Antenatal perineal massage - risk of perineal injuries, pain, urinary incontinence and dyspereunia - a systematic review.

BACKGROUND: Natural childbirth is associated with the risk of damage to the perineum - a tears or a episiotomy. Adequate preparation of the woman for childbirth is essential to minimize the occurrence of perinatal injuries. AIM: The aim of the review is to assess and analyze the impact of APM (antental perineal massage) on perinatal perineal injuries and the development of pelvic pain and other complications in postpartum women, such as dyspareunia, urinary (UI), gas (GI), and fecal incontinence (FI). METHODS: PubMed, Web of Science, Scopus and Embase were searched. Three authors independently searched databases and selected articles for inclusion and exclusion criteria. Next one author did Risk of Bias 2 and ROBINS 1 analyze. FINDINGS: Of 711 articles, 18 publications were left for the review. All 18 studies examined the risk of perineal injuries (tearing and episiotomy), 7 pain in postpartum period, 6 postpartum urinary, gas/fecal incontinence and 2 described dyspareunia. Most authors described APM from 34 weeks of pregnancy until delivery. There were different techniques and times for doing APM procedures. DISCUSSION: APM has many benefits for women during labor and the postpartum period (e.g. lower rate of perineal injuries and pain). However, it can be observed that individual publications differ from each other in the time of massage, the period and frequency of its performance, the form of obtaining instruction and control of patients. These components may affect the results obtained. CONCLUSION: APM can protects the perineum from injuries during labor. It also reduces risk of fecal and gas incontinence in postpartum period.

Progressive pre-disconnection of urethral mucosal flap during transurethral plasmakinetic enucleation of prostate improves postoperative urinary continence. / å°¿é“é»è†œç“£æ¸è¿›å¼é¢„ç¦»æ–­å¯æ”¹å–„ç»å°¿é“å‰åˆ—è ºç­‰ç¦»å­å‰œé™¤æœ¯æ‚£è€ å°¿æŽ§åŠŸèƒ½.

OBJECTIVES: To investigate the effect of progressive pre-disconnection of urethral mucosal flap during transurethral plasmakinetic enucleation of prostate (TUPEP) on early recovery of urinary continence. METHODS: Clinical data of patients with benign prostatic hyperplasia (BPH) admitted in Zhujiang Hospital of Southern Medical University during February and May 2022 were collected. All the patients underwent TUPEP, and the progressive pre-disconnection of urethral mucosal flap was performed in the procedure. The total operation time, enucleation time, postoperative bladder irrigation time and catheter indwelling time were recorded. Urinary continence was evaluated 24 h, 1 week, and 1, 3, 6 months after the removal of urinary catheter. RESULTS: All surgeries were successfully completed at one time with less intraoperative bleeding, and there were no complications such as rectal injury, bladder injury or perforation of prostate capsule. The total operation time was (62.2±6.5) min, the enucleation time was (42.8±5.2) min, the postoperative hemoglobin decrease by (9.5±4.5) g/L, the postoperative bladder irrigation time was (7.9±1.4) h, and the postoperative catheter indwelling time was 10.0 (9.2, 11.4) h. Only 2 patients (3.6%) had transient urinary incontinence within 24 h after catheter removal. No urinary incontinence occurred at 1 week, and 1, 3, 6 months after operation, and no safety pad was needed. The Qmax at 1 month after operation was 22.3 (20.6, 24.4) mL/s, international prostate symptom scores were 8.0 (7.0, 9.0), 5.0 (4.0, 6.0) and 4.0 (3.0, 4.0) at 1, 3 and 6 months after surgery, and quality of life scores at 1, 3 and 6 months after surgery were 3.0 (2.0, 3.0), 2.0 (1.0, 2.0) and 1.0 (1.0, 2.0), all of these indicators were better than those before surgery (all P<0.01). CONCLUSIONS: In the treatment of BPH, the application of progressive pre-disconnection of urethral mucosal flap in TUPEP can completely remove the hyperplastic glands and promote early recovery of postoperative urinary continence with less perioperative bleeding and decreased surgical complications.

Can you breathe yourself to a better pelvic floor? A systematic review.

INTRODUCTION: Some authors suggest that breathing exercises should be recommended instead of or in combination with pelvic floor muscle training (PFMT) to prevent and treat urinary incontinence (UI) and pelvic organ prolapse (POP). AIMS: The primary aim of the present study was to investigate the evidence for breathing as an intervention alone or in addition to PFM contraction in treatment of UI and POP. MATERIALS & METHODS: This systematic review included short-term experimental studies and randomize controlled trials (RCTs) indexed on PubMed, EMBASE, and PEDro database. A form was used to extract data that was analyzed qualitatively due to the heterogeneity in interventions and outcome measures of the included studies. The individual methodological quality of RCTs was analyzed using the PEDro scale. RESULTS: A total of 18 studies were included, 374 participants from short-term experimental studies and 765 from nine RCTs. PEDro score varied from 4 to 8. Activation of the PFM during expiration was significantly less than during a PFM contraction. In general, the RCTs showed that training the PFM is significantly more effective to improve PFM variables and UI and POP than breathing exercises, and that adding breathing exercises to PFMT have no additional effect. CONCLUSION: This systematic review indicates that the evidence for incorporating breathing exercise in clinical practice in addition to or instead of PFMT is scant or non-existing, both based on short-term experimental studies and small RCTs.

Effect of Vitamin D Supplementation on Overactive Bladder and Urinary Incontinence Symptoms in Older Men: Ancillary Findings From a Randomized Trial.

PURPOSE: Our goal was to evaluate vitamin D supplementation for preventing or treating overactive bladder and urinary incontinence in men. MATERIALS AND METHODS: Ancillary study of men aged ≥55 years in VITAL (VITamin D and OmegA-3 TriaL). Randomized treatments included: vitamin D3 (cholecalciferol), marine omega-3 fatty acids, or matching placebo. Structured urinary incontinence questions measured the prevalence of overactive bladder at year 5 and urinary incontinence at years 2 and 5, along with incidence and progression of urinary incontinence from years 2 to 5. Prespecified subgroup analyses examined men with low baseline serum 25-hydroxyvitamin D (<20 ng/mL). RESULTS: Among the 11,486 men who provided data at year 2 and 10,474 at year 5, mean age was 68 years at year 2, with 23% racial/ethnic minorities. In primary analyses, vitamin D supplementation compared to placebo did not lower odds of overactive bladder at year 5 (OR 0.97, 95% CI 0.87-1.08) or weekly urinary incontinence at year 2 (OR 0.94, 95% CI 0.83-1.05) or year 5 (OR 0.98, 95% CI 0.88-1.09). We found interactions of baseline serum 25-hydroxyvitamin D level with vitamin D supplementation for overactive bladder (P value for interaction = .001), and secondarily, for any urinary incontinence at year 2 (P value for interaction = .05). Men with baseline 25-hydroxyvitamin D <20 ng/mL, who were assigned to vitamin D supplements, had lower odds of overactive bladder (OR 0.51, 95% CI 0.35-0.76) compared to placebo, yet higher odds of any urinary incontinence (OR 1.24, 95% CI 0.93-1.64). CONCLUSIONS: Overall, vitamin D supplementation did not improve overactive bladder or urinary incontinence compared to placebo. However, specific use of vitamin D in men with lower 25-hydroxyvitamin D levels had inconsistent findings.

Perineal Massage during Pregnancy for the Prevention of Postpartum Urinary Incontinence: Controlled Clinical Trial.

Background and objectives: Urinary incontinence is any involuntary loss of urine. It may result in anxiety, depression, low self-esteem and social isolation. Perineal massage has spread as a prophylactic technique for treating complications during labor. Acknowledged effects of perineal massage are reduction of incidence and severity of perineal tear and use of equipment directly related to the intrapartum perineal trauma. The aim of this study was to determine the effectiveness of massage in urinary incontinence prevention and identification of possible differences in its form of application (self-massage or by a physiotherapist), with the previous assumption that it is effective and that there are differences between the different forms of application. Materials and Methods: A controlled clinical trial with a sample of 81 pregnant women was conducted. The participants were divided into three groups: a group that received the massage applied by a specialized physiotherapist, another group that applied the massage to themselves, and a control group that only received ordinary obstetric care. Results: No differences were identified in the incidence or severity of urinary incontinence among the three groups. The severity of the incontinence was only affected by the body mass index and the weight of the baby at the time of delivery. Conclusions: A relationship between perineal massage interventions and development of urinary incontinence has not been observed.

Effect of vitamin D supplementation on urinary incontinence in older women: ancillary findings from a randomized trial.

BACKGROUND: Observational studies among older women have associated vitamin D insufficiency with a greater prevalence and incidence of urinary incontinence. However, little is known about the effect of vitamin D supplementation in reducing urinary incontinence. OBJECTIVE: This study aimed to evaluate the effects of vitamin D supplementation in reducing the frequency of urinary incontinence in older women. STUDY DESIGN: We conducted an ancillary study of women aged ≥55 years in the Vitamin D and Omega-3 Trial, a randomized trial with a 2×2 factorial design. Recruitment of participants started from 2011 to 2014 across 50 US states, and the follow-up of participants ended in January 2018. Randomized treatments in the parent study included (1) vitamin D3 (cholecalciferol) at a dosage of 2000 IU/d, (2) marine omega-3 fatty acids at a dosage of 1 g/d, and (3) matching placebo. Here, we analyzed women according to their randomization to vitamin D supplementation or placebo, regardless of treatment with omega-3 fatty acid supplementation. Validated frequency of urinary incontinence questions were added in year 2 of the study and were used again in year 5 at the end of trial. Prespecified ancillary outcomes included the prevalence of urinary incontinence at years 2 and 5, along with incident incontinence and progression of incontinence (from lower to higher frequency) from year 2 to year 5. Preplanned subgroup analyses examined the following outcomes: prerandomization of low serum levels of vitamin D (serum 25-hydroxyvitamin D<20 ng/mL), incontinence types, weight categories, and African American race. RESULTS: Among the randomized women who provided urinary incontinence data, 11,646 women at year 2 and 10,527 women at year 5, the mean age was 70 years at year 2, with 29% racial and ethnic minorities. The prevalence of urinary incontinence that occurred at least weekly was 29% at year 2 and increased to 37% at year 5. Vitamin D supplementation compared to with placebo was not associated with lower odds of urinary incontinence occurring at least weekly at year 2 (odds ratio, 1.08; 95% confidence interval, 0.99-1.19) or year 5 (odds ratio, 1.04; 95% confidence interval, 0.94-1.15). Vitamin D supplementation compared to placebo was not associated with lower incidence or progression of urinary incontinence from year 2 to year 5: incidence (odds ratio, 1.06; 95% confidence interval, 0.83-1.35) or progression (odds ratio, 0.94; 95% confidence interval, 0.82-1.08). Women with prerandomization of low serum levels of vitamin D (n=836) did not have lower odds of the prevalence, incidence, or progression of urinary incontinence. The findings were null in subgroups according to incontinence type, women with obesity, and African American women. Only women with healthy weight randomized to vitamin D had lower odds of progression of urinary incontinence (odds ratio, 0.78; 95% confidence interval, 0.63-0.95; P=.01). CONCLUSION: Vitamin D supplementation compared to placebo for 2 to 5 years was not associated with differences in the prevalence, incidence, or progression of urinary incontinence in older women with and without adequate serum vitamin D levels, with inconsistent differences among subgroups. The findings showed that the broad use of moderate doses of vitamin D supplementation did not reduce urinary incontinence in older women.

Denonvilliers' fascia acts as the fulcrum and hammock for continence after radical prostatectomy.

BACKGROUND: Radical prostatectomy (RP) is the primary treatment of localized prostate cancer. Immediate urinary incontinence post-RP was still common and depressing without specific reason. METHODS: A multicenter cohort of 154 consecutive patients from 2018 to 2020, who was diagnosed with localized prostate cancer underwent either modified mini-incision retropubic radical prostatectomy (Mmi-RRP) or laparoscopic radical prostatectomy (LRP) or robotic-assisted radical prostatectomy (RARP). Seventy-two patients with Denonvilliers' fascia (DF) spared were included in DFS (Denonvilliers' fascia sparing) group. Whereas eighty-two patients with DF completely or partially dissected were set as Group Control. The primary outcome was immediate continence (ImC). Continuous data and categorical data were analyzed with t-test and Chi-square test, respectively. Odds ratios (ORs) were calculated with logistic regression. RESULTS: Urinary continence of Group DFS was significantly better than that of Group Control at each time point within one year after operation. Incidence rate of continence in Group DFS and Group Control were 83.3% vs 13.4% (P < 0.01) for ImC, 90.3% vs 30.5% (P < 0.01) at 3 months, 91.7% vs 64.6% (P < 0.01) at 6 months, and 93.1% vs 80.5% (P = 0.02) at 1 year after operation, respectively. Positive surgical margin (PSM) showed no significant difference (20.8% vs 20.7%, P = 1.0). In multivariate analysis, DFS showed importance for ImC post RP (OR = 26.4, P < 0.01). CONCLUSIONS: Denonvilliers' fascia acted as the fulcrum and hammock for continence post RP. Preservation of DF contributed to better continence after RP without increase of PSM. Trail registration Our research was conducted retrospectively and approved by the ethical committees of Minhang Hospital, but not registered.

Training women's pelvic floor muscles during pregnancy and postpartum at primary health centers: a best practice implementation project.

INTRODUCTION AND AIMS: Pelvic floor muscle training (PFMT) enhances muscle strength and coordination, and prevents urinary incontinence associated with giving birth. The goal was to improve women's PFMT during pregnancy and postpartum in La Rioja, Spain. METHODS: This evidence implementation project used the JBI evidence implementation framework. First, we conducted the PFMT baseline audit: to assess the criteria for midwife training, we sent a questionnaire to all midwives. To measure the criteria for PFMT and urinary incontinence risk assessment, we reviewed the medical records of 60 women selected through consecutive sampling and 15 other women at risk of urinary tract infections (UTIs) for the inclusion criteria in a PFMT program. Second, we used the Getting Research into Practice guidelines to identify barriers to the fulfillment of each criterion and design and implement strategies to improve compliance. Finally, we repeated the audit to measure compliance and verify the changes. RESULTS: The midwives received updated PFMT, optimizing compliance with the first criterion from 67 to 100%. The remaining criteria -- providing PFMT for pregnant women, identifying women at high risk of incontinence, and facilitating a supervised PFMT program for women at high risk of UTIs -- went from 0% compliance to 17, 96, and 67%, respectively. CONCLUSION: This project was effective in building consensus, improving midwives' practice, and facilitating mothers' PFMT. The project continued during the novel coronavirus [coronavirus disease 2019 (COVID-19)] epidemic in Spain as the midwives, women, and managers were involved in the change because of a well designed registration system and the use of online tools for communication between midwives and women.

Evaluation of Femaxeen® for control of urinary incontinence in women: A randomized, double-blind, placebo-controlled study.

BACKGROUND AND AIMS: Urinary incontinence (UI) is common in women, with up to 50 % experiencing involuntary loss of urine at some point. Femaxeen®, a formulation containing purified and specific cytoplasmic extracts of pollen, pumpkin seed extract and vitamin E (referred to hereafter as Femaxeen), is indicated for control of UI in women. This study investigated the efficacy and safety of Femaxeen for the prevention and treatment of UI symptoms in women. METHODS: In this randomized, double-blind, placebo-controlled trial, 81 women with moderate, severe, or very severe urge (43.4 %), stress (31.6 %) or mixed (25.0 %) UI were allocated to receive Femaxeen or placebo once daily for 90 days. Treatment efficacy was assessed using three validated questionnaires. FINDINGS: Thirty-eight patients per group were analyzed. Femaxeen produced statistically significant improvements from baseline to Day 90 (p < 0.001 for all comparisons) in scores on the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), Measurement of Urinary Handicap (MHU) questionnaire, and Sandvik Incontinence Severity Index. Reduction from baseline in ICIQ-SF and MHU scores at Day 60 and Day 90 was significantly greater with Femaxeen than placebo (p < 0.05 for all comparisons). Femaxeen significantly reduced ICIQ-SF and MHU scores from baseline to Day 60 and Day 90 in all UI types (p < 0.05 for all comparisons except ICIQ-SF scores for stress UI). Femaxeen and placebo were well tolerated. Associated adverse events were few and mild in intensity. CONCLUSIONS: Femaxeen is effective for treating UI, and has a safety profile comparable to that of placebo.

Feasibility and continence outcomes of extended prostatic urethral preservation during robot-assisted radical prostatectomy.

BACKGROUND: The prostatic urethra is conventionally resected during robot-assisted radical prostatectomy (RARP). We describe the technical feasibility and urinary continence outcomes of extended prostatic urethral preservation (EPUP) during RARP. METHODS: A single surgeon at a National Comprehensive Cancer Network institute performed 48 consecutive RARP operations using EPUP from March 2014 to March 2016, during which time 177 conventional non-EPUP RARP operations were performed by other surgeons. Prior to this period, the EPUP surgeon had performed 17 non-EPUP RARP operations over 15 months. Total intracorporeal urethral length (IUL) preserved during EPUP was measured intraoperatively. Associations of EPUP and IUL with continence recovery rates and/or times were tested in Fisher's exact and log rank univariate analyses and Cox logistic regression multivariable analyses. RESULTS: Median IUL preserved during EPUP was 4.0 cm (range 2.5-6.0 cm), and urethral dissections typically spanned the prostatic apex to mid-gland or base. Seven-week continence rates were significantly higher with versus without EPUP. EPUP patient rates of using 0 or 0-1 pads per day immediately after catheter removal were 19% and 35%, respectively. These rates increased significantly (53% and 76%, respectively), as did the IUL preserved (median 5.0 cm), among more recent EPUP patients (n = 17), which suggested a learning curve. In multivariable analyses including all patients, an EPUP approach was an independent predictor of faster continence recovery. In multivariable analyses of the EPUP subset, a longer IUL preserved was independently associated with faster continence recovery. No EPUP patient had a urethral fossa positive margin, and apical positive margins were similarly infrequent among EPUP and non-EPUP patients. CONCLUSIONS: EPUP is technically feasible during RARP and associated with faster continence recovery. Future investigation into the generalizability of these findings and the oncologic safety of EPUP is warranted.

How can we prevent postprostatectomy urinary incontinence by patient selection, and by preoperative, peroperative, and postoperative measures? International Consultation on Incontinence-Research Society 2018.

AIMS: To review current prevention strategies for urinary incontinence among patients undergoing radical prostatectomy (RP). METHODS: This is a consensus report of the proceedings of a research proposal from the annual International Consultation on Incontinence-Research Society (ICI-RS), 14 to 16 June 2018 (Bristol, UK): "How can we prevent postprostatectomy incontinence by patient selection, and by preoperative, peroperative, and postoperative measures?" RESULTS: Several baseline parameters were proposed as predicting factors for postprostatectomy urinary incontinence (PPUI), including age, tumor stage, prostate volume, preoperative lower urinary tract symptoms, maximum urethral closure pressure, and previous transurethral resection of the prostate. More recently, magnetic resonance imaging has been used to measure the membranous urethral length and sphincter volume. Peroperative techniques include preservative and reconstructive approaches. Bladder neck preservation improved early (6 months), as well as long-term (>12 months) continence rates. Several prospective studies have reported earlier return of continence following preservation of puboprostatic ligaments, although no long-term data are available. Preservation of the urethral length yielded controversial outcomes. Concerning postoperative strategies, it is probably optimal to remove the catheter in a window between 4 and 7 days if clinically appropriate; however, more research in this regard is still required. Postoperative PFME (preoperative pelvic floor muscle exercise) appears to speed up the recovery of continence after RP. CONCLUSIONS: Conservative strategies to prevent PPUI include proper patient selection and PFME. Peroperative techniques have largely shown benefit in the short term. Postoperative complications and timing of trial without catheter can influence continence status. Future research initiatives must assess peroperative and postoperative measures, with longer-term follow-up.

Exercise Professionals Improve Their Poor Skills in Contracting Pelvic-Floor Muscles: A Randomized Controlled Trial.

A quick, well-timed pelvic-floor muscle contraction during physical effort is recommended for active women to prevent urine leakage. PURPOSE: We address two research questions: how well do future female exercise professionals contract the pelvic-floor muscles, and whether the biofeedback session is necessary to train them to contract pelvic-floor muscles? METHOD: Participants were 84 nulliparous future exercise professionals (age 23 ± 3 years, mean ± SD), randomly allocated into biofeedback (n = 27), usual-advice (n = 26), and control (no advice, n = 21) groups. Contraction of pelvic-floor muscles on a 4-point scale (1 = incorrect through 4 = correct) was assessed in all groups by surface electromyography (sEMG) with a vaginal probe before and after 6 weeks of intervention. RESULTS: In pretest, almost one in five participants (17%) could not activate the pelvic floor and less than half of them (45%) presented correct technique. The technique score for the three groups was 3.1 ± 1.1 (mean ± SD). After training, both intervention groups presented better technique score by 0.6 (90% confidence limits ± 0.5) relative to the control group, and two-thirds (65%) of the intervention groups presented the correct technique. CONCLUSIONS: Future exercise professionals displayed poor skills in contracting pelvic-floor muscles. Both training interventions (with and without biofeedback) were effective for this study group.

Repair of sphincter urethral strictures preserving urinary continence: surgical technique and outcomes.

INTRODUCTION: Repair of post-TURP sphincter urethral strictures represents challenging problem, due to the risk of urinary incontinence after the repair. We described a surgical technique we use to repair these strictures preserving urinary continence in patients with incompetent bladder neck. MATERIALS AND METHODS: An observational, retrospective, study was conducted to include patients with post-TURP urethral strictures in the area of distal sphincter. We included only patients with complete clinical data and follow-up who previously underwent TURP or HOLEP or TUIP, and subsequently developed proximal bulbar urethral strictures close to the membranous urethra and the related distal urethral sphincter. Patients were included, if they were fully continent after TURP or other procedures to treat BPH. The primary outcome of the study was treatment failure, defined as the need for any post-operative instrumentation. Secondary outcome was post-urethroplasty urinary continence. Patients showing stricture recurrence or post-operative incontinence were classified as failure. RESULTS: Overall, 69 patients were included in the study. Median patient's age was 67 years; median stricture length was 4 cm. Thirty-tree patients (47.8%) underwent previous urethrotomy. Median follow-up was 52 months. Out of 69 patients, 55 (79.7%) were classified as success and 14 (20.3%) as failure. Out of the whole cohort, thus, 11/69 (16%) have a risk of recurrent strictures and 3/69 (4.3%) have incontinence. CONCLUSIONS: The use of modified ventral onlay graft urethroplasty, using particular non-aggressive steps, is a suitable surgical technique for repair of sphincter urethral stricture in patients who underwent BPH transurethral surgery, using different procedures (TURP, HOLEP, TUIP).

Perineal outcome following educational intervention: a retrospective audit of primiparous women.

The management of vaginal delivery appears to offer an opportunity to reduce the morbidity of pelvic floor dysfunction (PFD) which is very common in the postpartum period. Research by the authors suggests that an episiotomy is protective against PFD, in particular urinary incontinence. The aim of this subsequent audit was to see if educational intervention can alter the common medical practice of episiotomy and in turn reduce postpartum PFD. Nine hundred and fifty four primiparous women with a non-instrumental vaginal delivery were included, of which 30% had an intact perineum, 51% a spontaneous tear and 19% an episiotomy. The intervention was a teaching session by the Head of Urogynaecology encompassing the anatomy, the impact of a vaginal delivery on PFD, in addition to local and international research. Whilst no significant difference was noted overall in the episiotomy rates as a result of the educational intervention (p = .17), significant differences were noted with the different accoucheur types. Where the accoucheur was an obstetrician or obstetrics registrar, the episiotomy rates increased from 56% to 70% (p < .01); where the midwife was the accoucheur the episiotomy rate changed minimally (11-18%, respectively; p = .27). This demonstrates that feedback about the provider's own practice patterns can change the behaviour to conform with the agreed upon standards. Impact Statement What is already known on this subject? Pelvic floor dysfunction (PFD) is the most common complication of childbirth, affecting approximately 85% of Australian women following a vaginal delivery. A link has been made between the perineal outcome and PFD, which has a significant impact on the quality of life. Previous research suggests that the management of a vaginal delivery offers an opportunity to reduce its morbidity, with an episiotomy being protective. However, there is a wide variation in the use of episiotomy which ranges from 9% to 100%. What the results of this study add? The literature suggests that the strongest factor associated with the episiotomy rates arises from differences in the attitude and training. Consequently, this study explored whether an educational intervention can change the common medical practice of episiotomy and in turn reduce postpartum PFD. What are the implications of these findings for clinical practice and/or further research? No significant difference was noted overall in the episiotomy rates as a result of the educational intervention, however, the response to the educational intervention was varied among the different types of accoucheurs with the obstetricians, obstetric registrars and student midwives significantly increasing their rate of episiotomy, whilst the midwives demonstrated no significant change. This suggests that there are contributing factors which may include past education and experience; this is an area for further research.

[Methods of preventing perineal injury and dysfunction during pregnancy: CNGOF Perineal prevention and protection in obstetrics]. / Quelles interventions au cours de la grossesse diminuent le risque de lésions périnéales ? RPC Prévention et protection périnéale en obstétrique CNGOF.

OBJECTIVE: Several interventions during pregnancy have been described that might prevent the risk of postnatal perineal injury or dysfunction; these include prenatal perineal massage, use of the Epi-No device, and pelvic floor muscle training exercises. Our objective was to evaluate the effectiveness of these different interventions during pregnancy. METHODS: A systematic review of the literature was conducted on PubMed, including articles in French and English published before May 2018, to evaluate the effectiveness of these different interventions on perineal protection in the post-partum period. RESULTS: Perineal massage during pregnancy diminishes the episiotomy rate (LE1) as well as post-partum perineal pain and flatus (LE2). It does not reduce the rate of either OASIS (LE1) or post-partum urinary incontinence (LE2). The Epi-No device does not provide benefits for perineal protection (LE1). Prenatal pelvic floor muscle training exercises do not reduce the risk of perineal lacerations (LE2); they reduce the prevalence of post-partum urinary incontinence at 3 to 6 months but not at 12 months post-partum (LE2). CONCLUSION: Perineal massage during pregnancy must be encouraged among women who want it (Grade B). The use of the Epi-No device during pregnancy is not recommended for the prevention of OASIS (grade B). Pelvic floor muscle training during pregnancy is not recommended for the prevention of OASIS (grade B); moreover, its absence of effect in the medium term does not allow us to recommend it for urinary incontinence (professional consensus).

[Strategies of preserving urinary continence in transurethral plasmakinetic enucleation of the prostate for benign prostate hyperplasia].

OBJECTIVE: To explore the strategies of preserving urinary continence in transurethral plasmakinetic enucleation of the prostate (PKEP) for benign prostate hyperplasia (BPH). METHODS: We treated 65 BPH patients by PKEP with preservation of urinary continence (UC-PKEP), which involved protection of the external urethral sphincter in the beginning of surgery, proper preservation of the anterior lobe of the prostate to protect the internal urethral sphincter in the middle, and preservation of the integrity of the bladder neck towards the end. We compared the postoperative status of urinary continence of the patients with that of the 54 BPH cases treated by complete plasmakinetic enucleation of the prostate (Com-PKEP). RESULTS: All the operations were performed successfully with the urinary catheters removed at 5 days after surgery. In comparison with Com-PKEP, UC-PKEP achieved evidently lower incidence rates of urinary incontinence at 24 hours (31.49% vs 13.85%, P <0.05), 1 week (18.52% vs 4.62%, P <0.05), 2 weeks (14.81% vs 3.08%, P <0.05), 1 month (3.70% vs 1.54%, P >0.05), and 3 months (3.70% vs 0%, P >0.05) after catheter removal. Compared with the baseline, the maximum urinary flow rate (Qmax) was significantly improved postoperatively in both the Com-PKEP (ï¼»7.43 ± 3.26ï¼½ vs ï¼»20.58 ± 3.22ï¼½ ml, P <0.05) and the UC-PKEP group (ï¼»8.04 ± 2.28ï¼½ vs ï¼»20.66 ± 3.08ï¼½ ml, P <0.05). CONCLUSIONS: Transurethral PKEP is a safe and effective method for the management of BPH, during which the strategies of avoiding blunt or sharp damage to the external urethral sphincter in the beginning, properly preserving the anterior lobe of the prostate in the middle and preserving the integrity of the bladder neck towards the end may help to achieve rapid recovery of urinary continence.

Decreasing Urinary Incontinence in Home Healthcare.

Urinary incontinence (UI) in older adult patients poses a risk for complications and hospitalization. The aim of this quality improvement project was to develop and implement a protocol to promote continence in older adults with UI. Data were collected from a convenience sample of 26 participants, 80 years of age or older, in a midsize suburban home care agency. All participants were diagnosed with UI as documented in the Outcomes and Assessment Information Set (OASIS). OASIS question M1610 was used to identify patients with UI status, and M1650 was used, to identify UI frequency. The outcomes for these questions were assessed to examine change over time in UI status and frequency. Eligible patients completed a 3-day bladder diary, then patient education was conducted on UI, risk factors, bladder training, pelvic floor exercises, and hydration/nutrition parameters. Patients then completed 3-day bladder diaries postintervention. At pretest, 100% of the participants were incontinent. At posttest, 24 participants (92.3%) were incontinent. The results suggest that the median frequency of UI declined overtime from 2 (range: 1-4) at pretest to 1 (range: 0-4) at posttest. This decline was statistically significant (z = -3.83; p < .001). Future studies should examine changes in the UI complications and hospitalization rates.

Early urological care of patients with spinal cord injury.

PURPOSE: After spinal cord injury (SCI), the initial goals of urological management include maintaining safe storage of urine with efficient bladder emptying, maximising urinary continence, and minimising the risk of urological complications. METHODS: This review was performed according to the methodology recommended by the Joint SIU-ICUD International Consultation. Embase and Medline databases were used to identify literature relevant to the early urological care of SCI patients. Recommendations were developed by consensus and graded using a modified Oxford system which identifies level of evidence (LOE) and grade of recommendation (GOR). RESULTS: Clinicians must ensure appropriate bladder emptying immediately after SCI (LOE 3, GOR A) and perform the initial neuro-urological assessment within 3 months after injury (LOE 3, GOR A), including history, validated questionnaires, bladder diary, physical examination, measurement of renal function, and urinary tract imaging (LOE 4, GOR B). Urodynamics, if available video-urodynamics, must be performed to detect and specify lower urinary tract dysfunction (LOE 1, GOR A). Spontaneous voiding and/or intermittent catheterization must be considered in appropriate patients once they are medically stable (LOE 3, GOR A). Antimuscarinics are the first-line and intradetrusor botulinum toxin A injections are the second-line treatment for neurogenic detrusor overactivity (LOE 1, GOR A). Irreversible surgical interventions should be delayed until the second year after injury due to the potential for neurological recovery (LOE 4, GOR B). CONCLUSIONS: Careful clinical assessment and pertinent urological testing including urodynamic investigation are necessary for appropriate counselling and treatment of new SCI patients.

Serous-lined, stapled pouch wall plication: initial results of a simple and quick novel continence mechanism in troubleshooting secondary to continent cutaneous urinary diversion.

OBJECTIVES: To report a novel and straightforward technique of a secondary continent outlet for continent cutaneous urinary diversion (CCUD) reservoirs without the need for further bowel resection, reducing operating time and length of hospitalization. PATIENTS AND METHODS: From 2015 to 2017, six patients with unreconstructable, incontinent outlets (out of a total pool of 595 patients with CCUD) have undergone the technique described in the present paper at our department. The technique relies on the Mitrofanoff principle, using a stapled full-thickness pouch wall plication, which creates a flap-valve continence mechanism. RESULTS: All patients enjoyed full continence with ease of clean intermittent catheterization (CIC) in the postoperative period and on follow-up to a mean (range) of 12.4 (7-18) months. No major complications were encountered in any patient and the average capacity of the reservoirs was not compromised by the procedure (540 mL preoperatively vs 500 mL in further follow-up). CONCLUSION: In revisional surgery for secondary CCUD incontinence, especially if the patient has already lost a significant amount of bowel or has previously undergone radiation therapy, the technique described here represents a safe and effective alternative to restore continence.