Elastin density: Link between histological and biomechanical properties of vaginal tissue in women with pelvic organ prolapse?

Introduction and hypothesis

The aim of the study was to correlate histological and biomechanical characteristics of the vaginal wall in women with pelvic organ prolapse (POP).

Methods

Tissue samples were collected from the anterior [point Ba; POP Questionnaire (POP-Q)] and/or posterior (point Bp; POP-Q) vaginal wall of 15 women who underwent vaginal surgery for POP. Both histological and biomechanical assessments were performed from the same tissue samples in 14 of 15 patients. For histological assessment, the density of collagen and elastin fibers was determined by combining high-resolution virtual imaging and computer-assisted digital image analysis. For biomechanical testing, uniaxial tension tests were performed to evaluate vaginal tissue stiffness at low (C₀) and high (C₁) deformation rates.

Results

Biomechanical testing highlights the hyperelastic behavior of the vaginal wall. At low strains (C₀), vaginal tissue appeared stiffer when elastin density was low. We found a statistically significant inverse relationship between C₀ and the elastin/collagen ratio (p?=?0.048) in the lamina propria. However, at large strain levels (C₁), no clear relationship was observed between elastin density or elastin/collagen ratio and stiffness, likely reflecting the large dispersion of the mechanical behavior of the tissue samples.

Conclusion

Histological and biomechanical properties of the vaginal wall vary from patient to patient. This study suggests that elastin density deserves consideration as a relevant factor of vaginal stiffness in women with POP.

     

Is the levator–urethra gap helpful for diagnosing avulsion?

Introduction and hypothesis

Levator avulsion is a risk factor for female pelvic organ prolapse (POP) and recurrence after POP surgery. Imaging diagnosis requires the observation of an abnormal muscle insertion on tomographic ultrasound imaging (TUI). This study was designed to compare the diagnostic performance of the qualitative diagnosis (visual qualitative assessment) to measurement of the distance between muscle insertion and urethra [levator–urethra gap; (LUG)].

Methods

This was a retrospective analysis of data obtained in a tertiary urogynecological unit. All patients presented with symptoms of pelvic floor dysfunction and underwent 4D translabial pelvic floor ultrasound (US), supine, and after voiding. Avulsion was defined qualitatively as abnormal muscle insertion and quantitatively as LUG ≥25 mm on at least three consecutive central axial plane slices, with one examiner using both methods. We examined the correlation between both methods and validated them against clinical prolapse, significant organ descent on US, and hiatal ballooning.

Results

Between January and July 2013, 233 patients were seen, of whom 202 had complete volume data sets. The qualitative method diagnosed avulsion in 22 % and the quantitative method in 24.3 %. Agreement was good, with a kappa of 0.79 (0.70–0.87). Avulsion diagnosed by either method was associated with clinical and sonographic prolapse and hiatal ballooning, with odds ratios nonsignificantly higher for the quantitative method.

Conclusion

Qualitative analysis of slices on TUI and a method using LUG measurement show good agreement for the diagnosis of avulsion. The LUG method is at least equally as valid in its capacity to predict significant prolapse on clinical examination and US, as well as ballooning of the levator hiatus.

     

Surgery for stress urinary incontinence in Finland 1987–2009

Introduction and hypothesis

To estimate the incidence rates of stress urinary incontinence (SUI) surgery among Finnish women from 1987 to 2009 by age, and to evaluate the trends in SUI surgery.

Methods

We conducted a retrospective register-based study. All SUI procedures on adult women over age 18 years in Finland were identified from the nationwide Care Register for Health Care. Age-specific incidence rates per 1,000 women were calculated for each year. The cumulative incidence of SUI surgery was calculated.

Results

There were 38,340 procedures for SUI in 1987–2009. The overall age-adjusted incidence rate increased 2.6-fold from 0.5/1,000 women in 1987 to 1.3/1,000 in 2002, but declined thereafter by 2009 to 0.8/1,000. There was a six-fold increase in the incidence rate in the age group 60–69 years and a ten-fold increase in the age group 70–79 years from 1987 to 2002. These marked increases in operation rates coincided with the increased use of tension-free vaginal tape (TVT). In 2002, TVT accounted for 96 % of all SUI procedures. Mid-urethral slings with transobturator techniques surpassed TVT in popularity in 2007. The life-long cumulative incidence of SUI surgery was 9.9 % in 2002 and 6.3 % in 2009.

Conclusions

The incidence rates of SUI surgery increased significantly in Finland, especially among women aged 60 to 79 years. Mid-urethral slings have become the dominant procedure.

     

Oestrogen-soaked vaginal packing for decubitus ulcer in advanced pelvic organ prolapse: a case series

Introduction

Cervicovaginal decubitus ulceration is a well-known complication of advanced pelvic organ prolapse (POP). There is no consensus for its management. This case series describes the outcome of using repeated vaginal packs soaked with oestrogen cream to reduce POP and promote decubitus ulcer healing. We aimed to investigate the speed of ulcer healing and endometrial safety with this regimen.

Methods

This was a retrospective study of patients with stage 3 or 4 POP and intact uterus with decubitus ulcer who were planned for surgery that included hysterectomy after ulcer healing. Vaginal packs are replaced at least biweekly—or more frequently if extruded—until ulcer resolution.

Results

Thirteen patients were studied. Mean age was 69?±?6 years and mean duration of menopause was 19?±?6 years. Nine patients had a single ulcer and four had multiple ulcers. Mean ulcer diameter was 2.8?±?1.5 cm and mean duration for ulcer healing was 26?±?14 days. Hysterectomy and pelvic floor reconstruction was performed a median of 5 (range 0–153) days after ulcer healing was first noted. Histopathological examination of the endometrium following hysterectomy showed three specimens with endocervical hyperplasia; one had concurrent proliferative endometrium, two had simple endometrial hyperplasia and another two had proliferative endometrium.

Conclusion

Oestrogen-soaked vaginal packing is a viable option for managing a decubitus ulcer in advanced POP. We document a measurable impact on the endometrium with this short-term preoperative regimen. Further research is needed to evaluate its efficacy in promoting ulcer healing and endometrial safety.

     

Obstetric anal sphincter injuries after episiotomy: systematic review and meta-analysis

Introduction

There is conflicting evidence on whether mediolateral episiotomy (MLE) reduces the risk of obstetric anal sphincter injuries (OASI) in spontaneous vaginal deliveries (SVD).

Objectives

A systematic review was undertaken to compare rates of OASI amongst women who had undergone mediolateral episiotomy versus those who did not.

Methods

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Search strategy

Electronic searches were performed in literature databases: CINAHL, Cochrane, EMBASE, Medline and MIDIRS from database inception to July 2015. Studies were eligible if MLE was compared to spontaneous tears and if OASI was the outcome of interest.Two reviewers independently selected and extracted data on study characteristics, quality and results. We computed events of OASI in those who did and did not have an episiotomy from individual studies and pooled these results in a meta-analysis where possible.

Main results

Of the 2090 citations, 16 were included in the review. All were non-randomised, population based or retrospective cohort studies. There was great variation in quality amongst these studies. Data from 7 studies was used for meta-analysis. On collating data from these studies where the majority of women (636755/651114) were nulliparous, MLE reduced the risk of OASI (RR 0.67 95 % CI 0.49-0.92) in vaginal delivery.

Conclusion

The pooled analysis of a large number of women undergoing vaginal birth, most of who were nulliparous, indicates that MLE has a beneficial effect in prevention of OASI. An accurately given MLE might have a role in reducing OASI and should not be withheld, especially in nulliparous women. Caution is advised as the data is from non-randomised studies.

     

Safety and efficacy of single-incision sling for female stress urinary incontinence: 3 years’ results

Introduction and hypothesis

The purpose of this study was to investigate the success and complication rates of single-incision sling for treating stress urinary incontinence (SUI), with a 3-year follow-up.

Methods

This study comprised 173 female patients with SUI or mixed urinary incontinence (MUI) with dominant SUI who underwent minisling procedure. All patients had positive cough stress test preoperatively; they were followed up for 3 years after surgery (1, 3, 6, 12 months, and yearly).

Results

Total follow-up was 36 months, and mean age 51 years (44–77); 128 (74 %) patients presented SUI and 45 (26 %) MUI. Objective and subjective cure and failure rates were 83.8 % (145 cases), 6.4 % (11 cases), and 9.8 % (17 cases), respectively. There were no differences in cure rates between 1 and 3 years. Mean body mass index was 28.7 (26.1–35.2), and mean operating time 7.9 min. (6.5–11.9). There were no major intraoperative complications. Eleven patients (6.4 %) had de novo urge incontinence that resolved using anticholinergic drugs; no patient had urinary retention. Vaginal mesh extrusion was reported in nine (5.2 %) patients.

Conclusions

The minisling system attained high success rates at 3 years’ follow-up. The procedure was easy to learn and has lower complication rate.

     

Functional mapping of the pelvic floor and sphincter muscles from high-density surface EMG recordings

Introduction and hypothesis

Knowledge of the innervation of pelvic floor and sphincter muscles is of great importance to understanding the pathophysiology of female pelvic floor dysfunctions. This report presents our high-density intravaginal and intrarectal electromyography (EMG) probes and a comprehensive innervation zone (IZ) imaging technique based on high-density EMG readings to characterize the IZ distribution.

Methods

Both intravaginal and intrarectal probes are covered with a high-density surface electromyography electrode grid (8?×?8). Surface EMG signals were acquired in ten healthy women performing maximum voluntary contractions of their pelvic floor. EMG decomposition was performed to separate motor-unit action potentials (MUAPs) and then localize their IZs.

Results

High-density surface EMG signals were successfully acquired over the vaginal and rectal surfaces. The propagation patterns of muscle activity were clearly visualized for multiple muscle groups of the pelvic floor and anal sphincter. During each contraction, up to 218 and 456 repetitions of motor units were detected by the vaginal and rectal probes, respectively. MUAPs were separated with their IZs identified at various orientations and depths.

Conclusions

The proposed probes are capable of providing a comprehensive mapping of IZs of the pelvic floor and sphincter muscles. They can be employed as diagnostic and preventative tools in clinical practices.

     

Total colpocleisis: technical considerations

Introduction

We present a video describing the technical considerations for performing a total colpocleisis in the management of symptomatic post-hysterectomy pelvic organ prolapse.

Methods

A 76-year old female presented with pelvic pressure and the presence of a palpable vaginal bulge. She had significant bother and had previously failed use of a pessary. She wasnot sexually active, with no plans for future sexual activity. Her medical history was significant for coronary artery disease with prior myocardial infarction. She had high-grade vaginal vault prolapse, without occult incontinence. After discussing observation, pessaries, restorative and obliterative procedures, she elected to undergo colpocleisis. Following hydrodissection with lidocaine with epinephrine, a quadrant-based dissection was performed to remove the vaginal epithelium circumferentially. Following this, serial purse string sutures were used to reduce the prolapse, with meticulous hemostasis. The vaginal epithelium was then closed transversely. Next, a perineorrhaphy was performed. The midline was plicated and the perineal body reconstructed.

Results

The patient had an uncomplicated postoperative course. At six-week follow-up she had no evidence of recurrent prolapse and was voiding without difficulty.

Conclusions

Colpocleisis can provide excellent anatomic and subjective outcomes. Our goal is to highlight pertinent technical considerations in order to optimize patient outcomes.

     

Trends in internet search activity,media coverage,and patient-centered health information after the FDA safety communications on surgical mesh for pelvic organ prolapse

Introduction

In July 2011, the US Food and Drug Administration (FDA) issued a safety communication regarding serious complications associated with surgical mesh for pelvic organ prolapse, prompting increased media and public attention. This study sought to analyze internet search activity and news article volume after this FDA warning and to evaluate the quality of websites providing patient-centered information.

Methods

Google Trends? was utilized to evaluate search engine trends for the term “pelvic organ prolapse” and associated terms between 1 January 2004 and 31 December 2014. Google News? was utilized to quantify the number of news articles annually under the term “pelvic organ prolapse.” The search results for the term “pelvic organ prolapse” were assessed for quality using the Health On the Net Foundation (HON) certification.

Results

There was a significant increase in search activity from 37.42 in 2010 to 57.75 in 2011, at the time of the FDA communication (p?=?0.021). No other annual interval had a statistically significant increase in search activity. The single highest monthly search activity, given the value of 100, was August 2011, immediately following the July 2011 notification, with the next highest value being 98 in July 2011. Linear regression analysis of news articles per year since the FDA communication revealed r²?=?0.88, with a coefficient of 186. Quality assessment demonstrated that 42 % of websites were HON-certified, with .gov sites providing the highest quality information.

Conclusions

Although the 2011 FDA safety communication on surgical mesh was associated with increased public and media attention, the quality of relevant health information on the internet remains of poor quality. Future quality assurance measures may be critical in enabling patients to play active roles in their own healthcare.

     

Recurrent pelvic organ prolapse: International Urogynecological Association Research and Development Committee opinion

Introduction and hypothesis

This committee opinion paper summarizes available evidence about recurrent pelvic organ prolapse (POP) to provide guidance on management.

Method

A working subcommittee from the International Urogynecological Association (IUGA) Research and Development Committee was formed. The literature regarding recurrent POP was reviewed and summarized by individual members of the subcommittee. Recommendations were graded according to the 2009 Oxford Levels of Evidence. The summary was reviewed by the Committee.

Results

There is no agreed definition for recurrent POP and evidence in relation to its evaluation and management is limited.

Conclusion

The assessment of recurrent POP should entail looking for possible reason(s) for failure, including persistent and/or new risk factors, detection of all pelvic floor defects and checking for complications of previous surgery. The management requires individual evaluation of the risks and benefits of different options and appropriate patient counseling. There is an urgent need for an agreed definition and further research into all aspects of recurrent POP.