Urinary Incontinence in Nulliparous Women and Their Parous Sisters

Association between vaginal or cesarean delivery and later development of stress urinary incontinence or pelvic organ prolapse: A retrospective population-based cohort study

INTRODUCTION AND HYPOTHESIS

Child delivery mode may be associated with pelvic floor disorders. We explored the association between different delivery modes and later development of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in Taiwanese women.

METHODS

This was a retrospective population-based cohort study. Women who delivered babies between January 1, 2000, and December 31, 2018, were selected for this study. The study used Taiwan's National Health Insurance (NHI) Research Database. After propensity score matching, 51,587 women who underwent cesarean section (C/S) and 51,587 women who underwent vaginal delivery (VD) were recruited. Primary outcomes were the presence of SUI and POP after delivery.

RESULTS

The incidence of SUI (1.6/1000 person-years) and POP (1.5/1000 person-years) was higher in the VD group than in the C/S group (0.8 and 0.6 in 1000 person-years). VD was associated with an increased risk of SUI [hazard ratio (HR): 2.79, 95% confidence interval (CI): 2.45-3.17] and POP (HR: 1.96, 95% CI: 1.75-2.19) compared to C/S. We also found that age (HR: 1.06, 95% CI: 1.05-1.08 in SUI, HR: 1.08, 95% CI: 1.07-1.09 in POP) and Charlson Comorbidity Index (CCI) (HR: 1.28, 95% CI: 1.12-1.46 in SUI, HR: 1.27, 95% CI: 1.13-1.43 in POP) were associated with an increased risk of SUI and POP. The cumulative incidence of SUI and POP was higher in the VD group than in the C/S group (log-rank test, P < 0.05).

CONCLUSIONS

The current study was the largest retrospective cohort study regarding the influence of delivery mode on SUI and POP so far. VD was found to be associated with an increased risk of SUI and POP compared with C/S. Postpartum care for pelvic physical therapy should be provided particularly to women undergoing VD.

Signs of connective tissue dysplasia in women with genital prolapse

Introduction. Despite a long history of the disease, genital prolapse still have not been definitively solved. A relevance of pelvic organ prolapse in women has been increasing in recent years largely due to a change in the quality of life and desire to sustain their youth. The number of studies pinpointing the cause of the disease in connective tissue dysplasia (CTD) has been increasing annually.Aim: to conduct a systematic analysis and determine most common signs of CTD in women with genital prolapse.Materials and methods. CTD criteria and the relationship with genital prolapse were analyzed. The study was conducted using questionnaires and including clinical studies examining residents of the Belgorod region (135 women). The main group included 91 patients who had signs of pelvic organ prolapse, and control group consisted of 44 healthy women. CTD intensity score proposed by T.Yu. Smolnova et al. (2003) was used to assess signs of dysplasia in women examined allowing to build up three groups in which each symptom was evaluated as severity score.Results. Asthenic constitution was noted in high percentage of women suffering from genital prolapse (16.70 ± 0.38 %) compared with healthy women (2.30 ± 0.15 %; p = 0.016). Mild bruising, increased tissue bleeding tended to rise in main vs. control group (16.50 ± 0.37 % in main group and 0.0 in control group; p = 0.016). Signs of varicose veins and hemorrhoids requiring no surgical treatment were found in 33.00 ± 0.47 % and 4.50 ± 0.21 % in main vs. control group (p = 0.0002), respectively. Genital prolapse and hernia in first-line relatives were recorded in 9.90 ± 0.30 % in main group (p = 0.031), women without signs of prolapse did not indicate prolapse in close relatives.Conclusion. Asthenic constitution, hernias, varicose veins and hemorrhoids, female pelvic and hernial prolapse in close female relatives, a tendency to mild bruising, skeletal anomalies, elastosis skin were among common CTD signs in women with genital prolapse.

Prevention of Urinary Incontinence in Women

PURPOSE OF REVIEW

Despite available treatments for urinary incontinence, the data regarding prevention is less established. This review sought to identify prevention measures and discuss their underlying evidence base with an attempt to include the most recent updates in the field.

RECENT FINDINGS

Urinary incontinence is a prevalent issue among women, particularly surrounding pregnancy and menopause. Interventions regarding pregnancy include not only general health promotion but also potentially interventions such as pelvic floor muscle training and decisions regarding method of delivery. With regard to menopause, the literature suggests avoiding treatments that have adverse effects on continence. Lastly, promoting healthy life style and reducing effects of co-morbid conditions can impact a woman's continence. The literature indicates that preventative strategies exist for urinary incontinence, though the data is limited in this area. Further work is needed to determine the impact of prevention measures and how best to implement them.

Oxidative status of cardinal ligament in pelvic organ prolapse

Pelvic organ prolapse (POP) is a common and distressing health problem in adult women, but the pathophysiological mechanism is yet to be fully elucidated. Previous studies have indicated that oxidative stress may be associated with POP. Thus, the aim of the present study was to investigate the oxidative status of pelvic supportive tissue in POP and further demonstrate that oxidative stress is associated with the pathogenesis of POP. A total of 60 samples were collected from females undergoing hysterectomy for POP or cervical intraepithelial neoplasia (CIN). This included 16 females with POP II, 24 females with POP III–IV (according to the POP-Q system) and 20 females with CIN II–III as the control group. Immunohistochemistry was utilized to measure the expression of oxidative biomarkers, 8-hydroxydeoxyguanosine (8-OHdG) and 4-hydroxynonenal (4-HNE). Major antioxidative enzymes, mitochondrial superoxide dismutase (MnSOD) and glutathione peroxidase 1 (GPx1) were measured through reverse transcription-quantitative polymerase chain reaction, western blotting and enzyme activity assays. The results demonstrated that in the cardinal ligament, the expression of 8-OHdG and 4-HNE was higher in the POP III–IV group compared with the POP II group and control group. The MnSOD and GPx1 protein level and enzyme activity were lower in the POP III–IV group compared with the POP II or the control group, while the mRNA expression level of MnSOD and GPx1 was increased. In conclusion, oxidative damage is increased in the pelvic supportive ligament of female patients with POP and the antioxidative defense capacity is decreased. These results support previous findings that oxidative stress is involved in the pathogenesis of POP.

Estrogen receptor and laminin genetic polymorphism among women with pelvic organ prolapse

OBJECTIVE

Laminin is a connective tissue component. The LAMC1 gene encodes for gamma-1 chain of laminin, which is associated with familial clustering of POP. The ERα gene which encodes for cellular estrogen receptor has also been associated with POP. The aim of this study was to evaluate a possible correlation between polymorphism in these genes and the risk for developing POP.

MATERIALS AND METHODS

Blood samples were drawn from 33 women with advanced POP (study group) and 33 women without POP (control group). DNA was extracted, and the presence of the rs10911193 C/T mutation in LAMC1 and of the rs2228480 G/A mutation in ERα was detected using the PCR technique.

RESULTS

26 samples were available for each group regarding ERα. 33 samples were available for each group, regarding LAMC1. The prevalence of homozygotes for the ERα rs2228480 G/A mutation was 19.2% and 0% among women with and without POP, respectively (OR 39.77, 95% CI 1.93-817.0, P = 0.00046). The prevalence of heterozygotes for this mutation was 83.3% and 11.5%, respectively (OR 19.2, 95% CI 4.15-88.6, P < 0.0001). The prevalence of homozygotes for the LAMC1 gene rs10911193 C/T mutation was 3.6% and 6.1% among women with and without POP (NS), while the respective for heterozygotes for this mutation was 21.4% and 33.3% (NS).

CONCLUSIONS

Polymorphism in the ERα gene is associated with an increased risk for advanced POP. However, polymorphism in the LAMC1 gene does not seem to be associated with such risk.

Characteristics Associated with Induction of Labor and Delivery Route Among Primiparous Women with Term Deliveries in the Listening to Mothers III Study

BACKGROUND

Induction of labor (IOL) is increasingly common in the United States, yet characteristics associated with IOL among primiparous women delivering at term are not well understood.

MATERIALS AND METHODS

Data from the Listening to Mothers III study, a survey of women aged 18-45 with singleton deliveries in U.S. hospitals in 2011-2012, were utilized. Weighted logistic regression models examined predictors of IOL among 924 primiparous women with term deliveries. Associations of maternal characteristics with delivery route (cesarean and vaginal delivery) were examined among primiparous women induced at term.

RESULTS

Four hundred twenty-three (45.8%) primiparous women with term deliveries underwent IOL; subjective reasons were reported by 53% of induced women. Women who were married (odds ratios [OR] = 1.8, 95% confidence intervals [CI] 1.2-2.9), felt pressure from a provider for IOL (OR = 3.5, 95% CI 2.0-6.2), and whose provider was concerned about the size of the baby (OR = 1.9, 95% CI 1.2-2.9) were significantly more likely to undergo IOL. Nearly 30% of primiparous women who underwent IOL at term had a cesarean delivery (CD). Among the induced women, those who were overweight/obese (OR = 4.9, 95% CI 2.5-10.0), felt pressure from a provider for CD (OR = 8.6, 95% CI 3.5-21.2), and whose provider suspected the baby might be getting large near end of pregnancy (OR = 2.7, 95% CI 1.1-7.0) were significantly more likely to have CD.

CONCLUSIONS

In this study, nearly half of the primiparous women with term deliveries underwent IOL, with a sizeable proportion reporting subjective reasons for induction. A better understanding of the characteristics associated with IOL at term may help reduce unnecessary interventions and, ultimately, primary CD.

Clinical epidemiological insights into urinary incontinence

INTRODUCTION AND HYPOTHESIS

Urinary incontinence (UI) is very common and heterogeneous among women with limited knowledge of progression or prognosis. Evidence based on clinical epidemiology can help to better understand the natural history of UI.

METHODS

We examine the challenges of UI definition and its subtypes, its impact on quality of life and health-seeking behavior. We review the proposed pathophysiology of UI subtypes and known risk factors as they relate to our current knowledge of the disease state. Finally, we emphasize the role of epidemiology in the process of acquiring new insight, improving knowledge, and translating this information into clinical practice.

RESULTS

Stress UI is most common overall, but mixed UI is most prevalent in older women. The three UI subtypes have some common risk factors, and others that are unique, but there remains a significant gap in our understanding of how they develop. Although the pathophysiology of stress UI is somewhat understood, urgency UI remains mostly idiopathic, whereas mixed UI is the least studied and most complex subtype. Moreover, there exists limited information on the progression of symptoms over time, and disproportionate UI health-seeking behavior. We identify areas of exploration (e.g., epigenetics, urinary microbiome), and offer new insights into a better understanding of the relationship among the UI subtypes and to develop an integrated construct of UI natural history.

CONCLUSION

Future epidemiological strategies using longitudinal study designs could play a pivotal role in better elucidating the controversies in UI natural history and the pathophysiology of its subtypes leading to improved clinical care.

Psychological and Physical Environmental Factors in the Development of Incontinence in Adults and Children: A Comprehensive Review

The aim of this review was to identify etiological environmental factors related to incontinence in children and adults. A variety of etiological environmental factors for the development of incontinence were identified. In children, these encompass stressful life events and trauma, family dysfunction, parental psychopathology, school-related stressors, toilet or "potty" training, fluid consumption habits, housing conditions, and the availability of toilets. In adults, physical exercise, obesity, working conditions, fluid intake, and the availability of toilets play a role. Intervening variables such as hormonal variations due to work shifts have also been identified as influencing the likelihood of incontinence. Current research suggests that environmental factors influence the development of incontinence in children and adults. The interactions between biological factors, the immediate environment, and intervening variables need to be explored in greater detail. Practical solutions to reduce barriers to adequate fluid intake and healthy toileting habits should be implemented in school and work settings.

Refractory Urinary Incontinence in Girls: The Role of the Bladder Neck

BACKGROUND

Prevalence of lower urinary tract dysfunction (LUTD) in children is between 6 and 9% with urinary incontinence (UI) being one of the most common symptom.

VARIOUS ASPECTS OF LOWER URINARY TRACT SYMPTOMS LUTS

Anatomical anomalies of the urinary tract as well as neurogenic underlying pathology can results in LUTS. Comorbidities and long-term consequences of the LUTD for the female patients as well as genetic issues are also briefly discussed.

THE ROLE OF THE BLADDER NECK

Thanks to urodynamics, we have learnt a lot about the lower urinary tract function, but the role of the bladder neck in the pathophysiology of LUTS in children is not clear. Secondary bladder neck hypertrophy is a well-described pathology, but there is no standardized treatment for this phenomenon. Primary bladder neck dysfunction has already been defined by the International Children's Continence Society.

REFRACTORY UI IN GIRLS

Uniform diagnostic protocols are used in these girls with UI. Treatment consists of standard urotherapy, additional interventions, and pharmacotherapy in selected cases. Those with refractory UI require careful reassessment to look for the unrecognized disorders. Invasive urodynamics should be done in those patients. Ultrasound of the bladder neck region and the pelvic floor can be helpful, but its interpretation is very subjective. In a small group bladder neck insufficiency can be found and those might benefit from a surgical intervention.

FUTURE PERSPECTIVE

Strict criteria of the bladder neck insufficiency in children must be defined. Early surgical intervention in girls with bladder neck insufficiency might reduce the long period of intensive conservative treatment.

Familial predisposition to pelvic floor dysfunction: prolapse and incontinence surgery among family members and its relationship with age or parity in a Swedish population

OBJECTIVE

To estimate the relationship between heredity and proband's age/parity on the risk of undergoing surgery for pelvic organ prolapse and stress incontinence.

STUDY DESIGN

Swedish population based study. Data from two national Swedish registers were used: the Hospital Discharge Register, National Board of Health and Welfare, containing information on all in-patient surgical procedures on Swedish hospitals, and the Multi-Generation Register, Statistics Sweden, containing information on individuals belonging to the same family. Women who had a surgical procedure for urinary incontinence or genital organ prolapse between the years 1987 and 2002 were identified (probands). Mothers and sisters of the probands were identified and information on incontinence or prolapse operations was linked to those relatives from the Hospital Discharge file, after which adjusted analyses were performed.

RESULTS

Sisters to probands had a relative risk (RR) of 4.69 (95% confidence intervals (CI) 4.49-48.9) and mothers a RR of 2.17 (95% CI 2.07-2.27) for pelvic floor surgery. For sisters the risk decreased with increasing age and parity of the proband.

CONCLUSION

Sisters and mothers of women operated for urinary incontinence/urogenital prolapse had a higher risk of surgery for pelvic floor conditions, in particular sisters of women operated at a young age (<50) and with a low parity. This suggests that heredity plays a lesser role for the development of pelvic floor dysfunction at older age and with increasing parity.

Segmentation of female pelvic cavity in axial T2-weighted MR images towards the 3D reconstruction

The anatomies of pelvic structures are critical for the diagnosis of pelvic floor dysfunctions. However, because of the complex background, the imaging appearances of pelvic organs and muscles are frequently distorted by noise and partial volume effect. Magnetic resonance imaging with its clear imaging quality of the female pelvic cavity is preferred for many studies. As such, correct segmentations of the pelvic structures on MR images are required for accurate diagnoses. Effective algorithms for axial T2-weighted MR images have been proposed, which are based on the imaging features of different structures and various image clues. In this paper, we review these algorithms and evaluate their performance, and discuss implementation issues and aspects towards constructing the three-dimensional models.

Pelvic floor disorders: linking genetic risk factors to biochemical changes

Pelvic floor disorders (PFDs) such as stress urinary incontinence (SUI) and pelvic organ prolapse (POP) may share a common pathophysiological process related to pelvic floor tissue laxity and loss of support. We reviewed recent literature on observed biochemical changes in women with SUI and POP, linking them to genetic predisposition. We found that studies of pelvic tissues showed differences between control subjects and women with POP and SUI in collagen and elastin structure at a molecular and fibrillar level. Studies were heterogeneous but showed a trend towards decreased collagen and elastin content. The contribution of matrix metalloproteinases to increased collagenolysis can be related to genetic polymorphisms present in higher frequency in women with PFD. Extracellular matrix (ECM) protein turnover plays a role in the development of POP and SUI, but much remains to be understood of this complex dynamic interplay of enzymes, proteins and molecules. Genotyping of candidate genes participating in ECM formation will elucidate the missing link between the manifestation of the disease and the biochemical changes observed systematically, in addition to those in the pelvic floor.

Novel biomarkers for overactive bladder

Biomarkers constitute any objectively measurable indicator of a biological process. The classic biomarker used in the diagnosis of overactive bladder (OAB) has been detrusor overactivity, which is assessed urodynamically. In the search for a reliable, noninvasive alternative to urodynamics, interest has focused on genetic, imaging, and urinary factors. Along with other cytokines detectable in urine, prostaglandin E2 and nerve growth factor are indicators of low-grade inflammation. Although they correlate with OAB symptom severity, they have not been shown to have independent prognostic benefit. Imaging biomarkers have been investigated since the earliest days of video urodynamics. Despite extensive research on the ultrasonographic estimation of bladder wall thickness, further standardization of the technique is required before conclusions can be reached regarding diagnostic accuracy. Genetic factors contribute approximately half of the total risk for urgency incontinence. Functional polymorphisms of the cytochrome P450 IID6 gene significantly alter the metabolism of some commonly used anticholinergic drugs, but no genetic loci that influence risk of OAB have been definitively identified. The first genome-wide association studies for OAB are in progress, and should identify new susceptibility genes. Although current putative biomarkers correlate with OAB severity, much future work is required to assess their prognostic value, and establish their role in clinical practice.

Feature-based tracking of urethral motion in low-resolution trans-perineal ultrasound

This paper describes a novel algorithm for tracking the motion of the urethra from trans-perineal ultrasound. Our work is based on the structure-from-motion paradigm and therefore handles well structures with ill-defined and partially missing boundaries. The proposed approach is particularly well-suited for video sequences of low resolution and variable levels of blurriness introduced by anatomical motion of variable speed. Our tracking method identifies feature points on a frame by frame basis using the SURF detector/descriptor. Inter-frame correspondence is achieved using nearest-neighbor matching in the feature space. The motion is estimated using a non-linear bi-quadratic model, which adequately describes the deformable motion of the urethra. Experimental results are promising and show that our algorithm performs well when compared to manual tracking.

Urge incontinence: estimating environmental and obstetrical risk factors using an identical twin study

INTRODUCTION AND HYPOTHESIS

The objective of this study was to determine risk factors for urge urinary incontinence (UUI).

METHODS

A multi-item survey was administered to a community sample of identical twin sisters from 2002-2008. Generalized estimating equations accounting for co-twin correlation were used to perform three different regression models on the outcome: UUI (yes vs. no).

RESULTS

Mean age, median parity, and BMI were 41.4 +/- 16.4 (18-85), 1.0, and 26.0 +/- 6.5 (13.5-55.8), respectively. Thirty-five percent of women were post-menopausal, and 27.5% had UUI. Urge urinary incontinence was reported in 40.1% of parous versus 14.1% among nulliparous women (p < .0001). The rate of UUI was 40.6% after vaginal delivery, 36.7% after cesarean delivery, and 14.1% in nulliparous women (p < .0001). Obesity, age >40, and chronic constipation were also identified as risk factors for urge urinary incontinence.

CONCLUSION

Risk factors for UUI include parity, age, obesity, and chronic constipation. There was a 2.5-fold increased risk of UUI after one or more births, regardless of type of delivery.

Vaginal delivery and pelvic floor dysfunction: current evidence and implications for future research

Vaginal delivery is the major risk factor for the development of pelvic organ prolapse and urinary and fecal incontinence, resulting from damage to the pelvic floor muscles, nerves and connective tissue. This article reviews the perineal trauma mechanism during vaginal delivery and discusses implications of current and future research projects.

Influence of visual feedback on pelvic floor muscle strength

OBJECTIVE

The objective of this study is to evaluate the visual feedback influence on pelvic floor muscle contraction.

STUDY DESIGN

Seventeen nulliparous, urinary-continent women participated in this study. Pelvic floor muscle strength with and without the use of visual feedback was measured with a dynamometric speculum in two directions (anteroposterior and left-right). To compare the mean strength values with and without the use of visual feedback, the t test was applied.

RESULTS

There was no significant difference between the pelvic floor muscle anteroposterior strength values with and without the use of visual feedback (p=0.30), and no significant difference for the left-right strength (p=0.37).

CONCLUSION

There was no difference between the pelvic floor muscle strength values with and without the use of visual feedback.

Incidence and etiology of pelvic floor dysfunction and mode of delivery: an overview

Elective cesarean section at patient request is becoming common place. Women are requesting the intervention for preservation of the pelvic floor, but there is conflicting evidence to suggest that this mode of delivery has such benefits. The risks vs. benefits of both vaginal delivery and cesarean section need to be well understood before deciding on a surgical delivery. This review outlines the current available evidence of the risks and benefits associated with vaginal delivery and elective cesarean section and the incidence and mechanisms of injury that lead to pelvic floor dysfunction. As in most surgical conditions, a better understanding of causality of pelvic floor dysfunction may help treatment effectiveness.

Symptomatic pelvic organ prolapse and possible risk factors in a general population

OBJECTIVE

We sought to examine the prevalence of pelvic organ prolapse (POP) symptoms and risk factors in a general white population.

STUDY DESIGN

This was a cross-sectional study. All female residents aged 45-85 years in a small Dutch city received validated questionnaires. Women were classified as symptomatic if they reported feeling and/or seeing vaginal bulge.

RESULTS

Response rate was 62.7% (1869/2979). Prevalence of POP was 11.4%. Multivariate analysis revealed POP symptoms during pregnancy, a maternal history of POP, and heavy physical work, with a total population-attributable risk of 46%.

CONCLUSION

There is high prevalence of symptomatic POP in a general white population of which independent risk factors are POP symptoms during pregnancy, a maternal history of POP, and heavy physical work. Clinicians should focus on risk factors in counseling of (pregnant) women to inform women to be aware of further exposures for themselves and their daughters.

Incontinence and pelvic organ prolapse in parous/nulliparous pairs of identical twins

AIM

To evaluate the role of vaginal delivery in the development of urinary incontinence and pelvic organ prolapse in four sets of identical twins.

METHODS

Four sets of identical twins were identified from 101 pairs of parous/nulliparous postmenopausal sister pairs, who completed a comprehensive questionnaire, and underwent clinical evaluation of urinary incontinence and pelvic organ prolapse as part of a study. Findings of identical twin sisters were compared to each other.

RESULTS

Ages ranged from 52 to 56 years; the parous sister in each pair had two vaginal deliveries. Two twin pairs reported no incontinence. One pair reported incontinence with activities and stress incontinence was confirmed with VLPP of 120 and 130 cm H(2)O in the nulliparous and parous sister respectively. In one pair only the nulliparous sister reported incontinence, however both sisters were diagnosed with stress incontinence with VLLP of 130 and 120 cm in the nulliparous and parous sister respectively. Using POP-Q staging for relaxation of the pelvic support system, only one twin pair had a greater than 1 stage difference in any compartment.

CONCLUSIONS

All four pairs of identical twins were diagnosed with identical continence status. Three pairs were identical with regard to support in all three compartments. Vaginal delivery was not associated with urinary incontinence or clinically relevant differences in relaxation of the pelvic support system within four sets of postmenopausal identical twins with different parity status.

Inherited pelvic organ prolapse in the mouse: preliminary evaluation of a new murine model

The objective of this study was to report the initial anatomic, radiographic, and genetic evaluations of a novel form of spontaneous pelvic organ prolapse (S-POP) in mice. We observed S-POP in a colony of UPII-SV40T transgenic mice developed for studies on bladder cancer. We utilized magnetic resonance imaging and necropsy to characterize this finding. We have established a breeding colony to identify inheritance patterns and for future studies. Selective breeding isolated the S-POP phenotype from the transgene. In contrast to other animal models, the S-POP mouse does not require an obligatory antecedent event to manifest pelvic organ prolapse. Necropsy and imaging demonstrate significant displacement of the pelvic organs distal to the pelvic floor in both sexes. The appearance of the POP is similar to that seen in the human female phenotype. Preliminary breeding studies indicate an autosomal dominant inheritance pattern. This mouse may be an effective animal model for the study of POP in humans.

Women's autonomy and scheduled cesarean sections in Brazil: a cautionary tale

BACKGROUND

In Brazil, one-fourth of all women deliver in the private sector, where the rate of cesarean deliveries is extremely high (70%). Most (64%) private sector cesareans are scheduled, although many women would have preferred a vaginal delivery. The question this study addresses is whether childbearing women were induced to accept the procedure by their physicians, and if so, how?

METHODS

Three face-to-face structured interviews were conducted with 1,612 women (519 private sector and 1,093 public sector) early in pregnancy, approximately 1 month before their due date, and approximately 1 month postpartum. For all private sector patients having a scheduled cesarean section, women's self-reported reasons given for programming surgical delivery were classified into three groups according to obstetrical justification.

RESULTS

After loss to follow-up (19.2% of private sector and 34.4% of public sector), our final sample included 1,136 women (419 private sector and 717 public sector). Compared with public sector participants in the final sample, on average, private sector participants were older by 3.4 years (28.7 vs 25.3 yr), had 0.4 fewer previous deliveries (0.6 vs 1.0), and had 3.4 more years of education (11.0 vs 7.6 yr). The final samples also differed slightly with respect to preference for vaginal delivery: 72.3 percent among those in the private sector and 79.6 percent in public sector. The cesarean section rate was 72 percent in the private sector and 31 percent in the public sector. Of the women with reports about the timing of the cesarean decision, 64.4 percent had a scheduled cesarean delivery in the private sector compared with 23.7 percent in the public sector. Many cesarean sections were scheduled for an "unjustified" medical reason, especially among women who, during pregnancy, had declared a preference for a vaginal delivery. Among 96 women in this latter group, the reason reported for the procedure was unjustified in 33 cases. On the other hand, more cesarean deliveries were scheduled for "no medical justification," including physician's or the woman's convenience, among women who preferred to deliver by cesarean (35/65). The incidence of real medical reasons for a scheduled cesarean section diagnosed before the onset of labor among private sector patients who had no previous cesarean birth and who wanted a vaginal delivery was 13 percent (31/243).

CONCLUSIONS

The data suggest that doctors frequently persuaded their patients to accept a scheduled cesarean section for conditions that either did not exist or did not justify this procedure. The problem identified in this paper may extend well beyond Brazil and should be of concern to those with responsibility for ethical behavior in obstetrics.

Familial transmission of urogenital prolapse and incontinence

PURPOSE OF REVIEW

To summarize recent evidence suggesting a genetic basis for the development of urogenital prolapse and stress urinary incontinence.

RECENT FINDINGS

Epidemiological evidence suggests that some women have a genetic predisposition to the development of urogenital prolapse and stress incontinence. Abnormal expression of various structural proteins is thought to be the molecular genetic mechanism for the development of these conditions. A group of families with an autosomal dominant pattern of transmission of urogenital prolapse with high penetrance has been identified. No similar cohort of families with familial stress incontinence currently exists, although candidate genes have been identified that appear to predispose women to urogenital prolapse and stress incontinence. Additionally, animal models of urogenital prolapse have been developed that closely parallel the development of prolapse in humans.

SUMMARY

A growing body of evidence suggests a genetic basis for the development of urogenital prolapse and stress incontinence. Candidate genes have been identified that may result in alteration of the normal metabolism of various structural proteins which may ultimately predispose some women to both urogenital prolapse and stress incontinence. Further research into the genetic basis of these conditions may provide a comprehensive understanding of the biological basis of these disorders.

Is parity in the eye of the beholder?

To investigate whether parity status can be predicted by physical examination and which findings are most predictive. A retrospective chart review of 75 postmenopausal nulliparous/parous sister pairs who underwent gynecological examination as part of a study. An examiner, blinded to parity status, predicted parity status based on physical findings recorded on 146 women. Parity status was correctly predicted for 84.9% of the women. Of the 22 women for whom parity prediction was incorrect, 11 were nulliparous and 11 parous. The physical findings most commonly used for prediction were presence or absence of abdominal striae, appearance of the cervical os, and condition of hymen. Absence of the hymen at 6 o'clock alone correctly predicted parity in 11 of 12 parous and 11 of 11 nulliparous women. Parity status can be predicted based on physical exam in the majority of women. Blinding of investigators to parity status may not be feasible.

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study

OBJECTIVE

To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery.

DESIGN

Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health.

SETTING

410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided data

PARTICIPANTS

106,546 deliveries reported during the three month study period, with data available for 97,095 (91% coverage).

MAIN OUTCOME MEASURES

Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics.

RESULTS

Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective.

CONCLUSIONS

Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.

Labor and delivery management for women with diabetes

Diabetes in pregnancy confers a number of risks for both the mother and her baby, and many of these risks are encountered in the labor and delivery unit. The obstetric provider caring for women with diabetes should be alert to the risk of hypertension and the potential for difficult delivery due to an overgrown fetus. Women with preexisting diabetes or poor glycemic control are at increased risk for poor obstetrical outcomes such as stillbirth or delivery of a malformed infant. Meticulous attention to avoiding maternal hyperglycemia during labor can prevent neonatal hypoglycemia.

Elective Cesarean Delivery: The Pelvic Perspective

Elective cesarean delivery, or cesarean delivery on maternal request, was the focus of a recent State-of-the-Science Conference sponsored by the National Institutes of Health. On the basis of the information from comprehensive literature review and expert speakers, the panelists determined that weak-quality evidence supported elective cesarean delivery over planned vaginal delivery for urinary incontinence, although the duration of effect is not clear. For other maternal outcomes related to pelvic floor function, including pelvic organ prolapse, fecal incontinence and other anorectal symptoms, and sexual function, weak-quality evidence did not favor either route of delivery.

The role of neutrophil elastase in elastin metabolism of pelvic tissues from women with stress urinary incontinence

OBJECTIVE

Altered elastin metabolism is implicated in pelvic floor disorders. We studied neutrophil elastase (NE) and matrix metalloproteinase (MMP) activities in vaginal tissues from premenopausal women with stress urinary incontinence (SUI).

METHODS

Elastase and NE activities in vaginal tissues were assessed. Protein and mRNA expressions were determined by RT-PCR and Western blot. Total elastin and collagen contents were evaluated. To compare the relative elastolytic effect of NE and MMP-2, we used their respective antibodies to immunoprecipitate these proteins from vaginal fibroblast extracts prior to assessing elastase activity.

RESULTS

Elastase activity in vaginal wall tissues was significantly higher in the secretory compared to the proliferative phase. NE mRNA and protein expressions were similar between control and SUI tissues from the secretory phase. However, NE activity in the SUI tissues was higher compared to control tissues. The mRNA expression of alpha-1 antitrypsin (ATT) was higher in control tissues from the proliferative phase compared to those from the secretory phase, while no difference was observed in SUI tissues between either phase. Protein expression of the active form of ATT was decreased in SUI tissues compared to controls during the secretory phase. Anti-NE antibody reduced total elastase activity by 60-70%, compared to less than 20% reduction with anti-MMP-2 antibody.

CONCLUSION

During the secretory phase, elastolytic activity is increased in pelvic tissues from women with SUI, through an increase in NE activity and a concurrent decrease in ATT expression. The serine protease, NE, appears to be a more significant modulator of elastase activity compared to MMP-2.

A urogynecologist's view ofthe pelvic floor effects of vaginal delivery/cesarean section for the urologist

Pregnancy and parturition have been implicated in the development of pelvic floor dysfunction. These disorders include urinary incontinence, fecal incontinence, pelvic organ prolapse, and other pelvic and sexual dysfunctions. The urologist caring for women with urinary dysfunction needs to be familiar with the causes of pelvic floor dysfunction and their implications. Defects of the pelvic floor have clearly resulted from the traumatic effect of vaginal delivery. The likely mechanisms of injuries during vaginal delivery involve stretching and compression of the pudendal nerve and peripheral branches, as well as an additional tearing of muscles and connective tissue. Optimal management of labor and optimal techniques of repair of unavoidable sphincteric lacerations, ante- and postpartum pelvic floor muscle conditioning, and timely and proper indications for cesarean delivery will minimize the effect of incidental traumatic delivery.

Pelvic Organ Prolapse in Nulliparous Women and Their Parous Sisters

OBJECTIVE

To investigate the role of vaginal delivery and familial factors in the development of pelvic organ prolapse by comparing the prevalence of this condition in nulliparous women and their parous sisters.

METHODS

Pairs of nulliparous and parous postmenopausal sisters were recruited for assessment of pelvic organ prolapse. One hundred one sister pairs underwent clinical evaluation. Pelvic organ prolapse was recorded using the Pelvic Organ Prolapse Quantification System.

RESULTS

The majority of women had no pelvic organ prolapse. By compartment there was a 74.3% to 91.1% concordance in prolapse stage within sister pairs. In discordant sister pairs, the parous sister was found to have the more advanced prolapse 88% of the time.

CONCLUSION

High concordance of pelvic organ prolapse in nulliparous and parous sister pairs suggests a familial predisposition toward developing this condition. However, vaginal delivery does appear to confer a risk for more advanced pelvic organ prolapse.

LEVEL OF EVIDENCE

II-2.

Risk of urinary incontinence after childbirth: a 10-year prospective cohort study

OBJECTIVE

To estimate prospectively the effect of first delivery on subjective bladder function and to assess the influence of subsequent deliveries and obstetric events

METHODS

We performed a prospective, observational cohort study. During a 10-week period in 1995, 304 of 309 eligible primiparous women (98%) entered the study at the postpartum maternity ward and completed a bladder function questionnaire. The 10-year observational period was completed by 246 of 304 subjects (81%).

RESULTS

Prevalence of moderate-severe stress urinary incontinence increased from 5 of 304 subjects (2%) at baseline to 27 of 229 (12%) at 10 years follow-up (P < .001). Prevalence of moderate-severe urinary urgency increased from 0 subjects (0%) at baseline to 31 of 229 (13%) at the 10-year follow-up (P < .001). The relative risk (RR) (adjusted for maternal age and parity) of moderate to severe urinary incontinence increased significantly 10 years after first delivery (RR 5.8, 95% confidence interval [CI] 1.2-33.7). At multivariable analysis adjusted for age and parity, stress urinary incontinence symptoms at 9 months and 5 years follow-up were independently associated with the presence of symptoms at 10 years after index delivery (RR 13.3, 95% CI 3.9-33.1 and RR 14.1, 95% CI 2.5-18.8, respectively). Number of vaginal deliveries or other obstetric covariates did not affect the risk of stress urinary incontinence or urinary urgency.

CONCLUSION

Vaginal delivery is independently associated with a significant long-term increase in stress urinary incontinence symptoms, as well as urinary urgency, regardless of maternal age or number of deliveries.

LEVEL OF EVIDENCE

II-2.

Sequence variant in the laminin gamma1 (LAMC1) gene associated with familial pelvic organ prolapse

Pelvic organ prolapse is a common condition, affecting up to a third of women throughout their lifetime. Genetic factors are believed to account for about 30% of the incidence, and are the least understood component of the disorder. Familial cases, particularly those in which prolapse manifests in young women, are especially valuable in the effort to find the genes involved. We recently reported autosomal dominant transmission as the most likely mode of inheritance, based on a collection of families with high incidence of prolapse. Of greatest interest was a family in which three generations of female relatives suffered from prolapse at a very young age. A genome-wide linkage scan performed using the Affymetrix GeneChip Human mapping 10K array identified ten regions with a LOD score of 1.5, the maximum possible for this family. Candidate genes within those regions were analyzed for expression in vaginal tissue by RT-PCR. Of the genes confirmed to be expressed, LAMC1 was further evaluated by sequencing and select single nucleotide polymorphism (SNP) genotyping for causative sequence variants in affected family members. We identified one such SNP, rs10911193. The rare T variant segregating with the condition is present at a frequency of 4.9% in the general population and 22% among probands from our cohort of families. It affects the binding site for NFIL3, a transcription factor that we verified to be co-expressed in vaginal tissue. Altogether these data suggest that a polymorphism in the promoter of LAMC1 may increase the susceptibility to early-onset pelvic organ prolapse.