Malcolm Waterfield

Prevention of postpartum stress incontinence in primigravidae with increased bladder neck mobility: a randomised controlled trial of antenatal pelvic floor exercises

To test whether supervised pelvic floor exercises antenatally will reduce the incidence of postpartum stress incontinence in at‐risk primigravidae with bladder neck mobility, ultrasonically proven.

The effect of cannabis on urge incontinence in patients with multiple sclerosis: a multicentre, randomised placebo-controlled trial (CAMS-LUTS)

Objective: To test whether cannabinoids reduce urge incontinence episodes without affecting voiding in patients with multiple sclerosis. This was part of the multicentre trial of the Cannabinoids in Multiple Sclerosis (CAMS) study. Subjects and methods: The CAMS study randomised 630 patients to receive oral administration of cannabis extract, Δ9-tetrahydrocannabinol (THC) or matched placebo. For this substudy subjects completed incontinence diaries. Results: All three groups showed a significant reduction, p<0.01, in adjusted episode rate (i.e. correcting for baseline imbalance) from baseline to the end of treatment: cannabis extract, 38%; THC, 33%; and placebo, 18%. Both active treatments showed significant effects over placebo (cannabis extract, p=0.005; THC, p=0.039). Conclusion: The findings are suggestive of a clinical effect of cannabis on incontinence episodes in patients with MS. This is in contrast to the negative finding of the CAMS study, where no difference was seen in the primary outcome of spasticity.

The long‐term effectiveness of antenatal pelvic floor muscle training: eight‐year follow up of a randomised controlled trial

Objective  To determine the long‐term effectiveness of antenatal pelvic floor muscle training (PFMT) on stress urinary incontinence (SUI).

Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS)

Introduction and hypothesisThere seems to be a temporal association between increasing use of “hands off” the perineum in labour and reduced use of episiotomy with an increasing rate of anal sphincter injuries. We aimed to determine how common the practice of “hands off” the perineum is.MethodsAn observational postal questionnaire study of 1,000 midwives in England in which the main objective was to obtain an estimate of the number of midwives practising either “hands on” or “hands off” was conducted.ResultsSix hundred and seven questionnaires were returned; 299 (49.3%, 95% CI 45.2–53.3%) midwives prefer the “hands-off” method. Less-experienced midwives were more likely to prefer the “hands off” (72% vs. 41.4%, p < 0.001). A higher proportion of midwives in the “hands-off” group would never do an episiotomy (37.1% vs. 24.4%, p = 0.001) for indications other than fetal distress.ConclusionsThe “hands off” the perineum technique is prevalent in the management of labour. We hypothesise that a possible consequence might be an increased incidence of obstetric anal sphincter injury.

A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study. Reply to comment

Dear Editor, We would like to thank Dr Long and colleagues for pointing out the error in our paper [1], i.e. we inadvertently used the word “grade” instead of “stage” for the POPQ. This is a good example of how even those who purport to understand and use the POPQ, still make errors, in our case with terminology. Unfortunately, Dr Long and colleagues [2] have done likewise! In their letter they state that “at least 1 cm above or beyond the hymeneal remnants should be the stage 3 or more of POP-Q”. In fact (as we stated) this is stage II, i.e. leading edge greater than or equal to −1, but less than or equal to +1 [3]. Our baseline data are presented in the results section of the paper [1]: point C was +0.12 for the abdominal and +0.28 for the laparoscopic sacrocolpopexy (i.e. POPQ stage II). At 3 months this was −6.65 (SD 138) and −6.48 (SD 1.50) and the corresponding results at 1 year were −6.63 (SD 1.35) and −6.65 (SD 1.15) for abdominal and laparoscopic sacrocolpopexy respectively. The IUGA/ICS standardization report for the outcomes of prolapse surgery [4] recommends that the leading edge of the prolapse at each site should be reported in detail. This includes all the points as well as the ordinal stage. It could be argued that the points are more meaningful than the stage, but these seem to be reported inconsistently with a recent literature review showing that 47 % of studies used the ordinal stage only and not the points [5]. It is important that there is some form of staging or grading of prolapse and maybe the “simplified POPQ”, which uses the ordinal stage, could be used in routine practice [6], as some clinicians perceive the full POPQ to be “too complex”. The “simplified” system has been validated and shown to have a good association with the full POPQ [6]. However, the latter should be used in all research [4] and those undertaking the examination must be fully trained in the technique to ensure accurate data and reporting. Whether this occurs or not is unclear. It is encouraging to see the improved uptake in the use of the POPQ since our study in 2004, which showed that only 40 % of IUGA and AUGS members used it routinely in their clinical practice [7]. A recent study has suggested that 76 % of AUGS and ICS members are now using the POPQ, but the authors state that the technique “varied considerably” [8]. This raises further concern about training and maybe the reliability of some data. Dr Long’s comments are helpful and allow us to highlight these concerns. The POPQ was originally described in 1998 and maybe now is the time for the ICS, AUGS, SGS and IUGA to revisit it and, more importantly, the training. R. M. Freeman (*) :K. Pantazis : L. Bombieri :M. Waterfield Urogynaecology Unit, Directorate of Women’s Health, Derriford Hospital, Derriford Road, Crownhill, Plymouth PL6 8DH, UK e-mail: robert.freeman@nhs.net

Author Response to: The long-term effectiveness of antenatal pelvic floor muscle training: 8-year follow up of a randomised controlled trial

d A 3-year follow-up study was attempted by postal questionnaire using the King’s Health Questionnaire. However, the response rate was low and, therefore, the data were not published other than in abstract form.2 The results in fact did show a significant difference in quality of life (QoL) scores in favour of the study group compared with controls, but the conclusions had to be interpreted very cautiously in view of the low response rate. In the current 8-year follow-up study,3 we decided to send an invitation letter followed by a phone call during which the questionnaires were completed.