Urinary incontinence: prevalence,need for treatment,and effectiveness of intervention by nurse.

OBJECTIVE--To measure the unmet need of patients with regular urinary incontinence (incontinence twice or more a month) treatable by a nurse. DESIGN--Self completed postal questionnaire and randomised controlled trial of assessment and intervention by a nurse. SETTING--One urban and one rural general practice in Somerset. SUBJECTS--7300 adults randomly selected from 10,300 aged 35 and over on the combined practice lists. 515 women and 185 men with regular incontinence were offered assessment and treatment, of whom 134 women and 49 men had no intervention for three months (historical controls). They then joined the assessment and treatment programme. INTERVENTION--Four sessions of pelvic floor exercises and bladder retraining supervised by non-specialist nurse who had taken a three week course on assessing and treating uncomplicated incontinence. MAIN OUTCOME MEASURES--Number of patients desiring treatment; self reported cure, improvement, or deterioration in continence after three months. RESULTS--The questionnaire achieved a 79% response. Validated responses showed a prevalence of 4.4% in men and 16.4% in women aged 35-64. 315 (45%) of the 700 patients offered assessment refused it and seven had moved away or died, 64 men and 41 women were referred to their general practitioner. 197 of 292 treated women (68%) reported cure or improvement compared with seven (5%) of controls. 22 of the 86 men desiring treatment were suitable for intervention by the nurse. Seventeen were cured or improved compared with none of the men in the control group. CONCLUSIONS--About half the people with regular urinary incontinence took up the offer of treatment (9.2% of women and 3.4% of men in the study population). This condition can be effectively managed by a nurse with limited training.     

Reported prevalence of urinary incontinence in women in a general practice

To determine the prevalence of urinary incontinence and other urinary symptoms a questionnaire was sent to all women aged 25 and over and to women under 21 taking oral contraceptives registered with a rural practice (n=937); the questionnaire was completed by 833 women (89%). The overall prevalence of urinary incontinence was 41% (343/833); rates were lower in nulliparous and postmenopausal women (30/181 (17%) and 120/344 (35%) respectively) than parous and premenopausal women (313/652 (48%) and 225/479 (47%) respectively). Incontinence was significantly associated with perineal suturing after childbirth, being present in 201 of 376 (53%) women with sutures compared with 113 of 270 (42%) without. Of the 166 women with a history of minor gynaecological surgery, 100 had symptoms of incontinence, compared with 263 of the 657 (37%) without such a history. Incontinence was not related to type of delivery, and postnatal exercises for the pelvic floor were not beneficial.Inappropriate leakage of urine is perceived by many women as common and therefore not serious; thus it is often not reported to the doctor. Nevertheless, the 6% of women who always require protection against leakage could be helped by treatment.     

The prevalence of urinary incontinence

Urinary incontinence is a significant health problem with considerable social and economic impact. It is important to distinguish between prevalence and incidence with regard to incontinence, and prevalence-the probability of having incontinence within a defined population at a defined point in time-is the more important when considering its impact and the utilization of healthcare resources. There are large variations in the severity and impact of incontinence, and its severity, frequency, and predictability all need to be considered when evaluating its effects on patients, The degree of bother is particularly significant when determining who will need treatment. Incontinence may be a result of bladder dysfunction, sphincter dysfunction, or a combination of both, but large-scale studies are not designed to determine the etiology. In young women, the prevalence of incontinence is usually low, but prevalence peaks around menopause, with a steady rise there-after into later life. Although the prevalence of stress and mixed (stress and urge) incontinence is higher than urge incontinence, the latter is more likely to require treatment. In women, moderate and severe bother have a prevalence ranging from about 3% to 17%. Severe incontinence has a low prevalence in young women, but rapidly increases at ages 70 through 80. In men, the prevalence of incontinence is much lower than in women, about 3% to 11% overall, with urge incontinence accounting for 40% to 80% of all male patients. Stress incontinence accounts for less than 10% of cases and is attributable to prostate surgery, trauma, or neurological injury. Incontinence in men also increases with age, but severe incontinence in 70- to 80-year-old men is about half of that in women. The most effective therapy for incontinence will rely on targeting the correct populations to be treated, which depends on how data is collected on prevalence and severity.     

Health checks in general practice: another example of inverse care?

OBJECTIVE--To assess attendance at and the characteristics of patients attending health checks for cardiovascular disease offered in a general practice over a period of five years (1984-9). DESIGN--Medical record audit and postal questionnaire survey. SETTING--One general practice in Oxfordshire with a socially diverse population. PARTICIPANTS--1101 Men and 1110 women aged 35-64 registered with the practice. MAIN OUTCOME MEASURES--Age, sex, marital state, social class, smoking habits, alcohol consumption, and diet. RESULTS--Of the 2211 men and women in the target age group (35-64) in 1989, 1458 (65.9%) had been offered screening and 963 (43.6%) had attended for a health check. Attenders were more likely to be women, aged greater than or equal to 45, married, non-smokers, and of higher social class than patients who did not respond to the invitation. The relative likelihood of non-attendance was 1.24 for smokers, 1.20 for the overweight, 1.16 for heavy drinkers, and 1.28 for those with a less healthy diet, even after adjustment for age, sex, marital state, and social class. CONCLUSIONS--After five years of offering health checks, opportunistically (to men) and in the context of cervical smear tests (to women), less than half of the eligible patients had attended. The likelihood of acceptance of an invitation to attend was inversely related to the patient''s cardiovascular risk for all factors measured except age. A coherent strategy to reduce cardiovascular disease depends on more careful targeting of scarce health service resources and more emphasis on public health measures (such as dietary regulation and tobacco taxation). Doctors should be careful not to absolve the government of its public health obligations by substituting unproved preventive interventions aimed at the individual patient.     

Urinary incontinence in the community--analysis of a MORI poll.

OBJECTIVES--To investigate the prevalence of urinary incontinence among people living at home, their responses to it, and its emotional and social effects. DESIGN--Random sample of 4007 adults interviewed in their own homes. SETTING--Random sample of 178 constituency sampling points throughout Great Britain. SUBJECTS--1883 men, 2124 women aged 30 and over. MAIN OUTCOME MEASURES--Responses to questionnaire. RESULTS--6.6% (125) men and 14.0% (297) women had been incontinent of urine at some time--2.8% (52) men and 7.5% (159) women in the previous two months and 61% (124) of these for more than four years. 52% (108) had consulted their general practitioner at the onset of incontinence and a further 31% (65) later. Doctors commonly took a urine sample (163, 54%), referred the patient to a specialist (127, 42%), and prescribed tablets (109, 36%); only 22% (66) carried out an abdominal, rectal, or vaginal examination. Patients were not embarrassed in seeing their doctor and most thought they were treated sympathetically. 60% (265) of all those affected were concerned or worried about their incontinence, and in almost half incontinence limited their daily social activities. CONCLUSION--More people with incontinence seem to be consulting their doctors about it than has been found in previous studies, but the procedures carried out by general practitioners still seem to be suboptimal. Urinary incontinence has a profound effect on the day to day lives of most of those who suffer from it.     

Prevalence of knee problems in the population aged 55 years and over: identifying the need for knee arthroplasty.

OBJECTIVE--To determine the prevalence of knee problems in people aged 55 years and over and identify those who should be considered for knee arthroplasty. DESIGN--Postal survey; questionnaires were sent to a multistage stratified probability sample of residents of North Yorkshire Health Authority aged 55 and over. SETTING--A health district with a population of 210,000 aged 55 and over. RESULTS--An initial four page postal questionnaire produced an 86% response rate among 18,827 eligible patients. A subsequent detailed questionnaire sent to 1277 patients with knee problems (with a response rate of 78%) then determined the prevalence of severe pain and severe disability. Pain and disability consistent with the need to consider arthroplasty was found in 20.4/1000 (95% confidence interval 18.0 to 23.1); of these, 4.1 (2.7 to 5.8)/1000 had extreme disability. Age and sex specific rates in men who might benefit from arthroplasty were, in those aged 55-64, 12.9 (8.4 to 19.0)/1000; aged 65-74, 12.1 (7.4 to 18.4)/1000; aged 75 and over, 20.3 (12.9 to 30.5)/1000. In women aged 55-64 the rates were 12.9 (8.6 to 18.7)/1000; aged 65-74, 19.6 (13.9 to 26.7)/1000; aged 75 years and over, 42.6 (34.3 to 52.4)/1000. CONCLUSIONS--Total knee replacement has until recently been considered unreliable and often seen as a last resort for many with severe knee problems. Advances in prosthesis design and surgical and anaesthetic techniques have transformed this procedure into a reliable option with a potential for reducing disability and dependency in a large number of people in the community. Understandably, the prevalence pool of those who may benefit is large; health authorities and, increasingly, general practitioners should consider purchasing more total knee replacement surgery to offer real choice to those in need.     

Coverage and uptake of systematic postal screening for genital Chlamydia trachomatis and prevalence of infection in the United Kingdom general population: cross sectional study

Objective To measure the coverage and uptake of systematic postal screening for genital Chlamydia trachomatis and the prevalence of infection in the general population in the United Kingdom. To investigate factors associated with these measures.Design Cross sectional survey of people randomly selected from general practice registers. Invitation to provide a specimen collected at home.Setting England.Participants 19 773 men and women aged 16-39 years invited to participate in screening.Main outcome measures Coverage and uptake of screening; prevalence of chlamydia.Results Coverage of chlamydia screening was 73% and was lower in areas with a higher proportion of non-white residents. Uptake in 16-24 year olds was 31.5% and was lower in men, younger adults, and practices in disadvantaged areas. Overall prevalence of chlamydia was 2.8% (95%confidence interval 2.2% to 3.4%) in men and 3.6% (3.1% to 4.9%) in women, but it was higher in people younger than 25 years (men 5.1%; 4.0% to 6.3%; women 6.2%; 5.2% to 7.8%). Prevalence was higher in the subgroup of younger women who were harder to engage in screening. The strongest determinant of chlamydial infection was having one or more new sexual partners in the past year.Conclusions Postal chlamydia screening was feasible, but coverage was incomplete and uptake was modest. Lower coverage of postal screening in areas with more non-white residents along with poorer uptake in more deprived areas and among women at higher risk of infection could mean that screening leads to wider inequalities in sexual health.     

Insulin Resistance Is Associated with Prevalence of Physician-Diagnosed Urinary Incontinence in Postmenopausal Non-Diabetic Adult Women: Data from the Fourth Korea National Health and Nutrition Examination Survey

Objective

To investigate the association between insulin resistance (IR) and urinary incontinence in Korean adult women by analyzing the data from the Korea National Health and Nutrition Examination Survey IV (KNHANES) 2007–2009

Methods

A nationally representative sample of 5318 non-diabetic Korean women ≥19-years-of-age (3043 premenopausal and 2275 postmenopausal women) was included from KNHANES 2008–2010. IR was measured using the homeostasis model assessment of IR (HOMA-IR). Participants in the highest and lowest quartile of HOMA-IR were defined as insulin-resistant and insulin-sensitive respectively. Women who have current physician-diagnosed urinary incontinence were classified as having urinary incontinence.

Results

Incontinence was found in 9.18% of the total population, 8.51% of the premenopausal population, and 10.86% of the postmenopausal population. The prevalence of incontinence increased with age, reaching a peak at 60-69-years-of-age. The prevalence of urinary incontinence increased significantly with higher HOMA-IR quartiles in pre- and post-menopausal women (p for linear association = 0.0458 and 0.0009 respectively). Among post-menopausal women, those in the highest quartile of HOMA-IR were significantly more likely to have urinary incontinence compared to those in the lowest quartile [adjusted odds ratio, 1.72; 95% confidence interval, 1.07–2.77]. However premenopausal population exhibited no association between incontinence and HOMA-IR quartiles

Conclusion

Our results suggest that the prevalence of incontinence increased across HOMA-IR in non-diabetic adult women, and especially, IR might be a risk factor for incontinence in postmenopausal non-diabetic women.     

Self-destructive behaviour in the Hungarian population

In Hungary today the mortality rate of middle aged (55-64 years old) men is higher than it was in the 1930s. Within these statistics there are considerable socioeconomic differences, the mortality rate of lower secondary or lower educated middle aged men is 1.45 times higher than among those with higher education. About 40% of these socioeconomic mortality differences can be explained by higher prevalence of risk behaviour in lower socioeconomic groups. According to the results of our national representative survey conducted in the Hungarian population with 12640 persons in 1995, the prevalence of smoking was 45.5% among men and 26.6% among women. In the populaton younger than 45 years old the prevalence of smoking among men was 47.9%, among women 31.9%. Among men there is a clear socioeconomic gradient in smoking, in the number of daily cigarettes, the quantity of spirit consumption in one occasion, among women this socioeconomic gradient is not so obvious. The effectiveness of health promotion programmes depends on effective management of the motivational, psychological determinants of risk behaviour.     

Mental distress and social conditions and lifestyle in northern Norway.

In a cross sectional survey of risk factors for coronary heart disease three questions about mental distress were included in a questionnaire completed by 13,704 people, 64% of the total population aged 20-54 in one municipality. Overall, 860 (12.5%) of the men and 1141 (16.8%) of the women reported having at least one symptom of mental distress. There were no distinct differences between the age groups. Single people, separated and divorced people, and those who reported that the financial situation of the family during their childhood was difficult reported more mental problems. Heavy smoking, frequent alcohol consumption, and, in men, little or no physical activity in leisure time were also associated with a high prevalence of mental distress. By multiple regression analyses, marital state, financial situation of family during childhood, and current lifestyle were found to be highly significantly associated with mental distress. Including a few questions on mental distress in health surveys provides a way to establish relations between such symptoms and social conditions and lifestyle in large numbers of subjects.     

West Berkshire perineal management trial: three year follow up.

Women who had participated in a randomised controlled trial of policies of restricted (10%) versus liberal (51%) episiotomy during spontaneous vaginal delivery were recontacted by postal questionnaire three years after delivery. Altogether 674 out of 1000 responded, and there was no evidence of a differential response rate between the two trial groups. Similar numbers of women in the two groups reported further deliveries, almost all of which had been vaginal and spontaneous. Fewer women allocated to restrictive use of episiotomy required perineal suturing after subsequent delivery, but this difference was not significant. Pain during sexual intercourse and incontinence of urine were equally reported in the two groups. The similarity in incontinence rates persisted when severity, type of incontinence, and subsequent deliveries were taken into account. Liberal use of episiotomy does not seem to prevent urinary incontinence or increase long term dyspareunia.     

Patterns in self-rated health according to age and sex in a Japanese national survey, 1989–2004

Background: Perceived good health or good self-rated health is considered to be a predictor of longer survival and maintenance of good quality of life, which is a public health goal.Objective: This study assessed trends in the percentage of self-rated poor health among Japanese residents, based on data from the National Comprehensive Survey of the Living Conditions of People on Health and Welfare.Methods: Results of the survey (which is conducted in Japan every 3 years to determine the living conditions of people receiving health and welfare services) were analyzed using multistage and stratified cluster sampling of households. Self-rated health was measured by response to the question, “Recently, would you say that in general your health has been good, fairly good, fair, fairly poor, or poor?” The trend in fairly poor or poor health status during the period from 1989 through 2004 was stratified by sex and age group.Results: The rates of response to the survey were 90.9% (246,892/271,588) in 1995 and 79.8% (220,836/276,682) in 2004. Target subjects were aged ≥20 years in each year of the study. The prevalence of self-reported fairly poor or poor health was lowest in 1995 and then increased every year until 2001, when it appeared to reach a plateau. The prevalence of having fairly poor or poor health among women aged 35 to 44, 45 to 54, 55 to 64, and 65 to 74 years were as follows in 1995: 9.2%, 11.7%, 15.3%, and 19.8%, respectively. In 2004, the rates were 13.3%, 17.2%, 22.1%, and 31.7%, respectively. By comparison, the prevalence of self-reported fairly poor or poor health was 8.1%, 9.3%, 13.7%, and 17.9% among men aged 35 to 44, 45 to 54, 55 to 64, and 65 to 74 years, respectively, in 1995. In 2004, these rates were 12.8%, 14.8%, 19.0%, and 27.9%, respectively.Conclusions: In this survey, conducted every 3 years between 1989 and 2004 in Japanese households, older subjects had a greater prevalence of self-reported fairly poor or poor health than did younger subjects. The proportion of respondents who described their health as poor or fairly poor was highest in 1995. Women generally had a greater prevalence of self-reported poor or fairly poor health.     

Self-Rated Health in the Last 12 Years of Life Compared to Matched Surviving Controls: The Health and Retirement Study

Self-rated health (SRH) is a valid measure of health status and associated with mortality. Based on individual-level biannual repeat data on SRH we sought to characterize the natural history of poor SRH during the 12 years prior to death in men and women in different age groups. We conducted a retrospective analysis of the Health and Retirement Study participants who died between 1998 and 2010 and had at least two SRH measurements in the 12 years prior to death. We used a nested case-control design to compare SRH trajectories of deceased men and women aged 30–64, 65–79 and 80 years versus surviving participants. The cases comprised 3,350 deceased participants who were matched to surviving controls (n = 8,127). SRH was dichotomized into good vs. poor health. Men and women dying at age 65–79 and ≥80 years had 1.5 to 3 times higher prevalence of poor SRH already 11–12 years prior to death compared to surviving controls. The risk estimates remained statistically significant even after adjusting for life-style related risk factors and diagnosed diseases. Prevalence of poor SRH before death was lowest among those aged ≥80 years and highest in 30–64 year-olds. In conclusion, men and women who subsequently die perceive their health worse already 11–12 years prior to death compared to their surviving controls.     

Treatment of urinary incontinence in women in general practice: observational study.

OBJECTIVE--To examine what is attainable when treating urinary incontinence in women in general practice. DESIGN--Observational study with 12 months'' follow up. Interview and clinical examination before, during, and after treatment of women seeking help for urinary incontinence in general practice. SETTING--General practice in the rural district of Rissa, Norway. SUBJECTS--105 women aged 20 or more with urinary incontinence. INTERVENTIONS--Treatment with pelvic floor exercises, electrostimulation, oestrogen, anticholinergic drugs, bladder training, and protective pads. MAIN OUTCOME MEASURES--Subjective and objective measures of urinary incontinence; number of patients referred to a specialist. RESULTS--After 12 months'' follow up 70% (69/99) of the women were cured or much better; the mean score on a 100 mm visual analogue scale decreased from 37 to 20 mm; and the proportion of women who were greatly bothered by their incontinence decreased by 62%. 20% (20/98) of women became continent, and the percentage of women with severe incontinence decreased from 64% (63/99) to 28% (27/98). Mean leakage per 24 hours measured by a pad test decreased from 28 g at the start of treatment to 13 g after 12 months. The number of light weight pads or sanitary towels decreased from 1.6 to 0.6 a day. In all, 17/105 (16%) patients were referred to a specialist. CONCLUSIONS--Urinary incontinence in women can be effectively managed in general practice with fairly simple treatment. Most women will be satisfied with the results.     

Loss of employment and mortality.

OBJECTIVE--To assess effect of unemployment and early retirement on mortality in a group of middle aged British men. DESIGN--Prospective cohort study (British Regional Heart Study). Five years after initial screening, information on employment experience was obtained with a postal questionnaire. SETTING--One general practice in each of 24 towns in Britain. SUBJECTS--6191 men aged 40-59 who had been continuously employed for at least five years before initial screening in 1978-80: 1779 experienced some unemployment or retired during the five years after screening, and 4412 remained continuously employed. MAIN OUTCOME MEASURE--Mortality during 5.5 years after postal questionnaire. RESULTS--Men who experienced unemployment in the five years after initial screening were twice as likely to die during the following 5.5 years as men who remained continuously employed (relative risk 2.13 (95% confidence interval 1.71 to 2.65). After adjustment for socioeconomic variables (town and social class), health related behaviour (smoking, alcohol consumption, and body weight), and health indicators (recall of doctor diagnoses) that had been assessed at initial screening the relative risk was slightly reduced, to 1.95 (1.57 to 2.43). Even men who retired early for reasons other than illness and who appeared to be relatively advantaged and healthy had a significantly increased risk of mortality compared with men who remained continuously employed (relative risk 1.87 (1.35 to 2.60)). The increased risk of mortality from cancer was similar to that of mortality from cardiovascular disease (adjusted relative risk 2.07 and 2.13 respectively). CONCLUSIONS--In this group of stably employed middle aged men loss of employment was associated with an increased risk of mortality even after adjustment for background variables, suggesting a causal effect. The effect was non-specific, however, with the increased mortality involving both cancer and cardiovascular disease.     

Disability as identified from general practice records.

Thirty eight doctors who attended a postgraduate educational course provided information about disabled patients identified in a search of 7000 records. Disablement was defined as a major disruption to the normal lifestyle of patients in appropriate age and sex groups. Altogether 242 people were identified as disabled, equivalent to 32 per 1000 population, which is closely similar to that published by Harris, who identified patients by postal questionnaire. Among adults aged 15 to 64 more men were identified than women, and we suggest that a higher rate of disablement might be expected in men. Disablement among women may be underestimated because of underrecognition by doctors of disability in housewives. Fifty two per cent of all disabled people were able to attend the doctor''s surgery, and 72% were receiving regular medication; 79% were dependent on relatives, but only 30% were dependent on statutory services. In the opinion of the recording doctors medical and nursing needs were well met, though not the social needs, where the importance of living alone is noteworthy.     

Prevalence of facial acne vulgaris in late adolescence and in adults.

A survey of 1066 healthy women and 1089 healthy men aged 18-70 years, performed to determine the prevalence of facial acne, showed that clinical acne was not confined to adolescents. Though it was more prevalent among men than women at 18, beyond the age of 23 clinical acne was more prevalent among women as the prevalence in men gradually declined. At 40-49 years 3% of men and 5% of women still had definite, albeit mild, clinical acne, and at 50-59 years 6% of men and 8% of women had physiological acne. The surprisingly high prevalence of acne in adults may be related to antibiotic treatment or, in women, to the use of oral contraceptives or cosmetics, though this survey did not study their influence. Further studies in different populations are needed to establish the prevalence of acne in the community, and its distribution.     

Prevalence of symptoms of Raynaud's phenomenon in general practice.

OBJECTIVE--To investigate the prevalence of Raynaud''s phenomenon in the populations of five general practices. DESIGN--Two populations studied. A questionnaire was given to all new patients attending five general practices over four weeks, and the same questionnaire was sent by post to a random sample of adults from two of the practices. SETTING--General practices in inner London, Merseyside, and Cheshire. SUBJECTS--1532 Patients who completed questionnaires (1119 who attended the surgeries (response rate unknown) and 413 respondents to the postal survey (response rate 69%)). MAIN OUTCOME MEASURES--Response to questionnaire on symptoms of Raynaud''s phenomenon: patients were regarded as having the disease if they had episodes of blanching of the fingers that were precipitated by cold and accompanied by sensory symptoms (pins and needles or numbness). Subsequent interview and clinical appraisal of patients with the disease according to their responses to the questionnaire. RESULTS--The prevalence of Raynaud''s phenomenon was 11% (26/231) and 19% (34/182) respectively in men and women who completed the postal questionnaire and 16% (56/357) and 21% (157/762) respectively in those who completed the questionnaire when attending their general practice. Thus the overall rates were slightly higher in women, but there was no effect of age even after adjustment of the rates for practice and method of survey. CONCLUSION--The prevalence of Raynaud''s phenomenon is high compared with the low number of patients who seek treatment for the disease.     

High prevalence of diabetes in an urban population in south India.

An urban population in a township in south India was screened for diabetes with an oral glucose tolerance test, every fifth person aged 20 and over registered at the local iron ore company''s hospital being screened. Of 678 people (346 men and 332 women) who were tested, 34 (5%; 20 men and 14 women) had diabetes and 14 (2%; 8 men and 7 women) had impaired glucose tolerance. Thirteen subjects were already known to be diabetic. Diabetes was present in 21% (37/179) of people aged over 40. The peak prevalence (41%; 7/17) was in the group aged 55-64. A family history of diabetes was present in 16 of the 34 subjects with diabetes and nine of the 15 with impaired glucose tolerance. Diabetes was significantly related to obesity in women but not in men (57% (8/14) v 5% (1/20)). The plasma glucose concentration two hours after glucose loading was correlated to body mass index, age, and income in both sexes. The prevalence of diabetes was significantly higher in subjects whose income was above the mean. When the overall prevalence of diabetes was adjusted to the age distribution of the Indians living in Southall, London, and in Fiji it increased to 10% and 9%, respectively. The prevalence of diabetes is high among urban Indians and is comparable with the high prevalence seen in migrant Indian populations.