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Incontinence Types, Treatments, & Prevention

 

Incontinence is an embarrassing condition that anyone could experience at any age however, it is more frequent in older people. There are two types of incontinence fecal or bowel and urinary. Now we are going to learn together what incontinence is, how to deal with it, and how to prevent yourself from getting this condition.

Urinary Incontinence (UI)

What is urinary incontinence?

It is the leakage of urine unintentionally or loss of bladder control that affects millions of people around the world whatever their age is. It could be minor leakages like passing out some droplets of urine or total leakage.

What are the symptoms of Urinary Incontinence?

All of the patients experience the same symptom which is urine leakage but they differ in grades or severity of the condition. Some people experience passing some droplets of urine while others experience complete evacuation of their bladder unintentionally.

What are the Causes of Urinary Incontinence?

Urinary incontinence is considered a symptom that results from other diseases or a daily habit or specific medications. There are reasons that could lead to temporary urinary incontinence and other reasons that cause persistent urinary incontinence.

Temporary Urinary Incontinence

Causes of temporary urinary incontinence that may act as diuretics that stimulate your bladder for frequent urination are:

  • Certain drinks such as alcohol, caffeine, carbonated drinks, sparkling water, and artificial sweeteners
  • Certain foods such as those high in spice, sugar, or acid, especially citrus fruits, chocolate, chili peppers
  • Some medications such as heart and high blood pressure medications, sedatives, muscle relaxants, and high doses of vitamin C
  • Certain medical conditions such as urinary tract infection that could irritate your bladder and increase the urge to urinate. Also, constipation could result in urinary incontinence as the bladder and the rectum share many nerves so the presence of impacted feces in your rectum will make the nerves to be overactive.

Persistent Urinary Incontinence

Causes of Persistent urinary incontinence are:

  • Pregnancy: during pregnancy, the woman experiences many hormonal changes in addition to the weight of the fetus that makes pressure on the mother’s bladder resulting in stress incontinence.
  • Age: as we become older, our bladder's capacity to store urine decreases as well as involuntary contractions of the bladder increases.
  • Menopause: estrogen is responsible for keeping the lining of the bladder and urethra healthy. After menopause, the estrogen levels decrease which increases the risk of getting urinary incontinence
  • Low testosterone levels in women
  • Childbirth: vaginal delivery can weaken pelvic floor muscles and sometimes damage bladder nerves and supportive tissue resulting in prolapsed pelvic floor and incontinence.
  • Hysterectomy: it is a procedure for removing the uterus. The bladder and uterus are sharing many muscles and ligaments that support them. Any mistake during the operation could damage the supporting pelvic floor muscles leading to urinary incontinence
  • Enlarged prostate (Benign prostatic hyperplasia): usually older men suffer this condition leading to overactive bladder and urinary incontinence.
  • Prostate cancer: urinary incontinence could be a result of untreated prostate cancer or as a side effect of prostate cancer medications
  • Obstruction: obstruction of the urinary tract by urinary stones or tumor can cause overflow urinary incontinence.
  • Neurological disorders such as multiple sclerosis, Parkinson's disease, a stroke, a brain tumor, or a spinal injury can affect brain signals of the bladder leading to urinary incontinence.

What are the types of Urinary Incontinence?

Urinary incontinence types are as follows:

  1. Stress incontinence: here the incontinence is a result of anything that exerts pressure on the bladder such as pregnancy, lifting something heavy, exercising, coughing, sneezing, and laughing
  2. Urge incontinence: it is a sudden, intense urge to urinate to the extent that you can’t sometimes reach the toilet.
  3. Overflow incontinence: you experience frequent urine leakage due to the incomplete evacuation of the bladder
  4. Functional incontinence: any physical disability or mental impairment that makes you unable to reach the toilet in time or unbutton your pants quickly enough.
  5. Mixed incontinence: here you experience more than one type of incontinence.

What are the risk factors of urinary incontinence?

Risk factors of urinary incontinence are factors that make you at a high risk of getting the condition such as

  • Gender: Both men and women can experience incontinence but they differ in the type of incontinence. Women are more vulnerable to stress incontinence due to pregnancy, menopause, and childbirth while men with prostate problems are more vulnerable to overflow incontinence.
  • Age: as you get older, the muscles of the bladder become weak with increased chances of involuntary bladder contractions and decreased urine storage capacity.
  • Obesity: excess weight could exert pressure on the bladder making you at a high risk of developing urinary incontinence with cough or sneezing.
  • Smoking: there is some evidence that smoking is a risk factor of urinary incontinence because smoking can irritate the bladder as well as produce coughing that will make the stress incontinence worse.
  • Some medical conditions: neurological diseases and diabetes may increase the risk of urinary incontinence
  • Family history: if someone in your family suffers urinary incontinence, you may have a high risk of developing the condition.

How could doctors diagnose Urinary Incontinence?

The doctor will take your history and make a physical examination to determine the cause and type of incontinence to prescribe the proper treatment then you may be asked to make some tests such as

  • Urinalysis: by checking your urine sample for infection, traces of blood, or other abnormalities.
  • Bladder diary: you will be asked to write down how much fluid you drink, how many times you urinate, the amount of urine you produce, the number of incontinence episodes, and if there is urging in urination or not.
  • Post-void residual measurement: the doctor will ask you to urinate in a container that measures urine output then your doctor will measure the amount of leftover urine in your bladder using a catheter or ultrasound test. The more leftover urine, the higher chance of having urinary tract obstruction or a problem with your bladder nerves or muscles
  • urodynamic testing and pelvic ultrasound: these tests are usually done if you are going to have surgery.

 

What about Urinary Incontinence treatment?

If there is an underlying problem causing urinary incontinence, it has to be treated first. The treatment of urinary incontinence includes many options as illustrated in the following chart

 

Now, it is time to discuss every treatment in details

Medications

The commonly used medications are:

  • Anticholinergics: such as oxybutynin (Ditropan XL), and tolterodine (Detrol). The anticholinergics act on the overactive bladder to reduce the urge incontinence by relaxing the bladder and reducing its overactivity.
  • Mirabegron (Myrbetriq): this medication helps treat the urge incontinence by relaxing your bladder muscles, increasing your bladder storage capacity of the urine, and increasing the efficacy of your urination through the complete evacuation of the bladder so there won’t be leftover urine.
  • Alpha-blockers: such as tamsulosin (Flomax), doxazosin (Cardura), and terazosin. Alpha-blockers help treat urge and overflow incontinence in men as they relax the bladder neck as well as prostate muscles.
  • Topical estrogen: those are topical estrogen creams, rings, or patches used for women to apply them in the vaginal and urethral areas in low doses to rejuvenate and strengthen them. Be careful that estrogen pills are not recommended in urinary incontinence as the condition may become worse.

Exercises

The doctor will tell you about some exercises to increase the strength of your pelvic floor muscles, and also may recommend you to see a physiotherapist for additional exercises and biofeedback techniques. One of these exercises is the Kegel exercise.

Kegel exercise: this exercise is performed to increase the strength of pelvic floor muscles that control urination. It is effective in stress incontinence more than any other type but also may help in urge incontinence too.

How to be performed?

Step 1: By using the muscles of your pelvic floor that you normally use to stop urination

Step 2: Contract those muscles for five seconds

Step 3: Relax for five seconds

Step 4: By the time, try to increase the contraction period gradually

Step 5: Perform this exercise three times daily and each time do ten repetitions

To learn more about Kegel exercise, watch this video from Michigan Medicine

 

Behavioral techniques

Your doctor may recommend the following techniques to help you deal with the condition

  • Bladder training:
    Bladder training is performed by delaying the urination when you feel the urge by holding off for 10 minutes. The goal is to decrease the frequency of going to the toilet to be only every 2.5 to 3.5 hours.
  • Double voiding: perform this technique by urinating, then waiting a few minutes and trying again to train the bladder to be evacuated completely. It helps mainly in overflow incontinence treatment.
  • Scheduled toilet trips: it means to set certain timing to urinate such as going to the toilet every 2 or 3 hours rather than waiting for the feeling of the urge
  • Fluid and diet management: by avoiding alcohol, caffeine or acidic foods in addition to reducing fluids consumption

 

Interventional therapies

  • Electrical stimulation: This procedure is done by inserting electrodes into your rectum or vagina temporarily to stimulate and strengthen pelvic floor muscles. The number of sessions depends on the severity of the case and the type of incontinence. Minor electrical stimulation can have a rapid positive effect on stress incontinence.
  • Urethral insert: It is a tampon-like device that is inserted into a woman’s urethra to act as a plug to prevent urine leakage. It is disposable and is inserted temporarily, just before certain activities that could trigger incontinence such as exercising
  • Pessary: it is a rigid ring that is used in cases of prolapse causing urinary incontinence. The device is inserted into a woman’s vagina to be worn all day. The urinary bladder lies near the vagina, so the pessary could hold the bladder thus prevent incontinence.
  • Bulking material injections: your doctor will inject a synthetic bulking agent into the urethra’s tissue to help close the urethra and prevent leakage of urine. The injections need to be repeated regularly for better results However, it is appeared to be less effective than surgery in case of stress incontinence.
  • Botulinum toxin type A (Botox): the injection of Botox into the urinary bladder may benefit patients with overactive bladder but doctors use this option eventually if other medications did not make a progress. In our bladder, we have a muscle called (detrusor muscle). When the detrusor muscle is relaxed, your bladder can store urine but if it is contracted, you will feel the urge to urinate and empty the bladder. The Botox will be injected into the detrusor muscle causing peripheral denervation to decrease the incontinence episodes.
  • Nerve stimulators: this is a device that produces painless electrical pulses to stimulate your sacral nerves-nerves of bladder control- to reduce urge incontinence. The device will be implanted under the skin of your buttock, it may be connected to wires on the lower back or to a special device inserted in the vagina. The doctor may use this option if other therapies did not work.
  • Pads and protective garments: these are products that help you deal with incontinence comfortably without embarrassment. For example, men can use a drip collector to collect the dribbles of urine leaked, it is worn over the penis and held in place by close-fitting underwear.
  • Catheter: it is a soft tube that is inserted into the urethra to get rid of the leftover urine if your bladder doesn't empty properly. The doctor will teach you how to perform the procedure and how to clean the catheter

 

Surgery

If other therapies did not work, you might opt for surgery to treat the cause of the incontinence such as

  1. Sling procedures: it is a process used for treating stress incontinence. The goal is to help keep the urethra closed, especially when you cough or sneeze. The doctors will make a pelvic sling around your urethra and bladder neck, this sling is strips of your body's tissue, synthetic material, or mesh.
  2. Bladder neck suspension: this process is used to add support to the urethra and bladder neck. The doctor will make sutures in vaginal tissue near the neck of the bladder and attach them to ligaments near the pubic bone.
  3. Prolapse surgery: it is a procedure for correcting the prolapse. In the case of women with mixed incontinence and pelvic prolapse, they will require a sling procedure and prolapse surgery
  4. Artificial urinary sphincter: it is a small, fluid-filled ring that is implanted around a man’s bladder neck to help keep it closed thus prevent urine leakage. When you want to urinate, you are going to press on a valve that is implanted under your skin, then the ring will be deflated allowing the urine to pass.

What are the complications of Urinary Incontinence?

Chronic urinary incontinence could lead to the following complications

  1. Urinary incontinence causes wet skin that will be at high risk of infections, rashes, sores, and dermatitis
  2. Urinary tract infections
  3. Impacts on your social life, you will be introverted because of the feeling of embarrassment and the fear of being bullied.

What about prevention?

Urinary Incontinence cannot be prevented completely However, the following steps would reduce your risk of getting the condition

  1. Avoid obesity
  2. Practice pelvic floor exercises daily
  3. Avoid foods that could irritate your bladder such as caffeine, alcohol, and acidic foods
  4. Quit smoking
  5. If you suffer urinary stones or any urologic infection, see your doctor at once to get the right treatment
  6. Avoid having constipation by eating some fibers and using laxatives

Is there a relationship between Urinary Incontinence and nutrition?

YES, what you eat or drink can control your incontinence or make it worse, here is some advice for you to know what you should avoid and consume

  • You should avoid:
  1. Caffeinated drinks such as coffee, colas, energy drinks, and teas
  2. Acidic fruit juices, especially orange, grapefruit, and tomato
  3. Alcohol
  4. Carbonated beverages, sodas, or seltzers
  5. Drinks with artificial sweeteners, such as aspartame and saccharin as they may irritate the bladder
  6. Citrus fruits (lemons, limes, oranges, and grapefruit), tomatoes, and tomato products (like tomato sauce or salsa)
  7. Spicy foods as may affect the bladder negatively
  8. Salty foods such as Potato chips, salted nuts, and other salty foods, they will make you thirst and drink more water then finally you will have a full bladder. Also, salty foods cause water retention in your body which worsen the incontinence
  9. High carbohydrate foods:
    The Korea National Health and Nutrition Examination Survey data said that high carbohydrate intake could be related to urinary incontinence, they gave us two explanations for this theory.
    The first one is that high carbohydrate intake is related to obesity which is a risk factor for urinary incontinence. The second one is when you eat high carbohydrate foods such as white rice, your blood glucose will be high (hyperglycemia). Acute hyperglycemia produces free radicals that might cause fat deposition in your arteries (atherogenesis) that impairs the dilation of blood vessels so your pelvic floor won’t get enough oxygen (hypoxia). This chronic hypoxia could lead to urinary incontinence 
  • Prebiotics and probiotics

             Prebiotics and probiotics have been proven to improve the urinary tract microbiome that could prevent urinary incontinence and other urologic disorders according to this research. You can find probiotics in fermented foods such as plain Greek yogurt, cheese, and a drink called Kefir or as supplements. Foods that are good sources of prebiotics are Dandelion greens, Garlic, Chicory root, Onions, Jerusalem artichokes, Whole oats, and Apples.

 

 

 

Fecal Incontinence (Bowel Incontinence)

What is Fecal Incontinence?

Fecal incontinence or bowel incontinence is the leakage of feces involuntarily due to the inability to control bowel movements.

What are the symptoms of bowel incontinence?

All patients experience the passage of feces unintentionally. It could be temporary accompanied by bloating, diarrhea, constipation, or recurring due to the presence of another condition that leads to bowel incontinence.

 

What are the causes of Bowel Incontinence?

Fecal incontinence could be present due to many reasons such as the following:

1. Muscle damage: Damage to the anal sphincter muscles that could happen during childbirth, this makes the woman unable to hold stool back properly.

2.  Nerve damage: Damage to the nerves of the anal sphincter or those that sense stool in the rectum. This damage occurs as a result of childbirth, constant straining during bowel movements, spinal cord injury, diabetes, and multiple sclerosis.

3.  Chronic constipation: this leads to the formation of dry, hard, and a large mass of feces in the rectum that tends the rectum to stretch. Recurrent stretching of the rectum will weaken its muscles allowing watery stool from the digestive tract to come around the impacted feces and eventually pass out

4.  Diarrhea: loose stool could leak out easier than impacted one and this makes the bowel incontinence worse.

5.  Hemorrhoids: hemorrhoids is the swelling of rectal veins that could hinder the anus from closing completely leading to passing out of the stool.

6.  Loss of storage capacity in the rectum: this means that your rectum can’t stretch as usual to accommodate stool. This may occur due to surgery, radiation treatment, or inflammatory bowel disease.

7.  Rectal prolapse: it is when your rectum drops down into the anus causing stretching of the rectal sphincter that damages the nerves which control the rectal sphincter. If it is not treated as soon as possible, the condition could be permanent

8.  Rectocele: it is the protrusion of the rectum through a woman’s vagina

What are the types of bowel incontinence?

1. Urge incontinence: when you feel the urge to defecate but the stool leaks out before reaching the toilet

2. Flatus (wind) incontinence: when you feel that your rectum is full but you can’t distinguish if it is stool or wind.

3. Passive incontinence: when the patient is unaware that the rectum is full and needs to defecate, so the stool passes out without their knowledge

4. Anal and rectal incontinence: when there is nerve damage in the rectum causing weakness of rectal and anal sphincter muscles.

5. Overflow incontinence: it is the leakage of watery feces due to chronic constipation.

 

What are the risk factors of fecal incontinence?

There are many risk factors that could make you susceptible to bowel incontinence such as

    • Age: although people at any age can experience fecal incontinence, elder people especially those aged over 65 are more vulnerable to it
    • Gender: females are more vulnerable to bowel incontinence than males because it could be a complication of childbirth. Also, the usage of menopausal hormone therapy among postmenopausal women is associated with a modestly increased risk of fecal incontinence according to this study
    • Nerve damage’s causes: people with long-standing diabetes, multiple sclerosis as well as people who have trauma due to injury or surgery are at a high risk of developing fecal incontinence.
    • Some diseases: late-stage Alzheimer's disease and dementia.
    • Physical disability that makes you unable to reach the toilet on time

 

How could doctors diagnose Fecal Incontinence?

Your doctor will perform a physical examination of the anus by visual inspection and probe examination to determine if there is nerve damage. Then, the doctor may ask you for some tests to know the reason and grade of bowel incontinence to be treated

 

    • Digital rectal exam: the doctor will insert a lubricated and gloved finger into your rectum to check any abnormalities, muscle strength, and rectal prolapse
    • Balloon expulsion test: the doctor will insert a balloon filled with 50 ml water into your rectum, then you will be asked to go to the toilet and expel the balloon. If it takes more than one to three minutes to expel it, you likely have a defecation disorder.
    • Anal manometry: the doctor will insert into your rectum a thin flexible tube with a small balloon at its tip to measure the tightness of your anal sphincter and if your rectum is functioning well.
    • Anorectal ultrasonography: it is video imaging that is performed by inserting a narrow, wand-like instrument that produces video images into your rectum
    • Evacuation proctography: it is an x-ray video imaging of the rectum and surrounding organs to evaluate the function of the pelvic floor during defecation and how much stool your rectum can hold. To know more about the test and how it is performed, click here for some instructions from The Ottawa Hospital.
    • Colonoscopy: it is a test used to examine the colon and rectum by inserting a long, flexible tube with a small camera at its tip into your rectum. To learn more, click here.
    • Magnetic resonance imaging (MRI)

What about Bowel Incontinence treatment?

Treatment of bowel incontinence varies depending on the cause and severity of the condition. Treatment options include four categories: medications, exercises, other therapies, and surgery.

 

Medications

Medications are not working directly on treating fecal incontinence but they are used to prevent diarrhea and constipation that could worsen the condition

    1. Anti-diarrheal drugs such as diphenoxylate and atropine sulfate (Lomotil) if you suffer diarrhea
    2. laxatives such as psyllium (Metamucil) if you suffer chronic constipation

 

Exercises

The following exercises aim to strengthen the pelvic floor muscles and improve anal sphincter control

    • Pelvic floor exercises (Kegel exercises):

 

How to perform?

        Step 1: Contract the muscles that you normally use to stop the urine flow

        Step 2: Hold the contraction for three seconds

        Step 3: Relax for three seconds then repeat 10 times

By time, you can increase the contraction time gradually. Perform this exercise three times daily.

    • Biofeedback: it is a special training which done under the supervision of a physiotherapist to teach you certain exercises that strengthen the pelvic floor muscles, improve your sensation when feces is going to be released, and how to control your muscles when you want to defecate in an inappropriate time. Sometimes the physiotherapist uses anal manometry and a rectal balloon during the sessions.
    • Bowel training: your doctor will ask you to make a bowel movement at a certain time of the day such as after meals, this may need some effort but eventually you will reach great control over your muscles.

Other Therapies

Other therapies that help in treating fecal incontinence are:

    • Bulking agents: the doctor will inject nonabsorbable bulking agents into your rectum to thicken the wall of the anus thus prevent leakage.
    • Sacral nerve stimulation (SNS): this is done by implanting a device that sends minor electrical impulses to the sacral nerve that is responsible for the regulation of the sensation of your rectal and anal sphincter muscles and their strength.
    • Vaginal balloon (Eclipse System): it is an inflated balloon that is inserted into a woman’s vagina to make pressure on the rectal area resulting in fewer episodes of fecal incontinence.
    • Radiofrequency therapy (the Secca procedure): this procedure is minimally invasive and is performed under local anesthesia and sedation. The doctor will expose the wall of your anal canal to temperature-controlled radiofrequency energy for improving your muscle tone.

 

Surgery

Sometimes the condition needs surgery to treat the underlying problem that led to fecal incontinence such as rectal prolapse or sphincter damage

    • Sphincteroplasty: it is a surgery that repairs the damaged anal sphincter muscles during childbirth
    • Rectal prolapse surgery: this operation should be performed as soon as you figure it out as if it is left untreated, the prolapse may damage the nerves and muscles of the sphincter
    • Rectocele repair: rectocele is a bulge or herniation in the front wall of the rectum, if rectocele is left untreated, the bowel incontinence will become worse
    • Hemorrhoidectomy: This is a procedure to remove hemorrhoids.
    • Colostomy (bowel diversion): this is the last option if there is no improvement in the condition with other therapies. The aim of this procedure is to create another way rather than the anus for the feces to release. The doctors make an opening in the abdomen with a special bag attached where the stool will be collected.

What are the complications of Bowel Incontinence?

    1. Emotional distress: the inability to control defecation especially in front of people is very embarrassing. The patient will be depressed and introverted.
    2. Skin irritation: the frequent leakage of the stool will result in skin irritation, pain, itching, and may end will ulcers.

How to prevent Bowel Incontinence?

Depending on the cause, some of them could be controlled to prevent fecal incontinence while others could be out of control However, the following advice would reduce your risk

    1. Reduce constipation: if you suffer chronic constipation, try to drink plenty of water, don’t overeat high-fiber foods, exercise more, and use laxatives.
    2. Control diarrhea: diarrhea may be a symptom of other problems such as an intestinal infection, so you should treat the cause of diarrhea in addition to eating high-fiber foods and using anti-diarrheal drugs.
    3. Avoid straining: don’t strain during bowel movements as this may weaken the muscles of the anal sphincter and damage the nerves.
    4. Avoid anal intercourse: The National Health and Nutrition Examination Survey stated that anal intercourse is a high risk of developing fecal incontinence in both men and women.

 

Nutrition and Bowel Incontinence

    1. Write down in a notebook the foods you eat daily as some foods may increase fecal incontinence. Once you figure them out, cut them off your meals.
    2. Avoid foods that cause diarrhea or gas such as spicy foods, fatty and greasy foods, dairy products, Caffeine-containing beverages, and alcohol
    3. Avoid zinc supplements and don’t overeat zinc-rich foods as zinc intake was independently associated with increased risk of bowel leakage of gas or liquid according to this survey

 

Conclusion

Incontinence is the unintentional leakage of urine (urinary incontinence) or stool (fecal incontinence). The inability to control your bladder or bowel movements is very embarrassing but don’t hesitate to see your doctor once you feel the problem. There are many treatment options from medications and exercises to surgeries that will solve your problem.

 

 

 

References

  1. https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/symptoms-causes/syc-20352808
  2. https://pubmed.ncbi.nlm.nih.gov/28847480/
  3. https://pubmed.ncbi.nlm.nih.gov/30230164/
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4735668/
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810204/
  6. https://www.mayoclinic.org/bladder-neck-suspension/img-20007033 
  7. https://pubmed.ncbi.nlm.nih.gov/29964368/
  8. https://www.webmd.com/urinary-incontinence-oab/food-drink 
  9. https://onlinelibrary.wiley.com/doi/full/10.1111/iju.13439
  10. https://pubmed.ncbi.nlm.nih.gov/28753805/
  11. https://www.webmd.com/diet/foods-high-in-prebiotic#1
  12. https://www.health.harvard.edu/aging/stay-a-step-ahead-of-urinary-tract-infections
  13. https://rcni.com/hosted-content/rcn/continence/types-of-incontinence
  14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5447480/
  15. https://www.mayoclinic.org/diseases-conditions/prostate-cancer/multimedia/digital-rectal-exam/img-20006434 
  16. https://www.ottawahospital.on.ca/en/clinical-services/deptpgrmcs/clinics-and-services/proctographydefecography/
  17. https://www.mayoclinic.org/tests-procedures/colonoscopy/about/pac-20393569
  18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5231615/
  19. https://www.mayoclinic.org/diseases-conditions/fecal-incontinence/symptoms-causes/syc-20351397
  20.   https://onlinelibrary.wiley.com/doi/full/10.1111/jon.12589
  21. https://pubmed.ncbi.nlm.nih.gov/25803402/
  22. https://pubmed.ncbi.nlm.nih.gov/32939644/    
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