tag:theconversation.com,2011:/au/topics/incontinence-29189/articlesIncontinence – The Conversation2022-10-19T19:06:35Ztag:theconversation.com,2011:article/1915852022-10-19T19:06:35Z2022-10-19T19:06:35ZRight now, more adult incontinence products than baby nappies go to landfill. By 2030, it could be ten times higher<figure><img src="https://images.theconversation.com/files/490281/original/file-20221018-15512-s2kcro.jpg?ixlib=rb-1.1.0&rect=40%2C26%2C2955%2C1836&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Many parents worry about the <a href="https://theconversation.com/what-other-countries-can-teach-us-about-ditching-disposable-nappies-114604">waste</a> created by <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/291130/scho0808boir-e-e.pdf">disposable nappies</a>.</p>
<p>But while baby nappy waste is well known, there’s a hidden waste stream that <a href="https://www.sciencedirect.com/science/article/abs/pii/S0956053X22003920">our research</a> has found is actually a bigger issue. More adult incontinence products go to landfill than baby nappies in Australia.</p>
<p>Adult incontinence is often underreported and undertreated. The social stigma and lack of access to affordable health support may stop people seeking treatment and instead rely on incontinence products.</p>
<p>As Australia’s population ages, this issue will grow. By 2030, we predict adult incontinence waste will be four to ten times greater than baby nappies. We’ll need to get much better at dealing with the waste issues associated with these products. </p>
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<a href="https://images.theconversation.com/files/490563/original/file-20221019-22-gy6i0u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Baby nappy changed" src="https://images.theconversation.com/files/490563/original/file-20221019-22-gy6i0u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/490563/original/file-20221019-22-gy6i0u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/490563/original/file-20221019-22-gy6i0u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/490563/original/file-20221019-22-gy6i0u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/490563/original/file-20221019-22-gy6i0u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/490563/original/file-20221019-22-gy6i0u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/490563/original/file-20221019-22-gy6i0u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Baby nappies are a well known waste issue. But adult incontinence products now outweigh them as an issue.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<h2>Adult incontinence is common and long-lasting</h2>
<p>The reason these products will soon outstrip baby nappies is because infants usually only need nappies for a couple of years. By contrast, adult incontinence can stay with you for a lot longer – and it can emerge in <a href="https://www.ics.org/education/icspublications/icibooks/6thicibook">many different ways</a>. </p>
<p>How common is adult incontinence? It varies widely. The risk of urinary incontinence increases with age, and women experience higher levels of incontinence compared to men across all age groups. Women over 60 experience the biggest issues, with an <a href="https://www.sciencedirect.com/science/article/abs/pii/S0090429510000191?via%3Dihub">estimated 30% to 63% </a>of women over 65 living with some degree of urinary incontinence. </p>
<p>It’s common for people to manage their incontinence with single-use absorbent hygiene products, an umbrella term for incontinence products for both babies and adults. </p>
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<a href="https://images.theconversation.com/files/490562/original/file-20221019-12-gu4913.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="older couple walking away" src="https://images.theconversation.com/files/490562/original/file-20221019-12-gu4913.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/490562/original/file-20221019-12-gu4913.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/490562/original/file-20221019-12-gu4913.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/490562/original/file-20221019-12-gu4913.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/490562/original/file-20221019-12-gu4913.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/490562/original/file-20221019-12-gu4913.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/490562/original/file-20221019-12-gu4913.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Single use incontinence products offer convenience and normality as we age but produce waste.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>Like baby nappies, adult incontinence products are <a href="https://pubmed.ncbi.nlm.nih.gov/18843748/">usually made from</a> a combination of natural fibres, plastics, glues and synthetic absorbent materials. </p>
<p>What happens to these products after use <a href="https://journals.sagepub.com/doi/10.1177/0734242X20954271">varies around the world</a>, and can range from illegal dumping, to landfill, composting or burning in a waste-to-energy plant. </p>
<p>In Australia, both infant and adult products typically end up in landfill. The problem is, when you deposit organic waste in landfill, it gives off biogas (a mix of methane and carbon dioxide) and leachate, a polluted liquid that can leak through the lining at the bottom of landfills. </p>
<p>Some landfills in Australia are equipped with collection systems for leachate and biogas – but <a href="https://www.dcceew.gov.au/sites/default/files/documents/landfill-survey-data.pdf">not all</a>. Biogas emissions and leachate leaks can still occur even if there are collection systems in place.</p>
<p>Food and garden waste are the main source of biogas and organic contaminants in leachate. While councils look to remove food and garden waste from landfills, our ageing population will contribute more incontinence product waste to them.</p>
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Read more:
<a href="https://theconversation.com/why-we-need-to-talk-about-incontinence-86080">Why we need to talk about incontinence</a>
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<h2>Could we divert adult incontinence products from landfill?</h2>
<p>Right now, we estimate about half of all adult incontinence products used in Australia end up in landfills without biogas collection. </p>
<p>The European Union has moved to <a href="https://environment.ec.europa.eu/topics/waste-and-recycling/landfill-waste_en">ban disposal</a> of untreated organic waste – including these products – to landfill. Because adult incontinence products usually contain plastics, the EU requires them to be incinerated where possible rather than biodegraded. Australia has no such laws for this waste. </p>
<p>Could biodegradable incontinence products tackle the waste issue? Only if there are systems in place to manage the waste and recover the resources. </p>
<p>A recycling pathway for biodegradable incontinence products could include <a href="https://www.epa.gov/agstar/how-does-anaerobic-digestion-work">anaerobic digestion</a> – systems that harness bacteria to take our waste and make useful products such as renewable natural gas and biofertiliser. This waste stream could also be composted, if the temperature rises high enough to kill off any pathogens and recover the resources. </p>
<h2>Problem solving</h2>
<p>This is only part of the solution. Tackling the stigma around incontinence and ensuring access to affordable treatment options could cut the waste stream. </p>
<p>Encouraging manufacturers to use biodegradable materials for both adult and baby incontinence products could enable resource recovery, provided policies, systems and infrastructure are put in place to divert and process the waste. And while this is happening, it’s important these improved incontinence products are accessible and affordable to people who need them.</p>
<p>The reason disposable baby nappies and adult incontinence products have come to dominate the market is simple: they’re convenient, despite the environmental impact. This is especially true for the quality of life for our ageing population. </p>
<p>As our population gets older, we’ll need to rethink this. Let’s bring the issue into the open and talk about it. And let’s find alternative solutions that give people dignity and a better quality of life – while minimising landfill waste and the impact on our environment. </p>
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<strong>
Read more:
<a href="https://theconversation.com/urinary-incontinence-can-be-a-problem-for-women-of-all-ages-but-there-is-a-cure-49365">Urinary incontinence can be a problem for women of all ages, but there is a cure</a>
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<img src="https://counter.theconversation.com/content/191585/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Beth Rounsefell is a Casual Academic at The University of Queensland, and currently works for EDL.</span></em></p><p class="fine-print"><em><span>Emma Thompson-Brewster and Kate O'Brien do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Could we divert incontinence products from landfill? Yes – if we tackle social stigma and access to affordable health services, encourage biodegradable products and introduce supportive waste policiesBeth Rounsefell, Casual Academic, The University of QueenslandEmma Thompson-Brewster, Lecturer, Southern Cross UniversityKate O'Brien, Professor, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1844512022-06-28T02:00:42Z2022-06-28T02:00:42ZMen have pelvic floors too – and can benefit when they exercise them regularly<figure><img src="https://images.theconversation.com/files/469907/original/file-20220621-22-zu5l9t.jpg?ixlib=rb-1.1.0&rect=13%2C41%2C4580%2C3021&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/sick-man-prostate-cancer-premature-600w-791204665.jpg">Shutterstock</a></span></figcaption></figure><p>“Kegels” and pelvic floor exercises are usually associated with “women’s business” – think pregnancy, childbirth, and menopause. But men have pelvic floors too. </p>
<p>Just like women, at various times in their lives men can benefit from training their pelvic floors to address a variety of health concerns. About 30% of men visiting the doctor have <a href="https://www.continence.org.au/incontinence/who-it-affects/men">urinary incontinence</a>, or bladder leakage, but a large majority don’t bring it up. Around 15% of men also experience faecal incontinence, or bowel leakage, and take longer to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4069320/">seek help</a> for it compared to women. </p>
<p>The pelvic floor muscles are also involved in sexual function. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1324914/">Erectile dysfunction</a> affects around 10% of healthy men, and up to almost 40% of men with chronic health conditions, and can be associated with pelvic floor issues.</p>
<p>People sometimes assume these problems are just a normal part of ageing; but common doesn’t mean inevitable. There is often much improvement to be had with some simple strategies – including pelvic floor rehabilitation. </p>
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<h2>Pelvic floor dysfunction in men is really common</h2>
<p>Though pelvic floor problems are <a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2000.tb11669.x">more common in women</a>, one in eight men <a href="https://choose.physio/your-lifestage/adults/mens-health">have issues</a> with their pelvic floor, bladder or bowel. </p>
<p>The pelvic floor is a group of muscles lining the base of the pelvis. For men, this <a href="https://www.continence.org.au/who-it-affects/men/male-pelvic-floor-muscles">supports</a> the bladder, prostate gland and bowel. It is essential in maintaining core stability, bladder and bowel control, and for erectile function and sexual satisfaction. </p>
<p>Most men have little reason to think about their pelvic floor for the majority of their lives, until something goes wrong medically (in comparison to women, who tend to be introduced to pelvic floor exercises much younger, often in the context of pregnancy and childbirth). </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="couple look affectionate in bed" src="https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469908/original/file-20220621-25-eny4r6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Working on your pelvic floor strength might even improve your sex life.</span>
<span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/happy-asian-senior-couple-having-600w-1684173169.jpg">Shutterstock</a></span>
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Read more:
<a href="https://theconversation.com/playing-games-with-your-pelvic-floor-could-be-a-useful-exercise-for-urinary-incontinence-182431">Playing games with your pelvic floor could be a useful exercise for urinary incontinence</a>
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<h2>Why it happens</h2>
<p><a href="https://www.continence.org.au/who-it-affects/men/male-pelvic-floor-muscles">Risk factors</a> for incontinence and pelvic floor problems in men include ageing, prostate issues, pelvic surgery, bowel issues including constipation, chronic coughing, frequent heavy lifting, and being overweight. </p>
<p>Prostate cancer affects up to 15% of men and is the <a href="https://www.wcrf.org/cancer-trends/worldwide-cancer-data/">second most common cancer</a> in men (and fourth most common cancer overall). </p>
<p>The largest source of pelvic floor physiotherapy referrals for men tends to be in the context of prostate surgery. This is because surgery on the prostate gland (which sits very close to the base of the bladder) causes trauma to the nearby structures and nerves that maintain bladder control and erectile function. </p>
<p>However, we know that training the pelvic floor early (starting pre-operatively) means post-operative side effects like incontinence <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7471070/">resolve more quickly</a>. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/prostate-cancer-linked-to-bacteria-raising-hope-of-new-test-and-treatment-181542">Prostate cancer linked to bacteria, raising hope of new test and treatment</a>
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<h2>How can men exercise their pelvic floors?</h2>
<p>To engage the pelvic floor, the sensation should feel like a squeeze, lift and relax of the muscles running between the pubic bone, tailbone, and sit bones. Some popular cues include visualising: </p>
<ul>
<li> stopping urine mid-flow (but <a href="https://www.wellandgood.com/im-a-pelvic-floor-therapist-and-this-is-why-you-shouldnt-stop-your-flow-mid-pee/">not actually doing this</a>)</li>
<li> holding in wind</li>
<li> retracting the penis/testicles</li>
<li> pulling the perineum (skin between the genitals and back passage) away from your underwear.</li>
</ul>
<p>It is important to ensure that the abdominal, gluteal (buttock) and thigh muscles stay relaxed, with breathing maintained throughout. </p>
<p>Exercises can be performed in any position, and if done right, should be able to be done inconspicuously (even when there are other people around!). But it’s quite common to find the exercises difficult to do without some coaching. </p>
<p>Working with a health professional such as a <a href="https://choose.physio/find-a-physio">pelvic floor physiotherapist</a> may be beneficial. Physiotherapists trained in men’s health and pelvic floor conditions will teach clients how to perform exercises correctly. Often they do this with biofeedback devices such as real-time ultrasound imaging that can help identify the right muscles to use and refine technique. </p>
<p>Not all pelvic floor problems require more strengthening. Optimal muscle function requires good strength, but also correct timing, co-ordination and relaxation. </p>
<p>A pelvic floor that is too tight can be problematic, for both men and women, and can contribute to symptoms of pelvic or genital pain, sexual dysfunction, urinary issues including overactive bladder, and bowel problems. </p>
<p>Your specific concerns will inform the way in which your physio might prescribe exercises, but good targets to aim for are to be able to: </p>
<ol>
<li>turn the pelvic floor on and off 10 times in 10 seconds</li>
<li>strongly hold 10 seconds, repeated 10 times</li>
<li>maintain an easy hold for 1 minute.</li>
</ol>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/technology-for-incontinence-hasnt-developed-that-much-since-ancient-egyptian-times-98349">Technology for incontinence hasn't developed that much since ancient Egyptian times</a>
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<h2>If I don’t have pelvic floor problems, do I need to do exercises?</h2>
<p>Like a good gym program keeps you in optimal physical health and helps stave off injuries, it stands to reason that a regular pelvic floor training routine might serve to combat the likelihood of bladder, bowel and erectile dysfunction. However, the literature is scarce for preventative use in asymptomatic men.</p>
<p>Knowing where your pelvic floor is and how to exercise it properly can never be a bad thing – and training might even have some happy side effects, like <a href="https://link.springer.com/article/10.1007/s11934-013-0358-1">reduced waking in the night</a> with the need to urinate, reduced dribbling post-urination, better bowel emptying, and improved sexual satisfaction. </p>
<p>If you are unsure whether pelvic floor exercises are suitable for you or if you’re doing them properly, check in with a trusted health professional.</p><img src="https://counter.theconversation.com/content/184451/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mischa Bongers is the Founder and Principal Physiotherapist at Pelvic Fix Physiotherapy. She is affiliated with CQUniversity as a Sessional Lecturer, Curtin University as a Physiotherapy Clinical Supervisor, and Queensland Health as a Senior Women's Health Physiotherapist. </span></em></p>Knowing where your pelvic floor is and how to exercise it properly can help male incontinence – and might even have some happy side effects.Mischa Bongers, Sessional Lecturer, CQUniversity AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1082062019-01-02T09:11:52Z2019-01-02T09:11:52ZWhy improving access to surgery in childbirth makes economic sense<figure><img src="https://images.theconversation.com/files/251276/original/file-20181218-27758-j579lr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pregnant women waiting to see a doctor at a hospital in Uganda. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Maternal mortality remains high around the world, with more than <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00838-7/fulltext">303,000</a> women dying in pregnancy, childbirth or shortly afterwards. The majority (99%) of these deaths occur in developing countries. More than half of these deaths are in sub-Saharan Africa. </p>
<p>A major reason for this is that women in developing countries have no real access to proper medical care and therefore miss out on the help required for difficult births. About <a href="http://apps.who.int/iris/bitstream/handle/10665/255760/9789241565493-eng.pdf?sequence=1">15%</a> of all women experience severe complications when giving birth. Most of these cases require major intervention, including surgery. In developed countries, emergency surgery ensures that women and their babies survive childbirth, and mothers are spared the severe physical and emotional trauma that often follows a complicated birth.</p>
<p>One potentially devastating complication in childbirth is <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/fistula/en/">obstetric fistula</a>. This usually happens during a protracted or obstructed labour that isn’t given sufficient attention. A hole develops in the birth canal between the vagina and rectum or between the vagina and bladder. An estimated <a href="https://www.who.int/reproductivehealth/topics/maternal_perinatal/fistula/en/">50 000 to 100 000 women </a>in sub-Saharan Africa develop fistula every year. </p>
<p>If women don’t have access to quality emergency obstetric care, the fistula can cause long term damage. This can include incontinence. In turn this can lead to women being stigmatised and isolated from their families and communities among other socio-economic losses.</p>
<p>While conducting <a href="https://www.ncbi.nlm.nih.gov/pubmed/27918334">research</a> in East Africa, I personally witnessed the profound lack of safe anaesthesia. This meant that there was a delay in access to safe and immediate caesarean sections. The lack of access was due to a number of issues. These include few anaesthetists, lack of equipment and emergency drugs, shortage of blood supply and failed referral systems.</p>
<p>In my more <a href="https://academic.oup.com/heapol/article/33/9/999/5106382">recent research</a> I conducted a cost evaluation to see if it made sense to provide women with fistula repair surgery. We looked at it both from the point of view of the long-term cost to women as well as the financial cost. </p>
<p>Our study found that fistula surgery is cost-effective and can significantly reduce disability in women of childbearing age in Uganda.</p>
<p>Our findings were consistent with a previous modelled analysis on the issue in low- and middle-income countries. Increasing access to high quality obstetric and fistula surgery could improve the health of many women in resource-limited settings. </p>
<h2>What we found</h2>
<p>Our study is the first publication on the cost-effectiveness of obstetric fistula repair in the East African region. </p>
<p>We built a model to estimate the cost-effectiveness of vesico-vaginal and recto-vaginal fistula surgery versus no surgery to Uganda’s national health system. </p>
<p>We assessed long-term disability outcomes based on a lifetime Markov model. This involved mapping a sequence of possible events in which the probability of each event depended only on the state attained in the previous event. Surgical costs were estimated by micro-costing local Ugandan health resources. Disability weights associated with vesico-vaginal, recto-vaginal fistula, and mortality rates in the general population in Uganda were based on published sources.</p>
<p>We estimated that the cost of providing fistula repair surgery in Uganda was $378 per procedure. For a hypothetical 20-year-old woman, surgery was estimated to decrease the number of years lost to disability from 8.53 to 1.51. </p>
<h2>What is needed</h2>
<p>Our model found obstetric fistula surgical repair to be the optimal strategy for management of this condition, and one that is highly cost-effective in Uganda. Our study provides data for policy makers to prioritise implementation of this procedure in developing countries. </p>
<p>But this will require significant social and economic attention. The lack of action to date has been because of insufficient political commitment, the low numbers of skilled healthcare providers and the inability to retain skilled birth attendants in priority areas. </p>
<p>Three vital ways to prevent obstetric fistula are to provide access to skilled care during delivery, to closely monitor progress during labour, and to provide emergency caesarean sections. But low and middle-income countries lack sufficient surgeons and resources to treat patients with obstetric fistula. </p>
<p>While the current estimates of the unmet need for fistula surgical repair in low-income countries are not well documented, 10 years ago it was estimated to be as high <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1016/j.ijgo.2007.06.011">as 99%</a>. Therefore, there is an urgent need to strengthen care in low income countries for better maternal and neonatal outcomes. </p>
<p>All this needs to change if countries are going to achieve the goal of making sure that every citizen – whatever their income – has access to universal health care. And priority must be given to investing in medical facilities that are able to provide adequate prenatal care as well as healthy deliveries. Strengthening the option for women to have safe surgery during birth complications would decrease maternal and neonatal morbidity and move closer to the goal of safe motherhood.</p><img src="https://counter.theconversation.com/content/108206/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Isabella Epiu received funding from USA National Institute of Health, World Federation of Societies of Anaesthesiologists, University of California Global Health Institute - Center for Expertise in Women, SONKE Gender Justice.</span></em></p>If women don’t have access to quality emergency surgery, they can develop dibilitating complications such as fistula.Isabella Epiu, MD PhD, Postdoctoral Fellow Global Health, University of California Global Health Institute (UCGHI), Makerere UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/983492018-07-30T16:07:42Z2018-07-30T16:07:42ZTechnology for incontinence hasn’t developed that much since ancient Egyptian times<figure><img src="https://images.theconversation.com/files/228599/original/file-20180720-142411-1tceemj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closeup-young-sick-woman-hands-holding-704812942">Voyagerix/Shutterstock.com</a></span></figcaption></figure><p>Today’s healthcare is full of technology that would seem like science fiction to our grandparents. But this is far from true in every area: some remain woefully neglected by innovation. Hop in a time machine back to ancient Egypt and you would find recognisable examples of the absorbent pads and catheters which are still a mainstay in the management of incontinence today.</p>
<p>The earliest known reference to an absorbent pad dates from 4th-century Egypt: the female scientist <a href="https://www.jstor.org/stable/2975600">Hypatia</a> is recorded as having thrown her menstrual rag at a student to ward off his infatuation with her. The pad remained a homemade “product” for many centuries until the 19th century, when manufactured versions of reuseable “antiseptic cotton for absorbing discharges” could be purchased from pharmacies. Disposable pads, first produced by Kotex in 1920, were in widespread use by the late 1930s. Since then, the only major innovation in their design has been the introduction of <a href="https://www.sciencedirect.com/science/article/pii/S2090123213000969">super absorbent polymers</a> in the 1980s, which have dramatically improved absorbency. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1566&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1566&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1566&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1967&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1967&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228597/original/file-20180720-142408-14vitiw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1967&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Silver catheter.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/ehqvfsjp?query=catheter">Wellcome Collection</a></span>
</figcaption>
</figure>
<p>Again, we can thank the Egyptians for the first records of devices like catheters. These were made of bronze, reeds, straws or curled-up palm leaves that would be inserted into the urethra to drain the bladder. Various versions, mostly made of silver, appeared over the following centuries, but these were predominately rigid devices only suitable for intermittent use until the <a href="https://en.wikipedia.org/wiki/Foley_catheter">Foley catheter</a> was invented in 1929, which provided a solution for long-term use. Despite many drawbacks, such as an increased likelihood of developing urinary tract infections, Frederic Foley’s flexible design is still the most commonly used type of <a href="https://www.nhs.uk/conditions/urinary-catheters/types/#indwelling-urinary-catheters">indwelling</a> catheter worldwide.</p>
<p>Research into this area has long been stagnant, perhaps stalled by the persistent <a href="https://doi.org/10.12968/gasn.2014.12.1.16">stigma</a> surrounding this health condition. Potential researchers who are either unaware of the <a href="https://doi.org/10.1177/0954411918784073">diverse challenges</a> of incontinence, unwilling to battle for traditionally limited funding in this area, or unable to jump the many <a href="https://doi.org/10.1007/s10439-014-1104-7">barriers</a> necessary to translate research advances into clinical benefit. But finally, there are some promising technological developments in continence care.</p>
<h2>Incontinence today</h2>
<p>These are needed. Incontinence is a subject people usually feel too embarrassed to talk about, one they sometimes ridicule, and one the research community rarely considers. Yet such is its impact and prevalence that overlooking it will cost us at economic, societal and personal levels.</p>
<p>We know that <a href="https://doi.org/10.1016/S0020-7292(03)">urinary incontinence</a> effects on average around 28% of females and 10% of males worldwide, while a study in the US in 2009 showed that around 8% of adults endure <a href="https://doi.org/10.1053/j.gastro.2009.04.054">faecal incontinence</a>. Prevalence increases with age but the condition doesn’t only affect adults; about 10% of <a href="http://dx.doi.org/10.1136/adc.2006.098335">school-aged children</a> experience urinary incontinence and about 4% faecal incontinence. Together these conditions account for more than <a href="https://doi.org/10.1111/j.1464-410X.2004.04810.x">2% of the total UK healthcare budget</a> and urinary incontinence alone <a href="https://doi.org/10.1016/S0029-7844(01)01464-8">cost the US</a> over US$16 billion in 1995.</p>
<p>Living with incontinence long term can lead to social isolation and psychological issues, damaging well-being and creating a vicious cycle of care need. In <a href="https://theconversation.com/why-we-need-to-talk-about-incontinence-86080">low and middle-income countries</a> the burden is magnified by <a href="http://eprints.whiterose.ac.uk/131482/">limited access to affordable aids</a> such as fluid absorbing materials or catheters and the need for products that do not increase the strain on municipal waste disposal. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228598/original/file-20180720-142417-h7nw4w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A urine bag (Foley catheter).</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/urine-bag-pee-beside-bed-hospital-103952396?src=Uq2PNkx5GpaGYvD9jD7azg-1-79">Suphatthra olovedog/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Addressing the problem</h2>
<p>While many people today are able to deal with their condition independently, they often resort to using homemade solutions because they are plagued by feeling unable to control their condition <a href="https://theconversation.com/solving-the-toilet-shortage-needs-a-bottom-up-approach-20202">to the level society expects</a>. </p>
<p>Meanwhile, technological care has long been at a standstill. For example, the design of stoma and catheter systems have remained fundamentally unchanged since their introduction. This means that the invasive procedures, poor tolerance and infection issues that characterise them continue to obstruct individual’s daily lives and strain our healthcare systems. </p>
<p>On top of this, little has been done to address diversity. Appropriate provision for different groups, such as school aged children and young adults, remains comparatively scant. Continence pads are the popular choice despite their issues of bulk, noise, efficacy and disposal – they continue to be tolerated simply because better alternatives haven’t been developed. </p>
<p>Faecal incontinence is especially challenging, and here the shortfall runs much deeper. Pads have always been designed primarily for urine so their capacity for containment of faecal matter is profoundly lacking. While anal plugs can be useful, they can’t cope with major episodes. To top it all, nothing really tackles people’s anxiety over smell.</p>
<h2>Promising options</h2>
<p>But there is <a href="http://events.imeche.org/ViewEvent?code=CON6475">growing recognition</a> and action among scientists to develop new technology for continence care. A number of organisations recently collaborated to publish a white paper on <a href="https://doi.org/10.1177/0954411918784073">continence technologies</a>, with the aim of inspiring and guiding new engineering science research. Our paper highlights that there is a wealth of opportunity for innovation spanning basic science, materials and coatings, bioengineering, informatics and smart systems. </p>
<p>For instance, tissue engineering provides opportunities for new procedures to repair damaged bladder or pelvic musculature, and <a href="https://www.bbc.co.uk/news/uk-northern-ireland-31737679">new bioengineered coating technologies</a> are beginning to impact on previously stagnant areas such as catheter performance. In basic science, <a href="https://doi.org/10.1016/B978-0-12-374248-3.00002-1">neuromodulation</a> seeks to directly target the nerve pathways which control continence.</p>
<p>Meanwhile, the remarkable advancements in smart technology are ripe for creative application. Such technologies could, for example, be used to create a new generation of <a href="http://agiledata.org/">agile</a> and personalised data handling software systems which could transform how incontinence is managed and diagnosed. This might make procedures such as <a href="https://doi.org/10.1046/j.1365-2648.2000.01627.x">urodynamics</a> and <a href="http://dx.doi.org/10.1097/MPG.0000000000001595">anorectal manometry</a> less invasive, an exemplary improvement that <a href="http://dx.doi.org/10.1136/bmjopen-2016-015544">undeserved groups such as young adults</a> would benefit from greatly.</p>
<p>Genuine change will require sustained effort and support. Addressing this situation requires <a href="http://www.imeche.org/policy-and-press/reports/detail/incontinence-engineering-innovation-to-enhance-quality-of-life">attention</a> from government, industry, academia and healthcare bodies equally. The main thing everyone else can do to help is <a href="https://theconversation.com/why-we-need-to-talk-about-incontinence-86080">discuss incontinence more openly</a> so that stigma is addressed through awareness and education.</p>
<hr>
<p><em>This piece was written with input from <a href="http://impress-network.com/team/sarah-king/">Sarah King</a>, research manager at IMPRESS, an initiative which aims to encourage more engineers and scientists to work on researching new technologies for incontinence. She is co-author on the <a href="https://doi.org/10.1177/0954411918784073">white paper on continence technologies</a>.</em></p><img src="https://counter.theconversation.com/content/98349/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pete Culmer receives funding from EPSRC (EP/N027345/1) and the NIHR.</span></em></p>The persistent stigma surrounding incontinence has paralysed today’s inventive minds.Pete Culmer, Associate Professor in Surgical Technologies, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/954442018-06-14T20:38:33Z2018-06-14T20:38:33ZShould all women do pelvic floor exercises? We asked five experts<figure><img src="https://images.theconversation.com/files/216067/original/file-20180424-94149-16edwtn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doing them properly is key. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p><a href="https://www.continence.org.au/pages/key-statistics.html">Over a third</a> of Australian women suffer from urinary incontinence, and it’s estimated at least <a href="https://womhealth.org.au/conditions-and-treatments/genital-prolapse-fact-sheet">half of women</a> who’ve had more than one child have some degree of genital prolapse. </p>
<p>Pelvic floor disorders affect many women, and <a href="https://www.thewomens.org.au/health-information/pregnancy-and-birth/a-healthy-pregnancy/the-pelvic-floor">health professionals often recommend</a> exercising the pelvic floor muscles in order to keep them strong to reduce symptoms and prevent disorder.</p>
<p>We asked five experts if all women should be exercising these muscles regularly. </p>
<h2>Five out of five experts said yes</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=99&fit=crop&dpr=1 600w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=99&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=99&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=125&fit=crop&dpr=1 754w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=125&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/216058/original/file-20180424-94145-1s8b3qo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=125&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><strong><em>Here are their detailed responses:</em></strong></p>
<p><iframe id="tc-infographic-265" class="tc-infographic" height="400px" src="https://cdn.theconversation.com/infographics/265/a8d28f39b496b1a291906a67fa31edf2fbe09e89/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<p><em>If you have a “yes or no” health question you’d like posed to Five Experts, email your suggestion to: alexandra.hansen@theconversation.edu.au</em></p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/210303/original/file-20180314-113452-h7un11.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><em>Disclosures: Hannah Dahlen has received funding from the NHMRC and ARC. Victoria Salmon receives funding from the UK National Institute for Health Research (NIHR). The views and opinions expressed in this article are those of the authors and do not necessarily reflect those of the NIHR, NHS or the Department of Health.</em></p><img src="https://counter.theconversation.com/content/95444/count.gif" alt="The Conversation" width="1" height="1" />
If you haven’t had kids you probably haven’t given much thought to your pelvic floor muscles. But 5 out of 5 experts say all women should regularly exercise them.Alexandra Hansen, Deputy Editor and Chief of Staff, The Conversation AUNZLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/944282018-06-05T13:44:43Z2018-06-05T13:44:43ZSuffering in silence: how Kenyan women live with profound childbirth injuries<figure><img src="https://images.theconversation.com/files/221387/original/file-20180601-142083-1j8anm5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><a href="http://vc.bridgew.edu/cgi/viewcontent.cgi?article=1942&context=jiws">Sasha</a> is 22-years-old. She was married off when she was just nine and by the time she was 11, she was pregnant with her first child, and unprepared for childbirth. </p>
<p>So when labour came, in the middle of the night – in her geographically isolated village in rural Kenya – she was unaware of the painful fate awaiting her. </p>
<p>During childbirth, the baby’s head was too big to fit through Sasha’s pelvis, causing the baby to get stuck in her birthing canal. Traditional birth attendants tried their best to help Sasha but they were not skilled enough to handle the complications. She needed surgery, and quickly. But because she could not access emergency obstetric services, she spent the next six days trying to push out the baby that was stuck inside of her. </p>
<p>In the end, Sasha delivered a dead, rotten baby in macerated form. She was not only in grief of her lost child, but was also traumatised by her experience which left her with profound injuries and a double <a href="https://www.ncbi.nlm.nih.gov/pubmed/8873157">obstetric vaginal fistula</a>. </p>
<p>An obstetric vaginal fistula is a tear between a woman’s vagina and another body part – usually caused by obstructed or prolonged labour. It occurs when the baby’s head is trapped against the pelvic bone and cannot descend further. As the labour intensifies, the blood supply is cut and the surrounding tissues die. Shortly after the baby dies and labour continues until the baby is pushed out.</p>
<p>Across the world, there is an estimated <a href="https://www.booktopia.com.au/tears-for-my-sisters-l-lewis-wall/prod9781421424170.html">two million</a> women and girls just like Sasha who live with vaginal fistulas. There are up to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3937166/#B1">100 000 new cases each year</a>. In Kenya, at least 3000 new cases are reported annually but <a href="https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-13-56">research</a> shows that only 7.5% are treated.</p>
<p>But these statistics are bound to be grossly inaccurate
due to under-reporting, poor and non-existent data keeping in most African hospitals. This is made worse by women feeling internalised shame which keeps them from seeking help for their fistulas. It means that the magnitude of the problem on the continent is assumed to be much higher. </p>
<p>Sasha was one of the women I interviewed in <a href="https://www.springer.com/us/book/9789811305641">my research</a> which investigated how Kenyan women with fistulas negotiated the complexities of living with a body that leaks. This included the process of trying to get treatment as well as the journey to recovery from childbirth traumas that rendered their bodies abject, damaged and at times irreparable.</p>
<p>My research revealed a lack of resources and the structural challenges that prevent women from getting the help they need. This is particularly prevalent in remote areas, where access to health services is not available or is very limited.</p>
<p>It also reinforces what <a href="https://www.gfmer.ch/Medical_education_En/PGC_RH_2004/Obstetric_fistula_Kenya.htm">researchers</a> and <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/ajmw.2011.5.2.95">medical professionals</a> in Kenya have established over the years. </p>
<h2>Negotiating the challenges around fistula</h2>
<p>Kenya continues to face enormous challenges as far as dealing with vaginal fistula are concerned. The biggest is the lack of resources to treat fistulas along with a <a href="https://www.reuters.com/article/us-kenya-health-fistula/as-surgeries-triple-kenya-aims-to-end-shame-of-fistula-idUSKBN18L1DN">severe shortage of fistula surgeons</a>. By 2014, Kenya only had three internationally renowned fistula surgeons and less than 10 surgeons who could perform simple obstetric operations.</p>
<p>This has made it logistically impossible to treat all the women who seek treatment every year. It also means that many are left untreated for years adding to the ever increasing backlog.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/221755/original/file-20180605-119853-19yq0q0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women awaiting fistula surgery at the Gynocare Women’s and Fistula Hospital in Kenya, which is the only private facility which specifically treats fistulas for free.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/directrelief/11197145265/in/photolist-i4sibH-i4sXtH-9MdDUt-i4spDd-i4ta9P-i4sodN-i4sYRn-i4sp71-i4t9Yt-i4siDA-i4sk2B-i4t6AL-i4sidq-bsqR9F-9MgyxN-i4sg3e-i4seaM-bsqSpe-i4sfQR-i4tHbH-i4srtA-6YgpYi-i4tefW-i4sYja-i4sk2f-i4t5V8-i4tPb8-i4sozY-i4t6Tj-i4siBn-i4taUf-i4t7wo-i4t7M4-75QQSQ-i4tHVi-i4t5Ww-bVLPEU-i4tcgd-bm1xDN-bm1xCW-6YkrxW-byVqGZ-6YgrpP-6YgryX-i4tQUP-8gTYV2-6Ygqra-i4tezJ-i4t8RZ-i4sQ3o">Direct Relief/Flickr</a></span>
</figcaption>
</figure>
<p>But for most women with fistulas, the damage is not only physical, it’s also psychological. They negotiate rejection and social exclusion on a day-to-day basis which can have severe psychological consequences. This can be more destructive than the actual fistula.</p>
<p>The women I engaged with explained how their fistula diagnosis threatened their social and intimate lives. They explained how having a “leaking body” was constructed as being dirty, deviant and contaminated. </p>
<p>Many described that the way they went about their lives was primarily occupied with finding ways to protect themselves from being “outed” or shamed for the pungent smell that they carried with them.</p>
<p>Their stories revealed the structural and sociocultural challenges that explain why women in Kenya are at risk of developing vaginal fistulas and then having adequate treatment delayed or denied them. This is particularly prevalent in remote areas, where there are transport barriers, impassable roads, and limited or unavailable access to health services or emergency obstetric care. </p>
<h2>Responding to fistulas</h2>
<p>In the last decade, the Kenyan government has initiated a programme under which local health workers train traditional birth attendants working in remote areas to mitigate maternal casualties. But despite the fact that the training includes skills to manage birthing complications, some women require immediate medical intervention. </p>
<p>Kenya also rolled out other public health campaigns to end maternal deaths. One was the <a href="https://www.beyondzero.or.ke/official-launch-of-the-beyond-zero-campaign/">Beyond Zero campaign</a> which was initiated by Kenya’s First Lady, Margaret Kenyatta to raise funds and awareness on issues of safe delivery, and obstetric injuries that lead to vaginal fistulas. </p>
<p>Although the initiative was heavily <a href="https://www.pambazuka.org/food-health/beyond-zero-kenyan-first-lady%E2%80%99s-charity-can%E2%80%99t-cure-healthcare-neglect-and-theft">criticised</a> as an attempt to provide a quick fix to structural problems, it raised national awareness about vaginal fistulas and mobilised resources for free surgeries for women with the condition. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/better-maternal-care-in-africa-can-save-women-from-suffering-in-childbirth-59688">Better maternal care in Africa can save women from suffering in childbirth</a>
</strong>
</em>
</p>
<hr>
<p>The criticism reflects the importance of addressing the underlying causes of fistula. These causes have been summed by one of Kenya’s most renown fistula surgeons <a href="https://scholar.google.co.uk/citations?user=Cku3H4wAAAAJ&hl=en">Dr Weston Khisa</a>, who says</p>
<blockquote>
<p>Medically, fistula is caused by obstructed labour, but the underlying causes are obstructed transport, obstructed family planning, obstructed emergency care, and obstructed human rights.</p>
</blockquote>
<p>Ending fistulas means eradicating both cultural and structural obstacles that put women at risk of developing preventable tragedies such as fistulas. It requires a complete overhaul of health infrastructure in Kenya to ensure that maternal care and women’s reproductive health are prioritised – and that no woman has to lose her life while trying to give one.</p><img src="https://counter.theconversation.com/content/94428/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathomi Gatwiri PhD does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Each year an estimated 100 000 women have complications during childbirth which leave them with obstetric vaginal fistula.Kathomi Gatwiri PhD, Lecturer, Southern Cross UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/911912018-02-14T12:03:05Z2018-02-14T12:03:05ZIncontinence affects more than 200m people worldwide, so why isn’t more being done to find a cure?<figure><img src="https://images.theconversation.com/files/205276/original/file-20180207-74482-i0y468.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=QgLs1Y_X6daOlftRSDWL3w-1-96">Shutterstock</a></span></figcaption></figure><p>For a chronic health condition that causes shame and misery for countless people and costs billions, urinary incontinence keeps a low profile. </p>
<p>Media reports about chronic health conditions appear with alarming regularity, but it is rare to read about the debilitating impact of the involuntary leakage of urine. Nevertheless, urinary incontinence is a condition which, next to Alzheimer’s or strokes, is reported as most negatively affecting “<a href="https://www.ncbi.nlm.nih.gov/pubmed/14608795">health-related quality of life</a>”.</p>
<p>The reasons for this are not too hard to fathom. Urinary incontinence, of course, elicits some embarrassment. And there also seems to be a feeling this is a low priority condition: urinary incontinence does not directly bear up against the terrible impacts of life threatening conditions and illnesses. </p>
<p>But to those who suffer urinary incontinence, it can be a tragedy. This condition is often associated with shame, loss of self-confidence, and low quality of life. It is a condition that increases with older age – approximately <a href="https://www.ncbi.nlm.nih.gov/pubmed/21105895">half of nursing home residents</a> suffer from urinary incontinence.</p>
<p>The financial cost to society is also great. The total cost of urinary incontinence in the US is estimated to exceed US$80 billion by 2020, according to one <a href="https://www.ncbi.nlm.nih.gov/pubmed/24456314">report</a>. <a href="https://www.ncbi.nlm.nih.gov/pubmed/18268289">Another study</a> shows that the treatment costs associated with incontinence in general exceeds those connected to treating pneumonia, influenza and breast cancer. </p>
<h2>Talking about incontinence</h2>
<p>In a collaboration between Lund University in Sweden and Leeds University in the UK, we recently began looking at this subject as part of a <a href="https://www.vbe.lu.se">wider research project</a> on decision making among health experts. </p>
<p>We reviewed the literature on preventions and treatments and interviewed five experts working in this field in Sweden. Three key findings emerged: a general lack of awareness about the condition, a lack of research on its treatments, and challenges around implementation of the research. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205282/original/file-20180207-74487-1bnbty0.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Your pelvic floor muscles are the muscles you use to control the flow of urine as you urinate.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/white-ceramic-male-toilet-127726/">Pexels</a></span>
</figcaption>
</figure>
<p>The experts we spoke to all agreed there was a lack of awareness about urinary incontinence among health care professionals. We heard how many in the health care sector did not always recognise patients who experience problems with urinary incontinence – perhaps because the affliction is considered to be a low priority. And it often didn’t occur to doctors to ask about urinary incontinence at all. </p>
<p>One of the experts we interviewed said:</p>
<blockquote>
<p>Maybe 90% of those with urinary incontinence are managed in primary care, but they are given very little attention.</p>
</blockquote>
<p>And another expert added:</p>
<blockquote>
<p>Finding these patients isn’t easy … Health care providers often say that, no we don’t have any patients with urinary incontinence and then they see that yes, they do…</p>
</blockquote>
<h2>Bladder issues</h2>
<p>Urinary incontinence seems to be especially neglected among the elderly. <a href="https://www.rcplondon.ac.uk/file/nacc-full-organisational-and-clinical-report-national-audit-continence-care-2010">The National Audit for Continence Care</a> found that in primary and emergency care settings in the UK, older people were less likely to have a record of incontinence, despite the fact that the condition becomes more common with age. </p>
<p>Our second key finding was that there is an alarming lack of research into treatments for urinary incontinence. Our interviewees noted that urinary incontinence was simply not an attractive area for study. One expert told us:</p>
<blockquote>
<p>Who does a study on how many times you should help an elderly person to empty the bladder in order to minimise leakage?</p>
</blockquote>
<p>Instead, <a href="http://www.cochrane.org/search/site?f%5B0%5D=im_field_terms_cochrane_library%3A51632">most researchers</a> seem more interested in understanding surgical and pharmaceutical treatments. Yet, in practice, the most common treatments for urinary incontinence typically include incontinence pads and behavioural interventions such as toileting programmes or pelvic floor training. </p>
<h2>Lack of research</h2>
<p>While research on the effectiveness of incontinence treatments is sorely lacking, even less is known about the prevention of incontinence. Pelvic floor training, restricting fluid intake and promoting weight loss are all suggested, but there is simply insufficient research to reliably inform practice. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/205285/original/file-20180207-74512-adhue8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Urinary incontinence in women is a common problem.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=QgLs1Y_X6daOlftRSDWL3w-1-2">Shutterstock</a></span>
</figcaption>
</figure>
<p>While there is some research on toileting programmes and pelvic floor training, it does not provide enough practical guidance about how to implement those strategies, or for how long. One expert explained the impact this can have:</p>
<blockquote>
<p>It is often hard to implement scientific results regarding pelvic training, because the level of detail is too low to actually learn from each other. You need to know how it is done concretely.</p>
</blockquote>
<p>Ultimately, urinary incontinence is a health condition that seriously undermines quality of life. And informed, sensible discussion and dedicated research could go a long way towards raising its profile and ultimately, improving the lives of millions. </p>
<p>But for this to happen, people need to start talking about incontinence. We cannot be shy about a condition that is likely to affect many of us at some point in our lives.</p><img src="https://counter.theconversation.com/content/91191/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annika Wallin receives funding from Riksbankens Jubileumsfond (The Swedish foundation for Humanities and Social Sciences) </span></em></p><p class="fine-print"><em><span>Nils-Eric Sahlin receives funding from Riksbankens Jubileumsfond (The Swedish foundation for Humanities and Social Sciences).</span></em></p><p class="fine-print"><em><span>Wändi Bruine de Bruin receives funding from Riksbankens Jubileumsfond (The Swedish foundation for Humanities and Social Sciences) </span></em></p>The shame of incontinence and why no one wants to talk about it.Annika Wallin, Associate professor in Cognitive Science, Lund UniversityNils-Eric Sahlin, Professor, Lund UniversityWändi Bruine de Bruin, University Leadership Chair in Behavioural Decision Making, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/860802017-11-16T11:57:45Z2017-11-16T11:57:45ZWhy we need to talk about incontinence<figure><img src="https://images.theconversation.com/files/191215/original/file-20171020-13936-1jy9u2x.JPG?ixlib=rb-1.1.0&rect=30%2C1056%2C3971%2C1913&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Claire Scott/Cranfield University</span>, <span class="license">Author provided</span></span></figcaption></figure><p>We rarely hear or speak about incontinence. But the <a href="https://www.ncbi.nlm.nih.gov/pubmed/20025020">condition</a> – the involuntary loss of urine or faecal matter – is frighteningly common. </p>
<p>Incontinence does not know wealth divides. It brings profound personal and socio-economic consequences across the income spectrum and around the world. <a href="https://www.ncbi.nlm.nih.gov/pubmed/19410574">Best estimates</a> reveal that about 8% of adults experience faecal incontinence, increasing to 15% for those over 70 years. Urinary incontinence is even more prevalent, affecting approximately <a href="https://www.ncbi.nlm.nih.gov/pubmed/14499979">24% of men and 53% of women</a> (the condition is more prevalent in women due to strong causative links with childbirth). It is <a href="https://www.ncbi.nlm.nih.gov/pubmed/20617303">equally prevalent in lower income countries</a>. </p>
<p>Incontinence is a symptom which can have <a href="http://www.ics.org/public/factsheets">many underlying causes</a>. It can result from a weakened pelvic floor (often resulting from childbirth), obstetric fistula, cancer, bladder or bowel dysfunction, emotional distress and many other conditions. And it can be traumatising regardless of where you call home. Many cultures consider incontinence to be a taboo topic, not to be spoken about in polite conversation:</p>
<blockquote>
<p>For the majority of my 34 years I’ve kept my daily accidents a secret. Even as a four year old I remember hiding my dirty underwear from my parents.</p>
</blockquote>
<p>This experience, recounted by a person experiencing faecal incontinence in the UK (to our colleagues in the <a href="http://impress-network.com/">IMPRESS Network</a>) is typical, and reveals that the condition affects all ages. Equally, a recent study in <a href="http://impress-network.com/wp-content/uploads/2017/10/Claire-Scott-Thesis-Incontinence-in-Zambia-1.pdf">Zambia</a>, conducted by a Cranfield University researcher, revealed that incontinence is sometimes considered a “curse”, particularly when it is not linked to an obvious causative “trauma” or illness. This results in the condition being more stigmatised for women (as childbirth is perceived as “natural” and not traumatic or an illness).</p>
<p>A similar study in Pakistan, conducted by the London School of Tropical Hygiene and Medicine (but not yet published) asked those experiencing incontinence to take photographs of people and objects that represented their experience. A common theme was photographs portraying the isolation they feel. Often they are excluded from their community, particularly if they are unable to bathe often enough to manage odour.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/194560/original/file-20171114-27573-1qr5ny.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Incontinence can lead to ostracism and loneliness.</span>
<span class="attribution"><span class="source">De Visu/Shutterstock.com</span></span>
</figcaption>
</figure>
<h2>What is normal?</h2>
<p>In both low and high resource contexts, there is confusion around what is “normal” when it comes to continence-related conditions, particularly those caused by <a href="https://theconversation.com/pelvic-floor-training-in-pregnancy-could-help-prevent-the-need-for-barbaric-vaginal-mesh-surgery-76440">childbirth</a> and ageing. </p>
<p>People are often unaware, for example, that appropriate medical intervention could treat or better manage the condition. This can be compounded by non-specialist healthcare professionals dismissing the condition. One British patient we have worked with reported visiting several doctors over a 30-year period before undergoing surgery that has dramatically reduced her urinary incontinence symptoms. She told us: “It has really improved my quality of life.”</p>
<p>But in locations where traditional healers are common, rural Zambia for example, those who experience incontinence (and recognise it as a health issue) may choose to visit such healers, who have not undergone medical training. If these healers are unable to address their concerns, people often simply “give up” on treating the condition at all, preferring to manage it privately and not visit a trained medical practitioner.</p>
<h2>Access is important</h2>
<p>In high income countries, primary treatment of incontinence includes pharmaceutical, surgical and lifestyle modifying interventions. Where the condition cannot be fully treated, management strategies are dominated by disposable products including catheters, colostomy bags and absorbent pads. This can have a severe impact on everyday life, bringing worries about where the nearest public toilet will be and making even short outings stressful, requiring extensive planning. This is exacerbated when those experiencing incontinence are also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3980491/">homeless</a>. </p>
<p>For those with internet access, Google Maps now allows users in some Indian cities to <a href="https://www.guidingtech.com/63154/google-maps-public-toilet-locator-india/">find their nearest public toilet</a>. Extending this facility worldwide would transform lives.</p>
<p>In low income contexts and in <a href="http://www.sphereproject.org/resources/sphere-essentials/">emergencies</a>, those with incontinence often cannot afford treatment or expensive management products (or appropriate infrastructure is not there to deliver it). The previously mentioned studies in <a href="http://impress-network.com/wp-content/uploads/2017/10/Claire-Scott-Thesis-Incontinence-in-Zambia-1.pdf">Zambia</a> and Pakistan both highlighted an affordability issue for those experiencing incontinence, but not necessarily of specialised incontinence aids such as catheters and colostomy bags. Rather, the primary issue was the unaffordability of the soap they required to wash themselves, their reusable pads and their surroundings. Disposable options are often not even a consideration due to their exorbitant cost.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/194561/original/file-20171114-27616-112ec0x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not being able to afford washing powder entrenches stigma around incontinence.</span>
<span class="attribution"><span class="source">Laboko/Shutterstock.com</span></span>
</figcaption>
</figure>
<h2>A complex issue</h2>
<p><a href="http://www.un.org/sustainabledevelopment/blog/2016/01/sanitation-becomes-separate-un-human-right-in-enhanced-fight-against-infection/">Sanitation is a human right</a>. How can we ensure that it is realised for everyone, including those experiencing incontinence? </p>
<p>Incontinence is treated and managed in a variety of ways around the world. But it is never as simple as installing a technology, selling a product or delivering an intervention. Even the most basic of management measures require supply chains, infrastructure and policies. Even where these are in place, affordability and a reluctance to seek medical help can result in many suffering quietly, often tagged with a stigma of being “smelly” or “cursed”.</p>
<p>So perhaps the heart of the challenge, and the solution to better tackling incontinence, lies in raising awareness and understanding. Through <a href="http://www.bladderandboweluk.co.uk/">education</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26555779">public discussion</a>, <a href="http://www.telegraph.co.uk/health-fitness/body/kate-winslet-has-opened-the-floodgates-literally-how-to-cope-wit/">media coverage</a>, better <a href="http://www.bradforddistrictsccg.nhs.uk/news/lets-talk-about-incontinence/">recognition in healthcare</a> and even <a href="http://www.theguardian.com/healthcare-network/2017/aug/10/why-wrote-comedy-show-incontinence-edinburgh-fringe">comedy</a>, we can tackle stigma and reduce social barriers to appropriate healthcare. Furthermore, education can help transform the current burden of postpartum urinary incontinence through better awareness of preventative measures such as <a href="http://www.cochrane.org/CD007471/INCONT_pelvic-floor-muscle-training-for-prevention-and-treatment-of-urinary-and-faecal-incontinence-in-pregnant-women-and-women-who-have-recently-given-birth">pelvic floor training during pregnancy</a>.</p>
<p>We all urinate and defecate every day. <a href="https://data.unicef.org/topic/water-and-sanitation/sanitation/">Two thirds of us</a> have some basic sanitation system that we rely on to help us manage this, and don’t often think about what would happen if we didn’t have such access. But, undoubtedly, there have been instances where you, or someone you care for, has needed to “go” and hasn’t reached these facilities in time. Remembering the inconvenience, perhaps even embarrassment, of these experiences highlights why we need to be more open to discussing incontinence and developing management methods that allow everyone to live happy, productive and healthy lives.</p><img src="https://counter.theconversation.com/content/86080/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dani J Barrington is Editor-in-Chief of Engineers Without Borders, Australia's Journal of Humanitarian Engineering. This article grew out of conversations between Dani and Pete with Zara Ansari (Masters student, London School of Hygiene and Tropical Medicine), Claire Scott (Masters student, Cranfield University) and Sarah House (independent consultant) following a side event that they facilitated together at the WEDC 2017 Conference.
</span></em></p><p class="fine-print"><em><span>Pete Culmer receives funding from UK research councils – EPSRC and the UK National Institute of Health Research (NIHR). He is a member of the iMechE Biomedical Engineering Association.</span></em></p>Incontinence is frighteningly common.Dani Barrington, Lecturer in Water, Sanitation and Health, University of LeedsPete Culmer, Associate Professor in Surgical Technologies, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/810892017-07-19T20:00:15Z2017-07-19T20:00:15ZLatest research shows surgery for early stage prostate cancer doesn’t save lives<figure><img src="https://images.theconversation.com/files/178557/original/file-20170718-21752-1v5r92p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Surgery to remove early-stage prostate cancer has serious side-effects including incontinence and impotence. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>From the 1980s, when prostate screening became available, many men over 40 were diagnosed with early stage prostate cancer even though they may not have had any symptoms. The word cancer understandably strikes fear into the hearts of many, and most would assume the best course of action would be to have the cancer removed, whatever the side effects may be. </p>
<p>But impotence and incontinence are no small side effects, especially when you consider, as two new studies have done, removing the cancer isn’t necessarily the best option, and the cancer may not in fact require treatment at all. </p>
<p>Most prostate cancers take decades to exit the prostate, and most men will usually die <em>with</em>, but not <em>from</em>, prostate cancer. <a href="https://www.ncbi.nlm.nih.gov/pubmed/18304396">Autopsy studies reveal</a> prostate cancer in up to 40% of men in their forties and 65% in their sixties, but a much smaller figure of <a href="http://www.abs.gov.au/ausstats/abs@.nsf/mf/3303.0">3-4% of Australian men actually die of prostate cancer</a> at a median age of 82.</p>
<p>Two recent clinical trials undermine the categorisation of prostate cancer as a death sentence. They are unambiguous in their findings and seismic in their implications. Both found men with early stage abnormalities of the prostate who do not undergo surgery or radiation treatment, but whose condition is monitored for any progression of the cancer, live just as long as men who opted for complete removal of the prostate and now live with its immediate consequences, including incontinence, intimacy issues, bowel problems and intervention regret.</p>
<h2>The hard evidence</h2>
<p>In a <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1606220">UK trial</a>, three groups of men were assigned to either surgical removal of the prostate (553 men), radiation treatment (545 men) or active monitoring (545 men). After ten years, the total number of deaths due to any cause was 55, 55 and 59, respectively in each group.</p>
<p>Thus 90% of men were still alive after ten years, including those who did not receive any radical intervention. Although surgery delayed the development of metastases (or secondary cancers) in a small number of men, the number of deaths definitively attributable to prostate cancer in each of the groups was low, only three, four and seven deaths respectively. So the odds of dying specifically from prostate cancer in the first ten years is of the order of 1%.</p>
<p>In a <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1615869">second study from the US published last week</a>, two groups of men were assigned to either surgical removal of the prostate (364 men) or active monitoring (367 men). After nearly 20 years of follow up, the number of deaths due to any cause was 223 and 245 respectively in each group. So once again nearly the same number of men in each group were still alive after 20 years. </p>
<p>Surgery did not prevent death any more than active monitoring. Strikingly, the number of deaths definitively attributable to prostate cancer in the two groups was only 18 and 22 respectively. This means the odds of dying specifically from prostate cancer in the first 20 years after a cancer diagnosis from a prostate-specific antigen (PSA) test was about 5% for the surgical group and 6% for the active monitoring group.</p>
<p>The survival from prostate cancer is so high it’s not a question of deciding which treatment is best, but whether any early radical treatment is required at all. The current position has been clearly articulated by the Chief Medical Officer of the American Cancer Society Dr Otis Brawley, an expert on prostate cancer screening. <a href="https://apnews.com/00e47efea81e4eb9a12db06cd0ca54da">He points out aggressive PSA screening</a> and treatment has resulted in more than one million American men undergoing needless treatment.</p>
<p>This is not to mention that <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1615869">patients who have undergone surgery</a> are four times more likely to require absorbent pads for incontinence and three times more likely to have erectile dysfunction. These are not issues that are routinely highlighted.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/178600/original/file-20170718-22000-vmszgb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/178600/original/file-20170718-22000-vmszgb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/178600/original/file-20170718-22000-vmszgb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/178600/original/file-20170718-22000-vmszgb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/178600/original/file-20170718-22000-vmszgb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/178600/original/file-20170718-22000-vmszgb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/178600/original/file-20170718-22000-vmszgb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/178600/original/file-20170718-22000-vmszgb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Experts have condemned screening for prompting unnecessary interventions.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<h2>The future</h2>
<p>The latest DNA research has had minimal impact on how to tell whether an early stage prostate cancer will grow slowly or whether it will become aggressive and spread outside the prostate, and lead to death. The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3775342/">current evidence is</a> the future behaviour of any cancer is determined very early, and diagnosing it early and actively monitoring its progress will have no effect on the outcome. </p>
<p>The key problem in searching for genetic and DNA based markers is that most pre-clinical studies focus on human prostate cancer cells in dishes, or in mice. This is far removed from cells growing in a patient. Mice are not small humans and their prostates, hormonal balances, diet and genetics are quite different from our own.</p>
<p>Similarly, while MRI scanning means we can find sites in a prostate gland that are abnormal, we can’t yet distinguish between the potentially dangerous and the indolent cell populations. More research is needed to develop better screening techniques.</p>
<h2>The current implications</h2>
<p>For the moment, the first step must be to educate doctors so they can provide full disclosure to any patient of the results of these two trials. The second step is that in speaking to their own doctors about possible treatment options, patients should be active in asking them about the most up-to-date evidence. Surgery is a big step to take for any condition.</p>
<p>Similar to countless past treatments which the evidence has made redundant – such as lobotomy for mental illness and stomach surgery for ulcers – it’s now clear radical surgery removing the prostate should not be the go-to option.</p>
<hr>
<p><em>I’m pleased to acknowledge my trusted scientific colleague George L Gabor Miklos, Founder of <a href="http://www.atomiconcology.com">Atomic Oncology</a>, for his invaluable advice and input.</em></p><img src="https://counter.theconversation.com/content/81089/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Haines does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many men live with prostate cancer rather than die from it. Here’s the evidence for why they shouldn’t jump to surgery.Ian Haines, Adjunct Clinical Associate Professor, AMREP Department of Medicine, Alfred Hospital, Melbourne & Senior Medical Oncologist and Palliative Care Physician, Melbourne Oncology Group, Cabrini Haematology and Oncology Centre, Wattletree Road, Malvern, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/605962016-07-15T12:19:34Z2016-07-15T12:19:34ZBillions are spent on clinical research that gets ignored – here’s the answer<figure><img src="https://images.theconversation.com/files/130048/original/image-20160711-9295-1reuklr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Worth the effort?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=health%20research&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=341386256">Paradise Picture</a></span></figcaption></figure><p>Heart failure is a major killer, <a href="https://www.nice.org.uk/guidance/cg108/chapter/introduction">affecting</a> well over a million people in the UK alone. We now have over 20 years’ worth of evidence from clinical trials that show strong benefits for a package of treatment involving not only drugs and devices but also where patients stay, how they are cared for and how the different healthcare professionals work with one another. Yet in many cases, doctors <a href="http://www.ncbi.nlm.nih.gov/pubmed/21159794">are not</a> acting on the findings. </p>
<p>This is just one example of a major problem in healthcare across the world. Billions of pounds are spent each year researching clinical treatments, but a staggering <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140673609603299/fulltext?rss=yes">85% of all research ends up</a> not being put into practice – much of it passed over for reasons that could be avoided. Even when research findings are taken up by clinicians and those in charge of health policy, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22179294">the average delay</a> between publication and practice is 17 years. </p>
<p>The more medical conditions you consider, the more examples crop up. Research into a new care package for chronic kidney disease <a href="http://fampra.oxfordjournals.org/content/early/2016/06/12/fampra.cmw049.abstract">was shown</a> to be effective, for example, but it is not implemented by GPs because they are struggling to prioritise it over other conditions and competing demands.</p>
<p>Or take Bell’s palsy, a condition where muscle weaknesses cause a sufferer’s facial features to droop on one side. Many patients are not <a href="http://bmjopen.bmj.com/content/3/7/e003121.short">being given</a> the treatment shown in trials to be the most effective. In lung cancer of the non-small cells, meanwhile, a new radiotherapy treatment <a href="http://www.ncbi.nlm.nih.gov/pubmed/10577699">has been proven</a> to be a better cure than conventional radiotherapy. Yet it is not widely given because of doctors’ preferences and the practicalities of providing it in hospitals. </p>
<h2>Trials and context</h2>
<p>So what’s the problem? This gap between evidence and practice has produced a whole field of research in its own right called <a href="http://implementationscience.biomedcentral.com">implementation science</a> or knowledge transfer, which has identified various issues. Some trials <a href="https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-015-0917-5%20Pearce%20et%20al">are not</a> of high enough quality. This can be for any number of reasons including problems with the way participants are selected, conducting the wrong trials or conducting the right trials the wrong way. </p>
<p>Other trials are <a href="http://www.economist.com/news/science-and-technology/21659703-failure-publish-results-all-clinical-trials-skewing-medical">not published</a> because they did not produce a result in favour of the new treatment being tested. Initiatives such as the <a href="http://www.alltrials.net/">All Trials campaign</a> aim to get all trials registered and their results published so that we can see the full picture, not a distorted one.</p>
<p>Yet this won’t solve everything. This is because one of the biggest problems, which has perhaps not received enough attention in the past, is that research findings are frequently much less meaningful to clinicians and policymakers in the real world than they could be. </p>
<p>Trials <a href="http://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-13-95">don’t collect</a> sufficient information about the context in which they were conducted, or about how contextual factors affected the results. So outside the direct trial setting, the results can either be less useful or it <a href="http://bmcmedresmethodol.biomedcentral.com/articles/10.1186/1471-2288-11-79">can be</a> hard to judge whether they will be useful or not.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=722&fit=crop&dpr=1 600w, https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=722&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=722&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=908&fit=crop&dpr=1 754w, https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=908&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/130049/original/image-20160711-9267-1qzmg3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=908&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Never simple.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=fWFKwxQHilRDHgQfoDh61A&searchterm=medication&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=392709652">Jaroon Magnuch</a></span>
</figcaption>
</figure>
<p>Even a seemingly simple switch from one pill to another can stumble because of things like its cost and availability, patient preferences, or beliefs among staff as to the benefits of the old drug. And when it comes to complex team-delivered treatments such as surgery or rehabilitation, the scope for context to matter increases enormously. </p>
<h2>The need to look closer</h2>
<p>Many <a href="http://trialsjournal.biomedcentral.com/articles/10.1186/1745-6215-14-15">specialists believe</a> the answer is to run separate studies alongside clinical trials that aim to understand their context, their processes and
all the relevant variables that come into play. These are expensive, though not prohibitively so, and <a href="http://www.trialforge.org/">work is going on</a> into how to make them cheaper. The UK Medical Research Council last year <a href="https://www.mrc.ac.uk/documents/pdf/mrc-phsrn-process-evaluation-guidance-final/">published guidance</a> on how such studies should be conducted. </p>
<p>One thing lacking from this guidance, however, was much explanation of how context should be explored in these studies. This is because we’ve yet to fully understand the problem. An <a href="http://bmjopen.bmj.com/content/5/12/e009993.abstract">overview of 70 reviews</a> looking at why GPs and other professionals in primary care don’t put research findings into practice recently concluded that future research needs to concentrate on how and why contextual factors play a part. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=393&fit=crop&dpr=1 600w, https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=393&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=393&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=494&fit=crop&dpr=1 754w, https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=494&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/130051/original/image-20160711-9292-1q0wptz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=494&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">GP’s perspective still poorly understood.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&search_tracking_id=fWFKwxQHilRDHgQfoDh61A&searchterm=medication&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=323840159">Nonwarit</a></span>
</figcaption>
</figure>
<p>There also appears to be another obstacle. There is growing pressure to prioritise funding for research that has the greatest impact on clinical care. Methodology research into the context problem doesn’t have an immediate impact on clinical care, which makes it harder to attract funding. It currently attracts only a small part of the <a href="http://www.hrcsonline.net/pages/uk-health-research-analysis-2014">overall budget</a> for healthcare research. </p>
<p>The paradox is that until we properly understand how context influences trials, their results will continue failing to achieve their potential impact on clinical care. In other words, 85% of research will continue to be wasted. When the alternative is that millions of people do not get the best treatment available, the only logical move is to make this a top priority.</p><img src="https://counter.theconversation.com/content/60596/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aileen Grant has received funding from NHS Research Scotland, part of the Chief Scientist’s Office, The Tayside Centre for Academic Sciences, NHS Tayside and NHS Lothian. The views in this piece are entirely her own. </span></em></p><p class="fine-print"><em><span>Mary Wells has in the past received funding from Chief Scientist Office, Macmillan Cancer Support, Cancer Research UK, World Cancer Research Fund, Tenovus Scotland, Dundee Cancer Centre, University of Dundee, Tayside Oncology Fund, Big Lottery Fund, NHS Tayside and Molnlyke Healthcare. </span></em></p><p class="fine-print"><em><span>Shaun Treweek has received funding from the Chief Scientist's Office, European Union, National Institute for Health Research, Medical Research Council and the University of Aberdeen’s Development Trust.
</span></em></p>Some 85% of research into drugs and treatments ends up on the cutting room floor but not all of that should.Aileen Grant, Research Fellow, University of StirlingMary Wells, University of StirlingShaun Treweek, Professor of Health Services Research, University of AberdeenLicensed as Creative Commons – attribution, no derivatives.