Conservative Treatment of Stress Urinary Incontinence and Pelvic Floor Defects

Inkontinencija je često stanje koje zahvaća milijune ljudi diljem svijeta, a koje se i u današnje doba premalo dijagnosticira i liječi. Kod gotovo polovine žena starijih od 50 godina nalazi se određen stadij prolapsa organa male zdjelice, a oko 30% žena starije životne dobi ima tegobe u obliku statičke inkontinencije. Inkontinencija je svaki nevoljan gubitak urina, a statička inkontinencija definira se kao neželjeno otjecanje urina pri naporu, kihanju ili kašljanju. Prolaps zdjeličnih organa (engl. pelvic organ prolaps – POP) jest spuštanje zdjeličnih organa u rodnicu ili kroz otvor rodnice. Za postavljanje ispravne dijagnoze važni su detaljna anamneza, ginekološki pregled, različiti klinički testovi te, prema potrebi, cistoskopija i urodinamska obrada. Liječenje može biti konzervativno i operativno. Kao konzervativne metode liječenja na raspolaganju nam stoje različite higijensko-dijetetske mjere, bihevioralna terapija, vježbe jačanja mišića dna zdjelice, biofeedback, različite vrste pesara, vaginalni utezi te elektrostimulacija i izvantjelesna magnetska inervacija. Iako je uspješnost operativnog liječenja statičke inkontinencije i defekata dna zdjelice veća, konzervativni tretmani pogodni su za bolesnike s umjerenim simptomima, kod starijih, bolesnika s komorbiditetima i visokim operativnim rizikom te u bolesnika koji ne žele operativno liječenje. U znatnom postotku bolesnika konzervativni tretmani dovode do poboljšanja njihova stanja i kvalitete života te se mogu preporučiti bolesnicima kao prva linija terapije.Incontinence is a common condition that affects millions of people worldwide, but it is still underdiagnosed and undertreated. Almost 50% of women above 50 years of age have a certain degree of pelvic organ prolapse, and about 30% of elderly women have problems in terms of stress incontinence. Incontinence is the involuntary loss of urine. Stress incontinence is defined as an involuntary loss of urine during exercise, sneezing or coughing. Pelvic organ prolapse is defined as the descent of pelvic organs into the vagina or through the introitus of the vagina. Detailed medical history, gynaecological examination, various clinical tests and, if necessary, cystoscopy and urodynamic evaluation must be performed to obtain the proper diagnosis. Treatment can be conservative or operative. The available conservative treatment methods include different hygienic dietary measures, behavioural therapy, exercises to strengthen the pelvic floor muscles, biofeedback, different types of pessaries, vaginal weights, electrical stimulation and extracorporeal magnetic innervation. Although greater success is achieved with surgical treatment of incontinence and pelvic floor defects, conservative treatments are suitable for patients with moderate symptoms, elderly patients with comorbidities, patients with high surgical risk and those who do not want surgical treatment. In a significant percentage of patients conservative treatments improve their conditions and quality of life, and can be recommended as first-line therapy

Urinary Incontinence in Men and Guidelines for Treatment

Urinarna inkontinencija (UI) svako je nevoljno otjecanje urina. Može se javiti kod osoba obaju spolova u svakoj životnoj dobi, izaziva osjećaj srama i nelagode, mijenja životni stil bolesnika i narušava kvalitetu života. Kod žena je dva puta češća nego kod muškaraca i najčešće se povezuje sa ženskim uroginekološkim patološkim stanjima. Vrlo je malo istraživanja o muškoj UI. Prevalencija UI kod muškaraca raste s dobi bolesnika, a faktori rizika su osim starije dobi simptomi donjeg urinarnog trakta (LUTS), infekcije mokraćnog sustava, funkcionalna i kognitivna oštećenja i neurološki poremećaji. Karakteristično je za muškarce da su faktor rizika i benigne i maligne bolesti prostate, odnosno njihovo liječenje. Radikalna prostatektomija kao vrlo čest kirurški zahvat veže se uz mušku UI. UI je veliko opterećenje za bolesnika, njegova liječnika i zdravstveni sustav u cjelini. Prema američkim studijama, ekonomski trošak liječenja UI kod muškaraca u SAD-u iznosi 3,8 milijarda dolara na godinu. U Njemačkoj je u 2002. godini ukupni trošak (direktni i indirektni) za oba spola za cjelokupni zdravstveni sustav bio 3,97 milijarda eura. Problematici UI treba pristupiti holistički. Potrebno je detaljno uzeti anamnezu, učiniti fizikalni pregled te ciljanu preporučenu dijagnostičku obradu kako bi se na najbolji mogući način za bolesnika, a i zdravstveni sustav, napravila strategija liječenja koja može biti konzervativna, medikamentna i kirurška.Urinary incontinence (UI) is the involuntary loss of urine. It affects men and women of all ages; patients feel shame and embarrassment, it changes their lifestyle and deteriorates quality of life. In women it is twice as common as in men. UI is usually associated with female urogynecologic diseases. Research on male incontinence is scarce. Prevalence of male UI rises with age. The risk factors for male UI, in addition to old age, are: lower urinary tract symptoms (LUTS), urinary tract infections, functional and cognitive impairment, and neurological impairment. Last but not least, risk factors for UI in male population include benign and malignant prostatic diseases and their treatment. Radical prostatectomy as a common operative procedure is connected with male UI. UI is a major burden for patients, physicians and the whole healthcare system. According to US studies, total cost of UI treatment in men in the USA adds up to 3.8 billion dollars per annum. In Germany, total cost (direct and indirect) of UI treatment in men and women in 2002 was 3.97 billion euros. It is certain that the problem of UI needs a holistic approach. Detailed patient history is essential, as well as physical examination and recommended diagnostics in order to create the best conservative, pharmacological and surgical treatment strategy, which would be optimal for both the patient and the healthcare system

Sakralna neuromodulacija u liječenju bolesnika s prekomjerno aktivnim mokraćnim mjehurom - prva primjena u Hrvatskoj

Sacral neuromodulation (SNM) is a safe, efficacious, and minimally invasive advanced therapy that involves electrical stimulation to sacral nerve root to modulate neural pathway. Indications for SNM include symptoms of overactive bladder (OAB), urinary incontinence, urinary retention, urgency and frequency and, regarding bowel dysfunction, fecal incontinence . In Europe and Canada, indication is also established for chronic constipation. The mechanism of action is still not fully elucidated and complete understanding is yet to be determined. It is proposed that SNM modulates neural circuits in both central and peripheral pathways, thus having an impact on the brain, as well as on the bladder-targeting neuronal activity. Another possible significant effect on irregular bladder activity is through inhibition of the bladder afferent pathways by stimulation of the pudendal nerve. Over the past two decades, with more than 300 000 treated patients, SNM has confirmed its efficacy to relieve refractory OAB symptoms, as well as urinary retention or fecal incontinence. First SNM applications in Croatia were uneventful and we are glad to offer our patients this novel therapy in the future.Sakralna neuromodulacija (SNM) je sigurna, učinkovita i minimalno invazivna napredna terapija koja uključuje električnu stimulaciju korijena sakralnog živca s ciljem podešavanja aktivnosti neuralnih putova. Indikacije za SNM uključuju simptome prekomjerno aktivnog mokraćnog mjehura (PAMM), inkontinenciju mokraće, zadržavanje mokraće, urgenciju i učestalost, kao i fekalnu inkontinenciju. U Europi i Kanadi dodatno je postavljena indikacija za kroničnu opstipaciju. Mehanizam djelovanja još uvijek nije u cijelosti razjašnjen te potpuno razumijevanje tek treba utvrditi. Smatra se da SNM modulira neuronske krugove središnjih i perifernih živčanih putova čime utječe na aktivnost u mozgu, kao i na neuronsku aktivnost usmjerenu na mjehur. Drugi mogući značajan učinak na poremećenu aktivnost mokraćnog mjehura je inhibicijom aferentnih putova mjehura stimulativnim djelovanjem na pudendni živac. Tijekom posljednja dva desetljeća s više od 300.000 liječenih bolesnika SNM se sve češće rabi za ublažavanje refraktornih simptoma PAMM-a, kao i za liječenje zadržavanja mokraće te fekalne inkontinencije. Prvi postupci postavljanja SNM-a u Hrvatskoj protekli su bez komplikacija i zadovoljastvo nam je bolesnicima ponuditi ovu novu terapiju i u budućnosti

SEXUAL DYSFUNCTION IN PATIENTS WITH EPILEPSY

Background: Patients with epilepsy commonly report sexual dysfunction (SD) and reproductive difficulties. This study aimed to evaluate the relationship between epilepsy, antiepileptic drugs (AEDs) and SD, and its association with the quality of life and depressive symptoms. Subjects and methods: This was a prospective study carried out in a tertiary healthcare centre. SD was evaluated using the internationally acclaimed questionnaire Arizona Sexual Experiences Scale (ASEX) that was successfully translated into Croatian and validated for this purpose. Depressive symptoms and quality of life were evaluated using the Hamilton Rating Scale for Depression (HAM-D17) and Quality of life in epilepsy-31 inventory (QOLIE-31). Results: Of 108 patients (68 (63 %) women, 40 (37 %) men, mean age 39.54±15.91 (range18-80) years) with epilepsy, 16 (14.8%) had focal, 38 (35.2%) generalized and 44 (40.7%) both types of epilepsy. Mean overall total score on the ASEX questionnaire was 11.94±5.61 (mean total score women 12.85±6.00, mean total score men 10.4±4.55), with 48 reporting that they had sexual activity in the past week. Nine (8.33%) patients (7 (6.48%) women, 2 (1.85%) men, mean age 47.66±19.33 (range 25-80) years) had a score 19 and above, 38 (35.18%) patients (27 (25%) women, 9 (8.33%) men, mean age 46.82±17.78 (range 19-80) years) individual score 5 and above on any one item, and 33 (30.55%) patients (26 (24.07%) women, 7 (6.48%) men, mean age 48.87±17.8 (range 19-80) years) had an individual score 4 and above on any three items. Significant correlations were found between SD and older age (p=0.001) and between more pronounced symptoms regarding SD on ASEX and female gender (p=0.000). There were no significant correlations between the type of epilepsy and SD, nor between the AEDs (old generation vs. modern) and SD. Significant correlations were found between the SD and more pronounced depressive symptoms (p=0.003) and between the SD and a lower quality of life (p=0.001). Conclusions: Results of our study suggest SD is experienced by around one-third of patients in our group, which is similar to the previous percentage of SD reported in the community sample. Women were found to experience more pronounced symptoms of SD on ASEX. Symptoms of SD were found to be significantly correlated with older age, female gender, lower quality of life and depressive symptoms, while no significant correlations were found with the type of epilepsy and the AEDs

LOWER URINARY TRACT SYMPTOMS AND DEPRESSION IN PATIENTS WITH MULTIPLE SCLEROSIS

Background: Both depression and lower urinary tract symptoms (LUTS) may be present in patients with multiple sclerosis (MS). The objective of this study was to give an insight on depression and LUTS in patients with MS in Croatia and to determine the possible association between LUTS and depression in patients with MS. Subjects and methods: This was a prospective cross-sectional study conducted in a tertiary healthcare center in Croatia. Hundred and one consecutive patients with MS (75 female, 26 male, mean age 42.09 (range 19-77) years, mean Expanded Disability Status Scale (EDSS) score 3.1 (range 0.0-7.0)) participated in this study. We evaluated LUTS and related quality of life (QoL) using three International Consultation on Incontinence Questionnaires (ICIQ) enquiring about overactive bladder (ICIQ-OAB), urinary incontinence short form (ICIQ-UI SF) and lower urinary tract symptoms related quality of life (ICIQLUTS-QoL). ICIQ-OAB and ICIQLUTS-QoL were for this purpose with permission successfully translated and validated into Croatian, while ICIQ-UI SF was already previously validated for the Croatian language. Information regarding treatment for depression was obtained during the medical interview. Data were analyzed and interpreted using IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA). Results: 89.10% (N=90) patients with MS reported urgency with urge urinary incontinence (UUI) present in 70.29% (N=71). 81.18% (N=82) patients reported nocturia, and 90.09% (N=91) reported feeling drowsy or sleepy during the day due to bladder symptoms. Neurological deficit measured by EDSS was found to positively correlate with LUTS on all three questionnaires: ICIQOAB (r=0.390, p<0.05), ICIQ-UI SF (r=0.477, p<0.01) and ICIQ-LUTSQoL (r=0.317, p<0.05). 25 patients were in treatment for depression. There were no significant differences between female and male patients regarding treatment for depression (2=0.018, df=1, p>0.05). Results on ICIQ-UI SF showed that depressive patients had more pronounced LUTS (t=2.067, df=99, p<0.05), which was also true for the ICIQ-LUTSQoL (t=-2.193, df=99, p<0.05). Positive correlations were found between depression and LUTS on ICIQ-UI SF (r=0.203, p<0.05) and ICIQ-LUTSQoL (r=0.215, p<0.05). Conclusion: This study gives insight into the presence of depression and LUTS in Croatian patients with MS for which purpose ICIQ-OAB and ICIQ-LUTSQoL were with permission successfully translated and validated into Croatian. The connection between depression and LUTS must be considered when managing patients with MS

SEXUAL DYSFUNCTION IN PATIENTS WITH EPILEPSY

Background: Patients with epilepsy commonly report sexual dysfunction (SD) and reproductive difficulties. This study aimed to evaluate the relationship between epilepsy, antiepileptic drugs (AEDs) and SD, and its association with the quality of life and depressive symptoms. Subjects and methods: This was a prospective study carried out in a tertiary healthcare centre. SD was evaluated using the internationally acclaimed questionnaire Arizona Sexual Experiences Scale (ASEX) that was successfully translated into Croatian and validated for this purpose. Depressive symptoms and quality of life were evaluated using the Hamilton Rating Scale for Depression (HAM-D17) and Quality of life in epilepsy-31 inventory (QOLIE-31). Results: Of 108 patients (68 (63 %) women, 40 (37 %) men, mean age 39.54±15.91 (range18-80) years) with epilepsy, 16 (14.8%) had focal, 38 (35.2%) generalized and 44 (40.7%) both types of epilepsy. Mean overall total score on the ASEX questionnaire was 11.94±5.61 (mean total score women 12.85±6.00, mean total score men 10.4±4.55), with 48 reporting that they had sexual activity in the past week. Nine (8.33%) patients (7 (6.48%) women, 2 (1.85%) men, mean age 47.66±19.33 (range 25-80) years) had a score 19 and above, 38 (35.18%) patients (27 (25%) women, 9 (8.33%) men, mean age 46.82±17.78 (range 19-80) years) individual score 5 and above on any one item, and 33 (30.55%) patients (26 (24.07%) women, 7 (6.48%) men, mean age 48.87±17.8 (range 19-80) years) had an individual score 4 and above on any three items. Significant correlations were found between SD and older age (p=0.001) and between more pronounced symptoms regarding SD on ASEX and female gender (p=0.000). There were no significant correlations between the type of epilepsy and SD, nor between the AEDs (old generation vs. modern) and SD. Significant correlations were found between the SD and more pronounced depressive symptoms (p=0.003) and between the SD and a lower quality of life (p=0.001). Conclusions: Results of our study suggest SD is experienced by around one-third of patients in our group, which is similar to the previous percentage of SD reported in the community sample. Women were found to experience more pronounced symptoms of SD on ASEX. Symptoms of SD were found to be significantly correlated with older age, female gender, lower quality of life and depressive symptoms, while no significant correlations were found with the type of epilepsy and the AEDs