Women's Health Medicine最新文献

Acute infections of the breast have become less common in the UK with improvements in personal hygiene and the prescription of antibiotics. Breast infection is divided into lacational and non-lactational. Either can cause abscess formation, which can be avoided by the early prescription of appropriate antibiotics, although once established an abscess requires aspiration or incision and drainage. Lactational infection (including neo-natal mastitis) comprises around 25% of breast infections. They are usually caused by skin commensal organisms such as Staphylococcus aureus, and the route of infection is usually through a defect in the skin such as a cracked nipple. Treatment is with flucloxacillin or erythromycin. Non-lactational infection, perductal mastitis, affects young women. The most common organisms are Staphylococcus aureus, enterococci, anaerobic streptococci and bacteroides. Non-lactational breast infection is treated with co-amoxiclav, flucloxacillin or erythromycin, and metronidazole. It usually presents as periarelor inflammamation and will form an abscess if left untreated. If the abscess discharges or requires incision a mammillary duct fistula is likely to develop, which will require definitive surgical treatment by total duct excision and excision of the fistula.

This contribution discusses the history of breast implants and the materials used, and provides a review of the risks associated with implants. The surgical techniques, clinical applications and complications of augmentation mammaplasty and breast reduction and mastopexy are covered, in addition to reduced scar breast reduction and mastopexy techniques.

Urodynamics is the measurement of the ability of the bladders and urethra to store and expel urine. This article describes some of the investigations that are used in the diagnosis and management of incontinence in women and that come under the umbrella of ‘urodynamics’.

Pad tests quantify the amount of urine loss and are also helpful in patient counselling and measuring the results of intervention. Urinary flow rates are assessed by uroflowmetry and help identify poor bladder emptying (the cause of which can then be determined by pressure-flow studies). Filling cystometry is the main test of the lower urinary tract’s ability to store urine and measures the capacity, stability and compliance of the bladder, as well as assessing the competence of the urethra. Pressure-flow studies are used to identify the cause of poor bladder emptying. In selected cases, it is necessary to image the lower urinary tract whilst simultaneously measuring pressure and flow; this is achieved by videourodynamics. When abnormalities cannot be demonstrated by any of these clinic-based investigations, ambulatory urodynamics provide a means of measuring the physiological function of the lower urinary tract over a long period of time, away from the hospital environment. The ability of the urethra to contain urine within the bladder can be quantified by a variety of techniques including urethral pressure profilometry, urethro retro-resistance pressure and leak point pressure, but currently, these tests have limited clinical value. Urodynamics is not necessary for every woman with urinary incontinence but is highly desirable before considering irreversible surgical intervention.

Pain relief in childbirth: self appraisal 2:4

Bedwetting is a common childhood condition affecting over half a million children between the ages of 5 and 16 years in the UK. It is estimated that 0.8% of girls aged between 15 and 16 years are still bedwetting at least once every 3 months. During 2003–2004, 6.7% of all calls to the Education and Resources for Improving Childhood Continence (ERIC) Helpline were from girls between the ages of 12 and 18 years.

Adolescence is a period of physical and emotional change; bedwetting can have a negative effect on self-image and can cause feelings of isolation and depression. By the time they reach adolescence, many girls will have tried different treatments and believe they will never stop wetting. It is important for health professionals to make a careful assessment of individual circumstances and to choose the most appropriate treatment plan. The ‘three systems’ model can help this process by linking the underlying cause with the most effective form of treatment. This could be: medication, such as desmopressin, which mirrors the naturally produced hormone vasopressin and reduces kidney output overnight; oxybutinin for young people with a voiding dysfunction or bladder overactivity, which works by relaxing the detrusor muscle of the bladder; or enuresis alarms, which help the young person to make the connection between ‘waking up’ and ‘holding on’. Helpful, practical information is vital to support the programme – and careful follow-up will establish rapport and trust and engage the young person effecting trends in successful conclusion.

The costs of managing urinary incontinence have increased significantly over the past decades. Better quality of life expectations, better accessibility to healthcare, and increased awareness of the condition have contributed to this escalation. All financial analysis aiming to treat urinary incontinence should include the direct and indirect costs of urinary incontinence. Direct costs can be divided into diagnostic, treatment, routine care and consequence costs. Only a small proportion of the direct costs result from hospital-related treatment: the vast majority of patients with urinary incontinence remain treated within the community. The impact of indirect costs such as depression related to urinary incontinence, loss of productivity or poor performance at work is yet to be objectively quantified. At the other end of the spectrum, recent estimates by the US Census Bureau suggest that in the coming years there will be an even more significant increase in the number of consultations related to pelvic-floor disorders. This may add financial stress to a healthcare system where funding appears to be finite, and may limit the care we are able to provide to our patients. Different epidemiological models have been used to analyse cost-effectiveness of any medical intervention. Measures of the value of health outcomes, like the Quality Adjusted Life Year (QALY), are routinely incorporated into the economical analysis to facilitate financial decision-making. Economic assessment of the value of individual treatment strategies will in the future define our ability to treat and improve the quality of life of our patients.

Women suffering from overactive bladders frequently need to pass urine urgently, and may suffer from urinary incontinence. Bladders from women with this condition show characteristic changes, including loss of some of the motor nerves and an increased sensitivity of the smooth muscles to stimuli. In most cases it is not clear what causes these changes, although predisposing factors are increasing age, childbirth and pregnancy, menopause, hysterectomy and obesity. The condition is, however, more common in patients with neurological disorders, and can sometimes occur as a result of operations for stress incontinence. Results from research using animal models have shown that reduced blood flow to the bladder can result in death of neurones in the bladder wall and the development of overactivity. In many of the predisposing factors and conditions in humans, enhanced pressure rises in the bladder during voiding may occur, which result in periodic reduction in blood flow, or else reduced blood flow may occur due to pressure on the vessels supplying the bladder. It is thus possible that bladder overactivity in humans also results from damage to the nerves innervating the bladder, and that this damage, which may be caused by reduced blood flow to the bladder wall, changes the muscle properties predisposing to overactivity.

Until recently, the options for medical treatment in stress incontinence were limited, mainly by the severe side effects of the drugs. However, a drug has now been developed which has shown good results in the treatment of stress urinary incontinence.

Catheters are widely used for effective bladder drainage, either temporarily or permanently, when physiological and anatomical defects or obstruction of the lower urinary tract are present. Before long-term catheterization is considered, all other possibilities for treatment or management must be explored following appropriate investigation. The urethral catheter is the most frequently used but for long-term catheterization supra-pubic catheterization is the preferred route. They are not without associated complications including urinary tract infection, encrustation, trauma, stricture formation, urethral perforation, bladder calculi and even neoplastic changes. All catheters used in the UK must conform to British Standards. Plastic or PVC and latex rubber are for short-term use only. To reduce urethritis and encrustation, latex catheters have been ‘siliconized’, producing a lubricant effect to facilitate insertion and coated in Teflon (polytetrafluoroethylene or PTFE)) to make it more inert. Silver alloy hydrogel coated latex catheters have been advocated for the inhibition of bacterial growth. For long-term use (12 weeks) in both urethral and supra-pubic catheters, hydrogel coated latex should be used whenever possible.

Catheters are measured in ‘French’ gauge (Fg) or ‘Charriere’ (Ch). Catheters used in women should range from size 12Ch to 16Ch, with a 10ml balloon. Catheters can be either connected to a drainage bag or a valve. Whenever possible, intermittent catheterization should be taught to patients to facilitate bladder emptying. Long-term indwelling catheterization should be a last resort as ‘treatment’ for women with lower urinary tract dysfunction.

Online resources for urinary incontinence