AustrAliAn And new ZeAlAnd © Copyright CFA 2011 Continence ...continencexchange.org.au/journals.php/49/anzcj-vol... · Masters Cert Biofeedback Nurse Practitioner Ms Denise Edgar

Continence JournalA u s t r A l i A n A n d n e w Z e A l A n d

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the Official Journal of the Continence Foundation of Australia and the new Zealand Continence Association

Autumn 2011 | Volume 17 number 1 | issn 1448-0131

• Incontinence:Alocalissuewithglobalimplications for nursesJ Paterson & M H Palmer

• DietarysupplementusagebyJapaneseadultswithurinaryincontinenceAH Lee & F Hirayama

• Communityphysiotherapyandcontinencenursespecialistmanagementofawomanwithmultiplesclerosisandurinaryincontinence:acasestudyJ Hay-smith, D Standring, N Solomon

• Pelvicfloormuscleassessmentinstandingandlyingpositionusingtransabdominalultrasound:Comparison between women with and without stressurinaryincontinenceAM Arab, M Chehrehrazi & B Parhampour

© Copyright CFA 2011

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Guest editorial 4

Dietary supplement usage by Japanese adults with urinary incontinence 6

Community physiotherapy and continence nurse specialist management of a woman with multiple sclerosis and urinary incontinence: a case study 14

Pelvic floor muscle assessment in standing and lying position using transabdominal ultrasound 19

Parents describe experiences in KEEA survey 24

Vale: Dr Gordon Baron-Hay 25

The remarkable story of the Continence Foundation of Australia 26

Australian and New Zealand news 28

Calendar of events 30

Official journal of the Continence Foundation of Australia and the New Zealand Continence AssociationACN 007 325 313

ContentsVolume 17 Number 1 – Autumn 2011

A u s t r a l i a n a n d n e w Z e a l a n d C o n t i n e n c e J o u r n a l

1Volume 17 number 1 – Autumn 2011



2 Volume 17 number 1 – Autumn 2011

Chair and Editor

Assoc Prof Pauline ChiarelliDipPhysio(SydUni), GradDipHSocSc(HthProm), MMedSc(HthProm), PhD, FACP Programme Convener, Discipline of Physiotherapy, University of Newcastle, NSW

CFa rEprEsEntativE

Mr Barry Cahill, CEO

nZCa rEprEsEntativE

Ms Jan Zander, CEO

CommittEE

Hans Peter DietzMD, PhD, FRANZCOG, DDU, CU Professor, Obstetrics & Gynaecology, Nepean Clinical School, University of Sydney, Nepean Hospital, Penrith, NSW

Dr Jenny KrugerBSc (Nurs & Midwif) MSc (Sport & Exercise) PhD Royal Society of New Zealand Postdoctoral Rutherford Fellowship, Auckland Bioengineering Institute, Auckland NZ

Ms Shona McKenzieBSc, MCHC, MN, CNA Nurse Practitioner, Royal Brisbane and Women’s Hospital, QLD

Ms Debbie RigbyBPharm GradDipClinPharm CGP FPS FASCP AACPA Consultant Clinical Pharmacist, Brisbane QLD

Dr Margaret SherburnPhD, BAppSc, MWomen’s Health Lecturer School of Physiotherapy, The University of Melbourne and Royal Women’s Hospital, VIC

Assoc Prof Winsome St JohnRN, RM, BAppScNsg, MNsg, G/Dip Ed, PhD School of Nursing & Midwifery Griffith University, Gold Coast, QLD

Dr Vincent TseMB, BS(Hons), MS(Syd), FRACS Urologist

Assoc Prof Mark WeatherallMBChB, BA, FRACP, MAppStats Geriatrician President NZCA

Co-optEd mEmbErs

Assoc Prof Kate MooreMBBS, MD, FRCOG, FRANZCOG, CU Urogynaecologist

Prof Beverly O’ConnellRN, BAppSc, MSc, PhD Inaugural Chair in Nursing Southern Health-Deakin University Director Ageing and Chronic Illness Research Network

produCtion Editor

Jacinta MillerRN, BA, BN PO Box 117 Wycheproof, VIC 3527 Tel (03) 5493 7755 Fax (03) 5493 7799 Email [email protected]

pEEr rEviEw panEl

Dr Wendy BowerPhD, BAppSc(Physio)

Assoc Prof Pauline ChiarelliDipPhysio(SydUni) GradDipHSocSc(HthProm) MMedSc(HthProm), PhD, Fellow Australian College of Physiotherapists

Dr Sue BrownRN, BN, DN

Dr Richard ClarkBSc, MPH, DHSc

Mrs Donna CoatesRN, RM, CNA, CNP, BN Grad Cert Gyn Nurs, Masters Cert Biofeedback Nurse Practitioner

Ms Denise EdgarRN BN MPubHlth

Dr Hugh GreenlandMD(Manchester), MB, ChB(Manchester)MRCOG, FRANZCOG

Assoc Prof Peter (Graham) HerbisonMSc

Ms Christine LeechBAppSc(OT)

Dr Yik LimMBBS, FRANZCOG

Dr Doreen McClurgDip Physiotherapy (Ulster) PhD, MCSP

Ms Irmina NahonBAppSc(Physio), M(Physio)

A/Prof Tryggve NevéusMD, PhD

Dr Helen O’ConnellMBBS MMed MD FRACS(Urol)

Mrs Joan OstaszkiewiczRN MN

Dr Nick RiegerMBBS, FRACS

Dr Margaret SherburnPhD, BAppSc(Physio), MWomen’s Health

Dr Winsome St JohnRN, RM, BAppScNsg, MNS GradDip Ed, PhD

Dr George SzonyiMB, BS, FRACP, FAFRM

Dr Bobby TsangBHB, Bm, BS, MBChB, FRACP

Dr Ian TuckerMB, BS, FROCG, FRANZCOG, CU

Ms Elizabeth WattRN, MN, BAppScAdvNsg

Assoc Prof Judy WollinRN, BA, DipCommHth, MAppSc CertContNsg, PhD

Editorial Committee – Peer review Panel

The Australian and New Zealand Continence Journal seeks articles and original research papers from people practising and researching the management and treatment of incontinence and continence health promotion.

Do you need topic ideas? A variety of topics are possible and include, but are not limited to: outcome studies, aged care, paediatrics, pregnancy and childbirth, novel drug therapies, reviews of devices either surgical or non-surgical, assessment articles, literature reviews of continence-related topics, home and community care issues and successes, men’s health, nursing management, physiotherapy management, support by other allied health disciplines (including occupational therapy and social workers), the psychological impact of living with incontinence, ethical issues, cultural issues and collaborative approaches to care.

Articles may be papers for peer review, clinical updates, case studies or evaluation of programmes.

To discuss topics, or for assistance in the preparation of papers and articles, contact the Production Editor Email [email protected]

Call for papers


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Guest editorial

Incontinence: A local issue with global implications for nurses

and encourage help-seeking behaviour; and to develop, test

and refine nursing interventions to prevent, improve or cure

incontinence.

The International Continence Society (ICS) was formed in

1971 by a group of researchers interested in developing global

collaborations to investigate both bladder and anorectal function

and dysfunction. The development of standardised terms

and definitions was a priority to ensure comparisons across

researchers and studies and to improve communication about

continence. While nurses have been active in the ICS, it was

not until 2007 that the ICS Nursing Committee was established

with the aim:

... to develop and refine evidence-based global bladder and bowel

care nursing to prevent, treat, and manage bladder and bowel

conditions, promote the quality of care and quality of life of affected

individuals, and support caregivers.

Information is available on the website: www.icsoffice.org/

ViewCommittee.aspx?ViewCommitteeID=30

Committee membership is not limited to nurses alone. Members

include clinicians with an interest in the nursing care of patients

with bladder and bowel conditions. To further the broad purpose

of the work of the committee, in 2009 four subcommittees

were formed in the areas of practice, research, education and

communications. The Nursing Committee holds a Nurses

Forum prior to each meeting of the ICS. This year our meeting

will take place on Sunday 28 August 2011 in Glasgow, Scotland.

The ICS website has more information about the conference:

www.icsoffice.org/

At the Nurses Forum the practice subcommittee will report

on the conclusion of work that it commenced in 2009 when

it identified – through a Delphi survey technique of the ICS

nursing membership and members from several nationally based

continence nursing organisations – three practice issues that

were of concern across the world. These were the:

• need to articulate the roleof the continencenurse advisor

and continence nursing

When we started our nursing practice, incontinence was a

given. It just happened to some people, mostly the elderly and

especially those who had dementia. Our role was to keep our

patients ‘clean and dry’; so we contained it in pads or mopped

it up. Being incontinent embarrassed some of our patients, but

many of them accepted it as a burden to be borne, just as we did.

But then we began to ask the questions: Why should it just

be borne? What can be done to improve the situation? We

embraced these questions over the course of our nursing careers

and are gratified that great advances in understanding the causes

of and risk factors for urinary incontinence have been made.

Evidence for many of our nursing practices has emerged.

Continence nurses across the world use strategies on a daily basis

to proactively prevent incontinence; to improve incontinence

and lessen its burden on affected adults and their carers; and

to alleviate suffering in those whose incontinence cannot be

improved. At the same time, nurses are actively engaging in

research to better understand efficacious and effective nursing

practices for incontinent people. Nurses interested in issues of

incontinence are joining local, state, national and international

multidisciplinary groups and consumer-led organisations to

continue the efforts to: reduce the public health impact of

urinary incontinence; remove the stigma of being incontinent

Jan Paterson(Health Care for Older People), School of Nursing & Midwifery, Flinders University, Adelaide, Australia Chair ICS Nursing Committee: Practice subcommittee

Mary H PalmerHelen W & Thomas L Umphlet Distinguished Professor in Aging, School of Nursing & Interim Co-Director, UNC Institute on Aging, University of North Carolina at Chapel Hill, USA, Chair ICS Nursing Committee: Research subcommittee




• almosttotallackofguidanceonpostnatalbladdercare

• reuse of catheters for long-term intermittent self-

catherisation and reuse of urinary drainage bags.

Subsequent to the identification of these issues, the members

of the practice subcommittee surveyed the ICS nursing

membership to determine their practices related to sterile

or clean catheters and urinary drainage bags. This group

also prepared an evidence-based paper addressing aspects of

postnatal bladder care and undertook a literature search and

consultative process to begin the identification of the scope

of practice of continence nurse specialisation. Opinion papers

– building on the work undertaken in 2009 and the current

literature being developed in relation to postnatal bladder care,

urinary catheter and leg bag reuse, and the identification of the

scope of practice of the continence nurse specialist – will be

complete in July 2010. Another Delphi survey is planned in 2011

to identify new practice issues and these will also be presented at

the forum in Glasgow.

Historically, few nurses present their research during the ICS

scientific meeting. In 2009, 883 abstracts were submitted and,

of those, 372 abstracts (42%) were submitted by individuals

who did not identify their profession. Of the remainder, nurses

submitted 21 abstracts and, of those, five were accepted for

presentation. Nurses have been and continue to be leaders in

promoting best practices. Our science provides a solid basis for

those practices. Thus, to encourage and to promote nursing

research related to continence, the research subcommittee

recently issued a call for abstracts for paper presentations

during the Nurses Forum. Topics for completed or ongoing

research include: urinary incontinence in different health care

delivery settings such as long-term, acute and community care;

different populations such as paediatric, adult and geriatric;

ante and postnatal incontinence; urinary catheter care, and the

scope of nursing practice relation to incontinence. For further

information, see the website: www.icsoffice.org/Documents/

Documents.aspx?DocumentID=864

As opportunities arise we urge you to consider taking part in

the efforts of these two subcommittees of the ICS Nursing

Committee. Our practice and research efforts must be shaped

by and disseminated to local and global audiences in order for it

to reach those who need our services.

As we look back over the years, we are pleased with the progress

within the nursing profession, but as we look forward we see

much more work remains to be done. As the population ages and

as technological advances make the world a smaller place, we are

offered both challenges and opportunities to work together to

question the status quo and seek out better solutions to practices

that are evidence-based, culturally sensitive, and able to meet the continence needs of the dramatically increasing number of people over the age of 65 years1.

According to the World Health Organization2, it is highly likely that there will not be an adequate number of specialist, trained health professionals to meet the health demands of this increasingly older population. It is well established that the prevalence of incontinence increases with age and in the presence of chronic diseases like diabetes mellitus and dementia. Clearly, if there is a corresponding increase in requirements for continence services with no increase in workforce, then continence-specific services will only be able to deal with a limited number of people. To ensure that all people have the right to continence promotion and care, an ongoing commitment by nurses in the coming decades to a policy driven, systematic, population health-based approach to continence care will be required.

This approach focuses on prevention, community ownership, primary care and integration with tertiary services. However, research into the prevention of incontinence, especially in adults, is scarce3,4 and there is some evidence5 that indicates some generalist health professionals do not readily provide continence care and advice because of the difficulty in implementing their clinical knowledge6 or failure to ask the patient about the problem7. Thus our work is not finished. We must garner our resources to work together, near and far, to achieve another common goal: preventing incontinence from occurring and when that is not practicable, improving the lives and care of our current and future incontinent patients through state-of-the-science nursing practice and research that readily challenges the current status quo.

references1. World Population Ageing 1950–2050 Report of the Population

Division, DESA, United Nations. Executive Summary 2001–2002. Available at: http://www.un.org/esa/population/publications/worldageing19502050/

2. World Health Organization. Ageing and Life Course Workforce Development. Available at: http://www.who.int/ageing/workforce_development/en/index.html

3. Sampselle C, Palmer M, Boyington A, O’Dell K & Woolridge L. Prevention of urinary incontinence in adults. Nurs Res (suppl) 2004; 53(6A):561–567.

4. Palmer M. Primary prevention incontinence research in older adults. West J Nurs Res 2002; 24(4):390-405.

5. Keilman L & Dunn K. Knowledge, attitudes and perceptions of advanced practice nurses regarding urinary incontinence in older adult women. Res Theory Nurs Pract 2010; 24(4):260–279.

6. Dingwall L. Promoting effective continence care for older people: A literature review. Br J Nurs 2008;17(3):166–172.

7. Mardon R, Pawlson L & Haffer S. Management of urinary incontinence in Medi-care managed beneficiaries: Results from the 2004 Medicare hearth outcomes Survey. Arch Intern Med 2006;166(10):321–5.




Peer review

Dietary supplement usage by Japanese adults with urinary incontinence

to be higher for women and increases with age, obesity and

smoking2-4.

Dietary supplements, especially multivitamins and mineral

supplements, have been widely consumed, even though their

effectiveness is unclear5. In recent years, the market for dietary

supplements has been increasing worldwide. Many people

consume multiple supplements in the hope of gaining additional

benefit. According to a recent study, the overall prevalence of

dietary supplementation was estimated to be 45.8% among

Japanese adults aged over 55 years. Within the five categories

of supplements, the most popular reported were multivitamins

for men and vitamin C for women6. Various types of dietary

supplements are now available on the market, but, despite the

immense community interest, there has been no published

report in the literature documenting their usage in the daily life

of incontinent adults.

Nutritional therapy for UI has gained some credibility since

the recognition of complementary and alternative medicine

by government as part of integrated health care7. Anecdotal

evidence has suggested that certain vitamin and mineral

Andy H lee *School of Public Health, Curtin Health Innovation Research Institute, Curtin University, Perth, WA Email [email protected]

Fumi HirayamaSchool of Public Health, Curtin Health Innovation Research Institute, Curtin University, Perth, WA

* Corresponding author

Competing interest statement: No competing interest declared.

Abstract

Urinary incontinence (UI) is a distressing condition that affects the lifestyle of older people. This study documented the prevalence and type of dietary supplements usage among incontinent adults in Japan. A total of 683 men and 298 women (mean age 63.6, SD 7.6 years) were recruited from the community in central Japan. The International Consultation on Incontinence Questionnaire – Short Form (ICIQ-SF) was administered by face-to-face interview to ascertain UI status. Detailed information on dietary supplementation, including frequency and duration of usage, was obtained from the participants. The prevalence of UI was 8% (n=54) among the male participants and 28% (n=83) among the female participants, who had experienced urine leakage for 2.6 (SD 1.8) years and 4.2 (SD 5.1) years, respectively. Of these 137 incontinent adults, 49.6% took supplements on a weekly or daily basis, the prevalence being higher for women (n=45, 54.2%) than men (n=23, 42.6%). The most popular dietary supplements were vinegar, vitamin C and tree kale juice. The prevalence of dietary supplementation among incontinent adults was higher than that reported for the Japanese general population. Further research to determine the factors affecting their usage is recommended.

Keywords: Incontinence, dietary supplements, prevalence, urine leakage.

Introduction

Urinary incontinence (UI) is a distressing condition and costly

problem in middle-aged and older people. The International

Continence Society in 2002 defined UI as “a condition where

involuntary loss of urine is a social or hygienic problem and

is objectively demonstrable”1. The prevalence of UI is known


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supplements, plant extracts and herbs, taken as an adjunct to

standard treatment, may produce an enhanced, synergistic

activity similar to the drugs used to treat UI8. However, scientific

evidence is still lacking and claims concerning their effectiveness

have not been substantiated, unlike pelvic floor muscle exercise

and bladder training9. There is clearly a paucity of research

concerning UI and usage of dietary supplements. The present

study aimed to ascertain the prevalence and type of dietary

supplements taken by adults with UI in Japan.

Methods

subjects

Seven hundred men and 300 women aged 40 to 75 years living

in central Japan were recruited from the community. This

convenience sample of subjects was interviewed by the second

author at shopping malls or when they attended community

centres or undertook health checks at hospital clinics. Subjects

were excluded if they were non-residents or outside the desired

age range. A quota sampling scheme was adopted and data

collection was conducted over 18 months.

A total of 683 eligible men and 298 women were available

for analysis after excluding participants with missing personal

details or those who subsequently withdrew from the study. The

purpose and procedure were explained to the participants before

obtaining their written consent. Confidentiality and the right

to withdraw without prejudice were ensured and maintained

throughout the study. The project protocol was approved by

the Human Research Ethics Committee of Curtin University

of Technology.

Instruments

A structured questionnaire incorporating the International

Consultation on Incontinence Questionnaire – Short Form

(ICIQ-SF)10 was administered face to face to assess UI status.

The ICIQ-SF is a measure for evaluating the severity of urinary

loss and condition-specific quality of life. The reliability, validity,

and sensitivity of the instrument have been established10,11, while

linguistic validation of its Japanese version was completed12. It

consists of three components to determine frequency, quantity,

and impact of urine leakage. Frequency was categorised into 0

(never), 1 (about once a week or less often), 2 (two or three times

a week), 3 (about once a day), 4 (several times a day), and 5 (all

the time). UI was considered present for those subjects within

categories 1 to 5. Quantity was measured from 0 (none), 2 (a

small amount), 4 (a moderate amount) to 6 (a large amount).

The impact of leakage on daily life was scored on an incremental

scale from 0 (not at all) to 10 (a great deal).

The circumstances of incontinence were recorded via a separate

self-diagnostic item, with urge incontinence defined as “leaks

before you can get to the toilet”, stress incontinence defined as

either “leaks when you cough or sneeze” or “leaks when you

are physically active or exercising”, while the combinations of

these symptoms were regarded as mixed incontinence. Other

incontinence referred to “leaks when you are asleep”, “when

you have finished urinating and are dressed”, “for no obvious

reason”, and “all the time”. Two questions were appended to the

ICIQ-SF to find out how long the subject had had the condition

and whether treatment was sought.

Information on dietary supplement usage was next solicited from

the participants. Specific dietary supplements were classified into

five categories, namely, multivitamin, beta-carotene, vitamin C,

vitamin E, and miscellaneous, following the convention adopted

by the Japan Public Health Centre-based prospective study on

cancer and cardiovascular disease7. The brand name, frequency,

duration and dosage of all supplements consumed by each

participant were recorded. Users of dietary supplements were

defined as subjects who used at least one category of dietary

supplement on a weekly basis for one year or longer7.

The third part of the structured questionnaire collected

demographic information (including age, height, weight,

marital status, education level, retirement status and location of

residence) and lifestyle characteristics such as smoking habit and

alcohol consumption, as well as health conditions (hypertension,

ischaemic stroke, diabetes mellitus, depression and cancer). On

average, each interview took about 30 minutes to complete.

statistical analysis

Participants with UI were first identified on the basis of positive

outcomes to the ICIQ-SF questions. Descriptive statistics were

applied to summarise this subgroup of incontinent individuals,

and their characteristics were compared between genders using

chi-square and t-tests. Statistical significance was assessed

at the 5% level. The prevalence of dietary supplementation

by category was tabulated. Frequency and duration of usage

was also examined among users. All statistical analyses were

performed using the SPSS package version 17.

results

Among the 981 participants, 137 (14%) had self-reported UI,

including 54 men (8%, mean age 65.4 years) and 83 women

(28%, mean age 62.6 years). Table 1 presents the demographic

and lifestyle characteristics of this subgroup by gender and shows

that most respondents in this group were married, had high

school or below education and were still employed. About half of




them had another health condition in addition to UI. Compared

with the women who reported symptoms of incontinence,

the men who reported incontinence were three years older

on average (p=0.036) and more likely to smoke (p=0.026) and

consume alcohol on at least a monthly basis (p=0.003).

Table 2 summarises the ICIQ-SF outcomes. Urine leakage

among the 137 incontinent subjects was typically “a small

amount” and occurred once a week or less often. Only a few

considered the condition to have interfered with their daily

life to a great extent. The distribution of incontinence type

was different (p<0.001) between men and women, with urge

incontinence being the most common type for men (n=31,

57.4%), whereas the majority of incontinent women reported

stress type leakage (n=56, 67.5%). The duration of the condition

was also significantly longer (p=0.011) for women (mean 4.2, SD

5.1 years) than men (mean 2.6, SD 1.8 years). However, only two

men and one woman consulted their physician to discuss their

incontinence.

Characteristic Both genders Male Female pa

n 137 54 83

Age: mean (SD) years 63.6 (7.6) 65.4 (7.2) 62.6 (7.8) 0.036

BMI: mean (SD) kg/m2 23.7 (3.9) 23.0 (4.0) 24.2 (3.8) 0.090

Marital status

single/divorced/separated 39 (28.5%) 9 (16.7%) 30 (36.1%) 0.014

married 98 (71.5%) 45 (83.3%) 53 (63.9%)

Educationb

high school or below 102 (74.5%) 44 (81.5%) 58 (69.9%) 0.128

college/university 35 (25.5%) 10 (18.5%) 25 (30.1%)

retirement statusb

working 85 (62.0%) 29 (53.7%) 56 (68.3%) 0.086

retired 51 (37.2%) 25 (46.3%) 26 (31.7%)

location of residenceb

metropolitan 45 (32.8%) 13 (24.5%) 32 (38.6%) 0.090

suburban 91 (66.4%) 40 (75.5%) 51 (61.4%)

Presence of comorbidityc

no 64 (46.7%) 26 (48.1%) 38 (45.8%) 0.786

yes 73 (53.3%) 28 (51.9%) 45 (54.2%)

smoking status

non-smoker 113 (82.5%) 38 (70.4%) 75 (90.4%) 0.003

current smoker 24 (17.5%) 16 (29.6%) 8 (9.6%)

Alcohol consumption

none 72 (52.6%) 22 (40.7%) 50 (60.2%) 0.026

monthly 65 (47.4%) 32 (59.3%) 33 (39.8%)

weekly to daily 36 (26.3%) 19 (35.2%) 17 (20.5%)

a based on chi-square or t-tests; b missing data present; c hypertension, stroke, diabetes, cancer or depression

Table 1. Demographic and lifestyle characteristics of Japanese adults with UI (n=137).




ICIQ item Male Female pa

Frequency of leakage 0.219

once a week or less often 32 (59.3%) 61 (73.5%)

two or three times a week 11 (20.4%) 11 (13.3%)

once a day 11 (20.4%) 11 (13.3%)

Quantity of urine loss 0.543

a small amount 47 (87%) 75 (90.4%)

a moderate amount 7 (13%) 8 (9.6%)

a large amount 0 (0%) 0(0%)

Interfere with everyday life 0.031

0–2 32 (59.3%) 64 (77.1%)

3–5 19 (35.2%) 13 (15.7%)

6-10 (a great deal) 3 (5.5%) 6 (7.2%)

ICIQb mean (SD) score 6.0 (2.7) 5.3 (3.4) 0.217

Type of UI < 0.001

urge 31 (57.4%) 13 (15.7%)

stress 5 (9.3%) 56 (67.5%)

mixed 2 (3.7%) 11 (13.3%)

others 16 (29.6%) 3 (3.6%)

Duration of UI, mean (SD) years 2.6 (1.8) 4.2 (5.1) 0.011

sought treatment 2 (3.7%) 1 (1.2%)

a based on chi-square or t-tests; b International Consultation on Incontinence Questionnaire

Table 2. Characteristics of incontinence in Japanese men (n=54) and women (n=83).

Overall, 68 (49.6%) subjects who self reported symptoms of

incontinence used dietary supplement, but the prevalence for

females (n=45, 54.2%) was higher than males (n=23, 42.6%).

Prevalence of the five dietary supplement categories7 is given

in Table 3. Apart from supplements listed in the miscellaneous

category7, the most popular supplement was vitamin C for

both genders. Within the miscellaneous supplements, vinegar

was ranked the highest, with one-third of users who took it

on a regular basis, followed by tree kale juice (10.3%). Further

examination on frequency and duration of usage indicated that

these popular supplements were often taken once daily and

consumed by users within the past two years (data not presented

for brevity).

Discussion

This is the first study to investigate the prevalence and type of

dietary supplements taken by middle-aged and older Japanese

adults with UI using validated instruments. The UI prevalence

estimates of 8% (male) and 28% (female) were comparable with

previous reports for the Japanese population13,14. Although a few

subjects with UI perceived the condition as interfering with daily

life, the low number seeking help is of concern. It is possible

that the older adults were either embarrassed or unaware that

the condition is treatable. Education and regular assessment for

urinary tract symptoms are needed as people become older.

The overall prevalence of dietary supplementation of 49.6%

(42.6% for male and 54.2% for female) among adults who

reported incontinence was higher than the 45.8% usage reported

for the Japanese general population6. The most popular dietary

supplements were vinegar, vitamin C and tree kale juice. Vinegar

is a widely advertised beverage supplement, while tree kale

juice is another natural product commonly available in Japan.

It is unknown, however, whether the respondents used these

supplements to treat their condition.




Category Both genders Male Female

Multivitamin 6 (4.4%) 1 (1.9%) 5 (6.0%)

Beta-carotene 0 (0%) 0 (0%) 0 (0%)

Vitamin C 10 (7.3%) 3 (5.6%) 7 (8.4%)

Vitamin E 3 (2.2%) 1 (1.9%) 2 (2.4%)

Miscellaneousa 63 (46.0%) 22 (40.7%) 41 (49.4%)

Vinegar 23 (16.8%) 8 (14.8%) 15 (18.1%)

Tree kale juice 7 (5.1%) 4 (7.4%) 3 (3.6%)

Energy drink 6 (4.4%) 4 (7.4%) 2 (2.4%)

Calcium 6 (4.4%) 2 (3.7%) 4 (4.8%)

Overall supplement use 68 (49.6%) 23 (42.6%) 45 (54.2%)

a 39 other supplements not listed

Table 3. Prevalence of the five dietary supplement categories7 and most popular miscellaneous supplements consumed by Japanese adults with UI (n=137).




For the elderly, nutritional deficiencies can lead to systemic

changes and can directly affect the health of the kidneys and the

bladder. In particular, deficiencies in calcium, zinc, magnesium,

vitamin C and vitamin B12 have been reported to contribute

to bladder instability8. Their supplementation may increase

the contractile strength and overall functional capabilities of

the pelvic floor muscles, as well as reducing detrusor instability

or sensory urgency in women8. Nevertheless, the role of these

supplements remains controversial. Further research is needed

in the clinical efficacy and physiological mechanisms of using

dietary supplements as an adjunct therapy for treating UI.

In this study, detailed information on UI and dietary

supplementation was obtained from self-report. As with other

surveys, especially with elderly subjects, the responses from our

participants inevitably incurred some recall error due to possible

memory and cognitive loss. Therefore, the short version of

ICIQ and face-to-face interview were used to increase the

response rate and to improve the accuracy of their answers. All

interviews were conducted by the same investigator (second

author) to avoid misinterpretation of the questions and to reduce

interviewer bias.

It should be noted that the ICIQ-SF neither provides an

objective measurement of urine loss nor accounts for seasonal

alterations4. The instrument has good measurement properties

and encompasses all aspects of incontinence10,11,15. Indeed,

despite the differences between clinical measures of symptom

severity and the subjective perception of the condition, use of

psychometrically robust self-completion questionnaires such

as the ICIQ-SF have been recognised as a valid approach for

assessing UI15.

A major limitation of this study concerned the adequacy of

our convenience sample of subjects recruited from community

centres, shopping malls and hospital out-patient clinics. Selection

bias could not be ruled out because these voluntary participants

were not randomly selected. Nevertheless, all participants

resided in the community and should still be representative of

the underlying population. Also, community-based, randomised

sampling would be difficult to implement with high refusal rate

expected in practice.

Another limitation was the lack of qualitative data on the

perception and belief by the respondents who reported symptoms

of incontinence. Opinions about dietary supplementation,

facilitators and intentions behind dietary supplement use were

not investigated due to time constraints. An in-depth qualitative

study to explore these issues is thus recommended, as well as

further research to determine the extent of using other types

of complementary and alternative medicine by those who have

incontinence.

references1. Hunskaar S, Burgio K, Diokno AC, Herzog AC, Hjälmaás K &

Lapitan MC, eds. Incontinence: Second International Consultation on Incontinence Paris, 1–3 July 2001, 2nd edn. Plymouth: Health Publication Ltd, 2002.

2. Dallosso HM, McGrother CW, Matthews RJ & Donaldson MM. The association of diet and other lifestyle factors with overactive bladder and stress incontinence: a longitudinal study in women. BJU Int 2003; 92:69–77.

3. Danforth KN, Townsend MK, Lifford K, Curhan GC, Resnick NM & Grodstein F. Risk factors for urinary incontinence among middle-aged women. Am J Obstet Gynecol 2006; 194:339–345.

4. Yoshimura K, Kamoto T, Tsukamoto T, Oshiro K, Kinukawa N & Ogawa O. Seasonal alterations in nocturia and other storage symptoms in three Japanese communities. Urology 2007; 69:864–870.

5. Rock CL. Multivitamin-multimineral supplements: who uses them? Am J Clin Nutr 2007; 85:277S–279S.

6. Hirayama F, Lee AH, Binns CW, Watanabe F & Ogawa T. Dietary supplementation by older adults in Japan. Asia Pac J Clin Nutr 2008; 17:280–284.

7. Ishihara J, Sobue T, Yamamoto S, Sasaki S & Tsugane S. Demographics, lifestyles, health characteristics, and dietary intake among dietary supplement users in Japan. Int J Epidemiol 2003; 32:546–553.

8. Bottomley, J. Complementary nutrition in treating urinary incontinence. Top Geriatr Rehabil 2000; 16:61–77.

9. Shamliyan TA, Kane RL, Wyman J & Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 2008; 148:459–473.

10. Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M & Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn 2004; 23:322–330.

11. Karantanis E, Fynes M, Moore KH & Stanton SL. Comparison of the ICIQ-SF and 24-hour pad test with other measures for evaluating the severity of urodynamic stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 2004; 15:111–116.

12. Gotoh M, Donovan J, Corcos J et al. Scored ICIQ-SF (International Consultation on Incontinence Questionnaire-Short From) for symptoms and QOL assessment in patients with urinary incontinence. J Jpn Neurogen Bladder Soc 2001; 12:227–231.

13. Honjo H, Nakao M, Sugimoto Y, Tomiya K, Kitakoji H & Miki T. Prevalence of lower urinary tract symptoms and seeking acupuncture treatment in men and women aged 40 years or older: a community-based epidemiological study in Japan. JAM 2005; 1:27–35.

14. Matsumoto M & Inoue K. Predictors of institutionalization in elderly people living at home: the impact of incontinence and commode use in rural Japan. J Cross Cult Gerontol 2007; 22:421–432.

15. Avery KN, Bosch JL, Gotoh M et al. Questionnaires to assess urinary and anal incontinence: review and recommendations. J Urol 2007; 177:39–49.


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Peer review

Community physiotherapy and continence nurse specialist management of a woman with multiple sclerosis and urinary incontinence: a case study

might have contributed to the continence outcomes. A brief summary of the case is presented as a vehicle for discussing the synergy between the separate but potentially complementary interventions (Clinical Pilates and pelvic floor muscle (PFM) training) and the possible benefits to be gained from deliberate teamwork between health professionals.

Ethics approvalThe Lower South Regional Ethics Committee confirmed that ethical approval was not needed for this case study report. The patient gave written informed consent for her case to be reported and she was offered this manuscript to check and agree before it was submitted for publication.

Case presentationThe patient was a late-middle-aged, postmenopausal woman with an 11-year history of symptoms of relapsing-remitting MS and worsening urinary symptoms. There was no other important medical history. Medications included oral oxybutynin 5mg twice daily (recently prescribed by the general practitioner), vitamin B12 injections, iron tablets and complementary therapies (evening primrose oil and other dietary measures) but no immunotherapy.

On referral, the patient was bothered by fatigue, although she was able to participate in all activities of daily living and she was on sick leave. The patient lived with her spouse in their own home, which was accessible. She was independently mobile, although the physiotherapist reported the patient had fallen during an assessment of her balance and gait.

AssessmentAt her first hospital out-patient continence clinic appointment, the patient reported symptoms of urinary frequency and urgency,

Jean Hay-smith *Senior Lecturer in Rehabilitation, Rehabilitation Teaching and Research Unit, Department of Medicine University of Otago, Wellington, New ZealandSenior Lecturer in Women’s Health, Department of Women’s and Children’s Health, Dunedin School of Medicine, University of Otago, Dunedin New Zealand Email: [email protected]

Debbie standringSenior Physiotherapist, Southern District Health Board Dunedin, New Zealand

Nicky solomonClinical Nurse Specialist (Continence), Southern District Health Board, Dunedin, New Zealand



Abstract

This case study presents information about the care of a woman with multiple sclerosis (MS) who had walking/balance difficulties and urinary incontinence. Post-treatment, the community physiotherapist and continence clinical nurse specialist (CNS) both thought the longer-term outcomes were better than either expected. We have reported this case to stimulate debate about future research on the effectiveness (or not) of transversus abdominis (TrA) contraction along with pelvic floor muscle (PFM) training for urinary incontinence in people with neurological conditions, and to advocate for more deliberate teamwork outside the usual members of the continence team.

Keywords: Urinary incontinence, multiple sclerosis, Clinical Pilates, pelvic floor muscle training.

IntroductionA woman with an 11-year history of symptoms that were diagnosed as relapsing-remitting multiple sclerosis (MS) was referred, during a relapse, to a physiotherapist for rehabilitation of walking and balance problems. When it became clear the patient had bothersome urinary symptoms, including urinary incontinence, the physiotherapist referred the patient to a continence clinical nurse specialist (CNS).

After the patient was discharged from physiotherapy, the two clinicians met in a corridor and experienced an ‘aha’ moment; both had observed better than expected outcomes in this case. They postulated that the interplay between treatments


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urge urinary incontinence and stress urinary incontinence. There was no nocturia, dysuria, haematuria or bladder pain. Urinary flow was good and there were no symptoms suggestive of obstruction. Urinary leakage (drops each time) occurred most days. No bowel problems were reported.

A 24-hour bladder diary was completed 1. The diary showed voided volumes between 100ml and 250ml every two to three hours during the day, two urge episodes and a total fluid intake (all non-caffeinated) of 1.5 litres.

The King’s Health Questionnaire (KHQ)2 showed some bother for five of the 10 listed bladder symptoms; the most bothersome (“a lot”) were urgency, urge incontinence and stress incontinence. Urinary symptoms had most effect on the role limitations quality of life (QoL) domain, with moderate effect on the emotional and physical/social limitations domains. Overall, the KHQ scores suggested good general health, although the patient’s urinary symptoms moderately affected her QoL.

Abdominal examination was unremarkable. Vaginal examination showed no atrophic vaginitis, no demonstrable urinary incontinence with cough and a grade one cystocoele on Valsalva. An Oxford Scale grade one voluntary PFM contraction was palpated vaginally3. Portable ultrasound bladder scan revealed an elevated post-void residual of 183ml, reduced to 21ml two weeks later after the oral oxybutynin dose was reduced from 10mg to 5mg daily. The midstream urine sample and urine cytology were normal.

ManagementTreatment began with an explanation of common urinary symptoms in MS and why these might happen. The patient’s current fluid intake of about 1.5 litres per 24 hours with minimal caffeinated fluids was considered appropriate and endorsed. Frequency strategies were suggested; in particular, resisting the temptation to void "just in case".

PFM training was introduced after the patient felt confident with frequency strategies; it was hoped that improved PFM performance would assist with urge suppression4 and reduce stress urinary leakage5. Although at initial assessment the patient had a Grade i voluntary PFM contraction, a Grade iii contraction was palpated with a concurrent transversus abdominis (TrA) muscle contraction. The patient was familiar with a TrA muscle contraction because this was a key component of the Clinical Pilates programme taught and supervised by the physiotherapist.

The PFM strength training programme began with three contractions held for two seconds each, with a two-second rest between contractions, repeated twice daily. Patient and CNS agreed that, initially, a ‘combined’ TrA and PFM contraction might be a useful way to facilitate a very weak PFM contraction. Each week the programme was progressed, with the addition of either one further contraction or one second longer hold. The training goal was 10 to 12 contractions held for six to eight seconds, each repeated three times daily6. After eight weeks,

the patient began integrating her exercise into daily activity to establish a routine or exercise habit. She used a voluntary PFM contraction to counteract an intra-abdominal pressure7 and to suppress urgency4, as needed.

Outcome

The patient has continued a daily Clinical Pilates programme, and integrated her PFM training with this throughout (what is now) a two and a half years of active review by the CNS who sees the patient monthly to check post-void residual urine. At 12 months the 24-hour urinary diary data suggested that voiding frequency increased and voided volumes decreased over this period, with fewer urge episodes. Frequency, urgency, urge and stress incontinence were still bothersome, although less so. The KHQ also suggested an improvement in continence-specific QoL, with a reduction in role limitations, physical/social limitations and less emotional impact. Patient-reported benefits were a greater sense of symptom control and increased confidence in being able to participate in social activities without worrying about her bladder. This was congruent with the patient-reported outcome relayed by the physiotherapist in the corridor conversation; the patient had told the physiotherapist she had an improved feeling of overall wellbeing that was attributed to a greater sense of symptom control.

Discussion

Based on her prior clinical experience of the nature and usual progression of continence symptoms in people with MS, and the patient’s poor PFM function at the time of referral, the CNS was surprised by an apparent improvement and then maintenance in incontinence-specific QoL. In addition, the reasonably slow deterioration in other typical MS bladder symptoms (such as frequency) was unexpected.

It is acknowledged that the variable nature of MS symptoms and progression, and the lack of control comparison, means that it is not possible to say with any certainty that there was an association between the interventions and outcomes.

Clinical Pilates programme and PFM training synergy

Core stability, achieved through training of core muscles, including the abdominal muscles, is thought to be pivotal for efficient biomechanical function during physical activity8. Sapsford stated that PFM rehabilitation: “does not reach its optimum level until the muscles of the abdominal wall are rehabilitated as well”; within the abdominal muscle group the focus of training appears to be the TrA9. While there is a developing evidence base for co-contraction of the TrA muscles and PFM during spinal, abdominal and pelvic activity in women with and without urinary incontinence9, the extent to which training of one can be used to treat dysfunction in the other is contested10.


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Clinical Pilates is one approach used widely in rehabilitation to deliver core stability training, although most literature to date concerns its use in sport and musculoskeletal rehabilitation. Kibler et al. defined core stability as:

... the ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer and control of force and motion to the terminal segment in integrated athletic activities8.

In core stability training, initial exercises target muscles of the trunk and pelvis (particularly the TrA) while maintaining a neutral spinal position; exercises are then progressed to incorporate complex movements11 to create proximal stability for distal mobility8. In the present case, the physiotherapist considered that a combination of greater proximal stability and lower limb strength was needed to improve mobility and balance and decrease the risk of falls. We have not found any clinical studies reporting the effect of core stability or TrA training in people with neurological conditions.

The use of PFM training in the management of urinary incontinence is supported by a biological rationale based on the role of the muscles in bladder neck support, their contribution to the sphincteric closure mechanism of the urethra and inhibition of a detrusor contraction with a voluntary PFM contraction12.

In women with MS there may be little relationship between their neurological or urinary symptoms and their PFM function, although typically women with MS seem to have very weak PFM that tires quickly and some will also have PFM ‘spasticity’ 13. We agree with Sherburn and Frawley that “there is no substitute for isolated muscle rehabilitation” 14. Nevertheless, we hypothesise that where a voluntary PFM contraction is not or barely possible due to complex motor and sensory nerve conduction abnormalities such as this case, facilitating a contraction through co-contraction of a functioning TrA muscle is useful and might improve continence outcomes. Further research is needed in this area.

Interprofessional rehabilitationOnly in retrospect did the physiotherapist and CNS recognise the potential synergy in their interventions. Multidimensional community-based neurorehabilitation aims to enhance QoL and function 15. This multidimensional rehabilitation typically includes contributions from more than one health professional 16. Teamwork is recognised as a core component, even cornerstone, of contemporary rehabilitation 17, and it seems that collaborative teamwork is an expected and essential part of the current drive to patient-centred care 18.

Such interprofessionality occurred retrospectively in this case. As interprofessionality is espoused as a process that will improve patient outcomes 19 we speculated that prospective and deliberate collaborative and coherent teamwork could have made more use of the synergy between the treatments and perhaps resulted in other gains in effectiveness or efficiency. In the absence of

collaborative teamwork, there was a risk the patient could have been overwhelmed and fatigued by multiple interventions and apparently conflicting advice; fortunately, this did not seem to happen here.

references1. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B,

Lee J, Monga A, Petri E, Rizk DE, Sand PK & Shaer GN. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010; 29:4–20.

2. Kelleher CJ, Cardozo LD, Khullar V & Salvatore S. A new questionnaire to assess the quality of life of urinary incontinent women. [comment]. Br J Obstet Gynaecol 1997; 104:1374–1379.

3. Laycock J & Jerwood D. Pelvic floor muscle assessment: The PERFECT scheme. Physiotherapy 2001; 97:631–642.

4. Burgio KL, Goode PS, Locher JL et al. Behavioral training with and without biofeedback in the treatment of urge incontinence in older women: a randomized controlled trial. JAMA 2002; 288:2293–2299.

5. Hay-Smith EJ & Dumoulin C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev 2006; CD005654.

6. Bø K. Pelvic floor muscle exercise for the treatment of stress urinary incontinence: an exercise physiology perspective. Int Urogynecol J 1995; 6:282–291.

7. Miller JM, Ashton-Miller JA & DeLancey JO. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc 1998; 46:870–874.

8. Kibler WB, Press J & Sciascia A. The role of core stability in athletic function. Sports Med 2006; 36:189–198.

9. Sapsford R. The pelvic floor. A clinical model for function and rehabilitation. Physiotherapy 2001; 87:620–630.

10. Bø K, Morkved S, Frawley H & Sherburn M. Evidence for benefit of transversus abdominis training alone or in combination with pelvic floor muscle training to treat female urinary incontinence: A systematic review. Neurourol Urodyn 2009; 28:368–373.

11. Bliss L S & Teeple P. Core stability: the centerpiece of any training program. Curr Sports Med Rep 2005; 4:179–183.

12. Hay-Smith J, Berghmans B, Burgio K, Dumoulin C, Hagen S, Moore K & Nygaard I. Adult conservative management. In: Incontinence, Abrams P, Cardozo L, Khoury S & Wein A, eds. Health Publication Ltd, 2009, pp 1025–1120.

13. De Ridder D, Vermeulen C, De Smet E, Van Poppel H, Ketelaer P & Baert L. Clinical assessment of pelvic floor dysfunction in multiple sclerosis: urodynamic and neurological correlates. Neurourol Urodyn 1998; 17:537–542.

14. Sherburn M & Frawley H. Beyond the pelvic floor: the evidence examined. Aust NZ Continence J 2008; 14:43–44.

15. Chard SE. Community neurorehabilitation: A synthesis of current evidence and future research directions. NeuroRx 2006; 3:525–534.

16. Long AF, Kneafsey R & Ryan J. Rehabilitation practice: challenges to effective team working. Int J Nurs Stud 2003; 40:663–673.

17. Strasser DC, Falconer JA & Martino-Saltzmann D. The rehabilitation team: staff perceptions of the hospital environment, the interdisciplinary team environment, and interprofessional relations. Arch Phys Med Rehabil 1994; 75:177–182.

18. Suter E, Arndt J, Arthur N, Parboosingh J, Taylor E & Deutschlander S. Role understanding and effective communication as core competencies for collaborative practice. J Interprof Care 2009; 23:41–51.

19. D’Amour D & Oandasan I. Interprofessionality as the field of interprofessional practice and interprofessional education: An emerging concept. J Interprof Care 2005; 19:8–20.




Peer review

Pelvic floor muscle assessment in standing and lying position using transabdominal ultrasound: Comparison between women with and without stress urinary incontinence

most common type of incontinence, involving approximately

50% of women with urinary incontinence3. Pelvic floor muscle

(PFM) dysfunction has been commonly associated with the

development of SUI4-8.

The PFM play an important role in supporting the pelvic viscera

and control of their outlets to maintain urinary continence9.

Previous studies have shown that there is a positive relationship

between the increase in PFM function and improvement in

SUI10,11. Therefore, assessment of PFM contraction before and

after treatment has been commonly accepted as an important

parameter in clinical and scientific issues to investigate the

efficacy of treatment programmes12.

In physiotherapy, transabdominal and transperineal ultrasound

are often used to assess PFM contraction13-19. Ultrasound

gives direct visualisation and feedback about PFM contraction

and exercise performance. Using transperineal ultrasound, the

assessor can measure the amount of bladder neck elevation

during PFM contraction13,14. However, the transperineal method

may be unsuitable for use in certain populations, who are unable

Amir Massoud Arab *

Assistant Professor, Department of Physical Therapy University of Social Welfare and Rehabilitation Sciences Evin, Tehran, Iran Email [email protected]

Mahshid Chehrehrazi

PhD candidate,

Isfahan University of Medical Sciences, Isfahan, Iran

Behrouz Parhampour

Seyedolshohada Hospital, Isfahan, Iran



Abstract

The aim of the study was to investigate pelvic floor muscle function in lying and standing positions, using transabdominal ultrasound,

to determine if the difference in positions varies between women with and without stress urinary incontinence. This was a two-way

mixed-design study. Thirty non-pregnant women participated in the study. The subjects were categorised into two groups: continent

and incontinent. The amount of bladder base movement on transabdominal ultrasound was measured in two positions: crook-lying

and standing. The testing position was randomly selected and the mean value of three maximal contractions (normalised to body mass

index) was taken for analysis. The result of two-way mixed-design ANOVA revealed no significant interaction between continence

status and test position for contraction (p=0.60). The main effect of test position on PFM contraction was statistically significant

(p=0.02) but the continence status had no significant effect on bladder base displacement (p=0.11). The amount of difference in two

positions was not significant between two groups (p=0.61). Bladder base displacement in a cranial direction is greater in the standing

position compared to crook-lying position in females, both with and without SUI.

Keywords: Pelvic floor, muscles, ultrasonography, urinary stress incontinence, patient positioning.

Introduction

Urinary incontinence is a major and widespread health-related

problem in women1,2. Stress urinary incontinence (SUI) is the




to tolerate placement of the ultrasound transducer on the

perineum. The location of the probe on the perineum can also

limit some functional manoeuvres. Transabdominal ultrasound

has several clinical advantages and is regarded as being safe,

non-invasive and comfortable for the patient. Another advantage

is that the patient does not need to be undressed. This may be

important in specific populations in which vaginal assessment

might not be desirable. The amount of bladder base movement,

as an indicator of PFM function, can be measured using

transabdominal ultrasound imaging13-17.

Symptoms of SUI (urine leakage during activities) usually occur

in standing position due to the influence of gravity on the pelvic

floor16. However, PFM function is commonly assessed in lying

position. The assessment of PFM contraction in standing position

seems essential for functional evaluation, particularly in women

with SUI whose symptoms are aggravated in this position.

Some studies have investigated the effect of body positions

on PFM assessment16,20,21. These studies used different

designs, testing procedures and sample population. Some

assessed PFM contraction among continent women’s health

physiotherapists21 or healthy university students16 and

found significant difference in vaginal squeeze pressure and

transabdominal ultrasound scores between positions. However,

a study using perineometry found no significant difference in

vaginal squeeze pressure between standing and lying positions

in incontinent women20.

To our knowledge, no study has evaluated the PFM contraction

in standing and lying positions in women with and without SUI

using transabdominal ultrasound. The purpose of this study

was to investigate the difference in PFM function, assessed by

transabdominal ultrasound, in standing and lying positions and

to determine if this difference varies between continent and

incontinent women.

Material and methods

subjects

A total of 30 non-pregnant women between the ages of

25 and 50 years were selected from two hospitals in Iran.

Subjects were categorised into two groups: continent (n=15,

mean age=38.47±5.23 years), and with SUI (n=15, mean

age=41.66±6.44 years). A female urologist referred the women

with symptoms of SUI. Inclusion criteria were willingness to

participate, ability to contract the PFM evaluated by vaginal

palpation, or having experienced urine leakage during coughing,

sneezing, laughing, lifting and any activity that increased intra-

abdominal pressure. Asymptomatic women were subjectively

evaluated by the urologist and found to have no symptoms

of urinary incontinence. Subjects were excluded if they had a

known neurological disease, or a history of pelvic surgery, pelvic

fracture, abdominal scar, significant respiratory disease, pelvic

organ prolapse, urinary tract infection, vaginal infection and

menstruation at the time of assessment. To omit the effect of

training, subjects were excluded if they had PFM training within

the previous two years.

This research was reviewed and approved by the Human

Subjects Committee at the University of Social Welfare and

Rehabilitation Sciences. All subjects signed an informed consent

form approved by the Human Subjects Committee at the

University of Social Welfare and Rehabilitation Sciences before

participating in the study.

Procedures

Transabdominal ultrasound measurement of PFM contraction

was performed in two positions: crook-lying and standing.

The testing position was randomly selected. In crook-lying,

supine position, subjects used one pillow under the head,

with the hips and knees flexed to 60º and the lumbar spine

was positioned in neutral. In standing, participants stood in

a comfortable position, with feet apart at shoulder width and

hands by their sides.

A diagnostic ultrasound imaging unit set in B-mode

(Ultrasonix-ES500, Canada) with a 3.5 MHz curved array

transducer was used for ultrasound measurement. We followed

the procedure described by others13-17 to measure the amount

of bladder base movement as indicator of PFM contraction.

A standardised procedure for bladder filling was used prior

to imaging to ensure that subjects had sufficient fluid in their

bladders to allow clear imaging of the base of the bladder. The

women were asked to void one hour prior to testing and then to

fill their bladder by consuming 600–750 ml of water in half an

hour, one hour prior to testing. The ultrasound transducer was

placed transversely in the midline on the supra-pubic region and

angled in a caudal/posterior direction to obtain a clear image of

the inferior-posterior aspect of the bladder. A marker was placed

on the bladder base on the ultrasound screen at the rest. The

participants were then asked to perform maximal voluntary PFM

contraction; the instructions were to “draw in and lift the PFM,

and hold the contraction while breathing normally”. When the

contraction was visualised on the ultrasound screen, the image was

captured at the point of maximal displacement. The amount of

bladder base displacement from resting position at the end of each




contraction was measured in millimetres (mm). The ultrasound

transducer was not moved during the testing procedure. Only

contractions with cephalic movement of the bladder base were

measured as correct. The ultrasound transducer was not displaced

during the testing procedure and the subjects were not able

to see the ultrasound screen so that the training biofeedback

effect could be omitted. Subjects performed three maximal

contractions. All contractions were held for three seconds, with a

rest of 10 seconds between each contraction. The mean of three

measurements was used for statistical analysis. The reliability of

transabdominal ultrasound measurement for PFM contraction

has been previously established13.

Data analysis

In all subjects, the calculated transabdominal ultrasound

measurement for PFM contraction was normalised to their

calculated Body Mass Index (BMI). There is a considerable body

of literature which shows that body size has a major role in the

muscle performance, strength or function22-26. It is reasonable to

expect that individuals with a higher BMI have stronger muscle

strength. In this study, like our previous study22, the calculated

transabdominal ultrasound measurement of PFM contraction

was normalised to their calculated BMI. The normalised data

were used in analysis.

We tested the difference in PFM contraction between positions

and groups by using two-way, mixed-design ANOVA, accounting

for position (crook-lying versus standing), continence status

(continent or incontinent) and interaction of position and health

status effects. An independent t-test was used to compare the

amount of difference in PFM contraction between positions

(standing minus crook-lying) across women with and without

SUI.

results

The demographic data for the subjects are presented in Table 1.

Statistical analysis showed no significant difference in subjects’

age (p=0.15), height (p=0.28), weight (p=0.56) and parity

(p=0.26) among the two groups. Detailed descriptive statistics

(mean ± SD) for normalised ultrasound measurement and

absolute value of the amount of bladder base displacement (mm)

are presented in Table 2.

The result of two-way, mixed-design ANOVA revealed no

significant continence status by position interaction effect

for ultrasound measurement of PFM contraction at α=0.05

(f=0.28, p=0.60). The main effect of test position on PFM

contraction was statistically significant (f=6.03, p=0.02). Overall,

the movement of the bladder base in a cranial direction,

although not statistically significant, was greater in the standing

position compared to lying in both females with and without

SUI (Table 2). The continence status had no significant effect

on PFM movement (f=2.65, p=0.11). The mean difference in

PFM movement (normalised to BMI) as measured by movement

in the bladder base in a cranial direction between positions was

0.07 and 0.04 for continent and incontinent women respectively.

The amount of difference in positions was not significant

between the two groups (p=0.61).

Discussion

The results of this study indicate that movement of the bladder

base in a cranial direction, although not statistically significant,

was greater in the standing position compared to crook-lying,

regardless of health continence status. This finding is in

accordance with other studies showing a significant difference

in the amount of bladder base displacement during PFM

Variables Continent (n=15) Incontinent (n=15) P-value

Age (years) 38.47 ± 5.23 41.66 ± 6.44 0.15

Weight (kg) 67.20 ± 9.36 69.35 ± 10.52 0.56

Height (cm) 160.53 ± 6.78 158.14 ± 4.72 0.28

BMI (kg/m2) 25.61 ± 3.50 27.52 ± 4.14 0.14

Parity 2.60 ± 0.9 3.06 ± 1.2 0.26

BMI = Body Mass Index

Table 1. Demographic data of the women in each group (mean ± SD).




contraction between standing and lying position, which can be

seen using transabdominal ultrasound16,21.

The lifting of the pelvic floor, as seen via transabdominal

ultrasound, provides information about the functional status of

PFM. Via the ultrasound screen, the elevation of the bladder

base can be seen and is due to the tensioning of the fascia during

PFM contraction27,28.

Investigators have attributed the greater pelvic floor displacement

in standing position compared with lying position to the effect

of gravity. It is assumed that gravity improves the length-tension

relationship of the PFM as a result of the weight of pelvic viscera

that act on the pelvic floor muscles16,21. Additionally, gravity

gives proprioceptive feedback about the correct direction of

contraction and stretch facilitation to the PFM contraction.

It has been suggested that a similar mechanism facilitates

deep abdominal muscle contraction in the four-point kneeling

position, compared with the supine position, for patients with

low back pain who have difficulty activating their deep abdominal

muscles29,30. However, the participants in similar previous studies

were continent women’s health physical therapists21 or healthy

university students16 and those with SUI were not included.

In this study, our data showed that the difference in bladder

base movement between positions, although not statistically

significant, was greater in continent women (0.07) compared to

those with SUI (0.04). The small difference between positions

in incontinent women may be related to the fact that the bladder

base is lower in women with SUI symptoms. One reason for the

lack of difference between SUI and asymptomatic women may

Variable Group Position Difference P-value

Crook-lying standing between positions

Bladder base movement Continent (n=15) 0.19 ± 0.18 0.26 ± 0.25 0.07 0.05

on ultrasound

(normalised to BMI) Incontinent (n=15) 0.11 ± 0.05 0.15 ± 0.06 0.04 0.07

Absolute value of the Continent (n=15) 4.86 ± 3.8 6.65 ± 5.42 1.79 0.04

amount of bladder base

displacement (mm) Incontinent (n=15) 3.02 ± 2.5 4.12 ± 1.97 1.1 0.13

PFM = Pelvic Floor Muscles

BMI = Body Mass Index

Table 2. The (mean ± SD) scores of transabdominal ultrasound measurement for PFM contraction (normalised to BMI) and absolute value of the bladder base displacement (mm) in each position for continent and incontinent women.

be the use of the transabdominal ultrasound method, which

detects movement at the bladder base and not the bladder neck.

Dietz and Clarke31, using transperineal ultrasound, found that

in women with symptoms of lower urinary tract dysfunction,

the resting level of the bladder neck was lower in the standing

position than the supine position.

In transabdominal ultrasound imaging, the measures of pelvic

floor displacement are expressed relative to the bladder base

at rest. The small difference measured between positions in

incontinent women may also be related to the fact that the

position of the bladder base at rest in standing is probably lower

in these women compared to continent women but the resting

level of the bladder base at rest in the supine position is identical

for both group because gravity is not a factor.

One of the limitations of transabdominal ultrasound measurement

is the lack of a fixed bony landmark as a reference point and

measurement of the bladder base displacement is only expressed

relative to a movable starting point rather than an anatomical

landmark, which is used in transperineal ultrasound14.

Two methods of probe placement in transverse or sagittal plane

over the lower abdomen have been offered in the literature13,15.

In this study, the probe was transversely placed on the supra-

pubic region. The value of the transverse view is that it allows

for evaluation of both sides of the pelvic floor at once. Another

advantage is that any pressures by the transducer against the

abdominal wall, and movement of the abdominal wall, are

dissipated by the fluid-filled bladder and so do not affect the

PFM displacement values.




Another limitation in our study is the sample size. We excluded

the subjects with urge or mixed urinary incontinence in order to

assess the correlation in the more homogenous group. However,

power calculation was not done and this could account for lack

of significance.

Conclusion

This study assessed bladder base movement, which is a measure

of one aspect of PFM function in standing and lying positions in

women with and without SUI using transabdominal ultrasound.

Our data indicate that displacement of the bladder base in a

cranial direction, although not statistically significant, is greater

in the standing position than crook-lying.

references1. Bernasconi F, Grasso M, Mantovani M, Luccini E, Arienti S & Cerri

C. Social cost of female urinary incontinence: epidemiology, cost of illness and cost-effectiveness: Urogynaecologia I J 2003; 17:9–46.

2. Parazzini F, Colli E, Origgi G, Suraceb M, Bianchib M, Benzid G & Artibanie W. Risk factors for urinary incontinence in women. Eur Urol 2000; 37:637–43.

3. Ortiz O. Stress urinary incontinence in gynecological practice. Int J Gynecol Obstet 2004; 86:S6–S16.

4. Morin M, Bourbonnais D, Gravel D, Dumoulin C & Lemieux MC. Pelvic floor muscle function in continent and stress urinary incontinent women using dynamometric measurements: Neurourol Urodyn 2004; 23:668–74.

5. Devreese A, Staes F, De Weerdt W, Feys H, Van Assche A, Penninckx F, & Vereecken R. Clinical evaluation of pelvic floor muscle function in continent and incontinent women. Neurourol Urodyn 2004; 23:190–97.

6. Madill SJ, Harvey MA & McLean L. Women with SUI demonstrate motor control differences during voluntary pelvic floor muscle contractions. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20:447–59.

7. Thompson JA, O’Sullivan PB, Briffa NK & Neumann P. Assessment of voluntary pelvic floor muscle contraction in continent and incontinent women using transperineal ultrasound, manual muscle testing and vaginal squeeze pressure measurements. Int Urogynecol J Pelvic Floor Dysfunct. 2006; 17:624–30.

8. Amaro JL, Moreira EC, De Oiliveira Orsi Gameiro M & Padovani CR. Pelvic floor muscle evaluation in incontinent patients. Int Urogynecol J Pelvic Floor Dysfunct 2005; 16:352–54.

9. DeLancey JO. Anatomy and physiology of urinary continence. Clin Obstet Gynecol 1990; 33:298–307.

10. Bø K. Pelvic floor muscle strength and response to pelvic muscle training for stress urinary incontinence. Neurourol Urodyn 2003; 22: 654–58.

11. Amro J, Gameiro M & Padovani C. Treatment of urinary stress incontinence by intravaginal electrical stimulation and pelvic floor physiotherapy. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:204-8.

12. Peschers UM, Gingelmaier A, Jundt K, Leib B & Dimpfl T. Evaluation of pelvic floor muscle strength using four different techniques. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12:27–30.

13. Thompson JA, O’Sullivan PB, Briffa NK, Neumann P & Court S. Assessment of pelvic floor movement using transabdominal and transperineal ultrasound. Int Urogynecol J Pelvic Floor Dysfunct 2005; 16:285–92.

14. Thompson JA, O’Sullivan PB, Briffa NK & Neumann P. Comparison of transperineal and transabdominal ultrasound in the assessment of voluntary pelvic floor muscle contractions and functional manoeuvres in continent and incontinent women. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18:779–86.

15. Sherburn M, Murphy CA, Carroll S, Allen TJ & Galea MP. Investigation of transabdominal real-time ultrasound to visualize the muscles of the pelvic floor. Aust J Physiother 2005; 51:167–70.

16. Kelly M, Tan BK, Thompson J, Carroll S, Follington M, Alicia Arndt A & Seet M. Healthy adults can more easily elevate the pelvic floor in standing than in crook-lying: an experimental study. Aust J Physiother 2007; 53:187–91.

17. Bø K, Sherburn M & Allen T. Transabdominal ultrasound measurement of pelvic floor muscle activity when activated directly or via a transversus abdominis muscle contraction. Neurourol Urodyn 2003; 22:582–88.

18. Dietz H, Wilson P & Clarke B. The use of perineal ultrasound to quantify levator activity and teach pelvic floor muscle exercises. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12:166–69.

19. Dietz H, Steensma A & Vancaillie T. Levator function in nulliparous women. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14:24–26.

20. Bø K & Finckenhagen HB. Is there any difference in measurement of pelvic floor muscle strength in supine and standing position? Acta Obstet Gynecol Scand 2003; 82:1120_24.

21. Frawley H, Galea M, Phillips B, Sherburn M & Bø K. Effect of test position on pelvic floor muscle assessment. Int Urogynecol J Pelvic Floor Dysfunct 2006; 17:365–71.

22. Arab AM, Bazaz Behbahani R, Lorestani L & Azari A. Assessment of pelvic floor muscle function in women with and without low back pain using transabdominal ultrasound. Man Ther 2010; 15:235–239. DOI:10.1016/j.math.2009.12.005.

23. Jaric S. Muscle strength testing: use of normalisation for body size. Sports Med 2002; 32(10):615–31. Review.

24. Aasa U, Jaric S, Barnekow-Bergkvist M & Johansson H. Muscle strength assessment from functional performance tests: role of body size. J Strength Cond Res 2003; 17:664–70.

25. Mannion AF, Adams MA, Cooper RG & Dolan P. Prediction of maximal back muscle strength from indices of body mass and fat-free body mass. Rheumatology (Oxford) 1999; 38:652–5.

26. Markovic G & Jaric S. Movement performance and body size: the relationship for different groups of tests. Eur J Appl Physiol 2004; 92:139–49.

27. Ashton-Miller JA, Howard D & Delancey JO. The functional anatomy of the female pelvic floor and stress continence control system. Scand J Urol Nephrol Suppl 2001; 207:1–7; discussion 106–25.

28. Whittaker JL, Thompson JA, Teyhen DS & Hodges P. Rehabilitative ultrasound imaging of pelvic floor muscle function. J Orthop Sports Phys Ther 2007; 37:487–98.

29. Richardson CA, Jull GA, Hodges PW & Hides JA. Therapeutic exercise for spinal segmental stabilization in low back pain. Scientific basis and clinical approach. Edinburgh: Churchill Livingstone, 1999.

30. Jull GA & Richardson CA. Rehabilitation of active stabilization of the lumbar spine. In: Twomey LT, & Taylor JR, eds. Physical Therapy for the low back. Clinics in Physical Therapy. New York: Churchill Livingston, 1987.

31. Dietz HP & Clarke B. The influence of posture on perineal ultrasound imaging parameters. Int Urogynecol J Pelvic Floor Dysfunct 2001; 12(2):104–6.




Parents describe experiences in KEEA survey

I have been unable to find any literature specific to the impact of

childhood incontinence on the family. There is a small amount

of literature on the effects on the family of children with other

chronic health conditions, for example cystic fibrosis and reflux.

Many of the effects can be extrapolated to the incontinence

context.

Kratz and colleagues1 found that challenges included: “… social

isolation, strained relationships and ongoing frustrations with

health care and educational systems”. Parents would, they

suggest, benefit from: “… being prepared, connecting with

peers, becoming an advocate, developing partnerships and caring

for one’s self.”1 Similarly, Sullivan-Bolyai and colleagues2 suggest

that parents have four main roles that they are expected to

perform when caring for a child with chronic illness: managing

the illness; identifying, accessing and coordinating resources;

maintaining the family unit; and maintaining self.

recommendations for practice

Health professionals can support parents by:

• Keepingup-to-datewithchildren’scontinencebestpractice

so that advice is accurate and empowering.

• Taking time to listen to parental concerns and involve

parents and the family in care planning. Determine who will

be coordinating care.

• Making it clear to parents and family that achieving or

re-achieving continence is a journey, not just a destination –

it will take time.

• Providingrelevantinformationandbeingopentoquestions.

• Referringearlytotheschoolpublichealthnurse,paediatric

outreach nurse, specialist continence nurse, or paediatrician.

• Referring to support services, for example, counselling,

social worker, Work and Income New Zealand (WINZ),

NZCA or CFA.

• Follow-upwitharegularphonecallbetweenappointments

to keep the lines of communication open.

• Putting parents in touch with other parents who have

children with the same problem.

references1. Kratz L, Uding N, Trahms CM, Villareale N & Kieckhefer

GM. Managing childhood chronic illness: parent perspectives and implications for parent-provider relationships. Fam Syst Health 2009; 27(4):303–13.

2. Sullivan-Bolyai S, Sadler L, Knafl KA, Gilliss CL & Ahmann E. Great expectations: a position description for parents as caregivers: Part I. Pediatr Nurs 2003; 29(6):457–61.

Jacqueline BrownNurse Coordinator, Kiwi Enuresis Encopresis Association (KEEA) Children’s Division of NZCA Email [email protected]

In September 2009 a survey was mailed out to the 438 parents and health professionals on the Kiwi Enuresis Encopresis Association (KEEA) Children’s Division of New Zealand Continence Association (NZCA) database. The response rate was low, with only 30 surveys returned, so the data could not be generalised; however, the comments section of the surveys that were returned showed a depth of feeling among those parents who did respond. These comments provide an insight into the wider impact of incontinence on children and their families.

Comments from parents included:

“It [faecal incontinence] has changed my son for the rest of his life, the teasing from other kids, the length of time it took us to get help so we could understand him and help him, the constant negative treatment from being told he had just a behaviour issue. The pressure on the family was huge and I will never look back on this time with a smile, as it was bloody hard work. It should be made so much more aware in schools and also at your local general practitioner (GP).”

“Very stressful on the whole family, our relationship and […] has been bullied and stigmatised at school. All of this and the encopresis itself has affected […] attitude, behaviour and self-esteem. We have been battling for four years and it is exhausting”.

“I’ll never forget what a big impact and stress this soiling problem was in our lives for at least 10 years.”

“ It has affected our family dynamics, my son’s self-esteem and behaviour and my own confidence (and health) as his mother.”

“Confidence destroying on child. Social stigma [is] an issue. Limited support, initially for parents and family going through this. Medical profession is ignorant as to how damaging it is on family and relationships and normal social development of the child.”

“As a family it has been a huge challenge […] her behaviour at home has sometimes just about driven us all mad, and we are never quite sure if it is because she is feeling ‘yuk’ or she is just badly behaved.”

They may be over-representative of parents who are not coping as well as those who chose not to respond. Bias or no bias, there is much work still to be done to adequately support parents and children with wetting and soiling problems.




Vale: Dr Gordon Baron-Hay 26/5/1935 – 26/1/2011A surgeon with a special interest in paediatric surgery, he was one of the first medical students to attend the School of Medicine at the University of Western Australia (UWA).

Gordon undertook his surgical fellowship in Scotland and was admitted for membership of the Royal College of Surgeons. Upon his return to Western Australia he took up an appointment in general surgery at Royal Perth Hospital. He was later offered a position as a paediatric surgeon at Princess Margaret Hospital for Children (PMH), where he continued working until his retirement in 2002.

Many children and families owe him a debt of gratitude for his skilful surgical work, which was lifesaving in a number of cases. Fondly known as “the Baron”, he instilled in his students the need to listen to their patients and he had an incredible skill of never forgetting the names of the children that he had operated on.

As Director of Surgical Services, Clinical Care Unit at PMH he developed an appreciation of the importance of the work conducted by Christine Harkess a continence nurse who had established a successful paediatric nocturnal enuresis program at PMH. Gordon encouraged Chris to train many nurses throughout Western Australia to run the program in their local communities. As a result many Western Australian children have had treatment to successfully overcome their bed wetting problems.

Our sincere condolences to his wife Pat, his family and friends.

Deborah Gordon, CEO Continence Advisory Service of Western Australia

Dr Gordon Baron-Hay, was Patron of the Continence Foundation of Australia (CFA) WA Branch from its inception in 2002 until he died on 26 January 2011. While his initial role with CFA WA was to provide governance for the Home and Community Care funded program – the Continence Advisory Service of WA, when the Continence Advisory Service became incorporated in its own

right as the CFA WA Branch, Gordon assisted in establishing a Board for the new organisation.

He became the inaugural President of the Board, a position he held up until his death. In this role his commitment was tireless and he attended training courses on governance issues, playing a pivotal role in developing governance standards for the Board. He was an irreplaceable guiding light for the Board and had a calm and thoughtful approach to dealing with difficult matters.

He took an active interest in the organisation and, in addition to his role as President, regularly helped out at community events, Continence Awareness Week and was on the Scientific Committee for the Continence Foundation of Australia conference held in Fremantle in 2004.

Born in Western Australia on 26 May 1935, he excelled as a sportsman playing rugby, hockey, golf and tennis and was an avid yachtsman.

Gordon Baron-Hay

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The robert Taylor Memorial Address 2010 19th National Conference on Incontinence 27–30 October 2010 Alice springs, NT

The remarkable story of the Continence Foundation of Australia – an organisation created to tackle the stigma and apathy attached to incontinence

in Australia, lack of services and to develop a broad outline

of what services were needed and a strategy for change.

Through meetings and workshops, it was determined that

there was a great need to develop effective approaches to

the identification, diagnosis, treatment and management of

incontinence throughout the community, particularly for older

and people with a disability.

In June 1988, a five-year grant from the Department of

Community Services enabled the establishment of the National

Continence Secretariat (NCS). Following consultation and

liaison with the emerging State Continence Promotion Groups,

a Constitution was developed. The Continence Foundation

Australia (CFA) was incorporated on 31 October 1989 and the

inaugural Board elected with David Fonda as its Foundation

President. The CFA was officially launched at the second

National Conference on Incontinence in Sydney in November

1989.

1989–1994: running on empty

The CFA Board recognised that its sustainability depended

heavily on its successful interaction with government, at both

state and federal level. Considerable effort was directed to

nurturing these relationships with ever-changing key government

players. Considerable effort was also made to lobby the products

industry to provide unconditional grants to help keep the

organisation afloat. The annual scientific meetings became an

important source of funding via sponsorship by the products

industry. State branches were emerging with lots of enthusiasm

and zeal. Projects of all sorts began to be funded.

Presented by David FondaConsultant Geriatrician and Rehabilitation Specialist Cabrini Medical Centre, Melbourne, VIC Associate Professor Monash Medical School, Melbourne, VIC

For successful progress and evolution, a group should be always

aware of the why and how of its formation and its original

mission and vision. Hence, I present this brief history of the

Continence Foundation of Australia.

1986–1989: the antenatal era

The collaboration of like-minded leaders in the mid-1980s

would prove to be the forerunner of the National Task Force on

Incontinence (NTFI). An informal meeting was held and those

who attended included: the late Robert Taylor (from continence

products company Sancella), Cynthea Wellings, a continence

nurse adviser at Heidelberg Repatriation Hospital, Cliff Picton,

CEO of the Australian Council Of The Ageing (ACOTA),

and Rosemary Calder, Project Officer at ACOTA. Soon the

Australian Council for the Rehabilitation of the Disabled

(ACROD) joined and, not long after, a Continence Working

Party was established with a broad national participation of

medical specialists, nurses, physiotherapists, and representatives

from non-government organisations and government agencies.

In 1986, this group established the NTFI to promote incontinence

as a major health issue in the Australian community. They put

in place processes to document the extent of incontinence




1995 to today

The Board and staff of the CFA have worked tirelessly from its

earliest inception to bring the CFA from a fledgling collaboration

to a more secure and vibrant organisation. A significant leap

forward in the life of the CFA was the implementation of the

National Continence Helpline, a project managed by the CFA

for the Australian Government.

A major outcome following years of CFA lobbying was the

creation of the National Continence Management Strategy

(NCMS) first funded in the 1998 Australian Government

Budget. Under the NCMS more than $50m has been allocated

for a broad range of initiatives in the areas of public awareness,

professional education and research. More than 120 projects

have been funded.

Another significant step was the achievement of peak body

status in 2002, which ensured ongoing government funding,

subject to satisfactory performance. Lobbying for funding for

the Continence Product Scheme, Continence Awareness Week,

leadership on the international front through the International

Continence Society, the national newsletter (Voice) now Bridge,

The Australian Journal of Incontinence, now the Australian and New

Zealand Continence Journal, and the annual National Conference

on Incontinence are just a few of the ongoing activities.

During these 21 years the CFA has reduced the issues of stigma

and taboo that surround incontinence and to do this has required

the selfless work of many of you here today.

At this, the 19th National Conference on Incontinence, our 21st

birthday, the CFA can be proud that its leadership team, Board

and members have never lost sight of the reason for its existence:

to represent the needs and interests of people with incontinence

and those who care for them. The CFA can acknowledge its

considerable achievements, with the hope of celebrating many

more years of partnering with stakeholders to work towards an

increasingly continent community.

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News

Australian news

Bladder Bowel Collaborative

The Directors of the Continence Foundation of Australia (CFA)

are pleased to advise that we have been successful in securing

Australian Government funding under the National Continence

Programme for the delivery of the Bladder Bowel Collaborative

project. The project was approved in late December 2010 and

operates for the period 1 January 2011 to 31 June 2014.

The new programme includes continued funding for the core

activities of the CFA, including the National Continence

Helpline, along with new initiatives such as:

• TheestablishmentofahealthpromotionofficerinVictoria,

New South Wales, South Australia, Queensland and Western

Australia.

• The development of a centralised website for health

professionals to house all continence-related information

(best practice guidelines, resources and so on).

• Abiannualpaediatriccontinenceeducationprogram.

• Use of webinars targeting health professionals working in

rural and remote Australia.

Staff at the National Office of the CFA will work with our

members to deliver programmes specified under our new

funding agreement.

special project helps kids at school

The CFA is undertaking a new project, working in partnership

with health and education professionals, government and peak

bodies, to support children with continence problems within the

school system.

In December 2010, the CFA hosted a Continence in Schools

Stakeholders Forum, which brought together a range of

health and education professionals who play a key role in the

management of incontinence among school-aged children.

Recurring themes identified at the forum include the need

to improve school toilets, better education for teachers about

continence issues and mapping services and resources.

The first phase of the project is now under way, with the

finalisation of strategies and planning, informed by suggestions

provided at the forum. If you would like to receive updates

about the continence in schools project, please e-mail: media@

continence.org.au

Every Body’s Business heads to Canberra

The next Every Body’s Business education forum will be held

in Canberra during March 2011. Aged care and continence will be

the theme of the day, with more details available on our website:

www.continence.org.au

World Continence Week, 20–26 June 2011

In 2011, the CFA will align Continence Awareness Week in

Australia with the International Continence Society (ICS)’s

World Continence Week. This was put to a vote of members

at the CFA’s 2010 AGM and is expected to increase the global

profile of the work being done in Australia, as well as support the

national and international efforts of our colleagues.

World Continence Week 2011 will take place 20–26 June 2011,

with this year’s theme dedicated to Exercise and the pelvic floor.

This topic was selected to support the launch of the Pelvic Floor

First project and will be supported by a range of communication

activities and events in the months leading up to World

Continence Week. CFA members will receive an information

kit during May. If you would like more information at any time,

please email [email protected]

National Conference on Incontinence

The 19th National Conference on Incontinence was held at the

Alice Springs Convention Centre, in the Northern Territory,

27–30 October 2010. Attended by 422 delegates, the programme

featured a range of national and international speakers covering

topics such as the ageing bladder and bowel, nocturnal enuresis,

pelvic pain, dermatological advances in continence care, and

meeting the needs of Indigenous clients in western model health

services.

We thank our international speakers for their contributions:

• Catherine DuBeau, Professor of Medicine and Clinical

Chief of Geriatrics, University of Massachusetts, United

States of America.




• Hans Smola, Professor of Dermatology University

of Cologne and Medical Director, Paul Hartmann AG,

Germany.

• Tryggve Neveus, Secretary General of the International

Children’s Continence Society, Sweden.

• Wendy Bower, Chair, International Continence Society’s

Paediatric Subcommittee, Hong Kong.

Thank you to our members for their continued support of

the national conference. We look forward to seeing you at

the 20th National Conference on Incontinence, at the Crown

Convention Centre, Melbourne, 16–19 November 2011.

Election of Ordinary Director

Under the Constitution of the CFA, one of the three Ordinary

Directors elected by the members retires from office at each

AGM. This year we had three nominations for the vacant

Ordinary Director’s position due to Kay Josephs retiring after

a three-year term and eligible for re-election. The AGM

confirmed the election of Janet Chase to the Board. The CFA

Board would like to thank Kay Josephs for her untiring support

of the CFA and especially for her contribution as a Director

over the last seven years, having been first elected to the Board

in December 2003.

Janet Chase is a physiotherapist whose chosen area of practice

for 30 years has been the treatment of incontinence in women,

men and children. She has a strong interest in incontinence

education. Janet co-wrote the curriculum and set up the

postgraduate continence course for physiotherapists at the

University of Melbourne, that now attracts interstate and

international students. She has worked at Southern Continence

Clinic, Melbourne, for 18 years and continues to do so, and

is also involved in advancing the continence care of children.

She is presently practising in paediatric continence clinics at

Monash Medical Centre, Cabrini Hospital and The Royal

Children’s Hospital. She has undertaken research in both

women’s and paediatric continence care and has published

locally and internationally. Janet has been active in the CFA

since it was established and served on the National Continence

Management Strategy Advisory Committee. She is currently

Chairperson of the CFA Paediatric Advisory Subcommittee,

committee member of the Physiotherapy Group of CFA Victoria

and a Board member of the International Children’s Continence

Society.

Barry Cahill, CEO CFA

New Zealand news

Welcome to 2011. As I write this, the

North Island of New Zealand has had

a storm lashing with some flooding,

but it is nothing in comparison to

the massive flooding experienced by so

many Australians in the last month. We

would like to express our sympathy for

what they have been through there.

We so appreciate the support that the New Zealand Continence

Association (NZCA) receives from the CFA. For a number

of years the Foundation has been very generous in sharing

information resources with us and it has now offered for us to

partner with it in Continence Awareness Week activities.

Originally, New Zealand’s Continence Awareness Week was

the last week in September and in Australia in August. ICS

announced an international week in June several years ago. We

changed our date last year but Australia needed agreement from

the government as their funding body. The CFA will realign

dates this year.

After discussions with the CFA it was decided that we would

work together to develop an awareness programme each year.

ICS does not choose a theme and we have found this is important

to get the media interested, so Australia and New Zealand will

launch the Continence Awareness Week theme Pelvic Floor First

in June. The programme will focus on promoting continence

health in gyms and educating gym instructors. NZCA office

administrator Zoe is currently working on a database listing

every gym in New Zealand.

For the past two years, we have successfully run education days

but we acknowledge that it is important to have the New Zealand

Qualifications Authority (NZQA) recognise our courses. The

way to do this is through a recognised training organisation. We

have partnered with Careerforce to do this. We have developed

the first unit standard at entry level. Eventually the education

will include higher levels of learning. Education at the entry

level will be taught in-house at rest home facilities but as we

move through the levels the NZCA and other organisations will

provide training sessions.

Jan Zander, CEO NZCA




Experts from the disciplines involved in continence treatment, management and promotion and those who are expert in research methods and statistical analysis are invited to nominate to join the Australian and New Zealand Continence Journal Peer Review Panel.

Peer review was introduced to the journal in 2004 and began an exciting new era in our publication. Peer review of articles is aimed to increase the calibre of academic and research papers published and to raise the standing of the journal.

The journal is proud to promote Australian and New Zealand scholarship.

For details regarding the Peer Review Panel, please email Jacinta Miller [email protected]

Nominations sought for Peer review Panel

2011

1–5 MarchSociety for Urodynamic and Female Urology (SUFU) 2011 Winter MeetingArizona Biltmore, Phoenix, Arizona, USAIncludes presentations on: RAND IC Epidemiology Study Update, IC/PBS and urogenital painWeb: www.sufuorg.com/meetings/2011/

14 MarchCourse: Contemporary issues in continence for the advanced practitionerThe College of Nursing, 14 Railway Parade, Burwood NSWWeb: www.nursing.edu.au

18–22 MarchEuropean Association of Urology (EAU) ESU Course 13 Chronic Pelvic Pain Syndromes (CPPS) with special focus on Chronic Prostatitis (CP) and Painful Bladder Syndrome/Interstitial Cystitis (PBS/IC)Vienna, AustriaWeb: www.eauvienna2011.org/home/

24–25 MarchWinds of Change – Council of Children’s Nurses (Inc)Sydney, NSWWeb: http://www.ccnnsw.org.au/2011-conference/

6–8 AprilUnited Kingdom Continence Society

18th Annual Scientific MeetingBristol, UKWeb: http://www.ukcs.uk.net

11–13 AprilNursing for Continence, Module 1Flinders University, Adelaide, SAWeb: http://flinders.edu.au/nursing/studentsandcourses/continuing-education/nursing-for-continence-module-1.cfm

25–29 MayInternational Pelvic Pain Society (IPPS) Annual Scientific MeetingIstanbul, TurkeyWeb: www.ipps2011.org

2–5 JuneThe 1st Asia Pacific Congress on Controversies to Consensus in Diabetes, Obesity and Hypertension (CODHy)Shanghai, ChinaWeb: www.codhy.com/AP/2011/Submission.aspx

Calendar of events

4 June Pelvic Floor Assessment CourseNepean Hospital, SydneyInformation: Maree Yabsley, [email protected]

20–26 JuneContinence Awareness Week Australia and World Continence WeekExercise and the pelvic floorWeb: www.continence.org.au

28 June – 2 JulyIUGA 36th Annual MeetingLisbon, PortugalWeb: www.iuga.org/annual-meetings/iuga-2011

29 August – 2 september41st Annual Meeting of the International Continence Society (ICS)Web: www.icsoffice.org

11–13 OctoberUrogynz 2011 Evidence Based Urogynaecology ConferenceQueenstown, NZInformation: Don Wilson, [email protected]

16–19 November20th National Conference on IncontinenceCrown Convention Centre, Melbourne, VICWeb: www.continence.org.au




16–19 November 2011Crown Conference CentreMelbourne

20th National Conference on Incontinence

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THE NATIONALCONTINENCE HELPLINE

A team of continence consultants providing free and confidential adviceabout bladder and bowel control problems, plus local referrals, free brochures and product information.

A free service for everyone, including all clinicians interested in continence> Supplementary information about

incontinence for GPs, physiotherapists, pharmacists and allied health professionals

> Free brochures and posters available in quantity as client resources – ask for a sample range with the Helpline Order Form

National Continence HelplineFREECALL™

1800 33 00 66Monday to Friday

www.continence.org.au

The Helpline is funded under the Australian Government’s National Continence Management Strategy and managed by the Continence Foundation of Australia

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The Continence Foundation of Australia gratefully acknowledges our 2010

Conference sponsorsPlease support these organisations whenever you can


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• Maintains water and electrolyte balance2,5,6

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• Iso-osmotic2 4-in-1 action4 for a comfortable bowel movement 1. Bulks 2. Softens 3. Triggers Peristalsis 4. Lubricates

• Recommended first line agent for treatment of constipation8

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Norgine Pty Limited (ABN 78 005 022 882) 3/14 Rodborough Road, Frenchs Forest NSW 2086 ® Registered Trademark NORG2748 N-0486 11/10

*Elderly (3), Cardiovascular and / or renal impairment (2) 1. Seinela L et al. Comparison of Polyethylene Glycol with and without electrolytes in the treatment of Constipation in Elderly Institutionalised Patients. Drugs Aging 2009; 26 (8): 703-713 2. Ungar A. Movicol in treatment of constipation and faecal impaction. Hosp.Med.2000; b1 (1); 37-40 3. Merante A et al. Laxative – induced rhabdomyolysis. Clin interventions in Aging 2010: b 71-73 4. MacCara ME. The uses and abuses of laxatives. Canadian Med Assoc Journal 1982; 126: 780 – 782 5. Gruss H-J & Teucher T. Treatment of chronic constipation. Results of a multi-centre observation period on the use of polyethylence glycol 3350 plus electrolytes. Cen Pract 1992; 21 (16): 13 42-50 6. MOVICOL Approved Production Information 20107. Tytgat G N et al. Contemporary understanding and management of reflux and constipation in the general population and pregnancy: a consensus meeting. Aliment Pharmacol Ther 2003: 18; 291-310 8.IMPACT Bowel care for the older patient. A guide to the management of constipation and faecal impaction in the older patient. 2010 developed by a multi-disciplinary team of healthcare professionals with the assistance of an unrestricted grant from Norgine Pty Limited. 3/4 Rodborough Rd Frenchs Forest NSW 2086.

In the treatment of chronic constipation and faecal impaction, the potential for electrolyte imbalance exists,1,2

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MOVICOL maintains a neutral water and electrolyte balance 2,5,6

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*MOVICOL® PBS Information(1) Restricted benefit; (a) Chronic constipation or faecal impaction not adequately controlled with first line interventions such as bulk-forming agents (b) Severe neurogenic impairment of bowel function

(c) constipation in malignant neoplasia (d) patients receiving palliative care(2) Authority required; Palliative care patients where constipation is a problem

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NORG2694_Movicol ContJournal Ad_ART.indd 1 23/9/10 2:45:39 PM
