Pelvic floor dysfunction: a conceptual framework for collaborative patient-centred care

Validation of the Thai version of the Prolapse and Incontinence Knowledge Questionnaire (PIKQ)

Introduction and hypothesis

The Prolapse and Incontinence Knowledge Questionnaire (PIKQ) was developed and validated to assess women’s knowledge regarding etiology, diagnosis and treatment of pelvic organ prolapse (POP) and urinary incontinence (UI). We aimed to translate and validate a Thai version of the PIKQ to use as a tool to evaluate knowledge of POP and UI among Thai-speaking women.

Methods

The English PIKQ, which comprises the PIKQ-POP and PIKQ-UI sections, was translated into Thai. Psychometric properties of the final version of the Thai PIKQ were tested for content validity, construct validity, internal consistency and test-retest reliability among 168 women attending a gynecology clinic and 150 nurses.

Results

Regarding content validity of the final Thai PIKQ, the number of missing items was 0. Participants in the nurse group were more likely than those in the patient group to select the correct answer for all items for the POP scale and UI scale (P < 0.001). For internal consistency testing, Cronbach’s alpha coefficient was 0.745 for the PIKQ-POP and 0.754 for the PIKQ-UI scales, suggesting that the items had relatively high internal consistency. The item-total correlation values ranged from 0.204 to 0.539, showing an adequate correlation of each item with the scale overall. The correlation coefficients between the test and retest for PIKQ-POP and PIKQ-UI were 0.685 and 0.735, respectively (P < 0.001).

Conclusions

The Thai PIKQ is a simple instrument which shows good validity and high reliability and could be a useful tool for assessing knowledge regarding POP and UI in clinical practice.

Spanish Questionnaires for the Assessment of Pelvic Floor Dysfunctions in Women: A Systematic Review of the Structural Characteristics and Psychometric Properties

BACKGROUND

Pelvic floor dysfunctions affect a third of the adult female population, including a large number of clinical conditions, which can be evaluated through validated questionnaires that inform us of the status and perception of women both objectively and subjectively. The main objective of this study was to review and explain the topics of the validated questionnaires in Spanish on pelvic floor dysfunctions and to review their psychometric properties.

METHODS

A systematic review was carried out in the PUBMED and WOS databases. The keywords used were in PUBMED: (((((((("Fecal Incontinence" [Mesh]) OR "Urinary Incontinence" [Mesh]) OR "Pelvic Organ Prolapse" [Mesh]) OR "Pelvic Floor Disorders" [Mesh]) OR "Sexual Dysfunction, Physiological" [Mesh]) OR "Pelvic Girdle Pain" [Mesh]) OR "sexual function" [Title/Abstract]) OR "Prolapse" [Title/Abstract]) AND "Surveys and Questionnaires" [Mesh] AND "Validation" [Title/Abstract] combined with the Boolean operators "AND"/"OR". In contrast, in WOS, a segregated search was carried out with each of the terms of pelvic floor dysfunction together with "Validation" and "Surveys and Questionnaires". All articles published up to 19 November 2021 were considered. Methodological quality was assessed with the COSMIN scale.

RESULTS

A total of 687 articles were identified, of which 13 were included. The evaluated questionnaires and the structural characteristics and psychometric properties of each of them were collected.

CONCLUSION

The Spanish versions of the questionnaires show good basic structural and psychometric characteristics for the evaluation of patients with pelvic floor dysfunctions and that they resemble other versions of the same questionnaire published in other languages.

It Takes a Village: The First 100 Patients Seen in a Multidisciplinary Pelvic Floor Clinic

OBJECTIVE

This study aimed to assess the characteristics of patients assessed and treated at a multidisciplinary pelvic floor program that includes representatives from multiple specialties. Our goal is to describe the process from triaging patients to the actual collaborative delivery of care. This study examines the factors contributing to the success of our multidisciplinary clinic as evidenced by its ongoing viability.

METHODS

This is a descriptive study retrospectively analyzing a prospectively maintained database that included the first 100 patients seen in the Program for Abdominal and Pelvic Health clinic between December 2017 and October 2018. We examined patient demographics, their concerns, and care plan including diagnostic tests, findings, treatments, referrals, and return visits.

RESULTS

The clinic met twice monthly, and the first 100 patients were seen over the course of 10 months. The most common primary symptoms were pelvic pain (45), constipation (30), bladder incontinence (27), bowel incontinence (23), high tone pelvic floor dysfunction (23), and abdominal pain (23); most patients had more than one presenting symptom (76). The most common specialties seen at the first visit to the clinic included gastroenterology (56%), followed by physical medicine and rehabilitation (45%), physical therapy (31%), female pelvic medicine and reconstructive surgery (25%), behavioral health (19%), urology (18%), and colorectal surgery (13%). Eleven patients were entirely new to our hospital system. Most patients had diagnostic tests ordered and performed.

CONCLUSIONS

A multidisciplinary clinic for abdominal and pelvic health proves a sustainable model for comprehensive treatment for patients with pelvic floor dysfunction, including difficulties with defecation, urination, sexual dysfunction, and pain.

Regional Variation and Temporal Trends in Surgery for Pelvic Organ Prolapse in Canada, 2004-2014

OBJECTIVES

We sought to examine temporal trends in pelvic organ prolapse (POP) surgery in Canada.

METHODS

In this observational cross-sectional study, we used diagnostic and procedure codes from all hospitalizations and outpatient clinic visits in Canada (excluding Québec) from 2004 to 2014 to identify and analyze data on POP surgery.

RESULTS

There were 204 301 POP surgery visits from 2004 to 2014, and the rate of POP surgery declined from 19.3 to 16.0 per 10 000 women during this period. The rates of "native tissue reconstructive repair" and "hysterectomy without other procedure" declined from 15.0 to 12.8 per 10 000 women and 2.6 to 1.6 per 10 000 women, respectively. The rate of obliteration increased from 0.1 to 0.3 per 10 000 women (all P values for trend <0.01). Mesh procedures increased from 1.6 per 10 000 women in 2004 to 2.4 per 10 000 women in 2007 and 2008, and then declined to 1.3 per 10 000 women in 2014. Reconstructive mesh surgery using an abdominal open approach declined, while laparoscopic procedures increased over the period examined.

CONCLUSION

The rates of POP surgery declined in Canada between 2004 and 2014. An increase was observed in obliteration procedures and in laparoscopic vaginal suspension and fixation with mesh.

Pelvic floor dysfunctions in female cheerleaders: a cross-sectional study

INTRODUCTION AND HYPOTHESIS

Cheerleaders perform high-impact maneuvers that can be associated with pelvic floor dysfunction. We hypothesized that female cheerleaders would report more symptoms of pelvic floor dysfunction and fewer symptoms of premenstrual syndrome than nonathletic women.

METHODS

This cross-sectional study included high-performance female cheerleaders and young nonathletic, nulliparous, and normal-weight females. Demographics, sports practices, and pelvic floor dysfunction data were collected through an electronic questionnaire. Urinary symptoms were collected through the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and King's Health Questionnaire. Intestinal symptoms were collected through the use of Criterion F of item C3, referring to functional constipation of Rome III and Fecal Incontinence Severity Index. Data on sexual function were collected through the Female Sexual Function Index. Data on pelvic organ prolapse were obtained through the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS). In addition, questions about premenstrual syndrome-dysmenorrhea, irritability, headache, tiredness, fluid retention, and constipation-were collected through the Menstrual Symptom Questionnaire. The comparison between groups of the quantitative variables was performed using the Mann-Whitney U test. Odds ratios (OR) and 95% confidence intervals (CI) were estimated for comparison between groups on the occurrence of pelvic floor muscle dysfunction symptoms. A significance level of 5% was adopted.

RESULTS

A total of 156 women (78 cheerleaders and 76 nonathletes) completed the electronic questionnaire. Anal incontinence was the most prevalent symptom of pelvic floor muscle dysfunction. Cheerleaders were 2.3 times more likely to report symptoms regarding anal incontinence than nonathletic women. For the other symptoms of pelvic floor dysfunction, no statistical differences between the groups were found. Cheerleaders reported fewer symptoms of tiredness and constipation during the premenstrual period than did nonathletic women.

CONCLUSION

Pelvic floor dysfunction, particularly anal incontinence, appears to be more prevalent among cheerleaders than among nonathletic women. In addition, cheerleaders demonstrated fewer symptoms of tiredness and constipation during the premenstrual period.

Integrated Rehabilitation Approach with Manual and Mechanic-Acoustic Vibration Therapies for Urinary Incontinence

This study aims to verify whether an integrated rehabilitation protocol comprising neuromuscular manual therapy and focused mechanical-acoustic vibrations can significantly reduce pelvic floor dysfunctions in women affected by stress, urge, or mixed urinary incontinence. Sixty-two women were treated with a combination of neuromuscular manual therapy and mechanical-acoustic vibrations at the level of superficial pelvic floor muscle groups. The results were analyzed before the beginning and after the end of the study protocol with the myometric measuring device MyotonPRO, the Pelvic Floor Disability Index (PFDI-20), and the Pelvic Floor Impact Questionnaire (PFIQ-7). Two patients withdrew from the study after the first visit. The 60 remaining patients showed significant improvements of myometric parameters, with the percentage variations ranging from +8.5% to +20.7% for the muscle logarithmic decrement, from -11.2 to -13.9% for muscle frequency, and from -4.8% to -12.3% for muscle stiffness. There has been a reduction of 56% in the perceived disability induced by urinary incontinence, measured with the PFDI-20, and 43% reduction in the impact of the problem on daily living, measured with the PFIQ-7. We conclude that a combination of neuromuscular manual therapy and mechanical-acoustic vibrations effectively reduces pelvic symptoms in patients affected by urinary incontinence, with minimal invasiveness.

Prospective Outcomes of a Pelvic Floor Rehabilitation Program Including Vaginal Electrogalvanic Stimulation for Urinary, Defecatory, and Pelvic Pain Symptoms

OBJECTIVES

This study evaluated our experience after implementing a pelvic floor rehabilitation program including behavioral modification, biofeedback, and vaginal electrogalvanic stimulation (EGS).

METHODS

This prospective cohort study evaluated outcomes of patients with pelvic floor dysfunction (urinary or defecatory dysfunction, pelvic pain/dyspareunia) who underwent pelvic floor rehabilitation. Patients received 4 to 7 sessions (1 every 2 weeks) including biofeedback and concluded with 30 minutes of vaginal EGS. Surveys assessed subjective changes in symptoms; success was evaluated using a 10-point visual analog scale (VAS) at the final session (10 = most successful). Paired comparisons of responses at baseline and final treatment were evaluated.

RESULTS

Ninety-four patients were followed up through therapy completion. Treatment indications included urinary (89.4%), defecatory (33.0%), and pelvic pain or dyspareunia (30.9%); 44.7% of patients had a combination of indications. Among women with urinary symptoms, the percentage reporting leakage decreased from 92.9% to 79.3% (P = 0.001), leakage at least daily decreased from 69.0% to 39.5% (P < 0.001), daily urgency with leakage decreased from 42.7% to 19.5% (P = 0.001), daily urgency without leakage decreased from 41.5% to 18.3% (P < 0.001), and median VAS rating (0 = not at all, 10 = a great deal) of daily life interference decreased from 5 to 1.5 (P < 0.001). The median success ratings were 8, 8, and 7 for treatment of urinary symptoms, pelvic pain/dyspareunia, and bowel symptoms, respectively.

CONCLUSIONS

An aggressive pelvic rehabilitation program including biofeedback with vaginal EGS had a high rate of self-reported subjective success and satisfaction and should be considered a nonsurgical treatment option in patients with pelvic floor dysfunction.

Multimodal vaginal toning for bladder symptoms and quality of life in stress urinary incontinence

Introduction and hypothesis

Treatment options for women with stress urinary incontinence (SUI) have limitations. We hypothesized that multimodal vaginal toning therapy would improve bladder symptoms and quality of life in women with postpartum SUI and sexual function complaints.

Methods

Patients self-administered 24 sessions of multimodal vaginal toning therapy lasting 10 min each over 50 days. Outcomes included 1-h pad weight test, Urogenital Distress Inventory Short Form (UDI-6), Incontinence Impact Questionnaire-Short Form (IIQ-7), Female Sexual Distress Scale-Revised 2005 (FSDS-R), Female Sexual Function Index (FSFI), pelvic floor muscle strength, patient satisfaction, and adverse events.

Results

Of the 55 patients enrolled (safety population), 48 completed the study per-protocol (PP population). A total of 38 (79%) patients had a positive 1-h pad weight test at baseline. In this group, urine leakage was moderate or severe in 82% of patients at baseline, but in only 18% after treatment. Treatment success was 84%, defined as >50% improvement in pad weight relative to baseline. In the PP population, mean UDI-6 score improved by 50% (p < 0.001) and IIQ-7 score improved by 69% (p < 0.001). Sexual function quality of life improved by 54% for FSDS-R and 15% for FSFI (both p < 0.001). Pelvic floor muscle strength significantly improved (p < 0.001). Patient satisfaction with therapy was reported in 83% of patients. In the safety population, 2 (3.6%) adverse events were reported—1 urinary tract infection and 1 report of discomfort due to excessive warmth.

Conclusions

Multimodal vaginal toning therapy yields clinically meaningful improvements in bladder symptoms, pelvic floor muscle strength, and quality of life in women with SUI.

The future of pelvic floor services in the UK

AIM

The study aimed to determine the current state of UK pelvic floor services and to discuss future strategies.

METHOD

A questionnaire developed by the Pelvic Floor Society was sent in 2014 to the 175 colorectal units recognized by the Association of Coloproctology of Great Britain and Ireland. Questions included type of centre, frequency of pelvic floor clinics/interdisciplinary joint pelvic floor clinics/multidisciplinary meetings (MDMs) and workload.

RESULTS

Sixty-seven (38%) centres replied including 75% of units with a consultant who was as member of the Pelvic Floor Society. Of the 67 centres 39% were tertiary centres for pelvic floor surgery (tertiary), 48% performed some pelvic floor surgery (regional) and 13% did not perform any (local). Ninety-six per cent of tertiary referral centres served a population over 500 000. The mean number of whole time equivalent consultants in tertiary centres was 1.03 and 0.77 in regional centres. Eighty per cent of tertiary centres and 56% of regional centres ran pelvic floor clinics. Eighty-four per cent of tertiary referral and 75% of regional units held or attended an MDM. Anal ultrasonography, anorectal physiology and proctography were performed in 96% of tertiary centres compared with 50% of non-tertiary units.

CONCLUSION

The provision of pelvic floor services includes local, regional and tertiary centres. The overall response rate was low (38%) and biased to centres with a consultant who was a member of the Pelvic Floor Society. Not all regional or tertiary centres held an MDM or a pelvic floor clinic. Given the nature of pelvic floor pathology an integrated service should be aimed at linking different centres and specialities.

Incontinência urinária na gestação: implicações na qualidade de vida

Objetivos: comparar a qualidade de vida de gestantes com e sem perda urinaria, identificando os principais fatores que interferem negativamente na qualidade de vida durante essa fase de vida da mulher. Métodos: foram incluídas 15 gestantes com queixa de perda urinaria e presença de sintomas miccionais e 25 gestantes sem queixa miccional, avaliadas em dois momentos, na 24-28" e 34-36" semana gestacional. As avaliações consistiram na aplicação de dois questionários de qualidade de vida (King Health Questionnaire e o World Health Organization Quality of Life). Os dados foram tabulados no Excel e analisados estatisticamente no programa Statistica. Adotou-se um nível de significância de 5%. Resultados: as gestantes sem sintomas miccionais apresentaram melhor qualidade de vida em relação àquelas com sintomas miccionais nos domínios físico, social e ambiental. Para as gestantes com sintomas miccionais ocorreu piora dos escores dos domínios percepção geral de saúde e impacto da incontinência entre a 1" e 2" avaliação. Conclusões: a perda urinária reduz a qualidade de vida das gestantes. Outros fatores como o suporte social e emoções também podem ter impactos negativos na qualidade de vida durante a gestação.

The responses of healthcare professionals to the admission of people with cognitive impairment to acute hospital settings: an observational and interview study

AIMS AND OBJECTIVES

To explore the responses of healthcare professionals to the admission of people with cognitive impairment to the acute hospital setting.

BACKGROUND

While improving care for people with dementia has been identified as a national priority, providing appropriate care in acute hospitals for people with comorbid cognitive impairment presents challenges to healthcare professionals.

DESIGN

Based on the principles of ethnography, this was a qualitative interview and nonparticipation observational study.

METHODS

Seventy-two hours of nonparticipant observations of care together with semi-structured interviews with family carers of 34 older people who had been admitted to a UK general hospital and had a cognitive impairment. Interviews and observations were conducted in 2009 and 2010. Analysis was undertaken using Strauss and Corbin's framework.

RESULTS

The results identified a core problem, 'disruption', and a core process, 'gaining or giving a sense of control to cope with disruption'. Healthcare professionals respond to the disruption in three ways: by acting to preserve the personhood of the individual; by seeking to protect themselves from the stresses associated with caring for the person with cognitive impairment; and by suspending the personhood of the individual.

CONCLUSION

Where healthcare professionals acted to suspend the personhood of the patient, they appeared to be demonstrating signs of 'burnout'.

RELEVANCE TO CLINICAL PRACTICE

There is a need both to challenge poor practice and for positive development work with healthcare professionals who work in acute hospitals with people with dementia and cognitive impairment so that they are equipped with the skills, emotional resilience and organisational support to be effective in meeting the needs of people with dementia and cognitive impairment.

Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) is the most common type of urinary incontinence (UI) in pregnant women and is known to have detrimental effects on the quality of life in approximately 54.3 %. Pregnancy is the main risk factor for the development of SUI. This review provides details of the pathophysiology leading to SUI in pregnant women and SUI prevalence and treatment during pregnancy.

METHODS

We conducted a PubMed search for English-language and human-study articles registered from January 1990 to September 2012. This search was performed for articles dealing with prevalence and treatment of SUI during pregnancy. In the intervention studies, we included studies that used a randomized controlled trial (RCT) design or studies comparing a treatment intervention to no treatment.

RESULTS

A total of 534 articles were identified; 174 full-text articles were reviewed, and 28 of them met eligibility criteria and are reported on here. The mean prevalence of SUI during pregnancy was 41 % (18.6-60 %) and increased with gestational age. The increasing pressure of the growing uterus and fetal weight on pelvic-floor muscles (PFM) throughout pregnancy, together with pregnancy-related hormonal changes, may lead to reduced PFM strength as well as their supportive and sphincteric function. These cause mobility of the bladder neck and urethra, leading to urethral sphincter incompetence. Pelvic floor muscle exercise (PFME) is a safe and effective treatment for SUI during pregnancy, without significant adverse effects.

CONCLUSIONS

Understanding these issues can be useful for health-care professionals when informing and counseling pregnant women to help prevent SUI during pregnancy and the postpartum period.

Knowledge and perceptions of pelvic floor disorders among african american and latina women

OBJECTIVE

: The objective of this study was to explore knowledge, barriers to seeking sociocultural perceptions of pelvic floor disorders (PFDs) among African American (AA) and Latina (LA) community-dwelling women.

METHODS

: Thirty-two women participated in 4 focus groups. The sample included AA and LA women aged 24 to 77 years. Focus groups were stratified by age and race/ethnicity. Discussion questions included knowledge of and related health needs and barriers to seeking care with respect to PFDs, urinary incontinence, and pelvic organ prolapse. Demographics and basic knowledge and experience with PFDs were also captured by survey.

RESULTS

: Several significant themes emerged from the data. AA and LA women had general misconceptions about PFDs and were unaware of PFDs causes, symptoms, and available treatments. Women were eager to receive more information, particularly prevention information that could be shared with their daughters. A major barrier to seeking care was the pattern of placing family demands before their own health needs.

CONCLUSIONS

: Findings suggest that there is a gap in information on PFDs among AA and LA women, yet a demand for information exists. Sociocultural perspectives discerned from focus group with AA and LA women can be used to tailor educational information and materials on PFDs. Findings may increase health provider awareness of the unique sociocultural barriers to seeking care for AA and LA women and improve patient education on PFDs.

Idiopathic scoliosis and pelvic floor dysfunction

Background: Research suggests that trunk and pelvic floor muscles work as a functional unit for postural and continence activities. Back pain increases the risk of incontinence, and practitioners treating incontinence often treat trunk muscles, while those treating back and sacroiliac problems often incorporate pelvic floor treatments in management programmes. It was hypothesized that women with scoliosis might have pelvic floor dysfunction.

Methods: Pelvic floor function was evaluated in a convenience sample of four nulliparous women with idiopathic scoliosis. Evaluation included scoliometer and perineometer measures, manual muscle testing of the pelvic floor, the Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20), and the Scoliosis Research Society Outcomes Instrument (SRS-22)

Findings: Half the participants reported clinically significant PFDI-20 score elevations. All had back pain, attributed to their scoliosis.

Conclusion: Pelvic floor strength assessments lacked sensitivity in this population of young women, but PFDI-20 scores identified who might benefit from further evaluation. Practitioners treating women with scoliosis should be aware of possible co-existing pelvic floor disorders and of the known link between back pain and incontinence. By raising this issue or using a sensitive tool like the PFDI-20 it may be possible to identify and treat problems early, and implement pelvic floor disorder prevention programmes.

Pelvic organ distribution of mesenchymal stem cells injected intravenously after simulated childbirth injury in female rats

The local route of stem cell administration utilized presently in clinical trials for stress incontinence may not take full advantage of the capabilities of these cells. The goal of this study was to evaluate if intravenously injected mesenchymal stem cells (MSCs) home to pelvic organs after simulated childbirth injury in a rat model. Female rats underwent either vaginal distension (VD) or sham VD. All rats received 2 million GFP-labeled MSCs intravenously 1 hour after injury. Four or 10 days later pelvic organs and muscles were imaged for visualization of GFP-positive cells. Significantly more MSCs home to the urethra, vagina, rectum, and levator ani muscle 4 days after VD than after sham VD. MSCs were present 10 days after injection but GFP intensity had decreased. This study provides basic science evidence that intravenous administration of MSCs could provide an effective route for cell-based therapy to facilitate repair after injury and treat stress incontinence.

Pelvic floor dysfunction: a scoping study exploring current service provision in the UK, interprofessional collaboration and future management priorities

OBJECTIVE

Pelvic floor dysfunction (PFD) has a significant socioeconomic and healthcare cost. This study aimed to investigate current service provision for PFD in the UK, highlighting any gaps and areas for improvement to inform future service improvement.

METHODS

A three-phase design comprised a scoping literature review, consultation survey with frontline practitioners from four key professional groups and an overarching synthesis. An interpretative analytical framework was informed by the concepts of interdisciplinary and interprofessional collaboration.

RESULTS

Empirical evidence on PFD service provision is limited. No overarching strategic approach to PFD as a single clinical entity in the UK was identified. Two hundred and forty-three medical, nursing and physiotherapy practitioners from different clinical subspecialties participated in the survey. Access and availability to services, models of delivery and individual practice vary widely within and across the disciplines. Time restrictions, mixed professional attitudes, lack of standardisation and low investment priority were identified as major barriers to optimal service provision. Five overlapping areas for improvement are highlighted: access and availability, team working and collaboration, funding and investment, education, training and research, public and professional awareness.

CONCLUSIONS

Current services are characterised by a fragmented approach with asynchronous delivery, limited investment and poor interprofessional integration. An improved service delivery model has the potential to improve outcomes through better interdisciplinary collaboration and efficient use of resources.

Pelvic floor dysfunction is not a risk factor for febrile urinary tract infection in adults

OBJECTIVE

To determine whether pelvic floor dysfunction (PFD) might be a risk factor for or consequence of febrile urinary tract infection (UTI), as UTI in adults is a common infection in which an underlying urological abnormality is often considered, and as in children, PFD is also thought to have a pathophysiological role in adults with UTI.

PATIENTS AND METHODS

A multicentre case-control study was conducted at 26 primary-care centres and at six Emergency Departments of regional hospitals. Cases were consecutive patients aged > or =18 years, who presented with febrile UTI. Controls were randomly selected subjects who visited their general practitioner for reasons other than UTI or fever. A validated pelvic floor questionnaire (the Pelvic Floor Inventories Leiden, PelFIs) was used to assess pelvic floor function.

RESULTS

Between October 2006 and December 2007, 153 cases were included; of these, the completed questionnaires of 102 (response rate 67%) were compared to those of 100 of 110 (response rate 91%) controls. The median age of cases and controls was 65 and 58 years, respectively; 40% of cases and controls were men. The percentage of PelFIs outcomes consistent with PFD were comparable between cases and controls, at 21% vs 23%, respectively (odds ratio 0.9, 95% confidence interval, CI, 0.4-1.78). In the multivariate analysis, comorbidity (odds ratio 4.9, 95% CI 2.2-11.1) and a history of UTI (odds ratio 2.5, 95% CI 1.0-6.1) were independent significant risk factors for febrile UTI, whereas PFD was not (odds ratio 1.0, 0.5-2.2). Within the group of cases, PFD was not associated with bacteriuria during assessment of PelFIs (odds ratio 1.1, 95% CI 0.4-3.5) and inversely related to a history of UTI within the previous year (odds ratio 0.2, 0.1-0.9).

CONCLUSIONS

PFD is common among adults but it does not seem to be a risk factor for febrile UTI.

Pelvic floor muscle function in a general female population in relation with age and parity and the relation between voluntary and involuntary contractions of the pelvic floor musculature

Introduction and hypothesis

The objective of this study is to describe pelvic floor muscle function (PFMF) in relation to age and parity in a general female population and to test whether strength/endurance measurements represent all functions of the pelvic floor musculature.

Methods

A cross-sectional study was performed on 95% of the women aged 45–85 years from a small Dutch town. Validated questionnaires were used to obtain general information, and vaginal examination to test PFMF was performed on 649 women. Chi-square tests were used to analyse the relation between PFMF versus age and parity. Analysis of variance was used to compare muscle strength and endurance to the other PFMF items.

Results

Response rate to the questionnaire was 62.7% (1,869/2,979). PFM strength and endurance are not positively associated with the effective involuntary muscle contractions during coughing.

Conclusions

Voluntary muscle contractions decreased with age, but there was no relation with parity. Muscle strength and endurance measurements alone are not sensitive enough to determine PFMF.

[Pelvic floor disorders]

Fecal and urinary incontinence are frequently associated, together with pelvic organ prolapse. The most important risk factors for pelvic floor disorders are vaginal delivery and chronic constipation. Irrespective of the symptom prompting the patient to seek medical attention and the specialist consulted, symptoms in other compartments must be investigated because patients rarely report them spontaneously. Patients with pelvic floor disorders should be evaluated by a multidisciplinary group of specialists. Complete evaluation includes urodynamics, anal manometry, endoanal ultrasonography and neurophysiologic study of the pelvic floor and is recommended in most patients, given that pelvic floor disorders have a complex and multifactorial pathophysiology and that all anatomic and functional abnormalities must be detected to provide the most appropriate treatment. Conservative treatment resolves or improves the problem in a large proportion of patients with mild-to-moderate symptoms. Surgery should be indicated in selected patients with careful evaluation to identify preoperatively all anatomical and functional defects that can be surgically corrected. The identification of risk factors and better knowledge of the prevalence and pathophysiology of this health problem will allow preventive strategies to be established and improve therapeutic outcomes.

Clinical characteristics and quality of life in a cohort of 621 patients with faecal incontinence

AIM

The aim of this study was to study a cohort of patients with faecal incontinence (FI) to gain a better insight into the clinical and epidemiological characteristics of this pathology and its repercussions on quality of life (QL).

MATERIALS AND METHODS

Consecutive patients with FI seen at tertiary centres filled in a self-questionnaire. The severity of FI, constipation and urinary incontinence (UI) was evaluated, respectively, by the Jorge and Wexner score, the Knowles-Eccersley-Scott Symptom score and the Urological Distress Inventory score. ROME II criteria were used to assess the existence of an associated irritable bowel syndrome. The repercussion on QL was evaluated by the Gastrointestinal Quality of Life index score and the Ditrovie score. The psychological status was assessed by the Hospital Anxiety and Depression scale.

RESULTS

Six hundred twenty-one patients (114 men), mean age 58 +/- 15 years (range: 20-92), with FI, filled in the questionnaire. The mean Jorge and Wexner score was 11 +/- 4. Twenty-seven presented with an irritable bowel syndrome. Thirty-eight percent had an associated constipation. A UI was associated in 48% women and 25% men. QL was significantly altered, and anxiety and depression were frequent.

CONCLUSIONS

FI symptoms are frequently severe, QL very altered and anxiety and depression common. FI is frequently associated with other digestive and perineal symptoms, which argue in favour of a multi-disciplinary management of FI.

Risk estimates of hysterectomy and selected conditions commonly treated with hysterectomy

PURPOSE

This study presents corrected rates and probability (risk) estimates of experiencing a hysterectomy and of selected conditions commonly treated with hysterectomy.

METHODS

Analyses are based on hysterectomy prevalence data from the Behavior Risk Factor Surveillance Survey (calendar years 2000-2006), hysterectomy incidence data from the National Hospital Discharge Survey (2001-2005), and population estimates from the U.S. Census Bureau (2001-2005). The correction involved removing those women without a uterus from the denominator in the rate calculation.

RESULTS

Corrected hysterectomy incidence rates per 1000 women were greater than the uncorrected rates for women ages 18-44 years (6.0 vs. 5.0), 45-64 years (10.4 vs. 7.1), and 65 years and older (4.9 vs. 2.6). Correcting the rates had a comparatively larger impact in the South. Incidence rates of selected conditions associated with the female reproductive system were greater after correction for hysterectomy prevalence. For example, corrected compared with uncorrected rates of uterine fibroids per 1000 women were 2.9 vs. 2.7 for ages 18-44 and 5.0 vs. 3.4 for ages 45-64. The uncorrected and corrected 10-year risk of being diagnosed with uterine fibroids among women aged 50 who have not previously had fibroids is 3.87 (1 in 26) and 4.54 (1 in 22), respectively.

CONCLUSIONS

The correction method employed produces greater incidence and age-conditional-risk estimates of hysterectomy and of conditions commonly treated with hysterectomy. Corrected rates and age-conditional risk estimates may allow women with intact uteri to better assess their probability of undergoing a hysterectomy and certain other conditions of the reproductive system.

Effects of introducing a specialized nurse in the care of community-dwelling women suffering from urinary incontinence: a randomized controlled trial

PURPOSE

Urinary incontinence (UI) often remains inadequately treated. In the literature, there are indications that continence nurses' diagnoses and treatment advices are beneficial in terms of clinical outcomes. However, the precise short-term and long-term effects are unclear. This study investigates the short-term and long-term effects of the introduction of a continence nurse in the care of community-dwelling women suffering from UI.

METHODS

In a cluster randomized study, 38 women were referred to the continence nurse who, guided by a protocol, assessed and advised the patients about therapy, lifestyle, or medication. If progress was disappointing, therapy was revised. Results were compared to a group of 13 women who received "usual care" by the general practitioner. Data on frequency and volume of incontinence, quality of life, and patient satisfaction were collected at baseline and after 3, 6, and 12 months.

RESULTS

After 6 months, women in the intervention group reported a greater reduction in "moderate" incontinent episodes when compared to women in the control group. No treatment effect was found after 12 months. Although there was a stronger improvement in scores as regards to quality of life in the intervention group, with the exception of the dimension "physical," no treatment effect was found.

CONCLUSION

The introduction of a continence nurse demonstrates short-term benefit to community-dwelling women suffering from UI. However, the long-term effects should be further explored with larger study populations.

TRIAL REGISTRATION NUMBER

ISRCTN15553880.

Evaluation of pelvic floor muscle function in a random group of adult women in Austria

Despite an increasing clinical interest in female pelvic floor function, there is a lack of data with respect to the knowledge of average adult women about the physiological role of the pelvic floor and their ability to contract pelvic floor muscles (PFM) voluntarily. It was the aim of our study to evaluate the percentage of PFM dysfunction in adult women and the impact of risk factors, such as age, body mass index (BMI), number of children delivered, and the influence of previous PFM training. A total of 343 Austrian adult women (mean age, 41.2 +/- 14.6 years; range, 18-79 years), selected at random, were examined to test their ability to contract the PFM. The examination was carried out by three independent gynecologists during the course of a routine gynecological visit. The ability to contract the PFM voluntarily or involuntarily was assessed by digital intravaginal palpation with the patients in a supine position. The muscle strength was graded according to the Modified Oxford Grading Scale by Laycock. A high percentage (44.9%) of the women was not able to voluntarily perform a normal PFM contraction. In only 26.5%, an involuntary contraction of the pelvic floor was present before an increase in intra-abdominal pressure. The inability to contract the PFM did not correlate with women's age but revealed a weak relationship with the number of childbirths and the patient's BMI. A significant correlation was found between the Oxford Grading Scale rating and the patient's report about previous PFM training.

Psychological morbidity and female urinary incontinence

Female urinary incontinence is a common yet distressing condition. It affects women of all ages, but is especially common in the elderly. Its prevalence ranges from 15 to 55%, depending on age and population studied. Despite the ubiquity of female urinary incontinence, many incontinent women do not voice their suffering, and urinary incontinence has therefore been dubbed 'the silent epidemic'. The physical impact and social isolation associated with urinary incontinence lead to impairment of quality of life and psychological well-being. It is the aim of this review to discuss the epidemiology and psychological impact of urinary incontinence. The recognition and management of incontinence-related psychological morbidity are also explored.

[Female geriatric patients with urinary incontinence symptoms and their control over pelvic floor muscles]

Not only do anatomy and function of the pelvic floor play an important role as possible causes of female urinary incontinence, they are also crucial for its therapy. The aim of this case control study of female geriatric patients with symptoms of urinary incontinence was to determine the knowledge about their pelvic floor and to assess their ability to contract pelvic floor muscles voluntarily and reflexly.

METHODS

A total of 377 female geriatric patients with symptoms of urinary incontinence were investigated in a Basis Assessment for Urinary incontinence. The ability to contract their pelvic floor muscles was examined by a digital vaginal palpation. The extent of the registered muscle strength was graded by the Modified Oxford Grading Scale by Laycock (1994).

RESULTS

Of the patients, 65.5% were not aware of their pelvic floor and were not able to contract the pelvic floor muscles (Grade 0 to 1 by Laycock), 22% had an inaccurate knowledge and only performed an insufficient pelvic floor muscle contraction (Grade 2 by Laycock). Only 12.5% could contract their pelvic floor muscles properly (Grade 3 to 4 by Laycock). A subgroup of 83 patients had already absolved pelvic floor exercises in the past, 80 patients with conventional instructions, 3 patients with digital vaginal control. In this subgroup 54.2% of the patients were not able to contract the pelvic floor muscles (Grade 0 to 1 by Laycock) 25.3% only performed an insufficient contraction (Grade 2 by Laycock), while 20% were able to perform a sufficient and powerful contraction (Grade 3 to 4 by Laycock). The three patients in the past controlled by a digital vaginal palpation were part of this group and managed a pelvic floor muscle strength Grade 4 by Laycock. A high percentage of female geriatric patients with symptoms of urinary incontinence have a lack of understanding regarding the position and function of their pelvic floor. These results suggest that conventional pelvic floor muscle exercises without specific control are not an appropriate method to improve geriatric patients' ability to contract their pelvic floor muscles and to prevent urine leakage.

The role of the nurse in community continence care: a systematic review

Urinary incontinence (UI) is a condition that is associated with decreased quality of life. Apart from this impact on quality of life, UI is also a very costly problem. It is recognised that 'usual care' for patients suffering from UI is not optimal. Specialised nurses can play an important role in the care for community-dwelling incontinent patients, as they have the appropriate interpersonal and technical skills to provide patient-tailored care. This systematic review analyses the effect of treatment by nurses on clinical and economic outcomes. A total of 12 randomised controlled trials (RCTs) were found, varying in terms of population, setting, outcome measurement and control/intervention. There is limited evidence that treatment by nurses results in a decrease in incontinence. No evidence was found for cost reduction. Recommendations are made for future studies.

Midline intravaginal slingplasty for treatment of urinary stress incontinence: results of an independent audit up to 2 years after surgery

Recently, the midline intravaginal slingplasty (anterior IVS) directed at reinforcing the pubourethral ligament was introduced for treatment of urinary stress incontinence. An independent telephone interview to evaluate urinary symptoms and surgery-related changes in quality of life was performed between 12 and 32 months after surgery. Of 52 women initially enrolled, 3 were lost during follow-up. None of the patients experienced infection, rejection or erosion of the tape. The procedure failed in 7 patients whereas in 42 patients cure of stress incontinence was achieved. This was not only verified by clinical examination at initial follow-up but also confirmed by the patients at the time of the interview. Although about two-thirds of the patients reported urge incontinence and/or voiding difficulties during their interview, the validation of the surgery was rather high and only in a minority did urinary complaints translate into reduced quality of life.

Clinical Evaluation and Management Strategy for Sexual Dysfunction in Men and Women

INTRODUCTION

The optimal approach for identification and evaluation of the sexual problems in men and women in primary care or general medicine practice has not been consensed.

AIM

To provide recommendations/guidelines concerning state-of-the-art knowledge for clinical evaluation and management strategies in the evaluation and treatment of sexual dysfunction in men and women, emphasizing evidence-based medicine and a patient-centered framework.

METHODS

An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. Concerning the Clinical Evaluation and Management Strategies Committee, there were 12 experts from five countries.

MAIN OUTCOME MEASURE

Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate.

RESULTS

Three concepts underlie sexual medicine management: (i) adoption of a patient-centered framework for evaluation and treatment; (ii) application of the principles of evidence-based medicine in diagnostic and treatment planning; and (iii) use of a unified management approach in men and women. When taken together, these three principles provide a balanced and integrated approach to sexual dysfunction management. Common algorithms for diagnosis and management of men and women with sexual dysfunction, brief sexual symptom checklists, basics in history and physical examination, indications for specialized referral and development of a follow-up strategy are presented.

CONCLUSIONS

More research is needed in understanding the role of evidence-based and patient-centered medicine in the clinical evaluation and management strategies of men and women with sexual dysfunction.

“The Cut Above” and “the Cut Below”: The Abuse of Caesareans and Episiotomy in São Paulo, Brazil

In the last 50 years, a rapid increase in the use of technology to start, augment, accelerate, regulate and monitor the process of birth has frequently led to the adoption of inadequate, unnecessary and sometimes dangerous interventions. Although research has shown that the least amount of interference compatible with safety is the paradigm to follow, vaginal birth is still being treated as if it carries a high risk to women's health and sexual life in Brazil. This paper describes the impact of the intervention model on women's birth experience, and discusses how the organisation of public and private maternity services in Brazil influences the quality of obstetric care. Brazil is known for high rates of unnecessary caesarean section ("the cut above"), performed in over two-thirds of births in the private sector, where 30% of women give birth. The 94.2% rate of episiotomy ("the cut below") in women who give birth vaginally, affecting the 70% of poor women using the public sector most, receives less attention. A change in the understanding of women's bodies is required before a change in the procedures themselves can be expected. Since 1993, inspired by campaigns against female genital mutilation, a national movement of providers, feminists and consumer groups has been promoting evidence-based care and humanisation of childbirth in Brazil, to reduce unnecessary surgical procedures.