Maria Vella

Tolerability and efficacy of duloxetine in a nontrial situation

Objective  To assess the tolerability and efficacy of duloxetine in a nontrial situation.

Pregnancy and delivery following tension-free vaginal tape

The tension-free vaginal tape (TVT) has become an increasingly popular, minimally invasive surgical treatment for urodynamic stress incontinence. As a consequence of its popularity, more women of childbearing age are undergoing surgery, and thus the incidence of pregnancy following surgery is likely to increase. We report two cases of unplanned pregnancy following TVT, both of which remained continent following delivery.

Management of overactive bladder syndrome

Overactive bladder (OAB) syndrome is the term used to describe the symptom complex of urinary urgency with or without urge incontinence, usually with frequency and nocturia. Drug treatment continues to have an important role in the management of women with OAB. Other treatment options include conservative management with lifestyle interventions, modification of fluid intake, and physiotherapy including bladder retraining. Surgery remains the last resort in the treatment and is usually reserved for intractable detrusor overactivity, as it is associated with significant morbidity. This article reviews the management of the overactive bladder with specific focus on newer developments in the medical treatment of OAB in women.

Prolapse and sexual function in women with benign joint hypermobility syndrome

To determine whether pelvic organ prolapse (POP) and sexual dysfunction are more severe in women with benign joint hypermobility syndrome (BJHS) than in the normal population.

Prevalence of incontinence and incontinence-specific quality of life impairment in women with cystic fibrosis†‡

Cystic fibrosis (CF) is the commonest autosomal recessive disorder in Caucasians. With advancing medical technology, the life expectancy has more than double in the last twenty years. This has led to new unforeseen health problems like urinary incontinence. The aim was to establish the prevalence, symptomatic typology, and quality of life impact of incontinence in a population of women with CF.

The bladder diary: do women perceive it as a useful investigation?

OBJECTIVE The completion of a bladder diary is routinely undertaken as part of the initial assessment of women presenting with lower urinary tract symptoms. Anecdotally some women find it a nuisance to fill in a fluid volume chart. The QQ10 is a questionnaire which has been developed to evaluate the use of other questionnaires or investigations. This study aims to assess womens perception of completing a bladder diary as part of their investigative process and to identify reasons why some may fail to complete one. STUDY DESIGN All women attending a one-stop urogynaecology clinic were sent instructions to fill in a three-day bladder diary. Those who filled a diary in were asked to fill in a QQ10 questionnaire. Those who did not fill one in were asked to give a reason for not doing so. RESULTS 128 women attended the clinic over a study period. Of these 100 (78%) completed a diary and hence a modified QQ10 form and 28 women (22%) did not. The mean value score was found to be high, at 72.6 (SD 17.87) whilst the mean burden score was low at only 27.7 (SD. 21.14). The majority of women who did not fill one in claimed they had not received a diary in the first place. CONCLUSION Most women appear to fill in a diary. The high mean value score and the low mean burden score indicate that women do not find filling in a diary a particularly onerous task.

Predicting detrusor overactivity using a physician-based scoring system

Women with lower urinary tract symptoms (LUTS) commonly present to primary care. Management is often based on a symptomatic diagnosis alone although LUTS correlate with urodynamic diagnosis in 65% of cases. The aim of this study was to develop a scoring system to discriminate between the symptoms of stress urinary incontinence (SUI) and overactive bladder (OAB). Physicians completed a specially developed questionnaire for all women complaining of LUTS. Women then underwent videocystourethrography. A scoring system based on the likelihood of each symptom for DO was developed using odds ratios and 95% confidence intervals (CI). This scoring system was subsequently used to discriminate those women with OAB from those with SUI. One hundred seventy one women were recruited to the study. This scoring system had a sensitivity of 79%, a specificity of 78% and a positive predictive value of 73% to identify detrusor overactivity (DO) This new OAB scoring system may be used in primary care to help discriminate between USI and DO.

Review of fesoterodine

Introduction: Overactive bladder syndrome is a common condition that adversely affects the quality of life. It is mainly treated with a combination of bladder retraining and antimuscarinics. In a quest to reduce the side effect profile of these drugs, whilst improving their efficacy, more bladder-selective antimuscarinics were developed. One of the more recent of these antimuscarinics which has come to the market is fesoterodine. This review examines the evidence of the safety and efficacy of this drug. Areas covered: A literature search performed identified two main multi-center trials which highlight the safety, efficacy and tolerability of fesoterodine. These together with the pharmacologic properties of the drug are discussed at length throughout the review. An expert opinion is then formulated based on the current evidence available and on comparison with other antimuscarinics. Expert opinion: It is concluded that fesoterodine has the added advantage of flexible dosing over some other antimuscarinics. It does, however, have a similar tolerability and side effect profile to other antimuscarinics and is, therefore, unlikely to revolutionize the treatment of the overactive bladder.

A Reappraisal of Storage and Voiding Dysfunction

Lower urinary tract symptoms are common in women. They may be more broadly classified into storage and voiding disorders. Recent literature has focussed on the management of voiding dysfunction and the spectrum of symptoms presented by women with such disorders. Symptoms of voiding dysfunction and storage symptoms may coexist, making diagnosis and management even more challenging. The purpose of this paper is to review the literature regarding the definition and management of voiding dysfunction with and without associated storage symptoms.

The predictive value of pre-treatment cystometry in the outcome of women with mixed incontinence treated with duloxetine

OBJECTIVES Whilst auditing the results of women treated with duloxetine, it was noted that some women with mixed urodynamic stress incontinence (USI) and detrusor overactivity (DO) reported worsening of their incontinence. Duloxetine works by increasing urethral resistance and may alter voiding function. Worsening voiding may result in worsening irritative symptoms. The aim of our study was to assess whether pre-treatment pressure flow studies predicted which women with mixed USI and DO became worse after treatment with duloxetine. STUDY DESIGN Women were recruited from our one-stop urogynaecology clinic. All women complained of troublesome mixed urinary symptoms with moderate or severe stress incontinence. Their initial assessment included a detailed history, a physical examination, a 3-day urinary diary, Kings Quality of Life questionnaire and filling cystometry. RESULTS Fifty seven women were recruited. Thirty (52%) women recorded an improvement in their patient global impression of improvement (PGI-I) score; 18 (32%) recorded no change and nine (16%) women reported worsening bladder symptoms. Pressure flow studies of women who recorded a worsening of their incontinence were compared to those women who recorded no change or an improvement of their incontinence. The maximum flow rate (p=0.78), average flow rate (p=0.61), bladder capacity (p=0.14), detrusor pressure at maximum flow (p=0.68) and volume voided (0.66) showed no statistical difference when the two groups were compared. The pre-treatment voiding time (p=0.04) was statistically longer in women who got worse following treatment with duloxetine. CONCLUSION Pre-treatment pressure flow studies may be useful in predicting the outcome of treatment with duloxetine. Women who report worsening of their incontinence are more likely to have a longer voiding time compared to women who do not report worsening. Hence a prolonged voiding time may predict a poorer outcome for women treated with duloxetine.