Anal and urinary incontinence in women with obstetric anal sphincter rupture

Objective To assess the long term impact of obstetric anal sphincter rupture on the frequency of anal and urinary incontinence and to identify factors to predict women at risk.
Design An observational study.
Settings Departments of Obstetrics and Gynaecology and of Surgery D, Glostrup County University Hospital, Denmark.
Participants Ninety-four consecutive women who had sustained an obstetric anal sphincter rupture.
Interventions Assessment of history, anal manometry, anal sphincter electromyography and pudendal nerve terminal motor latency at three months postpartum. A questionnaire regarding anal and urinary incontinence was sent two to four years postpartum.
Main outcome measures The frequency of anal and urinary incontinence and risk factors for the development of incontinence.
Results Thirty of 72 women (42%) who responded had anal incontinence two to four years postpartum; 23 (32%) had urinary incontinence and 13 (18%) had both urinary and anal incontinence. Overall, 40 of 72 women (56%) had incontinence symptoms. The occurrence of anal incontinence was associated with pudendal nerve terminal motor latencies of more than 2.0 ms, and the occurrence of urinary incontinence was associated with the degree of rupture, the use of vacuum extraction and previous presence of urinary incontinence. Seventeen women had subsequently undergone a vaginal delivery in relation to which four (24%) had aggravation of anal incontinence, and three (18%) had aggravation of urinary incontinence. Of the women with incontinence, 38% wanted treatment but only a few had sought medical advice.
Conclusions Obstetric anal sphincter rupture is associated with a risk of approximately 50% for developing either anal or urinary incontinence or both. The prediction of women at risk is difficult. Information and routine follow up of all women with obstetric anal sphincter rupture is mandatory.     

Urethral stress relaxation phenomenon in healthy and stress incontinent women.

Urethral stress relaxation was induced by sudden forced dilatation. The stress relaxation parameter, Pt0.5, was defined as the relative pressure decrease 0.5 s after dilatation, where the pressures at 0.1 s and at the new equilibrium were set to 100% and 0% respectively. Pt0.5 was calculated in 28 healthy and 30 women with genuine stress incontinence. Measurements were performed at the bladder neck, in the high pressure zone and in the distal urethra. The measurements showed that all along the urethra, Pt0.5 was statistically significantly greater in the healthy women than in the incontinent women, the greatest difference being found at the bladder neck. Although there was a slight overlap in values between the 2 groups, this parameter seems useful in differentiating between competent and incompetent urethral sphincters.     

Effect of a vaginal device on quality of life with urinary stress incontinence

OBJECTIVE: To assess the effect of a vaginal device (Continence Guard) on urine leakage and quality of life. METHODS: Fifty-five women with stress incontinence participated in a 3-month study. They were assessed by the Incontinence Impact Questionnaire, two incontinence-related quality-of-life questions, a generic quality-of-life questionnaire (Short Form-36), two 24-hour home pad weighing tests, a 2-day voiding diary, uroflowmetry, urine cultures, and a questionnaire about subjective effectiveness of the device. RESULTS: Forty-one (74.5%) women completed the study. Estimated on an intent-to-treat basis, the vaginal device was associated with subjective cure in 11 women (20%) and improvement in 27 (49%). The mean 24-hour pad test leakage and leakage episodes in the voiding diary decreased significantly. Fifty-eight percent of the 55 women enrolled wanted to continue using the device after 3 months. The quality of life measured by the Incontinence Impact Questionnaire showed highly significant improvement, and the results of the two incontinence-related quality of life questions also showed significant improvement. Responses to the Short Form-36 general health questionnaire showed no significant changes. Improvement on the Incontinence Impact Questionnaire correlated with improvements in incontinence, whereas the Short Form-36 scores were unchanged. CONCLUSION: Treatment with the Continence Guard significantly decreases leakage and improves quality of life in women with symptoms of urinary stress incontinence. An incontinence-specific, rather than a generic, quality-of-life questionnaire was important in assessing treatment outcomes.     

Discrepancies between patient-reported outcome measures when assessing urinary incontinence or pelvic- prolapse surgery

Introduction and hypothesis

In order to assess the outcome following surgery for urinary incontinence (UI) and pelvic organ prolapse (POP) the importance of patient-reported outcome measures, in addition to the clinical objective measures, has been recognised. The International Consultation on Incontinence has initiated the development and evaluation of disease-specific questionnaires (ICIQ) to compare the patient’s degree of improvement. Alternatively, the Patient’s Global Impression of Improvement (PGI-I score) with an inherent before–after assessment has been widely accepted in recent studies. The aim of this study was to compare the PGI-I versus the ICIQ score for women undergoing UI or POP surgery.

Methods

This study is based on self-administered pre- and postoperative questionnaires, completed by women undergoing surgery for UI or POP in Denmark in 2013. Weighted Kappa statistics and 95 % limits of agreement method were used when comparing the PGI-I and ICIQ scores.

Results

Among the 3,310 women included the PGI-I score showed a higher improvement than the IQIC score, for UI 0.83 (CI 95 %: 0.80–0.85) vs 0.62 (0.60–0.64) and for POP 0.77 (0.75–0.78) vs 0.66 (0.65–0.67).

Conclusions

The PGI-I score renders higher satisfaction than the ICIQ score and the PGI-I score overestimates the improvement following UI and POP surgery.

     

Post-void residual urine under 150 ml does not exclude voiding dysfunction in women

Introduction and hypothesis

It has been claimed that post-void residual urine (PVR) below 150 ml rules out voiding dysfunction in women with stress urinary incontinence (SUI) and provides license to perform sling surgery. The cut-off of 150 ml seems arbitrary, not evidence-based, and so we sought to investigate the ability of PVR?<?150 ml to exclude voiding dysfunction.

Methods

We retrospectively reviewed the charts of all patients who underwent invasive urodynamics from 1 January 2013 to 31 December 2013. Voiding dysfunction was diagnosed if both the invasive urodynamic and the free flow showed abnormal results. We registered the PVR in patients with voiding dysfunction and divided them into groups with PVR?<?150 ml and PVR?≥?150 ml. Patients were then analyzed for bladder outlet obstruction and detrusor underactivity.

Results

Of the 205 patients undergoing invasive urodynamics in 2013, a total of 20 had voiding dysfunction, 2 with PVR?≥?150 ml. Eighteen patients had PVR?<?150 ml (range 0–50 ml); 9 had bladder outlet obstruction while 7 had detrusor underactivity. Two patients were uncategorized. Out of the 20 patients, 7 had no symptoms or complaints indicating voiding dysfunction.

Conclusions

Patients with voiding dysfunction often have normal PVR and so PVR?<?150 ml cannot exclude voiding dysfunction. All patients should be evaluated using free flow measurements along with PVR to obtain a reliable, objective measurement of their voiding pattern, before anti-incontinence surgery.

     

Clinical pharmacology of the lower urinary tract. New aspects

Neurohistochemical, electron-microscopic, pharmacological and urodynamic investigations have over the past 10 years led to a new concept of the innervation and function of the lower urinary tract. A survey is given of the peripheral innervation, transmitters and receptor functions in the parasympathetic, sympathetic, somatic and sensory innervation of the lower urinary tract. Based on this, rational principles of pharmacological treatment are outlined in the management of the most common dysfunctions of detrusor function and the urethral closure mechanism. Furthermore, a survey is given of dysfunctions of the lower urinary tract which may arise inadvertently during pharmacotherapy of disorders of other organ systems.     

Autorosette inhibition factor: a positive acute phase reactant in interstitial cystitis

Autorosette inhibition factor (AIF), complement C3d and eosinophil cationic protein (ECP) in urine were determined in 28 patients with painful bladder disease. In patients with interstitial cystitis (IC), diagnosed by the demonstration of detrusor mastocytosis, a positive correlation (r = 0.73, p less than 0.01) between AIF and C3d was found, whereas no reliable correlation was found in the remaining patients. The median concentration of urinary ECP was significantly elevated in the group of patients with IC whereas the median concentration of C3d was significantly elevated in both groups. AIF seems to behave as a positive acute phase reactant in IC. It is hypothesized that AIF may play a role in the pathogenesis of IC by influencing the normal barrier function of the epithelium of the bladder.     

Sexual activity and lower urinary tract symptoms

Lower urinary tract symptoms (LUTS) have a profound impact on womens physical, social, and sexual well being. The LUTS are likely to affect sexual activity. Conversely, sexual activity may affect the occurrence of LUTS. The aims of the study were to elucidate to which extent LUTS affect sexual function and to which extent sexual function affect LUTS in an unselected population of middle-aged women in 1 year. A questionnaire was sent to 4,000 unselected women aged 40–60 years. All 2,284 women (57.1%) who completed a baseline questionnaire and a similar questionnaire 1-year later were included. Data comprised age, occurrence of LUTS, hormonal status, and sexual activity. A multiple conditional logistic regression model was used to analyze the relationship between sexual activity and LUTS adjusted for age and hormonal status. At baseline and 1-year later, 49 women (2.2%) had no sexual intercourse, and 298 women (13.0%) either ceased or resumed sexual relationship. Compared to women having sexual relationship, a statistically significant three to sixfold higher prevalence of LUTS was observed in women with no sexual relationship. In women who ceased sexual relationship an increase, although not statistically significant, in the de novo occurrence of most LUTS was observed. In women who resumed sexual relationship an insignificantly decrease in LUTS was observed. In women whose sexual activity was unchanged no change in the occurrence of LUTS was observed. Our study confirms a close association between sexual activity and the occurrence of LUTS. A hypothesis that sexual inactivity may lead to LUTS and vice versa cannot be rejected.     

Variation in the RAD51 gene and familial breast cancer

Introduction  

Human RAD51 is a homologue of the Escherichia coli RecA protein and is known to function in recombinational repair of double-stranded DNA breaks. Mutations in the lower eukaryotic homologues of RAD51 result in a deficiency in the repair of double-stranded DNA breaks. Loss of RAD51 function would therefore be expected to result in an elevated mutation rate, leading to accumulation of DNA damage and, hence, to increased cancer risk. RAD51 interacts directly or indirectly with a number of proteins implicated in breast cancer, such as BRCA1 and BRCA2. Similar to BRCA1 mice, RAD51 ^-/- mice are embryonic lethal. The RAD51 gene region has been shown to exhibit loss of heterozygosity in breast tumours, and deregulated RAD51 expression in breast cancer patients has also been reported. Few studies have investigated the role of coding region variation in the RAD51 gene in familial breast cancer, with only one coding region variant – exon 6 c.449G>A (p.R150Q) – reported to date.