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Aim: The vaginal introitus is the entrance to the vagina, encompassing the anterior and posterior vestibules and the perineum. The surgical anatomy of the vaginal introitus, the lowest level of the vagina, has not been subject to a recent comprehensive examination and description. Vaginal introital surgery (perineorrhaphy) should be a key part of surgery for a majority of pelvic organ prolapse., Methods: Cadaver studies were performed on the anterior and posterior vestibules and the perineum. Histological studies were performed on the excised perineal specimens of a cohort of 50 women undergoing perineorrhaphy. Included are pre- and postoperative studies which were performed on 50 women to determine the anatomical and histological changes achieved with a simple (anterior) perineorrhaphy., Results: The vaginal introitus is equivalent to the Level III section of the vagina, measured posteriorly from the clitoris to the anterior perineum then down the perineum to the anal verge. The anterior and posterior vestibules, with nonkeratinizing epithelium, extend laterally to the keratinized epithelium of the labia minora (Hart's line). The anterior vestibule has six anatomical layers while the posterior vestibule has three. The perineum has an inverse trapezoid shape. Perineorrhaphy specimens were a mean 2.9 cm wide and 1.6 cm deep. They show squamous epithelium with loose underlying connective tissue. There were no important structures seen histologically, for example, ligaments or muscles. Microscopically, only 6 (12%) were completely normal with 44 (88%) showing minor changes including inflammation and scarring. Considerable anatomical benefits were achieved with such a perineorrhaphy including a 27.6% increase in the perineal length and a 30.8% reduction in the genital hiatus., Conclusion: An understanding of the anatomy and histology of the vaginal introitus can assist with performing a simple and effective perineorrhaphy, the main surgical intervention at the vaginal introitus., (© 2022 The Authors. Neurourology and Urodynamics published by Wiley Periodicals LLC.)

Aim: Vaginal vault (VV) surgery should be a key part of surgery for a majority of pelvic organ prolapse (POP). The surgical anatomy of the VV, the upper most part of the vagina, has not been recently subject to a dedicated examination and description., Methods: Cadaver studies were performed in (i) 10 unembalmed cadaveric pelves (observation); (ii) 2 unembalmed cadaveric pelves (dissection); (iii) 5 formalinized hemipelves (dissection). The structural outline and ligamentous supports of the VV were determined. Further confirmation of observations in post-hysterectomy patients were from a separate study on 300 consecutive POP repairs, 46% of whom had undergone prior hysterectomy., Results: The VV is equivalent to the Level I section of the vagina, measured posteriorly from the top of the posterior vaginal wall (apex or highest part of the vagina) to 2.5 cm below this point. It comprises the anterior fornix (through which cervix protrudes or is removed at hysterectomy), posterior fornix and two lateral fornices. Before hysterectomy, the posterior aspects of the cervix and upper vagina are supported by the uterosacral (USL) and cardinal ligaments (CL), the distal segments of which fuse together to form a cardinal-uterosacral ligament complex (cardinal utero-sacral complex), around 2-3 cm long. Post---hysterectomy, there is some residual USL support to the anterior fornix but the posterior fornix has no ligamentous support and is thus more vulnerable to prolapse., Conclusion: Effective management of VV prolapse will need to be part of most POP repairs. Enhanced understanding of the surgical anatomy of the vaginal vault allows more effective planning of those POP surgeries., (© 2022 The Authors. Neurourology and Urodynamics published by Wiley Periodicals LLC.)

Aim: The mid-vagina (MV) represents Level II of the vagina. The surgical anatomy of the MV has not been recently subject to a comprehensive examination and description. MV surgery involving anterior and posterior colporrhaphy represents a key part of surgery for a majority of pelvic organ prolapse (POP)., Methods: Literature review and surgical observations of many aspects of the MV were performed including MV length and width; MV shape; immediate relationships; histological analysis; anterior and posterior MV prolapse assessment and anterior MV surgical aspects. Unpublished pre- and postoperative quantitative data on 300 women undergoing posterior vaginal compartment repairs are presented., Results: The MV runs from the lower limit of the vaginal vault (VV) to the hymen. Its length is a mean of 5 cm. Its shape in section overall is a compressed rectangle. Its longitudinal shape is created by its anterior and posterior walls being inverse trapezoid in shape. Histology comprises three layers: (i) mucosa; (ii) muscularis; (iii) adventitia. MV prolapse staging uses pelvic organ prolapse quantification (POP-Q). Anterior MV prolapse can be quantitatively assessed using POP-Q while posterior MV prolapse can be assessed with POP-Q or PR-Q. Around 50% of both cystocele and rectocele are due to VV defects. POP will increase anterior MV width and length. Native tissue anterior colporrhaphy is the current conventional repair with mesh disadvantages outweighing advantages. Posteriorly, Level II (MV) defects are far smaller (mean 1.3 cm) than Level I (mean 6.0 cm) and Level III (mean 2.9 cm)., Conclusion: An understanding of the surgical anatomy of the MV can assist anterior and posterior colporrhaphy. In particular, if VV support is employed, the Level II component of a posterior repair should be relatively small., (© 2022 The Authors. Neurourology and Urodynamics published by Wiley Periodicals LLC.)

Introduction: Limited data exist associating vaginal vault and introital defects before and after posterior repairs (PR). We hypothesize: (i) a positive association between the size of vaginal vault and introital defects preoperatively; and (ii) a positive association between the reduction of these defects postoperatively if vault fixation (sacrospinous colpopexy-SSC) is used with the PR., Methods: In a cross-sectional study of 300 consecutive PRs, the following were measured pre- and immediately postoperatively: (i) from POP-Q: genital hiatus (GH-Level III); (ii) from PR-Q: perineal gap (PG-Level III), posterior vaginal vault descent (PVVD-Level I). The data for introital defects (GH, PG) were separated according to the need for vault fixation using a SSC due to a larger vaginal defect (PVVD over 5 cm)., Results: Mean (SD) preoperative GH and PG were both significantly larger in the SSC versus no SSC group: GH (3.73 [0.94] vs 3.36 [0.83] cm, P = 0.01); PG (2.91 [1.0] vs 2.61 [0.91] cm, P = 0.05). SSC performed with the PR (84%); not performed (16%) cases. The mean (SD) postoperative reduction in GH (antero-posterior) was significantly (29%-P = 0.002) greater-1.1 (0.69) cm (29.5%) in the SSC group and 0.77 (0.49) cm (22.9%) in the no SSC group. The decrease in the PG (transverse) was greater by 11% (0.05)., Conclusions: Levels I and III defects are associated with PRs; preoperatively larger vaginal vault (PVVD over 5 cm) and larger introital defects (GH, PG). Postoperatively, vault fixation resulted in significantly greater reduction in the introital defects., Summary: Vaginal vault fixation (SSC) significantly improves the vaginal introital repair., (© 2018 Wiley Periodicals, Inc.)

It is possible that the controversy involving prostheses implanted into women with pelvic floor problems might result in the majority of, or even all such products being restricted, banned or withdrawn in certain jurisdictions. A clear distinction between "tapes" for urinary incontinence and "mesh" for prolapse has been made in the enquiries and subsequent rulings in Australia and New Zealand. Transvaginal "mesh" will be unavailable with the range of "tapes" much more restricted in those countries from January 2018. The Chair of the all-party parliamentary group on surgical mesh implants in the United Kingdom was reported as describing the New Zealand announcement as "hugely significant" and "it's precisely what we've been calling for the UK." The title of this article has changed from a hypothetical piece to a potential reality review. Where does that leave the clinicians treating stress urinary incontinence (SUI) and the large number of female sufferers? "Tapes" (synthetic midurethral slings-MUS) have become very popular over the last 20 years since their original development and introduction in Scandanavia. Evidence-based medicine has shown their advantages over previous surgeries, in terms of ease of use, safety and efficacy. This article outlines the options which countries potentially rejecting the use of tapes, must now resort to for women with SUI. Those countries considering such action need the note of caution that none of the options are as good as tapes., (© 2018 Wiley Periodicals, Inc.)

Introduction: The terminology for adult neurogenic lower urinary tract dysfunction (ANLUTD) should be defined and organized in a clinically based consensus Report., Methods: This Report has been created by a Working Group under the auspices and guidelines of the International Continence Society (ICS) Standardization Steering Committee (SSC) assisted at intervals by external referees. All relevant definitions for ANLUTD were updated on the basis of research over the last 14 years. An extensive process of 18 rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus)., Results: A Terminology Report for ANLUTD, encompassing 97 definitions (42 NEW and 8 CHANGED, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different groups involved not only in lower urinary tract dysfunction but additionally in many other medical specialties., Conclusion: A consensus-based Terminology Report for ANLUTD has been produced to aid clinical practice and research., (© 2017 Wiley Periodicals, Inc.)

The vaginal vestibule has not been the subject of a dedicated journal article. Recent terminology has suggested its division into anterior and posterior components. The case for this division has not yet been assessed. Both components extend laterally from the hymen to the junction with the labia minora. The posterior vaginal vestibule is proposed to extend from the posterior aspect of the hymen to the anterior edge of the perineum whilst the anterior vestibule extends from the posterior aspect of the hymen to just below the clitoris. Anatomical considerations (differing layers) might firstly support the above division. The posterior vestibule, by necessity, is far more flexible with the superficial aspect (approximately 1.5 cm), anatomically and histologically, comprising skin and subcutaneous tissue, with perineal musculature deep to this. In turn, it is more likely to be subject to obstetric and surgical considerations than the anterior vaginal vestibule. Obstetric trauma, in particular, would tend to create defects, particularly at its posterior margin. Many dermatological and microbiological considerations may be common to both anterior and posterior vestibule. Any dermatological condition of the vestibule can result in sexual dysfunction and can be complicated by secondary muscular spasm. Congenital anomalies will differ anteriorly and posteriorly. Multiple considerations can be identified to support the case for division of the vaginal vestibule into anterior and posterior components. Neurourol. Urodynam. 36:979-983, 2017. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Introduction and Hypothesis: There has been an increasing need for the terminology on the conservative management of female pelvic floor dysfunction to be collated in a clinically based consensus report., Methods: 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., Results: A Terminology Report on 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 ease of use 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., Conclusion: 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.

Introduction and Hypothesis: The terminology for anorectal dysfunction in women has long been in need of a specific clinically-based Consensus Report., Methods: This Report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted on Committee by experts in their fields to form a Joint IUGA/ICS Working Group on Female Anorectal Terminology. Appropriate core clinical categories and sub classifications were developed to give an alphanumeric coding to each definition. An extensive process of twenty rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus)., Results: A Terminology Report for anorectal dysfunction, encompassing over 130 separate definitions, has been developed. It is clinically based with the most common diagnoses 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. Female-specific anorectal investigations and imaging (ultrasound, radiology and MRI) has been included whilst appropriate figures have been included to supplement and help clarify the text. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible., Conclusions: A consensus-based Terminology Report for female anorectal dysfunction terminology has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Introduction and Hypothesis: Traditionally, it has been believed that posterior vaginal compartment prolapse was largely due to defects in the rectovaginal fascia, with surgical repairs concentrating on addressing this defect. We aimed to determine the relative size of defects at the different vaginal levels (I-III) following a large number of posterior vaginal compartment repairs (PRs) to determine whether this traditional viewpoint is still appropriate., Methods: In a cross-sectional study of 300 consecutive PRs, mostly following prior or concomitant hysterectomy, two sets of markers of posterior compartment prolapse were used to measure anatomical defects at levels I-III: (i) from Pelvic Organ Prolapse Quantification (POP-Q) system points C, Ap, Bp, and genital hiatus (GH), and from Posterior Repair Quantification (PR-Q) perineal gap (PG), posterior vaginal-vault descent (PVVD), midvaginal laxity (MVL)-vault undisplaced, and rectovaginal fascial laxity (RVFL)., Results: The largest defects were found at level I (PVVD: mean 6.0 cm; point C, mean minus 0.9 cm), and level III (PG, mean 2.9 cm; GH, mean 3.7 cm). Level II defects (MVL-vault undisplaced, mean 1.3 cm; RVFL, mean 1.1 cm; points Ap, Bp, both mean 1.0 cm) were relatively small., Conclusions: This study suggests that the defects found at surgery for posterior vaginal compartment prolapse were more frequent at the vaginal vault (level I) and vaginal introitus (level III) than at midvagina (level II). These findings should have implications for surgical planning.

Introduction: The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically-based consensus Report., Methods: This Report combines the input of members of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of fourteen rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus)., Results: A Terminology Report for female POP, encompassing over 230 separate definitions, has been developed. It is clinically-based with the most common diagnoses 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 and POP. Female-specific imaging (ultrasound, radiology and MRI) and conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 year) review is anticipated to keep the document updated and as widely acceptable as possible., Conclusion: A consensus-based Terminology Report for female POP has been produced to aid clinical practice and research.

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., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Introduction: The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically-based consensus Report., Methods: This Report combines the input of members of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give a coding to definitions. An extensive process of fourteen rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus)., Results: A Terminology Report for female POP, encompassing over 230 separate definitions, has been developed. It is clinically-based with the most common diagnoses 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 and POP. Female-specific imaging (ultrasound, radiology and MRI) and conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 year) review is anticipated to keep the document updated and as widely acceptable as possible., Conclusion: A consensus-based Terminology Report for female POP has been produced to aid clinical practice and research., (© 2016 Wiley Periodicals, Inc., and The International Urogynecological Association.)

Introduction and Hypothesis: Perineorrhaphy (Pe) has not been subject to a comprehensive perioperative quantitative assessment (QA). We wish to nominate such an assessment (Pe-QA) for any Pe, through testing the QA on the excision of the perineal gap (PG) at the time of posterior repair (PR)., Methods: At 50 consecutive PRs, the following measurements were taken pre- and postoperatively: (i) perineorrhaphy width (PW) equals PG [1]; (ii) perineorrhaphy depth (PD); (iii) perineal length (PL); (iv) midperineal thickness (MPT); (v) genital hiatus (GH) and (vi) total posterior vaginal length (TPVL). The total vaginal length was also measured. Surgical details deemed appropriate to each repair were recorded., Results: The overall means and ranges (cm) were: (i) PW 2.9 (1.5-5.5); (ii) PD 1.6 (0.8-2.0); (iii) PL 2.9 (1.5-4.5); (iv) MPT 0.7 (0.4-1.1); (v) GH 3.9 (2.3-6.5); (vi) TPVL 9.2 (6.0-12.5). Excision of PG (100 % cases reducing PW and PD to zero) resulted in a mean 23.6 % increase in total vaginal length over that if the repair was commenced at the hymen, despite a 3.3 % decrease in the TPVL perioperatively. There was a mean 30.8 % reduction in the GH, a mean 27.6 % increase in the PL and a mean 57.1 % increase in the MPT., Conclusions: Pe and the anatomical results of such surgery can be subject to quantitative assessment allowing comparison studies between different forms of Pe and possibly other types of perineal surgeries.

Introduction and Hypothesis: Posterior vaginal compartment repairs (PR) have traditionally involved a subjective approach. We aim to quantify such repairs using key anatomical indicators (KAI)., Methods: At 50 consecutive PRs: perineal gap (PG); posterior vaginal vault descent (PVVD); mid-vaginal laxity (MVL-vault undisplaced/displaced); and recto-vaginal fascial laxity (RVFL) were measured. The total posterior vaginal length (TPVL) and from POP-Q, TVL, GH, Ap, Bp C, D were also measured. Surgical details deemed appropriate to each repair were recorded., Results: A mean preoperative PG of 2.5 cm was reduced to 0.0 cm postoperatively by excision (100 % cases) with an average increase of 21.6 % in total vaginal length over that if the repair was commenced at the hymen. There was an average reduction of 25.0 % in the genital hiatus (GH). Mean PVVD was 5.3 cm overall; 6.4 cm for 31 out of 50 (62 %) undergoing sacrospinous colpopexy; 3.5 cm for 19 out of 50 (38 %) with no ligamentous vault fixation. An approximate "cut-off" for PVVD of 5 cm may assist with the differentiation of cases where vault fixation may be desirable. Up to 52 % (1.4/2.7 cm) of preoperative MVL displacement was due to vaginal vault descent. The MVL undisplaced (mean 1.3 cm) may better guide vaginal mucosal trimming. RVFL averaged just 0.8 cm with 22 out of 50 (44 %) RVFL being 0.5 cm or less, and not requiring any RVF plicatory sutures., Conclusions: It is possible to use KAI to assist the planning and execution of posterior vaginal compartment surgery. The PG, PVVD, MVL, and RVFL can indicate surgical measures in the perineum, vaginal vault, vaginal mucosa, and recto-vaginal space respectively.

Introduction and Hypothesis: We attempted to improve the accuracy of the clinical diagnosis of detrusor overactivity (DO) by using other significant clinical parameters in addition to overactive bladder (OAB) symptoms alone., Methods: One thousand one hundred and forty women attending for their initial urogynecological assessment, including urodynamics, due to symptoms of pelvic floor dysfunction, underwent a comprehensive clinical and urodynamic assessment. Multivariate logistic regression analysis of a wide range of clinical parameters was used in order to determine a model of factors most accurately predicting the urodynamic diagnosis of DO. Data were separated according to women without DO; women with DO. The analysis involved the stepwise building of an optimal clinical model for predicting DO., Results: In multivariate analysis, the OAB symptoms of urgency incontinence, urgency and nocturia (not frequency) were significantly associated with DO. Their prediction of DO was not particularly accurate (sensitivity 0.64; specificity 0.67). The addition of other significant clinical parameter, i.e. absent symptoms of stress incontinence; lower parity (0-1); no signs of prolapse, to the diagnostic model, resulted in marginally improved accuracy (area under the ROC curve increased from 0.70 to 0.74)., Conclusions: Overactive bladder symptoms alone are not accurate in predicting DO. Adding other significant clinical parameters to the model resulted in a small statistical advantage, which is not clinically useful. An accurate clinical diagnosis of DO in women would appear to remain elusive.

Introduction and Hypothesis: Results of interobserver reliability studies for the International Urogynecological Association-International Continence Society (IUGA-ICS) Complication Classification coding can be greatly influenced by study design factors such as participant instruction, motivation, and test-question clarity. We attempted to optimize these factors., Methods: After a 15-min instructional lecture with eight clinical case examples (including images) and with classification/coding charts available, those clinicians attending an IUGA Surgical Complications workshop were presented with eight similar-style test cases over 10 min and asked to code them using the Category, Time and Site classification. Answers were compared to predetermined correct codes obtained by five instigators of the IUGA-ICS prostheses and grafts complications classification. Prelecture and postquiz participant confidence levels using a five-step Likert scale were assessed., Results: Complete sets of answers to the questions (24 codings) were provided by 34 respondents, only three of whom reported prior use of the charts. Average score [n (%)] out of eight, as well as median score (range) for each coding category were: (i) Category: 7.3 (91 %); 7 (4-8); (ii) Time: 7.8 (98 %); 7 (6-8); (iii) Site: 7.2 (90 %); 7 (5-8). Overall, the equivalent calculations (out of 24) were 22.3 (93 %) and 22 (18-24). Mean prelecture confidence was 1.37 (out of 5), rising to 3.85 postquiz. Urogynecologists had the highest correlation with correct coding, followed closely by fellows and general gynecologists., Conclusions: Optimizing training and study design can lead to excellent results for interobserver reliability of the IUGA-ICS Complication Classification coding, with increased participant confidence in complication-coding ability.

Introduction: Severe adolescent female stress urinary incontinence (SAFSUI) can be defined as female adolescents between the ages of 12 and 17 years complaining of involuntary loss of urine multiple times each day during normal activities or sneezing or coughing rather than during sporting activities. An updated review of its likely prevalence, etiology, and management is required., Materials and Methods: The case of a 15-year-old female adolescent presenting with a 7-year history of SUI resistant to antimuscarinic medications and 18 months of intensive physiotherapy prompted this review. Issues of performing physical and urodynamic assessment at this young age were overcome in order to achieve the diagnosis of urodynamic stress incontinence (USI). Failed use of tampons was followed by the insertion of (retropubic) suburethral synthetic tape (SUST) under assisted local anesthetic into tissues deemed softer than the equivalent for an adult female., Results: Whereas occasional urinary incontinence can occur in between 6 % and 45 % nulliparous adolescents, the prevalence of non-neurogenic SAFSUI is uncertain but more likely rare. Risk factors for the occurrence of more severe AFSUI include obesity, athletic activities or high-impact training, and lung diseases such as cystic fibrosis (CF). This first reported use of a SUST in a patient with SAFSUI proved safe and completely curative. Artificial urinary sphincters, periurethral injectables and pubovaginal slings have been tried previously in equivalent patients., Conclusions: SAFSUI is a relatively rare but physically and emotionally disabling presentation. Multiple conservative options may fail, necessitating surgical management; SUST can prove safe and effective.

Introduction and Hypothesis: The cardinal ligament (CL) still requires more precise anatomical mapping. We aim to elucidate the anatomy of the CL and the roles it plays in gynecological surgery., Methods: Studies employed sharp dissection of 28 formalin-fixed cadaveric hemipelves and 10 unembalmed cadaveric hemipelves., Results: The CL (total length averaging 10.0 cm) can be subdivided into three sections: a distal (cervical) section, on average 2.1 cm long, attached to the lateral aspect of the cervix (posteriorly, it was confluent with the attachment of the uterosacral [USL] ligament to form the cardinal-uterosacral confluence [CUSC]); an intermediate section, on average 3.4 cm long, running laterally (slightly posteriorly) from the cervix; a proximal (pelvic) section, relatively thick, triangular-shaped on cross-section, averaging 4.6 cm long, attached to the lateral pelvic sidewall, with its apex at the first branching of the internal iliac artery. Only the distal section is free of any significant neural or vascular component (ureter is in the intermediate section) and therefore safe for surgical use. The CUSC (first pedicle of a vaginal hysterectomy and later pedicle of an abdominal hysterectomy), if attached to the vaginal vault at hysterectomy has the potential for both lateral (CL) and supero-posterior (USL) surgical support. This pedicle would not be subsequently accessible for other surgeries., Conclusions: Suggested cardinal points at hysterectomy are: know the CL anatomy; the distal section (as part of the CUSC) can provide vaginal vault support; the intermediate and proximal sections are surgically dangerous.

Introduction and Hypothesis: This study aims to assess anatomically the likely effects of dual vaginal vault support using the uterosacral (USL) and sacrospinous ligaments (SSL) at colporrhaphy., Methods: Observations were made from 13 formalinized cadaver hemipelves to determine the vaginal vault support likely to be provided by traction on the (a) USLs and (b) the posterior vaginal vault towards the SSL., Results: Traction on the USLs and SSLs both appeared to create a posterior and superior vector of vaginal vault tension, though that on the USLs appeared to be mainly on the anterior vaginal vault (and wall) with that on the SSL seemingly mostly on the posterior vaginal vault (and wall)., Conclusions: Concomitant USL and SSL traction on the vaginal vault, now technically possible, appears, from these preliminary findings, to give complementary support to the anterior and posterior aspects of the vaginal vault and walls in a similar posterior and superior vector.

Introduction and Hypothesis: A terminology and standardized classification has yet to be developed for those complications related to native tissue female pelvic floor surgery., Methods: This report on the terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many external referees. A process of rounds of internal and external review took place with decision making by collective opinion (consensus)., Results: A terminology and classification of complications related to native tissue female pelvic floor surgery has been developed, with the classification based on category (C), time (T), and site (S) classes and divisions that should encompass all conceivable scenarios for describing operative complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, colour charts and online aids ( www.icsoffice.org/ntcomplication )., Conclusions: A consensus-based terminology and classification report for complications in native tissue female pelvic floor surgery has been produced. It is aimed at being a significant aid to clinical practice and particularly to research.

Introduction and Hypothesis: A terminology and standardized classification has yet to be developed for those complications related to native tissue female pelvic floor surgery., Methods: This report on the terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many external referees. A process of rounds of internal and external review took place with decision-making by collective opinion (consensus)., Results: A terminology and classification of complications related to native tissue female pelvic floor surgery has been developed, with the classification based on category (C), time (T), and site (S) classes and divisions, that should encompass all conceivable scenarios for describing operative complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, color charts, and online aids (www.icsoffice.org/ntcomplication)., Conclusions: A consensus-based terminology and classification report for complications in native tissue female pelvic floor surgery has been produced. It is aimed at being a significant aid to clinical practice and particularly to research., (Copyright © 2012 Wiley Periodicals, Inc.)

Introduction and Hypothesis: A terminology and standardized classification has yet to be developed for those complications arising directly from the insertion of synthetic (prostheses) and biological (grafts) materials in female pelvic floor surgery., Methods: This report on the above terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many expert external referees. An extensive process of 11 rounds of internal and external review took place with exhaustive examination of each aspect of the terminology and classification. Decision-making was by collective opinion (consensus)., Results: A terminology and classification of complications related directly to the insertion of prostheses and grafts in female pelvic floor surgery has been developed, with the classification based on category (C), time (T) and site (S) classes and divisions, that should encompass all conceivable scenarios for describing insertion complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, colour charts and online aids (www.icsoffice.org/complication)., Conclusion: A consensus-based terminology and classification report for prosthesis and grafts complications in female pelvic floor surgery has been produced, aimed at being a significant aid to clinical practice and research., (© 2010 Wiley-Liss.)

Introduction and Hypothesis: a terminology and standardized classification has yet to be developed for those complications arising directly from the insertion of synthetic (prostheses) and biological (grafts) materials in female pelvic floor surgery., Methods: this report on the above terminology and classification combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS) and a Joint IUGA/ICS Working Group on Complications Terminology, assisted at intervals by many expert external referees. An extensive process of 11 rounds of internal and external review took place with exhaustive examination of each aspect of the terminology and classification. Decision-making was by collective opinion (consensus)., Results: a terminology and classification of complications related directly to the insertion of prostheses and grafts in female pelvic floor surgery has been developed, with the classification based on category (C), time (T) and site (S) classes and divisions, that should encompass all conceivable scenarios for describing insertion complications and healing abnormalities. The CTS code for each complication, involving three (or four) letters and three numerals, is likely to be very suitable for any surgical audit or registry, particularly one that is procedure-specific. Users of the classification have been assisted by case examples, colour charts and online aids ( www.icsoffice.org/complication )., Conclusions: a consensus-based terminology and classification report for prosthess and grafts complications in female pelvic floor surgery has been produced, aimed at being a significant aid to clinical practice and research.

Introduction and Hypothesis: the objective of this study is to examine the surgical safety and early efficacy of the midline uterosacral (ligament) plication anterior colporrhaphy (MUSPACC) procedure., Methods: a retrospective review of the perioperative data of 41 women who had undergone an MUSPACC procedure without any other vaginal vault supportive procedure was performed., Results: the MUSPACC procedure can be performed comfortably through a single midline anterior vaginal wall incision, providing concomitant levels 1 and 2 support at anterior colporrhaphy. The procedure is safe and relatively quick (median 23 min) with consistent access to the intermediate section of the uterosacral ligament. Blood loss is generally minimal to small. Dissection is relatively limited. The ureters (2 cm or more lateral) are not deemed to be at risk. Short-term anatomical results are promising. There was no significant change in vaginal length., Conclusions: the MUSPACC procedure is safe, relatively quick, and free of significant bleeding. It provides concomitant levels 1 and 2 vaginal support.

Introduction and Hypothesis: This study aims to elucidate and expand current knowledge of the uterosacral ligament (USL) from a surgical viewpoint., Methods: Studies were performed on 12 unembalmed cadaveric pelves and five formalin-fixed pelves., Results: The USL, 12-14-cm long, can be subdivided into three sections: (1) distal (2-3 cm), intermediate (5 cm), and proximal (5-6 cm). The thick (5-20 mm) distal section, attached to cervix and upper vagina, is confluent laterally with the cardinal ligament. The proximal section is diffuse in attachment and generally thinner. The relatively unattached intermediate section is wide, and thick, well defined when placed under tension, more than 2 cm from the ureter and suitable for surgical use. The strength of the USL is perhaps derived not only from the ligament itself, but also from the addition of extraperitoneal connective tissue., Conclusions: The USL can be subdivided into three sections according to thickness and attachments with the intermediate section suitable for surgical use, particularly for vaginal vault support.

Introduction and Hypothesis: Next to existing terminology of the lower urinary tract, due to its increasing complexity, the terminology for pelvic floor dysfunction in women may be better updated by a female-specific approach and clinically based consensus report., Methods: This report combines the input of members 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. Appropriate core clinical categories and a subclassification were developed to give an alphanumeric coding to each definition. An extensive process of 15 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus)., Results: A terminology report for female pelvic floor dysfunction, encompassing over 250 separate definitions, has been developed. It is clinically based with the six most common diagnoses 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. Female-specific imaging (ultrasound, radiology, and MRI) has been a major addition while appropriate figures have been included to supplement and help clarify the text. Ongoing review is not only anticipated but will be required to keep the document updated and as widely acceptable as possible., Conclusions: A consensus-based terminology report for female pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

The understanding of voiding dysfunction has been greatly assisted by the current introduction of clear definitions for its diagnosis and for the abnormalities of urine flow rates and postvoid residuals that are its basis. Its prevalence in women with symptoms of pelvic floor dysfunction is up to 40%. Most of the recent research has centered on the associations of voiding dysfunction with age, pelvic organ prolapse, and prior continence surgery. The effects of parity, medications, and pelvic tumors have also been explored.

Introduction and Hypothesis: The prevalence and clinical associations of recurrent (two or more symptomatic and medically documented in the previous 12 months) urinary tract infections (UTIs) have not been subjected to comprehensive analysis in a large group of women with symptoms of pelvic floor dysfunction., Methods: A prospective study was conducted involving 1,140 women presenting for their initial urogynecological assessment., Results: The overall prevalence of recurrent UTI was 19%. Significant positive associations of recurrent UTI were: (1) nulliparity with a 3.7 x (up to 50 years) increase over the prevalence for parous women and 1.8 x (over 50 years); and (2) women with an immediate postvoid residual (PVR) over 30 ml, which is significant in women over 50 years., Conclusions: The early age decline (18-45 years) in the prevalence of recurrent UTI might be related to increasing parity. The later increase (over 55 years) was probably due to the increasing PVR effect superimposed on the nulliparity effect.

The aim of this study is to assess the diagnostic relevance of the presenting bladder volume (PBV) at urodynamics in women. Its measurement is most accurately made by adding the voided volume at uroflowmetry and the postvoid residual. The study involved 1,140 women presenting for their initial urogynecological assessment. Multivariate analysis of the relationships between high or low PBVs and different clinical and urodynamic variables. Median PBV was 174 mL. In overall terms, women with lower PBVs (0-174 mL) are significantly more likely to be older, of lower parity (0-1), have the symptom of nocturia, and the final diagnoses of sensory urgency and detrusor overactivity. These women are significantly less likely to have posterior vaginal and apical vaginal prolapse. Women with higher PBVs (over 174 mL) are significantly less likely to have either bladder storage diagnoses. The relatively low median PBV might reduce the demonstration of clinical stress leakage and restrict the interpretation of uroflowmetry data.

Uroflowmetry, the simple, non-invasive measurement of urine flow over time during micturition, has a long and interesting history, clear definitions, a clear purpose in screening for voiding difficulty and, most importantly, technical accuracy. Data interpretation is currently limiting its clinical utility, despite appropriate analysis being available in long-standing existing research. The main clinically important numerical parameters are the maximum and average urine flow rates and the voided volume. Urine flow rates are strongly dependent on voided volume. Reference to established (Liverpool) nomograms will most accurately correct for this dependency. Nomograms will also optimise the validation of uroflowmetry data and the accurate assessment of its normality, compared with fixed urine flow rates and "cutoffs" for voided volume. Abnormally slow urine flow (under the 10th centile Liverpool Nomograms) is the most clinically significant abnormality. Repeat uroflowmetry, concomitant post-void residual measurement and voiding cystometry studies are appropriate options for evaluating any abnormal uroflowmetry.

Objective: To estimate the prevalence and clinical and urodynamic associations of postvoid residual volumes (PVRs), measured immediately after micturition, in women with symptoms of pelvic floor dysfunction., Methods: The patients were 1,140 women presenting consecutively for their initial urogynecological assessment, including urodynamics. They were studied prospectively. Measurement of PVRs was by transvaginal ultrasonography within 60 seconds of micturition. After the estimation of prevalence of the different levels of PVR, an appropriate upper limit of normal PVR was estimated and associations then were sought for PVRs with a wide range of clinical and urodynamic parameters., Results: The overall prevalence of PVRs was 76% at 0-10 mL, 5% at 11-30 mL, 5% at 31-50 mL, 8% at 51-100 mL, and 6% at more than 100 mL. Thus, using transvaginal ultrasonography, 81% of immediate PVRs were 30 mL or less. Higher than 30 mL, a significantly increased prevalence of women presenting with recurrent urinary tract infections (UTIs) was noted (P<.001). The level of 30 mL was deemed to be an appropriate upper limit of normal PVR. The prevalence of PVRs higher than 30 mL increased significantly with age (P<.001) and higher grades of prolapse (P<.001). There was a significant inverse relation of PVRs higher than 30 mL to the symptom of stress incontinence (P=.018) and the diagnosis of urodynamic stress incontinence (P<.001)., Conclusion: Eighty-one percent of immediate PVRs (95% confidence interval 79-84%) in symptomatic women are 30 mL or less. Postvoid residual volumes higher than this level are significantly associated with increasing age, higher grades of prolapse, and an increased prevalence of recurrent UTIs., Level of Evidence: II.

Transvaginal ultrasound with an empty bladder is recommended as a standardised ultrasonic technique for the accurate diagnosis of the retroverted uterus. Using this method, the prevalence of the retroverted uterus in 480 general gynaecological patients attending for subspecialist gynaecological ultrasound was 18%. The anteverting effect of the full bladder required for transabdominal ultrasound reduces the prevalence of the retroverted uterus to 13% (P < 0.001).

The empty (near-empty) bladder can have a volume ranging from 0 to 30 ml. Its diagnosis is effectively and least invasively made by ultrasound (transvaginal superior). It is a key marker of normal bladder function. It is necessary for the accurate assessment of uterovaginal prolapse, as increasing bladder volume has been shown to reduce the extent of the prolapse. Any negative effect of prolapse on voiding is reduced at high bladder volumes compared to voiding from low bladder volumes (due to the same reduction in the extent of the prolapse). An empty bladder is optimal for bimanual pelvic examination and most transvaginal ultrasound examinations including that for uterine version. The retroverted uterus is proving to be of increasing relevance to prolapse. The woman whose bladder is empty post-voiding is at a significantly lower risk of recurrent urinary tract infections. The bladder that can't be emptied is a marker of bladder dysfunction, requiring a fuller investigation. From a surgical point of view, the empty bladder improves access and reduces surgical risks with laparotomy, as well as both laparoscopic and vaginal surgery.