Vaginal prolapse repair with or without a midurethral sling in women with genital prolapse and occult stress urinary incontinence: a randomized trial.

INTRODUCTION AND HYPOTHESIS: We compared pelvic organ prolapse (POP) repair with and without midurethral sling (MUS) in women with occult stress urinary incontinence (SUI). METHODS: This was a randomized trial conducted by a consortium of 13 teaching hospitals assessing a parallel cohort of continent women with symptomatic stage II or greater POP. Women with occult SUI were randomly assigned to vaginal prolapse repair with or without MUS. Women without occult SUI received POP surgery. Main outcomes were the absence of SUI at the 12-month follow-up based on the Urogenital Distress Inventory and the need for additional treatment for SUI. RESULTS: We evaluated 231 women, of whom 91 randomized as follows: 43 to POP surgery with and 47 without MUS. A greater number of women in the MUS group reported absence of SUI [86 % vs. 48 %; relative risk (RR) 1.79; 95 % confidence interval (CI) 1.29-2.48]. No women in the MUS group received additional treatment for postoperative SUI; six (13 %) in the control group had a secondary MUS. Women with occult SUI reported more urinary symptoms after POP surgery and more often underwent treatment for postoperative SUI than women without occult SUI. CONCLUSIONS: Women with occult SUI had a higher risk of reporting SUI after POP surgery compared with women without occult SUI. Adding a MUS to POP surgery reduced the risk of postoperative SUI and the need for its treatment in women with occult SUI. Of women with occult SUI undergoing POP-only surgery, 13 % needed additional MUS. We found no differences in global impression of improvement and quality of life.

Uterine electromyography for identification of first-stage labor arrest in term nulliparous women with spontaneous onset of labor.

OBJECTIVE: We sought to study whether uterine electromyography (EMG) can identify inefficient contractions leading to first-stage labor arrest followed by cesarean delivery in term nulliparous women with spontaneous onset of labor. STUDY DESIGN: EMG was recorded during spontaneous labor in 119 nulliparous women with singleton term pregnancies in cephalic position. Electrical activity of the myometrium during contractions was characterized by its power density spectrum (PDS). RESULTS: Mean PDS peak frequency in women undergoing cesarean delivery for first-stage labor arrest was significantly higher (0.55 Hz), than in women delivering vaginally without (0.49 Hz) or with (0.51 Hz) augmentation of labor (P = .001 and P = .01, respectively). Augmentation of labor increased the mean PDS frequency when comparing contractions before and after start of augmentation. This increase was only significant in women eventually delivering vaginally. CONCLUSION: Contraction characteristics measured by uterine EMG correlate with progression of labor and are influenced by labor augmentation.

[The premenstrual syndrome]. / Het premenstrueel syndroom.

Premenstrual syndrome (PMS) is characterised by the occurrence of physical and psychological symptoms during the luteal phase of almost every menstrual cycle. These symptoms disappear at the beginning of menstruation, and a symptom-free period of at least a week ensues. Premenstrual dysphoric disorder (PMDD) is a variation of PMS, with predominantly psychological symptoms. The aetiology of PMD and PMDD is not known. A possible explanation however is an abnormal, stronger reaction to physiologically normal hormonal fluctuations. Diagnosing PMS and PMDD requires prospective daily monitoring of symptoms over at least two menstrual cycles. No effective medication for the treatment of PMS has been registered in the Netherlands. In randomized placebo-controlled trials selective serotonin reuptake inhibitors and oral contraceptives containing drosperinone have been found to have a positive effect on the physical and psychological symptoms of PMS and PMDD.

Time to pregnancy after a previous miscarriage in subfertile couples.

OBJECTIVE: To assess the time to spontaneous ongoing pregnancy after a previous miscarriage in subfertile couples. DESIGN: A prospective cohort study. SETTING: The study was conducted in 38 fertility centers in the Netherlands. PATIENT(S): Subfertile couples who miscarried after completing their basic fertility work-up. INTERVENTION(S): Expectant management after a miscarriage. MAIN OUTCOME MEASURE(S): Spontaneous ongoing pregnancy. RESULT(S): We included 5,663 subfertile couples, of which 1,098 (19%) conceived spontaneously. Among these 1,098 couples, 199 (18%) miscarried and these couples were included in the present study. Follow-up was completed for 171 couples, of which 95 conceived again within 24 months of follow-up. Of these 95 pregnancies, 86 (91%) were ongoing. The cumulative spontaneous ongoing pregnancy rate (PR) after 24 months was 70% (95% confidence interval [CI] 59%-81%). CONCLUSION(S): Subfertile couples, who experience a treatment-independent pregnancy resulting in a miscarriage, have very good prospects of a spontaneous ongoing pregnancy in the near future. This information is useful in counseling couples who had a miscarriage after a previous period of subfertility.

The placebo effect in the pharmacologic treatment of patients with lower urinary tract symptoms.

OBJECTIVES: We reviewed placebo responses in randomised controlled trials (RCTs) for pharmacologic treatment of lower urinary tract symptoms (LUTS), including urinary incontinence (UI), overactive bladder, and benign prostatic hyperplasia. Review papers on placebo effects in non-urologic disorders were assessed to compare the magnitude of placebo responses in drugs for LUTS with those reported for other diseases. METHODS: Data were retrieved from registration trials for LUTS drugs on the Web sites of the Food and Drugs Administration and the European Medicines Agency. Reviews were retrieved from Medline using the MeSH term "placebo effect" (English language; published between 1990 and 2005). RESULTS: Placebo treatment of LUTS yields reductions in incontinence episodes (IEs) ranging from 32% to 65%, whereas prostate or UI symptom scores are reduced by 9-34%. Genuine drugs decrease IEs by 45-77% and symptom scores by 22-45%. Placebo responses are much lower when objective changes in voided volume or peak flow rate are assessed. CONCLUSIONS: The placebo effect in LUTS has a strong behavioural component as patients become aware of their voiding habits and potential risk factors. Symptom severity, treatment naivety, study duration, and interaction with health care providers may also influence it. Proper patient selection, study duration, and objective and subjective outcome measures may better separate genuine treatment effects from artefacts. Observational studies with patients representative for real-life situations and covering a sufficient period of time could allow for better understanding of RCT results and their applicability in clinical practice.

A randomised controlled trial comparing abdominal and vaginal prolapse surgery: effects on urogenital function.

OBJECTIVE: To compare the effects of vaginal hysterectomy (combined with anterior and/or posterior colporraphy) and abdominal sacro-colpopexy (with preservation of the uterus) on urogenital function. DESIGN: Randomised trial. SETTING: Three teaching hospitals in The Netherlands. POPULATION: Eighty-two patients undergoing surgical correction of uterine prolapse stages II-IV. METHODS: Participating patients completed the urogenital distress inventory (UDI), before and at six weeks, six months and one year after surgery, to measure discomfort of prolapse and micturition symptoms. Domain scores of the UDI (ranging from 0 to 100, higher scores indicating more discomfort) were compared between groups at all time points. Findings at pelvic examination, number of doctor visits within the first year after surgery because of pelvic floor symptoms and performed or planned surgery of recurrent genital prolapse were also compared. MAIN OUTCOME MEASURE: Domain scores of the UDI at one year after surgery. RESULTS: At one year after surgery, scores on the discomfort/pain domain (mean difference 7.1, 95% confidence interval [CI] 1.1-13.2), overactive bladder domain (mean difference 8.7, 95% CI 0.5-16.9) and obstructive micturition domain (mean difference 10.3, 95% CI 0.6-20.1) of the UDI were significantly higher in the abdominal group than in the vaginal group. Findings at pelvic examination were similar in both groups. Doctor visits because of pelvic floor symptoms were more frequent in the abdominal group than in the vaginal group. Re-operation was performed or planned in 9 of the 41 patients who underwent abdominal surgery and in 1 of the 41 patients who underwent vaginal surgery (odds ratio [OR] = 11.2, 95% CI 1.4-90.0). CONCLUSIONS: Our findings suggest that vaginal hysterectomy with anterior and/or posterior colporraphy is preferable to abdominal sacro-colpopexy with preservation of the uterus as surgical correction in patients with uterine prolapse stages II-IV.