Single-dose Tadalafil Reduces Opening Urethral Pressure: A Randomized, Double-blind, Placebo-controlled, Crossover Trial in Healthy Women.

INTRODUCTION AND HYPOTHESIS: Phosphodiesterase enzymes are widely distributed in female urogenital tissues. Yet, the understanding of their physiological roles and the impact of phosphodiesterase inhibitors on lower urinary tract symptoms in women remains limited. Current hypotheses are conflicting: one suggests that vasodilation might expand the periurethral vascular plexus, leading to increased urethral pressure, whereas the other proposes a relaxation of urethral musculature, resulting in decreased pressure. To further clarify this, we investigated the effect of tadalafil on the opening urethral pressure and voiding function in healthy women. METHODS: We conducted a randomized, double-blind, placebo-controlled crossover trial involving 24 healthy women. Participants were randomly assigned to receive a single dose of tadalafil (40 mg) or placebo during their initial visit and then switched to the alternative treatment during their second visit. Opening urethral pressure was measured with urethral pressure reflectometry during both resting and squeezing conditions of the pelvic floor. Subsequently, voiding parameters were recorded. RESULTS: Compared with placebo, a single dose of tadalafil significantly reduced opening urethral pressure during both resting (-6.8 cmH20; 95% confidence interval [CI], -11.8 to -1.9; p = 0.009) and squeezing conditions (-8.8 cmH20; 95% CI, -14.6 to -3.1; p = 0.005). Voiding parameters did not show significant differences (average flow rate: -0.8 ml/s [95% CI, -2.0 to 0.4; p = 0.2]; maximum flow rate: -1.7 ml/s [95% CI, -4.8 to 1.5; p = 0.3]). CONCLUSIONS: A single dose of 40 mg tadalafil moderately reduced urethral pressure in healthy women, without affecting voiding parameters. The clinical implications of this are yet to be determined.

Increased risk of stress urinary incontinence surgery after hysterectomy for benign indication-a population-based cohort study.

BACKGROUND: Hysterectomy is a common procedure used to treat different gynecologic conditions. The association between hysterectomy for benign indication and stress urinary incontinence has previously been established. Stress urinary incontinence can be treated surgically, and options have improved after introduction of the midurethral sling procedure in 1998. OBJECTIVE: This study aimed to estimate the risk of stress urinary incontinence surgery after hysterectomy for benign indication. STUDY DESIGN: The study was carried out as a matched register-based cohort study including Danish women born from 1947 to 2000. Women who underwent hysterectomy for benign indication were matched to nonhysterectomized women in a 1:5 ratio on the basis of age and calendar year of hysterectomy. The risk of stress urinary incontinence surgery after hysterectomy was estimated. We adjusted for income, educational level, and parity. The risk of stress urinary incontinence surgery was further estimated in a subcohort excluding all vaginal hysterectomies. The joint effect of hysterectomy and parity was estimated in the main cohort, and the joint effect of hysterectomy and vaginal birth or cesarean delivery on stress urinary incontinence surgery was explored in a subgroup of women who only had 1 mode of delivery. All analyses were made using the Cox proportional hazards model. RESULTS: We included 83,370 women who underwent hysterectomy and 413,969 reference women. The overall risk of stress urinary incontinence surgery was more than doubled for women who underwent hysterectomy (adjusted hazard ratio, 2.6; 95% confidence interval, 2.4-2.8). The adjusted hazard ratio decreased slightly to 2.4 (95% confidence interval, 2.3-2.6) when excluding all vaginal hysterectomies. We found a trend of increasing risk of stress urinary incontinence surgery with increased parity among both women who underwent hysterectomy and the reference group. In the subgroup of women who only had 1 mode of delivery, we found the risk of stress urinary incontinence surgery to be particularly increased for women with a history of ≥1 vaginal births. The hazard ratio was 15.1 (95% confidence interval, 10.3-22.1) for women with a history of 1 vaginal birth who underwent hysterectomy, whereas the hazard ratio for women in the reference group with 1 vaginal birth was 5.1 (95% confidence interval, 3.8-8.1). Overall, women who underwent hysterectomy had a 3 times higher risk of stress urinary incontinence surgery than the reference group, irrespective of the number of vaginal births. CONCLUSION: This study indicates, in accordance with previous studies, that hysterectomy increases the risk of subsequent stress urinary incontinence surgery. Women should be informed and gynecologists include this knowledge in decision-making. Further precautions should be taken when treating parous women, particularly those with a history of ≥1 vaginal births.

Cervical cancer after the Manchester procedure: a nationwide cohort study.

INTRODUCTION AND HYPOTHESIS: The Manchester procedure is a successful operation to treat uterine prolapse. However, the influence on cervical cancer remains unknown. We hypothesized a lower risk of cervical cancer after the Manchester procedure. METHODS: We included all Danish women undergoing the Manchester procedure during 1977-2018 (N = 23,935). Women undergoing anterior colporrhaphy (N = 51,008) were included as references due to comparable health-seeking behaviors. The study cohort is as previously described. We assessed the risk of cervical cancer mortality after the Manchester procedure versus anterior colporrhaphy using cumulated incidence plots and Cox hazard regressions. We applied Fisher's exact test to compare the distribution of histological subtypes after the operations. RESULTS: Generally, few women were diagnosed with cervical cancer (0.1% after Manchester procedure and 0.2% after anterior colporrhaphy). After the Manchester procedure, the risk of cervical cancer was reduced (HR 0.60 [95% CI 0.39-0.94]). Furthermore, we found a slightly reduced risk of overall death (HR 0.96 [95% 0.94-0.99]), but no association regarding death due to cervical cancer (HR 0.66 [95% 0.34-1.25]). The distribution of histological subtypes was not changed. CONCLUSIONS: Women undergoing the Manchester procedure are at lower risk of being diagnosed with cervical cancer, while the risk of cancer specific mortality is unchanged compared to women undergoing anterior colporrhaphy. Based on this study, we cannot recommend that women exit ordinary screening programs for human papillomavirus/cervical dysplasia after a Manchester procedure.

Colpocleisis: reoperation risk and risk of uterine and vaginal cancer: A nationwide cohort study.

INTRODUCTION AND HYPOTHESIS: We aimed to evaluate the risk of reoperation and uterine (myometrial, endometrial, and cervical) and vaginal cancer after colpocleisis performed during the years 1977-2018. Furthermore, we also aimed to assess the development in colpocleisis procedures performed during the study period. METHODS: Danish nationwide registers covering operations, diagnoses, and life events can be linked on an individual level owing to the unique personal numbers of all Danish residents. We performed a nationwide historical cohort study including women born before year 2000 who underwent colpocleisis between 1977 and 2018 (N = 2,228) using the Danish National Patient Registry (DNPR). We followed the cohort until death/emigration/31 December 2018, whichever came first. Primary outcomes were number of pelvic organ prolapse (POP) operations performed after colpocleisis and uterine and vaginal cancer diagnosed after colpocleisis in a subgroup of women with the uterus in situ. This was assessed with cumulative incidences. RESULTS: During follow-up (median 5.6 years) 6.5% and 8.2% underwent POP surgery within 2 and 10 years after colpocleisis respectively. Within 10 years after colpocleisis 0.5% (N = 8) were diagnosed with uterine or vaginal cancer in the subgroup of women with their uterus (N = 1,970). During the study time 37-80 women underwent colpocleisis yearly and the mean age increased (77.1 to 81.4 years). CONCLUSION: Despite smaller studies showing no recurrence after colpocleisis, we found that 6.5% underwent reoperation within 2 years. Few women were diagnosed with uterine or vaginal cancer after colpocleisis. The increased age at the time of colpocleisis indicates changed attitudes regarding surgical treatment for elderly women with comorbidities.

Perineal resuturing versus conservative treatment for dehisced perineal wounds and episiotomies: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Perineal wound dehiscence is associated with complications, such as infections, perineal pain, dyspareunia, and altered sexual function, that severely affects women's health. Currently, few studies have examined secondary repair of first- and second-degree perineal wound dehiscence and episiotomies, and there is currently no consensus on the optimal treatment option for dehisced perineal wounds. The objective was to evaluate whether resuturing or conservative treatment of first- and second-degree dehisced perineal wounds and episiotomies is the optimal treatment modality in terms of postoperative healing time and other secondary outcomes. METHODS: A systematic literature search was carried out using PubMed, Embase, and Cochrane databases. All included studies were evaluated using the SIGN methodology checklist, with the purpose of assessing the study quality. RESULTS: Three randomized controlled trials were included. Only two small sample-sized studies presented data regarding healing time for both the resuturing and the conservative treatment groups. However, no significant difference was found between the two groups at 4-6 weeks' healing time (RR 1.16, 95% CI 0.53-2.52). One study found that women being resutured experienced a significantly reduced healing time and higher satisfaction with the appearance of the wound healing at 3 months compared with the conservative treatment group. CONCLUSION: We found no significant differences in the healing time between the resuturing group and the conservative treatment group. However, the sample sizes of the studies were small. A well-designed, large, and prospective randomized controlled trial is needed to evaluate the optimal treatment modality for dehisced perineal wounds.

Bleeding risk in female patients undergoing intravesical injection of onabotulinumtoxinA for overactive bladder: a Danish retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: We aimed to examine the risk of bleeding in female patients undergoing intravesical onabotulinumtoxinA (BTX-A) treatments and provide clinical recommendations for the perioperative management of patients on antithrombotic therapy prior to BTX-A treatments. METHODS: This was a retrospective cohort of Danish female patients, who had their first BTX-A treatment because of an overactive bladder at the Department of Gynecology and Obstetrics, Herlev and Gentofte University Hospital, between January 2015 and December 2020. Data extraction was from an electronic medical journal system. BTX-A, Botox® Allergan was injected in the detrusor at 10-20 sites. Significant bleeding during or after a BTX-A treatment was defined as persistent macroscopic hematuria. Bleeding reporting was based on information obtained from journal notes. RESULTS: We included 400 female patients, who had a total of 1,059 BTX-A treatments. Median age at first BTX-A treatment was 70 years (IQR 21), and median number of BTX-A treatments was 2 (range 1-11). In total, 27.8% (n=111) received antithrombotic therapy. Within this group, 30.6% and 69.4% were on anticoagulant and antiplatelet therapy. No cases of hematuria were reported in our cohort. We found that no patients stopped their antithrombotic therapy, were bridged, or monitored by International Normalized Ration (INR) levels. CONCLUSIONS: We suggest that BTX-A treatments might be classified as low-risk procedures. Discontinuation of antithrombotic therapy is not required in the perioperative management of this patient group.

Hysterectomy on benign indication and risk of pelvic organ prolapse surgery: A national matched cohort study.

INTRODUCTION: Hysterectomy is a frequently performed gynecological procedure but long-term effects remain understudied. Pelvic organ prolapse reduces life quality significantly. The lifetime risk of undergoing pelvic organ prolapse surgery is 20% and parity is known to be the largest risk factor. Studies have shown an increased risk of pelvic organ prolapse surgery after hysterectomy; however, few have studied the compartments which are affected and how this association is affected by surgical route and parity. MATERIAL AND METHODS: In this Danish nationwide cohort study, we identified women born in 1947-2000 who underwent hysterectomy during 1977-2018 who were indexed on the day of hysterectomy. We excluded women who immigrated when older than 15 years, who underwent pelvic organ prolapse surgery prior to index, and who were diagnosed with a gynecological cancer prior to or within 30 days of index. Women who underwent hysterectomy were matched 1:5 to references on age and year of hysterectomy. Women were censored at the time of death, emigration, a gynecological cancer diagnosis, radical or unspecified hysterectomy or December 31, 2018, whichever came first. The risk of pelvic organ prolapse surgery after hysterectomy was computed using Cox proportional hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, calendar year, parity, income and educational level. RESULTS: We included 80 444 women who underwent hysterectomy and 396 303 reference women. Women who underwent hysterectomy had a significantly higher risk of undergoing pelvic organ prolapse surgery: HRadjusted  1.4 (95% CI 1.3-1.5). In particular, the risk of a posterior compartment prolapse operation was increased: HRadjusted 2.2 (95% CI 2.0-2.3). The risk of prolapse surgery increased with increased parity and by an additional 40% after hysterectomy. Cesarean sections did not seem to increase the risk of prolapse surgery. CONCLUSIONS: This study shows that hysterectomy, regardless of surgical route, leads to an increased risk of pelvic organ prolapse surgery, especially in the posterior compartment. The risk of prolapse surgery increased with the number of vaginal births, and not cesarean sections. Women should be thoroughly informed about the risk of pelvic organ prolapse and other treatment options should be considered before choosing hysterectomy to treat benign gynecological diseases -particularly women who have had numerous vaginal births.

Pelvic organ prolapse following hysterectomy on benign indication: a nationwide, nulliparous cohort study.

BACKGROUND: Hysterectomy is commonly performed and may increase the risk of pelvic organ prolapse. Previous studies in parous women have shown an increased risk of pelvic organ prolapse surgery after hysterectomy. Parity is a strong risk factor for pelvic organ prolapse and may confuse the true relation between hysterectomy and pelvic organ prolapse. OBJECTIVE: This study aimed to investigate whether hysterectomy performed for benign conditions other than pelvic organ prolapse leads to an increased risk of pelvic organ prolapse surgery in a cohort of nulliparous women. STUDY DESIGN: We conducted a historical matched cohort study based on a nationwide population of nulliparous women born in 1947 to 2000 and living in Denmark during 1977 to 2018 (N=549,197). The data were obtained from the Danish Civil Registration System, the Danish National Patient Registry, the Fertility Register, and Statistics Denmark. Women who had a hysterectomy performed in 1977 to 2018 were included in the study (n=9535). For each of these women we randomly retrieved five nonhysterectomized women matched on age and calendar year to constitute the reference group (n=47,370). Cox proportional hazard regression analyses were performed to compare the risk of pelvic organ prolapse surgery in the 2 groups of women. RESULTS: The study included 56,905 women whom we observed for up to 42 years, entailing 809,435 person-years in risk. Overall, 9535 women who underwent a hysterectomy were matched individually with 47,370 reference women. Subsequently, a total of 29 women (30.4%) who underwent a hysterectomy and 85 reference women (17.9%) had a pelvic organ prolapse surgery performed, corresponding to incidence rates of 20.5 and 12.7 per 100,000 risk years, respectively. In addition, the risk of pelvic organ prolapse surgery increased by 60% in women who underwent a hysterectomy compared with women in the reference group (crude hazard ratio, 1.6; 95% confidence interval, 1.0-2.5; P=.04; adjusted hazard ratio, 1.6; 95% confidence interval, 1.0-2.5; P=.04). After the exclusion of women who underwent vaginal hysterectomy and their matches, the results were significantly the same (crude hazard ratio, 1.5; 95% confidence interval, 1.0-2.4; P=.05). Furthermore, we found higher rates of pelvic organ prolapse surgery in women who had a subtotal hysterectomy, total hysterectomy, or vaginal and laparoscopic-assisted vaginal hysterectomies than in women in the reference group. CONCLUSION: Hysterectomy increased the risk of pelvic organ prolapse surgery for nulliparous women by 60%. Previous studies of multiparous women have similarly shown an increased risk of prolapse after hysterectomy. As the most common risk factor for pelvic organ prolapse-vaginal birth-was not included and women were >72 years of age in this study, the numbers of pelvic organ prolapse surgeries were low. Despite the low absolute risk of pelvic organ prolapse surgery in nulliparous women, they were important in investigating the association between hysterectomy and pelvic organ prolapse, excluding vaginal birth, which is the most common risk factor for pelvic organ prolapse. As this cohort study of nulliparous women found an increased risk of pelvic organ prolapse surgery after hysterectomy, it is implied that the uterus per se protects against pelvic organ prolapse. As such, gynecologists should be aware of the risks associated with hysterectomy, and alternative uterus-sparing treatments should be considered when possible. Furthermore, women should be informed about the risks before being offered a hysterectomy.

Effect of single doses of citalopram and reboxetine on urethral pressure: A randomized, double-blind, placebo- and active-controlled three-period crossover study in healthy women.

AIMS: Urethral closure function is essential for urinary continence in women and decreased urethral pressure is associated with stress urinary incontinence (SUI). For decades, the effects of serotonergic drugs on central neural control of urethral closure have been investigated and discussed. Epidemiological studies suggest that the use of selective serotonin reuptake inhibitors (SSRIs), such as citalopram, is associated with SUI. However, the literature findings are conflicting. This study aimed to evaluate citalopram's effect on opening urethral pressure (OUP) in healthy women. METHODS: We conducted a randomized, double-blind, placebo- and active-controlled crossover study in 24 healthy women. On three study days, which were separated by 8 days of washout, the subjects received single doses of either 40 mg citalopram (and placeboreboxetine ), 8 mg reboxetine (and placebocitalopram ), or two placebos. Study drugs were administered at a 1-h interval due to a difference in estimated time to peak plasma concentration (tmax ). We measured OUP with urethral pressure reflectometry under both resting and squeezing conditions of the pelvic floor at estimated tmax for both study drugs (one timepoint). RESULTS: Compared to placebo, citalopram increased OUP by 6.6 cmH2 0 (95% confidence interval [CI] 0.04-13.1, p = 0.048) in resting condition. In squeezing condition, OUP increased by 7.1 cmH2 0 (95% CI: 1.3-12.9, p = 0.01). Reboxetine increased OUP by 30.0 cmH2 0 in resting condition compared to placebo (95% CI: 23.5-36.5, p < 0.001), and 27.0 cmH2 0 (95% CI: 21.2-32.8, p < 0.001) in squeezing condition. CONCLUSION: Citalopram increased OUP slightly compared to placebo suggesting that SSRI treatment does not induce or aggravate SUI.

Endometrial cancer after the Manchester procedure: a nationwide cohort study.

INTRODUCTION AND HYPOTHESIS: We aimed to investigate whether the Manchester procedure affects the risk and prognosis of endometrial cancer. METHODS: All Danish residents have a personal number permitting linkage of nationwide registers on the individual level enabling epidemiological studies with lifelong follow-up. We performed a nationwide historical cohort study including Danish women born before 2000 undergoing the Manchester procedure (N = 23,935) during 1977-2018. We included women undergoing anterior colporrhaphy as a reference group (N = 51,008) because of comparable inclination to consult a doctor and clinical similarities. Main outcomes were the number of women diagnosed with endometrial cancer, the stage of endometrial cancer at time of diagnosis, and cancer-specific and overall mortality. We followed the cohort until endometrial cancer/death/emigration/hysterectomy/31 December 2018. We performed chi-square test for trend to compare the diagnostic stage and Cox regressions to analyze the risk of endometrial cancer and mortality. The models were adjusted for age, calendar year, income level, and parity. RESULTS: During follow-up (median 13 years), 271 (1.13%) women were diagnosed with endometrial cancer after the Manchester procedure and 520 (1.05%) after anterior colporrhaphy. The adjusted hazard ratio (HR) for endometrial cancer was 1.00 [95% confidence interval (CI) 0.86-1.16]. No difference in stage of cancer was found (p = 0.18) nor when stratifying for calendar year. The HR for cancer-specific mortality and overall mortality after the Manchester procedure was 0.87 (95% CI 0.65-1.16) and 0.93 (95% CI 0.77-1.12), respectively. CONCLUSIONS: The Manchester procedure does not affect the risk or prognosis of endometrial cancer.

Urinary incontinence before and after pelvic organ prolapse surgery-A national database study.

INTRODUCTION AND HYPOTHESIS: To investigate how pelvic organ prolapse (POP) surgery affects symptoms of urinary incontinence (UI) in women with POP and concomitant UI. METHODS: Data from the Danish Urogynaecological Database were collected from 2013 to 2016. Inclusion criteria were urinary incontinent women who underwent POP surgery alone. Based on the preoperative results of the International Consultation on Incontinence Questionnaire-Urinary Incontinence-short form (ICIQ-UI-sf), women were categorized with stress urinary incontinence (SUI), urgency urinary incontinence (UUI) or mixed urinary incontinence (MUI). Postoperatively, the women were categorized based on the postoperative ICIQ-UI-sf, except here, undefined urinary incontinence and urinary continence were added to the categories. Statistical analyses included multivariate logistic regression analyses, examining the odds of urinary continence in each category. The included parameters were preoperative POP stage (POP-Q), compartment, BMI, age and preoperative ICIQ-UI-sf total score. P-values < 0.05 were considered statistically significant. RESULTS: A total of 1657 women were included. Significantly more women with preoperative UUI achieved urinary continence (60%) compared to women with preoperative SUI (52%) and MUI (38%). More than 70% of all women achieved either urinary continence or an improvement in UI, regardless of subtype. For women with UUI, the likelihood of achieving urinary continence was higher if the anterior compartment was involved. Women with MUI were more likely to achieve urinary continence if they had POP-Q stage 3-4. CONCLUSIONS: Most women with symptomatic POP and concomitant UI find that their UI is either cured or improved after POP surgery alone.

Minimum standards for reporting outcomes of surgery in urogynaecology.

INTRODUCTION AND HYPOTHESIS: The IUGA special interest group (SIG) identified a need for a minimum data set (MDS) to inform outcome measurements to be included and simplify data capture and standardise reporting for data collection systems. To define a minimum data set for urogynaecological surgical registries. METHODS: Existing registries provide an inventory of items. A modified Delphi approach was used to identify a MDS. At each stage reviewers ranked data points and used free text to comment. The rating used a scale of 0-10 at each review and a traffic light system rated the scores as desirable, highly desirable and mandatory. The scores were collated and reported back to clinicians prior to the further rounds. Outliers were highlighted and reviewers re-assessed prior to repeating the process. A comparison of the MDS was made with published outcomes. RESULTS: Reviewers were from the outcome SIG with emphasis on widespread representation. Fifteen clinicians from eight countries were involved. Four reviewers dissected the existing databases. Eighty data points were considered in four categories, background, preoperative, intraoperative and postoperative. Consensus was reached by the third round. Two points were added on review (date of surgery and urodynamics). Three background points, five preoperative points, seven intraoperative points and nine postoperative points were identified giving 24 minimum data points in the final recommendation. CONCLUSIONS: An MDS has been developed for urogynaecological surgical registries. These should be mandatory points which then allow larger varying points to be assessed. These points correspond well to data points used in published papers from established databases.

Surgical repair of vaginal vault prolapse; a comparison between ipsilateral uterosacral ligament suspension and sacrospinous ligament fixation-a nationwide cohort study.

INTRODUCTION AND HYPOTHESIS: Hysterectomy is frequently performed and associated with increased risk of subsequent genital prolapse including vaginal vault prolapse. Ipsilateral uterosacral ligament suspension (IUSLS) and sacrospinous ligament fixation (SSLF) are two commonly performed surgical techniques to treat vaginal vault prolapse. There is no consensus on the ideal operation technique. The aim of this study was to compare IUSLS and SSLF to treat vaginal vault prolapse based on the number of repeat surgeries. METHODS: Previously hysterectomized patients operated on with IUSLS or SSLF in Denmark in 2010-2016 were included in this nationwide register-based cohort study and followed until June 2017. Data were obtained from Danish National Databases, to which reporting is mandatory by law, entailing high validity and completeness of data. Data were analyzed using Cox proportional hazard regression analysis adjusted for age, preoperative prolapse stage, smoking, BMI, and previous prolapse surgery. RESULTS: In total, 744 patients were included; 384 underwent IUSLS while 360 underwent SSLF. After 5 years, 6.5% of patients operated on with IUSLS and 21.8% operated on with SSLF had a repeat surgery in the apical compartment and 12.4% and 30.6% in any compartment, respectively. The risk of repeat surgery was 4.8 times higher after SSLF compared to IUSLS [confidence interval (CI): 2.7-8.4] in the apical compartment and 2.4 times higher (CI: 1.2-5.1) in the anterior compartment. No difference was seen in the posterior compartment. CONCLUSIONS: This study finds significantly higher numbers of repeat surgeries after SSLF compared to after IUSLS in a Danish nationwide cohort.

Continuous vs stepwise anal acoustic reflectometry: An improved technique for physiological measurement of anal sphincter function?

BACKGROUND: Anal acoustic reflectometry (AAR) is a technique for measuring the physiological profile of the anal canal, primarily the internal anal sphincter. Evaluation of a new continuous method, recently developed for the urethra, would enable its future application for investigation of rectal reflexes. METHODS: Patients aged 18 and over with fecal incontinence (FI) were included. Stepwise AAR parameters were compared with continuous opening pressure (Op, cmH2 O), opening elastance (Oe, cmH2 O/mm2 ), closing pressure (Cp, cmH2 O), closing elastance (Ce, cmH2 O/mm2 ), hysteresis (Hys, [%]), squeeze opening pressure (SqOp, cmH2 O), and squeeze opening elastance (SqOe, cmH2 O/mm2 ). Vaizey incontinence and Manchester Health Questionnaire scores were also collected. RESULTS: Thirty-two patients, 26 females were analyzed. Median age: 60 (range, 32-75). Median AAR parameters of Op (37.50 vs 35.15, P = .031), Oe (1.31 vs 0.84, P < .0001), Ce (1.11 vs 0.88, P < .0001), Hys (37.75 vs 19.04, P < .0001), and SqOe (1.27 vs 1.06, P = .005) were significantly higher with the continuous method. Cp (22.70 vs 27.22, P = .003) is lower and SqOp (96.87 vs 59.47, P = .71) not significantly different. The continuous technique had superior repeatability between cycles for all AAR parameters except Oe, which was equivalent and continuous SqOp had a stronger negative correlation with Vaizey score than stepwise (-0.46, P = .009 vs -0.37, P = .038). CONCLUSIONS: The differences seen between the two techniques are likely to be related to the rate of stretch. The continuous technique appears to represent a more physiological measurement of anal sphincter function than the stepwise technique particularly in the assessment of voluntary squeeze function.

Validity of bladder volume measurement by ultrasound in women postpartum.

INTRODUCTION: Vaginal birth increases the risk of urinary retention and overdistention of the bladder. To avoid unnecessary discomfort by catheterization, it is preferable to use ultrasound for diagnosis of these conditions. The aim of this study was to determine the validity of transabdominal ultrasound and a portable ultrasound system, Biocon-700, to measure bladder volume in women postpartum. METHODS: Fifty women were included in this method comparison study. Within 48 h of giving birth, their bladder volume was measured in randomized order with both transabdominal ultrasound and Biocon-700. After urination, participants were scanned with Biocon-700 to measure residual bladder volume, and finally the bladder was emptied by catheterization. The total bladder volume was calculated as the voided volume plus the catheterized volume. RESULTS: Biocon-700 measured 43.4 ml ± 117.4 ml (mean ± SD) lower than the total bladder volume, while volumes measured by transabdominal ultrasound were 117.8 ml ± 110.0 ml (mean ± SD) lower. Linear regression showed significant proportional bias in both methods. The Biocon-700 could detect a residual bladder volume > 150 ml with a positive predictive value of 66.7% and a negative predictive value of 100%. CONCLUSIONS: Neither transabdominal ultrasound nor the portable ultrasound system, Biocon-700, can be used to measure bladder volume precisely after vaginal delivery. However, both ultrasound methods can be used as screening tools to prevent overdistention of the bladder, and Biocon-700 can furthermore be used to screen women for a residual bladder volume > 150 ml.

Trends in apical prolapse surgery between 2010 and 2016 in Denmark.

INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse is a common diagnosis. Today there is no consensus on the ideal operation technique for apical prolapse. Vaginal hysterectomy with suspension of the vaginal cuff is the most frequently used, but the popularity of uterus-preserving techniques is increasing. The aim of this study was to describe trends in surgical techniques used to treat primary apical prolapse in Danish hospitals. METHODS: Data were obtained from the Danish Urogynecological Database and included women with primary prolapse surgery in the apical compartment operated in Denmark 2010-2016. Public hospital departments were divided into three categories according to degree of urogynecological specialization: high level, moderate level, and no specialization. RESULTS: The number of vaginal hysterectomies decreased and the number of uterus-preserving operations increased from 2010 to 2016. The proportion of uterus-preserving techniques versus vaginal hysterectomy differed substantially between different hospital types. At departments with high and moderate levels of specialization, uterus-preserving techniques increased during the period, accounting for nearly 90% and 40%, respectively, in 2016, while decreasing to < 35% for departments with no specialization. Three of the four departments with high-level specialization preferred the Manchester-Fothergill procedure, while one preferred sacrospinous hysteropexy. Only 2.3% of all procedures were performed at private hospitals. CONCLUSIONS: The proportion of uterus-preserving techniques to treat apical prolapse increased from 2010 to 2016. However, there is a wide variation in practice at the different hospitals. An agreement on uterus-preserving techniques has not been reached.

Evaluation of suture material used in anterior colporrhaphy and the risk of recurrence.

INTRODUCTION AND HYPOTHESIS: The wide variety of suture material used in colporrhaphy shows a lack of consensus on the optimal choice. The evidence guiding the choice of suture material is scant. The aim of this study was to investigate the effects of rapid versus slowly absorbable suture on risk of recurrence after native tissue anterior colporrhaphy. METHODS: This longitudinal cohort study was performed secondary to a previously published study on pelvic organ prolapse recurrence after the Manchester-Fothergill procedure versus vaginal hysterectomy. Data were collected from four Danish databases and corresponding electronic medical records. In this study, women having had anterior colporrhaphy performed were included. Suture materials were divided in three groups: rapid absorbable multifilament suture (RAMuS), rapid absorbable monofilament suture (RAMoS) and slowly absorbable monofilament suture (SAMoS). The main outcome was recurrence of prolapse in the anterior compartment. RESULTS: A total of 462 women were included in this study. No significant difference in recurrence was found among the three suture groups. However, a non-significant tendency towards a higher risk of recurrence in the RAMoS group [HR 2.14 (0.75-6.10) p = 0.16] compared to the RAMuS group was observed. CONCLUSION: In this study, the use of rapid absorbable multifilament suture compared to slowly absorbable monofilament suture does not seem to lead to a higher risk of recurrence after anterior colporrhaphy.

De novo urinary incontinence after pelvic organ prolapse surgery-a national database study.

INTRODUCTION AND HYPOTHESIS: To investigate the prevalence and risk factors of de novo urinary incontinence (UI) after pelvic organ prolapse (POP) surgery. METHODS: Data from 2013 to 2016 were collected from the Danish Urogynecological Database, where registration for any urogynecological procedure performed in Denmark is mandatory. Inclusion criteria were urinary continent women who underwent POP surgery. A woman was urinary continent if her total score on the International Consultation on Incontinence Questionnaire-Urinary Incontinence-short form (ICIQ-UI-sf) was 0 and she answered 'never' to 'When does urine leak?' Postoperatively, the women were categorized as continent or women with stress urinary incontinence (SUI), urgency urinary incontinence (UUI), mixed urinary incontinence (MUI) or undefined UI. We performed multivariate logistic regression analyses. The included parameters were preoperative POP stage (POP-Q), compartment, BMI and age. P values < 0.05 were considered statistically significant. RESULTS: We included 1198 women. The risk of de novo UI was 15%; 45% had SUI, 30% had UUI, 16% had MUI, and 10% had undefined UI. BMI was highly associated with de novo UI; the risk was 12% for women with BMI < 25, 16% for women with BMI 25 - < 30 and 23% for women with BMI ≥ 30. Age, compartment and POP stage were not associated with de novo UI. CONCLUSIONS: The prevalence of de novo UI is the same regardless of the involved compartment/s and POP stage. BMI is significantly associated with de novo UI; twice as many women with BMI ≥ 30 had de novo UI compared with women with BMI < 25.

A structured review on the female urethral anatomy and innervation with an emphasis on the role of the urethral longitudinal smooth muscle.

A damaged sphincteric unit or support system, unstable urethral deformability or damaged sensory innervation are all potential causes of a dysfunctional urethral sphincter. With the current improvement in pharmacological targets and urodynamic understanding, studies have begun quantifying individual structures and their importance in closure pressure and consequently urethral continence. However, when it comes to the function of the longitudinal urethral smooth muscle layer, there is currently no consensus. The intent of this structured review is to critically examine literature regarding the female urethral anatomy and closure mechanism. We hypothesized that the longitudinal smooth muscle is a prerequisite for sufficient urethral closure and not merely involved during micturition. Overall opinions on a dysfunctional closure mechanism are controversial. Nonetheless, basic mechanics may be applied to understand simple urodynamics. With the assumption of longitudinal muscles forming a plug when contracted, this could have a substantial effect on the continence mechanism.

Long term continuation with repeated Botulinum toxin A injections in people with neurogenic detrusor overactivity after spinal cord injury.

STUDY DESIGN: Retrospective chart study. OBJECTIVES: The aim was to examine continuation of treatment of individuals with spinal cord injury including myelomeningocele and neurogenic detrusor overactivity, treated with repeated intra-detrusor Botulinum toxin A injections, and to investigate factors associated with discontinuation of treatment. SETTING: Rigshospitalet, Denmark METHODS: This study included 128 individuals with spinal cord injury and neurogenic detrusor overactivity, who were offered repeated Botulinum toxin A injections between 2001 and 2018. Continuation rates of the treatment were estimated using Kaplan Meier analysis. A Cox proportional hazard analysis was used to investigate factors predictive of discontinuation. RESULTS: A total of 1156 treatments were performed. The median number of treatments was six (IQR 9, range 1-51), and median follow-up was 10.6 years (IQR 8.5, range 0-16.9). All urodynamic parameters changed significantly after the first treatment (p < 0.001). The continuation group had significantly higher mean maximum bladder capacity after the first injections compared with the discontinuation group, with a mean difference between the groups of 84.5 mL (95% CI 4.7-164.2) (p = 0.038). The probability of continuing treatments after 5 years was 59% (95% CI 50.0-67.8) and 50% (95% CI 40.1-59.3) after 10 years. Individuals aged 31-50 years were more likely to continue treatment compared with those aged >50 years (95% CI 0.21‒0.79) (p = 0.008). No other factors predicted discontinuation. CONCLUSIONS: This long-term follow-up study showed that 50% of people with spinal cord injury starting intra-detrusor Botulinum toxin A for neurogenic detrusor overactivity are still receiving injections after 10 years.