Noctural Enuresis as a Risk Factor for Falls in Older Community Dwelling Women with Urinary Incontinence.

PURPOSE: We determined the association of urinary symptoms with fall risk and physical limitations in older community dwelling women with urinary incontinence. MATERIALS AND METHODS: We performed an in-depth assessment of daytime and nighttime urinary symptoms, fall risk, physical function, physical performance tests and mental function in older community dwelling women with urinary incontinence who had not sought care for urinary symptoms. All assessments were performed in participant homes. We used univariable and multivariable linear regression to examine the relationship of urinary symptoms to fall risk, physical function and physical performance. RESULTS: Of 37 women with a mean ± SD age of 74 ± 8.4 years who had urinary incontinence 48% were at high risk for falls. Nocturnal enuresis was reported by 50% of the women. Increased fall risk was associated with increasing frequency of nocturnal enuresis (p = 0.04), worse lower limb function (p <0.001), worse upper limb function (p <0.0001) and worse performance on a composite physical performance test of strength, gait and balance (p = 0.02). Women with nocturnal enuresis had significantly lower physical performance test scores than women without nocturnal enuresis (median 7, range 0 to 11 vs 9, range 1 to 12, p = 0.04). In a multivariable regression model including age, nocturnal enuresis episodes and physical function only physical function was associated with an increased fall risk (p <0.0001). CONCLUSIONS: Nocturnal enuresis is common in older community dwelling women with urinary incontinence. It may serve as a marker of fall risk even in women who do not seek care for urinary symptoms. Interventions targeting upper and lower body physical function could potentially decrease the risk of falls in older women with urinary incontinence.

Management of arterial and venous hemorrhage during sacrospinous ligament fixation: cases and review of the literature.

INTRODUCTION AND HYPOTHESIS: Sacrospinous ligament fixation (SSLF) for pelvic organ prolapse repair can incur significant intraoperative hemorrhage. Management of vascular injury is challenging because of limited visualization of the surrounding pararectal space and is not well described in the literature. METHODS: We evaluate cases of intraoperative venous and arterial hemorrhage during SSLF. Based on a review of the literature, we present a systematic approach to the treatment of venous and arterial hemorrhage associated with SSLF. RESULTS: Vascular injury to the hypogastric and pudendal venous plexi may be controlled using directed compression and topical hemostatic agents. Vascular injury to the inferior gluteal artery, its coccygeal branch, or other arteries, may require embolization. CONCLUSION: Life-threatening bleeding is a rare complication of transvaginal SSLF. Knowledge of surrounding pelvic vascular anatomy, treatment options, and communication with ancillary staff is essential for the treatment of sacrospinous ligament hemorrhage.

Physical examination of the female internal and external genitalia with and without pelvic organ prolapse: A review.

Pelvic organ prolapse, a herniation of pelvic organs through the vagina, is a common condition in older women. Pelvic organ prolapse distorts vaginal anatomy making pelvic examination difficult. A clinician must accurately identify anatomic landmarks both in women presenting with symptoms of prolapse and in women noted to have coincidental prolapse during routine gynecologic examination. We present a systematic approach to the female pelvic examination including anatomic landmarks of the external genitalia, vagina, and uterus in women with normal support as well as changes that occur with pelvic organ prolapse. Knowledge and awareness of normal anatomic landmarks will improve a clinician's ability to identify defects in pelvic support and allow for better diagnosis and treatment of pelvic organ prolapse.

The Effect of a Diagnosis on Patients With Interstitial Cystitis/Bladder Pain Syndrome: A Qualitative Approach.

INTRODUCTION: Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic pain condition that significantly affects patient quality of life. We investigated whether receiving a formal medical diagnosis of IC/BPS was perceived by patients to improve symptoms and disease-specific quality of life. METHODS: Participants with self-reported IC/BPS completed publicly available online surveys. Surveys included demographic information, validated questionnaires, and a free-text response. Participants were asked to comment on the utility of obtaining a diagnosis. Investigators coded the responses and analyzed the results using grounded theory methodology. RESULTS: Six hundred seventy-three participants who responded to the free-text were analyzed. The mean age of respondents was 52 years, with an average of 10 years since IC/BPS diagnosis. The IC/BPS pain syndrome diagnosis had wide ranging effects on both symptoms and coping. These effects were often mediated by improvements in perceived control and empowerment after diagnosis. Although most participants noted benefit after diagnosis of IC/BPS, some reported harmful effects ranging from stigmatization by providers to desperation when told that there was not a cure. CONCLUSIONS: A formal medical diagnosis of IC/BPS has a significant effect on patients who experience the condition. Although diagnosis usually improves symptoms and coping, a universal experience was not described by all IC/BPS patients. Given that most patients report improvement, more work is needed to expedite diagnosis. In addition, we must better understand factors associated with lack of symptom and quality of life improvement after an IC/BPS diagnosis has been made by medical providers.

Comparison of Anorectal Manometry Testing in Left Lateral and Lithotomy Positions.

OBJECTIVES: Anorectal manometry (ARM) is typically performed in left lateral position, but many practitioners are more familiar with the lithotomy position. We aimed to evaluate agreement between ARM performed in left lateral and lithotomy positions and patient preference for testing position. METHODS: We performed a prospective comparison study of left lateral versus lithotomy position for women undergoing ARM for the evaluation of fecal incontinence. Women were randomly assigned to undergo testing in either left lateral position first followed by lithotomy position, or vice versa. Women then completed a survey assessing preference of position. We performed Bland-Altman analysis to measure the level of agreement between anorectal measurements obtained in the 2 positions. RESULTS: Twenty-one women were enrolled (mean age, 65 ± 2.2 years). We noted an acceptable level of agreement between anal pressure values obtained in left lateral versus lithotomy positions: anal resting pressure (mean difference, 0.9 mm Hg; 95% limits of agreement, 30.2 and -28.5) and anal squeeze pressure (mean difference, 1.8 mm Hg; 95% limits of agreement, 54.3 and -50.7). The level of agreement for sensory values was outside the predetermined clinical acceptability range. Most women (17/21 [81%]) reported a "good" or "very good" experience in both positions. CONCLUSIONS: Anorectal manometry testing in the 2 positions can be used interchangeably for anal resting and squeeze pressures, but not for anorectal sensation. This modification can be introduced into clinical practice to accommodate the preference of women and practitioners who favor lithotomy position.

Comparison of Patient Impact and Clinical Characteristics Between Urgency and Passive Fecal Incontinence Phenotypes.

OBJECTIVE: To determine if categorizing fecal incontinence (FI) as urgency or passive FI is clinically meaningful, we compared clinical severity, quality of life, physical examination findings, and functional and anatomic deficits between women with urgency and passive FI. METHODS: This study is a prospective cross-sectional study of women with at least monthly FI. All women completed the St Mark's Vaizey and the Fecal Incontinence Quality of Life questionnaires and underwent anorectal manometry and endoanal ultrasound. We compared women with urgency FI to women with passive FI. RESULTS: Forty-six women were enrolled, 21 (46%) with urgency FI and 25 (54%) with passive FI. Clinical severity by Vaizey score did not differ between groups (urgency 11.7 ± 1.6 vs passive 11.0 ± 1.0, P = 0.51). Women with urgency FI had worse median (range) lifestyle and coping scores than passive FI (Fecal Incontinence Quality of Life: lifestyle domain 2.5 [1, 4] vs 3.8 [1, 4], P = 0.04; coping domain 1.7 [1, 3] vs 2.4 [0.9, 4], P < 0.01). Women with urgency FI had higher anal resting and squeeze pressure than passive FI (60 ± 4 mm Hg vs 49 ± 3 mm Hg, P = 0.03; 78 [48, 150] mm Hg vs 60 [40, 103], P = 0.05). Internal anal sphincter defects were more common in women with passive FI (41.7% vs 30.0%, P = 0.53) and external anal sphincter defects more common in women with urgency FI (25% vs 16.7%, P = 0.71), but this did not reach statistical significance. CONCLUSIONS: We identified functional and anatomic differences between women with urgency FI and passive FI. Pheonotyping women with FI into these subtypes is clinically meaningful.

Barriers to Exercise Among Women With Urgency Urinary Incontinence: Patient and Provider Perspectives.

OBJECTIVE: The aim of this study was to describe important barriers to exercise in older women with urgency urinary incontinence (UUI) from the patient and provider perspectives. METHODS: Six focus groups (2 in active women, 2 in sedentary women, and 2 in providers) were conducted with 36 women with UUI and 18 providers. Focus group discussions were transcribed verbatim. All transcripts were coded and analyzed by 2 independent reviewers. Investigators identified emergent themes and concepts using a modified biopsychosocial conceptual model. RESULTS: A wide range of physical, psychological, social, and environmental factors were perceived to influence exercise. Although women with UUI identified pain as a strong barrier to exercise, providers did not. Both women with UUI and providers identified shame associated with incontinence as a significant barrier, and, conversely, satisfaction with UUI treatment was noted as an enabler for exercising. Women and providers had incongruent views on the need for supervision during exercise; women viewed supervision as a barrier to exercise, whereas providers viewed lack of supervision as a barrier to exercise. Opportunity for socialization was noted as a major enabler of exercise by all groups and suggests that exercise programs that promote interactions with peers may increase exercise participation. The importance of financial incentive and reimbursement was congruent between women and their providers. CONCLUSIONS: Women with UUI have unique perspectives on barriers to exercise. Understanding women's perspective can aid clinicians and researchers in improving exercise counseling and in creating exercise programs for women with UUI.