Ruwan Fernando

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 obstetric anal sphincter injury: a systematic review & national practice survey

BackgroundWe aim to establish the evidence base for the recognition and management of obstetric anal sphincter injury (OASI) and to compare this with current practice amongst UK obstetricians and coloproctologists.MethodsA systematic review of the literature and a postal questionnaire survey of consultant obstetricians, trainee obstetricians and consultant coloproctologists was carried out.ResultsWe found a wide variation in experience of repairing acute anal sphincter injury. The group with largest experience were consultant obstetricians (46.5% undertaking ≥ 5 repairs/year), whilst only 10% of responding colorectal surgeons had similar levels of experience (p < 0.001). There was extensive misunderstanding in terms of the definition of obstetric anal sphincter injuries. Overall, trainees had a greater knowledge of the correct classification (p < 0.01). Observational studies suggest that a new overlap repair using PDS sutures with antibiotic cover gives better functional results. However, our literature search found only one randomised controlled trial (RCT) on the technique of repair of OASI, which showed no difference in incidence of anal incontinence at three months. Despite this, there was a wide variation in practice, with 337(50%) consultants, 82 (55%) trainees and 80 (89%) coloproctologists already using the overlap method for repair of a torn EAS (p < 0.001). Although over 50% of colorectal surgeons would undertake long-term follow-up of their patients, this was the practice of less than 10% of obstetricians (p < 0.001). Whilst over 70% of coloproctologists would recommend an elective caesarean section in a subsequent pregnancy, only 22% of obstetric consultants and 14% of trainees (p < 0.001).ConclusionAn agreed classification of OASI, development of national guidelines, formalised training, multidisciplinary management and further definitive research is strongly recommended.

Repair Techniques for Obstetric Anal Sphincter Injuries: A Randomized Controlled Trial

OBJECTIVE: To compare one-year outcomes of primary overlap versus end-to-end repair of the external anal sphincter after acute obstetric anal sphincter injury. METHODS: Women who sustained third-degree (3b = greater than 50% external anal sphincter thickness, 3c = internal sphincter injury) or fourth-degree (including anorectal epithelium) perineal tears were randomly allocated to either immediate primary overlap or end-to-end repair. They were prospectively followed up for 12 months postrepair with serial questionnaires. The primary outcome was fecal incontinence at 12 months. Secondary outcomes were fecal urgency, flatus incontinence, perineal pain, dyspareunia, quality of life, and improvement of anal incontinence symptoms. RESULTS: Thirty-two women were randomized to each group. At 12 months, 24% (6/25) in the end-to-end and none in the overlap group reported fecal incontinence (P = .009, relative risk [RR] 0.07, 95% confidence interval [CI] 0.00–1.21, number needed to treat 4.2). Fecal urgency at 12 months was reported by 32% (8/25) in the end-to-end and 3.7% (1/27) in the overlap group (P = .02, RR 0.12, 95% CI 0.02–0.86, number needed to treat 3.6). There were no significant differences in dyspareunia and quality of life between the groups. At 12 months, 20% (5/25) reported perineal pain in the end-to-end and none in the overlap group (P = .04, RR 0.08, 95% CI 0.00–1.45, number needed to treat 5). During 12 months, 16% (4/25) in the end-to-end and none in the overlap group reported deterioration of defecatory symptoms (P = .01). CONCLUSION: Primary overlap repair of the external anal sphincter is associated with a significantly lower incidence of fecal incontinence, urgency, and perineal pain. When symptoms do develop, they appear to remain unchanged or deteriorate in the end-to-end group but improve in the overlap group. LEVEL OF EVIDENCE: I

Management of the neglected vaginal ring pessary

We present two cases of vaginal pessaries left in situ for prolonged periods and subsequent impaction that were managed differently. One was partially epithelialized and removed in the outpatient clinic by a new technique whereby the ring pessary was divided by a bone-cutter and passed through the epithelial tunnel without anesthesia. The second, which was a completely epithelialized metal ring pessary, was removed under anesthesia. Resulting fibrosis can cure the prolapse.

Urodynamics are necessary for patients with asymptomatic pelvic organ prolapse

To evaluate the role of pre‐operative urodynamics in women with pelvic organ prolapse, who are asymptomatic for urinary symptoms. Correlate urodynamics findings with Kings Health Questionnaire (KHQ) responses.

Measuring the effect of antimuscarinics in the bladder

Dear Editor, We thank Professor Wiwanitikit for his letter [1] regarding our recent publication [2]. In answer to his queries, we feel that the visual analogue scale (VAS) for urgency is a subjective measure of sensory function as felt by the patient. The motor function was determined using the ultrasound measurement of bladder wall thickness (BWT), on the basis that if there was increased motor activity of the detrusor muscle, as in detrusor overactivity, this would be reflected in hypertrophy, which we proposed would be reversed if antimuscarinics had an effect on motor function. The VAS for urgency was used to determine the changes in the cardinal symptom of urgency associated with detrusor overactivity. We acknowledge we cannot prove the direct relationship to bladder sensory processes. In this study we are attempting to determine whether the sensation of urgency and its improvement, as reported by the patient, corresponds to any changes in motor function as measured by BWT. The observation of continued lessening of sensation of urgency after the BWT had stopped declining led to the conclusion that the amelioration of urgency is not wholly explained by the reversing of the hypertrophy seen in detrusor overactivity. It is on this basis that we concluded that the mechanism by which antimuscarinics improve patients’ symptoms is more complex than simply inhibiting detrusor contractions and may involve a sensory effect. We do acknowledge that we have not provided evidence of this interrelationship other than these observations. The PPBC score was used to provide additional information as to improvement of overall bladder condition rather than being directly related to changes in motor or sensory processes. We believe it is important to use subjective measures of improvement when analyzing the effect of any treatment as these subjective measures form the basis of assessing the impact of a condition as well as the effect.