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Objective To investigate the prevalence of persistent and long term postpartum urinary incontinence and associations with mode of first and subsequent delivery. Design Longitudinal study. Setting Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). Population Women (4214) who returned postal questionnaires three months and six years after the index birth. Methods Symptom data were obtained from both questionnaires and obstetric data from case-notes for the index birth and the second questionnaire for subsequent births. Logistic regression investigated the independent effects of mode of first delivery and delivery mode history. Main outcome measures Urinary incontinence—persistent (at three months and six years after index birth) and long term (at six years after index birth). Results The prevalence of persistent urinary incontinence was 24%. Delivering exclusively by caesarean section was associated with both less persistent (OR = 0.46, 95% CI 0.32–0.68) and long term urinary incontinence (OR = 0.50, 95% CI 0.40–0.63). Caesarean section birth in addition to vaginal delivery, however, was not associated with significantly less persistent incontinence (OR 0.93, 95% CI 0.67–1.29). There were no significant associations between persistent or long term urinary incontinence and forceps or vacuum extraction delivery. Other significantly associated factors were increasing number of births and older maternal age. Conclusions The risk of persistent and long term urinary incontinence is significantly lower following caesarean section deliveries but not if there is another vaginal birth. Even when delivering exclusively by caesarean section, the prevalence of persistent symptoms (14%) is still high.

Our objective was to determine the availability and utilization of urodynamic investigations by gynecologists in the preoperative evaluation of women with urinary incontinence. Gynecologists in the UK, USA, Australia, New Zealand and Canada were asked what urodynamic investigations were required for four clinical scenarios. Analysis was restricted to frequent operators. Urodynamic investigations were available to 70% of frequent operators. For uncomplicated stress incontinence, cystometry was utilized by 72% of subspecialists and 44% of generalists ( P

Objective To describe the development, organization, implementation and evaluation of a yearly multicentre, identical and simultaneous objective structured clinical examination (OSCE). Subjects All fifth-year medical students in a 6-year undergraduate medical programme. Setting The Christchurch, Dunedin and Wellington Schools of Medicine of the University of Otago, New Zealand. Method One practice and two full 18-station OSCEs have been completed over 2 years, for up to 72 students per centre, in three centres. The process of development and logistics is described. Data are presented on validity, reliability and fairness. Results Face and content validity were established. Internal consistency was 0·83–0·86 and interexaminer reliability, as assessed by the coefficient of correlation, averaged 0·78. Students rated the OSCE highly on relevance. Of the total variance in total OSCE marks, the schools contributed 6·9%, and the students 93·1%, in the first year. In the second year the schools contributed 6·2% and the students 93·8%. Conclusion Implementation of a psychometrically sound, multicentre, simultaneous and identical OSCE is possible with a low level of interschool variation.

The value of vaginal cones for genuine stress incontinence was assessed in 34 women with this condition. Subjective and objective assessments were made before and after 6 weeks of treatment using urinary diaries, perineometry, 'home' pad test and cone weights with and without voluntary pelvic floor contraction. There was a subjective improvement in 23 of the 34 women (68%) after 6 weeks of cone use with 16 (47%) deciding that no additional treatment other than cone therapy was required at this time. Statistical analyses showed that there were significant improvements in the objective indices. There were no side-effects observed with cone use. When followed up 12-24 (mean 15.8) months from the start of the study, 14 women (41%) were still improved with either cone or pelvic floor exercises. Vaginal cones would seem to be a simple and practical means of improving both pelvic floor strength and genuine stress incontinence.

Objective To determine the long term effects of a conservative nurse-led intervention for postnatal urinary incontinence. Design Randomised controlled trial. Setting Community based intervention in three centres in the United Kingdom and New Zealand. Participants 747 women with urinary incontinence at three months after childbirth, of whom 516 were followed up again at 6 years (69%). Intervention Active conservative treatment (pelvic floor muscle training and bladder training) at five, seven, and nine months after delivery or standard care. Main outcome measures Urinary and faecal incontinence, performance of pelvic floor muscle training. Results Of 2632 women with urinary incontinence, 747 participated in the original trial. The significant improvements relative to controls in urinary (60% v 69%) and faecal (4% v 11%) incontinence at one year were not found at six year follow up (76% v 79% (95% confidence interval for difference in means −10.2% to 4.1%) for urinary incontinence, 12% v 13% (−6.4% to 5.1%) for faecal incontinence) irrespective of subsequent obstetric events. In the short term the intervention had motivated more women to perform pelvic floor muscle training (83% v 55%) but this fell to 50% in both groups in the long term. Both urinary and faecal incontinence increased in prevalence in both groups during the study period. Conclusions The moderate short term benefits of a brief nurse-led conservative treatment of postnatal urinary incontinence may not persist, even among women with no further deliveries. About three quarters of women with urinary incontinence three months after childbirth still have this six years later.

EDITORIAL COMMENT: Resistance of Trichomonas vaginalis to metronidazole has been controversial because of the inability to confirm conclusively the resistance of strains isolated from patients with refractory vaginal trichomoniasis. Treatment failure has thus been attributed to reinfection by the sexual partner, noncompliance, poor absorption or inactivation by vaginal flora. The authors of this study do appear to have conclusively demonstrated resistance to metronidazole using an appropriate test method. They do not however, exclude noncompliance or possible poor absorption. The treatment of refractory trichomoniasis is usually to treat again with higher doses of metronidazole. This has sometimes been successful but in other cases has been unsuccessful despite high doses and prolonged courses of treatment. Povidone-iodine (Betadine) has often been used successfully in the treatment of vaginal trichomoniasis, but treatment failures have occurred. It is believed that treatment failures are due to the inability of topical therapy to eradicate the organism from extravaginal sites, e.g. urethra, Bartholin glands. The fact that the authors of this paper found povidone-iodine douches more effective on the second occasion could relate to the fact that povidone-iodine releases iodine slowly. Antiprotozoal action is dependent upon the release of iodine. Thus a 10-minute douche could be more effective than a 2-minute douche. There remains the possibility of spontaneous resolution in the reported patient. Although povidone-iodine douches are generally safe, it is possibly not a good idea to recommend such a practice unreservedly. There have been several reports of neonatal hypothyroidism following maternal use of povidone-iodine in pregnancy (negative feedback in the fetus, the iodine causing inhibition of thyroid stimulating hormone release); also hypersensitivity reactions to iodine can be expected in approximately 1 in 3,000 patients.

A new dimension has been added to the concerns regarding the Zn status of healthy pregnant women: the effect of Fe or Fe/folate supplements on Zn nutrition. This recent concern is an example of the increasing importance attached to interactions among the elements, particularly when those interactions are competitive and when they concern two or more essential elements. Such biologically important interactions were predicted almost 20 years ago on the basis of chemical similarities among elements.1 Metabolic studies in non-pregnant human subjects have confirmed in most cases a competitive interaction, manifested as a a reduction in Zn absorption in the presence of inorganic ferrous iron,2 and there is one report of the converse, i.e., a seduction in Fe absorption in the presence of excess Zn in human subjects.3