Urinary and fecal incontinence in stroke survivors followed in general practice: A retrospective cohort study

Incidence and influencing factors of urinary incontinence in stroke patients: A meta-analysis

BACKGROUND

The incidence of stroke in China ranks first in the world and is the leading cause of death and disability in adults. Urinary incontinence is an independent risk factor leading to poor prognosis of stroke. However, studies on the incidence of urinary incontinence in stroke patients and its influencing factors are different, fluctuate greatly, and there is no unified basis.

OBJECTIVE

To quantitatively analyze the incidence of urinary incontinence in stroke patients and its related influencing factors, and further make public health strategic decisions to reduce the occurrence of adverse outcomes.

METHODS

Computer searches were conducted in PubMed, Medline, Web of Science, Cochrane Library, Embase, CLNAHL Complete, China National Knowledge Infrastructure (CNKI), Chinese Biomedical database(CBM), Wan Fang Database, VIP Database, observational studies such as cohort studies, case-control studies or cross-sectional studies on the incidence or influencing factors of urinary incontinence in stroke patients from the establishment of the database to the publication in August 2023. Studies selection, quality evaluation and data extraction were conducted independently by two researchers according to the established search strategy. Stata 14.0 statistical software was used for meta-analysis.

RESULTS

A total of 21 manuscripts were included, with a cumulative sample size of 7327 cases, including 2887 patients with urinary incontinence. Meta-analysis results showed that the incidence of urinary incontinence in stroke patients was 38% [95% confidence interval (34%, 41%)], including married patients and lacunar infarction were the protective factors for urinary incontinence in stroke patients, while age, chaperone, low educational level, chronic cough, lesion sites (parietal lobe, frontal lobe, and temporal lobe), stroke type (cerebral hemorrhage, subarachnoid hemorrhage and cerebral hemorrhage complicated with subarachnoid hemorrhage), dysfunction (aphasia dyslexia, dysphagia, eye movement abnormalities, leg muscle disorders), post-stroke depression, the higher the NIHSS score, the lower the Bachmann index (BI) score, OCSP classification (total anterior circulation infarction) and other 11 items were risk factors for urinary incontinence in stroke patients.

CONCLUSION

The incidence of urinary incontinence in stroke patients is 38%. Marriage and lacunar infarction are the protective factors of urinary incontinence. Age, carer, low educational level, chronic cough, lesion site (parietal, frontal and temporal lobes), stroke type (cerebral hemorrhage, subarachnoid hemorrhage, cerebral hemorrhage combined with subarachnoid hemorrhage), dysfunction (aphasia and dysarthria syndrome, dysphagia, eye movement abnormalities, leg muscle disorders), post-stroke depression, and higher NIHSS score, Lower BI score and OCSP classification (total anterior circulation infarction) were risk factors for urinary incontinence in stroke patients.

Subacute stroke: new-onset poststroke bladder and bowel dysfunctions and possible associated factors

PURPOSE

Bladder and bowel poststroke dysfunctions negatively impact patients' health. Stroke-related characteristics associated to these dysfunctions are poorly known. This study aims to estimate the prevalence of new-onset poststroke bladder and bowel dysfunctions, characterize their associated factors, and describe the dysfunctions' clinical approach.

MATERIALS AND METHODS

Cross-sectional study including 157 patients admitted to a single hospital's stroke unit with a first-ever stroke, during 3 months. An 18-item questionnaire was applied to assess dysfunctions pre and poststroke. The McNemar test was used to compare pre and poststroke prevalence. A logistic regression was used to estimate associations (OR, 95% CI) between individual characteristics and new-onset dysfunctions.

RESULTS

We had 113 (72%) respondents. There was a significant increase in the prevalence of bladder and bowel dysfunctions poststroke (p < 0.001). Higher stroke severity was significantly associated with both new-onset poststroke bladder and bowel dysfunctions (OR = 15.00, 95% CI [4.92,45.76] and OR = 5.87,95%CI [2.14,16.12], respectively). Total anterior circulation strokes, cardioembolic strokes, and lower functionality at discharge were also significantly associated with both dysfunctions. Thirteen patients (11.5%) reported that health professionals addressed these dysfunctions.

CONCLUSIONS

Poststroke bladder and bowel dysfunctions are highly prevalent. Being aware of their epidemiology helps draw attention to patients at higher risk of developing these dysfunctions, enhancing the rehabilitation process.IMPLICATIONS FOR REHABILITATIONPoststroke bladder and bowel dysfunctions are highly prevalent and under-recognised consequences of stroke.Being aware of their epidemiology and associated factors may help identify patients at higher risk of developing these dysfunctions.It is necessary to raise clinical awareness to ensure a more efficient diagnostic and therapeutic approach, enhancing patients' rehabilitation process, quality of life and lowering collateral societal burden.

Electroacupuncture for post-stroke urinary incontinence: a systematic review and meta-analysis with trial sequential analysis

Background

The evidence for the effectiveness of electroacupuncture (EA) for post-stroke urinary incontinence (PSUI) patients remains unclear. Therefore, the purpose of this systematic review and meta-analysis was to assess the efficacy of EA for PSUI.

Methods and analysis

Eight English and Chinese databases were searched from their inception until 1 August 2023 to collect randomized controlled trials (RCTs) that investigated the effect of EA on PSUI. Two reviewers independently selected studies that met the eligibility criteria, extracted the necessary data, and assessed the risk of bias for included studies using Cochrane Handbook version 5.1.0. Meta-analysis was performed using Review Manager software (version 5.4.1). Publication bias detection was conducted using STATA (version 16.0). Sequential analysis was performed using TSA 0.9.5.10 Beta. The Grading of Recommendations Assessment, Development, and Evaluation System (GRADE) was used for assessing the certainty of evidence.

Results

We included 15 RCTs involving a total of 1,414 patients. The narrative analysis revealed that compared with sham EA, genuine EA exhibited greater efficacy in reducing occurrences of 24-h urinary incontinence while also enhancing maximum cystometric capacity (MCC). Moreover, this effect remained significant even during the 3-month follow-up period. Fourteen studies were encompassed within the quantitative analysis. In contrast to active interventions, EA did not yield an improvement in the responder rate (RR 1.53, 95% CI 0.61 to 3.80, p = 0.36). When compared with basic treatments, the combination of EA with them led to a reduction in 24-h urinary incontinence occurrences (MD -0.56, 95% CI -0.60 to -0.52, p < 0.00001), an improvement in MCC (MD 43.23, 95% CI 28.86 to 57.60, p < 0.00001), and a decrease in residual urine volume (RUV; MD -19.99, 95% CI -29.75 to -10.23, p < 0.0001). However, it did not lead to an increase in the responder rate (RR 1.39, 95% CI 0.88 to 2.20, p = 0.16). In comparison to basic treatments combined with active interventions, the amalgamation of EA and them led to an increase in the responder rate (RR 1.24, 95% CI 1.14 to 1.35, p < 0.00001), a reduction in 24-h urinary incontinence occurrences (MD -2.90, 95% CI -5.26 to -0.55, p = 0.02), a decrease in International Consultation on Incontinence Questionnaire-Short Form scores, and an improvement in both MCC (MD 42.11, 95% CI 23.26 to 60.96, p < 0.0001) and RUV (MD 42.11, 95% CI 23.26 to 60.96, p < 0.0001). Furthermore, all reported adverse effects associated with EA were mild. The trial sequential analysis suggested that a sufficient sample size was available to yield results. However, the level of evidence was predominantly assessed as low or very low.

Conclusion

Electroacupuncture improved post-stroke urinary incontinence with no serious adverse effects. Caution is warranted due to methodological issues, and more high-quality studies are required to confirm its efficacy and safety.Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023449599, Identifier CRD42023449599.

Gastrointestinal Dysfunction in Stroke

Gastrointestinal (GI) complications are seen in over 50% of ischemic stroke survivors; the most common complications are dysphagia, constipation, and GI bleeding. The bidirectional relationship of the gut-brain axis and stroke has recently gained traction, wherein stroke contributes to gut dysbiosis (alterations in the normal host intestinal microbiome) and gut dysbiosis perpetuates poor functional neurologic outcomes in stroke. It is postulated that the propagation of proinflammatory cells and gut metabolites (including trimethylamine N-oxide and short-chain fatty acids) from the GI tract to the central nervous system play a central role in gut-brain axis dysfunction. In this review, we discuss the known GI complications in acute ischemic stroke, our current knowledge from experimental stroke models for gut-brain axis dysfunction in stroke, and emerging therapeutics that target the gut-brain axis.

Prevalence and Features of Post-stroke Urinary Incontinence: A Retrospective Cohort Study

BACKGROUND

Long-term complications of stroke, persisting for more than 6 months after the initial event, substantially reduce the quality of life (QoL) in a significant percentage of stroke survivors. In this paper, we studied the prevalence of long-term urinary incontinence (UI) in post-stroke patients. In addition, we attempted to identify patient characteristics which were associated with higher UI prevalence, higher UI severity, and less UI-associated QoL.

METHODS

Medical records in a tertiary referral hospital were used to contact patients who had experienced a stroke between 6 to 32 months before the study date. The patients were given the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI-SF) questionnaire for determining the presence of UI and its severity. UI-positive patients were then given the I-QOL questionnaire to determine their QoL.

RESULTS

The prevalence of UI in our study population (n=189) was 31%. Older age at the time of stroke was associated with higher UI severity (r=0.290) and lower QoL (r=-0.265). Furthermore, the presence of movement limitation was associated with higher UI prevalence (P<0.001, OR=3.89) and severity (P=0.002, d=1.05). Movement limitation also significantly impacted the psychological and social aspects of UI-associated QoL (P=0.035, d=-0.74). Conversely, higher body mass indices (BMIs) were associated with lower UI severity (r=-0.346) and higher QoL (r=0.281).

CONCLUSION

In conclusion, UI continues to be prevalent in stroke survivors long after the cerebrovascular accident (CVA). As a result, these patients require continuous monitoring and UI prevention.

Effect of pelvic floor muscle training on pelvic floor muscle function and lower urinary tract symptoms in stroke patients: a systematic review

BACKGROUND

Pelvic floor muscle (PFM) dysfunction and lower urinary tract symptoms (LUTS) are common in stroke patients. Although pelvic floor muscle training (PFMT) is a promising intervention, its effects on stroke patients have not been fully studied.

OBJECTIVE

The goal of this study was to conduct a systematic review of the effect of PFMT on PFM and urinary function of stroke patients.

METHODS

The databases AMED, MEDLINE, CINAHL, Cochrane Library, and PEDro were searched for title/abstract on PFMT and stroke. RCTs and quasi-experimental trials that compared the effects of PFMT to a control intervention in stroke patients were included. The RoB 2.0 and ROBINS-I were used to assess the methodological quality of the included studies. The Standardized mean difference (SMD) and its 95% confidence interval (CI) were calculated.

RESULTS

The current review included three RCTs and one quasi-experimental study, all of which were moderate to high quality. The analysis revealed that PFMT significantly improved PFM contraction (SMD: 0.92; 95% CI, 0.47 to 1.38; p < .0001), dynamic endurance (SMD: 0.61; 95% CI, 0.06 to 1.16; p = .030), daytime frequency (SMD: -0.81; 95% CI, -1.37 to -0.25; p = .004), ICIQ-SF (SMD: -1.64; 95% CI, -2.39 to -0.89; p < .0001), and LUTS (SMD: -1.82; 95% CI, -2.67 to -0.96; p < .0001). Differences in PFM strength, static endurance, nocturia, UI frequency, and 24-hour pad weight were insignificant or non-existent between the two groups.

CONCLUSION

This review demonstrates that PFMT improves PFM contraction, PFM dynamic endurance, daytime frequency, and overall LUTS in stroke patients. To validate these findings, well-designed RCTs with large sample sizes and reliable outcome measures should be conducted.

Sarcopenia Is Associated with Fecal Incontinence in Patients with Dysphagia: Implication for Anal Sarcopenia

OBJECTIVES

To examine the relationship between sarcopenia and fecal incontinence in patients with dysphagia.

DESIGN

Cross-sectional study using the Japanese sarcopenic dysphagia database.

SETTING

19 hospitals including 9 acute care hospitals, 8 rehabilitation hospitals, 2 long-term care hospitals, and 1 home visit rehabilitation center.

PARTICIPANTS

460 dysphagic patients, aged 20 years and older.

MEASUREMENTS

Sarcopenia was diagnosed by the 2019 criteria of the Asian Working Group for Sarcopenia. Fecal incontinence was assessed by health care professionals at baseline according to the definition of the Japanese Practice Guidelines for Fecal Incontinence. We examined whether there was a significant difference between the rate of fecal incontinence in patients with/without sarcopenia. Age, sex, type of dwelling, Barthel index, Charlson comorbidity index (CCI), calf circumference, handgrip strength, body mass index, malnourishment, C-reactive protein level, serum albumin level, and delivery of enteral nutrition by nasogastric and/or gastrostomy tube were measured. To examine the relationship between sarcopenia and fecal incontinence, logistic regression analysis was performed with adjustments for age, sex, sarcopenia, CCI, enteral nutrition, and dwelling.

RESULTS

The mean age of patients was 81 ± 10 years. Of the 460 study patients, 404 (88%) patients had sarcopenia and 104 had fecal incontinence (23%). The rate of fecal incontinence was higher in the sarcopenia group than the non-sarcopenia group (25% vs. 7%, P = 0.003). Logistic regression analysis showed that sarcopenia was independently associated with fecal incontinence (odds ratio: 3.114, 95% confidence interval: 1.045, 9.282).

CONCLUSION

The prevalence of fecal incontinence was 23% in patients with dysphagia. Sarcopenia was independently associated with fecal incontinence, which suggests the presence of anal sarcopenia. Defecation control should be assessed in patients with sarcopenia.

Current Incidence and Risk Factors of Fecal Incontinence After Acute Stroke Affecting Functionally Independent People

Background: Previously published retrospective series show a high prevalence of fecal incontinence (FI) in stroke patients. We aimed to analyze in a prospective series the current incidence of FI in acute stroke in functionally independent patients and its evolution over time and the patient characteristics associated with the appearance of FI in acute stroke. Methods: We included consecutive patients with acute stroke admitted in our stroke unit who fulfilled the following inclusion criteria: a first episode of stroke, aged >18 years, with no previous functional dependency [modified Rankin Scale (mRS) ≤ 2] and without previous known FI. FI was assessed by a multidisciplinary trained team using dedicated questionnaires at 72 ± 24 h (acute phase) and at 90 ± 15 days (chronic phase). Demographic, medical history, clinical and stroke features, mortality, and mRS at 7 days were collected. Results: Three hundred fifty-nine (48.3%) of 749 patients (mean age 65.9 ± 10, 64% male, 84.1% ischemic) fulfilled the inclusion criteria and were prospectively included during a 20-month period. FI was identified in 23 patients (6.4%) at 72 ± 24 h and in 7 (1.9%) at 90 days ± 15 days after stroke onset. FI was more frequent in hemorrhagic strokes (18 vs. 5%, p 0.007) and in more severe strokes [median National Institute of Health Stroke Scale (NIHSS) 18 (14-22) vs. 5 (3-13), p < 0.0001]. No differences were found regarding age, sex, vascular risk factors, or other comorbidities, or affected hemisphere. Patients with NIHSS ≥12 (AUC 0.81, 95% CI 0.71 to 0.89) had a 17-fold increase for the risk of FI (OR 16.9, IC 95% 4.7-60.1) adjusted for covariates. Conclusions: At present, the incidence of FI in acute stroke patients without previous functional dependency is lower than expected, with an association of a more severe and hemorrhagic stroke. Due to its impact on the quality of life, it is necessary to deepen the knowledge of the underlying mechanisms to address therapeutic strategies.

The acupuncture-related therapy for post-stroke urinary incontinence: A protocol for systematic review and network meta-analysis

BACKGROUND

With the rising incidences stroke, the Post-Stroke Urinary Incontinence (PSUI) has become one of the common clinical sequelae. PSUI not only lowers the quality of life of patients, but also impacts tremendously to mental health. As a treasure of Chinese medicine, acupuncture and its related therapies have been widely accepted in clinical treatment of PSUI. Recently, there have been many clinical studies on the treatment of PSUI with acupuncture and related therapies, but the best way to treat PSUI is controversial. Therefore, the purpose of this paper is to provide an optimal ranking regarding acupuncture and its related therapies for PSUI.

METHODS

The five domestic and foreign databases including PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database will be systematically searched. The time range of the literature search is from the date of establishment to August 31, 2020. The main evaluation outcome was the number of patients after treatment, and the frequency of urinary incontinence. The secondary evaluation outcome was International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), Barthel Activities of Daily Living Index (Barthel ADL Index) and the incidence rate of adverse events. The methodological quality of the article will evaluated by Cochrane Collaboration's Tool and the quality of evidence will evaluated through Grading of Recommendations Assessment, Development and Evaluation (GRADE) instrument. The Network Meta-Analysis (NMA) will be completed using Stata statistical software.

RESULTS

The final results of this study will be published in a peer-reviewed journal.

CONCLUSION

This network meta-analysis will compare the efficacy and safety of different acupuncture therapies in the treatment of PSUI and summarize the best treatment options, which will help patients and doctors to choose effective acupuncture methods in time.