Effect of vaginal delivery on the pelvic floor: a 5-year follow-up

Intermittent vs continuous catheterization for postpartum urinary retention: A multicenter randomized controlled trial

BACKGROUND

Postpartum urinary retention is a common complication in the immediate postpartum period. However, there is no consensus regarding optimal management.

OBJECTIVE

This study aimed to compare 2 catheterization strategies for the treatment of postpartum urinary retention.

STUDY DESIGN

A multicenter prospective randomized controlled trial was conducted at 4 university-affiliated medical centers between January 2020 and June 2022. Individuals with postpartum urinary retention (bladder volume of >150 mL) up to 6 hours after vaginal or cesarean delivery were randomly allocated to 1 of 2 protocols: intermittent catheterization every 6 hours, up to 4 times, or continuous catheterization with an indwelling urinary catheter for 24 hours. If postpartum urinary retention was not resolved after 24 hours, an indwelling catheter was inserted for an additional 24 hours in both groups. The primary endpoint was the mean time to postpartum urinary retention resolution. The secondary endpoints included postcatheter urinary tract infection rate and length of hospital stay. The satisfaction rate was estimated using the 30-Item Birth Satisfaction Scale questionnaire.

RESULTS

After randomization, 73 individuals were allocated to the intermittent catheterization group, and 74 individuals were allocated to the continuous catheterization group. The mean time to postpartum urinary retention resolution was significantly shorter in the intermittent catheterization group than in the continuous catheterization group (10.2±11.8 vs 26.5±9.0 hours; P<.001), with 75% and 93% resolution rates after 1 and 2 catheterizations, respectively. The number of individuals who achieved resolution at 24 hours was 72 (99%) in the intermittent catheterization group and 67 (91%) in the continuous catheterization group (P=.043). The satisfaction rate was higher in all categories in the intermittent catheterization group than in the continuous catheterization group (P<.001). No intercohort difference was found in the urinary tract infection rates (P=.89) or hospital stay length (P=.58).

CONCLUSION

Compared with indwelling catheterization, intermittent catheterization for urinary retention after delivery was associated with quicker postpartum urinary retention resolution and a higher satisfaction rate without increasing the complication rates.

Stem cell therapy combined with controlled release of growth factors for the treatment of sphincter dysfunction

Sphincter dysfunction often occurs at the end of tubule organs such as the urethra, anus, or gastroesophageal sphincters. It is the primary consequence of neuromuscular impairment caused by trauma, inflammation, and aging. Despite intensive efforts to recover sphincter function, pharmacological treatments have not achieved significant improvement. Cell- or growth factor-based therapy is a promising approach for neuromuscular regeneration and the recovery of sphincter function. However, a decrease in cell retention and viability, or the short half-life and rapid degradation of growth factors after implantation, remain obstacles to the translation of these therapies to the clinic. Natural biomaterials provide unique tools for controlled growth factor delivery, which leads to better outcomes for sphincter function recovery in vivo when stem cells and growth factors are co-administrated, in comparison to the delivery of single therapies. In this review, we discuss the role of stem cells combined with the controlled release of growth factors, the methods used for delivery, their potential therapeutic role in neuromuscular repair, and the outcomes of preclinical studies using combination therapy, with the hope of providing new therapeutic strategies to treat incontinence or sphincter dysfunction of the urethra, anus, or gastroesophageal tissues, respectively.

Brain-Derived Neurotrophic Factor Is Indispensable to Continence Recovery after a Dual Nerve and Muscle Childbirth Injury Model

In women, stress urinary incontinence (SUI), leakage of urine from increased abdominal pressure, is correlated with pudendal nerve (PN) injury during childbirth. Expression of brain-derived neurotrophic factor (BDNF) is dysregulated in a dual nerve and muscle injury model of childbirth. We aimed to use tyrosine kinase B (TrkB), the receptor of BDNF, to bind free BDNF and inhibit spontaneous regeneration in a rat model of SUI. We hypothesized that BDNF is essential for functional recovery from the dual nerve and muscle injuries that can lead to SUI. Female Sprague-Dawley rats underwent PN crush (PNC) and vaginal distension (VD) and were implanted with osmotic pumps containing saline (Injury) or TrkB (Injury + TrkB). Sham Injury rats received sham PNC + VD. Six weeks after injury, animals underwent leak-point-pressure (LPP) testing with simultaneous external urethral sphincter (EUS) electromyography recording. The urethra was dissected for histology and immunofluorescence. LPP after injury and TrkB was significantly decreased compared to Injury rats. TrkB treatment inhibited reinnervation of neuromuscular junctions in the EUS and promoted atrophy of the EUS. These results demonstrate that BDNF is essential to neuroregeneration and reinnervation of the EUS. Treatments aimed at increasing BDNF periurethrally could promote neuroregeneration to treat SUI.

Does parity impact obstructed defecation in women with normal anorectal anatomy?

INTRODUCTION AND HYPOTHESIS

Obstructed defecation (OD) is often associated with trauma to pelvic connective tissue and nerves sustained during pregnancy and childbirth. Although there are multiple potential etiologies of defecatory dysfunction, the pathophysiology of this symptom complex is not well understood. The purpose of this study is to determine the role of parity in the development of obstructed defecatory symptoms in women with normal anorectal anatomy in a search for evidence of a presumptive neuropathic effect of pregnancy and childbirth.

METHODS

This study retrospectively evaluated the records of 754 women presenting at a tertiary urogynecology unit for pelvic floor dysfunction with no anatomical abnormalities of the anorectum on imaging. They were stratified according to parity. The authors determined the prevalence of obstructed defecation symptoms in these groups. Chi-squared test was performed for statistical analysis.

RESULTS

Median age was 51 (range 16-88) years, and median vaginal parity was 2 (0-8); 399 (53%) women reported symptoms of OD. When anatomical abnormalities of the anorectum were excluded, parity did not seem to have a major effect on the prevalence of symptoms of OD.

CONCLUSIONS

In this cohort, parity is unlikely to be a cause of OD in women with normal anorectal anatomy.

Brain-Derived Neurotrophic Factor Is an Important Therapeutic Factor in Mesenchymal Stem Cell Secretions for Treatment of Traumatic Peripheral Pelvic Injuries

Traumatic neuromuscular injury to the pudendal nerve and urethra during childbirth does not regenerate well and contributes to stress urinary incontinence in women. Mesenchymal stem cells (MSCs) can improve neuroregeneration via their secretions, or secretome, which includes brain-derived neurotrophic factor (BDNF). In this study, we investigated whether BDNF is a key factor in the secretome of MSCs for the facilitation of functional recovery following a dual simulated childbirth injury. BDNF knockdown (KD) MSCs were created using an anti-BDNF shRNA lentivirus vector. A scrambled sequence was used as a transduction control (scrambled). Cells were cultured for 24 h before media was concentrated 50x to create concentrated conditioned media (CCM) containing MSC secretome. CCM of unmanipulated MSCs was screened for high BDNF expression (high BDNF CCM). Concentrated control media (CM) was created by concentrating media not conditioned by cells. Female Sprague-Dawley rats underwent bilateral pudendal nerve crush and vaginal distension (Injury) or sham injury. One hour and 1 week after injury, sham injured rats received CM, and injured rats received CM, high BDNF CCM, KD CCM, or scrambled CCM (300 μl intraperitoneally). Three weeks after injury, rats underwent leak point pressure (LPP) and pudendal nerve sensory branch potential (PNSBP) recordings. The urethra and pudendal nerve were harvested for anatomical assessment. ANOVA followed by the Student-Newman-Keuls test determined significant differences between groups (p < 0.05). BDNF KD CCM had significantly decreased BDNF concentration compared to scrambled CCM, while the concentration in high BDNF CCM was significantly increased. LPP was significantly decreased in CM and KD CCM treated animals compared to sham injury, but not with scrambled or high BDNF CCM. PNSBP firing rate showed a significant decrease with CM treatment compared to sham injury. Neuromuscular junctions in the urethral sphincter in KD CCM, scrambled CCM, and high BDNF CCM were healthier than CM treated rats. While anatomical and nerve function tests demonstrate regeneration of the pudendal nerve with any CCM treatment, LPP results suggest it takes longer to recover continence with reduced BDNF in CCM. BDNF in MSC CCM is an important factor for the acceleration of recovery from a dual nerve and muscle injury.

Understanding the physiology of human defaecation and disorders of continence and evacuation

The act of defaecation, although a ubiquitous human experience, requires the coordinated actions of the anorectum and colon, pelvic floor musculature, and the enteric, peripheral and central nervous systems. Defaecation is best appreciated through the description of four phases, which are, temporally and physiologically, reasonably discrete. However, given the complexity of this process, it is unsurprising that disorders of defaecation are both common and problematic; almost everyone will experience constipation at some time in their life and many will develop faecal incontinence. A detailed understanding of the normal physiology of defaecation and continence is critical to inform management of disorders of defaecation. During the past decade, there have been major advances in the investigative tools used to assess colonic and anorectal function. This Review details the current understanding of defaecation and continence. This includes an overview of the relevant anatomy and physiology, a description of the four phases of defaecation, and factors influencing defaecation (demographics, stool frequency/consistency, psychobehavioural factors, posture, circadian rhythm, dietary intake and medications). A summary of the known pathophysiology of defaecation disorders including constipation, faecal incontinence and irritable bowel syndrome is also included, as well as considerations for further research in this field.

CORRELATION BETWEEN PELVIC FLOOR DYSFUNCTION ON DYNAMIC 3D ULTRASOUND AND VAGINAL DELIVERY, PARITY, AND AGE IN WOMEN WITH OBSTRUCTED DEFECATION SYMPTOMS

BACKGROUND

Few studies have investigated the constipation or obstructed defecation symptoms identified by using imaging, as dynamic three-dimensional ultrasound and correlate vaginal delivery, parity, and age.

OBJECTIVE

The aim of this study was to assess the prevalence of pelvic floor dysfunctions in female patients with obstructed defection symptoms and to determine whether specific pelvic floor dysfunctions identified by dynamic three-dimensional ultrasonography (echodefecography) are correlated with vaginal delivery, parity, and age. The secondary goal is to report the prevalence of coexisting pelvic floor dysfunctions.

METHODS

This is a retrospective cohort study including patients with obstructed defecation symptoms underwent echodefecographyto evaluate pelvic floor dysfunctions in the posterior compartment and correlate with vaginal delivery, parity, and age.

RESULTS

Of 889 female: 552 (62%) had had vaginal delivery and 337 (38%) were nulliparous. The prevalence of dysfunctions identified by echodefecography (rectocele, intussusception, enterocele/sigmoidocele, and dyssynergia) was similar between the two groups and was not associated with number of deliveriesor age. However, the prevalence of sphincter defects showed higher rates in women with vaginal delivery and increased with the parity. Up to 33% of patients had coexisting dysfunctions.

CONCLUSION

The prevalence of dysfunctions such as rectocele, intussusception, dyssynergia, and enterocele/sigmoidocele assessed by echodefecography in patients with obstructed defecation symptoms are found similar regardless of vaginal delivery, number of deliveries or stratified-age. In vaginal delivery, number of deliveries does impact on detection of sphincter defects and liability to fecal incontinence.

Pelvic Floor Dysfunction After Hysterectomy: Moving the Investigation Forward

The role of hysterectomy in the development of pelvic floor dysfunction (PFD) remains widely disputed. The controversy is fueled by two key factors. The first is conflicting association studies that make it difficult to establish whether a link truly exists. Although many retrospective studies report a correlation between hysterectomy and increased risk of stress urinary incontinence (SUI) or pelvic organ prolapse (POP), prospective studies often fail to replicate these results, leading some to conclude that no association exists. However, most prospective studies do not follow up for a sufficient length of time to account for the long latency of PFD and cannot unilaterally prove the absence of an association. The second source of controversy is the absence of a plausible mechanism to explain how hysterectomy could predispose patients to PFD. In this paper, we investigate autonomic innervation and smooth muscle in the three layers of pelvic floor support and propose a mechanism through which autonomic damage from hysterectomy could predispose patients to PFD. We then identify key research areas needed to evaluate this theory. This report aims to inspire a discussion on how to further the collective understanding of the relationship between hysterectomy and PFD. Clarifying the nature of this connection could have enormous consequences in redefining the risks and benefits of hysterectomy.

Brain derived neurotrophic factor mediates accelerated recovery of regenerative electrical stimulation in an animal model of stress urinary incontinence

OBJECTIVE

Stress urinary incontinence (SUI) is prevalent among older women and can result from insufficient regeneration of the pudendal nerve (PN). Electrical stimulation (ES) of the PN upregulates brain derived neurotrophic factor (BDNF) and accelerates regeneration. Using tyrosine kinase B (TrkB) to reduce the availability of free BDNF, the aim of this study was to determine if BDNF is necessary for accelerated recovery via ES in a model of SUI.

METHODS

Our SUI model consists of Female Sprague-Dawley rats, whose PNs were crushed bilaterally twice for 30 s, followed by insertion of a modified Foley catheter into the vagina with balloon inflation for 4 h. These rats were divided into 4 groups: 1) Sham PN crush and sham vaginal distension without electrode implantation and with saline treatment (sham injury); 2) SUI with sham stimulation and saline treatment (SUI); 3) SUI and ES with saline treatment (SUI&ES); and 4) SUI and ES with TrkB treatment (SUI&ES&TrkB). Animals underwent ES or sham stimulation four times a week for two weeks. Four weeks after injury, animals underwent functional testing consisting of leak point pressure (LPP) with simultaneous external urethral sphincter (EUS) electromyography (EMG) and pudendal nerve recordings. Data was analyzed using ANOVA with Holm-Sidak posthoc test (p < 0.05). EUS and PN specimen were sectioned and stained to semi-quantitatively evaluate morphology, regeneration, and reinnervation.

RESULTS

LPP and EUS EMG firing rate were significantly increased in the sham injury and SUI&ES groups compared to the SUI and SUI&ES&TrkB groups. EUS of SUI rats showed few innervated neuromuscular junctions compared to sham injured rats, while both treatment groups showed an increase in reinnervated neuromuscular junctions.

CONCLUSION

ES accelerates functional recovery via a BDNF-mediated pathway in a model of SUI. These findings suggest ES could be used as a potential regenerative therapy for women with SUI.

Association between levator ani avulsion and urinary incontinence in women: A systematic review and meta-analysis

Background

Urinary incontinence is a bothersome symptom. Although the relationship between stress urinary incontinence (SUI) and vaginal delivery is established, the pathology underlying SUI after vaginal birth remains to be elucidated.

Objectives

To determine whether levator ani muscle avulsion predisposes for SUI in women.

Search strategy

Pubmed and Embase were searched for terms and their variations “levator ani muscle avulsion” and “urinary incontinence”, from inception until 5 November 2019.

Selection criteria

Inclusion criterion: studies describing the relationship between urinary incontinence and levator ani muscle avulsion in women at least 1 year after delivery. Exclusion criterion: studies only analyzing the urethral sphincter or hiatus dimensions.

Data collection and analysis

Odds ratios were used and if not available, were calculated as means of data synthesis, adjusted odds ratios if presented by the study, random‐effects model to compute a pooled estimate.

Results

Seven studies were included, accounting for 2388 women. Comparing women with and without levator ani muscle avulsion, the overall odds ratio for SUI is 0.87 (95% confidence interval 0.56–1.34), and after adjustment for possible confounders was 0.72 (95% confidence interval 0.40–1.30).

Conclusion

There is no relationship between levator ani muscle avulsion and SUI in women.

A systematic review and meta‐analysis was conducted to evaluate the relationship between levator ani muscle avulsion and stress urinary incontinence, which could not be supported.

The prevalence of urinary incontinence symptoms among multiparous women: a survey of Saudi health-care centers

OBJECTIVE

To determine the distribution of urinary incontinence (UI) symptoms and their relation to childbirth events.

METHODS

This cross-sectional study used a structured self-administered questionnaire that included the Questionnaire for Female Urinary Incontinence Diagnosis and the Urogenital Distress Inventory Short Form. The study included 802 women sampled from four primary health care centers in Dammam, KSA. A chi-square test and adjusted logistic regression models were used to examine the relation between UI symptoms and obstetric events.

RESULTS

Of the participants, 56.6% (n = 454) had at least one UI symptom. Symptoms were most commonly associated with grand multiparity (80.47%), a history of abortion (72%), assisted vaginal delivery (70%), an age of ≤ 18 years at first birth (66.67%) and ≥ 35 years at last birth (75.48%), and a history of macrosomia (84.62%) and episiotomy (67.89%). Unlike the risk of urgency UI, the risk of stress UI was statistically significantly linked to obstetric events. Grand multiparity was associated with a higher risk of both stress UI (odds ratio [OR]: 3.75, confidence interval [95% CI]: 1.68-8.40) and urgency UI (OR: 2.87, 95% CI: 1.07-7.73).

CONCLUSION

UI symptoms are common among grand multiparas. Unlike urgency UI, stress UI is associated with previous obstetric events.

Factors associated with persistent pain after childbirth: a narrative review

A systematic literature search was performed to identify studies that reported risk factors for persistent pain after childbirth. Many studies have sought to identify risk factors for post-delivery pain in different populations, using different methodologies and different outcome variables. Studies of several different but interrelated post-partum pain syndromes have been conducted. Factors strongly and specifically associated with persistent incisional scar pain after Caesarean delivery include a coexisting persistent pain problem in another part of the body and severe acute postoperative pain. For persistent vaginal and perineal pain, operative vaginal delivery and the magnitude of perineal trauma have been consistently linked. History of pregnancy-related and pre-pregnancy back pain and heavier body weight are robust risk factors for persistent back pain after pregnancy. Unfortunately, limitations, particularly small samples and lack of a priori sample size calculation designed to detect specific effect sizes for risk of persistent pain outcomes, preclude definitive conclusions about many other predictors and the strength of outcome associations. In future studies, assessments of specific phenotypes using a rigorous analysis with appropriate predetermined sample sizes and validated instruments are needed to allow elucidation of stronger and reliable associations. Interventional studies targeting the most robustly associated, modifiable risk factors, such as acute post-partum pain, may lead to solutions for the prevention and treatment of these common problems that impact a large population.

Is Mode of Delivery Associated With Sexual Response? A Pilot Study of Genital and Subjective Sexual Arousal in Primiparous Women With Vaginal or Cesarean Section Births

INTRODUCTION

Although postpartum sexual concerns are common, limited data exist on postpartum sexual response. Furthermore, the physiological process of vaginal birth may negatively impact genital response compared with unlabored cesarean section (C-section), but this hypothesis has yet to be tested.

AIM

To (i) compare genital and subjective sexual response and sexual concordance by mode of delivery with inclusion of a control group, (ii) compare groups on self-reported sexual function over the past month, (iii) examine the relationship between laboratory measurement of sexual response and self-reported sexual function, and (iv) investigate association between obstetrical factors and breastfeeding and between sexual response and self-reported sexual function.

METHODS

3 groups of cisgender women were recruited from the community: primiparous women who delivered via vaginal birth within the past 2 years (VB group; n = 16), primiparous women who delivered via unlabored C-section within the past 2 years (CS group, n = 15), and age-matched nulliparous women (NP group, n = 18). Laser Doppler imaging was used to assess genital response while participants watched a neutral and erotic film.

MAIN OUTCOME MEASURES

The main outcome measures were change in flux units from neural to erotic video as a measure of genital response, subjective sexual arousal rated continuously throughout films, perceived genital response rated after films, and Female Sexual Function Index (FSFI).

RESULTS

Women in the VB group had significantly lower change in flux units than women in the CS (P = .005, d = 1.39) and NP (P < .001, d = 1.80) groups. Groups did not differ on their subjective indices of sexual response or in sexual concordance. Women in both postpartum groups reported lower FSFI scores than women in the NP group. No relationship was determined between FSFI scores and sexual response in the laboratory. Results suggested that genital trauma and breastfeeding may negatively impact FSFI scores, but they were not related to genital response or subjective sexual arousal as measured in the laboratory.

CLINICAL IMPLICATIONS

Results underscore the importance of balancing objective and subjective indices of sexual response and function, especially considering the biopsychosocial nature of postpartum sexuality.

STRENGTHS & LIMITATIONS

The present study is the first to apply modern sexual psychophysiological methodology to the study of postpartum sexuality. Cross-sectional methodology limits the ability to make causal inferences, and the strict inclusion criteria limits generalizability.

CONCLUSION

Physiological changes as a result of labor and delivery may have a detrimental impact on genital response; however, these physiological differences may not impact women's subjective experience of postpartum sexuality. Cappell J, Bouchard KN, Chamberlain SM, et al. Is Mode of Delivery Associated With Sexual Response? A Pilot Study of Genital and Subjective Sexual Arousal in Primiparous Women With Vaginal or Cesarean Section Births. J Sex Med 2020; 17:257-272.

Ultrasound imaging of the perineal body: a useful clinical tool

Introduction and hypothesis

The perineal body is a fibromuscular pyramidal structure located between the vagina and the anus. It has been difficult to image because of its small size and anatomical location. This study used 2D transperineal ultrasound to measure the perineal body and assess whether there is an association with prolapse.

Methods

An observational, cross-sectional study was carried out in a tertiary level Urogynaecology department and included prolapse patients and healthy nulliparous volunteers (control group). This was a clinical assessment, including POP-Q and trans-perineal 2D ultrasound measurement of the perineal body height, length, perimeter, and area. Parametric tests were used, as the data were normally distributed. Results are reported as mean and 95% confidence interval (±95% CI).

Results

A total of 101 participants were recruited of which 22 were nulliparous healthy volunteers. Mean perineal body measurements in controls were height 22.5 ± 3.3 mm, length 17.4 ± 2.7 mm, perimeter 7.5 ± 0.9 mm, and area 2.8 ± 0.38 cm². Perineal body measurements in 79 prolapse patients: height 16.9 ± 1.7 mm, length 16.0 ± 1.4 mm, perimeter 6.5 ± 0.5 mm and area 2.1 ± 0.5 cm². A small perineal body was strongly associated with posterior compartment prolapse (paired t test, p < 0.0001) and wider POP-Q GH (paired t test, p = 0.0003). Surprisingly, Pelvic Organ Prolapse Quantification Perineal Body (POP-Q PB) of the two groups was not significantly different. A perineal body mid-sagittal area of less than 2.4 cm² has been shown to be associated strongly with posterior compartment prolapse.

Conclusions

It is possible to measure the perineal body on 2D ultrasound. This technique facilitates the objective diagnosis of perineal deficiency. POP-Q PB does not predict the length or area of the perineal body.

Clinical Significance of Neuropeptide Y Expression in Pelvic Tissue in Patients with Pelvic Floor Dysfunction

OBJECTIVES

To investigate the neuropeptide Y (NPY) expression in the tissue of pelvic floor ligament and anterior vaginal wall in female patients with pelvic organ prolapse (POP) and stress urinary incontinence (SUI).

METHOD

Seventeen patients with POP, 6 with SUI, 13 with POP and SUI (POP&SUI), and 10 controls were included in this study from First Affiliated Hospital of JiNan University. Immunohistochemical assay was used to examine NPY expression in the tissue of round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall. NPY expression were compared between POP, SUI, POP&SUI and controls.

RESULTS

NPY was positive expressed in the round ligament, cardinal ligament of uterus, uterosacral ligament, and anterior vaginal subepithelial connective tissue. Compared with the control group, NPY expression in the round, cardinal, and uterosacral ligaments in patients with POP&SUI group was decreased with significant statistical difference (p<0.05). NPY expression in anterior vaginal wall was significantly decreased in POP, SUI, and POP&SUI groups compared to normal group (p<0.05). Compared to POP group, NPY expression in SUI and POP&SUI groups were significantly decreased (p<0.05), however the difference was not statistical different between SUI and POP&SUI groups (p>0.05). In POP and POP&SUI groups, the NPY expression in the cardinal ligament of uterus, uterosacral ligament, and anterior vaginal wall were negatively correlated with age (p<0.05), however, was not correlated with number of pregnancy, number of delivery, and BMI (p>0.05).

CONCLUSIONS

NPY expression was reduced in the round ligament, cardinal ligament of uterus, Uterosacral ligament, and vaginal anterior wall of the patients with POP and SUI. The decreased NPY expression may play an important role in the development of pelvic floordysfunction.

The relationship between residual sphincter damage after primary repair, faecal incontinence, and anal sphincter function in primiparous women with an obstetric anal sphincter injury

BACKGROUND AND AIMS

Anal sphincter injury has been identified as a primary cause of post-partum fecal incontinence in women with obstetric anal sphincter injury. However, women without obstetric anal sphincter injury may also develop fecal incontinence. The aim is to determine the relationship between fecal incontinence severity; and i) residual anal sphincter injury, quantified by the Starck score, and ii) anal sphincter tone.

METHODS

Consecutive case series of prospectively collected data set in a Pelvic Floor Unit within a tertiary teaching hospital in Australia. Population 181 primiparous women with Sultan classification Grade 3 and 4 sphincter injuries.

MAIN OUTCOME MEASURES

Sultan classification, anal manometry, pudendal nerve terminal motor latency, St Mark's fecal incontinence score, and Starck ultrasound score.

RESULTS

45% of women reported some degree of fecal incontinence. One third of women with normal external sphincter tone were incontinent. Those with higher Starck score had higher St Mark's scores. A higher Sultan classification correlated with more severe incontinence regardless if the repair was complete. Forceps delivery had a twofold risk of incontinence when compared to non-forceps delivery.

CONCLUSION

The importance of an effective anal sphincter repair is confirmed. However, overall there is no direct relationship between residual sphincter damage, anal sphincter tone, and fecal incontinence severity. These data indicate that anal sphincter integrity alone is not the sole mechanism for maintaining fecal continence. Rectal and colonic motor function may also play a role and investigation into these components may provide greater insight into the effect of vaginal delivery upon fecal continence mechanisms.

Prenatal exercise (including but not limited to pelvic floor muscle training) and urinary incontinence during and following pregnancy: a systematic review and meta-analysis

OBJECTIVE

To examine the relationships between prenatal physical activity and prenatal and postnatal urinary incontinence (UI).

DESIGN

Systematic review with random effects meta-analysis and meta-regression.

DATA SOURCES

Online databases were searched up to 6 January 2017.

STUDY ELIGIBILITY CRITERIA

Studies of all designs were included (except case studies) if they were published in English, Spanish or French and contained information on the Population (pregnant women without contraindication to exercise), Intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ["exercise-only"] or in combination with other intervention components [e.g., dietary; "exercise + co-intervention"]), Comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and Outcome (prenatal or postnatal UI).

RESULTS

24 studies (n=15 982 women) were included. 'Low' to 'moderate' quality evidence revealed prenatal pelvic floor muscle training (PFMT) with or without aerobic exercise decreased the odds of UI in pregnancy (15 randomised controlled trials (RCTs), n=2764 women; OR 0.50, 95% CI 0.37 to 0.68, I²=60%) and in the postpartum period (10 RCTs, n=1682 women; OR 0.63, 95% CI 0.51, 0.79, I²=0%). When we analysed the data by whether women were continent or incontinent prior to the intervention, exercise was beneficial at preventing the development of UI in women with continence, but not effective in treating UI in women with incontinence. There was 'low' quality evidence that prenatal exercise had a moderate effect in the reduction of UI symptom severity during (five RCTs, standard mean difference (SMD) -0.54, 95% CI -0.88 to -0.20, I²=64%) and following pregnancy (three RCTs, 'moderate' quality evidence; SMD -0.54, 95% CI -0.87 to -0.22, I²=24%).

CONCLUSION

Prenatal exercise including PFMT reduced the odds and symptom severity of prenatal and postnatal UI. This was the case for women who were continent before the intervention. Among women who were incontinent during pregnancy, exercise training was not therapeutic.

Multiparity affects conduction properties of pelvic floor nerves in rabbits

INTRODUCTION

Women often develop pelvic floor dysfunction due to damage to the pelvic musculature during childbirth; however, the effect on pelvic floor nerves function is less understood. This study used adult rabbits to evaluate the electrophysiological and histological characteristics of the bulbospongiosus (Bsn) and pubococcygeus nerves (Pcn) in multiparity.

METHODS

Compound nerve action potentials (CNAP) were compared between age-matched nulliparous and multiparous animals and associated to the histological characteristics of myelinated axons from the Bsn and Pcn nerves. The extensor digitorum longus nerve (EDLn) was used as negative control. Data were analyzed with unpaired two-tailed Student's t test or Mann-Whitney U test to determine significant differences between groups.

RESULTS

The onset and peak latencies, duration, and conduction velocity of the motor fibers in these pelvic nerves were not significantly different between nulliparous and multiparous animals. However, the peak-to-peak amplitude and area of the CNAP in both Bsn and Pcn were reduced in multiparous rabbits. Histology showed a higher percentage of axons with myelin disorganization caused by multiparity in these pelvic nerves. Together, the data indicate a reduction in the number of functional pelvic axons due to multiparity. As expected, no effect of parity was observed in the EDLn controls.

CONCLUSIONS

Present findings demonstrated that multiparity affects myelination and consequently conduction properties in the small pelvic floor nerves.

Electrical stimulation of the pudendal nerve promotes neuroregeneration and functional recovery from stress urinary incontinence in a rat model

The pudendal nerve can be injured during vaginal delivery of children, and slowed pudendal nerve regeneration has been correlated with development of stress urinary incontinence (SUI). Simultaneous injury to the pudendal nerve and its target muscle, the external urethral sphincter (EUS), during delivery likely leads to slowed neuroregeneration. The goal of this study was to determine if repeat electrical stimulation of the pudendal nerve improves SUI recovery and promotes neuroregeneration in a dual muscle and nerve injury rat model of SUI. Rats received electrical stimulation or sham stimulation of the pudendal nerve twice weekly for up to 2 wk after injury. A separate cohort of rats received sham injury and sham stimulation. Expression of brain-derived neurotrophic factor (BDNF) and β_II-tubulin expression in Onuf's nucleus were measured 2, 7, and 14 days after injury. Urodynamics, leak point pressure (LPP), and EUS electromyography (EMG) were recorded 14 days after injury. Electrical stimulation significantly increased expression of BDNF at all time points and β_II-tubulin 1 and 2 wk after injury. Two weeks after injury, LPP and EUS EMG during voiding and LPP testing were significantly decreased compared with sham-injured animals. Electrical stimulation significantly increased EUS activity during voiding, although LPP did not fully recover. Repeat pudendal nerve stimulation promotes neuromuscular continence mechanism recovery possibly via a neuroregenerative response through BDNF upregulation in the pudendal motoneurons in this model of SUI. Electrical stimulation of the pudendal nerve may therefore improve recovery after childbirth and ameliorate symptoms of SUI by promoting neuroregeneration after injury.

Breaking news in the prediction of pelvic floor disorders

Urinary incontinence (UI) and fecal incontinence (FI) together with pelvic organ prolapse (POP) constitute a huge global health problem affecting millions of women throughout the world. These pelvic floor disorders (PFDs) can have a negative influence on a woman's well-being, quality of life, and sexual function and prevent many women from participating in recreational and sporting activities. The global costs of PFDs to health care systems and society are enormous and approximately one in five women will undergo surgery for genital prolapse or UI by the age of 85 years.

Risk factors for postpartum urinary retention after vaginal delivery at term without epidural anesthesia

Objective: We performed a retrospective case-control study of vaginal delivery at term without epidural anesthesia to identify clinical predictions of postpartum urinary retention (PUR). Methods: We reviewed the obstetric records of all singleton vaginal deliveries at Japanese Red Cross, Katsushika Maternity Hospital form January 2016 through December 2017. Results: There were 58 women (2.4%) complicated by PUR and 2391 women without PUR. A multivariate analysis revealed nulliparity, instrumental delivery, and episiotomy as independent risk factors for PUR (nulliparity: adjusted OR 2.39, 95%CI 1.2-4.8, p = 0.01; instrumental delivery: 3.53, 95%CI 1.9-6.7, p < .01, episiotomy: adjusted OR 1.96, 95%CI 1.0-3.8, p = .04). While, urination (or urethral catheterization) within 1 hour before delivery revealed as independent prevention factor for PUR (adjusted OR 0.54, 95%CI 0.30-0.99, p = .048). Conclusions: The risk factors identified in our institute seemed to approximately similar to those observed in the institutes capable of performing epidural anesthesia. In addition, urination just before delivery seemed to be an independent prevention factor for PUR.

Pelvic muscles' mechanical response to strains in the absence and presence of pregnancy-induced adaptations in a rat model

BACKGROUND

Maternal birth trauma to the pelvic floor muscles is thought to be consequent to mechanical demands placed on these muscles during fetal delivery that exceed muscle physiological limits. The above is consistent with studies of striated limb muscles that identify hyperelongation of sarcomeres, the functional muscle units, as the primary cause of mechanical muscle injury and resultant muscle dysfunction. However, pelvic floor muscles' mechanical response to strains have not been examined at a tissue level. Furthermore, we have previously demonstrated that during pregnancy, rat pelvic floor muscles acquire structural and functional adaptations in preparation for delivery, which likely protect against mechanical muscle injury by attenuating the strain effect.

OBJECTIVE

We sought to determine the mechanical impact of parturition-related strains on pelvic floor muscles' microstructure, and test the hypothesis that pregnancy-induced adaptations modulate muscle response to strains associated with vaginal delivery.

STUDY DESIGN

Three-month-old Sprague-Dawley late-pregnant (N = 20) and nonpregnant (N = 22) rats underwent vaginal distention, replicating fetal crowning, with variable distention volumes. Age-matched uninjured pregnant and nonpregnant rats served as respective controls. After sacrifice, pelvic floor muscles, which include coccygeus, iliocaudalis, and pubocaudalis, were fixed in situ and harvested for fiber and sarcomere length measurements. To ascertain the extent of physiological strains during spontaneous vaginal delivery, analogous measurements were obtained in intrapartum rats (N = 4) sacrificed during fetal delivery. Data were compared with repeated measures and 2-way analysis of variance, followed by pairwise comparisons, with significance set at P < .05.

RESULTS

Gross anatomic changes were observed in the pelvic floor muscles following vaginal distention, particularly in the entheseal region of pubocaudalis, which appeared translucent. The above appearance resulted from dramatic stretch of the myofibers, as indicated by significantly longer fiber length compared to controls. Stretch ratios, calculated as fiber length after vaginal distention divided by baseline fiber length, increased gradually with increasing distention volume. Paralleling these macroscopic changes, vaginal distention resulted in acute and progressive increase in sarcomere length with rising distention volume. The magnitude of strain effect varied by muscle, with the greatest sarcomere elongation observed in coccygeus, followed by pubocaudalis, and a smaller increase in iliocaudalis, observed only at higher distention volumes. The average fetal rat volume approximated 3 mL. Pelvic floor muscle sarcomere lengths in pregnant animals undergoing vaginal distention with 3 mL were similar to intrapartum sarcomere lengths in all muscles (P > .4), supporting the validity of our experimental approach. Vaginal distention resulted in dramatically longer sarcomere lengths in nonpregnant compared to pregnant animals, especially in coccygeus and pubocaudalis (P < .0001), indicating significant attenuation of sarcomere elongation in the presence of pregnancy-induced adaptations in pelvic floor muscles.

CONCLUSION

Delivery-related strains lead to acute sarcomere elongation, a well-established cause of mechanical injury in skeletal muscles. Sarcomere hyperelongation resultant from mechanical strains is attenuated by pregnancy-induced adaptations acquired by the pelvic floor muscles prior to parturition.

Expert consensus document: Advances in the evaluation of anorectal function

Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.

Vaginal delivery-related changes in the pelvic organ position and vaginal cross-sectional area in the general population

PURPOSE

Evaluate the effect of vaginal delivery on pelvic organ positions and vaginal cross-sectional areas.

METHODS

MRI of 119 premenopausal women were grouped according to the number of deliveries. The distances from the three 3-reference points (bladder, uterus, and rectum) to two 2-lines (pubococcygeal-line (PCL) and midpubic-line (MPL)), length of H- and M-lines and vaginal cross-sectional area were compared between the groups.

RESULTS

With increasing parity, distance from the rectum to PCL tended to increase (nullipara vs. bipara; p<0.01). Vaginal cross-sectional area was larger in bipara and tripara than in nullipara (p<0.01).

CONCLUSIONS

Rectal position is more caudally located and vaginal cross-sectional area is larger in bipara than in nullipara.

Clinical relevance of neurological evaluation in patients suffering urinary retention in the absence of subvesical obstruction

PURPOSE

Clinical relevance of neurological evaluation in patients suffered urinary retention in the absence of subvesical obstruction. Determining whether (1) women complaining residual bladder volume without prolapse and obstruction always suffer pudendal nerve damage; (2) neurogenic damage can be linked to patients history/clinical examination; (3) therapy alters regarding to neurological findings; and (4) electromyography (EMG) of musculus sphincter ani externus (MSAE) can be omitted with electronically stimulated pudendal nerve latency (ESPL) as the standard investigation.

METHODS

Women with urinary retention without ≥stage 2 prolapse or obstruction have neurological investigation including vaginally and anally pudendal terminal nerve latency (PTNL) (>2.4 ms considered abnormal) and EMG seen 7/2005-04/2010.

RESULTS

(1) 148/180 (82.2%) suffered at least moderate neurogenic damage and (2) severe neurogenic damage occurs with urge odds ratio (OR) = 3.1 or age (OR = 3.2). Correlations: spasticity with therapy changes (OR = 11.1), latencies. (a) Anally: (i) right and peripheral neuropathy (PNP) (OR = 2.5), chemotherapy (OR = 5.0); (ii) left and PNP (OR = 3.9), chemotherapy (OR = 4.8); (iii) left or right with PNP (OR = 3.9), chemotherapy (OR = 6.8); and (iv) left and right with chemotherapy (OR = 5.0). (b) Vaginally: (i) right with age >60 (OR = 3.2), radical operation (OR = 10.6); (ii) left with diabetes mellitus (OR = 2.5); and (iii) left or right with age (OR = 3.3), radical operation (OR = 8.7). (3) 19.6% therapy changes (36 patients). (4) Neither EMG nor ESPL can be replaced one by another (p = 0.12 anal, p = 0.05 vaginal).

CONCLUSION

Red flags are neurogenic damage, age >60, chemotherapy, PNP, radical operation or diabetes. In unclear situations, EMG and ESPL need to be performed to gain relevant information.

Electrical stimulation structurally affects the tissues of the rectum and anus of nulliparous rats

Considering that the muscles of the anus perform a critical role in maintaining continence, losses in their structure can negatively affect the physiological control of the intestinal contents. Anorectal electro-stimulation (ARES) has been reported to have a positive effect on the functionality of treated patients, but how ARES affects the structural tissues of the anorectal segment remains unknown. Because the study of how ARES structurally affects human tissues is not possible, this study aimed to clarify these effects in a murine model, which has a similar anorectal segment (structure and physiology) to humans. For the descriptive and comparative study, randomly selected nulliparous adult Wistar rats (n = 5) were submitted to 30 anorectal sessions of ARES with a biphasic current (700 μs, 50 Hz from 2 to 4 mA). After treatment, the animals were euthanized, and the anorectal segments were dissected and processed for histopathological analysis. Our results showed that ARES increased the widths of the mucosal, submucosal and muscle layers of the rectum, as well as the number of leukocytes in the mucosa. ARES also caused hyperplasia of the smooth muscle of the internal anal sphincter and hypertrophy of the external anal sphincter muscle. In conclusion, our results showed that ARES had not only a positive effect on the structure (morphology) of all tissues associated with the rectum and anus but, more importantly, on the structural gain of the muscles (hyperplasia and hypertrophy), which could point to a functional gain of the anal sphincter, reinforcing the applicability of ARES as a non-invasive treatment for anal incontinence.

Diagnostic Evaluation of Chronic Pelvic Pain

Chronic pelvic pain can result from various intra- and extra-pelvic etiologies. Although patient history and physical examination may narrow the differential diagnosis, frequently, the different etiologies have overlapping presentations. Imaging examinations such as US and/or MR imaging may help delineate the cause of pain, particularly when related to intra-pelvic organs, pelvic floor dysfunction or prolapse, synthetic material such as pelvic mesh or slings, and in some cases of neuropathic pain. Etiologies of neuropathic pain can also be assessed with non-imaging tests such as nerve conduction studies, electromyography, and testing of sacral reflexes.

Impact of caesarean section on mode of delivery, pregnancy-induced and pregnancy-associated disorders, and complications in the subsequent pregnancy in Germany

Objectives: To analyze the impact of caesarean section (CS) on mode of delivery, pregnancy-induced and pregnancy-associated disorders, as well as complications in the subsequent pregnancy within German gynecological practices.

Methods: 1,801 women with CS and 1,801 matched women with vaginal delivery (VD) from the IMS Disease Analyzer database were included. The impact of previous CS on the mode of delivery and pregnancy-associated disorders as well as complications prior to or during birth in the subsequent pregnancy were analyzed. Cox regressions were used to determine the influence of CS with regard to these outcomes.

Results: Medical abortion and single spontaneous delivery were significantly less frequent in women with a history of CS compared to VD (OR equal to 0.52 and 0.04 respectively), whereas CS after CS was the significantly more common mode of delivery (79.0% versus 9.3%, OR=36.47). Gestational hypertension without significant proteinuria, gestational hypertension with significant proteinuria, and polyhydramnios were more frequent in women with CS than in women with VD (OR equal to 6.80, 1.71, and 2.29). Hemorrhage and maternal care for known or suspected disproportion were more common in the CS group than in the VD group (OR equal to 1.34 and 3.75). Prolonged pregnancy, preterm labor, abnormalities arising from forces of labor, and perineal laceration during delivery were significantly less frequent in women with CS than in women with VD (OR between 0.32 and 0.75), whereas long labor was more common (OR=2.09).

Conclusion: Women with CS were more likely to undergo further CS and to develop major pregnancy-associated diseases in the following pregnancy compared to women with VD.

Reversal of sensory deficit through sacral neuromodulation in an animal model of fecal incontinence

BACKGROUND

Sacral neuromodulation (SNM) is a treatment option for intractable fecal incontinence. The mechanism of action is unclear, however, increasing evidence for afferent somatosensory effects exists. This study's aim was to elucidate effects of acute SNM on the cerebral cortex in a rodent model of pudendal nerve injury.

METHODS

The effects of 14 Hz and 2 Hz SNM on sensory cortical activation were studied. In 32 anesthetized rats, anal canal evoked potentials (EPs) were recorded over the primary somatosensory cortex. Pudendal nerve injury was produced by 1-hour inflation of two intra-pelvic balloons. Four groups were studied: balloon injury, balloon injury plus either 14 Hz or 2 Hz SNM, sham operation. Immunohistochemistry for the neural plasticity marker polysialylated neural cell adhesion molecule (PSA-NCAM) positive cells (numerical density and location) in the somatosensory cortex was performed.

KEY RESULTS

Anal EP amplitudes diminished during balloon inflation; 14 Hz SNM restored diminished anal EPs to initial levels and 2 Hz SNM to above initial levels. Evoked potential latencies were prolonged during balloon inflation. The numerical density of PSA-NCAM positive cells increased in the SNM groups, but not in sham or balloon injury without SNM. Stimulated cortices showed clusters of PSA-NCAM positive cells in layers II, IV, and V. Post SNM changes were similar in both SNM groups.

CONCLUSIONS & INFERENCES

Sacral neuromodulation augments anal representation in the sensory cortex and restores afferent pathways following injury. PSA-NCAM positive cell density is increased in stimulated cortices and positive cells are clustered in layers II, IV, and V.

Topography and landmarks for the nerve supply to the levator ani and its relevance to pelvic floor pathologies

The aim of this study was to explore the anatomical variations of the nerve to the levator ani (LA) and to relate these findings to LA dysfunction. One hundred fixed human female cadavers were dissected using transabdominal, gluteal, and perineal approaches, resulting in two hundred dissections of the sacral plexus. The pudendal nerve and the sacral nerve roots were traced from their origin at the sacral foramina to their termination. All nerves contributing to the innervation of the LA were considered to be the nerve to the LA. Based on the spinal nerve components, the nerve to the LA was classified into the following categories: 50% (n = 100) originated from S4 and S5 (type I); 19% (n = 38) originated from S5 (type II); 16% (n = 32) originated from S4 (type III); 11% (n = 22) originated from S3 and S4 (type IV); 4% (n = 8) originated from S3, S4, and S5 (type V). Two patterns of nerve termination were observed. In 42% of specimens, the nerve to the LA penetrated the coccygeus muscle and assumed an external position along the inferior surface of the LA muscle. In the remaining 58% of specimens, the nerve crossed the superior surface of the coccygeus muscle and continued along the superior surface of the iliococcygeus muscle. Damage to the nerve to LA has been associated with various pathologies. In order to minimize injuries during surgical procedures, a thorough understanding of the course and variations of the nerve to the LA is extremely important.

Delivery-related risk factors for covert postpartum urinary retention after vaginal delivery

Introduction and hypothesis

Postpartum urinary retention (PUR) is a common consequence of bladder dysfunction after vaginal delivery. Patients with covert PUR are able to void spontaneously but have a postvoid residual bladder volume (PVRV) of ≥150 mL. Incomplete bladder emptying may predispose to bladder dysfunction at a later stage of life. The aim of this cross-sectional study was to identify independent delivery-related risk factors for covert PUR after vaginal delivery in order to identify women with an increased risk of covert PUR.

Methods

The PVRV of women who delivered vaginally was measured after the first spontaneous micturition with a portable bladder-scanning device. A PVRV of 150 mL or more was defined as covert PUR. Independent risk factors for covert PUR were identified in multivariate regression analysis.

Results

Of 745 included women, 347 (47 %) were diagnosed with covert PUR (PVRV ≥150 mL), of whom 197 (26 %) had a PVRV ≥250 mL (75th percentile) and 50 (7 %) a PVRV ≥500 mL (95th percentile). In multivariate regression analysis, episiotomy (OR 1.7, 95 % CI 1.02 – 2.71), epidural analgesia (OR 2.08, 95 % CI 1.36 – 3.19) and birth weight (OR 1.03, 95 % CI 1.01 – 1.06) were independent risk factors for covert PUR. Opioid analgesia during labour (OR 3.19, 95 % CI 1.46 – 6.98), epidural analgesia (OR 3.54, 95 % CI 1.64 – 7.64) and episiotomy (OR 3.72, 95 % CI 1.71 – 8.08) were risk factors for PVRV ≥500 mL.

Conclusions

Episiotomy, epidural analgesia and birth weight are risk factors for covert PUR. We suggest that the current cut-off values for covert PUR should be reevaluated when data on the clinical consequences of abnormal PVRV become available.

Perineal outcome and the risk of pelvic floor dysfunction: a cohort study of primiparous women

BACKGROUND

Pelvic floor dysfunction (PFD) is the most common complication of childbirth. Assumptions have been made that perineal trauma increases the risk of PFD compared to an intact perineum, however the evidence for this is lacking. The aim of this study was to explore the relationship between perineal outcome and postpartum PFD.

MATERIALS AND METHODS

Prospective cohort study design, with a self-reported quality of life (QOL) questionnaire mailed to all primiparous women with a non-instrumental delivery at The Townsville Hospital between 2011 and 2012 (n = 766). ANOVA was used to compare how the symptoms of PFD affect QOL in women with an intact perineum, episiotomy or spontaneous tear.

RESULTS

Seventy-nine percent of the population had perineal injury; 60% had a spontaneous tear and 19% had an episiotomy. Ninety-seven percent of women who completed the questionnaire (n = 196) complained of PFD symptoms. Women with episiotomy had the best QOL, reporting the lowest levels of urinary dysfunction (statistically significant). No differences between the groups were found for symptoms of bowel, prolapse or sexual dysfunction.

CONCLUSIONS

This study shows a relationship between perineal outcome and PFD and suggests that an episiotomy is associated with the least morbidity due to symptoms of urinary incontinence. Additional large-scale prospective research is required to further investigate and delineate the impact of childbirth on PFD.

Brain-derived neurotrophic factor in urinary continence and incontinence

Urinary incontinence adversely affects quality of life and results in an increased financial burden for the elderly. Accumulating evidence suggests a connection between neurotrophins, such as brain-derived neurotrophic factor (BDNF), and lower urinary tract function, particularly with regard to normal physiological function and the pathophysiological mechanisms of stress urinary incontinence (SUI) and bladder pain syndrome/interstitial cystitis (BPS/IC). The interaction between BDNF and glutamate receptors affects both bladder and external urethral sphincter function during micturition. Clinical findings indicate reduced BDNF levels in antepartum and postpartum women, potentially correlating with postpartum SUI. Experiments with animal models demonstrate that BDNF is decreased after simulated childbirth injury, thereby impeding the recovery of injured nerves and the restoration of continence. Treatment with exogenous BDNF facilitates neural recovery and the restoration of continence. Serotonin and noradrenaline reuptake inhibitors, used to treat both depression and SUI, result in enhanced BDNF levels. Understanding the neurophysiological roles of BDNF in maintaining normal urinary function and in the pathogenesis of SUI and BPS/IC could lead to future therapies based on these mechanisms.

Improvement in stress urinary incontinence after abdominoplasty

BACKGROUND

Abdominoplasty is indicated in cosmetic surgery to improve body contour. Results from several studies suggest that abdominoplasty also could be therapeutic for certain individuals with urinary incontinence.

OBJECTIVES

The authors sought to determine the potential therapeutic effect of abdominoplasty on urinary incontinence in a large population to confirm the findings of smaller studies and to identify common characteristics of patients who experience the greatest improvement in these symptoms postoperatively.

METHODS

Through a retrospective chart review, the authors identified 250 patients who underwent cosmetic abdominoplasty. These patients were invited to participate in a survey to ascertain changes in stress urinary incontinence (SUI) symptoms after abdominoplasty. Patients were subgrouped according to postoperative changes in their urinary incontinence symptoms, and the subgroups were evaluated for common within-group characteristics.

RESULTS

Of the 250 patients who underwent abdominoplasty during the period of interest, 100 (40%) completed the survey, half of whom (n=50) reported incontinence preoperatively. After abdominoplasty, 30 (60%) of these 50 patients noted improvement in their symptoms, and the other 20 (40%) reported no improvement. Lack of previous cesarean section was a predictor of improvement in SUI symptoms after abdominoplasty.

CONCLUSIONS

Abdominoplasty to improve body contour also may alleviate symptoms of SUI, especially among patients who have not undergone previous cesarean section.

LEVEL OF EVIDENCE

4.