How do we make progress in phenotyping patients with LUT such as OAB and underactive detrusor, including using urine markers and microbiome data, in order to personalize therapy? ICI-RS 2023: Part 1.

INTRODUCTION: Overactive bladder (OAB) and Underactive bladder (UAB) could be associated with metabolic syndrome, affective disorders, sex hormone deficiency, changes in urinary microbiota, functional gastrointestinal disorders, or autonomic nervous system dysfunction. OBJECTIVES: The aim of this Think Tank was to provide a guide on how to investigate OAB and/or detrusor underactivity (DU) patients to better clarify the underlying pathophysiology and possibly personalize the treatment. METHODS: A compendium of discussion based on the current evidence related to phenotyping patients with OAB or DU investigating metabolic, neurogical, psychological and gastrointestinal aspects with the aim to personalize the treatment. RESULTS AND CONCLUSIONS: The article emphasizes the critical significance of adopting a comprehensive yet tailored approach to phenotyping patients with lower urinary tract symptoms, such as OAB and UAB. The intricate interplay between the lower urinary tract and various factors, metabolic, neurological, psychological, and gastrointestinal can define unique LUT profiles, enabling personalized therapies to replace the one-size-fits-all approach.

How do we make progress in phenotyping patients with lower urinary tract such as overactive bladder and underactive detrusor, including using urine markers and microbiome data, to personalize therapy? ICI-RS 2023-Part 2.

INTRODUCTION: Overactive bladder (OAB) and underactive bladder (UAB) could be associated with metabolic syndrome, affective disorders, sex hormone deficiency, changes in urinary microbiota, functional gastrointestinal disorders, or autonomic nervous system dysfunction. OBJECTIVES: The aim of this Think Tank was to provide a guide on how to investigate OAB and/or detrusor underactivity (DU) patients to better clarify the underlying pathophysiology and possibly personalize the treatment. METHODS: A compendium of discussion based on the current evidence related to phenotyping patients with OAB or DU using urodynamic tests, functional neuro-imaging, urinary markers, and microbiome. RESULTS AND CONCLUSIONS: The article emphasizes the critical significance of adopting a comprehensive yet tailored approach to phenotyping patients with lower urinary tract (LUT) symptoms, such as OAB and UAB. The intricate interplay between the LUT and various factors, metabolic, neurological, psychological, and gastrointestinal can define unique LUT profiles, enabling personalized therapies to replace the one-size-fits-all approach.

How should prospective research be designed to legitimately assess the value of urodynamic studies in female urinary incontinence?

AIMS: Since formal evidence demonstrating the value of urodynamic studies (UDS) in functional urology remains elusive, we aimed to consider how best to design robust research for this purpose in female urinary incontinence. METHODS: An expert group was convened to debate the following considerations: (a) precedents for formally proving the value of a gold standard diagnostic test, (b) key research principles, (c) defining a study population, (d) selecting endpoints, (e) defining interventional and controls arms, (f) blinding, (g) powering the study, and (h) duration of follow-up. In each case, we considered the strengths and weaknesses of different approaches in terms of scientific validity, ethical acceptability, practicality, and likelihood of bias. RESULTS: We agreed that unlike evaluating therapies, attempting to judge the value of a diagnostic test based on eventual treatment success is conceptually flawed. Nonetheless, we explored the design of a hypothetical randomized controlled trial for this purpose, agreeing that: (1) the study population must sufficiently reflect its real-world counterpart; (2) clinical endpoints should include not only continence status but also other lower urinary tract symptoms and risks of management; (3) participants in the interventional arm should receive individualized management based on their UDS findings; (4) the most scientifically valid approach to the control arm-empiric treatment-is ethically problematic; (5) sufficient statistical power is imperative; and (6) ≥ 2 years' follow-up is needed to assess the long-term impact of management. CONCLUSIONS: Although a perfect protocol does not exist, we recommend careful consideration of our observations when reflecting on past studies or planning new prospective research.

When does oasis cause de novo pelvic floor dysfunction? role of the surgeon's skills.

INTRODUCTION AND HYPOTHESIS: Minorly skilled gynecologists are less likely to repair obstetric anal sphincter injuries (OASIS), and this can lead to higher rate of de novo onset of pelvic floor dysfunction (PFD). The aim of this study was to understand the impact of surgeon skills in OASIS repair on de novo incidence of PFDs. METHODS: An observational prospective cohort study performed between January 2019 and December 2020. We included 116 women with OASIS. At 6-weeks from delivery, women were divided into two groups in relation to the onset of PFDs. Characteristics were compared; categorical and continuous variables were assessed with chi-squared test and the Mann-Whitney rank-sum test respectively. Factors involved in PFDs development were analysed with explorative univariate analysis; significant (p<0.05) or approaching significance (p≤0.10) variables were included in multivariable analysis. RESULTS: Seventy-six women (76/116; 65.5%) reported at least one PFD symptom and anal incontinence was the most prevalent (44.73%; 34/76). OASIS management by a skilled gynaecologist resulted protective for PFDs [aOR 0.33 (0.13-0.61)]. Skilled surgeon reported fewer PFDs than less skilled surgeon (4% vs 82.4%; p<0.0001). Operative delivery was more performed (32.5% vs 15.8%; p= 0.03) and severe OASIS resulted more prevalent (60% vs 17.1%; p<0.0001) among women without PDFs, even if these didn't affect the incidence of de novo PFDs [aOR 1.03 (0.23-1.45) and 0.83 (0.13-1.45), respectively]. CONCLUSIONS: Surgeons skilled in OASIS repair resulted the only protective factor for incidence of de novo PFDs in women with OASIS at 6 weeks of follow up. Improvement of training in OASIS repair is necessary.

Predictors of persistent overactive bladder following surgery for advanced pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Reliable risk factors for persistent urgency following pelvic organ prolapse (POP) surgery are still unclear. We aimed to identify preoperative parameters related to persistent postoperative urgency in a cohort of women following surgery for POP stage 3-4 with concomitant overactive bladder (OAB). METHODS: In this retrospective analysis, women with POP stage 3-4 and OAB who underwent POP repair during November 2012-December 2020 were included. Preoperative evaluation included history, Pelvic Organ Prolapse Quantification (POP-Q), multi-channel urodynamic studies and Pelvic Floor Distress Inventory (PFDI-20). Surgical procedures included: anterior and posterior colporrhaphy, sacrospinous ligament suspension, anterior vaginal wall mesh repair and robotic-assisted laparoscopic sacrocolpopexy. At the 12-month follow-up, urogynecological history, POP-Q evaluation, cough stress test and the PFDI-20 questionnaire were repeated. RESULTS: One hundred seventy-three patients were included in the analysis. Resolution of urgency was observed in 56% of women. Variables associated with persistent postoperative urgency included body mass index (BMI) (27 kg/m2 vs 25.7 kg/m2, p = 0.04), preoperative increased daytime frequency (46.39% vs 61.84%, p = 0.05), urgency urinary incontinence (UUI) (51.46% vs 80.26%, p = 0.0001), detrusor overactivity (DO) (40.2% vs 61.84%, p = 0.009) and lower maximum flow rate on UDS (13.9 ml/s vs 15 ml/s, p = 0.04). Multivariate analysis confirmed preoperative DO (OR: 12.2 [95% CI: 1.4-16.6]; p = 0.01), preoperative UUI (OR 3.8 [95% CI: 1.3-11.0]; p = 0.008) and BMI > 25 kg/m2 (OR 1.8 [95% CI: 1.1-7.2]; p = 0.04) as predictive factor for persistent urgency. CONCLUSIONS: In women with advanced POP and OAB, being overweight, preoperative UUI and DO are related to persistent postoperative urgency. These findings will guide our future preoperative counseling and reinforce the role of UDS in POP management.

New Advances in Female Pelvic Floor Dysfunction Management.

Pelvic floor dysfunctions (PFDs), which include various disorders such as urinary and anal incontinence, pelvic organ prolapse, and sexual disorders, are widespread amongst females, so much so that they affect one fifth of adult women [...].

Does the Polydimethylsiloxane Urethral Injection (Macroplastique®) Improve Sexual Function in Women, in Fertile Age, Affected by Stress Urinary Incontinence?

Background and Objectives: Stress urinary incontinence (SUI) negatively affects women's quality of life, including sexual function. The aim of the current study was to evaluate the effect of polydimethylsiloxane (Macroplastique®) on sexual function in women of fertile age affected by SUI. Materials and Methods: Single-center prospective study. Sexually active women of fertile age with symptoms of pure SUI, which were urodynamically proven, were submitted to intraurethral Macroplastique® injection. At 6-months follow-up, their sexual function was evaluated with Female Sexual Function Index (FSFI), while the SUI cure rate was objectively assessed through a negative stress test and subjectively by a Patient Global Impression of Improvement (PGI-I) score < 3. The difference of coital incontinence prevalence was assessed between the baseline and the 6-month follow-up. Peri- and postoperative complications of Macroplastique® injection were recorded and classified according to the Clavien-Dindo system. Results: Twenty-one women fulfilled inclusion criteria and were submitted to Macroplastique® procedure. The concerning sexual function, desire, satisfaction, and overall FSFI score significantly improved. Since other domains were less impaired at the baseline, we could not assess significant improvement for all of them. We observed a complete regression of coital incontinence (0/21, 0%) in comparison with the baseline (5/21, 23.8%; p = 0.04). The objective SUI cure rate was 76% (16/21), while the subjective SUI cure rate was 80.9% (17/21). One woman developed de novo overactive bladder, and two women developed postoperative voiding dysfunction (self-solved in 24 h). Conclusions: The Macroplastique® urethral injection was demonstrated to be safe and effective in improving sexual function in sexually active women of fertile age affected by pure SUI, urodinamically proven at 6-months follow-up.

Is Diastasis Recti Abdominis Rehabilitation after Childbirth Able to Prevent the Onset of Stress Urinary Incontinence? A Case-Control Study.

Background and Objectives: Pelvic floor muscle training (PFMT) represent the first-line approach to pelvic floor dysfunctions (PFDs). Recently, studies have shown a synergy between the pelvic floor and abdominal muscles, hypothesizing that the anatomical and functional integrity of the abdominal wall plays a role in the prevention of pelvic floor disorders. Some studies have shown a significant correlation between diastasis recti abdominis (DRA) and stress urinary incontinence (SUI). Nevertheless, the evidence reported in the literature is controversial and based on low-quality data. The aim of the study is to clarify whether DRA-specific abdominal rehabilitation is needed in women with SUI after childbirth. Materials and Methods: All consecutive women who had at least one delivery and complained of symptoms of pure SUI that were urodynamically proven were considered for the study. The group of symptomatic patients was compared with a series of consecutive women, identified during the same study period, without any symptoms of SUI. In both groups, we measured the inter-rectal distance (IRD) with an ultrasound scanner above and below the navel. Results: A total of 102 women eligible for the study group and 100 women who did not report any symptoms of SUI were enrolled. The inter-rectal distance above the umbilicus showed no significant difference between the two groups (2.12 ± 0.98 vs. 2.1 ± 0.77; p = 0.94). In contrast, the data from the sub-umbilical measurements showed a significant difference. Surprisingly, the asymptomatic group showed significantly greater (0.98 ± 0.9 vs. 1.33 ± 0.87 p-value: 0.009) IRD compared to the symptomatic group. Conclusions: The study shows that DRA is not a risk factor for SUI in women after childbirth. Therefore, specific abdominal wall rehabilitation after childbirth does not seem to be indicated.

The International Female Coital Incontinence Questionnaire (IFCI-Q): Development, Validation and Reliability Study.

INTRODUCTION: Coital urinary incontinence is an underestimated urinary symptom characterized by urine leakage during intercourse with a serious impact on female sexual function, which often may lead to the abandon of sexual activity. To date, there are no specific validated questionnaires for coital incontinence (CI). AIM: Aim of the study was to develop and validate a questionnaire "International Female Coital Incontinence- Questionnaire" (IFCI-Q) to evaluate the presence, severity and type of CI and its impact on quality of sexual intercourse. METHODS: The IFCI-Q validation process included the following stages: (i) Questionnaire development and expert focus group (urologists and gynecologists experts in the field of functional urology); (ii) Administration of IFCI-Q to sexually active women complained for CI, by cognitive interview; (iii) Expert focus group to assess for content validity; (iv) Psychometric assessment of internal consistency by Cronbach's alpha calculation; (v) Test-retest reliability. MAIN OUTCOME MEASURE: Aim of the questionnaire was to evaluate the presence, severity and type of CI, its impact on quality of sexual intercourse and psychological status and to identify concomitant urinary symptoms. Psychometric properties outcomes: internal consistency and reliability are considered acceptable for Cronbach's α coefficient >0.7 and Cohen's k-test >0.6, respectively. Test-retest reliability was detected by administering the questionnaire twice to the all included women with a time interval of 2 weeks. The content validity was evaluated by a panel of clinical experts. RESULTS: Thirty women (mean ± SD age: 43.4 ± 17.1 years) complained of CI completed the IFCI-Q. A total of 43.4% of patients had OAB symptoms, 23.3% had mixed urinary incontinence (UI) and 6.6% complained of stress UI. Patients with CI during penetration had a higher prevalence of predominant SUI (7/10), and all women suffering from CI during orgasm had OAB symptoms (11/11). A total of 80% women feel depressed and 56.6% patients reported that CI restricts their sexual activity. Internal consistency and replicability of data were in the adequate range (Cronbach α = 0.737). The test-retest procedure revealed that the k-values of each item are very good. CONCLUSION: IFCI-Q is a reliable questionnaire on CI and demonstrated a high level of internal consistency and reliability. Gubbiotti M, Giannantoni A, Rubilotta E, et al. The International Female Coital Incontinence Questionnaire (IFCI-Q): Development, Validation and Reliability Study. J Sex Med 2022;19:158-163.

Acceptability and perceived value of urodynamics from the patient perspective: A narrative review.

BACKGROUND: The value and application of urodynamic evaluation (UDS) have been a controversial topic in recent years. Gaining robust data on the patient viewpoint in this area is important since, even when UDS findings do not change the management plan, the objective diagnostic information gained from UDS may be valued by patients. Moreover, insights from UDS may empower treating physicians to counsel patients more effectively and manage their expectations regarding treatment outcomes. OBJECTIVE: This expert narrative review aims to analyze the findings of published studies in this area, looking at two topics in turn: (a) the tolerability and acceptability of the UDS procedure itself from the patient perspective and (b) patient perceptions of the clinical value of insights provided by UDS. DESIGN, SETTING, PARTICIPANTS, AND OUTCOME MEASUREMENTS: An evidence assessment was conducted using selected articles from the literature reporting data on patients' perspectives on the tolerability, acceptability, utility, and value of the urodynamic investigation. RESULTS AND LIMITATIONS: Although pain, discomfort, and infection risks are frequently used as a rationale to skip UDS when initial management fails, there is good evidence that, from the patients' perspective, the procedure is very well tolerated in most cases. There are only a few articles available that assess patient perceptions of the usefulness of UDS, but those that do exist appear to demonstrate that the insights gained from UDS are widely welcomed by patients in the interest of receiving a more tailored and personalized treatment approach. CONCLUSION: From the patient perspective, UDS appears to be a well-accepted and well-tolerated diagnostic tool in patients with lower urinary tract symptoms, particularly when an appropriate explanation is provided before the examination. Our review also highlights that patients value the objective information provided by UDS and that this outweighs the temporary invasiveness of the test. This information is particularly relevant in light of the relative lack of evidence in the literature about patient expectations of specialist care in functional urology, which may have hindered progress with quality of care.

Evaluation of the effect of 100U of Onabotulinum toxin A on detrusor contractility in women with idiopathic OAB: A multicentre prospective study.

AIMS: Intradetrusor injection of Onabotulinum Toxin A (BTX-A) is a third-line treatment for overactive bladder (OAB). Voiding dysfunction and the need for intermittent catheterization are potential complications, consequent to bladder contractility (BC) decrement. Primary aim: to evaluate BC variation after BTX-A detrusor injection in women with idiopathic OAB. METHODS: A prospective multi-institutional observational study was conducted. Medical history, bladder diary, 24-h pad test, and invasive urodynamic parameters were recorded before and 4-6 weeks after BTX-A 100U administration. BC was measured as Modified Projected Isovolumetric Pressure (PIP1), that is, maximum flow rate (Qmax) + detrusor pressure at Qmax (PdetQmax). Continuous variables were expressed as median and interquartile range. We compared continuous variables using Wilcoxon test and proportions between two times with Fisher exact test. RESULTS: No changes in PIP1 were observed (p > 0.05) in 45 women enrolled between January 2018 and September 2019. Median age was 54.6 years. At baseline, 91.1% had urge urinary incontinence, with 4.9 ± 2.6 daily pads used and a 24-h pad test of 205.4 ± 70.8 g. Baseline detrusor contractility was normal in all the patients. Postoperatively, an improvement in the 24-h pad test (p < 0.01), daily voids (p < 0.01), and nocturia (p < 0.01) occurred. Urodynamics pointed out a significant reduction of detrusor overactivity rate (p < 0.01) and an increase of median maximum cystometric capacity (p < 0.01). No difference was observed in median Qmax (p > 0.05), PdetQmax (p > 0.05), and PVR (p > 0.05). No patient needed postoperative catheterization. CONCLUSIONS: The current series provides evidence that detrusor injection of botulinum toxin is an effective option for treating OAB, without causing voiding dysfunction and BC impairment.

The subjective and objective very long-term outcomes of TVT in the COVID era: A 20-year follow-up.

INTRODUCTION AND HYPOTHESIS: Few studies in literature have assessed the long-term durability and mesh-related complications of mid-urethral slings (MUSs). The aim of this study is to assess the efficacy and safety of retro-pubic tension-free vaginal tape (TVT) 20 years after implantation for the treatment of female stress urinary incontinence (SUI). METHODS: A prospective observational study was conducted in two urogynaecologic units in two countries. All the patients involved were consecutive women with urodynamically proven pure SUI treated by TVT. The patients underwent preoperative clinical and urodynamic evaluations. Subjective outcomes, objective outcomes and adverse events were recorded during the follow-up period. RESULTS: Fifty-two patients underwent a TVT surgical procedure. Twenty years after surgery, 32 out of 36 patients (88.8%) declared themselves cured (p = 0.98). Similarly, 33 out of these 36 patients (91.7%) were objectively cured (p = 0.98). No significant deterioration of subjective and objective cure rates was observed over time (p for trend 0.50 and 0.48). Fifteen of the 36 patients (41.6%) at the 20-year follow-up reported the onset of de novo overactive bladder (OAB) (p = 0.004). No significant vaginal bladder or urethral erosion or de novo dyspareunia was recorded and no patient required tape release or resection during this period. The cause of death of seven out of ten women who died in the last year of the follow-up period was coronavirus disease 19 (COVID 19). CONCLUSIONS: The 20-year results of this study showed that TVT is a highly effective and safe option for the treatment of SUI. The impact of COVID 19 on the mortality rate of elderly women has drastically reduced the number of eligible patients for future evaluations in our region.

International Urogynaecology Consultation chapter 1 committee 4: patients' perception of disease burden of pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: This manuscript from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) reports on the patients' perception of disease burden associated with pelvic organ prolapse. MATERIALS AND METHODS: An international group containing a team of eight urogynaecologists, a physiotherapist and a statistician performed a search of the literature using pre-specified search terms in PubMed and Embase (January 2000 to August 2020). The division of sections within this report includes: (1) perception of POP and the relationship with body image and poor health; (2) a vaginal bulge as it impacts health and wellbeing in women; (3) the impact of POP on sexual life; (4) body image and pelvic floor disorders; (5) POP and mood; (6) appropriate use of treatment goals to better meet patients' expected benefits; (7) using health-related quality of life questionnaires to quantify patients' perception of POP; (8) The financial burden of POP to patients and society. Abstracts were reviewed and publications were eliminated if not relevant or did not include populations with POP or were not relevant to the subject areas as noted by the authors. The manuscripts were next reviewed for suitability using the Specialist Unit for Review Evidence (SURE) checklists for cohort, cross-sectional and case-control epidemiologic studies. RESULTS: The original individual literature searches yielded 2312 references of which 190 were used in the final manuscript. The following perceptions were identified: (1) women were found to have varying perceptions of POP including shame and embarrassment. Some regard POP as consequence of aging and consider there is no effective therapy. (2) POP is perceived as a vaginal bulge and affects lifestyle and emotional wellbeing. The main driver for treatment is absence of bulge sensation. (3) POP is known to affect frequency of sexual intercourse but has less impact on satisfaction. (4) Prolapse-specific body image and genital self-image are important components of a women's emotional, physical and sexual wellbeing. (5) POP is commonly associated with depression and anxiety symptoms which impact HRQoL although are not correlated with objective anatomical findings. (6) Patient-centered treatment goals are useful in facilitating communication, shared decision-making and expectations before and after reconstructive surgery. (7) Disease-specific HRQoL questionnaires are important tools to assess bother and outcome following surgery, and there are now several tools with Level 1 evidence and a Grade A recommendation. (8) The cost of POP to the individual and to society is considerable in terms of productivity. In general, conservative measures tend to be more cost-effective than surgical intervention. CONCLUSIONS: Patients' perception of POP varies in different patients and has a far-reaching impact on their overall state of health and wellbeing. However, recognizing that it is a combination of body image and overall health (which affects mental health) allows clinicians to better tailor expectations for treatment to individual patients. There are HRQoL tools that can be used to quantify these impacts in clinical care and research. The costs to the individual patient (which affects their perception of POP) is an area that is poorly understood and needs more research.

Is the Deep Endometriosis or the Surgery the Cause of Postoperative Bladder Dysfunction?

STUDY OBJECTIVE: To assess whether deep endometriosis surgery affects the bladder function. DESIGN: Prospective multicenter observational study (Canadian Task Force classification II-2). SETTING: Academic research centers. PATIENTS: Thirty-two patients with diagnosis of deep endometriosis requiring surgery. INTERVENTIONS: Women were evaluated with urodynamic studies, International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form, and International Consultation on Incontinence Questionnaire Overactive Bladder Module questionnaires before and 3 months after surgery. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was the impact of deep endometriosis surgery on urodynamic parameters. All cystomanometric parameters showed an improvement postoperatively: in particular, the first desire to void (120 vs 204 mL; p <.001) and the bladder capacity (358 vs 409 mL; p = .011) increased significantly after surgery. Of the uroflow parameters, the maximal voiding flow improved significantly postoperatively (19 vs 25 mL/s; p = .026). The International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (2.5 vs 0; p = .0005) and International Consultation on Incontinence Questionnaire Overactive Bladder Module (4.3 vs 1.2; p <.001) questionnaires showed a significant postoperative improvement too. CONCLUSION: Our data show that in a selected population of patients with deep infiltrating endometriosis (not requiring bowel or ureteral resection), the bladder function improves after surgery, both during filling and on voiding urodynamic phases. Postoperatively, patients with deep infiltrating endometriosis become aware of bladder filling later, have a higher bladder capacity, and have a higher maximal flow. The postoperative urodynamic results are corroborated by the improved scores on the bladder questionnaires.

Vaginal Laser Therapy for Female Stress Urinary Incontinence: New Solutions for a Well-Known Issue-A Concise Review.

Background and Objectives: Insufficient connective urethra and bladder support related to childbirth and menopausal estrogen decrease leads to stress urinary incontinence (SUI). The aim of this review is to narratively report the efficacy and safety of new mini-invasive solutions for SUI treatment as laser energy devices, in particular, the microablative fractional carbon dioxide laser and the non-ablative Erbium-YAG laser. Materials and Methods: For this narrative review, a search of literature from PubMed and EMBASE was performed to evaluate the relevant studies and was limited to English language articles, published from January 2015 to February 2022. Results: A significant subjective improvement, assessed by the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-UI-SF) was reported at the 6-month follow up, with a cure rate ranged from 21% to 38%. A reduction of effect was evidenced between 6 and 24-36 months. Additionally, the 1-h pad weight test evidence a significant objective improvement at the 2-6-month follow up. Conclusions: SUI after vaginal laser therapy resulted statistically improved in almost all studies at short-term follow up, resulting a safe and feasible option in mild SUI. However, cure rates were low, longer-term data actually lacks and the high heterogeneity of methods limits the general recommendations. Larger RCTs evaluating long-term effects are required.

New Innovations for the Treatment of Vulvovaginal Atrophy: An Up-to-Date Review.

Vulvovaginal atrophy (VVA) is a chronic progressive disease involving the female genital apparatus and lower urinary tract. This condition is related to hypoestrogenism consequent to menopause onset but is also due to the hormonal decrease after adjuvant therapy for patients affected by breast cancer. Considering the high prevalence of VVA and the expected growth of this condition due to the increase in the average age of the female population, it is easy to understand its significant social impact. VVA causes uncomfortable disorders, such as vaginal dryness, itching, burning, and dyspareunia, and requires constant treatment, on cessation of which symptoms tend to reappear. The currently available therapies include vaginal lubricants and moisturizers, vaginal estrogens and dehydroepiandrosterone (DHEA), systemic hormone therapy, and Ospemifene. Considering, however, that such therapies have some problems that include contraindications, ineffectiveness, and low compliance, finding an innovative, effective, and safe treatment is crucial. The present data suggest great efficacy and safety of a vaginal laser in the treatment of genital symptoms and improvement in sexual function in patients affected by VVA. The beneficial effect tends to be sustained over the long-term, and no serious adverse events have been identified. The aim of this review is to report up-to-date efficacy and safety data of laser energy devices, in particular the microablative fractional carbon dioxide laser and the non-ablative photothermal Erbium-YAG laser.

Up-to-Date Procedures in Female Stress Urinary Incontinence Surgery: A Concise Review on Bulking Agents Procedures.

To avoid complications related to mid-urethral slings (MUS), alternative procedures to treat stress urinary incontinence (SUI), such as urethral bulking agents (UBAs) have been adopted. The aim of this review is to narratively report the efficacy and safety of UBAs for SUI treatment. For this review, research from PubMed and EMBASE was performed to evaluate relevant studies that were undertaken from January 2012 to January 2022. Nineteen prospective studies were included. Several definitions of subjective and objective success were adopted. At a follow-up of <24 months, significant improvement was widely observed, even if with a heterogeneous rate of success between 32.7−90%, and a reinjection rate of 8.3−77.3%. Compared with other procedures, MUS resulted as significantly superior to UBAs but was balanced by a higher complication rate. Acute urinary retention, urinary tract infection and de novo urgency, and other complications, such as injection site rupture, urethral erosion and particle migration have been described after UBAs. SUI after UBAs treatment resulted in improvements in all studies and can be considered a safe and effective option to treat SUI. However, homogenous and longer-term data lack, limiting general recommendations. Thus, larger RCTs evaluating long-term effects are required.

Female Sexual Dysfunctions and Urogynecological Complaints: A Narrative Review.

Female sexual dysfunctions represent a real widespread problem, usually faced from a psychological point of view; however, millions of women worldwide are impacted by pelvic floor dysfunction, personal shame and social taboos, however, continue to inhibit free conversation on the subject. Women's quality of life is considerably improved by screening, diagnosing, and controlling urogenital and sexual issues. This review aims to provide a critical perspective of urogenital conditions and common disturbances in female sexual function associated with these issues. It also includes a discussion of postpartum pelvic dysfunction.

The Learning Curve of Urodynamics for the Evaluation of Lower Urinary Tract Symptoms.

Background and Objectives: Urodynamics is considered the gold standard for lower urinary tract functional assessment. However, it requires very specific skills and training, which are currently difficult to master due to its reduced use. Moreover, no studies or data are available to define the workload and the learning curve of this diagnostic tool. As a consequence, we aimed to evaluate the learning curve of residents with no previous experience to correctly perform and interpret urodynamics, and properly address and manage patients with pelvic floor disorders based on urodynamics findings. Materials and Methods: This prospective study analyzed a series of proficiency parameters in residents performing urodynamics under consultant supervision, including the following: duration of procedure, perceived difficulty, need for consultant intervention, accuracy of interpretation, and therapeutic proposal. The number of procedures performed was then divided into groups of five to evaluate the progressive grade of autonomy (technical and full management autonomy) reached by each resident. Results: In total, 69 patients underwent urodynamics performed by three residents, with every resident performing at least 20 exams. Duration of procedure, perceived difficulty, need for consultant intervention, accuracy of interpretation, and the appropriateness of the hypothetical proposal of management/treatment based on their interpretation of clinical data and urodynamic findings was shown to be directly related to the number of exams performed. Technical autonomy in the execution of uroflowmetry was reached in the group performing 6-10 procedures, while technical autonomy in the execution of cystomanometry with pressure/flow study was obtained in the group of 16-20 procedures. The latter corresponded also to the gain of full autonomy which also included an optimal therapeutic proposal. Conclusion: We found that there is a tangible learning curve for urodynamics in terms of several proficiency parameters. A workload of 5 uroflowmetries and 15 cystomanometries with pressure/flow studies may be adequate to complete the learning curve.

Native Tissue Posterior Compartment Repair for Isolated Posterior Vaginal Prolapse: Anatomical and Functional Outcomes.

Background and Objectives: Posterior compartment prolapse is associated with constipation and obstructed defecation syndrome. However, there is still a lack of consensus on the optimal treatment for this condition. We aim to investigate functional, anatomical, and quality-of-life outcomes of native tissue transvaginal repair of isolated symptomatic rectocele. Materials and Methods: We retrospective analyzed patients who underwent transvaginal native tissue repair for stage ≥ II and symptomatic posterior vaginal wall prolapse between January 2018 and June 2021. Anatomical and functional outcomes were evaluated. Wexner constipation score was used to assess bowel symptoms, while the Patient Global Impression of Improvement (PGI-I) score was used to evaluate subjective satisfaction after surgery. Results: Twenty-eight patients were included in the analysis. The median age was 64.5 years, and half of them underwent a previous hysterectomy for benign reasons. The median follow-up time was 33.5 months. A significant anatomical improvement in the posterior compartment was noticed compared with preoperative assessment (p < 0.001 for Ap and Bp), with only two (7.1%) anatomical recurrences. Additionally, obstructed defecation symptoms decreased significantly compared to baseline (p < 0.001), as well as vaginal bulging, with no new-onset cases of fecal incontinence or de novo dyspareunia. PGI-I resulted in 89.2% of patients being satisfied (PGI-I ≥ 2), with a median score of 1.5. Conclusions: Transvaginal native tissue repair for isolated posterior prolapse is safe and effective in managing bowel symptoms, with excellent anatomical and functional outcomes and satisfactory improvement in patients' quality of life.