Effect of prolapse repair on voiding and bladder overactivity.

PURPOSE OF REVIEW: To determine the effects of repair of pelvic organ prolapse (POP) on detrusor overactivity, overactive bladder (OAB) symptoms and voiding function. Understanding the cause of OAB in women with prolapse gives us more insight into the cause of detrusor overactivity and OAB in general. Understanding the different causes involved in OAB will allow us to target our treatments more effectively. This review discusses the evidence linking OAB and prolapse. Relevant studies or review articles were identified by performing a literature search using PubMed and MEDLINE. RECENT FINDINGS: Prolapse and OAB may occur by chance together, but epidemiological studies support a link between OAB and prolapse. Also, POP repair (surgical correction or a ring pessary placement) is associated with improvement or resolution of OAB symptoms and detrusor overactivity. For these reasons, there seems to be a causal link between prolapse and OAB. The cause of OAB and detrusor overactivity is not fully understood, but theories relate to myogenic, neurogenic and obstructive elements. The most commonly accepted pathophysiology when prolapse is involved is that of increased bladder outlet obstruction or resistance. This is supported when the correction of POP improves voiding function, which is associated with a reduction in OAB. SUMMARY: POP repair (surgery/ring pessary) has a positive effect on the resolution of OAB, detrusor overactivity and voiding dysfunction, providing a theory for a causal effect between the conditions. Larger prospective observational studies are needed.

Uterus conserving prolapse surgery--what is the chance of missing a malignancy?

INTRODUCTION AND HYPOTHESIS: Recently, there has been a move towards uterine preserving surgery in the management of pelvic organ prolapse. The negative implications of such surgery have not been delineated. This study aims to identify the risk of finding an unexpected malignancy in these cases. METHODS: A database containing details of vaginal hysterectomies performed over a 10-year period was searched. Women who underwent surgery for uterine prolapse were included. Women with other indications for surgery and those who presented with symptoms relating to endometrial or cervical malignancy were excluded. As this is a non-interventional observational study, formal ethical approval was not obtained. RESULTS: Out of 517 women who underwent a vaginal hysterectomy for prolapse, four cases of endometrial carcinoma were identified giving an incidence of 0.8%. CONCLUSIONS: Conserving a prolapsed uterus without further investigations runs the risk of missing women with endometrial malignancy.

TVT vs TOT: a case controlled study in patients with mixed urodynamic stress incontinence and detrusor overactivity.

INTRODUCTION: Although transobturator tapes (TOT) have been suggested to be equivalent to retropubic tension-free vaginal tapes (TVT) in the management of urodynamic stress incontinence, there is very little evidence for their use in women with mixed incontinence. The aim of this study was to evaluate the efficacy of the TOT against the retropubic TVT in women with mixed incontinence. PATIENTS AND METHODS: A case controlled study was used with 34 women matched for age and type of procedure. RESULTS: Ten out of 34 (29.4%) patients in the TOT group required a repeat continence procedure versus 0/34 (0%) in the retropubic group. Patients who had undergone a TOT were significantly more likely to require repeat surgery (odds ratio 10.1, 95% confidence interval 2.6-38.2). CONCLUSIONS: This study suggests a higher failure rate in women undergoing a TOT for USI and DO compared to a retropubic TVT when assessed with a case controlled study.

The risk and severity of developing symptomatic palpitations when prescribed mirabegron for overactive bladder.

OBJECTIVES: Mirabegron is a new selective ß3-adrenoreceptor agonist licensed for the treatment of overactive bladder (OAB). In clinical trials, mirabegron is well-tolerated with a low side-effect profile. There is little data available on the risks in a non-selected population. The presence of ß-adrenoreceptors in cardiac and vascular tissue leads to the possibility of the development of adverse cardiovascular events. We conducted a consecutive cohort study to assess the risk of developing palpitations, the severity of the condition and to investigate any underlying risk factors that predispose patients with OAB to develop palpitations whilst taking mirabegron. STUDY DESIGN: A consecutive cohort of patients with OAB was studied between February 2013 and June 2014. Patients were prescribed mirabegron 50mg daily and outcomes assessed at 6 weeks. Patients with known cardiac arrhythmias were excluded. In patients who developed palpitations, a detailed account of their symptoms and medical history were documented and a 12-lead electrocardiogram (ECG) was performed to assess heart rate, QT interval and the presence of any persisting arrhythmia was conducted. RESULTS: A total of 279 patients were started on mirabegron. Eight patients (2.9%) reported palpitations whilst taking the drug. Two patients with a history of palpitations with no history of prolonged QT interval or arrhythmia on ECG developed worsening palpitations. The QTc was prolonged in two patients at 0.458 and 0.441s (QTc <420). Three patients developed chest pain or tightness. The palpitations resolved once therapy was stopped and did not result in serious adverse events such as hospitalisation. CONCLUSIONS: Palpitations in an unselected population have a similar incidence to that demonstrated in previous drug trials. Palpitations may be associated with a worsening of cardiovascular dysfunction.

Update on duloxetine for the management of stress urinary incontinence.

Duloxetine is a relatively balanced serotonin and noradrenaline reuptake inhibitor (SNRI), which is the first drug with widely proven efficacy to have been licensed for the medical treatment of women with stress urinary incontinence (SUI). Despite favorable results from randomized controlled trials, surgical management continues to be the mainstay of treatment for SUI. In this review we explore the pharmacology of duloxetine in the nervous system and lower urinary tract, and the evidence for its use in the management of women with urinary incontinence.

The effect of local anaesthetic infiltration on urethral function during the tension-free vaginal tape (TVT) procedure.

Different anaesthetic techniques are used for the tension-free vaginal tape (TVT) procedure. Using local anaesthetic and spinal techniques allows surgeons to adjust sling tension with the cough test. The aim of this study was to asses whether the periurethral infiltration of the local anaesthetic technique for TVT results in a significant alteration in urethral function. Twenty-five women who underwent a TVT procedure for stress incontinence were studied prospectively. Urethral function was assessed with the urethral retro-resistance pressure (URP) before and after the infiltration of local anaesthetic. Paired t tests were used to compare values. The mean URP value was 48.0 cm/H2O (SD, 18.4) before and 52.0 cm/H2O (SD, 34.5) after the periurethral infiltration of local anaesthetic. There was no statistical significance between the two groups (p = 0.37). Local anaesthetic does not alter urethral function, as measured by URP, allowing coughing to mimic non-anaesthetic conditions.

Tension-free vaginal tape for stress incontinence in women with detrusor overactivity.

In this case report, we discuss two cases of the successful use of the tension-free vaginal tape (TVT) to treat women with detrusor overactivity (DO) but no evidence of urodynamic stress incontinence (USI). The use of the TVT for the treatment of DO has been evaluated in a small number of studies of women with mixed incontinence. There is no data in the literature concerning its use in women with DO only. Here, we briefly review the literature including the postulated mechanism by which stress leakage due to DO is cured by the TVT.

The predictive value of preoperative pressure-flow studies in the resolution of detrusor overactivity and overactive bladder after tension-free vaginal tape insertion.

OBJECTIVE: To determine whether preoperative pressure-flow studies (PFS) predict the resolution of detrusor overactivity (DO) and overactive bladder (OAB) symptoms after a tension-free vaginal tape procedure (TVT). PATIENTS AND METHODS: Thirty-five consecutive women with mixed DO and urodynamic stress incontinence (USI) undergoing a TVT had PFS before and afterward reviewed, and the results compared. RESULTS: There was resolution of OAB symptoms in 51%; the persistence of OAB symptoms was predicted by a significant decrease (20.0 to 14.0 mL/s) in the maximum flow rate after the TVT (P = 0.027) and a significant increase in the detrusor pressure at maximum flow after the TVT (P = 0.04). DO was absent on cystometry in 46% of women after the TVT. Women with persistent DO on cystometry had a significantly lower (P = 0.02) maximum flow rate before the TVT (mean 19.3 mL/s) than those with no persistent DO (mean 26.9 mL/s). This finding persisted when flow rates were corrected for voided volume (P = 0.04). Before and after TVT there were no significant differences between the groups in voiding time and acceleration of flow. USI was objectively cured in 92% of the women. CONCLUSIONS: Women whose maximum flow rate decreases significantly after the TVT are more likely to have persistent OAB symptoms. The urinary flow rate before the TVT was significantly higher in women with an objective cure of DO after TVT than in women with persistent DO. These findings support an obstructive cause in women in whom DO does not resolve.

Effect of tension-free vaginal tape in women with a urodynamic diagnosis of idiopathic detrusor overactivity and stress incontinence.

OBJECTIVE: To determine the effect of tension-free vaginal tape (TVT) in women with idiopathic detrusor overactivity (DO) and urodynamic stress incontinence (USI) and to propose appropriate pre-operative counselling based on this information. DESIGN: Retrospective cohort study. SETTING: Urogynaecology Unit, District General Hospital, Kent. POPULATION: Fifty-one women (from a total of 344 women undergoing TVT) with urodynamic evidence of both DO and USI who underwent TVT insertion between November 1999 and March 2003. METHODS: Women with more than six-month follow up were assessed objectively with cystometry. Subjective results were assessed using structured interview and condition specific Kings Quality of Life Questionnaire. MAIN OUTCOME MEASURES: Objective resolution of DO and subjective absence of urge syndrome after TVT. Cure of USI was the secondary outcome measure analysed. The effect of drug therapy on residual urge symptoms was assessed. RESULTS: Objective cure of DO was demonstrated in 47% and subjective cure of urge symptoms in 63%. In women with persistent urge symptoms, the addition of anticholinergic medication resulted in resolution of urge incontinence in a further 22% of women. USI was objectively cured in 92%. CONCLUSIONS: More than 60% of women diagnosed urodynamically with DO and USI experience complete resolution of urge symptoms following TVT. Further symptom improvement can be achieved with additional anticholinergic medication.

Groin pain after a tension-free vaginal tape or similar suburethral sling: management strategies.

OBJECTIVE: To review different treatment strategies for women with groin pain after tension-free vaginal tape (TVT) or similar suburethral sling procedures. PATIENTS AND METHODS: The series comprised 450 women who had a TVT procedure, with a follow-up of 3-50 months. Five women (1%) reported significant groin pain and were offered further treatment. In addition, one woman was referred from another centre and received treatment. RESULTS: Women with pain were initially treated conservatively, and in most the pain resolved and required no further treatment. Persistent or severe discomfort was treated with a combined steroid (methyl prednisolone, 2 mL, 80 mg) and local anaesthetic (bupivacaine, 10 mL, 0.5%) injection in four women. There were no side-effects from the treatment. One woman was relieved of her pain and required no further treatment. In one woman the local injections failed to improve her symptoms but the pain was not severe enough to warrant further treatment. Two women developed recurrent pain after an initially successful injection, and in these women the TVT was excised. One woman referred from another centre was primarily treated with TVT excision. In the three women treated with distal tape excision, the mean pain scores decreased from 8.7 before excision to 0.7 afterward. One woman is awaiting tape excision. CONCLUSION: If conservative management fails to relieve the symptoms of groin pain it can be treated by injecting a mixture of steroid and local anaesthetic. However, local injection failed to provide long-term relief in three of four women. More severe symptoms might require TVT mesh dissection and excision, which provided significant pain relief.