Healthcare professional's choice for surgical management of stress urinary incontinence in a U.K. tertiary hospital.

OBJECTIVE: In July 2018, NHS England, introduced a pause on vaginal mesh, including the mid-urethral sling (MUS) for treatment of stress urinary incontinence (SUI). NICE guidelines recommend MUS as one of the surgical options for SUI. The aim of our study was to investigate healthcare professionals choices for surgical treatment of SUI, if conservative measures failed. STUDY DESIGN: The urogynaecology department at our tertiary level hospital devised a questionnaire using SurveyMonkey. This was distributed via email to 1058 healthcare professionals of different medical backgrounds. The surgical options were based on the NICE guideline and its patient decision making aid. We also used surgical information from the British society of Urogynaecology (BSUG) and British association of urological surgeons (BAUS). RESULTS: We received 214 responses of which 204 were complete. Twenty six percent of replies were from obstetricians and gynaecologists, 36 % had over 20 years experience and 79 % were female. Forty four percent had no previous knowledge of surgical options. Mid-urethral sling was the most popular choice based on description, success and specific complications. Urethral bulking agent was the only option that increased in popularity after describing complications. Twenty two percent would avoid surgery due to the risk of complications. CONCLUSION: This is the first study evaluating healthcare professionals surgical choice for SUI. Despite negative media publicity and NHS pause on MUS, it was still the most popular choice before and after informing of specific complications. The urethral bulking agent was the only surgical treatment, which increased in popularity after considering complications.

Modern management of genitourinary syndrome of menopause.

The genitourinary syndrome of menopause (GSM) is the accepted term used to describe the broad spectrum of genitourinary tract symptoms and signs caused by the loss of endogenous sex steroids that occurs at the time of and after the menopause. Global improvements in healthcare have resulted in an ageing population. Today, women are spending 40% of their lives in the postmenopausal state, and with 50-70% of postmenopausal women reporting symptomatic GSM, safe and efficacious treatments are needed for this troublesome condition. This article reviews current evidence for non-pharmacological and pharmacological treatments with a focus on novel and minimally invasive procedures such as energy-based devices (CO2 laser, YAG laser), hyaluronic acid, dehydroepiandrosterone, and selective oestrogen receptor modulators.

Pharmacist's knowledge regarding the management of overactive bladder in elderly women.

OBJECTIVE: Anticholinergic drugs are the mainstay treatment of OAB. Anticholinergic load is the cumulative effect of taking anticholinergic medication. Recent evidence suggests that in the elderly this can have a detrimental affect, with the potential to develop dementia. A previous study found that knowledge of anticholinergic load was lacking in our healthcare professionals. The aim of this study was to assess knowledge of pharmacists, who in the UK have the potential where qualified to prescribe as well as dispense. STUDY DESIGN: A questionnaire was formulated based on the previous study. It was sent out to 418 pharmacists from; a south London hospital trust, a south London clinical commissioning group and United Kingdom Clinical Pharmacists Association. RESULTS: Seventy-five pharmacists completed the questionnaire. Solifenacin and tolterodine was the most popular drug prescribed in the elderly without dementia, whilst mirabegron was the most popular in the elderly with dementia. One pharmacist suggested using oxybutynin. Sixty-two percent discuss anticholinergic load with the patients, 40 % advice prescribers and 42 % consider anticholinergic load when dispensing the drug. Fifteen percent have had patients report confusion/memory loss. Thirty percent know how to assess anticholinergic load. Only 15 % felt dementia was a concern with anticholinergic drugs. Worryingly, 54 % though mirabegron exerted anticholinergic effects. CONCLUSION: This is the first study looking at pharmacist knowledge on the use of anticholinergic medication for OAB in elderly women. Knowledge amongst all healthcare professionals including pharmacists is lacking and needs to be improved.

Defining nocturnal polyuria in women.

AIMS: Nocturnal polyuria (NP) is defined by the International Continence Society (ICS) as "excessive production of urine during the main sleep period" and is one of the main causes of nocturia. The ICS recognized that "excessive" is not clearly defined and that this needs to be highlighted in both clinical and research settings. The aim of this study was to identify different definitions of NP and apply them to a population of women attending the Urogynaecology clinic. METHODS: This was a retrospective study of complete bladder diaries collected from women attending a tertiary Urogynaecology Unit. Six different definitions were identified and were divided into "absolute," "relative," and "functional definitions." Prevalence data were calculated and values generated for sensitivity, specificity, positive and negative predictive values when related to women voiding ≥ 2 times per night. RESULTS: Complete bladder diaries were obtained from 1398 women, over 6 years, with a mean age of 57 years. Prevalence varied across the definitions from 21.5% (absolute definition) to 77% (relative definition). Sensitivity ranged from 43% (absolute) to 87% (relative). The definitions that showed the highest combined sensitivity and specificity were the functional definitions. CONCLUSION: From this study it is clear that more work needs to be done to arrive at a consensus for defining NP to enable accurate diagnosis and development of treatment pathways. We propose that a relative definition may provide a more clinically relevant method of defining NP.

Recent advances in managing overactive bladder.

Overactive bladder syndrome (OAB) is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency incontinence, in the absence of urinary tract infection or other obvious pathology. In this review, we focus on recent advances in the management of OAB. We examine the evidence on the effect of anticholinergic load on OAB patients. Advances in medical treatment include a new beta-3 agonist, vibegron, which is thought to have fewer drug interactions than mirabegron. Treatment of genitourinary syndrome of the menopause with oestrogens and ospemifene have also shown promise for OAB. Botulinum toxin has been shown to be an effective treatment option. We discuss the new implantable neuromodulators that are on the market as well as selective bladder denervation and laser technology.

Recent advances in urodynamics in women.

Urodynamics is the study of the storage and evacuation of urine from the urinary tract. The aim is to reproduce the patient's symptoms and provide a pathophysiological explanation for them by identifying all factors that contribute to the lower urinary tract dysfunction, including those that are asymptomatic. Urodynamics consists of various tests, each of which is designed to assess a different aspect of lower urinary tract function. There is a lack of evidence regarding when urodynamics should be used in the non-neurogenic bladder. Some small randomised controlled trials suggest that urodynamics does not alter the outcome of surgery for stress urinary incontinence when compared with office evaluation alone. However, this is widely felt to be inaccurate and many health-care professionals still advocate the use of urodynamics prior to any invasive treatment, especially surgery on the lower urinary tract. There have been few technological advances in urodynamics in recent years. Air-charged rather than fluid-filled catheters were thought to help reduce artefact, but the evidence is unclear, and there is doubt over their accuracy. Ambulatory urodynamics is carried out over a longer period of time, enabling physiological bladder filling, but it remains invasive and artificial. To attempt to replicate symptoms more accurately, there have been efforts to develop wireless devices to measure detrusor pressure directly. These may be promising but are far from suitable in humans at present. Urodynamics continues to provide useful information for assessing lower urinary tract function, but further large studies are required to assess its value and develop innovations to improve the accuracy of the tests and acceptability to patients.

Antibiotic resistance in urinary tract infections: A re-visit after five years and experience over two sites.

OBJECTIVE: The aim of this study was to repeat a previous audit, performed from 2009 to 2013, for the cohort of 2018 to determine how the resistance rates in urinary pathogens in women over 18 years of age have changed. A secondary aim of the study was to use resistance data from a different UK hospital in the same year to compare differences in resistance rates across different geographic locations. STUDY DESIGN: This was a retrospective study of all positive urine cultures grown from female patients attending two different hospitals in the year 2018. Resistance patterns were analysed. RESULTS: The resistance rate to co-amoxiclav continues to increase with amoxicillin retaining high resistance patterns. There are some significant differences in resistance patterns between the different locations. CONCLUSION: Antimicrobial resistance is a significant problem in the UK particularly in antibiotics used to treat UTI. These patterns can vary across different geographical locations and over time; therefore, up-to-date knowledge of local anti-biotic resistance is essential when making an appropriate prescription choice.

What affects the placebo effect?

OBJECTIVE: To determine whether electronic bladder diaries are associated with a larger placebo effect than paper diaries in studies of overactive bladder (OAB). To identify any other factors in study design that may influence the placebo effect. STUDY DESIGN: This is a secondary analysis of a previous systematic review and network meta-analysis on the efficacy and tolerability of mirabegron. Each study was analysed and placebo response rate (PRR) was calculated. Statistical analysis was used to look for associations with different factors and PRR. RESULTS: The PRR was considerable in the studies analysed (10.5 % when calculated for change in number of micturitions over 24 h and 41.2 % for change in urgency urinary incontinence episodes over 24 h). Paper bladder diaries were associated with a significantly larger placebo response rate than electronic (10.76 % vs 10.22 %), although this may be clinically small. The size of study had a moderate positive correlation with PRR. Length of bladder diary was not associated with increased PRR. CONCLUSIONS: The PRR in studies of OAB is varied and significant. It is clear that it can be affected by factors in study design including type of bladder diary. When designing clinical studies this should be borne in mind. Equally, when attempting to optimise patient care, the benefit of the therapeutic encounter should be remembered.

Mesh-related complications of laparoscopic sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: Apical vaginal support for post-hysterectomy vault prolapse can be provided by vaginal, abdominal, or laparoscopic routes. Sacrocolpopexy is associated with higher satisfaction rates and a lower re-operation rate than vaginal sacrospinous fixation. The laparoscopic approach can reduce hospital stay and blood loss. There are concerns about the use of mesh in urogynaecological procedures, but limited data indicate a low mesh complication rate with sacrocolpopexy (0-5%). This study was aimed at establishing the incidence of complications following laparoscopic sacrocolpopexy. METHODS: We carried out a retrospective cohort study of patients who underwent laparoscopic sacrocolpopexy at a large tertiary hospital. Cases were identified from coding data, theatre logs and the national urogynaecology procedure database. Data were gathered from theatre records, patient notes and the national database. Demographic data, concomitant procedures performed, duration of surgery, intra-operative complications, change in pelvic organ prolapse quantification point C, duration of stay, late complications and further urogynaecological surgery were assessed. RESULTS: A total of 660 patients underwent laparoscopic sacrocolpopexy between 2005 and 2017 (median time from surgery 4 years 3 months). Five cases (0.7%) developed vaginal mesh exposure. Two were successfully managed conservatively with topical oestrogen. Three required surgical excision of the mesh. Four patients (0.6%) presented with erosion of non-absorbable vaginal sutures. Two were successfully managed conservatively with topical oestrogen and oral antibiotics. Two were managed with vaginal suture excision. CONCLUSIONS: This large series suggests that laparoscopic sacrocolpopexy might confer a low risk of mesh exposure. Together with good anatomical and patient-reported outcomes, laparoscopic sacrocolpopexy is a safe option for patients presenting with post-hysterectomy vault prolapse.

Obturator nerve injury: a rare complication of retropubic tension-free vaginal sling.

The tension-free vaginal tape (TVT) retropubic sling is a very effective treatment for stress urinary incontinence. High cure rates are typically achieved, and the reported complication rate is relatively low. Obturator neuralgia secondary to insertion of a midurethral sling is a rare and specific type of chronic pain that is more commonly associated with transobturator tape slings. The purpose of this video case report was to demonstrate that obturator nerve injury is a possible complication of TVT retropubic slings placement. A discussion of symptoms and signs of obturator nerve injury and how these should be managed is also presented.

Low prevalence of risk markers in cases of sudden death due to Brugada syndrome relevance to risk stratification in Brugada syndrome.

OBJECTIVES: The objective of this study was to determine the prevalence of conventional risk factors in sudden arrhythmic death syndrome (SADS) probands with Brugada syndrome (BrS). BACKGROUND: Patients with BrS and previous aborted sudden cardiac death (SCD) are at high risk of recurrent events. Other universally accepted clinical features associated with higher risk include unheralded syncope and the presence of a spontaneous type 1 electrocardiogram (ECG). METHODS: We analyzed reported symptoms and reviewed ECGs from SADS probands with familial diagnoses of BrS, established by cardiological evaluation, including ECG, 2-dimensional echocardiography, Holter monitoring, exercise tolerance testing, and ajmaline provocation. These cases underwent familial evaluation between 2003 and 2010. RESULTS: A total of 49 consecutive families with a confirmed SADS death and a diagnosis of BrS were evaluated, comprising assessment of 202 family members in total. One family had 2 members with SADS, resulting in a total of 50 probands included. Mean age of death of probands was 29.1 ± 10.6 years, with 41 males (82%) (p < 0.05). Antemortem ECGs were available for 5 SADS probands, 1 of which demonstrated a spontaneous type 1 pattern. In 45 probands, symptoms before death were reported reliably by family members. Of these, 9 (20%) had experienced at least 1 syncopal episode before the fatal event. Importantly, 68% of probands would not have fulfilled any current criteria for consideration of implantable cardioverter-defibrillator. CONCLUSIONS: The "low-risk" asymptomatic BrS group comprises the majority of SCD in this cohort. Current risk stratification would appear to be inadequate, and new markers of risk are vital.