Management of Urinary Incontinence

(Great Britain—The Practitioner, August 1997, p. 470.) Approximately 10 percent of women report some form of incontinence of urine, and it is estimated that 70 percent of cases can be cured. Stress incontinence is characterized by daytime leakage of urine on movement or Valsalva maneuver. Patients with detrusor instability are often older and report an overwhelming urge to void, large urinary loss and nocturia. The integrity of the pelvic floor muscles may be better assessed when the patient is examined in a standing position. Once the diagnosis has been established, therapies such as treatment of constipation, weight loss and adjustment of fluid intake may have dramatic results. Estrogen therapy may also be helpful. Pelvic floor exercises benefit both types of incontinence. Patients with detrusor instability should attempt bladder training by voiding regularly and frequently to retrain the bladder over a period of several weeks. Anticholinergic drugs such as oxybutinin may be helpful, but their use is limited by side effects. Imipramine is a useful therapy in patients with nocturia. Electric and mechanical devices are also available for the treatment of urinary incontinence in selected patients.

Preventing Spread of Meningeal Disease

(Ireland—Forum, September 1997, p. 22.) When a case of meningococcal meningitis occurs in a community, family physicians should be prepared to give appropriate prophylactic advice. The risk of meningeal disease is greatest in persons who have had close contact with the index patient in the past seven days. Antibiotic prophylaxis should be offered to those who have shared living accommodations or had oral contact with an index patient within the past seven days. Infants and young children who share day care with a patient with meningitis should be considered for prophylaxis, but classmates of older children may not require treatment unless contact is unusually close or two or more cases occur in the same class. The optimal prophylactic antibiotic is rifampicin, which should be given in a twice-daily dosage of 600 mg for two days in adults, although a single 250-mg intramuscular dose of ceftriaxone may be substituted. Rifampicin is contraindicated in patients with severe liver disease and during pregnancy. It may also interfere with anticoagulant and contraceptive medications and can cause discoloration of body fluids.

Medical Management of Menorrhagia

(New Zealand—New Zealand Family Physician, August 1997, p. 9.) Excessive menstruation is a common cause of discomfort and lifestyle disruption for many women. When excessive bleeding occurs in regular cycles, the patient is likely to be ovulating, whereas irregular heavy bleeding usually indicates an anovulatory cause such as puberty, perimenopause or polycystic ovarian syndrome. If a significant pathologic cause has been excluded, non-steroidal anti-inflammatory drugs are a logical first line of treatment since they reduce prostaglandin levels. Mefenamic acid, ibuprofen, naproxen and diclofenac are all effective therapies and provide the added benefit of pain relief for women who have dysmenorrhea. In some countries, antifibrinolytic agents such as tranexamic acid are used to depress fibrinolytic activity, and blood loss may be reduced by up to one half. Combined oral contraceptive pills also reduce blood loss by approximately 40 percent, depending on the type of agent used, and are especially useful in regulating menstrual cycles. Progesterone is useful in controlling an acute episode of bleeding, but the common therapy of progesterone given during the luteal phase has had disappointing results in clinical trials. Danazol produces atrophy of the endothelium and controls blood loss, but its use is limited by severe side effects.

Advances in Immunization

(Australia—Australian Family Physician, August 1997, p. 919.) The diseases targeted by the World Health Organization for vaccine development include pneumococcal disease, meningococcal meningitis, respiratory syncytial virus, rotavirus, shigella, enterotoxic Escherichia coli, human immunodeficiency virus infection/acquired immunodeficiency syndrome, malaria, schistosomiasis and dengue fever. Quadrivalent infant vaccines with diphtheria, tetanus, pertussis and hepatitis B are under development, as are vaccines that incorporate injectable polio components. Combined hepatitis A and B vaccines are undergoing trial and are indicated for use in groups at significant risk, such as military personnel, travelers to endemic regions, homosexual men, injecting drug users and some residents of institutions. A vaccine against Helicobacter pylori is likely to become available as an oral agent administered with mucosal adjuvants.