Women's Health Medicine最新文献

Geriatric incontinence is a prevalent problem, morbid, costly and has effects that are devastating, causing psychological dysfunction, which often leads to isolation and early admission to a residential care facility. The reported prevalence of urinary incontinence (UI) in the elderly varied widely between 10% and 70% in those over 65 years of age. There is evidence that less than half of the patients with UI consult their healthcare provider. Incontinence is associated with significant anxiety and depression which has negative effect on self perception. Continence depends on multiple factors – mental state, mobility, manual dexterity, health status and motivation – as well as urinary function. The aetiology and risk factors of incontinence in older people are little different from those in younger age groups but the elderly are more prone to physiological, pharmacological and psychological factors that may affect their incontinence status. Assessment of elderly patients with UI should follow a holistic approach; it must include transfer ability, mobility, balance, arm strength and body flexibility, manual dexterity, eyesight and toileting ability. Simple conservative measures such as general lifestyle advice are all that is needed in many cases. Primary care team including continence advisors play important role in treating these patients. Pelvic-floor exercise, bladder retraining and biofeedback are useful first-line management, but they require intact cognitive function and motivation. Due to the side effects, older people should be observed carefully when given new medications, and polypharmacy should be avoided at all cost. Age in itself is not a barrier to surgical treatment, especially if performed under local anaesthesia. Environmental measures are an essential part of the treatment package. Preventive strategies should be used, when possible, to reduce the burden of incontinence on elderly sufferers and enhance their quality of life.

Stress urinary incontinence can have a debilitating effect on quality of life. Where conservative therapy with pelvic-floor physiotherapy has failed, surgery is recommended. Traditional techniques include open retro-pubic colposuspension and sub-urethral sling procedure. Newer approaches that have been developed include laparoscopic colposuspension and minimally invasive sling procedures. Recent data supports the use of the latter, particularly Tension-free Vaginal Tape as primary treatment for SUI. New innovations and techniques continue to be developed at a very rapid pace in this field. The efficacy and evidence for the different surgical approaches to SUI are reviewed in this article.

Urinary stress incontinence may affect up to 50% of women in their postpartum period. This is often present during pregnancy with 54.3% of sufferers experiencing an impact on quality of life antenatally and 71.1% postnatally. Antenatal stress incontinence is caused by a combination of factors including anatomical factors and connective tissue changes. Changes have been shown in the bladder neck, functional urethral length and intravaginal and intra-anal pressures in relation to pregnancy and childbirth. Postpartum incontinence occurs for these reasons and additionally, delivery-related factors. Whilst vaginal delivery is a risk factor for the subsequent development of postnatal symptoms, the evidence of a protective effect of performing caesarean sections is less compelling. Evidence regarding delivery factors and their influences on the development of stress incontinence varies regarding infant weight, mode of delivery, head position, duration of labour and use of epidural analgesia. Eighty percent of women have partial denervation of their pelvic floor after their first vaginal delivery. The relationship between epidural analgesia and postpartum stress incontinence has become a contentious issue and as anaesthetic techniques have changed, the literature is no longer valid. It is not clear whether pelvic-floor exercises will prevent stress incontinence. There are many barriers to women receiving pelvic-floor education. Specialist physiotherapists are best placed to supervise this. Over 60% of women with leakage do not seek help and healthcare workers must be aware of the significant and common problem of stress incontinence so that they can offer appropriate advice and referral as necessary. Management options also include surgery, drug treatment and containment products. Women having antenatal stress incontinence have double the risk of having stress incontinence 15 years later.

Pelvic-floor physiotherapy remains the mainstay of conservative treatment for women with urinary stress incontinence. Various intravaginal and intraurethral devices have been developed for women who continue to suffer from troublesome stress incontinence despite pelvic-floor rehabilitation. The advent of new, highly effective, minimally invasive surgical treatments for stress incontinence and the new pharmaceutical agent, duloxetine, has reduced the demand for non-surgical treatments. Some women, who wish to avoid surgery, or for whom stress incontinence is only troublesome during predictable periods of exercise, may still wish to use such devices. Whilst reduced demand has led to problems in supply of these devices, they are obtainable and offer a useful choice for women with stress urinary incontinence.

Urinary incontinence affects 15–30% of people of all ages. It can affect the social, psychological, domestic, occupational, physical and sexual aspects of their lives. Traditional assessment of urinary incontinence has been based on symptom scores and objective investigations concentrating on its aetiology, diagnosis and treatment. Recently, a more multidimensional approach to urinary incontinence has incorporated the concept of quality of life (QoL) in its routine evaluation. The different aspects of QoL can be assessed using two main types of questionnaire: generic and condition-specific questionnaires. Whereas generic questionnaires cover a wide range of different health states, condition-specific questionnaires reflect a particular condition, and are more relevant to patients’ symptoms, the bother they cause and how their lives are affected. Development of a QoL questionnaire in urinary incontinence is a complex task and requires the end result to be a reproducible measure of QoL. The final questionnaire is usually made up of a number of questions presented in different sections, with each section measuring a specific domain of QoL experienced by patients. Several QoL questionnaires are available in urinary incontinence. Selecting the most appropriate questionnaire is not a straightforward choice. In an attempt to simplify this, in 1998 the first International Consultation on Incontinence (ICI) proposed the concept of the modular ICI questionnaire (ICIQ), as an instrument that utilized the strengths of each individual questionnaire. In order to make questionnaires easier to use in clinical practice, short-form and screening versions of the most commonly used questionnaires are being developed.

Urinary incontinence, the involuntary leakage of urine, is a distressing symptom causing embarrassment and impairing quality of life. When occurring during intercourse, it can lead to the disruption of relationships. Studies have shown that up to 43% of women attending gynaecology clinics complain of a degree of sexual dysfunction when specifically asked. One of the causes is intercourse incontinence, which has been shown to affect up to 25% of women presenting with incontinence. Due to the embarrassing nature of the symptom, patients rarely volunteer it as a symptom, hence stressing the importance of doctors incorporating questions into their history taking. Leakage of urine can occur at different stages of sexual intercourse, namely on arousal, on penetration of the vagina and on achievement of orgasm. Studies have shown that there is a correlation between the urodynamic diagnosis and the stage of intercourse when this occurs. Women with detrusor overactivity tend to leak at orgasm whereas women with urodynamic stress incontinence tend to leak on vaginal penetration. There is, however, no underlying proven theory and despite these associations, laboratory studies have failed to show any cystometric differences.

Management of these patients would include a careful history, physical examination and a set of investigations trying to find out the underlying cause. Treatment is difficult as these specific symptoms often do not response to conventional methods of treatment.

Urinary incontinence is the involuntary loss of urine. This is a common condition that can lead to a significant impairment in quality of life. There are several types of urinary incontinence. Stress urinary incontinence (SUI), the most common form in women, is the involuntary leakage of urine on exertion or when coughing or sneezing. Involuntary loss of urine accompanied by or immediately preceded by urgency, is termed urge urinary incontinence (UUI). Some women will experience both stress and urge symptoms and have mixed urinary incontinence (MUI). Systematic clinical assessment is important in determining the most appropriate management of women complaining of urinary incontinence. An accurate history will help differentiate between symptoms of stress incontinence, urgency and urge incontinence and assess factors contributing to these problems. A general physical examination should be performed and should include pelvic assessment for genital prolapse and pelvic-floor muscle tone. Several basic investigations can be initiated in the primary care setting and include urinary dipstick analysis to exclude urinary tract infection and frequency volume diary-keeping to assess fluid intake/output and incidence of leakage. In uncomplicated SUI or UUI, women may be empirically managed. For example, women with SUI may benefit from physiotherapy input on pelvic-floor muscle exercises. Women with mixed incontinence, with significant genital prolapse and/or symptoms such as persistent haematuria or bladder pain should be referred to a specialist for further investigation.

The bladder has a dual role: to store urine for much of the time without excess leakage; to void the bladder content completely and rapidly at a time that is under the control of the individual. An inability to achieve these objectives will result in incontinence, ineffective voiding or retention of urine, and is a cause of a considerable reduction in the quality of life, and significant medical problems. To understand the pathological causes of these conditions it is necessary to understand the normal and physiological processes that result in controlled voiding of urine.

This article describes the important anatomical structures that comprise the urinary tract and its afferent and efferent nerve supply. There has been considerable recent advance in understanding how the central nervous system coordinates the controlled voiding and storage of urine. The reflex pathways in the spinal cord, brainstem and higher regions of the brain that mediate this process are described. Finally the smooth muscle in the wall of the bladder (detrusor smooth muscle) plays a vital role in regulating within the bladder lumen and hence storage and voiding of urine. The cellular pathways that regulate detrusor contraction are outlined. A detailed knowledge of each of these components is vital if we are to understand the nature of urinary tract pathologies and devise therapeutic and other modes of regulating abnormal urinary tract function.

Stress urinary incontinence (SUI) is defined by the international Continence Society (ICS) in 2002 as the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing.

Almost all surveys concluded that SUI is the most common type of urinary incontinence (UI) in women with about 50% of the incontinent women have SUI. The prevalence of SUI is highest in the younger age group (<55 years) with a peak in the 4th decade (35–44 years). Risk factors: genetic factors may have a role in the development of SUI. Caucasian women are more susceptible than the African-American ladies. SUI is more common during pregnancy but it is most likely to be transient. Obesity is an established risk factor. All conditions that increase intra-abdominal pressure would increase the risk of SUI including constipation, lung diseases and some occupations. SUI could be a side effect of some medications, such as alpha-adrenoceptor antagonists. Pelvic organ prolapse strongly correlates with SUI. There is association between impaired mobility and incontinence. However, it remains controversial whether pelvic floor surgery, radiotherapy and menopause have any effect on developing SUI later in life. Pathophysiology: there are currently two patho-anatomical explanations for SUI: anatomical defects leading to bladder neck/urethral hypermobility and/or neuromuscular defects resulting in intrinsic sphincter deficiency (ISD).

Most women have little or no idea of where their pelvic-floor muscles are, what they do or how they can be exercised. Assessment and instruction by a specialist physiotherapist should be the first line of treatment for women with stress or urge incontinence or genital prolapse. Without expert instruction a woman may exercise conscientiously but entirely ineffectually. Correct pelvic-floor exercise has been shown to be cost-effective, to have no side effects, and to help women who wish to avoid surgery as well as those who wish to build up the strength of their muscles before surgery. The teaching of effective pelvic-floor exercise is described, and common faults identified. Periodic review by the physiotherapist ensures that the exercises continue to be performed properly, and can help to sustain motivation. Correctly performed pelvic-floor exercise is extremely beneficial and should be continued for life.