[Principles of continence in women: the formula of continence].

Urinary incontinence in women is a widespread disease . In recent years, significant progress in its treatment was achieved. Despite this, the mechanisms of continence are still poorly understood. According to the principles of biomechanics, incontinence occurs when bladder pressure exceeds urethra pressure. We represent the formula for calculating the pressure loss of urine, which takes into account the main factors involved in the formation of urethral pressure. According to our data, the involuntary leakage of urine during physical conditions may occur if the bladder pressure exceeds intraurethral pressure, which can be calculated using a formula based on urethral closing pressure and passive resistance of the bladder neck.

[Analysis of the results of urinary incontinence treatment in women using free suburethral synthetic sling: the experience of 1000 operations].

The study presents an analysis of the experience of treatment of urinary incontinence in women using free synthetic suburethral sling. Between 2001 and 2008, 1081 patients underwent surgery. Of these, 841 (77.8%) suffered from stress urinary incontinence, 202 (18.62%) suffered from the mixed form of urinary incontinence with a predominance of the stress component, and 38 (3.52%) had recurrent urinary incontinence. Group 1 included patients with stress urinary incontinence who underwent surgery using suburethral synthetic sling with retropubic access (TVT operation); Group 2 included patients, who underwent surgery using suburethral sling implanted with transobturator access (TVT-O operation). Group 3 consisted of patients with mixed urinary incontinence, who underwent TVT-O operation. Retropubic suburethral TVT sling was implanted in 273 (25.25%) patients, transobturator TVT-O sling--in 740 (68,45%) patients, and other synthetic suburethral slings--in 68 (6.3%) patients. The average follow-up period was 50.1, 31.1 and 32,6 months in each group, respectively. Cough test was used for the objective evaluation of the effectiveness, and visual analogue scale--for the subjective evaluation of effectiveness. In the TVT group, the negative cough test in the postoperative period remained at 85.58% of the patients, and in in TVT-O group--in 84.36% of patients. Analysis of the frequency of intraoperative complications showed that the probability of occurrence of complications was not associated with age, body mass index and obstetric history of patients. It was noted that the perforation of the bladder and pelvic hematoma were more likely to occur when using the retropubic access. Transobturator access is associated with a higher risk of injury of the lateral vaginal fornix, although bladder injury is not ruled out. Objective and subjective indicators of efficacy of treatment of mixed form of urinary incontinence were 86.15 and 87.69%, respectively. The study suggests that the operations using suburethral TVT and TVT-O slings are safe and effective methods of treatment of stress urinary incontinence in women.

[Flexible approach to the appointment of solifenacin: for whom and when?].

Solifenacin at a dose of 5 mg per day has demonstrated the high efficacy in the treatment of patients with overactive bladder. However, for patients who remained dissatisfied with the outcome of treatment, the dose may be increased to 10. mg per day, which leads to the improvement of patient's condition. However, there is an opinion that treatment should be started with the use of high doses of the drug. Efficiency of solifenacin at a dose of 10 mg was accompanied by favorable safety and tolerability profile. Despite the fact that numerous studies have shown that the clinical efficacy of different anticholinergics is not very different from one another, it is known that patients may prefer some other drugs. Application of solifenacin in these patients leads to significant improvement in quality of life. Thus, flexible approach to the use of solifenacin allows to achieve the best results in the treatment of patients, including those cases where the initial treatment is not effective or is interrupted due to pronounced side effects.

[Methods of diagnosis and treatment of asymptomatic bacteriuria in postmenopausal women suffering from type 2 diabetes mellitus].

We studied prophylactic potential of local use of estriol in respect of urinary infections (UI) in postmenopausal women with asymptomatic bacteriuria (AB) suffering from type 2 diabetes mellitus (DM). A two-stage trial has been conducted. Stage one (a prospective study) was made to detect AB in DM women with AB. Of 414 female examinees AB was detected in 87 women. At stage two these women were randomized into two groups: group 1 received 0.5 mg estriol as vaginal cream, group 2 (control) received no prophylactic treatment. After 9 months of the trial AB was detected in 19.4% women of group 1 and 68.4% of the control group (p<0.001). Clinically significant UI was detected in 8.3 and 18.4% examinees (p<0.001), respectively. No correlation was found between AB development and a HbA1c level. Estriol treatment resulted in a rise of vaginal health index (VHI), appearance of lactobacteria in the vaginal smear, lowering of atrophic vaginitis detection rate. No significant changes were registered in the controls. Thus, local estriol administration effectively prevents and treats UI in postmenopausal females.

[Mini-invasive operations for correction of urinary incontinence in females].

We compared efficacy of surgical treatment of urinary incontinence in women depending on the size of the synthetic sling and technique of its installation. From January to September 2009 we made 75 operations with synthetic suburethral slings: TVT-SECUR (TVT-S)--group 1 (n = 35) and TVT-O- group 2 (n = 40). The sling was installed in U position in 14 patients of group 1 and in H position in 21 patients. The control examinations included questionnaire survey, cough stress test (in bladder volume more than 150 ml), vaginal investigation, uroflowmetry, in urgency--complex urodynamic examination. A total of 32 patients of group 1 and 40 patients of group 2 were examined postoperatively. A positive result was achieved in 20 (62%) and 38 (95%) (p = 0.0006) patients of group 1 and 2, respectively. Quality of life was assessed as good and very good by 22 (68%) and 37 (93%) patients of groups 1 and 2 (p = 0.0105), respectively. The control examination after 6 months of follow-up showed good result in 7 (53%) and 13 (68%) patients of group 1 (subgroups U and H, respectively). Reoperation for urinary incontinence was made in 4 (30%) patients of subgroup U and 1 (5%)--of subgroup H. Thus, surgical treatment of urinary incontinence in women according to TVT-0 technique is more effective than in TVT-S surgery, but minisling TVT-S is more effective in patients with bad somatic status and in H position.

[Effects of synthetic materials used for the treatment of genital prolapse on lower urinary tract function].

Functional results of surgical correction of genital prolapse were compared with those of transvaginal implantation of the prolift in 26 and 22 women, respectively. Standard protocol required gynecological examination, cough test, complex urodynamic investigation. Patients of both groups were matched by anthropometric parameters. All the patients were reexamined 1, 3 and 6 months after surgery. Comparison of the results showed that most of the urodynamic parameters changed insignificantly in patients treated surgically for prolapse of the urinary bladder. Moreover, there was no significant association between these findings and surgical methods of the prolapse treatment. Stress urinary incontinence arose in 13.64% (3/22) patients who had undergone prolift implantation and in 3.85% (1/26) patients after colporraphy. Postoperative overactive bladder was observed in 9.09% (2/22) and 11.54% (3/26) patients, respectively. No significant difference by the above symptoms between the groups were registered in relation to the operation type. Similar data were obtained in respect of incidence of lower urinary tract infections. Thus, it is found that prolift plastic operations for cystocele do not increase the incidence of urinary incontinence, overactive bladder, lower urinary tract infection. Further studies with greater number of patients and longer follow-up are needed.

[Remote results of using synthetic loop in the treatment of urinary incontinence in females (8-year study results)].

Out of 21 female patients who had undergone TVT operation for stress urinary incontinence from March 2000 to February 2001, 15 females responded to the interview in the telephone survey conducted in 2009. A Russian version of the King's Health Questionnaire was used. Seven (46.8%) patients assessed the effect of the operation as good, 4 (26.6%) patients--as satisfactory, 2 (13.3%) and 2 (13.3%) as bad and poor, respectively. Thus, a positive effect was achieved in 11 (73.4%) responders, while a negative effect was seen in 4 (26.6%) patients. Nine (60%) patients experienced no effect of urination problem on quality of life, 3 (20%) and 3(20%) patients experienced moderate and strong effect, respectively. Frequent voiding, urgencies at night, imperative voiding and urgent urinary incontinence were recorded in 3 (20%), 4 (26.7%), 2 (13.3%) and 2 (13.3%) patients, respectively. All 15 (100%) responders stated no incontinence in cough, sneezing and physical activity. Thus, our 8-year follow-up confirms that TVT operation is highly effective in stress urinary incontinence in women.

[Hyperbaric oxygenation in combined treatment of interstitial cystitis].

A total of 116 female patients with painful bladder syndrome/interstitial cystitis aged 32-78 years (mean age 56 +/- 2.4 years) entered the trial. They were divided into two groups according to treatment. Group 1 (n = 54) received 10-day combined conservative treatment consisting of antimicrobial drugs (if urinary infection was diagnosed), angioprotectors, mast cell activity stabilizers and bladder instillation with combined solution. Group 2 included 62 patients whose treatment included complex anti-inflammatory therapy in combination with HBO sessions (7-10 sessions in barochamber OKA-MT, 2.0 +/- 0.2 atm). Subjective (the disease course, pain intensity, 24-h and nocturnal pollakiuria, effective urine volume) and objective (microcirculation in the bladder wall) results were assessed. Dopplerograms revealed venous stagnation. Patients of group 2 had a persistent improvement of microcirculation in bladder mucosa as shown by better blood flow in the veins and arterioles. In group 1 the above improvement was less pronounced. Thus, HBO in combined treatment of interstitial cystitis improves treatment results and promotes long-term remission of the disease.

[Anatomic characteristics of transobturative approach in application of a tension-free tape for treatment of women with stress urinary incontinence].

We studied safety and topographic characteristics of a transobturative approach in application of an "inside out" tension free tape (TFT) for management of stress urinary incontinence (SUI) in women. The anatomic sections were made on 6 fresh female cadavers (mean age of the deceased 78.5 +/- 4 years). After the tape placement a femoral section was made with its extension to the perineum and retropelvic section. We found that the TFT passes far from the major femoral structures. The distance from the obturator canal to the TFT averaged 24.4 mm +/- 1.8 mm (from 23.9 to 30.4 mm, median 21.4 mm). Dissection of the dorsal nerve and artery of the clitoris as well as the pudendal nerve showed that these structures are not damaged in correct operative technique. Moreover, the tape passes beneath the pelvic fascia and levators, it does not penetrate the pelvic cavity. Thus, the transobturative approach is safe, does not damage vital organs and anatomic structures in the treatment of women with SUI.

[The free synthetic loop in the treatment of urinary stress incontinence in women: comparative analysis of postoperative complications].

Operations with application of a free synthetic loop were made in 504 female patients with urinary stress incontinence (USI). The patients were divided into two groups. Patients after TVT operation, not operated with reconstruction of the pelvic fundus entered group 1 (n = 207). Patients after TVT-0 operations (n = 109) entered group 2. The data were processed with the criterium chi-square, significance was stated in p < = 0.05. The following intra- and postoperative complications were registered: de novo imperative symptoms, pelvic hematoma, perforation of the urinary bladder. The latter complication occurred in 1 (0.48%) patient of group 1 and in none from group 2. Pelvic hematomas were in 2.9 and 0.92% patients, respectively. De novo imperative symptoms were observed in 2.9 and 1.83%, respectively. It was stated that differences in complications between the groups were insignificant. Further multicenter controlled randomized studies are necessary.

Chloral hydrate disposition following single-dose administration to critically ill neonates and children.

Although the metabolism and pharmacokinetics of chloral hydrate (CH) have been studied in healthy adults, no comprehensive studies have been done in neonates and young infants. Major physiological differences between these groups could greatly affect drug disposition. In this study the patient population (22 patients) was divided into three groups according to postconceptual age: group 1 = preterm infants (31-37 weeks), group 2 = fullterm infants (38-42 weeks) and group 3 = toddler-child patients (57-708 weeks). After receiving one 50 mg/kg oral dose of CH, the parent drug and its metabolites were determined by gas chromatography utilizing an electron capture detector. CH, contrary to what has been reported in the adult, was detectable for several hours after oral administration to patients in all three groups. A highly significant negative correlation was observed amongst the three groups for the half-life (t1/2) and area-under-the-curve for 0 to infinity values for trichloroethanol (TCE), the active metabolite responsible for the sedation effect. The t1/2 value for TCE in group 3 (9.67 h) was similar to that reported for the adult population, but in the less mature subjects it was approximately three (group 2: 27.8 h) to four times (group 1: 39.8 h) greater. Trichloroacetic acid had a remarkably long residence time in the study population after a single dose of CH. The concentration of this metabolite failed to decline even 6 days after dose. These issues should be carefully considered when CH administration is contemplated for clinical use in neonates, infants and children.

Epiglottitis in Canada: A multiregional review.

Epiglottitis is an acute, life threatening infection usually caused by Haemophilus influenzae type b. Although antibiotic therapy is an important part of management, the optimal route and duration is unknown. A multicentre retrospective review of 305 children with epiglottitis was carried out in order to relate antibiotic therapy to hospital course and outcome, as well as to examine regional variation in patient demographics, clinical presentation and course of disease. A standardized form was used to extract data from hospital records. Although management varied significantly among the six centres in terms of mean duration of intubation (46 to 81 h), intravenous antibiotic therapy (3.8 to 5.7 days) and hospital stay (5.3 to 8.4 days), there were no significant centre-related differences in epidemiology, clinical course or outcome of epiglottitis. An extraepiglottic focus of infection was present in 15% of patients and included three with septic arthritis and one with meningitis. The duration of fever in hospital and maximum recorded temperature in hospital were significantly greater for children with extraepiglottic infection compared to those with epiglottitis alone. The data presented in this review suggest that most children with epiglottitis have an uncomplicated course and respond rapidly to antimicrobial therapy following airway securement. A short period of intravenous and oral antibiotic therapy is likely adequate for most children with epiglottitis. A well designed multicentre prospective trial is still needed to determine the optimal duration of antibiotic therapy.

Apparent life-threatening prolonged infant apnea in Saskatchewan.

Life-threatening events such as prolonged apnea and severe bradycardia are uncommon in infants. When such events occur in a family, however, the results may be disastrous. Over a period of 3 years ending June 1986, we have looked after 111 such infants aged 4 weeks to 40 weeks with a mean age of 14 weeks (male-female ratio 1.26:1). Of these infants, 33 had an identifiable cause and were treated according to the diagnoses. A structural approach to this problem yielded good results. Only 10 infants were treated with a home monitor (4 prescribed by physician and 6 by parental request). Sleep and pneumogram (polysomnogram) studies showed fewer apneic episodes with advancing age (P less than .01). Giving theophylline seemed to abolish pneumogram abnormalities. No infants died.

Bacterial tracheitis in children.

We examined the records of 14 patients aged 7 months to 10 1/4 years who were treated for bacterial tracheitis from May 1982 to December 1987; the management protocol for 13 of the patients included the use of nasotracheal intubation. The infection was caused by Staphylococcus aureus in seven, Haemophilus influenzae in three, Branhamella catarrhalis in one and Streptococcus pneumoniae in one. Both H. influenzae and B. catarrhalis were isolated in another patient, and no organism was found in the remaining patient. In addition to the bacteria, viruses were cultured from the tracheal secretions of two patients. The mean duration of intubation was 7.6 days and of hospital stay 9.2 days. Twelve of the cases occurred during the cold months of the year (October to March). Of the three deaths only one occurred in the pediatric intensive care unit and was due to severe bronchospasm and an air leak that caused bilateral pneumothorax and pneumomediastinum. In one patient subglottic stenosis developed that necessitated tracheostomy. Healing began 5 to 9 days after the onset of symptoms, as demonstrated with the use of repeated fibreoptic bronchoscopy. We found that the airway could be safely managed with the use of a nasotracheal tube. Bronchoscopy helped to confirm the diagnosis, to remove adherent secretions and to monitor the course of the disease. The ventilation tube can be removed after the patient's temperature returns to normal, if there is an air leak around the tube, if the quantity and viscosity of the secretions decrease and if healing is observed at bronchoscopy.

Chloral hydrate sedation in neonates and infants--clinical and pharmacologic considerations.

Chloral hydrate has been used clinically for over 100 years. There is significant paucity of information regarding chloral hydrate metabolism in neonates and infants. Chloral hydrate and its various metabolites were quantitated in 12 neonates and 2 infants at prescribed time intervals. The analysis of the data indicates accumulation of trichloroacetic acid and trichloroethanol in tissue of compromised infants. There is indirect evidence of competition for hepatic glucuronidation for bilirubin with trichloroethanol in ill preterm infants. Multiple dosing of chloral hydrate in preterm infants should be used with caution and frequent monitoring of serum bilirubin concentrations is indicated in such cases. The mechanism of chloral hydrate metabolism is discussed in detail.

Branhamella catarrhalis bronchopulmonary isolates in PICU patients.

Branhamella catarrhalis is commonly considered a respiratory commensal but has recently been implicated as a pathogen, particularly in adults. Over a 28 month period, B. catarrhalis was isolated from bronchopulmonary secretions of 14 PICU patients with acute respiratory infections. Twelve patients had pneumonia and two had tracheitis. The mean age was 3.5 years. Seven patients had chronic cardiopulmonary disease including two who were immunosuppressed. Three had an acute underlying condition and four had no complicating medical problem. Polymorphs and Gram-negative diplococci on Gram stain were found in respiratory secretions of all patients. Twelve of 14 isolates produced beta-lactamase, and six patients had a second potentially pathogenic bronchopulmonary isolate. All patients were treated for B. catarrhalis infection and none died. When isolated in pure culture from bronchopulmonary secretions in symptomatic patients, B. catarrhalis should be considered a pathogen. When isolated in mixed culture, its pathogenic role is uncertain. We conclude that B. catarrhalis can be a bronchopulmonary pathogen in critically ill children with otherwise normal cardiopulmonary function as well as in those with chronic cardiopulmonary dysfunction. When administering antibiotics the high frequency of beta-lactamase-producing strains must be taken into consideration.