P-475 Similar fertilization rates and preimplantation embryo development among testosterone-treated transgender men and cisgender women

Study question

What are the effects of testosterone treatment on fertilization rates and preimplantation embryo development among transgender men who underwent fertility preservation?

Summary answer

Testosterone exposure among transgender men has no adverse impacts on fertilization rates and preimplantation embryo development and quality.

What is known already

Transmen are assigned female sex at birth but identify as men. This mismatch might induce distress that is termed gender dysphoria. Testosterone therapy induces “masculine” physical traits, suppresses “feminine” ones, and relieves gender dysphoria. More transmen present for testosterone therapy, their average age is decreasing, and many express the desire to have biological children. Therefore, understanding the effects of testosterone on fertility is crucial. Previous data suggest that despite testosterone treatment, the ovarian reserve and the in-vitro oocyte maturation are preserved among transmen. However, the fertility potential in terms of fertilization rate and early embryo development was not explored.

Study design, size, duration

This retrospective cohort study included 7 testosterone-treated transgender men and 34 cisgender women between April 2016 and November 2021.

Participants/materials, setting, methods

Testosterone-treated transgender men who cryopreserved embryos were compared to 10 fertile women who cryopreserved embryos and to 24 women who underwent IVF treatment due to unexplained or mechanical infertility. Statistical analyses compared assisted reproductive technology data and outcomes between the transgender men group and the two cisgender women groups. Morphokinetic and morphological parameters were compared between 210 embryos of transgender men and 411 embryos of cisgender women.

Main results and the role of chance

The transgender men (30.2±3.59 years) were significantly younger than the cisgender women who cryopreserved embryos (35.1±1.85 years; P = 0.005) and the cisgender women who underwent fertility treatment (33.8±3.23 years; P = 0.017). Among the transgender men, the mean length of testosterone exposure was 99.7±49.24 months (range 14-156 months) and the mean time of discontinuation of testosterone prior to stimulation was 6.57±2.14 months (range 4-10 months). After adjusting for the patient’s age, the fertilization rate was comparable between the transgender men and both cisgender women groups (P = 0.391 and 0.659). No significant differences in the number of cryopreserved embryos (7.2±5.09 and 3.5±2.66; P = 0.473) and the days on which they were frozen (P = 0.576) were observed between the transgender men and the fertile cisgender women. All morphokinetic parameters that were evaluated using time-lapse imaging, as well as the morphological characteristics, were comparable between transgender men and both groups of cisgender women.

Limitations, reasons for caution

All transgender men in our study discontinued the testosterone treatment before starting ovarian stimulation. Stopping hormonal therapy might cause considerable anguish and gender dysphoria. Therefore, further studies that include subjects who did not stop testosterone before fertility preservation are needed.

Wider implications of the findings

Transgender men have acceptable fertilization rates and normal preimplantation embryo development and quality after long-term testosterone treatment. Embryo cryopreservation is, therefore, a feasible and effective way for them to preserve their fertility for future biological parenting.

Trial registration number

Not applicable

The impact of a nationwide hands-on workshop on the diagnostic rates and management of obstetrical anal sphincter Injuries in Israel

AIM

The aim was to evaluate the influence of a half day, hands-on, workshop on the detection and repair of obstetric anal sphincter injuries (OASIs).

METHOD

Starting in February 2011, hands-on workshops for the diagnosis and repair of OASIs were delivered by trained urogynaecologists in departments of tertiary medical centres in Israel. The structure of the hands-on workshop resembles the workshop organized at the International Urogynecological Association annual conferences. Participants included medical staff, midwives and surgical residents from each medical centre. We collected data regarding the rate of OASIs, 1 year before and 1 year following the workshop, in 11 medical centres. The study population was composed of parturients with the following inclusion criteria: singleton pregnancy, vertex presentation and vaginal delivery. Pre-viable preterm gestations (< 24 weeks), birth weight < 500 g, stillborn, and those with major congenital anomalies, multifoetal pregnancies, breech presentations and caesarean deliveries were excluded from the analysis.

RESULTS

In the reviewed centres, 70 663 (49.3%) women delivered prior to the workshop (pre-workshop group) and 72 616 (50.7%) women delivered following the workshop (post-workshop group). Third- or fourth-degree perineal tears occurred in 248 women (0.35%) before the workshop, and in 328 (0.45%) following the workshop, a significant increase of 28.7% (P = 0.002). The increase in diagnosis was significant also in women with third-degree tears alone, 226 women (0.32%) before the workshop and 298 (0.41%) following the workshop, an increase of 28.3% (P = 0.005).

CONCLUSION

The detection rate of OASIs has significantly increased following the hands-on workshop. The implementation of such programmes is crucial for increasing awareness and detection rates of OASI following vaginal deliveries.

Risk factors for severe perineal injury during childbirth: a case-control study of 60 consecutive cases

AIM

The study aimed to evaluate the current risk factors for severe perineal tears in a single university-affiliated maternity hospital.

METHOD

An obstetric database of 31 784 consecutive women who delivered from January 2007 to December 2009 was screened for cases of third-degree or fourth-degree perineal tears. Four controls, matched by time of delivery, were selected for each case of third- or fourth-degree perineal tear. Maternal and obstetric parameters were analyzed and compared between the study and control groups.

RESULTS

Sixty women (0.25% of all vaginal deliveries) had a third-degree (53 women) or a fourth-degree (seven women) perineal tear. The control group comprised 240 matched vaginal deliveries without severe tears. Primiparity, younger maternal age, Asian ethnicity, longer duration of second stage of labour, vacuum-assisted delivery and heavier newborn birth weight were significantly more common among women who had third- or fourth-degree perineal tears. Of the variables that were found to be statistically significant in the univariate analysis, only primiparity (OR = 2.809, 95% CI: 1.336-5.905), vacuum delivery (OR = 10.104, 95% CI: 3.542-28.827) and heavier newborn birth weight (OR = 1.002, 95% CI: 1.001-1.003) were found to be statistically significant independent risk factors for severe perineal trauma.

CONCLUSION

Identification of women at risk may facilitate the use, or avoidance, of certain obstetric interventions to minimize the occurrence of childbirth-associated perineal trauma.

Evaluation of female external genitalia sensitivity to pressure/touch: a preliminary prospective study using Semmes-Weinstein monofilaments

OBJECTIVES

To assess the use of pressure aesthesiometers (Semmes-Weinstein monofilaments) in the evaluation of female external genitalia. The pressure aesthesiometers are widely used to assess the pressure/touch perceptions of the hand, face, and breast dermatomes.

METHODS

Thirty-two consecutive neurologically intact women (mean age 48.7 +/- 13.8 years) and 5 neurologically impaired women referred for a routine gynecologic examination were prospectively enrolled. The monofilaments were applied to the S2-S5 vulvar dermatomes using specific anatomic landmarks. Test-retest reliability studies were performed at the same clinical session. A comparison was made between premenopausal (n = 17) and postmenopausal (n = 15) women; hypoestrogenic (n = 9) and normoestrogenic (n = 23) women; postmenopausal women with (n = 6) and without (n = 9) estrogen replacement therapy; women with normal (n = 18) and abnormal (n = 14) sexual function; and neurologically impaired (n = 5) and neurologically intact (n = 5) women, matched by age, parity, and estrogen status.

RESULTS

A clear association was found between reduced vulvar sensitivity to pressure/touch and estrogen deficiency, sexual dysfunction, and neurologic impairment. Postmenopausal women had significantly reduced sensitivity to pressure/touch compared with premenopausal women. Similar decreased sensitivity was found in hypoestrogenic compared with normoestrogenic women, with significantly reduced sensitivity in postmenopausal women not using estrogen replacement therapy. Women with sexual dysfunction and those with neurologic impairment had significantly reduced vulvar sensitivity to pressure/touch. No correlation was found between the sensitivity to pressure/touch and either levator ani muscle bulk or the levator contraction score, but significant differences were found between women with and without vulvovaginal atrophy at the time of the examination. Test-retest analysis confirmed the reliability of the monofilaments in testing vulvar sensation.

CONCLUSIONS

The Semmes-Weinstein monofilaments may be used as a valid and reliable diagnostic tool in the evaluation of vulvar sensitivity to pressure/touch. Additional studies with larger series are needed to establish the role of this clinical tool in the evaluation of various treatment outcomes.

Role of urethrocystoscopy in the evaluation of refractory idiopathic detrusor instability

OBJECTIVES

To assess the role of diagnostic urethrocystoscopy in the evaluation of women with idiopathic detrusor instability (DI) refractory to conventional pharmacologic management.

METHODS

One hundred consecutive women (mean age 62.1 +/- 15.1 years) with idiopathic DI refractory to conventional pharmacologic management were prospectively enrolled. All patients underwent a meticulous evaluation, including a detailed history, urogynecologic questionnaire, micturition diary and pad test, urinalysis and culture, physical examination, and urodynamic studies. Refractory DI was defined as the lack of clinical improvement after at least 6 months of conventional drug therapy. These patients underwent additional evaluation with diagnostic urethrocystoscopy.

RESULTS

All patients had a normal urinalysis and negative cytologic findings. Diagnostic urethrocystoscopy revealed isolated bladder tuberculosis in one and transitional cell carcinoma in another. Seven other patients had bladder diverticula (only one of which was also diagnosed by sonographic examination) and 22 had mild-to-moderate bladder trabeculations.

CONCLUSIONS

The absence of other alarming signs (ie, recurrent urinary tract infection, hematuria, significant residual urinary volume, positive cytologic findings, or suspicious sonographic findings) cannot confirm the lack of significant lower urinary tract abnormalities among patients with refractory DI. Diagnostic urethrocystoscopy, a simple and safe office procedure, facilitates timely diagnosis and appropriate treatment for these patients.

Combined genitourinary prolapse repair and prophylactic tension-free vaginal tape in women with severe prolapse and occult stress urinary incontinence: preliminary results

OBJECTIVES

Continent patients with a positive stress test demonstrated on repositioning of severe genitourinary prolapse are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence (SUI). Our aim was to evaluate in a prospective study whether a prophylactic, tension-free vaginal tape (TVT) procedure, performed during prolapse repair, may prevent the development of postoperative SUI in these women.

METHODS

Thirty consecutive, clinically continent women (mean age 64.5 +/- 9.04 years) with severe genitourinary prolapse and occult SUI were prospectively enrolled. Occult SUI was defined as a positive stress test with repositioning of the prolapse during the preoperative urodynamic studies. All patients had urethral hypermobility; none had intrinsic sphincter deficiency. In addition to genitourinary prolapse repair, these patients underwent concomitant TVT to prevent postoperative SUI. Patients were followed up for at least 1 year. Repeated urodynamic studies were performed at 3 to 6 months postoperatively. The main outcome measures were postoperative SUI, persistent or de novo detrusor instability, and recurrence of prolapse.

RESULTS

The mean duration of follow-up was 14.25 +/- 3.08 months (range 12 to 24). None of the patients developed postoperative symptomatic SUI. However, three asymptomatic patients (10%) had a positive stress test during their postoperative urodynamic evaluation. Nine patients (30%) had detrusor instability before surgery, which persisted in six (66%) postoperatively. Postoperative de novo detrusor instability was diagnosed in four other patients (13.33%). None of the patients had recurrent urogenital prolapse, nor did they have clinical evidence of bladder outlet obstruction.

CONCLUSIONS

The preliminary results of TVT as a prophylactic procedure in clinically continent women with severe prolapse and occult SUI are encouraging. Long-term follow-up is required to confirm the durability of these results.

Evaluation of female lower urinary tract symptoms: overview and update

Female lower urinary tract symptoms are nonspecific, and a thorough clinical evaluation is required to establish the correct diagnosis. Such evaluation should consist of a structured micturition history or questionnaire, physical examination with full bladder, micturition diary, pad test and urodynamic evaluation. The urodynamic evaluation should consist at least of cystometry, detrusor pressure/uroflow study, simple ('free') uroflowmetry, assessment of the relative contribution of urethral hypermobility and intrinsic sphincter deficiency, and estimation of postvoid residual urine by ultrasound or catheterization. Recent studies regarding the role of pad tests, micturition diaries and urodynamic studies in the evaluation of female voiding dysfunction are presented. Factors that are associated with the use of transurethral catheter during pressure-flow studies and current controversies regarding the diagnosis of female bladder outlet obstruction are reviewed and discussed. Although the urodynamic study is considered to be the best diagnostic tool in assessment of lower urinary tract function, some practitioners believe that urodynamic evaluation is not routinely warranted and prefer to employ a symptom-based empirical management strategy. Lower urinary tract symptoms are nonspecific, however, and should be used mainly to identify what bothers the patient. Urodynamic studies define the underlying pathophysiology. We believe that treatment of the underlying pathophysiology facilitates better treatment of symptoms.

Videourodynamic studies in men with lower urinary tract symptoms: a comparison of community based versus referral urological practices

PURPOSE

We compared the clinical and urodynamic characteristics of men referred for evaluation of lower urinary tract symptoms in community based versus referral urological practices and examined the various pathophysiological mechanisms of these symptoms.

MATERIALS AND METHODS

We reviewed a multicenter urodynamics database of 963 consecutive men referred for the evaluation of persistent lower urinary tract symptoms at 2 community based and 1 urological referral center. Of the 963 patients in the database 422 (44%) were excluded from study due to neurological disorder in 41%, previous urinary or pelvic surgery in 27% and the use of medications known to affect voiding in 24%. A total of 541 patients with a mean age plus or minus standard deviation of 64.4 +/- 13.8 years met study inclusion criteria and were analyzed further. We compared the clinical and urodynamic characteristics of patients at the community and referral centers.

RESULTS

Lower urinary tract symptoms were equally common in men presenting to community and referral centers. The most common symptom was difficult voiding, followed by frequency, urgency and nocturia in 58%, 54%, 43% and 40% of the study population, respectively. Urodynamic diagnoses were also similar in the 2 groups. Although bladder outlet obstruction was diagnosed in 69% of patients, it was the only urodynamic finding in a third of the patients with obstruction. The main concomitant urodynamic diagnoses were detrusor overactivity, bladder hyposensitivity, impaired detrusor contractility, low bladder compliance and bladder hypersensitivity in 47%, 10%, 10%, 9% and 3% of obstructed cases, respectively.

CONCLUSIONS

The pathophysiology of lower urinary tract symptoms in men is multifactorial, and similar at community practice and tertiary referral centers. The disparity in urodynamic findings and subjective symptoms emphasizes the need for a thorough and early clinical and urodynamic evaluation.

Use of cadaveric solvent-dehydrated fascia lata for cystocele repair--preliminary results

OBJECTIVES

To present a surgical technique in which cadaveric fascia lata is used for cystocele repair.

METHODS

Twenty-one consecutive women (mean age 67 +/- 10 years) with severe cystocele were prospectively enrolled. All patients underwent meticulous clinical and urodynamic preoperative evaluations. Solvent-dehydrated, Tutoplast-processed, cadaveric fascia lata was used for cystocele repair. The fascia was anchored transversally between the bilateral arcus tendineus and the cardinal and uterosacral ligaments. Standard endopelvic plication was performed thereafter as a second layer. Patients with overt or occult sphincteric incontinence underwent concomitant pubovaginal sling (PVS) surgery as well, using the same material. The main outcome measures included recurrent urogenital prolapse, persistent or de novo urinary incontinence (stress or urge), and dyspareunia.

RESULTS

Of the 21 patients, 19 underwent concomitant PVS, 3 concomitant vaginal hysterectomy, and 8 posterior colporrhaphy in addition to their cystocele repair. The mean follow-up was 20.1 +/- 6.7 months (range 12 to 30). No postoperative complications related to the material or technique occurred. None of the patients developed a recurrent cystocele. Two patients (9%), one of whom underwent concomitant posterior colporrhaphy, developed mild recto-enterocele at 4 to 6 months postoperatively. Six patients underwent concomitant PVS for occult sphincteric incontinence. None developed postoperative stress incontinence. Thirteen other patients underwent concomitant PVS for overt sphincteric incontinence. All but two were stress-continent postoperatively. One half of the patients with preoperative urge or mixed incontinence had persistent urge incontinence postoperatively. None of the patients developed postoperative de novo urge incontinence or dyspareunia.

CONCLUSIONS

The use of solvent-dehydrated cadaveric fascia lata for cystocele repair, as well as PVS, is associated with encouraging short and medium-term results. Long-term follow-up is needed to evaluate whether these results are durable.

Detrusor instability in men: correlation of lower urinary tract symptoms with urodynamic findings

PURPOSE

We evaluated the correlation of lower urinary tract symptoms suggestive of detrusor instability with urodynamic findings in men.

MATERIALS AND METHODS

Enrolled in our prospective study were 160 consecutive neurologically intact men referred for urodynamic evaluation of persistent lower urinary tract symptoms. All patients had storage symptoms suggestive of detrusor instability. Patients were further clinically categorized according to the chief complaint of urge incontinence, frequency and urgency, nocturia or difficult voiding. The clinical and urodynamic diagnosis in all patients as well as specific urodynamic characteristics of those with detrusor instability were analyzed according to the these 4 clinical categories.

RESULTS

Mean patient age was 61 +/- 15 years. The chief complaint was urge incontinence in 28 cases (17%), frequency and urgency in 57 (36%), nocturia in 30 (19%) and difficult voiding in 45 (28%). Detrusor instability was diagnosed in 68 cases (43%). A higher incidence of detrusor instability was associated with urge incontinence than with the other clinical categories (75% versus 36%, p <0.01). Of the patients 109 (68%) had bladder outlet obstruction, including 50 (46%) with concomitant detrusor instability. The prevalence of bladder outlet obstruction was similar in all patients regardless of the chief complaint. All other urodynamic diagnoses were also similar in the 4 clinical categories. The mean bladder volume at which involuntary detrusor contractions occurred were lower in patients with urge incontinence and frequency and urgency than in those with nocturia and difficult voiding (277.1 +/- 149.4 and 267.7 +/- 221.7 versus 346.7 +/- 204.6 and 306.2 +/- 192.1 ml., respectively, not statistically significant, p = 0.07).

CONCLUSIONS

Detrusor instability and bladder outlet obstruction are common in men with lower urinary tract symptoms. The symptom of urge incontinence strongly correlated with detrusor instability. Other lower urinary tract symptoms did not correlate well with any urodynamic findings. Therefore, we believe that an accurate urodynamic diagnosis may enable focused and more efficient management of lower urinary tract symptoms in men.

Involuntary detrusor contractions: correlation of urodynamic data to clinical categories

Data regarding the prevalence and urodynamic characteristics of involuntary detrusor contractions (IDC) in various clinical settings, as well as in neurologically intact vs. neurologically impaired patients, are scarce. The aim of our study was to evaluate whether the urodynamic characteristics of IDC differ in various clinical categories. One hundred eleven consecutive neurologically intact patients and 21 consecutive neurologically impaired patients, referred for evaluation of persistent irritative voiding symptoms, were prospectively enrolled. All patients were presumed by history to have IDC, and underwent detailed clinical and urodynamic evaluation. Based on clinical evaluation, patients were placed into one of four categories according to the main presenting symptoms and the existence of neurological insult: 1) frequency/urgency; 2) urge incontinence; 3) mixed stress incontinence and irritative symptoms; and 4) neurogenic bladder. IDC was defined by detrusor pressure of > or = 15 cm H2O whether or not the patient perceived the contraction; or < 15 cm H2O if perceived by the patient. Eight urodynamic characteristics of IDC were analyzed and compared between the four groups. IDC were observed in all of the neurologically impaired patients, compared with 76% of the neurologically intact patients (P < 0.001). No correlation was found between amplitude of IDC and subjective report of urgency. All clinical categories demonstrated IDC at approximately 80% of cystometric capacity. Eighty-one percent of the neurologically impaired patients, compared with 97% of the neurologically intact patients, were aware of the IDC at the time of urodynamics (P < 0.04). The ability to abort the IDC was significantly higher among continent patients with frequency/urgency (77%) compared with urge incontinent patients (46%) and neurologically impaired patients (38%). In conclusion, when evaluating detrusor overactivity, the characteristics of the IDC are not distinct enough to aid in differential diagnosis. However, the ability to abort IDC and stop incontinent flow may have prognostic implications, especially for the response to behavior modification, biofeedback, and pelvic floor exercise.

Learned voiding dysfunction (non-neurogenic, neurogenic bladder) among adults

Data concerning learned voiding dysfunction (Hinman syndrome; non-neurogenic, neurogenic bladder) in adults are scarce. The present study was conducted to assess the pre-valence and clinical characteristics of this dysfunction among adults referred for evaluation of lower urinary tract symptoms. Learned voiding dysfunction was suggested by a characteristic clinical history and intermittent "free" uroflow pattern and by the absence of any detectable neurological abnormality or anatomic urethral obstruction. A definitive diagnosis was made by the demonstration of typical external urethral sphincter contractions during micturition by EMG or fluoroscopy. A urodynamic database of 1,015 consecutive adults was reviewed. Twenty-one (2%) patients (age, 24-76 years) met our strict criteria of learned voiding dysfunction. Obstructive symptoms were the most common presenting symptoms, followed by frequency, nocturia, and urgency. Eight (35%) patients had recurrent urinary tract infections, seven of these being women. None of the patients had any clinically significant upper urinary tract damage. First sensation volume was significantly lower in women than in men. Both detrusor pressure at maximum flow and maximum detrusor pressure during voiding were found to be significantly higher in men than in women. Further differentiation between adult women and men failed to reveal any other clinically significant differences. In conclusion, by strict video-urodynamic criteria, 2% of our patients had learned voiding dysfunction. Other patients, with presumed learned voiding dysfunction, who did not undergo video-urodynamics were not included in the present series. Thus, the prevalence of learned voiding dysfunction among adults referred for evaluation of lower urinary tract symptoms is likely to be even higher.

Does the method of cystometry affect the incidence of involuntary detrusor contractions? A prospective randomized urodynamic study

The International Continence Society (ICS) defines overactive detrusor as "one that is shown objectively to contract during the filling phase while the patient is attempting to inhibit micturition." The aim of the present study was to assess whether instructing the patient neither to try void nor to inhibit micturition during filling cystometry may improve the detection rate of involuntary detrusor contractions (IDCs). Forty-two consecutive patients (mean age 65 +/- 13.5 years), referred for urodynamic evaluation of persistent irritative lower urinary tract symptoms were prospectively enrolled. All patients were presumed, by history, to have IDCs. Cystometry was performed twice at the same session, each time by using randomly different instructions: Method 1, patients were instructed to try to inhibit micturition during bladder filling; and Method 2, patients were instructed to neither try to void nor try to inhibit micturition, but simply report his or her sensations to the examiner. The occurrence, as well as the urodynamic characteristics of IDCs, were analyzed separately and compared between the two filling methods. Method 1 identified only 20 cases of IDCs, while Method 2 identified 27 cases (48 versus 64 % of the study population, respectively; P = 0.02). Analysis of urodynamic characteristics revealed a clear trend of reduced bladder volume at which IDCs occurred when patients were instructed to neither try to void nor to inhibit micturition during bladder filling; however, statistical significance was not established (189 +/- 122 versus 240 +/- 149 mL, respectively; P = 0.13). All other urodynamic characteristics of IDCs were similar in both methods. In conclusion, better detection rates of IDCs were achieved by instructing the patient to neither try to void nor try to inhibit micturition, but simply report his or her sensations to the examiner, during filling cystometry. If the patient is instructed to inhibit micturition during bladder filling-about 26 % of the IDC cases are misdiagnosed.

Pubovaginal sling surgery for simple stress urinary incontinence: analysis by an outcome score

PURPOSE

We assessed the results of pubovaginal sling surgery in women with simple stress urinary incontinence using strict subjective and objective criteria.

MATERIALS AND METHODS

Simple incontinence was defined as sphincteric incontinence with no concomitant urge incontinence, pipe stem or fixed scarred urethra, urethral or vesicovaginal fistula, urethral diverticulum, grade 3 or 4 cystocele, or neurogenic bladder. A total of 67 consecutive women with a mean age plus or minus standard deviation of 56 +/- 11 years who underwent pubovaginal sling surgery for simple sphincteric incontinence were prospectively followed for 12 to 60 months (mean 33.9 +/- 22.2). Treatment outcomes were classified according to a new outcome score. Cure was defined as no urinary loss due to urge or stress incontinence, as documented by 24-hour diary and pad test, with the patient considering herself cured. Failure was defined as poor objective results with the patient considering surgery to have failed. Cases that did not fulfill these cure-failure criteria were considered improved and further classified into a good, fair or poor response.

RESULTS

Of the 67 patients 46 (69%) had type II and 21 (31%) had type III incontinence. Preoperative diary and pad tests revealed a mean of 5.9 +/- 3.6 stress incontinence episodes and a mean urinary loss of 91.8 +/- 81.9 gm. per 24 hours. There were no major intraoperative, perioperative or postoperative complications. Two patients (3%) had persistent minimal stress incontinence and 7 (10%) had new onset urge incontinence within 1 year after surgery. Overall using the strict criteria of our outcome score 67% of the cases were classified as cured and the remaining 33% were classified as improved. The degree of improvement was defined as a good, fair and poor response in 21%, 9% and 3% of patients, respectively.

CONCLUSIONS

Mid-term outcome results defined by strict subjective and objective criteria confirm that the pubovaginal sling is highly effective and safe surgery for simple sphincteric incontinence. A followup of more than 5 years is required to establish the long-term durability of this procedure.

The use of prophylactic Stamey bladder neck suspension to prevent post-operative stress urinary incontinence in clinically continent women undergoing genitourinary prolapse repair

The present study was undertaken to evaluate the efficacy of Stamey bladder neck suspension in preventing post-perative stress urinary incontinence in clinically continent women undergoing surgery for genitourinary prolapse. Thirty clinically continent women with severe genitourinary prolapse were found to have a positive stress test with re-positioning of the prolapse. They all had significant urethrovesical junction hypermobility. In addition to the genitourinary prolapse repair, these patients underwent a prophylactic Stamey procedure to prevent the possible development of post-operative stress urinary incontinence. The mean duration of follow-up was 8+/-4.5 months (range, 3-19 months). Seven (23.30%) patients developed overt post-operative stress urinary incontinence that was confirmed urodynamically. Eleven (36.7%) other patients denied stress incontinence; however, post-operative urodynamics demonstrated sphincteric incontinence. Post-operative complications were uncommon and minor. In conclusion, continent patients with a positive stress test demonstrated on re-positioning of the prolapse during pre-operative urodynamic evaluation are considered to be at high risk of developing post-operative stress urinary incontinence. In these patients, an additional, effective anti-incontinence procedure should be considered during surgical correction of genitourinary prolapse. The Stamey procedure, although simple and safe, does not appear to be the optimal solution to this clinical problem.

Bladder outlet obstruction nomogram for women with lower urinary tract symptomatology

The aim of our study was to construct a bladder outlet obstruction nomogram for women with lower urinary tract symptoms. A urodynamic database of 600 consecutive women was reviewed. Bladder outlet obstruction, utilizing strict diagnostic criteria, was diagnosed in 50 (8.3%) patients. A comparison of patient characteristics, uroflowmetry, and detrusor pressure-uroflow studies was carried out between the obstructed patients (mean age, 64.4 +/- 17.6 years) and 50 age-matched unobstructed controls (mean age, 64.8 +/- 10.7 years). Maximum flow rates were significantly higher in free uroflow studies (free Qmax) than in pressure-flow studies (Qmax), in both obstructed (9.3 +/- 3.7 versus 5.7 +/- 3.6 mL/s, respectively. P = 2. 6 10(-6)) and unobstructed (25.6 +/- 11.2 versus 11.8 +/- 5.9 mL/s, respectively. P = 8.7 10(-12)) patients. Comparison of detrusor pressure at maximum flow (pdet.Qmax) and maximum detrusor pressure during voiding (pdet.max) values did not reveal significant differences, in both obstructed (39.3 +/- 18.4 versus 49.7 +/- 25.5 cm H(2)O, respectively) and unobstructed (16.5 +/- 8.4 versus 20.6 +/- 9.2 cm H(2)O, respectively) patients. Further statistical analysis was carried out to construct bladder outlet obstruction nomogram. The nomogram classifies any pair of values of free Qmax and pdet.max into one of the following four zones: no obstruction, mild obstruction, moderate obstruction, and severe obstruction. Of the 50 obstructed women, 34 (68%) were classified by the nomogram as mildly, 12 (24%) as moderately, and 4 (8%) as severely obstructed. A positive correlation was found between subjective severity of the symptoms (assessed by the AUA Symptom Index score) and the four nomogram zones. In conclusion, the nomogram makes it possible to differentiate between obstructed and unobstructed women and between various degrees of obstruction. We believe the nomogram may also serve as an instrument to assess treatment outcomes.

Outcome results of transurethral collagen injection for female stress incontinence: assessment by urinary incontinence score

PURPOSE

We assessed the results of collagen injection for female sphincteric incontinence using strict subjective and objective criteria.

MATERIALS AND METHODS

We evaluated 63 consecutive women with sphincteric incontinence who underwent a total of 131 transurethral collagen injections. Sphincteric incontinence was confirmed by urodynamics. All patients were treated with 1 to 5 transurethral collagen injections and treatment outcome was classified according to a new outcome score. Cure was defined as no urinary loss due to urge or stress incontinence documented by a 24-hour diary and pad test, and patient assessment that cure was achieved. Failure was defined as poor objective results and patient assessment that treatment failed. Cases that did not fulfill these cure and failure criteria were considered improved and further classified as a good, fair or poor response.

RESULTS

Mean patient age plus or minus standard deviation was 67.7 +/- 12.8 years. All women had a long history of severe stress urinary incontinence, 18 (29%) underwent previous anti-incontinence surgery, and 41% had combined stress and urge incontinence. Preoperatively diary and pad tests revealed a mean of 7.5 +/- 4.6 incontinence episodes and 152 +/- 172 gm. of urine lost per 24 hours. Overall 1 to 5 injections were given in 26, 17, 13, 3 and 4 patients, respectively. Mean interval between injections was 4.4 +/- 5.7 months, mean followup was 12 +/- 9.6 months, and mean interval between the final injection and outcome assessment was 6.4 +/- 4.9 months. There was a statistically significant decrease in the total number of incontinence episodes per 24-hour voiding diary after each injection session. Although there was a clear trend toward decreased urinary loss per 24-hour pad test, statistical significance was not established. Using the strict criteria of our outcome score overall 13% of procedures were classified as cure, 10%, 17% and 42% as good, fair and poor, respectively, and 18% as failure.

CONCLUSIONS

As defined by strict subjective and objective criteria, we noted a low short-term cure rate after collagen injection in women with severe sphincteric incontinence. It remains to be determined how patients with less severe incontinence would fare using our outcome assessment instruments.

Management of urethral erosion caused by a pubovaginal fascial sling

Urethral erosion by a fascial sling is a rare postoperative complication, and its repair can become a major surgical endeavor. We present a case of autologous fascial sling erosion into the mid-urethra in a 46-year-old woman that was diagnosed after traumatic urethral catheterization. After 3 months of conservative management failed, we released the sling tension surgically by bilateral excision of the graft, leaving the midline structures undisturbed. This allowed resumption of normal voiding, with complete long-term symptomatic relief.

Persistent postpartum urinary retention in contemporary obstetric practice. Definition, prevalence and clinical implications

OBJECTIVE

To prospectively evaluate the prevalence, presumed etiologies and clinical implications of persistent postpartum urinary retention in modern obstetric practice.

STUDY DESIGN

The study population comprised 8,402 consecutive, unselected parturients delivered in a university-affiliated maternity hospital over a one-year period. If a woman was unable to void spontaneously until the third postpartum day despite intermittent use of a Foley catheter, a diagnosis of persistent postpartum urinary retention was established. Patients were treated by insertion of a Foley catheter for up to two weeks and subsequently by a suprapubic catheter. Obstetric data were collected from the hospital records.

RESULTS

Four patients (0.05% of the study population), aged 29-37 years, developed persistent postpartum urinary retention. Risk factors included vaginal delivery after cesarean section, prolonged second stage of labor, epidural analgesia, and delayed diagnosis and intervention. Urodynamic evaluation, performed on two patients one month after removal of the suprapubic catheter, revealed genuine stress incontinence in one and detrusor instability in another. None had had any lower urinary tract symptoms before pregnancy and delivery.

CONCLUSION

Persistent postpartum urinary retention in contemporary obstetric practice is rare but may be associated with long-term bladder dysfunction. Early diagnosis and intervention are required to prevent irreversible bladder damage.

Noninvasive outcome measures of urinary incontinence and lower urinary tract symptoms: a multicenter study of micturition diary and pad tests

PURPOSE

We assessed the test-retest reliability of a 24, 48 and 72-hour micturition diary and pad test in patients referred for the evaluation of urinary incontinence and lower urinary tract symptoms.

MATERIALS AND METHODS

We prospectively enrolled 109 patients referred for the evaluation of lower urinary tract symptoms in our multicenter study. Patients were requested to complete a 72-hour micturition diary and pad test, and repeat each test during a 1-week interval. The test-retest reliability of various parameters of the 72-hour micturition diary and pad test was analyzed and compared. Further analysis was done to compare the test-retest reliability of 24, 48 and 72-hour studies performed on the same days after a 1-week interval. Reliability was assessed by Lin's concordance correlation coefficient (CCC) with a cutoff value of 0.7 indicating test-retest reliability.

RESULTS

Of the 109 patients 106 (97%) with a median age of 64 years completed the study. The number of pads and total weight gain appeared to be reliable measures of the 24, 48 and 72-hour pad tests. For the 24-hour diary the total number of incontinence episodes was a reliable measure, while the total number of voiding episodes was marginally reliable (mean CCC 0.785 and 0. 689, respectively). For the 48-hour diary the number of incontinence episodes and total number of voiding episodes were reliable measures (mean CCC 0.78 and 0.83, respectively), while for the 72-hour diary each parameter was highly reliable (CCC 0.86 and 0.826, respectively). However, an increased test period was associated with decreased patient compliance.

CONCLUSIONS

The 24-hour pad test and micturition diary are reliable instruments for assessing the degree of urinary loss and number of incontinent episodes, respectively. Increasing test duration to 48 and 72 hours increases reliability but is associated with decreased patient compliance.

Urethral diverticulum in women: diverse presentations resulting in diagnostic delay and mismanagement

PURPOSE

We describe various clinical presentations of urethral diverticulum, which may mimic other pelvic floor disorders and result in diagnostic delay. Management and outcome results are reported.

MATERIALS AND METHODS

We reviewed retrospectively 46 consecutive cases of urethral diverticulum. Patient characteristics, history, clinical evaluation, management and long-term followup are reported.

RESULTS

Mean patient age plus or minus standard deviation was 36.3 +/- 11.7 years. Most (83%) cases were referred as diagnostic dilemmas with symptoms present for 3 months to 27 years. Mean interval between onset of symptoms to diagnosis was 5.2 years. The most common symptoms were pain (48% of cases), urinary incontinence (35%), dyspareunia (24%) and frequency/urgency (22%). The number of physicians previously consulted ranged from 3 to 20 and prior therapies included oral and/or vaginal medications, anti-incontinence surgery and psychotherapy. The diverticulum was palpable on examination in 24 patients (52%), in only 6 of whom was it possible to "milk" contents per meatus. Of these 24 palpable diverticula 2 contained malignancy, and 2 others contained endometriosis and stones, respectively. Diagnosis was made by voiding cystourethrography in 30 cases (65%), double balloon urethrography in 5 (11%) and transvaginal ultrasound or magnetic resonance imaging in 7 (15%). Diverticula were incidental findings during vaginal surgery in 4 cases (9%). Treatment consisted of diverticulectomy and/or Martius flap, pubovaginal sling and urethral reconstructive procedures when indicated in 35 cases (76%), and 2 other patients underwent radical surgery for diverticular malignancy. Subsequently all but 2 patients with pain were cured. In another patient de novo stress incontinence developed postoperatively. None of the patients who underwent concomitant pubovaginal sling had postoperative incontinence.

CONCLUSIONS

The symptoms of urethral diverticulum may mimic other disorders. This condition should be considered in women with pelvic pain, urinary incontinence and irritative voiding symptoms not responding to therapy. Surgical treatment is usually effective in alleviating associated symptoms.

Is amniotic fluid volume influenced by a 24-hour fast?

OBJECTIVE

To assess the influence of fasting for 24 hours on the amniotic fluid index (AFI).

STUDY DESIGN

The AFI of 22 parturients in the second trimester of uncomplicated pregnancy was evaluated on the morning after a 24-hour fast. Patients were prospectively matched to another group of 25 patients who did not fast. Both groups were reevaluated after one week. Two different observers, blind to each other's results, performed the examinations.

RESULTS

A statistically significant difference was found in the AFI between the two groups on the day after fasting (11.73 +/- 2.12 versus 15.4 +/- 1.2, respectively; P < .01). After one week there was no difference in AFI between the two groups (15.35 +/- 1.2 and 15.42 +/- 1.2, respectively; P > .01).

CONCLUSION

Fasting may reduce the amniotic fluid volume as shown by the AFI, and fluid intake may restore the normal amount of amniotic fluid volume.

Detrusor pressure uroflowmetry studies in women: effect of a 7Fr transurethral catheter

PURPOSE

We evaluated whether a 7Fr transurethral catheter affects urinary flow in women undergoing pressure flow studies for voiding symptoms.

MATERIALS AND METHODS

We reviewed a urodynamic database of 600 consecutive women referred for the evaluation of voiding symptoms. Before urodynamics all patients voided privately using a standard toilet and free flow was recorded. Urodynamics were performed using a 7Fr double lumen transurethral catheter. At functional bladder capacity patients were asked to void in the sitting position and pressure flow studies were performed. All uroflowmetry tracings were inspected and analyzed manually. Only patients who voided similar volumes varying by less than 20% on the free and pressure flow studies were assessed. Free and pressure flow parameters were compared according to voided volume category, main urodynamic diagnosis, uroflowmetry pattern and pre-void bladder volume.

RESULTS

A similar volume was voided on the free and pressure flow studies of 100 women. In each voided volume category and urodynamic diagnosis pressure flow parameters were significantly different from the equivalent free flow parameters in all but 4 cases. Specifically the maximum flow rate was significantly less and flow time was significantly longer on pressure versus free flow studies (each p <0.01). An intermittent flow pattern was more common on pressure than in free flow measurements (43% versus 9%).

CONCLUSIONS

A 7Fr transurethral catheter may adversely affect uroflowmetry parameters in women undergoing pressure flow studies for lower urinary tract symptoms. This finding may have further clinical implications regarding the interpretation of these parameters as well as establishment of an accurate diagnosis.

Anal incontinence: prevalence among female patients attending a urogynecologic clinic

The present study prospectively surveyed the prevalence of anal incontinence among 283 consecutive female patients attending a urogynecologic outpatient clinic in a maternity hospital. Data concerning bowel habits, laxative use, previous anorectal surgery, and the presence, severity, and frequency of anal incontinence were collected by interviewing the patients. Anal incontinence was reported by 83 women, representing 29% of the study population. Of those reporting anal incontinence, 30% (9% of the study population) were incontinent to solid feces, 22% (6%) to liquid feces, and 48% (14%) to gas. Age distribution demonstrates progressive rise and a high prevalence of anal incontinence in patients older than 60 years. A significant higher rate of vacuum deliveries was found among patients with anal incontinence, compared with continent patients (9.6% vs. 2.5%; P = 0.01). Increased prevalence of anal incontinence was also found among patients with past history of hemorrhoidectomy and those with urodynamic diagnosis of combined genuine stress incontinence and detrusor instability/sensory urgency. In conclusion, in patients attending a urogynecologic clinic, anal incontinence is a frequent, although rarely volunteered, symptom.

Development of postoperative urinary stress incontinence in clinically continent patients undergoing prophylactic Kelly plication during genitourinary prolapse repair

The present study was undertaken to evaluate the efficacy of Kelly plication in preventing postoperative urinary stress incontinence in clinically continent patients undergoing surgery for genitourinary prolapse. Thirty clinically continent patients with grade-3 genitourinary prolapse were found to have a positive stress test with repositioning of the prolapse during preoperative urodynamic evaluation. In addition to the genitourinary prolapse repair, these patients underwent a Kelly plication as a preventive measure against possible development of postoperative urinary stress incontinence. Postoperative follow-up included a detailed urogynecologic questionnaire, pelvic examination, urine culture, Q-tip cotton swab test, and a full urodynamic evaluation. The mean duration of follow-up was 25.5 +/- 14.1 months. Fifteen (50%) patients developed subjective and objective postoperative stress incontinence. Eleven (37%) patients developed objective postoperative stress incontinence (proven by urodynamic evaluation) with no subjective complaints of stress incontinence. Prophylactic Kelly plication as performed by the method described does not appear to be effective in preventing postoperative urinary stress incontinence in clinically continent patients who undergo surgery for genitourinary prolapse.

Bladder outlet obstruction in women: definition and characteristics

The prevalence of bladder outlet obstruction in women is unknown and most probably has been underestimated. Moreover, there are no standard definitions for the diagnosis of bladder outlet obstruction in women. Our study was conducted to define as well as to examine the clinical and urodynamic characteristics of bladder outlet obstruction among women referred for evaluation of voiding symptoms. Bladder outlet obstruction was defined as a persistent, low, maximum "free" flow rate of <12 mL/s in repeated non-invasive uroflow studies, combined with high detrusor pressure at a maximum flow (p(det.Q)(max) >20 cm H(2)O) during detrusor pressure-uroflow studies. A urodynamic database of 587 consecutive women identified 38 (6.5%) women with bladder outlet obstruction. The mean age of the patients was 63.9 +/- 17.5 years. The mean maximum "free" flow, voided volume, and residual urinary volume were 9.4 +/-3.9 mL/s, 144. 9 +/- 72.7 mL, and 86.1 +/- 98.8 mL, respectively. The mean p(det. Q)(max) was 37.2 +/- 19.2 cm H(2)O. Previous anti-incontinence surgery and severe genital prolapse were the most common etiologies, accounting for half of the cases. Other, less common, etiologies included urethral stricture (13%), primary bladder neck obstruction (8%), learned voiding dysfunction (5%), and detrusor external sphincter dyssynergia (5%). Symptomatology was defined as mixed obstructive and irritative in 63% of the patients, isolated irritative in 29%, and isolated obstructive in other 8%. In conclusion, bladder outlet obstruction in women appears to be more common than was previously recognized, occurring in 6.5% of our patients. Micturition symptoms relevant to bladder outlet obstruction are non-specific, and a full urodynamic evaluation is essential in making the correct diagnosis and formulating a treatment plan.

The pathophysiology of post-radical prostatectomy incontinence: a clinical and video urodynamic study

PURPOSE

We examine various mechanisms of post-radical prostatectomy incontinence.

MATERIALS AND METHODS

A total of 83 consecutive men (mean age 68 +/- 6.6 years) referred for evaluation of persistent post-radical prostatectomy incontinence were enrolled in the study. All patients underwent clinical and urodynamic evaluation. Final diagnosis was based on clinical judgment considering patient history, pad test, voiding diary, free (unintubated) uroflow measurements, video urodynamics and linear passive urethral resistance relation curves. We compared free uroflow and pressure flow obtained with a 7Fr urethral catheter in place, and empirically defined low urethral compliance as at least 10 ml. per second difference between these measurements.

RESULTS

Sphincteric incontinence was the most common urodynamic finding, occurring in 73 patients (88%). Detrusor instability was identified in 28 patients (33.7%) and in 6 (7.2%) was the main cause of incontinence. In 2 other patients bladder outlet obstruction (1.2%) or impaired detrusor contractility (1.2%) was the only urodynamic finding. Impaired detrusor contractility was diagnosed by linear passive urethral resistance relation in 82% of cases but considered to be clinically relevant in only a third. In 25 cases (30.1%) low urethral compliance was noted, which we consider nearly synonymous with urethral scarring.

CONCLUSIONS

Sphincteric incontinence is the most common urodynamic finding in patients with post-radical prostatectomy incontinence, although other findings may coexist. The most accurate diagnosis is attained when all objective measures are put in perspective with the clinical setting.

A simplified urinary incontinence score for the evaluation of treatment outcomes

There are no standardized definitions for anti-incontinence therapy outcomes. The present study was conducted to evaluate whether the incorporation of several non-invasive outcome measures into a new score may serve as a meaningful outcome instrument. Ninety-four consecutive sphincteric incontinent women who underwent a pubovaginal sling by a single surgeon were enrolled. All patients underwent a full clinical evaluation, including pre- and post-operative questionnaires, 24-hour voiding diary, and 24-hour pad test. Surgery outcomes were classified twice: First, by analyzing the patient questionnaire, voiding diary, and pad test separately, according to previously published criteria, and second, by combining the three outcome tools into a new response score. The new score was constructed in a simple, easy-to-remember format and divided into five categories: cure, good response, fair response, poor response, and failure. All patients were evaluated at least 1 year post-operatively. Comparison of the old and new classifications suggests that the new response score provides a more accurate evaluation of the surgical outcomes. Although 64 to 69% of the patients were originally classified as cure according to the old classification, only 44.7% were re-classified as cure by the strict criteria employed in the new score. Furthermore, the response score also differentiates between various degrees of clinical improvement (i.e., good, fair, or poor response). Twenty-five (26.6%) patients, most of whom were previously classified as cure, were re-classified as good response, whereas 20 others were re-classified as fair (13. 9%), or poor (7.4%) response. Seven (7.4%) patients were re-classified as surgical failures. All were diagnosed pre-operatively as having complex sphincteric incontinence. Specific failure rates were therefore 11.3% for complex and 0% for simple cases. In conclusion, the suggested post-operative response score incorporates in a user-friendly format three popular outcome tools (i.e., 24-hour diary, 24-hour pad test, and patient questionnaire) and seems to reflect the surgical results more accurately. Further studies are needed to assess its validity and reproducibility in other treatment modalities. Neurourol Urodynam. 19:127-135, 2000.

Predicting the need for anti-incontinence surgery in continent women undergoing repair of severe urogenital prolapse

PURPOSE

We determined the indications for anti-incontinence surgery in continent women undergoing surgical repair of severe urogenital prolapse.

MATERIALS AND METHODS

We prospectively evaluated 24 continent women referred for evaluation of severe urogenital prolapse. All patients underwent a meticulous clinical evaluation, including a complete history and physical examination, urinary questionnaire, voiding diary, pad test, cotton swab test, video urodynamics and cystoscopy. The urodynamic evaluation was repeated with prolapse repositioning by a fitted vaginal pessary. Surgical intervention was tailored according to urodynamic findings.

RESULTS

Reduction of prolpase with a pessary unmasked sphincteric incontinence in 14 women (58%). Ten women with no urodynamic evidence of sphincteric incontinence underwent anterior colporrhaphy and no additional anti-incontinence procedure was performed. Mean followup was 44 months (range 12 to 96). None had postoperative stress incontinence but 1 (10%) had a recurrent grade 2 cystocele. The 14 remaining women with sphincteric incontinence after prolapse reduction underwent anterior colporrhaphy with a pubovaginal sling procedure. Mean followup in these cases was 47 months (range 12 to 108). In 2 patients (14%) stress incontinence developed postoperatively and 1 (7%) had a recurrent grade 3 cystocele. The incidence of urge incontinence did not appear to be significantly influenced by either surgical intervention. Overall 12 patients had preoperative urge incontinence, of whom 9 (75%) had persistent urge incontinence postoperatively. In another woman new onset urge incontinence developed.

CONCLUSIONS

Preoperative urodynamic evaluation with and without prolapse reduction is essential for making the correct diagnosis of masked stress incontinence in women with urogenital prolapse. The decision to perform a concomitant prophylactic anti-incontinence procedure should be tailored to individual urodynamic findings. Larger series and longer followup are needed to establish the most effective preventive procedure for this troublesome clinical problem.

The significance of the American Urological Association symptom index score in the evaluation of women with bladder outlet obstruction

PURPOSE

The American Urological Association (AUA) symptom index was originally designed to assess the severity of lower urinary tract symptoms in men with benign prostatic hyperplasia. Data concerning the clinical application of the AUA symptom index to women are sparse. We evaluated the significance of the AUA symptom index in women with urodynamically defined bladder outlet obstruction.

MATERIALS AND METHODS

From a urodynamic database of 587 consecutive women 38 (6.5%) were identified with bladder outlet obstruction, defined as a maximum flow rate of less than 12 ml. per second on repeat noninvasive uroflowmetry studies with a detrusor pressure at a maximum flow of greater than 20 cm. water on pressure flow study. All patients underwent a complete clinical and urodynamic evaluation, and completed the AUA symptom index questionnaire. Results in women with urodynamic obstruction were compared with those in 2 control groups, including women without obstruction but with sphincteric incontinence and asymptomatic healthy women.

RESULTS

Mean symptom score was significantly higher in women with obstruction than in those with sphincteric incontinence or no symptoms (15.8+/-8.4 versus 10.3+/-6.4 and 2.1+/-2.7, respectively). Likewise, scores were classified as severe in 34% of women with obstruction compared with only 7% of those with sphincteric incontinence. However, no correlation was noted between symptom index scores and objective urodynamic parameters, which is similar to data already reported in male populations.

CONCLUSIONS

The AUA symptom index score may be useful as a bothersomeness index in women with bladder outlet obstruction. However, subjective symptoms associated with bladder outlet obstruction are nonspecific and a complete urodynamic evaluation is essential for making the diagnosis.

Timing of sonohysterography in menstruating women

A prospective, blind study was carried out on 44 patients to evaluate the most suitable time to perform transvaginal sonohysterography. On the day of arrival at our unit, regardless of their cycle day, the women underwent sonohysterographic evaluation, which was repeated during the first 10 days of the next cycle. Patients with sonohysterographic findings underwent hysteroscopy. According to the timing of the first examination, they were divided into two groups, i.e. group 1 for the first 10 days of the cycle, and group 2 for days 16 through 28. At the end of the study the groups were compared. The results showed a false-positive rate of 27% in group 2, while no false-positive was found in group 1. We concluded that the best time for sonohysterography in patients who still have their menstrual period is during the first 10 days of the cycle.

[PVT--tension-free vaginal tape--a new minimally invasive surgical technique for female stress incontinence: preliminary results]

We evaluated the safety and efficacy of the tension-free vaginal tape procedure (TVT) in 20 consecutive women with urodynamically proven genuine stress incontinence. Mean operating time under spinal analgesia was 37.2 +/- 13 minutes and 80% were discharged within 24 hours. There were 5 uncomplicated, intraoperative bladder perforations, but no defects in healing nor tape rejection. The objective cure rate was 95%, while the subjective rate was 100%. Although follow-up was short (9-16 months), the TVT method seems to be safe and effective for stress urinary incontinence.

Sexual function in women attending a urogynecology clinic

The study prospectively evaluated the relationship between sexual dysfunction and urodynamic diagnoses in 100 consecutive female patients referred for urogynecologic evaluation. Sexual function was evaluated by a detailed questionnaire that addressed four phases of the sexual cycle: desire, arousal, orgasm and satisfaction. Each phase of the sexual cycle was assessed separately using a score of 1-4. Total sexual function (TSF) score was calculated by combining the scores of the four examined parameters (range 4-16). Analysis revealed statistically significant (P < 0.05) lower TSF scores in patients with detrusor instability (DI) than in those with genuine stress incontinence, sensory urge or mixed urodynamic diagnoses (8.65 +/- 4 versus 12.22 + 3.6, 10.25 +/- 4.1 and 11.47 +/- 4.1, respectively). Three per cent of the elderly women (>60 years) compared to 29% of the younger women (< or = 60 years) reported urinary incontinence during sexual activity. Sexual function should therefore be routinely evaluated in women presenting with urinary symptoms.

Stress urinary incontinence: prevalence among nulliparous compared with primiparous and grand multiparous premenopausal women

The study was conducted to assess the prevalence of stress urinary incontinence in premenopausal nulliparae, primiparae, and grand multiparae, and to examine possible obstetric risk factors. Three hundred consecutive nulliparae, primiparae, and grand multiparae, 20 to 43 years of age, were interviewed during the third postpartum day of their consequent delivery about the symptom of stress urinary incontinence. Women were asked whether they had experienced stress urinary incontinence before, during, or after previous pregnancies and how troubled they were by their incontinence. Details of general and gynecologic history, parity, mode of previous deliveries, and birth weights were sought. Main outcome measures included prevalence of pregnancy-related and (persistent) nonpregnancy-related stress urinary incontinence. Prevalence of persistent stress urinary incontinence was significantly higher in grand multiparae compared with nulliparae (21% vs. 5%, respectively; P = 0.0008). Prevalence of persistent stress urinary incontinence among grand multiparae who had been delivered of at least one baby weighing more than 4,000 g was significantly higher than in those who did not (29.4% vs. 16.7%, respectively). The birth weight of the first newborn and operative vaginal delivery were not found to be associated with increased risk of stress urinary incontinence. Grand multiparity was found to be associated with an increased risk of developing persistent stress urinary incontinence during reproductive ages. The delivery of at least one baby weighing more than 4,000 g seems to be a predominant factor. Neurourol. Urodynam. 18:419-425, 1999.

Prevalence and characteristics of voiding difficulties in women: are subjective symptoms substantiated by objective urodynamic data?

OBJECTIVES

To examine the prevalence and characteristics of voiding difficulties in women.

METHODS

Two hundred six consecutive female patients who attended a urogynecology clinic were recruited. Patients were interviewed regarding the presence and severity of symptoms that would suggest voiding difficulties (ie, hesitancy, straining to void, weak or prolonged stream, intermittent stream, double voiding, incomplete emptying, reduction, and positional changes to start or complete voiding). Urodynamic evidence of voiding difficulty was considered as a peak flow rate less than 12 mL/s (voided volume greater than 100 mL), or residual urine volume greater than 150 mL, on two or more readings. Residual urinary volume, flow patterns, and pressure-flow parameters were analyzed and compared between symptomatic and asymptomatic patients who had urodynamic parameters of voiding difficulties.

RESULTS

One hundred twenty-seven (61.7%) women reported having voiding difficulty symptoms; 79 others (38.3%) were free of such symptoms. Urodynamic diagnosis of voiding difficulty was made in 40 women (19.4% of the study population): 27 in the symptomatic group and 13 in the asymptomatic group (21.2% and 16.5%, respectively). Only 1 patient had voiding difficulty due to bladder outlet obstruction. All other cases of low flow rate were due to impaired detrusor contractility.

CONCLUSIONS

Objective evidence of voiding difficulty may be found in both symptomatic and asymptomatic patients and is usually due to impaired detrusor contractility. The clinical significance of the abnormal flow parameters in asymptomatic patients is unclear.

Involvement of internal genitalia in female patients undergoing radical cystectomy for bladder cancer: a clinicopathologic study of 37 cases

Radical cystectomy for invasive bladder cancer in female patients implies anterior pelvic exenteration. The necessity for routine removal of all internal female genitalia has not, as yet, been investigated. The present study was conducted to investigate the involvement of internal genitalia in these patients. Cystectomy specimens from 37 consecutive female patients with bladder cancer were examined for internal genitalia and urethral involvement. Clinical data were retrospectively collected from hospital charts. Thirty-four patients were available for postoperative follow-up. Of the 37 cases, 30 were transitional cell carcinoma (TCC), 4 squamous cell carcinoma, 1 adenocarcinoma, and 2 undifferentiated carcinoma. Uterine involvement was observed in only 1 case: TCC, stage D1, grade IV. All patients had normal ovaries and a normal vagina regardless of tumor site or stage; however, late ovarian and vaginal recurrences developed in one patient, in whom one ovary had been preserved. Sixteen percent of the patients had urethral involvement. We conclude that synchronous or metachronous involvement of female internal genitalia in bladder cancer is uncommon. Preservation of ovaries and vagina in young patients undergoing radical cystectomy may be considered under strict criteria.

[Pelvic floor exercise and biofeedback in women with urinary stress incontinence]

Stress urinary incontinence is a medical and social problem. In the past decade there has been increased awareness of this condition and the number of those affected who seek help is increasing. Treatment is usually surgical-elevation of the bladder neck. Pelvic floor exercise is an accepted conservative treatment modality used for mild to moderate cases who have not yet completed their families. We present our results in 30 women, aged 28-71 years, av. 49% with genuine stress incontinence treated with pelvic floor exercise and biofeedback. 14 patients (46.7%) were completely cured and 15 (50%) were improved. In only 1 was there no improvement. Our results show significant improvement in the duration and intensity of pelvic floor contractions after treatment. Pelvic floor exercise with biofeedback is a very important treatment modality, requiring a highly motivated patient and a physiotherapist specialized in pelvic floor exercise.

Incidence and obstetric risk factors of postpartum anal incontinence

BACKGROUND

Anal incontinence in young women may be the result of injury to the pelvic floor during vaginal delivery. This study was conducted to evaluate the relationship between obstetric risk factors and the prevalence of anal incontinence 3 months and 1 year after delivery.

METHODS

Three hundred consecutive women who delivered in the obstetric ward of the Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, were prospectively interviewed 3 months postpartum with regard to the symptom of anal incontinence. Patients with anal incontinence that started after delivery were questioned about the type, frequency, and severity of the problem, concomitant stress urinary incontinence (SUI), previous colorectal assessment, and wish for further evaluation and treatment. Obstetric data were collected from the women's medical charts. Symptomatic patients were followed-up 1 year postpartum.

RESULTS

Anal incontinence was reported by 21 patients: 19 were incontinent to gas, whereas only 2 patients were incontinent to solid feces (6.3% and 0.7% of the study population, respectively). Five patients (24% of the anal-incontinent patients) also had concomitant SUI. The length of the first and second stages of labor, operative vaginal delivery, and episiotomy were found to be associated (P < 0.05) with the development of anal incontinence at 3 months postpartum. At I year postpartum all patients with combined anal incontinence and SUI had persistent symptoms.

CONCLUSION

The major obstetric risk factors for postpartum anal incontinence are prolonged first and second stages of labor, operative vaginal delivery, and the use of episiotomy.

Successful treatment of advanced interstitial pregnancy with methotrexate and hysteroscopy. A case report

BACKGROUND

Data concerning medical treatment of interstitial ectopic pregnancies are scarce. These pregnancies are characterized by late and serious clinical manifestations. We report a case of advanced interstitial pregnancy treated successfully by combining methotrexate (MTX) and hysteroscopy.

CASE

A routine ultrasonic evaluation of a 10-week pregnancy revealed a right interstitial gestational sac 58 mm in diameter and containing an embryo with a crownrump length of 29 mm and embryonic heartbeats. Serum beta-human chorionic gonadatropin (hCG) level was 97,950 mIU/mL. The patient was treated with a systemic MTX/leucovorin regimen. At the end of the one-week course, no embryonic cardiac activity was detected, and a decrease in beta-hCG levels commenced. Persistent trophoblastic tissue, manifested by a low (26 mIU/mL) beta-hCG level in plateau, was successfully removed by way of hysteroscopy.

CONCLUSION

Early detection of interstitial pregnancy may facilitate conservative medical treatment.

The effect of early epidural block administration on the progression and outcome of labor

This study was undertaken to prospectively evaluate the effect of early administration of epidural bupivacaine (0.25%) on the progression and outcome of labor in 60 nulliparous patients. Patients were randomly divided into two groups. In group 1 (30 patients, early administration), the epidural catheter was sited and the first epidural injection of 0.25% bupivacaine administered at a cervical dilatation of <4 cm; group 2 (30 patients, late administration) received the epidural catheter and first epidural injection of 0.25% bupivacaine at a cervical dilatation of >or=4 cm. The progression and outcome of labor were compared between the two groups. There were no statistically significant differences between the two groups in rate of cervical dilatation, duration of the second stage, numbers of instrumental deliveries or cesarean sections or Apgar scores at 1 and 5 min. We conclude that there is no need to restrict epidural top-ups until cervical dilatation of 4 cm, when active management of labor is advocated.

Double-blind, placebo-controlled study of magnesium hydroxide for treatment of sensory urgency and detrusor instability: preliminary results

In a prospective, randomised, double-blind, placebo-controlled study 40 women with sensory urgency or detrusor instability randomly received either magnesium hydroxide (group A) or placebo (group B). Pre- and post-treatment symptoms, frequency-volume charts and cystometry results were compared. Eleven of 20 patients receiving magnesium (55%) reported a subjective improvement of their urinary symptoms, compared with five patients taking placebo (20%). In both study groups there was no statistically significant difference in pre- and post-treatment urodynamic parameters in those reporting symptomatic improvement. Magnesium was well tolerated by patients in group A, and no side effects were reported. These results suggest that magnesium hydroxide may be beneficial for detrusor instability or sensory urgency in women.

Influence of ovulation induction with human menopausal gonadotropin on uterine blood flow: comparison of unexplained and mechanical infertility

A prospective study in patients undergoing in vitro fertilization treatment was conducted to assess whether any difference may be present in uterine blood flow between unexplained and mechanical infertility, before and during ovulation induction. The ascending branch of the uterine artery, the arcuate arteries, and the radial arteries were examined by transvaginal, color pulsed Doppler sonography on day 3 and on the day of human chorionic gonadotropin administration. Patients with mechanical factor demonstrated a decrease in resistance to blood flow in all the examined vessels during ovulation induction. Patients with unexplained infertility showed a contrasting trend in changes of uterine blood flow (e.g., as the cycle progressed, the resistance index increased). Moreover, the resistive index values on the day of human chorionic gonadotropin administration were significantly higher in patients with unexplained infertility. It is quite possible that the rise in impedance to uterine blood flow during ovulation induction and the higher impedance on the day of human chorionic gonadotropin administration in patients with unexplained infertility may be one of the factors responsible for the lower conception rate in these patients.

Comparison of transmyometrial and transcervical embryo transfer in patients with previously failed in vitro fertilization-embryo transfer cycles and/or cervical stenosis

OBJECTIVE

To compare ultrasound-guided transmyometrial and transcervical ET in patients with cervical stenosis or in patients who failed to conceive after at least three previous IVF-ET cycles.

DESIGN

A prospective, randomized study.

SETTING

The IVF-ET Unit at Serlin Maternity Hospital.

PATIENT(S)

Forty patients undergoing IVF-ET.

INTERVENTION(S)

Ultrasound-guided transvaginal, transmyometrial, versus transcervical ET.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate.

RESULT(S)

Transmyometrial ET was performed in 20 patients and resulted in one clinical pregnancy. Transcervical ET, performed in another 20 similar patients, resulted in three clinical pregnancies.

CONCLUSION(S)

No benefit was derived by electing transmyometrial ET in preference to transcervical ET in patients who had failed to conceive in previous cycles.

Cervical dilatation during ovum pick-up in patients with cervical stenosis: effect on pregnancy outcome in an in vitro fertilization-embryo transfer program

OBJECTIVE

To evaluate the results of cervical dilatation during an ovum pick-up session in patients with cervical stenosis who participated in an IVF-ET program.

DESIGN

A retrospective study.

SETTING

In vitro fertilization-ET unit.

PATIENT(S)

Forty-one treatment cycles in 22 patients with known cervical stenosis. In all patients previous transcervical ET had been either extremely difficult or impossible.

INTERVENTION(S)

Cervical dilatation under general anesthesia during an ovum pick-up session, 48 hours before transcervical ET.

MAIN OUTCOME MEASURE(S)

Ease of ET procedure and clinical pregnancy rate (PR).

RESULT(S)

Cervical dilatation was performed in 41 IVF-ET cycles and resulted in easier transcervical ET in 39 cycles, but only one clinical and one extrauterine pregnancy.

CONCLUSION(S)

Cervical dilatation during the ovum pick-up session leads to easier ET in patients with cervical stenosis, but PRs after this procedure are very low.