Use of a visual analog scale for evaluation of bother from pelvic organ prolapse

Educational telerehabilitation program for women with pelvic floor dysfunctions after gynecological pelvic cancer treatment: protocol study for a randomized and controlled clinical trial

BACKGROUND

Educational and self-care measures are important for women after gynecological pelvic cancer treatment. Pelvic floor muscle training exercises (PFMT) are a conservative treatment for pelvic floor (PF) dysfunction. The purpose is to evaluate the impact of a telerehabilitation and self-care program on PF dysfunctions, reports of urinary incontinence (UI), and physical-emotional factors of participants post-treatment for gynecological pelvic cancer.

METHODS

Two-arm randomized clinical trial: an intervention group (IG) will evaluate the effect of a telerehabilitation program on women undergoing clinical practice of radiotherapy for the treatment of gynecological pelvic cancer and a control group (CG) will maintain the routine. Primary outcome is the prevalence of reports of UI, which will be assessed using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF). The secondary outcomes will be the severity and impact of UI on quality of life, location and perception of pain intensity, presence and intensity of dyspareunia, vaginal stenosis, fecal incontinence (FI), and levels of physical activity. Statistical analysis will be performed by intention-to-treat, and multivariate mixed effects analysis will be used to compare results.

DISCUSSION

Activities in the context of telerehabilitation using PFMT and self-care can represent a viable and effective solution to minimize the side effects of gynecological cancer treatment and improve women's quality of life.

Analysis of minimal levator ani hiatus area based on MRI in female adults without pelvic floor dysfunction at different age groups

PURPOSE

To investigate the association of minimal levator ani hiatus area with age in female adults without pelvic floor dysfunction.

METHODS

532 female subjects aged 18 ~ 90 years without pelvic floor dysfunction, divided into four groups (Group A, 18 ~ 29 years old; Group B, 30 ~ 39 years old; Group C, 40 ~ 49 years old; Group D, ≥ 50 years old) based on age, underwent traditional pelvic two-dimensional (2D) T2-weighted imaging (T2WI) axial to the body (AxB) for measuring the minimal levator ani hiatus area. 39 female volunteers were re-recruited to undergo both traditional pelvic 2D T2WI AxB and three-dimensional (3D) T2WI. An axial plane parallel to the direction of the puborectalis muscle (AxPRM) was acquired based on 3D T2WI. The difference of levator ani hiatus area measured on AxB and AxPRM images in 39 female volunteers was compared by one-sample t test, to verify if minimal levator ani hiatus area can be acquired on the traditional pelvic 2D T2WI AxB images. Spearman analysis evaluated the association of minimal levator ani hiatus area with age and the rank-sum test analyzed the area differences among four age groups.

RESULTS

Female age was positively correlated with minimal levator ani hiatus area (r = 0.23; p < 0.001). The minimal levator ani hiatus areas of 532 subjects were: 15.17 ± 1.77 cm2 in Group A, 15.52 ± 2.21 cm2 in Group B, 16.03 ± 2.16 cm2 in Group C, and 16.40 ± 2.10 cm2 in Group D. ANOVA showed significant statistical differences among four age groups (F = 7.519, p < 0.0001). Significant differences in minimal levator ani hiatus areas were found between Group A and Group C (p = 0.0491), Group A and Group D (p = 0.0007), and Group B and Group D (p < 0.001). There was no statistical difference in minimal levator ani hiatus areas measured on AxB and AxPRM images in 39 female volunteers (p = 0.1000). There were no statistical difference in minimal levator ani hiatus areas between nulliparous and multiparous group for each age group (all p > 0.05).

CONCLUSIONS

Based on a large sample, this study summarized the minimum levator ani hiatus area of female adults without pelvic floor dysfunction in different age groups. We found significant differences among different age groups. In addition, a positive correlation was found between age and the minimum levator ani hiatus area. These findings can provide reference criteria for diagnosing pelvic organ prolapse in female adults of different age groups.

Determinants of Dissatisfaction After Laparoscopic Cure of Vaginal and/or Rectal Prolapse using Mesh: a Comprehensive Retrospective Cohort Study

INTRODUCTION AND HYPOTHESIS

The primary objective is to identify determinants of dissatisfaction after surgical treatment of vaginal prolapse ± rectal prolapse, using laparoscopic mesh sacrohysteropexy (LSH) or sacrocolpopexy (LSC) ± ventral mesh rectopexy (VMR). The secondary objective is the evaluation of complications and objective/subjective recurrence rates.

METHODS

The study performed was a single-surgeon retrospective review of prospectively collected data. LSH/LSC ± VMR were performed between July 2005 and September 2022. Primary investigated outcome was patients' satisfaction, assessed using the Patient Global Impression of Improvement (PGI-I) score and the bother visual analog scale (VAS) obtained postoperatively (at a 1-month interval and on a 6-month/yearly basis thereafter). We looked for a correlation between the level of satisfaction (as reflected by the VAS) and potential determinants.

RESULTS

There were 355 patients with a mean age of 62 ±12 years. Nearly all the patients (94.3%) had a stage 3 or 4 prolapse according to the POP-Q classification. The mean postoperative bother VAS was 1.8, with only 12.7% of patients reporting a bother VAS score ≥ 3/10, indicating a dissatisfaction. PGI-I showed improvement in the vast majority of patients (96.4% scoring 1 to 3). Patients with anal incontinence preoperatively scored higher on the bother VAS postoperatively (r=0.175, p < 0.05). The use of a posterior arm mesh (for posterior vaginal prolapse) correlated with better satisfaction overall (r= -0.178, p = 0.001), whereas the performance of VMR was associated with a bothering sensation (r = 0.232, p < 0.001). A regression analysis confirmed the impact of posterior mesh and VMR on satisfaction levels, with odds of dissatisfaction being 2.18 higher when VMR was combined with LSH/LSC.

CONCLUSIONS

Posterior mesh use improves patient satisfaction when the posterior compartment is affected. In patients with concomitant vaginal and rectal prolapse, combining VMR with anterior LSC/LSH appears to negatively impact patients' satisfaction. Preoperative anal incontinence was demonstrated to be a risk factor for postoperative dissatisfaction.

The effect of prolapse surgery on voiding function

INTRODUCTION AND HYPOTHESIS

Of women with symptomatic prolapse, 13-39% experience voiding dysfunction (VD). The aim of our observational cohort study was to determine the effect of prolapse surgery on voiding function.

METHODS

Retrospective analysis of 392 women who underwent surgery between May 2005 and August 2020. All had a standardized interview, POP-Q, uroflowmetry and 3D/4D transperineal ultrasound (TPUS) pre-and postoperatively. Primary outcome was change in VD symptoms. Secondary outcomes were changes in maximum urinary flow rate (MFR) centile and post-void residual urine (PVR). Explanatory measures were change in pelvic organ descent as seen on POP-Q and TPUS.

RESULTS

Of 392 women, 81 were excluded due to missing data, leaving 311. Mean age and BMI were 58 years and 30 kg/m2, respectively. Procedures performed included anterior repair (n = 187, 60.1%), posterior repair (n = 245, 78.8%), vaginal hysterectomy (n = 85, 27.3%), sacrospinous colpopexy (n = 170, 54.7%) and mid-urethral sling (MUS) (n = 192, 61.7%). Mean follow-up was 7 (1-61) months. Pre-operatively, 135 (43.3%) women reported symptoms of VD. Postoperatively, this decreased to 69 (22.2%) (p < 0.001), and of those, 32 (10.3%) reported de novo VD. The difference remained significant after excluding concomitant MUS surgery (n = 119, p < 0.001). Postoperatively, there was a significant decrease in mean PVR (n = 311, p < 0.001). After excluding concomitant MUS surgery, there was a significant increase in mean MFR centile (p = 0.046).

CONCLUSIONS

Prolapse repair significantly reduces symptoms of VD and improves PVR and flowmetry.

Patient-Specific Pessaries for Pelvic Organ Prolapse Using Three-Dimensional Printing: A Pilot Study

IMPORTANCE

Vaginal pessaries are an effective nonsurgical treatment for pelvic organ prolapse (POP) when properly fitted. However, pessary fitting and use are often unsuccessful or imperfect.

OBJECTIVE

The objective of this study was to assess the feasibility of using patient-specific pessaries fabricated from three-dimensional (3D)-printed molds to improve POP symptoms and increase overall satisfaction of pessary treatment in patients using standard vaginal pessaries.

STUDY DESIGN

Patients undergoing POP treatment with standard vaginal pessaries were enrolled in this pilot prospective study. Patient-specific pessaries were designed and fabricated for each patient using patient input, physician input, and anatomic measurements from clinical assessment. Pessary fabrication involved injection of biocompatible liquid silicone rubber into 3D-printed molds followed by a biocompatible silicone coating. Pelvic organ prolapse symptomatic distress and pessary treatment satisfaction were evaluated before and after a 3-week patient-specific pessary home trial using the validated Pelvic Organ Prolapse Distress Inventory-6 form and a visual analog scale, respectively.

RESULTS

Eight women were included in this study. Changing from standard pessary to patient-specific pessary treatment was associated with an improvement in prolapse symptoms on the Pelvic Organ Prolapse Distress Inventory-6 (median change, -3.5; interquartile range, -5 to -2.5; P = 0.02) and an increase in overall pessary satisfaction on a visual analog scale (median change, +2.0; interquartile range, +1.0 to +3.0; P = 0.02). All patients reported either an improvement or no change in pessary ease of use, comfort, and the feeling of support provided by the pessary.

CONCLUSION

Patient-specific vaginal pessaries are a promising alternative to standard pessaries for alleviating POP symptoms and improving patient satisfaction with pessary use.

Oestrogen therapy for treating pelvic organ prolapse in postmenopausal women

BACKGROUND

Pelvic organ prolapse (POP) is the descent of a woman's uterus, bladder, or rectum into the vagina. It affects 50% of women over 50 years old who have given birth to at least one child, and recognised risk factors are older age, higher number of births, and higher body mass index. This review assesses the effects of oestrogen therapy, alone or in combination with other treatments, on POP in postmenopausal women.

OBJECTIVES

To assess the benefits and harms of local and systemic oestrogen therapy in the management of pelvic organ prolapse symptoms in postmenopausal women, and to summarise the principal findings of relevant economic evaluations.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register (up to 20 June 2022), which includes CENTRAL, MEDLINE, two trials registers, and handsearching of journals and conference proceedings. We also checked the reference lists of relevant articles for additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, multi-arm RCTs, and cross-over RCTs that evaluated the effects of oestrogen therapy (alone or in combination with other treatments) versus placebo, no treatment, or other interventions in postmenopausal women with any grade of POP.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included trials using prespecified outcome measures and a piloted extraction form. The same review authors independently assessed the risk of bias of eligible trials using Cochrane's risk of bias tool. Had data allowed, we would have created summary of findings tables for our main outcome measures and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We identified 14 studies including a total of 1002 women. In general, studies were at high risk of bias in terms of blinding of participants and personnel, and there were also some concerns about selective reporting. Owing to insufficient data for the outcomes of interest, we were unable to perform our planned subgroup analyses (systemic versus topical oestrogen, parous versus nulliparous women, women with versus without a uterus). No studies assessed the effects of oestrogen therapy alone versus no treatment, placebo, pelvic floor muscle training, devices such as vaginal pessaries, or surgery. However, we did identify three studies that assessed oestrogen therapy in conjunction with vaginal pessaries versus vaginal pessaries alone and 11 studies that assessed oestrogen therapy in conjunction with surgery versus surgery alone.

AUTHORS' CONCLUSIONS

There was insufficient evidence from RCTs to draw any solid conclusions on the benefits or harms of oestrogen therapy for managing POP symptoms in postmenopausal women. Topical oestrogen in conjunction with pessaries was associated with fewer adverse vaginal events compared with pessaries alone, and topical oestrogen in conjunction with surgery was associated with reduced postoperative urinary tract infections compared with surgery alone; however, these findings should be interpreted with caution, as the studies that contributed data varied substantially in their design. There is a need for larger studies on the effectiveness and cost-effectiveness of oestrogen therapy, used alone or in conjunction with pelvic floor muscle training, vaginal pessaries, or surgery, for the management of POP. These studies should measure outcomes in the medium and long term.

Is posterior compartment prolapse associated with anal incontinence?

OBJECTIVE

It has been claimed that manifestations of posterior compartment prolapse, such as rectocele, enterocele and intussusception, are associated with anal incontinence (AI), but this has not been studied while controlling for anal sphincter trauma. We aimed to investigate this association in women with intact anal sphincter presenting with pelvic floor dysfunction.

METHODS

This retrospective study analyzed 1133 women with intact anal sphincter presenting to a tertiary urogynecological center for pelvic floor dysfunction between 2014 and 2016. All women underwent a standardized interview, including assessment of symptoms of AI, clinical examination and three-/four-dimensional transperineal ultrasound. Descent of the rectal ampulla, true rectocele, enterocele, intussusception and anal sphincter trauma were diagnosed offline.

RESULTS

Mean age was 54.1 (range, 17.6-89.7) years and mean body mass index was 29.4 (range, 14.7-67.8) kg/m2 . AI was reported by 149 (13%) patients, with a median St Mark's anal incontinence score of 12 (interquartile range, 1-23). Significant posterior compartment prolapse was seen in 693 (61%) women on clinical examination. Overall, 638 (56%) women had posterior compartment prolapse on imaging: 527 (47%) had a true rectocele, 89 (7.9%) had an enterocele and 26 (2.3%) had an intussusception. Women with ultrasound-diagnosed enterocele had a significantly higher rate of AI (23.6% vs 12.3%; odds ratio (OR), 2.21 (95% CI, 1.31-3.72); P = 0.002), but when adjusted for potential confounders, this association was no longer significant (OR, 1.56 (95% CI, 0.82-2.77); P = 0.134).

CONCLUSION

In women without anal sphincter trauma, posterior compartment prolapse, whether diagnosed clinically or by imaging, was not shown to be associated with AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Clinical assessment of pelvic organ prolapse by consecutive cough maneuver

INTRODUCTION AND HYPOTHESIS

Staging of pelvic organ prolapse (POP) is important in clinical practice and research. Pelvic organ descent on Valsalva can be confounded by levator co-activation, which may be avoided by assessment on coughing. We evaluated the performance of a three consecutive coughs maneuver in the assessment of POP compared with standardised 6-second Valsalva.

METHODS

This was a retrospective observational study carried out in women attending a tertiary urogynaecological service in 2017-2019. Patients underwent a standardised interview and clinical examination. Clinical assessment was performed twice, with both 6-s Valsalva and three consecutive coughs performed in random order. Main outcomes were Ba, C and Bp as defined by Pelvic Organ Prolapse-Quantification (POP-Q). Association between coordinates and prolapse symptoms was investigated with receiver-operating characteristic (ROC) statistics.

RESULTS

Datasets of 855 women were analysed. POP symptoms were reported by 447 patients (52%) with a mean bother of 6.1 (SD 3.0). On clinical assessment, relevant prolapse was found in 716 (84%) patients on Valsalva and in 730 (85%) on coughing (p=0.109). Clinically relevant prolapse in the apical compartment was more likely to be detected on Valsalva (p<0.0001). Mean POP-Q measurements were not significantly different between maneuvers, except for Ba (p=0.004). ROC curve analysis yielded an area under the curve of 0.74 (95% CI, 0.70-0.77) for maximum POP-Q stage on Valsalva and 0.72 (95% CI, 0.69-0.75) after three consecutive coughs, with a similar performance of both maneuvers in predicting prolapse symptoms (p=0.95).

CONCLUSIONS

Clinical assessment of POP by consecutive coughing seems complementary to standardised Valsalva, especially if Valsalva performance is poor.

All or nothing? A second look at partial levator avulsion

OBJECTIVE

To define associations between partial levator trauma and symptoms and signs of pelvic organ prolapse (POP).

METHODS

This was a retrospective study of 3484 women attending a tertiary urogynecology unit for symptoms of pelvic floor dysfunction between January 2012 and February 2020. All women underwent a standardized interview, clinical pelvic organ prolapse quantification (POP-Q) examination and tomographic ultrasound imaging of the pelvic floor. Women with full levator avulsion were excluded from analysis. Partial levator avulsion was quantified using the tomographic trauma score (TTS), in which slices 3-8 are scored bilaterally for abnormal insertions. Binomial multiple logistic regression was analyzed independently for the outcome variables prolapse symptoms, symptom bother and objective prolapse on clinical examination and imaging, with age and body mass index as covariates. Two continuous outcome variables, prolapse bother score and hiatal area on Valsalva, were analyzed using multiple linear regression.

RESULTS

Of the 3484 women, ultrasound data were missing or incomplete in 164 due to lack of equipment, clerical error and/or inadequate image quality. Full levator avulsion was diagnosed in 807 women, leaving 2513 for analysis. TTS ranged from 0-10, with a median of 0. Partial trauma (TTS > 0) was observed in 667/2513 (26.5%) women. All subjective and objective measures of POP were associated significantly with TTS, most strongly for cystocele. Associations were broadly linear and similar for all slice locations but disappeared after accounting for hiatal area on Valsalva.

CONCLUSION

Partial avulsion is associated with POP and prolapse symptoms. This association was strongest for cystocele, both on POP-Q and ultrasound imaging. The effect of partial avulsion on POP and prolapse symptoms is explained fully by its effect on hiatal area. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

The Relationship Between Perineal Body Size, Total Vaginal Length, Apical Prolapse, and Prolapse Symptoms

IMPORTANCE

Currently, apical prolapse is diagnosed via assessing the levels of C and D points in the pelvic organ prolapse quantification (POP-Q) system. However, it is not yet known whether the other components of this system are useful for diagnosing apical prolapse and its symptoms.

OBJECTIVE

The aim of the study was to evaluate the association between the perineal body size (PB), total vaginal length (TVL), and apical prolapse and its symptoms.

STUDY DESIGN

Two hundred women, 100 women with apical prolapse and 100 women without, were included in this cross-sectional study. The association between the PB, TVL, and apical prolapse and its symptoms were evaluated. The relationship between the other POP-Q measurements and apical prolapse/prolapse symptoms were also evaluated as the secondary outcome of the study.

RESULTS

The TVL (cutoff value, ≤8 cm; sensitivity, 80%; specificity, 60%) and the genital hiatus size (GH; cutoff value of >4.5 cm; sensitivity, 90%; specificity, 91%) were significantly associated with apical prolapse. The PB cutoff value of 3.4 cm or less had lower sensitivity (49%) and specificity (70%) for the diagnosis of apical prolapse. The GH (cutoff value, >4.8 cm; area under curve [AUC], 0.927), C (cutoff value, >-5.8 cm; AUC, 0.955), and Ba (cutoff value, >-1.1 cm; AUC, 0.891) were significantly associated with apical prolapse symptoms. However, there was no association between the PB or TVL with symptoms.

CONCLUSIONS

The study results showed that the TVL and GH were more strongly associated with apical prolapse than PB. The GH, C, and Ba were also associated with prolapse symptoms, but PB and TVL were not.

The relationship between symptom severity, bother and psychological factors in women with pelvic organ prolapse: A cross-sectional observational study

AIM

The primary aim is to explore the relationship between symptom severity and prolapse bother in women with pelvic organ prolapse (POP). The secondary aim is to determine the association between psychological variables and prolapse bother.

METHODS

A cross-sectional observational study was conducted via online surveys assessing POP bother (visual analog scale for bother), POP symptom severity (International Consultation on Incontinence Questionnaire-Vaginal Symptoms), and psychological measures of depression and anxiety (Kessler psychological distress scale [K-10]), catastrophizing (modified pain catastrophizing scale [mPCS]), and self-efficacy (modified pain self-efficacy questionnaire [mPSEQ]) in women with self-reported POP. Symptom severity, bother and psychological variables were analyzed using linear regression.

RESULTS

Seventy-six women with a mean (SD) age of 42.8 (14.57) years were included in analysis. A moderate to strong positive linear relationship (R²  = 0.449, p < 0.001) was found between symptom severity and POP bother. Prolapse bother and psychological variables were moderately correlated, where increased K-10 scores (R²  = 0.230, p = 0.001), higher mPCS scores (R²  = 0.460, p < 0.001), and lower mPSEQ scores (R²  = 0.460, p < 0.001) were associated with increased POP bother. Moderate and severe catastrophizing was associated with significantly higher POP bother, with mean POP bother scores of 7.861 ± 0.45 (p < 0.001) and 8.652 ± 0.45 (p < 0.001), respectively.

CONCLUSION

A moderate positive relationship between POP bother and symptom severity was found, with greater psychological distress and lower self-efficacy associated with increasing POP bother. Women presenting with POP should be screened for psychological factors to guide management.

Is the Visual Analogue Scale inferior to the Pelvic Organ Prolapse Distress Inventory for assessing symptom bother of pelvic organ prolapse?

AIMS

Disease-specific validated questionnaires are used to quantify symptom severity, but they are time consuming to complete and evaluate. A Visual Analogue Scale (VAS) assessment of bother is simpler and faster. The aim of this study is to compare VAS with individual and composite pelvic floor disability index-short form 20 items in predicting significant pelvic organ prolapse (POP).

METHODS

A retrospective analysis of data was obtained at a tertiary urogynaecological clinic between February 2017 and August 2018. All women filled out the PFDI-20 and underwent a standardised physician-directed interview, POP-Q and translabial ultrasound. Women with symptoms of POP were asked to indicate the degree of bother using a VAS. Receiver operating characteristic curves were used to evaluate the performance of individual Pelvic Organ Prolapse Distress Inventory (POPDI)-6 items, the six-item composite POPDI-6 score, and VAS in predicting significant POP on clinical and ultrasound examination.

RESULTS

The complete data sets of 231 women were analysed. Median VAS for POP was 2.9 (range 0-10). Median POPDI-6 individual and composite scores for items one to six were 2, 2, 2, 1, 2, 0 (all range 0-4) and 9 (range 0-22), respectively. The majority had significant prolapse on clinical examination (n = 195, 84%) and on ultrasound (n = 192, 83%). The composite POPDI-6 prolapse score provided areas under the curve of 0.68 and 0.64 for the prediction of clinical and sonographic POP, compared to 0.74 and 0.69, respectively, for VAS. The difference was not significant (P = 0.3 and 0.8, respectively).

CONCLUSIONS

The VAS score was not inferior to the POPDI-6 in predicting significant POP. It has the potential to simplify the assessment of symptom severity.

Abdominal pressure and pelvic organ prolapse: is there an association?

INTRODUCTION AND HYPOTHESIS

The primary aim of this study was to assess for an association between maximal intra-abdominal pressure reached on Valsalva (MAP) and pelvic organ prolapse (POP) on subjective, clinical and sonographic evaluation. Another objective was to test for association between MAP and body mass index (BMI).

METHODS

A retrospective cross-sectional study was carried out on 504 archived datasets of women seen for pelvic floor dysfunction symptoms between January 2017 to September 2019 at a tertiary urogynaecology clinic. Patients underwent a standardized interview including use of visual analogue scores (VAS) to evaluate bother of pelvic floor symptoms, examination using the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q), dual-channel filling and voiding cystometry, test for MAP as well as four-dimensional (4D) transperineal ultrasound. Analysis of ultrasound volumes for pelvic organ descent was performed blinded against all other data.

RESULTS

There was a weak but significant association between MAP and sonographic rectal ampulla descent (p = 0.0275). There was also a significant association between MAP and bother of obstructed defecation symptoms (p = 0.0065). Symptomatic, clinical and sonographic POP in the anterior or the apical compartments was not significantly associated with MAP. On multivariate analysis, the association between MAP and rectal descent remained significant (p = 0.01). There was no significant association between BMI and MAP.

CONCLUSIONS

This cross-sectional study showed an association between MAP and posterior compartment prolapse on imaging as well as between MAP and the bother score of obstructed defecation symptoms. There was no association between BMI and MAP.

Does the presence of a true radiological rectocele increase the likelihood of symptoms of prolapse?

INTRODUCTION AND HYPOTHESIS

Posterior compartment prolapse is commonly due to a 'true' rectocele, i.e., a diverticulum of the rectal ampulla. This condition is associated with symptoms of obstructed defecation and may contribute to prolapse symptoms. We tested the hypothesis: 'A true rectocele is an independent predictor of symptoms of prolapse.'

METHODS

This was a retrospective cohort study of patients presenting to a urogynecology unit for symptoms of pelvic floor dysfunction between September 2011 and June 2016. Assessment included a structured interview, POP-Q examination and 4D TLUS. Ultrasound volume data were acquired on Valsalva. Offline measurements were performed by analysis of stored volume data sets at a later date, blinded to all clinical data.

RESULTS

One hundred six patients were excluded because of incomplete data. Of the remainder, Bp was the most distal point on POP-Q in 348. Statistical analysis was performed on this cohort. Mean age was 60 (33-86) years and mean BMI 31 (18-55) kg/m². One hundred fifty-three patients (44%) presented with symptoms of prolapse; 272 were diagnosed with a true rectocele on TLUS. Bp on POP-Q and true rectocele on TLUS were both significantly associated with prolapse symptoms; however, on multivariate analysis the latter became nonsignificant (p = 0.059). Receiver-operating characteristic (ROC) analysis confirmed that the presence of a true rectocele on TLUS did not contribute significantly to symptoms of prolapse (AUC 0.66 for model with rectocele, AUC 0.65 without).

CONCLUSIONS

The presence of a true rectocele on TLUS does not seem to contribute substantially to the manifestation of clinical symptoms of prolapse.

Prevalence of anal sphincter defects and association with anal incontinence in women scheduled for pelvic organ prolapse surgery

AIMS

Some women with pelvic organ prolapse (POP) have concomitant symptoms of anal incontinence. Our aim was to assess the prevalence of anal sphincter defects and the association with incontinence in women undergoing POP surgery.

METHODS

Cross-sectional study of 200 women scheduled for POP surgery. They answered yes/no and graded any symptoms of fecal and flatal incontinence on a visual analog scale (0-100). 3D/4D transperineal ultrasound was used to assess internal (IAS) and external anal sphincter (EAS) defects. A defect of ≥30° in ≥4 of 6 slices on tomographic imaging was regarded significant. The association between incontinence and sphincter defects was tested with multivariable logistic regression analysis.

RESULTS

The prevalence of any sphincter defect was 50/200 (25%). Combined IAS/EAS defect was found in 19/200 (9.5%) women, 8/200 (4.0%) had isolated IAS, and 23/200 (11.5%) had isolated EAS defects. In women with defect and intact IAS, 37% and 11% reported fecal incontinence, respectively, adjusted odds ratio (aOR) 2.3 (95% confidence interval [CI], 0.7-7.0), p = .147 and in women with defect versus intact EAS, 36% and 9% had fecal incontinence, aOR 4.0 (95% CI, 1.5-10.8), p = .005. In women with defect and intact IAS, 85% versus 43% reported flatal incontinence, aOR 5.2 (95% CI, 1.6-17.2), p = .007 and in women with defect versus intact EAS, 71% versus 43% had flatal incontinence, aOR 1.9 (95% CI, 0.8-4.5), p = .131.

CONCLUSIONS

One of four women scheduled for POP surgery had an anal sphincter defect. EAS defects were associated with fecal incontinence and IAS defects were strongly associated with flatal incontinence.

Effect of preoperative pelvic floor muscle training on pelvic floor muscle contraction and symptomatic and anatomical pelvic organ prolapse after surgery: randomized controlled trial

OBJECTIVES

To evaluate the effect of preoperative pelvic floor muscle training (PFMT) on pelvic floor muscle (PFM) contraction, symptoms of pelvic organ prolapse (POP) and anatomical POP, 6 months after prolapse surgery, and to assess the overall changes in PFM contraction, POP symptoms and pelvic organ descent after surgery.

METHODS

This was a randomized controlled trial of 159 women with symptomatic POP, Stage 2 or higher, scheduled for surgery. Participants were randomized to intervention including daily PFMT from inclusion to surgery (n = 81) or no intervention (controls; n = 78). Participants were examined at inclusion, on the day of surgery and 6 months after surgery. PFM contraction was assessed by: vaginal palpation using the Modified Oxford scale (MOS; 0-5); transperineal ultrasound, measuring the percentage change in levator hiatal anteroposterior diameter (APD) from rest to maximum PFM contraction; vaginal manometry; and surface electromyography (EMG). POP distance from the hymen in the compartment with the most dominant prolapse and organ descent in the anterior, central and posterior compartments were measured on maximum Valsalva maneuver. POP symptoms were assessed based on the sensation of vaginal bulge, which was graded using a visual analog scale (VAS; 0-100 mm). Linear mixed models were used to assess the effect of PFMT on outcome variables.

RESULTS

Of the 159 women randomized, 151 completed the study, comprising 75 in the intervention and 76 in the control group. Mean waiting time for surgery was 22 ± 9.7 weeks and follow-up was performed on average 28 ± 7.8 weeks after surgery. Postoperatively, no difference was found between the intervention and control groups with respect to PFM contraction assessed by vaginal palpation (MOS, 2.4 vs 2.2; P = 0.101), manometry (19.4 vs 19.7 cmH₂ O; P = 0.793), surface EMG (33.5 vs 33.1 mV; P = 0.815) and ultrasound (change in hiatal APD, 20.9% vs 19.3%; P = 0.211). Furthermore, no difference between groups was found for sensation of vaginal bulge (VAS, 7.4 vs 6.0 mm; P = 0.598), POP distance from the hymen in the dominant prolapse compartment (-1.8 vs -2.0 cm; P = 0.556) and sonographic descent of the bladder (0.5 vs 0.8 cm; P = 0.058), cervix (-1.3 vs -1.1 cm; P = 0.569) and rectal ampulla (0.3 vs 0.4 cm; P = 0.434). In all patients, compared with findings at initial examination, muscle contraction improved after surgery, as assessed by palpation (MOS, 2.1 vs 2.3; P = 0.007) and ultrasound (change in hiatal APD, 17.5% vs 20.1%; P = 0.001), and sensation of vaginal bulge was reduced (VAS, 57.6 vs 6.7 mm; P < 0.001). In addition, compared with the baseline examination, POP distance from the hymen in the dominant prolapse compartment (1.9 vs -1.9 cm; P < 0.001) and sonographic descent of the bladder (1.3 vs 0.6 cm; P < 0.001), cervix (0.0 vs -1.2 cm; P < 0.001) and rectal ampulla (0.9 vs 0.4 cm; P = 0.001) were reduced.

CONCLUSIONS

We found no effect of preoperative PFMT on PFM contraction, POP symptoms or anatomical prolapse after surgery. In all patients, PFM contraction and POP symptoms were improved at the 6-month follow-up, most likely due to the anatomical correction of POP. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Is vaginal flatus related to pelvic floor functional anatomy?

INTRODUCTION AND HYPOTHESIS

Vaginal flatus is an embarrassing condition that can impair women's quality of life. The underlying pathophysiology is unclear. We aimed to evaluate the association between vaginal flatus and pelvic floor anatomy.

METHODS

Retrospective observational study on women seen in a tertiary urogynaecological service. All had undergone a standardised interview, clinical examination and four-dimensional transperineal ultrasound. Offline analysis of volume data was performed blinded against clinical data.

RESULTS

Datasets of 570 women were analysed. Five hundred twelve (90%) were vaginally parous. Vaginal flatus was reported by 190 (33%). Mean bother score was 4.2 (SD 3.4, range 0-10). One hundred eighty-five reported frequency of vaginal flatus: it occurred < once a month in 25 (14%), once a month in 70 (38%), once a week in 47 (25%), once daily in 28 (15%) and > once daily in 15 (8%). One hundred two women identified the following precipitating factors: intercourse in 72 (71%), postural change in 22 (22%) and physical activities in 9 (9%). Vaginal birth, central and posterior compartment prolapse, anal incontinence, higher levator resting tone and younger age were associated with vaginal flatus. The latter was moderately correlated with symptom bother (correlation coefficient - 0.21).

CONCLUSIONS

Vaginal flatus is a prevalent and bothersome condition affecting one-third of our study population. The condition is associated with pelvic floor functional anatomy. A higher resting tone may confer a higher resistance against which trapped air is expelled during physical activities. Younger age was moderately correlated with symptom bother.

The Influence of Vaginal Native Tissue Repair (VNTR) on Various Aspects of Quality of Life in Women with Symptomatic Pelvic Organ Prolapse-A Prospective Cohort Study

Pelvic organ prolapse (POP) and the associated functional disorders are a major epidemiological problem that compromises the quality of life (QoL). The aim of this study was to assess the impact of lower urinary tract symptoms (LUTS) related to POP and vaginal native tissue repair (VNTR) on QoL. Two hundred patients with symptomatic POP were stratified into four groups according to the dominant storage phase function disorders: Urgency; stress urinary incontinence (SUI); mixed urinary incontinence (MUI), and without clinically significant symptoms from lower urinary tract (LUT). They underwent VNTR from January 2018 to February 2019. After 12 months, the QoL was assessed by the Prolapse Quality of Life (P-QoL) and visual analogue scale (VAS) questionnaires. The data were analyzed with Statistica package version 12.0 (StatSoft, Krakow, Poland), using the Kalmogorow–Smirnoff, Shapiro–Wilk W and the one-way analysis of variance with post hoc Tukey tests. The results of P-QoL showed significant improvement (p < 0.05) in all the study groups in most domains assessed before surgery and 12 months after surgery. Significant improvements in all the symptoms assessed by the VAS scale results were found in groups Urgency and MUI. The LUTS questionnaire revealed significant improvement in all voiding and post voiding symptoms in these groups. VNTR effectively eliminated LUTS and significantly improved the patients’ QoL associated with POP.

Definition of apical descent in women with and without previous hysterectomy: A retrospective analysis

Background

While normal pelvic organ support has been defined for women with intact uterus, this is not the case for post- hysterectomy vault descent. A recent systematic review found that definitions of apical prolapse are highly variable.

Objectives

To investigate the relationship between prolapse symptoms and apical POP-Q measurements and establish cutoffs for ‘significant apical descent using receiver–operator characteristics (ROC) statistics.

Study design

Retrospective analysis of patients seen at a tertiary urogynecological unit. Evaluation included a standardized interview and clinical assessment using the Pelvic Organ Prolapse Quantification (POP-Q) system. ROC curves were prepared for the relationship between prolapse symptoms and POP-Q measure “C”.

Results

The records of 3010 women were available for analysis. Prolapse symptoms were reported by 52.3% (n = 1573), with a mean bother of 5.9 (SD 3.0, range 0–10). POP-Q point “C” was associated with symptoms of prolapse (p <0.0001) and prolapse bother (p <0.0001) on both univariate and multivariate analysis. ROC curves for women with and without uterus were similar, although the relationship between apical descent and symptoms of prolapse was stronger for women with uterus (AUC 0.728 versus 0.678). After controlling for multi-compartment prolapse, the models improved, resulting in AUCs of 0.782 and 0.720. For prediction of prolapse symptoms, cutoffs were set at C = -5 (sensitivity 0.73, specificity 0.67 with uterus in situ, sensitivity 0.59, specificity, 0.73 after hysterectomy).

Conclusion

A cut- off for ‘significant central compartment descent’ of 5 cm above the hymen on Valsalva seems valid regardless of previous hysterectomy.

Medium- to Long-term Follow-up of Obstetric Anal Sphincter Injury

BACKGROUND

Obstetric anal sphincter injury is the primary modifiable risk factor for anal incontinence in women. Currently, endoanal ultrasound is most commonly used to detect residual anal sphincter defects after childbirth. Translabial ultrasound has recently been introduced as a noninvasive alternative.

OBJECTIVES

This study aimed to determine medium- to long-term outcomes in women after obstetric anal sphincter injuries diagnosed and repaired at delivery.

DESIGN

This is a cross-sectional study.

SETTINGS

This study was performed in a tertiary obstetric unit.

PATIENTS

Between 2005 and 2015, 707 women were diagnosed with obstetric anal sphincter injuries; 146 followed an invitation for follow-up.

INTERVENTIONS

Clinical examination, anal manometry, and translabial ultrasound were performed.

MAIN OUTCOME MEASURES

The primary outcomes measured were the St Mark incontinence score and the evidence of sphincter disruption on translabial ultrasound.

RESULTS

Of 372 contactable patients, 146 attended at a mean follow-up of 6.6 years (1.7-11.9), of which 75 (51%) reported symptoms of anal incontinence with a median "bother score" of 6 (interquartile range, 3-8). Median St Mark score was 3 (interquartile range, 2-5). Twenty-four (16%) had a score of ≥5. Women who had been diagnosed with a 3c/4th degree tear had more symptoms (58% vs 44%), significantly lower mean maximal resting pressure (p < 0.001), maximal squeeze pressure (p < 0.001), and more residual external (p < 0.001) and internal (p = 0.012) sphincter defects in comparison with those who had a 3a/3b tear. Women with residual external sphincter defects had lower mean maximal squeeze pressure (p = 0.02). Residual internal sphincter defects (p = 0.001) and levator avulsion (p = 0.048) are independent risk factors for anal incontinence on multivariate modeling.

LIMITATIONS

This study was limited by the lack of predelivery data of bowel symptoms and BMI and incomplete intrapartum documentation of tear grade.

CONCLUSIONS

Symptoms of anal incontinence were highly prevalent (51%), with a high bother score of 6. St Mark scores were associated with residual internal anal sphincter defects and levator avulsion. Women who had a higher tear grade showed a higher incidence of residual sphincter defects and lower manometry pressures. See Video Abstract at http://links.lww.com/DCR/A824.

Does Patient Posture Affect the Ultrasound Evaluation of Pelvic Organ Prolapse?

OBJECTIVES

Translabial ultrasound (US) imaging is an emerging method for the evaluation of pelvic organ prolapse (POP). Normative data to date are limited to imaging in the supine position. The purpose of this study was to evaluate the effect of posture changes on US pelvic organ mobility.

METHODS

This work was a retrospective study of 175 women seen in a tertiary urogynecologic center for symptoms of lower urinary tract and pelvic floor dysfunction. All underwent a standardized interview, POP quantification prolapse assessment, and 4-dimensional translabial US examination in supine and standing positions. Offline measurement of organ descent on the Valsalva maneuver was undertaken at a later date and was blinded against all other data.

RESULTS

The mean age was 58 (SD, 13.5; range, 17 to 89) years, with a mean body mass index of 29 (SD, 6.1; range, 18 to 53) kg/m² . In total, 58.9% (n = 103) presented with symptoms of prolapse. Clinically, 82.8% (n = 145) had substantial prolapse on the POP quantification assessment. On imaging, bladder, uterine, and rectal ampulla positions were significantly lower, and the hiatal area on the Valsalva maneuver was larger in the standing position (P < .03). On receiver operating characteristic statistics assessing correlations between POP symptoms and US pelvic organ descent, the area under the curve was higher in the standing position, but the difference was not statistically significant.

CONCLUSIONS

Measurements of organ descent and hiatal dimensions are generally higher in the standing position. However, they are not reflected in a stronger association between symptoms and organ descent. Hence, imaging in the standing position can be limited to those patients in whom a false-negative assessment result is suspected.

Prevalence of Maternal Birth Trauma in Nepali Women

OBJECTIVES

Pelvic organ prolapse is very common among women in Nepal, especially uterine prolapse. This would suggest a high rate of levator trauma, which is a strong predictor of such prolapse in the Western world. Hence, we decided to study the prevalence of maternal birth trauma in Nepali women.

METHODS

In November 2016, we offered an interview, clinical examination, and 4-dimensional translabial sonography to women attending a gynecology clinic. Of 129 women seen, 5 were excluded due to previous pelvic surgery. Translabial sonography volume data sets were obtained and analyzed by tomographic imaging for levator ani and anal sphincter trauma at a later date, blinded against all clinical data.

RESULTS

Mean age was 39 (21-74) years, median vaginal parity was 2 (0-9), mean age at first delivery 21 (14-40). Seventeen (14%) had not given birth vaginally; of these, 14 (11%) delivered by cesarean only, and 3 (2%) were nulliparous. Tomographic assessment for levator avulsion and anal sphincter trauma was possible in 124 women and performed as previously described. We found 2 (2%) unilateral avulsions and significant external anal sphincter defects in another 2 women.

CONCLUSIONS

Levator and anal sphincter trauma are significantly less prevalent in Nepali women in comparison to Western populations. This is intriguing, especially in view of the high prevalence of prolapse in Nepali women.

Long term Follow-up of Transvaginal Anatomical Implant of Mesh in Pelvic organ prolapse

Transvaginal mesh (TVM) is a minimally invasive but effective treatment for pelvic organ prolapse (POP). However, mesh exposure is a common and problematic complication after TVM. This study assessed the safety and long-term outcomes of TVM. A retrospective review was performed on the medical records of 175 consecutive patients who underwent TVM with the anatomical implant technique for pelvic organ prolapse at our center from April 2007 to December 2012. All operations were performed using TVM with the anatomical implant technique. Intraoperative variables, postoperative complications, and TVM outcomes were assessed. In average of 8 years (ranging from 4 to 10 years), the objective cure ratio reached 99.4%; and the subjective success rate of the TVM operation was 91.4%. Only 2 cases (1.1%) were identified as having mesh exposure. The reoperation rate was 4.0% (95% CI, 1.1–6.9%). No patients abstained from sex due to the operation or postoperative discomfort. Our anatomical implant technique for correcting POP is feasible in TVM procedures, which lead to favourable subjective and objective outcomes with the lowest rates of mesh exposure (1.1%) in published data. Therefore, performing TVM operations with the appropriate technique could consider to be permitted.

Functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic

INTRODUCTION AND HYPOTHESIS

Limited existing evidence suggests that there is a high prevalence of female pelvic organ prolapse (POP) amongst Nepali women. However, to date, no comprehensive assessment of pelvic floor functional anatomy has been undertaken in this population. Our study aimed to determine functional pelvic floor anatomy in Nepali women attending a general gynaecology clinic.

METHODS

One hundred and twenty-nine consecutive women attending the clinic were offered an interview, clinical examination [International Continence Society Pelvic Organ Prolapse Quantification system (ICS/POP-Q)] and 4D translabial ultrasound (TLUS). Most presented with general gynaecological complaints. Five were excluded due to previous pelvic surgery, leaving 124.

RESULTS

A POP-Q exam was possible in 123 women, of whom 29 (24%) were diagnosed with a significant cystocele, 50 (41%) significant uterine prolapse and seven (6%) significant posterior compartment prolapse. Evaluation of 4D TLUS data sets was possible in 120 women, of whom 25 (21%) had a significant cystocele, 45 (38%) significant uterine prolapse and ten (8%) significant descent of the rectal ampulla. In 13 cases, there was a rectocele with a mean depth of 14 (10-28) mm. Of 114 women in whom uterine position could be determined, 68 (60%) had a retroverted uterus associated with significant uterine prolapse (P 0.038).

CONCLUSIONS

POP is common in Nepali women attending a general gynaecology clinic, with a high prevalence of uterine prolapse (40%). Uterine retroversion was seen in 60% and was associated with uterine prolapse. Patterns of POP in Nepal seem to be different from patterns observed in Western populations.

Is a "dragging sensation" a symptom of female pelvic organ prolapse?

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) commonly presents with a "vaginal lump or bulge" and/or a "dragging sensation." The first symptom correlates strongly with clinical and imaging data. However, a "dragging sensation" may be less specific. Hence, we investigated the predictive value of both symptoms for POP.

METHODS

This was a retrospective study involving archived data sets of women seen between November 2013 and May 2014. All underwent a clinical interview, POPQ examination, and 4D translabial ultrasound (TLUS). The main outcome measure was organ descent on clinical examination and TLUS. Offline analysis for organ descent was undertaken blinded against all other data.

RESULTS

A total of 224 women were assessed. Mean age was 57 (23-84) years. Median parity was 3 (0-7). Ninety-three percent (n=208) were vaginally parous. Fifty-eight percent (n=129) complained of symptoms of prolapse: 49% (n=110) of a vaginal lump, 27% (n=61) of a dragging sensation. Clinically, mean point B anterior (Ba) was -0.86 (-3 to +7.5) cm, mean cervical station (C) was -4.1 (-9 to +8) cm, mean point B posterior (Bp) was -1.1 (-3 to +5) cm. On imaging, mean bladder, uterine, and rectal descent were -8.3 (-68.0 to 34) mm, +18.6 (-56.4 to 46.3) mm, and -5.3 (-39.8 to 36) mm respectively. On univariate analysis, both symptoms were strongly associated with objective prolapse clinically and on TLUS, with "vaginal lump" consistently the stronger predictor.

CONCLUSIONS

The symptom of a "vaginal lump or bulge" was consistently a stronger predictor of objective POP than "dragging sensation." This finding was insensitive to adjustments for potential confounders. However, a "dragging sensation" is clearly a symptom of prolapse.

Vaginal Pessary in Women With Symptomatic Pelvic Organ Prolapse: A Randomized Controlled Trial

OBJECTIVE

To compare pelvic floor symptoms, quality of life, and complications in women with symptomatic pelvic organ prolapse (POP) with or without vaginal pessaries in addition to those who do pelvic floor exercises for 12 months.

METHODS

This was a parallel-group, single-blind, randomized controlled trial with 12 months of follow-up. Women with symptomatic stage I to stage III POP were randomized to either pelvic floor exercises training (control group) or pelvic floor exercises training and insertion of a vaginal pessary (pessary group). The primary outcome was the change of prolapse symptoms and quality of life by using the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaires. Secondary outcomes included bothersome of prolapse symptoms, desired treatment, and any complications.

RESULTS

From December 2011 through November 2014, 311 women were screened and 276 were randomized as follows: 137 to the control and 139 to the pessary group. One hundred thirty-two (95.0%) women in the pessary group and 128 (93.4%) in the control group completed the study. The Pelvic Organ Prolapse Distress Inventory of Pelvic Floor Distress Inventory and the Pelvic Organ Prolapse Impact Questionnaire of Pelvic Floor Impact Questionnaire scores decreased in both groups after 12 months, but the mean score differences were higher in the pessary group (Pelvic Organ Prolapse Distress Inventory: -29.7 compared with -4.7, P<.01; Pelvic Organ Prolapse Impact Questionnaire: -29.0 compared with 3.5, P<.01). Complication rates were low and similar in both groups.

CONCLUSION

We provided further evidence in nonsurgical treatment for POP. Prolapse symptoms and quality of life were improved in women using a vaginal pessary in addition to pelvic floor exercises.

CLINICAL TRIAL REGISTRATION

Centre for Clinical Research and Biostatistics-Clinical Trials Registry, https://www2.ccrb.cuhk.edu.hk/web/?page_id=746, ChiCTR-TRC-11001796.

The 'bother' of obstructed defecation

OBJECTIVE

To examine the relationship of visual analog scale (VAS) 'bother' scores for obstructed defecation (OD) with demographic data, physical examination and sonographic findings of the posterior compartment.

METHODS

All patients seen at a urogynecology clinic between January and October 2013 were included. Patients were diagnosed with OD if they had any of the following: incomplete bowel emptying, straining with bowel movement or need for digitation. Patients used a VAS to rate OD bother on a scale of 0-10 (0, no bother; 10, worst imaginable bother). For each patient, a comprehensive history was obtained, the International Continence Society Pelvic Organ Prolapse Quantification was performed and four-dimensional translabial ultrasound volumes were recorded on maximal Valsalva maneuver. Linear and multiple regression models were used to correlate bother VAS scores with demographic, clinical and sonographic findings.

RESULTS

Among 265 patients included in the analysis, 61% had OD symptoms with a mean VAS bother score of 5.6. OD bother scores were associated with a history of previous prolapse surgery (P = 0.0001), previous hysterectomy (P = 0.0006), descent of the posterior compartment (Bp; P = 0.004) and hiatal dimensions (Pb and Gh + Pb; P = 0.006 and P = 0.004). OD bother was associated with the following sonographic findings: true rectocele (P = 0.01), depth of rectocele (P = 0.04), descent of rectal ampulla (P = 0.02), enterocele (P = 0.03) and rectal intussusception (P < 0.0001).

CONCLUSIONS

VAS bother scores are associated with both clinical and sonographic measures of posterior compartment descent. Rectal intussusception was most likely to result in highly bothersome symptoms of OD. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Is it necessary to diagnose levator avulsion on pelvic floor muscle contraction?

OBJECTIVE

Avulsion of the levator ani muscle commonly occurs at vaginal birth. This condition is usually diagnosed by translabial ultrasound (TLUS) during pelvic floor muscle contraction (PFMC). Some patients are unable to achieve a satisfactory PFMC and in these cases avulsion is assessed at rest. The aim of this study was to validate the diagnosis of levator avulsion by means of TLUS at rest.

METHODS

This was a retrospective study of 233 women seen at a tertiary urogynecological center. All women underwent four-dimensional TLUS in the supine position and after voiding. Volumes were obtained on maximal PFMC and at rest. Analysis of the volumes was performed with the observer blinded against all clinical data. Avulsion was defined as an abnormal levator ani muscle insertion that was visible in at least three consecutive axial plane slices, at and above the level of minimal hiatal dimensions, at 2.5-mm intervals. We examined the correlation between both assessment methods using Cohen's kappa coefficient and tested the association of each method with female pelvic organ prolapse on clinical examination, organ descent on ultrasound and hiatal ballooning.

RESULTS

In total, datasets from 202 women were available for analysis. The correlation between a diagnosis of avulsion in volumes obtained at rest and those on PFMC was moderate, with a kappa value of 0.583 (95% CI, 0.484-0.683). Agreement for defects visualized on single slices was moderate, with a kappa value of 0.556 (95% CI, 0.520-0.591). When avulsion diagnoses at rest and on PFMC were tested against symptoms of prolapse, and prolapse on clinical examination and on ultrasound, neither of the two methods was superior.

CONCLUSION

Although tomographic ultrasound imaging during PFMC enhances tissue discrimination, this may not translate to superior diagnostic performance. Hence, volumes obtained at rest may be used in women unable to contract their pelvic floor. The diagnosis of levator avulsion by tomographic pelvic floor ultrasound is equally valid when performed at rest or on PFMC. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Warping of the levator hiatus: how significant is it?

OBJECTIVES

The levator hiatus is the largest potential hernial portal in the human body. Excessive distensibility is associated with female pelvic organ prolapse (POP). Distension occurs not just laterally but also caudally, resulting in perineal descent and hiatal deformation or 'warping'. The aim of this study was to quantify the warping effect in symptomatic women, to validate the depth of the rendered volume used for the 'simplified method' of measuring hiatal dimensions and to determine predictors for the degree of warping.

METHODS

This was a retrospective study utilizing records of patients referred to a tertiary urogynecological service between November 2012 and March 2013. Patients underwent a standardized interview, clinical assessment using the POP quantification system of the International Continence Society and four-dimensional translabial ultrasound. The craniocaudal difference in the location of minimal distances in mid-sagittal and coronal planes was determined by offline analysis of ultrasound volumes, and provided a numerical measure of warping. We tested potential predictors, such as demographic factors, signs and symptoms of prolapse, levator avulsion and levator distensibility, for an association with warping.

RESULTS

Full datasets were available for 190 women. The mean craniocaudal difference in location of minimal distances in mid-sagittal and coronal planes was -1.26 mm (range, -6.7 to 4.6 mm; P < 0.001). This measure of warping was associated with hiatal area on Valsalva maneuver (r = - 0.284; P < 0.0001) and signs of significant prolapse on clinical and ultrasound examination (both P < 0.0001).

CONCLUSIONS

The plane of minimal dimensions of the levator ani hiatus is non-Euclidean, i.e. warped, and the degree of warping is associated with hiatal distension, or 'ballooning', and with POP. However, the degree of warping is minor, the largest difference we found in the location of the plane of minimal dimensions being 6.7 mm. Hence, our results support the determination of hiatal area in a rendered volume of 1-2 cm in depth. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

The bother of anal incontinence and St. Mark's Incontinence Score

BACKGROUND

Patient self-report is important in the assessment of the impact of anal incontinence (AI) on quality of life. This study aimed to (1) determine the correlation between total St. Mark's Incontinence Score (SMIS) and a single-item visual analogue scale (VAS) for bother from AI, and (2) determine the correlation between individual components of SMIS and VAS.

METHODS

This is a retrospective study conducted on a cohort of 516 women seen for symptoms of lower urinary tract and pelvic floor dysfunction between January 2013 and August 2014. If a woman responded "yes" to the question "Do you experience any leakage from the back passage/anus?" they were considered to have AI, and the SMIS was administered. They were also asked "How much are you bothered by these symptoms?" to assess bother from AI by VAS. Statistical analyses were performed using Spearman's correlation and Mann-Whitney U test.

RESULTS

Eighty-four (16.3 %) women reported AI with a mean SMIS of 11 (SD ± 5.11, range 2-24) and median bother of 5 (VAS 1-10). There was a fair correlation between VAS for the bother from AI and SMIS (Spearman's r = 0.523, p < 0.001). Fecal urgency, impact on lifestyle, and use of pad/plug were significantly associated with VAS (p = 0.05, p = 0.002 and p < 0.001, respectively).

CONCLUSIONS

There is a fair, positive correlation between VAS for bother from AI and SMIS. Patients' bother from AI is strongly associated with its impact on lifestyle as quantified by individual SMIS components.

Delivery mode and pelvic organ prolapse: a retrospective observational study

OBJECTIVE

To analyse the associations between delivery mode and symptoms and signs of pelvic organ prolapse (POP) in a cohort of symptomatic women.

DESIGN

Retrospective observational study.

POPULATION

A total of 1258 consecutive women attending a tertiary urogynaecological unit for the investigation of lower urinary tract or pelvic floor disorders between January 2012 and December 2014.

METHODS

Obstetric history and clinical examination data were obtained from the unit database. Prolapse quantification on imaging was performed using stored four-dimensional translabial ultrasound volume data sets. Women were grouped into four groups according to the most traumatic delivery reported. The presence of symptoms and signs of POP were compared between delivery groups while controlling for potential confounders.

MAIN OUTCOME MEASURES

Prolapse symptoms, visual analogue score for prolapse bother, International Continence Society Prolapse Quantification System findings and ultrasound findings of anterior, central and posterior compartment descent.

RESULTS

Nulliparae showed the lowest prevalence of most measures of POP, followed by women exclusively delivered by caesarean section. Highest prevalences were consistently found in women delivered at least once by forceps, although the differences between this group and women delivered by normal vaginal delivery and/or vacuum extraction were significant in three out of eight measures only. Compared with women in the caesarean section group, the adjusted odds ratios for reporting symptoms of prolapse were 2.4 (95% CI 1.30-4.59) and 3.2 (95% CI 1.65-6.12) in the normal vaginal delivery/vacuum extraction group and forceps group, respectively.

CONCLUSIONS

There is a clear link between vaginal delivery and symptoms and signs of pelvic organ prolapse in urogynaecological patients.

TWEETABLE ABSTRACT

Compared with caesarean section a history of vaginal delivery more than doubles the risk for POP.

Discrepancies between patient-reported outcome measures when assessing urinary incontinence or pelvic-prolapse surgery

INTRODUCTION AND HYPOTHESIS

In order to assess the outcome following surgery for urinary incontinence (UI) and pelvic organ prolapse (POP) the importance of patient-reported outcome measures, in addition to the clinical objective measures, has been recognised. The International Consultation on Incontinence has initiated the development and evaluation of disease-specific questionnaires (ICIQ) to compare the patient's degree of improvement. Alternatively, the Patient's Global Impression of Improvement (PGI-I score) with an inherent before-after assessment has been widely accepted in recent studies. The aim of this study was to compare the PGI-I versus the ICIQ score for women undergoing UI or POP surgery.

METHODS

This study is based on self-administered pre- and postoperative questionnaires, completed by women undergoing surgery for UI or POP in Denmark in 2013. Weighted Kappa statistics and 95 % limits of agreement method were used when comparing the PGI-I and ICIQ scores.

RESULTS

Among the 3,310 women included the PGI-I score showed a higher improvement than the IQIC score, for UI 0.83 (CI 95 %: 0.80-0.85) vs 0.62 (0.60-0.64) and for POP 0.77 (0.75-0.78) vs 0.66 (0.65-0.67).

CONCLUSIONS

The PGI-I score renders higher satisfaction than the ICIQ score and the PGI-I score overestimates the improvement following UI and POP surgery.

The association between different measures of pelvic floor muscle function and female pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

We aimed to compare palpatory and translabial ultrasound (TLUS) measurements of pelvic floor muscle (PFM) function with symptoms and signs of female pelvic organ prolapse (FPOP) to determine a possible association.

METHODS

We analysed data from 726 women with a mean age of 56 (SD 13.7, range 18-88) years, seen for symptoms of pelvic floor dysfunction between August 2011 and April 2013. The examination included a standardised interview and clinical assessment of FPOP with Pelvic Organ Prolapse Quantification (POP-Q) measurements, Modified Oxford Scale (MOS) grading and 4D TLUS.

RESULTS

Symptoms of prolapse were reported in 51.4% (373 out of 726) with a mean bother score of 5.8 (SD 2.91, range 0-10). A clinically significant POP (Incontinence Society [ICS]-POP-Q stage ≥ 2) in any compartment was diagnosed in 77.1%. Mean MOS was 2.4 (SD 1.1, range 0-5). Significant POP on TLUS was seen in 54.6% (389 out of 712). TLUS volumes at rest and on maximal PFM contraction were analysed on a desktop PC, to assess the degree of bladder neck (BN) cranioventral shift and levator antero-posterior (AP) diameter reduction, blinded against other data. Mean cranioventral BN shift was 7.11 (SD 4.36, range 0.32-25.32) mm and mean levator AP diameter reduction was 8.6 (SD 4.8, range 0.3-31.3) mm. MOS was strongly associated with subjective and objective POP (P ≤ 0.001), whereas this was not true for TLUS measurements of tissue displacement.

CONCLUSION

The MOS seems to be a more valid measure of PFM function than sonographically determined BN displacement or reduction of hiatal AP diameter observed on PFM contraction.