Cornelia Betschart

On pelvic reference lines and the MR evaluation of genital prolapse: a proposal for standardization using the Pelvic Inclination Correction System

Five midsagittal pelvic reference lines have been employed to quantify prolapse using MRI. However, the lack of standardization makes study results difficult to compare. Using MRI scans from 149 women, we demonstrate how use of existing reference lines can systematically affect measurements in three distinct ways: in oblique line systems, distances measured to the reference line vary with antero-posterior location; soft issue-based reference lines can underestimate organ movement relative to the pelvic bones; and systems defined relative to the MR scanner are affected by intra- and interindividual differences in the pelvic inclination angle at rest and strain. Thus, we propose a standardized approach called the Pelvic Inclination Correction System (PICS). Based on bony structures and the body axis, the PICS system corrects for variation in pelvic inclination, at rest of straining, and allows for the standardized measurement of organ displacement in the direction of prolapse.

Comparison of muscle fiber directions between different levator ani muscle subdivisions: in vivo MRI measurements in women.

Introduction and hypothesisThis study describes a technique to quantify muscle fascicle directions in the levator ani (LA) and tests the null hypothesis that the in vivo fascicle directions for each LA subdivision subtend the same parasagittal angle relative to a horizontal reference axis.MethodsVisible muscle fascicle direction in the each of the three LA muscle subdivisions, the pubovisceral (PVM; synonymous with pubococcygeal), puborectal (PRM), and iliococcygeal (ICM) muscles, as well as the external anal sphincter (EAS), were measured on 3-T sagittal MRI images in a convenience sample of 14 healthy women in whom muscle fascicles were visible. Mean ± standard deviation (SD) angle values relative to the horizontal were calculated for each muscle subdivision. Repeated measures ANOVA and post-hoc paired t tests were used to compare muscle groups.ResultsPubovisceral muscle fiber inclination was 41 ± 8.0°, PRM was −19 ± 10.1°, ICM was 33 ± 8.8°, and EAS was −43 ± 6.4°. These fascicle directions were statistically different (p < 0.001). Pairwise comparisons among levator subdivisions showed angle differences of 60° between PVM and PRM, and 52° between ICM and PRM. An 84° difference existed between PVM and EAS. The smallest angle difference between levator divisions was between PVM and ICM 8°. The difference between PRM and EAS was 24°. All pairwise comparisons were significant (p < 0.001).ConclusionsThe null hypothesis that muscle fascicle inclinations are similar in the three subdivisions of the levator ani and the external anal sphincter was rejected. The largest difference in levator subdivision inclination, 60°, was found between the PVM and PRM.

Bryophyllum pinnatum inhibits detrusor contractility in porcine bladder strips - a pharmacological study towards a new treatment option of overactive bladder

AIMS A broad spectrum of synthetic agents is available for the treatment of overactive bladder. Anti-cholinergic drugs show a poor compliance due to side effects. There is an increasing use of plant extracts in medicine. We have therefore investigated the inhibitory effects of leaf press juice from Bryophyllum pinnatum (Lam.) Oken (Kalanchoe pinnata L.) on bladder strips and compared the effects to that of oxybutynin. METHODS Strips of porcine detrusor were prepared in Krebs solution and contractility was measured in a myograph system chamber aired with O₂/CO₂ at 37 °C. To induce contractions, electrical field stimulation (32 Hz, 40 V) was used for the inhibitory effect measurements, and carbachol (50 μM) for the relaxant effect measurements. Recordings were obtained in the absence and presence of increasing concentrations of Bryophyllum pinnatum leaf press juice (BPJ, 0.1-10%), and oxybutynin (10⁻⁷-10⁻³ M) as a reference substance. RESULTS In inhibition experiments, BPJ as well as oxybutynin inhibited electrically induced contractions of porcine detrusor. BPJ at concentrations of 5% inhibited the contraction compared to a time matched control significantly by 74.6±10.2% (p<0.001). BPJ as well as oxybutynin relaxed carbachol pre-contracted porcine detrusor strips. The maximum relaxant effect of BPJ compared to a time matched control was 18.7±3.7 (p<0.05) at a concentration of 10% BPJ. CONCLUSIONS Our investigations show that BPJ inhibits contractions induced by electrical field stimulation and relaxes carbachol-induced contractions. However, the effect was lower than that of the reference substance oxybutynin. It is important to continue in vitro experiments as well as clinical studies with BPJ that might offer a new treatment option for patients with OAB.

Anatomy of the pubovisceral muscle origin: Macroscopic and microscopic findings within the injury zone.

The levator ani muscle (LA) injury associated with vaginal birth occurs in a characteristic site of injury on the inner surface of the pubic bone to the pubovisceral portion of the levator ani muscles origin. This study investigated the gross and microscopic anatomy of the pubic origin of the LA in this region.

Randomized, double-blind placebo-controlled trial with Bryophyllum pinnatum versus placebo for the treatment of overactive bladder in postmenopausal women.

INTRODUCTION Overactive bladder syndrome (OAB) is a chronic disorder that often requires long-term treatment. There is a growing interest in new substances. In vitro experiments of Bryophyllum pinnatum (BP) on porcine bladder muscle have shown a muscle-relaxing effect. In this clinical trial we evaluated BP versus placebo regarding efficacy and safety. MATERIALS AND METHODS Prospective, double-blind randomized, placebo-controlled study with 20 patients (10 BP, 10 placebo); medication over 8 weeks; dosage 3×2 capsules BP 50% (350 mg)/day or placebo (lactose). Primary aim: reduction of the micturition frequency/24h. Secondary aim: change in quality of life, alterations of parameters in the bladder diary and adverse events (AE). Statistical analysis was performed with IBM SPSS Statistics 20. The groups were compared using Fishers exact test and the Mann-Whitney test; the visits using the Wilcoxon signed ranks test. RESULTS Both groups did not differ significantly in demographical data. For the primary endpoint, a trend in the reduction of the micturition frequency/24h in the BP group was found: 9.5±2.2 before and 7.8±1.2 after BP versus 9.3±1.8 before and 9.1±1.6 after placebo, p=0.064. From visit 2 to visit 4, micturition frequency/24h improved in 8/10 patients in the BP group (p=0.037). In the placebo group, micturition frequency/24h improved in 5/9 patients (p=0.89). Improvement of the QoL did not differ between the two groups. The incidence of AE was similar in both groups, no SAE occurred. CONCLUSION The successful safety outcome and positive trend for efficacy permits BP to be further evaluated as a favorable treatment option for OAB.

The surgical management of recurrent stress urinary incontinence: a systematic review

Despite a wide spectrum of interventions, surgical treatments of recurrent stress urinary incontinence (SUI) are associated with high failure rates.

Pelvic floor muscle training for urinary incontinence: a comparison of outcomes in premenopausal versus postmenopausal women.

Objectives Previous studies examining the effectiveness of pelvic floor muscle training (PFMT) for urinary incontinence in premenopausal and postmenopausal women have shown ambiguous results. The aim of this study was to compare subjective PFMT outcome in premenopausal versus postmenopausal women. Methods This is a retrospective study including premenopausal and postmenopausal women after PFMT for urodynamically proven stress urinary incontinence, mixed urinary incontinence, or urgency urinary incontinence from January 2003 to December 2008, with assessment of the need of an incontinence surgery in a follow-up time of least 24 months. Patients evaluated the change of their urinary incontinence on a 4-point Likert scale (1, no improvement; 2, slightly better; 3, no relevant incontinence; 4, excellent outcome; no incontinence at all) and their goal attainment on a 3-point Likert scale (1, less than expected; 2, as expected; and 3, more than expected). Results Successful outcome was reported by 59% of the premenopausal patients and 70% of the postmenopausal patients (P = 0.16), the attainment of the subjective goal by 68% and 81% (P = 0.09), and the need of an incontinence operation in a follow-up of 30 to 102 months by 15% and 14% (P = 1.0), respectively. None of the outcome parameters reached significance. Conclusions In comparing premenopausal to postmenopausal women, we could not detect any statistically significant difference with regard to patients’ satisfaction for the outcome of PFMT.

Impact of menopausal status on the outcome of pelvic floor physiotherapy in women with urinary incontinence

Introduction and hypothesisThe purpose of this study was to evaluate the effectiveness of pelvic floor muscle training in pre- and postmenopausal women using a quality-of-life questionnaire.MethodsWe retrospectively reviewed the medical records of 96 patients with urinary incontinence who participated in a pelvic floor muscle-training (PFMT) program at the Physiotherapy Department in a London University Hospital between January 2010 and August 2011.ResultsA period of supervised PFMT resulted in significant improvement in symptoms of stress urinary incontinence, urge urinary incontinence, urgency, frequency, and nocturia, irrespective of menopausal status.ConclusionsPre- and postmenopausal women experience similar outcomes in relation to urinary symptoms following a short-term supervised PFMT.

Management of apical compartment prolapse (uterine and vault prolapse): A FIGO Working Group report

Apical prolapse includes descent of the uterus, vagina cuff, or rarely solely of the cervix. It is estimated that women have an 11–19% life‐time risk of undergoing surgery for POP. This rate is projected to increase over the next 2–3 decades. In this FIGO working group report we address the conservative and surgical treatment options for apical prolapse.

Surgical technique of a recurrent post-radiation vesicovaginal fistula with a small intestine graft

Vesicovaginal fistulas are devastating conditions for the affected women. The combination of a hysterectomy and radiation increases the fistula risk 5–10 times. Radiation-induced recurrent vesicovaginal fistulas have the lowest success rate and require the most demanding treatment. We present the case of a recurrent post-radiation vesicovaginal fistula treated with a small intestine graft after unsuccessful conservative and failed previous operative treatments. The surgical management with a small intestine graft led to a permanently closed fistula. We describe the surgical abdominal procedure step-wise and review the rather scarce, post-radiation fistula literature. The closure of a vesicovaginal fistula with a small intestine graft is a complex surgical treatment with a long-term, successful result.