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Objective:
To determine the social impact of surgery for incontinence on women's
lives.
Design:
Prospective longitudinal cohort study.
Setting and Participants:
Female patients with stress incontinence recruited pre-operatively from
a variety of specialist and non-specialist units.
Methods:
442 women were assessed pre-operatively and 3, 6 and 12 months post-operatively.
Questionnaires looking at the social impact of incontinence were used.
The financial cost of incontinence pads pre-operatively and 12 months
after surgery was also examined.
Results:
The degree of improvement in the restriction of activity caused by incontinence
depended on the pre-operative severity. The greater the pre-operative
impact, the greater the post-surgical improvement. However, the results
of surgery were not as good in patients with a poor pre-operative status.
Before surgery, the median cost of pads was £3.84 per month. Twelve
months post-surgery, the median cost was £1.36 per month.
Conclusions:
This is a useful study in that it examines the social impact of
both incontinence and its surgical treatment on women's lives. However,
the study includes centres both with and without specialist expertise:
separate results for specialist centres would be interesting.
Implications for Practice:
Not all women will be cured by surgery but a significant improvement
in the quality of life can be expected - the more so among women with
worse pre-operative incontinence, although absolute benefit may not
be as good. The study also demonstrates significant cost-savings in
pad usage.
AC (1)
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Urge Incontinence: Drugs or
Behavioural Techniques?
Behavioural vs Drug Treatment for Urge Incontinence in Older Women:
K.Burgio, J.L.Locher, P.S.Goode, J.M.Hardin, B.J.McDowell, M.Dombrowski,
D.Candib: JAMA 1998; 280:1995-2000
GP CS
Objective:
To compare the efficacy of behavioural techniques versus drug and placebo
treatment in urge and mixed incontinence in older women.
Design:
Randomised, placebo-controlled trial throughout 1989-1995, each patient
having an eight-week intervention.
Setting and Participants:
197 volunteer women with urodynamically proven urge incontinence attending
a university geriatric outpatient clinic (age 55-92).
Methods:
Behavioural techniques included pelvic floor therapy assisted by
anorectal biofeedback, bladder retraining, home pelvic floor exercises
and 'urge strategies' (to postpone voiding). Drug treatment consisted
of oxybutynin in a double-blind fashion. Dosing was titrated to the
most effective response.
Results:
The study reported a statistically significant improvement in incontinence
episodes following behavioural interventions (mean change 13 episodes
weekly) over oxybutinin therapy alone (mean change 10 episodes weekly).
There were fewer drop-outs in the behavioural technique group.
Conclusions:
This is the first randomised trial of behavioural therapies to be directly
compared to drug treatment for urinary urge incontinence. It reports
a significant effect within the confines of an eight-week period. Following
the trial, 15% of the behavioural group and 50% of the oxybutinin group
entered into a combined treatment regimen. However, there is evidence
that anticholinergic therapies may take up to ten weeks to exert their
maximum beneficial effect. The analysis only compared change with time
and not the change in variables between intervention groups, limiting
the validity of the conclusions. In addition, a standardised dose of
oxybutinin was not used, making interpretation of the data difficult.
Implications for practice:
This trial shows that in the short term behavioural techniques
may be an effective and acceptable alternative to oxybutinin treatment
alone.
AW (1)
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Pelvic Floor Exercises Proved
to Work
Single
Blind, Randomised Controlled Trial of Pelvic Floor Exercises, Electrical
Stimulation, Vaginal Cones and No Treatment in Management of Genuine
Stress Incontinence in Women: K.Bø, T.Talseth, I.Holme: Br Med J 1999;
318:487-93
GP CS PCN
Objective:
To assess the relative efficacy of three treatment modalities in
the treatment of genuine stress incontinence.
Design:
Randomised, single blind trial with a 'no treatment' group acting as
control.
Setting and participants:
Norwegian specialist physiotherapy service recruiting women with stress
incontinence who had no prior treatment.
Methods:
107 women randomized to four groups: pelvic floor exercises, electrostimulation,
vaginal cones, and no treatment. Outcome was reviewed at six months
and assessed according to muscle strength during pelvic floor contractions.
Objective cure rates were also assessed and compared for each group.
Results:
The pelvic floor exercise group had a significantly increased strength
compared to the other groups. The rate of objective cure was also significantly
higher in this group (44% PFE, 28% electrostimulation, 15% cones).
Conclusions:
Pelvic floor exercises are superior in efficacy to other conservative
treatment modalities.
Implications for practice:
The regimen used in this study (8-12 contractions thrice daily,
plus a weekly group session) may not be achievable by all women. In
addition, the way in which the data were analysed means that the conclusions
of the study must be guarded. Despite this the weight of evidence is
now firmly in favour of efficacy for pelvic floor exercises.
AW (1)
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Management of Faecal Incontinence
Laxatives and Faecal Incontinence in Long Term Care: J.Brocklehurst,
E.Dickinson, J.Windsor: Nursing practice 1998; 10:22-25.
GP CS PCN
Objective:
To investigate the levels of faecal incontinence and laxative usage
in long-term care settings.
Design: Questionnaire-based study.
Patients and methods:
Data were provided for 498 residents from 22 long-term care facilities.
Information was collected on functional status, medical diagnosis, sex,
mobility, the presence and frequency of faecal incontinence, doses and
frequency of laxatives, enemas and suppositories.
Results:
52% of residents had faecal incontinence. It was more common in
men. Use of the irritant laxatives co-danthramer and co-danthrusate
was positively associated with faecal incontinence. Laxatives were unsuccessful
in its treatment but use of suppositories was associated with a lower
incidence of faecal incontinence.
Conclusions:
The management of faecal incontinence in these settings is not optimal
and the prescription of laxatives should be carefully reviewed.
Implications for practice:
This study continues to raise questions about the appropriateness
of laxative prescribing in long-term care. The potential of laxatives
to exacerbate faecal incontinence is highlighted. Use should be under
regular review.
CV (1)
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Poor Results following Repair of Parturition
Injury
Third-degree Obstetric Perineal Tear: Long Term Clinical
and Functional Results after Primary Repair: A.C.Poen, R.J.Felt-Bersma,
R.L.Strijers, G.A.Dekker, M.A.Cuesta, S.G.Meuwissen: Br J Surg 1998;
85:1433-1438
GP CS
Objective:
To investigate the long-term clinical and anorectal functional results
following primary repair of a third-degree obstetric tear.
Design:
Retrospective, questionnaire-based study.
Patients and methods:
117 women, mean 4.7 years (range 1-10 years) after an anal sphincter
repair. 40 women also underwent anorectal physiological testing and
endo-anal ultrasound.
Results:
44 % of women were symptom-free. 40% had anal incontinence, and of these
just under half had incontinence on a weekly or daily basis. 88% (35/40)
of women had a residual defect in the sphincter muscles on endo-anal
ultrasound. The other symptoms recorded included urinary incontinence
and dyspareunia. Subsequent vaginal deliveries and the presence of a
combined internal and external sphincter defect increased the risk of
incontinence.
Conclusions:
Anal incontinence occurs in 40% of women after primary repair of a third-degree
tear.
Implications for practice:
This study highlights the relatively poor long-term outcome from
repairs of this type and illustrates the summative effect of repeated
vaginal delivery.
CV (1)
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Conservative Treatment effective for
the Physically Disabled
Effectiveness of Behavioral Therapy to Treat Incontinence
in Homebound Older Adults: B.J.McDowell, S.Engberg, S.Sereika, N.Donovan,
M.E.Jubeck, E.Weber, R.Engberg: J Am Geriatr Soc 1999 Mar; 47(3):309-18
GP CS PCN
Objectives:
To examine the short-term effectiveness of behavioural therapies in
housebound older adults and characterise the responders and non-responders
to the therapies.
Design:
Prospective, controlled clinical trial with cross-over design.
Setting and participants:
One hundred and five adults aged 60 and over with urinary incontinence
who met Health Care Financing Administration criteria for being homebound
and were referred to the study by their community nurses.
Methods:
The
study assessed activities of daily living, mental state and presence
of depression in addition to a structured incontinence and general questionnaire.
Results:
The subjects were randomized to biofeedback-assisted pelvic floor muscle
training and no specific treatment. The treatment group experienced
a statistically significant reduction in incontinence episodes compared
to the control group over the time of the study. Following the control
phase, control group subjects crossed over to the treatment protocol.
Those patients then matched the reduction in incontinence found in the
original treatment group. The most consistent predictor of responsiveness
to the behavioural therapy was compliance with the exercise regimen.
Conclusions:
Despite high levels of co-existent morbidity and disability, exercise
programmes to manage urinary incontinence can be effective.
Implications for practice:
This study shows that patients who are physically limited should
not be excluded from active conservative management of their urinary
problems. All of these patients were, however, cognitively intact and
therefore the conclusions of this study may not be applicable to the
housebound elderly at large.
AW (1)
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Conservative Treatment effective
for Elderly Women
Long-term Efficacy of Nonsurgical Urinary Incontinence
Treatment in Elderly Women: M.W.Weinberger, B.M.Goodman; M.Carnes: J
Gerontol A Biol Sci Med Sci 1999 Mar; 54(3): M117-21
GP CS PCN
Objective:
To establish the long-term efficacy of conservative treatment for urinary
incontinence in a population of elderly women.
Design:
Questionnaire survey. Setting and Participants: University hospital
based gynaecology service: 81 community-dwelling women over age 60 who
had had any conservative treatment for their incontinence and had attended
the service at least a year previously.
Results:
There was a 65% response to the questionnaire. The mean follow-up interval
was 21 ±8 months. 43% of women reported incontinence was not a problem
or mild, 33% reported moderate incontinence, and 21% reported severe
incontinence. When patients compared their initial with current incontinence
severity, improvement was significant. Improvement did not vary consistently
by incontinence diagnosis. Older patients had more severe incontinence
at presentation and reported less improvement than younger ones. The
overall likelihood of improvement was greatest among patients with the
most severe incontinence at presentation. Subjects considered pelvic
muscle exercises, bladder retraining and caffeine restriction the most
effective interventions.
Conclusions:
Elderly women derive long-term clinical benefit from nonsurgical incontinence
therapy. Younger patients and those with more severe incontinence are
most likely to respond.
Implications for Practice:
This study shows that conservative measures may be of benefit
in managing incontinence in elderly women. No data on incontinence severity
of those not responding to the questionnaire were presented. This and
the subjective nature of reporting may limit the value of the conclusions
drawn.
AW (1)
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When to Use Injection Therapy
Periurethral Injection for the Treatment of Urinary Incontinence:
A.Benshushan, A.Brzezinski, O.Shoshani, N.Rojansky: Obstet Gynecol Survey
1998; 53(6):383-388
GP CS
Objective:
To examine the place of periurethral injections in the treatment of
incontinence.
Design:
Review article assessing published data and comparing the different
substances used.
Results:
Periurethral injection as a treatment for genuine stress incontinence
has few side effects and results in fast patient recovery. It appears
most efficacious in the elderly population and those with intrinsic
sphincter deficiency and previous failed surgery. Repeated treatments
may be performed.
Conclusions:
Injections have a specific place in the treatment of genuine stress
incontinence. There appears to be little difference between materials
in the results achieved.
Implications for practice:
Although the minimal nature of the surgery makes it appear a very
attractive option, it should not be considered a quick easy cure for
all patients. It appears most suitable for women with mild or moderate
stress incontinence and perhaps those with contra-indications to more
extensive surgery.
AC (1)
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Preventing UTI in the Elderly
Low Dose Oestrogen Prophylaxis for Recurrent Urinary Tract
Infection in Elderly Women: L.Cardozo, C.Benness, D.Abbott: Brit. J
Obst. Gynaec 1998; 105:403-407
GP
Objective:
To assess the efficacy of oral oestriol in the prevention of recurrent
urinary infection in elderly women.
Design:
Double-blind randomised parallel-group, placebo-controlled trial.
Setting and Participants:
Urogynaecology department of a teaching hospital with some patients
recruited from neighbouring geriatric units. 72 women over the age of
60 with recurrent UTI (defined as more than three a year)
Methods:
Oral oestriol 3mg/day or placebo for six months. Main outcome measure:
incidence of new UTI.
Results:
Oral oestriol was not shown to be superior to placebo in the prevention
of recurrent UTI in this group of women. Both oestriol and placebo improved
urinary symptoms to a similar extent within the confines of the trial.
Conclusions:
The study design did not involve the prior calculation of sample size
to ascertain the required power of the study. Notwithstanding, this
route and dose appear to be ineffective at predicting the desired outcome.
Implications for practice:
This is a relatively short-term study and is limited by the relatively
small sample size in the absence of any prior thought about what difference
in outcome would have been considered significant. The jury is still
out on the question of oestrogen replacement and urinary tract infection.
There are some data from younger women suggesting that oestrogen replacement
is effective in preventing recurrent UTI. It is not known whether the
vaginal epithelium of older women is in any way less responsive to oestrogens
than that of younger females. The chance of making an erroneous conclusion
from the results of this study is considerable. At the time of writing
there is no need to change current practice in this area.
AW (1)
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Superiority of Colposuspension Again
Demonstrated
Five-Year results after anti-incontinence operations: K.F. Tamussino,
F. Zivkovic, D. Pieber, F. Moser, J. Haas, G. Ralph: Am J Obstet Gynecol
1999; 181(6):1347-1352
GP CS
Objective:
To evaluate the cure rates of three different continence operations
(anterior repair, anterior repair with needle suspension and colposuspension)
at five years.
Design:
327 patients who had undergone one of the above operations between 1989
and 1993 were recalled for follow-up subjective and objective testing
five years after the operation.
Results:
Burch-colposuspension resulted in a significantly higher cure rate than
the other two operations. This was despite the fact that overall the
women who underwent a colposuspension had more severe incontinence prior
to the operation and more women in this group had undergone previous
surgery. The five-year objective cure rate for the colposuspension was
79%.
Conclusions:
The place of anterior repair with or without needle suspension is limited,
especially if the patient has severe incontinence.
Implications for Practice:
Although colposuspension is a more serious operation, this is yet
another study that demonstrates that it is superior to minor vaginal
surgery. There is always marked attraction for less invasive procedures
but it must be remembered that the primary aim of surgery is to cure
the patient. Minor degrees of incontinence which do not warrant major
surgery are possibly best treated with conservative measures.
AC (2)
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Urodynamics Vital before Surgery
Pure stress leakage symptomatology: is it safe to discount detrusor
instability? M. James, S. Jackson, A. Shepherd, P. Abrams. Br J Obstet
Gynaecol 1999; 106:1255-1258.
GP CS
Objective:
To determine whether urodynamic investigations are necessary prior to
surgery in those women who complain of predominantly stress incontinence.
Design:
5193 women who were referred for urodynamic investigations had a detailed
history taken and filled in a urinary diary. Those women with symptoms
of stress incontinence but no symptoms of bladder irritability and a
normal urinary diary were included in the study. Thus 555 women with
symptoms of pure stress incontinence had their urodynamic findings analysed.
Results:
Incontinence secondary to genuine stress incontinence alone was confirmed
in 72% of the women. 10% of women had detrusor instability and 7% had
urethral sphincter incompetence and detrusor instability; 3% of women
had no incontinence on urodynamic investigation.
Conclusions:
This retrospective review of symptom and urodynamic data clearly demonstrates
the need for urodynamic investigations to make an accurate diagnosis
even in a highly selected group where the presumed diagnosis is of genuine
stress incontinence. Without urodynamics, up to 28% of the women would
have had inappropriate surgery.
Implications for Practice:
This data adds to the literature demonstrating the dangers of operating
without an accurate diagnosis. It also demonstrates that to persevere
with conservative therapy on the basis of symptoms alone as a long-term
measure may well result in despondent patients.
AC (2)
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How to avoid Incontinence after
Prolapse Surgery
Predicting the need for anti-incontinence surgery in continent women
undergoing repair of severe urogenital prolapse: D.C. Chaikin, A. Groutz,
J.G. Blaivas: J Urol 2000; 163:531-534.
GP CS
Objective:
To determine the effects of prolapse reduction on lower urinary
tract function in asymptomatic women.
Design:
A prospective evaluation of 24 continent women referred for surgery
for severe prolapse with no lower urinary tract symptoms. They underwent
a detailed history and examination. Urodynamic investigations were performed
both before and after the prolapse was re-positioned by a vaginal pessary.
The women with genuine stress incontinence after prolapse re-positioning
underwent a sling procedure in addition to an anterior repair. Evaluation
of the repair and lower urinary tract function is reported for a minimum
follow-up time of one year.
Results:
18 women had bladder outflow obstruction before the prolapse was repositioned.
Before the prolapse reduction, none of the women had genuine stress
incontinence but after 14 out of 24 had evidence of genuine stress incontinence.
At follow up, the 10 women who had no evidence of stress incontinence
pre-operatively were continent. Of the 14 women who also underwent the
sling procedure, 2 remained incontinent.
Conclusions:
The reduction of a severe prolapse revealed occult genuine stress incontinence
in 58% of women. The reduction of a prolapse during the urodynamic investigation
enables the surgery to be tailored to the individual's needs.
Implications for Practice
Although this is a small series, the demonstration of alterations
in urodynamic variables, both for outflow obstruction and incontinence,
is important when considering surgery in this group of patients. To
repair a patient's prolapse but to leave her incontinent is an unsatisfactory
outcome especially if the patient is not warned. Discussion about future
surgery that may be necessary can be addressed prior to the primary
procedure if an underlying problem is revealed.
AC (2)
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Symptoms of lower urinary tract dysfunction vary over time
Incidence and remission rates of lower urinary tract symptoms
at one year in women aged 40-60: L.A. Møller, G. Lose, T. Jørgensen:
Brit Med J 2000; 320:1429-32
GP CS
Objective:
To determine the incidence and remission rates of lower urinary
tract symptoms at one year's follow up. To assess factors which may
be associated with remission.
Design and setting:
Longitudinal cohort study in 4000 women from rural and urban populations
in Denmark.
Results:
2860 (72%) women responded to the initial questionnaire and 2284 (80%)
did so at one year. Prevalence of symptoms was 29%, estimated yearly
incidence 5.8% and remission 29% at one year. Women were probably influenced
to seek advice or treatment as an effect of the study.
Conclusion:
This is one of few studies which have addressed the longitudinal course
of symptoms. The prevalence of incontinence in the women studied is
in general agreement with data from other series. Remission of symptoms
is common, but the reasons for this were not explored in the study
Implications for practice:
Women experience marked variation in lower urinary tract symptoms
over time. Awareness of the factors influencing these changes will help
in tailoring management of symptoms.
AW (2)
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Incontinence affects sex life - but
minimally
Urinary incontinence in both sexes: prevalence rates and impact on quality
of life and sexual life: C. Temml, G. Haidinger, J. Schidbauer, G. Schatzl,
S. Madersbacher: Neurourol Urodyn 2000; 19: 259-71
GP CS PCN
Objective:
To determine the prevalence of urinary incontinence and to assess its
impact upon quality of life and sexual function.
Design and Setting:
Questionnaire-based cross-sectional survey over one year in population
of 2,498 attending for free health screening in Vienna, Austria. Prevalence
data were adjusted for age according to national data for Austria.
Results:
26.3% of women and 5% of men reported incontinence within the four weeks
prior to the questionnaire. Prevalence was higher in greater age. The
female population was statistically significantly younger than the male.
66% of affected women and 58% of men reported a negative impact of their
incontinence upon general quality of life, with impairment of sex life
reported by 25% of affected women and 30% of affected men, the majority
of sufferers noting a minor impact. Only 5% of women and 16% of men
with incontinence had previously consulted a doctor regarding their
problem.
Conclusions:
Prevalence of incontinence for the Austrian population may be obtained
by extrapolation; although the method and definition of incontinence
may lead to significant bias, the results are in general agreement with
other studies. The impact of incontinence on sexual function appears
to be minor. Most people do not consult a health professional regarding
their problem.
Implications for practice:
These data, although subject to some selection bias, reinforce the
need to actively case find, by whatever means necessary. The data on
impact upon sexual functioning are interesting but a further in depth
study is clearly needed. This subject should not be neglected as a result.
AW (2)
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Drug and behavioural therapy combined
are better than either alone
Combined behavioural and drug therapy for urge incontinence in older
women: K. Burgio, J.L. Locher, P.S. Goode: J American Geriatrics Society
2000; 48:370--374
GP CS PCN
Objective:
To examine the combined effect of behavioural and drug therapy for urge
incontinence in older women.
Design and setting:
Extension of previously reported randomized clinical trial with a crossover
design. Subjects not totally continent or unsatisfied after two months
of single therapy could cross over onto combined therapy. Subjects were
community dwelling women >55 years of age attending a university outpatients
clinic.
Method:
One group received 8 weeks of behavioural therapy followed by titrated
drug therapy, the other group received drug therapy first.
Results:
Additional benefit, 73% to 84% improvement, was seen when patients on
behavioural therapy received additional drug therapy, although only
12% crossed over. Likewise, patients who received drug therapy initially
also experienced an increased (59% to 77%) effect when they crossed
over to combined treatment.
Conclusion:
This study, although a within-group comparison, provides data which
indicate an enhanced effect of combined therapy for urge incontinence
when introduced in a stepwise fashion.
Implications for practice:
A combined approach to the treatment of urge incontinence at initial
presentation may achieve superior results to conservative therapies
alone. This may act to motivate patients to persist with behavioural
therapies until control can be maintained without drugs.
AW (2)
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Tension-free Tape Procedure for Stress
Incontinence
The Tension-Free Vaginal Tape Procedure: correction of Stress Incontinence
with Minimal Alteration in Proximal Urethral Mobility: J.J. Klutke,
B.I. Carlin, C.J. Klutke: Urology 2000; 55(4):512-514
GP CS
Objective:
To assess the degree of urethral hypermobility in the preoperative and
postoperative periods after the tension-free vaginal tape (TVT) procedure
and correlate the findings with surgical outcome.
Design:
Prospective study
Patients and methods:
Twenty female patients with genuine stress incontinence were studied
prospectively. Evaluation preoperatively included urodynamics and the
Q-tip test. (The Q-tip test consists of placing a cotton swab into the
urethra and measuring the angle to the horizontal at rest. On straining,
the swab moves upwards where there is urethral hypermobility. The new
angle is measured. A Q-tip test result of +30 is positive.) TVT was
performed. Cure was assessed subjectively and objectively. The Q-tip
test was repeated.
Results:
In the postoperative period 17 patients (85%) reported a cure, 2 patients
(10%) were significantly improved and 1 patient (5%) failed. The operation
was successful in 11 out of the 12 patients who still had a positive
Q-tip test postoperatively.
Conclusions :
Although a small study, the results have been repeated elsewhere. It
shows that there is more to successful stress incontinence surgery than
correcting urethral hypermobility. Sling procedures provide a suburethral
support mechanism. It is postulated that an increase in abdominal pressure
compresses the urethra against a stable supporting layer (the hammock
hypothesis, 1994).
Implications for practice:
The study highlights the need for a better understanding of the mechanism
of genuine stress incontinence. Urethral hypermobility is important
but successful surgery does not necessarily entail its correction. Sling
procedures may in future supplant the colposuspension.
FC (2)
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Pelvic floor exercises in men effective
after prostatectomy
Effect of pelvic floor re-education on duration and degree
of incontinence after radical prostatectomy: M. Van Kampen, H. Van Poppel,
D.De Ridder: The Lancet 2000; 355:98-102
GP CS PCN
Objective:
To discover whether pelvic floor re-education reduces the duration and
degree of urinary incontinence following radical prostatectomy.
Design:
A randomised controlled trial.
Patients and methods:
102 consecutive incontinent patients following radical prostatectomy
(classic retropubic retrograde approach maintaining the pelvic floor
structures). Patients were placed in one of 6 sub-groups according to
amount of initial urine loss and if they had had a transurethral resection,
and then randomly assigned to either the treatment group or the control
group. Treatment group: active pelvic muscle exercise and biofeedback
+ electrical stimulation, performing 90 voluntary contractions per day
for up to one year. Control group: weekly attendance at clinic with
no active treatment or placebo electrical stimulation. A 24-hour pad
test was done daily until patients became continent.
Results:
In the treatment group, 88% achieved continence after 3 months, compared
with 56% in the control group (p=0.001). Although not a primary end-point
of the study, at one year 5% of the patients in the treatment group
were incontinent compared with 19% of the controls. Conclusions: Physiotherapy
should be started as soon as possible after surgery.
Implications for practice:
The regimen used involves multiple visits to hospital, which may
not be achievable in some areas of the country. Also, access to specialist
physiotherapists is difficult and patchy. However, since physiotherapy
is an effective treatment for post-prostatectomy incontinence and carries
no risks or side-effects, it should be used for these patients.
GG (2)
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Midline Episiotomy Increases
Risk of Faecal Incontinence and Incontinence of Flatus
Midline episiotomy and anal incontinence: retrospective
cohort study: L.A. Signorell, B.L. Harlow, A.K. Chekos, J.T. Repke:
British Medical Journal 2000; 320:86-90
GP CS
Objective:
To evaluate the relation between midline episiotomy and postpartum anal
incontinence.
Design:
Retrospective cohort study with three study arms and six months' follow
up.
Methods:
Primiparous women who vaginally delivered a live full-term, singleton
baby were studied over a 6-month period to evaluate the relation between
midline episiotomy and postpartum anal incontinence. The study group
was made up of 209 women who received an episiotomy, 206 who did not
but experienced a second, third or fourth degree spontaneous perineal
laceration and 211 who experienced either no laceration or a first degree
perineal tear. Self-reported faecal and flatus incontinence at three
and six months postpartum was the main outcome measure.
Results:
Women who had episotomies had a higher risk of faecal incontinence at
three months postpartum compared with women with an intact perineum.
Compared with women with a spontaneous laceration, episiotomy tripled
the risk of faecal incontinence at three and six months postpartum and
doubled the risk of flatus incontinence at three and six months. A non--extending
episiotomy tripled the risk of faecal incontinence and nearly doubled
the risk of flatus incontinence at three months postpartum compared
with women who a second degree spontaneous tear. The effect of episiotomy
was independent of maternal age, infant birth weight, duration of second
stage of labour, use of obstetric instrumentation during delivery and
complications of labour.
Conclusion:
Midline episiotomy is not effective in protecting the perineum and
sphincters during childbirth and may impair anal continence.
Implications for Practice:
This study needs to be viewed with caution in the United Kingdom
where mediolateral episiotomies are normally carried out. A recent editorial
in the BMJ (Midline versus mediolateral episiotomy: British Medical
Journal 2000; 320:1615-1616) emphasises the need for randomised controlled
trials to be carried out to assess the relevant benefits of midline
versus mediolateral technique.
MW (2)
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Retrospect: Why Pelvic Floor
Exercises don't work
Progressive Resistance Exercise in the Functional Restoration of the
Perineal Muscles: A.Kegel: Am J Obstet Gynecol 1948; 56:238-48
GP CS PCN
When Kegel published this article 51 years ago, he was commenting on
15 years of experience of teaching pelvic floor exercises in the post-partum
period. Many of his points have enduring relevance which is why his
article is still much quoted in the 1990's. Kegel correctly noted that
pelvic floor exercises do not work when:
the
exercises are taught incorrectly
It is easy to teach exercises for muscle groups in the pelvic area without
recruiting the pelvic floor muscles at all.
verbal instruction is the only instruction
given
Kegel wrote in some detail about the need to teach pelvic floor exercises
as part of a vaginal examination and the value of using a perineometer
as a method of biofeedback for the patient. He incorporated the principle
of working the muscles maximally and progressing the exercise programme
as the woman is able. These are principles that skilled clinicians use
today in order to get maximum results. It has been documented more recently
that some women after only verbal instruction may bear down rather than
pull the muscles up, thus actually doing more damage rather than improving
matters.
they are performed only for a short
period of time
Kegel suggested exercising for between 20-60 days with a weekly use
of biofeedback in the out- patient clinic. In line with current thinking
about how muscles change with exercise it is widely accepted that an
exercise regime needs to be performed for between 3-6 months in order
to gain maximum improvement, and regular reviews in clinic achieve even
greater compliance.
the patient has severe symptoms (of
prolapse, incontinence or bladder instability)
Kegel recommended that the exercises were particularly beneficial for
symptoms of early cystocoele or rectocoele and symptoms of urinary stress
incontinence and helped retain the contraceptive diaphragm where this
had become difficult. Pelvic floor exercises are still known to be most
beneficial when symptoms are not too severe. However, they are also
of benefit in conjunction with surgery, bladder training or anti-cholinergic
medication.
Implications for practice:
The key to success in teaching and assessing pelvic floor exercises
is in ensuring that patients have access to specialist clinicians (usually
specialist physiotherapists or specialist nurses) with an interest in
pelvic floor therapy who are suitably experienced. Exercise régimes
should also replicate those for which there is proven efficacy.
SG (1)
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Retrospect:
Caffeine Restriction - Where's the Evidence?
GP CS PCN
Caffeine is found in tea, coffee, coke and chocolate as well as in some
proprietary medicines. Caffeinated drinks are the staple of most peoples
fluid intake. However, it is widely accepted that caffeine consumption
can affect an individuals well being and there is a drive for people
to drink more decaffeinated fluids.
Most specialist practitioners working with patients with bladder and
bowel problems tend to give advice on reducing caffeine intake. However,
there is a dearth of evidence evaluating the effect of dietary caffeine
on the bladder and its role in individuals with overactive bladder symptoms.
There are no studies that have investigated the relationship between
the time caffeine is consumed and the occurrence of symptoms. There
is no data on whether patients develop side effects from caffeine restriction
and for how long these lasted.
Caffeine withdrawal symptoms include headache, fatigue with anxiety,
impaired psychomotor performance and nausea/vomiting. Withdrawal symptoms
typically begin at 12-24 hours and peak 20-48 hours after cessation
of caffeine consumption. Symptoms may persist for a week (Benowitz,
1990).
One of the most important mechanisms of action of caffeine is the antagonism
of adenosine receptors, these can be found in the renal system (Fredhohn,
B., 1985). Caffeine causes a mild diuresis by acting on the renal tubules
(Maren, 1961), this may be the reason for urinary frequency. It is also
possible that caffeine has a direct effect on the bladder, increasing
detrusor muscle activity (Creighton and Stanton, 1990).
Caffeine is complete absorbed from caffeinated beverages and reaches
a peak in the blood in about 30-60 minutes. It has a half-life of 4-6
hours (Benowitz, 1990) reaching a plateau in the afternoon or early
evening (Brown et al, 1988). Caffeine is susceptible to a number of
other drug interactions and these include those with cimetidine, disulfiram
and oestrogen containing oral contraceptive agents. Caffeine metabolism
is also accelerated by smoking (Benowitz, 1990).
Evidence exists that people with urgency and urge incontinence tend
to reduce fluid intake in order to reduce the severity of their symptoms
(Pearson and Kelber, 1996). However, although there is some evidence
of fluid advice being used in clinical trials until recently there has
been no conclusive evidence that such an intervention works on its own.
Studies that are available highlight the effect of caffeine and the
amount and type of fluid taken. Creighton and Stanton (1 990) found
that patients who were administered caffeine had a significant increase
in detrusor pressure during bladder filling in urodynamic investigation
when compared to those who had not. This was however a study using only
laboratory measures of effect.
James and Sawczuk (1989) found in a small"group of psycho-geriatric
inpatients that incontinence levels were significantly reduced during
periods of caffeine abstinence. However, the study lacked a control
group and merely observed an effect over time.
In a recent large study, Tomlinson et al (1999) found that a decrease
in dietary caffeine led to fewer daytime incontinence episodes and that
an increase in the average amount of fluid drank related to an increase
in the amount of urine voided. This study provides evidence that by
making recommendations about fluid and caffeine intake, bladder symptoms
may be improved. However, the study numbers were small (41 women aged
over 55 years). In addition all bladder symptoms were included in the
analysis, including those of stress incontinence, urge incontinence
and mixed incontinence. The study clearly did not have the power to
perform any sub-analysis. This study provides evidence that by making
recommendations about fluid and caffeine intake, bladder symptoms may
be improved but the study did not address the issue of caffeine alone.
However the results do give clinicians preliminary advice on which to
base their practice.
MW (2)
References
Benowitz N.L. (1990), Clinical Pharmacology of Caffeine, Annual Review
of Medicine: 41:277-88
Brown C.R., Jacob P.III, Wilson M and Benowitz N.L. (1988), Changes
in rate and pattern of caffeine metabolism after cigarette abstinence,
Clinical Pharmacological Therapy: 43:488-491
Creighton S. and Stanton S. (1990), Caffeine: does it affect your bladder?
British Journal of Urology: 66(6):13-14
James J.E. and Sawczuk D. (1989), The effect of chronic caffeine consumption
on urinary incontinence in psychogeriatric inpatients, Psychology and
Health: 3:297-305
Maren T.H. (1961), The additive renal effect of oral aminophylline and
tricholoromethazide in man, Clinical Research: 9:57
Pearson B.D. and Kelber A. (1996), Urinary Incontinence: Treatments,
Interventions and Outcomes, Clinical Nurse Specialist: 10(4):177-182
Tomlison B.U., Dougherty M.C., Pendergast J.F., Boyington A.R., Coffman
M.A. and Pickens S.M. (1999), Dietary Caffeine, Fluid Intake and Urinary
Incontinence in Older Rural Women, International Urogynaecology Journal:
10:22-28
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[Revised 4 April 2001]
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