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Impact of age on preoperative and postoperative urinary incontinence quality of life
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Impact of age on preoperative and postoperative urinary incontinence quality of life Vivian W. Sung, MD, MPH; Michelle A. Glasgow, BA; Kyle J. Wohlrab, MD; Deborah L. Myers, MD OBJECTIVE: The objective of the study was to estimate the effect of age on quality of life in women with urinary incontinence before and following antiincontinence surgery. STUDY DESIGN: We performed a retrospective cohort study of
women who underwent surgery for stress urinary incontinence from December 2003 to August 2005. Younger women were defined as age younger than 60 years and older women were defined as age 60 years or older. Quality of life was measured using Incontinence Impact Questionnaire (IIQ)-7 and Urogenital Distress Inventory (UDI)-6 questionnaires pre- and postoperatively. Multiple linear regression was performed to estimate the effect of age on improvement in quality-of-life scores.
RESULTS: One hundred sixty-eight younger women and 81 older women were included. Older women had lower mean baseline IIQ-7 scores (P ⬍ .01) and had less improvement in IIQ-7 scores postoperatively (P ⫽ .02) when compared with younger women. After adjusting for baseline IIQ-7 score using multiple linear regression, age was no longer associated with decreasing improvements in quality-of-life scores following surgical treatment. CONCLUSIONS: Antiincontinence surgery is associated with improved
quality of life in both older and younger women. Key words: age, quality of life, surgical management, urinary incontinence
Cite this article as: Sung VW, Glasgow MA, Wohlrab KJ, et al. Impact of age on preoperative and postoperative urinary incontinence quality of life. Am J Obstet Gynecol 2007;197:680.e1-680.e5.
T
he US. population is growing older with improved overall health. It is projected that by 2030, there will be more than 40 million women over the age of 64 years.1 With these population changes, it is anticipated that the number of older women seeking care and undergoing surgery for urinary incontinence will increase significantly.2 From the Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology (Drs Sung, Wohlrab, and Myers), Brown Medical School, and Brown Medical School (Ms. Glasgow), Providence, RI. Presented at the 33rd Annual Scientific Meeting of the Society of Gynecologic Surgeons, Orlando, FL, April 12-14, 2007. Received Jan. 16, 2007; revised May 7, 2007; accepted Aug. 27, 2007. Reprints are not available. This study was supported by Grant 5-K12HD050108-02 from Women and Infants’ Hospital/Brown Women’s Reproductive Health Research Career Development Award, National Institute of Child Health and Human Development (to V.W.S.). 0002-9378/$32.00 © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.08.076
680.e1
Urinary incontinence is not a life-threatening disorder; however, it can significantly affect a woman’s psychological, emotional, sexual, and social functioning. Older women facing treatment decisions for urinary incontinence have many factors to consider including surgical risk, life expectancy, and expectations in qualityof-life improvements. Regarding surgical risks, smaller uncontrolled studies have suggested that preexisting comorbidities, and not age, are the predominant determinant of perioperative morbidity and mortality following urogynecologic surgeries.3-5 In contrast, larger studies have shown that elderly women over the age of 60 years have an increased risk of mortality and morbidity, compared with women younger than age 60 years following urogynecologic procedures regardless of comorbidities, although the absolute risk of death is small.6 Many studies evaluating quality-of-life outcomes after antiincontinence surgery have demonstrated an improvement in quality of life for most women. However, results are conflicting with regard to the impact of incontinence on quality of life in older women.7,8 A study by Tennstedt et al9 suggests that older women are less bothered by incontinence, compared with
American Journal of Obstetrics & Gynecology DECEMBER 2007
their younger counterparts preoperatively. Few studies have specifically evaluated the impact of age on improvements in quality of life following antiincontinence surgery. Therefore, it is unclear whether older women may experience the same benefits and improvements in quality of life following these procedures, compared with younger women. Particularly for procedures aimed at improving a woman’s quality of life, information with regard to these outcomes in older women would be important for physician counseling, patient decision making, and expectations. The primary aim of this study was to estimate the effect of age on urinary incontinence quality of life prior to surgery. Our secondary aim was to estimate the effect of age on improvement in urinary incontinence quality of life following antiincontinence surgery for stress urinary incontinence.
M ATERIAL AND M ETHODS We conducted a retrospective cohort study of women who underwent antiincontinence surgery for stress urinary incontinence through the Division of Urogynecology at our institution from December 2003 through August 2005. This study was approved by the Institu-
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www.AJOG.org tional Review Board at Women and Infants’ Hospital (Providence, RI). Women who did not complain of urinary incontinence at their initial visit or did not have an antiincontinence procedure for stress incontinence were excluded. Antiincontinence procedures included midurethral or suburethral slings, Burch urethropexies, and transurethral collagen injections. Women reporting mixed incontinence symptoms were included in this study only if they had predominant stress incontinence symptoms defined by self-report and if stress incontinence was confirmed on urodynamic testing. These women were still classified as having mixed incontinence based on symptoms, even if urodynamic testing did not reveal detrusor overactivity. Urinary incontinence quality of life was measured using the short forms of the Incontinence Impact Questionnaire (IIQ)-7 and the Urogenital Distress Inventory (UDI)-6 preoperatively and 12 months postoperatively.10 The IIQ-7 measures the impact of urinary incontinence on activities, roles, and emotional states, with higher scores indicating a greater impact or a worse quality of life. The UDI-6 measures the bothersomeness of incontinence symptoms, with higher scores indicating a greater degree of bother or a worse quality of life. All subjects completed these questionnaires. Incontinence severity was measured using the Sandvik’s Incontinence Severity Index.11 In addition, all patients underwent preoperative multichannel urodynamic testing confirming stress urinary incontinence. All patients had complete urogynecological examinations preoperatively and postoperatively including a cough stress test and prolapse evaluation using the Pelvic Organ Prolapse Quantification (POPQ) examination.12 We categorized women into 2 age groups: younger women were defined as age younger than 60 years, and older women were defined as age 60 years or older. We chose to dichotomize women into these 2 age groups for multiple reasons. First, previous studies in the general surgery literature have shown that patients over age 60-65 years are at increased risk for postoperative functional
decline, death, and lower overall 5 year survival.13-15 Second, our previous work showed that women aged 60 years and older are at increased risk for mortality and morbidity following urogynecologic surgery when compared with women younger than age 60 years.6 Therefore, information on improvements in quality of life following antiincontinence procedures between these 2 age groups, and specifically in women over age 60 years, would be extremely useful for patient counseling to help weigh the risks of morbidity and mortality and expectations in quality-of-life improvement. Descriptive statistics, Student’s t test, 2 and paired t tests were performed as appropriate. We compared preoperative quality-of-life scores between the 2 age groups. We also compared changes between preoperative and postoperative IIQ-7 and UDI-6 scores between the 2 age groups. Responses to individual questionnaire items were compared between the 2 age groups to identify domains most affected by age. Multiple linear regression was performed to estimate the effect of age on changes in IIQ-7 and UDI-6 scores between preoperative and postoperative scores, adjust for confounders. Variables found to be significantly different on bivariate analyses between the 2 age groups were added to our model (P ⱕ .10). To estimate a sample size calculation, we used 2 studies in the literature that evaluated subjective outcomes following antiincontinence procedures. Based on a study by Davis et al16 evaluating 66 women of all ages, the overall subjective improvement rate following antiincontinence surgery was 80%. Based on a study by Carey and Leach17 evaluating antiincontinence procedures in older women, the rate of subjective continence improvement and satisfaction was 55%. On the basis of these estimates, we determined that a sample size of 62 women per group would have an 80% power to detect a 20% difference with a significance level of .05.
R ESULTS During the study period, 379 charts were reviewed and 249 women met study in-
clusion criteria. Of the eligible women, 168 (67%) were younger than 60 years (range 26-59 years) and 81 (33%) were 60 years of age or older (range 61-91 years). The median split for age was 59.6 years. Patient demographics and clinical characteristics are presented in Table 1. Ninety-six percent of women were Caucasian. Eighty-three percent of women underwent a midurethral sling, 6.4% underwent Burch urethropexy, 7.6% underwent a suburethral Mersilene sling, and 3% underwent transurethral collagen injection. This did not differ between age groups (P ⬎ .05). The overall mean follow-up time was 11.8 ⫾ 1.2 months and was not significantly different between the 2 groups. Preoperatively, older women had lower mean IIQ-7 scores, compared with younger women. When individual items on the IIQ-7 were compared, older women reported a lower impact of incontinence on the physical activity and emotional health subscales as compared with younger women (P ⬍ .01 for both). There was no difference in overall preoperative UDI-6 scores between the 2 age groups. These results are summarized in Table 2. Postoperatively, both age groups had significant improvement in their overall IIQ-7 scores, compared with baseline (P ⬍ .01 for both). However, the older women had less improvement in their overall IIQ-7 scores, compared with younger women (mean IIQ improvement 15.9 ⫾ 5.0 vs 30.8 ⫾ 4.7, P ⫽ .02). When evaluating individual item score improvements, older women trended toward less improvement in both questions in the travel subscale, compared with younger women, although this trend did not reach statistical significance: question 3, “Has urine leakage affected entertainment activities” (mean item improvement .20 ⫾ .11 vs .81 ⫾ .2, P ⫽ .06) and question 4, “Has urine leakage affected travel more than 30 minutes away from home” (mean item improvement .40 ⫾ .23 vs .94 ⫾ .21, P ⫽ .07) for older vs younger women. We then performed multiple linear regression to control for potential confounders found to be significantly different between the 2 age groups on bi-
DECEMBER 2007 American Journal of Obstetrics & Gynecology
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SGS Meeting Papers variate analysis. Two hundred forty women had complete data and were included in the regression analysis. Explanatory variables were entered into the regression in the following order: (1) age, (2) parity, (3) postmenopausal status, (4) hypertension, (5) intrinsic sphincter deficiency, (6) insurance, and (7) baseline IIQ-7 score. The results of the final regression are presented in Table 3. Prior to adding baseline IIQ-7 scores to the model, older age and intrinsic sphincter deficiency were significantly associated with decreased improvements in IIQ-7 scores (P ⬍ .05). However, when the final variable of baseline IIQ-7 score is added in the final stage of the model, the effect of age on improvement in quality of life was no longer significant. This suggests that when adjusting for a lower baseline IIQ-7 score, older women still experience a significant improvement in quality of life following antiincontinence procedures, as do younger women. To summarize the findings from our multiple linear regression, women over the age of 60 years on average had a lower mean IIQ-7 score improvement by 10.3 points, compared with younger women, although this was not statistically significant after adjusting for other variables. Women with intrinsic sphincter deficiency had on average a 15.3 point higher improvement in IIQ-7 scores, compared with women without intrinsic sphincter deficiency (ISD), holding all other variables constant. Finally, on average, each 1 point increase in preoperative IIQ-7 score corresponds to a 3.8 point improvement in IIQ-7 score, holding all other variables constant. Of note, excluding women with procedures other than midurethral slings did not significantly change our findings. These analyses were not performed for UDI-6 scores because these were not different between the age groups preoperatively or postoperatively.
C OMMENT This current study provides further information regarding the impact of age on quality of life following antiinconti680.e3
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TABLE 1
Demographic and clinical characteristics by age group Younger than 60 y (n ⴝ 168) Age (mean ⫾ SD)
60 y or older (n ⴝ 81)
P value
47.6 (.59)
70.6 (.91)
⬍.05
2.2 (1.0)
3.1 (1.6)
⬍.05
..............................................................................................................................................................................................................................................
Parity (mean ⫾ SD)
..............................................................................................................................................................................................................................................
Insurance (n, %)
.....................................................................................................................................................................................................................................
Medicare
2 (1.1%)
Medicaid
1 (.5%)
12 (14.8%)
.....................................................................................................................................................................................................................................
0
.....................................................................................................................................................................................................................................
Private
160 (95.2%)
45 (55.6%)
Other
3 (1.7%)
23 (28.3%)
Unknown
2 (1.1%)
1 (1.2%)
Prior urogynecologic surgery (n, %)
35 (20.8%)
25 (30.9%)
.21
Post-menopausal (n, %)
82 (48.8%)
81 (100%)
⬍.05
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
⬍.05
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Comorbidities (n, %)
.....................................................................................................................................................................................................................................
Diabetes mellitus
9 (5%)
7 (8%)
.31
Hypertension
31 (18%)
33 (40%)
⬍.01
Asthma
15 (8.9%)
10 (12%)
.40
24 (14.3%)
11 (13.6%)
.35
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Current smoker (n,%)
..............................................................................................................................................................................................................................................
Median POPQ stage
2
3
.30
..............................................................................................................................................................................................................................................
Concurrent prolapse surgery (n, %)
108 (64.3%)
54 (66.7%)
.78
.............................................................................................................................................................................................................................................. a
Type of incontinence (n, %)
.....................................................................................................................................................................................................................................
Stress incontinence only
60 (35.7%)
30 (37%)
.....................................................................................................................................................................................................................................
Mixed incontinence
108 (64.3%)
51 (63.0%)
.27
16 (9.5%)
22 (27.2%)
⬍.01
Preoperative Sandvik’s score (mean ⫾ SD)
6.8 (.5)
7.4 (.8)
Perioperative complications (n, %)
2 (1%)
1 (1%)
.51
149 (88.7%)
71 (87%)
.50
.............................................................................................................................................................................................................................................. b
Intrinsic sphincter deficiency (n, %)
..............................................................................................................................................................................................................................................
.53
.............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Negative postoperative cough stress test (n, %)
.............................................................................................................................................................................................................................................. a
Defined by self-report and urodynamic testing.
b
Defined as maximum urethral closure pressure 20 cm H2O or less or abdominal leak point pressure 60 cm H2O or less.
Sung. Impact of age on preoperative and postoperative urinary incontinence quality of life. Am J Obstet Gynecol 2007.
nence surgery for stress urinary incontinence. Our findings suggest that there is no difference between the degree of improvement in quality of life between older and younger women undergoing antiincontinence surgery. Prior studies regarding the impact of age on incontinence quality of life are few and have conflicting results. In a large study by Tennstedt et al,9 which identified clinical and demographic factors associated with IIQ scores, baseline quality of life was found to be more severely affected by stress incontinence in younger women. This is consistent with
American Journal of Obstetrics & Gynecology DECEMBER 2007
our findings. It is possible that older women may have had symptoms for a longer duration of time and have adapted their behaviors to minimize the effects of incontinence on their everyday lives. In contrast, a large study by Monz et al7 found that increasing age was associated with more severe incontinence quality-of-life scores as measured by the Incontinence Quality of Life questionnaire in women seeking treatment for urinary incontinence. Some of these conflicting findings may be the result of differing properties among the various quality-of-life instruments. However,
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TABLE 2
Baseline and improvements in IIQ-7 and UDI-6 scores, by age group (mean ⴞ SD) Questionnaire items and subscales
Younger than 60 y (n ⴝ 168)
60 y or older (n ⴝ 81)
P value
Preoperative IIQ-7 score
43.5 ⫾ 2.20
34.6 ⫾ 3.11
⬍.01
.......................................................................................................................................................................................................................................................................................................................................................................
Household chores (physical activity)
0.98 ⫾ 0.08
0.93 ⫾ 0.12
.74
Physical recreation (physical activity)
1.91 ⫾ 0.08
1.36 ⫾ 0.13
⬍.01
Entertainment activities (travel)
1.01 ⫾ 0.08
0.79 ⫾ 0.11
.13
Travel longer than 30 minutes (travel)
1.16 ⫾ 0.09
0.89 ⫾ 0.12
.08
Social activities (social/relationships)
1.10 ⫾ 0.09
0.96 ⫾ 0.12
.22
Emotional health (emotional health)
1.12 ⫾ 0.09
0.92 ⫾ 0.13
.19
Feeling frustrated (emotional health)
1.83 ⫾ 0.09
1.43 ⫾ 0.14
⬍.01
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Improvement in pre- and postoperative IIQ-7 score
30.8 ⫾ 4.71
15.9 ⫾ 5.01
Preoperative UDI-6 score
48.3 ⫾ 1.81
45.8 ⫾ 2.62
.02
................................................................................................................................................................................................................................................................................................................................................................................
.43
.......................................................................................................................................................................................................................................................................................................................................................................
Frequent urination (irritative symptoms)
1.76 ⫾ 0.09
1.85 ⫾ 0.11
.54
Urine leakage related to urgency (irritative symptoms)
1.51 ⫾ 0.09
1.65 ⫾ 0.14
.39
Urine leakage related to physical activity (stress symptoms)
2.18 ⫾ 0.09
1.69 ⫾ 0.13
⬍.01
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................................................................................................................................
Small amounts of urine leakage (stress symptoms)
1.76 ⫾ 0.09
1.25 ⫾ 0.13
⬍.01
Difficulty emptying your bladder (obstructive/discomfort symptoms)
1.04 ⫾ 0.09
0.87 ⫾ 0.12
.25
Pain/discomfort in lower abdominal or genital area (Obstructive/ discomfort symptoms)
1.06 ⫾ 0.09
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
0.85 ⫾ 0.12
.17
................................................................................................................................................................................................................................................................................................................................................................................
Improvement in pre- and postoperative UDI-6 score
7.44 ⫾ 1.31
5.88 ⫾ 1.05
.39
Sung. Impact of age on preoperative and postoperative urinary incontinence quality of life. Am J Obstet Gynecol 2007.
TABLE 3
Variables associated with improvement in post-operative IIQ-7 score on multiple linear regression analysis Variable
Coefficient (SE)
P value
Age 60 y or older
–10.3 (5.5)
.07
Parity
–1.9 (2.7)
.47
Postmenopausal status
–0.06 (.17)
.68
Hypertension
–7.9 (8.7)
.37
Intrinsic sphincter deficiency
15.3 (8.2)
.03
........................................................................................................... ...........................................................................................................
........................................................................................................... ...........................................................................................................
........................................................................................................... a
Insurance
–3.5 (4.9)
.49
3.8 (.61)
⬍.01
...........................................................................................................
Preoperative IIQ-7 score
........................................................................................................... b
Constant
8.39 (6.3)
.41
........................................................................................................... a
Compared with private insurance.
b
Constant ⫽ y-intercept of regression line equation.
Sung. Impact of age on preoperative and postoperative urinary incontinence quality of life. Am J Obstet Gynecol 2007.
both Tennstedt et al and Monz et al included only baseline scores and did not estimate the impact of age on improvements in quality of life following treatment for stress incontinence. Our findings indicate that baseline IIQ-7 scores were the primary explanatory variable of differences between older and younger women in the improvement in IIQ-7 scores postoperatively. This is an important point to consider when counseling older women. Although baseline IIQ-7 scores were lower in older women, suggesting a decreased impact of incontinence on quality of life, older women can still expect a comparable degree of improvement in quality of life following surgery. If we considered only the absolute value of the postoperative IIQ-7 score or only the mean improvements in scores without considering baseline scores, we would incorrectly conclude that older women have less improvement following antiincontinence procedures.
Many studies have reported that postoperative cure rates in older women are comparable with younger women,18,19 whereas other studies have reported that older women are less likely to report subjective continence and satisfaction following surgery.17 However, these studies do not specifically address improvements in quality of life before and after surgery. There is often the perception that incontinence in older women may be more difficult to treat because of more severe incontinence, increased prevalence of urge incontinence, and intrinsic sphincter deficiency. In our study population, incontinence severity measured using the Sandvik’s Incontinence Severity Index and urgency symptoms measured by the UDI-6 were comparable between the 2 age groups. And although older women were more likely to be diagnosed with ISD, there was no difference in quality of life improvement between older and younger women after adjusting for this in our multiple linear regres-
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SGS Meeting Papers sion model. This suggests that older, active adult women should still be thoroughly counseled regarding their options for treatment because they can still expect significant improvements in quality of life. One limitation of our study was that we were unable to compare women in more extreme age groups, such as the young elderly (60-70 years), compared with the old elderly (older than 80 years) because of the small numbers of women in the older age group. Therefore, we were unable to make specific conclusions regarding these extremes. However, based on previous work, the risk of morbidity and mortality following urogynecologic procedures increases after age 60 years.6 Therefore, our findings add an important component for women over age 60 years to consider when making decisions regarding antiincontinence surgery. We were also unable to make conclusions regarding whether these quality-of-life improvements are similar and sustained beyond 12 months following surgery. In conclusion, urinary incontinence can have significant effects on a woman’s quality of life. Although incontinence tends to have less of an impact on quality of life in older women, older women can still expect to have a significant improvement in quality of life following antiincontinence surgery. This information is important for counseling
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www.AJOG.org women considering surgery for stress f urinary incontinence. REFERENCES 1. US Census Bureau. Projected population of the Untied States. Available at: http://www. consus.gov. Accessed January 15, 2007. 2. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol 2001;184:1496-501; discussion 1501-3. 3. Toglia MR, Nolan TE. Morbidity and mortality rates of elective gynecologic surgery in the elderly woman. Am J Obstet Gynecol 2003;189:1584-7; discussion 1587-9. 4. Stepp KJ, Barber MD, Yoo EH, Whiteside JL, Paraiso MF, Walters MD. Incidence of perioperative complications of urogynecologic surgery in elderly women. Am J Obstet Gynecol 2005;192:1630-6. 5. Lambrou NC, Buller JL, Thompson JR, Cundiff GW, Chou B, Montz FJ. Prevalence of perioperative complications among women undergoing reconstructive pelvic surgery. Am J Obstet Gynecol 2000;183:1355-8.; discussion 1359-60. 6. Sung VW, Weitzen S, Sokol ER, Rardin CR, Myers DL. Effect of patient age on increasing morbidity and mortality following urogynecologic surgery. Am J Obstet Gynecol 2006;194:1411-7. 7. Monz B, Chartier-Kastler E, Hampel C, et al. Patient Characteristics associated with quality of life in European women seeking treatment for urinary incontinence: results from PURE. Eur Urol 2006;51:1073-81.; discussion 1081-2. 8. Monz B, Pons ME, Hampel C, et al. Patientreported impact of urinary incontinence—results from treatment seeking women in 14 European countries. Maturitas 2005;52(Suppl 2):S24-34. 9. Tennstedt SL, Fitzgerald MP, Nager CW, et al. Quality of life in women with stress urinary
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incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2006;18:543-9. 10. Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn 1995; 14:131-9. 11. Sandvik H, Espuna M, Hunskaar S. Validity of the incontinence severity index: comparison with pad-weighing tests. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:520-4. 12. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-7. 13. Walsh TH. Audit of outcome of major surgery in the elderly. Br J Surg 1996;83:92-7. 14. Wenger NS, Solomon DH, Roth CP, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med 2003;139:740-7. 15. Edwards AE, Seymour DG, McCarthy JM, Crumplin MK. A 5-year survival study of general surgical patients aged 65 years and over. Anaesthesia 1996;51:3-10. 16. Davis TL, Lukacz ES, Luber KM, Nager CW. Determinants of patient satisfaction after the tension-free vaginal tape procedure. Am J Obstet Gynecol 2004;191:176-81. 17. Carey JM, Leach GE. Transvaginal surgery in the octogenarian using cadaveric fascia for pelvic prolapse and stress incontinence: minimal one-year results compared to younger patients. Urology 2004;63:665-70. 18. Allahdin S, McKinley CA, Mahmood TA. Tension free vaginal tape: a procedure for all ages. Acta Obstet Gynecol Scand 2004; 83:937-40. 19. Gordon D, Gold R, Pauzner D, Lessing JB, Groutz A. Tension-free vaginal tape in the elderly: is it a safe procedure? Urology 2005;65:479-82.
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Impact of age on preoperative and postoperative urinary incontinence quality of life Vivian W. Sung, MD, MPH; Michelle A. Glasgow, BA; Kyle J. Wohlrab, MD; Deborah L. Myers, MD OBJECTIVE: The objective of the study was to estimate the effect of age on quality of life in women with urinary incontinence before and following antiincontinence surgery. STUDY DESIGN: We performed a retrospective cohort study of
women who underwent surgery for stress urinary incontinence from December 2003 to August 2005. Younger women were defined as age younger than 60 years and older women were defined as age 60 years or older. Quality of life was measured using Incontinence Impact Questionnaire (IIQ)-7 and Urogenital Distress Inventory (UDI)-6 questionnaires pre- and postoperatively. Multiple linear regression was performed to estimate the effect of age on improvement in quality-of-life scores.
RESULTS: One hundred sixty-eight younger women and 81 older women were included. Older women had lower mean baseline IIQ-7 scores (P ⬍ .01) and had less improvement in IIQ-7 scores postoperatively (P ⫽ .02) when compared with younger women. After adjusting for baseline IIQ-7 score using multiple linear regression, age was no longer associated with decreasing improvements in quality-of-life scores following surgical treatment. CONCLUSIONS: Antiincontinence surgery is associated with improved
quality of life in both older and younger women. Key words: age, quality of life, surgical management, urinary incontinence
Cite this article as: Sung VW, Glasgow MA, Wohlrab KJ, et al. Impact of age on preoperative and postoperative urinary incontinence quality of life. Am J Obstet Gynecol 2007;197:680.e1-680.e5.
T
he US. population is growing older with improved overall health. It is projected that by 2030, there will be more than 40 million women over the age of 64 years.1 With these population changes, it is anticipated that the number of older women seeking care and undergoing surgery for urinary incontinence will increase significantly.2 From the Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology (Drs Sung, Wohlrab, and Myers), Brown Medical School, and Brown Medical School (Ms. Glasgow), Providence, RI. Presented at the 33rd Annual Scientific Meeting of the Society of Gynecologic Surgeons, Orlando, FL, April 12-14, 2007. Received Jan. 16, 2007; revised May 7, 2007; accepted Aug. 27, 2007. Reprints are not available. This study was supported by Grant 5-K12HD050108-02 from Women and Infants’ Hospital/Brown Women’s Reproductive Health Research Career Development Award, National Institute of Child Health and Human Development (to V.W.S.). 0002-9378/$32.00 © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.08.076
680.e1
Urinary incontinence is not a life-threatening disorder; however, it can significantly affect a woman’s psychological, emotional, sexual, and social functioning. Older women facing treatment decisions for urinary incontinence have many factors to consider including surgical risk, life expectancy, and expectations in qualityof-life improvements. Regarding surgical risks, smaller uncontrolled studies have suggested that preexisting comorbidities, and not age, are the predominant determinant of perioperative morbidity and mortality following urogynecologic surgeries.3-5 In contrast, larger studies have shown that elderly women over the age of 60 years have an increased risk of mortality and morbidity, compared with women younger than age 60 years following urogynecologic procedures regardless of comorbidities, although the absolute risk of death is small.6 Many studies evaluating quality-of-life outcomes after antiincontinence surgery have demonstrated an improvement in quality of life for most women. However, results are conflicting with regard to the impact of incontinence on quality of life in older women.7,8 A study by Tennstedt et al9 suggests that older women are less bothered by incontinence, compared with
American Journal of Obstetrics & Gynecology DECEMBER 2007
their younger counterparts preoperatively. Few studies have specifically evaluated the impact of age on improvements in quality of life following antiincontinence surgery. Therefore, it is unclear whether older women may experience the same benefits and improvements in quality of life following these procedures, compared with younger women. Particularly for procedures aimed at improving a woman’s quality of life, information with regard to these outcomes in older women would be important for physician counseling, patient decision making, and expectations. The primary aim of this study was to estimate the effect of age on urinary incontinence quality of life prior to surgery. Our secondary aim was to estimate the effect of age on improvement in urinary incontinence quality of life following antiincontinence surgery for stress urinary incontinence.
M ATERIAL AND M ETHODS We conducted a retrospective cohort study of women who underwent antiincontinence surgery for stress urinary incontinence through the Division of Urogynecology at our institution from December 2003 through August 2005. This study was approved by the Institu-
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www.AJOG.org tional Review Board at Women and Infants’ Hospital (Providence, RI). Women who did not complain of urinary incontinence at their initial visit or did not have an antiincontinence procedure for stress incontinence were excluded. Antiincontinence procedures included midurethral or suburethral slings, Burch urethropexies, and transurethral collagen injections. Women reporting mixed incontinence symptoms were included in this study only if they had predominant stress incontinence symptoms defined by self-report and if stress incontinence was confirmed on urodynamic testing. These women were still classified as having mixed incontinence based on symptoms, even if urodynamic testing did not reveal detrusor overactivity. Urinary incontinence quality of life was measured using the short forms of the Incontinence Impact Questionnaire (IIQ)-7 and the Urogenital Distress Inventory (UDI)-6 preoperatively and 12 months postoperatively.10 The IIQ-7 measures the impact of urinary incontinence on activities, roles, and emotional states, with higher scores indicating a greater impact or a worse quality of life. The UDI-6 measures the bothersomeness of incontinence symptoms, with higher scores indicating a greater degree of bother or a worse quality of life. All subjects completed these questionnaires. Incontinence severity was measured using the Sandvik’s Incontinence Severity Index.11 In addition, all patients underwent preoperative multichannel urodynamic testing confirming stress urinary incontinence. All patients had complete urogynecological examinations preoperatively and postoperatively including a cough stress test and prolapse evaluation using the Pelvic Organ Prolapse Quantification (POPQ) examination.12 We categorized women into 2 age groups: younger women were defined as age younger than 60 years, and older women were defined as age 60 years or older. We chose to dichotomize women into these 2 age groups for multiple reasons. First, previous studies in the general surgery literature have shown that patients over age 60-65 years are at increased risk for postoperative functional
decline, death, and lower overall 5 year survival.13-15 Second, our previous work showed that women aged 60 years and older are at increased risk for mortality and morbidity following urogynecologic surgery when compared with women younger than age 60 years.6 Therefore, information on improvements in quality of life following antiincontinence procedures between these 2 age groups, and specifically in women over age 60 years, would be extremely useful for patient counseling to help weigh the risks of morbidity and mortality and expectations in quality-of-life improvement. Descriptive statistics, Student’s t test, 2 and paired t tests were performed as appropriate. We compared preoperative quality-of-life scores between the 2 age groups. We also compared changes between preoperative and postoperative IIQ-7 and UDI-6 scores between the 2 age groups. Responses to individual questionnaire items were compared between the 2 age groups to identify domains most affected by age. Multiple linear regression was performed to estimate the effect of age on changes in IIQ-7 and UDI-6 scores between preoperative and postoperative scores, adjust for confounders. Variables found to be significantly different on bivariate analyses between the 2 age groups were added to our model (P ⱕ .10). To estimate a sample size calculation, we used 2 studies in the literature that evaluated subjective outcomes following antiincontinence procedures. Based on a study by Davis et al16 evaluating 66 women of all ages, the overall subjective improvement rate following antiincontinence surgery was 80%. Based on a study by Carey and Leach17 evaluating antiincontinence procedures in older women, the rate of subjective continence improvement and satisfaction was 55%. On the basis of these estimates, we determined that a sample size of 62 women per group would have an 80% power to detect a 20% difference with a significance level of .05.
R ESULTS During the study period, 379 charts were reviewed and 249 women met study in-
clusion criteria. Of the eligible women, 168 (67%) were younger than 60 years (range 26-59 years) and 81 (33%) were 60 years of age or older (range 61-91 years). The median split for age was 59.6 years. Patient demographics and clinical characteristics are presented in Table 1. Ninety-six percent of women were Caucasian. Eighty-three percent of women underwent a midurethral sling, 6.4% underwent Burch urethropexy, 7.6% underwent a suburethral Mersilene sling, and 3% underwent transurethral collagen injection. This did not differ between age groups (P ⬎ .05). The overall mean follow-up time was 11.8 ⫾ 1.2 months and was not significantly different between the 2 groups. Preoperatively, older women had lower mean IIQ-7 scores, compared with younger women. When individual items on the IIQ-7 were compared, older women reported a lower impact of incontinence on the physical activity and emotional health subscales as compared with younger women (P ⬍ .01 for both). There was no difference in overall preoperative UDI-6 scores between the 2 age groups. These results are summarized in Table 2. Postoperatively, both age groups had significant improvement in their overall IIQ-7 scores, compared with baseline (P ⬍ .01 for both). However, the older women had less improvement in their overall IIQ-7 scores, compared with younger women (mean IIQ improvement 15.9 ⫾ 5.0 vs 30.8 ⫾ 4.7, P ⫽ .02). When evaluating individual item score improvements, older women trended toward less improvement in both questions in the travel subscale, compared with younger women, although this trend did not reach statistical significance: question 3, “Has urine leakage affected entertainment activities” (mean item improvement .20 ⫾ .11 vs .81 ⫾ .2, P ⫽ .06) and question 4, “Has urine leakage affected travel more than 30 minutes away from home” (mean item improvement .40 ⫾ .23 vs .94 ⫾ .21, P ⫽ .07) for older vs younger women. We then performed multiple linear regression to control for potential confounders found to be significantly different between the 2 age groups on bi-
DECEMBER 2007 American Journal of Obstetrics & Gynecology
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SGS Meeting Papers variate analysis. Two hundred forty women had complete data and were included in the regression analysis. Explanatory variables were entered into the regression in the following order: (1) age, (2) parity, (3) postmenopausal status, (4) hypertension, (5) intrinsic sphincter deficiency, (6) insurance, and (7) baseline IIQ-7 score. The results of the final regression are presented in Table 3. Prior to adding baseline IIQ-7 scores to the model, older age and intrinsic sphincter deficiency were significantly associated with decreased improvements in IIQ-7 scores (P ⬍ .05). However, when the final variable of baseline IIQ-7 score is added in the final stage of the model, the effect of age on improvement in quality of life was no longer significant. This suggests that when adjusting for a lower baseline IIQ-7 score, older women still experience a significant improvement in quality of life following antiincontinence procedures, as do younger women. To summarize the findings from our multiple linear regression, women over the age of 60 years on average had a lower mean IIQ-7 score improvement by 10.3 points, compared with younger women, although this was not statistically significant after adjusting for other variables. Women with intrinsic sphincter deficiency had on average a 15.3 point higher improvement in IIQ-7 scores, compared with women without intrinsic sphincter deficiency (ISD), holding all other variables constant. Finally, on average, each 1 point increase in preoperative IIQ-7 score corresponds to a 3.8 point improvement in IIQ-7 score, holding all other variables constant. Of note, excluding women with procedures other than midurethral slings did not significantly change our findings. These analyses were not performed for UDI-6 scores because these were not different between the age groups preoperatively or postoperatively.
C OMMENT This current study provides further information regarding the impact of age on quality of life following antiinconti680.e3
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TABLE 1
Demographic and clinical characteristics by age group Younger than 60 y (n ⴝ 168) Age (mean ⫾ SD)
60 y or older (n ⴝ 81)
P value
47.6 (.59)
70.6 (.91)
⬍.05
2.2 (1.0)
3.1 (1.6)
⬍.05
..............................................................................................................................................................................................................................................
Parity (mean ⫾ SD)
..............................................................................................................................................................................................................................................
Insurance (n, %)
.....................................................................................................................................................................................................................................
Medicare
2 (1.1%)
Medicaid
1 (.5%)
12 (14.8%)
.....................................................................................................................................................................................................................................
0
.....................................................................................................................................................................................................................................
Private
160 (95.2%)
45 (55.6%)
Other
3 (1.7%)
23 (28.3%)
Unknown
2 (1.1%)
1 (1.2%)
Prior urogynecologic surgery (n, %)
35 (20.8%)
25 (30.9%)
.21
Post-menopausal (n, %)
82 (48.8%)
81 (100%)
⬍.05
..................................................................................................................................................................................................................................... .....................................................................................................................................................................................................................................
⬍.05
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Comorbidities (n, %)
.....................................................................................................................................................................................................................................
Diabetes mellitus
9 (5%)
7 (8%)
.31
Hypertension
31 (18%)
33 (40%)
⬍.01
Asthma
15 (8.9%)
10 (12%)
.40
24 (14.3%)
11 (13.6%)
.35
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Current smoker (n,%)
..............................................................................................................................................................................................................................................
Median POPQ stage
2
3
.30
..............................................................................................................................................................................................................................................
Concurrent prolapse surgery (n, %)
108 (64.3%)
54 (66.7%)
.78
.............................................................................................................................................................................................................................................. a
Type of incontinence (n, %)
.....................................................................................................................................................................................................................................
Stress incontinence only
60 (35.7%)
30 (37%)
.....................................................................................................................................................................................................................................
Mixed incontinence
108 (64.3%)
51 (63.0%)
.27
16 (9.5%)
22 (27.2%)
⬍.01
Preoperative Sandvik’s score (mean ⫾ SD)
6.8 (.5)
7.4 (.8)
Perioperative complications (n, %)
2 (1%)
1 (1%)
.51
149 (88.7%)
71 (87%)
.50
.............................................................................................................................................................................................................................................. b
Intrinsic sphincter deficiency (n, %)
..............................................................................................................................................................................................................................................
.53
.............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Negative postoperative cough stress test (n, %)
.............................................................................................................................................................................................................................................. a
Defined by self-report and urodynamic testing.
b
Defined as maximum urethral closure pressure 20 cm H2O or less or abdominal leak point pressure 60 cm H2O or less.
Sung. Impact of age on preoperative and postoperative urinary incontinence quality of life. Am J Obstet Gynecol 2007.
nence surgery for stress urinary incontinence. Our findings suggest that there is no difference between the degree of improvement in quality of life between older and younger women undergoing antiincontinence surgery. Prior studies regarding the impact of age on incontinence quality of life are few and have conflicting results. In a large study by Tennstedt et al,9 which identified clinical and demographic factors associated with IIQ scores, baseline quality of life was found to be more severely affected by stress incontinence in younger women. This is consistent with
American Journal of Obstetrics & Gynecology DECEMBER 2007
our findings. It is possible that older women may have had symptoms for a longer duration of time and have adapted their behaviors to minimize the effects of incontinence on their everyday lives. In contrast, a large study by Monz et al7 found that increasing age was associated with more severe incontinence quality-of-life scores as measured by the Incontinence Quality of Life questionnaire in women seeking treatment for urinary incontinence. Some of these conflicting findings may be the result of differing properties among the various quality-of-life instruments. However,
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TABLE 2
Baseline and improvements in IIQ-7 and UDI-6 scores, by age group (mean ⴞ SD) Questionnaire items and subscales
Younger than 60 y (n ⴝ 168)
60 y or older (n ⴝ 81)
P value
Preoperative IIQ-7 score
43.5 ⫾ 2.20
34.6 ⫾ 3.11
⬍.01
.......................................................................................................................................................................................................................................................................................................................................................................
Household chores (physical activity)
0.98 ⫾ 0.08
0.93 ⫾ 0.12
.74
Physical recreation (physical activity)
1.91 ⫾ 0.08
1.36 ⫾ 0.13
⬍.01
Entertainment activities (travel)
1.01 ⫾ 0.08
0.79 ⫾ 0.11
.13
Travel longer than 30 minutes (travel)
1.16 ⫾ 0.09
0.89 ⫾ 0.12
.08
Social activities (social/relationships)
1.10 ⫾ 0.09
0.96 ⫾ 0.12
.22
Emotional health (emotional health)
1.12 ⫾ 0.09
0.92 ⫾ 0.13
.19
Feeling frustrated (emotional health)
1.83 ⫾ 0.09
1.43 ⫾ 0.14
⬍.01
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................
Improvement in pre- and postoperative IIQ-7 score
30.8 ⫾ 4.71
15.9 ⫾ 5.01
Preoperative UDI-6 score
48.3 ⫾ 1.81
45.8 ⫾ 2.62
.02
................................................................................................................................................................................................................................................................................................................................................................................
.43
.......................................................................................................................................................................................................................................................................................................................................................................
Frequent urination (irritative symptoms)
1.76 ⫾ 0.09
1.85 ⫾ 0.11
.54
Urine leakage related to urgency (irritative symptoms)
1.51 ⫾ 0.09
1.65 ⫾ 0.14
.39
Urine leakage related to physical activity (stress symptoms)
2.18 ⫾ 0.09
1.69 ⫾ 0.13
⬍.01
....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................................................................................................................................
Small amounts of urine leakage (stress symptoms)
1.76 ⫾ 0.09
1.25 ⫾ 0.13
⬍.01
Difficulty emptying your bladder (obstructive/discomfort symptoms)
1.04 ⫾ 0.09
0.87 ⫾ 0.12
.25
Pain/discomfort in lower abdominal or genital area (Obstructive/ discomfort symptoms)
1.06 ⫾ 0.09
.......................................................................................................................................................................................................................................................................................................................................................................
.......................................................................................................................................................................................................................................................................................................................................................................
0.85 ⫾ 0.12
.17
................................................................................................................................................................................................................................................................................................................................................................................
Improvement in pre- and postoperative UDI-6 score
7.44 ⫾ 1.31
5.88 ⫾ 1.05
.39
Sung. Impact of age on preoperative and postoperative urinary incontinence quality of life. Am J Obstet Gynecol 2007.
TABLE 3
Variables associated with improvement in post-operative IIQ-7 score on multiple linear regression analysis Variable
Coefficient (SE)
P value
Age 60 y or older
–10.3 (5.5)
.07
Parity
–1.9 (2.7)
.47
Postmenopausal status
–0.06 (.17)
.68
Hypertension
–7.9 (8.7)
.37
Intrinsic sphincter deficiency
15.3 (8.2)
.03
........................................................................................................... ...........................................................................................................
........................................................................................................... ...........................................................................................................
........................................................................................................... a
Insurance
–3.5 (4.9)
.49
3.8 (.61)
⬍.01
...........................................................................................................
Preoperative IIQ-7 score
........................................................................................................... b
Constant
8.39 (6.3)
.41
........................................................................................................... a
Compared with private insurance.
b
Constant ⫽ y-intercept of regression line equation.
Sung. Impact of age on preoperative and postoperative urinary incontinence quality of life. Am J Obstet Gynecol 2007.
both Tennstedt et al and Monz et al included only baseline scores and did not estimate the impact of age on improvements in quality of life following treatment for stress incontinence. Our findings indicate that baseline IIQ-7 scores were the primary explanatory variable of differences between older and younger women in the improvement in IIQ-7 scores postoperatively. This is an important point to consider when counseling older women. Although baseline IIQ-7 scores were lower in older women, suggesting a decreased impact of incontinence on quality of life, older women can still expect a comparable degree of improvement in quality of life following surgery. If we considered only the absolute value of the postoperative IIQ-7 score or only the mean improvements in scores without considering baseline scores, we would incorrectly conclude that older women have less improvement following antiincontinence procedures.
Many studies have reported that postoperative cure rates in older women are comparable with younger women,18,19 whereas other studies have reported that older women are less likely to report subjective continence and satisfaction following surgery.17 However, these studies do not specifically address improvements in quality of life before and after surgery. There is often the perception that incontinence in older women may be more difficult to treat because of more severe incontinence, increased prevalence of urge incontinence, and intrinsic sphincter deficiency. In our study population, incontinence severity measured using the Sandvik’s Incontinence Severity Index and urgency symptoms measured by the UDI-6 were comparable between the 2 age groups. And although older women were more likely to be diagnosed with ISD, there was no difference in quality of life improvement between older and younger women after adjusting for this in our multiple linear regres-
DECEMBER 2007 American Journal of Obstetrics & Gynecology
680.e4
SGS Meeting Papers sion model. This suggests that older, active adult women should still be thoroughly counseled regarding their options for treatment because they can still expect significant improvements in quality of life. One limitation of our study was that we were unable to compare women in more extreme age groups, such as the young elderly (60-70 years), compared with the old elderly (older than 80 years) because of the small numbers of women in the older age group. Therefore, we were unable to make specific conclusions regarding these extremes. However, based on previous work, the risk of morbidity and mortality following urogynecologic procedures increases after age 60 years.6 Therefore, our findings add an important component for women over age 60 years to consider when making decisions regarding antiincontinence surgery. We were also unable to make conclusions regarding whether these quality-of-life improvements are similar and sustained beyond 12 months following surgery. In conclusion, urinary incontinence can have significant effects on a woman’s quality of life. Although incontinence tends to have less of an impact on quality of life in older women, older women can still expect to have a significant improvement in quality of life following antiincontinence surgery. This information is important for counseling
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www.AJOG.org women considering surgery for stress f urinary incontinence. REFERENCES 1. US Census Bureau. Projected population of the Untied States. Available at: http://www. consus.gov. Accessed January 15, 2007. 2. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol 2001;184:1496-501; discussion 1501-3. 3. Toglia MR, Nolan TE. Morbidity and mortality rates of elective gynecologic surgery in the elderly woman. Am J Obstet Gynecol 2003;189:1584-7; discussion 1587-9. 4. Stepp KJ, Barber MD, Yoo EH, Whiteside JL, Paraiso MF, Walters MD. Incidence of perioperative complications of urogynecologic surgery in elderly women. Am J Obstet Gynecol 2005;192:1630-6. 5. Lambrou NC, Buller JL, Thompson JR, Cundiff GW, Chou B, Montz FJ. Prevalence of perioperative complications among women undergoing reconstructive pelvic surgery. Am J Obstet Gynecol 2000;183:1355-8.; discussion 1359-60. 6. Sung VW, Weitzen S, Sokol ER, Rardin CR, Myers DL. Effect of patient age on increasing morbidity and mortality following urogynecologic surgery. Am J Obstet Gynecol 2006;194:1411-7. 7. Monz B, Chartier-Kastler E, Hampel C, et al. Patient Characteristics associated with quality of life in European women seeking treatment for urinary incontinence: results from PURE. Eur Urol 2006;51:1073-81.; discussion 1081-2. 8. Monz B, Pons ME, Hampel C, et al. Patientreported impact of urinary incontinence—results from treatment seeking women in 14 European countries. Maturitas 2005;52(Suppl 2):S24-34. 9. Tennstedt SL, Fitzgerald MP, Nager CW, et al. Quality of life in women with stress urinary
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incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2006;18:543-9. 10. Uebersax JS, Wyman JF, Shumaker SA, McClish DK, Fantl JA. Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group. Neurourol Urodyn 1995; 14:131-9. 11. Sandvik H, Espuna M, Hunskaar S. Validity of the incontinence severity index: comparison with pad-weighing tests. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:520-4. 12. Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-7. 13. Walsh TH. Audit of outcome of major surgery in the elderly. Br J Surg 1996;83:92-7. 14. Wenger NS, Solomon DH, Roth CP, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med 2003;139:740-7. 15. Edwards AE, Seymour DG, McCarthy JM, Crumplin MK. A 5-year survival study of general surgical patients aged 65 years and over. Anaesthesia 1996;51:3-10. 16. Davis TL, Lukacz ES, Luber KM, Nager CW. Determinants of patient satisfaction after the tension-free vaginal tape procedure. Am J Obstet Gynecol 2004;191:176-81. 17. Carey JM, Leach GE. Transvaginal surgery in the octogenarian using cadaveric fascia for pelvic prolapse and stress incontinence: minimal one-year results compared to younger patients. Urology 2004;63:665-70. 18. Allahdin S, McKinley CA, Mahmood TA. Tension free vaginal tape: a procedure for all ages. Acta Obstet Gynecol Scand 2004; 83:937-40. 19. Gordon D, Gold R, Pauzner D, Lessing JB, Groutz A. Tension-free vaginal tape in the elderly: is it a safe procedure? Urology 2005;65:479-82.