Diagnosis and Therapy of Female Urinary Incontinence. Guideline of the DGGG, OEGGG and SGGG (S2k Level, AWMF Registry No. 015/091, January 2022)

Aim This completely revised interdisciplinary S2k-guideline on the diagnosis, therapy, and follow-up care of female patients with urinary incontinence (AWMF registry number: 015-091) was published in December 2021. This guideline combines and summarizes earlier guidelines such as “Female stress urinary incontinence,” “Female urge incontinence” and “Use of Ultrasonography in Urogynecological Diagnostics” for the first time. The guideline was coordinated by the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group for Urogynecology and Plastic Pelvic Floor Reconstruction (Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V., AGUB).

Methods This S2k-guideline was developed using a structured consensus process involving representative members from different medical specialties and was commissioned by the Guidelines Commission of the DGGG, OEGGG and SGGG. The guideline is based on the current version of the guideline “Urinary Incontinence in Adults” published by the European Association of Urology (EAU). Country-specific items associated with the respective healthcare systems in Germany, Austria and Switzerland were also incorporated.

Recommendations The short version of this guideline consists of recommendations and statements on the surgical treatment of female patients with stress urinary incontinence and urge incontinence. Specific solutions for the diagnostic workup and treatment of uncomplicated and complicated urinary incontinence are discussed. The diagnostics and surgical treatment of iatrogenic urogenital fistula are presented.

Diagnosis and Therapy of Female Urinary Incontinence. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/091, January 2022)

Aim This completely revised interdisciplinary S2k-guideline on the diagnosis, therapy, and follow-up care of female patients with urinary incontinence (AWMF registry number: 015-091) was published in December 2021. This guideline combines and summarizes earlier guidelines such as “Female stress urinary incontinence,” “Female urge incontinence” and “Use of Ultrasonography in Urogynecological Diagnostics” for the first time. The guideline was coordinated by the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe, DGGG) and the Working Group for Urogynecology and Plastic Pelvic Floor Reconstruction (Arbeitsgemeinschaft für Urogynäkologie und plastische Beckenbodenrekonstruktion e. V., AGUB).

Methods This S2k-guideline was developed using a structured consensus process involving representative members from different medical specialties and was commissioned by the Guidelines Commission of the DGGG, OEGGG and SGGG. The guideline is based on the current version of the guideline “Urinary Incontinence in Adults” published by the European Association of Urology (EAU). Country-specific items associated with the respective healthcare systems in Germany, Austria and Switzerland were also incorporated.

Recommendations The short version of this guideline consists of recommendations and statements on the epidemiology, etiology, classification, symptoms, diagnostics, and treatment of female patients with urinary incontinence. Specific solutions for the diagnostic workup and appropriate conservative and medical therapies for uncomplicated and complication urinary incontinence are discussed.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

The investigation and treatment of female pelvic floor dysfunction

BACKGROUND

25% of all women report involuntary loss of urine, and 7% may require treatment.

METHODS

This review is based on a selection of pertinent literature, including guidelines and Cochrane reviews.

RESULTS

The assessment of pelvic floor dysfunction in women begins with a basic evaluation that is followed by special diagnostic tests if indicated. The physician taking the clinical history should inquire about the patient's behavior, personality, social and other stressors, and eating and drinking habits, as well as any mental disorders that may be present, including anxiety disorders, depression, somatization disorders, and disorders of adaptation. Conservative treatment consists mainly of lifestyle changes, physiotherapy, and medication. Stress incontinence is most commonly treated with pelvic floor exercises, with a documented success rate of 56.1% vs. 6% without such treatment (relative risk 8.38, 95% confidence interval 3.67-19.07). If incontinence persists, surgery may be indicated ( implantation of suburethral tension-free slings, or colposuspension). Feedback and biofeedback training can be used to treat an overactive bladder. If these techniques and drug therapy are unsuccessful, botulinum toxin injections can be considered.

CONCLUSION

Well-validated treatments for pelvic floor dysfunction are available. Psychosomatic factors must be taken into account and can have a major effect on treatment outcomes.

Is a dipstick test sufficient to exclude urinary tract infection in women with overactive bladder?

INTRODUCTION AND HYPOTHESIS

A dipstick test is recommended to screen for urinary tract infection in patients with overactive bladder (OAB). It was the aim of this study to test if a dipstick test is sufficient to identify patients with urinary tract infection attending a urological private practice because of OAB.

METHODS

All patients who attended the practice because of OAB symptoms were routinely catheterized; a urine specimen was tested with dipstick, the spun sediment was examined microscopically, and the specimen was sent for microbiological examination.

RESULTS

Two thousand two hundred fifty-two patients were examined. Of 1,754 patients with negative dipstick screening, 353 patients (20.1%) had growth of ≥10(3) colony forming units. The dipstick test had a sensitivity of 0.442 and a specificity of 0.865 for the correct identification of urinary tract infection.

CONCLUSIONS

Dipstick screening is not sufficient to identify patients with urinary tract infection and symptoms of OAB.

Obstetrical parameters influencing the duration of the second stage of labor

OBJECTIVE

To investigate the impact of parameters influencing the duration of the second stage of labor in vaginal deliveries.

STUDY DESIGN

1200 consecutive vaginal deliveries were analyzed. Descriptive statistics are reported for parity, duration of first and second stage of labor, maternal age, birth weight, position of the fetal head, epidural analgesia and oxytocin augmentation. Logistic regression analysis was performed to assess the contribution of different variables to the length of the second stage of labor.

RESULTS

The mean length of the second stage was 70 min. In univariate analysis, parity, oxytocin augmentation and epidural analgesia, as well as occipito-posterior presentation were significant parameters associated with a prolonged second stage of labor. No correlation was found for birth weight and maternal age. In multivariate regression analysis, nulliparity and epidural analgesia were the strongest risk factors for a prolonged second stage.

CONCLUSIONS

The impact of epidural analgesia on the second stage of labor should be considered in obstetrical management.

Is the histomorphological concept of the female pelvic floor and its changes due to age and vaginal delivery correct?

AIMS

To compare the histomorphology of pelvic floor specimens of 94 female cadavers, ten male cadavers, and 24 female symptomatic patients who underwent pelvic floor surgery, and to evaluate the association of age, parity, and sex to myogenic and/or neurogenic changes to the levator ani muscle (LAM).

METHODS

The pelvic floor was biopsied at the pubococcygeus, the iliococcygeus and the coccygeus muscle. After staining, signs for myogenic/neurogenic changes to the muscle were evaluated (fibrosis, variation in fiber diameter, centralization of nuclei, small angulated fibers, and type grouping). To identify the intact neuromuscular junction stainings with NCAM (neuronal cell adhesion molecule) and acetylcholinesterase (ACE) were used.

RESULTS

A significant influence of age and parity on the histomorphological criteria of myogenic cell-damage was shown in this study. Although these criteria were found even in young nulliparous women, there was a significant increase in older or parous women with at least one vaginal delivery. We failed to demonstrate significant changes between the nulliparous LAM, the male LAM, and the LAM from women with prolapse and incontinence. None of the specimen showed any obvious evidence of neuropathy.

CONCLUSIONS

We have evaluated histological criteria adapted from the examination of limb muscles in the LAM of nulliparous young women. "Myogenic changes" seem to be a normal finding in the LAM. The increase of these changes with aging and parity points to mechanical stress to the LAM as the most plausible causative factor. We propose that further studies using histomorphological techniques of the pelvic floor muscle in nulliparous and parous women should clarify the potential role of our histological findings.

Sonographie in der Urogyn�kologie

Radiologic procedures such as lateral cystography have been substituted by ultrasound in urogynecology. The techniques are standardized and reproducible. Ultrasound is also useful for evaluating the bladder neck (funneling), the urethra (diverticula) and the paraurethral tissues (vaginal cysts, vaginal fibroids). The technique is limited in patients with genital prolapse beyond the hymenal ring. Advantages include the avoidance of x-rays and catherization.

Updated recommendations on ultrasonography in urogynecology

Ultrasound is a supplementary, indispensable diagnostic procedure in urogynecology; perineal, introital, and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be demonstrated. In patients undergoing diagnostic work-up for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings will lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound, different parts of the sphincter ani muscle can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.

Age effects on urethral striated muscle. I. Changes in number and diameter of striated muscle fibers in the ventral urethra

OBJECTIVE

This study was undertaken to test the null hypothesis that the number of striated muscle fibers in the ventral wall of the female urethra remains constant with increasing age.

STUDY DESIGN

The urethra and surrounding tissues from 25 female cadavers, mean age 52 years (+/-SD 18, range 15-80 years), were selected for this study. Each specimen was divided along the midsagittal plane, and a Masson trichrome histologic section was prepared. A systematic count of striated muscle fibers in the ventral wall was then obtained at each decile of urethral length.

RESULTS

A decrease in the total number of fibers within the sampled area was found with increasing age. The mean of the total fibers across all urethrae was 17,423 (+/-SD 9,624, range 4,788-35,867). Over the life span, an average of 364 fibers (2%) were lost per year (95% CI 197-531; P <.001). Mean fiber density was 671 (+/- SD 296, range 228-1374) fibers/mm2 and decreased by 13 fibers/mm2 per year (95% CI 8-17; P <.001). The mean lesser fiber diameter was 24 microm and did not change significantly with age ( P =.3).

CONCLUSIONS

The number and density of urethral striated muscle fibers decline with age.

The prognostic impact of a prolonged second stage of labor on maternal and fetal outcome

OBJECTIVE

While obstetrical management has changed significantly over years, the optimal duration of the second stage of labor still remains to be defined. The purpose of this study was to evaluate the effect of the duration of labor on fetal distress and maternal perinatal morbidity.

METHODS

There were 1457 consecutive patients delivered of a singleton fetus in cephalic presentation beyond the 34th week of gestation at the I. Frauenklinik, Ludwig-Maximilians University, Munich between May 1999 and June 2000. The 257 patients (17.6%), who underwent cesarean section prior to or during labor, were excluded from the study. Of the 1200 vaginal deliveries, 1017 (84.8%) were normal spontaneous deliveries, while 183 (15.2%) were instrumentally assisted. Data were contemporaneously collected and analyzed for the presence of severe pelvic floor damage, maternal hemorrhage, maternal fever, delayed involution of the uterus, fetal acidosis and APGAR score, and the necessity for admitting the newborn to the intensive care unit (NICU). A second stage duration of > 2 hr was considered to be prolonged.

RESULTS

The mean duration of the second stage of labor was 70 min (range 2-387, SD 73 min). For 952 patients (79.3%), the second stage was less than 2 h. For 47 patients (3.9%), it exceeded 4 h. A prolonged duration of the second stage was not associated with low Apgar scores 5 and 10 min postpartum (P = 0.76 and P = 0.38, respectively), a higher incidence of umbilical artery pH levels of < 7.20 (P = 0.60), nor with an increased rate of admission to the NICU (P = 0.24). A significant increase in the rate of maternal blood loss was noted after long second stages (1.84 g/dl median difference between the intrapartum and postpartum hemoglobin level) in comparison to patients with normal duration of second stage (0.79 g/dl), both by univariate (P < 0.0001) and multivariate (P < 0.001) analysis. The incidence of third degree anal sphincter tears was significantly correlated with a prolonged duration of second stage in univariate analysis (7.7%, P = 0.001), but not in multivariate analysis after allowing for duration of the second stage, maternal age, birth weight, episiotomy, and mode of delivery (P = 0.26).

CONCLUSION

There is no evidence that prolonged second stage of labor is a serious disadvantage to the fetus, if adequate monitoring is provided. Because the increase of maternal morbidity in patients with prolonged labor may be partially attributed to a higher rate of operative procedures in these patients, interventions should not be solely based on the elapsed time after full cervical dilatation.

Matched pair analysis of survival after chest-wall recurrence compared to mammary recurrence: a long-term follow up

BACKGROUND

Local recurrence remains a major concern after primary treatment of breast cancer and has a major impact on subsequent survival. While most studies report a poorer survival rate in patients with a local recurrence after mastectomy than after breast conservation, it remains controversial whether different risk profiles at the time of primary diagnosis may account for this difference.

METHOD

Matched pair analysis of 134 patients with newly diagnosed locoregional recurrence of breast cancer without evidence of systemic disease. Matching criteria included the primary surgical treatment, tumor size, nodal status, and age. The significance of various prognostic parameters at the time of primary diagnosis and at the time of recurrence were evaluated, by univariate and multivariate analyses, with respect to survival after recurrence. The median follow-up was 8.4 years.

RESULTS

Risk factors at the time of presentation, such as tumor size and lymph node status, were comparable between both groups. Local recurrence occurred on an average 9 months earlier in patients after mastectomy (P = 0.08). Univariate analysis showed that lymph node status (P = 0.0001) and disease-free interval from primary treatment to local recurrence (P = 0.0002) were the most significant single prognostic factors for subsequent survival after local recurrence. The primary surgical treatment modality was shown to be of marginal statistical influence (only P = 0.05).

CONCLUSION

Local recurrence after mastectomy seems to be associated with worse survival than after breast-conserving therapy. Early onset of chest-wall recurrence, moreover, represents the highest independent risk for cancer-associated death.

Radiotherapy of the chest wall following mastectomy for early-stage breast cancer: impact on local recurrence and overall survival

INTRODUCTION

Recent studies have renewed an old controversy about the efficacy of adjuvant radiotherapy following mastectomy for breast cancer. Radiotherapy is usually recommended for advanced disease, but whether or not to use it in pT1-T2 pN0 situations is still being debated. This study was designed to clarify whether or not routine radiotherapy of the chest wall following mastectomy reduces the risk of local recurrence and if it influences the overall survival rate.

METHODS

Retrospective analysis of patients treated with mastectomy for pT1-T2 pN0 tumors and no systemic treatment. Patients treated with radiotherapy of the chest wall following mastectomy (Group A) are compared with those treated with mastectomy alone (Group B).

RESULTS

A total of 918 patients underwent mastectomy. Patients who received adjuvant radiotherapy after mastectomy (n = 114) had a significantly lower risk for local recurrence. Ten years after the primary diagnosis, 98.1% of the patients with radiotherapy were disease free compared to 86.4% of the patients without radiotherapy. The average time interval from primary diagnosis until local recurrence was 8.9 years in Group A and 2.8 years in Group B. The Cox regression analysis including radiotherapy, tumor size and tumor grading found the highest risk for local recurrence for patients without radiotherapy (p < 0.0004). In terms of overall survival however, the Kaplan-Meier analysis showed no difference between the two groups (p = 0.8787) and the Cox regression analysis failed to show any impact on overall survival.

CONCLUSION

With observation spanning over 35 years, this study shows that adjuvant radiotherapy of the chest wall following mastectomy reduces the risk for local recurrence in node-negative patients with pT1-T2 tumors but has no impact on the overall survival rate.

Treatment of female urinary incontinence with EMG-controlled biofeedback home training

The aim of the study was to evaluate the efficacy of pelvic floor training with EMG-controlled home biofeedback in the treatment of stress and mixed incontinence in women. Subjects were recruited from the urodynamic outpatient clinic and performed pelvic muscle training with an EMG-controlled biofeedback device for 20 minutes daily for 6 months. The number of pads used per day, the number of incontinence and urgency episodes, voiding frequency, maximum urethral closure pressure, functional urethral length and pressure/transmission ratio during stress were assessed before and after treatment. Thirty-three patients (13 with stress and 20 with mixed incontinence) completed the study. There was a significant decrease in the number of pads used per day, the number of incontinence and urgency episodes, and the voiding frequency. Twenty-eight patients (85%) reported that they were cured or improved. Urodynamic parameters did not change significantly. It was concluded that home pelvic floor training with EMG-controlled biofeedback is efficient in 85% of patients in alleviating the symptoms of genuine stress and mixed incontinence without causing side effects.

Sonographic evaluation of the bladder neck in continent and stress-incontinent women

OBJECTIVE

To evaluate a new sonographic method to measure depth and width of proximal urethral dilation during coughing and Valsalva maneuver and to report its use in a group of stress-incontinent and continent women.

METHODS

Fifty-eight women were evaluated, 30 with and 28 without stress incontinence proven urodynamically, with a bladder volume of 300 mL and the subjects upright. Urethral pressure profiles at rest were performed with a 10 French microtip pressure catheter. Bladder neck dilation and descent were assessed by perineal ultrasound (5 MHz curved linear array transducer) with the help of ultrasound contrast medium (galactose suspension-Echovist-300), whereas abdominal pressure was assessed with an intrarectal balloon catheter. Statistical analysis used the nonparametric Mann-Whitney test.

RESULTS

The depth and diameter of urethral dilation could be measured in all women. During Valsalva, all 30 incontinent women exhibited urethral dilation. One incontinent woman showed dilation only while performing a Valsalva maneuver, not during coughing. In the continent group, 12 women presented dilation during Valsalva and six during coughing. In continent women, dilation was visible only in those who were parous. Nulliparous women did not have dilation during Valsalva or coughing. Bladder neck descent was visible in continent and incontinent women.

CONCLUSION

This method permits quantification of depth and diameter of bladder neck dilation, showing that both incontinent and continent women might have bladder neck dilation and that urinary continence can be established at different locations along the urethra in different women. Parity seems to be a main prerequisite for a proximal urethral defect with bladder neck dilation.

Intraurethral ultrasound correlated with urethral histology

OBJECTIVE

To examine the anatomic identity of sonographically visible sphincteric structures of the female urethra.

METHODS

The urethra, urinary bladder, and vagina were removed from 11 fresh female cadavers and placed in a water bath. Intraurethral ultrasound was performed with a 360 degrees-rotating 7.5-MHz ultrasound probe. Afterward, the specimens were fixed and cross sections were made transverse to the urethral axis at 5-mm intervals. Corresponding ultrasonograms and histologic images were matched and depicted simultaneously side by side. The anatomic identity of sonographically visible structures was determined by histologic examination and thickness of the longitudinal smooth urethral sphincter measured.

RESULTS

Structures visible sonographically were the striated and smooth urethral sphincter muscle layers, vagina, and blood vessels with diameters exceeding 0.2 mm. The longitudinal smooth muscle layer appeared as a well-defined internal hypoechoic ring. The outer circular smooth muscle layers and the striated muscle layers were a more irregular and hyperechoic zone. The circular smooth muscle layers and the striated sphincter muscle layers could not always be differentiated easily. With formalin fixation, tissue shrinkage resulted in a smaller thickness of the longitudinal smooth muscle measured on the histologic specimen.

CONCLUSION

With intraurethral ultrasound, the longitudinal smooth muscle layer appears as a well-defined and measurable hypoechoic ring. The region of the circular smooth muscle and the striated muscle emerges as a hyperechoic and less definable outer zone.

Changes in vesical neck mobility following vaginal delivery

OBJECTIVE

To assess changes in urethral movement during the Valsalva maneuver and pelvic floor muscle contraction following vaginal delivery.

METHODS

In a prospective repeated-measures study, 25 primigravidas, 20 multiparas, and ten women who were to have elective cesarean delivery were examined sonographically at 36-42 weeks of pregnancy and 6-10 weeks after delivery. Vesical neck position at rest and excursion during Valsalva maneuver and maximum pelvic muscle contraction were measured with perineal ultrasound. Data about resting bladder neck position and bladder neck elevation at contraction were compared with findings in age-matched nulligravid volunteers.

RESULTS

The bladder neck was significantly lower at rest in women after vaginal delivery than in those who had an elective cesarean delivery and in nulligravid controls. Bladder neck mobility had increased during the Valsalva maneuver in 16 of 25 primigravidas and 15 of 20 multiparas 6-10 weeks after vaginal delivery. The ability to elevate the vesical neck during pelvic muscle contraction was decreased in six of 25 primigravidas and in two of 20 multiparas 6-10 weeks after birth. Two women, one primigravid and one para 2 (with a previous elective cesarean delivery), both of whom had forceps delivery, completely lost the ability to contract voluntarily the pelvic floor muscles.

CONCLUSION

Vaginal delivery alters vesical neck descent during the Valsalva maneuver, and the ability of the pelvic muscles to elevate the urethra in some women.

[The VIVA urethral plug: a sensible expansion of the spectrum for conservative therapy of urinary stress incontinence?]

OBJECTIVE

To evaluate applicability, acceptance, side effects and complications and the possible curative effect on female stress urinary incontinence of the treatment with the urethral plug VIVA (Braun Melsungen, Germany).

DESIGN

Part I: Prospective clinical study. Part II: Ongoing prospective-longitudinal study. Additionally two case reports.

SUBJECTS

Part II: 156 consecutive patients of the urodynamic out patient clinic. Part II: 21 patients with urinary stress incontinence (SUI).

MAIN OUTCOME MEASURES

Part I: Ability to hold the plug while walking and standing, acceptance rate of plug therapy. Part II: Subjective improvement of SUI, pad-weighing test, cough test, urinary tract infections, other complications during four months of plug treatment.

RESULTS

Part I: 62% of 156 patients were able to hold the plug. 40% of 53 patients with SUI accepted the plug treatment. Part II: 14 patients completed the study. 4 pat. were subjectively and objectively cured, 3 were improved, 7 unchanged. The cured patients all had a low grade SUI with a urine loss of 3 g in the pad-weighing test before treatment. 12/21 pat, showed 1-2 urinary tract infections and 1 patient dropped out from the study because of recurrent urinary tract infections. In one patient a plug migrated into the bladder and was removed cystoscopically. In two case reports the possibility of symptomatic plug treatment for patients with severe stress incontinence after surgical and radiological treatment of cervical cancer is demonstrated.

CONCLUSIONS

Plug treatment is a broadening of the spectrum of conservative treatment of SUI as a symptomatic treatment in pat. with contraindications to anti-incontinence surgery and as a curative treatment in low grade SUI.