Fluctuations in lower urinary tract symptoms in women. Reassurance and watchful waiting can prevent overtreatment.
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Decision Making↗
Biomedical subjects
S Hunskaar
Publications and source records attributed to S Hunskaar.
A severity index for epidemiological surveys of female urinary incontinence: comparison with 48-hour pad-weighing tests.
In epidemiological surveys of female urinary incontinence, it is not feasible to demonstrate urine loss objectively. The aim of this study was to develop a valid epidemiological instrument (a severity index) for assessing the severity of incontinence. The severity index is based on information about frequency (four levels) and amount of leakage (two or three levels). By multiplication, an index value (1-8 or 1-12) is reached. This index value is further categorized into a severity index of three or four levels. The index was compared with the results of 315 pad-weighing tests performed by 265 women in hospital and general practice. Data from an epidemiological survey were also re-analyzed by applying the four-level severity index. Mean pad-weighing results (grams per 24 hours, 95% confidence interval) for the three-level severity index was slight (6; 2-9), moderate (17; 13-22), and severe (56; 44-67). For the four-level severity index, the results were slight (6; 2-9), moderate (23; 15-30), severe (52; 38-65), and very severe (122; 84-159). Spearman's correlation coefficient for pad-weighing results and the three-level severity index was 0.47 (P < 0.01) and for the four-level severity index 0.54 (P< 0.01). The four-level severity index gave a more balanced distribution among the women in the clinical materials, and data from the epidemiological survey showed that the four-level severity index identifies a sub-group of older women with very severe incontinence. The four-level severity index seems to be a valid representation of incontinence severity as measured by pad-weighing tests in women presenting for clinical care. It should be considered a potentially valid measure of incontinence severity in epidemiological studies. Neurourol. Urodynam. 19:137-145, 2000.
Adolescent↗
Epidemiology and natural history of urinary incontinence.
This paper examines or current state of knowledge of the epidemiology of urinary incontinence. The population studied was community-dwelling non-institutionalized persons. The review includes discussion of the prevalence, incidence, natural history and presence of racial and ethnic differences in the epidemiology of urinary incontinence. We also review correlates and potential risk factors that have been revealed in epidemiological studies. Differences between epidemiological and clinical approaches to a health problem, help-seeking behavior and methodological issues for research are also discussed. We have reviewed a large number of completed studies in the field of urinary incontinence, and have emphasized high-quality and population-based studies. We also wished to present studies from a variety of countries. Because of the abundance of studies, only a small fraction can be presented here. Other studies may have equal standards and useful information, but lack of space precludes their inclusion.
Adult↗
A community-based epidemiological survey of female urinary incontinence: the Norwegian EPINCONT study. Epidemiology of Incontinence in the County of Nord-Trøndelag.
OBJECTIVES: The aim was to assess the prevalence of any urinary leakage in an unselected female population in Norway, and to estimate the prevalence of significant incontinence. METHODS: The EPINCONT Study is part of a large survey (HUNT 2) performed in a county in Norway during 1995-97. Everyone aged 20 years or more was invited. 27,936 (80%) of 34,755 community-dwelling women answered a questionnaire. A validated severity index was used to assess severity. RESULTS: Twenty-five percent of the participating women had urinary leakage. Nearly 7% had significant incontinence, defined as moderate or severe incontinence that was experienced as bothersome. The prevalence of incontinence increased with increasing age. Half of the incontinence was of stress type, 11% had urge and 36% mixed incontinence. CONCLUSIONS: Urinary leakage is highly prevalent. Seven percent have significant incontinence and should be regarded as potential patients.
Adult↗
Usefulness of urodynamic examination in female urinary incontinence--lessons from a population-based, randomized, controlled study of conservative treatment.
OBJECTIVE: To test the usefulness of urodynamic examination in female urinary incontinence. MATERIAL AND METHODS: As part of a population-based, randomized, controlled treatment study in general practice, the control group was offered urodynamic examination before and after delayed treatment starting 6 months after inclusion in the study, i.e. after the first outcome evaluation comparing the initially treated group with the control group. The intervention group was offered urodynamic examination only after the final outcome evaluation at 12 months. Eighty-seven women, aged 50-74, from three Norwegian municipalities participated. RESULTS: There was no difference in treatment outcome whether the patients had urodynamic examination or not. Eleven patients (26% of 42 control patients) had their diagnosis revised after urodynamic examination, ten of them with a subsequent change in treatment. The outcome for this group was no different than for the other patients. As a subgroup, the 11 patients had more severe leakage (p = 0.048) and more previous gynecological operations (p = 0.038) than the other control group patients. CONCLUSIONS: Our study supports the idea that in general practice, or in rather unselected patients, women with urinary incontinence may be classified and treated without urodynamic examination. If there is little or no improvement during the first few months referral should be considered, and this should be done sooner for patients with severe incontinence or prior gynecological operations than for other patients.
Aged↗
A Norwegian version of the Incontinence Stress Questionnaire-Staff Reaction: translation and validation for cross-cultural use.
The aim of the present study was to translate and validate the Incontinence Stress Questionnaire--Staff Reaction (ISQ-SR) for cross-cultural adaptation to Norway. The ISQ-SR is a 30-item questionnaire developed in the U.S.A. by Dr. Lucy C. Yu. The questionnaire examines the experience of nursing home staff when working with patients with urinary incontinence. This article describes both the translation and testing procedure. Statistical analyses were carried out in the following steps of the testing procedure: (a) bivariate examination, (b) principal components factor analysis, (c) determination of internal consistency, (d) frequency analysis, and (e) estimation of test-retest reliability. Finally, the translated and tested questionnaire was compared with the original version. The Norwegian version consists of three factors with a total of 24 items, and is shown to be a valid and reliable version of the ISQ-SR. We conclude that we have achieved equivalence with the original version.
Adult↗
Violence in an urban community: a population-based interview study.
BACKGROUND: This study aimed to estimate the proportion of an unselected population in an urban community (Bergen, Norway) that was exposed to physical violence during the preceding year, and to determine the proportion seeking medical treatment and pressing legal charges. METHOD: A structured telephone interview was performed as part of monthly opinion polls. RESULTS: During a one-year period in 1997/1998, 3,005 residents of Bergen were interviewed. Of these, 41 (1.4%) had been exposed to physical violence during the preceding year; 10 (24%) of them had sought medical treatment, and 16 (39%) had pressed legal charges. The majority of the victims had been treated at Bergen Accident and Emergency Department. The interviewees knew about a total of 347 other people who had been assaulted during the preceding year. Of these assault victims, 224 (65%) sought medical treatment and 181 (52%) pressed legal charges, according to the respondents. CONCLUSION: A high proportion of the assault victims did not seek medical treatment and did not press legal charges.
Adolescent↗
Female urinary incontinence--the role of the general practitioner.
SUBJECT: Urinary incontinence is a frequent disorder among adult females, but very few of the incontinent women have consulted a doctor. DISCUSSION: This paper reviews and discusses the possible roles of the general practitioner in the diagnostic and therapeutic work with women with urinary incontinence. Some characteristics of general practice and the selection process from primary care to the specialist level are described. The selection process (gatekeeper function) of patients from community to hospitals may introduce bias into research and hamper the generalization of hospital-based research back to general practice. Recommendations and guidelines for diagnosis or therapy developed at secondary or tertiary care levels may be inappropriate at the primary care level, with a significantly different clinical picture of this condition. RESULTS: Several studies show that most women seeking help in general practice can be satisfactorily treated at this level of care with fairly simple treatments, and that treatment is effective also in the long term. Some women with urinary incontinence need to be referred primarily to a specialist, or later if the response to treatment is disappointing. RECOMMENDATIONS: Based on literature studies and the authors' own experiences from clinical work and research, recommendations are presented for a basic evaluation and treatment of women with urinary incontinence who seek help in general practice.
Adult↗
Equal symptomatic outcome after antibacterial treatment of acute lower urinary tract infection and the acute urethral syndrome in adult women.
OBJECTIVE: To compare symptomatic outcome after antibacterial treatment in patients with acute lower urinary tract infection and the acute urethral syndrome. DESIGN: A multipractice study; patients registering symptoms prospectively for 3 days by means of a diary. SETTING: General practices in western Norway. SUBJECTS: 153 adult women with acute lower urinary tract symptoms. MAIN OUTCOME MEASURE: Patient's prospective registration of symptom distribution and duration after starting antibacterial treatment. RESULTS: Fifty-one patients with acute lower urinary tract infection and 58 patients with the acute urethral syndrome were included. There were no differences in age, history of urinary tract infection, actual symptoms, or symptom duration between the groups. Symptom duration was nearly identical in the two groups among those who became asymptomatic during the 3 days of registration, ranging from 1.2 days for urgency to 1.6 days for dysuria. Almost half of the patients in each group still had some symptom left after 3 days. CONCLUSIONS: Symptomatic outcome was equal after antibacterial treatment whether the patient was classified as having acute cystitis or the acute urethral syndrome. Consequently, the general practitioner may rely on symptoms alone when starting antibacterial treatment in adult women with suspected cystitis.
Acute Disease↗
Anaemia and iron deficiency screening in adolescence: a pilot study of iron stores and haemoglobin response to iron treatment in a population of 14-15-year-olds in Norway.
Screening for haemoglobin (Hb) and s-ferritin, in 176 of all 189 (93%) pupils at 8th grade (14-15-years-old) in one Norwegian community was performed in order to map the prevalence of anaemia and depleted iron stores. In order to determine the clinical significance of the findings, a questionnaire aimed at detecting symptoms or risk factors for iron deficiency was completed by all participants, and a 3 mo therapeutic trial with iron was offered to subjects with s-ferritin values below 15 microg/l. Four percent of girls and 8% of boys were anaemic according to WHO cut-off levels. S-ferritin <15 microg/l was found in 25% of girls and 30% of boys. Forty-four of 48 pupils with s-ferritin <15 microg/l completed the therapeutic trial. Only three pupils had a clinically significant increase in Hb, representing less than 2% of the population. The questionnaire gave no clues that could identify subjects with depleted iron stores. To increase Hb in one 14-15-y-old with depleted iron stores, 59 (95% CHI: 20-285) had to be screened and 16 (6-76) had to be given iron treatment. This pilot study suggests that functional iron deficiency is rare in Norwegian adolescents despite a high frequency of low iron stores. A double blind, placebo controlled study covering the entire span of pubescence is needed to confirm these results.
Adolescent↗
Are resistance patterns in uropathogens published by microbiological laboratories valid for general practice?
During 7 months from August 1994, 171 urine samples were collected consecutively in general practice in Western Norway from female patients with suspected lower urinary tract infection. For each of the 171 samples, 2 samples from adult females received from general practice at the microbiological laboratory on the same day were selected using a predetermined system. Samples noted as treatment controls and samples from pregnant patients were discarded. Bacteriuria was found in 101/171 (59.1%) vs 220/342 (64.3%) of the samples. The general practice material contained more bacteriuric samples with Escherichia coli (83.2% vs 71.8%, p<0.05) and Staphylococcus saprophyticus (11.9 vs 6.4%), and fewer with other Gram-negative rods (4.0% vs 15.9%, p<0.01) and enterococci (1.0% vs 5.9%, p<0.01). The frequency of resistant isolates was substantially lower in the samples from general practice for all antibacterial agents tested: amoxycillin 18.9% vs 23.9%, mecillinam 1.1% vs 4.7%, trimethoprim 12.9% vs 18.5%, cotrimoxazole 12.0% vs 15.4%, sulphonamide 20.0% vs 28.4%, nitrofurantoin 3.0% vs 9.7% (p<0.05). Data from local laboratories exaggerate the resistance problems among uropathogens found in urine samples in general practice.
Adult↗
Prevalence, 1-year incidence and factors associated with urinary incontinence: a population based study of women 50-74 years of age in primary care.
OBJECTIVES: To study prevalence, incidence, remissions and factors associated with urinary incontinence in women 50-74 years of age. METHODS: Cross-sectional study of prevalence and associated factors and a 1-year prospective study of incidence and remissions. A random sample of 698 women were invited for a gynecological examination in general practice in three municipalities in Northern Norway in 1994-1995. Five hundred and seven (73%) met for the first consultation, 489 of them for the second one. Questionnaires were answered by women and doctors during consultations at inclusion and 1 year later. Prevalence was estimated at three levels of evidence. RESULTS: Any leakage was reported by 47% and regularly by 31%. For 19%, leakage was objectively demonstrated and claimed to be a social or hygienic problem. Incontinence was associated with high body weight, with poor ability to contract pelvic floor muscles and with previous gynecological operations excluding hysterectomy. Three women (0.6%) developed regular incontinence during the year of investigation. There was no convincing case of spontaneous remission. CONCLUSION: Urinary incontinence is very frequent in women aged 50-74 years and about one in five are potential patients needing treatment. Urinary incontinence is an enduring condition with little tendency for remission without treatment.
Aged↗
Female urinary incontinence: long-term follow-up after treatment in general practice.
BACKGROUND: Several reports have been published showing that women with urinary incontinence (UI) can be taken care of and treated satisfactorily in general practice. AIM: To find out whether the treatment of women with UI in general practice is effective also in the long term. METHOD: One hundred and five women with UI who consulted their general practitioner (GP) were examined and treated according to a treatment protocol. Treatment options were pelvic floor exercises, electrical stimulation, oestrogen supplements, bladder training, and protective pads. Three to six years after inclusion, all women received a postal questionnaire to evaluate the long-term effectiveness of treatment. Women who had been referred to a specialist were excluded. RESULTS: Eighty out of 82 eligible patients answered the questionnaire after a mean follow-up period of 56 months. Twenty-seven per cent were continent, 26% much better, 23% a little better, 21% unchanged, and 3% were worse compared with before the treatment. The median score on a 100 mm visual analogue scale was 16 compared with 31 before treatment, and the percentage of women that were 'much' or 'a great deal' bothered by UI was reduced from 35% to 12%. The percentage of women with severe UI was reduced from 59% to 30%, and the number of women using pads was reduced from 62% to 39%. CONCLUSION: This study confirms that management of female UI in general practice is effective also in the long term.
Adult↗
A new primary care rostering and capitation system in Norway: lessons for Canada?
Providing every patient with a personal primary care physician or, from the physician's perspective, establishing a stable roster or list of patients is currently being actively debated in Canada. Norway's system of primary care medicine, similar to Canada's, faces many of the same problems. In 1992 a trial rostering system with blended funding (capitation, fee-for-service and user fees) was established in 4 Norwegian municipalities. After 3 years of close monitoring, the results of system evaluations have attracted strong interest. This article reports on the benefits and problems encountered with the new rostering system in Norway. If Canada is moving in the same direction, some of the lessons learned may be helpful.
Canada↗
Management in general practice significantly reduced psychosocial consequences of female urinary incontinence.
Urinary incontinence is a common health problem among women, and a spectrum of psychosocial problems is associated with this disorder. We have investigated how psychosocial impact changed during a management programme for urinary incontinence in general practice. One hundred and five women seeking help for urinary incontinence were treated with conservative treatment options. Psychosocial consequences, grouped as mental distress (nine items), practical inconveniences (five items), and social restrictions (11 items) were noted before treatment, and after 3, 6 and 12 months follow-up. Urge symptoms, high degree of severity, and long duration were associated with higher psychosocial impact. During treatment, psychosocial impact was significantly reduced and the degree of impact in the three consequence groups was reduced to about one third compared with before treatment. In conclusion, changes in psychosocial impact during a management programme occur as a response to successful treatment. These findings support the view that female urinary incontinence can be successfully treated in general practice.
Activities of Daily Living↗
Iron supplementation in pregnancy: is less enough? A randomized, placebo controlled trial of low dose iron supplementation with and without heme iron.
BACKGROUND: The purpose of the present study was to evaluate the efficacy of low dose iron supplementation with and without a heme component, prescribed for women in the second half of pregnancy. METHOD: A randomized, double-blind, placebo controlled trial. Thirty-one women received a daily dose of 27 mg elemental iron in a product containing both heme iron and non-heme iron (Hemofer), 30 women received the same dose as pure non-heme iron with vitamin C (Collets jern med vitamin C), and 29 women received placebo. A double dummy technique was used to mask tablets. The women were tested for red cell indices and iron status markers (s-ferritin, s-iron, Total Iron Binding Capacity and erythrocyte protoporphyrin) throughout pregnancy and 8 and 24 weeks postpartum. The results were analyzed according to the 'intention to treat' principle. RESULTS: The hematological effects were equal in the two treatment groups. 25% of the supplemented women fell below 110 g/l in Hb vs 52% in the placebo group (p < 0.05); none fell below 100 g/l in the supplemented groups, 14% in the placebo group. Iron status was significantly better for all measured parameters in the heme iron group compared to placebo at the end of pregnancy. Differences between the other groups were only shown for some parameters, probably due to the small sample size. In the heme iron group there were fewer women with empty iron stores postpartum than at the start of pregnancy (from 14% to 8%), in the non-heme iron group there was a significant increase (from 3% to 27%), and in the placebo group the percentage of women with empty iron stores was more than doubled (from 21% to 52%). CONCLUSIONS: A daily dose of 27 mg elemental iron, containing a heme component, given in the second half of pregnancy, prevents depletion of iron stores after birth in most women. An equivalent dose of pure inorganic iron seems less effective, but the sample size in this study was too small to demonstrate significant differences between the two treatment groups.
Anemia, Iron-Deficiency↗
Focus groups as a path to clinical knowledge about the acutely and severely ill child.
OBJECTIVE: To identify elements of clinical information beyond the area of knowledge presented in medical textbooks, but used by the general practitioner when confronted with the acutely and severely ill child. DESIGN: Focus group approach. SETTING: A course for teachers in General Practice at the Division for General Practice, University of Bergen, Norway. SUBJECTS: 25 experienced general practitioners serving as clinical teachers at the Division for General Practice. MAIN OUTCOME MEASURES: Clinical descriptions arising from incident-based anecdotes and experiences. RESULTS: Issues were reported concerning the doctor's emotional reactions, cues from the parents of the child, atypical contact between doctor and child, cognitive discrepancies, and difficulties in acting on cues. CONCLUSION: This material identifies elements of tacit clinical knowledge which may provide a basis for further analysis and shared action.
Acute Disease↗
Treatment of urinary incontinence in women in general practice: observational study.
OBJECTIVE: To examine what is attainable when treating urinary incontinence in women in general practice. DESIGN: Observational study with 12 months' follow up. Interview and clinical examination before, during, and after treatment of women seeking help for urinary incontinence in general practice. SETTING: General practice in the rural district of Rissa, Norway. SUBJECTS: 105 women aged 20 or more with urinary incontinence. INTERVENTIONS: Treatment with pelvic floor exercises, electrostimulation, oestrogen, anticholinergic drugs, bladder training, and protective pads. MAIN OUTCOME MEASURES: Subjective and objective measures of urinary incontinence; number of patients referred to a specialist. RESULTS: After 12 months' follow up 70% (69/99) of the women were cured or much better; the mean score on a 100 mm visual analogue scale decreased from 37 to 20 mm; and the proportion of women who were greatly bothered by their incontinence decreased by 62%. 20% (20/98) of women became continent, and the percentage of women with severe incontinence decreased from 64% (63/99) to 28% (27/98). Mean leakage per 24 hours measured by a pad test decreased from 28 g at the start of treatment to 13 g after 12 months. The number of light weight pads or sanitary towels decreased from 1.6 to 0.6 a day. In all, 17/105 (16%) patients were referred to a specialist. CONCLUSIONS: Urinary incontinence in women can be effectively managed in general practice with fairly simple treatment. Most women will be satisfied with the results.
Adult↗