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Journal of Wound, Ostomy & Continence Nursing:
doi: 10.1097/WON.0b013e31825dd60a
Continence Care Literature Review

Continence Care Literature Review 2011

Netsch, Debra S. MSN, RN, DNP, CWOCN; Contributor

Section Editor(s): Gray, Mikel L.

Free Access
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General Concepts in Continence Care

C1: Weight Loss Improves Fecal Incontinence Severity in Overweight and Obese Women With Urinary Incontinence

Markland AD, Richter HE, Burgio KL, Myers DL, Hernandez AL, Subak LL. International Urogynecology Journal. 2011;22(9):1151–1157.

Article Type: Research Study

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Description/Results:

* 18-month, multi-center, randomized control trial studying effects of weight loss on fecal incontinence severity and improvements for overweight and obese women with urinary incontinence.

* Women who were overweight or obese with weight loss had a 13% improvement in fecal incontinence severity and frequency. Improved fecal incontinence severity was associated with reduced urinary tract symptoms.

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What does this mean for me and my practice?

Overweight or obese women with urinary and fecal incontinence should be educated on the positive effects of weight loss. Weight loss of 5 kg or use of fiber improved fecal incontinence and was associated with reduced lower urinary tract symptoms.

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C2: Constipation and LUTS—-How Do They Affect Each Other?

Averbeck MA, Madersbacher H. International Brazilian Journal of Urology. 2011;37(1):16–28.

Article Type: Systematic Review

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Description/Results:

* Data found through literature review of the relationship between constipation and lower urinary tract symptoms (LUTS) were synthesized in 4 population groups: (1) children, (2) middle-aged women, (3) elderly, and (4) neuropathic patients.

* Constipation was linked to urinary tract problems in children. A high prevalence of constipation among middle-aged women occurred with lower urinary tract dysfunction. Few studies of the elderly exist but there is some indication of improved concomitant LUTS when constipation is treated. Neuropathic patient data indicate that chronic constipation may mechanically interfere with complete bladder emptying and may cause upper urinary tract dilatation.

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What does this mean for me and my practice?

Prospective large-scale controlled studies are necessary. However, this systematic review found that there may be association of constipation and concomitant LUTS with improvement or resolution of LUTS with adequate treatment of constipation.

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C3: Fluid Intake and Risk of Stress, Urgency, and Mixed Urinary Incontinence

Townsend MK, Jura YH, Curhan GC, Resnick NM, Grodstein F. American Journal of Obstetrics & Gynecology. 2011;205:73.e1–73.e6.

Article Type: Research Study

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Description/Results:

* Daily fluid intake was measured using food frequency questionnaires in 65,176 women aged 37 to 79 years without incontinence. Incident incontinence was identified through 4 years of follow-up questionnaires.

* No association was found between high total fluid intake and risk of incident stress, urgency, or mixed incontinence.

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What does this mean for me and my practice?

Women should be instructed not to restrict their fluid intake to prevent development of incontinence.

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C4: Randomized Trial of Estradiol Vaginal Ring Versus Oral Oxybutynin for the Treatment of Overactive Bladder

Nelken R, Ozel BZ, Leegant AR, Fleix JC, Mishell DR. The Journal of the North American Menopause Society. 2011;18(9):962–966.

Article Type: Research Study: Randomized Control Trial

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Description/Results:

* Compared low-dose estradiol vaginal ring to oral oxybutynin in 59 postmenopausal women with overactive bladder. Women allocated to oxybutynin had a mean decrease of 3.0 voids per day. Women who were allocated to the vaginal ring had a mean decrease of 4.5 voids per day. This difference was not statistically significant. No significant difference was found in urogenital distress inventory or incontinence impact questionnaire scores.

* Both groups had significant improvement compared to baseline.

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What does this mean for me and my practice?

This RCT provides evidence that low-dose estrogen vaginal ring reduces voiding frequency as well as oral oxybutynin in postmenopausal women with overactive bladder.

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C5: The Meanings of Silence in Brazilian Women With Urinary Incontinence

Higa R, Chvatal VL, Lopes MH, Turato ER. Journal of Wound, Ostomy and Continence Nursing. 2011;38(5):565–568.

Article Type: Research Study

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Description/Results:

* Used semistructured interviews to record and analyze life experiences of low-income Brazilian women with incontinence. Respondents avoided discussing incontinence and initially resisted describing themselves as incontinent. Nonverbal behaviors including crying and emotional distress were associated with urinary leakage.

* Low-income Brazilian women used silence and nonverbal communication when seeking help for urinary incontinence.

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What does this mean for me and my practice?

Results of this study indicate that low-income women may resist reporting urinary incontinence to their health care providers. WOC nurses should support low-income women in recognizing urinary incontinence through nonverbal behavior.

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C6: Effect of Weight Loss on Urinary Incontinence in Women

Whitcomb EL, Subak LL. Open Access Journal of Urology. 2011;3:123–132.

Article Type: Systematic Literature Review

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Description/Results:

* Retrieved 12 studies that evaluated the effect of weight loss on urinary incontinence in women. Pooled analysis revealed that each 5 unit gained in body mass index was associated with likelihood of urinary incontinence rising 20%. The odds of developing urinary incontinence over 5- to 10-year period increased 30% to 60% for each 5-unit gained in body mass index. The association was stronger for stress rather than for urge incontinence.

* Weight loss studies indicated that surgical and nonsurgical weight loss results in significantly improvements in frequency and severity of incontinence.

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What does this mean for me and my practice?

Continence nurses should teach patients that weight gain increases urinary incontinence and weight loss significantly reduces risk for and severity of incontinence.

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C7: Evaluation of a Behavioral Treatment for Female Urinary Incontinence

Santacreu M, Fernandez-Ballesteros R. Clinical Interventions in Aging. 2011;6:133–139.

Article Type: Research Study

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Description/Results:

* Daily pelvic floor muscle training with a weekly control was taught to 14 participants during a 2-month period with follow-up 2 months after the last control session.

* Reduction of urinary incontinence episodes by 75.67% was found after program completion.

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What does this mean for me and my practice?

Significant reduction of urinary leakage can occur with pelvic floor muscle training with controlled and constant supervision. Maintenance of reduced urinary leakage requires continuation of exercises.

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C8: Overactive Bladder and Nocturia in Middle-Age American Women: Symptoms and Impact Are Significant

Levkowicz R, Whitmore KE, Muller N. Urologic Nursing. 2011;31(2):106–111.

Article Type: Research Study

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Description/Results:

* Nocturia with overactive bladder (OAB) symptoms increase with age. This study focused on the issues of the severity of OAB and nocturia in middle-age American women and the impact of symptoms on quality of life along with attitudes toward seeking treatment.

* Most study participants with OAB void at least once during the night (n = 586 of 611 [96%]). Nighttime voiding of 3 or more times occurred in nearly half of all participants (n = 280 of 611 [46%]). Women with nocturia were more likely to change behaviors than women with OAB without nocturia; 65% of women with nocturia and OAB in this study admitted to waiting longer than they should have to seek treatment. Many of those who sought care were dissatisfied and/or ultimately discontinued treatment.

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What does this mean for me and my practice?

Health care providers should strive to make greater efforts to address OAB, including nocturia, and keep patients actively involved in treatment.

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C9: Antimuscarinics for Treatment of Storage Lower Urinary Tract Symptoms in Men: A Systematic Review

Kaplan SA, Roehrborn CG, Abrams P, Chapple CR, Bavendam T, Guan Z. The International Journal of Clinical Practice. 2011;65(4):487–507.

Article Type: Systematic Review

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Description/Results:

* Antimuscarinics in men may not be prescribed due to safety concerns. This systematic review was performed with ultimately 27 articles included in the qualitative synthesis. Antimuscarinics alone or in combination with an α-blocker appears in this systematic review to be effective and safe for treatment of urgency, frequency, and urge urinary incontinence in men with overactive bladder (OAB) who do not have clinically significant bladder outflow obstruction. Postvoid residual volumes did not significantly clinically increase in 2 of the studies with or without an α-blocker.

* Men may experience OAB symptoms in the absence of bladder outlet obstruction or in the absence of voiding symptoms. Despite treatment for prostatic enlargement, many men continue to experience OAB or DO symptoms.

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What does this mean for me and my practice?

Antimuscarinics can be effective and safely utilized in men who do not have clinically significant bladder outflow obstruction. Postvoiding residuals in men at risk of urinary retention should be assessed prior to prescribing and monitored during the use of antimuscarinic therapy.

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C10: Behavioral Versus Drug Treatment for Overactive Bladder in Men: The Male Overactive Bladder Treatment in Veterans (MOTIVE) Trial

Burgio KL, Goode PS, Johnson TM, Hammontree L, Ouslander JG, Markland AD, Colli J, Vaughan CP, Redden DT. Journal of American Geriatric Society. 2011;59:2209–2216.

Article Type: Research Study

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Description/Results:

* The effectiveness of behavioral treatment was compared with that of antimuscarinic therapy in men without bladder outlet obstruction who continue to have overactive bladder symptoms with α-blocker therapy.

* Behavioral treatment decreased mean voids per day from 11.3 to 9.1 (−18.8%) and reductions in nocturia (mean = −0.70 vs −0.32 episodes per night; P = .05). Drug therapy decreased mean voids per day from 11.5 to 9.5 (−16.9%) and greater reduction in urgency scores (mean = −0.44 vs −0.12; P = .02). Posttreatment means were equivalent (P < .01).

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What does this mean for me and my practice?

Behavioral therapy is at least as effective as antimuscarinic therapy when added to α-blocker treatment.

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C11: Efficacy of Botulinum Toxin A Injection for Neurogenic Detrusor Overactivity and Urinary Incontinence: A Randomized, Double-Blind Trial

Hershcorn S, Gajewski J, Ethans JM, Corcos J, Carlson K, Bailly G, et al. Journal of Urology. 2011;185:2229–2235.

Article Type: Research Study

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Description/Results:

* A prospective double-blind multicenter study of 57 patients aged 18 to 75 years with urinary incontinence failing antimuscarinic treatment and neurogenic detrusor overactivity due to spinal cord injury or multiple sclerosis.

* Urinary incontinence was significantly reduced for onabotulinum toxin when compared to placebo at week 6 (1.31 vs 4.76, P < .0001) and at weeks 24 and 36. Urodynamic and quality-of-life improvement were also found for treatment versus placebo at week 6 and persisted to weeks 24 to 36.

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What does this mean for me and my practice?

* Onabotulinum toxin A use in patients is well tolerated and provides clinical improvement in adults with refractory neurogenic detrusor overactivity secondary to spinal cord injury or multiple sclerosis despite antimuscarinic therapy. Onabotulinum toxin A should be considered as another therapy for this particular group of patients.

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C12: Urodynamic Profile of Diabetic Patients With Lower Urinary Tract Symptoms: Association of Diabetic Cystopathy With Autonomic and Peripheral Neuropathy

Bansal R, Agarwal MM, Modi M, Mandal AK, Singh SK. Urology. 2011;77:699–705.

Article Type: Research Study

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Description/Results:

* Fifty-two men with lower urinary tract symptoms (LUTS) and diabetes mellitus (mean age 61.3 ± 12.1 years, diabetes mellitus 11.0 ± 7.5 years) completed this study. Abnormal sympathetic skin responses, motor and sensory nerve-conduction velocity studies, and combined neuropathy (all 3 tests abnormal) were found in 80.7%, 57.7%, 57.7%, and 51.9%, respectively. Urodynamic studies revealed impaired first sensation (>250 ml), increased capacity (>600 ml), detrusor underactivity, detrusor overactivity, high postvoid residual urine volume (more than one-third of capacity), and bladder outlet obstruction (Abrams-Griffiths number > 40) in 23.1%, 25.0%, 78.8%, 38.5%, 65.4%, and 28.8% of completing participants, respectively.

* Both sensory and motor diabetic cystopathy (DC) correlated with abnormal motor and sensory nerve-conduction velocity studies (P = .015 and P = .005, respectively). Correlation of only motor DC with abnormal sympathetic skin responses was found (P = .015). Correlations in the presence of combined neuropathy were stronger (sensory DC, P = .005; motor DC, P = .0001).

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What does this mean for me and my practice?

Diabetic male patients presenting with LUTS and neuropathy will most likely have cystopathy.

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C13: Caffeine Intake, and the Risk of Stress, Urgency, and Mixed Urinary Incontinence

Jura YH, Townsend MK, Curhan GC, Resnick NM, Grodstein F. The Journal of Urology. 2011;185:1775–1780.

Article Type: Research Study

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Description/Results:

* Caffeine intake was measured using food frequency questionnaires in 65,176 women aged 37 to 79 years without incontinence. Incident incontinence was identified through 4 years of follow-up questionnaires.

* A modest significantly increased risk of at least weekly incontinence was associated with high daily caffeine intake (>450 mg) vs the lowest daily intake (less than 150 mg) (RR 1.19, 95% CI: 1.06-1.34). A significant trend was found of increasing risk of incontinence with increasing intake (P for trend = .01). This increasing risk of incident incontinence occurred with urgency incontinence (>450 mg vs <150 mg daily, RR 1.34, 95% CI: 1.00-1.80, P for trend = .05) but not for stress or mixed incontinence. The risk of urgency incontinence was attributable at 25% with high caffeine intake.

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What does this mean for me and my practice?

Higher, but not lower, caffeine intake may be associated with a modest increase in urgency incontinence incidence; 25% of the cases in this study with the highest caffeine consumption would be eliminated if high caffeine intake were eliminated. Patients should be asked regarding caffeine intake and showed the results of this study if they consume high amounts of caffeine.

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C14: Effectiveness of Educational Interventions to Raise Men's Awareness of Bladder and Bowel Health

Tuckett AG, Hodgkinson B, Hegney DG, Paterson J, Kralik D. International Journal of Evidence Based Health Care. 2011;9: 81–96.

Article Type: Systematic Literature Review

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Description/Results:

* The authors reviewed literature concerning the effectiveness of educational interventions on men's awareness of bladder and bowel health. Twelve randomized controlled trials and 2 before-after studies met inclusion criteria.

* Evidence concerning men's awareness of bladder and bowel health is sparse. The single exception appears to be instruction in pelvic floor muscle exercises following radical prostatectomy. Based on multiple trials that enrolled women as well as men, existing evidence suggests that men can increase their awareness of bladder and bowel health following appropriate health education.

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What does this mean to me and my practice?

Sparse evidence exists concerning the effect of education on bladder and bowel health in men. Development of educational interventions to raise awareness of bladder and bowel health in men is urgently needed along with research evaluating their impact.

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C15: The Impact of Follow-up Educational Telephone Calls on Patients After Radical Prostatectomy: Finding Value in Low-Margin Activities

Inman DM, Maxson PM, Johnson KM, Myers RP, Holland DE. Urologic Nursing. 2011;31:83–91.

Article Type: Research Study

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Description/Results:

* This randomized controlled trial compared the effect of an additional telephone call on self-management following radical prostatectomy and utilization of health care resources. Primary and secondary outcomes were measured using the Care Transition Measure tool (CTM-3), a validated instrument.

* Sixty subjects participated in the study. No statistically significant differences were detected when men randomly allocated to receiving the follow-up telephone call were compared to control subjects. No statistically significant differences were found when resource use was analyzed.

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What does this mean to me and my practice?

Results of this randomized controlled trial found no differences in CTM-3 score or resources utilization when men receiving a follow-up telephone call were compared to men who did receive such a call. While patient satisfaction was high following such a call, there is insufficient evidence to justify its completion based on changes in self-management score or health care resource utilization.

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C16: Pencil-and-Paper Test: A New Tool to Predict the Ability of Neurological Patients to Practice Clean Intermittent Self-catheterization

Amarenco G, Guinet A, Jousse M, Verollet D. Ismael SS. Journal of Urology 2011;185:587–582.

Article Type: Research Study

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Description/Results:

* The researchers evaluated the predictive power of a pencil-and-paper test designed to measure patients' ability to perform intermittent self-catheterization. The test was designed to mimic typical gestures, along with cognitive skills and physical resources needed to perform self-catheterization.

* The predictive value of the test was evaluated in a group of 118 patients with a neurological condition and neurogenic bladder dysfunction. A strong association between test scores and ability to perform clean, intermittent self-catheterization was found. The highest possible test score was 15; the researchers found that a test cutoff of 10 was needed to practice self-catheterization independently. Based on this cut point, the test achieved a positive predictive value of 85% and negative predictive value of 94%.

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What does this mean to me and my practice?

Intermittent self-catheterization is an essential skill for managing neurogenic bladder dysfunction in many cases. A validated instrument that predicts the ability of patients with neurological conditions to perform self-catheterization is a valuable tool for the WOC nurse.

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C17: Incontinence Brief Use in Acute Hospitalized Patients With No Prior Incontinence

Zisberg A. Journal of Wound, Ostomy and Continence Nursing. 2011;38:559–564.

Article Type: Research Study

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Description/Results:

* The study evaluated the incidence of in-hospital use of adult containment briefs in a cohort of 465 older patients. Fourteen percent of patients who did not use briefs prior to hospital admission required containment briefs during their hospital course. In contrast, 8.2% of patients were successfully managed using specialized commodes or urinals.

* The relative risk of incontinence brief use when entering an acute care facility was 18.76 (95% CI: 4.36–43.72) for patients with low to moderate mobility impairment during their hospital course. Women were more likely to be placed in briefs than men.

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What this means to me and my practice?

Results of this study suggest that acutely impaired mobility and female gender raise the likelihood of placement in an incontinence brief during hospitalization. The WOC nurse should work with staff nurses to carefully evaluate the use of incontinence briefs in this population and determine whether assisted toileting using specialized urinals or commode devices is a reasonable alternative. These data also suggest that patients and families should be reminded that the use of an incontinence brief during hospitalization does not predict the need for long-term use.

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C18: Attitudes Toward Urinary Incontinence Among Community Nurses and Community-Dwelling Older People

Yuan HB, Williams BA, Liu M. Journal of Wound, Ostomy and Continence Nursing. 2011;38:184–189.

Article Type: Research Study

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Description/Results:

* Random samples of 100 community-dwelling older persons and 100 community health nurses in the Shanghai were queried to determine their attitudes toward urinary incontinence. The Urinary Incontinence Attitude Scale, a validated instrument, was used to measure outcomes.

* Both groups perceived urinary incontinence as preventable and requiring family support. Nurses were more likely to perceive incontinence as a condition that can be effectively treated.

* Community-dwelling adults were more likely to perceive urinary incontinence as shameful, their own fault, and frustrating to manage. They were also more unwilling to talk about incontinence and consider it not sufficiently serious to justify professional care.

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What does this mean to me and my practice?

Urinary incontinence continues to be perceived as shameful by community-dwelling persons. This attitude, combined with the perception that incontinence is not serious enough to seek professional care, comprises significant barriers to its identification and treatment. WOC nurses should continue to educate the public about urinary incontinence, including its prevalence, and likelihood to improve with treatment.

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Defecation Disorders

C19: Effect of Laxatives and Pharmacological Therapies in Chronic Idiopathic Constipation: Systematic Review and Meta-analysis

Ford AC, Suares NC. Gut. 2011;60:209–218.

Article Type: Systematic Review

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Description/Results:

* Twenty-one eligible RCTs found laxatives, prucalopride, lubiprostone, and linaclotide were all more effective than placebo in treatment of chronic idiopathic constipation (CIC).

* When studies were pooled, 50% to 85% of patients did not fulfill response criteria.

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What does this mean for me and my practice?

Current CIC guidelines do not make strong recommendations for either laxative or pharmacological therapies. The use of old therapies (PEG, sodium picosulfate, and bisacodyl) and newer pharmacological agents are supported by this systematic review and data analysis.

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C20: Biofeedback for Fecal Incontinence: A Randomized Study Comparing Exercise Regimens

Bartlett L, Sloots K, Nowak M, Ho YK. Diseases of the Colon & Rectum. 2011;54(7):846–856.

Article Type: Research Study

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Description/Results:

* This study aimed to investigate the difference between the standard clinical biofeedback protocol (sustained submaximal anal and pelvic floor exercises) and the alternative biofeedback group (rapid squeeze plus sustained submaximal exercises).

* No difference was found between the 2 study protocols. Overall the severity of fecal incontinence decreased significantly (11.5/20 to 5.0/20, P < .001). Fecal incontinence improved in 86% of study participants. All participants had significant improvement in quality of life (P < .001). While the results were sustained for 2 years, those who continued to practice the prescribed number of exercises at least had better outcomes than those who practiced less.

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What does this mean for me and my practice?

Biofeedback improves fecal incontinence and quality of life with sustained improvement if the exercises are practiced as prescribed.

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C21: The Impact of Laxative Use Upon Symptoms in Patients With Proven Slow Transit Constipation

Dinning PG, Hunt L, Lubowski DZ, Kalantar JS, Cook IJ, Jones MP. BMC Gastroenterology. 2011;11:121.

Article Type: Research Study

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Description/Results:

* A total of 94 patients with confirmed slow transit constipation were studied regarding the effects of laxatives on constipation symptoms.

* Laxatives neither changed the feeling of complete evacuation nor had an effect upon straining, pain, or bloating scores.

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What does this mean for me and my practice?

Patients with slow transit constipation will not have resolution of straining, pain, or bloating systems following the use of laxatives.

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C22: Conservative Treatment of Patients With Faecal Soiling

Van der Hagen SJ, Soeters PB, Baeten CG, van Gemert WG. Tech Coloproctol. 2011;15:291–295.

Article Type: Research Study

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Description/Results:

* Fifty patients with fecal soiling but normal anorectal function determined by endoanal ultrasound, magnetic resonance imaging and anal manometry were started with psyllium therapy and daily fiber-rich diet for 2 months followed by rectal irrigation in cases of incomplete response and 4 months later with 4-g cholestyramine. The Vaizey incontinence score and a 2-week diary card were completed by all patients.

* Complete resolution of soiling was found in 79% of patients. Complete resolution of fecal soiling was found after treatment with psyllium, rectal irrigation, and cholestyramine with 24%, 73%, and 79% patients, respectively. Vaizey incontinence scores were reduced significantly after treatment with psyllium and reduced significantly after treatment with rectal irrigation (P < .001).

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What does this mean for me and my practice?

Fecal soiling with normal anorectal function is caused by insufficient clearing of the anal canal. Conservative treatment to promote complete evacuation or clearing of the anorectal canal is effective in the treatment of patients with fecal soiling.

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C23: Posterior Tibial Nerve Stimulation and Faecal Incontinence: A Review

Findlay JM, Maxwell-Armstrong C. International Journal of Colorectal Disease. 2011;26:265–273.

Article Type: Integrative Review

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Description/Results:

* Review of 8 studies examining the effect of posterior tibial nerve stimulation (PTNS) with fecal incontinence. A definitive conclusion regarding the use of PTNS with fecal incontinence was not determined in this article.

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What does this mean for me and my practice?

The efficacy of PTNS has been established in patients with overactive bladder and urge incontinence disorders but remain uncertain in fecal incontinence. Further study is needed regarding the role of PTNS in fecal incontinence.

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C24: Symptoms Associated With Dietary Fiber Supplementation Over Time in Individuals With Fecal Incontinence

Bliss DZ, Savik K, Hans-Joachim GJ, Whitebird R, Lowry A. Nursing Research. 2011;60(3S):S58–S67.

Article Type: Research Study

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Description/Results:

* Randomized clinical trial of 189 participants with fecal incontinence assigned to placebo or dietary fiber groups of gum arabic, psyllium, or carboxymethylcellulose. Gastrointestinal (GI) symptoms were reported daily based on incremental doses of fiber or placebo.

* No significance was found in GI symptoms between the study arms including placebo except reporting of feeling of fullness in the psyllium group. Emotional upset to intolerance of GI symptoms was suggested in this study through fiber reduction and study withdrawal.

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What does this mean for me and my practice?

While this study is not generalizable, these data indicate that informing patients of anticipated GI symptoms may facilitate adherence to therapies such as fiber supplementation.

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C25: Systematic Review of Abdominal Surgery for Chronic Idiopathic Constipation

Arebi N, Kalli T, Howson W, Clark S, Norton C. Colorectal Disease. 2011;13:1335–1343.

Article Type: Systematic Review

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Description/Results:

* Evaluated effects of elective abdominal surgery for chronic idiopathic constipation (total or subtotal colectomy with anastomosis, sigmoid colectomy with anastomosis, left or right hemicolectomy, total colectomy with ileal pouch anal anastomosis, ileostomy). Forty-eight studies were retrieved including 1443 patients.

* Authors found that 65% of patients had a mean increase of defecation frequency from 1.1 to 19.7 per week; 88% discontinued laxatives postoperatively. Complications included prolonged postoperative ileus, anastomotic leakage, and postoperative infection. Overall mortality was 0.2%.

* Findings from this systematic review support elective abdominal surgery for chronic idiopathic constipation when conservative measures fail.

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Indwelling Catheters

C26: Relationship of Catheter-Associated Urinary Tract Infection to Mortality and Length of Stay in Critically Ill Patients: A Systematic Review and Meta-analysis of Observational Studies

Chant C, Smith OM, Marshall JC, Frederich JO. Critical Care Medicine. 2011;39:1167–1173.

Article Type: Systematic Literature Review

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Description/Results:

* This systematic review queried whether catheter-associated urinary tract infection was associated with increased length of stay and morality in critically ill patients. Eleven observational studies met inclusion criteria; they enrolled 60,719 control patients (without catheter-associated urinary tract infection) versus 2,745 patients with infections.

* Catheter-associated urinary tract infection was associated with a higher mortality rate (odds ratio, 1.99; 95% CI: 1.72–2.31) and an increased length of stay in the intensive care unit and total hospital length of stay.

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What does this mean to me and my practice?

A preponderance of evidence from these observational case-control studies strongly suggests that catheter-associated urinary tract infection increases the risk for mortality, length of stay in the critical care unit, and overall hospital length of stay. These findings reinforce its status as a CMS never event that should be prevented whenever possible.

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C27: Reduction of Inappropriate Urinary Catheter Use at a Veteran's Affairs Hospital Through a Multifaceted Quality Improvement Project

Knoll BM, Wright D, Ellingson L, Kraemer L, Patire R, Kuskowski MA, Johnson JR. Clinical Infectious Disease. 2011;52:1283–1290.

Article Type: Research Report

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Description/Results:

* Researchers combined several strategies that have proven effective over the short term for reducing catheter use to determine whether they could achieve a long-term reduction in urinary catheter use in their facility.

* The bundled intervention they selected included education of staff, system redesigns to include routine alerts concerning catheter use, rewards and feedback for staff, and a dedicated Foley catheter nurse. The intervention bundle was introduced in 3 phases with hiring of the nurse comprising the final phase.

* The daily prevalence of indwelling urinary catheters declined from 15.2% at baseline to a low of 9.3% after introducing phase 1 (education) but rose again during a subsequent hiatus that persisted for 1.2 months. The prevalence of indwelling catheters declined again during implementation of phases 2 and 3 from a maximum of 17% to 1.2%.

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What does this mean to me and my practice?

A bundled intervention incorporating staff education, routine monitoring of indwelling catheter use in individual patients, and employment of a catheter nurse champion reduced the facility prevalence of indwelling urinary catheters. Of all the interventions, the most sustained reduction was achieved when a dedicated nurse champion was added to the bundled intervention.

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C28: Preventing Catheter-Associated Urinary Tract Infections in the Zero-Tolerance Era

Marra AR, Comargo TZ, Goncalves P, Sogayar AM, Moura DF Jr, Guastelli LR, et al. American Journal of Infection Control. 2011;39:817–822.

Article Type: Research Study

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Description/Results:

* This nonrandomized study evaluated the effects of multiple interventions designed to reduce catheter-associated urinary tract infection in a medical-surgical intensive care unit and 2 step-down units.

* Phase 1 of the study comprised individualized insertion and removal of indwelling catheters based on physician order. Phase 2 of the study included creation of an indwelling catheter insertion cart, hand hygiene, chlorhexidine skin and meatal insertion antisepsis, use of a sterile filed and sterile gloves during catheter insertion, reduction of catheter insertion to a single attempt before disposing of the catheter and replacing with a new indwelling catheter, proper balloon inflation based on the manufacturer's recommendation, and daily review of catheter placement with prompt removal when deemed no longer necessary.

* Implementation of the bundled intervention resulted in a statistically significant reduction in catheter-associated urinary tract infection incidence in the critical care unit from 7.6 infections per 1000 catheter days (95% CI: 6.6–8.6) to 5.0 infections per 1000 catheter days (95% CI: 4.2–5.8) following phase 2 implementation. A statistically significant reduction in infection incidence was also achieved in the step-down units.

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What does this mean to me and my practice?

The findings from this study further reinforce the growing body of evidence, suggesting that employment of bundled evidence-based interventions effectively reduces the incidence of catheter-associated urinary tract incidence in the acute care facility.

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Bowel and Bladder Infection

C29. Optimal Management of Urinary Tract Infections in Older People

Beveridge LA, Davey PG, Phillips G, McMurdo ME. Aging. 2011; 6:173–180.

Article Type: Integrative Review

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Description/Results:

* Provides a comprehensive review of evaluation, diagnosis and treatment of urinary tract infections (UTIs) in the elderly. Subtopics of review were diagnosis, asymptomatic bacteriuria, catheter associated UTI, management of UTI with antimicrobial prescribing, and UTI prevention.

* This review gives an overview of clinical research for evidence based treatment of UTIs in the elderly patient. UTIs are frequently over diagnosed without supportive clinical symptoms. This is especially true for hospitalized older patients with indwelling catheters.

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What does this mean for me and my practice?

Over diagnosis and treatment of UTIs with antibiotics in the elderly patient population currently exists. Correlation of clinical symptoms, proper diagnosis and treatment of UTI in the elderly is essential in light of the increasing presence of resistant organisms and C. difficile. Local policies and antibiotic treatment guidelines should be implemented.

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C30. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases

Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, Moran GJ, Nicolle LE, et al. Clinical Infectious Diseases. 2011; 52(5):e103–e120.

Article Type: Integrative Review

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Description/Results:

* These updated guidelines focus on treatment of women with acute uncomplicated cystitis and pyelonephritis limited to premenopausal, nonpregnant women with no known urological abnormalities or comorbidities. Optimal treatment choices reflected prevalence of in vitro resistance and ecological adverse effects of therapy.

* Optimal therapy is dependent not only on the specific host factors (allergies, etc) on the severity of illness and local resistance patterns. Evidence based practice recommendations for specific antibiotic prescribing are provided in this article.

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What does this mean for me and my practice?

Urine culture and susceptibility testing should be performed. Initial empirical treatment should be based on local antibiotic resistance and the basis of the infecting uropathogen. These guidelines aim to present evidence based practice to the treatment of acute uncomplicated cystitis and pyelonephritis in these specific patient populations.

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C31. Sleep Disruption and Interstitial Cystitis Symptoms in Women

Panzera AK, Reishtein J, Shewokis P. Urologic Nursing. 2011;31(3): 159–165,172.

Article Type: Research study

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Description/Results:

* 407 study postmenopausal women between the ages of 55 and 60, participated in this study. 33.6% had a diagnosis of interstitial cystitis (IC) for at least 10 years. Linear regression controlled for other variables including depression, age, years with IC, and menstrual status.

* Nocturia, pain, and urinary urgency correlated with poor sleep quality (R2 = 0.21, P < 0.001). The largest relationship between specific symptoms and poor sleep quality were nocturia (r = 0.427, P < 0.001) and pain (r = 0.411, P < 0.001)

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What does this mean for me and my practice?

Women with IC exhibit poor sleep quality. Managing the symptoms of nocturia, pain and urgency could lead to better sleep.

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C32. Interstitial Cystitis/Bladder Pain Syndrome and Nonbladder Syndromes: Facts and Hypotheses

Warren JW, van de Merwe JP, and Nickel JC. Urology. 2011;78(4): 727–732.

Article Type: Integrative Review

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Description/Results:

* Patients with interstitial cystitis have sequel of nonbladder syndromes. The pathogenesis is poorly understood and many studies have undertaken testing of etiology hypothesis.

* The authors surmise through literature review that ≥ 5 etiology hypotheses are feasible. This article reviews the hypotheses and makes recommendations for further study.

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What does this mean for me and my practice?

Little is understood regarding the etiology of interstitial cystitis. Many patients have additional nonbladder symptoms. Further study is necessary before interstitial cystitis is fully understood. Patients with interstitial cystitis need to be reassured and supported that the etiology is not known at this time.

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C33. ASID/AICA Position Statement – Infection Control Guidelines for Patients With Clostridium Difficile Infection in Healthcare Settings

Stuart RL, Marshall C, McLaws ML, Boardman C, Russo PL, Harrington G, Ferguson JK. Healthcare Infection 2011; 16:33–39.

Article Type: Integrative Review

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Description/Results:

* New infection control guidelines for patients with Clostridium difficile infection were developed based upon literature and current guideline review with significant input from Australasian Society for Infectious Disease and the Australian Infection Control Association.

* These guidelines cover topics of surveillance & patient identification, microbiology, routes of transmission, infection prevention & control precautions, antimicrobial stewardship, hand hygiene, contact precautions, ceasing contact precautions, environmental cleaning & disinfection, education & quality improvement, patient visitors, and cluster investigation & outbreak management.

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What does this mean for me and my practice?

These guidelines provide practical infection control guidelines for everyday clinical use aimed in reducing the incidence of Clostridium difficile infection.

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C34. The Appendix May Protect Against Clostridium Difficile Recurrence

Im GY, Modayil RJ, Lin CT, Geier SJ, Katz DS, Feuerman M, Grendell J. Clinical Gasteroenterology and Hepatology 2011; 9:1072–77.

Article Type: Research Study

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Description/Results:

* Chart review of 396 patients with toxin proven Clostridium Difficile (C. difficile). Multivaried analysis revealed that the presence of the appendix exerted a protective effect against C. difficile recurrence.

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What does this mean for me and my practice?

Prospective studies are needed to verify this finding. Never the less study findings suggest that appendectomy may increase the risk of recurrent C. difficile and preservation of the appendix may act as a protective factor.

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Pediatrics

C35: A Comparative Analysis of Pediatric Uroflowmetry Curves

Vijverberg MAW, Klijn AJ, Rabenort J, Bransen J, Kok ET, Wingens JPM, de Jong TP. Neurourology and Urodynamics 2011;30:1576–1579.

Article Type: Research Report

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Description/Results:

* This study measured level of agreement between 9 pediatric incontinence professionals when viewing uroflowmetry tracings.

* Uroflowmetry assessment was assessed based on 4 factors: normal, staccato (defined as 3 or more peaks and troughs without touching 0 mL/s), interrupted flow (defined as interruption in flow touching 0 mL/s), and obstructed flow pattern (similar to prolonged flow pattern using International Continence Society nomenclature).

* Interrater agreement varied from moderate to substantial, with least agreement obtained based on interpretation of staccato flow.

* This study attempts to define additional flow patterns in children. When clinicians were asked to rate flow as normal, intermediate, and anomalous, interobserver rates were ≥0.80. Interobserver agreement rates for staccato flow were 0.44.

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What does this mean for me and my practice?

The International Continence defines 3 basic uroflowmetry patterns, continuous, interrupted, and prolonged. This comparatively simplistic taxonomy for characterizing uroflowmetry patterns reflects the screening nature of this examination. This attempt to establish a more complex schema for categorizing uroflowmetry patterns paradoxically reinforces the traditional schema proposed by the International Continence Society and reminds continence nurses that uroflowmetry, alone, is not a reliable indicator of abnormal voiding due to functional or mechanical obstruction versus poor detrusor contraction strength.

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C36: Bladder Augmentation Versus Urinary Diversion in Patients With Spina Bifida in the United States

Weiner JS, Antonelli, J, Shea AM, Curtis LH, Schulman, KA, Krupski TL, Scales CD Jr. Journal of Urology. 2011;186:161–165.

Article Type: Research Report

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Description/Results:

* The researchers described patterns of augmentation enterocystoplasty and urinary diversion in persons with neurogenic bladder dysfunction associated with spina bifida.

* Data estimates were based on the Nationwide Inpatient Sample and included patients who underwent augmentation enterocystoplasty between 1998 and 2005.

* Augmentation enterocystoplasty was performed in 3403 patients and urinary diversion was completed in 772.

* Patients undergoing augmentation enterocystoplasty tended to be younger (mean 16 vs 36 years, P < .001) and male (P = .02) and have private insurance (46% vs 29%, P < .001).

* Patients undergoing urinary diversion required more health care resources, had longer hospital stays, and greater use of home health care support after discharge.

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What does this mean for me and my practice?

Augmentation enterocystoplasty is the most common form of urinary reconstruction in patients with neurogenic bladder dysfunction associated with spina bifida. The procedure alleviates the deleterious effect of low bladder wall compliance and/or refractory detrusor overactivity, while maintaining an intact urinary system that can be managed by clean intermittent catheterization. Despite disadvantages including greater cost, longer hospital stays and increased use of home health care resources after hospital discharge, a significant proportion of patients with neurogenic bladder associated with spina bifida continue to undergo urinary diversion. The WOC nurse should counsel patients with spina bifida about advantages and limitations of both procedures when contemplating urinary system reconstruction for neurogenic bladder dysfunction refractory to conservative management with intermittent catheterization and antimuscarinic medications.

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C37: Factors Influencing Quality of Life in Children With Urinary Incontinence

Deshpande AV, Criag JC, Smith GHH, Caldwell PHY. Journal of Urology. 2011;186:1048–1052.

Article Type: Research Report

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Description/Results:

* Health-related quality of life was measured in 138 Australian children with urinary incontinence. Approximately half were male; the mean age of the sample was 10 years.

* Multivariate analysis revealed that girls had a lower quality of life than boys, and nonwhite children reported a lower quality of life as compared to white children.

* Older age and underlying disease was associated with a diminished quality of life, but increasing symptom severity was not.

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What does this mean to me and my practice?

Urinary incontinence is associated with a reduced quality of life in children. While all children should be carefully assessed for negative consequences of urinary incontinence, girls, older children, and minority children are especially influenced by urinary incontinence and should receive aggressive support to minimize the negative impact of this chronic condition on quality of life.

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C38: Effectiveness of Biofeedback for Dysfunctional Elimination Syndrome in Pediatrics: A Systematic Review

Desantis DJ, Leonadr MP, Preston MA, Barrowman NJ, Guerra LA. Journal of Pediatric Urology. 2011;7:342–348.

Article Type: Systematic Literature Review

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Description/Results:

* Dysfunctional elimination syndrome is defined as the inability to empty the bladder because of pelvic floor muscle dysfunction. Clinical manifestations include urinary tract infections, urinary incontinence, and constipation.

* The authors completed a systematic review and identified 27 studies that met inclusion criteria; only 1 was a randomized controlled trial. The remaining 26 studies were multiple-case series without comparison groups. Analysis of pooled data found an 83% improvement (95% CI: 79%-86%) in urinary tract infection and 80% improvement (95% CI: 76%-85%) in daytime urinary incontinence.

* The only randomized controlled trial identified in this systematic review found no statistically significant difference when biofeedback was compared to pelvic floor muscle training without biofeedback.

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What does this mean to me and my practice?

Clinical experience strongly suggests that pelvic floor muscle training is effective for dysfunctional elimination syndrome. Nevertheless, this systematic review that included 26 studies without a comparison group clearly reveals that there is insufficient evidence to determine the efficacy of pelvic floor muscle training for dysfunctional elimination syndrome. There is insufficient evidence to determine whether biofeedback is more effective than pelvic floor muscle training without computer-supported biofeedback, but this difference must be interpreted with caution since it is difficult to complete pelvic floor muscle training without some form of biofeedback. Additional research is urgently needed to establish the value of this noninvasive treatment option for management of children with dysfunctional elimination syndrome.

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C39: Impact of a Nurse-Led Clinic for Chronic Constipation in Children

Ismail N, Ratchford I, Proudfoot C, Gibbs J. Journal of Child Health Care. 2011;15(3):221–229.

Article Type: Research Study

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Description/Results:

* The authors summarize their experience with 50 children whose median age was 4 years (range, 1.5–10 years) managed in a nurse-led clinic for chronic constipation. Children referred to this clinic had experienced constipation for at least 6 months and had attended 3 appointments in a general pediatrician-run clinic.

* Interventions included counseling and education of the child and/or family, advice about fluid and dietary factors affecting constipation, and adherence with prescribed laxative regimens. Results were based on responses to a questionnaire completed at baseline and after visit 3 completed 3 to 4 months later.

* Defecation was more frequent after 3 clinic visits; 43% reported soft stools at baseline versus 86% after 3 clinic visits. The frequency of fecal soiling declined from 78% to 40% and pain with defecation declined from 70% to 18%. Parental satisfaction with support from the nurses was 90% after 3 visits.

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What does this mean to me and my practice?

Results from this multicase series suggest that a nurse-led clinic that relied on conservative management of chronic constipation refractory to routine management in a pediatric clinic was associated with improvement in bowel elimination symptoms including more frequent defecation, softer stools, reduction in fecal soiling, and pain associated with defecation.

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C40: Behavioral and Cognitive Interventions With or Without Other Treatment for the Management of Fecal Incontinence in Children

Brazellei M, Griffiths PV, Cody JD, Tappin D. Cochrane Review, DOI: 10:1002/14651858.CD002240. October 28, 2011.

Article Type: Systematic Review

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Description/Results:

* A systematic literature review evaluated findings from 21 randomized controlled trials that enrolled 1371 children with fecal incontinence; all but one study enrolled children with functional fecal incontinence. Researchers used a variety of behavioral interventions for management of fecal incontinence including reward systems, pelvic floor muscle training, with or without biofeedback, and laxative therapy.

* Behavioral interventions plus laxative therapy improved fecal incontinence at 3 and 12 months in one randomized controlled trial.

* There was insufficient evidence to conclude that biofeedback enhanced the efficacy of behavioral therapies for functional fecal incontinence in children but this conclusion must be viewed with caution, given the difficulty segregating biofeedback techniques when teaching pelvic floor muscle training.

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What does this mean to me and my practice?

Behavioral therapy plus laxative therapy is more effective than laxative therapy alone for children with functional fecal incontinence. There is insufficient evidence to determine whether computer-driven biofeedback techniques are more effective than behavioral treatment plus laxatives without this adjunctive technique.

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C41: Family History of Nocturnal Enuresis and Urinary Incontinence: Results From a Large Epidemiological Study

Von Gontard A, Heron J, Joinson C. Journal of Urology. 2011;185:2303–2307.

Article Type: Research Study

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Description/Results:

* Data on the prevalence and familial patterns of nocturnal enuresis were obtained from a prospective cohort study of approximately 14,000 children followed from birth. Questionnaires completed by families within the cohort revealed a prevalence rate of enuresis prevalence of 15.5% when children reached 7.5 years. This number provides a robust estimate of nocturnal enuresis in early childhood since it falls well after an age that most children have developed nighttime continence. The majority (12.8%) reported occasional bedwetting and 2.6% experienced 2 or more episodes of enuresis per week.

* The prevalence rate of daytime urinary incontinence in this cohort was 7.8%; 1% were classified as having severe incontinence.

* Statistically significant associations were detected when both fathers and mothers were queried about a childhood history of enuresis and daytime urinary incontinence.

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What does this mean to me and my practice?

Findings from this study reinforce knowledge of the prevalence and familial nature of nocturnal enuresis. Study results also reveal a high prevalence and familial pattern among children with daytime urinary incontinence. Additional research is needed to clarify the genetic factors that predispose certain families to daytime and nighttime urinary incontinence.

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C42: Nocturnal Enuresis in Adolescent With Anorexia Nervosa: Prevalence, Potential Causes, and Pathophysiology

Kanbur N, Pinehas L, Lorenzo A, Farhat W, Licht C, Katzman DK. International Journal of Eating Disorders. 2011;44:349–355.

Article Type: Research Report

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Description/Results:

* Fifty-nine adolescents with anorexia completed the Incontinence Symptom Index-Pediatric (ISI-P) and those reporting secondary nocturnal enuresis after the onset of anorexia nervosa underwent additional evaluation of lower urinary tract symptoms including uroflowmetry.

* Seventeen percent of adolescents with anorexia nervosa reported secondary lower urinary tract symptoms including daytime and nighttime urinary incontinence in 62.7%, urge incontinence symptoms in 57.6%, stress incontinence symptoms in 32.2%, and incontinence without sensory awareness in 17%.

* Detrusor overactivity and reduced functional bladder capacity are hypothesized to contribute to lower urinary tract symptoms in children with anorexia nervosa.

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What this means to me and my practice?

Children with anorexia nervosa are at increased risk for lower urinary tract symptoms including daytime urinary incontinence and nocturnal enuresis and children with anorexia nervosa should be routinely queried for the presence of urinary incontinence. Additional research is needed to more fully understand this association.

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Incontinence-Associated Dermatitis

C43: Issues Related to Accurate Classification of Buttocks Wounds

Mahoney M, Rozenboom B, Doughty D, Smith H. Journal of Wound, Ostomy and Continence Nursing. 2011;38:635–642.

Article Type: Research Study

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Description/Results:

* One hundred wound care nurses viewed 9 unique wound care photographs to determine their primary etiologic factors as pressure, moisture, or skin tear. Overall agreement was low.

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What does this mean to me and my practice?

The level of agreement concerning etiologic classification of intergluteal cleft wounds reveals the urgent need for professional societies such as the WOCN society to develop guidelines and provide additional education to ensure greater accuracy in wound classification.

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C44: A 3-in-1 Perineal Washcloth Impregnated With Dimethicone 3% Versus Water and pH Neutral Soap to Prevent and Treat Incontinence-Associated Dermatitis

Beeckman D, Verhaege S, Defloor T, Schoonhoven L, Vanderwee K. Journal of Wound, Ostomy and Continence Nursing. 2011;38:627–634.

Article Type: Research Study

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Description/Results:

* This randomized controlled trial evaluated the effect of a 3-in-1 perineal washcloth designed to cleanse, moisturize, and protect the skin via a dimethicone-based skin protectant to cleansing with a pH neutral soap and water in 11 nursing home units. Study participants were residents at risk for or experiencing incontinence-associated dermatitis. Block randomization was used to allocate 6 wards to the experimental intervention (perineal washcloth) and 5 to the control group receiving standard perineal skin care.

* Use of the perineal washcloth was associated with a significantly reduced incidence of incontinence associated dermatitis when compared with standard skin care using soap and water (8.1% vs 27.1%, F = 3.1; P = .003). The effect of the intervention in severity was not statistically significant.

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What does this mean to me and my practice?

A defined or structured skin care regimen remains the mainstay for prevention or incontinence-associated dermatitis. Findings from this randomized controlled trial provide evidence that a disposable washcloth that combines cleansing agents, an emollient-based moisturizer, and dimethicone-based skin protectant is more effective for reducing incontinence-associated dermatitis incidence in a high-risk population than washing with a pH neutral soap and water.

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C45: The Effects of a Multi-intervention Incontinence Care Program on Clinical Economic and Environmental Outcomes

Palese A, Carniel G. Journal of Wound, Ostomy and Continence Nursing. 2011;38:177–183.

Article Type: Research Study

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Description/Results:

* This study evaluated a multi-intervention, facility-wide program designed to reduce the incidence of incontinence-associated dermatitis, and reduce product usage in a nursing home in northern Italy.

* All of the 63 subjects who participated in the study were found to have incontinence-associated dermatitis on baseline evaluation. The study intervention was introduced in 2 phases; it included introduction of new absorbent products and a structured skin care regimen, followed by introduction of advice from continence nurse specialists in a second phase.

* Each phase of the intervention bundle (adding new absorptive and a structured skin care regimen) followed by introduction of advice from continence nurse specialists was found to significantly reduce the relative risk for incontinence-associated dermatitis.

* The interventions were also associated with a statistically significant reduction in daily waste production from soiled incontinence briefs.

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What does this mean to me and my practice?

Introduction of facility-wide changes in incontinence management, including consideration of the quality and effect of available absorbent products, introduction of a structure skin care regimen, and advice from continence nurse specialists reduced the relative risk for incontinence-associated dermatitis and exerted a positive impact on production of waste generated by the nursing home. WOC nurses should consider these strategies when consulting with nursing homes seeking to comply with requirements of CMS F-Tag 315.

Copyright © 2012 by the Wound, Ostomy and Continence Nurses Society

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