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There has been an increasing need for the terminology for the conservative management of female pelvic floor dysfunction to be collated in a clinically-based consensus report.This report combines the input of members and elected nominees of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. An extensive process of nine rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Before opening up for comments on the webpages of ICS and IUGA, five experts from physiotherapy, neurology, urology, urogynecology and nursing were invited to comment on the paper.A terminology report for the conservative management of female pelvic floor dysfunction, encompassing over 200 separate definitions, has been developed. It is clinically-based with the most common symptoms, signs, assessments, diagnoses and treatments defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Ongoing review is not only anticipated but will be required to keep the document updated and as widely acceptable as possible.A consensus-based terminology report for the conservative management of female pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Objectifs Lors d’une chirurgie pour incontinence urinaire d’effort et/ou prolapsus genital des dispositifs medicaux non-resorbables sont souvent utilises. Les complications dependent de l’experience du chirurgien, des caracteristiques des patientes, de la voie d’abord, de la technique de pose, et des materiaux utilises. L’observatoire VIGIMESH permet depuis 2017 un recueil prospectif de l’utilisation de ces dispositifs et de leurs complications (exposition, complications fonctionnelles [douleur, obstruction, consequences sexuelles]). Methodes A partir de fevrier 2017, dans les 13 centres participants toutes les patientes operees d’une incontinence urinaire d’effort (IUE) et/ou un prolapsus genital ou rectal pouvaient participer au suivi. Seuls les patientes ayant une bandelette sous-uretrale (BSU) ou une colposuspension, une reparation vaginale avec ou sans meche par voie vaginale ou abdominale ou une reparation endo-anale ont ete incluses. Les patientes ayant une pose de sphincter urinaire artificiel, de ballons peri-uretraux ou des injections de produits de comblements n’ont pas ete incluses. Chaque chirurgien declarait leurs interventions et complications. Celles-ci etaient verifiees avec les informations du departement d’information medicale et par des questionnaires de suivi. Resultats Au total, 1873 patientes ont ete incluses et analysees. Les chirurgies index ont ete reparties en 5 groupes ( Tableau 1 ). Les patientes operees d’une IUE isolee par BSU ont beneficie dans la moitie des cas d’une procedure retropubienne (338 cas soit 51,4 %). Quinze patientes ont eu un colpocleisis dans le groupe reparation vaginale sans materiel. Soixante-trois plaies peroperatoires (3,36 %) ont ete rapportes (34 de vessie, 2 de l’uretre, 2 du rectum et 19 du vagin). Seulement dans 8 cas ces plaies ont amene a l’arret de l’intervention et/ou de la mise en place de materiel. Cinquante-deux patientes (2,78 %) ont eu des complications graves durant la chirurgie ou dans les premiers mois postoperatoires (grade III ou plus) ( Tableau 2 et Fig. 1 ). Sept patientes ont necessite de multiples interventions pour traiter la complication. Conclusion L’observatoire est un outil qui permet de rapporter, de facon organisee, les complications des chirurgies du plancher pelvien et permettra sur le plus long terme de comparer les differents materiaux utilises et techniques d’implantation. Il permettra egalement a terme de proposer des recommandations sur la prevention et la prise en charge des complications de ces chirurgies et de leurs sequelles.

Resume Objectif Etablir des recommandations du College national des gynecologues et obstetriciens francais (CNGOF) concernant l’hysterectomie pour pathologie benigne. Materiel et methode Revue exhaustive de la litterature, etablissement de niveaux de preuve et de grades de recommandation selon la methodologie des recommandations pour la pratique clinique. Resultats Il est recommande qu’une hysterectomie soit realisee par un chirurgien pratiquant au moins 10 hysterectomies par an (grade C). Il est recommande de realiser une desinfection vaginale par povidone iodee en debut d’hysterectomie (grade B). Une antibioprophylaxie par une cephalosporine est recommandee lors d’une hysterectomie, quelle que soit la voie d’abord (grade B). Une preparation digestive mecanique n’est pas recommandee avant une hysterectomie (grade B). En cas d’hysterectomie pour pathologie benigne, il est recommande de preferer la voie vaginale ou la cœlioscopie (grade B), meme si l’uterus est gros et/ou si la patiente est obese (grade C). Le choix entre ces 2 voies d’abord dependra d’autres parametres dont l’experience de l’operateur, le mode d’anesthesie et les contraintes organisationnelles (duree operatoire et aspect medico-economique). L’hysterectomie vaginale pour pathologie benigne n’est pas contre-indiquee en cas de nulliparite (grade C), ni en cas d’antecedent de cesarienne (grade C). Aucune technique d’hemostase ne peut etre recommandee par rapport aux autres dans le seul but d’eviter des plaies urinaires (grade C). En l’absence de pathologie ovarienne et/ou d’antecedents personnels ou familiaux de cancer du sein/ovaire, il est recommande de conserver les ovaires chez les femmes non menopausees (grade B). Il n’est pas recommande de realiser une hysterectomie subtotale pour diminuer le risque de complications per- ou postoperatoires (grade B). Conclusion L’application de ces recommandations devrait contribuer a diminuer la prevalence des complications associees aux hysterectomies.

Resume But Faire un etat des lieux de la prevalence de l’incontinence anale du post-partum, en exposer les facteurs de risque, evaluer les modalites et les resultats des moyens actuels de prise en charge. Materiel et methode Revue de la litterature realisee a partir d’une recherche bibliographique sur PubMed, Medline, Embase et Cochrane. Les termes utilises etaient : anal incontinence postpartum, fecal incontinence postpartum, perineal rehabilitation, anal surgery. Resultats La prevalence de l’incontinence anale du post-partum variait selon les etudes de 4 % (primipare) a 39 % (multipare) a 6 semaines du post-partum, tandis que l’incontinence fecale pouvait atteindre respectivement 8 a 12 % a 6 ans de l’accouchement. Comparativement a la cesarienne, l’accouchement par voie basse augmentait le risque d’incontinence anale (OR : 1,32 [IC 95 % : 1,04–1,68]). Les extractions instrumentales augmentaient le risque d’incontinence anale (OR : 1,47 [IC 95 % : 1,22–1,78]) par rapport a l’accouchement par voie basse spontanee mais il s’agissait principalement de l’extraction par forceps (OR : 1,50 [IC 95 % : 1,19–1,89]) et non par ventouse (OR : 1,31 [IC 95 % : 0,97–1,77]). L’âge maternel (> 35 ans : OR : 6 [IC 95 % : 1,85–19,45]), le nombre de naissances (3 naissances : OR : 2,91 [IC 95 % : 1,32–6,41]) et la survenue d’un perinee complet (OR : 2,3 [IC 95 % : 1,1–5]) etaient associes a une augmentation du risque d’incontinence anale quelle que soit la voie d’accouchement comparativement a un groupe de femmes sans incontinence anale. Les resultats de la reeducation perineale sont a interpreter avec prudence du fait de l’absence d’essais controles randomises. Une reevaluation a 6 mois du post-partum en vue d’un traitement chirurgical par sphincteroplastie pourrait etre envisagee en cas de persistance des symptomes. Les resultats de la sphincteroplastie etaient satisfaisants mais avec un taux de succes s’estompant dans le temps (60 a 90 % a 6 mois contre 50 a 40 % a 5 et 10 ans). Conclusion L’incidence et le retentissement de l’incontinence anale du post-partum necessite une prise en charge specifique. Des recommandations sur sa prise en charge seraient utiles.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 44 - N° 9 - p. 802-811

Aims To explore the involvement of a distraction task in involuntary reflex pelvic floor muscle contraction following cough. Methods Informed consent was obtained from 33 healthy volunteers. Involuntary contraction of the external anal sphincter (EAS) was induced by means of coughing. Cough efforts were elicited by electronic order. The electromyographic (EMG) activity of the EAS was recorded during involuntary contraction elicited by coughing. The trials were carried out twice: combined (or not) with a mental distraction task; the paced auditory serial additional test (PASAT). Reaction time (RT) defined as latency between the stimulus and maximum EAS EMG activity (RT1), latency between the stimulus and external intercostal (EIC) muscle EMG activity (RT2), latency between EIC EMG activity and EAS EMG activity (RT3), duration of the contraction, and the area under the EAS EMG activity curve (perineal contraction) were measured. Results The distraction task altered anticipation of the PFM contraction: RT3 was −80.00 ms (IQR −107; −56) without the PASAT versus −56.67 ms (IQR: −94; −2) with the distraction task (ratio 0.71, P = 0.0045, Wilcoxon test). RT2 was altered during the distraction task: 583.33 ms (IQR: 344–775) without PASAT versus 652.71 ms (503–790) during PASAT (ratio 1.12, P = 0.031, Wilcoxon test). Finally, when the two conditions (respectively with and without the mental distraction task) were compared, there was a significant difference between the area under the EAS EMG activity curve (0.0115 mv sec vs. 0.0103 mv sec, ratio 0.90, P = 0.023). Conclusions The mental distraction task altered involuntary reflex contraction of the pelvic floor muscles. Neurourol. Urodynam. 36:160–165, 2017. © 2015 Wiley Periodicals, Inc.

Resume Introduction La fin de l’annee 2012 a ete marquee par des alertes mediatiques sur les contraceptions hormonales combinees (CHC) et des plaintes de patientes contre les laboratoires commercialisant ces pilules. Nous nous sommes interroges sur l’impact de ces annonces sur le nombre d’interruptions volontaires de grossesse (IVG). Patientes et methode Etude prospective evaluant le nombre de femmes ayant demande une IVG et qui declaraient spontanement que cet echec de contraception etait survenu suite a un arret de leur contraception orale parce qu’elles avaient eu peur des informations vehiculees dans les medias. Resultats Onze centres sur 16 ont repondu a l’enquete totalisant 2300 IVG sur cette periode dont 98 (4,2 %) pour des grossesses survenues suite a un arret de contraception que les femmes declaraient comme une consequence des alertes mediatiques. L’âge moyen etait de 26 ans. Ces grossesses avaient debute dans 4 cas (6 %) en decembre 2012, soit 3 mois apres le debut de l’alerte, dans 11 cas (16 %) en janvier, dans 24 cas (36 %) en fevrier et dans 18 cas (27 %) en mars 2013, soit 4 a 6 mois apres. Les CHC interrompues par « peur » des informations vehiculees dans les medias etaient de 2e generation dans 7 cas (10 %), de 3e generation dans 17 cas (25 %), de 4e generation dans 32 cas (48 %) ou microprogestative dans 2 cas (3 %). Conclusion Les demandes d’IVG de femmes declarant avoir interrompu leur contraception par peur des informations vehiculees dans les medias ont represente 4 % des IVG entre le 18/02/2013 et le 30/04/2013.

Summary Introduction There is increasing interest in noninvasive treatment of female stress urinary incontinence (SUI), including a vaginal laser procedure. In view of a lack of data on this technique, we conducted a non-systematic review of the literature. Methods We reviewed studies concerning the laser treatment of SUI from PubMed, Medline, the Cochrane Library and Web of Science. Study design, outcome measure, number of participants, procedural complications and results were analyzed. Results The use of laser treatment of female SUI has been described in 7 prospective, single-center and non-comparative (no control group) studies, all of which used an erbium YAG or a CO 2 laser in thermal non-ablative treatment. Primary outcome was ICIQ-UI-SF score in six studies, and pad tests in one study. Follow-up ranged from 5 to 36 months. Improvement rates ranged from 62% to 78%. No major adverse events were noted. Minor side effects included sensation of warmth, increased vaginal discharge and transient urge urinary incontinence. Conclusion The efficacy of vaginal laser treatment of SUI has not been assessed in comparative studies. More rigorous and adequately powered trials are required to assess the relative benefits and adverse event profile of laser treatment of SUI, as compared with other minimally invasive procedures.

Summary Objective To compare the functional outcomes and complication rates following laparoscopic sacrocolpopexy (LS) with those occurring in robot-assisted laparoscopic sacrocolpopexy (RALSCP) in obese women. Patients and methods A comparative retrospective multicentre study was made, involving 39 obese women (BMI ≥ 30 kg/m 2 ) who underwent LS, and 17 obese women who underwent RASCLP. The operative parameters (length of operation, associated procedures, complication rate and length of hospitalization) and the objective and subjective results were evaluated at 12 months follow-up. Results The median (IQR) BMI was 30.5 kg/m 2 (30–32) in the LS group vs 31.6 kg/m 2 (30–34) in the RALSCP group ( P = 0.402). The anatomical results were comparable in both groups (LS vs RALSCP): post-operative stage of prolapse (POP-Q-ICS): stage 0–1: 34/39 (88%) vs 16/17 (94.1%), P = 0.7; stage 2: 4/39 (10%) vs 0/17 (0%), P = 0.7; stage 3–4: 1/39 (2%) vs 1/17 (5.9%), P = 0.7. The complication rate was similar in both groups (LS vs RALSCP): bladder injury 2.5% (1/39) vs 0% (0/17), P = 0.6, laparoconversion 5.1% (2/39) vs 5.9% (1/17), P = 0.5. The overall reoperation rate was (LS vs RALSCP): 18% (7/39) vs 5.9% (1/17), P = 0.4. Conclusion Laparoscopic sacrocolpopexy and robot-assisted laparoscopic sacrocolpopexy have equal results in obese women. The complication rates and outcomes appear to be similar in both groups of obese women. Level of evidence 3.

Resume But Evaluer l’impact de la mise en place d’une bandelette sous-uretrale sur la sexualite des patientes. Materiels et methodes Il s’agit d’une revue de la litterature realisee a partir d’une recherche bibliographique sur Pubmed, Medline, Embase et Cochrane. Les termes utilises etaient stress urinary incontinence , sexual function , anti-incontinence surgery , minimaly invasive slings , mid-urethral slings , tension-free vaginal tape , transobturator vaginal tape . Nous avons selectionne 69 etudes se rapportant aux troubles sexuels survenant apres pose de BSU. Resultats Les resultats sont exprimes en mediane (IQR). Apres chirurgie de l’incontinence urinaire a l’effort par bandelette sous-uretrale, 30 % (21–37) des patientes presentaient une amelioration de leur fonction sexuelle, 8,5 % (4,7–14) presentaient une alteration de leur sexualite et 60 % (53–73) n’avaient aucun retentissement des bandelettes sous-uretrales sur leur sexualite. Conclusion La chirurgie de l’incontinence urinaire par bandelette sous-uretrale ne semble pas avoir d’impact negatif significatif sur la sexualite des patientes.

Aims Attention may play a key role in the contraction of pelvic floor muscles in stressful situations, meaning that mental distraction may be involved in urinary incontinence. Methods Informed consent was obtained from 20 healthy volunteers. The electromyographic (EMG) activity of the external anal sphincter (EAS) was recorded during voluntary contraction elicited by local stimulation. The trials were carried out twice: combined (or not) with a mental distraction task (PASAT), Paced auditory serial additional test. Reaction time, latency between the stimulus and maximum EAS EMG activity, duration of the contraction, maximum EAS EMG activity, and the area under the EAS EMG activity curve were measured. Results The mental distraction task led to a 3.98 times greater reaction time (RT), (P = 0.00001 Wilcoxon's test). The RT increased from 217 (IQR: 170–270) to 779 msec (IQR: 550–1,025, P

Resume But La physiopathologie des troubles de la miction et de la continence urinaire a fait l’objet de nombreuses recherches sans que l’on puisse trouver une cause uniciste aux pathologies mictionnelles. La notion de miction cognitive apporte de nouvelles pistes de recherche pour montrer le role fondamental du cortex et du sous-cortex dans ces pathologies. Materiel et methodes Il s’agit d’une revue de la litterature realisee a partir d’une recherche bibliographique sur Pubmed, Medline, Embase et Cochrane. Les termes utilises etaient cognition , urinary tract , urinary continence , neuroimaging , IRMf , micturition , urge , brain factor , cognitive therapy . Nous avons selectionne les 72 articles se rapportant reellement a la problematique de la miction et de la cognition. Resultats L’emergence des nouvelles techniques d’imageries a permis de montrer l’interconnexion de zones corticales dans le controle mictionnel tels que la substance grise periacqueductale, l’hypothalamus, l’insula, le gyrus cingulaire anterieur et le cortex prefrontal. Ces memes regions cerebrales sont impliquees dans les differentes facettes de la cognition. Une alteration du comportement mictionnel implique une modification d’activation de ces aires corticales. Conclusion Une meilleure comprehension de la partie cognitive de la miction et de la continence urinaire permettra d’ameliorer la prise en charge des pathologies associees.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 42 - N° 8 - p. 1028-1031

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 42 - N° 8 - p. 1032-1049

Le principali patologie che portano a ipotizzare un intervento chirurgico addominale nel corso della gravidanza sono le patologie annessiali (tumore benigno o maligno, torsione), la colecistectomia, l’appendicectomia e le occlusioni digestive. La maggior parte delle equipe realizza una laparoscopia in prima intenzione ormai da una decina di anni. Degli studi comparativi hanno mostrato un’assenza di differenze nell’incidenza di complicanze dopo laparotomia e laparoscopia a proposito dei tassi di aborti e di parti prematuri. D’altra parte, la ripresa del transito e il ricovero in ospedale sono piu brevi e i dolori sono meno importanti dopo la laparoscopia. Se l’intervento puo essere ritardato (il che avviene raramente), sembra consigliato realizzarlo all’inizio del secondo trimestre, una volta terminata l’organogenesi. L’installazione dei trocar dipende dall’indicazione della laparoscopia e dal termine della gravidanza; all’inizio del primo trimestre, sono possibili tutte le tecniche, ma, dal secondo trimestre, sara necessario prendere in considerazione una tecnica open o un accesso all’ipocondrio sinistro. Piu la gravidanza e evoluta, piu e raccomandata l’open-laparoscopia e piu il trocar mediano deve essere posto in alto. Per una laparoscopia a partire dal secondo trimestre di gravidanza, la paziente deve essere installata su una tavola inclinata verso il suo lato sinistro, in modo da ridurre il rischio di compressione della vena cava inferiore da parte dell’utero. La pressione di insufflazione deve essere mantenuta a un massimo di 12 mmHg, salvo in occasione del posizionamento dei trocar.

Resume Objectif Determiner quels sont les mecanismes d’action prouves de la reeducation perineale dans le cadre de l’incontinence urinaire de la femme. Methode Revue de la litterature sur PubMed, Embase, Cochrane Database, utilisant les mots cles : female ; urinary incontinence ; overactive bladder syndrome ; stress urinary incontinence ; bladder training ; bladder diary ; pelvic floor muscle training ; pelvic floor rehabilitation ; physiotherapy ; cognitive therapies . Sur 2906 articles (etudes animales ou anatomiques exclues), 66 articles ont ete retenus. Resultats Les etudes concernant les exercices de contraction volontaire des muscles pelvi-perineaux ont montre une augmentation significative de la force de contraction de ces muscles et celle-ci etait correlee avec l’amelioration des scores d’incontinence urinaire et le pad-test (coefficient de correlation r entre 0,23 et 0,34) pour les femmes ayant une incontinence urinaire a l’effort. Ces etudes n’ont pas observe d’augmentation de la pression de cloture uretrale maximum (PCUM), ni de correction de l’hypermobilite uretrale correlee a l’amelioration de l’incontinence apres les seances de reeducation. Les etudes concernant l’electrostimulation des muscles pelvi-perineaux ont observe une augmentation de la force de contraction de ces muscles apres reeducation et une diminution de l’intensite des contractions detrusoriennes, sans modification de la PCUM. Il existait tres peu de donnees sur les mecanismes d’action precis du biofeedback et des therapies cognitivo-comportementales. Conclusion Dans les etudes ayant evalue objectivement les mecanismes d’action de la reeducation perineale, il a ete observe que les exercices de contraction volontaire des muscles pelvi-perineaux et l’electrostimulation entrainaient une augmentation de leur force de contraction, sans modifier la PCUM.

Las principales indicaciones quirurgicas abdominales durante el embarazo son las enfermedades anexiales (tumor benigno o maligno, torsion), la colecistectomia, la apendicectomia y las obstrucciones intestinales. Desde hace unos 10 anos, la mayoria de los equipos optan en primer lugar por la laparoscopia. Los estudios comparativos no han mostrado diferencias en cuanto a la prevalencia de complicaciones tras la laparotomia y la laparoscopia en terminos de abortos y de parto prematuro. Ademas, la laparoscopia se asocia a una reanudacion del transito intestinal mas precoz, un tiempo de hospitalizacion mas corto y un dolor menos intenso. Si la intervencion puede postergarse (lo que rara vez es posible), se recomienda efectuarla al comienzo del segundo trimestre, una vez que haya finalizado la organogenesis. La posicion de los trocares depende de la indicacion de la laparoscopia y de la edad gestacional; al comienzo del primer trimestre, se pueden emplear todas las tecnicas, pero a partir del segundo trimestre habra que considerar una tecnica abierta o una via de acceso en el hipocondrio izquierdo. Cuanto mas avanzado este el embarazo, mas se recomienda la laparoscopia abierta y mas alta debe ser la posicion del trocar medial. Para una laparoscopia a partir del segundo trimestre del embarazo, hay que colocar a la paciente en una mesa inclinada hacia la izquierda, para limitar el riesgo de compresion de la vena cava inferior por el utero. La presion de insuflacion debe mantenerse en un valor maximo de 12 mmHg, excepto en el momento de colocar los trocares.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 42 - N° 1 - p. 86-90

Objective Develop guidelines for surgery for primary pelvic organ prolapse (POP). Methods Literature review, establishment of levels of evidence, external review, and grading of recommendations by 5 French academic societies: Association Francaise d'Urologie, College National des Gynecologues et Obstetriciens Francais, Societe Interdisciplinaire d'Urodynamique et de Pelvi-Perineologie, Societe Nationale Francaise de Colo-proctologie, and Societe de Chirurgie Gynecologique et Pelvienne. Results It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (grade B). A bowel preparation before vaginal (grade B) or abdominal surgery (grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (grade C).

Providing clinical practice guidelines for first surgical treatment of female pelvic organ prolapse.Systematic literature review, level of evidence rating, external proofreading, and grading of recommendations by 5 French academic societies: Association française d'urologie, Collège national des gynécologues et obstétriciens français, Société interdisciplinaire d'urodynamique et de pelvi-périnéologie, Société nationale française de coloproctologie, and Société de chirurgie gynécologique et pelvienne.It is useful to evaluate symptoms, their impact, women's expectations, and to describe the prolapse prior to surgery (Grade C). In the absence of any spontaneous or occult urinary sign, there is no reason to perform urodynamics (Grade C). When a sacrocolpopexy is indicated, laparoscopy is recommended (Grade B). A bowel preparation before vaginal (Grade B) or abdominal surgery (Grade C) is not recommended. There is no argument to systematically use a rectovaginal mesh to prevent rectocele (Grade C). The use of a vesicovaginal mesh by vaginal route should be discussed taking into account an uncertain long-term risk-benefit ratio (Grade B). Levator myorrhaphy is not recommended as a first-line rectocele treatment (Grade C). There is no indication for a vaginal mesh as a first-line rectocele treatment (Grade C). There is no reason to systematically perform a hysterectomy during prolapse repair (Grade C). It is possible to not treat stress incontinence at the time of prolapse repair, if the woman is advised of the possibility of a 2-step surgical treatment (Grade C). Clinical practice guidelines. © 2016 Published by Elsevier Masson SAS.

To provide clinical practice guidelines (CPGs) based on the best evidence available (level of evidence (LE)), concerning colpocleisis as a surgical treatment of pelvic organ prolapse.This article concern a systematically review of the literature concerning colpocleisis (obliterative surgery).At short term follow-up, colpocleisis is associated with an anatomical success rate of 98 % (LE3) and a subjective success rate of 93% (LE3). A decrease in genital, urinary and anorectal symptoms and an enhancement of quality of life are observed in most women following colpocleisis (LE4). At mid-term (1 to 3 years) follow-up, patients' satisfaction ("satisfied" or "very satisfied" ranges from 85 to 100% (LE3)). At long-term follow-up, regret rate (women who regret having had the surgery) is 5% (LE4). In women over 80 years old, colpocleisis is associated with a decrease in per-and post-operative complication rates when compare to other surgical techniques used for pelvic organ prolapse surgery (LE2).Colpocleisis is a valid surgical option for elderly patients with pelvic organ prolapse surgery, and who are definitely permanently sexually inactive (Grade C). © 2016 Published by Elsevier Masson SAS.

The use of prosthetic surgery by vaginal route has been widely used to try to reduce the risk of prolapse recurrence in the surgical treatment of vaginal cystoceles. Specific complications including type of erosion have led to randomized studies comparing surgery by vaginal route with and without use of Mesh.This work is based on a systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane database of systemactic reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement (AP)).The use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1). However, there is no difference in the functional outcome and there is an increase in the number of reoperations related to specific complications, including vaginal erosions.If the use of inter-vesicovaginal synthetic mesh improves the anatomical result compared to the autologous surgery for the treatment of cystocele (NP1), no difference in functional outcome and the increased number of related reoperations specific complications including vaginal erosions, do not argue for the systematic use of mesh in the treatment of primary cystocele. It must be discussed case by case basis taking into account a risk-benefit uncertain at long-term (grade B). Its use should be supported by additional studies focused on specific populations at risk of recurrence. © 2016 Published by Elsevier Masson SAS.

International audience; INTRODUCTION AND HYPOTHESIS:Given its increasing complexity, the terminology for female pelvic floor disorders needs to be updated in addition to existing terminology of the lower urinary tract. To do this, it seems preferable to adopt a female-specific approach and build on a consensus based on clinical practice.METHODOLOGY:This paper summarizes the work of the standardization and terminology committees of two international scientific societies, namely the International Urogynecological Association (IUGA) and the International Continence Society (ICS). These committees were assisted by many external expert referees. A ranking into relevant major clinical categories and sub-categories was developed in order to allocate an alphanumeric code to each definition. An extensive process of 15 internal and external reviews was set up to study each definition in detail, with decisions taken collectively (consensus).RESULTS:Terminology was developed for female pelvic floor disorders, bringing together more than 250 definitions. It is clinically based and the six most common diagnoses are defined. The emphasis was placed on clarity and user-friendliness to make this terminology accessible to practitioners and trainees in all the specialties involved in female pelvic floor disorders. Imaging investigations (ultrasound, radiology, MRI) exclusively for women have been added to the text, relevant figures have also been included to complete the text and help clarify the meaning. Regular reviews are planned and are also required to keep the document up-to-date and as widely acceptable as possible.CONCLUSIONS:The work conducted led to the development of a consensual terminology of female pelvic floor disorders. This document has been designed to provide substantial assistance in clinical practice and research.LEVEL OF EVIDENCE:4.

Resume But Etudier la valeur diagnostique intrinseque des examens prescrits pour explorer une dysurie de la femme. Materiel Revue de la litterature sur PubMed, Embase, Cochrane Database, utilisant les mots-cles : female , bladder outlet obstruction , post-void residual, uroflowmetry , flow pattern , cystoscopy , MRI , retrograde cystography , bladder wall thickness , bladder trabeculation , urinary retention , voiding cystometry , pressure flow studies , electromyography . Sur 2660 articles (etudes animales ou anatomiques exclues), 40 articles focalises sur l’evaluation de la valeur intrinseque des examens complementaires ont ete retenus. Resultats L’enregistrement concomitant des pressions vesicales et abdominales pendant la miction (etude pression debit) permet de rechercher une hypocontractilite detrusorienne, de mettre en evidence une poussee abdominale et de suspecter une obstruction en cas de debit faible associe a une pression vesicale elevee. La reproductibilite de cette etude pression debit etait tres bonne dans les etudes publiees. Des nomogrammes ont ete decrits pour juger d’une eventuelle obstruction, mais certaines etudes ne montrent pas de correlation entre la severite des symptomes de dysurie et les resultats sur le principal nomogramme (nomogramme de Blaivas). La mesure de l’epaisseur de la paroi vesicale semble correctement correlee au diagnostic d’obstruction mais les mesures varient significativement selon la voie d’abord abdominale ou vaginale. Conclusion Dans la litterature, ce sont essentiellement les mesures du debit maximum urinaire et du residu post-mictionnel, qui ont ete etudiees de facon precise.

Resume La laparoscopie est une voie d’abord qui est generatrice de nouvelles complications. Un tiers des complications est secondaire a la creation d’un pneumoperitoine. La procedure laparosocopique initiale debute par la mise en place d’un pneumoperitoine qui peut se faire soit par un trocart d’open cœlio, soit par l’utilisation d’une methode fermee a l’aide d’une aiguille de Veress, puis introduction d’un trocart ou l’introduction directe du trocart sans pneumoperitoine prealable. Lors de cette derniere technique, les complications peuvent survenir lors de l’introduction de l’aiguille de Veress ou le plus souvent lors de l’introduction du trocart ombilical. Nous avons aborde uniquement les problemes de la creation d’un pneumoperitoine par une technique fermee et les tests de securite. La ponction a l’aiguille de Palmer dans l’hypochondre gauche chez un patient en decubitus dorsal semble etre la technique la plus sure. Parmi les quatre tests de securite pour l’analyse du bon placement de l’aiguille de Veress (double « clic », test a la seringue, test d’aspiration, pression initiale avant insufflation) pour l’insufflation, seul le test de verification de la pression semble posseder une valeur diagnostique. Celui-ci consiste a mesurer les cinq premieres pressions enregistrees par l’insufflateur a cinq secondes d’intervalle et qui doivent etre inferieures a 10 mmHg avec une pression d’insufflation de 1 L/min, chez un patient bien curarise. L’hyperpression transitoire de 25 mmHg permet l’introduction du premier trocart dans les meilleures conditions de securite. A ce jour, malgre l’absence d’augmentation significative de plaie digestive ou vasculaire lors de l’introduction d’un trocart sans pneumoperitoine, il n’existe pas de test de securite pour sa mise en place.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 40 - N° 8 - p. 827-850

Resume Objectif Editer des recommandations pour la pratique clinique concernant les techniques d’installation en cœlioscopie et leurs complications, par le College national des gynecologues et obstetriciens francais (CNGOF), fondees sur les preuves disponibles. Materiel et methode Revue de la litterature portant sur des articles en francais et en anglais issus de Medline, PubMed et de la Cochrane database en utilisant les mots cles suivants : laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, optical trocar radially expanded trocars, and laparoscopic complications. Resultats En l’absence d’antecedent de laparotomie, quatre techniques ayant ete largement evaluees peuvent etre utilisees en premiere intention (grade B) : technique aveugle transombilicale apres creation d’un pneumoperitoine a l’aiguille ; open cœlioscopie (a ciel ouvert) ; abord en hypochondre gauche : pneumoperitoine et insertion du trocart (mini- ou microcœlioscopie) ; trocart direct transombilical sans pneumoperitoine prealable. Les systemes d’introduction a dilatation radiale et les trocarts optiques ne peuvent pas etre recommandes en premiere intention du fait de leur evaluation encore insuffisante (grade C). En cas d’antecedent de laparotomie mediane, quelle que soit la technique utilisee, on recommande un abord premier a distance des cicatrices (grade B). Il est recommande de realiser un abord en hypochondre gauche (grade C). Le niveau de mise en place du premier trocart cœlioscopique en cours de grossesse devra etre adapte au volume de l’uterus (grade B). A partir du deuxieme trimestre, deux techniques d’insertion des trocarts sont alors recommandees : l’open cœlioscopie (par voie transombilicale ou sus-ombilicale selon le volume de l’uterus) ou un abord dans l’hypochondre gauche (grade C). Pour l’etablissement du pneumoperitoine a l’aiguille, une fois l’aiguille introduite, et quel que soit le lieu d’insertion, la realisation d’un ou plusieurs tests de securite est recommandee (grade B) et toute mobilisation de l’aiguille doit etre proscrite. La patiente doit etre placee en decubitus dorsal a plat (sans Trendelenburg) (grade B). Il est recommande d’etablir une hyperpression transitoire (entre 15 et 25 mmHg) (grade C). Conclusion L’application de ces recommandations devrait optimiser les decisions concernant le choix d’une technique pour l’installation en cœlioscopie.

Resume Objectif Rapporter les regles de fonctionnement et l’activite du Comite d’ethique de la recherche en obstetrique et gynecologie (CEROG) cree en 2008. Les modalites pratiques de soumission sont decrites. Materiel et methodes Etude retrospective. Resultats Le Comite d’ethique de la recherche du College national des gynecologues et obstetriciens francais (CNGOF) a examine 65 projets d’etudes en 2008. Le nombre median d’etudes soumises etait de 5,5 par mois (IQR : 3,75–6,25). L’origine institutionnelle des soumissions etait la suivante : centre hospitalier universitaire (n = 63, 97 %), Inserm (n = 1), Inra (n = 1). Les projets de recherche soumis ont ete juges comme etant en conformite avec la legislation francaise et comme repondant aux principes scientifiques et ethiques dans 44 cas (68 %). Dans 13 cas (20 %), le projet d’etude a ete transmis a un comite de protection des personnes (CPP) car il relevait de la recherche biomedicale ou du « soin courant ». Dans six cas (9 %), les investigateurs n’ont pas repondu aux suggestions et demandes de modification du comite d’ethique. Dans deux cas (3 %), la fiche d’information a ete jugee non satisfaisante. Conclusion Le CEROG est le premier comite d’ethique de la recherche national specialise en gynecologie obstetrique, permettant de soumettre des etudes non interventionnelles.

Les troubles du transit (constipation) et de la defecation (dyschesie) sont des symptomes assez frequemment rapportes chez les femmes qui consultent pour un prolapsus genital. Toutefois, il existe tres peu de donnees sur la prevalence des troubles anorectaux survenant de novo apres une chirurgie pour prolapsus genital. L’evaluation comporte un interrogatoire et un examen clinique complet, ainsi que des explorations physiologiques comme la manometrie anorectale, le test d’expulsion au ballonnet, la defecographie et l’IRM pelvienne. Une constipation de novo est rapportee par des femmes operees (jusqu’a 26 %) d’une promontofixation par laparotomie, et cette prevalence varie de 5 a 19 % chez les femmes operees d’une promontofixation coelioscopique. La prevalence de la dyschesie de novo varie de 2 a 4 % chez les femmes perees soit par promontofixation coelioscopique, soit par voie vaginale avec mise en place d’une prothese synthetique en polypropylene. Au total, la survenue de novo de troubles anorectaux apres chirurgie du prolapsus n’est pas une situation si exceptionnelle, et les patientes doivent en etre informees avant l’intervention.

Chez la femme, l’incontinence urinaire est une affection frequente qui peut etre handicapante et couteuse (NP1). Chez la patiente qui consulte pour incontinence urinaire, il est recommande de preciser les circonstances, la frequence et la severite des fuites (grade B). Le test a la toux est recommande avant la chirurgie (grade C). Il n’est pas utile de prescrire un bilan urodynamique avant reeducation perineale pour incontinence urinaire chez la femme (grade B). Un bilan urodynamique complet est recommande avant une chirurgie pour incontinence urinaire (grade C). En cas d’incontinence urinaire d’effort (IUE) isolee, le bilan urodynamique n’est pas indispensable avant la chirurgie si l’evaluation clinique est complete (questionnaire standardise, test a la toux, catalogue mictionnel, residu postmictionnel) et concordante (AP). Il est recommande de debuter le traitement de l’IUE par des exercices musculaires du plancher pelvien (grade C). La reeducation comportementale est recommandee de premiere intention en cas de syndrome d’hyperactivite vesicale (grade C). En cas de surpoids, la perte de poids ameliore l’incontinence urinaire (NP1). Pour la chirurgie de l’IUE de la femme, la bandelette sous-uretrale (voie retropubienne ou transobturatrice) est la technique recommandee de premiere intention (grade B). La chirurgie par bandelette sous-uretrale comporte des risques operatoires, postoperatoires et d’echec qui doivent faire l’objet d’une information prealable (grade A). La cesarienne programmee et l’episiotomie systematique ne sont pas des methodes de prevention de l’incontinence urinaire (grade B). La reeducation perineale par exercice musculaire du plancher pelvien est le traitement de premiere intention de l’incontinence urinaire pre- et postnatale (grade A). Avant toute decision therapeutique chez la femme âgee, il est recommande de realiser une bandelette de depistage de l’infection urinaire, un catalogue mictionnel et une mesure du residu postmictionnel (grade C). Il est recommande de realiser un test a la toux et la recherche d’une incontinence masquee avant la chirurgie du prolapsus genital (grade C). Il est conseille de realiser un bilan urodynamique avant la chirurgie du prolapsus genital quand il existe une symptomatologie urinaire ou une incontinence urinaire masquee (grade C).

Objectif Rapporter les resultats anatomiques et fonctionnels d’une cure de cystocele par voie vaginale en utilisant une prothese libre de polypropylene.

Resume Les troubles de la statique pelvienne, qu’ils soient isoles ou s’accompagnent de troubles anorectaux ou urinaires, sont souvent associes a une atteinte neurogene peripherique qui selon les cas peut etre consideree comme cause ou consequence de l’anomalie anatomique ou fonctionnelle. Les inter relations prolapsus – troubles anorectaux – ont ete les plus etudiees. Concernant les prolapsus urogenitaux, il est vraisemblable que l’hypotonie musculaire induite par une neuropathie distale puisse etre parfois tenue comme responsable d’un prolapsus. Les explorations electrophysiologiques perineales vont permettre, sans equivoque, de mettre en evidence ce facteur neurogene, de preciser son siege et de le quantifier. S’agissant des troubles vesicosphincteriens, si le facteur neurogene est bien suppose dans la genese de certaines incontinences urinaires a l’effort, peu de donnees d’evidence sont disponibles, et le lien direct prolapsus–denervation peripherique–alteration sphincterienne–incontinence meme s’il est conceptuellement satisfaisant a ete moins investigue. Le bilan electrophysiologique ne doit pas etre considere comme un test de routine dans l’exploration des prolapsus mais doit etre realise chaque fois qu’une origine neurologique sous-jacente est suspectee.

The subjects presented at scientific congresses often remain confidential because of the non-indexation of the communications. A subsequent publication is necessary for the dissemination of knowledge. The value of a congress is somehow rated by the level of its publications.To analyze, quantitatively and qualitatively, the fate of the communications presented orally at the annual meeting of the SIFUD-PP between 2006 and 2012.From the authors' names and the title of the communications presented orally at congresses between 2006 and 2012, we investigated if those communications had resulted as an indexed publication PubMed/Medline until April 2015. We studied anonymously the correlation between the data presented in the communication provided at the SIFUD-PP congress and the data published in the final article. We evaluated the "value" of the publication according to the language of publication (French/English), the ranking of the magazine (A or B versus others), and the number of citations of the article in Google-Scholar.A total of 270 oral communications were presented at the SIFUD congress between 2006 and 2012, so an average of 38.5 (±15) per year. Globally, 110 articles (40%) have been published in an indexed journal PubMed/MedLine to date (April 2015). Note that 10 articles of the oral communications (8%) were published before the congress. The average time of publication was 22 months±15 months. In terms of the language of publication, 79 articles (71%) were published in English magazines. They were published in 31 different journals (49 articles [44%] in urology, 14 articles [12%] in gynecology, 12 articles [10%] in urogynecology, 11 articles [10%] in coloproctology, 16 articles [14%] in neuro-urology and physical medicine and rehabilitation, 3 articles [2%] in sexology). Sixty-three articles (57%) were published in journals with an impact factor (IF) higher than 2 and 39 articles (35%) were published in journals of rank A or B.The rate of publications of oral communications varies according to specialties and the type of the congress. For example, the rate of the published communications at the ICS Congress (International Continence Society) in 2003 was 61% and of the AFU (French Association of Urology) in 2000, was 34.5%. The rate of publication of the oral abstracts presented at the SIFUD (40% over the period 2006-2012) is comparable to other national congresses but slightly inferior to those of international congresses. Several hypotheses may explain the non-publication of the oral communications (quitting the project, communication about preliminary results, refused publication by many journals) and unfortunately we do not have those results. We should get back individually to the submitters to know the reasons for non-publication of their works.In the end, 40% of the oral communication presented at the annual congress of the SIFUD were published in an indexed journals PubMed/MedLine. Seventy-one percent of them are in English.4.

The objective of the study was to provide guidelines for clinical practice from the French college of obstetrics and gynecology (CNGOF), based on the best evidence available, concerning hysterectomy for benign pathology.Each recommendation for practice was allocated a grade which depends on the level of evidence (guidelines for clinical practice method).Hysterectomy should be performed by a high volume surgeon (10 procedures of hysterectomy per year) (grade C). Rectal enema stimulant laxatives are not recommended prior to hysterectomy (grade C). It is recommended to carry out vaginal disinfection using povidone iodine solution prior to an hysterectomy (grade B). Antibioprophylaxis is recommended during a hysterectomy, regardless of the surgical route (grade B). The vaginal or the laparoscopic routes are recommended for hysterectomy for benign pathology (grade B), even if the uterus is large and/or the patient is obese (grade C). The choice between these two surgical approaches depends on others parameters, such as the surgeon's experience, the mode of anesthesia and organizational constraints (operative duration and medico economic factors). Hysterectomy by vaginal route is not contraindicated in nulliparous women (grade C) or in women with previous c-section (grade C). No specific technique to achieve hemostasis is recommended with a view to avoid urinary tract injuries (grade C). In the absence of ovarian pathology and personal or family history of breast/ovarian carcinoma, it is recommended to conserve ovaries in pre-menopausal women (grade B). Subtotal hysterectomy is not recommended in order to diminish the risk of per- or postoperative complications (grade B).The application of these recommendations should minimize risks associated with hysterectomy.

To determine the post-partum management of women and their newborn whatever the mode of delivery.The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.Because breastfeeding is associated with a decrease in neonatal morbidity (lower frequency of cardiovascular diseases, infectious, atopic or infantile obesity) (EL2) and an improvement in the cognitive development of children (EL2), exclusive and extended breastfeeding is recommended (grade B) between 4 to 6 months (Professional consensus). In order to increase the rate of breastfeeding initiation and its duration, it is recommended that health professionals work closely with mothers in their project (grade A) and to promote breastfeeding on demand (grade B). There is no scientific evidence to recommend non-pharmacological measures of inhibition of lactation (Professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breastfeed (Professional consensus). Because of potentially serious adverse effects, bromocriptin is contraindicated in inhibiting lactation (Professional consensus). For women aware of the risks of pharmacological treatment of inhibition of lactation, lisuride and cabergolin are the preferred drugs (Professional consensus). Whatever the mode of delivery, numeration blood count is not systematically recommended in a general population (Professional consensus). Anemia must be sought only in women with bleeding or symptoms of anemia (Professional consensus). The only treatment of post-dural puncture headache is the blood patch (EL2), it must not be carried out before 48 h (Professional consensus). Women vaccination status and their family is to be assessed in the early post-partum (Professional consensus). Immediate postoperative monitoring after caesarean delivery should be performed in the recovery room, but in exceptional circumstances, it may be performed in the delivery unit provided safety rules are maintained and regulatory authorities are informed (Professional consensus). An analgesic multimodal protocol developed by the medical team should be available and oral way should be favored (Professional consensus) (grade B). For every cesarean delivery, thromboprophylaxis with elastic stockings applied on the morning of the surgery and kept for at least 7 postoperative days is recommended (Professional consensus) with or without the addition of LMWH according to the presence or not of additional risk factors, and depending on the risk factor (major, minor). Early postoperative rehabilitation is encouraged (Professional consensus). Postpartum visit should be planned 6 to 8 weeks after delivery and can be performed by an obstetrician, a gynecologist, a general practitioner or a midwife, after normal pregnancy and delivery (Professional consensus). Starting effective contraception later 21 days after delivery in women who do not want closely spaced pregnancy is recommended (grade B), and to prescribe it at the maternity (Professional consensus). According to the postpartum risk of venous thromboembolism, the combined hormonal contraceptive use before six postpartum weeks is not recommended (grade B). Rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long-term is not recommended (Expert consensus). Pelvic-floor rehabilitation using pelvic-floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C). Postpartum pelvic-floor rehabilitation is not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). The optimal time for maternity discharge for low risk newborn depends more on the organisation of the post-discharge follow up (Professional consensus). The months following the birth are a transitional period, and psychological alterations concern all parents (EL2). It is more difficult in case of psychosocial risk factors (EL2). In situations of proven psychological difficulties, the impact on the psycho-emotional development of children can be important (EL3). Among these difficulties, postpartum depression is the most common situation. However, the risk is generally higher in the perinatal period for all mental disorders (EL3).Postpartum is, for clinicians, a unique and privileged opportunity to address the physical, psychological, social and somatic health of their patients.

Provide guidelines for clinical practice concerning postpartum rehabilitation.Systematically review of the literature concerning postpartum pelvic floor muscle training and abdominal rehabilitation.Pelvic-floor rehabilitation using pelvic floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. At least 3 guided sessions with a therapist is recommended, associated with pelvic floor muscle exercises at home. This postpartum rehabilitation improves short-term urinary incontinence (1 year) but not long-term (6-12 years). Early pelvic-floor rehabilitation (within 2 months following childbirth) is not recommended (grade C). Postpartum pelvic-floor rehabilitation in women presenting with anal incontinence, is associated with a lower prevalence of anal incontinence symptoms in short-term (1 year) (EL3) but not long-term (6 and 12) (EL3). Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C) but results are not maintained in medium or long term. No randomized trials have evaluated the pelvic-floor rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long term. It is therefore not recommended (expert consensus). Rehabilitation supervised by a therapist (physiotherapist or midwife) is not associated with better results than simple advice for voluntary contraction of the pelvic floor muscles to prevent/correct, in short term (6 months), a persistent prolapse 6 weeks postpartum (EL2), whether or not with a levator ani avulsion (EL3). Postpartum pelvic-floor rehabilitation is not associated with a decrease in the prevalence of dyspareunia at 1-year follow-up (EL3). Postpartum pelvic-floor rehabilitation guided by a therapist is therefore not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). No randomized trials have evaluated the effect of pelvic floor muscle training after an episode of postpartum urinary retention or bladder outlet obstruction symptoms, or for the primary prevention of anal incontinence following third-degree anal sphincter tear or in patients presenting with anal incontinence after third-degree anal sphincter tear. The electrostimulation devices used alone were not assessed in this postpartum context (regardless of symptoms); therefore, isolated pelvic floor electrostimulation is not recommended (expert consensus).Pelvic floor muscle therapy is recommended for persistent postpartum urinary (grade A) or anal (grade C) incontinence (3 months after delivery).

Resume Objectif Faire une revue de la litterature de l’efficacite et la tolerance de la toxine botulinique A (onabotulinumtoxinA, BOTOX ® , Allergan, Irvine, CA, Etats-Unis) dans l’hyperactivite vesicale idiopathique (HAVi) refractaire. Methodes La recherche bibliographique (PubMed) etait centree sur l’efficacite, la toxicite et les effets indesirables observes dans les etudes cliniques de niveau de preuve 1 et 2. Resultats Onze etudes randomisees controlees, dont 3 phases III ont ete selectionnees. Elles regroupent 1008 patients ayant une HAVi refractaire traites par toxine botulinique A BOTOX ® . Les doses de 50U a 300U ont ete evaluees, 100U etait la dose la plus etudiee (676 patients). Dans les 2 etudes pivots de phases III, BOTOX ® 100U est plus efficace que placebo en termes de patients continents, de symptomes et de qualite de vie (QdV). Les resultats des analyses urodynamiques, rapportes dans les etudes de phase II, montraient des changements plus importants que le groupe placebo a partir de la dose 100U, neanmoins pas toujours significatifs. Les effets indesirables (retention urinaire, dysurie, infection urinaire) etaient traitables et n’influencaient pas les resultats de la QdV. Conclusions Les injections intradetrusoriennes de toxine botulinique A BOTOX ® dans le traitement de l’HAVi refractaire, une procedure mini-invasive, semblent efficaces et bien tolerees.

To analyse the prevalence of postpartum anal incontinence, its risk factors, and its management.A comprehensive systematic review of the literature on PubMed, Medline, Embase and Cochrane using: postpartum anal incontinence, postpartum fecal incontinence, perineal rehabilitation, anal surgery.The prevalence of postpartum anal incontinence varied from 4% (primipare) to 39% (multipare) at 6 weeks postpartum, whereas fecal incontinence can reach respectively 8 to 12% 6 years after delivery. Identified risk factors were: vaginal delivery (OR: 1.32 [95%CI: 1.04-1.68]) compared to cesarean section, instrumental extractions (OR: 1.47 [95%CI: 1.22-1.78]) compared to spontaneous vaginal delivery but it was only with forceps (OR: 1.50 [95%CI: 1.19-1.89]) and not with vaccum (OR: 1.31 [95%CI: 0.97-1.77]). Maternal age over 35 years (OR: 6 [95%CI: 1.85-19.45]), number of births (3 births: OR: 2.91 [95%CI: 1.32-6.41]) and the occurrence of anal-sphincter injury (OR: 2.3 [95%CI: 1.1-5]) were associated with an increased risk of anal incontinence regardless of the type of delivery compared to a group of women without anal incontinence. Perineal rehabilitation should be interpreted with caution because of the lack of randomized controlled trials. A reassessment at 6 months postpartum in order to propose a surgical treatment by sphincteroplasty could be considered if symptoms persist. The results of the sphincteroplasty were satisfactory but with a success rate fading in time (60 to 90% at 6 months against 50 to 40% at 5 and 10 years).Postpartum anal incontinence requires special care. Recommendations for the management of postpartum anal incontinence would be useful.

This was a comprehensive literature review using Pubmed, Medline, Embase and Cochrane, whose aim was to analyse the prevalence of anal sphincter injuries, their risk factors, their management and their functional prognosis. The prevalence of 3rd and 4th degree perineal tears varies between studies from 2.95% regardless the parity to 25% in nulliparous women. Twenty-eight percent to 48% of these lacerations were clinically occult. Perineal tears were associated with (multivariate analysis) forceps (6.021 [IC 95% 1.23-19.45]), nulliparity (OR 9.8 [IC 95% 3.6-26.2]), gestational age over 42 SA (OR 2.5 [IC 95% 1-6.2]), fundal pressure (OR 4.6 [IC 95% 2.3-7.9]), midline episiotomy (OR 5.5 [IC 95% 1.4-18.7]) or fetal weight in interval of 250g (OR 1.3 [IC 95% 1.1-1.6]). There was no difference between the sphincter repair techniques. Post-partum laxative use showed less painful bowel motion and earlier postnatal discharge. Data concerning rehabilitation were contradictory. The rate of anal incontinence 6 months after vaginal delivery were 3.6% following third degree of perineal tear and 30.8% in case of fourth degree of perineal tear. Thirty years after anal sphincter disruption, the prevalence of fecal incontinence reached 6.9%.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 35 - N° 5 - p. 465-471