Appearance of levator ani muscle subdivision defects on level III vaginal support structures in women with and without pelvic organ prolapse: an MRI study.

INTRODUCTION AND HYPOTHESIS: Injury of the levator ani muscle (LAM) is a significant risk factor for pelvic organ prolapse (POP). The puborectalis (PRM) and pubovisceral (PVM) subdivisions are level III vaginal support structures. The null hypothesis was that there is no significant difference in patterns of LAM subdivisions in healthy nulliparous women. Secondarily, we evaluated the presence of different LAM injury in a POP-symptomatic cohort. METHODS: This retrospective magnetic resonance imaging study included: 64 nulligravidae without any pelvic floor dysfunction (PFD) and 526 women of various parity with symptomatic POP. Primary outcome was PVM and PRM morphology on the axial planes: the attachment site on the pubic bone, and the visible separation/border between the PVM and PRM. The attachment was scored as "normal" or "abnormal". The "abnormal" attachment was divided in two types: "type I"-loss of the muscle substance, but preservation of the overall muscle architecture-and "type II"-muscle detachment from the pubic bone. RESULTS: The puboanal muscle (PAM) subdivision was evaluated as a representative part of the PVM. The PAM and PRM attachments and separation were distinguished in all asymptomatic nulliparae. PAM and PRM attachments did not significantly differ. POP group characteristics were parity 1.9 ± 0.8, instrumental delivery 5.6%, hysterectomy or POP surgery 60%, all Pelvic Organ Prolapse Quantification (POP-Q) stages, LAM defect 77.6% (PRM: 77.1%; PAM: 51.3%). Type I injuries were more frequent (PRM 54.7%; PAM 53.9%) compared with type II (PRM 29.4%; PAM 42.1%). CONCLUSIONS: A LAM defect was present in 77.6% of women with symptomatic POP. In PRM and PAM subdivisions type I injury was more frequent than type II.

Questionnaire study of prevalence of urinary incontinence in pregnancy and early six weeks.

OBJECTIVE: Detect prevalence of urinary incontinence in pregnant women depending on risk factors. DESIGN: Questionnaire study. SETTING: GONA company s.r.o., Gynaecology and Obstetrics Practise. CASE REPORT: During the annual follow-up, 20 women out of a total reported complaining about the incontinence of power. The trouble was discreet, the women did not limit, they could engage in all activities. They wore inserts as a precaution, but did not shed their fluid intake and were unconcerned by the posible stench of escaping power. Women had the most trouble after 30 weeks of gestation, the condition improved after delivery and none of the interviewees had trouble escaping after six weeks. Three women devoted themselves to rehabilitate after giving birth. CONCLUSION: Pregnancy is a specific condition for a womanś body, so the changes that occur in this area can only mimic the symptoms of incontinence and hyperactive bladder. Prevention before and during pregnancy plays an important role. Collaboration with a physical therapist is appropriate. Preventive strengthening of the pelvic floor reduces the incidence of urinary incontinence.

Anatomy and biomechanic of the musculus levator ani.

OBJECTIVE: The aim of the rewiew is to provide complex new informations about anatomy and biomechanics features of the musculus levator ani. Described are risk factors leading to it´s injury and options of imaging the muscle complex (ultrasound, magnetic imaging resonance and 3D modeling). DESIGN: Review. SETTINGS: Departement of Obstetrics and Gynaecology, Hospital in Frýdek-Místek, GONA Co. Ltd , Institute for Mother and Child Prague. RESULTS: Musculus levator ani (MLA) has a complex structure composed mainly of striated muscles. Minority of smooth muscle fibres are also found. Particular parts of the MLA hold together different angles. Inervation is provided through somatic and visceral nerve fibres. During delivery, more there three times stretching of the muscle was observed. Less strenght is needed do the same stretching of the muscle in repeating stress situations. In the MRI studies, two types of injury of the MLA, were found. Predisponed to the injury is medial part of the MLA known as pubovisceral muscle (PVM). PVM has three insertions. The most fragile is it´s medial insertion to the pubic bone described as enthesis. During experimental delivery studies was found, that the pressure in this part of the muscle reach almost 36MPa. CONCLUSION: MLA is a difficult muscle. Because of the ethical reasons we don´t have, and probably never will have informations, how structuraly and elasticaly differs muscle, that was damaged during the delivery, compared to muscle without any damage. Promising are computer delivery simulations. In future, they would give us an answer, how risky is vaginal delivery in concrete expectant mother.

[MRI analysis of the musculo-fascial component of pelvic floor in woman before planned vaginal reconstruction procedur for symptomatic pelvic organ prolapse]. / Analýza stavu muskulo-fasciální slozky pánevního dna pomocí MRI u pacientek pred plánovaným vaginálním rekonstrukcním výkonem pro symptomatický sestup pánevního dna.

OBJECTIVE: The aim of the study is to analyse the musculo-fascial component of the pelvic floor in symptomatic group of woman with pelvic organ prolapse before planned vaginal reconstruction using synthetic vaginal mesh. DESIGN: Observational cohort study. SETTING: Department of Obstetrics and Gynaecology, Hospital in Frýdek-Místek; GONA Ltd, Prague; Institute for Care of Mother and Child, Prague; 3rd Faculty of Medicine CHU Prague. METHODOLOGY: The study involved 285 female volunteers (6 nulliparous, all other patients gave birth vaginally at least once) that in the period 2008-2015 before the planned reconstructive vaginal operations have undergone a comprehensive urogynaecology examination supplemented by magnetic resonance imaging (MRI) of the pelvic floor. Assessed was musculofascial component of the pelvic floor containing -musculus levator ani (MLA), endopelvic fascia (EF) and sacrouterine ligaments (SUL). MLA and EF were evaluated at two levels. The first level corresponds to the puborectalis muscle (evaluation of MRI trauma stage and avulsion), the second level correspondes to the iliococcygeus muscule (evaluation only avulsion injury to the muscle). RESULTS: Normal appereance of musculus puborectalis (level 1) was captured only in 25 (8.8) women. In 117 (41.1%) of women were present MRI minor trauma, 143 (50,2%) women were present with MRI major trauma. Avulsion of the muscle was captured in 85 cases (29.8%) at level 1 and in 165 cases (57.9%) in level 2. Preserved architecture of the EF was caught only 99 (34.7%) of the cases in level 1 and in 47 cases (16.5%) in level 2. Sacrouterine ligaments showed normal morphology in 100 cases (35.1%).Conslusion: Defects of musculofascial component of the pelvic floor is found frequently in women with symptomatic pelvic organ prolapse. Often a combination of defects MLA, EF and SUL are found. These comprehensive pelvic floor defects require careful urogynecological examination and planing operating methods with a view to minimizing the likelihood of recurrence of the descent. In indicated cases the use of the synthetic vaginal mesh is as a method of first choice.

[Degree of satisfaction of patients continuing overactive bladder treatment with mirabegron]. / Stupen spokojenosti pacientu pokracujících v lécbe hyperaktivního mocového mechýre mirabegronem.

OBJECTIVE: Overactive bladder syndrome is chronic disease with high prevalence rate (9-42%). This syndrome requires long term therapy, but the treatment persistence is after 3 months over all 26% with further decline in one-year period as low as 18.5%. Main reasons for stopping the treatment are low efficacy, the medication didnt work as expected and side effects. How much satisfied are patients with mirabegron persisting on its treatment? To answer this question, we provided secondary analysis of multicentre follow-up study of patients on mirabegron. We compared subjective and objective parameters between patients continuing mirabegron treatment and those who discontinued the medication. DESIGN: Secondary analysis multicentre prospective follow-up. SETTINGS: Ob/Gyn department First Faculty of Medicine, Charles University and General University Hospital, Prague. METHODS: It is secondary analysis of multicentre prospective study following patients with mirabegron 50 mg treatment. We have analysed objective data from micturition diary and subjective data using visual analogue scales (UB-VAS - urgency bother visual analogue scale, and TS-VAS - treatment satisfaction visual analogue scale) and compared data between the group of patients continuing mirabegron treatment and patients who stopped the medication during the study. RESULTS: We included 206 patients (176 women, 30 men) with diagnosis of overactive bladder. Patients continuing the treatment (group n1) had baseline UB-VAS 70.1 vs. 75.0 (p = n.s.) in patients who stopped the medication during the follow-up period (group n2). Baseline episodes of severe urgency and urge incontinence where n1 - 5.1 vs. n2 - 6.2 (p = n.s.). Six months urgency bother score UB-VAS was n1 - 32.4 vs. n2 - 58.9 (p < 0,001). Treatment satisfaction TS-VAS was n1 - 80.3 vs. n2 - 57.7 (p < 0,001). Number of severe urgencies with or without urge incontinence was after 6 months n1 - 2.1 vs. n2 - 3.3 (p = n.s.), lower in group continuing the treatment. When comparing the data between patients stopping the medication for reason of low efficacy (group s1) with patients stopping for other reasons (group s2) UB-VAS bas: s1 - 68.5 vs. s2 - 43.9 (p = 0.001); TS VAS s1 - 45.1 vs. s2 - 58.4 (p = n.s.) and number of severe urgency with or without incontinence s1 - 5.9 vs. s2 - 3.2 (p = 0.009). CONCLUSION: Our data shows that patients expectation on treatment with mirabegron is not low. Patients accept treatment either without side effects or with decrease of severe urgency with or without urge incontinence around 50%. Regardless the reason the patients continuing the treatment scale treatment satisfaction - TS-VAS over 70 points.

[Nocturnal polyuria, treatment with desmopressin]. / Lécba nocní polyurie desmopresinem.

UNLABELLED: Nonpharmacologic and especially pharmacologic treatment options are available for nocturnal polyuria. Desmopressin represents the basis of pharmacologic treatment. Desmopressin acetate is a synthetic analogue of arginine vasopressin with high affinity to V2 receptors with antidiuretic effect. It is the only medicament currently registered for antidiuretic treatment. Desmopressin has not any relevant affinity to V1 receptors, and therefore there is no hypertensive effect in contrary to natural vasopressin. Desmopressin use before a bedtime leads to reduced production of urine during a sleep, therefore time between desires to void is prolonged and number of nocturia is reduced. Clinical effect, in a meaning of reduced urine production and increased osmolality of urine, lasts approximately 8-12 hours. In the treatment of nocturnal polyuria desmopressin is used orally one hour before a bedtime. It is essential to titrate an ideal dose, the initial dose is 60 µg of MELT formula (fast melting oral formulation) and it can be increased according to the clinical effect up to the maximal recommended daily dose 240 µg. Patients treated with desmopressin should cut down a fluid intake 1 hour before and 8 hours after the use of desmopressin. Total number of adverse events connected withdesmopressin treatment in clinical studies was higher compared to placebo but the side effects were mostly mild. The most common adverse events were headaches, nausea, diarrhoea, abdominal pain, dry mouth and hyponatremia both in the short-term and long-term clinical trials. Hyponatremia was observed mainly in patients over 65 year of age. Therefore treatment with desmopressin should not be commended in patients over 65 year of age without close monitoring of the natrium level in serum and all patients should be informed about the first symptoms of hyponatremia - headache, nausea and insomnia. According to Evidence Based Medicine, the level of evidence for treatment of nocturnal polyuria with desmopressin is 1b and the grade of recommendation for treatment is A. KEYWORDS: nocturnal polyuria - treatment - desmopressin.

[Nocturia, incidence, ethiology, diagnostics]. / Epidemiologie, etiologie a diagnostika nykturie.

Nocturia is the complaint that the individual has to wake at night one or more times to void, according to the International Continence Society definition from the ICS Standardisation of Terminology Report 2002. As the nocturia definition is complicated there are also other slightly modified definitions. It is currently not absolutely clear if prevalence or incidence is more important for epidemiology evaluation of nocturia. Nocturia is a variable symptom and its presence in individuals is reversible therefore it is very difficult to obtain reliable incidence data. Nocturia prevalence varies remarkably in different studies according to evaluation methodology, nocturia definition, methods of data collection and characteristics of evaluated population. There are not enough studies, especially demographic ones, evaluating lower urinary tract symptoms and/or nocturia in males and females. There is relatively large number of comparative studies confirming strong correlation between aging and prevalence of nocturia. Prevalence of two or more voids per night in individuals in their twenties varies between 5-15 %, it progresses with age, and in the seventh decade of life ranges between 35-50 %. Prevalence evaluated by gender is higher among younger women compared to older women and older men compared to younger men. Currently there are only limited sources of data regarding nocturia incidence. Incidence of nocturia (two or more voids per night) in a population older than 60 years is 213 new cases/1000 persons/1 year in two year observation. Incidence of two or more voids per night is 75 new cases/1000 male/1 year in five year observation and 126 new cases/1000 male/1 year in ten year observation in male population. Incidence of nocturia rises significantly with age. Incidence of two or more voids per night increases by 2,7 % in the population of women after child birth during 5 year follow up and by 5,9 % during 12 year follow up. Incidence of nocturia newly diagnosed in a pregnancy drops down by 98% in 3 month after the child birth. The incidence data indicate that incidence of nocturia rises with age and probability of nocturia relief decreases with age. Incidence of mild nocturia is higher compared to incidence of severe nocturia and significant relief of nocturia in women after child birth is very inconsistent compared to increase of other lower urinary tract symptoms. Ethiology of nocturia might be polyuria, nocturnal polyuria or reduced bladder capacity. Nocturia and its ethiology can be determined in most cases with simple and commonly used investigative methods on the out-patients bases. The diagnostic algorithm should lead to verification of nocturia and identifying its cause because treatment of nocturia differs remarkably according to the etiology.

[Prevalence of women with overactive bladders in the Czech Republic]. / Prevalence zen s hyperaktivním mocovým mechýrem v Ceské republice.

INTRODUCTION: The term OAB (overactive bladder) was introduced in praxis in the year 2002 by Abrams. This term includes symptoms of urgency, with or without urgent incontinence, and it is generally accompanied by urinary frequency and nocturia. OAB is widespread among our female population. Approximately 20% of women suffer from this problem, but the frequency of the syndrome has not been assessed more precisely by means of questionnaires. The aim of our study was to assess the prevalence of OAB among patients who visited gynecologists in the first line and completed the Bladder Control Self Assessment Questionnaire (BCSAQ). MATERIAL AND METHODS: Five gynecologists in the first line questioned 492 consecutive patients as to whether they suffered from urgency, frequency, nocturia and urgent incontinence, and their answers were later evaluated. The BCSA questionnaires completed by the patients in the waiting room before seeing the doctor were subsequently also evaluated. RESULTS: Due to inquiries made by the gynecologist, 320 patients took the BCSA questionnaires in the waiting room before seeing the doctor, and 314 completed them; 14 patients completed the questionnaires after seeing the doctor who questioned them about problems with urgency. The patients then handed the completed questionnaires to the nurse, i.e. the total of 328 questionnaires were assessed. 159 patients suffered from urgency, and 35% of these patients had problems with leakage of urine. In reply to the question: Is it difficult to hold urine when you have the urge to go? 22% of patients from the whole group of patients (n = 492) answered yes. 24% of patients had problems with frequency, 32% with nocturia and 14% with urgent incontinence. CONCLUSION: OAB syndrome is widespread in our population; it constitutes a major problem which must be treated. Awareness of this problem has now improved; patients feel less embarrassed to discuss about problem, and increasingly they seek treatment, while at the same time gynecologists have improved their knowledge about the diagnosis and treatment of OAB. This means that the quality of life for these patients can be improved.

[The effectiveness of recurrent stress urinary incontinence treatment after Burch colposuspension failure with transobturatory tape procedure]. / Efektivita lécby recidivující stresové inkontinence moci pomocí transobturatorní pásky po seláhní kolposuspenze podle Burche.

OBJECTIVE: To evaluate the safety and efficacy of the transobturatory tape (TOT) procedure in the treatment of female recurrent stress urinary incontinence after the Burch colposuspension failure. DESIGN: Retrospective clinical trial. SETTING: Obstetrics and Gynecology Department, Charles University, 2nd Medical School and Faculty Hospital Motol, Prague. METHODS: The group of fifteen women was treated for recurrent stress urinary incontinence with TOT procedure. Preoperative evaluation consisted of complete urogynecological examination. The cure rate and complications were determined in postoperative follow up 6 weeks and 12 months after the surgery. RESULTS: The mean age was 58.7 (46-64) years. Burch colposuspension was performed 6.4 (1-13) years before current TOT procedure. The cure rate in 12 month follow-up was 86.6% (13 of 15 patients), one patient was improved (6.7%). Postoperative complications occurred in 2 (13.4%) cases--one lower urinary tract infection and one overactive bladder symptomatology cured by anticholinergic therapy. CONCLUSION: The study showed that the TOT procedure is a safe and effective minimally invasive method in the treatment of recurrent stress urinary incontinence after Burch colposuspension.

[Evaluation of initial experience with safety and short efficacy of mini-sling antiincontinence procedures MiniArc and AJUST system]. / Vyhodnocení prvých zkuseností s bezpecností a krátkodobým efektem mini-páskových antiinkontinentních operací MiniArc a AJUST.

OBJECTIVE: The aim of our study is to present initial experiences, with regard to safety and short-term efficacy, of mini-sling MiniArc and AJUST operations for stress urinary incontinence (SUI). DESIGN: Cross-sectional clinical study. SETTINGS: Gynecological and Obstetric Clinic 1. LF UK and VFN Prague; Gynecological and Obstetric Clinic FN Bulovka and 1. LF UK Praha; Urological dpt. FTN Prague; GONA spol. s r.o.; Urological dpt. FN Ostrava Poruba. MATERIALS AND METHODS: We present briefly the technique employed in the operations, the urodynamic examination procedure before and after the operation, and the subjective and objective outcomes of these procedures from the 5 above-mentioned hospitals which participated on the study. Objectively the leakage of urine was assessed during urodynamic examination and by cough test. Subjectively leakage of urine was assessed by ICIQ-SF questionnaire (The International Consultation on Incontinence, short form). This study evaluated the cure effect and complications accompanying the MiniArc and AJUST procedures, and compared these results. The clinical study included 66 women with previously untreated stress urinary incontinence. These women were randomly divided by envelop method into two groups; the first group of patients underwent operations using the MiniArc (n=33) technique and the second group the AJUST (n=33) technique. Mean age was 57.9 years in the AJUST group and 57.7 years in the MiniArc group. Mean body mass index (BMI) was 29.2/28.7 in the AJUST/MiniArc groups respectively, and mean parity was 2.09/2.24. We did not find statistically significant differences between these two groups. RESULTS: The curative rate of the MiniArc and AJUST procedure was evaluated 3 months after the operation (+/- 1 week). We can conclude from the outcomes of the cough test that this test was negative in 61 (92%) of patients overall; in the AJUST group it was 31 (94%) of patients and in the MiniArc group 30 (91%) of patients. In the subjective evaluation of the leakage of urine before operation (ICIQ-SF) the mean score in the group of patients who subsequently underwent the AJUST operation was 15.4 (SD-3.39; median-16, range 8-21) and in women who underwent the MiniArc operation it was 15.5 (SD-3.3; median-16, range 8-21). The AJUST/MiniArc procedure caused a statistical significant decrease in the total score to -14.09(SD-5.18)/-14.45 (SD-3.73). The difference in the decrease of the score between the AJUST/MiniArc groups was not statistically significant. In the AJUST group of patients, according to the ICIQ-SF, 30 (91%) women were without problem or improved [27 (81.7%) of women were without problem], while in the MiniArc group 32 (96.9%) were without problem or improved [24 (72.7%) of women were without problem]. The urodynamic examination before and after operation indicated that there were no differences between the groups of patients either before and or after the operation. Changes in the parameters MUCP, Qmax and others caused by the operation were not significant, and there were no statistical significant differences in the values of these parameters between the groups of patients. Complications of the MiniArc and AJUST procedures were not recorded. CONCLUSIONS: Our first experiences with MiniArc and AJUST procedures, including possible complications and curative rate, are positive. From the preliminary results the cure effect of MiniArc and AJUST 3 months after the operation (+/- 1 week) is similar. It will be important to evaluate the efficacy of these procedures one year after the operation for a definitive evaluation of the cure effect.

[Registry of the urogynaecologic procedures involving implant in the Czech Republic during the year 2007]. / Registr urogynekologických výkonu s implantáty v Ceské republice za rok 2007.

OBJECTIVE: The aim of this paper is to report the outcomes of the registry of the urogynaecologic procedures involving implant in the Czech Republic during the year 2007. SUBJECT: Retrospective registry analysis. SETTING: Czech Urogynaecological Association, Prague. SUBJECT AND METHOD: We performed a retrospective analysis of all urogynaecologic procedures involving implant registered in the Czech Registry during the year 2007. CONCLUSION: We report the results of 2557 urogynaecologic procedures involving implant from the 33 referring centres from the Czech Republic. 2232 (87%) implants were intended to treat the stress urinary incontinence and 325 (13%) were used to treat the pelvic organ prolapse. Intraoperative complications were reported in 36 (1.41%) cases, early postoperative complications intervened in 117 cases (4.58%) and the late complications were found in 121 females (4.73%).

[Abdominal sacrocolpopexy--simple and still actual method in the treatment of vaginal vault prolapse?]. / Abdominální sakrokolpopexe--jednoduchá a stále aktuální metoda 1écby prolapsu posevního pahýlu?

OBJECTIVE: To evaluate the effectiveness and complications of abdominal sacrocolpopexy in the treatment of vaginal vault prolapse. DESIGN: Review article. SETTING: Obstetrics and Gynecology Department, Charles University 2nd Medical Faculty and Teaching Hospital Motol, Prague. METHODS: Review from biomedical database Medline from 1960 till 2006. The articles were found under the key words: vaginal vault prolaps, abdominal sacrocolpopexy, effectiveness, complications, urinary incontinence, female sexual dysfunctions. RESULTS: The effectiveness of surgery is getting near to 100 percent in the smaller groups between 11 and 21 women. The larger groups are presenting greater success rate variability from 85 to 97 percent. The studies with up to 2 years of follow up are giving representative results of the effectiveness of surgery. Prolapse recurrence and cystocele, rectocele, enterocele and stress urinary incontinence occurrance belong among the characteristic failure signs. Studies evaluating abdominal sacrocolpopexy argue low incidence of complications. Complications connected with surgery can be divided to intraoperative and early and late postoperative. Bleeding from injured medial sacral artery, cystotomy, enterotomy and ureterotomy are the most common intraoperative complications. Wound infection, ileus and urinary tract infection are the most often early postoperative complications. Stress urinary incontinence, anterior or posterior vaginal wall descent, recurrence of vaginal vault prolapse and mesh erosion through vaginal wall are characteristic late postoperative complications. CONCLUSIONS: Abdominal sacrocolpopexy can be a method of choice in the treatment of vaginal vault prolapse, mainly because of the low morbidity and high success rate. Polypropylene mesh is the prefered suspension structure but the accurate surgical technique is the most important for the abdominal sacrocolpopexy success and safety.

[Effectivity and complications rate of surgical treatment of stress urinary incontinence with tension-free vaginal tape--Uretex]. / Efektivita a komplikace chirurgické lécby stresové mocové inkontinence pomocí volne ulozene pásky pod uretrou--Uretex.

OBJECTIVE: To evaluate the safety and efficacy of the Uretex tension-free vaginal tape procedure in the treatment of female stress urinary incontinence. DESIGN: Retrospective multicenter clinical trial. SETTING: Obstetrics and Gynecology Department, The Charles University 2nd Medical School and Teaching Hospital Motol, Prague. METHODS: A group of 145 patients with stress urinary incontinence who underwent Uretex tension-free vaginal tape procedure was studied. Procedures were performed from vaginal retropubic route. Patients were operated on in one urological and five gynecological departments in Czech Republic. Preoperative evaluation consisted of complete urogynecological examination, age, parity, body mass index, history of previous pelvic surgery and hormonal status. The cure rate and complications were determined in short-term postoperative follow-up. RESULTS: The mean age was 56 (25-80) years, the median parity was 2.25 (1-4), 113 (78%) patients were slightly overweight (BMI 25-30 kg/m2) and others had normal weight (BMI 20-25 kg/m2). The cure rate after surgery was 903% (131 women). Complications occured in 22 (15.2%) cases. In two (1.4%) patients perforation of the urinary bladder wall occurred. In two (1.4%) women nonperforated injury of bladder wall was postoperatively diagnosed. Retropubic haematoma occurred in another two patients (1.4%). 16 (11%) patients had mild early postoperative complications (eight times short-term urinary retention, six lower urinary tract infections, two urgent symptomatology). Erosion of vaginal wall did not occur postoperatively. All complications were resolved and the patients were free of negative postoperative symptoms 6 month after the procedure. CONCLUSION: This study shows that Uretex tension-free vaginal tape procedure is an effective and safe minimally invasive surgical procedure in the treatment of stress urinary incontinence.

[Abdominal hysterectomy--risk factor in development of urinary incontinence? Results of a questionnaire study]. / Abdominální hysterektomie--rizikový faktor vzniku mocové inkontinence? Výsledky dotazníkové studie.

OBJECTIVE: To evaluate the risk of urinary incontinence development after abdominal hysterectomy for benign gynecological disease. DESIGN: Retrospective questionnaire study. SETTING: Obstetrics and Gynecology Department, Charles University 2nd Medical Faculty and Teaching Hospital Motol, Prague. METHODS: Questionnaire study of women in which abdominal hysterectomy for benign gynecological disease was performed from January till December 2001 at our Department of Gynecology and Obstetrics. The questionnaire included questions about symptoms of stress, urge and mixed urinary incontinence. They were evaluated in connection with age, parity, hormonal status and body mass index. Student t-test was used for the statistical analysis. RESULTS: 114 (59.7%) from all sent-out questionnaires were obtained. In 15.8% cases (18 from 114) de novo urinary incontinence after surgery developed. 77.8% (14 from 18) from these patients suffered from genuine stress incontinence. The rest (4 from 18) of the women had symptoms of mixed incontinence. Study results draw attention to 13.1% women (15 from 114) in which preoperative stress incontinence persisted even after hysterectomy. Preoperative stress incontinence was cured in 6.1% (7 from 114) cases after hysterectomy. Age, parity, hormonal status and body mass index were not statistically different in all groups after surgery. CONCLUSIONS: The results of the study show relatively high risk of urinary incontinence development after abdominal hysterectomy in previously continent women. The results also show high persistence of the stress incontinence symptoms in women who did not inform about their incontinence even if they were asked about it. Higher quality of further health education of the women with drawing their attention to both the possibility of surgical treatment of urinary incontinence simultaneously with hysterectomy are the most important aspects how to make the current gynecological surgical therapy more effective.

[Conservative therapy of female urinary incontinence--potential and effect]. / Konzervativní terapie zenské mocové inkontinence--moznosti a efektivita.

Non-surgical treatment of female stress urinary incontinence is not as effective as surgical methods but it is very successful in indicated cases. Rehabilitation of the pelvic floor muscles (Kegel exercises, vaginal cones, and electrostimulation of the pelvic floor muscles), drug treatment (alfa-mimetics, tricyclic antidepressives, estrogens, duloxetin), pessarotherapy and uretral obturator devices represent possibilities of conservative therapy of the stress incontinence. Conservative therapy is the method of choice in the treatment of urge incontinence. The most successful are anticholinergic drugs but they have very frequent serious side effects (dryness of the mucous membranes, accommodation disorders, constipation). Spasmolytics, estrogens and tricyclic antidepressives are the other popular used drugs. Life style modification, bladder training and electrostimulation represent very important parts of the conservative treatment. Effectiveness of the non-surgical treatment of both urge and stress urinary incontinence can not reach 100 percent but it helps very much in the quality of life improvement of incontinent women.

[Lower urinary tract infections in urogynaecology]. / Infekce dolních mocových cest v urogynekologii.

Urinary tract infections belong among the most common infectious diseases in adult women. Sporadic infection is usually not a diagnostic and therapeutic problem. Recurrent lower urinary tract infections significantly decrease the quality of life of the affected women. Colonisation of the vagina, vulva and the perineum by the uropathogens is the main risk factor of any urinary infection, but only concomitant action of some other factor (e.g. immunosuppression, urethral stenosis, urolithiasis, urethral diverticulum, diabetes and urinary incontinence) can induce the recurrent infection. Correct primary treatment and proper used preventive method is highly advantageous not only from the individual but also from the global point of view (high diagnostic and therapeutic expenses, increase of resistance and imminent success decrease of the modern treatment). Continuous low dose antimicrobial treatment is the most common prophylactic modality. Postcoital antimicrobial prophylaxis and immunomodulative therapy are the other used modalities. Local vaginal estrogen therapy is recommended in postmenopausal women. Estrogens improve the symptoms of the urogenital atrophy and decrease the vaginal pH, which is very important in prevention of the pathological bacterial colonisation of the vagina. Decision about the individual therapy and prophylaxis must be preceded by the evaluation of the risk factors with positives and negatives of the used drug.

[Epidemiological aspects of the female urinary incontinence]. / Epidemiologické aspekty zenské mocové inkontinence.

Urinary incontinence is defined as an involuntary loss of urine, which makes social and hygienic problem. It is a symptom with different causes. According to the typical clinical manifestation it is classified as stress, urge, reflex and paradox urinary incontinence. Loss of small amount of urine related to the increase of intraabdominal pressure (during coughing, sneezing or running) is characteristic for stress urinary incontinence. Sudden and uncontrollable voiding with loss of greater amount of urine is typical for urge incontinence. Reflex incontinence means that urinary bladder is emptying without voiding. Paradox incontinence is caused by an acquired smooth muscle weakness of the bladder and it manifests with incomplete emptying and with growing residual urine. Prevalence of urinary incontinence increases with age. Significant increase of female urinary incontinence symptoms is found in fifth and sixth decade. Urinary incontinence in young women is more a dynamic than a permanent symptom but the postmenopausal incontinence obviously does not disappear spontaneously. Urge and mixed incontinence are less frequent than stress symptomatology (between 10 and 15%). According to the prevalence studies only 1,5 to 6% of incontinent women are looking for a medical help. Because the urge symptoms are more limiting, the patients with urge incontinence are searching treatment possibilities more often than those with stress incontinence.

[Contemporary potential of the mini-invasive surgical treatment of the female stress urinary incontinence]. / Soucasné moznosti miniinvazivní chirurgické lécby zenské stresové mocové inkontinence.

In 1994 DeLancey published the hammock hypothesis. According to this theory the increase of the urethral closure pressure depends on the urethral compression by the suburethral supportive tissue and the intraabdominal position of the proximal urethra and the bladder neck are not the main factors ensuring the continence. In connection with this new theory Ulmsten published (in 1996) results of the stress incontinence treatment with the tension-free polypropylene vaginal tape (TVT). This operation represents a revolution in the antiincontinent surgery. The success rate of this procedure is about 90% and it is the same in obese and in non obese women. Concomitant TVT and transvaginal procedures for prolapse do not decrease the effectiveness and do not increase the perioperative and postoperative morbidity. The procedure is connected with some peroperative (bladder perforation, retropubic haematoma), early postoperative (urinary retention) and late postoperative complications (urge incontinence, vaginal protrusion of the tape). In 2003 newly developed tape procedure--TOT (transobturator tape) was an evolutionary step in the improvement of tape procedures. The evaluation of the efficacy and complications rate of this modification is premature up to this time but hitherto positive results predetermine this surgical modality to successful expand.

[Effectiveness and safety of the tension-free vaginal tape (TVT) operation during the learning period]. / Ucinnost a bezpecnost TVT operace v "dobe ucení" metody.

OBJECTIVE: To evaluate the safety and efficacy of the tension-free vaginal tape procedure in the treatment of female stress urinary incontinence during the learning phase. DESIGN: Retrospective clinical trial. SETTING: Obstetrics and Gynecology Department, 2nd Medical Faculty, Charles University and Faculty Hospital Motol, Prague. METHODS: A group of first 20 patients with stress urinary incontinence who underwent tension-free vaginal tape procedure was studied. Surgical procedure was performed according to Ulmsten's technique under the spinal anaesthesia. All patients were operated on by one surgeon and none had undergone any previous anti-incontinence surgery. Preoperative evaluation consisted of urodynamic examination, Q-tip test, stress test, age, parity, body mass index, history of previous pelvic surgery and hormonal status. The cure rate and complications were determined in short-term postoperative follow-up. RESULTS: The mean age was 59.5 (43-74) years, the median parity was 1.55 (1-2), 16 (80%) patients were slightly overweight (BMI 25-30 kg/m2) and others had normal weight (20-25 kg/m2). The cure rate in 6 months follow-up was 95% (19 of 20 patients). The complications occurred in 7 (35%) cases. 5 (25%) patients had mild early postoperative complications (two lower urinary tract infections, one defect healing of vaginal suture, one urge symptomatology, one short-time urinary retention) and 2 (10%) had serious late postoperative complications (urethral diverticulum, retropubic haematoma) which required surgery (diverticulectomy, transabdominal evacuation of the haematoma). All complications were resolved and the patients were 6 month after the procedure free of negative postoperative symptoms. CONCLUSIONS: This study shows that tension-free vaginal tape procedure is an effective and safe minimally invasive surgical procedure in the treatment of stress urinary incontinence in short-term follow-up. The study also suggests that a learning phase of approximately 20 operations performed in a standard manner by one surgeon is required for good results. The operative technique is simple but the TVT procedure should be performed by experienced urogynecologists who are able to resolve intraoperative and postoperative complications.

[The Barnett-Macku method of anterior colporrhaphy in the prevention and treatment of urinary stress incontinence in women with cystocele]. / Prední posevní plastika podle Barnetta-Macku v prevenci a lécbe stresové inkontinence u zen s cystokélou.

OBJECTIVE: The evaluation of the success rate in prevention and treatment of stress incontinence in patients with cystocele operated by Barnett-Macku modification of anterior colporrhaphy. DESIGN: Retrospective clinical trial. SETTING: Obstetrics and Gynecology Department, Charles University 2nd Medical Faculty and Teaching Hospital Motol, Prague. METHODS: Comparative questionnaire study of 41 patients operated between 1998 and 2000 for cystocele by Barnett-Macku modification of anterior colporrhaphy and the control group of 75 patients operated by Stoeckel modification. Preoperative examination included history, gynecological examination and evaluation of urinary continence. Body mass index, obesity, age, parity and hormonal status were recorded in the time of surgery. Stress and urge incontinence, lower urinary tract infections, hormonal therapy, recurrency of the prolapse and quality of life improvement were evaluated in follow-up. Yes-no logistic regression test and chi 2 test were used for the statistical analysis. RESULTS: In the group of patients operated for cystocele by Barnett-Macku modification of anterior colporrhaphy statistically significant higher success rate in the prevention and treatment of concomitant stress urinary incontinence was demonstrated. Prophylactic effect of the procedure was also documented by the fact that no one stress incontinent woman after surgery appeared in this group. CONCLUSION: Barnett-Macku modification of anterior colporrhaphy is reliable and successful contribution into the register of reconstructive vaginal operations primary for the treatment of cystocele and secondary for the prevention of latent and treatment of concomitant stress incontinence.