The association of obstructive defecation, lower urinary tract dysfunction and the benign joint hypermobility syndrome: a case-control study

A Comprehensive Case Study of a Hyperlaxity Dilemma: An Injury-Prone Young Athlete

A prevalent condition that is frequently linked to joint trauma is joint hyper-laxity. The knee joint is one of the most complex and injury-prone joints in sports. The most commonly injured is the anterior cruciate ligament (ACL). The case presented below is of a 24-year-old athlete with a past history of many sports-related injuries who is now presented with a complete tear of the ACL with hyper-laxity as a risk factor. The patient has a Beighton score of six out of nine without any other symptoms, which is suggestive of benign hyper-laxity of the joints and not hyper-laxity syndrome. Here, we emphasize that medical professionals must know the fundamental connection between hyper-laxity and musculoskeletal injuries and their proper management and rehabilitation for future prevention.

Severity of Nocturia and Constipation in Patients With Ulcerative Colitis

OBJECTIVE

To investigate the association between nocturia and constipation in patients with ulcerative colitis (UC). Constipation has recently been recognized as an important symptom in patients with UC. Although nocturia has been associated with constipation in the general population, the association between nocturia and constipation in UC patients is uncertain.

METHODS

Consecutive series of 290 Japanese patients with UC, Information on constipation, nocturia, and lifestyle habits was obtained using self-administered questionnaires. The definition of constipation was based on Rome I criteria and/or current medication for constipation. Patients were divided into three groups based on nighttime urination: (1) no nocturia, (2) mild nocturia (nocturnal urination - one), and (3) serious nocturia (nocturnal urination - two or more). Multivariate logistic regression was used to evaluate the association between nocturia and constipation.

RESULTS

Among all of the UC patients, the prevalence of mild nocturia, serious nocturia, and constipation was 35.2%, 26.9%, and 12.4%, respectively. The prevalence of constipation in the none, mild, and serious nocturia groups was 8.2%, 10.8%, and 20.5%, respectively. After adjustment for confounders such as age, sex, current drinking, current smoking, body mass index, and steroid use, nocturia severity was independently and positively associated with constipation (adjusted odds ratio for mild nocturia: 1.55 [95% confidence interval: 0.57-4.28], serious nocturia: 3.19 [95% confidence interval: 1.09-9.81], P for trend=.035).

CONCLUSION

The severity of nocturia is positively associated with constipation, and physicians should consider the interrelationships between nocturia and constipation in managing UC patients.

Hypermobility prevalence, measurements, and outcomes in childhood, adolescence, and emerging adulthood: a systematic review

General Joint Hypermobility (GJH) is a common condition found in 2-57% of the population. Of those with GJH, 10% suffer from accompanying physical and/or psychological symptoms. While the understanding of GJH in the general population is unfolding, its implication in a cohort of children, adolescents and young adults are not yet understood. This systematic review explored GJH's prevalence, tools to measure it, its physical and psychosocial symptoms, with a special interest in aesthetic sports. The CINHAL, MEDLINE, PsycINFO, SPORTDiscus and Scopus databases were searched for relevant studies. Inclusion criteria were (1) Age range of 5-24; (2) Participants had GJH; (3) A measurement for GJH; (4) Studies written in English language. Study screening for title, abstract and full text (when needed) and quality assessment were performed by two independent individuals. 107 studies were included in this review and were thematically grouped into six clusters expressing different foci: (1) GJH's Core Characteristics; (2) Orthopedic; (3) Physical Other; (4) Psychosocial; (5) Treatment and (6) Aesthetic Sports. The review revealed a growing interest in GJH in this cohort in the last decade, especially regarding non-musculoskeletal physical implications and psychosocial aspects. Prevalence varied between different ethnic groups and as a parameter of age, gender and measurement. The most widespread tool to measure GJH was the Beighton scale, with a cut-off varying between 4 and 7. Children show fewer, but similar GJH implication to those in the general population, however, more research on the topic is warranted, especially regarding psychosocial aspects and treatment.

Gastrointestinal medication burden among persons with the Ehlers-Danlos syndromes

BACKGROUND

The Ehlers-Danlos syndromes (EDSs) are a group of heritable disorders of connective tissue associated with an increased prevalence of both structural and functional GI conditions.

METHODS

We used 10 years (2005-2014) of administrative claims data comprised of 4294 people with clinician-diagnosed EDS, aged 5-62 years, and compared their frequency of GI drug prescription claims to their age-, sex-, state of residence-, and earliest claim date-matched controls. We categorized the GI medications into the following groups: acid suppressants, anti-emetics, irritable bowel syndrome drugs, and visceral hypersensitivity (VHS) medications.

KEY RESULTS

Compared to controls, a significantly higher proportion of persons with EDS had prescription claims for at least one GI drug group, as well as for drugs in each of the four GI drug groups included in our study. By age-group, 25.7% children and 45.1% adults with EDS had prescription claims for at least one GI drug group compared with only 7.4% and 21.0% of controls, respectively (p < 0.0001). By gender, 44.0% of women and 25.3% of men with EDS had prescription claims for at least one class of GI drugs compared with 19.2% and 9.6% of controls, respectively (p < 0.0001).

CONCLUSIONS AND KEY INFERENCES

Predominant medication burden occurs among women with EDS, beginning peri-pubertally for anti-emetics and VHS drugs. High GI medication burden underscores previous evidence that GI dysmotility is common among persons with EDS.

Prevalence and Predictors of Gastrointestinal Dysmotility in Patients with Hypermobile Ehlers-Danlos Syndrome: A Tertiary Care Center Experience

Introduction Ehlers-Danlos syndrome (EDS), specifically the hypermobility type (hEDS), is associated with a variety of gastrointestinal (GI) conditions. This study aims to evaluate the prevalence of and factors associated with gut dysmotility in patients with hEDS. Methods This is a retrospective study of hEDS patients conducted at the Cleveland Clinic's Center for Personalized Genetic Healthcare between January 2007 and December 2017. Demographics, GI motility testing, endoscopic, and imaging data were extracted from the patients' charts. Results A total of 218 patients with hEDS were identified. Among them, 136 (62.3%) patients had at least one GI symptom at the time of EDS diagnosis. Motility testing was performed and reported in 42 (19.2%) patients. Out of them, five (11.9%) had esophageal dysmotility, 18 (42.8%) had gastroparesis, five (11.9%) had small bowel/colon altered transit time, and four (9.5%) had global dysmotility. In univariable analysis, patients with postural orthostatic tachycardia syndrome (POTS) [odds ratio (OR): 8.88, 95% CI: 3.69-24.9, p<0.0001], fibromyalgia (OR: 4.43, 95% CI: 2.04-10.1, p=0.0002), history of irritable bowel syndrome (OR: 5.01, 95% CI: 2.31-11.2, p<0.0001), and gastroesophageal reflux disease (OR: 3.33, 95% CI: 1.55-7.44, p=0.002) were more likely to be diagnosed with GI dysmotility. On multivariable analysis, only POTS (OR: 5.74, 95% CI: 2.25-16.7, p=0.0005) was significantly associated with an increased likelihood of GI dysmotility. Conclusions This study suggests that GI symptoms are relatively common among patients with hEDS. Of the patients tested for dysmotility, 76.2% were found to have some form of dysmotility. POTS was found to be an independent predictive factor for GI dysmotility.

Urogenital and pelvic complications in the Ehlers-Danlos syndromes and associated hypermobility spectrum disorders: A scoping review

The Ehlers-Danlos syndromes (EDS) and associated hypermobility spectrum disorders (HSD) are a heterogenous group of connective tissue disorders associated with significant morbidity. The urogenital aspects of these disorders are understudied and there is little guidance on the prevalence, types, or outcomes of urogenital complications in EDS/HSD. Our objective was to perform a scoping review to characterize and synthesize the literature reporting urogenital and pelvic complications in EDS/HSD patients. We performed a systematic search of three databases (Medline, CINAHL, Embase) to January 2019. English language, full-text articles reporting on urogenital or pelvic complications in EDS/HSD were included. A total of 105 studies were included (62 case reports/series, 43 observational) involving patients with hypermobile (23%), vascular (20%), classical (12%) EDS, and HSD (24%). Some studies looked at multiple subtypes (11%) or did not report subtype (33%). Reported complications included urinary (41%), gynecological (36%), obstetrical (25%), renal (9%), and men's health problems (7%), with some studies reporting on multiple areas. Urinary and gynecological complications were most prevalent in patients with HSD, while a broad range of complications were reported in EDS. While further research is required, results suggest a higher index of suspicion for urogenital problems is probably warranted in this population.

Gastrointestinal disorders in joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type: A review for the gastroenterologist

BACKGROUND

Joint hypermobility syndrome (JHS)/Ehlers-Danlos syndrome hypermobility type (EDS-HT) is the most common hereditary non-inflammatory disorder of connective tissue, characterized by a wide range of symptoms, mainly joint hyperextensibility and musculoskeletal symptoms. A majority of patients also experiences gastrointestinal (GI) symptoms. Furthermore, JHS/EDS-HT has specifically been shown to be highly prevalent in patients with functional GI disorders, such as functional dyspepsia and irritable bowel syndrome.

PURPOSE

The aim of this review was to examine the nature of GI symptoms and their underlying pathophysiology in JHS/EDS-HT. In addition, we consider the clinical implications of the diagnosis and treatment of JHS/EDS-HT for practicing clinicians in gastroenterology. Observations summarized in this review may furthermore represent the first step toward the identification of a new pathophysiological basis for a substantial subgroup of patients with functional GI disorders.

The association between Ehlers-Danlos syndrome-hypermobility type and gastrointestinal symptoms in university students: a cross-sectional study

BACKGROUND

Patients with Ehlers-Danlos syndrome-hypermobility type (EDS-HT) have increased prevalence of gastrointestinal (GI) symptoms, particularly reflux and dyspepsia. EDS-HT is associated with dysautonomia, psychopathology, and chronic pain which can be associated with GI symptoms. The association between GI symptoms and EDS-HT in a 'non-patient' population and the effect of the above-mentioned factors has never been studied.

METHODS

In a cross sectional study, a hypermobility questionnaire was used to screen university students; further clinical examination established the diagnosis of EDS-HT. Validated questionnaires assessed for GI, somatic, pain and autonomic symptoms, psychopathology and quality of life (QOL). These were compared in students with and without EDS-HT; logistic regression analysis examined associations between EDS-HT, GI symptoms and other variables.

KEY RESULTS

Of 1998 students screened, 162 were included: 74 EDS-HT (21.0 years, 53% female) vs 88 Non-EDS-HT (21.5 years, 65% female). Compared to non-EDS-HT students, EDS-HT students were more likely to have multiple GI symptoms (41.9% vs 27.3% P=.05), particularly postprandial fullness (34.4% vs 15.9%, P=.01) and early satiety (32% vs 17%, P=.03), greater autonomic (P<.001) and somatic symptoms (P=.04) but not psychopathology (P>.8). The association between EDS-HT and postprandial symptoms was dependent on autonomic factors but independent of pain and psychopathology. Pain-related QOL scores were reduced in the EDS-HT group (80 vs 90, P=.03).

CONCLUSIONS AND INFERENCES

The previously described association between EDS-HT, dyspepsia, pain and autonomic symptoms in patients is also present in non-patient groups. Future studies are necessary to explore the etiological role of connective tissue in GI and extra intestinal symptoms.

Hypermobile Ehlers-Danlos syndrome (a.k.a. Ehlers-Danlos syndrome Type III and Ehlers-Danlos syndrome hypermobility type): Clinical description and natural history

The hypermobile type of Ehlers-Danlos syndrome (hEDS) is likely the most common hereditary disorder of connective tissue. It has been described largely in those with musculoskeletal complaints including joint hypermobility, joint subluxations/dislocations, as well as skin and soft tissue manifestations. Many patients report activity-related pain and some go on to have daily pain. Two undifferentiated syndromes have been used to describe these manifestations-joint hypermobility syndrome and hEDS. Both are clinical diagnoses in the absence of other causation. Current medical literature further complicates differentiation and describes multiple associated symptoms and disorders. The current EDS nosology combines these two entities into the hypermobile type of EDS. Herein, we review and summarize the literature as a better clinical description of this type of connective tissue disorder. © 2017 Wiley Periodicals, Inc.

Mobile phone applications in management of enuresis: The good, the bad, and the unreliable!

INTRODUCTION

The proliferation of medical-type applications or 'apps' on smartphones is a typical example of the impact technology has had on medical practice. Maintaining a bladder diary is a recommended part of evaluating the effect of interventions for patients suffering from enuresis. Traditional pen-and-paper bladder diaries have poor completion rates, inconsistent patterns in data entry, and are deficient in validation. Electronic bladder diaries have been proposed to overcome these obstacles. With increasing numbers of smartphone apps available to the general public, it is important to distinguish well-designed apps for childhood enuresis.

PURPOSE

To identify, evaluate, and rank all available mobile-phone apps for the management of childhood enuresis.

METHODS

On August 21, 2014, a search was conducted on iTunes, Android Play Store, and BlackBerry World for smartphone apps using the following search terms: bladder, bedwetting, bladder diary, enuresis, incontinence, and wetting. Apps that did not have a bladder diary function and that were unrelated to the investigation, follow-up, and treatment of childhood enuresis were excluded. Apps were rated by a paediatric urology consultant, fellow, registrar, and resident medical officer using standardised criteria including: design; ease of use; languages; quality of instructions; security; accordance with ICCS definition of enuresis; and ability to store histories; record bowel habits; transfer data to other devices; and print data.

RESULTS

Across all three search platforms, a total of 1041 apps were identified. Only 24 were included and reviewed based on exclusion criteria. Average ratings for apps ranged from 10 to 30.75 out of 50 based on standardised criteria.

DISCUSSION

Smartphone apps are playing an increasingly significant role in the management of enuresis in place of pen-and-paper bladder diaries. Apps available to the general public vary in quality and it can be difficult for patients to identify one appropriate for use. We found apps with higher ratings consistently had engaging interfaces, were easy to use, and defined the primary purpose clearly. Lower ratings and performance often was caused by poor quality of experience through "freezing"/"crashing."

CONCLUSION

Bladder diary apps can eliminate disadvantages of pen-and-paper diaries in the management of enuresis. Currently, apps available vary in quality. The three best-rated apps currently available are My Dryness Tracker, Bedwetting Tracker, and HapPee Time. There is room for medical associations to collaborate with developers for further app development.

Gastrointestinal and nutritional issues in joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type

Gastrointestinal involvement is a well known complication of Ehlers-Danlos syndromes (EDSs), mainly in form of abdominal emergencies due to intestinal/abdominal vessels rupture in vascular EDS. In the last decade, a growing number of works investigated the relationship between a wide spectrum of chronic gastrointestinal complaints and various EDS forms, among which the hypermobility type (a.k.a. joint hypermobility syndrome; JHS/EDS-HT) was the most studied. The emerging findings depict a major role for gastrointestinal involvement in the health status and, consequently, management of JHS/EDS-HT patients. Nevertheless, fragmentation of knowledge limits its impact on practice within the boundaries of highly specialized clinics. In this paper, literature review on gastrointestinal manifestations in JHS/EDS-HT was carried out and identified papers categorized as (i) case-control/cohort studies associating (apparently non-syndromic) joint hypermobility and gastrointestinal involvement, (ii) case-control/cohort studies associating JHS/EDS-HT and gastrointestinal involvement, (iii) case reports/series on various gastrointestinal complications in (presumed) JHS/EDS-HT, and (iv) studies reporting gastrointestinal features in heterogeneous EDS patients' cohorts. Gastrointestinal manifestations of JHS/EDS-HT were organized and discussed in two categories, including structural anomalies (i.e., abdominal/diaphragmatic hernias, internal organ/pelvic prolapses, intestinal intussusceptions) and functional features (i.e., dysphagia, gastro-esophageal reflux, dyspepsia, recurrent abdominal pain, constipation/diarrhea), with emphasis on practice and future implications. In the second part of this paper, a summary of possible nutritional interventions in JHS/EDS-HT was presented. Supplementation strategies were borrowed from data available for general population with minor modifications in the light of recent discoveries in the pathogenesis of selected JHS/EDS-HT features.

Association between joint hypermobility and pelvic organ prolapse in women: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

Abnormalities of common collagen proteins have been noted in individuals affected by POP and JHM, suggesting a common aetiology. We assessed strength, consistency and potential for bias in pooled associations of the relationship between JHM and POP.

METHODS

We searched MEDLINE, EMBASE and CINAHL, as well as International Continence Society (ICS) and International Urogynaecologic Association (IUGA) annual meeting abstracts, including reference lists, without language restrictions. We included case-control and cohort studies and applied strict criteria for choosing eligible studies. Methodologically trained reviewers independently screened abstracts and full texts to confirm eligibility. We extracted data on study and patient characteristics, clinical assessment tools, and methodology. We assessed comparability and representativeness of source populations, confidence in the assessment of JHM and POP and adjustment for confounding and missing data. Meta-analysis was performed using a random effects model.

RESULTS

We retrieved 39 full texts, of which 14 were used in the meta-analysis. Overall pooled odds ratio (OR) was 2.37 [95 % confidence interval (CI) 1.54-3.64, I(2) = 77.0 %]. We identified no significant factors in meta-regression, and there was no evidence of publication bias; six studies were at high risk of bias with frequent differences in sampling frames, limited validity for clinical assessments and failure to match for important prognostic variables.

CONCLUSIONS

We found a strong association between POP and JHM, with an effect size that is clinically relevant. Our findings are limited by high heterogeneity and the potential for residual confounding factors. JHM is an important early indicator for POP risk, and future longitudinal studies should explore the shared aetiology.

Joint hypermobility syndrome subclassification in paediatrics: a factor analytic approach

OBJECTIVE

To determine if exploratory factor analysis can identify subtypes comprising recognisable clinical patterns of the presenting signs and symptoms of children with joint hypermobility syndrome (JHS).

PATIENTS

Eighty-nine children with JHS aged 6-16 years.

METHODS

Twelve tests comprising anthropometric, musculoskeletal and functional assessments were conducted. Signs, symptoms and family history were recorded. Exploratory factor analysis was performed, factor scores generated, and correlations calculated to identify associations.

RESULTS

Sixty-six percent of the variance in the score set could be accounted for by five JHS subtypes (Eigenvalues >1). Factor 1, 'joint affected' JHS, had loadings on multiple joint pain, recurrent joint instability and postural orthostatic hypotension symptoms, and factor scores were associated with worse pain (r=0.48, p<0.01), fatigue (r=-0.54, p<0.01) and reduced health-related quality of life (HRQOL) (r=-0.5, p<0.01). Factor 2, 'athletic' JHS, loaded on muscle endurance, balance and motor skill proficiency, and scores were associated with less fatigue (r=0.3, p<0.01) and better HRQOL (r=0.44, p<0.01). Factor 3, 'systemic' JHS, loaded on skin involvement, incontinence symptoms, bowel involvement and recurrent joint instability, and was associated with reduced HRQOL (r=-0.24, p=0.03). Factor 4, 'soft tissue affected' JHS, loaded on recurrent soft tissue injuries and reduced muscle length, and was associated with greater fatigue (r=-0.43, p<0.01) and reduced HRQOL (r=-0.44, p<0.0001). Factor 5, 'high BMI' JHS, had high loadings on body mass index (BMI) for age, muscle endurance and no gastrointestinal involvement, and was associated with higher pain (r=0.33, p<0.01).

CONCLUSIONS

The presenting signs and symptoms of children with JHS can be summarised in five clinically recognisable subtypes.

Joint hypermobility: a common association with complex functional gastrointestinal disorders

OBJECTIVE

To evaluate the prevalence of joint hypermobility (JH) and comorbid conditions in children and young adults referred to a tertiary care neurogastroenterology and autonomic disorders clinic for functional gastrointestinal complaints.

STUDY DESIGN

This was a retrospective chart review of 66 new patients aged 5-24 years who fulfilled at least 1 pediatric Rome III criteria for a functional gastrointestinal disorder (FGID) and had a recorded Beighton score (n = 45) or fibromyalgia tender point score (n = 45) based on physician examination. Comorbid symptoms were collected and autonomic testing was performed for evaluation of postural tachycardia syndrome (POTS).

RESULTS

The median patient age was 15 years (range, 5-24 years), 48 (73%) were females, and 56% had JH, a significantly higher rate compared with population studies of healthy adolescents (P < .001; OR, 10.03; 95% CI, 5.26-19.13). POTS was diagnosed in 34% of patients and did not correlate significantly with hypermobility. Comorbid conditions were common, including sleep disturbances (77%), chronic fatigue (93%), dizziness (94%), migraines (94%), chronic nausea (93%), and fibromyalgia (24%).

CONCLUSION

JH and other comorbid symptoms, including fibromyalgia, occur commonly in children and young adults with complex FGIDs. POTS is prevalent in FGIDs but is not associated with hypermobility. We recommend screening patients with complex FGIDs for JH, fibromyalgia, and comorbid symptoms such as sleep disturbances, migraines, and autonomic dysfunction.

Systematic review of the relationship between bladder and bowel function: implications for patient management

BACKGROUND

The complex relationship between bladder and bowel function has implications for treating pelvic disorders. In this systematic review, we discuss the relationship between bladder and bowel function and its implications for managing coexisting constipation and overactive bladder (OAB) symptoms.

METHODS

Multiple PubMed searches of articles published in English from January 1990 through March 2011 were conducted using combinations of terms including bladder, bowel, crosstalk, lower urinary tract symptoms, OAB, incontinence, constipation, hypermotility, pathophysiology, prevalence, management and quality of life. Articles were selected for inclusion in the review based on their relevance to the topic.

RESULTS

Animal studies and clinical data support bladder-bowel cross-sensitization, or crosstalk. In the rat, convergent neurons in the bladder and bowel as well as some superficial and deeper lumbosacral spinal neurons receive afferent signals from both bladder and bowel. On a functional level, in animals and humans, bowel distention affects bladder activity and vice versa. Clinically, the bladder-bowel relationship is evident through the presence of urinary symptoms in patients with irritable bowel syndrome and bowel symptoms in patients with acute cystitis. Functional gastrointestinal disorders, such as constipation, can contribute to the development of lower urinary tract symptoms, including OAB symptoms, and treatment of OAB with antimuscarinics can worsen constipation, a common antimuscarinic adverse effect. The initial approach to treating coexisting constipation and OAB should be to relieve constipation, which may resolve urinary symptoms.

CONCLUSIONS

The relationship between bladder and bowel function should be considered when treating patients with urinary symptoms, bowel symptoms, or both.

Ehlers-danlos syndrome, hypermobility type: an underdiagnosed hereditary connective tissue disorder with mucocutaneous, articular, and systemic manifestations

Ehlers-Danlos syndrome, hypermobility type, constituting a phenotypic continuum with or, perhaps, corresponding to the joint hypermobility syndrome (JHS/EDS-HT), is likely the most common, though the least recognized, heritable connective tissue disorder. Known for decades as a hereditary condition with predominant rheumatologic manifestations, it is now emerging as a multisystemic disorder with widespread manifestations. Nevertheless, the practitioners' awareness of this condition is generally poor and most patients await years or, perhaps, decades before reaching the correct diagnosis. Among the various sites of disease manifestations, skin and mucosae represent a neglected organ where the dermatologist can easily spot diagnostic clues, which consistently integrate joint hypermobility and other orthopedic/neurologic manifestations at physical examination. In this paper, actual knowledge on JHS/EDS-HT is summarized in various sections. Particular attention has been posed on overlooked manifestations, including cutaneous, mucosal, and oropharyngeal features, and early diagnosis techniques, as a major point of interest for the practicing dermatologist. Actual research progresses on JH/EDS-HT envisage an unexpected link between heritable dysfunctions of the connective tissue and a wide range of functional somatic syndromes, most of them commonly diagnosed in the office of various specialists, comprising dermatologists.

Association of bowel habits with lower urinary tract symptoms in men: findings from the 2005-2006 and 2007-2008 National Health and Nutrition Examination Survey

PURPOSE

We examine the association between self-reported lower urinary tract symptoms and bowel habits in men in a large, cross-sectional, population based cohort study.

MATERIALS AND METHODS

The study included 3,077 men participating in the 2005-2006 or 2007-2008 cycles of the NHANES (National Health and Nutrition Examination Survey) who were 40 years old or older and without a history of prostate cancer. Men were considered to have lower urinary tract symptoms if they reported nocturia, urinary hesitancy and/or incomplete bladder emptying. Bowel habits were characterized by frequency of bowel movements per week and stool consistency based on the Bristol Stool Form Scale. Weighted associations between bowel habits and lower urinary tract symptoms were determined using univariate and multivariate techniques, adjusting for age, race, body mass index, diabetes, alcohol intake, activity level and smoking.

RESULTS

The prevalence of lower urinary tract symptoms was 37%, with 4% reporting all 3 symptoms. Reporting 3 or fewer bowel movements per week was associated with nocturia (OR 1.67, 95% CI 1.21-2.30), incomplete bladder emptying (OR 2.14, 95% CI 1.06-4.31) and urinary hesitancy (OR 2.06, 95% CI 1.06-4.02). Reporting more than 10 bowel movements per week was associated with nocturia only (OR 1.42, 95% CI 1.01-1.55). Hard (OR 1.76, 95% CI 1.31-2.37) and loose (OR 1.25, 95% CI 1.01-1.55) stool consistency increased the odds of reporting nocturia.

CONCLUSIONS

Lower urinary tract symptoms in the adult male were independently associated with low stool frequency, hard stool type and loose stool type. These data suggest causality or a common pathophysiology of lower urinary tract symptoms and abnormalities of bowel habits.

Management of pain and fatigue in the joint hypermobility syndrome (a.k.a. Ehlers-Danlos syndrome, hypermobility type): principles and proposal for a multidisciplinary approach

Joint hypermobility syndrome (JHS), or Ehlers-Danlos syndrome (EDS) hypermobility type (EDS-HT), is a underdiagnosed heritable connective tissue disorder characterized by generalized joint hypermobility and a wide range of visceral, pelvic, neurologic, and cognitive dysfunctions. Deterioration of quality of life is mainly associated with pain and fatigue. Except for the recognized effectiveness of physiotherapy for some musculoskeletal features, there are no standardized guidelines for the assessment and treatment of pain and fatigue. In this work, a practical classification of pain presentations and factors contributing in generating painful sensations in JHS/EDS-HT is proposed. Pain can be topographically classified in articular limb (acute/subacute and chronic), muscular limb (myofascial and fibromyalgia), neuropathic limb, back/neck, abdominal and pelvic pain, and headache. For selected forms of pain, specific predisposing characteristics are outlined. Fatigue appears as the result of multiple factors, including muscle weakness, respiratory insufficiency, unrefreshing sleep, dysautonomia, intestinal malabsorption, reactive depression/anxiety, and excessive use of analgesics. A set of lifestyle recommendations to instruct patients as well as specific investigations aimed at characterizing pain and fatigue are identified. Available treatment options are discussed in the set of a structured multidisciplinary approach based on reliable outcome tools.

Do the urinary bladder and large bowel interact, in sickness or in health? ICI-RS 2011

Normal functioning of the urinary bladder and the distal gut is an essential part of daily physiological activity coordinated by the peripheral and central nervous systems. Pathological changes in one of these organs may induce the development of cross-organ sensitization in the pelvis and underlie clinical co-morbidity of genitourinary and GI dysfunctions. Experimental human and animal data suggest that the bladder and distal colon interact under both normal and pathological conditions, however, the directions of these interactions can change dramatically depending on the nature and duration of the applied stimuli. This review article aimed to summarize the clinical data on colon-bladder cross-reflexes in healthy individuals, as well as in patients with co-morbid disorders. It also discusses currently used animal models, experimental approaches, and suggested mechanisms of colon-bladder cross-talk. Additionally, it provides an overview of the potential pharmacological targets to develop treatment options for patients with co-morbid disorders. Presented work resulted from the discussion of colon/bladder interactions during "Think Tank 9" presentations at the International Consultation on Incontinence Research Society meeting held in Bristol, UK, 2011.

Bladder dysfunction in diabetes mellitus

Diabetic cystopathy is a well-recognized complication of diabetes mellitus, which usually develops in middle-aged or elderly patients with long-standing and poorly controlled disease. It may have broad spectrum clinical presentations. Patients may be asymptomatic, or have a wide variety of voiding complaints from overactive bladder and urge incontinence to decreased bladder sensation and overflow incontinence. This review focuses on pathophysiological mechanisms responsible for urologic complications of diabetes and emphasizing on recent developments in our understanding of this condition. We also tried to shed some light on therapeutic modalities like behavioral, pharmacological, and surgical approaches.

Connective tissue disorder--a new subgroup of boys with slow transit constipation?

PURPOSE

Slow transit constipation (STC) is a form of chronic constipation, with delayed colonic passage of stool. Possible etiologies include reduced neurotransmitter levels, reduced interstitial cells of Cajal density, or a disorder of connective tissue (CT) synthesis. A common CT disorder is generalized joint hypermobility (GJH). This study aimed to investigate whether there was a greater prevalence of GJH among patients with STC than controls.

METHODS

Children (aged 7-17) diagnosed with STC by radio/nuclear transit study were recruited from outpatient clinics. Controls (no history of constipation) were recruited from outpatient clinics and a scout jamboree. Hypermobility was assessed using the Beighton score (4 or more = hypermobile). This project received ethical approval by the human research ethics committee.

RESULTS

Thirty-nine STC subjects and 41 controls were measured. Of 39 STC subjects, 15 (38%) were hypermobile, compared to 8 (20%) of 41 controls (P = .06). Analyzed by gender, 10 (38%) of 26 STC males and 1 (4%) of 23 control males were hypermobile (P < .01).

CONCLUSIONS

These results show that GJH is higher in STC children, particularly males, suggesting that a disorder of CT synthesis plays a role in the etiology of STC. Further research is required to ascertain the nature of any relationship and how this knowledge may aid our understanding and treatment of STC.

Developmental Coordination Disorder and Joint Hypermobility Syndrome--overlapping disorders? Implications for research and clinical practice

BACKGROUND

Joint Hypermobility Syndrome (JHS) and Developmental Coordination Disorder (DCD) are two childhood disorders usually identified separately. DCD is a heterogeneous condition with little known of the underlying aetiology of the disorder. This paper examines the potential overlap between DCD and JHS and examines children with DCD for symptoms which may be consistent with a diagnosis of JHS. Implications for research and clinical practice are considered.

METHODS

A questionnaire covering a range of symptoms consistent with a diagnosis of JHS and related autonomic nervous systemic symptoms was completed by parents from 27 children with DCD and compared with responses from parents of 27 typically developing children.

RESULTS

Children with DCD showed a significant difference from the group of typically developing children on questions regarding hypermobility, pain and autonomic nervous system symptoms, typifying JHS.

CONCLUSIONS

This study has shown a similarity in symptoms seen in some DCD children to those with a diagnosis of JHS. In addition, children are also presenting with multi-system symptomatology including those involving the autonomic nervous system. This study reinforces other recent work showing the reverse pattern of JHS children showing similar functional similarities to DCD children. This has implications for future research in DCD in order to understand the underlying aetiology of this complex disorder. In addition, it is important for clinicians to be aware of these findings in order to provide appropriate and tailored support and treatment for children presenting with differing patterns of co-ordination difficulties. Children with DCD and JHS may require appropriate podiatry as well as recognition of their symptoms of pain and how this may affect participation in physical activity.

Urinary incontinence and diabetes: a review

Both urinary incontinence and diabetes are chronic and costly conditions affecting millions of Americans. Unfortunately, these chronic conditions often coexist in the same person, compounding the economic and social costs and diminishing quality of life. The connection between urinary incontinence and diabetes has been mentioned in subsets of articles under prevalence or risk factors. The relationship is strong enough that researchers and clinicians should be aware of this link when formulating protocols or providing clinical care. This article summarizes knowledge of diabetes mellitus and urinary incontinence and explores the nature of their relationship.

Hypermobility disorders in children and adolescents

It is well recognized that many if not most children and adolescents attending paediatric rheumatology clinics will have a non-inflammatory origin for their complaints or disorder. Mechanical causes are frequently identified, and hypermobility or ligamentous laxity of joints is increasingly recognized as an aetiological factor in the presentation. Such conditions include 'growing pains', recurrent lower-limb arthralgia, anterior knee pain syndromes, and back pain. Studies of significant cohorts of such patients have now been published supporting the link of ligamentous laxity to particular symptom complexes. However, much disagreement remains as to the validity of hypermobility as an aetiogical factor. What seems clear is that not all hypermobile individuals will be symptomatic or indeed possibly have any risk for specific musculoskeletal disorders in later life. Screening tools such as the Beighton score are likely to be inadequate in many paediatric populations. Along with increasing recognition of these disorders in childhood and adolescence has been the development of a multidisciplinary management approach, which usually involves predominantly allied health professionals such as podiatrists, physiotherapists and occupational therapists. The challenge remains to interpret symptoms correctly as being related to the hypermobility and to predict why such children become symptomatic. The answer is likely to involve physiological and psychosocial factors. In addition, early identification and modification of risk factors may have major implications for subsequent prevalence of many adult medical disorders such as low back pain, chronic pain syndromes and degenerative osteoarthritis.

Patterns of constipation in urogynecology: clinical importance and pathophysiologic insights

OBJECTIVE

We have analyzed the prevalence and patterns of constipation in women with urinary symptoms and/or genital prolapse.

STUDY DESIGN

Seven hundred and eighty-six consecutive urogynecologic patients underwent a questionnaire and structured clinical assessment. Comparison between constipated and nonconstipated women was made. Fisher exact test, Wilcoxon rank sum test, and logistic regression were used for statistical analysis (P < .05 for significance).

RESULTS

Thirty-two percent of women were constipated (172 difficult stool passage, 13 reduced stool frequency, 64 both). A genital prolapse > or = 2 degree Half Way System (HWS) was present in 44% of women. A posterior colpocele was more frequent in constipated women (35% vs 19%; P < .0001), resulting in a risk factor for constipation (OR 2.31; 95% CI 1.63-3.27). By contrast, higher degrees of anterior colpocele appeared to protect against constipation (OR 0.80; 95% CI 0.66-0.96). No differences in prevalence of constipation were observed for urinary symptoms or urodynamic diagnosis.

CONCLUSION

Bowel dysfunction correlates exclusively with posterior aspects of the pelvic floor support.

Prevalence of incontinence in women with benign joint hypermobility syndrome

The objective of this study was to determine whether the prevalence of urinary and anal incontinence in women with benign joint hypermobility syndrome (BJHS) was more than in a control group without this condition. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the Manchester Health Questionnaire were sent to 30 patients with benign joint hypermobility syndrome and 30 healthy women without this condition and results were compared. It was found out that the prevalence of urinary incontinence in the study group we surveyed was 18/30 and in the control group was 9/30 (60 vs 30%; p=0.037). Twenty-three percent (7/30) of the women with BJHS had a problem with anal incontinence but none of the controls had problems with anal incontinence (23 vs 0%; p=0.01). Therefore, the prevalence of both urinary and anal incontinence appears to be significantly higher in women with BJHS when compared to women without this condition.

Pelvic floor dysfunction after Burch colposuspension--a comprehensive study. Part I

OBJECTIVE

To evaluate the occurrence of voiding dysfunction and symptoms of genital prolapse at long-term follow-up after Burch colposuspension (Bc) in relation to the occurrence of the symptoms in an age-matched normal population.

MATERIALS AND METHODS

A follow-up study of the 190 patients who underwent Bc in 1980-88 and 305 age-matched control women randomly selected from the general population. The participants answered a questionnaire in 1998 with detailed questions about the pelvic floor function. Univariate and multivariate analyses were performed.

RESULTS

The prevalence and frequency of urinary incontinence were significantly higher in the patient group compared with those in the control group as were urge incontinence, difficulty to start voiding, time needed at the toilet for voiding, the need to return to the toilet for emptying the bladder, feeling of incomplete emptying of the bladder, and limitation of social life because of the leakage. The symptoms of genital prolapse were significantly more common in the patient group in spite of a significantly larger proportion of genital prolapse surgery in this group. Parity, high body mass index, heavy lifting work, chronic pulmonary diseases, hiatus hernias, and hysterectomy were significantly more common in the patient group than among the controls.

CONCLUSIONS

At long-term follow-up, patients exhibit substantial symptoms of pelvic floor dysfunction (PFD) concerning voiding dysfunction and symptoms of genital prolapse compared with a normal population. This highlights the importance and need of treating pelvic floor disorders in a comprehensive way. Scientific works with comprehensive studies of PFD are needed.