Is there a pelvic organ prolapse threshold that predicts pelvic floor symptoms?

Assessing the link between birth interval and pelvic organ prolapse severity in reproductive-age women in rural Turkey: A cross-sectional study on quality of life

OBJECTIVE

Pelvic organ prolapse (POP) impacts women's quality of life globally. We aimed to assess the association between the number of births, minimum birth intervals, and POP grade, and their relationship with quality of life in reproductive-aged women in rural Turkey.

METHODS

This cross-sectional study was conducted in rural Turkey from June to September 2024, involving women attending a rural state hospital's gynecology clinic. Participants were divided into group 1 (n = 96, POP stage 0-1) and group 2 (n = 96, POP stage 2-3-4), using Pelvic Organ Prolapse Quantification (POP-Q) system staging. Genital hiatus and perineal body measurements were recorded, and the Prolapse Quality of Life (P-QOL) questionnaire was administered. As outcome measures, we assessed the number of births, minimum birth intervals, genital hiatus, perineal body measurements, and sociodemographic factors, for their associations with POP-Q stage and quality of life.

RESULTS

Participants' mean age was 38.0 ± 7.4 years. Women in group 2 had more vaginal deliveries (4.4 ± 1.5 vs. 4.0 ± 1.5; P = 0.042), shorter minimum birth intervals (18.5 ± 7.9 vs. 25 ± 29.5 months; P = 0.004), higher birth weight of the heaviest child (3667.5 ± 540.6 vs. 3468.1 ± 523.3 g; P = 0.008), and larger genital hiatus (4.3 ± 0.9 vs. 3.5 ± 1.0 cm; P < 0.001). Group 2 had significantly higher P-QOL scores, indicating poorer quality of life. Receiver operating characteristic (ROC) curve analysis identified predictive thresholds for severe prolapse: six or more vaginal deliveries, genital hiatus diameter ≥5.25 cm, and heaviest child's birth weight ≥4250 g.

CONCLUSION

Increased number of vaginal births, higher birth weight of the heaviest baby, and shorter intervals between births are significantly associated with more severe POP stages.

Knowledge of Pelvic Floor Disorders in English- and Spanish-Speaking Postpartum Patients

IMPORTANCE

Postpartum patients generally have limited knowledge of urinary incontinence (UI) and pelvic organ prolapse (POP). However, it is unclear what differences exist in knowledge level between English- and Spanish-speaking postpartum patients for each condition.

OBJECTIVE

The objective of this study was to report rates of knowledge proficiency on UI and POP in English- and Spanish-speaking postpartum patients.

STUDY DESIGN

In this cross-sectional study of postpartum patients at a tertiary care center, knowledge was assessed using the English and Spanish language-validated Prolapse and Incontinence Knowledge Questionnaire. Knowledge proficiency on UI was defined as answering correctly ≥80% of the questions and for POP as answering correctly ≥50% of the questions, based on cutoffs implemented by Geynisman-Tan et al previously. Pelvic floor disorder symptom severity was assessed using the Pelvic Floor Distress Inventory-20 and the Pelvic Floor Impact Questionnaire-7.

RESULTS

Fifty English- and 50 Spanish-speaking patients completed the survey questionnaires. Spanish-speaking patients had lower rates of UI proficiency compared to English-speaking patients (10.0% vs 40.0%, P < 0.001) and were less likely to identify childbirth to be a risk factor for UI compared to English-speaking patients. For POP, proficiency levels were low but similar between English and Spanish speakers. Pelvic floor disorder symptom severity and impact on quality of life were low, did not differ between the 2 groups, and did not correlate with knowledge scores.

CONCLUSION

English- and Spanish-speaking postpartum patients have low knowledge of both UI and POP. Postpartum patients need educational resources to understand the risks and treatments for pelvic floor disorders.

Prevalence and impact of pelvic floor dysfunctions on quality of life in women 5-10 years after their first vaginal or caesarian delivery

Background

Pelvic floor dysfunction (PFD) in women is a health problem with repercussions on quality of life. The literature agrees that PFD prevention strategies begin with identifying women who are most at risk of developing PFD in the future. However, recent evidence addressing its multifactorial origin is scant.

Objective

Our aim was to investigate late prevalence, risk factors, and the impact on quality of life of PFD in women after their first vaginal or caesarian birth.

Methods

We conducted an ambispective cohort observational study. Participants were primiparous women who had given birth to only one child by vaginal delivery or cesarean section between 2012 and 2016. Exposure and response variables, assessed using the International Consultation on Incontinence Questionnaire and the Pelvic Floor Distress Inventory, were collected during a phone interview 5-10 years after childbirth. Pearson's Chi-square, Student's t-test and odds ratio (OR) with their respective 95 % confidence intervals (CI) were calculated.

Findings

A total of 456 women were included in the study. Overall, 50 % of the women had 1 or more PFD within 10 years of giving birth, while 43.9 % of women presented urinary incontinence, 5.5 % presented pelvic organ prolapse, and 15.6 % of women reported some type of anal incontinence. A third of the women perceived the symptoms as a dysfunction and a half of them reported mild or moderate symptoms.

Conclusion

PFD in women is a prevalent and underdiagnosed problem. Our study advocates for early detection of PFD risk factors and emphasizes the need for increased visibility, awareness, and proactive health measures related to PFD.

Efficacy and safety of transvaginal mesh repair in a cohort with a minimum of 10-year follow-up

Although transvaginal mesh (TVM) repair is no longer used in some countries, long-term outcomes after TVM surgery are of great importance globally. However, reports with follow-up >10 years are limited. Thus, this study aimed to report outcomes in a prospective cohort with at least 10 years of follow-up. Women with stage III-IV symptomatic prolapse were approached consecutively from 2008 to 2013 at one tertiary hospital. The main outcome measure was symptomatic failure. Secondary outcomes included anatomic failure, recurrence, patient satisfaction, complications, and reoperation. The Kaplan-Meier curve was used to estimate the cumulative failure rate. Of the 121 patients enrolled in the study, 103 (85.1%) completed a median follow-up of 11 years. The estimated probability rates of symptomatic and anatomic failure were 17.6% and 8.8% in 11 years, respectively. The estimated incidence of symptomatic failure increased by 8.2% between 5 and 11 years; however, the corresponding rate for anatomic failure was 3.7%. The most common complication was vaginal mesh exposure, and its estimated probability increased from 19.3% to 28.4% from 5 to 11 years, respectively. Office trimming resolved 80.0% of vaginal exposures. These patients did not report decreased overall satisfaction. Patients with vaginal mesh exposure requiring>3 office procedures or mesh removal in the operating room (5.8% by 11 years) had lower satisfaction rates (P<0.01) and were defined as having severe mesh exposure. The rates of postoperative pain, reoperation, and Patient Global Impression of Improvement ⩾2 were 2.5%, 3.3%, and 94.2%, respectively. The results of this study implied that TVM treatment gradually increased the symptomatic failure rate but provided durable anatomical support of the vaginal wall. Vaginal mesh exposure was common in women who were largely not sexually active; however, 80% of the cases could be managed in the outpatient clinic, which did not affect patient satisfaction.

Measuring Pelvic Organ Prolapse: An Evolution

INTRODUCTION AND HYPOTHESIS

Advances in our understanding of pelvic organ prolapse (POP) have been made with the introduction of valid, reliable measures of anatomy and patient-reported outcome measures.

METHODS

This review provides an overview of the evolution of POP measurement and its implications for clinical practice and research.

RESULTS

Since the introduction of the Pelvic Organ Prolapse Quantification (POPQ), studies have demonstrated that some degree of loss of anatomic support is normal, with as many as 40% of normal women having stage 2 prolapse. Vaginal support is dynamic and can wax and wane but is largely stable over time. Vaginal bulge symptoms are the most reliable and specific symptom for POP and the hymen is an important threshold for symptom development. Most pelvic floor symptoms have only weak to moderate correlation with the anatomic severity of POP. Treatment success rates are highly variable depending upon criteria used and definitions of anatomic success commonly used are too strict and often not clinically relevant. There is substantial discordance between subjective and anatomic measures of success, and both are dynamic, fluctuating between success and failure for many patients without intervening treatment.

CONCLUSIONS

Pelvic organ prolapse is multidimensional, dynamic, and has a complex impact on patients. Patients' symptoms are more clinically relevant than anatomic support. Symptomatic cure, particularly the absence of vaginal bulge symptoms, is more clinically relevant than anatomic cure and composite outcomes can be misleading and overestimate failure rates. Future studies should compare treatments using continuous variables along multiple dimensions rather than using composite outcomes or dichotomizing patients into success or failure.

Prevalence and risk factors of pelvic organ prolapse among women in Sidama region, Ethiopia: A community-based survey

BACKGROUND

Pelvic organ prolapse is a descent of the vaginal compartments and the surrounding organ due to loss of support of the vaginal tissue. It has a significant psychological, physical, and social impact that affects women's quality of life. However, its true prevalence is unknown due to the variability in the methods used to diagnose the disorder.

OBJECTIVES

This study aimed to determine the prevalence of pelvic organ prolapse and its associated risk factors among women in Sidama region, Ethiopia.

STUDY DESIGN

A community-based cross-sectional survey was conducted in the Dale-Wonsho Health and Demographic Surveillance Site, Sidama region, from March to October 2023.

METHODS

A multi-stage stratified cluster sampling was used to select a sample of 816 women. Anatomical prolapse was diagnosed based on the standardized pelvic organ prolapse quantification method, and symptomatic prolapse was assessed by patient-reported symptoms. A complex survey-based modified Poisson regression was used to assess the risk factors associated with prolapse.

RESULTS

A total of 815 participated in the interview, and 779 (95.6%) underwent pelvic examination to assess for prolapse status. Anatomical prolapse (Stages II-IV) was observed in 241 (30.9%; 95% confidence interval = 24-38.7) of the participants. The prevalence of symptomatic pelvic organ prolapse was 78.5% (95% confidence interval = 69.1-85.7) among women with anatomical prolapse (189/241). This prevalence falls to 24.27% (95% confidence interval = 19.98-29.16) for the total sample population. Higher frequency of childbirth, prolonged heavy lifting activities, and prolonged labor increased the likelihood of developing anatomical prolapse. Childbirth at an early age and prolonged heavy lifting activities were significantly associated with symptomatic prolapse.

CONCLUSION

Anatomical prolapse and symptomatic prolapse are high in the study area. Parity, prolonged heavy lifting, prolonged labor, and early age childbirth were associated with pelvic organ prolapse. Community-based education and interventions that focus on the modification of risk factors are needed.

Differences Between 25-hydroxyvitamin D Levels in Patients with Pelvic Organ Prolapse and Non-Pelvic Organ Prolapse: A Systematic Review

OBJECTIVES

Treatment options for cases of pelvic organ prolapse still lead to the use of a pessary rather than a surgical method. Additional therapy is needed to help treat or prevent pelvic organ prolapse. Vitamin D deficiency has consistently been associated with decreased muscle function, so it is assumed that it will affect the pelvic floor muscles. This paper systematically explores the differences between 25-hydroxyvitamin D levels in patients with pelvic organ prolapse and non-pelvic organ prolapse.

STUDY DESIGN

A systematic review was conducted through the PubMed, Google Scholar, Cochrane Library, and ScienceDirect databases using relevant keywords. Articles published in the last 10 years-from 2012 to 2022-that were written in English, that discuss the status or effect of vitamin D on pelvic organ prolapse, and that focus on 25 OH-vitamin D were included in the review.

RESULTS

In total, 717 articles were filtered but 8 articles met the criteria. A total of 1339 women with prolapse and without prolapse with ages ranging from 20 years to 78 years were included in the study. The studies found did not use the same standard threshold in determining deficiency status. Most studies have found that there are lower levels of vitamin D in women who have had pelvic organ prolapse. A total of 7 of 8 studies confirmed the comparison of vitamin D-25OH levels in women with pelvic organ prolapse and without pelvic organ prolapse at P < 0.05.

CONCLUSIONS

There are differences between 25-hydroxyvitamin D levels in patients with pelvic organ prolapse and non-pelvic organ prolapse.

Anatomical and symptomatic mid-term outcomes of patients with isolated anterior compartment defect repair or stress urinary incontinence : Anatomical and symptomatic outcomes of anterior compartment repair or SUI

BACKGROUND

An evaluation of preoperative and postoperative 12th month Pelvic Organ Prolapse Quantification (POP-Q) and Lower Urinary Tract Symptoms (LUTS) changes in patients operated for the diagnosis of isolated anterior compartment defect (ACD) or Stress Urinary Incontinence (SUI).

METHOD

Patients who were diagnosed with isolated ACD or SUI were retrospectively analyzed at urogynecology unit of our tertiary referral center. All pelvic examinations were performed by the same experienced urogynecologist. Pre-operative and post-operative 12th month POP-Q scores and the responses to a detailed LUTS questionnaire in the unit were assessed.

RESULTS

Of the 90 patients with isolated ACD or SUI, midurethral sling with mini-sling and retropubic transobturator tape methods was applied in 24, iliococcygeal fixation in 28, trapezoid repair in 9 patients, anterior bridge operation in 14, and plication of pubocervicovaginal fascia to the cervical ring in 15. We compared the POP-Q score and pre and post-operative 12th month LUTS. Between pre and post-operative 12th month, there was a statistically significant difference at Aa and Ba points (p < 0.00, 0.001). Comparative LUTS questionnaire showed statistically significant differences in stress urinary incontinence, frequency, urgency, abnormal emptying, nocturia, pelvic pain (p: <0.001, p < 0.001, p: <0.001, p:0.001, p:<0.001, p:0.003, respectively).

CONCLUSION

Anatomical and symptomatic recovery is achieved with appropriate surgical intervention in women with isolated ACD or SUI. When LUTS were evaluated in terms of symptomatic recovery, they were found to be related not only to symptoms involving the anterior compartment, but also to symptoms involving other compartments.

Robot-Assisted Sacrocolpopexy versus Trans-Vaginal Multicompartment Prolapse Repair: Impact on Lower Bowel Tract Function

BACKGROUND

This study evaluated the effectiveness, safety, and possible changes in bowel symptoms after multicompartment prolapse surgery by comparing two different surgical approaches, transvaginal mesh surgery with levatorplasty (TVMLP) and robot-assisted sacrocolpopexy (RSC).

METHODS

All patients underwent pelvic (POP-Q staging system) and rectal examination to evaluate anal sphincter tone in the lithotomy position with the appropriate Valsalva test. The preoperative evaluation included urodynamics and pelvic magnetic resonance defecography. Patient Global Impression of Improvement (PGI-I) at follow-up measured subjective improvement. All patients completed Agachan-Wexner's questionnaire at 0 and 12 months of follow-up to evaluate bowel symptoms.

RESULTS

A total of 73 cases were randomized into the RSC group (36 cases) and TVMLP group (37 cases). After surgery, the main POP-Q stage in both groups was stage I (RCS 80.5% vs. TVMLP 82%). There was a significant difference (p < 0.05) in postoperative anal sphincter tone: 35%. The TVMLP group experienced a hypertonic anal sphincter, while none of the RSC group did. Regarding subjective improvement, the median PGI-I was 1 in both groups. At 12 months of follow-up, both groups exhibited a significant improvement in bowel symptoms.

CONCLUSIONS

RSC and TVMLP successfully corrected multicompartment POP. RSC showed a greater improvement in the total Agachan-Wexner score and lower bowel symptoms.

Anatomic Criterion for Clinically Relevant Apical Prolapse in Urogynecology Populations

IMPORTANCE

Despite recognition of the critical role of the apex in vaginal support, there is no consensus on the anatomic criteria for clinically relevant apical prolapse.

OBJECTIVE

The aim of this study was to define an optimal anatomic criterion for clinically relevant apical prolapse.

STUDY DESIGN

This retrospective cohort study included 3,690 patients who had visited a tertiary hospital for ambulatory urogynecologic care. Vaginal bulge symptom was defined as a response of "somewhat," "moderately," or "quite a bit" to Question 3 on the Pelvic Floor Distress Inventory-20. Receiver operating characteristic curves were generated for a vaginal bulge symptom and apical support (Pelvic Organ Prolapse Quantification point C and C/total vaginal length [TVL]).

RESULTS

Both point C and the C-to-TVL ratio (C/TVL) had excellent performance for predicting vaginal bulge symptoms (area under the curve, 0.917 and 0.927, respectively). The optimal cutoffs were -3.0 for C and -0.50 for C/TVL. When we analyzed the data set according to the TVL, there was a significant difference in the cutoffs for C, whereas those for C/TVL had little difference. There was no difference in the cutoffs of C and C/TVL according to hysterectomy status.

CONCLUSIONS

The C/TVL is more appropriate than point C as a measure to define an anatomic criterion for clinically relevant apical prolapse. Descent of the vaginal apex beyond the halfway point of the vagina could be considered as an anatomic threshold for clinically relevant apical prolapse. This finding needs to be validated in nonurogynecology populations.

Incidence of de novo stress urinary incontinence following minimally invasive sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the incidence and risk factors of postoperative de novo stress urinary incontinence (SUI) in stress-continent women following minimally invasive sacrocolpopexy without an anti-incontinence procedure.

METHODS

We completed a multicenter, retrospective cohort study of women undergoing laparoscopic sacrocolpopexy without concurrent anti-incontinence procedures from October 2006 through January 2021.

RESULTS

Of the 169 women who underwent minimally invasive sacrocolpopexy, 17.1% (n=30) developed de novo SUI, and 7.1% eventually underwent a midurethral sling placement. On logistic regression, BMI, preoperative urinary urgency, and history of transvaginal mesh repair were found to be significantly associated with and predictive of de novo SUI. When the concordance index (C-index) was calculated with the model published by Jelovsek et al. for women who developed de novo SUI within 12 months of the prolapse surgery, the current de novo SUI calculator was able to discriminate de novo SUI outcome (C-index = 0.71).

CONCLUSIONS

The incidence of de novo SUI after minimally invasive sacrocolpopexy without anti-incontinence procedure correlates directly with higher BMI, preoperative urinary urgency, and transvaginal mesh history for POP. Preoperative counseling for minimally invasive sacrocolpopexy should include discussing the risk of de novo SUI and preoperative factors that may increase this risk.

Reliability and validity of the Sidaamu Afoo version of the pelvic organ prolapse symptom score questionnaire

BACKGROUND

Both for clinical and research purposes, it is critical that clinicians and researchers use a tool that is trans-culturally adapted and tested for its psychometric properties. The English version of the Pelvic Organ Prolapse Symptom Score (POP-SS) questionnaire was developed in 2000. Since then it has been translated into other languages and verified. However, the tool has not been adapted for use in Sidaamu Afoo language in the Sidama Region of Ethiopia.

OBJECTIVE

This study aimed to translate and adapt the Pelvic Organ Prolapse Symptom Score questionnaire into Sidaamu Afoo and evaluate its psychometric properties.

METHODS

A total of 100 women with symptomatic prolapse completed version-2 of the POP-SS questionnaire during the first round of interviews, and 61 of them completed the questionnaire during the second round of interviews (to establish the test-retest reliability). We adapted the scale translation process recommended by Beaton and his colleagues. The content validity was assessed using the content validity index and the construct validity was done based on exploratory factor analysis using the principal component analysis model. The criterion validity was evaluated by using the Kruskal-Wallis test based on stages of the prolapse established via pelvic examination. The internal consistency reliability of the scale was assessed using Cronbach's alpha value, and test-retest reliability was evaluated using the intraclass correlation coefficient.

RESULTS

The questionnaire was successfully translated to Sidaamu Afoo, and achieved a good content validity index (0.88), high internal consistency (Cronbach's alpha of 0.79), and test-retest reliability (an intraclass correlation coefficient of 0.83). The exploratory factor analysis revealed two factors based on an eigenvalue of 1. The two factors explained 70.6% of the common variance, and each item loaded well (0.61 to 0.92) to its corresponding factor. There is a significant difference in the median score of prolapse symptoms across different stages of prolapse (Kruskal-Wallis χ², 17.5, p < 0.001).

CONCLUSION

The Sidaamu Afoo version of the POP-SS tool is valid and reliable. Further studies that involve a balanced number of women in each stage of prolapse are needed to avoid the ceiling and floor effects.

Robotic sacrocolpopexy with autologous fascia lata: A case series

Objectives

Apical prolapse involves the upper vagina or vaginal vault after hysterectomy. Treatment is indicated for symptomatic women, and surgical approach is considered for women who failed or refused conservative therapy. We performed 10 pickups of autologous fascia, used for robotic sacrocolpopexy (RSCP).

Materials and Methods

We included patients between 60 and 80 years old who showed a Pelvic Organ Prolapse Quantification (POP-q) over the second stage and with symptoms related to prolapse.

Results

All of them underwent autologous fascia lata (AFL) pickup from the right leg and after to RSCP. One patient underwent also posterior colporrhaphy. The mean intraoperative time was 199.2 min (183-230 min). No intra-operatory complications were reported. POP-q assessment during follow-up showed improvements: C point gained on average 7.6 points (5-8) and mean values went from -0.6 to - 8.2 cm (-7 to -9 cm). The three women who had anterior compartment defects shows good anatomical reconstitution with a mean Aa and Ba value of - 2.83 cm (-2.5 to -3 cm) and gained 4 points (average gain: 3.5-4.5 cm). Total vaginal lenght (TVL).

Conclusion

According to these data, in our experience, AFL employment showed a good anatomical result from the first to last follow-up.

Clinical assessment of pelvic organ prolapse by consecutive cough maneuver

INTRODUCTION AND HYPOTHESIS

Staging of pelvic organ prolapse (POP) is important in clinical practice and research. Pelvic organ descent on Valsalva can be confounded by levator co-activation, which may be avoided by assessment on coughing. We evaluated the performance of a three consecutive coughs maneuver in the assessment of POP compared with standardised 6-second Valsalva.

METHODS

This was a retrospective observational study carried out in women attending a tertiary urogynaecological service in 2017-2019. Patients underwent a standardised interview and clinical examination. Clinical assessment was performed twice, with both 6-s Valsalva and three consecutive coughs performed in random order. Main outcomes were Ba, C and Bp as defined by Pelvic Organ Prolapse-Quantification (POP-Q). Association between coordinates and prolapse symptoms was investigated with receiver-operating characteristic (ROC) statistics.

RESULTS

Datasets of 855 women were analysed. POP symptoms were reported by 447 patients (52%) with a mean bother of 6.1 (SD 3.0). On clinical assessment, relevant prolapse was found in 716 (84%) patients on Valsalva and in 730 (85%) on coughing (p=0.109). Clinically relevant prolapse in the apical compartment was more likely to be detected on Valsalva (p<0.0001). Mean POP-Q measurements were not significantly different between maneuvers, except for Ba (p=0.004). ROC curve analysis yielded an area under the curve of 0.74 (95% CI, 0.70-0.77) for maximum POP-Q stage on Valsalva and 0.72 (95% CI, 0.69-0.75) after three consecutive coughs, with a similar performance of both maneuvers in predicting prolapse symptoms (p=0.95).

CONCLUSIONS

Clinical assessment of POP by consecutive coughing seems complementary to standardised Valsalva, especially if Valsalva performance is poor.

Translation, reliability, and validity of Amharic versions of the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7)

Purpose

Pelvic Floor Disorders (PFDs) affects many women and have a significant impact on their quality of life. Pelvic Floor Impact Questionnaire (PFIQ-7) and Pelvic Floor Distress Inventory (PFDI-20) help to assess PFDs; however, both are not culturally translated into the Amharic-language. Hence, we aimed to translate the English versions of short forms of the PFDI-20 and PFIQ-7 into Amharic-language and evaluate their psychometric properties in Amharic-speaking Ethiopian women with symptomatic PFDs.

Methods

The PFDI-20 and PFIQ-7 were translated into Amharic language using standard procedures. The Amharic versions were completed by 197 patients (response rate 92%) with PFDs from University of Gondar specialized and comprehensive Hospital. Internal consistency and test-retest reliability were examined through Cronbach’s alpha and Intraclass correlation coefficients (ICC). A relative criterion standard, POP-SS-7 score, was correlated with total PFDI-20 and subscale POPDI-6 scores using spearman’s rank order correlation (SCC). Construct validity was evaluated by known group validity using the Mann–Whitney U test.

Results

Both instruments were successfully translated and adapted with an excellent content validity (> 0.90). The Amharic versions of the PFDI-20 and PFIQ-7 showed excellent internal consistency and test-retest reliability in both summary and subscales (Cronbach’s alpha: 0.92 for PFDI-20 and 0.91 for PFIQ-7; and ICC: 0.97 for PFDI-20 and 0.86 for PFIQ-7). Criterion validity was good for POPDI-6 (SCC = 0.71; p < 0.001). Moreover, construct validity was acceptable, showing significant differences among groups of PFDs in the PFDI-20 and PFIQ-7 scores (Mann–Whitney U Test; p < 0.001).

Conclusions

The Amharic versions of the PFDI-20 and PFIQ-7 are comprehensible, reliable, valid, and feasible in Ethiopian Amharic-speaking women with PFDs to evaluate symptoms and its impact during research and clinical practice. However, further studies are needed to evaluate the responsiveness.

Lipoleiomyomas of the Uterine Cervix: A New Series including the First Recurrent Case and the First Systematic Literature Review

Uterine leiomyomas usually arise from the uterine body (95%), and rarely from the cervix (0.6%) or other urogenital sites. Lipoleiomyomas are benign, uncommon variants of leiomyomas (0.03-0.2%), histologically composed of smooth muscle cells and mature adipocytes; they usually occur in the uterine body and exceptionally in the cervix. We performed the first systematic literature review of cervical lipoleiomyomas (PRISMA guidelines), presenting five new cases. Including our series, thirty-one detailed cases were reported in the literature (mainly in Asia). The age range was 35-74 years, revealing a higher mean age than conventional cervical leiomyomas (46.5 vs. 39.4 years). Patients were usually multiparous (94%), typically complaining of vaginal bleeding (11/31, 36%), pelvic/abdominal pain (10/31, 32%), and/or urinary disturbances (6/31, 19%) 1 week to 10 months before presentation. Clinical examination revealed a pedunculated tumor (48%), or prolapse of ≥1 pelvic organs (16%). Twenty-four (77%) patients underwent total hysterectomy ± additional surgery; simple myomectomy/excision was performed in five (16%) cases. Only one (3%) of our cases recurred 2 years after partial excision; no evidence of disease was found 13 years after recurrence excision. Adipocytes occupied ≤50% of the tumor volume. Hyaline or myxoid changes and cartilaginous metaplasia were uncommon histological findings. Surgically challenging cases or pregnant patients may require expert gynecologists. Interventional radiology or conservative treatments were rarely proposed.

Determining the Ideal Intraoperative Resting Genital Hiatus Size-Balancing Surgical and Functional Outcomes

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.

AUGS-PERFORM: A New Patient-Reported Outcome Measure to Assess Quality of Prolapse Care

Patient-reported outcomes (PRO) are important for measuring quality of care, particularly for interventions aimed at improving symptom bother such as procedures for pelvic organ prolapse. We aimed to create a concise yet comprehensive PRO measurement tool to assess pelvic organ prolapse care in high-volume clinical environments.

Methods

The relevant concepts to measure prolapse treatment quality were first established through literature review, qualitative interviews, and a patient and provider-driven consensus-building process. Extant items mapping to these concepts, or domains, were identified from an existing pool of patient-reported symptoms and condition-specific and generic health-related quality of life measures. Item classification was performed to group items assessing similar concepts while eliminating items that were redundant, inconsistent with domains, or overly complex. A consensus meeting was held in March 2020 where patient and provider working groups ranked the remaining candidate items in order of relevance to measure prolapse treatment quality. After subsequent expert review, the revised candidate items underwent cognitive interview testing and were further refined.

Results

Fifteen relevant PRO instruments were initially identified, and 358 items were considered for inclusion. After 2 iterative consensus reviews and 4 rounds of cognitive interviewing with 19 patients, 11 final candidate items were identified. These items map 5 consensus-based domains that include awareness and bother from prolapse, physical function, physical discomfort during sexual activity, pain, and urinary/defecatory symptoms.

Conclusions

We present a concise set of candidate items that were developed using rigorous patient-centered methodology and a national consensus process, including urogynecologic patients and providers.

36-Month Prospective Study of Transvaginal Bovine Graft versus Native Tissue Repair for the Treatment of Pelvic Organ Prolapse

OBJECTIVE(S)

To compare the safety and effectiveness of dermal bovine transvaginal graft, Xenform, to native tissue in the surgical treatment of anterior and/or apical pelvic organ prolapse. This study was designed in conjunction with FDA requirements.

METHODS

This was a prospective, non-randomized, parallel cohort, multi-center trial. The primary objective was to demonstrate non-inferiority between transvaginal graft and native tissue repair at 36 months compared to baseline. Treatment success was based on a composite of objective and subjective measures. The co-primary outcome was the rate of serious device- or procedure-related adverse events. A total of 228 patients at 25 sites were included in the study arm and 485 patients underwent native tissue repair. Propensity score stratification was applied to achieve balance between treatment groups. Study outcomes were compared in per protocol and intent-to-treat analysis.

RESULTS

The primary outcome, treatment success at 36 months, was 83.6% (191/228) for transvaginal graft and 80.5% (390/485) native tissue repair (0.2%, 90%CI [-5.6%, 5.9%]), demonstrating non-inferiority at a preset margin of -12%. The overall rate of severe adverse events was 5.3% (12/228) in transvaginal graft vs 2.7% (13/485) in native tissue repair groups. The study group demonstrated non-inferiority in serious adverse events at the preset margin of 11.6% (2.0%, 90%CI [-0.8%, 4.7%]). There were no reports of graft erosion, and graft exposure rates were low (0.9% [2/228]).

CONCLUSIONS

Transvaginal repair of anterior and/or apical prolapse with a biological graft is non-inferior to traditional native tissue repair in effectiveness and safety at 36 months.

Ultrasound-Measured Urethral Length Does Not Change following Minimally Invasive Sacrocolpopexy for Pelvic Organ Prolapse

OBJECTIVES

To compare urethral length (UL), as measured by three-dimenstional transvaginal ultrasound, before and after minimally invasive sacrocolpopexy (SCP).

METHODS

Secondary analysis of a prospective cohort study of women undergoing SCP for prolapse beyond the hymen with or without a concomitant anti-incontinence procedure. Participants underwent ultrasound at baseline and 14 weeks postoperatively. UL was measured in a reconstructed sagittal plane from the bladder neck to the urethral meatus. All of the participants underwent multichannel urodynamics preoperatively. Data were analyzed in SPSS using independent or paired t tests as indicated for continuous variables and the McNemar test for paired dichotomous variables. Correlations including nonparametric data are reported as Spearman rho.

RESULTS

A total of 28 participants, with a mean ± standard deviation age of 56 ± 10 years and median (interquartile range) preoperative prolapse stage of 3 (3-3), were analyzed. There was no change in UL between the baseline and 14-week visits (29.8 ± 11.0 mm vs 29.3 ± 10.0 mm, P = 0.83). There was no difference in baseline UL (29.4 ± 11.8 mm vs 30.9 ± 8.9 mm, P = 0.74) in those with and without preoperative stress urinary incontinence (SUI), nor was there a difference in baseline functional UL on multichannel urodynamics between these groups. In total, 21 participants (75%) had preoperative SUI and 19 (90%) underwent a concomitant anti-incontinence procedure. UL at 14 weeks was similar in those with and without SUI symptoms (26.5 ± 10.9 mm vs 31.1 ± 11.3 mm, P = 0.32) when controlling for those who underwent anti-incontinence procedures.

CONCLUSION

UL does not change following suspension of the anterior vaginal wall with SCP.

What is known from the existing literature about self-management of pessaries for pelvic organ prolapse? A scoping review protocol

INTRODUCTION

Pelvic organ prolapse (POP) can be managed with a pessary; however, regular follow-up may deter women from pessary management due to the inconvenience of frequent appointments, as well as preventing pessary users from autonomous decision-making. Pessary self-management, whereby the woman removes and inserts her own pessary may be a solution to these issues. However, there remains a number of uncertainties regarding the potential benefits and risks of pessary self-management. This scoping review aims to map available evidence about the subject of pessary self-management for POP to identify knowledge gaps providing the basis for future research.

METHODS AND ANALYSIS

The scoping review will be conducted using the Joanna Briggs Institute scoping review methodology and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A search of Medline, CINAHL, Embase and PsycInfo will be undertaken to identify relevant articles which meet the eligibility criteria using the search terms 'pessary' and 'self-management' or 'self-care'. A hand search of the reference list of non-original research identified during the search but excluded, will be conducted for additional publications which meet the inclusion and exclusion criteria. Data relevant to the topic of pessary self-management will be extracted and critical appraisal of all included publications undertaken.

ETHICS AND DISSEMINATION

No ethical or Health Research Authority approval is required to undertake the scoping review. However, it has been registered with The Open Science Framework (DOI 10.17605/OSF.IO/DNGCP). The findings will inform future research exploring pessary self-management and be disseminated via both a presentation at a national conference and publications in peer reviewed journals.

A Preference-Sensitive Online Instrument to Support Shared Decision Making for Patients With Pelvic Organ Prolapse: A Pilot Multicenter Randomized Controlled Trial

A preference-sensitive instrument for women with pelvic organ prolapse was developed to increase shared decision-making. This study aimed to assess the feasibility of a randomized controlled trial to measure the effectiveness of the instrument. A pilot randomized controlled trial was conducted at three Danish gynecological clinics to assess feasibility through recruitment rates, per-protocol use and women's perception of (1) support for decision-making, (2) shared decision-making (Shared Decision-Making Questionnaire), and (3) satisfaction with their decisions. In addition, a focus group interview with participating gynecologists (five gynecologists) was conducted. We invited 226 women and recruited 46 (20%). The most common reason (45%) for nonparticipation was overlooking the invitation in their online public mailbox. Shared Decision-Making Questionnaire showed high data completeness (96%) but indicated a ceiling effect. Women felt the developed instrument supported their decision-making and more so if it was used interactively during consultations. Despite finding the instrument generally useful, gynecologists tended to apply the instrument inconsistently and not per protocol (41%), and some used it as a template for all consultations. This pilot study indicates that recruitment methods, for a future randomized controlled trial, for example, nurse-led preconsultations, need reconsideration due to low recruitment rates and inefficient per-protocol use. In a future randomized controlled trial, cluster randomization should avoid the carryover effect bias.

Hip and Pelvic Floor Muscle Strength in Women with and without Urgency and Frequency Predominant Lower Urinary Tract Symptoms

Background

Urgency and frequency are common lower urinary tract symptoms (UF-LUTS) in women. There is limited evidence to guide physical therapist-led treatment.

Objectives

To compare hip and pelvic floor muscle strength between women with and without UF-LUTS. We hypothesized women with UF-LUTS would demonstrate 1) diminished hip external rotator and abductor strength and 2) equivalent pelvic floor strength and diminished endurance compared to controls.

Study Design

A matched case-control study.

Methods

Women with UF-LUTS (cases) and controls were matched on age, body mass index (BMI), vaginal parity. Examiner measured participants' 1) hip external rotator and abductor strength via dynamometry (maximum voluntary effort against fixed resistance) and 2) pelvic floor muscle strength (peak squeeze pressure) and endurance (squeeze pressure over a 10 second hold) via vaginal manometry. Values compared between cases and controls with paired-sample t-tests (hip) or Wilcoxon signed rank tests (pelvic floor).

Results

21 pairs (42 women): Hip external rotation (67.0 ± 19.0 N vs 83.6 ± 21.5 N; P=0.005) and hip abduction strength (163.1 ± 48.1 N vs 190.1 ± 53.1 N; P=0.04) were significantly lower in cases than controls. There was no significant difference in pelvic floor strength (36.8 ± 19.9 cmH₂0 vs 41.8 ± 21.0 cmH₂0; P=0.40) or endurance (234.0 ± 149.6 cmH₂0*seconds vs 273.4 ± 149.1 cmH₂0*seconds; P=0.24).

Conclusion

Women with UF-LUTS had weaker hip external rotator and abductor muscles, but similar pelvic floor strength and endurance compared to controls. Hip strength may be important to assess in patients with UF-LUTS, further research is needed.

International Urogynecological Consultation: clinical definition of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This segment of Chapter 1 of the International Urogynecology Consultation (IUC) on pelvic organ prolapse (POP) reviews the literature on the clinical definition of POP with the intent of creating standard terminology.

METHODS

An international group containing nine urogynecologists and one university-based medical librarian performed a search of the literature using pre-specified search terms in PubMed, Embase, and Scopus. Publications were eliminated if not relevant to the clinical definition of POP, and those articles remaining were evaluated for quality using the Specialist Unit for Review Evidence (SURE). The resulting list of articles was used to inform a comprehensive review and creation of the clinical definition of POP.

RESULTS

The original search yielded 31,931 references, of which 167 were used by the writing group. Ultimately, 78 are referenced in the manuscript.

CONCLUSIONS

The clinical definition of POP for this review of the literature is: "anatomical prolapse with descent of at least one of the vaginal walls to or beyond the vaginal hymen with maximal Valsalva effort WITH the presence either of bothersome characteristic symptoms, most commonly the sensation of vaginal bulge, or of functional or medical compromise due to prolapse without symptom bother."

Pelvic organ prolapse recurrence after apical prolapse repair: does obesity matter?

INTRODUCTION AND HYPOTHESIS

We hypothesized obesity increases the risk of pelvic organ prolapse recurrence (POP-R) after primary apical prolapse repair.

METHODS

We conducted a retrospective cohort study of 353 women who underwent primary apical prolapse surgery from 2011 to 2016. Demographic and clinical data were abstracted from medical records. Multivariable Cox proportional hazard models were used to generate hazard ratios (HR) for association between obesity (BMI ≥ 30 kg/m²) and POP-R (leading edge > 0), adjusting for potential confounders. Given the potential for outcome ascertainment bias due to differential loss to follow-up, a sensitivity analysis was performed assuming all patients with < 6 months of follow-up developed POP-R.

RESULTS

Ten percent of women developed POP-R. The median follow-up time was 7 months (range 1.4, 63.9). Twenty-four percent of patients were Black and 70% were White; 37% were obese. After controlling for confounders, obese women did not have an increased risk of POP-R (aHR 1.39; 95% CI 0.67, 2.86, p = 0.38). Although only marginally statistically significant, patients who developed POP-R were more likely to be current smokers (aHR 3.48, 95% CI 1.14, 10.67; p = 0.06) or previous smokers (aHR 1.86, 95% CI 0.82, 4.24, p = 0.06) in comparison to non-smokers. Sensitivity analysis showed loss to follow-up had the potential to influence our results.

CONCLUSIONS

Obesity was not a risk factor for POP-R in our cohort. Larger, prospective studies with longer postoperative follow-up time are needed to fully elucidate the relationship between obesity and POP-R.

Clinical relevance of routine transvaginal ultrasound in women referred with pelvic organ prolapse

Background

The aim of this study was to investigate the prevalence of incidental findings on transvaginal ultrasound scan in women referred with pelvic organ prolapse by a general practitioner and to investigate which further examinations and treatments were performed as a result of these findings.

Methods

This was a retrospective cohort study that investigated women with pelvic organ prolapse referred to the outpatient urogynaecological clinics at Randers Regional Hospital and Aarhus University Hospital, Denmark.

Results

A total of 521 women were included and all of them were examined with a routine transvaginal ultrasound scan and a gynaecological examination. Prolapse symptoms only and no specific indication for transvaginal ultrasound scan were seen in 507 women (97.3%), while 14 women (2.7%) received scans on indication. Among the latter women, five (35.7%) had cancer. In the women with solely prolapse symptoms, 59 (11.6%) had incidental findings on transvaginal ultrasound scan, but all were benign. However, two patients were later diagnosed with cancer unrelated to the initial ultrasound findings. The treatment was extended with further examinations not related to POP in 19 of the women (32.2%) with incidental ultrasound findings.

Conclusion

The prevalence of incidental ultrasound findings was not high in the women referred with pelvic organ prolapse and no additional symptoms, and all these findings were benign. However, it should be considered that these findings resulted in further investigations and changes to the patients’ initial treatment plans. A meticulous anamnesis and digital vaginal examination are crucial to rule out the need for vaginal ultrasound.

Pelvic organ prolapse and treatment decisions- developing an online preference-sensitive tool to support shared decisions

Background

Female patients with pelvic organ prolapse and clinicians need to take decisions regarding treatment that are often unpredictable in relation to how they impact the future everyday lives of the patients.

This study formed the developmental phase of a larger study to develop and test an online tool to support shared decision-making.

Methods

Patients, health care professionals and other stakeholders participated in the development and evaluation process of this tool. The collected data was generated from observational studies, exploratory interviews with prompt cards and workshops with end users from four Danish gynecology outpatient clinics.

Results

Content analysis led to important themes. For the patients three themes emerged: 1) how the impact of symptoms on everyday life affected the need for relief, 2) their bodily perception and sex life and 3) their worries about the future. For clinicians the different symptoms and their severity was a main theme.

Conclusions

This article provides an overall description and discussion of the development methodology. It demonstrates how user involvement informed the prototyping process and how patients’ preferences were included in the final prototype. Whether the tool actually increases SDM, remains to be tested in a pilot feasibility study.

Does apical prolapse in addition to early stage anterior prolapse have any effect on lower urinary tract symptoms?

OBJECTIVE

To investigate whether apical prolapse in addition to early-stage anterior prolapse has any effect on lower urinary tract symptoms (LUTS).

METHODS

Patients with early-stage pelvic organ prolapse (POP) were retrospectively analyzed at the urogynecology unit of a tertiary referral center. Cases with posterior POP were excluded, and the remaining women were distributed across four main groups: (1) no determinable anterior and/or apical POP (control); (2) isolated anterior POP; (3) anterior + apical POP; and (4) isolated apical POP. Each LUTS symptom in these groups was recorded. Women with isolated anterior POP and women with anterior + apical POP were then compared to define the additional effects of apical prolapse on LUTS. In order to asses; symptoms of urgency, urinary incontinence, stress urinary incontinence, frequency, abnormal emptying, hesitancy, interrupted stream, nocturia, post-micturition dribble, and dysuria were noted and Incontinence Impact Questionnaire (IIQ-7), and domains of Urinary Distress Inventory (UDI-6) were compared between the groups.

RESULTS

Of the 225 patients, 66 were excluded from the analysis due to accompanying posterior compartment defect. There was no statistically significant difference for age, systemic disease history, or smoking status between the groups (p > 0.05). However, history of traumatic vaginal delivery was significantly lower in the control group than in the other groups (p = 0.039). The prevalence of hesitancy and interrupted stream were found to be significantly higher in the anterior + apical POP group than in the isolated POP group (p<0.05). Obstructive subscale of the Urinary Distress Inventory was higher both in the isolated anterior POP and anterior + apical POP groups than the control group (p<0.05).

CONCLUSION

The current study demonstrates that even minimal loss of apical support accompanying anterior prolapse exacerbates LUTS.

Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214

Pelvic organ prolapse (POP) is a common, benign condition in women. For many women it can cause vaginal bulge and pressure, voiding dysfunction, defecatory dysfunction, and sexual dysfunction, which may adversely affect quality of life. Women in the United States have a 13% lifetime risk of undergoing surgery for POP (). Although POP can occur in younger women, the peak incidence of POP symptoms is in women aged 70-79 years (). Given the aging population in the United States, it is anticipated that by 2050 the number of women experiencing POP will increase by approximately 50% (). The purpose of this joint document of the American College of Obstetricians and Gynecologists and the American Urogynecologic Society is to review information on the current understanding of POP in women and to outline guidelines for diagnosis and management that are consistent with the best available scientific evidence.

Genome-wide association identifies seven loci for pelvic organ prolapse in Iceland and the UK Biobank

Pelvic organ prolapse (POP) is a downward descent of one or more of the pelvic organs, resulting in a protrusion of the vaginal wall and/or uterus. We performed a genome-wide association study of POP using data from Iceland and the UK Biobank, a total of 15,010 cases with hospital-based diagnosis code and 340,734 female controls, and found eight sequence variants at seven loci associating with POP (P < 5 × 10-8); seven common (minor allele frequency >5%) and one with minor allele frequency of 4.87%. Some of the variants associating with POP also associated with traits of similar pathophysiology. Of these, rs3820282, which may alter the estrogen-based regulation of WNT4, also associates with leiomyoma of uterus, gestational duration and endometriosis. Rs3791675 at EFEMP1, a gene involved in connective tissue homeostasis, also associates with hernias and carpal tunnel syndrome. Our results highlight the role of connective tissue metabolism and estrogen exposure in the etiology of POP.

Pelvic organ prolapse in Northwest Ethiopia: a population-based study

INTRODUCTION AND HYPOTHESIS

Epidemiological studies aimed at pelvic organ prolapse and its risk factors can help to identify women at a higher risk and therefore promote prevention strategies. We aimed to assess the prevalence of and factors associated with symptomatic prolapse.

METHODS

A community-based study was conducted in Dabat district, Northwest Ethiopia. Initially, women were interviewed on their prolapse symptoms using validated questionnaires at their home. Subsequently, they were invited for pelvic examination and examined by gynecologists using the simplified pelvic organ prolapse quantification. Symptomatic prolapse was assessed by pelvic examination findings and patient-reported symptoms. Multivariate logistic regression was used to assess the factors associated with symptomatic prolapse.

RESULTS

A total of 880 women were interviewed and invited for pelvic examination, of whom 824 (93.6%) showed up for examination. Of the 824 women examined, 464 (56.3%) had POP stages II-IV and 145 (17.6%) had POP stages III-IV. The overall prevalence of symptomatic prolapse was 46.7% (217 out of 464). Of these, 41.0%, 42.8%, and 3.2% accounted for stage II, III, and IV respectively. Increasing age, multiparity, and heavy lifting/carrying significantly increased the odds of developing symptomatic prolapse.

CONCLUSIONS

Symptomatic prolapse affects a substantial proportion of women in the study area and increased with age. Multiparity and carrying heavy objects are associated with prolapse, all of which have the potential to be modified. More attention is needed to improve prevention, diagnosis, and treatment services to mitigate the health burden of these at-risk women.

Sacrocolpopexy: Patient Outcomes Support the Use of Non-Crosslinked Acellular Dermal Matrix as an Alternative to the Synthetic Polypropylene Mesh

Objective: This study was conducted to evaluate the use of non-crosslinked acellular dermal matrix (ADM) in laparoscopic sacrocolpopexy by analyzing clinical outcomes and patient-satisfaction surveys.

Materials and Methods: Two hundred and eleven patients underwent laparoscopic sacrocolpopexy for pelvic organ prolapse (POP) between January 6, 2012, and December 31, 2017. Each patient had her pelvic-floor measurements diagrammed with the POP-Q [Quantification] system using the interactive tool provided by the American Urogynecologic Society. The Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7), used to make comprehensive assessments of women with urogynecologic problems, were mailed to all patients. If responses were not received, the patients were contacted by telephone. Patients who were not reached by either mail or telephone had their charts individually reviewed to extract the information. Trained surveyors scored the PFDI-20 and the PFIQ-7 questionnaires. The de-identified data were analyzed for patient satisfaction and outcomes. This information was obtained by a review of patient charts at 4-week postoperative and annual examinations; any phone calls with complaints and/or problem office visits were noted. Biopsies from the sacrocolpopexy area were taken if a patient had another incidental gynecologic procedure unrelated to the prolapse or at the time of repeat sacrocolpopexy for POP and the paraffin cell block was sent to McGowan Institute for Tissue Regeneration.

Results: One hundred and five patients responded to the survey. Charts were completed for 106. The majority of interviewed patients stated that they were doing a “little better” or “much better” (77/88; 87.5%). The third-quartile PFDI-20 score was 93 with a median of 60 and the PFIQ-7 score was 43 with a median of 29. Five patients underwent reoperations (4.76%). The most-common postoperative complaint was overactive bladder symptoms, followed by vaginal discharge. Histology showed either a lack of regenerative healing tissue at the failure site or good results showing neovascularization and a presence of connective and ligamentous tissue around the matrix. No intense fibrosis or neoplastic formation was reported.

Conclusions: A non-crosslinked ADM patch can be a good alternative to synthetic polypropylene mesh in patients undergoing sacrocolpopexy for POP.

How to use the Pelvic Organ Prolapse Quantification (POP-Q) system?

AIMS

To set out the basic description of pelvic organ prolapse (POP) using the International Continence Society/International Urogynecology Association Pelvic Organ Prolapse Quantification (POP-Q) system.

METHODS

The basic approach to use of the POP-Q was identified and summarized.

RESULTS

Six defined points in the vagina are identified; points Aa and Ba for the anterior vagina, Ap and Bp for the posterior vagina, and C and D for the cervix/vault. Point D is not used in women who previously had a hysterectomy. The patient is asked to strain, ideally when in the standing position, to elicit the POP to its maximum extent. The location of the defined points is then gauged relative to the hymenal ring and recorded on a grid. Three additional measurements are taken to achieve a full description; the genital hiatus length, perineal body length, and total vaginal length. Staging a POP relies on identifying the lowest extent of any part of the six defined points; if any point reaches close to the hymenal ring (at least stage 2), the prolapse is usually symptomatic.

CONCLUSIONS

The POP-Q system is readily cataloged and offers detailed description of considerable benefit in clinical practice and research.

Breastfeeding and pelvic floor disorders one to two decades after vaginal delivery

BACKGROUND

Postpartum recovery from pelvic floor trauma associated with vaginal delivery may be impaired by the transient hypoestrogenic state associated with breastfeeding.

OBJECTIVE

The aim of our study was to examine the association between exclusive breastfeeding and pelvic floor disorders 1-2 decades after the first vaginal delivery. We hypothesize that compared with women who did not breastfeed following vaginal delivery, women who breastfeed would have a higher proportion of pelvic floor disorders s, and those women who practiced sustained exclusive/unsupplemented breastfeeding would have the highest proportion.

STUDY DESIGN

This is a secondary analysis of the Mothers' Outcomes After Delivery study, a prospective cohort study of pelvic floor disorders after childbirth. Participants were recruited 5-10 years after their first delivery and followed up annually for up to 9 years. This analysis focused on participants who experienced at least 1 vaginal delivery. Each participant completed a self-administered questionnaire regarding breastfeeding. Based on questionnaire responses, breastfeeding status was classified into 3 ordinal categories: unexposed (did not breastfeed or breastfed <1 week); limited exclusive breastfeeding (breastfed without supplementation for ≥1 week but <12 weeks); and sustained exclusive breastfeeding (unsupplemented breastfeeding ≥12 weeks). Our primary outcomes of interest were the proportions of stress urinary incontinence, anal incontinence, and pelvic organ prolapse. The outcomes of interest were defined using the Epidemiology of Prolapse and Incontinence Questionnaire and the Pelvic Organ Prolapse Quantification Examination at enrollment and annually for up to 9 years thereafter. Additionally, a subanalysis examined the relationship between breastfeeding and anal incontinence in an obstetric anal sphincter injury-specific population. Generalized estimating equations were utilized to determine the relationship between breastfeeding and the outcomes of interest.

RESULTS

Among 705 women, 189 (27%) were classified as unexposed, 145 (20%) were categorized as limited exclusive breastfeeding, and the remaining 371 women (53%) met our definition of sustained exclusive breastfeeding. Median follow-up was 5 years, contributing to a total of 3079 person years. The proportion of each pelvic floor disorder, based on 3079 person-years of follow-up was: stress urinary incontinence (27%), pelvic organ prolapse (20%), or anal incontinence (25%). Using generalized estimating equations adjusting for race, education, parity, and body mass index, sustained exclusive breastfeeding was not significantly associated with stress urinary incontinence (adjusted odds ratio, 0.82, 95% confidence interval, 0.55-1.23), pelvic organ prolapse (adjusted odds ratio, 0.78, 95% confidence interval, 0.49-1.26), and anal incontinence (adjusted odds ratio, 0.67, 95% confidence interval, 0.44-1.00). Regarding our obstetric anal sphincter injury subanalysis, 123 women within our cohort experienced obstetric anal sphincter injuries at delivery. Anal incontinence was reported in 32% of these women. However, there was no observed relationship between breastfeeding and the development of anal incontinence during study follow-up in this population.

CONCLUSION

Breastfeeding after vaginal childbirth was not associated with the development of stress urinary incontinence, pelvic organ prolapse, or anal incontinence 1-2 decades after the first vaginal delivery.

Medium-term outcome of laparoscopic sacrocolpopexy using polivinylidene fluoride as compared to a hybrid polyglecaprone and polypropylene mesh: A matched control study

AIM

To compare 2-year outcomes of laparoscopic sacrocolpopexy (LSCP) either with polyvinylidene fluoride (PVDF) or hybrid polypropylene containing a resorbable polyglecaprone (PP+ PG) mesh.

MATERIALS AND METHODS

Retrospective audit on 105 consecutive patients undergoing LSCP a with PVDF-mesh (DynaMesh, FEG Textiltechniken), matched by prolapse stage and cervicopexy or vault suspension to 105 controls undergoing LSCP with a hybrid PP + PG-mesh (Ultrapro, Ethicon). Patients are part of an ongoing prospective study. The primary outcome measure was the Patient Global Impression of Change score (PGIC), the coprimary variable was failure rate at the vault (≤1 cm). Other outcomes were intraoperative and postoperative complications within 3 months categorized by the Clavien-Dindo classification, reinterventions, graft-related complications (GRCs) and functional outcomes. All assessments were performed by an independent assessor. Data are reported as median (interquartile range) number and percent as appropriate, the Mann-Whitney U, χ² , or Fisher exact were used for comparison.

RESULTS

Patient satisfaction in the PVDF group, as measured with the PGIC, was high (90.9% PGIC, ≥4) as well as was the anatomical success (97.3%) at a follow-up of 26 months. These outcomes were comparable to those of PP + PG-patients (84.8% PGIC, ≥4; 94.9% anatomical success). There were five patients (2.4%) with Dindo-III or higher complications and three patients had GRCs (1.5%), without differences between mesh type. Level-II posterior defects (Bp ≥ -1) were less likely in PVDF patients (34.1% vs 50% for PP + PG-patients; P = .003). Women in the PVDF group also were less bothered by prolapse (7.5% vs 26.4%; P = .001), yet they complained more of constipation (15.0% vs 9.0%; P = .01).

CONCLUSION

There were no differences in patient satisfaction and anatomical outcomes after LSCP either with PVDF or PP + PG mesh.

The use of implanted materials for treating women with pelvic organ prolapse and stress urinary incontinence

PURPOSE OF REVIEW

To review the current clinical management of stress urinary incontinence and pelvic organ prolapse following the adverse complications seen in the use of polypropylene mesh to treat both.

RECENT FINDINGS

Materials developed for use in abdominal hernia repair have not proven risk-free when used to support pelvic organs particularly when inserted via the vagina. Following unacceptably high levels of severe complications when high-density polypropylene mesh is inserted via the vagina to treat pelvic organ prolapse, reported over the last decade, there is now an agreed consensus between surgeons about surgical approaches and materials, which should be recommended for use in stress urinary incontinence and pelvic organ prolapse.

SUMMARY

There is a need for new biomaterials and tissue engineered/regenerative medicine approaches to treat stress urinary incontinence and pelvic organ prolapse. New materials need to be evaluated critically in both preclinical and clinical studies before being adopted into routine clinical use.

Definition of apical descent in women with and without previous hysterectomy: A retrospective analysis

Background

While normal pelvic organ support has been defined for women with intact uterus, this is not the case for post- hysterectomy vault descent. A recent systematic review found that definitions of apical prolapse are highly variable.

Objectives

To investigate the relationship between prolapse symptoms and apical POP-Q measurements and establish cutoffs for ‘significant apical descent using receiver–operator characteristics (ROC) statistics.

Study design

Retrospective analysis of patients seen at a tertiary urogynecological unit. Evaluation included a standardized interview and clinical assessment using the Pelvic Organ Prolapse Quantification (POP-Q) system. ROC curves were prepared for the relationship between prolapse symptoms and POP-Q measure “C”.

Results

The records of 3010 women were available for analysis. Prolapse symptoms were reported by 52.3% (n = 1573), with a mean bother of 5.9 (SD 3.0, range 0–10). POP-Q point “C” was associated with symptoms of prolapse (p <0.0001) and prolapse bother (p <0.0001) on both univariate and multivariate analysis. ROC curves for women with and without uterus were similar, although the relationship between apical descent and symptoms of prolapse was stronger for women with uterus (AUC 0.728 versus 0.678). After controlling for multi-compartment prolapse, the models improved, resulting in AUCs of 0.782 and 0.720. For prediction of prolapse symptoms, cutoffs were set at C = -5 (sensitivity 0.73, specificity 0.67 with uterus in situ, sensitivity 0.59, specificity, 0.73 after hysterectomy).

Conclusion

A cut- off for ‘significant central compartment descent’ of 5 cm above the hymen on Valsalva seems valid regardless of previous hysterectomy.

Robotic sacrocolpopexy for the management of pelvic organ prolapse: quality of life outcomes

BACKGROUND

Our aim was to investigate longer-term surgical and quality of life (QOL) outcomes in a cohort of women undergoing robotic-assisted laparoscopic sacrocolpopexy (RALS) for pelvic organ prolapse (POP).

METHODS

We performed a retrospective cohort study at a single institution of female patients undergoing RALS with and without concomitant robotic-assisted laparoscopic hysterectomy, urethral sling, and rectocele repair. Scores from the Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) surveys were used to evaluate QOL outcomes. Clinical improvement was defined by a decrease in a patient's PFDI and PFIQ postoperative score by ⩾70%.

RESULTS

Clinical improvement was seen in 62.6% by the PFIQ and in 64% by the PFDI survey. Younger patient age (OR 0.92, p = 0.011) and worse preoperative American Urological Association (AUA) Quality of Life score (OR 1.42, p = 0.046) were associated with clinical improvement. Within the PFIQ, 35.6% of patients saw clinical improvement with their bowel symptoms, compared with bladder (54.1%, p < 0.001) and prolapse (45.6%, p = 0.053) symptoms. Within the PFDI, 45.5% of patients reached clinical improvement with their bowel symptoms, compared with bladder (56.7%, p = 0.035) and prolapse (62.6%, p < 0.001) symptoms. Of the patients who had a rectocele repair, 46.3% reached clinical improvement in their CRADI-8 score, and 51% saw clinical improvement in the bowel portion of the PDFI.

CONCLUSIONS

Significantly fewer patients reached clinical improvement within the portions of the surveys that focus on bowel symptoms, compared with symptoms related to urination and POP. Of those that had a concomitant rectocele repair, approximately half reached clinical improvement with their bowel symptoms.

Extraperitoneal uterosacral suspension technique for post hysterectomy apical prolapse in 472 women: results from a longitudinal clinical study

OBJECTIVES

The study aims to evaluate the long-term results of the extraperitoneal uterosacral ligament suspension (bilateral) technique in women with apical prolapse following hysterectomy.

DESIGN

Longitudinal clinical follow up conducted between June 2002 and December 2017.

SETTING

Tertiary urogynaecology centre in Melbourne, Australia.

POPULATION

A total of 472 women with symptomatic vault prolapse who underwent bilateral extraperitoneal uterosacral ligament suspension (EPUSLS). Of these patients, 61% (287/472) had previously had a procedure for pelvic organ prolapse (POP).

METHODS

Follow up using structured, standardised questionnaires and examination by POP-Q and Baden-Walker system pre- and postoperatively.

MAIN OUTCOME MEASURES

Functional and anatomical results and surgical complications.

RESULTS

Mean follow-up duration was approximately 5 years. The objective success rate at vaginal cuff support was 89% (420/472). Only 4% needed revision surgery for vault recurrence. There was improvement in bladder, bowel, and sexual symptoms after the procedure. Mesh exposure rate was 17% (of the 138 having mesh augmentation), with the majority of cases managed conservatively or with minor interventions. The ureteric injury rate was 1% and mainly occurred in patients operated early on in the series. No women had buttock pain.

CONCLUSION

EPUSLS is an effective, suture-based procedure for vault prolapse with few complications even on long-term follow up. This technique avoids the need to open the peritoneum vaginally and has a low risk of ureteric injury and gluteal pain.

TWEETABLE ABSTRACT

Bilateral extraperitoneal USL suspension of vault is effective with low morbidity and a high success rate.

Surgery for Anterior Compartment Vaginal Prolapse: Suture-Based Repair

Native tissue anterior compartment prolapse repair remains an important surgical procedure for pelvic prolapse. Native tissue repair has been well-studied and is successful in relieving vaginal bulge symptoms and reducing prolapse within the vagina. Native tissue cystocele repair has been performed safely since the advent to modern vaginal surgery for prolapse. Reoperation rates are low and the contribution of apical support in the durability of vaginal wall defect repair surgery has been well-established. Native tissue cystocele repair addresses symptom relief for women, and should continue to be a part of pelvic floor reconstructive surgery.

Clinical effectiveness and cost-effectiveness of surgical options for the management of anterior and/or posterior vaginal wall prolapse: two randomised controlled trials within a comprehensive cohort study - results from the PROSPECT Study

BACKGROUND

The use of mesh in prolapse surgery is controversial, leading to a number of enquiries into its safety and efficacy.

OBJECTIVE

To compare synthetic non-absorbable mesh inlay, biological graft and mesh kit with a standard repair in terms of clinical effectiveness, adverse effects, quality of life (QoL), costs and cost-effectiveness.

DESIGN

Two randomised controlled trials within a comprehensive cohort (CC) study. Allocation was by a remote web-based randomisation system in a 1 :1 : 1 ratio (Primary trial) or 1 : 1 : 2 ratio (Secondary trial), and was minimised on age, type of prolapse repair planned, need for a concomitant continence procedure, need for a concomitant upper vaginal prolapse procedure and surgeon. Participants and outcome assessors were blinded to randomisation; participants were unblinded if they requested the information. Surgeons were not blinded to allocated procedure.

SETTING

Thirty-five UK hospitals.

PARTICIPANTS

Primary study: 2474 women in the analysis (including 1348 randomised) having primary anterior or posterior prolapse surgery. Secondary study: 398 in the analysis (including 154 randomised) having repeat anterior or posterior prolapse surgery. CC3: 215 women having either uterine or vault prolapse repair.

INTERVENTIONS

Anterior or posterior repair alone, or with mesh inlay, biological graft or mesh kit.

MAIN OUTCOME MEASURES

Prolapse symptoms [Pelvic Organ Prolapse Symptom Score (POP-SS)]; prolapse-specific QoL; cost-effectiveness [incremental cost per quality-adjusted life-year (QALY)].

RESULTS

Primary trials: adjusting for baseline and minimisation covariates, mean POP-SS was similar for each comparison {standard 5.4 [standard deviation (SD) 5.5] vs. mesh 5.5 (SD 5.1), mean difference (MD) 0.00, 95% confidence interval (CI) -0.70 to 0.71; standard 5.5 (SD 5.6) vs. graft 5.6 (SD 5.6), MD -0.15, 95% CI -0.93 to 0.63}. Serious non-mesh adverse effects rates were similar between the groups in year 1 [standard 7.2% vs. mesh 7.8%, risk ratio (RR) 1.08, 95% CI 0.68 to 1.72; standard 6.3% vs. graft 9.8%, RR 1.57, 95% CI 0.95 to 2.59]. There were no statistically significant differences between groups in any other outcome measure. The cumulative mesh complication rates over 2 years were 2 of 430 (0.5%) for standard repair (trial 1), 46 of 435 (10.6%) for mesh inlay and 2 of 368 (0.5%) for biological graft. The CC findings were comparable. Incremental costs were £363 (95% CI -£32 to £758) and £565 (95% CI £180 to £950) for mesh and graft vs. standard, respectively. Incremental QALYs were 0.071 (95% CI -0.004 to 0.145) and 0.039 (95% CI -0.041 to 0.120) for mesh and graft vs. standard, respectively. A Markov decision model extrapolating trial results over 5 years showed standard repair had the highest probability of cost-effectiveness, but results were surrounded by considerable uncertainty. Secondary trials: there were no statistically significant differences between the randomised groups in any outcome measure, but the sample size was too small to be conclusive. The cumulative mesh complication rates over 2 years were 7 of 52 (13.5%) for mesh inlay and 4 of 46 (8.7%) for mesh kit, with no mesh exposures for standard repair.

CONCLUSIONS

In women who were having primary repairs, there was evidence of no benefit from the use of mesh inlay or biological graft compared with standard repair in terms of efficacy, QoL or adverse effects (other than mesh complications) in the short term. The Secondary trials were too small to provide conclusive results.

LIMITATIONS

Women in the Primary trials included some with a previous repair in another compartment. Follow-up is vital to identify any long-term potential benefits and serious adverse effects.

FUTURE WORK

Long-term follow-up to at least 6 years after surgery is ongoing to identify recurrence rates, need for further prolapse surgery, adverse effects and cost-effectiveness.

TRIAI REGISTRATION

Current Controlled Trials ISRCTN60695184.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 95. See the NIHR Journals Library website for further project information.

Effect of Mula Bandha Yoga in Mild Grade Pelvic Organ Prolapse: A Randomized Controlled Trial

Background

Pelvic organ prolapse is the growing health issue related to women of the reproductive and postmenopausal age group in India and across the globe. Treatment option for pelvic organ prolapse includes both surgical and non-surgical intervention. The development of pelvic organ prolapse is an indication for major surgery among 20% of all women. Nevertheless, the recurrence of pelvic organ prolapse is detected among 58% of the patient after surgery. This highlights the need for preventive measures for reducing the impact of pelvic organ prolapse.

Aims and Objective

To study the effect of 3 months yoga therapy in female patients suffering from mild pelvic organ prolapse.

Material and Methods

50 Participants were allocated into two groups (25 in each group) by generating Random allocation sequence. Women aged 20-60 with symptomatic mild pelvic organ prolapse in the yoga group were offered Mulabandha yoga therapy along with other conventional treatment modalities, while the control group was only on conventional treatment. All participants gave written informed consent. An assessment was done by improvement in chief complaints and Pelvic Floor Distress Inventory-20 (PFDI-20) & Pelvic floor impact Questionnaire-7 (PFIQ-7) at baseline and at the end of 4, 8 & 12 weeks. Results At the end of 12 weeks, Post-study comparison between the two groups showed a significant improvement in chief complaints like perennial pain, P/V discharge, Perineal muscle laxity and Feeling of something coming out P/V (P < 0.001). Participants in the yoga group improved by (on average) 5.7 (95% confidence interval 3.1 to 14.7) points more on the PFDI-20 than did participants in the control group (P = 0.1) and a mean score of PFIQ-7 was also improved significantly.

Conclusions

Although Mulabandha (Root Lock) yoga therapy led to a significantly greater improvement in PFDI-20 & PFIQ-7 scores the difference between the groups was below the presumed level of clinical relevance (15 points). More studies are needed to identify factors related to the success of Mulabandha (Root Lock) yoga therapy and to investigate long-term effects.