The association between vulvodynia and interstitial cystitis/bladder pain syndrome: A systematic review

BACKGROUND

Vulvodynia (VVD) is a debilitating chronic vulvar pain significantly affecting patients' quality of life. Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic and complex illness characterized by an unpleasant sensation related to the filling of the bladder and it strongly impacts patients' lives. The exact mechanisms of the two syndromes remain unknown, but there is an overlap between suspected pathophysiologies.

OBJECTIVE

To present an overview of the current research on the association between VVD and IC/BPS.

SEARCH STRATEGY

A systematic search of three electronic databases was conducted. Studies examining the correlation between VVD and IC/BPS with male and female patients aged over 18 years were included.

SELECTION CRITERIA

Studies assessing the coexistence of VVD and IC/BPS were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers screened the studies for eligibility. Eligible studies were screened for quality.

MAIN RESULTS

A total of 13 studies were included in the final review. Among them, 11 presented a positive association between the two syndromes. The studies highlighted that VVD and IC/BPS share common comorbidities and possibly etiopathogenic pathways.

CONCLUSION

VVD and IC/BPS are both complex and multifactorial syndromes. This review highlights an association between them, but additional studies on the topic should be conducted for a more precise conclusion.

Antibiotic prophylaxis in invasive urodynamics, a Delphi consensus of the Italian Society of Urodynamics (SIUD)

INTRODUCTION

Although antibiotic prophylaxis (AB) demonstrated a statistically significant reduction in bacteriuria after invasive urodynamics (UDS), no significant decrease in the incidence of urinary tract infections (UTI) has been confirmed. No absolute recommendations on the use of AB in case of relevant potential risk of UTI have been reported, though some categories of patients at increased infective probability after UDS have been recognized. The aim of this study is to report the experts' consensus on the best practice for the use of AB before UDS in the main categories of patients at potential risk of developing UTI.

MATERIALS AND METHODS

A systematic literature review was performed on AB before UDS in males and females. A panel of experts from the Italian Society of Urodynamics, Continence, Neuro-Urology, and Pelvic Floor (SIUD) assessed the review data and decided by a modified Delphi method on 16 statements proposed and discussed by the panel. The cut-off percentage for the consensus was a ≥70% of positive responses to the survey. The study was a Delphi consensus with experts' opinions, not a clinical trial involving directly patients.

RESULTS

The panel group was composed of 57 experts in functional urology and UDS, mainly urologists, likewise gynaecologists, physiatrists, infectivologists, pediatric urologists, and nurses. A positive consensus was achieved on 9/16 (56.25%) of the statements, especially on the need for performing AB before UD in patients with neurogenic bladder and immunosuppression. Urine analysis and urine culture before UDS are mandatory, and in the event of their positivity, UDS should be postponed. A consensus was reached on avoiding AB in menopausal status, diabetes, age, gender, bladder outlet obstruction, high postvoid residual, chronic catheterization, previous urological surgery, lack of urological abnormalities, pelvic organ prolapse, and negative urine analysis.

CONCLUSIONS

Antibiotic prophylaxis is not recommended for patients without notable risk factors and with a negative urine test due to the potential morbidities that may result from antibiotic administration. However, AB can be used for risk categories such as neurogenic bladder and immunosuppression. The evaluation of urine analysis and urine culture and postponing UDS in cases of positive tests were considered good practices, as well as performing AB in the neurogenic bladder and immunosuppression.

Prevalence and severity of sexual disorders in the third trimester of pregnancy

BACKGROUND

Female sexual function in pregnancy is an under-investigated topic by care providers. This study aimed to investigate the sexual function and the impact of traditional risk factors for pelvic floor disorders (PFDs) during the third trimester of pregnancy.

METHODS

This is a secondary analysis of a multicenter cross-sectional study conducted in eight hospitals in Italy and Italian-speaking Switzerland. Women at the third trimester of pregnancy aged 18 years and over completed the Italian-PFQPP questionnaire anonymously.

RESULTS

Overall, 927 patients in the third trimester of pregnancy answered the questionnaire. About 29.5% of women reported reduced or absent sexual activity. The less reported symptom was coital incontinence (1.3%), while painful intercourses was the most frequent one (50.3%). Nicotine abuse was associated with traumatic sexual intercourses, impaired vaginal sensibility, and negative impact on sexual life and well-being. Familiarity for pelvic floor disorder resulted as a risk factor for coital incontinence (OR=3.61).

CONCLUSIONS

Sexual symptoms, with pain during intercourses being the most widely reported, are extremely common in the third trimester of pregnancy and can greatly affect quality of life. Familiarity for pelvic floor disorders and nicotine abuse resulted as significant risk factors for at least one sexual symptom.

Italian validation of the Pelvic Floor Distress Inventory (PFDI-20) questionnaire

INTRODUCTION AND HYPOTHESIS

The use of validated Quality of Life (QoL) questionnaires is useful in the standardization and interpretation process of pelvic floor patient symptoms, due to their functional nature and high prevalence. The Pelvic Floor Distress Inventory QoL questionnaire (PFDI-20) serves both as a symptom inventory and a measure of the degree of bother and distress caused by pelvic floor symptoms. It includes items related to pelvic organ prolapse and lower gastrointestinal and bladder dysfunction.

METHODS

After consensus translation and a comprehension test, the Italian version of the questionnaire was submitted to patients reporting bowel, bladder, or pelvic disorders (cases) and to asymptomatic women (controls). Cases received the questionnaire once again 2 weeks later by email.

RESULTS

A total of 254 patients answered the questionnaire. Construct validity was demonstrated by discriminating between cases and controls. Convergent validity was demonstrated for each domain (F < 0.001). In-ernal consistency reliability showed a satisfactory range (0.816-0.860).

CONCLUSIONS

The PFDI-20 allows a comprehensive assessment of the effect of pelvic floor disorders on the quality of life of women. Moreover, the PFDI-20 represents a very solid QoL tool, since it has been extensively used in literature, and its use is highly recommended by the International Consultation on Incontinence. The present study demonstrated good features for the Italian version of the PFDI-20 questionnaire.

Prevalence and severity of lower urinary tract symptoms in the third trimester of pregnancy

INTRODUCTION AND HYPOTHESIS

Pregnancy is a risk factor for urinary disorders, mainly in the third trimester. Lower urinary tract symptoms (LUTS) are often underreported by health care professionals and significantly impact the quality of life of pregnant women. Our objective is to analyse lower urinary tract function during the third trimester of pregnancy and assess the impact of traditional risk factors for pelvic floor dysfunctions on bladder health in pregnant women.

METHODS

This is a secondary analysis of a multicentre cross-sectional study. Third-trimester pregnant women aged 18 years or older anonymously filled in the "Italian Pelvic Floor Questionnaire for pregnant and postpartum women" questionnaire, validated for pelvic floor disorders in pregnancy and postpartum.

RESULTS

A total of 927 pregnant patients completed the questionnaire. Among them, 97.3% complained of at least one urinary disorder. Frequency was the symptom reported most often (77.3%), whereas nocturnal enuresis was the least reported (17%). Despite the high prevalence of LUTS in our sample, only 13.4% reported that they negatively impact their quality of life. Overweight and obesity, advanced maternal age, smoking, family history of pelvic floor disorders and poor pelvic floor contraction capacity were confirmed to be risk factors for the onset of LUTS, even in our population.

CONCLUSIONS

Urinary symptoms are extremely common in the third trimester and significantly affect the quality of life of pregnant women. Since overweight, obesity, smoking and reduced pelvic floor contractility emerged as modifiable risk factors for the development of these symptoms, prevention and adequate counselling are cornerstones of pregnancy care.

Prevalence and severity of bowel disorders in the third trimester of pregnancy

BACKGROUND

Bowel-related disorders are common conditions associated with pregnancy and are a cause of significant distress and healthcare burden. However, there is a lack of data in the literature about these disorders.

OBJECTIVE

This study aimed to investigate bowel dysfunctions during the third trimester of pregnancy in a large cohort of women using the validated bowel domain of the Italian version of the Pelvic Floor Questionnaire for Pregnant and Postpartum Women.

STUDY DESIGN

This was a secondary analysis of a multicenter cross-sectional study conducted in hospitals in Italy and Italian-speaking Switzerland. Women in the third trimester of pregnancy were asked to complete the Italian Pelvic Floor Questionnaire for Pregnant and Postpartum Women.

RESULTS

During the study period, 927 pregnant women in the third trimester of pregnancy responded to the questionnaire and were included in the analysis. Overall bowel dysfunctions were reported by 29.6% of patients. Constipation was reported by 66.6% of pregnant women, whereas symptoms of obstructed defecation were reported by 49.9% of patients. In contrast, urgency was reported by 41.1% of patients. Incontinence to flatus and incontinence to stool were reported by 45.1% and 2.8% of patients, respectively. Moreover, age >35 years, familiarity with pelvic floor disorders, nicotine abuse, and pelvic floor contraction inability were identified as independent risk factors for at least 1 bowel symptom.

CONCLUSION

Bowel symptoms are extremely common in the third trimester of pregnancy and can greatly affect a patient's quality of life; therefore, bowel symptoms deserve to be investigated and managed properly. The use of validated questionnaires represents a precious tool to investigate functional symptoms that could be very frequent and disabling in this particular period of life for women.

Prevalence and Severity of Pelvic Floor Disorders during Pregnancy: Does the Trimester Make a Difference?

(1) Background: Women experience pelvic floor dysfunction symptoms during pregnancy. This study is the first to investigate and compare variances in the prevalence and severity of pelvic floor symptoms between trimesters using a valid pregnancy-targeted questionnaire. (2) Methods: A retrospective cohort study was conducted between August 2020 to January 2021 at two university-affiliated tertiary medical centers. Pregnant women (n = 306) anonymously completed the Pelvic Floor Questionnaire for Pregnancy and Postpartum with its four domains (bladder, bowel, prolapse, and sexual). (3) Results: Thirty-six women (11.7%) were in the 1st trimester, eighty-three (27.1%) were in the 2nd trimester, and one hundred and eighty-seven (61.1%) were in the 3rd trimester. The groups were similar in age, pregestational weight, and smoking habits. A total of 104 (34%) had bladder dysfunction, 112 (36.3%) had bowel dysfunction, and 132 (40.4%) reported sexual inactivity and/or sexual dysfunction. Least prevalent (33/306; 10.8%) were prolapse symptoms. Increased awareness of prolapse and significantly higher rates of nocturia and the need to use pads due to incontinence were recorded in the 3rd trimester. Sexual dysfunction or abstinence were equally distributed in all three trimesters. (4) Conclusions: Bladder and prolapse symptoms, equally frequent throughout pregnancy, significantly intensified in the 3rd trimester. Bowel and sexual symptoms, equally frequent throughout pregnancy, did not intensify in the third trimester.

Hematocolpos due to imperforate hymen: a case report and literature systematic review

INTRODUCTION AND HYPOTHESIS

Hematocolpos is a rare condition, where menstrual blood fills the vagina, instead of being expelled, due to a series of uterovaginal pathologies, the most frequent of which is the imperforate hymen. To date, few cases of hematocolpos have been reported in the literature.

METHODS

We report a case of hematometrocolpos due to imperforate hymen initially misdiagnosed as constipation and subsequently as ovarian mass; moreover, the present study undertakes a systematic review of studies on hematometrocolpos due to imperforate hymen to synthesize available knowledge on epidemiology, diagnosis, and management about this rare condition.

RESULTS

A total of 35 studies, describing 61 patients, were identified. The presence of hematocolpos should be suspected in premenarchal patients complaining of low abdominal pain, abdominal swelling, and urinary retention. Genital examination disclosing a tender, pale hymen and ultrasound represent a useful tool for diagnosis. The goal of the management is to timely perform hymenotomy to drain the hematocolpos, followed by hymenectomy to prevent recurrence. Follow-up is needed to diagnose possible recurrences.

CONCLUSIONS

In the case of an adolescent girl complaining of genital pain associated with primary amenorrhea, hematocolpos due to imperforate hymen should be suspected.

Update on Italian-validated questionnaires for pelvic floor disorders

INTRODUCTION

Pelvic floor disorders (PFDs), which include urinary incontinence, pelvic organ prolapse, sexual dysfunction and gastrointestinal disorders, affect over 20% of the adult population. Prevalence may also be underestimated, since a certain portion of patients may be reluctant to talk to physicians about PFDs due to embarrassment. Consequently, there is a need for self-assessed diagnostic tools with the capability to screen population and collect clinical information. Symptom and quality of life (QoL) questionnaires - also identified as patient-reported outcomes (PROs) - have been developed with this purpose. Despite the large number of questionnaires available for the assessment of PFDs and QoL-related issues in the English language, few of them have been validated for the Italian language. The objective of this article is to update the list of Italian-validated PROs for PFDs along with practical information concerning literature references and suggestions on how to obtain every single questionnaire.

EVIDENCE ACQUISITION

PubMed/MEDLINE databases and websites were used to update the list of available Italian-validated questionnaires about PFDs. Once identified, the possibility to get a copy of the questionnaire was verified and steps to obtain it are reported in the tables.

EVIDENCE SYNTHESIS

Eight additional questionnaires validated into the Italian language, for diagnosis and overall management of common urinary, vaginal, sexual and bowel conditions, were retrieved. The complete list of PFDs PROS is reported in a modular format for consultation.

CONCLUSIONS

This format is intended to serve as a tool to promote appropriateness in PROs adoption while investigating PFDs in Italian patients.

Coexisting overactive-underactive bladder and detrusor overactivity-underactivity in pelvic organ prolapse

OBJECTIVE

The coexisting overactive-underactive bladder (COUB) syndrome could be related to the increased urethral resistance caused by severe pelvic organ prolapse (POP). We aimed to evaluate the clinical and urodynamic findings of patients with COUB and/or detrusor overactivity-underactivity (DOU) in a cohort of patients scheduled for POP surgery and the possible risk factors of COUB after surgery.

METHODS

This retrospective study analyzed all patients who underwent POP repair between 2008 and 2013, excluding women with a history of pelvic floor surgery. Patients were divided into COUB and non-COUB according to baseline symptoms and into DOU and non-DOU based on urodynamic findings. A multivariate model was performed to identify risk factors for COUB symptoms after surgery.

RESULTS

A total of 533 women underwent POP surgery. Preoperatively, patients with COUB had more severe anterior compartment prolapse (Pelvic Organ Prolapse Quantification staging system Aa point, P = 0.008) and more frequently had overactive bladder compared with controls (P = 0.023). The rate of COUB decreased significantly after surgery. Preoperative opening detrusor pressure resulted as the only independent predictor of postoperative COUB symptoms (P = 0.034).

CONCLUSION

POP is a valid pathogenetic model for COUB development. POP repair induced a significant decrease in COUB symptoms with low opening detrusor pressure resulting as the only independent predictor of postoperative COUB.

Coexistent Detrusor Overactivity-Underactivity in Patients with Pelvic Floor Disorders

Introduction and Hypothesis: Pelvic floor disorders represent a series of conditions that share, in part, the same etiological mechanisms, so they tend to be concomitant. Recently, awareness of a new lower urinary tract clinical syndrome has risen, namely the coexisting overactive–underactive bladder (COUB). The etiopathogenetic process, prevalence, and related instrumental findings of COUB are not well-established. We aimed to evaluate the prevalence, clinical features, and urodynamic findings of patients with COUB in a large cohort of patients with pelvic floor disorders. Methods: A cohort of 2092 women was retrospectively analyzed. A clinical interview, urogenital examination, and urodynamic assessment were performed by a trained urogynecologist. Based on baseline symptoms, patients were divided into COUB and non-COUB groups, and the degree of concordance between COUB and urodynamic findings, and other parameters related to the clinical aspects of these patients were measured and analyzed. Results: 18.8% of patients were classified as COUB. The association between COUB and patients with coexisting detrusor overactivity–underactivity (DOU) was statistically significant and there were substantial similarities in terms of population characteristics, symptoms, and urodynamic findings. Conclusions: Our study showed a high prevalence of COUB, and a link between this clinical syndrome and DOU was demonstrated. They showed substantial similarities in terms of clinical and urodynamics correlates. Based on these findings, we do think that urodynamic tests can be useful to improve knowledge on COUB and may be of help in the management of this condition.

Risk factors for obstetric anal sphincter injury recurrence: A systematic review and meta-analysis

BACKGROUND

Women with previous obstetric anal sphincter injuries (OASIs) are at a higher risk of recurrence in the subsequent pregnancy, which may lead to the development or worsening of anal incontinence. Due to a lack of evidence, few recommendations can be made about the factors that may affect the risk of OASI recurrence.

OBJECTIVE

We sought to conduct a systematic review and meta-analysis to investigate potential risk factors for recurrent OASIs.

SEARCH STRATEGY

Studies up to May 2019 were identified from PubMed, Scopus, Cochrane Library, and ISI Web of Science.

SELECTION CRITERIA

Studies assessing the impact of risk factors on OASI recurrence in subsequent pregnancies were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted by two independent reviewers. Odds ratio and standardized mean difference were chosen as effect measures. Pooled estimates were calculated using the random-effects model.

MAIN RESULTS

The meta-analysis showed that maternal age, gestational age, occiput posterior presentation, oxytocin augmentation, operative delivery, and shoulder dystocia were associated with the risk of recurrent OASIs in the subsequent delivery.

CONCLUSION

Prenatal and intrapartum risk factors are associated with recurrence of OASI. PROSPERO registration no. CRD42020178125.

Correlation between urinary symptoms and urodynamic findings: Is the bladder an unreliable witness?

OBJECTIVE

The role of urodynamics as the gold standard to investigate bladder function has recently been questioned. We aimed to evaluate the agreement of lower urinary tract symptoms and urodynamic diagnosis and to build predictive models.

STUDY DESIGN

Patients who underwent urodynamics for pelvic floor disorders between 2008 and 2016 were retrospectively analyzed. Clinical evaluation investigated the presence of genital prolapse, stress urinary incontinence (SUI), overactive bladder (OAB), urge urinary incontinence (UUI), voiding symptoms (VS), and bulging symptoms. The degree of concordance/agreement between symptoms and corresponding urodynamic findings was measured. Multivariate models to predict specific urodynamic findings were built.

RESULTS

1972 women were analyzed. The best agreement was found for SUI and urodynamic SUI, with a proportion of agreement of 0.68 and a Cohen's Kappa of 0.37. Very poor agreement was found for OAB/UUI and detrusor overactivity, voiding dysfunction, and positive post-void residuals. Multivariate models resulted in poor accuracy for all urodynamic findings (AUC range 0.64-0.72).

CONCLUSION

Lower urinary tract symptoms and gynecological examination are poor predictors of urodynamic findings. This confirms the role of urodynamic assessment in defining bladder function and providing precious information to counsel patients and establishing optimal clinical guidance.

Native-tissue prolapse repair: efficacy and adverse effects of uterosacral ligaments suspension at 10-year follow up

Objective

To evaluate the 10‐year outcomes of high uterosacral ligaments suspension as a primary repair for apical prolapse and to evaluate the long‐term impact of prognostic factors.

Methods

A retrospective study analyzed 10‐year follow up after repair of primary apical prolapse through high uterosacral ligament suspension. Bulging symptoms and postoperative prolapse stage II or above were considered subjective and objective recurrences, respectively. Patient Global Impression of Improvement score was used to evaluate subjective satisfaction after surgery.

Results

A total of 287 women were analyzed. Ten‐year recurrence rates were 19.1% for objective recurrence and 6.3% for subjective recurrence; surgical retreatment rate was 2.1%. Premenopausal status was related to 15‐fold increased risk of developing either objective or subjective recurrence. Conversely, anterior and posterior repair were protective factors against reoperation.

Conclusion

High uterosacral ligaments suspension is a safe and long‐lasting effective procedure for the treatment of uterovaginal prolapse even 10 years after index surgery. Premenopausal status and lack of anterior and posterior repair represented long‐term risk factors for surgical failure.

Learning Curve of Botulinum Toxin Bladder Injection for the Treatment of Refractory Overactive Bladder

PURPOSE

Intradetrusor botulinum toxin injections is an established second-line treatment for patients with refractory overactive bladder syndrome (OAB). We aimed to evaluate the learning curve of intradetrusor injections with botulinum toxin for the treatment of refractory OAB.

PATIENTS AND METHODS

This retrospective study analyzed all women with idiopathic and refractory OAB who underwent botulinum toxin bladder injections performed by residents with no previous experience with operative cystoscopy under consultant supervision. Baseline International Consultation on Incontinence Questionnaire-Short Form questionnaire (ICIQ-SF) and Euroqol (EQ-5D) questionnaires were collected. Procedural data (operative time, number of valid injections, complications, subjective easiness, perceived tolerability) and patients' outcomes (Patients Global Impression of Improvement (PGI-I), ΔICIQ-SF, ΔEQ-5D, need for self intermittent catheterization, duration of efficacy) were considered as markers to evaluate learning curves for each resident.

RESULTS

Twenty-seven patients underwent intravesical injection of botulinum toxin performed by residents. Only a grade 1 Clavien-Dindo complication occurred, and none of the patients had urinary retention. PGI-I was very satisfactory, scoring 1.4 ± 0.9. Both ICIQ-SF and EQ-5D 2-2 were statistically improved (p < 0.00001 and p = 0.04, respectively). The mean duration of efficacy resulted to be 8.0±4.3 months. A positive effect of the learning curve was observed only for operative time, subjective easiness, and perceived tolerability.

CONCLUSION

Intradetrusor botulinum toxin injection for the treatment of refractory OAB is characterized by high efficacy and very low complications even at the very beginning of the learning curve when performed under proper mentorship.

Stem Cells in Clinical Trials for Pelvic Floor Disorders: a Systematic Literature Review

Pelvic floor disorders (PFDs) include a series of conditions that can be poorly tolerated, negatively affecting the quality of life. Current treatment options show unsatisfactory results and new ones are therefore needed. Stem cell (SC) therapy might be an alternative treatment strategy. This systematic review aims to define the state of art of SC therapy for PFDs in clinical trials, by systematically reviewing the available evidence. A systematic search strategy was conducted up to November 7, 2020, in PubMed, Scopus, Cochrane Library, and ISI Web of Science. Preclinical studies on animal models were not considered. Studies were included when the patients were affected by any PFDs and cells were isolated, cultured, and characterized as SC. The study protocol was registered in PROSPERO (CRD42020216551). A total of 11 prospective clinical studies were included in the final assessment, specifically 7 single-arm studies dealing with SC therapy for stress urinary incontinence and 4 with anal incontinence. Among the latter, there were two prospective, single-arm studies and two randomized controlled trials. No papers concerning the use of SC for prolapse repair were retrieved. Due to the great heterogeneity, data pooling was not possible. Stem cell injection resulted in a safe procedure, with few mild adverse side effects, mostly related to harvesting sites. However, a clear beneficial impact of SC treatment for the treatment of pelvic floor disorders could not be demonstrated. Further larger targeted studies with control arms are needed before any conclusions can be made.

Detrusor underactivity prevalence and risk factors according to different definitions in women attending urogynecology clinic

INTRODUCTION AND HYPOTHESIS

There is still no consensus on definitions of detrusor underactivity; therefore, it is difficult to estimate the prevalence. The primary objective of the study was to evaluate the prevalence of detrusor underactivity in a cohort of patients with pelvic floor disorders according to different proposed urodynamics definitions. The secondary objectives were to estimate the association between detrusor underactivity and symptoms, anatomy and urodynamic findings and to build predictive models.

METHODS

Patients who performed urodynamic evaluation for pelvic floor disorders between 2008 and 2016 were retrospectively analyzed. Detrusor underactivity was evaluated according to Schafer's detrusor factor, Abrams' bladder contractility index and Jeong cut-offs. The degree of concordance between each method was measured with Cohen's kappa, and differences were tested using Student's t test, Wilcoxon test and Pearson's chi-squared test.

RESULTS

The prevalence of detrusor underactivity among a cohort of 2092 women, concerning the three urodynamic definitions, was 33.7%, 37.0% and 4.1%, respectively. Age, menopausal status, voiding/bulging symptoms, anterior and central prolapse, first desire to void and positive postvoid residual were directly related to detrusor underactivity. Conversely, stress urinary incontinence, detrusor pressures during voiding and maximum flow were inversely associated. Final models for detrusor underactivity resulted in poor accuracy for all considered definitions.

CONCLUSIONS

The prevalence of detrusor underactivity varies depending on the definition considered. Although several clinical variables resulted as independent predictors of detrusor underactivity, instrumental evaluation still plays a key role in the diagnosis.

Clinical and urodynamic predictors of Q-tip test urethral hypermobility

BACKGROUND

Urodinamics and Q-tip test represent diagnostic tools for the assessment of stress urinary incontinence. The aim of the present study is to investigate the possibility to predict the Q-tip test urethral hypermobility on the basis of clinical and urodynamic parameters.

METHODS

We analyzed all women performed urodynamics between 2008 and 2016 presenting urodynamic stress urinary incontinence. Symptoms were collected by the Incontinence Questionnaire-Short Form questionnaire.

RESULTS

A total of 501 women presented urodynamic stress incontinence, of which 270 had urethral hypermobility, according to the Q-tip test. Patients with urethral hypermobility were younger (p<0.0001) and presented a more advanced anterior compartment descensus according to the POP-Q system (Aa point p=0.0155; Ba point p=0.0374), a higher detrusor pressure at maximum flow (p=0.0075) and maximum flow rate compared to controls.

CONCLUSIONS

Age, Aa POP-Q point and detrusor pressure at maximum flow were found to be independent predictors of Q-tip test urethral hypermobility. However, the final model can not be used as an effective predictor of the Q-tip test result.

Inability to walk and persistent thigh pain after transobturator tape procedure for stress urinary incontinence: surgical management

INTRODUCTION AND HYPOTHESIS

Groin pain after transobturator tape is often a self-limiting situation, but can occasionally persist and be associated with serious neurological sequelae. The video is aimed at presenting the surgical management of persistent groin pain and inability to walk after transobturator sling placement and subsequent partial removal.

METHODS

The featured patient is a 31-year-old woman unable to walk after transobturator sling implantation 2 years before. She reported left thigh pain immediately after surgery that was not responsive to postoperative medication. Six months later, suburethral portion excision was performed but no pain relief was obtained. She was unable to walk, and needed a wheelchair. Electromyography showed axonal injury of the left obturator nerve. After providing proper informed consent, the patient was admitted for combined transvaginal and transcutaneous transobturator tape arm removal.

RESULTS

The featured procedure was completed in 120 min and blood loss was <100 ml. No surgical complications were observed. The patient is currently doing left leg rehabilitation, has regained the ability to walk with the aid of a crutch, and the need for chronic pain control medication is greatly reduced.

CONCLUSION

This represents a valid surgical approach for the late management of this mesh-related complication.

Female Genital Hair-Thread Tourniquet Syndrome: A Case Report and Literature Systematic Review

"Hair-thread tourniquet syndrome" (HTTS) describes the condition in which fibers of hair or thread wrap around an appendage (ie, toes, fingers, genital structures, tongue, uvula, and neck), eventually causing ischemia and tissue necrosis. To date, few cases of female genitalia HTTS have been described. We report a case of female genitalia HTTS in a 5-year-old girl and report the state of the art by systematically reviewing all existing evidence about female genital HTTS. A total of 29 studies, describing a total of 34 patients, were identified. The presence of a hair-thread wrapping genitalia should be suspected in prepubertal girls complaining of genital pain associated with vulvar/vaginal swelling, wide-based gait, and voiding symptoms. Genital examination disclosing an extremely tender, swollen, and erythematous lesion on the clitoris or labia minora encircled by a hair confirms the diagnosis. The aim of the management is to remove the hair-thread in the shortest time possible, with the use of forceps, scissors, or scalpels, and this is often performed under sedation/anesthesia because of the patient's pain reaction. When the hair-thread is difficult to find or when the lesion is necrotic, excision of the lesion itself can be the only option. Complications include partial or total amputation because of tissue necrosis and recurrence.

Telephone interview in urogynecology in the era of COVID-19 pandemic

Objective:

During the Coronavirus disease-2019 (COVID-19) pandemic deferable access, including non-urgent outpatient visits, have been suspended. In our practice non-urgent routine visits for pelvic floor symptom assessment were discontinued and rescheduled, and telephone interview was performed. The aim was to evaluate patients’ satisfaction for this alternative approach.

Material and Methods:

Telephone interviews were conducted using a validated questionnaire to investigate pelvic floor symptoms. Patients were also asked if they had other symptoms or disorders, to identify patients who may need urgent hospital evaluation. At the end of the phone call, patients were asked to score their satisfaction with the telephone interview by grading their response to three questions from 0 (minimum) to 10 (maximum). The questions were: 1) “Was the telephone interview useful to check your state of health?”; 2) “Was the telephone interview an adequate healthcare tool in consideration of COVID-19 outbreak?”; 3) “Could the telephone interview replace the conventional visit?”.

Results:

Fifty-three patients were evaluated. All patients showed great satisfaction with telephone interview (Q1 median: 10, IQ range: 10-10) and were similarly positive in response to the second question (Q2 median: 10, IQ range: 10-10). Although fewer patients felt that telephone interview could replace conventional clinic visits most remained positive (Q3 median: 7; IQ range: 6-8).

Conclusion:

This simple experience showed that phone interviews with validated questionnaires are appreciated and effective to safely perform interview of selected urogynecologic patients.

Urodynamic predictors of de novo overactive bladder after single-incision sling

OBJECTIVE

To identify urodynamic predictors for de novo overactive bladder (OAB) after single-incision sling implantation.

METHODS

This retrospective study analyzed women with pure, urodynamically proven stress urinary incontinence, without OAB, between 2008 and 2015, in a university hospital. De novo OAB was investigated during clinical interviews.

RESULTS

A total of 192 patients were analyzed; 21 patients with de novo OAB were considered as group A while 171 control patients formed group B. Univariate analysis demonstrated that patients with de novo OAB have the first desire to void at a lower bladder volume (124 mL versus 160 mL, P = 0.0052), smaller maximum cystometric capacity (357 mL versus 406 mL, P = 0.0061), lower maximum flow (17 mL/s versus 23 mL/s, P = 0.0006), and higher bladder outlet obstruction index (BOOI; -11 versus -23, P = 0.0022) compared with controls. According to multivariate analysis, maximum cystometric capacity (parameter estimate [PE] =0.008, P = 0.04) and BOOI (PE = -0.029, P = 0.01) were independent urodynamic predictors of de novo OAB. The final model showed good predictive accuracy (area under the curve =0.81).

CONCLUSION

The present study identified maximum cystometric capacity and BOOI as independent predictors of de novo overactive bladder after single-incision sling implantation. Therefore, preoperative urodynamics may be useful to improve preoperative counseling and to tailor surgical treatment.

COVID-19 does not stop obstetrics: what we need to change to go on safely birthing. The experience of a University Obstetrics and Gynecology Department in Milan

Since SARS-COV-2 appeared in Wuhan City, China and rapidly spread throughout Europe, a real revolution occurred in the daily routine and in the organization of the entire health system. While non-urgent clinical services have been reduced as far as possible, all kind of specialists turned into COVID-19 specialists. Obstetric assistance cannot be suspended and, at the same time, safety must be guaranteed. In addition, as COVID-19 positive pregnant patients require additional care, some of the clinical habits need to be changed to face emerging needs for a vulnerable but unstoppable kind of patients. We report the management set up in an Obstetrics and Gynecology Unit during the COVID-19 era in a University Hospital in Milan, Italy.

Obstetric outcomes after uterus-sparing surgery for uterine prolapse: A systematic review and meta-analysis

Up-to-date there are no guidelines about uterus-sparing prolapse repair procedures for women desiring childbearing. This systematic review and meta-analysis aims to evaluate obstetrical outcomes after uterus-sparing apical prolapse repair in terms of pregnancy rate, obstetrical adverse outcomes and delivery mode according to the type of procedure. To identify potentially eligible studies, we searched PubMed, Scopus, Cochrane Library and ISI Web of Science (up to April 15, 2020). Case reports, reviews, letters to Editor, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded. Twenty-four studies met inclusion criteria and were incorporated into the final assessment, which included 1518 surgical procedures. In total 151 patients got pregnant after prolapse surgical repair, for a resulting pregnancy raw rate of 9.9 %. Overall, adverse obstetric outcomes resulted low, rating 4.6 %. Manchester procedure resulted associated with the highest risk of adverse obstetrical outcomes and preterm premature rupture of membranes (p < 0.0001). After exclusion of Manchester procedure, sacrohysteropexy was found to be associated with higher risk of obstetrical adverse outcomes compared to native-tissue procedures (p = 0.04). Native-tissue surgery might represent the most cautious option for women wishing for pregnancy.

Postpartum urinary retention: Absolute risk prediction model

OBJECTIVES

To evaluate the incidence and assess clinical factors that can predict the occurrence of postpartum urinary retention (PPUR). PPUR is a puerperal condition defined as the inability to void over 6 hours after birth or after catheter removal in case of cesarean section, requiring catheterization. Lack of prompt diagnosis of this condition may lead to severe sequelae, including infection, chronic voiding difficulties, and renal failure.

METHODS

This retrospective cohort study analyzed all deliveries from January 2011 to December 2017 in a single Italian university hospital. We used multivariate logistic regression to develop a predictive score for PPUR.

RESULTS

By multivariate logistic regression, our analysis shows as minor (odds ratio [OR] < 2) risk factors for PPUR: non-Caucasian ethnicity (OR = 1.46, CI = 1.05-2.03), nulliparity (OR = 1.47, CI = 1.01-2.14), body mass index (BMI) at the end of the pregnancy <30 kg/m² (OR = 1.54, CI = 1.10-2.17). On the other hand, epidural analgesia (OR = 3.93, CI = 2.96-5.22), meconium-stained amniotic fluid (OR = 2.07, CI = 1.54-2.77), nonoperative vaginal birth vs cesarean section (OR = 6.25, CI = 2.16-18.13), vacuum extraction vs cesarean section (OR = 8.80, CI = 2.86-27.01), pushing stage ≥60 minutes (OR = 3.00,CI = 2.26-3.97), and perineal tear (OR = 2.87, CI = 1.86-4.43) proved to be major (OR > 2) risk factors for PPUR. Using our final model (area under curve = 0.84), we created a nomogram for PPUR absolute risk calculation. Specifically, a 116-point cutoff might be used to identify high-risk patients who deserve more intensive micturition monitoring.

CONCLUSIONS

Our study identified non-Caucasian ethnicity, nulliparity, and a BMI <30 kg/m² at the end of the pregnancy as minor and epidural analgesia, meconium-stained amniotic fluid, vaginal nonoperative birth, vacuum extraction, pushing stage ≥60 minutes, and perineal tear as major independent risk factors for PPUR.

Single-incision slings for the treatment of stress urinary incontinence: efficacy and adverse effects at 10-year follow-up

INTRODUCTION AND HYPOTHESIS

Single-incision slings are not considered a first-choice surgical treatment owing to a lack of data about long-term outcomes. We aimed to assess the long-term results of urinary incontinence treatment after single-incision sling implantation at 10 years' follow-up and to investigate possible deterioration over time.

METHODS

This retrospective study analyzed women with subjective and urodynamically proven stress urinary incontinence who underwent single-incision sling procedure. The objective cure rate was assessed with a 300-ml stress test. The subjective cure rate was determined by the Patient Global Impression of Improvement (PGI-I) questionnaire. International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire scores and self-answered patient-satisfaction scales were collected to assess symptom severity. Findings were compared with short-term outcomes in the same patients, available through our previous database, in order to detect possible outcome deterioration over time.

RESULTS

The records of 60 patients were analyzed. Nine patients (15%) were lost to follow-up. A total of 51 patients completed the evaluation, with a mean follow-up of 10.3 ± 0.7 years. Objective and subjective cure resulted 86.3% and 88.2% respectively. Mean PGI-I scores and ICIQ-SF were 1.5 ± 1.0 and 3.2 ± 4.8 respectively. Patients' satisfaction scored 8.6 ± 2.6 out of 10. No long-term complications occurred. Comparison of short-term (2.6 ± 1.4 years after surgery) and long-term follow-up did not show a significant deterioration of outcome over time.

CONCLUSIONS

Single-incision slings were shown to be a procedure with a great efficacy and safety profile at very long-term follow-up. Cure rates and functional outcomes did not show any deterioration over time compared with short-term results.

Update in fertility-sparing native-tissue procedures for pelvic organ prolapse

Uterine-sparing prolapse surgery has been gaining back popularity with clinicians and patients. Although both prosthetic and native-tissue surgery procedures are described, the latter is progressively regaining a central role in pelvic reconstructive surgery, owing to a lack of mesh-related complications. Available native-tissue procedures have different advantages and pitfalls, as well as different evidence profiles. Most of them offer anatomical and subjective outcomes comparable with those of hysterectomy-based procedures. Moreover, native-tissue procedures in young women desiring childbearing allow to avoid synthetic material implantation, which may lead to potentially serious complications during pregnancy. As a consequence, we do think that offering a reconstructive native-tissue procedure for uterine preservation (with the exception of the Manchester procedure) is the safest option in women wishing for pregnancy. Sacrospinous ligament hysteropexy and high uterosacral ligament hysteropexy may be considered first-line options in consideration of the higher level of evidence and lack of adverse obstetrical outcomes.

Cesarean section rate is a matter of maternal age or parity?

OBJECTIVE

To determine the impact of women's age on the cesarean section (CS) rate according to Robson groups 1, 2A, 3 and 4A.

STUDY DESIGN

Retrospective cohort study of term, livebirth, singleton pregnancies with spontaneous or induced labor who delivered at the San Paolo Hospital from 1996 through 2019, and had the Robson group assigned. Women were grouped in 5 age classes (≤24, 25-29, 30-34, 35-39 and ≥40 years). The primary outcome was the rate of CS.

RESULTS

24 843 women were included: 36.4% classified as Robson group 1, 18.9% as Robson group 2A, 34.4% as Robson group 3 and 10.2% as Robson group 4A. The CS rate of women in Robson groups 1, 2A, 3 and 4A was 6.6%, 21.8%, 1.6% and 4.3% respectively. In nulliparous women [Robson groups 1 and 2A] group 1, the adjusted OR of CS increased steadily from 30 to ≥40 years, when compared to women aged 25-29 years. On the contrary, in multiparous women [Robson groups 3 and 4A] significant increased OR were present only for women ≥40 years. In young women [≤24 years] there was a significant reduction in the number of cesarean sections only in Robson group 1.

CONCLUSION

The results of our study show that multiparous women aged ≥40, either in spontaneous or induced labor have an independent twofold increased risk of delivering by cesarean section when compared to women of 25-29 years. On the contrary, in nulliparous women, the risk slightly, but significantly, increases with age and again becomes twofold in women ≥40 years.

Italian validation of the German Pelvic Floor Questionnaire for pregnant and postpartum women

OBJECTIVE

The only available validated questionnaire for pelvic floor disorders in pregnant and postpartum women is in German. The aim of this study was to translate and validate the German Pelvic Floor Questionnaire for pregnant and postpartum women into Italian.

STUDY DESIGN

The questionnaire was translated into Italian by standardized procedural steps. The final version of the questionnaire was submitted to women in the third trimester of pregnancy or within 6 weeks post partum. Construct validity was tested using the Wilcoxon test, and internal consistency was tested using Cronbach's alpha. Test-retest reliability was measured with Cohen's kappa and intraclass correlation coefficient.

RESULTS

Fifty women answered the questionnaire. Construct validity was demonstrated, as the questionnaire discriminated significantly between patients with and without symptoms for four domains of pelvic floor disorders. Internal consistency was satisfactory (0.62-0.93). Cohen's kappa values for test-retest reliability were between 0.46 (moderate agreement) and 1.00 (complete agreement). Intraclass correlation coefficients ranged between 0.93 and 0.96, indicating very satisfactory overall agreement for each functional domain.

CONCLUSIONS

The Italian version of the German Pelvic Floor Questionnaire for pregnant and postpartum women is reliable, valid and consistent.

Surgical management of bladder erosion and pelvic pain after laparoscopic lateral suspension for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Mesh-augmented lateral suspension for prolapse repair seems to be associated with few complications. However, mesh-related complications can negatively affect the quality of life and may be challenging to manage. This video is aimed at presenting the surgical management of a case of severe pelvic pain and dyspareunia after lateral laparoscopic suspension associated with mesh erosion in the bladder.

METHODS

A 46-year-old woman was referred to our Unit for severe pelvic pain and inability to have sexual intercourses since undergoing a uterus-sparing laparoscopic lateral suspension procedure for genital prolapse 2 years before in another hospital. Moreover, she reported bladder pain and recurrent urinary tract infections. Cystoscopy showed mesh erosion in the bladder. She was admitted to laparoscopic hysterectomy plus subtotal mesh excision and bladder reconstruction (video).

RESULTS

No surgical complications were observed. The postoperative course was uneventful. At the current follow-up, the patient reported complete resolution of her symptoms.

CONCLUSION

The featured video shows laparoscopic subtotal mesh excision, concomitant hysterectomy and bladder repair for pelvic pain, dyspareunia and bladder erosion after lateral suspension. This video may be useful in providing anatomical views and surgical steps necessary for achieving successful surgical management of this mesh-related complication.

Surgical excision of paraurethral cyst

Purpose

Patients with paraurethral cyst may be asymptomatic or bothered by sensation of a mass, pain, distorted urinary outflow, dyspareunia, and dysuria (1). Differential diagnosis includes ectopic ureterocele, pelvic organ prolapse, and urethral diverticulum. At present, the management of paraurethral cysts is unclear, but surgical excision appears as the best treatment option (1-3). Alternative methods include waiting for spontaneous rupture, needle aspiration and marsupialization (4). The aim of the video-tutorial is to provide anatomic views and surgical steps necessary to achieve a successful complete excision of a paraurethral cyst.

Materials and methods

A 54-year-old woman with a 2cm paraurethral cyst bothered by intermittent sensation of an introital mass, dyspareunia, and dysuria was admitted to surgical excision according to the described technique. Urethrocystoscopy and ultrasonography were preoperatively performed to confirm the diagnosis and rule out an urethral diverticulum. Surgical steps included: cyst exposure; vaginal mucosa incision; adequate dissection (needle injection of saline solution inside the cyst can be performed to inflate the cyst) with scissors and swab, isolation and excision of paraurethral cyst, layered reconstruction with avoidance of suture layers overlapping.

Results

Surgical procedure was successfully achieved without complications. The postoperative course was uneventful. No recurrence was observed and the patient reported complete resolution of her symptoms.

Conclusions

The featured video showed complete excision of a paraurethral cyst successfully achieved without complications. Surgical excision represents a safe and effective procedure to manage paraurethral cysts. This step-by-step video-tutorial may represent an important tool to improve surgical know-how.

Long-term outcomes and five-year recurrence-free survival curves after native-tissue prolapse repair

OBJECTIVE

To evaluate the long-term objective and subjective outcomes to build recurrence-free survival curves after mesh-free uterosacral ligament suspension and to evaluate the long-term impact of prognostic factors on outcome measures.

METHODS

A retrospective study analyzed 5-year follow-up after repair of primary prolapse through high uterosacral ligament suspension. Bulging symptoms and post-operative prolapse stage II or above were considered subjective and objective recurrences, respectively. The cumulative proportion of relapse-free patients in time was analyzed by Kaplan-Meier curves.

RESULTS

A total of 353 women were analyzed. Five-year recurrence rates were 15.0% for objective recurrence, 13.0% for subjective recurrence, and 4.0% for the combined objective and subjective recurrences. Premenopausal status was shown to be a risk factor for anatomic (P=0.022), symptomatic (P=0.001), and combined (P=0.047) recurrence. Conversely, anterior repair was shown to be a protective factor for symptomatic (P=0.012) and combined (P=0.002) recurrence. Most of the recurrences occurred within 2 years after surgery.

CONCLUSION

Long-term outcomes after high uterosacral ligament suspension were satisfactory. Premenopausal status and lack of anterior repair represented risk factors for recurrence in the long term.

Efficacy of needle retractor device in single-incision slings for treatment of stress urinary incontinence

BACKGROUND

Single-incision slings demonstrated overall similar effectiveness and less pain and recovery time compared to standard tapes. Efficacy rates vary widely among different commercial kits and may be affected by device characteristics. The aim was to evaluate the impact needle removal device of single-incision sling on objective, subjective and functional outcomes.

METHODS

This was a retrospective study. Single-incision sling without needle removal device (Group A) were compared to same single-incision sling with needle removal device (Group B) in terms of complications, objective, subjective and functional outcomes.

RESULTS

A total of 191 patients were analyzed: 51 in group A and 140 in group B. Estimated blood loss, operative time and overall complications were not different. No bladder perforation or other intraoperative complications were observed. At 12-month follow-up visit, objective cure rate was similar irrespective of the presence of the needle retractor lever (Group A: 84.3%, Group B: 87.1%; P=0.61). Subjective outcomes evaluated as International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score, ICIQ-SF score improvement and Patient Global Impression of Improvement score were similar between groups. De-novo onset of overactive bladder syndrome resulted more frequent in Group A (Group A: 19.6%, Group: B 7.9%; P=0.02) while voiding symptoms were reported without differences between groups.

CONCLUSIONS

The current study showed that the presence of a needle retractor device to avoid unintentional tip displacement for single-incision sling had no impact on objective and subjective postoperative continence. However, a reduced rate of de-novo overactive bladder syndrome was observed after implantation of single-incision sling with needle retractor.

Transvaginal native-tissue repair of vaginal vault prolapse

BACKGROUND

Posthysterectomy vaginal vault prolapse repair is a challenge for pelvic floor surgeons. Native-tissue repair procedures imply lower costs and reduced morbidity. Our study aims to evaluate operative data, complications, objective, subjective and functional outcomes of transvaginal native-tissue repair for posthysterectomy vaginal vault prolapse. We also investigated differences among available techniques.

METHODS

Retrospective study including patients with symptomatic vaginal vault prolapse (≥stage 2), previously treated with transvaginal vault suspension through native-tissue repair. Objective recurrence was defined as the descent of at least one compartment ≥II stage according to Pelvic Organ Prolapse Quantification (POP-Q) system or need of reoperation. Subjective recurrence was defined as the presence of bulging symptoms. Patients satisfaction was evaluated with PGI-I Score.

RESULTS

The study included 111 patients. Apical suspension was achieved either by uterosacral ligament suspension (16), levator myorrhaphy (17), iliococcygeus fascia fixation (65) or sacrospinous ligament fixation (13). No intraoperative complications were observed. Perioperative/postoperative complications occurred in 8 patients (7.2%). Mean follow-up was 24.5±12.1 months. Objective recurrence was observed in 28 patients (25.2%). Reintervention was required by 3 patients (2.7%). Subjective recurrence was referred by 6 patients (5.4%). Mean satisfaction evaluated with PGI-I Score was 1.2±0.6. No differences in terms of operative data, overall complications, objective, subjective cure rate and perceived satisfaction were found among different techniques.

CONCLUSIONS

Transvaginal repair with native-tissue procedures is safe and effective in correcting posthysterectomy vaginal vault prolapse and represents a valid alternative to prosthetic procedures for vaginal vault prolapse treatment.

Transvaginal native-tissue repair of enterocele

INTRODUCTION AND HYPOTHESIS

Enterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS).

METHODS

A 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique.

RESULTS

Surgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how.

CONCLUSIONS

Transvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.