Reviews in Gynaecological Practice最新文献

Chronic pelvic pain (CPP) is a common problem with a prevalence of about 38/1000 among women aged 20–50 years. The main gynaecological diagnoses include endometriosis, pelvic inflammatory disease and adhesions. The most common gastrointestinal diagnosis is irritable bowel syndrome and genitourinary diagnosis includes pathology such as interstitial cystitis. It is a challenge instigating the right investigations for patients with chronic pelvic pain because there is a considerable symptom overlap. They also have a higher prevalence for symptoms such as dysmenorrhea and dyspareunia. In this review, we aim to discuss the clinical consultation necessary to help us decide upon which investigative tools we need to use to help diagnose the cause(s) of CPP, although one needs to stress that a specific cause may not be found in patients with CPP and symptom focused multidisciplinary management of CPP is at least as important as diagnosis of specific pathology and disease focused treatment.

Burch colposuspension remains the most effective surgical procedure for stress urinary incontinence with a continence rate, which shows better longevity than other methods of treatment. Sling procedures have a comparable continence rate to colposuspension and there appears to be little reduction in continence over time. It is expected that the tension-free vaginal tape will eventually supersede the open Burch colposuspension as the preferred method of primary incontinence surgery principally because it is a minimal-access procedure and medium-term data suggest similar effectiveness to colposuspension. Initial reports on the trans-obturator tape, which minimises bladder and vascular trauma, are encouraging but longer term results remain uncertain. Although the injectable agents have a lower success rate than other procedures, they may still have a role when other procedures have failed due to their low morbidity. Anterior colporrhaphy and needle suspension procedures should no longer be offered as treatments for stress urinary incontinence.

The surgical options for detrusor activity should be considered when pharmacological options have been exhausted. Appropriate patient selection is crucial when choosing which surgical option would be most suitable, especially as many of these procedures carry with them a significant risk of morbidity. Some surgical options are becoming less invasive and modern developments, such as intravesical botulinum toxin injection may in future become a first line treatment option for detrusor overactivity.

Malignant ovarian germ cell tumours (OGCT) comprise only 2–5% of all ovarian cancers but are significantly different to epithelial ovarian cancers. They affect women of child bearing age and are much more curable than their epithelial counterparts. In addition, the majority of patients will retain their fertility after multimodal treatment. The small numbers of patients mean that randomised controlled trials of chemotherapy, the gold standard test of treatment effectiveness in other malignancies, have proved impossible to perform. The different types of OGCT have variable degrees of chemosensitivity and differing prognoses. Treatment outcomes are also dependent on the stage of disease at diagnosis. In this article, dysgerminomas and non-dysgerminomas are analyzed separately, as there are notable differences in their behaviour and outcomes. It is difficult to think of many diseases in which prognosis has improved as greatly as ovarian germ cell tumours and this is due to modern combination chemotherapy. Like the treatment of testicular cancer, this represents one of the successes of modern medicine.

The overactive bladder syndrome is a relatively new-term defined by the International Continence Society in 2002. Previous definitions were based on urodynamic diagnoses; however, the overactive bladder syndrome is a symptomatic diagnosis with urgency as the cornerstone symptom, thus allowing treatment to be initiated by primary care physicians before embarking on complex investigations. It affects millions of people worldwide and has considerable economic costs. Its aetiology is unknown but some people suggest that it may be a nerve-related problem while others suggest that it may be a muscle-related problem. The true cause probably lies somewhere between the two theories. With this in mind, treatment is aimed at relief of symptoms and improving quality of life. Conservative treatments combined with antimuscarinic drugs are the main treatment for overactive bladders. There are many antimuscarinics available, with several under development, which have different specificities for the muscarinic receptors. Other drugs have also been tried but with limited success.

If conservative and oral medical treatments fail, the options include intravesical therapy, neuromodulation or major surgery. However, urodynamics are essential for patients referred for these treatments, which are mainly initiated by specialists rather than primary care physicians. The aim of this review is to give an overview of the overactive bladder and detrusor overactivity, their diagnosis and treatment options.

The impact of common congenital anomalies of the female genital tract is hugely variable. Some anomalies are asymptomatic chance findings requiring no intervention. Others have a major impact on the potential for sexual activity and fertility. A good knowledge of basic embryology is important to understand the pathogenesis and clinical features of these anomalies. All gynaecologists should be aware of these conditions and possible clinical presentations. Whilst some conditions, such as imperforate hymen require a simple surgical intervention, other more complex anomalies need careful assessment and accurate pre-operative assessment to optimise the long-term outcomes. The contribution of uterine anomalies to subfertility is poorly understood and the role of uterine surgery needs further research.

Locally advanced cancer of the uterine cervix covers a broad disease spectrum comprising primary tumours of >4 cm in size or FIGO stage >IIA and all local tumour relapses except the rare cases of small recurrences in a retained cervix. Treatment designs have to consider the probability of pelvic and periaortic lymph node metastases and – albeit less frequent in primary disease – distant metastases.

Established treatment standards aiming to achieve pelvic and eventually periaortic tumour control are chemoradiation for locally advanced primary disease as well as post-surgical pelvic recurrences, and pelvic exenteration for post-radiation central relapses. A subset of patients with pelvic side wall relapses can now be successfully treated by laterally extended endopelvic resection as well. Based on the current results it is not evident whether neoadjuvant chemotherapy, radical hysterectomy and eventually adjuvant radiation are comparable or superior treatment alternatives for locally advanced intermediate stage cases. Likewise, the benefit of (laparoscopic) surgical staging including the exstirpation of bulky pelvic and periaortic lymph nodes has not been convincingly demonstrated to date. Both surgical treatment concepts need further well-designed prospective randomized trials for their evaluation. From the surgeon's perspective total mesometrial resection, therapeutic lymph node dissection, laterally extended endopelvic resection and new developments in restoration/substitution of pelvic functions have the potential to improve the therapeutic index for defined cohorts of patients suffering from locally advanced cancer of the uterine cervix.

The standard form of surgical intervention in advanced ovarian cancer is to undertake a pelvic clearance, and remove all tumour. When the latter is not feasible, then a ‘debulking’ operation is performed. This is a procedure whereby the intra-abdominal tumour load is reduced to what is termed ‘optimum’ residual disease (which has varied definitions). Compared with other intra-abdominal solid tumours, this approach is unique to ovarian malignancies. Whilst many retrospective studies, and meta-analyses may indicate that patients with ‘optimum’ debulking survive longer than those with a greater amount of residual disease, the reality is that this surgical intervention has never been exposed to a randomised controlled trial. Therefore, rather than ‘optimum’ debulking enhancing survival, it could be that the ability to achieve the ‘optimum’ is only reflecting the inherent tumour biology of a more chemo-sensitive disease. This debate will continue until such studies are completed.