Stergios K. Doumouchtsis

Prospective evaluation of combined local bupivacaine and steroid injections for the management of chronic vaginal and perineal pain

PurposeVaginal/perineal pain is common following obstetric trauma or vaginal surgery for prolapse and may have a serious impact on sexual function and quality of life. Local injections of corticosteroids, local anaesthetic and hyaluronidase are treatment options for chronic pain; however, there are no published studies to support their efficacy. The objective of this study was to evaluate prospectively the efficacy of perineal/vaginal injections for chronic localised pain following childbirth or vaginal surgery.MethodsConsecutive women with chronic vaginal/perineal pain were recruited in this prospective series (audit). Pain severity and sexual function were determined using a visual analogue scale (VAS 0–10) and the abbreviated sexual function questionnaire (ASFQ) respectively. Patients underwent local injections with a combination of 0.5% bupivacaine (10xa0ml), hydrocortisone (100xa0mg) and hyaluronidase (1,500xa0IU). Follow-up was undertaken at four-weekly intervals. Further injections were performed as clinically indicated.ResultsFifty-three women underwent ≥1 injections [mean: 1.86 (range: 1–4)]. Mean interval from index childbirth [43/53 (81%)] or surgical intervention [10/53 (19%)] was 8xa0months (range 12xa0weeks–20xa0years). Twenty-seven women (51%) were sexually active. All reported dyspareunia. Fifteen (28%) women required 1 and 31(59%) two injections. Pre treatment VAS pain scores were 6.1 versus 4.1 after first injection (pxa0=xa00.0002, 95% CI 1.01–3.05) and mean ASFQ scores increased from 18.1 to 29.1 (pxa0=xa00.01, 95% CI −17.2 to −2.3) 4xa0weeks post-injection. There were no adverse events or morbidity. 24/27 (89%) sexually active women with dyspareunia resolved and 18/26 (69%) sexually inactive women resumed satisfactory sexual activity 8xa0weeks post-injection.ConclusionIn our series, this treatment was well tolerated and significant improvements in pain scores and sexual function were observed.

Long-term outcomes of modified high uterosacral ligament vault suspension (HUSLS) at vaginal hysterectomy.

Introduction and hypothesisThe aim of this study was to prospectively evaluate long-term outcomes of a modified high uterosacral ligament suspension (HUSLS) at vaginal hysterectomy for pelvic organ prolapse (POP).MethodsPOP was assessed 5xa0years postoperatively in 42 women who underwent vaginal hysterectomy and HUSLS for POP. Bladder, bowel, sexual function and quality of life (QoL) were evaluated.ResultsPreoperatively, 27/42 women had at least BW grade 2 uterine prolapse. At a mean follow-up period of 59.4xa0months (range: 40–79xa0months), two women had undergone surgical intervention for vault prolapse, 33 had no vault prolapse and six grade 1 vault prolapse. One woman declined vaginal examination. Twenty women were sexually active and 18 completed the PISQ-31. The mean total score for all domains was 91/125. On QoL assessments high scores were noted in all domains.ConclusionsModified HUSLS at vaginal hysterectomy is associated with satisfactory long-term objective and subjective outcomes, sexual function and quality of life scores.

Patient satisfaction with nurse-led telephone follow-up in women with lower urinary tract symptoms:

We assessed the clinical effectiveness and patient satisfaction with nurse-led telephone follow-up of women with lower urinary tract symptoms. Participants were offered telephone follow-up with a nurse instead of a conventional outpatient appointment. Suitability was decided by the doctor who saw the women at her last visit. The consultation was conducted using the same principles as a routine clinic visit. Patient satisfaction was evaluated by postal questionnaire and they were also sent a standard urinary continence questionnaire, the Kings Health Questionnaire (KHQ), to evaluate their current symptoms. In total, 116 women were included. The mean number of telephone consultations was 2 (range 1–12). The mean overall satisfaction score was 77 (maximum 100, where a higher score indicates greater satisfaction). Only 16 patients (17%) did not prefer telephone follow-up to a clinic visit. Women who had been discharged via the telephone follow-up clinic expressed similar mean satisfaction scores to those whose next visit was a clinic visit (80 and 82, respectively). The KHQ also indicated that the patients had been appropriately discharged or given a further follow-up appointment. Nurse-led telephone follow-up is associated with high satisfaction and has the advantages of consistent follow-up by the same clinician, convenience to the patient and cost-savings.

High uterosacral ligament vault suspension at vaginal hysterectomy: Objective and subjective outcomes of a modified technique

Aims:u2002 To evaluate the outcomes of a modified high uterosacral ligament suspension (HUSLS) performed at vaginal hysterectomy for uterine prolapse.

A modified technique for the surgical correction of urethral diverticula using a porcine xenograft

We report a case of urethral diverticulectomy re-enforced with a porcine xenograft to prevent the risk of recurrence or fistula in the presence of a large urethral communication. The use of porcine small intestinal submucosal xenograft (SIS, Surgisis™, Cook, Ireland) material has a low graft rejection rate and erosion is rare as the material is degraded after 3 to 6xa0months. In this case, xenograft achieved tension-free closure of the urethral defect without any postoperative complications.

Continence outcomes following partial excision of vaginal mesh exposure after mid-urethral tape insertion

OBJECTIVEnTo assess the incidence of recurrent stress urinary incontinence (SUI) following vaginal excision of exposed mid-urethral tape (MUT).nnnSTUDY DESIGNnThis was a retrospective observational study in a tertiary urogynaecology unit of an inner city teaching hospital. The population consisted of 41 consecutive women seen with a vaginal mesh exposure following MUT insertion between 2000 and 2009, which failed to resolve with conservative measures. The primary outcome measure was the presence of symptoms of stress urinary incontinence following surgical excision of exposed mesh.nnnRESULTSnThe incidence of recurrent SUI following tape excision was 34.1%. Type of mid-urethral tape, menopausal status, and the time interval between tape insertion and excision were not found to be significantly associated with the risk of recurrent SUI.nnnCONCLUSIONSnOver a third of women experience recurrent SUI after surgical management of vaginal mesh exposure following MUT insertion. Risk factors may be more comprehensively studied using prospectively collected cohorts.

Perineal trauma in women undergoing vaginal delivery following intra-uterine fetal demise: a case-control analysis.

Introduction and hypothesisThis study aimed to evaluate any differences in the incidence of perineal trauma in women undergoing vaginal delivery following intrauterine fetal death (IUFD) versus live-births. This information would be of interest in evaluating the possible effect of fetal demise on the mechanism of labour in the second stage and thus may provide invaluable insights to contribute to our understanding of the impact of fetal tone on the mechanics of labour and delivery.Methods323 women who delivered vaginally following IUFD were matched with 1,000 women with a live-birth for age, parity, gestation and birth weight. Women undergoing assisted vaginal delivery and/or episiotomy were excluded.ResultsWomen with an IUFD had a significantly lower risk of perineal trauma overall (relative risk 0.16) as well as a lower risk of obstetric anal sphincter injury specifically (RR 0.12).ConclusionsWomen delivering vaginally after IUFD have a lower incidence of perineal trauma compared with women delivering a live infant. This may be due to differences in biomechanics following an IUFD.

Is Doppler planimetry a valid technique for the evaluation of postpartum urinary bladder volume

The objective of this prospective study was to evaluate the accuracy of conventional 2D ultrasound (CUS) versus doppler planimetry (DP) in the assessment of postpartum urinary bladder volume compared to a true estimate using urethral catheterisation. Fifty-two women were assessed within 24 hours of delivery. Evaluation of bladder volume was performed using CUS (1-estimate) and DP (6-estimates). CUS had a higher correlation (r=0.796) with the true volume and lower % error than DP in the postpartum group. DP readings were highly reproducible (ICC 0.81) but tended to overestimate the true value especially with smaller volumes. DP was suboptimal for the assessment of the postpartum PVR. Postpartum evaluation using CUS is more accurate in calculating the true urinary volume.

A systematic review on vaginal laser therapy for treating stress urinary incontinence: Do we have enough evidence?

Introduction and hypothesisCurrent treatment strategies for stress urinary incontinence (SUI) raise concerns about safety and efficacy. The purpose of this systematic review was to present available evidence related to vaginal laser therapy as a treatment option for SUI.MethodsWe searched the MEDLINE (1966–2017), Scopus (2004–2017), Clinicaltrials.gov (2008–2017) and Cochrane Central Register of Controlled Trials (CENTRAL) (1999–2017) databases for relevant studies in this field. We aimed to include all observational studies (prospective and retrospective, randomized and nonrandomized) that reported outcomes on vaginal laser therapy as a treatment option for SUI.ResultsThirteen studies were included that recruited 818 patients who underwent laser therapy for SUI. The methodological quality of most included studies was low, as they were either individual case–control studies, case series or poor-quality cohorts (Oxford Level of Evidence 3b and 4). According to the existing evidence, laser therapy may be a useful, minimally invasive approach for treating SUI. However, the methodological limitations of included studies render them prone to significant bias, limiting their scientific integrity.ConclusionsAs the demand for minimally invasive approaches for treating SUI increases, it is expected that more patients will seek alternative treatments over current standards (midurethral slings). Given the limitations of the existing studies, it seems that conducting future trials is necessary to elucidate this field.

Are voiding parameters a marker for the severity of quality of life impairment in women with overactive bladder symptoms

There is evidence of an association between voiding parameters and the presence of overactive bladder symptoms. The aim of this study was to evaluate whether there is any association between pressure flow study parameters and the degree of health related quality of life impairment in women with OAB symptoms. The null hypothesis is that there is no significant correlation between quality of life domain scores and pressure flow study parameters.