Fecal incontinence in nonpregnant nulliparous women aged 25 to 64 years-a randomly selected national cohort prevalence study.

BACKGROUND: The extent to which fecal incontinence is associated with obstetrical history or pelvic floor injuries is still a controversial and unresolved issue. One crucial first step toward answering this question is the need to study fecal incontinence in nonpregnant, nulliparous women. OBJECTIVE: The aim of this study was to present detailed, descriptive measures of the accidental leakage of liquid or solid stool and gas in a randomly selected, large national cohort of nonpregnant, nulliparous women aged 25 to 64 years. STUDY DESIGN: The Swedish Total Population Register identified the source population. Four independent, age-stratified, simple random samples in a total of 20,000 nulliparous women aged 25 to 64 years were drawn from 625,810 eligible women. Information was collected in 2014 using postal and web-based questionnaires. The 40-item questionnaire included questions about the presence and frequency of the leakage of solid and liquid stool and gas, which provided the basis for the generic terms fecal and anal incontinence. Statistical analyses of the differences between the groups were performed using the Fisher's exact test for dichotomous variables and the Mann-Whitney U-test for continuous variables. The trend between >2 ordered categories of dichotomous variables was analyzed with Mantel-Haenszel statistics. When analyzing the trend between multiple ordered vs nonordered categorical variables, the Kruskal-Wallis test was used. The age-related probability and risk increase per 10 years for incontinence parameters was calculated from logistic regression models adjusted for body mass index. RESULTS: The study population was 9197 women, and the response rate was 52.2%, ranging from 44.7% in women aged 25 to 34 years to 62.4% among those from 55 to 64 years. All the types of incontinence, except severe isolated gas incontinence, increased with age up to 64 years. The estimated probability of fecal incontinence was 8.8% at age 25 years and 17.6% at age 64. The leakage of liquid stool was dominant, occurring in 93.1% (95% confidence interval, 91.4-94.5) of the women with fecal incontinence, whereas leakage of solid stool occurred in 33.9% (95% confidence interval, 31.1-36.7), of which approximately 80% also had concomitant leakage of liquid stool. The leakage of liquid stool increased markedly up to age 65, whereas the increase in the isolated leakage of solid stool was negligible across all ages (overall <0.4%). Liquid and solid stool, separate or in combination, co-occurred with gas in approximately 80%. The distribution pattern of the different types of leakage, single or combined, was similar in all the age groups. Both age and body mass index (kg/m2) were risk factors for fecal incontinence (P<.0001), with an interaction effect of P=.16. CONCLUSION: Abnormal stool consistency has been identified as the strongest risk factor for accidental bowel leakage. The same pattern characterized by a dominance of liquid stool and gas leakage, prevalent concomitant leakage of solid and liquid stool, and a negligible rate of isolated leakage of solid feces was observed across all ages. The low rates of isolated leakage of solid stool support the impression that dysfunction of the continence mechanism of the pelvic floor had a negligible role for bowel incontinence, which is essential information for comparison with women with birth-related injuries.

Childhood nocturnal enuresis-a marker for pelvic floor disorders and urinary tract symptoms in women?

INTRODUCTION AND HYPOTHESIS: A systematic survey on the association between childhood nocturnal enuresis (CNE) and adult pelvic floor disorders (PFDs) has not been presented previously. The aim was to describe the prevalence of PFDs and lower urinary tract symptoms in nulliparous women, with or without a history of CNE, at the age of ≥ 5 years. METHODS: This national survey of urinary (UI) and fecal incontinence (FI) and symptoms of pelvic organ prolapse (sPOP) was a random sample of 20,000 nulliparous women aged 25-64 years conducted in 2014. Women ≥ 5 years of age having CNE were compared with those without the condition. Fisher's exact test and logistic regression adjusted for BMI and age were used to analyze differences between groups. RESULTS: The response rate was 52% and 10.2% of adult women reporting CNE. One or more PFDs occurred in 38.3% of women with CNE compared to 23.8% in those without CNE (p < 0.0001). Mixed UI had the strongest association with CNE, odds ratio (OR) 2.63 (95% CI 2.03-3.40). The rate of FI was 11.2% in the non-CNE group and 16.8% in those with CNE (p < 0.0001) and sPOP 2.6% in the non-CNE and 4.8% in the CNE group (p = 0.0004), respectively. The prevalence of lower urinary tract symptoms was consistently higher in women with a history of CNE: overactive bladder 32.6% versus 18.4% (OR 2.34 95% CI 2.03-3.40), daytime micturition ≥ 8/day 29.6% versus 24.0% (p < 0.0001), and nocturia ≥ 2/night 12.4% versus 7.8% (p < 0.0001) in the CNE group. CONCLUSION: PFDs and lower urinary tract symptoms in nulliparous women were approximately doubled in women with a history of CNE and could therefore act as a strong confounding factor.

New types of diaphragms and cervical caps versus older types of diaphragms and different gels for contraception: a systematic review.

INTRODUCTION: Our primary objective was to evaluate whether new types of single-size diaphragms or cervical caps differ in prevention of pregnancy compared with older types of diaphragms, and whether different types of gels differ in their ability to prevent pregnancy. A secondary aim was to evaluate method discontinuation and complications. METHODS: A comprehensive search was conducted in PubMed, Embase and the Cochrane Library. The certainty of evidence was assessed according to the GRADE system. RESULTS: Four randomised controlled studies were included in the assessment. When comparing the new and old types of female barrier contraceptives the 6-month pregnancy rate varied between 11%-15% and 8%-12%, respectively. More women reported inability to insert or remove the FemCap device (1.1%) compared with the Ortho All-Flex diaphragm (0%) (p<0.0306). Urinary tract infections were lower when using the single-size Caya, a difference of -6.4% (95% CI -8.9 to -4.09) compared with the Ortho All-Flex diaphragm. The 6-month pregnancy rate for acid-buffering gel and spermicidal nonoxynol-9 gel varied between 10% and 12%. The discontinuation rate was lower in women who used acid-buffering gel compared with nonoxynol-9 gel (risk ratio (RR) 0.77, 95% CI 0.68 to 0.97). CONCLUSIONS: Pregnancy rates were generally high in women using female barrier contraceptives. There was no difference in the efficacy for pregnancy prevention between the new types of diaphragms and cervical caps and the older diaphragms. The new types of diaphragms and cervical caps resulted in fewer urinary tract infections. Acid-buffering gels did not differ from spermicidal nonoxynol-9 gels regarding pregnancies but seemed to be better tolerated.

Symptomatic pelvic organ prolapse in middle-aged women: a national matched cohort study on the influence of childbirth.

BACKGROUND: The relative impact of age, pregnancy, and vaginal delivery on symptomatic pelvic organ prolapse is still an unresolved issue that involves the controversial question about the protective effect of cesarean section. OBJECTIVE: The purpose of this study was to compare the age-related prevalence of symptomatic genital prolapse in nulliparous, vaginal- and cesarean-delivered women aged 40-64 years. STUDY DESIGN: This Swedish, nationwide matched cohort study involved 14,335 women. Three restricted, randomly selected source cohorts of women (nulliparous women unexposed to childbirth [n = 9136], 1-para cesarean delivered women, exposed to 1 pregnancy [n = 1412], and 1-para women exposed to 1 pregnancy followed by vaginal delivery [n = 3787]) were retrieved from the Swedish Medical Birth Register and Statistics Sweden and surveyed in 2008 and 2014. The surveys used a postal and Internet-based questionnaire containing validated questions for pelvic floor disorders. Symptomatic prolapse was defined by the question, "Do you have a sensation of tissue protrusion (a vaginal bulge) from your vagina?" In this study the symptom frequencies, sometimes and often, were defined as a positive response. Parous women were all assessed 20 years postnatally. One-to-one matching with an age interval for pairing of 3 years and 3 units of body mass index (kilograms per square meter) was used in women aged 40-64 years. The procedure succeeded in 2635 of 2640 women (99.8%), resulting in an adequate distribution of age and body mass index (kilograms per square meter) between matched groups. For comparison between groups, a Fisher exact test was used for categorical variables and the Mann-Whitney U test for continuous variables. Trend between matched groups was analyzed with Mantel-Haenszel statistics. Estimated, age-related values of symptomatic prolapse were obtained by logistic regression analysis. RESULTS: In nulliparous and cesarean-delivered women, the prevalence of symptomatic prolapse was relatively similar and below 5% across ages 40-64 years. In contrast, in women after vaginal delivery, there was an accelerating increase in the prevalence of symptomatic genital prolapse up to 65 years of age. Estimated probability from the regression model increased 4-fold, from 3.8% at 40 years to 13.4% at 64 years of age. The observed induction period associated with 1 vaginal delivery seemed to be at least 20 years among women giving birth in their early 20s. At age 64 years, the estimated probability of symptomatic prolapse was 12 times higher after vaginal delivery compared with cesarean deliery (13.4% [95% confidence interval, 9.4-18.9] vs 1.1% [95% confidence interval, 0.4-2.5], P < .0001). The calculated reduction of symptomatic prolapse by cesarean delivery at 64 years of age was thus 92%. CONCLUSION: In this national matched cohort study, the interaction between vaginal delivery and aging was the most important factor for the occurrence of symptomatic prolapse. Because the effect of aging can be modified only to a small extent, preventive strategies for genital prolapse should focus on how to avoid the adverse events related to a vaginal delivery.

The symptom of vaginal bulging in nulliparous women aged 25-64 years: a national cohort study.

INTRODUCTION AND HYPOTHESIS: Vaginal bulging is considered the key symptom for genital organ prolapse. The aim was to investigate the age-related prevalence and frequency of symptomatic pelvic organ prolapse (sPOP) and other pelvic floor symptoms in nonpregnant nullipara aged 25-64 years. METHODS: This national postal and web-based questionnaire survey was conducted in 2014 and included four independent random samples of women aged 25-34, 35-44, 45-54, and 55-64 years. The association of sPOP with demographics and with other pelvic floor conditions and with clustering to other pelvic floor conditions, was presented in women with and without sPOP. Logistic regression was used to identify and rank variables associated with symptomatic prolapse. RESULTS: The response rate was 52% (n = 10,187) and 726 nullipara confirmed sPOP. Women with sPOP were younger (p < 0.001), shorter (p < 0.001), and more often overweight and obese (p < 0.01) compared with asymptomatic women. Previous surgery for prolapse was reported by 15 women only (0.16%). Symptomatic POP decreased from 9.8% in the youngest age group (25-34 years) to 6.1% in the oldest (55-64 years) (p < 0.0001). Symptomatic POP was more often experienced as bothersome (p = 0.012), and aggravated by straining and heavy lifting (p = 0.003), in older women. Vaginal/vulval chafing/rubbing feeling was most prevalent among the youngest 14.2%, decreasing to 7.8% among the oldest (<0.0001). This symptom occurred three to five times more often in those with sPOP (p < 0.0001). Clustering of pelvic floor symptoms was four times more prevalent in women with sPOP (23.2% versus 6.1%) (p < 0.0001). CONCLUSIONS: The high prevalence of sPOP in this study was contradictory to most earlier reports, which have shown that genital prolapse is rare in nullipara. The explanation of our results may be the low probability of the clinical condition, the dominance of weak and infrequent symptoms, and not least clustering of alternative conditions mimicking sPOP.

Urinary incontinence in nulliparous women aged 25-64 years: a national survey.

BACKGROUND: A systematic survey of pelvic floor disorders in nulliparous women has not been presented previously. OBJECTIVE: The purpose of this study was to determine the prevalence of urinary incontinence parameters in a large cohort of nonpregnant, nulliparous women, and thereby construct a reference group for comparisons with parous women. STUDY DESIGN: This postal and World Wide Web-based questionnaire survey was conducted in 2014. The study population was identified from the Total Population Register in Sweden and comprised women who had not given birth and were aged 25-64 years. Four independent age-stratified, random samples comprising 20,000 women were obtained from the total number of eligible nullipara (n = 625,810). A 40-item questionnaire about pelvic floor symptoms, its severity, and its consequences were used. Age-dependent differences for various aspects of urinary incontinence were analyzed with the youngest group (25-34 years) serving as reference. Crude and body mass index-adjusted prevalence and its 95% confidence limits were calculated for each 10-year category. RESULTS: The response rate was 52% and the number of study participants was 9197. Urinary incontinence increased >5-fold from 9.7% in the youngest women with a body mass index <25 kg/m2 to 48.4% among the oldest women with a body mass index ≥35 kg/m2. The prevalence of bothersome urinary incontinence almost tripled from 2.8-7.9% among all nulliparas. The proportion with bothersome urinary incontinence among incontinent women increased from 24.4% in the youngest age group to 32.3% in the age group 55-64 years. Nocturia ≥2/night increased 4-fold to 17.0% and leakage ≥1/wk increased 3-fold to 12.8% among the oldest women. Mixed urinary incontinence increased from 22.9-40.9% among the oldest 0-para with incontinence, whereas stress urinary incontinence decreased inversely from 43.6-33.0%. In the total cohort surgical treatment for urinary incontinence occurred in 3 per thousand. CONCLUSION: Almost every aspect of urinary incontinence was present in nulliparous women of all ages and prevalence increased with advancing age between 25-64 years. This must be taken into account when using nullipara as a control group in comparisons with parous women to estimate the effect of pregnancy and childbirth.