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New findings What is the central question of this study? Given that the bladder in 60% of patients with detrusor overactivity exhibits increased atropine-resistant contractile responses to nerve stimulation and that high intravesicular pressure is associated with episodes of hypoxia-glucopenia and reperfusion, we asked whether cycles of hypoxia-glucopenia and reoxygenation increases purinergic signalling in the rat bladder in vitro., What is the main finding and its importance? Four cycles of hypoxia-glucopenia and reoxygenation augmented atropine-resistant contractile responses of rat detrusor muscle strips subjected to electrical field stimulation via increased purinoceptor P2X1 expression and ATP release. Purinergic antagonists blocked this augmentation, suggesting a possible therapeutic role for purinergic antagonists in the treatment of detrusor overactivity., Bladders from patients with detrusor overactivity have an increased atropine-resistant contractile response to nerve stimulation. The bladder has also been shown to be very susceptible to hypoxia-glucopenia and reperfusion injury, leading to the hypothesis that episodes of hypoxia-glucopenia and reoxygenation result in increased atropine-resistant responses to nerve stimulation in the detrusor muscle. Detrusor muscle strips were suspended in a Perspex organ bath chamber of volume 0.2 ml perfused with Krebs solution at 37°C aerated with 21% O2, 5% CO2 and the balance nitrogen. Hypoxia-glucopenia was induced by switching perfusion to Krebs solution without glucose, gassed with 95% nitrogen and 5% CO2. Atropine-resistant contractile responses increased by 40.5 ± 7.3% after four cycles of hypoxia-glucopenia (10 min) and reoxygenation (1 h), whereas α,β-methylene ATP-resistant responses did not increase. Expression of P2X1 receptors in the bladder was increased after hypoxia-glucopenia and reoxygenation cycling, and ATP release from stimulated bladder strips during cycling was also increased. Other P2X receptor-mediated mechanisms may also be involved in the augmentation of bladder contraction during hypoxia-glucopenia and reoxygenation cycling, because a non-specific P2X antagonist blocked most of the augmented response, whereas a P2X1-specific antagonist prevented only part of the augmentation of contractile response induced by hypoxia-glucopenia and reoxygenation. In conclusion, four cycles of hypoxia-glucopenia and reoxygenation increased the purinergic, but not the cholinergic, contractile responses to nerve stimulation. Increased P2X1 receptor expression and ATP release may have contributed to the augmentation of contractile response induced by hypoxia-glucopenia and reoxygenation. Purinergic antagonists may, therefore, be a useful therapeutic option for the treatment of overactive bladder with increased purinergic-mediated contractions. [ABSTRACT FROM AUTHOR]

In a multicentre randomised, unblinded patient preference pilot trial to assess the feasibility of a definitive randomised trial comparing colposuspension with tension-free vaginal tape (TVT) plus anterior repair in women with incontinence and prolapse, we found that 31 of 56 eligible women agreed to participate (55%). Recruitment was more successful face to face (87%) than by letter (16%). Only four of our women agreed to be randomised, 21 (68%) chose anterior repair + TVT and six (19%) chose colposuspension. This study demonstrates the importance of pilot work for complex trials to identify issues likely to adversely affect recruitment. [ABSTRACT FROM AUTHOR]

The aim of this study was to establish how accurately a trained continence nurse could allocate appropriate second-line conservative treatment to women without urodynamic investigations. Depending on the number of patients coming taking up the service, there were between five and 12 nurses operating at any one time. Women aged 40 years and over, of which there were 2421 reporting lower urinary tract symptoms, were randomly allocated to a new nurse-led continence service. Of these women, 450 subsequently underwent urodynamic investigation, before which the nurses documented which second-line conservative treatment would be appropriate. The results showed that of all women with detrusor overactivity, 79.1% were correctly allocated anticholinergic treatment, and 64.8% were allocated pelvic floor exercises (PFE). Of all women with urodynamic stress incontinence, 88.8% were correctly allocated PFE, and 43.4% were allocated anticholinergic therapy. Of all women with mixed incontinence, 44.8% were correctly allocated both PFE and anticholinergic therapy, while 52.1% were allocated only one treatment. This study showed that a trained continence nurse is able to allocate conservative treatment appropriately the majority of women without the need for urodynamic investigation. This indicated that the management of urinary dysfunction by a team of trained, dedicated nurses has the potential to reduce waiting lists for urodynamic investigation, avoid unnecessary investigations and achieve greater patient satisfaction. [ABSTRACT FROM AUTHOR]

This article discusses various issues related to glass injury to the perineum, and presents a case study in this regard. A 35-year-old woman presented as an emergency complaining of persistent perineal pain and swelling. The original injury had occurred after the patient had fallen through a glass table at a dinner party. Inspection of the injury revealed a 2-cm laceration overlying the right ischiorectal fossa and palpation demonstrated exquisite tenderness medial to this area, together with the presence of a foreign body palpable within the ischiorectal fossa. The case highlights the need to remain aware of the appropriate investigations for rare injuries.

A 10 point questionnaire was given to 239 women attending for second trimester fetal abnormality ultrasound scans to explore their level of knowledge about the nature, purpose and limitations of the procedure. Questions were included about the conditions which could or could not be diagnosed, and about the accuracy and sensitivity of the procedure. Demographic data was also recorded. Two hundred and thirty-five forms were correctly completed. The percentage of women returning correct answers ranged from 58.8% to 100% and response rate was correlated with years of full time education in some questions. The results suggest that patients perceive the scan as a chance to see their baby and that many do not fully appreciate either the purpose or the limitations of fetal anomaly scanning. This may complicate the post-test counselling required if an abnormality is detected. [ABSTRACT FROM AUTHOR]

Objective: To assess construct validity of the Patient Global Impression scales (Severity [PGI-S], Bother [PGI-B] and Improvement [PGI-I]) for symptoms of detrusor overactivity (DO)., Design: Secondary analysis of a randomised trial of onabotulinum toxin A., Setting: Eight UK urogynaecology departments., Population: A total of 240 women with DO refractory to medical treatment randomised to receive 200 iu onabotulinum toxin A or placebo in the RELAX trial and followed up for 6 months., Main Outcome Measures: Urinary diaries and disease-specific quality of life (QoL) questionnaires were completed at baseline and during follow up. Discriminatory ability of the PGI-S, PGI-B and PGI-I scales to identify symptom severity and change in severity was assessed by comparing mean diary and QoL outcomes across the response categories, analysed by one-way analysis of variance., Results: Data were available from 237 women (98.8%) for validation of PGI-S and PGI-B at baseline, and 192 women (80%) at 6 weeks follow up for validation of PGI-I. Leakage episodes (P = 0.01), urgency episodes (P = 0.019), urgency severity (P = 0.012), and QoL scores (all P < 0.001) were greater in women with more severe problems on PGI-S. Similar results were seen for PGI-B: leakage (P = 0.051), urgency episodes (P < 0.001), urgency severity (P < 0.001), and QoL scores (all P < 0.001). PGI-I responses demonstrated significant relationships with size of change of all variables (P < 0.001). The generic instrument EQ-5D had weaker relationships (PGI-S, P = 0.09; PGI-B, P = 0.004; PGI-I, P = 0.06), suggesting that it was less sensitive., Conclusions: The PGI scales are robust and valid instruments to assess disease severity, bother and improvement after treatment in women with detrusor overactivity., (© 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.)

Objective: To report the numbers of patients having childbirth after pelvic floor surgery in England., Design: Retrospective analysis of Hospital Episode Statistics data., Setting: Hospital Episode Statistics database., Population: Women, aged 20-44 years, undergoing childbirth after pelvic floor surgery between the years 2002 and 2008., Methods: Analysis of the Hospital Episode Statistics database using Office of Population, Censuses and Surveys: Classification of Interventions and Procedures, 4th Revision (OPCS-4) code at the four-character level for pelvic floor surgery and delivery, in women aged 20-44 years, between the years 2002 and 2008., Main Outcome Measures: Numbers of women having delivery episodes after previous pelvic floor surgery, and numbers having further pelvic floor surgery after delivery., Results: Six hundred and three women had a delivery episode after previous pelvic floor surgery in the time period 2002-2008. In this group of 603 women, 42 had a further pelvic floor surgery episode following delivery in the same time period. The incidence of repeat surgery episode following delivery was higher in the group delivered vaginally than in those delivered by caesarean (13.6 versus 4.4%; odds ratio, 3.38; 95% confidence interval, 1.87-6.10)., Conclusions: There were 603 women having childbirth after pelvic floor surgery in the time period 2002-2008. The incidence of further pelvic floor surgery after childbirth was lower after caesarean delivery than after vaginal delivery, and this may indicate a protective effect of abdominal delivery., (© 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.)

Seven episiotomy incisions are described in the literature, although only midline, mediolateral or lateral episiotomies are commonly used. Recent research has demonstrated variations in both site and direction of the incision, and differences between the angle of incision at the time of crowning of the fetal head and the angle of the scar once the wound has been repaired. We review this evidence and suggest that this variation may undermine the reliability of much published work. We suggest a standardised definition of each type of episiotomy to establish uniformity going forward, so that future studies are amenable to comparison and meta-analysis., (© 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.)

Objective: To assess computerised fetal heart rate recordings between 24 and 28 weeks of gestation for gestation related differences., Design: Prospective, cross sectional observational study., Setting: Liverpool Women's Hospital., Population: 112 women: 28 at 27 weeks, 30 at 26 weeks, 27 at 25 weeks and 27 at 24 weeks of gestation, respectively., Methods: Fetal heart recordings of 60 minutes duration were performed once in each pregnancy using the System 8000 fetal heart rate programme (System 8000, Oxford Sonicaid Ltd, Chichester, UK). For each gestational age, records were analysed for short term variation, basal heart rate, accelerations and time spent in high episodes., Results: The mean short term variation increased with gestation (P = 0.05). No record had a short term variation <4 msecs. There was no relationship between heart rate and increasing gestation. The mean number of accelerations per record increased with increasing gestation (P < 0.01). 20% of recordings showed no accelerations > 15 bpm. The mean duration spent in episodes of high variation increased with gestation (P = 0.05). 13% of recordings showed no time spent in high episodes. All fetuses had normal outcomes at delivery., Conclusions: Absence of episodes of high variation or absence of accelerations is not an abnormal finding at lower gestations. The standard threshold of 4 msecs for short term variation appears to remain valid at lower gestations. These differences should be considered when using computerised CTG analysis at early gestations.

Computerised cardiotocograph analysis has been used in our medical antenatal clinic for women with insulin dependent diabetes mellitus for five years. We had observed that many of the patients failed the computer criteria and wished to examine this finding in more detail. All cardiotocographs from 40 pregnant women with insulin dependent diabetes mellitus who delivered between 1992 and 1995 were reviewed. The number of traces failing the criteria were calculated. Outcome was compared between patients with a normal trace and those with an abnormal trace. 233 recordings were examined. 30.5% of antenatal CTGs failed the criteria because of absent high episodes of variation (a parameter which is a specific marker of fetal well-being). After excluding repeat traces on all patients a sample of 26 traces was examined. 34.6% of these had failed because of absent high episodes of variation. Both these figures are significantly higher than the published normal values. There was no apparent difference in neonatal outcome between women whose trace had failed (9) and those with a normal trace (17). We suggest that the normal values of criteria used to analyse computerised CTGs may not be valid when applied to fetuses of women with diabetes mellitus.