Associated factors of vaginal laxity and female sexual function: a cross-sectional study.

BACKGROUND: Female sexual dysfunction (FSD), including vaginal laxity (VL), can lead to a decrease in quality of life and affect partner relationships. AIM: We aimed to investigate the associated factors of VL and FSD and their relationship with other pelvic floor disorders in a female population. METHODS: This cross-sectional study was conducted at Chelsea and Westminster Hospital from July to December 2022. All women referred to clinical care at the urogynecology clinic were included. Participants were assessed according to sociodemographic and clinical aspects, the Pelvic Organ Prolapse Quantification system, sexual function, VL, sexual attitudes, sexual distress, sexual quality of life, vaginal symptoms, and pelvic floor disorders. Unadjusted and adjusted associated factors of VL and FSD were analyzed. OUTCOMES: The primary outcome was the identification of the associated factors of VL and FSD in a female population, and secondary outcomes included the association between VL and pelvic organ prolapse (POP) with the questionnaire scores. RESULTS: Among participants (N = 300), vaginal delivery, multiparity, perineal laceration, menopause, and gel hormone were significantly more frequent in those reporting VL (all P < .05). When compared with nulliparity, primiparity and multiparity increased the odds of VL by approximately 4 and 12 times, respectively (unadjusted odds ratio [OR], 4.26 [95% CI, 2.05-8.85]; OR, 12.77 [95% CI, 6.53-24.96]). Menopause and perineal laceration increased the odds of VL by 4 and 6 times (unadjusted OR, 4.65 [95% CI, 2.73-7.93]; OR, 6.13 [95% CI, 3.58-10.49]). In multivariate analysis, menopause, primiparity, multiparity, and POP remained associated with VL. CLINICAL IMPLICATIONS: Parity, as an obstetric factor, and menopause and staging of POP, as clinical factors, were associated with VL. STRENGTHS AND LIMITATIONS: The investigation of associated factors for VL will contribute to the understanding of its pathophysiology. The study design makes it impossible to carry out causal inference. CONCLUSION: Menopause, primiparity, multiparity, and POP were highly associated with VL complaints in multivariate analysis.

Treatment of women with vaginal laxity: systematic review with meta-analysis.

BACKGROUND: Despite several treatments that have been used for women reporting vaginal laxity (VL), to our knowledge no systematic review is available on the topic so far. AIM: In this study, we sought to summarize the best available evidence about the efficacy and safety of interventions for treating VL, whether conservative or surgical. METHODS: A comprehensive search strategy was performed in Medline, Embase, Scopus, Web of Science, and Cochrane Library for reports of clinical trials published from database inception to September 2022. Studies selected for inclusion were in the English language and were performed to investigate any type of treatment for VL, with or without a comparator, whether nonrandomized studies or randomized controlled trials (RCTs). Case reports and studies without a clear definition of VL were excluded. OUTCOMES: The outcomes were interventions (laser, radiofrequency, surgery, and topical treatment), adverse effects, sexual function, pelvic floor muscle (PFM) strength, and improvement of VL by the VL questionnaire (VLQ). RESULTS: From 816 records, 38 studies remained in the final analysis. Laser and radiofrequency (RF) were the energy-based treatment devices most frequently studied. Pooled data from eight observational studies have shown improved sexual function assessed by a Female Sexual Function Index score mean difference (MD) of 6.51 (95% CI, 5.61-7.42; i2 = 85%, P < .01) before and after intervention, whether by RF (MD, 6.00; 95% CI, 4.26-7.73; i2 = 80%; P < .001) or laser (MD, 6.83; 95% CI, 5.01-8.65; i2 = 92%; P < .01). However, this finding was not shown when only 3 RCTs were included, even when separated by type of intervention (RF or laser). When RF treatment was compared to sham controls, VLQ scores did not improve (MD, 1.01; 95% CI, -0.38 to 2.40; i2 = 94%; P < .001). Patient PFM strength improved after interventions were performed (MD, 4.22; 95% CI, 1.02-7.42; i2 = 77%; P < .001). The ROBINS-I (Risk Of Bias In Nonrandomized Studies of Interventions) tool classified all non-RCTs at serious risk of bias, except for 1 study, and the risk of bias-1 analysis found a low and unclear risk of bias for all RCTs. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) certainty of the evidence was moderate for sexual function and the VLQ questionnaire and low for PFM strength. CLINICAL IMPLICATIONS: Sexual function in women with VL who underwent RF and laser treatment improved in observational studies but not in RCTs. Improvement in PFM strength was observed in women with VL after the intervention. STRENGTHS AND LIMITATIONS: Crucial issues were raised for the understanding of VL, such as lack of standardization of the definition and for the development of future prospective studies. A limitation of the study was that the heterogeneity of the interventions and different follow-up periods did not make it possible to pool all available data. CONCLUSIONS: Vaginal tightening did not improve sensation in women with VL after intervention, whereas RF and laser improved sexual function in women with VL according to data from observational studies, but not from RCTs. PFM strength was improved after intervention in women with VL.

Pelvic floor muscle training vs radiofrequency for women with vaginal laxity: randomized clinical trial.

BACKGROUND: Vaginal laxity (VL) is a complaint of excessive vaginal looseness with a prevalence ranging from 24% to 38% across studies. AIM: The study sought to compare the effect of radiofrequency (RF) and pelvic floor muscle training (PFMT) on the treatment of women with VL. METHODS: From February 2020 to December 2021, a prospective, parallel, noninferiority, randomized clinical trial was carried out in women ≥18 years of age and complaining of VL in a tertiary hospital. Two groups (RF and PFMT) were evaluated at the beginning of the study and 30 days and 6 months postintervention. A total of 42 participants per arm was sufficient to demonstrate a difference in sexual function on the Female Sexual Function Index at 90% power, 1-sided type 1 error of 0.025 with a noninferiority margin of 4 on the FSFI total score. Analysis was intention-to-treat and per-protocol based. OUTCOMES: The primary endpoint was the change of FSFI score after treatment, and the secondary outcomes were improvement in symptoms of VL and changes in questionnaire scores of sexual distress, vaginal symptoms, and urinary incontinence, in the quantification of pelvic organ prolapse, and pelvic floor muscle (PFM) contraction. RESULTS: Of 167 participants recruited, 87 were included (RF: n = 42; PFMT: n = 45). All questionnaires improved (P < .05) their total scores and subscales in both groups and during the follow-ups. After 30 days of treatment, RF was noninferior to PFMT to improving FSFI total score (mean difference -0.08 [95% confidence interval, -2.58 to 2.42]) in the per-protocol analysis (mean difference -0.46 [95% confidence interval, -2.92 to 1.99]) and in the intention-to-treat analysis; however, this result was not maintained after 6 months of treatment. PFM contraction improved significantly in both groups (RF: P = .006, 30 days; P = .049, 6 months; PFMT: P < .001, 30 days and 6 months), with better results in the PFMT group. CLINICAL IMPLICATIONS: Sexual, vaginal, and urinary symptoms were improved after 30 days and 6 months of treatment with RF and PFMT; however, better results were observed in the PFMT group after 6 months. STRENGTHS & LIMITATIONS: The present randomized clinical trial used several validated questionnaires evaluating quality of life, sexual function and urinary symptoms, in addition to assessing PFM contraction and classifying the quantification of pelvic organ prolapse aiming at anatomical changes in two follow-up periods. The limitations were the lack of a sham-controlled group (third arm) and the difficulty of blinding researchers to assess treatments due to the COVID-19 pandemic. CONCLUSION: After 30 days and 6 months of treatment, sexual, vaginal, and urinary symptoms improved with RF and PFMT; however, better results were observed in the PFMT group after 6 months. RF was noninferior to PFMT in improving FSFI total score after 30 days; however, this result was not maintained after 6 months of treatment.

Cross sectional study on assessment of ring pessary cleaning and removal every six months: adverse events and complications.

INTRODUCTION AND HYPOTHESIS: Despite its frequent use, there is little evidence of adequate management of pessaries for treating pelvic organ prolapse (POP). Thus, the aims the study were to assess the rate of complications in women using ring-type pessaries with cleaning and monitoring every 6 months and to correlate the time of use of the pessary with possible complications. METHODS: This is a cross-sectional study including women diagnosed with stage 3 or 4 genital prolapse, who were already in outpatient follow-up and who used a ring pessary. We excluded patients using another type of pessary, with severe comorbidities and with POP-Q ≤ 2 staging. The chi-square test or Fisher exact test was applied for categorical variables, the t-test for continuous variables with normal distribution and Mann-Whitney test for non-parametric variables. RESULTS: A total of 83 women using a ring pessary were assessed. The mean in months of pessary use was 31.8 ± 14.9 months. Vaginal discharge was the most frequent complaint representing 26.5%, followed by foul smell in 13.3%. No significant correlation was found between length of pessary use and clinical variables. However, a significant correlation was found between immediate complications and the length of pessary use (21.3 ± 5.9 months; p < 0.0044). CONCLUSION: There was no increase in complication rate in the continuous use of a ring pessary with cleaning and monitoring every 6 months. Determining a follow-up time that reduces the risk of complications is necessary not only for the organization of the attendance services, allowing a greater number of monitored patients, but also for the access of patients who need regular monitoring.

Measurement of the vaginal wall thickness by transabdominal and transvaginal ultrasound of women with vaginal laxity: a cross-sectional study.

INTRODUCTION AND HYPOTHESIS: An objective diagnostic method to understand vaginal laxity (VL) is still missing. The aim of our study is to determine whether vaginal wall thickness (VWT) measured by ultrasound may differ according to the abdominal or vaginal techniques and to assess whether clinical variables are associated with vaginal measurements of women with VL. METHODS: A cross-sectional study conducted at a tertiary hospital included 82 women aged ≥ 18 years with VL complaints assessed by the Vaginal Laxity Questionnaire. Women who reported severe comorbidities or vulvovaginal disorders, previous treatment for VL, and use of vaginal estrogen in the last 6 months were excluded. Participants reporting VL underwent transabdominal (TAUS) and transvaginal ultrasound (TVUS) and physical examination and answered validated questionnaires. Descriptive data were given as mean and standard deviation, median (range), and absolute and relative frequency. The significance level adopted for this study was 5%. Sample size calculation was not performed for the present study. RESULTS: Mean age was 41.20 ± 8.64 years, and most participants were multiparous, with previous vaginal delivery and having vaginal intercourse. A statistically significant difference (up to 3 mm) between TAUS and TVUS measurements of the VWT was found in the proximal, middle-third, and distal compartments. A significant correlation was found between VWT and TAUS or TVUS in the mid-third and distal compartments. CONCLUSION: A significant correlation was found between the VWT measurements in TVUS and TAUS. Our findings might give the health professional more possibilities for investigating VWT according to patient characteristics.

Vaginal stenosis in women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study of vaginal measurements, risk for sexual dysfunction and quality of life.

INTRODUCTION AND HYPOTHESIS: Radiotherapy (RT) for cervical (CC) and endometrial cancer (EC) is known to lead to vaginal stenosis (VS), but the comparison between vaginal anatomical measurements and the risk of sexual dysfunction presents a wide variety of results among the literature. Thus, we sought to assess the prevalence of VS, vaginal measurements, sexual dysfunction and QOL in women with CC and EC submitted to pelvic RT with or without previous surgery. METHODS: Cross-sectional study that included 61 women with CC and 69 with EC. VS was classified by the Common Terminology Criteria for Adverse Effects version 5.0 (CTCAE v5.0), sexual function by the validated Female Sexual Function Index (FSFI) and QOL by the validated World Health Organization questionnaire (WHOQOL-BREF). Acrylic cylinders were used for vaginal measurements. Uni-/multivariate analyses to address factors associated with VC in both groups were performed. RESULTS: The prevalence of VS was 79% and 67% within patients with CC and EC, respectively. Vagina length was decreased in both groups without statistical difference (7.2 ± 1.7 vs. 6.6 ± 1.8;p = 0.072). Vaginal diameter was significantly higher (p = 0.047) in women with EC (25.4 ± 6.3) than in those with CC (23.1 ± 5.7). Sexual dysfunction was highly prevalent for both CC and EC (88% vs. 91%; p = 0.598). There was no difference in all WHOQOL-BREF domains between women with CC and EC. CONCLUSIONS: VS is highly prevalent in CC and EC patients, with vaginal length decreased in both groups but with a higher vaginal diameter in those with EC. Nevertheless, sexual dysfunction is highly prevalent in both groups.

Cross-cultural adaptation and validation of the Brazilian Portuguese version of the Female Sexual Distress Scale-Revised questionnaire for women with vaginal laxity.

INTRODUCTION AND HYPOTHESIS: Vaginal laxity (VL) can impair women´s quality of life and there are not many tools aimed at quantitatively addressing this complaint. Sexual distress can be present within this group of patients. The aim of our study is to carry out the cross-cultural adaptation/translation and validation of the Female Sexual Distress Scale-Revised (FSDS-R) for Brazilian Portuguese women with VL. METHODS: Women age ≥ 18 years, with VL (n=82), and without VL (n=53) were included. Continuous variables were described in the form of mean/standard deviation or median/range, and Student's t test was used. The Chi-squared test was used for dichotomous variables. Cronbach's alpha coefficient was used for internal consistency and Spearman's correlation was used to assess construct validity (FSDS-R, Female Sexual Function Index [FSFI], and Incontinence Questionnaire Vaginal Symptoms [ICIQ-VS]). A significance level of 5% was established using a two-tailed test. RESULTS: Women with VL presented more anal/vaginal sexual intercourse than women without VL (p=0.030). All three instruments (FSDS-R, FSFI, and ICIQ-VS) presented discriminant validity between women with and without VL (p<0.001). A high internal consistency (Cronbach´s alpha =0.887) was found in women with VL and without VL (0.917). Regarding construct validity (n=82), there was a strong positive correlation between FSDS-R score and ICIQ-VS scales, except for a weaker correlation between the ICIQ-VS vaginal symptoms subscale (r: +0.2788; p=0.013). A moderate negative correlation was found between FSDS-R and all FSFI domains (p<0.001), except for pain (p<0.062). CONCLUSIONS: The Brazilian version of the FSDS-R showed adequate internal consistency and discriminant validity, and a correlation was found with other instruments such as FSFI and ICIQ-VS.

Vaginal stretching therapy and class IIIB vaginal laser treatment for pelvic floor myofascial pain: a randomized clinical trial.

PURPOSE: Several treatment options are proposed for the management of pelvic floor myofascial pain (PFMP). Manual therapy, such as vaginal stretching (VS), is one of these options. Photobiomodulation therapy (PBMT) with a laser device is a treatment option for PFMP that has been tested on other muscles. The aim of this study was to evaluate the effect of VS combined or not with PBMT for PFMP treatment. METHODS: One hundred three women with PFMP were enrolled in a double-blind randomized trial and assigned to VS+PBMT (10 treatments over 2 weeks with 100 mw delivering 12 joules to surface intravaginally, using near-infrared light 808 nm) and VS+shamPBMT treatment groups. Pain severity was assessed by Visual Analog Scale (VAS). Pelvic floor muscle function was assessed by Oxford Scale and surface electromyography. Urinary symptoms were evaluated by ICIQ-OAB and ICIQ-SF questionnaires, and intestinal constipation was assessed by ROMA criteria. RESULTS: There was a significant improvement in pain intensity (VAS) after treatment in both groups, with no difference between groups (p = 0.46). More than 50% of the women complained of severe pain before treatment, and after treatments, it was reported by less than 20% of women (p < 0.001), with no difference between groups (p = 0.08). Urinary symptoms improved in both groups (p < 0.001) with no difference between groups (p = 0.37). Intestinal constipation improved in the VS+PBMT group only (p = 0.01). CONCLUSION: VS and VS with near-infrared vaginal laser therapy were equally effective at decreasing myofascial pelvic pain and reducing urinary symptoms TRIAL REGISTRATION: REBEC (Registro Brasileiro de Ensaios Clínicos; Brazilian Registry of Clinical Trials) under no.RBR-2TDCQ4 (November 11, 2018).

ESTROgen use for complications in women treating pelvic organ prolapse with vaginal PESSaries (ESTRO-PESS)-a randomized clinical trial.

INTRODUCTION AND HYPOTHESIS: To evaluate the complications of new users' vaginal pessaries (VP), with and without the use of vaginal estrogen after a 6-month follow-up. METHODS: A parallel, single-blinded, randomized, controlled trial. Symptomatic postmenopausal women (n = 98) with pelvic organ prolapse (POP) (stage 3/4) were recruited from August 2018 to October 2019. Patients were randomized into the local estrogen group (promestriene 3 × for a week) and the control group (no estrogen). They were evaluated for their vaginal symptoms at the baseline, after 3 months, and after 6 months, and a physical examination and vaginal sampling for microbiological analysis were done. Data were analyzed according to an intention-to-treat analysis (ITT). A 5% significance level was established for statistical analysis. RESULTS: Twenty women discontinued treatment (20.4%), mainly due to pessary extrusion (n = 15) and 5 for other reasons (lost to follow-up, pain, and surgery). Baseline characteristics were not statistically different between the estrogen and control groups. Regarding the presence of complications, the presence of erosion was 10% in the control group, but there was no significant difference between the groups (p = 0.175) after 6 months. Bacterial vaginosis (BV) was more prevalent in the control group, according to the Nugent (p = 0.007) and Amsel (p = 0.014) criteria. Urinary urgency and increased urinary frequency were significantly improved in the estrogen group after 6 months. CONCLUSION: There was no evident benefit related to complications such as ulcerations, itching, and vaginal discharge/odor from the use of vaginal estrogen in POP women using pessaries.

Pelvic floor muscle assessment by digital palpation and translabial ultrasound of women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study.

INTRODUCTION AND HYPOTHESIS: We hypothesized that anatomical changes in the pelvic floor muscles (PFM) could be detected using four-dimensional translabial ultrasound (4D TLUS) in patients with cervical (CC) or endometrial cancer (EC) who underwent pelvic radiotherapy (RT) as digital palpation may present sensitivity limitations. METHODS: This was a cross-sectional study that included 64 women (26 with CC and 38 with EC). PFM function was assessed by digital palpation, grading muscle strength according to the Modified Oxford Scale and by 4D TLUS. Ultrasonographic variables were: levator plate angle, hiatal area, puborectalis muscle thickness, puborectalis strain and levator ani muscle integrity. These variables were also correlated with clinical and sociodemographic data from all these patients. A 5% significance level was adopted. RESULTS: When assessed by digital palpation, no significant difference was found in PFM strength between women with CC and those with EC (p = 0.747). However, when assessed by 4D TLUS, women with CC presented greater thickening of the left (p = 0.039) and right (p = 0.014) lower portion of the puborectalis muscle during PFM contraction compared to those with EC. After pooling the groups, higher cancer staging (p = 0.028) was associated with smaller narrowing in the symphysis-levator distance, and shorter RT finishing duration (< 60 months) was associated with higher thickening in the left (p = 0.029) and right (p = 0.013) upper portion of the puborectalis muscle during PFM contraction as well as a shorter menopause duration (p = 0.007 and p = 0.002, respectively). CONCLUSIONS: Anatomical changes in the puborectalis muscle during PFM contraction were detected by 4D TLUS within gynecological cancer patients after pelvic RT.

Interventional treatment for myofascial pelvic floor pain in women: systematic review with meta-analysis.

INTRODUCTION AND HYPOTHESIS: Female myofascial pain (MFP) of the pelvic floor muscles (PFM) is a subtype of chronic pelvic pain associated with urinary, anorectal, and sexual symptoms, such as dyspareunia. Treatment remains poorly discussed, and we hypothesized that different treatments could improve outcomes versus placebo or no treatment. METHODS: A systematic review (CRD 42020201419) was performed in June 2020 using the following databases: PubMed, Cochrane Library, Web of Science, Embase, Scopus, BVSalud, Clinicaltrials.gov , and PEDro, including randomized clinical trials related to MPF of PFM. Primary outcome was pain after treatment, and secondary outcomes were quality of life and sexual function. Risk of bias and quality of evidence (GRADE criteria) were evaluated. Meta-analysis for continuous variables was performed (mean difference between baseline and treatment and post-treatment mean between groups). RESULTS: Five studies were included (n = 218). Final mean VAS score (GRADE: very low) after 4 weeks of treatment (p = 0.14) and the mean difference from baseline and 4 weeks (p = 0.66) between groups were not different between the intervention and control groups. Quality of life according to the SF-12 questionnaire (GRADE: very low) followed the same pattern. However, sexual function (GRADE: low) according to the total FSFI score (MD = -5.07 [-8.31, -1.84], p < 0.01, i2 = 0%) and the arousal, orgasm, and pain domains improved in the intervention groups when the mean difference from baseline and 4 weeks was compared with controls. CONCLUSION: Pain and quality of life after 4 weeks of heterogeneous intervention differed between the intervention and control groups in sexual function: FSFI in studies improved in almost all domains. VAS (in three studies) and SF-12 (in two studies) failed to demonstrate differences.

Factors associated with unsuccessful pessary fitting in women with symptomatic pelvic organ prolapse: Systematic review and metanalysis.

AIMS: To identify the factors associated with unsuccessful pessary fitting and reasons for discontinuation for women with symptomatic pelvic organ prolapse (POP). METHODS: This systematic review is registered at the PROSPERO database. We have included all studies, regardless of the study design whose primary outcomes were factors associated with unsuccessful pessary fitting and discontinuation for symptomatic POP women. Exclusion criteria were case series, literature reviews, other forms of conservative treatment. Data selection/extraction was performed by two investigators. For pessary fitting, a meta-analysis was performed for at least two studies pooled in a forest plot. The risk of bias was classified by the ROBINS-I and ROB-2 classification. RESULTS: From 409 studies retrieved after data search, only twenty-one articles remained for final analysis (18 cohort studies, 1 cross-sectional study, and 2 RCTs). Meta-analysis was performed in nine studies for pessary fitting and the associated factors were: higher body mass index (BMI) (MD = 0.688 [0.233-1.143]; P = .03; i2 = 0%), previous reconstructive surgery (OR = 1.705 [1.016-2.860]; P = .043; i2 = 69%) and advanced POP (OR = 4.2 [2.9-6.1]; P < .05; i2 = 92%). Older age, larger total vaginal length (TVL), and genital hiatus and previous hysterectomy were not associated factors. Regarding discontinuation, thirteen reasons were quoted, and the most frequent were: the desire for surgical treatment (111/3.601), pessary extrusion (385/3.601), and pain/discomfort (163/3.601). CONCLUSION: Obese, previously reconstructive pelvic surgery, advanced prolapse are at risk for unsuccessful pessary fitting. Pain is the most quoted reason for discontinuation. These pooled data may help clinicians to identify patients that may not succeed in their attempt for pessary treatment.

Selective episiotomy versus no episiotomy for severe perineal trauma: a systematic review with meta-analysis.

INTRODUCTION AND HYPOTHESIS: We hypothesized whether a non-episiotomy protocol or administration of selective episiotomy as an intrapartum intervention would modify the incidence of obstetric anal sphincter injuries (OASIS). METHODS: We registered this systematic review with the PROSPERO database (CRD42018111018). Prospective randomized controlled trials (RCTs) were included from databases until February 2019. The primary outcome was OASIS, and the secondary outcomes were any perineal trauma, duration of the second stage of labor, instrumental delivery, and post-partum hemorrhage. The risk of bias (Cochrane Handbook) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria were used to assess the RCTs. RESULTS: A total of 1,833 results (PubMed 650, SCOPUS 1,144, Cochrane Library 33, LILACS 6) were obtained. However, only 2 studies fulfilled the criteria for quantitative analysis and meta-analysis (n = 574). The non-episiotomy arm included two episiotomies (1.7% of deliveries), whereas the selective episiotomy included 33 episiotomies (21.4%). Performance of selective episiotomy demonstrated no difference compared with that of the non-episiotomy group with regard to OASIS (OR = 0.46 [0.15-1.39]; n = 543; I2 = 0%,p = 0.17), any perineal trauma (OR = 0.90 [0.61-1.33]; I2 = 0%, n = 546, p = 0.59), instrumental delivery (OR = 1.40 [0.80-2.45]; I2 = 0%, n = 545, p = 0.24), duration of the second stage of labor (MD = -3.71 [-21.56, 14.14]; I2 = 72%,n = 546, p = 0.68), perineal pain (MD = 0.59 [0.01-1.17]; I2 = 0%,p = 0.05), and post-partum hemorrhage (OR = 1.75 [0.87-3.54]; I2 = 0%,n = 546,p = 0.12). The evaluated studies displayed a low risk of bias in at least four of the seven categories analyzed. GRADE demonstrated a low certainty for severe perineal tears, postpartum hemorrhage, duration of the second stage of labor, and a moderate certainty for any perineal tear. CONCLUSIONS: There was no significant difference between non-episiotomy and selective episiotomy regarding OASIS. No RCT was able to confirm a benefit of the non-performance of episiotomies in the non-episiotomy arm.

Severity of urinary incontinence is associated with prevalence of sexual dysfunction.

INTRODUCTION AND HYPOTHESIS: Urinary incontinence (UI) affects overall health-related and sexual quality of life (QoL) in women. There is no consensus on the impact of severity and type of UI on the prevalence of sexual dysfunction (DS). The aim of this study was to evaluate the association between types and severity of UI and DS. METHODS: A cross-sectional study of women with UI. INCLUSION CRITERIA: women complaining of UI and > 18 years old. Women with a history of previous treatment for UI, recurrent urinary tract infections, renal lithiasis, previous radiation therapy or pelvic organ prolapse above stage 2 in the Pelvic Organ Prolapse Quantification (POP-Q) system were excluded. Clinical and epidemiological data were collected, and the following questionnaires were applied: ICIQ-SF, ICIQ-OAB, King's Health Questionnaire (KHQ) and Female Sexual Function Index (FSFI). RESULTS: Concerning the type of UI, the majority of women had MUI (69.1%) and 56.8% reported having coital UI. The mean score was 20.81 ± 8.45 in the FSFI questionnaire. There was a prevalence of SD in 71.6% of women, with no difference in types of UI (p = 0.753) and loss during sexual intercourse (p = 0.217). There was a correlation between severity of UI (ICIQ-SF) and arousal (r = -0.26; p = 0.008), lubrication (r = -0.25; p = 0.009), orgasm (r = -0.25; p = 0.009), pain (r = -0.26; p = 0.007) and total (r = -0.28; p = 0.004) domain scores. CONCLUSIONS: There is a high prevalence of SD in women with urinary incontinence, irrespective of the type of UI and urine leakage during sexual intercourse. However, the greater the severity of UI is, the worse the sexuality questionnaire scores.

Efficacy of Fractional CO2 Laser, Promestriene, and Vaginal Lubricant in the Treatment of Urinary Symptoms in Postmenopausal Women: A Randomized Clinical Trial.

BACKGROUND AND OBJECTIVES: Evaluating the efficacy of the fractional CO2 laser, promestriene, and vaginal lubricant to treat urinary symptoms in women with genitourinary syndrome of menopause. STUDY DESIGN/MATERIALS AND METHODS: We conducted a randomized clinical trial with 72 postmenopausal women aged 50 years or older. The participants were randomized to one intervention each in three treatment groups fractional CO2 laser, promestriene, and vaginal lubricant. Urinary symptoms were assessed prior to treatment and 2 weeks after treatment completion using validated questionnaires, the International Consultation on Incontinence Questionnaire (ICIQ-UI SF), and the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB). RESULTS: There was a significant reduction in the total ICIQ-UI SF score in the intragroup comparison (baseline vs. week 14) of the CO2 laser group (P = 0.004). This group also showed a statistically significant reduction in nocturia (1.33 ± 0.87 vs. 1.00 ± 0.76, respectively; P = 0.031). In the intergroup comparison after treatment, nocturia in the lubricant group had worsened compared with that of the other two groups (P = 0.002). Regarding the total ICIQ-OAB score, the results of the CO2 laser group were superior to those of the lubricant group in the intergroup comparison (7.76 ± 3.36, P = 0.020; analysis of variance P = 0.038). CONCLUSION: The results were significantly different between the intravaginal fractional CO2 laser and topical estrogen groups for treating urinary symptoms related to the genitourinary syndrome of menopause. Further controlled and randomized studies are needed. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Vaginal axis after abdominal sacrocolpopexy versus vaginal sacrospinous fixation-a randomized trial.

AIMS: To compare postoperative vaginal axis (VA) following vaginal sacrospinous fixation (VSF) or abdominal sacrocolpopexy (ASC) using magnetic resonance imaging (MRI) at postoperative period, in a randomized sample. METHODS: Seventy-one patients randomized to VSF with an anterior mesh or ASC were recruited with a mean 27-month follow-up for pelvic MRI; 40 patients underwent the examination. VA was calculated in relation to the pelvic inclination correction line. All patients were submitted to physical examination according to the pelvic organ prolapse quantification system, subjective impression questionnaires and quality of life (QoL) questionnaires (International Consultation on Incontinence Questionnaire, ICIQ). Objective failure was defined as points Ba, Bp, or C > 0. Subjective cure was defined as questions 5a and 6a from the ICIQ-VS questionnaire equal to zero. RESULTS: VA exhibited two portions (inferior and medium). Mean medium axis was equally more obtuse in VSF (85.9° ± 9.9°; P < 0.001) and ASC (87.1° ± 14.7°; P < 0.001) groups, with no difference between them. Mean inferior axis was more acute for both groups (VSF, 72.5° ± 19.1°, P < 0.001; ASC, 75.7° ± 15.5°, P < 0.001). All women had normal medium axes and 47.5% had inferior axis values above the 95th or below the fifth percentile, without differences regarding type of surgery performed. Women with abnormal vs normal VA did not present any difference regarding pre or postoperative physical examination, demographic characteristics, objective or subjective cure, patient satisfaction, QoL scores, or sexuality. CONCLUSIONS: Both VSF and ASC deviate the physiological VA, both in its medium and inferior portions, where values fall outside normality percentiles. However, this alteration was not associated with worse objective, subjective, QoL, or sexual outcomes.

Adherence and quality of life in women with breast cancer being treated with oral hormone therapy.

PURPOSE: To evaluate adherence to oral hormone therapy (HT) and which factors impact in incomplete adherence and quality of life. METHODS: This was a cross-sectional study. SETTING: Women's Hospital Prof. Dr. José Aristodemo Pinotti. PARTICIPANTS: women with breast cancer under treatment with oral HT. MAIN OUTCOME MEASURES: interview and performed an adherence questionnaire (Morisky-Green) and two questionnaires of quality of life (EORTC-QLQ30/BR23). The interviews were done once in a 5-month period. RESULTS: Fifty-eight women were interviewed: 42 under treatment with tamoxifen (TX) and 16 under treatment with aromatase inhibitor (AI). Twenty-six women (44%) showed high adherence to the treatment, 31 (54%) medium adherence, and 1 (2%) low adherence. Statistical analysis showed a relation between incomplete adherence and systemic therapy side effects as well as higher stages of disease, with no difference between the two drugs. When treatments were compared, this study showed treatment with AI presented less breast symptoms and better role functioning. Quality of life score was high, compared to the reference value. CONCLUSIONS: A low percentage of women with breast cancer were highly adherent to HT treatment. Low/medium adherence was associated with higher stages of disease and systemic side effects. Quality of life had high scores, with better role function and less breast symptoms in women being treated with an AI.

The Impact of Bariatric Surgery on Pelvic Floor Dysfunction: A Systematic Review.

OBJECTIVE: To determine the effect of bariatric surgery (BS) on the prevalence of pelvic floor dysfunctions (PFD), specifically on urinary incontinence (UI), pelvic organ prolapse (POP), and fecal incontinence (FI). DATA SOURCES: A systematic review (PROSPERO registration no. CRD42017068452) with a literature search was performed using the PubMed, Scopus, and SciELO databases for all publications related to BS and PFD, with no language restrictions, from inception to September 2018. METHODS OF STUDY SELECTION: Two authors screened for study eligibility and extracted data. Only prospective cohorts assessing women with morbid obesity and the prevalence of PFD before and after BS in multiple academic and private centers were included. UI, POP, and FI were defined according to the International Urogynecological Association/International Continence Society joint consensus, and diagnosis was made based on self-report or questionnaires. TABULATION, INTEGRATION, AND RESULTS: Our search strategy retrieved 957 results. Of those, 28 studies were included for full analysis, and 20 studies (n = 3684 patients) were selected for final analysis. The main reasons for exclusion were missing data before and after BS (n = 7) and combined data of men and women who underwent BS (n = 1). Laparoscopic Roux-en-Y gastric bypass was the most common surgical technique. Pooled analysis (16 studies) showed that women had a mean body mass index reduction of 12.90 kg/m2 after treatment (95% confidence interval [CI], -14.82 to -10.97; p < .0001). The relative risk reduction was 67% (n = 19; odds ratio [OR], 0.33; 95% CI, 0.26-0.41; p < .0001) for UI, 52% (n = 5; OR, 0.48; 95% CI, 0.22-1.07; p = .07) for POP, and 20% (n = 9; OR, 0.80; 95% CI, 0.53-1.21; p = .29) for FI. Funnel plots for UI and FI did not suggest any publication bias. With regard to the standardized questionnaires for PFD, the International Consultation on Incontinence-Short Form, Pelvic Floor Impact Questionnaire-7 and its subscale Colorectal-Anal Impact Questionnaire-7, Pelvic Floor Distress Inventory-20, and its subscale Urinary Distress Inventory-6 showed statistically significantly lower scores. Sexual function, represented by the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12, showed no statistically significant improvement after surgery. CONCLUSION: BS has a significant impact on reducing UI, but FI and POP, in obese women.

Severe depression and anxiety in women with overactive bladder.

AIM: Depression and anxiety are prevalent psychiatric conditions and are associated with overactive bladder. The objective of this study was to determine prevalence and severity of anxiety and depression associated with overactive bladder (OAB) in women. METHODS: 274 women with clinical diagnosis of OAB were recruited from 2012 to 2015. They were submitted to the International Consultation on Incontinence Questionnaire-Overactive Bladder (ICIQ-OAB), the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI). RESULTS: Severe or moderate depression was present in 59.8% of women and severe or moderate anxiety was identified in 62.4%. Higher scores of depression and anxiety were associated with higher scores of ICIQ-OAB (P = 0.0031 and 0.0049). Women with severe depression had higher nocturia score than those with mild depression (P = 0.0046). Also, women with severe depression had higher urgency incontinence score than those with minimal depression (P = 0.0261). Patients with severe anxiety had higher nocturia score than those with minimal anxiety (P = 0.0118) and women with moderate anxiety had higher urgency incontinence score than with minimal anxiety (P = 0.0300). CONCLUSIONS: Moderate or severe depression and anxiety are prevalent in women with OAB. There is a correlation between intensity of OAB symptoms with depression and anxiety. Anxiety and depression levels are mainly related with urgency incontinence and nocturia.

Does the Severity of Overactive Bladder Symptoms Correlate With Risk for Female Sexual Dysfunction?

BACKGROUND: Several studies have associated overactive bladder (OAB) with female sexual dysfunction (FSD); however, there are no reports using a quantitative approach to measure OAB severity and to relate OAB to the risk of FSD. AIM: To evaluate women with OAB and to correlate the severity of their urinary symptoms with their sexual function. METHODS: This cross-sectional study included 267 women older than 18 years with untreated OAB. All subjects completed the International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB) and the Female Sexual Function Index (FSFI). OUTCOMES: Linear regression was used to analyze the association between variables and the numeric FSFI score, and categorical FSFI scores were analyzed using logistic regression. Spearman rank correlation coefficient was used to assess the correlation between ICIQ-OAB results and the different FSFI domains. The significance level was 5%. RESULTS: Subjects' mean age was 50.2 ± 11.9 years. Most women were married, had at least three children, and were postmenopausal (54.3%). Mean FSFI total score was 19.2 ± 9.8. For menopausal status, 65.6% of premenopausal women had a risk for FSD vs 86.2% of postmenopausal women. Mean ICIQ-OAB score was 10 ± 3.17. Postmenopausal women had the following risk factors statistically associated with sexual dysfunction: age, ICIQ score, and marital status. For these women, greater OAB severity, especially those with urgency and/or urge incontinence, was associated with worse scores in the arousal, lubrication, orgasm, and sexual pain domains. However, there was no statistically significant association for premenopausal women. CLINICAL IMPLICATIONS: Health professionals have to pay attention to OAB in women because of the greater risk for FSD in these patients. STRENGTHS AND LIMITATIONS: The strength was using a quantitative approach to measure OAB severity in a larger population. Limitations include a convenience sample with no power calculation; exclusion of women who did not have sexual intercourse in the past month; unmeasured distress caused by sexual disorders; and the impossibility of establishing causality between OAB and sexual dysfunction. CONCLUSION: Women with OAB frequently have a risk for sexual dysfunction. In the postmenopausal group, women with scores indicating severe OAB had worse sexual function, mainly in the arousal, lubrication, orgasm, pain, and total domains. Juliato CRT, Melotti IGR, Junior LCS, et al. Does the Severity of Overactive Bladder Symptoms Correlate With Risk for Female Sexual Dysfunction? J Sex Med 2017;14:904-909.