Bladder pain syndrome and pregnancy

Bladder pain syndrome (BPS) is a poorly understood condition. In pregnancy, lower urinary tract symptoms and pain are common, but the possibility of BPS is rarely considered and almost never explored. The consequences of BPS on pregnancy and vice versa are poorly understood, and management options appear to be limited. This article reviews the current evidence to allow us to better counsel, investigate, diagnose and manage patients with suspected or known BPS who fall pregnant or who are considering pregnancy. MEDLINE, EMBASE and PubMed were searched for a combination of mesh terms of keywords: 'cystitis', 'interstitial', 'bladder', 'pain' and 'pregnancy'. Relevant articles were identified, reviewed and further relevant articles identified from the references. CONCLUSION: BPS symptoms are very common in pregnancy, with limited data suggesting significant negative effects on the woman and pregnancy. There are safe options for investigation, diagnosis and management in pregnancy. There is a need to raise awareness of the impact of BPS symptoms in pregnancy and the available options for diagnoses and management, improving patient experience and outcomes. PATIENT SUMMARY: Patients with BPS or symptoms akin to BPS need not be abandoned in pregnancy. There is data to support them in making decisions around investigation and management in pregnancy.

Feasibility study for the value of pelvic floor distension in predicting mode of birth for women undergoing Vaginal Birth After Caesarean

Indroduction & hypothesis

Women having Vaginal Birth (VB) have different soft tissue dynamics to women requiring emergency Lower Section Caesarean Section (LSCS).

Aims

To assess the role of ultrasound in the assessment of LH distensibility in predicting outcomes for women wishing for Vaginal Birth After Caesarean section (VBAC). To inform subsequent trial design including understanding womens attitudes to the use of ultrasound in prediction of vaginal birth

Methods

Nulliparous, previous VB and previous LSCS underwent a transvaginal ultrasound. This scan looked at the distensibility of the LH and then correlated with mode of birth. Analysis used logistic regression and ROC curves analysis for static measurements and distensibility. A second cohort was also asked about their views as to the usefulness of such a tool to help inform on the utility of such a model.

Results

The original hypothesis confirmed maternal BMI, Anterior Posterior (AP) diameter at rest and AP distensibility all being significant predictors of VB in nulliparous women. As expected this relationship was also seen in women who had previously had a vaginal birth. Of the VBAC group, 23 women had LSCS. Five were Robson category, 18 had emergency LSCS in labour. 25 women had VB. Whilst there were trends towards lesser distensibility in VBAC women who delivered vaginally, none of these reached sgnificance. The concept of the use of scanning to inform women as to likelihood of successful vaginal birth was supported by the survey.

Conclusion

Previously noted characteristics in nulliparous women for pelvic floor distension were confirmed. This relationship was not demonstrated for the VBAC cohort. We were unable to establish criteria for a simple ultrasound model to predict VB in women wishing for VBAC. Overall, women would welcome such model if it were available.

2D USS of the pelvic floor in the 3rd trimester versus mode of delivery

OBJECTIVE

Biomechanics of pelvic floor muscles is becoming an important field of research in understanding a complex process of labour. Current evidence indicates that the levator ani stretches to allow passage of the fetus through the birth canal. We sought to identify properties of the functional female pelvic floor during pregnancy that could help to predict the mode of delivery, especially in women who underwent caesarean section in the past.

METHODS

A single centre prospective cohort study of pregnant women in the 3rd trimester attending antenatal clinic. Participants were categorised into three groups: 1. nulliparous, 2. previous one vaginal delivery and 3. previous one caesarean section who chose a trial of labour in their current pregnancy. All women underwent ultrasonographic evaluation of their pelvic floor muscles. Distensibility and the mode of delivery were assessed in participants' current pregnancies. The primary outcome was the mode of delivery. ANOVA test was used for statistical analysis.

RESULTS

133 women were included: 55 nulliparous, 52 primiparous (previous one vaginal birth), and 26 primiparous (previous one LSCS and planned for vaginal delivery after caesarean (VBAC)). Participants were scanned at an average gestation of 32 weeks. The inter-observer reliability test for puborectalis distensibility was good (kappa 0.75). Overall, women who delivered vaginally had a more distensible puborectalis muscle than those who delivered by emergency LSCS regardless of their previous type of delivery. Women who underwent a successful VBAC had less distensible pelvic floor muscles compared to their nulliparous and primiparous counterparts (who delivered vaginally in the past).

CONCLUSION

These results support our basic conceptual theory of puborectalis muscle distensibility influencing the mode of delivery and endorse application of dynamic pelvic floor ultrasound in future studies. We identified measurable differences in the functional female pelvic anatomy aiding a better understanding of physiology of the labour. There are trends towards lesser distensibility in women who delivered by LSCS.

Indirect treatment comparison (ITC) of medical therapies for an overactive bladder

BACKGROUND

Overactive bladder syndrome (OAB) is a chronic and prevalent condition which has a negative impact on Quality of Life. The National Institute of Clinical Excellence issued two documents which give slightly varying algorithms of pharmacotherapy for OAB, offering mirabegron as a possible treatment in certain circumstances. In the absence of trials involving a direct comparison of therapies, an indirect comparison can provide useful information on the difference in treatment effects between competing interventions.

OBJECTIVE

To compare effectiveness of available medical therapies for OAB using Bucher indirect treatment comparison (ITC) model.

METHODS

A systematic literature search identified randomised controlled trials (RCT) assessing effectiveness of drugs for OAB versus placebo. Then indirect comparisons of the treatments effects were made, preserving the randomisation of the originally assigned patient groups, using Bucher method.

MAIN RESULTS

25 RCTs met inclusion criteria. In keeping with ITC method validity, four assessments were undertaken of mirabegron against anticholinergics, which were number of incontinence episodes, micturition episodes, urgency episodes in 24 h and volume of micturition. This indirect treatment analysis suggests that mirabegron is as effective as anticholinergics in managing of OAB, except for solifenacin which appears to be superior.

CONCLUSIONS

These findings suggest that work looking into treatment choice should be individualized to patient characteristics rather than fitting patients to a treatment. Further work is required to identify what patient characteristics may be crucial and indicate that studies exploring the most effective sequence of managing treatment naïve patients and those with refractory disease.