Proper understanding of recurrent stress urinary incontinence treatment in women (PURSUIT): a randomised controlled trial of endoscopic and surgical treatment.

BACKGROUND: Women with stress urinary incontinence (SUI) experience urine leakage with physical activity. Currently, the interventional treatments for SUI are surgical, or endoscopic bulking injection(s). However, these procedures are not always successful, and symptoms can persist or come back after treatment, categorised as recurrent SUI. There are longstanding symptoms and distress associated with a failed primary treatment, and currently, there is no consensus on how best to treat women with recurrent, or persistent, SUI. METHODS: A two-arm trial, set in at least 20 National Health Service (NHS) urology and urogynaecology referral units in the UK, randomising 250 adult women with recurrent or persistent SUI 1:1 to receive either an endoscopic intervention (endoscopic bulking injections) or a standard NHS surgical intervention, currently colposuspension, autologous fascial sling or artificial urinary sphincter. The aim of the trial is to determine whether surgical treatment is superior to endoscopic bulking injections in terms of symptom severity at 1 year after randomisation. This primary outcome will be measured using the patient-reported International Consultation on Incontinence Questionnaire - Urinary Incontinence - Short Form (ICIQ-UI-SF). Secondary outcomes include assessment of longer-term clinical impact, improvement of symptoms, safety, operative assessments, sexual function, cost-effectiveness and an evaluation of patients' and clinicians' views and experiences of the interventions. DISCUSSION: There is a lack of high-quality, randomised, scientific evidence for which treatment is best for women presenting with recurrent SUI. The PURSUIT study will benefit healthcare professionals and patients and provide robust evidence to guide further treatment and improve symptoms and quality of life for women with this condition. TRIAL REGISTRATION: International Standard Randomised Controlled Trials Number (ISRCTN) registry ISRCTN12201059. Registered on 09 January 2020.

Urinary incontinence persisting after childbirth: extent, delivery history, and effects in a 12-year longitudinal cohort study.

OBJECTIVE: To investigate the extent of persistent urinary incontinence (UI) 12 years after birth, and association with delivery-mode history and other factors. DESIGN: Twelve-year longitudinal cohort study. SETTING: Maternity units in Aberdeen, Birmingham, and Dunedin. POPULATION: Women who returned questionnaires 3 months and 12 years after index birth. METHODS: Data on all births over a period of 12 months were obtained from the units and then women were contacted by post. MAIN OUTCOME MEASURE: Persistent UI reported at 12 years, with one or more previous contact. RESULTS: Of 7879 women recruited at 3 months, 3763 (48%) responded at 12 years, with 2944 also having responded at 6 years; non-responders had similar obstetric characteristics. The prevalence of persistent UI was 37.9% (1429/3763). Among those who had reported UI at 3 months, 76.4% reported it at 12 years. Women with persistent UI had lower SF12 quality of life scores. Compared with having only spontaneous vaginal deliveries (SVDs), women who delivered exclusively by caesarean section were less likely to have persistent UI (odds ratio, OR 0.42, 95% CI 0.33-0.54). This was not the case in women who had a combination of caesarean section and SVD births (OR 1.01, 95% CI 0.78-1.30). Older age at first birth, greater parity, and overweight/obesity were associated with persistent UI. Of 54 index primiparae with UI before pregnancy, 46 (85.2%) had persistent UI. CONCLUSIONS: This study, demonstrating that UI persists to 12 years in about three-quarters of women, and that risk was only reduced with caesarean section if women had no other delivery mode, has practice implications. TWEETABLE ABSTRACT: A longitudinal study of 3763 women showed a prevalence of persistent UI 12 years after birth of 37.9%.

Effect of anticholinergics on the overactive bladder and bowel domain of the electronic personal assessment questionnaire (ePAQ).

INTRODUCTION AND HYPOTHESIS: Evidence suggests that OAB (overactive bladder) can occur alongside disorders of the colon, such as irritable bowel syndrome (IBS). Moreover, patients with constipation are more likely to develop OAB symptoms than those without. Anticholinergic medications (AcH) are commonly used for treating OAB, and can result in the unwanted side effects of constipation. We aimed to study the relationship of AcH, and their effects on quality of life using the electronic Personal Assessment Questionnaire (ePAQ) by assessing changes in the bowel and bladder domains, pre- and post-AcH treatment. METHODS: Ninety patients completed the ePAQ pre- and post-AcH treatment from January 2011 to April 2014. Data were collected retrospectively and prospectively, and analysed using a paired t test. Effect size (ES) was calculated for OAB and bowel domains to quantify the effect on QoL. RESULTS: There was a significant improvement in the OAB (p = 0.0005) and bowel domains (p = 0.0005). In the bowel domains, the largest effect size was seen for IBS (0.5) followed by continence (0.4), evacuation (0.375) and a small ES was seen for constipation (0.2). There was a reduction in the "degree of bother" in OAB and bowel domains. CONCLUSIONS: Patients may benefit from the possible effects of AcH on their bowels, and assessment of all aspects of pelvic floor function is important before commencing AcH. This may help to counsel patients, with possibly improved compliance with therapy.

Impact of ethnicity on urodynamic outcomes.

The aim of this study was to assess the impact of ethnicity on urodynamic outcomes. The urodynamic studies (UDS) of 100 women were analysed; 41 were of white Caucasian origin, 35 of Asian origin and 24 of African origin. The presence of detrusor overactivity (DOA) in the three ethnic groups was compared and the nature of DOA in terms of cystometric capacity, volume of strong desire, maximum flow rate (Qmax), volume at which DOA occurred, mean amplitude of contraction and number of contractions, were compared. Asian (p < 0.003) and African (p < 0.008) women were more likely to have a diagnosis of DOA compared with white Caucasian women. There was no difference in UDS outcomes when comparing Asian and African Women. The ethnicity did not appear to impact significantly on the nature of the DOA. Women of Asian and African origin attending for UDS presented with DOA more commonly than those of white Caucasian origin.

Cervical cerclage and type of suture material: a survey of UK consultants' practice.

OBJECTIVE: The main aim of the survey was to explore current practices with regards to cervical cerclage procedures amongst UK consultants with particular emphasis on the type of suture material used. METHODS: An electronic survey of UK consultant members and fellows of the Royal College of Obstetricians and Gynaecologists and who previously agreed to be contacted for survey purposes. RESULTS: There were 261 respondents to the survey and 88% routinely performed cerclage. The majority performed the procedure between 12 and 16 weeks' gestation (88.7%; n = 180/203), following the McDonald technique (83.4%; n = 166/199) and using a braided suture material (86.6%; n = 175/202). Although only 27 of the 202 responders (13.4%) used a monofilament suture for cerclage (75%; n = 149/201) of clinicians stated that they were not sure what is the best suture material to be used. CONCLUSION: There is considerable variation in practice amongst Consultant obstetricians with regards to cervical cerclage. Although most respondents use the traditional braided suture material, a significant proportion of them were not sure what is the best suture material to use. The "gestation at delivery" rate was judged to be the most important outcome for a future study.

Bladder exstrophy combined with uterovaginal prolapse and its surgical management: case report and literature review.

We describe a case of a postmenopausal woman with a corrected bladder exstrophy (BE) who presented with a uterovaginal prolapse complicated by calcified fibroids and discuss its surgical management. A 51-year-old woman presented with a uterovaginal prolapse. She had previously had one full term delivery by caesarean section 20 years ago. She had an ileal conduit performed for her BE at birth. A computed tomography scan revealed significant pelvic anomaly and the uterus contained multiple calcified fibroids. Due to the complexity of her condition the surgical management was planned in two stages: initial examination under anaesthetic in conjunction with a consultant urologist and then the definitive planned reconstructive surgery. This case describes the need for careful evaluation and planning of complex surgery and the successful surgical management option for correction of uterovaginal prolapse in patients with BE. A vaginal approach seemed to be a most sensible route to correct the prolapse in view of her previous multiple abdominal surgeries.

Bladder perforation during sling procedures: diagnosis and management of injury.

INTRODUCTION AND HYPOTHESIS: Midurethral slings are an effective and minimally invasive treatment for stress urinary incontinence. One of the most common intraoperative complications is bladder perforation, complicating between 2 and 10% of all operations, and on average 4.7%. It is usually corrected during surgery, with repositioning of the trocars. The purpose of this video is to demonstrate a method of replacing the trocars under direct vision. METHODS: This video exhibits a bladder perforation during insertion of a retropubic midurethral sling (Advantage Fit; Boston Scientific) and gives a step-by step guide to the removal and repositioning of the sling under direct visualisation. CONCLUSION: Repositioning of the trocars under direct vision in cases of bladder perforation may have numerous advantages. It may prevent damage to the urethra, possibly reduce the risk of postoperative infection and may be beneficial for trainees.

Pregnancy outcome after elective cervical cerclage in relation to type of suture material used.

Cervical weakness is an important cause of late miscarriage and extreme preterm labour. Women have been traditionally offered a cervical cerclage procedure, though studies failed to demonstrate a therapeutic effect. None of these studies has addressed the effect of non-braided to braided suture material on cerclage outcome. Type of suture material is an important determinant of surgical outcomes. This issue is of particular relevance to cerclage because the traditionally braided suture has been associated with increased risk of infection in other surgical procedures. Indeed, infection is an important underlying cause for cerclage failure. It is for this reason that some surgeons use non-braided suture material. Therefore, we hypothesise that the unrealised benefit of cervical cerclage is at least in part due to the type of suture material used. In this article, we present the rationale behind our hypothesis and a proposed way of testing it.

Childbirth and prolapse: long-term associations with the symptoms and objective measurement of pelvic organ prolapse.

OBJECTIVES: To investigate prolapse symptoms and objectively measured pelvic organ prolapse, 12 years after childbirth, and association with delivery mode history. DESIGN: Twelve-year longitudinal study. SETTING: Maternity units in Aberdeen, Birmingham and Dunedin. POPULATION: Women dwelling in the community. METHODS: Data from women were collected 12 years after an index birth and women were invited for examination. Logistic regression investigated associations between risk factors and prolapse symptoms and signs. MAIN OUTCOME MEASURES: Prolapse symptom score (POP-SS); objectively measured prolapse (POP-Q). RESULTS: Of 7725 continuing women, 3763 (49%) returned questionnaires at 12 years. The median POP-SS score was 2 (IQR 0-4). One or more forceps deliveries (OR 1.20, 95% CI 1.04-1.38) and a body mass index (BMI) over 25 were associated with higher (worse) POP-SS scores, but age over 25 years at first delivery was associated with lower (better) scores. There was no protective effect if all deliveries were by caesarean section (OR 0.84, 95% CI 0.69-1.02). Objective prolapse was found in 182/762 (24%) women. Women aged over 30 years when having their first baby and parity were significantly associated with prolapse. Compared with women whose births were all spontaneous vaginal deliveries, women who had all births by caesarean section were the least likely to have prolapse (OR 0.11, 95% CI 0.03-0.38), and there was a reduced risk after forceps or a mixture of spontaneous vaginal delivery and caesarean section. CONCLUSIONS: These findings are at odds with each other, suggesting that prolapse symptoms and objective prolapse may not be in concordance, or are associated with different antecedent factors. Further follow-up is planned.

Faecal incontinence persisting after childbirth: a 12 year longitudinal study.

OBJECTIVES: To investigate persistent faecal incontinence (FI) 12 years after birth and association with delivery mode history and quality of life. DESIGN: Twelve-year longitudinal study. SETTING: Maternity units in Aberdeen, Birmingham and Dunedin. POPULATION: Women who returned questionnaires 3 months and 12 years after index birth. METHODS: Data on all births over 12 months were obtained from units and women were contacted 3 months, 6 years and 12 years post birth. MAIN OUTCOME MEASURE: Persistent FI, defined as reported at 12 years and one or more previous contacts. SF12 assessed quality of life. RESULTS: Of 7879 women recruited at 3 months, 3763 responded at 12 years, 2944 of whom also responded at 6 years: nonresponders were similar in obstetric factors. Prevalence of persistent FI was 6.0% (227/3763); 43% of 12-year responders who reported FI at 3 months also reported it at 12 years. Women with persistent FI had significantly lower SF12 scores. Compared with only spontaneous vaginal deliveries, women who had one or more forceps delivery were more likely to have persistent FI (odds ratio [OR] 2.08, 95% confidence interval [95% CI] 1.53-2.85) but it was no less likely with exclusively caesarean births (OR 0.93, 95% CI 0.54-1.58). More obese women than normal weight women reported persistent FI (OR 1.52, 95% CI 1.06-2.17). CONCLUSIONS: This longitudinal study has demonstrated persistence of FI many years after birth and shown that one forceps birth increased the likelihood, whereas exclusive caesarean birth showed no association. Obesity, which increased symptom likelihood, is a modifiable risk factor.

Anaesthesia for incontinence surgery: spinal anaesthesia or sedation?

This was a patient and assessor blinded randomised controlled trial to compare the patient and surgeon's satisfaction for retropubic tapes inserted under sedation vs spinal anaesthesia and also looking at the bladder sensation following insertion of the tape. A total of 38 patients completed the study (19 in each group). The differences in mean visual analogue scores were in favour of spinal anaesthesia. The surgeon's assessment of patient cooperation was 24.2, 95% CI 9.6-38.8 p = 0.002, while for pain, the difference in the mean scores was -21.6, 95% CI -36.6 to -6.5, p = 0.006. The difference in the mean scores for the feeling of being in control was 21.4, 95% CI 0.85 to 41.63, p = 0.004. The only significant difference in bladder sensation postoperatively was the strong desire to void at 1 hour. This study demonstrates that spinal anaesthesia has better patient and surgeon satisfaction, with a difference in bladder sensation at 1 hour postoperatively.

Colposuspension or TVT with anterior repair for urinary incontinence and prolapse: results of and lessons from a pilot randomised patient-preference study (CARPET 1).

In a multicentre randomised, unblinded patient preference pilot trial to assess the feasibility of a definitive randomised trial comparing colposuspension with tension-free vaginal tape (TVT) plus anterior repair in women with incontinence and prolapse, we found that 31 of 56 eligible women agreed to participate (55%). Recruitment was more successful face to face (87%) than by letter (16%). Only four of our women agreed to be randomised, 21 (68%) chose anterior repair+TVT and six (19%) chose colposuspension. This study demonstrates the importance of pilot work for complex trials to identify issues likely to adversely affect recruitment.

Mycoplasma and ureaplasma colonisation in women with lower urinary tract symptoms.

To assess the prevalence of mycoplasma and ureaplasma (MH/UU) in women with bladder symptoms with or without sterile pyuria and to assess the effect of long-term (3 months) antibiotics on symptom improvement in women with significant pyuria and positive culture for MH/UU, urine reports on midstream samples of urine sent from urogynaecology department of one tertiary referral centre over 1 year were studied. Notes for sterile pyuria with positive culture for atypical organisms were retrieved and the data were entered onto Microsoft Excel and analysed. A total of 1,032 urine specimens were analysed between January and December 2005. Out of these, 319 were studies for atypical organisms (31%) and 31 of these were samples repeated on the same patients. The total positive culture rate was 33.7% (97/288). The prevalence of ureaplasma only was 26% (75) and combined mycoplasma and ureaplasma was 7.6% (22) in the first test samples. Of the 97 samples that were positive for atypical organisms, 34% (33) were also positive for typical organisms. Out of the 14 case notes studied, 10 women reported improvement of symptoms (71.4%) with 3 months of antibiotics and 2/9 who had repeat culture were positive for ureaplasma in spite of improvement in symptoms. There was no correlation found for co-existence of typical and atypical UTI or for sterile pyuria and mycoplasma/ureaplasma colonisation. There is a trend towards improvement of symptoms following long-term (3 months) antibiotics in women who have positive culture of MH/UU. A larger prospective randomised controlled trial is necessary to assess the effectiveness of this intervention.

Does preoperative urodynamics change the management of prolapse?

The objective of this study was to evaluate whether preoperative urodynamics (UDS) changed the management of patients undergoing prolapse surgery, and if so in what way. A retrospective study of 72 randomly selected cases was conducted. We assessed which women undergoing prolapse surgery were more likely to undergo UDS and in what way UDS altered management. SPSS version 13 was used to analyse the data. A total of 60% (43/72) of the patients underwent preoperative UDS and 53% (23/43) of the women undergoing UDS had an abnormal result with prolapse reduction; 19% (8/43) had pure urodynamic stress incontinence; 30% (13/43) had detrusor overactivity either in isolation or as mixed incontinence. The surgical management was altered in 7% (3/43), who had an additional continence procedure performed as a consequence of the UDS. Preoperative UDS changed management in 33% (14/43) patients and in 7% (3/43 undergoing UDS) of patients, the surgical procedure was changed.

Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review.

OBJECTIVES: To assess if mode of delivery is associated with increased symptoms of anal incontinence following childbirth. DESIGN: Systematic review of all relevant studies in English. DATA SOURCES: Medline, Embase, Cochrane Library, bibliographies of retrieved primary articles and consultation with experts. STUDY SELECTION AND DATA EXTRACTION: Data were extracted on study characteristics, quality and results. Exposure to risk factors was compared between women with and without anal incontinence. Categorical data in 2 x 2 contingency tables were used to generate odds ratios. RESULTS: Eighteen studies met the inclusion criteria with 12,237 participants. Women having any type of vaginal delivery compared with a caesarean section have an increased risk of developing symptoms of solid, liquid or flatus anal incontinence. The risk varies with the mode of delivery ranging from a doubled risk with a forceps delivery (OR 2.01, 95% CI 1.47-2.74, P < 0.0001) to a third increased risk for a spontaneous vaginal delivery (OR 1.32, 95% CI 1.04-1.68, P = 0.02). Instrumental deliveries also resulted in more symptoms of anal incontinence when compared with spontaneous vaginal delivery (OR 1.47, 95% CI 1.22-1.78). This was statistically significant for forceps deliveries alone (OR 1.5, 95% CI 1.19-1.89, P = 0.0006) but not for ventouse deliveries (OR 1.31, 95% CI 0.97-1.77, P = 0.08). When symptoms of solid and liquid anal incontinence alone were assessed, these trends persisted but were no longer statistically significant. CONCLUSION: Symptoms of anal incontinence in the first year postpartum are associated with mode of delivery.

Direct imaging of the pelvic floor muscles using two-dimensional ultrasound: a comparison of women with urogenital prolapse versus controls.

OBJECTIVE: To evaluate the anatomy of the levator ani muscle in women with urogenital prolapse versus matched controls without prolapse using real-time two-dimensional (2-D) ultrasound. DESIGN: Prospective observational study. SETTING: Tertiary referral urogynaecology unit. POPULATION: Forty-three women with pelvic organ prolapse (POP) and 24 women (controls) attending a gynaecology clinic without prolapse. METHODS: All participants completed a standardised symptom questionnaire. MAIN OUTCOME MEASURES: The morphology of the vagina and paravaginal tissue was recorded at different levels. The thickness of the levator ani and the hiatal area were measured at rest. Reproducibility of the method was assessed by repeated measurements to assess intra-observer variability and inter-observer variability. RESULTS: This method showed good intra-observer and inter-observer reproducibility and reliability. In controls, the pubococcygeus muscle showed more regular echogenicity with no evidence of trauma, whereas in women with prolapse the muscle had mixed echogenicity. (P = 0.002). The mean thickness of the pubococcygeus did not differ between groups. The levator hiatal area was significantly larger in women with pelvic floor prolapse versus controls (17.8 cm2 versus 13.5 cm2, P < 0.001). This increase in hiatal area positively and significantly correlated with prolapse severity (P < 0.001). CONCLUSIONS: Morphology and hiatal area can be reliably imaged using 2-D ultrasound. Prolapse was related to changes in pelvic floor morphology and increased levator hiatal area. The use of 2-D ultrasound provides an important insight into the pathophysiology of prolapse.