Pelvic floor disorders and quality of life in women with self-reported irritable bowel syndrome.

BACKGROUND: Quality of life among women with irritable bowel syndrome may be affected by pelvic floor disorders. AIM: To assess the association of self-reported irritable bowel syndrome with urinary incontinence, pelvic organ prolapse, sexual function and quality of life. METHODS: We analysed data from the Reproductive Risks for Incontinence Study at Kaiser Permanente, a random population-based study of 2109 racially diverse women (mean age = 56). Multivariate analyses assessed the association of irritable bowel syndrome with pelvic floor disorders and quality of life. RESULTS: The prevalence of irritable bowel syndrome was 9.7% (n = 204). Women with irritable bowel had higher adjusted odds of reporting symptomatic pelvic organ prolapse (OR 2.4; 95% CI, 1.4-4.1) and urinary urgency (OR 1.4; 95% CI, 1.0-1.9); greater bother from pelvic organ prolapse (OR 4.3; 95% CI, 1.5-11.9) and faecal incontinence (OR 2.0; 95% CI, 1.3-3.2); greater lifestyle impact from urinary incontinence (OR 2.2; 95% CI, 1.3-3.8); and worse quality of life (P < 0.01). Women with irritable bowel reported more inability to relax and enjoy sexual activity (OR 1.8; 95% CI, 1.3-2.6) and lower ratings for sexual satisfaction (OR 1.8; 95% CI, 1.3-2.5), but no difference in sexual frequency, interest or ability to have an orgasm. CONCLUSIONS: Women with irritable bowel are more likely to report symptomatic pelvic organ prolapse and sexual dysfunction, and report lower quality of life.

Effects of urinary incontinence, comorbidity and race on quality of life outcomes in women.

PURPOSE: We investigated the effects of comorbidity and urinary incontinence on both generic and incontinence specific quality of life outcome measures, and investigated whether the association between urinary incontinence and quality of life varies by race. MATERIALS AND METHODS: Study participants were 2,109 women 40 to 69 years old randomly selected from an urban health maintenance organization and interviewed in person for a study of risk factors for urinary incontinence. The sample was racially diverse consisting of 48% white, 18% black, 17% Hispanic and 16% Asian-American women. In addition to incontinence, reproductive and medical history questionnaires, all participants completed the Medical Outcomes Study Short Form 36, a measure of health related quality of life. All participants with daily and weekly incontinence (29%) completed the Incontinence Impact Questionnaire, an incontinence specific quality of life measure. The health maintenance organization's inpatient and outpatient electronic databases were used to calculate a Charlson comorbidity index score for each participant. ANCOVA was used to produce a model adjusting for sociodemographic variables, comorbidity and incontinence frequency. The same model was run for each of 4 racial groupings to examine differences by race/ethnicity. RESULTS: Urinary incontinence is significantly associated with a decreased quality of life and those with more frequent incontinence have significantly lower quality of life scores. In our model the Charlson score, an objective measure of comorbidity based on hospital and physician records, also has a significant negative impact on quality of life. When comorbidity is controlled, incontinence frequency continues to have a significant negative association with quality of life except among the sickest women. For women with the greatest extent of comorbidity, incontinence frequency is not significantly associated with negative quality of life outcomes. We did not find clear patterns of variation by race. CONCLUSIONS: Urinary incontinence and comorbidity each have an independent and significant role in reducing quality of life outcomes for all but the sickest women.

Urinary incontinence and pelvic floor dysfunction in Asian-American women.

OBJECTIVE: The objective of the study was to describe the prevalence, risk factors, and impact of urinary incontinence and other pelvic floor disorders among Asian-American women. STUDY DESIGN: This was a population-based cohort study of older women randomly selected from age and race strata. RESULTS: Weekly urinary incontinence was reported by 65 of 345 Asian women (18%), with stress and urge incontinence being approximately equally common. In multivariate analysis, higher body mass index (greater than 25 kg/m2) was associated with both stress incontinence (odds ratio 4.90, 95% confidence interval 1.76 to 13.68) and urge incontinence (odds ratio 2.49, 95% confidence interval 1.01 to 6.16) in Asians. Hysterectomy was a significant risk factor for stress incontinence (odds ratio 2.79, 95% confidence interval 1.03 to 7.54). Only 34% of Asian women with weekly urinary incontinence reported ever having sought treatment. Pelvic floor exercises were the most common form of treatment, being used by 29% of Asian women with weekly incontinence. Asians were less likely then white women to report anal incontinence (21% versus 29%, P = .007), although this difference became nonsignificant after adjusting for differences in risk factors. CONCLUSION: Asian women share some risk factors for stress and urge urinary incontinence with white women. Urinary incontinence is associated with anal incontinence among Asian women.

Cost of pelvic organ prolapse surgery in the United States.

OBJECTIVE: To estimate the annual direct cost to society of pelvic organ prolapse operations in the United States. METHODS: We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures. RESULTS: In 1997, direct costs of pelvic organ prolapse surgery were 1012 million dollars (95% confidence interval [CI] 775 dollars, 1251 million), including 494 dollars million (49%) for vaginal hysterectomy, 279 million dollars (28%) for cystocele and rectocele repair, and 135 million dollars (13%) for abdominal hysterectomy. Physician services accounted for 29% (298 million dollars) of total costs, and hospitalization accounted for 71% (714 million dollars). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures (218 million dollars). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to 1543 million dollars. CONCLUSION: The annual direct costs of operations for pelvic organ prolapse are substantial.

Physician behaviors that predict patient trust.

OBJECTIVE: The goal for this study was to assess the relative strength of the association between physician behaviors and patient trust. STUDY DESIGN AND POPULATION: Patients (N=414) enrolled from 20 community-based family practices rated 18 physician behaviors and completed the Trust in Physician Scale immediately after their visits. Trust was also measured at 1 and 6 months after the visit. The association between physician behaviors and trust was examined in regard to patient sex, age, and length of relationship with the physician. RESULTS: All behaviors were significantly associated with trust (P<.0001), with Pearson correlation coefficients (r) ranging from 0.46 to 0.64. Being comforting and caring, demonstrating competency, encouraging and answering questions, and explaining were associated with trust among all groups. However, referring to a specialist if needed was strongly associated with trust only among women (r=0.61), more established patients (r=0.62), and younger patients (r=0.63). The behaviors least important for trust were gentleness during the examination, discussing options/asking opinions, looking in the eye, and treating as an equal. CONCLUSIONS: Caring and comfort, technical competency, and communication are the physician behaviors most strongly associated with patient trust. Further research is needed to test the hypothesis that changes in identified physician behaviors can lead to changes in the level of patient trust.

Training physicians to increase patient trust.

Patient trust in the physician is an important aspect of the patient-physician relationship that has recently become a focus of interest, in part due to the rise of managed care in the US healthcare system. In a previous study, we identified physician behaviours reported by patients as important to establishing their trust in the physician. The current study attempted to modify these behaviours via a short training programme and thereby to increase patient trust and improve associated outcomes. After baseline measurements, 10 physicians were randomized to the intervention group and 10 remained as a control group. While intervention physicians showed a net improvement in 16 of 19 specific patient-reported behaviours when compared to control physicians, these differences were not statistically significant. There was also no significant difference in patient trust, patient satisfaction, continuity, self-reported adherence, number of referrals or number of diagnostic tests ordered. This short training course in a group of self-selected physicians was not a sufficiently strong intervention to achieve the desired effect. Suggestions are given for designing a stronger training intervention.

Hysterectomy and urinary incontinence: a systematic review.

BACKGROUND: Serious complications after hysterectomy are estimated to occur in around six women per 10,000 hysterectomies in the USA. We did a systematic review of evidence that hysterectomy is associated with urinary incontinence. METHODS: We identified English-language and non-English-language articles registered on MEDLINE from January, 1966, to December, 1997, did manual review of references, and consulted specialists. We identified 45 articles reporting on the association of urinary incontinence and hysterectomy. We selected reports that presented original data on development of incontinence in women who underwent hysterectomy compared with those who did not. Results were abstracted by two independent reviewers and summarised with a random-effects model. FINDINGS: 12 papers met our selection criteria--eight cross-sectional studies, two prospective cohort studies, one case-control study, and one randomised controlled trial. The summary estimate was consistent with increased odds for incontinence in women with hysterectomy. Because incontinence might not develop for many years after hysterectomy, we stratified the findings by age at assessment of incontinence. Among women who were 60 years or older, the summary odds ratio for urinary incontinence was increased by 60% (1.6 [95% CI 1.4-1.8]) but odds were not increased for women younger than 60 years. INTERPRETATION: When women are counselled about sequelae of hysterectomy, practitioners should discuss the possibility of an increased likelihood of incontinence in later life.

Differences in socioeconomic status and survival among white and black men with prostate cancer.

After diagnosis with prostate cancer, Black men in the United States have poorer survival than White men, even after controlling for differences in cancer stage. The extent to which these racial survival differences are due to biologic versus non-biologic factors is unclear, and it has been hypothesized that differences associated with socioeconomic status (SES) might account for much of the observed survival difference. The authors examined this hypothesis in a cohort study, using cancer registry and US Census data for White and Black men with incident prostate cancer (n = 23,334) who resided in 1,005 census tracts in the San Francisco Bay Area during 1973-1993. Separate analyses were conducted using two endpoints: death from prostate cancer and death from other causes. For each endpoint, death rate ratios (Blacks vs. Whites) were computed for men diagnosed at ages <65 years and at ages > or =65 years. These data suggest that differences associated with SES do not explain why Black men die from prostate cancer at a higher rate when compared with White men with this condition. However, among men with prostate cancer, SES-associated differences appear to explain almost all of the racial difference in risk of death from other causes.

Further validation and reliability testing of the Trust in Physician Scale. The Stanford Trust Study Physicians.

OBJECTIVES: To further validate and assess the reliability and validity of the Trust in Physician Scale. METHODS: Consecutive adult patients (n = 414) from 20 community-based, primary care practices were enrolled in a prospective, 6-month study. At enrollment, subjects completed the 11-item Trust in Physician Scale plus measures of demographics, preferences for care, and satisfaction with care received from the physician. Continuity, satisfaction with care, and self-reported adherence to treatment were measured at 6 months. Reliability, construct validity, and predictive validity were assessed using correlation coefficients and analysis of variance techniques. RESULTS: The Trust in Physician Scale showed high internal consistency (Cronbach's alpha = .89) and good 1-month test-retest reliability (intraclass correlation coefficient = .77). As expected, trust increased with the length of the relationship and was higher among patients who actively chose their physician, who preferred more physician involvement, and who expected their physician to care for a larger proportion of their problems (P < 0.001 for all associations). Baseline trust predicted continuity with the physician, self-reported adherence to medication, and satisfaction at 6 months after adjustment for gender, age, education, length of the relationship, active choice of the physician, and preferences for care. After additional adjustment for baseline satisfaction with physician care, trust remained a significant predictor of continuity, adherence, and satisfaction. CONCLUSIONS: The Trust in Physician Scale has desirable psychometric characteristics and demonstrates construct and predictive validity. It appears to be related to, but still distinct from, patient satisfaction with the physician and, thus, provides a valuable additional measure for assessment of the quality of the patient-physician relationship.

An intervention to increase patients' trust in their physicians. Stanford Trust Study Physician Group.

PURPOSE: To investigate the effect of a one-day workshop in which physicians were taught trust-building behaviors on their patients' levels of trust and on outcomes of care. METHOD: In 1994, the study recruited 20 community-based family physicians and enrolled 412 consecutive adult patients from those physicians' practices. Ten of the physicians (the intervention group) were randomly assigned to receive a one-day training course in building and maintaining patients' trust. Outcomes were patients' trust in their physicians, patients' and physicians' satisfaction with the office visit, continuity in the patient-physician relationship, patients' adherence to their treatment plans, and the numbers of diagnostic tests and referrals. RESULTS: Physicians and patients in the intervention and control groups were similar in demographic and other data. There was no significant difference in any outcome. Although their overall ratings were not statistically significantly different, the patients of physicians in the intervention group reported more positive physician behaviors than did the patients of physicians in the control group. CONCLUSIONS: The trust-building workshop had no measurable effect on patients' trust or on outcomes hypothesized to be related to trust.

Research interests of physicians in two practice-based primary care research networks.

Regional practice-based network research has grown significantly in the past 15 years. Previous studies have reported on characteristics of physicians who participate in network research, but little is known about the specific a priori research interests of practicing physicians. Knowledge of such interests could be useful in planning network research studies. We conducted a mail survey to assess the research interests of primary care physicians in two contiguous research networks at the University of California at San Francisco (UCSF) and at Stanford University. Among 120 respondents from the UCSF Collaborative Research Network and 85 from the Stanford Ambulatory Research Network, the most common topics of interest were disease prevention, communication and compliance, and managed care. Among specific conditions, heart disease, hypertension, and respiratory infection were of interest to the majority of respondents. Topics not of interest to network members were obstetrics, diagnostic procedures, alcoholism, drug abuse, tuberculosis, male genito-urinary problems, occupational hazards, domestic violence, and AIDS and HIV. Identification of network physician research interests can help focus research and recruitment efforts on topics of interest and provide estimates of participation levels for planning studies and preparing funding applications for research networks.

Reproductive and hormonal risk factors for urinary incontinence in later life: a review of the clinical and epidemiologic literature.

OBJECTIVES: To review and integrate the current literature on the role of reproductive factors in the development of urinary incontinence in later life. DESIGN: An extensive literature review using Medline and Science Citation Index for the period 1966 through 1997 was undertaken to identify published studies of the association between parturition events, hysterectomy, menopause, estrogen therapy, and later urinary incontinence. RESULTS: Vaginal delivery is an established risk factor for both transient postpartum incontinence and the development of incontinence in later life. Several studies have found evidence of nerve and muscle damage that provide a physiologic basis for this association. Prospective studies of incontinence after hysterectomy have generally found no increased risk in the first few years. In contrast, cross-sectional epidemiologic studies have consistently found an increased risk many years after hysterectomy. Although menopause is often considered a risk factor for urinary incontinence, epidemiological studies have generally not found an increase in the prevalence of incontinence in the perimenopausal period. Oral estrogen replacement therapy seems to have little short-term clinical benefit in regard to incontinence and is associated consistently with increased risk of incontinence in women aged 60 years and older in epidemiologic studies. CONCLUSIONS: This review provides a framework for further investigation of the complex relationships between reproductive risk factors and urinary incontinence. Integration of physiologic, clinical, and epidemiologic studies is needed to address the compelling health care issue of urinary incontinence. Suggestions are made for further areas of research.

Evaluation of parturition and other reproductive variables as risk factors for urinary incontinence in later life.

OBJECTIVE: To assess specific parturition and reproductive variables as potential risk factors for urinary incontinence in later life. METHODS: A mail survey was conducted with a random sample of 1922 women members of a large health maintenance organization. Multivariate analysis was used to estimate the independent association between parturition factors, hysterectomy, hormone use, and incontinence. RESULTS: Completed surveys were returned by 939 women (49%), 682 of whom reported at least one episode of incontinence in the past 12 months or ever having been treated for incontinence. On univariate analysis, women with incontinence were more likely to be white and heavier and to have had a hysterectomy before age 45, at least one live birth, a postdate (at least 42 weeks' gestation) birth, a labor lasting longer than 24 hours, and exposure to oxytocin. The risk of incontinence increased significantly with the number of exposures to oxytocin. In a multivariate model including age, there was a significant association between incontinence and white race (odds ratio [OR] 1.8, 95% confidence interval [CI] 1.2, 2.8), body mass (OR for fourth quartile 3.0, 95% CI 1.8, 5.0), estrogen replacement (OR 1.9, 95% CI 1.3, 2.8) and oxytocin (OR 1.9, 95% CI 1.0, 3.6). Parity was also associated with incontinence (P < .05). CONCLUSION: This study supports previous findings of a positive association between urinary incontinence and body mass, parity, and use of estrogen. In addition, we found a significant independent association between exposure to oxytocin during labor and incontinence in later life.

Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality.

OBJECTIVES: this study examined the association between medically recognized urinary incontinence and risk of several disease conditions, hospitalization, nursing home admission and mortality. DESIGN: review and abstraction of medical records and computerized data bases from 5986 members, aged 65 years and older, of a large health maintenance organization in northern California. RESULTS: there was an increased risk of newly recognized urinary incontinence following a diagnosis of Parkinson's disease, dementia, stroke, depression and congestive heart failure in both men and women, after adjustment for age and cohort. The risk of hospitalization was 30% higher in women following the diagnosis of incontinence [relative risk (RR) = 1.3, 95% confidence interval (CI) = 1.2-1.5] and 50% higher in men (RR = 1.5, 95% CI = 1.3-1.6) after adjustment for age, cohort and co-morbid conditions. The adjusted risk of admission to a nursing facility was 2.0 times greater for incontinent women (95% CI = 1.7-2.4) and 3.2 times greater for incontinent men (95% CI = 2.7-3.8). In contrast, the adjusted risk of mortality was only slightly greater for women (RR = 1.1; 95% CI = 0.99-1.3) and men (RR= 1.2; 95% CI= 1.1-1.4). CONCLUSIONS: urinary incontinence increases the risk of hospitalization and substantially increases the risk of admission to a nursing home, independently of age, gender and the presence of other disease conditions, but has little effect on total mortality.

Patient-physician trust: an exploratory study.

BACKGROUND: Patients' trust in their physicians has recently become a focus of concern, largely owing to the rise of managed care, yet the subject remains largely unstudied. We undertook a qualitative research study of patients' self-reported experiences with trust in a physician to gain further understanding of the components of trust in the context of the patient-physician relationship. METHODS: Twenty-nine patients participants, aged 26 to 72, were recruited from three diverse practice sites. Four focus groups, each lasting 1.5 to 2 hours, were conducted to explore patients' experiences with trust. Focus groups were audio-recorded, transcribed, and coded by four readers, using principles of grounded theory. RESULTS: The resulting consensus codes were grouped into seven categories of physician behavior, two of which related primarily to technical competence (thoroughness in evaluation and providing appropriate and effective treatment) and five of which were interpersonal (understanding patient's individual experience, expressing caring, communicating clearly and completely, building partnership/sharing power and honesty/respect for patient). Two additional categories were predisposing factors and structural/staffing factors. Each major category had multiple subcategories. Specific examples from each major category are provided. CONCLUSIONS: These nine categories of physician behavior encompassed the trust experiences related by the 29 patients. These categories and the specific examples provided by patients provide insights into the process of trust formation and suggest ways in which physicians could be more effective in building and maintaining trust.

Respiratory infection with Chlamydia pneumoniae in middle-aged and older adult outpatients.

This study was undertaken to characterize the epidemiology and clinical presentation of infection with Chlamydia pneumoniae in a population composed primarily of middle-aged and older adults. Pharyngeal swabs and acute and convalescent phase sera were obtained from outpatients presenting with signs and symptoms of an acute respiratory infection. Sera were examined using the micro-immunofluorescence (MIF) test to detect antibody to Chlamydia pneumoniae and complement fixation tests to detect Mycoplasma pneumoniae, influenza A virus, influenza B virus, respiratory syncytial virus and adenovirus. Pharyngeal swab specimens were cultured for Chlamydia pneumoniae and tested for Chlamydia pneumoniae by the polymerase chain reaction (PCR). A total of 743 patients with a mean age of 40.5 +/- 16.1 years were enrolled in the study. Twenty-one patients were serologically positive for acute Chlamydia pneumoniae infection in the MIF test. PCR was positive in 15 of the 20 serologically positive patients tested. Acute Chlamydia pneumoniae infection was identified in 3% (2/76) of subjects with pneumonia, 5% (12/247) of those with bronchitis, 5% (3/61) of those with sinusitis only and 2% (2/103) of those with pharyngitis only. Of the 21 patients with Chlamydia pneumoniae infection, seven (mean age of 33 years) had an antibody pattern suggesting a primary infection while 14 (mean age of 54 years) had a reinfection pattern. Patients with reinfection had milder disease than those with primary infection. PCR testing in the current study confirms the previously proposed serologic criteria of acute Chlamydia pneumoniae infection.

Association of prior infection with Chlamydia pneumoniae and angiographically demonstrated coronary artery disease.

OBJECTIVE: To evaluate the association between prior infection with Chlamydia pneumoniae, as measured by IgG antibody, and coronary artery disease. DESIGN: A population-based, case-control study. SETTING: Group Health Cooperative of Puget Sound, a Seattle-based health maintenance organization. PARTICIPANTS: Men 55 years of age and younger and women 65 years of age and younger. Cases (n = 171) were members of Group Health Cooperative undergoing diagnostic coronary angiography who had at least one coronary artery lesion occupying 50% or more of the luminal diameter. The population controls (n = 120) were Group Health Cooperative members without known coronary heart disease. MAIN OUTCOME MEASURE: The adjusted odds ratio (OR) for coronary artery disease associated with prior C pneumoniae infection as measured by the presence of IgG antibody. RESULTS: After adjusting for age, gender, and calendar quarter of blood drawing, the OR for coronary artery disease associated with the presence of antibody was 2.6 (95% confidence interval, 1.4 to 4.8). The association was limited to cigarette smokers, in whom the OR was 3.5 (95% confidence interval, 1.7 to 7.0). Among never-smokers, the OR was 0.8 (95% confidence interval, 0.3 to 1.9). When cases and controls were restricted to those assayed concurrently, the adjusted OR (smokers and nonsmokers combined) was 4.2 (95% confidence interval, 1.8 to 10.0). Adjustment for serum cholesterol, hypertension, alcohol use, diabetes, and socioeconomic status did not change these results. Only a week association was found when cases were compared with 63 subjects whose angiographic results were normal (OR, 1.2; 95% confidence interval, 0.6 to 2.2). CONCLUSIONS: These results generally support the previously reported association between C pneumoniae infection and coronary heart disease. However, caution should be used in interpreting the basis for this association.

Spontaneous abortion and subsequent adverse birth outcomes.

OBJECTIVE: Our purpose was to evaluate the association between spontaneous abortion and subsequent adverse birth outcomes. STUDY DESIGN: Washington State birth certificate records for 1984 to 1987 were used to examine the association between spontaneous abortion and adverse outcomes in the subsequent live birth. Adverse birth outcomes were examined for women with one spontaneous abortion before the index pregnancy (n = 2146) and for women with three or more prior spontaneous abortions and no other prior pregnancies (n = 638); compared with women with no prior spontaneous abortions (n = 3099). Logistic regression was used to estimate the relative risk associated with prior spontaneous abortion of each adverse outcome. RESULTS: Women with three or more prior spontaneous abortions were at higher risk for delivery at less than 37 weeks' gestation (relative risk 1.5, 95% confidence interval 1.1 to 2.1), placenta previa (relative risk 6.0, 95% confidence interval 1.6 to 22.2), having membranes ruptured greater than 24 hours (relative risk 1.8, 95% confidence interval 1.2 to 2.9), breech presentation (relative risk 2.4, 95% confidence interval 1.6 to 3.6), and having an infant with a congenital malformation (relative risk 1.8, 95% confidence interval 1.1 to 3.0). CONCLUSION: These findings suggest that common causes may underlie recurrent spontaneous abortion and certain adverse birth outcomes. They may also help guide clinical management of pregnancies in women with a history of recurrent spontaneous abortions.