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A case of large 11cm phaeochromocytoma at 35 weeks with preceding diagnoses of pre-eclampsia and gestational diabetes (GDM), which confounded initial management., Competing Interests: Nil.

Introduction and Hypothesis: Variations exist in urogynaecological practice to decide on hysterectomy in managing prolapse. This study evaluates the outcomes of uterine preservation during anterior colporrhaphy with apparent uterine descent with cervical traction under anaesthesia. We hypothesize that cervical traction should not be used to assess uterine prolapse., Methods: Thirty-five women opting for surgery for symptomatic anterior prolapse (≥ stage 2) with no uterine prolapse (point C at -3 or above) were recruited. "Validated cervical traction" was applied under anaesthesia. Only an anterior repair was performed. Incontinence Modular Questionnaire Vaginal Symptoms (ICIQ-VS) questionnaires were used for follow-up. Wilcoxon test was used for statistical analysis., Results: Stage 2 uterine prolapse (POPQ) was demonstrated in all women with traction under anaesthesia. Follow-up was possible in 29 women, 5 did not respond and 1 needed a hysterectomy at 6 months (2.86 %, 95 % CI 0.07-14.91 %). The mean follow-up time was 23 months (range: 13-34 months). There was a significant reduction in the ICIQ-VS scores from 22.7 (pre-operative) to 7.97 at 23 months (p < 0.001) and a significant improvement in the quality of life scores (4.3 to 1.86; p < 0.0001). There was also a significant reduction in the complaint of a bulge in the vagina (question 5a-ICIQ-VS; 2.91 to 0.89; p < 0.0001)., Conclusions: The "cervical traction" test seems unnecessary, and the decision for a hysterectomy should be based on examination findings in the clinic. Larger RCTs are needed to evaluate cervical traction in the assessment of prolapse.

Background: There is a risk that people who have invasive urodynamic studies (cystometry) will develop urinary tract infections or bacteria in the urine or blood. However, the use of prophylactic antibiotics before or immediately after invasive cystometry or urodynamic studies is not without risks of adverse effects and emergence of resistant microbes., Objectives: To assess the effectiveness and safety of administering prophylactic antibiotics in reducing the risk of urinary tract infections after urodynamic studies. The hypothesis was that administering prophylactic antibiotics reduces urinary tract infections after urodynamic studies., Search Methods: We searched the Cochrane Incontinence Group Specialised Trial Register, MEDLINE (January 1966 to January 2009), CINAHL (January 1982 to January 2009), EMBASE (January 1966 to January 2009), PubMed (1 January 1980 to January 2009), LILACS (up to January 2009), TRIP database (up to January 2009), and the UK NHS Evidence Health Information Resources (searched 10 December 2009). We searched the reference lists of relevant articles, the primary trials and the proceedings of the International Urogynaecological Association International Continence Society and the American Urological Association for the years 1999 to 2009 to identify articles not captured by electronic searches. There were no language restrictions., Selection Criteria: All randomized controlled trials and quasi-randomized trials comparing the use of prophylactic antibiotics versus a placebo or no treatment in patients having urodynamic studies were selected. Two authors (PL and RF) independently performed the selection of trials for inclusion and any disagreements were resolved by discussion., Data Collection and Analysis: All assessments of the quality of trials and data extraction were performed independently by two authors of the review (PL and RF) using forms designed according to Cochrane guidelines. We attempted to contact authors of the included trials for any missing data. Data were extracted on characteristics of the study participants including details of previously administered treatments, interventions used, the methods used to measure infection and adverse events.Statistical analyses were performed according to Cochrane Collaboration guidelines. Data from intention-to-treat analyses were used where available. For the dichotomous data, results for each study were expressed as a risk ratio (RR) with 95% confidence interval (CI) and combined for meta-analysis using the Mantel-Haenszel method.The primary outcome was urinary tract infection. Heterogeneity was assessed by the P value and I(2) statistic., Main Results: Nine randomized controlled trials involving the prophylactic use of antibiotics in patients having urodynamic studies were identified and these included 973 patients in total; one study was an abstract. Two further trials were excluded from the review. The methods of the included trials were poorly described.The primary outcome in all trials was the rate of developing significant bacteriuria, defined as the presence of more than 100,000 bacteria per millilitre of a mid-stream urine sample on culture and sensitivity testing. The other outcomes included pyrexia, haematuria, dysuria and adverse reactions to antibiotics.The administration of prophylactic antibiotics when compared to a placebo reduced the risk of significant bacteriuria (4% with antibiotics versus 12% without, risk ratio (RR) 0.35, 95% CI 0.22 to 0.56) in both men and women. The administration of prophylactic antibiotics also reduced the risk of haematuria (RR 0.46, 95% CI 0.23 to 0.91). However, there was no statistically significant difference in the primary outcome, risk of symptomatic urinary tract infection (40/201, 20% versus 59/214, 28%; RR 0.73, 95% CI 0.52 to 1.03); or in the risk of fever (RR 5.16, 95% CI 0.94 to 28.16) or dysuria (RR 0.83, 95% CI 0.5 to 1.36). Only two of 135 people had an adverse reaction to the antibiotics. The number of patients needed to treat with antibiotics to prevent bacteriuria was 12.3. Amongst women, the number needed to treat to prevent bacteriuria was 13.4; while amongst men it was 9.1 (number needed to treat = 1/ absolute risk reduction)., Authors' Conclusions: Prophylactic antibiotics did reduce the risk of bacteriuria after urodynamic studies but there was not enough evidence to suggest that this effect reduced symptomatic urinary tract infections. There was no statistically significant difference in the risk of fever, dysuria or adverse reactions. Potential benefits have to be weighed against clinical and financial implications, and the risk of adverse effects.

Objective: To evaluate the surgical outcome of uterine preservation during anterior colporrhaphy, in women with apparent uterine descent, after the application of validated cervical traction under anaesthesia., Study Design: This study was conducted at a tertiary referral hospital in the United Kingdom. Thirty five patients with symptomatic anterior compartment prolapse (stage 2 or more) with the cervix, pelvic organ prolapse quantification (POPQ) point C, at or higher than -3 cm (stage 1), who had requested surgical repair, were recruited. In all patients there was no evidence of apical descent, with point D at -8 cm or above. All patients had a validated 'cervical traction' force applied intra-operatively to the cervix, and if the cervix, point C, did not come down further than 'stage 2' (+1cm) the uterus was conserved. These patients had an anterior repair, without a vaginal hysterectomy or apical support procedure, and were reviewed 3 months postoperatively. International Consultation on Incontinence Questionnaire-vaginal symptoms (ICIQ-VS) and POP-Q scores were completed pre- and post-operatively, with another POPQ performed intraoperatively during validated cervical traction. The Wilcoxon test was used to look at differences in vaginal descent and also to compare specific items of the ICIQ., Results: In all 35 women, there was cervical descent below -1cm (stage 2) when a validated amount of cervical traction was applied. When examined at follow up, however, the cervix (point C) had returned to its preoperative, asymptomatic level (stage 1) in all except one patient. There was no significant change in the position of point C pre- and 3 months post- operatively. Only one of the 35 women required a subsequent vaginal hysterectomy for prolapse (2.86%, 95% CI 0.07-14.91%). Significant improvements in ICIQ-VS scores were observed following anterior repair with uterine conservation., Conclusion: The degree of uterine descent with cervical traction under anaesthesia has not been shown to be helpful in assessing the need for vaginal hysterectomy at the time of vaginal repair. The 'cervical traction' test is therefore unnecessary, and the decision as to whether to perform a concomitant vaginal hysterectomy should be based on the clinical findings on examination in the clinic., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Urinary urgency and the associated symptoms which comprise overactive bladder are prevalent amongst the general population and adversely affect quality of life. Disease management consists of a sequential series of options starting with behavioural and lifestyle techniques, pharmacological management (antimuscarinics) and, in severe cases, surgical treatment (urinary diversion, neuromodulation, augmentation cystoplasty and detrusor myectomy). There is increasing recognition of pathophysiological mechanisms in the urothelium, interstitial cells and afferent neurons allowing the importance of peripheral integrative interaction to be identified. The hierarchy of the central nervous system control adds additional complexity to understanding the oflower urinary tract function. Some newer methods of treatment include Botulinum toxin A intramural injections, oral beta-3 adrenergic agonists and rho-kinase inhibitors. The lack of a disease generating hypothesis, the lack of animal models for disease and the subjective nature of the central symptom (urgency) still pose considerable theoretical and scientific hurdles that need to be overcome in the treatment of this condition.

Objective: To evaluate the effect of regional anesthesia and mode of delivery on the function of the urinary bladder. The primary outcome was the time taken for urinary bladder sensation to return following various modes of delivery and analgesia/anesthesia. The secondary outcome was the volume of urine present in the bladder when sensation returned., Methods: The study was conducted at the Birmingham Women's Foundation Trust, Birmingham, UK. A total of 120 postnatal patients were studied between January 2007 and March 2008. The volume of urine in the bladder when sensation first returned was measured by release of a clamp for women fitted with an indwelling catheter, and/or estimated using ultrasound., Results: The median times for sensation to return to the bladder in patients who had a vaginal delivery without epidural analgesia, vaginal delivery with epidural analgesia, and after elective cesarean delivery under spinal anesthesia were 122 minutes (IQR, 112-136 minutes), 234 minutes (IQR, 202-291 minutes), and 374 minutes (IQR, 311-425 minutes), respectively. The median urine volumes were 144 mL (IQR, 112-192 mL), 200 mL (IQR, 136-336 mL), and 152.5 mL (IQR, 125-270 mL), respectively., Conclusion: These results should be taken into consideration when formulating a postdelivery bladder care protocol., (Copyright 2010 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Study Type: Therapy (meta-analysis) Level of Evidence 1a., Objectives: To assess the effectiveness and complications of transobturator tape (inside-out and outside-in, TOT) by means of a systematic review of direct and indirect randomized controlled trials (RCTs)., Method: MEDLINE, EMBASE, CINAHL, LILIACS (up to December 2008), CENTRAL (The Cochrane Library, Issue 1, 2009), MetaRegister of Controlled Trials, The National Library for Health, the National Research Register and Google Scholar were searched using various relevant search terms. The citation lists of review articles and included trials were searched and contact with the Correspondence of each included trials was attempted. RCTs which compared the effectiveness of synthetic transobturator (inside-out tape TVTO, or outside-in TOT) with TVT by the retropubic route (Gynecare, Ethicon, Inc., or similar tape by a different company) or with each other for the treatment of stress urinary incontinence (SUI), and in all languages, were included. Two reviewers extracted data on participants' characteristics, study quality, intervention, cure and adverse effects independently. The data were analysed using Review Manager 5 software., Results: There were 12 RCTs that compared TOT with TVT, and 15 that compared TVTO vs TVT for treating SUI. There were four direct comparison RCTs of TVTO vs TOT. When compared at 1-44 months, the subjective (odds ratio 1.16; 95% confidence interval 0.83-1.6) and objective (0.94; 0.66-1.32) cure of TOT was similar to TVT. For TVTO, the subjective (1.06, 0.85-1.33) and objective cure (1.03, 0.77-1.39) was also similar to TVT. Adverse events such as bladder injuries (TOT, odds ratio 0.11, 0.05-0.25; TVTO, 0.15, 0.06-0.35) and haematomas (0.06, 0.01-0.30) were less in the TOT than TVT. Voiding difficulties (TOT, odds ratio 0.61, 0.35-1.07); TVTO, 0.81, 0.48-1.31) were slightly lower in TOT but this was not statistically significant. Groin/thigh pain (TVTO, odds ratio 8.05, 3.78-17.16) and vaginal injuries (TOT, 5.82, 1.85-18.3; TVTO, 1.69, 0.73-3.91) were more common in the transobturator tapes. Mesh erosion in TVTO (0.77, 0.22-2.72) and TOT (1.11, 0.54-2.28) was similar to TVT. The effectiveness data over 6 months available from four direct comparison studies of TVTO vs TOT suggested equivalent results for objective cure (1.06, 0.65-1.73) and subjective cure (1.37, 0.93-2.00). When compared indirectly, TVTO has similar subjective (1.23, 0.83-1.82) and objective cure (0.97, 0.62-1.52) to TOT. On indirect comparison, the de novo risk of urgency was similar in the two groups but voiding difficulties seemed to be less in the inside-out group., Conclusion: The evidence for the equivalent effectiveness of TOT and TVTO when compared with each other is established over the short-term. Bladder injuries and voiding difficulties seem to be less with inside-out tapes on indirect comparison. An adequate long-term follow-up of the RCTs is desirable to establish the long-term continued effectiveness of transobturator tapes.

The objective of this study is to assess the objective recurrence and complications of adjuvant materials in the treatment of anterior vaginal wall prolapse. The inclusion criteria were randomised controlled trials (RCTs) using adjuvant materials versus standard surgery for anterior vaginal wall prolapse. The main outcome measures were objective recurrence and complications. Ten RCTs (1,087 patients) were included in the systematic review. Meta-analysis showed a lower risk of objective recurrence after 1 year in the patients having an anterior repair with a biological adjuvant material (odds ratio 0.56; 95% confidence interval 0.34-0.92) and absorbable synthetic adjuvant material (odds ratio 0.44; 95% confidence interval 0.21-0.89). The evidence for the use of biological adjuvant materials in anterior vaginal wall prolapse surgery shows trends towards reduction of objective recurrence at 12 months.

Background: The guidance on SUI has not been rigorously assessed using GRADE system., Objective: To determine if the quality and results of existing systematic reviews on conservative treatment of stress urinary incontinence (SUI) can underpin evidence-based recommendations for practice., Study Design: Review of systematic reviews. Data sources Electronic search in PubMed, Medline (OVID 1966-version), CINAHL, Biomed, Psychinfo, the Cochrane library, National Library for Health, the National Research Register and hand search of reference lists., Methods: Two reviewers independently selected systematic review articles in which a publicly available database was searched for randomised trials on conservative treatment of SUI and assessed them for quality of methods and results (OR and 95% CIs). The extracted information was used to classify strength of evidence as per the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system., Results: There were 13 reviews of variable quality. Quality assessment of studies included in the reviews and their findings were adequately tabulated in all but four reviews. Meta-analysis of data was carried out in six reviews. Pelvic floor muscle training (PFMT) and other physical treatments, estrogens and duloxetine were better than no treatment in SUI. Based on the assessment as per GRADE system, only 2/13 (15.4%) reviews were deemed to be of high quality, 8/13 (61.5%) of moderate quality and 3/13 (23.1%) of low quality. The case for recommendation of PFMT and duloxetine was strong., Conclusion: Systematic reviews of conservative treatments of SUI are not always suitable to generate robust recommendations for practice as they are weak in methodological quality or lack power to produce reliable results.

Aims: To assess the effectiveness and safety of administering prophylactic antibiotics in reducing the risk of urinary tract infection (UTI) after urodynamic studies (UDS)., Methods: The CENTRAL, MEDLINE, EMBASE, CINAHI, LILIACS (up to January 2007), TRIP database, The National Library for Health, the citation lists of review articles, conference abstracts (2004-2006) and hand search of reference lists to identify relevant reviews and articles. Randomised controlled trials (RCTs) comparing effectiveness of prophylactic antibiotics with placebo or nothing in reducing bacteriologically proven UTI after invasive cystometry were included. Two reviewers extracted data independently and the results were expressed as peto odds ratio with 95% confidence intervals using fixed effects model in ReV Man 4.2.8 software., Results: Eight RCTs with 995 patients were included. The majority of the patients were female. The studies were methodologically poor. The primary outcome in all but one study was newly acquired infection defined as colony count >10(5)/ml in urine tested post UDS. On meta-analysis, there was 40% reduction in the risk of significant bacteriuria with administration of prophylactic antibiotics (Peto odds ratio 0.39; 95% confidence interval 0.24-0.61). The antibiotics used differed in dose, type and duration. One minor skin rash and one major anaphylactic reaction requiring steroid injection therapy was reported in the treatment group. One would need to give prophylactic antibiotics to 13 individuals undergoing UDS to prevent one significant bacteriuria of unknown clinical significance., Conclusion: The use of prophylactic antibiotics in urodynamics reduces the risk of significant bacteriuria., ((c) 2007 Wiley-Liss, Inc.)

Background: Various types of suburethral tapes inserted via the transobturator route (tension-free vaginal tape obturator route [TVTO] and transobturator tape [TOT]) have been widely adopted for treatment of stress urinary incontinence (SUI) before proper evaluation of their effectiveness and complications., Objectives: To assess the effectiveness and complications of TOTs as treatment of SUI by means of a systematic review., Search Strategy: MEDLINE, EMBASE, CINAHL, LILIACS (up to September 2006), CENTRAL (The Cochrane Library, Issue 3, 2006), MetaRegister of Controlled Trials, The National Library for Health, the National Research Register and Google Scholar were searched using various relevant search terms. The citation lists of review articles and included trials were searched, and contact with the corresponding author of each included trials was attempted., Selection Criteria: Randomised controlled trials (RCTs) that compared the effectiveness of TVTO or TOT with synthetic tension-free vaginal tape (TVT) by retropubic route (Gynecare; Ethicon Inc., NJ, USA) for the treatment of SUI in all languages were included., Data Collection and Analysis: Two reviewers extracted data on participants' characteristics, study quality, population, intervention, cure and adverse effects independently. The data were analysed in the Review Manager 4.2.8 software., Main Results: There were five RCTs that compared TVTO with TVT and six RCTs that compared TOT with TVT. When compared by subjective cure, TVTO and TOT at 2-12 months were no better than TVT (OR 0.85; 95% CI 0.60-1.21). Adverse events such as bladder injuries (OR 0.12; 95% CI 0.05-0.33) and voiding difficulties (OR 0.55; 95% CI 0.31-0.98) were less common, whereas groin/thigh pain (OR 8.28; 95% CI 2.7-25.4), vaginal injuries or erosion of mesh (OR 1.96; 95% CI 0.87-4.39) were more common after tape insertion by the transobturator route., Author's Conclusions: The evidence for short-term superiority of effectiveness of TOTs is currently limited. Bladder injuries and voiding difficulties are lower, but the risk of vaginal erosions and groin pain is higher with TVTO/TOT. Methodologically sound and sufficiently powered RCTs with long-term follow up are needed, and the results of continuing trials are awaited.

Background: The use of quality of life (QoL) instruments in menorrhagia research is increasing but there is concern that not enough emphasis is placed on patient-focus in these measurements, i.e. on issues which are of importance to patients and reflect their experiences and concerns (clinical face validity). The objective was to assess the quality of QoL instruments in studies of menorrhagia., Study Design: A systematic review of published research. Papers were identified through MEDLINE (1966-April 2000), EMBASE (1980-April 2000), Science Citation Index (1981-April 2000), Social Science Citation Index (1981-April 2000), CINAHL (1982-1999) and PsychLIT (1966-1999), and by manual searching of bibliographies of known primary and review articles. Studies were selected if they assessed women with menorrhagia for life quality, either developing QoL instruments or applying them as an outcome measure. Selected studies were assessed for quality of their QoL instruments, using a 17 items checklist including 10 items for clinical face validity (issues of relevance to patients' expectations and concerns) and 7 items for measurement properties (such as reliability, responsiveness, etc.)., Results: A total of 19 articles, 8 on instrument development and 11 on application, were included in the review. The generic Short Form 36 Health Survey Questionnaire (SF36) was used in 12/19 (63%) studies. Only two studies developed new specific QoL instruments for menorrhagia but they complied with 7/17 (41%) and 10/17 (59%) of the quality criteria. Quality assessment showed that only 7/19 (37%) studies complied with more than half the criteria for face validity whereas 17/19 (90%) studies complied with more than half of the criteria for measurement properties (P = 0.0001)., Conclusion: Among existing QoL instruments, there is good compliance with the quality criteria for measurement properties but not with those for clinical face validity. There is a need to develop methodologically sound disease specific QoL instruments in menorrhagia focussing both on face validity and measurement properties., (Copyright 2002 Elsevier Science Ltd.)