Urinary Incontinence Naturopathic Treatment
Under normal circumstances, in a woman with a healthy lower urinary tract, urine will only leave the bladder via the urethra when the intravesical pressure exceeds the maximum urethral pressure. In general terms and in the majority of cases of urinary incontinence, the bladder pressure exceeds the urethral pressure because the urethral sphincter mechanism is weak (urodynamic stress incontinence) or because the detrusor pressure is excessively high (detrusor overactivity neurogenic detrusor overactivity).
Table 49.1 shows the prevalence of urinary incontinence in women living at home according to a report published by the Royal College of Physicians 8 . Thomas et al. 9 have shown that urinary incontinence occurs twice or more per month in at least a third of the female population over the age of 35 years and, although there is a small rise with increasing age, it is a very common problem in women of all ages. The situation is worst amongst the elderly and in psychogeriatric hospital wards, where up to 90 of female Table 49.1 Prevalence of urinary incontinence Table 49.1 Prevalence of urinary incontinence patients are incontinent of urine. AMORI poll 10 showed that at last 3.5 million women in the UK suffer from urinary incontinence and it is possible that the number is far greater 11 . More recently a large epidemiological study of urinary incontinence has been reported in 27,936 women from Norway 12 . Overall 25 of women reported urinary incontinence of...
Lower urinary tract infections (cystitis or urethritis) may uncommonly cause incontinence of urine which is temporary and will resolve once treatment with the appropriate antibiotics has been employed. Diuretics, especially in the elderly, may also be responsible for urgency, frequency and incontinence. In older people, anything which limits their independence may cause urge incontinence where only urgency existed before. This applies particularly to immobility, and if an older person is unable to reach the toilet in a short space of time, she may become incontinent. Thus, the provision of appropriate facilities and adequate lighting can alleviate the problem. Faecal impaction may cause urinary incontinence or retention of urine which will resolve once suitable laxatives or enemas have been effective.
Symptoms of lower urinary tract dysfunction fall into three main groups (1) incontinence (2) overactive bladder symptoms and (3) voiding difficulties. Apart from the symptoms of lower urinary tract dysfunction, it is important to take a full history from all women who present with urinary incontinence. Other gynaecological symptoms such as prolapse or menstrual disturbances may be relevant. A fibroid uterus may compress the bladder and can cause urinary frequency and urgency. There is an increased incidence of stress incontinence amongst women who have had large babies, particularly following instrumental vaginal delivery, so an obstetric history may be helpful. Information regarding other urological problems such as recurrent urinary tract infections, episodes of acute urinary retention or childhood enuresis should be sought. Urinary incontinence is sometimes the first manifestation of a neurological problem (notable multiple sclerosis) so it is important to enquire about...
The etiology of childhood disintegrative disorder is unknown. It is most likely genetic in origin given the characteristic regression following an at least two-year period of normal development. Diagnosis is based on documentation of specific characteristics. As described in the DSM-IV, specific criteria include normal development for at least two years after birth. After 2 years of age, but before 10 years of age, there is significant loss in at least two areas of development such as expressive or receptive language, social skills or adaptive behavior, bowel or bladder control, play, and motor skills. In addition, similar to autism, there are abnormalities in two areas of functioning such as qualitative impairment in social interaction and communication and restricted patterns of behavior or interests. Given the developmental regression, mental retardation is often a comorbid diagnosis with childhood disintegrative disorder.
Instruments such as the SF-36 4 and European Quality of Life (EuroQol) 5 have been used with success in numerous studies on FI. The primary concern with the use of general HRQoL instruments is the sensitivity of the instrument to specific issues associated with FI as well as the presence of floor and ceiling effects. While mixed, the findings are encouraging. For example, the new version of the SF-36 (v 2.0) appears to demonstrate increased sensitivity to HRQoL in FI compared with the original SF-36 6 . At a minimum, these instruments can serve as gross indicators of HRQoL in the FI population and provide the opportunity to compare within as well as between populations e.g., urinary incontinence (UI) vs. FI .
The history of the artificial sphincter has its beginning in the treatment of urinary incontinence (UI), in which satisfactory results are reported in medium-term follow-up and many thousands of applications over 20 years 7 . The same concept applied to FI began 15 years ago, with a similar prosthesis that was changed as experience in the field grew 7 . Many
The goals for the medical management of patients include maintaining the integrity of the urinary tract, controlling or preventing infection, and preventing urinary incontinence. Many of the non-surgical approaches to managing neurogenic bladder depend on independent nursing interventions such as the Crede method, Valsalva's maneuver, or intermittent catheterization (see below). pelvic catheterization, or other urinary diversion procedures. Some surgeons may recommend implantation of an artificial urinary sphincter if urinary incontinence continues after surgery.
Prostate cancer treatment with curative intent can also predispose to urinary retention. Although the true incidence of bladder neck contracture following radical prostatectomy is not known, 1.3 -27 of patients will develop symptomatic BNC requiring treatment (Anger et al. 2005). Surgical technique remains a critical determinant of BNC development however, risk factors for microvascular disease such as smoking, hypertension, and diabetes mellitus also appear to play a role (Borboroglu et al. 2000). Simple dilation appears to be effective however, some authors question the long-term patency rates with such treatment. Transurethral incision of the contracture using cold knife, electrocautery, or the holmium YAG laser is the most commonly recommended treatment for severe BNC and those cases involving urinaryretention (Anger et al. 2005 Salant et al. 1990). Great care must be taken when performing transurethral incision since deep incision may cause sphincteric damage and, in turn, stress...
Harari et al. 16 have also provided some indication of the impact of fecal incontinence on other adverse outcomes. Incontinent patients were more likely to be in long-term care (28 vs. 6 ) and to receive district nurse services (20 vs. 11 ) than continent patients at 3 months. This suggests that fecal incontinence in stroke survivors may increase the risk of institutionalization and the need for nursing support in the community. It is presumed that incontinence is a predicting factor for poor prognosis for different reasons the same lesion might cause neurogenic bowel and bladder dysfunction in addition to cognitive or motor impairment moreover, fecal and urinary incontinence may induce marked psychological problems that hamper functional recovery.
Urinary incontinence is a distressing condition that, although rarely life threatening, severely affects all aspects of a woman's quality of life. Through ignorance, embarrassment and a belief that loss of bladder control is a 'normal' result of child birth and ageing, many women suffer for years before seeking help 1 . This is unfortunate because with appropriate investigations an accurate diagnosis can be made and many women can be cured, most improved and all helped by various different management strategies. Urinary incontinence is defined as the complaint of any involuntary loss of urine 2 . Conversely, continence is the ability to hold urine within the bladder at all times except during micturition. Both continence and micturition depend upon a lower urinary tract, consisting of the bladder and urethra, which is structurally and functionally normal. In order to understand urinary incontinence in women it is necessary to have a basic knowledge of the embryology, anatomy and...
Oestrogen preparations have been used for many years in the treatment of urinary incontinence 245, 246 although their precise role remains controversial. A further meta-analysis performed in Italy has analysed the results of randomized controlled clinical trials on the efficacy of oestrogen treatment in postmenopausal women with urinary incontinence 248 . A search of the literature (1965-1996) revealed 72 articles of which only four were considered to meet the meta-analysis criteria. There was a statistically significant difference in subjective outcome between oestrogen and placebo although there was no such difference in objective or urodynamic outcome. systemic hrt and urinary incontinence The role of oestrogen replacement therapy in the prevention of ischaemic heart disease has been assessed in a 4-year randomized trial, the Heart and Estrogen progestin Replacement Study (HERS) 250 involving 2,763 postmenopausal women younger than 80 years. Overall combined hormone replacement...
Congenital abnormalities are uncommon and are usually diagnosed at birth or in childhood. The most gross abnormality is ectopia vesicae, which requires surgical reconstruction during the neonatal period. Other less obvious congenital abnormalities include epispadias, which can be diagnosed by the bifid clitoris. This abnormality is difficult to treat and may require reconstruction in the form of a neourethra. An ectopic ureter may open into the vagina and cause urinary incontinence which is not diagnosed until childhood, and spina bifida occulta may present with urinary symptoms during the prepubertal growth spurt.
All incontinent women benefit from simple measures such as the provision of suitable incontinence pads and pants. Those with a high fluid intake should be advised to restrict their drinking to a litre a day, particularly if frequency of micturition is a problem. Caffeine-containing drinks (such as teas, coffee and cola) and alcohol are irritant to the bladder and act as diuretics, so should be avoided, if possible. Anything which increases intra-abdominal pressure will aggravate incontinence, so patients with a chronic cough should be advised to give up smoking, and constipation should be treated appropriately. Pelvic floor exercises may be particularly helpful in the puerperium or after pelvic surgery. For younger, more active women who have not yet completed their family, a device or sponge tampon may be used during strenuous activity such as sport. Oestrogen replacement therapy for postmenopausal women is often beneficial as it improves quality of life as well as helps with the...
Finally, increased integration of knowledge and cooperation between coloproctologists, urologists, and gynecologists will improve the effectiveness of treatment of double fecal and urinary incontinence 42-43 . This condition requires an accurate multimodal diagnostic assessment. Treatment could provide rehabilitative procedures, surgery, or both precise indications toward the behavioral approach, prosthetic reconstructive surgery, or SNS need to be defined.
Frequency and urgency are common symptoms in women of all ages which often coexist and may occur in conjunction with other symptoms such as urinary incontinence or dysuria. It is unusual for urgency to occur alone because once it is present it almost invariably leads to frequency to avoid urge incontinence and to relieve the unpleasant painful sensation. Bungay et al. 253 found that approximately 20 of a group of 1120 women aged between 30 and 65 years admitted to frequency of micturition and 15 of women from the same series reported urgency. In this study there was no specific increase in the prevalence of frequency or urgency with age or in relation to the menopause.
Detrusor overactivity is defined as a urodynamic observation characterized by involuntary contractions during the filling phase which maybe spontaneous or provoked 2 . It is the second commonest cause of urinary incontinence in women and accounts for 30-40 of cases. The incidence is higher in the elderly and after failed incontinence surgery. The actual cause of detrusor overactivity is unknown and in the majority of cases it is idiopathic, occurring when there is a failure of adequate bladder training in childhood or when the bladder escapes voluntary control in adult life. Often emotional or other psychosomatic factors are involved. In some cases detrusor overactivity may be secondary to an upper motor neurone lesion, especially multiple sclerosis. In such cases it is known as neurogenic detrusor overactivity. In men detrusor overactivity may be secondary to outflow obstruction and will be cured when the obstruction is relieved. However, outflow obstruction in women is rare. Most...
Electromyography is not useful in the routine clinical evaluation of patients with uncomplicated urinary incontinence. However, it may be useful in the assessment of women with neurological abnormalities or those with voiding difficulties and retention of urine. However, work from our own unit showed no difference in urethral sphincter electromyography parameters when women with urodynamically proven urodynamic stress incontinence (n 33) and a continent control group (n 35) were compared. Our findings suggested that dener-vation and reinnervation of the striated urethral sphincter may not be a major aetiological factor in the development of urodynamic stress incontinence 64 . Urethral electric conductance has not gained wide acceptance in the routine urodynamic assessment of women with urinary incontinence 65, 66 . A 7 French flexible probe with two ring electrodes 1 mm apart is withdrawn along the urethra. It measures the passage of urine along the urethra by registering the change...
Still unable to void after this and will go into AUR. For this reason, it is part of good practice to ensure any patient undergoing surgery for stress urinary incontinence is counseled on the possible need for CISC pre-operatively, and has the technique demonstrated so that she is able to perform it should the need arise. Consequently, most patients presenting in AUR after this sort of surgery should be able to perform CISC.
From a lower abdominal midline incision, the dome of the bladder is opened and the lesion repaired intravesically with 3 0 absorbable sutures. To avoid secondary complications such as urinary incontinence or erectile dysfunction (ED), injuries of the bladder neck, the proximal urethra, the prostate, or the vagina must be excluded. These injuries should be carefully reconstructed intravesically via the bladder dome incision. If the vagina is affected, a formal repair from a transvaginal approach is necessary.
Chemically cross-linked with glutaraldehyde to help resist breakdown by collagenases. It is easy to inject through a 21-gauge needle and does not appear to cause problems with granuloma formation. However, in vivo degradation appears to limit its long-term efficacy, and there was also a report of a urethrovaginal fistula following periurethral injection for stress urinary incontinence 10 . A further problem is its antigenicity therefore, skin testing must be performed prior to definitive treatment injections. In urinary incontinence, the long-term results of periurethral collagen injections have been described as disappointing and particularly poor in women with intrinsic sphincter deficiency. Even medium-term results were described as only being acceptable. A Cochrane Review found no studies that compared collagen injection with conservative treatment in urinary incontinence 11 . A recent randomised clinical trial comparing collagen injections with surgery for stress urinary...
Also influence nerve sparing male gender, tumor size, intraoperative blood loss, and surgeon expertise. When urinary incontinence and or disturbances of sexual function occur as secondary effects of nerve damage, they contribute to worsening of the patient's clinical condition 39 .
Urinary incontinence will occur in many women immediately following delivery and approximately 15 of women will have urinary incontinence which persists for 3 months after birth 8 . However, a recent study by Glazener et al. 9 showed that three quarters of women with urinary incontinence 3 months after childbirth still have this 6 years later. Urinary incontinence is more frequently seen following instrumental delivery and least frequently seen after elective Caesarean section. Urinary fistulae are uncommon in obstetric practice today although direct injury from the obstetric forceps may occasionally occur. Complications to the ureter are most commonly seen at a complicated Caesarean section when ureteric injury may either result in a ureteric fistula or ureteric occlusion. Women with this type of urinary problem should not be managed by obstetricians but should be referred to a urological colleague for surgical management.
Table 49.8 Investigations of female urinary incontinence Incontinence can be confirmed (without diagnosing the cause) by performing a pad weighing test. Many different types of pad test have been described. The following is just an example. The subject is asked to drink 500 ml of water. She then applies a preweighed perineal pad (sanitary towel) to her perineum and spends the next hour walking around, performing normal household duties. She performs a series of exercises, including coughing and deep knee bending and washes her hands under running water before the pad is reweighed. A weight gain of more than 1 g in 1 h normally represents urinary incontinence. The 24- and 48-h home pad tests have been described and, although they may be more representative, they require greater patient compliance and motivation to perform.
Sakakibara et al. 27 reported that fecal incontinence in PD patients commonly occurred together with urinary incontinence, but there was no significant relation between sexual dysfunction and bladder or bowel dysfunction. Although much less common than constipation, fecal incontinence may also occur in MSA patients, which does not seem to be related with the presence of voiding dysfunction and, in particular, urinary incontinence. A low resting anal tone is not a typical finding in MSA and PD patients, and only some patients have marked sphincter hypotonia involved in facilitating fecal incontinence 26 .
If it is possible, it is far better to avoid urinary retention by implementing prophylactic measures. The human female bladder, once overdistended, may never contract normally again 244 . When bladder neck surgery for urinary incontinence or radical pelvic surgery for malignant disease is undertaken, adequate postoperative bladder drainage (preferably with a suprapubic catheter) should be employed until normal voiding per urethram has resumed. When epidural anaesthesia is used for surgical procedures or childbirth, an indwelling Foley catheter should be left in situ for at least 6 and probably 12 h after normal sensation to the lower limbs is present. Those women who are known to have inefficient voiding (a low flow rate together with a low maximum voiding pressure) should be taught clean intermittent self-catheterization prior to any surgical intervention for urodynamic stress incontinence.
Fisher et al. 20 used the Hospital Anxiety and Depression Scale (HADS) on patients with FI. They found that patients who had unsuccessful surgical intervention had significantly higher scores than did subjects with FI who had successful surgical outcomes. This finding mirrors several investigations in the urinary incontinence literature in which patients showed elevated levels of distress when treatment for incontinence was unsuccessful and no longer showed such elevations when treatment was successful
Although the colon and the pelvic floor sphincter muscles are peripherally innervated by the autonom-ic nervous system, voluntary cortical control is an essential feature of their physiological behavior. Whereas clinical information is defined in relation to the cortical control of the bladder, much less is known about cerebral determinants of bowel function. The medial prefrontal area and the anterior cin-gulate gyrus seem to represent two of the most important cortical centers that modulate bowel function, mediating voluntary control through spinal pathways. In particular, frontal-lobe lesions of the inferior and medial surfaces are associated with fecal and urinary incontinence 4 .
Dysfunction of the smooth muscles at several levels of the gastrointestinal tract in myasthenia gravis is well known, and about 33 of patients complain of significant fatigable dysphagia 95, 96 . Mastication and swallowing difficulties worsen as a meal progresses, in particular at the end of the day. Myasthe-nia gravis can also present with a clinical picture of fecal and urinary incontinence 97 .
Developed to treat genital prolapse and female urinary incontinence 14 , pelviperineal kinesitherapy may also be employed in the coloproctology field for rehabilitating fecal disorders 15 . This is a type of muscular training that selectively aims at the levator ani muscles. It is applied in patients with fecal incontinence with the general aim of improving the pelvic viscera bearing and endurance and coordination of pelvic floor muscles and specific targets in order to strengthen the stress abdominal-perineal reflex and reinforce the puborectalis muscle resting tone (with positive effects on the anorectal angle) 16 . Pelviperineal kinesitherapy is useful when descending perineum syndrome 17 or pelvic floor support defects 18 are present in patients with fecal incontinence.
Patients presenting with fecal incontinence are often not hospitalized for instance, in Italy in 2003, the number of hospitalizations with a diagnosis of fecal incontinence on discharge amounted to 222 7 . To place this figure in its proper perspective, it should be compared with the number of hospitaliza-tions for two very common disorders with a heavy clinical and social impact, namely, hemorrhoids and urinary incontinence, which accounted for 36,073 and 2,274 hospitalizations, respectively, in 2003 7 .
Since its first descriptions in the early 1960s, normal pressure hydrocephalus (NPH) has been difficult to recognize, and conclusive diagnosis relied on response to cerebrospinal fluid shunting. The clinical manifestations classically consist of the triad of gait apraxia, urinary incontinence, and dementia.
Faecal incontinence may affect up to 40 of subjects immediately following a stroke, with a frequency of up to 15 of those who survive 3 years. It is associated with a higher mortality and greater likelihood of need for long-term (institutional) care (exceeding dementia as a reason for requesting nursing home placement). In the immediate poststroke period, incontinence has been shown to be associated with female gender, a history of previous stroke, and comorbidity of other disabling diseases, especially diabetes mellitus and hypertension. The cerebral lesions in those with incontinence are significantly more often a haemorrhage, larger in size, and more often involved the cerebral cortex than those without faecal incontinence 26 . The pathophysiology of urinary incontinence following a stroke has been categorised into three main mechanisms disruption of neuromicturition pathways, stroke-related cognitive and language deficits and concurrent neuropathy and medication use. Presumably,...
Impairment of neural function caused by diabetic microvascular disease can to a lesser or greater extent affect all the mechanisms involved in the maintenance of faecal incontinence. So whether an individual develops faecal incontinence or not is likely to be dependent on the interplay between all of these mechanism. Physiological studies have shown that cohorts of patients with long-standing diabetes have an abnormally low anal tone, weak squeeze pressures, and impaired rectal sensation 44-46 . Anal sensitivity may also be impaired 47, 48 , although it has also been suggested that perception and nociception are well preserved in diabetics, even in those with evidence of neuropathy 48 . In a study of 11 patients with diabetes and faecal incontinence and 20 healthy controls, Sun et al. 40 found that nine of the 11 patients had impaired rectal sensitivity. During rectal distension, four patients showed no anal relaxation, and in the remainder, relaxation occurred at an abnormally high...
It is important in the initial examination to determine if PROM actually occurred. Often, urinary incontinence, loss of the mucous plug, and increased leukorrhea, which are common occurrences during the third trimester, are mistaken for PROM. Inspect the perineum and vaginal vault for presence of fluid, noting the color, consistency, and any foul odor. Normally, amniotic fluid is clear or sometimes blood-tinged with small white particles of vernix. Meconium-stained fluid, which results from the fetus passing stool in utero, can be stained from a light tan to thick green, resembling split pea soup. Take the patient's vital signs. An elevated temperature and tachycardia are signs that infection is present as a result of PROM. Auscultate the lungs bilaterally. Palpate the uterus for tenderness, which is often present if infection is present. Check the patient's reflexes, and inspect all extremities for edema.
Enterocystoplasty is a commonly utilized technique within pediatric urology as a method of both increasing vesical storage capacity and decreasing pressure transmission to the upper urinary tracts in children with inadequate bladder volumes and abnormal bladder wall dynamics. The most frequent indications for augmentation include a poorly compliant, high-pressure, low-capacity bladder secondary to spina bifida (or other spinal cord anomaly or insult), posterior ure-thral valves (PUV), or bladder exstrophy. Augmentation is inherently associated with significant risks and therefore should only be recommended in select patients following an exhaustive trial of medical therapy. Only those with ongoing risk of renal deterioration or socially unacceptable urinary incontinence, despite maximal medical treatment and clean intermittent catheterization (CIC), should be considered for augmentation. Furthermore, vigilance and selection of patients and their families in whom compliance with CIC is...
(Smyrnium olusatrum) A Mediterranean plant, naturalised now in Britain, chiefly near the sea, probably as a relic of old cultivation as a potherb (Grigson). There have been a number of medicinal uses in past times, notably for dropsy, for which Dioscorides recommended it. A 15th century leechdom also prescribed it, and other herbs, for all manner of dropsies take sage and betony, crop and root, even portions, and seed of alexanders, and seed of sow thistle, and make them into a powder, of each equally much and powder half an ounce of spikenard of Spain, put it thereto, and then put all these together in a cake of white dough and put it in a stewpan full of good ale, and stop it well and give it the sick to drink all day (W M Dawson). Alexanders also used to be prescribed for bladder problems.
Sion analysis interestingly demonstrated rates of faecal incontinence to be higher in women than in men, but that the difference did not reach statistical significance 42 . Among the elderly, faecal incontinence can be broadly categorised as overflow incontinence, reservoir incontinence and rectosphincteric incontinence. Faecal incontinence among nursing home residents is associated with multiple factors urinary incontinence, impaired ability to perform activities of daily living, tube feeding, the use of physical restraints, diarrhoea, poor vision and constipation impaction.
Fecal incontinence has a significant impact on health care expenditure, the burden being comparable to that of better known diseases such as urinary incontinence (with which fecal incontinence is often associated). It accounts, for example, for a mean cost per patient (females) per year of 500 euros in Europe (359 euros in the UK, 515 euros in Germany, and 655 euros in Spain) and US 800 in the USA 12,13 (Table 5).
It has had its medicinal uses in the past, even though strongly derivative of the doctrine of signatures. As Grigson put it, yellow suggests yellow, so one should not be surprised to find the early herbalists prescribing it for bladder problems. Parkinson. 1640, for instance, said, the Tode Flaxe is accounted to be good, to cause one to make water . Earlier, Gerard had claimed that the decoction would provoke urine, in those that pisse drop by drop , and it would unstop the kidneys and bladder. The same decoction was used for a second ailment, jaundice, also obviously from the same doctrine. Gerard produced yet another yellow remedy - the decoction of Tode-flax taketh
Childbirth may result in damage to the pelvic floor musculature as well as injury to the pudendal and pelvic nerves. The association between increasing parity and urinary incontinence has been reported in several studies. Some authorities have found this relationship to be linear whilst others have demonstrated a threshold at the first delivery and some have shown that increasing age at first delivery is significant. A large Australian study has demonstrated a strong relationship between urinary incontinence and parity in young women (18-23 years) although in middle age (45-50 years) there was only a modest association and this was lost in older women (70-75 years) 20 . Obstetric factors themselves may also have a direct effect on continence following delivery. The risk of incontinence increases by 5.7-fold in women who have had a previous vaginal delivery although a previous caesarean section did not increase the risk 21 . In addition, an increased risk of urinary incontinence has...
The urogenital tract and lower urinary tract are sensitive to the effects of oestrogen and progesterone throughout adult life. Epidemiological studies have implicated oestrogen deficiency in the aetiology of lower urinary tract symptoms occurring following the menopause with 70 of women relating the onset of urinary incontinence to their final menstrual period. Lower urinary tract symptoms have been shown to be common in postmenopausal women attending a menopause clinic with 20 complaining of severe urgency and almost 50 complaining of stress incontinence. Urge incontinence in particular is
Urinary incontinence is a common and distressing condition known to adversely affect quality of life 22 . Research has often concentrated on the prevalence, aetiology, diagnosis and management of urinary incontinence with little work being performed on the effects of this chronic condition, or its treatment, on quality of life (QoL). Over the last few decades interest in the incorporation of patient assessed health status or QoL measures into the evaluation of the management of urinary incontinence has increased 23 .
A 38-year-old woman was referred because of childhood onset SW with pronounced worsening during the 18 months prior to evaluation. During a period of intense stress, she had gained 70 pounds to a weight of 295 pounds. She had become depressed with complaints of diminished memory and concentration. SW spells had been occurring once or more nightly and included injuries to ankles, knees, hips, and shoulders from falling. When awakening outside of her bedroom, she had found herself lighting cigarettes, and occasionally eating food. She admitted to snoring and also suffered significant excessive daytime sleepiness with embarrassing sleep onsets and at least one instance of missing her stop when sleeping on a bus. Past history included some difficulty with bladder control and alleged childhood physical, emotional, and sexual
The evaluation begins as a comprehensive history. Questions to define the patients' symptoms and their onset and to exclude other causes of fecal incontinence are essential. An obstetric history includes number and mode of deliveries, birthweight, complications of the pregnancy or labor, whether an episiotomy was performed, perineal wound complications, and postpartum infections. Prior anorectal surgery is noted. Concomitant symptoms of urinary continence and or organ prolapse are also components of a colorectal surgeon's evaluation, as there is evidence that combining sphincter repair with procedures for treating urinary incontinence and pelvic organ prolapse is cost effective, with favorable outcomes 85 .
Social aspects of pelvic injury are particularly important to consider in the pedi-atric population. Pediatric pelvic fractures often require prolonged hospitalizations, multiple surgeries, and cause gait and genitourinary dysfunction that may lead to acute or chronic psychological conditions (4,5). In turn, these conditions may stunt social development and inhibit optimal life functioning. Subasi et al. (4) reported that, for children in their study, education had been negatively affected by long hospital stays, surgeries, and follow-up visits. Significantly, children who experienced prolonged hospitalization exhibited connection disorders with family, friends, and health care personnel. Physical problems exacerbated social isolation as well. Children who had an abnormal gait, urinary incontinence, or an indwelling catheter tended to avoid social situations.