- Email: [email protected]
Protecting the Pelvic Floor: Obstetric Management to Prevent Incontinence and Pelvic Organ Prolapse
1036
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY
phenolate mofetil, and corticosteroids (triple therapy) were compared with a control group of 98 kidney recipients who received tacrolimus and corticosteroids (double therapy). Results. There was a significant reduction in the incidence of biopsy-confirmed acute rejection in the triple therapy group (8.2%)compared with the double therapy group (21%;P = 0.003). One-year patient and graft survival did not differ between groups. The incidence of posttransplant diabetes mellitus was 18%and 21% in the triple and double therapy groups, respectively. Leukopenia and gastrointestinal side effects were the most common cause for discontinuation of mycophenolate mofetil. Conclusions. The combination of tacrolimus with mycophenolate mofetil and corticosteroids is more effective at preventing early acute rejection than tacrolimus and corticosteroids alone. The use of mycophenolate mofetil was associated with a higher incidence of leukopenia and diarrhea, often leading to discontinuation of the drug.
Editorial Comment: Mycophenolate mofetil and tacrolimus are the most significant new maintenance immunosuppressiveagents to be developed for use in kidney transplantation since the introduction of cyclosporine 15 years ago. Recent studies evaluating each of these agents in combination with other maintenance drugs have indicated a significant reduction in the incidence of acute rejection episodes. Strategies for accomplishing the latter are relevant in view of the close relationship between acute rejection and the subsequent development of chronic graft dysfunction. There have been only limited data to date on the immunological efficacy of combined mycophenolate-tacrolimus maintenance therapy in clinical transplantation. Notwithstanding the retrospective nature of this study, the results indicate a remarkable 8.2% incidence of acute rejection in patients receiving mycophenolate, tacrolimus and steroids. Some investigators have suggested that mycophenolate and tacrolimus exert a synergistic immunosuppressive effect when used together. The excellent results in this study may also reflect the concurrent use of antilymphoid antibody induction therapy in most patients. These promising initial data merit further evaluation within the context of a randomized prospective trial with longer followup to assess the impact on chronic graft loss. Andrew C. Novick, M.D.
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY Pudendal Nerve Function During Pregnancy and After Delivery T. TETZSCHNER, M. SBRENSEN, G. LOSEAND J. CHRISTIANSEN, Glostrup County Hospital and Herlev County Hospital, University of Copenhagen, Copenhagen, Denmark Int. Urogynec. J., 8 66-68, 1997 Abstract: The aim of the study was to assess pudendal nerve function serially during pregnancy and after delivery. Twenty-eight women participated at 14,30 and 36 weeks of pregnancy and 12 weeks postpartum. A prospective study of pudendal nerve terminal motor latency during pregnancy and after delivery was carried out. Results showed that pudendal nerve terminal motor latency did not increase significantly during pregnancy but increased significantly after delivery. Protecting the Pelvic Floor: Obstetric Management to Prevent Incontinence and Pelvic Organ Prolapse V. L. HANDA,T. A. HARRISAND D. R. OSTERGARD, Department of Obstetrics and Gynecology, University of California Davis Medical Center, Sacramento, and Department of Obstetrics and Gynecology, University of California Irvine and Long Reach Memorial Medical Center, Zrvine, California Obst. Gynec., 88: 470-478, 1996 Objectives: To review the literature regarding the effects of childbirth on the muscles, nerves, and connective tissue of the pelvic floor; review the evidence to support an association between childbirth and anal incontinence, urinary incontinence, and pelvic organ prolapse; and present recommendations for the prevention of these sequelae. Data Sources: Sources were identified from a MEDLINE search of English-language articles published from 1984 to 1995. Additional sources were identified from references cited in relevant research articles. Methods of Study Selection: We studied articles on the following topics: anatomy of the pelvic floor; association of childbirth with neuromuscular injury, biomechanical and morphologic alterations in muscle function, and connective tissue structure and function; the long-term effects of childbirth on continence and pelvic organ support; and the effects of obstetric interventions on the pelvic floor. Tabulation, Integration, and Results: Articles were reviewed and summarized. An overview of the structure and function of the pelvic floor was developed to provide a context for subsequent data. Childbirth
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY
1037
was found to be associated with a variety of muscular and neuromuscular injuries of the pelvic floor that are linked to the development of anal incontinence, urinary incontinence, and pelvic organ prolapse. Risk factors for pelvic floor injury include forceps delivery, episiotomy, prolonged second-stage of labor, and increased fetal size. Cesarean delivery appears to be protective, especially if the patient does not labor before delivery. Conclusion: The pelvic floor plays an important role in continence and pelvic organ support. Obstetricians may be able to reduce pelvic floor injuries by minimizing forceps deliveries and episiotomies, by allowing passive descent in the second stage, and by selectively recommending elective cesarean delivery.
Risk Factors for Development and Recurrence of Urinary Incontinence K. B0, Norwegian Centre for Physiotherapy Research, Oslo, Norway curr. Opin. Urol., 7: 193-196, 1997 Three months postpartum, risk factors for development of urinary incontinence were found to be vaginal delivery, obesity and multiparity (>5). Caesarean section and daily antenatal pelvic floor muscle exercises appear to be protective, although not completely. In two studies the importance of pelvic floor muscle function in continence was addressed. In a case-control study of stress incontinent and healthy women, significantly thicker pelvic floor muscles were found in the healthy subjects. In another study urethral pressure parameters were all reduced following pudendal nerve blockade. A threefold prevalence of urinary stress incontinence among first degree relatives of female patients with stress urinary incontinence was demonstrated. In a review article associations between psychological and cognitive factors and sensory urgency and idiopathic detrusor instability were discussed. In another review article urinary incontinence in old age was addressed. In the elderly, urinary incontinence may be either transient or established. However, it should never be considered normal due to age. On the contrary, it seems to be treatable and often curable a t all ages, even in the frail elderly. Editorial Comment: The inference to be drawn from these articles is that damage to the nerves responsible for at least a portion of pelvic floor innervation occurs during vaginal delivery by pressure, stretching or cutting. Although stress incontinence occurs in as many as 300/0 of primigravidas during pregnancy,resolution after delivery is the rule. Damage to the pelvic floor musculature during vaginal delivery can clearly result in factors that contribute to stress incontinence. There is some argument about whether denervation iqjury truly occurs but it is difficult to argue with results such as those reportedby Tetzschner et al. However, whether such nerve damage and stress incontinence are related is still controversial. Whether the pathology is neurological andor muscular, following the suggestions made by Handa et a1 would seem to minimize this risk as much as possible. Alan J. Wein, M.D. Clinical Effect of Propiverine in Patients With Urge or Stress Incontinence H. OKADA,J. SENGOKU, K. GOHJI,S. ARAKAWA, S. KAMIDONO AND KOBEUNIVERSITY INCONTINENCE STUDY GROUP, Department of Urology, Kobe University School of Medicine, Kobe, Japan Acta Urol. Jap., 44:65-69, 1998 The efficacy and tolerability of propiverine hydrochloride (20 mg day) were evaluated in the treatment of a total of 49 Japanese patients (35 with urge incontinence and 14 with stress incontinence) in an open multicenter trial lasting 28 days. The effects on the frequency of urination, urinary incontinence, urinary urgency, and daily living activities were evaluated through the voiding diaries filled out by the patients. Moderate or greater degree of improvement was attained in micturition frequency by 52 and 54% of the patients with urge incontinence and with stress incontinence, respectively, in urinary urgency by 91 and 58%, in urinary incontinence by 97 and 71%, and in daily living activities by 94 and 64%. Although minor adverse reactions (5 patients) and abnormal values in blood chemistry (2 patients) were recorded in 7 patients, all of these patients completed the trial. These results suggest that propiverine hydrochloride is a safe and effective drug of choice for the treatment of not only urge incontinence but also stress incontinence in patients diagnosed in a clinical setting. Effectof Intermittent Urethral Catheterizationand OxybutyninBladder Instillation on Urinary Continence Status and Qualityof Life in a Selected Group of Spinal Cord hj- Patients With Neuropathic Bladder Dysfunction s. V M D ~ A N A NB.T M. ~ , SONI,E. BROWN,P. SETT, K. R. KRISHNAN, J. BINCLEYAND S. W K E Y , Regional Spinal Injuries Centre, District General Hospital, Southport, Merseyside, United Kingdom Spinal Cord, 3 6 409-414, 1998 Objectives: A comparative assessment of(i) urinary continence status, (ii)qUditY of life, and (iii)sexuality in spinal cord injury patients prior to, and during intermittent catheterization with adjunctive intravesical oxybutynin therapy (Cystin: manufactured by Leiras OY,Helsinki, F i n h d ) .
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY
phenolate mofetil, and corticosteroids (triple therapy) were compared with a control group of 98 kidney recipients who received tacrolimus and corticosteroids (double therapy). Results. There was a significant reduction in the incidence of biopsy-confirmed acute rejection in the triple therapy group (8.2%)compared with the double therapy group (21%;P = 0.003). One-year patient and graft survival did not differ between groups. The incidence of posttransplant diabetes mellitus was 18%and 21% in the triple and double therapy groups, respectively. Leukopenia and gastrointestinal side effects were the most common cause for discontinuation of mycophenolate mofetil. Conclusions. The combination of tacrolimus with mycophenolate mofetil and corticosteroids is more effective at preventing early acute rejection than tacrolimus and corticosteroids alone. The use of mycophenolate mofetil was associated with a higher incidence of leukopenia and diarrhea, often leading to discontinuation of the drug.
Editorial Comment: Mycophenolate mofetil and tacrolimus are the most significant new maintenance immunosuppressiveagents to be developed for use in kidney transplantation since the introduction of cyclosporine 15 years ago. Recent studies evaluating each of these agents in combination with other maintenance drugs have indicated a significant reduction in the incidence of acute rejection episodes. Strategies for accomplishing the latter are relevant in view of the close relationship between acute rejection and the subsequent development of chronic graft dysfunction. There have been only limited data to date on the immunological efficacy of combined mycophenolate-tacrolimus maintenance therapy in clinical transplantation. Notwithstanding the retrospective nature of this study, the results indicate a remarkable 8.2% incidence of acute rejection in patients receiving mycophenolate, tacrolimus and steroids. Some investigators have suggested that mycophenolate and tacrolimus exert a synergistic immunosuppressive effect when used together. The excellent results in this study may also reflect the concurrent use of antilymphoid antibody induction therapy in most patients. These promising initial data merit further evaluation within the context of a randomized prospective trial with longer followup to assess the impact on chronic graft loss. Andrew C. Novick, M.D.
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY Pudendal Nerve Function During Pregnancy and After Delivery T. TETZSCHNER, M. SBRENSEN, G. LOSEAND J. CHRISTIANSEN, Glostrup County Hospital and Herlev County Hospital, University of Copenhagen, Copenhagen, Denmark Int. Urogynec. J., 8 66-68, 1997 Abstract: The aim of the study was to assess pudendal nerve function serially during pregnancy and after delivery. Twenty-eight women participated at 14,30 and 36 weeks of pregnancy and 12 weeks postpartum. A prospective study of pudendal nerve terminal motor latency during pregnancy and after delivery was carried out. Results showed that pudendal nerve terminal motor latency did not increase significantly during pregnancy but increased significantly after delivery. Protecting the Pelvic Floor: Obstetric Management to Prevent Incontinence and Pelvic Organ Prolapse V. L. HANDA,T. A. HARRISAND D. R. OSTERGARD, Department of Obstetrics and Gynecology, University of California Davis Medical Center, Sacramento, and Department of Obstetrics and Gynecology, University of California Irvine and Long Reach Memorial Medical Center, Zrvine, California Obst. Gynec., 88: 470-478, 1996 Objectives: To review the literature regarding the effects of childbirth on the muscles, nerves, and connective tissue of the pelvic floor; review the evidence to support an association between childbirth and anal incontinence, urinary incontinence, and pelvic organ prolapse; and present recommendations for the prevention of these sequelae. Data Sources: Sources were identified from a MEDLINE search of English-language articles published from 1984 to 1995. Additional sources were identified from references cited in relevant research articles. Methods of Study Selection: We studied articles on the following topics: anatomy of the pelvic floor; association of childbirth with neuromuscular injury, biomechanical and morphologic alterations in muscle function, and connective tissue structure and function; the long-term effects of childbirth on continence and pelvic organ support; and the effects of obstetric interventions on the pelvic floor. Tabulation, Integration, and Results: Articles were reviewed and summarized. An overview of the structure and function of the pelvic floor was developed to provide a context for subsequent data. Childbirth
VOIDING FUNCTION AND DYSFUNCTION, AND FEMALE UROLOGY
1037
was found to be associated with a variety of muscular and neuromuscular injuries of the pelvic floor that are linked to the development of anal incontinence, urinary incontinence, and pelvic organ prolapse. Risk factors for pelvic floor injury include forceps delivery, episiotomy, prolonged second-stage of labor, and increased fetal size. Cesarean delivery appears to be protective, especially if the patient does not labor before delivery. Conclusion: The pelvic floor plays an important role in continence and pelvic organ support. Obstetricians may be able to reduce pelvic floor injuries by minimizing forceps deliveries and episiotomies, by allowing passive descent in the second stage, and by selectively recommending elective cesarean delivery.
Risk Factors for Development and Recurrence of Urinary Incontinence K. B0, Norwegian Centre for Physiotherapy Research, Oslo, Norway curr. Opin. Urol., 7: 193-196, 1997 Three months postpartum, risk factors for development of urinary incontinence were found to be vaginal delivery, obesity and multiparity (>5). Caesarean section and daily antenatal pelvic floor muscle exercises appear to be protective, although not completely. In two studies the importance of pelvic floor muscle function in continence was addressed. In a case-control study of stress incontinent and healthy women, significantly thicker pelvic floor muscles were found in the healthy subjects. In another study urethral pressure parameters were all reduced following pudendal nerve blockade. A threefold prevalence of urinary stress incontinence among first degree relatives of female patients with stress urinary incontinence was demonstrated. In a review article associations between psychological and cognitive factors and sensory urgency and idiopathic detrusor instability were discussed. In another review article urinary incontinence in old age was addressed. In the elderly, urinary incontinence may be either transient or established. However, it should never be considered normal due to age. On the contrary, it seems to be treatable and often curable a t all ages, even in the frail elderly. Editorial Comment: The inference to be drawn from these articles is that damage to the nerves responsible for at least a portion of pelvic floor innervation occurs during vaginal delivery by pressure, stretching or cutting. Although stress incontinence occurs in as many as 300/0 of primigravidas during pregnancy,resolution after delivery is the rule. Damage to the pelvic floor musculature during vaginal delivery can clearly result in factors that contribute to stress incontinence. There is some argument about whether denervation iqjury truly occurs but it is difficult to argue with results such as those reportedby Tetzschner et al. However, whether such nerve damage and stress incontinence are related is still controversial. Whether the pathology is neurological andor muscular, following the suggestions made by Handa et a1 would seem to minimize this risk as much as possible. Alan J. Wein, M.D. Clinical Effect of Propiverine in Patients With Urge or Stress Incontinence H. OKADA,J. SENGOKU, K. GOHJI,S. ARAKAWA, S. KAMIDONO AND KOBEUNIVERSITY INCONTINENCE STUDY GROUP, Department of Urology, Kobe University School of Medicine, Kobe, Japan Acta Urol. Jap., 44:65-69, 1998 The efficacy and tolerability of propiverine hydrochloride (20 mg day) were evaluated in the treatment of a total of 49 Japanese patients (35 with urge incontinence and 14 with stress incontinence) in an open multicenter trial lasting 28 days. The effects on the frequency of urination, urinary incontinence, urinary urgency, and daily living activities were evaluated through the voiding diaries filled out by the patients. Moderate or greater degree of improvement was attained in micturition frequency by 52 and 54% of the patients with urge incontinence and with stress incontinence, respectively, in urinary urgency by 91 and 58%, in urinary incontinence by 97 and 71%, and in daily living activities by 94 and 64%. Although minor adverse reactions (5 patients) and abnormal values in blood chemistry (2 patients) were recorded in 7 patients, all of these patients completed the trial. These results suggest that propiverine hydrochloride is a safe and effective drug of choice for the treatment of not only urge incontinence but also stress incontinence in patients diagnosed in a clinical setting. Effectof Intermittent Urethral Catheterizationand OxybutyninBladder Instillation on Urinary Continence Status and Qualityof Life in a Selected Group of Spinal Cord hj- Patients With Neuropathic Bladder Dysfunction s. V M D ~ A N A NB.T M. ~ , SONI,E. BROWN,P. SETT, K. R. KRISHNAN, J. BINCLEYAND S. W K E Y , Regional Spinal Injuries Centre, District General Hospital, Southport, Merseyside, United Kingdom Spinal Cord, 3 6 409-414, 1998 Objectives: A comparative assessment of(i) urinary continence status, (ii)qUditY of life, and (iii)sexuality in spinal cord injury patients prior to, and during intermittent catheterization with adjunctive intravesical oxybutynin therapy (Cystin: manufactured by Leiras OY,Helsinki, F i n h d ) .