If We Don't Ask, They Won't Tell: Screening for Urinary and Fecal Incontinence by Primary Care Providers

Urinary Incontinence in Primary Care-The Gap Between Recommendations and Real World

IMPORTANCE

Routine screening for urinary incontinence (UI) by primary care providers (PCPs) is recommended.

OBJECTIVES

We aimed to describe the rate of incident UI diagnosed at annual PCP visits, the prevalence of UI in a large primary care population, and estimate the rate of screening for UI during primary care preventive and annual wellness visits. Secondary aims were to describe PCP knowledge and behavior as they relate to UI screening and diagnosis.

STUDY DESIGN

The electronic health record was used to abstract the number of adult female patients seen by PCPs within a regional health system with a diagnosis of UI before our study period and with a new diagnosis over a 2-year period. Additional new diagnoses and screening practices were found on chart review of an additional 824 representative charts. Primary care providers within the health system were surveyed about their screening practices and knowledge about UI.

RESULTS

There were 192,053 women primary care patients seen over 2 years. A total of 5.7% had a UI diagnosis preceding the study period and 3.4% had a UI diagnosis during the study period. A total of 42% of PCPs reported that they screen for UI at least half the time and none were completely satisfied with their ability to screen for UI. Sixteen percent of annual wellness visits had any documentation of screening for UI.

CONCLUSION

In a large primary care population, screening for and detection of UI in women was low.

Developing a urinary incontinence primary care pathway: a mixed methods study

BACKGROUND

While nearly 50% of adult women report at least one episode of urinary incontinence (UI), most never receive treatment.

OBJECTIVE

To better integrate primary and specialty UI care, we conducted (i) an environmental scan to assess the availability of key pathway resources in primary care, (ii) interviews with primary care providers to understand barriers to care, and (iii) a pilot UI care pathway intervention.

METHODS

Environmental scan: Clinic managers from all primary care clinics within a Midwestern healthcare system were invited to participate in an interview covering the availability of clinic resources. Provider interviews: Primary care providers were invited to participate in an interview covering current practices and perceived barriers to UI care. Pilot UI care pathway: Patients who screened positive for UI were provided resources for first-line behavioral management. Pilot patients completed questionnaires at baseline, 8 weeks, and 6 months.

RESULTS

While many clinics had point-of-care urinalysis (17/21, 81%), most did not have a working bladder ultrasound (14/21, 67%) or on-site pelvic floor physical therapy (18/21, 86%). Providers (n = 5) described barriers to completing almost every step of diagnosis and treatment for UI. The most persistent barrier was lack of time. Patients (n = 15) reported several self-treatment strategies including avoiding bladder irritants (7/15, 47%) and performing Kegel exercises (4/15, 27%). Five patients (33%) requested follow-up care. At 6 months, patients reported small improvements in UI symptoms.

CONCLUSION

Promising results from a novel UI care pathway pilot indicate that streamlining UI care may assist primary care providers in the first-line treatment of UI.

Referral and Prescription Patterns for Female Patients With Urinary Incontinence

IMPORTANCE

Although behavioral modifications, medications, and other interventions can improve urinary incontinence (UI), many women never receive them.

OBJECTIVES

To better characterize UI treatment patterns in primary care, we examined prescriptions and referrals to pelvic floor physical therapy (PFPT) and specialist physicians within a large Midwestern academic health system.

STUDY DESIGN

Electronic health records were queried to identify a cohort of adult female patients receiving a new UI diagnosis during outpatient primary care visits from 2016 to 2020. Urinary incontinence referrals and referral completion were examined for the overall cohort, and medication prescriptions were examined for women with urgency or mixed UI. Logistic regression was used to assess the association of prescriptions and/or referrals with patient demographics, comorbidities, and UI diagnosis dates.

RESULTS

In the year after primary care UI diagnosis, 37.2% of patients in the overall cohort (n = 4,382) received guideline-concordant care. This included 20.6% of women who were referred for further management: 17.7% to urology/urogynecology and 3.2% to PFPT. Most women who were referred attended an initial appointment. Among those with urgency (n = 2,398) or mixed UI (n = 552), 17.1% were prescribed medication. Women with stress (odds ratio [OR], 3.10; 95% CI, 2.53-3.79) and mixed UI (OR, 6.17; 95% CI, 4.03-9.66) were more likely to be referred for further management, and women diagnosed during the COVID-19 pandemic were less likely to be referred for further care (OR, 0.39; 95% CI, 0.29, 0.48).

CONCLUSION

Only slightly above 1 in 3 women with a new diagnosis of UI in primary care received guideline-based medications or referrals within 1 year, suggesting missed opportunities for timely care.

Primary care providers practice patterns regarding female pelvic floor disorders

INTRODUCTION

Pelvic floor disorders (PFDs) pose substantial physical and psychological burdens for a growing number of women. Given the ubiquity of these conditions and known patient reluctance to seek care, primary care providers (PCPs) have a unique opportunity to increase treatment and provide appropriate referrals for these patients.

METHODS

An online survey was administered to PCPs to assess provider practices, knowledge, comfort managing and ease of referral for PFDs. Logistic regression was used to assess the association between demographic/practice characteristics of PCPs and two primary outcomes of interest: discomfort with management and difficulty with referral of PFDs.

RESULTS

Of the 153 respondents to the survey, more felt comfortable managing stress urinary incontinence (SUI) and overactive bladder (OAB), compared with pelvic organ prolapse (POP) and faecal incontinence (FI) and were less likely to refer patients with urinary symptoms. Few providers elicited symptoms for POP and FI as compared with SUI and OAB. Provider variables that were significantly associated with discomfort with management varied by PFD, but tended to correlate with less exposure to PFDs (eg, those with fewer years of practice, and internal medicine and family physicians as compared with geriatricians); whereas the factors that were significantly associated with difficulty in referral, again varied by PFD, but were related to practice characteristics (eg, specialist network, type of practice, practice setting and quantity of patients).

CONCLUSION

These findings highlight the need to increase PCPs awareness of PFDs and develop effective standardised screening protocols, as well as collaboration with pelvic floor specialists to improve screening, treatment and referral for patients with PFDs.

The Prevalence of Incontinence and Its Association With Urinary Tract Infections, Dermatitis, Slips and Falls, and Behavioral Disturbances Among Older Adults in Medicare Fee-for-Service

PURPOSE

The purpose of this study was to examine the prevalence of urinary (UI), fecal (FI), and dual incontinence (DI) in older adults and their association with urinary tract infections, dermatitis, slips and falls, and behavioral disturbances based on Medicare fee-for-service (FFS) claims data.

DESIGN

Retrospective analysis.

SUBJECTS AND SETTINGS

Data from administrative claims from the CMS Medicare Limited Data Set (5% sample) for all months in 2018 were reviewed. The analysis was limited to FFS Medicare beneficiaries, with minimum of 3-month enrollment in Parts A and B who were at least 65 years old. This cohort included 1.2 million beneficiaries in the United States.

METHODS

We used diagnosis codes to identify members with incontinence and grouped these members into 3 categories (UI only, FI only, and DI). We also divided claims based on 4 sites of care (nursing home, skilled nursing facility, home health, and self- or family care). We then determined the prevalence of (1) urinary tract infections (UTIs), (2) dermatitis, (3) slips and falls, and (4) behavioral disturbances for each type of incontinence.

RESULTS

We found that 11.2% of Medicare members had a claims-based diagnosis of incontinence in 2018. On average, those diagnosed with incontinence experienced 5 times more UTIs, 2 times as many dermatitis events, more than twice as many slips and falls, and 2.8 times more behavior disturbances compared to those without an incontinence diagnosis. For those with DI, the prevalence of the 4 outcomes was significantly higher (between 22% and 185%) compared to those with UI only.

CONCLUSIONS

Findings show that Medicare beneficiaries diagnosed as incontinent experience a much higher prevalence of UTIs, dermatitis, slips and falls, and behavioral disturbances compared to those without a diagnosis of incontinence. Our results suggest that incontinence may be an important indicator diagnosis for multiple other conditions and, if not well-managed, may challenge the desire for those who are incontinent to age at home.

Diagnostic tools for fecal incontinence: Scoring systems are the crucial first step

The main aim of this editorial is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023; 29: 4593-4603. This original research presents a new scoring system for fecal incontinence. Fecal incontinence is a chronic disease with a severe impact on the quality of life of the patients. Substantial social stigmatization often leads to significant underreporting of the condition even during visits to a specialist and could lead to further mismanagement or non-existent management of the disease. An important fact is that patients are often unable to describe their condition when not asked precisely defined questions. This problem is partially resolved by scoring questionnaires. Several scoring systems are commonly used; however, each of them has their shortcomings. For example, the absence of different kinds of leakage besides flatus and stool could further lead to underscoring the incontinence severity. Therefore, there has long been a call for a more precise scoring system. The correct identification of the presence and severity of fecal incontinence is paramount for further diagnostic approach and for choosing the appropriate therapy option. This editorial describes fecal incontinence, its effect on quality of life in general and further evaluates the diagnostic approach with a particular focus on symptom scoring systems and their implications for clinical practice.

Accuracy of patient-reported bowel symptoms for fecal incontinence: Historical recall versus prospective evaluation

INTRODUCTION

Fecal incontinence (FI) is characterized by both irregular and unpredictable bowel symptoms. An accurate history of symptoms is important for diagnosis and guiding management. Whether a patient's history of bowel symptoms is reliable or if there is recall bias is unknown.

AIM

To evaluate the accuracy of FI symptoms based on patient's recall compared with a prospective stool diary.

METHODS

FI (Rome IV) patients completed a bowel questionnaire that included leakage episodes and stool consistency. Subsequently they completed a one-week FI stool diary. Agreement and correlation between historical recall and stool diary were compared.

RESULTS

One hundred patients participated. On average they reported 12 bowel movements (BMs) and five FI episodes per week. Fifty-two percent had completed under-graduation, 33% high school and 15% postgraduation. Using recall, 23% of patients accurately reported the number of FI episodes, whereas 41% underestimated and 36% overestimated its prevalence compared to the FI diary. Similarly, the concordance for the number of BMs was 30%, urgency was 54%, amount of stool leakage was 16%, and stool consistency was 12.5%. The concordance for nocturnal FI events, use of pads and lack of stool awareness were 63%, 75%, and 66.6% respectively.

CONCLUSION

There is poor concordance for key bowel symptoms including the number of FI episodes as reported by FI patients, suggesting significant recall bias. Thus, historical recall of chronic FI symptoms may be less accurate. A prospective stool diary could provide more accurate information for the evaluation of FI patients.

Screening and Treating Urinary Incontinence in Primary Care: A Missed Opportunity

More than 60% of adult women in the United States have urinary incontinence (UI), with the prevalence increasing to over 80% in women over age 65. Despite its high prevalence, most patients do not seek care and few clinicians screen for UI. The Medicare Health Outcomes Survey queries patients about satisfaction with their provider's discussion and management of UI, but formal recommendations about screening, diagnosis, and treatment are lacking. This review presents a practical algorithm for primary care providers to incorporate management of UI into routine preventive care for women, and outlines UI prevalence, risk factors, screening, and non-surgical treatment options.

Artificial Intelligence and Anorectal Manometry: Automatic Detection and Differentiation of Anorectal Motility Patterns-A Proof-of-Concept Study

INTRODUCTION

Anorectal manometry (ARM) is the gold standard for the evaluation of anorectal functional disorders, prevalent in the population. Nevertheless, the accessibility to this examination is limited, and the complexity of data analysis and report is a significant drawback. This pilot study aimed to develop and validate an artificial intelligence model to automatically differentiate motility patterns of fecal incontinence (FI) from obstructed defecation (OD) using ARM data.

METHODS

We developed and tested multiple machine learning algorithms for the automatic interpretation of ARM data. Four models were tested: k-nearest neighbors, support vector machines, random forests, and gradient boosting (xGB). These models were trained using a stratified 5-fold strategy. Their performance was assessed after fine-tuning of each model's hyperparameters, using 90% of data for training and 10% of data for testing.

RESULTS

A total of 827 ARM examinations were used in this study. After fine-tuning, the xGB model presented an overall accuracy (84.6% ± 2.9%), similar to that of random forests (82.7% ± 4.8%) and support vector machines (81.0% ± 8.0%) and higher that of k-nearest neighbors (74.4% ± 3.8%). The xGB models showed the highest discriminating performance between OD and FI, with an area under the curve of 0.939.

DISCUSSION

The tested machine learning algorithms, particularly the xGB model, accurately differentiated between FI and OD manometric patterns. Subsequent development of these tools may optimize the access to ARM studies, which may have a significant impact on the management of patients with anorectal functional diseases.

Clinical outcomes with of the Contix Faecal Incontinence Management System: preliminary results

Fecal incontinence (FI) has a significant long-term impact on patient quality of life for which there is a range of medical and surgical management alternatives. We report the preliminary outcome using the ForConti Contix Faecal Incontinence Management System (FIMS) in FI patients who had failed conservative therapy and who were recruited at 2 tertiary institutions between September 2018 and September 2020. Comparative assessments were made before and after 2 week periods of treatment using bowel diaries and subjective Wexner and Faecal Incontinence Quality of Life scores. Of 17 patients enrolled, 11 completed an 8-week assessment with a significant fall in the average percentage of FI days reported from 84% before treatment to 16.8% at the first posttreatment assessment and down to 13.2% by the second assessment period. This finding correlated with a similar reduction in the total weekly number of episodes of frank FI, minor soiling, and fecal urgency reported by patients along with concomitant improvements in the Wexner scores. For those using the device, there was less concern about accidental bowel leakage, high rates of satisfaction, and minimal problems with the device. Initial results are encouraging warranting further study.

Surgical Effect Observation and Treatment Strategy Analysis of Pseudo Urgency Syndrome

Background and Objectives: pseudo urgency syndrome among patients with mixed incontinence (MUI) causes and the corresponding treatment strategies is explored. Materials and Methods: A total of 40 patients with MUI are treated with transobturator tape (TOT) and/or solifenacin succinate. Further, 30 patients with simple stress urinary incontinence (SUI) that were treated with transobturator tape (TOT) from the period of December 2018 to August 2020 are retrospectively analyzed; then, their clinical characteristics and therapeutic effects were summarized and analyzed. Results: The effective rates of SUI symptoms in MUI and simple SUI groups were 85% and 90%, respectively; further, the difference was noted as not statistically significant (P > 0.05). Among the 40 patients with MUI, 12 patients had unstable bladder contraction, and the other 28 patients showed normal bladder compliance. The treatment effectiveness rates of SUI symptoms in patients with unstable bladder contraction and normal bladder compliance were 83.3% and 85.7%, respectively; further, no significant difference was noted (P > 0.05). However, the effective rates of urge urinary incontinence (UUI) were 50% and 85.7%, respectively, however the difference was noted as statistically significant (P < 0.05). Conclusions: Most of the UUI symptoms in MUI patients may be “pseudo urgency syndrome” caused by the worry about the leakage of urine, rather than a real sense of UUI that is caused by excessive bladder excitement. Direct surgical treatment in patients with MUI can improve the symptoms of urinary incontinence, and the effect is more obvious in patients with urinary frequency who have normal bladder compliance according to urodynamics.

Functional bowel disorders with diarrhoea: Clinical guidelines of the United European Gastroenterology and European Society for Neurogastroenterology and Motility

Irritable bowel syndrome with diarrhoea (IBS‐D) and functional diarrhoea (FDr) are the two major functional bowel disorders characterized by diarrhoea. In spite of their high prevalence, IBS‐D and FDr are associated with major uncertainties, especially regarding their optimal diagnostic work‐up and management. A Delphi consensus was performed with experts from 10 European countries who conducted a literature summary and voting process on 31 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus (defined as >80% agreement) was reached for all the statements. The panel agreed with the potential overlapping of IBS‐D and FDr. In terms of diagnosis, the consensus supports a symptom‐based approach also with the exclusion of alarm symptoms, recommending the evaluation of full blood count, C‐reactive protein, serology for coeliac disease, and faecal calprotectin, and consideration of diagnosing bile acid diarrhoea. Colonoscopy with random biopsies in both the right and left colon is recommended in patients older than 50 years and in presence of alarm features. Regarding treatment, a strong consensus was achieved for the use of a diet low fermentable oligo‐, di‐, monosaccharides and polyols, gut‐directed psychological therapies, rifaximin, loperamide, and eluxadoline. A weak or conditional recommendation was achieved for antispasmodics, probiotics, tryciclic antidepressants, bile acid sequestrants, 5‐hydroxytryptamine‐3 antagonists (i.e. alosetron, ondansetron, or ramosetron). A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of IBS‐D and FDr.

Prevalence of double incontinence in patients with fecal incontinence undergoing anorectal manometry and discriminating factors

Background: Double incontinence (DI) is the concomitant presence of incontinence for urine and stool. Aim of this study is to assess prevalence of DI in patients with fecal incontinence (FI) undergoing Ano-Rectal Manometry (ARM) in a tertiary care center and to identify factors discriminating between both. Methods: Medical records of consecutive patients referred for ARM for FI during 2 years at University Hospital Brussels were retrospectively reviewed. Results from ARM, presence of diarrhea, diseases from recto-anal or peri-anal region, prior abdominal, proctological or urological surgery and neurological comorbidities were recorded. Results: Of 101 enrolled patients, 77% suffered from solitary FI and 23% from DI. Diarrhea was more common in DI vs. FI (43,5% vs. 15,4%, P=.008), as was the presence of neurological comorbidities (34.8% vs. 10.3%, P=.009) and urological interventions (21.7% vs. 1.3%, P=.002). In respect to women only, more urological interventions were performed (20% vs. 0%, P=.006) and more diseases from recto-anal or peri-anal region were encountered in DI vs. FI (35.0 % vs. 12.5 %, P= .045). In men, neurological disorders were significantly more common in DI (100.0% vs. 3.3%, P=.002). Conclusions: This study identified gender-specific patterns of comorbidities in FI and DI. ARM had no distinctive value between FI and DI in men and women. A prospective study should provide more information on patients at risk for incontinence and help to identify distinct features between FI and DI in men and women.

Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration

INTRODUCTION

The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI.

METHODS

These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus.

RESULTS

These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients.

CONCLUSION

These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI.

Primary care providers' knowledge about the therapeutic management of refractory pelvic floor dysfunctions in Flanders, Belgium: a cross-sectional study

BACKGROUND

Pelvic floor dysfunctions (PFD) are prevalent conditions in primary care practice. Basic knowledge of second-line therapies among primary care providers (PCPs) is indispensable to well-inform refractory patients and improve their access to specialized care.

OBJECTIVES

Getting insight into the extent of knowledge about second-line therapies for refractory PFD among PCPs in Flanders, Belgium.

METHODS

From January to March 2019 Flemish PCPs participated in the OptiLUTS trial - Part A (EC/2018/0244), by the completion of a 22-item online Dutch questionnaire. Prevalence of PCPs having awareness about sacral neuromodulation (SNM), intradetrusor botulinum toxin injections (BTX) and percutaneous tibial nerve stimulation (PTNS) was explored. Descriptive statistics, univariate analyses, and multiple logistic regression analyses were performed.

RESULTS

Sixty PCPs, 55% GPs, 45% GP trainees, median age 29 years, participated. Respectively, 90, 73 and 5% had ever heard about BTX, SNM and PTNS. The profession was an independent predictive factor for never having heard of SNM therapy, GPs being more likely to have a lack of knowledge than trainees (OR = 29, 95%CI [1.9-442.5]). Ninety-three percent want to learn more about these therapies.

CONCLUSION

There is a margin for improvement in the knowledge of PCPs regarding therapies for refractory PFD. Awareness among PCPs should be increased for the optimization of patient care.

Knowledge, skills, and barriers to management of faecal incontinence in Australian primary care: a cross-sectional study

BACKGROUND

GPs play an important role in the diagnosis and management of patients with faecal incontinence (FI). However, their confidence and ability in this role are unknown.

AIM

This study aimed to investigate the knowledge, skills, and confidence of GPs to manage FI in primary care, and identify barriers to optimal management.

DESIGN & SETTING

A cross-sectional study using self-administered questionnaires of GPs attending health education seminars, which took place across Australian capital cities.

METHOD

Main outcome measures included: (i) clinical exposure to and previous training in FI; (ii) knowledge and skills in screening, diagnosing, and managing FI; and (iii) barriers and facilitators to optimising care. Associations between demographics, training and knowledge and skills were assessed.

RESULTS

Some 1285 of 1469 GPs (87.5%) participated (mean 47.7 years [standard deviation {SD} 11.3]). The vast majority reported poor clinical exposure to (88.5%) and training in FI management (91.3%). Subjectively, 69.7% rated their knowledge and skills in screening, assessing, and treating FI as suboptimal. The most commonly reported barrier to FI care was 'insufficient skills' (56.1%); facilitators were improved referral pathways (84.6%) and increased training (67.9%). GPs with more training had better knowledge (odds ratio [OR] = 24.62, 95% confidence interval [CI] = 13.32 to 45.51) and skills (OR = 13.87, 95% CI = 7.94 to 24.24) in managing FI.

CONCLUSION

Clinical exposure to and training in FI among GPs was poor. Accordingly, knowledge, skills, and confidence to manage FI was suboptimal. GPs recognise the importance of FI and that increased training and/or education and formalisation of referral pathways may improve the care of patients with FI in primary care.

Exploring literature on knowledge, attitudes, beliefs and practices towards urinary incontinence management: a scoping review

INTRODUCTION AND HYPOTHESIS

Urinary incontinence affects women of all ages, influencing 8.5% of the world's population in 2018. Effective management of urinary incontinence is influenced by patients help-seeking behaviour and services offered by healthcare professionals within the healthcare system. To facilitate behavioural change, it is important to understand the knowledge(Knowledge: "the comprehension and understanding of acquired facts or information about UI in adults"), attitudes (Attitude: "a predisposed perspective which influences nurses' thoughts, feelings, perceptions and behaviours towards care of adults with UI") and beliefs (Beliefs: "a theoretically conceptualized conviction or expectation regarding UI in general") of healthcare practitioners towards urinary incontinence management. The aim of this review is thus to systematically map the existing literature, reporting on how knowledge, attitude, belief and practices towards urinary incontinence management have been explored.

METHODS

Six databases were systematically searched. Included studies were published between January 2013 to January 2020 in English, investigating urinary incontinence management in women.

RESULTS

The search yielded 39 studies, with data emanating from 16 counties. Quantitative, Qualitative and mixed methodologies were used to explore the four concepts of knowledge, attitudes, beliefs and practices. A wide range of healthcare practitioners were questioned and management was explored in five healthcare settings. All factors explored related to the four concepts are reported and factors reaching consensus in included literature were highlighted.

CONCLUSION

The summarized factors can assist further investigations into the four concepts to change healthcare practitioner's behaviour towards urinary incontinence management.

Prevalence and Associated Factors of Fecal Incontinence and Double Incontinence among Rural Elderly in North China

Fecal and double incontinence are known to be more prevalent among the rural elderly. Yet, there have been few studies on their epidemic condition among Chinese rural elders. This study estimated the prevalence and correlates of fecal and double incontinence in rural elderly aged 65 years and over in North China. A multisite cross-sectional survey was conducted in 10 villages, yielding a sampling frame of 1250 residents. Fecal and urinary incontinence assessments were based on the self-reported bowel health questionnaire and the International Consultation on Incontinence Questionnaire-Short Form, respectively. The concomitant presence of fecal and urinary incontinence in the same subject was defined as double incontinence. The prevalence of fecal and double incontinence was 12.3% and 9.3%, respectively. Factors associated with fecal incontinence included urinary incontinence, lack of social interaction, traumatic brain injury, cerebrovascular disease, and poverty. Physical activities of daily living dependence, traumatic brain injury, lack of social interaction, and poor sleep quality were associated with higher odds of having double incontinence, whereas tea consumption was correlated with lower odds. Individualized intervention programs should be developed targeting associated factors and high-risk populations. These intervention programs should be integrated into existing public health services for the rural elderly to facilitate appropriate prevention and management of incontinence.

Cebranopadol reduces cocaine self-administration in male rats: Dose, treatment and safety consideration

As a novel first-in-class potent analgesic acting as an agonist of multiple opioid receptors, cebranopadol showed high efficacy and good tolerability in a broad range of preclinical models and clinical trials related to pain. In the present study, to evaluate the efficacy and safety of cebranopadol as a potential treatment of cocaine dependence, we tested the effects of cebranopadol with single and repeated doses (25, 50, 75, or 100 μg/kg, oral gavage) using rat models of cocaine fixed-ratio (FR) self-administration (SA), cocaine progressive-ratio (PR) SA, and sucrose pellet SA. In single-dosing treatment paradigm, cebranopadol significantly and dose-dependently reduced cocaine SA under FR and PR schedules and suppressed food intake under FR schedule without causing apparent side effects. In repeated-dosing treatment scheme, i.e. daily administration of 25, 50, 75, or 100 μg/kg cebranopadol for a week, the similar reduction in cocaine intake was detected, while non-negligible complications/side effects were observed at repeated high doses (75 and 100 μg/kg). The observed side effects were similar to the common toxic signs elicited by heroin at high doses, although cebranopadol did not fully substitute heroin's discriminative stimulant effects in our drug discriminative tests. These results demonstrated that the most appropriate oral dose of cebranopadol to balance the efficacy and safety is 50 μg/kg. Collectively, although cebranopadol may serve as a new treatment for cocaine dependence, more consideration, cautiousness, and a clear optimal dose window to dissociate its therapeutic effects from opioid side effects/complications in male and female subjects will be necessary to increase its practical clinical utility.

Occupational Therapy Interventions for Urinary Dysfunction in Primary Care: A Case Series

Urinary dysfunction is commonly reported in primary care contexts. A shortage of primary care providers is affecting access to relevant services. Occupational therapy practitioners work in primary care settings and typically address urinary dysfunction in an outpatient context. Evidence regarding the delivery of occupational therapy interventions for urinary dysfunction in primary care has been limited. In this study, 3 women received 9-14 occupational therapy sessions in a primary care setting to address urinary symptoms. Plan-of-care duration, assessments, and urinary dysfunction interventions were individualized to accommodate personal and environmental factors. Across all case-series participants, Canadian Occupational Performance Measure scores demonstrated clinically significant improvement. Mixed results were found for SF-36 health-related quality-of-life subscale scores. Assessment scores specific to urinary dysfunction decreased, indicating reduced symptom severity and functional impact. This article provides preliminary evidence regarding the feasibility of occupational therapy interventions addressing urinary dysfunction in primary care settings.