Management of mixed urinary incontinence: IUGA committee opinion.

INTRODUCTION AND HYPOTHESIS: Mixed urinary incontinence (MUI) is defined by the International Urogynecology Association (IUGA) and International Continence Society as the complaint of involuntary leakage of urine associated with urgency and also with exertion, effort, sneezing or coughing. It therefore implies the coexistence of both stress urinary incontinence (SUI) and urgency urinary incontinence (UUI). MUI is a heterogeneous diagnosis that requires an assessment of its individual components of SUI and UUI. Management requires an individualised approach to the symptom components. The aim of this review is to identify the assessment/investigations and management options for MUI. METHODS: A working subcommittee from the IUGA Research & Development (R&D) Committee was created and volunteers invited from the IUGA membership. A literature review was performed to provide guidance focused on the recommended assessment and management of MUI. The document was then evaluated by the entire IUGA R&D Committee and IUGA Board of Directors and revisions made. The final document represents the IUGA R&D Committee Opinion. RESULTS: The R&D Committee MUI opinion paper provides guidance on the assessment and management of women with MUI and summarises the evidence-based recommendations. CONCLUSIONS: Mixed urinary incontinence is a complex problem and successful management requires alleviation of both the stress and urge components. Care should be individualised based on patient preferences. Further research is needed to guide patients in setting goals and to determine which component of MUI to treat first. The evidence for many of the surgical/procedural treatment options for MUI are limited and needs to be explored in more detail.

What is the role of the multidisciplinary team meeting in primary prolapse surgery and are alternative formats acceptable?

INTRODUCTION AND HYPOTHESIS: In 2019, the UK National Institute for Health and Care Excellence (NICE) recommended discussion of all primary prolapse cases at a multidisciplinary team (MDT) meeting prior to surgery. However, following the COVID-19 pandemic, face-to-face meetings were suspended. The aim of this study was to evaluate the role of MDT meetings in an observational retrospective review of primary prolapse cases and determine whether alternatives to face-to-face MDT meetings such as virtual and remote paper result in different outcomes. METHODS: A total of 100 consecutive patients with primary prolapse, who had already been through face-to-face MDT meetings in 2019, were subjected to remote paper (independent review by team members, who then submit a paper outcome to the MDT meeting chair) and a virtual MDT meeting by the same team (blinded). Outcomes included agree, minor amendment (changing the order of priority of the compartment, changing procedure from + to +/-), major amendment (adding/removing a compartment) and insufficient information. MDT outcomes were compared for remote paper, virtual, and face-to-face MDT options. RESULTS: In 88% of cases, face-to-face MDT meetings agreed to proceed unchanged (4% minor amendment, 7% major amendment, 1% insufficient information). This compared with 80% at virtual MDT (5% minor amendment, 11% major amendment, 4% insufficient information) and 74% when conducted by remote paper (5% minor amendment, 15% major amendment, 6% insufficient information). There was no significant difference in outcomes among the MDT meeting formats (Chi-squared 7.73, p=0.26). CONCLUSIONS: Multidisciplinary team discussion changes management in a minority of primary prolapse cases. Similar MDT decisions are produced by virtual and remote paper formats, although the latter had the lowest concordance of opinions.

A pilot study to evaluate changes in pelvic floor muscle tone following pelvic organ prolapse surgery using a novel intra-vaginal pressure sensor device.

INTRODUCTION AND HYPOTHESIS: Pelvic floor muscle weakness is a common cause of pelvic organ prolapse and urinary incontinence. Surgical repair of prolapse is commonly undertaken; however, the impact on pelvic floor muscle tone is unknown. The aim of this study was to compare the effect of anterior and posterior colporrhaphy on pelvic floor activation. METHODS: Patients aged under 70 undergoing primary anterior or posterior colporrhaphy were recruited. Intra-vaginal pressure was measured at rest and during pelvic floor contraction using the Femfit® device (an intra-vaginal pressure sensor device [IVPSD]). Peak pressure and mean pressure over 3 s were measured in millimetres of mercury. The pre- and post-operative measurements were compared. The difference between the means was assessed using Cohen's D test, with significance set at p<0.05 RESULTS: A total of 37 patients completed pre- and post-operative analysis, 25 in the anterior colporrhaphy group and 12 in the posterior colporrhaphy group. Anterior colporrhaphy showed no significant change in pelvic floor tone. Change in peak pressure was -1.71mmHg (-5.75 to 2.33; p=0.16) and change in mean pressure was -0.86 mmHg (-4.38 to 2.66; p=0.31). Posterior colporrhaphy showed a significant increase in peak pelvic floor muscle tone of 7.2 mmHg (0.82 to 13.58; p=0.005) and mean pressure of 4.19 mmHg (-0.09 to 8.47; p=0.016). CONCLUSIONS: Posterior colporrhaphy significantly improves pelvic floor muscle tone, whereas anterior colporrhaphy does not. Improved understanding of the impact of pelvic floor surgery may guide future management options for other pelvic floor disorders. Further work is needed to confirm the association of this improvement in pelvic floor disorders.

Do vaginal pessaries used to treat pelvic organ prolapse impact on sexual function? A systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is common and associated with sexual dysfunction. Vaginal pessaries are an effective treatment for POP, but their impact on sexual function is not well established. The aim of this systematic review and meta-analysis was to establish the impact of vaginal pessaries used for POP on female sexual function. METHODS: Systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. A comprehensive search was conducted across Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, CINAHL, ClinicalTrials.gov , The WHO International Clinical Trials Registry Platform, ProQuest Dissertations & Theses, Open Grey and Scopus Citation Database. Randomised controlled trials and cohort studies that assessed sexual function in women pre- and post-pessary treatment for POP were included, assessed for risk of bias and their results synthesised. RESULTS: A total of 1,945 titles and abstracts were screened, 104 full-text articles were assessed for eligibility, 14 studies were included in the narrative analysis and 7 studies were included in the meta-analysis. The results suggest that, in sexually active women, there is no evidence of a deterioration in sexual function and some evidence of an improvement. DISCUSSION: This review offers reassurance that in sexually active women who successfully use a pessary for treatment of their prolapse, there is no deterioration in sexual function. There is some evidence of an improvement in sexual function, but given the clinical heterogeneity in the studies included, caution should be taken in generalising these findings.

Mediolateral/lateral episiotomy with operative vaginal delivery and the risk reduction of obstetric anal sphincter injury (OASI): A systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: OASI complicates approximately 6% of vaginal deliveries. This risk is increased with operative vaginal deliveries (OVDs), particularly forceps. However, there is conflicting evidence supporting the use of mediolateral/lateral episiotomy (MLE/LE) with OVD. The aim of this study was to assess whether MLE/LE affects the incidence of OASI in OVD. METHODS: Electronic searches were performed in OVID Medline, Embase and the Cochrane Library. Randomised and non-randomised observational studies investigating the risk of OASI in OVD with/without MLE/LE were eligible for inclusion. Pooled odds ratios (OR) were calculated using Revman 5.3. Risk of bias of was assessed using the Cochrane RoB2 and ROBINS-I tool. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS: A total of 703,977 patients from 31 studies were pooled for meta-analysis. MLE/LE significantly reduced the rate of OASI in OVD (OR 0.60 [95% CI 0.42-0.84]). On sub-group analysis, MLE/LE significantly reduced the rate in nulliparous ventouse (OR 0.51 [95% CI 0.42-0.84]) and forceps deliveries (OR 0.32 [95% CI 0.29-0.61]). In multiparous women, although the incidence of OASI was lower when a ventouse or forceps delivery was performed with an MLE/LE, this was not statistically significant. Heterogeneity remained significant across all studies (I2 > 50). The quality of all evidence was downgraded to "very low" because of the critical risk of bias across many studies. CONCLUSIONS: MLE/LE may reduce the incidence of OASI in OVDs, particularly in nulliparous ventouse or forceps deliveries. This information will be useful in aiding clinical decision-making and counselling in the antenatal period and during labour.

International Urogynecology Consultation: Patient Reported Outcome Measures (PROs) use in the evaluation of patients with pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Patient-reported outcome measure instruments include patient-reported outcomes (PROs) and patient-reported goals (PRGs), which allow practitioners to measure symptoms and determine outcomes of treatment that matter to patients. METHODS: This is a structured review completed by the International Urogynecology Consultation (IUC), sponsored by the International Urogynecological Association (IUGA). The aim of this working group was to evaluate and synthesize the existing evidence for PROs and PRGs in the initial clinical work-up/evaluation and research arena for patients with pelvic organ prolapse (POP). RESULTS: The initial search generated 3589 non-duplicated studies. After abstract review by 4 authors, 211 full texts were assessed for eligibility by 2 writing group members, and 199 studies were reviewed in detail. Any disagreements on abstract or full-text articles were resolved by a third reviewer or during video meetings as a group. The list of POP PROs and information on PRGs was developed from these articles. Tables were generated to describe the validation of each PRO and to provide currently available, validated translations. CONCLUSIONS: All patients presenting for POP should be evaluated for vaginal, bladder, bowel and sexual symptoms including their goals for symptom treatment. This screening can be facilitated by a validated PRO; however, most PROs provide more information than needed to provide clinical care and were designed for research purposes.

The psychosexual effects of risk-reducing bilateral salpingo-oophorectomy in female BRCA1/2 mutation carriers: A systematic review of qualitative studies.

INTRODUCTION: It is estimated that up to 20% of ovarian cancers have an inherited genetic etiology with the most common being BRCA1/2 mutations. For women with these mutations risk-reducing bilateral salpingo-oophorectomy (RRBSO) to reduce the risk of primary ovarian cancer is often performed, however the surgery results in immediate onset of surgical menopause. AIM: The aim of this systematic review was to explore the psychosexual impacts of risk reducing bilateral salpingo oophorectomy in the published qualitative literature. METHODS: PubMed, Medline, Web of Science and PsycInfo were searched for qualitative papers that looked at the psychosexual impact of RRBSO on individuals who were pre-menopausal at the time of surgery. Studies were quality assessed using Mixed Method Appraisal Tool (MMAT) and Standard for Reporting Qualitative Research (SRQR) checklists and data were extracted. Thematic synthesis of the results was performed. RESULTS: Of 143 papers identified in searching, 5 qualitative papers were identified relating to interviews with 115 women after RRBSO published between 2000 and 2020. The quality of the papers was moderate. Five different themes were identified related to individual experiences with RRBSO: (1) information needs, (2) psychological impact, (3) psychosexual impact, (4) partner support and (5) hormone replacement therapy (HRT). CONCLUSION: Individual experiences of RRBSO were varied and influenced by multiple factors but psychosexual problems were common, often caused significant distress to the women and their partners and were often poorly explained before surgery. Women do not feel adequately prepared for the psychological and sexual side effects of RRBSO. The qualitative data provides invaluable insight into the individual experiences of women and can be used to better help women mitigate the effects of the surgery.

Risk of reoperation 10 years after surgical treatment for stress urinary incontinence: a national population-based cohort study.

BACKGROUND: There is a debate about the safety and effectiveness of surgical treatments for stress urinary incontinence. Controversy about the use of synthetic mesh sling insertion has led to an increased uptake of retropubic colposuspension and autologous sling procedures. Comparative evidence on the long-term outcomes from these procedures is needed. OBJECTIVE: To compare the risk of reoperation at 10 years after operation between women treated for stress urinary incontinence with retropubic colposuspension, mesh sling insertion, and autologous sling procedures. STUDY DESIGN: The records of admissions to National Health Service hosptials were used to identify women who had first-time stress incontinence surgery between 2006 and 2013 in England. The first incidence of the following outcomes was assessed: further stress incontinence surgery, surgery for a complication (either mesh removal, prolapse repair, or incisional hernia repair), and any reoperation (either further stress incontinence surgery, mesh removal, prolapse repair, or incisional hernia repair). The cumulative incidence of each of these outcomes up to 10 years after surgery was calculated, considering death as a competing event. Multivariable modeling was then used to estimate the reoperation hazard ratios for the different initial surgery types with adjustments for patient characteristics and concurrent prolapse surgery or hysterectomy. RESULTS: The analysis included 2262 women treated with retropubic colposuspension, 92,524 treated with mesh sling insertion, and 1234 treated with autologous sling. The cumulative incidence of any first reoperation at 10 years was 21.3% (95% confidence interval, 19.5-23.0) after retropubic colposuspension, 10.9% (10.7-11.1) after mesh sling insertion, and 12.0% (10.2-13.9) after autologous sling procedures. The women who had a retropubic colposuspension were significantly more likely to have a reoperation than women who had an autologous sling (adjusted hazard ratio for any reoperation: 1.79 [1.47-2.17]; for further stress incontinence surgery: 1.64 [1.19-2.26]; for surgery for complications: 1.89 [1.49-2.40]), whereas the women who had mesh slings had a similar hazard (for any reoperation: 0.90 [0.76-1.07]; for further stress incontinence surgery: 0.75 [0.57-0.99]; for surgery for complications: 1.11 [0.89-1.36]). A sensitivity analysis excluding the women who had concurrent prolapse surgery or hysterectomy produced similar results. CONCLUSION: Retropubic colposuspension is associated with higher risk of reoperation at 10 years after surgery than mesh sling insertion or autologous sling procedures, with 1 in 5 women requiring reoperation.

A systematic review of English language patient-reported outcome measures for use in urogynaecology and female pelvic medicine.

INTRODUCTION: Patient-reported outcome measures (PROMs) are widely used in clinical practice and research in urogynaecology. There is no consensus on which PROMs should be used. No unifying document identifies all available PROMs and compares the psychometric properties of these. METHODS: Systematic review of the literature following PRISMA guidelines. Studies where women had been administered an English-language PROM which assessed pelvic-floor symptomatology and psychometric properties had been reported were included. RESULTS: 85 PROMs assessing pelvic-floor symptoms in a urogynaecology population were identified. 43 PROMs assessed lower urinary tract symptoms in 95 studies, four PROMS assessed vaginal symptoms in seven studies, 20 PROMs assessed bowel symptoms in 27 studies and three PROMs assessed sexual symptoms in seven studies. 15 PROMs assessed two or more of these symptom areas in 60 studies. PROMs with the with the best available psychometric evidence within these five areas were (urinary symptoms) the Incontinence Quality-of-Life questionnaire (I-QOL aka ICIQ-UIqol) and International Consultation on Incontinence Questionnaire (ICIQ-UI-SF), (bowel symptoms) the Accidental Bowel Leakage Evaluation (ABLE) questionnaire and the International Consultation on Incontinence Bowel questionnaire (ICIQ-B), (vaginal symptoms) the Pelvic Organ Prolapse Symptom Score (POPSS), (sexual symptoms) the Pelvic organ prolapse- urinary Incontinence Sexual function Questionnaire- IUGA revised (PISQ-IR) and (comprehensive PROMs) the Australian Pelvic Floor Questionnaire and the Electronic Personal Assessment Questionnaire-Pelvic-Floor (ePAQ-PF). CONCLUSIONS: Multiple PROMs with robust psychometric properties are available. Some widely used PROMs have weak evidence. Formal recommendations on which English-language PROMs to use within clinical practice and research in urogynaecology are required.

Botulinum injections for myofascial pelvic pain.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to assess the impact of botulinum toxin injection in women with myofascial pelvic pain (MFPP) syndrome of the pelvic floor who had failed conservative treatment. METHODS: This was a retrospective descriptive observational study of 48 consecutive patients receiving botulinum toxin to the pelvic floor for MFPP syndrome in a tertiary teaching hospital over an 8-year period. Trigger points were identified, and botulinum toxin was injected into the pelvic floor at the trigger points in doses ranging from 50 to 200 units. The patient-reported global impression of improvement scale was used to evaluate the success at follow-up, and adverse effects were recorded. RESULTS: Forty-six women attended for follow-up at 3-6 months. Of these, 34 (74%) reported an improvement in their symptoms (slightly better, much better, very much better), 12 (26%) had no change, and no patients reported worsening of symptoms. One patient (2%) reported transient postoperative faecal incontinence, which resolved after 2 weeks. There appeared to be no difference in outcome between the doses. CONCLUSIONS: Botulinum toxin injection into the pelvic floor of women with MFPP appears to be beneficial in those who have failed conservative treatment. Prospective studies, including dose-finding studies, are now required.

Paediatric and adolescent gynaecology services in a tertiary teaching hospital.

This was a retrospective review of a tertiary Paediatric and Adolescent Gynaecology (PAG) referral service catering to the South Yorkshire population in the UK. All patients referred to the PAG clinic from May 2014 to May 2018 were included. Treatments offered in clinic (surgical and pharmacological) were assessed and referral made to alternative services were analysed. Reasons for referral and the number of patients requiring intervention, pharmacological or surgical including a breakdown of the treatments offered were analysed. Forty-four percent (44%) of referrals were for menstrual disorders, with pain (15%) and vulvar problems (13%) being the next common causes. Only 5% of patients needed specialist surgery. Patients attending a PAG clinic are predominantly managed with pharmacological intervention and this could be provided in primary care with referrals limited to complex patients or those who require surgery. By understanding the case load for the PAG clinics, commissioners can better streamline the services.IMPACT STATEMENTWhat is already known on this subject? PAG services are relatively new and there are no clear pathways of how these should be configured. A better understanding of the case load in PAG clinics will allow configuration of services with better stratification of care to primary secondary and tertiary care providers.What do the results of this study add? The results of this study identify that the vast majority of patients attending PAG services do so with menstrual problems and relatively minor problems that can be addressed by primary care physicians with adequate training.What are the implications of these findings for clinical practice and/or further research? For more rare congenital anomalies, patients are best managed in a specialised centre that can offer a range of different treatments.

Postnatal pelvic floor muscle stiffness measured by vaginal elastometry in women with obstetric anal sphincter injury: a pilot study.

INTRODUCTION AND HYPOTHESIS: Vaginal childbirth is associated with pelvic floor muscle (PFM) damage in a third of women. The biomechanics prediction, detection and management of PFM damage remain poorly understood. We sought in this pilot study to determine whether quantifying PFM stiffness postnatally by vaginal elastometry, in women attending a perineal trauma clinic (PTC) within 6 months of obstetric anal sphincter injury, correlates with their antecedent labour characteristics, pelvic floor muscle damage, or urinary/bowel/sexual symptoms, to inform future definitive prospective studies. METHODS: In this pilot study, we measured postnatal PFM stiffness by vaginal elastometry in 54 women. A subset of participants (n = 14) underwent magnetic resonance imaging (MRI) to define any levator ani (LA) muscle defects from vaginal childbirth. We investigated the association of PFM stiffness with demographics, labour and delivery characteristics, clinical features and MRI evidence of LA damage. RESULTS: Raised maternal BMI was associated with reduced pelvic floor stiffness (r = -0.4; p < 0.01). Higher stiffness values were associated with forceps delivery for delayed second stage of labour (n = 14) vs non-forceps vaginal delivery (n = 40; 630 ± 40 N/m vs 500 ± 30 N/m; p < 0.05), and a non-significant trend towards longer duration of the second stage of labour. Women with urinary, bowel or sexual symptoms (n = 37) demonstrated higher pelvic floor stiffness values than those without (570 ± 30 N/m vs 450 ± 40 N/m; p < 0.05). CONCLUSIONS: A history of delayed second stage of labour and forceps delivery was associated with higher PFM stiffness values in the postnatal period. Whether high pelvic muscle stiffness antenatally is a risk factor for instrumental vaginal delivery and LA avulsion is unknown.

Utility of patient decision aids (PDA) in stress urinary incontinence surgery.

INTRODUCTION AND HYPOTHESIS: Patient decision aids (PDAs) facilitate shared decision making allowing patients to make decisions about their healthcare that take into account their personal values and preferences. The aim of this study was to establish whether a PDA used in women requiring stress incontinence surgery is helpful to women when making choices about the treatments they choose by using a Decision Conflict Scale (DCS). METHODS: Forty-five consecutive women were identified as having stress urinary incontinence and had completed all conservative treatments. All patients included in the study had stress urinary incontinence confirmed on urodynamic testing and were given the PDA at the point where they needed to make a decision about surgery. Following completion of the PDA, patients were given a DCS to complete which measures personal perceptions of uncertainty when making a decision about treatment. RESULTS: Forty-three out of 45 (95.5%) patients scored 4/4 for the DCS indicating they were sure of their decision. Two patients (4.5%) scored 3/4 and were therefore unsure of their choice. No patient scored < 3 on the DCS. The choice of procedures varied in all the ages and two women opted to have no treatment. CONCLUSIONS: The use of a PDA in the surgical treatment of stress urinary incontinence reduces decision conflict and ensures patients are sure of their decision, understand the information provided as well as the risk benefit ratio of the various options and feel they have adequate support and advice to make a choice.

National BSUG audit of stress urinary incontinence surgery in England.

INTRODUCTION AND HYPOTHESIS: The aim of the British Society of Urogynaecology (BSUG) 2013 audit for stress urinary incontinence (SUI) surgery was to conduct a national clinical audit looking at the intra- and postoperative complications and provide outcomes for these procedures. This audit was supported by the Healthcare Quality Improvement Partnership (HQIP) and National Health Service (NHS) England. METHODS: Data were collected for all continence procedures performed in 2013 through the BSUG database. All clinicians in England performing SUI surgery were invited to submit data to a central database. Outcomes data for the different continence procedures were collected and included intraoperative and postoperative complications and the change in continence scores at postoperative follow-up Changing trends in stress incontinence surgery were also assessed. RESULTS: We recorded 4993 urinary incontinence procedures from 177 consultants at 110 centres in England: 94.6% were midurethral slings; 86.7% (4331) were submitted by BSUG members with the remaining 13.3% submitted by non-BSUG members. Postoperative follow-up data were available for 3983 (80%) patients: 92.3% (3676) were very much better/much better postoperatively, and 4806 (96.3%) proceeded with no reported complications. There were 187 cases (3.7%) in which a perioperative complication was recorded. Pain persisting >30 days was reported in 1.9% of all patients. CONCLUSIONS: Surgery for SUI has good outcomes in the short term. Midurethral synthetic slings have been shown to be safe and effective as a treatment option, with >90% being very much/much better at their postoperative follow-up.

Patient-reported outcome measures which assess body image in urogynaecology patients: a systematic review.

AIM: Urogynaecological conditions can have a significant impact on body image. Patient-reported outcome measures (PROMs) are widely used in urogynaecology to assess symptoms and their impact on quality of life. This systematic review aimed to identify currently available PROMs used to assess body image within a urogynaecological population and to identify the most psychometrically robust and appropriate PROM tools to use in this context. METHODS: Ovid Medline, AMED, CINAHL, Cochrane Collaboration, EMBASE and Web of Science databases were searched from January 1966 to November 2018 to identify studies that had administered a PROM to assess body image to patients diagnosed with a urogynaecological condition. The information extracted and critically appraised included study setting, PROM instrument used and the reported psychometric properties of the PROM. RESULTS: Seventeen studies were included from 3207 screened articles. Seven different PROMs used to assess body image in a urogynaecological population were identified. Two of these PROMs (Genital Self-Image Scale-20 and Body Image in Pelvic Organ Prolapse questionnaire) had good psychometric evidence for use, but this was only in the context of women with prolapse. Evidence for validity and reliability was limited for the other five PROMs identified. CONCLUSION: Further development and psychometric testing of PROMs to assess body image in urogynaecology, for both research purposes and clinical practice, are required. Further research is also required to investigate the relationship between body image and urogynaecological symptomatology, and developing valid, reliable and functional PROMs will be integral to this.

A systematic review of non-invasive modalities used to identify women with anal incontinence symptoms after childbirth.

INTRODUCTION AND HYPOTHESIS: Anal incontinence following childbirth is prevalent and has a significant impact upon quality of life (QoL). Currently, there is no standard assessment for women after childbirth to identify these symptoms. This systematic review aimed to identify non-invasive modalities used to identify women with anal incontinence following childbirth and assess response and reporting rates of anal incontinence for these modalities. METHODS: Ovid Medline, Allied and Complementary Medicine Database (AMED), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Cochrane Collaboration, EMBASE and Web of Science databases were searched for studies using non-invasive modalities published from January 1966 to May 2018 to identify women with anal incontinence following childbirth. Study data including type of modality, response rates and reported prevalence of anal incontinence were extracted and critically appraised. RESULTS: One hundred and nine studies were included from 1602 screened articles. Three types of non-invasive modalities were identified: validated questionnaires/symptom scales (n = 36 studies using 15 different instruments), non-validated questionnaires (n = 50 studies) and patient interviews (n = 23 studies). Mean response rates were 92% up to 6 weeks after childbirth. Non-personalised assessment modalities (validated and non-validated questionnaires) were associated with reporting of higher rates of anal incontinence compared with patient interview at all periods of follow-up after childbirth, which was statistically significant between 6 weeks and 1 year after childbirth (p < 0.05). CONCLUSIONS: This systematic review confirms that questionnaires can be used effectively after childbirth to identify women with anal incontinence. Given the methodological limitations associated with non-validated questionnaires, assessing all women following childbirth for pelvic-floor symptomatology, including anal incontinence, using validated questionnaires should be considered.

The UK National Prolapse Survey: 10 years on.

INTRODUCTION AND HYPOTHESIS: To assess trends in the surgical management of pelvic organ prolapse (POP) amongst UK practitioners and changes in practice since a previous similar survey. METHODS: An online questionnaire survey (Typeform Pro) was emailed to British Society of Urogynaecology (BSUG) members. They included urogynaecologists working in tertiary centres, gynaecologists with a designated special interest in urogynaecology and general gynaecologists. The questionnaire included case scenarios encompassing contentious issues in the surgical management of POP and was a revised version of the questionnaire used in the previous surveys. The revised questionnaire included additional questions relating to the use of vaginal mesh and laparoscopic urogynaecology procedures. RESULTS: Of 516 BSUG members emailed, 212 provided completed responses.. For anterior vaginal wall prolapse the procedure of choice was anterior colporrhaphy (92% of respondents). For uterovaginal prolapse the procedure of choice was still vaginal hysterectomy and repair (75%). For posterior vaginal wall prolapse the procedure of choice was posterior colporrhaphy with midline fascial plication (97%). For vault prolapse the procedure of choice was sacrocolpopexy (54%) followed by vaginal wall repair and sacrospinous fixation (41%). The laparoscopic route was preferred for sacrocolpopexy (62% versus 38% for the open procedure). For primary prolapse, vaginal mesh was used by only 1% of respondents in the anterior compartment and by 3% in the posterior compartment. CONCLUSION: Basic trends in the use of native tissue prolapse surgery remain unchanged. There has been a significant decrease in the use of vaginal mesh for both primary and recurrent prolapse, with increasing use of laparoscopic procedures for prolapse.

Evaluation of coital incontinence by electronic questionnaire: prevalence, associations and outcomes in women attending a urogynaecology clinic.

INTRODUCTION AND HYPOTHESIS: Coital incontinence is the involuntary leakage of urine during sexual intercourse and is divided into that occurring with penetration and that occurring with orgasm. Mechanisms of coital incontinence are poorly understood. The aim of this retrospective study was to measure the prevalence of coital incontinence and evaluate the association among various types of coital incontinence with stress urinary incontinence (SUI), overactive bladder (OAB) and impact on quality-of-life in women attending a urogynaecology clinic. METHODS: A total of 2,312 women completed the electronic Personal Assessment Questionnaire-Pelvic Floor (ePAQ-PF) in advance of their urogynaecology consultation. Logistic regression and Spearman's rank-order correlation evaluated associations between types of coital incontinence and OAB and SUI. The Mann-Whitney test evaluated the relationship between coital incontinence and self-reported quality of sex life and self-avoidance and partner avoidance of sex. Subgroup analysis analysed outcomes in 84 women with coital incontinence undergoing treatment with tension-free vaginal tape (TVT). RESULTS: Prevalence of coital incontinence in the cohort was 30%. Symptoms of OAB (p < 0.005) and SUI (p < 0.005) were significantly and independently associated with both types of coital incontinence (orgasm and penetration). In women with coital incontinence compared with those without, there was significant self-avoidance of sex (p < 0.0005), partner avoidance of sex (p < 0.0005) and impaired quality of sex life due to sexual problems (p < 0.005). The impact of this was significant in each group. Subgroup analysis of 84 women undergoing TVT showed significant improvement in all coital incontinence symptoms 3 months post-operatively. CONCLUSION: Using an electronic questionnaire before consultation has identified coital incontinence to be a prevalent symptom, having a significant impact on the patient's sex life. Coital incontinence at orgasm and penetration are both significantly associated with SUI and OAB.