International Urogynecology Journal最新文献

Introduction and Hypothesis

To assess the outcomes of mid-urethral sling (MUS) procedures for urodynamic stress incontinence (USI) following extensive pelvic reconstructive surgery (PRS) and identify risk factors for persistent USI (P-USI).

Methods

This retrospective study analyzed 84 women who underwent a staged approach to MUS for USI after PRS for advanced pelvic organ prolapse (Pelvic Organ Prolapse Quantification III and IV). The primary outcome was objective cure rate, defined by negative urine leakage on urodynamic study and a 1-h pad test weight of < 2 g. Subjective cure rate was through a negative response to question 3 of UDI-6.

Results

The overall objective cure rate was 81.0%. The highest cure rate was observed in de novo USI (MUS-D; 89.7%) compared with women with persistent USD (MUS-P). Patients with overt SUI exhibited lower cure rates than those with occult SUI. Predictive factors for persistent USI were lower pre-operative maximum urethral closure pressure (MUCP; p = 0.031) and higher BMI in the MUS-P group than in the MUS-D group (p = 0.008). Subjective improvement was noted, especially in the MUS-D group, with a subjective cure rate of 78.6%. Those with MUS-D reported a higher impact on patient well-being post-surgery. No complications were observed after MUS surgery at follow-up.

Conclusions

Overt USI, low MUCP and high BMI are independent predictors of persistent USI after a staged MUS approach after pelvic reconstructive surgery.

Introduction and Hypothesis

Lumbosacral discitis and osteomyelitis constitute a rare but devastating complication after mesh sacrocolpopexy for pelvic organ prolapse.

Methods

We present a case series of 3 patients at a single institution and a literature review of 30 patients suffering from this complication along with presenting symptoms, evaluation with laboratory and imaging findings, and management.

Results

Lumbosacral discitis can present after sacrocolpopexy of any route (abdominal, laparoscopic, and robotic) and with various suture types and tacking devices. Patients presented with lower back pain at varying time frames and with elevated inflammatory markers, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP).

Conclusion

The majority of cases required both excision of pelvic mesh via laparotomy or laparoscopy in combination with an extended course of intravenous (IV) antibiotics.

Introduction and Hypothesis

Postpartum urinary incontinence (UI) is common and a concern for many women, as UI leads to a lower quality of life and self-esteem. Perineal tears may be a risk factor for UI, yet few studies have investigated the association between the degree of perineal tear and risk of developing UI postpartum. The objective was to examine how the degree of perineal tear and selected obstetric risk factors were associated with any UI and stress ultrasound (SUI) 12 months postpartum among primiparous women.

Methods

A prospective cohort study was conducted at four Danish hospitals. Baseline data were obtained at a clinical examination 2 weeks postpartum. Symptoms of UI were evaluated 12 months postpartum by the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form questionnaire (web-based). Multivariate regression analyses were performed to investigate the risk factors for UI.

Results

A total of 603 primiparous women (203 with none/labia/first-degree tears, 200 with second-degree tears and 200 with third-/fourth-degree tears) were included between July 2015 and January 2018. Women with tears involving the perineal muscles reported any UI more often than women with no/labia or first-degree tears (spontaneous second-degree tear: RR 2.04, 95% CI 0.92–4.50; episiotomy: RR 2.22, 95% CI 0.99–4.96; third- or fourth-degree tear: RR 2.73, 95% CI 1.18–6.28). The same was found for SUI, but with wider confidence intervals.

Conclusions

A higher prevalence of any UI and SUI was found among women with perineal tears involving any perineal muscles, compared with women with no, labia, or first-degree tears.

Introduction and Hypothesis

Pelvic floor muscles (PFMs) are involved in respiratory mechanisms. Additionally, stress urinary incontinence (SUI) can affect physical function. This randomized controlled trial was aimed at investigating the effects of inspiratory muscle training (IMT) on SUI severity, PFM function, and physical function in Tunisian women with SUI.

Methods

Twenty-seven incontinent women were randomly assigned to either the experimental group or the control group. The following parameters were assessed: respiratory muscle strength (RMS; maximal inspiratory and expiratory pressures), SUI severity (Urogenital Distress Inventory-6; Incontinence Impact Questionnaire-7; pad test), PFM function (Modified Oxford Scale, electromyography, and endurance), and physical function (Timed Up & Go test; 6-min walk test; incremental shuttle walking test). IMT was conducted using threshold IMT.

Results

The IMT program significantly reduced the severity of SUI (p < 0.01), improved PFM function (p < 0.001), enhanced physical function (p < 0.01), and increased RMS (p < 0.001).

Conclusion

Inspiratory muscle training could be an effective method for improving pelvic floor disorders and physical function in women with SUI.

Introduction and Hypothesis

Urodynamics (UDS) assesses voiding dysfunction using intravesical, vaginal, or rectal catheters, which can be distressing. This study was aimed at utilizing mindfulness to reduce anxiety and pain in patients undergoing UDS.

Methods

A single-institution randomized controlled trial was conducted on 60 patients who underwent UDS. Patients were assigned to a mindfulness group (n = 30) or a control group (n = 30). Before UDS testing, all patients completed validated questionnaires assessing lower urinary tract symptoms (Urogenital Distress Inventory 6, UDI-6), anxiety (State-Trait Anxiety Inventory 6, STAI-6), and pain (Visual Analog Scale, VAS). The mindfulness group listened to a mindfulness audio prompt before UDS. All patients received standardized UDS education before UDS testing in a calm environment. After UDS testing, all patients completed validated UDS-perception questionnaires, STAI-6, Likert scale, and VAS surveys. Statistical analysis was performed using paired t tests, independent t tests, Wilcoxon, and Chi-squared tests.

Results

Both groups had similar demographics, history of prior UDS, anxiety, and baseline UDI-6 and STAI-6. Post-UDS, anxiety scores decreased in both groups, with the mindfulness group reporting significant improvement in “calmness” (mean 1.7, SD = 0.84) compared with the control group (mean 2.3, SD = 1.0, p < 0.05). The mindfulness group reported increased relaxation whereas the control group reported decreased relaxation post-UDS. Patients in both groups without a history of UDS had a significant improvement in total anxiety compared with those with a history of UDS.

Conclusion

Mindfulness meditation may improve calmness and relaxation for patients undergoing UDS.

Introduction and Hypothesis

Guidelines recommend episiotomy for instrumental vaginal delivery with an optimal incision angle of 60° to protect the anal sphincter. The “Episiometer” is a new device promising a 60° incision angle. We compared the incidence of obstetric anal sphincter injury (OASI) and post-repair suture angle of episiotomies made with conventional “eyeballing” versus Episiometer guided during instrumental delivery.

Methods

We conducted this randomized controlled trial in a tertiary care teaching institute in southern India after ethical committee approval, trial registration, and informed consent. We randomized (block) 328 pregnant women aged 18 years and above with term, singleton fetuses delivered by instruments into Episiometer-guided (164) or conventional episiotomy (164) groups (allocation concealed). We compared the OASI (identified clinically) and the suture angle measured from the midline (assessor blinded) in the two groups. We followed up on the subjects at 6 and 12 weeks to assess perineal pain and fecal/flatus incontinence.

Results

The incidence of OASI of 0.61% in the Episiometer group was significantly lower compared with 4.88% in the eyeballing group (Chi-squared = 5.6; p = 0.02; adjusted risk ratio = 5.9; CI 0.7–46.1; p = 0.09). A significantly higher proportion of subjects (59.1%) in the Episometer group had a post-suture angle between 36 and 40° compared with 36.6% in the eyeballing group (Chi-squared = 21.8, p < 0.001). We found no significant difference in the perineal pain or Wexner score during follow-up.

Conclusion

The Episiometer-guided episiotomy during instrumental delivery resulted in a significantly higher suture angle and lower obstetric anal sphincter injuries than with conventional eyeballing.

Introduction and Hypothesis

The proximity of the pudendal nerve to the sacrospinous ligaments (SSLs) can lead to serious complications during sacrospinous ligament fixation (SSLF). This case series is aimed at providing an overview of the anatomy of the pudendal nerve, including insights from cadaver dissections and discussions on rare variations observed during these dissections.

Methods

Dissections were conducted on five female cadavers using a posterior gluteal approach on both sides. The course, morphometric features and variations in the branches of the pudendal nerve were assessed at the level of the SSL and within the pudendal canal.

Results

The number of pudendal trunks cranial to the SSL ranged from one to three, with double trunks being the most common (70%). In 2 out of 10 (20%) sides inferior rectal nerves (IRNs) pierced through the SSL. In Case 1, IRNs pierced the SSL bilaterally before entering the pudendal canal and exiting at distances of 23.81 mm and 41.18 mm from the ischial spine on the right and left sides respectively. In Case 2, nerves with a width of 2.12 mm and 2.49 mm pierced the SSL and joined the IRN, piercing the SSL at 13.38 mm and 12.55 medial to the ischial spine and 16.80 mm and 19.32 mm lateral to the sacrum, on the left and right sides respectively. In 60% of cases, the IRN entered the pudendal canal, exiting at a median distance of 21.25 mm from the ischial spine.

Conclusions

We identified significant variations in the number of trunks and branching patterns of the pudendal nerve around the SSL and the course of the IRN caudal to the SSL. We documented IRNs or nerves joining the IRNs piercing the SSL. Identifying these variations is crucial for surgeons to minimize the risk of pudendal nerve injury during SSLF.

Introduction and Hypothesis

Pelvic organ prolapse (POP) has a profound influence on a woman's quality of life (QoL). Assessment of QoL using patient-reported outcome (PRO) measures in pelvic organ prolapse surgery is common practice in developed countries, but despite the burden of POP in developing countries, such as Ethiopia, the use of PROs to record preoperative and postoperative QoL scores is limited. This study is aimed at assessing the QoL among Ethiopian women with POP before and after surgery using the validated Pelvic Organ Quality of Life (P-QoL) questionnaire. Additionally, we will compare postoperative QoL measurements of reconstructive procedures with those of obliterative procedures.

Methods

This is a prospective observational study conducted at a single hospital in Ethiopia on women who were scheduled for surgery for symptomatic POP. Patients' QoL was assessed preoperatively using the P-QoL questionnaire and at each subsequent follow-up visit for 1 year (3, 6, 9, and 12 months). Patients undergoing an obliterative procedure were evaluated and compared with those having reconstructive procedures.

Results

The mean score for general health perceptions, prolapse impact, role limitations, physical limitations, social limitations, and emotions was 0 at 12 months postoperatively. Despite significant improvements from baseline, personal relationships, sleep or energy disturbance, and symptom severity measures continued to negatively impact QoL at 12 months postoperatively.

Conclusions

Quality of life among Ethiopian women with POP is poor across all domains. Native tissue repair employing either reconstructive or obliterative methods significantly improves QoL across all domains up to 12 months postoperatively. The use of validated tools to assess PROs is essential to provide evidence-based care that improves QoL in ways that are meaningful to patients.

Introduction and hypothesis: Perineal massage during labor reduces the need for episiotomy and shortens the length of the episiotomy. Pregnant women should be offered instrumented (EPI-NO) or manual perineal massage in labor. This study was conducted to determine the effect of perineal massage applied with (EPI-NO) and without an instrument during the active phase of labor on episiotomy rate and episiotomy length in women who gave birth vaginally.

Methods: The study included 101 pregnant women aged 18-35 years, with gestational ages between 38 and 42 weeks and indications for vaginal delivery. Participants were randomly assigned to one of three groups: EPI-NO massage, manual massage, and control. The perineal massage was administered during the active labor phase (4- to 8-cm dilation) for 20 min in the intervention groups. Postpartum episiotomy rates and lengths were recorded using standardized forms. The research data were collected using the Introductory Information Form and Birth Assessment Form.

Results: The episiotomy rate was found to be 33.3% in group I, 75.0% in group II, and 74.4% in the Control group, and a statistically significant difference was found between the groups (p = 0.001; p < 0.01). The mean episiotomy length of the women was 1.5 cm (mean ± SD: 1.50 ± 1.20) for group I, 3 cm (mean ± SD 2.70 ± 1.50) for group II, and 3.5 cm (mean ± SD 3.10 ± 2.00) for the control group (p < 0.000).

Conclusion: Perineal massage with EPI-NO was the most effective method at decreasing the episiotomy rate and shortening the episiotomy length compared with other groups.