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The
Continence Foundation Review is aimed at those in primary care and includes
abstracts of selected research reports plus brief articles and items of
news.
It is sent free of charge to any health professional to whom it is of
interest. If you wish to receive it in future, go to the section PUBLICATIONS
Some of the RECENT REVIEWS AND RETROSPECTS are
reproduced below after an introductory article by the editor.
Why Another Review?
by Adrian Wagg, editor of the Continence Foundation
Review
A survey of General Practitioners carried out for the group General
Practitioners with an interest in Urology and Gynaecology (GPiUG)
(1) questioned 200 GPs about their beliefs
and education about urinary incontinence and their understanding
of treatments for it. The results made interesting if disheartening
reading.
Bladder problems are common. A recent poll (2)
suggested that up to 6 million people in the UK have bladder problems,
though not all suffer from urinary incontinence. Moreover, a major
population study by the MRC in Leicestershire and Rutland (3)
has shown that as many as 34% of adults over the age of 40 reported
clinically significant symptoms of incontinence, nocturia, urgency
or frequency. More significantly, 3.8% said they wanted help with
their problems - on average about 50 for every GP - and most of
these reported that the impact of their problems was socially disabling,
having "a lot of impact on activities, social life, relationships,
feelings or quality of life". For the smaller proportion of people
with bowel control problems, the impact of their condition is of
course even more severe.
Indeed, there is evidence that the effect of incontinence on quality
of life can equal that of major organ failure. (4)
Similarly, elderly people suffering only from incontinence are significantly
more likely to be institutionalized than their continent contemporaries.
(5) Many sufferers are elderly and are more
likely to be suffering from the effects of other illness and/or
polypharmacy, compounding the problem.
In these circumstances, one would expect General Practitioners to
be knowledgeable and experienced in helping their patients. Regrettably
the GPiUG survey showed otherwise. Most GPs received limited education
in urinary incontinence at medical school and have had little further
exposure, although some felt that their general medical experience
helped. Moreover, a considerable number of them share the view of
the general public that there are no effective treatments for incontinence.
The truth is quite the contrary: there are effective cures and well
tolerated management strategies for those with bladder and bowel
problems. Many of these involve nurses and physiotherapists rather
than doctors, but GPs - still by far the most important "gatekeepers"
for NHS healthcare - need to know of these treatments as well as
the medical and surgical possibilities. The need is all the greater
with the advent of Primary Care Groups and will be underlined in
new guidance expected shortly from the NHSE.
Our intention, therefore, in this review is to present to everyone
in primary care three times a year with a careful selection of high
quality, clinically relevant publications in the field of continence.
Each will be analysed and commented upon by an expert in the relevant
specialism to make the findings easily digestible for practitioners
with limited time availability.
We hope that you will find the Review valuable and we shall welcome
your comments.
Adrian Wagg
NOTES
1. Details from GPiUG, PO Box 5632, Leicester LE8 6WL
2. Unpublished survey by SIFO Research and Consulting commissioned
by Pharmacia Ltd.
3. Perry S et al (2000): An epidemiological study to establish the
prevalence of urinary symptoms and felt need in the community: the
Leicestershire MRC Incontinence Study: Journal of Public Health
Medicine 22: 3: 427-434
4. Johnson TM; Kincade JE, Bernard SL, Busby-Whitehead J, Hertz-Picciotto
I, DeFriese GH: The association of urinary incontinence with poor
self-rated health: J Am Geriatr Soc 1998 Jun; 46(6):693-9.
5. Thom et al, Medically recognized urinary incontinence and risks
of hospitalization, nursing home admission and mortality: Age and
Ageing 1997; 26:367-374
Reviews and Retrospects
The Reviews that follow are our own abstracts of articles we judge
particularly relevant to primary care. The Retrospects are brief
articles by our reviewers. Please note that the opinions expressed
are those of the reviewers and do not necessarily reflect those
of the Continence Foundation.
The issue on which they were first published is indicated in parenthesis
after the reviewer's initials - issue 1: winter 2000; issue 2: summer
2000.
Relevance:
GP General practitioners
CS Continence specialists
PCN Primary Care Nurses
Reviewers:
FC: Frank Chinegwundoh, consultant urologist, St Bartholomew's Hospital
AC: Alfred Cutner, consultant gynaecologist, Elizabeth Garrett Anderson
Hospital
SG: Sharon Green, physiotherapist
GG: Georgie Gulliford, physiotherapist, King's College Hospital
Department of Obstetrics and Gynaecology
CV: Carolynne Vaizey, consultant colorectal surgeon, Middlesex Hospital
AW: Adrian Wagg, senior lecturer, University College London and
St Pancras Hospital
MW: Mandy Wells, senior clinical continence nurse specialist, Camden
and Islington Community Health Services NHS Trust
LIST OF ITEMS
Stress Incontinence Surgery for Women
Urge Incontinence: Drugs or Behavioural Techniques?
Pelvic Floor Exercises Proved to Work
Management of Faecal Incontinence
Poor Results following Repair of Parturition Injury
Conservative Treatment effective for the Physically
Disabled
Conservative Treatment effective for Elderly Women
When to Use Injection Therapy
Preventing UTI in the Elderly
Superiority of Colposuspension Again Demonstrated
Urodynamics Vital before Surgery
How to avoid Incontinence after Prolapse Surgery
Symptoms of lower urinary tract dysfunction vary over
time
Incontinence affects sex life - but minimally
Drug and behavioural therapy combined are better than
either alone
Tension-free Tape Procedure for Stress Incontinence
Pelvic floor exercises in men effective after prostatectomy
Midline Episiotomy Increases Risk of Faecal Incontinence
and Incontinence of Flatus
Why Pelvic Floor Exercises don't work (retrospect)
Caffeine Restrictions - Where's the Evidence? (retrospect)
Stress
Incontinence Surgery for Women
Impact of Surgery for Stress Incontinence on the Social Lives of
Women: N.A.Black, A.Bowling, J.M.Griffiths, C.Pope, P.D.Abel: Br
J Obstet Gynaecol 1998; 105:605-612
GP CS PCN
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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