Marielle M. E. Lakeman

A Randomized, Controlled Trial Comparing an Innovative Single Incision Sling With an Established Transobturator Sling to Treat Female Stress Urinary Incontinence

PURPOSE Mid urethral sling procedures have become the surgical treatment of choice for female stress urinary incontinence. Innovative modifications of mid urethral sling procedures were recently introduced with the claim of offering similar efficacy and decreased morbidity. We compared the efficacy and morbidity of an innovative single incision mid urethral tape and an established transobturator procedure. MATERIALS AND METHODS We performed a prospective, randomized, controlled trial in 6 teaching hospitals in Belgium and The Netherlands between 2007 and 2009. A total of 96 patients received a TVT Secur™ single incision sling and 98 received a TVT™ Obturator System. We collected data on patient characteristics, surgery related parameters, adverse events, clinical followup, Urogenital Distress Inventory and SF-36® scores, validated questionnaires on daily life activities and visual analog scores objectifying pain. Followup was 1 year. RESULTS One-year followup was available for 75 single incision sling and 85 obturator system cases. Stress urinary incontinence could be objectified in 16.4% of the patients with a single incision sling and in 2.4% with an obturator system (p <0.05). Stress urinary incontinence was subjectively reported by 24% of single incision sling and 8% of obturator system patients (p <0.05). One year after surgery the mean ± SD UDI incontinence domain score in the single incision sling and obturator system groups was 21 ± 24 and 13 ± 21, respectively (p <0.01). Patients with a single incision sling experienced significantly less pain during the first 2 weeks after surgery (p <0.05) and returned significantly earlier to normal daily activity. The OR of re-intervention for stress urinary incontinence 1 year after receiving a single incision sling vs an obturator system was 2.3 (95% CI 1.9-2.7). CONCLUSIONS The single incision sling procedure is associated with less postoperative pain and a lower objective cure rate than the obturator system procedure.

Predictors of Task-Persistent and Fear-Avoiding Behaviors in Women with Sexual Pain Disorders

INTRODUCTION Dyspareunia and vaginismus are the most common sexual pain disorders (SPDs). Literature suggests that many women with dyspareunia continue with intercourse despite pain (task persistence), whereas many women with vaginismus avoid penetrative activities that may cause pain (fear avoidance). Both forms of sexual pain behavior may maintain or aggravate complaints. AIM This study examined (i) whether women with SPD differ from pain-free controls in motives for sexual intercourse, sexual autonomy, maladaptive beliefs regarding vaginal penetration, and partner responses to pain; and (ii) which of these factors best predict whether women with SPD stop or continue painful intercourse (attempts). METHODS Women with superficial dyspareunia (n = 50), women with lifelong vaginismus (n = 20), and pain-free controls (n = 45) completed questionnaires. MAIN OUTCOME MEASURES For Aim 1, the main outcome measures were (i) motives for intercourse; (ii) sexual autonomy; (iii) maladaptive beliefs regarding vaginal penetration; and (iv) partner responses to pain. For Aim 2, sexual pain behavior (to continue or discontinue with painful intercourse) was the outcome measure. RESULTS (i) Women with dyspareunia exhibited more mate guarding and duty/pressure motives for intercourse and were less sexually autonomous than controls. (ii) Symptomatic women had more maladaptive penetration-related beliefs than controls, with women with vaginismus reporting the strongest maladaptive beliefs. (iii) Partners of women with dyspareunia self-reported more negative responses to pain than those of women with vaginismus. (iv) The factors that best predicted sexual pain behavior were the partner responses to pain and the womans maladaptive beliefs regarding vaginal penetration. CONCLUSIONS Our findings reveal support for task persistence in women with dyspareunia and fear avoidance in women with lifelong vaginismus. As such, it is important to consider these distinct types of responding to sexual pain when treating SPD.

Hysterectomy and Lower Urinary Tract Symptoms: A Nonrandomized Comparison of Vaginal and Abdominal Hysterectomy

Background/Aims: It has been reported that lower urinary tract symptoms (LUTS) are more prevalent in patients who have undergone hysterectomy. However, the effects of surgical approach of hysterectomy on micturition have not been well documented. The aim of this study is to compare LUTS between patients who underwent vaginal and abdominal hysterectomy. Methods: Prospective observational study among 430 patients undergoing vaginal or abdominal hysterectomy for benign disease other than genital prolapse. Participating patients completed a validated disease-specific questionnaire before surgery, 6 months and 3 years after surgery. Results: 112 women underwent vaginal hysterectomy and 318 abdominal hysterectomy. After correction for differences in uterine size, descent of the uterus and other differences, LUTS were more common at 3 years after surgery following vaginal than following abdominal hysterectomy (OR 2.2, 95% CI 1.3–4.0). After adjustment for descent of the uterus, uteral size, parity and indication for hysterectomy, this difference was still statistical significant (adjusted OR 3.0, 95% CI 1.4–6.2). Conclusion: As compared to abdominal hysterectomy, LUTS appear to be more common following vaginal hysterectomy.

Electrosurgical Bipolar Vessel Sealing Versus Conventional Clamping and Suturing for Total Abdominal Hysterectomy: A Randomized Trial

STUDY OBJECTIVE To compare the effects of bipolar vessel sealing versus conventional clamping and suturing in women undergoing total abdominal hysterectomy. DESIGN A randomized controlled trial was performed. Patients were randomized to vessel sealing or conventional surgery. Postoperative pain was the primary outcome. An intention-to-treat analysis was performed (Canadian Task Force classification I). SETTING Two Dutch teaching hospitals. PATIENTS A total of 57 women undergoing abdominal hysterectomy for benign conditions. MEASUREMENTS AND MAIN RESULTS During the first 3 postoperative days, patients operated on using vessel sealing had statistically significantly lower pain scores. The amount of blood loss, surgery time, complication risk, and duration of hospitalization were similar between both groups. Patients in the vessel-sealing group resumed their normal daily activities on average 8 days earlier as compared with the conventional group. Postoperative pelvic floor function was similar in both groups. CONCLUSION The use of vessel sealing during abdominal hysterectomy for benign conditions appears to be associated with reduced postoperative pain and faster recovery.

The effects of prolapse surgery on vaginal wall sensibility, vaginal vasocongestion, and sexual function: A prospective single centre study

Prolapse surgery has been shown to positively alter body image and decrease pelvic floor symptoms, hereby possibly improving sexual function. However, the surgical trauma itself may adversely affect sexual function, by damaging vaginal innervation and vascularization. The aim of this study is to evaluate the effects of vaginal prolapse surgery on vaginal vasocongestion, vaginal wall sensibility, and sexual function.

The Effect of Prolapse Surgery on Vaginal Sensibility

INTRODUCTION Prolapse surgery has been shown to have major impact on sexual function. Since prolapse surgery not only influences psychological factors but might also influence physiological conditions such as vaginal innervation, there is a need for objective outcome measurements to better understand the effects of prolapse surgery on sexual function. AIMS To assess the effects of prolapse surgery with or without stress incontinence surgery on vaginal sensibility and to assess the relationship between vaginal wall sensibility and sexual well-being. METHODS This study was performed parallel to a randomized controlled trial comparing vaginal and abdominal prolapse surgery with or without incontinence surgery in women with uterine prolapse stage 2 or more. MAIN OUTCOME MEASURES Vaginal wall sensibility was defined as mean sensation threshold to electrical stimulation of the vaginal wall at four standardized places, measured before and 6 months after surgery. Higher sensation thresholds postsurgery relative to presurgery indicate diminished vaginal wall sensibility. Sexual function was assessed at the same time points using a questionnaire. RESULTS Data on vaginal wall sensibility were obtained from 65 patients. The sensibility of the distal posterior (P = 0.02) and distal anterior (P = 0.10) vaginal wall decreased after vaginal surgery compared to abdominal surgery. Abdominal prolapse surgery with incontinence surgery decreased sensibility of the distal part of the anterior vaginal wall significantly more than abdominal prolapse surgery only (P = 0.01). Before surgery, vaginal wall sensibility was lower in women who reported vaginal dryness or anorgasmia. The presence of genital pain was associated with higher vaginal wall sensibility. Postoperative vaginal wall sensibility was similar in women with and without sexual problems. CONCLUSION Vaginal prolapse surgery as well as abdominal prolapse surgery with additional incontinence surgery resulted in decreased vaginal wall sensibility. This pilot study shows no influence of the decreased vaginal wall sensibility on sexual well-being. Larger studies are needed to better understand the association between changes in vaginal wall sensibility and changes in sexual well-being.

Predicting the development of stress urinary incontinence 3 years after hysterectomy

Introduction and hypothesisWe aimed to develop a prediction rule to predict the individual risk to develop stress urinary incontinence (SUI) after hysterectomy.MethodsProspective observational study with 3-year follow-up among women who underwent abdominal or vaginal hysterectomy for benign conditions, excluding vaginal prolapse, and who did not report SUI before surgery (n = 183). The presence of SUI was assessed using a validated questionnaire.ResultsSignificant prognostic factors for de novo SUI were BMI (OR 1.1 per kg/m2, 95% CI 1.0–1.2), younger age at time of hysterectomy (OR 0.9 per year, 95% CI 0.8–1.0) and vaginal hysterectomy (OR 2.3, 95% CI 1.0–5.2). Using these variables, we developed the following rule to predict the risk of developing SUI: 32 + BMI − age + (7.5 × route of surgery).ConclusionsWe defined a prediction rule that can be used to counsel patients about their individual risk on developing SUI following hysterectomy.

A long-term prospective study to compare the effects of vaginal and abdominal hysterectomy on micturition and defecation

Please cite this paper as: Lakeman M, van der Vaart C, Roovers J. A long‐term prospective study to compare the effects of vaginal and abdominal hysterectomy on micturition and defecation. BJOG 2011;118:1511–1517.

The Effects of Vaginal Prolapse Surgery Using Synthetic Mesh on Vaginal Wall Sensibility, Vaginal Vasocongestion, and Sexual Function: A Prospective Single‐Center Study

INTRODUCTION Vaginal mesh surgery in patients with pelvic organ prolapse (POP) has been associated with sexual dysfunction. Implantation of synthetic mesh might damage vaginal innervation and vascularization, which could cause sexual dysfunction. AIM We aim to evaluate the effects of vaginal mesh surgery on vaginal vasocongestion and vaginal wall sensibility in patients with recurrent POP. METHODS A prospective study was performed among patients with previous native tissue repair, scheduled for vaginal mesh surgery. Measurements were performed before and 6 months after surgery, during nonerotic and erotic visual stimuli, using a validated vaginal combi-probe. MAIN OUTCOME MEASURES The combi-probe involves vaginal photoplethysmography to assess Vaginal Pulse Amplitude (VPA) (representing vaginal vasocongestion) and four pulse-generating electrodes to measure vaginal wall sensibility (representing vaginal innervation). Sexual function was assessed using validated questionnaires (Female Sexual Function Index, Female Sexual Distress Scale-Revised, and Subjective sexual arousal and affect questionnaire). RESULTS Sixteen women were included, 14 completed the 6-month follow-up visit. Vaginal vasocongestion under erotic conditions did not significantly alter after mesh implantation. Vaginal wall sensibility of the distal posterior wall was significantly increased after mesh surgery (preoperative threshold 6.3 mA vs. postoperative 3.4 mA, P = 0.03). Sexual function as assessed with questionnaires was not significantly affected. CONCLUSIONS In women with a history of vaginal prolapse surgery, vaginal mesh surgery did not decrease vaginal vasocongestion or vaginal wall sensibility. Vaginal vasocongestion prior to mesh surgery appeared to be lower than that of women never operated on. Apparently, native tissue repair decreased preoperative vaginal vasocongestion levels to such extent that subsequent mesh surgery had no additional detrimental effect. Our findings should be interpreted cautiously. Replication of the findings in future studies is essential.

Urinary tract infections in women with urogynaecological symptoms.

Purpose of review Urinary tract infections are common in the field of urogynaecology. Women with persistent urinary symptoms seem more likely to have bacteriuria despite negative cultures. In this review, we will give an overview of the recent insights on the relationship between urinary tract infection and persistent urinary symptoms and possible new therapeutic options. Recent findings Recently published articles evaluated the prevalence of low-count bacteriuria (≥103 CFU/ml) or intracellular bacterial communities in women with overactive bladder symptoms (OAB). Differences in urinary microbioma observed in women with and without OAB symptoms were evaluated. In the light of these findings, current screening strategies were discussed and alternative screening methods for bacteriuria developed. Summary Low-count bacteriuria (≥103 CFU/ml) seems to be more prevalent in women with OAB. Also intracellular bacterial communities are more commonly detected in these women. The microbioma found in women with urinary symptoms appeared to differ from healthy controls. The current screening methods might be insufficient as they are targeted at detecting uropathogenic Escherichia coli, mostly using a detection threshold of at least 105 CFU/ml and failing to detect intracellular bacterial communities. Studies evaluating the efficacy of treating women with low-count bacteriuria are limited but promising.