Maurizio Serati

Female Sexual Function during Pregnancy and after Childbirth

INTRODUCTION Healthy sexual function during pregnancy and after childbirth is one of the cornerstones for couples to evolve from partners to parents. AIM The aim of our review is to evaluate the available evidence and define present knowledge about female sexual function during pregnancy and after childbirth. METHODS PubMed was searched for articles on sexual function during pregnancy and after childbirth, published from 1960 up to date. The most relevant articles have been reviewed and included. MAIN OUTCOME MEASURES The main outcome is the review of the effect of pregnancy, delivery, and postpartum on female sexuality. RESULTS A total of 48 articles which specifically addressed this topic were included. Sexual function was found to have a significant global decline during pregnancy, particularly in the third trimester and this persisted for 3-6 months following delivery. The lack of adequate information about sex in pregnancy and concerns about the possible adverse obstetric outcomes are the most relevant factors responsible for the avoidance of sexual activity during pregnancy. Breast-feeding, dyspareunia, and postpartum pelvic floor dysfunction were reported as possible causes for the delay in resuming sexual intercourses after childbirth. CONCLUSIONS Couples should be informed about the decline of libido, desire and orgasm, commonly encountered during pregnancy, particularly in the last trimester, and puerperium which may lead to reduction in sexual intercourse frequency.

Tension-free Vaginal Tape for the Treatment of Urodynamic Stress Incontinence: Efficacy and Adverse Effects at 10-Year Follow-Up

BACKGROUND One of the most effective and popular current procedures for the surgical treatment of stress urinary incontinence (SUI) is tension-free midurethral slings. OBJECTIVE To evaluate the outcomes of women with retropubic tension-free vaginal tape (TVT) for urodynamic stress incontinence (USI) after 10-yr follow-up. DESIGN, SETTING, AND PARTICIPANTS This was a prospective observational study. Consecutive women with proven USI were treated with TVT. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded. INTERVENTION Standard retropubic TVT. MEASUREMENTS Patients underwent preoperative clinical and urodynamic evaluations. During follow-up examinations, women were assessed for subjective satisfaction and objective cure rates. Multivariable analyses were performed to investigate outcomes. RESULTS AND LIMITATIONS A total of 63 women were included. After 10 yr, 5 patients (8%) were lost or no longer evaluable. The 10-yr subjective, objective, and urodynamic cure rates were 89.7%, 93.1%, and 91.4%, respectively. These rates were stable across the whole study period (p>0.99). De novo overactive bladder was reported by 30.1% and 18.9% of patients at 3-mo and 10-yr follow-up, respectively (p for trend = 0.19). A total of 84.2% of women with detrusor overactivity received antimuscarinic drugs, but 43.8% were nonresponders 12 wk later. At multivariable analysis, maximum detrusor pressure during the filling phase >9cm H(2)O (hazard ratio [HR]: 16.2; p=0.01) and maximum detrusor pressure during the voiding phase ≤29cm H(2)O (HR: 8.0; p=0.01) were independent predictors for the recurrence of SUI, as well as obesity was for the recurrence of objective SUI (HR: 17.1; p=0.01) and of USI (HR: 8.9; p=0.02), respectively. Intraoperatively, bladder perforation occurred in two cases; no severe bleeding or other complications occurred. CONCLUSIONS The 10-yr results of this study seem to demonstrate that TVT is a highly effective option for the treatment of female SUI, recording a very high cure rate with low complications after a 10-yr follow-up.

Female Urinary Incontinence During Intercourse: A Review on an Understudied Problem for Women's Sexuality

INTRODUCTION Coital urinary incontinence is a frequently underreported symptom, with a relevant impact on womens sexuality and quality of life. AIM This article will review the available evidence on incidence, pathophysiology, and treatment of coital urinary incontinence with the attempt to present the current state of the art. METHODS PubMed was searched for reports about coital urinary incontinence that were published from 1970 to 2008, and the most relevant articles were reviewed. MAIN OUTCOME MEASURES Review on epidemiology, pathophysiology, diagnosis, and treatment of coital incontinence. RESULTS The incidence of coital incontinence in incontinent women has been reported to range between 10% and 27%. At present, some evidence suggests an association between urinary leakage at penetration and urodynamic stress (USI) incontinence as well as urinary leakage during orgasm and detrusor overactivity (DO). When treatment for these conditions are based upon urodynamic findings, pelvic floor muscle training, surgery, and pharmacotherapy show satisfactory cure rates. CONCLUSIONS Coital urinary incontinence deserves much more attention in clinical practice: women should be specifically interviewed for this disturbance because it has a very negative impact on their sexuality. If a reliable urodynamic diagnosis is made, coital urinary incontinence at penetration can be cured in more than 80% of cases by surgery in the presence of USI. The form of coital incontinence during orgasm is curable by antimuscarinic treatment in about 60% of cases when associated with DO.

Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature

OBJECTIVE To determine the incidence of vaginal cuff dehiscence after minimally invasive hysterectomy, we reported our series of total laparoscopic hysterectomies with transvaginal colporraphy. STUDY DESIGN We then conducted a systematic search of PubMed to retrieve published series of laparoscopic and robotic hysterectomies, in which different techniques for vaginal cuff closure were used. RESULTS In our study group, vaginal cuff dehiscence occurred in 2 of 665 (0.3%) patients. Our literature search identified 57 articles, for a total of 13,030 endoscopic hysterectomies. Ninety-one postoperative vaginal separations were reported (0.66%). The pooled incidence of vaginal dehiscence was lower for transvaginal cuff closure (0.18%) than for both laparoscopic (0.64%; odds ratio [OR], 0.28; 95% confidence interval [CI], 0.12-0.65) and robotic (1.64%; OR, 0.11; 95% CI, 0.04-0.26) colporraphy. Laparoscopic cuff closure was associated with a lower risk of dehiscence than robotic closure (OR, 0.38; 95% CI, 0.28-0.6). CONCLUSION Current evidence indicates that transvaginal colporraphy after total laparoscopic hysterectomy is associated with a 3- and 9-fold reduction in risk of vaginal cuff dehiscence compared with laparoscopic and robotic suture, respectively.

Urinary tract infections in women

Urinary tract infections (UTIs) are conditions frequently complained by women both in the general population and in the hospital setting. Indeed it has been estimated that one woman out of three will experience at least an episode of UTI during lifetime. A comprehensive literature review of published experimental and clinical studies of UTI was carried out at the University of Insubria electronic library (SFX Bicocca-Insubria) with cross-search of seven different medical databases (AMED, BIOSIS Previews on Web of Knowledge, Cochrane Library, Embase and Medline on Web of Knowledge, OvidSP and PubMed). We aimed to draw a clinical guideline addressed to the management of UTI, based on the most recent evidence.

Robot-assisted Sacrocolpopexy for Pelvic Organ Prolapse: A Systematic Review and Meta-analysis of Comparative Studies

CONTEXT Surgery represents the mainstay of treatment for pelvic organ prolapse (POP). Among different surgical procedures, abdominal sacrocolpopexy (SC) is the gold standard for apical or multicompartmental POP. Research has recently focused on the role of robot-assisted sacrocolpopexy (RASC). OBJECTIVE To conduct a systematic review on the outcomes of RASC. EVIDENCE ACQUISITION PubMed, Scopus, and Web of Science databases as well as ClinicalTrials.gov were searched for English-language literature on RASC. A total of 509 articles were screened; 50 (10%) were selected, and 27 (5%) were included. Studies were evaluated per the Grading of Recommendations, Assessment, Development, and Evaluation system and the European Association of Urology guidelines. EVIDENCE SYNTHESIS Overall, data on 1488 RASCs were collected from 27 studies, published from 2006 to 2013. Objective and subjective cures ranged from 84% to 100% and from 92% to 95%, respectively. Conversion rate to open surgery was <1% (range: 0-5%). Intraoperative, severe postoperative complications, and mesh erosion rates were 3% (range: 0-19%), 2% (range: 0-8%), and 2% (range: 0-8%), respectively. Surgical-related outcomes have improved with increased experience, with an estimated learning curve of about 10-20 procedures. Laparoscopic SC is less costly than RASC, although the latter has lower costs than abdominal SC. CONCLUSIONS RASC is a safe and feasible procedure for POP; it allows the execution of complex surgical steps via minimally invasive surgery without medium- and long-term anatomic detriments. Further prospective studies are needed to confirm these findings. PATIENT SUMMARY We looked at the outcomes of robotic sacrocolpopexy for prolapse. We found that the use of robotic technology is safe and effective for the treatment of prolapse in women.

Identification of risk factors for genital prolapse recurrence.

To assess the relationship between prolapse recurrence and some risk factors in a group of women submitted to reconstructive pelvic surgery.

Prospective study to assess risk factors for pelvic floor dysfunction after delivery

Background. To identify obstetric risk factors for de novo pelvic floor disorders after vaginal delivery. Methods. Antenatally asymptomatic women who delivered vaginally were interviewed on urinary, anal and sexual disorders antenatally, 6 and 12 months postpartum. Results. Of 967 women, 336 were included for final analysis. Urinary symptoms occurred in 27 and 23% of women at 6 and 12 months postpartum: univariate analysis showed a significant relation to the use of epidural analgesia (p =0.04) and to a second stage of labour >1 h (p =0.02), the latter was confirmed significant by multivariate analysis. Anal incontinence occurred in 7.1 and 6.8% of women at 6 and 12 months postpartum, respectively. Dyspareunia was reported by 24% at 6 months, decreasing to 8% at 12 months (p <0.0001). Conclusions. Our study shows that a second stage longer than 1 h is associated with the development of postpartum urinary incontinence. Except for dyspareunia, pelvic floor dysfunction rarely resolves spontaneously.

Microscopic and ultrastructural modifications of postmenopausal atrophic vaginal mucosa after fractional carbon dioxide laser treatment

Vaginal atrophy occurring during menopause is closely related to the dramatic decrease in ovarian estrogens due to the loss of follicular activity. Particularly, significant changes occur in the structure of the vaginal mucosa, with consequent impairment of many physiological functions. In this study, carried out on bioptic vaginal mucosa samples from postmenopausal, nonestrogenized women, we present microscopic and ultrastructural modifications of vaginal mucosa following fractional carbon dioxide (CO2) laser treatment. We observed the restoration of the vaginal thick squamous stratified epithelium with a significant storage of glycogen in the epithelial cells and a high degree of glycogen-rich shedding cells at the epithelial surface. Moreover, in the connective tissue constituting the lamina propria, active fibroblasts synthesized new components of the extracellular matrix including collagen and ground substance (extrafibrillar matrix) molecules. Differently from atrophic mucosa, newly-formed papillae of connective tissue indented in the epithelium and typical blood capillaries penetrating inside the papillae, were also observed. Our morphological findings support the effectiveness of fractional CO2 laser application for the restoration of vaginal mucosa structure and related physiological trophism. These findings clearly coupled with striking clinical relief from symptoms suffered by the patients before treatment.

Surgical treatment for female stress urinary incontinence: what is the gold-standard procedure?

In the last few years, the Burch colposuspension and the fascial slings were often defined from the pages of the most relevant journals of general medicine, as gold-standard procedures for the surgical treatment of stress urinary incontinence (SUI), whereas mid-urethral slings (tension-free vaginal tape (TVT) and tension-free vaginal tape obturator) were attributed a marginal and almost experimental role in this field. This poorly reflect the current scenario of the surgical management of SUI: Recently, a number of meta-analysis have demonstrated that TVT is significantly more effective if compared to colposuspension and that it is followed by significantly lower perioperative morbidity if compared to pubovaginal slings. It is not realistic to suggest to general practitioners that the surgical gold standard for SUI includes the performance of a wide laparotomy, long hospital stays and a high risk of long-lasting intermittent self-catheterisation. This would inevitably discourage women from embarking on surgical treatment, which instead could actually improve their quality of life.