Marie-Andrée Harvey

Urogenital prolapse and atrophy at menopause: a prevalence study.

Abstract: For 285 subjects referred to a menopause clinic data were prospectively collected on the time elapsed since the onset of menopause (menopausal age), sexual activity, dyspareunia, smoking, chronic cough and constipation. Prolapse and atrophy were sought on examination. FSH assay confirmed menopausal status. We found an anterior wall prolapse in 51% of the subjects, of which 6% were protruding beyond the introitus. Posterior wall prolapse was present in 27% and apical prolapse in 20%; none was protruding beyond the introitus. No trend was noted between prolapse and menopausal age. Atrophy was evident in 34% of the women, and this was related to menopausal age (P<0.001). Forty per cent of the sexually active women admitted to dyspareunia, of which 2/3 were superficial. This correlated with advancing menopausal age (P<0.02). In conclusion, genital prolapse was frequent in the population of postmenopausal women, predominantly cystocele, but the prevalence did not correlate with menopausal age.

Recurrent Urinary Tract Infection

OBJECTIVE to provide an update of the definition, epidemiology, clinical presentation, investigation, treatment, and prevention of recurrent urinary tract infections in women. OPTIONS continuous antibiotic prophylaxis, post-coital antibiotic prophylaxis, and acute self-treatment are all efficient alternatives to prevent recurrent urinary tract infection. Vaginal estrogen and cranberry juice can also be effective prophylaxis alternatives. EVIDENCE a search of PubMed and The Cochrane Library for articles published in English identified the most relevant literature. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions. VALUES this update is the consensus of the Sub-Committee on Urogynaecology of the Society of Obstetricians and Gynaecologists of Canada. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care (Table 1). OPTIONS recurrent urinary tract infections need careful investigation and can be efficiently treated and prevented. Different prophylaxis options can be selected according to each patients characteristics.

Predictive value of clinical evaluation of stress urinary incontinence: a summary of the published literature.

Abstract: Our objective was to evaluate the symptom and sign of stress incontinence in predicting the presence of urodynamically diagnosed genuine stress incontinence (GSI). The study was a computation of the sensitivity and predictive values from the published literature (1975–1998), evaluating the history and/or physical examination for the diagnosis of GSI, with calculation of efficacy variables. Results show that the isolated symptom of stress incontinence has a positive predictive value (PPV) of 56% for the diagnosis of pure GSI and 79% for GSI with additional abnormalities. The PPV of stress incontinence in association with other symptoms is 77% in detecting GSI (with or without additional abnormalities). A positive cough stress test has a PPV of 55% for detecting pure GSI and 91% for the mixed condition (GSI plus additional diagnosis). When isolated, the symptom or the sign of stress incontinence is a poor predictor of GSI. In combination, the prediction may be more promising.

Women with SUI demonstrate motor control differences during voluntary pelvic floor muscle contractions.

Introduction and hypothesisTo compare maximum abdominal and pelvic floor muscle (PFM) electromyographic (EMG) and intravaginal pressure (IVP) amplitudes and muscle activation patterns during voluntary PFM contractions between women with and without stress urinary incontinence (SUI).MethodsTwenty-eight continent women and 44 women with SUI performed single and repeated PFM contractions in supine. Surface EMG data were recorded simultaneously with IVP. Maximum EMG and IVP amplitudes and ensemble average IVP versus EMG curves were determined from the single contractions. Muscle activation timing was determined with cross-correlation functions from the repeated contractions.ResultsThe continent group produced higher PFM EMG amplitudes than the SUI group; there were no between group differences in IVP. The women with SUI delayed activating rectus abdominus. The IVP versus EMG curves’ shapes were similar between the groups, however the SUI group had higher abdominal muscle y-intercepts than the continent women.ConclusionsThese findings suggest that women with SUI demonstrate altered motor control strategies during voluntary PFM contractions.

A Review of the Epidemiology and Pathophysiology of Pelvic Floor Dysfunction: Do Racial Differences Matter?

OBJECTIVE To describe the current state of knowledge regarding etiology of pelvic floor dysfunction with special consideration to the effect of racial background on the epidemiology and pathophysiology of this disease. METHODS We performed a nonsystematic review of the literature to detail the current knowledge of the etiology of pelvic floor dysfunction. Additionally, we performed a systematic search of MEDLINE, Cinahl, and the Cochrane database for English-language articles registered from January 1, 1989, to June 31, 2003, that evaluated racial differences in the epidemiology and pathophysiology of pelvic floor dysfunction. We also reviewed the references of identified articles. RESULTS We identified 11 articles that examined the effect of racial background on stress urinary incontinence (SUI), urodynamic stress incontinence, and (or) pelvic organ prolapse. We identified 2 studies that measured the prevalence of subjective stress urinary incontinence. Six cross-sectional studies compared the prevalence of urodynamically confirmed SUI and (or) pelvic organ prolapse among different groups. White women had a higher risk of developing urodynamic stress incontinence. Three studies noted anatomical and physiological differences among the different groups. CONCLUSIONS Both quantitative and qualitative defects in collagen (endopelvic fascia) and compromised levator ani muscle function have been identified as important etiologic factors in the development of pelvic floor dysfunction. Parity, vaginal delivery, menopause, and aging have been most clearly associated with collagen defects and levator ani muscle dysfunction. The literature suggests that white women are at increased risk for SUI. At present, there is insufficient evidence to draw any conclusions regarding the role of racial differences in pelvic organ prolapse. It is possible that differences in prevalence rates for both SUI and pelvic organ prolapse may be attributed to inherent anatomical and physiological differences among racial groups.

A new external urethral occlusive device for female urinary incontinence

Objective Determine the efficacy of a new external antiincontinence urethral device. Methods A before-after 1 month trial, open longitudinal study of 155 women complaining of urinary incontinence recruited from a referral urogynecology practice and local media advertising was performed. Primary outcomes included assessing the efficacy of the device using visual analogue scales, quality-of-life questionnaires, 1and 48hour standardized pad tests, and voiding diary. Secondary outcomes consisted of the evaluation of the adverse effects and the clinical profile of patients willing to use the device after study completion. Results Ninety-six (62%) of 155 women enrolled completed the study. Scores on the visual analogue scales improved for the symptoms of stress incontinence, urgency, and urge incontinence (P < .001). The score for irritation/discomfort increased (P < .001). Data from diaries showed that 38 (44%, n = 86) patients were dry. Of 454 recorded patient-days, 325 (72%) were dry days. On pad testing, incontinence was cured in 49% (1-hour pad test, n = 59, P < .001) and 44% (48-hour pad test, n = 32, P < .001) of patients. Quality-of-life scores were significantly improved in 48% (n = 96, Incontinence Impact Questionnaire, P < .001) and 32% (n = 96, Urogenital Distress Inventory, P < .001) of patients. There was no increase in bacteriuria. After study completion, 61 (39%) women chose to continue using the device, but this was not predictable from baseline data. Conclusion Use of this device resulted in a significant reduction in incontinence and improvement in quality-oflife issues with minimal adverse events in the majority of women. This new anti-incontinence device could become a useful addition to the armamentarium of nonsurgical options.

Pelvic Floor Muscle Training in Women With Stress Urinary Incontinence Causes Hypertrophy of the Urethral Sphincters and Reduces Bladder Neck Mobility During Coughing

The purpose of this study was to determine the effect of a 12‐week pelvic floor muscle (PFM) training program on urethral morphology and mobility in women with stress urinary incontinence (SUI).

Technical Update on Pessary Use

OBJECTIVE To review the use, care, and fitting of pessaries. OPTIONS Pessaries are an option for women presenting with prolapse and/or urinary incontinence. OUTCOMES Pessaries can be successfully fitted in the majority of women with excellent satisfaction rates and minimal complications. EVIDENCE PubMed and Medline were searched for articles published in English to September 2010, using the key words pessary, prolapse, incontinence, fitting, and complications. Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis, and articles were incorporated in the guideline to May 2012. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force (Table 1). BENEFITS, HARMS, AND COSTS Women may choose a pessary for management of their prolapse and/or stress incontinence rather than opt for surgery. Major complications have been seen only with neglected pessaries. Minor complications such as vaginal discharge, odour, and erosions can usually be successfully treated. SUMMARY STATEMENTS AND RECOMMENDATION: Summary Statements 1. Most women can be successfully fitted with a pessary when they present with prolapse. (II-2) 2. Complications of pessary use are usually minor, and vaginal discharge is the most common complaint. (II-3) 3. Vaginal erosions can be treated with removal of the pessary and optional vaginal estrogen supplementation. (II-2) 4. Satisfaction rates with pessary use are very high. (II-2) Recommendation 1. Pessaries should be considered in all women presenting with symptomatic prolapse and/or urinary stress incontinence. (II-1A).

Women with stress urinary incontinence demonstrate motor control differences during coughing

INTRODUCTION This study compared the patterns of pelvic floor muscle (PFM) activity during coughing between women with stress urinary incontinence (SUI) and continent women, using surface electromyography (EMG) and posterior vaginal wall (PVW) pressure. METHODS Twenty-four women participated: eight continent, eight with mild SUI and eight with severe SUI. Volunteers performed three maximum coughs in supine and standing. Maximum PFM EMG and PVW pressure amplitudes and the timing of the EMG peak relative to the PVW pressure peak were determined. Ensemble average PVW pressure versus EMG curves were created. RESULTS There were no significant differences among the groups in the maximum EMG or PVW pressure amplitudes. The EMG and PVW pressure peaked simultaneously in both positions in the continent group. In the mild SUI group, the EMG and PVW pressure peaked simultaneously in supine, but the EMG peaked before the PVW pressure in standing. In the severe SUI group, the EMG peaked before the PVW pressure in both positions. The shapes of the PVW pressure versus EMG curves were similar among the groups and positions, however the SUI groups displayed higher EMG-intercepts than the continent women. CONCLUSION These findings suggest that urine leakage during coughing in women with SUI may be related to delays in force generation rather than PFM weakness.

Ethical Issues Associated With the Introduction of New Surgical Devices, or Just Because We Can, Doesn’t Mean We Should

Surgical devices are often marketed before there is good evidence of their safety and effectiveness. Our paper discusses the ethical issues associated with the early marketing and use of new surgical devices from the perspectives of the six groups most concerned. Health Canada, which is responsible for licensing new surgical devices, should amend their requirements to include rigorous clinical trials that provide data on effectiveness and safety for each new product before it is marketed. Industry should comply with all Health Canada requirements to obtain licenses for new products. Until Health Canada requires effectiveness and safety data, industry should cooperate with physicians in appropriate studies before releasing new products and should make balanced presentations of all the available evidence. Surgeons should, before using a new surgical device, assess the evidence on its effectiveness and safety and ensure they are properly trained and competent in using the device. Surgeons should provide their patients with an evaluation of the available evidence and inform them about possible complications and the surgeons level of experience with the new device. Patients, who should be given an honest evaluation of the available evidence, possible complications, and the surgeons experience, should be encouraged to evaluate the evidence and information to their own satisfaction to ensure that fully informed consent is given. Health institutions, responsible for regulating practice within their walls, should review new devices for safety, effectiveness, and economic impacts, before allowing their use. They should also limit the use of new surgical devices to surgeons trained and competent in the new technology. Professional societies should provide guidance on the early adoption of new surgical devices and technologies. We urge all those involved in the development, licensing, and use of new surgical devices to aim for higher ethical standards to protect the health and safety of patients requiring surgery. The lowest acceptable ethical standard would require device manufacturers to provide surgeons with accurate and timely information on the efficacy and safety of their products, allowing surgeons and patients to evaluate the evidence (and the significance of information not yet available) before surgery.