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To develop and validate a tool for automatic selection of the slice of minimal hiatal dimensions (SMHD) and segmentation of the urogenital hiatus (UH) in transperineal ultrasound (TPUS) volumes.Manual selection of the SMHD and segmentation of the UH was performed in TPUS volumes of 116 women with symptomatic pelvic organ prolapse (POP). These data were used to train two deep-learning algorithms. The first algorithm was trained to provide an estimation of the position of the SMHD. Based on this estimation, a slice was selected and fed into the second algorithm, which performed automatic segmentation of the UH. From this segmentation, measurements of the UH area (UHA), anteroposterior diameter (APD) and coronal diameter (CD) were computed automatically. The mean absolute distance between manually and automatically selected SMHD, the overlap (dice similarity index (DSI)) between manual and automatic UH segmentation and the intraclass correlation coefficient (ICC) between manual and automatic UH measurements were assessed on a test set of 30 TPUS volumes.The mean absolute distance between manually and automatically selected SMHD was 0.20 cm. All DSI values between manual and automatic UH segmentations were above 0.85. The ICC values between manual and automatic UH measurements were 0.94 (95% CI, 0.87-0.97) for UHA, 0.92 (95% CI, 0.78-0.97) for APD and 0.82 (95% CI, 0.66-0.91) for CD, demonstrating excellent agreement.Our deep-learning algorithms allowed reliable automatic selection of the SMHD and UH segmentation in TPUS volumes of women with symptomatic POP. These algorithms can be implemented in the software of TPUS machines, thus reducing clinical analysis time and simplifying the examination of TPUS data for research and clinical purposes. © 2021 The Authors. Ultrasound in Obstetricsamp; Gynecology published by John Wileyamp; Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Introduction and hypothesis The puborectal muscle (PRM), one of the female pelvic floor (PF) muscles, can get damaged during vaginal delivery, leading to disorders such as pelvic organ prolapse. Current diagnosis involves ultrasound (US) imaging of the female PF muscles, but functional information is limited. Previously, we developed a method for strain imaging of the PRM from US images in order to obtain functional information. In this article, we hypothesize that strain in the PRM would differ from intact to the avulsed end. Methods We calculated strain in PRMs at maximum contraction, along their muscle fiber direction, from US images of two groups of women, which consisted of women with intact (n1 = 8) and avulsed PRMs (unilateral) (n2 = 10). Normalized strain ratios between both ends of the PRM (avulsed or intact) and the mid region were calculated. Subsequently, the difference in ratio between the avulsed and intact PRMs was determined. Results We observe from the obtained results that the contraction/strain pattern of intact and undamaged PRMs is different from PRMs with unilateral avulsion. Normalized strain ratios between avulsed and intact PRMs were statistically significant (p = 0.04). Conclusion In this pilot study, we were able to show that US strain imaging of PRMs can show differences between intact PRMs and PRMs with unilateral avulsion.

Contains fulltext : 249111.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To compare the 24-month efficacy of pessary or surgery as the primary treatment for symptomatic pelvic organ prolapse (POP). DESIGN: Multicentre prospective comparative cohort study. SETTING: Twenty-two Dutch hospitals. POPULATION: Women referred with symptomatic POP of stage ≥2 and moderate-to-severe POP symptoms. METHODS: The primary outcome was subjective improvement at the 24-month follow-up according to the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcomes included improvement in prolapse-related symptoms measured with the Pelvic Floor Distress Inventory (PFDI-20), improvement in subjective severeness of symptoms according to the Patient Global Impression of Severity (PGI-S) scale and crossover between therapies. The primary safety outcome was the occurrence of adverse events. MAIN OUTCOME MEASURE: PGI-I at 24 months. RESULTS: We included 539 women, with 335 women (62.2%) in the pessary arm and 204 women (37.8%) in the surgery arm. After 24 months, subjective improvement was reported by 134 women (83.8%) in the surgery group compared with 180 women (74.4%) in the pessary group (risk difference 9.4%, 95% CI 1.4-17.3%, P

Objectives To measure the length, width and area of the urogenital hiatus (UH), and the length and mean echogenicity (MEP) of the puborectalis muscle (PRM), automatically and observer‐independently, in the plane of minimal hiatal dimensions on transperineal ultrasound (TPUS) images, by automatic segmentation of the UH and the PRM using deep learning. Methods In 1318 three‐ and four‐dimensional (3D/4D) TPUS volume datasets from 253 nulliparae at 12 and 36 weeks' gestation, two‐dimensional (2D) images in the plane of minimal hiatal dimensions with the PRM at rest, on maximum contraction and on maximum Valsalva maneuver, were obtained manually and the UH and PRM were segmented manually. In total, 713 of the images were used to train a convolutional neural network (CNN) to segment automatically the UH and PRM in the plane of minimal hiatal dimensions. In the remainder of the dataset (test set 1 (TS1); 601 images, four having been excluded), the performance of the CNN was evaluated by comparing automatic and manual segmentations. The performance of the CNN was also tested on 117 images from an independent dataset (test set 2 (TS2); two images having been excluded) from 40 nulliparae at 12 weeks' gestation, which were acquired and segmented manually by a different observer. The success of automatic segmentation was assessed visually. Based on the CNN segmentations, the following clinically relevant parameters were measured: the length, width and area of the UH, the length of the PRM and MEP. The overlap (Dice similarity index (DSI)) and surface distance (mean absolute distance (MAD) and Hausdorff distance (HDD)) between manual and CNN segmentations were measured to investigate their similarity. For the measured clinically relevant parameters, the intraclass correlation coefficients (ICCs) between manual and CNN results were determined. Results Fully automatic CNN segmentation was successful in 99.0% and 93.2% of images in TS1 and TS2, respectively. DSI, MAD and HDD showed good overlap and distance between manual and CNN segmentations in both test sets. This was reflected in the respective ICC values in TS1 and TS2 for the length (0.96 and 0.95), width (0.77 and 0.87) and area (0.96 and 0.91) of the UH, the length of the PRM (0.87 and 0.73) and MEP (0.95 and 0.97), which showed good to very good agreement. Conclusion Deep learning can be used to segment automatically and reliably the PRM and UH on 2D ultrasound images of the nulliparous pelvic floor in the plane of minimal hiatal dimensions. These segmentations can be used to measure reliably UH dimensions as well as PRM length and MEP. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

OBJECTIVES: To assess change in levator hiatal dimensions between pregnancy and different timepoints after vaginal delivery, and map recovery of the hiatus in order to contribute to secondary prevention of symptoms of pelvic floor disorders. METHODS: Twenty nulliparous women with a singleton pregnancy underwent ultrasound assessment of the pelvic floor at rest, on maximum pelvic floor muscle contraction (PFMC) and on Valsalva maneuver at 12 weeks' gestation and at 1 day and 1, 2, 3, 4, 6, 12, 18 and 24 weeks after vaginal delivery. Dimensions of the levator hiatus were measured and contractility and distensibility were calculated. The Wilcoxon signed rank test was used to compare each postpartum value with that at 12 weeks' gestation. RESULTS: Levator hiatal area at rest, on PFMC and on Valsalva maneuver was significantly increased at 1 day and at 1 and 2 weeks after vaginal delivery compared with measurements at 12 weeks' gestation. Hiatal area at rest and on PFMC from 3 weeks postpartum onward, as well as contractility from 6 weeks onward, were comparable to values at 12 weeks' gestation, whereas, a significant difference remained on Valsalva maneuver until 24 weeks after delivery. Moreover, distensibility was still increased at 24 weeks postpartum compared with measurements at 12 weeks' gestation. CONCLUSION: The puborectalis muscle has the ability to recover anatomically from a first vaginal delivery, and recovery occurs mainly during the first 3 weeks after delivery. Stretching of the puborectalis muscle, as reflected by distensibility, persisted 24 weeks after the first vaginal delivery. The data provide a better understanding of the early 'normal' regeneration process and we hypothesize that the first 3 weeks postpartum is the best window in which to start secondary prevention. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Objectives The introduction of three‐dimensional (3D) analysis of the puborectalis muscle (PRM) for diagnostic purposes into daily practice is hindered by the need for appropriate training of observers. Automatic segmentation of the PRM on 3D transperineal ultrasound may aid its integration into clinical practice. The aims of this study were to present and assess a protocol for manual 3D segmentation of the PRM on 3D transperineal ultrasound, and to use this for training of automatic 3D segmentation method of the PRM. Methods The data used in this study were derived from 3D transperineal ultrasound sequences of the pelvic floor acquired at 12 weeks' gestation from nulliparous women with a singleton pregnancy. A manual 3D segmentation protocol was developed for the PRM based on a validated two‐dimensional segmentation protocol. For automatic segmentation, active appearance models of the PRM were developed, trained using manual segmentation data from 50 women. The performances of both manual and automatic segmentation were analyzed by measuring the overlap and distance between the segmentations. Intraclass correlation coefficients (ICCs) and their 95% CIs were determined for mean echogenicity and volume of the puborectalis muscle, in order to assess inter‐ and intraobserver reliabilities of the manual method using data from 20 women, as well as to compare the manual and automatic methods. Results Interobserver reliabilities for mean echogenicity and volume were very good for manual segmentation (ICCs 0.987 and 0.910, respectively), as were intraobserver reliabilities (ICCs 0.991 and 0.877, respectively). ICCs for mean echogenicity and volume were very good and good, respectively, for the comparison of manual vs automatic segmentation (0.968 and 0.626, respectively). The overlap and distance results for manual segmentation were as expected, showing an average mismatch of only 2–3 pixels and reasonable overlap. Based on overlap and distance, five mismatches were detected for automatic segmentation, resulting in an automatic segmentation success rate of 90%. Conclusions This study presents a reliable manual segmentation protocol and automatic 3D segmentation method for the PRM, which will facilitate future investigation of the PRM, allowing for the reliable measurement of potentially clinically valuable parameters such as mean echogenicity. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology Published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Objective: One of the functional parameters that can be assessed by ultrasound is muscle strain, which represents the extent of deformation of the muscle from its original shape when forces are applied to the tissue under study. The aim of this study was to evaluate the effect of pregnancy and delivery on the puborectalis muscle, by assessing changes in global strain of the muscle during and after pregnancy. Methods: This was a secondary analysis of a prospective observational study on the association between stress urinary incontinence and levator ani muscle avulsion after delivery. Two-hundred and eighty nulliparous pregnant women underwent four-dimensional transperineal ultrasound assessments at 12 and 36 weeks of gestation, and 6 months postpartum. Tomographic ultrasound images were constructed and the puborectalis muscle was delineated by hand using programming software. After delineation, the length of the midline of the puborectalis muscle was measured at rest and during maximum pelvic floor muscle contraction, and global strain was expressed as percentile difference. Postpartum results were analyzed separately for vaginal, operative (vacuum) vaginal and Cesarean delivery. Differences in global strain of the puborectalis muscle according to mode of delivery were compared using a paired-sample t-test. The effect of partial or complete avulsion of the puborectalis muscle on postpartum strain was evaluated by ANOVA. Results: In total, 254 datasets were analyzed. Global strain of the puborectalis muscle did not change during pregnancy, but after spontaneous or operative vaginal delivery the global strain diminished significantly. No significant change was observed in strain of the puborectalis muscle after Cesarean delivery. Women who suffered complete bilateral avulsion had significantly lower strain compared with women with an intact puborectalis muscle. Conclusion: Spontaneous or operative vacuum vaginal birth and complete bilateral avulsion of the puborectalis muscle influence negatively the strain of the puborectalis muscle.

Objective In recent years, a large number of studies have been published on the clinical relevance of pelvic floor three-dimensional (3D) transperineal ultrasound. Several studies compare sonography with other imaging modalities or clinical examination. The quality of reporting in these studies is not known. The objective of this systematic review was to determine the compliance of diagnostic accuracy studies investigating pelvic floor 3D ultrasound with the Standards for Reporting of Diagnostic Accuracy (STARD) guidelines. Methods Published articles on pelvic floor 3D ultrasound were identified by a systematic literature search of MEDLINE, Web of Science and Scopus databases. Prospective and retrospective studies that compared pelvic floor 3D ultrasound with other clinical and imaging diagnostics were included in the analysis. STARD compliance was assessed and quantified by two independent investigators, using 22 of the original 25 STARD checklist items. Items with the qualifier ‘if done’ (Items 13, 23 and 24) were excluded because they were not applicable to all papers. Each item was scored as reported (score = 1) or not reported (score = 0). Observer variability, the total number of reported STARD items per article and summary scores for each item were calculated. The difference in total score between STARD-adopting and non-adopting journals was tested statistically, as was the effect of year of publication. Results Forty studies published in 13 scientific journals were included in the analysis. Mean ± SD STARD checklist score of the included articles was 16.0 ± 2.5 out of a maximum of 22 points. The lowest scores (

To confirm our previous observation that levator hiatal dimensions and mean echogenicity of the puborectalis muscle (MEP) are significantly different at 12 weeks' gestation in women who delivered by Cesarean section due to failure to progress compared with those who delivered vaginally. The secondary objective was to assess the association between the echogenicity of the cervix and vastus lateralis muscle and mode of delivery.In this prospective multicenter study, 306 nulliparous women with a singleton pregnancy underwent ultrasound assessments of the pelvic floor at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, of the cervix and of the vastus lateralis muscle at 12 weeks' gestation. Dimensions of the levator hiatus, MEP and mean echogenicity of the cervix and vastus lateralis muscle were measured and compared according to mode of delivery.Two hundred and forty-nine women were included in the analyses. We were unable to confirm our previous finding that MEP and levator hiatal transverse diameter and area at 12 weeks' gestation are associated significantly with mode of delivery. In addition, we could not demonstrate a significant association between echogenicity of the cervix or vastus lateralis muscle and mode of delivery. Overall, MEP was a mean of 20 points lower in women in the new database as compared with the previous study, despite the use of the same ultrasound equipment.In a second, independent multicenter dataset, we were unable to confirm our previous finding that levator hiatal dimensions and MEP on pelvic floor muscle contraction are associated significantly with mode of delivery. We also found no association between echogenicity of the cervix or vastus lateralis and mode of delivery. Copyright © 2018 ISUOG. Published by John WileySons Ltd.

To evaluate the structural composition of the puborectalis muscle before and at several timepoints after first vaginal delivery, by the use of echogenicity and area measurements, in order to explore its recovery.Twenty nulliparous women with a singleton pregnancy underwent 3D/4D transperineal ultrasound assessments at rest, on pelvic floor muscle contraction and on Valsalva maneuver at 12 weeks' gestation and at 1 day and 1, 2, 3, 4, 6, 12, 18 and 24 weeks after vaginal delivery. The puborectalis muscle was delineated for measurements of mean echogenicity (MEP) and area (PMA). To assess changes in MEP and PMA over time, linear mixed model analysis was used. The exact number of days after delivery at each ultrasound examination was used as a covariate.For all timepoints after delivery, MEP was significantly decreased compared with that at 12 weeks' gestation. MEP values increased significantly over time from 1 day to 24 weeks after delivery. Although not statistically significant, a decrease in MEP was observed between 3 and 4 weeks after delivery for all maneuvers. PMA at rest and on Valsalva maneuver remained constant after delivery.When compared with measurements taken during pregnancy, a sharp decrease in MEP was observed soon after vaginal delivery, which was most likely caused by stretch trauma to the puborectalis muscle and subsequent formation of (micro) hematoma and edema. Subsequent increases in MEP may reflect the disappearance of hematoma and edema, and also the formation of connective and scar tissue. Copyright © 2018 ISUOG. Published by John WileySons Ltd.

Objectives To develop a semi-automated method to assess puborectalis muscle echogenicity on three-dimensional/four-dimensional (3D/4D) volume transperineal ultrasound images using 4D View and Matlab® software and evaluate its intra- and interobserver reliability. Method The data of 23 women in their first trimester were included. 3D/4D volume datasets were obtained at rest. Two inexperienced observers were trained by an experienced observer to construct tomographic ultrasound images (TUI) from the original data and to delineate all structures. Puborectalis muscle area (PMA) and the mean echogenicity of the puborectalis muscle (MEP) were calculated offline. Intra- and interobserver reliability were determined by intraclass correlation coefficients (ICC) and their 95% CIs. Results The development of a semi-automated method to calculate puborectalis area and echogenicity is described in detail. PMA and MEP measurements in pregnant women demonstrated almost perfect intraobserver reliability for both inexperienced observers, with ICC values ranging from 0.88 to 0.99. The interobserver reliability showed ICCs of 0.63 for PMA and almost perfect ICC values, of 0.96–0.98, for echogenicity. The majority of intraobserver mismatch between two delineations of PMA occurred near the borders. Conclusions Matlab software can be used to provide reliable measurements of the area and echogenicity of the puborectalis muscle. As the latter can be used to assess structural changes in the puborectalis muscle, it appears a promising new tool for studying pelvic floor structural anatomy. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Contains fulltext : 170673.pdf (Publisher’s version ) (Closed access) INTRODUCTION AND HYPOTHESIS: To evaluate the interobserver reliability of diagnosing levator avulsions between observers from different centers using tomographic ultrasound imaging (TUI) in women after their first delivery. METHODS: Transperineal ultrasound volume datasets of 40 women 6 months after their first delivery were analyzed by five observers from four different centers. Levator avulsions were diagnosed using TUI and datasets were assessed as optimal or suboptimal image quality and optimal or suboptimal pelvic floor contraction. Cohen's kappa was used to evaluate the interobserver reliability of diagnosing levator avulsions for the total group, the group with optimal and suboptimal image quality, and the group with optimal and suboptimal pelvic floor contraction. Consensus on the presence or absence of avulsions was scored according to the number of observers who diagnosed an avulsion (0 = consensus on the absence of avulsion, 1-4 = avulsion diagnosed by 1 to 4 observers, 5 = consensus on the presence of avulsion). RESULTS: For the total group, the interobserver reliability varied widely, with kappa values ranging from -0.07 to 0.72. Analyzes in the subgroups showed comparable results. Of the women who potentially have an avulsion (avulsion diagnosed by at least one observer), consensus on the presence of an avulsion was reached in 0.0 to 20.0 %. Of the women who potentially have no avulsion (no avulsion diagnosed by at least one observer), consensus on the absence of an avulsion was reached in 46.7 to 85.7 %. CONCLUSIONS: Diagnosing levator avulsions using TUI in women 6 months after their first delivery is strongly observer-dependent and therefore not generalizable.

Objectives The combination of prolapse surgery with an incontinence procedure can reduce the incidence of stress urinary incontinence (SUI) after surgery, but may increase adverse events. We compared the effectiveness and safety of prolapse surgery versus combined prolapse and incontinence surgery in women with pelvic organ prolapse. Design and setting Pubmed, EMBASE, DARE, the Cochrane Library and the register of Current Controlled Trials were searched for randomised trials (restricted to Burch colposuspension and midurethral sling as incontinence procedure) from 1995 to 2013 limited to the English literature. Methods Two reviewers selected eligible articles and extracted the data. Pooling for SUI was based on three patient groups: (1) women with coexisting SUI; (2) women asymptomatic for SUI; and (3) women with occult SUI. For adverse events, pooling was based on incontinence procedure. Main outcome measures The primary outcome was SUI. The secondary outcomes were treatment for SUI, bladder storage symptoms, obstructive voiding and adverse events. Results Seven trials were included. Pooling for women with coexisting SUI was possible for objective SUI with two studies and showed no difference. Statistical (I2 = 95%) and clinical heterogeneity was, however, high. The largest study showed a lower incidence of persisting SUI (5% versus 23%) and treatment for this (0% versus 57%) in women who underwent prolapse repair with a midurethral sling. The second study did not find a difference in women undergoing a sacrocolpopexy with or without Burch colposuspension. In asymptomatic women, combination surgery resulted in a lower incidence of de novo subjective SUI (two studies; 24% versus 41%; relative risk [RR], 0.6; 95% confidence interval [CI], 0.3–0.9; I2 = 36%) and the need for subsequent anti-incontinence surgery (three studies; 2% versus 7%; RR, 0.4; 95% CI, 0.2–0.8; I2 = 13%). For the outcome objective SUI, pooling was possible for five studies, but statistical heterogeneity was high (I2 = 82%) and the difference was not statistically significant. In the subgroup of women with occult stress incontinence, we found a lower incidence of objective SUI after combination surgery (two studies; 22% versus 52%; RR, 0.4; 95% CI, 0.3–0.8; I2 = 32%). There were no differences in bladder storage symptoms, urgency incontinence or long-term obstructive voiding symptoms. Adverse events (two studies; 15% versus 10%; RR, 1.6; 95% CI, 1.0–2.5; I2 = 0%) and prolonged catheterisation (three studies; 6% versus 1%; RR, 4.5; 95% CI, 1.5–13.3; I2 = 0%) were more frequent after vaginal prolapse repair with a midurethral sling. Conclusions Combination surgery reduces the risk of postoperative stress incontinence, but short-term voiding difficulties and adverse events were more frequent after combination surgery with a midurethral sling.

Objectives To evaluate the reliability of measurements of the levator hiatus and levator–urethra gap (LUG) using three/four-dimensional (3D/4D) transperineal ultrasound in women during their first pregnancy and 6 months postpartum, and to assess the learning process for these measurements. Methods An inexperienced observer was taught to perform measurements of the levator hiatus and LUG by an experienced observer. After training, 3D/4D ultrasound volume datasets of 40 women in the first trimester were analyzed by these two observers. Another training session then took place and both observers repeated the analyses of the same volume datasets. Finally, analyses of 40 volume datasets of the women 6 months postpartum were performed by both observers. Intra- and interobserver reliability were determined by intraclass correlation coefficients (ICC) with 95% CIs. Results For levator hiatal measurements, in the women during their first pregnancy the interobserver reliability was substantial to almost perfect after both the first and second training session (ICC, 0.62–0.83 and 0.71–0.89, respectively, for anteroposterior diameter, transverse diameter and area at rest, on contraction and on Valsalva) and the intraobserver reliability was substantial to almost perfect for both observers. For these measurements performed once the women had delivered, interobserver reliability was moderate to almost perfect. For LUG measurements performed during pregnancy, interobserver reliability was slight to moderate after the first training session (ICC, 0.14–0.54), but improved after the second training session (ICC, 0.38–0.71), and intraobserver reliability was moderate to substantial for the experienced observer and slight to moderate for the inexperienced observer. For these measurements performed when the women had delivered, interobserver reliability was fair to moderate. Conclusions The levator hiatus and LUG can be measured reliably using 3D/4D ultrasound in primigravid and primiparous women. The technique to measure dimensions of the levator hiatus requires limited teaching, but LUG measurements are more difficult and require more extensive training. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.

One of the functional parameters that can be assessed by ultrasound is muscle strain, which represents the extent of deformation of the muscle from its original shape when forces are applied to the tissue under study. The aim of this study was to evaluate the effect of pregnancy and delivery on the puborectalis muscle, by assessing changes in global strain of the muscle during and after pregnancy.This was a secondary analysis of a prospective observational study on the association between stress urinary incontinence and levator ani muscle avulsion after delivery. Two-hundred and eighty nulliparous pregnant women underwent four-dimensional transperineal ultrasound assessments at 12 and 36 weeks of gestation, and 6 months postpartum. Tomographic ultrasound images were constructed and the puborectalis muscle was delineated by hand using programming software. After delineation, the length of the midline of the puborectalis muscle was measured at rest and during maximum pelvic floor muscle contraction, and global strain was expressed as percentile difference. Postpartum results were analyzed separately for vaginal, operative (vacuum) vaginal and Cesarean delivery. Differences in global strain of the puborectalis muscle according to mode of delivery were compared using a paired-sample t-test. The effect of partial or complete avulsion of the puborectalis muscle on postpartum strain was evaluated by ANOVA.In total, 254 datasets were analyzed. Global strain of the puborectalis muscle did not change during pregnancy, but after spontaneous or operative vaginal delivery the global strain diminished significantly. No significant change was observed in strain of the puborectalis muscle after Cesarean delivery. Women who suffered complete bilateral avulsion had significantly lower strain compared with women with an intact puborectalis muscle.Spontaneous or operative vacuum vaginal birth and complete bilateral avulsion of the puborectalis muscle influence negatively the strain of the puborectalis muscle. Copyright © 2017 ISUOG. Published by John WileySons Ltd.

In recent years, a large number of studies have been published on the clinical relevance of pelvic floor three-dimensional (3D) transperineal ultrasound. Several studies compare sonography with other imaging modalities or clinical examination. The quality of reporting in these studies is not known. The objective of this systematic review was to determine the compliance of diagnostic accuracy studies investigating pelvic floor 3D ultrasound with the Standards for Reporting of Diagnostic Accuracy (STARD) guidelines.Published articles on pelvic floor 3D ultrasound were identified by a systematic literature search of MEDLINE, Web of Science and Scopus databases. Prospective and retrospective studies that compared pelvic floor 3D ultrasound with other clinical and imaging diagnostics were included in the analysis. STARD compliance was assessed and quantified by two independent investigators, using 22 of the original 25 STARD checklist items. Items with the qualifier 'if done' (Items 13, 23 and 24) were excluded because they were not applicable to all papers. Each item was scored as reported (score = 1) or not reported (score = 0). Observer variability, the total number of reported STARD items per article and summary scores for each item were calculated. The difference in total score between STARD-adopting and non-adopting journals was tested statistically, as was the effect of year of publication.Forty studies published in 13 scientific journals were included in the analysis. Mean ± SD STARD checklist score of the included articles was 16.0 ± 2.5 out of a maximum of 22 points. The lowest scores ( 50%) were found for reporting of handling of indeterminate results or missing responses, adverse events and the time interval between tests. Interobserver agreement for rating the STARD items was excellent (intraclass correlation coefficient, 0.77). An independent t-test showed no significant mean difference ± SD in total STARD checklist score between STARD-adopting and non-adopting journals (16.4 ± 2.2 vs 15.9 ± 2.6, respectively). Mean ± SD STARD checklist score for articles published in 2003-2009 was lower, but not statistically different, compared with those published in 2010-2015 (15.2 ± 2.5 vs 16.6 ± 2.4, respectively).The overall compliance with reporting guidelines of diagnostic accuracy studies on pelvic floor 3D transperineal ultrasound is relatively good compared with other fields of medicine. However, specific checklist items require more attention when reported. Copyright © 2016 ISUOG. Published by John WileySons Ltd.

Please cite this paper as: Vollebregt A, Fischer K, Gietelink D, van der Vaart C. Primary surgical repair of anterior vaginal prolapse: a randomised trial comparing anatomical and functional outcome between anterior colporrhaphy and trocar-guided transobturator anterior mesh. BJOG 2011;118:1518–1527. Objective To compare anterior colporrhaphy with a trocar-guided transobturator mesh procedure (Avaulta® anterior). Design Randomised, controlled trial. Setting Three teaching hospitals. Population Women with a symptomatic cystocele at least stage II requiring primary surgical correction. Methods A total of 125 women were assessed at baseline and 1-year follow up. A sacrospinous hysteropexy or posterior colporrhaphy was performed when indicated. Main outcome measures The primary outcome was the difference in anatomical cure (defined as Pelvic Organ Prolapse-Quantification

Objective We compared micturition and defecation symptoms with the route of hysterectomy over a period of 10 years. Design Prospective multicentre observational study. Setting Thirteen teaching hospitals in the Netherlands. Population A total of 430 women who underwent vaginal or abdominal hysterectomy for benign conditions (pelvic organ prolapse excluded). Methods The presence and discomfort experienced as a result of micturition and defecation symptoms were assessed using validated questionnaires before surgery, and at 6 weeks, 6 months, 1 year, 3 years and 10 years after surgery. Statistically significant differences in symptoms between vaginal and abdominal hysterectomy were adjusted for pre-operative differences in uterine descent, uterine size, parity and indication for hysterectomy. Main outcome measure Presence of bothersome micturition and defecation symptoms, as assessed by the Urogenital Distress Inventory (UDI) and Defecation Distress Inventory (DDI). Results Ten years after hysterectomy the response rate was 73%. Preoperatively, no differences were observed in the prevalence of micturition symptoms between patients who underwent vaginal and abdominal hysterectomy. However, 10 years after vaginal hysterectomy, significantly more women had been treated for micturition symptoms (18 versus 8%; P = 0.02; adjusted OR 3.8, 95% CI 1.2-11.6). Defecation symptoms also seemed more common after vaginal hysterectomy (58 versus 46%; P = 0.08). After adjustment, no statistically significant differences in defecation symptoms were found. Conclusions Despite the same incidence of micturition symptoms before surgery, patients undergoing vaginal hysterectomy are more likely to seek medical help for micturition symptoms. Defecation symptoms were also more common after vaginal hysterectomy; however, this difference was not statistically significant.

Pelvic organ prolapse (POP) is characterized by the failure of vaginal wall support and protrusion of the pelvic organs through the vaginal orifice. The exact etiology of POP remains elusive to date, and one of the primary hurdles is the limited availability of animal models, which provide a means to better understand the weakening of supportive tissues in POP and the mechanisms of treatment failures. Each animal model has its own set of advantages and disadvantages. In this chapter, we review the various animal models of POP and provide an indepth analysis of sheep as a robust large animal model for urogynecological research. The ease of handling, short lifespan, and relatively low costs are major advantages of rodent models, which have been used extensively to investigate connective tissue physiology and pathophysiology as it relates to POP. However, sheep have supporting structures for pelvic organs, as well as structural and mechanical properties more similar to humans. Many of the risk factors for sheep prolapse have close analogues in humans, including high fetal weight, obesity, dystocia, parity, and family history of prolapse. In addition, large animal models, such as sheep, are likely more appropriate for evaluation of novel therapeutic strategies for treatment. Future research using sheep and other animal models will illuminate the pathophysiology of POP as well as provide essential information on pelvic floor biomechanics and treatment efficacy.

Introduction and hypothesis: To identify practice variation in management of patients with a vaginal pessary for pelvic organ prolapse (POP). Methods: A nationwide survey was sent to all Dutch gynecologists with a special interest in urogynecology. Results: The response rate was 59 %. Of the respondents, 13 % had a written protocol for pessary treatment in their department. Pessary treatment was proposed by 69 % of respondents as a treatment option. Counseling about side effects varied. All respondents provided information concerning the possibility of serious vaginal discharge. Concerning this side effect, 15 % of the respondents stated that it occurs in 5 – 20 % of patients, 27 % that it occurs in 20 – 40 % of patients, and 57 % that it occurs in more than 40 % of patients. Another item concerned counseling for the likelihood of vaginal blood loss. All respondents provided information concerning the possibility of vaginal blood loss. Concerning this side effect, 53 % of the respondents stated that it occurs in 5 – 20 % of patients, 33 % that it occurs in 20 – 40 %, and 14 % that it occurs in more than 40 % of patients. Follow-up after initial placement was done by 69 % of the respondents at 2 – 6 weeks, by 2 % at 8 weeks, and by 29 % at 12 weeks or more. Most (98 %) of the respondents extended the interval between visits when the patient had no complaints, and 96 % of the respondents reported that they routinely instruct patients about self-management. Conclusions: Pessaries are suggested as a treatment option by a majority of gynecologists, but practice varies widely. We consider that the variation in practice is due to a lack of available protocols and lack of evidence.

OBJECTIVE: To compare transvaginal prolapse repair combined with midurethral sling (MUS) versus prolapse repair only. DESIGN: Multi-centre randomised trial. SETTING: Fourteen teaching hospitals in the Netherlands. POPULATION: Women with symptomatic stage two or greater pelvic organ prolapse (POP), and subjective or objective stress urinary incontinence (SUI) without prolapse reduction. METHODS: Women were randomly assigned to undergo vaginal prolapse repair with or without MUS. Analysis was according to intention to treat. MAIN OUTCOME MEASURES: The primary outcome at 12 months' follow-up was the absence of urinary incontinence (UI) assessed with the Urogenital Distress Inventory and treatment for SUI or overactive bladder. Secondary outcomes included complications. RESULTS: One hundred and thirty-four women were analysed at 12 months' follow-up (63 in MUS and 71 in control group). More women in the MUS group reported the absence of UI and SUI; respectively 62% versus 30% UI (relative risk [RR] 2.09; 95% confidence interval [CI] 1.39-3.15) and 78% versus 39% SUI (RR 1.97; 95% CI 1.44-2.71). Fewer women underwent treatment for postoperative SUI in the MUS group (10% versus 37%; RR 0.26; 95% CI 0.11-0.59). In the control group, 12 women (17%) underwent MUS after prolapse surgery versus none in the MUS group. Severe complications were more common in the MUS group, but the difference was not statistically significant (16% versus 6%; RR 2.82; 95% CI 0.93-8.54). CONCLUSIONS: Women with prolapse and co-existing SUI are less likely to have SUI after transvaginal prolapse repair with MUS compared with prolapse repair only. However, only 17% of the women undergoing POP surgery needed additional MUS. A well-informed decision balancing risks and benefits of both strategies should be tailored to individual women.

Objectives To determine the association between levator hiatal dimensions, measured using transperineal ultrasound, in women during their first pregnancy and the subsequent mode of delivery, stratified by the indication for intervention. Methods In this prospective observational study, 280 nulliparous women with a singleton pregnancy were invited for transperineal ultrasound examination at 12 and 36 weeks' gestation. Their levator hiatal dimensions were measured at rest, on pelvic floor muscle contraction and on Valsalva maneuver. The subsequent mode of delivery was classified into five categories: spontaneous vaginal delivery, instrumental vaginal delivery owing to fetal distress, instrumental vaginal delivery owing to failure to progress, Cesarean section owing to fetal distress and Cesarean section owing to failure to progress. Levator hiatal dimensions according to mode of delivery were compared by analysis of variance and Tukey's post-hoc test. Since multiple comparison tests were performed, the statistical significance level was corrected using the Bonferroni method. Results Of the 252 women included, those who delivered by Cesarean section because of failure to progress had a significantly smaller levator hiatal transverse diameter on pelvic floor contraction at 12 weeks' gestation than did women who had a spontaneous vaginal delivery (Tukey's post-hoc test, P

The purpose of this paper is to assess the efficacy of physiotherapy and quality of life in women treated for urinary incontinence by specialized physiotherapists in daily community-based practices. Three hundred and fifty-five women were treated in five physiotherapy practices between January 2000 and December 2004. After a minimum follow-up of 12 months, these women received a questionnaire at home. With the questionnaire, we collected demographic data, data on the efficacy of treatment, satisfaction with the result, and the Urogenital Distress Inventory, and Incontinence Impact Questionnaire. Additional information was derived from the medical files. One hundred and eighty-seven women responded. Fifty percent of women were satisfied with the result of physiotherapy. After a mean follow-up of 32 months, 123 out of 130 women (94.6%), who only had physiotherapy, recorded to experience incontinence episodes daily to several times a week. Women who underwent additional incontinence surgery after insufficient physiotherapy recorded significantly less urinary incontinence symptoms and a better quality of life. Pelvic floor muscle training for urinary incontinence is effective in half of the women. If not successful, women seem to benefit significantly from incontinence surgery.

Childbirth is a substantial physical and emotional endeavor. Because emergency Cesarean and instrumental vaginal delivery impose a greater mortality and physical and emotional morbidity on both the mother and the infant than normal vaginal delivery, it is important to identify factors that are associated with the risk of operative delivery. In previous investigations, some associations have been found, but the effect of psychosocial factors is not clear. In this study we examined several factors which could be associated with the risk for instrumental and surgical delivery. In addition to biomedical factors we included psychosocial factors such as depressive symptoms, quality of the relationship of the woman with her partner, personality, lifestyle and educational level. We assessed 354 healthy nulliparous pregnant women with a child in vertex presentation and spontaneous onset of term labor using validated questionnaires. We found that social support from the woman's partner in pregnancy, lack of depressive symptoms and specific personality traits are not protective against instrumentally assisted vaginal delivery or emergency Cesarean section. Predictive factors for operative delivery after spontaneous onset of labor are higher fetal weight, non-occiput anterior presentation and advanced gestational age, and foremost fetal distress during parturition.

In recent years, the overactive bladder syndrome in women has become an important issue in clinical practice. International consensus about the definition, diagnostic work-up and treatment options will lead to a better understanding of the problem and will eventually be of benefit for the patients. In this review, current practice regarding diagnostic procedures and treatment are discussed.

One hundred and three women underwent sacrospinous hysteropexy (n=54) or vaginal hysterectomy with a vaginal vault suspension (n=49) for the management of descensus uteri. They were sent a postal questionnaire. Logistic regression analysis was used to obtain crude and adjusted odds ratios. Seventy-four (72%) women responded. The adjusted odds ratios for urge incontinence is 3.4 (1.0-12.3) and for overactive bladder 2.9 (0.5-16.9) greater after vaginal hysterectomy. The women recovered significantly more quickly after sacrospinous hysteropexy. There were no differences in anatomical outcome or recurrence rate. When performed to correct a descensus uteri of grade 2 or more we found that vaginal hysterectomy is associated with a three times higher risk for urge incontinence and overactive bladder symptoms. In addition, the women who underwent sacrospinous hysteropexy also reported a quicker recovery from surgery. Sacrospinous hysteropexy, therefore, appears to be promising for the correction of descensus uteri.

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

Objective To assess the consequences that the symptoms of urinary incontinence and an overactive bladder have on the quality of life in young, community-dwelling women. Subjects and methods A population-based, cross-sectional cohort study was conducted in women aged 20-45 years. Urogenital symptoms and quality of life were assessed using standardized questionnaires, e.g. the Urogenital Distress Inventory and Incontinence Impact Questionnaire. Results The prevalence of symptoms of stress incontinence (39%), urge incontinence (15%) and an overactive bladder (12%) was high in this young population. Compared with urge incontinence, the symptoms of an overactive bladder similarly reduced the quality of life, but stress incontinence did not significantly affect the quality of life. Women with symptoms of an overactive bladder were especially limited in their mobility, whereas urge incontinence was especially associated with feelings of embarrassment. Although many women reported to be bothered by their symptoms, only a minority consulted their physician for them. Conclusions The symptoms of urinary incontinence and overactive bladder are common among young adult women and have the same detrimental effect on quality of life as urge incontinence. The reduction in mobility associated with overactive bladder symptoms may be especially distressing for these young and active women.

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

Contains fulltext : 153685.pdf (Publisher’s version ) (Closed access) INTRODUCTION AND HYPOTHESIS: To predict who will undergo midurethral sling surgery (surgery) after initial pelvic floor muscle training (physiotherapy) for stress urinary incontinence in women. METHODS: This was a cohort study including women with moderate to severe stress incontinence who were allocated to the physiotherapy arm from a previously reported multicentre trial comparing initial surgery or initial physiotherapy in treating stress urinary incontinence. Crossover to surgery was allowed. RESULTS: Data from 198/230 women who were randomized to physiotherapy was available for analysis, of whom 97/198 (49 %) crossed over to surgery. Prognostic factors for undergoing surgery after physiotherapy were age

Objectives To describe changes in the absolute values of levator hiatal dimensions and in the contractility and distensibility of the levator hiatus during pelvic floor contraction and Valsalva maneuver, using three/four-dimensional (3D/4D) transperineal ultrasound in women during and after their first pregnancy. Methods Two-hundred and eighty nulliparous pregnant women underwent ultrasound examination at 12 and 36 weeks' gestation and 6 months postpartum. Hiatal dimensions were measured at rest, on pelvic floor contraction and on Valsalva maneuver. The contractility and distensibility were determined by the difference between hiatal dimensions at rest and those on contraction or Valsalva, respectively. After exclusions, there were 231 datasets from women at rest, 199 for pelvic floor contraction and 230 for Valsalva maneuver. Data at 36 weeks' gestation and 6 months postpartum were compared with data at 12 weeks' gestation. Results At 36 weeks' gestation, the absolute values of hiatal dimensions and the contractility and distensibility of the levator hiatus were significantly increased compared with those at 12 weeks' gestation. Women who delivered vaginally showed a persistent significant increase in hiatal dimensions on Valsalva, whereas women who delivered by prelabor or first-stage Cesarean section showed no significant changes in hiatal dimensions on Valsalva. After both vaginal and Cesarean section delivery, there was a persistent increase in the distensibility of the hiatus during Valsalva compared with in early pregnancy. Conclusion During first pregnancy, the absolute values of levator hiatal dimensions and the contractility and distensibility of the levator hiatus increase. Regardless of delivery mode, increased distensibility of the levator hiatus during Valsalva persists after childbirth. This increased pelvic floor distensibility may play a role in the development of pelvic floor dysfunction in later life. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

To compare anterior colporrhaphy with a trocar-guided transobturator mesh procedure (Avaulta(®) anterior).Randomised, controlled trial.Three teaching hospitals.Women with a symptomatic cystocele at least stage II requiring primary surgical correction.A total of 125 women were assessed at baseline and 1-year follow up. A sacrospinous hysteropexy or posterior colporrhaphy was performed when indicated.The primary outcome was the difference in anatomical cure (defined as Pelvic Organ Prolapse-Quantificationstage II cystocele). Secondary outcomes were complications, self-reported urogenital symptom severity, and quality of life, as measured with validated questionnaires.In all, 64 women were allocated to the anterior colporrhaphy group and 61 to the mesh group; 58/64 women versus 56/61 completed 12 months of follow-up analysis. Compared with the anterior colporrhaphy group, the mesh reduced the risk of anatomical failure at 12 months follow up from 59 to 9% (risk reduction 50.3%, 95% CI 35.5-65.1). Only three (5%) re-operations for anatomical failure in the anterior colporrhaphy group were performed versus 0% in the mesh group. Functional outcome improved significantly at 12 months on almost all domains, with similar results between groups. Mesh exposure occurred in two (4%) women. Baseline dyspareunia disappeared significantly more often after an anterior colporrhaphy (80%) than in the mesh group (20%). There was a trend towards more de novo dyspareunia in the mesh group (15% versus 9%).Primary cystocele repair with trocar-guided transobturator mesh resulted in a statistically significant better anatomical outcome compared with the anterior colporrhaphy. However, functional outcome was similar between groups.

We compared micturition and defecation symptoms with the route of hysterectomy over a period of 10 years.Prospective multicentre observational study.Thirteen teaching hospitals in the Netherlands.A total of 430 women who underwent vaginal or abdominal hysterectomy for benign conditions (pelvic organ prolapse excluded).The presence and discomfort experienced as a result of micturition and defecation symptoms were assessed using validated questionnaires before surgery, and at 6 weeks, 6 months, 1 year, 3 years and 10 years after surgery. Statistically significant differences in symptoms between vaginal and abdominal hysterectomy were adjusted for pre-operative differences in uterine descent, uterine size, parity and indication for hysterectomy.Presence of bothersome micturition and defecation symptoms, as assessed by the Urogenital Distress Inventory (UDI) and Defecation Distress Inventory (DDI).Ten years after hysterectomy the response rate was 73%. Preoperatively, no differences were observed in the prevalence of micturition symptoms between patients who underwent vaginal and abdominal hysterectomy. However, 10 years after vaginal hysterectomy, significantly more women had been treated for micturition symptoms (18 versus 8%; P = 0.02; adjusted OR 3.8, 95% CI 1.2-11.6). Defecation symptoms also seemed more common after vaginal hysterectomy (58 versus 46%; P = 0.08). After adjustment, no statistically significant differences in defecation symptoms were found.Despite the same incidence of micturition symptoms before surgery, patients undergoing vaginal hysterectomy are more likely to seek medical help for micturition symptoms. Defecation symptoms were also more common after vaginal hysterectomy; however, this difference was not statistically significant.

To evaluate the reliability of measurements of the levator hiatus and levator-urethra gap (LUG) using three/four-dimensional (3D/4D) transperineal ultrasound in women during their first pregnancy and 6 months postpartum, and to assess the learning process for these measurements.An inexperienced observer was taught to perform measurements of the levator hiatus and LUG by an experienced observer. After training, 3D/4D ultrasound volume datasets of 40 women in the first trimester were analyzed by these two observers. Another training session then took place and both observers repeated the analyses of the same volume datasets. Finally, analyses of 40 volume datasets of the women 6 months postpartum were performed by both observers. Intra- and interobserver reliability were determined by intraclass correlation coefficients (ICC) with 95% CIs.For levator hiatal measurements, in the women during their first pregnancy the interobserver reliability was substantial to almost perfect after both the first and second training session (ICC, 0.62-0.83 and 0.71-0.89, respectively, for anteroposterior diameter, transverse diameter and area at rest, on contraction and on Valsalva) and the intraobserver reliability was substantial to almost perfect for both observers. For these measurements performed once the women had delivered, interobserver reliability was moderate to almost perfect. For LUG measurements performed during pregnancy, interobserver reliability was slight to moderate after the first training session (ICC, 0.14-0.54), but improved after the second training session (ICC, 0.38-0.71), and intraobserver reliability was moderate to substantial for the experienced observer and slight to moderate for the inexperienced observer. For these measurements performed when the women had delivered, interobserver reliability was fair to moderate.The levator hiatus and LUG can be measured reliably using 3D/4D ultrasound in primigravid and primiparous women. The technique to measure dimensions of the levator hiatus requires limited teaching, but LUG measurements are more difficult and require more extensive training.

Objective The aim of this study was to determine prevalence of and experienced distress from pelvic floor symptoms in cervical cancer survivors (CCS). Methods For this cross-sectional matched cohort study, we matched CCS, treated in the Academic Medical Center, Amsterdam between 1997 and 2007, to a random female population sample aged 20 to 70 years (reference group). We assessed prevalence of and distress from bladder and bowel symptoms with validated pelvic-floor-related questionnaires. Severe distress was defined as values above the 90th percentile of reference group's symptom domain scores. Results One-hundred and forty-six CCS underwent radical hysterectomy and pelvic lymph node dissection (RH and LND), 49 underwent surgery and adjuvant radiotherapy (SART), and 47 underwent primary radiotherapy (PRT). Urinary incontinence and obstructive voiding were reported by each treatment group more frequently than by the reference group and caused more distress. Patients treated with RH and LND reported more distress from most uro-genital symptoms, except from overactive bladder symptoms. Patients treated with PRT reported more distress from each uro-genital symptom than matched controls. The RH and LND group reported more distress from constipation and obstructive defecation than the reference group. Patients who underwent primary or adjuvant radiotherapy reported more distress from anal incontinence than their matched controls. Conclusions Treatment of cervical cancer impairs pelvic floor function. Patients treated with PRT report the most adverse effects on pelvic floor function. The results of our study enable physicians to counsel accurately about specific symptoms. Furthermore, to facilitate referral to pelvic floor specialists when bothersome symptoms occur, we recommend evaluating pelvic floor symptoms as a standard during follow-up.

Common adverse effects of hysterectomy include lower urinary tract symptoms (LUTS), especially urinary incontinence. A difference in the prevalence of LUTS between patients who have undergone vaginal and abdominal hysterectomy may be an additional factor in the choice between these 2 surgical approaches in women who need a hysterectomy. The possibility of differential effects of the 2 procedures on the development and persistence of urinary incontinence has not been well investigated. This prospective observational multicenter study compared the long-term effect of vaginal and abdominal hysterectomy on LUTS in women with benign disease. The study was conducted between 1999 and 2003 at 13 teaching hospitals in the Netherlands. The occurrence of LUTS was determined among 430 patients undergoing vaginal (n = 112) or abdominal (n = 318) hysterectomy for benign disease other than genital prolapse. Because subjective self-reporting of symptoms after surgery provides a more useful assessment than urodynamic testing, data were obtained by use of a questionnaire completed by the study subjects. Multiple logistic regression analysis was used to adjust for possible confounders. LUTS were more common at 3 years after surgery among patients who underwent vaginal hysterectomy than among those who had abdominal hysterectomy; the adjusted odds ratio was 2.2, with a 95% confidence interval of 1.3 to 4.0 after correction for differences in uteral size, descent of the uterus, and other differences. The results remained statistically significant (odds ratio: 3.0; 95% confidence interval: 1.4-6.2) after adjustment for uteral size, descent of the uterus, parity, and indication for hysterectomy. These findings show that LUTS is more common among patients who undergo vaginal hysterectomy than among those who have abdominal hysterectomy

We determined whether parents of children with overactive bladder and dysfunctional voiding had had similar symptoms in childhood. A case-control study was done in parents with and without children with overactive bladder or dysfunctional voiding. All were recruited from an outpatient clinic. Diagnoses in children were made according to the International Children's Continence Society standardization report. Childhood symptoms in parents were assessed by a 19-item questionnaire and current urogenital symptoms were assessed by the Urogenital Distress Inventory. Comparisons between groups were made with categorical and interval statistics. A total of 173 cases and 98 controls were entered in the study. Statistically significantly more mothers of children with overactive bladder or dysfunctional voiding reported having had similar symptoms in childhood than mothers of children without lower urinary tract symptoms. Overactive bladder symptoms of childhood persisted into adulthood. No association between childhood dysfunctional voiding symptoms and adult emptying disorders was noted. Fathers of children with overactive bladder reported to have stopped bed-wetting at a significantly later age than control fathers. Results reveal an association between overactive bladder symptoms in children and their parents. To a lesser extent this finding also holds true for dysfunctional voiding symptoms

Objective To evaluate which factors determine sexual activity and satisfaction with the sexual relationship 1 year after the first delivery. Design Prospective longitudinal cohort study. Setting Ten midwifery practices. Population Three hundred and seventy-seven nulliparous women were included. Methods The Maudsley Marital Questionnaire is a standardised and validated questionnaire with 15 items relating to marital and sexual adjustment, with a nine-point (0–8) scale appended to each question. Scores on the sexual scale (MMQ-S) range from 0 to 40. Higher scores are indicative of greater dissatisfaction. Sexual intercourse was dichotomised into having sexual intercourse or not having sexual intercourse. Several obstetric and maternal factors were analysed. Main outcome measurements Sexual intercourse at 1 year postpartum and dissatisfaction with the sexual relationship as assessed by the MMQ-S scale. Results In multiple logistic regression analysis, the main predictive factor for no sexual intercourse 1 year postpartum was no sexual intercourse at 12 weeks of gestation (β 11.0 [4.01–30.4]). Women were five times less likely to be sexually active after a third/fourth degree anal sphincter tear as compared with women with an intact perineum (β 0.2 [0.04–0.93]). Dissatisfaction with the sexual relationship 1 year after childbirth, assessed with the MMQ-S scale, is associated with not being sexually active at 12 weeks of gestation (β– 0.208, P= 0.004) and with an older maternal age at delivery (β 0.405, P= 0.032). Conclusion An important prognostic factor for dissatisfaction with the sexual relationship 1 year postpartum was not being sexually active in early pregnancy. Satisfaction with the sexual relationship seems not to depend on pregnancy- and parturition-associated factors.

We performed a prospective cohort study to characterize the feasibility of urinary stress incontinence and pelvic organ prolapse surgery in day care. Two hundred and one women were prepared for day surgery by a standardised protocol; 132 women underwent a single Tension-free Vaginal Tape/Tension-free Vaginal Tape–Obturator procedure, and 69 women had additional or only pelvic organ prolapse surgery. The main outcome measures were complications, satisfaction score and recommendation to others, recorded after 3 days and 6–10 weeks. We found that it is feasible and safe to perform pelvic organ prolapse and urinary incontinence surgery in day care. Patients’ satisfaction is high in all aspects of care and the majority would recommend it to others. In multivariate logistic regression analysis, only dissatisfaction with the care provided by the staff of the surgical ward was significantly associated with a negative recommendation to others (odds ratio 7.3, 95% confidence interval 1.6–33.5).

Aims With respect to urogenital function, vaginal hysterectomy combined with anterior and/or posterior colporraphy has been shown to be superior to abdominal sacrocolpopexy with preservation of the uterus. We performed a randomized trial to compare the effects of both procedures on pain, quality of life and physical performance during the first six weeks after surgery. Methods Eighty-two patients were randomized to have surgery either by vaginal or abdominal approach. All patients were asked to complete the RAND-36 before surgery and 6 weeks after surgery and to keep a diary for the first 6 weeks after surgery. This diary assessed the pain perception and use of pain medication, bother of limitations due to the surgery and performance of daily activities after surgery. These outcomes were compared. Results All patients completed the RAND-36 and 68 patients completed the diary. Patients who had undergone abdominal surgery had a statistically lower score on the health change domain (56 vs 68), bodily pain domain (63 vs 80) and mental health domain (74 vs 81) of the RAND-36, as compared to patients who had undergone vaginal prolapse surgery. During hospital stay, the abdominal group experienced on average more days of pain (4.5 vs 3.0) and impaired mobility (3.7 vs 2.9) as compared to the vaginal group. Patients received more pain medication following abdominal surgery as compared to vaginal surgery. Conclusions The vaginal operation to correct a descensus uteri is associated with less pain, better quality of life and better mobility during the first 6 weeks of the recovery period as compared to the abdominal approach. Neurourol. Urodynam. © 2005 Wiley-Liss, Inc.

Aims To investigate the association between overactive bladder symptoms and objective parameters from the bladder diary and conventional filling cystometry. Methods We reviewed the records of the 95 consecutive patients presenting at our center for urodynamic investigation. These women were asked to self-complete a questionnaire and a bladder diary for 48 hr. Urogenital symptoms and disease-specific quality of life were assessed with standardized questionnaire, namely the Dutch version of the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). Results The frequency symptom as well as the urge incontinence symptom is significantly associated with the presence of detrusor overactivity. In univariate analysis both frequency and urgency symptoms are associated with lower micturition and bladder sensation volumes. In multivariate (ANOVA) analysis, the frequency symptom is associated with a higher 24-hr frequency, lower maximum volume voided, and mean volume voided per micturition on the bladder diary. It is also associated with lower sensation volumes on the filling cystometry. Conclusions Of the four symptoms that are currently considered to be part of the overactive bladder syndrome, the frequency symptom is the best associated with objective parameters from the bladder diary, filling cystometry, and with the occurrence of detrusor overactivity. Therefore, we would like to suggest that reporting subjective symptoms frequency is obligatory for considering one to have an overactive bladder. Neurourol. Urodynam. 23:38–42, 2004. © 2003 Wiley-Liss, Inc.

To assess the consequences that the symptoms of urinary incontinence and an overactive bladder have on the quality of life in young, community-dwelling women.A population-based, cross-sectional cohort study was conducted in women aged 20-45 years. Urogenital symptoms and quality of life were assessed using standardized questionnaires, e.g. the Urogenital Distress Inventory and Incontinence Impact Questionnaire.The prevalence of symptoms of stress incontinence (39%), urge incontinence (15%) and an overactive bladder (12%) was high in this young population. Compared with urge incontinence, the symptoms of an overactive bladder similarly reduced the quality of life, but stress incontinence did not significantly affect the quality of life. Women with symptoms of an overactive bladder were especially limited in their mobility, whereas urge incontinence was especially associated with feelings of embarrassment. Although many women reported to be bothered by their symptoms, only a minority consulted their physician for them.The symptoms of urinary incontinence and overactive bladder are common among young adult women and have the same detrimental effect on quality of life as urge incontinence. The reduction in mobility associated with overactive bladder symptoms may be especially distressing for these young and active women.

To establish the prevalence of urinary incontinence in non-institutionalized Dutch women and determine the consequences of urinary incontinence for their quality of life.Cross sectional questionnaire survey.A random sample of 1905 women aged 45-70 years of the population of Zeist, the Netherlands, were sent a questionnaire. Generic quality of life was measured with the RAND-36 and disease specific quality of life was measured with a Dutch translation of the Urogenital Distress Inventory (UDI) and Incontinence Impact Questionnaire (IIQ). Based on the answers to the questionnaire four groups of women were formed: no incontinence, only stress, only urge or a combination of stress and urge incontinence. These 4 groups were compared as to questionnaire scores.A total of 1086 questionnaires could be analysed. The prevalence of urinary incontinence was 57.1%: 28.7% stress incontinence, 5.6% urge incontinence and 22.7% both. Of those who reported urinary incontinence 6% were severely inconvenienced by it. Women with urinary incontinence reported a decrease in physical functioning and vitality as compared with women without incontinence (RAND-36). Especially women with urge or a combination of stress and urge incontinence had more severe impairment of their quality of life as compared to women with only stress incontinence.The prevalence of urinary incontinence is higher than it is usually reported. Especially the urge component affects the quality of life in a negative way.

In recent years it has been reported that the chemotherapeutic CYVADIC regime has contributed well to the treatment of advanced soft tissue sarcomas. We treated a patient with a large gastric epithelioid leiomyosarcoma with a combination of surgery and the CYVADIC regime. We believe that our result warrants further investigation in this field.