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No description available.

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Objectives To determine obstetric, maternal and fetal variables that increase the risk of postnatal urinary and anal incontinence. To establish how anal and urinary incontinence impact on Quality of Life (QoL) with particular reference to sexual psychology. Finally, to ascertain the extent of disclosure of incontinence problems to partners and health professionals. Design A longitudinal, prospective, repeated measures, cohort study using five data sources. Data was collected in the last trimester of pregnancy, at 6 weeks postnatal, 6 months postnatal and finally at one year postnatal. Setting Wirral University Teaching Hospital NHS Foundation Trust. Participants Primiparous women with no pre-existing disease (N=516). Participants were recruited after a normal 20 week obstetric ultrasound scan. Results Stress incontinence was reported by 39.7% antenatally, 28.2% at 6 weeks postnatal, 31% at 6 months and 26.5% at one year postnatal. Urge incontinence was reported by 23.5% antenatally, 21.2% at 6 weeks, 21.4% at 6 months and 16.4% at one year postnatal. Anal incontinence at one year postnatal was reported by 9.39%. Those participants under the age of 20yrs had higher rates of postnatal urge incontinence (p<.001) possibly associated with increased rates of infection in this group. BMI>30 was associated with higher rates of antenatal stress incontinence but was not significant in the postnatal period. BMI<20 was associated with an increase in postnatal urge incontinence. Prolonged periods of time in labour without bladder emptying was associated with increased rates of both urinary incontinence (OR 2.36) and anal incontinence (p=.026). Forceps delivery was associated with postnatal stress incontinence (OR 2.41). Although caesarean section appeared protective against urinary incontinence initially, long-term data show a progressive increase in reported rates of urinary incontinence even after elective caesarean section. Elective caesarean section was protective for anal incontinence. Faecal incontinence was significantly higher (OR 3.26) in the group who had their labour induced (12.1%) compared to those who had a spontaneous labour (4.6%). Perineal trauma was not associated with anal incontinence. However, it was associated with urinary incontinence throughout the postnatal year with anal sphincter disruption having the highest rates of stress incontinence (p<.005). Birth weight, duration of labour, feeding method, epidural anaesthesia and smoking were not significant. Overall, urinary incontinence appears to be a regressive condition, although the impact on QoL is cumulative and seems to increase over time. Some participants had a progressive, deteriorating condition which appears to be associated with a higher BMI or >6 hours from bladder emptying to delivery of the baby. Urinary and anal incontinence had a detrimental effect on all QoL domains. Those reporting nocturnal enuresis, pain, intercourse incontinence and urge incontinence were effected the most. The greatest impact is on the emotion domain. Only 8.7% with urinary incontinence and 9.7% with anal incontinence discussed their symptoms with a health professional. Discussion with a partner was 32.8% and 21.4% respectively. The most common reasons for non-disclosure were embarrassment, fear of not being taken seriously and not wanting to waste the time of the health professional. Those participants who did disclose tended to have multiple symptoms. Pregnancy and childbirth appear to have a detrimental impact on sexual psychology, irrespective of continence status. Those who reported incontinence appear to have less sexual depression than the continent group suggesting the adoption of defense mechanisms to preserve the sexual Self. Conclusion Generally, urinary incontinence is a regressive condition. Risk factors for a progressive condition have been identified. Younger pregnant women appear to be more prone to infection which can sensitise the bladder and result in long term urinary incontinence. Prolonged periods of time in labour without voiding increases the risk of urinary and anal incontinence and is associated with a deterioration of symptoms over time. Whilst for all other modes of delivery the rate of UI decreased over time, in the elective CS group, the rate of UI increased steadily throughout the postnatal year. These findings support previous studies and suggest a degree of under-recognition or under-reporting of anal sphincter trauma leading to dysfunction. The impact of incontinence on quality of life domains shows clear evidence that the condition has a detrimental impact on many aspects of an individuals well being. Those women reporting intercourse incontinence had the greatest impact on QoL domains. Few women seek help for their condition and a number of personal and organisational factors have been highlighted which contribute to keeping incontinence both secret and taboo. It is clear that what incontinent women think is affecting the way they feel and ultimately their behaviour. Psychological defence mechanisms are employed to justify their inaction.

BACKGROUND There is an extraordinary common medical condition that affects millions of people, mostly women. It is associated with high levels of disability, discomfort and loss of productivity. People seldom talk about it and suffer in silence and have a fear of being ridiculed or embarrassed. It is not breast cancer, nor osteoporosis, nor heart disease nor is it depression. It is urinary incontinence – the loss of bladder control, which affects the lives of millions of people globally. General Practitioners (GP‟s) do not have a good knowledge about the topic and are therefore not managing Urinary Incontinence (UI) appropriately. AIM To assess the knowledge, attitudes and reported practices of general practitioners related to adult female patients with urinary incontinence in Greater Johannesburg. OBJECTIVES To determine the demographics of the respondents belonging to the various Independent Practitioner Associations (IPA's). Variables include age, sex, year qualified, postgraduate qualifications, and the number of years in clinical practice. To determine the demographics of the respondents practice. Variables include, age distribution, gender distribution, and the number of patients seen with urinary incontinence per month. To determine the knowledge of the respondents regarding urinary incontinence in adult females. Variables include prevalence, aetiology, types of urinary incontinence, associated risk factors and reversible factors. v To determine the attitudes of the respondents regarding urinary incontinence in adult females. Variables include feelings of empathy, frustration, etc. To determine the management of the respondents regarding urinary incontinence in adult females. Variables include access of referral facilities, screening, examination, investigation, and medication. METHODS The study was done amongst the Independent Practitioner Associations in the greater Johannesburg area. A questionnaire was administered to GP‟s attending IPA meetings, data was collected with regards to the demographics of the GPs and their practices as well as the knowledge, attitudes and reported practices of the GPs. RESULTS The response rate cannot be calculated as the number of GPs who attended the IPA meetings is not known. One hundred and thirteen respondents met the inclusion criteria for the study. The data was collected over a 10-month period during 2006. Males accounted for 76 (68.5%) and females for 35 (31.5%) of all respondents. Two (1.8%) respondents had three postgraduate qualifications, 11 (9.7%) respondents had two postgraduate qualifications and 38 (33.6%) respondents had one postgraduate qualification. The prevalence of patients with UI was higher amongst female respondents, 33 (97.1%) as compared to male respondents 67 (88.2%). Feelings of empathy was experienced by 94 (88.7%) respondents and 81 (81%) respondents would never avoided the discussion about UI with patients. Most respondents rated their knowledge on aetiology 82 (78.1%), diagnosis 79 (73.8%), investigation 58 (54.2%) and management 58 (54.7%) as good and very good.

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Dans le monde médical moderne un débat est en train de prendre de plus en plus d'ampleur, c'est celui du bénéfice thérapeutique. En effet, il ne s'agit plus de se « contenter » de guérir un patient à « n'importe quel prix » mais bien de lui proposer un traitement qui lui assure un survie maximale avec une qualité de vie optimale. Il est de moins en moins accepté que le traitement induise une diminution importante de la qualité de la vie du patient si le bénéfice en terme de survie n'est pas significatif. L'incontinence urinaire affecte de manière significative la qualité de la vie des patients qui en souffrent. Nous nous sommes proposés de chercher quel rôle pouvait jouer le kinésithérapeute dans la prévention de cette affection invalidante pour le patient opéré d'une prostatectomie radicale totale pour cancer de la prostate. Dans une première partie nous avons étudié la prévalence de l'incontinence urinaire masculine en général et précisé un moyen de l'évaluer. Dans la littérature nous avons relevé toutes les variables qui sont reconnues comme pouvant avoir une influence sur la continence urinaire postopératoire. Ainsi nous avons retenu de cette recherche bibliographique les éléments suivants : l'âge, le stade histopathologique de la tumeur, le score de Gleason, la préservation des pédicules vasculaires et nerveux, les résultats d'examens urodynamiques préopératoires, la corpulence et la rééducation. A partir de notre population de 487 hommes opérés par un unique chirurgien expert dans cette chirurgie nous avons étudié séparément toutes ces variables. Nous avons pu ainsi confirmer ou infirmer certaines hypothèses relatives à la part que chacune de ces variables portaient dans l'étiologie de l'incontinence postopératoire. Le rôle de la rééducation a fait dans ce travail l'objet de recherches originales. Nous avons montré que deux séances de kinésithérapie préopératoires diminuent l'impact de la chirurgie sur la qualité de la vie des patients en réduisant tant le risque que la sévérité de l'incontinence postopératoire. Parallèlement à cette étude nous avons mesuré les paramètres musculaires que sont la force, la capacité du patient à tenir une contraction et l'endurance du plancher périnéal. Cette étude a permis de mettre en évidence les meilleures modalités de rééducation. Enfin, au cours de ce travail nous avons découvert et pu observer de très grandes variations dans la mobilité périnéale; allant d'un périnée immobile, rigide, dur à un périnée très mobile. Nous avons conçu un appareil de mesure afin de quantifier ce mouvement. Il est clairement démontré l'importance de la mobilité périnéale dans la préservation de la continence chez la femme. Nous avons mis à jour le rôle important qu'elle avait également chez l'homme. L'âge, certaines qualités vésicales et la mobilité périnéale ont une valeur prédictive du risque et de la sévérité de l'incontinence postopératoire. Une étude multivariée a mis en relation ces variables. Nous pouvons conclure en affirmant que la rééducation a un place importante à prendre dans le maintien d'une qualité de vie optimale chez les patients candidats à une prostatectomie radicale totale.

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EMG sphincter mapping is a standard investigation for faecal incontinence but is restricted in children by limited cooperation and tolerance. In adult studies, trans-rectal pudendal nerve stimulation and trans-cutaneous cauda equina stimulation have permitted more precise localisation of pelvic floor neuropathic lesions. However, the use of these new non-invasive techniques has not been assessed in children. In this study, clinical neurophysiological assessment was undertaken in 124 children. EMG examination (109 cases) with analysis of individual motor unit potentials (isolated under low frequency attenuation) was combined with attempted pudendal nerve (44 cases) and/or spinal stimulation (21 cases). In 80 children with various ano-rectal malformations, a substantial external anal sphincter could be demonstrated with EMG mapping (often under anaesthesia) in the great majority, even in those with high anomalies, and this was found to be useful for surgical correction. The presence and position of an external anal sphincter could be checked by pudendal nerve stimulation in the post-operative group. Unexpected evidence of abnormal external anal sphincter function in Hirschprung's disease was found in 5 children with persisting incontinence following surgical correction. Eight children with chronic constipation and 6 with encopresis did not show the high incidence of neurogenic lesions reported in adult series. The neurophysiological features in 10 children with possible cauda equina lesions (including sacral dysplasia) correlated well with radiological findings. The established clinical value of EMG sphincter mapping in perineal trauma was confirmed in 3 children. These studies suggest that clinical neurophysiological assessment of children with faecal incontinence contributes to the management of these difficult clinical problems. In addition it may help to improve our understanding of some of the mechanisms underlying both normal and abnormal function in the development and maintenance of continence in childhood.

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