International Urogynecology Journal最新文献

Introduction and hypothesis: The objective was to assess trends in hysterectomy routes by patients who are likely and unlikely candidates for a vaginal approach.

Methods: We performed a retrospective cohort study of patients who underwent vaginal, abdominal, or laparoscopic/robotics-assisted laparoscopic hysterectomy between 2017 and 2020 using the National Surgical Quality Improvement Program database. Patients undergoing hysterectomy for a primary diagnosis of benign uterine pathology, dysplasia, abnormal uterine bleeding, or pelvic floor disorders were eligible for inclusion. Patients who were parous, had no history of pelvic or abdominal surgery, and had a uterine weight ≤ 280 g on pathology were considered likely candidates for vaginal hysterectomy based on an algorithm developed to guide the surgical approach. Average annual changes in the proportion of likely vaginal hysterectomy candidates and route of hysterectomy were assessed using logistic regression.

Results: Of the 77,829 patients meeting the inclusion criteria, 13,738 (17.6%) were likely vaginal hysterectomy candidates. Among likely vaginal hysterectomy candidates, the rate of vaginal hysterectomy was 34.5%, whereas among unlikely vaginal hysterectomy candidates, it was 14.1%. The overall vaginal hysterectomy rate decreased -1.2%/year (p < 0.01). This decreasing trend was nearly twice as rapid among likely vaginal hysterectomy candidates (-1.9%/year, p < .01) compared with unlikely vaginal hysterectomy candidates (-1.1%/year, P < 0.01); the difference in trends was statistically significant (p < 0.01).

Conclusions: The rate of vaginal hysterectomy performed for eligible indications decreased between 2017 and 2020 in a national surgical registry. This negative trend was more pronounced among patients who were likely candidates for vaginal hysterectomy based on favorable parity, surgical history, and uterine weight.

Introduction and hypothesis: This study surveyed urogynecologists and Advanced Practice Providers (APPs) in the USA to gauge their interest and willingness to embrace customizable pessaries as a viable treatment option. We hypothesize that clinicians might be interested in using customizable pessaries in their practice.

Methods: A cross-sectional survey was conducted among urogynecologists and their APPs who fit pessaries to gain insights into their experiences with standard pessaries and perspectives on the value and feasibility of customizable devices. The survey was distributed through email lists associated with women's health and pelvic floor disorders and gathered data on the difficulty in fitting pessaries and the perceived advantages of integrating customizable options into clinical practice.

Results: There were 122 participants, including 76 physicians and 46 APPs. Thirty-five percent of clinicians advocated for pessaries as a first-line therapy for pelvic floor disorders. APPs were more inclined to recommend pessaries as a primary therapy than physicians (p < 0.01). Fifty-three percent of providers reported occasional difficulties, and 12% reported frequent difficulties fitting patients with standard-shaped pessaries. APPs were significantly more likely to encounter fitting issues due to pessary shape (p = 0.023). Clinicians suggested additional practices, such as modifying pessaries to enhance retention in patients with an enlarged genital hiatus, shortened vaginas, or apical narrowing.

Conclusions: This study indicates that clinicians are inclined to incorporate customizable pessaries into their treatment protocols for pelvic floor disorders, emphasizing the need for continued innovation in pessary customization that prioritizes a patient-centric approach to pelvic floor disorder management.

Introduction and hypothesis: Coital incontinence (CI) is common, with a significant impact on quality of life and sexual function. This multicentre study was aimed at measuring the association between overactive bladder (OAB), stress urinary incontinence (SUI) and different aspects of CI including orgasm and penetration incontinence.

Methods: Following ethical approval, data from the electronic Personal Assessment Questionnaire-Pelvic Floor patient-reported outcome measure was collated for Urogynaecology outpatients from seven participating UK Hospitals between April 2018 and January 2022. Data were anonymised and analysed centrally using Excel.

Results: A total of 12,877 responses were obtained, of which 4,843 were valid for inclusion. 79.3% of women presented with urinary incontinence of whom 41.6% also reported CI. 96.8% of women with CI reported mixed OAB and SUI, with 2.1% and 1.1% reporting pure OAB and SUI respectively. There was a small subset (2.4%) with no overt urinary incontinence who occasionally experienced CI. Spearman's rank-order correlation demonstrated a statistically significant association between CI symptom score with both SUI (R = 0.57, p < 0.001) and OAB (R = 0.40, p < 0.001); orgasm incontinence with SUI (R = 0.49, p < 0.001) and OAB (R = 0.36, P < 0.001); penetration incontinence with SUI (R = 0.48, p < 0.001) and OAB (R = 0.35, p < 0.001).

Conclusions: Coital incontinence is experienced by 42% of women with urinary incontinence. There is a statistically significant association between both SUI and OAB with orgasm incontinence and penetration incontinence, suggesting (a) common underlying mechanism(s). Limitations of this study include the large amount of missing data and the NHS outpatient setting that limit the conclusions that can be drawn from the data.

Introduction and hypothesis: The objective was to explore the correlation between total testosterone levels and stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) in older patients, emphasizing frailty.

Methods: This prospective cross-sectional study included 1,328 women over 60 years of age at an incontinence specialty clinic. Participants were assessed for UI, frailty, using the Japanese Frailty Scale, and total testosterone levels. Analysis of a logistic regression model was employed for age, body mass index (BMI), and vaginal deliveries adjustment, with association and multivariate analyses to evaluate the associations with SUI and UUI.

Results: The frailty and nonfrailty groups each consisted of 664 individuals. After age, BMI, and the number of vaginal deliveries adjustment, the analysis showed a negative association between total testosterone levels and both SUI (p < 0.001) and UUI (p < 0.001) in the frailty group. Multivariate analysis revealed that, in the nonfrailty group, factors such as low total testosterone levels (p = 0.0145), diabetes (p = 0.0052), and cerebral infarction (p = 0.0254) were related to SUI, whereas no significant factors were associated with UUI. In the frailty group, factors associated with SUI included low total testosterone levels (p < 0.0001), the number of vaginal deliveries (p < 0.0001), smoking (p = 0.0240), chronic lung disease (p < 0.0248), and hypertension (p < 0.0265). Factors associated with UUI were age (p < 0.0001), low total testosterone levels (p = 0.0025), diabetes (p < 0.0001), and the number of vaginal deliveries (p = 0.0152).

Conclusions: The study highlights the significance of incorporating the assessment of frailty and testosterone levels in addressing UI among older women, particularly in the aged population, underscoring the need for tailored approaches in this demographic.

Introduction and hypothesis: The aim was to assess the association between the degree of physical activity (PA) and the presence of pelvic floor disorders (PFDs) in a cohort of parous Ugandan women.

Methods: In this cross-sectional study, PFDs were measured using symptom assessment, standardized questionnaires (Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire), and a standardized physical examination (POP-Q and cough stress test [CST]). Degree of PA was assessed using the International Physical Activity Questionnaire. Interquartile ranges were used to describe the age, parity, and body mass index (BMI) of participants. To examine the association between PA and PFDs, a log transformation was applied to the weekly minutes of PA variable and a logistic regression model was constructed with weekly minutes of moderate/vigorous PA, age, BMI, and parity as the predictors.

Results: A total of 159 women were enrolled. Median age was 35 (IQR 32-37), median parity 4 (IQR 3-5), and median BMI 29.0 (IQR 24-33). The prevalence of PFD as determined by symptom assessment was 28% (n=44). The most frequent stage of prolapse identified by POP-Q was stage II (57%, n=91). Thirty-six percent of the women (n=58) reported vigorous PA. Ninety-nine percent of the cohort (n=158) reported moderate PA. When controlling for age, parity, and BMI there was a significant positive association between PFD (defined as a combination of stage II prolapse, positive CST, and urinary incontinence (UI)) and moderate PA (OR 2.20, 95% CI 1.08-5.14, p value 0.045).

Conclusions: Pelvic floor disorders are common among parous Ugandan women and are associated with moderate PA when controlling for age, BMI, and parity. Understanding the risk factors associated with PFD in this population may better equip providers to screen and care for individuals.

Introduction and hypothesis: This study investigated pessary self-management (PSM). The primary outcome was how often PSM was taught to patients with pelvic organ prolapse (POP). Secondary outcomes were associations of PSM with treatment continuation, side effects, changing to surgery, and number of doctor consultations in the first year after treatment initiation compared with clinical management (CM).

Methods: A retrospective cohort study was conducted in 300 patients visiting three Dutch medical centres in 2019, and receiving a pessary for POP. The t test, Chi-squared test and logistic regression were performed to compare PSM with CM and to identify factors associated with treatment continuation.

Results: A total of 35% of patients received PSM instructions, of which 92% were able to perform PSM successfully. Treatment was continued by 83% of patients practicing PSM and 75% of patients having CM (p = 0.16), side effects occurred in 26% and 39% respectively (p = 0.18). Pain or discomfort was associated with treatment discontinuation (p < 0.01). In a subgroup analysis of patients who had a pessary suitable for PSM, treatment continuation was significantly higher in the PSM group (97%) than in the CM group (74%; p < 0.01).

Conclusions: Pessary self-management was only taught to 35% of patients who received a pessary, although the ability to perform PSM was high (92%). Treatment discontinuation was significantly lower in the PSM subgroup, when assessing the subgroup of patients using a pessary suitable for PSM. The large number of patients using a pessary suitable for PSM in the CM group implies that there is a lot to gain by promoting PSM.

Introduction and hypothesis: Congenital cervicovaginal agenesis in the presence of a functional endometrium is a rare Müllerian anomaly. The management ranges from hysterectomy historically to various reconstructive procedures more recently. We report our experience with utero-colo-vaginoplasty in the management of this anomaly and its long-term follow-up.

Methods: The case records of all the patients with vaginal or cervicovaginal agenesis in our hospital from January 2002 to December 2019 were reviewed retrospectively. The patients were then called for an outpatient visit and examined in detail. The anatomical variations, surgical procedures and outcomes were recorded and analysed.

Results: Sixteen patients aged 14 to 26 years were included during the study period. They presented with cyclical painful cryptomenorrhea. Magnetic resonance imaging (MRI) confirmed cervicovaginal or distal vaginal agenesis. All the patients underwent utero-colo-vaginoplasty. Intraoperative rectal injury led to post-operative faecal leak from the perineal wound in one patient in the post-operative period. Restoration of painless menstrual flow was possible in all 16 cases. Long-term complications were seen in 4 patients. These were stenosis of the perineal neovaginal orifice in 2 patients, obstruction at colo-uterine anastomosis in 1 patient and mucosal prolapse at the neovagina in 1 patient. Three of these patients needed secondary surgical procedures. Five were sexually active and reported consummation of penetrative intercourse. None of them had conceived.

Conclusion: In our experience, utero-colo-vaginoplasty allows for regular painless menstruation and coitus with minimal long-term complications. The sole disadvantage is the failure to conceive.

Introduction and hypothesis: The objective was to compare the rate of levator ani muscle avulsion following vaginal birth after routine and restrictive episiotomy.

Methods: This study consists of two cohorts of pregnant women prospectively enrolled between September 2015 and December 2017 at a university hospital. The pregnant women were subject to a randomized controlled trial, in which participants received a restrictive episiotomy protocol versus a routine episiotomy protocol for vaginal delivery. Levator ani avulsion was evaluated by four-dimensional ultrasound screening.

Results: Sixty-one post-partum primipara women were enrolled in our study. Thirty-two women (52.5%) had undergone routine episiotomy whereas 29 women (47.5%) had gone through restrictive episiotomy. Right mediolateral episiotomies were performed in all cases. The rate of anal sphincter tear was 12.5% in the routine episiotomy group versus 13.8% in the restrictive episiotomy group (p = 1.00). Levator ani avulsion was detected in 9.4% of the routine episiotomy group (only on the right side) and in 10.3% of the restrictive episiotomy group (p = 1.00). No bilateral levator avulsion was detected in either of the groups. There were no statistical differences in the distances of the bladder neck descent, cystocele descent, uterine descent, rectocele descent, and the ballooning of the genital hiatus area between the groups.

Conclusions: In our pilot study, there was no reduction of the rate of levator ani avulsion in women with restrictive episiotomy compared with routine episiotomy. There were no differences in pelvic floor ultrasound parameters between the two groups.

Recently, the debate surrounding the use of mesh in urogynecological procedures has intensified, leading to FDA warnings and heightened safety concerns. This clinical opinion emphasizes the vital need to specify mesh types in these procedures, drawing attention to the risk profiles and clinical outcomes associated with various meshes and the procedures that utilize them. A significant issue identified in contemporary literature is the tendency to group diverse mesh types under the same umbrella, disregarding their unique characteristics and applications. We describe the range of mesh types, their application routes, and associated complications, highlighting the risks of this nonspecific approach to patient safety and informed decision making. We critically examine the generalization of mesh terminology in clinical and research dialogues. Concluding with specific recommendations for health care providers and researchers, the paper advocates for a more nuanced understanding and communication in the field, ultimately aiming to improve patient care and safety in urogynecological practice.