Introduction and hypothesis
Obstetric anal sphincter injury causes anal incontinence in half of the women affected. However, most symptoms are mild. The objective of this study was to evaluate the ...prevalence of anal incontinence and quality of life in women at long term after delivery with obstetric anal sphincter injury. We also wanted to identify a relevant cutoff level of the Wexner score (also known as the Cleveland Clinic Incontinence Score) to indicate affected quality of life in these women.
Methods
We performed a population-based questionnaire cohort study with prospective follow-up, including all women in Denmark with obstetric anal sphincter injury and one subsequent delivery between 1997 and 2005. We performed uni- and multivariate analyses and calculated the area under the ROC curve.
Results
In Denmark, 3885 women had an obstetric anal sphincter injury in their first delivery and a second delivery between 1997 and 2005 and no subsequent deliveries until 2010–2011. Questionnaires were sent to 3259 eligible women, and the response rate was 74.6%. In total, 2004 women could be included in the final analyses. Of these, 29.2% (
n
= 584) reported affected quality of life due to anal incontinence at long-term follow-up. We found that all symptoms of anal incontinence were associated with affected quality of life. The median age at follow-up was 40.3 years.
The area under the ROC curve was 0.96 (95% CI 0.95–0.97) with a sensitivity of 0.94 (95% CI 0.92–0.96) and a specificity of 0.85 (95% CI 0.84–0.87) corresponding to an optimal cutoff level of the Wexner score of ≥ 2 to identify women with affected quality of life due to anal incontinence.
Conclusions
In women with obstetric anal sphincter injury, 29% reported affected quality of life due to anal incontinence at long-term follow-up, and we found a low Wexner score cutoff level of ≥ 2 to identify women with affected quality of life.
Objective To determine modifiable risk factors and incidence of obstetric anal sphincter injury (OASIS) in primiparous women. Study Design We performed a population-based retrospective cohort study, ...using data from the Danish Medical Birth Registry. The population consisted of primiparous women with a vaginal delivery in the time period 2000-2010. Univariable and multivariable logistic regressions were used to determine risk factors of OASIS. Main outcome measures were incidence of OASIS in first vaginal delivery, odds ratios for possible risk factors: age, body mass index, birthweight, head circumference, gestational age, presentation, induction of labor, oxytocin augmentation, epidural, mediolateral episiotomy, vacuum extraction, forceps, shoulder dystocia, and year of delivery. Results Of 214,256 primiparous women with a vaginal delivery, 13,907 (6.5%; 95% confidence interval CI 6.4–6.6%) experienced an OASIS. The incidence of OASIS increased in the time period (adjusted odds ratio aOR, 1.02; 95% CI, 1.02–1.03; P < . 0001, per year). We found a protective effect of epidural analgesia (aOR, 0.84; 95% CI, 0.81–0.88; P = . 0001). Vacuum extraction without episiotomy was a significant risk factor of OASIS (aOR, 2.99; 95% CI, 2.86–3.12; P < . 0001), and episiotomy was protective in vacuum-assisted deliveries compared with vacuum-assisted deliveries without episiotomy (aOR, 0.60; 95% CI, 0.56–0.65; P < . 0001). Birthweight was found to be an important nonmodifiable risk factor (aOR, 2.76; 95% CI, 2.62–2.90; P < . 0001). Conclusion Epidural analgesia in itself was protective against OASIS. Vacuum extraction increased the risk of OASIS, although mediolateral episiotomy was protective when applied in deliveries assisted by vacuum extraction.
Anal incontinence is a major concern following delivery with obstetric anal sphincter injury (OASIS), and has been related to the degree of sphincter tear.
The aims of this study were (1) to evaluate ...whether women with a fourth-degree OASIS in the first delivery have an increased risk of long-term anal and fecal incontinence after a second delivery, and (2) to assess the impact of mode of second delivery on anal incontinence and related symptoms in these patients.
We performed secondary analyses of a national questionnaire study in all Danish women with an OASIS in their first delivery and 1 subsequent delivery, both deliveries in 1997 to 2005. The questionnaires were sent a minimum of 5 years since the second delivery. In Denmark, women with anal incontinence after a delivery with OASIS are recommended elective cesarean deliveries in subsequent pregnancies. We performed uni- and multivariable logistic regression analyses to evaluate the outcomes.
In total, 2008 patients had an OASIS, of whom 12.2% (n = 245) had a fourth-degree tear in the first delivery. The median follow-up time since the first delivery with OASIS was 11.6 years (IQR, 10.2−13.2 years) and since the second delivery 8.5 years (IQR, 7.1−10.1 years). Women with a fourth-degree sphincter injury in the first delivery were at higher risk for anal incontinence (58.8%, n = 144) as well as fecal incontinence (30.6%, n = 75) than patients with a third-degree injury in the first delivery (41.0%, n = 723, and 14.6%, n = 258, respectively). The differences between groups persisted after adjustment for important maternal, fetal, and obstetric characteristics (adjusted odds ratio aOR, 2.14; 95% confidence interval CI, 1.52−3.02; P < 0.001 for anal incontinence; and aOR, 2.49; 95% CI, 1.73−3.56; P < 0.001 for fecal incontinence). In subgroup analyses of patients with fourth-degree anal sphincter injury in the first delivery, the mode of second delivery was not associated with the risk of anal incontinence (aOR, 0.97; 95% CI, 0.41−1.84; P = 0.71) or fecal incontinence (aOR, 1.28; 95% CI, 0.65−2.52; P = 0.48). The effect of the mode of the second delivery did not differ between women with a fourth-degree OASIS and those with a third-degree injury with regard to both anal (P = 0.09) and fecal (P = 0.96) incontinence.
After a second delivery, women with a fourth-degree OASIS in the first delivery have a higher risk of long-term anal and fecal incontinence than women with a third-degree sphincter injury. Adjusted odds of long-term anal and fecal incontinence did not differ significantly by mode of second delivery. Women with a fourth-degree OASIS should be informed about the increased risk of long-term anal incontinence and advised that subsequent elective cesarean delivery is not protective.
Photocoagulation of low-grade, intermediate-risk urothelial bladder tumors can be done in the outpatient department without anesthesia. The efficacy of photocoagulation to clear the bladder of these ...tumors is not inferior to that of traditional transurethral resection in general anesthesia.
Transurethral resection of recurrent low-grade intermediate-risk Ta bladder tumor (BT) in general anesthesia (GA) is burdensome to patients and health care system. Laser technologies enable treatment in office-based settings, reducing morbidity and costs.
To compare 4-mo recurrence-free survival after outpatient department (OPD) diode laser coagulation of BT in local anesthesia and gold standard transurethral resection of BT (TUR-BT) in GA in intermediate-risk Ta low-grade BT, and to evaluate treatment-related morbidity.
A prospective randomized noninferiority trial with 4-mo follow-up, in the hospital setting, was conducted in Capital Region of Denmark from 2016 to 2020. Participants were patients with histologically verified Ta low-grade BT recurrence. A total of 206 patients were randomized; 176 finished treatment and follow-up as per protocol.
Laser photocoagulation of bladder tumor (PC-BT) in OPD using a 980 nm diode laser compared with gold standard TUR-BT in GA, both performed with photodynamic diagnosis (PDD) guidance.
Four-month recurrence-free survival was assessed; predefined inferiority criterion was set at 15%. The secondary outcomes were pain during PC-BT, postoperative morbidity, postoperative complications, and patient’s preference.
Four-month recurrence-free survival was 8% higher after PC-BT (95% confidence interval CI: –8% to 24%). The predefined noninferiority criterion was met. Pain score (1–10) during PC-BT was 2.4 (interquartile range 0.8–3.3). Postoperative lower urinary tract symptom score (0–100) was 13.9 points higher (95% CI: 6.9–21.0, p < 0.001) in the group with transurethral resection of the bladder. The frequency of minor complications was 8.1% higher after TUR-BT (95% CI: 1.0–14.6%, p = 0.026). Of the patients, 98% (95% CI: 92–100%) preferred PC-BT.
PDD-guided PC-BT in OPD is as good as TUR-BT in GA to remove recurrent low-grade Ta BT. Postoperative quality of life is better after PC-BT and the frequency of minor complications was lower.
This study evaluates the efficacy of outpatient laser removal of low-grade noninvasive bladder tumor. Outpatient tumor removal with laser was as good as transurethral resection in general anesthesia and less burdensome to patients.
Background Primiparous women have an increased risk of obstetric anal sphincter injury; because most of these patients deliver again, there are major concerns about mode of delivery: the risk of ...recurrent obstetric anal sphincter injury and the risk of long-term symptoms of anal incontinence. Although an elective cesarean delivery protects against recurrent obstetric anal sphincter injury, it is uncertain how the second delivery affects the risk of long-term anal incontinence. Objective The purpose of this study was to evaluate whether the mode of delivery for a second pregnancy, after a documented obstetric anal sphincter injury at the time of first delivery, had a significant impact on the prevalence of anal and fecal incontinence in the long term. Study Design We performed a population-based questionnaire cohort study that evaluated anal and fecal incontinence, fecal urgency, and affected quality of life caused by anal incontinence in 1978 patients who had obstetric anal sphincter injury in the first delivery and a second vaginal (n = 1472 women; 71.9%) or elective cesarean delivery (n = 506 women; 24.7%) delivery. We performed uni- and multivariable logistic regression analyses to compare groups. Results Long-term anal incontinence was reported in 38.9% of patients (n = 573) with second vaginal compared with 53.2% (n = 269) with elective cesarean delivery. The corresponding numbers that reported anal incontinence before the second pregnancy was 29.4% for those with vaginal delivery compared with 56.2% of those with elective cesarean delivery (ie, there was a significantly larger change in the risk of anal incontinence in the group with a second vaginal delivery compared with the change in the group with elective cesarean in second delivery). However, adjusted for important maternal and obstetric characteristics, the risk of long-term anal incontinence was nonsignificantly lower in patients with elective cesarean delivery (adjusted odds ratio, 0.77; 95% confidence interval, 0.57–1.05; P = .09). Furthermore, the risk of fecal incontinence was not affected by mode of delivery in the multivariable analysis (adjusted odds ratio, 1.04; 95% confidence interval, 0.76–1.43; P = .79). Patients with persistent anal incontinence before the second pregnancy (n = 496) had an increased risk of long-term anal incontinence (adjusted odds ratio, 64.70; 95% confidence interval, 42.85–97.68; P < .001) and long-term fecal incontinence (adjusted odds ratio, 13.76, 95% confidence interval, 10.03–18.88, P <0.001) compared with patients without anal incontinence before the second pregnancy. Conclusion Mode of second delivery did not significantly affect the risk of long-term anal or fecal incontinence in multivariable analyses of patients with previous obstetric anal sphincter injury in this population in which patients with anal incontinence before the second pregnancy were recommended to have an elective cesarean delivery in the subsequent delivery. Nonetheless, we found that patients with vaginal delivery had a higher risk of deterioration of anal incontinence symptoms compared with those with an elective cesarean delivery.
Purpose: To examine clinimetric properties of the de Morton Mobility Index (DEMMI) in patients with hip fracture in comparison with the modified Barthel Index (BI), Cumulated Ambulation Score (CAS), ...and 30-s Chair Stand Test (30-s CST).
Materials and methods: Two hundred and twenty two patients with a hip fracture admitted to a geriatric ward following surgery were assessed on day 1 and at discharge (mean of 9 SD 5.1 post-surgery days).
Results: Ninety eight percent and 89% of patients were not able to perform the 30-s CST at baseline and at discharge (large floor effect), respectively. Corresponding floor effects were 39% and 31% for DEMMI, 12% and 5% for BI, and 22% and 6%, respectively, for CAS. Convergent validity was strong between DEMMI and CAS (r = 0.76, 95% CI: 0.69-0.81), and moderate between DEMMI and BI (r = 0.58, 95% CI: 0.48-0.66) and CAS and BI (r = 0.49, 95% CI: 0.39-0.59). Responsiveness, as indicated by the effect size was 0.76 for DEMMI, 1.78 for BI and 1.04 for CAS. Baseline scores of DEMMI, BI, and CAS showed similar properties in predicting discharge destination of patients from own home.
Conclusions: The value of using DEMMI and 30-s CST in patients with hip fracture during the acute hospitalization seems limited in comparison with BI and CAS. DEMMI and CAS seem to assess similar constructs.
Implications for Rehabilitation
Outcome measures used for the evaluation of patients with hip fracture should be validated in the specific time-line and rehabilitation setting following surgery, before being implemented in daily clinical practice.
We suggest the Cumulated Ambulation Score for monitoring basic mobility during the acute hospitalization for the entire group of patients recovering from a hip fracture, while DEMMI seems more feasible for the subgroup of patients with higher functional levels.
The modified Barthel Index seems useful for the assessment of activities of daily living in the acute care setting of patients with hip fracture. We cannot recommend the original 30-s Chair Stand Test to be used for the evaluation of patients with hip fracture in the acute hospital setting.
Abstract Background Women with an obstetric anal sphincter injury are concerned about the risk of recurrent obstetric anal sphincter injury in their second pregnancy. Existing studies have failed to ...clarify whether recurrence of obstetric anal sphincter injury affects the risk of anal- and fecal incontinence at long term follow up. Objective To evaluate whether recurrent obstetric anal sphincter injury influenced the risk of anal- and fecal incontinence more than 5 years after the second vaginal delivery. Study Design We performed a secondary analysis of data from a postal questionnaire study in women with obstetric anal sphincter injury in the first delivery and one subsequent vaginal delivery. The questionnaire was sent to all Danish women who fulfilled inclusion criteria and had two vaginal deliveries 1997 -2005. We performed uni- and multivariable analyses to assess how recurrent obstetric anal sphincter injury affects the risk of anal incontinence. Results In 1,490 women with a second vaginal delivery after a first delivery with obstetric anal sphincter injury, 106 had a recurrent obstetric anal sphincter injury. Of these, 50.0% (n=53) reported anal incontinence compared to 37.9% (n=525) of women without recurrent obstetric anal sphincter injury. Fecal incontinence was present in 23.6% (n=25) of women with recurrent obstetric anal sphincter injury and in 13.2% (n=182) of women without recurrent obstetric anal sphincter injury. After adjustment for third or fourth degree of obstetric anal sphincter injury in first delivery, maternal age at answering the questionnaire, birth weight of first and second child, years since first and second delivery and whether AI was present before second pregnancy, the risk of flatal and fecal incontinence was still increased in patients with recurrent obstetric anal sphincter injury, aOR 1.68 (95%CI 1.05-2.70) P = .03 and aOR 1.98 (95%CI 1.13-3.47) P =.02, respectively. More women with recurrent obstetric anal sphincter injury reported affected quality of life due to anal incontinence (34.9%, n=37) compared with women without recurrent obstetric anal sphincter injury (24.2%, n=335), although this difference did not reach statistical significance after adjustment, aOR 1.53 (95%CI 0.92-2.56) P =.10. Conclusion Women opting for vaginal delivery after obstetric anal sphincter injury should be informed about the risk of recurrence, which is associated with increased risk of long term flatal- and fecal incontinence.
Low back pain is highly prevalent among pregnant women, but evidence of an effective treatment are still lacking. Supervised exercise-either land or water based-has shown benefits for low back pain, ...but no trial has investigated the evidence of an unsupervised water exercise program on low back pain. We aimed to assess the effect of an unsupervised water exercise program on low back pain intensity and days spent on sick leave among healthy pregnant women.
In this randomised, controlled, parallel-group trial, 516 healthy pregnant women were randomly assigned to either unsupervised water exercise twice a week for a period of 12 weeks or standard prenatal care. Healthy pregnant women aged 18 years or older, with a single fetus and between 16-17 gestational weeks were eligible. The primary outcome was low back pain intensity measured by the Low Back Pain Rating scale at 32 weeks. The secondary outcomes were self-reported days spent on sick leave, disability due to low back pain (Roland Morris Disability Questionnaire) and self-rated general health (EQ-5D and EQ-VAS).
Low back pain intensity was significantly lower in the water exercise group, with a score of 2.01 (95% CI 1.75-2.26) vs. 2.38 in the control group (95% CI 2.12-2.64) (mean difference = 0.38, 95% CI 0.02-0.74 p = 0.04). No difference was found in the number of days spent on sick leave (median 4 vs. 4, p = 0.83), disability due to low back pain nor self-rated general health. There was a trend towards more women in the water exercise group reporting no low back pain at 32 weeks (21% vs. 14%, p = 0.07).
Unsupervised water exercise results in a statistically significant lower intensity of low back pain in healthy pregnant women, but the result was most likely not clinically significant. It did not affect the number of days on sick leave, disability due to low back pain nor self-rated health.
ClinicalTrials.gov NCT02354430.
Abstract Objective The aim of this study is to investigate the association between five-year changes in occupational sitting and body mass index (BMI) in working adults. Methods We analyzed data from ...The Danish Work Environment Cohort Study (2005 and 2010, n = 3.482). Data on occupational sitting, weight, height and several potential confounders were self-reported. The association between change in occupational sitting (hours) (categorized as large decrease < − 7.5, moderate decrease − 7.5 to < − 2.5, no change − 2.5 to 2.5, moderate increase > 2.5 to 7.5 and large increase > 7.5) and change in BMI was explored by multiple linear regression analyses. Results 43.0% men and 36.1% women had high occupational sitting time (≥ 25 h per week) at baseline. 31.8% men and 27.2% women decreased while 30.0% men and 33.0% women increased occupational sitting. The proportion of obese (BMI ≥ 30) increased almost 3% for both genders. BMI changed 0.13 (CI: 0.06; 0.20, p = 0.0003), per category of change in occupational sitting in women, but no association was found in men. Conclusion In women, there is a positive association between five-year changes in occupational sitting and BMI.
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