5 on well controlled analyses. The odds of incident urinary incontinence during 5 to 10 years increased by approximately 30% to 60% for each 5-unit increase in body mass index. There may be a stronger association of increasing weight with prevalent and incident stress incontinence, including mixed incontinence, than with urge incontinence and overactive bladder syndrome. Weight loss studies indicated that surgical and nonsurgical weight loss led to significant improvements in urinary incontinence symptoms.Epidemiological studies document overweight and obesity as important risk factors for urinary incontinence. Weight loss by surgical and more conservative approaches is effective to decrease urinary incontinence symptoms and should be strongly considered a first line treatment in this patient population.

View details for DOI 10.1016/j.juro.2009.08.071

View details for Web of Science ID 000271668800002

View details for PubMedID 19846133

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Sexual Function Among Overweight and Obese Women With Urinary Incontinence in a Randomized Controlled Trial of an Intensive Behavioral Weight Loss Intervention JOURNAL OF UROLOGY Huang, A. J., Stewart, A. L., Hernandez, A. L., Shen, H., Subak, L. L., Program Reduce Incontinence Diet & 2009; 181 (5): 2235?42
Abstract

We examined sexual function in overweight and obese women with urinary incontinence, and evaluated the effects of an intensive behavioral weight reduction intervention on sexual function in this population.A total of 338 overweight and obese women reporting 10 or more incontinence episodes weekly were randomized to an intensive behavioral change (226) or structured education program (112) for 6 months. Sexual function was assessed using self-administered questionnaires. Multivariate regression was used to examine factors associated with baseline and 6-month change in sexual function as well as intervention effects.Two-thirds of participants (233) were sexually active at baseline but more than half (188) reported low desire and a quarter (91) were sexually dissatisfied. More than half of sexually active participants (123) reported problems with arousal, lubrication, orgasm or incontinence during sex. Compared to controls women in the intervention group demonstrated a borderline increase in frequency of sexual activity at 6 months (OR 1.34, 95% CI 0.99-1.81, p = 0.06) but no differences in satisfaction (OR 1.28, 95% CI 0.83-1.99, p = 0.26), desire (OR 1.12, 95% CI 0.79-1.61, p = 0.52) or problems (beta +/- SE 0.03 +/- 0.07, p = 0.68 for intervention effects on problems score). Neither clinical incontinence severity nor body mass index was independently associated with baseline or 6-month change in function (p >0.10 for all).Sexual dysfunction is common in overweight and obese women with incontinence but the severity of this dysfunction may not be directly related to the severity of incontinence or obesity. An intensive 6-month behavioral weight reduction intervention did not significantly improve sexual function in this population relative to controls.

View details for DOI 10.1016/j.juro.2009.01.046

View details for Web of Science ID 000265074800100

View details for PubMedID 19296980

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Weight Loss to Treat Urinary Incontinence in Overweight and Obese Women. NEW ENGLAND JOURNAL OF MEDICINE Subak, L. L., Wing, R., West, D., Franklin, F., Vittinghoff, E., Creasman, J. M., Richter, H. E., Myers, D., Burgio, K. L., Gorin, A. A., Macer, J., Kusek, J. W., Grady, D., PRIDE Investigators 2009; 360 (5): 481?90
Abstract

Obesity is an established and modifiable risk factor for urinary incontinence, but conclusive evidence for a beneficial effect of weight loss on urinary incontinence is lacking.We randomly assigned 338 overweight and obese women with at least 10 urinary-incontinence episodes per week to an intensive 6-month weight-loss program that included diet, exercise, and behavior modification (226 patients) or to a structured education program (112 patients).The mean (+/-SD) age of the participants was 53+/-11 years. The body-mass index (BMI) (the weight in kilograms divided by the square of the height in meters) and the weekly number of incontinence episodes as recorded in a 7-day diary of voiding were similar in the intervention group and the control group at baseline (BMI, 36+/-6 and 36+/-5, respectively; incontinence episodes, 24+/-18 and 24+/-16, respectively). The women in the intervention group had a mean weight loss of 8.0% (7.8 kg), as compared with 1.6% (1.5 kg) in the control group (P<0.001). After 6 months, the mean weekly number of incontinence episodes decreased by 47% in the intervention group, as compared with 28% in the control group (P=0.01). As compared with the control group, the intervention group had a greater decrease in the frequency of stress-incontinence episodes (P=0.02), but not of urge-incontinence episodes (P=0.14). A higher proportion of the intervention group than of the control group had a clinically relevant reduction of 70% or more in the frequency of all incontinence episodes (P<0.001), stress-incontinence episodes (P=0.009), and urge-incontinence episodes (P=0.04).A 6-month behavioral intervention targeting weight loss reduced the frequency of self-reported urinary-incontinence episodes among overweight and obese women as compared with a control group. A decrease in urinary incontinence may be another benefit among the extensive health improvements associated with moderate weight reduction. (ClinicalTrials.gov number, NCT00091988.)

View details for DOI 10.1056/NEJMoa0806375

View details for Web of Science ID 000262812400007

View details for PubMedID 19179316

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High costs of urinary incontinence among women electing surgery to treat stress incontinence OBSTETRICS AND GYNECOLOGY Subak, L. L., Brubaker, L., Chai, T. C., Creasman, J. M., Diokno, A. C., Goode, P. S., Kraus, S. R., Kusek, J. W., Leng, W. W., Lukacz, E. S., Norton, P., Tennstedt, S., Urinary Incontinence Treatment Ne 2008; 111 (4): 899?907
Abstract

To estimate costs for incontinence management, health-related quality of life, and willingness to pay for incontinence improvement in women electing surgery for stress urinary incontinence.A total of 655 incontinent women enrolled in the Stress Incontinence Surgical Treatment Efficacy Trial, a randomized surgical trial. Baseline out-of-pocket costs for incontinence management were calculated by multiplying self-report of resources used (supplies, laundry, dry cleaning) by national resource costs (USD2,006). Health-related quality of life was estimated with the Health Utilities Index Mark 3. Participants estimated willingness to pay for 100% improvement in incontinence. Potential predictors of these outcomes were examined by using multivariable linear regression.Mean age was 52+/-10 years, and mean number of weekly incontinence episodes was 22+/-21. Mean and median (25%, 75% interquartile range) estimated personal costs for incontinence management among all women were USD14+/-USD24 and USD8 (interquartile range USD3, USD18) per week, and 617 (94%) women reported any cost. Costs increased significantly with incontinence frequency and mixed compared with stress incontinence. The mean and median Health Utilities Index Mark 3 scores were 0.73+/-0.25 and 0.84 (interquartile range 0.63, 0.92). Women were willing to pay a mean of USD118+/-USD132 per month for complete resolution of incontinence, and willingness to pay increased significantly with greater expected incontinence improvement, household income, and incontinent episode frequency.Urinary incontinence is associated with substantial costs. Women spent nearly USD750 per year out of pocket for incontinence management, had a significant decrement in quality of life, and were willing to pay nearly USD1,400 per year for cure.

View details for DOI 10.1097/AOG.0b013e31816a1e12

View details for Web of Science ID 000254433700013

View details for PubMedID 18378749

View details for PubMedCentralID PMC2593129
Urinary incontinence in women: Direct costs of routine care. American journal of obstetrics and gynecology Subak, L., Van Den Eeden, S., Thom, D., Creasman, J. M., Brown, J. S. 2007; 197 (6): 596.e1?9
Abstract

The purpose of this study was to estimate the direct costs of routine care for urinary incontinence (UI) in community-dwelling, racially diverse women.In the Reproductive Risks for Incontinence Study at Kaiser population-based study, 528 women with UI weekly or more quantified resources that were used for UI. Routine care costs were calculated with the use of national resource costs ($2005). Potential predictors of these outcomes were examined by multivariable linear regression.Mean age was 55 +/- 9 (SD) years. Among women with weekly UI, 69% reported incontinence-related costs. Median weekly cost was $1.83 (25%-75% interquartile range [IQR], $0.50, $5.23), increasing from $0.93 (IQR, $0, $3) for moderate to $7.82 (IQR, $5, $37) for very severe incontinence. Costs that increased with incontinence severity (P < .001) and body mass index (P < .001) were 2.2-fold higher for African American versus white women (P < .0001) and 42% higher for women with mixed versus stress incontinence (P < .05).Women pay a mean of >$250 per year out-of-pocket for UI routine care. Effective incontinence treatment may decrease costs.

View details for DOI 10.1016/j.ajog.2007.04.029

View details for PubMedID 17880904
The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence ANNALS OF INTERNAL MEDICINE Brown, J. S., Bradley, C. S., Subak, L. L., Richter, H. E., Kraus, S. R., Brubaker, L., Lin, F., Vittinghoff, E., Grady, D., Diagnost Aspects Incontinence Stu 2006; 144 (10): 715?23
Abstract

Urinary incontinence is common in women. Because treatments differ, urge incontinence should be distinguished from stress incontinence. To make this distinction, current guidelines recommend an extensive evaluation that is too time-consuming for primary care practice.To test the accuracy of a simple questionnaire to categorize type of urinary incontinence in women.Multicenter, prospective study of the accuracy of the 3 Incontinence Questions (3IQ) compared with an extended evaluation to distinguish between urge incontinence and stress incontinence.5 academic medical centers in the United States.301 women enrolled from April to December 2004 who were older than 40 years of age (mean age, 56 years [SD, 11]) with untreated incontinence for an average of 7 years (SD, 7) and a broad range of incontinence severity.All participants included in the analyses answered the 3IQ questionnaire, and a urologist or urogynecologist who was blinded to the responses performed the extended evaluation. Sensitivity, specificity, and likelihood ratios were determined for the 3IQ.For classification of urge incontinence and with the extended evaluation as the gold standard, the 3IQ had a sensitivity of 0.75 (95% CI, 0.68 to 0.81), a specificity of 0.77 (CI, 0.69 to 0.84), and a positive likelihood ratio of 3.29 (CI, 2.39 to 4.51). For classification of stress incontinence, the sensitivity was 0.86 (CI, 0.79 to 0.90), the specificity was 0.60 (CI, 0.51 to 0.68), and the positive likelihood ratio was 2.13 (CI, 1.71 to 2.66).Participants were enrolled by urologists and urogynecologists at academic medical centers.The 3IQ questionnaire is a simple, quick, and noninvasive test with acceptable accuracy for classifying urge and stress incontinence and may be appropriate for use in primary care settings. Similar studies are needed in other populations. We also need a clinical trial comparing the outcomes of treatments based on the 3IQ and the extended evaluation.

View details for DOI 10.7326/0003-4819-144-10-200605160-00005

View details for Web of Science ID 000237636400002

View details for PubMedID 16702587

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The "costs" of urinary incontinence for women Subak, L. L., Brown, J. S., Kraus, S. R., Brubaker, L., Lin, F., Richter, H. E., Bradley, C. S., Grady, D., DAISy Grp LIPPINCOTT WILLIAMS & WILKINS. 2006: 908?16
Abstract

To estimate costs of routine care for female urinary incontinence, health-related quality of life, and willingness to pay for incontinence improvement.In a cross-sectional study at 5 U.S. sites, 293 incontinent women quantified supplies, laundry, and dry cleaning specifically for incontinence. Costs were calculated by multiplying resources used by national resource costs and presented in 2005 United States dollars (2005). Health-related quality of life was estimated with the Health Utilities Index. Participants estimated willingness to pay for 25-100% improvement in incontinence. Potential predictors of these outcomes were examined using multivariable linear regression.Mean age was 56 +/- 11 years; participants were racially diverse and had a broad range of incontinence severity. Nearly 90% reported incontinence-related costs. Median weekly cost (25%, 75% interquartile range) increased from 0.37 dollars (0, 4 dollars) for slight to 10.98 dollars (4, 21 dollars) for very severe incontinence. Costs increased with incontinence severity (P < .001). Costs were 2.4-fold higher for African American compared with white women (P < .001) and 65% higher for women with urge compared with those having stress incontinence (P < .001). More frequent incontinence was associated with lower Health Utilities Index score (mean 0.90 +/- 0.11 for weekly and 0.81 +/- 0.21 for daily incontinence; P = .02). Women were willing to pay a mean of 70 dollars +/- 64 dollars per month for complete resolution of incontinence, and willingness to pay increased with income and greater expected benefit.Women with severe urinary incontinence pay 900 dollars annually for incontinence routine care, and incontinence is associated with a significant decrement in health-related quality of life. Effective incontinence treatment may decrease costs and improve quality of life.III.

View details for DOI 10.1097/01.AOG.0000206213.48334.09

View details for Web of Science ID 000241296200025

View details for PubMedID 16582131

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Fecal incontinence in females older than aged 40 years: who is at risk? Diseases of the colon and rectum Varma, M. G., Brown, J. S., Creasman, J. M., Thom, D. H., Van Den Eeden, S. K., Beattie, M. S., Subak, L. L. 2006; 49 (6): 841?51
Abstract

This study was designed to estimate the prevalence of, and identify risk factors associated with, fecal incontinence in racially diverse females older than aged 40 years.The Reproductive Risks for Incontinence Study at Kaiser is a population-based study of 2,109 randomly selected middle-aged and older females (average age, 56 years). Fecal incontinence, determined by self-report, was categorized by frequency. Females reported the level of bother of fecal incontinence and their general quality of life. Potential risk factors were assessed by self-report, interview, physical examination, and record review. Multivariate logistic regression analysis was used to determine the independent association between selected risk factors and the primary outcome of any reported fecal incontinence in the past year.Fecal incontinence in the past year was reported by 24 percent of females (3.4 percent monthly, 1.9 percent weekly, and 0.2 percent daily). Greater frequency of fecal incontinence was associated with decreased quality of life (Medical Outcome Short Form-36 Mental Component Scale score, P = 0.01), and increased bother (P < 0.001) with 45 percent of females with fecal incontinence in the past year and 100 percent of females with daily fecal incontinence reporting moderate or great bother. In multivariate analysis, the prevalence of fecal incontinence in the past year increased significantly [odds ratio per 5 kg/m2 (95 percent confidence interval)] with obesity [1.2 (1.1-1.3)], chronic obstructive pulmonary disease [1.9 (1.3-2.9)], irritable bowel syndrome [2.4 (1.7-3.4)], urinary incontinence [2.1 (1.7-2.6)], and colectomy [1.9 (1.1-3.1)]. Latina females were less likely to report fecal incontinence than white females [0.6 (0.4-0.9)].Fecal incontinence, a common problem for females, is associated with substantial adverse affects on quality of life. Several of the identified risk factors are preventable or modifiable, and may direct future research in fecal incontinence therapy.

View details for DOI 10.1007/s10350-006-0535-0

View details for PubMedID 16741640

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Differences in prevalence of urinary incontinence by race/ethnicity. The Journal of urology Thom, D. H., van den Eeden, S. K., Ragins, A. I., Wassel-Fyr, C., Vittinghof, E., Subak, L. L., Brown, J. S. 2006; 175 (1): 259?64
Abstract

We compared the prevalence of urinary incontinence by type among white, black, Hispanic and Asian-American women.The RRISK is a population based cohort study of 2,109 randomly selected middle-aged and older women. Incontinence and other variables were assessed by self-report questionnaires and in person interviews. Labor and delivery and surgical data were abstracted from medical records archived since 1946. Logistic regression was used to estimate the OR with 95% CIs for incontinence while adjusting for covariates.The age adjusted prevalence of weekly incontinence was highest among Hispanic women, followed by white, black and Asian-American women (36%, 30%, 25% and 19%, respectively, p <0.001). Type of incontinence also differed among groups, with weekly stress incontinence prevalence being 18%, 15%, 8% and 8% (p <0.001), and weekly urge incontinence prevalence being 10%, 9%, 14% and 7% (p <0.001). After adjustment for age, parity, hysterectomy, estrogen use, body mass, menopausal status and diabetes, the risk of stress incontinence remained significantly lower in black (adjusted OR 0.36, 95% CI 0.23-0.57) and Asian-American (adjusted OR 0.54, 95% CI 0.34-0.86) women compared to white women. In contrast, the risk of urge incontinence was similar in black (adjusted OR 1.19, 95% CI 0.79-1.81) and Asian-American (adjusted OR 0.86, 95% CI 0.52-1.43) women compared to white women.Significant differences in the adjusted risk of stress incontinence among Hispanic, white, black and Asian-American women suggest the presence of additional, as yet unrecognized, risk or protective factors for stress incontinence.

View details for DOI 10.1016/S0022-5347(05)00039-X

View details for PubMedID 16406923

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Postmenopausal hormone therapy - Does it cause incontinence? OBSTETRICS AND GYNECOLOGY Steinauer, J. E., Waetjen, L. E., Vittinghoff, E., Subak, L. L., Hulley, S. B., Grady, D., Lin, F., Brown, J. S., Heart Estrogen Progestin Replacem 2005; 106 (5): 940?45
Abstract

To estimate the effect of hormone therapy on risk of stress and urge urinary incontinence.The Heart Estrogen/progestin Replacement Study was a randomized, placebo-controlled, double-blinded trial to evaluate daily oral conjugated estrogen (0.625 mg) plus medroxyprogesterone acetate (2.5 mg) therapy for the prevention of heart disease events in women with established heart disease. The 1,208 participants in Heart Estrogen/progestin Replacement Study who reported no loss of urine in the previous 7 days at baseline are included in this analysis.During 4.2 years of treatment, 64% of women randomly assigned to hormone therapy compared with 49% of those assigned to placebo reported weekly incontinence (P < .001). The higher risk of incontinence in the hormone group was evident at 4 months, persisted throughout the treatment period, and was independent of the age of the women. The odds ratios for weekly incontinence among women on hormone therapy compared with placebo were 1.5 for urge incontinence (95% confidence interval [CI] 1.2-1.8; P < .001) and 1.7 for stress incontinence (95% CI 1.5-2.1; P < .001). Four years of treatment with hormone therapy caused an excess risk of 12% for weekly urge incontinence and 16% for weekly stress incontinence; the corresponding numbers needed to harm were 8.6 (95% CI 5.8-16.6) and 6.2 (95% CI 4.6-9.4).Estrogen plus progestin therapy increases risk of urge and stress incontinence within 4 months of beginning treatment.I.

View details for DOI 10.1097/01.AOG.0000180394.08406.15

View details for Web of Science ID 000233018800008

View details for PubMedID 16260510

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Weight loss: A novel and effective treatment for urinary incontinence JOURNAL OF UROLOGY Subak, L. L., Whitcomb, E., Shen, H., Saxton, J., Vittinghoff, E., Brown, J. S. 2005; 174 (1): 190?95
Abstract

We evaluated the effect of weight loss on urinary incontinence (UI) in overweight and obese women.A randomized, controlled clinical trial was conducted among overweight and obese women experiencing at least 4 UI episodes per week. Women were randomly assigned to a 3-month liquid diet weight reduction program (24 in the immediate intervention group) or a wait-list delayed intervention group (24 in the wait-list control group). Participants in the wait-list control group began the weight reduction program in month 3 of the study. All women were followed for 6 months after completing the weight reduction program. Wilcoxon tests were used to compare intergroup differences in change in weekly UI episodes and quality of life scores.A total of 48 women were randomized and 40 were assessed 3 months after randomization. Median (with 25% to 75% interquartile range [IQR]) baseline age was 52 years (IQR 47 to 59), weight was 97 kg (IQR 87 to 106) and UI episodes were 21 weekly (IQR 11 to 33). Women in the immediate intervention group had a 16 kg (IQR 9 to 20) weight reduction compared with 0 kg (IQR -2 to 2) in the wait-list control group (p <0.0001). The immediate intervention group experienced a 60% reduction (IQR 30% to 89%) in weekly UI episodes compared with 15% (IQR -9% to 25%) in the wait-list control group (p <0.0005) and had greater improvement in quality of life scores. Stress (p =0.003) and urge (p =0.03) incontinent episodes decreased in the immediate intervention vs wait-list control group. Following the weight reduction program the wait-list control group experienced a similar median reduction in weekly UI episodes (71%). Among all 40 women mean weekly UI episodes decreased 54% (95% CI 40% to 69%) after weight reduction and the improvement was maintained for 6 months.Weight reduction is an effective treatment for overweight and obese women with UI. Weight loss of 5% to 10% has an efficacy similar to that of other nonsurgical treatments and should be considered a first line therapy for incontinence.

View details for DOI 10.1097/01.ju.0000162056.30326.83

View details for Web of Science ID 000229946400049

View details for PubMedID 15947625

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Evaluating an incontinence intervention in nursing home residents JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Wagner, T. H., Subak, L. L. 2003; 51 (2): 275-276
View details for Web of Science ID 000180605400020

View details for PubMedID 12558729
Proceedings of the National Institute of Diabetes and Digestive and Kidney Diseases International Symposium on Epidemiologic Issues in Urinary Incontinence in Women. American journal of obstetrics and gynecology Brown, J. S., Nyberg, L. M., Kusek, J. W., Burgio, K. L., Diokno, A. C., Foldspang, A., Fultz, N. H., Herzog, A. R., Hunskaar, S., Milsom, I., Nygaard, I., Subak, L. L., Thom, D. H. 2003; 188 (6): S77?88
Abstract

The Epidemiologic Issues in Urinary Incontinence: Current Databases and Future Collaborations Symposium included an international group of 29 investigators from 10 countries. The purpose of the symposium was to discuss the current understanding and knowledge gaps of prevalence, incidence, associated risk factors, and treatment outcomes for incontinence in women. During the symposium, investigators identified existing large databases and ongoing studies that provide substantive information on specific incontinence research questions. The investigators were able to form an international collaborative research working group and identify potential collaborative projects to further research on the epidemiology of urinary incontinence and bladder dysfunction.

View details for PubMedID 12825024
Cost-effectiveness analyses in Obstetrics & Gynecology - Evaluation of methodologic quality and trends JOURNAL OF REPRODUCTIVE MEDICINE Subak, L. L., Caughey, A. B., Washington, A. E. 2002; 47 (8): 631?39
Abstract

To evaluate methodologic quality and trends of cost-effectiveness analyses (CEAs) published in Obstetrics & Gynecology.Ten methodologic principles that should be incorporated in CEAs are used to evaluate CEAs published in Obstetrics & Gynecology from 1966 through 1999. We included articles that were cost-effectiveness or cost-benefit analyses or performed such analyses as part of their studies.Thirty-four CEAs met our inclusion criteria. Seven (20%) analyses adhered to 10, five (15%) to 9, and two (6%) to 8 of the 10 methodologic principles. The mean (+/- SD, median) number of principles to which studies adhered was 5.7 (+/- 3.3, 4). Studies had high compliance (> or = 85%) with principles of research questions, probabilities and effectiveness measures. Studies significantly improved over time in adherence to principles of time frame, perspective, costs, incremental analysis, sensitivity analysis, discounting and total score (all P < .05).The CEAs evaluated adhered to approximately half the methodologic principles for performing CEAs but showed significant improvements in quality over time. Understanding the methodology of CEAs is critical for researchers, editors and readers to accurately interpret the results of the growing body of CEA studies.

View details for Web of Science ID 000177657900007

View details for PubMedID 12216429
The effect of behavioral therapy on urinary incontinence: A randomized controlled OBSTETRICS AND GYNECOLOGY Subak, L. L., Quesenberry, C. P., Posner, S. F., Cattolica, E., Soghikian, K. 2002; 100 (1): 72?78
Abstract

To evaluate the effect of a low-intensity behavioral therapy program on urinary incontinence in older women.A randomized clinical trial for community-dwelling women at least 55 years reporting at least one urinary incontinent episode per week was conducted. Women were randomly assigned to a behavioral therapy group (n = 77) or a control group (n = 75). The treatment group had six weekly instructional sessions on bladder training and followed individualized voiding schedules. The control group received no instruction but kept urinary diaries for 6 weeks. After this period, the control group underwent the behavioral therapy protocol. Using per-protocol analyses, t and chi(2) tests were used to compare the treatment and control groups, and paired t tests were used to evaluate the efficacy of behavioral therapy for all women (treatment and control groups before and after behavioral therapy).Women in the treatment group experienced a 50% reduction in mean number of incontinent episodes recorded on a 7-day urinary diary compared with a 15% reduction for controls (P =.001). After behavioral therapy, all women had a 40% decrease in mean weekly incontinent episodes (P =.001), which was maintained over 6 months (P <.004). Thirty (31%) women were 100% improved (dry), 40 (41%) were at least 75% improved, and 50 (52%) at least 50% improved. There were no differences in treatment efficacy by type of incontinence (stress, urge, mixed) or group assignment (treatment, control).A low-intensity behavioral therapy intervention for urinary incontinence was effective and should be considered as a first-line treatment for urinary incontinence in older women.

View details for DOI 10.1016/S0029-7844(02)01993-2

View details for Web of Science ID 000176524400011

View details for PubMedID 12100806
Pelvic organ prolapse surgery in the United States, 1997 AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Brown, J. S., Waetjen, L. E., Subak, L. L., Thom, D. H., Van den Eeden, S., Vittinghoff, E. 2002; 186 (4): 712-716
Abstract

Our purpose was to describe the prevalence, regional rates and demographic characteristics, morbidity, and mortality of pelvic organ prolapse surgeries in the United States.We used data from the 1997 National Hospital Discharge Survey and the 1997 National Census to calculate rates of pelvic organ prolapse surgeries by age, race, and regional trends.In 1997, 225,964 women underwent surgery for prolapse (22.7 per 10,000 women). The mean age of these women was 54.6 years (+/-15.2). The South had the highest rate of surgery (29.3 per 10,000) and the Northeast had the lowest (16.1 per 10,000). The surgery rate for whites (19.6 per 10,000) was 3 times greater than that for African Americans (6.4 per 10,000). Although 16% of surgeries had complications, mortality was rare (0.03%).Pelvic organ prolapse surgery is common. Regional and racial differences in rates of surgery may reflect physician practice, patient preferences, and gynecologic care utilization.

View details for DOI 10.1067/mob.2002.121897

View details for Web of Science ID 000175545300018

View details for PubMedID 11967496
Does weight loss improve incontinence in moderately obese women? INTERNATIONAL UROGYNECOLOGY JOURNAL Subak, L. L., Johnson, C., Whitcomb, E., Boban, D., Saxton, J., Brown, J. S. 2002; 13 (1): 40-43
Abstract

The aim of this study was to evaluate the effect of weight reduction on urinary incontinence in moderately obese women. This prospective cohort study enrolled moderately obese women experiencing four or more incontinence episodes per week. BMI and a 7-day urinary diary were collected at baseline and on the completion of weight reduction. The study included 10 women with a mean (+/-SD) baseline BMI of 38.3 (+/-10.1) kg/m2 and 13 (+/-10) incontinent episodes per week. Participants had a mean BMI reduction of 5.3 (+/-6.2) kg/ m2 (P < 0.03). Among women achieving a weight loss of > or = 5%, 6/6 had > or = 50% reduction in incontinence frequency compared to 1 in 4 women with < 5% weight loss (P < 0.03). Incontinence episodes decreased to 8 (+/-10) per week following weight reduction (P < 0.07). The study demonstrated an association between weight reduction and improved urinary incontinence. Weight reduction should be considered for moderately obese women as part of non-surgical therapy for incontinence.

View details for Web of Science ID 000174940100009

View details for PubMedID 11999205
Cost of pelvic organ prolapse surgery in the United States OBSTETRICS AND GYNECOLOGY Subak, L. L., Waetjen, L. E., Van den Eeden, S., Thom, D. H., Vittinghoff, E., Brown, J. S. 2001; 98 (4): 646-651
Abstract

To estimate the annual direct cost to society of pelvic organ prolapse operations in the United States.We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures.In 1997, direct costs of pelvic organ prolapse surgery were 1012 million dollars (95% confidence interval [CI] 775 dollars, 1251 million), including 494 dollars million (49%) for vaginal hysterectomy, 279 million dollars (28%) for cystocele and rectocele repair, and 135 million dollars (13%) for abdominal hysterectomy. Physician services accounted for 29% (298 million dollars) of total costs, and hospitalization accounted for 71% (714 million dollars). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures (218 million dollars). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to 1543 million dollars.The annual direct costs of operations for pelvic organ prolapse are substantial.

View details for Web of Science ID 000171374400021

View details for PubMedID 11576582
Annual direct cost of urinary incontinence OBSTETRICS AND GYNECOLOGY Wilson, L., Brown, J. S., Shin, G. P., Luc, K. O., Subak, L. L. 2001; 98 (3): 398?406
Abstract

To estimate the annual direct cost of urinary incontinence in 1995 US dollars.Epidemiologically based models using diagnostic and treatment algorithms from published clinical practice guidelines and current disease prevalence data were used to estimate direct costs of urinary incontinence. Prevalence and event probability estimates were obtained from literature sources, national data sets, small surveys, and expert opinion. Average national Medicare reimbursement was used to estimate costs, which were determined separately by gender, age group, and type of incontinence. Sensitivity analyses were performed on all variables.The annual direct cost of urinary incontinence in the United States (in 1995 dollars) was estimated as $16.3 billion, including $12.4 billion (76%) for women and $3.8 billion (24%) for men. Costs for community-dwelling women ($8.6 billion, 69% of costs for women) were greater than for institutionalized women ($3.8 billion, 31%). Costs for women over 65 years of age were more than twice the costs for those under 65 years ($7.6 and $3.6 billion, respectively). The largest cost category was routine care (70% of costs for women), followed by nursing home admissions (14%), treatment (9%), complications (6%), and diagnosis and evaluations (1%). Costs were most sensitive to changes in incontinence prevalence, routine care costs, and institutionalization rates and costs.Urinary incontinence is a very costly condition, with annual expenditures similar to other chronic diseases in women.

View details for DOI 10.1016/S0029-7844(01)01464-8

View details for Web of Science ID 000170657900007

View details for PubMedID 11530119
Measuring cost-effectiveness of surgical procedures CLINICAL OBSTETRICS AND GYNECOLOGY Subak, L. L., Caughey, A. B. 2000; 43 (3): 551?60
Abstract

Our review of CEA of surgical procedures suggests that much of the existing cost analysis literature does not adhere to basic recommended analytic guidelines. However, those authors who specifically planned to perform a CEA analysis met all or nearly all of the methodologic principles (Table 1). Investigators who conduct CEA are strongly encouraged to use the many outstanding methodologic reviews for CEA. An example of threshold analysis was presented by Gray et al in their CEA of laparoscopy versus laparotomy for the treatment of ectopic pregnancy. They calculated that cost per successful treatment would be equal between the two strategies at an initial failure rate of 32% for laparoscopy (compared with their baseline value of 19%). This type of analysis is helpful, in addition to sensitivity analyses, to identify the value of a variable that results in an equal outcome. In the only cost-utility analysis performed on gynecologic surgery, Sculpher studied the trade-offs between a less invasive, less costly procedure (transcervical resection of the endometrium) with a more invasive, more costly, and more effective procedure (abdominal hysterectomy) to treat menorrhagia. Hysterectomy resulted in an incremental cost of 1,500 British pounds per QALY during 2 years of follow-up. This is much less than the range of $30,000 to $100,000 that represents a currently acceptable C/E ratio. Grover et al evaluated the cost-effectiveness of performing a concurrent hysterectomy in women undergoing bilateral salpingo-oophorectomy. They observed that in 45-year-old women, the additional concurrent procedure dominated the alternative strategy of bilateral salpingo-oophorectomy, being both less expensive and increasing average life expectancy. The concurrent hysterectomy strategy also dominated for women aged 55, but both with less cost-savings and gains in life expectancy compared with 45-year-old women. Selecting an appropriate time frame for the analysis is difficult and may dramatically affect the results of the analysis. The time frame should be long enough to measure all clinically relevant costs and benefits. For example, Kung et al compared the cost per cure of stress urinary incontinence of laparoscopic and open Burch procedures. The probability of cure after each procedure was estimated from a retrospective cohort of 62 women with a mean follow-up of 1.2 years for the laparoscopic Burch strategy and 2.7 years in the open Burch strategy. The authors found that the laparoscopic Burch dominated, with lower costs and a higher cure rate. However, the analysis would be more informative with much longer follow-up, because most women who undergo an incontinence procedure have a life expectancy far greater than 1 to 2 years. Ramsey et al performed an economic analysis to assess the long-term costs of behavioral therapy, pharmacotherapy, and surgical therapy used for stress urinary incontinence. They found that in the short-term, behavioral and pharmacotherapy were less costly. However, if life expectancy was equal to or greater than 3.5 years, surgical therapy was least costly. In many articles that evaluate the cost of managing ectopic pregnancy, only short-term costs of the procedures and follow-up visits are considered. Mol et al considered a longer time frame and also included the costs of infertility management based on the future probability of conception correlated with the different management strategies. Selection of an effectiveness measure after surgical intervention is often difficult and controversial. For benign disease, life years or QALYs will be minimally affected by a reasonably safe intervention. In the short-term, utility may be negatively affected by surgery and recovery. In longer-term analyses, these effects will be diluted by time and be negligible. Intermediate measures such as days of hospitalization averted or lives saved are often more appropriate for gynecologic interventions than are longer-term outcomes such as lif

View details for DOI 10.1097/00003081-200009000-00016

View details for Web of Science ID 000088587400015

View details for PubMedID 10949758
Urge incontinence: The patient's perspective JOURNAL OF WOMENS HEALTH Brown, J. S., Subak, L. L., Gras, J., Brown, B. A., Kuppermann, M., Posner, S. F. 1998; 7 (10): 1263?69
Abstract

Urge incontinence has a profound effect on the day-to-day lives of women. The purpose of this study was to identify specific aspects of functioning and well-being affected by urge incontinence or mixed incontinence with a primary urge component. We conducted six focus groups of 65 racially and age diverse, community-dwelling women with urge incontinence. Transcripts of the focus groups were quantitatively analyzed for word use frequency with QSR NUD*IST software. Demographics, symptomatology, and the impact of incontinence on daily activities and feelings were assessed by questionnaire. Participants in the focus groups were on average 62 years of age; 52% were nonwhite, and 26% had a high school or less education. In the three identified broad domains, 52% of domain-related words were associated with feelings, 40% with activities, and 8% with relationships. Frequently identified references were bathroom availability (24%), loss of control (14%), anxiety (11%), and sleep disturbance (10%). Women under the age of 70 compared with older women more commonly identified feeling unattractive and low self-esteem (12% versus 2%, p < 0.007) and adverse effects on dating and sexual activity (45% versus 0%, p < 0.02). The effect of incontinence on quality of life correlated with frequency, nocturia, and pad use (Kendall's tau beta 0.02-0.32, p < 0.05). Urge incontinence affects many quality of life issues and contributes to limitation of activities, loss of control, and negative self-perception. Focus groups of diverse women with urge incontinence symptomatology are useful in understanding these effects.

View details for DOI 10.1089/jwh.1998.7.1263

View details for Web of Science ID 000078241700017

View details for PubMedID 9929859
Preoperative staging of cervical carcinoma: Phased array coil fast spin-echo versus body coil spin-echo T2-weighted MR imaging AMERICAN JOURNAL OF ROENTGENOLOGY Yu, K. K., Hricak, H., Subak, L. L., Zaloudek, C. J., Powell, C. B. 1998; 171 (3): 707?11
Abstract

This study was performed to compare the diagnostic efficacy of MR imaging in the preoperative evaluation of invasive cervical cancer using the pelvic phased array coil in combination with fast spin-echo T2-weighted imaging and the body coil in combination with conventional spin-echo T2-weighted imaging.Ninety-four women (22-68 years old) with invasive cervical cancer underwent MR imaging (at 1.5 T) using a body coil conventional spin-echo protocol (n = 62) or a phased array coil fast spin-echo protocol (n = 32). Imaging preceded surgery by no more than 5 weeks. MR images were evaluated for tumor size, local stage, and nodal metastasis using surgical pathology as the standard of reference.Overall staging accuracy for the body coil conventional spin-echo protocol (89%) was not significantly different from that of the phased array coil fast spin-echo protocol (91%). Both techniques also achieved similar accuracy in diagnosing parametrial invasion (95% versus 94%) and lymph node metastases (85% versus 91%) and in tumor sizing (correlation coefficient, .93 versus .94).In the preoperative staging of cervical carcinoma by MR imaging, both the newer (phased array coil fast spin-echo protocol) and the older (body coil conventional spin-echo protocol) techniques achieved similarly high accuracies in local staging, assessment of parametrial invasion, and evaluation of tumor size. Decreased imaging time and increased image resolution are advantages of the newer technique, although in our series they did not increase staging accuracy.

View details for DOI 10.2214/ajr.171.3.9725301

View details for Web of Science ID 000075496700035

View details for PubMedID 9725301
Radiological evaluation of lymph node metastases in patients with cervical cancer - A meta-analysis JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Scheidler, J., Hricak, H., Yu, K. K., Subak, L., Segal, M. R. 1997; 278 (13): 1096?1101
Abstract

To apply meta-analysis to compare the utility of lymphangiography (LAG), computed tomography (CT), and magnetic resonance (MR) imaging for the diagnosis of lymph node metastasis in patients with cervical cancer.MEDLINE literature search and manual reviews of article bibliographies.Studies selected included at least 20 patients with imaging-histologic correlation, described diagnostic criteria for lymph node metastasis, and presented data to allow calculation of contingency tables.Independently by 2 investigators, stratified for stage of disease (early vs late) and for lymph node location (pelvic vs para-aortic).Seventeen studies met the inclusion criteria for LAG, 17 for CT, and 10 for MR imaging. Summary receiver operator characteristic analysis showed no significant differences in the overall performance of LAG, CT, and MR imaging. There was, however, a trend toward better performance for MR imaging than for LAG or CT, both globally and when stratified for stage of disease or for lymph node location. Bayesian analysis of clinical utility showed only moderate increases in positive posttest probability of lymph node metastasis for all methods. Negative test results had a greater impact and, depending on the clinical setting, decreased the probability of lymph node metastasis from 15% to 44% (pretest) to 3% to 18% (posttest).The LAG, CT, and MR imaging perform similarly in the detection of lymph node metastasis from cervical cancer. As CT and MR imaging are less invasive than LAG and also assess local tumor extent, they should be considered the preferred adjuncts to clinical evaluation of invasive cervical cancer.

View details for DOI 10.1001/jama.278.13.1096

View details for Web of Science ID A1997XX30300035

View details for PubMedID 9315770
Comparison of diagnostic studies in the pretreatment evaluation of stage Ib carcinoma of the cervix Hricak, H., Yu, K. K., Powell, C. B., Subak, L. L., Stern, J., Arenson, R. L. ASSOC UNIV RADIOLOGISTS. 1996: S44?S46
Abstract

The results of our study highlight the need for change in the pretreatment workup of clinical stage Ib cervical cancer. The routine use of excretory urography, barium enema, cystoscopy,and sigmoidoscopy is not justified. MR evaluation is recommended in patients with lesions larger than 2 cm (the group with the greatest increase in predictive value). Although CT scanning is not recommended for the evaluation of parametrial invasion, both CT scanning and MR imaging provide similar positive and negative posttest probabilities for the evaluation of nodal disease.

View details for DOI 10.1016/S1076-6332(96)80479-X

View details for Web of Science ID A1996UE51900018

View details for PubMedID 8796509
Invasive cervical carcinoma: Role of MR imaging in pretreatment work-up - Cost minimization and diagnostic efficacy analysis RADIOLOGY Hricak, H., Powell, C. B., Yu, K. K., Washington, E., Subak, L. L., Stern, J. L., Cisternas, M. G., Arenson, R. L. 1996; 198 (2): 403?9
Abstract

To examine the cost and efficacy of diagnostic work-up in patients with invasive cervical cancer.In 246 patients with invasive cervical cancer, all diagnostic tests performed before treatment were recorded. Patients were divided into two groups: those who underwent magnetic resonance (MR) imaging as the initial study (n = 105) and those who did not (n = 141). A list of 1995 Medicare global payments was used to measure cost. Bayesian analysis (likelihood ratios derived from a literature search) was performed for bladder, rectal, parameterial, and nodal involvement in stage Ib disease.Significantly fewer procedures and fewer invasive studies were performed in the MR imaging group. Net cost savings for the MR imaging group was $401 for all patients and $449 for patients with stage Ib disease. For stage Ib disease, the 0% pretest probability of bladder or rectal invasion does not justify the routine use of barium enema examination, cystoscopy, or proctoscopy. The increase in predictive values for parameterial and nodal disease was highest for MR imaging when tumor size was at least 2 cm.Guidelines for the pretreatment work-up of clinical stage Ib cervical cancer need revision. MR imaging should be used as an adjunct to clinical evaluation.

View details for DOI 10.1148/radiology.198.2.8596840

View details for Web of Science ID A1996TR36300021

View details for PubMedID 8596840
THERAPEUTIC DONOR INSEMINATION - A PROSPECTIVE RANDOMIZED TRIAL OF FRESH VERSUS FROZEN SPERM 58TH ANNUAL MEETING OF THE PACIFIC COAST OBSTETRICAL AND GYNECOLOGICAL SOC Subak, L. L., Adamson, G. D., BOLTZ, N. L. MOSBY-YEAR BOOK INC. 1992: 1597?1606
Abstract

We evaluated the efficacy of fresh versus frozen sperm in therapeutic donor insemination.Fifty-seven women underwent 72 courses of treatment (a maximum of six therapeutic donor insemination cycles--three fresh and three frozen) totaling 198 cycles. Each woman served as her own control and was prospectively randomized to receive a single, timed insemination of either fresh or frozen sperm.Fecundity was 20.6% for fresh sperm cycles and 9.4% for frozen (p less than 0.03, by chi 2 analysis). Fresh cervical cap insemination fecundity was 20.3%; frozen was 7.8% (p less than 0.03, by chi 2 analysis). Fresh intrauterine insemination fecundity was 21.2%; frozen was 15.8% (p = 0.63, by chi 2 analysis). Fresh 3-month life-table pregnancy rates were 48% +/- 10%; frozen rates were 22% +/- 8% (p = 0.05 by Breslow analysis). Survival analysis with fixed covariates showed a positive association with the use of fresh sperm (p = 0.04).Cycle fecundity was significantly greater with fresh sperm in women undergoing cervical cap insemination or intrauterine insemination and in women undergoing only cervical cap insemination. These results have important implications for contemporary management of patients undergoing therapeutic donor insemination with frozen sperm.

View details for PubMedID 1615966
COMPARISON OF CO2-LASER LAPAROSCOPY WITH LAPAROTOMY FOR TREATMENT OF ENDOMETRIOMATA FERTILITY AND STERILITY Adamson, G. D., Subak, L. L., Pasta, D. J., HURD, S. J., VONFRANQUE, O., Rodriguez, B. D. 1992; 57 (5): 965-973
Abstract

To assess the effectiveness of laparoscopy versus laparotomy in the treatment of endometriomata.Controlled study using data prospectively tabulated.Treatment performed by senior author in a referral reproductive endocrinology and surgery private practice.One hundred infertile women were diagnosed with endometriomata.Forty-eight women were treated with CO2 laser laparoscopy (laparoscopy group) and 52 women were treated with CO2 laser or nonlaser laparotomy (laparotomy group).The hypothesis that laparoscopy group pregnancy rates (PRs) would be equal to or greater than laparotomy group was formulated before data analysis but after data tabulation.The 1 and 3-year life table estimated cumulative PRs +/- SE were 0.30 +/- 0.07 and 0.52 +/- 0.09 for laparoscopy group and 0.23 +/- 0.06 and 0.46 +/- 0.09 for laparotomy group (Breslow P = 0.48). Monthly fecundity over 3 years was 2.4% for laparoscopy group and 2.0% for laparotomy group.Laparoscopy with CO2 laser can be a safe and effective modality for treating endometriomata.

View details for PubMedID 1533375
FAILURE OF INTRAUTERINE INSEMINATION IN A REFRACTORY INFERTILITY POPULATION FERTILITY AND STERILITY ADAMSON, G. D., SUBAK, L. L., BOLTZ, N. L., MCNULTY, M. A. 1991; 56 (2): 361?63
Abstract

Intrauterine insemination by itself for multiple and/or severe infertility factors had no benefit over cervical cap with whole ejaculate or coitus in this study. The PRs for IUI and cervical cap with whole ejaculate or coitus were similar and low, suggesting that IUI by itself has limited, if any, utility in enhancing PRs in this type of infertility population. Couples attempting IUI should be advised about the low probability of achieving pregnancy. Ovulation stimulation and/or heterologous donor insemination, IVF, or gamete intrafallopian transfer may be beneficial therapeutic options.

View details for Web of Science ID A1991FZ44200035

View details for PubMedID 2070868
ANALGESIA AFTER CESAREAN DELIVERY - PATIENT EVALUATIONS AND COSTS OF 5 OPIOID TECHNIQUES REGIONAL ANESTHESIA Cohen, S. E., Subak, L. L., Brose, W. G., Halpern, J. 1991; 16 (3): 141-149
Abstract

The study was designed to compare five opioid analgesic regimens administered after cesarean delivery in a routine hospital setting with respect to patients' perceptions of their pain relief and the impact of analgesic technique on recovery and hospital costs. After cesarean delivery, 684 patients received one of the following: epidural morphine, alone (EM,n = 128), or with fentanyl (EM + F,n = 245); subarachnoid morphine (n = 48); intramuscular meperidine (n = 165), or patient-controlled analgesia using meperidine (PCA, n = 98). On the first three postoperative days (Days 1-3; day of operation is Day 1) patients were surveyed regarding their impressions of their analgesia, the incidence of side effects, times to resume normal activities and satisfaction with their technique. Information regarding drug interventions and costs was obtained from anesthetic records and nursing charts. Patients receiving intramuscular and PCA opioids reported significantly more severe pain during the first 16 hours than those receiving intraspinal opioids (p less than 0.05); differences were minimal for the remainder of Day 1. Among the intraspinal groups, analgesia was best overall with EM; specifically, fentanyl did not decrease early postoperative pain. Analgesia with PCA and intramuscular opioids was similar during the first 16 hours; however, PCA patients felt they had less pain thereafter. Side effects were common in all intraspinal groups and were least frequent with PCA (p less than 0.05 versus all intraspinal groups). Times to sit, walk and drink were similar in all patients except those receiving intramuscular opioids after general anesthesia, who experienced a several-hour delay. Other aspects of recovery did not differ among the groups. Satisfaction parallelled pain relief and was better with intraspinal than with systemic opioids. Costs were greatest with PCA, although differences were small (less than 1%) relative to total hospital charges.

View details for PubMedID 1883771
IMPROVED PREDICTION OF POSTOVULATORY DAY USING TEMPERATURE RECORDING, ENDOMETRIAL BIOPSY, AND SERUM PROGESTERONE FERTILITY AND STERILITY PILLET, M. C., Wu, T. F., Adamson, G. D., Subak, L. L., Lamb, E. J. 1990; 53 (4): 614-619
Abstract

The use of basal body temperature (BBT) recording and a single progesterone (P) level at the time of the endometrial biopsy in the late luteal phase improved our ability to predict the onset of the next menstrual period (NMP) and determine the postovulatory day (POD) in 124 regularly menstruating infertile women. We determined BBT shift using a microcomputer program, analyzed P levels by radioimmunoassay, and evaluated endometrial biopsies both prospectively (blinded) and retrospectively (with knowledge of the other variables). Serum P levels were within the normal range for the luteal phase and prospective and retrospective histological diagnoses closely agreed (82% within 2 days). The best correlation with the NMP was the BBT shift (r = 0.493) followed by P (r = 0.426) and prospective histologic dating (r = 0.390). Multiple regression analysis confirmed that use of all of the variables markedly improved the ability to estimate the POD (R2 = 0.51).

View details for PubMedID 2318322
LAPAROSCOPIC CO2-LASER VAPORIZATION OF ENDOMETRIOSIS COMPARED WITH TRADITIONAL TREATMENTS FERTILITY AND STERILITY Adamson, G. D., Lu, J., Subak, L. L. 1988; 50 (5): 704-710
Abstract

This study reports on 108 infertile patients with endometriosis diagnosed at laparoscopy. Sixty-four patients had endometriosis and adhesions vaporized with a CO2 laser (LAS) and were prospectively compared with a control group (CON) of 44 patients who had laparoscopy. The 6- and 12-month estimated cumulative pregnancy rates for LAS were 0.32 +/- 0.07 and 0.55 +/- 0.09 respectively, and for CON 0.17 +/- 0.06 and 0.43 +/- 0.09 (Breslow P = 0.10). Monthly fecundity rates were 6.7% in LAS and 4.5% in CON. Survival analysis with fixed covariates showed that pregnancy rates were increased in patients with adhesions (P = 0.002) and other pelvic disease (P = 0.0001). Pregnancy rates were reduced by age (P = 0.02), previous adhesiolysis (P = 0.0000) and post-laparoscopy medical treatment (P = 0.0002). Our findings indicate that CO2 laser laparoscopy vaporization of endometriosis can be a safe, effective, and possibly improved modality for treating endometriosis.

View details for PubMedID 2972565

Leslee L.Subak, MD

Katharine Dexter McCormick and Stanley McCormick Memorial Professor and Professor, by courtesy, of Urology

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