Energy and protein levels in dairy cow diets to recover milk ethanol stability.

The objective of this study was to evaluate the effect of energy and protein in the diet on the recovery of milk ethanol stability (MES) induced by feed restriction. Twelve Holstein and Holstein × Jersey crossbred cows with an average of 146 ± 50 DIM, 575.4 ± 70 kg of BW, and 18.93 ± 5.46 kg/d of milk yield were distributed in a 3 × 3 Latin square design with 3 treatments and 3 experimental periods. Each experimental period lasted 24 d, comprising 3 phases: a 13-d adaptation phase (100E+100P), a 4-d induction phase for milk ethanol instability (50E+50P), and a 7-d recovery phase for MES (3 treatments). The 3 treatments during the recovery phase consisted of 3 diets aiming to meet the requirements of energy and protein (100E+100P), only energy (100E+50P), or only protein (50E+100P). The diet during the adaptation and induction phases was common for all cows. The energy and protein levels to meet each cow's requirements were based on the group average. Restriction of energy and protein reduced DM, CP, and total digestive nutrient intake for cows fed 100E+50P and 50E+100P. The lowest BW was observed for cows fed 50E+100P, with no difference for BCS. During the induction phase, MES was reduced by 9 percentage units. Cows fed 100E+100P recovered MES in the first days of the recovery phase, whereas 100E+50P slightly improved MES, and 50E+100P had a constant decrease in MES. Cows fed 100E+50P and 50E+100P produced, respectively, 3.6 and 5.9 kg less milk than those fed 100E+100P. The 50E+100P treatment exhibited the highest milk fat content and SCS, along with the lowest milk lactose content. Protein content was higher in the 100E+100P treatment. Cows fed 50E+100P showed higher serum albumin levels compared with those on the 100E+100P treatment, not differing from the 100E+50P treatment. We concluded that the complete recovery of MES in cows with feed restrictions is possible only by supplying both the energy and protein requirements in the cows' diet. However, restricting energy intake poses a greater limitation on MES recovery compared with restricting protein.

Vaginal laser therapy for GSM/VVA: where we stand now - a review by the EUGA Working Group on Laser.

Vulvovaginal atrophy (VVA) is a chronic progressive condition that involves the genital and lower urinary tracts, related to the decrease of serum estrogenic levels when menopause occurs. The definition of genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing and publicly acceptable term than VVA. Due to the chronic progressive trend of GSM, symptoms tend to reappear after the cessation of therapy, and frequently long-term treatment is required. First-line therapies include vulvar and vaginal lubricant or moisturizers, and, in the case of failure, low-dose vaginal estrogens are the preferred pharmacological therapy. Populations of patients, such as breast cancer (BC) survivors, are affected by iatrogenic GSM symptoms with concerns about the use of hormonal therapies. The non-ablative erbium:YAG laser and the fractional microablative CO2 vaginal laser are the two main lasers evaluated for GSM treatment. The aim of this comprehensive review is to report the efficacy and safety of Er:YAG and CO2 vaginal lasers for GSM treatment. Vaginal laser therapy has been demonstrated to be effective in restoring vaginal health, improving VVA symptoms and sexual function. The data suggest that both Er:YAG and CO2 vaginal lasers are safe energy-based therapeutic options for management of VVA and/or GSM symptoms in postmenopausal women and BC survivors.

Effects of turmeric extract supplementation on the lipid and lipoprotein subfraction profile in hemodialysis patients: A randomised, double-blind, crossover and controlled trial.

Dyslipidemia is common in patients with chronic kidney disease. Curcumin, a bioactive polyphenol from Curcuma longa, can improve lipid profile. This study aims to analyze the effects of Curcuma Longa extract supplementation on lipid profile and lipoprotein subfractions in hemodialysis (HD) patients. This is a longitudinal, double-blind, washout-period randomized clinical trial. The patients were randomized into two groups: the curcumin group (n = 10) (orange and carrot juice with 2.5 g of Curcuma Longa extract) and the control group (n = 11) (juice without curcumin) 3x/w during HD sessions for 3 months. After the washout period, patients continued the supplementation as a crossover for the same period. The lipid profile was measured using enzymatic assays. The high-density lipoprotein and low-density lipoprotein subfractions analyses were performed using LipoprintTM. In the curcumin group, the triglyceride values tended to decrease with a different triglyceride variation between the pre and post-intervention for the control and curcumin groups of 38.5 (19.8) mg/dL (p = 0.06). There was no statistical difference in the others parameters. In conclusion, Curcuma longa extract may be a good nutritional strategy to reduce triglyceride plasma levels in hemodialysis patients, but it seems ineffective for the other parameter.

Can pelvic organ prolapse in postmenopausal women be treated with laser therapy?

PURPOSE: This study aims to assess the effectiveness of the non-ablative photothermal erbium laser (Er:YAG laser) for managing anterior and/or posterior vaginal compartment prolapse. METHODS: A randomized, single-blind, 1:1 trial was performed comparing Er:YAG laser treatment to watchful waiting in postmenopausal women with symptomatic cystocele and/or rectocele stage 2 or 3 who opted to undergo surgery due to bothersome prolapse symptoms. Three Er:YAG laser treatments at monthly intervals were applied for the Er:YAG laser group, while there was no treatment for the watchful-waiting group. The primary outcome was the proportion of patients with stage 0 or 1 following laser treatment, while secondary outcomes included the Pelvic Organ Prolapse Quantification System (POP-Q points), Pelvic Floor Distress Inventory Questionnaire short-form, Pelvic Floor Impact Questionnaire short-form, and Patients Global Impression of Improvement (PGI-I). All outcomes were evaluated at baseline and 4 months post baseline. RESULTS: Thirty women (15 vs. 15) were eligible to be included. No participants (0%) in either group had POP-Q stage 0 or 1 at 4 months. Moreover, no change was present in the secondary outcomes. In the PGI-I, 2/15 (14%) and 0/15 (0%) participants declared much better/very much better in the laser and watchful-waiting group, respectively. CONCLUSIONS: The findings of this study do not support use of the intravaginal Er:YAG laser for treatment of the anterior/posterior vaginal wall. Clinical trial identification number: NCT03714607.

Managing overactive bladder.

Overactive bladder (OAB) is a common and distressing condition which is known to increase with age and has a significant effect on quality of life. Whilst OAB is a symptomatic diagnosis, many patients will require basic investigations prior to initiating the appropriate management. This article will review the initial clinical assessment and management of women complaining of OAB including conservative measures and drug therapy, and will also focus on the role of estrogen. In addition, the management of refractory OAB will also be discussed including more invasive strategies such as neuromodulation, Botulinum Toxin, and reconstructive surgery.

Rationale and design for fractional microablative CO2 laser versus photothermal non-ablative erbium:YAG laser for the management of genitourinary syndrome of menopause: a non-inferiority, single-blind randomized controlled trial.

Genitourinary syndrome of menopause (GSM) is a common condition affecting up to 50% of postmenopausal women and up to 70% of postmenopausal breast cancer survivors. GSM is a chronic condition with a significant impact on sexual health and quality of life. The mainstay of treatment has been with symptomatic relief using topical emollients or lubricants. Second-line treatment is with topical vaginal estrogens to restore the physiology of the vaginal epithelium. For some, the latter is not suitable or acceptable. Newer treatments with ospemifene and vaginal lasers have now been introduced. The two main types of laser currently used for the treatment of GSM are the fractional microablative CO2 laser and the non-ablative photothermal erbium:YAG laser. We present a study protocol for a multicenter, prospective, non-inferiority, single-blinded, randomized controlled trial comparing the fractional microablative CO2 laser versus the photothermal non-ablative erbium:YAG laser for the management of GSM. We will recruit 88 postmenopausal women across two sites who will be randomized to one of the two laser groups. Participants will all have GSM symptoms and a Vaginal Health Index Score < 15. All participants will receive an active treatment. Each participant will receive three applications of vaginal laser 1 month apart and will be followed up at 1 month, 6 months, and 12 months. Our primary outcomes will look at all changes of GSM symptoms (dryness, dyspareunia, itching, burning, dysuria, frequency, urgency), urinary incontinence (if present), and overall sexual satisfaction. Both subjective and objective means will be used to assess participants. The findings of this trial have the potential to allow clinicians and women suffering from GSM to make an informed decision when opting for a specific laser type. The trial will add to the current growing body of evidence for the safe use of vaginal lasers in GSM as an alternative treatment. We hope this trial will provide robust and long-term data for the safe use of both lasers.

Is there a link between overactive bladder and the metabolic syndrome in women? A systematic review of observational studies.

OBJECTIVES: To conduct a systematic review to determine whether there is an association between metabolic syndrome (MetS) and lower urinary tract symptoms (LUTS) or overactive bladder (OAB) in women. METHODS: We systematically reviewed English language observational studies on the effect of MetS (or component factors) on the presence of OAB or LUTS in women. We searched PubMed, Web of Science and The Cochrane Library with no date restrictions, checked reference lists and undertook citation searches in PubMed and Google Scholar. Studies were assessed for risk of bias. Because of heterogeneity, results were not pooled, but are reported narratively. RESULTS: Of 27 included studies, only three looked at the link between MetS and OAB. The rest looked at links between OAB and components of MetS such as obesity or insulin resistance (n = 10), between MetS and urinary symptoms (n = 3) and between urinary symptoms and components of MetS, such as obesity (n = 14). Evidence is currently limited, but it does suggest that there may be important links between MetS and OAB and components of MetS such as obesity. CONCLUSIONS: The literature on MetS and OAB or LUTS in women is limited, and poor quality. However, the evidence available on obesity appears to support MetS as a contributor and predictor of LUTS in women. Many of the women with LUTS will be overweight and will have features of the MetS, if looked for. This provides not only an opportunity to encourage weight loss as an adjunct to therapy for the OAB symptoms but also a window of opportunity to address cardiovascular risk factors and prevent future cardiovascular morbidity and mortality.

Risk factors for the occurrence of new and chronic cases of subclinical mastitis in dairy herds in southern Brazil.

The aim of this research was to evaluate the risk factors for new and chronic subclinical intramammary infections (IMI) using the monthly somatic cells count of dairy cows. The study took place at 30 dairy herds with approximately 1,700 cows in lactation. Data characterizing the dairy farms and their milking management were obtained from a survey questionnaire. The somatic cells count values from 2 consecutive months were used to classify cows as either healthy or with new or chronic infections. A chi-squared test was used in the analysis of subclinical IMI to evaluate associations between each independent variable, followed by logistic regression to estimate the risk of a new infection in healthy cows and of chronic infection in cows with new infections. Factors increasing the odds ratio of a cow developing a new case of subclinical mastitis were (1) cows with more than 3 lactations, (2) cows with a mean hyperkeratosis score above 3, (3) cows with the udder below the hock, (4) cows with very dirty udders, and (5) milking of infected animals before healthy cows. Factors increasing the risk of a subclinical chronic infection compared with new cases of subclinical mastitis were (1) a lack of regular maintenance of milking machinery, (2) cows over 100 d in lactation, and (3) cows with the udder on or below the hock. The risk factors identified in this study can be used in IMI control programs to reduce the frequency of new and chronic cases of subclinical mastitis.

Psychological characteristics and motivation of women seeking labiaplasty.

BACKGROUND: Labiaplasty is an increasingly popular surgical intervention but little is known about the characteristics and motivation of women who seek the procedure or the psychosexual outcome. METHOD: A total of 55 women seeking labiaplasty were compared with 70 women who did not desire labiaplasty. Various general measures of psychopathology as well as specific measures (Genital Appearance Satisfaction; Cosmetic Procedure Screening for labiaplasty) were used. Labia measurements of the women seeking labiaplasty were also obtained. RESULTS: Women seeking labiaplasty did not differ from controls on measures of depression or anxiety. They did, however, express increased dissatisfaction towards the appearance of their genitalia, with lower overall sexual satisfaction and a poorer quality of life in terms of body image. Women seeking labiaplasty reported a significantly greater frequency of avoidance behaviours on all the domains assessed, and greater frequency of safety-seeking behaviours for most of the domains. Key motivations reported for labiaplasty were categorized as cosmetic, functional or sexual. Of the 55 women seeking labiaplasty, 10 met diagnostic criteria for body dysmorphic disorder. CONCLUSIONS: This is the first controlled study to describe some of the characteristics and motivations of women seeking labiaplasty. We identified a wide range of avoidance and safety-seeking behaviours, which occurred more frequently in the labiaplasty group than the control group. These could be used clinically as part of a psychological intervention for women seeking labiaplasty.

Quality assurance in quality of life assessment--measuring the validity of the King's Health Questionnaire.

INTRODUCTION AND HYPOTHESIS: The King's Health Questionnaire (KHQ) is a disease-specific, self-administered questionnaire designed to assess the impact of urinary incontinence on quality of life (QOL) in women. To our knowledge there are no data on women's perception of completing the KHQ. Do they feel the KHQ to be useful and valuable or do they feel it to be too burdensome to be used in clinical practice? Therefore, we designed this study to evaluate patients' perception of the KHQ using QQ-10. The QQ-10 is a validated tool designed to measure patient's views on questionnaires. METHODS: This was a prospective observational study conducted at a tertiary referral teaching hospital. Patients were recruited from a one-stop urodynamics clinic. The study participants were asked to complete QQ-10 to give their views regarding KHQ. This produces two responses: positive value (communication, relevance, ease of use, comprehensiveness, enjoyableness, willingness to repeat) and negative burden (over-long, embarrassing, complicated, and upsetting). Mean scores and standard deviation for positive and negative responses were calculated RESULTS: The KHQ was found to have a high mean value (73; range 13-100) and a low mean burden (25; range 0-81) regarding responses to individual QQ-10 items. This was reinforced by the positive comments provided in the text boxes. CONCLUSIONS: Women perceived the KHQ as a valuable tool in their assessment without being bothersome.

The value of vaginal packing in pelvic floor surgery: a randomised double-blind study.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to evaluate the effect of vaginal packing following pelvic floor surgery with regard to post-operative pain, bleeding and infection. This was a double-blind randomised study of women undergoing vaginal hysterectomy and/or pelvic floor repair at a tertiary urogynaecology unit. METHODS: The primary outcome of day 1 post-operative pain was assessed using the short-form McGill Pain score. Secondary outcomes were haematological and infective morbidity, evaluated using changes in full blood count, and cultures of midstream urine and high vaginal swabs. A transvaginal ultrasound scan to exclude pelvic haematoma was performed at 6 weeks in all women who underwent vaginal hysterectomy with or without a pelvic floor repair. RESULTS: In total, 190 women were recruited: mean age 58.3 years (27-91 years), mean body mass index 27.4 kg/m(2) and median parity 3. Women were randomised into the 'pack' (n = 86) and 'no pack' (n = 87) arms with no demographic differences between the groups. No statistically significant differences in the post-operative pain scores or secondary outcome measures were demonstrated. Incidence of haematoma formation (14.8 % no pack, 7.3 % pack, p = 0.204) was not statistically significant. There were three clinically significant complications in the no pack group and none in the pack group. CONCLUSIONS: This is the first study to examine pain in association with post-operative vaginal packing. There is no evidence to suggest that packing increases pain scores or post-operative morbidity. A trend towards increased haematoma and significant complications was seen in the no pack group. As vaginal packing does no harm and may be of some benefit it may be argued that packing should be recommended as routine clinical practice.

Managing urinary incontinence: what works?

Urinary incontinence is a common condition, which, although not life-threatening, impairs the health-related quality of life of affected individuals. All women complaining of incontinence require a basic assessment and those with complex or refractory symptoms may benefit from urodynamic studies. Initial treatment includes lifestyle advice, behavioral modifications, bladder retraining and pelvic floor muscle training. For those women with persistent stress urinary incontinence following conservative therapy, surgical management might be considered. The development of the minimally invasive, retropubic, synthetic, mid-urethral sling procedures has revolutionized stress incontinence surgery and reduced the popularity of 'traditional' procedures, such as colposuspension and autologous fascial sling. In an attempt to reduce further the morbidity, transobturator and single-incision slings have been introduced. While antimuscarinic agents are the mainstay of the current medical management of urgency urinary incontinence, a recently developed selective ß3-adrenergic receptor agonist (mirabegron) offers an alternative pharmacological option. Modalities such as intravesical botulinum toxin and neuromodulation (peripheral or sacral) are available to women with refractory urgency incontinence. Finally, when all other options have been explored and proven unsuccessful, inappropriate or not feasible, reconstructive surgery or catheter insertion might be considered as a last resort. The aim of this paper is to review conservative, medical and surgical management for urinary incontinence by using the best available evidence in the literature.

Efficacy and safety of fesoterodine 8 mg in subjects with overactive bladder after a suboptimal response to tolterodine ER.

AIMS: To assess fesoterodine 8 mg efficacy over time and vs. placebo in subjects with overactive bladder (OAB) who responded suboptimally to tolterodine extended release (ER) 4 mg. METHODS: In a 12-week, double-blind trial, subjects with self-reported OAB symptoms for ≥ 6 months, mean of ≥ 8 micturitions and ≥ 2 to < 15 urgency urinary incontinence (UUI) episodes/24 h, and suboptimal response to tolterodine ER 4 mg (defined as ≤ 50% reduction in UUI episodes during 2-week run-in) were randomised to fesoterodine (4 mg for 1 week, 8 mg for 11 weeks) or placebo once daily. Change from baseline to week 12 in UUI episodes (primary end-point) was analysed in step-wise fashion: first, baseline vs. week 12 for fesoterodine; if significant, then change from baseline to week 12 for fesoterodine vs. placebo. RESULTS: By week 12, subjects receiving fesoterodine 8 mg had significantly greater improvement from baseline vs. placebo in UUI episodes, urgency episodes and scores on the Patient Perception of Bladder Control, Urgency Perception Scale and OAB Questionnaire Symptom Bother and Health-Related Quality of Life scales and domains (all p < 0.05). 50% and 70% UUI responder rates were also significantly higher with fesoterodine 8 mg vs. placebo at week 12 (p < 0.05). Dry mouth (placebo, 4%, 12/301; fesoterodine, 16.6%, 51/308) and constipation (placebo, 1.3%, 4/301; fesoterodine, 3.9%, 12/308) were the most frequent adverse events. CONCLUSIONS: Subjects who responded suboptimally to tolterodine ER 4 mg showed significant improvements in UUI and other OAB symptoms and patient-reported outcomes, with good tolerability, during treatment with fesoterodine 8 mg vs. placebo.

Urgency and pain in patients with overactive bladder and bladder pain syndrome. What are the differences?

BACKGROUND: The Overactive Bladder Syndrome (OAB) and the Bladder Pain Syndrome/Interstitial Cystitis (BPS/IC) are different urological conditions sharing 'urgency' as a common symptom. The aim of this review is to address our existing knowledge and establish how these symptoms are interrelated and to determine whether or not there is a common link between both symptoms complexes that help to distinguish one from the other. METHODS: Pubmed was used to obtain references for this non-systematic review aiming to discuss differences between OAB and BPS/IC. Guidelines of several professional associations and discussions based on expert opinion from the authors were implemented. RESULTS: Whilst in BPS the hallmark symptom is pain on bladder filling, urgency is the defining symptom of OAB. Whilst it is likely that the pain in BPS/IC arises from local inflammation in the bladder wall, the nature of urgency as a symptom, its origin, and the relationship between urgency and pain, as well as the different afferent mechanisms associated with the genesis of these sensory symptoms, remains unknown. Although the aetiology of both OAB and PBS/IC is unclear, the influence of environmental factors has been suggested. Both are chronic conditions with very variable symptom resolution and response to therapy. The relationship with voiding dysfunction, gynaecological causes of chronic pelvic pain or the possible alteration of the hypothalamic-pituitary-adrenal axis and psychological disorders has not been established. Inflammation has been suggested as the common link between OAB and BPS/IC. CONCLUSIONS: OAB and BPS/IC are different symptoms complexes that share urgency as a common symptom. None of them have a specific symptom although pain on bladder filling is the hallmark symptom in BPS/IC. Bladder pain with urgency should be a trigger for referral to the provider with appropriate knowledge and expertise in this disease state, whereas the management of OAB should be part of normal routine care in the community.

Prolapse and sexual function in women with benign joint hypermobility syndrome.

OBJECTIVE: To determine whether pelvic organ prolapse (POP) and sexual dysfunction are more severe in women with benign joint hypermobility syndrome (BJHS) than in the normal population. DESIGN: Case-control study. SETTING: King's College Hospital NHS Foundation Trust, London, UK and University College Hospital, London, UK. POPULATION: Women diagnosed with BJHS (n = 60) at University College Hospital. Control participants (n = 60) recruited from King's College Hospital NHS Foundation Trust. METHODS: Objective assessment of POP was undertaken using the Pelvic Organ Prolapse Quantification System (POP-Q). Both groups were asked to complete the Prolapse quality of life (P-QOL) and pelvic organ prolapse/urinary incontinence sexual (PISQ-12) questionnaires. MAIN OUTCOME MEASURES: Comparison of vaginal anatomy using POP-Q between the two groups. Comparison of P-QOL and PISQ-12 quality of life scores between the two groups. RESULTS: In all, 120 women (60 in Study group, 60 in Control group) were recruited. All women in the study group were matched with healthy control women according to age, parity and ethnicity. There was a statistically significant difference between points Aa, Ba, Ap, Bp and C in study and control groups showing that prolapse is objectively more severe in those with BJHS. Significantly more women with BJHS felt that POP interfered with sex and defecation compared with the control group. The impact of prolapse symptoms on quality of life was statistically different in almost all nine P-QOL domains. CONCLUSIONS: A large number of women with BJHS have prolapse symptoms, which significantly affect their quality of life. POP is more severe in women with BJHS.

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.

Lower urinary tract symptoms in women with benign joint hypermobility syndrome: a case-control study.

INTRODUCTION AND HYPOTHESIS: Benign joint hypermobility syndrome (BJHS) is a connective tissue disorder associated with joint hypermobility. BJHS is under-recognised by medical professionals and is poorly managed. The aim of our study was to determine whether lower urinary tract symptoms (LUTS), including urinary incontinence (UI) and anterior compartment prolapse, are more common in women with BJHS than in the normal population. METHODS: This was a prospective case-control study. Women diagnosed with BJHS according to the Brighton criteria were recruited from a tertiary referral clinic. Controls were recruited from hospital personnel. Both groups completed the King's Health Questionnaire (KHQ) and the Prolapse Quality of Life Questionnaire (P-QoL). Objective assessment of pelvic organ prolapse (POP) was undertaken using the Pelvic Organ Prolapse Quantification (POP-Q) system. Analyses were performed using SPSS version 17.0. The statistical difference was analysed using McNemar's test. Comparison of QoL scores was performed with the Wilcoxon signed-rank test. RESULTS: Sixty individuals were recruited and matched with 60 healthy women. The prevalence of UI in those with BJHS was significantly higher than in controls(73.3 % vs. 48.3 %). The impact of UI on QoL was statistically significant in all domains of the KHQ. There was a significant difference between groups in most urinary-specific symptoms of the KHQ. A significant number of women with BJHS suffer from voiding difficulties. Prolapse of the anterior vaginal wall was objectively more severe in those with BJHS. CONCLUSIONS: Women with BJHS have LUTS and anterior compartment prolapse, which significantly impair their QoL. It is important to identify women who are symptomatic. The addition of a systematic active case-finding approach may be more effective in identifying these cases.

Management of refractory overactive bladder.

Overactive bladder (OAB) is a clinical syndrome describing the symptom complex of urgency, with or without urgency incontinence and is usually associated with frequency and nocturia. It is a common, under-diagnosed and therefore under-treated condition which can have a detrimental effect on physical functioning and psychological well-being. Initial treatment of OAB includes lifestyle advice, behavioural modifications, bladder retraining and pelvic floor muscle training, usually in combination with antimuscarinic agents. However, approximately 40% either do not achieve an acceptable level of therapeutic benefit or remain completely refractory to treatment. Our review will focus on the management of this challenging group of women with refractory OAB. For those women with persistent symptoms following conservative therapy, a thorough clinical assessment and appropriate investigations are required. Treatment of any underlying pathology should be considered. The introduction of bladder selective antimuscarinic agents, extended release formulations, alternative routes of administration or use of other drugs could be explored. Modalities such as intravesical Botulinum toxin, neuromodulation (peripheral or sacral) may be offered. Finally, when all other options have been explored and proven unsuccessful, inappropriate or not feasible, reconstructive surgery or catheter insertion (suprapubic or transurethral) can be considered as a last resort.

Role of composite endpoints as an outcome assessment tool in urogenital prolapse.

UNLABELLED: Our aim was to assess the role of composite endpoints as outcome assessment tools in urogenital prolapse. Women undergoing surgery for urogenital prolapse were recruited and followed-up over 1 year. 'Cure' following surgery was defined as: (1) OBJECTIVE: POP-Q ordinal = 0 (pelvic organ prolapse quantification system); (2) Subjective: PGI-I = 1 or 2 (patient global impression of improvement); (3) Composite endpoint of cure: POP-Q ordinal = zero and patient goal achievement = 60%. Our results showed 'Composite cure' of POP was in 88.7%, while objective and subjective cure were 85.3% and 95.5%, respectively. Defining 'success' or 'failures' based on PGI-I scores was most discriminatory. Quality of life (QoL) was similar in treatment success or failure groups, where cure was measured objectively or using the composite endpoint. Composite endpoints should accurately represent cure as they combine objective measures and patient goals. However, these were not demonstrated as valid methods in defining success of prolapse surgery.