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Long-term bladder symptomatology following radiotherapy for cervical carcinoma
Radiotherapy and Oncology, 9 (1987) 195-199 Elsevier
195
RTO 00339
Long-term bladder symptomatology following radiotherapy for cervical carcinoma D. E. Parkin", J. A. Davis! and R. P. SymondsI
Department of Obstetrics and Gynaecology, Stobhill General Hospital, Glasgow, U.K., and 2 Department of Radiotherapy. Western Infirmary. Glasgow, U.K.
(Received 23 September 1986, revision received 9 February 1987, accepted 17February 1987)
Key words: Radiotherapy; Cervical carinorna: Bladder symptoms
Summary The prevalence of long-term bladder symptoms 5-11 years after radiotherapy for cervical carcinoma was investigated by postal questionnaire. Sixty-six replies (68%) were received. Only 29 (44%) were asymptomatic and 17 (26%) had severe symptoms. Urgency and urge incontinence were the most common symptoms occurring in 30 women (45%). Significant frequency and nocturia occurred in 23 women (35%) but voiding problems were less common. These results suggest that long-term bladder dysfunction is a common problem following radiotherapy for cervical carcinoma. Introduction
Most studies of bladder complications following radiotherapy have concentrated on major structural complications but have found little non-structural incontinence following radiotherapy. Postal questionnaires have been successfully used to investigate the prevalence of bladder symptoms in the population at large [9,11]. The aim of this study was to discover the prevalence of long-term bladder dysfunction following radiotherapy for cervical carcinoma and to indicate whether work is needed to discover the causes and possible treatment of this.
Radiotherapy is the only effective treatment for cervical carcinoma except for those few early cases in whom radical hysterectomy may be applicable [7]. Due to the anatomical proximity of the bladder to the cervix, the bladder and urethra inevitably receive a proportion of the radiation dose during treatment. Although "radiation cystitis" is common during and for a short time after treatment, late effects such as Vesico- Vaginal Fistula (VVF), haemorrhagic cystitis and bladder ulcers have been well studied and are known to be uncommon [5,10].
Materials and methods
Address for correspondence: D. E. Parkin, Department of Obstetrics and Gynaecology, Stobhill General Hospital, Glasgow, U.K.
The notes of all patients surviving following radiotherapy alone for cervical carcinoma at the Western Infirmary, Glasgow from 1974 to 1980 inclusive
o167-8140jg7 /$03.50 (f:)
1987 Elsevier Science Publishers B.V. (Biomedical Division)
196 were reviewed. The patients thought still to be alive were identified by the West of Scotland Cancer Surveillance Unit, RuchiIl Hospital Glasgow. Patients were excluded from the study if they had known recurrent or metastatic disease, were aged over 75 years, had a VVF or urinary diversion or if they had been lost to follow up. Of 132 patients identified, 97 fulfilled these criteria. Two were excluded due to the presence of a VVF treated by urinary diversion. These women were excluded as we wished to study symptoms in the absence of major complications. Early lesions (stage I and II) received two intracavity insertions using "Manchester" type applicators containing radium (1974) or radiocaesium (1975-1980). The total dose to point A was 60 Gy and the dose rate was 0.55 GY/h. This was followed by 3 weeks treatment with 4 MeV X-rays to parallel opposed diamond-shaped fields with the radium or caesium treated area covered by a specially shaped wedge. This gave a combined maximum dose to point A of 76.5 Gy and a pelvic side wall dose of 49.5 Gy. More advanced lesions (stage III and IV) were treated over 4 weeks with 4 MeV irradiation to the whole true pelvis using a 4-field box technique. A dose of 42.5 Gy was given in 20 fractions followed by a single intracavity insertion giving point A a further 33.5 Gy. The total dose to point A was 76 Gy and the combined pelvic side wall dose was 50 Gy. Bladder dose was not measured. No patient had any surgical treatment, apart from a cervical biopsy. A detailed questionnaire and explanatory letter was sent to all 97 patients at their last known address. No reminder was sent to non-responders to reduce the risk of upsetting relatives if the patient had recently died, The questionnaire enquired into most aspects of bladder symptomatology and was made as simple as possible for patients to complete unaided. Age, parity and any previous bladder surgery were obtained from the case records. The following details were obtained from the questionnaire: symptoms of incontinence: voiding frequency, nocturia, urgency, urge incontinence
TABLE I Symptom scoring system. Score
Symptom
2 Voiding frequency Nocturia Urgency Urge incontinence Stress incontinence
3-4 h 0-1 Absent Absent Absent
2h 2-3 Occasional Occasional Occasional
1h
4+ Regular Regular Regular
and stress incontinence. Voiding disorders: dysuria, incomplete bladder emptying, poor urinary flow, straining and haematuria. The questionnaire incorporated a 10 em analogue scale (scored from 1 to 100) for the patients to subjectively indicate the severity of their bladder symptoms when asked "How much trouble does your bladder give you" [6]. The severity of continence symptoms were assessed using an arbitrary scoring system (Table I). Severity was then graded as follows: grade 1 (score 0-2), grade 2 (score 3-5), grade 3 (score 6-8) and grade 4 (score 9-10). This was done in an attempt to quantify the multiple symptomatology complained of by these patients. Numerical data was statistically assessed with the unpaired students-z test. Permission to approach these patients was obtained from all the consultant radiotherapists and gynaecologists responsible for these patients' follow up. TABLE II Responders by stage. Stage
No. sent
Useful replies
% Response
Mean age (yrs) (S.D.)
Ia Ib IIa lIb IlIa IlIb
6 33 14 31 1 12
5 25 9 18 8
83 75 64 58 100 67
44.6 ( 6.1)' 58.6 (10.6) 57.2 (14.I) 61.4 ( 9.6) 62 60.6 (11.5)
Total
97
66
68
58.6 (11.3)
• p<0.05,
I
197
Results
TABLE IV Voiding symptoms (n = 66).
From the 97 questionnaires sent, 74 replies were received. Of these, five said the patient had moved from that address, one had developed a WF since last seen and two had died. This left 66 analysable replies, 68% of the total sent. All correctly completed the questionnaire. The proportion of responders was similar for each stage of the disease and there were no significant age differences between the stages except that those with stage Ia carcinoma were significantly younger than all other stages, p < 0.05 (Table II). The mean time since treatment was 7,85 years (S.D. 2.36) and the mean parity was 3.1 (S.D. 2.17). Symptoms were present before the radiotherapy in seven women and six women had undergone bladder neck surgery at some time. The most common symptoms were urgency and urge incontinence (Table III). These both occurred in at least 30 women. Frequency and nocturia were less common occurring significantly in 24 and 23 women respectively. Overall, the mean daytime voiding frequency was 2.89 h (S.D. 0.947), range 0.5 to 4 h and the mean episodes of nocturia was 1.32/night (S.D. 1.18), range 0 to 4. Stress incontinence was less common occurring regularly in 14 women. Voiding problems were less frequent (Table IV). Of the six women who strained to void, all had previous bladder neck surgery. Haematuria was complained of by IS patients. Using the symptom scoring system described in Table I, 29 were grade 1,20 were grade 2, 15 were grade 3 and 2 were grade 4. The mean grade was
Symptom Dysuria Incomplete emptying Strain to void Poor flow
24
36
23 31 (+ II occasional) 30 (+ 9 occasional) 14 (+ 7 occasional)
35 47 (64) 45 (59)
21 (32)
6 7
9 II
TABLE V Symptom grades. Grade
Mean grade (S.D.) 2
Frequency = or < 2 h Nocturia = or<2 Urgency Urge incontinence Stress incontinence
12 21
The most important aim when treating curable cervical carcinoma is to control the disease. In our unit, 5-year survival rates are high varying from 83% in stage Ib to 40% in stage BIb. As radiotherapy has advanced, more emphasis has been placed on the side effects of treatment, though the worst complication is failure to control the disease. The incidence of major bladder complications
Continence symptoms (II = 66). %
8 14
Discussion
Stage
No.
%
1.86 and there was no statistically significant difference between any stage (Table V). The analogue scale was correctly marked by 52 patients. Of these patients 41 had symptoms of grades I and 2 and in these women the mean score was 17.7 mm (S.D. 18.6). Eleven women had symptoms of grade 3 or 4. The mean score for this group was 59.8 mm (S.D. 25.9). This difference was statistically significant, p < 0.001. Overall, 14 women had a score greater than 40 mm.
TABLE TIl
Symptom
No.
2 II 5 7
4
3
IIlb
1 3
7 0 3
0 8 2 4 0 I
Total
29
20
15
la
Ib lIa
lIb IlIa
3
5
2
0 1 0 0 0 I
2.00 (1.06)
2
1.86 (0.87)
1.60 (0.54) 1.96 (0.97) 1.66 (0.86) 1.83 (0.78)
198 has been well studied [4,5] and lies between 1.5 and 7%. These workers describe little long-term bladder dysfunction. This group of patients was chosen as they are probably cured and sufficient time has elapsed since the radiotherapy to assess the longterm residual effects. The response rate to the questionnaire (68%) was better than one bladder questionnaire study which had a response rate of 53%, but worse than another with a response rate of89% [9,11]. The results show that only 29 patients are asymptomatic and that the 17 patients (26%) graded as 3 or 4 have severe symptoms and that three women apparently cured of their disease have developed a VVF. This is a much greater prevalence than previously found. Perez et al. [8] found only 13 cases of "chronic cystitis" and one of incontinence in 811 women and Jones et al. [4] found that in total there were 21 % with minor symptoms but only 4.1O/c were incontinent. Both studies involved a retrospective analysis of case records. The problem may have been underestimated because women are embarassed to mention urinary symptoms in a busy clinic, but will respond to a questionnaire. They may be so grateful at being cured that they do not wish to complain. These factors mean that case records may underestimate the problem. Our case records of 16S patients treated between 1974 and 1980 and knowr: to be alive in 1985 show that 147 women had nc bladder morbidity, 6 slight (out-patient treatment: morbidity, 13 moderate (in-patient treatment) morbidity and 3 required operative treatment for severe complications. This is considerably less than the morbidity found by the questionnaire. The cause of these symptoms is not certain. A shrunken contracted bladder is said to be the cause of some of the problems [2], but our results suggest that urgency and urge incontinence are the greatest problem, possibly indicating the presence of detrusor instability. Frequency and nocturia are less marked than would be expected if bladder capacity was greatly reduced. The mean visual analogue score is high (60 mm) in those women with more severe symptoms (grade 3-4). If the score is greater than 40 mm, this sug-
ges:s a diagnosis of detrusor instability [6]. In symptom grades I and 2 the mean score is much lower (18 mm) and is below the mean score of any patients complaining of incontinence [6]. Although 21 % complain of stress incontinence this is a subjective symptom and without urodynamic investigation cannot be proved [3]. The incidence of voiding disorders is relatively low with dysuria in particular being relatively uncommon. Unfortunately, as bladder dose was not measured we cannot say if the development of symptoms was dose related. Other factors apart from the radiotherapy may be responsible. These patients are relatively old and are all naturally or iatrogenically menopausal. Thomas [9] found that 8.5% of women aged 15-64 were incontinent, and 11.6% in women aged over 65, considerably less than in this study with a mean age of 58 years, range 39 :0 74 years. Our findings suggest that there is significant longterm bladder dysfunction after radiotherapy for cervical carcinoma. The cause of these symptoms needs to be investigated urodynamically, as has been done following radical hysterectomy [I]. Retrospective and prospective studies are now in progress. Patients attending for radiotherapy follow up should be closely questioned about bladder symptomatology especially about urgency and urge incontinence. References I Forney, P. 1. The effect of radical hysterectomy on bladder physiology. Am. 1. Obstet. Gynecol, 138: 374-382, 1980. 2 International Continence Society. Fourth report on the standardisation of terminology of lower urinary tract function. Br. J. Urol. 53: 333-335, [981. 3 Jarvis, G. Hall, S" Stamp, S., Millar, D. and Johnson, A. An assessment of urodynamic examination in incontinent women. Br. J. Obstet. Gyneacol. 87: 893-896, \ 980. 4 Jones, C.R. Woodhouse, C.R.J. and Hendry, W.F. Urological problems following treatment of carcinoma of the cervix. Br. J. Ural. 56: 609-613, 1984. 5 Kottmeier, H. L. Comp.ications following radiation therapy in carcinoma of the cervix and their treatment. Am. J. Obstet. Gynecol. 88: 854-866, 1964. 6 Parkin, D. E. and Davis, J. A. The use ofa visual analogue scale in the diagnosis of urinary incontinence, Br. Med. 1. 293: 365-366, 1986.
199 7 Perez, C. A., Breaux, S., Madoc-Jones, H., Bedwinek, J. M., Camel, H. M., Purdy, J. A. and Wall, B. J. Radiation therapy alone in the treatment of carcinoma of uterine cervix. Cancer 51: 1393-1402, 1983. 8 Perez, C. A., Breaux, S., Bedwinek, 1. Mv.Madoc-Jones. H., Camel, H. M.,Purdy, J. A. and Walz, B. J. Radiation therapy alone in the treatment of carcinoma of the cervix. 2. Analysis of complications. Cancer 54: 235-246, 1984. 9 Thomas, T. M., Kay, R. P., Blannin, J. and Meade, T. W.
Prevalence of urinary incontinence. Br. Med. J. 281: 12431245,1980. 10. Unal, A.• Hamberger. A. D., Seski, J. C. and Fletcher, G. H. An analysis of the severe complications of irradiation of carcinoma of the uterine cervix: treatment with intracavity radium and parametrial irradiation. Int. 1. Radial. Oncol, BioL Phys. 7: 999-1004, 1981. 11 Walker. M., Heady, J. A. and Shaper, A. G. Prevalence of urinary tract infection symptoms in women. 1. Epidcmiol, Commun. Health 35: 152-153,1981.
195
RTO 00339
Long-term bladder symptomatology following radiotherapy for cervical carcinoma D. E. Parkin", J. A. Davis! and R. P. SymondsI
Department of Obstetrics and Gynaecology, Stobhill General Hospital, Glasgow, U.K., and 2 Department of Radiotherapy. Western Infirmary. Glasgow, U.K.
(Received 23 September 1986, revision received 9 February 1987, accepted 17February 1987)
Key words: Radiotherapy; Cervical carinorna: Bladder symptoms
Summary The prevalence of long-term bladder symptoms 5-11 years after radiotherapy for cervical carcinoma was investigated by postal questionnaire. Sixty-six replies (68%) were received. Only 29 (44%) were asymptomatic and 17 (26%) had severe symptoms. Urgency and urge incontinence were the most common symptoms occurring in 30 women (45%). Significant frequency and nocturia occurred in 23 women (35%) but voiding problems were less common. These results suggest that long-term bladder dysfunction is a common problem following radiotherapy for cervical carcinoma. Introduction
Most studies of bladder complications following radiotherapy have concentrated on major structural complications but have found little non-structural incontinence following radiotherapy. Postal questionnaires have been successfully used to investigate the prevalence of bladder symptoms in the population at large [9,11]. The aim of this study was to discover the prevalence of long-term bladder dysfunction following radiotherapy for cervical carcinoma and to indicate whether work is needed to discover the causes and possible treatment of this.
Radiotherapy is the only effective treatment for cervical carcinoma except for those few early cases in whom radical hysterectomy may be applicable [7]. Due to the anatomical proximity of the bladder to the cervix, the bladder and urethra inevitably receive a proportion of the radiation dose during treatment. Although "radiation cystitis" is common during and for a short time after treatment, late effects such as Vesico- Vaginal Fistula (VVF), haemorrhagic cystitis and bladder ulcers have been well studied and are known to be uncommon [5,10].
Materials and methods
Address for correspondence: D. E. Parkin, Department of Obstetrics and Gynaecology, Stobhill General Hospital, Glasgow, U.K.
The notes of all patients surviving following radiotherapy alone for cervical carcinoma at the Western Infirmary, Glasgow from 1974 to 1980 inclusive
o167-8140jg7 /$03.50 (f:)
1987 Elsevier Science Publishers B.V. (Biomedical Division)
196 were reviewed. The patients thought still to be alive were identified by the West of Scotland Cancer Surveillance Unit, RuchiIl Hospital Glasgow. Patients were excluded from the study if they had known recurrent or metastatic disease, were aged over 75 years, had a VVF or urinary diversion or if they had been lost to follow up. Of 132 patients identified, 97 fulfilled these criteria. Two were excluded due to the presence of a VVF treated by urinary diversion. These women were excluded as we wished to study symptoms in the absence of major complications. Early lesions (stage I and II) received two intracavity insertions using "Manchester" type applicators containing radium (1974) or radiocaesium (1975-1980). The total dose to point A was 60 Gy and the dose rate was 0.55 GY/h. This was followed by 3 weeks treatment with 4 MeV X-rays to parallel opposed diamond-shaped fields with the radium or caesium treated area covered by a specially shaped wedge. This gave a combined maximum dose to point A of 76.5 Gy and a pelvic side wall dose of 49.5 Gy. More advanced lesions (stage III and IV) were treated over 4 weeks with 4 MeV irradiation to the whole true pelvis using a 4-field box technique. A dose of 42.5 Gy was given in 20 fractions followed by a single intracavity insertion giving point A a further 33.5 Gy. The total dose to point A was 76 Gy and the combined pelvic side wall dose was 50 Gy. Bladder dose was not measured. No patient had any surgical treatment, apart from a cervical biopsy. A detailed questionnaire and explanatory letter was sent to all 97 patients at their last known address. No reminder was sent to non-responders to reduce the risk of upsetting relatives if the patient had recently died, The questionnaire enquired into most aspects of bladder symptomatology and was made as simple as possible for patients to complete unaided. Age, parity and any previous bladder surgery were obtained from the case records. The following details were obtained from the questionnaire: symptoms of incontinence: voiding frequency, nocturia, urgency, urge incontinence
TABLE I Symptom scoring system. Score
Symptom
2 Voiding frequency Nocturia Urgency Urge incontinence Stress incontinence
3-4 h 0-1 Absent Absent Absent
2h 2-3 Occasional Occasional Occasional
1h
4+ Regular Regular Regular
and stress incontinence. Voiding disorders: dysuria, incomplete bladder emptying, poor urinary flow, straining and haematuria. The questionnaire incorporated a 10 em analogue scale (scored from 1 to 100) for the patients to subjectively indicate the severity of their bladder symptoms when asked "How much trouble does your bladder give you" [6]. The severity of continence symptoms were assessed using an arbitrary scoring system (Table I). Severity was then graded as follows: grade 1 (score 0-2), grade 2 (score 3-5), grade 3 (score 6-8) and grade 4 (score 9-10). This was done in an attempt to quantify the multiple symptomatology complained of by these patients. Numerical data was statistically assessed with the unpaired students-z test. Permission to approach these patients was obtained from all the consultant radiotherapists and gynaecologists responsible for these patients' follow up. TABLE II Responders by stage. Stage
No. sent
Useful replies
% Response
Mean age (yrs) (S.D.)
Ia Ib IIa lIb IlIa IlIb
6 33 14 31 1 12
5 25 9 18 8
83 75 64 58 100 67
44.6 ( 6.1)' 58.6 (10.6) 57.2 (14.I) 61.4 ( 9.6) 62 60.6 (11.5)
Total
97
66
68
58.6 (11.3)
• p<0.05,
I
197
Results
TABLE IV Voiding symptoms (n = 66).
From the 97 questionnaires sent, 74 replies were received. Of these, five said the patient had moved from that address, one had developed a WF since last seen and two had died. This left 66 analysable replies, 68% of the total sent. All correctly completed the questionnaire. The proportion of responders was similar for each stage of the disease and there were no significant age differences between the stages except that those with stage Ia carcinoma were significantly younger than all other stages, p < 0.05 (Table II). The mean time since treatment was 7,85 years (S.D. 2.36) and the mean parity was 3.1 (S.D. 2.17). Symptoms were present before the radiotherapy in seven women and six women had undergone bladder neck surgery at some time. The most common symptoms were urgency and urge incontinence (Table III). These both occurred in at least 30 women. Frequency and nocturia were less common occurring significantly in 24 and 23 women respectively. Overall, the mean daytime voiding frequency was 2.89 h (S.D. 0.947), range 0.5 to 4 h and the mean episodes of nocturia was 1.32/night (S.D. 1.18), range 0 to 4. Stress incontinence was less common occurring regularly in 14 women. Voiding problems were less frequent (Table IV). Of the six women who strained to void, all had previous bladder neck surgery. Haematuria was complained of by IS patients. Using the symptom scoring system described in Table I, 29 were grade 1,20 were grade 2, 15 were grade 3 and 2 were grade 4. The mean grade was
Symptom Dysuria Incomplete emptying Strain to void Poor flow
24
36
23 31 (+ II occasional) 30 (+ 9 occasional) 14 (+ 7 occasional)
35 47 (64) 45 (59)
21 (32)
6 7
9 II
TABLE V Symptom grades. Grade
Mean grade (S.D.) 2
Frequency = or < 2 h Nocturia = or<2 Urgency Urge incontinence Stress incontinence
12 21
The most important aim when treating curable cervical carcinoma is to control the disease. In our unit, 5-year survival rates are high varying from 83% in stage Ib to 40% in stage BIb. As radiotherapy has advanced, more emphasis has been placed on the side effects of treatment, though the worst complication is failure to control the disease. The incidence of major bladder complications
Continence symptoms (II = 66). %
8 14
Discussion
Stage
No.
%
1.86 and there was no statistically significant difference between any stage (Table V). The analogue scale was correctly marked by 52 patients. Of these patients 41 had symptoms of grades I and 2 and in these women the mean score was 17.7 mm (S.D. 18.6). Eleven women had symptoms of grade 3 or 4. The mean score for this group was 59.8 mm (S.D. 25.9). This difference was statistically significant, p < 0.001. Overall, 14 women had a score greater than 40 mm.
TABLE TIl
Symptom
No.
2 II 5 7
4
3
IIlb
1 3
7 0 3
0 8 2 4 0 I
Total
29
20
15
la
Ib lIa
lIb IlIa
3
5
2
0 1 0 0 0 I
2.00 (1.06)
2
1.86 (0.87)
1.60 (0.54) 1.96 (0.97) 1.66 (0.86) 1.83 (0.78)
198 has been well studied [4,5] and lies between 1.5 and 7%. These workers describe little long-term bladder dysfunction. This group of patients was chosen as they are probably cured and sufficient time has elapsed since the radiotherapy to assess the longterm residual effects. The response rate to the questionnaire (68%) was better than one bladder questionnaire study which had a response rate of 53%, but worse than another with a response rate of89% [9,11]. The results show that only 29 patients are asymptomatic and that the 17 patients (26%) graded as 3 or 4 have severe symptoms and that three women apparently cured of their disease have developed a VVF. This is a much greater prevalence than previously found. Perez et al. [8] found only 13 cases of "chronic cystitis" and one of incontinence in 811 women and Jones et al. [4] found that in total there were 21 % with minor symptoms but only 4.1O/c were incontinent. Both studies involved a retrospective analysis of case records. The problem may have been underestimated because women are embarassed to mention urinary symptoms in a busy clinic, but will respond to a questionnaire. They may be so grateful at being cured that they do not wish to complain. These factors mean that case records may underestimate the problem. Our case records of 16S patients treated between 1974 and 1980 and knowr: to be alive in 1985 show that 147 women had nc bladder morbidity, 6 slight (out-patient treatment: morbidity, 13 moderate (in-patient treatment) morbidity and 3 required operative treatment for severe complications. This is considerably less than the morbidity found by the questionnaire. The cause of these symptoms is not certain. A shrunken contracted bladder is said to be the cause of some of the problems [2], but our results suggest that urgency and urge incontinence are the greatest problem, possibly indicating the presence of detrusor instability. Frequency and nocturia are less marked than would be expected if bladder capacity was greatly reduced. The mean visual analogue score is high (60 mm) in those women with more severe symptoms (grade 3-4). If the score is greater than 40 mm, this sug-
ges:s a diagnosis of detrusor instability [6]. In symptom grades I and 2 the mean score is much lower (18 mm) and is below the mean score of any patients complaining of incontinence [6]. Although 21 % complain of stress incontinence this is a subjective symptom and without urodynamic investigation cannot be proved [3]. The incidence of voiding disorders is relatively low with dysuria in particular being relatively uncommon. Unfortunately, as bladder dose was not measured we cannot say if the development of symptoms was dose related. Other factors apart from the radiotherapy may be responsible. These patients are relatively old and are all naturally or iatrogenically menopausal. Thomas [9] found that 8.5% of women aged 15-64 were incontinent, and 11.6% in women aged over 65, considerably less than in this study with a mean age of 58 years, range 39 :0 74 years. Our findings suggest that there is significant longterm bladder dysfunction after radiotherapy for cervical carcinoma. The cause of these symptoms needs to be investigated urodynamically, as has been done following radical hysterectomy [I]. Retrospective and prospective studies are now in progress. Patients attending for radiotherapy follow up should be closely questioned about bladder symptomatology especially about urgency and urge incontinence. References I Forney, P. 1. The effect of radical hysterectomy on bladder physiology. Am. 1. Obstet. Gynecol, 138: 374-382, 1980. 2 International Continence Society. Fourth report on the standardisation of terminology of lower urinary tract function. Br. J. Urol. 53: 333-335, [981. 3 Jarvis, G. Hall, S" Stamp, S., Millar, D. and Johnson, A. An assessment of urodynamic examination in incontinent women. Br. J. Obstet. Gyneacol. 87: 893-896, \ 980. 4 Jones, C.R. Woodhouse, C.R.J. and Hendry, W.F. Urological problems following treatment of carcinoma of the cervix. Br. J. Ural. 56: 609-613, 1984. 5 Kottmeier, H. L. Comp.ications following radiation therapy in carcinoma of the cervix and their treatment. Am. J. Obstet. Gynecol. 88: 854-866, 1964. 6 Parkin, D. E. and Davis, J. A. The use ofa visual analogue scale in the diagnosis of urinary incontinence, Br. Med. 1. 293: 365-366, 1986.
199 7 Perez, C. A., Breaux, S., Madoc-Jones, H., Bedwinek, J. M., Camel, H. M., Purdy, J. A. and Wall, B. J. Radiation therapy alone in the treatment of carcinoma of uterine cervix. Cancer 51: 1393-1402, 1983. 8 Perez, C. A., Breaux, S., Bedwinek, 1. Mv.Madoc-Jones. H., Camel, H. M.,Purdy, J. A. and Walz, B. J. Radiation therapy alone in the treatment of carcinoma of the cervix. 2. Analysis of complications. Cancer 54: 235-246, 1984. 9 Thomas, T. M., Kay, R. P., Blannin, J. and Meade, T. W.
Prevalence of urinary incontinence. Br. Med. J. 281: 12431245,1980. 10. Unal, A.• Hamberger. A. D., Seski, J. C. and Fletcher, G. H. An analysis of the severe complications of irradiation of carcinoma of the uterine cervix: treatment with intracavity radium and parametrial irradiation. Int. 1. Radial. Oncol, BioL Phys. 7: 999-1004, 1981. 11 Walker. M., Heady, J. A. and Shaper, A. G. Prevalence of urinary tract infection symptoms in women. 1. Epidcmiol, Commun. Health 35: 152-153,1981.