Ian Ramsay

Retrospective multicentre study of the new minimally invasive mesh repair devices for pelvic organ prolapse

Objectives  To assess the complications and short‐term outcomes of prolapse repair mesh devices used in the management of female pelvic organ prolapse (POP).

How common are tape erosions?: A comparison of two versions of the transobturator tension-free vaginal tape procedure

To compare two transobturator suburethral tapes (ObtapeTM, Mentor‐Porges and TVT‐OTM, Gynaecare, Johnson & Johnson) used in the management of urodynamic stress incontinence (USI), for tape erosion (vaginal/urethral) rates, clinical presentation, management and outcome.

A randomized controlled trial of urodynamic investigations prior to conservative treatment of urinary incontinence in the female

Sixty patients complaining of frequency, urgency, nocturia, urge incontinence and stress incontinence were randomly allocated to either undergo conservative treatment by way of combined physiotherapy and bladder retraining as an inpatient without prior urodynamics, or to have urodynamic investigations and treatment tailored to the urodynamic diagnosis. The assessment period was 3 months and assessment was made pre- and posttreatment by urinary diary, pad testing and subjective questionnaire. There was a significant improvement posttreatment for each parameter studied, with the exception of pad testing. There was no significant difference between the two groups for any parameter. Two-thirds of patients were cured to the extent that they did not require further treatment, and again there was no difference between the two groups. We conclude that patients attending for the first time with an uncomplicated story of urinary incontinence can be effectively treated conservatively without prior urodynamics.

A prospective, randomized controlled trial of inpatient versus outpatient continence programs in the treatment of urinary incontinence in the female

Seventy-four patients presenting with a mixed pattern of urinary symptoms were randomly allocated to undergo either inpatient or outpatient continence programs as initial treatment, without prior urodynamic investigation. Both programs consisted of physiotherapy, bladder retraining, fluid normalization, dietary advice and general support and advice. Nine out of 39 in the outpatient group and 8 out of the 35 of the impatient group failed to complete the study. There was a significant decrease in frequency, nocturia, number of incontinent episodes and visual analog scores for both groups. In addition the outpatients had a significant reduction in loss on pad testing, and a significantly greater improvement in their visual analog score. In each group 63% were cured or improved to the extent that they did not require further treatment. Staff costs per outpatient were half those for an inpatient. We conclude that outpatient conservative treatment as detailed above is a successful first-line treatment of urinary incontinence in women. It is as successful and possibly better than inpatient treatment, and is significantly cheaper.

Poor maternal weight gain between 28 and 32 weeks gestation may predict small-for-gestational-age infants

Summary. In a retrospective analysis of 158 women considered to have had normal, low‐risk pregnancies, 30 gave birth to infants with a birth‐weight less than the 10th centile for gestation. These 30 women had a significantly poorer mean increase in weight (0·99 kg) between 28 and 32 weeks gestation than the other 128 women (1·95 kg) who gave birth to infants with birthweights above the 10th centile for gestation. There was no statistically significant difference in booking weight, overall weight gain or other variables associated with low birthweight between the two groups of women which suggests that poor maternal weight gain specifically between 28 and 32 weeks gestation may predict small‐for‐gestational‐age infants.

The presentation of osteomalacia in pregnancy. Case report

A 3 I-year-old, primigravid, Kenyan Asian was first seen in the antenatal clinic at 14 weeks of an otherwise uneventful pregnancy, following a prolonged period of infertility. She was Hindu, vegetarian, and had lived in Great Britain for 10 years and rarely left her home. She was followed by her general practitioner until 36 weeks, when, on review at hospital, she was found to have preeclampsia, a small-for-dates baby and a normochromic, normocytic anaemia (haemoglobin 10.1 g/dl), despite regular supplements of iron and folic acid. The 24-h oestriol excretion and plasma human placental lactogen (hPL) levels for the subsequent 2-week period are presented in Fig. 1. Pelvimetry confirmed the clinical impression of a small pelvis, precluding a normal delivery. An elective caesarean section was performed at 38 weeks and a female infant of 2270g was delivered. The baby was thereafter bottle fed. The patient came to the endocrine clinic 9 months later having suffered a comminuted fracture of the right forearm, following an episode of minimal trauma, and with pain in her left arm. X-rays revealed pseudo-fractures in the left ulna, radius and both scapulae and major fractures through both pubic rami (Fig. 2). A marked reduction in bone density and subperiosteal erosions in the hands, were also noted. The fasting serum calcium was 2.18 mmol/l (normal range 2.1-2.6), phosphate 0.72 mmol/l (normal range 0.8-1.4), alkaline phosphatase 366 i.u. (normal range 30-1 15), parathyroid hormone (PTH) 0.27 yg/l (normal range <0.73) and 25-

Transobturator tape: a new method in the treatment of female stress urinary incontinence?

The tension‐free vaginal tape has revolutionised the surgical treatment of stress urinary incontinence but remains an abdominal procedure with all of the potential complications therein. The transobturator tape procedure described here produces the same end result i.e. a tension‐free tape left under the midurethra, but without the risks of an abdominal procedure. This article describes the development and early experience of this very promising procedure.

The symptomatic characterization of patients with detrusor instability and those with genuine stress incontinence

The histories of 100 patients with detrusor instability and 100 with genuine stress incontinence were studied to define the symptomatology of these two conditions, looking particularly at certain areas which had not been reported previously, namely the severity of incontinence and its relationship to the menstrual cycle. By using a scoring system for the four most significant symptoms, as determined by logistic regression analysis, a model was constructed in an effort to more accurately predict the diagnosis from history alone. Frequency, urgency and nocturia scored together, and urge incontinence were significantly associated with detrusor instability. The frequency of urinary leakage and the amount of protection required were significantly associated with genuine stress incontinence. By scoring these four sets of symptoms alone, it is predicted from the logistic model constructed that the diagnosis can be correctly made from the history in 76% of cases.

Postpartum thyroiditis‐an underdiagnosed disease

Stanley Clayton, who edited the Journal from 1963 to 1972, died suddenly on Friday 12th September. It has been the policy since his time that obituaries were no part of the Journal’s function, but Stanley Clayton was the Journal at an important stage of its development and his going leaves a scar which we cannot ignore. He had high literary standards and hated pretension either in the content or the style of papers. Not everyone warmed to his editorial treatment, although all received a courteous handwritten letter of explanation, but he was unfailingly kind and .helpful to the young and inexperienced, and a whole generation in obstetrics and gynaecology benefited from his guidance.

Duloxetine: the long awaited drug treatment for stress urinary incontinence

Duloxetine is a newly licensed drug treatment for stress urinary incontinence in women. It is a combined noradrenaline and serotonin reuptake inhibitor and its adverse-effect profile can be attributed to its pharmacological action. It has clinically important interactions with other drugs including warfarin and antidepressants. Duloxetine is believed to act by increasing sphincter activity in the storage phase of the micturition cycle. A meta-analysis of phase II and III double-blind placebo controlled trials involving 1913 women (aged 22-83 years) with stress urinary incontinence symptoms demonstrated a highly significant difference in reduction of diary reported incontinence episodes per week, mean increase in time between voids and quality of life. However, we feel that first-line therapy remains physiotherapy. The availability of duloxetine in primary care should not deny referral and assessment for surgery for those women who would benefit.Duloxetine is a newly licensed drug treatment for stress urinary incontinence in women. It is a combined noradrenaline and serotonin reuptake inhibitor and its adverse-effect profile can be attributed to its pharmacological action. It has clinically important interactions with other drugs including warfarin and antidepressants. Duloxetine is believed to act by increasing sphincter activity in the storage phase of the micturition cycle. A meta-analysis of phase II and III double-blind placebo controlled trials involving 1913 women (aged 22-83 years) with stress urinary incontinence symptoms demonstrated a highly significant difference in reduction of diary reported incontinence episodes per week, mean increase in time between voids and quality of life. However, we feel that first-line therapy remains physiotherapy. The availability of duloxetine in primary care should not deny referral and assessment for surgery for those women who would benefit.Duloxetine is a newly licensed drug treatment for stress urinary incontinence in women. It is a combined noradrenaline and serotonin reuptake inhibitor and its adverse‐effect profile can be attributed to its pharmacological action. It has clinically important interactions with other drugs including warfarin and antidepressants. Duloxetine is believed to act by increasing sphincter activity in the storage phase of the micturition cycle. A meta‐analysis of phase II and III double‐blind placebo controlled trials involving 1913 women (aged 22‐83 years) with stress urinary incontinence symptoms demonstrated a highly significant difference in reduction of diary reported incontinence episodes per week, mean increase in time between voids and quality of life. However, we feel that first‐line therapy remains physiotherapy. The availability of duloxetine in primary care should not deny referral and assessment for surgery for those women who would benefit.