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Background: To reduce the risk of postoperative stress urinary incontinence (POSUI) prolapse repair might be combined with incontinence surgery.Objectives: Compare efficacy and safety of prolapse surgery with and without incontinence surgery.Search Strategy: Including our earlier review a systematic search in PubMed, EMBASE, the Cochrane Library and the Register of Current Controlled Trials was performed from 1995 to 2017.Selection Criteria: Randomised trials comparing prolapse surgery with a midurethral sling (MUS) or Burch colposuspension.Data Collection and Analysis: Two reviewers selected eligible articles and extracted data. Stress urinary outcomes were pooled for preoperative SUI. Urgency incontinence and adverse events were pooled for incontinence procedure.Main Results: Ten trials were included. Women with preoperative SUI symptoms or occult SUI had a lower risk to undergo subsequent incontinence surgery for POSUI after vaginal prolapse surgery with a MUS than after prolapse surgery only: 0 versus 40% [relative risk (RR) 0.0; 95% CI 0.0-0.2] and 1 versus 15% (RR 0.1; 95% CI 0.0-0.6), respectively. These differences were not significant in continent women not tested for occult SUI or without occult SUI. Serious adverse events were more frequent after vaginal prolapse repair with MUS (14 versus 8%; RR 1.7; 95% CI 1.1-2.7), but not after sacrocolpopexy with Burch colposuspension. Combination surgery did not increase the risk of overactive bladder symptoms, urgency incontinence and surgery for voiding dysfunction.Conclusions: Vaginal prolapse repair with MUS reduced the risk of postoperative SUI in women with preoperative SUI symptoms or occult SUI, but serious adverse events were more frequent.Tweetable Abstract: Less stress incontinence after vaginal prolapse repair with sling, but more adverse events. [ABSTRACT FROM AUTHOR]

Objectives: To compare translabial three-dimensional (3D) ultrasound with magnetic resonance imaging (MRI) for the measurement of levator hiatal biometry at rest in women with pelvic organ prolapse, and to determine the interobserver reliability between two independent observers for ultrasound and MRI measurements.Methods: Data were derived from a multicenter prospective cohort study in which women scheduled for conventional anterior colporrhaphy underwent translabial 3D ultrasound and MRI prior to surgery. Intraclass correlation coefficients (ICCs) were calculated to estimate interobserver reliability between two independent observers and determine the agreement between ultrasound and MRI measurements. Bland-Altman plots were created to assess the agreement between ultrasound and MRI measurements.Results: Data from 139 women from nine hospitals were included in the study. The interobserver reliability of ultrasound assessment at rest, during Valsalva maneuver and during contraction and of MRI assessment at rest were moderate or good. The agreement between ultrasound and MRI for the measurement of levator hiatal biometry at rest was moderate, with ICCs of 0.52 (95%CI, 0.32-0.66) for levator hiatal area, 0.44 (95%CI, 0.21-0.60) for anteroposterior diameter and 0.44 (95%CI, 0.22-0.60) for transverse diameter. Levator hiatal biometry measurements were statistically significantly larger on MRI than on translabial 3D ultrasound.Conclusions: The agreement between translabial 3D ultrasound and MRI for measurement of the levator hiatus at rest in women with pelvic organ prolapse was only moderate. The results of translabial 3D ultrasound and MRI should therefore not be used interchangeably in daily practice or in clinical research. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Introduction: Stress urinary incontinence (SUI) is a debilitating condition affecting up to 35% of women. A decline in oestrogen at menopause is thought to contribute to urinary incontinence, with 70% of women relating the onset to their last menses1. Theoretically, vaginal oestrogen should have a treatment effect in women with SUI, as oestrogen receptors are found in the bladder, urethra, vagina and pelvic floor muscles 1. Topical oestrogens increase urethral resistance by thickening the superficial layer of the urethral epithelium and increasing the periurethral vascularity. Because the vascular network accounts for one third of the urethral pressure, the estriol thus raises the urethral closure pressure and creates a more efficient mucosal seal. Vaginal oestrogen cream changes urethral cytology by increasing intermediate and superficial epithelial cells and decreasing transitional cells (known as a positive maturation index). A positive maturation index has been shown to correspond to improvement in SUI symptoms. Unfortunately, the quantitative evidence for the benefit of vaginal oestrogen cream in women with stress incontinence is very limited. The latest Cochrane review published in 2012 on vaginal oestrogen therapy concluded that such treatment may improve or cure incontinence2. However, sample sizes were small and there were marked differences in types, dosages, duration and routes of administration of the oestrogen therapy. It is recommended that future research should include standardised, validated, reproducible and simple outcome measures including quality-of-life tests. A more recent pragmatic pilot study using estriol cream for six weeks showed significant benefit for the SUI domain of the Urogenital Distress Inventory-6 (UDI-6)3. However, the most recent United States Food and Drug Administration (FaDA) report4 indicated that 12 weeks of estriol cream was needed for treatment of vaginal atrophy. Therefore, the aim of this prospective multinational observational study was to provide quantitative measures of urinary incontinence in women after 12 weeks of vaginal estriol cream as monotherapy. Material & methods: Postmenopausal women with symptoms of either pure SUI or stress predominant mixed urinary incontinence were instructed to apply a constant dose of estriol cream vaginally (with written instructions). Baseline and post treatment outcome measures were obtained. Main outcome measures: The stress domain of the UDI-6 was the primary subjective outcome measure and the vaginal pH was the primary objective outcome. Other subjective outcomes included the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-SF), Incontinence Impact Questionnaire-7 (IIQ-7), Most Bothersome Symptom (MBS) approach and Patient's Global Impression of Improvement (PGI-I). The secondary objective outcome used was the erect cough stress test. Patient compliance was also recorded. The study was approved by the local health district research ethics committees. Results: There were 46 postmenopausal participants, median age 62.1 (IQR 56.2-65.4). At 12 weeks the stress domain of UDI-6 significantly improved from 83.3 (IQR 50-100) to 33.3 (33.3-66.6, P=0.001) and the vaginal pH from 5.1 (4.9-5.9) to 4.9 (4.6-5.0, p=0.005). The pad test at 12-week follow-up measured <1g in 18/43 patients (42%) and dry rate for the ICIQ-SF was 14/43 (33%). See Table 1 for results of primary and secondary outcome measures. Conclusion: Twelve weeks of vaginal estriol cream significantly reduced symptoms of stress urinary incontinence in post-menopausal women. [ABSTRACT FROM AUTHOR]

Objective: The decline in available oestrogen after menopause is a possible etiological factor in pelvic floor disorders like vaginal atrophy (VA), urinary incontinence (UI), overactive bladder (OAB) and pelvic organ prolapse (POP). This systematic review will examine the evidence for local oestrogen therapy in the treatment of these pelvic floor disorders. Evidence Acquisition: We performed a systematic search in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and the non-MEDLINE subset of PubMed from inception to May 2014. We searched for local oestrogens and VA (I), UI/OAB (II) and POP (III). Part I was combined with broad methodological filters for randomized controlled trials (RCTs) and secondary evidence. For part I and II two reviewers independently selected RCTs evaluating the effect of topical oestrogens on symptoms and signs of VA and UI/OAB. In part III all studies of topical oestrogen therapy in the treatment of POP were selected. Data extraction and the assessment of risk of bias using the Cochrane Risk of Bias Tool was undertaken independently by two reviewers. Evidence Synthesis: The included studies varied in ways of topical application, types of oestrogen, dosage and treatment durations. Objective and subjective outcomes were assessed by a variety of measures. Overall, subjective and urodynamic outcomes, vaginal maturation and vaginal pH changed in favor of vaginal oestrogens compared to placebo. No obvious differences between different application methods were revealed. Low doses already seemed to have a beneficial effect. Studies evaluating the effect of topical oestrogen in women with POP are scarce and mainly assessed symptoms and signs associated with VA instead of POP symptoms. Conclusion: Topical oestrogen administration is effective for the treatment of VA and seems to decrease complaints of OAB and UI. The potential for local oestrogens in the prevention as well as treatment of POP needs further research. [ABSTRACT FROM AUTHOR]

The I in-vivo i behavior of pelvic floor implants and the foreign-body response they induce show great interpatient variability, depending on both patient and implant characteristics. A recent study demonstrated that ultra-high-frequency ultrasound (UHFU) offers improved quality of vaginal imaging compared to conventional ultrasound, allowing clear visualization of the vaginal walls2. We performed two-dimensional cross-sectional imaging and three-dimensional (3D) brightness (B)-mode imaging, and measured pore size and cross-sectional fiber surface area of the different materials. [Extracted from the article]

Objectives: To prospectively explore the clinical application of diffusion tensor imaging (DTI) and fibre tractography in evaluating the pelvic floor.Methods: Ten patients with pelvic organ prolapse, ten with pelvic floor symptoms and ten asymptomatic women were included. A two-dimensional (2D) spin-echo (SE) echo-planar imaging (EPI) sequence of the pelvic floor was acquired. Offline fibre tractography and morphological analysis of pelvic magnetic resonance imaging (MRI) were performed. Inter-rater agreement for quality assessment of fibre tracking results was evaluated using weighted kappa (κ). From agreed tracking results, eigen values (λ1, λ2, λ3), mean diffusivity (MD) and fractional anisotropy (FA) were calculated. MD and FA values were compared using ANOVA. Inter-rater reliability of DTI parameters was interpreted using the intra-class correlation coefficient (ICC).Results: Substantial inter-rater agreement was found (κ = 0.71 [95% CI 0.63-0.78]). Four anatomical structures were reliably identified. Substantial inter-rater agreement was found for MD and FA (ICC 0.60-0.91). No significant differences between groups were observed for anal sphincter, perineal body and puboperineal muscle. A significant difference in FA was found for internal obturator muscle between the prolapse group and the asymptomatic group (0.27 ± 0.05 vs 0.22 ± 0.03; P = 0.015).Conclusion: DTI with fibre tractography permits identification of part of the clinically relevant pelvic structures. Overall, no significant differences in DTI parameters were found between groups.Key Points: Diffusion tensor MRI offers new insights into female pelvic floor problems. DTI allows 3D visualisation and quantification of female pelvic floor anatomy. DTI parameters from pelvic floor structures can be reliably determined. No significant differences in DTI parameters between groups with/without prolapse. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Hakvoort R, Nieuwkerk P, Burger M, Emanuel M, Roovers J. Patient preferences for clean intermittent catheterisation and transurethral indwelling catheterisation for treatment of abnormal post-void residual bladder volume after vaginal prolapse surgery. BJOG 2011;118:1324-1328. Objective To determine patient preferences for clean intermittent catheterisation (CIC) relative to transurethral indwelling catheterisation (TIC) as the treatment of abnormal post-void residual bladder volume (PVR) following vaginal prolapse surgery. Design Scenario-based preference assessment during face-to-face interview. Setting Teaching hospital. Population A sample of consecutive patients scheduled for vaginal prolapse surgery. Methods Preference for CIC relative to TIC was assessed using written treatment scenarios. Initially, treatment duration was set at 3 days and the risk for urinary tract infection (UTI) was 30% for both interventions. Both treatment duration and UTI risk related to TIC were kept constant. Treatment duration and UTI risk after CIC were varied until patients altered their preference. In this way, the duration of catheterisation and level of UTI risk related to CIC at which patients would prefer CIC to TIC could be determined. Main outcome measures Patients' preference for CIC relative to TIC. Results When both duration of treatment and UTI risk were identical for both interventions, 64% of patients prefer CIC. Ninety-two percent of patients prefer CIC when CIC lasts 3 days but results in a 15% lower risk of UTI. Assuming that CIC results in a 15% risk of UTI, a total of 98 and 99% of patients prefer CIC to TIC when catheterisation with CIC last 2 and 1 day, respectively. Conclusions Most patients with abnormal PVR prefer CIC to TIC. The results of a recent randomised controlled trial showed that CIC resulted in a 2 days shorter catheterisation and more than 20% reduced risk of UTI. These conditions correspond to a preference of 99% of patients for CIC. [ABSTRACT FROM AUTHOR]

Objective To compare clean intermittent catheterisation with transurethral indwelling catheterisation for the treatment of abnormal post-void residual bladder volume (PVR) following vaginal prolapse surgery. Design Multicentre randomised controlled trial. Setting Five teaching hospitals and one non-teaching hospital in the Netherlands. Population All patients older than 18 years experiencing abnormal PVR following vaginal prolapse surgery, with or without the use of mesh. Exclusion criteria were: any neurological or anxiety disorder, or the need for combined anti-incontinence surgery. Methods All patients were given an indwelling catheter directly after surgery, which was removed on the first postoperative day. Patients with a PVR of more than 150 ml after their first void were randomised for clean intermittent catheterisation (CIC), performed by nursing staff, or for transurethral indwelling catheterisation (TIC) for 3 days.Main outcome measure Bacteriuria rate at end of treatment. Results A total of 87 patients were included in the study. Compared with the TIC group (n = 42), there was a lower risk of developing bacteriuria (14 versus 38%; P = 0.02) or urinary tract infection (UTI; 12 versus 33%; P = 0.03) in the CIC group (n = 45); moreover, a shorter period of catheterisation was required (18 hours CIC versus 72 hours TIC; P < 0.001). Patient satisfaction was similar in the two groups, and no adverse events occurred. Conclusion Clean intermittent catheterisation is preferable over indwelling catheterisation for 3 days in the treatment of abnormal PVR following vaginal prolapse surgery. [ABSTRACT FROM AUTHOR]

Background/Aims: It has been reported that lower urinary tract symptoms (LUTS) are more prevalent in patients who have undergone hysterectomy. However, the effects of surgical approach of hysterectomy on micturition have not been well documented. The aim of this study is to compare LUTS between patients who underwent vaginal and abdominal hysterectomy. Methods: Prospective observational study among 430 patients undergoing vaginal or abdominal hysterectomy for benign disease other than genital prolapse. Participating patients completed a validated disease-specific questionnaire before surgery, 6 months and 3 years after surgery. Results: 112 women underwent vaginal hysterectomy and 318 abdominal hysterectomy. After correction for differences in uterine size, descent of the uterus and other differences, LUTS were more common at 3 years after surgery following vaginal than following abdominal hysterectomy (OR 2.2, 95% CI 1.3–4.0). After adjustment for descent of the uterus, uteral size, parity and indication for hysterectomy, this difference was still statistical significant (adjusted OR 3.0, 95% CI 1.4–6.2). Conclusion: As compared to abdominal hysterectomy, LUTS appear to be more common following vaginal hysterectomy. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background The serotonin/noradrenaline uptake inhibitor duloxetine has been shown to be effective in the medical treatment of stress urinary incontinence (SUI) in women. Aim To review the safety and tolerability of duloxetine with SUI. Methods A systematic Medline search for the key word ‘duloxetine’ was performed, and abstracts from recent international gynaecological and urological meetings were also considered. Results Various unpleasant adverse effects exist, among which nausea is the most frequent, but is mild to moderate and transient in most cases. Dose escalation upon initiation of treatment improves the tolerability of duloxetine. The use of duloxetine appears safe as it lacks the cardiovascular adverse effects of older amine reuptake inhibitors. Conclusions Duloxetine has an acceptable safety profile. Dose escalation combined with patient counselling on the intensity and transient nature of adverse effects may help to further improve the benefit/tolerability ratio of duloxetine in the treatment of SUI. [ABSTRACT FROM AUTHOR]

Patients who undergo surgery because of genital prolapse and coexisting stress incontinence can be treated by a combination of surgical procedures via a unified route. We performed a retrospective study among 47 patients to compare micturition, defecation and prolapse symptoms after surgery, as well as duration of hospital stay and complication rate between patients who underwent a unified vaginal or abdominal surgical correction. All patients were treated between January 1995 and December 1997 in the University Medical Center Utrecht or St Antonius Hospital Nieuwegein, The Netherlands. Abdominal surgery was associated with a higher prevalence of difficulty in bladder emptying (relative risk (RR) 2.3 (95% CI 1.4–8.4)), fecal incontinence (RR 3.4, CI 1.1–10.7) and soiling (OR 2.8, CI 1.2–6.2), as well as with a longer postoperative hospital stay (8.6 vs 7.3 days) and a higher complication rate (25.0% vs. 11.4%) than vaginal surgery. These results suggest that a unified vaginal surgical correction of genital prolapse and coexisting stress incontinence appears to be preferable to a unified abdominal surgical correction. [ABSTRACT FROM AUTHOR]

Objective: Hysterectomy may affect bladder and bowel function. A retrospective study was performed to compare the prevalence of micturition and defecation symptoms between different modes of hysterectomy.Methods: All pre-operatively asymptomatic patients, with uteral size < or =10 cm, who underwent hysterectomy between 1988 and 1997 were interviewed about the prevalence of micturition and defecation symptoms and the experienced physical and emotional limitations of these symptoms. Using logistic regression analysis, odds ratios (OR) were calculated for all symptoms of which the prevalence between modes of hysterectomy differed more than 10%. These odds ratios were adjusted for differences in other prognostic factors.Results: Vaginal hysterectomy was performed on 68 patients, total abdominal hysterectomy on 109 patients and subtotal abdominal hysterectomy on 50 patients. An increased prevalence of urge incontinence (adjusted OR 1.5 (95% CI 0.8-3.1)) and feeling of incomplete evacuation (adjusted OR 1.9 (95% CI 1.0-4.0)) was observed among patients who had undergone vaginal hysterectomy as compared to patients who had undergone total abdominal hysterectomy. The prevalence of urge incontinence (adjusted OR 1.8 (95% CI 0.8-4.2)) and difficulty emptying the rectum (adjusted OR 1.8 (95% CI 0.7-4.4)) was higher among patients who had undergone vaginal hysterectomy than among patients who had undergone subtotal abdominal hysterectomy. Statistically significant odds ratios were not observed. Relevant differences in physical and emotional limitations related to micturition and defecation symptoms were not observed between groups.Conclusion: Our results suggest that technique of hysterectomy may influence the prevalence of micturition and defecation symptoms following hysterectomy. [ABSTRACT FROM AUTHOR]