Patient preferences for clean intermittent catheterisation and transurethral indwelling catheterisation for treatment of abnormal post-void residual bladder volume after vaginal prolapse surgery.

OBJECTIVE: To determine patient preferences for clean intermittent catheterisation (CIC) relative to transurethral indwelling catheterisation (TIC) as the treatment of abnormal post-void residual bladder volume (PVR) following vaginal prolapse surgery. DESIGN: Scenario-based preference assessment during face-to-face interview. SETTING: Teaching hospital. POPULATION: A sample of consecutive patients scheduled for vaginal prolapse surgery. METHODS: Preference for CIC relative to TIC was assessed using written treatment scenarios. Initially, treatment duration was set at 3 days and the risk for urinary tract infection (UTI) was 30% for both interventions. Both treatment duration and UTI risk related to TIC were kept constant. Treatment duration and UTI risk after CIC were varied until patients altered their preference. In this way, the duration of catheterisation and level of UTI risk related to CIC at which patients would prefer CIC to TIC could be determined. MAIN OUTCOME MEASURES: Patients' preference for CIC relative to TIC. RESULTS: When both duration of treatment and UTI risk were identical for both interventions, 64% of patients prefer CIC. Ninety-two percent of patients prefer CIC when CIC lasts 3 days but results in a 15% lower risk of UTI. Assuming that CIC results in a 15% risk of UTI, a total of 98 and 99% of patients prefer CIC to TIC when catheterisation with CIC last 2 and 1 day, respectively. CONCLUSIONS: Most patients with abnormal PVR prefer CIC to TIC. The results of a recent randomised controlled trial showed that CIC resulted in a 2 days shorter catheterisation and more than 20% reduced risk of UTI. These conditions correspond to a preference of 99% of patients for CIC.

Comparing clean intermittent catheterisation and transurethral indwelling catheterisation for incomplete voiding after vaginal prolapse surgery: a multicentre randomised trial.

OBJECTIVE: To compare clean intermittent catheterisation with transurethral indwelling catheterisation for the treatment of abnormal post-void residual bladder volume (PVR) following vaginal prolapse surgery. DESIGN: Multicentre randomised controlled trial. SETTING: Five teaching hospitals and one non-teaching hospital in the Netherlands. POPULATION: All patients older than 18 years experiencing abnormal PVR following vaginal prolapse surgery, with or without the use of mesh. Exclusion criteria were: any neurological or anxiety disorder, or the need for combined anti-incontinence surgery. METHODS: All patients were given an indwelling catheter directly after surgery, which was removed on the first postoperative day. Patients with a PVR of more than 150 ml after their first void were randomised for clean intermittent catheterisation (CIC), performed by nursing staff, or for transurethral indwelling catheterisation (TIC) for 3 days. MAIN OUTCOME MEASURE: Bacteriuria rate at end of treatment. RESULTS: A total of 87 patients were included in the study. Compared with the TIC group (n = 42), there was a lower risk of developing bacteriuria (14 versus 38%; P = 0.02) or urinary tract infection (UTI; 12 versus 33%; P = 0.03) in the CIC group (n = 45); moreover, a shorter period of catheterisation was required (18 hours CIC versus 72 hours TIC; P < 0.001). Patient satisfaction was similar in the two groups, and no adverse events occurred. CONCLUSION: Clean intermittent catheterisation is preferable over indwelling catheterisation for 3 days in the treatment of abnormal PVR following vaginal prolapse surgery.

Diagnostic evaluation of the endometrium in postmenopausal bleeding: an evidence-based approach.

Postmenopausal bleeding (PMB) is a common complaint in general gynecological practice. Women with PMB have around a 10% chance of having endometrial carcinoma and therefore PMB always needs further evaluation. This article summarizes the reviews on the subject and provides an overview of the use of diagnostic tools in patients with PMB. Four types of diagnostic test are described: sonographic measurement of endometrial thickness, endometrial sampling, hysteroscopy and saline infusion sonography. All four have been independently shown to be accurate in excluding endometrial cancer. However, neither in systematic reviews nor in international guidelines is consensus found regarding the sequence in which these methods should be employed in women with PMB. For measurement of endometrial thickness in symptomatic women, a cut-off value of 3mm is recommended, but the cost-effectiveness of this strategy has yet to be shown. Research should now focus on the incorporation of individual patient characteristics and pre-test probabilities for cancer in algorithms for the investigation of PMB, and the most cost-effective sequenced combination of the four types of test.

Long-term cervical cancer survivors suffer from pelvic floor symptoms: a cross-sectional matched cohort study.

OBJECTIVE: The aim of this study was to determine prevalence of and experienced distress from pelvic floor symptoms in cervical cancer survivors (CCS). METHODS: For this cross-sectional matched cohort study, we matched CCS, treated in the Academic Medical Center, Amsterdam between 1997 and 2007, to a random female population sample aged 20 to 70 years (reference group). We assessed prevalence of and distress from bladder and bowel symptoms with validated pelvic-floor-related questionnaires. Severe distress was defined as values above the 90th percentile of reference group's symptom domain scores. RESULTS: One-hundred and forty-six CCS underwent radical hysterectomy and pelvic lymph node dissection (RH and LND), 49 underwent surgery and adjuvant radiotherapy (SART), and 47 underwent primary radiotherapy (PRT). Urinary incontinence and obstructive voiding were reported by each treatment group more frequently than by the reference group and caused more distress. Patients treated with RH and LND reported more distress from most uro-genital symptoms, except from overactive bladder symptoms. Patients treated with PRT reported more distress from each uro-genital symptom than matched controls. The RH and LND group reported more distress from constipation and obstructive defecation than the reference group. Patients who underwent primary or adjuvant radiotherapy reported more distress from anal incontinence than their matched controls. CONCLUSIONS: Treatment of cervical cancer impairs pelvic floor function. Patients treated with PRT report the most adverse effects on pelvic floor function. The results of our study enable physicians to counsel accurately about specific symptoms. Furthermore, to facilitate referral to pelvic floor specialists when bothersome symptoms occur, we recommend evaluating pelvic floor symptoms as a standard during follow-up.

Reasons for not seeking medical help for severe pelvic floor symptoms: a qualitative study in survivors of gynaecological cancer.

OBJECTIVE: (1) To explore the reasons for not seeking help for severe pelvic floor symptoms after gynaecological cancer treatment. (2) To determine the willingness to undergo treatment for these symptoms. (3) To invite suggestions to improve outpatient care. DESIGN: Qualitative study using semistructured interviews. SETTING: Vulvar, endometrial or cervical cancer survivors treated in the Academic Medical Centre, Amsterdam, the Netherlands between 1997 and 2007. POPULATION: Purposively selected sample from 138 eligible respondents to pelvic floor-related questionnaires, who were severely bothered by their symptoms (>75th percentile of domain sum score of questionnaires) and had not sought medical help. METHODS: After each semistructured interview, a checklist with reasons for not seeking help was complemented with newly mentioned reasons. The interviews were stopped when data saturation was accomplished, i.e. three consecutive interviewees had not revealed new reasons. The interviews were analysed by two researchers independently. MAIN OUTCOME MEASURE: Help-seeking behaviour for bothersome pelvic floor symptoms. RESULTS: Fifteen interviews were conducted. Most reported reasons for not seeking help were that women found their symptoms bearable in the light of their cancer diagnosis and lacked knowledge about possible treatments. Seven women were willing to undergo treatment. Eleven women stated that care should be improved, specifically by timely referral to pelvic floor specialists and additional care by oncology nurses. CONCLUSIONS: There is a need for standardised attention to adverse effects on pelvic floor function after cancer treatment. This could be realised by quantifying symptoms using questionnaires, standardised attention for such symptoms by gynaecological oncologists or oncology nurses, and timely referral to pelvic floor specialists of women with bothersome pelvic floor symptoms.

A nationwide survey to measure practice variation of catheterisation management in patients undergoing vaginal prolapse surgery.

INTRODUCTION AND HYPOTHESIS: Urinary catheterisation following vaginal prolapse surgery causes inconvenience for patients, risk of urinary tract infections and potentially longer hospitalisation. Possibly, practice variation exists concerning diagnosis and management of abnormal postvoid residual (PVR) volume implying suboptimal treatment for certain subgroups. METHODS: Nationwide questionnaire-based survey. RESULTS: Post-operatively, 77% performed transurethral indwelling catheterisation, 12% suprapubic catheterisation and 11% intermittent catheterisation. Catheterisation was applied 3 days (1-7 days) following anterior repair and 1 day (1-3 days) following all other procedures. The median cut-off point for abnormal PVR was 150 mL (range 50-250 mL). Treatment of abnormal PVR consisted mostly of prolonging transurethral indwelling catheterisation for 2 days (range 1-5 days; 57%), 29% by intermittent and 12% by suprapubic catheterisation. Antibiotics were administered by 21% either routinely or based on symptoms only. CONCLUSIONS: Due to insufficient evidence and suboptimal implementation of available evidence, practice variation in catheterisation regimens is high.

Adjuvant radiotherapy in patients with vulvar cancer and one intra capsular lymph node metastasis is not beneficial.

AIM OF THE STUDY: The aim of the study was to analyze the benefit from adjuvant radiotherapy in patients with vulvar cancer and a single positive node without extra capsular spread. MATERIALS AND METHODS: The study population comprised data of 75 patients with vulvar cancer and one lymph node metastasis. The patients were treated in three different university centers in Amsterdam, Groningen and Rotterdam between 1984 and 2005. RESULTS: Out of 75 patients, 31 (41%) were treated with adjuvant radiotherapy. Both disease-free survival (DFS) and disease-specific survival (DSS) were comparable between the groups who did and who did not receive adjuvant radiotherapy (HR 0.98, 95% CI 0.45-2.14, p=0.97 and HR=1.02, 95% CI 0.42-2.47, p=0.96). CONCLUSION: We could not demonstrate any beneficial effect of adjuvant radiotherapy in the group of patients with one intra capsular metastasis.

A tool to balance benefit and harm when deciding about adjuvant therapy.

Adjuvant therapy aims to prevent outgrowth of residual disease but can induce serious side effects. Weighing conflicting treatment effects and communicating this information with patients is not elementary. This study presents a scheme balancing benefit and harm of adjuvant therapy vs no adjuvant therapy. It is illustrated by the available evidence on adjuvant pelvic external beam radiotherapy (RT) for intermediate-risk stage I endometrial carcinoma patients. The scheme comprises five outcome possibilities of adjuvant therapy: patients who benefit from adjuvant therapy (some at the cost of complications) vs those who neither benefit nor contract complications, those who do not benefit but contract severe complications, or those who die. Using absolute risk differences, a fictive cohort of 1000 patients receiving adjuvant RT is categorised. Three large randomised clinical trials were included. Recurrences will be prevented by adjuvant RT in 60 patients, a majority of 908 patients will neither benefit nor suffer severe radiation-induced harm but 28 patients will suffer severe complications due to adjuvant RT and an expected four patients will die. This scheme readily summarises the different possible treatment outcomes and can be of practical value for clinicians and patients in decision making about adjuvant therapies.

Partial urethral resection in the surgical treatment of vulvar cancer does not have a significant impact on urinary continence. A confirmation of an authority-based opinion.

Partial resection of the urethra is sometimes necessary in the surgical treatment of locally advanced vulvar cancer. In this study, the frequency of urinary incontinence after partial urethral resection was compared with that of patients who were treated without partial resection of the urethra. Eighteen patients with vulvar cancer encroaching or infiltrating the urethra, treated by a radical vulvectomy and partial urethrectomy, were compared with 17 patients treated by vulvectomy without partial removal of the urethra. Data on urinary incontinence pre- and postoperatively from both groups were retrospectively collected from the patient files. A questionnaire on urinary incontinence was sent to a subset of patients from both groups in order to get information on the current micturation pattern. In four out of 18 patients (22%) with a partial urethrectomy, incontinence was reported, versus two out of 17 patients (12%) in the control group (P= 0.860). Eight patients in the study group and 12 in the control group are currently alive, and all responded to the questionnaire. Two (25%) in the study group and three (25%) in the control group reported to have current symptoms of urinary incontinence. This retrospective study shows that partial resection of 1-1.5 cm of the distal urethra in addition to a radical local excision for vulvar cancer does not result in a significant increase in the frequency of urinary incontinence, compared with vulvar cancer patients without partial urethrectomy.

In the absence of (early) invasive carcinoma, vulvar intraepithelial neoplasia associated with lichen sclerosus is mainly of undifferentiated type: new insights in histology and aetiology.

BACKGROUND: Differentiated vulvar intraepithelial neoplasia (VIN) is presumed to be the precursor of invasive squamous cell carcinoma (SCC) of the vulva. It is commonly assumed that differentiated VIN is related to lichen sclerosus (LS). However, evidence for this is limited to a small number of studies describing epithelial alterations adjacent to vulvar SCC. AIM: To study the histology and human papillomavirus (HPV) status in patients with a history of both LS and VIN without coexistent SCC. METHODS: Original biopsy specimens and surgical specimens of patients retrieved from the pathology files were revised for the presence of LS, VIN and (early) invasive SCC, specifically focused on the two different types of VIN: differentiated and undifferentiated. Thereafter, VIN lesions were tested for the presence of HPV DNA. RESULTS: Twenty-seven patients fulfilled the criteria for LS and VIN without SCC. In all 27 patients, LS was found to be related to undifferentiated VIN. Grading yielded the following results: VIN 1 (n=10), VIN 2 (n=11) and VIN 3 (n=6). Additionally, VIN lesions from 26 patients could be tested for the presence of HPV DNA. HPV DNA, predominantly type 16, was present in 8 (31%) of them. Seven of these eight patients had VIN 2 or 3. During follow-up, three patients progressed to (early) invasive carcinoma. In two of these patients, differentiated VIN was observed overlying early invasive SCC. CONCLUSIONS: VIN related to LS without coexisting SCC is likely to be undifferentiated, in contrast to what was previously thought. HPV DNA was demonstrated in 31% of the lesions, and was strongly related to high-grade VIN.

[Two adult patients with pneumococcal peritonitis]. / Twee volwassen patiënten met pneumokokkenperitonitis.

Two women, aged 31 and 37 years, had abdominal pain and fever several months after giving birth and a few weeks after receiving an intrauterine device. Both patients were admitted and treated under the working diagnosis of pelvic inflammatory disease (PID). They appeared to have pneumococcal adnexitis and pneumococcal peritonitis. Both patients recovered after initiating directed antibiotic treatment. Peritonitis in previously healthy adults is seldom caused by pneumococci. Standard antibiotics that are effective when given empirically for PID may be a suboptimal treatment for pneumococcal peritonitis.

Squamous cell cancer of the vulva with occult lymph node metastases in the groin: the impact of surgical technique on recurrence pattern and survival.

OBJECTIVE: The triple incision technique is an established surgical method of management for early vulvar cancer. There is only limited data available on the efficacy of this form of treatment for patients with occult inguinofemoral lymph node metastases. It was the objective of this study to obtain more insight into the efficacy of this treatment compared with the en bloc resection, when utilized in surgical pathological advanced disease. METHODS: A retrospective review was performed in patients with vulvar cancer in the presence of occult inguinofemoral lymph node metastases. Tumor diameter, extracapsular nodal spread, FIGO stage, number of positive lymph nodes, and type of treatment were analyzed in relation to recurrence pattern and survival in both univariate and multivariate analyses. RESULTS: There was no significant impact of surgical technique on disease-specific and overall survival. When corrected for other prognostic variables in a multivariate analysis, the type of surgical treatment was an independent predictor for vulvar recurrence (HR 0.10, 95% CI 0.02-0.44, P = 0.002) but not for inguinal/pelvic recurrence. CONCLUSION: The type of surgical technique did not influence disease-specific and overall survival in patients with occult inguinofemoral lymph node metastases. The triple incision technique is an independent poor prognostic variable for vulvar recurrence.

[Two women with a chronic process in the lower abdomen]. / Twee patiëntes met een chronisch proces in de onderbuik.

Two women, aged 50 and 45 years, had a chronic process in the lower abdomen. The first presented with cough and progressive dyspnoea, and her chest X-ray raised the suspicion of a metastasis of a malignancy. The second patient had abdominal pain, frequent urination and irregular vaginal bleeding. She was initially treated for a urinary-tract infection. Diagnostic investigations showed pelvic actinomycosis in both patients. Both had used an intrauterine device (IUD). In the first patient a pelvic abscess was drained. Antimicrobial treatment consisted of penicillin i.v. for several weeks and orally for 6 months. Actinomycosis is a slowly progressive bacterial infection that characteristically expands through anatomic structures and can lead to fistulae and abscesses. The disease is caused by Actinomyces species. Diagnosis is often delayed because other diseases (e.g. malignancy) are considered more probable. Actinomycosis is associated with prolonged use of an IUD, but it is rare and removal of the IUD is not indicated unless symptoms of pelvic inflammatory disease are present. The mainstay of actinomycosis therapy is administration of an effective antibiotic (e.g. penicillin). Except for drainage of abscesses, surgical intervention is rarely necessary. When antimicrobial therapy is continued for 6-9 months, prognosis is favourable, as was the case in both patients.

Using a new HPV detection system in epidemiological research: change of views on cervical dyskaryosis?

UNLABELLED: The prevalence of human papillomavirus (HPV) rises with increasing histological severity of neoplasia, more cigarettes smoked per day and higher lifetime number of sexual partners in women with cervical dyskaryosis. Recently, the highly sensitive SPF10 primers and Inno-LiPA (line probe assay) HPV prototype research assay became available for the detection and typing of HPV. BACKGROUND: using this system, we challenged the previously reported findings. STUDY DESIGN: the study group comprised 304 women referred because of abnormal pap smears in whom a histological diagnosis was made. Data on the lifetime number of sexual partners and smoking behaviour were obtained by questionnaire. HPV analysis was performed on cervical scrapes obtained at the enrollment visit. RESULTS: oncogenic HPV was found in 288 (95%) women. A total of 86 (30%) out of these 288 women disclosed multiple types. HPV 16 occurred significantly less often in multiple infections than was expected on the basis of chance alone. The grade of neoplasia was significantly associated with the presence of oncogenic HPV, and this association depended on the presence of HPV type 16. No association was found between grade of neoplasia and the presence of multiple HPV types. Neither the lifetime number of sexual partners nor smoking were associated with oncogenic HPV, the five most frequent HPV types separately or the presence of multiple types. CONCLUSION: we conclude that the association between the detection of HPV and the epidemiological risk factors, as found with the GP5/6 PCR in the past, could not be confirmed when using SPF10 PCR primers and LiPA HPV genotyping. We suggest that the number of sexual partners and smoking may be determinants of high HPV viral load rather than determinants of the presence of HPV per se.

Cytokines in cervicovaginal washing fluid from patients with cervical neoplasia.

Human papillomavirus (HPV) infections play an important role in the development of cervical neoplasia. To get to a better understanding of the role of cytokines in the development of these neoplasias, we analysed the presence of various cytokines in cervicovaginal washings of healthy volunteers (n=22), cervical intraepithelial neoplasia (CIN) patients (n=63) and cervical cancer patients (n=33). IL-12p40, IL-10, TGF-beta1, TNF-alpha and IL-1beta levels were significantly higher in patients with cervical cancer than in controls and CIN patients. The levels of IFN-gamma were not different. Our data demonstrate alterations in the local cervical immune environment in cervical cancer patients. This could have important consequences for the further development of immune modulating therapies and vaccination strategies.

Epidemiologic and mucosal immunologic aspects of HPV infection and HPV-related cervical neoplasia in the lower female genital tract: a review.

Human papillomavirus (HPV) infections are known to play an important role in the pathogenesis of cervical neoplasia. Considering the morbidity and mortality of cervical cancer, infection with HPV can be regarded as a worldwide problem, especially in developing countries. Currently, many studies focus on the development of both prophylactic and therapeutic HPV vaccines. Crucial for these vaccination protocols to be successful is that they will result in a long-lasting ability to generate an immune response that will eliminate the virus. HPV transmission and subsequent infection is a local event in the lower female genital tract and therefore the efficacy of vaccines against this locally transmitted infection can be best assessed by parameters of local immunity. In this review we describe both the epidemiology of HPV-related cervical neoplasia and the general aspects of mucosal immunity in the female genital tract while focusing on the local humoral immunity in HPV-related cervical neoplasia.

No association of anti-Chlamydia trachomatis antibodies and severity of cervical neoplasia.

OBJECTIVE: To explore whether the presence of Chlamydia trachomatis antibodies is associated with the severity of neoplastic lesions in women with cervical dyskaryosis. METHODS: In a cross sectional study in two groups of women referred for an abnormal Papanicolaou smear (group A: 296, group B: 331 women) blood samples were analysed for antichlamydial antibodies by enzyme immunoassay. Cervical neoplasia was graded histologically. RESULTS: In group A no association was found between increasing grade of CIN and the presence of antichlamydial antibodies. The proportion (93%) of women with antichlamydial antibodies was higher in 14 women with (micro)invasive carcinoma than in women with CIN (35%). As the high prevalence of antichlamydial antibodies in women with cervical carcinoma is not consistent with prevalences reported in recent literature, we analysed a second group of women in which indeed the high prevalence was not confirmed CONCLUSION: Our results suggest that the presence of circulating antichlamydial antibodies is not associated with the severity of neoplastic lesions and it seems unlikely that C trachomatis has a role in the progression of cervical neoplasia.

IgG antibodies against human papillomavirus type 16 E7 proteins in cervicovaginal washing fluid from patients with cervical neoplasia.

Little information is available about the cervicovaginal mucosal antibodies against human papillomavirus (HPV) proteins. In this study specific IgG antibodies against HPV 16 E7 protein were determined in paired samples of cervicovaginal washing fluid and serum from patients with cervical cancer (n = 22), cervical intraepithelial neoplasia (CIN) (n = 38), healthy individuals (n = 22), and serum from children (n = 41) by a radioactive immunoprecipitation assay (RIPA). HPV 16 E7 specific IgG antibodies were found in cervicovaginal washings (n = 8) and in sera (n = 8) of the patients with cervical cancer. About 60% of the patients with HPV 16 positive cervical cancer had HPV 16 E7 specific IgG antibodies. Titration studies showed that the IgG antibody reactivity in cervicovaginal washings was higher than in the paired serum samples of six patients with cervical cancer (P < 0.001). In the CIN group we found no IgG reactivity in the serum, but in five patients we found a low IgG reactivity in the cervicovaginal washings. No IgG reactivity was found in cervicovaginal washings and sera from healthy individuals and sera from children. HPV 16 E7 specific IgG antibodies seem to be locally produced in a number of patients with HPV 16 positive (pre)malignant cervical lesions. For more definitive evidence for the local production of these antibodies immunostaining should be performed to demonstrate the presence of specific anti-HPV 16 E7 IgG producing plasma cells in the cervical epithelium.