Utilizing preoperative 20-minute pad testing with vaginal gauze packing for indicating concomitant midurethral sling during cystocele repair

The prevalence of overt, occult, and no-demonstrated stress urinary incontinence and their clinical and urodynamic findings in women with advanced-stage cystoceles

OBJECTIVES

To elucidate the prevalence of overt, occult and no demonstrated (ND) stress urinary incontinence (SUI) in women with advanced-stage cystoceles.

STUDY DESIGN

Between November 2011 and January 2017, all women with ≥stage 2 cystoceles were retrospectively enrolled. Overt SUI was diagnosed before the prolapse reduction test, and occult SUI was diagnosed when urine leakage was noted after a reduction test with vaginal gauze. Otherwise, a diagnosis of ND-SUI was made.

MAIN OUTCOME MEASURES

The prevalence, clinical and urodynamic findings of overt SUI, occult SUI, and ND-SUI.

RESULTS

In 480 enrolled women, 62% had overt SUI, 17% had occult SUI, and 21% had ND-SUI. The occult SUI group had the most advanced prolapse. The pad weight results after prolapse reduction (37.3 ± 44.3 vs. 13.4 ± 21.9, p < 0.05), the bladder capacity (243 ± 54 vs. 273 ± 48, p < 0.001), and questionnaires regarding life quality were significantly different between the overt SUI and the occult SUI groups. Bladder oversensitivity (BO) was the most common urodynamic diagnosis (389/480, 81%), especially in overt SUI, while urodynamic stress incontinence (56/480, 12%) and detrusor overactivity (60/480, 13%) were uncommon. The cutoff value of stage 3 uterine prolapse was the strongest predictor for predicting occult SUI (sensitivity = 30.3%, specificity = 78.5%; area = 0.60, 95% CI: 0.52-0.68).

CONCLUSIONS

SUI occurs in a ratio of 3:1:1 among cases with overt, occult, and no demonstrable symptoms. BO is the most common urodynamic diagnosis. Pad test with prolapse reduction remains an important tool, especially for coexistent stage 3 uterine prolapse.

Urodynamic profile of voiding in patients with pelvic organ prolapse after surgery: a systematic review with meta-analysis

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) is a defect of the female pelvic floor. Stress urinary incontinence (SUI), urge urinary incontinence (UUI), and obstructive symptoms may occur in these patients. The objective of surgical treatment is to restore the anatomy and function of the pelvic floor; however, it may prompt urinary symptoms not present previously. We performed a systematic review and meta-analysis to determine urodynamic changes in patients undergoing surgical correction for POP.

METHODS

PubMed and Cochrane databases were searched for studies that contained data from urodynamic evaluation before and after vaginal surgery for POP. The main urodynamic data collected were free uroflowmetry (maximum flow [Qmax], voided volume, and post-void residual volume [PVR]), cystometry (bladder capacity, presence of detrusor overactivity [DO], SUI or UUI, and Valsalva leak point pressure), and pressure × flow study (detrusor pressure at maximum flow [PdetQmax], Qmax, and PVR).

RESULTS

A total of 22 studies were included (1,549 women). Patients had a significantly higher prevalence of DO before surgery (OR = 1.56; 95% CI = 1.06-2.29), and surgeries without sling placement demonstrated a tendency to ameliorate DO. Patients who did not receive a sling were more incontinent after surgery. Bladder-emptying parameters improved after surgery, with higher PdetQmax before surgery (IV = 3.23; 95% CI = 0.45-1.18). Patients who did not receive MUS presented a lower Qmax (IV = -3.19; 95%CI = -4.09 to -2.30) and a higher PVR (IV = 27.89; 95%CI = 15.68-40.1) before surgery.

CONCLUSION

Correction surgery for POP yields better urodynamic emptying parameters, with a reduction in the prevalence of DO. In contrast, sling placement enhances obstructive parameters.

Severity of cystocele and risk factors of postoperative stress urinary incontinence after laparoscopic sacrocolpopexy for pelvic organ prolapse

Objectives:

Materials and Methods:

Results:

Conclusion:

Level of agreement and acceptance of the 20-Minute versus 60-Minute sanitary pad test as a method for measuring the severity of stress urinary incontinence: randomised crossover trial

We aimed to measure the level of agreement and acceptance ratio of the 20-minute versus 60-minute sanitary pad test in female patients with stress urinary incontinence (SUI). This is one-sample cross-experimental design. SUI patients at the Urogynecology Outpatient Clinic at Cipto Mangunkusumo Hospital in Jakarta, Indonesia were consecutively enrolled as participants. We first administered the 20-minute test, followed by the 60-minute test, or vice versa, within 1 week. The participants did not know the type of test performed or asked during the interview. Random Number Generator software by stattrek.com was used to determine which test was performed first for each participant. Participants were interviewed using a questionnaire at the end of each test. The 20-minute sanitary pad test exhibited a good level of agreement with the 60-minute sanitary pad test (kappa R = 0.84). Forty-two respondents (84.0%) reported that they were "satisfied" with the 20-minute sanitary pad test and eight respondents (16.0%) reported that they were "very satisfied". There was a good agreement between the 20-minute and 60-minute sanitary pad test for assessing the severity of SUI. The 20-minute sanitary pad test achieved a relatively higher level of participant satisfaction.Impact statementWhat is already known on this subject? Patients at the Urogynecology Outpatient Clinic at Cipto Mangunkusumo Hospital have a positive acceptance in the 20-minute and 60-minute sanitary pad test for assessing the severity of SUI.What do the results of this study add? From this result, the authors considered that this method can help in assessing the severity of SUI, especially in Indonesia.What are the implications of these findings for clinical practice and/or further research? As these findings, the authors think that they might be useful as a standard of assessed the severity of SUI. This method does not harmful and easy to apply for every patient with SUI.

Is there a correlation between a 20-min pad-test and subjective urine leakage amount?

INTRODUCTION AND HYPOTHESIS

The quantification of urinary incontinence (UI) is widely used in clinical practice to guide the prognosis and treatment, and the pad test is an inexpensive, quick, and easy tool to assess UI that has been used in studies in the literature. Another way to evaluate UI is the subjective urine leakage amount, but no studies have tried to correlate it with the 20-min pad test. Therefore, this study aimed to assess the correlation of the 20-min pad test with the subjective urine leakage amount and compare it with the pelvic floor function.

METHODS

This is a cross-sectional study with a sample size of 72 participants. It evaluated pelvic floor muscle strength as well as the duration of symptoms and pad weight. It used mean, standard deviation, median, and 95% confidence interval. In addition, ANOVA, Kruskal-Wallis, and Spearman's correlation coefficient were used. The significance level was fixed at 5% (significant if P < 0.05).

RESULTS

Only age was different between leakage volumes; participants who report greater UI volume were older than the participants who leaked less urine. There were no differences related to the duration of symptoms between different UI volumes and pad weights according to the subjective volume reported. Spearman's coefficient between pad weight and subjective volume of urine leakage was r_s = 0.558 (P ≤ 0.0001), demonstrating a moderate positive correlation.

CONCLUSIONS

There was a moderate correlation between the UI volume reported and the 20-min pad test. Additionally, no differences related to pelvic floor function were detected.

Predictors for de novo stress urinary incontinence following pelvic reconstruction surgery with transvaginal single-incisional mesh

The study aims to identify predictors for de novo stress urinary incontinence (SUI) following Elevate mesh surgery. A total of 164 women who underwent Elevate mesh surgeries between November 2011 and February 2014 in a single center were included. Seventy-three women were excluded due to preoperative incontinence or concomitant mid-urethral sling surgery. Fourteen others were excluded due to incomplete medical records. Fisher’s exact test and χ² test were applied. The univariate logistic regression was used for odds ratios. Of the 77 continent women, 24 (31.2%) experienced de novo SUI after the operation. Significantly more women with de novo SUI were over the age of 64 years (75.0% vs. 47.2%, p = 0.023, OR 3.36, 95% CI 1.15–9.79). Preoperative occult urodynamic stress incontinence (29.2% vs. 3.8%, p = 0.003, OR 10.0, 95% CI 2.0–50.0) and previous SUI history (41.7% vs. 7.6%, p = 0.001, OR 9.1, 95% CI 2.38–33.3) were 2 other predictors of de novo SUI postoperatively. In conclusion, age over 64 years old, occult urodynamic stress incontinence, and previous history of SUI are 3 significant predictors for de novo SUI following the single-incision mesh surgeries.

Three-Dimensional Transperineal Ultrasonography for Diagnosis of Female Occult Stress Urinary Incontinence

Background

We evaluated the utility of three-dimensional transperineal ultrasonography in detecting occult stress urinary incontinence in women undergoing anterior pelvic floor reconstruction surgery for severe cystocele.

Material/Methods

We enrolled 207 women with stage III–IV cystocele without urinary stress incontinence. One week before the operation, the patients underwent pelvic floor ultrasonography. We measured the vertical distance between the bladder neck and posterior margin of the pubic symphysis, the posterior vesicourethral angle, the urethral rotation angle, the formation of funnel shape, the hiatus area, and the length of the urethra and the funnel shape. Postoperatively, the patients were evaluated for symptoms of stress urinary incontinence and with the 20-minute pad test.

Results

The posterior vesicourethral angle with Valsalva maneuver, the difference in the posterior vesicourethral angle between the resting state and with the Valsalva state, and the angle of the proximal urethra were larger in the incontinence-positive group than in the incontinence-negative group (P<0.05). Funnel shape urethra was longer in the incontinence-positive group than in the incontinence-negative group (P<0.05). The cutoff value was 137.5° for the posterior vesicourethral angle with Valsalva maneuver, 39.5° for the difference in the posterior vesicourethral angle, 44.5° for the angle of the proximal urethra, and 0.35 cm for the length of the funnel shape. Multivariate analysis revealed that the difference between the posterior vesicourethral angle in the resting state and with Valsalva, the angle of the proximal urethra, and the length of funnel shape were strongly correlated with occult stress urinary incontinence.

Conclusions

Ultrasonography is an effective method for identifying occult stress urinary incontinence.

Clinical and urodynamic effects of baclofen in women with functional bladder outlet obstruction: Preliminary report

AIM

To investigate the efficacy and urodynamic effects of baclofen in women with functional bladder outlet obstruction.

METHODS

Between January 2011 and December 2012, women who underwent baclofen treatment for functional bladder outlet obstruction, defined as <15 mL/s maximum flow rate and >20 cmH2 O detrusor pressure at maximum flow rate, but without significant anatomic causes, were retrospectively reviewed. Urodynamic variables at baseline and after 12 weeks of treatment were compared.

RESULTS

Twenty women with functional bladder outlet obstruction underwent 12 weeks of baclofen treatment (oral baclofen 5 mg, three times daily). All patients reported improvement in voiding dysfunction symptoms after treatment, and no significant adverse effects were found on review of medical records. All patients underwent urodynamic studies after 12 weeks' treatment. Voided volume, voiding efficiency and maximum flow rate at voiding cystometry were significantly improved (mean, 273 vs. 368 mL, P = 0.002; 62.8% vs. 73.6%, P <0.001, and 10.3 vs. 11.6 mL/s, P = 0.046; respectively). Moreover, baclofen did not affect continence function, as indicated by non-significant changes in the parameters of urethral pressure profiles.

CONCLUSIONS

Oral baclofen can improve symptoms of voiding dysfunction, voided volume, voiding efficiency and maximum flow rate in women with functional bladder outlet obstruction. None of the patients experienced intolerable side-effects. Thus, oral baclofen may be used as an initial treatment for women with symptoms of voiding dysfunction.

Clinical Outcomes and Urodynamic Effects of Tailored Transvaginal Mesh Surgery for Pelvic Organ Prolapse

Objective. To evaluate the clinical outcomes and urodynamic effects of tailored anterior transvaginal mesh surgery (ATVM) and tailored posterior transvaginal mesh surgery (PTVM). Methods. We developed ATVM for the simultaneous correction of cystocele and stress urinary incontinence and PTVM for the simultaneous correction of enterocoele, uterine prolapse, vaginal stump prolapse, and rectocele. Results. A total of 104 women enrolled. The median postsurgical follow-up was 25.5 months. The anatomic cure rate was 98.1% (102/104). Fifty-eight patients underwent urodynamic studies before and after surgeries. The pad weight decreased from 29.3 ± 43.1 to 6.4 ± 20.9 g at 3 months. Among the 20 patients with ATVM, 13 patients had objective stress urinary incontinence (SUI) at baseline while 8 patients came to have no demonstrated SUI (NDSUI), and 2 improved after surgery. Among the 38 patients who underwent ATVM and PTVM, 24 had objective SUI at baseline while 18 came to have NDSUI, and 2 improved after surgery. Mesh extrusion (n = 4), vaginal hematoma (n = 3), and voiding difficulty (n = 2) were noted postoperatively. Quality of life was substantially improved. Conclusions. Our findings document the advantages of these two novel pelvic reconstructive surgeries for pelvic organ prolapse, which had a positive impact on quality of life. ATVM surgery additionally provided an anti-incontinence effect. This clinical trial is registered at ClinicalTrials.gov (NCT02178735).

The value of the preoperative 1-h pad test with pessary insertion for predicting the need for a mid-urethral sling following pelvic prolapse surgery: a cohort study

PURPOSE

Part of the patients with pelvic organ prolapse but without symptoms of stress urinary incontinence (SUI) may demonstrate SUI after prolapse surgery (occult SUI), and no optimal preoperative screening method is currently available for it. The aim of this study was to estimate the value of the preoperative 1-h pad test with pessary insertion for predicting the need for a mid-urethral sling (MUS) following prolapse surgery.

METHODS

Two hundred and six patients were enrolled for advanced prolapse without complaining of urinary incontinence (UI) in this prospective cohort study. Exclusion criteria included prior or concomitant anti-incontinence surgery. Preoperatively, a stress test, the 1-h pad test and uroflowmetry were performed with prolapse reduction. Primary outcome was postoperative de novo UI. Median follow-up was 31 months (range 12-48 months).

RESULTS

Of the 206 patients, 45 (21.8 %) had evidence of occult SUI preoperatively, 62 (30.1 %) exhibited de novo UI postoperatively, and only 13 (6.3 %) opted MUSs. Patients with occult SUI experienced higher de novo UI rate (53.3 vs. 23.6 %; P = 0.000). The OSUI and concomitant hysterectomy were identified as independent risk factors related to de novo UI (P = 0.000, P = 0.044). We performed receiver operating characteristic (ROC) curve analysis to evaluate the value of preoperative 1-h pad test. The area under ROC curve was 0.816 ± 0.085 (95 % CI 0.649-0.983); the cutoff value was 1.9 g (sensitivity 80.0 %, specificity 83.9 %).

CONCLUSIONS

The preoperative 1-h pad test with prolapse reduction is feasible for screening occult SUI, and more than 1.9 g may be a practical indicator of a postoperative subsequent MUS.

The surgical trends and time-frame comparison of primary surgery for stress urinary incontinence, 2006-2010 vs 1997-2005: a population-based nation-wide follow-up descriptive study

INTRODUCTION AND HYPOTHESIS

The purpose of our study was to describe the surgical trends for female stress urinary incontinence (SUI) during 2006-2010, and a time-frame comparison with 1997-2005, based upon the National Health Insurance (NHI) claims data in Taiwan.

METHODS

Women who underwent various primary surgeries for SUI during 2006-2010 were identified, with a total of 15,099 inpatients. The variables included surgical types, patient age, surgeon age and gender, specialty, and hospital accreditation levels. Chi-squared tests and SAS version 9.3.1 were used for statistical analysis.

RESULTS

During the follow-up study, midurethral sling (MUS) application increased significantly from 53.09 % in 2006 to 78.74 % in 2010. It was associated concomitantly with a decrease in retropubic urethropexy (RPU) from 29.68 % to 12.99 %, and pubovaginal sling treatment (PVS) from 9.33 % to 3.46 %. MUS was most commonly used among all patients' and surgeons' age groups, and different accreditation hospital levels. MUS was more commonly used by gynecologists (71.38 %) than urologists (57.91 %); while PVS and periurethral injection were more commonly performed by urologists than gynecologists. Similar surgical trends were found during time-frame comparison, 2006-2010 vs 1997-2005. SUI surgeries increased in patients aged ≥60, surgeons aged ≥ 50, and in regional hospitals.

CONCLUSION

This follow-up study depicts the increase in popularity of MUS and offers evidence of surgical trends and a paradigm shift for female SUI surgery. More older women were willing to seek healthcare and undergo surgery. The surgical skills and knowledge spread from medical centers into regional hospitals. The time-frame shift may have a profound impact on patients, as well as the healthcare providers.