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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., Competing Interests: Conflict of Interest The conflicts of interest of the authors are listed in the long version of the guideline ( https://register.awmf.org/de/leitlinien/detail/015-091 )./ Die Interessenkonflikte der Autoren sind in der Langfassung der Leitlinie ( https://register.awmf.org/de/leitlinien/detail/015-091 ) aufgelistet., (Thieme. All rights reserved.)

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., Competing Interests: Conflict of Interest The conflicts of interest of all the authors are listed in the long version of the guideline ( https://register.awmf.org/de/leitlinien/detail/015-091 )./ Die Interessenkonflikte der Autoren sind in der Langfassung der Leitlinie ( https://register.awmf.org/de/leitlinien/detail/015-091 ) aufgelistet., (Thieme. All rights reserved.)

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.

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.

Background: We conducted a prospective randomized controlled noninferiority trial to compare objective and subjective outcomes of retropubic tension-free vaginal tape (TVT) with those of transobturator tape (TVT-O) as primary treatment for stress urinary incontinence (SUI) in women., Study Design: The study was conducted at 25 gynecology units in Austria and Germany; regional and academic hospitals participated. A total of 569 patients were randomly assigned to undergo TVT or TVT-O., Results: A total of 480 patients (85%) were examined at 3 months. A negative cough stress test with stable cystometry to 300 ml was seen in 87% of patients after TVT and in 84% after TVT-O; 64% and 59% of patients, respectively, reported no pad use, and 88% of patients in both groups considered themselves much or very much better on the Patient Global Impression of Improvement (PGI-I) scale. Quality of life (QoL) as assessed with the SF-12 Health Survey, Kings' Health Questionnaire, (KHQ), and EuroQol-5D (EQ-5D) was significantly improved in both arms, with no differences between arms. There were no significant differences in postoperative pain or complications., Conclusions: Results of this trial demonstrate noninferiority between TVT and TVT-O with regard to postoperative continence and QoL and suggest little difference in perioperative problems (ClinicalTrials.gov NCT 00441454).

Purpose: To evaluate how many patients with overactive bladder still take their prescribed medication at least 12 months later and to find out the reasons for discontinuation of the therapy., Methods: Two hundred and ten patients who had received a prescription for anticholinergic medication were contacted by telephone 12-46 months later., Results: Out of 210 eligible patients 132 (63%) could be contacted and gave consent to participate in the study. 38% of them still took their medication after at least 12 months. 17% were continent or much improved, 13% a little improved, 8% were not improved, although still taking their medication. 62% did not take the original medication any more. 10% had never started with the medication, 42% took the medication for 3 months and 8% for 4-12 months. 25% had changed to another anticholinergic drug., Conclusion: Anticholinergic therapy is often discontinued by patients and doctors. Patients with OAB therefore need counselling and follow-up in the long term to make sure that alternative treatment is offered if anticholinergic treatment does not work.

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.

Objective: To compare the pelvic floor function of primiparous women to women after a second delivery regarding symptoms of urinary and anal incontinence, anal sphincter ruptures and bladder-neck mobility., Methods: A questionnaire evaluating symptoms of urinary and anal incontinence was used in nulliparous women before and 27 months after childbirth. Furthermore these symptoms were correlated with functional changes of the pelvic floor based on a careful gynecologic examination as well as perineal and endoanal ultrasound., Results: 112 nulliparous women were included, 49 women returned for follow-up on average 27 months (SD 4.4 months) after the first delivery. 39 women (group A) had just one delivery, 10 women (group B ? 10/49) had had a second delivery. Apart from levator ani muscle strength, no significant difference between pelvic floor function of group A vs group B was demonstrable. Furthermore, we could show no significant difference for symptoms of urinary (11 (28.2%) vs. 5 (50.0%)) and anal incontinence (14 (35.9%) vs. 4 (40.0%)) between both groups. However, we found a lasting increase of stress urinary and anal incontinence as well as overactive bladder symptoms after one or more deliveries. The position of the bladder neck at rest was lower in both groups compared to the position before the first delivery and bladder neck mobility increased after one or more deliveries., Discussion: Our study shows several statistically significant changes of the pelvic floor function even on average 27 months after delivery, but a subsequent delivery did not compromise the pelvic floor any further.

Objective: To compare the function of the pelvic floor in primiparae before and during pregnancy with the status post partum concerning symptoms of incontinence, sphincter ruptures, bladder-neck mobility and the influence of the different modes of deliveries., Methods: Questionnaire evaluating symptoms of urinary and anal incontinence in nulliparous women before and after delivery and correlating these symptoms with functional changes of the pelvic floor based on a careful gynaecologic examination as well as perineal and endoanal ultrasound., Results: 112 women were included in our study and came for the first visit, 99 women returned for follow-up 6 months after childbirth. Stress and flatus incontinence significantly increased from before pregnancy (3 and 12%) to after childbirth (21 and 28%) in women with spontaneous delivery or vacuum extraction. No new symptoms occurred after c-section. There was no significant difference between the bladder neck position before and after delivery. The mobility of the bladder neck was significantly higher after vaginal delivery using a vacuum extraction compared to spontaneous delivery or c-section. The bladder neck in women with post partum urinary stress incontinence was significantly more mobile than in continent controls. The endoanal ultrasound detected seven occult sphincter defects without any correlation to symptoms of anal incontinence., Conclusion: Several statistically significant changes of the pelvic floor after delivery were demonstrated. Spontaneous vaginal delivery or vacuum extraction increases the risk for stress or anal incontinence, delivery with vacuum extraction leads to higher bladder neck mobility and stress incontinent women have more mobile bladder necks than continent women.

Objective: Many surgeons perform an anti-incontinence procedure during prolapse surgery in women in whom occult stress urinary incontinence has been demonstrated. Others prefer a two-step approach. It was the aim of the study to find out how many women really need a second operation and if a positive cough stress test with the prolapse reduced is associated with the development of stress urinary incontinence after prolapse surgery., Methods: 233 women were operated for primary or recurrent prolapse without complaining of SUI. Preoperatively, 53/233 women had a full urogynecological workup with the prolapse reduced. Postoperatively, if the patient suffered from stress urinary incontinence, an anti-incontinence surgery was performed., Results: 19/53 (35.8%) women who had a stress test with the prolapse reduced before surgery were defined as occult stress incontinent. Only 3 women (15.8%) of these 19 women developed symptoms of incontinence after prolapse surgery and had to be operated because of that. 18/233 (7.7%) complained of SUI 6 weeks to 6 months after surgery and received a TVT-tape., Conclusion: The incidence of stress urinary incontinence manifesting after prolapse surgery is low in this study with 7.7%. This fact and the possible severe side effects of an incontinence operation justify a two-step approach if the patient is counseled and agrees. However, there is a small subgroup of women (3/19, 15.8%) with preoperative OSUI and SUI after surgery, who would benefit from a one-step approach. Further research is required to identify these women before surgical intervention.

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.

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.

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.

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.

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.

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 conservative treatment of stress or mixed incontinence results in improvement or cure in about 60 % of patients. Pelvic floor muscle training without or with biofeedback, electrical stimulation and vaginal cones are not superior to each other.

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.

Objective: To evaluate the mobility of the vesical neck during coughing and valsalva in healthy nulliparous volunteers and to test the reliability of the technique applied., Design: Clinical observational study., Setting: Department of Obstetrics and Gynaecology, Cantonal Hospital Lucerne, Switzerland., Population: Thirty-nine nulliparous volunteers., Methods: Vesical neck motion was assessed with perineal ultrasound. Intra-abdominal pressure was controlled for with an intrarectal probe. Intra-rater reliability was evaluated., Results: Vesical neck mobility was significantly lower during coughing (8 mm, SD 4 mm) than during valsalva (15 mm, SD 10 mm) (P < 0.005). Between individuals mobility varied from 4 mm to 32 mm during coughing and from 2 mm to 31 mm during valsalva. Test-retest-studies showed a maximum difference between to tests during coughing of 4 mm and during valsalva of 5 mm., Conclusion: The bladder neck is mobile in normal continent women and bladder neck mobility is lower during coughing than during Valsalva.

The aim of this study was to describe normal characteristics of spontaneous and voluntary pelvic muscle function in nulliparous healthy continent women and to assess the reaction of the pelvic floor to stress and fatigue. Ten nulliparous volunteers were recruited. Pelvic muscle strength was evaluated by palpation and perineal ultrasound. Kinesiological EMG and perineal ultrasound were performed to test for possible fatigue and to assess bladder neck mobility during coughing with a pre-contraction of the pelvic floor muscles. Bladder neck mobility did not increase after attempts to fatigue the pelvic floor muscles. Bladder neck descent was significantly less when the women were instructed to contract the pelvic floor muscles before coughing. The contraction of the pelvic floor muscles stabilizes the vesical neck in nulliparous women.

The aim of the study was to determine the efficacy of cotrimoxazole administration after urodynamic testing to prevent urinary tract infections. In a single-blind prospective randomized study 94 women who attended for urodynamic evaluation were included. After multichannel urodynamic testing, including two catheterizations, the women received a single dose of cotrimoxazole or placebo. A clean-catch urine specimen was tested for infection after 1 week. Seventy women returned a urine specimen after 1 week: 2/37 (5.4%) in the treatment and 2/33 (6.1%) in the placebo group had acquired a new urinary tract infection after urodynamics. One major and one minor adverse reaction to cotrimoxazole were reported. The power of the sample size was unfortunately too small to draw conclusions as to the efficacy of prophylaxis.

The aim of the study was to evaluate whether four different techniques were able to correctly measure pelvic floor muscle strength only. Sixteen volunteers performed a set of muscle contractions using the pelvic floor muscles (PFM) only, the abdominal muscles with and without PFM, gluteal muscles with and without PFM, adductor muscles with and without PFM and Valsalva maneuver with and without PFM. Pelvic floor muscle strength was evaluated by digital palpation, intravaginal EMG, pressure perineometry and perineal ultrasound. A 'non-pelvic muscle induced' reading was defined as a significant increase even though the pelvic floor muscles were not contracted. Results were as follows: isolated abdominal muscle contraction: non-pelvic muscle induced readings in 3/8 women with EMG and in 3/8 with pressure perineometry; isolated gluteal muscle contraction: non-pelvic muscle induced readings in 1/2 women with EMG perineometry; isolated adductor muscle contraction: non-pelvic muscle induced readings in 6/11 women with EMG perineometry and in 2/11 women with pressure perineometry; Valsalva maneuver: non-pelvic muscle induced readings in 4/9 women with EMG perineometry and 9/9 women with pressure perineometry. It was concluded that EMG and pressure perineometry do not selectively depict pelvic floor muscle activity.

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.

The aim of the study was to evaluate the relationship between Valsalva leak-point pressure (VLPP) and cough leak-point pressure (CLPP). Sixty women with stress urinary incontinence were included. One woman was excluded from evaluation because of detrusor instability. At a bladder volume of 200-300 mL (mean, 284; standard deviation, 29) CLPP and VLPP were measured in the sitting position. Intra-abdominal pressure was recorded with a rectal balloon catheter. A standardized pad test and multi-channel urodynamics were performed. VLPP was significantly lower than CLPP (58.9+/-27.6 versus 112.5+/-46.9 cm H(2)O, P<0.0001). Although CLPP was negative in two women only, VLPP was negative in 24 of 59 women (40.1%). If intrinsic sphincter deficiency was defined as a leak-point pressure of 65 cm H(2)O, 16.9% of women fulfilled this criterion using the CLPP compared to 35.6% if the VLPP is used. In conclusion, coughing and Valsalva seem to result in a different reaction of the pelvic floor.

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.

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.

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.

Background: To describe the cross-sectional anatomy of the anal sphincter mechanism relevant to magnetic resonance imaging (MRI) and ultrasound cross-sectional images., Method: Axial, sagittal, and coronal 5-mm sections of female pelves were reviewed from six cadaver specimens (ages 24-72 years). Fetal anatomy was studied in plastinated histologic sections from 19 and 26 weeks' gestation. Images of the anal sphincter were obtained by MRI in six and by ultrasound using an exoanal technique in 12 nulliparous volunteers., Experience: The internal anal sphincter is clearly visible in anatomic sections central to the external sphincter and is visible in MRI and ultrasound images. The external anal sphincter can be subdivided into a subcutaneous and a deep portion. On anatomic sections and on MRI, the subcutaneous part shows as two parallel muscle strips in the axial plane; the deep portion presents with a characteristic teardrop form in the section perpendicular to the axis of the anal canal. The puborectalis muscle and the external anal sphincter form a "double bump" in the sagittal section. The longitudinal muscle can be identified by its fiber orientation in anatomic sections but is not clearly visible in imaging studies., Conclusion: This information should make it possible to identify accurately anal sphincter anatomy in two-dimensional sectional images of the anal sphincter.

Objective: To evaluate pelvic floor muscle strength before and after vaginal birth., Design: Prospective repeated measures study., Setting: Main district hospital., Population: Fifty-five women: 25 primiparae and 20 multiparae following vaginal birth, and 10 women following elective caesarean delivery as a control group., Methods: Pelvic muscle strength was evaluated by palpation, perineometry and perineal ultrasound before childbirth in the 36th to 42nd week of pregnancy, three to eight days postpartum and six to ten weeks postpartum., Main Outcome Measures: Pelvic floor muscle strength on palpation, intravaginal squeeze pressure and vesical neck elevation during squeeze., Results: Pelvic floor muscle strength is significantly reduced three to eight days postpartum in women following vaginal birth but not in women after caesarean delivery. Six to ten weeks later palpation and vesical neck elevation on perineal ultrasound do not show any significant differences to antepartum values, while intravaginal pressure on perineometry remains significantly lower in primiparae, but not in multiparae., Conclusions: Pelvic floor muscle strength is impaired shortly after vaginal birth, but for most women returns within two months.

Objective: To describe the sonographic appearance of normal anal sphincter anatomy and sphincter defects evaluated with a conventional 5 MHz convex transducer placed on the perineum., Design: Prospective, single-blind study., Setting: Department of Obstetrics and Gynecology, University of Michigan Medical Center, USA., Population: Twenty-five women with symptoms of faecal incontinence, 11 asymptomatic nulliparous women, and 32 asymptomatic parous women., Methods: A convex scanner was placed on the perineum with the woman in lithotomy position. Images were taken at three levels of the sphincter canal. Pictures were evaluated by two examiners who were blinded to the case history of the women and to the results of each other for the presence or absence of sphincter defects., Main Outcome Measures: Description of anal sphincter appearance on endoanal ultrasound. Reproducibility of the evaluation of sphincter defects., Results: The internal anal sphincter is visible as a hypoechoic circle; the external anal sphincter shows a hyperechoic pattern. Proximally the sling of the puborectalis muscle is visible. Sphincter defects were detected in 20 women. In all five women who subsequently underwent surgery, the presence and location of the defect was confirmed at the time of surgery. Examiners were in agreement 100% of the time on the presence or absence of internal defects. They disagreed in one patient on the presence of an external defect., Conclusion: Exoanal ultrasound provides information on normal anatomy and on defects of the anal sphincter.

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.

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.