Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 1010 - файл
.pdf
Chapter 31 Quality of Life with a Permanent Colostomy
might also result in a higher percentage of patients using more sophisticated instruments such as stoma irrigation,which leads to further improvement in QoL.
Another possible factor for our observation might be a very simple climatic reason.
It is possible that in countries that have warm weather for most of the year,the effect
of a colostomy might be more pronounced since the patient will have not more than
one layer of clothing covering the stoma bag. Patients in northern countries, however,
will be able to hide their colostomy much more easily.
Furthermore, the constant and statistically significant observation of the geographic influence in the various domains of quality of life proves that the situation after formation of a permanent colostomy is dependent on individual factors influenced by the
social context and the patient’s community. We feel that this observation should be
taken into account when patients are given preoperative counseling. Furthermore,
evaluations of QoL studies should also consider important aspects of the patient’s life
such as social background, culture and religion.
31.5 Conclusion
Assessment of QoL gives valuable information of consequences created by different
procedures. QoL studies in patient’s with the necessity to receive a permanent stoma
have increased our knowledge about possible sequel to various factors in patient’s well
being. Preoperative expectations as well as postoperative QoL results are influenced by
individual factors and it must be accepted that statements about the impact of various
procedures to QoL should never be generalized.
However, the availability of already existing information may help the surgeon
when obtaining informed consent from patients before major surgery for rectal cancer as well as for individual counseling.
437
References
Allum WH,Slaney G, McConkey CC, Powell J (1994) Cancer of the colon and rectum in the West
Midlands, 1957–1981.Br J Surg 81: 1060–1063
Audisio R, Filiberti A, Geraghty J et al (1997) Personalised surgery for rectal tumours: the
patient’s opinion counts. Support Care Cancer 5: 17–21
Awad RW, El-Gohary TM, Skilton JS, Elder JB (1993) Life quality and psychological morbidity
with an ileostomy. Br J Surg 80 : 252–253
Baumel H,Fabr JM,Manderscheid JC, Domergue J,Visset J (1994) Conséquences médico-sociales
des stomies digestives définitives. Etude retrospective multicentrique nationale. Presse Med
23: 1849–1853
Camilleri-Brennan J, Steele RJC (1998) Quality of life after treatment for rectal cancer.Br J Surg
85: 1036–1043
Camilleri-Brennan J,Steele RJC (2001) Prospective analysis of quality of life and survival follow-
ing mesorectal excision for rectal cancer. Br J Surg 88: 1617–1622
Fleshman JW, Lewis MG (1991) Complications and quality of life after stoma surgery: a review of
16,470 patients in the UOA data registry. Semin Colon Rectal Surg 2: 66–72
Furlani R, Ceolim MF (2002) Living with a permanent intestinal stoma: changes told by stoma
patients. Rev Bras Enferm 55 :586–591
Goligher JC (1951) Sexual function after excision of the rectum. J R Soc Med 44:824–827
Gotay CC,Korn EL, McCabe MS,Moore TD,Cheson BD (1992) Quality of life assessment in can-
cer treatment protocols: research issues in protocol development. J Natl Cacer Inst 84:
575–579
438
Brigitte Holzer,Harald R. Rosen
Grumann MM, Noack EM, Hoffmann IA et al (2001) Comparison of quality of life in patients
undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Ann Surg
233: 149–156
Karadag A, Mentes BB, Uner A, Irkorucu O, Ayaz S, Ozkan S (2003) Impact of stomatherapy on
quality of life in patients with permanent colostomies or ileostomies.Int J Colorectal Dis 18 :
234–238
Koller M, Kussmann J, Lorenz W et al (1996) Symptom reporting in cancer patients. The role of
negative affect and experienced social stigma. Cancer 77: 983–995
Kuzu MA,Topcu Ö, Ucar K et al (2002) Effect of sphincter-sacrificing surgery for rectal carcino-
ma on quality of life in Muslim patients.Dis Colon Rectum 45: 1362–1366
Miles WE (1971) A method of performing abdomino-perineal excision for carcinoma of the rec-
tum and of the terminal portion of the pelvic colon. Lancet ii: 1812
Nugent KP, Daniels P, Stewart B, Patankar R, Johnson CD (1999) Quality of life in stoma patients.
Dis Colon Rectum 42: 1569–1574
Olschewski M, Schulgen G, Schumacher M,Altman DG (1994) Quality of life assessment in clin-
ical cancer research.Br J Cancer 70: 1–5
Renner K, Rosen HR, Novi G,Hölbling N, Schiessel R (1999) Quality of life after surgery for rec-
tal cancer.Dis Colon Rectum 42: 1160–1167
Rolstad BS,Wilson G,Rothenberger DA (1983) Sexual concerns in the patient with an ileostomy.
Dis Colon Rectum 26: 170–171
Salomon MJ, Pager CK, Findlay M, Butow P, Salkeld GP (2003) What do patients want? Patient
preferences and surrogate decision making in the treatment of colorectal cancer. Dis Colon
Rectum 46: 1351–1357
Sprangers MAG,Taal BG, Aaronson NK et al (1995) Quality of life in colorectal cancer: stoma vs
nonstoma patients.Dis Colon Rectum 38 : 361–369
Stryker SJ, Pemberton JH, Zinsmeister AR (1985) Long-term results of ileostomy in older pa-
tients. Dis Colon Rectum 28 : 844–846
White CA, Hunt JC (1997) Psychological factors in postoperative adjustment to stoma surgery.
Ann R Coll Surg Eng 79: 3–7
Williams NS,Johnston D (1983) The quality of life after rectal excision for low rectal cancer.Br J
Surg 70: 460–462
31
Part IX
How Can We Improve
the Treatment of Incontinence?
IX
Chapter 32
Chapter 32 Is Urinary or Fecal Incontinence a Preventable
Is Urinary or Fecal Incontinence
a Preventable Event?
Daniele Perucchini,Daniel Faltin
441
32
Contents
32.1 General Consideration . . . . . . . . . . . . . . . . . . . 442
32.2 Incidence of Urinary and Fecal Incontinence . . . . . . 442
32.2.1 Incidence of Urinary Incontinence . . . . . . . . . . . . 443
32.2.1.1 Incidence of Urinary Incontinence
Before First Pregnancy . . . . . . . . . . . . . . . . . . . 443
32.2.1.2 Incidence of Urinary Incontinence During Pregnancy . 443
32.2.1.3 Incidence of Urinary Incontinence After Childbirth . . . 443
32.2.2 Incidence of Fecal Incontinence . . . . . . . . . . . . . . 444
32.3 Factors That Might Influence Continence
During Pregnancy and Delivery . . . . . . . . . . . . . . 444
32.4 Primary Prevention of Urinary and Fecal Incontinence . 445
32.4.1 Before Pregnancy . . . . . . . . . . . . . . . . . . . . . . 445
32.4.2 During Pregnancy . . . . . . . . . . . . . . . . . . . . . 446
32.4.3 At Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . 446
32.4.3.1 Episiotomy . . . . . . . . . . . . . . . . . . . . . . . . . 446
32.4.3.2 Instrumental Delivery . . . . . . . . . . . . . . . . . . . 447
32.5 Secondary Prevention of Urinary
and Fecal Incontinence . . . . . . . . . . . . . . . . . . . 447
32.5.1 Urinary Incontinence . . . . . . . . . . . . . . . . . . . . 447
32.5.1.1 Pelvic Floor Muscle Exercise During Pregnancy . . . . . 447
32.5.1.2 Pelvic Floor Muscle Exercise After Pregnancy
and Delivery . . . . . . . . . . . . . . . . . . . . . . . . . 448
32.5.2 Fecal Incontinence: Diagnosing and Treating
Anal Sphincter Tears After Childbirth . . . . . . . . . . 449
32.5.2.1 Improving the Recognition of Anal Sphincter Tears . . . 449
32.5.2.2 Repair of Anal Sphincter Tears . . . . . . . . . . . . . . 450
32.5.2.3 Pelvic Floor Training . . . . . . . . . . . . . . . . . . . . 450
32.5.2.4 The Role of Subsequent Deliveries . . . . . . . . . . . . 450
32.6 Tertiary Prevention of Urinary Fecal Incontinence . . . 451
32.7 The Role of Cesarean Section . . . . . . . . . . . . . . . 451
32.7.1 Should Women with or Without Risk Factors
for Incontinence Be Allowed to Choose
a Planned Cesarean Section? . . . . . . . . . . . . . . . . 452
32.7.2 Will the Urinary or Fecal Incontinence Rate Decrease
as the Cesarean Section Rate Increases? . . . . . . . . . 452
References . . . . . . . . . . . . . . . . . . . . . . . . . . 453
32
442
Daniele Perucchini, Daniel Faltin
32.1 General Consideration
Increasing attention has focused on maternal morbidity and the long-term sequelae of
childbirth, since both perinatal and maternal mortality rates have fortunately decreased in the last few decades. Urinary and fecal incontinence are debilitating conditions not only leading to medical problems and costs, but also to embarrassment, isolation and loss of independence.
The pelvic floor is a dynamic system of interconnected muscles,nerves, ligaments,
and viscera controllingcontinence and reproduction. The exact mechanism by which
childbirth may lead to incontinence is unclear. Common mechanisms proposed to be
responsible for childbirth-associated urinary incontinence include denervation injury
and mechanical trauma. Other less commonly blamed mechanisms of damage include
hormonal variation, abnormal vascular pulsations of the periurethral plexus, and decreased functional urethral length. Three phases of damage and repair regarding the
effect of childbirth on the pelvic floor can be recognized. The first phase concerns the
injury that occurs during pregnancy and delivery. The next is the repair phase, when
the body heals this injury as best it can.The last is the maintenance phase.Factors such
as age and disease influencethe healed injury and may alter the body’s ability to compensate for it. There may also be recovery after an acute injury and there may be a
gradual decline in function, especially with age, as has been shown for urethral function (Perucchini et al. 2002). This deterioration may be accelerated following vaginal
delivery. Even though the continence mechanism is repeatedly damaged, women are
able to remain continent and compensate for the damage. But also without pregnancy
and delivery,a significant number of older nulliparous women complain of stress urinary incontinence (Buchsbaum et al. 2002).
Care is needed to put the findings of studies of childbirth injury in proper context.
The gold standard for evidence-based medicine is the randomized clinical trial. Randomized controlled trials (RCT) are rare in the area of childbirth and incontinence.
The ability to conduct RCTs is hampered by the long follow-up needed to truly understand the impact of childbirth on incontinence. On the one hand, what may seem like
a major injury during the 1st months after delivery may heal entirely with time and be
of no long-term importance. On the other hand,what may at first seem to be a minor
injury can become clinically important years later, after age and disease have taken
their toll.
Three grades of prevention can be distinguished: primary prevention aims to remove the causes of a disease,secondary prevention aims to detect asymptomatic dysfunction and treat it early to stop progression, and tertiary prevention aims to treat existing symptoms to prevent progression of disease.When doing studies on prevention
of incontinence, it may be very difficult to screen all potential trial participants to see
if a disease process (i.e., incontinence) is absent altogether, or present but asymptomatic. In addition, there are many factors that contribute to incontinence (denervation, poor muscle function, fascial defects). It is therefore difficult to distinguish
between primary and secondary prevention when talking about incontinence.
32.2 Incidence of Urinary and Fecal Incontinence
Incidence of urinary and fecal incontinence is discussed separately. Prevalence studies
of double incontinence are rare and show extremely varying results, ranging between
5% and 69%.
Chapter 32 Is Urinary or Fecal Incontinence a Preventable Event?
32.2.1 Incidence of Urinary Incontinence
32.2.1.1 Incidence of Urinary Incontinence Before First Pregnancy
The prevalence of urinary incontinence in fertile women varies depending on the target population, the definition and the design used. Few studies have focused on urinary incontinence before the first pregnancy. Most often data on the prevalence of incontinence are taken from studies that focus on incontinence after or during pregnancy. The prevalence found most often varies between 4% and 12%, and little information is available on the severity of the symptoms.Furthermore, symptoms may vary in
intensity and depend on a women’s activity, and it has been reported that nulliparous
women complain less regarding symptoms than parous women. Francis found that
40% of primigravid women had a history of occasional incontinence before becoming
pregnant (Francis 1960). If such a history was present, then incontinence invariably
became worse during pregnancy. Wilson et al. (2002) found that 84% of the women
with onset of incontinence before pregnancy were still incontinent 5–7 years later,
compared with only 31.8% of women who were dry before pregnancy.
32.2.1.2 Incidence of Urinary Incontinence During Pregnancy
Urinary incontinence is a common occurrence during pregnancy,affecting 4%–82% of
women (Baessler and Schüssler 2003). Often it is a transient condition. Incontinence
during pregnancy is attributed to the enlarged uterus, fluctuating hormone levels, increased glomerular filtration rate, temporary changes in the urethrovesical angle and
other changes of normal pregnancy. There are some data on the severity of incontinence. In a recent study by Chaliha, 43.7% of 549 nulliparous women were found to
have incontinence during pregnancy,9.3% claiming daily leakage and 24.9% reporting
incontinence less than once a week.Incontinence symptoms seem to increase during
pregnancy.At 16 weeks of pregnancy, Hojberg et al. (1999) found 3.9% of nulliparous
women with incontinence (but only 0.5% reporting incontinence at least once a week).
Two older studies report on incontinence in early pregnancy at a rate of 6%–15% in
nulliparous women.According to most studies, incontinence is more frequent in multiparous than in nulliparous women throughout the whole pregnancy. Incontinence
during early pregnancy is reported by 15%–26% of multiparous women.
443
32.2.1.3 Incidence of Urinary Incontinence After Childbirth
It has been suggested that that vaginal delivery is the main contributing factor for incontinence,possibly because of damage to important muscle tissue or nerves.According to several studies after childbirth, incontinence is a common problem, with a reported incidence of 20%–38% in the first 3 months after delivery (Wilson et al. 1996;
Chaliha et al. 2003; Farell et al.2001; Viktrup 1992).About 3% report daily or more frequent leakage.
Stress urinary incontinence (SUI) may persist 1 year postpartum in 24%–75% of
primiparous women (Viktrup et al. 1992; Baessler and Schuessler 2003). De novo SUI
has been reported to develop in 4%–19% of women who gave birth vaginally (Meyer et
al. 2001).Women with stress incontinence 3 months after first delivery carry a partic-
32
444
Daniele Perucchini, Daniel Faltin
ular risk of 92% of having stress incontinence symptoms 5 years later; without any
symptoms after the first delivery, the incidence of stress incontinence was 19% (Viktrup and Lose 2001).According to the same authors,subsequent deliveries seem not to
play an important role in the development of long-lasting stress incontinence.
32.2.2 Incidence of Fecal Incontinence
Fecal incontinence, defined as the involuntary loss of flatus or feces, is reported in
4%–38% of women after vaginal delivery (Thacker and Banta 1983; MacArthur and
Bick 1997; Hall et al. 2003). Obviously, these discrepancies in the observed prevalence
of fecal incontinence depends on the population studied, the definition of incontinence used and on how the data were collected. Furthermore, the prevalence of (fecal)
incontinence is probably underestimated, as few affected women voice their symptoms (Johanson and Lafferty 1996). Fecal incontinence reduces the quality of life of affected women and has substantial direct and indirect long-term costs (Mellgren and
Jensen 1999; Rockwood and Church 2000).
32.3 Factors That Might Influence Continence During Pregnancy
and Delivery
The contribution of obstetric factors to the development of SUI is controversial. Historically, it was assumed that perineal trauma should be prevented.According to a Cochrane database review of the literature on episiotomy by Carroli,the traditional routine use of episiotomy in general and midline episiotomy in particular cannot be justified. An increased risk of anterior perineal trauma but not of incontinence was
found. Viktrup et al. (1992) found a higher rate of SUI after mediolateral episiotomy
5 years after childbirth.
In some studies, the duration of the second stage of labor and birth weight was associated with a higher incidence of stress incontinence.Other investigators found no
significant correlation between stress incontinence and fetal head circumference, the
second stage of labor,or birth weight (Baessler and Schüssler 2003; Reilly et al.2002).
Viktrup et al. (1992) showed that all statistically significant associations between obstetrical risk factors and the incidence of SUI immediately after delivery had vanished
3 months later! No significant obstetrical risk factor was correlated to incontinence
5–7 years after delivery in a study by Wilson et al.(2002). Leighton and Halpern (2002)
performed a systematic review on the effect of epidural analgesia on urinary incontinence and found urinary incontinence to be only more frequent in the immediate
postpartum period. No positive or negative effects of epidural analgesia on continence
were found by Meyer et al. (2002).
Obesity has been associated with a higher risk of urinary incontinence during
pregnancy and postpartum (Burgio et al. 2003; Baessler and Schüssler 2003; Reilly et
al. 2002).Wilson et al.(1996) examined maternal risk factors for postpartum UI. In addition to vaginal delivery and multiparity, they also found obesity to be associated
with the development of incontinence 3 months after childbirth. The same author
found the prevalence of incontinence similar in women having three or more Caesarean sections (38.9%) to those delivered vaginally (37.7%). Markers of collagen weakness, including striae, varicose veins, hemorrhoids, and joint hypermobility, which
previously had been implicated in the pathogenesis of incontinence, did not predict
Chapter 32 Is Urinary or Fecal Incontinence a Preventable Event?
postpartum urinary or fecal incontinence in a later study. Changes in collagen may result in greater mobility of the bladder neck, resulting in stress incontinence.This was
suggested by King and Freeman (1998), who used perineal ultrasonography in 128
primigravidae antenatally and then again 10–14 weeks after delivery. They found an
increase in bladder neck mobility antenatally in those women who subsequently developed postpartum stress incontinence.
Risk factors for anal sphincter injury and postpartum fecal incontinence include
vaginal delivery,primiparity, instrumental delivery,especially if forceps are used, episiotomy, delivering a large baby, a baby in occipitoposterior presentation, maternal position during delivery (squatting), maternal age, oxytocin augmentation, prolonged
second stage of labor, and delivering at night (Handa et al. 1996; Jander and Lyrenas
2001). Interventions to reduce the exposure of mothers to these risk factors are progressively being evaluated. Most of these risk factors of urinary and fecal incontinence
are actually correlated, and intervention that could ease overall the process of childbirth will act on several of these factors.
32.4 Primary Prevention of Urinary and Fecal Incontinence
32.4.1 Before Pregnancy
Wilson et al.examined maternal risk factors for postpartum UI. In addition to vaginal
delivery and multiparity,they found obesity to be associated with the development of
incontinence 3 months after childbirth (Wilson et al. 1996). The impact of weight loss
in association with pregnancy on the long-term incidence of urinary incontinence has
not been studied. Chaliha evaluated the role of antenatal history and physical markers
suggestive of collagen weakness, and their role in predicting postpartum incontinence. Postnatal urinary incontinence and anal incontinence was not related to race,
antenatal body mass index, the presence of striae, hernia, varicose veins, piles or a
family history of incontinence, prolapse or collagen weakness. Higher joint mobility
scores were associated with incontinence of flatus but not fecal urgency or urinary
symptoms (Chaliha et al. 1999). In a recent prospective cohort study in nulliparous
women, Tincinello also found a significant association between elbow hyperextension
and stress urinary incontinence but no association between joint mobility scoring and
postpartum stress incontinence. Although collagen weakness has been implicated in
the pathogenesis of incontinence, generally accepted physical markers of collagen
weakness are not established. Perhaps the studied markers were not representative of
collagen weakness, or a larger study with a longer follow-up is required.
It is only by identification of meaningful predisposing factors that place an individual patient at risk that we will be able to make meaningful progress toward effective
primary prevention. At the same time, we should establish strategies for secondary
prevention by identifying alterable promoting factors that over a women’s lifetime can
contribute to the progression from damage but compensated pelvic floor to a decompensated and symptomatic pelvic floor disorder.
Elective caesarean section could be discussed if there were clear markers for postpartum urinary incontinence.However, there are many unanswered questions regarding the protective effect of elective caesarean section (see ”During Pregnancy” below).
Risk factors for fecal incontinence are present before pregnancy. Several authors
have pointed out that fecal incontinence is present before pregnancy in a substantial
445
32
446
Daniele Perucchini, Daniel Faltin
proportion of women and is a predictor of incontinence after delivery.Some constitutional characteristics will increase the risk of pelvic floor damage during delivery. A
narrow subpubic arch angle (below 90°) has been found to be associated with prolonged labor and postpartum fecal incontinence (Frudinger et al. 2002). Interestingly,
perineal and anal sphincter trauma, assessed by ultrasound, was found not to account
for the higher rate of postpartum anal incontinence in these women.Women with irritable bowel syndrome are more likely to experience subjective alteration of fecal
continence postpartum compared with the healthy primigravid population, but they
are not at increased risk of anal sphincter injury (Donnelly and O’Herlihy 1998). Currently, there is no intervention that could influence the outcome of delivery in these
women with a higher risk of postpartum incontinence.
32.4.2 During Pregnancy
Perineal massage involves massaging the vaginal introitus and the perineum 10 min a
day from the 34th week of pregnancy until delivery and is believed to reduce perineal
trauma by increasing tissue elasticity. Several randomized trials have evaluated this
intervention. In a large multicentric study on perineal massage conducted in Canada,
among participants without a previous vaginal birth, 24.3% from the perineal massage
group and 15.1% from the control group were delivered vaginally with an intact perineum, for a 9.2% absolute difference (95% confidence interval, 3.8%–14.6%) (Labrecque and Eason 1999). However,the intervention did not reduce the risk of severe
perineal laceration and there were no differences with respect to perineal pain,dyspareunia, sexual satisfaction, and incontinence of urine, gas, or stool 3 months postpartum (Labrecque and Eason 2000). In another trial, perineal massage was found to reduce the risk of anal sphincter tears from 3.6% to 1.7%, p=0.04, but did not reduce the
risk of pain, dyspareunia,or urinary and fecal problems (Stamp and Kruzins 2001).
Since birthweight is a risk factor for a difficult delivery and anal sphincter tear, reducing the weight of the baby could be beneficial.The strategy for this outcome would
be identifying large babies before delivery and offering early labor induction to the
mother.This involves several difficulties but has been evaluated in a randomized trial.
32.4.3 At Delivery
32.4.3.1 Episiotomy
The debate around the practice of episiotomy to expedite vaginal delivery and reduce
the severity of perineal pain has produced numerous articles (Thacker and Banta 1983;
Woolley 1995). A systematic review from the Cochrane library has summarized the
current knowledge on the topic (Carroli and Belizan 2001).This review was restricted
to randomized trials of acceptable quality, the best strategy to reduce bias. The authors
found that the restrictive use of episiotomy was associated with fewer posterior perineal traumas (relative risk [RR], 0.88; 95% confidence interval [CI], 0.84–0.92), need
for suturing perineal trauma (RR, 0.74; 95% CI, 0.71–0.77), and healing complications
at 7 days (RR, 0.69; 95% CI, 0.56–0.85). No difference was shown in the incidence of
major outcomes such as severe vaginal or perineal trauma nor in pain,dyspareunia or
urinary incontinence. The fact that fecal incontinence was not considered a relevant is-
Соседние файлы в папке @xirurgi_2025