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

OBJECTIVE: To assess the incidence of recurrent stress urinary incontinence (SUI) following vaginal excision of exposed mid-urethral tape (MUT). STUDY DESIGN: This 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. RESULTS: The 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. CONCLUSIONS: Over 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.

Two-year follow-up of an open-label multicenter study of polyacrylamide hydrogel (Bulkamid®) for female stress and stress-predominant mixed incontinence.

INTRODUCTION AND HYPOTHESIS: Polyacrylamide hydrogel (PAHG, Bulkamid®) is a promising urethral bulking agent. This article presents the 2-year follow-up results of a multicenter study of PAHG injections for treating stress and stress-predominant mixed urinary incontinence. METHODS: Submucosal injection of PAHG was performed in 135 women with urinary incontinence, with subjective and objective assessment of the efficacy and safety 24 months postinjection. RESULTS: At 24 months, the subjective responder rate was 64 % (a statistically non-significant reduction from 67 % at 12 months). The decreased number of incontinence episodes and urine leakage were maintained compared with the result from the 12-month evaluations, as were objective result rates and quality of life data. No safety issues occurred. CONCLUSIONS: PAHG is an effective and safe treatment option for women with stress-predominant mixed urinary incontinence, with maintained medium-term responder rates.

Evaluation of holmium laser for managing mesh/suture complications of continence surgery.

OBJECTIVES: • To evaluate transurethral endoscopic excision using the holmium laser (TEEH) for the management of lower urinary tract mesh or suture complications of continence intervention. • To compare the outcomes, complications and recurrence rates of TEEH with the published results from studies using other techniques. PATIENTS AND METHODS: • A retrospective review of six patients who underwent TEEH for eroded mid-urethral tape or suture into the urethra or bladder. • Patients with urethral and bladder exposure of mesh or suture material managed by TEEH were identified from the operating records, electronic data records and the Holmium Laser Registry at our institution. • Outcome variables included resolution of the presenting symptoms and continence status, recurrent mesh or suture exposure, and symptoms or other morbidity, including haematoma, urinary sepsis, voiding dysfunction and recurrent stress incontinence. • A literature review on the available evidence on holmium laser for lower urinary tract complications of continence surgery was undertaken. RESULTS: • Between September 2006 and March 2010, six women underwent TEEH. All presented with bladder storage symptoms and/or haematuria with recurrent cystitis. The interval between surgery and the diagnosis of erosion was 1-13 years. • Four women had previously undergone retropubic mid-urethral tape, one colposuspension and one a suprapubic arc procedure followed by a transobturator tape insertion. • Complete excision with TEEH was achieved in all cases. • Two women had postoperative haematuria, which resolved after 2 weeks. There were no other immediate complications. • Four patients had recurrent erosion at follow-up. Two of them were symptomatic, requiring repeat TEEH. One was asymptomatic and managed expectantly. In one case, recurrent mesh erosion occurred at the bladder neck in the submucosal layer. This was considered unsuitable for further TEEH. A laparotomy and open excision was undertaken. CONCLUSIONS: • TEEH is a minimally invasive technique, with minimal morbidity and complications, compared to open vaginal or abdominal excision of mesh or suture exposure into the lower urinary tract. Open urethrotomy involves risks of damage to the continence (sphincter) mechanism, with subsequent stress incontinence. In addition, anterior wall scarring may lead to dyspareunia, vaginal pain, urethral stricture and/or fistula. When mesh erosion involves the bladder, transabdominal open or laparoscopic excision may be required. • Although the recurrence rates in our series are high, the majority of them were managed easily by repeat TEEH, with minimal morbidity or expectantly if asymptomatic. • In selected patients, TEEH is an acceptable novel technique for the first-line management of this complication of continence interventions, although longer or pooled prospective studies evaluating TEEH are now required.

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

INTRODUCTION AND HYPOTHESIS: The 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). METHODS: POP was assessed 5 years postoperatively in 42 women who underwent vaginal hysterectomy and HUSLS for POP. Bladder, bowel, sexual function and quality of life (QoL) were evaluated. RESULTS: Preoperatively, 27/42 women had at least BW grade 2 uterine prolapse. At a mean follow-up period of 59.4 months (range: 40-79 months), 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. CONCLUSIONS: Modified HUSLS at vaginal hysterectomy is associated with satisfactory long-term objective and subjective outcomes, sexual function and quality of life scores.

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

PURPOSE: Vaginal/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. METHODS: Consecutive 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 (10 ml), hydrocortisone (100 mg) and hyaluronidase (1,500 IU). Follow-up was undertaken at four-weekly intervals. Further injections were performed as clinically indicated. RESULTS: Fifty-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 8 months (range 12 weeks-20 years). 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 (p = 0.0002, 95% CI 1.01-3.05) and mean ASFQ scores increased from 18.1 to 29.1 (p = 0.01, 95% CI -17.2 to -2.3) 4 weeks 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 8 weeks post-injection. CONCLUSION: In our series, this treatment was well tolerated and significant improvements in pain scores and sexual function were observed.

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

AIMS: To evaluate the outcomes of a modified high uterosacral ligament suspension (HUSLS) performed at vaginal hysterectomy for uterine prolapse. METHODS: Prolapse was assessed pre- and postoperatively in 53 consecutive women, using Baden-Walker Halfway and Pelvic Organ Prolapse Quantification systems. Sexually active women completed the Prolapse and Incontinence Sexual Function Questionnaire at follow up. The technique involves placement of one HUSLS suture on each side without a fascial reconstruction. RESULTS: Preoperatively, 37 (66%) women had at least Grade 2 prolapse of the cervix. At mean follow-up of 15 months, 45 (85%) had no vault prolapse and 7 (13%) had Grade 1 prolapse. Nineteen (36%) women were sexually active at follow up and completed the Prolapse and Incontinence Sexual Function Questionnaire. Mean scores for pain, vaginal tightness, partner perception of tightness and vaginal length were 2.8, 3.2, 4.0, and 3.8 respectively, indicating excellent function. CONCLUSIONS: We report excellent objective, subjective and sexual function outcomes following this modified HUSLS.

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 6 months. In this case, xenograft achieved tension-free closure of the urethral defect without any postoperative complications.

Evaluation of outpatient cystoscopy in urogynaecology.

OBJECTIVE: Prospective evaluation of outpatient cystoscopy in a Urogynaecology Unit. DESIGN: Prospective observational series. SETTING: St. George's Hospital, London. Department of Pelvic Reconstructive Surgery and Urogynaecology. POPULATION: A total of 131 consecutive women, who underwent outpatient rigid cystoscopy over a 24-month-period. MATERIALS AND METHODS: Prospective data collection included cystoscopic findings, microbiology data, uroflowmetry and radiological results. An Immediate Feedback Questionnaire was completed at the end of the procedure. MAIN OUTCOME MEASURES: Success rates of the procedure, cystoscopy findings, requirements for additional investigations, including inpatient cystoscopy and patient satisfaction rates. RESULTS: The mean age was 56.4 years (range 20-87 years). A total 126 women (96.2%) had a successful outpatient cystoscopy. In five (3.8%) women the procedure had to be abandoned because of inability to insert the cystoscope. Eleven women (8.7%) experienced pain but were able to tolerate the discomfort. Fifty-three (42.7%) women had abnormalities detected at cystoscopy. Thirty-seven women had trabeculations. Focal vesical lesions were found in 21 women. Thirty-nine (30.9%) women did not require any additional treatment. Six (6.9%) women were scheduled for repeat cystoscopy under general anaesthetic to facilitate a bladder biopsy. Fifteen women (17.2%) were referred for urodynamics or renal imaging. Three women (3.4%) were referred to a urologist. More than 75% reported high satisfaction with the care they received. Four women had symptoms of UTI and two had positive urinary cultures and required antibiotics. CONCLUSIONS: The benefits of outpatient cystoscopy include high levels of tolerability and patient satisfaction, shorter waiting time, quicker implementation of treatment strategies, avoidance of the risks of general anaesthesia and lower procedural cost.

Are voiding symptoms really associated with abnormal urodynamic voiding parameters in women?

OBJECTIVES: To examine the relationship between voiding symptoms and objective measurements of voiding dysfunction. METHODS: We prospectively collected data from 116 consecutive women attending for urodynamic investigations. Symptoms of voiding dysfunction and objective voiding parameters including uroflowmetry and post-void residual volume were evaluated. RESULTS: Sixteen (14%) patients reported a symptom of straining, 21 (18%) double voiding, 32 (27%) post-micturition dribbling, 10 (8%) poor stream and 34 (29%) incomplete emptying. Using receiver-operator curves we were unable to determine a cut-off value for flow or residual volume where symptoms became more prevalent. Poor stream was, however, a good predictor for a residual volume of >100 mL and >150 mL. Strain predicted a residual volume of >100 and >150 mL and it correlated with maximum flow rate <15 mL/s. The other three symptoms did not correlate with any of the cut-off values. CONCLUSIONS: Poor steam and strain are weakly predictive of abnormal voiding function.

Female voiding dysfunction.

Female voiding dysfunction unrelated to childbirth is common but poorly understood, and most often occurs as a result of detrusor hypotonia and less frequently in association with bladder outlet obstruction. Specific causes include anti-incontinence surgery, bladder over-distension, painful infective, allergic or chemical reactions of the urogenital tissues, bladder outlet obstruction, dyssynergia of the bladder-urethral sphincter mechanism, neurogenic, pharmacological, and psychogenic causes. A thorough history and examination is essential in the clinical assessment. It should be followed by investigations including urine microbiology, frequency volume diaries, ultrasound scan, uroflowmetry, and, when indicated, subtracted voiding cystometry, electromyography, and cystourethroscopy. The main treatment modalities are catheterization (self-intermittent, suprapubic, urethral, in order of preference), bladder retraining, biofeedback, and, rarely, surgery or sacral neuromodulation.

Is there an alternative to pad tests? Correlation of subjective variables of severity of urinary loss to the 1-h pad test in women with stress urinary incontinence.

OBJECTIVE: To compare the 1-h pad test in women who have urodynamically confirmed stress incontinence (USI) with a patient-based 3-point symptom severity scale and validated quality of life (QoL) questionnaires. PATIENTS AND METHODS: In all, 98 women with USI were prospectively recruited; all had a 1-h pad test and completed the validated disease-specific QoL questionnaires, including short forms of the International Consultation on Incontinence Questionnaire (ICIQ-SF), Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7). In addition, the severity of incontinence was determined using the Stamey grading scale, a visual analogue scale (VAS) score, and a patient-based 3-point symptom severity scale. RESULTS: The VAS, symptom severity scale, Stamey grade, UDI-6, and IIQ-7 failed to correlate significantly with the 1-h pad test. Only the ICIQ-SF correlated significantly with this test. CONCLUSION: The ICIQ-SF is easy to administer and, in this study, correlated best with the 1-h pad test in women with pure primary or secondary USI. It incorporates both symptom severity and QoL variables. We recommend its routine use in clinical practice.

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.

Female sexual dysfunction.

Female sexual dysfunction is a common problem with detrimental effects on woman's quality of life. It also has an economical and societal impact. It is defined as disorders of sexual desire, arousal, orgasm, and sexual pain, which lead to personal distress. The etiology of sexual dysfunction is frequently multifactorial as it relates to general physical and mental well-being, quality of relationship, past sexual functioning, social class, education, employment, life stressors, personality factors, the presence of a sexual partner, and partner's age and health. It is very important to adopt the most efficient approach to gather information, and this may be achieved via standardized questionnaires or open-ended questions. Therapy should be tailored according to the patient's needs and may involve a multidisciplinary team approach including psychosexual counselor/sexologist/therapist and the physician. There is still more work needed to optimize the care of women with this problem. Priority should be given to international standardization and training of health care professionals.

Efficacy and complications of intradetrusor injection with botulinum toxin A in patients with refractory idiopathic detrusor overactivity.

OBJECTIVES: To evaluate the efficacy and complications of botulinum A toxin (Dysport, Ipsen Ltd, Slough, UK) 500 U in refractory idiopathic detrusor overactivity (IDO). PATIENTS AND METHODS: In a prospective study of 25 patients with refractory IDO, the baseline evaluation included an assessment of symptoms, a 7-day voiding diary, 24-h pad test, record of symptoms on a visual analogue scale (VAS) (0-10), the Kings Health Questionnaire (KHQ) and urodynamics. Dysport 500 U was administered at 20 sites in the bladder, sparing the trigone. Patients were followed at 6 weeks and 3, 6 and 9 months; the urodynamic assessment was repeated at 3 months. RESULTS: Fifteen (63%) patients reported being continent from 1 week after treatment; at 3 months, six (32%) (P = 0.01) patients were still dry, remaining so at 6 months (P = 0.025). Weekly leakage episodes decreased from 5.5 to 1.8 (P = 0.044) at 6 weeks and this was sustained, at 2.7 episodes (P = 0.012), at 9 months. The mean VAS score (0-10) decreased from 8.3 to 5.0 (P = 0.001) at 1 week, to 5.0 at 6 weeks (P = 0.001) and 3 months (P = 0.03) and to 6.1 (P = 0.013) at 6 months. On the KHQ there was a significant improvement in the severity measures domain (P = 0.021) and incontinence impact domain (P = 0.015) up to 9 months. The volume at first desire to void increased from 177 to 251 mL (P = 0.04) at 3 months. At 6 weeks and 3 months, 35% of patients required catheterization, as did 22% at 6 months, but only one at 9 months. CONCLUSIONS: Intradetrusor Dysport 500 U was associated with significant subjective and objective improvements in refractory IDO. The present patients initially had a significant increase in voiding dysfunction that resolved by 9 months.

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.

Symphysial pelvic dysfunction.

PURPOSE OF REVIEW: Symphysial pelvic dysfunction is a condition which develops during pregnancy and may lead to significant morbidity affecting quality of life. While postpartum resolution is common, symptoms may persist for many years. The consequences, specifically disabling pain, are even more detrimental on mothers with a young family. This review summarizes current understanding of the condition, including pathogenesis, risk factors and management. RECENT FINDINGS: There is no current international consensus on definition, diagnostic criteria, and treatment protocols for symphysial pelvic dysfunction. Discrepancy between the reported rates of prevalence stems from ambiguity in definition and inclusion criteria in reported studies. The pathogenesis of the condition is still unclear although numerous theories have been proposed. It is likely to be multifactorial in origin with multiple factors both biomechanical and genetic factors playing an important role. There is also a paucity of information in the literature about the best management strategy. SUMMARY: There is an urgent need to standardize terminology and define diagnostic criteria for symphysial pelvic dysfunction in order to improve the management and better understand the pathophysiology of this condition.

Female urethral diverticula.

Urethral diverticula are frequently under-diagnosed. The pathogenesis of this condition is poorly understood, and these lesions represent a spectrum of disorders ranging from isolated suburethral cysts to herniation of the urethral lining into the vaginal mucosa. Women with this disorder frequently complain of a host of symptoms referable to the lower urinary and genital tracts. Accurate diagnosis is based on history and clinical evaluation. Perineal ultrasound and MRI are often helpful. Repeated courses of antibiotics and urethral dilatation often fail to resolve the problem, and definitive intervention usually requires surgical excision to provide relief. This chapter describes the current management of this condition, and it heralds a re-look at the patho-aetiology in view of recent MRI findings of symptomatic non-communicating microcystic lesions.

Tension-free vaginal tape exposure presenting as a recurrent sterile paraurethral abscess.

We report a case of tension-free vaginal tape (TVT) exposure presenting as a recurrent sterile paraurethral abscess at 25 months and 40 months following successful continence surgery and describe the management of this problem.

The tension-free vaginal tape in older women.

OBJECTIVE: To evaluate peri-operative morbidity, continence outcome and patient satisfaction in older women (>/=65 years) compared with younger women undergoing tension-free vaginal tape. DESIGN: Case controlled study. SETTING: Tertiary Urogynaecology Unit. SAMPLE: Women undergoing tension-free vaginal tape for urodynamic stress incontinence between July 1999 and July 2002 were included. Those with detrusor overactivity, voiding difficulty at urodynamics or requiring concomitant prolapse surgery were excluded. METHODS: Older women were case matched to a younger cohort for BMI, parity, mode of anaesthesia and whether it was a primary or secondary continence procedure. MAIN OUTCOME MEASURES: Operative morbidity and continence outcome were assessed at six weeks. After a minimum six months follow up, patient satisfaction and continence outcome were assessed using the Genitourinary Treatment Satisfaction Score (GUTSS). RESULTS: The median hospital stay was one day and overall urinary tract infection rate was similar in both groups. Post-operative voiding difficulty rates were 3% in older versus 15% in younger women (P= 0.09). At six weeks, 65% of older versus 79% of younger women were dry (P= 0.2). At a median of 12 months, 15 (45%) of older versus 24 (73%) of younger women had no urinary symptoms (P= 0.05). Median GUTSS scores for satisfaction with continence outcome were lower for older 90% compared with 100% in younger women (P= 0.003). CONCLUSIONS: Tension-free vaginal tape is an effective continence intervention in older women but has a lower continence satisfaction rate compared with younger women.