Aswini Balachandran

The risk and severity of developing symptomatic palpitations when prescribed mirabegron for overactive bladder

OBJECTIVES Mirabegron is a new selective β3-adrenoreceptor agonist licensed for the treatment of overactive bladder (OAB). In clinical trials, mirabegron is well-tolerated with a low side-effect profile. There is little data available on the risks in a non-selected population. The presence of β-adrenoreceptors in cardiac and vascular tissue leads to the possibility of the development of adverse cardiovascular events. We conducted a consecutive cohort study to assess the risk of developing palpitations, the severity of the condition and to investigate any underlying risk factors that predispose patients with OAB to develop palpitations whilst taking mirabegron. STUDY DESIGN A consecutive cohort of patients with OAB was studied between February 2013 and June 2014. Patients were prescribed mirabegron 50mg daily and outcomes assessed at 6 weeks. Patients with known cardiac arrhythmias were excluded. In patients who developed palpitations, a detailed account of their symptoms and medical history were documented and a 12-lead electrocardiogram (ECG) was performed to assess heart rate, QT interval and the presence of any persisting arrhythmia was conducted. RESULTS A total of 279 patients were started on mirabegron. Eight patients (2.9%) reported palpitations whilst taking the drug. Two patients with a history of palpitations with no history of prolonged QT interval or arrhythmia on ECG developed worsening palpitations. The QTc was prolonged in two patients at 0.458 and 0.441s (QTc <420). Three patients developed chest pain or tightness. The palpitations resolved once therapy was stopped and did not result in serious adverse events such as hospitalisation. CONCLUSIONS Palpitations in an unselected population have a similar incidence to that demonstrated in previous drug trials. Palpitations may be associated with a worsening of cardiovascular dysfunction.

Mesonephric adenocarcinoma of the vagina masquerading as a suburethral cyst

Mesonephric adenocarcinoma (MA) of the vagina is an extremely rare tumour of the female genital tract. There are currently 22 reported cases in the published literature. Consequently, its pathophysiology and disease progression remain poorly understood. A 63-year-old woman presented with a history of a swelling in her vagina. Two-dimensional pelvic floor ultrasound and MRI demonstrated a multiloculated cyst with no malignant features. Initial workup provided a working diagnosis of a suburethral cyst. The diagnosis of MA was made on histology after excision of the cyst. Subsequent postoperative investigation showed no spread of the disease. The patient completed a course of prophylactic brachytherapy to prevent the possibility of any recurrence of disease. Due to its rarity, it remains difficult to diagnose MA of the vagina even on histological analysis. We would therefore recommend a low threshold to excise or perform tissue biopsy of unspecified vaginal masses.

The long term predictive value of preoperative pressure flow studies in the resolution of overactive bladder after insertion of a retropubic midurethral sling

To identify if the short term association of pressure flow rates with resolution of overactive bladder (OAB) is maintained in the long term in patients with mixed urodynamic incontinence treated with a retropubic midurethral sling. To assess if other demographic factors are associated with the long term resolution of OAB.

Cystodistension: Is there evidence to support its use in current practice for patients with overactive bladder?

Abstract Cystoscopy and cystodistension have been part of common treatment protocols for a variety of bladder conditions for many years. However, the science behind the procedure is not strong and continued use of the operation may not be justified. Much research is old and was not planned or executed with the current rigour demanded by current trial methods. Newer treatments such as intravesical botulinum toxin have been extensively researched and found to be effective. This review article aimed to review the evidence behind the use of cystodistension for overactive bladder (OAB) with the aim of identifying the weaknesses in the current evidence. The article aimed to identify whether a general anaesthetic cystoscopy and distension has sufficient evidence to recommend its continued use in current practice for patients with OAB resistant to conservative and drug therapies. Impact statement Cystodistension is often used in current practice in patients with overactive bladder (OAB) resistant to conservative and drug therapies. Older data suggested that this may be of benefit but there are no randomized controlled trails with appropriate assessment of symptoms and quality of life outcomes. This paper reviews the current evidence regarding the use of cystodistension in patients with OAB. There is no standardized method of cytodistension making direct comparisons difficult. The data consists of case series from individual units. Some series show benefit but in most cases this is not sustained. Initial improvement may fall to around 10–20% after 6 months. Urodynamic parameters may also fail to improve. The procedure is associated with a complication rate of 10–20%. A randomised controlled trial of cystodistension is needed to identify if this procedure should be performed for patients with OAB.

Should we use a vaginal pack to reduce blood loss at the time of prolapse surgery

OBJECTIVE Vaginal packs are commonly inserted after pelvic organ prolapse (POP) surgery to absorb excess blood loss and to reduce haematoma formation. Randomised trials have shown little benefit in terms of reduced haematoma formation. However, the amount of blood loss absorbed on the pack has not been studied. The use of packs has financial costs and is associated with catheterisation and may delay hospital discharge. If packs are not effective in reducing blood loss and haematoma formation there could be an argument that packs should not be used at all. This study was designed to identify how much blood is actually absorbed onto packs after POP surgery. STUDY DESIGN Consecutive patients undergoing elective vaginal surgery for POP were prospectively recruited by the lead author. Demographics were recorded. Vaginal packs inserted after POP surgery in 63 women were weighed before insertion and at the time of removal the day after surgery. Pain score were noted and the difference in the weight of packs recorded. Any complications were reported by the patients at the 6 week routine post operative visit and cross referenced with the clinical records. RESULTS There was a statistically significant increase in pack weight of 6.7g (p<0.01). Five percent of the patients had a bleed of more than 25g into the pack. Removal of the pack was associated with minor discomfort. Complications in the post operative period were low with 11% of patients seen in the first 6 weeks with bleeding or discharge. CONCLUSION The majority of women undergoing prolapse surgery have minimal bleeding onto a routinely introduced vaginal pack placed after POP surgery. Packs are probably not required for controlling post operative blood loss in the majority of patients.

Management of Stress Urinary Incontinence

Stress urinary incontinence is a common debilitating condition affecting millions of women worldwide. Conservative treatments are recommended as first-line therapies, but many women need surgical treatment if pelvic floor muscle training is ineffective. In the past the colposuspension operation was the gold standard, but over the last 15 years, this technique has been replaced by mid-urethral sling procedures. These have a high success rate and reduced morbidity. The original retropubic (down-up) sling has been modified and now transobturator slings (inside-out and outside-in) are also available. Recently, short single-incision slings (mini-slings) have been introduced, although current evidence suggests an inferior outcome. We are still learning the benefits and limitations of each type of sling, and many surgeons express a keen preference for one sling over another. Different surgeons obtain very different results with similar slings. As surgeons we should aim to audit our results so that we ensure we give our patients the best possible outcome. This article reviews the current surgical treatment options for stress urinary incontinence.

What is the role of the multidisciplinary team in the management of urinary incontinence

Multidisciplinary teams (MDT) are a well-established part of service provision and clinical care in the UK. In 2013, the National Institute for Health and Care Excellence (NICE) Urinary Incontinence guideline recommended that MDT review should be mandatory before invasive therapy is offered to all patients with stress urinary incontinence (SUI) and overactive bladder (OAB). Currently, there is no evidence in the literature regarding the use of MDTs in urogynaecology. The aim of this paper is to assess the potential benefits and disadvantages of the creation of routine MDT meetings for the management of urinary incontinence.

Metastatic breast cancer presenting as detrusor overactivity.

Breast carcinoma metastatic to the bladder is rare and accounts for approximately 3% of all secondary bladder neoplasms. We examine a case of breast cancer metastatic to the bladder with normal findings at cystoscopy. A 53-year-old woman with a history of breast carcinoma presented with a 6-month history of severe urgency and urgency incontinence. Treatment with multiple antimuscarinic therapies was unsuccessful. Vaginal examination demonstrated a non-mobile uterus with a suggestion of parametrial thickening. Urodynamic studies confirmed detrusor overactivity. CT showed a thickened bladder wall and cystoscopy revealed normal bladder mucosa with reduced bladder capacity. Bladder biopsies identified a poorly differentiated adenocarcinoma with strong oestrogen receptor staining. This was reported as a secondary deposit from a primary breast malignancy. The patient is currently under the care of the breast team and undergoing palliative chemotherapy.