Maya Basu

The predictive value of preoperative pressure‐flow studies in the resolution of detrusor overactivity and overactive bladder after tension‐free vaginal tape insertion

To determine whether preoperative pressure‐flow studies (PFS) predict the resolution of detrusor overactivity (DO) and overactive bladder (OAB) symptoms after a tension‐free vaginal tape procedure (TVT).

Update on duloxetine for the management of stress urinary incontinence.

Duloxetine is a relatively balanced serotonin and noradrenaline reuptake inhibitor (SNRI), which is the first drug with widely proven efficacy to have been licensed for the medical treatment of women with stress urinary incontinence (SUI). Despite favorable results from randomized controlled trials, surgical management continues to be the mainstay of treatment for SUI. In this review we explore the pharmacology of duloxetine in the nervous system and lower urinary tract, and the evidence for its use in the management of women with urinary incontinence.

Can the incidence of obstetric anal sphincter injury be reduced? The STOMP experience

OBJECTIVE To reduce the incidence of third and fourth degree perineal tears. STUDY DESIGN This was a quality improvement project followed by an audit of outcomes. The population consisted of all women delivering vaginally over a 12 month period following implementation of the quality improvement measures. Following a review of clinical factors associated with all third and fourth degree tears over a 3 month period and a review of relevant evidence, a series of measures to try and reduce the incidence of such tears were introduced. These measures were collectively known as STOMP (Stop Traumatic OASIS Morbidity Project). These were adopted by all staff in our unit, with an accompanying programme of workshops and a publicity campaign to promote staff engagement. Data were collected on all third and fourth degree tears for a 12 month period following project launch. The primary outcome was the incidence of third and fourth degree perineal tears over a 12 month period. RESULTS There were a total of 3902 vaginal births during the 12 month period following project launch. Following full STOMP implementation, there was a significant decrease in the incidence of third/fourth degree tears (4.7% vs 2.2%, p<0.0001). The reduction was most pronounced in the first 5 months (4.7% vs 1.51%, p<0.0001). CONCLUSIONS STOMP is a simple and low cost series of measures that has lead to a significant decrease in the incidence of third and fourth degree tears in this cohort of women.

The association of changes in opening detrusor pressure with the resolution of overactive bladder symptoms after repair of pelvic organ prolapse

To evaluate whether changes in opening detrusor pressure (ODP) are associated with resolution of overactive bladder symptoms in women undergoing surgical correction of pelvic organ prolapse.

TVT vs TOT: a case controlled study in patients with mixed urodynamic stress incontinence and detrusor overactivity.

IntroductionAlthough transobturator tapes (TOT) have been suggested to be equivalent to retropubic tension-free vaginal tapes (TVT) in the management of urodynamic stress incontinence, there is very little evidence for their use in women with mixed incontinence. The aim of this study was to evaluate the efficacy of the TOT against the retropubic TVT in women with mixed incontinence.Patients and methodsA case controlled study was used with 34 women matched for age and type of procedure.ResultsTen out of 34 (29.4%) patients in the TOT group required a repeat continence procedure versus 0/34 (0%) in the retropubic group. Patients who had undergone a TOT were significantly more likely to require repeat surgery (odds ratio 10.1, 95% confidence interval 2.6–38.2).ConclusionsThis study suggests a higher failure rate in women undergoing a TOT for USI and DO compared to a retropubic TVT when assessed with a case controlled study.

Tension-free vaginal tape for stress incontinence in women with detrusor overactivity

In this case report, we discuss two cases of the successful use of the tension-free vaginal tape (TVT) to treat women with detrusor overactivity (DO) but no evidence of urodynamic stress incontinence (USI). The use of the TVT for the treatment of DO has been evaluated in a small number of studies of women with mixed incontinence. There is no data in the literature concerning its use in women with DO only. Here, we briefly review the literature including the postulated mechanism by which stress leakage due to DO is cured by the TVT.

What is the relationship between free flow and pressure flow studies in women

Introduction and hypothesisThe relationship between free flow (FFS) and pressure flow (PFS) voiding studies remains uncertain and the effect of a urethral catheter on flow rates has not been determined. The relationship between residuals obtained at FF and PFS has yet to be established.MethodsThis was a prospective cohort study based on 474 consecutive women undergoing cystometry using different sized urethral catheters at different centres. FFS and PFS data were compared for different conditions and the relationship of residuals analysed for FFS and PFS. The null hypothesis was that urethral catheters do not produce an alteration in maximum flow rates for PFS and FF studies.ResultsUrethral catheterisation results in lower flow rates (p < 0.01) and this finding is confirmed when flows are corrected for voided volume (p < 0.01). FFS and PFS maximum flow rates are lower in women with DO than USI (p < 0.01). A 6-F urethral catheter does not have a significantly greater effect than a 4.5-F urethral catheter. A mathematical model can be applied to transform FFS to PFS flow rates and vice versa. There was no significant difference between the mean residuals of the two groups (FFS vs PFS—two-tailed t = 0.54, p = 0.59). Positive residuals in FFS showed a good association with positive residuals in the PFS (r = 0.53, p < 0.01)ConclusionsUrethral catheterisation results in lower maximum flow rates. The relationship can be compared mathematically. The null hypothesis can be rejected.

Short-term morbidity following vaginal prolapse surgery: what the surgeon does not see

The aim of this study was to estimate the incidence of minor complications after pelvic floor surgery as well as service utilisation for these complaints. One hundred consecutive women were asked about any troublesome symptoms following pelvic floor surgery. Sixty-six percent of women reported a troublesome complaint in the post-operative period. The most common symptom was vaginal discharge. Forty-four percent of this cohort sought the advice of a medical practitioner. These findings are important since patients may wish to know about the more common but fairly troublesome minor complaints found in this study. They also have implications for resource use following surgery.

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.

Long‐term outcomes of the Stop Traumatic OASI Morbidity Project (STOMP)

To evaluate long‐term sustainability of the Stop Traumatic OASI Morbidity Project (STOMP) in reducing the incidence of obstetric anal sphincter injury (OASI).