The impact of pregnancy and childbirth on pelvic sensation: a prospective cohort study.

Pelvic organ prolapse, urinary, bowel and sexual dysfunction, collectively called pelvic floor dysfunction (PFD) affects 1 in 3 women and has a significant public health impact. The causes of PFD are not fully understood but involve injury to connective tissue and motor nerve during childbirth. Women with PFD also have sensory nerve impairment, and it is likely this occurs during childbirth, but this has never been investigated. In the current study 150 women underwent quantitative sensory testing for vibration sensation at the vagina and clitoris, and stretch sensation at the vagina and introitus, in the third trimester, 3 and 6 months postnatal. Antenatally vibration sensation was reduced but stretch sensation was normal. Postnatally vibration sensation deteriorated whilst stretch sensation initially deteriorated but recovered by 6 months postnatal to antenatal levels (all p < 0.001). Mode of birth had a significant impact on sensation, with caesarean section appearing neuroprotective, normal vaginal birth resulted in a transient deterioration in sensation that recovered by 6 months, whilst assisted vaginal delivery was prolonged suggesting persistent neurological impairment (all p < 0.015). Further research is required to study the clinical effect of these changes on pelvic floor dysfunction in the medium and long-term.

PROSPECT: 4- and 6-year follow-up of a randomised trial of surgery for vaginal prolapse.

INTRODUCTION AND HYPOTHESIS: Our aim was to compare the mid-term results of native tissue, biological xenograft and polypropylene mesh surgery for women with vaginal wall prolapse. METHODS: A total of 1348 women undergoing primary transvaginal repair of an anterior and/or posterior prolapse were recruited between January 2010 and August 2013 from 35 UK centres. They were randomised by remote allocation to native tissue surgery, biological xenograft or polypropylene mesh. We performed both 4- and 6-year follow-up using validated patient-reported outcome measures. RESULTS: At 4 and 6 years post-operation, there was no clinically important difference in Pelvic Organ Prolapse Symptom Score for any of the treatments. Using a strict composite outcome to assess functional cure at 6 years, we found no difference in cure among the three types of surgery. Half the women were cured at 6 years but only 10.3 to 12% of women had undergone further surgery for prolapse. However, 8.4% of women in the mesh group had undergone further surgery for mesh complications. There was no difference in the incidence of chronic pain or dyspareunia between groups. CONCLUSIONS: At the mid-term outcome of 6 years, there is no benefit from augmenting primary prolapse repairs with polypropylene mesh inlays or biological xenografts. There was no evidence that polypropylene mesh inlays caused greater pain or dyspareunia than native tissue repairs.

Public understanding of female genital anatomy and pelvic organ prolapse (POP); a questionnaire-based pilot study.

INTRODUCTION AND HYPOTHESIS: Health literacy underpins informed consent and shared decision-making. In gynaecology, this includes understanding of normal anatomy and urogenital disease. This study evaluated public knowledge of external female genital anatomy and pelvic organ prolapse (POP). METHODS: A questionnaire study asked participants for their demographics and to label a female external genitalia diagram and included free-text questions on POP, its symptoms and treatment. Questionnaires were distributed at general outpatient (OPD) and urogynaecology (UG) departments at a UK teaching hospital. Differences in the number of correct anatomy labels between participant genders were assessed via chi-squared tests and, within female participants, multivariable linear and logistic regressions assessed associations with increasing correct anatomical labels and an understanding (versus no understanding) of POP, respectively. RESULTS: Within 191 (n = 160 OPD, n = 31 UG), 9/103 (9%) labelled all anatomical structures correctly. Females had more correct labels (median 1, IQR 0,3) versus males (median 0, IQR 0,1), P = 0.022). Higher education (vs. < secondary) and white ethnicity were associated with greater numbers of correct labels [coefficient (95% CI): 1.05 (0.14, 1.96), P = 0.024, 1.45 (0.58, 2.33), P = 0.001 respectively]. Fifty-three per cent understood POP. POP understanding increased with increasing age, white ethnicity (OR: 4.38, 95% CI: 1.36, 14.08, P = 0.013) and more correct anatomy labels (OR: 1.43, 95% CI 1.14, 1.79, P = 0.002). Of those who understood POP, only 35% identified "bulge" as a symptom and 7% physiotherapy as a treatment option. CONCLUSION: There was poor public understanding of external female genital anatomy and POP, which may have significant implications for health-seeking, shared decision-making and informed consent.

An assessment of techniques and practices used to elevate intra-abdominal pressure when assessing pelvic floor dysfunction.

AIMS: To determine terminology and methods for raising intra-abdominal pressure (IAP) currently used by clinicians to assess pelvic floor dysfunction (PFD) and to measure the effect of these maneuvers on IAP. METHODS: Three-hundred questionnaires were distributed at two scientific meetings in the United Kingdom to determine methods clinicians used to raise IAP and their perceptions of these methods. Twenty healthy volunteers were also recruited to measure the effect of two methods of raising IAP: Valsalva maneuver (VM) and bear down maneuver (BDM). IAP pressure was measured with rectal catheters connected to pressure sensors. The IAP was measured during each maneuver in both standing and supine positions. RESULTS: Maneuvers used in practice were cough (79%), BDM (60%), and VM (38%). 44% of clinicians felt patients found it difficult to raise their IAP. There was uncertainty among clinicians as to which method was the most effective in raising IAP and whether the different methods produced the same rise in IAP. On testing IAP in 20 healthy volunteers, median (interquartile range) IAP generated during BDM; 101 (59.1) cmH2 O was significantly higher than that generated during VM; 80.3 (43.6) cmH2 O (p < .0001). CONCLUSION: Clinicians varied widely in the maneuvers they used to raise patients' IAP to test for PFD and there was uncertainty about the maneuvers' effect on IAP. In healthy volunteers, BDM produced significantly higher IAP than VM. We recommend standardization of terminology and techniques used to raise IAP when assessing PFD, to ensure consistency of diagnosis and assessment of treatment outcomes.

Prospective study of anterior transobturator mesh kit (Prolift™) for the management of recurrent anterior vaginal wall prolapse.

INTRODUCTION AND HYPOTHESIS: Assessment of the 2-year outcome of anterior Prolift™ for women with recurrent anterior vaginal wall prolapse. This is a prospective study which was conducted in a tertiary unit in the North West of England and comprised 36 consecutive women with recurrent anterior vaginal wall prolapse. METHODS: Women were assessed preoperatively and postoperatively at 6 months and 2 years. Women completed the Prolapse Quality of Life Questionnaire (P-QOL), Prolapse and Incontinence Sexual Function Questionnaire-Short Form (PISQ-12), and postoperatively, the Global Impression of Improvement Questionnaire. Women were examined using the Pelvic Organ Prolapse Quantification System (POP-Q). Anatomical success was defined as stage ≤1 prolapse in the anterior compartment. Main outcome measures Postoperative POP-Q stage, quality of life domains and mesh exposure rate. RESULTS: Preoperatively all but two women had stage 2 or greater anterior vaginal wall prolapse. At a mean follow-up of 24.6 months, 19 women (53%) had stage ≤1 anterior wall prolapse. Fifteen women had stage 2 anterior wall prolapse and two women had stage 3 prolapse. Twenty-nine women felt improvement in their prolapse symptoms. 16 women were sexually active preoperatively, of whom seven reported worsening dyspareunia. There was poor correlation between anatomical and functional outcomes. Seven women had mesh exposure. Five needed revision in theatre. CONCLUSIONS: Anterior Prolift™ for recurrent anterior vaginal wall prolapse has 53% anatomical success rate in the medium term, with mesh exposure rate of 19%. Majority of patients felt overall improvement in their symptoms, but this did not correlate with the anatomical outcome.

The long-term outcome of laparoscopic colposuspension: a 10-year cohort study.

INTRODUCTION AND HYPOTHESIS: The aim of this study is to provide long-term outcome data, at least 10 years, following laparoscopic colposuspension. METHODS: The study includes a control group who underwent open colposuspension. A consecutive series of 139 women who had undergone laparoscopic colposuspension were reviewed and compared to 52 women who had an open colposuspension in the same unit. Subjects were contacted by telephone, at least 10 years post-operatively, at which time a structured interview was performed which included the short-form Bristol Female Lower Urinary Tract Symptom questionnaire. RESULTS: There was deterioration in subjective cure rates from 71% and 67% at 6 months to 52% and 36% at 10 years for the laparoscopic and open procedures, respectively. CONCLUSION: This study provides evidence that laparoscopic colposuspension is probably as durable as open colposuspension. However, cure rates for both procedures appear to deteriorate over time, emphasising the importance of long-term follow-up.

Which questionnaire? A psychometric evaluation of three patient-based outcome measures used to assess surgery for stress urinary incontinence.

AIMS: The aim of the study was to further validate three patient-based outcome measures (PBOM) used to assess the outcome of surgery for stress urinary incontinence and to compare their psychometric properties with a view to determining the most appropriate measure for clinical use. METHODS: The work was embedded within a randomized controlled trial of laparoscopic and open colposuspension. The trial recruited 291 women from six centers. The three instruments compared were Bristol Female Lower Urinary Tract Symptom Questionnaire (BFLUTS), Kings Health Questionnaire (KHQ), and the Symptom Severity Index and Symptom Impact Index (SSI/SII). The International Consultation on Incontinence (ICI) ABC grading system of psychometric propertie's reliability, validity, and responsiveness was used to evaluate the instruments. RESULTS: From the analysis of the psychometric properties of the three instruments, the SSI/SII appeared to have the best psychometric profile; Grade A, BFLUTS was of grade A, and KHQ was of grade B. SSI/SII had a good degree of internal consistency (Cronbach's alpha 0.74-0.78). BFLUTS and KHQ both had domains in which the internal consistency was <0.7. The SSI domain of the SSI/SII was the only domain to correlate to the 1-hr pad test. All domains of the SSI/SII were able to distinguish those cured from not cured and it was most responsive to change. Unlike the KHQ, the SSI/SII had no significant ceiling or floor effects. CONCLUSIONS: This study has demonstrated that when instruments are used in different populations their psychometric properties may change. All three instruments analyzed had limitations when used as an outcome measure for surgery for stress urinary incontinence.