Desmopressin therapy in children and adults: pharmacological considerations and clinical implications.

PURPOSE: This review aims to provide prescribing clinicians a deeper appreciation of desmopressin's clinical indications and formulation types, to better balance efficacy and safety through proper formulation selection. BACKGROUND: Since its discovery 50 years ago, desmopressin's antidiuretic properties have been used for central diabetes insipidus, primary monosymptomatic nocturnal enuresis and adult nocturnal polyuria, while its coagulant effects are useful for mild hemophilia A and von Willebrand Disease. During this time, newer formulations of desmopressin have also been introduced to the market raising questions on interchangeability, dose conversion and safety. The wide array of clinical indications and variable pharmacokinetic properties of different desmopressin preparations raises the possibility of medication error, especially the risk of hyponatraemia. METHODOLOGY: A narrative review to explore clinically relevant aspects of desmopressin therapy, synthesising information obtained from searches of published literature. RESULTS: We identified that the risk factors for developing hyponatremia include extremes of age, existing comorbidity, drug interaction, intranasal formulations and intercurrent illness. We describe the dose equivalence between all formulations to facilitate conversion. We highlight that in view of inter-subject variability, close monitoring is recommended when switching preparations. We found that paediatric data remains limited, leading to recent proposals for age- and weight-based dosing regimens. CONCLUSION: The risk of hyponatremia, albeit small, can be reduced by adhering to the indication-specific doses and taking steps to govern the safe prescription of the drug. Further paediatric clinical trials are awaited to expand the evidence base of childhood desmopressin therapy.

Five-year outcomes of an anterior mesh kit for severe pelvic organ prolapse in women.

AIMS: The Elevate™ Anterior mesh was designed to correct anterior vaginal wall defects by providing level 1 and 2 support via a single incision and transvaginal approach. This study aimed to examine the objective and subjective outcomes following prolapse repair using the Elevate™ Anterior mesh kit. METHODS: A retrospective case series review of 270 patients with Baden-Walker Grades 3 or 4 anterior compartment prolapse who underwent the Elevate™ Anterior mesh kit was undertaken. Operative complications were recorded with follow-up intervals arranged at 1, 6, 12, 24, 36, 48 and 60 months. A standardized questionnaire directed at urinary, pain and recurrence symptoms was used at each follow-up visit. Pelvic examinations were performed at each follow-up visit to assess for objective cure and for detection of complications. The primary outcome was to assess the cure rate defined as anterior vaginal wall prolapse ≤ Grade 1. RESULTS: The follow-up rate was 28.9%. Subjective and objective cure rates at 60 months were 100% and 96.2%, respectively. Ten (3.7%) intraoperative complications were recorded. At 60 months, three (3.8%) patients complained of de novo stress/urge urinary incontinence. One patient had dyspareunia at 6 months postsurgery which resolved by the end of 1 year. Prolapse recurrences in the anterior compartment was 3.8% at the end of 5 years. Mesh exposure into the vagina occurred in three patients. CONCLUSIONS: In conclusion, our experience with the Elevate™ Anterior mesh kit had promising subjective and objective outcomes with high patient satisfaction rates.

Knowledge of pelvic floor disorder in pregnancy.

INTRODUCTION AND HYPOTHESIS: Pelvic floor dysfunction is a common condition which can lead to distressing consequences such as urinary incontinence (UI), pelvic organ prolapse (POP) and fecal incontinence (FI). Pregnancy is a known major risk factor. This study aims to assess the level of knowledge about pelvic floor disorders among pregnant women in our local population. METHODS: A cross-sectional study was conducted in a population of pregnant women in their third trimester. A 47-question questionnaire was distributed to a random sample group. Knowledge scores were calculated. Possible predictive factors for knowledge level such as age, ethnicity, parity, ethnicity and educational levels were studied. RESULTS: Thirty-three out of 104 respondents (31.7%) reported history of urinary incontinence, 3 respondents (2.9%) reported sensation of prolapse, and 1 respondent (0.96%) reported fecal incontinence. The knowledge score for urinary incontinence was the highest at 46.2% and lowest in pelvic organ prolapse at 35.3%. Mean knowledge scores increased significantly with age (p = 0.021) and educational level (p = 0.046). The nulliparous women scored higher than the multiparous women. Age and educational level had a significant impact on multivariate analysis scores. CONCLUSIONS: The knowledge on pelvic floor disorders is poor among our local pregnant women. Healthcare professionals should place increased emphasis on advocating pelvic floor exercises for pregnant women during their routine antenatal care.

Labial adhesions in postmenopausal women: presentation and management.

Labial adhesion is defined as complete or partial fusion of the labia minora in the midline through flimsy or dense adhesions. It may be congenital or acquired. Acquired cases are mainly seen in oestrogen deficiency states in prepubertal girls and postmenopausal women. Aggravating factors include chronic inflammation due to poor hygiene, eczema, lichen planus or sclerosus, seborrhic dermatitis, eczema, local trauma and recurrent urinary tract infections. Patients may be asymptomatic or present with urinary or vulval symptoms. Management in mild cases includes the application of topical oestrogen with or without topical steroids. If there is no response to topical therapy, surgical separation under anaesthesia should be performed. Herein, we report six cases of complete labial fusion in postmenopausal women who presented to our clinic with various urinary and vulval complaints. The mean age of these patients was 76 (range 61-85) years.

Tension-free vaginal tape-Abbrevo procedure for female stress urinary incontinence: a prospective analysis over 22 months.

INTRODUCTION: We aimed to study the efficacy and safety of the tension-free vaginal tape (TVT)-Abbrevo procedure for female stress urinary incontinence (SUI). METHODS: This was a prospective cohort study that aimed to determine the subjective and objective cure, improvement of SUI and incidence of complications among women who underwent TVT-Abbrevo for SUI during a period of 22 months from September 2011 to June 2013. RESULTS: A total of 76 patients, with a mean age of 48.2 ± 8.1 years, underwent TVT-Abbrevo during the study period. Among them, 86.8% had vaginal delivery and 5.3% had instrumental delivery. Mean parity was 2.3 ± 0.8 and mean body mass index was 27.0 ± 5.0 kg/m2. 11 (14.5%) patients had previously tried physiotherapy. Mean follow-up duration was 12.3 ± 5.6 months. The subjective cure rate for SUI at one-month, six-month and one-year follow-up was 95.7%, 90.8%, and 90.6%, respectively. Among the nine patients who completed the two-year follow-up, 88.9% reported either cure or improvement of SUI. At six months, the proportion of patients with objective cure was 86.8%, and the rates of postoperative groin pain and complications were low. In addition, overactive bladder symptoms disappeared in 76.3% of patients. CONCLUSION: Our results are comparable with those of other studies, although long-term results remain to be seen.

Incidence of hydronephrosis in severe uterovaginal or vault prolapse.

INTRODUCTION: We aimed to evaluate the local incidences of hydronephrosis and renal impairment in the presence of severe uterovaginal or vault prolapse, and determine whether treatment by surgery or ring pessary resulted in the resolution of hydronephrosis in these patients. METHODS: This was a retrospective case study of 121 patients who presented with severe uterovaginal or vault prolapse. All patients who had fourth degree uterovaginal or vault prolapse, and underwent renal ultrasonography and renal function blood tests were included in the study. Follow-up imaging for hydronephrosis was performed to determine the outcome after patients received treatment. RESULTS: The mean age of the study population was 66.1 years. The overall incidence of hydronephrosis was 20.6%. The incidence of hydronephrosis in patients with severe vault prolapse was 7.1%, while that in patients with severe uterovaginal prolapse was 22.4%. Of the 25 patients with hydronephrosis, 16 (64.0%) had complete resolution of hydronephrosis after treatment, 5 (20.0%) had residual but smaller degrees of hydronephrosis, and 4 (16.0%) were lost to follow-up. The incidence of renal impairment was 3.3%. CONCLUSION: The local incidence of hydronephrosis in patients with severe uterovaginal or vault prolapse was 20.6% in our study. We established that 3.3% of women with severe uterovaginal or vault prolapse had mild renal impairment. Treatment by vaginal surgery for severe uterovaginal or vault prolapse appears to result in either complete resolution or improvement of hydronephrosis in the majority of patients.

Retrospective study of transobturator polypropylene mesh kit for the management of pelvic organ prolapse.

INTRODUCTION: This retrospective study assessed the surgical outcomes of patients for whom the transobturator polypropylene mesh kit was used for the management of pelvic organ prolapse (Gynecare Prolift) in a tertiary urogynaecological centre in Singapore from January 1, 2006 to December 31, 2007. METHODS: 169 patients (2006 n = 95; 2007 n = 74) with total (n = 76), anterior (n = 82) and posterior (n = 11) Prolifts were followed up for two years post-surgery. RESULTS: Intraoperatively, the incidence of haematoma, blood loss > 1,000 mL and blood transfusion was lower in 2007 than in 2006, although the difference was not statistically significant. One (1.4%) patient had rectal perforation in 2007. The mesh erosion rates were similar for all Prolift types (total 17.2%; posterior 14.5%; anterior 18.2%). Two patients, who had total Prolift in 2006, required mesh excision under anaesthesia for mesh extrusion. 138 (81.7%) patients were available for review at two years - nine (6.5%) patients had recurrent cystourethrocoeles and two (1.4%) had recurrent vault prolapse. Of the nine patients who had total Prolift with uterine conservation, two (1.4%) had recurrent uterine descent. The subjective cure rates two years after Prolift surgery were 98.7% for patients from 2006 and 100% for patients from 2007. The objective cure rates were 89.6% for patients from 2006 and 91.8% for patients from 2007. CONCLUSION: Prolift mesh surgery appears to have a very high success rate for pelvic reconstructive surgery. The learning curve of the surgeon may, however, be a factor determining surgical outcome in these patients.

Retrospective study on tension-free vaginal tape obturator (TVT-O).

INTRODUCTION AND HYPOTHESIS: We aim to report the 3-year outcome and complications of the tension-free vaginal tape obturator (TVT-O) in treating female stress urinary incontinence (SUI). METHODS: Retrospective analysis for complications and outcome of surgery was performed in 419 women undergoing the TVT-O from 2004 to 2006. RESULTS: Three patients (0.8%) with an isolated TVT-O had a blood loss of more than 200 ml. Two patients (0.5%) had bladder perforation. Out of 11 readmitted patients (2.6%), 10 were due to voiding difficulty. Six patients (1.4%) required tape loosening or division. Persistent pain occurred in 3.6% and erosion in 2.4% of patients. One hundred eighty-five patients (44.2%) came for follow-up at 3 years. The actual subjective and objective success rates were 89.7% and 99.9% at 3 years follow-up, respectively. With imputation, the 3-year subjective and objective success rates were 86.9% and 97.4%, respectively. CONCLUSIONS: The TVT-O is effective in treating female SUI with minimal complications.

Use of the Gynecare Prolift system in surgery for pelvic organ prolapse: 1-year outcome.

INTRODUCTION AND HYPOTHESIS: This retrospective study reports the 1-year outcome in women who underwent mesh-augmented Prolift surgery performed from 2006 to 2008. There were a total of 254 patients, with 128, 106 and 20 patients receiving total, anterior and posterior Prolift, respectively. METHODS: Incidence of thigh pain was lower in 2008 compared to 2006 and 2007 (p < 0.0001). The percentage of patients requiring blood transfusions (p = 0.09), duration of IDC ≥ 7 days (p = 0.27), wound dehiscence and re-operation rate were lower in 2008 in contrast to 2006 and 2007 (p = 0.43). Only 209 patients (82.3%) were available for review at 1 year. There were two (1.0%) cases of recurrent vault prolapse. RESULTS: The subjective and objective cure rates at 1 year after this mesh implant surgery in 2006, 2007 and 2008 were 92.1% and 92.1%; 97.0% and 92.4% and 100% and 97%, respectively. The mesh erosion rate was remarkably lower in 2008 as compared to 2007 and 2006 (p < 0.001). CONCLUSIONS: This synthetic mesh-augmented implant surgery is effective and safe, and surgical outcome appears related to the learning curve of the surgeon.

The adjustable tension-free vaginal tape--obturator.

A 59-year-old woman presented with stress urinary incontinence, had adjustment of tension-free vaginal tape-obturator (TVT-O) performed using a method that does not require lateral dissection, after a failed TVT-O. Despite having TVT-O tape erosion, she has remained continent for a period of 24 months. The case demonstrates an effective and simple method of TVT-O tape readjustment.