The ability of history and a negative cough stress test to detect occult stress incontinence in patients undergoing surgical repair of advanced pelvic organ prolapse

To determine if a negative preoperative reduction cough stress test is a viable method of detecting occult stress incontinence or urge incontinence in women undergoing surgical repair of advanced pelvic organ prolapse. A retrospective chart review was done on all patients who denied any urinary complaints and had repair of advanced pelvic organ prolapse, grade two or greater, without the addition of an anti-incontinence procedure. Additionally patients had a simple office filling study done at the time of initial examination that failed to show the sign of stress incontinence or detrusor instability. Any urinary dysfunction that developed postoperatively was noted. A total of 53 patients met the inclusion criteria. Of these patients, one patient (1.9%) developed genuine stress incontinence, and one patient complained of urgency (1.9%). Patients without urinary complaints and a negative office filling study, who were present for surgical correction of advanced pelvic organ prolapse, have a low incidence of developing occult stress incontinence. Further work-up would not be cost effective.     

传统阴式手术治疗盆腔脏器脱垂术后疗效研究

目的 评价我院传统阴式手术治疗盆腔脏器脱垂的效果,探讨导致手术后复发的危险因素. 方法 对我院2000年1月～2005年12月因中重度盆腔脏器脱垂行首次传统手术治疗(经阴道全子宫切除、阴道前后壁修补以及会阴修补)的73例进行回顾分析以及随访.问卷调查主观症状治愈、手术前后尿失禁情况,依据POP-Q(Pelvic Organ Prolapse Quantification)评分判定客观治愈情况.比较复发组与客观治愈组之间的差异. 结果 73例随访8～62个月,平均28.6月.主观治愈率94.5%(69/73),客观治愈率61.6%(45/73).单纯前壁膨出复发24.7%(18/73),单纯后壁膨出复发8.2%(6/73),同时存在阴道前壁以及后壁的膨出复发5.5%(4/73).无阴道穹隆脱垂或子宫脱垂.因复发二次手术2.7%(2/73).复发组与未复发组在手术时年龄、手术时是否绝经、手术前脱垂程度、是否伴慢性咳嗽等方面差异均无显著性(P＞0.05).手术后35例原有尿失禁患者中有17.1%(6/35)症状消失,5.7%(2/35)尿失禁加重.术前无尿失禁患者23.7%(9/38)手术后出现尿失禁.73例中共有11例手术后尿失禁加重. 结论 传统手术方式治疗中重度盆腔脏器脱垂,客观治愈率低,阴道前壁膨出复发率高.对前盆腔的修补以及对潜在的尿失禁的治疗应该引起足够重视.     

The development of pelvic organ prolapse following isolated Burch retropubic urethropexy

The purpose of our study was to examine the incidence of prolapse in a group of women who had had an isolated Tanagho modification of the Burch colposuspension performed without significant pelvic organ prolapse preoperatively. Sixty women were identified who underwent an isolated Burch procedure for genuine stress incontinence between 1991 and 1999. Thirty-four women returned for postoperative Pelvic Organ Prolapse Quantification (POP-Q) staging evaluation. Overall, 6 (17.6%) had stage II anterior prolapse. Eleven (32.4%) had stage II posterior prolapse. Three (8.8%) had stage II uterine prolapse. None of these patients with identified support defects was symptomatic. Two patients had subsequently undergone vaginal hysterectomy. One had this performed for dysfunctional uterine bleeding 3 years after her Burch procedure. One patient developed symptomatic uterine prolapse and underwent a vaginal hysterectomy 5 months after her Burch procedure. The majority of patients undergoing an isolated Tanagho modification Burch procedure without preoperative prolapse do not appear to be placed at increased risk for subsequent operative intervention.     

Videocystourethrography with a ring pessary in situ. A clinically useful preoperative investigation for continent women with urogenital prolapse?

The aim of the study was to evaluate the use of a vaginal pessary in the detection of genuine stress incontinence (GSI) in women with urogenital prolapse undergoing urodynamic investigation. Continent women with urogenital prolapse, with or without associated urinary symptoms, were studied. All underwent video-cystourethrography using a standarized protocol. None had evidence of incontinence on provocative testing in the upright position. A well-fitting vaginal ring pessary was inserted to reduce the prolapse and mimic a vaginal repair. The provocative tests were then repeated while the bladder was screened. Seventy women with a mean age 59.0 years (range 34–83) were recruited over a 21-month period: 15 women complained of prolapse alone and 55 had concurrent urinary symptoms; 19 women (27%) developed GSI only following the insertion of a vaginal pessary. The women who became incontinent were significantly older (mean age 63.9 years) than those who remained continent (mean age 56.8 years) (P<0.020). The use of a vaginal pessary increases the detection rate of GSI in continent women with urogenital prolapse undergoing videocystourethrography. These findings are important becasuse women with prolapse and coexisting incontinence should be offered a continence procedure rather than a simple vaginal repair.Editorial Comment: All patients with significant uterovaginal prolapse require preoperative evaluation to rule out the presence of potential stress incontinence. The simplest and best way to perform this preoperatively has yet to be determined, although several methods have been described. These include a cough stress test or cough urethral profile performed with a full bladder with the prolapse reduced with a Sims' speculum, a pessary or vaginal packing. A pad test with the prolapse reduced in a similar fashion has also been used clinically to identify patients at risk for postoperactive potential stress incontinence following correction of pelvic prolapse. The authors present their experience using a ring pessary to reduce the prolapse during videourodynamic evaluation of lower urinary tract function, finding this technique to be effective in identifying patients who leak only with the pessary in place, and therefore, require an incontinence procedure. The pickup rate for this cohort of patients is similar to previous studies using alternative methods of detection. Perhaps the only question yet to be answered is the percentage of patients with negative testing preoperatively, yet who develop urinary incontinence immediately following surgical correction of pelvic relaxation. Only this determination will truly assess the clinical utility of the preoperative methods used to identify potential stress incontinence.     

Development of postoperative urinary stress incontinence in clinically continent patients undergoing prophylactic Kelly plication during genitourinary prolapse repair

The present study was undertaken to evaluate the efficacy of Kelly plication in preventing postoperative urinary stress incontinence in clinically continent patients undergoing surgery for genitourinary prolapse. Thirty clinically continent patients with grade-3 genitourinary prolapse were found to have a positive stress test with repositioning of the prolapse during preoperative urodynamic evaluation. In addition to the genitourinary prolapse repair, these patients underwent a Kelly plication as a preventive measure against possible development of postoperative urinary stress incontinence. Postoperative follow-up included a detailed urogynecologic questionnaire, pelvic examination, urine culture, Q-tip cotton swab test, and a full urodynamic evaluation. The mean duration of follow-up was 25.5 ± 14.1 months. Fifteen (50%) patients developed subjective and objective postoperative stress incontinence. Eleven (37%) patients developed objective postoperative stress incontinence (proven by urodynamic evaluation) with no subjective complaints of stress incontinence. Prophylactic Kelly plication as performed by the method described does not appear to be effective in preventing postoperative urinary stress incontinence in clinically continent patients who undergo surgery for genitourinary prolapse. Neurourol. Urodynam. 18:193–198, 1999. © 1999 Wiley-Liss, Inc.     

Anatomical correction of vaginal vault prolapse by uterosacral ligament fixation in women who also require a pubovaginal sling

PURPOSE: We describe the anatomical and functional outcome in patients who underwent vaginal vault fixation to the proximal uterosacral ligaments for the treatment of vault prolapse and who also required a concomitant pubovaginal sling for associated stress urinary incontinence as well as the repair of other sector defects. MATERIALS AND METHODS: We retrospectively analyzed the records of 33 patients who underwent such repairs between November 1998 and December 2001. Endopelvic fascial defects were described using the pelvic organ prolapse quantitative system (POPQ). Outcome measures included anatomical and functional assessment of pelvic floor defects and urinary incontinence. RESULTS: Preoperatively all patients complained of a vaginal bulge and stress urinary incontinence, while 17 of the 33 had urge incontinence, and 24 and 9 had POPQ stage III or IV and stage II prolapse, respectively. Mean followup was 28 months (range 6 to 43). There was significant improvement in all POPQ measurements (p <0.05). Most notably vaginal cuff support improved by a mean of 7 cm. Stages IIAp (rectocele) and IIC (cuff) prolapse developed in 4 and 2 failed cases, respectively. Stress urinary incontinence was cured in all 33 patients and urge incontinence was cured in 14 of 17, while in 27 vaginal prolapse symptoms resolved and most had improved defecation dysfunction. No patients had urinary obstructive symptoms. There were no ureteral, bladder or rectal complications but 1 patient required blood transfusion. CONCLUSIONS: Suspension of the vaginal cuff to the proximal uterosacral ligaments with site specific repair of other associated endopelvic fascial defects provides excellent anatomical and functional correction of vault prolapse. Furthermore, a concomitant pubovaginal sling is a compatible repair for associated stress urinary incontinence. It did not compromise vaginal repair and prolapse repair did not jeopardize the outcome of the sling.     

Do Women Understand Urogynecologic Terminology?

OBJECTIVES: The aims of this study were to describe women's stated knowledge of the primary urogynecologic diagnostic terms (urinary incontinence, pelvic floor disorder, and pelvic organ prolapse) and to assess factors associated with knowledge. METHODS: Before any education about pelvic floor disorders, 376 women presenting to primary care-level gynecologic clinics were asked whether they knew what the terms urinary incontinence, pelvic organ prolapse, and pelvic floor disorder meant. χ(2) and t tests were used to compare characteristics of women with complete knowledge versus partial or no knowledge of terms. P < 0.05 was considered significant. RESULTS: Of all women, 25% knew all 3 terms and 18% knew none. Moreover, 80%, 52%, and 27% of women reported that they knew the meaning of the terms urinary incontinence, pelvic organ prolapse, and pelvic floor disorder, respectively. Of women with stress urinary incontinence symptoms, 88% knew the term urinary incontinence compared with 78% without stress urinary incontinence (P = 0.07). Of 41 women, 31 (76%) with the symptom of vaginal bulge knew the term pelvic organ prolapse compared with 49% without (P = 0.001). Only higher education and symptom of vaginal bulge were associated with complete knowledge of the 3 terms; 30% of women who completed college or higher reported complete knowledge compared with 18% who did not (P = 0.013). CONCLUSIONS: Public health campaigns using terms pelvic organ prolapse or pelvic floor disorders are unlikely to reach most women. Further education and research are needed to improve women's health literacy in urogynecology.     

同期手术治疗女性压力性尿失禁与盆腔脏器脱垂的临床研究

目的 探讨同期手术治疗女性压力性尿失禁(SUI)与盆腔脏器脱垂(POP)的适应证及治疗效果.方法 回顾性总结16例同期手术治疗SUI与POP患者的病例资料,其中有SUI症状并伴有中度以上阴道前壁膨出的患者12例,主诉阴道脱出物,检查发现子宫中度以上脱垂伴排尿困难4例,术前经查体、尿动力及膀胱造影检查确诊均存在Ⅱ型SUI.盆底修补手术包括Gynemesh网片、Prolift前片及全片植入,抗尿失禁手术采用TVT或TVT-O术,术中先行盆底修补术.结果 随访6～30个月,全部患者获满意效果,达到完全控尿,同时无排尿困难发生,未发现盆底膨出复发.结论 对合并有症状或中度以上POP的SUI患者,应积极同期处理相应的POP,以免加重POP的程度或排尿困难的发生;对单独发生的POP患者,应警惕隐性SUI的可能,同期行相应的控尿手术可避免术后SUI的发生.     

Related factors of urge,stress, mixed urinary incontinence and overactive bladder in reproductive age womenin <Emphasis Type="Bold">Tabriz,Iran</Emphasis>: a cross-sectional study

Urinary incontinence remains a pressing problem, particularly for women. So this study was conducted to assess risk factors for stress, urge, mixed urinary incontinence and overactive bladder (OVB). Three hundred and thirty women aged 15–49, non-pregnant, non-breastfeeding who were referred to gynecologic clinics were surveyed. A questionnaire was used to collect data. Women with no symptoms related to urinary incontinence (UI) and OVB served as the reference group. The risk of all types of UI and OVB increased with constipation. Posterior pelvic organ prolapse was associated with stress and urge incontinence. Vaginal delivery was a predictor of stress, urge and mixed incontinence. BMI and PID were predictors of OVB. Pelvic muscle strength was a predictor of stress incontinence. Vaginal length was associated with mixed incontinence. Optimal weight gain, having a healthy lifestyle, treatment of constipation and pelvic organ prolapse, and improving pelvic floor muscle strength can be suggested as preventive measures against UI and OVB. Pelvic measurement can be included in evaluation of UI.     

经闭孔尿道中段吊带术治疗女性压力性尿失禁的疗效分析

目的:探讨女性压力性尿失禁(SUI)的临床特征及经闭孔尿道中段吊带术(TVT-O)治疗SUI的疗效。方法:回顾性分析2009年10月至2018年6月海军军医大学第一附属医院收治的319例女性SUI患者的病例资料。中位年龄58(39~91)岁,其中≥60岁145例(45.5%)。伴高血压病96例(30.1%),糖尿病24例(7.5%)。未婚未孕2例(0.6%),有生育史317例(99.4%)。31例(9.7%)合并Ⅱ~Ⅳ度盆腔脏器脱垂。SUI中位病程5(0.2~40.0)年。中度尿失禁155例(48.6%),重度尿失禁164例(51.4%)。319例术前中位最大尿流率30(5.2~72.6)ml/s,中位尿流量380.5(56.7~1013.6)ml。术前国际尿失禁咨询委员会尿失禁问卷表简表(ICIQ-SF)中位评分14(9~19)分。288例行TVT-O。31例合并Ⅱ~Ⅳ度盆腔脏器脱垂者,一期行经闭孔四臂网片盆底修复术联合TVT-O。结果:288例TVT-O平均手术时间(32.3±8.0)(19~60)min,31例盆腔修复手术联合TVT-O平均手术时间(75.5±17.0)(50~120)min。术后随访265例,随访率83.1%,随访时间12~24个月。其中254例(95.8%)客观治愈,248例(93.6%)主观治愈,10例(3.8%)主观缓解,7例(2.6%)主观无改善。30例(96.8%)盆腔脏器脱垂治愈。术后并发症分别为腹股沟区疼痛28例(10.6%),新发尿急12例(4.5%),尿路感染9例(3.4%),排尿困难7例(2.6%),性交痛3例(1.1%),膀胱损伤、吊带侵蚀、切口瘢痕增生各1例(0.4%)。结论:女性SUI患者以中老年为主,就诊时以中重度患者为主。TVT-O治愈率高、并发症较少且大多在可控范围内。对于SUI合并中重度盆腔脏器脱垂患者,可一期行TVT-O联合盆底修复手术。     

Results of the tension-free vaginal tape procedure for the treatment of type II stress urinary incontinence at a minimum followup of 1 year

PURPOSE: We evaluated the safety and efficacy of the tension-free vaginal tape procedure for treating type II stress urinary incontinence in females. MATERIALS AND METHODS: Between April 1998 and April 1999, 62 women 28 to 86 years old (mean age 62.8) were treated consecutively for stress urinary incontinence with the tension-free vaginal tape procedure. Preoperative evaluation included history, physical examination and multichannel video urodynamics. All patients had type II stress urinary incontinence, none had preoperative detrusor instability or significant pelvic prolapse and in 16 previous surgery for stress incontinence had failed. RESULTS: All patients were followed at least 12 months after the procedure (median 16.2). A total of 42 and 20 women received spinal and local anesthesia, respectively. We noted 6 bladder perforations, including 5 in patients with a history of surgery for stress urinary incontinence. Blood loss was less than 200 cc in all cases. We observed no prolonged postoperative pain, infection or sling rejection. Post-void residual urine was less than 100 cc the day after surgery in 59 cases. Only 3 patients self-catheterized a maximum of 4 days. At followup 54 women (87.1%) were cured of stress urinary incontinence, 6 were improved (9.6%) and 2 had failure (3. 3%), while 4 (6.4%) had new onset detrusor instability without evidence of bladder outlet obstruction. CONCLUSIONS: The tension-free vaginal tape procedure appears to be a minimally invasive, safe and effective treatment for type II stress urinary incontinence. A history of surgery for stress incontinence seems to be a risk factor for bladder perforation.     

409例症状性盆腔器官脱垂手术患者基本情况及手术方式分析

目的探讨因症状性盆腔器官脱垂（pelvicorganprolapse,POP）接受手术治疗患者的年龄分布、基本情况和手术方式等特点。方法2004年4月至2010年10月在本院因POP接受手术治疗的患者共409例,回顾性分析患者基本资料及手术相关资料。结果患者平均年龄（61．9±12．0）岁（28～89岁）,体重指数（24．3±2．9）kg／m^2（16．3～35．6kg／m^2）,产次（2．2±1．2）;手术患者合并高血压、糖尿病和冠心病分别为181例（44．3％）,64例（15．6％）和46例（11．2％）;93例（22．7％）因合并压力性尿失禁（SUI）同时接受抗尿失禁手术。结论本组患者年龄、体重指数及产次偏高,与既往研究相符。因症状性POP接受手术治疗的患者内科合并症较多,手术成功进行需多科合作。POP患者合并SUI者不容忽视,术前需仔细评估,必要时同时进行抗尿失禁手术。     

Pelvic floor disorders among indigenous women living in Xingu Indian Park, Brazil

Introduction and hypothesis  Current assessment for pelvic floor disorders (PFDs) allows comparison between different communities. Methods  A total of 377 indigenous women living in Xingu Indian Park were evaluated. The pelvic organ prolapse quantification (POP-Q) was the system used to quantification the staging of pelvic support. The pelvic floor muscle strength was assessed by a perineometer. Logistic regression analysis was used to determine risk factors that were associated with prolapse. Results  Only 5.8% of women reported urinary incontinence. The overall distribution of POP-Q stage system was the following: 15.6% stage 0, 19.4% stage I, 63.9% stage II and 0.8% stage III. Parity and age were the risk factors for pelvic organ prolapse (p < 0.0001). Conclusions  Urinary incontinence was uncommon in Xingu indigenous women. Like non-indigenous communities, age and parity were the most important risk factors to the genital prolapse.     

Morphologic study on levator ani muscle in patients with pelvic organ prolapse and stress urinary incontinence

The objective of this study was to determine the morphologic changes of the levator ani muscle of patients with pelvic organ prolapse and stress urinary incontinence. Histological and histochemical analyses of the biopsy specimens of the levator ani muscle obtained from patients with stress urinary incontinence (SUI), pelvic organ prolapse (POP), and a control group were performed. The striated muscle-positive biopsy rate was 26.7% in the SUI group, 15.8% in the POP group, whereas it was 100% in the control group. The diameters of types I and II fibers decreased significantly with age and menopausal time in the control group. Splitting or fragmentation of fibers with red granules, which are called ragged-red fibers, were found in the SUI group. The diameters of levator ani muscle fibers in the control group were significantly larger than those in the SUI group (p=0.034<0.05). The degenerative change in histology and decrease in relative number of levator ani muscle might be associated with women suffering from SUI.     

Urodynamic indices and pelvic organ prolapse quantification 3?months after vaginal delivery in primiparous women

Introduction and hypothesis

This study aims to describe multichannel urodynamic indices and pelvic organ prolapse quantification (POP-Q) in primiparous women 3?months after vaginal delivery.

Methods

This was a secondary analysis of a group of women who had been randomized to either coached or non-coached pushing during the second stage of labor. Primiparous women were evaluated with POP-Q examination and multichannel urodynamic testing 3?months after vaginal delivery.

Results

Of 128 women evaluated, the cumulative stage of prolapse was distributed as 4.7% stage 0, 39% stage I, 56% stage II, and none with stage III prolapse or greater. For the anterior compartment, most had stage II prolapse. Stage I prolapse predominated for both the central and posterior compartments. Of the women, 14.1% had urodynamic stress incontinence, 12.5% had detrusor overactivity, and 6% had both.

Conclusions

In a predominantly Hispanic primiparous population, ICS POP-Q stage II prolapse of the vagina, urodynamic stress incontinence, and detrusor overactivity are common findings at a 3-month postpartum assessment.     

经闭孔无张力尿道中段吊带术联合阴道前壁修补术治疗女性压力性尿失禁

目的 评价经闭孔无张力尿道中段吊带术(TVT-O)联合阴道前壁修补术治疗合并阴道前壁脱垂的女性压力性尿失禁(stress urinary incontinence,SUI)的效果.方法 行TVT-O联合阴道前壁修补术治疗合并阴道前壁脱垂的女性压力性尿失禁18例.术后随访12个月,进行主观治疗结果及术后远期并发症的调查.术后12个月时,复查盆腔器官脱垂定量分度法(POP-Q)分期、尿流率、性生活质量评分(PISQ-12).结果 尿失禁主观治愈率为88.9%(16/18),主观改善率为11.1%(2/18).4例阴道前壁脱垂复发(术前Ⅲ期3例,Ⅱ期1例,术后均为Ⅰ期),11名有规律性生活的患者PISQ-12评分术前术后分别为27.5±4.4和31.2±6.1(P＜0.05).结论 TVT-O联合阴道前壁修补术治疗合并中度阴道前壁脱垂的女性压力性尿失禁简便易行,疗效可靠,对患者性功能无不利影响.     

Delayed onset advanced pelvic organ prolapse after pelvic trauma in a nulliparous young female: case report

Reports have shown that high-energy pelvic trauma might be associated with advanced pelvic organ prolapse in conjunction with other causes. We report the case of a 21-year-old nulliparous, premenopausal, non-overweight woman with no predisposing factors for prolapse who developed stage IV massive pelvic organ prolapse and stress urinary incontinence 4 years after a severe pelvic traumatic accident. Most likely, the pelvic trauma, as a single factor, was the causative factor for the massive procidentia. The onset on the prolapse was delayed until 4 years after the pelvic accident. The patient was managed with sacrospinous ligament hysteropexy along with anterior and posterior vaginal wall repair and perineorrhaphy. Despite satisfactory surgical management, long-term regular follow-up is still required.     

Pelvic organ prolapse and urinary incontinence in nulliparous women at the United States Military Academy

The objective of this study was to evaluate both baseline pelvic support and incontinence in relation to physical activity in nulliparous college women. Participants were examined using the pelvic organ prolapse and quantification system (POP-Q) and completed a questionnaire. Women with stage 0 prolapse and any other stage were compared. Potential risk factors and levels of physcial activity were analyzed using the chi-square test. We evaluated 144 women. Fifty percent had stage 0 support and 50% had stage I or II. Nineteen percent of participants reported incontinence. No risk factors for prolapse were identified, however running was associated with incontinence. Forty-six percent of physically active nulliparous college students had stage I pelvic support without identifiable risk factors. Stage I and II prolapse represent normal support.Presented at the annual meeting of The Society of Gynecologic Surgeons March 2003