A Roadmap for Training in Urogynecology: IUGA International Initiative.

INTRODUCTION AND HYPOTHESIS: Training in urogynecology is an important mission of the International Urogynecological Association (IUGA). Promoting official training programs in countries around the world is an integral part of this mission. METHODS: The IUGA established the Fellowship Development Committee to develop a roadmap to assist countries to develop a professional training program in urogynecology. Two focus groups were created: the curricula topics focus group and the survey focus group. The curricula topics focus group is aimed at developing a list of subjects that can be the basis for a training syllabus. The survey focus group is aimed at understanding the main steps and the difficulties in establishing an official training program by interviewing representatives from both accredited and non-accredited countries and developing a roadmap for an official training program recognized by the local authorities. RESULTS: The fellowship development committee included 13 members. The curricula topics focus group developed a format for the description of each included topic. Each topic had to include a description of the required related skills and procedures. Two curricula topics lists were created: one for basic training and a second for advanced training. The survey focus group conducted two table discussions with representatives from countries with accredited training programs and countries without accredited training programs. The comments of these meetings were summarized in documents submitted to the IUGA board of directors. CONCLUSION: The fellowship development committee studied the main hurdles to developing an official training program in urogynecology. The roadmap document should form the basis of the IUGA international initiative to assist countries around the world to develop an official training program in urogynecology recognized by the local authority.

Establishment and initial implementation of the Australasian Pelvic Floor Procedure Registry.

INTRODUCTION AND HYPOTHESIS: Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are common pelvic floor disorders (PFDs). Owing to significant adverse events associated with mesh-related pelvic floor procedures (PFPs) in a proportion of the surgically treated population, and deficits in collection and reporting of these events, the Australian Government identified an urgent need for a tracking mechanism to improve safety and quality of care. The Australasian Pelvic Floor Procedure Registry (APFPR) was recently established following the 2018 Senate Committee Inquiry with the aim of tracking outcomes of PFP involving the use of devices and/or prostheses, with the objective of improving the health outcomes of women who undergo these procedures. This paper will describe the APFPR's aims, development, implementation and possible challenges on the way to its establishment. METHODS: The APFPR has been developed and implemented in accordance with the national operating principles of clinical quality registries (CQRs). The minimum datasets (MDS) for the registry's database have been developed using a modified Delphi process, and data are primarily being collected from participating surgeons. Patient recruitment is based on an opt-out approach or a waiver of consent. Patient-reported outcome measures (PROMs) providing additional health and outcome information will be obtained from participating women to support safety monitoring of mesh-related adverse events. RESULTS: Currently in the Australasian Pelvic Floor Procedure Registry (APFPR) there are 32 sites from various jurisdictions across Australia, that have obtained relevant ethics and governance approvals to start patient recruitment and data collection as of January 2023. Additionally, there are two sites that are awaiting governance review and five sites that are having documentation compiled for submission. Seventeen sites have commenced patient registration and have entered data into the database. Thus far, we have 308 patients registered in the APFPR database. The registry also published its first status report and a consumer-friendly public report in 2022. CONCLUSIONS: The registry will act as a systematic tracking mechanism by collecting outcomes on PFP, especially those involving devices and/or prostheses to improve safety and quality of care.

Do doctors preferring forceps encounter more obstetric anal sphincter injuries: A retrospective analysis.

BACKGROUND: Obstetric anal sphincter injuries (OASIS) is a hospital-acquired injury and can affect a woman's quality of life with problems such as anal incontinence, perineal pain, dyspareunia, mental health, psychosexual issues, and concerns about future childbirth choices. AIMS: The aim of this study was to determine whether there is a correlation between a doctor's preference for instruments, their individual OASIS rate and whether factors such as their fully dilated caesarean section rate, rate of double instrumental and seniority, influences their individual rate of OASIS. MATERIALS AND METHODS: A population-based retrospective cohort study was performed on 1340 term nulliparous women with singleton pregnancies who underwent an instrumental delivery or fully dilated caesarean section. A survey of doctors involved in these deliveries was performed. The risk of OASIS was analysed for maternal age, ethnicity, birth position, level of training and doctor's instrument preference using a generalised linear mixed model. Doctors' instrument preferences were established in two ways: a self-reported survey and data-inferred preference based on the most used instrument per doctor. The OASIS rate for individual doctors was calculated. RESULTS: The overall risk of OASIS is higher for forceps compared to vacuum deliveries. Doctors with a preference for forceps compared to vacuum, correlated with both a lower OASIS rate and a higher fully dilated caesarean section rate. CONCLUSIONS: Doctors preferring forceps report a lower OASIS and higher fully dilated caesarean section rate. Doctors preferring vacuum must consider carefully whether forceps should follow if a vacuum fails as OASIS is more likely to occur.

Postpartum anal incontinence in women with and without obstetric anal sphincter injuries.

INTRODUCTION AND HYPOTHESIS: Postpartum anal incontinence is common and distressing for women. We sought to look at the prevalence of anal incontinence in women who sustained obstetric anal sphincter injuries (OASI) compared with women who did not, and factors leading to these symptoms during the postpartum period. METHODS: A total of 129 primiparous women sustaining OASI were compared with 131 women who did not (controls). They were contacted at approximately 6-10 weeks postpartum to obtain information on their symptoms of anal incontinence (AI). The data underwent univariate and multivariate analysis. RESULTS: There was no difference in the prevalence of AI symptoms, occurring in 30% of women with OASI, and 23% of women without at 6-10 weeks postpartum; however, in women with high-grade tears the prevalence was 59%. Severe OASI (grade 3c and 4) was associated with an increased prevalence of both AI and severe AI, whereas forceps delivery and increasing maternal age were associated with an increased prevalence of severe AI only. CONCLUSION: Women with less severe (grade 3a and 3b) OASI do not experience a higher prevalence of AI than women without OASI in the postpartum period. Higher grade (3c and 4) tears, forceps delivery and increasing maternal age are associated with higher rates of AI. These factors should be avoided where possible to reduce postpartum AI. All women should be warned of the 23-30% chance of experiencing some mild AI in this period. Whether these symptoms are transient or long-lasting requires further investigation.

What not to expect when you're expecting - Postpartum proximal ureteric rupture: A case report.

INTRODUCTION: Spontaneous ureteric rupture is an extremely rare cause of acute abdominal pain in the intrapartum and postpartum period. We present the case of a right ureteric rupture diagnosed immediately postpartum. CASE: A 23-year-old woman in her second pregnancy (who had had a previous caesarean section) developed acute-onset right-flank pain 12 h after vaginal delivery. A contrast computerized tomography scan suggested a ureteric injury; ureteroscopy diagnosed a proximal ureteric rupture and a stent was placed. DISCUSSION: This case outlines an extremely rare cause of abdominal pain in the peripartum. There can be serious complications, including urinoma, abscess and sepsis, and therefore the diagnosis should not be delayed.

Patient attitude and acceptance towards episiotomy during pregnancy before and after information provision: a questionnaire.

INTRODUCTION AND HYPOTHESIS: Evidence regarding how women feel about episiotomies is not recorded in the literature. As the most common surgical procedure, there is a need to understand how women feel about episiotomy. METHODS: The primary outcome was to identify the percentage of women who would accept an episiotomy if required. A literature review was compiled to provide nulliparous women in their third trimester with evidence-based information about episiotomies and perineal tears. Questions eliciting demographics, pre-information level of anxiety and acceptance of episiotomy were asked. After reading the information sheets, anxiety and knowledge were assessed again. Changes in anxiety levels from pre- to post-information were investigated using paired samples t tests. Because anxiety was measured on a scale, we assessed potential departures from normality by using the Wilcoxon signed-rank test. Questions also assessed the value women placed on this form of education. RESULTS: There were 105 responses, with 88% accepting episiotomy, 2% declining and 10% seeking more information to decide. Eighty-one percent of women agreed that the information provided helped them to understand more about childbirth and 62% agreed that they felt more comfortable with the birthing process after reading the material. There was a reduction in anxiety levels regarding episiotomies after reading information (p = 0.002) and perineal tears (p = 0.02). CONCLUSIONS: Most women will accept an episiotomy if required. Antenatal education about episiotomies is important to women and helps them feel more comfortable with the birthing process. Written information increases acceptance and reduces anxiety levels regarding episiotomies.

Prospective comparison of obstetric anal sphincter injury incidence between an Asian and Western hospital.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury (OASIS) rates are reported to be higher in Asian women living in Western countries than in those living in Asia, but the reasons for the differences remain unclear. The objectives of this study were for a single examiner to prospectively compare OASIS rates in primiparous Asian women in an Asian and Western birth unit and determine potential birth factors that may influence the possible difference in OASIS incidence. METHODS: This was a prospective observational study based in Hong Kong, China, and Sydney, Australia, involving primiparous women > 36 weeks gestation of Asian descent undergoing vaginal delivery. A single examiner recorded basic patient demographics, observed all the deliveries at both sites, noting birthing techniques, and then examined the women, including a rectal examination, to determine OASIS incidence. RESULTS: Seventy births in Hong Kong and 66 in Sydney were studied. The incidence of OASIS was 34% in Sydney and 10% in Hong Kong (p = 0.001). Birthweight, epidural rate, body mass index, and instrumental delivery were higher in Sydney. Episiotomy rates were higher in Hong Kong (59.2% vs. 82.9%; p = 0.007). When comparing OASIS with no-OASIS, perineal length (OR = 0.36, 95% CI 0.17 to 0.76, p = 0.004) and birthweight (OR = 1.14, 95% CI 1.00 to 1.30, p = 0.039) were independent risk factors for OASIS. CONCLUSIONS: The incidence of OASIS in Asian women is significantly higher in a Western than in an Asian setting. In Asian women, perineal length and birthweight can affect the risk of OASIS at the time of vaginal delivery.

The relationship between residual sphincter damage after primary repair, faecal incontinence, and anal sphincter function in primiparous women with an obstetric anal sphincter injury.

BACKGROUND AND AIMS: Anal sphincter injury has been identified as a primary cause of post-partum fecal incontinence in women with obstetric anal sphincter injury. However, women without obstetric anal sphincter injury may also develop fecal incontinence. The aim is to determine the relationship between fecal incontinence severity; and i) residual anal sphincter injury, quantified by the Starck score, and ii) anal sphincter tone. METHODS: Consecutive case series of prospectively collected data set in a Pelvic Floor Unit within a tertiary teaching hospital in Australia. Population 181 primiparous women with Sultan classification Grade 3 and 4 sphincter injuries. MAIN OUTCOME MEASURES: Sultan classification, anal manometry, pudendal nerve terminal motor latency, St Mark's fecal incontinence score, and Starck ultrasound score. RESULTS: 45% of women reported some degree of fecal incontinence. One third of women with normal external sphincter tone were incontinent. Those with higher Starck score had higher St Mark's scores. A higher Sultan classification correlated with more severe incontinence regardless if the repair was complete. Forceps delivery had a twofold risk of incontinence when compared to non-forceps delivery. CONCLUSION: The importance of an effective anal sphincter repair is confirmed. However, overall there is no direct relationship between residual sphincter damage, anal sphincter tone, and fecal incontinence severity. These data indicate that anal sphincter integrity alone is not the sole mechanism for maintaining fecal continence. Rectal and colonic motor function may also play a role and investigation into these components may provide greater insight into the effect of vaginal delivery upon fecal continence mechanisms.

Risk factors for obstetric anal sphincter injuries and postpartum anal and urinary incontinence: a case-control trial.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injuries (OASIS) cause serious maternal morbidity for mothers. A clearer understanding of aetiological factors is needed. We aimed to determine the risk factors for OASIS . METHODS: Birth details of 222 primiparous women sustaining OASIS were compared with 174 women who did not sustain OASIS (controls) to determine the relevant risk factors. The data underwent univariate analysis and logistic regression analysis. RESULTS: Asian or Indian ethnicity, operative vaginal birth (p = 0.00), persistent occipito-posterior position (p = 0.038) and rapid uncontrolled delivery of the head were identified as risk factors for OASIS. Pushing time, use of epidural, episiotomy and head circumference were not predictors of OASIS. CONCLUSIONS: Women with Asian or Indian ethnicity, operative vaginal birth, persistent occipito-posterior position and rapid uncontrolled delivery of the fetal head were likely to sustain OASIS. Awareness of these factors may help to minimise the incidence of OASIS.

Randomized controlled trial of cough test versus no cough test in the tension-free vaginal tape procedure: effect upon voiding dysfunction and 12-month efficacy.

INTRODUCTION AND HYPOTHESIS: This is a prospective randomized controlled trial of cough versus no cough test in the tension-free vaginal tape (TVT) procedure to determine its effect upon voiding dysfunction and 12-month efficacy. METHODS: The trial was conducted in a single tertiary urogynecology unit. Women ≥21 years old with primary urodynamic stress incontinence without voiding dysfunction were considered eligible. Participants were randomized to undergo the TVT procedure using either an intraoperative cough test or using no intraoperative cough test. Our hypothesis was that postoperative voiding dysfunction would be more common in the "no cough test" arm. The primary outcome was proportion of patients successfully completing a trial of void (TOV) within 24 h of catheter removal. Efficacy at 12 months comprised the secondary outcome. Participants were randomized using a computer-generated randomization sequence by an independent party who was not the operating surgeon. Due to the nature of the intervention to be tested, neither the patients nor the operating surgeons were blinded to the randomization process during the procedure. RESULTS: This trial is reported according to the recommendations of the 2010 CONSORT statement. In total, 94 women were recruited over a 4-year study period. Of these, 92 women were randomized (47 in the "cough" group and 45 in the "no cough" group). In one case, the TVT procedure was abandoned intraoperatively, leaving 91 women who underwent analysis. There was no significant difference in the proportion of women with a successful TOV within 24 h between the two arms (79% in the "cough" group versus 71% in the "no cough" group; p = 0.47). Efficacy data at 12 months were not significantly different between groups. CONCLUSION: Our data suggest that the performance of the intraoperative cough test during the TVT procedure does not reduce the incidence of postoperative voiding dysfunction (as determined by successful TOV within 24 h) nor affect efficacy. The removal of the cough test from the standard TVT technique may be appropriate.

Does patient activity level affect 24-hr pad test results in stress-incontinent women?

AIM: Standardization of the 24-hr pad test procedure would increase its validity as an objective measure of urinary incontinence. Our aim was to establish whether patient activity levels affect pad test results in stress-incontinent women, and if so, to develop a standard activity level during the testing period. METHODS: In this prospective observational study, 25 women with pure stress urinary incontinence (SUI) completed two 24-hr pad tests and documented their daily activities during a "normally active" and "minimally active" day. Activity level was compared with pad weight gain and the number of leakage episodes due to activity according to a patient activity diary (diarized activity leakage episodes) using non-parametric tests. RESULTS: There was a significant difference between the "normally active" and "minimally active" days for median pad weight gain (9.9 g vs. 5.2 g, P < 0.05) and diarized activity leakage episodes (2 vs. 1, P < 0.05). When the days were re-categorized, there was a significant difference between "mild activity" and "moderate activity" days for median pad weight gain (4.85 g vs. 7.1 g, P < 0.05) and diarized activity leakage episodes (0 vs. 2, P < 0.05). CONCLUSION: Increased patient activity levels increase the degree of leakage as measured by 24-hr pad weight gain therefore patients with SUI should perform the 24-hr pad test with standardized activity instructions. In scientific research, we recommend that women perform minimal physical activity, as this decreases the variation of activity. This approach will enhance the function of the 24-hr pad test as a severity measure between patients with SUI.

Vaginal hysterectomy versus total laparoscopic hysterectomy for benign disease: a metaanalysis of randomized controlled trials.

OBJECTIVE: Recent randomized trials comparing total laparoscopic hysterectomy (TLH) and vaginal hysterectomy (VH) have produced conflicting results. The role of TLH in women suitable for VH remains uncertain. STUDY DESIGN: This study was a metaanalysis of randomized studies comparing TLH and VH for benign disease. Pooled outcome measures (odds ratio [OR] and weighted mean difference [WMD]) were calculated using random-effects models. RESULTS: No differences in perioperative complications, either total (pooled odds ratio, 0.87; P = .74) or by grade of severity, were demonstrated. TLH was associated with reduced postoperative pain scores (WMD -2.1; P = .03) and reduced hospital stay (WMD -0.62 days; P < .0001) but took longer to perform (WMD 29.3 minutes; P = .003). No differences in blood loss, rate of conversion to laparotomy, or urinary tract injury were identified. CONCLUSION: TLH may offer benefits compared with VH for benign disease, although this analysis is likely underpowered for rare complications. Further studies of long-term outcomes, including prolapse, urinary incontinence, and sexual function, are required.

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.

Comparison of the ICIQ-SF and 24-hour pad test with other measures for evaluating the severity of urodynamic stress incontinence.

This study compared the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the 24-h pad test with other measures that assess severity of urinary loss in women with urodynamic stress incontinence (USI). Ninety-five women with primary or recurrent (secondary) USI were recruited. Assessment of the severity of urinary loss was made using the ICIQ-SF, a 24-h pad test, continence questionnaire, Stamey grade, and 3-day frequency volume diary. The relationship between these measures of incontinence severity was analysed. The mean age was 54 years (SD+/-12) and median parity 2 (IQR 1-3). In the primary USI group there was a strong correlation between the ICIQ-SF and the 24-h pad test (r=0.458, P =0.000). Both the ICIQ-SF (Kendall's' tau b=0.331, p =0.003) and 24-h pad test (Kendall's tau b=0.399, p =0.002) also correlated with the mean frequency of urinary loss on diary but not with the Stamey grade. No subjective or objective tests correlated with each other in women with secondary USI. These results demonstrate a good correlation between the 24-h pad test diary loss, and ICIQ-SF in women with primary USI. Because it also includes a measure of quality of life impact in a short user-friendly format, we suggest that the ICIQ-SF should have widespread applicability as an outcome measure in patients with stress incontinence.