Posterior compartment prolapse and perineal descent: systematic review of available support devices.

OBJECTIVE: The aim of our study is to systematically review the literature about available devices facilitating perineal support during defecation in patients with obstructive defecation syndrome (ODS) and posterior pelvic organ prolapse (POP). METHODS: We searched for the terms "defecat/ion or ODS" and" pessar/ies or device/aid/tool/perineal/perianal/prolapse and support" in MEDLINE, PubMed and Web of Science. Data abstraction was performed according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-analysis) guidelines. A two-stage inclusion was performed, selecting first on title and abstract and secondly the full text. For variables with sufficient data, a meta-analysis was performed using a random-effects model. Other variables were descriptively reported. RESULTS: Ten studies out of 1332 were included for systematic review. The devices could be categorized into three groups: pessaries (n = 8), vaginal stent (n = 1) and external support device (n = 1). Methodology and data reporting is heterogeneous. Meta-analysis could be performed for the Colorectal-Anal Distress Inventory (CRADI-8) and Impact Questionnaire (CRAI-Q-7) in three pessary studies which showed a significant mean change. Significant improvement of stool evacuation was seen in two other pessary studies. The vaginal stent significantly decreases ODS. Subjective perception of constipation improved significantly using the posterior perineal support device. CONCLUSION: All reviewed devices seem to improve ODS in patients with POP. There are no data on their efficacy with regard to perineal descent-associated ODS. There is a lack of comparative studies between devices. Studies are difficult to compare due to different inclusion criteria and evaluation tools.

Detailed Investigation of Bladder Diary Parameters During Sacral Neuromodulation in Patients With Overactive Symptoms.

AIMS: Sacral neuromodulation (SNM) is a well-accepted, minimally invasive modality for patients with overactive bladder (OAB). Successful response to SNM is defined as at least 50% improvement in key symptoms, evaluated in a bladder diary (BD). BDs provide much useful information on bladder behavior during daily life. The aim of this study is to investigate BD parameter changes during SNM therapy in patients with OAB. MATERIALS AND METHODS: The International Consultation on Incontinence Questionnaires (ICIQ)-BD was filled out by 34 patients with OAB, for three days at baseline and after three weeks of subthreshold sensory stimulation. The patients were considered responders for SNM when 50% improvement was seen in the BD. They underwent implantation of an internal pulse generator (IPG), and subsequently, an ICIQ-BD and a visual analog scale (VAS) evaluating bladder satisfaction during three days were filled out six weeks, six months, and one year after IPG implantation. RESULTS: IPGs were implanted in 29 patients (85%). The BD showed a significant decrease in 24-hour leakage at three weeks from 4.2 to 0.6 (-86%, p < 0.001), similar significant decreases at six weeks and six months, and at one year (-80%). Voided volume (VV) at corresponding bladder sensation codes was not different between baseline and at three weeks of tined-lead procedure (TLP) (p > 0.05), and at six weeks (p > 0.05), six months (p > 0.1), and one year of IPG (p > 0.08). After three weeks of TLP, urgency episodes decreased from 4.8 to 3.4 (-30%, p = 0.025), with 59% reduction at six-weeks IPG (p < 0.001) and 49% at six-months IPG (p = 0.013). At one year, a decrease from 4.7 to 2.3 (52% reduction, p = 0.017) was noted. VAS showed the strongest correlation with urgency (p < 0.001) and frequency (p = 0.006). No significant correlation was found with VV (p = 0.87). CONCLUSIONS: Our study describes how bladder sensation parameters change over time in patients on SNM. VV does not significantly increase, nor does frequency significantly decrease over the first year. Leaks and the percentage of urgency episodes significantly decrease, reaching a plateau level between six-weeks and six-months SNM.

Rectocele: victim of availability bias? Results of a Belgian survey of colorectal and gynecological surgeons.

INTRODUCTION AND HYPOTHESIS: Women with a symptomatic rectocele may undergo different trajectories depending on the specialty consulted. This survey aims to evaluate potential differences between colorectal surgeons and gynecologists concerning the management of a rectocele. METHODS: A web-based survey was sent to abdominal surgeons (CS group) and gynecologists (G group) asking about their perceived definition, diagnostic workup, multidisciplinary discussion (MDT) and surgical treatment of rectoceles. The answers of both groups were analyzed with the chi-square test or Fisher's exact test at p < 0.050. RESULTS: A rectocele was defined as a prolapse of the posterior vaginal wall by 78% of the G and 41% of the CS group. All gynecologists and 49% of the CS group evaluated a rectocele clinically in dorsal decubitus, with 91% of gynecologists using a speculum and 65% using the Pelvic Organ Prolapse-Quantification (POP-Q) scoring system, compared to < 1/3 of colorectal surgeons. A digital rectal examination was performed by 90% of the CS group and 57% of the G group. A transvaginal ultrasound was only used by the G group, while anal manometry was opted for by the CS group (65%) and minimally by the G group (14%). In the G group, a posterior repair was the preferred surgical technique (78%), whereas 63% of the CS group preferred a rectopexy. Multidisciplinary discussions (MDT) were mostly organized ad hoc. CONCLUSIONS: An availability bias is seen in different aspects of rectocele evaluation and treatment. Colorectal surgeons and gynecologists are acting based on their training and experience. Motivation for pelvic floor MDT starts with creating awareness of the availability bias.

Implementing a new method of group toilet training in daycare centres: a cluster randomised controlled trial.

Despite the existing methods, a trend towards a later initiation and completion of toilet training has been seen in Western society. This study is the first to investigate prospectively the efficacy of intensive group toilet training in daycare centres. The primary outcome of interest is the duration until the child is toilet trained. A cluster randomised controlled trial was established in daycare centres; clusters of participants were randomly allocated to an intervention or control group. Intervention group was subjected to an intensive toilet training session. Innovative aspects of this toilet training method were a 2-h training on two consecutive days, carried out in small groups in daycare centres. Parents of children in the control group were encouraged to start TT in their own manner. Children were monitored until they were considered to be fully toilet trained during the day. Median toilet training duration in the intervention group was 2 weeks compared to 5 weeks in controls (p value log rank test = 0.007). The hazard of being clean during the follow-up of 6 weeks was twice as high in the intervention compared to controls (p = 0.018).Conclusion: The intervention had a significant influence on the duration of toilet training in healthy children, with a median duration of 2 weeks. Our findings are clinically relevant for daycare educators, having a considerable responsibility in the development of children.Trial Registration Number: ClinicalTrials.gov NCT04221776. What is Known: • Despite different existing methods, a later initiation of toilet training has been seen in Western society and coherent to this an increasing age of acquiring full bladder control. • Child daycare centres have a growing role in the toilet training process. What is New: • This is the first prospective report describing the results of a new method of toilet training healthy children in small groups in daycare centres. • The intervention had a significant influence on the duration of toilet training, with a median duration of 2 weeks.

Information as a crucial factor for toilet training by parents.

BACKGROUND: Toilet training (TT) is a milestone in a child's development. Nowadays, children complete TT later than previous generations. This can have detrimental consequences for the child, the parents, and the environment. TT is experienced as difficult and time-consuming; parents could benefit from guidelines to assist in this process. METHODS: Focus group discussions (FGDs) were used to explore parents' experiences in an inductive approach applying purposive sampling. The FGDs aimed to explore the type of information parents wanted to receive on TT, from whom and how. RESULTS: After six FGDs, including 37 participants with personal experience in TT, data saturation was achieved. The findings of this qualitative study show that reputable agencies, family, friends, day-care workers, and nursery school teachers were considered very helpful and trustworthy sources. TT information should be easily understandable and not contain scientific terms or much text. A colourful and illustrated brochure sent by regular mail is preferred. CONCLUSION: Our study allows to develop a source of correct and wanted information about TT that parents can and want to use, which helps them completing this training more easily and timely.

Knowledge of the pelvic floor in nulliparous women.

[Purpose] Proper pelvic floor function is important to avoid serious dysfunctions including incontinence, prolapse, and sexual problems. The current study evaluated the knowledge of young nulliparous women about their pelvic floor and identified what additional information they wanted. [Subjects and Methods] In this cross-sectional survey, a validated, 36 item questionnaire was distributed to 212 nulliparous women. The questionnaire addressed demography, pelvic floor muscles, pelvic floor dysfunction, and possible information sources. Descriptive statistics were generated for all variables. Stability and validity testing were performed using Kappa statistics and intra class correlation coefficients to define agreement for each question. The study was approved by the ethics Committee (B300201318334). [Results] Using a VAS scale (0 to 10), the women rated their knowledge about the pelvic floor as a mean of 2.4 (SD 2.01). A total of 93% of the women were insufficiently informed and requested more information; 25% had concerns about developing urinary incontinence, and 14% about fecal incontinence. Many of the women were unaware what pelvic floor training meant. [Conclusion] There was a significant lack of knowledge about pelvic floor function among nulliparous women. The majority of nulliparous women expressed a need for education, which might offer a way to reduce dysfunction.

Knowledge of the pelvic floor in menopausal women and in peripartum women.

[Purpose] Pelvic floor dysfunction is an important health-care issue, with pregnancy, childbirth, and menopause as the most important risk factors. Insufficient knowledge about pelvic floor dysfunction is the largest barrier to seeking care. The aim of this study was to investigate the level of knowledge and information on pelvic floor dysfunction in peripartum and menopausal women. [Subjects and Methods] The present study was a cross-sectional survey. A valid and reliable questionnaire of 48 items was distributed to 402 women who were pregnant or had recently given birth and to 165 postmenopausal women. All answers were analyzed and interpreted. The study was approved by an ethics committee (B300201318334). [Results] On a VAS scale of 0 to 10, the mean ratings of the peripartum and postmenopausal women concerning their knowledge were 4.38 (SD 2.71) and 4.92 (SD 2.72). Peripartum women held significantly more pessimistic perceptions about the occurrence of postpartum pelvic floor dysfunction. The results showed that 75% of the peripartum women and 68% of the postmenopausal women felt insufficiently informed or want to get better informed. [Conclusion] The results reveal sparse knowledge about the pelvic floor among women of all ages and that a major proportion of them would be interested in more information. Amelioration of common knowledge could improve help-seeking behavior in women.

The voiding pattern in healthy pre- and term infants and toddlers: a literature review.

Toilet training in Western culture starts between 18 and 24 months. At this age, a child is assumed to have procured the competences needed for bladder control. Since the knowledge of reference values of a normal micturition serves as a guide to diagnose urologic pathology, the aim of this systematic review is to obtain a more comprehensive picture of normal voiding pattern in healthy infants, who have not yet reached bladder control. The systematic literature search was performed in two databases. This systematic review was conducted by the preferred reporting items for systematic reviews and meta-analyses (PRISMA statement). Twenty-one studies were selected that demonstrate factors associated with voiding pattern. Diuresis, interrupted voiding, post-void residual urine and voiding frequency are parameters decreasing with age. Bladder capacity, the lowest volume triggering micturition, flow rate, voiding volume and the level of awake voiding expand with age. CONCLUSION: When evaluating the voiding pattern in infants, the normal evaluation of micturition parameters in healthy normal developing infants must be taken into consideration. WHAT IS KNOWN: • Different voiding parameters in healthy infants who are not yet toilet trained are reported. • Voiding was believed to be induced by a constant bladder volume, while nowadays, it is detected that infants possess a functional spino-pontospinal voiding pathway. WHAT IS NEW: • Arousal was detected in less than 60 % of all preterm micturitions, while it was present in more than 90 % of the micturitions of healthy "term" infants. • Voided volume, bladder capacity, and flow rate tend to increase with age. In contrast, voiding frequency, post-void residual urine, and interrupted voiding diminishes with an increasing age.

Pelvic floor awareness and the positive effect of verbal instructions in 958 women early postdelivery.

INTRODUCTION AND HYPOTHESIS: It is uncertain how reliable a personal belief is about the ability to do pelvic floor muscle (PFM) contractions early postdelivery and how instructional feedback affects pelvic floor muscle contraction (PFMC) performance. We hypothesize that many women do not have a reliable idea about PFMC and that instructional feedback can help improve their control. METHODS: Prospective observational study in 958 women (median 30 years) early postdelivery PFMC was evaluated with visual observation: an inward movement of the perineum was accepted as sign of good contraction. The women who could not show PFMC three consecutive times got verbal instructions, and re-evaluation was afterward. RESULTS: In 500 women, no inward movement of the perineum was observed: 275 women (29%) showed no movement at all, and 225 women (24%) showed some movement but no inward displacement. In 33.4%, the personal conviction to be able or not to perform PFMC proved false. After verbal instructions, 74% improved their PFMC. CONCLUSIONS: The belief of doing correct PFM contraction was false in at least one of five postpartum women. Verbal instructions have a positive effect on performing PFMC in 73.6% of women.

Toilet training in healthy children: results of a questionnaire study involving parents who make use of day-care at least once a week.

AIMS: To investigate how toilet training (TT) is dealt with and what the associated feelings are in Flemish families using day-care at least once a week. METHODS: A questionnaire was provided to 256 parents of healthy children between 15 and 35 months old, using day-care every week. Data were analyzed using SPSS18.0. RESULTS: Two hundred twenty-two questionnaires were completed (response rate: 87%), of which 221 were valid. The overall results show that the start of TT and method used are mainly in line with current recommendations, and that the cooperation between parents and day-care is seen as positive, providing support for the parents in guiding their child in the TT-process. Most parents (74%) stated that day-care and parents should play an equal role in the TT-process. However, 17% of the parents experienced uncertainty, stress, and/or frustration related to TT. This percentage increased to 30% when asked about the right moment to start TT. Moreover, 18% of the parents reported a lack of time to guide their child in the TT-process. Eighteen percent of the parents agreed that responsibility for TT is increasingly passed on to day-care, while 46% remained undecided. In addition, 40% of the parents had no idea whether they used the same TT method as the day-care center. CONCLUSIONS: The results, in general, reflect a positive image of how TT is dealt with. However, several concerns were raised about the shared TT between parents and day-care, implying that further research on this topic is needed.

Readiness signs used to define the proper moment to start toilet training: a review of the literature.

Confusion exists about when to start toilet training, which causes stress and anxiety. Another consequence can be the actual postponement of the toilet training process, which has created extra social problems. Therefore, in this review we will focus on the proper moment to start toilet training, more specific on readiness signs. This will clarify on which topics further research is necessary. We searched databases for publications on toilet training. Next, we gathered information about the normal development of healthy children and at which age skills needed for each readiness sign are acquired. Twenty-one readiness signs were found. Our results show that there is no consensus on which or how many readiness signs to use. Depending on the readiness sign, the moment to start toilet training can vary a lot. More studies are needed to define which readiness signs are most important and how to detect them easily.

Toilet training in daycare centers in Flanders, Belgium.

Several changes have occurred in the toilet training (TT) process in recent decades. There has been an increase in the use of daycare as both parents now often work outside the home. Most children attend daycare centers during the period TT usually takes place, and daytime training has shifted from home to daycare. This study is the first to evaluate the way TT is done in daycare centers. A questionnaire was sent to 1,500 daycare centers, of which 429 replied (response rate of 28.6%). The results show that half of the childcare workers base the decision to start TT on readiness signs. The combination of age and readiness signs is used by 44.5%. The majority of the respondents spent more than 1 h per day on TT (81.8%); 79.8% considered that daycare and parents should play an equal role in TT. However, more than a third of the respondents thought that parents pass the responsibility for TT on to daycare and that not enough attention was paid to TT in the home. Most respondents stated that daycare centers had the facilities and means to be able to give the children proper TT (88.5%). Other research indicated that the outcome of TT is not that good overall and that there is room for improvement in the methods used. More research is needed on the role division and on the interaction between daycare and parents and their combined influence on the process and outcome of TT.

Observing signs of toilet readiness: results of two prospective studies.

OBJECTIVE: The aims of this study were to check the possibility of observing readiness signs proposed in the literature (Study 1) and to investigate the interrater reliability of observing readiness signs between different researchers (Study 2). MATERIAL AND METHODS: In Study 1, 24 healthy children, recruited in Flemish childcare centres, were observed. Each child was observed for 8 h. In this study a list of readiness signs was used as described in a recent literature review on readiness signs in young, healthy children. In Study 2, two observers independently evaluated an adapted list with readiness signs in another 24 healthy children recruited in a similar setting. SPSS was used to analyse the interrater reliability between these observations, calculating Cohen's kappa per readiness sign. RESULTS: The results of Study 1 show that not all readiness signs are easy to assess. This resulted in a shortened checklist with 20 signs, which can be easily observed in young, healthy children during an 8 h period, and which was used in Study 2. The results of Study 2 show that, for most readiness signs, Cohen's kappa and the agreement between observers varied from good to perfect. CONCLUSIONS: This article presents the results of two studies that are the first in a series investigating the use of readiness signs. Further research on readiness signs is being conducted to reach consensus on when to start toilet training based on readiness signs, and to obtain evidence-based guidelines.

Associations Between Online Pornography Consumption and Sexual Dysfunction in Young Men: Multivariate Analysis Based on an International Web-Based Survey.

BACKGROUND: Expanding access to the internet has resulted in more and earlier consumption of online pornography. At the same time, a higher prevalence of erectile dysfunction (ED) among young men is seen. Increased pornography consumption has been suggested as a possible explanation for this rise. OBJECTIVE: The aim of this study was to better understand associations between problematic pornography consumption (PPC) and ED. METHODS: A 118-item survey was published online, and data collection took place between April 2019 and May 2020. Of the 5770 men who responded, the responses from 3419 men between 18 years old and 35 years old were analyzed. The survey used validated questionnaires such as the Cyber Pornography Addiction Test (CYPAT), International Index of Erectile Function (IIEF-5), and Alcohol Use Disorders Identification Test-Concise (AUDIT-C). The estimated amount of porn watching was calculated. Univariable and multivariable analyses were performed. For the multivariable analysis, a logistic regression model using a directed acyclic graph was used. RESULTS: According to their IIEF-5 scores, 21.48% (444/2067) of our sexually active participants (ie, those who attempted penetrative sex in the previous 4 weeks) had some degree of ED. Higher CYPAT scores indicating problematic online pornography consumption resulted in a higher probability of ED, while controlling for covariates. Masturbation frequency seemed not to be a significant factor when assessing ED. CONCLUSIONS: This prevalence of ED in young men is alarmingly high, and the results of this study suggest a significant association with PPC. TRIAL REGISTRATION: Research Registry researchregistry5111; https://tinyurl.com/m45mcaa2.

Development Signs in Healthy Toddlers in Different Stages of Toilet Training: Can They Help Define Readiness and Probability of Success?

There is much uncertainty about when to start toilet training. Age cannot be a strict stand-alone criterion, as every child has its own pace of development. We observed toilet training (TT) related development signs (DS) in healthy toddlers and determined which can help to define the proper time to start TT and to predict success. The study group consisted of 269 healthy children, in different stages of TT: not started, during, and after completion. Sitting stable, picking up small objects, and spontaneously putting objects in containers were present in all children and had no predictive value. All other DS were significantly more present in those who had started and became more prevalent during completion of TT. Age had a significant association with 13/15 DS. Understanding and following instructions, and having a broader vocabulary were significantly more present when TT had been started. Dry during midday nap reached no significance.

Observing postprandial bowel movements in diaper-dependent toddlers.

The gastrocolic reflex is a response of the colon to the presence of food in the stomach. Our goal was to observe bowel movements in healthy infants and toddlers not yet toilet trained, in response to a meal. Stool behavior of 40 toddlers, aged 18-27 months, was monitored. We observed a bowel movement within the first hour after a meal in 75% of the children. This occurred 15, 30 or 60 minutes after a meal in, respectively, 25%, 48% and 66% of the observations. If we limit to the ones that actually defecated, 37% would defecate within 15 minutes and 72% within half an hour. Fifty-nine percent of all children defecated in the morning, 54% at noon and 28% in the evening. In conclusion, we believe the gastrocolic reflex can be used as a facilitating factor to help a child to defecate on the potty, 15-30 minutes after a meal. In 50% of the cases, a child will have a bowel movement on the potty and learn to defecate on it much easier.

'Elimination signals' in healthy, NON toilet trained children aged 0-4 years: A systematic review.

OBJECTIVE: An early start of toilet training, which is related to a younger age of acquiring full bladder control, can generate important health advantages. Children display different 'elimination signals' related to voiding or defaecation. The aim of this systematic review is to map these 'elimination signals' in young, healthy children aged 0-4 years. METHOD: The systematic literature search was performed in two databases and was conducted using the preferred reporting items for systematic reviews and meta-analyses (PRISMA statement). RESULTS: Two main distinctions in elimination signals were made. The first could be classified as visual, auditory and tactile, most frequently involving a change in facial expression, often combined with body movements and verbal expressions such as a short cry or grunting. Secondly significant changes in heart rate, respiratory frequency or EEG frequency could be defined as 'clinically assessed elimination signals'. CONCLUSION: Different 'elimination signals' could be detected in healthy children while voiding or defaecating and should be observed when initiating toilet training. Detection of noticeable visual, auditory and tactile signals will facilitate and shorten this process.

The efficacy of a wetting alarm diaper for toilet training of young healthy children in a day-care center: a randomized control trial.

AIMS: To evaluate, in a randomized controlled way, the use of a daytime wetting alarm in a day-care center during three consecutive weeks in healthy children. METHODS: Thirty-nine healthy young children, between 18 and 30 months old, were selected at random for a wetting alarm diaper training (n = 27) or control wearing a placebo alarm (n = 12). Toilet behavior was observed during a period of 10 hr by independent observers before, at the end of, and 2 weeks after training. Children were defined as completing daytime toilet training when the child wore undergarments, showed awareness of a need to void, initiated the toileting without prompts or reminder from the trainer and had maximum one leakage accident per day. RESULTS: Children in the wetting alarm diaper training group achieved independent bladder control in 51.9% and did significantly better than in the control group (8.3%) (P = 0.013). The results were sustained during the following 14 days (P = 0.013). CONCLUSION: The wetting alarm diaper training is an effective option for toilet training young healthy children in a day-care center. It offers day-care providers clear guidelines and limits the time to complete toilet training in many children without putting too much burden on the child and the day-care center activities.

Toilet training of healthy young toddlers: a randomized trial between a daytime wetting alarm and timed potty training.

OBJECTIVE: Toilet training (TT) is important for every child, but there is no agreement on what is the best training method. We evaluated in a randomized way the comprehensive use of a daytime wetting alarm at home for 5 days in healthy children and compared it with timed potty training. METHODS: Thirty-nine children, between 20 and 36 months of age, were randomized to wetting alarm diaper training (WAD-T; n = 20) or timed potty training (TP-T; n = 19). Toilet behavior was observed by parents and independent observers before, at the end, and after 2 weeks of training. Late evaluation at 1 month was done by telephone. RESULTS: The WAD-T group did significantly better than the TP-T group at the end training (p = .041), at 14 days (p = .027), and 1 month after training (p = .027). Independent bladder control was achieved in 88.9% of the WAD-T group. CONCLUSIONS: The WAD-T method is a structured, child-friendly, highly effective option for TT young healthy children. It offers the parents clear guidelines, a limited time needed to complete TT, a high success rate, and minor emotional conflicts. Results must now be confirmed in a larger sample size.

Common errors made in attempt to contract the pelvic floor muscles in women early after delivery: A prospective observational study.

OBJECTIVES: The ability to perform a correct pelvic floor muscle contraction (PFMC) is necessary to start pelvic floor muscle training after delivery. COMMOV are "c"ontractions of "o"ther "m"uscles (m. rectus abdominus, the gluteal muscles, and the adductors), and other "mov"ements (pelvic tilt, breath holding, and straining) performed in addition to or instead of the PFMC. COMMOV are probably the most common errors in attempt to contract the pelvic floor muscles during the first days after delivery. The aims of this study were to observe the prevalence of COMMOV, to investigate whether COMMOV influence the ability to perform a PFMC, and whether verbal instructions are effective to unlearn the COMMOV postpartum. STUDY DESIGN: A Prospective Observational Study was performed in women during the first through sixth day postpartum. PFMC and COMMOV were evaluated with visual observation. Women who did not show correct isolated PFMC received verbal instructions and were re-evaluated. Interobserver variability and agreement were calculated. Chi-square, Kappa, Risk Ratio, and McNemar were used. RESULTS: A total of 382 women participated, 2.36 (±1.2) days postpartum. Twohundred sixteen, 57%, CI (52-62%), showed COMMOV. The chance to perform a correct PFMC was 2.65 times higher without COMMOV (p=0.0001). Verbal feedback was effective (57% reduced to 3%) to abandon COMMOV during PFMC. CONCLUSION: COMMOV are common errors performed during attempts to contract the pelvic floor muscles after delivery. They can reduce the ability to contract the pelvic floor muscles, but can easily been unlearned with visual observation and verbal feedback.