Duphaston

Soheir Saeed Adam, MBBCh

• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/soheir-saeed-adam-mbbch

Of interest pregnancy zumba , less specialised nerve-muscle junctions were also observed menopause 87 , suggestive of autonomic endings with a 50 -120 nm neuromuscular cleft womens health 4 garcinia , contact slow and fast muscle fibres menopause 54 years old . From the appearance of vesicles in the nerve endings these were identified as cholinergic, adrenergic or peptidergic endings. However, the concept of a dual somatic and autonomic innervation of the canine prostate was later questioned from anatomical studies that suggested that autonomic nerves merely passed through the skeletal muscle enroute to the urethral smooth muscle [392]. The lack of muscle spindles, small unmyelinated (-afferents) and Golgi tendon organs, is also a feature of urethral rhabdosphincter [391, 393], and implies that there are few spinal reflexes that optimise muscle function. The muscles fibres are unusual in that they do not attach directly to a skeletal structure so that there is little active shortening on excitation. However, there is attachment to the levator ani muscles that will provide some rigid support as discussed above. The relationship between the urethral rhabdosphincter and other structures in the pelvic floor demonstrates differences between men and women [344]. In females, the striated muscles are embedded in a matrix with many elastic fibrils [385] and is continuous with a perineal membrane to allow connection with the pelvic ischia. In males this attachment to the levator ani is provided by a fairly rigid fascia that contains many smooth muscle cells. Electromechanical External Urethral Muscle Properties of Rhabdosphincter Measurement of electrical activity of the urethral rhabdosphincter with extracellular electrodes is a valuable tool for evaluating normal and abnormal function of the external urethra [394, 395]. However, there is very little information about the electrophysiological or contractile properties of urethral rhabdosphincter muscle to help interpret clinical extracellular recording. Isolated canine circular strips of membranous urethra responded to stimuli designed to excite embedded nerves [392]. At low frequencies (5 Hz) twitch contractions were generated and at 20 Hz fused tetanic contractions developed. Responses were unaffected by atropine or phentolamine, consistent with somatic nerve stimulation. A human urethral rhabdosphincter cell culture model was generated that retained a skeletal cell phenotype; some cells developed spontaneous contractions and more in the presence of acetylcholine [396]. It has not been ascertained if they represent a model of differentiated urethral rhabdosphincter myocytes. Their use as a cell replacement therapy for sphincter incompetence or stress urinary incontinence can add to the range of other cell types for this purpose, including muscle-derived and adipose-derived stem cells [397-399]. Ionic currents have been recorded from human and pig myoblasts after four days of culture. Cells were prepared from biopsies of urethral rhabdosphincter, as well as pig adductor muscles as a comparator [400]. Recording micropipettes contained CsCl, to block outward (K+) current leaving inward currents for analysis. Inward Na+ current was measured in both types of pig muscle cells and was of a magnitude that would support an action potential. In pig myocytes an inward Ca2+ (in fact a Ba2+ current, as Ba2+ travel through Ca2+ channels) was also recorded with the characteristics of flux through an L-type Ca2+ channel. Of interest, with human cells the Ba2+ current had characteristics of flux through an L-type and also a Ttype channel. The significance of a T-type Ca2+ channel in urethral rhabdosphincter skeletal muscle is not known but have been proposed to aid the formation of myotubes [401]. However, because T-type channels are activated at membrane potentials near the resting value they have been proposed to enhance the ability of an excitable cell to generate an action potential. A recent Cochrane review gave a guarded response indicating some improvements of urodynamic parameters with a single injection of botulinum toxin-A [410]. This enhanced discharge is reflective of greater contractile activation of the skeletal muscle to generate an increased urethral resistance. However, despite there being no experimental evidence of this unusual phenomenon the idea has gained some traction. Ephaptic transmission is the direct electrical coupling of excitable cells without synaptic transmission (as in nerves) or through low resistance intercellular junction (as in myocardium). It usually occurs in conditions when the extracellular resistance is high so that local electrical fields in one cell generate a change of membrane potential in another. This is generally in unphysiological conditions but can occur between nerve axons [415, 416] and the electrical conditions under which it occurs have been summarised [417].

Pelvic floor electrical stimulation in the treatment of genuine stress incontinence: a multicenter menstruation after giving birth , placebocontrolled trial menstruation is triggered by a drop in the levels of . Non-operative methods in the treatment of female genuine stress incontinence of urine menstruation 6 weeks after birth . An evaluation of a new pattern of electrical stimulation as a treatment for urinary stress incontinence: a randomized women's health center york , double-blind, controlled trial. Comparison between two different neuromuscular electrical stimulation protocols for the treatment of female stress urinary incontinence: a randomized controlled trial. Pelvic floor muscle training for stress urinary incontinence: a randomized, controlled trial comparing different conservative therapies. Evaluation of neuromuscular electrical stimulation in the treatment of genuine stress incontinence. A comparative study of vaginal cone therapy, cones + Kegel exercises, and maximal electrical stimulation in the treatment of female genuine stress incontinence (Abstract number 76). Prospective randomized comparison of oxybutynin, functional electrostimulation, and pelvic floor training for treatment of detrusor overactivity in women. Comparison of electric stimulation and oxybutynin chloride in management of overactive bladder with special reference to urinary urgency: a randomized placebo controlled trial. A Norwegian national cohort of 3198 women treated with home managed electrical stimulation for urinary incontinence: Effectiveness and treatment results. Treatment of urinary incontinence in men with electrical stimulation: is practice evidence based? Anticholinergic drugs versus non drug active therapies for non neurogenic overactive bladder syndrome in adults. Noninvasive transcutaneous electrical stimulation in the treatment of overactive bladder. Percutaneous Tibial Nerve Stimulation in the Treatment of Overactive Bladder: Urodynamic Data. Urodynamic effect of acute transcutaneous posterior tibial nerve stimulation in overactive bladder. Use of peripheral neuromodulation of the S3 region for treatment of detrusor overactivity: a urodynamic based study. Percutaneous tibial nerve stimulation produces effects on brain activity: study on the modifications of the long latency somatosensory evoked potentials. Percutaneous tibial nerve stimulation effects on detrusor overactivity incontinence are not due to a placebo effect: a randomized, double blind, placebo controlled trial. Magnetic stimulation of the human brain and peripheral nervous system: an introduction and the results of an initial clinical evaluation. Conservative treatment of female urinary incontinence with functional magnetic stimulation. A critical review on magnetic stimulation: What is its role in the management of pelvic floor disorders? Response to multipulse magnetic stimulation of spinal nerve roots mapped over the sacrum in man (Abstract). Conservative treatment of female stress urinary incontinence with functional electrical stimulation. The neurophysiological basis of bladder inhibition in response to intravaginal electrical stimulation. Magnetic stimulation of the sacral roots for the treatment of stress incontinence: an investigational study and placebo controlled trial. Repetitive magnetic stimulation of the sacral roots for the treatment of stress incontinence: a brief report. Randomized, doubleblind, sham controlled evaluation of the effect of functional continuous magnetic stimulation in patients with urgency incontinence. A double blind randomised trial comparing magnetic stimulation of the pelvic floor to sham treatment for women with stress urinary incontinence (Abstract). Comparative efficacy of behavioral interventions in the management of female urinary incontinence. Treatment of urinary incontinence in men and older women: the evidence shows the efficacy of a variety of techniques.

A Systematic Review and Meta-analysis of Functional Outcomes and Complications Fol-lowing Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Be-nign Prostatic Obstruction: An Update women's health center laguna hills . Holmium laser vs transurethral resection of the prostate: a randomized prospective trial with 1-year followup womens health tucson . Meta-analysis of holmium laser enucleation vs transurethral resection of the prostate for symptomatic prostatic obstruction pregnancy jeans . Comparison of standard transurethral resection menstruation y sus sintomas , transurethral vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of >40 g. Transurethral holmium laser enucleation of the prostate vs transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. Holmium laser enucleation vs transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). Threeyear outcome following holmium laser enucleation of the prostate combined with mechanical morcellation in 330 consecutive patients. Risk Factors for Transi-ent Urinary Incontinence after Holmium Laser Enucleation of the Prostate. Energy delivery systems for treatment of benign prostatic hyperplasia: an evidence-based analysis. A randomised trial com-paring holmium laser enucleation vs tran-surethral resection in the treatment of pros-tates larger than 40 grams: results at 2 years. Holmium laser resection of the prostate vs tran-surethral resection of the prostate: results of a randomized trial with 4year minimum long-term followup. Threeyear follow-up of laser prosta-tectomy vs transurethral resection of the prostate in men with benign prostatic hyper-plasia. Is pilates as effective as conventional pelvic floor muscle exercises in the con-servative treatment of post-prostatectomy uri-nary incontinence? New surgical technique for sphincter urinary control system using upper transverse scrotal incision. Long-term results of transurethral collagen injection in men with intrinsic sphincter deficiency. Transurethral collagen injections for male intrinsic sphincter deficiency: the University of Texas-Houston experience. The male sling for stress urinary incontinence: 24-month followup with questionnaire based assessment. Technical factors affecting morbidity in definitive irradiation for localized carcinoma of the prostate. Treatment related sequelae following external beam radiation for prostate cancer: a review with an update in patients with stages T1 and T2 tumor. Quality of life study in prostate cancer patients treated with three-dimensional conformal radiation therapy: comparing late bowel and bladder quality of life symptoms to that of the normal population. Long-term urinary toxicity after 3-dimensional conformal radiotherapy for prostate cancer in patients with prior history of transurethral resection. Retrospective analysis of results of p(65)+Be neutron therapy for treatment of prostate adenocarcinoma at the cyclotron of Louvain-la-Leuve. Prospective evaluation of urinary and intestinal side effects after BeamCath stereotactic dose-escalated radiotherapy of prostate cancer. Long-term outcomes among localized prostate cancer survivors: health-related quality-oflife changes after radical prostatectomy, external radiation, and brachytherapy. Functional outcomes and complications following radiation therapy for prostate cancer: a critical analysis of the literature. Stereotactic body radiation therapy vs intensity-modulated radiation therapy for prostate cancer: comparison of toxicity. Use, complications, and costs of stereotactic body radiotherapy for localized prostate cancer. Sequelae of definitive radiation therapy for prostate cancer localized to the pelvis. Urinary incontinence following externalbeam radiotherapy for clinically localized prostate cancer. Is there an increase in genitourinary toxicity in patients treated with transurethral resection of the prostate and radiotherapy? Urinary incontinence in prostate cancer patients treated with external beam radiotherapy.

. 100m Open Women Final Queensland Open Championships QSAC 3/02/2018.

Switzerland) where the reservoir is incorporated into the pump in the scrotum has become available menstruation kits , 881 though a recent publication reports disappointing results women's health center methuen ma . The high price in some countries at the time (Georgia breast cancer her2 , Hong-Kong women's health center of oregon , Romania and Saudi Arabia) precluded its use. Very few gynecologists implant the sphincter, probably since the majority of patients receiving the device are male. The vast majority of available studies are retrospective cases and case series (level 3 evidence). While spontaneous closure and success with a one-stage procedure has been reported, most cases to date involve 3 stages (double diversion, closure technique, and undiversion). Surgical intervention offers symptomatic relief and improved quality of life in most patients. Regardless of complexity, rectourethral fistulas have an initial closure rate approaching 90% when the transperineal approach is used. Permanent fecal and/or urinary diversion should be a last resort in patients with devastated, nonfunctional fecal and urinary systems. All reports are still only retrospective case series (Level of evidence 3; grade of recommendation C). Subsequently, the bladder can then empty either by bladder contraction and/or by abdominal straining. Accordingly, patients voiding with the Valsalva maneuver because of an underactive or neurologically acontractile bladder, do not seem to be at an increased risk of complications. A recent analysis by Ziegelmann et al897 demonstrated that patients over 80 years of age were more likely to experience device erosion or infection compared to a reference group of patients under 60. Patients can be positioned in either lithotomy or supine ­ lithotomy is preferred for perineal approach while supine is preferred if a trans-scrotal approach is to be performed. An appropriate scrub should be performed -chlorhexidine-alcohol has been shown to be superior to povidine-iodine. The cuff of the sphincter is placed around the bulbar urethra via a midline perineal incision, while the pressure regulating balloon and the scrotal pump are inserted via a separate inguinal incision. The inguinal incision is carried through the fascia, above the level of the ligament and an area in the prevesical space is bluntly cleared. The pressure-regulating balloon is placed there and filled with 23 cc of saline or contrast after which the fascia is closed. A tunnel is made under Scarpas fascia into the scrotum deep to the dartos fascia where a pocket for the pump is developed. The cuff tubing is transferred from the perineum to the inguinal incision after which the excess tubing is cut off and the appropriate connections are made with the quick connect system. Another surgical approach has been described using a single, upper transverse scrotal incision which allows the placement of all 3 components of the system, the cuff, the pump in a scrotal pouch, and the reservoir behind the fascia transversalis. Thus, the perineal approach for initial artificial urinary sphincter implantation appears to control male stress incontinence better than the trans-scrotal approach. With the patient in lithotomy position, a perineal incision is made behind the scrotum to exposure the bulbar urethra. The urethra is mobilized circumferentially within the bulbospongiosus muscle and the measuring tape is used to obtain the cuff size. They demonstrated a $7, 000 cost savings when both devices were implanted simultaneously through a scrotal approach, compared to staged implantation with 2 separate surgeries. Alteration in bladder function has been reported principally in patients with neurogenic bladder dysfunction, especially in children. Modifications in detrusor behavior (including its consequences on the upper urinary tract) occur in up to 57% of cases. Certain "centers of excellence" perform substantially more procedures than do community hospitals. Comparable erosion/infection rates have been reported from centers with fewer than 50 or more than 100 cases. In the other 19 where no specific cause was found 14 had the device replaced with a new, but same size cuff and pressure regulating balloon. They hypothesize that material failure of the cuff or balloon, likely because of age and the resulting inability to generate the appropriate pressure is the cause of failure and that urethral atrophy does not exist. In fact in 6 patients in whom the restrictive fibrous sheath around the cuff was excised, the urethral circumference was noted to immediately return to normal. Mechanical Failure this includes perforation of one of the components with loss of fluid from the system, air bubbles or organic debris within the system causing inadequate function of the pump, disconnection of the tubes, or kinking of the tubes.

The preparation has been approved in parts of Europe for use as an intravesical therapy breast cancer medication . It has been shown in a pilot study to relieve some symptoms of radiation cystitis pregnancy upset stomach . Zeidman et al first reported that 5 patients who did not respond to other therapies showed symptomatic improvement breast cancer ultrasound results . Three articles reported that lidocaine and dexamethasone were instilled following hydrodistention pregnancy 34 weeks . According to the report by Rosamilia et al, 85% of the patients had a good result, with the effect persisting for 6 months in 25%. However, further randomized, placebocontrolled trials are needed to ascertain efficacy, optimal treatment parameters, and length of response to intravesical lidocaine preparations. In the absence of more definitive clinical trials with various lidocaine preparations, it is reasonable to try daily instillations of 10-20ml of a 2% lidocaine solution with or without alkalinization for 7 days to see if a clinical response justifies ongoing treatment. There were significant decreases in daytime frequency, nocturia and pain, and a significant increase in first desire to void and maximal cystometric capacity. Three patients required clean intermittent catheterization for 2-3 months following therapy. The three non-responders to the first intravesical treatment session underwent further treatment 3 months later with satisfactory results. One hundred units were injected suburothelially into 20 sites in five patients, while 100 U were injected into the trigone in the remaining five. None of the patients became symptom-free; two showed only limited improvement in bladder capacity and pain score. A total of 60 patients including 40 in the Botox and 20 in the N/S groups were enrolled. The other variables did not differ significantly between groups except for cystometric bladder capacity, which was increased significantly in the Botox group. The overall success rates were 63% (26/40) in the Botox group and 15% (3/20) in the N/S group (p=0. Patients with refractory interstitial cystitis were randomly divided into two groups: immediate injection or 1 month delayed injection of botulinum toxin type A after allocation. The rate of treatment response and changes in symptom scores and frequency volume chart variables were compared between groups 1 month after allocation. Using subjects of both groups as a single cohort, predictive factors for treatment response at 1 month post-injection and the duration of response were explored. In a total of 34 patients the response rate was significantly higher in the immediate injection group (72. Those who received repeated injections had a better success rate during the long-term follow-up period. Further studies will be needed to obtain conclusive evidence for its efficacy, duration of effect, and side-effect profile. As early as 1989, Tanago et al showed that stimulation of S3 may modulate detrusor and urethral sphincter function (488). Pain and accompanying bladder dysfunction were improved by temporary and permanent sacral nerve stimulation for up to six months (489). Mean voided volume during treatment increased and mean daytime frequency, nocturia and pain decreased significantly. Treatment response may coincide with a decrease in urine levels of chemokines, especially monocyte chemoattractant protein-1. At an average of 14 months follow-up mean daytime frequency, nocturia and mean voided volume improved significantly. Of the 17 patients 16 (94%) with a permanent stimulator demonstrated sustained improvement in all parameters at the last postoperative visit. Whitmore el al (493) applied percutaneous sacral nerve root stimulation on 33 patients with refractory interstitial cystitis. However, Elhilali and colleagues (495) found that both of two patients with interstitial cystitis reported no improvement following sacral neuromodulation. Zabihi et al (496) more extensively stimulate S2-S4 by implanting electrodes into epidural space through sacral hiatus.

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