Incontinence, bladder neck mobility, and sphincter ruptures in primiparous women.

OBJECTIVE: To compare the function of the pelvic floor in primiparae before and during pregnancy with the status post partum concerning symptoms of incontinence, sphincter ruptures, bladder-neck mobility and the influence of the different modes of deliveries. METHODS: Questionnaire evaluating symptoms of urinary and anal incontinence in nulliparous women before and after delivery and correlating these symptoms with functional changes of the pelvic floor based on a careful gynaecologic examination as well as perineal and endoanal ultrasound. RESULTS: 112 women were included in our study and came for the first visit, 99 women returned for follow-up 6 months after childbirth. Stress and flatus incontinence significantly increased from before pregnancy (3 and 12%) to after childbirth (21 and 28%) in women with spontaneous delivery or vacuum extraction. No new symptoms occurred after c-section. There was no significant difference between the bladder neck position before and after delivery. The mobility of the bladder neck was significantly higher after vaginal delivery using a vacuum extraction compared to spontaneous delivery or c-section. The bladder neck in women with post partum urinary stress incontinence was significantly more mobile than in continent controls. The endoanal ultrasound detected seven occult sphincter defects without any correlation to symptoms of anal incontinence. CONCLUSION: Several statistically significant changes of the pelvic floor after delivery were demonstrated. Spontaneous vaginal delivery or vacuum extraction increases the risk for stress or anal incontinence, delivery with vacuum extraction leads to higher bladder neck mobility and stress incontinent women have more mobile bladder necks than continent women.

Occult incontinence in women with pelvic organ prolapse - Does it matter?

OBJECTIVE: Many surgeons perform an anti-incontinence procedure during prolapse surgery in women in whom occult stress urinary incontinence has been demonstrated. Others prefer a two-step approach. It was the aim of the study to find out how many women really need a second operation and if a positive cough stress test with the prolapse reduced is associated with the development of stress urinary incontinence after prolapse surgery. METHODS: 233 women were operated for primary or recurrent prolapse without complaining of SUI. Preoperatively, 53/233 women had a full urogynecological workup with the prolapse reduced. Postoperatively, if the patient suffered from stress urinary incontinence, an anti-incontinence surgery was performed. RESULTS: 19/53 (35.8%) women who had a stress test with the prolapse reduced before surgery were defined as occult stress incontinent. Only 3 women (15.8%) of these 19 women developed symptoms of incontinence after prolapse surgery and had to be operated because of that. 18/233 (7.7%) complained of SUI 6 weeks to 6 months after surgery and received a TVT-tape. CONCLUSION: The incidence of stress urinary incontinence manifesting after prolapse surgery is low in this study with 7.7%. This fact and the possible severe side effects of an incontinence operation justify a two-step approach if the patient is counseled and agrees. However, there is a small subgroup of women (3/19, 15.8%) with preoperative OSUI and SUI after surgery, who would benefit from a one-step approach. Further research is required to identify these women before surgical intervention.

What harm does a second delivery to the pelvic floor?

OBJECTIVE: To compare the pelvic floor function of primiparous women to women after a second delivery regarding symptoms of urinary and anal incontinence, anal sphincter ruptures and bladder-neck mobility. METHODS: A questionnaire evaluating symptoms of urinary and anal incontinence was used in nulliparous women before and 27 months after childbirth. Furthermore these symptoms were correlated with functional changes of the pelvic floor based on a careful gynecologic examination as well as perineal and endoanal ultrasound. RESULTS: 112 nulliparous women were included, 49 women returned for follow-up on average 27 months (SD 4.4 months) after the first delivery. 39 women (group A) had just one delivery, 10 women (group B ? 10/49) had had a second delivery. Apart from levator ani muscle strength, no significant difference between pelvic floor function of group A vs group B was demonstrable. Furthermore, we could show no significant difference for symptoms of urinary (11 (28.2%) vs. 5 (50.0%)) and anal incontinence (14 (35.9%) vs. 4 (40.0%)) between both groups. However, we found a lasting increase of stress urinary and anal incontinence as well as overactive bladder symptoms after one or more deliveries. The position of the bladder neck at rest was lower in both groups compared to the position before the first delivery and bladder neck mobility increased after one or more deliveries. DISCUSSION: Our study shows several statistically significant changes of the pelvic floor function even on average 27 months after delivery, but a subsequent delivery did not compromise the pelvic floor any further.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016).

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Obstetrical parameters influencing the duration of the second stage of labor.

OBJECTIVE: To investigate the impact of parameters influencing the duration of the second stage of labor in vaginal deliveries. STUDY DESIGN: 1200 consecutive vaginal deliveries were analyzed. Descriptive statistics are reported for parity, duration of first and second stage of labor, maternal age, birth weight, position of the fetal head, epidural analgesia and oxytocin augmentation. Logistic regression analysis was performed to assess the contribution of different variables to the length of the second stage of labor. RESULTS: The mean length of the second stage was 70 min. In univariate analysis, parity, oxytocin augmentation and epidural analgesia, as well as occipito-posterior presentation were significant parameters associated with a prolonged second stage of labor. No correlation was found for birth weight and maternal age. In multivariate regression analysis, nulliparity and epidural analgesia were the strongest risk factors for a prolonged second stage. CONCLUSIONS: The impact of epidural analgesia on the second stage of labor should be considered in obstetrical management.

Radiotherapy of the chest wall following mastectomy for early-stage breast cancer: impact on local recurrence and overall survival.

INTRODUCTION: Recent studies have renewed an old controversy about the efficacy of adjuvant radiotherapy following mastectomy for breast cancer. Radiotherapy is usually recommended for advanced disease, but whether or not to use it in pT1-T2 pN0 situations is still being debated. This study was designed to clarify whether or not routine radiotherapy of the chest wall following mastectomy reduces the risk of local recurrence and if it influences the overall survival rate. METHODS: Retrospective analysis of patients treated with mastectomy for pT1-T2 pN0 tumors and no systemic treatment. Patients treated with radiotherapy of the chest wall following mastectomy (Group A) are compared with those treated with mastectomy alone (Group B). RESULTS: A total of 918 patients underwent mastectomy. Patients who received adjuvant radiotherapy after mastectomy (n = 114) had a significantly lower risk for local recurrence. Ten years after the primary diagnosis, 98.1% of the patients with radiotherapy were disease free compared to 86.4% of the patients without radiotherapy. The average time interval from primary diagnosis until local recurrence was 8.9 years in Group A and 2.8 years in Group B. The Cox regression analysis including radiotherapy, tumor size and tumor grading found the highest risk for local recurrence for patients without radiotherapy (p < 0.0004). In terms of overall survival however, the Kaplan-Meier analysis showed no difference between the two groups (p = 0.8787) and the Cox regression analysis failed to show any impact on overall survival. CONCLUSION: With observation spanning over 35 years, this study shows that adjuvant radiotherapy of the chest wall following mastectomy reduces the risk for local recurrence in node-negative patients with pT1-T2 tumors but has no impact on the overall survival rate.

Matched pair analysis of survival after chest-wall recurrence compared to mammary recurrence: a long-term follow up.

BACKGROUND: Local recurrence remains a major concern after primary treatment of breast cancer and has a major impact on subsequent survival. While most studies report a poorer survival rate in patients with a local recurrence after mastectomy than after breast conservation, it remains controversial whether different risk profiles at the time of primary diagnosis may account for this difference. METHOD: Matched pair analysis of 134 patients with newly diagnosed locoregional recurrence of breast cancer without evidence of systemic disease. Matching criteria included the primary surgical treatment, tumor size, nodal status, and age. The significance of various prognostic parameters at the time of primary diagnosis and at the time of recurrence were evaluated, by univariate and multivariate analyses, with respect to survival after recurrence. The median follow-up was 8.4 years. RESULTS: Risk factors at the time of presentation, such as tumor size and lymph node status, were comparable between both groups. Local recurrence occurred on an average 9 months earlier in patients after mastectomy (P = 0.08). Univariate analysis showed that lymph node status (P = 0.0001) and disease-free interval from primary treatment to local recurrence (P = 0.0002) were the most significant single prognostic factors for subsequent survival after local recurrence. The primary surgical treatment modality was shown to be of marginal statistical influence (only P = 0.05). CONCLUSION: Local recurrence after mastectomy seems to be associated with worse survival than after breast-conserving therapy. Early onset of chest-wall recurrence, moreover, represents the highest independent risk for cancer-associated death.

Intraurethral ultrasound correlated with urethral histology.

OBJECTIVE: To examine the anatomic identity of sonographically visible sphincteric structures of the female urethra. METHODS: The urethra, urinary bladder, and vagina were removed from 11 fresh female cadavers and placed in a water bath. Intraurethral ultrasound was performed with a 360 degrees-rotating 7.5-MHz ultrasound probe. Afterward, the specimens were fixed and cross sections were made transverse to the urethral axis at 5-mm intervals. Corresponding ultrasonograms and histologic images were matched and depicted simultaneously side by side. The anatomic identity of sonographically visible structures was determined by histologic examination and thickness of the longitudinal smooth urethral sphincter measured. RESULTS: Structures visible sonographically were the striated and smooth urethral sphincter muscle layers, vagina, and blood vessels with diameters exceeding 0.2 mm. The longitudinal smooth muscle layer appeared as a well-defined internal hypoechoic ring. The outer circular smooth muscle layers and the striated muscle layers were a more irregular and hyperechoic zone. The circular smooth muscle layers and the striated sphincter muscle layers could not always be differentiated easily. With formalin fixation, tissue shrinkage resulted in a smaller thickness of the longitudinal smooth muscle measured on the histologic specimen. CONCLUSION: With intraurethral ultrasound, the longitudinal smooth muscle layer appears as a well-defined and measurable hypoechoic ring. The region of the circular smooth muscle and the striated muscle emerges as a hyperechoic and less definable outer zone.

Changes in vesical neck mobility following vaginal delivery.

OBJECTIVE: To assess changes in urethral movement during the Valsalva maneuver and pelvic floor muscle contraction following vaginal delivery. METHODS: In a prospective repeated-measures study, 25 primigravidas, 20 multiparas, and ten women who were to have elective cesarean delivery were examined sonographically at 36-42 weeks of pregnancy and 6-10 weeks after delivery. Vesical neck position at rest and excursion during Valsalva maneuver and maximum pelvic muscle contraction were measured with perineal ultrasound. Data about resting bladder neck position and bladder neck elevation at contraction were compared with findings in age-matched nulligravid volunteers. RESULTS: The bladder neck was significantly lower at rest in women after vaginal delivery than in those who had an elective cesarean delivery and in nulligravid controls. Bladder neck mobility had increased during the Valsalva maneuver in 16 of 25 primigravidas and 15 of 20 multiparas 6-10 weeks after vaginal delivery. The ability to elevate the vesical neck during pelvic muscle contraction was decreased in six of 25 primigravidas and in two of 20 multiparas 6-10 weeks after birth. Two women, one primigravid and one para 2 (with a previous elective cesarean delivery), both of whom had forceps delivery, completely lost the ability to contract voluntarily the pelvic floor muscles. CONCLUSION: Vaginal delivery alters vesical neck descent during the Valsalva maneuver, and the ability of the pelvic muscles to elevate the urethra in some women.

Cross-sectional imaging anatomy of the anal sphincters.

BACKGROUND: To describe the cross-sectional anatomy of the anal sphincter mechanism relevant to magnetic resonance imaging (MRI) and ultrasound cross-sectional images. METHOD: Axial, sagittal, and coronal 5-mm sections of female pelves were reviewed from six cadaver specimens (ages 24-72 years). Fetal anatomy was studied in plastinated histologic sections from 19 and 26 weeks' gestation. Images of the anal sphincter were obtained by MRI in six and by ultrasound using an exoanal technique in 12 nulliparous volunteers. EXPERIENCE: The internal anal sphincter is clearly visible in anatomic sections central to the external sphincter and is visible in MRI and ultrasound images. The external anal sphincter can be subdivided into a subcutaneous and a deep portion. On anatomic sections and on MRI, the subcutaneous part shows as two parallel muscle strips in the axial plane; the deep portion presents with a characteristic teardrop form in the section perpendicular to the axis of the anal canal. The puborectalis muscle and the external anal sphincter form a "double bump" in the sagittal section. The longitudinal muscle can be identified by its fiber orientation in anatomic sections but is not clearly visible in imaging studies. CONCLUSION: This information should make it possible to identify accurately anal sphincter anatomy in two-dimensional sectional images of the anal sphincter.

Sonographic evaluation of the bladder neck in continent and stress-incontinent women.

OBJECTIVE: To evaluate a new sonographic method to measure depth and width of proximal urethral dilation during coughing and Valsalva maneuver and to report its use in a group of stress-incontinent and continent women. METHODS: Fifty-eight women were evaluated, 30 with and 28 without stress incontinence proven urodynamically, with a bladder volume of 300 mL and the subjects upright. Urethral pressure profiles at rest were performed with a 10 French microtip pressure catheter. Bladder neck dilation and descent were assessed by perineal ultrasound (5 MHz curved linear array transducer) with the help of ultrasound contrast medium (galactose suspension-Echovist-300), whereas abdominal pressure was assessed with an intrarectal balloon catheter. Statistical analysis used the nonparametric Mann-Whitney test. RESULTS: The depth and diameter of urethral dilation could be measured in all women. During Valsalva, all 30 incontinent women exhibited urethral dilation. One incontinent woman showed dilation only while performing a Valsalva maneuver, not during coughing. In the continent group, 12 women presented dilation during Valsalva and six during coughing. In continent women, dilation was visible only in those who were parous. Nulliparous women did not have dilation during Valsalva or coughing. Bladder neck descent was visible in continent and incontinent women. CONCLUSION: This method permits quantification of depth and diameter of bladder neck dilation, showing that both incontinent and continent women might have bladder neck dilation and that urinary continence can be established at different locations along the urethra in different women. Parity seems to be a main prerequisite for a proximal urethral defect with bladder neck dilation.

[Ultrasound in urogynecology]. / Sonographie in der Urogynäkologie.

Radiologic procedures such as lateral cystography have been substituted by ultrasound in urogynecology. The techniques are standardized and reproducible. Ultrasound is also useful for evaluating the bladder neck (funneling), the urethra (diverticula) and the paraurethral tissues (vaginal cysts, vaginal fibroids). The technique is limited in patients with genital prolapse beyond the hymenal ring. Advantages include the avoidance of x-rays and catherization.

Updated recommendations on ultrasonography in urogynecology.

Ultrasound is a supplementary, indispensable diagnostic procedure in urogynecology; perineal, introital, and endoanal ultrasound are the most recommended techniques. The position and mobility of the bladder neck can be demonstrated. In patients undergoing diagnostic work-up for urge symptoms, ultrasound occasionally demonstrates urethral diverticula, leiomyomas, and cysts in the vaginal wall. These findings will lead to further diagnostic assessment. The same applies to the demonstration of bladder diverticula, foreign bodies in the bladder, and bullous edema. With endoanal ultrasound, different parts of the sphincter ani muscle can be evaluated. Recommendations for the standardized use of urogenital ultrasound are given.

[Possibilities and limits of the conservative treatment for urinary incontinence]. / Möglichkeiten und Grenzen der konservativen Therapie der Harninkontinenz.

The conservative treatment of stress or mixed incontinence results in improvement or cure in about 60 % of patients. Pelvic floor muscle training without or with biofeedback, electrical stimulation and vaginal cones are not superior to each other.

Differences between cough and Valsalva leak-point pressure in stress incontinent women.

The aim of the study was to evaluate the relationship between Valsalva leak-point pressure (VLPP) and cough leak-point pressure (CLPP). Sixty women with stress urinary incontinence were included. One woman was excluded from evaluation because of detrusor instability. At a bladder volume of 200-300 mL (mean, 284; standard deviation, 29) CLPP and VLPP were measured in the sitting position. Intra-abdominal pressure was recorded with a rectal balloon catheter. A standardized pad test and multi-channel urodynamics were performed. VLPP was significantly lower than CLPP (58.9+/-27.6 versus 112.5+/-46.9 cm H(2)O, P<0.0001). Although CLPP was negative in two women only, VLPP was negative in 24 of 59 women (40.1%). If intrinsic sphincter deficiency was defined as a leak-point pressure of 65 cm H(2)O, 16.9% of women fulfilled this criterion using the CLPP compared to 35.6% if the VLPP is used. In conclusion, coughing and Valsalva seem to result in a different reaction of the pelvic floor.