Roger P. Goldberg

Site-Specific Rectocele Repair Compared With Standard Posterior Colporrhaphy

OBJECTIVE: To compare the anatomic and functional outcomes of site-specific rectocele repair and standard posterior colporrhaphy. METHODS: We reviewed charts of all patients who underwent repair of advanced posterior vaginal prolapse in our institution between July 1998 and June 2002 with at least 1 year of follow-up. RESULTS: This study comprised 124 consecutive patients following site-specific rectocele repair and 183 consecutive patients following standard posterior colporrhaphy without levator ani plication. Baseline characteristics, including age, body mass index, parity, previous pelvic surgeries, and preoperative prolapse were not significantly different between the 2 study groups. Recurrence of rectocele beyond the midvaginal plane (33% versus 14%, P = .001) and beyond the hymenal ring (11% versus 4%, P = .02), recurrence of a symptomatic bulge (11% versus 4%, P = .02), and postoperative Bp point (–2.2 versus –2.7 cm, P = .001) were significantly higher after the site-specific rectocele repair. Rates of postoperative dyspareunia (16% versus 17%), constipation (37% versus 34%), and fecal incontinence (19% versus 18%) were not significantly different between the 2 study groups. CONCLUSION: Site-specific rectocele repair is associated with higher anatomic recurrence rates and similar rates of dyspareunia and bowel symptoms than standard posterior colporrhaphy. LEVEL OF EVIDENCE: II-3

Histologic characterization of vaginal vs. abdominal surgical wound healing in a rabbit model

We aimed to compare the histologic characteristics of vaginal vs. abdominal surgical wound healing in the rabbit. Bilateral 6 mm full‐thickness circular segments were excised from the vagina and abdominal skin in 34 New Zealand white female rabbits. Animals were euthanized on the day of and 4, 7, 10, 14, 21, 28, and 35 days after wounding, and their wounds were evaluated using a modified scoring system. The inter‐ and intraobserver agreements of the scoring system were good (weighted κ 0.63 and 0.71, respectively). A transient fibrinous crust was evident in 75% of the abdominal and in none of the vaginal wound specimens on days 4–7 after wounding (p=0.01). Acute inflammation peaked at day 4 in both the vaginal and abdominal wounds, while chronic inflammation peaked at days 4–7 and 14–21 in the abdomen and vagina, respectively. Both neovascularization and the amount of granulation tissue peaked at days 4 and 7 in the vagina and abdomen, respectively. Maturation of granulation tissue and collagen deposition increased persistently in both tissues until postwounding day 35. Reepithelialization increased after wounding, and was completed by day 14 in both tissues. The surgical wound‐healing process in both the vagina and abdomen includes transient acute and chronic inflammation, fibroblast proliferation, and neovascularization, as well as progressive maturation of granulation tissue, reepithelialization, and collagen deposition. A transient fibrinous crust forms in the abdomen but not in the vagina 4–7 days after wounding. The modified histologic scoring system described here was found to be reliable and reproducible.

Effect of parity on sexual function : An identical twin study

OBJECTIVE: To assess the impact of childbirth on female sexual function by using an identical twin study design. METHODS: A survey including the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) was administered to 542 twin sisters, and PISQ-12 scores of 29 twin pairs discordant for parity were compared. Multiple linear regression models were used to evaluate impact on total PISQ-12 scores in 276 identical, sexually active twins. Three models were used 1) to evaluate the effect of parity and general risk factors, 2) to examine the impact of birth mode, and 3) to examine the role of episiotomy and operative delivery. RESULTS: Mean PISQ-12 scores were significantly higher for discordant nulliparous twins than for parous twins (102.5 versus 93.5, P < .001). The mean (standard deviation) PISQ-12 score was 99.3 (11.7). Age of 50 years or older (difference in mean scores –5.4, P = .019), stress urinary incontinence (−3.3, P = .02), urge urinary incontinence (−5.9, P < .001), parity (−6.5, P < .001), and fecal incontinence (−5.7, P = .048) were associated with decreased mean PISQ scores in the univariable analysis. Parity (−4.9, P < .001) and urge urinary incontinence (−4.3, P = .009) were the only factors remaining independently predictive of diminished sexual function in the multivariable analysis. Mode of delivery did not significantly affect mean PISQ scores (P = .763). Among women who had vaginal deliveries only, neither episiotomy nor operative delivery was associated with change in PISQ scores (P = .553). CONCLUSION: Nulliparous women reported superior sexual satisfaction scores compared with parous women, regardless of age and mode of delivery. Childbirth appears to have a lasting impact on sexual function, due to psychological more than physical factors, well beyond the postpartum period. LEVEL OF EVIDENCE: II-2

Risk factors for female anal incontinence: new insight through the Evanston-Northwestern twin sisters study.

OBJECTIVE: To evaluate risk factors for anal incontinence using an identical twin sisters study design to provide control over genetic variance. METHODS: A total of 271 identical twin sister pairs (mean age 47 years) completed the validated Colorectal Anal Distress Inventory questionnaire detailing the presence and severity of anal incontinence. Data were analyzed using a stepwise logistic regression with repeated binary measures to account for correlated data within twin pairs. Three different statistical models were used to analyze nonobstetric as well as obstetric risk factors separately. RESULTS: Significant risk factors for anal incontinence and higher Colorectal Anal Distress Inventory anal incontinence subscale scores included age 40 years or older (fecal: odds ratio [OR] 2.82, 95% confidence interval [CI] 1.21–6.0; flatal: OR 1.90, 95% CI 1.11–3.24), menopause (fecal: OR 2.10, 95% CI 1.15–3.8; flatal: OR 2.11, 95% CI 1.43–3.13), increasing parity (parity ≥ 2; fecal: OR 3.09, 95% CI 1.25–7.65; flatal: OR 2.72, 95% CI 1.65–4.51), and the presence of stress urinary incontinence (fecal: OR 2.11, 95% CI 1.12–3.98; flatal: OR 1.72, 95% CI 1.14–2.59). Obesity was associated with significantly higher Colorectal Anal Distress Inventory anal incontinence subscale scores (mean difference 5.18, P = .007). Cesarean delivery after initiation of labor was associated with a lower prevalence of anal incontinence than vaginal birth; however, this difference was not statistically significant (17% compared with 4%, P = .11). No anal incontinence was noted in women who had only elective cesarean deliveries. CONCLUSION: Age, menopause, obesity, parity, and stress urinary incontinence are the major risk factors for female anal incontinence. LEVEL OF EVIDENCE: II-2

Anterior or posterior sacrospinous vaginal vault suspension: long-term anatomic and functional evaluation

OBJECTIVE To compare vaginal anatomy and sexual function after the conventional posterior and anterior sacrospinous vault suspension. METHODS A retrospective repeated measures cohort study included all 168 consecutive sacrospinous vault suspension procedures between July 1990 and February 1997. The posterior suspension (n = 92) used a posterior vaginal incision and pararectal dissection. Anterior suspension (n = 76) involved an anterior rather than posterior vaginal incision, retropubic perforation, and dissection of a paravaginal‐paravesical rather than pararectal space to accommodate the vaginal vault. Two polytetrafluoroethylene (00) sutures anchored the anterior vaginal cuff (for the anterior sacrospinous suspension) or the posterior vaginal cuff (for the posterior sacrospinous suspension) to the ligament. Postoperative evaluation included an examination using the pelvic organ prolapse quantitative system, assessment of vaginal width and axis, and symptom questionnaire. RESULTS Total vaginal length and apical suspension were slightly greater after the anterior suspension, and recurrent anterior vaginal relaxation was less likely. No differences were found in maximal dilator size or apical narrowing between the two groups. New onset dyspareunia was reported by two subjects in the anterior vault suspension group, and two in the posterior vault suspension group. Three of these four cases of de novo dyspareunia were attributable to either severe atrophy or recurrent prolapse, and none to vaginal narrowing or shortening. CONCLUSION After anterior sacrospinous vault suspension, vaginal length and apical suspension were slightly increased, and recurrent anterior vaginal prolapse decreased compared with the posterior sacrospinous suspension technique. Upper vaginal caliber and sexual function appear well preserved using either technique.

Predictors of persistent detrusor overactivity after transvaginal sling procedures

OBJECTIVE Determine predictors of persistent postoperative detrusor overactivity and urge urinary incontinence after sling procedures for stress urinary incontinence STUDY DESIGN Three hundred five women with mixed urinary incontinence underwent sling procedures for stress urinary incontinence. Risk factors for persistent detrusor overactivity and urge urinary incontinence were examined using logistic regression models. RESULTS Women (31.5%) who had postoperative resolution of detrusor overactivity. Transobturator slings had the lowest rate of persistent detrusor overactivity (53%), followed by retropubic (SPARC = 66%; TVT = 64%) and bladder neck slings (86%). Predictors for persistent detrusor overactivity included age (odds ratio [OR], 1.38; P = .001), prior hysterectomy (OR, 1.95; P = .012), paravaginal repair (OR, 0.46; P = .015), nocturia (OR, 1.91; P = .013), maximum cystometric capacity (OR, 0.79; P < .001), detrusor overactivity volume (OR, 0.83; P = .006), urethral closure pressure (OR, 0.83; P < .001), and maximum urinary flow rate (OR, 0.77; P = .014). Persistent urge urinary incontinence was predicted by sling type (P < .001). CONCLUSION When treating women with mixed urinary incontinence, age, nocturia, maximum cystometric capacity, and choice of sling procedure impact persistence of detrusor overactivity and urge urinary incontinence.

A randomized controlled trial comparing a modified Burch procedure and a suburethral sling: long-term follow-up

The aim of this study was to compare the long-term results of a modified Burch procedure with a sling procedure for the treatment of stress incontinence with a low-pressure urethra. Thirty-six women with urodynamic stress incontinence, low-pressure urethra, urethral hypermobility and no significant pelvic organ prolapse were randomly assigned to undergo either a modified Burch procedure (n=19) or a sling placement (n=17). Cure of the stress incontinence (defined as a negative stress test and negative pad-weight test) was the primary long-term endpoint. Secondary endpoints included subjective cure of stress incontinence (defined as no incontinence episodes on a 1-week voiding diary) and voiding function studies. Comparisons of group means were performed with the Mann–Whitney U-test, pooled variance t-tests and separate variance t-tests. Proportions were compared with Fishers exact test. A logistic regression analysis was performed to control for covariates that differed in our two groups despite randomization. Long-term follow-up (mean=72.6 months) was available for 82% (28/34) of the original study group. The objective cure rates for the Burch and sling groups were 84.6% and 100%, respectively (P=0.17). Mean uroflowmetry rates for the Burch and sling groups were 7.38 and 6.8 ml/s, respectively (P=0.58, 95%CI −2.5, 4.4). Mean postvoid residual volumes for both groups were 35 ml (P=0.97, 95% CI −23.8, 65.9). Two sling patients (12%) required partial resection of their slings because of erosion. Both patients remained continent. In terms of voiding function and stress incontinence cure, there were no differences between groups undergoing modified Burch or sling procedures for treatment of urodynamic stress incontinence with low-pressure urethra.

Comparison of microtransducer and fiberoptic catheters for urodynamic studies

OBJECTIVE To assess the validity and reproducibility of a fiberoptic transducer urodynamic catheter for urethral closure pressure profiles and leak point pressure determination, using a microtransducer catheter as the standard. METHODS Ninety women without significant pelvic organ prolapse underwent urodynamic evaluations with both fiberoptic and microtransducer catheters. Maximal urethral closure pressures and “leak point pressures” were repeatedly measured by the two catheters and statistically compared. The order of catheter use was randomized. RESULTS Significantly lower mean maximal urethral closure pressures were recorded by the fiberoptic system than by the microtransducer system (28.9 cmH2O ± 17.3 versus 43.2 cmH2O ± 24.9, P < .001). The fiberoptic catheter predicted microtransducer values for maximum urethral closure pressure only within a range of 27 cmH2O. Mean “leak point pressure” recorded by the fiberoptic catheters (66.9 cmH2O ± 2.9) was not significantly different than that recorded by the microtransducer catheters (66.4 cmH2O ± 2.9, P = .97). CONCLUSION There is a significant difference between maximum urethral closure pressure values recorded by the microtransducer and fiberoptic catheter systems. No significant difference was found between the two systems in measurement of Valsalva “leak point pressure.”

The development of pelvic organ prolapse following isolated Burch retropubic urethropexy.

The purpose of our study was to examine the incidence of prolapse in a group of women who had had an isolated Tanagho modification of the Burch colposuspension performed without significant pelvic organ prolapse preoperatively. Sixty women were identified who underwent an isolated Burch procedure for genuine stress incontinence between 1991 and 1999. Thirty-four women returned for postoperative Pelvic Organ Prolapse Quantification (POP-Q) staging evaluation. Overall, 6 (17.6%) had stage II anterior prolapse. Eleven (32.4%) had stage II posterior prolapse. Three (8.8%) had stage II uterine prolapse. None of these patients with identified support defects was symptomatic. Two patients had subsequently undergone vaginal hysterectomy. One had this performed for dysfunctional uterine bleeding 3 years after her Burch procedure. One patient developed symptomatic uterine prolapse and underwent a vaginal hysterectomy 5 months after her Burch procedure. The majority of patients undergoing an isolated Tanagho modification Burch procedure without preoperative prolapse do not appear to be placed at increased risk for subsequent operative intervention.

Pelvic floor fitness using lay instructors.

OBJECTIVE: Typically, pelvic muscle training for women with pelvic floor disorders is provided by medical personnel. We sought to evaluate the feasibility and symptom improvement after a nonmedical pelvic muscle training class in a prospective cohort. METHODS: Study participants volunteered to participate in an 11-week pelvic fitness and education class taught by a lay instructor at five fitness classrooms in the Chicago area. Participation was limited to adult women who verbally indicated that their pelvic symptoms included a minimum of some urge urinary symptom. Standardized assessments were completed before class, at the end of class, and 1 year after completion of the classes. These assessments included the 12-item short-form, validated pelvic questionnaires (Urogenital Distress Inventory Short Form, Incontinence Impact Questionnaire Short Form, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire), and self-reported goals selection and achievement. RESULTS: Eighty-seven of 102 participants provided before and after class data, and 76 also provided 1-year data. Participants had a mean age of 58 years and a mean body mass index of 26.3. Most (91%) were white, and 63% had at least completed college. After class improvements in Urogenital Distress Inventory Short Form bothersomeness ratings were noted for all items and maintained at 1 year for all but pain or discomfort. Significant quality-of-life and sexual function improvements were reported after class and at 1 year. The 12-item short-form responses documented improvements in six areas of general health. The most important self-selected goal was achieved in 71% after class and maintained by 67% at 1 year. CONCLUSION: Nonmedical pelvic fitness classes are promising for pelvic symptom improvement in self-selected participants. LEVEL OF EVIDENCE: II