Ectopic hyperprolactinaemia due to a malignant uterine tumor resembling ovarian sex cord tumors (UTROCST).

PURPOSE: Moderate hyperprolactinaemia (2-5 times upper limit of normal) occurring in a patient with a normal pituitary MRI is generally considered to be due to a lesion below the level of detection of the MRI scanner assuming macroprolactin and stress have been excluded. Most patients with mild-to-moderate hyperprolactinaemia and a normal MRI respond to dopamine agonist therapy. We present the rare case of a patient who had prolactin elevation typical of a prolactin-secreting pituitary macroadenoma,with a normal cranial MRI, and in whom the prolactin rose further with dopamine agonist treatment. Subsequent investigations revealed ectopic hyperprolactinaemia to a uterine tumor resembling ovarian sex cord tumor (UTROSCT) which resolved following tumor resection. Although mostly considered to be benign, the UTROSCT recurred with recurrent hyperprolactinaemia and intraabdominal metastases. METHODS: We have systematically and critically reviewed existing literature relating to ectopic hyperprolactinaemia in general and UTROCST specifically. RESULTS: Fewer than 80 cases of UTROSCTs have been reported globally of which about 23% have shown malignant behaviour. There are fewer than 10 cases of paraneoplastic hyperprolactinaemia originating from uterine neoplasms including one other case of ectopic hyperprolactinaemia to a UTROSCT. CONCLUSIONS: Our case demonstrates the importance of screening for extracranial hyperprolactinaemia in the context of: (1) substantially raised prolactin (10× ULN) and (2) normal cranial MRI assuming macroprolactin has been excluded. The majority of extracranial ectopic prolactin-secreting tumors occur in the reproductive organs.

Outcome measures in urogynaecology: the clinicians' perspective.

There is currently a paucity of information regarding clinicians' expectations of treatment and whether their perception of bothersome symptoms is similar to that of the patient. Equally there is often a dichotomy of opinion when comparing clinician-centered evaluation with that of patients. The objectives of this study were to determine clinicians' expectations following treatment, to assess the methods of outcome assessment used in the clinical and research settings, and to compare clinician's expectations with those of patients. This was a prospective postal questionnaire-based study sent to members of the International Continence Society (UK). The questionnaire asked about expectations following treatment and use of outcome measures. These results were also compared to those of an identical patient questionnaire that have previously been published. Tests of agreement were performed between clinicians and patients using Cohen's kappa statistic. Two hundred ninety-nine questionnaires were distributed with a response rate of 52.7%. Overall, 85.9% of responding clinicians felt a good improvement in urinary symptoms, so that they no longer interfered with quality of life, was a realistic outcome. The majority of clinicians thought that small or infrequent episodes of leakage were acceptable following treatment, although frequent or large leaks were not. Irritative urinary symptoms such as urgency and urge incontinence were felt to be less acceptable as were the symptoms of frequency and nocturia. Overall, there was found to be poor agreement between clinicians and patients attitudes to acceptability of symptoms with values of kappa ranging from -0.103 to 0.105, indicating that this agreement was no better than chance. In the research setting, 61% felt both subjective and objective outcome measures should be used, whereas in clinical practice, 42% thought subjective improvement alone, and 36% subjective improvement in QoL, were appropriate. Clinicians have realistic expectations following treatment, although there is poor agreement with those expectations expressed by patients. These findings may help to explain why patients may be disappointed regarding treatment outcomes and why there may be a difference between subjective clinical impression of success and patient satisfaction. In addition there is a lack of conformity in the use of outcome measures in both the clinical and research settings.

A prospective observational trial of pelvic floor muscle training for female stress urinary incontinence.

OBJECTIVE: To assess the impact of pelvic floor muscle training (PFMT) on bladder neck mobility in a prospective observational study, and to correlate any observed changes with objective, standardized outcome measures of the severity of stress urinary incontinence (SUI). PATIENTS AND METHODS: Women with the symptom of SUI were recruited prospectively over a 3-year period from a tertiary referral urogynaecology clinic in a teaching hospital. A group of 97 treatment-naive women complaining of SUI and confirmed as having urodynamic SUI on video-urodynamic assessment agreed to participate. Bladder neck mobility on perineal ultrasonography was assessed immediately before and on completing a 14-week programme of 'PFM rehabilitation'. Treatment outcome was assessed using a standardized pad-test and a condition-specific, validated quality-of-life questionnaire (King's Health Questionnaire). Changes in functional anatomy were quantified using transperineal ultrasonography to measure the bladder neck position at rest, maximum PFM contraction and maximum Valsalva manoeuvre. Bladder neck rotational mobility from rest to maximum incursion and maximum excursion was calculated. RESULTS: Treatment with an intensive package of PFMT and behavioural modification resulted in significant elevation of the bladder neck position at all three measured positions. Displacement of the bladder neck on Valsalva (rotational excursion) was reduced after treatment, suggesting increased levator 'stiffness'. These changes in functional anatomy were associated with a statistically and clinically significant reduction in urine loss and improvement in condition-specific quality of life. CONCLUSION: The present results show that PFMT is an effective treatment for SUI and provide an important new insight into how dynamic pelvic floor anatomy can be modified by this widely used intervention.

Can ultrasound replace ambulatory urodynamics when investigating women with irritative urinary symptoms?

OBJECTIVE: To determine whether transvaginal ultrasound measurement of bladder wall thickness could replace ambulatory urodynamics when investigating women with lower urinary tract dysfunction not explained by conventional laboratory urodynamic studies. DESIGN: A blinded prospective study. SETTING: Tertiary referral unit in a London teaching hospital. POPULATION: One hundred and twenty-eight women referred for ambulatory urodynamics with equivocal laboratory urodynamic findings or whose symptoms were not explained by the laboratory urodynamic findings. METHODS: Transvaginal ultrasound assessment of bladder wall thickness was performed in three planes with an empty bladder prior to ambulatory urodynamics. Mean bladder wall thickness was calculated and the results analysed with respect to the ambulatory urodynamic diagnosis. MAIN OUTCOME METHODS: Mean bladder wall thickness in women with a normal ambulatory study or a diagnosis of detrusor instability, genuine stress incontinence (GSI) or mixed incontinence. RESULTS: Using a one way analysis of variance (ANOVA) bladder wall thickness was found to be significantly different in all diagnostic groups and this reached significance (P = 0.0001). There was no overlap in the 95% confidence intervals representing a diagnosis of detrusor instability or genuine stress incontinence. CONCLUSIONS: Transvaginal ultrasound assessment of mean bladder wall thickness is a sensitive screening tool, which can detect detrusor instability in those women with equivocal laboratory urodynamics. In women who have no evidence of GSI on laboratory studies, a cutoff of 6.0mm is highly suggestive of detrusor instability. However, in those women with GSI then ambulatory studies probably remain the investigation of choice.