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PubMed2006

Canadian Urological Association guidelines on urinary incontinence.

OBJECTIVE: To develop the first Canadian guidelines for the management of adult urinary incontinence (UI). METHOD: Following a mandate of the Canadian Urological Association, six Canadian urologists collaborated to produce these guidelines after having extensively reviewed existing foreign guidelines and literature from 1966 to June 2005. RESULTS: The terminology proposed by the standardization committee of the International Continence Society (ICS) is recommended. Basic evaluation must include a history, physical examination, evaluation of post void residual volume, urinalysis and voiding diary. A more detailed evaluation is recommended for complex cases or if initial management fails. As non-pharmacological treatments, devices (catheters, pessaries, etc...) play an important role in selected patients. Lifestyle adjustments are recommended to be implemented first before considering other forms of treatment. Pelvic exercises can be helpful for the mildest cases of pelvic relaxation, in motivated compliant patients. In highly selected patients neuromodulation can improve the patient's quality of life. Probantheline, oxybutinin and tolterodine have a proven efficacy in the treatment of UI. Imipramine and oestrogens are suggested while flavoxate has an unproven efficacy. Surgery in women is indicated when the degree of incontinence is sufficiently troublesome to the patient, the incontinence has been observed by the examiner, its causes adequately evaluated and conservative therapies have been reviewed. Primary stress urinary incontinence in the female is effectively treated by a retropubic suspension (Burch or Marshall- Marchetti-Krantz), or a pubovaginal sling procedure. Pubovaginal slings are the procedure of choice in the presence of significant intrinsic sphincteric deficiency (ISD), the absence of hypermobility, or in the treatment following a failed retropubic suspension. Peri urethral injectables are recommended first line treatment of SUI when available. In men, artificial sphincter is the treatment of choice in neurogenic and non-neurogenic SUI. In neurogenic bladders and sometimes in non neurogenic bladders other forms of surgeries such as bladder denervation, bladder augmentations, neurostimulation, urinary diversion can be considered as the treatment of choice for individual patients. CONCLUSION: Canadian guidelines on incontinence have been completed in 2005 reflecting the Canadian health environment. This field of UI is in constant progression and, when of proven efficacy, new medications and devices have to be included in the proposed algorithm of care.

Exercise↗
PubMed2005

The longue durée of contraceptive methods.

Medical history has so far paid hardly any attention to the longue durée, a history in which, according to Braudel, 'all change is slow'. It is therefore one of the challenges of the emerging field of the social history of medicine to work audaciously across time as well as across space. An interesting subject, for example, is the history of contraception. Throughout history, there has been almost nothing people have worried about more than having sex without fear of consequence. At first sight, the story of contraception seems to be one of progress, from the Ancient Egyptian crocodile-dung pessary to the modern-day condom and contraceptive pill. A closer look, however, shows a pattern of remarkable continuities in the reproductive behaviour of men and women over the last two thousand years. In this paper, I shall attempt to show why traditional male-dominated contraceptive methods still linger on despite the sexual revolution brought about by the invention of the 'pill' in the late 1950s.

Attitude to Health↗
PubMed1991

Investigative procedures in urogynecology.

History and physical examination do not always correlate with final urodynamic diagnoses in incontinent women. A large number of diagnostic procedures are available to help the clinician establish the correct diagnosis. The importance of urine culture, Q-tip test, ultrasound, pessary test for potential incontinence, neurophysiologic testing, endoscopy, urethral pressure profiles, stress/pad tests, uroflowmetry, and cystometry are discussed. The physician should understand the importance and limitations of each of the different investigative procedures.

Cystoscopy↗
PubMed1991

Evaluation of the causes and severity of geriatric incontinence. A critical appraisal.

The evaluation of urinary incontinence in the elderly differs from that in younger patients because of altered or nonspecific disease presentation, the different spectrum of pathophysiology, greater variation between individuals and, in some cases or settings, variable treatment goals. Evaluation must be multifactorial and extend beyond the genitourinary system, because many age-related conditions and the drugs used to treat them can cause or exacerbate urinary incontinence. Voiding records are a reliable measure of severity, although studies of their validity are still lacking. History-taking requires more time in this age group. Stress incontinence symptoms remain very sensitive, whereas obstructive symptoms fall in predictive value. Clinical algorithms based on a combination of symptoms and simple bedside examination and maneuvers may prove most useful in specific settings such as nursing homes. The targeting and interpretation of the physical examination must also change because of age-related conditions (e.g., BPH, atrophic vaginitis) and prevalent comorbid diseases, especially neurologic ones. The Q-tip, elevation, and pessary tests for stress incontinence offer little diagnostic or therapeutic information in the elderly. Routine laboratory tests should be performed to exclude reversible causes of urinary incontinence, while interpretation of the urinalysis must consider the prevalence of asymptomatic bacteriuria. No radiographic studies are routinely needed; bead-chain cystourethrography and IVU in particular probably offer little additional information. Voiding cystourethrography, although little studied, offers dynamic data that may be helpful, especially in evaluating outlet obstruction. Bedside cystometry is simple but may be insensitive to the most prevalent type of detrusor instability in the institutionalized elderly. Finally, multichannel urodynamic study is safe and feasible even in frail elderly patients and should be considered when empiric therapy is risky or has failed, complicated comorbidity exists, or surgery is anticipated.

Aged↗
PubMed1990

The inflammatory cervical smear: a study in general practice.

This study set out to determine whether the term 'inflammatory' in a cervical smear report implies underlying infection or whether it could be masking cancerous or precancerous changes. Of 826 smears taken in one practice over one year, 42 demonstrated some degree of inflammatory change. Thirty four of these women presented for swabs and almost half (47%) had a microbiologically proven infection. This group was further subdivided, and of those whose smears were reported as simple 'inflammation', just over one third (35%) were infected but of those whose smears were reported as 'severe inflammation', over two thirds were infected (73%). The commonest organisms isolated were Gardnerella vaginalis and Candida albicans. It would therefore appear to be worthwhile to treat patients who report severe inflammation with metronidazole and with anti-fungal pessaries before the smear is repeated. Following treatment two women went on to show dyskaryosis within five months. On colposcopy one of these women was found to have invasive cervical squamous cell carcinoma. It is concluded that whether women with inflammatory smears are treated or not, it is mandatory to repeat the smear, ideally within five months.

Adult↗
PubMed1990

Premature rupture of the membranes in a single twin gestational sac. A case report.

Premature rupture of the membranes was diagnosed with ultrasound and subsequent injection of dye into the upper sac of a 15-week twin gestation. Because of a history of prolonged infertility, conservative treatment (including bed rest, antibiotics and intravaginal povidone-iodine pessaries) was given. Four weeks later the leakage of amniotic fluid stopped, and at 32 gestational weeks the patient delivered healthy twins by cesarean section. No sign of chorioamnionitis was noted clinically or histologically. It seems that in this unusual case the lower sac was acting as a tampon and at some stage prevented further escape of amniotic fluid as well as ascending infection.

Adult↗
PubMed1989

Gestrinone in the treatment of myomas.

In a study involving over 300 women, gestrinone has been found to induce regression of uterine myomas. Gestrinone was given in doses of 2.5-5 mg (orally or by vaginal pessary), two or three times weekly. The treatment regimen depended upon tumor size and tumor age. Patients with small tumors, i.e. uterine volumes of less than 200 cm3, were treated for 6 months, whereas those with uterine volumes of 200-300 cm3 were treated for 1 year. In severe cases where uterine volumes were greater than 400 cm3, the patients were treated for 2 years. Large myomas of 300 cm3 or more required higher doses of steroid. During the first 6 months of treatment there was a marked reduction in uterine volume, but subsequently the rate of tumor regression was slower. Following discontinuation of treatment, reactivation of tumor growth was slow in most patients. Gestrinone caused amenorrhea in all patients and in most women it lasted throughout therapy. The abdominal discomfort, dyspareunia and dysuria which resulted from the myoma were progressively alleviated during treatment. Most patients experienced at least some side-effects associated with the mild androgenicity of gestrinone. These included weight gain, seborrhea and acne (which developed in most patients). Hirsutism, hoarseness and increase in libido were less common, affecting 10-20% of patients, depending on the dose and duration of treatment. All side effects were reversible.

Adolescent↗
PubMed1989

Vaginal administration of gemeprost for preoperative cervical dilatation in non pregnant patients.

The use of Gemeprost vaginal suppositories has been evaluated in a trial for induction of the cervical dilatation in non pregnant women. 30 voluntary patients, 22 nulliparous and 8 pluriparous, had to be subjected to biopsy of the endometrium; 24 were treated for the control of sterility and 6 for menstrual perimenopausal disorders. The biopsies of the sterility control were effected in the second half of the cycle, generally without having recourse to narcosis. A single Gemeprost pessary containing 1 mg of 16, 16-dimethyl-trans-delta 2 PGE1 methyl ester was intravaginal administered, deeply into the posterior fornix, 3 hours before the biopsy. The success rate was 86.66 (26 pts.) with an average dilatation of 5.38 H (Hegar) +/- 0.75 SD. For 4 patients (13.33%) having a dilatation less than 4 H, it was necessary to complete the dilatation mechanically. All the observed side effects presented a modest intensity: cephalalgia 6.6% (no. 2), gastralgia 3.3% (no. 1), vaginal burning 6.6% (no. 2). No significant variation of vital function parameters was recorded. In conclusion this type of preparation of the cervix has permitted us to achieve a more gradual dilatation and to prevent the traumata of the cervico-isthmic system due to forced mechanical dilatations by the exclusive use of Hegar's dilators.

Administration, Intravaginal↗
PubMed1988

Prostaglandins and antigestagens for the interruption of early pregnancy.

During pregnancy the uterus is maintained in a quiescent state by the secretion of progesterone. Antigestagens antagonize the biological action of progesterone by binding to the nuclear receptor in the target organs. Administration of the antigestagen mifepristone to women induces bleeding during the luteal phase and in early pregnancy by releasing endogenous prostaglandins from the endometrium or decidua. In addition, the sensitivity of the myometrium to exogenous prostaglandins is markedly increased. Although mifepristone will induce bleeding in the majority of women in early pregnancy, the incidence of incomplete abortion or ongoing pregnancies increases with increasing gestational age and is too high to be clinically useful as an agent for therapeutic abortion. However, a single dose of mifepristone (400-600 mg) followed by a vaginal pessary of a prostaglandin analogue (0.5-1.0 mg), gemeprost, induced complete abortion in 95 of 100 women of gestational age less than 42 days (less than or equal to 56 days amenorrhoea). The incidence of diarrhoea (15%) and abdominal pain requiring opiate analgesia (10%) was much lower than when abortion was induced with prostaglandin alone. Vaginal bleeding continued for 13.8 +/- 0.8 days after administration of the prostaglandin. A combination of an antigestagen with a small dose of a prostaglandin analogue is an effective alternative to vacuum aspiration for the therapeutic termination of early pregnancy.

Abortifacient Agents↗
PubMed1977

[Investigations on the contraceptive action of the Graefenberg ring. Historical review (author's transl)].

The biological activity of 2 Graefenberg rings was tested in vitro by electrone microscopy and X-ray microanalysis. The investigation showed that Graefenberg rings made of silver contain a varying amount of copper. The Graefenberg rings showed dissociation of copper in vitro which probably also occurred in the uterine cavity. The effect of the copper on the endometrium was probably a factor in the good contraceptive effectiveness of the Graefenberg silver ring compared for the silk thread intrauterine pessaries.

Copper↗
PubMed1986

Comparison of terconazole and clotrimazole vaginal tablets in the treatment of vulvovaginal candidosis.

The clinical efficacy of terconazole (triaconazole), a new triazole ketal structurally similar to ketoconazole, was evaluated in a single-blind, randomized comparative clinical trial including 60 patients with symptoms and clinical signs of vulvovaginal candidosis confirmed by microscopic examination and positive culture for Candida albicans. Three comparable groups were treated with 200 mg clotrimazole or 80 mg terconazole vaginal tablets once daily for 3 consecutive days, or one 240 mg terconazole vaginal tablet followed by 2 identical placebo pessaries. No differences in relief and initial symptomatic cure according to patient recordings on diary cards were demonstrated between the three regimens. Cure rates were 90% or more in all treatment groups 1 week after completion of therapy. At the second follow-up visit 3 weeks later, a significantly higher mycological cure rate (94%), due to significantly better therapeutic response in patients with recurrent vulvovaginal candidosis, was recorded after 3-day therapy with terconazole, while the mycological cure rates after clotrimazole and single-dose terconazole treatment only were 65% and 55%, respectively. It was concluded that terconazole represents an efficient and well-tolerated therapeutic alternative in the topical treatment of vulvovaginal candidosis.

Antifungal Agents↗
PubMed1987

[Rare foreign body fistulas of the female bladder].

Fistulae between kidney and vagina caused by foreign bodies are very rare nowadays. Two casuistics illustrate the curious anamnesis of such patients: in an 18-year-old girl a foreign body inserted during masturbation led to a perforation, in the case of a 66-year-old woman a pessary which had been forgotten since 35 years penetrated into the urinary bladder.

Adolescent↗
PubMedDate not supplied

[Urologic consequences of severe genital prolapse].

From three observations, the authors analyse the ureteric dilatation and genital prolapse association from an anatomo-clinic point of view. The bladder-base displacement situated in the vaginal prolapse and the resulting very sharp angle formed by the terminal ureter portion are enough to explain the pathogenesis of the observed urinary lesions. The repercussions of advanced prolapses upon upper urinary tracts are rarely mentioned in literature. The three reported clinic cases are absolutely demonstrative: for every one, the major uretero pyelectasis is associated with a progressive renal insufficiency. Authors insist upon urologic symptoms quick regression after a prolapse cure. This correction is made either by putting a pessary, either by a surgical cure unless the risk should be too important for the patient.

Aged↗
PubMedDate not supplied

[Technic and use of a silastic vaginal mold: urodynamic evaluation].

A pessary is rarely needed to treat prolapse or incontinence. In certain cases, the anatomical conditions are unsuitable for the use of this device which is sometimes poorly tolerated in the long term. The authors propose an original solution of a vaginal cast made from silastic foam. The technique of making the cast, its advantages and disadvantages are described together with the modifications which it is able to induce on the urodynamic parameters. This technique will certainly be useful in certain rare indications.

Evaluation Studies as Topic↗
PubMed1985

The incompetent cervix.

All methods for the management of CI have been described as producing a significant improvement in fetal salvage. The Lash procedure and the pessary have been deemed the most effective. However, the methods of patient selection in many of the older studies are not described, and their statistical validity is suspect. CI is thus a disease of uncertain etiology. Its pathophysiology is poorly understood, and methods of treatment vary greatly both as to technique and efficacy.

Cervix Uteri↗
PubMed1977

[Quantitative determination of menstrual blood loss using the clinical whole-body counter].

In 20 females the whole-body retention test using 59Fe was carried out for quantitative determination of menstrual blood loss. In hypomenorrhoea blood loss ranged from 10 to 40 ml and in normal menstruation from 70 to 150 ml. Blood losses in excess of 150 ml should be considered as hypermenorrhoea. This method constitutes an extension of diagnostic facilities with respect to confirmation of data given in the history of the patients concerning blood loss at menstruation and with particular problems (e.g. undisclosed cases of anaemia, bleedings with uterus myomatosus or with an indwelling endouterine pessary).

Adult↗
PubMed1979

[Precancerous lesions of the cervix. Diagnosis and treatment (author's transl)].

In gynaecological practice, the problem of precancerous lesions of the cervix arises under three different circumstances : --ectropion, --dysplasia, --in a young girl when the mother has taken Stilbestrol. The literature is reviewed in these three cases : --ectropion is an anatomical state which does not absolutely require treatment. According to the majority of authors it would not appear that its destruction is useful in the prophylaxis of carcinoma of the cervix; --dysplasia, although it does not always progress to a carcinoma, would seem to be a potentially malignant state, the diagnosis of which must be made by the combination of cytology, colposcopy and biopsy. Treatment is based upon the topography of the lesion, its severity and the age of the patient : either conservative if the patient is young and wishes to have children, or surgical (conisation or hysterectomy) if she is older, does not want any more children or has an additional gynaecological problem. --in the presence of a lesion in a young girl whose mother has taken Stilboestrol, precise diagnosis must be made by biopsy with surveillance and treatment of lesions of adenosis, either by progesterone pessaries or by excision.

Adolescent↗
PubMed1978

[Contraception in children and adolescents].

It is discussed how the adult type contraception fits the divergent needs of the youngsters. Oral contraceptives are suitable from the 16th year of life. Vaginal globuli and foams have also proved to be an effective means of contraception over that period of life. For anatomical reasons pessaries are not recommended, insertion of intrauterine devices is contraindicated because of their possible adverse effects. Experiences with university students taking d-Norgestrel as "morning-after-pill" have been favorable. The therapeutic abortion is regarded as an emergency measure to be employed only if anticonception failed. Adaequate education at the proper age and the importance of preventive measures are stressed.

Abortion, Spontaneous↗