Angelo E. Gousse

Female Sexual Dysfunction Following Vaginal Surgery: A Review

PURPOSE Depending on age it has been estimated that up to 40% of women have complaints of sexual problems, including decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm. In this review we address the etiologies and incidence, evaluation and treatment of female sexual dysfunction following vaginal surgery for indications such as stress urinary incontinence and pelvic organ prolapse; anterior/posterior colporrhaphy, perineoplasty and vaginal vault prolapse. MATERIALS AND METHODS Literature on the mechanisms by which vaginal surgery affects female sexual function are discussed along with related pathophysiology to potential causes. The anatomy, neurovascular supply of the clitoris and introitus, and intrapelvic nerve supply are discussed as related to vaginal surgery. Techniques to avoid neurovascular damage during pelvic floor surgery were corroborated by supporting literature. Literature regarding female sexual dysfunction following other procedures, such as vaginal hysterectomy, Martius flap interposition, and vesicovaginal and rectovaginal fistula repair were also discussed. RESULTS Current literature does not support an association between vaginal length following vaginal surgery and sexual function. The proportion of women who are sexually active does not appear to be affected by vaginal surgery. Sling surgery for urinary incontinence does not appear to adversely affect overall sexual function, although individual parameters of sexual function scores may vary, eg a significant percent of women report pain during intercourse. Some patients experience improved overall sexual function due to complete relief from coital incontinence CONCLUSIONS Symptomatic vaginal narrowing is rare even in women undergoing simultaneous posterior repair. Overall sexual satisfaction appears to be independent of therapy for urinary incontinence or prolapse. Data indicate that defect specific posterior colporrhaphy with the avoidance of levator ani plication may improve sexual function. The possible etiological factors for sexual dysfunction following vaginal surgery deserve further investigations.

The impact of lower urinary tract symptoms and urinary incontinence on female sexual dysfunction using a validated instrument.

INTRODUCTION Lower urinary tract symptoms (LUTS) is a common problem in women and frequently coexists with female sexual dysfunction (FSD). However, the relationship of LUTS and FSD is poorly characterized. AIM To evaluate the relationship of LUTS and urinary incontinence (UI) to FSD using a validated instrument, the female sexual function index (FSFI). METHODS We performed an institutional review board-approved retrospective evaluation of 236 female patients over a 3-year time-period who completed an FSFI-validated questionnaire and underwent urodynamics (UDS) evaluation for LUTS or UI. Patients were categorized based upon history and physical exam into different LUTS groups. Additionally, the presence or absence of UI, detrusor overactivity (DO), stress urinary incontinence, and maximal cystometric capacity (MCC) > or <200 mL on UDS were used to further evaluate these patients. FSFI domain and total scores were compared between the different LUTS groups. MAIN OUTCOME MEASURE FSFI scores were evaluated for women with similar clinical LUTS diagnosis and UDS findings. The Kruskal-Wallis nonparametric test and the Dwass-Steel test determined statistical significance and performed multiple pairwise comparisons between the different voiding dysfunction groups and those with normal UDS (Leak-/DO-/urodynamic stress incontinence-). RESULTS The mean age of the cohort was 49.5 (range 18-69), and there was no statistically significant difference in mean age within each LUTS subgroup. MCC < 200 mL did not significantly impair female sexual function. Patients with clinical diagnosis of overactive bladder (OAB)-Dry had the highest sexual function while those with mixed urinary incontinence had the worst. Additionally, women with UI and DO had the greatest degree of FSD, which was significantly worse than those with normal UDS. Additionally, for women with or without UI, the presence of DO on UDS resulted in a trend toward worse sexual function. CONCLUSIONS The sexual function of women is negatively impacted by the presence of LUTS, with UI and DO causing the greatest degree of FSD. The sexual domains most affected are desire, lubrication, orgasm, and sexual satisfaction.

Predictors of Success for First Stage Neuromodulation: Motor Versus Sensory Response

PURPOSE We investigated whether intraoperative motor or sensory response is more predictive of successful sacral neuromodulation using the InterStim system. MATERIALS AND METHODS A total of 35 patients with medically refractory frequency, urgency and urge incontinence were enrolled in the study. All patients underwent lead placement for quadripolar test stimulation under local anesthesia with intravenous sedation. Confirmation of correct lead placement was by observation of known motor and sensory responses that result from third sacral nerve stimulation. Motor and sensory responses were documented intraoperatively. Patients had a 1-week trial of stimulation, and those who had greater than 50% improvement in symptoms had placement of the implantable pulse generator. Those without at least 50% improvement in their symptoms had the quadripolar lead removed. RESULTS Of the 35 patients enrolled 21 had successful quadripolar test stimulation and went on to permanent implantable pulse generator placement. Of the patients who had successful quadripolar test stimulation 95% demonstrated positive intraoperative motor response whereas only 21.4% of patients with unsuccessful quadripolar test stimulation demonstrated positive motor response. If only a positive sensory response was elicited, patients had only a 4.7% chance of having a positive quadripolar test stimulation. CONCLUSIONS A positive quadripolar test stimulation (greater than 50% improvement in symptoms) with InterStim sacral neuromodulation is more likely when intraoperative lead placement results in positive motor response vs only sensory response.

Preliminary results of a dose‐finding study for botulinum toxin‐A in patients with idiopathic overactive bladder: 100 versus 150 units

To evaluate the clinical outcomes of two different doses of BTX‐A in patients with I‐OAB.

Current practice patterns in the urologic surveillance and management of patients with spinal cord injury

OBJECTIVES To determine current trends in management and surveillance of the spinal cord injury (SCI) population among specialized urologists who routinely work and provide care to patients with SCI. There is a lack of consensus on the optimal urologic surveillance and management protocol of the urinary tract in SCI patients. METHODS A mailed questionnaire was sent to the 269 American members of the Society for Urodynamics and Female Urology (SUFU). The type of investigation used in the assessment and follow-up of upper and lower urinary tract function in SCI patients and their optimal frequency and management modalities were the topics of inquiry. RESULTS One hundred sixty of the 269 urologists responded for a response rate of 60%. Most physicians (85%) favor a yearly renal ultrasound for routine surveillance of the upper tracts, whereas more than half (65%) routinely use videourodynamic studies for evaluation of the lower urinary tract. The combination of clean intermittent catheterization (CIC) plus anticholinergic agents is the favored modality for management of hyperreflexic bladder, whereas CIC alone is preferred for the areflexic bladder. CONCLUSIONS This study confirms that most urologists working with SCI patients follow principles reported in published data regarding the need for evaluation, surveillance, and management of the urinary tract. However, there is a lack of consensus in the specific methods used for surveillance of the urinary system. The present results emphasize the need for clear guidelines in this area.

Interposition flaps in transabdominal vesicovaginal fistula repairs: are they really necessary?

Objectives. To evaluate the use of interposition flaps in repairing vesicovaginal fistulas (VVFs) of benign and malignant etiologies. Interposition flaps are not routinely used in the repair of VVFs when the surrounding tissues appear healthy and well-vascularized, such as in a benign etiology.Methods. We retrospectively reviewed the charts of 37 women (mean age 49.1 years) at our institution who underwent transabdominal repair of their VVF by urologic surgeons between August 1978 and June 1999. The preoperative and postoperative medical records were reviewed.Results. Of the 37 VVFs repaired transabdominally, 29 had a benign etiology (25 related to gynecologic procedures) and 8 a malignant etiology (all related to gynecologic neoplasia). Of the 29 benign VVFs, an interposition flap was used in 10 repairs with all 10 successful (100%). The remaining 19 benign VVF repairs were performed without using a flap, with 12 successful (63%). Of the 8 malignant fistulas, an interposition flap was used in 2 repairs with both successful (100%). The remaining 6 malignant VVF repairs were performed without a flap, with 4 successful (67%).Conclusions. The results of our study indicate a higher success rate for transabdominal VVF repairs performed with an interposition flap (100% success rate at our institution). This observation holds true regardless of the appearance of healthy surrounding tissue or, more importantly, a benign or malignant etiology. We recommend interposition flaps in transabdominal repairs of VVFs, even in the cases of benign fistulas with well-preserved surrounding tissue.

Management of neobladder-vaginal fistula and stress incontinence following radical cystectomy in women: a review

Contemporary literature regarding the management of neobladder-vaginal fistula and stress urinary incontinence following radical cystectomy and neobladder reconstruction in women is reviewed in this article. Neobladder-vaginal fistula is uncommon but mandates meticulous repair. Compared to the native bladder, the wall of the neobladder is much thinner that may render it vulnerable to fistulization. Preservation of the anterior vaginal wall during radical cystectomy decreases the likelihood of pouch-vaginal fistula. Omental flap interposition between the vaginal stump and neobladder at cystectomy may not always prevent fistulization if anterior vaginal wall is violated or overlapping suture lines are not avoided. Surgery for intractable stress incontinence following neobladder reconstruction is fraught with severe complications and requires judicious use of allograft pubovaginal slingplasty possibly with bone anchors. Martius flap interposition appears to play a crucial role in improving the outcome following transvaginal repair of the neobladder-vaginal fistula in multiple non-overlapping layers.

Validation of a Two-item Quantitative Questionnaire for the Triage of Women With Urinary Incontinence

OBJECTIVE: To evaluate the reproducibility, construct validity, and preferences for the 2-item Stress/Urge Incontinence Questionnaire. METHODS: The questionnaire asks a patient to recall the number of stress urinary incontinence and urge urinary incontinence episodes she experienced during the preceding week. The 4-week prospective study included 3 office visits and enrolled women with stress, urge, or mixed urinary incontinence symptoms. The test–retest reproducibility was assessed after 3 days, and the construct validity of the questionnaire was evaluated against a diary and other measures of incontinence severity and effect. The bother associated with completing (patients) or analyzing (physicians) the diary was assessed. Both groups also reported their time requirements and preferences for the questionnaire or diary. RESULTS: Reproducibility for the classification of symptoms was moderately strong (&kgr; = .536). Test–retest agreement was good (64–80%) for all but balanced mixed incontinence (38%). Intraclass correlations revealed good reproducibility for the number of stress (.694), urge (.703), and total (.726) incontinence episodes. Significant (P < .01) correlations with other measures of incontinence established construct validity. Patients and physicians reported it took less time to complete the questionnaire than the diary, but the majority said the completion or analysis of the diary was of little or no bother and preferred the diary. CONCLUSION: The Stress/Urge Incontinence Questionnaire is a valid tool that can be used in clinical practice to differentiate between symptoms of stress and urge urinary incontinence to make an initial diagnosis, especially in primary care where incontinence is not a focus of the practice. LEVEL OF EVIDENCE: III

Value of express T2-weighted pelvic MRI in the preoperative evaluation of severe pelvic floor prolapse: a prospective study

OBJECTIVES To report our prospective experience with extended-phase conjugate-symmetry rapid spin-echo sequence (EXPRESS) magnetic resonance imaging (MRI) of the female pelvis in the preoperative staging of severe pelvic floor prolapse (PFP). Severe PFP represents a significant diagnostic and reconstructive challenge for clinicians. Although the clinical utility of dynamic MRI has already been demonstrated, EXPRESS MRI has not been prospectively studied in the evaluation of PFP. METHODS Between January 1999 and December 2001, 31 consecutive female patients with severe PFP were referred to our institution. Twenty of them underwent EXPRESS dynamic pelvic MRI. The physical examination, MRI, and intraoperative findings were statistically correlated. RESULTS The mean age of the 20 patients undergoing preoperative EXPRESS MRI was 67 years. The mean duration of prolapse was 6.1 years. All 20 patients underwent surgery for symptomatic PFP with or without associated voiding dysfunction. No postoperative complications or recurrent PFP had occurred at a median follow-up of 19 months. Significant correlations were found between the preoperative pelvic examination findings and operative findings of cystourethrocele and vaginal cuff prolapse, and significant correlations were found between MRI findings and operative findings of enterocele, cystourethrocele, vaginal cuff prolapse, and uterine prolapse. CONCLUSIONS EXPRESS MRI can accurately stage PFP. The technique is rapid, precise, and noninvasive. Practitioners should consider obtaining dynamic, rapid-sequence sagittal pelvic MRI scans in cases of severe PFP when the diagnosis is not clear before surgery. More accurate preoperative information may ultimately result in improved long-term surgical outcomes and guide the refinement of surgical techniques.

Collaboration and practice patterns among urologists and gynecologists in the treatment of urinary incontinence and pelvic floor prolapse: A survey of the International Continence Society members

Both urologists and gynecologists are involved in the care of women with urinary incontinence (UI) and pelvic floor prolapse (PFP). This study was designed to examine the differences among urologists and gynecologists who treat UI and PFP, and to characterize the collaboration between them. A 14‐question survey was mailed to the International Continence Society (ICS) members who are urologists or gynecologists. Questions dealt with professional training, type of practice, volume of UI and PFP procedures, preferred procedures for various types of UI and PFP, and the type and extent of collaboration. Of the 666 urologists and gynecologists to whom the questionnaire was sent, 229 responded (34.4% response rate). Among them, 63.7% were urologists and 36.2% were gynecologists. Collaboration in the operating room was reported by 140 responders (50.7%) and was significantly correlated with the specialty, and with the country of practice, with P values of 0.004, and 0.004, respectively. Collaboration in the operating room was reported mainly in procedures for the correction of vaginal vault prolapse or enterocele, and hysterectomy. It was not statistically correlated with the time dedicated to UI and PFP, the volume of surgeries performed, UI and PFP fellowship training, university hospital affiliation, and years in practice. Reasons for not collaborating in the operating room included familiarity with all or most of the anti‐incontinence and pelvic floor reconstruction procedures (44.5%), unavailability of the other professional (6.1%), and reimbursement problems (3.1%).%While urologists and gynecologists do collaborate extensively in clinical research and diagnosis of challenging cases, surgical collaboration is limited to procedures traditionally performed by gynecologists. Future training programs exposing trainees to both fields of expertise may enable better ground for collaboration and improved care for women with UI and PFP. Neurourol. Urodynam. 20:3–11, 2001.