Predictors of unsuccessful pessary fitting in women with prolapse:a cross-sectional study in general practice

Pelvic organ prolapse is a common condition. There is inconsistency between predictors of unsuccessful pessary fitting in urological/gynaecological clinics. Research in general practice is scarce. The aim was to estimate the proportion of women in general practice with a symptomatic pelvic organ prolapse and unsuccessful pessary fitting, and to identify characteristics associated with unsuccessful pessary fitting. A cross-sectional study in general practice (n = 20) was carried out among women (>= 55 years) with symptomatic prolapse (n = 78). Multivariate logistic regression analysis was used to identify predictors of unsuccessful pessary fitting. In total, 33 women (42 %) had unsuccessful pessary fitting. Factors associated with unsuccessful pessary fitting were age (per year, OR 0.93 [95 % CI 0.87-1.00]), body mass index (per kg/m(2), OR 1.14 [95 % CI 1.00-1.30]), and having underactive pelvic floor muscles (OR 2.60 [95 % CI 0.81-8.36]). Pessary fitting was successful in 58 %, indicating that pessary treatment may be suitable for many, but not for all women in general practice with symptomatic prolapse. The condition of the pelvic floor probably plays a role in the success of pessary fitting, as demonstrated by the association with underactive pelvic floor muscles, and body mass index. The association with age may reflect the higher acceptance of conservative treatments for prolapse in older women. This is the first study on predictive factors for unsuccessful pessary fitting in general practice. Therefore, further research should seek to confirm these associations before we can recommend the use of this information in patient counselling

Ongecompliceerde urineweginfecties in de huisartspraktijk: De voorspellende waarde van anamnese en urineonderzoek

Objective To examine whether uncomplicated urinary tract infection can be predicted on the basis of symptoms, if necessary combined with information about urine clarity and smell and dipstick results for nitrite and leukocyte-esterase. Design of study Cross sectional study Methods Between March and June 2011 80 women (aged 12 years and older) whose urine was investigated because of urinary tract complaints in one of the four participating primary practices were included. Symptoms, urine clarity and smell and dipstick results for nitrite and leukocyte-esterase were documented. Dipslides were used as reference standard, a urinary tract infection was diagnosed if growth of ≥104 colony forming units was present. Results Urinary tract infection was diagnosed in 57,5% of included women. Dysuria, frequency and nitrite were associated with urinary tract infection. The positive predictive value of this combination of variables was 100% and specificity was also 100%. When nitrite was negative, the positive predictive value and specificity of dysuria and frequency were too low to confirm urinary tract infection (59% and 54%). Exclusion of urinary tract infection was not possible on the basis of the tests investigated in this study, who all had low sensitivity and low negative predictive value. Conclusion Uncomplicated urinary tract infection can not be confirmed or excluded on the basis of symptoms. When a patient has complaints of frequency and has turbid urine, the possibility of finding urinary tract infection is 93% and specificity is good (97%), so dipstick testing is not necessary. Urinary tract infection is very likely when a patient presents with dysuria and frequency and has a positive nitrite, but the symptoms have little added value because a positive nitrite dipsticktest in itself is already affirmative for urinary tract infection. When nitrite is negative, the symptom’s predictive value is too low to confirm a urinary tract infection. It is not possible to exclude uncomplicated urinary tract infection on the basis of symptoms, urine clarity and smell and dipstick results for nitrite and leukocyte esterase.

Pelvic Organ Prolapse: Conservative treatments in primary care

Pelvic organ prolapse is defined as descent of the anterior or posterior vaginal wall, the uterus, or the vaginal vault (after hysterectomy). Pelvic floor muscle training (PFMT) and pessaries are commonly used in the conservative treatment of prolapse. Although both treatments could typically be applied in primary care, there have been no high-quality studies on the effectiveness of these treatments in women with prolapse in this setting. The main objective of this thesis was to investigate the effectiveness and cost-effectiveness of conservative treatments for older women with symptomatic prolapse in a primary care population. The thesis comprises two randomized controlled trials: in the first trial, watchful waiting was compared with PFMT in women with a symptomatic mild prolapse (leading edge above the hymen); in the second trial, PFMT was compared with pessary treatment in women with a symptomatic advanced prolapse (leading edge at or beyond the hymen). During the two years of follow-up, PFMT resulted in greater pelvic floor symptom improvement compared with watchful waiting in women with mild prolapse, but the difference between groups was too small to be clinically relevant. Nevertheless, PFMT more often led to women’s perceived improvement of symptoms and lower absorbent pads costs. In women with advanced prolapse, there was no significant difference between PFMT and pessary treatment in the reduction of pelvic floor symptoms. However, women with typical prolapse symptoms seemed to benefit more from pessary treatment than from PFMT. Also, pessary treatment was preferable to PFMT in the cost-effectiveness analysis