Prevalence, associated factors, and relationship to quality of life of lower urinary tract symptoms: a cross-sectional, questionnaire survey of cancer patients.

BACKGROUND: Few studies conducted outside of Asia have shown that lower urinary tract symptoms (LUTS) could be a concern for cancer patients. This gap necessitates more research on LUTS among cancer patients in Asia, particularly regarding associated factors and the relationship between quality of life and LUTS. OBJECTIVES: This study investigates the prevalence, associated factors, and relationship to quality of life of LUTS based on a sample of cancer patients. DESIGN: A cross-sectional, questionnaire survey. SETTINGS/PARTICIPANTS: This study was conducted at two oncology outpatient departments in two hospitals in Taiwan, and included 134 Asian cancer patients. METHODS: We collected information about each participant's individual characteristics, personal habits, LUTS, and quality of life by using a questionnaire. We calculated descriptive statistics to demonstrate the distribution of collected information, and used multivariate logistic regression to identify the factors associated with LUTS. We used Student's t-test to compare the mean quality of life scores for participants with and without LUTS. RESULTS: Ninety-nine (73.9%) participants experienced at least one type of LUTS, and the prevalence rates for various types of LUTS ranged from 3.7% to 52.2%. Radiotherapy and the time since the diagnosis of cancer were associated with LUTS. Participants with LUTS reported lower quality of life scores than participants without LUTS. CONCLUSIONS: The high prevalence of LUTS suggests that cancer treatment might be linked to LUTS, which in turn has a negative effect on a patient's quality of life. These results suggest that future research should involve studies in larger, more homogeneous samples. Health care providers should monitor the presence of LUTS and deliver the management and treatments of LUTS to optimise cancer patients' quality of life.

Revisiting reliability of quantified perineal ultrasound: Bland and Altman analysis of a new protocol for the rectangular coordinate method.

AIMS: This study tested the reliability of a new protocol for the rectangular coordinate method of quantifying perineal ultrasound. METHODS: Representative scans of healthy primiparous females were quantified by positioning a pubic bone template, drawn onto an acetate sheet containing x-y axes, over scans, by aligning the x-axis with the pubic bone central axis. Values for x (D(x)) and y (D(y)) located the urethrovesical junction (UVJ) at Rest, and at maximal Valsalva and Kegel. Range of motion (V-K) was calculated. Bland and Altman analysis, correlations, and t-tests determined intra- and inter-rater reliability, and variance due to designation of the pubic bone central axis (template control). RESULTS: Correlations averaged 0.72, 0.70, and 0.92 for intra-rater, inter-rater, and template control experiments. D(x) Rest, D(x) Kegel, and V-K were reliable in all experiments. First and second measures for inter-rater D(y) Rest and D(y) Kegel, and template control D(y) Valsalva were significantly different. Bland and Altman analysis showed D(y) Rest, D(y) Kegel, and D(x) and D(y) Valsalva for both reliability experiments to have limits of agreement (LOA's) large enough to explain >or=50% of the actual value ranges. Template control LOA's explained

Posttraumatic stress disorder and pregnancy complications.

OBJECTIVE: To assess the associations between specific pregnancy complications and posttraumatic stress disorder based on neurobiologic and behavioral characteristics, using Michigan Medicaid claims data from 1994-1996. METHODS: Two thousand, two hundred nineteen female recipients of Michigan Medicaid who were of childbearing age had posttraumatic stress disorder on the basis of International Classification of Diseases, 9th Revision (ICD-9) codes. Twenty percent (n = 455) of those recipients and 30% of randomly selected comparison women with no mental health diagnostic codes (n = 638; P <.001) had ICD-9 diagnostic codes for pregnancy complications. We used multiple logistic regression to investigate associations between specific pregnancy complications and posttraumatic stress disorder, controlling for demographic and psychosocial variables. Obstetric complications were hypothesized based on high-risk behaviors and neurobiologic alterations in stress axis function in posttraumatic stress disorder. RESULTS: After controlling for demographic and psychosocial factors, women with posttraumatic stress disorder had higher odds ratios (ORs) for ectopic pregnancy (OR 1.7, 95% confidence interval [CI] 1.1, 2.8), spontaneous abortion (OR 1.9, 95% CI 1.3, 2.9), hyperemesis (OR 3.9, 95% CI 2.0, 7.4), preterm contractions (OR 1.4, 95% CI 1.1, 1.9), and excessive fetal growth (OR 1.5, 95% CI 1.0, 2.2). Hypothesized labor differences were not confirmed and no differences were found for complications not thought to be related to traumatic stress. CONCLUSIONS: Pregnant women with posttraumatic stress disorder might be at higher risk for certain conditions, and assessment and treatment for undiagnosed posttraumatic stress might be warranted for women with those obstetric complications. Prospective studies are needed to confirm present findings and to determine potential biologic mechanisms. Treatment of traumatic stress symptoms might improve pregnancy morbidity and maternal mental health.

Behavioral intervention for urinary incontinence in women: evidence for practice.

In the past, clinicians have relied heavily on pharmacologic and surgical interventions for urinary incontinence in women. However, evidence now exists that less invasive, behavioral therapies can be extremely effective in helping women become continent; thus, strategies that involve bladder and pelvic floor muscle training should generally be the first line of treatment. Before behavioral intervention is initiated, it is important to assess for any medical or associated conditions that should be treated first. Bladder training enables women to accommodate increasingly greater volumes of urine in the bladder and gradually to extend the interval between voiding. Pelvic floor muscle training increases awareness of function and strengthens these voluntary muscles, promoting continence.

Continence for women: a test of AWHONN's evidence-based protocol in clinical practice. Association of Women's Health Obstetric and Neonatal Nurses.

OBJECTIVE: To test the effectiveness of an evidence-based protocol for urinary incontinence in increasing identification of women with the condition and improving their outcomes. DESIGN: Prospective formative evaluation study. SETTING: Twenty-one public, private, and other women's health care sites. PARTICIPANTS: Women in ambulatory care settings (N = 1,474) provided descriptive statistics. Clinical outcomes were tested in 132 cases for whom pre- and posttreatment data were available. INTERVENTIONS: Standardized screening and baseline follow-up forms were used to minimize time burden on clinicians; bladder and pelvic floor muscle training materials were provided to clinicians for distribution. MAIN OUTCOME MEASURES: Self-reported frequency, volume, and quality of life related to incontinence and cost of self-management were used to assess protocol effectiveness. RESULTS: Frequency of incontinence episodes, estimated volume lost per episode, and the cost of self-management decreased. Quality of life improved, as reflected in decreased bother attributed to incontinence and in the number of women avoiding activities such as shopping, exercising, or travel because of incontinence. CONCLUSIONS: This simple program of pelvic floor muscle and bladder training, as it has been systematically implemented in a variety of ambulatory women's health care settings, has benefited women's continence status. The results of this project strongly support widespread application.

Continence for women: evaluation of AWHONN's third research utilization project. Association of Women's Health Obstetric and Neonatal Nurses.

OBJECTIVE: To develop an evidence-based protocol for initial evaluation and treatment of urinary incontinence and to design procedures that would facilitate the protocol's implementation into clinical practice. DESIGN: Descriptive report of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) Continence for Women Project. SETTING: Twenty-one public, private, and other women's health sites. PARTICIPANTS: Women in ambulatory care settings (N = 1,474) provided demographic statistics. METHODS: The protocol was developed, sites were selected, site coordinator training was provided, data collection was facilitated by project-specific teleforms, and the overall process was evaluated by the science team. MAIN OUTCOME MEASURES: Site representation, patient representation, site coordinator feedback on the training program, and site coordinator experience during project implementation. RESULTS: The process yielded a representative mix of site and patient diversity appropriate for testing of the protocol. Site coordinators felt well-prepared to implement the protocol and experienced increased professional satisfaction because of therapeutic benefits achieved for patients and positive collaboration with physicians. CONCLUSIONS: The Continence for Women Project demonstrated the potential for developing and testing evidence-based protocols for clinical practice when the resources of an organization such as AWHONN and the research community are combined.

Continence for women: evidence-based practice.

Approximately 20% of women ages 25-64 years experience urinary incontinence. The symptoms increase during perimenopause, when 31% of women report that they experience incontinent episodes at least once per month. Bladder training and pelvic muscle exercise are the recommended initial treatment and can be taught effectively in the ambulatory care setting. Bladder training enables women to accommodate greater volumes of urine and extend between-voiding intervals. Pelvic muscle exercise increases muscle strength and reduces unwanted urine leakage. Accumulated research results provide evidence-based guidelines for nursing practice. The Association of Women's Health, Obstetric and Neonatal Nurses has identified continence for women as the focus of its third research utilization project. This article presents the rationale, evidence base, and educational strategies compiled by the Research Utilization 3 Nurse Scientist Team. Nurses can enable women to incorporate these noninvasive techniques into self-care.

Spontaneous pushing during birth. Relationship to perineal outcomes.

Vaginal birth is a recognized factor in perineal tissue damage and postpartum perineal pain. This study examined outcomes of 39 primiparous women who had spontaneous vaginal births. In a retrospective survey, women were asked to describe the type of pushing used to give birth and what the level of pain had been in the perineal (or vaginal) area during the first week postpartum. Labor and delivery chart data documented extent of episiotomy and/or laceration sustained. Eleven (28%) women reported using spontaneous bearing down efforts, and the remaining 28 (72%) were directed. Women who used spontaneous pushing were more likely to have intact perineums postpartum and less likely to have episiotomies, and second or third degree lacerations (chi 2 [3, N = 39] = 8.1, P = .043). Other variables, such as maternal age, infant birth weight, length of second stage, provider type, and use of epidural, did not demonstrate a significant difference in perineal outcome. Further analysis showed a significant relationship between the extent of perineal disruption and pain (F [3,30] = 5.08, P = .005).

Comfort in labor and midwifery art.

PURPOSE: To examine the phenomenon of comfort in the context of childbirth. Enhancement of comfort for laboring women is a valued outcome of nursing and midwifery care. Interventions that increase comfort during labor support a woman's effort to participate more fully in the birth thereby keeping her more aware of her body, emotions, and experience. ORGANIZING CONSTRUCT: The concept of comfort is analyzed and defined in the context of laboring women. Comfort studied from a feminist perspective is suggested. SOURCES: A literature review of nursing, midwifery, and medical texts from the 1920s to 1998 provides information about labor, pain in labor, and goals of providers caring for laboring women. Research articles focusing on comfort are identified as they relate to the concept of comfort in labor. Writings of contemporary feminist authors provided the ideas for designing the study of comfort from a feminist perspective. METHODS: To develop a theory of comfort during labor, early nursing and midwifery texts were searched to identify goals of care. The meaning of comfort was analyzed from the early 1920s to the present by concept analysis. Validation of findings was sought from publications on comfort research. FINDINGS: Comfort can exist in spite of great pain and nurses and midwives may be able to assist laboring women to achieve a level of comfort during labor. Intervening to promote the comfort of laboring women can empower these women during birthing. CONCLUSIONS: For clinicians caring for birthing women, particularly midwives, promotion of comfort is a high priority. Increasing comfort can redefine the meaning of pain in childbirth. Increasing comfort may create a decreased need for medical interventions and lower costs.

Physical activity and postpartum well-being.

OBJECTIVE: To describe reported patterns of postpartum physical activity and to identify benefits or risks associated with postpartum physical activity at 6 weeks postpartum. DESIGN: Secondary analysis of longitudinal data collected prenatally and postpartum in a study of obstetric outcomes at a midwestern tertiary-care center and its ambulatory satellite and hospital clinics. PARTICIPANTS: One thousand three women completed a questionnaire at the 6-week postpartum clinic visit. Mean age was 29.7 years, and mean education level was 15.3 years. VARIABLES OF INTEREST: Participation in vigorous exercise, change in postpartum activity level, postpartum weight retention, infant feeding method, maternal postpartum adaptation, and participation in activities for fun. RESULTS: Nearly 35% reported doing vigorous exercise with a modal frequency of three times per week. More active women had retained significantly less weight (8.6 lb [3.9 kg]) than their less active counterparts (11.3 lb [5.1 kg]). Vigorous exercisers demonstrated a consistent pattern of better scores on measures of postpartum adaptation and were more likely than nonexercisers to participate in fun activities, such as socializing, hobbies, and entertainment. Breastfeeding was not adversely affected by vigorous exercise. CONCLUSIONS: These exploratory results indicate that physical and psychologic benefits may accrue to postpartum women who are able to exercise vigorously and avoid decreasing their usual level of activity. A prospective randomized test of this relationship is warranted. Although positive outcomes of physical activity have been demonstrated in the population at large, exercise has rarely been an element in postpartum care plans. Nurses who care for women after childbirth should assess women's exercise goals and support them in their desired activities.

Anatomy of female continence.

Various muscle, connective tissue, and neurologic structures within the pelvic floor play critical roles in the maintenance of both urinary and fecal continence. Recent advances in technology, combined with greater precision during anatomic study, have expanded our understanding of the role played by the pelvic floor in maintaining continence. The goal of this article is to summarize recent research on female pelvic anatomy, with a particular emphasis on the evidence base related to urinary incontinence. The content is organized to accomplish three aims: (1) identify, within the context of pelvic floor anatomy, the structures that comprise the urinary continence system, (2) Describe the functional dynamics of urinary continence, including factors in resting urethral pressure and pressure transmission, and (3) Present the rationale, technique, and interpretation of various methods of measuring pelvic floor function.

Effect of pelvic muscle exercise on transient incontinence during pregnancy and after birth.

OBJECTIVE: To test the effect of pelvic muscle exercise on postpartum symptoms of stress urinary incontinence and pelvic muscle strength in primigravidas during pregnancy and postpartum. METHODS: A prospective trial randomized women into treatment (standardized instruction in pelvic muscle exercise) or control (routine care with no systematic pelvic muscle exercise instruction). Urinary incontinence symptoms were measured by questionnaire. Pelvic muscle strength was quantified by an instrumented gynecologic speculum. Time points were 20 and 35 weeks' gestation and 6 weeks, 6 months, and 12 months postpartum. RESULTS: Outcomes are reported for 46 women with vaginal or cesarean birth and for a subsample of 37 women with vaginal birth. Longitudinal analyses are reported for cases with complete data across time points. Diminished urinary incontinence symptoms were seen in the treatment group, with significant treatment effects demonstrated at 35 weeks' gestation (F [1,43] = 4.36, P = .043), 6 weeks postpartum (F [1,43] = 4.94, P = .032), and 6 months postpartum (F [1,43] = 4.29, P = .044). A repeated measures analysis of variance showed a significant interaction between time and treatment for urinary incontinence (F [4, 41] = 2.83, P = .037). A significant effect of initial pelvic muscle strength was demonstrated; ie, pelvic muscle strength at 20 weeks' gestation predicted significantly 12-months postpartum strength (F [1, 13] = 8.12, P = .014). Group differences in pelvic muscle strength were observed (the treatment group had greater strength at 6 weeks and at 6 months postpartum than did controls), but these differences were not statistically significant. CONCLUSION: Practice of pelvic muscle exercise by primiparas results in fewer urinary incontinence symptoms during late pregnancy and postpartum.

Continence for women: evidence-based practice.

Approximately 20% of women ages 25-64 years experience urinary incontinence. The symptoms increase during perimenopause, when 31% of women report that they experience incontinent episodes at least once per month. Bladder training and pelvic muscle exercise are the recommended initial treatment and can be taught effectively in the ambulatory care setting. Bladder training enables women to accommodate greater volumes of urine and extend between-voiding intervals. Pelvic muscle exercise increases muscle strength and reduces unwanted urine leakage. Accumulated research results provide evidence-based guidelines for nursing practice. The Association of Women's Health, Obstetric, and Neonatal Nurses has identified continence for women as the focus of its third research utilization project. This article presents the rationale, evidence base, and educational strategies compiled by the Research Utilization 3 Nurse Scientist Team. Nurses can enable women to incorporate these noninvasive techniques into self-care.

A digital test for pelvic muscle strength in women with urinary incontinence.

This article reports further experience with a Version 2 digital test performed on 208 community-residing women, 25 to 87 years old. Test-retest (n = 208) and interrater reliability (n = 36) scores for pressure, displacement, and duration were r = .54, .51, and .53 and r = .67, .73, and .55, respectively. Interrater reliability percentage agreement figures were exact for 94% of the women on pressure and 67% on displacement. With duration permitted to vary by 1 second, agreement was 75%. Validity was tested using vaginal electromyography scores with correlation coefficients ranging from .37 to .63. A weak but significant correlation was found between the digital score and the stand-up test pad gain (r = -.12). No significant relationship was found between the digital test and a history of being able to stop the urine stream or other leakage measures. To address limitations in Version 2, a third version of the digital scale is proposed.

Kegel dyspareunia: levator ani myalgia caused by overexertion.

BACKGROUND: The onset of unexplained dyspareunia with a normal pelvic examination requires a careful evaluation to search for an etiology. CASES: The initiation of Kegel exercises led to dyspareunia in several patients whose pain could be localized to the levator ani muscles. Elimination of the muscular overexertion led to resolution of the dyspareunia in all cases. CONCLUSION: Dyspareunia associated with the initiation of Kegel exercises may be due to levator ani myalgia. Once recognized as a potential source of dyspareunia, levator myalgia is easy to diagnose and treat.

Using a stopwatch to assess pelvic muscle strength in the urine stream interruption test.

Pelvic muscle strength is important in maintaining urinary continence. The urine stream interruption test provides a simple measure of pelvic muscle strength. This study evaluated the accuracy of the test as adapted for clinical use. Women (n = 75) were tested according to standardized protocol. The test was simultaneously timed using a uroflowmeter (for research purposes) and a stopwatch (a technique more feasible in the practice setting). The stopwatch-timed urine stream interruption test was consistent with the uroflowmeter score (r = 0.90, p < 0.00) and demonstrated adequate repeatability (r = -0.69, p < 0.00). The stopwatch test was related to a digital measure of pelvic muscle strength (r = -0.49, p = 0.00), i.e., women with greater pelvic muscle strength were able to interrupt the stream of urine more quickly. Significantly less involuntary urine loss was seen in women whose stopwatch test score was two seconds or less as compared with those whose scores were greater than two seconds (t = -4.83, p = < 0.00, df = 73). Clinicians can use the urine stream interruption test as a baseline measure and as a tool to assess changes in pelvic muscle strength.

Prevalence of abuse among pregnant women choosing certified nurse-midwife or physician providers.

Despite the fact that violence against women is a widespread problem in the United States, many providers do not routinely screen for it, particularly if the woman is not from a lower socioeconomic group. This was a secondary analysis of survey data from 940 antenatal women in private CNM and MD practices. Median annual income was $40,000 to $49,000 and mean schooling completed was 15 years. It was found that 91 (9.7%) had a history of previous abuse and eight (0.9%) were currently in an abusive relationship. Women with a previous history of abuse were found in the CNM caseloads at higher than expected levels. Annual income was predictive of women currently being abused, but not for women with past history. Abused women had on average less education than nonabused, with the most marked difference seen in women reporting current abuse. These results provide further evidence that the problem of abuse is not restricted to women of lower socioeconomic status. The finding that women with history of abuse were more likely to appear in CNM caseloads adds further support to the need for routine screening.