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Filippini M, Bugli S, Biordi N, Muccioli F, Reggini V, Benedettini M, Migliore S, Pieri L, Comito A, Pennati BM, Fusco I, Isaza PG, Dominguez AP, Zingoni T, Farinelli M. Myostatin Changes in Females with UI after Magnetic Stimulation: A Quasi-Experimental Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1399. [PMID: 39336440 PMCID: PMC11434281 DOI: 10.3390/medicina60091399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 07/01/2024] [Accepted: 08/08/2024] [Indexed: 09/30/2024]
Abstract
Background and Objectives: Urinary incontinence (UI) is the involuntary loss of urine caused by a weakness in the pelvic floor muscles (PFMs) that affects urethral closure. Myostatin, which prevents the growth of muscles, is a protein expressed by human skeletal muscle cells. Indeed, it has been observed that myostatin concentration rises during skeletal muscle inactivity and that suppressing serum myostatin promotes muscle growth and strength. Furthermore, therapeutic interventions that reduce myostatin signalling may lessen the effects of aging on skeletal muscle mass and function. For this reason, the aim of the study was to assess if flat magnetic stimulation technology affects serum myostatin levels, as myostatin can block cell proliferation at the urethral sphincter level. Materials and Methods: A total of 19 women, 75% presenting stress urinary incontinence (SUI) and 25% urgency urinary incontinence (UUI), were enrolled. A non-invasive electromagnetic therapeutic system designed for deep pelvic floor area stimulation was used for eight sessions. Results: The ELISA (enzyme linked immunosorbent assay) test indicated that the myostatin levels in blood sera had significantly decreased. Patients' ultrasound measurements showed a significant genital hiatus length reduction at rest and in a stress condition. The Pelvic Floor Bother Questionnaire consistently revealed a decrease in mean scores when comparing the pre- and post-treatment data. Conclusions: Effective flat magnetic stimulation reduces myostatin concentration and genital hiatus length, minimizing the severity of urinary incontinence. The results of the study show that without causing any discomfort or unfavourable side effects, the treatment plan significantly improved the PFM tone and strength in patients with UI.
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Affiliation(s)
- Maurizio Filippini
- Department of Obstetrics and Gynaecology, Hospital State of Republic of San Marino, 47893 San Marino, San Marino
| | - Simona Bugli
- Department of Obstetrics and Gynaecology, Hospital State of Republic of San Marino, 47893 San Marino, San Marino
| | - Nicoletta Biordi
- Department of Obstetrics and Gynaecology, Hospital State of Republic of San Marino, 47893 San Marino, San Marino
| | - Fausto Muccioli
- Department of Transfusion Medicine and Clinical Pathology, Hospital State of Republic of San Marino, 47893 San Marino, San Marino
| | - Valentina Reggini
- Department of Transfusion Medicine and Clinical Pathology, Hospital State of Republic of San Marino, 47893 San Marino, San Marino
| | - Milena Benedettini
- Department of Transfusion Medicine and Clinical Pathology, Hospital State of Republic of San Marino, 47893 San Marino, San Marino
| | - Serena Migliore
- Department of Obstetrics and Gynaecology, Hospital State of Republic of San Marino, 47893 San Marino, San Marino
| | | | | | | | | | - Pablo Gonzalez Isaza
- Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics and Gynecology, San Jorge University Hospital, Pereira 660002, Colombia
| | - Antonio Posada Dominguez
- Colsposcopy Unit, Department Obstetrics and Gynecology, Centro Hospitalario La Concepcion, Saltillo 25230, Mexico
| | | | - Miriam Farinelli
- Department of Obstetrics and Gynaecology, Hospital State of Republic of San Marino, 47893 San Marino, San Marino
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Chang OH, Ferrando CA, Paraiso MFR, Propst K. Dynamic Changes of the Genital Hiatus at the Time of Prolapse Surgery: 1-Year Follow-Up Study. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024:02273501-990000000-00250. [PMID: 38990755 DOI: 10.1097/spv.0000000000001537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
IMPORTANCE The genital hiatus (GH) has been identified as a predictor of pelvic organ prolapse. An enlarged preoperative GH is a risk factor for recurrent prolapse after surgery. OBJECTIVE The objective of this study was to determine the changes in preoperative and postoperative GH size compared with the intraoperative resting GH at 6 weeks and 12 months after native-tissue pelvic organ prolapse surgery. STUDY DESIGN This was a descriptive analysis of a prospective cohort study of women undergoing native-tissue prolapse repair with apical suspension. Resting GH was obtained at the start and conclusion of surgery. Measurements were obtained preoperatively, and 6 weeks and 12 months postoperatively under Valsalva maneuver. Comparisons were made using paired t tests for the following time points: (1) preoperative measurements under Valsalva maneuver to resting presurgery measurements under anesthesia, and (2) resting postsurgery measurements under anesthesia to 6 weeks and 12 months postoperatively under Valsalva maneuver. RESULTS Sixty-seven patients were included, with a median age of 66 years and median body mass index (calculated as weight in kilograms divided by height in meters squared) of 29.1. There was no significant difference in GH when measured preoperatively to resting presurgical measurements under anesthesia (P = 0.60). For all, the median GH was 3.0 cm at the conclusion of surgery and remained at 3.0 cm at 6 weeks and 12 months postoperatively. In patients who had a concurrent posterior colporrhaphy, the median resting postsurgery GH was 3.0 cm, then decreased to 2.5 cm at 6 weeks then 3.5 cm at 12 months under Valsalva. CONCLUSIONS Preoperative GH size under Valsalva maneuver and resting under anesthesia were comparable. For all patients undergoing native-tissue pelvic organ prolapse repair, the genital hiatus size remains the same from the intraoperative final resting measurements to the 6-week and 12-month measurements under Valsalva maneuver.
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Affiliation(s)
- Olivia H Chang
- From the Center for Pelvic Floor Disorders Research, Division of Female Urology, Pelvic Reconstruction and Voiding Dysfunction, Department of Urology, University of California Irvine, Irvine, CA
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Marie Fidela R Paraiso
- Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Katie Propst
- Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland Clinic, Cleveland, OH
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DeLancey JOL, Masteling M, Pipitone F, LaCross J, Mastrovito S, Ashton-Miller JA. Pelvic floor injury during vaginal birth is life-altering and preventable: what can we do about it? Am J Obstet Gynecol 2024; 230:279-294.e2. [PMID: 38168908 PMCID: PMC11177602 DOI: 10.1016/j.ajog.2023.11.1253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024]
Abstract
Pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. These disorders require 10 times as many operations as anal sphincter injuries. Imaging shows that injuries of the levator ani muscle, perineal body, and membrane occur in up to 19% of primiparous women. During birth, the levator muscle and birth canal tissues must stretch to more than 3 times their original length; it is this overstretching that is responsible for the muscle tear visible on imaging rather than compression or neuropathy. The injury is present in 55% of women with prolapse later in life, with an odds ratio of 7.3, compared with women with normal support. In addition, levator damage can affect other aspects of hiatal closure, such as the perineal body and membrane. These injuries are associated with an enlarged urogenital hiatus, now known as antedate prolapse, and with prolapse surgery failure. Risk factors for levator injury are multifactorial and include forceps delivery, occiput posterior birth, older maternal age, long second stage of labor, and birthweight of >4000 g. Delivery with a vacuum device is associated with reduced levator damage. Other steps that might logically reduce injuries include manual rotation from occiput posterior to occiput anterior, slow gradual delivery, perineal massage or compresses, and early induction of labor, but these require study to document protection. In addition, teaching women to avoid pushing against a contracted levator muscle would likely decrease injury risk by decreasing tension on the vulnerable muscle origin. Providing care for women who have experienced difficult deliveries can be enhanced with early recognition, physical therapy, and attention to recovery. It is only right that women be made aware of these risks during pregnancy. Educating women on the long-term pelvic floor sequelae of childbirth should be performed antenatally so that they can be empowered to make informed decisions about management decisions during labor.
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Affiliation(s)
- John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.
| | - Mariana Masteling
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI
| | - Fernanda Pipitone
- Faculty of Medicine, Hospital das Clinicas of the University of São Paulo, São Paulo, Brazil
| | - Jennifer LaCross
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Sara Mastrovito
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - James A Ashton-Miller
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI
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Szymański JK, Starzec-Proserpio M, Bartosińska-Raczkiewicz D, Krawczyk A, Kukulski P, Jakiel G. Impact of preoperative pelvic floor muscle function on the success of surgical treatment of pelvic organ prolapse. Int Urogynecol J 2024; 35:85-93. [PMID: 37819368 PMCID: PMC10811015 DOI: 10.1007/s00192-023-05653-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/05/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective of this study was to identify the potential characteristics of pelvic floor muscles (PFM) in the preoperative assessment that could be associated with post-surgical prolapse severity. We hypothesized that the same variables, if identified, could be addressed in preoperative rehabilitation to improve surgical results. METHODS This was a single-center prospective observational study that included women who underwent surgical pelvic organ prolapse repair between 2020-2022. Genital prolapse was evaluated according to the Pelvic Organ Prolapse Quantification (POP-Q) system. All the participants underwent a PFM assessment, including a vaginal digital assessment and manometry (Peritron™ 9300 V) before surgery and at 1-, 3-, and 6-month follow-ups. Several PFM variables were recorded: vaginal resting pressure, vaginal pressure during maximal voluntary contraction (MVC), area under the curve during a 10-second MVC, ability to correctly contract the PFMs, and reflexive activation during cough and relaxation. The primary endpoint of the analysis was objective surgical success defined as POP-Q 0 or 1 at the 6-month follow-up. Additionally, a change in pelvic floor muscle function was recorded during postoperative visits. RESULTS A total of 106 females were included in the study. Fifty-one were lost during the 6-month follow-up, which is a major limitation of the study. None of the examined parameters evaluating PFM were associated with surgical success. No statistically significant difference was found in MVC and PFM endurance before and after surgery. Post-surgery, a significant change was observed in the vaginal resting pressure and the ability to correct PFM activation and relaxation. CONCLUSIONS Preoperative PFM function is not associated with surgical success 6 months after surgery.
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Affiliation(s)
- Jacek Krzysztof Szymański
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Żelazna 90 Str., 01-004, Warsaw, Poland.
| | | | | | - Agata Krawczyk
- Department of Rehabilitation, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Kukulski
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Żelazna 90 Str., 01-004, Warsaw, Poland
| | - Grzegorz Jakiel
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Żelazna 90 Str., 01-004, Warsaw, Poland
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Casas-Puig V, Yao M, Propst KA, Ferrando CA. Is there an association between 6-month genital hiatus size and 24-month composite prolapse recurrence following minimally invasive sacrocolpopexy? Int Urogynecol J 2023; 34:2593-2601. [PMID: 37401961 DOI: 10.1007/s00192-023-05578-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/08/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Although an enlarged postoperative genital hiatus (GH) size has been identified as a predictor of recurrence following pelvic organ prolapse (POP) surgery, the protective role of concurrent level III support procedures to reduce the GH size at the time of minimally invasive sacrocolpopexy (MI-SCP) remains unclear. The objective of this study was to compare 24-month composite prolapse recurrence following MI-SCP between patients with a 6-month postoperative GH measurement of <3 cm versus ≥3 cm; and to explore the impact of concurrent level III support procedures on prolapse recurrence, bowel, and sexual function. METHODS This was a secondary analysis of two randomized controlled trials of women who underwent MI-SCP from 2014 to 2020. Our primary outcome was composite prolapse recurrence defined as retreatment with either pessary or surgery, and/or subjective bothersome vaginal bulge. A receiver operating characteristic (ROC) curve was generated to identify a 6-month GH cutoff point associated with 24-month composite recurrence. RESULTS Of the 108 women who met the inclusion criteria, 13 (12%) had composite prolapse recurrence at 24 months: 12 patients (11.1%) reported a bothersome vaginal bulge, and 3 patients (2.8%) underwent retreatment with surgery. A ROC curve demonstrated that a 6-month postoperative GH size of 3 cm had 84.6% sensitivity to predict vaginal bulge and/or retreatment at 24 months (area under curve = 0.52). There was no difference in the composite prolapse recurrence between the groups; however, only patients with a 6-month GH >3 cm underwent retreatment. CONCLUSIONS Twenty-four-month composite prolapse recurrence does not differ based on 6-month GH size; however, surgical failure may be more common in those with a GH size greater than 3 cm.
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Affiliation(s)
- Viviana Casas-Puig
- Division of Female Pelvic Medicine and Reconstructive Surgery, Advent Health, 960 Rinehart Road, Lake Mary, FL, USA.
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Katie A Propst
- Urogynecology & Reconstructive Pelvic Surgery, Obstetrics & Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Cecile A Ferrando
- Center for Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
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Bradley MS, Sridhar A, Ferrante K, Andy UU, Visco AG, Florian-Rodriguez ME, Myers D, Varner E, Mazloomdoost D, Gantz MG. Association Between Enlarged Genital Hiatus and Composite Surgical Failure After Vaginal Hysterectomy With Uterosacral Ligament Suspension. UROGYNECOLOGY (PHILADELPHIA, PA.) 2023; 29:479-488. [PMID: 36701331 PMCID: PMC10132998 DOI: 10.1097/spv.0000000000001309] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE The impact of a persistently enlarged genital hiatus (GH) after vaginal hysterectomy with uterosacral ligament suspension on prolapse outcomes is currently unclear. OBJECTIVES This secondary analysis of the Study of Uterine Prolapse Procedures Randomized trial was conducted among participants who underwent vaginal hysterectomy with uterosacral ligament suspension. We hypothesized that women with a persistently enlarged GH size would have a higher proportion of prolapse recurrence. STUDY DESIGN Women who underwent vaginal hysterectomy with uterosacral ligament suspension as part of the Study of Uterine Prolapse Procedures Randomized trial (NCT01802281) were divided into 3 groups based on change in their preoperative to 4- to 6-week postoperative GH measurements: (1) persistently enlarged GH, 2) improved GH, or (3) stably normal GH. Baseline characteristics and 2-year surgical outcomes were compared across groups. A logistic regression model for composite surgical failure controlling for advanced anterior wall prolapse and GH group was fitted. RESULTS This secondary analysis included 81 women. The proportion with composite surgical failure was significantly higher among those with a persistently enlarged GH (50%) compared with a stably normal GH (12%) with an unadjusted risk difference of 38% (95% confidence interval, 4%-68%). When adjusted for advanced prolapse in the anterior compartment at baseline, the odds of composite surgical failure was 6 times higher in the persistently enlarged GH group compared with the stably normal group (95% confidence interval, 1.0-37.5; P = 0.06). CONCLUSION A persistently enlarged GH after vaginal hysterectomy with uterosacral ligament suspension for pelvic organ prolapse may be a risk factor for recurrent prolapse.
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Affiliation(s)
- Megan S Bradley
- From Obstetrics & Gynecology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Amaanti Sridhar
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
| | - Kimberly Ferrante
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Diego, San Diego, CA
| | - Uduak U Andy
- Obstetrics & Gynecology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | | | - Deborah Myers
- Obstetrics & Gynecology, Alpert Medical School of Brown University, Providence, RI
| | - Edward Varner
- Obstetrics & Gynecology, University of Alabama School of Medicine, Birmingham, AL
| | - Donna Mazloomdoost
- Gynecologic Health and Disease Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) National Institutes of Health (NIH), Bethesda, MD
| | - Marie G Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
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Surgical outcomes in patients aged 70 years and older following uterosacral ligament suspension: a comparative study. Arch Gynecol Obstet 2023; 307:2033-2040. [PMID: 36840767 DOI: 10.1007/s00404-023-06974-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 02/09/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE The number of elderly patients bothered by pelvic organ prolapse symptoms is growing rapidly. The aim of this study was to evaluate the relationship between age and surgical outcomes in women undergoing uterosacral ligament suspension for treatment of apical prolapse. METHODS We performed a retrospective cohort study including women who underwent uterosacral ligament suspension between 2010 and 2020. The cohort was divided into two groups: (1) Patients 70 years or older; (2) Patients under the age of 70. Outcome measures included clinical, anatomical, and composite outcomes as well as patient satisfaction. RESULTS A total of 271 patients were included in the final analysis. Of them 209 patients were under age 70 and 62 patients 70 years or older. Mean age was 59 ± 6 vs. 73 ± 3 for the young and elderly age groups, respectively. Clinical success was high for both groups, reaching 94% vs. 89% for elderly and young patients, respectively (p = 0.34). Anatomical and composite outcome success were higher in the young age group (76% vs. 56%, p < 0.01 and 70% vs. 54%, p = 0.02, respectively); however, following multivariate analysis these differences were no longer statistically significant. Following multivariate logistic regression analysis for the dependent parameter of anatomical success, increased pre-operative genital hiatus and vaginal surgical route were associated with anatomical failure while performing a concomitant posterior colporrhaphy increased likelihood for anatomical success. CONCLUSION Women over the age of 70 undergoing uterosacral ligament suspension for treatment of apical prolapse have comparable outcomes to younger patients.
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Mothes AR, Raguse I, Kather A, Runnebaum IB. Native-tissue pelvic organ prolapse (POP) repair with perineorrhaphy for level III support results in reduced genital hiatus size and improved quality of life in sexually active and inactive patients. Eur J Obstet Gynecol Reprod Biol 2023; 280:144-149. [PMID: 36493583 DOI: 10.1016/j.ejogrb.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/06/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Recent findings address the importance of Level III defects with increased genital hiatus being associated with pelvic organ prolapse (POP), correlated with Level I defects and strongly related to POP recurrence. We hypothesised that concomitant perineorrhaphy in POP repair reduces genital hiatus (gh) and increases perineal body (pb), that gh would be larger with number of vaginal deliveries and that patients' QOL was not different comparing sexually active vs inactive patients with overall judgement of cure comparable to the literature at evaluation. METHODS Retrospective observational study including consecutive patients with indications for posterior repair and Level III support between 2016 and 2018. Concomitant perineorrhaphy was indicated due to complaints of wide introitus or genital hiatus of ≥ 3.5 cm. Primary objective was to compare pre- and postoperative gh and pb according to POP-Q. Secondary objectives were preoperative gh and pb values by parity, POMs obtained with P-QOL/D comparing sexually active vs inactive patients, and subjective judgement of cure according to EGGS system. RESULTS In n = 121 patients, mean gh value was reduced postoperatively by 29.5 % (31 ± 6 vs 44 ± 10 mm, p < 0.001), mean pb value increased by 25.5 % (47 ± 8 vs 35 ± 8 mm, p < 0.001). Influence of parity on preoperative gh (p = 0.020), but not pb values (p = 0.119) was observed. All P-QOL/D domain scores improved significantly postoperatively without differences seen in sexually active vs inactive patients. EGGS responses indicated partial/full goal achievement in 90 % and cure in 87 %. CONCLUSIONS In the study cohort, perineorrhaphy as concomitant in POP repair led to Level III support reflected by decreased genital hiatus size. Functional QOL was improved regardless of sexual activity status and the majority of patients reported partial or full cure.
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Affiliation(s)
- Anke R Mothes
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747 Jena, Germany; Department of Gynaecology, St. Georg Hospital Eisenach, Academic Teaching Hospital of Friedrich-Schiller-University Jena, Eisenach, Germany
| | - Isabel Raguse
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747 Jena, Germany; Department of Traumatology, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Angela Kather
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Ingo B Runnebaum
- Department of Gynaecology and Reproductive Medicine, Jena University Hospital, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747 Jena, Germany.
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Comparison of the Perineal Body Between Chinese Women With Pelvic Organ Prolapse and Women With Normal Support by Magnetic Resonance Imaging With 3-Dimensional Reconstruction. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 28:778-785. [PMID: 36288117 DOI: 10.1097/spv.0000000000001244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE This study aimed to determine whether the perineal body (PB) is different between women with and without prolapse and to analyze its association with prolapse. METHODS This cross-sectional observational study was performed in a tertiary-level urology department and included patients with stage II-IV pelvic organ prolapse (POP) and normal controls with all points 1 cm or more above the hymen. The patients underwent supine midsagittal magnetic resonance imaging (MRI) at rest and during the maximum Valsalva maneuver. Perineal mobility and PB length, height, perimeter, and area were measured; in addition, the genital hiatus and PB were measured according to the definition of the Pelvic Organ Prolapse Quantification system. Univariate associations of POP with characteristics were assessed using the chi-square test or Fisher exact test for categorical variables and the t test for continuous variables. Multivariate logistic regression analysis was used to estimate the adjusted odds ratios and 95% confidence intervals. RESULTS Seventy-two controls and 130 patients were analyzed. The PB length, height, and area measurements were significantly lower in the POP group. The perineal mobility in different directions was significantly higher in the POP group. Multivariate analysis demonstrated that the PB area and perineal mobility in the ventral-dorsal and cranio-caudal directions were associated with POP. CONCLUSIONS Our data suggest that a smaller PB area and greater dorsal or caudal mobility are associated with prolapse.
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Chen L, Schmidt P, DeLancey JO, Swenson CW. Analysis of long-term structural failure after native tissue prolapse surgery: a 3D stress MRI-based study. Int Urogynecol J 2022; 33:2761-2772. [PMID: 34626202 PMCID: PMC8993938 DOI: 10.1007/s00192-021-04925-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/12/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We sought to identify postoperative structural failure sites associated with long-term prolapse recurrence and their association with symptoms and satisfaction. METHODS Women who had a research MRI prior to native-tissue prolapse surgery were recruited for examination, 3D stress MRI, and questionnaires. Recurrence was defined by Pelvic Organ Prolapse Quantification System (POP-Q)Ba/Bp > 0 or C > -4. Measurements were performed at rest and maximum Valsalva ("strain") including vaginal length, apex location, urogenital hiatus (UGH), and levator hiatus (LH). Measures were compared between subjects and to women with normal support. Failure frequency was the proportion of women with measurements outside the normal range. Symptoms and satisfaction were measured using validated questionnaires. RESULTS Thirty-one women participated 12.7 years after surgery-58% with long-term success and 42% with recurrence. Failure site comparisons between success and failure were: impaired mid-vaginal paravaginal support (62% vs. 28%, p = 0.01), longer vaginal length (54% vs. 22%, p = 0.03), and enlarged urogenital hiatus (54% vs. 22%, p = 0.03). Apical paravaginal location had the lowest failure frequency (recurrence: 15% vs. success: 7%, p = 0.37). Patient satisfaction was high (recurrence: 5.0 vs. success: 5.0, p = 0.86). Women with bothersome bulge symptoms had a 33% larger UGH strain on POP-Q (p = 0.01), 8.7% larger resting UGH (p = 0.046), 11.5% larger straining LH (p = 0.01), and 9.3% larger resting LH (p = 0.01). CONCLUSIONS Abnormal low mid-vaginal paravaginal location (Level II), long vaginal length (Level II), and large UGH (Level III) were associated with long-term prolapse recurrence. Patient satisfaction was high and unrelated to anatomical recurrence. Bothersome bulge symptoms were associated with hiatus enlargement.
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Affiliation(s)
- Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA.
- Pelvic Floor Research Group, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - Payton Schmidt
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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11
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Chang OH, Yao M, Ferrando CA, Paraiso MFR, Propst K. Determining the Ideal Intraoperative Resting Genital Hiatus Size-Balancing Surgical and Functional Outcomes. Female Pelvic Med Reconstr Surg 2022; 28:649-657. [PMID: 35830588 DOI: 10.1097/spv.0000000000001227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE The intraoperative resting genital hiatus (GH) size can be surgically modified but its relationship to prolapse recurrence is unclear. OBJECTIVES The objective of this study was to identify the optimal intraoperative resting GH size as it relates to prolapse recurrence and functional outcomes at 1 year. STUDY DESIGN This prospective cohort study was conducted at 2 hospitals from 2019 to 2021. Intraoperative measurements of the resting GH, perineal body, and total vaginal length were collected. The composite primary outcome consisted of anatomic recurrence, subjective recurrence, and/or conservative or surgical retreatment at 1 year. Comparisons of anatomic, functional, and sexual outcomes were compared between patients stratified by the optimal intraoperative GH size identified by receiver operating characteristic curve analysis. RESULTS Sixty-eight patients (median age of 63 years) underwent surgery, with 59 (86.8%) presenting for follow-up at 1 year. Based on the 13 patients (22%) with composite recurrence, receiver operating characteristic curve analysis demonstrated an intraoperative resting GH size of 3 cm, had 76.9% sensitivity (confidence interval [CI], 54-99.8%), and 34.8% specificity (CI, 21.0-48.5%) for composite recurrence at 1 year (area under curve = 0.61). Nineteen patients had an intraoperative GH less than 3 cm (32.2%) and 40 had a GH of 3 cm or greater (67.8%). The intraoperative resting GH size was significantly larger in patients with prolapse beyond the hymen at 1 year (4 cm [3.0, 4.0]) compared with those with prolapse at or proximal to the hymen (3.0 cm [2.5, 3.5], P = 0.009). CONCLUSIONS Intraoperative GH size may not reliably predict composite prolapse recurrence at 1 year, although there was an association between intraoperative resting GH size with prolapse beyond the hymen.
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Affiliation(s)
- Olivia H Chang
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Cecile A Ferrando
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
| | - Marie Fidela R Paraiso
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
| | - Katie Propst
- From the Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute
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Serrano S, Henriques A, Valentim-Lourenço A, Pereira I. Levator ani muscle avulsion in patients with pelvic floor dysfunction – does it help in understanding pelvic organ prolapse? Eur J Obstet Gynecol Reprod Biol 2022; 279:140-145. [DOI: 10.1016/j.ejogrb.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022]
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Liu Z, Sharen G, Wang P, Chen L, Tan L. Clinical and pelvic floor ultrasound characteristics of pelvic organ prolapse recurrence after transvaginal mesh pelvic reconstruction. BMC Womens Health 2022; 22:102. [PMID: 35379231 PMCID: PMC8981864 DOI: 10.1186/s12905-022-01686-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/28/2022] [Indexed: 11/29/2022] Open
Abstract
Background Recurrence of pelvic organ prolapse (POP) after transvaginal mesh (TVM) implantation pelvic floor reconstruction surgery remains an unresolved problem in clinical practice. In this retrospective observational study, clinical and pelvic floor ultrasound (PFUS) parameters were analyzed in order to identify high-risk factors of POP recurrence.
Methods The clinical and PFUS data from September 2013 to November 2019 of patients who underwent TVM were retrospectively analyzed. The patients with prolapse recurrence on postoperative follow-up diagnosed by PFUS were selected as case group, the clinical and PFUS parameters of them were compared with the control group in which the patients had no sign of prolapse recurrence. Univariate and multivariate regression analyses were performed based on age, BMI, gravidity, parity, surgical history (non-POP hysterectomy and incontinence-or-POP surgery), preoperative POP stage, follow-up in years, levator avulsion and hiatal area (HA) on Valsalva. Results Altogether 102 patients entered the study and the median interval between PFUS and TVM surgery was 2.5 years. Univariate analysis showed that levator avulsion and HA were significantly different between case group and control; multivariate regression analysis showed that only HA was related to prolapse recurrence after TVM (OR = 1.202, 95% CI 1.100–1.313, P < 0.001). The area under the ROC curve was 0.775 (95% CI 0.684–0.867, P < 0.001). Conclusions Hiatal area on Valsalva was related to prolapse recurrence after TVM surgery and it is an important parameter for postoperative follow-up of TVM surgery.
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Affiliation(s)
- Zhenzhen Liu
- Department of Ultrasound Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Gaowa Sharen
- Department of Health Management, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China
| | - Pan Wang
- Department of Ultrasound, The Sixth Hospital of Beijing, Beijing, China
| | - Liyuan Chen
- Department of Ultrasound, Bozhou People's Hospital Affiliated to Anhui University of Technology, Anhui Province, China
| | - Li Tan
- Department of Ultrasound Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing, China.
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Nyhus MØ, Mathew S, Salvesen KÅ, Volløyhaug I. The impact of levator ani muscle trauma and contraction on recurrence after prolapse surgery. Int Urogynecol J 2022; 33:2879-2885. [PMID: 35347367 PMCID: PMC9477913 DOI: 10.1007/s00192-022-05168-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/02/2022] [Indexed: 12/01/2022]
Abstract
Introduction and hypothesis The objective was to explore the impact of levator ani muscle (LAM) trauma and pelvic floor contraction on symptoms and anatomy after pelvic organ prolapse (POP) surgery. Methods Prospective study including 200 women with symptomatic POP ≥ grade 2 examined 3 months prior to and 6 months after surgery. Prolapse in each compartment was graded using the Pelvic Organ Prolapse Quantification (POP-Q) system, and women answered yes/no to a question about bulge sensation. Pelvic floor muscle contraction was assessed with transperineal ultrasound measuring proportional change in levator hiatal anteroposterior diameter from rest to contraction. LAM trauma was diagnosed using tomographic ultrasound imaging. Statistical analysis was performed using multivariate logistic regression analysis. Results A total of 183 women (92%) completed the study. Anatomical recurrence (POP ≥ grade 2) was found in 76 women (42%), and a bulge sensation was reported by 35 (19%). Ninety-two women (50%) had LAM trauma, and this was associated with increased risk of anatomical recurrence (OR 2.1 (95% CI 1.1–4.1), p = 0.022), but not bulge sensation (OR 1.1 (95% CI 0.5–2.4), p = 0.809). We found a reduced risk of bulge sensation for women with absent to weak contraction compared with normal to strong contraction (OR 0.4 (95% CI 0.1–0.9), p = 0.031), but no difference in risk for POP ≥ 2 after surgery (OR 1.5 (95% CI 0.8–2.9), p = 0.223). Conclusions Levator ani muscle trauma was associated with increased risk of anatomical failure 6 months after POP surgery. Absent to weak pelvic floor muscle contraction was associated with reduced risk of bulge sensation after surgery.
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Schmidt P, Chen L, DeLancey JO, Swenson CW. Preoperative level II/III MRI measures predicting long-term prolapse recurrence after native tissue repair. Int Urogynecol J 2022; 33:133-141. [PMID: 34043048 PMCID: PMC8626527 DOI: 10.1007/s00192-021-04854-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/09/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION AND HYPOTHESIS To identify preoperative level II/III MRI measures associated with long-term recurrence after native tissue prolapse repair. METHODS Women who previously participated in pelvic floor research involving MRI prior to undergoing primary native tissue prolapse repair were recruited to return for repeat examination and MRI. Recurrence was defined by POP-Q (Ba/Bp > 0 or C > -4), repeat surgery, or pessary use. Preoperative MR images were used to perform five level II/III measurements including a new levator plate (LP) shape analysis at rest and maximal Valsalva. Principal component analysis (PCA) was used to evaluate LP shape variations. Principal component scores calculated for two independent shape variations were noted. RESULTS Thirty-five women were included with a mean follow-up of 13.2 ± 3.3 years. Nineteen (54%) were in the success group. There were no statistical differences between success versus recurrence groups in demographic, clinical, or surgical characteristics. Women with recurrence had a larger preoperative resting levator hiatus [median 6.4 cm (IQR 5.7, 7.1) vs. 5.8 cm (IQR 5.3, 6.3), p = 0.03]. This measure was associated with increased odds of recurrence (OR 8.2, CI 1.4-48.9, p = 0.02). Using PCA, preoperative LP shape PC1 scores were different between success and recurrence groups (p = 0.02), with a more dorsally oriented LP shape associated with recurrence. CONCLUSIONS Larger preoperative levator hiatus at rest and a more dorsally oriented levator plate shape were associated with prolapse recurrence at long-term follow-up. For every 1 cm increase in preoperative resting levator hiatus, the odds of long-term prolapse recurrence increases 8-fold.
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Affiliation(s)
- Payton Schmidt
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
| | - John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, 1500 E. Medical Center Dr., Ann Arbor, MI, 48109, USA
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Ekmez M, Ekmez F. Effect of anogenital distance on stress urinary incontinence. AFRICAN JOURNAL OF UROLOGY 2021. [DOI: 10.1186/s12301-021-00247-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To clarify the effect of anogenital distance (AGD) on stress urinary incontinence (SUI) in female patients.
Methods
Charts of patients who admitted to urogynecology polyclinic between December 2020 and February 2021 were analyzed retrospectively. The AGD parameters including anogenital distance from the anus to the clitoris (AGDAC), anogenital distance from the anus to the fourchette (AGDAF) and genital hiatus (GH) were measured. To identify effect of ADG parameters on SUI, patients were divided into the two subgroups (patients with SUI and without SUI). Demographic characteristics of patients and perineal anatomy measurement were compared between groups.
Results
Totally, 256 female patients met study inclusion criteria. In comparison of patients with and without SUI, demonstrated that age, weight, height, and BMI were similar between groups (p = 0.200, p = 0.455, p = 0.131, and p = 0.215, respectively). The AGDAF was measured 22.6 mm in patients with SUI and 25.5 mm in patients without SUI (p = 0.014). In contrast, AGDAC was significantly longer in patients with SUI (81.1 mm vs. 72.2 mm, p = 0.001). Also, GH was significantly longer in patients with SUI (p = 0.016). Multivariate logistic regression analysis revealed that one mm increment in AGDAC and GH, is associated with 1.108- and 1.038-fold time of SUI development risk, respectively (p = 0.001 and p = 0.004). In contrast, decrease in AGDAF is resulted with significantly higher risk for SUI (p = 0.001).
Conclusion
The present study demonstrated that shorter AGDAF, and longer AGDAC and GH were resulted with significantly higher incidence of SUI. Considering the ease and non-invasiveness of anogenital distance measurement, an important implication of the results of current study is that it is a measurement that can be easily performed during routine gynecological and obstetric examinations as a suitable tool for use in the prediction of women who will develop stress incontinence in the future.
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Schmidt P, Cox CK, DeLancey JO, Suresh S, Horner W, Chen L, Swenson CW. Does preoperative resting genital hiatus size predict surgical outcomes? J Obstet Gynaecol Res 2021; 47:4023-4029. [PMID: 34412156 DOI: 10.1111/jog.14993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/18/2021] [Accepted: 08/09/2021] [Indexed: 11/27/2022]
Abstract
AIM To determine whether preoperative genital hiatus at rest is predictive of medium-term prolapse recurrence. METHODS We conducted a retrospective study of women who underwent native tissue prolapse surgery from 2002 to 2017 with pelvic organ prolapse quantification data including resting genital hiatus at one of three time points: preoperatively, 6 weeks, and ≥1 year postoperatively. Demographics and clinical data were abstracted from the chart. Prolapse recurrence was defined by anatomic outcomes (Ba > 0, Bp > 0, and/or C ≥ -4) or retreatment. Descriptive statistics, bivariate analyses, and logistic regression analyses were performed. RESULTS Of the 165 women included, 36 (21.8%) had prolapse recurrence at an average of 1.5 years after surgery. Preoperative resting genital hiatus did not differ between women with surgical success versus recurrence (3.5 cm [interquartile range, IQR 2.25, 4.0) vs 3.5 cm (IQR 3.0, 4.0), p = 0.71). Point Bp was greater in the recurrence group at every time point. Preoperative Bp (odds ratio [OR] 1.24, confidence interval [CI] [1.06-1.45], p = 0.01) and days from surgery (OR 1.001, CI [1.000-1.001], p < 0.01) were independently associated with recurrence. Preoperative genital hiatus at rest and strain were significantly larger among women who underwent a colpoperineorrhaphy (rest: 4.0 [3.0, 4.5] cm vs 3.5 [3.0, 4.0] cm, p < 0.01; strain: 6.0 [4.0, 6.5] cm vs 5.0 [4.0, 6.0] cm, p = 0.01). CONCLUSIONS Preoperative genital hiatus at rest was not associated with prolapse recurrence when the majority of women underwent colpoperineorrhaphy. Preoperative Bp was more predictive of short-term prolapse recurrence. For every 1 cm increase in point Bp, there is a 24% increased odds of recurrence.
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Affiliation(s)
- Payton Schmidt
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Caroline K Cox
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - John O DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Shriya Suresh
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Whitney Horner
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Luyun Chen
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Carolyn W Swenson
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
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Risk factors for recurrence of pelvic organ prolapse after vaginal surgery among Ugandan women: a prospective cohort study. Int Urogynecol J 2021; 33:1933-1939. [PMID: 34319430 PMCID: PMC9270288 DOI: 10.1007/s00192-021-04930-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/25/2021] [Indexed: 11/01/2022]
Abstract
INTRODUCTION AND HYPOTHESIS This study was aimed at determining the recurrence rate and risk factors for the recurrence of pelvic organ prolapse (POP), at 1 year post-vaginal reconstructive surgery in a resource-limited setting. METHODS We enrolled women who underwent vaginal surgery for POP at the urogynecology unit of Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda between December 2018 and February 2020. The surgeries that were performed include anterior colporrhaphy for cystocele, posterior colporrhaphy for rectocele, vaginal hysterectomy with vault suspension for uterine prolapse, and cervicopexy in those with uterine prolapse where uterine-sparing surgery was desired. The women were followed up for a period of 1 year after surgery. Pelvic examinations in lithotomy position under maximum strain were carried out to assess for recurrence using the Pelvic Organ Quantification (POP-Q) system. Recurrence was defined as a prolapse of ≥POP-Q stage II. Descriptive analyses and multivariate log binomial regression were performed to determine risk factors for recurrence. RESULTS Of the 140 participants enrolled, 127 (90.7%) completed the follow-up at 1 year. The recurrence rate was 25.2% (32 out of 127). Most (56.3%) of the recurrences occurred in the anterior compartment and in the same site previously operated. Women aged <60 years (RR = 2.34; 95% CI: 1.16-4.72; p = 0.018) and those who had postoperative vaginal cuff infection (RR = 2.54; 95% CI: 1.5-4.3; p = 0.001) were at risk of recurrence. CONCLUSION Recurrence of POP was common. Younger women, and those with postoperative vaginal cuff infection, were more likely to experience recurrent prolapse after vaginal repair.
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Garcia AN, Ulker A, Aserlind A, Timmons D, Medina CA. Enlargement of the genital hiatus is associated with prolapse recurrence in patients undergoing sacrospinous ligament fixation. Int J Gynaecol Obstet 2021; 157:96-101. [PMID: 34270804 DOI: 10.1002/ijgo.13828] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/02/2021] [Accepted: 07/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To correlate genital hiatus (GH) size with surgical failures in patients undergoing sacrospinous ligament fixation (SSLF) and compare anatomic outcomes after classification based on GH size. METHODS A retrospective review of 81 patients who underwent SSLF for apical prolapse from 2010 to 2016 at a teaching hospital. Anatomical outcome is reported using the Pelvic Organ Prolapse Quantifications System. A comparison of parametric continuous variables was performed using unpaired Student t test. Categorical variables were evaluated using Pearson's χ2 test and Fisher's exact test. A P value <0.05 was considered significant. RESULTS Among the 81 patients, no difference in age, parity, body mass index, preoperative prolapse stage or follow-up time was noted between those whose surgery succeeded and those with failed surgery. Postoperatively, a widened GH was significantly associated with recurrent prolapse (P < 0.001). When the preoperative size of the GH was dichotomized into widened (≥4 cm) or normal (<4 cm), there was a non-significant (P = 0.444) trend of more failures in the widened GH group. A posterior colporrhaphy did not improve success. CONCLUSION Both preoperative and postoperative widened GH correlated with having more surgical failures following SSLF. Importantly, postoperatively a normal size GH was significantly associated with more surgical success.
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Affiliation(s)
- Alexandra N Garcia
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, Jackson Memorial Hospital, University of Miami Health Systems, Miami, Florida, USA
| | - Ashley Ulker
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, Jackson Memorial Hospital, University of Miami Health Systems, Miami, Florida, USA
| | - Alexandra Aserlind
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, Jackson Memorial Hospital, University of Miami Health Systems, Miami, Florida, USA
| | - Douglas Timmons
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, Jackson Memorial Hospital, University of Miami Health Systems, Miami, Florida, USA
| | - Carlos A Medina
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics, Gynecology and Reproductive Sciences, Jackson Memorial Hospital, University of Miami Health Systems, Miami, Florida, USA
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Kikuchi JY, Muñiz KS, Handa VL. Surgical Repair of the Genital Hiatus: A Narrative Review. Int Urogynecol J 2021; 32:2111-2117. [PMID: 33606054 DOI: 10.1007/s00192-021-04680-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND HYPOTHESIS An enlarged genital hiatus (GH) is associated with the development of prolapse and may be associated with prolapse recurrence following surgery; however, there is insufficient evidence to support surgical reduction of the GH as prophylaxis against future prolapse. The objective of this review is (1) to review the association between GH size and pelvic organ prolapse and (2) to discuss the existing literature on surgical procedures that narrow the GH. METHODS A literature search was performed in the PubMed search engine, using the keyword "genital hiatus." Articles were included if they addressed any of the following topics: (1) normative GH values; (2) associations between the GH and prolapse development or recurrence; (3) surgical alteration of the GH; (4) indications, risks or benefits of surgical alteration of the GH. RESULTS An enlarging GH has been observed prior to the development of prolapse. Multiple studies show that an enlarged pre- and/or postoperative GH is associated with an increased risk of recurrent prolapse following prolapse repair surgery. There are limited data on the specific risks of GH alteration related to bowel and sexual function. CONCLUSIONS GH size and prolapse appear to be strongly associated. Because GH size appears to be a risk factor for pelvic organ prolapse, the GH size should be carefully considered at the time of surgery. Surgeons should discuss with their patients the risks and potential benefits of additional procedures designed to reduce GH size.
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Affiliation(s)
- Jacqueline Y Kikuchi
- Department of Gynecology and Obstetrics, Division of Female Pelvic Medicine and Reconstructive Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, MD, 21224, USA.
| | - Keila S Muñiz
- Department of Gynecology and Obstetrics, Division of Female Pelvic Medicine and Reconstructive Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, MD, 21224, USA
| | - Victoria L Handa
- Department of Gynecology and Obstetrics, Division of Female Pelvic Medicine and Reconstructive Surgery, Johns Hopkins University School of Medicine, 4940 Eastern Ave, Baltimore, MD, 21224, USA
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Impact of Genital Hiatus Size on Anatomic Outcomes After Mesh-Augmented Sacrospinous Ligament Fixation. Female Pelvic Med Reconstr Surg 2021; 27:564-568. [PMID: 33411455 DOI: 10.1097/spv.0000000000000986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Our objective is to compare anatomic outcomes at medium term after mesh-augmented sacrospinous ligament fixation among women categorized by their preoperative and postoperative genital hiatus size. METHODS We performed a retrospective cohort study in women undergoing Uphold mesh-augmented sacrospinous ligament fixation between 2010 and 2017. We compared 3 groups: (1) women with a wide genital hiatus preoperatively and 6 weeks postoperatively ("Persistently Wide" cohort), (2) women with a wide genital hiatus preoperatively but normal hiatus 6 weeks postoperatively ("Improved" cohort), and (3) women with a normal genital hiatus preoperatively and 6 weeks postoperatively ("Stably Normal" cohort). We defined a wide hiatus as 4 cm or greater and a normal hiatus as less than 4 cm. The primary outcome was anatomic failure, defined as recurrent prolapse beyond the hymen or retreatment for prolapse with surgery or pessary. RESULTS Ninety-seven women were included in the study. Overall, mean age was 68 years (±7.15 years), mean body mass index was 28.36 kg/m2 (±5.34 kg/m2) and mean follow up time was 400 ± 216 days. Anatomic failure did not differ between groups (Persistently Wide, 15.4%; Improved, 11.1%; Stably Normal, 10.0%; P = 0.88). In logistic regression, the odds of anatomic failure remained similar among all groups (P = 0.93). CONCLUSIONS A persistently wide genital hiatus alone was not associated with anatomic failure in this small study cohort. Therefore, surgical reduction of the genital hiatus with level III support procedures may not affect prolapse recurrence at the time of mesh-augmented sacrospinous ligament fixation. Further studies are needed to confirm this relationship and investigate other potential mechanisms for these findings.
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Immediate Postoperative Pelvic Organ Prolapse Quantification Measures and 2-Year Risk of Prolapse Recurrence. Obstet Gynecol 2020; 136:792-801. [PMID: 32925609 DOI: 10.1097/aog.0000000000004043] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess whether resting genital hiatus, perineal body, and total vaginal length measured intraoperatively at the conclusion of surgery are associated with prolapse recurrence 2 years after native tissue pelvic organ prolapse reconstruction. METHODS This ancillary analysis of the OPTIMAL (Operations and Pelvic Muscle Training in the Management of Apical Support Loss) trial included women who had an immediate postoperative pelvic organ prolapse quantification (POP-Q) examination and 2-year follow-up. Primary outcome was bothersome bulge symptoms. Secondary outcomes were anatomic failure, surgical failure (either anatomic failure or bothersome bulge symptoms), and sexual function. Descriptive statistics assessed relationships between postprocedure POP-Q measures and these four outcomes. Multivariable models were fit to the data to control for baseline differences in bivariate comparisons. Receiver operating characteristic curves were generated to identify an optimal genital hiatus cut point associated with bothersome bulge, and this threshold was explored. RESULTS This analysis included 368 participants. Bivariate analyses identified age, body mass index, vaginal deliveries, baseline genital hiatus, perineal body, and advanced POP-Q stage (3 or higher vs 2) as clinically relevant variables to include in multivariable models. After adjusting for these variables, the association between immediate postoperative genital hiatus and bothersome bulge (adjusted odds ratio [aOR] 1.4; 95% CI 0.9-2.1) was not significant at the P<.05 level; however, immediate postoperative genital hiatus was associated with anatomic (aOR 1.6; 95% CI 1.1-2.3) and surgical failure (aOR 1.5; 95% CI 1.0-2.1). Immediate postoperative genital hiatus of 3.5 cm was the selected cutoff (area under the curve 0.58, 95% CI 0.50-0.66 from the bothersome bulge model). Women with genital hiatus 3.5 cm or greater were more likely to have anatomic and surgical failures at 2 years. No POP-Q measures were correlated with 2-year sexual function. CONCLUSION A larger immediate postoperative genital hiatus measurement of 3.5 cm or greater is not associated with bothersome bulge symptoms or sexual dysfunction but is associated with anatomic and surgical failures 2 years after native tissue vaginal reconstructive surgery.
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Szymański JK, Starzec-Proserpio M, Słabuszewska-Jóźwiak A, Jakiel G. Is PREHAB in Pelvic Floor Surgery Needed? A Topical Review. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E593. [PMID: 33172196 PMCID: PMC7694951 DOI: 10.3390/medicina56110593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 12/03/2022]
Abstract
Pelvic organ prolapse and urinary incontinence affect approximately 6-11% and 6-40% of women, respectively. These pathologies could result from a weakness of pelvic floor muscles (PFM) caused by previous deliveries, aging or surgery. It seems reasonable that improving PFM efficacy should positively impact both pelvic floor therapy and surgical outcomes. Nonetheless, the existing data are inconclusive and do not clearly support the positive impact of preoperative pelvic floor muscle training on the improvement of surgical results. The restoration of deteriorated PFM function still constitutes a challenge. Thus, further well-designed prospective studies are warranted to answer the question of whether preoperative PFM training could optimize surgical outcomes and if therapeutic actions should focus on building muscle strength or rather on enhancing muscle performance.
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Affiliation(s)
- Jacek K. Szymański
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Żelazna 90 str., 00-004 Warsaw, Poland; (J.K.S.); (A.S.-J.); (G.J.)
| | | | - Aneta Słabuszewska-Jóźwiak
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Żelazna 90 str., 00-004 Warsaw, Poland; (J.K.S.); (A.S.-J.); (G.J.)
| | - Grzegorz Jakiel
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Żelazna 90 str., 00-004 Warsaw, Poland; (J.K.S.); (A.S.-J.); (G.J.)
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Can we define excess vaginal space? - Genital hiatus size and prolapse severity are correlated with cube pessary size. Eur J Obstet Gynecol Reprod Biol 2020; 253:61-64. [PMID: 32791394 DOI: 10.1016/j.ejogrb.2020.07.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 07/17/2020] [Accepted: 07/24/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Prior studies demonstrated a positive association between increased genital hiatus (GH), advanced prolapse stage and levator ani muscle injury. Moreover wide GH is an established risk factor for recurrent pelvic organ prolapse (POP). Since excess vaginal space is not yet a dimension to estimate in Pelvic Organ Prolapse, we hypothesized that excess vaginal space has a positive correlation with increased GH and could be a new aspect for the assessment of the severity of POP and underlying pelvic muscle damage. We attempted to quantify excess vaginal space by different volumes of different cube pessary sizes. STUDY DESIGN In a prospective study, 716 symptomatic POP patients without any prior operations were enrolled from January 2011 to December 2017. All patients suffered from stage 2 POP or greater, where either the anterior, middle or posterior compartments or combinations of these were affected. As a conservative self-therapy, space-filling (Dr. Arabin®) cube pessaries were fitted. The size of each was individually adapted for each woman. For data analysis we used Spearman correlation test and Nonparametric statistical test. RESULTS All patients included in the study were asymptomatic one week after fitting the pessary. We revealed a positive significant correlation between the genital hiatus (GH) and the size of the cube pessary (ƍ = 0.777,p ≤ 0.001). We also found a positive significant correlation between the size of the cube pessaries and the POP-Q stage. We also managed to find significant differences between cube pessary sizes and corresponding GH values. CONCLUSIONS Cube pessary sizes may indicate the amount of excess vaginal space. Since excess vaginal space significantly correlates with the increase of the genital hiatus, it could be consider - as well as GH - as a marker for advanced prolapse stage, and a risk factor for the recurrence of pelvic organ prolapse.More studies are needed to identify factors related to excess vaginal space.
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Nyhus MØ, Mathew S, Salvesen Ø, Salvesen KÅ, Stafne S, Volløyhaug I. Effect of preoperative pelvic floor muscle training on pelvic floor muscle contraction and symptomatic and anatomical pelvic organ prolapse after surgery: randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:28-36. [PMID: 32144829 DOI: 10.1002/uog.22007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/12/2020] [Accepted: 02/22/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the effect of preoperative pelvic floor muscle training (PFMT) on pelvic floor muscle (PFM) contraction, symptoms of pelvic organ prolapse (POP) and anatomical POP, 6 months after prolapse surgery, and to assess the overall changes in PFM contraction, POP symptoms and pelvic organ descent after surgery. METHODS This was a randomized controlled trial of 159 women with symptomatic POP, Stage 2 or higher, scheduled for surgery. Participants were randomized to intervention including daily PFMT from inclusion to surgery (n = 81) or no intervention (controls; n = 78). Participants were examined at inclusion, on the day of surgery and 6 months after surgery. PFM contraction was assessed by: vaginal palpation using the Modified Oxford scale (MOS; 0-5); transperineal ultrasound, measuring the percentage change in levator hiatal anteroposterior diameter (APD) from rest to maximum PFM contraction; vaginal manometry; and surface electromyography (EMG). POP distance from the hymen in the compartment with the most dominant prolapse and organ descent in the anterior, central and posterior compartments were measured on maximum Valsalva maneuver. POP symptoms were assessed based on the sensation of vaginal bulge, which was graded using a visual analog scale (VAS; 0-100 mm). Linear mixed models were used to assess the effect of PFMT on outcome variables. RESULTS Of the 159 women randomized, 151 completed the study, comprising 75 in the intervention and 76 in the control group. Mean waiting time for surgery was 22 ± 9.7 weeks and follow-up was performed on average 28 ± 7.8 weeks after surgery. Postoperatively, no difference was found between the intervention and control groups with respect to PFM contraction assessed by vaginal palpation (MOS, 2.4 vs 2.2; P = 0.101), manometry (19.4 vs 19.7 cmH2 O; P = 0.793), surface EMG (33.5 vs 33.1 mV; P = 0.815) and ultrasound (change in hiatal APD, 20.9% vs 19.3%; P = 0.211). Furthermore, no difference between groups was found for sensation of vaginal bulge (VAS, 7.4 vs 6.0 mm; P = 0.598), POP distance from the hymen in the dominant prolapse compartment (-1.8 vs -2.0 cm; P = 0.556) and sonographic descent of the bladder (0.5 vs 0.8 cm; P = 0.058), cervix (-1.3 vs -1.1 cm; P = 0.569) and rectal ampulla (0.3 vs 0.4 cm; P = 0.434). In all patients, compared with findings at initial examination, muscle contraction improved after surgery, as assessed by palpation (MOS, 2.1 vs 2.3; P = 0.007) and ultrasound (change in hiatal APD, 17.5% vs 20.1%; P = 0.001), and sensation of vaginal bulge was reduced (VAS, 57.6 vs 6.7 mm; P < 0.001). In addition, compared with the baseline examination, POP distance from the hymen in the dominant prolapse compartment (1.9 vs -1.9 cm; P < 0.001) and sonographic descent of the bladder (1.3 vs 0.6 cm; P < 0.001), cervix (0.0 vs -1.2 cm; P < 0.001) and rectal ampulla (0.9 vs 0.4 cm; P = 0.001) were reduced. CONCLUSIONS We found no effect of preoperative PFMT on PFM contraction, POP symptoms or anatomical prolapse after surgery. In all patients, PFM contraction and POP symptoms were improved at the 6-month follow-up, most likely due to the anatomical correction of POP. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Ø Nyhus
- Department of Obstetrics and Gynecology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - S Mathew
- Department of Obstetrics and Gynecology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ø Salvesen
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
| | - K Å Salvesen
- Department of Obstetrics and Gynecology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - S Stafne
- Department of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway
- Clinical Services, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - I Volløyhaug
- Department of Obstetrics and Gynecology, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Restoring Genital Hiatus to Normative Values After Apical Suspension Alone Versus With Level 3 Support Procedures. Female Pelvic Med Reconstr Surg 2019; 25:226-230. [PMID: 29210807 DOI: 10.1097/spv.0000000000000528] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate postoperative genital hiatus after apical suspension procedures without a level 3 support procedure (L3SP), posterior repair, and perineorrhaphy, compared with normative-value genital hiatus of 3.4 cm. METHODS This an analysis of a pre-existing retrospectively collected database that included all minimally invasive sacrocolpopexies and uterosacral ligament suspensions performed at a tertiary medical center from January 2009 to August 2015. RESULTS We identified 1006 surgical cases: 160 (15.9%) apical suspensions with L3SPs and 846 (84.1%) without. Mean (SD) age was 59 (9) years and body mass index was 27.6 (4.7) kg/m. Women were mainly white (97.4%) with stage III prolapse (67.8%). Those who underwent L3SPs were more likely to be premenopausal and undergo hysterectomy and USLS.Baseline genital hiatus was similar with and without L3SPs (4.8 [1.2] cm vs 4.6 [1.1] cm, P = 0.096). Postoperative genital hiatus was reduced beyond normative (3.4 cm) after apical suspension without (3.0 [0.7] cm, P < 0.001) and with (2.8 [0.9] cm, P < 0.001) L3SPs. Postoperative genital hiatus after L3SPs was similar to those without (2.8 [0.9] cm vs 3.0 [0.7] cm, P = 0.06). We found that change in genital hiatus was greater, by 0.7 cm, when L3SP was performed versus not performed (2.3 [1.2] cm vs 1.6 [1.1] cm, P < 0.001). CONCLUSIONS Level 3 support procedures may be unnecessary to restore genital hiatus to normal at time of apical suspension procedures and should be reserved for select patients.
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Hill AM, Shatkin-Margolis A, Smith BC, Pauls RN. Associating genital hiatus size with long-term outcomes after apical suspension. Int Urogynecol J 2019; 31:1537-1544. [DOI: 10.1007/s00192-019-04138-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 09/23/2019] [Indexed: 11/25/2022]
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Surgical Alteration of Genital Hiatus Size and Anatomic Failure After Vaginal Vault Suspension. Obstet Gynecol 2019; 131:1137-1144. [PMID: 29742664 DOI: 10.1097/aog.0000000000002593] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare anatomic outcomes after native tissue vaginal vault suspension among women categorized by their preoperative and 6-week postoperative genital hiatus size. METHODS We performed a retrospective cohort study in women who underwent native tissue vaginal vault suspension between 2005 and 2015. We defined a wide genital hiatus as 4 cm or greater and a normal genital hiatus as less than 4 cm. We compared three groups: 1) women with a wide genital hiatus preoperatively and 6 weeks postoperatively (persistently wide group), 2) women with a wide genital hiatus preoperatively but normal genital hiatus 6 weeks postoperatively (improved group), and 3) women with a normal genital hiatus preoperatively and 6 weeks postoperatively (stably normal group). Our primary outcome was composite anatomic failure at medium term, defined as either recurrent prolapse beyond the hymen or retreatment for prolapse with surgery or a pessary. Data were analyzed with appropriate bivariate analysis and logistic regression. RESULTS Our study population consisted of 260 women, with 39 of 260 (15.0%) in the persistently wide group, 157 of 260 (60.4%) improved, and 64 of 260 (24.6%) stably normal. Composite anatomic failure was significantly more likely in the persistently wide cohort as compared with the other groups (persistently wide 51.3%, improved 16.6%, stably normal 6.3%, overall P<.01, significant for all pairwise comparisons). These results were consistent when examining the anterior, apical, and posterior compartments individually. In a logistic regression analysis, the persistently wide group was associated with a 4.4-fold increased odds of composite failure (adjusted odds ratio [OR] 4.41, 95% CI 1.99-9.76, P<.01) compared with the improved group and a 15.8-fold increased odds compared with the stably normal group (adjusted OR 15.79, 95% CI 4.66-53.57, P<.01). CONCLUSION Women with a preoperative genital hiatus 4 cm or greater that is not surgically normalized after native tissue vaginal vault suspension are at significantly increased odds of anatomic failure in all compartments.
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Liang Y, Li X, Wang J, Liu Y, Yang Yang, Dong M. Effect of Pelvic Floor Muscle Training on Improving Prolapse-related Symptoms After Surgery. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2019.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mastwyk S, McClelland J, Rosamilia A, Frawley H. The impact of pelvic organ prolapse and/or continence surgery on pelvic floor muscle function in women: A systematic review. Neurourol Urodyn 2019; 38:1467-1481. [DOI: 10.1002/nau.24025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Sally Mastwyk
- School of Allied Health, Human Services and SportLa Trobe UniversityMelbourne Victoria Australia
| | - Jodie McClelland
- School of Allied Health, Human Services and SportLa Trobe UniversityMelbourne Victoria Australia
| | - Anna Rosamilia
- Department of Obstetrics and GynaecologyMonash UniversityClayton Victoria Australia
- Monash HealthClayton Victoria Australia
| | - Helena Frawley
- Department of Physiotherapy, Faculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourne Victoria Australia
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Brandt C, Janse van Vuuren EC. Dysfunction, activity limitations, participation restriction and contextual factors in South African women with pelvic organ prolapse. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2019; 75:933. [PMID: 30863799 PMCID: PMC6407468 DOI: 10.4102/sajp.v75i1.933] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/10/2019] [Indexed: 11/17/2022] Open
Abstract
Background Pelvic organ prolapse (POP) is a multifactorial, poorly understood condition impacting quality of life (QOL). The pathology and aetiology might imply population-specific differences in domains of the International Classification of Function, Disability and Health (ICF). There is, however, a lack of research in this regard in South Africa. Objectives To describe the dysfunction, activity limitations, participation restrictions and contextual factors in South African women with POP. Method One hundred women were conveniently sampled in a primary health care setting. They completed a self-compiled medical and exercise history questionnaire, the standardised Prolapse-Quality of Life (P-QOL) questionnaire and the Visual Faces Scale. The stage of prolapse was determined by the Pelvic Organ Prolapse Quantification (POP-Q) Scale. Means, medians, standard deviations, percentages and frequencies were calculated. Results Eighty-six per cent had a stage III POP, 57% had overactive bladder, 50% had constipation, 37% had stress urinary incontinence, 31% had urge urinary incontinence, 32% had incomplete emptying and 30% had anal incontinence. Comorbidities included cardiovascular disease (65%), depressive symptoms (12%) and hypothyroidism (18%). Other contextual factors included limited physical activity (80%), an increased body mass index (29 kg/m2), older age (59 years) and unemployment (80%). Quality of life was affected in the severity, social, emotional and sleep/energy domains (median scores were 66.7% – 33.3%). Conclusion The dysfunction domain of the ICF was similar to other populations with POP. Activity and participation restrictions included social, emotional and sleep/energy aspects. Contextual factors seem to be population-specific, possibly leading to differences comparing QOL amongst different populations. Clinical implications Activity and participation restrictions, as well as contextual factors, may differ in different populations with POP. Interactions between contextual factors and movement impairment should be considered during management and be further investigated.
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Affiliation(s)
- Corlia Brandt
- Department of Physiotherapy, University of the Witwatersrand, South Africa
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Durnea CM, Basu M, Dadhwal K, Gayle YV, Gauthaman N, Khunda A, Doumouchtsis SK. Perioperative changes in superficial pelvic organ prolapse quantification system measurements after prolapse surgery. Int J Gynaecol Obstet 2019; 145:239-243. [PMID: 30748012 DOI: 10.1002/ijgo.12783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 10/18/2018] [Accepted: 02/08/2019] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To evaluate the values of perineal body (PB) and genital hiatus (GH) before and after posterior repair. We also evaluated the introital surface area (ISA)-a sum of transverse and longitudinal GH measurements. METHODS This secondary analysis of a prospective case series included 94 women undergoing posterior vaginal prolapse surgery at a consultant urogynecology clinic between October 3, 2011, and October 2, 2014. Patients were examined in clinic using the pelvic organ prolapse quantification system with Valsalva maneuver, and in theatre pre- and postoperatively with traction. RESULTS Immediately postoperatively, a statistically significant change (all P<0.001) was noted for GH (mean difference -0.59 cm), PB (-0.56 cm), and ISA (-0.87 cm) compared with preoperative measurement. This effect was maintained for GH (-0.42 cm) and PB (-0.40 cm) at 2 months' follow-up (both P<0.001), and for PB alone (-0.43 cm; P=0.04) at 8 months. ISA had a moderate correlation with GH (r=0.55). CONCLUSIONS Posterior repair significantly improved PB length at months 2 and 8, and GH length at month 2. ISA did not correlate with prolapse stage. Changes in GH were not maintained beyond postoperative month 2.
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Affiliation(s)
- Constantin M Durnea
- Department of Obstetrics and Gynaecology, Epsom & St Helier University Hospitals NHS Trust, Epsom, UK.,Northwick Park Hospital, London North West University Healthcare NHS, Harrow, UK
| | - Maya Basu
- Medway NHS Foundation Trust, Gillingham, Kent, UK
| | | | | | | | - Azar Khunda
- St. Thomas' Hospital, Guy's and St. Thomas' Hospitals Foundation Trust, London, UK
| | - Stergios K Doumouchtsis
- Department of Obstetrics and Gynaecology, Epsom & St Helier University Hospitals NHS Trust, Epsom, UK.,St. George's, University of London, London, UK
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Resende APM, Bernardes BT, Stüpp L, Oliveira E, Castro RA, Girão MJBC, Sartori MGF. Pelvic floor muscle training is better than hypopressive exercises in pelvic organ prolapse treatment: An assessor-blinded randomized controlled trial. Neurourol Urodyn 2018; 38:171-179. [PMID: 30311680 DOI: 10.1002/nau.23819] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/05/2018] [Indexed: 11/08/2022]
Abstract
AIMS To verify if hypopressive exercises (HEs) can improve pelvic organ prolapse (POP) symptoms equally or better than pelvic floor muscle training (PFMT). METHODS Randomized controlled trial. Symptomatic women with untreated stage II POP according to the Pelvic Organ Prolapse Quantification System (POP-Q) having the ability to contract their pelvic floor muscles were invited. The outcome measures were POP symptoms as measured by specific questions and Prolapse Quality of Life (P-QoL); POP severity as measured by POP-Q; and PFM function. Intervention consisted by 12 weeks of PFMT or an HE home exercise program with bimonthly sessions with a physiotherapist. The protocol consisted of three initial sessions to learn how to perform the exercises correctly, followed by 3 months of exercise with monthly progression. Volunteers filled out exercise diaries to record their compliance. RESULTS PFMT presented better results in terms of the following symptoms: a bulge/lump from or in the vagina, heaviness or dragging on the lower abdomen, and stress incontinence. PFMT also presented better results regarding the Prolapse impact and role, social and personal limitations of P-QoL. Regarding the total number of symptoms at the end, the PFMT group presented a mean of 1.7 (±1.2), and the HE group presented a mean of 2.8 (±1,1); the effect size was 1.01 in favor of the PFMT group (95%CI = 1.002-1.021). CONCLUSION Both groups exhibited improvements in POP symptoms, quality of life, prolapse severity, and PFM function. PFMT was superior to HE for all outcomes.
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Affiliation(s)
- Ana Paula M Resende
- Department of Physiotherapy, Federal University of Uberlândia, Uberlândia, Brazil.,Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | - Bruno T Bernardes
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil.,Department of Gynecology and Obstetrics, Federal University of Uberlândia, Uberlândia, Brazil
| | - Liliana Stüpp
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | - Emerson Oliveira
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | - Rodrigo A Castro
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | - Manoel J B C Girão
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | - Marair G F Sartori
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
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Sánchez-Ferrer ML, Prieto-Sánchez MT, Moya-Jiménez C, Mendiola J, García-Hernández CM, Carmona-Barnosi A, Nieto A, Torres-Cantero AM. Anogenital Distance and Perineal Measurements of the Pelvic Organ Prolapse (POP) Quantification System. J Vis Exp 2018. [PMID: 30295651 DOI: 10.3791/57912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Anogenital distance (AGD) is a sexually dimorphic attribute, twice longer in males than in females, and a marker of intrauterine hormonal environment. Interest in AGD measurements is increasing due to mounting evidence on their potential clinical implications. A parallel set of perineal measurements, the Pelvic Organ Prolapse Quantification System (POP-Q), include similar, but not exactly the same, landmarks: the perineal body (PB) and the genital hiatus (GH) lengths. However, clinical reproducibility of both perineal measurements and their usefulness to describe perineal anthropometry needs to be elucidated. To our knowledge, there is no publication in video format showing the methodology of these measurements. The main objective of this work is to show how to properly perform perineal anthropometry, including measurements of the AGD in its two variants [anoclitoral (AGDAC) and anofourchette (AGDAF)], genital hiatus (GH) and perineal body (PB). Moreover, we explored if there were differences in these measurements in women with and without Pelvic Organ Prolapse (POP). We research whether the anthropometric characteristics of the perineum, such as AGD (which is determined prenatally), may be altered in these women and be an independent etiological factor for pelvic floor dysfunction. We show two different ways of measuring perineal lengths, as they might be quite comparable. Our suggestion is that unifying perineal measurements could be useful for clinical and biomedical investigation. More studies are needed in order to compare GH and PB measurements and its AGD counterparts to analyze which procedures are more reproducible with less intra and interobserver variability.
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Affiliation(s)
- María Luisa Sánchez-Ferrer
- Department of Obstetrics & Gynecology, "Virgen de la Arrixaca", University Clinical Hospital; Institute for Biomedical Research of Murcia, IMIB-Arrixaca
| | - María Teresa Prieto-Sánchez
- Department of Obstetrics & Gynecology, "Virgen de la Arrixaca", University Clinical Hospital; Institute for Biomedical Research of Murcia, IMIB-Arrixaca;
| | - Carlos Moya-Jiménez
- Department of Obstetrics & Gynecology, "Virgen de la Arrixaca", University Clinical Hospital
| | - Jaime Mendiola
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca; Division of Preventive Medicine and Public Health, Department of Public Health Sciences, University of Murcia School of Medicine; Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP)
| | | | - Ana Carmona-Barnosi
- Department of Obstetrics & Gynecology, "Virgen de la Arrixaca", University Clinical Hospital
| | - Anibal Nieto
- Department of Obstetrics & Gynecology, "Virgen de la Arrixaca", University Clinical Hospital; Institute for Biomedical Research of Murcia, IMIB-Arrixaca
| | - Alberto M Torres-Cantero
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca; Division of Preventive Medicine and Public Health, Department of Public Health Sciences, University of Murcia School of Medicine; Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP); Department of Preventive Medicine, "Virgen de la Arrixaca", University Clinical Hospital
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Sánchez-Ferrer ML, Prieto-Sánchez MT, Moya-Jiménez LC, Adoamnei E, Mendiola J, Torres-Cantero AM. Comparability between adult female anogenital distance and perineal measurements standardized by POP-Q system (GH and PB). Neurourol Urodyn 2018; 37:2847-2853. [DOI: 10.1002/nau.23798] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/09/2018] [Indexed: 01/24/2023]
Affiliation(s)
- María L. Sánchez-Ferrer
- Departmentof Obstetrics and Gynecology; “Virgen de la Arrixaca” University Clinical Hospital and Institute for Biomedical Research of Murcia; El Palmar Murcia Spain
| | - María T. Prieto-Sánchez
- Departmentof Obstetrics and Gynecology; “Virgen de la Arrixaca” University Clinical Hospital and Institute for Biomedical Research of Murcia; El Palmar Murcia Spain
| | - Luis C. Moya-Jiménez
- Department of Obstetrics and Gynecology; University General Hospital Santa Lucía; Cartagena Murcia Spain
| | - Evdochia Adoamnei
- Division of Preventive Medicine and Public Health; Department of Public Health Sciences; University of Murcia School of Medicine; Espinardo Murcia Spain
- Institute for Biomedical Research of Murcia; El Palmar Murcia Spain
| | - Jaime Mendiola
- Division of Preventive Medicine and Public Health; Department of Public Health Sciences; University of Murcia School of Medicine; Espinardo Murcia Spain
- Institute for Biomedical Research of Murcia; El Palmar Murcia Spain
| | - Alberto M. Torres-Cantero
- Division of Preventive Medicine and Public Health; Department of Public Health Sciences; University of Murcia School of Medicine; Espinardo Murcia Spain
- Institute for Biomedical Research of Murcia; El Palmar Murcia Spain
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Should Genital Hiatus/Perineal Body Be Measured at Rest or on Valsalva? Female Pelvic Med Reconstr Surg 2018; 25:415-418. [PMID: 29979358 DOI: 10.1097/spv.0000000000000608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Genital hiatus (Gh) and perineal body (Pb) are part of the Pelvic Organ Prolapse Quantification assessment system, but it is unclear whether measurements should be taken at rest or on Valsalva. This study was designed to assess the predictive value of Gh and Pb measurements obtained at rest and on Valsalva for signs and symptoms of pelvic organ prolapse (POP). METHODS This is a retrospective study involving 416 women who presented to a tertiary urogynecology unit with symptoms of pelvic floor dysfunction. Genital hiatus and Pb were measured at rest and on maximal Valsalva. The strength of association between binary markers of POP and measurements of Gh/Pb was estimated using logistic regression analysis. Receiver operator characteristic statistics were used to compare predictive values of Gh and Pb measurements obtained at rest and on Valsalva. RESULTS A total of 451 women were seen during the study period. Thirty-five were excluded owing to missing data, leaving 416. Fifty-four percent (n = 223) complained of POP symptoms. On examination, 80% (n = 332) had significant POP (stage 2+ in anterior or posterior compartments or stage 1+ in the central compartment). On imaging, significant POP was diagnosed in 66% (n = 275). Mean hiatal area was 22 cm (SD, 7; range, 5-49 cm) at rest and 30 cm (SD, 10; range, 11-69 cm) on Valsalva. Genital hiatus and Pb measured on Valsalva were consistently stronger predictors of prolapse symptoms and objective prolapse (by clinician examination and by ultrasound) than at Gh and Pb measured at rest. The corresponding area under the curve values were significantly larger for Gh/Pb measures on Valsalva after adjusting for multiple confounders. CONCLUSIONS Genital hiatus/Pb measured on maximal Valsalva is a superior predictor of symptoms and signs of POP compared with Gh/Pb at rest.
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Baubil F, Guerby P, Léonard F, Rimailho J, Parant O, Tanguy le Gac Y, Chantalat E, Vidal F. [Evolution of clinical practices in the surgical management of pelvic organ prolapse in a "vaginalist" team over the period 2010-2015: A paradigm shift towards pluripotency]. ACTA ACUST UNITED AC 2018; 46:619-624. [PMID: 29941338 DOI: 10.1016/j.gofs.2018.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To determine whether the 2011 FDA alert and French Guidelines have impacted the routine surgical practice in the management of pelvic organ prolapse in a "vaginalist" team over the period 2010-2015. METHODS Retrospective study involving all patients undergoing surgical management of anterior and/or apical symptomatic pelvic organ prolapse during the civil years 2010 and 2015. Both naive and relapsed prolapses were eligible. RESULTS Overall, 338 patients were included: 187 in 2010 and 151 in 2015. Among patients with naive prolapse, we observed a significant increase in the number of laparoscopic sacrocolpopexies (11.1% in 2010 versus 34.4% in 2015, P=0.001) and a significant decline in the use of native tissue repair (67.6% in 2010 versus 39% in 2015, P=0.001). While the number of transvaginal meshes did not decline over the study period, their indications displayed a significant evolution towards a restricted use to advanced stages. We did not observe any difference regarding the treatment of recurred pelvic organ prolapse. Vaginal route remained the preferred approach in this indication. CONCLUSION In our "vaginalist" team, routine practice has significantly evolved over the period 2010-2015, resulting in a diversification of the healthcare offer. This paradigm shift towards pluripotency is mandatory, since patients' preference should also drive the choice of both surgical route and technique.
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Affiliation(s)
- F Baubil
- Pôle de gynécologie obstétrique, hôpital Paule-de-Viguier, CHU de Toulouse, 31059 Toulouse, France
| | - P Guerby
- Pôle de gynécologie obstétrique, hôpital Paule-de-Viguier, CHU de Toulouse, 31059 Toulouse, France; UMR1027, université de Toulouse III, 31073 Toulouse, France
| | - F Léonard
- Service de gynécologie obstétrique, centre hospitalier de Cahors, 46000 Cahors, France
| | - J Rimailho
- Service de chirurgie générale et gynécologique, hôpital Rangueil, CHU de Toulouse, 31059 Toulouse, France
| | - O Parant
- Pôle de gynécologie obstétrique, hôpital Paule-de-Viguier, CHU de Toulouse, 31059 Toulouse, France; UMR1027, université de Toulouse III, 31073 Toulouse, France
| | - Y Tanguy le Gac
- Pôle de gynécologie obstétrique, hôpital Paule-de-Viguier, CHU de Toulouse, 31059 Toulouse, France
| | - E Chantalat
- UMR1027, université de Toulouse III, 31073 Toulouse, France; Service de gynécologie obstétrique, centre hospitalier de Cahors, 46000 Cahors, France; Service de chirurgie générale et gynécologique, hôpital Rangueil, CHU de Toulouse, 31059 Toulouse, France
| | - F Vidal
- Pôle de gynécologie obstétrique, hôpital Paule-de-Viguier, CHU de Toulouse, 31059 Toulouse, France; UMR1027, université de Toulouse III, 31073 Toulouse, France.
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Suh DH, Jeon MJ. Risk factors for the failure of iliococcygeus suspension for uterine prolapse. Eur J Obstet Gynecol Reprod Biol 2018; 225:210-213. [PMID: 29747142 DOI: 10.1016/j.ejogrb.2018.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 04/05/2018] [Accepted: 05/02/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate the risk factors for the failure of iliococcygeus suspension (ICG) for uterine prolapse and estimate its long-term success rates using a clinically relevant criterion. STUDY DESIGN This retrospective cohort study included 144 women who underwent transvaginal reconstructive surgery including ICG for symptomatic pelvic organ prolapse. Surgical failure was defined as anatomic recurrence (descent of the vaginal apex beyond the halfway point of the vagina or descent of the anterior or posterior vaginal wall beyond the hymen), symptomatic recurrence (vaginal bulge symptoms), or retreatment for prolapse. RESULTS During the median 4-year follow-up period, surgical failure was observed in 20 women (13.9%). Multivariate analysis with the Cox proportional hazard model showed that advanced prolapse (preoperative pelvic organ prolapse quantification [POP-Q] stage >II and point C >0) and uterus-saving techniques were independent risk factors for failure. When the ICG was performed as a vault suspension procedure together with hysterectomy, the estimated 4-year success rates were 100% for mild prolapse (POP-Q stage II or point C ≤0) and 91.2% for advanced prolapse. When the procedure was done as a hysteropexy, the corresponding success rates decreased to 75.3% and 48.0%, respectively. CONCLUSIONS This study indicates that the severity of prolapse and the uterus-saving technique affect the prognosis after ICG. The ICG provides a durable apical vaginal support when performed together with hysterectomy, irrespective of the severity of the prolapse. In addition, it appears to be an acceptable hysteropexy option for mild uterine prolapse.
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Affiliation(s)
- Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Myung Jae Jeon
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Bradley MS, Askew AL, Vaughan MH, Kawasaki A, Visco AG. Robotic-assisted sacrocolpopexy: early postoperative outcomes after surgical reduction of enlarged genital hiatus. Am J Obstet Gynecol 2018; 218:514.e1-514.e8. [PMID: 29425837 DOI: 10.1016/j.ajog.2018.01.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 12/19/2017] [Accepted: 01/31/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Currently, the decision to perform a concurrent posterior repair/perineoplasty at the time of robotic-assisted sacrocolpopexy is not standardized. OBJECTIVE We sought to compare anatomic failure after robotic-assisted sacrocolpopexy among 3 groups of patients categorized by their preoperative and postoperative genital hiatus size. STUDY DESIGN We performed a retrospective cohort study of women who underwent robotic-assisted sacrocolpopexy, from January 2013 through September 2016. We defined a wide genital hiatus as ≥4 cm and a normal genital hiatus as <4 cm. We compared 3 groups: (1) wide preoperative and postoperative genital hiatus (persistently wide); (2) wide preoperative and normal postoperative genital hiatus (improved); and (3) normal preoperative and postoperative genital hiatus (stably normal). Our primary outcome was composite anatomic failure defined as either recurrent prolapse in any compartment past the hymen or retreatment for prolapse with either surgery or pessary. Our data were analyzed using 1-way analysis of variance and χ2 test. Logistic regression was performed to evaluate for independent risk factors for anatomic failure among the 3 groups. P < .05 was considered significant. RESULTS Our study population consisted of 452 women with a mean age of 59.3 ± 10.0 years and a mean body mass index of 27.8 ± 5.3 kg/m2. Of the women with reported race, 394/447 (88.1%) were white. The genital hiatus groups were distributed as follows: 57 (12.6%) were persistently wide, 296 (65.5%) were improved, and 99 (21.9%) were stably normal. The stably normal group had less advanced preoperative prolapse (stage ≥3) than the other groups (P < .01). A similar percentage of patients among groups had a concomitant posterior repair/perineoplasty (P = .09) with a total of 84 (18.6%) women undergoing this procedure. There was a statistically significant difference in overall composite anatomic failure among the groups (P = .03). There was an increase in failure in the persistently wide group (14.0%) compared to the improved group (5.7%, P = .04) and compared to the stably normal group (4.0%, P = .03). In a logistic regression model, controlling for number of vaginal deliveries and posterior repair/perineoplasty, there was a 5.3-fold increased odds of composite anatomic failure in the persistently wide group (adjusted odds ratio, 5.3; 95% confidence interval, 1.4-19.1; P = .01) compared to the stably normal group. In a subanalysis of failure by compartment, there was an increase in failure of the posterior compartment in the persistently wide group compared to the improved group (8.8% vs 2.0%, P < .01), but not the stably normal group (3.0%, P = .12). There was not a statistically significant difference in failure of the combined apical and anterior compartments among groups (P = .29). CONCLUSION Surgical reduction of an enlarged preoperative genital hiatus decreases early composite anatomic failure, after robotic sacrocolpopexy, specifically related to the posterior compartment. Studies investigating the correlation of intraoperative measurement of genital hiatus to postoperative genital hiatus are needed to help clinicians determine who may benefit from a concomitant posterior repair/perineoplasty at the time of robotic-assisted sacrocolpopexy.
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Nekooeimehr I, Lai-Yuen S, Bao P, Weitzenfeld A, Hart S. Automated contour tracking and trajectory classification of pelvic organs on dynamic MRI. J Med Imaging (Bellingham) 2018; 5:014008. [PMID: 29651450 DOI: 10.1117/1.jmi.5.1.014008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 03/12/2018] [Indexed: 11/14/2022] Open
Abstract
A method is presented to automatically track and segment pelvic organs on dynamic magnetic resonance imaging (MRI) followed by multiple-object trajectory classification to improve understanding of pelvic organ prolapse (POP). POP is a major health problem in women where pelvic floor organs fall from their normal position and bulge into the vagina. Dynamic MRI is presently used to analyze the organs' movements, providing complementary support for clinical examination. However, there is currently no automated or quantitative approach to measure the movement of the pelvic organs and their correlation with the severity of prolapse. In the proposed method, organs are first tracked and segmented using particle filters and [Formula: see text]-means clustering with prior information. Then, the trajectories of the pelvic organs are modeled using a coupled switched hidden Markov model to classify the severity of POP. Results demonstrate that the presented method can automatically track and segment pelvic organs with a Dice similarity index above 78% and Hausdorff distance of [Formula: see text] for 94 tested cases while demonstrating correlation between organ movement and POP. This work aims to enable automatic tracking and analysis of multiple deformable structures from images to improve understanding of medical disorders.
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Affiliation(s)
| | - Susana Lai-Yuen
- University of South Florida, Department of Industrial and Management Systems Engineering, Tampa, Florida, United States
| | - Paul Bao
- University of South Florida, Department of Computer Science and Engineering, Tampa, Florida, United States
| | - Alfredo Weitzenfeld
- University of South Florida, Department of Computer Science and Engineering, Tampa, Florida, United States
| | - Stuart Hart
- University of South Florida, Department of Obstetrics and Gynecology, Tampa, Florida, United States.,Medtronic, Tampa, Florida, United States
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Schachar JS, Devakumar H, Martin L, Farag S, Hurtado EA, Davila GW. Pelvic floor muscle weakness: a risk factor for anterior vaginal wall prolapse recurrence. Int Urogynecol J 2018; 29:1661-1667. [PMID: 29552738 DOI: 10.1007/s00192-018-3626-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/01/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Native tissue vaginal repairs are associated with relatively high levels of recurrence. Systematic reviews have noted that preoperative pelvic floor muscle strength was associated with increased risk of recurrence in the short term. METHODS This is a retrospective review of patients who underwent a primary reconstructive surgery for anterior compartment vaginal prolapse between 2001 and 2015. Patients were divided into "absent," "weak" and "good" preoperative PFM strength (aPFM, wPFM and gPFM, respectively) based on a modified Oxford scale. Failure rates were determined by a composite of subjective and objective anatomic outcomes. Subjects who underwent re-operations or procedures for recurrent prolapse of the anterior compartment were considered failures. A p value < 0.05 was considered statistically significant. RESULTS Two hundred ninety-nine patients were included. The aPFM (n = 36), wPFM (n = 115) and gPFM (n = 148) groups had similar descriptive statistics, except subjects in the aPFM and wPFM groups were significantly older than the gPFM group (p = 0.008). All groups underwent similar reconstructive surgeries. Average length of follow-up of 143.9 weeks (41 to 717 weeks) was similar among the three groups (p = 0.472). For the primary outcome of composite failure, aPFM had significantly more anterior vaginal wall recurrences than both the wPFM and gPFM groups, 13.89% vs. 3.48% and 4.05%, respectively (p = 0.033). CONCLUSIONS Patients with preoperative absent pelvic floor muscle strength (nonfunctioning PFM) had a significantly higher anterior vaginal wall recurrence rate than those with weak or good pelvic floor muscle strength.
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Affiliation(s)
- Jeffrey S Schachar
- Department of Gynecology-Section of Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
| | - Hemikaa Devakumar
- Department of Gynecology-Section of Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Laura Martin
- Department of Gynecology-Section of Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Sara Farag
- Department of Gynecology-Section of Minimally Invasive Gynecologic Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Eric A Hurtado
- Department of Gynecology-Section of Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - G Willy Davila
- Department of Gynecology-Section of Female Pelvic Medicine and Reconstructive Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
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Duarte TB, Bonacin MAP, Brito LGO, Frawley H, Dwyer PL, Thomas E, Ferreira CHJ. Does pelvic floor muscle maximum voluntary contraction improve after vaginal pelvic organ prolapse surgery? A prospective study. Neurourol Urodyn 2018. [DOI: 10.1002/nau.23503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Thaiana B. Duarte
- Department of Biomechanics; Medicine and Rehabilitation; Postgraduate Program in Rehabilitation and Performance; Ribeirão Preto Medical School; University of São Paulo; Brazil
| | - Marília A. P. Bonacin
- Department of Biomechanics; Medicine and Rehabilitation; Postgraduate Program in Rehabilitation and Performance; Ribeirão Preto Medical School; University of São Paulo; Brazil
| | - Luiz G. O. Brito
- Department of Gynecology and Obstetrics; School of Medical Sciences; University of Campinas; Brazil
| | - Helena Frawley
- Department of Physiotherapy; School of Primary and Allied Health Care; Monash University; Melbourne Australia
| | - Peter L. Dwyer
- Urogynaecology Department; Mercy Hospital for Women; Melbourne Australia
| | - Elizabeth Thomas
- Urogynaecology Department; Mercy Hospital for Women; Melbourne Australia
| | - Cristine H. J. Ferreira
- Department of Biomechanics; Medicine and Rehabilitation; Postgraduate Program in Rehabilitation and Performance; Ribeirão Preto Medical School; University of São Paulo; Brazil
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Correlation between the posterior vaginal wall and apex in pelvic organ prolapse. Obstet Gynecol Sci 2018; 61:505-508. [PMID: 30018905 PMCID: PMC6046363 DOI: 10.5468/ogs.2018.61.4.505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/14/2017] [Accepted: 12/12/2017] [Indexed: 12/01/2022] Open
Abstract
Objective The aim of our study is to reveal the correlation between the posterior vaginal wall and apex in pelvic organ prolapse. Methods We retrospectively reviewed the records of all new patient visits to a urogynecology clinic between January 2013 and December 2015. Results Four hundred five cases were enrolled in our study. When all POP stages were included, the Bp (pelvic organ prolapse quantification point) had a moderate correlation with the C (Pearson's r=0.419; P<0.001). Cases where Bp was stage 3 and above presented strong positive correlations with C (Spearman's ρ=0.783; P<0.001). Cases where C was stage 3 and above presented also strong positive correlations with Bp (Spearman's ρ=0.718; P<0.001). Conclusion Posterior vaginal wall prolapse and apical prolapse were correlated with each other, and this correlation was more prominent as stage increased. Therefore, when admitting a patient suspected of posterior vaginal wall prolapse or apical prolapse, it is necessary to evaluate both conditions. Especially in cases more severe or equal to stage 3, it is a must to suspect both conditions as the 2 are strongly correlated.
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Risk factors for prolapse recurrence: systematic review and meta-analysis. Int Urogynecol J 2017; 29:13-21. [DOI: 10.1007/s00192-017-3475-4] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 08/29/2017] [Indexed: 12/30/2022]
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Increasing Anteroposterior Genital Hiatus Widening Does Not Limit Apical Descent for Prolapse Staging During Valsalva's Maneuver: Effect on Symptom Severity and Surgical Decision Making. Female Pelvic Med Reconstr Surg 2017; 24:412-418. [PMID: 28914705 DOI: 10.1097/spv.0000000000000474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Determine if anteroposterior genital hiatus (GH) widening obscures rather than facilitates signs and symptoms, inadvertently altering management decisions for women with pelvic organ prolapse (POP) during Valsalva's Maneuver, at a given total vaginal length (TVL). METHODS We performed a retrospective cohort with nested cross-sectional study of patients who underwent POP surgery. Data from obstetric and gynecologic history, preoperative and postoperative physical examinations, and 20-item Pelvic Floor Distress Inventory (PFDI-20) and 7-item Pelvic Floor Impact Questionnaire (PFIQ-7) scores were extracted. Study participants were compared in 2 groups: anteroposterior widened (>3 cm) and not widened (≤3 cm) GH, for baseline leading edge and POP stage, while controlling for TVL. Baseline PFDI-20 and PFIQ-7 scores were evaluated within GH groups. Delta GH, PFDI-20, and PFIQ-7 scores after apical suspension with and without posterior colporrhaphy were compared to assess the clinical value of the procedure. RESULTS Study participants with anteroposterior GH widening during Valsalva maneuver had greater baseline leading edge descent and higher POP stage compared with those without anteroposterior GH widening after controlling for TVL. Baseline PFDI-20 and PFIQ-7 scores were similar within both GH categories controlling for prolapse severity. Adding posterior colporrhaphy to apical suspension resulted in a greater anteroposterior GH reduction without improving delta PFDI-20 or PFIQ-7 scores. CONCLUSIONS Facilitation through herniation rather than obscuration from anteroposterior GH widening explains why patients will not be undertreated based on signs and symptoms of disease. Adding posterior colporrhaphy to apical suspension more effectively reduces anteroposterior GH widening without differential improvement in symptoms rendering the operation to no more than a cosmetic procedure.
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Wong V, Shek KL. The mesh debate: Transvaginal anterior anchored mesh should not be abandoned. Aust N Z J Obstet Gynaecol 2017; 57:105-107. [DOI: 10.1111/ajo.12589] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 12/08/2016] [Indexed: 01/30/2023]
Affiliation(s)
- Vivien Wong
- Sydney Medical School Nepean; Nepean Hospital; University of Sydney; Sydney New South Wales Australia
| | - Ka Lai Shek
- Sydney Medical School Nepean; Nepean Hospital; University of Sydney; Sydney New South Wales Australia
- Liverpool Clinical School; Western Sydney University; Sydney New South Wales Australia
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Huang WC, Yang SH, Yang JM. Pelvic floor muscle functions are improved after successful transobturator vaginal mesh procedures. Neurourol Urodyn 2017; 36:380-384. [PMID: 28235165 DOI: 10.1002/nau.22937] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/16/2015] [Indexed: 11/07/2022]
Abstract
AIMS To explore functional changes of pelvic floor muscle (PFM) after successful Perigee procedures. METHODS We retrospectively analyzed information from 145 women having achieved anatomic success, defined as <stage II cystocele according to the pelvic organ prolapse quantification (POP-Q) system. The investigated data included results from the POP-Q system and four-dimensional ultrasound at the preoperative and 12-month postoperative evaluations. The involuntary and voluntary PFM functions were, respectively, investigated during coughing and squeezing using the ultrasound parameters of the bladder neck distance (BND), bladder neck angle (BNA), genitohiatal distance (GHD), and genitohiatal angle. RESULTS Postoperatively more women displayed normal involuntary PFM function in maintaining a stable bladder neck (preoperative vs. postoperative: 4.8% vs. 22.8%, P < 0.001) and genitohiatal (preoperative vs. postoperative: 16.6% vs. 30.3%, P = 0.008) locations upon coughing and could perform voluntary PFM contractions (preoperative vs. postoperative: 49.7% vs. 64.1%, P = 0.018). Compared with preoperative manifestations, less caudal displacement of the bladder neck indicated by smaller ranges of dynamic changes in BNA following coughing (preoperative vs. postoperative: 28° vs. 12°, P < 0.001), more cranial movement of the bladder neck indicated by larger values of changes in BND following squeezing (-0.26 vs. 0.06 cm, P < 0.001), and less reduction of genitohiatal size indicated by larger values of changes in GHD following squeezing (preoperative vs. postoperative: -0.95 vs. -0.63 cm, P = 0.027) were demonstrated postoperatively. CONCLUSIONS Involuntary and voluntary PFM functions are improved after successful Perigee procedures. Neurourol. Urodynam. 36:380-384, 2017. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Wen-Chen Huang
- Department of Obstetrics and Gynecology, Cathay General Hospital, Taipei, Taiwan.,Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shwu-Huey Yang
- School of Nutrition and Health Sciences, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan
| | - Jenn-Ming Yang
- Department of Obstetrics and Gynecology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Obstetrics and Gynecology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
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Sánchez-Ferrer M, Moya-Jiménez L, Mendiola J. Comparison of the anogenital distance and anthropometry of the perineum in patients with and without pelvic organ prolapse. Actas Urol Esp 2016; 40:628-634. [PMID: 27372734 DOI: 10.1016/j.acuro.2016.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 04/06/2016] [Accepted: 04/07/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine whether there are differences in the anthropometric measures of the perineum for women with symptomatic pelvic organ prolapse who are candidates for surgery, with or without urinary incontinence, and for patients without pelvic floor dysfunction. The main objective was to measure the anogenital distance in its 2 variants: anoclitoral and anofourchette. The anogenital distance appears to be determined prenatally and is influenced by the intrauterine hormonal environment. The secondary objective was to measure the length of the genital hiatus, the perineal body and the distance between the 2 ischial tuberosities. MATERIAL AND METHODS An observational case-control study was conducted with 58 patients. The cases (n=22) were patients with stages >II 2 in the Baden-Walker classification system. The controls were patients with normal pelvic floors. Measurements were performed with a digital calliper. The patients' tocogynecological history, lifestyle habits and risk factors were recorded. RESULTS The case patients had a significantly shorter anogenital anofourchette distance than that of the control patients (P=.001), a significantly longer anogenital anoclitoral distance than the control patients (P=.0001) and a significantly longer genital hiatus length than the control patients (P=.02). CONCLUSIONS This was an observational study with a small sample. We cannot determine whether the difference in these distances are caused by or are the result of this disease. Given that the anogenital distance appears to be determined prenatally, we question whether this changed distance could be a risk factor for developing pelvic floor dysfunction.
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Ismail S, Duckett J, Rizk D, Sorinola O, Kammerer-Doak D, Contreras-Ortiz O, Al-Mandeel H, Svabik K, Parekh M, Phillips C. Recurrent pelvic organ prolapse: International Urogynecological Association Research and Development Committee opinion. Int Urogynecol J 2016; 27:1619-1632. [DOI: 10.1007/s00192-016-3076-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 06/14/2016] [Indexed: 12/13/2022]
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