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Introduction and hypothesis Obstructive defecation syndrome (ODS) is a common urogynaecology presentation. This study compares two questionnaires, the electronic Personal Assessment Questionnaire (e-PAQ), used in urogynaecology clinics, with the ODS-Score (ODS-S), a simple validated scoring system used in colorectal clinics for diagnosing ODS, to identify patients with an ODS-S cut-off ≥9. Methods A total of 221 paired ODS-S and e-PAQ questionnaires were completed; 80 during the second trimester of pregnancy, 73 during the third and 68 post-natally, including women sustaining obstetric anal sphincter injury (OASI). e-PAQ score and ODS-S were compared and Pearson’s correlation coefficient calculated. Areas under the curve assessed the diagnostic ability of e-PAQ scores to identify patients with ODS-S of ≥9. Results The e-PAQ and ODS-S scores showed a positive correlation in the second and third trimesters of pregnancy, post-natally and following OASI. Pearson’s correlation coefficient was calculated (0.77; p p p = 0.001 and 0.79; p 0.90 for all groups. Conclusions Comparison of e-PAQ evacuatory domain scores and ODS-S show a strong correlation, with an e-PAQ score of ≥33 promising for identifying women with an ODS score of ≥9, indicating ODS. This study will enable us to identify women during pregnancy and post-natally with ODS for whom early recognition and intervention may be beneficial.

IntroductionPelvic organ prolapse (POP) can be effectively managed using a pessary. A scoping review found that pessary self-management appears to benefit women with no increased risk. Despite this, many are unwilling to self-manage their pessary. At present, there is a lack of understanding about what affects willingness to self-manage a pessary. However, there may be relevant, transferable findings from other literature about barriers to the self-management of other chronic conditions. Therefore, this systematic review aims to identify, appraise and synthesise the findings of published qualitative research exploring the barriers and facilitators to self-management of chronic conditions reported by women.Methods and analysisThe systematic review will be conducted and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and a guide for the systematic review of qualitative data. A search of MEDLINE, CINAHL, Embase and PsycInfo will be undertaken to identify relevant articles that meet the eligibility criteria using the search terms ‘Women’, ‘Woman’ ‘Female,’ ‘Chronic’, ‘Long-term’, ‘Disease’, ‘Illness’, ‘Condition’ ‘Health,’ ‘Self-management,’ ‘Qualitative,’ ‘Barrier’ and ‘Facilitator’. A hand search of the reference list of non-original research identified during the search but excluded will be conducted for additional publications, which meet the inclusion and exclusion criteria. Studies published before 2005 and those not available in English will be excluded. Data relevant to the topic will be extracted and critical appraisal of all included publications undertaken.Ethics and disseminationNo ethical or Health Research Authority approval is required to undertake the systematic review. The systematic review findings will be disseminated by publication. The findings will also inform subsequent exploratory work regarding pessary self-management.PROSPERO registration numberCRD42022327643.

IntroductionPelvic organ prolapse (POP) can be managed with a pessary; however, regular follow-up may deter women from pessary management due to the inconvenience of frequent appointments, as well as preventing pessary users from autonomous decision-making. Pessary self-management, whereby the woman removes and inserts her own pessary may be a solution to these issues. However, there remains a number of uncertainties regarding the potential benefits and risks of pessary self-management. This scoping review aims to map available evidence about the subject of pessary self-management for POP to identify knowledge gaps providing the basis for future research.Methods and analysisThe scoping review will be conducted using the Joanna Briggs Institute scoping review methodology and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A search of Medline, CINAHL, Embase and PsycInfo will be undertaken to identify relevant articles which meet the eligibility criteria using the search terms ‘pessary’ and ‘self-management’ or ‘self-care’. A hand search of the reference list of non-original research identified during the search but excluded, will be conducted for additional publications which meet the inclusion and exclusion criteria. Data relevant to the topic of pessary self-management will be extracted and critical appraisal of all included publications undertaken.Ethics and disseminationNo ethical or Health Research Authority approval is required to undertake the scoping review. However, it has been registered with The Open Science Framework (DOI 10.17605/OSF.IO/DNGCP). The findings will inform future research exploring pessary self-management and be disseminated via both a presentation at a national conference and publications in peer reviewed journals.

Introduction An increasing number of women are presenting with symptoms after the placement of mesh implants for prolapse which may be attributable to a mesh implant complication. MRI imaging can be used to evaluate abdominally placed mesh but there is no published research evaluating the use of MRI in this group of women. The objective of our study was to report our experience as a tertiary centre in evaluating abdominal mesh with MR imaging and the agreement of MR reports with surgical findings. Study design A retrospective observational cohort study (Canadian Task Force classification II-2) of all women referred to our tertiary unit who underwent an MR scan for investigation of symptoms of mesh complication following an abdominally placed mesh implant between June 2006 and September 2018 was performed. The reports of MR images were compared with the findings at surgery. Results MR scan was performed in 87 with suspected mesh complications. MR scan detected mesh failure in 42.1% of women (37/87), infection in 12.6% (11/87), compression in 2.3% (2/87), exposure in 12.6% (11/88), bowel extrusion in 2.3% (2/87) and inflammation in 11.5% (10/87). Agreement between MR scan report and surgical diagnosis was almost perfect for mesh failure, infection and compression, whilst agreement was only moderate for mesh erosion and signs of inflammation (failure κ = 0.97, infection κ = 0.94, compression κ = 1.0, exposure κ = 0.58 and inflammation κ = 0.24). Conclusion These data provide information on the role of MR imaging in the investigation of women presenting with suspected intra-abdominal POP mesh complications including recurrence.

BACKGROUND: Anterior compartment prolapse is the most common pelvic organ prolapse (POP) with a range of surgical treatment options available. // OBJECTIVES: To compare the clinical and cost effectiveness of surgical treatments for the repair of anterior POP. // METHODS: We conducted a systematic review of randomised controlled trials (RCTs) comparing surgical treatments for women with POP. Network meta-analysis (NMA) was possible for anterior POP, same site recurrence outcome. A Markov model was used to compare the cost-utility of surgical treatments for the primary repair of anterior POP from a UK National Health Service perspective. // MAIN RESULTS: We identified 27 eligible trials for the NMA involving eight surgical treatments tested on 3,194 women. Synthetic mesh was the most effective in preventing recurrence at the same site. There was no evidence to suggest a difference between synthetic non-absorbable mesh, synthetic partially absorbable mesh, and biological mesh. The cost-utility analysis which incorporated effectiveness, complications, and cost data found non-mesh repair to have the highest probability of being cost-effective. The conclusions were robust to model inputs including effectiveness, costs, and utility values. // CONCLUSIONS: Anterior colporrhaphy augmented with mesh appeared to be cost-ineffective in women requiring primary repair of anterior POP. There is a need for further research on long-term effectiveness and the safety of mesh products to establish their relative cost-effectiveness with a greater certainty. // FUNDING: The guideline referred to in this article was produced by the National Guideline Alliance (NGA) at the Royal College of Obstetricians and Gynaecologists (RCOG) for the National Institute for Health and Care Excellence (NICE). The views expressed in this article are those of the authors and not necessarily those of RCOG, NGA or NICE.

Introduction and hypothesisOur aim was to determine the intraoperative feasibility and complication rate of laparoscopic sacrocolpopexy (LSC) in overweight and obese women compared with women of normal weight.MethodsThis was a retrospective observational cohort study (Canadian Task Force classification II-2) conducted at a tertiary urogyaenocology unit evaluating 119 women who underwent LSC between March 2005 and January 2013.ResultsBody mass index (BMI) was classified as normal (22.89 ± 1.55), overweight (27.12 ± 1.40) and obese (33.47 ± 3.26) according to the World Health Organisation (WHO) classification. There was no difference in intraoperative complication rates for bladder, bowel, ureteric or vascular injury; haemorrhage; conversion to laparotomy; or anaesthetic complications for normal weight, overweight or obese women. Similarly there was no difference in operating time, duration of anaesthetic or hospital stay between BMI class (p = 0.070, p = 0.464, p = 0.898, respectively) postoperative or mesh complication rates. At 6-months’ follow-up, there was no difference in Patient Global Impression of Improvement scale (PGI-I) (defined as very much better or much better) between normal weight, overweight and obese women (76.9, 72 and 65.4%, p = .669) or objective cure using the Pelvic Organ Prolapse Quantification (POP-Q) examination (p = 0.402).ConclusionsLSC is feasible, with equivalent intraoperative complication rates for normal weight, overweight and obese women when performed by experienced laparoscopic urogynaecologists. Given the benefits of a laparoscopic approach in obese women, the authors suggest they should be offered LSC as an option to treat vault prolapse when surgical management is being considered.

What you need to know Pelvic organ prolapse is common in women over the age of 50 and negatively affects their quality of life.1 Management includes lifestyle modification, pelvic floor muscle training, vaginal pessary, or surgery.2 Pessaries may be preferred by women as an alternative to surgery or while they await surgery. In an observational study in the UK (680 women), two thirds of women initially preferred conservative management with pessaries. Women were more likely to consider surgery if they were bothered by severe symptoms affecting bowel emptying, sexual function, and quality of life.3 A pessary is inserted into the vagina to hold up the vaginal walls and pelvic organs and to relieve symptoms of prolapse (figure 1 shows types of pessary). Two types of pessary are commonly used: support pessaries—such as rings—and space occupying pessaries—such as Gellhorn or shelf pessaries. Pessaries can be inserted by general practitioners, specialist nurses, specialist physiotherapists, or gynaecologists. Guidance from the National Institute for Health and Care Excellence (NICE) recommends removing and replacing the pessary at least every six months to prevent and detect complications such as vaginal ulceration.2 NICE guidance does not …

Pessaries have been used to manage prolapse symptoms since Ancient Egyptian times. Modern pessaries are either support or space-filling vaginal devices that are made of vinyl, polythene or silicone. A ring pessary is the most commonly used pessary and can be either self-managed or changed by a healthcare professional every 6 months. Frequent adverse effect include expulsion, vaginal discharge, pain or discomfort and bleeding. Rarer more severe complications include incarceration, vesicovaginal and rectovaginal fistula and cancer. There are very few high-quality trials looking at the effect of pessary use on improving prolapse symptoms and quality of life but prospective studies report similar improvements in prolapse symptoms and quality of life compared with surgery. There is a variation in follow-up care but the most common pattern is for the women to be seen every 6 months in a clinic for pessary removal, examination and reinsertion.

Background Pelvic organ prolapse is a common problem in women. About 40% of women will experience prolapse in their lifetime, with the proportion expected to rise in line with an ageing population. Women experience a variety of troublesome symptoms as a consequence of prolapse, including a feeling of 'something coming down' into the vagina, pain, urinary symptoms, bowel symptoms and sexual difficulties. Treatment for prolapse includes surgery, pelvic floor muscle training (PFMT) and vaginal pessaries. Vaginal pessaries are passive mechanical devices designed to support the vagina and hold the prolapsed organs back in the anatomically correct position. The most commonly used pessaries are made from polyvinyl-chloride, polythene, silicone or latex. Pessaries are frequently used by clinicians with high numbers of clinicians offering a pessary as first-line treatment for prolapse. This is an update of a Cochrane Review first published in 2003 and last published in 2013. Objectives To assess the effects of pessaries (mechanical devices) for managing pelvic organ prolapse in women; and summarise the principal findings of relevant economic evaluations of this intervention. Search methods We searched the Cochrane Incontinence Specialised Register which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 28 January 2020). We searched the reference lists of relevant articles and contacted the authors of included studies. Selection criteria We included randomised and quasi-randomised controlled trials which included a pessary for pelvic organ prolapse in at least one arm of the study. Data collection and analysis Two review authors independently assessed abstracts, extracted data, assessed risk of bias and carried out GRADE assessments with arbitration from a third review author if necessary. Main results We included four studies involving a total of 478 women with various stages of prolapse, all of which took place in high-income countries. In one trial, only six of the 113 recruited women consented to random assignment to an intervention and no data are available for those six women. We could not perform any meta-analysis because each of the trials addressed a different comparison. None of the trials reported data about perceived resolution of prolapse symptoms or about psychological outcome measures. All studies reported data about perceived improvement of prolapse symptoms. Generally, the trials were at high risk of performance bias, due to lack of blinding, and low risk of selection bias. We downgraded the certainty of evidence for imprecision resulting from the low numbers of women participating in the trials. Pessary versus no treatment: at 12 months' follow-up, we are uncertain about the effect of pessaries compared with no treatment on perceived improvement of prolapse symptoms (mean difference (MD) in questionnaire scores -0.03, 95% confidence interval (CI) -0.61 to 0.55; 27 women; 1 study; very low-certainty evidence), and cure or improvement of sexual problems (MD -0.29, 95% CI -1.67 to 1.09; 27 women; 1 study; very low-certainty evidence). In this comparison we did not find any evidence relating to prolapse-specific quality of life or to the number of women experiencing adverse events (abnormal vaginal bleeding or de novo voiding difficulty). Pessary versus pelvic floor muscle training (PFMT): at 12 months' follow-up, we are uncertain if there is a difference between pessaries and PFMT in terms of women's perceived improvement in prolapse symptoms (MD -9.60, 95% CI -22.53 to 3.33; 137 women; low-certainty evidence), prolapse-specific quality of life (MD -3.30, 95% CI -8.70 to 15.30; 1 study; 116 women; low-certainty evidence), or cure or improvement of sexual problems (MD -2.30, 95% -5.20 to 0.60; 1 study; 48 women; low-certainty evidence). Pessaries may result in a large increase in risk of adverse events compared with PFMT (RR 75.25, 95% CI 4.70 to 1205.45; 1 study; 97 women; low-certainty evidence). Adverse events included increased vaginal discharge, and/or increased urinary incontinence and/or erosion or irritation of the vaginal walls. Pessary plus PFMT versus PFMT alone: at 12 months' follow-up, pessary plus PFMT probably leads to more women perceiving improvement in their prolapse symptoms compared with PFMT alone (RR 2.15, 95% CI 1.58 to 2.94; 1 study; 260 women; moderate-certainty evidence). At 12 months' follow-up, pessary plus PFMT probably improves women's prolapse-specific quality of life compared with PFMT alone (median (interquartile range (IQR)) POPIQ score: pessary plus PFMT 0.3 (0 to 22.2); 132 women; PFMT only 8.9 (0 to 64.9); 128 women; P = 0.02; moderate-certainty evidence). Pessary plus PFMT may slightly increase the risk of abnormal vaginal bleeding compared with PFMT alone (RR 2.18, 95% CI 0.69 to 6.91; 1 study; 260 women; low-certainty evidence). The evidence is uncertain if pessary plus PFMT has any effect on the risk of de novo voiding difficulty compared with PFMT alone (RR 1.32, 95% CI 0.54 to 3.19; 1 study; 189 women; low-certainty evidence). Authors' conclusions We are uncertain if pessaries improve pelvic organ prolapse symptoms for women compared with no treatment or PFMT but pessaries in addition to PFMT probably improve women's pelvic organ prolapse symptoms and prolapse-specific quality of life. However, there may be an increased risk of adverse events with pessaries compared to PFMT. Future trials should recruit adequate numbers of women and measure clinically important outcomes such as prolapse specific quality of life and resolution of prolapse symptoms. The review found two relevant economic evaluations. Of these, one assessed the cost-effectiveness of pessary treatment, expectant management and surgical procedures, and the other compared pessary treatment to PFMT.

Background Process evaluations have become a valued component, alongside clinical trials, of the wider evaluation of complex health interventions. They support understanding of implementation, and fidelity, related to the intervention and provide valuable insights into what is effective in a practical setting by examining the context in which interventions are implemented. The TOPSY study consists of a large multi-centre randomised controlled trial comparing the effectiveness of pessary self-management with clinic-based care in improving women’s condition-specific quality of life, and a nested process evaluation. The process evaluation aims to examine and maximise recruitment to the trial, describe intervention fidelity and explore participants’ and healthcare professionals’ experiences. Methods The trial will recruit 330 women from approximately 17 UK centres. The process evaluation uses a mixed-methods approach. Semi-structured interviews will be conducted with randomised women (18 per randomised group/n = 36), women who declined trial participation but agreed to interview (non-randomised women) (n = 20) and healthcare professionals recruiting to the trial (n ~ 17) and delivering self-management and clinic-based care (n ~ 17). The six internal pilot centres will be asked to record two to three recruitment discussions each (total n = 12–18). All participating centres will be asked to record one or two self-management teaching appointments (n = 30) and self-management 2-week follow-up telephone calls (n = 30). Process data (quantitative and qualitative) will be gathered in participant completed trial questionnaires. Interviews will be analysed thematically and recordings using an analytic grid to identify fidelity to the intervention. Quantitative analysis will be predefined within the process evaluation analysis plan. Discussion The wide variety of pessary care delivered across the UK for women with pelvic organ prolapse presents specific localised contexts in which the TOPSY interventions will be implemented. Understanding this contextual variance is central to understanding how and in what circumstances pessary self-management can be implemented (should it be effective). The inclusion of non-randomised women provides an innovative way of collecting indispensable information about eligible women who decline trial participation, allowing broader contextualisation and considerations of generalisability of trial findings. Methodological insights from examination of recruitment processes and mechanisms have the potential to inform recruitment mechanisms and future recruitment strategies and study designs. Trial registration ISRCTN62510577. Registered on 6 October 2017.

Additional file 1. SPIRIT 2013 Checklist: Recommended items to address in a clinical trial protocol and related documents.

Pelvic organ prolapse is a common condition with 1 in 10 women undergoing surgery during their lifetime. In the community 8% of women complain of the symptom of a vaginal bulge which is the symptom that most closely correlates with the finding of a prolapse on examination. Pelvic organ prolapse can impair urinary, bowel and sexual function. The NICE National Guideline Urinary Incontinence and Pelvic Organ prolapse in Women: Management makes recommendations on the assessment and treatment of pelvic organ prolapse. The most important part of prolapse management is obtaining a comprehensive pelvic floor history and understanding the woman's treatment goals and expectations. A standardised examination aids further decision making. Conservative treatment options include observation, lifestyle advice, pelvic floor muscle training and use of a pessary. Treatment choice is guided by patient preference.

Background Mesh surgery for stress urinary incontinence or pelvic organ prolapse can result in complications such as mesh exposure, mesh extrusion, voiding dysfunction, dyspareunia, and pain. There is limited knowledge or guidance on the effective management for mesh-related complications. Objective To determine the best management of mesh complications; a systematic review was conducted as part of the national clinical guideline 'Urinary incontinence (update) and pelvic organ prolapse in women: management'. Search strategy Search strategies were developed for each indication for referral. Selection criteria Relevant interventions included complete or partial mesh removal, mesh division, and non-surgical treatments such as vaginal estrogen. Data collection and analysis Characteristics and outcome data were extracted, and as a result of the heterogeneous nature of the data a narrative synthesis was conducted. Main results Twenty-four studies were included; five provided comparative data and four studies stated the indication for referral. Reported outcomes (including pain, dyspareunia, satisfaction, quality of life, incontinence, mesh exposure, and recurrence) and the reported incidences of these varied widely. Conclusions The current evidence base is limited in quantity and quality and does not permit firm recommendations to be made on the most effective management for mesh-related complications. Robust data are needed so that mesh complications can be managed effectively in the future. Tweetable abstract Systematic review demonstrates that the outcomes following mesh revision surgery are highly variable.

Pelvic organ prolapse is a significant quality of life issue for many women. Prolapse can be managed effectively with a mechanical device called a pessary therefore many women choose this as a conservative treatment option. Despite the extent to which pessaries are used in the UK, there are no clear guidelines regarding the training required for pessary practitioners. This article reviews literature related to pessary practitioner training. Methods: 13 publications were reviewed. Results: eight themes were identified, namely ‘prevalence of pessary training’, ‘type of pessary training’, confidence in pessary care provision’, ‘impact on pessary care’, ‘skills and knowledge required to be a pessary practitioner’, ‘barriers’, ‘speciality of pessary care providers’, and ‘ongoing support’. Conclusion: at present practitioners report a lack of pessary training, which impacts on care. Effective training includes didactic learning of agreed knowledge requirements, practice of clinical skills and ongoing support.

Objective Obstetric anal sphincter injury is common but the effect on body image is unreported. The aim of this study was to explore patient perceived changes in body image and other psychological aspects in women attending a perineal follow-up clinic. Study design This retrospective study analysed women’s responses to a self-reported questionnaire. Consecutive women with anal sphincter injury who attended a United Kingdom Maternity Hospital perineal follow-up clinic between January 1999 and January 2012 were identified and the records obtained and reviewed. Multivariate regression analyses were performed to examine variables influencing self-reported change in body image. Results Questionnaires and operation notes were analysed from 422 women who attended at a median of four months after delivery. 222 (53%) reported a change in body image with 80 (19%) reporting lower self-esteem and 75 (18%) a change in their personality due to the change in body image. 248 (59%) perceived an anatomical change due to the delivery. Factors associated with increased likelihood of reporting a change in body image were reporting a perceived change in anatomy due to the delivery, adjusted OR 6.11 (3.56–10.49), anal incontinence, OR 1.97 (1.16–3.36), and delivery by forceps, OR 2.59 (1.23–5.43). Conclusions This is the first study to quantify body image changes in women after anal sphincter injury sustained in childbirth. These were found to be very common, affecting up to 50% of women. The study has several limitations but it does highlight the significant psychosocial problems of negative self-esteem and personality changes associated with a perceived change in body image that has not previously been reported. It also outlines the further research questions that need to be addressed.

Women are seeking treatment for stress urinary incontinence more readily due to increasing awareness of minimally invasive surgical solutions and greater expectations of pelvic floor health with advancing age. Surgery for stress urinary incontinence should only be undertaken in women following a comprehensive assessment and when conservative treatments have failed. The current evidence favours a retropubic mid-urethral tape procedure using the bottom-up approach, or colposuspension. At present there is not enough long-term data on the transobturator tape technique, however short-term data show equal efficacy as the retropubic tape. Pubovaginal slings using autologous rectus sheath fascia have the highest success rate for recurrent stress incontinence, but also have significantly higher incidence of operative morbidity and voiding problems. Urethral bulking agents are an alternative, especially in those women where more invasive surgery is not desired. It is important to counsel that they have a lower success rate and repeat injections are often needed.

To compare levator ani muscle injury rates in primiparous women who had a forceps delivery owing to fetal distress with women delivered by forceps for second stage arrest; and to compare these injury rates with a historical control group of women who delivered spontaneously.Primiparous women who delivered by forceps were recruited retrospectively into 2 groups: forceps for fetal distress with short second stage (25±11 minutes; n=19); and forceps delivery for second stage arrest (137±26 minutes; n=19). MR images of the levator ani muscles were compared with a historical control group of women from a previous study who had delivered spontaneously (n=129).Major defect rates were: 42% for forceps and short second stage; 63% for forceps and second stage arrest; and 6% for spontaneous delivery. The odds ratios for major injury were: 11.0 for forceps and short second stage compared with spontaneous delivery; 25.9 for forceps and second stage arrest compared with spontaneous delivery; and 2.3 for forceps and second stage arrest compared with short second stage (P=0.07).Women delivered by forceps have a higher rate of levator ani injury compared with spontaneous delivery controls; the difference between the forceps groups did not reach significance.

• The postpartum bladder is vulnerable to urinary retention; if undetected, this can lead to bladder underactivity, recurrent urinary tract infection and incontinence. • The aim of intrapartum bladder care is to prevent bladder overdistension. • Following delivery or catheter removal, no woman should be allowed to go longer than 6 hours without voiding. • All units should have a guideline for bladder care and the management of postpartum voiding dysfunction. Learning objectives: • To be aware of the risk factors for the development of postpartum voiding dysfunction and the symptoms indicating voiding problems. • To learn about the management of postpartum voiding dysfunction. Ethical issues: • Is it acceptable to catheterise a woman to estimate the volume of residual urine when this can be estimated by ultrasound scanning of the bladder? Please cite this article as: Kearney R, Cutner A. Postpartum voiding dysfunction. The Obstetrician & Gynaecologist 2008;10:71–74.

Surgery for stress urinary incontinence is a commonly performed procedure. Thorough preoperative assessment, counselling and selection of the appropriate procedure are essential to a good surgical outcome. In the surgical treatment of stress urinary incontinence, evidence favours either a retropubic type 1 mesh mid-urethral tape using the bottom-up approach, or colposuspension. Data supporting the use of the transobturator technique for the insertion of a mid-urethral tape is emerging. The complications of the retropubic and transobturator tapes differ. Intraurethral bulking agents are associated with few complications but have poorer efficacy and often require repeated injections. Artificial urinary sphincters and urinary diversion are indicated only when other operations have failed. Augmentation cystoplasty for the treatment of urge incontinence is now less commonly performed due to the new modalities of sacral neuromodulation and botulinum A toxin. However, long-term data on the safety and outcome of these new treatments are awaited.

Aims: Defects in the pubovisceral portion of the levator ani muscle are seen with MR imaging. This study aims to determine interrater reliability of physical examination in detecting these defects, and to validate ¢ndings from physical examination using comparisons with MR images. Methods: Two examiners palpated the pubovisceral muscles of 29 women to assess for defects in this muscle. Each examiner was blinded to the others ¢ndings. MR scans were acquired on a further 24 women after structured clinical examination by one examiner. These images were read to determine pubovisceral muscle defects, blinded to patient identi¢ers. Agreement between raters and between MR imaging and clinical examination were calculated. Results: The two examiners had positive agreement (presence of a defect) of 72.7% and negative agreement (absence of a defect) of 83.3%. The positive agreement between physical examination and MR imaging was 27.3% and the negative agreement 86.5%. Conclusion: The structured physical examination to detect defects in the pubovisceral portion of the levator ani muscle can be learned as shown by good interrater agreement. However, examination alone underestimates these defects compared with MR imaging. Neurourol. Urodynam. 25:50 ^54, 2006. 2005 Wiley-Liss, Inc.

Objective To describe the variations in the location of the vaginal apex and the length of vagina excised in women undergoing the Michigan four-wall sacrospinous suspension for posthysterectomy vaginal vault prolapse. Methods A prospective observational study of 76 women who had the Michigan modification sacrospinous suspension performed between 1998 and 2001 for posthysterectomy vaginal vault prolapse was carried out. Demographics and preoperative, operative, and postoperative findings were noted, including the pelvic organ prolapse quantification score. The locations of the suspension points relative to the hysterectomy scar were recorded. The amount of vagina excised at surgery and the pre- and postoperative vaginal lengths are reported. Results The mean length and standard deviation of vagina excised was 4.6 ± 2.5 cm. The apex created at sacrospinous fixation was at the hysterectomy scar in only seven women (9%). It was most often situated behind the hysterectomy scar, in 58 cases (76%); it was situated in front of it in 11 (14%). In seven women no vagina was excised, and in the remaining 69 women a mean length of 5.1 ± 2.2 cm was removed. The mean vaginal lengths were 9.7 ± 1.7 cm preoperatively and 9.4 cm ± 0.8 postoperatively, a 0.3-cm difference. Conclusion When one performs the Michigan modification sacrospinous suspension, the chosen suspension points are often not at the hysterectomy scar, and in women with large prolapses excess vagina frequently is excised without compromising postoperative vaginal length.

Objectives: To determine the incidence of maternal morbidity following elective caesarean section in women with a history of at least two previous caesarean sections, and to determine if the incidence of morbidity correlates with the number of previous sections. Study design: We conducted an individual chart review of all women who had an elective caesarean section because of a history of two previous sections from 1990 to 1999. Results: There were 67,097 deliveries of babies weighing 500 g or more. The total number of cases eligible for the study was 250. There were 12 cases (4.8%) of placenta praevia of which four required a transfusion and two a hysterectomy. The incidence of wound infection was 6.3% and urinary tract infection was 11.2%. There were no cases of thromboembolism recorded. Conclusions: Maternal morbidity with elective repeat caesarean section is low. The major morbidity is associated with placenta praevia. We found no correlation between the incidence of maternal morbidity and the number of previous sections.

Objective To describe the appearance and occurrence of abnormalities in the levator ani muscle seen on magnetic resonance imaging (MRI) in nulliparous women and in women after their first vaginal birth. Methods Multiplanar proton density magnetic resonance images were obtained at 0.5-cm intervals from 80 nulliparous and 160 vaginally primiparous women. These had been previously obtained in a study of stress incontinence, and half the primiparas had stress incontinence. All scans were reviewed independently by at least two examiners blinded to parity and continence status. Results No levator ani defects were identified in nulliparous women. Thirty-two primiparous women (20%) had a visible defect in the levator ani muscle. Defects were identified in the pubovisceral portion of the levator ani in 29 women and in the iliococcygeal portion in three women. Within the pubovisceral muscle, both unilateral and bilateral defects were found. The extent of abnormality varied from one individual to the next. Of the 32 women with defects, 23 (71%) were in the stress incontinent group. Conclusion Abnormalities in the levator ani muscle are present on MRI after a vaginal delivery but are not found in nulliparas.

Ideally, any uterine conservation procedure for the treatment of prolapse should be effective, and yet, not significantly jeopardise subsequent surgery should a hysterectomy become a necessity in the future. We present our 1-year data on the new laparoscopic uterine sling suspension procedure. We have found significant anatomical improvements in points C and D on the pelvic organ prolapse quantification score, and improvements in vaginal, sexual and quality of life scores. We conclude that this technique is a promising new surgical method for treating uterine prolapse.

Objective To report the numbers of patients having childbirth after pelvic floor surgery in England. Design Retrospective analysis of Hospital Episode Statistics data. Setting Hospital Episode Statistics database. Population Women, aged 20–44 years, undergoing childbirth after pelvic floor surgery between the years 2002 and 2008. Methods Analysis of the Hospital Episode Statistics database using Office of Population, Censuses and Surveys: Classification of Interventions and Procedures, 4th Revision (OPCS-4) code at the four-character level for pelvic floor surgery and delivery, in women aged 20–44 years, between the years 2002 and 2008. Main outcome measures Numbers of women having delivery episodes after previous pelvic floor surgery, and numbers having further pelvic floor surgery after delivery. Results Six hundred and three women had a delivery episode after previous pelvic floor surgery in the time period 2002–2008. In this group of 603 women, 42 had a further pelvic floor surgery episode following delivery in the same time period. The incidence of repeat surgery episode following delivery was higher in the group delivered vaginally than in those delivered by caesarean (13.6 versus 4.4%; odds ratio, 3.38; 95% confidence interval, 1.87–6.10). Conclusions There were 603 women having childbirth after pelvic floor surgery in the time period 2002–2008. The incidence of further pelvic floor surgery after childbirth was lower after caesarean delivery than after vaginal delivery, and this may indicate a protective effect of abdominal delivery.

We reviewed 100 laparoscopy and dye studies performed in the Coombe Women's Hospital to determine whether recommended guidelines were followed for the investigation of infertility. Individual chart review provided information on patient demographics, preoperative investigations, operative findings and outcome. Preoperative assessment of ovulation or a semen analysis was not performed in 20 and 30 women, respectively. At laparoscopy bilateral tubal patency was demonstrated in 86 patients, three patients had bilateral blocked tubes and 11 patients had unilateral tubal occlusion. In 54% of patients there were no other additional findings. Following laparoscopy five women were referred for in vitro fertilisation and five patients had further surgery as a result of the findings at laparoscopy. In addition, three women were treated for hyperprolactinaemia and three male partners were referred for further investigation. Within one year 20 women became pregnant, 18 delivered a baby and two had a miscarriage.

To evaluate the relative contributions of urethral mobility and urethral function to stress incontinence.This was a case-control study with group matching. Eighty primiparous women with self-reported new stress incontinence 9-12 months postpartum were compared with 80 primiparous continent controls to identify impairments specific to stress incontinence. Eighty nulliparous continent controls were evaluated as a comparison group to allow us to determine birth-related changes not associated with stress incontinence. Urethral function was measured with urethral profilometry, and vesical neck mobility was assessed with ultrasound and cotton swab test. Urethral sphincter anatomy and mobility were evaluated using magnetic resonance imaging. The associations among urethral closure pressure, vesical neck movement, and incontinence were explored using logistic regression.Urethral closure pressure (+/-standard deviation) in primiparous incontinent women (62.9+/-25.2 cm H(2)0) was lower than in primiparous continent women (83.9+/-21.0, P.001; effect size d=0.91) who were similar to nulliparous women (90.3+/-25.0, P=.091). Vesical neck movement measured during cough with ultrasonography was the mobility measure most associated with stress incontinence; 15.6+/-6.2 mm in incontinent women compared with 10.9+/-6.2 in primiparous continent women (P.001, d=0.76) or nulliparas (9.9+/-5.0, P=.322). Logistic regression disclosed the two-variable model (max-rescaled R(2)=0.37, P.001) was more strongly associated with stress incontinence than either single-variable model, urethral closure pressure (R(2)=0.25, P.001) or vesical neck movement (R(2)=0.16 P.001).Lower maximal urethral closure pressure is the measure most associated with de novo stress incontinence after first vaginal birth followed by vesical neck mobility.II.

The surgical management of uterine prolapse in women who wish to retain their uterus remains a challenge. Several techniques have been reported using open abdominal, laparoscopic and vaginal approaches. The laparoscopic approach offers both excellent intraoperative visualisation of supportive and adjacent structures and quick postoperative recovery. Currently, laparoscopic suspension of the uterus to the round ligaments, uterosacral ligaments, suture and synthetic mesh suspension to the sacral promontory have been reported. This report describes a new surgical technique of laparoscopic uterine suspension, which has been performed successfully in eight women. Mersilene tape is used to suspend the uterus to the sacral promontory bilaterally and to recreate new uterosacral ligaments.

Identify and describe the separate appearance of 5 levator ani muscle subdivisions seen in axial, coronal, and sagittal magnetic resonance imaging (MRI) scan planes.Magnetic resonance scans of 80 nulliparous women with normal pelvic support were evaluated. Characteristic features of each Terminologia Anatomica-listed levator ani component were determined for each scan plane. Muscle component visibility was based on pre-established criteria in axial, coronal, and sagittal scan planes: 1) clear and consistently visible separation or 2) different origin or insertion. Visibility of each of the levator ani subdivisions in each scan plane was assessed in 25 nulliparous women.In the axial plane, the puborectal muscle can be seen lateral to the pubovisceral muscle and decussating dorsal to the rectum. The course of the puboperineal muscle near the perineal body is visualized in the axial plane. The coronal view is perpendicular to the fiber direction of the puborectal and pubovisceral muscles and shows them as "clusters" of muscle on either side of the vagina. The sagittal plane consistently demonstrates the puborectal muscle passing dorsal to the rectum to form a sling that can consistently be seen as a "bump." This plane is also parallel to the pubovisceral muscle fiber direction and shows the puboperineal muscle.The subdivisions of the levator ani muscle are visible in MRI scans, each with distinct morphology and characteristic features.

Objective—To identify obstetrical factors associated with development of levator ani injury after vaginal birth. Methods—Magnetic resonance images were taken of the pelvic floor of 160 women 9 to 12 months postpartum after first term vaginal delivery. Half the women had de novo stress incontinence and half were continent controls. Abnormalities of the pubovisceral portion were identified on magnetic resonance as present or absent. Defect severity was further scored in each muscle from 0 (no defect) to 3 (complete muscle loss). A summed score for the two sides (0 to 6) was assigned and grouped as minor (0 – 3) or major (4 – 6). Obstetric details were collected. The association between obstetric variables and muscle injury were analyzed using Fisher exact test and t-tests. Results—The following increased odds ratios for levator defect were found: forceps use 14.7 (95% confidence interval [CI] 4.9–44.3), anal sphincter rupture 8.1 (95% CI 3.3–19.5) and episiotomy 3.1 (95% CI 1.4–7.2) but not vacuum delivery 0.9 (95% CI 0.19–4.3), epidural use 0.9 (95% CI 0.4– 2.0), or oxytocin use 0.8 (95% CI 0.3–1.8). Women with levator injury were 3.5 years older and had a 78-minute longer second stage of labor. Differences in gestational age, birth weight, and head circumference were not statistically significant. A major defect in the pubovisceral muscle was seen in 22 women and a minor defect in 7 women. Conclusion—Injuries to the levator ani muscles in women after their first vaginal delivery are associated with several obstetric factors indicating difficult vaginal birth and with older age.

To examine the published literature and suggest a resolution to the confusion that exists in levator ani muscle descriptions and terminology.A MEDLINE search was performed using the keyword "levator ani," limited to human studies in women. References found in these articles were reviewed to identify research reported before 1966 and articles not included in the search.Studies were accepted if they contained direct observations of female specimens. Only those that contained specific descriptions or illustrations of the muscle origins and insertions in more than 5 female specimens were included. Review of 265 human studies yielded 9 qualifying articles, and reference tracing disclosed 3 additional reports.The literature review identified 5 origin-insertion pairs consistently described in studies directly examining the levator ani muscle in women, but 16 terms were used by authors for these 5 components of the muscle. Labeled illustrations often provided more precise information than was provided in the text. Terms were reviewed for inconsistencies of usage and appropriateness of term choice. The terms puboperineal, pubovaginal, and puboanal (for components of the pubovisceral ["pubococcygeal"] muscle), along with puborectal and iliococcygeal, are sufficient to describe the divisions of the levator ani muscle.Although there was great diversity and conflict in terms chosen among the original articles, the number of origin and insertion pairs was relatively consistent among authors and confusion can be avoided by standardizing terminology.

Objective To determine the mode of the next delivery for primigravid women who have an elective caesarean section for breech presentation. Design Retrospective cohort study. Setting University teaching hospital. Population All primigravid women who had an elective caesarean section for a singleton pregnancy in the years 1992 to 1997 and who delivered their next baby in the hospital before 1999. Methods Review of hospital computerised records. Main outcome measures Mode of delivery and fetal presentation at next delivery. Results Of 194 women who had an elective caesarean section with a breech presentation as a primigravida, 19 (9.8%) had a breech presentation at the time of elective caesarean section for their next baby compared with only two (1.7%) in the 121 women who had an elective caesarean section with a cephalic presentation as a primigravida (RR 5.9 [95% CI 1.4–25.0]). Despite the increased likelihood of another breech presentation, the overall repeat section rate was 43.8% (n= 85) in women with a previous breech presentation (n= 194), compared with 61.2% (n= 74) in women with a previous cephalic presentation (n= 121) (RR 0.72 [95% CI 0.58–0.89]). Of those women allowed to labour after elective caesarean section as a primigravid, the vaginal birth rate was 109/130 (84%) if the presentation previously was breech compared with 47/69 (68%) if the presentation previously was cephalic (RR 1.2 [95% CI 1.03–1.50]). Conclusions Women who have an elective caesarean section for a breech presentation in their first pregnancy have about a 1 in 10 chance of having an elective caesarean section for a breech presentation in their second pregnancy. Overall, the incidence of repeat caesarean section for their second baby was 43.8%, and of those allowed to labour, 84% achieved a vaginal delivery. These results compared favourably with women who had an elective caesarean section with a cephalic presentation in their first pregnancy. This information is important in advising primigravid women with a breech presentation about longer term implications of elective caesarean section. It also allows healthcare managers to anticipate the resource implications of any changes in clinical practice for women with a breech presentation in their first pregnancy.

Two thirds of women opt to use a vaginal pessary initially to manage the symptoms of pelvic organ prolapse. In the UK most women attend a health care professional at least every six months to change the pessary. This represents a significant burden both economically to the health care system and personally for the woman. Annually there are more than 300 appointments for pessary changes at our hospital. We developed a programme to teach women to self-manage their pessaries with the aim of improving patient experience and reducing outpatient attendances to free up outpatient capacity for new referrals. A physiotherapist was recuited to deliver this programme involving a one to one training session supplemented with written materials and an online video. Women using pessaries were offered the option of self-management. Eighty-eight women aged between 29 to 84 years enrolled in the programme. Sixty-three women (73% of those enrolled) successfully continued with self-management at six months, creating 126 extra outpatient appointment capacity in one year alone. Women self-managing reported higher levels of convenience (94% vs 81%), accessibility (97% vs 73%), support (100% vs. 83%), and comfort (86% vs. 53%) than those attending the hospital for GP practice for pessary change. Self-management appears to be an acceptable option for many women using vaginal pessaries, with personal benefits to the women and economic benefits to the hospital and commissioners.

To compare levator ani defects and pelvic floor function among women with prolapse and controls.Levator ani structure and function were measured in a case-control study with group matching for age, race, and hysterectomy status among 151 women with prolapse (cases) and 135 controls with normal support (controls) determined by pelvic organ prolapse quantification examination. Magnetic resonance imaging was used to determine whether there were "major" (more than half missing), "minor" (less than half of the muscle missing), or no defects in the levator ani muscles. Vaginal closure force at rest and during maximal pelvic muscle contraction was measured with an instrumented vaginal speculum.Cases were more likely to have major levator ani defects than controls (55% compared with 16%), with an adjusted odds ratio of 7.3 (95% confidence interval 3.9-13.6, P.001) but equally likely to have minor defects (16% compared with 22%). Of women who reported delivery by forceps, 53% had major defects compared with 28% for the nonforceps women, adjusted odds ratio 3.4 (95% confidence interval 1.95-5.78). Women with prolapse generated less vaginal closure force during pelvic muscle contraction than controls (2.0 Newtons compared with 3.2 Newtons P.001), whereas those with defects generated less force than women without defects (2.0 Newtons compared with 3.1 Newtons, P.001). The genital hiatus was 50% longer in cases than controls (4.7+/-1.4 cm compared with 3.1+/-1.0 cm, P.001).Women with prolapse more often have defects in the levator ani and generate less vaginal closure force during a maximal contraction than controls.II.