Speciality
Spotlight

 




 

Obstetric
& Gynaecology


 

 




Incontinence

   


  • Wyman
    JF, the continence program for Women Research Group
    [Virginea Commonwealth Univ/ Richmond, et al


    Comparative
    Efficacy of Behavioral Interventions in the
    Management of Female Urinary Continence


    Am J Obstet Gynaecol 179: 999-1007, 1998

     

    Objective

    – The relative efficacy of bladder training, pelvic
    muscle exercises with biofeedback-assisted
    instruction, and combination therapy in the
    management of female urinary incontinence was
    examined in a randomized clinical trial.

     

    Method

    Community-dwelling women average age 61 years with
    stress urinary incontinence [ n: 145], detrusor
    instability [ n:59], or both were divided into 3
    intervention groups: Bladder training [n:68], pelvic
    muscle exercise [n:69] and combination therapy
    [n:67]

     

    Results

     


     







     


    Combined
    Therapy

    Group



    Bladder
    Training

    Group



    Pelvic
    Exercise

    Group



    Attendance



    73%



    57%



    53%



    Cure
    Rates



    31%



    18%



    13%



    Improvement
    rate :

    Of > 50%



    70%



    51%



    56%



    Conclusion

    Whereas cure rates were not high women in all groups
    were satisfied indicating that helping women set
    realistic goals may be important to the intervention
    process.

     

    Whether
    they have stress incontinence, detrusor instability
    or both women do equally well in each of the 3
    intervention programs over the long term.

      

  • Miller
    JM, Ashton – Millor JA, Delancey JOL[ Univ of
    Michigan, Ann Arbor]


    A
    Pelvic Muscle Precontraction Can Reduce
    Cough-related Urine Loss in Selected Women With Mind
    SUI


    J Am Geriatr Soc 46: 870-874, 1998

      

    Introduction –

    Women instructed in pelvic muscle strengthening
    exercises could reduce their stress related leakage
    within as little as 1/day.

       

    Results

    As a week follow-up the ” knack ” was used
    successfully by 98.2% of women to reduce urine loss
    resulting from a medium cough compared with that of
    a similar cough performed 1 minute before without
    the knack. Urine loss resulting from a deep cough
    was reduced by an average of 73.3%.

         

  • V Khullar et al (King’s College, London).

    Prevalence of Faecal Incontinence Among women with Urinary Incontinence. 

    Br J Obstet Gynaecol 105: 1211-1213, 1998

      


    Authors studied particular problem and came to the conclusion that denervation and myogenic injuries occurring in childbirth may be the common cause for genuine stress and fecal incontinence. The occurrence of detrusor instability and fecal incontinence may be attributed to a different mechanism.

       


    Khullar et al have reported 30% and 21% incidence of fecal incontinence among women with detrusor instability and stress incontinence respectively.

       

  • KL
    Burgio, et al (Univ of Alabama, Birmingham; Univ of Pittsburgh, Pa: Allegheny Gen Hosp, Pittsburgh, Pa; et al)

    Behavioral vs Drug treatment for Urge Urinary Incontinence in Older Women: A Randomized Controlled Trial. 

    Jama 280: 1995-2000, 1998.

       


    About 38% of older community-dwelling women, age 60 years and older have urinary incontinence, which contributes to depression and social isolation.

       


    They have studied women divided into 3 groups, there was a group with 197 women aged 55-92 yrs who had urge urinary incontinence or mixed incontinence with urge as the predominant pattern were studied. Patients were randomized to receive 8 weeks of biofeedback assisted behavior treatment, drug treatment with oxybutynin chloride, possible range of doses, 2.5mg daily to 5mg 3 times daily or a placebo control condition.

       


    Results ; Reduction of incontinence was most pronounced early in treatment and progressed more gradually thereafter in all 3 treatment groups. There was an 80.75 reduction of incontinence episodes with behavior treatment, a 68.5% reduction with drug treatment, and a 39.4% reduction with placebo control.

       


    It was concluded that as a first line treatment for urge and mixed incontinence, behavioral treatment is a safe and effective conservative intervention that should be more readily available.

       


    Editorial comments: The only problem with behavioral treatments is that they are time-consuming and require dedicated professional teams.

       

  • A Pelvic Muscle Precontraction can Reduce Cough-related Urine Loss in Selected Women with Mild
    SUI. 


    JM Miller et al (Univ of Michigan, Ann Arbor). J Am Geriartr Soc. 46:870-874, 1998.

        


    Conservative treatment of stress urinary incontinence in women typically begins with repetitive strengthening, or Kegel exercises, for pelvic floor muscles. Some women have reported decreased stress-related urine loss as early as 1 to 2 days after beginning these exercises. Because pelvic floor hypertrophy cannot occur in such a short time span, these women have probably taught themselves a new skill – that of intentionally contracting the pelvic floor muscles just before and during an activity, which causes a rise in intra-abdominal pressure. This exercise is called “the Knack.” 

       


    The effect of the Knack was assessed at 1 week in 27 older women with mild-to-moderate SUI in a prospective, randomized, single-blind interventional trial to determine its effect on cough-related urine loss.

       


    It was concluded that selected older women with mild-to-moderate SUI can learn to effectively use a properly timed pelvic floor muscle contraction to significantly diminish urine leakage during a cough. The Knack is a simple and effective method for reducing stress-related urine loss in selected older women with mild SUI who are capable of performing pelvic floor muscle contractions.

       


    The Knack technique is simple and easy to learn. In fact the 2 techniques (i.e. Kegel and the Knack) work differently. While Kegel exercise is aimed toward strengthening the pelvic floor muscle and providing better support for the bladder, the current technique is aimed toward “self protection” by contracting the muscle before stress, rather than by permanently strengthening it.

       

  • An Open Study of the Bladder Neck Support Prosthesis in Genuine Stress Incontinence. 

    KH Moore et al (Univ of New South Wales, Sydney, Australia; Royal North Shore Hosp, Sydney, Australia) Br J Obstet Gynaecol 106:42-49, 1999.

         


    It was found that the bladder support prosthesis (incontinence ring) maybe a good non-surgical option for some women with stress urinary incontinence However women with a scarred vagina after a previous operation or prolapse of more than one wall may find the device difficult to fit or keep in place.

       
     

  • F
    Zivkovic, et al (Univ of Graz, Austria)

    Body Mass Index and Outcome of Incontinence Surgery. 

    Obstet Gynecol 93: 753-756, 1999

        


    The authors feel that the continence rate for anterior colporrhaphy at 5 years was 58%. The rate for anterior colporrhaphy with needle suspension of bladder neck was 51% at 5 years. The rate for Burch colposuspension at 5 years was 86%. There were no significant differences in the preoperative and postoperative body mass indexes of continent and incontinent women for each procedure.

        


    Conclusion : For failure of incontinence surgery, preoperative obesity was not a risk factor, but the power of this study was limited.

       


    Editor A Bergmann comments that Zivkovic et al indicate that, at least for the Burch operation, this is not the case. These women need a “fixed anchor” when their stress incontinence is corrected, and the Burch procedure offers that type of correction, i.e. attaching the endopelvic fascia to a fixed bony structure.

       

  • Surgical Correction of Stress Incontinence in Morbidly Obese Women. 


    JM Cummings, et al (Univ of south Alabam, Mobile; St. Louis Univ) J. Urol 160:754-755, 1998.

       


    Authors conclude that Morbidly obese women with stress urinary incontinence can be successfully treated with surgery. Sling operations appear to be the procedure of choice for this population.

           

      



 

 

Speciality Spotlight

 

 

Incontinence
   

  • Wyman JF, the continence program for Women Research Group [Virginea Commonwealth Univ/ Richmond, et al
    Comparative Efficacy of Behavioral Interventions in the Management of Female Urinary Continence
    Am J Obstet Gynaecol 179: 999-1007, 1998
     
    Objective
    – The relative efficacy of bladder training, pelvic muscle exercises with biofeedback-assisted instruction, and combination therapy in the management of female urinary incontinence was examined in a randomized clinical trial.
     
    Method Community-dwelling women average age 61 years with stress urinary incontinence [ n: 145], detrusor instability [ n:59], or both were divided into 3 intervention groups: Bladder training [n:68], pelvic muscle exercise [n:69] and combination therapy [n:67]
     
    Results

     

     

     

    Combined Therapy
    Group

    Bladder Training
    Group

    Pelvic Exercise
    Group

    Attendance

    73%

    57%

    53%

    Cure Rates

    31%

    18%

    13%

    Improvement rate :
    Of > 50%

    70%

    51%

    56%

    Conclusion Whereas cure rates were not high women in all groups were satisfied indicating that helping women set realistic goals may be important to the intervention process.
     
    Whether they have stress incontinence, detrusor instability or both women do equally well in each of the 3 intervention programs over the long term.
      

  • Miller JM, Ashton – Millor JA, Delancey JOL[ Univ of Michigan, Ann Arbor]
    A Pelvic Muscle Precontraction Can Reduce Cough-related Urine Loss in Selected Women With Mind SUI
    J Am Geriatr Soc 46: 870-874, 1998
      
    Introduction –
    Women instructed in pelvic muscle strengthening exercises could reduce their stress related leakage within as little as 1/day.
       
    Results As a week follow-up the ” knack ” was used successfully by 98.2% of women to reduce urine loss resulting from a medium cough compared with that of a similar cough performed 1 minute before without the knack. Urine loss resulting from a deep cough was reduced by an average of 73.3%.
         

  • V Khullar et al (King’s College, London).
    Prevalence of Faecal Incontinence Among women with Urinary Incontinence. 
    Br J Obstet Gynaecol 105: 1211-1213, 1998
      
    Authors studied particular problem and came to the conclusion that denervation and myogenic injuries occurring in childbirth may be the common cause for genuine stress and fecal incontinence. The occurrence of detrusor instability and fecal incontinence may be attributed to a different mechanism.
       
    Khullar et al have reported 30% and 21% incidence of fecal incontinence among women with detrusor instability and stress incontinence respectively.
       

  • KL Burgio, et al (Univ of Alabama, Birmingham; Univ of Pittsburgh, Pa: Allegheny Gen Hosp, Pittsburgh, Pa; et al)
    Behavioral vs Drug treatment for Urge Urinary Incontinence in Older Women: A Randomized Controlled Trial. 
    Jama 280: 1995-2000, 1998.
       
    About 38% of older community-dwelling women, age 60 years and older have urinary incontinence, which contributes to depression and social isolation.
       
    They have studied women divided into 3 groups, there was a group with 197 women aged 55-92 yrs who had urge urinary incontinence or mixed incontinence with urge as the predominant pattern were studied. Patients were randomized to receive 8 weeks of biofeedback assisted behavior treatment, drug treatment with oxybutynin chloride, possible range of doses, 2.5mg daily to 5mg 3 times daily or a placebo control condition.
       
    Results ; Reduction of incontinence was most pronounced early in treatment and progressed more gradually thereafter in all 3 treatment groups. There was an 80.75 reduction of incontinence episodes with behavior treatment, a 68.5% reduction with drug treatment, and a 39.4% reduction with placebo control.
       
    It was concluded that as a first line treatment for urge and mixed incontinence, behavioral treatment is a safe and effective conservative intervention that should be more readily available.
       
    Editorial comments: The only problem with behavioral treatments is that they are time-consuming and require dedicated professional teams.
       

  • A Pelvic Muscle Precontraction can Reduce Cough-related Urine Loss in Selected Women with Mild SUI. 
    JM Miller et al (Univ of Michigan, Ann Arbor). J Am Geriartr Soc. 46:870-874, 1998.
        
    Conservative treatment of stress urinary incontinence in women typically begins with repetitive strengthening, or Kegel exercises, for pelvic floor muscles. Some women have reported decreased stress-related urine loss as early as 1 to 2 days after beginning these exercises. Because pelvic floor hypertrophy cannot occur in such a short time span, these women have probably taught themselves a new skill – that of intentionally contracting the pelvic floor muscles just before and during an activity, which causes a rise in intra-abdominal pressure. This exercise is called “the Knack.” 
       
    The effect of the Knack was assessed at 1 week in 27 older women with mild-to-moderate SUI in a prospective, randomized, single-blind interventional trial to determine its effect on cough-related urine loss.
       
    It was concluded that selected older women with mild-to-moderate SUI can learn to effectively use a properly timed pelvic floor muscle contraction to significantly diminish urine leakage during a cough. The Knack is a simple and effective method for reducing stress-related urine loss in selected older women with mild SUI who are capable of performing pelvic floor muscle contractions.
       
    The Knack technique is simple and easy to learn. In fact the 2 techniques (i.e. Kegel and the Knack) work differently. While Kegel exercise is aimed toward strengthening the pelvic floor muscle and providing better support for the bladder, the current technique is aimed toward “self protection” by contracting the muscle before stress, rather than by permanently strengthening it.
       

  • An Open Study of the Bladder Neck Support Prosthesis in Genuine Stress Incontinence. 
    KH Moore et al (Univ of New South Wales, Sydney, Australia; Royal North Shore Hosp, Sydney, Australia) Br J Obstet Gynaecol 106:42-49, 1999.
         
    It was found that the bladder support prosthesis (incontinence ring) maybe a good non-surgical option for some women with stress urinary incontinence However women with a scarred vagina after a previous operation or prolapse of more than one wall may find the device difficult to fit or keep in place.
       
     

  • F Zivkovic, et al (Univ of Graz, Austria)
    Body Mass Index and Outcome of Incontinence Surgery. 
    Obstet Gynecol 93: 753-756, 1999
        
    The authors feel that the continence rate for anterior colporrhaphy at 5 years was 58%. The rate for anterior colporrhaphy with needle suspension of bladder neck was 51% at 5 years. The rate for Burch colposuspension at 5 years was 86%. There were no significant differences in the preoperative and postoperative body mass indexes of continent and incontinent women for each procedure.
        
    Conclusion : For failure of incontinence surgery, preoperative obesity was not a risk factor, but the power of this study was limited.
       
    Editor A Bergmann comments that Zivkovic et al indicate that, at least for the Burch operation, this is not the case. These women need a “fixed anchor” when their stress incontinence is corrected, and the Burch procedure offers that type of correction, i.e. attaching the endopelvic fascia to a fixed bony structure.
       

  • Surgical Correction of Stress Incontinence in Morbidly Obese Women. 
    JM Cummings, et al (Univ of south Alabam, Mobile; St. Louis Univ) J. Urol 160:754-755, 1998.
       
    Authors conclude that Morbidly obese women with stress urinary incontinence can be successfully treated with surgery. Sling operations appear to be the procedure of choice for this population.
           

      

 

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