Treatment Outcomes of Cesarean Scar Pregnancy Under a Novel Classification System: A Retrospective Cohort Study.

OBJECTIVES: To determine whether the new classification system published by Jordans et al for cesarean scar pregnancy (CSP) can guide management and treatment outcomes. METHODS: A retrospective study of women diagnosed with CSP from October 2010 to December 2022 in a single tertiary center was performed. Sonographic records of these women were classified into three types according to the classification published by Jordans et al. Treatment outcomes were compared across each type of CSP. RESULTS: The study included a total of 84 women, where 60 (71.4%), 17 (20.2%), and 7 (8.3%) of them were categorized into Type 1, 2, and 3 CSP, respectively. A total of 47 (55.9%) women were managed with methotrexate, 22 (26.2%) underwent surgical management of the CSP without removal of the Cesarean section (CS) niche, and 11 (13.1%) underwent surgery to remove the CSP and the CS niche. Overall treatment success rates for medical management and surgical management were 70 and 97%, respectively. Four women were managed expectantly and continued their pregnancies, among which three carried beyond 34 weeks and had good neonatal outcomes. CONCLUSIONS: The classification as published by Jordans et al is easily replicable and readily implemented clinically. Our findings show that a higher proportion of Type 1 and Type 2 CSP were treated successfully by a less invasive medical approach with a high success rate, whereas most Type 3 CSP required surgical resection to successfully remove the CSP and the CS niche. Prospective studies are required to confirm these findings and further validate the clinical utility of this nomenclature system.

Treatment outcome of women with urodynamic mixed urinary incontinence: an observational study.

INTRODUCTION AND HYPOTHESIS: Mixed urinary incontinence (MUI) is a common yet understudied condition. It remains a therapeutic challenge, with the presence of both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). There is limited information on the optimal management for women with urodynamic MUI (urodynamic stress incontinence and detrusor overactivity). We assessed the treatment outcome of pelvic floor muscle training (PFMT), medical treatment and surgery for women who were diagnosed with urodynamic MUI. METHODS: A prospective observational study was carried out on women with urodynamic MUI from 2010 to 2018. All women underwent clinical assessment and standardised urodynamic evaluation. All women received PFMT from a specialised continence advisor as initial management. Antimuscarinics and/or continence surgery were considered according to the woman's response and symptoms after PFMT. Subjective outcome after each treatment modality was analysed. RESULTS: A total of 198 women were included for analysis. All women received PFMT, 104 (52.5%) showing improvement in urinary incontinence. Eighty-seven (43.9%) women were offered antimuscarinics, of whom 58 (29.3%) showed subjective improvement in both SUI and UUI, and 10 (5%) reported a reduction in UUI but persistent SUI. A total of 55 (27.7%) women received surgical treatment, with 20 receiving continence procedures. Sixteen out of twenty (80%) of them reported improvement in both SUI and UUI. None reported worsening of urgency or UUI. Overall, across all treatment modalities, 73.8% of women showed improvement in both SUI and UUI. CONCLUSION: Future analyses can help to inform which patients will have a higher success rate after each treatment modality and help focus treatment effort on those with a high risk of persistent symptoms. This will provide relevant data in counselling women, giving reasonable expectations and directing the management of women with urodynamic MUI.

Effect of additional acupuncture to pelvic floor exercise on urinary incontinence: A randomized controlled trial.

AIMS: To investigate the additional benefit of acupuncture to pelvic floor exercise (PFE) on the improvement of urinary incontinence (UI) and quality of life (QoL) in women. METHODS: This was a single-blinded randomized controlled trial in a tertiary university hospital. Women with UI in various severity and types were randomized to receive either a weekly course of acupuncture with PFE or PFE alone for 6 weeks and then followed up for 24 weeks in every 6 weeks. Investigators were blinded to group allocation in pre- and postintervention assessments. Primary outcome was subjective changes of UI symptoms at 24 weeks. Secondary outcomes were episodes and severity of UI from bladder diary, severity by Visual Analogue Scale, and QoL scores by validated Chinese short-form of Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7). RESULTS: One hundred seventy-nine women were screened while 137 were randomized. Significant subjective improvement in UI symptoms was demonstrated at all follow-up, latest at 24 weeks (odds ratio [OR]: 2.29, 95% confidence Interval [CI]: 1.02-5.12, respectively), with reduced episodes and severity of UI after (p < 0.05), and a trend of improvement in IIQ-7 score (p = 0.05). No major adverse events occurred. History of 2 years or longer duration of UI symptoms was associated with lower effectiveness of acupuncture (OR: 0.08, 95% CI: 0.01-0.68).

Perioperative Outcomes After Preoperative Epidural Analgesia in Patients with Hip Fracture Undergoing Surgical Repair: A Systematic Review.

OBJECTIVE: To examine the effectiveness and safety of epidural analgesia in the presurgical period in patients with hip fracture undergoing surgical repair. DESIGN: Systematic review. METHODS: The study protocol was registered with the PROSPERO systematic reviews registry with the (identifier CRD42019140396). Electronic databases were searched for randomized controlled trials comparing preoperative epidural analgesia with other forms of pain management in patients with a hip fracture. The primary outcomes included perioperative cardiac events and death. Pain, noncardiac complications, and adverse effects were also examined as secondary outcomes. The heterogeneity of the included studies was assessed with the I2 statistic, and a random-effects meta-analysis was conducted once sufficient homogeneity was demonstrated. RESULTS: Four studies, which included a total of 221 patients, met the inclusion criteria. Preoperative epidural analgesia resulted in fewer cardiac events, which was a reported outcome in two included studies (relative risk 0.30; 95% confidence interval 0.14-0.63; I2=0%). Preoperative epidural analgesia was also associated with a decreased perioperative mortality rate in a meta-analysis of two studies (relative risk 0.13; 95% confidence interval 0.02-0.98; I2 = 0%). Pain was not pooled because of variability in assessment methods, but preoperative epidural analgesia was associated with reduced pain in all four studies. CONCLUSIONS: Preoperative epidural analgesia for hip fracture may reduce perioperative cardiac events and deaths, but the number of included studies in this systematic review was low. More research should be done to determine the benefit of early epidural analgesia for patients with hip fracture.

Peripheral anterior synechiae after selective laser trabeculoplasty among Chinese patients.

PURPOSE: Peripheral anterior synechiae (PAS) have been reported as a complication after argon laser trabeculoplasty, but rarely reported after selective laser trabeculoplasty (SLT). This study aims to determine the incidence and predictors of this potential complication in phakic eyes of Chinese patients. METHODS: A retrospective review of consecutive Chinese phakic patients who underwent SLT for primary open-angle glaucoma or ocular hypertension from 2011 to 2015 was analyzed for post-operative outcomes, including the development of PAS. RESULTS: There was a total of 292 patients (509 eyes) that were of Chinese ethnicity and eligible in our analysis. The 4-year incidence of PAS was 13.57% for the 221 eyes with documented gonioscopy after SLT, and the time, since first SLT, to PAS diagnosis was 5.62 years (2052 ± 75.2 days). After accounting for the inter-eye correlation by the mixed effect Cox regression model (AUC = 0.885), the predictors of earlier PAS diagnosis were baseline intraocular pressure (≥ 18 versus < 18) (HR = 4.6, p = 0.031), baseline use of bimatoprost (HR = 14.97, p = 0.006), and pre-existing hypertension (HR = 11.78, p = 0.016). There was no significant association of earlier PAS diagnosis with age (p = 0.434), baseline number of medications used (p = 0.693), and baseline use of brinzolamide (p = 0.326). CONCLUSION: PAS development after SLT appears to be more common in Chinese patients, with a presumed 4-year incidence of 13.6%, based on retrospective review of eyes with subsequent documented gonioscopy findings. TRIAL REGISTRATION: Hong Kong University Clinical Trials Registry (HKUCTR-2350).

Impact of COVID-19-related care disruptions on blood pressure management and control in community health centers.

BACKGROUND: Uncontrolled hypertension is a leading risk factor for cardiovascular disease. To ensure continuity of care, community health centers (CHCs) nationwide implemented virtual care (telehealth) during the pandemic. CHCs use the Centers for Medicare & Medicaid Services (CMS) 165v8 Controlling High Blood Pressure measure to report blood pressure (BP) control performance. CMS 165v8 specifications state that if no BP is documented during the measurement period, the patient's BP is assumed uncontrolled. METHODS: To examine trends in BP documentation and control rates in CHCs as telehealth use increased during the pandemic compared with pre-pandemic period, we assessed documentation of BP measurement and BP control rates from December 2019 - October 2021 among persons ages 18-85 with a diagnosis of hypertension who had an in-person or telehealth encounter in 11 CHCs. Rates were compared between CHCs that did and did not implement self-measured BP monitoring (SMBP). RESULTS: The percent of patients with hypertension with no documented BP measurement was 0.5% in December 2019 and increased to 15.2% (overall), 25.6% (non-SMBP CHCs), and 11.2% (SMBP CHCs) by October 2021. BP control using CMS 165v8 was 63.5% in December 2019 and decreased to 54.9% (overall), 49.1% (non-SMBP), and 57.2% (SMBP) by October 2021. When assessing BP control only in patients with documented BP measurements, CHCs largely maintained BP control rates (63.8% in December 2019; 64.8% (overall), 66.0% (non-SMBP), and 64.4% (SMBP) by October 2021). CONCLUSIONS: The transition away from in-person to telehealth visits during the pandemic likely increased the number of patients with hypertension lacking a documented BP measurement, subsequently negatively impacting BP control using CMS 165v8. There is an urgent need to enhance the flexibility of virtual care, improve EHR data capture capabilities for patient-generated data, and implement expanded policy and systems-level changes for SMBP, an evidence-based strategy that can build patient trust, increase healthcare engagement, and improve hypertension outcomes.

Prevalence of levator ani muscle avulsion and effect on quality of life in women with pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Levator ani muscle (LAM) avulsion is associated with pelvic organ prolapse (POP). There is limited information on the prevalence of LAM avulsion in Chinese women with POP. This study evaluated the prevalence of LAM avulsion in women presenting with POP and the effects on their quality of life (QoL). METHODS: This prospective study was conducted in a tertiary urogynecology center. Chinese women presenting with POP were recruited and completed standardized questionnaires exploring their symptoms and QoL and underwent gynecological examination to assess the stage of POP and involved compartments. Four-dimensional translabial ultrasound (US) was performed on all women, and evaluation of LAM avulsion was done offline. RESULTS: Three hundred and ninety-eight women completed the study. The prevalence of LAM avulsion was 38.9% [95% confidence interval (CI) 34.1-43.7%]; 31 (7.8%), 26 (6.5%), and 98 (24.6%) had left, right, and bilateral LAM avulsion, respectively. LAM avulsion was associated with a more advanced stage of prolapse (P < 0.005) and prolapse of stage ≥II of all three compartments. Bilateral LAM avulsion was associated with a more severe stage of prolapse. More women with LAM avulsion reported bothersome symptoms of prolapse and had higher Pelvic Organ Prolapse Distress Inventory (POPDI) and Urinary Incontinence Questionnaire (UIQ) scores, implying more impairment in QoL. However, after multivariate linear regression analysis, POP stage remained a significant predictor of POPDI and UDI scores (P ≤ 0.006); LAM avulsion was not a predictor (P = 0.2 and 0.27, respectively). CONCLUSIONS: LAM avulsion was detected in 39% of Chinese women with POP. It was associated with a more advanced POP stage, and these women had more impairment of QoL. However, LAM avulsion was not an independent factor influencing the QoL of these women.

Association of long-term glycaemic control on tear break-up times and dry eye symptoms in Chinese patients with type 2 diabetes.

IMPORTANCE: Diabetes mellitus is known to be associated with dry eye syndrome (DES), but the effects of long-term glycaemic control on tear film metrics and dry eye symptoms are not known in the Chinese population. BACKGROUND: To evaluate tear film stability and dry eye symptoms and their associations with systemic risk factors in Chinese patients with type 2 diabetes mellitus (T2DM). DESIGN: Cross-sectional study set at the Lo Fong Siu Po Eye Centre (Grantham Hospital), Hong Kong. PARTICIPANTS: A total of 80 Chinese participants, aged 18 or above, with T2DM recruited from the specialist outpatient setting were included. METHODS: The Oculus Keratograph 5M (Oculus Inc., Wetzlar, Germany) was used to measure the non-invasive tear break-up time (NITBUT). Ocular symptoms were evaluated using the Ocular Surface Disease Index (OSDI). The association between OSDI, NITBUT and metabolic parameters relating to diabetes were evaluated using multiple linear regression. MAIN OUTCOME MEASURES: The associations between long-term glycaemic control and NITBUT and OSDI scores. RESULTS: Stepwise multiple linear regression analysis revealed glycated haemoglobin to be the only significant independent variable for NITBUT (R2 = 0.099, P = 0.014) and OSDI (R2 = 0.062, P = 0.044) after controlling for potential confounders. The age-adjusted prevalence of DES was 20% (95% confidence interval: 11-30%) in the Chinese T2DM population. The odds of DES for increasing percentage of glycated haemoglobin was 1.49 (95% confidence interval: 1.03-2.17, P = 0.04). CONCLUSIONS AND RELEVANCE: Our findings highlight the importance of good glycaemic control as a modifiable risk factor for both dry eye symptoms and tear film instability in patients with T2DM.

An observational follow-up study on pelvic floor disorders to 3-5 years after delivery.

INTRODUCTION AND HYPOTHESIS: This study aimed to determine the prevalence of urinary incontinence (UI), fecal incontinence (FI), and pelvic organ prolapse (POP) 3-5 years after the first pregnancy and their associated risk factors. METHODS: We assessed 506 women using the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ). Maternal characteristics and obstetric data were analyzed using descriptive analysis, independent sample t test, chi-squared test, and logistic regression. RESULTS: The prevalence of UI, FI, and POP, respectively, at a mean of 43 months after first delivery was 40.8, 6.6, and 10.2% following vaginal delivery (VD) and 22.7, 4.5, and 4.5% following cesarean section (CS). Stress urinary incontinence (SUI) was reported by more women following VD than CS (38.7 vs 22.4%, P = 0.010). Compared with 8 weeks' postpartum, more women reported SUI at this later follow-up visit (40.1 vs 19.5%, P < 0.001), but fewer reported FI. More women who had an instrumental delivery reported symptoms of POP compared with those who had a normal VD. Higher body weight and weight gain from first trimester were risk factors of SUI [odds ratio (OR) 1.03] and urge urinary incontinence (UUI) (OR 1.18), respectively. Women who delivered vaginally had higher PFDI subscales scores. CONCLUSIONS: VD increased UI risk. Higher body weight and weight gain from first trimester were risk factors for SUI and UUI, respectively. More women reported symptoms of POP following an instrumental delivery than those who had a normal VD.

Efficacy and outcomes of transobturator tension-free vaginal tape with or without concomitant pelvic floor repair surgery for urinary stress incontinence: five-year follow-up.

OBJECTIVES: To compare the 5-year subjective and objective outcomes of transobturator tension-free vaginal tape alone versus the same procedure with concomitant pelvic floor repair surgery for pelvic organ prolapse in women with urinary stress incontinence. DESIGN: Prospective cohort study. SETTING: Urogynaecology unit at a university hospital in Hong Kong. PATIENTS: Of 218 women, 96 (44%) received transobturator tension-free vaginal tape alone and 122 (56%) received transobturator tension-free vaginal tape with concomitant pelvic floor repair surgery from September 2004 to December 2009. The women were followed up annually for up to 5 years after the operation. MAIN OUTCOME MEASURES: The 5-year subjective and objective cure rates were assessed. Subjective cure was defined as no urine loss during physical activity and objective cure was defined as no urine leakage on coughing during urodynamic study. RESULTS: Overall, 88 women receiving transobturator tension-free vaginal tape alone and 101 women receiving transobturator tension-free vaginal tape with concomitant pelvic floor repair surgery were followed up for 5 years after operation. The subjective and objective cure rates of the two groups were 70.5% versus 94.1% (P<0.01) and 80.3% versus 85.7% (P=0.58), respectively. CONCLUSIONS: Transobturator tension-free vaginal tape is an effective treatment for urinary stress incontinence in women who received it alone or with concomitant pelvic floor repair surgery for pelvic organ prolapse, providing high subjective and objective efficacy for up to 5 years after operation. Transobturator tension-free vaginal tape with concomitant pelvic floor repair surgery achieved similar, if not better, long-term outcome compared with transobturator tension-free vaginal tape alone.

Effect of levator ani muscle injury on primiparous women during the first year after childbirth.

INTRODUCTION AND HYPOTHESIS: To evaluate the effect of levator ani muscle (LAM) injury on pelvic floor disorders and health-related quality of life in Chinese primiparous women during the first year after delivery. METHODS: At 8 weeks and 12 months after delivery, 328 women were assessed for symptoms of pelvic floor disorders and quality of life using the standardised questionnaire, POP-Q; and translabial ultrasound to detect LAM injury. Descriptive analysis, independent sample t test, non-parametric testing, Chi-squared test and two-sided Fisher's exact test were used. RESULTS: At 8 weeks after delivery, 48 (19.0% [95% CI, 14.2-23.8%]) women with vaginal delivery had LAM injury; 38 women (79.2%) had persistent LAM injury at 12 months. At 8 weeks, LAM injury was associated with prolapse symptoms, descent at Pelvic Organ Prolapse Quantification (POP-Q) Aa and Ba points and a higher Pelvic Organ Prolapse Distress Inventory (POPDI) general and Urinary Distress Inventory (UDI) Obstructive subscale score. At 12 months, it was not associated with prolapse symptoms, Pelvic Floor Distress Inventory (PFDI) or Pelvic Floor Impact Questionnaire (PFIQ). There was also no association between stress urinary incontinence (SUI), urge urinary incontinence (UUI), mixed urinary incontinence (UI), faecal incontinence (FI) with LAM injury at both time points. CONCLUSIONS: Seventy-nine per cent of women who had LAM injury at 8 weeks after vaginal delivery had persistent LAM injury at 12 months. LAM injury was associated with prolapse symptoms, lower POP-Q Aa and Ba points at 8 weeks after delivery and a higher POPDI general and UDI Obstructive subscale scoring. However, we are not able to confirm the association between LAM injury and SUI, UUI, mixed UI, FI at 8 weeks or 12 months after delivery; or prolapse symptoms, PFDI or PFIQ scores at 12 months after delivery.

A pilot study of urine cytokines in ketamine-associated lower urinary tract symptoms.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to investigate urine cytokine and chemokine levels in symptomatic ketamine abusers compared with age-matched controls. METHODS: Midstream urine specimens were collected in a prospective study of 23 ketamine abusers and 27 controls who had never used ketamine. Their basic demographic and urinary symptoms were compared. The urine was analyzed by a multiplex panel screen for 19 cytokines/chemokines: EGF, GM-CSF, GRO, IL-1Ra, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12p40, IL-12p70, IP-10, MCP-1, MIP-1b, sCD40L, sIL-2Ra, VEGF, MCP-4, and TARC using Luminex™ xMAP® technology. Protein concentration values were normalized to urine creatinine concentrations. RESULTS: Mean age of the control group was 21.1 ± 4.3 years (n = 27) and of the ketamine group was 20.6 ± 3.7 years (n = 23). All participants were women. The urine cytokine analysis showed a significant elevation in EGF levels in the ketamine group with lower urinary tract symptoms (LUTS) compared with the control group (p < 0.005). Levels of the remaining 18 proteins tested were not different from control values. CONCLUSIONS: Urinary EGF levels were increased among symptomatic ketamine abusers. This suggests inflammation and epithelial repair may play a role in ketamine-associated LUTS, and this may in turn help in understanding the pathophysiology of this disease entity, leading to better treatment options.

Inside-out versus outside-in transobturator tension-free vaginal tape: a 5-year prospective comparative study.

OBJECTIVE: To compare the 1-year and 5-year outcomes of transobturator tension-free vaginal tape with outside-in and inside-out approaches in women with urinary stress incontinence, and to identify risk factors for treatment failure at 5 years. METHOD: A prospective observational study was carried out for women with urinary stress incontinence who underwent transobturator tension-free vaginal tape from September 2004 to March 2008 in a tertiary urogynecology center. Women (n = 213) had either an outside-in (n = 124) or inside-out (n = 89) procedure. They were followed up annually until 5 years after the operation. Subjective cure was defined as women not experiencing any urine loss on physical activity. Objective cure was defined as no urine leak at cough during a standard urodynamic study. RESULTS: At a mean follow up of 59.2 months, the subjective cure rates were 81.7% and 84.1%; the objective cure rate were 82.6% and 82.5% for the outside-in and inside-out approach, respectively. There was no statistically significant difference between the procedures. De novo overactive bladder syndrome (10.6% in outside-in and 14.6% in inside-out approach; P = 0.40) and de novo detrusor overactivity (5.8% in outside-in and 15% in inside-out approach; P = 0.11) was also comparable between the two groups. Complications at the fifth year were low and not significantly different among both methods. CONCLUSION: The outside-in approach and inside-out approach are both safe and effective in treating women with urinary stress incontinence up to 5 years.

Responsiveness of the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire in women undergoing treatment for pelvic floor disorders.

INTRODUCTION AND HYPOTHESIS: This study evaluated the responsiveness and minimal important differences (MID) of the Chinese Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) in women undergoing urodynamic stress incontinence (USI) and/or pelvic organ prolapse (POP) treatment. METHODS: One hundred and fifty-six women were assessed using the PFDI and PFIQ before and after they received continence surgery and or pelvic floor repair (PFR) surgery, or vaginal pessary. Symptom severity was recorded using a visual analog scale (VAS) before and after treatment as was rating of their satisfaction with the treatment they received. Responsiveness of the PFDI and PFIQ were evaluated by effect sizes, standardized response mean, paired samples t test or Wilcoxon Signed Rank Test. MID in the PFDI and PFIQ for different treatments were determined by satisfaction rating, change in VAS scoring, and distribution-based methods. RESULTS: There were significant improvements in the respective subscales of PFDI and PFIQ, demonstrating moderate to great responsiveness after different treatments. The estimation of MID for the Urinary Distress Inventory (UDI) was -30 to -14 and the Urinary Impact Questionnaire (UIQ) was -28 to -14 for women who underwent continence surgery. The MID for the Pelvic Organ Prolapse Distress Inventory (POPDI) was -44 to -21, the Pelvic Organ Prolapse Impact Questionnaire (POPIQ) -40 to -27, the UDI -22 to -16, the UIQ -37 to -31, the Colo-Rectal-Anal Distress Inventory (CRADI) -37 to -14, and the Colo-Rectal-Anal Impact Questionnaire (CRAIQ) -34 to -6 for women who underwent PFR surgery; and estimation of MID for the POPDI was -16, the POPIQ -29, the UDI -28, the UIQ -17, the CRADI -25, and the CRAIQ -31 for women who received a vaginal pessary. The MID of the respective subscales were supported by the distribution-based methods. CONCLUSIONS: The Chinese PFDI and PFIQ instruments are responsive to change in women undergoing continence surgery, PFR surgery or vaginal pessary for USI or POP.

Prevalence of urinary and fecal incontinence in Chinese women during and after their first pregnancy.

INTRODUCTION AND HYPOTHESIS: This study evaluated factors and their prevalence associated with urinary (UI) and fecal (FI) incontinence during and after a woman's first pregnancy. METHODS: Nulliparous Chinese women with no UI or FI before pregnancy were studied with a standardized questionnaire for UI and FI from early pregnancy until 12 months after childbirth. Maternal characteristics and obstetric data were analyzed using descriptive analysis, independent sample t test, chi-square test, and logistic regression. RESULTS: Three hundred and twenty-eight (74.2 %) women completed the study. The prevalence of antenatal UI increased with gestation. Overall, 192 (58.5 %), 60 (18.3 %), and 76 (23.1 %) had normal vaginal delivery, instrumental delivery, and cesarean section, respectively. Twelve months after delivery, prevalence of stress urinary incontinence (SUI) and urge urinary incontinence (UUI) was 25.9 % [95 % confidence interval (CI) 21.5-30.6] and 8.2 % (95 % CI 5.2-11.2), respectively. In those who delivered vaginally, the prevalence was 29.7 % and 9.1 %, respectively. Prevalence of FI was 4.0 % (95 % CI 1.9-6.1). On logistic regression, vaginal delivery [odds ratio (OR) 3.6], antenatal SUI (OR 2.8), and UUI (OR 2.4) were associated with SUI. Antenatal UUI (OR 6.4) and increasing maternal body mass index (BMI) at the first trimester (OR 1.2) were associated with UUI. Antenatal FI was associated with FI (OR 6.1). CONCLUSIONS: The prevalence of SUI, UUI, and FI were 25.9 %, 8.2 %, and 4.0 %, respectively, 12 months after delivery. Vaginal delivery, antenatal SUI, and UUI were associated with SUI; antenatal UUI and increasing maternal BMI at the first trimester were associated with UUI. Antenatal FI was associated with FI. Pregnancy, regardless of route of delivery and obstetric practice, had an effect on UI and FI.

Risk of malignancy in women who underwent hysterectomy for uterine prolapse.

AIMS: To evaluate the risk of missing a malignancy in surgical specimens following hysterectomy for uterine prolapse if routine pathological examination is not performed. Additionally, information on the risk of missing an hitherto unsuspected malignancy if uterine preservation is the preferred management option will be provided. MATERIALS AND METHODS: A retrospective study was performed on all cases of surgery performed for uterine prolapse in a tertiary referral institution from 2003 to 2011. Those with confirmed malignancy before operation were excluded. The study subjects had their clinical history, investigations, the type of operations and histopathology report analysed. They were classified into symptomatic or asymptomatic, depending on whether they reported symptoms that were suggestive of uterine malignancy. RESULTS: A total of 640 women were studied. Three cases of hitherto unsuspected uterine malignancy were found, giving an incidence of 0.47%. Among the 456 asymptomatic women, both pre- and postmenopausal, the risk of incidental malignancy was 0.22%. Within the postmenopausal group, risk of incidental malignancy was 0.26%. Another 3 cases of uterine premalignant conditions were identified, giving an overall risk of premalignant and malignant uterine condition of 0.94%. Five cases of cervical intra-epithelial neoplasia were found, contributing to a risk of 0.78%. CONCLUSIONS: The risk of missing an uterine malignancy in patients with uterine prolapse is low if appropriate investigations are carried out prior to surgery. If hysterectomy is to be performed, we recommend that all surgical specimens be subjected to histopathological examination.

Pelvic floor muscle training improves quality of life of women with urinary incontinence: a prospective study.

BACKGROUND: Women suffering from urinary incontinence have impaired quality of life (QoL). Pelvic floor muscle training (PFMT) has been recommended to be the first-line treatment for them. AIMS: This study evaluated the role of (PFMT) in women with urinary incontinence. MATERIALS AND METHODS: All women suffering from urinary incontinence without pelvic organ prolapse who attended the urogynaecology unit of a university hospital from January 2009 to June 2010 were recruited. Urinary symptoms and impact on QoL were assessed using the Chinese validated Urogenital Distress Inventory short form (UDI-6) and Incontinence Impact Questionnaire short form (IIQ-7) before and after PFMT. Urodynamic studies (UDS) were used to differentiate the diagnoses of urinary incontinence. RESULTS: Three hundred and seventy-two women, aged 52.3 ± 10.8 years and practised PFMT for 9.9 ± 7.3 months, completed the study. Over 65% recorded improvement in both UDI-6 and IIQ-7. Stratified for urodynamic diagnosis, stress incontinence group and those who had no UDS abnormality had significant improvement in their urinary symptoms and QoL after PFMT. UDI-6 and IIQ-7 also improved significantly after PFMT in groups where the clinical presentation was stress incontinence, overactive bladder symptoms or mixed urinary incontinence. Age was not associated with a significant difference in the response to PFMT. CONCLUSIONS: Pelvic floor muscle training appears to be an effective first-line intervention for improving urinary symptoms and QoL of women presenting with urinary incontinence. Future studies on long-term effectiveness and cost-effectiveness are also required.

Tension-free vaginal mesh for the treatment of pelvic organ prolapse in Chinese women.

OBJECTIVE: To assess perioperative and short-term outcomes after tension-free vaginal mesh repair of pelvic organ prolapse in local Chinese women. DESIGN: Case series. SETTING: The urogynaecology unit of a university teaching hospital in Hong Kong. PATIENTS: All women with stage III or more pelvic organ prolapse who underwent tension-free vaginal mesh repair with or without vaginal hysterectomy from May 2007 to June 2011. MAIN OUTCOME MEASURES: Perioperative and short-term outcomes. RESULTS: In all, 47 women underwent the procedure during the study period. The mean operating time was 94 minutes, the mean estimated blood loss was 163 mL, and the mean hospital stay was 4 days. Four patients had visceral injuries, all of which were identified and repaired during the operation; all four patients recovered uneventfully. The mean duration of follow-up was 25 (standard deviation, 13) months. Pelvic organ prolapse quantification improved significantly; nine (19%) of the patients had recurrent stage II prolapse but only one was symptomatic, six (13%) had postoperative mesh exposure, three of whom underwent mesh excision. There were five (11%) who had de-novo urodynamic stress incontinence, which was mostly mild and managed conservatively. Overall 91% (43/47) were satisfied with their operative outcome. CONCLUSIONS: The success rate of tension-free vaginal mesh repair for the treatment of pelvic organ prolapse in local Chinese women was comparable to rates reported internationally. There was a high degree of subjective satisfaction with the procedure. There were low rates of mesh exposure and de-novo stress incontinence that was mostly asymptomatic or mild.

Automated segmentation and measurement of the female pelvic floor from the mid-sagittal plane of 3D ultrasound volumes.

BACKGROUND: Transperineal ultrasound (TPUS) is a valuable imaging tool for evaluating patients with pelvic floor disorders, including pelvic organ prolapse (POP). Currently, measurements of anatomical structures in the mid-sagittal plane of 2D and 3D US volumes are obtained manually, which is time-consuming, has high intra-rater variability, and requires an expert in pelvic floor US interpretation. Manual segmentation and biometric measurement can take 15 min per 2D mid-sagittal image by an expert operator. An automated segmentation method would provide quantitative data relevant to pelvic floor disorders and improve the efficiency and reproducibility of segmentation-based biometric methods. PURPOSE: Develop a fast, reproducible, and automated method of acquiring biometric measurements and organ segmentations from the mid-sagittal plane of female 3D TPUS volumes. METHODS: Our method used a nnU-Net segmentation model to segment the pubis symphysis, urethra, bladder, rectum, rectal ampulla, and anorectal angle in the mid-sagittal plane of female 3D TPUS volumes. We developed an algorithm to extract relevant biometrics from the segmentations. Our dataset included 248 3D TPUS volumes, 126/122 rest/Valsalva split, from 135 patients. System performance was assessed by comparing the automated results with manual ground truth data using the Dice similarity coefficient (DSC) and average absolute difference (AD). Intra-class correlation coefficient (ICC) and time difference were used to compare reproducibility and efficiency between manual and automated methods respectively. High ICC, low AD and reduction in time indicated an accurate and reliable automated system, making TPUS an efficient alternative for POP assessment. Paired t-test and non-parametric Wilcoxon signed-rank test were conducted, with p < 0.05 determining significance. RESULTS: The nnU-Net segmentation model reported average DSC and p values (in brackets), compared to the next best tested model, of 87.4% (<0.0001), 68.5% (<0.0001), 61.0% (0.1), 54.6% (0.04), 49.2% (<0.0001) and 33.7% (0.02) for bladder, rectum, urethra, pubic symphysis, anorectal angle, and rectal ampulla respectively. The average ADs for the bladder neck position, bladder descent, rectal ampulla descent and retrovesical angle were 3.2 mm, 4.5 mm, 5.3 mm and 27.3°, respectively. The biometric algorithm had an ICC > 0.80 for the bladder neck position, bladder descent and rectal ampulla descent when compared to manual measurements, indicating high reproducibility. The proposed algorithms required approximately 1.27 s to analyze one image. The manual ground truths were performed by a single expert operator. In addition, due to high operator dependency for TPUS image collection, we would need to pursue further studies with images collected from multiple operators. CONCLUSIONS: Based on our search in scientific databases (i.e., Web of Science, IEEE Xplore Digital Library, Elsevier ScienceDirect and PubMed), this is the first reported work of an automated segmentation and biometric measurement system for the mid-sagittal plane of 3D TPUS volumes. The proposed algorithm pipeline can improve the efficiency (1.27 s compared to 15 min manually) and has high reproducibility (high ICC values) compared to manual TPUS analysis for pelvic floor disorder diagnosis. Further studies are needed to verify this system's viability using multiple TPUS operators and multiple experts for performing manual segmentation and extracting biometrics from the images.