Biomedical subjects
Publications and source records attributed to Vik Khullar.
We report a case of laparoscopic uterosacral ligament plication, which appears to be a successful, simple, minimally invasive, conservative procedure, not technically or time demanding, for the treatment of uterine descent. However, a long term follow up and further studies are needed to clarify the role of this procedure.
AIMS: To compare pressure flow parameters in the different urodynamic diagnoses in women with lower urinary tract symptoms (LUTS). MATERIALS AND METHODS: Urodynamic traces of women with LUTS were prospectively studied. Detrusor pressures at the start of flow (ODP), detrusor pressure at peak flow rate (PdetQmax), peak flow rate (Qmax) and detrusor pressure at the end of flow (CDP) were measured and compared with different urodynamic diagnoses. RESULTS: Six hundred and twenty one women were prospectively investigated between September 2000 and February 2002. Only 85% (529/621) of women had good quality pressure flow studies and was included in the study. Women with detrusor overactivity have higher ODP, CDP and PdetQmax than women with urethral sphincter incompetence. All these pressure flow parameters are significantly lower in women with urethral sphincter incompetence than continent women (P < 0.05, Bonferroni test). Qmax was significantly greater in women with urodynamic stress incontinence compared to women who had detrusor overactivity (P < 0.05, Bonferroni test). Women with mixed incontinence had pressure flow parameters intermediate between women with detrusor overactivity and those with urodynamic stress incontinence. CONCLUSIONS: Pressure flow parameters appear to be useful urodynamic tools in the evaluation of women with LUTS as they help the clinician in assessing the urethral and detrusor function.
The epidemiology and treatment of mixed incontinence has received relatively little attention. However, mixed incontinence--defined as the combination of stress and urge incontinence--accounts for approximately 33% of all cases of incontinence in women. The condition often responds poorly to treatment, either pharmacologic or surgical. Potential pharmacologic approaches for mixed incontinence include antimuscarinic agents, estrogen replacement therapy (for postmenopausal women), and dopamine, serotonin, or norepinephrine reuptake inhibitors. In a large-scale, multinational, placebo-controlled, clinical trial, the antimuscarinic agent tolterodine significantly reduced incontinence episodes in women with mixed symptoms. The benefits of tolterodine continued to increase during the 8 weeks of the trial and extended to additional end points, including frequency, urgency, and urge incontinence. A limited number of studies have examined the use of estrogen for mixed incontinence and have produced conflicting results. Duloxetine oxalate, a combined serotonin/norepinephrine reuptake inhibitor, has shown great promise in animal studies, as well as in phase 2 and 3 clinical trials. This agent is the first to demonstrate efficacy as a sole therapy for stress incontinence and has exhibited favorable effects on bladder capacity, suggesting possible benefits in mixed incontinence. Only 5 studies (2 of which were conducted during the 1980s) have specifically examined the use of surgery for the treatment of mixed incontinence; the cure rates reported have varied. The current body of information supports use of an antimuscarinic agent as initial therapy for mixed incontinence, although long-term trials are needed to shed more light on the duration of benefit.
OBJECTIVES: To examine the efficacy and tolerability of antimuscarinic therapy in women with urge-predominant mixed incontinence. METHODS: This was a double-blind, randomized, placebo-controlled trial comprising 854 women with urge-predominant mixed incontinence, including urge incontinence (five or more episodes per week), urinary frequency (eight or more micturitions on average in 24 hours), and urgency in combination with stress incontinence. Women received 8 weeks of treatment with tolterodine tartrate extended-release (ER) 4 mg or placebo once daily. The outcome measures included urge incontinence episodes per week, stress incontinence episodes per week, micturition frequency per 24 hours, urgency episodes per 24 hours, volume voided per micturition, patient perception of bladder condition, and assessment of treatment benefit. RESULTS: After 8 weeks, tolterodine ER produced a statistically significant decrease in the weekly urge incontinence episodes compared with placebo (-12.3 versus -8.0; P <0.0001). Other micturition variables improved significantly more with tolterodine ER. No difference was found between treatment groups regarding the change in the number of stress incontinence episodes. A significantly greater proportion of patients receiving tolterodine ER than those receiving placebo reported improvement in bladder condition (61% versus 46%; P <0.001) and treatment benefit (76% versus 55%; P <0.001). After 8 weeks, the tolterodine ER group had experienced statistically significant improvements compared with the placebo group in 9 of 10 quality-of-life domains. The frequency of adverse events was similar between treatment groups. CONCLUSIONS: Tolterodine ER is an effective treatment of urge urinary incontinence, frequency, and urgency in women with concomitant stress urinary incontinence. The efficacy of tolterodine ER in reducing urge incontinence episodes was unaffected by the presence of stress incontinence. The results of this study support the first-line use of antimuscarinic therapy to treat the urge incontinence component of urge-predominant mixed incontinence.
All women who had three elective caesarean sections were selected from a database of 40,000 women delivering between 1977 and 1998, and age-matched with women having three vaginal births. They all completed a (validated) urinary and bowel symptom questionnaire. Women who had vaginal births had a significantly higher prevalence of stress incontinence but not other urinary or faecal symptoms compared with those delivered by caesarean section. The prevalence of faecal incontinence was lower than the prevalence of urinary incontinence. Although the prevalence of faecal incontinence was lower after caesarean delivery, this was not statistically different. These data have shown that caesarean section was associated with a lower risk of urinary incontinence, although a protective effect on development of faecal symptoms was not seen.
The aim of this prospective double-blind randomized placebo-controlled trial was to determine the effect of systemic estrogen on the 'urge syndrome' in postmenopausal women. The trial took place in a tertiary referral urogynecology unit. Postmenopausal women with the 'urge syndrome' were randomly allocated to receive a 25 mg 17beta-estradiol implant or placebo implant. Serum estradiol levels and endometrial thickness were measured on entry to the trial and at 1, 3 and 6 months. The following outcome measures were employed: videocystourethrography, frequency volume chart, visual analogue score of symptoms, and King's Health Care Quality of life Questionnaire. Forty women were included. Subjectively there was a significant improvement in urgency in both groups and urge incontinence in the estradiol group, but no significant differences between the groups. Objectively no significant differences were demonstrated between the groups. Nine women in the estradiol group had vaginal bleeding, and 5 had a hysterectomy during or after the study. Despite using numerous outcome measures to examine its effect, 25 mg estradiol implants did not produce a greater improvement in the 'urge syndrome' than placebo and had a high complication rate.
OBJECTIVE: To validate the italian translated version of the prolapse quality of life questionnaire (P-QOL). STUDY DESIGN: The P-QOL questionnaire was translated into Italian and administered to women recruited from a gynaecology outpatient clinic. All women completed a P-QOL questionnaire at the time of the visit, and were examined in left lateral position using the ICS prolapse score. A second P-QOL questionnaire was posted and completed by women 1 week later. The validity was assessed by measuring levels of missing data, comparing symptom scores with objective prolapse stages and between affected and asymptomatic women. The reliability was assessed by testing internal consistency and stability using 1-week test retest analysis. RESULTS: 132 symptomatic and 61 asymptomatic women were studied. The number of missing items was 2%. P-QOL domain scores were significantly different between symptomatic and asymptomatic women (P<0.001). Severity according to P-QOL strongly correlated with the prolapse size (P<0.01, rho>0.5). All items achieved a Cronbach alpha greater than 0.8. The test retest reliability confirmed a highly significant correlation between the total scores for each domain. CONCLUSION: The Italian version of the P-QOL questionnaire has been validated, providing a reliable, easily comprehensible and valid instrument for the symptomatic assessment of Italian-speaking women with uterovaginal prolapse.
AIMS: The aim of our study was to determine whether the urodynamic diagnosis is useful in the management of women with symptoms of an overactive bladder (OAB). METHODS: Women with lower urinary tract symptoms, attending a tertiary referral urogynaecology clinic were studied. All women were fully evaluated, with history, urinary symptoms questionnaire, frequency-volume chart, vaginal examination, and videocystourethrography. Women with symptoms consistent with an overactive bladder (urinary frequency, urgency, and/or urge incontinence) were selected. Women with neurological disorders were excluded. Finally, urinary symptoms and urodynamic diagnosis were correlated. All terms and definitions are in accordance with the International Continence Society [Abrams et al., 1988, Scand J Urol Nephrol 114(Suppl):5-19.]. RESULTS: A total of 4,500 women 22-73 years of age were studied. Only 843 women (18.7%) could be classified as having an OAB. Of these, 457 women (54.2%) had urodynamically proven detrusor instability, whereas 386 women (45.8%) had a stable urodynamic trace. Sixty-eight (8.1%) of the women studied had postvoid residual greater than 100 mL. Of the 4,500 women studied, 1,641 (36.5%) had detrusor instability on laboratory urodynamics. Only 27.5% of these women (457 of 1,641) had OAB symptoms. CONCLUSIONS: Symptomatic diagnosis of OAB does not correlate with a urodynamic diagnosis of detrusor instability. The diagnosis of overactive bladder based on urinary symptoms underdiagnoses the condition of detrusor instability in a population of women suffering from lower urinary tract symptoms. Therefore, symptomatic diagnosis of OAB alone is not recommended. Our study suggested that urodynamic evaluation is mandatory in the management of the women with symptoms of an overactive bladder.
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OBJECTIVE: The aim of this study was to evaluate the intra- and inter-rater reliability of pressure flow parameters in women. DESIGN: A prospective study. SETTING: Tertiary referral unit in a London teaching hospital. POPULATION: Urodynamic traces of 621 women were studied to assess the reproducibility and reliability of pressure flow parameters. METHODS: Women with lower urinary tract symptoms were studied prospectively. Opening detrusor pressure (ODP), detrusor pressure at maximum flow rate P(detQ(max)), maximum flow rate (Q(max)) and closure detrusor pressure (CDP) were measured by the same observer twice, one week apart. Pressure flows were compared using different media for filling (saline and contrast). All parameters were also measured in nine women from multiple voids during ambulatory urodynamics to assess their reproducibility and finally were remeasured by a second observer. RESULTS: There was good intra-observer agreement for all pressure flow parameters except detrusor pressure at maximum flow rate and good inter-observer agreement for opening detrusor pressure, closure detrusor pressure and detrusor pressure at maximum flow rate. There was no significant difference between parameters using saline or contrast (P > 0.05, independent samples t test). CONCLUSION: Pressure flow parameters appear to be reproducible and consistent urodynamic measurements in women.
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BACKGROUND: Polycystic ovarian syndrome (PCOS) is a heterogeneous endocrine disorder affecting women of reproductive age. The syndrome is characterized by a combination of polycystic ovarian morphology, clinical features and biochemical indices. The objective of this prospective observational study was to investigate the relationship between the total ovarian volume and the ovarian stromal volume, measured using a three-dimensional (3D) ultrasound scan, with biochemical indices of PCOS. METHODS: Twenty-three infertile women (mean age +/- SD: 31 +/- 3.1 years; range: 26-37) with clomiphene citrate-resistant PCOS were examined. Early follicular phase (days 2-4) serum FSH, LH and testosterone concentrations were measured following a withdrawal bleed. Total ovarian volume, stromal volume, pre-antral follicle (<10 mm) number and total follicular volume were measured by 3D transvaginal ultrasound. RESULTS: Total ovarian volume, follicular volume and follicle number correlated positively with serum FSH and LH, but not testosterone, concentrations. Ovarian stromal volume correlated strongly with total ovarian volume only, but not with serum FSH, LH or testosterone concentrations. CONCLUSIONS: These findings demonstrate an association of the total ovarian volume, pre-antral follicle number and total follicular volume with some of the biochemical indices of PCOS, but no association was observed between ovarian stromal volume and these indices.
This is the second part of a study assessing 161 women 12 weeks after their first delivery. The urodynamic data have previously been published [Br J Obstet Gynaecol 2000;107:1354]. The symptoms have been assessed using a (non-validated) urinary symptom questionnaire. There was no correlation between symptoms and urodynamic findings and most importantly between the symptom of stress incontinence, a diagnosis of urodynamic stress incontinence (USI) and vaginal delivery. Symptoms of incontinence and abnormal urodynamic findings were also found in women who underwent caesarean section. These data explain why caesarean section does not appear to be wholly protective in preventing postpartum incontinence. This suggests that the aetiology of postpartum incontinence is multifactorial and urinary symptoms are misleading in determining the underlying causes.