1
|
Gyhagen M, Åkervall S, Larsudd-Kåverud J. Surgery for stress urinary incontinence and genital prolapse is almost exclusively related to vaginal births-pregnancy seemed to lack significant long-term effects. Am J Obstet Gynecol 2023; 229:351-351.e1. [PMID: 37120053 DOI: 10.1016/j.ajog.2023.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/23/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Maria Gyhagen
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Södra Älvsborg Hospital, SE-501 82 Borås, Sweden.
| | - Sigvard Åkervall
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Jennie Larsudd-Kåverud
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Södra Älvsborg Hospital, Borås, Sweden
| |
Collapse
|
2
|
Gyhagen J, Åkervall S, Larsudd-Kåverud J, Molin M, Milsom I, Wagg A, Gyhagen M. The influence of age and health status for outcomes after mid-urethral sling surgery-a nationwide register study. Int Urogynecol J 2023; 34:939-947. [PMID: 36181548 PMCID: PMC10038952 DOI: 10.1007/s00192-022-05364-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/03/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The efficacy of mid-urethral sling (MUS) surgery in older women and women with a significant disease burden is limited. We aimed to determine the influence of chronological age and physical status (assessed by the American Society of Anesthesiologists Physical Status, ASA) classification on outcomes. METHODS Cure rate, change in frequency of lower urinary tract symptoms, satisfaction, impact, and adverse events after MUS surgery were assessed in 5200 women aged 55-94 years with MUS surgery (2010-2017). Data were analysed by multivariate logistic regression and Mantel-Haenszel chi-square statistics. RESULTS The cure rate was 64.2% (95% CI, 60.0-68.4) in the ≥ 75-year cohort compared to 88.5% (95% CI, 87.1-89.8) in the 55-64-year cohort (trend p < 0.0001). The estimated probability of cure, improvement, and satisfaction with the procedure decreased by aOR10yr = 0.51 for cure to aOR10yr = 0.59 for satisfaction (all p < 0.0001). Women with a significant health burden (ASA class 3-4) had lower cure rates and satisfaction than those without (65.5% vs. 83.7%, p < 0.0001 and 65.7% vs. 80.6%, p < 0.0001). Older age was more likely to be associated with de novo urgency (p = 0.0022) and nocturia ≥ 2 (p < 0.0001). Adverse events, readmission, and 30-day mortality rates were low. Women, irrespective of age, were equally satisfied if they experienced a decrease of at least one step in leakage frequency. CONCLUSIONS Even if MUS surgery in older women and those with ASA class 3-4 was associated with a lower cure rate and less satisfactory outcome, a majority were satisfied provided they experienced a reduction of incontinence episodes.
Collapse
Affiliation(s)
- Julia Gyhagen
- Department of Geriatrics, Dalens Hospital, Stockholm, Sweden
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Sigvard Åkervall
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Jennie Larsudd-Kåverud
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, SE-501 82, Borås, Sweden
| | | | - Ian Milsom
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Adrian Wagg
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Maria Gyhagen
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
- Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, SE-501 82, Borås, Sweden.
| |
Collapse
|
3
|
Milsom I, Gyhagen M. Does the climacteric influence the prevalence, incidence and type of urinary incontinence? Climacteric 2023; 26:75-79. [PMID: 36690015 DOI: 10.1080/13697137.2022.2158730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Divergent opinions have been reported in the literature regarding the influence of the climacteric on the prevalence, incidence and types of urinary incontinence. In addition, the influence of hormonal therapy in the climacteric (HRT) on the occurrence of urinary incontinence in the perimenopausal period has been the subject of much discussion. This review evaluates the current literature regarding any possible association between the climacteric and the prevalence, incidence and types of urinary incontinence as well as illustrating the possible influence of HRT on urinary incontinence. Urinary incontinence is more common in women than in men and there is evidence to suggest that the prevalence of urinary incontinence in women increases in a linear fashion with age. There is no conclusive evidence to support a specific increase in the prevalence of urinary incontinence at the time of the menopause. Stress urinary incontinence is more common in premenopausal women and urgency urinary incontinence and mixed incontinence are more common in postmenopausal women. Women receiving systemic estrogen, with or without progestogen, are more likely to develop or experience worsening of incontinence.
Collapse
Affiliation(s)
- I Milsom
- Gothenburg Continence Research Centre, Department of Obstetrics & Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - M Gyhagen
- Gothenburg Continence Research Centre, Department of Obstetrics & Gynaecology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| |
Collapse
|
4
|
Larsudd-Kåverud J, Gyhagen J, Åkervall S, Molin M, Milsom I, Wagg A, Gyhagen M. The influence of pregnancy, parity, and mode of delivery on urinary incontinence and prolapse surgery-a national register study. Am J Obstet Gynecol 2023; 228:61.e1-61.e13. [PMID: 35932880 DOI: 10.1016/j.ajog.2022.07.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/01/2022] [Accepted: 07/19/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The long-term effects of vaginal delivery, parity, and pregnancy on the pelvic floor remain uncertain and controversial issues. In comparison with studies using self-reported symptoms, surgical register data may offer a more valid means for evaluating the relative influence of these risk factors. OBJECTIVE This study used data from 3 high-quality nationwide registers, namely the Swedish National Quality Register of Gynecological Surgery, the Swedish Medical Birth Register, and the Total Population Register, to evaluate the contribution of vaginal and cesarean delivery, parity, and factors not related to childbirth to the long-term risk for reconstructive urogenital surgery. STUDY DESIGN This was a register-based linkage study among women aged ≥45 years who underwent urinary incontinence or prolapse surgery from 2010 to 2017. This surgical cohort was divided into nulliparous women, women with ≥1 cesarean deliveries only, those with ≥1 vaginal deliveries, and according to the number of births. A corresponding reference group was constructed based on women born in 1960 from the Total Population Register (n=2,309,765). The Swedish Medical Birth Register was used to determine the rate of women with cesarean and vaginal delivery and their respective parity. Absolute and relative risk were presented per 1000 women with 95% confidence intervals. Pairwise differences were analyzed with Fisher exact tests and the Mann-Whitney U test for dichotomous and continuous variables. The trend between ≥3 ordered categories of dichotomous variables was analyzed with Mantel-Haenszel statistics. RESULTS A total of 39,617 women underwent prolapse surgery and 20,488 underwent incontinence surgery. Among women with prolapse surgery, 97.8% had ≥1 vaginal delivery, 0.4% had ≥1 cesarean delivery only, and 1.9% were nullipara. Corresponding figures for those with incontinence surgery were 93.1%, 2.6%, and 4.3%, respectively. Women with vaginal deliveries were overrepresented in the prolapse surgery (relative risk, 1.23; 95% confidence interval, 1.22-1.24; P<.001) and incontinence surgery groups (relative risk, 1.17; 95% confidence interval, 1.15-1.19; P<.001). Nulliparous and cesarean delivered women were underrepresented in the prolapse surgery (relative risk, 0.14; 95% confidence interval, 0.13-0.15 and relative risk 0.055; 95% confidence interval, 0.046-0.065; all P<.001) and incontinence surgery groups (relative risk, 0.31; 95% confidence interval, 0.29-0.33 and relative risk, 0.40; 95% confidence interval, 0.36-0.43). The absolute risk for prolapse surgery was lowest after cesarean delivery (0.09 per 1000 women; 95% confidence interval, 0.08-0.11) and differed by a factor of 23 (absolute risk, 2.11 per 1000 women; 95% confidence interval, 2.09-2.13) from that after vaginal birth. The absolute risk for prolapse and incontinence surgery increased consistently with parity after vaginal births. This trend was not observed after cesarean delivery, which is on par with that of nulliparous women. The first vaginal birth contributed the highest increase in the absolute risk for pelvic organ prolapse surgery (6-fold) and stress urinary incontinence surgery (3-fold). The second vaginal birth contributed the lowest increase in the absolute risk for pelvic organ prolapse surgery (∼1/3 of the first vaginal birth) and for stress urinary incontinence surgery (∼1/10 of the first vaginal birth). CONCLUSION Surgery for urinary incontinence and prolapse was almost exclusively related to vaginal parity. The risk for prolapse surgery increased consistently with parity after vaginal births but not after cesarean delivery, whereas the risk associated with cesarean delivery was on par with that of nulliparous women. Thus, cesarean delivery seems to offer protection from the need for pelvic organ prolapse and stress urinary incontinence surgery later in life.
Collapse
Affiliation(s)
- Jennie Larsudd-Kåverud
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - Julia Gyhagen
- Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - Sigvard Åkervall
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Mattias Molin
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Statistical Consultancy Group, Gothenburg, Sweden
| | - Ian Milsom
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Adrian Wagg
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Division of Geriatric Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Maria Gyhagen
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Geriatrics, Dalen Hospital, Stockholm, Sweden.
| |
Collapse
|
5
|
Nilsson IEK, Åkervall S, Molin M, Milsom I, Gyhagen M. Severity and impact of accidental bowel leakage two decades after no, one, or two sphincter injuries. Am J Obstet Gynecol 2022; 228:447.e1-447.e19. [PMID: 36513133 DOI: 10.1016/j.ajog.2022.11.1312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 11/20/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Information about the long-term severity and subjective impact of anal incontinence in women after 1 or 2 consecutive obstetrical anal sphincter injuries is still scarce and contradictory. OBJECTIVE This study aimed to describe the severity and impact of anal incontinence among women with 2 previous deliveries 2 decades after birth and to analyze the relative effect of 1 vs 2 obstetrical anal sphincter injuries in comparison with no obstetrical anal sphincter injuries and the possible influence of obstetrical anal sphincter injury on other pelvic floor disorders. STUDY DESIGN We linked prospectively registered data in the Swedish Medical Birth Register with information from a postal and web-based questionnaire in 2015. Statistics Sweden identified women with 2 vaginal births from 1992 to 1998, and a simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. To achieve equal-sized groups of women with 1 or 2 obstetrical anal sphincter injuries, the latter group was oversampled from 1987 to 2000. The final study cohorts consisted of 6760 women with no obstetrical anal sphincter injury, 357 women with 1 injury, and 324 women with 2 obstetrical anal sphincter injuries. Third- and fourth-degree perineal tears were grouped together for analysis. Anal incontinence was defined as either fecal or isolated gas incontinence, and fecal incontinence was defined as involuntary leakage of solid or liquid stool with or without concomitant gas. Frequencies of leakage of stool and gas were dichotomized into low frequency (less than once a month) and high frequency (several times a month or more often). Pairwise comparisons were analyzed using Fisher exact tests, Mantel-Haenszel statistics, and the Mann-Whitney U test. Trends were analyzed using Mantel-Haenszel statistics and the Spearman rank correlation test. Logistic regression models were used to obtain the age- and body-mass-index -adjusted odds ratios for outcomes. Statistical significance was set at P<.05. RESULTS The response rate was 65.5% in the randomly selected cohort and 70.1% among women with 2 obstetrical anal sphincter injuries. Bothersome fecal incontinence occurred in 3.3% (212/6458) of women without obstetrical anal sphincter injury, in 10.4% (36/345) (adjusted odds ratio, 3.25; 95% confidence interval, 2.23-4.73) of those with 1 injury, and in 16.5% (52/315) (adjusted odds ratio, 5.16; 95% confidence interval, 3.69-7.22) of those with 2 obstetrical anal sphincter injuries (trend P<.0001). Fecal incontinence was perceived as bothersome in 28.2% (212/753) of women without an obstetrical anal sphincter injury compared with in 43.9% (36/82) and 46.0% (52/113) of those with 1 or 2 obstetrical anal sphincter injuries (trend P<.0001). Leakage of liquid stool occurred in 10.8% (724/6717) of those without injury, in 21.7% (77/355) of women with 1 injury, and 34.9% (113/324) of women with 2 obstetrical anal sphincter injuries (trend P<.0001). Incontinence affecting daily life was reported by 8.6% (577/6672) of women without injury and by 19.7% (69/351) and 29.6% (96/324) of women with 1 and 2 sphincter injuries, respectively (trend P<.0001). The mean Jorge-Wexner score was 2.44, 3.26, and 3.88 for women with no, 1, or 2 sphincter injuries (trend P<.0001). Among women with a Jorge-Wexner score of 6, >50% had bothersome anal incontinence. The adjusted odds ratio for the overall effect of 1 vs 2 obstetrical anal sphincter injuries on measures of anal incontinence was 2.19 (95% confidence interval, 1.68-2.85) and 3.91 (95% confidence interval, 3.06-5.00), respectively, when compared with no obstetrical anal sphincter injury (both P<.0001). Having 1 or 2 obstetrical anal sphincter injuries had no significant effect on other pelvic floor disorders or on lower urinary tract symptoms (P=.73 and P=.69). CONCLUSION A consistent additive effect of 1 or 2 sphincter injuries on the severity and impact of anal incontinence was observed in women 2 decades after 2 vaginal births. This information is important for healthcare economics, clinical practice, and policy.
Collapse
Affiliation(s)
- Ida E K Nilsson
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden.
| | - Sigvard Åkervall
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Mattias Molin
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Statistical Consultancy Group, Gothenburg, Sweden
| | - Ian Milsom
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Gyhagen
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| |
Collapse
|
6
|
Al-Mukhtar Othman J, Åkervall S, Nilsson IEK, Molin M, Milsom I, Gyhagen M. Fecal incontinence in nonpregnant nulliparous women aged 25 to 64 years-a randomly selected national cohort prevalence study. Am J Obstet Gynecol 2022; 226:706.e1-706.e23. [PMID: 34774822 DOI: 10.1016/j.ajog.2021.11.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The extent to which fecal incontinence is associated with obstetrical history or pelvic floor injuries is still a controversial and unresolved issue. One crucial first step toward answering this question is the need to study fecal incontinence in nonpregnant, nulliparous women. OBJECTIVE The aim of this study was to present detailed, descriptive measures of the accidental leakage of liquid or solid stool and gas in a randomly selected, large national cohort of nonpregnant, nulliparous women aged 25 to 64 years. STUDY DESIGN The Swedish Total Population Register identified the source population. Four independent, age-stratified, simple random samples in a total of 20,000 nulliparous women aged 25 to 64 years were drawn from 625,810 eligible women. Information was collected in 2014 using postal and web-based questionnaires. The 40-item questionnaire included questions about the presence and frequency of the leakage of solid and liquid stool and gas, which provided the basis for the generic terms fecal and anal incontinence. Statistical analyses of the differences between the groups were performed using the Fisher's exact test for dichotomous variables and the Mann-Whitney U-test for continuous variables. The trend between >2 ordered categories of dichotomous variables was analyzed with Mantel-Haenszel statistics. When analyzing the trend between multiple ordered vs nonordered categorical variables, the Kruskal-Wallis test was used. The age-related probability and risk increase per 10 years for incontinence parameters was calculated from logistic regression models adjusted for body mass index. RESULTS The study population was 9197 women, and the response rate was 52.2%, ranging from 44.7% in women aged 25 to 34 years to 62.4% among those from 55 to 64 years. All the types of incontinence, except severe isolated gas incontinence, increased with age up to 64 years. The estimated probability of fecal incontinence was 8.8% at age 25 years and 17.6% at age 64. The leakage of liquid stool was dominant, occurring in 93.1% (95% confidence interval, 91.4-94.5) of the women with fecal incontinence, whereas leakage of solid stool occurred in 33.9% (95% confidence interval, 31.1-36.7), of which approximately 80% also had concomitant leakage of liquid stool. The leakage of liquid stool increased markedly up to age 65, whereas the increase in the isolated leakage of solid stool was negligible across all ages (overall <0.4%). Liquid and solid stool, separate or in combination, co-occurred with gas in approximately 80%. The distribution pattern of the different types of leakage, single or combined, was similar in all the age groups. Both age and body mass index (kg/m2) were risk factors for fecal incontinence (P<.0001), with an interaction effect of P=.16. CONCLUSION Abnormal stool consistency has been identified as the strongest risk factor for accidental bowel leakage. The same pattern characterized by a dominance of liquid stool and gas leakage, prevalent concomitant leakage of solid and liquid stool, and a negligible rate of isolated leakage of solid feces was observed across all ages. The low rates of isolated leakage of solid stool support the impression that dysfunction of the continence mechanism of the pelvic floor had a negligible role for bowel incontinence, which is essential information for comparison with women with birth-related injuries.
Collapse
Affiliation(s)
- Jwan Al-Mukhtar Othman
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Sigvard Åkervall
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Ida E K Nilsson
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | | | - Ian Milsom
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Gyhagen
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| |
Collapse
|
7
|
Gyhagen M, Ellström Engh M, Husslein H, Koelbl H, Nilsson IEK, Schulz J, Wagg A, Milsom I. Temporal trends in obstetric anal sphincter injury from the first vaginal delivery in Austria, Canada, Norway, and Sweden. Acta Obstet Gynecol Scand 2021; 100:1969-1976. [PMID: 34435349 DOI: 10.1111/aogs.14244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Obstetric anal sphincter injuries (OASI) are severe complications that can cause considerable short- and long-term morbidity. Austria, Canada, Norway, and Sweden have similar socio-economic characteristics, and all four countries have access to national birth registers. In this study, we hypothesized that the incidence of OASI should be very similar for different obstetric scenarios in these four countries. Therefore, the aim was to compare the incidence of OASI in these four countries in primiparous women, with spontaneous or instrumental delivery (vacuum or forceps), and in women with a first vaginal birth after cesarean section (VBAC). MATERIAL AND METHODS Aggregated data on 1 933 930 vaginally delivered primiparous women and women with VBAC were retrieved from the birth registers gathered in Austria, Canada, Norway, and Sweden. The annual rate of OASI (ICD-10 codes O70.2-O70.3) was presented as the percentage of women with a spontaneous delivery, vacuum or forceps delivery, and a VBAC during the period 2004-2016. RESULTS The incidence of OASI varied considerably between countries and over time. Canada and Sweden had the highest rates, and Austria and Norway the lowest. In Norway, the rate of OASI decreased consistently for all types of deliveries after introducing a perineal protection program in 2004 (p < 0.001). During vacuum delivery, the incidence of OASI varied between countries from 4.1% to 15.5% across the study period. In Canada and Norway, the rate of OASI after a forceps delivery was similar in 2004 at ~20% and with differing trajectories to 24.3% (β 0.49) and 6.2% (β -1.15) (trend, all p < 0.001) in 2016. CONCLUSIONS This comparative register study suggests that there may be considerable potential for lowering the incidence of OASI. The perineal protection program implemented by Norway has been successful. Each country should critically, without prejudice, analyze their current clinical practices and rate of OASI and consider the best preventive strategy.
Collapse
Affiliation(s)
- Maria Gyhagen
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - Marie Ellström Engh
- Department of Obstetrics and Gynecology, Akershus University Hospital, and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Heinrich Husslein
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Heinz Koelbl
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Ida E K Nilsson
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - Jane Schulz
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian Wagg
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ian Milsom
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
8
|
Nilsson IEK, Åkervall S, Molin M, Milsom I, Gyhagen M. Symptoms of fecal incontinence two decades after no, one, or two obstetrical anal sphincter injuries. Am J Obstet Gynecol 2021; 224:276.e1-276.e23. [PMID: 32835724 DOI: 10.1016/j.ajog.2020.08.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/06/2020] [Accepted: 08/19/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND The long-term effects of 1 or 2 consecutive obstetrical anal sphincter injuries on bowel continence are still inadequately investigated, and published results remain contradictory. OBJECTIVE This study aimed to present detailed descriptive measures of the current bowel incontinence 20 years after the first birth in women who had 2 vaginal deliveries with and without sphincter injuries. STUDY DESIGN Birth register data were used prospectively and linked to information from a questionnaire survey about current symptoms. Women with 2 singleton vaginal births, from 1992 to 1998, and no further births were retrieved and surveyed by the Swedish Medical Birth Register and Statistics Sweden in 2015. A simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. The cumulative effect was studied in all women with a repeat sphincter injury from 1987 to 2000. Postal and web-based questionnaires were used. The study population consisted of 6760 women with no sphincter injury, 357 with 1 sphincter injury, and 324 women with 2 sphincter injuries. Women with 2 deliveries without sphincter injuries aged 40 to 60 years as reference, were compared with those of women that sustained 1 or 2 consecutive sphincter injuries. Here, third- and fourth-degree perineal tears were presented as 1 group. Fecal incontinence was defined as current involuntary leakage of solid or liquid stool, with and without concomitant leakage of gas. The Fisher exact test and the Mann-Whitney U test were used to compare the results of the 2 groups. The trend was analyzed using the Mantel-Haenszel statistics. Logistic regression models obtained the estimated age-related probability of fecal incontinence components. RESULTS The risk of sphincter injury at first delivery was 3.9%, and the risk of a repeat sphincter injury was 10.0% (odds ratio, 2.70; 95% confidence interval, 1.80-4.07). The overall prevalence of fecal incontinence in women without sphincter injuries was 11.7%, which doubled to 23.8% (odds ratio, 2.27; 95% confidence interval, 1.75-2.94) in those with 1 sphincter injury and more than tripled to 36.1% (odds ratio, 3.97; 95% confidence interval, 3.11-5.07) after 2 sphincter injuries (trend P<.0001). The proportion of women with severe fecal incontinence increased 3-fold and 5-fold from 1.8% after no obstetrical anal sphincter injury to 5.4% (95% confidence interval, 3.3-8.2) and 9.0% (95% confidence interval, 6.1-12.6) after 1 or 2 obstetrical anal sphincter injuries, respectively (trend P<.0001). In women without sphincter injuries, the estimated probability of fecal incontinence increased from 7.0% at the age of 40 years to 19.8% at the age of 60 years. In contrast, in women with 1 or 2 sphincter injuries, the estimated probability of fecal incontinence increased from 26.1% and 33.3%, respectively, at the age of 40 years to 36.8% and 48.8% at the age of 60 years. The prevalence of fecal incontinence increased after 52 years of age in women with 1 or 2 sphincter injuries. The dominant types of leakage in women with fecal incontinence were the combination of liquid stool and gas, and the triple combination consisting of solid and liquid stools and gas. The triple combination increased from 18.9% in those without sphincter injury to 28.2% in women with 2 injuries (trend P=.0204). CONCLUSION The risk of sustaining a repeat sphincter injury at the second delivery was almost tripled compared with the risk at the first delivery. Furthermore, 1 or 2 sphincter injuries brought severe long-term consequences for bowel continence. Accidental leakage of stool and gas increased with each sphincter injury, and the effect was proportionally cumulative. After the age of 52 years, the prevalence of fecal incontinence seemed to accelerate.
Collapse
Affiliation(s)
- Ida E K Nilsson
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Southern Älvsborg Hospital, Borås, Sweden
| | - Sigvard Åkervall
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Ian Milsom
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Gyhagen
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Southern Älvsborg Hospital, Borås, Sweden.
| |
Collapse
|
9
|
Åkervall S, Al-Mukhtar Othman J, Molin M, Gyhagen M. Symptomatic pelvic organ prolapse in middle-aged women: a national matched cohort study on the influence of childbirth. Am J Obstet Gynecol 2020; 222:356.e1-356.e14. [PMID: 31639370 DOI: 10.1016/j.ajog.2019.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 10/03/2019] [Accepted: 10/13/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The relative impact of age, pregnancy, and vaginal delivery on symptomatic pelvic organ prolapse is still an unresolved issue that involves the controversial question about the protective effect of cesarean section. OBJECTIVE The purpose of this study was to compare the age-related prevalence of symptomatic genital prolapse in nulliparous, vaginal- and cesarean-delivered women aged 40-64 years. STUDY DESIGN This Swedish, nationwide matched cohort study involved 14,335 women. Three restricted, randomly selected source cohorts of women (nulliparous women unexposed to childbirth [n = 9136], 1-para cesarean delivered women, exposed to 1 pregnancy [n = 1412], and 1-para women exposed to 1 pregnancy followed by vaginal delivery [n = 3787]) were retrieved from the Swedish Medical Birth Register and Statistics Sweden and surveyed in 2008 and 2014. The surveys used a postal and Internet-based questionnaire containing validated questions for pelvic floor disorders. Symptomatic prolapse was defined by the question, "Do you have a sensation of tissue protrusion (a vaginal bulge) from your vagina?" In this study the symptom frequencies, sometimes and often, were defined as a positive response. Parous women were all assessed 20 years postnatally. One-to-one matching with an age interval for pairing of 3 years and 3 units of body mass index (kilograms per square meter) was used in women aged 40-64 years. The procedure succeeded in 2635 of 2640 women (99.8%), resulting in an adequate distribution of age and body mass index (kilograms per square meter) between matched groups. For comparison between groups, a Fisher exact test was used for categorical variables and the Mann-Whitney U test for continuous variables. Trend between matched groups was analyzed with Mantel-Haenszel statistics. Estimated, age-related values of symptomatic prolapse were obtained by logistic regression analysis. RESULTS In nulliparous and cesarean-delivered women, the prevalence of symptomatic prolapse was relatively similar and below 5% across ages 40-64 years. In contrast, in women after vaginal delivery, there was an accelerating increase in the prevalence of symptomatic genital prolapse up to 65 years of age. Estimated probability from the regression model increased 4-fold, from 3.8% at 40 years to 13.4% at 64 years of age. The observed induction period associated with 1 vaginal delivery seemed to be at least 20 years among women giving birth in their early 20s. At age 64 years, the estimated probability of symptomatic prolapse was 12 times higher after vaginal delivery compared with cesarean deliery (13.4% [95% confidence interval, 9.4-18.9] vs 1.1% [95% confidence interval, 0.4-2.5], P < .0001). The calculated reduction of symptomatic prolapse by cesarean delivery at 64 years of age was thus 92%. CONCLUSION In this national matched cohort study, the interaction between vaginal delivery and aging was the most important factor for the occurrence of symptomatic prolapse. Because the effect of aging can be modified only to a small extent, preventive strategies for genital prolapse should focus on how to avoid the adverse events related to a vaginal delivery.
Collapse
|
10
|
Gyhagen M, Åkervall S, Molin M, Milsom I. The effect of childbirth on urinary incontinence: a matched cohort study in women aged 40-64 years. Am J Obstet Gynecol 2019; 221:322.e1-322.e17. [PMID: 31121136 DOI: 10.1016/j.ajog.2019.05.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/04/2019] [Accepted: 05/14/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND The relative impact of age, pregnancy and vaginal delivery on urinary incontinence is still an unresolved issue that involves the controversial question about the protective effect of cesarean delivery. OBJECTIVE The purpose of this study was to estimate and compare the effect size of 1 pregnancy, 1 vaginal delivery, and the derived protective effect of cesarean delivery for different aspects of urinary incontinence in women 40-64 years old, all 20 years after birth. STUDY DESIGN This Swedish nationwide matched cohort study involved 14,335 women. Data from 3 restricted, randomly selected, source cohorts of (1) nulliparous women who were unexposed to childbirth (n=9136), (2) primiparous women who had experienced cesarean delivery and who had been exposed to 1 pregnancy (n=1412), and (3) primiparous women who had been exposed to 1 pregnancy followed by vaginal delivery (n=3787) were retrieved from The Swedish Medical Birth Register and Statistics Sweden and surveyed in 2008 and 2014, respectively. Parous women were all assessed 20 years postnatally. One-to-one matching with an interval for pairing of 3 years and 3 body mass index units was used in women 40-64 years old with information about body mass index (kilograms/square meters) and urinary incontinence. The procedure succeeded in 2630 of 2635 women (99.8%) and resulted in an adequate distribution of age and body mass index between groups. The surveys used a postal- and an internet-based questionnaire with validated questions for various aspects of urinary incontinence. Fisher's exact test and the Mann-Whitney U test were used for comparisons between matched groups; trend was analyzed with Mantel-Haenszel statistics. Predicted, age-related values of different aspects of urinary incontinence were obtained by logistic regression analysis. RESULTS Pregnancy increased the prevalence of urinary incontinence from 20.1-30.1% (odds ratio, 1.71; 95% confidence interval, 1.43-2.05; P<.0001]. Urinary incontinence increased further after vaginal delivery to 43.0% (odds ratio, 1.75; 95% confidence interval, 1.49-2.05; P<.0001); "moderate" and "severe" urinary incontinence increased from 12.7-19.5% (odds ratio, 1.67; 95% confidence interval, 1.35-2.07; P <.0001). There was a parallel increase in urinary incontinence from 40-65 years of age in nulliparous and vaginally and cesarean delivered women. Cesarean delivery, compared with vaginal delivery, was associated with a 30.0% reduction of urinary incontinence (P<.0001) and a 35-52% reduction of more severe grades of urinary incontinence (P<.0001) and was unaffected by age. CONCLUSION Both pregnancy and vaginal delivery incurred an increased risk of urinary incontinence in the long term. The age-related gap for urinary incontinence between nulliparous and primiparous women who were delivered by vaginal delivery or cesarean delivery was constant between parallel trajectories that spanned ages from 40-64 years. The calculated protective effect of cesarean delivery was unaltered and significant during the same age interval.
Collapse
Affiliation(s)
- Maria Gyhagen
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden; Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden.
| | - Sigvard Åkervall
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Mattias Molin
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ian Milsom
- Statistical Consultancy Group, Gothenburg, Sweden
| |
Collapse
|
11
|
Abstract
The reported prevalence of urinary incontinence (UI) among women varies widely in different studies due to the use of different definitions, the heterogenicity of different study populations, and population sampling procedures. Population studies from numerous countries have reported that the prevalence of UI ranged from approximately 5% to 70%, with most studies reporting a prevalence of any UI in the range of 25-45%. Prevalence figures increase with increasing age, and in women aged ≥70 years more than 40% of the female population is affected. Prevalence rates are even higher in the elderly-elderly and amongst nursing home patients. There are only a few studies describing progression as well as remission of UI in the general population as well as in selected groups of the population. The mean annual incidence of UI has been reported to range from 1% to 9%, while estimates of remission are more varying, from 4% to 30%. The prevalence of UI is strongly related to the age of the woman and thus, due to the increase in mean life expectancy, the overall prevalence of UI in women is expected to increase in the future.
Collapse
Affiliation(s)
- I Milsom
- a Department of Obstetrics & Gynaecology , Sahlgrenska Academy at Gothenburg University , Gothenburg , Sweden
| | - M Gyhagen
- a Department of Obstetrics & Gynaecology , Sahlgrenska Academy at Gothenburg University , Gothenburg , Sweden
| |
Collapse
|
12
|
Abstract
Urinary incontinence (UI) and fecal incontinence (FI) together with pelvic organ prolapse (POP) constitute a huge global health problem affecting millions of women throughout the world. These pelvic floor disorders (PFDs) can have a negative influence on a woman's well-being, quality of life, and sexual function and prevent many women from participating in recreational and sporting activities. The global costs of PFDs to health care systems and society are enormous and approximately one in five women will undergo surgery for genital prolapse or UI by the age of 85 years.
Collapse
Affiliation(s)
- Ian Milsom
- Department of Obstetrics & Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
| | - Maria Gyhagen
- Department of Obstetrics & Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| |
Collapse
|
13
|
Gyhagen M, Al-Mukhtar Othman J, Åkervall S, Nilsson I, Milsom I. The symptom of vaginal bulging in nulliparous women aged 25-64 years: a national cohort study. Int Urogynecol J 2018; 30:639-647. [PMID: 29934770 PMCID: PMC6451022 DOI: 10.1007/s00192-018-3684-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 05/28/2018] [Indexed: 12/17/2022]
Abstract
Introduction and hypothesis Vaginal bulging is considered the key symptom for genital organ prolapse. The aim was to investigate the age-related prevalence and frequency of symptomatic pelvic organ prolapse (sPOP) and other pelvic floor symptoms in nonpregnant nullipara aged 25–64 years. Methods This national postal and web-based questionnaire survey was conducted in 2014 and included four independent random samples of women aged 25–34, 35–44, 45–54, and 55–64 years. The association of sPOP with demographics and with other pelvic floor conditions and with clustering to other pelvic floor conditions, was presented in women with and without sPOP. Logistic regression was used to identify and rank variables associated with symptomatic prolapse. Results The response rate was 52% (n = 10,187) and 726 nullipara confirmed sPOP. Women with sPOP were younger (p < 0.001), shorter (p < 0.001), and more often overweight and obese (p < 0.01) compared with asymptomatic women. Previous surgery for prolapse was reported by 15 women only (0.16%). Symptomatic POP decreased from 9.8% in the youngest age group (25–34 years) to 6.1% in the oldest (55–64 years) (p < 0.0001). Symptomatic POP was more often experienced as bothersome (p = 0.012), and aggravated by straining and heavy lifting (p = 0.003), in older women. Vaginal/vulval chafing/rubbing feeling was most prevalent among the youngest 14.2%, decreasing to 7.8% among the oldest (<0.0001). This symptom occurred three to five times more often in those with sPOP (p < 0.0001). Clustering of pelvic floor symptoms was four times more prevalent in women with sPOP (23.2% versus 6.1%) (p < 0.0001). Conclusions The high prevalence of sPOP in this study was contradictory to most earlier reports, which have shown that genital prolapse is rare in nullipara. The explanation of our results may be the low probability of the clinical condition, the dominance of weak and infrequent symptoms, and not least clustering of alternative conditions mimicking sPOP. Electronic supplementary material The online version of this article (10.1007/s00192-018-3684-5) contains supplementary material, which is available to authorized users
Collapse
Affiliation(s)
- Maria Gyhagen
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.
- Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, 501 82, Borås, Sweden.
| | - Jwan Al-Mukhtar Othman
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Sigvard Åkervall
- Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Ida Nilsson
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, 501 82, Borås, Sweden
| | - Ian Milsom
- Gothenburg Continence Research Centre, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| |
Collapse
|
14
|
Robinson D, Åkervall S, Wagg A, Chapple C, Milsom I, Gyhagen M. Prevalence and predictors of overactive bladder in nonpregnant nulliparous women below 65 years of age. Int Urogynecol J 2017; 29:531-537. [PMID: 28779415 DOI: 10.1007/s00192-017-3435-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 07/14/2017] [Indexed: 12/16/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The aetiology of the overactive bladder (OAB) symptom complex is still poorly understood. In order to obtain further insight, the prevalence and predictors of the symptoms included in OAB, that is urgency, urgency incontinence (UUI), frequency and nocturia, were investigated in a sample of nonpregnant nulliparous women. METHODS A national, postal and web-based survey of OAB symptoms was conducted in women aged 25-64 years (n = 9,197). Crude prevalence and prevalence adjusted according to body mass index (BMI) were calculated from a logistic regression model to evaluate the prevalence of OAB. RESULTS The response rate was 52%. The prevalence of urgency, bothersome urgency, UUI, and nocturia, but not daytime frequency, increased consistently with advancing age and increasing BMI. Urgency was associated with BMI, age ≥45 years, nocturia, and daytime frequency of eight or more micturitions. Daytime urinary micturition frequency was not affected by age either in women with OAB or in women without OAB. Bothersome OAB affected almost half of the woman in the oldest age group and was strongly associated with nocturia of two or more micturitions and OAB with UUI. CONCLUSIONS There were contrasting changes in the prevalence of the different symptoms included in OAB. With increasing age and BMI, the prevalence of nocturia, urgency and UUI increased, while daytime frequency remained stable. These findings are of importance as the primary endpoint for the evaluation of drug therapies for OAB has often been daytime urinary frequency.
Collapse
Affiliation(s)
- Dudley Robinson
- Department of Urogynaecology, King's College Hospital, London, UK
| | - Sigvard Åkervall
- Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Adrian Wagg
- Division of Geriatric Medicine, University of Alberta, Edmonton, Canada.,Gothenburg Continence Research Centre, Department of Obstetrics and Gynecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Christopher Chapple
- Department of Urology, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Ian Milsom
- Gothenburg Continence Research Centre, Department of Obstetrics and Gynecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Maria Gyhagen
- Gothenburg Continence Research Centre, Department of Obstetrics and Gynecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden. .,Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Sahlgrenska Academy at Gothenburg University, SE-501 82, Borås, Sweden.
| |
Collapse
|
15
|
Chapple CR, Cruz F, Deffieux X, Milani AL, Arlandis S, Artibani W, Bauer RM, Burkhard F, Cardozo L, Castro-Diaz D, Cornu JN, Deprest J, Gunnemann A, Gyhagen M, Heesakkers J, Koelbl H, MacNeil S, Naumann G, Roovers JPWR, Salvatore S, Sievert KD, Tarcan T, Van der Aa F, Montorsi F, Wirth M, Abdel-Fattah M. Consensus Statement of the European Urology Association and the European Urogynaecological Association on the Use of Implanted Materials for Treating Pelvic Organ Prolapse and Stress Urinary Incontinence. Eur Urol 2017; 72:424-431. [PMID: 28413126 DOI: 10.1016/j.eururo.2017.03.048] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/30/2017] [Indexed: 01/30/2023]
Abstract
CONTEXT Surgical nonautologous meshes have been used for several decades to repair abdominal wall herniae. Implantable materials have been adopted for the treatment of female and male stress urinary incontinence (SUI) and female pelvic organ prolapse (POP). OBJECTIVE A consensus review of existing data based on published meta-analyses and reviews. EVIDENCE ACQUISITION This document summarises the deliberations of a consensus group meeting convened by the European Association of Urology (EAU) and the European Urogynecological Association, to explore the current evidence relating to the use of polypropylene (PP) materials used for the treatment of SUI and POP, with reference to the 2016 EAU guidelines (European Association of Urology 2016), the European Commission's SCENIHR report on the use of surgical meshes (SCENIHR 2015), other available high-quality evidence, guidelines, and national recommendations. EVIDENCE SYNTHESIS Current data suggest that the use of nonautologous durable materials in surgery has well-established benefits but significant risks, which are specific to the condition and location they are used for. Various graft-related complications have been described-such as infection, chronic pain including dyspareunia, exposure in the vagina, shrinkage, erosion into other organs of xenografts, synthetic PP tapes (used in SUI), and meshes (used in POP)-which differ from the complications seen with abdominal herniae. CONCLUSIONS When considering surgery for SUI, it is essential to evaluate the available options, which may include synthetic midurethral slings (MUSs) using PP tapes, bulking agents, colposuspension, and autologous sling surgery. The use of synthetic MUSs for surgical treatment of SUI in both male and female patients has good efficacy and acceptable morbidity. Synthetic mesh for POP should be used only in complex cases with recurrent prolapse in the same compartment and restricted to those surgeons with appropriate training who are working in multidisciplinary referral centres. PATIENT SUMMARY Synthetic slings can be safely used in the surgical treatment of stress incontinence in both male and female patients. Patients need to be aware of the alternative therapy and potential risks and complications of this therapy. Synthetic mesh for treating prolapse should be used only in complex cases with recurrent prolapse in specialist referral centres.
Collapse
Affiliation(s)
| | - Francisco Cruz
- Department of Urology, Hospital São João/Faculty of Medicine of Porto, Porto, Portugal; I3S Institute for Health, Porto, Portugal
| | - Xavier Deffieux
- Department of Gynaecologic Surgery, Antoine Béclère Hospital, Paris South University, Clamart, France
| | - Alfredo L Milani
- Department of Obstetrics & Gynaecology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Salvador Arlandis
- Department of Urology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Walter Artibani
- Department of Urology, Azienda Ospedaliero Universitaria di Verona, Verona, Italy
| | - Ricarda M Bauer
- Department of Urology, Ludwig-Maximilians-University Muenchen, Klinikum Großhadern, Muenchen, Germany
| | - Fiona Burkhard
- Department of Urology, University Hospital Bern, Bern, Switzerland
| | - Linda Cardozo
- Department of Urogynaecology, King's College Hospital, London, United Kingdom
| | - David Castro-Diaz
- Department of Urology, Hospital Universitario de Canarias, Universidad de La Laguna, Tenerife, Canary Islands, Spain
| | - Jean Nicolas Cornu
- Department of Urology, Rouen University Hospital and University of Rouen, Rouen Cedex, France
| | - Jan Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Alfons Gunnemann
- Klinikum Lippe Urologische Klinik, Akademisches Lehrkrankenhaus der Georg-August-Universität Göttingen, Germany
| | - Maria Gyhagen
- Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | | | - Heinz Koelbl
- Department of General Gynaecology and Gynaecologic Oncology, Medical University of Vienna, Vienna, Austria
| | - Sheila MacNeil
- Department of Tissue Engineering, University of Sheffield, Sheffield, United Kingdom
| | - Gert Naumann
- Department of Obstetrics and Gynaecology, Helios-Klinikum, Erfurt, Germany
| | - Jan-Paul W R Roovers
- Department of Obstetrics and Gynaecology, Academic Medical Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Stefano Salvatore
- Obstetrics and Gynaecology Unit, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Tufan Tarcan
- Department of Urology, Marmara University School of Medicine, Istanbul, Turkey
| | - Frank Van der Aa
- Department of Urology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Francesco Montorsi
- Department of Urology, Vita Salute San Raffaele University, Milan, Italy
| | - Manfred Wirth
- Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Mohamed Abdel-Fattah
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland, United Kingdom
| |
Collapse
|
16
|
Al-Mukhtar Othman J, Åkervall S, Milsom I, Gyhagen M. Urinary incontinence in nulliparous women aged 25-64 years: a national survey. Am J Obstet Gynecol 2017; 216:149.e1-149.e11. [PMID: 27720862 DOI: 10.1016/j.ajog.2016.09.104] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 09/20/2016] [Accepted: 09/29/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND A systematic survey of pelvic floor disorders in nulliparous women has not been presented previously. OBJECTIVE The purpose of this study was to determine the prevalence of urinary incontinence parameters in a large cohort of nonpregnant, nulliparous women, and thereby construct a reference group for comparisons with parous women. STUDY DESIGN This postal and World Wide Web-based questionnaire survey was conducted in 2014. The study population was identified from the Total Population Register in Sweden and comprised women who had not given birth and were aged 25-64 years. Four independent age-stratified, random samples comprising 20,000 women were obtained from the total number of eligible nullipara (n = 625,810). A 40-item questionnaire about pelvic floor symptoms, its severity, and its consequences were used. Age-dependent differences for various aspects of urinary incontinence were analyzed with the youngest group (25-34 years) serving as reference. Crude and body mass index-adjusted prevalence and its 95% confidence limits were calculated for each 10-year category. RESULTS The response rate was 52% and the number of study participants was 9197. Urinary incontinence increased >5-fold from 9.7% in the youngest women with a body mass index <25 kg/m2 to 48.4% among the oldest women with a body mass index ≥35 kg/m2. The prevalence of bothersome urinary incontinence almost tripled from 2.8-7.9% among all nulliparas. The proportion with bothersome urinary incontinence among incontinent women increased from 24.4% in the youngest age group to 32.3% in the age group 55-64 years. Nocturia ≥2/night increased 4-fold to 17.0% and leakage ≥1/wk increased 3-fold to 12.8% among the oldest women. Mixed urinary incontinence increased from 22.9-40.9% among the oldest 0-para with incontinence, whereas stress urinary incontinence decreased inversely from 43.6-33.0%. In the total cohort surgical treatment for urinary incontinence occurred in 3 per thousand. CONCLUSION Almost every aspect of urinary incontinence was present in nulliparous women of all ages and prevalence increased with advancing age between 25-64 years. This must be taken into account when using nullipara as a control group in comparisons with parous women to estimate the effect of pregnancy and childbirth.
Collapse
|
17
|
Gyhagen M, Åkervall S, Milsom I. Clustering of pelvic floor disorders 20 years after one vaginal or one cesarean birth. Int Urogynecol J 2015; 26:1115-21. [PMID: 25708677 DOI: 10.1007/s00192-015-2663-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 01/18/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to assess the prevalence and risk factors for co-occurring pelvic floor disorders (PFDs): urinary incontinence (UI), symptomatic pelvic organ prolapse (sPOP), and fecal incontinence (FI), 20 years after one vaginal (VD) or one cesarean (CS) delivery. METHODS We carried out a registry-based national cohort study of primiparae who delivered during the period 1985-1988 and had no further deliveries. Medical Birth Registry data were linked to data from postal questionnaires distributed 20 years post-partum (response rate 65.2%, n = 5,236). Main outcome measures were prevalence and risk factors for combined and isolated PFDs. RESULTS The prevalence of any PFD was 46.5; 31.7% had one symptom and 14.8% had two or more. Co-occurring symptoms doubled after VD (17.1%) compared with CS (8.4%) (adjOR 2.26; 95% CI 1.84-2.79). The strongest association was observed between VD and having all three symptoms (adjOR 5.20; 95% CI 2.73-9.91), followed by the combination of sPOP and UI (adjOR 3.38; 95% CI 2.24-5.10). The degree of frustration perceived by the women because of pelvic floor dysfunction increased with each additional co-occurring PFD (p < 0.001). The strongest risk factors for clustering of PFDs were: VD (OR 2.19; 95% CI 1.75-2.73), family history (OR 2.03; 95% CI 1.73-2.34), and ≥2 degree tear (OR 1.78; 95% CI 1.24-2.55). Vacuum extraction and episiotomy were not risk factors. CONCLUSIONS The prevalence of co-occurring PFDs was high and was doubled in women after VD compared with CS. Women with UI most likely had it as an isolated symptom, whereas FI and sPOP more often occurred in combination.
Collapse
Affiliation(s)
- Maria Gyhagen
- Department of Obstetrics and Gynecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden,
| | | | | |
Collapse
|
18
|
Gyhagen M, Milsom I. Authors' reply: A comparison of the long-term consequences of vaginal delivery versus caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes. BJOG 2014; 121:1740-1. [PMID: 25413750 DOI: 10.1111/1471-0528.12708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2014] [Indexed: 11/28/2022]
Affiliation(s)
- M Gyhagen
- Department of Obstetrics & Gynaecology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | | |
Collapse
|
19
|
Gyhagen M, Milsom I. Authors' reply: A comparison of the long-term consequences of vaginal delivery versus caesarean section of the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women. BJOG 2014; 121:1176. [PMID: 25047492 DOI: 10.1111/1471-0528.12673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2013] [Indexed: 11/29/2022]
Affiliation(s)
- M Gyhagen
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | | |
Collapse
|
20
|
Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Faecal incontinence 20 years after one birth: a comparison between vaginal delivery and caesarean section. Int Urogynecol J 2014; 25:1411-8. [DOI: 10.1007/s00192-014-2390-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 04/01/2014] [Indexed: 10/25/2022]
|
21
|
Gyhagen M, Milsom I. Authors' response to: Does the SWEPOP (Swedish Pregnancy, Obesity and Pelvic Floor) study suffer from a selection bias? BJOG 2013; 120:1579-80. [PMID: 24118816 DOI: 10.1111/1471-0528.12418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2013] [Indexed: 11/29/2022]
Affiliation(s)
- M Gyhagen
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | | |
Collapse
|
22
|
Gyhagen M, Milsom I. Prevalence of urinary incontinence (UI) 20 years after childbirth in a national cohort study in singleton primiparae after vaginal or caesarean delivery--authors' reply. BJOG 2013; 120:1152-3. [PMID: 23837777 DOI: 10.1111/1471-0528.12269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2013] [Indexed: 11/28/2022]
|
23
|
Gyhagen M, Milsom I. Authors' response to: Prevalence of urinary incontinence 20 years after childbirth in a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG 2013; 120:1150-1. [DOI: 10.1111/1471-0528.12268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2013] [Indexed: 11/29/2022]
Affiliation(s)
- M Gyhagen
- Department of Obstetrics & Gynaecology; Sahlgrenska Academy; Gothenburg University; Gothenburg; Sweden
| | - I Milsom
- Department of Obstetrics & Gynaecology; Sahlgrenska Academy; Gothenburg University; Gothenburg; Sweden
| |
Collapse
|
24
|
Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. A comparison of the long-term consequences of vaginal delivery versus caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women. BJOG 2013; 120:1548-55. [PMID: 23786421 DOI: 10.1111/1471-0528.12367] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To study the effect of one vaginal delivery (VD) compared with one caesarean section (CS) on the prevalence, severity and bothersomeness of urinary incontinence (UI) subtypes--stress (SUI), urge (UUI) and mixed (MUI)--20 years after delivery. DESIGN Registry-based national cohort study. SETTING Women who returned postal questionnaires (response rate 65.2%) in 2008. POPULATION Primiparae with one birth in 1985-88 (n = 5236) and no further births. METHODS Medical Birth Register data were linked to a questionnaire. Analysis of variance and multivariate analysis were used to obtain adjusted prevalences and odds ratios (adjOR). MAIN OUTCOME MEASURES Prevalence, risk factors, severity, bothersomeness of UI subtypes. RESULTS The prevalence of SUI, UUI and MUI was 15.3, 6.1, 14.4%, respectively, and was higher for all subtypes after VD versus CS. Moderate to severe incontinence was more prevalent after VD (21.3%) compared with CS (13.5%; adjOR 1.68, 95% confidence interval [95% CI] 1.40-2.03). Bothersome incontinence differed between MUI (38.9%), UUI (27.1%) and SUI (18.0%). The prevalence of bothersome UI was higher after VD compared with CS (11.2 versus 6.3%; adjOR 1.85, 95% CI 1.42-2.39) and consulting a doctor for UI was reported more often after VD than CS. Bothersome MUI occurred in 40.0% of incontinent women after VD compared with 29.9% after CS (adjOR 1.65, 95% CI 1.07-2.54). Symptomatic pelvic organ prolapse was an important modifier of UI with regard to its prevalence, duration, type and bothersomeness. CONCLUSION The prevalence of SUI, UUI and MUI was higher and moderate to severe UI and bothersome UI were reported more often after VD than CS 20 years after one delivery.
Collapse
Affiliation(s)
- M Gyhagen
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | | | | | | |
Collapse
|
25
|
Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG 2012; 120:152-160. [PMID: 23121158 DOI: 10.1111/1471-0528.12020] [Citation(s) in RCA: 174] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2012] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To investigate prevalence and risk factors for symptomatic pelvic organ prolapse (sPOP) and sPOP concomitant with urinary incontinence (UI) in women 20 years after one vaginal delivery or one caesarean delivery. DESIGN Registry-based national cohort study. SETTING Women who returned a postal questionnaire in 2008 (response rate 65.2%). POPULATION Singleton primiparae with a birth in 1985-88 and no further births (n = 5236). METHODS The SWEPOP study used validated questionnaires about sPOP and UI. MAIN OUTCOME MEASURES Prevalence rate and risk of sPOP with or without concomitant UI. RESULTS Prevalence of sPOP was higher after vaginal delivery compared with caesarean section (14.6 versus 6.3%, odds ratio [OR] 2.55; 95% confidence interval [95% CI] 1.98-3.28) but was not increased after acute compared with elective caesarean section. Episiotomy, vacuum extraction and second-degree or more laceration were not associated with increased risk of sPOP compared with spontaneous vaginal delivery. Symptomatic POP increased 3% (OR 1.03; 95% CI 1.01-1.05) with each unit increase of current BMI and by 3% (OR 1.03; 95% CI 1.02-1.05) for each 100 g increase of infant birthweight. Mothers ≤ 160 cm who delivered a child with birthweight ≥ 4000 g had a doubled prevalence of sPOP compared with short mothers who delivered an infant weighing < 4000 g (24.2 versus 13.4%, OR 2.06; 95% CI 1.19-3.55). Women with sPOP had UI and UI > 10 years more often than women without prolapse. CONCLUSION The prevalence of sPOP was doubled after vaginal delivery compared with caesarean section, two decades after one birth. Infant birthweight and current BMI were risk factors for sPOP after vaginal delivery.
Collapse
Affiliation(s)
- M Gyhagen
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, SwedenDepartment of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - M Bullarbo
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, SwedenDepartment of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - T F Nielsen
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, SwedenDepartment of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - I Milsom
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, SwedenDepartment of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| |
Collapse
|
26
|
Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. The prevalence of urinary incontinence 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG 2012; 120:144-151. [PMID: 22413831 DOI: 10.1111/j.1471-0528.2012.03301.x] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To investigate the prevalence and risk factors for urinary incontinence (UI) 20 years after one vaginal delivery or one caesarean section. DESIGN Registry-based national cohort study. SETTING Women who returned postal questionnaires (response rate 65.2%) in 2008. POPULATION Singleton primiparae who delivered in the period 1985-1988 with no further births (n = 5236). METHODS The Swedish Pregnancy, Obesity and Pelvic Floor (SWEPOP) study linked Medical Birth Register (MBR) data to a questionnaire about UI. MAIN OUTCOME MEASURES Prevalence of UI and UI for more than 10 years (UI > 10 years) were assessed 20 years after childbirth. RESULTS The prevalence of UI (40.3 versus 28.8%; OR 1.67; 95% CI 1.45-1.92) and UI > 10 years (10.1 versus 3.9%; OR 2.75; 95% CI 2.02-3.75) was higher in women after vaginal delivery than after caesarean section. There was no difference in the prevalence of UI or UI > 10 years after an acute caesarean section or an elective caesarean section. We found an 8% increased risk of UI per current body mass index (BMI) unit, and age at delivery increased the UI risk by 3% annually. CONCLUSIONS Two decades after one birth, vaginal delivery was associated with a 67% increased risk of UI, and UI > 10 years increased by 275% compared with caesarean section. Our data indicate that it is necessary to perform eight or nine caesarean sections to avoid one case of UI. Weight control is an important prophylactic measure to reduce UI. Current BMI was the most important BMI-determinant for UI, which is important, as BMI is modifiable.
Collapse
Affiliation(s)
- M Gyhagen
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, SwedenDepartment of Obstetrics and Gynaecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - M Bullarbo
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, SwedenDepartment of Obstetrics and Gynaecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - T F Nielsen
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, SwedenDepartment of Obstetrics and Gynaecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - I Milsom
- Department of Obstetrics and Gynaecology, Sahlgrenska Academy at Gothenburg University, Gothenburg, SwedenDepartment of Obstetrics and Gynaecology, Södra Älvsborgs Hospital, Borås, Sweden
| |
Collapse
|
27
|
Andersen B, Gyhagen M, Nielsen TF. Warm bath during labour. Effects on labour duration and maternal and fetal infectious morbidity. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443619609030037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|