Modified autologous fascial sling technique ('sling on a string') for stress incontinence.

INTRODUCTION AND HYPOTHESIS: Describe the modified autologous fascial sling procedure that has been employed in the largest randomized controlled trial comparing autologous slings, mesh slings and xenografts. METHODS: The video aims to demonstrate the modified Aldridge technique. The surgical procedure is demonstrated. A 6-cm suprapubic incision is made to harvest the rectus sheath fascia. Loop-0-PDS sutures are attached on either end of the sling. A marking suture is placed in the middle of the graft to facilitate tension-free adjustment. A vaginal incision is made at the mid-urethra. Paraurethral dissection is performed to create a tunnel for the fascial graft to be passed through (in the same manner as with transvaginal mesh slings). The ends of the graft PDS sutures are passed through the paraurethral tunnel. One hand is placed abdominally below the rectus muscles to palpate the pelvic floor from above. The graft sutures are passed through the pelvic floor with control on either side. A cystoscopy is performed to check the bladder integrity. The graft placement is adjusted to be tenson-free. The incisions are closed. The short- and long-term outcomes of this technique have been investigated and published. RESULTS: The cure rates and complication rates were no different in the mesh and autologous slings. The xenograft had inferior outcomes. CONCLUSION: Autologous fascial slings can be used in the surgical management of urodynamic stress incontinence. The technique demonstrated in this video is the technique employed in the largest randomized controlled trial investigating the efficacy of autologous fascial slings to xenografts and tapes.

Functional Brain Asymmetry and Menopausal Treatments: Is There a Link?

Background and Objectives: The human brain presents a functional asymmetry for every cognitive function, and it is possible that sexual hormones could have an impact on it. Visual−spatial attention, one of the most lateralized functions and one that is mainly dependent on the right hemisphere, represents a sentinel for functional cerebral asymmetry (FCA). The aim of this study was to evaluate whether menopausal hormone therapy (MHT) or phytoestrogens could modulate FCA in postmenopausal women. Materials and Methods: We enrolled postmenopausal women who were taking MHT or soy isoflavones or receiving no therapy and asked them to perform the line bisection test at study enrollment and after 18 and 36 months. Results: Ninety women completed the follow-up. At zero time, women who had not been subjected to therapy showed a leftward deviation (F = −3.0), whereas, after 36 months, the test results showed a rightward deviation (F = 4.5; p < 0.01). Women taking MHT showed a leftward deviation at the start (F = −3.0) and a persistent leftward deviation after 36 months (F = −4.0; p = 0.08). Conversely, women taking soy isoflavones started with a leftward deviation (F = −3.0) that became rightward (F = 3.0), with a significant difference shown after 36 months (p < 0.01). Conclusions: Our data suggest that hormonal modulation improves the interplay between the two hemispheres and reduces FCA. We propose, therefore, that the functions of the right hemisphere are mainly affected by aging and that this could be one of the reasons why the right hemisphere is more susceptible to the effects of MHT.

Effectiveness of percutaneous posterior tibial nerve stimulation for the management of bowel dysfunction in multiple sclerosis patients.

BACKGROUND: Neurogenic bowel dysfunctions (NBDs) in the form of both fecal incontinence (FI) and functional constipation (FC) are frequent in multiple sclerosis (MS) patients and significantly affect their quality of life. Therapeutic options are limited. OBJECTIVE: To investigate effectiveness of percutaneous posterior tibial nerve stimulation (PTNS) in MS patients suffering from FI and FC. METHODS: Prevalence and severity of FI and FC were prospectively collected among MS patients undergoing 12 weeks of PTNS for neurogenic bladder. The Cleveland Clinic Fecal Incontinence Score (CCFIS) and the Rome III criteria were used to define FI and FC, respectively. Subjective treatment satisfaction was estimated using the Benefit Satisfaction and Willingness to Continue (BSWC) questionnaire. RESULTS: A total of 60 patients undergoing PTNS suffered from NBDs (25 FI+/FC+, 5 FI+/FC-, 30 FI-/FC+). Median CCFIS decreased after PTNS from 12.0 (11.0-13.0) to 8.5 (7.0-11.0, p < 0.001), with particular improvements in liquid and flatal incontinence, pads' need, and lifestyle restrictions. Seven patients became FC free after PTNS and no patients developed FC during the study (p = 0.023). More than 50% of the patients were satisfied and willing to continue PTNS at study end. CONCLUSION: PTNS represents a valid minimally invasive alternative treatment for MS patients suffering from NBDs.

An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment.

INTRODUCTION: The terminology for female and male pelvic floor muscle (PFM) assessment has expanded considerably since the first PFM function and dysfunction standardization of terminology document in 2005. New terms have entered assessment reports, and new investigations to measure PFM function and dysfunction have been developed. An update of this terminology was required to comprehensively document the terms and their definitions, and to describe the assessment method and interpretation of the finding, to standardize assessment procedures and aid diagnostic decision making. METHODS: This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) Working Group 16, with contributions from recognized experts in the field and external referees. A logical, sequential, clinically directed assessment framework was created against which the assessment process was mapped. Within categories and subclassifications, each term was assigned a numeric coding. A transparent process of 12 rounds of full working group and external review was undertaken to exhaustively examine each definition, plus additional extensive internal development, with decision making by collective opinion (consensus). RESULTS: A Terminology Report for the symptoms, signs, investigations, and diagnoses associated with PFM function and dysfunction, encompassing 185 separate definitions/descriptors, has been developed. It is clinically based with the most common assessment processes defined. Clarity and user-friendliness have been key aims to make it interpretable by clinicians and researchers of different disciplines. CONCLUSION: A consensus-based Terminology Report for assessment of PFM function and dysfunction has been produced to aid clinical practice and be a stimulus for research.

Anal canal to pubis angle: a novel clinical ultrasound technique for the assessment of the anorectal region.

INTRODUCTION AND HYPOTHESIS: Posterior compartment prolapse is associated with severe morbidity including faecal incontinence and defaecation dysfunction. The aim of this study was to develop and validate a novel ultrasound marker (anal canal to pubis angle) for the assessment of the anal axis in the context of posterior compartment prolapse in women and in controls (healthy, nulliparous, non-pregnant volunteers). METHODS: Anal canal to pubis (AC/Pubis) angle is measured with 2D transperineal ultrasound in precisely the midsagittal plane. The image was inverted and zoomed out and the angle opened to 107° (maximum). The image includes the pubis, urethra and anal canal. The angle measurement starts from the anal canal, pivots on the anorectal junction and ends at the shadow of the pubis. Inter- and intra-observer agreement in AC/Pubis angle measurement was assessed and the angles measured in the two groups compared. RESULTS: Forty women with posterior prolapse and 17 controls were included. Close agreement was observed in inter- and intra-observer AC/Pubis angle measurements assessed with Bland-Altman analysis. AC/Pubis angle is significantly wider in prolapse patients compared to controls (t-test, p < 0.001), with mean AC/Pubis angle in prolapse patients 122.9° (SD 15.6°) and controls 98.2° (SD 15.9°). CONCLUSION: The AC/Pubis angle is a novel validated 2D ultrasound technique for the assessment of the anorectal axis that potentially can be performed using equipment that is widely available in routine clinical practice. The AC/Pubis angle is significantly wider in prolapse patients compared to controls.

The role of bladder instillation in the treatment of bladder pain syndrome: Is intravesical treatment an effective option for patients with bladder pain as well as LUTS?

The aetiology of bladder pain syndrome/interstitial cystitis is still unknown. Numerous mechanisms have been proposed and treatments targeting various aspects of these are used. This review looks at the existing evidence on bladder instillations and whether they could be used in the treatment of lower urinary tract symptoms as well.

Posterior tibial nerve stimulation for overactive bladder-techniques and efficacy.

The ideal treatment for overactive bladder is still elusive. In those where medication fails to improve symptoms options include invasive treatments such as botulinum toxin-A, sacral neural stimulation or posterior tibial nerve stimulation. Scientific professional society guidelines advise percutaneous posterior tibial nerve stimulation as a third line treatment option only after multi-disciplinary team review as well as failure of both conservative and pharmacological management. The aim of this article is to review all techniques for tibial nerve stimulation and their efficacy.

Ultrasound imaging of the perineal body: a useful clinical tool.

INTRODUCTION AND HYPOTHESIS: The perineal body is a fibromuscular pyramidal structure located between the vagina and the anus. It has been difficult to image because of its small size and anatomical location. This study used 2D transperineal ultrasound to measure the perineal body and assess whether there is an association with prolapse. METHODS: An observational, cross-sectional study was carried out in a tertiary level Urogynaecology department and included prolapse patients and healthy nulliparous volunteers (control group). This was a clinical assessment, including POP-Q and trans-perineal 2D ultrasound measurement of the perineal body height, length, perimeter, and area. Parametric tests were used, as the data were normally distributed. Results are reported as mean and 95% confidence interval (±95% CI). RESULTS: A total of 101 participants were recruited of which 22 were nulliparous healthy volunteers. Mean perineal body measurements in controls were height 22.5 ± 3.3 mm, length 17.4 ± 2.7 mm, perimeter 7.5 ± 0.9 mm, and area 2.8 ± 0.38 cm2. Perineal body measurements in 79 prolapse patients: height 16.9 ± 1.7 mm, length 16.0 ± 1.4 mm, perimeter 6.5 ± 0.5 mm and area 2.1 ± 0.5 cm2. A small perineal body was strongly associated with posterior compartment prolapse (paired t test, p < 0.0001) and wider POP-Q GH (paired t test, p = 0.0003). Surprisingly, Pelvic Organ Prolapse Quantification Perineal Body (POP-Q PB) of the two groups was not significantly different. A perineal body mid-sagittal area of less than 2.4 cm2 has been shown to be associated strongly with posterior compartment prolapse. CONCLUSIONS: It is possible to measure the perineal body on 2D ultrasound. This technique facilitates the objective diagnosis of perineal deficiency. POP-Q PB does not predict the length or area of the perineal body.

Ultrasound technique for the assessment of urethral descent assessment technique (UDAT) in healthy volunteers.

Bladder neck descent (BND) has been implicated in the pathophysiology of stress incontinence and prolapse. The aim of this study was to evaluate a novel 2D technique for the evaluation of BND, the Urethral Descent Assessment Technique (UDAT). UDAT involves measuring BND during dynamic manoeuvres in live 2D ultrasound, by using the geometrical properties of parallel lines. The internal urethral meatus and distal end of the urethra are used as reference points. Y1 is the urethral height at rest (also the urethral length when the urethra is straight). Y2 is the urethral height on Valsalva. Y1 and Y2 are parallel lines. Y1-Y2 = BND. A horizontal line (X) connecting Y1 and Y2 is the forward movement of the bladder neck.Y1 mean 30.4 mm (95% CI ± 1.36 mm). Y2 mean 24.2 mm (95% CI ± 2.58 mm). X mean 12.1 mm (95% CI ± 1.66 mm). BND mean 6.2 mm (95% CI ± 1.47 mm). Bland-Altman plots and linear regression showed that UDAT is repeatable and reliable.Impact statementWhat is already known on this subject? Bladder neck descent (BND) has been associated with stress incontinence and prolapse nearly a century. In 1975, Green introduced a classification based on X-ray cysto-urethrograms. Between 1989 and 1995, a 2D technique was described that had several limitations.What do the results of this study add? This study validates a novel technique for the assessment of bladder neck descent using 2D ultrasound and provides a reference range of BND for normal nulliparous women.What are the implications of these findings for clinical practice and/or further research? This is a simple and quick technique that could be adopted in research and clinical practice in the future to assess stress incontinence and anterior compartment prolapse.

Levator Ani avulsion: The histological composition of this site. A cadaveric study.

INTRODUCTION: The sonographic appearance of a levator muscle "avulsion" representing the literal detachment of the pubovisceral muscle (PVM) enthesis has been contested. The nature of the levator ani "avulsion" is still not fully understood. It is known, that the tensile strength of a tendon is dependent on collagen with increased synthesis of collagen occurring in tissue with increased mechanical load levels. This study aims to perform a quantitative histological evaluation of the PVM enthesis with or without the imaging finding of levator ani "avulsion" to determine if there is a difference in the proportion of muscle and collagen. METHOD: Three-dimensional translabial ultrasound for PVM "avulsion" was performed on cadavers using a GE Voluson I with a 5-9 MHz electronic probe. Cadavers were meticulously dissected to identify the presence or absence of an anatomical avulsion. The PVM enthesis was excised for further histopathological processing and treated with three different colorations. Quantitative analysis using ImageJ software was conducted to compare tissue composition in samples with or without sonographic "avulsion." All stages were performed by two separate investigators blinded to each other's results. The results were analyzed using SPSS v24, IBM. RESULTS: Twenty-three PVM enthesis with histological staining were procured. Ultrasonographic "avulsions" were seen in 5/23 PVM enthesis. No anatomical avulsions were seen. There was no difference in the overall muscle or collagen content (Kruskal-Wallis, P = 0.864). The mean organized skeletal muscle content was 23% in the sonographic "avulsion" group versus 62% in the no "avulsion" group (Kruskall-Walis, P = 0.02). "Avulsions" were associated with a disorganized appearance at histology. CONCLUSION: The tissue composition relating to the proportion of muscle and collagen was not significantly different in specimens with or without sonographic "avulsions." However, morphological differences were observed in the organization of the muscle fibres, which requires further evaluation.

The energy based devices for vaginal "rejuvenation," urinary incontinence, vaginal cosmetic procedures, and other vulvo-vaginal disorders: An international multidisciplinary expert panel opinion.

AIMS: Energy-based devices using radiofrequency and laser technologies have gained popularity as therapies for vaginal atrophy, urinary incontinence, and vaginal prolapse. They have been promoted by cosmetic and aesthetic industries for vaginal "laxity" and vaginal "rejuvenation," both of which are undefined conditions and terms. This article aims to review the current available literature and its quality on this emerging technology. METHODS: An international panel of gynaecologists, urogynaecologists, and urologists undertook a review of the available published literature, identifying articles, guidance, and society statements on the use vaginal energy-based devices. RESULTS: There is currently no formal guidance for the use of vaginal energy based therapies. No randomized controlled trials have been published. No comparative studies to existing treatment has been carried out. Studies suggest that vaginal laser can be used in the treatment of vaginal prolapse or "vaginal laxity" and stress urinary incontinence with no quality evidence supporting the use of the therapy for vaginal atrophy or lichen sclerosis. CONCLUSIONS: This international group propose that whilst there remains a paucity of good quality data describing the safety, benefits, and appropriate use of vaginal radiofrequency or laser treatments in gynaecology and urogynaecology, a consensus best practice document by an established scientific community needs to be developed.

The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology: An ICS/ISSVD best practice consensus document.

BACKGROUND: The clinical role of LASER for vulvar and vaginal treatments in gynecology and female urology is controversial. AIMS: In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. MATERIALS & METHODS: This project was developed between January and September 2018. The development of this document followed the ICS White Paper Standard Operating Procedures. RESULTS: Most of the available studies are limited by their design; for example they lack a control group, patients are not randomized, follow up is short term, series are small, LASER is not compared with standard treatments, and studies are industry sponsored. Due to these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration following LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. DISCUSSION: The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, while short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. CONCLUSION: At this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

The impact of bariatric surgery on urinary incontinence: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Obesity and overweight are strongly associated with stress and urgency urinary incontinence, and weight loss has been associated with improvement in urinary incontinence. We aimed to measure pooled effect sizes for different weight loss procedures on incontinence-specific quality of life and incontinence cure rate in a systematic review and meta-analysis. METHODS: MEDLINE, Embase and the Cochrane library were searched using a pre-defined strategy for relevant cohort studies. Random effects meta-analyses were conducted for the weighted mean difference for urinary quality of life scores and weighted overall pooled estimates for proportions of women cured. We explored heterogeneity using meta-regression, testing the type of bariatric surgery and change in BMI as predictors of effect size. The studies were categorised as either low or high risk of bias using a novel instrument specifically designed for longitudinal symptom research studies. RESULTS: Twenty-three studies (n = 3,225) were included. Incontinence-specific quality of life scores were improved by 14% (weighted mean difference = -14.79; CI = -18.47 to -11.11; I2 = 87.1%); the proportion of women cured of any urinary incontinence was 59% (95% CI = 51 to 66%) and the proportion of women cured of stress urinary incontinence was 55% (95% CI = 40 to 70%). CONCLUSIONS: Bariatric surgery results in clinically meaningful improvements in incontinence-specific quality of life. Current data are limited by both short-term follow-up and unexplained heterogeneity among studies.

The Clinical Role of LASER for Vulvar and Vaginal Treatments in Gynecology and Female Urology: An ICS/ISSVD Best Practice Consensus Document.

In this best practice document, we propose recommendations for the use of LASER for gynecologic and urologic conditions such as vulvovaginal atrophy, urinary incontinence, vulvodynia, and lichen sclerosus based on a thorough literature review. Most of the available studies are limited by their design; for example, they lack a control group, patients are not randomized, follow-up is short term, series are small, LASER is not compared with standard treatments, and most studies are industry sponsored. Because of these limitations, the level of evidence for the use of LASER in the treatment of these conditions remains low and does not allow for definitive recommendations for its use in routine clinical practice. Histological evidence is commonly reported as proof of tissue regeneration after LASER treatment. However, the histological changes noted can also be consistent with reparative changes after a thermal injury rather than necessarily representing regeneration or restoration of function. The use of LASER in women with vulvodynia or lichen sclerosus should not be recommended in routine clinical practice. There is no biological plausibility or safety data on its use on this population of women. The available clinical studies do not present convincing data regarding the efficacy of LASER for the treatment of vaginal atrophy or urinary incontinence. Also, although short-term complications seem to be uncommon, data concerning long-term outcomes are lacking. Therefore, at this point, LASER is not recommended for routine treatment of the aforementioned conditions unless part of well-designed clinical trials or with special arrangements for clinical governance, consent, and audit.

Racial differences in female urethral morphology and levator hiatal dimensions: an ultrasound study.

AIM: To compare the urethral sphincter morphology and levator hiatal dimensions between white and black premenopausal nulliparous asymptomatic women using 3D/4D translabial ultrasonography. METHODS: Nulliparous black and white women were recruited in a tertiary gynecological center. All women were completely asymptomatic for pelvic floor dysfunction. Women were assessed with 3D/4D translabial ultrasound scan of the pelvic floor, at rest. Measurements of the total urethral sphincter volume (TSV), rhabdosphincter volume, (RSV) and levator hiatal dimensions (LH) were taken at rest, after voiding. RESULTS: Twenty-three white and 14 black women (37 in total) were investigated. Subjects did not differ by age or body mass index (BMI). Black women were found to have significantly larger rhabdosphincters (RS) than their white counterparts (8.88 cm(3) ± 1.65 vs. 5.97 cm(3) ± 1.82, respectively, P = 0.000). With respect to levator hiatal dimensions at rest, black women had a significantly wider transverse diameter (LHt) than white women (mean difference of LHt = 0.43 cm, 95% CI 0.08-0.78, P < 0.05). CONCLUSIONS: Asymptomatic black nulliparous women have significantly larger rhabdosphincters than their white counterparts. Racial differences in the female urethral morphology could provide an insight on the pathophysiology of stress urinary incontinence.