The association between vulvodynia and interstitial cystitis/bladder pain syndrome: A systematic review

BACKGROUND

Vulvodynia (VVD) is a debilitating chronic vulvar pain significantly affecting patients' quality of life. Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic and complex illness characterized by an unpleasant sensation related to the filling of the bladder and it strongly impacts patients' lives. The exact mechanisms of the two syndromes remain unknown, but there is an overlap between suspected pathophysiologies.

OBJECTIVE

To present an overview of the current research on the association between VVD and IC/BPS.

SEARCH STRATEGY

A systematic search of three electronic databases was conducted. Studies examining the correlation between VVD and IC/BPS with male and female patients aged over 18 years were included.

SELECTION CRITERIA

Studies assessing the coexistence of VVD and IC/BPS were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers screened the studies for eligibility. Eligible studies were screened for quality.

MAIN RESULTS

A total of 13 studies were included in the final review. Among them, 11 presented a positive association between the two syndromes. The studies highlighted that VVD and IC/BPS share common comorbidities and possibly etiopathogenic pathways.

CONCLUSION

VVD and IC/BPS are both complex and multifactorial syndromes. This review highlights an association between them, but additional studies on the topic should be conducted for a more precise conclusion.

European Urogynaecological Association Position Statement: The role of urodynamics in stress urinary incontinence evaluation and treatment decision

Stress urinary incontinence (SUI) is defined as a condition characterized by the involuntary leakage of urine during activities that increase intra-abdominal pressure which may decrease quality of life with a significant economic impact on health systems, necessitating the implementation of cost-effective management plans. Urodynamics (UDS) has been considered during the last decades as the gold standard for assessment of lower urinary tract symptoms (LUTS) due to their high reproducibility. At the same time, concerns about the systematic use of UDS before SUI surgery were raised due to a limited evidenced base to recommend their routine use. In uncomplicated female patients with SUI, UDS can offer further insights into LUTS, potentially assisting the physician in determining the appropriate therapeutic approach. However, it has not been shown that preoperative UDS can directly impact the surgical outcome for continence. Indeed, evidence supports the conclusion that pre-operative UDS in women with uncomplicated, clinically demonstrable, SUI does not improve the outcome of surgery for SUI. Nevertheless, asymptomatic detrusor overactivity (DO) identified by urodynamic testing or pre-existing voiding dysfunction are associated with an increased occurrence of postoperative overactive bladder (OAB) and voiding dysfunction, respectively. The EUGA Working Group concluded that the evidence does not support the systematic preoperative use of UDS for uncomplicated cases. However, in cases where mixed symptoms, voiding dysfunction, previous surgery, or concomitant prolapse are present, preoperative UDS are advised as they can be beneficial in anticipating postoperative outcomes. This aids in conducting comprehensive and thorough preoperative counseling. The Group recommend performing preoperative UDS considering the patient's specific clinical situation and the surgeon's judgment, with consideration given to the potential benefits, risks, and impact on treatment decisions and patient outcomes.

How do we make progress in phenotyping patients with lower urinary tract such as overactive bladder and underactive detrusor, including using urine markers and microbiome data, to personalize therapy? ICI-RS 2023-Part 2

INTRODUCTION

Overactive bladder (OAB) and underactive bladder (UAB) could be associated with metabolic syndrome, affective disorders, sex hormone deficiency, changes in urinary microbiota, functional gastrointestinal disorders, or autonomic nervous system dysfunction.

OBJECTIVES

The aim of this Think Tank was to provide a guide on how to investigate OAB and/or detrusor underactivity (DU) patients to better clarify the underlying pathophysiology and possibly personalize the treatment.

METHODS

A compendium of discussion based on the current evidence related to phenotyping patients with OAB or DU using urodynamic tests, functional neuro-imaging, urinary markers, and microbiome.

RESULTS AND CONCLUSIONS

The article emphasizes the critical significance of adopting a comprehensive yet tailored approach to phenotyping patients with lower urinary tract (LUT) symptoms, such as OAB and UAB. The intricate interplay between the LUT and various factors, metabolic, neurological, psychological, and gastrointestinal can define unique LUT profiles, enabling personalized therapies to replace the one-size-fits-all approach.

How do we make progress in phenotyping patients with LUT such as OAB and underactive detrusor, including using urine markers and microbiome data, in order to personalize therapy? ICI-RS 2023: Part 1

INTRODUCTION

Overactive bladder (OAB) and Underactive bladder (UAB) could be associated with metabolic syndrome, affective disorders, sex hormone deficiency, changes in urinary microbiota, functional gastrointestinal disorders, or autonomic nervous system dysfunction.

OBJECTIVES

The aim of this Think Tank was to provide a guide on how to investigate OAB and/or detrusor underactivity (DU) patients to better clarify the underlying pathophysiology and possibly personalize the treatment.

METHODS

A compendium of discussion based on the current evidence related to phenotyping patients with OAB or DU investigating metabolic, neurogical, psychological and gastrointestinal aspects with the aim to personalize the treatment.

RESULTS AND CONCLUSIONS

The article emphasizes the critical significance of adopting a comprehensive yet tailored approach to phenotyping patients with lower urinary tract symptoms, such as OAB and UAB. The intricate interplay between the lower urinary tract and various factors, metabolic, neurological, psychological, and gastrointestinal can define unique LUT profiles, enabling personalized therapies to replace the one-size-fits-all approach.

Is Diastasis Recti Abdominis Rehabilitation after Childbirth Able to Prevent the Onset of Stress Urinary Incontinence? A Case-Control Study

Background and Objectives: Pelvic floor muscle training (PFMT) represent the first-line approach to pelvic floor dysfunctions (PFDs). Recently, studies have shown a synergy between the pelvic floor and abdominal muscles, hypothesizing that the anatomical and functional integrity of the abdominal wall plays a role in the prevention of pelvic floor disorders. Some studies have shown a significant correlation between diastasis recti abdominis (DRA) and stress urinary incontinence (SUI). Nevertheless, the evidence reported in the literature is controversial and based on low-quality data. The aim of the study is to clarify whether DRA-specific abdominal rehabilitation is needed in women with SUI after childbirth. Materials and Methods: All consecutive women who had at least one delivery and complained of symptoms of pure SUI that were urodynamically proven were considered for the study. The group of symptomatic patients was compared with a series of consecutive women, identified during the same study period, without any symptoms of SUI. In both groups, we measured the inter-rectal distance (IRD) with an ultrasound scanner above and below the navel. Results: A total of 102 women eligible for the study group and 100 women who did not report any symptoms of SUI were enrolled. The inter-rectal distance above the umbilicus showed no significant difference between the two groups (2.12 ± 0.98 vs. 2.1 ± 0.77; p = 0.94). In contrast, the data from the sub-umbilical measurements showed a significant difference. Surprisingly, the asymptomatic group showed significantly greater (0.98 ± 0.9 vs. 1.33 ± 0.87 p-value: 0.009) IRD compared to the symptomatic group. Conclusions: The study shows that DRA is not a risk factor for SUI in women after childbirth. Therefore, specific abdominal wall rehabilitation after childbirth does not seem to be indicated.

How should prospective research be designed to legitimately assess the value of urodynamic studies in female urinary incontinence?

AIMS

Since formal evidence demonstrating the value of urodynamic studies (UDS) in functional urology remains elusive, we aimed to consider how best to design robust research for this purpose in female urinary incontinence.

METHODS

An expert group was convened to debate the following considerations: (a) precedents for formally proving the value of a gold standard diagnostic test, (b) key research principles, (c) defining a study population, (d) selecting endpoints, (e) defining interventional and controls arms, (f) blinding, (g) powering the study, and (h) duration of follow-up. In each case, we considered the strengths and weaknesses of different approaches in terms of scientific validity, ethical acceptability, practicality, and likelihood of bias.

RESULTS

We agreed that unlike evaluating therapies, attempting to judge the value of a diagnostic test based on eventual treatment success is conceptually flawed. Nonetheless, we explored the design of a hypothetical randomized controlled trial for this purpose, agreeing that: (1) the study population must sufficiently reflect its real-world counterpart; (2) clinical endpoints should include not only continence status but also other lower urinary tract symptoms and risks of management; (3) participants in the interventional arm should receive individualized management based on their UDS findings; (4) the most scientifically valid approach to the control arm-empiric treatment-is ethically problematic; (5) sufficient statistical power is imperative; and (6) ≥ 2 years' follow-up is needed to assess the long-term impact of management.

CONCLUSIONS

Although a perfect protocol does not exist, we recommend careful consideration of our observations when reflecting on past studies or planning new prospective research.

Iron deficiency and sexual dysfunction in women

INTRODUCTION

Sexual dysfunction negatively affects approximately 40% to 50% of adult women across various stages of life. Common risk factors include sexual traumas, relationship problems, chronic conditions, medication side effects, and poor physical health, including iron deficiency.

OBJECTIVES

This review summarizes a presentation from a symposium that discussed the types and causes of sexual dysfunction at key times in women's lives, focusing on the relationship between iron deficiency and sexual dysfunction.

METHODS

The symposium was held at the XV Annual European Urogynaecological Association Congress, Antibes, France, in October 2022. Symposium content was identified through literature searches of PubMed. Original research, review articles, and Cochrane analyses discussing sexual dysfunction in association with iron deficiency/anemia were included.

RESULTS

Iron deficiency in women is commonly caused by abnormal uterine bleeding, but women may develop iron deficiency anemia (IDA) because of increased iron needs or reduced iron intake/absorption. Treatment with oral iron supplementation has been shown to improve sexual function in women with IDA. Ferrous sulphate is considered as a standard of care for oral iron treatment; prolonged-release iron formulations have improved tolerability, enabling lower doses and better tolerability.

CONCLUSION

IDA and sexual dysfunction are related, so the identification of sexual dysfunction or iron deficiency in a woman should prompt an investigation of the other condition. Testing for iron deficiency is an inexpensive and simple step that can be routinely included in the workup of women with sexual dysfunction. Once identified, IDA and sexual dysfunction in women should be treated and followed to optimize quality of life.

The Impact of Systemic Sclerosis on Sexual Health: An Italian Survey

OBJECTIVE

To evaluate the impact of systemic sclerosis (SSc) on vulvovaginal atrophy (VVA) and sexual health in an Italian population.

METHODS

An Italian survey about the prevalence and severity of VVA (on a 0 to 10 scale) and sexual dysfunction (using the Female Sexual Function Index-FSFI) through an anonymous online questionnaire. We investigated couple relationships and intimacy with partners, the predisposition of patients to talk about their sexual problems, physicians' receptivity, and treatment scenarios. Risk factors for VVA symptoms and sexual dysfunction were assessed.

RESULTS

A total of 107 women affected by SSc were enrolled. Of these, 83.2% of women (89/107) complained about VVA symptoms and 89.7% (among sexually active women; 87/97) about sexual dysfunction. Menopausal status did not affect VVA symptoms, while age was the only independent risk factor for sexual dysfunction. About 70% (74/107) of women reported a negative impact of disturbances on intimacy with their partner. A total of 63 women (58.9%) had never discussed their sexual problems and VVA condition with a physician. Lubricants were the only treatment prescribed, and 75% of women would welcome new therapies, even if experimental (62.9%).

CONCLUSIONS

In women with SSc, VVA symptoms and sexual dysfunction are highly prevalent, independently from menopause. In more than half of the investigated women with SSc, we found reluctance to talk about their sexual problems, despite being symptomatic. This should encourage physicians to investigate vulvovaginal and sexual health. SSc patients would welcome the advent of new treatment possibilities for their VVA and sexual complaints.

Linguistic translation and validation of the Arabic version of International Female Coital Incontinence Questionnaire (IFCI-Q)

Objectives

Aim of the study was to translate the International Female Coital Incontinence Questionnaire (IFCI-Q) into Arabic (Egyptian) and validate it into among Egyptian population complaining of coital urinary incontinence (CI).

Methods

Original questionnaire has been translated and back-translated by an expert panel, to produce the Arabic version. A pilot study was performed to make sure the questionnaire was understandable. Sixty patients included in the study were divided into two groups: Group A comprised patients with CI, and Group B comprised females who attended the urology clinic for other complaints, without CI. Reliability of the Arabic IFCI-Q was evaluated for internal consistency using Cronbach alpha coefficient. Test-retest reliability was determined using the Weighted Cohen's k-test. Discrimination validity was evaluated by comparing scores of patients with those of healthy females not complaining of CI using Mann-Whitney test.

Results

83.3% of women of both groups (mean age: 43.1 ± 10.6 yrs [Group A], 38.9 ± 8 [Group B] yrs) reported OAB symptoms, 73.3% had stress urinary incontinence and 46.7% reported mixed urinary incontinence. Regarding Group A, 10 patients had CI during penetration, 12 during orgasm and 8 had both forms of CI. The comparison of the responses between Group A and Group B demonstrated a statistically difference (p < 0.00). The content validity was assessed by a panel of expert functional urologists. The Cronbach's alpha coefficients for the total score were high (0.9-1), indicating high internal consistency. The difference between the two groups revealed an internal consistency of IFCI-Q of 0.563-0.851. The test-retest procedure revealed that the k-values of each item are very good.

Conclusions

The Arabic version will allow utilizing this tool in a large population of Arabic-speaking countries, with different ethnic and demographic backgrounds.

Vaginal laser therapy for GSM/VVA: where we stand now - a review by the EUGA Working Group on Laser

Vulvovaginal atrophy (VVA) is a chronic progressive condition that involves the genital and lower urinary tracts, related to the decrease of serum estrogenic levels when menopause occurs. The definition of genitourinary syndrome of menopause (GSM) is a medically more accurate, all-encompassing and publicly acceptable term than VVA. Due to the chronic progressive trend of GSM, symptoms tend to reappear after the cessation of therapy, and frequently long-term treatment is required. First-line therapies include vulvar and vaginal lubricant or moisturizers, and, in the case of failure, low-dose vaginal estrogens are the preferred pharmacological therapy. Populations of patients, such as breast cancer (BC) survivors, are affected by iatrogenic GSM symptoms with concerns about the use of hormonal therapies. The non-ablative erbium:YAG laser and the fractional microablative CO2 vaginal laser are the two main lasers evaluated for GSM treatment. The aim of this comprehensive review is to report the efficacy and safety of Er:YAG and CO2 vaginal lasers for GSM treatment. Vaginal laser therapy has been demonstrated to be effective in restoring vaginal health, improving VVA symptoms and sexual function. The data suggest that both Er:YAG and CO2 vaginal lasers are safe energy-based therapeutic options for management of VVA and/or GSM symptoms in postmenopausal women and BC survivors.

New Advances in Female Pelvic Floor Dysfunction Management

Pelvic floor dysfunctions (PFDs), which include various disorders such as urinary and anal incontinence, pelvic organ prolapse, and sexual disorders, are widespread amongst females, so much so that they affect one fifth of adult women [...].

Hysteropexy and Anterior Vaginal Native Tissue Repair in Women with Anterior and Central Compartment Prolapse: A Long Term Follow-Up

Although it is known that hysterectomy (HY) alone cannot resolve apical prolapse, vaginal hysterectomy (VH) remains the most common surgical procedure for this issue. In recent years, various procedures for uterine conservation have been proposed to avoid the surgical risks of HY. Furthermore, most women with symptomatic pelvic organ prolapse (POP) prefer uterine conservation in the absence of considerable benefit in uterine removal. In 2017, we proposed a new technique for hysteropexy and anterior vaginal native tissue repair (NTR) in women with cystocele and apical prolapse. The objective of this study is to assess the efficacy and safety of this new procedure after at least 5 years of follow-up. We included only patients with stage II or greater prolapse of the anterior vaginal wall and a concomitant stage II uterine prolapse in accordance with Pelvic Organ Prolapse Quantification (POP-Q) system. A Patient Global Impression of Improvement (PGI-I) score ≤ 2 in addition with the absence of POP symptoms was defined as subjective success. A descensus with a maximum point of less than −1 in any compartment was considered objective cure. A total of 102 patients who fulfilled the inclusion criteria were enrolled. At 60 months follow-up, 90 out of 102 patients (88%) were subjectively cured, whereas 88 out of the 102 (86%) patients were objectively cured. Subjective and objective cure rates persisted during the entire study period. Uni- and multivariate analysis of possible predictive factors associated with recurrence of prolapse showed that only a preoperative point C > 0 cm and BMI ≥ 25 kg/m2 were risk factors for failure. In conclusion, our study showed that hysteropexy with anterior vaginal native tissue repair may be an effective and safe option for the treatment of anterior vaginal prolapse and concomitant stage II uterine prolapse by at least 5 years of follow-up.

Outcomes of High-Grade Cervical Dysplasia with Positive Margins and HPV Persistence after Cervical Conization

The objective of this work is to assess the 5-year outcomes of patients undergoing conization for high-grade cervical lesions that simultaneously present as risk factors in the persistence of HPV infection and the positivity of surgical resection margins. This is a retrospective study evaluating patients undergoing conization for high-grade cervical lesions. All patients included had both positive surgical margins and experienced HPV persistence at 6 months. Associations were evaluated with Cox proportional hazard regression and summarized using hazard ratio (HR). The charts of 2966 patients undergoing conization were reviewed. Among the whole population, 163 (5.5%) patients met the inclusion criteria, being at high risk due to the presence of positive surgical margins and experiencing HPV persistence. Of 163 patients included, 17 (10.4%) patients developed a CIN2+ recurrence during the 5-year follow-up. Via univariate analyses, diagnosis of CIN3 instead of CIN2 (HR: 4.88 (95%CI: 1.10, 12.41); p = 0.035) and positive endocervical instead of ectocervical margins (HR: 6.44 (95%CI: 2.80, 9.65); p < 0.001) were associated with increased risk of persistence/recurrence. Via multivariate analyses, only positive endocervical instead of ectocervical margins (HR: 4.56 (95%CI: 1.23, 7.95); p = 0.021) were associated with worse outcomes. In this high-risk group, positive endocervical margins is the main risk factor predicting 5-year recurrence.

Predictors of persistent overactive bladder following surgery for advanced pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Reliable risk factors for persistent urgency following pelvic organ prolapse (POP) surgery are still unclear. We aimed to identify preoperative parameters related to persistent postoperative urgency in a cohort of women following surgery for POP stage 3-4 with concomitant overactive bladder (OAB).

METHODS

In this retrospective analysis, women with POP stage 3-4 and OAB who underwent POP repair during November 2012-December 2020 were included. Preoperative evaluation included history, Pelvic Organ Prolapse Quantification (POP-Q), multi-channel urodynamic studies and Pelvic Floor Distress Inventory (PFDI-20). Surgical procedures included: anterior and posterior colporrhaphy, sacrospinous ligament suspension, anterior vaginal wall mesh repair and robotic-assisted laparoscopic sacrocolpopexy. At the 12-month follow-up, urogynecological history, POP-Q evaluation, cough stress test and the PFDI-20 questionnaire were repeated.

RESULTS

One hundred seventy-three patients were included in the analysis. Resolution of urgency was observed in 56% of women. Variables associated with persistent postoperative urgency included body mass index (BMI) (27 kg/m² vs 25.7 kg/m², p = 0.04), preoperative increased daytime frequency (46.39% vs 61.84%, p = 0.05), urgency urinary incontinence (UUI) (51.46% vs 80.26%, p = 0.0001), detrusor overactivity (DO) (40.2% vs 61.84%, p = 0.009) and lower maximum flow rate on UDS (13.9 ml/s vs 15 ml/s, p = 0.04). Multivariate analysis confirmed preoperative DO (OR: 12.2 [95% CI: 1.4-16.6]; p = 0.01), preoperative UUI (OR 3.8 [95% CI: 1.3-11.0]; p = 0.008) and BMI > 25 kg/m² (OR 1.8 [95% CI: 1.1-7.2]; p = 0.04) as predictive factor for persistent urgency.

CONCLUSIONS

In women with advanced POP and OAB, being overweight, preoperative UUI and DO are related to persistent postoperative urgency. These findings will guide our future preoperative counseling and reinforce the role of UDS in POP management.

Update on Italian-validated questionnaires for pelvic floor disorders

INTRODUCTION

Pelvic floor disorders (PFDs), which include urinary incontinence, pelvic organ prolapse, sexual dysfunction and gastrointestinal disorders, affect over 20% of the adult population. Prevalence may also be underestimated, since a certain portion of patients may be reluctant to talk to physicians about PFDs due to embarrassment. Consequently, there is a need for self-assessed diagnostic tools with the capability to screen population and collect clinical information. Symptom and quality of life (QoL) questionnaires - also identified as patient-reported outcomes (PROs) - have been developed with this purpose. Despite the large number of questionnaires available for the assessment of PFDs and QoL-related issues in the English language, few of them have been validated for the Italian language. The objective of this article is to update the list of Italian-validated PROs for PFDs along with practical information concerning literature references and suggestions on how to obtain every single questionnaire.

EVIDENCE ACQUISITION

PubMed/MEDLINE databases and websites were used to update the list of available Italian-validated questionnaires about PFDs. Once identified, the possibility to get a copy of the questionnaire was verified and steps to obtain it are reported in the tables.

EVIDENCE SYNTHESIS

Eight additional questionnaires validated into the Italian language, for diagnosis and overall management of common urinary, vaginal, sexual and bowel conditions, were retrieved. The complete list of PFDs PROS is reported in a modular format for consultation.

CONCLUSIONS

This format is intended to serve as a tool to promote appropriateness in PROs adoption while investigating PFDs in Italian patients.

Percutaneous tibial nerve stimulation in the treatment of neurogenic detrusor overactivity in multiple sclerosis patients: a historically controlled study

Background

Percutaneous tibial nerve stimulation (PTNS) is widely used in the treatment of neurogenic detrusor overactivity (NDO) in multiple sclerosis (MS); however, controlled studies are still lacking.Objective:: To assess effectiveness of PTNS in MS patients with NDO unresponsive to pharmacological and behavioural therapies.

Methods

MS patients with NDO were enrolled. Inclusion criteria were NDO not responding to pharmacological and behavioural therapies. Exclusion criteria were the presence of relevant comorbidities and urinary tract infections. Patients were evaluated using 3-day bladder diaries and validated questionnaires at baseline, after 4 weeks of educational therapy and after 12 PTNS sessions. The primary outcome measure was the percentage of patients considered responders after the behavioural therapy and after the PTNS in a historical controlled fashion (definition of 'responder' was reduction ⩾50% of urgency episodes).

Results

A total of 33 patients (26 women, 7 men) were enrolled. Two patients dropped out for reasons not related to the protocol. Two out of 31 patients (6.5%) and 21/29 (72.4%) were considered responders at visits 1 and 2, respectively. In PTNS responders, a statistically significant improvement in both bladder diary results and standardized questionnaire scores was recorded, compared with that obtained with behavioural therapy alone. No serious adverse events were reported.

Conclusion

This historically controlled study suggests that PTNS may be effective in improving NDO in MS patients.

Bulking agents for the treatment of recurrent stress urinary incontinence: a suitable option?

BACKGROUND

The management of recurrent female stress urinary incontinence (SUI) still needs worldwide standardization. Few data on the role of urethral bulking agents (UBA) for the treatment of recurrent stress urinary incontinence exist. The aim of this study is to assess the efficacy and safety of urethral bulking agents for the treatment of recurrent SUI.

METHODS

A multicenter, prospective study was conducted in four tertiary referral centers in two countries. All consecutive women with urodynamically-proven recurrent SUI, and with a history of previous failed anti-incontinence surgical procedure (mid-urethral sling or single incision sling), treated by UBAs were included. We evaluated only patients who completed at least a 3-year follow-up. Data regarding subjective outcomes (International Consultation on Incontinence Questionnaire-Short Form, Patient Global Impression of Improvement, Urogenital Distress Inventory score and patient satisfaction score), objective cure (stress test) rates, and adverse events were collected during follow-up. Univariable and multivariable analyses was performed to investigate outcomes.

RESULTS

Forty-seven consecutive patients were enrolled. At 3-year follow-up, all women were available for the evaluation. At 3 years after surgery, 38 of 47 patients (81%) declared themselves cured. Similarly, at 3-year evaluation, 39 of 47 patients (83%) were objectively cured. Only five patients (10.6%) required re-operation for UBA failure. The urodynamic diagnosis of preoperative detrusor overactivity and the PDet Max filling phase ≥15 cmH<inf>2</inf>O (hazard ratio: 2.74; 95% CI, 1.64-10.7; P=0.009 and 1.62; 95% CI, 1.11-3.42; P=0.04, respectively) were the only predictors of failure. Only four complications were reported (8.5%).

CONCLUSIONS

The 3-year results of this study showed that bulking agents is an appropriately effective and safe option for the treatment of recurrent SUI. The presence of preoperative concomitant detrusor overactivity is associated with a significant decrease of the efficacy of this procedure.

Randomised Controlled Trials Assessing the Clinical Value of Urodynamic Studies: A Systematic Review and Meta-analysis

Context

The role of urodynamic studies (UDSs) in the diagnosis of lower urinary tract symptoms (LUTS) is crucial. Although expert statements and guidelines underline their value for clinical decision-making in various clinical settings, the academic debate as to their impact on patient outcomes continues.

Objective

To summarise the evidence from all randomised controlled trials assessing the clinical usefulness of UDS in the management of LUTS.

Evidence acquisition

For this systematic review, searches were performed without language restrictions in three electronic databases until November 18, 2020. The inclusion criteria were randomised controlled study design and allocation to receive UDS or not prior to any clinical management. Quality assessment was performed by two reviewers independently, using the Cochrane Collaboration’s tool for assessing the risk of bias. A random-effect meta-analysis was performed on the uniformly reported outcome parameters.

Evidence synthesis

Eight trials were included, and all but two focused on women with pure or predominant stress urinary incontinence (SUI). A meta-analysis of six studies including 942 female patients was possible for treatment success, as defined by the authors (relative risk 1.00, 95% confidence interval: 0.93–1.07), indicating no difference in efficacy when managing women with UDS.

Conclusions

Although UDSs are not replaceable in diagnostics, since there is no other equivalent method to find out exactly what the lower urinary tract problem is, there are little data supporting its impact on outcomes. Randomised controlled trials have focussed on a small group of women with uncomplicated SUI and showed no added value, but these findings cannot be extrapolated to the overall patient population with LUTS, warranting further well-designed trials.

Patient summary

Despite urodynamics being the gold standard to assess lower urinary tract symptoms (LUTS), as it is the only method that can specify lower urinary tract dysfunction, more studies assessing the clinical usefulness of urodynamic studies (UDSs) in the management of LUTS are needed. UDS investigation is not increasing the probability of success in the treatment of stress urinary incontinence.

Coexistent Detrusor Overactivity-Underactivity in Patients with Pelvic Floor Disorders

Introduction and Hypothesis: Pelvic floor disorders represent a series of conditions that share, in part, the same etiological mechanisms, so they tend to be concomitant. Recently, awareness of a new lower urinary tract clinical syndrome has risen, namely the coexisting overactive–underactive bladder (COUB). The etiopathogenetic process, prevalence, and related instrumental findings of COUB are not well-established. We aimed to evaluate the prevalence, clinical features, and urodynamic findings of patients with COUB in a large cohort of patients with pelvic floor disorders. Methods: A cohort of 2092 women was retrospectively analyzed. A clinical interview, urogenital examination, and urodynamic assessment were performed by a trained urogynecologist. Based on baseline symptoms, patients were divided into COUB and non-COUB groups, and the degree of concordance between COUB and urodynamic findings, and other parameters related to the clinical aspects of these patients were measured and analyzed. Results: 18.8% of patients were classified as COUB. The association between COUB and patients with coexisting detrusor overactivity–underactivity (DOU) was statistically significant and there were substantial similarities in terms of population characteristics, symptoms, and urodynamic findings. Conclusions: Our study showed a high prevalence of COUB, and a link between this clinical syndrome and DOU was demonstrated. They showed substantial similarities in terms of clinical and urodynamics correlates. Based on these findings, we do think that urodynamic tests can be useful to improve knowledge on COUB and may be of help in the management of this condition.

Female Sexual Dysfunctions and Urogynecological Complaints: A Narrative Review

Female sexual dysfunctions represent a real widespread problem, usually faced from a psychological point of view; however, millions of women worldwide are impacted by pelvic floor dysfunction, personal shame and social taboos, however, continue to inhibit free conversation on the subject. Women’s quality of life is considerably improved by screening, diagnosing, and controlling urogenital and sexual issues. This review aims to provide a critical perspective of urogenital conditions and common disturbances in female sexual function associated with these issues. It also includes a discussion of postpartum pelvic dysfunction.

Up-to-Date Procedures in Female Stress Urinary Incontinence Surgery: A Concise Review on Bulking Agents Procedures

To avoid complications related to mid-urethral slings (MUS), alternative procedures to treat stress urinary incontinence (SUI), such as urethral bulking agents (UBAs) have been adopted. The aim of this review is to narratively report the efficacy and safety of UBAs for SUI treatment. For this review, research from PubMed and EMBASE was performed to evaluate relevant studies that were undertaken from January 2012 to January 2022. Nineteen prospective studies were included. Several definitions of subjective and objective success were adopted. At a follow-up of <24 months, significant improvement was widely observed, even if with a heterogeneous rate of success between 32.7−90%, and a reinjection rate of 8.3−77.3%. Compared with other procedures, MUS resulted as significantly superior to UBAs but was balanced by a higher complication rate. Acute urinary retention, urinary tract infection and de novo urgency, and other complications, such as injection site rupture, urethral erosion and particle migration have been described after UBAs. SUI after UBAs treatment resulted in improvements in all studies and can be considered a safe and effective option to treat SUI. However, homogenous and longer-term data lack, limiting general recommendations. Thus, larger RCTs evaluating long-term effects are required.

Acceptability and perceived value of urodynamics from the patient perspective: A narrative review

Background

The value and application of urodynamic evaluation (UDS) have been a controversial topic in recent years. Gaining robust data on the patient viewpoint in this area is important since, even when UDS findings do not change the management plan, the objective diagnostic information gained from UDS may be valued by patients. Moreover, insights from UDS may empower treating physicians to counsel patients more effectively and manage their expectations regarding treatment outcomes.

Objective

This expert narrative review aims to analyze the findings of published studies in this area, looking at two topics in turn: (a) the tolerability and acceptability of the UDS procedure itself from the patient perspective and (b) patient perceptions of the clinical value of insights provided by UDS.

Design, Setting, Participants, and Outcome Measurements

An evidence assessment was conducted using selected articles from the literature reporting data on patients' perspectives on the tolerability, acceptability, utility, and value of the urodynamic investigation.

Results and Limitations

Although pain, discomfort, and infection risks are frequently used as a rationale to skip UDS when initial management fails, there is good evidence that, from the patients' perspective, the procedure is very well tolerated in most cases. There are only a few articles available that assess patient perceptions of the usefulness of UDS, but those that do exist appear to demonstrate that the insights gained from UDS are widely welcomed by patients in the interest of receiving a more tailored and personalized treatment approach.

Conclusion

From the patient perspective, UDS appears to be a well‐accepted and well‐tolerated diagnostic tool in patients with lower urinary tract symptoms, particularly when an appropriate explanation is provided before the examination. Our review also highlights that patients value the objective information provided by UDS and that this outweighs the temporary invasiveness of the test. This information is particularly relevant in light of the relative lack of evidence in the literature about patient expectations of specialist care in functional urology, which may have hindered progress with quality of care.

Vaginal Laser Therapy for Female Stress Urinary Incontinence: New Solutions for a Well-Known Issue. A Concise Review

Background and Objectives: Insufficient connective urethra and bladder support related to childbirth and menopausal estrogen decrease leads to stress urinary incontinence (SUI). The aim of this review is to narratively report the efficacy and safety of new mini-invasive solutions for SUI treatment as laser energy devices, in particular, the microablative fractional carbon dioxide laser and the non-ablative Erbium-YAG laser. Materials and Methods: For this narrative review, a search of literature from PubMed and EMBASE was performed to evaluate the relevant studies and was limited to English language articles, published from January 2015 to February 2022. Results: A significant subjective improvement, assessed by the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI-SF) was reported at the 6-month follow up, with a cure rate ranged from 21% to 38%. A reduction of effect was evidenced between 6 and 24–36 months. Additionally, the 1-h pad weight test evidence a significant objective improvement at the 2–6-month follow up. Conclusions: SUI after vaginal laser therapy resulted statistically improved in almost all studies at short-term follow up, resulting a safe and feasible option in mild SUI. However, cure rates were low, longer-term data actually lacks and the high heterogeneity of methods limits the general recommendations. Larger RCTs evaluating long-term effects are required.

The subjective and objective very long-term outcomes of TVT in the COVID era: A 20-year follow-up

Introduction and hypothesis

Few studies in literature have assessed the long-term durability and mesh-related complications of mid-urethral slings (MUSs). The aim of this study is to assess the efficacy and safety of retro-pubic tension-free vaginal tape (TVT) 20 years after implantation for the treatment of female stress urinary incontinence (SUI).

Methods

A prospective observational study was conducted in two urogynaecologic units in two countries. All the patients involved were consecutive women with urodynamically proven pure SUI treated by TVT. The patients underwent preoperative clinical and urodynamic evaluations. Subjective outcomes, objective outcomes and adverse events were recorded during the follow-up period.

Results

Fifty-two patients underwent a TVT surgical procedure. Twenty years after surgery, 32 out of 36 patients (88.8%) declared themselves cured (p = 0.98). Similarly, 33 out of these 36 patients (91.7%) were objectively cured (p = 0.98). No significant deterioration of subjective and objective cure rates was observed over time (p for trend 0.50 and 0.48). Fifteen of the 36 patients (41.6%) at the 20-year follow-up reported the onset of de novo overactive bladder (OAB) (p = 0.004). No significant vaginal bladder or urethral erosion or de novo dyspareunia was recorded and no patient required tape release or resection during this period. The cause of death of seven out of ten women who died in the last year of the follow-up period was coronavirus disease 19 (COVID 19).

Conclusions

The 20-year results of this study showed that TVT is a highly effective and safe option for the treatment of SUI. The impact of COVID 19 on the mortality rate of elderly women has drastically reduced the number of eligible patients for future evaluations in our region.

Single-incision mini-sling and trans-obturator sling for stress urinary incontinence: A 5-year comparison

OBJECTIVE

The aim of our study was to compare objective and subjective outcomes in women with stress urinary incontinence (SUI) submitted to either trans-obturator sling (TVT-ABBREVO®) or single incision mini-sling (SIMS-ALTIS®) at 5-year follow up.

STUDY DESIGN

A monocentric, retrospective study including women with isolated SUI and with concomitant proved urodynamic stress incontinence (USI), treated with an TVT-ABBREVO® or SIMS-ALTIS®. At 60-month follow up each woman was assessed subjectively, with two validated questionnaires (UDI-6 and ICQI-SF), and objectively with a cough stress test. Adverse events were collected.

RESULTS

Forty-two patients were evaluated in the ABBREVO® group and 58 in the ALTIS® group. No significant difference was found in subjective (88.1% vs 89.7%, p = 0.806) and objective (81.0% vs 86.2%, p = 0.479) cure rates between the two groups. Subjectively, improvement in urinary distress after surgery resulted statistically significant in both groups compared to baseline (p < 0.001). Long-term post-operative complications rate (i.e. de novo OAB and sling exposure) was similar in the two groups. They were, in fact, mainly classified as Dindo II grade and conservatively managed (i.e. antimuscarinics or β₃ agonists for de novo OAB).

CONCLUSION

This comparative study did not reveal significant difference between single-incision (ALTIS®) and trans-obturator (TVT-ABBREVO®) slings in terms of efficacy and morbidity at 5-year follow up.

International Urogynaecology Consultation chapter 1 committee 4: patients' perception of disease burden of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This manuscript from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reports on the patients' perception of disease burden associated with pelvic organ prolapse.

MATERIALS AND METHODS

An international group containing a team of eight urogynaecologists, a physiotherapist and a statistician performed a search of the literature using pre-specified search terms in PubMed and Embase (January 2000 to August 2020). The division of sections within this report includes: (1) perception of POP and the relationship with body image and poor health; (2) a vaginal bulge as it impacts health and wellbeing in women; (3) the impact of POP on sexual life; (4) body image and pelvic floor disorders; (5) POP and mood; (6) appropriate use of treatment goals to better meet patients' expected benefits; (7) using health-related quality of life questionnaires to quantify patients' perception of POP; (8) The financial burden of POP to patients and society. Abstracts were reviewed and publications were eliminated if not relevant or did not include populations with POP or were not relevant to the subject areas as noted by the authors. The manuscripts were next reviewed for suitability using the Specialist Unit for Review Evidence (SURE) checklists for cohort, cross-sectional and case-control epidemiologic studies.

RESULTS

The original individual literature searches yielded 2312 references of which 190 were used in the final manuscript. The following perceptions were identified: (1) women were found to have varying perceptions of POP including shame and embarrassment. Some regard POP as consequence of aging and consider there is no effective therapy. (2) POP is perceived as a vaginal bulge and affects lifestyle and emotional wellbeing. The main driver for treatment is absence of bulge sensation. (3) POP is known to affect frequency of sexual intercourse but has less impact on satisfaction. (4) Prolapse-specific body image and genital self-image are important components of a women's emotional, physical and sexual wellbeing. (5) POP is commonly associated with depression and anxiety symptoms which impact HRQoL although are not correlated with objective anatomical findings. (6) Patient-centered treatment goals are useful in facilitating communication, shared decision-making and expectations before and after reconstructive surgery. (7) Disease-specific HRQoL questionnaires are important tools to assess bother and outcome following surgery, and there are now several tools with Level 1 evidence and a Grade A recommendation. (8) The cost of POP to the individual and to society is considerable in terms of productivity. In general, conservative measures tend to be more cost-effective than surgical intervention.

CONCLUSIONS

Patients' perception of POP varies in different patients and has a far-reaching impact on their overall state of health and wellbeing. However, recognizing that it is a combination of body image and overall health (which affects mental health) allows clinicians to better tailor expectations for treatment to individual patients. There are HRQoL tools that can be used to quantify these impacts in clinical care and research. The costs to the individual patient (which affects their perception of POP) is an area that is poorly understood and needs more research.

Is the Deep Endometriosis or the Surgery the Cause of Postoperative Bladder Dysfunction?

STUDY OBJECTIVE

To assess if deep endometriosis surgery affects the bladder function.

DESIGN

Prospective multicenter observational study (Canadian Task Force classification II-2).

SETTING

Academic researches centers.

PATIENTS

Thirty-two patients with diagnosis of deep endometriosis requiring surgery.

INTERVENTIONS

Women were evaluated with urodynamic studies, ICIQ-UI SF and ICIQ-OAB questionnaires before and 3 months after surgery.

MEASUREMENTS AND MAIN RESULTS

The main outcome measure was the impact of deep endometriosis surgery on urodynamic parameters. All cystomanometric parameters showed an improvement postoperatively: in particular, the first desire to void (120 vs 204 ml, p<0.001) and the bladder capacity (358 vs 409 ml, p=0.011) increased significantly after surgery. Of the uroflow parameters, the maximal voiding flow improved significantly postoperatively (19 vs 25 ml/sec, p=0.026). The ICIQ-UI SF (2.5 vs 0, p=0.0005) and ICIQ-OAB (4.3 vs 1.2, p<0.001) questionnaires showed a significant postoperative improvement too.

CONCLUSIONS

Our data show that in a selected population of patients with DE (not requiring bowel or urethral resection), the bladder function improves after surgery, both during filling and on voiding urodynamic phases. Postoperatively, patients with DE become aware of bladder filling later, have a higher bladder capacity and have a higher maximal flow. The postoperative urodynamic results are corroborated by the improved scores on the bladder questionnaires.

The International Female Coital Incontinence Questionnaire (IFCI-Q): Development, Validation and Reliability Study

INTRODUCTION

Coital urinary incontinence is an underestimated urinary symptom characterized by urine leakage during intercourse with a serious impact on female sexual function, which often may lead to the abandon of sexual activity. To date, there are no specific validated questionnaires for coital incontinence (CI).

AIM

Aim of the study was to develop and validate a questionnaire "International Female Coital Incontinence- Questionnaire" (IFCI-Q) to evaluate the presence, severity and type of CI and its impact on quality of sexual intercourse.

METHODS

The IFCI-Q validation process included the following stages: (i) Questionnaire development and expert focus group (urologists and gynecologists experts in the field of functional urology); (ii) Administration of IFCI-Q to sexually active women complained for CI, by cognitive interview; (iii) Expert focus group to assess for content validity; (iv) Psychometric assessment of internal consistency by Cronbach's alpha calculation; (v) Test-retest reliability.

MAIN OUTCOME MEASURE

Aim of the questionnaire was to evaluate the presence, severity and type of CI, its impact on quality of sexual intercourse and psychological status and to identify concomitant urinary symptoms. Psychometric properties outcomes: internal consistency and reliability are considered acceptable for Cronbach's α coefficient >0.7 and Cohen's k-test >0.6, respectively. Test-retest reliability was detected by administering the questionnaire twice to the all included women with a time interval of 2 weeks. The content validity was evaluated by a panel of clinical experts.

RESULTS

Thirty women (mean ± SD age: 43.4 ± 17.1 years) complained of CI completed the IFCI-Q. A total of 43.4% of patients had OAB symptoms, 23.3% had mixed urinary incontinence (UI) and 6.6% complained of stress UI. Patients with CI during penetration had a higher prevalence of predominant SUI (7/10), and all women suffering from CI during orgasm had OAB symptoms (11/11). A total of 80% women feel depressed and 56.6% patients reported that CI restricts their sexual activity. Internal consistency and replicability of data were in the adequate range (Cronbach α = 0.737). The test-retest procedure revealed that the k-values of each item are very good.

CONCLUSION

IFCI-Q is a reliable questionnaire on CI and demonstrated a high level of internal consistency and reliability. Gubbiotti M, Giannantoni A, Rubilotta E, et al. The International Female Coital Incontinence Questionnaire (IFCI-Q): Development, Validation and Reliability Study. J Sex Med 2022;19:158-163.

Preoperative abdominal straining in uncomplicated stress urinary incontinence: is there a correlation with voiding dysfunction and de novo overactive bladder after mid-urethral sling procedures?

Objectives:

To evaluate the role of preoperative abdominal straining in predicting de novo overactive bladder (OAB) and voiding dysfunction in female patients undergoing suburethral taping by trans-obturator approach (TVT-O) for uncomplicated stress urinary incontinence (SUI).

Methods:

Data from patients who underwent TVT-O surgery for SUI were retrospectively analyzed. Inclusion criteria included: history of pure SUI. Exclusion criteria included previous surgery for urinary incontinence, pelvic radiation, pelvic surgery within the last 3 months, and anterior or apical pelvic organ prolapse (POP) ⩾ +1 cm. Voiding dysfunction has been defined through symptoms and or urodynamics (UDS) signs. Accordingly, patients were divided into group A and group B according to the presence of abdominal straining during UDS. Patients were observed clinically and with UDS at a 3-year follow-up.

Results:

A total of 192 patients underwent TVT-O surgery for uncomplicated SUI. Preoperative abdominal straining was identified in 60/192 patients (Group A: 31.2% vs Group B: 68.8%). Qmax was not different in the two groups (Group A: 19.5 vs Group B: 20.5 mL/s, p = 0.76). Demographics was similar for the two groups regarding age, parity. At 3-year follow-up, voiding dysfunction was reported in Group A: 9 and Group B: 8 patients (p = 0.056), de novo OAB was significantly reported in Group A: 23 and Group B: 26 patients (p = 0.007).

Conclusion:

Preoperative abdominal straining was found to be related to a significant incidence of de novo OAB. A significant correlation was not assessed for postoperative voiding dysfunction. Further studies may better define the impact of preoperative abdominal straining.

Wound dehiscence prevalence and relationship with prosthetic material extrusion in women underwent anterior colpotomy

Aim:

To assess the prevalence of anterior vaginal wall dehiscence in women who underwent anterior vaginal wall colpotomy for pelvic organ prolapse or stress urinary incontinence and to evaluate the influence of suture materials and techniques on wound dehiscence.

Materials and Methods:

This multicenter, prospective study enrolled naïve women for urogynecological surgery affected by anterior vaginal wall defect or stress urinary incontinence. Performed surgical procedures were anterior vaginal wall repair (AVWR) with native tissue (N-AVWR) or polypropylene mesh (M-AVWR), trans-obturator polypropylene in-out middle urethral sling (MUS). Used suture materials were Vicryl 2-0, Vicryl Rapide 2-0, and Monocryl 3-0. Suture techniques were running interlocking or interrupted. Follow-up was performed daily during hospitalization and in outpatient clinic after 10–14, 30 days, and after 3 months.

Results:

A total of 1139 patients were enrolled. AVWR were 790: 89.1% N-AVWR, and 10.9% M-AVWR. Polypropylene MUS were 349. Women with prosthetic implantation were 38.2%, while 61.8% had native tissue repair. Overall Vicryl was used in 53.9%, Vicryl Rapide in 37.4%, and Monocryl in 8.7%. Overall running interlocking sutures were 66.5%, while interrupted were 33.5%. Overall wound dehiscence prevalence was 0.9% (10/1139). Wound dehiscence rate of 0.6% (5/790) was documented in AVWR: 0.3% (2/704) in N-AVWR, and 3.5% (3/86) in M-AVWR. Among women underwent MUS, 1.4% (5/349) showed wound dehiscence. In patients who underwent prosthetic surgery, the overall dehiscence prevalence was 1.8% (8/435). A statistically significant higher rate of wound dehiscence was found in women with implanted prosthetic materials.

Discussion:

We reported for the first time the prevalence of wound dehiscence in females who underwent colpotomy for AVWR or MUS. Wound dehiscence occurrence was low, but non-negligible. We found that this complication was poorly associated to the suture methods and materials, while prosthetic material represented a risk factor for wound healing.

Evaluation of the effect of 100U of Onabotulinum toxin A on detrusor contractility in women with idiopathic OAB: A multicentre prospective study

Aims

Intradetrusor injection of Onabotulinum Toxin A (BTX‐A) is a third‐line treatment for overactive bladder (OAB). Voiding dysfunction and the need for intermittent catheterization are potential complications, consequent to bladder contractility (BC) decrement.

Primary aim: to evaluate BC variation after BTX‐A detrusor injection in women with idiopathic OAB.

Methods

A prospective multi‐institutional observational study was conducted. Medical history, bladder diary, 24‐h pad test, and invasive urodynamic parameters were recorded before and 4–6 weeks after BTX‐A 100U administration. BC was measured as Modified Projected Isovolumetric Pressure (PIP1), that is, maximum flow rate (Qmax) + detrusor pressure at Qmax (PdetQmax).

Continuous variables were expressed as median and interquartile range. We compared continuous variables using Wilcoxon test and proportions between two times with Fisher exact test.

Results

No changes in PIP1 were observed (p > 0.05) in 45 women enrolled between January 2018 and September 2019. Median age was 54.6 years. At baseline, 91.1% had urge urinary incontinence, with 4.9 ± 2.6 daily pads used and a 24‐h pad test of 205.4 ± 70.8 g. Baseline detrusor contractility was normal in all the patients.

Postoperatively, an improvement in the 24‐h pad test (p < 0.01), daily voids (p < 0.01), and nocturia (p < 0.01) occurred. Urodynamics pointed out a significant reduction of detrusor overactivity rate (p < 0.01) and an increase of median maximum cystometric capacity (p < 0.01). No difference was observed in median Qmax (p > 0.05), PdetQmax (p > 0.05), and PVR (p > 0.05). No patient needed postoperative catheterization.

Conclusions

The current series provides evidence that detrusor injection of botulinum toxin is an effective option for treating OAB, without causing voiding dysfunction and BC impairment.

Music Therapy for Preoperative Anxiety Reduction in Women Undergoing Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

STUDY OBJECTIVE

To assess the superiority of a music therapy intervention (Music) vs usual care (Control) in reducing the preoperative anxiety of patients undergoing total laparoscopic hysterectomy (TLH) with nononcologic indications.

DESIGN

This was a 1:2 (Music vs Control) randomized controlled study.

SETTING

A teaching hospital.

PATIENTS

One hundred patients were available for the analysis: 30 and 70 in the Music and Control arms, respectively.

INTERVENTIONS

Perioperative music therapy pathway in patients undergoing TLH for benign disease.

MEASUREMENTS AND MAIN RESULTS

Anxiety was evaluated with the State-Trait Anxiety Inventory Y Form (STAI-Y) at different time points: at baseline and during preoperative, early postoperative, and late postoperative periods. Pathologic anxiety was defined as STAI-Y state >45. Postoperative pain was registered using the visual analog scale. Women in the Music arm experienced lower anxiety levels (median STAI-Y scores 38.0 vs 41.0; p = .002) during the preoperative period. STAI-Y scores did not vary significantly by intervention at each subsequent time point. A significant difference between the groups (Music vs Control) was found in the proportion of women with pathologic anxiety during the preoperative (16.7% vs 37.2%; p = .04) and early postoperative periods (0% vs 12.9%; p = .04), whereas no significant difference between the groups was registered during the late postoperative period (6.6% vs 7.1%; p = .93). Postoperative pain intensity did not significantly differ between the groups at 1, 3, and 6 hours after surgery.

CONCLUSIONS

Music therapy might be a viable complementary modality to usual surgical care in the gynecologic setting for its ability to significantly decrease preoperative anxiety in women undergoing TLH for benign conditions.

High-risk HPV-positive and -negative high-grade cervical dysplasia: Analysis of 5-year outcomes

OBJECTIVE

To evaluate the outcomes of high-risk (HR) HPV-positive and -negative women affected by high-grade cervical dysplasia.

METHODS

This is a retrospective multi-institutional study. Medical records of consecutive patients with high-grade cervical dysplasia undergoing conization between 2010 and 2014 were retrieved. All patients included had at least 5 years of follow-up. A propensity-score matching was adopted in order to reduce the presence of confounding factors between groups. Kaplan-Meir and Cox hazard models were used to estimate 5-year outcomes.

RESULTS

Overall, data of 2966 women, affected by high-grade cervical dysplasia were reviewed. The study population included 1478 (85%) and 260 (15%) women affected by HR-HPV-positive and HR-HPV-negative high-grade cervical dysplasia. The prevalence of CIN2 and CIN3 among the HR-HPV-positive and -negative cohort was similar (p = 0.315). Patients with HR-HPV-positive high-grade cervical dysplasia were at higher risk of 5-year recurrence (after primary conization) that HR-HPV-negative patients (p < 0.001, log-rank test). Via multivariate analysis, HR-HPV-negative women were at low risk of recurrence (HR: 1.69 (95%CI: 1.05, 4.80); p = 0.018, Cox Hazard model). A propensity-score matched comparison was carried out in order to reduce biases that are related to the retrospective study design. In comparison to HR-HPV-negative patients, thosewith HR-HPV-positive CIN3 was associate with a 8-fold increase in the risk of recurrence (p < 0.001, log-rank test).

CONCLUSIONS

HR-HPV-negative high-grade cervical dysplasia is not uncommon, accounting for 15% of our study population. Those patients experience more favorable outcomes than patients with documented HR-HPV infection(s). Further prospective studies are needed to corroborate our data.

Extensive impact of COVID-19 pandemic on pelvic floor dysfunctions care: A nationwide interdisciplinary survey

Aims

To investigate the impact of COVID‐19 pandemic on health‐care provision to patients suffering from pelvic floor dysfunctions in Italy.

Methods

A retrospective web‐based interdisciplinary survey was mailed by the Italian Society of Urodynamics to members involved in pelvic floor dysfunctions management from June 22, 2020 to July 17, 2020. The 84‐item questionnaire investigated the period March–June 2020 (first epidemic wave) and showed high content validity. The primary outcome was the mean rate of cancellation for health‐care services. Secondary outcomes included estimation of the accumulated surgeries backload until return to baseline activity and of the recovery pattern, using linear regression and scenario‐based forecasting.

Results

A total of 85 participants provided complete responses. Respondents were mostly urologists (47%), followed by gynecologists (29.5%) and physiatrists (17.6%). On average, 78.4% of outpatient services and 82.7% of functional surgeries were canceled, without significant differences by geographical distribution. An impact on patients' quality of life was anticipated by most of the respondents (87%) and 48.2% also reported potentially serious health risks for patients. Thirty‐three percent of the respondents reported the use of telemedicine. If the nation‐wide surgical activity increases by 20% postpandemic, it would take 37 months to clear the backlog of functional surgeries. We acknowledge the inherent limitations of the survey methodology and retrospective design.

Conclusions

Access to care for patients suffering from pelvic floor dysfunctions has been dramatically affected by the COVID‐19 outbreak. The indirect effects of this unprecedented disruption on pelvic floor dysfunctions care may last for several months.

Can we predict the evolution of untreated first stage posterior vaginal wall prolapse in women operated for anterior or apical prolapse?

OBJECTIVE

The aim of this study was to evaluate the correlation between pre-existing conditions and worsening of Stage I untreated posterior vaginal wall prolapse (PVWP) after vaginal hysterectomy and anterior repair at 12-month follow-up.

METHODS

This is a multicenter retrospective study. Women with symptomatic (vaginal bulging and low back pain) anterior and/or apical pelvic organ prolapse (POP) and I stage PVWP were enrolled. Patients were submitted to vaginal hysterectomy and native-tissue anterior vaginal wall repair. Risk factors for POP development were collected for each woman before surgery. At 12 month-follow-up after surgery, women were evaluated and divided into two groups depending on the anatomical finding of the posterior vaginal wall according to the Pelvic Organ Prolapse Quantification System: women with Persistent I stage PVWP and patients with worsened PVWP more than or equal to II stage. Difference of distribution of risk factors for POP between the two groups was evaluated. Correlation between risk factors and development of PVWP more than I stage was assessed.

RESULTS

Seventy women were submitted to POP surgery. Significant difference in constipation before surgery and degree of anterior and central vaginal compartments descent was observed (p < .01) between the two groups. Constipation before surgery resulted as an independent factor in worsening of PVWP at 12-month follow-up (p value = .01; odds ratio 1.99 [1.49-2.33]).

CONCLUSION

Untreated Stage I PVWP, not included in the first surgical repair, can significantly get worse in women complaining of constipation at 12-month follow-up.

Effectiveness of percutaneous posterior tibial nerve stimulation for the management of bowel dysfunction in multiple sclerosis patients

BACKGROUND

Neurogenic bowel dysfunctions (NBDs) in the form of both fecal incontinence (FI) and functional constipation (FC) are frequent in multiple sclerosis (MS) patients and significantly affect their quality of life. Therapeutic options are limited.

OBJECTIVE

To investigate effectiveness of percutaneous posterior tibial nerve stimulation (PTNS) in MS patients suffering from FI and FC.

METHODS

Prevalence and severity of FI and FC were prospectively collected among MS patients undergoing 12 weeks of PTNS for neurogenic bladder. The Cleveland Clinic Fecal Incontinence Score (CCFIS) and the Rome III criteria were used to define FI and FC, respectively. Subjective treatment satisfaction was estimated using the Benefit Satisfaction and Willingness to Continue (BSWC) questionnaire.

RESULTS

A total of 60 patients undergoing PTNS suffered from NBDs (25 FI+/FC+, 5 FI+/FC-, 30 FI-/FC+). Median CCFIS decreased after PTNS from 12.0 (11.0-13.0) to 8.5 (7.0-11.0, p < 0.001), with particular improvements in liquid and flatal incontinence, pads' need, and lifestyle restrictions. Seven patients became FC free after PTNS and no patients developed FC during the study (p = 0.023). More than 50% of the patients were satisfied and willing to continue PTNS at study end.

CONCLUSION

PTNS represents a valid minimally invasive alternative treatment for MS patients suffering from NBDs.

The impact of HPV-specific infection in women diagnosed with atypical glandular cells: Results from the HPV-AGC study

OBJECTIVE

To evaluate the impact of various HPV types on the risk of developing lesions of the uterus (either uterine cervix and endometrium) in women diagnosed with "atypical glandular cells" (AGC) at Pap smear.

METHODS

This is a multi-institutional retrospective study. Data of women diagnosed with AGC were retrospectively reviewed. All patients included had data about HPV DNA testing and 1-year clinical follow-up.

RESULTS

Overall, chart of 480 patients were evaluated. After the exclusion of 286 patients, data of 194 patients were available for the analysis. Mean age was 43.9 (±6.0) years. HPV infection was documented in 136 women (70.1 %). Among HPV positive patients the risk of having/developing a lesion was 33.8 % (n = 46). Lesions included low- (L-SIL) and high- (H-SIL) squamous intraepithelial lesions, in situ adenocarcinoma of the uterine cervix, invasive cancer of the uterine cervix, endometrial hyperplasia and endometrial cancer in 16 (11.7 %), 18 (13.2 %), 6 (4.4 %), 3 (2.2 %), 2 (1.5 %) and 1 (1%), respectively. Among HPV negative patients the risk of having/developing a lesion was 15.5 %. They included l-SIL, H-SIL, in situ adenocarcinoma, endometrial hyperplasia and endometrial cancer in 1 (1.7 %), 1 (1.7 %), 1 (1.7 %), 3 (5.1 %) and 3 (5.1 %), respectively. Patients diagnosed with HPV16 were at higher risk of having/developing cervical lesions in comparison to patients with other HPV infections (p < 0.01). In comparison to other HPV types, the presence of HPV 18, 31, 33, and 45 did not increase the risk of developing a lesion over the time (p > 0.2). HPV positive patients were at higher risk of being diagnosed with a cervical lesion within 6 months from detection of AGC.

CONCLUSIONS

Patients diagnosed with AGC are at risk to have / developing cervical and uterine lesions. Further prospective evidence is needed.

Recurrence rate after loop electrosurgical excision procedure (LEEP) and laser Conization: A 5-year follow-up study

OBJECTIVE

Conization aims to remove pre-neoplastic lesions of the uterine cervix. Several techniques for conization have been compared, but evidence regarding the most effective therapeutic option is scant. Here, we aimed to compare the recurrence rate following laser conization and loop electrosurgical excision procedure (LEEP) in patients with high-grade cervical dysplasia (HSIL/CIN2+).

METHODS

This is a retrospective multi-institutional study. Medical records of consecutive patients with HSIL/CIN2+ undergoing conization between 2010 and 2014 were retrieved. A propensity-score matching (PSM) was applied in order to reduce allocation bias. The risk of developing recurrence was estimated using Kaplan-Meir and Cox hazard models.

RESULTS

Overall, 2966 patients had conization over the study period, including 567 (20%) and 2399 (80%) patients having laser conization and LEEP, respectively. Looking at predictors of recurrence, diagnosis of CIN3 (HR:3.80 (95%CI:2.01,7.21); p < 0.001) and HPV persistence (HR:1.81 (95%CI:1.11,2.96); p < 0.001) correlated with an increased risk of recurrence. After applying a PSM we selected 500 patients undergoing laser conization and 1000 undergoing LEEP. Patients undergoing LEEP were at higher risk of having positive surgical margins in comparison to patients undergoing laser conization (11.2% vs. 4.2%). The risk of having persistence of HPV was similar between the two groups (15.0% vs. 11.6%;p = 0.256). Five-year recurrence rate was 8.1% and 4% after LEEP and laser conization, respectively (p = 0.023). HPV persistence was the only factor associated with [5-]year recurrence after both laser conization (p = 0.003) and LEEP (p = 0.001).

CONCLUSIONS

HPV persistence is the only factor associated with an increased risk of recurrence after either laser conization or LEEP. Owing to the lack of data regarding obstetrical outcomes, we are not able to assess the best therapeutic option for women with cervical dysplasia.