Ultrasound bladder wall thickness and detrusor overactivity: a multicentre test accuracy study.

OBJECTIVE: Women with overactive bladder (OAB) often undergo urodynamics before invasive treatments are considered. Ultrasound measurement of bladder wall thickness (BWT) is a less invasive, less expensive and widely available test. It has the potential to diagnose the presence of detrusor overactivity (DO). We aimed to evaluate the accuracy of BWT in the diagnosis of DO. DESIGN: Prospective cohort study. SETTING: Twenty-two UK clinics (university and district general hospitals). METHODS: Consecutive eligible women with OAB symptoms had transvaginal ultrasound to estimate BWT (index test). The reference standard for the diagnosis of DO was urodynamic testing with multichannel subtracted cystometry. MAIN OUTCOME MEASURES: The sensitivity, specificity and likelihood ratios using a BWT threshold of ≥5 mm were used to indicate the presence of DO, and the area under the receiver operating characteristics (ROC) curve to give an overall estimate of BWT accuracy. RESULTS: Between March 2011 and 2013, 644/687 (94%) women recruited had both tests. The mean age was 52.7 years (standard deviation 13.9) and DO was diagnosed in 399/666 (60%) women. BWT had a sensitivity of 43% [95% confidence interval (CI) 38-48%], specificity of 62% (95% CI 55-68%), and likelihood ratios of 1.11 (95% CI 0.92-1.35) and 0.93 (95% CI 0.82-1.06) for positive and negative tests, respectively. The area under the ROC curve was 0.53 (95% CI 0.48-0.57). Extensive sensitivity analyses and subgroup analyses were carried out, but did not alter the interpretation. CONCLUSIONS: BWT is not a good replacement test for urodynamics in women with overactive bladder. TWEETABLE ABSTRACT: Bladder wall thickness is not a good replacement test for urodynamics in women with overactive bladder.

Management of female urinary incontinence: A survey of urogynaecologists' view on the NICE guideline.

We conducted a survey to obtain the opinions of urogynaecologists regarding the National Institute for Health and Care Excellence or NICE 2013 urinary incontinence guideline and whether it would change their current practice. A closed format questionnaire was sent electronically to all members of the British Society of Urogynaecology or BSUG between January and March 2014. There were three major areas of disagreement. First, 70.2% of respondents disagreed that a multidisciplinary team review was necessary before invasive treatment for urinary incontinence. Second, 53.8% of respondents disagreed that preoperative urodynamic studies were not required in stress urinary incontinence diagnosed clinically. Third, 58.6% of respondents disagreed that oxybutynin, tolterodine and darifenacin should be used as first-line drug therapy for overactive bladder. The questionnaire demonstrates that there are significant concerns leading to more than a third of respondents not altering their current practice in line with the entire guideline.

The effect of suture characteristics on short-term morbidity after vaginal prolapse surgery.

Previous studies suggest that larger sutures increase the risk of complications after prolapse surgery. This study aimed to assess whether multifilament sutures increased complications compared with monofilament sutures. A series of 100 women with 2/0 multifilament suture were matched by operation to a previous cohort when a size 2/0 monofilament suture was used. Offensive vaginal discharge was more common in the multifilament than in the monofilament group (24% vs. 12%; p = 0.04). However, there was no increased requirement to seek advice from a health professional (33% vs. 25%; p = 0.27) or to require antibiotics. Vaginal bleeding (10% vs. 5%; p = 0.28) and urinary infection (2% vs. 5%; p = 0.44) were statistically no more common in the multifilament 2/0 compared with the monofilament 2/0 group. Multifilament sutures used for closure of the vaginal skin are associated with a clinically non-significant higher incidence of vaginal discharge in the early post-operative period.

A decision-analytic Markov model to compare the cost-utility of anterior repair augmented with synthetic mesh compared with non-mesh repair in women with surgically treated prolapse.

OBJECTIVES: To assess the cost-effectiveness of a mesh-augmented anterior vaginal wall repair compared with a non-mesh fascial plication repair. DESIGN: Cost-utility analysis. SETTING: Data for outcomes of different surgical techniques were derived from systematic reviews and recent publications. METHODS: A decision-analytic Markov model, developed in TreeAge Pro 2007(®) , was used to compare the cost-utility of mesh and non-mesh anterior vaginal wall repairs. Sensitivity analysis was used to assess the impact of different scenarios and assumptions on results from the model. MAIN OUTCOME MEASURE: Health outcomes were expressed in terms of quality-adjusted life years (QALYs). RESULTS: Under base case assumptions at 5 years, the incremental cost-effectiveness ratio (ICER) for mesh-augmented anterior repairs was £15 million per QALY. Sensitivity analysis found no plausible model inputs that could make a mesh repair cost-effective by conventional criteria. This was mostly because of the extra costs associated with the price of the mesh, treating mesh erosion and difficulty finding data that support a lower reoperation rate for mesh anterior wall repairs. CONCLUSIONS: This model suggests that the use of mesh is not cost-effective.

Does self-motivation improve success rates of pelvic floor muscle training in women with urinary incontinence in a secondary care setting?

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle training (PFMT) is the recommended first-line treatment for women with urinary incontinence (UI). Success rates are variable and dependent on a number of factors. The development of an incontinence treatment motivation questionnaire (ITMQ) provides us with a tool to assess patient self-motivation with respect to PFMT and UI. The aim of this study was to determine the effect of women's self-motivation to perform PFMT on outcome. METHODS: Women with stress predominant UI completed an ITMQ and a 24-h pad test and then underwent a 12-week course of supervised PFMT. At the end of their treatment they completed a patient global impression of improvement questionnaire (PGI-I) and a second 24-h pad test. The PGI-I scores and the difference in pad test weight correlated with the ITMQ according to Spearman's correlation coefficient. RESULTS: Sixty-five women were recruited. Thirty-two (49%) patients perceived themselves as having improved, 28 women (43%) did not experience any change in symptoms and 5 women (8%) felt that their symptoms deteriorated following treatment. When correlating the PGI-I with the ITMQ, 3 of the 5 domains: MQS1 (positive attitude for treatment; p = 0.003), MQS3 (frustration of living with incontinence; p = 0.002) and MQS4 (desire for treatment; p = 0.002) correlated significantly with outcome. Desire for treatment was the only domain to correlate with change in pad weight (p = 0.001). CONCLUSION: Self-motivation is essential in order to determine improved success rates with PFMT.

The effect of age on pressure flow parameters in women with lower urinary tract symptoms.

This study aimed to evaluate changes in voiding with age in women with different urodynamic diagnoses. Correlation was used to analyse the association between age and voiding parameters (maximum flow rate, voided volume, flow rate centile and maximum detrusor pressure - PdetMax) in 896 datasets. Multivariate analysis was used to analyse the data further by age group and diagnosis - urodynamic stress incontinence (USI); detrusor overactivity (DO); mixed USI and DO; no urodynamic abnormality. Results showed that diagnosis accounts for a significant amount of variation in all four of the dependent variables Age group shows a significant effect on voiding volume but does not show significant effects on any other variable studied. There is no significant interaction term in any of the analyses, meaning that age and diagnosis do not appear to function together, e.g. age does not relate to flow rate centile, maximum flow rate or PdetQMax. It was concluded that the data suggest that there is no significant change in voiding function related to age. In the elderly, the main alteration in voiding is due to a higher prevalence of DO.

A retrospective analysis of the nature, extent and cost of alcohol-related emergency calls to the ambulance service in an English region.

AIMS: To measure the prevalence, pattern and associated financial cost of alcohol-related ambulance call outs in the North East of England using routinely collected data from the North East Ambulance Service (NEAS). METHODS: A retrospective cohort study over a 1-year time period (1 April 2009 to 31 March 2010) using NEAS patient record forms. RESULTS: In the North East, 10% of ambulance call outs were alcohol-related. Males were 2.5 times more likely than females to be attended by an ambulance on the street rather than at home. People aged 10-19 had the highest relative risk ratio (3.4) of an ambulance pick up being on the street compare with those aged over 60. These call outs and subsequent accident and emergency (A&E) attendances cost over £9 million in a 1-year period. When extrapolated to the whole country the cost could be as much as £152 million per year. CONCLUSION: In a 1-year period, we estimated that over 31,000 ambulance call outs were alcohol-related. A large discrepancy was found between manual and electronic recording of alcohol-related ambulance attendances to A&E. The workload and cost of alcohol-related call outs is high and mostly preventable. Ambulance visits may present a teachable moment for brief intervention to reduce alcohol-related risk and harm.

Ultrasound changes in the relationship between the urethra and bladder neck caused by prolapse repair: feasibility and reliability of measurements.

The objective of this study was to assess whether intraoperative transperineal ultrasound can be used to assess changes in the relationship between the urethra and bladder caused by a prolapse repair operation. The reliability of the measurements was also assessed. A total of 25 women having an anterior colporrhaphy operation had pre- and post-repair imaging using a standard bladder volume. There was a statistically significant change (p ≤ 0.04) in the posterior urethrovesical angle (PUA) from 115° (SD 37) before surgery, to 135° (SD 30) after surgery. There was no significant change (p = 0.93) in the anterior urethrovesical angle before 73° (SD 14) after surgery 73° (SD 14). Interclass correlation coefficients showed good reproducibility for all measurements. Ultrasound can be used to measure changes in the relationship of the urethra and bladder produced by anterior colporrhaphy. Clinically, the effect of these changes is to reduce the angulation of the urethra in relation to the bladder.

Short-term complications after vaginal prolapse surgery: do suture characteristics influence morbidity?

Pelvic organ prolapse (POP) surgery can be associated with early postoperative morbidity resulting in significant service utilisation. This study aimed to investigate whether different suture materials cause different rates of early postoperative morbidity by comparing two cohorts using case-control methodology. A total of 100 women undergoing POP surgery with vaginal closure with 1 Vicryl (polyglycolic acid) multifilament sutures were matched by operation with a cohort in which 2/0 Monocryl (poliglecaprone 25) monofilament sutures were used. The multifilament suture group had significantly higher rates of offensive discharge (p<0.001), vaginal bleeding (p<0.001) and vaginal pain (p=0.004). They were more likely to receive medical advice (0.007). Patients in the multifilament group were no more likely to suffer from a UTI (p=1.000) or to be readmitted postoperatively (p=1.000). Size 1 multifilament sutures result in higher levels of postoperative morbidity when compared with 2/0 monofilament sutures.

Prognostic research and its potential role in modern gynaecology: a call for more prognostic research in urogynaecology.

Over the last 30 years, many researchers have focussed on therapeutic and aetiological studies. Randomised controlled trials (RCT) are considered the 'gold standard' in research circles ( Ward et al. 2004 ). Prognostic research has been neglected probably due to a combination of a lack of perception of its importance and also a failure to produce good quality trials. The word 'prognosis' means the ability to foresee or predict an outcome or an event. Prognostic research in medicine is the ability to predict the likelihood of outcomes from a number of clinical variables. There are two main forms of prognostic research. One form identifies the prognostic value of a single risk factor (e.g. a tumour marker). The second one focuses on the development of a model based on multiple variables and is called multivariable prognostic modelling. The planning and powering of prognostic studies is managed differently from traditional randomised controlled trials.

A qualitative study of women's preferences for treatment of pelvic floor disorders.

OBJECTIVE: to explore women's perceptions of new and established treatments for stress urinary incontinence (SUI) and prolapse, and to identify factors important to women in decision-making about treatments. DESIGN: qualitative interview study. SETTING: urogynaecology unit in a large UK district general hospital. POPULATION: women referred from their general practitioner with SUI and/or prolapse symptoms. METHODS: each woman was given a questionnaire detailing nonsurgical and surgical treatments for SUI and/or prolapse. This briefly detailed the treatment, together with published success and complication rates. Participants were taken through a semi-structured interview based on their perceptions of each treatment, and the factors that lead them to find treatments acceptable or not acceptable. Interviews were conducted by a member of the research team before the initial appointment with the clinical team. Interviews were transcribed and subjected to thematic analysis using constant comparison derived from grounded theory. MAIN OUTCOME MEASURE: themes identified from analysis of interview transcripts. RESULTS: a total of 16 women were interviewed. Their median age was 54 years (range 48-70 years). Women with SUI were keen to have the treatment with the highest chance of long-term success, even if this was more invasive. Women with prolapse were more unsure about this, and less willing to risk potential complications for a higher chance of long-term success. CONCLUSIONS: many factors affect women's decision-making with regards to treatment choices. This analysis highlights the need for careful exploration of women's hopes and expectations before embarking on treatment.

To what extent are national guidelines for the management of urinary incontinence in women adhered? Data from a national audit.

UNLABELLED: OBJECTIVE To assess the degree of adherence to the current National Institute for Health and Clinical Excellence (NICE) guidelines on the management of urinary incontinence (UI) in women. DESIGN: Retrospective survey of consecutive female inpatients and outpatients with UI as part of a national audit. SETTING: NHS hospital and primary care (PC) trusts. POPULATION OR SAMPLE: Twenty-five women <65 years old and 25 women ≥ 65 years old from each participating site. METHOD: All NHS trusts in England, Wales and Northern Ireland were eligible to participate. A web-based data collection form aligned to the NICE guidelines was constructed for the study. All data submitted to the audit were anonymous and access to the web-tool was password-protected for confidentiality. RESULTS: Data were returned by 128 acute and 75 PC trusts on 7846 women. No diagnosis was documented in 6.8% (153/2254) of younger and 28% (571/2011) of older women in hospitals (P < 0.001), and by 8.6% (123/1435) of younger and 21% (380/1786) of older women in PC trusts. In hospitals, 26% (396/1524) of younger women and 15% (182/1231) of older women (P < 0.001) and in PC trusts 8.2% (77/934) of younger and 4.7% (46/975) of older women underwent multichannel cystometry before conservative therapy. Documentation of discussion of causes and treatment of UI occurred in 76% (1717/2254) of younger and 44% (884/2011) of older women in hospitals (P < 0.001) and in 75% (1080/1435) of younger and 53% (948/1786) of older women in PC trusts (P < 0.001). CONCLUSION Older women are less likely to receive NICE compliant management. Adherence varies according to recommendation. There needs to be concentration on evidence-based community provision of care by competent and interested clinicians before the aims of the NICE guidelines are met.

How do urogynaecologists treat failed suburethral slings? Experience from the British Society of Urogynaecology database and literature review.

Midurethral urethral sling (MUS) procedures have high success and satisfaction rates. A small percentage of MUS operations will fail and most centres have limited experience of treating this outcome. The aim of this study was to review the British Society of Urogynaecology (BSUG) database for women who underwent repeat anti-incontinence surgery after failed MUS. A total of 313 repeat surgical procedures were identified. For any failed MUS, the commonest second surgical intervention was a repeat retropubic MUS and was used in 54% (170/313) of repeat procedures. Bladder neck injections were the second commonest repeat procedure (43/313 cases: 14%). TVT-Os were used as repeat surgery in 12% (38/313) and TOTs in 8% (25/313). Small numbers of colposuspensions (20/313, 6%) and Aldridge slings (6/313, 2%) were also used. A variety of different surgical treatments are used for failed MUSs. From the BSUG database review, the commonest second surgical intervention was a repeat retropubic MUS.

A series of Advantage suburethral slings.

Since the introduction of original tension-free vaginal tape in 1995, a number of different suburethral slings have been marketed. Much of the published literature on midurethral sling procedures relates to the original TVT. Although there has been a considerable number of publications comparing different routes of tape insertion, there is relatively little published identifying the efficacy of different retropubic slings. This study was designed to identify the success rate and complications in a case series of Advantage slings. A total of 70 women were assessed 6 months after insertion of an Advantage midurethral sling by questionnaire. The absence of stress incontinence was reported in 94% of women. There were no intraoperative complications. Only 3% had short-term voiding dysfunction (<6 weeks). De novo overactive bladder symptoms developed in 3% of women. The Advantage sling has a good success rate, with low complications.

A randomised trial of a retropubic tension-free vaginal tape versus a mini-sling for stress incontinence.

OBJECTIVE: To compare a mini-sling with a retropubic tension-free vaginal tape (TVT) in the treatment of stress urinary incontinence (SUI) and urodynamic stress incontinence (USI). DESIGN: Randomised trial. SETTING: Urogynaecology unit in large UK district general hospital. POPULATION: Women with USI resistant to conservative management and requiring a suburethral sling. METHODS: A total of 71 women with SUI and confirmed USI were randomised to undergo treatment with either a retropubic TVT or mini-sling. Follow-up was at 6 weeks, with a history, examination and quality of life questionnaire, and at 6 months with further subjective evaluation and twin-channel subtraction cystometry and pressure-flow studies. MAIN OUTCOME MEASURES: The presence of SUI at 6 weeks and 6 months after treatment. RESULTS: The mini-sling was associated with a significantly higher rate of persistent SUI at 6 weeks (OR 9.49, 95% CI 2.8-32.6) and 6 months (OR 8.14, 95% CI 2.7-24.7), and of USI at 6 months (OR 7.58, 95% CI 2.7-24.7). The rate of complication was similar in the two groups. CONCLUSIONS: The mini-sling is associated with a higher failure rate than a retropubic TVT. Longer term and multicentre outcome data are necessary to explore these findings further. Until this is available, the mini-sling should be used with caution.

Transperineal ultrasound to assess the effect of tension-free vaginal tape position on flow rates.

OBJECTIVE: To determine whether the position of the tension-free vaginal tape (TVT) has an effect on postoperative flow rates and voiding function in women successfully cured of urodynamic stress incontinence. METHODS: Postoperatively 72 women who had undergone TVT surgery had a transperineal ultrasound examination to assess the position of the TVT on the urethra. The tape was categorized as proximal, mid or distal urethral. The effect on voiding was assessed using the maximum flow rate (MFR) centiles corrected for voided volume and detrusor pressure at maximum flow. RESULTS: Forty-six women had distal tapes and 26 mid-urethral tapes. A tape lying on the mid urethra was associated with a fall in MFR centile (P = 0.04) while a tape lying on the distal urethra did not cause a fall in the MFR centile (P = 0.52). There was no significant change in the detrusor pressure at maximum flow between mid and distally placed tapes. CONCLUSIONS: Distally placed tapes cause less alteration in flow rates than do mid-urethrally placed tapes. This may be beneficial in certain patient groups.

Barriers to seeking treatment for women with persistent or recurrent symptoms in urogynaecology.

The aim of this study was to identify the reasons why women with recurrent bothersome urogynaecological symptoms do not seek further treatment. A cohort of 17 women with recurrent incontinence or prolapse symptoms following a prolapse repair were identified and interviewed about their reasons for not seeking help when their symptoms recurred. The mean time between the surgery and the interview was 3 years. The interview transcripts were analysed using constant comparison derived from Grounded Theory. Dominant themes were beliefs about ageing, attitudes towards incontinence, health professionals and treatment and access to services. These factors may be important when counselling women postoperatively.

Pre-operative opening detrusor pressure is predictive of detrusor overactivity following TVT in patients with pre-operative mixed urinary incontinence.

AIMS: To determine if specific pre-operative urodynamic parameters could predict detrusor overactivity following TVT in patients with urodynamic mixed incontinence. METHODS: Notes of women with detrusor overactivity (DO) and urodynamic stress incontinence (USI) before undergoing tension-free vaginal tape (TVT) surgery were retrospectively reviewed. Patients underwent clinical evaluation pre-operatively including history, examination, and conventional urodynamic studies and were treated with pelvic floor exercises and anti-cholinergic medication. Those with persistent stress urinary incontinence (SUI) underwent TVT. Patients were re-assessed after at least 6 months post-operatively. Pre- and post-operative opening and closing detrusor pressure, and detrusor pressure at maximum flow were recorded retrospectively from pre-operative urodynamics traces by two clinicians independently and compared to the patients' post-operative symptoms and urodynamic diagnosis. RESULTS: Fifty-one women were reviewed. Forty-six of the 51 attended follow-up and 35/51 agreed to conventional urodynamic studies. Seventeen of the 35 reported OAB symptoms, and 18/35 were asymptomatic. Nineteen of the 35 women had DO and 16/35 had normal urodynamic studies (NUDS). The median pre-operative opening detrusor pressure was higher in women with overactive bladder symptoms post-operatively. The median pre-operative opening detrusor pressure in women with DO post-operatively was 33.0 cmH(2)O and the median pre-operative opening detrusor pressure in those with NUDS post-operatively was 16 cmH(2)O (15.0-23.0 cmH(2)O) (P < 0.05 Mann-Whitney U-test). CONCLUSIONS: Higher numbers of patients are required to demonstrate the value of opening detrusor pressure in predicting post-operative overactive bladder symptoms. Opening detrusor pressure is predictive of post-operative DO after TVT.

Female urinary incontinence - urodynamics: yes or no?

The National Institute for Clinical Excellence (NICE) recommends that cystometry need not be performed prior to conservative therapy for incontinence in women, nor is cystometry routinely recommended in the small group of women with a clearly defined diagnosis of pure stress incontinence. This review highlights the arguments for and against this recommendation and also looks at the place of cystometry and pressure flow studies in the assessment and management of women with lower urinary tract dysfunction.

Clinicians' views on the NICE guideline on the management of female urinary incontinence.

In October 2006, the National Institute for Health and Clinical Excellence (NICE) released Guideline No. 40: The management of female urinary incontinence. The objective of this study was to investigate the opinions of members of the British Society of Urogynaecology (BSUG) regarding the recommendations contained in the guideline. A closed format questionnaire using stems taken directly from the NICE guideline was sent to all UK-based members of BSUG. There was a 64% response rate. When asked if the guidance overall reflected their current practice, 56.8% agreed/strongly agreed. In terms of changing their practice to comply fully with the guideline, 53.3% disagreed/strongly disagreed. There were two major areas of disagreement. Some 80% of respondents disagreed that preoperative cystometry was not necessary in 'clinically pure' stress urinary incontinence; 72% of respondents disagreed that immediate release oxybutynin should be the first-line treatment for women with an overactive bladder (OAB). A smaller proportion disagreed with the statements on the use of duloxetine. The majority of the guidance formalises current practice among gynaecologists and urogynaecologists practicing in the UK. There are significant concerns regarding some of the recommendations, and the results indicate that over half of the respondents would not change their practice to follow these recommendations.