A Roadmap for Training in Urogynecology: IUGA International Initiative.

INTRODUCTION AND HYPOTHESIS: Training in urogynecology is an important mission of the International Urogynecological Association (IUGA). Promoting official training programs in countries around the world is an integral part of this mission. METHODS: The IUGA established the Fellowship Development Committee to develop a roadmap to assist countries to develop a professional training program in urogynecology. Two focus groups were created: the curricula topics focus group and the survey focus group. The curricula topics focus group is aimed at developing a list of subjects that can be the basis for a training syllabus. The survey focus group is aimed at understanding the main steps and the difficulties in establishing an official training program by interviewing representatives from both accredited and non-accredited countries and developing a roadmap for an official training program recognized by the local authorities. RESULTS: The fellowship development committee included 13 members. The curricula topics focus group developed a format for the description of each included topic. Each topic had to include a description of the required related skills and procedures. Two curricula topics lists were created: one for basic training and a second for advanced training. The survey focus group conducted two table discussions with representatives from countries with accredited training programs and countries without accredited training programs. The comments of these meetings were summarized in documents submitted to the IUGA board of directors. CONCLUSION: The fellowship development committee studied the main hurdles to developing an official training program in urogynecology. The roadmap document should form the basis of the IUGA international initiative to assist countries around the world to develop an official training program in urogynecology recognized by the local authority.

Systematic Review and Meta-analysis of the Prevalence of Levator Ani Avulsion with Obstetric Anal Sphincter Injury and its Effects on Pelvic Floor Dysfunction.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the prevalence of levator ani avulsion (LAA) among primiparous women with obstetric anal sphincter injury (OASI) and how this association could affect future pelvic floor dysfunction. METHODS: Three electronic databases (MEDLINE/PubMed/EMBASE) were searched in December 2018 and again in October 2022. Nine full-text articles were included in the analysis. The exclusion criteria were language other than English, studies not based on primiparous women only, conference abstracts, and evaluation without ultrasound or MRI. RESULTS: The overall prevalence of LAA was 24% (95% CI: 18-30%). Those with OASI, were at a higher risk of LAA, OR 3.49 (95% CI: 1.46 to 8.35). In women with LAA + OASI versus OASI alone, Three of Five studies showed worsened AI symptoms. Three of Five studies assessing urinary incontinence (UI) reported no significant difference in UI, whereas two reported increased UI. All studies that looked at pelvic organ prolapse reported a higher incidence of symptomatic prolapse and reduced pelvic floor muscle strength in women with LAA + OASI compared with those without LAA. CONCLUSION: Levator ani avulsion is prevalent following vaginal birth and is strongly associated with OASI. Incidence of AI does not increase in women with LAA and OASI, but they had greater symptom bother. OASI with LAA appears to increase the incidence of pelvic floor weakness and pelvic organ prolapse. There is no consensus agreement on the effect of LAA + OASI on UI.

Management of mid-urethral tape complications: a retrospective study.

BACKGROUND/PURPOSE OF THE STUDY: Following mid-urethral tape insertion, for stress urinary incontinence (SUI), a proportion of women experience complications such as voiding dysfunction or tape erosion which fail to respond to conservative management approaches. These women thus require further surgical treatment. Our objective was to describe the outcomes of the surgical management of complications in these women. METHODS: This retrospective study describes the results obtained following the surgical management of mid-urethral tape complications. Twenty-nine consecutive women who required mid-urethral tape lysis, loosening or excision for tape-related complications in the period 2007-2017 were included. Primary outcomes were improvement in voiding dysfunction and resolution of pain, while secondary outcomes were evaluation of the recurrence of stress urinary incontinence and patient satisfaction. Patient outcomes were measured using the Patient Global Impression of Improvement questionnaire. RESULTS: There were 1459 mid-urethral tape procedures performed in the study period. Twenty-nine women (1.99%) who had revision surgery for tape complication were identified. Interventions included tape loosening or lysis in 19 women and tape excision in ten women. Twenty-three of the 29 patients reported a significant improvement in their symptoms postoperatively. Two women had a recurrence of SUI in the tape excision cohort; all patients following tape loosening or lysis remained continent. CONCLUSIONS: Tape revision surgery is a safe and effective treatment for mid-urethral tape complications with the majority of women maintaining continence following revision. Early intervention and proactive management of complications, by the appropriate specialist, will improve outcomes.

Interventions to reduce morbidity from vault hematoma following vaginal hysterectomy: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: A frequent complication following vaginal hysterectomy is the formation of vaginal vault hematoma. The objective of our systematic review was to assess the impact of various interventions in reducing the incidence of vault hematoma or postoperative febrile morbidity following vaginal hysterectomy. METHODS: We carried out a systematic search of Cochrane, MEDLINE, Embase, CINAHL, HTA database, PROSPERO, meta-Register of Controlled Trials (mRCT), PubMed, CENTRAL, Google Scholar, conference abstracts, and a hand search of journals from inception until September 2018. Our search strategy included interventions in women undergoing vaginal hysterectomy with modified vault closure with inclusion of peritoneal edges, vaginal vault drainage, or vaginal packing to reduce the incidence of clinically significant vault hematomas. Two independent reviewers (SR and AD) extracted data using a structured proforma. Meta-analysis was carried out using RevMan 5.3 software. RESULTS: We identified two studies on modified vaginal vault closure incorporating peritoneal edges that reported a significant reduction in vault hematoma incidence. Meta-analysis of two randomized trials on vaginal drains showed no difference in postoperative febrile morbidity secondary to vault hematoma [risk ratio (RR) 0.8, 95% confidence intervals (CI) 0.43-1.50]. Similar results were seen on meta-analysis of four randomized trials on the use of vaginal packing (RR 0.8, 95% CI 0.43-1.50). CONCLUSIONS: Inclusion of peritoneal edges in vaginal vault closure may reduce the incidence of vault hematoma. The routine use of vaginal vault drainage and/or packing has not shown to reduce vault hematoma incidence or postoperative febrile morbidity. We recommend a change of practice to include peritoneal edges in vault closure based on the evidence available in our systematic review.

Should maximal urethral closure pressure be performed before midurethral sling surgery for stress incontinence? A time to revisit.

INTRODUCTION AND HYPOTHESIS: Maximum urethral closure pressure (MUCP) provides an objective assessment of urethral integrity, but its role in predicting outcome after midurethral sling (MUS) placement is debatable and current practice in the UK is variable. The study was carried out to determine if lower preoperative MUCP is associated with poor outcome following MUS. METHOD: The study was a retrospective review of the British Society of Urogynaecology (BSUG) database and urodynamics (UDS) data. Patients who reported outcome as "no improvement", "worse" or "much worse" on the Patient Global Impression of Improvement (PGII) scale were identified as having a poor outcome. Patients who reported "a little improvement", "improved" and "very much improved" on the PGII were thought to have a good outcome. The preoperative demographics, UDS findings and quality of life (International Consultation of Incontinence questionnaires [ICIQ-SF]) data of the two groups were compared. RESULT: A total of 236 women were identified for the study. Of these, 24 women (10.2 %) had a poor outcome. Of the remaining women reporting a good outcome, 50 cases were randomly selected. All urodynamic parameters, including mean functional urethral length (FUL), bladder capacity, and Qmax, were similar, except for mean MUCP 37.05 cm H2O, which was significantly lower in group 1 (poor outcome 37.05 cm H2O) compared with a mean MUCP of 50.6 cm H2O in group 2 (good outcome; p = 0.005). CONCLUSION: We conclude that failure following MUS is associated with preoperatively lower MUCP, which can be used as a predictor of failure.

The personal impact of pelvic floor symptoms and their relationship to age.

INTRODUCTION AND HYPOTHESIS: The aim was to evaluate the relationship between age and the impact of pelvic floor disorders (PFD) using a multi-dimensional pelvic floor questionnaire METHODS: Questionnaire data on 4,311 women attending urogynaecology clinics with PFD were stratified by age into four groups: ≤35, 36-50, 51-65 and >65 years. The symptom frequency (ranging from 0 to 100) was divided in to mild (0-33), moderate (34-67), and severe (68-100) symptoms. Impact scores for equivalent levels of symptom frequency (mild, moderate and severe symptoms) were compared in women of different ages. RESULTS: Overall, bowel continence was associated with the greatest bother and constipation the least. Older women were significantly less bothered by mild to moderate urinary, bowel and vaginal symptoms (except IBS and vaginal capacity) than younger women. There was no difference in the impact of severe symptoms in different ages. In contrast, for sexual symptoms, there was a significant difference in the impact in older women for all grades of severity. CONCLUSIONS: Women's views and attitudes towards symptoms are variable and age is a significant factor. In women attending urogynaecology clinics with pelvic floor symptoms the impact of most symptoms (particularly sexual dysfunction) become less bothersome with age.

Understanding women's experiences of electronic interviewing during the clinical episode in urogynaecology: a qualitative study.

INTRODUCTION AND HYPOTHESIS: Questionnaires for assessing health and related quality of life are increasingly advocated but little is known about women's views on them. The aim of the study was to understand women's experiences of using an electronic personal assessment questionnaire for pelvic floor disorders (ePAQ-PF) during the clinical episode. METHODS: A qualitative study was performed in a tertiary referral centre for urogynaecology. Women who completed the electronic questionnaire (ePAQ-PF) before and after intervention for pelvic floor disorders were recruited. Semi-structured interviews were conducted in 20 women and the transcripts were analysed using a thematic approach to identify themes and categories. The main outcome measures were: (1) women's feelings about their experience of using the questionnaire and the impact it had on their clinical episode, (2) exploration of ways in which the questionnaire influenced communication, (3) influence of the questionnaire on anxiety and expectations relating to clinical care and (4) women's feelings about how the use of the questionnaire has affected their health and well-being. RESULTS: Qualitative analysis identified eight themes relating to the burden and the benefit of questionnaire use with 'benefit' being the dominant theme. Women felt that the questionnaire improved their understanding of their condition, improved communication with clinicians and helped prepare them for clinical consultations, generally finding it relevant, easy and enjoyable to complete. Some women commented on the burden of questionnaire use and expressed concerns about its length and that it's closed multiple choice format was restrictive. CONCLUSIONS: The identified principal themes of enhanced communication and preparedness for clinical consultation provided by the questionnaire appeared to support improved focus and insight, which in turn contributed to the setting of realistic expectations.

The effect of prolapse repair on sexual function in women.

INTRODUCTION: Sexual dysfunction is common in women with pelvic organ prolapse (POP). Treatment of symptomatic prolapse often requires surgery. The outcome of prolapse symptoms following surgery is well studied and reported, but evidence on outcomes of sexual function following pelvic reconstructive surgeries is limited. AIM: The objective of this study was to assess the impact of different forms of surgery for POP on sexual function using prospectively collected data. METHODS: In this ethically approved project, data were collected prospectively for women undergoing prolapse repair between 2008 and 2010 and were stratified into four groups: "posterior repair,""anterior repair,""anterior repair with vaginal hysterectomy," and "combined anterior and posterior repair." The electronic personal assessment questionnaire-pelvic floor (ePAQ-PF) was used to assess symptoms. The sexual dimension of ePAQ-PF computes domain scores for sexual dysfunction secondary to vaginal symptoms and dyspareunia on a scale of 0-100 (0 = best possible and 100 = worst possible health status). ePAQ-PF was completed in 123 sexually active women both pre- and 3-6 month postoperatively. Results were analyzed using SPSS (SPSS Inc., Chicago, IL, USA). Pre- and postoperative scores for each domain were compared in all groups (Student's t-test). Individual symptoms in these domains were compared using Wilcoxon signed-rank test. MAIN OUTCOME MEASURES: Change in sexual symptoms and dyspareunia following prolapse surgery in each group. RESULTS: Women undergoing anterior repair or anterior repair and vaginal hysterectomy reported significant improvement in sexual symptoms and dyspareunia. Women undergoing a posterior repair in isolation had improved sexual function following surgery though improvement in dyspareunia was not significant. Women undergoing combined anterior and posterior repair had the least improvement in sexual function. CONCLUSIONS: Sexual function improves in women following pelvic reconstructive surgery, but the improvement is more substantial following anterior repair either alone or in combination with a vaginal hysterectomy when compared with posterior repair.

The effect of posterior colporrhaphy on anorectal function.

INTRODUCTION AND HYPOTHESIS: The objective of this study is to determine the effect of posterior colporrhaphy on bowel symptoms. METHODS: Comprehensive pelvic floor data were collected prospectively for 60 women undergoing posterior colporrhaphy. The electronic Personal Assessment Questionnaire-Pelvic Floor (ePAQ-PF) was completed at initial assessment and 3-6 months post-operatively. The bowel dimension of ePAQ-PF computes domain scores for IBS, constipation, evacuation, continence and QoL on a scale of 0-100. Preoperative bowel domain scores were compared with post-operative scores (Student t test). RESULTS: Significant improvement was seen in bowel evacuation (42%), continence (37%) and bowel-related QoL (61%) scores. IBS score improved by 28%, but this did not reach significance. There was no significant change noted in constipation (0.5%). All individual symptoms relating to bowel evacuation and continence improved significantly other than painful evacuation and incontinence to solid stool. CONCLUSIONS: Bowel evacuation and continence improve significantly 3-6 months following posterior colporrhaphy and are associated with parallel improvement in QoL.

Perineal length: norms in gravid women in the first stage of labour.

INTRODUCTION: The purpose of this study was to generate normative data for perineal length for Caucasian and Asian women in labour. METHODS: The distance from the posterior fourchette to the centre of the anal orifice was measured in 1,000 women in the first stage of labour. Data on ethnicity, body mass index, delivery mode and perineal trauma were collected prospectively. RESULTS: The mean perineal length in Caucasian women was 3.7 +/- 0.9 cm and in Asian women, 3.6 +/- 0.9 cm. Primigravid women with short perineum were more likely to have a third-degree perineal tear in labour (p = 0.03). CONCLUSION: This is the first paper to report normative data for perineal length in Caucasian and Asian women in labour. We found a negative correlation between perineal length and third-degree tear in primigravid women. These data may be useful in clinical practice to determine the risk of significant perineal tears in labour.