Hormonal Influence in Stress Urinary Incontinence During Pregnancy and Postpartum.

Hormonal changes have been proposed as an etiological factor of stress urinary incontinence (SUI) during pregnancy. Our main objective was to demonstrate the role of hormones in SUI development during pregnancy and postpartum. A prospective longitudinal study was designed. Primiparous women without previous urinary incontinence symptoms were included. Symptoms and Quality of Life (QoL) Questionnaires, physical examinations, and hormone concentration (progesterone, estradiol, and relaxin) were collected twice during pregnancy and three times during postpartum. Logistic regression models, with Wald's forward variable selection method, were used. Prevalence of SUI was 11% in the first trimester, 50% in the third trimester, and 16.4% at 6 months postpartum. The risk of developing SUI throughout pregnancy is higher in women with higher progesterone concentration in the first trimester (OR 1.38, 95% CI 1.06-1.81, p < 0.05) and it is lower in women with stronger pelvic floor muscles in the first trimester (OR 0.35, 95% CI 0.17-0.72, p < 0.05). When occurred during pregnancy, SUI has a 14-fold higher risk of persistence 6 months after birth. In addition, the severity of these symptoms is also an independent risk factor for SUI persistence at 6 months postpartum (OR 1.41, 95% CI 1.15-1.73, p < 0.05). Quality of Life was affected for pregnant women with SUI symptoms. SUI is a highly prevalent condition during pregnancy, affecting the QoL of women in many areas. Higher concentration of progesterone can play a role in SUI development during pregnancy. The presence and severity of SUI during pregnancy are risk factors for the persistence of symptoms 6 months postpartum. Sustaining an optimal pelvic floor muscle strength could prevent SUI during pregnancy.

Transperineal anal sphincter complex evaluation after obstetric anal sphincter injuries: With or without tomographic ultrasound imaging technique?

OBJECTIVES: "Significant" obstetric anal sphincter injuries (OASIS) have been defined as visible defects of at least 30° in at least 4/6 slices using tomographic ultrasound imaging (TUI) with transperineal ultrasound (TPUS). The objective of this study was to assess if TUI is mandatory for the evaluation of OASIS. METHODS: Patients with a history of OASIS were evaluated by performing 3D-endoanal ultrasound (EAUS) and 3D-TPUS with and without TUI. Any damage to the internal (IAS) or external (EAS) anal sphincters was recorded and scored using the Starck's and the Norderval's systems. Intraobserver and inter-techniques correlations were calculated. RESULTS: From September 2012 to May 2015, 63 women, mean age 32.5 ± 4.6 years, with OASIS (3a: 26 pts., 41.3 %; 3b: 26 pts., 41.3 %; 3c: 6 pts., 9.5 %, 4: 4 pts., 6.3 %, "button hole" tear: 1 pt., 1.6 %). Inter-technique and intraobserver correlations were excellent (TUI: k = 0.9; sweeping technique: k = 0.85; EAUS: k = 0.9) in determining OASIS. Using the Starck's Score, excellent correlation was found for both TPUS modalities (TUI: k = 0.86; sweeping technique: k = 0.89). However, for the different individual parameters, the correlation was moderate for EAS depth (TUI: k = 0.44; sweeping technique: k = 0.5) and good for IAS depth (TUI: k = 0.7; sweeping technique: k = 0.78). Similar results were found using the Norderval's classification. CONCLUSIONS: OASIS can be assessed by TPUS without TUI technique, dragging the rendered box and following the anal canal from the anal verge to the anorectal junction in the longitudinal plane and describing findings.

Anatomic and functional evaluation of the levator ani muscle after an obstetric anal sphincter injury.

PURPOSE: To study the relationship between symptoms of anal incontinence (AI) and the anatomy and functionality of the levator ani muscle in women with a history of obstetric anal sphincter injury (OASI). METHODS: This is a cohort study including patients with OASI from 2013 to 2016. Patients were assessed by a physical examination, endoanal ultrasound using Starck Scale, perineometry and 4D transperineal ultrasound. AI in all patients was measured with the Wexner scale. Correlation between variables has been analyzed in these patients. RESULTS: 72 patients were analyzed: 28 with a IIIA degree tear, 26 with a IIIB, 13 with a IIIC and 5 with a IV. 38 patients showed a residual anal sphincter (AS) defect on endoanal ultrasound with an average Starck score of 6.5 ± 3.7. 21 patients expressed AI, with an average Wexner score of 4.1 ± 2.4. In 27 (37.5%) patients, a levator ani avulsion was observed: 17 unilateral and 10 bilateral. Patients with a levator ani defect had weaker pelvic floor muscle (PFM) function. These differences were statistically significant with perineometry (p = 0.01 and p = 0.03) but not for the Oxford test (p = 0.08). Patients with a residual AS defect as well as an injury to the levator ani muscle expressed greater AI symptomatology than patients with residual sphincter injury who maintain the integrity of the levator ani: Wexner 4.9 0.9 vs 3.3 1 (p = 0.02). CONCLUSIONS: The PFM has correlation with AI symptom development in patients with a history of OASI. Therefore, we suggest a key role of anatomical and functional assessments of the levator ani muscle in these patients.

Reducing postoperative catheterisation after anterior colporrhaphy from 48 to 24 h: a randomised controlled trial.

INTRODUCTION AND HYPOTHESIS: There is a distinct lack of literature on postoperative management after anterior colporrhaphy (AC). Our traditional postoperative protocol consisted of 24 h of indwelling catheterisation followed by 24 h of self-intermittent catheterisation. We hypothesised that a new protocol consisting of only 24 h of indwelling catheterisation might produce better results without additional complications. METHODS: From April 2014 to July 2017, all candidates for AC were randomised to catheter removal 24 or 48 h after surgery. The primary outcome was the postoperative urinary retention (POUR) rate. Secondary outcomes included: asymptomatic bacteriuria (AB), urinary tract infection (UTI) and postoperative pain after 24 h. RESULTS: A total of 79 patients were recruited. Thirty-seven and 40 patients were randomised to follow the 48-h protocol and the 24-h protocol respectively. There were no significant differences in relation to the POUR rate: 3 patients (8.1%) vs 1 (2.5%) in the 48-h vs the 24-h group respectively (p = 0.346). The UTI rate was 2 (8.1%) vs 0 patients respectively (p = 0.139) and the postoperative AB rate was 3 (9.1%) vs 0 patients (p = 0.106). In the postoperative pain evaluation, the visual analogue scale score was significantly higher in the 48 h group (0.35 vs 0.13, p = 0.02). CONCLUSIONS: According to our results, reducing the catheterisation from 48 to 24 h after AC does not increase the risk of POUR and decreases the rate of UTI, AB and postoperative pain. This new postoperative management protocol of pelvic floor surgery would improve postoperative outcomes and shorten the stay in hospital.

Contasure-needleless® compared with Monarc® for the treatment of stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: For the treatment of stress urinary incontinence (SUI), various retropubic and transobturator techniques have demonstrated high cure rates. Single-incision tapes, such as Contasure-Needleless® (C-NDL), have demonstrated similar cure rates to the inside-out transobturator sling (TVT-O®). The aim of this study was to analyse if C-NDL® is equally as effective as an outside-in transobturator sling (Monarc®) for the treatment of SUI. METHODS: We carried out a prospective, single-centre, randomised trial. The results were analysed for a non-inferiority test with a minimum postoperative follow-up of 12 months. The objective and subjective cure rates were evaluated by a stress test and a postoperative Sandvik Severity Index respectively. Patient satisfaction and operative complications were registered. The cure was defined by a negative stress test and SSI 0. RESULTS: A total of 187 patients were included, 89 and 98 undergoing C-NDL® and Monarc® respectively. Epidemiological and clinical data did not show and significant differences between both groups except a high prevalence of women who smoke (15.7% C-NDL® vs 6.1% Monarc®, p 0.03). The negative stress test was negative in 72 patients (80.9%) in C-NDL® compared with 85 (88.5%) in Monarc® (p 0.082). The SSI was 0 in 47 (66.2%) for C-NDL® and 61 (70.1%) for the Monarc® group (p 0.01). There were 14 (16.1%) and 8 (8.3%) dissatisfied patients for the C-NDL® and Monarc® groups respectively (p 0.068). The rate of complications was similar in both groups. CONCLUSIONS: According to the non-inferiority test, C-NDL® is not inferior to Monarc® (post-surgical SSI test), but it is inferior in the comparison of a negative stress test and patient satisfaction.

Pelvic organ prolapse and stress urinary incontinence, do they share the same risk factors?

OBJECTIVE: To determine whether there are differences in the etiologies of two of the most common pelvic floor disorders (PFD), pelvic organ prolapse (POP) and stress urinary incontinence (SUI). STUDY DESIGN: This cross-sectional descriptive study included 1042 women, referred to a pelvic floor unit in a tertiary Spanish hospital, between 2008 and 2012. Subjects at their fist visit were interviewed and examined generally and specifically (medical and urogynecological history). Collected parameters included: age, weight, height, medical and surgical background (including in-depth obstetrical and gynecological characteristics). The participants were classified into 3 different groups (POP, SUI, and mixed pathology). Descriptive analyses of each variable and multinomial logistic regression were performed to determine factors associated with POP and SUI. RESULTS: Patients with POP were older, thinner, with greater parity and their newborns tended to be heavier. Furthermore, forceps, vaginal tears and vaginal surgeries were more common in the POP group. In contrast, family history was an important factor for the development of SUI, with a 6.45-fold increase (95% CI: 3.69-11.24). Two protective factors were identified for POP, cesarean section reduces the risk by 3 fold (OR=0.33) (95% CI: 0.13-0.85) whereas pelvic floor rehabilitation produces a 2 fold reduction (OR=0.49) (95% CI: 0.31-0.76). CONCLUSIONS: Our data study demonstrates differences in potential triggers and risk factors for POP and SUI. Cesarean section and pelvic floor rehabilitation have a protective effect on preventing the development of POP. Bringing up that a personal medical care and a specific urogynecological follow-up should be developed for those who are more susceptible or at risk of PFD.

Contasure-Needleless® single incision sling compared with transobturator TVT-O® for the treatment of stress urinary incontinence: long-term results.

INTRODUCTION AND HYPOTHESIS: This study compared transobturator tension-free vaginal tape (TVT-O®) and Contasure-Needleless (C-NDL®) at long-term follow-up . METHODS: Non-inferiority, prospective, single-centre , quasi-randomised trial started in September 2006 and finished in April 2011 to compare C-NDL® with transobturator vaginal tape (TVT-O®) mesh in the treatment of stress urinary incontinence (SUI) . Epidemiological information, intraoperative and postoperative complications, subjective estimates of blood loss and pain levels were recorded. We also analysed the postoperative stress test, the subjective impression of improvement using the Sandvik Severity Index and the quality of life during follow-up using the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) . RESULTS: Two hundred and fifty-seven women with primary SUI were scheduled to receive TVT-O® or C-NDL® and were followed up at least 3 years after the procedure . One hundred and eleven women in the C-NDL® group (84.7%) had a negative stress test, compared with 54 women (88.9%) in the TVT-O® group (p = 0.0065 for the non-inferiority test). The postoperative Sandvik Severity Index was 0 or better than the preoperative score in 90.7% of patients in the C-NDL® group and 95.4% of patients in the TVT-O® group (p = 0.0022). The complication rate was similar in both groups. There were significant differences (p = 0.02) in postoperative pain within the TVT-O® group. The degree of satisfaction was not statistically significant between the two groups. CONCLUSIONS: The outcomes for the C-NDL® group were similar to those of the TVT-O® group, adding the concept of "single incision tape" to the tension-free sling option.

Urinary incontinence during pregnancy. Is there a difference between first and third trimester?

OBJECTIVE: The aim of this study is to determine the prevalence and severity of urinary incontinence and to see if there are any differences between first and third trimester of pregnancy. STUDY DESIGN: A cross-sectional study of two groups of women was conducted. All patients attending our hospital for obstetric ultrasound examination during the first trimester (group 1=less than 13 weeks of pregnancy) and third trimester (group 2=up to 28 weeks of pregnancy) were eligible for inclusion. All participating women completed self-reported questionnaires: ICIQ-SF, PFDI-20 (UDI-6, CRADI-8, POPDI-6) and SF-36. The variables studied were biodemographic data and results from questionnaire responses. RESULTS: From March 2012 to May 2012, 224 consecutive pregnant women were included in this study: group 1 (n=58) and group 2 (n=166). The incidence of urinary incontinence during pregnancy is different in first and third trimester: 18.96% (11 of 58) and 39.76% (66 of 166) (p=0.008). 100% and 84.12% of women with UI in first trimester and third trimester respectively leak a small amount of urine. In 15.87% of group 2 the leakage was a moderate amount of urine. Participants mainly presented Stress UI (78.37%) and urge was only present in 12.16% of them. CONCLUSIONS: In conclusion, according to the results obtained, the prevalence of urinary incontinence in our population of pregnant women was 34.37%, which means that more than a third of the population of pregnant women is affected, and that this disorder is more common during the third trimester of pregnancy than during the first. The most common form was stress urinary incontinence, affecting 48.05% of the women. In all patients, leakage was slight-moderate that did not severely hamper their everyday life but did affect their physical, mental and social domains of their quality of life. Another problem, even more prevalent than incontinence itself, was the increase in urinary frequency, affecting 41.25% of the pregnant women and causing discomfort/distress in the 68.8%.

Surgical treatment of vaginal prolapse with Prolift® mesh in patients with risk of recurrence.

OBJECTIVE: The aim of this paper is to analyze the results obtained in pelvic floor surgery using a non-absorbable mesh in selected patients with risk factors of recurrent prolapse. METHODS: Case series including a total of 76 patients who were surgically treated for severe genital prolapse from July 2005 to December 2009, with risk factors for recurrence of genital prolapse. RESULTS: We detected 3 cases (6.8%) of symptomatic prolapse recurrence and 6 cases (13.6%) of prolapse of another compartment in the anterior Prolift® group. In the posterior Prolift® group there were no recurrences but there were 2 cases (10.52%) of prolapse of another compartment. In the total Prolift® group, there were 2 cases (16.6%) of symptomatic prolapse recurrence. As for de novo urgency, there were a total of 4 cases (5.33%), 3 in the anterior Prolift® group and 1 in the total Prolift® group. We did not detect any case of severe pain in the pelvis or mesh insertion points that required reoperation due to persistence. CONCLUSIONS: The use of mesh in pelvic floor reconstructive surgery in selected patients with risk factors for recurrence is a good treatment option to prevent or attempt to reduce the recurrence or reoperation rates currently described.

[Analysis of the efficacy and complications of the surgical treatment of stress urinary incontinence: retropubic and transobturator TVT. Our experience]. / Análisis de la eficacia y de las complicaciones en el tratamiento quirúrgico de la incontinencia urinaria de esfuerzo: TVT retropúbico y obturador. Nuestra experiencia.

OBJECTIVES: To evaluate the differences in results and complications between retropubic and obturator TVT. METHODS: Descriptive prospective study including 245 patients who underwent retropubic TVT and 90 obturator TVT after the diagnosis of stress urinary incontinence by means of clinical history, physical examination and urodynamic tests. Continence outcomes and Intraoperative/post operative complications were recorded. RESULTS: There were intraoperative complications in 12.65% of the retropubic TVT and 1.11% of the obturator TVT (p = 0.002). Immediate post operative complications appeared in 24.5% of the retropubic TVTs and 12.2% of the obturator TVTs: severe anemia (0.4 vs. 1.1%), inguinal pain (1.2 vs. 4.4%), hematoma (1.6 vs. 0%), urinary tract infection (12.2 vs. 4.4%), and acute urinary retention (8.9 vs. 2.2%) (p = 0.018). Complications during follow-up: partial exteriorization of the mesh (0.81 vs. 1.11%) and de novo urgency incontinence (9.38 vs. 4.44%) (p = 0.031). Post operative results were similar for both groups: 90.2% vs. 91.1% cured (p = 0.046), improvement in 8.2% vs. 6.7% (p = 0.18) and failure in 1.6% vs. 2.2% (p = 0.57). CONCLUSIONS: The obturator TVT seems to be preferable to retropubic TVT because it offers a lower complications rate without differences in post operative results in the short-term.

[Spanish registry of the TRT Reemex system in women with stress urinary incontinence (SUI)]. / Registro español del sistema TRT Remeex en mujeres con incontinencia urinaria de esfuerzo.

OBJECTIVES: Due to the absence of randomized studies, the Spanish Reemex Working Group started a registry to analyze and review the results of a large group of patients with mid-term and long-term follow-up to obtain conclusions based on clinical experience. METHODS: A registry of 715 patients who underwent surgical intervention for insertion of the SUI readjustable prosthesis Reemex TRT (tension free readjustable tape) in 15 Spanish hospitals (40% urology departments, 60% gynecology departments). The registry was established to evaluate the safety and efficacy of the sling adjustability concept in the surgical treatment of female SUI. The Spanish Working Group was able to evaluate results of the Reemex system in 683 patients of a total of 715. Mean age was 59.9 yr (range 21-87) with a mean follow-up of 23 months (6-93). The group includes: 30.2% patients with mixed incontinence, 73.1% patients with urodynamic intrinsic sphincteric deficit, 35.7% patients with previous history of failed surgical interventions for urinary incontinence, and 54.3% previous pelvic floor associated operations. All patients were evaluated preoperatively with history, physical examination and urinary incontinence questionnaire. Each follow-up visit included incontinence questionnaire, physical examination and stress test. RESULTS: Cure rate was 92.2%, with 6.9% improvement and 0.9% failures. Readjustment was performed in 416 patients (60.9%) as a second phase of surgery over the following 24-48 hours, before hospital discharge. 80 patients (11.7%) were readjusted in the mid- or long-term (between 6 and 8 months after surgery). The level of support of the sling was successfully reduced in three patients between 6 and 14 months after surgery. No other patient suffered voiding difficulties in the long-term. 1.7% of the patients needed extraction of the tensor due to persistent abdominal wall seroma. 0.8% presented vaginal extrusion of the sling. CONCLUSIONS: The Reemex system is a minimally invasive technique with consistent results and even improved in heterogeneous groups of patients including intrinsic sphincter defficiency, reoperations, mixed incontinence and associated pathologies.