Two potential sources of error in the measurement of residual urine volumes in women were quantif... more Two potential sources of error in the measurement of residual urine volumes in women were quantified. These were (i) whether a diuresis is operating at the time of measurement, and (ii) the time between voiding and residual urine volume collection. A regime is suggested for the accurate measurement of residual urine in women by urethral catheterisation.
9-77 (5 20) and 5 57 (4 05) (t=2-18; p<005). A significant inverse correlation was found between ... more 9-77 (5 20) and 5 57 (4 05) (t=2-18; p<005). A significant inverse correlation was found between the amount of tobacco used daily and the number of years preceding the onset of proteinuria in the uraemic patients (n=18; r=0 47; p<005) and controls (n=7; r=0-82; p<0-01). In the control group smokers more often than non-smokers had renal lesions (table). Comment In our series the proportion of tobacco users was not the only difference between the uraemic and control groups. The lifetime consumption of tobacco was significantly less in the controls than in the uraemic group and smoking as well as ex-smoking controls presented more signs of renal disorder than did controls who had never smoked. Smokers, whether controls or uraemic subjects, had an earlier onset of proteinuria (especially those with a large daily consumption of tobacco) than non-smokers. The duration of diabetes appeared to be of minor importance for the development of end stage diabetic nephropathy. Several factors seem to be responsible for the evolution of diabetic angiopathy and our findings suggest that one of the most important is smoking. Tobacco use in diabetics has been proposed as a trigger for progression from background to proliferative retinopathy and also from incipient to overt nephropathy.'I3 Our study supports this.
BJOG: An International Journal of Obstetrics & Gynaecology, 2019
Microbial colonisation and infection are an important cause of mesh complications and require the... more Microbial colonisation and infection are an important cause of mesh complications and require the treating surgical team to consider a range of interventions including antimicrobial strategies. There
Interstitial cystitis is rarely considered as a cause of urinary symptoms in referrals to gynaeco... more Interstitial cystitis is rarely considered as a cause of urinary symptoms in referrals to gynaecology clinics. Recent concepts in the diagnosis of this condition mean that it is emerging as a much more common entity, with both early and late forms of the disease being described. Mast cell density in the detrusor muscle has been reported to be useful as a disease marker to substantiate the diagnosis of interstitial cystitis where no classical diagnostic features exist. We assessed mast cell counts in bladder biopsies from 27 women with idiopathic sensory urgency and 10 control patients about to undergo a colposuspension procedure for pure genuine stress incontinence; 30% of the study group had a clear increase in the detrusor muscle mast cell population (detrusor mastocytosis). No control patient showed such an increase. Early interstitial cystitis should be considered as a possible cause of lower urinary tract symptoms in patients with apparently idiopathic sensory urgency.
In one of the numerous documents I have received on the NHS white paper for England I read the fo... more In one of the numerous documents I have received on the NHS white paper for England I read the following: “Clinical governance encompasses all the processes needed to achieve the highest quality clinical practice possible within available resources.” The last subordinate clause of that sentence is a killer and holds within it the reason this initiative may well be stillborn. In order to achieve the “highest quality of clinical practice” I need certain things. I need good quality information. l want this from a source I trust and respect. It should be easy to assimilate and have realistic goals. It also needs to address a commonly encountered clinical scenario. Local sources are best, preferably from someone occupying a similar post in a similar hospital to my own. I will look with the utmost cynicism on poorly written reports or recommendations handed down from ivory towers concerning diseases I hardly knew existed. Does anyone know whether this good quality information exists? In o...
About 20 years ago, many gynaecologists began to express disquiet about the long-term success of ... more About 20 years ago, many gynaecologists began to express disquiet about the long-term success of the conventional vaginal procedures performed for pelvic organ prolapse (POP), particularly for the long-term cure of cystocele. As dissatisfaction took hold towards the end of the 1990s, publications appeared that seemed to confirm what now seems set as a dogmatic assertion: all conventional vaginal surgeries for the correction of prolapse have unacceptably high failure rates. At the same time, evidence from general surgery began to accumulate, indicating that hernia repairs could be made more durable by using artificial polypropylene mesh. That observation stimulated a new insight in gynaecologists: maybe a prolapse was just like a hernia. By this time, the evidence appeared overwhelming that new procedures were required to replace the seemingly dated and unsatisfactory vaginal repairs – and the key to increased durability would be polypropylene mesh. Initially different types of mesh ...
We examined bladder biopsies from women with interstitial cystitis/chronic pelvic pain syndrome (... more We examined bladder biopsies from women with interstitial cystitis/chronic pelvic pain syndrome (IC/CPPS) for the presence of bacterial and viral DNA sequences using polymerase chain reaction. Bladder biopsies were taken during cystoscopy from patients under investigation for IC/CPPS, or controls undergoing colposuspension for stress incontinence. Biopsies were snap frozen to -70C. After DNA extraction, polymerase chain reaction (PCR) using specific primers for the hypoxanthine-guanine phosphoribosyl transferase gene confirmed the presence of human DNA. PCR for bacterial and viral gene sequences was performed using specific primers. Positive reactions were repeated to confirm the signal. A total of 92 patients with IC/CPPS (12 who met the National Institute of Diabetes and Digestive and Kidney Diseases criteria and 80 who did not) and 91 controls were recruited. PCR for hypoxanthine-guanine phosphoribosyl transferase gene was positive in all samples. PCR for the 16S ribosomal RNA gene, as well as for adenovirus, cytomegalovirus, herpes simplex virus types I and II, human papillomavirus (all subtypes) and Chlamydia trachomatis were negative in all samples. IC/CPPS is not associated with persistence of viral and bacterial DNA in the bladder. A chronic infective etiology for the condition is excluded by these findings.
The sensory aspects of bladder function are not clearly defined, are poorly understood and imperf... more The sensory aspects of bladder function are not clearly defined, are poorly understood and imperfectly managed. Sensory urgency or bladder hypersensitivity often present with symptoms without an obvious cause (idiopathic sensory urgency). This article reviews the evidence that some of these symptomatic patients are actually suffering from early interstitial cystitis. The implications of such a possibility are discussed and the possible role of detrusor mast-cell infiltration in the genesis of bladder symptoms in women is examined.
The pattern of bladder filling in response to a 1-litre fluid load was assessed in 20 women with ... more The pattern of bladder filling in response to a 1-litre fluid load was assessed in 20 women with urinary incontinence. The period between 60 and 120 min after the fluid load was identified as best for pad testing because of consistently high bladder volumes and filling rates. A 2-h pad test is recommended as achieving effective and reproducible test conditions for the quantification of urine loss.
To compare the safety and efficacy of the transobturator tape (Monarc®) with the retropubic tape ... more To compare the safety and efficacy of the transobturator tape (Monarc®) with the retropubic tape (tension-free vaginal tape, TVT®) for the treatment of urodynamic stress incontinence (USI) a prospective, single-blinded, multi-centre randomised clinical controlled trial was undertaken in four urogynaecology units in Australia. One hundred and eightyseven women with USI were randomly allocated to undergo surgery with either the Monarc sling (n=80) or TVT (n=107). Outcome measures were intra-operative complications (especially bladder injury), as well as peri-operative complications, symptomatology, quality of life and urodynamic outcomes. At 3 months, data were available on 140 women, 82 (59%) TVT and 58 (42%) Monarc. The TVT group was significantly more likely to be complicated by bladder injury (7 TVT, 0 Monarc, p<0.05). Blood loss and operative time were significantly less in the Monarc group, which was 49 mls (31) vs that of the TVT group, which was 64 mls (41) p< 0.05; 18.5 min (6.5) TVT vs 14.6 min (6) Monarc (p<0.001). The subjective and objective stress incontinence cure rates were 86.6% (71) vs 72.4% (42) p=0.77 and 79.3 vs 84.5%, p=0.51 for the TVT and Monarc groups, respectively. Both groups reported similar improvement in incontinence impact and satisfaction with their operation, although return to activity was significantly quicker with the transobturator route
International Urogynecology Journal and Pelvic Floor Dysfunction, 1999
Two hundred and fifty consecutive women referred because of symptoms of lower urinary tract dysfu... more Two hundred and fifty consecutive women referred because of symptoms of lower urinary tract dysfunction underwent a full clinical and urodynamic assessment. Their urine flow rates and residual urine volumes were analyzed. The urine flow rates of the urogynecology patients were found to be significantly less than those of an asymptomatic population. There were significant declines in urine flow rates in the presence of a previous hysterectomy and with increasing grades of prolapse, particularly uterine prolapse, cystocele and enterocele. Unlike the normal female population, there was also deterioration with increasing parity and age, the latter largely due to the increasing incidence of hysterectomy and prolapse with age. The 10th centile of the Liverpool Nomogram for the maximum urine flow rate was found to be the most useful discriminant for a final urodynamic diagnosis of voiding difficulties. Most urogynecology patients have no or small residual urine volumes, 74% &lt;10 ml and 81% &lt;30 ml (vs 95% &lt;30 ml in asymptomatic women). In urogynecology patients residuals were larger where there had been a prior hysterectomy or with grade 2 or higher uterine prolapse, cystocele and enterocele. Mean residual was 14.8 ml (vs 4.8 ml in asymptomatic women). These data indicate a higher incidence of voiding difficulties (abnormally slow urine flow (under 10th centile) and/or abnormally high residual urine volume (over 30 ml) in urogynecology patients, particularly those with higher grades of prolapse and with prior hysterectomy.
The effectiveness of different types of urinary catheters in completely draining the bladder has ... more The effectiveness of different types of urinary catheters in completely draining the bladder has not been tested. Transvaginal ultrasound, which is able to measure bladder volumes in women from 2 to 175 ml, provides a means of measuring any fluid volume remaining in the bladder following catheter drainage. Using transvaginal ultrasound, the post-catheterisation bladder volumes were measured in 26 female patients; 14 underwent urethral catheterisation using either a 14F short plastic female catheter or a Foley catheter of the same size (balloon not inflated); 12 had an indwelling 12F suprapublic catheter following bladder neck surgery. The mean post-catheterisation bladder volumes after using the short plastic female and Foley catheters were less than 1 ml and 77 ml respectively. A short plastic catheter should be used in women to collect the residual urine volume by urethral catheterisation. A Foley catheter is relatively ineffective in this task. A 12F suprapubic catheter was found to drain the bladder relatively well. The mean post-catheterisation bladder volume was 35 ml. Prior to removing a suprapubic catheter post-operatively, it is recommended that the residual urine volume (measured using the suprapubic catheter) be checked by measuring the post-catheterisation bladder volume (using either a short plastic catheter or transvaginal ultrasound).
The case histories of 494 women referred to a urodynamic clinic with the symptom of stress incont... more The case histories of 494 women referred to a urodynamic clinic with the symptom of stress incontinence were studied. None had undergone previous incontinence surgery. In only 12 patients was stress incontinence the sole symptom. In the remainder, symptoms suggestive of detrusor instability were present in 417, of a voiding disorder in 261 and of an inflammatory disorder in 166. The sign of stress incontinence was present in only 168 patients and was not a reliable guide to the diagnosis of genuine stress incontinence. Urodynamic studies were necessary in 488 patients in order to obtain an accurate diagnosis.
Two potential sources of error in the measurement of residual urine volumes in women were quantif... more Two potential sources of error in the measurement of residual urine volumes in women were quantified. These were (i) whether a diuresis is operating at the time of measurement, and (ii) the time between voiding and residual urine volume collection. A regime is suggested for the accurate measurement of residual urine in women by urethral catheterisation.
9-77 (5 20) and 5 57 (4 05) (t=2-18; p<005). A significant inverse correlation was found between ... more 9-77 (5 20) and 5 57 (4 05) (t=2-18; p<005). A significant inverse correlation was found between the amount of tobacco used daily and the number of years preceding the onset of proteinuria in the uraemic patients (n=18; r=0 47; p<005) and controls (n=7; r=0-82; p<0-01). In the control group smokers more often than non-smokers had renal lesions (table). Comment In our series the proportion of tobacco users was not the only difference between the uraemic and control groups. The lifetime consumption of tobacco was significantly less in the controls than in the uraemic group and smoking as well as ex-smoking controls presented more signs of renal disorder than did controls who had never smoked. Smokers, whether controls or uraemic subjects, had an earlier onset of proteinuria (especially those with a large daily consumption of tobacco) than non-smokers. The duration of diabetes appeared to be of minor importance for the development of end stage diabetic nephropathy. Several factors seem to be responsible for the evolution of diabetic angiopathy and our findings suggest that one of the most important is smoking. Tobacco use in diabetics has been proposed as a trigger for progression from background to proliferative retinopathy and also from incipient to overt nephropathy.'I3 Our study supports this.
BJOG: An International Journal of Obstetrics & Gynaecology, 2019
Microbial colonisation and infection are an important cause of mesh complications and require the... more Microbial colonisation and infection are an important cause of mesh complications and require the treating surgical team to consider a range of interventions including antimicrobial strategies. There
Interstitial cystitis is rarely considered as a cause of urinary symptoms in referrals to gynaeco... more Interstitial cystitis is rarely considered as a cause of urinary symptoms in referrals to gynaecology clinics. Recent concepts in the diagnosis of this condition mean that it is emerging as a much more common entity, with both early and late forms of the disease being described. Mast cell density in the detrusor muscle has been reported to be useful as a disease marker to substantiate the diagnosis of interstitial cystitis where no classical diagnostic features exist. We assessed mast cell counts in bladder biopsies from 27 women with idiopathic sensory urgency and 10 control patients about to undergo a colposuspension procedure for pure genuine stress incontinence; 30% of the study group had a clear increase in the detrusor muscle mast cell population (detrusor mastocytosis). No control patient showed such an increase. Early interstitial cystitis should be considered as a possible cause of lower urinary tract symptoms in patients with apparently idiopathic sensory urgency.
In one of the numerous documents I have received on the NHS white paper for England I read the fo... more In one of the numerous documents I have received on the NHS white paper for England I read the following: “Clinical governance encompasses all the processes needed to achieve the highest quality clinical practice possible within available resources.” The last subordinate clause of that sentence is a killer and holds within it the reason this initiative may well be stillborn. In order to achieve the “highest quality of clinical practice” I need certain things. I need good quality information. l want this from a source I trust and respect. It should be easy to assimilate and have realistic goals. It also needs to address a commonly encountered clinical scenario. Local sources are best, preferably from someone occupying a similar post in a similar hospital to my own. I will look with the utmost cynicism on poorly written reports or recommendations handed down from ivory towers concerning diseases I hardly knew existed. Does anyone know whether this good quality information exists? In o...
About 20 years ago, many gynaecologists began to express disquiet about the long-term success of ... more About 20 years ago, many gynaecologists began to express disquiet about the long-term success of the conventional vaginal procedures performed for pelvic organ prolapse (POP), particularly for the long-term cure of cystocele. As dissatisfaction took hold towards the end of the 1990s, publications appeared that seemed to confirm what now seems set as a dogmatic assertion: all conventional vaginal surgeries for the correction of prolapse have unacceptably high failure rates. At the same time, evidence from general surgery began to accumulate, indicating that hernia repairs could be made more durable by using artificial polypropylene mesh. That observation stimulated a new insight in gynaecologists: maybe a prolapse was just like a hernia. By this time, the evidence appeared overwhelming that new procedures were required to replace the seemingly dated and unsatisfactory vaginal repairs – and the key to increased durability would be polypropylene mesh. Initially different types of mesh ...
We examined bladder biopsies from women with interstitial cystitis/chronic pelvic pain syndrome (... more We examined bladder biopsies from women with interstitial cystitis/chronic pelvic pain syndrome (IC/CPPS) for the presence of bacterial and viral DNA sequences using polymerase chain reaction. Bladder biopsies were taken during cystoscopy from patients under investigation for IC/CPPS, or controls undergoing colposuspension for stress incontinence. Biopsies were snap frozen to -70C. After DNA extraction, polymerase chain reaction (PCR) using specific primers for the hypoxanthine-guanine phosphoribosyl transferase gene confirmed the presence of human DNA. PCR for bacterial and viral gene sequences was performed using specific primers. Positive reactions were repeated to confirm the signal. A total of 92 patients with IC/CPPS (12 who met the National Institute of Diabetes and Digestive and Kidney Diseases criteria and 80 who did not) and 91 controls were recruited. PCR for hypoxanthine-guanine phosphoribosyl transferase gene was positive in all samples. PCR for the 16S ribosomal RNA gene, as well as for adenovirus, cytomegalovirus, herpes simplex virus types I and II, human papillomavirus (all subtypes) and Chlamydia trachomatis were negative in all samples. IC/CPPS is not associated with persistence of viral and bacterial DNA in the bladder. A chronic infective etiology for the condition is excluded by these findings.
The sensory aspects of bladder function are not clearly defined, are poorly understood and imperf... more The sensory aspects of bladder function are not clearly defined, are poorly understood and imperfectly managed. Sensory urgency or bladder hypersensitivity often present with symptoms without an obvious cause (idiopathic sensory urgency). This article reviews the evidence that some of these symptomatic patients are actually suffering from early interstitial cystitis. The implications of such a possibility are discussed and the possible role of detrusor mast-cell infiltration in the genesis of bladder symptoms in women is examined.
The pattern of bladder filling in response to a 1-litre fluid load was assessed in 20 women with ... more The pattern of bladder filling in response to a 1-litre fluid load was assessed in 20 women with urinary incontinence. The period between 60 and 120 min after the fluid load was identified as best for pad testing because of consistently high bladder volumes and filling rates. A 2-h pad test is recommended as achieving effective and reproducible test conditions for the quantification of urine loss.
To compare the safety and efficacy of the transobturator tape (Monarc®) with the retropubic tape ... more To compare the safety and efficacy of the transobturator tape (Monarc®) with the retropubic tape (tension-free vaginal tape, TVT®) for the treatment of urodynamic stress incontinence (USI) a prospective, single-blinded, multi-centre randomised clinical controlled trial was undertaken in four urogynaecology units in Australia. One hundred and eightyseven women with USI were randomly allocated to undergo surgery with either the Monarc sling (n=80) or TVT (n=107). Outcome measures were intra-operative complications (especially bladder injury), as well as peri-operative complications, symptomatology, quality of life and urodynamic outcomes. At 3 months, data were available on 140 women, 82 (59%) TVT and 58 (42%) Monarc. The TVT group was significantly more likely to be complicated by bladder injury (7 TVT, 0 Monarc, p<0.05). Blood loss and operative time were significantly less in the Monarc group, which was 49 mls (31) vs that of the TVT group, which was 64 mls (41) p< 0.05; 18.5 min (6.5) TVT vs 14.6 min (6) Monarc (p<0.001). The subjective and objective stress incontinence cure rates were 86.6% (71) vs 72.4% (42) p=0.77 and 79.3 vs 84.5%, p=0.51 for the TVT and Monarc groups, respectively. Both groups reported similar improvement in incontinence impact and satisfaction with their operation, although return to activity was significantly quicker with the transobturator route
International Urogynecology Journal and Pelvic Floor Dysfunction, 1999
Two hundred and fifty consecutive women referred because of symptoms of lower urinary tract dysfu... more Two hundred and fifty consecutive women referred because of symptoms of lower urinary tract dysfunction underwent a full clinical and urodynamic assessment. Their urine flow rates and residual urine volumes were analyzed. The urine flow rates of the urogynecology patients were found to be significantly less than those of an asymptomatic population. There were significant declines in urine flow rates in the presence of a previous hysterectomy and with increasing grades of prolapse, particularly uterine prolapse, cystocele and enterocele. Unlike the normal female population, there was also deterioration with increasing parity and age, the latter largely due to the increasing incidence of hysterectomy and prolapse with age. The 10th centile of the Liverpool Nomogram for the maximum urine flow rate was found to be the most useful discriminant for a final urodynamic diagnosis of voiding difficulties. Most urogynecology patients have no or small residual urine volumes, 74% &lt;10 ml and 81% &lt;30 ml (vs 95% &lt;30 ml in asymptomatic women). In urogynecology patients residuals were larger where there had been a prior hysterectomy or with grade 2 or higher uterine prolapse, cystocele and enterocele. Mean residual was 14.8 ml (vs 4.8 ml in asymptomatic women). These data indicate a higher incidence of voiding difficulties (abnormally slow urine flow (under 10th centile) and/or abnormally high residual urine volume (over 30 ml) in urogynecology patients, particularly those with higher grades of prolapse and with prior hysterectomy.
The effectiveness of different types of urinary catheters in completely draining the bladder has ... more The effectiveness of different types of urinary catheters in completely draining the bladder has not been tested. Transvaginal ultrasound, which is able to measure bladder volumes in women from 2 to 175 ml, provides a means of measuring any fluid volume remaining in the bladder following catheter drainage. Using transvaginal ultrasound, the post-catheterisation bladder volumes were measured in 26 female patients; 14 underwent urethral catheterisation using either a 14F short plastic female catheter or a Foley catheter of the same size (balloon not inflated); 12 had an indwelling 12F suprapublic catheter following bladder neck surgery. The mean post-catheterisation bladder volumes after using the short plastic female and Foley catheters were less than 1 ml and 77 ml respectively. A short plastic catheter should be used in women to collect the residual urine volume by urethral catheterisation. A Foley catheter is relatively ineffective in this task. A 12F suprapubic catheter was found to drain the bladder relatively well. The mean post-catheterisation bladder volume was 35 ml. Prior to removing a suprapubic catheter post-operatively, it is recommended that the residual urine volume (measured using the suprapubic catheter) be checked by measuring the post-catheterisation bladder volume (using either a short plastic catheter or transvaginal ultrasound).
The case histories of 494 women referred to a urodynamic clinic with the symptom of stress incont... more The case histories of 494 women referred to a urodynamic clinic with the symptom of stress incontinence were studied. None had undergone previous incontinence surgery. In only 12 patients was stress incontinence the sole symptom. In the remainder, symptoms suggestive of detrusor instability were present in 417, of a voiding disorder in 261 and of an inflammatory disorder in 166. The sign of stress incontinence was present in only 168 patients and was not a reliable guide to the diagnosis of genuine stress incontinence. Urodynamic studies were necessary in 488 patients in order to obtain an accurate diagnosis.
Uploads
Papers by Malcolm Frazer