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Introduction and hypothesis: There is a need for expanded access to safe surgical care in low- and middle-income countries (LMICs) as illustrated by the report of the 2015 Lancet Commission on Global Surgery. Packages of closely-related surgical procedures may create platforms of capacity that maximize impact in LMIC. Pelvic organ prolapse (POP) and genital fistula care provide an example. Although POP affects many more women in LMICs than fistula, donor support for fistula treatment in LMICs has been underway for decades, whereas treatment for POP is usually limited to hysterectomy-based surgical treatment, occurring with little to no donor support. This capacity-building discrepancy has resulted in POP care that is often non-adherent to international standards and in non-integration of POP and fistula services, despite clear areas of similarity and overlap. The objective of this study was to assess the feasibility and potential value of integrating POP services at fistula centers.Methods: Fistula repair sites supported by the Fistula Care Plus project were surveyed on current demand for and capacity to provide POP, in addition to perceptions about integrating POP and fistula repair services.Results: Respondents from 26 hospitals in sub-Saharan Africa and South Asia completed the survey. Most fistula centers (92%) reported demand for POP services, but many cannot meet this demand. Responses indicated a wide variation in assessment and grading practices for POP; approaches to lower urinary tract symptom evaluation; and surgical skills with regard to compartment-based POP, and urinary and rectal incontinence. Fistula surgeons identified integration synergies but also potential conflicts.Conclusions: Integration of genital fistula and POP services may enhance the quality of POP care while increasing the sustainability of fistula care. [ABSTRACT FROM AUTHOR]

Introduction and hypothesis: Our aim was to determine the impact of pregnancy on sacral neuromodulation (SNM) and vice versa in patients with Fowler's syndrome (FS), which is typified by chronic urinary retention (CUR). Methods: We performed a retrospective study of pregnancy in patients with FS who underwent a two-stage SNM implantation. Data were obtained using a standard questionnaire and clinical interview. Results: There were a total of ten patients with 13 pregnancies. The SNM was switched off in ten of the 13 pregnancies, with CUR recurring in nine of the ten pregnancies and recurrent urinary tract infections (UTI) occurring in four of these pregnancies (more than three UTI in the pregnancy). Those in whom the device was left on continued to void normally. One woman had a first trimester miscarriage, eight pregnancies went to term, and four deliveries were premature. Caesarean section was performed in eight pregnancies for obstetric reasons. Four pregnancies resulted in a vaginal delivery. There were no congenital anomalies reported. Following delivery, four of nine women experienced dysfunction of their SNM device when it was switched back on. Conclusion: Turing off the SNM during pregnancy results in recurrence of CUR, with an increased risk of recurrent UTI associated with preterm delivery. This did not impact foetal well-being. The option of keeping the SNM on during pregnancy should therefore be considered, and as caesarean section affects the SNM device, we advise that caesarean section should only be performed for obstetric reasons. [ABSTRACT FROM AUTHOR]

Recurrent urinary tract infections (UTIs) in women are defined as three or more infections in a 12-month period. They occur commonly and often have a significant impact on quality of life. Although the etiology is multifactorial (including genetic, behavioral, anatomic, and hormonal factors), certain gynecological conditions, such as uterovaginal prolapse with dysfunctional voiding, have a higher disposition to causing UTIs. The clinical evaluation must therefore be comprehensive and include a detailed medical history, a thorough physical and gynecological examination, a full urinalysis including microbiological culturing of the specimen, and appropriate imaging. Antibiotics remain the mainstay of therapy for acute UTIs and also have a role in treatment of recurrent UTIs. Prophylactically, they can be given continuously using a low-dose formula or in the form of self-start treatment or immediately postcoitus. Other useful prophylactic measures include topical estrogen in postmenopausal women and cranberry products. Emergent therapies, such as immunization and probiotics, have a promising future, but their role has yet to be defined. [ABSTRACT FROM AUTHOR]

The remit of this article is to provide an overview of urinary retention in women, taking into account the predisposing factors, aetiology, investigations and treatments. The information presented is based on a widespread search of the English literature using multiple library sites on the internet and on personal experience. Urinary retention occurs when there is impaired bladder emptying, resulting in a high post-void urinary residual. It is often associated with restricted voiding. The aetiology is manifold and thus the symptomatic patient may present to the urologist, gynaecologist, neurologist or physician. Once the problem is identified, and predisposing factors excluded (e.g. opiates), the patient has to be investigated fully. In the Department of Uro-Neurology at the National Hospital for Neurology and Neurosurgery in the UK, we advocate the use of urethral sphincter assessments, including urethral pressure studies, ultrasound volume assessment and electromyography. This article will take a detailed look at all aspects of assessing these patients. In those in whom diagnosis is reached, sacral neuromodulation (SNM) is the treatment of choice. As a modality, SNM has its supporters but also its detractors. Thus, it is essential that all patients are fully counselled before undergoing this surgery. Urinary retention in women is still poorly understood. This article serves to demystify the issues raised in having this condition, by looking closely at the currently known science. It is clear that some patients may be diagnosed with Fowler's syndrome and may thus be more treatable by SNM than others, but this still leaves a significant proportion of patients with no diagnosis and no satisfactory therapy. A great deal of work still needs to be done on the understanding of the pathogenesis, the provision of more distinct investigations and the development of better treatment modalities. [ABSTRACT FROM AUTHOR]