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Acute and recurrent urinary tract infections in women presenting in primary practice Abstract. Acute and recurrent urinary tract infections in women of all age groups are becoming an increasing problem in primary care and medical practice. Symptoms can be relieved by a guideline-oriented acute therapy and a multimodal infection prophylaxis. The restoration of the body's natural defence mechanisms plays a central role. This article informs about the causes, the basic diagnostic examinations and the practical use of therapeutic and prophylactic measures.

Urogynecological ultrasound as a part of the diagnostic work-up of stress urinary incontinence enables the morphologic and dynamic assessment of the lower urinary tract and has replaced radiography in the primary diagnostic work-up of stress urinary incontinence. It is possible to classify the sonographically identified changes of the endopelvic fascia, whereby any dynamic changes must be interpreted in context with the clinical findings. Stress urinary incontinence, besides voiding dysfunction, recurrent urinary tract infections and dyspareunia, may be associated with urethral diverticula, which can be detected by ultrasound. Postoperative voiding problems, de novo urgency or recurrent urinary tract infections can be assessed by demonstrating possible causes, such as haematomas, overcorrection with postvoid residual, misplacement of the tape at the level of the bladder neck or intravesical displacement of suture or tape material. Introital and perineal ultrasound might also be used for monitoring the proper placement of sutures to reduce postoperative complications.

Objective: To evaluate the position of the bladder neck before and after open Burch colposuspension, using introital ultrasound., Design: Retrospective longitudinal study using pre- and post-operative sonographic assessment of the position and function of the bladder neck., Setting: Urogynecology units at the universities of Marburg/Göttingen and Witten/Herdecke and the DRK district hospital in Alzey, Germany., Patients: 310 women undergoing open Burch colposuspension for primary genuine stress incontinence between September 1992 and December 2001., Method: Two-dimensional introitus sonography of the bladder neck prior to, one week and six months after surgery., Results: The median age at surgery was 55 years (26 - 85). Open colposuspension lead to a 90.0 % (279/310) cure rate at 6 months with only 3.5 % (11/310) of the patients showing persistent micturation problems. A further 11.6 % (36/310) had symptoms of urgency and in 7 patients (2.3 %) a de novo urge-incontinence occurred. Post-operative bladder neck angles and movements at rest and during valsalva manoeuvre were significantly reduced while the resting bladder neck position was significantly elevated (p < 0.0001). Anatomical elevation of the bladder neck after open colposuspension varied between 2 - 39 with a median of 14.3 mm of neck elevation after one week and 9.9 mm at 6 month, respectively. Incontinence surgery lead to a significant reduction of the urethral funneling (p < 0.0001)., Conclusion: In our series, open Burch colposuspension decreased both the bladder neck angle and the linear movement at rest and on valsalva as a result of the surgically stabilized bladder neck. Thus, our results support the hammock hypothesis that even small changes in the position of neck position are sufficient to reverse incontinence. We believe that perioperative introitus sonography is a helpful tool for the clinical assessment and documentation of not only morphological but also functional changes of the female continence organ before and after open Burch colposuspension.

Radical surgery in stage I and II uterine sarcoma removing all tumor manifestations is the only curative therapy option for early stage disease. Larger tumors (> 4 cm) and the presence of lymph node metastasis correlate with a high local recurrence rate. For these tumors adjuvant radiation and/or adjuvant chemotherapy may be recommended after surgical therapy. Adjuvant therapy however, should preferably be considered for uterine stromal sarcomas and mixed mesodermal tumors. The toxicity of radiation and/or chemotherapy is greater than any possible benefit for patients with leiomysarcomas as these tumors rarely respond to radiation or chemotherapy. For advanced (> stage I and II) and recurrent disease, curative therapy options are not available and palliative therapy for these patients has to take into consideration the negative side effects and weigh up quality of life against an often very limited possible benefit of such therapy.

Endometrial cancer is usually diagnosed at an early stage where surgery alone is the adequate therapy. Chemotherapy and hormonal treatment are therefore almost exclusively performed in palliative situations. Hormonal treatment with progestogens (medroxyprogesterone acetate and megestrol acetate) should be the therapy of choice primarily as these drugs are very well tolerated. Tamoxifen and GnRH analogs are further options but are seldom used. The response rates to hormonal treatment are relatively low (max. 25 %) with short remissions in most cases. - So far neither hormonal treatment nor cytotoxic chemotherapy has been shown to have substantial benefits in the adjuvant setting. In some selected high risk cases (serous papillary carcinomas, extra uterine manifestation) adjuvant chemotherapy may be an option following surgery, before or after radiotherapy. Age, general condition and morbidity of the patients need to be considered as limiting factors for chemotherapy. Crucial for the prognosis of all endometrial cancer patients however, is the stage adapted surgery. - Cytotoxic chemotherapy has failed to bring a break through in the therapy of advanced endometrial cancer. Cisplatin plus doxorubicin is the standard combination to date, with anthracyclines being the more important component. In a mono-therapy setting, doxorubicin and epirubicin are well tolerated and convenient in their efficacy. For recurrent and metastatic disease, docetaxel is being evaluated for efficacy and side effects in a multicenter phase II trial.