Evolution and risk factors of anal incontinence during the first 6 years after first delivery: a prospective cohort study.

OBJECTIVE: To explore changes in prevalence of anal incontinence (AI) from late first pregnancy to 6 years postpartum, and to evaluate possible risk factors for changes in AI during the 6-year period. DESIGN: Prospective longitudinal cohort study. SETTING: Two Norwegian health regions. POPULATION OR SAMPLE: Women with first deliveries between May 2009 and December 2010. METHODS: Participants reported AI in late pregnancy, 6 months, 1 and 6 years after first delivery using postal or digital questionnaires. AI prevalence was calculated, and mixed effects Poisson regression analyses with robust variance were applied. MAIN OUTCOME MEASURES: AI from late pregnancy to 6 years postpartum. RESULTS: Among 1571 participants, 65% had normal vaginal first deliveries, 20% had vaginal deliveries complicated by instrumental intervention and/or obstetric anal sphincter injury (IVD ± OASIS). Nearly 1 in 10 women reported persistent incontinence during the 6 years. The overall AI prevalence was reduced from late pregnancy to 1 year postpartum for all modes of delivery. At 6 years postpartum, women with IVD ± OASIS had a higher AI prevalence (23%; 95% CI 16-30%) compared with women with caesarean section (8%; 95% CI 2-13%) or normal vaginal delivery (12%; 95% CI 9-16%). Moreover, women who were <23 years, ≥34 years, unemployed during first pregnancy, who had active bowel disease (PR: 2.4; 95% CI 2.0-2.7), or bowel evacuation problems during the 6-year period had higher AI prevalence. CONCLUSIONS: Mode of first delivery modified AI prevalence during the 6-year period, whereas age, bowel disease and bowel evacuation problems were associated with higher prevalence of AI from late first pregnancy to 6 years postpartum. TWEETABLE ABSTRACT: Complicated vaginal delivery, age and bowel emptying problems increase the risk of long-term anal incontinence.

Do pelvic floor muscle exercises reduce postpartum anal incontinence? A randomised controlled trial.

OBJECTIVE: To evaluate the effect of pelvic floor muscle exercises (PFME) for postpartum anal incontinence (AI). DESIGN: A parallel two-armed randomised controlled trial stratified on obstetrical anal sphincter injury with primary sphincter repair and hospital affinity. SETTING: Ano-rectal specialist out-patient clinics at two hospitals in Norway. POPULATION: One hundred and nine postpartum women with AI at baseline. METHODS: The intervention group received 6 months of individual physiotherapy-led PFME and the control group written information on PFME. Changes in St. Mark's scores and predictors of post-intervention AI were assessed by independent samples t-tests and multiple linear regression analyses, respectively. The study was not blind. MAIN OUTCOME MEASURES: The primary outcome measure was change in AI symptoms on the St. Mark's score from baseline to post-intervention. Secondary outcome measures were manometry measures of anal sphincter length and strength, endoanal ultrasound (EAUS) defect score and voluntary pelvic floor muscle contraction. RESULTS: There was a significant difference in the reduction of St. Mark's scores from baseline to post-intervention in favour of the PFME group (-2.1 versus -0.8 points, P = 0.040). No differences in secondary outcome measures were found between groups. Baseline St. Mark's, PFME group affinity and EAUS defect score predicted post-intervention St. Mark's score in the imputed intention-to-treat analyses. The analysis on un-imputed data showed that women performing weekly PFME improved their AI scores more than women in the control group did. CONCLUSIONS: Our results indicate that individually adapted PFME reduces postpartum AI symptoms. TWEETABLE ABSTRACT: Performing regular pelvic floor muscle exercises may be an effective treatment for postpartum anal incontinence.

Anal incontinence and Quality of Life in late pregnancy: a cross-sectional study.

OBJECTIVE: To evaluate the association between different types of anal incontinence (AI) and Quality of Life (QoL) in late pregnancy. DESIGN: Cross-sectional study. SETTING: Two maternity units in Norway 2009-2010. POPULATION: Primiparae aged 18 or over. METHODS: Participants answered questions about AI during the last 4 weeks of pregnancy on the St. Mark's score and impact of QoL in the Fecal Incontinence QoL score. Socioeconomic data were obtained from hospital records. MAIN OUTCOME MEASURES: Self-reported AI and impact on QoL. RESULTS: 1571 primiparae responded; 573 (37%) had experienced AI during the last 4 weeks of pregnancy. One third of the incontinent women reported reduced QoL in the domain 'Coping'. 'Women experiencing urgency alone reported markedly better QoL compared to any other AI symptoms. AI appeared to have the strongest impact on the domains 'Coping' and 'Embarrassment'. Depression was only associated with experiencing the combination of all three symptoms [odds ratio (OR) 13; 95%confidence interval (CI) 3.2-51]. Experiencing flatus alone weekly or more was associated with the highest impact on 'Embarrassment' (OR 20; 95%CI 6.4-61) compared with all other symptoms or combination of AI symptoms, except the combination of all three AI symptoms. CONCLUSIONS: Between 3 and 10% of the primiparae in this material experienced AI to such a extent that it affected QoL. The greatest impact was seen in the QoL domain 'Coping'. These findings highlight the importance of an increased awareness of AI in late pregnancy among health professionals and the need to implement routine discussions about AI with expectant and new mothers.

Prevalence and predictors of anal incontinence during pregnancy and 1 year after delivery: a prospective cohort study.

OBJECTIVE: To evaluate the prevalence and predictors of anal incontinence (AI) in late pregnancy and 1 year after delivery. DESIGN: Prospective population-based cohort study. SETTING: Two maternity units in Norway 2009-2010. POPULATION: Primiparae aged 18 years or over. METHODS: Primiparae answered questions on the St. Mark's score about AI during the last 4 weeks of pregnancy. One year later, the same questionnaires were distributed by postal mail. Socio-economic and delivery-related data were obtained from hospital records. MAIN OUTCOME MEASURES: Self-reported AI. RESULTS: Answers on AI in late pregnancy were obtained from 1571 women, and 1030 responded 1 year later. Twenty-four per cent experienced one and 4.7% experienced three or more AI symptoms in late pregnancy. One year later, this was reduced to 19% and 2.2%, respectively. Multivariate logistic regression analyses were applied. Formed and loose stool incontinence were strongly associated at both time points. The main predictor of AI 1 year after delivery was AI in late pregnancy. Obstetric anal sphincter injury increased the risk of incontinence of stool and flatus (odds ratio [OR], 4.1; 95% confidence interval [CI], 1.7-9.6) after delivery. Urgency was associated with greater age (OR, 1.8; 95% CI, 1.0-3.3) and operative delivery (OR, 2.0; 95% CI, 1.3-2.9). CONCLUSION: One in four primiparae experienced AI in late pregnancy. One year later, still one in five suffered from incontinence. Sphincter injury predicted incontinence of stool and flatus, whereas greater age and operative delivery predicted urgency. The identification and adequate follow-up of pregnant women with AI may reduce AI after delivery.

Translation and validation of the Norwegian version of the fecal incontinence quality-of-life scale.

BACKGROUND AND AIM: Fecal incontinence quality-of-life scale (FIQLS) is a condition-specific health-related quality-of-life questionnaire composed of four scales: lifestyle, coping/behaviour, depression/self-perception and embarrassment. It has been widely translated and used as an evaluation tool for patients with fecal incontinence. Our aim was to translate the FIQLS, and to test some of the psychometric properties of the Norwegian version of the questionnaire. MATERIAL AND METHODS: The FIQLS was translated to Norwegian, and administered to a sample of 76 patients (73 women) who completed the questionnaire at baseline and again after three weeks. In addition, the severity of incontinence was assessed by phone-interviews (St. Mark's score). RESULTS: Three of four domains had good internal consistency in terms of Cronbach's alpha (.83-.91), the fourth (embarrassment) somewhat lower (.64). Stability over time was acceptable for all domains with ICC ranging from .74 to .86. Correlation with severity of incontinence (St. Mark's score) was medium to large for all four domains (-.46 to -.63) supporting the construct validity of the Norwegian FIQLS. CONCLUSION: The Norwegian version of fecal incontinence quality-of-life scale has been successfully translated and tested.

[Establishment of routines for elective laparoscopic surgery]. / Etablering av rutiner for elektiv laparoskopisk kirurgi.

BACKGROUND: During the autumn of 1999, elective laparoscopic cholecystectomy was introduced as a new surgical procedure in the Central Hospital Østfold, Askim. A prospective evaluation of perioperative patient logistics and patient satisfaction was performed. MATERIAL AND METHODS: 214 patients were evaluated in the ambulatory; 116 of them were scheduled for operation. The operations were performed in general anaesthesia with continuous infusion of propofol and short acting opioides. Analgetics and anti-emetics were given pre- and perioperatively as prophylaxis against postoperative pain and nausea. RESULTS: There were three unexpected cancellations. Two patients had serious postoperative bleedings and two had symptoms indicating residual bile duct stones. Twenty-eight patients (24%) were discharged on the same day. 114 patients (98%) were satisfied with their stay in hospital. INTERPRETATION: The established patient logistics proved efficient and rational.

Intestinal permeability of x-ray constrast media iodixanol and iohexol during bacterial overgrowth of small intestines in rats.

To investigate the recovery of iodinated water-soluble contrast medium from small bowel with small morphological alterations, iohexol or iodixanol was instilled through an orogastric tube in rats 14 days after surgery that established a self-filling blind loop in the jejunum. This rat model induced small bowel bacterial overgrowth with only minor abnormalities observed on histology and scanning electron microscopy. Animals with end-to-end anastomosis of the jejunum or unoperated rats served as controls. Compared with unoperated animals, urinary recovery of iohexol and iodixanol was significantly higher in both groups that underwent surgery. Moreover, the contrast medium recovery was numerically higher in the self-filling blind loop group given iodixanol than in the end-to-end anastomosis group, although not statistically significant, P = 0.09. Our results indicate that iohexol and iodixanol may detect small barrier impairments in the intestines. Iodixanol, the largest of the two, may seem to differentiate better between normal and minimally impaired intestinal barrier.

The X-ray contrast medium iodixanol detects increased colonic permeability equally well as 51Cr-labeled ethylenediaminetetraacetic acid in experimental colitis of rats.

BACKGROUND: Non-ionic, water-soluble radiographic contrast media have been suggested as intestinal permeability probes. We studied the permeability of the isosmolar contrast medium iodixanol and 51Cr-labeled ethylenediaminetetraacetic acid (EDTA) from the non-perforated colon after induction of colonic inflammation. METHODS: Colonic inflammation and ulcerations were induced by luminal colonic instillation of trinitrobenzenesulfonic acid, dissolved in 40% ethanol. Controls received saline. Fourteen days later iodixanol, 320 mg I/ml, and 51Cr-EDTA were given as an enema. Urine was collected for the subsequent 6 h and subjected to high-performance liquid chromatography and gamma activity counting. RESULTS: Urinary recovery of iodixanol and 51Cr-EDTA increased gradually with severity of the colonic inflammation. The correlation between iodixanol and 51Cr-EDTA recovery was strong (corr.coeff = 0.97). CONCLUSIONS: Iodixanol shows as good properties as 51Cr-EDTA when used as intestinal permeability probe in the inflamed and ulcerated rat colon. Use of the radiopaque properties of iodixanol enable intestinal probe exposure registration by film or fluoroscopy.

Increased intestinal permeability for the isosmolar contrast medium iodixanol during small-bowel ischaemia in rats.

BACKGROUND: Intestinal ischaemia may be difficult to recognize in the early stages. Increased urinary recovery of water-soluble contrast medium during and intestinal follow-through has been suggested as a sign of bowel ischaemia. METHODS: Urinary excretion of the isosmolar water-soluble X-ray contrast medium iodixanol was measured after instillation via an orogastric tube in 56 rats with occlusion of the mesenteric blood vessels. RESULTS: Mesenteric venous occlusion caused only minor histologic alterations of the mucosa. High-performance liquid chromatography (HPLC) and X-ray fluorescence analysis measured urinary iodixanol concentrations 10 and 13 times higher than in the groups with mesenteric arterial occlusion than in controls (p < 0.001), and 3 and 4 times higher than in the group with venous occlusion (p < or = 0.05). Correlation between HPLC and X-ray fluorescence measurements of contrast medium in urine was strong (r = 0.98). CONCLUSION: Measuring urinary contrast medium levels during intestinal follow-through may aid in distinguishing bowel ischaemia following mesenteric arterial occlusion from mesenteric venous occlusion and from the normal bowel.

Referrals for double-contrast barium examination. Factors influencing the probability of finding polyps or cancer.

Predictors of the radiologic detection of colorectal polyps or cancer were studied in 1852 patients referred from primary health care for a double-contrast barium enema. Significant polyp predictors were age 40-79 years (odds ratio (OR), 2.4-5.0) and rectal bleeding (OR, 1.8). Previous colorectal neoplasm, familial history of cancer in general, and male sex were nearly significant predictors of polyps. Significant cancer predictors were age > or = 60 years (OR, 8.6-27.8), rectal bleeding (OR, 2.7), loss of weight (OR, 2.6), and male sex (OR, 2.2). Fatigue and abdominal pain were nearly significant negative predictors for cancer. No association was found between patient delay and the detection of polyps or cancer. Physician delay was significantly shorter in patients with cancer than in cancer-free patients. Age was the most important predictor for the detection of both polyps and cancer, more important than symptoms and history, including family history.

Double-contrast barium enema versus colonoscopy in the diagnosis of neoplastic disorders: aspects of decision-making in general practice.

A total of 190 patients, referred by general practitioners for a double-contrast barium enema, were subsequently examined with colonoscopy. With colonoscopy and histology as the reference standard, sensitivity, specificity, positive and negative predictive values, and accuracy for the radiological detection of cancer and polyps were calculated. No cancer was overlooked by the radiological examination, but there were four false positives. The overall sensitivity for polyps was 70%, increasing to 81% for polyps > or = 10 mm. The predictive value was 93-97% for the exclusion of polyps. The caecum was reached in 187 patients by double-contrast barium enema (98%) and in 164 patients (86%) by colonoscopy. Lesions in four of 12 patients who had radiological changes were undetected at the first colonoscopy, but a repeat examination showed polyps > or = 10 mm in size. Although colonoscopy is a more sensitive technique for the detection of small mucosal lesions, the general practitioners may, in the vast majority of patients, rely on a negative result for polyps and cancer obtained by the double-contrast barium enema. The latter is linked with a number of false-positive cases, while colonoscopy is associated with technical difficulties; both techniques may lead to repeated examinations, regardless of which was the first choice.

Experimental colonic inflammation and ulceration. Permeation of a water-soluble contrast medium as a measure of 'disease' activity.

The aim of this study was to investigate the permeation of an isosmolar water-soluble X-ray contrast medium (CM) from the unperforated colon after experimental induction of inflammation and ulceration. One hundred and sixty-five male rats were included. In 110 rats 0.25 ml of 40% ethanol + 15 mg or 30 mg trinitrobenzene (TNB) was instilled into the colon, 7-9 cm proximal to the anus, inducing different degrees of inflammation. Fifty-five rats served as controls and had 0.25 ml saline instilled with the same procedure. At 7, 14, 21, and 28 days 3 ml of the non-ionic CM iodixanol was applied as an enema, and subsequently all urine was collected for the next 4 h. High-performance liquid chromatography analyses of the urine showed a positive relation between the severity of inflammation/ulceration in the colonic wall as assessed by a macroscopic damage score and the amount of CM excreted in the urine. Water-soluble contrast media may have prospects of combining functional tests of intestinal membrane dysfunction with segmental exposure control.

Urinary excretion of iohexol after enteral administration in rats with radiation injury of the small intestine.

Gut membrane dysfunction after acute and subacute irradiation injury to 10-cm-long small-bowel segments was assessed in 85 rats receiving doses of 17 and 21 Gy. Four and 14 days after irradiation 2 ml iohexol was administered via orogastric tubes, and hourly radiographs were taken. After 8 h, blood and urine were sampled for testing, and the intestine biopsied for light and scanning electron microscopy. Dense opacification of the urinary bladder was seen on abdominal films, and increased serum and urinary levels of iodine were demonstrated by X-ray fluorescence analysis in irradiated animals. Urinary levels were up to 20 times higher than in controls 4 days after irradiation, subsiding after 14 days. The effects were prolonged in the 21-Gy group. Our results indicate that measurement of iodine levels in serum and urine may be helpful in assessment of bowel injury in the course of irradiation treatment to pelvic or abdominal organs.

Acute lethality after enteral administration of contrast media in anaesthetized rats with intestinal ischaemia.

The acute lethality was evaluated during enteric follow-through in anaesthetized rats with a ligature applied to the anterior mesenteric artery and vein. In 121 animals 3 ml of either sodium diatrizoate, iohexol or barium sulphate was administered via orogastric tube. Alternatively, they had the oro-gastric tube inserted but no test substance instilled (controls). A total of 103 rats was observed until spontaneous death while 18 were sacrificed after 8 hours of observation. The survival time in the sodium diatrizoate group was significantly shorter than for the other three groups (p less than 0.006). The 50% survival time was 5 h 42 min (range 2 h 48 min to 12 h 45 min) for sodium diatrizoate as compared with 8 h 4 min to 8 h 26 min for the other three groups; iohexol 8 h 4 min (range 2 h 4 min to 14 h 43 min), barium 8 h 13 min (range 4 h 55 min to 16 h 26 min) and no instilled substance 8 h 26 min (range 3 h 38 min to 16 h 10 min) with no significant differences between these 3 groups. The use of hyperosmolar contrast media in enteric follow-through significantly shortens the survival of rats with acute intestinal ischaemia. A more rapid spread of intestinal bacteria through the distended bowel wall and the ensuing septicaemia, accompanied by enhanced dehydration, are probably the mechanisms responsible for the earlier deaths.

Urinary excretion of iohexol after intestinal administration in rats with bowel ischaemia. The effects of mesenteric arterial and/or venous occlusion.

Serum and urinary levels of iohexol (Omnipaque) were evaluated in 28 rats after instillation of 1.5 ml of contrast medium directly into closed small bowel segments of equal length. Ten rats had a ligature applied to the anterior mesenteric artery and vein via laparotomy, 10 animals had a ligature of the vein only and 8 had no vascular occlusion (operated controls). In addition, 3 rats (non-operated controls, normals) were gavaged with a similar volume of the same contrast medium. Radiographs were obtained every hour. Biopsy samples and blood and urine tests were taken at the end of the 4-hour observation period. On radiographs, a marked increase of urinary bladder opacity was observed after 2 to 4 hours in the rats with both vessels tied. Correspondingly high iodine levels were measured in the urine and serum at 4 hours by x-ray fluorescence analysis. Urinary levels were 27 times and serum levels 8 times that of operated controls, respectively, and 81 and 25 times that of normals. Venous occlusion affected the bladder opacity to a lesser extent, giving urinary iodine levels 12 times and serum levels twice that of normal controls. Neither urinary nor serum iodine levels were significantly different from the operated controls. The operated controls had urinary concentrations of contrast medium 3 times that of the gavaged normal controls, but a barely visible urinary bladder on radiographs. Measuring iodine levels in serum or urine may be helpful in the evaluation of the degree of mucosal injury induced by intestinal ischaemia.

Water-soluble contrast media in obstructed in ischemic small intestine. A clinical and experimental study.

In this study the attention was focused on the possible application of the new low-osmolar water-soluble contrast media in already existing routines for radiologic diagnostic work-up and management of the abdominal emergencies of simple intestinal obstruction and ischemia: Iohexol was a good, or better, alternative to sodium diatrizoate regarding taste acceptance and patient reactions: Seventy-five per cent of patients characterized the taste of iohexol as good or neutral, while 52% gave sodium diatrizoate similar scores. The scores were also consistently in favor of iohexol as compared with sodium diatrizoate for the other chosen criteria; nausea, vomiting and diarrhea, but a larger number of patients may be needed for conclusive evaluation. Water-soluble media may have therapeutic effects on intestinal obstruction when preceded by conventional gastric suction using a short gastric tube: Twenty-three of 25 patients with subtotal small bowel obstruction due to peritoneal adhesions improved following the ingestion of either iohexol or sodium diatrizoate. Hyperosmolar contrast media might stimulate peristalsis and dilute the bowel contents, hence, easing the passage through a subtotally obstructed bowel. In rats, a direct relationship was found between contrast medium osmolality and the degree of intestinal distension, fluid influx to the bowel lumen and the speed of contrast medium progression. The water-soluble, low-osmolar contrast media seem promising as diagnostic aids in examination of the gastrointestinal tract: The low-osmolar contrast media gave better intestinal details on films than both barium sulphate and sodium diatrizoate in rats with intestinal obstruction or ischemia when high volumes of radiopaques were employed. Also in patients iohexol retained its radiographic density in the small bowel better than sodium diatrizoate. The diagnostic efficacy of the water-soluble radiographic media varied directly with their osmolality and the resulting fluid influx to bowel lumen. Hyperosmolality stimulated contrast medium progression and bowel distension, and reduced the radiographic density of the contrast media and the alignment to the bowel wall. Water-soluble contrast media may aid the diagnosis of bowel ischemia and the evaluation of the degree of ischemic injury: No bladder opacification, following absorption of water-soluble contrast media from the simply obstructed bowel, was observed in the majority of the animals and was only faintly present in 8%. Distinct radiographic opacification of the urinary bladder in rats with intestinal ischemia was demonstrated as early as 1-2 hours after the administration of contrast medium.(ABSTRACT TRUNCATED AT 400 WORDS)