Terminal care of gynaecological malignancy.

Gynaecologists in general are not trained to manage terminally ill patients. This article discusses the purpose of terminal care, some ethical difficulties in management, and who should be caring for these patients. It also reviews the clinical improvements that have developed over the past 10 years in other disciplines and their application to gynaecology.

Oestriol in the treatment of postmenopausal urgency: a multicentre study.

UNLABELLED: Oestrogen deficiency in postmenopausal women is thought to be important in the genesis of lower urinary tract symptoms, in particular the 'urge syndrome'. Evidence to support the use of oestrogen therapy in symptomatic postmenopausal women is, however, limited. Oestriol is a weak, naturally occurring oestrogen that may be beneficial to the urogenital tissues without stimulating the endometrium. We have investigated the use of oestriol in the treatment of postmenopausal sensory and motor urge incontinence. MATERIALS AND METHODS: A double-blind, placebo-controlled, randomised, multicentre study of 3 mg oral oestriol/day for 3 months in the treatment of women with urge incontinence was undertaken. RESULTS AND CONCLUSIONS: Sixty-four women were recruited into the study. Although oestriol produced both subjective and objective improvement in lower urinary tract function, it was not significantly better than placebo. Some of the difficulties of running a multicentre study were encountered.

The effect of beta-adrenergic stimulation on the bladder and urethra following radical hysterectomy.

The effect of two beta-adrenergic stimulating agents on bladder and urethral function was assessed in 16 patients 3 weeks after radical hysterectomy for carcinoma of the cervix. Urodynamic evaluation was performed before and after inhalation of metaproterenol by metered dose inhaler in 10 patients and injection of 0.25 mg of terbutaline sc in 6 patients. Although no change was observed following administration of metaproterenol, a significant decrease in maximum urethral pressure and urethral closure pressure, and a significant increase in volume of urine voided was found after administration of terbutaline. These results suggest that beta-sympathomimetic agents may benefit those patients with bladder dysfunction following radical hysterectomy.

Bladder drainage for caesarean section under epidural analgesia.

Fifty patients undergoing elective caesarean section under epidural analgesia were randomized prospectively to be catheterized with an 'in-out' or an indwelling urethral catheter. Of the patients who had catheterization for the time of surgery alone 44% subsequently required recatheterization, whereas all patients with indwelling catheters voided spontaneously on their removal. The frequency of significant bacteriuria was the same in both groups.

Effect of an intranasal LHRH agonist on gonadotrophins and hot flushes in post-menopausal women.

Alterations in circulating gonadotrophins have been reported at the time of onset of menopausal flushes. In order to study this association D-SER(TBU)6-EA10-LHRH, a luteinizing hormone releasing hormone (LHRH) agonist was given intranasally at a dose of 200 micrograms twice daily to 12 post-menopausal women to study its effect on gonadotrophin secretion and hot flushes. Following an initial period of 3-5 days of increased gonadotrophin secretion, pituitary desensitization occurred, with a significant suppression of circulating LH and follicle-stimulating hormone (FSH) levels (P less than 0.001) and a reduction in gonadotrophin pulse amplitude (P less than 0.05). This was accompanied by a significant diminution of the pituitary's response to exogenous LHRH (P less than 0.05). However, no significant alteration in the incidence of hot flushes was observed on such therapy.

Effect of labor on the postpartum bladder.

Urodynamic investigations were performed on 20 patients at 48 hours and at four weeks after delivery to assess the effect of modern obstetric practice on the postpartum bladder. Although there were significant differences in some values over this period, the mean urodynamic measurements on both occasions were within normal limits. It is concluded that the current management of labor does not predispose women to bladder hypotonia, the chief factors responsible being avoidance of prolonged labor and early catheterization after delivery.

The use of ultrasound and computed tomography scanning in the management of gynecologic cancer patients.

The contribution of abdominal-pelvic computed tomography (CT) and ultrasound scanning to the management of gynecologic malignancy patients was assessed retrospectively in 62 scans that were performed immediately preceding laparotomy. A total of 55.5% CT and 71.4% ultrasound scans were found to be helpful. Diagnostic problem areas included the detection of lymph node metastases, peritoneal implants, omental metastases, and parametrial extension. An additional 75 scans performed in patients not undergoing laparotomy were received to assess any alteration in management resulting from the scans. It is concluded that clinicians should be more discriminating in their requests for scanning procedures and that appropriate communication between the clinician and the radiologist may avoid unproductive scans.

The effect of a full bladder on labor.

The effect of a full bladder containing 300 ml or more of urine was studied during normal established labor in 20 patients and 10 controls. Uterine activity was measured in Montevideo units, and the progress of labor was assessed by partogram before and after catheterization. Although uterine activity increased after catheterization, there was no significant change in the slope of the partogram. It is concluded that a full bladder does not affect the course of normal established labor.

Effects of chronic LHRH agonist treatment on the endometrium and ovaries of the stumptailed macaque.

Eight stumptailed macaques were injected daily with 5 or 20 micrograms D-Ser(But)6des Gly luteinizing hormone releasing hormone ethylamide (LHRH agonist) for approximately one year in order to prevent ovulation. On the last day of treatment (7 monkeys) or during the mid-luteal phase of the first cycle after treatment (1 monkey), a laparotomy was performed. Uterine size was slightly smaller (P less than 0.01) than in controls with normal cycles (n = 6). A full thickness wedge of anterior uterine wall was excised and examined histologically. Five of the agonist-treated monkeys had endometrium consistent with an atropic or resting proliferative pattern, but in 2 the appearance varied from early proliferative to marked secretory. All appeared entirely benign. The remaining animal studied in the luteal phase after stopping treatment exhibited a normal secretory endometrium. Ovaries from 2 of the LHRH agonist-treated animals were also studied histologically and found to consist of follicles at various stages of maturation. The occurrence of endometrial activity in 2 of the 8 LHRH agonist-treated monkeys stresses the need for careful endometrial assessment during clinical trials involving repeated administration of LHRH agonists in women.

The incidence of urological symptoms in normal pregnancy.

We questioned 181 healthy pregnant women about their urological symptoms during pregnancy; frequency and stress incontinence were commonest. The incidences of stress incontinence and urge incontinence were increased and that of hesitancy was decreased by pregnancy. Descent of the presenting part did not affect any of these symptoms.

Evaluation of threatened abortion by ultrasound.

A retrospective analysis was made of 817 pregnancies that were examined ultrasonically because of the clinical diagnosis of threatened abortion. A total of 285 (34.9%) pregnancies aborted and the majority did so within seven days of ultrasonic examination. This examination predicted the presence of a noncontinuing pregnancy in each case. Very few ultrasonically diagnosed continuing pregnancies subsequently aborted. The incidence of preterm delivery in those pregnancies which continued beyond the 28th week was increased threefold. There was, however, no increased incidence of either congenital abnormalities or growth retarded infants in this group.

Treatment of delayed onset of spontaneous voiding after surgery for incontinence.

A preliminary study on 40 female patients who had undergone colposuspension surgery was carried out using four drugs in an attempt to reduce the time taken to void spontaneously following surgery and to define the cause of delay. Oral diazepam given as night sedation, was found to be the most effective drug.