John Bidmead

Can ultrasound replace ambulatory urodynamics when investigating women with irritative urinary symptoms

Objective To determine whether transvaginal ultrasound measurement of bladder wall thickness could replace ambulatory urodynamics when investigating women with lower urinary tract dysfunction not explained by conventional laboratory urodynamic studies.

The impact of the menstrual cycle on urinary symptoms and the results of urodynamic investigation

Four hundred and eighty‐three consecutive women referred for videocystourethrography completed a structured questionnaire about their menstrual status and urinary symptoms. Women were included in the study if they were premenopausal, had a regular menstrual cycle and were not taking hormonal therapy. One hundred and thirty‐three women satisfied the inclusion criteria of whom 55 (41%) complained that their urinary symptoms were cyclical. The times at which symptoms were said to be at their worst were reported by the women as follows: during a period (n=20; 36%); just after a period (n=4; 7%); middle of the month (n=8; 15%); just before a period (n=23; 42%). The prevalence of abnormal detrusor activity on videocystourethrography increased significantly with time from the last menstrual period (χ2 for trend=6.56, P=0.01) and might reflect increases in the circulating level of progesterone following ovulation. This study provides further indirect evidence that progesterone could have an adverse effect on female lower urinary tract function. In addition, it might be necessary to consider the stage within the menstrual cycle when interpreting the results of urodynamic investigation.

Genuine stress incontinence: colpocystourethropexy versus sling procedures.

Both colpocystourethropexy (colposuspension) and sling operations have been shown to be effective in treating female stress incontinence. The present review discusses the literature available and compares the results and complications of both procedures. Colposuspension can give excellent results as both primary and secondary surgery. Slings also give excellent results, but are prone to complications relating to the sling material and postoperative voiding difficulties. Slings are arguably best reserved for women in whom vaginal scarring makes colposuspension impossible. Colposuspension remains the gold standard operation against which new techniques should be compared.

Urinary Incontinence: A Gynaecologist’s Experience

Abstract Female urinary incontinence leads to significant morbidity, resulting in impaired quality of life and social and occupational life, and adversely affecting womens physical, psychological, sexual and domestic well-being. It is a distressing condition that affects a significant proportion of the population, with reported incidence rates of 15–30%. Of the 14% of the adult female population who are affected by stress incontinence, 61% have had the problem for more than 4 years and at least 25% have delayed seeking help for more than 5 years. This paper presents some of the causes of incontinence, of which genuine stress incontinence (GSI) and detrusor instability (DI) are by far the most common. With correct diagnosis and treatment, it is always possible to improve womens quality of life. There is a wide range of drugs for treating incontinence. These may be extended to include drugs acting specifically on the urethral sphincter and the reflex mechanism controlling sphincter tone, but these drugs are currently in Phase III clinical trials. Surgical techniques and materials for the treatment of stress incontinence continue to improve. These include slings, injectables, bulking agents and Burch colposuspension. Tension-free vaginal tape (TVT) has become widely available over the past 4–5 years, and published data show good results.

Impact of surgery for stress incontinence on the social lives of women

authors quite rightly point out that the results of the study cannot necessarily be generalised to hospitals without this level of monitoring. It does appear likely that at least some women with severe pre-eclamp sia benefit from MgSO, therapy. What is in doubt, is at what level of severity the benefits of MgSO, outweigh the risks, particularly in hospitals in poor countries where facilities for monitoring are limited and the workload and rapid ‘turnover’ of patients high. The South African study did not comment on postpartum haemorrhage and neonatal morbidity or mortality. The systematic review on MgSO, for the prevention of eclampsia suggests there may be an increased risk of postpartum haemorrhage. If MgSO, decreases the number of convulsions in women with severe pre-eclampsia by half (i.e. from 4% to 2%) 98/100 women with severe pre-eclampsia will receive the drug ‘unnecessarily’. All these women may be at increased risk of postpartum haemorrhage. Similar effects may be found in relation to caesarean section or neonatal outcome. Before advocating prophylactic MgSO,, the disadvantages, as well as the advantages, must be clearly quantified. In general, in poor countries and certainly in South Africa, women with mild asymptomatic pre-eclampsia do not receive MgSO,. For women with moderate or severe asymptomatic pre-eclampsia, there is uncertainty whether the benefits of MgSO, outweigh the risk. Some clinicians also have uncertainty about whether MgSO, is beneficial for women with imminent eclampsia. It is for these reasons that many clinicians in South Africa support the Magpie trial, as it may solve the considerable uncertainty about the use of MgSO, in pre-eclampsia, its safety for the mother and her baby, and its cost effectiveness.

An unusual cause of voiding dysfunction following colposuspension.

Case report In April 1997 a 43-year-old woman presented to the department of urogynaecology complaining of symptoms suggestive of stress incontinence. She was multiparous, having had two children delivered by caesarean section, a spontaneous vaginal delivery at term and a mid-trimester miscarriage at 20 weeks gestation. Having contracted tuberculosis as a child she complained of mild asthma but had no other relevant medical or gynaecological history. Videocystourethography was performed and confirmed severe genuine stress incontinence with a normal pressure-flow study and no urinary residual. She was initially managed conservatively with pelvic floor exercises, but as there as no improvement in her symptoms she underwent a colposuspension in July 1997. A standard open Burch colposuspension was performed under general anaesthesia with the insertion of a suprapubic catheter. The procedure was uncomplicated and there were no postoperative voiding problems. The catheter was left on free drainage for 48 hours following which it was clamped and released in keeping with the departmental protocol. She was discharged on the fifth postoperative day when she had urinary residuals less than 100 ml and when seen in clinic at 6 weeks was, subjectively, cured. As is standard practice in our unit following continence surgery she was invited for repeat urodynamic studies 6 months later, although she failed to attend. No further follow-up was arranged. In September 2000 she was admitted through casualty with 3-week history of abdominal pain and distension, vomiting, pyrexia and weight loss in addition to urinary and faecal incontinence. On clinical examination she had a grossly distended abdomen with a mass arising from the pelvis. Investigations on admission revealed the following: haemoglobin 10.1 g/dl, white cell count 32.5 10/l, sodium 128 mmol/l, potassium 5.0 mmol/l and creatinine 766 mmol/ l. A urethral catheter was inserted and 2,500 ml drained from the bladder over 1 hour. A diagnosis of acute renal failure secondary to sepsis was made and she was admitted under the care of the general surgeons. Subsequent blood cultures confirmed a Klebsiella septicaemia while urine cultures showed a heavy mixed growth. She responded well to intravenous gentamicin and Tazocin (Wyeth, Berkshire, UK) and her renal function continued to improve with free drainage and intravenous fluids. CT scan of the abdomen and pelvis at this time was unremarkable, except for some small volume para-aortic lymphadenopathy. A urogynaecological opinion was sought. Despite improving renal function she remained unwell. Pelvic examination revealed a large tumour adherent to the anterior vaginal wall and the pubic symphysis. Transvaginal ultrasound showed a 2.8 cm paraurethral mass while colour flow Doppler was suggestive of neo-vascularisation. The uterus, cervix and ovaries appeared normal. In light of the ultrasound findings a MRI scan of the pelvis was requested. This showed a 3 cm heterogeneous soft tissue mass arising within the line of the urethra and effacing the anterior vaginal wall (Figure 1). There was associated left inguinal lymphadenopathy although no evidence of intra-pelvic disease. The appearances were suggestive of a primary urethral carcinoma. In view of the imaging findings an examination under anaesthesia was arranged jointly with the urological team. Cystourethoscopy was performed and multiple urethral biopsies taken which revealed a poorly differentiated primary urethral adenocarcinoma. Biopsy of a right groin node confirmed metastatic disease. Subsequent intravenous pyleogram (IVP) revealed an obstructed left kidney and a left nephrostomy tube and ureteric stent were inserted prior to a transurethral resection of the primary tumour. Histological examination confirmed the biopsy findings while a repeat CT scan of the abdomen revealed disseminated lymph node metastases. Chest X-ray was normal. Following diagnosis she underwent a six-cycle course of cisplatin and doxorubicin adjuvant chemotherapy, which resulted in a decrease in tumour volume, although her treatment was complicated by recurrent malignant pleural effusions. In February 2001, during the course of chemotherapy, she was admitted under the care of the cardiology team with an anterior myocardial infarction and underwent angioplasty and insertion of a stent to the left anterior descending coronary artery. Unfortunately, despite making a good initial recovery she continued to deteriorate clinically and was admitted for palliative care and symptom control in June 2001. She died of metastatic disease later that month.

Incontinence and Prolapse—An Integrated View

Abstract There is a complex interaction of factors contributing to the development of urogenital prolapse and stress incontinence. These aetiological factors are exactly the same for prolapse as for urinary stress incontinence. These factors include pregnancy and childbirth, collagen status, weight, and chronic airways disease while anti-incontinence surgery itself can be a cause of prolapse. Our understanding of why some women develop stress incontinence, others develop prolapse without stress incontinence, and some develop both, is incomplete. However, the identical aetiologies of the two conditions suggest that an integrated approach to managing stress incontinence and prolapse may be beneficial. This paper looks at the advantages offered by some combined techniques including paravaginal repair and slings, combined cystocoele repair and slings, combining tension-free vaginal tape (TVT) and prolapse repair, combining vault prolapse repair with repair of stress incontinence, combined mesh sling, and a number of combined laparoscopic approaches. Although a combined approach to treatment should be beneficial, there is still insufficient evidence to assess which combined approach is best, which materials to use, and which patients to select.

Less Invasive Surgery in Stress Incontinence

Stress incontinence is a distressing symptom that has a major impact on a woman’s quality of life. It has proved difficult to accurately establish the true incidence of genuine stress incontinence (GSI), but even the most conservative estimate is that one in ten women will suffer from GSI at some time. In the past many women have accepted urinary incontinence as an inevitable consequence of childbearing and aging but today more women are coming forward requesting treatment and anticipating prompt and effective management. A number of new surgical techniques have also been developed which aim to offer improved results with lower morbidity than conventional surgery.

Minimally invasive techniques for the treatment of genuine stress incontinence in women

Currently, a modified Burch colposuspension is regarded as the “gold standard” surgical treatment for GSI. Colposuspension can give up to an 80% objective cure rate and as an extra-peritoneal procedure is well tolerated by all but the frailest of patients.1 It is nevertheless a major operation with significant morbidity. A number of new techniques are being developed in an attempt to achieve the success rates of a colposuspension with a less invasive approach and reduced morbidity, shorter hospital stay and faster return to normal activity. This paper outlines some of the alternatives to traditional surgery for stress incontinence, which are being assessed.

Ambulatory dynamics: do they help clinical management?

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