Radiation-Induced Sequelae Affecting the Continence Organ: Incidence,Pathogenesis, and Treatment

Introduction Incontinence is a late complication that causes symptoms years after radiation treatment and is difficult to deal with; it poses a particular challenge for care-providing physicians. Review This review looks at our current knowledge of the incidence, symptoms, and treatment of fecal incontinence induced by radiation treatment. An approximate estimation based on retrospective data suggests an incidence of fecal incontinence of up to one-third of patients. The mechanism that causes incontinence are changes in anal resting tone, squeeze pressure, and rectal volume or rectal compliance. The other associated aspects of incontinence include such further disorders as proctitis, colitis, and other disturbances involving the lower digestive tract. The therapeutic options mainly comprise the treatment of associated aspects, such as proctitis or diarrhea. Conclusion Surgical treatment should be the absolute exception. If the creation of a stoma is being considered, a resective procedure offering freedom from symptoms seems to be the more advantageous option. Presented at the meeting of the Coloproctology Group in the German Society of Visceral Surgery, Berlin, Germany, October 1, 2005. Reprints are not available.     

Pharmacotherapy for Fecal Incontinence: A Review

Fecal incontinence is a common clinical problem that often is frustrating to the patient and treating physician. Nonsurgical management for fecal incontinence includes dietary manipulation, Kegel exercises, perianal skin care, and biofeedback therapy. Pharmacotherapies often are used to assist in management of fecal incontinence. A variety of pharmacotherapies have been utilized for the management of fecal incontinence; limited data from randomized, placebo-controlled trials are available. This is a review of the existing literature on clinical trials of several classes of drugs and other medical therapies that may be beneficial for patients with fecal incontinence. The information in this article was obtained by a MEDLINE search for all clinical trials of drug therapy for fecal incontinence. These treatments and the existing data on their use are summarized. Treatments reviewed include stool bulking agents, with an emphasis on the most promising effect obtained with calcium polycarbophil, constipating agents, including loperamide, codeine, amitriptyline, atropine, and diphenoxylate agents injected into the anal sphincter, drugs to enhance anal sphincter function, including topical phenylepherine and oral sodium valproate, and trials of fecal disimpaction. A new classification to easily remember the treatment categories for this condition, based on the "ABCs of treatment for fecal incontinence," has been introduced into the structure of this review.     

脑卒中后尿失禁的针灸治疗进展

脑卒中后尿失禁是中风恢复期常见症状,严重影响患者的生活质量,针灸疗法作为传统中医疗法的重要组成部分,治疗该病具有简、便、廉、验的特点,临床疗效满意。从针灸治疗机理、常用穴位、临床疗效报道等方面介绍和总结近几年来脑卒中后尿失禁的针灸治疗进展,以期为该病的临床治疗提供参考。     

The effects of antimuscarinic treatments in overactive bladder: an update of a systematic review and meta-analysis

CONTEXT: Antimuscarinic agents are currently the first-line pharmacotherapy for overactive bladder. OBJECTIVES: A systematic review published in 2005 was updated, including data on a newly licensed antimuscarinic (fesoterodine). The primary aim of this study was to systematically review evidence on the efficacy of licensed administration of antimuscarinic treatments in overactive bladder from randomised controlled trials. Secondary aims were to review evidence on tolerability and safety and health-related quality of life (HRQL). EVIDENCE ACQUISITION: All relevant data sources from randomised controlled trials were searched, and two independent reviewers considered publications for inclusion and extracted relevant data. Meta-analysis was used to pool efficacy, tolerability, safety, and HRQL outcomes by treatment. Efficacy was measured by continent days, mean voided volume, urgency episodes, and micturition frequency. Tolerability and safety were measured by means of adverse event and withdrawal rates. HRQL was measured by various instruments. EVIDENCE SYNTHESIS: An additional 1118 references were retrieved with data on 83 studies extracted. Antimuscarinics were found to be more effective than placebo. Tolerability was good; few of the antimuscarinics were found to have significantly higher withdrawal rates in comparison to placebo. No serious adverse event for any product was statistically significant compared to placebo. Dry mouth (mild, moderate, severe) was the most commonly reported adverse event (29.6% on treatment vs 7.9% on placebo), followed by pruritus (15.4% on treatment vs 5.2% on placebo). Improvements were seen in HRQL with treatment by darifenacin, fesoterodine, oxybutynin transdermal delivery system, propiverine extended release (ER), solifenacin, tolterodine ER and immediate release, and trospium. Limitations of the study include restrictions on the types of patients typically included in overactive bladder trials and topics that have not been adequately addressed in the current antimuscarinic literature. CONCLUSIONS: Antimuscarinics are efficacious, safe, and well-tolerated treatments that improve HRQL. Profiles of each drug and dosage differ and should be considered in making treatment choices.     

RETRACTED ARTICLE: Transurethral ultrasonography-guided injection of adult autologous stem cells versus transurethral endoscopic injection of collagen in treatment of urinary incontinence

In the last years preclinical studies have paved the way for the use of adult muscle derived stem cells for reconstruction of the lower urinary tract. Between September 2002 and October 2004, 42 women and 21 men suffering from urinary stress incontinence (age 36–84 years) were recruited and subsequently treated with transurethral ultrasonography-guided injections of autologous myoblasts and fibroblasts obtained from skeletal muscle biopsies. The fibroblasts were injected into the urethral submucosa, while the myoblasts were implanted into the rhabdosphincter. In parallel, 7 men and 21 women (age 39–83 years) also diagnosed with urinary stress incontinence were treated with standard transurethral endoscopic injections of collagen. Patients were randomly assigned to both groups. After a follow-up of 12 months incontinence was cured in 39 women and 11 men after injection of autologous myoblasts and fibroblasts. Mean quality of life score (51.38 preoperatively, 104.06 postoperatively), thickness of urethra and rhabdosphincter (2.103 mm preoperatively, 3.303 mm postoperatively) as well as contractility of the rhabdosphincter (0.56 mm preoperatively, 1.462 mm postoperatively) were improved postoperatively. Only in two patients treated with injections of collagen incontinence was cured. The present clinical results demonstrate that, in contrast to injections of collagen, urinary incontinence can be treated effectively with ultrasonography-guided injections of autologous myo- and fibroblasts.     

Pudendal canal decompression in the treatment of urinary stress incontinence

Twelve women with urinary stress incontinence (USI) due to pudendal canal syndrome (PCS) were treated by pudendal canal decompression. The investigations comprised determination of the EMG activity of the external urethral sphincter (EUS) as well as the straining urethral reflex latency and pudendal nerve terminal motor latency (PNTML). The EMG of the EUS revealed diminished activity at rest and with coughing, with prolonged straining urethral reflex latency and PNTML. There was diminished sensation in the labia majora. These manifestations point to PCS and so pudendal canal decompression was performed. This comprised exposure of the inferior rectal nerve in the ischiorectal fossa through a para-anal incision. The nerve was traced to the pudendal nerve in the pudendal canal, which was split open. The patients were followed for a mean of 17.7 months ±4.2 SD.Three scores were defined: 1, where the patient became dry (6 patients); 2, where the patient unproved (5 patients); and 3, where no change was noted (1 patient). In scores 1 and 2 there was improvement in labia majora sensation and EMG activity of the EUS, as well as a decrease in the straining urethral reflex latency and the PNTML. The technique corrects a basic cause of USI, in contrast to other procedures which deal instead with the effects. The technique is simple, easy and without complications and can be done on an outpatient basis.     

The Incontinence Outcome Questionnaire: an instrument for assessing patient-reported outcomes after surgery for stress urinary incontinence

The aim of this study is to develop and psychometrically test a questionnaire (Incontinence Outcome Questionnaire, IOQ) for assessing quality of life (QOL) after surgery for stress urinary incontinence that can be used as a single measurement after the intervention. A total of 171 patients who underwent the tension-free vaginal tape (TVT/TVT-O) operation for stress urinary incontinence completed the King′s Health Questionnaire (KHQ), the Short Form-12 (SF-12) and the IOQ. The internal consistency, internal and external validity and responsiveness of the IOQ were tested. The IOQ–QOL subscale showed good internal consistency (Cronbach’s alpha = 0.83) and significant correlations with the KHQ and the SF-12 scales (r = 0.30–0.56). Partial correlations with objective parameters showed a significant relation for the IOQ–QOL subscale with objective continence/incontinence. The results of our study suggest that the IOQ is a valid and reliable instrument for assessing QOL after incontinence surgery and can be used if baseline or pre-operative data are unavailable.     

Sexual function following surgery for urodynamic stress incontinence

The objective of this study was to compare sexual function in women before and after surgery for urodynamic stress incontinence in the absence of pelvic organ prolapse. This was a prospective questionnaire survey. Fifty-four women undergoing surgery (tension-free vaginal tape/tension-free vaginal tape-obturator) for urodynamic stress incontinence with no evidence of detrusor overactivity or concomitant prolapse were assessed preoperatively and 6 months post operatively. Assessment was based on the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ), the International Consultation on Incontinence Questionnaire (ICIQ) and the Patient Global Impression of Improvement. Paired t-tests were used for comparing pre- and post-op scores and unpaired t-tests for comparing observations between groups. Spearman’s rank correlation was used for testing whether two numerically scored items were related, and McNemar test was used to compare pre- and postoperative responses to individual questions. ICIQ scores showed significant improvement after surgery (p < 0.001). Women completing PISQ were significantly younger (mean = 54) than those who did not (mean = 65; p < 0.001). The total PISQ score was better postoperatively (preoperative = 87.2, postoperative = 92.7; p < 0.001), with improvements in both the physical (preoperative = 31.0, postoperative = 35.2; p < 0.001) and partner-related domains (preoperative = 18.8, postoperative = 19.9; p = 0.002) but no improvement in behaviour emotive domains (preoperative = 37.3, postoperative = 37.6; p = 0.70). There was a reduction in episodes of coital incontinence postoperatively (preoperatively = 16/54, postoperatively = 39/54; p < 0.002). Previous vaginal surgery, oestrogen status of respondents and hysterectomy status did not affect the PISQ. Surgical correction of stress incontinence is associated with an improvement in sexual function.     

The prevalence of voiding difficulty after TVT,its impact on quality of life,and related risk factors

Objective: To determine the prevalence of voiding difficulty (VD), quality of life, and related risk factors after tension-free vaginal tape (TVT). Design: Prospective cohort study in 703 women with a TVT procedure for stress urinary incontinence. Main outcome measures: VD stated by women, Urogenital Distress Inventory (UDI-6) question 5 (difficulty in emptying the bladder), maximum flow rate, postvoid residual urine, necessity of postoperative catheterization, tape division, and impact on quality of life (Incontinence Impact Questionnaire, IIQ-7). Results: Postoperative catheterization (>24 h) was necessary in 11% and tape division in 1.3% of patients. There were 26% of women who stated VD and 25% reported moderate to great impairment on the UDI-6 after 36 months. While the negative impact on the outcome of TVT in women with abnormal voiding compared to women without is higher, the impact decreased significantly after TVT, implying a considerable improvement in quality of life. Pre-operative existing voiding difficulty and concomitant prolapse surgery were independent risk factors. Conclusions: Symptoms of VD occurred after TVT and caused lesser improvement in quality of life.     

The effect of catheter diameter on the urethral cough pressure profile of continent and incontinent patients

The importance of catheter diameter in causing inaccurate urethral pressure profile recordings was assessed with the aid of a special, dual diameter catheter. Cough pressure profiles obtained in premenopausal and postmenopausal incontinent patients were compared with control groups. The urethral functional length (FL) and pressure transmission ratio (PTR) did not change. The maximal urethral closing pressure (MUCP) decreased with the smaller catheter only in incontinent patients. Similarly, a decreased urethral surface at rest (USR) was observed for incontinent groups. Continent patients showed no modification of MUCP or USR with change in catheter diameter. The occlusive effect of the catheter was high (21 cmH₂O) in incontinent patients and less in continent patients (5 cmH₂O). The part played by the occlusive effect of the catheter may therefore be evaluated and considered an element explaining artificially high MUCP that do not reflect clinical reality in certain patients. This occurs most often in incontinent patients due to curvature of the catheter during coughing.