The when and how of the gynaecological examination: a survey among Norwegian general practitioners.

Introduction: Little is known about the indications general practitioners (GPs) perceive as relevant for performing gynaecological examinations (GEs), how GPs master the GE and associated procedures, and how they handle the sensitive nature of GEs. Methods: In 2015, 70 medical students at the University of Bergen distributed a questionnaire to all 175 GPs in the practices they visited. The questions covered practical routines related to GEs, insertion of intrauterine device, frequency of GEs in different clinical settings and use of assisting personnel. Statistical analyses included chi-square tests and multiple logistic regressions adjusting for age, gender, specialization and localization. Results: Ninety male and 61 female GPs (87% of invited GPs) responded to the questionnaire. A minority (8%) usually had other staff present during GEs. Compared with female colleagues, male GPs performed bimanual palpation significantly less often in connection with routine Pap smear (AOR 0.3 (95% CI 0.1-0.6)). Twenty-eight percent of the GPs stated that they often/always omitted the GE if the patient was anxious about GE and 35% when the patient asked for referral to a gynaecologist. Omission was more frequent among male GPs. When the GP decided to refer to a gynaecologist based on the patient's symptoms, more male than female GPs omitted GE (AOR 2.5 (95% CI 1.1-5.4)). Conclusion: Male gender of the GP may be associated with barriers to medical evaluation of pelvic symptoms in women, potentially leading to substandard care. Possibly, however, male GPs' reluctance to perform the GE may also limit unnecessary bimanual palpation in asymptomatic women.

Use of hormonal contraceptives among immigrant women and their daughters in Norway: Data from the Norwegian Prescription Database.

INTRODUCTION: Immigrants and their offspring constitute 16.3% of the population in Norway. Knowledge about their contraceptive use is important in order to inform adequate family planning services. Prior research has shown less use of contraception among first-generation immigrants than among non-immigrant women. Our aim is to compare the use of hormonal contraceptives between immigrants and their adult daughters. MATERIAL AND METHODS: Information from the Norwegian Prescription Database on all hormonal contraceptives dispensed at all pharmacies in Norway in 2008 was merged with demographic, socioeconomic and immigration data from the National Population Register and information from the Regular General Practitioner Database and the Medical Birth Registry Norway. A total of 10 451 women aged 16-30 from five countries with relatively large numbers of immigrants and adult daughters living in Norway in 2008 were included in the study. Descriptive statistics and logistic regression analyses were conducted. The main outcome measure was use of any hormonal contraceptive. RESULTS: More daughters of immigrants from Vietnam compared with immigrant women from these countries (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.8-2.8) and Poland (OR 2.3, 95% CI: 1.6-3.3) used hormonal contraceptives. However, no adjusted differences between generations were detected for immigrants from Pakistan (OR 1.2, 95% CI 1.0-1.4), Morocco (OR 1.0, 95% CI 0.7-1.4) or Chile (OR 1.3, 95% CI 0.8-1.9). CONCLUSIONS: Further research should explore the reasons for heterogeneity in use of contraception among daughters of immigrants from different origins and explore whether daughters of immigrant mothers from some areas have unmet needs of contraception.

Delivery parameters, neonatal parameters and incidence of urinary incontinence six months postpartum: a cohort study.

INTRODUCTION: Contradictory results have been reported regarding most delivery parameters as risk factors for urinary incontinence. We investigated the association between the incidence of urinary incontinence six months postpartum and single obstetric risk factors as well as combinations of risk factors. MATERIAL AND METHODS: This study was based on the Norwegian Mother and Child Cohort Study, conducted by the Norwegian Institute of Public Health during 1998-2008. This substudy was based on 7561 primiparous women who were continent before and during pregnancy. Data were obtained from questionnaires answered at weeks 15 and 30 of pregnancy and six months postpartum. Data were linked to the Medical Birth Registry of Norway. Single and combined delivery- and neonatal parameters were analyzed by logistic regression analyses. RESULTS: Birthweight was associated with significantly higher risk of urinary incontinence six months postpartum [3541-4180 g: odds ratio (OR) 1.4, 95% confidence interval (CI) 1.2-1.6; >4180 g: OR 1.6, 95% CI 1.2-2.0]. Fetal presentation, obstetric anal sphincter injuries, episiotomy and epidural analgesia were not significantly associated with increased risk of urinary incontinence. The following combinations of risk factors among women delivering by spontaneous vaginal delivery increased the risk of urinary incontinence six months postpartum; birthweight ≥3540 g and ≥36 cm head circumference; birthweight ≥3540 g and forceps, birthweight ≥3540 g and episiotomy; and ≥36 cm head circumference and episiotomy. CONCLUSION: Some combinations of delivery parameters and neonatal parameters seem to act together and may increase the risk of incidence of urinary incontinence six months postpartum in a synergetic way.

Association between mode of delivery and pelvic floor dysfunction.

BACKGROUND: Normal vaginal delivery can cause significant strain on the pelvic floor. We present a review of the current knowledge on vaginal delivery as a risk factor for urinary incontinence and pelvic organ prolapse compared to caesarean section. MATERIAL AND METHOD: We conducted a literature search in PubMed with an emphasis on systematic review articles and meta-analyses. The search was completed in January 2014. We also included articles from our own literature archives. RESULTS: Compared to vaginal delivery, caesarean section appears to protect against urinary incontinence, but the effect decreases after patients reach their fifties. The risk of pelvic organ prolapse increases (dose-response effect) with the number of vaginal deliveries compared to caesarean sections. There are few reliable studies on the association between mode of delivery and anal incontinence, but meta-analyses may indicate that caesarean section does not offer protection after the postpartum period. Women with previous anal sphincter rupture during vaginal delivery are a sub-group with an elevated risk of anal incontinence. The degree of severity of pelvic floor dysfunction is frequently unreported in the literature. INTERPRETATION: The prevalence of urinary incontinence and pelvic organ prolapse is lower in women who have only delivered by caesarean section than in those who have delivered vaginally. For urinary incontinence this difference appears to level out with increasing age. There is no basis for identifying sub-groups with a high risk of pelvic floor injury, with the exception of women who have previously had an anal sphincter rupture. Caesarean section will have a limited primary preventive effect on pelvic floor dysfunction at a population level.

Prevalence, incidence and remission of urinary incontinence in women: longitudinal data from the Norwegian HUNT study (EPINCONT).

BACKGROUND: To determine incidence and remission of UI as well as changes in UI prevalence in the Norwegian EPINCONT surveys. METHODS: The EPINCONT surveys were conducted in the county of Nord-Trøndelag, Norway, as part of two large cross-sectional health surveys (HUNT2 and HUNT3) in 1995 - 1997 (EPINCONT1 (E1)), and 2006 - 2008 (EPINCONT2 (E2)). EPINCONT collected information about prevalence of UI, as well as information about type and severity of UI. RESULTS: A 16% relative increase in UI prevalence was found in 11 years. The women who answered E2 were significantly older, had a higher BMI and higher prevalence of diseases such as asthma, diabetes and angina compared with the women who answered E1. CONCLUSION: Crude UI prevalence increased between the studies. Changes in known risk factors for UI such as age, BMI, weight and parity could explain some of the relative increase in prevalence, and were also found to be associated with either incidence of UI, remission of UI or both.

Diabetes related risk factors did not explain the increased risk for urinary incontinence among women with diabetes. The Norwegian HUNT/EPINCONT study.

BACKGROUND: Previous studies have shown an association between diabetes mellitus (DM) and urinary incontinence (UI) in women, especially severe UI. The purpose of this study was to investigate whether diabetes related variables could explain this association. METHODS: The study is part of the EPINCONT study, which is based on the large Nord-Trøndelag Health Study 2 (HUNT 2), performed in the county of Nord-Trøndelag, Norway, during the years 1995 - 1997. Questions on diabetes and UI were answered by a total of 21 057 women aged 20 years and older. Of these 685 were identified as having diabetes, and thus comprise the population of our study. A variety of clinical and biochemical variables were recorded from the participants. RESULTS: Blood-glucose, HbA1c, albumine:creatinine ratio (ACR), duration of diabetes, diabetes treatment, type of diabetes, cholesterol and triglycerides did not significantly differ in women with and without UI in crude analyses. However, the diabetic women with UI had more hospitalizations during the last 12 months, more homecare, and a higher prevalence of angina and use of oestrogene treatment (both local and oral/patch). After adjusting for age, BMI, parity and smoking, there were statistically significant associations between any UI and angina (OR 1.89; 95% CI: 1.22 - 2.93), homecare (OR 1.72; 95% CI: 1.02 - 2.89), and hospitalization during the last 12 months (OR 1.67; 95% CI: 1.18 - 2.38). In adjusted analyses severe UI was also significantly associated with the same variables, and also with diabetes drug treatment (OR 2.10; 95% CI: 1.07 - 4.10) and stroke (OR 2.47; 95% CI: 1.09 - 5.59). CONCLUSION: No single diabetes related risk factor seems to explain the increased risk for UI among women with diabetes. However, we found associations between UI and some clinical correlates of diabetes.

Diabetes and urinary incontinence − prevalence data from Norway.

BACKGROUND: Few large epidemiological studies have investigated whether diabetes might increase the risk for, or cause greater severity of, urinary incontinence. The aim of the present study was to investigate the association between diabetes and urinary incontinence, including the possible influence of diabetes on the severity of incontinence. METHODS: The study was a cross-sectional, population-based, study from the county of Nord-Trøndelag, Norway, from 1995 to 1997. Data were collected by means of questionnaires, simple clinical measurements, and some blood tests. A total of 21,057 women, 20 years or older, answered the questions on both diabetes and incontinence, and 685 women were identified with diabetes. RESULTS: The prevalence of incontinence among women with diabetes was 39% compared to 26% in women without diabetes. The women with diabetes had more urge and mixed incontinence. The associations between diabetes and urge incontinence (OR: 1.49; 95% CI: 1.03-2.16), mixed incontinence (OR: 1.32; 95% CI: 1.05-1.67), and severe incontinence (OR: 1.54; 95% CI: 1.21-1.96) were still significant after adjusting for age, body mass index, parity and smoking. CONCLUSION: We found a strong association between diabetes and urinary incontinence, especially for urge incontinence and severe degree of incontinence.

Familial risk of urinary incontinence in women: population based cross sectional study.

OBJECTIVE: To determine whether there is an increased risk of urinary incontinence in daughters and sisters of incontinent women. DESIGN: Population based cross sectional study. SETTING: EPINCONT (the epidemiology of incontinence in the county of Nord-Trøndelag study), a substudy of HUNT 2 (the Norwegian Nord-Trøndelag health survey 2), 1995-7. PARTICIPANTS: 6021 mothers, 7629 daughters, 332 granddaughters, and 2104 older sisters of 2426 sisters. MAIN OUTCOME MEASURES: Adjusted relative risks for urinary incontinence. RESULTS: The daughters of mothers with urinary incontinence had an increased risk for urinary incontinence (1.3, 95% confidence interval 1.2 to 1.4; absolute risk 23.3%), stress incontinence (1.5, 1.3 to 1.8; 14.6%), mixed incontinence (1.6, 1.2 to 2.0; 8.3%), and urge incontinence (1.8, 0.8 to 3.9; 2.6%). If mothers had severe symptoms then their daughters were likely to have such symptoms (1.9, 1.3 to 3.0; 4.0%). The younger sisters of female siblings with urinary incontinence, stress incontinence, or mixed incontinence had increased relative risks of, respectively, 1.6 (1.3 to 1.9; absolute risk 29.6%), 1.8 (1.3 to 2.3; 18.3%), and 1.7 (1.1 to 2.8; 10.8%). CONCLUSION: Women are more likely to develop urinary incontinence if their mother or older sisters are incontinent.

Vaginal delivery parameters and urinary incontinence: the Norwegian EPINCONT study.

OBJECTIVE: The study was undertaken to investigate the effect of nine delivery parameters on urinary incontinence in later life. STUDY DESIGN: Incontinence data from the EPINCONT study were linked to the Medical Birth Registry of Norway. Effects of birth weight, gestational age, head circumference, breech delivery, injuries in the delivery channel, functional delivery disorders, forceps delivery, vacuum delivery, and epidural anesthesia were investigated. The study covered women younger than 65 years, who had had vaginal deliveries only (n=11,397). RESULTS: Statistically significant associations were observed between any incontinence and birth weight 4000 g or greater (odds ratio [OR] 1.1, 95% CI 1.0-1.2); moderate or severe incontinence and functional delivery disorders (OR 1.3, 95% CI 1.1-1.6); stress incontinence and high birth weight (OR 1.2, 95% CI 1.1-1.3) and epidural anesthesia (OR 1.2, 95% CI 1.0-1.5); and urge incontinence and head circumference 38 cm or larger (OR 1.8, 95% CI 1.0-3.3). CONCLUSION: The effects were too weak to explain a substantial part of the association between vaginal delivery and urinary incontinence, and statistically significant results may have incurred by chance.

Urinary incontinence after vaginal delivery or cesarean section.

BACKGROUND: It is uncertain whether women who deliver by cesarean section have an increased risk of urinary incontinence as compared with nulliparous women and whether women who deliver vaginally have an even higher risk. METHODS: We studied 15,307 women enrolled in the Epidemiology of Incontinence in the County of Nord-Trøndelag (EPINCONT) study, which involved a community-based cohort. The data base for this study was linked to data from the Medical Birth Registry of Norway. We included women who answered questions related to urinary incontinence, were younger than 65 years of age, and had had no deliveries, cesarean sections only, or vaginal deliveries only. RESULTS: The prevalence of any incontinence was 10.1 percent in the nulliparous group; age-standardized prevalences were 15.9 percent in the cesarean-section group and 21.0 percent in the vaginal-delivery group. Corresponding figures for moderate or severe incontinence were 3.7 percent, 6.2 percent, and 8.7 percent, respectively; figures for stress incontinence were 4.7 percent, 6.9 percent, and 12.2 percent, respectively; figures for urge incontinence were 1.6 percent, 2.2 percent, and 1.8 percent, respectively; and figures for mixed-type incontinence were 3.1 percent, 5.3 percent, and 6.1 percent, respectively. As compared with nulliparous women, women who had cesarean sections had an adjusted odds ratio for any incontinence of 1.5 (95 percent confidence interval, 1.2 to 1.9) and an adjusted odds ratio for moderate or severe incontinence of 1.4 (95 percent confidence interval, 1.0 to 2.1). Only stress and mixed-type incontinence were significantly associated with cesarean sections. The adjusted odds ratio for any incontinence associated with vaginal deliveries as compared with cesarean sections was 1.7 (95 percent confidence interval, 1.3 to 2.1), and the adjusted odds ratio for moderate or severe incontinence was 2.2 (95 percent confidence interval, 1.5 to 3.1). Only stress incontinence (adjusted odds ratio, 2.4; 95 percent confidence interval, 1.7 to 3.2) was associated with the mode of delivery. CONCLUSIONS: The risk of urinary incontinence is higher among women who have had cesarean sections than among nulliparous women and is even higher among women who have had vaginal deliveries. However, these findings should not be used to justify an increase in the use of cesarean sections.

Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT Study.

OBJECTIVE: To examine whether modifiable lifestyle factors such as smoking, obesity, physical activity and intake of alcohol or caffeinated drinks were associated with urinary incontinence in women. DESIGN: Cross sectional population-based study. SETTING: The Norwegian Epidemiology of Incontinence in the County of Nord-Trøndelag (EPINCONT) Study is part of a large survey performed in a county in Norway during 1995-1997. POPULATION: Women >/=20 years (n = 34,755, 75% of the invited) attended the first part of the survey and received the questionnaire. There were 27,936 (80% of source population) women who completed the incontinence part of the questionnaire. METHODS: Questionnaire covering several health topics including urinary incontinence was received at a screening station. Logistic regression analysis was used to adjust for confounding and to establish associations with the different outcomes under investigation: any incontinence, severe incontinence and stress, urge and mixed subtypes. MAIN OUTCOME MEASURES: Effect measure were odds ratios with corresponding 95% confidence intervals. RESULTS: Former and current smoking was associated with incontinence, but only for those who smoked more than 20 cigarettes per day. Severe incontinence was weakly associated with smoking regardless of number of cigarettes. The association between increasing body mass index and incontinence was strong and present for all subtypes. Increasing levels of low intensity physical activity had a weak and negative association with incontinence. Tea drinkers were at slightly higher risk for all types of incontinence. We found no important effects of high intensity physical activity, intake of alcohol or coffee. CONCLUSIONS: Several potentially modifiable lifestyle factors are associated with urinary incontinence. Highest odds ratios were found for body mass index, heavy smoking and tea drinking.

Help-seeking and associated factors in female urinary incontinence. The Norwegian EPINCONT Study. Epidemiology of Incontinence in the County of Nord-Trøndelag.

OBJECTIVES: To assess the proportion of women who visit their doctor because of urinary incontinence and investigate factors associated with help-seeking. DESIGN: Postal invitation, questionnaire covering many health topics including urinary incontinence, received at a screening station. SETTING: The Norwegian EPINCONT Study is part of a large cross-sectional population-based survey performed in the county of Nord-Trøndelag during the period 1995-97. SUBJECTS: 6625 women (out of 27,936 participating women), 20 years or older, categorised as incontinent according to their answers to the questionnaire. RESULTS: 26% of the incontinent women had seen a doctor for their incontinence. Increasing age, impact, severity and duration were all significantly associated with consultation rate, as were urge and mixed types compared with stress incontinence, and having visited any doctor during the previous 12 months. Fifty percent of the women with significant incontinence (moderate/severe incontinence perceived as troublesome) had seen a doctor because of their incontinence. CONCLUSIONS: Only a fourth of the women with any incontinence, and half of the women with significant incontinence had consulted a doctor. Older age and high impact of the symptoms were the factors most strongly associated with help-seeking.