Fecal incontinence and associated pelvic floor dysfunction during and one year after the first pregnancy.

INTRODUCTION: Obstetric anal sphincter injury is an important risk factor for postpartum fecal incontinence but few studies have reported fecal incontinence occurring, even during pregnancy. The first objective of this study was to examine the prevalence of fecal incontinence, obstructed defecation and vaginal bulging early and late in pregnancy and postpartum. The second objective was to assess the association between symptoms in pregnancy, delivery characteristics, and bowel and vaginal bulging symptoms at 1 year postpartum. MATERIAL AND METHODS: This prospective cohort study was conducted between October 2014 and October 2017, including 898 nulliparous women enrolled with the maternity healthcare service in Örebro County, Sweden. The women responded to questionnaires regarding pelvic floor dysfunction in early and late pregnancy and at 8 weeks and 1 year postpartum. The data were analyzed using random effect logistic models estimating odds ratios (ORs) and generalized linear models estimating relative risks, with 95% confidence intervals (CIs). RESULTS: At 1 year postpartum, the prevalence of fecal incontinence, obstructed defecation and vaginal bulging was 6% (40/694), 28% (197/699) and 8% (56/695), respectively. Among women with vaginal delivery, the risk of fecal incontinence and vaginal bulging increased significantly both in late pregnancy, with ORs of 3.4 (95% CI 1.5-7.7) and 3.6 (95% CI 1.6-8.1), respectively, and at 1 year postpartum, with ORs of 5.0 (95% CI 2.1-11.5) and 8.3 (95% CI 3.8-18.1), respectively, compared with early pregnancy. Among all women, factors associated with increased prevalence of fecal incontinence 1 year postpartum were fecal incontinence during pregnancy (adjusted relative risk [aRR] 7.4; 95% CI 4.1-13.3), obstructed defecation during pregnancy (aRR 2.0; 95% CI 1.1-3.9) and concurrent obstructed defecation (aRR 2.4; 95% CI 1.3-4.5). CONCLUSIONS: This prospective study shows an increased risk of fecal incontinence by late pregnancy, suggesting that the pregnancy itself may be involved in the development of postpartum fecal incontinence. Obstructed defecation during pregnancy and postpartum was found to be associated with increased risk of fecal incontinence postpartum, indicating that postpartum fecal incontinence may be a result of incomplete bowel emptying.

Sexual function in primiparous women: a prospective study.

INTRODUCTION AND HYPOTHESIS: The aim of this prospective study was to examine the impact of sociodemographic, pregnancy and obstetric characteristics on sexual function 12 months postpartum in primiparous women. We hypothesized that sexual function would decrease after childbirth. METHODS: Between 1 October 2014 and 1 October 2017, all nulliparous women in early pregnancy registering for maternity health care in Region Örebro County, Sweden, were invited to participate in this prospective study. A total of 958 women were included. Sexual activity and function were measured at early pregnancy, 8 weeks postpartum and 12 months postpartum using the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). The associations between sociodemographic, pregnancy and obstetric characteristics and sexual activity and function from early pregnancy to 12 months postpartum were examined using linear and logistic models based on generalized estimating equations. RESULTS: We found that the prevalence of sexually active women decreased from 98.0% in early pregnancy to 66.7% at 8 weeks postpartum, but increased to 90.0% at 12 months postpartum. Age ≥ 35 years, second-degree perineal tear and current breastfeeding were statistically significant risk factors for sexual inactivity at 12 months postpartum. Poor self-reported health in early pregnancy was statistically significantly associated with decreased sexual function at 12 months postpartum. CONCLUSIONS: A majority of women resumed sexual activity at 8 weeks postpartum and most women at 12 months postpartum; the decrease in sexual function at 12 months postpartum was small and few risk factors were observed.

Stress and urgency urinary incontinence one year after a first birth-prevalence and risk factors. A prospective cohort study.

INTRODUCTION: Few prospective studies have examined the effect of pregnancy and childbirth on stress and urgency urinary incontinence separately. The aim of the present study was to assess the extent to which pregnancy, vaginal delivery, and vaginal delivery characteristics affect the risk of significant stress and urgency incontinence 1 year after delivery. MATERIAL AND METHODS: We conducted a prospective cohort study of 670 nulliparous women from early pregnancy to 1 year partum. The women were recruited at maternity health care service in Region Örebro County, Sweden, between October 1, 2014 and October 1, 2017 and completed questionnaires in early and late pregnancy and at 8 weeks and 1 year postpartum. Primary outcome measures were significant stress and urgency incontinence at 1 year postpartum in women who reported being continent before pregnancy. Generalized linear models were used. RESULTS: Stress and urgency incontinence commencing before pregnancy were reported by 4% and 3% of women, respectively, in the first questionnaire in early pregnancy, and these women were excluded from subsequent analysis. Stress and urgency incontinence were reported by 21% and 8%, respectively, at 1 year postpartum, in women not reporting incontinence before pregnancy. Stress incontinence during pregnancy increased the risk of stress incontinence postpartum (risk ratio [RR] 2.48, 95% CI 1.86-3.3). Urgency incontinence during pregnancy increased the risk of urgency incontinence postpartum (RR 4.07, 95% CI 2.1-7.89). Vaginal delivery increased the risk of stress incontinence postpartum (adjusted RR 2.63, 95% CI 1.39-5.01) but not of urgency incontinence. This effect of vaginal delivery on stress incontinence was similar irrespective of incontinence status during pregnancy. The population-attributable fraction of stress incontinence associated with vaginal delivery was 0.58 (95% CI 0.23-0.77). CONCLUSIONS: This study shows essentially different risk factors for stress and urgency incontinence, supporting stress incontinence as being the subtype mostly associated with pregnancy and childbirth, and urgency incontinence as being more stable over time. At a population level, vaginal delivery was the major risk factor for stress incontinence, followed by reporting stress incontinence during pregnancy.

A Mobile App for Self-management of Urgency and Mixed Urinary Incontinence in Women: Randomized Controlled Trial.

BACKGROUND: Many women experience urgency (UUI) and mixed (MUI) urinary incontinence but commonly hesitate to seek care. Treatment access and self-management for these conditions can be supported through eHealth approaches. OBJECTIVE: This study aimed to investigate the efficacy of the mobile app Tät II for self-management of UUI and MUI in women. METHODS: This randomized controlled trial included women ≥18 years old with UUI or MUI and ≥2 leakages per week. Those with red-flag symptoms were excluded. Participants were recruited via analog and digital advertisements and screened for initial selection through a web-based questionnaire. Data were collected using another questionnaire and a 2-day bladder diary. A telephone interview confirmed the symptom diagnosis. Participants were randomized (1:1) to receive access to a treatment app (including pelvic floor muscle training, bladder training, psychoeducation, lifestyle advice, tailored advice, exercise log, reinforcement messages, and reminders) or an information app (control group), with no external treatment guidance provided. The primary outcome was incontinence symptoms at the 15-week follow-up, measured using the International Consultation on Incontinence Questionnaire (ICIQ)-Urinary Incontinence Short Form (ICIQ-UI SF). Urgency symptoms were assessed using the ICIQ-Overactive Bladder Module (ICIQ-OAB) and quality of life using the ICIQ-Lower Urinary Tract Symptoms Quality of Life Module (ICIQ-LUTSqol). Incontinence episode frequency (IEF) was calculated per bladder diary entries. Improvement was measured using the Patient's Global Impression of Improvement. All outcomes were self-reported. Cure was defined as no leakages per the bladder diary. Intention-to-treat analysis was performed. RESULTS: Between April 2017 and March 2018, 123 women (mean age 58.3, SD 9.6 years) were randomized to the treatment (n=60, 2 lost to follow-up) or information (n=63) group. Of these, 35 (28%) women had UUI, and 88 (72%) had MUI. Mean ICIQ-UI SF score at follow-up was lower in the treatment group than in the information group (estimated difference -3.1, 95% CI -4.8 to -1.3). The estimated between-group difference was -1.8 (95% CI -2.8 to -0.99) for mean ICIQ-OAB score and -6.3 (95% CI -10.5 to -2.1) for the mean ICIQ-LUTSqol score at follow-up. IEF reduction from baseline to follow-up was greater in the treatment group (-10.5, IQR -17.5 to -3.5) than in the information group (P<.001). Improvement was reported by 87% (52/60) of treatment group participants and by 30% (19/63) of information group participants. The cure rate was 32% in the treatment group, and 6% in the information group (odds ratio 5.4, 95% CI 1.9-15.6; P=.002). About 67% (40/60) of the treatment group participants used the app more than thrice a week. CONCLUSIONS: The treatment app was effective for improving urgency and mixed incontinence in women. When self-management is appropriate, this app may be a good alternative to pharmacological treatment or other conservative management, thus increasing access to care. TRIAL REGISTRATION: ClinicalTrials.gov NCT03097549; https://clinicaltrials.gov/ct2/show/NCT03097549.

Risk factors for perineal and vaginal tears in primiparous women - the prospective POPRACT-cohort study.

BACKGROUND: The aim of this study was to estimate the incidence of second-degree perineal tears, obstetric anal sphincter injuries (OASI), and high vaginal tears in primiparous women, and to examine how sociodemographic and pregnancy characteristics, hereditary factors, obstetric management and the delivery process are associated with the incidence of these tears. METHODS: All nulliparous women registering at the maternity health care in Region Örebro County, Sweden, in early pregnancy between 1 October 2014 and 1 October 2017 were invited to participate in a prospective cohort study. Data on maternal and obstetric characteristics were extracted from questionnaires completed in early and late pregnancy, from a study-specific delivery protocol, and from the obstetric record system. These data were analyzed using unadjusted and adjusted multinomial and logistic regression models. RESULTS: A total of 644 women were included in the study sample. Fetal weight exceeding 4000 g and vacuum extraction were found to be independent risk factors for both second-degree perineal tears (aOR 2.22 (95% CI: 1.17, 4.22) and 2.41 (95% CI: 1.24, 4.68) respectively) and OASI (aOR 6.02 (95% CI: 2.32, 15.6) and 3.91 (95% CI: 1.32, 11.6) respectively). Post-term delivery significantly increased the risk for second-degree perineal tear (aOR 2.44 (95% CI: 1.03, 5.77), whereas, maternal birth positions with reduced sacrum flexibility significantly decreased the risk of second-degree perineal tear (aOR 0.53 (95% CI 0.32, 0.90)). Heredity of pelvic floor dysfunction and/or connective tissue deficiency, induced labor, vacuum extraction and fetal head circumference exceeding 35 cm were independent risk factors for high vaginal tears (aOR 2.32 (95% CI 1.09, 4.97), 3.16 (95% CI 1.31, 7.62), 2.53 (95% CI: 1.07, 5.98) and 3.07 (95% CI 1.5, 6.3) respectively). CONCLUSION: The present study corroborates previous findings of vacuum extraction and fetal weight exceeding 4000 g as risk factors of OASI. We found that vacuum extraction is a risk factor for second-degree tear, and vacuum extraction, fetal head circumference exceeding 35 cm and heredity of pelvic floor dysfunction and/or connective tissue deficiency were associated with increased risk of high vaginal tears. These findings have not been documented previously and should be confirmed by additional studies.

Development and validation of a protocol for documentation of obstetric perineal lacerations.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to develop a new protocol for documentation of perineal lacerations and to validate the latter against the most common obstetric record system in Sweden. The hypothesis was that the new protocol would render more complete data on perineal lacerations than the current documentation method. METHODS: A protocol for documentation of perineal lacerations was developed to be sufficiently comprehensive to serve research purposes. All women delivering their first child vaginally from 13 October 2015 to 1 February 2016 at Örebro University Hospital were eligible for the validation study. Perineal lacerations were documented using the protocol in parallel with the regular obstetric record system (ObstetriX). Cross tabulations were used to compare the coverage regarding perineal lacerations between the two documentation methods. McNemar's test was used to evaluate systematic differences between the methods. RESULTS: A total of 187 women were included. The coverage of documentation regarding perineal laceration was significantly higher (p < 0.001) in the new protocol (89%) compared with ObstetriX (18%). Incidence of second-degree perineal tears was 26% according to the new protocol and 11% according to ObstetriX. The incidence of third-degree perineal tears A, B, and C was 2.7%, 2.1%, and 2.1%, respectively, according to the new protocol, and 3.2%, 2.7%, and 1.1% according to ObstetriX. CONCLUSIONS: This validation study of a new documentation protocol showed that it delivered significantly more comprehensive information regarding perineal lacerations than the most common obstetric record system in Sweden.

Enhanced Recovery after Surgery Protocol in Abdominal Hysterectomies for Malignant versus Benign Disease.

BACKGROUND: The enhanced recovery after surgery (ERAS) protocol combines unimodal evidence-based interventions aiming to enhance recovery after surgery and reduce length of stay (LOS). We introduced an ERAS protocol in gynecological surgery and compared outcomes after hysterectomies performed for malignant vs. benign indications. METHODS: This prospective cohort study was conducted at the Department of Obstetrics and Gynecology, Örebro University Hospital, Sweden, among 121 consecutive patients undergoing abdominal hysterectomy and salpingo-oophorectomy for malignant (n = 40) or benign (n = 81) indications between 2012 and 2014. Clinical data were prospectively collected and extracted from the patient records and from a specific database. The primary outcomes were LOS and proportion of patients achieving target LOS (2 days). RESULTS: Patients operated for malignant vs. benign disease did not differ significantly in terms of LOS (2 (1-5) vs. 2 (1-11) days; p = 0.505), proportion discharged at target LOS (62 vs. 69%; p = 0.465; OR 0.74, 95% CI 0.3-1.6), complications (2 vs. 7% in primary stay, 8 vs. 11% within 30 days after discharge), reoperations (0 vs. 2%), or readmissions (2 vs. 1%). CONCLUSION: The ERAS protocol may be equally applicable to patients undergoing hysterectomy either for a malignant or for a benign disease.

The effect of conservative treatment of urinary incontinence among older and frail older people: a systematic review.

BACKGROUND: urinary incontinence (UI) is a common symptom among older people, with a higher prevalence among frail older persons living in nursing homes. Despite consequences such as reduced health and quality of life, many older people do not seek help for their symptoms, resulting in missed opportunity for treatment. OBJECTIVE: the aim of this study was to investigate the evidence and the effect of conservative treatment of UI and the quality of life among older and frail older persons. METHODS: a systematic review of randomised controlled studies and prospective, non-randomised studies was conducted, evaluating interventions of conservative treatment of UI in an older population (65 years or older). A total of 23 studies fulfilled the inclusion criteria and 9 were of high or moderate quality. Fourteen studies were of low quality and were therefore excluded from the analysis. RESULTS: documented and effective conservative treatments are available even for older persons with UI. Pelvic muscle exercise, physical training in combination with ADL, prompted voiding and attention training, and help to toilet are important treatments. In some studies, however, the evidence of effectiveness is limited. CONCLUSIONS: this systematic review concludes that there are conservative treatments for UI for older and frail older persons that reduce leakage and increase quality of life. There is however a need for further high-quality studies.

Surgery for urinary incontinence in women 65 years and older: a systematic review.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) is common among the elderly, but the literature is sparse on the surgical treatment of UI among the elderly. This systematic review aims to assess the effectiveness of surgical interventions as treatment for urinary incontinence in the elderly population ≥65 years of age. METHODS: Randomized controlled trials (RCT) and prospective nonrandomized studies (NRS) were included. The databases PubMed (NLM), EMBASE (Elsevier), Cochrane Library (Wiley), and Cinahl (EBSCO) were searched for the period 1966 up to October 2013. The population had to be ≥65 years of age and had to have undergone urethral sling procedures, periurethral injection of bulking agents, artificial urinary sphincter surgery, bladder injection treatment with onabotulinumtoxin A or sacral neuromodulation treatment. Eligible outcomes were episodes of incontinence/urine leakage, adverse events, and quality of life. The studies included had to be at a moderate or low risk of bias. Mean difference (MD) or standard mean difference (SMD)as well as risk difference (RD) and the 95% CI were calculated. RESULTS: Five studies--all on the suburethral sling procedure in women-- that fulfilled the inclusion criteria were identified. The proportion of patients reporting persistent SUI after surgery ranged from 5.2 to 17.6%. One study evaluating quality of life (QoL) showed a significant improvement after surgery. The complication rates varied between 1 and 26%, mainly bladder perforation, bladder emptying disturbances, and de novo urge. CONCLUSION: The suburethral sling procedure improves continence as well as QoL among elderly women with SUI; however, evidence is limited.

Implementing a structured Enhanced Recovery After Surgery (ERAS) protocol reduces length of stay after abdominal hysterectomy.

OBJECTIVE: To study the effects of introducing an Enhanced Recovery After Surgery (ERAS) protocol, modified for gynecological surgery, on length of stay and complications following abdominal hysterectomy. DESIGN: Observational study. SETTING: Department of Obstetrics and Gynecology, Örebro University Hospital, Sweden. POPULATION: Eighty-five patients undergoing abdominal hysterectomy for benign or malignant indications between January and December 2012, with or without salpingo-oophorectomy. Outcomes were compared with all consecutive patients who had undergone the same surgery from January to December 2011, immediately before establishing the ERAS protocol (n = 120). METHODS: The ERAS protocol was initiated in January 2012 as part of a targeted implementation program. Data were extracted from patient records and from a specific database. MAIN OUTCOME MEASURES: Length of stay and the proportion of patients achieving target length of stay (2 days). RESULTS: Length of stay was significantly reduced in the study population after introducing the ERAS protocol from a mean of 2.6 (SD 1.1) days to a mean of 2.3 (SD 1.2) days (p = 0.011). The proportion of patients discharged at 2 days was significantly increased from 56% pre-ERAS to 73% after ERAS (p = 0.012). No differences were found in complications (5% vs. 3.5% in primary stay, 12% vs. 15% within 30 days after discharge), reoperations (2% vs. 1%) or readmission (4% vs. 4%). CONCLUSIONS: Introducing the ERAS protocol for abdominal hysterectomy reduced length of stay without increasing complications or readmissions.

Validation of the Swedish version of the incontinence impact questionnaire and the urogenital distress inventory.

Objective. To validate the Swedish versions of the Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory (UDI-6). Design and setting. Prospective study, university hospital. Population and method. We analyzed reliability, validity, and responsiveness in a clinical sample of 96 women with urinary incontinence. Main outcome measures. Construct and criterion validity, reliability via test-retest and internal consistency. Responsiveness via calculation of effect size. Result. Test-retest reliability ranged from moderate to almost perfect. Cronbach's alpha was 0.39 (UDI-6) and 0.83 (IIQ-7). Effect size calculation of change after treatment demonstrated good responsiveness. The effect size at six months was moderate in the Stress Urinary Incontinence group and small in the Urge Urinary Incontinence + Mixed Urinary Incontinence group. There was a moderate to strong correlation between UDI-6 and IIQ-7 and treatment satisfaction at six, 12, and 24 months for both groups. Conclusion. The UDI-6 scale did not produce the same solid result in the psychometric analysis as the IIQ-7 scale, but these newly translated Swedish forms of UDI-6 and IIQ-7 show good responsiveness and are easy to administer and to fill out.

Electrical stimulation compared with tolterodine for treatment of urge/urge incontinence amongst women--a randomized controlled trial.

INTRODUCTION AND HYPOTHESIS: Few randomized controlled trials have compared electrical stimulation treatment with drug therapy. Our hypothesis was that electrical stimulation treatment in women with urgency/urge incontinence would be more efficient compared to drug treatment. METHODS: Women ≥18 years of age with urgency/urge incontinence were randomized to receive either ten electrical stimulation treatments vaginally and transanally over a period of 5-7 weeks or tolterodine 4 mg orally once daily. RESULTS: Sixty-one women completed the study. There was no significant difference between the two treatment groups in micturition rate from baseline to 6 months, mean difference, -0.40 (95% confidence interval (CI), -1.61 to 0.82), but a clearly significant difference within each group for electrical stimulation, -2.8 (95% CI, -3.7 to -1.9), and for tolterodine, -3.2 (95% CI, -4.1 to -2.4). CONCLUSIONS: Both treatments reduced the number of micturitions, but electrical stimulation was not found to be superior to tolterodine.

Effect of pharmacological treatment for urinary incontinence in the elderly and frail elderly: A systematic review.

AIM: The prevalence and severity of urinary incontinence (UI) increase with age and comorbidity. The benefits of pharmacotherapy for UI in the elderly are questionable. The aim of the present study was to systematically review the efficacy of pharmacological treatment for UI in the elderly and frail elderly. METHODS: We searched PubMed, EMBASE, Cochrane library and Cinahl databases through October 2013 to identify prospective controlled trials that evaluated pharmacological treatment for UI in persons aged ≥65 years. Elderly persons living in nursing homes were regarded as frail elderly. Outcomes were urinary leakage, quality of life and adverse events. RESULTS: We screened 1038 abstracts and assessed 309 full-text articles. We identified 13 trials of high or moderate quality; 11 evaluated anticholinergic drugs and two evaluated duloxetine. Oxybutynin, the only drug studied in the frail elderly population, had no effect on urinary leakage or quality of life in elderly with urgency UI (UUI). Seven trials evaluated the effects of darifenacin, fesoterodine, solifenacin, tolterodine or trospium. Urinary leakage decreased (standard mean difference: -0.24, 95% confidence interval -0.32-0.15), corresponding to a reduction of half a leakage per 24 h. Common side-effects of treatment were dry mouth and constipation. Data were insufficient for evaluation of the effect on quality of life or cognition. The evidence was insufficient to evaluate the effects of duloxetine. No eligible studies on mirabegron and estrogen were found. CONCLUSIONS: Anticholinergics have a small, but significant, effect on urinary leakage in older adults with UUI. Treatment with drugs for UUI in the frail elderly is not evidence based.

Urinary incontinence in women is not exclusively a medical problem: a population-based study on urinary incontinence and general living conditions.

OBJECTIVE: The aim of the study was to analyse differences in general health and general living conditions between women with and without urinary incontinence (UI). MATERIAL AND METHODS: This cross-sectional population-based study was conducted in Orebro County, Sweden. A public health questionnaire, "Life and Health", was sent to a randomly selected sample of the population. The questionnaire consisted of 87 questions on broad aspects of general and psychiatric health. An additional questionnaire was enclosed for those respondents who reported experiencing UI. The data were analysed using binary logistic regression. The final study population constituted 4609 women, 1332 of whom had completed both questionnaires. The remaining 3277 had completed only the Life and Health questionnaire. Effect measures were odds ratios (ORs) with corresponding 95% confidence intervals (CIs). RESULTS: Statistically significant associations were found between UI and the occurrence of musculoskeletal pain (OR 1.45, 95% CI 1.20-1.76), fatigue and sleeping disorders (OR 1.59, 95% CI 1.30-1.95), feelings of humiliation (OR 1.29, 95% CI 1.12-1.50), financial problems (OR 1.36, 95% CI 1.11-1.66), and reluctance to seek medical care (OR 1.43, 95% CI 1.21-1.68). CONCLUSION: UI among women is commonly associated with a number of different psychosocial problems as well as an expressed feeling of vulnerability.

Urinary incontinence: Evaluation of an information campaign directed towards the general public.

OBJECTIVE: To study and evaluate the effect of an information campaign in the form of a brochure on urinary incontinence (UI) directed towards the general public, concerning knowledge, individual health behaviour, self-reported healthcare utilization and how the information was perceived. MATERIAL AND METHODS: Within a community in central Sweden a random sample of the population, in age groups from 18 years upwards, was selected from the population registry, resulting in a total sample of 3,658 people. The study group was sent the brochure "Treatment of urinary incontinence", produced by SBU (Swedish Council on Technology Assessment in Health Care) in March 2003 and a questionnaire 1-2 months after the brochure was received. RESULTS: The overall response rate was 47.5%. Eighty per cent of the responders stated UI as an important health problem in society and 66% that they had gained new knowledge on UI. Twenty-eight per cent of the responders reported a current or previous history of UI, of whom 49% felt that they had received useful information for self-treatment and 21% had begun self-treatment. CONCLUSION: This population-based study found that the distribution of a brochure on UI to the general public was well received and can be an efficient method to spread knowledge and encourage self-management.