It is well and truly conference season. I’ve sat down to reflect on #POGP17 before I get my head into #WCAPP17.
What a fantasic year! I’d like to send a huge thanks to the conference committee – they put together a brilliant line up with an interesting array of topics by clinicians and researchers; calling on UK clinicians to develop excellence by diversifying practice, simplifying, and above all enhancing the patient experience. It was pitched perfectly and ran like clockwork. Thank you for a great weekend of engaging CPD.
I took oodles of notes, here’s a brief summary of my POGP17 Conference highlights.
Mr Ash Monga got conference to a flying start with his update on current and future urogynae practice. He discussed the potential for the composite effect of botox – can it cure bladders? And his experience with bladder medications – he finds either Betmiga works extremely well then stops working and needs higher doses, or doesnt work at all. Interesting – like with the recent Pregabalin data, maybe Betmiga isn’t our saviour in OAB?
He also directly addressed the Mesh crisis and his view that patients do extremely well with physio input, eradicating the need for surgery in the first place. It was good to hear such resounding support for Physio – which was a theme of the whole two days.
Keep your eyes peeled for the Blue Wind RENOVA istim device – implantable PTNS. Think SNS, but tibial nerve. Small anklet that patients wear for an hour a day or so. The pilot (N=36) found 70% reported >50% improvement in OAB symptoms. Watch this space.
There’s also some work into laser therapy for atrophy (by Salvatore et al if you want to read the data) and radiofrequency treatment for SUI with an RCT in Cork that we should be keeping our eyes open for.
Prof Maria Stokes gave us a detailed update on the professional use of ultrasound for biofeedback and imaging. Too much to summarise! Keep within your scope. My stand out fact/finding of the literature she referenced was that as there is a reduction in multifidus thickness in chronic LBP, there’s a concurrent thickening and contraction of the connective tissues, which serve to augment spinal mechanics in response. Interesting.
Prof Doreen McClurg gave a passionate speech about the stigmatisation of patients with neurological pathologies and AI. She talked about how the prevalence is much lower in those still living in their homes (cause or consequence?) and the variations in bowel presentations in MS and PD. The best bit was a detailed exploration of her updated systematic review and recent research – showing that 10mins of abdominal massage per day can effectivly improve constipation in MS.
Mandy Fader gave a practical and realistic talk about continence products and why/when they don’t work. She discussed how products change so quickly and research can’t keep up, and that the regulatory requirements for products are lower than for research so there’s no impetus to evidence efficacy before getting CE marking and distributing. There’s also a new website that has gone live to help you and your patient make decisions about which combinations of products may suit them – www.continenceproductadvisor.org
Mr Andrew Clarke and Sally Sheppard (PT) gave a thought provoking lecture looking to the history of surgery to address the future. A lot of what they said I wanted to use verbatim in the clinic, it was clear, precise and easy to understand: “Bad surgical outcomes don’t tell you about the natural history of a condition”, “The pelvic floor is like a fancy joint, we should be looking to orthopaedic MDT pathways”- this made a lot more sense with his fab slides..”We can get much better results in what we do by working with physios and maximising outcomes by discussing with the MT”.
And my favourite (re: suspension surgery for prolapse): “If your trousers fall down – yes you can shorten the leg but really you just need to pull up your trousers”.
If you’re in the process of setting up an MDT or want to improve yours – go and spend some time with them in Poole, their MDT sounds like a gold-standard service.
Yvonne McKenzie discussed inflammatory bowel responses and dietary changes, and provided my word of the day “Flatulogenic”. Hers was a talk I’d like to go back to and dig through in detail. Some quick notes I made: low fibre diets for FI reduce microbial diversity and thus aren’t helpful for settling inflammatory bowel issues. Don’t use Aloe Vera – it doesn’t help. Don’t talk about in/soluble fibre anymore, talk in terms of general goal of 30mg/day. Probiotics are safe in IBS but unlikely to produce substantial benefits, try one at a time for 4 weeks each til you feel any benefit. The Low FODMAP diet is great – use it but make sure to refer to dietetics for expertise and support. The are lots of useful fact sheets on the British Dietetics Association website www.bda.org.uk we can use.
Samantha Gillard’s DRAM presentation was fantastic – another I want to go back to and pour over. It was rich in research detail and clinical wisdom. I can’t wait to read her PhD. Some quick notes: if abdominal activity during pregnancy is maintained there’s a faster resolution of DRAM postnatally. There’s no evidence the linea alba can “heal” or recoil without exercise for rectus to take up the slack, and no consensus on where to measure. Best practice is to palpate using a tape measure (1/3 distance from xyphoid to super umbilicus) to ensure intra-testing standardisation. Posture matters – DRAM measured largest in standing vs lying and sitting vs lying. Tip: in the first 8/52 offload the tendon to allow natural recoil (firm supporting brace or underwear, then train to improve support and muscular synergy.
Day 2 kicked off with poster presentations from around the country – read them all in the upcoming JPOGP. Next up Dr Lisa Roberts, Dr Kay Crotty and I sought to demystify research, promote and empower women in research and to inspire our members to start finding and answering clinical questions.
This was followed by an Utterly Inspiring talk by Mr Stelios Myriknas & Mr Kostas Papadakis demonstrating their Anterior Non-Episiotomy Forceps delivery technique (ANEF) – with more than 380 cases they’ve demonstrated that they’re able to significantly cut the rate of OASIs by more than 3 quarters. This is achieved by mimicing the natural movement of the baby’s head into full extension and lifting the forceps through 90 degress whilst lowering the bed fully and allowing some central/anterior force, not just the 45 degrees with two hands pushing down through the forceps on the posterior pelvic floor. Mr Myriknas told us how having analysed the data dn his own experience he came to the conclusion that the OASI rate in forceps delivery had to be due to human error (and that he should have been a physio). Lets hope they’re able to roll it out internationally.
Mr Warren demonstrated and discussed surgical techniques in abdominal repairs – a really useful demonstration of when we can be thinking about referring for surgery, and the benefits it can bring.
Finally we had the MOD discussing openly their concerns for the pelvic health of serving personel and the problems with the stigma of injury/rehab protocols. This was a very touching and thoughtful lecture that called upon us, civilian clinicians, to contact and discuss our patients with their MOD medical teams when appropriate – for the best health of our patients, who will be required to perform physically to a much higher degree than maybe beneficial during rehab. The yearly fitness testing required is intense, and people are hiding their pelvic health issues. Let’s get talking and supporting our military colleagues!
That sums up my general thoughts on POGP 2017. It felt like a really productive and rich two days of learning, and I’m already looking forward to 2018!