Quantification of risk of emergency caesarean during labour after one previous caesarean section.

In its 2007 guideline, the Royal College of Obstetricians and Gynaecologists (RCOG) recommends vaginal birth after caesarean (VBAC) as safer than repeat elective caesarean sections. However, this document does not give details of risk of emergency caesarean section for women accepting VBAC. An emergency caesarean is associated with increased maternal and neonatal morbidity, and women do consider the eventuality of emergency delivery when deciding mode of delivery. We sought to quantify this risk by designing a retrospective cohort study in a consultant-led unit. While higher than average rates of successful planned VBAC were achieved, the odds of emergency caesarean delivery were increased in women undergoing VBAC (OR 3.0, 95% CI 1.2-7.6, p = 0.03). Odds of requiring a Category 1 emergency caesarean were markedly raised. Our data adds to the VBAC literature by quantifying the risk of Category 1 or 2 emergency caesarean section for women entering labour who have delivered by caesarean section once previously, giving the odds of emergency caesarean section on entering labour compared with women without a scar. This gives further information to those counselling women about birth after caesarean section.

Treatment of overactive bladder (OBA) with anti-cholinergic drugs and the risk of glaucoma.

Overactive bladder (OAB) and glaucoma are prevalent and frequently co-exist, particularly in the elderly. Anti-cholinergic drugs are the cornerstone of medical management of OAB. There is a great deal of confusion about the safety of use of the anti-cholinergic medication regarding the risk of glaucoma. This review examines the pharmacological relationship of anti-cholinergic medications used to treat OAB and the various types of glaucoma.

Intravesical migration of a GyneFix intrauterine device.

A case of intravesical migration of a GyneFix intrauterine device (IUD) is described, in which the patient presented with supra-pubic pain and urinary symptoms. The diagnosis was made 34 months after the insertion of the IUD, by ultrasound scan. The GyneFix was removed endoscopically. A description of the GyneFix device, the possible adverse effects and incidences of its complications, the importance of post-insertion follow-up, and the need for awareness of the possibility of intravesical migration are discussed.

Detection of glove puncture and skin contamination during caesarean section.

Measures that can be taken to reduce exposure to potentially infected body fluids are of particular relevance in obstetric and gynaecological surgery due to high rates of glove puncture and relatively higher prevalence of human immunodeficiency virus seropositivity in the obstetric age group. We describe the use of a simple electronic device that alarms following puncture of surgical gloves or the creation of a fluid bridge between surgeon and patient. Further exposure to potentially infected body fluids is thus prevented. This present study was performed in the context of caesarean section, but the application of the technique to gynaecological procedures is appropriate.

Changes in metabolism of collagen in genitourinary prolapse.

BACKGROUND: Genitourinary prolapse is a common problem, the pathophysiology of which is unknown. METHODS: We analysed vaginal-epithelial tissue from premenopausal women with genitourinary prolapse and compared them with controls. FINDINGS: We found that genitourinary prolapse is associated with a reduction in total collagen content and a decrease in collagen solubility. Both intermediate intermolecular cross-links and advanced glycation cross-links were increased in prolapse tissue. Collagen turnover, as indicated by matrix metalloproteinase activity, was up to four times higher in prolapse tissue. Collagen-type ratios, mature cross-link pyridinoline and total elastin content were similar in both prolapse and control tissues. Increased collagenolytic activity causes loss of collagen from prolapse tissue. INTERPRETATION: Based on these findings, we have identified a probable mechanism for genitourinary prolapse. Development of agents to inhibit collagenolytic activity may help in the treatment of this condition.

The continence control pad--a new external urethral occlusion device in the management of stress incontinence.

OBJECTIVE: To assess the use of an external urethral occlusion pad (the continence control pad, CCP) in the management of stress incontinence. PATIENTS AND METHODS: Nineteen women (median age 47 years, range 36-72) complaining of stress incontinence were taught to use the CCP. The patients were assessed during the week before, and again after using the CCPs for 2 weeks, by urinary diaries, pad-tests and a review of their symptoms. RESULTS: Use of the CCP was associated with a cure or improvement in 17 women, as assessed by the number of incontinent episodes per week. There was a significant decrease in both the number of incontinent episodes (P < 0.001) and pad-test leakage (P = 0.002) when using the CCP. Minor difficulties in placement and removal were described in a minority of women. CONCLUSION: The CCP offers a simple, non-invasive treatment for women complaining of stress incontinence. The short-term success rate was better than that with other conservative methods of treatment, is independent of the general practitioner and safe. It is a promising home-based method of managing stress incontinence.

Detection of urinary incontinence during ambulatory monitoring of bladder function by a temperature-sensitive device.

OBJECTIVES: To determine whether the difference between urinary and perineal temperatures is sufficient to allow registration of incontinent episodes by detection of temperature change alone. To design and assess the use of a diode-based temperature-sensitive device in the detection of episodes of urinary incontinence in long-term ambulatory monitoring (LTAM) studies. SUBJECTS AND METHODS: Perineal temperature recordings were made in 46 women during various activities. A temperature-sensitive device consisting of six IN4148 diodes, spanning 5 cm, and a nearby reference negative diode, was placed in a light perineal pad and attached to a portable amplifier/digitizer and recorder. The performance of the device was determined by comparison with increases in pad weight in 51 incontinent and 23 continent control subjects. RESULTS: A sufficient temperature differential existed between perineal and urinary temperature during all activities except being seated with crossed legs. Incontinence was reliably detected by the temperature-sensitive device. The device had a sensitivity of 95.2% and a specificity of 90.6% compared to a pad test. CONCLUSIONS: This temperature-sensitive device offers a new method for detecting urinary incontinence during LTAM studies. It can be fitted in an unobtrusive perineal pad and has a higher sensitivity and specificity for the detection of incontinence when compared to a pad test. It may also be used as a marker of voiding in ambulatory studies not employing an integrated voiding channel.

An open, in-patient incremental safety and efficacy study of desmopressin in women with multiple sclerosis and nocturia.

OBJECTIVES: To examine the safety and efficacy of desmopressin in three doses given to women with multiple sclerosis to treat nocturia with or without enuresis. PATIENTS AND METHODS: Eight women with clinically confirmed multiple sclerosis and nocturia with or without enuresis were entered as in-patients into an open, nonrandomized, placebo-controlled study of incremental doses of 20, 40 and 60 micrograms desmopressin. Urinary and serum sodium, plasma arginine vasopressin and urine osmolality were monitored every 4 h for 24 h. A single dose of placebo or desmopressin was given during each of four 24-h periods. RESULTS: There was a significant decrease in nocturnal urinary volumes and a significant increase in nocturnal urinary osmolalities in patients taking desmopressin when compared with those taking a placebo, but there was no difference among the desmopressin doses. There was no significant difference in serum sodium level between the desmopressin doses. However, at the end of the 24-h period with the 60 micrograms dose, serum sodium was decreased significantly. CONCLUSIONS: Neither a significant decrease in nocturnal urinary volumes nor an increase in urinary osmolality was achieved by doses of desmopressin > 20 micrograms. A dose of 60 g was associated with a decreased serum sodium level at the end of the 24-h period but there was no biochemical hyponatraemia. Because there were no benefits and a possibility of clinical hyponatraemia with higher doses, doses of > 20 micrograms desmopressin cannot be recommended.

Hydration monitoring in the prevention of recurrent idiopathic urinary tract infections in pre-menopausal women.

OBJECTIVE: To assess whether the use of simple hydration monitoring can encourage adequate hydration and reduce urinary osmolality and the incidence of urinary tract infections (UTIs) in a population of susceptible pre-menopausal women with recurrent idiopathic urinary infections. SUBJECTS AND METHODS: The study included 28 pre-menopausal women who had at least two idiopathic UTIs in the previous 6 months. Urinary osmolality was assessed by the patients at each void by a simple hand-held probe, and the readings over 4 months compared. Monthly urine culture was compared between successive 4-month periods in which the probe was or was not used. RESULTS: The study was completed by 17 women. There was a significant shift towards urine of lower osmolality over the 4-month period using the probe (Pearson's chi 2 < 0.001). Significantly fewer urinary tract infections developed during the 4 months using the probe (McNemar's chi 2 = 0.046). CONCLUSIONS: The use of the osmolality probe encouraged the subject to maintain adequate hydration. The resulting augmentation of the natural urethral 'washout' mechanism led to lower osmolality urine and a reduction in the incidence of UTIs.

Desmopressin in the treatment of nocturia and enuresis in patients with multiple sclerosis.

OBJECTIVES: To assess whether the synthetic vasopressin analogue desmopressin [1-desamino 8-D-arginine vasopressin] is efficacious and safe in the management of nocturia +/- enuresis in patients with multiple sclerosis. PATIENTS AND METHODS: Twenty-two women and 11 men, under 65 years of age, with clinically definite multiple sclerosis and nocturnal frequency +/- enuresis were entered into the study. A two week placebo run-in, to establish normal voiding patterns, followed by a double-blind, placebo-controlled, cross-over study of 20 micrograms intranasal desmopressin at night-time was carried out. RESULTS: Desmopressin caused a significant decrease in nocturnal urinary frequency, nocturnal urinary volume and the percentage of total daily urine passed at night. There was no significant fall in plasma sodium with desmopressin although there were two cases of asymptomatic hyponatraemia. CONCLUSION: Desmopressin is an efficacious and safe treatment for nocturia +/- enuresis in patients with multiple sclerosis.