Karen Guerrero

Trends in obstetric anal sphincter injuries over 10 years

Obstetric anal sphincter injuries (OASIS) is a known complication of vaginal delivery and has significant public health issues, as it can cause both short- and long-term morbidity in women. The most commonly reported complications include different grades of faecal/flatus incontinence, pain and sexual dysfunction. In our study, we found a rising trend in OASIS rates in vaginal deliveries, with the rising rate of forceps and the falling rate of SVD, which is at least partly due to increased awareness and training in OASIS. However, there is an actual increase in the number of such tears at vaginal deliveries. Midwifery and obstetric practices have certainly changed over the last decade and we discuss the possible factors, which might be contributing to such a rise.

Sacrocolpopexy (SCP) - A Cohort Study Looking at Short, Medium and Long Term Outcome

In this study we evaluate the outcome, complications and need for repeat surgery after Sacrocolpopexy (SCP) over the last 10 years. 49 (66%) case notes were reviewed. 28 (57%) patients SCP. The remainder had concomitant pelvic floor and / or incontinence procedures. 12 patients had laparoscopic SCP and 37 were performed by open technique. 8(16%) patients’ required further surgery either for new prolapse or recurrent prolapse. The short term success with sacrocolpopexy was high (97.9%) with the rate being maintained with medium term (100%) and long term (91.66%) follow up. Rates of complication, especially mesh exposure, was very low in our study. This suggests maintaining the integrity of vaginal vault during SCP might be a key factor in reducing the incidence of mesh exposure with SCP. However large numbers in long term follow up is needed to make any definite conclusion. Sacrocolpopexy (SCP) - A cohort study looking at short, medium and long term outcome.

Prospective observational study of the impact of vaginal surgery (pelvic organ prolapse with or without urinary incontinence) on female sexual function

Introduction and hypothesisThere is a difference of opinion in the literature as to whether pelvic organ prolapse (POP) is a direct cause of female sexual dysfunction (FSD). Sexual function in women is negatively impacted by the presence of urinary symptoms. Thus, sexual dysfunction (SD) might be improved, unchanged, or worsened by pelvic floor surgery.MethodsIn this study, we observed SD and impact of surgical intervention on female sexual function (FSF) using a validated Prolapse/Urinary Incontinence Sexual Questionnaire Short Form (PISQ-12) in women undergoing surgery for POP with or without urinary incontinence. Two hundred women were recruited and followed up at 6 and 12xa0months postoperatively.ResultsSexual function (SF) as measured by the PISQ-12 improved after surgery irrespective of the nature of surgery or the patient’s past gynaecology history. Improvement in SF was seen by 6xa0months (97 patients) postsurgery (Pxa0<xa00.05), after which (at 12xa0months; 80 patients) no further change was observed. Improved SF was associated with better patient satisfaction postoperatively.ConclusionsSexual function improved in women following surgery for POP with or withour urinary incontinence, irrespective of the nature of surgery and the patient’s past gynecologic history. Results of this study will assist when counselling women with POP with or without urinary incontinence regarding treatment options.

Cystoscopy – is it a specialist gynaecology procedure?

Cystourethroscopy (endoscopic examination of the urethra and the bladder) was once a procedure that all obstetricians and gynaecologists were familiar with. However, more recently it seems it is a procedure mainly used by urogynaecologists or gynaecologists with an interest in pelvic floor surgery, gynaecological oncologists undertaking cancer staging and endometriosis surgeons for the insertion of ureteric stents and checking ureteric patency. There may be several reasons for this, as discussed below. While the diagnostic indications for cystoscopies have not changed significantly over time, as well described by Lyttle and Fowler in this excellent article, the therapeutic indications, however, have become more common with the wider use of botulinum toxin, for refractory overactive bladder, and to a lesser extent, urethral bulking agents for stress urinary incontinence. These are procedures that require specific training. Another factor is that traditionally, most cystoscopies in gynaecology were conducted under general or regional anaesthesia, often because they were done as part of an operative procedure (such as mid-urethral sling). Practice now is evolving with increasing numbers of flexible cystoscopies done under local anaesthesia, mostly as outpatient procedures, being performed by urogynaecologists. Many units now have specially trained nurses running diagnostic flexible cystoscopy services. The article by Lyttle and Fowler in this issue eloquently explains the procedure of a basic cystourethroscopy. However, we stress the need for gynaecologists performing cystoscopy to be knowledgeable and skillful with the different types of scope and the specific indications for each type, allowing them to systematically examine the bladder/urethra appropriately. For example, a 30 cystoscope is generally recommended in this article; however, it is well-recognised that ‘0 or 12 ’ cystoscope will allow better urethral visualisation while a 70 cystoscope provides better visualisation of the upper lateral corners of the bladder, which is ideal for checking for bladder injuries during retropubic mid-urethral sling procedures. Similarly, a flexible cystoscope, with the ability to ‘fold back’ on itself, gives a full view of the bladder neck that a rigid cystoscope cannot. Incidental pathology (such as carcinoma and carcinoma in situ) can be discovered during examination for other indications. Pathology could easily be missed if systematic examination is not carried out and if the surgeon is not trained to recognise it. Clinicians performing cystoscopy should also be able to undertake bladder biopsies if indicated. Therefore, the question of whether cystoscopy is a ‘specialist gynaecology procedure’ ultimately relates to training, exposure and specialisation. Lyttle and Fowler raise the ethical dilemma about who should perform cystoscopies; urologists or gynaecologists. In reality, the debate is not ‘whether’ but ‘which’ gynaecologists should be performing cystoscopies. The Royal College of Obstetricians and Gynaecologists’ core curriculum only requires a diagnostic cystoscopy to be performed at level 2 – i.e. under direct supervision. Further training in Advanced Training Skills Modules or subspecialty training is required to achieve level 3 competence, i.e. independent practice. Training in flexible cystoscopy (diagnostic as well as operative) is currently only a requirement in subspecialty urogynaecology. Therefore, cystoscopy is at least considered a specialist procedure for training purposes with the likely end result being fewer, but more highly specialised, gynaecologists being able to undertake the procedure.

PROPEL: implementation of an evidence based pelvic floor muscle training intervention for women with pelvic organ prolapse: a realist evaluation and outcomes study protocol

BackgroundPelvic Organ Prolapse (POP) is estimated to affect 41%–50% of women aged over 40. Findings from the multi-centre randomised controlled “Pelvic Organ Prolapse PhysiotherapY” (POPPY) trial showed that individualised pelvic floor muscle training (PFMT) was effective in reducing symptoms of prolapse, improved quality of life and showed clear potential to be cost-effective. However, provision of PFMT for prolapse continues to vary across the UK, with limited numbers of women’s health physiotherapists specialising in its delivery. Implementation of this robust evidence from the POPPY trial will require attention to different models of delivery (e.g. staff skill mix) to fit with differing care environments.MethodsA Realist Evaluation (RE) of implementation and outcomes of PFMT delivery in contrasting NHS settings will be conducted using multiple case study sites. Involving substantial local stakeholder engagement will permit a detailed exploration of how local sites make decisions on how to deliver PFMT and how these lead to service change. The RE will track how implementation is working; identify what influences outcomes; and, guided by the RE-AIM framework, will collect robust outcomes data. This will require mixed methods data collection and analysis.Qualitative data will be collected at four time-points across each site to understand local contexts and decisions regarding options for intervention delivery and to monitor implementation, uptake, adherence and outcomes. Patient outcome data will be collected at baseline, six months and one year follow-up for 120 women. Primary outcome will be the Pelvic Organ Prolapse Symptom Score (POP-SS). An economic evaluation will assess the costs and benefits associated with different delivery models taking account of further health care resource use by the women. Cost data will be combined with the primary outcome in a cost effectiveness analysis, and the EQ-5D-5L data in a cost utility analysis for each of the different models of delivery.DiscussionStudy of the implementation of varying models of service delivery of PFMT across contrasting sites combined with outcomes data and a cost effectiveness analysis will provide insight into the implementation and value of different models of PFMT service delivery and the cost benefits to the NHS in the longer term.

Faecal incontinence: A life-course approach:

Faecal incontinence is under-reported and under-diagnosed. It is associated with negative social and psychological sequelae and reduced quality of life. Timely intervention potentially reduces its adverse impact throughout the life-course as most cases are potentially treatable. This review provides a summary of pre-disposing factors. It offers an overview of preventative and treatment options within the community setting, with signposting to further reading and a call to further research into this area of women’s health.