Paul A. Moran

Urinary leakage during coitus in women

During a 4-year period from 1993 to 1997, a total of 2153 women were referred to our urogynaecology clinic complaining of urinary incontinence. Of these women, 228 (10.6%) admitted to coital incontinence. Only 22 of these 228 women complained of this symptom without direct questioning. Urine loss occurred during penetration in 158 women, during orgasm in 45 women and during both in 25 women. Comparison of these groups showed few other differences in their presenting symptoms, examination findings, urodynamic data or diagnosis. Genuine stress incontinence was present in 79.8% of women with urinary leakage during penetration, in 93.2% with leak on orgasm and in 92.0% who leaked on both. Detrusor instability was uncommon. In most women who complain of urinary leakage during sexual intercourse, the underlying pathophysiological mechanism is urethral sphincter incompetence. Compared with women presenting with urinary incontinence in the absence of coital incontinence, women with coital leakage had a higher incidence of stress and urge incontinence, and a significantly greater incidence of anterior vaginal wall prolapse and demonstrable stress incontinence on examination.

The UK national prolapse survey: 5 years on

Introduction and hypothesisTo assess trends in the surgical management of pelvic organ prolapse (POP) amongst UK practitioners and changes in practice since a previous similar survey.MethodsAn online questionnaire survey (Typeform Pro) was emailed to British Society of Urogynaecology (BSUG) members. They included urogynaecologists working in tertiary centres, gynaecologists with a designated special interest in urogynaecology and general gynaecologists. The questionnaire included case scenarios encompassing contentious issues in the surgical management of POP and was a revised version of the questionnaire used in the previous surveys. The revised questionnaire included additional questions relating to the use of vaginal mesh and laparoscopic urogynaecology procedures.ResultsOf 516 BSUG members emailed, 212 provided completed responses.. For anterior vaginal wall prolapse the procedure of choice was anterior colporrhaphy (92% of respondents). For uterovaginal prolapse the procedure of choice was still vaginal hysterectomy and repair (75%). For posterior vaginal wall prolapse the procedure of choice was posterior colporrhaphy with midline fascial plication (97%). For vault prolapse the procedure of choice was sacrocolpopexy (54%) followed by vaginal wall repair and sacrospinous fixation (41%). The laparoscopic route was preferred for sacrocolpopexy (62% versus 38% for the open procedure). For primary prolapse, vaginal mesh was used by only 1% of respondents in the anterior compartment and by 3% in the posterior compartment.ConclusionBasic trends in the use of native tissue prolapse surgery remain unchanged. There has been a significant decrease in the use of vaginal mesh for both primary and recurrent prolapse, with increasing use of laparoscopic procedures for prolapse.

Laparoscopic versus open Burch colposuspension : a randomised controlled trial

Objective  To compare perioperative characteristics, short‐term, and long‐term outcomes for laparoscopic Burch colposuspension (LBC) and open Burch colposuspension (OBC) for the treatment of urinary stress incontinence.

An International Urogynecological Association (IUGA) / International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP)

The terminology for female pelvic floor prolapse (POP) should be defined and organized in a clinically‐based consensus Report.

Oral Methotrexate in the Management of Refractory Interstitial Cystitis

Summary: To establish the safety and efficacy of low‐dose oral methotrexate in treating refractory interstitial cystitis, 9 women who fulfilled internationally accepted criteria for the diagnosis of interstitial cystitis were enrolled in a prospective study. All had proven unresponsive to conventional treatment modalities. Assessment by pain score and frequency volume charts was performed pretreatment and up to 6 months during therapy. No significant adverse side effects were noted. At the end of follow‐up, 4 women had noted a subjective improvement in bladder pain and wished to continue on methotrexate, 4 women noted little change and 1 woman reported a worsening of symptoms. Overall there was a significant reduction in pain score (p = 0.047) posttreatment. However, there was no significant difference in urinary frequency per 24 hours (p = 0.40), maximum voided volume (p = 0.089) or mean voided volume (p = 0.59). Methotrexate significantly improved bladder pain in women with interstitial cystitis, although no significant change was found in voiding pattern.

Colposuspension or sling for low urethral pressure stress incontinence

Abstract: The aim of this study was to compare Burch colposuspension with the pubovaginal sling in the management of low urethral pressure urinary stress incontinence. Forty-five women with low urethral pressure stress incontinence were retrospectively reviewed: 21 underwent colposuspension and 24 a pubovaginal sling. The subjective success rate of the Burch colposuspension and the pubovaginal sling was 90% and 71% (P= 0.12), respectively; the objective success rate was 67% and 50% (P= 0.26), respectively. The incidence of postoperative complications, including de novo detrusor instability and symptomatic voiding dysfunction following the colposuspension, was 5% compared to 25% following the pubovaginal sling (P= 0.06). Colposuspension should be considered in the management of women undergoing surgical correction of low urethral pressure stress incontinence. In a clinically similar group of women, the Burch colposuspension had a superior subjective and objective success rate with a lower incidence of complications than did the pubovaginal sling. Although these differences failed to reach statistical significance, colposuspension can be safely considered in the management of women with low urethral pressure GSI.

Randomized Trial of Tension-Free Vaginal Tape and Tension-Free Vaginal Tape-Obturator for Urodynamic Stress Incontinence in Women

PURPOSE We compared the efficacy and complications of tension-free vaginal tape and tension-free vaginal tape-obturator. MATERIALS AND METHODS Women with pure urodynamic stress incontinence undergoing only primary continence surgery were randomized to tension-free vaginal tape or tension-free vaginal tape-obturator at 2 centers between March 2005 and March 2007. Primary outcome was objective cure rate at 6 months, defined by a 24-hour pad test of less than 5 gm. Secondary outcomes were the subjective cure rate on the Patient Global Impression of Improvement, quality of life on the Kings Healthcare Questionnaire and symptom severity scores on the International Consultation on Incontinence Questionnaire. RESULTS A total of 127 women were recruited. The study was stopped early due to excess leg pain in the tension-free vaginal tape-obturator group. Of the women 66 were randomized to tension-free vaginal tape and 61 were randomized to tension-free vaginal tape-obturator. Analysis was done by intent to treat. The objective and subjective cure rate at 6 months for tension-free vaginal tape vs tension-free vaginal tape-obturator was 69.7% vs 72.1% and 72.7% vs 67.2% (p = 0.76 and 0.49, respectively). Cure rates at 1 year were similar but loss to followup was high. Objective and subjective cure rates at 1 year for tension-free vaginal tape vs tension-free vaginal tape-obturator were 50% vs 41% and 53% vs 42.6% (p = 0.31 and 0.24, respectively). More women complained of leg pain after receiving a tension-free vaginal tape-obturator (26.4% vs 1.7%, p = 0.0001). The incidence of perioperative complications was low and similar between the groups. Time to discharge home and time to normal activity were not significantly different. CONCLUSIONS Short-term cure rates at 6 months were similar. Tension-free vaginal tape-obturator caused more transient leg pain. Each procedure achieved a high cure rate and a low complication rate.

Urethral Diverticula in Pregnancy

Summary: In 4 cases, the clinical presentation of urethral diverticulum (UD) during pregnancy was a paraurethral mass (3), urinary incontinence (2), irritative symptoms (2), urinary tract infection (1), urethral pain and discharge (1) and voiding difficulty (1). The diagnosis of UD during pregnancy was made by trans vaginal ultrasonography (2), cystoscopy (1), and after pregnancy by a voiding cystourethrogram (1). Management during pregnancy involved antibiotics (2), diverticulum aspiration (2) and incision and drainage (1). Delivery was by the vaginal route in 2 women with diverticular aspiration being performed during the second stage to aid delivery in 1 woman. Caesarean section was performed in the other 2 women for reasons unrelated to the presence of the UD. Three women had diverticulectomy performed following pregnancy for persisting symptoms. Although uncommon, it is important to diagnose urethral diverticula given the associated morbidity and the potential for causing complications during pregnancy.

Transvaginal placement of surgical mesh for pelvic organ prolapse: more FDA concerns—positive reactions are possible

Recently (July 13, 2011), the United States Food and Drug Administration (FDA) issued a document entitled “FDA Safety Communication: UPDATE on Serious Complications Associated with Transvaginal Placement of Surgical Mesh for Pelvic Organ Prolapse” [1]. This was stated as an update of a previous document issued on October 20, 2008, entitled “A Public Health Notification and Additional Patient Information on serious complications associated with surgical mesh placed through the vagina (transvaginal placement) to treat pelvic organ prolapse (POP) and SUI (stress urinary incontinence)”. Accompanying the recent FDA concerns was a 15-page document entitled “Urogynecologic Surgical Mesh: Update on the Safety and Effectiveness of Transvaginal Placement for Pelvic Organ Prolapse” which has a literature review identifying 27 key references [2]. The FDA’s aims in this update are to inform that: (1) “serious complications with surgical mesh for transvaginal repair of POP are not rare” (a change from the previous FDA notification) and (2) “it is not clear that transvaginal POP repair with mesh is more effective than traditional non-mesh repair in all patients with POP and it may expose patients to greater risk”. From January 1, 2008 through December 31, 2010, using the Manufacturer and User Device Experience (MAUDE) database, the FDA received 2,874 additional reports of complications associated with surgical mesh devices used to repair POP and SUI, with 1,503 reports associated with POP repairs and 1,371 associated with SUI repairs. The scope of the current safety communication was limited to POP surgery. The FDA noted mesh exposure (“erosion”) as the most common mesh-related complication and with mesh shrinkage (“contraction”), the leading cause of symptoms including bleeding, pelvic pain, dyspareunia, or apareunia. The results of the literature review [2], summarized in the FDA Safety Communication [1], were: (1) mesh used in transvaginal POP repair introduces risks not present in traditional non‐mesh surgery for POP repair; (2) mesh placed abdominally for POP repair appears to result in lower rates of mesh complications compared to transvaginal POP surgery with mesh; (3) there is no evidence that Further contributions to this debate can be found at doi:10.1007/ s00192-011-1581-2, doi:10.1007/s00192-011-1596-8 and doi:10.1007/s00192-011-1597-7.

Burch colposuspension for the treatment of coital urinary leakage secondary to genuine stress incontinence.

The efficacy of Burch colposuspension in treating the symptom of coital urinary leakage in women with genuine stress incontinence has to date never been reported. Women who presented to our clinic with regular coital urinary leakage and urodynamically proven genuine stress incontinence between 1993 and 1997, and who proceeded to a Burch colposuspension procedure, were reviewed to determine the outcome of surgery. Fifty-five women were identified (mean age 46.1 years) with a mean follow-up interval after surgery of 18 months (range 3-42 months). All 55 women had symptoms of stress, urge and coital incontinence preoperatively. Following colposuspension, the subjective cure rates for stress and urge incontinence were 84% and 85%, respectively. Of 52 women that were sexually active after surgery, 81% described no further coital incontinence. The success or failure of surgery was not influenced by whether leakage occurred with penetration or orgasm preoperatively.