Magali Robert

Prevalence of Primary Dysmenorrhea in Canada

OBJECTIVE The aim of this study was to describe the prevalence, clinical effect, characteristics, and underlying risk factors of primary dysmenorrhea (PD) in Canada. METHODS A stratified, random sample of 2721 women 18 years and older was identified, and the women were interviewed by telephone. Data about menstrual symptoms and patterns and socio-demographic factors were obtained. The frequency, severity, and effect of menstrual pain were quantified. Logistic regression analysis was performed in order to identify independent risk factors for PD. RESULTS In the sample, 1546 women were having menstrual periods; of these, 934 (60%) met the criteria for PD. Sixty percent of the women with PD described their pain as moderate or severe. Fifty-one percent reported that their activities had been limited, and 17% reported missing school or work because of PD. The prevalence of PD decreased with increasing age (P < 0.001) and increased with smoking (P = 0.002). Users of oral contraceptives (OCs) tended to have less pain than non-users (P = 0.005). Socio-economic status, nulliparity, and earlier age at menarche were not independently associated with PD. However, nulliparous women, smokers, and women not using OCs were more likely to report disabling symptoms. CONCLUSIONS The majority of Canadian women will suffer from dysmenorrhea at some time during their reproductive years. Available prescription treatments are underused. Young age, smoking, and non-use of OCs are independent risk factors for PD.

Transobturator tape compared with tension-free vaginal tape for stress incontinence: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of transobturator tape with tension-free vaginal tape (TVT) in terms of objective cure of stress urinary incontinence (SUI) at 12 months postoperatively. METHOD: Women with SUI were randomly allocated to either transobturator tape or TVT procedures and reviewed at 12 months after surgery. The primary outcome was objective evidence of “cure,” evaluated by standardized pad test (cure defined as less than 1 g urine leaked). Other outcomes included complications, subjective cure, incontinence-related quality of life, return to usual sexual activity, and satisfaction with surgery. Primary analysis compared the proportion of patients in each group who were cured at 12-month follow-up. RESULTS: A total of 199 women participated (94 in the transobturator tape group, 105 in the TVT group). Sixty-eight women (81%) in the transobturator tape group were cured, compared with 67 (77%) in the TVT group (relative risk 1.05, 95% confidence interval 0.90–1.23, P=.577). On vaginal examination, the tape was palpable for 68 women (80%) in the transobturator tape group and for 24 (27%) in the TVT group (relative risk 0.22, 95% confidence interval 0.13–0.37, P<.001). More women in the transobturator tape group experienced groin pain during vaginal palpation (13 [15%] in the transobturator tape group and five [6%] in the TVT group, P=.044). Quality of life improved significantly from baseline in both groups (30-point improvement in IIQ-7 score for both groups). CONCLUSION: At 12 months, the majority of women had minimal leakage and their quality of life had improved significantly, but differences were not observed between groups. The presence of palpable tape, particularly among the transobturator tape group, is concerning; longer follow-up is needed to determine whether this outcome leads to extrusion or resolves over time. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00234754. LEVEL OF EVIDENCE: I

Random protein-creatinine ratio for the quantitation of proteinuria in pregnancy.

Objective To compare random urine protein-creatinine rations with 24-hour protein excretion rates in patients hospitalized with hypertensive disorders in pregnancy. Methods All hospitalized, hypertensive patients requiring 24-hour urine protein excretion collections were eligible for the study. During the 24-hour urine collection a separate 2-mL aliquot was taken for a protein and creatinine determination. Results Seventy-one samples were collected from patients with the following diagnoses: gestational hypertension (n = 56), preexisting hypertension and superimposed gestational hypertension (n = 11), and syndrome of hemolysis, elevated liver enzymes and low platelets (n = 4). The correlation coefficient between the random protein-creatinine ratio and the 24-hour urine protein excretion was 0.94. Calculated excretion rates with at least 300 mg protein in 24 hours had a sensitivity of 0.93, specificity of 0.90, and positive and negative predictive values of 0.87 and 0.95, respectively. For those samples with calculated excretion rates at least 5 g protein in 24 hours, the sensitivity was 1.00, specificity was 0.99, and positive and negative and negative predictive values wee 0.75 and 0.99, respectively. Conclusion In nonambulatory hypertensive pregnant patients, there is a strong correlation between random voided protein-creatinine ratios and 24-hour urine protein excretions.

Recurrent Urinary Tract Infection

OBJECTIVE to provide an update of the definition, epidemiology, clinical presentation, investigation, treatment, and prevention of recurrent urinary tract infections in women. OPTIONS continuous antibiotic prophylaxis, post-coital antibiotic prophylaxis, and acute self-treatment are all efficient alternatives to prevent recurrent urinary tract infection. Vaginal estrogen and cranberry juice can also be effective prophylaxis alternatives. EVIDENCE a search of PubMed and The Cochrane Library for articles published in English identified the most relevant literature. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions. VALUES this update is the consensus of the Sub-Committee on Urogynaecology of the Society of Obstetricians and Gynaecologists of Canada. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). OPTIONS recurrent urinary tract infections need careful investigation and can be efficiently treated and prevented. Different prophylaxis options can be selected according to each patients characteristics.

Autologous Muscle Derived Cell Therapy for Stress Urinary Incontinence: A Prospective, Dose Ranging Study

PURPOSE In this feasibility study we assessed the 12-month safety and potential efficacy of autologous muscle derived cells (Cook MyoSite Incorporated, Pittsburgh, Pennsylvania) as therapy for stress urinary incontinence. MATERIALS AND METHODS A total of 38 women in whom stress urinary incontinence had not improved with conservative therapy for 12 or more months underwent intrasphincter injection of low doses (1, 2, 4, 8 or 16 × 10(6)) or high doses (32, 64 or 128 × 10(6)) of autologous muscle derived cells, which were derived from biopsies of their quadriceps femoris. All patients could elect a second treatment of the same dose after 3-month followup. Assessments were made at 1, 3, 6 and 12 months after the last treatment. The primary end point was the incidence and severity of adverse events. In addition, changes in stress urinary incontinence severity were evaluated by pad test, diary of incontinence episodes and quality of life surveys. RESULTS Of the 38 patients 33 completed the study. Treatment related complications were limited to minor events such as pain/bruising at the biopsy and injection sites. Of patients who received 2 treatments of autologous muscle derived cells who were eligible for analysis, a higher percentage of those in the high dose vs the low dose group experienced a 50% or greater reduction in pad weight (88.9%, 8 of 9 vs 61.5%, 8 of 13), had a 50% or greater reduction in diary reported stress leaks (77.8%, 7 of 9 vs 53.3%, 8 of 15) and had 0 to 1 leaks during 3 days (88.9%, 8 of 9 vs 33.3%, 5 of 15) at final followup. CONCLUSIONS Injection of autologous muscle derived cells in a wide range of doses appears safe with no major treatment related adverse events reported. In addition, treatment with autologous muscle derived cells shows promise for relieving stress urinary incontinence symptoms and improving quality of life.

Long-term Assessment of the Incontinence Ring Pessary for the Treatment of Stress Incontinence

Abstract A prospective cohort of 38 women who presented with predominantly stress incontinence symptoms were fitted with an incontinence ring pessary. They had documented stress incontinence on multichannel urodynamic testing. Nine women (24%) were not leaking by subjective measures. Six women (16%) continued using the pessary. This group of women had no statistically identifiable parameters that distinguished them from women who had not wanted to continue using the pessary. There was a trend showing that successfully fitted women were younger (41 vs 52 years old), had less pelvic surgery and leaked less on semiquantitative pad testing (10.7 g vs 19.2 g). In women who chose to continue using the pessary there was a trend showing a decrease in the semiquantitative pad score (1.2 g from 10.7 g) and 7-day voiding diary (1.5 episodes from 4.1). In conclusion, the incontinence pessary was successful in a small proportion of women with stress incontinence.

Five cases of tape erosion after transobturator surgery for urinary incontinence.

BACKGROUND: Before introducing the transobturator tape into our practice we undertook 52 transobturator tape procedures. The transobturator tape procedures were undertaken with an “outside-in” approach, using nonwoven polypropylene mesh with average pore size of 50 &mgr;m. CASES: Five cases of vaginal erosions have been identified, 1 complicated by a groin abscess. All cases required further procedures to trim (n = 3), resect (n = 1) or remove (n = 1) the tape. One woman had a tension-free vaginal tape procedure. To date, 3 women remain incontinent. CONCLUSION: Possible reasons for the complications include 1) surgical inexperience (unlikely, given that we have undertaken more than 2000 tension-free vaginal tape procedures without similar complication rates); 2) inherent susceptibility of the “hammock” position of the transobturator tape; or 3) the nonwoven polypropylene tape with mesh size of 50 &mgr;m itself may predispose to erosion or abscess.

Technical Update on Pessary Use

OBJECTIVE To review the use, care, and fitting of pessaries. OPTIONS Pessaries are an option for women presenting with prolapse and/or urinary incontinence. OUTCOMES Pessaries can be successfully fitted in the majority of women with excellent satisfaction rates and minimal complications. EVIDENCE PubMed and Medline were searched for articles published in English to September 2010, using the key words pessary, prolapse, incontinence, fitting, and complications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis, and articles were incorporated in the guideline to May 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force (Table 1). BENEFITS, HARMS, AND COSTS Women may choose a pessary for management of their prolapse and/or stress incontinence rather than opt for surgery. Major complications have been seen only with neglected pessaries. Minor complications such as vaginal discharge, odour, and erosions can usually be successfully treated. SUMMARY STATEMENTS AND RECOMMENDATION: Summary Statements 1. Most women can be successfully fitted with a pessary when they present with prolapse. (II-2) 2. Complications of pessary use are usually minor, and vaginal discharge is the most common complaint. (II-3) 3. Vaginal erosions can be treated with removal of the pessary and optional vaginal estrogen supplementation. (II-2) 4. Satisfaction rates with pessary use are very high. (II-2) Recommendation 1. Pessaries should be considered in all women presenting with symptomatic prolapse and/or urinary stress incontinence. (II-1A).

Trans-obturator surgery for stress urinary incontinence: 1-year follow-up of a cohort of 52 women

This study was a 1-year follow-up of a cohort of 52 women who underwent trans-obturator tape (TOT) procedures using Obtape. Follow-up information was available for 45/52 (87%) women. The rate of erosions was 8/52 (15%). Among 34 women examined, 26% experienced tenderness on palpation of operative site, and 72% were objectively cured on pad test. Forty women completed questionnaires (median Incontinence Impact Questionnaire-7, 0; median Urogenital Distress Inventory-6, 17) and of those, 93% would recommend TOT to a friend. We found a high rate of erosions among our cohort. Our high rate of erosions may be a result of our review of the majority of the cohort, and it is likely related to the specific device used (Obtape). The majority of women were satisfied with the outcome. Before introducing new procedures into widespread clinical practice, it is important to rigorously investigate their outcomes.

Success and Complications of Salpingectomy at the Time of Vaginal Hysterectomy

STUDY OBJECTIVES To document the success rates and complications of salpingectomy performed at the time of vaginal hysterectomy to possibly reduce ovarian cancer rates. DESIGN Retrospective cohort study (Canadian Task Force Classification II-2). SETTING Community-based hospital with university affiliation in Calgary, Canada. INTERVENTION All women undergoing hysterectomy for benign conditions were offered preferentially a vaginal approach with prophylactic salpingectomy. MEASUREMENTS AND MAIN RESULTS During the study period (October 2011 to January 2014), a total of 425 vaginal hysterectomies were performed. The overall success rate of salpingectomy was 88%. Pelvic adhesions significantly predicted the ability to perform salpingectomies (odds ratio, 6.3; 95% confidence interval, 2.8-14.3; p < .001). Age also was predictive of outcomes (p = .007), with increasing age predicting decrease success. The overall postoperative complication rate was 15%, with 3.8% possibly attributable to salpingectomy (i.e., intrapelvic complications). No associated factors were found on regression analysis. CONCLUSION Salpingectomy at the time of vaginal hysterectomy is a feasible procedure. Complication rates are low. Only pelvic adhesions are associated with failure to complete a salpingectomy.