Occult stress incontinence in women with pelvic organ prolapse.

OBJECTIVES: To study the prevalence of occult stress urinary incontinence (SUI) among Indian women with genitourinary prolapse, and determine the risk of developing SUI after vaginal hysterectomy and pelvic floor repair in Indian women with occult SUI. METHODS: A prospective cohort study of 78 women with significant genitourinary prolapse without symptoms of SUI was conducted at Christian Medical College, Vellore, India. Before the surgical intervention, the prolapse was repositioned using a pessary and a Pyridium (Parke Davis, Morris Plains, NJ, USA) pad test was performed to detect occult SUI. The primary outcome studied was the risk of developing postoperative urinary incontinence. RESULTS: Preoperatively, 67.9% of women were found to have occult SUI. The prevalence of SUI was 43.6% postoperatively, and 64.2% of the women with a positive result to the preoperative Pyridium pad test after pessary insertion were found to have urinary incontinence postoperatively. Postmenopausal women had twice the risk of developing occult SUI. CONCLUSION: Preoperative testing is useful to identify women with genitourinary prolapse who have occult SUI. Women with a positive result may need a systematic clinical evaluation and urodynamic studies to characterize the incontinence. They can be then counseled preoperatively regarding concomitant anti-incontinence procedures.     

Suburethral sling treatment of occult stress incontinence and intrinsic sphincter deficiency in women with severe vaginal prolapse of the anterior vs posterior/apical compartment

OBJECTIVE: The purpose of this study was to compare the efficacy of a Mersilene mesh suburethral sling for occult stress urinary incontinence (SUI) and intrinsic sphincter deficiency (ISD) in women with severe vaginal prolapse of the anterior compartment to the posterior/apical compartment. STUDY DESIGN: This was a retrospective study that compared women with stage or grade III/IV prolapse of the anterior compartment (group 1) with the posterior/apical compartment (group 2); both groups demonstrated occult SUI (leakage only with prolapse reduced) and ISD on urodynamics, and underwent concurrent pelvic reconstructive surgery. The sling was defined as efficacious if SUI was prevented in 85% of women and if obstructive symptoms (de novo or worsening urge incontinence, or urinary retention greater than 2 weeks) occurred in less than 10% of women. RESULTS: There were 39 women in group 1 and 25 women in group 2. There were no differences between women in group 1 or group 2 in preoperative demographics (except parity) or urodynamic findings. SUI cure rates were lower for group 1 than group 2, but this difference was not significant (87% vs 100%, P = .15). Rates of de novo or worsening urge incontinence (8% vs 4%, P = 1.00) and urinary retention (none occurred) were similar between groups. CONCLUSION: In women with severe vaginal prolapse, slings effectively treat occult SUI and ISD, whether associated with anterior or posterior/apical prolapse.     

Assessment and initial management of mesh complications

Synthetic polypropylene mesh have been used in the surgical management of pelvic organ prolapse (POP) and stress urinary incontinence (SUI) since 1990's. However, following patients'-led campaign with concerns regarding the complications associated with mesh, their use in surgical management of SUI and/or POP has been controversial. Complications associated with these mesh implants include chronic pain, vaginal mesh exposure, perforation into organs, infections and sinus tract formation. In April, 2019, the NICE guideline (NG123) provided an evidence review for management of mesh complications. Following Independent Medicine and Medical Devices Safety Review (IMMDS) publication in 2020, a network of specialized complex mesh centres across the UK have been set up. All patients with mesh-related complications should receive specialist multidisciplinary care in these centres. In this review, we outline the assessment and initial management of patients who present with mesh-related complications. Assessment and management options should be tailored per individual cases. Assessment includes clinical assessment and investigations including radiological imaging. All management options including no treatment, conservative, medical and surgical treatment, including minimally invasive treatment with the pros and cons of every option should be offered and patient should be actively involved in their decision making in a “shared-decision making” manner.     

Combined genital prolapse repair reinforced with a polypropylene mesh and tension-free vaginal tape in women with genital prolapse and stress urinary incontinence: a retrospective case-control study with short-term follow-up

BACKGROUND: To evaluate the tension-free vaginal tape (TVT) in both stress urinary incontinence (SUI) and occult SUI as an associated procedure at the time of tension-free polypropylene mesh repair for the treatment of genitourinary prolapse. METHODS: Forty-eight consecutive women undergoing surgery for genital prolapse and concurrent SUI from November 1999 to September 2002. Preoperatively, SUI was symptomatic in 29 women and occult in 19, with a positive stress test during repositioning of the prolapse. All patients had urethral hypermobility and none had intrinsic sphincter deficiency. The cystocele repair was performed in all patients according to the technique of tension-free polypropylene mesh. Twenty-six women had an associated TVT and 22 had no associated procedure for SUI (control group). The main outcome measures were postoperative SUI, voiding dysfunction, and recurrence of prolapse. RESULTS: The median follow-up was 20 +/- 10.1 months (range 7-41). Patient characteristics and preoperative urodynamic evaluation were similar in the two groups. In patients with preoperative SUI, postoperative SUI occurred in 1/15 of the TVT group (6.7%) vs. 5/14 (35.7%) in the control group (p < 0.05), and voiding dysfunction occurred in 2/15 patients of the TVT group (13.3%) vs. 0/14 in the control group (p > 0.05). In patients with preoperative occult SUI, postoperative SUI occurred in 0/11 of the TVT group vs. 1/8 (12.5%) in the control group (p > 0.05), and voiding dysfunction occurred in 3/11 patients of the TVT group (27.3%) vs. 0/8 in the control group (p < 0.05). Anatomic success on prolapse was 88.5% (23/26) and 86.4% (19/22) in the TVT and the control group, respectively (p > 0.05). CONCLUSION: In patients with preoperative SUI, TVT is more efficient than prosthetic cystocele repair alone to prevent postoperative SUI, without differences in voiding dysfunction. In patients with preoperative occult SUI, prosthetic cystocele repair is as efficient as TVT, with a decreased risk of voiding dysfunction.     

Review of transobturator and retropubic tape procedures for stress urinary incontinence

PURPOSE OF REVIEW: Recently, various types of tension free vaginal tapes via retropubic and transobturator route (inside-out technique; outside-in technique) have been adopted for treatment of stress urinary incontinence. The aim of this review is to assess the recent evidence on effectiveness and complications of these tapes in stress urinary incontinence. RECENT FINDINGS: There was no significant difference found between tension free vaginal tapes and colposuspension for the cure of stress urinary incontinence at 5 years in a multicentre randomized controlled trial. Vault and posterior vaginal wall prolapse were commoner after colposuspension. A recent systematic review and meta-analysis reported that subjective cure for inside-out technique (five randomized controlled trials) and outside-in technique (six randomized controlled trials) at 2-12 months was no better when compared with tension free vaginal tapes (odds ratio: 0.85; 95% confidence interval: 0.60-1.21). Bladder injuries (odds ratio: 0.12; 95% confidence interval: 0.05-0.33) and voiding difficulties (odds ratio: 0.55; 95% confidence interval: 0.31-0.98) were less common, whereas groin/thigh pain (odds ratio: 8.28; 95% confidence interval: 2.7-25.4) and vaginal injuries or mesh erosion (odds ratio: 1.96; 95% confidence interval: 0.87-4.39) were more common in transobturator tapes. Sexual function was overall improved; the pain being more with outside-in technique than inside-out technique route. SUMMARY: The tension free tapes are effective in treating stress urinary incontinence; evidence for superiority of transobturator over retropubic tapes is currently limited.     

Urodynamic and clinical effects of transvaginal mesh repair for severe cystocele with and without urinary incontinence

Objective

To demonstrate the urodynamic and clinical effects of transvaginal polypropylene mesh repair (TVM) for severe cystocele with or without stress urinary incontinence (SUI).

Methods

One hundred women with severe cystocele who underwent transvaginal cystocele repair using a tension-free polypropylene mesh were included in a retrospective study. A simultaneous transobturator tape (TOT) procedure was performed in 24 patients with concurrent urodynamic stress incontinence (USI). Postoperative follow-up examinations included urodynamic testing, pelvic organ prolapse quantification, and urogynecologic questionnaire.

Results

Mean follow-up was 35 months (range, 13-68 months). At 3-6 months after surgery, 2 (8.3%) of the 24 patients with USI who had undergone TVM and TOT had persistent SUI. Of the 30 women with occult USI who had undergone TVM alone, 6 (20%) developed symptomatic SUI and 9 (30%) had asymptomatic SUI. Thirteen (28.3%) of the 46 patients without USI developed postoperative SUI. The 1-year results showed de novo SUI in 10 (10%) women, recurrent cystocele in 6 (6%), and mesh erosions in 5 (5%). Four (13.3%) of the 30 patients engaging in sexual activity had dyspareunia.

Conclusion

TVM is effective and safe in patients with severe cystocele, but may have an impact on voiding and sexual activity.     

替代物治疗盆底功能障碍性疾病的应用前景

目前用于治疗盆底功能障碍性疾病（pelvic floor dysfunction，PFD）的替代物主要是指网片，根据材料分为人工合成网片、生物补片和组织工程学网片。中重度盆腔器官脱垂（pelvic organ prolapse，POP）和压力性尿失禁（stress urinary incontinence，SUI）使用网片的手术方法包括经阴道植入网片（transvaginal mesh implantation，TVM）手术、阴道骶骨固定术（sacrocolpopexy，SC）和无张力尿道中段吊带术（mid-urethralslings，MUS），网片的并发症使网片手术陷入争论。文章通过论述网片手术现状、网片材质、手术操作的改进、生物力学的发展和监管随访机制的建立，探讨网片在PFD中的应用。     

替代物治疗盆底功能障碍性疾病的应用前景

目前用于治疗盆底功能障碍性疾病（pelvic floor dysfunction，PFD）的替代物主要是指网片，根据材料分为人工合成网片、生物补片和组织工程学网片。中重度盆腔器官脱垂（pelvic organ prolapse，POP）和压力性尿失禁（stress urinary incontinence，SUI）使用网片的手术方法包括经阴道植入网片（transvaginal mesh implantation，TVM）手术、阴道骶骨固定术（sacrocolpopexy，SC）和无张力尿道中段吊带术（mid-urethralslings，MUS），网片的并发症使网片手术陷入争论。文章通过论述网片手术现状、网片材质、手术操作的改进、生物力学的发展和监管随访机制的建立，探讨网片在PFD中的应用。     

Prolift网片联合尿道中段悬吊治疗POP或合并SUI患者的近期疗效

目的:探讨全阴道修复网片(total vaginal mesh,TVM)即Gynecare Prolift网片修复系统及联合经闭孔无张力阴道吊带(tensiongfree vaginal tape-obtutor,TVT-O)尿道中段悬吊手术治疗盆腔器官脱垂(pelvic organ prolapse,POP)或合并压力性尿失禁(stress urinary incontinence,SUI)的近期疗效。方法:选择Ⅱ度以上子宫和(或)阴道壁脱垂患者24例,其中本次手术前已切除子宫5例,术中同时切除子宫12例,保留子宫7例。16例用全盆底修复网片(total Prolift),8例用前盆修复网片(anterior Prolift);10例因合并压力性尿失禁同时行TVT-O尿道中段悬吊术。结果:24例患者术中均无严重并发症发生,3例(12.5%)出血量超过500ml;术后随访12～20个月,1例至术后10个月时发现阴道壁网片侵蚀(4.2%,1/24),经门诊4次修剪好转;24例患者均无复发。结论:用Prolift盆底修复网片系统进行盆底重建术,手术安全、易行、微创,近期疗效肯定;合并SUI者同时使用TVT-O不增加手术难度和并发症的发生率。     

Vaginal hysterectomy for correcting genital prolapse. Long-term evaluation.

OBJECTIVE: To determine whether a transvaginal hysterectomy with anterior and posterior repair is effective in the long term in treating uterovaginal prolapse and stress urinary incontinence (SUI). STUDY DESIGN: Seventy-four patients subjected to vaginal hysterectomy for the treatment of severe genital prolapse, on average five years before the study, were contacted by letter for evaluation. Four of these patients had died, and 47 (67.1%) responded to the letter. The mean age of the patients at the time of reevaluation was 66.1 +/- 10.6 years, and mean parity was 6.6 deliveries. RESULTS: All patients but two presented some degree of genital prolapse at the time of reevaluation, with three cases of total vaginal vault prolapse. White patients (87.2%) predominated over African (black) patients (12.8%). SUI associated with prolapse persisted in 14 of the 20 patients, and 6 others had this complaint after surgical correction (22.2% of previously continent patients). CONCLUSION: The rate of unsuccessful surgical correction of severe genital prolapse was very high (95.7%), and cure of SUI was low (30%), with SUI actually arising after surgical correction in 25% of continent patients. In addition to parity, there seems to be a racial factor linked to the onset and maintenance of this pathology, with a higher prevalence among white patients.     

Concomitant trocar-guided transvaginal mesh surgery with a midurethral sling in treating advanced pelvic organ prolapse associated with stress or occult stress urinary incontinence

ObjectiveThe purpose of this study was to evaluate the efficacy and feasibility of concomitant trocar-guided transvaginal mesh (TVM) surgery with a midurethral sling (MUS) for treating women with advanced pelvic organ prolapse (POP) and stress urinary incontinence (SUI) or occult SUI (OSUI).Materials and methodsEighty-nine women with advanced POP and SUI or OSUI were retrospectively enrolled. The Total Prolift and Tension-free Vaginal Tape-Obturator Systems were used for trocar-guided TVM surgery and MUS. Patients received regular follow-up at 1 week, and 1 month, 3 months, 6 months, and 12 months postoperatively, and then annually thereafter. The endpoints were the success rate for POP, and perioperative and postoperative complications. Functional outcomes were the presence of voiding difficulty, persistent or de novo overactive bladder symptoms, postoperative SUI, and paresthesia.ResultsThe median follow-up period was 35 months (range, 12–50 months). Within the follow-up period, 84 patients (94.4%) were objectively cured, five patients (5.6%) had vaginal apical mesh exposure, 29 individuals (32.6%) had persistent or de novo overactive bladder symptoms, six individuals (22.5%) had de novo SUI (two were found by urodynamics), and nine individuals (10.1%) had voiding difficulties (two were found by urodynamics). In addition, the vaginal hysterectomy group had greater blood loss, longer operation times, and a higher mesh erosion rate compared to the uterine suspension group.ConclusionConcomitant trocar-guided TVM surgery and MUS with the use of total Prolift and Tension-free Vaginal Tape-Obturator offer good efficacy in treating women with advanced POP and SUI or OSUI. The vaginal hysterectomy group had more perioperative complications.     

盆底功能障碍性疾病尿动力学检查及临床应用价值

尿动力学如尿流率及膀胱测压等主要用于下尿路功能障碍的膀胱功能和尿道功能检测,盆腔器官脱垂的患者多合并各种下尿路症状,术前行膀胱测压对于复杂性尿失禁和合并盆腔器官脱垂的患者有重要的临床价值。     

北京郊区女性尿失禁及盆腔脏器脱垂发病情况及其对生活质量影响的抽样调查

目的 调查北京郊区女性尿失禁及盆腔器官脱垂发病情况及其对生活质量的影响。方法 按照整群抽样的方法，选取生活在北京市房山区某自然村18岁以上的常住已婚女性，进行问卷调查，并行妇科检查和B超检查。结果 全村符合调查的女性202人，回收问卷190份，应答率94．1％。调查结果显示，尿失禁的患病率为67例（35．3％）。子宫脱垂49例（25．8％），阴道前壁膨出79例（41．6％），阴道后壁膨出61例（32．1％）。尿失禁对女性日常生活、情绪和性生活的影响率分别为29．9％、23．9％、29．9％，尿失禁以轻度尿失禁为主（占82．1％），尿失禁合并子宫脱垂占31．3％，合并阴道前壁膨出59．7％，合并阴道后壁膨出44．8％。结论 整群抽样调查显示，北京郊区女性尿失禁及盆腔脏器脱垂均较常见，尿失禁患者多合并盆腔脏器脱垂，尤其是阴道前壁膨出，并对生活质量有较大影响。     

Sexual function in women following the transvaginal tension-free tape procedure for incontinence

OBJECTIVE: To assess the impact of the tension-free vaginal tape (TVT) procedure on the sexual function of women who underwent this treatment for stress urinary incontinence (SUI). METHOD: The Lemack questionnaire was mailed to 135 women treated for SUI only, with no concomitant pelvic organ prolapse repair. RESULTS: Of the 82 returned questionnaires (60.7%), 66 (80.5%) could be included in the analysis. Compared with preoperative responses, there were no significant postoperative changes regarding frequency of sexual intercourse, satisfaction with sexual intercourse, or personal importance of having an active sexual life. Although there was a significant postsurgical decrease in urinary coital incontinence (P=0.02) and 12 women (25.5%) reported improved satisfaction from intercourse, 11 women (23.4%) complained of a worsening. CONCLUSION: These results suggest that TVT for SUI does not significantly affect sexual function in women. Additional prospective studies are warranted to verify these preliminary findings and compare the impact of the TVT with that of other anti-incontinence procedures.     

Impact de la chirurgie réparatrice pelvienne sur la sexualité

Sexual well-being is an important parameter of women's health and quality of live. Sexual disorders may occur in women with pelvic organ prolapse and/or stress urinary incontinence and also after pelvic reconstructive surgery. Sexual dysfunction after POP or SUI surgery has been poorly documented but new condition specific questionnaires have been developed to help us to better evaluate such consequences. This paper reports available data and highlights more specifically consequences of surgery with mesh reinforcement which is, currently, an important issue particularly when performing by vaginal approach.     

Genitaldeszensus und Belastungsinkontinenz

Bladder dysfunction including stress urinary incontinence is common in women with pelvic organ prolapse. Pelvic floor exercises and pessaries may be successful in alleviating prolapse and incontinence symptoms. After anterior repair, 48% of preoperatively stress incontinent women are continent, 61% after transobturator mesh operations. Additional suburethral sling insertion considerably increases postoperative continence rates. In women with occult stress incontinence, concomitant placement of a suburethral tape also improves success rates for stress incontinence. The subethral sling may be inserted concomitantly or three months after prolapse surgery with similar results. However, nearly one third of women declined the suburethral tape because they were dry after anterior repair. Continent women with prolapse develop stress incontinence in 9% after anterior repair and in 14% after transobturator mesh implantation. In summary, women with occult or symptomatic stress incontinence benefit from additional suburethral tape insertion. However, almost one third of women will receive an unnecessary operation and delayed continence surgery should be considered.     

De novo stress urinary incontinence after vaginal repair for pelvic organ prolapse: one-year follow-up

Objective

A few studies have reported a wide range (2–43%) in incidence of de novo stress urinary incontinence (SUI) following surgical repair of pelvic organ prolapse (POP) in previously continent women. The aim of this study was to re-examine this incidence up to one year following vaginal repair of prolapse.

Study design

Retrospective review of a cohort of women who underwent reconstructive vaginal repair of POP without a concomitant anti-incontinence procedure between 2003 and 2007 at two tertiary referral centers. Women were considered eligible if they were stress continent by symptoms and objective assessment (including urodynamics testing) prior to surgical repair. All women who had had any anti-incontinence procedure previously were excluded. The endpoint was subjective SUI that prompted the patient to undergo any treatment within one year from their prolapse surgery.

Results

64 women, with a mean age of 61 (±11) years, were eligible for the study: 26 (41%) had preoperative symptoms of overactive bladder. Fifty-four patients were available for analysis at the one-year visit. Seven women (13.5%) had symptoms of SUI but only one (2%) was found to have SUI objectively. Another patient underwent anti-incontinence surgery following her prolapse surgery.

Conclusion

The incidence of de novo SUI requiring treatment in previously continent women who underwent vaginal repairs for POP without concomitant anti-incontinence surgery is low (4%). A large-scale prospective study is necessary to further evaluate this finding.     

Analysis of two sling procedures using polypropylene mesh for treatment of stress urinary incontinence.

OBJECTIVES: To evaluate and compare the surgical outcome between the innovative tension-free vaginal tape (TVT) and conventional pubovaginal sling (PVS) procedures using polypropylene mesh. METHODS: Eighty consecutive women with urodynamic stress urinary incontinence (SUI), who chose to undergo either a TVT (n=23) or a PVS (n=57) procedure using polypropylene mesh based on financial consideration, were recruited for this study. The surgical results were analyzed and compared subjectively and objectively. RESULTS: The mean follow-up interval was 23 months for the TVT and 20 months for the PVS procedure (P=0.062). Postoperatively, SUI (91.3% vs. 93.0%), concomitant urge symptoms (85.0% vs. 85.3%) and the negative impact of incontinence and urogenital distress on patients' quality of life (79.8% vs. 77.8%) (77.4% vs. 68.8%) had improved markedly. After a multivariable logistic regression analysis, the treatment outcome of SUI was found to be independent of the main effects of patient age, parity, concurrent gynecological surgeries, intrinsic sphincter deficiency, previous failed incontinence surgeries, and concomitant urge symptoms. However, it was significantly related to treatment procedures (TVT vs. PVS) and their interaction with patient body mass index (BMI). Based on the fitted logistic model, we see that TVT performs better than PVS when BMI is less than 27.27 kg/m2, and the advantage of TVT decreases as BMI increases. CONCLUSION: Both TVT and PVS procedures using polypropylene mesh are effective treatment modalities for female SUI. However, TVT was not as effective in treating overweight or obese women as PVS.     

Resolution of urge urinary incontinence with midurethral sling surgery in patients with mixed incontinence and low-pressure urethra

The aim of the study was to determine the rate of persistence of urgency or urge urinary incontinence following midurethral sling surgery compared to standard medication treatment in patients with mixed incontinence and ISD urethra. A prospective study was conducted at a tertiary referral Urogynecology Center. One hundred five women with stress urinary incontinence (SUI) and urgency were identified. Fifty-four consecutive women with SUI and urgency who underwent midurethral sling were compared to 51 women with SUI and urgency but treated with medications first. Women with persistent urgency or urge urinary incontinence (UUI) at 6-month follow-up following a TVT sling procedure were compared with those whose symptoms had resolved, to determine the risk factors for persistent symptoms. Forty out of 54 patients in the operation group also underwent a prolapse repair, either a colpopexy or a colpocleisis. All patients had demonstrated a mean urethral closure pressure of 20?mmHg or lower, indicating an intrinsic sphincteric deficiency. Persistent urgency (6 of 54, 11%) and UUI (3 of 54, 5.5%) were found in patients with mixed incontinence who underwent a sling operation. All 51 patients (100%) persisted with some urgency and urge incontinence despite anticholinergic medication treatment, only (7 of 51, 13.7%) reporting improvement of symptoms. Concomitant prolapse surgery, especially apical correction (OR 0.55, 95% CI 0.37–0.65), decreased the risk of urgency persistence, while age (OR 1.04, 95% CI 1.02–1.05), detrusor overactivity (OR 1.66, 95% CI 1.28–2.53), baseline symptom severity (OR 1.77, 95% CI 1.48–2.36), and previous incontinence surgery (OR 2.08, 95% CI 1.38–3.60) increased the risk of persistent urgency in the operated cohort. Women were happier in the operated cohort (45 of 54, 83.3% cure rate). A sling itself decreased the risk of persistent urge or UUI (OR 0.33, 95% CI 0.15–0.70). The most significant improvement was UUI at night. Urodynamic parameters, baseline urgency symptom severity, age, and concomitant prolapse operation are important predictors of persistent urgency or UUI following midurethral sling for mixed incontinence patients.     

河北省部分地区女性尿失禁流行病学调查

目的:研究河北省部分地区女性不同类型尿失禁(UI)的患病现状及影响因素,为临床防治工作提供依据。方法:用分层整群抽样法,抽取河北省石家庄、保定、邢台3个地区的城市和农村,年龄在20周岁以上不同职业的女性2500人,通过面对面问卷方式进行调查。数据录入和分析使用SPSS13.0统计软件完成。结果:合格问卷2448份,城市1485份,农村963份。河北省3个地区女性尿失禁患病率35.2%(862/2448)。其中,压力性尿失禁(SUI)、急迫性尿失禁(UUI)、混合性尿失禁(MUI)患病率分别是26.4%(647/2448)、1.9%(47/2448)和6.9%(168/2448),构成比分别是75.1%、5.4%和19.5%。年龄、便秘、盆腔器官脱垂、流产次数、剖宫产是SUI和MUI的共同影响因素;此外,SUI与体重指数、痛经、妇科炎症、胎儿体重、难产密切相关,MUI与居住地(城乡)、盆腔手术史、泌尿系感染、呼吸系统疾病、心脏疾病、饮酒密切相关。UUI的影响因素只有初潮年龄和难产。结论:尿失禁是调查地区女性的高发病,SUI是主要的患病类型。该病发生与多种因素有关,3种类型尿失禁的影响因素既有共同点,又存在差异,MUI并非SUI和UUI影响因素的简单相加。