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Abstract & commentary
Synopsis: In a population-based cohort of women younger than 65 with urinary incontinence, on average, 6% will experience spontaneous remission each year.
Source: Samuelsson EC, et al. Am J Obstet Gynecol 2000; 183:568-574.
Urinary incontinence is an extremely common condition in the adult female population. Symptoms vary greatly from minor disturbances to complete incontinence. The prevalence of the condition increases with age. The purpose of this study was to determine both the incidence and the spontaneous remission rates of urinary incontinence in a population of women 20-59 years of age.
This study was carried out in Sweden where all women are eligible for routine gynecologic examinations on a regular basis. Those women scheduled for an examination during 1993 in the population district chosen to serve as the basis for this study were potential participants. Pregnant and lactating women, and those with mental retardation, were excluded. In addition, a small number of women with severe incontinence who required immediate treatment were also excluded.
Incontinence was broadly defined and all women who reported any degree of incontinence were included as being affected. Samuelsson and colleagues then subdivided this group into those who experienced symptoms monthly, weekly, or daily. Four hundred ninety-one women answered the questionnaire, and 487 were examined and represented the starting point of this study. Five years later a similar questionnaire was administered and 382 women responded (88% participation rate).
The average age of the study group was 42.5 years at follow-up. Sixty-two percent had given birth at least once. Of those women 45 years old or older, 30% were receiving estrogens.
Of the 383 women who participated throughout the study, 23.6% were incontinent at baseline, and 27.5% were incontinent at the time of the follow-up questionnaire. However, considerable crossover had occurred. Specifically, 40 of the women who were originally continent became incontinent at follow-up, while 25 of the 90 women who were originally incontinent became continent at follow-up. Thus, the remission rate was approximately 6% and the incidence rate was approximately 3%.
In an effort to determine which variable might be responsible for the occurrence of incontinence, a multivariant logistic regression analysis was performed. Only estrogen treatment was found to be significant. However, the effect of the estrogen treatment was interesting. Those women who were receiving estrogen were more likely to be incontinent than those who were not. Samuelsson et al were unable to determine whether women with more severe symptoms had been given estrogen, or whether estrogen therapy itself might be a predictor of incontinence. The duration of incontinence prior to the study did not predict whether the disease would remit during the follow-up period.
Comment by Kenneth L. Noller, MD
Urinary incontinence is an almost unbelievably complex condition. The more it is studied, the more obvious it is that some of our long-held beliefs have been in error. For example, when I was in training it was common to suggest to women who were experiencing incontinence of a mild-to-moderate degree that they should have surgical correction while they were still "young" as the condition only worsened with age. A number of previously published articles using elderly populations as study participants have shown that incontinence is not always irreversible or progressive. This article from Sweden now demonstrates that the same facts are true for younger women. Specifically, women 20-65 years of age who have incontinence, and who are followed for five years, have approximately a one-in-four chance of the incontinence disappearing.
The observations concerning exogenous estrogen therapy in this study are certainly worthy of some thought. For many years it has been suggested that estrogen therapy can decrease the frequency of urinary incontinence among women who have no or low levels of endogenous estrogen. While the studies supporting this "fact" have not always been well conceived or executed, I think most of us have believed that estrogen could help reduce incontinence. This article found exactly the opposite effect; and namely, that women on exogenous estrogen had more incontinence than those not on estrogen. Because the reason for estrogen therapy was not known in this study it is likely that Samuelsson et al’s observation was due to the "fact" that the women with more significant incontinence were placed on estrogen, whereas those with minor difficulties were not. However, it must be recognized that it is at least possible that estrogen therapy does not help and may even hinder the remission of incontinence. The subject certainly deserves further study. (Dr. Noller is Professor and Chairman, Department of OB/GYN, Tufts University School of Medicine, Boston, Mass.)