Andrew Korda

Experience with silastic slings for female urinary incontinence.

EDITORIAL COMMENT: Peter Dwyer, Melbourne. Traditionally gynaecologists have used the anterior vaginal repair to treat stress incontinence in the female but over recent years there has been a trend to perform retropubic urethral suspension operations or slings in all patients with stress incontinence to improve the long‐term effectiveness of surgery. In this paper, a silastic sling was used mainly to treat primary stress incontinence in women with a high risk of failure from chronic lung disease or who had restricted vaginal mobility and were considered unsuitable for Burch colposuspension. Nine of the 54 women had recurrent stress incontinence with failed previous suprapubic surgery.

Which bowel symptoms are most strongly associated with a s rectocele

Background:  Posterior vaginal wall prolapse is common in parous women and may be due to rectocele, enterocele or perineal hypermobility. Translabial ultrasound can be used to detect defects of the rectovaginal septum, that is, a ‘true rectocele’, potentially avoiding the need for defecation proctography. However, it is currently unknown whether specific sonographic appearances are associated with bowel symptoms.

The incidence of preeclampsia and eclampsia and associated maternal mortality in Australia from population-linked datasets: 2000-2008

OBJECTIVE To determine the incidence of preeclampsia and eclampsia and associated mortality in Australia between 2000 and 2008. STUDY DESIGN Analysis of statutorily collected datasets of singleton births in New South Wales using International Classification of Disease coding. Analyzed using cross tabulation, logistic regression, and means testing, where appropriate. RESULTS The overall incidence of preeclampsia was 3.3% with a decrease from 4.6% to 2.3%. The overall rate of eclampsia was 8.6/10,000 births or 2.6% of preeclampsia cases, with an increase from 2.3% to 4.2%. The relative risk of eclampsia in preeclamptic women in 2008 was 1.9 (95% confidence interval, 1.28-2.92) when compared with the year 2000. The relative risk of a woman with preeclampsia/eclampsia dying in the first 12 months following birth compared with normotensive women is 5.1 (95% confidence interval, 3.07-8.60). CONCLUSION Falling rates of preeclampsia have not equated to a decline in the incidence of eclampsia. An accurate rate of both preeclampsia and eclampsia is vital considering the considerable contribution that these diseases make to maternal mortality. The identification and treatment of eclampsia should remain a priority in the clinical setting.

The association of obstructive defecation, lower urinary tract dysfunction and the benign joint hypermobility syndrome: A case–control study

It has been suggested that, apart from obstetric trauma, chronic straining at stool may also result in pudendal nerve damage, contributing to the etiology of genuine stress incontinence (GSI). The benign joint hypermobility syndrome (BJHS) has been associated with rectal as well as uterovaginal prolapse, suggesting that connective tissue abnormalities may also be implicated. This study was undertaken in order to further investigate whether – and if so, why – an association may exist between symptoms of obstructive defecation, lifetime constipation, chronic heavy lifting and lower urinary tract (LUT) dysfunction. Cases were female patients referred for urodynamic assessment with symptoms of LUT dysfunction. Controls were age-, sex- and postcode-matched community controls. Both cases and controls were assessed using a detailed questionnaire that also asked about symptoms of BJHS. Cases were also divided into their urodynamic classification of LUT dysfunction. All symptoms of obstructive defecation (52.3% vs 33.6%, P=0.00003), as well as chronic straining at stool (38.6% vs 23.4%, P=0.0005), were significantly more common in women with LUT dysfunction than in community controls. BJHS, chronic heavy lifting and a history of uterovaginal prolapse were significantly associated with patients with LUT and obstructive defecation compared to those with LUT dysfunction alone. Overall, symptoms of obstructed defecation were not more prevalent in any one urodynamic diagnostic group than in others. However, childhood constipation and current constipation were significantly more prevalent in women with voiding dysfunction than in those with other urodynamic diagnoses (16.7% vs 5.5%, P = 0.0030 and 13.0% vs 5.7%, P = 0.017). We concluded that women with LUT dysfunction are more likely to have symptoms of obstructive defecation than are community controls. Connective tissue disorders such as BJHS may be an important factor in this association.

Assessment of possible luteolytic effect of intra-ovarian injection of prostaglandin F2α in the human

A group of five patients awaiting laparoscopic tubal diathermy were followed by daily assay of luteinising hormone (LH) and progesterone. Between five and eight days after the LH peak, prostaglandin F-2ALPHA (PGF-2ALPHA) was injected into either the corpus luteum or the ovarian stroma. Doses of 100 mu-g into the corpus tuteum, 1000 mu-g into the adjacent stroma and 500 mu-g into an indeterminate ovarian structure had no effect on peripheral plasma progesterone levels or uterine bleeding. An injection of 500 mu-g or 1000 mu-g given unequivocally into the corpus luteum produced a rapid and profound fall in plasma progesterone levels, the nadir coinciding with the onset of uterine bleeding which commenced 24 hours after the injection and persisted for more than seven days. Injection of 100 mu-g in the same volume of saline had no such effect. Despite continued bleeding plasma progesterone levels returned to normal luteal levels for three days and then fell again.

Colposuspension for the Treatment of Female Urinary Incontinence

EDITORIAL COMMENT: This paper reviews the results of a large series of patients with urinary incontinence treated by the Burch colposuspension with a few minor alterations. The operation is performed entirely from above, the vagina being suspended on either side of the bladder neck and attached to the iliopectineal ligament at the pelvic brim. It is noteworthy that only 36 of the 174 patients had pure stress incontinence as a symptom and 59 were obese. Selection of the patient who requires surgery when stress incontinence is associated with urgency and other urinary symptoms is very difficult. All of the 30 patients who remained incontinent after the operaton had urodynamic investigaton and 16 were found to have detrusor instability. It would seem that the authors results justify their willingness to operate on patients with mixed urinary symptoms. The success rate and incidence of complications in this series is consistent with other studies — however, there was a high incidence of voiding difficulties postoperatively as revealed by a mean postoperative catheter drainage time of 10 days, 5 patients requiring to go home using self‐catheterization with 2 needing this long‐term, and a postoperative incidence of detrusor instability of 10%. One reviewer believes this is due to overelevation of the bladder neck at the time of colposuspension which may be avoided by leaving the suspending sutures long at the time of surgery. The takeaway message is that patients with mixed urinary symptoms who have stress incontinence confirmed urodynamically have a good chance of being cured by surgery. It would be prudent that such patients should have a trial of medical management and pelvic floor exercises before resorting to surgery.

The Value of Clinical Symptoms in the Diagnosis of Urinary Incontinence in the Female

EDITORIAL COMMENT: Urodynamic investigation is being used increasingly in patients with urinary incontinence. Although many gynaecologists stress the importance of a careful history and examination as the basis for surgery, the recent literature would support the rule that no patient should have a second operation for stress incontinence without the benefit of preoperative urodynamic assessment.

Paravaginal defects: a comparison of clinical examination and 2D/3D ultrasound imaging

Background: Paravaginal defects are often assumed to be the underlying anatomical abnormality in anterior compartment descent. Neither clinical examination nor ultrasound assessment are generally accepted diagnostic modalities.

Is there an association between fecal incontinence and lower urinary dysfunction

BACKGROUND: Urinary and fecal incontinence in females are both common and distressing conditions. Because common pathophysiologic mechanisms have been described, an association between the two would be expected. The aim of this study was to determine whether patients with lower urinary tract dysfunction have concomitant fecal incontinence when compared with age and gender matched community controls and, second, to determine whether they have predisposing factors that have led to lower urinary tract symptoms and concomitant fecal incontinence. METHODS: A case-control study was performed by means of detailed questionnaire and review of investigation results. One thousand consecutive females presenting for urodynamic investigation of lower urinary tract dysfunction, were compared with 148 age and gender matched community controls. RESULTS: Frequent fecal incontinence was significantly more prevalent among all cases than among community controls (5vs. 0.72 percent,P=0.023). Occasional fecal incontinence was also more prevalent (24.6vs. 8.4 percent,P<0.001). Fecal incontinence was not significantly more prevalent among females with genuine stress incontinence (5.1 percent) when compared with females with detrusor instability (3.8 percent) or any other urodynamic diagnosis. Symptoms of fecal urgency and fecal urge incontinence were significantly more prevalent among those with a urodynamic diagnosis of detrusor instability or sensory urgency than among females with other urodynamic diagnoses or community controls. Multivariate analysis comparing cases with fecal incontinence with other cases and also with community controls did not indicate that individual obstetric factors contributed significantly to the occurrence of fecal incontinence in these patients. CONCLUSIONS: There is an association between genuine stress incontinence, lower urinary tract dysfunction, and symptoms of fecal incontinence, but the exact mechanism of injury related to childbirth trauma is questioned.

The effect of intra-uterine prostaglandin F2α on corpus luteum function in the human

Prostaglandin F2α (PGF2α) was administered via a Foley catheter over a 12 hour period to 8 healthy volunteers awaiting laparoscopic sterilisation. The amount of PGF2α infused varied between 500 μg and 2000 μg every 2 hours for 6 doses. Plasma progestins and oestradiol 17β, and urinary estrogens and pregnanediol were assayed throughout the study period. There was no evidence of luteolysis in any patient although vaginal bleeding of varying duration occurred in all women within 36 hours of administration of PGF2α.