Background
Sacral nerve stimulation (SNS) is effective for some patients with faecal incontinence. Before insertion of a costly implant, percutaneous nerve evaluation (PNE) is undertaken to identify ...patients likely to report success from SNS. The aim of this study was to determine whether variables of anal sphincter function measured by anal acoustic reflectometry (AAR) could predict the outcome of PNE for faecal incontinence.
Methods
Women with faecal incontinence undergoing PNE were recruited. AAR, followed by anal manometry, was performed on the day of surgery, immediately before PNE. The outcome of PNE was determined by bowel diary results and incontinence severity score. Patients with a successful PNE outcome were compared with those with an unsuccessful outcome; logistic regression analysis was used to identify any independent predictors of success.
Results
Fifty‐two patients were recruited, of whom 32 (62 per cent) had a successful PNE outcome and 20 (38 per cent) an unsuccessful outcome. The AAR variable opening pressure was significantly greater in patients who subsequently had a successful PNE result compared with the pressure in patients who did not (28 versus 17 cmH2O; P = 0·008). No difference was seen in the manometric equivalent, maximum resting pressure. Opening pressure was an independent predictor of success with an odds ratio of 1·08 (95 per cent confidence interval 1·01 to 1·16; P = 0·018).
Conclusion
AAR is a sensitive test of sphincter function and can identify differences between patients who respond to PNE and those who do not. Opening pressure is an independent predictor of success in PNE, and may be of value in the selection of patients for this expensive treatment option.
Opening pressure predicts percutaneous nerve evaluation success
Objective To determine the prevalence of bacterial vaginosis (BV) in the second trimester of pregnancy in a Danish population using the Schmidt criteria and to examine whether BV was associated with ...subsequent preterm delivery, low birthweight or perinatal infections.
Design Prospective cohort study.
Setting Department of Obstetrics and Gynaecology at a University Hospital, Denmark.
Population Three thousand five hundred and forty pregnant women aged 18 years or more.
Methods A smear from the vagina was obtained from all women, air‐dried and stored for subsequent diagnosis of BV. After rehydration with isotonic saline, the smear was examined in a phase‐contrast microscope at 400×, and the numbers of lactobacilli morphotypes and small bacterial morphotypes were counted. A score for BV was calculated according to the method described by Schmidt. The outcome of pregnancy from 20 weeks of gestation was examined in the 3262 singleton pregnant women who were included in this study before 20 weeks of gestation. The relationship between BV and adverse outcome of pregnancy was examined by univariate and multivariate analyses.
Main outcome measures Prevalence of BV, preterm delivery (<37 weeks), low birthweight (<2500 g), preterm delivery of a low‐birthweight infant and clinical chorioamnionitis.
Results The prevalence of BV was 16%, and the rate of preterm delivery was 5.2% in the study population of 3262 singleton pregnant women who were included before 20 weeks of gestation. Mean birthweight was significantly lower in infants of women with BV than in infants of women without BV (3408 versus 3511 g, P < 0.01). Univariate analyses showed that BV was marginally associated with preterm delivery but significantly associated with low birthweight, preterm delivery of a low birthweight infant, indicated preterm delivery and clinical chorioamnionitis. Multivariate analyses, which adjusted for previous miscarriage, previous preterm delivery, previous conisation, smoking, gestational diabetes, fetal death and preterm premature rupture of membranes, showed that BV was significantly associated with low birthweight (OR 1.95, 95% CI 1.3–2.9), preterm delivery of a low‐birthweight infant (OR 2.5, 95% CI 1.6–3.9), indicated preterm delivery (OR 2.4, 95% CI 1.4–4.1) and clinical chorioamnionitis (OR 2.7, 95% CI 1.4–5.1).
Conclusions The prevalence of BV determined using the Schmidt criteria in the early second trimester of pregnancy was similar to that found in similar studies. The presence of BV before 20 weeks of gestation was an independent risk factor for delivery of an infant with low birthweight, preterm delivery of a low‐birthweight infant, indicated preterm delivery and clinical chorioamnionitis.
To assess the proportion of women who consult their doctor about urinary incontinence (UI), and explore factors associated with help-seeking in France, Germany, Spain and the UK.
A representative ...sample of 29,500 women received a 13 item postal questionnaire to identify those with UI. A randomly selected sub-sample of 2953 women with UI received a more detailed follow-up questionnaire.
There was a response rate of 58% in the initial survey and 53% in the second. Thirty-one percent of all women had consulted a doctor about their UI symptoms with more women consulting in France and Germany than in the UK and Spain. A number of factors relating to general health care, UI and women's attitudes were found to be associated with help-seeking after adjusting for women's age, UI duration and frequency, and ‘bothersomeness’ of UI; factors traditionally associated with help-seeking. After adjusting for these factors, willingness to take long-term medication and having spoken to others about UI were found to be strong predictors of help-seeking in all four countries.
To our knowledge we report the first long-term use of desmopressin for nocturia. Patients previously responding to desmopressin in short-term studies were enrolled in this long-term open label study.
...Patients received treatment for 10 or 12 months with the optimal desmopressin dose (0.1, 0.2 or 0.4 mg orally at bedtime). Patients were followed a further month without treatment. Of the patients completing the short-term study 132 males (92%) and 117 females (83%) were recruited, and 95 (72%) and 87 (75%), respectively, completed long-term treatment.
The mean number of nocturnal voids was decreased in males and females throughout the study (1.3 to 1.6 and 1.2 to 1.3) compared with baseline (3.1 and 2.9, respectively). After followup the number of voids increased after treatment cessation. From baseline to 12 months the mean duration of the first sleep period gradually increased in males (157 to 288 minutes) and females (142 to 310 minutes). After followup the mean duration of the first sleep period decreased, confirming that it was a treatment related benefit. Desmopressin was well tolerated with few males (14%) or females (10%) withdrawing due to adverse events. Most adverse events were mild (44%) or moderate (44%) in severity. Four males experienced serious drug related adverse events, namely dizziness in 1, cardiac failure, headache and vomiting in 2, and chest pain and hypertension in 1. A female experienced 4 serious drug related adverse events, that is hyponatremia, headache, nausea and vertigo. Two patients had clinically significant hyponatremia.
This long-term study shows that desmopressin is a generally well tolerated and effective treatment for nocturia.
Objectives
To assess the efficacy of an oestradiol‐releasing vaginal ring and oestriol pessaries in the alleviation of lower urinary tract symptoms occurring after the menopause.
Design
Randomised, ...parallel group, controlled trial.
Setting
Twenty‐six clinics of practising gynaecologists and one outpatient clinic at a department of obstetrics and gynaecology.
Population
Two hundred and fifty‐one postmenopausal women, with a mean age of 66 years, reporting at least one bothersome lower urinary tract symptom.
Methods
One hundred and thirty‐four women were treated with the oestradiol‐releasing ring for 24 weeks; 117 women were treated with oestriol pessaries 0.5 mg every second day for 24 weeks.
Main outcome measures
Subjective scores of urgency, frequency, nocturia, dysuria, stress incontinence and urge incontinence.
Results
The two treatments were equally efficacious in alleviating urinary urgency (51%vs 56%), urge incontinence (58%vs 58%), stress incontinence (53%vs 59%) and nocturia (51%vs 54%). Dysuria was alleviated in 76%vs 67%, equivalence was not demonstrated. No statistically significant difference was found for any primary efficacy endpoint. Sixty percent of the participants rated the form of administration via the vaginal ring as excellent, compared with 14% for the pessaries (P < 0.0001).
Conclusions
Low dose vaginally administered oestradiol and oestriol are equally efficacious in alleviating lower urinary tract symptoms which appear after the menopause. The form of administration of the vaginal ring, seems to be more acceptable than oestriol pessaries.
Purpose We assessed the use of urethral pressure reflectometry in detecting pressure increases in the female urethra and compared the usefulness of urethral pressure reflectometry vs urethral ...pressure profilometry in a pharmacodynamic intervention study. Materials and Methods In this randomized, double-blind, placebo controlled, crossover study 17 women with stress urinary incontinence or mixed urinary incontinence received 4 mg esreboxetine or placebo for 7 to 9 days followed by a washout period before crossing over treatments. Urethral pressure reflectometry and urethral pressure profilometry were performed before and at the end of each treatment period. Results The urethral opening pressure measured with urethral pressure reflectometry increased significantly compared to placebo by 13.7 cm H2 O (p <0.0001) with an observed within subject standard deviation of 5.4. The increase in maximum urethral closure pressure was 8.4 cm H2 O compared to placebo (p = 0.06) and for maximum urethral pressure the increase was 9.9 cm H2 O (p = 0.04). However, the within subject SD for these parameters was higher at 11.4 and 12.2, respectively, implying lower power for these analyses. While receiving esreboxetine patients had significantly fewer incontinence episodes and reported a treatment benefit (global impression of change) compared to placebo. Conclusions The opening pressure measured with urethral pressure reflectometry was less variable compared to the parameters measured with urethral pressure profilometry (maximum urethral closure pressure and maximum urethral pressure). Consequently using urethral pressure reflectometry would result in a more efficient study design when investigating pharmacological effects on the urethra in future studies. We also found that esreboxetine was well tolerated, and had a positive and clinically relevant effect on urethral closure function and symptoms of stress urinary incontinence.
Objective Anal acoustic reflectometry (AAR) is a new technique that offers an assessment of anal sphincter function by the measurement of additional parameters not available with conventional ...manometry. The aim of this study is to describe the technique, methodology and initial pilot study results.
Method Wideband sounds (100 Hz to 16 kHz) are transmitted into a thin polyurethane bag placed within the anal canal. Calculation of cross‐sectional area from reflected sound waves, over a range of pressures (0–200 cm H2O) during inflation/deflation of the bag, results in five physiological parameters of anal canal function. Five patients three continent (two female) and two incontinent (both female) were assessed with AAR and anal manometry.
Results Anal acoustic reflectometry parameters were reduced in incontinent when compared with continent patients. Resting Opening Pressures (cmH2O) were 27 and 16 in patients with faecal incontinence (FI) vs 44 and 72 in continent patients; Resting Opening Elastance (cmH2O/mm2) was 0.88 and 1.08 in FI patients vs 1.65 and 1.34 in continent patients. The Resting Opening Pressure of a similarly aged continent male (55 cmH2O) was greater than three of the females. During assessment of voluntary contraction (one FI female vs one continent female), Squeeze Opening Pressure (cmH2O) was 31 vs 100 and Elastance (cmH2O/mm2) 0.61 vs 2.07.
Conclusion Anal acoustic reflectometry appears to be promising technique. Further work is in place to clarify whether it will be useful in clinical assessment of incontinent patients.
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