Ranee Thakar

Regular review: management of urinary incontinence in women.

Urinary incontinence is defined by the International Continence Society as an involuntary loss of urine that is objectively shown and a social and hygiene problem.1 Urinary incontinence not only causes considerable personal discomfort but is also of economic importance to the NHS, costing around £424m per annum.2 In a survey of 10 226 adults aged over 40, the prevalence of incontinence in women was reported as 20.2%.3 Table ​Table11 summarises the prevalence of urinary incontinence from a variety of studies.4 It is likely that about 3 million people are regularly incontinent in the United Kingdom, a prevalence of around 40 per 1000 adults.5 Table 1 Prevalence of urinary incontinence Incontinence can be broadly divided into genuine stress incontinence and an overactive bladder (detrusor instability) (fig ​(fig1).1). Bladder symptoms often do not correlate with the underlying diagnosis. Thus urge incontinence often but not always results from an overactive bladder. Emphasis must be placed on the management of urinary incontinence in primary care, as this is effective in both the short term and the long term and benefits secondary care by ensuring that only patients who cannot be managed in primary care are referred.6,7 Urodynamic studies can be reserved for when conservative treatment has failed, surgery is intended, there are voiding difficulties, or a neuropathy is present. Summary points Urinary incontinence affects 20% of women over the age of 40 It affects the quality of life and causes a financial burden to the NHS Emphasis must be placed on primary health care as many patients can be managed at this level, thus ensuring appropriate referral to hospital The main causes of urinary incontinence are urethral sphincter incompetence and an overactive bladder Urodynamic studies are reserved for when conservative treatment has failed, surgery is intended, or voiding difficulties or neuropathy is present Figure 1 Classification of incontinence

Occult anal sphincter injuries—myth or reality?

Objectives  To establish the true prevalence of clinically recognisable and occult obstetric anal sphincter injuries (OASIS).

Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse.

OBJECTIVE: To prospectively evaluate the effects of vaginal pessaries on symptoms associated with pelvic organ prolapse and identify the risk factors for failure. METHODS: All women referred to a specialist urogynecology unit with symptomatic pelvic organ prolapse who elected to use a pessary were included in this study. All completed the Sheffield pelvic organ prolapse symptom questionnaire before use and after 4 months of use. The primary outcome measure was change of symptoms from baseline to 4 months. RESULTS: Of 203 consecutive women fitted with a pessary, 153 (75%) successfully retained the pessary at 2 weeks, and 97 completed the questionnaires at 4 months. Multivariate logistic regression analysis showed that failure to retain the pessary was significantly associated with increasing parity (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14–2.02, P = .004) and hysterectomy (OR 4.57, 95% CI 1.71–12.25, P = .002). In the success group at 4 months (n = 97), a significant improvement in voiding was reported by 39 participants (40%, P = .001), in urinary urgency by 37 (38%, P = .001), in urge urinary incontinence by 28 (29%, P = .015), in bowel evacuation by 27 (28%, P = .045), in fecal urgency by 22 (23%, P = .018), and in urge fecal incontinence by 19 (20%, P = .027), but there was no significant improvement in stress urinary incontinence in 22 participants (23% P = .275). Of the 26 (27%) who were sexually active, 16 (17%, P = .001) reported an increase in frequency of sexual activity, and 11 (11%, P = .041) had improved in sexual satisfaction. CONCLUSION: A vaginal pessary is an effective and simple method of alleviating symptoms of pelvic organ prolapse and associated pelvic floor dysfunction. Failure to retain the pessary is associated with increasing parity and previous hysterectomy. LEVEL OF EVIDENCE: II-3

Management of genital prolapse

Prolapse (from the Latin prolapsus , a slipping forth) refers to the falling or slipping out of place of a part or viscus. Pelvic organ prolapse is descent of the pelvic organs into the vagina, often accompanied by urinary, bowel, sexual, or local pelvic symptoms. The incidence of genital prolapse is difficult to determine, as many women do not seek medical advice. It has been estimated that a half of parous women lose pelvic floor support, resulting in some degree of prolapse, and that of these women 10-20% seek medical care.1 In the United Kingdom genital prolapse accounts for 20% of women on the waiting list for major gynaecological surgery.2 The incidence of prolapse requiring surgical correction in women who have had a hysterectomy is 3.6 per 1000 person years of risk; the cumulative risk is 1% at 3 years and 5% at 17 years after a hysterectomy.3 The chance of a woman having a prolapse increases with age.4 Therefore, the incidence of prolapse will rise as life expectancy increases. This article deals with the management in primary care of women with genital prolapse and the options in secondary care. #### Summary points Doctors should consider the patients history of rectal prolapse, bladder and bowel function, and sexual activity It is important to treat predisposing factors such as obesity, obstructive airway disease, constipation, and pelvic masses Although prolapse can occur in the anterior, middle, or posterior compartments, the pelvic floor should be considered as a single unit in the treatment of prolapse When surgery is needed, doctors should check for potential stress incontinence There is a lack of good data on the prevention and treatment of prolapse, and in particular more research is needed on the role of pelvic floor exercises and on the pros and cons of vaginal, … RETURN TO TEXT

Postpartum female sexual function

Although many women experience sexual problems in the postpartum period, research in this subject is under-explored. Embarrassment and preoccupation with the newborn are some of the reasons why many women do not seek help. Furthermore, there is a lack of professional awareness and expertise and recognition that a prerequisite in the definition of sexual dysfunction is that it must cause distress to the individual (not her partner). Sexual dysfunction is classified as disorders of sexual desire, arousal, orgasm and pain. However, in the postpartum period the most common disorder appears to be that of sexual pain as a consequence of perineal trauma. Health care workers need to be made aware of this silent affliction as sexual morbidity can have a detrimental effect on a womens quality of life impacting on her social, physical and emotional well-being.

Bladder, bowel and sexual function after hysterectomy for benign conditions

Approximately 28 per 10,000 women undergo hysterectomy every year, rendering it the commonest major gynaecological operation in the UK’. The procedure disrupts the intimate anatomical relationship between the uterus, bowel, bladder and vagina, and inevitably the local nerve supply. It is therefore reasonable to suppose that hysterectomy might alter their function, such change being either detrimental or beneficial. Since Hanley’s2 work in the late 1960s, there has been an increasing awareness of and research into the sequelae of hysterectomy. The procedure may be total, when both the body of the uterus and the cervix are removed, or subtotal, when the cervix is conserved. The operation may be performed via an abdominal incision, or by the vaginal route, or more recently by minimal access techniques. If hysterectomy does indeed affect urinary, bowel or sexual function, the type and route of the operation may also affect the degree of change. This article reviews current literature on this topic.

Obstetric levator ani muscle injuries: current status

Levator ani muscle (LAM) injuries occur in 13–36% of women who have a vaginal delivery. Although these injuries were first described using magnetic resonance imaging, three‐dimensional transperineal and endovaginal ultrasound has emerged as a more readily available and economic alternative to identify LAM morphology. Injury to the LAM is attributed to vaginal delivery resulting in reduced pelvic floor muscle strength, enlargement of the vaginal hiatus and pelvic organ prolapse. There is inconclusive evidence to support an association between LAM injuries and stress urinary incontinence and there seems to be a trend towards the development of fecal incontinence. Longitudinal studies with long‐term follow‐up assessing the LAM before and after childbirth are lacking. Furthermore, the consequence of LAM injuries on quality of life due to prolapse and/or urinary and fecal incontinence have not been evaluated using validated questionnaires. Direct comparative studies using the above‐mentioned imaging modalities are needed to determine the true gold standard for the diagnosis of LAM injuries. This would enable consistency in definition and classification of LAM injuries. Only then could high‐risk groups be identified and preventive strategies implemented in obstetric practice. Copyright

Outcome of primary repair of obstetric anal sphincter injuries (OASIS): does the grade of tear matter?

To assess risk factors and outcome of different grades of obstetric anal sphincter injuries (OASIS) after primary repair, and to assess the relationship between outcome of anal sphincter defects as diagnosed by endoanal ultrasound.

Are mediolateral episiotomies actually mediolateral

This study investigated potential differences in the cutting of mediolateral episiotomy between doctors and midwives. Depth, length, distance from midline and shortest distance from the midpoint of the anal canal to the episiotomy were measured in a sample of primigravid women. The angle subtended from the sagittal or parasagittal plane was calculated. Two hundred and forty‐one women participated of whom 98 (41%) had a mediolateral episiotomy. Doctors performed episiotomies that were significantly deeper, longer and more obtuse than those by midwives. No midwife and only 13 (22%) doctors performed truly mediolateral episiotomies. It appears that the majority of episiotomies are not truly mediolateral but closer to the midline. More focused training in mediolateral episiotomy technique is required.

A new measure of sexual function in women with pelvic floor disorders (PFD): the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR)

Introduction and hypothesisThe objective of this study was to create a valid, reliable, and responsive sexual function measure in women with pelvic floor disorders (PFDs) for both sexually active (SA) and inactive (NSA) women.MethodsExpert review identified concept gaps and generated items evaluated with cognitive interviews. Women underwent Pelvic Organ Prolapse Quantification (POPQ) exams and completed the Incontinence Severity Index (ISI), a prolapse question from the Epidemiology of Prolapse and Incontinence Questionnaire (ISI scores), the Pelvic Floor Distress Inventory-20 (PFDI-20), and the Female Sexual Function Index (FSFI). Principle components and orthogonal varimax rotation and principle factor analysis with oblique rotation identified item grouping. Cronbach’s alpha measured internal consistency. Factor correlations evaluated criterion validation. Change scores compared to change scores in other measures evaluated responsiveness among women who underwent surgery.ResultsA total of 589 women gave baseline data, 200 returned surveys after treatment, and 147 provided test-retest data. For SA women, 3 subscales each in 2 domains (21 items) and for NSA women 2 subscales in each of 2 domains (12 items) emerged with robust psychometric properties. Cronbach’s alpha ranged from .63 to .91. For SA women, correlations were in the anticipated direction with PFDI-20, ISI, and FSFI scores, POPQ, and EPIQ question #35 (all p < .05). PFDI-20, ISI, and FSFI subscale change scores correlated with Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire International Urogynecological Association-revised (PISQ-IR) factor change scores and with mean change scores in women who underwent surgery (all p < .05). For NSA women, PISQ-IR scores correlated with PFDI-20, ISI scores, and with EPIQ question #35 (all p < .05). No items demonstrated differences between test and retest (all p ≥ .05), indicating stability over time.ConclusionsThe PISQ-IR is a valid, reliable, and responsive measure of sexual function.