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.

Cloning of a non-catalytic form of human trkB and distribution of messenger RNA for trkB in human brain.

A truncated form of the human trkB gene has been cloned and sequenced. This gene is related to the trk family of tyrosine kinases, the products of which act as receptors for the neurotrophins. Of these, brain-derived neurotrophic factor and mammalian neurotrophin-4 are the known ligands for the TrkB receptor. Catalytic and non-catalytic (or truncated) forms of the trkB gene have been cloned for rat and mouse. In this study, using in situ hybridization, we describe the distribution of trkB messenger RNA in fetal and adult human brain.

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.

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.

Ureteric obstruction in pregnancy--diagnosis and management.

OBJECTIVE: To discuss the aetiology, diagnosis and management of ureteric obstruction in pregnancy and to describe the use of double-pigtail ureteric stents in a series of 10 patients. DESIGN: Retrospective study of women presenting to a maternity unit in whom the diagnosis of ureteric obstruction is reached. SETTING: Southmead Hospital in Bristol; a large district general hospital with a throughput of around 6000 maternity patients per year. SUBJECTS: 10 women (8 in their first pregnancy, 1 in her second and 1 in her third; mean age 29.2 years (range 18-31 years). INTERVENTIONS: Double-pigtail ureteric stents were electively passed after a diagnosis of ureteric obstruction. Stents remained in situ for a mean 15.5 weeks (range 8-25 weeks) and were electively removed 4-6 weeks post partum. RESULTS: Nine women progressed uneventfully through the remainder of their pregnancy. One developed strangury, haematuria and discomfort after stent insertion. Seven women had normal vaginal deliveries, two assisted vaginal deliveries and one was delivered by caesarean section. None required to have external urinary drainage. CONCLUSIONS: Double-pigtail ureteric stents are easy to place and remove and are well tolerated. They provide a simple, safe and effective method of internal upper urinary tract drainage in ureteric obstruction in pregnancy.

Para-urethral collagen implantation for female stress incontinence.

A series of 25 women with genuine stress incontinence were treated by para-urethral injection of glutaraldehyde cross-linked collagen. The technique was simple and associated with few complications. Follow-up at 3 months revealed 20 patients (80%) to have been symptomatically improved or cured. An increase in urethral closure pressure together with a decrease in urine flow rate and increase in detrusor pressure was found post-operatively. The success rate was significantly higher (90%) in patients who had undergone previous surgery for urinary incontinence when compared with those who had had no previous surgery (73%).

Abdominal aortic aneurysms presenting as renal colic.

In a 6-year period, 9 patients were referred by their General Practitioners to the urology unit with a clinical diagnosis of renal colic but were subsequently found to have leaking abdominal aortic aneurysms (AAA). In all cases of loin pain, especially in the elderly patient, the possibility of a leaking abdominal aneurysm must be considered. If no intrinsic urological cause for the pain is found or patterns suggestive of ureteric obstruction are seen on urography, ultrasound examination of the aorta-iliac vessels should be performed. Magnetic resonance imaging (MRI) and computed tomography (CT) scans may be useful adjuncts to this investigation.

Surgical treatment of urinary stress incontinence.

This article reviews traditional vaginal and suprapubic procedures as well as more recent advances such as urethral bulking agents and artificial sphincters. It illustrates how the chosen operation must be tailored to the individual patient and how the surgeon treating urinary incontinence requires a variety of procedures in his repertoire.

Management of detrusor instability.

Detrusor instability is a socially disabling condition of unknown aetiology which may cause diurnal urinary frequency, urgency and incontinence in either sex. Current management of this characteristically fluctuating disease ranges from simple conservative measures through behavioural and medical therapy to endoscopic and major abdominal surgery.

Cytological changes associated with tubo-endometrioid metaplasia of the uterine cervix.

Two women who had undergone previous cervical surgery for the treatment of glandular intraepithelial neoplasia (GIN) and cervical intraepithelial neoplasia (CIN), were found to have severely dyskaryotic cells of glandular and metaplastic type in follow-up cervical smears. A third patient was found to have similar abnormal cells in a routine screening smear. All of the patients were subjected to either hysterectomy or cervical conization and in all cases histological examination showed tubo-endometrioid glands in the endocervix, well away from the uterine isthmus, with no associated endometrial stromal tissue. All of the cervical smears were reviewed and cytological features that facilitate the distinction between tubo-endometrioid metaplasia and squamous or glandular dyskaryosis were identified. These features include the smaller size of affected cells, more marked nuclear hyperchromasia, inconspicuous nucleoli, the formation of glandular structures, the lack of discrete squamous dyskaryosis and the absence of the typical 'feathering' noted with GIN. The possibility of tubo-endometrioid metaplasia should be considered when atypical glandular or metaplastic cells are noted in cervical smears, particularly, but not exclusively, in women who have been treated for CIN or GIN. In the presence of these changes clinicians should rebiopsy the cervix before embarking on further unnecessary surgery which may adversely affect fertility and pregnancy, particularly in younger patients.

Surgical treatment and complications of urinary incontinence.

Numerous surgical approaches to the management of incontinence, particularly genuine stress incontinence, have been reported. No single operation is a panacea for the condition, and many factors must be taken into account before deciding which procedure is best tailored to an individual's needs. The procedures vary in their results, morbidity, and associated complications. Awareness of these previous complications encourages their avoidance and permits better management should they occur.

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.

Intravesical foreign bodies: five-year review.

All manner of foreign bodies have been extracted from the bladder. Introduction into the bladder may be through self-insertion, iatrogenic means or migration from adjacent organs. Extraction should be tailored according to the nature of the foreign body and should minimise bladder and urethral trauma. Complete extraction should also be confirmed by panendoscopy at the end of the extraction procedure. A 5-year review of our experience in this field has been conducted and the management and complications of intravesical foreign bodies are described. Of the 15 patients presenting to this department, 11 presented acutely and 4 presented with chronic symptoms due to complications which arose later. The possibility of an intravesical foreign body should be considered in any patient with chronic unexplained lower urinary tract symptoms.