Katrina Parkin

Risk factors for obstetric anal sphincter injuries and postpartum anal and urinary incontinence: a case–control trial

Introduction and hypothesisObstetric anal sphincter injuries (OASIS) cause serious maternal morbidity for mothers. A clearer understanding of aetiological factors is needed. We aimed to determine the risk factors for OASIS .MethodsBirth details of 222 primiparous women sustaining OASIS were compared with 174 women who did not sustain OASIS (controls) to determine the relevant risk factors. The data underwent univariate analysis and logistic regression analysis.ResultsAsian or Indian ethnicity, operative vaginal birth (p = 0.00), persistent occipito-posterior position (p = 0.038) and rapid uncontrolled delivery of the head were identified as risk factors for OASIS. Pushing time, use of epidural, episiotomy and head circumference were not predictors of OASIS.ConclusionsWomen with Asian or Indian ethnicity, operative vaginal birth, persistent occipito-posterior position and rapid uncontrolled delivery of the fetal head were likely to sustain OASIS. Awareness of these factors may help to minimise the incidence of OASIS.

Decreased Intravesical Adenosine Triphosphate in Patients with Refractory Detrusor Overactivity and Bacteriuria

PURPOSE Although several studies have examined the relationship between adenosine triphosphate release from the urothelium and bladder sensations including painful filling and urgency, the association between bacteriuria and urothelial adenosine triphosphate release has not been well studied. We evaluated women with refractory detrusor overactivity who were experiencing an acute exacerbation of detrusor overactivity symptoms including frequency, urgency and nocturia (and/or urge incontinence). We measured changes in intravesical adenosine triphosphate levels in these women with and without bacteriuria. MATERIALS AND METHODS In this prospective cohort study women with refractory detrusor overactivity were invited to our unit during acute symptomatic exacerbation. On presentation a catheter urine specimen was collected and 50 ml normal saline instilled into the bladder to evoke gentle stretch, with removal after 5 minutes. Adenosine triphosphate concentrations were determined on fresh washings using a bioluminescence assay. RESULTS The incidence of bacteriuria 10(3) cfu/ml or greater was 27% (15 of 56 specimens) during the 16-month study period. Adenosine triphosphate concentrations were lower during episodes of bacteriuria in the overall cohort (p = 0.0013) and paired samples from individual patients (p = 0.031) compared to episodes of sterile urine. CONCLUSIONS In the first study on the subject to our knowledge, we demonstrated a striking difference between adenosine triphosphate levels measured in the presence and absence of bacteriuria in this patient group.

Objective efficacy of the tension-free vaginal tape in obese/morbidly obese women versus non-obese women, at median five year follow up.

One subjective long‐term evaluation of the tension‐free vaginal tape (TVT) success rate in obese women showed a worse prognosis in the obese, but objective studies have been limited to short‐term follow‐up (less than two years).

Rectus fascia pubovaginal sling for recurrent stress urinary incontinence after failed synthetic mid-urethral sling: Letter

We were very interested to read the recent study by Welk and Herschorn, and the related commentary by Steele, regarding the role of autologous rectus fascial slings for complex recurrent female stress urinary incontinence (SUI).1,2 The authors report that, on medium-term follow-up of 33 women with previous failed continence surgery, pubovaginal sling was associated with a significant reduction in pad usage and good patient satisfaction rates.1 In 2010, we reviewed the published literature on therapeutic options for managing women with recurrent SUI after failed synthetic mid-urethral sling (MUS).3 At that time, no studies reporting outcomes after PVS for a previous failed MUS had been reported and thus, the data reported by Welk and Herschorn are particularly welcome. We also recently collected data on women undergoing rectus fascial PVS for complex recurrent SUI in our tertiary urogynecology unit. Preoperative video-urodynamics was performed in all women considering PVS. The surgical technique used was very similar to that by Welk and Herschorn,1 with a 13 × 2-cm strip of rectus fascia harvested. All cases were seen in the clinic at 6 weeks and 12 months postoperatively and at variable follow-up periods thereafter. At follow-up visits, uroflowmetry and post-void residual volume were performed and subjective cure of SUI was assessed. We identified 7 women who underwent PVS after a previously failed MUS, who were contacted by telephone to complete the ICIQ-SF questionnaire4 and to ascertain cure (Table 1). Women had a median age of 61 (range: 41–73) years and were a complex group, with a median of 2 (range: 1–4) prior continence surgeries. All women completed the telephone survey and the median interval since the PVS was 5 years (range: 0.5–9 years). The long-term failure rate following PVS for recurrent SUI in our population was 14% (1/7). This patient had preoperative voiding dysfunction and was still requiring self-catheterizing 4.5 years after the PVS. A second patient required self-catheterization for de novo voiding dysfunction but was dry. Table 1. Overall, 71% (5/7) of women were completely cured and 86% (6/7) were satisfied. The rate of de novo OAB in women with a stable bladder preoperatively was 80% (4/5). One woman, with a history of known thrombophilia, suffered a large pulmonary embolus on postoperative day 12 but recovered fully. We agree with the comments of Steele that autologous PVS still has a role as a salvage procedure in complex recurrent female SUI. We found that PVS was associated with a low failure rate, but a high rate of de novo OAB at 5 years in a small population of women with previous failed synthetic MUS. Although the case of pulmonary embolus in our population raises some concern, previous work from the Urinary Incontinence Treatment Network reported a low rate (0.3%) of venous thromboembolism after PVS, which is reassuring.5

Vascular measures of atherosclerosis in detrusor overactivity and controls

The mechanisms leading to the development of detrusor overactivity (DO) are still relatively poorly understood, however, animal studies suggest that atherosclerosis and reduced blood flow to the bladder may be one etiological pathway. Thus, the aim of this study was to evaluate signs of atherosclerosis in a large cohort of women with detrusor overactivity, using two precise measures of atherosclerotic vascular impairment, Ankle Brachial Index (ABI), and Brachial—ankle Pulse Wave Velocity (baPWV).

A prospective “bottom up” study of the costs of faecal incontinence in ambulatory patients

The few studies that have examined direct costs of faecal incontinence are limited in that they employed retrospective databases, postal surveys, and focused upon institutionalised patients or post partum women. The aim of the current study was to identify the direct pre‐treatment costs of faecal incontinence expended by a range of home dwelling patients and identify relationships between costs and severity of incontinence.

Does motivation predict outcome of pelvic floor muscle retraining

Although pelvic floor muscle training (PFMT) is effective for stress urinary incontinence (SUI), patients need to be motivated to obtain cure. An instrument to assess motivation in such patients was published in 2009: the Incontinence Treatment Motivation Questionnaire (ITMQ). The ITMQ consists of five domains: (i) positive attitudes toward PFMT; (ii) reasons for not doing PFMT; (iii) difficulties living with incontinence; (iv) desire for treatment; and (v) incontinence severity influencing motivation. The aim of the present study was to examine the relationship between ITMQ scores and treatment success.