Clinicians' views on the NICE guideline on the management of female urinary incontinence.

In October 2006, the National Institute for Health and Clinical Excellence (NICE) released Guideline No. 40: The management of female urinary incontinence. The objective of this study was to investigate the opinions of members of the British Society of Urogynaecology (BSUG) regarding the recommendations contained in the guideline. A closed format questionnaire using stems taken directly from the NICE guideline was sent to all UK-based members of BSUG. There was a 64% response rate. When asked if the guidance overall reflected their current practice, 56.8% agreed/strongly agreed. In terms of changing their practice to comply fully with the guideline, 53.3% disagreed/strongly disagreed. There were two major areas of disagreement. Some 80% of respondents disagreed that preoperative cystometry was not necessary in 'clinically pure' stress urinary incontinence; 72% of respondents disagreed that immediate release oxybutynin should be the first-line treatment for women with an overactive bladder (OAB). A smaller proportion disagreed with the statements on the use of duloxetine. The majority of the guidance formalises current practice among gynaecologists and urogynaecologists practicing in the UK. There are significant concerns regarding some of the recommendations, and the results indicate that over half of the respondents would not change their practice to follow these recommendations.

Barriers to seeking treatment for women with persistent or recurrent symptoms in urogynaecology.

The aim of this study was to identify the reasons why women with recurrent bothersome urogynaecological symptoms do not seek further treatment. A cohort of 17 women with recurrent incontinence or prolapse symptoms following a prolapse repair were identified and interviewed about their reasons for not seeking help when their symptoms recurred. The mean time between the surgery and the interview was 3 years. The interview transcripts were analysed using constant comparison derived from Grounded Theory. Dominant themes were beliefs about ageing, attitudes towards incontinence, health professionals and treatment and access to services. These factors may be important when counselling women postoperatively.

Retropubic urethrolysis of colposuspension: does it improve voiding and overactive bladder symptoms?

The study aimed to assess the efficacy of retropubic urethrolysis (RU) on obstructive and overactive bladder (OAB) symptoms and to assess the effect on voiding parameters in a small series of six women. Each patient had significant obstructive or OAB symptoms, and was obstructed on urodynamics. RU was performed if conservative measures, anticholinergics and urethral dilatation failed. The mean time since colposuspension was 10 years. All patients complained of poor flow, with 5/6 complaining of OAB symptoms. Postoperatively, all the women reported improved voiding. The maximum flow rate increased from a mean of 11.2 ml/s to 16.4 ml/s, with the Pdet at a maximum flow decreasing from a mean of 43.2 cm H(2)O to 34.7 cm H(2)O. The post-void residual was less than 100 ml in all six patients postoperatively. One reported improved OAB symptoms. There are variable success rates for RU reported in the literature. Careful patient selection and counselling is necessary.

Predicting early voiding dysfunction after tension-free vaginal tape.

The purpose of this study was to determine whether early postoperative voiding dysfunction can be predicted before inserting a tension-free vaginal tape (TVT). Multiple parameters including demographic data, history of previous anti-incontinence surgery, anaesthetic type, operator experience, type of surgical procedure (TVT alone or combined with other prolapse surgery) and preoperative urodynamic studies were analysed by univariate analysis and stepwise multiple logistic regression. The data from 500 women were prospectively collected. Early voiding dysfunction occurred in 5.8% of women postoperatively. Using stepwise multiple logistic regression, voiding by other than a detrusor contraction (p = 0.02), preoperative pressure flow rate <15 ml/s (p = 0.04) and general anaesthesia (p = 0.02) were the only factors that predicted early postoperative voiding dysfunction. The point estimate relative risks were 5.6, 11.6 and 4.4 and the positive predicting values were 11.4%, 11.8% and 16.1%, respectively. Despite statistically significant associations with early voiding dysfunction, the positive predictive values of the identified factors remain low, limiting the accurate prediction of early voiding dysfunction.

Tolerability and efficacy of duloxetine in a nontrial situation.

OBJECTIVE: To assess the tolerability and efficacy of duloxetine in a nontrial situation. DESIGN: Prospective observational study. SETTING: Urogynaecology Unit, District General Hospital, UK. POPULATION: Two hundred and twenty-two women with a diagnosis of urodynamic stress incontinence (USI) or mixed USI and detrusor overactivity (DOA) took duloxetine for 4 weeks. METHODS: The results of therapy were assessed with a Patient Global Impression of Improvement (PGI-I) questionnaire. One hundred and forty-eight (67%) women were initially treated with 40 mg twice a day, 67 (30%) women were treated with an escalating dose initially at 20 mg twice a day increasing to 40 mg twice a day after 2 weeks and seven (3%) women were started on a dose of 20 mg twice a day which they continued. MAIN OUTCOME MEASURES: Discontinuation rates and PGI-I scores. RESULTS: Overall 146/222 (66%) women discontinued therapy due to adverse effects or lack of efficacy. Significantly more women starting on the 40 mg twice a day dose stopped due to adverse effects when compared with the escalating dose (P < 0.025). Of the women who tolerated therapy, 80 out of 120 (67%) had a PGI-I score indicating an improvement. However, the overall rate of improvement was 37%. PGI-I scores and discontinuation rates were not significantly different between the group with USI and the group with mixed USI and DOA (P > 0.05). CONCLUSION: In a nontrial situation duloxetine is poorly tolerated. Introducing an escalating dose may improve tolerability. A similar number of women with USI and mixed incontinence had a PGI-I score indicating improvement.

Duloxetine treatment for women awaiting continence surgery.

The study assessed the effect of offering a 4-week course of duloxetine therapy to 73 women awaiting a tension-free vaginal tape (TVT) operation. Twenty-seven women (37%) declined taking the drug, leaving 46 women (63%) willing to take drug therapy. Thirteen women were scheduled for a TVT with concurrent prolapse surgery, and 1 of these women decided that she no longer needed the surgery. Eight of the 33(24%) women scheduled for a TVT without concurrent prolapse surgery came off the waiting list. Nine women of the 33 women scheduled for a TVT without concurrent surgery (27%) found that the medication did not work sufficiently well. Sixteen of the 33 women (48%) discontinued medication due to side-effects. Women on a waiting list for surgery may be unwilling to take duloxetine therapy and less tolerant of side-effects.

National audit of incontinence surgery in the United Kingdom.

The aim of the study was to describe the experience, current trends and management of incontinence surgery for urodynamic stress incontinence (USI) in the United Kingdom. The study was a postal questionnaire survey that was sent to a cohort of surgeons known to be performing continence surgery. The subjects addressed included the considered role of the surgeon, the total number and type of operations performed in the last year, urodynamics and physiotherapy prior to incontinence surgery, operative complications, postoperative advice and follow-up (lengths and methods). The response rate was 54%. Large variations were found in all areas. The survey provides evidence of the number of incontinence operations performed, potentially important trends and differences in the practice and management of incontinence in the United Kingdom. This survey may be helpful in making guidelines and standards for audit at regional, local and individual levels as well as recommendations for strategies to enhance professional expertise in urogynaecology in the United Kingdom.

Tension-free vaginal tape (TVT) in the United Kingdom.

Four hundred and twenty-six surgeons identified as performing TVT in the United Kingdom in the year ended 1 January 2002 were sent a postal questionnaire to identify the technique employed and the complications encountered. An 81% response rate was achieved. Over 7000 TVT operations were reported. Large numbers of surgeons perform a small number of operations each year. A variety of different surgical techniques and anaesthetics are used. Bladder perforations have been reported by 44% and de novo bladder overactivity by 37% of surgeons. Tape erosion is seen in 0.33%. Twenty-eight per cent of surgeons have seen voiding abnormalities that persist for more than 6 weeks. Fifty-seven per cent of surgeons perform short-term follow-up only. The operation is performed in a variety of different ways, by surgeons with variable experience and volumes of work. The different surgical techniques have not been evaluated prospectively and complications are seen more commonly than originally reported.