Acceptability and effectiveness of a multidisciplinary team approach involving counselling for mesh-removal patients.

Patients with complications following mesh removal risk a variety of symptoms, and can view medical intervention negatively. This study explored the patient-acceptability of a Multidisciplinary Team (MDT), and whether the presence of a Counsellor would be accepted and effective. Twenty consecutively referred women, who had undergone mesh-removal but experienced complications were interviewed about their experiences, and completed the Queensland scale for pelvic floor symptoms, McGill Pain Questionnaire, and Hospital Anxiety and Depression Scales, before and after treatment. Patients had high levels of pelvic-floor symptoms, sensory and affective pain, anxiety, and depression. 70% reported a positive MDT experience; predicted by higher anxiety, and lower depression. 60% elected to receive Counselling, which commenced within one week of referral, typically lasted 1-4 sessions, and reduced pelvic-floor symptoms, affective pain, anxiety, and depression. Results suggest that the MDT approach is generally acceptable for this patient group, and that mesh-removal patients accept and benefit from input by a Counsellor.Impact statementWhat is already known on this subject? Concerns have been raised regarding the safety of mesh insertion. Multidisciplinary Teams (MDTs) are suggested to offer a strong approach to managing many women's health conditions, but no studies have examined mesh-removal patients, making generalisation difficult to the current patient group. Furthermore, it is unknown whether an MDT approach, including a Counsellor, would be acceptable to mesh-removal patients.What do the results of this study add? Patients had high levels of pelvic-floor symptoms, pain, anxiety, and depression. 70% reported the MDT experience as positive, predicted by higher anxiety, and lower depression. 60% elected to receive Counselling, which reduced pelvic-floor symptoms, affective pain, anxiety, and depression.What are the implications of these findings for clinical practice and/or further research? The Counselling provided as part of the MDT approach was able to commence quickly, did not require many sessions, and reduced reported pelvic-floor symptoms, affective pain, anxiety, and depression. These findings suggest that an MDT approach involving Counselling is generally acceptable, and that mesh-removal patients accept and benefit from the input of a Counsellor, as part of their treatment.

Do patients with central sensitivity syndromes have poor subjective outcomes despite anatomical cure from pelvic organ prolapse surgery?

INTRODUCTION: Pelvic organ prolapse(POP) has an adverse impact on quality of life with lifetime risk of surgery varying from 11 to 20%. Conditions such as fibromyalgia (FMS), chronic fatigue syndrome (CFS/ME) and irritable bowel syndrome (IBS), collectively known as central sensitivity syndromes (CSS), may affect the outcome of POP surgery. The aim of this article is to compare the outcomes of vaginal POP surgery between women with and without CSS. METHOD: This was a prospective cohort study. The validated Central Sensitisation Inventory (CSI) was used to identify women with CSS. Subjective and objective outcomes were compared between the two groups using POP-SS, Expectation and satisfaction/"EGGS", pain scores and the POP quantification system (POP-Q). A non-parametric test was used for analysis. RESULT: Seventy-eight women were recruited. Complete data were available in 62 patients; 23 patients had evidence of CSS and 39 did not. Women with CSS had significantly higher pre- and post-operative POP-SS scores than those without (p < 0.0005, p = 0.004). Seventeen (73.9%) women with CSS compared to 38 (97.4%) women without CSS demonstrated improvement of a minimum 6 points on the POP-SS scale; however, this was not stastically significant. McGill's pain scores were higher in women with CSS both pre- and post-surgery. Ninety-five per cent of women without CSS achieved their goals and were satisfied with the surgery compared to 69.5% of women with CSS (p < 005). CONCLUSION: There is a less favourable outcome of POP surgery in women with CSS compared to those without in terms of persistence of symptoms, pain and overall satisfaction.

The proportion of women with central sensitivity syndrome in gynecology outpatient clinics (GOPDs).

INTRODUCTION AND HYPOTHESIS: Patients in gynecology outpatient clinics (GOPDs) may present with symptoms that do not correlate well with the observed pathology and are usually labelled as having a functional disorder or medically unexplained symptoms (MUS). Underlying central sensitivity syndrome (CSS) with central sensitization (CS) as a potential mechanism may be responsible for some of their symptoms. The aim of this study is to identify the proportion of women with central sensitivity syndrome attending GOPDs. METHODS: This was a prospective study. All women attending a GOPD included in the study were asked to complete a validated Central Sensitization Inventory (CSI). The responses were graded on a Likert scale from 0 (never) to 4 (always). The total score ranges from 0 to 100. For screening purposes, a single CSI cutoff score of 40 was used to identify the group of women who may have central sensitization syndrome. RESULTS: Three hundred twenty-six women participated in the study. Overall, 123 (37%) women achieved a score above 40. This could be interpreted as these patients having increased risk of underlying central sensitization. Of these, 43 had a previously confirmed diagnosis of migraine, 55 (44%) depression, 39 (31.7%) anxiety, 11 fibromyalgia (FM), 34 irritable bowel syndrome (IBS) and 16 chronic fatigue syndrome (CFS/ME). CONCLUSIONS: Managing patients and their expectations in gynecological outpatient departments when symptoms are inconsistent with observable pathological findings is challenging. This is further complicated when patients have a concomitant central sensitivity syndrome, which can also influence the surgical outcome. Identifying these patients is a key factor for appropriate management.

Should maximal urethral closure pressure be performed before midurethral sling surgery for stress incontinence? A time to revisit.

INTRODUCTION AND HYPOTHESIS: Maximum urethral closure pressure (MUCP) provides an objective assessment of urethral integrity, but its role in predicting outcome after midurethral sling (MUS) placement is debatable and current practice in the UK is variable. The study was carried out to determine if lower preoperative MUCP is associated with poor outcome following MUS. METHOD: The study was a retrospective review of the British Society of Urogynaecology (BSUG) database and urodynamics (UDS) data. Patients who reported outcome as "no improvement", "worse" or "much worse" on the Patient Global Impression of Improvement (PGII) scale were identified as having a poor outcome. Patients who reported "a little improvement", "improved" and "very much improved" on the PGII were thought to have a good outcome. The preoperative demographics, UDS findings and quality of life (International Consultation of Incontinence questionnaires [ICIQ-SF]) data of the two groups were compared. RESULT: A total of 236 women were identified for the study. Of these, 24 women (10.2 %) had a poor outcome. Of the remaining women reporting a good outcome, 50 cases were randomly selected. All urodynamic parameters, including mean functional urethral length (FUL), bladder capacity, and Qmax, were similar, except for mean MUCP 37.05 cm H2O, which was significantly lower in group 1 (poor outcome 37.05 cm H2O) compared with a mean MUCP of 50.6 cm H2O in group 2 (good outcome; p = 0.005). CONCLUSION: We conclude that failure following MUS is associated with preoperatively lower MUCP, which can be used as a predictor of failure.

Practices in pelvic organ prolapse operations among surgeons: an international survey identifying needs for further research.

OBJECTIVE AND HYPOTHESIS: Our aim was to identify variation in surgical technique for treating pelvic floor disorders looking specifically at differences in approach between subspeciality trained urogynaecologists and general gynaecologists. We hypothesised that speciality trained surgeons would have a more uniform operative technique. We did not make a hypothesis about which operative areas would have the most variation overall. METHODS: We performed a single-timepoint online survey of members of the International Urogynaecological Association (IUGA). Probability of difference from mean is presented as a raw value and significance of difference of means between surgical cohorts was calculated using the t test for independent variables. RESULTS: We received 205 responses from 118 general gynaecologists and 87 from subspecialty trained urogynaecologists (8 % response rate) to 27 questions concerning operative steps in four common urogynaecological operations. Surgeons had low levels of variation. The probability of any surgeon providing a different answer from the mode of their cohort was not significant within or between surgeons with and without subspeciality training (p = 0.47). Two areas with high levels of variation between surgeons were identified (probability of variation >0.5). These were: "In order to reduce cystocele, do you plicate the fascia covering the bladder or use vaginal tissue?" and "Would you usually plicate the rectovaginal facial septum to the vault?" CONCLUSIONS: Most urogynaecological surgeries were of similar technique; however there were two areas of significant variation between surgeons that may affect outcomes and warrant further study.

Clinical use of the ß3 adrenoceptor agonist mirabegron in patients with overactive bladder syndrome.

Mirabegron is a ß3 adrenoceptor agonist licensed for the treatment of overactive bladder symptoms, such as urinary urgency or urgency incontinence. ß3 adrenoceptor activation causes detrusor muscle relaxation, but mirabegron may also act by binding other targets in the bladder, and it may also reduce activity in sensory nerves. Phase III clinical trials (SCORPIO, ARIES, and CAPRICORN) evaluated mirabegron at various doses, demonstrating reduction from baseline to endpoint in mean incontinence episodes and mean number of micturitions per 24 h (coprimary endpoints), along with health-related quality of life and a range of secondary measures. Efficacy was seen in many patients who had previously discontinued antimuscarinic therapy on the grounds of lack of efficacy or poor tolerability. Treatment emergent adverse effects were documented in a long-term study (TAURUS), mostly being of mild or moderate severity. The most frequent adverse effects were hypertension, dry mouth, constipation, and headache, with a lower incidence of dry mouth than for the antimuscarinic active comparator. Efficacy and safety are not substantially different in older patients. A urodynamic safety study in men showed no consistent effect on voiding function, but a small increase in postvoid residual. Use of mirabegron in combination with α-adrenergic blockers does not appear to increase adverse effects. Dose reduction is needed in people with severe renal failure, or moderate hepatic failure. Dose adjustment is not needed in relation to food intake. Ongoing research is evaluating the potential for combination therapy with antimuscarinics.

Classification of stress urinary incontinence.

INTRODUCTION: The relevant terminology for stress urinary incontinence (SUI) is affected by the context, namely the clinical assessment (the symptom of SUI elicited on history taking and the sign of SUI observed during examination) or diagnostic investigations (urodynamic stress incontinence). In some cases, SUI may only be observed after the reduction in coexistent prolapse (occult SUI). Classifying SUI often relies on distinguishing between intrinsic sphincter deficiency (ISD), and urethral malposition or hypermobility, although this potentially an over-simplification. REVIEW: Classification systems have been derived based on clinical assessment and diagnostic testing, notably videourodynamics. Modern developments in imaging technology may allow other techniques such as ultrasound to offer additional basis for future developments in classification. Other urodynamic approaches include urethral pressure profilometry and Valsalva leak point pressure; these may offer indicators of thresholds below which ISD is more likely to explain SUI, but they are not generally accepted in routine practice. CONCLUSIONS: While SUI classification is potentially relevant to treatment selection, evidence for influence on management outcome is limited. Generating a high-quality evidence base for treatment selection on these criteria is problematic, particularly due to the range of confounding factors. In practice, the modern practitioner relies on various tools to form an opinion on some key aspects, using the findings to derive a treatment strategy. Accordingly, there remains a need to confirm how a classification of SUI translates into treatment selection and better outcomes.

Interstitial cystitis: diagnosis and management.

Interstitial cystitis/painful bladder syndrome is a chronic condition that causes debilitating bladder pain which can be associated with urgency, frequency and nocturia. Its cause is not clear and it is still a disease diagnosed by exclusion. Oral or intravesical therapies are the main stay of treatment whilst surgical procedures are reserved for refractory cases. This condition usually warrants a multidisciplinary approach for optimum outcome. This article gives an overview of the changes in definition, aetiopathogenesis and available treatments.

Emerging drugs for treatment of urinary incontinence.

IMPORTANCE OF THE FIELD: Urinary incontinence (UI) is a common problem and there are so many advances done in the field to help treat this common and distressing condition. AREAS COVERED IN THIS REVIEW: In this article we have tried to give an overview about current and emerging drugs available for the management of UI. WHAT THE READERS GAIN: Reading the article will help to fill the knowledge gap regarding drugs available for treatment of UI. TAKE HOME MESSAGE: Anti-muscarinic drugs remain the first-line treatment of overactive bladder (OAB) and a favorable efficacy/tolerability:safety ratio can be confirmed, but adverse effects and decreasing compliance remains an issue. Promising new alternatives are emerging but require further controlled studies to confirm their place in treatment of OAB. Surgery is still the mainstay for treatment of stress incontinence although duloxetine is the only drug licensed for this indication.

Overactive bladder: diagnosis and treatment.

Overactive bladder syndrome is a chronic condition that requires long-term management and is associated with a significant impairment in the quality of life of the individual as well as having an economic impact on healthcare. Behavioral interventions, along with lifestyle modifications, are effective, but medical management remains the mainstay of treatment. Challenges to improving the overactive bladder syndrome burden and outcomes include underdiagnosis, undertreatment and patient nonadherence to medication. Recent pharmacological advances, along with behavioral interventions, have helped to improve patient compliance. Healthcare providers should acknowledge the need for education regarding overactive bladder syndrome symptoms, its diagnosis and its management options. This article gives an overview of overactive bladder syndrome, its diagnosis and the different treatment options available, as well as discussing recent advances in the field.

Current and future approaches to the management of female urinary incontinence.

Urinary incontinence is an increasingly prevalent condition affecting women of all ages and is known to have significant impact on quality of life. At present there are a variety of treatment options available to manage urinary incontinence in the form of conservative therapies, medication and surgical interventions. However, research continues to explore other treatment options that offer improved efficacy, tolerability and a reduction in adverse effects. This article aims to provide a review of all available treatment options for women with urinary incontinence and highlights current research outcomes that may be further developed in this area.