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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 28 | Prevalence and Severity of Urinary Incontinence and Pelvic Genital Prolapse in Females with Anal Incontinence or Rectal Prolapse [2001년 7월 DCR] | 2011-11-17 | 3582 |
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F. Xavier Gonzalez-Argente, M.D.,Anil Jain, M.D.,Juan J. Nogueras, M.D.,G. Willy Davila, M.D.,Eric G. Weiss, M.D., Steven D. Wexner, M.D.
From the Department of Cotorectal Surgery and Department of Gynecology/Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida
PURPOSE: The aim of this study was to determine the prevalence, severity', and associations between urinary incontinence and genital prolapse in females after surgery for fecal incontinence or rectal prolapse.
METHODS: All patients who underwent surgery for fecal incontinence (Group I) or rectal prolapse (Group II) were compared with a control group of females (Group III) by 43 questions regarding demographic data, past medical and surgical history, and diagnosis and treatment of anal and urinary incontinence and genital and rectal prolapse. The type (stress, urge, and total) of urinary incontinence was determined and graded using an incontinence severity questionnaire (Individual Incontinence Impact Questionnaire).
RESULTS: Overall response rate in the three groups of patients was 40.1 percent. The questionnaire was sent to 240 patients operated on for fecal incontinence or rectal prolapse, and 83 of them responded (34.5 percent). The patients were distributed into three groups: Group I consisted of 51 patients (mean age 56.7 + 14); Group II consisted of 32 patients (69.7 -+ 11); and Group III consisted of 40 patients (60.5 +
16). The prevalence of urinary incontinence in Group I was 27 (54 percent), in Group II was 21 (65.6 percent), and Group III was 12 patients (30 percent; P = 0.003). Genital prolapse was present in 9 (17.6 percent), 11 (34.3 percent), and 5 patients (12.5 percent), respectively (P = 0.03). The prevalence of coexistent urinary incontinence and genital prolapse in both study groups was 22.8 percent (19 patients). There were no statistically significant differences between Groups I and II relative to prevalence, type, and severity of urinary incontinence and genital prolapse, but there were significant differences between the two study groups and the control group. Of the patients in the study group, 67 percent had urinary incontinence before or at the time of surgerY. CONCLUSION: There is a higher prevalence and severity of urinary- incontinence and pelvic genital
prolapse in females operated on for either fecal incontinence or rectal prolapse than in a control group. Therefore, female patients with fecal incontinence or rectal prolapse should be evaluated and treated by a multidisciplinary group of pelvic floor clinicians, including a gynecologist or urologist with special training in female pelvic floor dysfunction and a colorectal surgeon. Numerous studies suggest a common cause for the development of fecal incontinence, urinary
incontinence, and pelvic organ prolapse. Damage to the pelvic support mechanism is thought to be the result of a combination of factors, including vaginal childbirth, connective tissue disorders, pelvic neuropathies, congenital deficiencies, pelvic surgery, and other factors. The prevalence of fecal incontinence in adult healthy females ranges from 1 to 16 percent, with an
increasing prevalence with advancing age. Urinary incontinence is estimated to affect 30 to 40 percent of older Americans. Contrary to popular belief, some studies that have examined urinary incontinence have shown only minimal increases in prevalence with advanced age. The overall prevalence of pelvic organ prolapse in the general population is difficult to ascertain, but it is
estimated that nearly 50 percent of parous females lose pelvic floor support, resulting in prolapse. Only 10 to 20 percent of these patients seek medical care for their symptoms. Few studies have evaluated the prevalence of combined urinary and fecal incontinence in females, reporting rates of 35 to 50 percent. This wide variation may be caused partially by the use of different
definitions and data-sampling methods, different age groups studied, or real differences in the population studied. Therefore, the aim of this study was to determine the prevalence, severity, and factors associated with urinary incontinence and genital prolapse in females previously operated on for either fecal incontinence or rectal prolapse. DISCUSSION
In this study patients operated on for fecal incontinence and or rectal prolapse reported high prevalence
rates of urinary incontinence (58 percent) and genital prolapse (24 percent). These rates are higher than control group patients with similar clinical characteristics and also higher than rates reported in other published studies of the general population. Prevalence rates of urinary incontinence and genital prolapse in the control group were 30 percent and 12.5 percent, respectively, and are similar to other epidemiologic studies, which have shown a prevalence of urinary incontinence between 15 and 45 percent in females over the age of 60. Because the medical records of enrolled patients were not reviewed, it is likely that the actual incidence of genital prolapse is higher than reported. In addition, although the symptoms of urinary incontinence are quite obvious to the sufferer, even moderate genital prolapse can be minimally symptomatic. Our results confirm the concept of multisystem dysfunction in females with pelvic floor dysfunction. Patients in Group II (females operated on for rectal prolapse) had a higher prevalence of urinary incontinence and genital prolapse than did patients in Group I (fecal incontinence). Although our numbers are too small to confirm this notion, the occurrence of rectal prolapse may indeed represent a greater degree of pelvic floor dysfunction. This finding is confirmed by the relatively lower incidence of fecal incontinence and rectal prolapse found in females undergoing surgery for genital prolapse and urinary incontinence.
The relatively low questionnaire response rate (34.5 percent in the two study groups and 40.1 percent
in the three groups) could be caused by multiple factors. The patient population is primarily an older group of patients with possible underlying physical impairment. In addition, many patients are only seasonal Florida residents. Fifteen questionnaires were returned unanswered relating the death of the patient. We attempted to improve this response rate by resending a new questionnaire and by telephone contact. The control group had a higher response rate because the purpose of the study was explained to them, and many of the subjects completed the questionnaire while waiting for their physician visit. Another limitation common to all questionnaire surveys is reliance on a given definition to diagnose a
condition. In this study the nature of the questions on urinary incontinence enabled an interpretation of three types (stress, urge, and total) and five levels of frequency (Tables 3 and 4). Many patients may be hesitant to classify their bladder dysfunction as "incontinence" and tend to minimize the severity and impact of their urine loss. A myriad of risk factors has been cited in published epidemiologic studies of pelvic organ prolapse and
urinary incontinence including advancing age, white race, obesity, vaginal delivery, estrogen deficiency, activities or conditions associated with chronically increased intra-abdominat pressure, cigarette smoking, underlying connective tissue disease, neuropathy. and prior hysterectomy. In this study only lower back pain, a history of previous pelvic surgery, hysterectomy, number of vaginal deliveries, and number of forceps deliveries showed a more significant correlation in the study group than in the control group. These factors by themselves may be enough to explain the high prevalence of urinary incontinence and genital prolapse in the study group. Despite pelvic organ prolapse being one of the most common indications for gynecologic surgery,
there is a lack of epidemiologic information regarding the condition. Terminology describing prolapse is at times confusing. Because prolapse may not become symptomatic until the descending segment is through the introitus, pelvic organ prolapse frequently is not recognized until end-stage disease exists. For this reason, genital prolapse was evaluated with the following question: have you had genital prolapse (dropped bladder or vagina) or have you been operated on for these reasons? It is not uncommon for urinary incontinence, anal incontinence, and pelvic organ prolapse to be metachronous rather than synchronous. In the present study 67 percent of the patients in the study group
(Group t plus Group II) presented with urinary incontinence before or at the same time as fecal incontinence or rectal prolapse surgery. Nevertheless, only 45 percent of patients described urinary incontinence or genital prolapse symptoms to their colorectal surgeons. Prior studies have reported that only 44 percent of females with significant urinary incontinence and 22 percent of those with minor incontinence had reported the problem to their physicians. Therefore, all females being evaluated for colorectal disease should be routinely questioned regarding
the presence or absence of symptoms indicative of urinary incontinence and examined to exclude genital prolapse. Similarly, patients undergoing urogynecologic assessment for urinary incontinence or genital prolapse should be queried about bowel control and examined for rectal prolapse. |
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