Alex Digesu

An International Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP)

The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically‐based consensus Report.

Caesarean section is protective against stress urinary incontinence: an analysis of women with multiple deliveries

All women who had three elective caesarean sections were selected from a database of 40,000 women delivering between 1977 and 1998, and age‐matched with women having three vaginal births. They all completed a (validated) urinary and bowel symptom questionnaire. Women who had vaginal births had a significantly higher prevalence of stress incontinence but not other urinary or faecal symptoms compared with those delivered by caesarean section. The prevalence of faecal incontinence was lower than the prevalence of urinary incontinence. Although the prevalence of faecal incontinence was lower after caesarean delivery, this was not statistically different. These data have shown that caesarean section was associated with a lower risk of urinary incontinence, although a protective effect on development of faecal symptoms was not seen.

Optimizing the duration of assessment of stage-1 sacral neuromodulation in nonobstructive chronic urinary retention.

The duration of test stimulation using two‐stage sacral neuromodulation (SNM) is not studied. This study will determine the restoration of normal bladder sensation and resultant voiding in chronic urinary retention (CUR) after stage‐1 SNM.

Mode of delivery after obstetric anal sphincter injury.

OBJECTIVE To assess the effect of vaginal delivery and caesarean section on faecal symptoms and structure and function of anal sphincter in women who sustained obstetric anal sphincter injuries (OASIS) in their previous pregnancy and were advised about the mode of delivery based on faecal incontinence symptoms, anal manometry and endoanal ultrasound. STUDY DESIGN It is a descriptive study on a cohort of women who had OASIS from 2006 to 2013. They were assessed after OASIS and during subsequent pregnancy with a questionnaire, endoanal ultrasound and anal manometry. Vaginal delivery was recommended to asymptomatic women with normal investigations. Elective caesarean section was recommended to women with faecal symptoms, anal sphincter defects of more than 30° or low resting or incremental anal pressures. All women were reassessed after subsequent delivery. RESULTS Fifty women who had pregnancies after OASIS, were seen after OASIS, during subsequent pregnancy and after the second delivery. 15 women had faecal symptoms after OASIS. The external, internal and combined anal sphincter defects were seen in 13, 11 and 9 women respectively. Low resting and incremental pressure were seen in 15 and 11 women respectively. Caesarean section was done in 22 women and 28 women delivered vaginally. Worsening of faecal symptoms and reduction in anal pressures were not observed in planned vaginal delivery or elective caesarean section groups. Faecal symptoms were worse with reduced anal pressures in three women from the planned caesarean section group. One of the women had a vaginal delivery and two women had emergency caesarean section at 7cm and 10cm dilatation. There were no new sphincter defects or recurrent OASIS in any of the women in the study group. CONCLUSION Decision about the mode of delivery of pregnancy after OASIS based on symptoms, anal manometry and endoanal ultrasound helps in preserving the anal sphincter function and avoiding unnecessary caesarean sections. Further follow-up of these patients is essential to evaluate the long-term effects of this decision.

Lack of association of joint hypermobility with urinary incontinence subtypes and pelvic organ prolapse

To test the hypothesis that joint hypermobility (JHM) is associated with specific urinary incontinence (UI) subtypes and uterovaginal prolapse.

A randomised controlled trial comparing immediate versus delayed catheter removal following vaginal prolapse surgery

OBJECTIVE It is unclear if any catheterisation is necessary after vaginal surgery for pelvic organ prolapse. The aim of this study was to determine if indwelling catheterisation is necessary after these procedures. STUDY DESIGN A randomised controlled trial of immediate post-operative removal of catheter compared to a suprapubic catheter (SPC) after vaginal prolapse surgery. In the Suprapubic group the catheter was left on free drainage until a voiding trial was commenced at 48h. Women in the immediate removal group underwent in/out catheterisation only if they had not voided by 8h after surgery to ensure the bladder did not over-distend. RESULTS 55% (n=17) of patients in the immediate removal group did not require catheterisation postoperatively. A further 13 (42%) patients only required one in/out catheterisation 8h post operatively. In the immediate removal group duration of catheterisation was significantly shorter (median 0h, IQR 0-8h, range 0-16h) vs (6days (IQR 2-8days, range 2-19h) p=0.001). The duration of hospital stay (7days (range 3-16) vs. 9 (range 3-27) p=0.014), day of first mobilisation (Day 1, range 0-2, vs. Day 2, range 1-4, p=0.001), and rate of Symptomatic bacturia (16% vs. 52%, p<0.01) were all significantly better with immediate catheter removal. CONCLUSIONS After vaginal surgery for pelvic organ prolapse, the majority of patients do not require extended catheterisation. Early removal of a catheter reduces urinary tract infection and significantly decreases hospital stay. Such a policy should result in improved patient satisfaction and reduced hospital costs.

Laser vaginal rejuvenation: not ready for prime time—response to comments by Maggiore et al.

Dear Editor, I would like to thank Dr Maggiore and colleagues for their input and remarks on our original editorial “Laser vaginal rejuvenation: not ready for prime time” [1, 2], as well as congratulate them on their work and contribution to a growing body of evidence-based techniques for managing important aspects of sexual dysfunction and vulvovaginal atrophy. However, I feel that their remarks reflect a misinterpretation and thus they are missing the major point of our editorial. While I am in complete agreement that the widespread clinical application of the CO2 laser as a surgical tool in some areas of modernmedicine is both significant and beneficial, its other uses and advantages and disadvantages are beyond the scope of the original editorial. We did not suggest that the CO2 laser did not have any clinical or surgical indication, but merely that its application in the context of genital rejuvenation needs to be very cautiously appraised, as currently there is a lack of a robust, qualitative body of data on the therapeutic advantages of the CO2 laser. The claim byMaggiore et al. that laser vaginal rejuvenation is popular in that it improves certain aspects of appearance and sexual function, according to our editorial, has not yet been substantiated by a large enough body of evidence. To this end, it must be reiterated that there is an imminent and important need to build on the small case studies, such as those reported by Maggiore et al., in the form of a larger, multi-centred study. While we accept and commend the efforts of Dr Maggiore and colleagues, who have published several recent articles, including the short-term 12-week follow-up and single-centre pilot studies on the efficacy of CO2 laser therapy for vulvovaginal atrophy and dyspareunia, to our knowledge, their results for these conditions have not been reproduced by any other authors to date. This is despite the fact that these treatments have been offered to women for over 10 years. We continue to feel strongly that there still remains a significantly under-regulated and potentially dangerous practice of laser vaginal rejuvenation driven through potentially misleading marketing and a subsequent misguided uptick of this intervention, whether through laser CO2 therapy or otherwise. We feel that the therapeutic advantages of the CO2 laser in the context of vaginal rejuvenation can only be realistically upheld on the back of conclusive, reproducible, objective and wide-ranging, reliable trials.

Prolapse Surgery and Outcome Measures

A number of outcome measures can be used when considering the surgical treatment of pelvic organ prolapse (POP).

What is the exact working mechanism of botulinum toxin A and sacral nerve stimulation in the treatment of overactive bladder/detrusor overactivity? ICI-RS 2017.

Botulinum toxin A (BTX‐A) and sacral nerve stimulation (SNS) are established treatments for overactive bladder (OAB) and are standard of care in refractory cases in international guidelines. Despite long term use over decades their “exact” working mechanisms are not entirely clear. At the ICI‐RS meeting in Bristol in 2017 a think tank was convened to address the question.

Urinary metabolic phenotyping of women with lower urinary tract symptoms

Lower urinary tract symptoms (LUTS), including urinary incontinence, urgency and nocturia, affect approximately half of women worldwide. Current diagnostic methods for LUTS are invasive and costly, while available treatments are limited by side effects leading to poor patient compliance. In this study, we aimed to identify urine metabolic signatures associated with LUTS using proton nuclear magnetic resonance (1H NMR) spectroscopy. A total of 214 urine samples were collected from women attending tertiary urogynecology clinics (cases; n = 176) and healthy control women attending general gynecology clinics (n = 36). Despite high variation in the urine metabolome across the cohort, associations between urine metabolic profiles and BMI, parity, overactive bladder syndrome, frequency, straining, and bladder storage were identified using KODAMA (knowledge discovery by accuracy maximization). Four distinct urinary metabotypes were identified, one of which was associated with increased urinary frequency and low BMI. Urine from these patients was characterized by increased levels of isoleucine and decreased levels of hippurate. Our study suggests that metabolic profiling of urine samples from LUTS patients offers the potential to identify differences in underlying etiology, which may permit stratification of patient populations and the design of more personalized treatment strategies.